Trauma Practice Questions

Q: Haemodynamically unstable patient with blunt trauma to abdomen and suspected liver injury; which of the following is the first investigation performed in the emergency room?

FAST. ***FAST*** - For a **hemodynamically unstable** patient with blunt abdominal trauma, **Focused Assessment with Sonography for Trauma (FAST)** is the quickest and most appropriate initial investigation to detect **free fluid** (indicating hemorrhage) in the abdomen or pericardium. - Its **rapidity and non-invasiveness** make it ideal for immediate decision-making regarding surgical intervention. *CT Scan* - **CT scans** provide detailed anatomical information but require the patient to be **hemodynamically stable** and are time-consuming for an emergency assessment. - Moving an unstable patient to radiology for a CT scan can significantly **delay definitive treatment**. *Diagnostic peritoneal lavage* - While historically used, **diagnostic peritoneal lavage (DPL)** is an **invasive procedure** that is less commonly performed now due to the availability of FAST. - It has a high rate of **false positives** and potential complications, making it less favorable as a first-line investigation. *Standing X ray Abdomen* - A **standing X-ray of the abdomen** is primarily useful for detecting **free air under the diaphragm** (indicating bowel perforation) or major bony injuries. - It is **poor at detecting free fluid** or organ injury, which is the primary concern in suspected liver trauma in an unstable patient.

Q: A 43-year-old window cleaner fell off a scaffold. He sustained an open wound on the right leg. Debridement was carried out in the emergency department, and the edges of the wound were left open. Which factor is least likely to inhibit wound contraction?

Transforming growth factor β. ***Transforming growth factor β*** - **TGF-β** is a potent **pro-fibrotic cytokine** that plays a crucial role in promoting wound contraction and fibrosis by stimulating **fibroblast proliferation**, **myofibroblast differentiation**, and **collagen synthesis**. - Its presence and activity would *enhance* rather than inhibit wound contraction, making it the **least likely factor to inhibit** this process. - In wound healing, TGF-β is essential for the contraction phase and tissue remodeling. *Radiation* - **Ionizing radiation** can damage cells, including **fibroblasts** and **myofibroblasts**, which are essential for wound contraction. - This cellular damage and reduction in viable cells can significantly **impair** the contractile forces within the wound. - Radiation therapy is a known factor that inhibits wound healing and contraction. *Full-thickness skin graft* - A **full-thickness skin graft** introduces a complete layer of skin, including the dermis, into the wound. - The presence of the **dermis** within the graft provides a structural barrier and helps to **anchor the wound edges**, thereby reducing the tendency for contraction. - In contrast, **split-thickness grafts** allow more wound contraction due to less dermal tissue. *Cytolytic drug* - **Cytolytic drugs** are designed to kill cells, and if applied to a wound, they would destroy **fibroblasts** and **myofibroblasts**. - The destruction of these critical cells would directly **inhibit** the cellular machinery responsible for pulling the wound edges together, hence preventing contraction. - These drugs impair the proliferative phase of wound healing.

Q: The following are indications for performing thoracotomy after blunt injury of the chest, except -

Rib fracture. ***Rib fracture*** - While a **rib fracture** is a common injury in blunt chest trauma, it is generally managed conservatively with pain control and supportive care. - An isolated rib fracture is **not an indication for thoracotomy** unless complicated by significant associated injuries requiring surgical intervention, such as severe lung injury or ongoing hemorrhage. - Management focuses on adequate analgesia, pulmonary hygiene, and prevention of complications like pneumonia. *Continuous bleeding through intercostal tube of more than 200 ml/hour for three or more hours* - This criterion indicates persistent and significant **intrathoracic hemorrhage** that is unlikely to resolve with conservative management alone. - Such ongoing bleeding suggests a major vessel injury (intercostal, internal mammary, or pulmonary vessel) or severe parenchymal tear requiring surgical exploration and repair. - This is a **standard indication for urgent thoracotomy** in blunt chest trauma. *1000 ml drainage after placing intercostal tube* - A large initial drainage of **1000-1500 ml of blood** from a chest tube immediately after insertion signifies massive intrathoracic hemorrhage. - This volume indicates a clinically significant injury, such as a major vessel laceration, hilar injury, or severe lung laceration. - This is a **classic indication for immediate thoracotomy** to identify and control the source of bleeding. *Large air leak suggesting tracheobronchial injury* - A **persistent large air leak** through the chest tube, especially with failure of lung re-expansion, suggests a major bronchial or tracheal injury. - Tracheobronchial injuries occur in severe blunt chest trauma and require surgical repair to prevent complications like pneumomediastinum, persistent pneumothorax, and respiratory compromise. - This is a recognized **indication for thoracotomy** to repair the airway injury and restore pulmonary function.

Q: In trauma transfusion, what is the ratio of RBCs, FFP, and platelets?

1:1:1. ***1:1:1*** - A **1:1:1 ratio** of **Red Blood Cells (RBCs), Fresh Frozen Plasma (FFP), and platelets** is the current recommendation for massive transfusion protocols in trauma. - This ratio aims to mimic whole blood and address the "lethal triad" of acute traumatic coagulopathy: **acidosis, hypothermia, and coagulopathy**. *1:1:3* - This ratio provides proportionally more **platelets** than typically recommended in massive transfusion protocols as compared to FFP and RBCs. - While platelets are crucial for hemostasis, a 1:1:3 ratio might not optimally balance all components for initial trauma resuscitation. *1:1:4* - This ratio implies an even higher proportion of **platelets** relative to RBCs and FFP. - Such a high platelet ratio is generally not the initial target for massive transfusion protocols in trauma, which prioritize balanced component replacement. *1:1:2* - This ratio suggests a slightly higher proportion of **platelets** compared to the standard 1:1:1, but still less than 1:1:3 or 1:1:4. - While closer to the recommended range than other incorrect options, the 1:1:1 ratio is currently considered the ideal balance for comprehensive trauma resuscitation.

Q: A head injured patient, who opens eyes to painful stimulus, is confused and localizes to pain. What is the Glasgow coma score?

11. ***11*** - The Glasgow Coma Scale (GCS) comprises three components: **Eye opening**, Verbal response, and Motor response. - In this case, **eyes opening to pain** scores 2, **confused verbal response** scores 4, and **localizing to pain** scores 5, totaling 2 + 4 + 5 = 11. *9* - A score of 9 would correspond to a lower response in one or more categories, such as **abnormal flexion (decorticate)** as a motor response (3 points) or incomprehensible sounds as verbal response (2 points). - This option does not match the patient's described responses for eye opening (2), verbal (4), and motor (5) components. *7* - A score of 7 indicates a more severe neurological impairment, for instance, no eye opening (1), incomprehensible sounds (2), and **abnormal extension (decerebrate)** as a motor response (2 points). - This GCS score is much lower than what would be calculated from the patient's described responses. *13* - A score of 13 would indicate better neurological function, potentially with spontaneous eye opening (4) or responding with an oriented verbal response (5). - This score suggests less severe injury than the patient's responses of eyes opening to pain (2) and confused verbal response (4).

Q: The Monro-Kellie doctrine is used in?

Head injury. ***Head injury*** - The **Monro-Kellie doctrine** states that the sum of volumes of brain, cerebrospinal fluid (CSF), and intracranial blood is constant within the rigid skull. - In **head injury**, any increase in one component (e.g., hematoma, edema) must be compensated by a decrease in another to maintain intracranial pressure (ICP), otherwise, ICP rises, leading to potential herniation. *Cervical injury* - This doctrine applies to the **closed intracranial compartment**, not the spinal canal or cervical spine. - Cervical injuries primarily involve the vertebrae, spinal cord, and surrounding tissues, which do not have the same rigid, fixed-volume characteristics. *Pelvic injury* - The **pelvic cavity** is not a closed, rigid system like the cranium. - It accommodates changes in volume (e.g., from fluid, blood, or organ displacement) without the same direct impact on pressure seen in the skull. *Aortic injury* - **Aortic injuries** concern cardiovascular trauma and blood loss, typically presenting as hypovolemic shock or hemorrhage. - These conditions do not involve the intracranial compartment, and thus, the Monro-Kellie doctrine is irrelevant to their pathophysiology.

Q: An 80 kg male with bilateral upper limb, right lower limb, and perineum burns (3rd degree). What is the amount of fluid required in the first 8 hours?

5920 ml. ***5920 ml*** - Calculate the **Total Body Surface Area (TBSA)** affected: Both upper limbs (9% each = 18%), right lower limb (18%), and perineum (1%). Thus, 18 + 18 + 1 = 37%. - Using the **Parkland formula** (4 mL x weight in kg x TBSA%), the total fluid required in 24 hours is 4 mL x 80 kg x 37% = 11840 mL. Half of this volume is given in the first 8 hours: 11840 mL / 2 = 5920 mL. *3920 ml* - This value would be incorrect for **TBSA calculation** or the application of the Parkland formula. - An accurate calculation of TBSA and fluid volume for the first 8 hours is essential for **burn management**. *4920 ml* - This volume suggests an inaccurate TBSA or a miscalculation in the Parkland formula application. - Failure to administer adequate fluid volume can lead to **hypovolemic shock** in burn patients. *6560 ml* - This volume is significantly higher than required, indicating a potential overestimation of TBSA or an error in the Parkland formula. - Over-resuscitation can lead to complications such as **fluid overload** and **pulmonary edema**.

Q: According to "rule of nines", burns involving perineum are:

1%. ***Correct: 1%*** - According to the **rule of nines**, the **perineum** (genital region) is allocated **1%** of the total body surface area (TBSA). - This specific percentage is used for calculating burn extent, particularly relevant for fluid resuscitation in adults. - This is a standard component of the rule of nines used in burn assessment. *Incorrect: 27%* - This percentage is inaccurate for any single anatomical region in the standard adult **rule of nines** calculation. - It would represent a combination of large body areas, such as the entire back and one arm, or combinations of multiple regions. *Incorrect: 18%* - In the **rule of nines**, **18%** is assigned to an **entire lower limb** (front and back) or the **entire back** or **entire front of the trunk**. - The perineum is a much smaller area and does not account for this large a percentage. *Incorrect: 9%* - According to the **rule of nines**, **9%** is assigned to an **entire upper limb** (arm) or the **head and neck** region (adult). - The perineum is a considerably smaller area and is not assigned this proportion.

Q: A woman who weighs 50 kg is brought to you with severe burns over the body. You estimate that the non superficial burns cover 60% of body surface area. What is the rate of fluid to be given in the first 8 hours for this patient?

750 ml/hr. ***750 ml/hr*** - The Parkland formula is used for fluid resuscitation in burn patients: **4 mL x kg x %TBSA burn**. For this patient: 4 mL x 50 kg x 60% = **12,000 mL** over 24 hours. - Half of this total fluid (6,000 mL) is given in the **first 8 hours**: 6,000 mL / 8 hours = **750 mL/hr**. *1000 ml/hr* - This rate would deliver 8,000 mL in the first 8 hours, which is **over-resuscitation** for this patient according to the Parkland formula. - Excessive fluid administration can lead to complications such as **compartment syndrome** and **pulmonary edema**. *500 ml/hr* - This rate would deliver 4,000 mL in the first 8 hours, which is **under-resuscitation** for this patient according to the Parkland formula. - Inadequate fluid resuscitation can lead to **burn shock**, **renal failure**, and increased mortality. *1250 ml/hr* - This rate would deliver 10,000 mL in the first 8 hours, which represents significant **over-resuscitation** and is not indicated. - Such a high rate is well beyond the calculated needs and could result in severe fluid overload and its associated complications.

Q: For the immediately life-threatening injuries of the chest "Flail chest", select the proper intervention (SELECT 1 INTERVENTION)

Endotracheal intubation. ***Endotracheal intubation*** - **Endotracheal intubation** with **positive pressure ventilation** is the definitive intervention for flail chest to stabilize the chest wall and ensure adequate ventilation. - This prevents paradoxical chest wall movement and improves oxygenation, addressing the life-threatening impact on respiratory mechanics. *Tube thoracostomy* - **Tube thoracostomy** is primarily indicated for **pneumothorax** or **hemothorax**, which may co-exist with flail chest but is not the direct treatment for the flail segment itself. - While necessary for associated conditions, it does not stabilize the flail segment to improve ventilation. *Subxiphoid window* - A **subxiphoid window** is a diagnostic procedure performed to detect **pericardial effusion** or **cardiac tamponade**, not a primary intervention for flail chest. - It does not address the mechanical instability or respiratory compromise caused by a flail chest. *Cricothyroidotomy* - **Cricothyroidotomy** is an emergency procedure for securing an airway when **oral or nasal intubation is not possible** due to obstruction or trauma to the upper airway. - It is an airway intervention but does not specifically address the chest wall instability or paradoxical movement seen in flail chest.

Question 1

Haemodynamically unstable patient with blunt trauma to abdomen and suspected liver injury; which of the following is the first investigation performed in the emergency room?

Accepted Answer

FAST

Answer

CT Scan

Answer

Diagnostic peritoneal lavage

Answer

Standing X ray Abdomen

Question 2

A 43-year-old window cleaner fell off a scaffold. He sustained an open wound on the right leg. Debridement was carried out in the emergency department, and the edges of the wound were left open. Which factor is least likely to inhibit wound contraction?

Accepted Answer

Transforming growth factor β

Answer

Radiation

Answer

Full-thickness skin graft

Answer

Cytolytic drug

Question 3

The following are indications for performing thoracotomy after blunt injury of the chest, except -

Accepted Answer

Rib fracture

Answer

Continuous bleeding through intercostal tube of more than 200 ml/hour for three or more hours

Answer

1000 ml drainage after placing intercostal tube

Answer

Large air leak suggesting tracheobronchial injury

Question 4

In trauma transfusion, what is the ratio of RBCs, FFP, and platelets?

Accepted Answer

1:1:1

Answer

1:1:3

Answer

1:1:4

Answer

1:1:2

Question 5

A head injured patient, who opens eyes to painful stimulus, is confused and localizes to pain. What is the Glasgow coma score?

Accepted Answer

11

Answer

9

Answer

7

Answer

13

Question 6

The Monro-Kellie doctrine is used in?

Accepted Answer

Head injury

Answer

Cervical injury

Answer

Pelvic injury

Answer

Aortic injury

Question 7

An 80 kg male with bilateral upper limb, right lower limb, and perineum burns (3rd degree). What is the amount of fluid required in the first 8 hours?

Accepted Answer

5920 ml

Answer

3920 ml

Answer

4920 ml

Answer

6560 ml

Question 8

According to "rule of nines", burns involving perineum are:

Accepted Answer

1%

Answer

27%

Answer

18%

Answer

9%

Question 9

A woman who weighs 50 kg is brought to you with severe burns over the body. You estimate that the non superficial burns cover 60% of body surface area. What is the rate of fluid to be given in the first 8 hours for this patient?

Accepted Answer

750 ml/hr

Answer

1000 ml/hr

Answer

500 ml/hr

Answer

1250 ml/hr

Question 10

For the immediately life-threatening injuries of the chest "Flail chest", select the proper intervention (SELECT 1 INTERVENTION)

Accepted Answer

Endotracheal intubation

Answer

Tube thoracostomy

Answer

Subxiphoid window

Answer

Cricothyroidotomy

Trauma — MCQs

Trauma — MCQs

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