Trauma Practice Questions

Q: Following a blunt trauma abdomen, a patient had renal laceration and urinoma. Even after 12 days, urinoma persisted, but the patient was stable and there was no fever. Next step in management would be:

Double-J stent. ***Double-J stent*** - A persistent urinoma for 12 days, even in a stable, afebrile patient, suggests ongoing urine leakage from the renal laceration. A **double-J stent** can bridge the laceration, **diverting urine flow** from the injury site into the bladder, which promotes healing and resolves the urinoma. - This minimally invasive procedure allows the kidney to drain properly, preventing further accumulation of urine and reducing the risk of complications such as infection or fibrosis without the need for open surgery. *Percutaneous nephrostomy* - While a percutaneous nephrostomy can drain urine, it usually involves external drainage and does not directly address the *internal* diversion of urine flow to promote healing of the laceration effectively. - This option is more commonly used for **obstructive uropathy** or in cases where the urinoma is infected and requires drainage which is not seen here as the patient is afebrile. *Wait and watch* - Waiting and watching for 12 days has already shown that the urinoma persists, indicating that the laceration is not healing spontaneously. - Continued persistence of a urinoma increases the risk of complications such as infection, obstruction, or fibrosis, so intervention is warranted. *Surgical exploration and repair* - **Surgical exploration and repair** is a more aggressive open surgical intervention, generally reserved for cases with ongoing hemorrhage, escalating infection, or significant tissue damage that cannot be managed by less invasive means. - Given the patient's stability and absence of fever, a less invasive approach like stenting is preferred before considering more extensive surgical repairs.

Q: In blunt trauma abdomen, maximum injury to the small bowel occurs at:

Proximal jejunum. ***Proximal jejunum*** - The **proximal jejunum** is particularly vulnerable to blunt abdominal trauma due to its relatively fixed position at the **ligament of Treitz** and its proximity to the impact forces. - The rapid change in momentum during deceleration can cause tearing or shearing injuries at this point of relative immobility. *Ileocecal junction* - While the ileocecal junction is another relatively fixed point, it is less commonly injured in blunt abdominal trauma compared to the proximal jejunum. - Its anatomical position often shields it from the direct impact and shearing forces that typically affect the more superior small bowel. *Mid ileum* - The **mid ileum** is generally more mobile within the abdominal cavity, making it less susceptible to the shearing forces that affect fixed segments. - Injuries to this region are usually associated with more severe, widespread trauma or direct crushing mechanisms, rather than a specific point of maximum vulnerability. *Proximal ileum* - Similar to the mid ileum, the **proximal ileum** also has considerable mobility, reducing its risk of injury from acceleration-deceleration forces. - The more common sites of injury in the small bowel are those with relative fixation points, such as the jejunum near the ligament of Treitz.

Q: A patient presented with bleeding from thigh and broken 5th rib on right side. What should be done first:

Control bleeding. ***Control bleeding*** - In trauma cases, **hemorrhage control** is the immediate priority to prevent exsanguination and hypovolemic shock, which can be rapidly fatal. - The **ABCDE approach** in trauma management (Airway, Breathing, Circulation, Disability, Exposure) dictates that controlling life-threatening bleeding falls under "Circulation" and often takes precedence over other injuries once the airway is secured. *Strapping of chest* - While a fractured rib can cause pain and impair breathing, **chest strapping** is generally not recommended as it restricts chest wall movement, potentially leading to **atelectasis** and **pneumonia**. - Furthermore, it does not address the immediate life threat of uncontrolled bleeding from the thigh. *Internal fixation of rib* - **Internal fixation** of a broken rib is an advanced and elective surgical procedure, typically performed significantly later for specific indications such as flail chest or non-union. - It is not an emergent intervention and would be performed only after the patient is stable and all life-threatening conditions, including active bleeding, have been addressed. *Wait & watch* - A "wait and watch" approach is inappropriate for a patient with active bleeding and a fractured rib, as it delays critical interventions and can lead to **deterioration** of the patient's condition. - Immediate assessment and intervention are required to manage both the bleeding and the potential respiratory compromise from the rib fracture.

Q: A 30-year-old female with a history of burns involving abdomen, both limbs, and back presented after 8 hours. Which of the following is the formula for calculation of fluid infusion:

4 mL/kg × % TBSA over 24 hours. ***4 mL/kg × % TBSA over 24 hours*** - This is the **Parkland formula**, the gold standard for burn resuscitation in adults. - The total fluid requirement is **4 mL/kg × % TBSA**, with **half given in the first 8 hours** from the time of burn and **half in the remaining 16 hours**. - Since this patient presented after 8 hours, the resuscitation timeline needs adjustment, but the formula itself remains the standard Parkland calculation. - This provides adequate **fluid resuscitation** while minimizing risks of under-resuscitation or fluid overload. *3 mL/kg × % TBSA* - This formula provides **insufficient fluid volume** for adequate burn resuscitation in adults. - Using only 3 mL/kg would lead to **under-resuscitation**, risking hypovolemic shock and inadequate tissue perfusion. - This is significantly below the evidence-based Parkland formula requirement. *5 mL/kg × % TBSA* - This fluid resuscitation rate is **excessive** and significantly higher than the standard Parkland formula. - Using this amount increases the risk of **fluid overload, pulmonary edema**, and **abdominal compartment syndrome**. - Over-resuscitation can be as harmful as under-resuscitation in burn patients. *2 mL/kg × % TBSA* - This formula provides **grossly inadequate fluid resuscitation** for major burns in adults. - This represents only **half of the Parkland formula** requirement and would result in severe under-resuscitation. - Using this reduced volume could lead to **hypovolemic shock, renal failure**, and increased mortality.

Q: In the primary survey, which of the following is not included?

CECT to look for bleeding. ***CECT to look for bleeding*** - A **CECT scan** is a detailed imaging study that is performed during the **secondary survey**, not during the primary survey. - The primary survey focuses on the immediate **ABCDE assessment** (Airway, Breathing, Circulation, Disability, Exposure) to identify and treat immediately life-threatening conditions. - While identifying bleeding is critical, detailed imaging like CECT is done only after initial stabilization is achieved in the primary survey. *ABC* - **Airway, Breathing, and Circulation (ABC)** are the fundamental first three components of the primary survey. - These represent the immediate priorities for life support in trauma management according to ATLS guidelines. - Ensuring a patent airway, adequate breathing, and circulatory stability are critical first steps. *Exposure of the whole body* - **Exposure** (the "E" in ABCDE) is an essential part of the primary survey. - Complete exposure allows full assessment for injuries and prevents missing critical external wounds. - This step also involves maintaining **thermoregulation** to prevent hypothermia. *Recording BP* - **Recording blood pressure** is a crucial part of assessing circulation (the "C") during the primary survey. - It helps quickly evaluate hemodynamic status and identify potential signs of shock or internal bleeding. - Vital signs monitoring is integral to the initial trauma assessment.

Q: For open pneumothorax which of the following is management of choice?

ICD with underwater seal. ***ICD with underwater seal*** - An **intercostal drain (ICD)** with an **underwater seal** is the definitive management for an open pneumothorax once the initial wound has been covered. - This system allows air to escape the pleural space but prevents its re-entry, helping the lung to re-expand. *Wait and watch.* - This approach is suitable for very small, **stable spontaneous pneumothoraces** when the patient is asymptomatic, which is not the case for an open pneumothorax. - In an open pneumothorax, air continuously enters the pleural space, leading to **tension pneumothorax** and rapid deterioration if not addressed promptly. *Thoracostomy and close the rent* - **Thoracostomy** (creation of a surgical opening into the chest) might be part of the overall management, but simply closing the rent without addressing the underlying pneumothorax, often with a drain, is incomplete. - The immediate priority for an open pneumothorax is to convert it into a **closed pneumothorax** and then drain the air. *IPPV* - **Intermittent positive pressure ventilation (IPPV)** with a high enough pressure can worsen an open pneumothorax by forcing more air into the pleural space if the wound is not sealed. - While mechanical ventilation might be needed for respiratory failure, it's not the primary or sole management for the open pneumothorax itself and can be dangerous without proper sealing and drainage.

Q: First treatment of flail chest is

O2 administration and analgesia. ***O2 administration and analgesia*** - The immediate priority in flail chest is to ensure adequate **oxygenation** and manage pain to allow for effective ventilation and prevent respiratory compromise. - **Analgesia** helps reduce pain during breathing, improving tidal volume and reducing the risk of atelectasis and pneumonia. *Mechanical ventilation* - While mechanical ventilation may be necessary in cases of severe respiratory distress or failure, it is not the **first-line treatment** for all flail chest patients. - Its use is indicated if initial supportive measures like oxygen and analgesia fail, or if there's evidence of **respiratory acidosis** or persistent hypoxemia. *Intrapleural analgesia* - This is a form of advanced pain management and is typically not the initial step in treating flail chest. - While effective for pain control, it requires specific expertise and equipment, making it a **secondary intervention** after basic analgesia and oxygen. *Surgical stabilization* - Surgical stabilization of the fractured ribs is considered when there is significant chest wall deformity, persistent respiratory failure despite other treatments, or in cases of non-union. - It is an **elective procedure** and not the immediate first treatment for flail chest.

Q: Which among the following is the best method to assess adequacy of fluid resuscitation in a polytrauma patient:

Urine output. ***Urine output*** - **Urine output** is a direct and real-time reflection of **renal perfusion**, which is highly sensitive to changes in circulating blood volume and cardiac output in trauma patients. - Maintaining a urine output of **0.5-1 mL/kg/hr** is generally accepted as a key indicator of adequate fluid resuscitation and organ perfusion in polytrauma. *CVP* - **Central Venous Pressure (CVP)** can be influenced by multiple factors beyond fluid status, such as **intrathoracic pressure**, **venous tone**, and **right ventricular function**, making it an unreliable sole indicator. - While it offers some insight into preload, CVP measurements alone do not provide a direct and dynamic assessment of **end-organ perfusion** in trauma. *Pulse rate* - **Pulse rate** is a non-specific indicator that can be affected by pain, anxiety, medications, and other systemic responses beyond fluid status in polytrauma. - While **tachycardia** often suggests hypovolemia, a normal pulse rate does not guarantee adequate fluid resuscitation, especially in patients with compensatory mechanisms. *BP* - **Blood pressure (BP)** is a relatively late indicator of hypovolemia in trauma, as compensatory mechanisms can maintain BP near normal despite significant blood loss. - Relying solely on BP can lead to delayed recognition of **inadequate resuscitation** and potential end-organ damage.

Q: Which one of the following is a secondary brain injury?

Intracerebral haematoma with raised intracranial pressure. ***Intracerebral haematoma with raised intracranial pressure*** - **Intracerebral haematoma** is a potentially treatable, secondary injury directly contributing to **raised intracranial pressure (ICP)**, leading to further brain damage if not managed. - **Secondary brain injuries** occur minutes to days after the initial impact, resulting from a cascade of events like ischaemia, oedema, and intracranial hypertension. *Diffuse axonal injury* - **Diffuse axonal injury (DAI)** is a **primary brain injury** caused by shearing forces at the moment of impact. - It is a direct consequence of the initial trauma, not a subsequent physiological process. *Cortical lacerations* - **Cortical lacerations** are **primary injuries**, representing a direct tearing or cutting of brain tissue due to the initial traumatic force. - These are immediately present at the time of injury and are not a consequence of subsequent physiological changes. *Brainstem and hemispheric contusions* - **Contusions** are localised areas of bruising on the brain, characteristic of a **primary brain injury**, occurring directly from the impact. - While contusions can evolve and contribute to secondary injury mechanisms like oedema, the contusion itself is a direct result of the initial trauma.

Q: Neurological status is assessed under which step of ABCDE of trauma care?

D - Disability: neurological status. ***D - Disability: neurological status*** - The "D" in ABCDE trauma assessment specifically stands for **Disability**, which involves a rapid assessment of the patient's **neurological status**. - This step typically includes evaluating **level of consciousness** using tools like the AVPU scale (Alert, Voice, Pain, Unresponsive) or the Glasgow Coma Scale (GCS), assessing pupillary response, and identifying any gross motor deficits. *C - Circulation with haemorrhage control* - This step focuses on assessing and managing **blood flow**, including evaluating heart rate, blood pressure, capillary refill, and controlling any sources of external hemorrhage. - While neurological issues can result from poor circulation, the primary assessment of the nervous system itself is not performed here. *E - Exposure: completely undress the patient and assess for other injuries* - This final step involves a thorough **inspection of the entire body** to identify hidden injuries, such as bruising, lacerations, or deformities, while simultaneously ensuring temperature regulation. - It is for overall physical assessment, not for initial neurological evaluation. *B - Breathing and ventilation* - This step involves assessing the patient's **respiratory effort**, checking for symmetrical chest rise, listening to breath sounds, and intervening to ensure adequate oxygenation and ventilation. - While critical for brain function, this step focuses on the respiratory system, not the direct assessment of neurological function.

Question 1

Following a blunt trauma abdomen, a patient had renal laceration and urinoma. Even after 12 days, urinoma persisted, but the patient was stable and there was no fever. Next step in management would be:

Accepted Answer

Double-J stent

Answer

Percutaneous nephrostomy

Answer

Wait and watch

Answer

Surgical exploration and repair

Question 2

In blunt trauma abdomen, maximum injury to the small bowel occurs at:

Accepted Answer

Proximal jejunum

Answer

Ileocecal junction

Answer

Proximal ileum

Answer

Mid ileum

Question 3

A patient presented with bleeding from thigh and broken 5th rib on right side. What should be done first:

Accepted Answer

Control bleeding

Answer

Strapping of chest

Answer

Internal fixation of rib

Answer

Wait & watch

Question 4

A 30-year-old female with a history of burns involving abdomen, both limbs, and back presented after 8 hours. Which of the following is the formula for calculation of fluid infusion:

Accepted Answer

4 mL/kg × % TBSA over 24 hours

Answer

3 mL/kg × % TBSA

Answer

5 mL/kg × % TBSA

Answer

2 mL/kg × % TBSA

Question 5

In the primary survey, which of the following is not included?

Accepted Answer

CECT to look for bleeding

Answer

ABC

Answer

Exposure of the whole body

Answer

Recording BP

Question 6

For open pneumothorax which of the following is management of choice?

Accepted Answer

ICD with underwater seal

Answer

IPPV

Answer

Wait and watch

Answer

Thoracostomy and close the rent

Question 7

First treatment of flail chest is

Accepted Answer

O2 administration and analgesia

Answer

Mechanical ventilation

Answer

Intrapleural analgesia

Answer

Surgical stabilization

Question 8

Which among the following is the best method to assess adequacy of fluid resuscitation in a polytrauma patient:

Accepted Answer

Urine output

Answer

CVP

Answer

Pulse rate

Answer

BP

Question 9

Which one of the following is a secondary brain injury?

Accepted Answer

Intracerebral haematoma with raised intracranial pressure

Answer

Diffuse axonal injury

Answer

Cortical lacerations

Answer

Brainstem and hemispheric contusions

Question 10

Neurological status is assessed under which step of ABCDE of trauma care?

Accepted Answer

D - Disability: neurological status

Answer

C - Circulation with haemorrhage control

Answer

E - Exposure: completely undress the patient and assess for other injuries

Answer

B - Breathing and ventilation

Trauma — MCQs

Trauma — MCQs

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