Trauma Practice Questions

Q: A patient with severe burns covering 40% of his body surface area presents with hypotension and tachycardia. Which of the following is the most likely cause of his symptoms?

Increased capillary permeability. ***Increased capillary permeability*** - Severe burns cause extensive damage to the **endothelial cells** of capillaries, leading to a significant increase in their **permeability**. - This increased permeability allows **plasma proteins** and fluid to leak out of the intravascular space into the interstitial space, resulting in **hypovolemia**, hypotension, and tachycardia. *Increased systemic vascular resistance* - While initial sympathetic response to shock can cause some vasoconstriction, severe burn shock leads to profound **fluid loss** and **reduced cardiac output**, which would typically lead to a **decrease** in effective systemic vascular resistance due to inadequate vascular filling, not an increase as the primary cause of hypotension. - Increased SVR would generally cause hypertension, not hypotension, unless coupled with severe pump failure, which isn't the primary mechanism in early burn shock. *Increased plasma protein levels* - In severe burns, plasma proteins leak out of the capillaries, leading to a **decrease** in plasma protein levels, especially albumin. - This reduction in plasma oncotic pressure further exacerbates fluid shifts out of the intravascular space. *Increased cardiac output* - Severe burn injury leads to significant **fluid loss** and a large decrease in **preload**, which consequently causes a **decrease** in cardiac output despite compensatory tachycardia. - An increased cardiac output would typically raise blood pressure, not lead to hypotension.

Q: A 30-year-old man is brought to the emergency department after a head injury. He has a Glasgow Coma Scale (GCS) score of 8. Which of the following best describes his level of consciousness?

Severe head injury. ***Severe head injury*** - A **Glasgow Coma Scale (GCS) score of 3-8** defines a **severe head injury**. - This typically indicates a significant compromise in **neurological function** requiring immediate and aggressive medical intervention, including **airway protection and ICU care**. *Mild head injury* - A **mild head injury** is generally associated with a **GCS score of 13-15**. - Patients with mild head injuries may experience brief loss of consciousness or altered mental status but are typically able to follow commands. *Moderate head injury* - A **moderate head injury** is characterized by a **GCS score of 9-12**. - Patients in this category often have a more prolonged period of confusion or loss of consciousness compared to mild injuries, but are still responsive. *Fully conscious* - **Fully conscious** individuals have a **GCS score of 15**, indicating they are alert, oriented, and able to respond appropriately. - A GCS of 8 clearly indicates a significant impairment in consciousness, ruling out full consciousness.

Q: What is the investigation of choice for diagnosing solid organ injuries in abdominal trauma?

CT scan. ***CT scan*** - A **CT scan** is the investigation of choice for diagnosing solid organ injuries due to its high sensitivity and specificity in detecting **hemoperitoneum**, organ lacerations, and active bleeding. - It provides detailed cross-sectional images, allowing for precise localization and grading of injuries, crucial for **surgical planning**. *Ultrasound* - While useful for rapid assessment of **free fluid** (FAST scan), it has limited sensitivity for detecting parenchymal organ injuries and cannot reliably assess the extent of damage or active bleeding. - Its utility is primarily in the **initial triage** of hemodynamically unstable patients to identify the presence of significant intra-abdominal bleeding. *MRI* - **MRI** offers excellent soft tissue contrast but is typically too time-consuming and often impractical in the acute trauma setting, especially for **unstable patients**. - Its role is usually reserved for specific indications, such as spinal cord injuries, or when **CT scans** are contraindicated for certain reasons, like **pregnancy**. *X-ray* - **X-rays** are primarily used to detect skeletal injuries, such as fractures, or to visualize air under the diaphragm indicating **hollow viscus perforation**, rather than solid organ damage. - They provide very limited information regarding the **parenchyma of solid organs** and are not sufficient for diagnosing or staging solid organ injuries.

Q: A 35-year-old female with 30% total body surface area burns is hypotensive and tachycardic. Analyze the resuscitation plan using the Parkland formula.

4 ml/kg/%TBSA, half in the first 8 hours. ***4 ml/kg/%TBSA, half in the first 8 hours*** - The **Parkland formula** is 4 mL of crystalloid per kg of body weight per percentage of total body surface area (TBSA) burned. - Of the total calculated fluid, **half is administered in the first 8 hours** from the time of injury, and the remaining half over the next 16 hours. *4 ml/kg/%TBSA, all in the first 8 hours* - Administering the entire calculated fluid volume within the first 8 hours would lead to **excessive fluid administration** and potential complications like compartment syndrome or pulmonary edema. - While 4 ml/kg/%TBSA is the correct total volume per day, it should be distributed over 24 hours (half in the first 8 hours, half in the next 16 hours). *2 ml/kg/%TBSA, all in the first 8 hours* - This formula implies a **total daily fluid volume of 2 mL/kg/%TBSA**, which is typically used for pediatric patients or electrical burns, not general adult thermal burns. - Administering all of this reduced volume in the first 8 hours would still be an incorrect distribution and likely lead to **under-resuscitation** for severe burns. *4 ml/kg/%TBSA, one third in the first 8 hours* - While 4 ml/kg/%TBSA is the correct daily fluid calculation, administering only **one-third** in the first 8 hours would likely result in **inadequate resuscitation** during the critical initial phase. - The standard dictates delivering a larger proportion, typically half, within the crucial first 8 hours of post-burn injury.

Q: In a trauma patient with a pelvic fracture and hemodynamic instability, what is the priority intervention?

Pelvic binder application. ***Pelvic binder application*** - A pelvic binder stabilizes the **pelvis**, compresses potential bleeding sites, and reduces the pelvic volume, thereby helping to control **hemorrhage** in hemodynamically unstable patients with pelvic fractures. - It is a rapid, non-invasive intervention that can be applied in the pre-hospital or emergency department setting as an initial measure to improve stability and facilitate resuscitation. *Immediate external fixation surgery* - While definitive management for unstable pelvic fractures often involves **surgical fixation**, it is not the *priority* initial intervention for a hemodynamically unstable patient. - Surgery requires operating room setup, anesthesia, and time, which may delay critical hemorrhage control when immediate action is needed. *CT scan of the pelvis* - A **CT scan** provides detailed anatomical information about the fracture and associated injuries, but it should not delay life-saving interventions for a hemodynamically unstable patient. - Moving an unstable patient to the CT scanner can worsen their condition and delay critical resuscitation efforts. *Administration of IV fluids only* - While **intravenous fluids** are crucial for resuscitation in hemorrhagic shock, they do not address the source of bleeding from an unstable pelvic fracture. - Without stabilizing the fracture and controlling the hemorrhage, fluid administration alone may lead to **dilutional coagulopathy** and continued blood loss.

Q: Basilar skull fracture with Battle's sign: What are the clinical signs and the at-risk nerve?

Bruising behind ears, CSF otorrhea; Facial nerve. ***Bruising behind ears, CSF otorrhea; Facial nerve*** - **Battle's sign** is periauricular **ecchymosis** appearing hours to days after trauma, indicating a basilar skull fracture. **CSF otorrhea**, leakage of cerebrospinal fluid from the ear, also signifies penetration of the tympanic membrane associated with a temporal bone fracture. - The **facial nerve (CN VII)** passes through the temporal bone and is commonly injured in basilar skull fractures affecting this region, leading to facial paralysis. *Bruising around eyes, CSF rhinorrhea; Optic nerve* - **Raccoon eyes** (periorbital ecchymosis) and **CSF rhinorrhea** (CSF leakage from the nose) are indeed signs of a basilar skull fracture, particularly involving the anterior cranial fossa. - However, the **optic nerve (CN II)** is typically not directly at risk from these types of fractures unless there is severe trauma directly impinging on the optic canal, and the question specifically asks for the at-risk nerve in the context of Battle's sign and CSF otorrhea. *Blood in sclera, anosmia; Olfactory nerve* - **Subconjunctival hemorrhage** (blood in sclera) can be a sign of head trauma but is less specific for a basilar skull fracture than Battle's sign or Raccoon eyes. - **Anosmia** (loss of smell) and injury to the **olfactory nerve (CN I)** are associated with fractures of the cribriform plate in the anterior cranial fossa, not typically with the temporal bone fractures causing Battle's sign or CSF otorrhea. *Hearing loss, swallowing difficulty; Glossopharyngeal nerve* - **Hearing loss** can occur with temporal bone fractures due to damage to the ossicles or inner ear structures, but it is a symptom, not a specific sign like Battle's sign. - **Swallowing difficulty** and injury to the **glossopharyngeal nerve (CN IX)** are rare complications of basilar skull fractures and are primarily associated with fractures near the jugular foramen.

Q: A 20-year-old male involved in a motor vehicle accident presents with facial asymmetry and trismus. A CT scan shows a fracture of the zygomatic arch. What is the best treatment approach?

Minimally invasive zygomatic arch elevation. ***Minimally invasive zygomatic arch elevation*** - This technique is suitable for **isolated zygomatic arch fractures** without significant displacement of the zygomatic body, which often present with **facial asymmetry** and **trismus**. - It involves using a hook or other instruments inserted through a small incision to elevate and restore the arch to its anatomical position. *Closed reduction* - While closed reduction can be used for some fractures, it is generally less effective for **zygomatic arch fractures** that lead to significant **trismus** and asymmetry due to lack of stable fixation. - This method carries a higher risk of **re-displacement** and suboptimal cosmetic and functional outcomes compared to arch elevation. *Open reduction and internal fixation* - This approach is typically reserved for more complex fractures, such as **tripod (zygomaticomaxillary complex) fractures**, or significantly displaced zygomatic body fractures with involvement of multiple suture lines. - ORIF is generally **overkill** for an isolated, less comminuted zygomatic arch fracture and carries risks of larger incisions, more extensive dissection, and potential plate palpability. *Jaw wiring* - **Jaw wiring**, or maxillomandibular fixation (MMF), is primarily used for **mandibular fractures** to immobilize the jaw and facilitate bony healing. - It is not an appropriate treatment for **zygomatic arch fractures**, as it does not address the displacement of the zygoma or the impingement on the coronoid process causing trismus.

Q: A patient with a history of head trauma presents with cerebrospinal fluid rhinorrhea. What is the most appropriate management?

Observation. ***Observation (Conservative management)*** - **Initial management** of post-traumatic CSF rhinorrhea is conservative, as **80-85% of cases resolve spontaneously** within 7-10 days. - Conservative measures include **bed rest, head elevation (30-45 degrees)**, avoidance of straining, nose blowing, and Valsalva maneuvers. - A **lumbar drain** may be placed to reduce CSF pressure and promote dural healing. - Surgical intervention is reserved for leaks **persisting beyond 2 weeks** or high-flow leaks that fail conservative management. *Surgical repair* - Indicated only for **persistent CSF leaks** (>2 weeks), high-flow leaks, or recurrent leaks after conservative management. - Not the **first-line approach** as most traumatic CSF rhinorrhea resolves without surgery. - Approaches include endoscopic or transcranial repair depending on the location and size of the defect. *Antibiotics* - **Prophylactic antibiotics are NOT recommended** for CSF rhinorrhea due to lack of evidence for benefit and risk of promoting resistant organisms. - Antibiotics should only be given if there is evidence of **active meningitis or infection**. - The risk of meningitis is approximately 10-25% with persistent leaks, reinforcing the need for definitive management if conservative measures fail. *Nasal packing* - **Contraindicated** in CSF rhinorrhea as it can increase intracranial pressure, worsen the leak, and introduce infection risk. - Does not address the underlying **dural defect** and may impede natural healing.

Q: A 40-year-old woman sustains a 20% total body surface area burn. She presents with hypotension and tachycardia. What is the most appropriate initial fluid therapy?

Lactated Ringer's. ***Lactated Ringer's*** - **Lactated Ringer's solution** is the **resuscitation fluid of choice** for burn patients per the **Parkland formula** - Its composition is similar to **extracellular fluid**, effectively restoring fluid and electrolyte balance - Contains **lactate** which is metabolized in the liver to **bicarbonate**, helping counteract the **mild acidosis** often seen in burn patients - Isotonic crystalloid that provides adequate **intravascular volume expansion** in hypovolemic shock *Incorrect: D5W* - **D5W (5% Dextrose in Water)** is a **hypotonic solution** that primarily distributes into the **intracellular compartment** - Does not effectively expand intravascular volume necessary for resuscitation - Inappropriate for patients with **significant burns and hypovolemia** requiring urgent volume replacement *Incorrect: Normal saline* - While **normal saline (0.9% NaCl)** is an isotonic crystalloid, large volumes lead to **hyperchloremic metabolic acidosis** due to high chloride content (154 mEq/L) - Can exacerbate existing acidosis in burn patients - Less physiologically balanced than Lactated Ringer's for burn resuscitation *Incorrect: Plasma* - **Plasma** is a colloid solution **not used for initial fluid resuscitation** in the acute burn phase - Reserved for specific situations: **severe hypoproteinemia** or **coagulation factor deficiencies** - Carries risks including **allergic reactions** and **transfusion-related acute lung injury (TRALI)** - Not part of standard burn resuscitation protocols

Question 1

A patient with severe burns covering 40% of his body surface area presents with hypotension and tachycardia. Which of the following is the most likely cause of his symptoms?

Accepted Answer

Increased capillary permeability

Answer

Increased systemic vascular resistance

Answer

Increased plasma protein levels

Answer

Increased cardiac output

Question 2

A 30-year-old man is brought to the emergency department after a head injury. He has a Glasgow Coma Scale (GCS) score of 8. Which of the following best describes his level of consciousness?

Accepted Answer

Severe head injury

Answer

Mild head injury

Answer

Moderate head injury

Answer

Fully conscious

Question 3

What is the investigation of choice for diagnosing solid organ injuries in abdominal trauma?

Accepted Answer

CT scan

Answer

Ultrasound

Answer

MRI

Answer

X-ray

Question 4

A 35-year-old female with 30% total body surface area burns is hypotensive and tachycardic. Analyze the resuscitation plan using the Parkland formula.

Accepted Answer

4 ml/kg/%TBSA, half in the first 8 hours

Answer

4 ml/kg/%TBSA, all in the first 8 hours

Answer

2 ml/kg/%TBSA, all in the first 8 hours

Answer

4 ml/kg/%TBSA, one third in the first 8 hours

Question 5

In a trauma patient with a pelvic fracture and hemodynamic instability, what is the priority intervention?

Accepted Answer

Pelvic binder application

Answer

Immediate external fixation surgery

Answer

CT scan of the pelvis

Answer

Administration of IV fluids only

Question 6

What is the most appropriate initial management for a patient with a knife wound to the abdomen who is experiencing hemodynamic instability?

Accepted Answer

Immediate surgical intervention to control bleeding and repair injuries.

Answer

Perform a bedside ultrasound to assess for internal bleeding.

Answer

Obtain detailed imaging of the abdomen to identify injuries.

Answer

Monitor the patient closely without immediate intervention.

Question 7

Basilar skull fracture with Battle's sign: What are the clinical signs and the at-risk nerve?

Accepted Answer

Bruising behind ears, CSF otorrhea; Facial nerve

Answer

Bruising around eyes, CSF rhinorrhea; Optic nerve

Answer

Blood in sclera, anosmia; Olfactory nerve

Answer

Hearing loss, swallowing difficulty; Glossopharyngeal nerve

Question 8

A 20-year-old male involved in a motor vehicle accident presents with facial asymmetry and trismus. A CT scan shows a fracture of the zygomatic arch. What is the best treatment approach?

Accepted Answer

Minimally invasive zygomatic arch elevation

Answer

Closed reduction

Answer

Jaw wiring

Answer

Open reduction and internal fixation

Question 9

A patient with a history of head trauma presents with cerebrospinal fluid rhinorrhea. What is the most appropriate management?

Accepted Answer

Observation

Answer

Antibiotics

Answer

Surgical repair

Answer

Nasal packing

Question 10

A 40-year-old woman sustains a 20% total body surface area burn. She presents with hypotension and tachycardia. What is the most appropriate initial fluid therapy?

Accepted Answer

Lactated Ringer's

Answer

D5W

Answer

Normal saline

Answer

Plasma

Trauma — MCQs

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