Trauma — MCQs

Trauma Indian Medical PG Practice Questions and MCQs

Question 981: A third degree circumferential burn in the arm and forearm region, which of the following is most important for monitoring -

A. Blood gases
B. Peripheral pulse and circulation (Correct Answer)
C. Carboxy-oxygen level
D. Urine output

Explanation: ***Peripheral pulse and circulation*** - **Circumferential third-degree burns** can act as a tourniquet, leading to **compartment syndrome** and critically impaired blood flow to the distal limb due to edema accumulating beneath the inelastic burn eschar. - Monitoring **peripheral pulses** and assessing **capillary refill** and skin color are crucial to detect early signs of **ischemia** and prompt intervention like escharotomy. *Blood gases* - While important in severely burned patients for assessing **respiratory status** and overall metabolic acid-base balance, it is not the *most immediate and critical* concern for a localized circumferential burn. - **Hypoxemia** or **acidosis** can result from extensive burns or smoke inhalation, but the primary threat from a circumferential limb burn is **limb viability**. *Carboxy-oxygen level* - This likely refers to **carboxyhemoglobin (COHb) levels**, which are vital for detecting **carbon monoxide poisoning**, especially in burn patients exposed to smoke inhalation. - While important for systemic toxicity, it doesn't directly address the immediate threat of vascular compromise to the limb from a circumferential burn. *Urine output* - Monitoring **urine output** is essential in extensive burn management as part of **fluid resuscitation** protocols (e.g., Parkland formula), targeting 0.5-1 mL/kg/hr to ensure adequate tissue perfusion. - However, for a **localized circumferential limb burn**, the immediate priority is preventing **limb ischemia** and potential loss, making peripheral pulse monitoring more critical than systemic fluid balance indicators.

Question 982: Escharotomies are required in which degree/type of burns:

A. 1st degree
B. 3rd degree (full thickness) (Correct Answer)
C. Electrical
D. 2nd degree superficial

Explanation: ***3rd degree (full thickness)*** - **Full-thickness burns** destroy all layers of the skin, including nerve endings, making the burn site **insensate** and forming a tough, non-elastic eschar. - This **rigid eschar** can impair circulation, especially in circumferential burns, and restrict ventilation in thoracic burns, necessitating **escharotomies** to relieve pressure and restore blood flow or breathing. *1st degree* - **First-degree burns** only affect the epidermis, causing redness and mild pain without blistering; they do not form a constricting eschar. - These burns heal spontaneously within a few days and do not require surgical intervention like **escharotomies**. *Electrical* - **Electrical burns** can cause deep tissue damage and internal organ injury, but the primary concern is often cardiac arrhythmias and deep tissue necrosis rather than a constricting eschar that requires escharotomy. - While they can lead to full-thickness skin damage, **escharotomy** is performed if a full thickness burn with constricting eschar. The primary reason for escharotomy is the nature of the burn not its cause. *2nd degree superficial* - **Superficial partial-thickness burns** involve the epidermis and superficial dermis, causing blisters, pain, and redness, but the skin remains pliable and does not form a constricting eschar. - These burns typically heal without scarring and do not require **escharotomies**.

Question 983: The golden period for treatment of open wounds is _____ hours?

A. 6
B. 12
C. 4 (Correct Answer)
D. 24

Explanation: ***4*** - The "golden period" refers to the time frame within which an **open wound can be primarily closed** with a low risk of infection. - This period is generally considered to be within **4-6 hours** post-injury due to the bacterial colonization kinetics. *6* - While 6 hours falls within the broader recommended range for primary closure in certain contexts, **4 hours** is often cited as the safer and more conservative initial "golden period." - Surgical intervention after 6 hours starts to carry a **higher risk of infection** for primary closure, especially for contaminated wounds. *12* - By 12 hours, most open wounds will have undergone significant **bacterial colonization**, making primary closure much riskier. - Wounds presenting after this time typically require **delayed primary closure** or secondary intention healing. *24* - At 24 hours, an open wound is considered to be **chronically colonized** and highly susceptible to infection if primarily closed. - Primary closure is generally **contraindicated** and would lead to a high rate of wound infection and dehiscence.

Question 984: After 30% loss of blood volume in road traffic accident. What immediate management is to be given?

A. IV fluid only (Correct Answer)
B. Dopamine
C. Vasopressor drug
D. IV fluid with cardiac stimulant

Explanation: ***IV fluid only*** - A 30% blood volume loss constitutes **Class III hemorrhagic shock**, where immediate replacement of circulating volume with **intravenous fluids (crystalloids)** is the priority to restore perfusion. - Rapid infusion of warmed crystalloids (2-3 liters) is essential to stabilize hemodynamics immediately. While **blood products will likely be needed** after initial fluid resuscitation in Class III shock, the **immediate first step** is crystalloid infusion. - The principle is "fluid first" - restore circulating volume before considering other interventions. *Dopamine* - Dopamine is a **vasopressor** and **inotropic agent** that increases blood pressure and cardiac output. - It is **contraindicated** as first-line treatment for hypovolemic shock, as the primary issue is lack of volume, not cardiac dysfunction or inadequate vascular tone. - Using inotropes on an empty vascular system is like "flogging a dying horse" - ineffective and potentially harmful. *Vasopressor drug* - Vasopressors constrict blood vessels and increase blood pressure, but they are **contraindicated in acute hypovolemic shock** until adequate fluid resuscitation is achieved. - In hypovolemic shock, vasopressors without correcting the volume deficit worsen organ perfusion by increasing afterload on an already volume-depleted cardiovascular system and reducing tissue oxygenation. - Remember: "Fill the tank before you pressurize the pipes." *IV fluid with cardiac stimulant* - While IV fluids are critical, adding a **cardiac stimulant** (like dobutamine or epinephrine) is **not indicated** as an immediate step in **hypovolemic shock** caused by blood loss. - The heart is functioning normally but has insufficient preload due to volume loss. Stimulating an empty heart can be detrimental and does not address the primary problem. - Cardiac stimulants are reserved for cardiogenic shock or refractory hypotension after adequate volume resuscitation.

Question 985: 32 year old female presents with 15% burns following cylinder blast. How much fluid should be administered in first 8 hours of admission, if she weighs 60 kg?

A. 1800 mL (Correct Answer)
B. 800 mL
C. 600 mL
D. 500 mL

Explanation: ***1800 mL*** - The **Parkland formula** for fluid resuscitation in burn patients is **4 mL × body weight (kg) × total body surface area (TBSA) burned (%)**. - For this patient: 4 mL × 60 kg × 15% = 3600 mL over 24 hours. Half of this volume (1800 mL) is given in the **first 8 hours**, while the remaining half is administered over the next 16 hours. *800 mL* - This volume is significantly **less than recommended** by the Parkland formula for the initial 8 hours. - Inadequate fluid resuscitation can lead to **hypovolemic shock** and organ dysfunction in burn patients. *600 mL* - This amount would be **insufficient for initial resuscitation** and would not meet the fluid requirements to prevent burn shock. - Providing too little fluid early on can result in **poor tissue perfusion** and increased morbidity. *500 mL* - This is a severely **under-resuscitative dose** for a patient with 15% TBSA burns. - Such a low volume would likely result in **critical electrolyte imbalances** and **renal failure**.

Question 986: All of the following are causes of death in burn patients except

A. ARDS
B. Sepsis
C. Hyponatremia (Correct Answer)
D. Shock

Explanation: ***Hyponatremia*** - While **hyponatremia** can occur in burn patients due to fluid shifts or inappropriate ADH secretion, it is rarely a direct cause of death on its own. - Severe hyponatremia would typically need to be profound and uncorrected to be lethal, and other major burn complications are more immediate and common causes of mortality. *ARDS* - **Acute Respiratory Distress Syndrome (ARDS)** is a severe and common complication in burn patients, often due to smoke inhalation injury or systemic inflammation. - It leads to profound **hypoxemia** and is a significant cause of mortality in both early and late stages of burn care. *Sepsis* - **Sepsis** is a leading cause of death in burn patients, especially with extensive burns, due to the loss of skin barrier function and increased susceptibility to infection. - The systemic inflammatory response and subsequent **multiple organ dysfunction syndrome (MODS)** are often fatal. *Shock* - **Hypovolemic shock** is a prominent cause of early death in severely burned patients due to massive fluid loss from the burn wound. - Other forms of shock, such as **distributive (septic) shock**, can also occur later and contribute significantly to overall mortality.

Question 987: Initial resuscitation of a trauma patient is best done by administration of which of the following?

A. Ringer's lactate solution (Correct Answer)
B. D5W and 0.45% normal saline
C. D5W
D. 5% plasma protein solution

Explanation: ***Ringer's lactate solution*** - **Ringer's lactate** is an **isotonic crystalloid solution** that closely mimics the electrolyte composition of plasma, making it ideal for rapid volume resuscitation in trauma patients. - It helps restore **intravascular volume** effectively and is the preferred initial crystalloid in trauma resuscitation. - The lactate in the solution is metabolized to bicarbonate by the liver, which may help buffer acidosis, though this is not the primary reason for its use in acute trauma. - Modern trauma guidelines (ATLS) recommend crystalloids as the initial resuscitation fluid, with rapid transition to **blood products** in cases of ongoing hemorrhage. *D5W and 0.45% normal saline* - This combination is **hypotonic** relative to plasma and is primarily used for maintenance fluids or replacing free water deficits, not for large-volume resuscitation in trauma. - Administering large amounts in trauma can worsen **cerebral edema** in patients with head injuries or dilute electrolytes dangerously. *D5W* - **D5W (5% dextrose in water)** is essentially free water once the dextrose is metabolized, making it a **hypotonic solution**. - It is not suitable for initial trauma resuscitation as it primarily distributes intracellularly and is ineffective at rapidly expanding **intravascular volume**. - May cause hyperglycemia and worsen outcomes in critically ill patients. *5% plasma protein solution* - **Plasma protein solutions** are colloids, which can expand intravascular volume, but they are more expensive and not recommended for initial resuscitation. - Crystalloids like Ringer's lactate are preferred as the first line of fluid resuscitation due to their ready availability, lower cost, proven safety profile, and efficacy in the initial management of **hypovolemic shock** in trauma. - Current evidence does not show superiority of colloids over crystalloids for trauma resuscitation.

Question 988: A boy presents with diplopia and restriction of eye movements following blunt trauma to his eye. X-ray reveals blow out fracture of orbit. Which part of orbit is most likely damaged?

A. Inferior wall (Correct Answer)
B. Medial wall
C. Lateral wall
D. Superior wall

Explanation: ***Inferior wall*** - The **inferior wall** (orbital floor) is the most common site for **blowout fractures** because it is the weakest and thinnest part of the orbital bone. - A fracture here often causes **entrapment** of the inferior rectus muscle and/or periorbital tissues, leading to **diplopia** and **restricted eye movements**, especially on upward gaze. *Medial wall* - While relatively thin, the medial wall is less commonly fractured in isolation than the inferior wall in typical blowout injuries. - Fractures here might involve the **ethmoid sinuses** and can lead to **subcutaneous emphysema** or **epistaxis**, which are not reported as primary symptoms in this case. *Lateral wall* - The lateral wall is the **thickest and strongest** part of the orbit, making fractures of this wall less common in isolated blowout injuries. - Fractures here typically require significant force and are often associated with other facial bone trauma. *Superior wall* - The superior wall (orbital roof) is made of the **frontal bone** and is relatively thick, making fractures here uncommon. - Fractures of the superior wall carry a risk of **intracranial injury** due to proximity to the brain, which is not suggested by the patient's presentation.

Question 989: The earliest manifestation of increased intracranial pressure following head injury is:

A. Hemiparesis
B. Ipsilateral pupillary dilatation
C. Altered mental status (Correct Answer)
D. Contralateral pupillary dilatation

Explanation: ***Altered mental status*** - **Altered mental status** (e.g., confusion, irritability, drowsiness) is often the earliest sign of increased intracranial pressure (ICP) due to its profound effect on global brain function. - This change reflects the **brain's reduced perfusion** and metabolic compromise as pressure within the rigid skull rises. *Hemiparesis* - **Hemiparesis** indicates focal neurological deficits, usually resulting from direct injury or significant pressure on specific motor pathways, which typically manifest later than global mental status changes. - It suggests a more advanced stage of neurological compromise or a localized mass effect. *Ipsilateral pupillary dilatation* - **Ipsilateral pupillary dilatation** is a classic sign of uncal herniation, where the temporal lobe compresses the **oculomotor nerve** (CN III) on the same side. - While critical, it is generally a *late and ominous sign* of significantly elevated ICP, indicating severe brainstem compression. *Contralateral pupillary dilatation* - **Contralateral pupillary dilatation** is highly unusual in the context of typical uncal herniation, which almost always causes *ipsilateral* signs due to direct compression. - Its presence would suggest atypical herniation patterns or other causes of pupillary asymmetry.

Question 990: Fluid given in first 8 hours to a 28 years old woman with 50 kg weight having burns on both lower limbs?

A. 950 ml
B. 3600 ml (Correct Answer)
C. 1900 ml
D. 7400 ml

Explanation: ***3600 ml*** - Both lower limbs account for **36% TBSA deep burns** (18% for each leg). Using the Parkland formula (4mL x Body weight (kg) x %TBSA burned) gives 4mL x 50kg x 36% = **7200 mL total fluid** for the first 24 hours. - Half of the total fluid (7200 mL / 2 = 3600 mL) should be administered in the **first 8 hours** following the burn injury. *950 ml* - This amount is significantly less than the calculated fluid requirement for a patient with deep burns over 36% TBSA, which would lead to **under-resuscitation** and potential burn shock. - Inadequate fluid resuscitation can result in **organ hypoperfusion** and increased mortality in burn patients. *1900 ml* - While a substantial amount, 1900 mL is still less than half of the calculated 24-hour fluid requirement, meaning this would still lead to **under-resuscitation** in the critical initial 8-hour window. - This represents roughly a quarter of the total 24-hour fluid, which is insufficient for the **initial rapid fluid shift** seen in severe burns. *7400 ml* - This amount represents more than the entire 24-hour fluid requirement according to the Parkland formula (7200 mL). Administering this much fluid in the first 8 hours would lead to **over-resuscitation**. - **Over-resuscitation (fluid creep)** can cause complications such as pulmonary edema, abdominal compartment syndrome, and acute respiratory distress syndrome (ARDS).

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