Trauma Practice Questions

Q: Which of the following is a primary aim of damage control laparotomy?

Arrest hemorrhage and control contamination.. ***Arrest hemorrhage and control contamination.*** * The overarching goal of a **damage control laparotomy** is to rapidly address immediate life threats, primarily **hemorrhage** and **bowel contamination**, in severely injured, unstable patients. * This approach prioritizes patient survival by performing essential steps quickly, deferring definitive repairs until the patient is physiologically stable. *Control contamination* * While **controlling contamination** is a critical component of damage control laparotomy, it is not the sole primary aim. * Uncontrolled bleeding, even without contamination, can rapidly lead to death in a trauma patient. *Prevent coagulopathy* * Preventing **coagulopathy** is an important consideration during damage control, but it is a consequence of uncontrolled hemorrhage and hypothermia, rather than a primary surgical aim in the initial damage control phase. * The surgical steps in damage control directly address the sources of bleeding and contamination. *Arrest hemorrhage* * **Arresting hemorrhage** is indeed a primary aim, but it is often accompanied by the need to control contamination from injured hollow organs. * Many abdominal trauma cases involve both significant bleeding and potential contamination.

Q: Polytrauma patients with massive open bleeding wounds of the right thigh with active hemorrhage should be managed first of all by?

Tourniquet application. ***Tourniquet application*** - For **massive open bleeding wounds** with active hemorrhage in an extremity, a tourniquet is the most immediate and effective way to control life-threatening bleeding. - Rapid application of a **tourniquet proximal to the wound** significantly reduces blood loss, improving patient survival in trauma. *Tight bandage application* - While useful for less severe bleeding, a **tight bandage** is often insufficient to control massive, active arterial or venous hemorrhage. - It might temporarily slow bleeding but can easily be overwhelmed, leading to continued significant blood loss. *Blood transfusion* - **Blood transfusion** is a critical intervention for replacing lost blood volume due to hemorrhage but is not the *first* step in managing active bleeding. - Controlling the source of bleeding (e.g., with a tourniquet) must precede or occur simultaneously with fluid and blood resuscitation. *Airway maintenance* - **Airway maintenance** is a fundamental principle in trauma management (ABCs: Airway, Breathing, Circulation), but in the presence of massive, uncontrolled external bleeding, hemorrhage control takes immediate priority. - The patient will die from exsanguination before an airway becomes the primary fatal problem if massive bleeding is not addressed.

Q: Which of the following is NOT a characteristic of a deep burn?

Blisters. ***Blisters*** - The presence of **blisters** is a characteristic feature of **second-degree (partial-thickness) burns**, where the epidermis and part of the dermis are damaged. - In **deep (full-thickness) burns**, the skin layers are completely destroyed, and blisters typically do not form. *Black charred skin* - **Black charred skin** is indicative of a **full-thickness burn**, often resulting from prolonged exposure to intense heat. - This appearance signifies the complete destruction of skin tissue. *White leathery skin* - **White, leathery, and dry skin** is typical of **full-thickness or deep partial-thickness burns**, where the dermis is severely damaged. - This indicates **coagulation** and destruction of dermal components. *Loss of pain sensation* - **Loss of pain sensation** in the affected area is a hallmark of a **deep (full-thickness) burn** because nerve endings in the dermis are completely destroyed. - In contrast, shallower burns are typically very painful due to exposed and irritated nerve endings.

Q: Which of the following is not a type of skull fracture?

Diffuse axonal injury. ***Diffuse axonal injury*** - **Diffuse axonal injury (DAI)** is a type of **traumatic brain injury** caused by shearing forces that damage axons. - It is a **microscopic brain injury** and does not involve a fracture of the skull bones. *Linear* - A **linear skull fracture** is a break in a cranial bone that appears as a thin line without bone displacement. - It is a common type of skull fracture, often occurring from low-energy blunt trauma. *Depressed* - A **depressed skull fracture** occurs when pieces of fractured bone are driven inward towards the brain. - This type of fracture often requires surgical intervention to elevate the bone fragments and reduce pressure on the brain. *Basal* - A **basal skull fracture** involves a break in the bones at the base of the skull. - It is often associated with signs like **raccoon eyes**, **Battle's sign**, and cerebrospinal fluid (CSF) leakage from the nose or ears.

Q: In frostbite, the skin becomes hard and black in about:

2 weeks. ***2 weeks*** - In cases of severe frostbite, the affected **skin and underlying tissue** typically become **hard, black, and mummified** within approximately 2 weeks after the injury. - This progression indicates **full-thickness tissue necrosis** and often leads to the need for **amputation or debridement**. *3 days* - While initial signs of **tissue damage**, such as blistering and swelling, may appear within 24-48 hours, the full extent of **mummification or eschar formation** usually takes longer. - **Hardening and blackening** within 3 days would be an unusually rapid progression, typically associated with very severe and immediate tissue death, which is not the common timeline for such extensive changes. *7 days* - By 7 days, there can be significant **blistering and tissue discoloration**, but the complete **mummification and blackening** characteristic of full-thickness necrosis generally takes longer to develop. - Necrotic tissue may start to become firm and discolored, but may not fully achieve the typical **hard, black appearance** indicative of complete demarcation. *4-6 weeks* - By 4-6 weeks, the **demarcation line** between viable and non-viable tissue is usually well-established, and spontaneous **auto-amputation** or surgical intervention may have already occurred. - The initial **hardening and blackening** of the skin would have developed much earlier, typically by 2 weeks.

Q: Most common cause of acquired atrioventricular fistula is -

Penetrating trauma. ***Penetrating trauma*** - **Penetrating injuries**, such as stab wounds or gunshot wounds to the chest, are the most frequent cause of **acquired atrioventricular fistulas**. - These injuries can directly transect or damage the walls of adjacent cardiac chambers and great vessels, creating an abnormal communication. *Bacterial infection* - While bacterial infections can lead to conditions like **endocarditis** or abscess formation, they are not the most common direct cause of an **acquired atrioventricular fistula**. - Endocarditis primarily involves valve damage and can rarely extend to form fistulas, but this is less frequent than trauma. *Fungal infection* - Fungal infections, especially in immunocompromised individuals, can cause **mycotic aneurysms** or severe endocarditis. - However, they are a rare cause of direct **atrioventricular fistula formation** compared to traumatic injuries. *Blunt trauma* - **Blunt chest trauma** can cause myocardial contusion, rupture of cardiac chambers, or vessel dissection. - While severe blunt trauma can lead to cardiac injury, it is less likely to create a discrete **atrioventricular fistula** than a sharp penetrating injury that punctures both structures.

Q: A 40-year-old woman was brought to the casualty 8 hours after sustaining burns on the abdomen, both limbs, and back. What is the best formula to calculate the amount of fluid to be replenished?

4 mL/kg x %TBSA. ***4 mL/kg x %TBSA*** - This is the **Parkland formula** (also known as Baxter formula), which is the most widely accepted method for calculating fluid resuscitation in burn patients. - The formula calculates a **total 24-hour fluid requirement** of **4 mL of Ringer's lactate per kilogram of body weight per percentage of total body surface area (%TBSA)** burned. - **Timing protocol:** Half of the calculated total volume (2 mL/kg x %TBSA) is given in the **first 8 hours post-burn**, and the remaining half over the **next 16 hours**. - This is the **gold standard** for initial burn fluid resuscitation. *2 mL/kg x %TBSA* - This represents **only half the total 24-hour fluid volume** recommended by the Parkland formula. - Using only 2 mL/kg x %TBSA as the total would lead to **severe under-resuscitation**, increasing the risk of burn shock, acute kidney injury, and other complications. - This volume is correct only for the **first 8 hours**, not the total calculation. *8 mL/kg x %TBSA* - This suggests **twice the fluid volume** recommended by the Parkland formula. - Administering 8 mL/kg x %TBSA would result in **over-resuscitation**, leading to complications such as pulmonary edema, abdominal compartment syndrome, acute respiratory distress syndrome (ARDS), and extremity compartment syndrome. *4 mL/kg x %TBSA in first 8 hours followed by 2 mL/kg/hour x %TBSA* - This option incorrectly suggests giving the **entire 24-hour calculated volume** in the first 8 hours, then continuing with an additional **hourly rate**. - This would result in **massive over-resuscitation** and life-threatening complications. - The correct Parkland protocol gives **half the total** (2 mL/kg x %TBSA) in the first 8 hours, then the **remaining half over 16 hours** (not an additional continuous rate).

Q: Treatment of choice for a stab injury to the caecum is

Primary repair. ***Primary repair*** - For most stab injuries to the caecum, **primary repair** is the treatment of choice, especially when the injury is small and there is no significant tissue loss or contamination. - The caecum has a relatively **large diameter** and **rich blood supply**, which facilitates successful primary closure. - Primary repair is simple, effective, and avoids the morbidity associated with ostomy creation. *Caecostomy* - A **caecostomy** involves bringing a portion of the caecum to the surface as a temporary fecal diversion. - It is generally reserved for more complex injuries with significant tissue loss, severe contamination, or hemodynamic instability requiring damage control surgery. - This procedure carries risks of **infection** and **fistula formation**, and is more invasive than primary repair for isolated stab injuries. *Transverse colostomy* - A **transverse colostomy** is a diverting ostomy created in the transverse colon. - It is typically used for injuries to the distal colon or rectum, or in cases of severe abdominal contamination requiring fecal diversion from a more compromised section of the bowel. - This is a more extensive procedure than necessary for an isolated low-grade caecal injury and would involve unnecessary diversion of a longer segment of colon. *Sigmoid colostomy* - A **sigmoid colostomy** is a diverting ostomy created in the sigmoid colon. - It is primarily indicated for injuries or diseases affecting the distal colon or rectum, providing fecal diversion to allow healing of those structures. - This option is inappropriate for a caecal injury as it is too distal and would not directly protect the site of injury or provide adequate proximal diversion.

Q: In pneumothorax due to blunt injury, the treatment of choice is

Intercostal drainage. ***Intercostal drainage*** - **Intercostal drainage** (chest tube insertion) is the treatment of choice for pneumothorax caused by **blunt injury**, especially if the pneumothorax is large or causing respiratory distress. - This procedure effectively evacuates air from the **pleural space**, allowing the lung to re-expand and alleviating symptoms like shortness of breath. *Observation* - **Observation** is generally reserved for **small, asymptomatic pneumothoraces**, typically less than 20% of the hemithorax volume, particularly in spontaneous pneumothorax. - In cases of pneumothorax due to **blunt injury**, there is a higher likelihood of associated injuries and progression, making observation often insufficient or unsafe. *Pneumonectomy* - **Pneumonectomy** involves the surgical removal of an entire lung and is a drastic procedure indicated for conditions like **severe lung cancer** or extensive, irreparable lung damage. - It is not a primary treatment for pneumothorax, as the goal is to re-expand the existing lung, not remove it. *Thoracotomy* - **Thoracotomy** is a major surgical incision into the chest cavity, typically performed to access organs like the lung, heart, or esophagus for complex surgical repairs. - While it can be necessary in cases of persistent air leak or severe bleeding after chest tube insertion, it is not the **initial treatment of choice** for pneumothorax from blunt injury.

Q: All of the following are suggestive of a positive diagnostic peritoneal lavage (DPL) except.

Clear effluent with RBCs <100,000/mm3. ***Clear effluent with RBCs <100,000/mm³*** - A **clear effluent** with an **RBC count 10 mL of gross blood is aspirated directly from peritoneal cavity* - Direct aspiration of **>10 mL of gross blood** from the peritoneal cavity is a **positive DPL criterion** and indicates significant intra-abdominal hemorrhage. - This finding is a strong indicator for **immediate surgical exploration (laparotomy)** and represents one of the most definitive positive DPL findings. - When this much gross blood is aspirated initially, it confirms the need for surgery without requiring further lavage analysis. *Effluent contains RBCs >100,000/mm³* - An **RBC count >100,000/mm³** in the DPL effluent is a standard criterion for a **positive DPL**, indicating significant hemoperitoneum. - This finding typically warrants **surgical intervention** to identify and manage the source of bleeding. *Effluent contains Amylase >175 IU/dL* - An **amylase level >175 IU/dL** in the DPL effluent suggests possible **pancreatic or intestinal injury**. - This is a significant indicator of visceral injury and constitutes a **positive DPL**, often prompting surgical exploration.

Question 1

Which of the following is a primary aim of damage control laparotomy?

Accepted Answer

Arrest hemorrhage and control contamination.

Answer

Control contamination

Answer

Prevent coagulopathy

Answer

Arrest hemorrhage

Question 2

Polytrauma patients with massive open bleeding wounds of the right thigh with active hemorrhage should be managed first of all by?

Accepted Answer

Tourniquet application

Answer

Tight bandage application

Answer

Blood transfusion

Answer

Airway maintenance

Question 3

Which of the following is NOT a characteristic of a deep burn?

Accepted Answer

Blisters

Answer

Loss of pain sensation

Answer

Black charred skin

Answer

White leathery skin

Question 4

Which of the following is not a type of skull fracture?

Accepted Answer

Diffuse axonal injury

Answer

Linear

Answer

Depressed

Answer

Basal

Question 5

In frostbite, the skin becomes hard and black in about:

Accepted Answer

2 weeks

Answer

3 days

Answer

7 days

Answer

4-6 weeks

Question 6

Most common cause of acquired atrioventricular fistula is -

Accepted Answer

Penetrating trauma

Answer

Bacterial infection

Answer

Fungal infection

Answer

Blunt trauma

Question 7

A 40-year-old woman was brought to the casualty 8 hours after sustaining burns on the abdomen, both limbs, and back. What is the best formula to calculate the amount of fluid to be replenished?

Accepted Answer

4 mL/kg x %TBSA

Answer

2 mL/kg x %TBSA

Answer

8 mL/kg x %TBSA

Answer

4 mL/kg x %TBSA in first 8 hours followed by 2 mL/ kg/hour x %TBSA

Question 8

Treatment of choice for a stab injury to the caecum is

Accepted Answer

Primary repair

Answer

Transverse colostomy

Answer

Sigmoid colostomy

Answer

Caecostomy

Question 9

In pneumothorax due to blunt injury, the treatment of choice is

Accepted Answer

Intercostal drainage

Answer

Observation

Answer

Pneumonectomy

Answer

Thoracotomy

Question 10

All of the following are suggestive of a positive diagnostic peritoneal lavage (DPL) except.

Accepted Answer

Clear effluent with RBCs <100,000/mm3

Answer

Effluent contains RBCs >100,000/mm3

Answer

Effluent contains Amylase >175 IU/dL

Answer

>10 mL of gross blood is aspirated directly from peritoneal cavity

Trauma — MCQs

Trauma — MCQs

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