Trauma Practice Questions

Q: What percentage of burns in a child involves the head region?

20%. **Explanation:** The assessment of burn surface area in children differs significantly from adults due to their unique body proportions. In adults, the **Rule of Nines** (Wallace) is used, where the head and neck account for 9%. However, children have a disproportionately larger head and smaller lower limbs. **1. Why 20% is Correct:** According to the modified Rule of Nines for infants/children, the **head and neck account for 18%** (often rounded to 20% in clinical exams). As a child grows, 1% is subtracted from the head and added to each leg for every year of age over one. By age 10, the child’s proportions approximate those of an adult. **2. Analysis of Incorrect Options:** * **A (10%):** This is closer to the adult value (9%). Selecting this would underestimate the fluid resuscitation requirements in a pediatric patient. * **C & D (30% & 40%):** These values are excessively high. Even in a neonate, the head does not exceed 18-20% of the total body surface area (TBSA). **3. Clinical Pearls for NEET-PG:** * **Lund and Browder Chart:** This is the **most accurate** method for calculating TBSA in children as it accounts for age-specific changes in body surface area. * **Palmar Method:** The patient’s palm (including fingers) represents approximately **1% TBSA**. This is useful for small or patchy burns. * **Fluid Resuscitation:** Children require more maintenance fluid than adults. The **Parkland Formula** (4ml/kg/% burn) is used, but in children, maintenance fluids (using the Holliday-Segar formula) must be added to the resuscitation volume to prevent hypoglycemia and dehydration. * **Critical Area:** In children, the head is a major source of heat loss; hence, keeping the head covered during burn management is vital to prevent hypothermia.

Q: An 81-year-old female falls and presents to the emergency department. What injury to a tissue or structure causes lower leg extremities to be externally rotated?

Lateral meniscus. **Explanation:** The correct answer is **Lateral meniscus**. This question focuses on the **"Screw-home mechanism"** of the knee joint. In the final stages of knee extension (the last 30 degrees), the femur undergoes internal rotation relative to the tibia to "lock" the knee. Conversely, to initiate flexion, the knee must "unlock." If there is a tear or displacement of the **lateral meniscus**, it can act as a mechanical wedge, preventing normal tracking and causing the tibia to remain in a position of **external rotation** (or the femur in internal rotation) to accommodate the displaced tissue. **Analysis of Options:** * **A. Sacroiliac joint:** Injuries here typically present with pelvic instability and pain but do not result in a characteristic external rotation of the lower leg. * **B. Neck of femur & D. Intertrochanteric fracture:** While these fractures classically present with external rotation and shortening of the limb, the rotation occurs at the **hip joint**, involving the entire lower extremity. The question specifically points toward a structure causing rotation of the **lower leg extremities** (distal to the knee), which is a classic sign of a "locked knee" due to meniscal pathology. **Clinical Pearls for NEET-PG:** * **Screw-home mechanism:** Medial rotation of the femur on the tibia during the terminal phase of extension. * **Unlocking the knee:** Performed by the **Popliteus muscle** (the "key" to the knee), which laterally rotates the femur on the tibia. * **Bucket-handle tears:** Most common cause of a "locked knee" where the patient cannot fully extend the leg, often held in slight external rotation.

Q: Which statement about diaphragmatic injury is true?

Left-sided injury is more common. **Explanation:** Diaphragmatic injuries typically result from blunt or penetrating trauma. **Option C is correct** because left-sided diaphragmatic ruptures are significantly more common (approx. 70-80% of cases). This is due to two primary factors: 1. **The Protective Effect of the Liver:** On the right side, the liver acts as a buffer, absorbing and distributing the kinetic energy of the impact. 2. **Congenital Weakness:** The left hemidiaphragm has a natural point of weakness at the posterolateral aspect (the site of embryonic fusion). **Analysis of Incorrect Options:** * **Options A & B:** Diaphragmatic injuries **never** resolve spontaneously and cannot be treated conservatively. Due to the pressure gradient between the positive-pressure abdomen and negative-pressure thorax, abdominal viscera will eventually herniate into the chest. Therefore, surgical repair (laparotomy or thoracotomy) is mandatory once diagnosed. * **Option D:** While a pneumothorax *can* coexist with trauma, diaphragmatic injury is classically associated with **hemothorax** or the presence of **bowel sounds/hollow viscera** in the thoracic cavity, rather than being defined by pneumothorax itself. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Investigation:** Diagnostic Laparoscopy (especially for small penetrating wounds). * **Chest X-ray Finding:** Look for the "Gurgle sign" (bowel loops in the chest) or a nasogastric tube coiled in the thorax. * **Surgical Approach:** In acute cases, **Laparotomy** is preferred to inspect for associated intra-abdominal organ injuries. In chronic/delayed presentations, a **Thoracotomy** is often preferred due to adhesions.

Q: A 27-year-old patient presented with left-sided abdominal pain to the emergency room, 6 hours after trauma. The patient is hemodynamically stable and FAST positive. A contrast-enhanced CT scan shows a contrast blush along with a Grade I laceration. What is the most appropriate management?

Splenic Artery Embolization. ### **Explanation** The management of splenic trauma is primarily dictated by the patient's **hemodynamic stability** rather than the grade of injury alone. **1. Why Splenic Artery Embolization (SAE) is Correct:** The patient is **hemodynamically stable**, which is the prerequisite for Non-Operative Management (NOM). However, the presence of a **"contrast blush"** on CECT indicates active extravasation of contrast (active bleeding) or a pseudoaneurysm. In a stable patient, a contrast blush is a specific indication for **Angiography and Embolization**. SAE increases the success rate of NOM by stopping the focal bleed while preserving splenic immune function. **2. Why the other options are incorrect:** * **Splenectomy (A) & Splenorrhaphy (B):** These are operative interventions. Surgery is indicated only if the patient is hemodynamically **unstable**, has peritonitis, or if NOM/Embolization fails. * **Conservative Management (D):** While Grade I injuries are often managed conservatively (observation), the presence of a **contrast blush** is a "red flag" that significantly increases the risk of delayed rupture and failure of simple observation. Therefore, active intervention via embolization is required. --- ### **High-Yield Clinical Pearls for NEET-PG** * **Gold Standard Investigation:** CECT (only for stable patients). * **Most Common Organ Injured:** Spleen (in Blunt Abdominal Trauma). * **Indications for SAE:** Hemodynamically stable patient with CECT showing contrast blush, pseudoaneurysm, or high-grade injury (Grade IV/V). * **Kehr’s Sign:** Referred pain to the left shoulder due to diaphragmatic irritation (classic for splenic rupture). * **Post-Splenectomy Prophylaxis:** Vaccination against encapsulated organisms (*H. influenzae, B. meningitidis, S. pneumoniae*) should be given 14 days after emergency surgery or 14 days before elective surgery.

Q: What diameter of cerebellar hematoma requires surgical evacuation?

Greater than 3 cm. **Explanation:** The management of cerebellar hematomas is a critical topic in neurotrauma because the posterior fossa is a confined space. Unlike supratentorial bleeds, even small increases in volume here can rapidly lead to brainstem compression, obstructive hydrocephalus, or tonsillar herniation. **Why Option D is Correct:** According to the **Guidelines for the Management of Spontaneous Intracerebral Hemorrhage**, surgical evacuation is indicated for patients with a cerebellar hemorrhage greater than **3 cm in diameter** who are experiencing neurological deterioration or who have brainstem compression and/or hydrocephalus. A 3 cm threshold is the established clinical "cutoff" where the risk of fatal brainstem herniation outweighs the risks of suboccipital craniectomy. **Why Other Options are Incorrect:** * **Options A & B (0.5 cm and 1 cm):** These are considered small hematomas. They are typically managed conservatively with close neurological monitoring and serial CT scans, as they rarely cause significant mass effect. * **Option C (2 cm):** While a 2 cm bleed requires vigilant observation, it does not meet the standard surgical criteria unless accompanied by significant clinical deterioration or acute hydrocephalus. **High-Yield Clinical Pearls for NEET-PG:** 1. **The "Rule of 3":** For cerebellar hematomas, think of **3 cm** as the magic number for surgery. 2. **Clinical Presentation:** Look for the triad of ataxia, headache, and vomiting. 3. **GCS vs. Size:** Even if a patient has a high GCS, a hematoma >3 cm is often treated surgically because "talk and die" syndrome is common due to sudden brainstem compression. 4. **Associated Findings:** Always check for **obstructive hydrocephalus** (due to 4th ventricle compression), which may require an EVD (External Ventricular Drain) in addition to or before evacuation.

Q: What is the degree of burns in a patient presenting with blister formation?

2nd degree superficial. **Explanation:** The presence of **blisters (bullae)** is the hallmark clinical feature of **2nd-degree (partial-thickness) burns**. Specifically, **2nd-degree superficial burns** involve the epidermis and the superficial (papillary) dermis. Because the dermal-epidermal junction is damaged, fluid accumulates to form blisters. These burns are characteristically **exquisitely painful**, blanch on pressure, and remain moist. **Analysis of Options:** * **2nd degree superficial (Correct):** As described, these present with blisters, significant pain, and a weeping/moist surface. They typically heal within 2-3 weeks without scarring. * **2nd degree deep:** These involve the deeper (reticular) dermis. While they may have blisters, the base is usually pale or white, they are less painful (due to nerve damage), and they do not blanch. They often result in hypertrophic scarring. * **1st degree burns:** These involve only the epidermis (e.g., sunburn). They present with erythema and pain but **no blisters**. * **Full thickness (3rd degree) burns:** These involve the entire dermis and underlying subcutaneous tissue. The skin appears leathery, charred, or waxy white. They are **painless** (anesthetic) because sensory nerve endings are destroyed. **High-Yield Clinical Pearls for NEET-PG:** * **Rule of Nines:** Used to estimate Total Body Surface Area (TBSA) in adults. * **Parkland Formula:** $4 \text{ ml} \times \text{Body Weight (kg)} \times \% \text{ TBSA}$ (Note: 1st-degree burns are excluded from TBSA calculation). * **Critical Indicator:** The most sensitive sign of adequate fluid resuscitation in a burn patient is **Urinary Output** (Target: $0.5\text{--}1 \text{ ml/kg/hr}$ in adults).

Question 1

All of the following are true about rib fractures except:

Accepted Answer

Intermittent positive pressure ventilation is the preferred treatment for flail chest.

Answer

The most common rib fractured during CPR is the 4th-6th rib.

Answer

Fracture of the 11th, 12th, and first rib is uncommon.

Answer

In flail chest, two or more consecutive ribs are fractured in two or more places.

Question 2

What percentage of burns in a child involves the head region?

Accepted Answer

20%

Answer

10%

Answer

30%

Answer

40%

Question 3

An 81-year-old female falls and presents to the emergency department. What injury to a tissue or structure causes lower leg extremities to be externally rotated?

Accepted Answer

Lateral meniscus

Answer

Sacroiliac joint

Answer

Neck of femur

Answer

Intertrochanteric fracture

Question 4

Which statement about diaphragmatic injury is true?

Accepted Answer

Left-sided injury is more common

Answer

Treatment is conservative

Answer

It resolves spontaneously

Answer

It is associated with pneumothorax

Question 5

A 27-year-old patient presented with left-sided abdominal pain to the emergency room, 6 hours after trauma. The patient is hemodynamically stable and FAST positive. A contrast-enhanced CT scan shows a contrast blush along with a Grade I laceration. What is the most appropriate management?

Accepted Answer

Splenic Artery Embolization

Answer

Splenectomy

Answer

Splenorrhaphy

Answer

Conservative management

Question 6

Which criteria indicate that a burn patient should be referred for specialized care?

Accepted Answer

25% deep burn in an adult

Answer

10% superficial burn in a child

Answer

Scald burn on the face

Answer

25% superficial burn in an adult

Question 7

What diameter of cerebellar hematoma requires surgical evacuation?

Accepted Answer

Greater than 3 cm

Answer

Greater than 0.5 cm

Answer

Greater than 1 cm

Answer

Greater than 2 cm

Question 8

A 28-year-old male involved in a motorcycle accident presents with severe respiratory distress, hypotension (BP 80/40 mm Hg), cyanosis, epistaxis, an open femur fracture, and decreased breath sounds on the right side. What is the initial management priority?

Accepted Answer

Endotracheal intubation with inline cervical traction.

Answer

Control of hemorrhage with anterior and posterior nasal packing.

Answer

Tube thoracostomy in the right hemithorax.

Answer

Obtain intravenous access and begin emergency type O blood transfusions.

Question 9

Early reversible shock is characterized by?

Accepted Answer

Cold, clammy extremities and increased peripheral resistance

Answer

Decreased blood pressure

Answer

Decreased heart rate

Answer

Oliguria

Question 10

What is the degree of burns in a patient presenting with blister formation?

Accepted Answer

2nd degree superficial

Answer

2nd degree deep

Answer

1st degree burns

Answer

Full thickness burns

Trauma — MCQs

Trauma — MCQs

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