Trauma Practice Questions

Q: A 70 kg female has 50% burns and an inhalation burn injury. What is the fluid requirement in the first 8 hours according to the Parkland formula?

875 ml/hr. ### Explanation **1. Understanding the Parkland Formula** The Parkland formula is the gold standard for fluid resuscitation in burn patients. It calculates the total volume of Ringer’s Lactate (RL) required in the first 24 hours from the time of injury: * **Formula:** $4 \text{ ml} \times \text{Body Weight (kg)} \times \text{Total Body Surface Area (TBSA) \%}$ * **Calculation:** $4 \times 70 \text{ kg} \times 50\% = 14,000 \text{ ml}$ in 24 hours. **2. Distribution of Fluids** * **First 8 hours:** 50% of the total volume ($14,000 / 2 = 7,000 \text{ ml}$). * **Next 16 hours:** Remaining 50% ($7,000 \text{ ml}$). * **Hourly rate for the first 8 hours:** $7,000 \text{ ml} / 8 \text{ hours} = \mathbf{875 \text{ ml/hr}}$. **3. Analysis of Incorrect Options** * **Option A (625 ml/hr):** This would result from using 3 ml/kg/% (Modified Brooke formula) instead of the standard Parkland 4 ml/kg/%. * **Option B (732 ml/hr):** This is a common calculation error or misapplication of the 24-hour total divided by 24 hours ($14,000 / 24 \approx 583$) plus a slight increase. * **Option D (1000 ml/hr):** This overestimates the requirement and could lead to "fluid creep" and pulmonary edema, especially in elderly patients. **Clinical Pearls for NEET-PG:** * **Inhalation Injury:** While the question asks for the Parkland calculation, clinically, inhalation injuries often require **more** fluid than the formula predicts. * **Endpoint of Resuscitation:** The most reliable indicator of adequate fluid resuscitation is **Urine Output (0.5–1 ml/kg/hr in adults)**. * **Fluid of Choice:** Crystalloids (Ringer’s Lactate) are preferred. Colloids are generally avoided in the first 24 hours due to increased capillary permeability. * **Rule of 9s:** Always use Wallace’s Rule of 9s to calculate TBSA; do not include first-degree burns (erythema) in the calculation.

Q: A male patient is admitted following a fall from height. On arrival his Glasgow Coma Scale score is 5/15 and he is therefore intubated. During primary resuscitation, a chest film is taken which shows a widened mediastinum and right-sided deviation of the trachea. What is the most likely diagnosis?

Aortic rupture. ### Explanation **Correct Answer: D. Aortic Rupture** The clinical presentation of a high-energy mechanism (fall from height) combined with specific radiological findings—**widened mediastinum** (>8 cm at the level of the sternal angle) and **right-sided deviation of the trachea**—is a classic triad for **Traumatic Aortic Disruption (Aortic Rupture)**. In blunt trauma, the aorta is most commonly injured at the **isthmus** (just distal to the origin of the left subclavian artery) due to tethering by the ligamentum arteriosum, leading to deceleration injury. The hematoma surrounding the injury site displaces the trachea and esophagus to the right and depresses the left mainstem bronchus. **Why other options are incorrect:** * **Ruptured Esophagus:** While it can cause pneumomediastinum or a widened mediastinum, it is rare in blunt trauma and typically presents with surgical emphysema or pleural effusion (Boerhaave syndrome). * **Cardiac Tamponade:** This is a clinical diagnosis (Beck’s Triad: hypotension, JVP distension, muffled heart sounds). Radiologically, it may show a "water bottle" heart, but it does not typically cause tracheal deviation or significant mediastinal widening in the acute setting. * **Right Lobe Collapse:** This would cause tracheal deviation *towards* the side of collapse (ipsilateral), not away from it, and would show increased opacity of the affected lung field rather than mediastinal widening. **NEET-PG High-Yield Pearls:** * **Most common site of aortic injury:** Aortic Isthmus (90%). * **Gold Standard Investigation:** CT Angiography (CTA) is the investigation of choice in stable patients. * **Chest X-ray signs of Aortic Rupture:** 1. Widened mediastinum (>8 cm). 2. Obliteration of the aortic knob. 3. Deviation of the trachea/esophagus/NG tube to the right. 4. Depression of the left mainstem bronchus (>140°). 5. Left apical pleural cap (extrapleural blood).

Q: A patient admitted to the casualty department after a road traffic accident shows bruising behind the mastoid. This sign is known as?

Battle sign. **Explanation:** The correct answer is **Battle sign**. This clinical sign refers to ecchymosis (bruising) over the mastoid process, caused by the extravasation of blood along the path of the posterior auricular artery. **1. Why Battle Sign is Correct:** Battle sign is a classic clinical indicator of a **Basilar Skull Fracture**, specifically involving the **petrous portion of the temporal bone**. It typically appears 1–3 days after the initial trauma. When the skull base fractures, blood tracks through the tissue planes to the retroauricular area. **2. Analysis of Incorrect Options:** * **Prehn sign:** Used in urology to differentiate between acute epididymitis and testicular torsion. A "positive" Prehn sign occurs when physical lifting of the testicles relieves pain (suggestive of epididymitis). * **Catel sign:** (Often confused with Cattell-Braasch maneuver) There is no standard "Catel sign" in trauma surgery; however, the Cattell-Braasch maneuver is a surgical technique for medial visceral rotation to expose the retroperitoneum. * **Dietl’s crisis/sign:** Refers to severe episodic renal pain caused by acute hydronephrosis, often due to a kinking of the ureter in patients with a mobile (wandering) kidney. **3. NEET-PG High-Yield Pearls for Basilar Skull Fracture:** * **Raccoon Eyes (Panda Sign):** Periorbital ecchymosis indicating a fracture of the **anterior cranial fossa**. * **CSF Otorrhea/Rhinorrhea:** Leakage of clear fluid; confirm with the **"Halo sign"** on gauze or by testing for **Beta-2 transferrin** (most specific). * **Hemotympanum:** Blood behind the tympanic membrane. * **Management:** Most are managed conservatively; avoid nasogastric (NG) tubes as they may inadvertently enter the cranial vault.

Q: What is the most important aspect of management of burn injury in the first 24 hours?

Fluid resuscitation. **Explanation:** The primary goal in the management of major burns during the first 24 hours (the **emergent phase**) is the prevention and treatment of **hypovolemic (burn) shock**. Burn injuries lead to a massive systemic inflammatory response, causing increased capillary permeability and "third-spacing" of fluids. This results in a rapid depletion of intravascular volume. Therefore, **Fluid Resuscitation** is the most critical intervention to maintain organ perfusion and prevent acute kidney injury. **Why other options are incorrect:** * **Dressing:** While important for wound care and preventing heat loss, it is secondary to hemodynamic stabilization. * **Escharotomy:** This is a life- or limb-saving procedure indicated only in circumferential full-thickness burns causing compartment syndrome or respiratory compromise. It is not the "most important" general management step for all burn patients. * **Antibiotics:** Prophylactic systemic antibiotics are **not recommended** in the early management of burns as they do not prevent wound sepsis and may promote the growth of resistant organisms. **High-Yield Clinical Pearls for NEET-PG:** * **Parkland Formula:** The gold standard for fluid calculation in the first 24 hours is **4 mL × Body Weight (kg) × % TBSA** (Total Body Surface Area). * **Fluid Choice:** **Ringer’s Lactate** is the fluid of choice. * **Timing:** Half of the calculated fluid is given in the first 8 hours (from the time of injury), and the remaining half over the next 16 hours. * **Monitoring:** The most reliable indicator of adequate fluid resuscitation is **Urinary Output** (Target: 0.5–1.0 mL/kg/hr in adults).

Q: A 40-year-old man presents to the emergency department one hour after a motor vehicle accident with severe maxillofacial trauma. His pulse rate is 120/min, BP is 100/70 mm Hg, and SpO2 is 80% on oxygen. What is the immediate management?

Orotracheal intubation. **Explanation:** The primary objective in trauma management follows the **ABC (Airway, Breathing, Circulation)** protocol. This patient presents with severe maxillofacial trauma and respiratory distress (SpO2 80%), indicating an immediate need for a definitive airway. **1. Why Orotracheal Intubation is correct:** In the emergency setting, **Orotracheal intubation** is the preferred method for establishing a definitive airway. Despite the maxillofacial trauma, it is faster and more reliable than surgical options. It allows for direct visualization (often with the aid of a video laryngoscope or manual in-line stabilization if a cervical spine injury is suspected) and immediate ventilation to correct hypoxia. **2. Why other options are incorrect:** * **Nasotracheal intubation:** This is **contraindicated** in severe maxillofacial or suspected basilar skull fractures (e.g., Le Fort II/III) due to the risk of accidental intracranial tube placement through a fractured cribriform plate. * **Intravenous fluid resuscitation:** While the patient is tachycardic and potentially hypotensive (Circulation), the immediate life-threat is the airway and hypoxia (SpO2 80%). Airway management always takes precedence over fluid resuscitation in the ABC sequence. * **Tracheostomy:** This is a time-consuming surgical procedure and is not the first-line "immediate" management. If orotracheal intubation fails, a **Cricothyroidotomy** is the preferred emergency surgical airway, not a tracheostomy. **Clinical Pearls for NEET-PG:** * **Definitive Airway:** Defined as a cuffed tube in the trachea (Orotracheal, Nasotracheal, or Surgical). * **Golden Rule:** In trauma, always assume a cervical spine injury; perform intubation with **Manual In-Line Stabilization (MILS)**. * **Hard Signs for Airway Intervention:** Apnea, GCS ≤ 8, severe maxillofacial fractures, or impending airway obstruction (stridor/hematoma).

Q: What is the most common complication following blunt injury to the thorax?

Rib fracture. **Explanation:** **1. Why Rib Fracture is the Correct Answer:** Rib fractures are the **most common injury** identified following blunt thoracic trauma, occurring in approximately 50% of patients admitted for chest injuries. They serve as a primary indicator of the severity of the impact. In clinical practice, the 4th through 9th ribs are most frequently involved because they are relatively thin and less protected by overlying musculature compared to the upper ribs. **2. Analysis of Incorrect Options:** * **A. Pneumothorax:** While common, it is usually a *consequence* of a rib fracture (where a jagged bone end punctures the lung) or sudden barotrauma. It occurs less frequently than the fractures themselves. * **C. Haemopneumothorax:** This represents a combination of air and blood in the pleural space. While a significant finding in trauma, it is statistically less common than isolated rib fractures. * **D. Aortic Rupture:** This is the most common cause of **immediate death** at the scene of high-velocity blunt trauma (e.g., deceleration injuries), but it is a relatively rare occurrence compared to the high incidence of rib fractures. **3. NEET-PG High-Yield Pearls:** * **Most common rib fractured:** 4th to 9th ribs. * **First and Second Rib Fractures:** Indicate high-energy trauma; always screen for associated injuries to the brachial plexus or subclavian vessels. * **Lower Rib Fractures (10th–12th):** High index of suspicion for **liver** (right side) or **spleen** (left side) injuries. * **Flail Chest:** Defined as $\geq$ 3 ribs fractured in $\geq$ 2 places; characterized by **paradoxical respiration**. * **Management:** The mainstay of treatment for simple rib fractures is **adequate analgesia** (to prevent splinting and subsequent pneumonia) and aggressive pulmonary toilet.

Q: A 70-year-old man presents after a motor vehicle accident with a fractured left rib and right femur. Abdominal CT reveals a left retroperitoneal hematoma adjacent to the left kidney, with no urine extravasation. How should this hematoma be managed?

Observation. **Explanation:** The management of retroperitoneal hematomas (RPH) is determined by the mechanism of injury (blunt vs. penetrating) and the anatomical zone involved. This patient has a **Zone 2 retroperitoneal hematoma** (perinephric/flank) following blunt trauma. **1. Why Observation is Correct:** In blunt trauma, Zone 2 hematomas are managed **conservatively (observation)** if the patient is hemodynamically stable and there is no evidence of expanding hematoma or major renal pedicle injury. The CT scan confirms no urine extravasation (ruling out significant ureteral/pelvic injury) and the hematoma is contained. Most blunt renal injuries are Grade I-III and resolve without intervention. **2. Why Incorrect Options are Wrong:** * **B & D (Surgical Exploration):** In blunt trauma, Zone 2 hematomas are only explored if they are rapidly expanding, pulsatile, or associated with hemodynamic instability. Routine exploration often leads to unnecessary nephrectomies. Flank approaches (Option D) are generally avoided in trauma as they do not allow for full abdominal inspection. * **C (CT-guided aspiration):** This is not indicated in the acute setting. Aspiration carries a risk of introducing infection (converting a hematoma into an abscess) and does not address the underlying injury. **NEET-PG High-Yield Pearls:** * **Zone 1 (Central/Midline):** Contains the aorta and IVC. **Always explore** in both blunt and penetrating trauma. * **Zone 2 (Flank/Perinephric):** Contains kidneys and adrenals. Explore in **penetrating** trauma; **observe** in blunt trauma (unless unstable). * **Zone 3 (Pelvic):** Associated with pelvic fractures. **Never explore** (unless expanding); management involves pelvic binding or angioembolization. * **The "Mattox Maneuver":** Left-sided medial visceral rotation to expose Zone 1 and 2 structures.

Question 1

A 70 kg female has 50% burns and an inhalation burn injury. What is the fluid requirement in the first 8 hours according to the Parkland formula?

Accepted Answer

875 ml/hr

Answer

625 ml/hr

Answer

732 ml/hr

Answer

1000 ml/hr

Question 2

A male patient is admitted following a fall from height. On arrival his Glasgow Coma Scale score is 5/15 and he is therefore intubated. During primary resuscitation, a chest film is taken which shows a widened mediastinum and right-sided deviation of the trachea. What is the most likely diagnosis?

Accepted Answer

Aortic rupture

Answer

Ruptured esophagus

Answer

Cardiac tamponade

Answer

Right lobe collapse

Question 3

A man presented with fractures of 4th to 10th ribs and respiratory distress after a Road Traffic Accident. He is diagnosed to have flail chest. What is the recommended management?

Accepted Answer

IPPV with oral intubation

Answer

Tracheostomy

Answer

Fixation of ribs

Answer

Strapping of chest

Question 4

A patient admitted to the casualty department after a road traffic accident shows bruising behind the mastoid. This sign is known as?

Accepted Answer

Battle sign

Answer

Prehn sign

Answer

Catel sign

Answer

Dietel's sign

Question 5

What is the most important aspect of management of burn injury in the first 24 hours?

Accepted Answer

Fluid resuscitation

Answer

Dressing

Answer

Escharotomy

Answer

Antibiotics

Question 6

A 40-year-old man presents to the emergency department one hour after a motor vehicle accident with severe maxillofacial trauma. His pulse rate is 120/min, BP is 100/70 mm Hg, and SpO2 is 80% on oxygen. What is the immediate management?

Accepted Answer

Orotracheal intubation

Answer

Nasotracheal intubation

Answer

Intravenous fluid resuscitation

Answer

Tracheostomy

Question 7

In a trauma patient experiencing shock, an initial 500ml infusion of normal saline over 5-10 minutes resulted in a temporary blood pressure improvement that lasted only 15 minutes before it began to fall again. What is your inference?

Accepted Answer

The patient has moderate ongoing fluid loss.

Answer

The patient has major ongoing fluid loss.

Answer

The patient is not actively losing fluid but requires volume replacement to achieve normal status.

Answer

The patient is experiencing fluid overload, which has precipitated further shock.

Question 8

A 50-year-old chronic alcoholic, while having dinner, suddenly becomes aphonic and presents with respiratory distress. What is the immediate management?

Accepted Answer

Heimlich maneuver

Answer

Cricothyroidotomy

Answer

Emergency tracheostomy

Answer

Humidified oxygen

Question 9

What is the most common complication following blunt injury to the thorax?

Accepted Answer

Rib fracture

Answer

Pneumothorax

Answer

Haemopneumothorax

Answer

Aortic rupture

Question 10

A 70-year-old man presents after a motor vehicle accident with a fractured left rib and right femur. Abdominal CT reveals a left retroperitoneal hematoma adjacent to the left kidney, with no urine extravasation. How should this hematoma be managed?

Accepted Answer

Observation

Answer

Exploratory laparotomy through a midline incision

Answer

CT-guided aspiration

Answer

Surgical exploration through a left-flank retroperitoneal approach

Trauma — MCQs

Trauma — MCQs

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