Trauma Practice Questions

Q: Which one of the following statements is not true regarding the Glasgow Coma Scale?

All of the above statements are true.. The **Glasgow Coma Scale (GCS)** is a standardized clinical tool used to assess the level of consciousness in patients with head injuries or acute neurological insults. It evaluates three specific parameters: **Eye Opening (E)**, **Verbal Response (V)**, and **Motor Response (M)**. ### Explanation of Options: * **Option A (Scores range from 3 to 15):** This is **true**. The minimum score for any individual component is 1, and the maximum total score is 15 (E4 + V5 + M6). A score of 0 is impossible; even a brain-dead patient scores a 3. * **Option B (Motor response maximum 6 points):** This is **true**. The motor component (M) is scored from 1 (no response) to 6 (obeys commands). It is considered the most reliable predictor of outcome. * **Option C (Eye opening maximum 4 points):** This is **true**. Eye opening (E) is scored from 1 (none) to 4 (spontaneous). * **Option D (Correct Answer):** Since all the individual statements (A, B, and C) accurately describe the components and scoring of the GCS, this is the correct choice. ### High-Yield Clinical Pearls for NEET-PG: * **Mnemonic (EVM 456):** Eye = 4, Verbal = 5, Motor = 6. * **Severity Classification:** * **GCS 13–15:** Mild Head Injury. * **GCS 9–12:** Moderate Head Injury. * **GCS ≤ 8:** Severe Head Injury (Indicative of Coma; "GCS of 8, Intubate"). * **Modified GCS:** If a patient is intubated, the Verbal score is recorded as **'T'** (e.g., GCS 10T). * **GCS-P:** A newer variant that includes **Pupillary reactivity** (GCS score minus number of non-reactive pupils).

Q: A Grade 2 burn indicates involvement of which layer of the skin?

Dermis. ### Explanation The classification of burns is based on the **depth of tissue destruction**. A **Grade 2 (Partial-thickness)** burn involves the entire epidermis and extends into the underlying **dermis**. * **Why Dermis is Correct:** Grade 2 burns are subdivided into superficial and deep partial-thickness. Superficial partial-thickness burns involve the papillary dermis and are characterized by painful blisters. Deep partial-thickness burns involve the reticular dermis; these may appear waxy white and have reduced sensation. Because the dermis contains sensory nerve endings and microvasculature, these burns are typically very painful and show blanching. **Analysis of Incorrect Options:** * **A. Epidermis:** This corresponds to a **Grade 1 (Superficial)** burn. A classic example is a sunburn. It involves only the outermost layer, presenting with erythema and pain but no blisters. * **C. Subcutaneous tissue:** This corresponds to a **Grade 3 (Full-thickness)** burn. The destruction extends through the entire dermis into the subcutaneous fat. These burns are leathery (eschar), non-blanching, and painless due to the destruction of nerve endings. * **D. Deep fascia:** This corresponds to a **Grade 4** burn. These are deep injuries involving underlying structures like fascia, muscle, or bone, often seen in high-voltage electrical injuries. **High-Yield Clinical Pearls for NEET-PG:** 1. **Wallace Rule of Nines:** Used to estimate Total Body Surface Area (TBSA) in adults. Note that the head is 9% in adults but 18% in infants. 2. **Parkland Formula:** $4 \text{ ml} \times \text{kg body weight} \times \% \text{ TBSA}$. Give half in the first 8 hours and the remainder over the next 16 hours. 3. **Fluid of Choice:** Ringer’s Lactate is the preferred crystalloid for resuscitation. 4. **Pain Paradox:** Grade 1 and 2 burns are highly painful; Grade 3 burns are anesthetic (painless).

Q: Flail chest means fracture of:

Four ribs on two sides. ### Explanation **Concept and Definition** Flail chest is a clinical diagnosis defined by the fracture of **two or more adjacent ribs** in **two or more places** along their length. This creates a "flail segment"—a portion of the chest wall that is no longer in bony continuity with the rest of the thoracic cage. This segment moves **paradoxically**: it sucks inward during inspiration (due to negative intrathoracic pressure) and bulges outward during expiration. **Why Option C is Correct** Option C ("Four ribs on two sides") is the most accurate description among the choices because it fulfills the criteria of multiple fractures per rib. If four ribs are fractured at two different sites (sides) each, it creates a large, unstable segment that results in the classic clinical presentation of flail chest. **Analysis of Incorrect Options** * **Option A & B:** A single fracture in two ribs (whether on the same or opposite sides) does not create a free-floating segment. The chest wall remains stable. * **Option D:** While fracturing all ribs would certainly cause instability, it is not the minimum definition required for the diagnosis. **Clinical Pearls for NEET-PG** * **Primary Pathology:** The main cause of respiratory failure in flail chest is not the paradoxical movement itself, but the underlying **Pulmonary Contusion**. * **Management:** The mainstay of treatment is **adequate analgesia** (often epidural) and aggressive pulmonary toilet. Mechanical ventilation is reserved for patients with respiratory failure, not for "internal splinting" of the fractures. * **Associated Findings:** Always look for associated injuries like hemothorax or pneumothorax. * **Radiology:** Flail chest is a **clinical diagnosis**, though X-rays or CT scans are used to confirm the number and location of fractures.

Q: For the evaluation of blunt abdominal trauma, which of the following imaging modalities is ideal?

Computed tomography. In blunt abdominal trauma (BAT), **Computed Tomography (CT) with IV contrast** is the gold standard and the imaging modality of choice for hemodynamically stable patients. ### Why CT is the Correct Answer: * **Superior Sensitivity and Specificity:** CT is highly accurate in identifying and grading solid organ injuries (liver, spleen, kidneys) and detecting hemoperitoneum. * **Retroperitoneal Evaluation:** Unlike ultrasound, CT can reliably visualize the retroperitoneum, including the pancreas, duodenum, and major vessels. * **Hollow Viscus Injury:** It is the most sensitive tool for detecting signs of bowel injury (e.g., wall thickening, free air, or mesenteric hematoma). * **Whole-Body Imaging:** In polytrauma, CT allows for a "Pan-scan" to evaluate the head, chest, and pelvis simultaneously. ### Why Other Options are Incorrect: * **A. Ultrasonography:** While **FAST (Focused Assessment with Sonography for Trauma)** is the initial screening tool for hemodynamically unstable patients, it cannot grade organ injuries or reliably detect retroperitoneal pathology. * **C. Nuclear Scintigraphy:** This is too time-consuming and lacks the anatomical detail required for acute trauma management. * **D. Magnetic Resonance Imaging:** MRI is contraindicated in emergency settings due to long scan times, difficulty in monitoring unstable patients, and incompatibility with metallic life-support equipment. ### High-Yield Clinical Pearls for NEET-PG: * **Hemodynamically Unstable + Positive FAST:** Proceed directly to **Laparotomy**. * **Hemodynamically Stable:** **CECT (Contrast-Enhanced CT)** is the investigation of choice. * **CT "Shock Bowel":** Look for diffuse small bowel wall thickening and hyper-enhancement, indicating hypovolemic shock. * **Splenic Injury:** The spleen is the most commonly injured organ in blunt abdominal trauma.

Q: Which of the following are signs of tentorial herniation?

All of the above. Tentorial herniation (specifically central or uncal herniation) occurs when increased intracranial pressure (ICP) forces brain tissue through the tentorial notch [2], [3]. This leads to the compression of vital brainstem structures and cranial nerves, manifesting in the signs listed. * **Sunset Sign:** This refers to the downward deviation of the eyes where the iris is partially covered by the lower eyelid. It occurs due to pressure on the midbrain tectum (specifically the superior colliculi) and is a classic sign of increased ICP and obstructive hydrocephalus. * **Sixth Nerve Palsy:** The Abducens nerve (CN VI) has a long intracranial course. Increased ICP causes the nerve to be stretched against the petrous part of the temporal bone or compressed during herniation, leading to lateral rectus palsy (false localizing sign) [2]. * **Decerebrate Rigidity:** As herniation progresses, it causes midbrain and upper pontine dysfunction. This results in an abnormal posturing characterized by extension of the elbows and knees, internal rotation of the shoulders, and plantar flexion, indicating severe brainstem distress [1]. **High-Yield Clinical Pearls for NEET-PG:** * **Uncal Herniation Triad:** Ipsilateral dilated pupil (CN III compression), contralateral hemiparesis (compression of the cerebral peduncle), and deteriorating consciousness [1], [2]. * **Kernohan’s Notch Phenomenon:** A paradoxical sign where the herniating uncus displaces the brainstem, compressing the *opposite* cerebral peduncle, resulting in **ipsilateral** hemiparesis [2]. * **Cushing’s Triad:** Hypertension, bradycardia, and irregular respirations—a late sign of impending herniation [2].

Q: Which IV fluid should not be used in a patient with head injury?

5% Dextrose. In neurotrauma management, the primary goal is to maintain cerebral perfusion pressure and prevent secondary brain injury caused by **cerebral edema**. ### Why 5% Dextrose is Contraindicated 5% Dextrose is an **isostonic-in-the-bag** but **hypotonic-in-the-body** solution. Once infused, the glucose is rapidly metabolized by the liver, leaving behind "free water." This free water moves from the intravascular space into the brain cells (intracellular space) via osmosis, significantly worsening **cerebral edema** and increasing intracranial pressure (ICP). Furthermore, hyperglycemia in the setting of acute brain injury can exacerbate neuronal damage through lactic acidosis. ### Analysis of Other Options * **Normal Saline (0.9% NaCl):** This is an **isotonic** crystalloid and the fluid of choice in head injuries. It stays within the extracellular compartment, maintaining blood pressure without causing brain cell swelling. * **Dextrose Normal Saline (DNS):** While it contains dextrose, the presence of 0.9% NaCl makes it hypertonic/isotonic enough to prevent the massive fluid shift seen with pure 5% Dextrose. However, it is still generally avoided unless the patient is hypoglycemic. ### NEET-PG High-Yield Pearls * **Fluid of Choice in Head Injury:** Normal Saline (0.9% NaCl) or Ringer's Lactate (though some prefer NS as RL is slightly hypotonic). * **Hypertonic Saline (3%):** Used specifically to reduce ICP in cases of cerebral edema or herniation. * **Avoid Hypotonic Fluids:** Never use 0.45% NS or 5% Dextrose in neuro-surgical patients. * **Target:** Maintain **Euvolemia** and avoid hypotension (SBP >100-110 mmHg) to ensure adequate Cerebral Perfusion Pressure (CPP).

Q: What is true regarding a second-degree deep burn?

Dry white color. **Explanation:** Burns are classified based on the depth of tissue involvement. A **second-degree deep partial-thickness burn** extends into the deeper layers of the dermis (reticular dermis), damaging hair follicles and sweat glands. **Why "Dry white color" is correct:** In deep second-degree burns, the damage to the dermal vasculature is significant. The destruction of the superficial capillary plexus leads to a lack of perfusion, resulting in a **waxy white or mottled appearance**. Unlike superficial burns, these are often **dry** because the sweat glands and sebaceous units are compromised. **Analysis of Incorrect Options:** * **A & B (Blanches on pressure / Erythema):** These are hallmarks of **First-degree** or **Superficial Second-degree** burns. In deep burns, the capillary refill is absent because the dermal vessels are thrombosed. * **D (Painless):** While deep second-degree burns have decreased sensation (hypoalgesia) due to damage to nerve endings, they are typically **painful to deep pressure**. A completely **painless** (anesthetic) wound is characteristic of a **Third-degree (Full-thickness)** burn. **NEET-PG High-Yield Pearls:** * **Superficial 2nd Degree:** Characterized by **blisters**, extreme pain, and brisk capillary refill. * **Deep 2nd Degree:** Characterized by a **cheesy white** appearance and takes >3 weeks to heal, often requiring skin grafting to prevent hypertrophic scarring. * **Jackson’s Burn Zones:** The **Zone of Stasis** is the critical area surrounding the central necrosis that can either recover or progress to deeper injury depending on resuscitation. * **Gold Standard for Depth:** Laser Doppler Imaging (LDI) is the most accurate tool to assess burn depth clinically.

Question 1

How should a displaced mandibular fracture in a child be managed?

Accepted Answer

Early mobilization

Answer

Circum mandibular wiring

Answer

Intermaxillary fixation

Answer

Transosseous wiring

Question 2

Which one of the following statements is not true regarding the Glasgow Coma Scale?

Accepted Answer

All of the above statements are true.

Answer

Scores range from 3 to 15.

Answer

The motor response component has a maximum of 6 points.

Answer

The eye opening component has a maximum of 4 points.

Question 3

A 60-year-old man presents to the emergency department following an accident with engorged neck veins, pallor, and a rapid pulse. He has muffled heart sounds. What is the likely diagnosis?

Accepted Answer

Aortic dissection

Answer

Cardiac tamponade

Answer

Pneumothorax

Answer

Diaphragmatic rupture

Question 4

A Grade 2 burn indicates involvement of which layer of the skin?

Accepted Answer

Dermis

Answer

Epidermis

Answer

Subcutaneous tissue

Answer

Deep fascia

Question 5

Flail chest means fracture of:

Accepted Answer

Four ribs on two sides

Answer

Two ribs on the same side

Answer

Two ribs on opposite sides

Answer

All ribs

Question 6

For the evaluation of blunt abdominal trauma, which of the following imaging modalities is ideal?

Accepted Answer

Computed tomography

Answer

Ultrasonography

Answer

Nuclear scintigraphy

Answer

Magnetic resonance imaging

Question 7

Which of the following are signs of tentorial herniation?

Accepted Answer

All of the above

Answer

Sunset sign

Answer

Sixth nerve palsy

Answer

Decerebrate rigidity

Question 8

Which IV fluid should not be used in a patient with head injury?

Accepted Answer

5% Dextrose

Answer

Normal saline

Answer

Dextrose normal saline

Answer

All of the above

Question 9

A patient with burns dies within 24 hours. What is the most probable cause?

Accepted Answer

Physical burn injury to the airways above the larynx

Answer

Circulatory shock

Answer

Physical burn injury to the airways below the larynx

Answer

Circumferential burn

Question 10

What is true regarding a second-degree deep burn?

Accepted Answer

Dry white color

Answer

Blanches on pressure

Answer

Erythema

Answer

Painless

Trauma — MCQs

Trauma — MCQs

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