Trauma Practice Questions

Q: In a patient of head injury, the following sign is noted on his handkerchief. Which is the next test to confirm the diagnosis? (AIIMS Nov 2017)

Beta trace protein. ***Beta trace protein*** - The image shows a "double ring" or "halo" sign, where blood spreads in a central area and is surrounded by a clear ring of fluid, indicating the presence of **cerebrospinal fluid (CSF) mixed with blood**. - **Beta trace protein (BTP)**, also known as protoprostaglandin D synthase, is a specific and sensitive marker for the detection of CSF leakage, differentiating it from other body fluids. *Beta 2 micro-globulin* - **Beta 2 micro-globulin** is a protein found on the surface of most nucleated cells and is elevated in various conditions like renal failure, inflammatory diseases, and lymphomas. - While it can be present in CSF, it is not a specific marker for CSF leakage and can be influenced by other factors. *Beta amyloid* - **Beta amyloid** is a protein primarily associated with Alzheimer's disease, forming plaques in the brain. - Its detection is used in the diagnosis and research of neurodegenerative disorders, not acute CSF leaks after head injury. *Beta glucuronidase* - **Beta glucuronidase** is a lysosomal enzyme found in various tissues and bodily fluids. - It is associated with conditions like bacterial vaginosis or urinary tract infections, and it is not a recognized marker for CSF leakage.

Q: A 62-year-old diabetic female patient presented with history of progressive right sided weakness of a month duration. The patient also had speech difficulty. Fundus examination showed papilledema. 2 months ago she also had a fall in her bathroom and struck her head against the wall. The most like diagnosis based on the image given below could be?

Left chronic subdural hematoma. ***Left chronic subdural hematoma*** - The CT image shows a **crescent-shaped, hypodense collection** along the left convexity, consistent with a **chronic subdural hematoma**. The arrow points to this collection, which is typically found between the dura mater and arachnoid mater. - The patient's history of a fall 2 months prior, progressive neurological symptoms (right-sided weakness, speech difficulty), and **papilledema** (indicating increased intracranial pressure) are all highly suggestive of a chronic subdural hematoma. *Alzheimer's* - Alzheimer's disease is a **neurodegenerative disorder** characterized by progressive cognitive decline, memory loss, and behavioral changes. - While it causes progressive neurological symptoms, it does not typically present with acute or subacute focal neurological deficits like **right-sided weakness or papilledema**, nor would it be directly linked to a fall 2 months prior with the imaging findings. *Left parietal glioma* - A left parietal glioma is a **brain tumor** that could cause focal neurological deficits like right-sided weakness and speech difficulty, and can lead to increased intracranial pressure and papilledema. - However, the image shows a **crescent-shaped fluid collection** rather than an intra-axial mass lesion, making glioma unlikely. A glioma would appear as a solid or cystic mass within the brain parenchyma. *Left MCA territory stroke* - An **ischemic stroke** in the left middle cerebral artery (MCA) territory would cause acute onset of right-sided weakness and speech difficulty (aphasia). - However, the acute onset (usually within minutes to hours), and the CT image would typically show an area of **hypodensity within the brain parenchyma** reflecting ischemic changes, not a crescent-shaped extra-axial collection. Papilledema is also not a common acute finding in stroke.

Q: A 25 -year-old patient presents in coma with GCS of 5 and extensor posturing after a bike accident. Which of the following will be the best immediate management of the patient?

Burr hole surgery. **Correct: Burr hole surgery** - The patient's presentation with a **GCS of 5** and **extensor posturing** after a bike accident, along with the CT scan showing a significant **epidural hematoma** (lenticular shape, commonly associated with middle meningeal artery bleed), indicates severe **intracranial pressure (ICP)** and impending herniation. - **Burr hole surgery** or **craniotomy** is indicated for urgent decompression of the brain by evacuating the hematoma, which can be life-saving in cases of acute epidural hematoma. *Incorrect: Hypertonic saline* - While **hypertonic saline** can temporarily reduce **intracranial pressure (ICP)** by drawing fluid out of the brain cells, it is a temporizing measure. - It does not address the underlying mass effect caused by the large hematoma, which requires surgical evacuation. *Incorrect: Thrombolysis* - **Thrombolysis** is used to dissolve blood clots in cases of **ischemic stroke** but is contraindicated in the presence of a **hemorrhagic stroke** or **traumatic intracranial bleeding** as it would worsen the hemorrhage. - The imaging clearly shows a hematoma, not an ischemic event. *Incorrect: Pentobarbital coma* - A **pentobarbital coma** is used to reduce cerebral metabolic demand and blood flow, thereby lowering **intracranial pressure (ICP)** in severe cases of **intracranial hypertension** refractory to other measures. - However, in the presence of a large, surgically accessible hematoma causing mass effect, **surgical evacuation** is the primary treatment, not a pharmacological coma.

Q: Which of the following regions marked in the picture represents zone 4 of retroperitoneal hemorrhage? (AIIMS Nov 2016)

D. ***D*** - **Line D marks the superior border of Zone 4** (pelvic retroperitoneum), thereby indicating and identifying the location of Zone 4 in the retroperitoneal classification system. - Zone 4 encompasses the **pelvic retroperitoneum** below this line, which includes the **bladder**, **rectum**, **reproductive organs**, and the major **iliac vessels**. - Retroperitoneal hemorrhage in Zone 4 is typically associated with **pelvic fractures** and injuries to the **iliac vessels** or their branches. - In retroperitoneal trauma classification, identifying the boundaries between zones is crucial for surgical decision-making and management approach. *A* - Line A marks the boundary between the **suprarenal zone (Zone 1)** and the **perirenal zone (Zone 2)**. - This region involves structures like the kidneys, adrenal glands, and major vessels such as the renal arteries and veins. - Hemorrhage here would be classified as suprarenal or perirenal, not pelvic. *B* - Line B points to the superior limit of the **suprarenal zone (Zone 1)**, which lies just inferior to the diaphragm. - This zone contains the **suprarenal glands** and the **superior poles of the kidneys**, along with the great vessels (aorta and IVC). - Injuries here affect structures high in the retroperitoneum, distinct from the pelvic region. *C* - Line C indicates a lateral or anterior boundary of the **perirenal space (Zone 2)**. - Zone 2 primarily contains the **kidneys**, **ureters**, and **adrenal glands** within the perirenal fascia (Gerota's fascia). - This represents the mid-abdominal retroperitoneum, not the pelvic retroperitoneum.

Q: Which is the best method to secure airway and administer oxygen in case of burns shown below?

Elective intubation. ***Elective intubation*** - The image shows **severe facial burns** consistent with potential **inhalation injury**, which can lead to rapid **airway edema and obstruction**. Elective intubation is critical to secure the airway *before* it becomes impossible to intubate due to swelling. - Signs of inhalation injury, such as **sooty sputum**, **facial burns**, and **singed nasal hairs**, warrant aggressive airway management. *Mask* - Using a mask for oxygen delivery provides only a **low flow of oxygen** and does not secure the airway, which is crucial in cases of severe facial burns and suspected inhalation injury. - A mask will not prevent **airway swelling and obstruction**, which can rapidly worsen in burn patients. *Nasal prongs* - Nasal prongs are a **low-flow oxygen delivery system** and are entirely inadequate for patients with severe burns, especially when airway compromise is a significant risk. - They also would not address the impending **airway edema** associated with facial and inhalation burns. *Tracheostomy* - A tracheostomy is a **surgical airway** procedure that is more invasive and typically reserved for situations where endotracheal intubation is either impossible or long-term airway support is required. - While it provides a secure airway, **elective intubation** is the preferred initial approach because it is less invasive and can be performed more rapidly in an emergency setting.

Q: A soldier was airlifted from Siachen glacier after being trapped in an avalanche. All of the following are done in this condition except:

Slow rewarming. ***Slow rewarming*** - **Slow rewarming is NOT recommended** for frostbite management and is the practice that should be avoided. - Slow rewarming extends the period of tissue ischemia and leads to worse outcomes, including greater tissue damage and necrosis. - It is associated with increased intracellular ice crystal formation and progressive endothelial damage. - **This is the correct answer** to what is NOT done in frostbite management. *Rapid rewarming* - **Rapid rewarming** is the gold standard treatment for frostbite. - The affected extremity should be immersed in warm water (37-39°C/98.6-102.2°F) for 15-30 minutes. - This promotes faster tissue reperfusion and reduces the duration of ischemic injury, minimizing tissue loss. *Analgesia* - **Analgesia** is essential in frostbite management as the rewarming process is extremely painful. - Opioid analgesics are often required due to the severe pain from rapid blood flow return to ischemic tissues. - Adequate pain control improves patient comfort and compliance with treatment. *Surgery to be postponed till demarcation appears* - **Surgical intervention** (debridement or amputation) should be delayed until clear demarcation between viable and non-viable tissue appears. - This process typically takes several weeks to months. - The principle is "frozen in January, amputate in July" - early surgery risks removing viable tissue.

Q: A 28-year-old male is brought to the emergency department following a road traffic accident with left-sided chest pain and breathlessness. On examination, there is decreased air entry on the left side and tracheal deviation to the right. Heart sounds are normal. The chest X-ray is shown below. What is the most appropriate immediate management?

Chest tube insertion. ***Chest tube insertion*** - The clinical presentation of **decreased air entry on the left side** and **tracheal deviation to the right** following trauma indicates a **tension hemothorax** requiring immediate chest tube insertion for decompression and drainage. - **Chest tube insertion** is the **immediate first-line management** for hemothorax in trauma patients - it rapidly drains blood, relieves compression, and prevents hemodynamic compromise. *Needle aspiration* - Needle aspiration is the immediate management for **tension pneumothorax**, not hemothorax where blood accumulation requires drainage through a larger bore tube. - A needle cannot adequately drain the **viscous blood** that accumulates in hemothorax, making it ineffective for this condition. *Pericardiocentesis* - Pericardiocentesis is indicated for **cardiac tamponade** which presents with **Beck's triad** (hypotension, elevated JVP, muffled heart sounds). - This patient has **normal heart sounds** and the clinical findings point to pleural pathology, not pericardial involvement. *Immediate thoracotomy* - Emergency thoracotomy is reserved for **massive hemothorax** with >1500 mL immediate drainage or >200 mL/hr ongoing loss after chest tube insertion. - It is not the **immediate first-line management** - chest tube insertion must be attempted first to assess the severity and ongoing blood loss.

Q: A 25-year-old patient presents in coma with GCS of 5 and extensor posturing after a bike accident. CT head was performed. Which of the following will be the best management of the patient?

Burr hole surgery. ***Burr hole surgery*** - The CT scan shows a large **epidural hematoma (EDH)**, which is a neurosurgical emergency requiring rapid evacuation to relieve pressure on the brain. - A GCS of 5 with extensor posturing indicates severe neurological compromise with **brainstem compression** and critically elevated **intracranial pressure (ICP)**, requiring immediate surgical decompression. - Surgical indications for EDH include: **hematoma volume >30 mL**, **midline shift >5 mm**, or any EDH with neurological deterioration regardless of size. - Burr hole craniotomy or formal craniotomy is the definitive treatment, with choice depending on size and accessibility of the hematoma. *Hypertonic saline* - This medication is used to acutely reduce **intracranial pressure** by creating an osmotic gradient that draws fluid out of brain tissue. - It serves only as a **temporizing measure** during preparation for surgery or transport, not as definitive treatment for a large EDH requiring evacuation. - Medical management alone would be fatal in this scenario with such severe neurological compromise. *Thrombolysis* - **Thrombolysis** is used to dissolve blood clots in conditions like acute ischemic stroke or pulmonary embolism where the clot is causing vascular obstruction. - It is **absolutely contraindicated** in cases of intracranial hemorrhage or recent head trauma, as it would exacerbate bleeding and worsen outcome. - Using thrombolysis in this patient would likely be fatal. *Ventriculoperitoneal shunting* - This procedure is used to treat **chronic hydrocephalus** by diverting excess cerebrospinal fluid (CSF) from the brain ventricles to the peritoneal cavity for absorption. - While traumatic hydrocephalus can occur, it develops weeks after injury, not acutely. - The immediate life-threatening issue is the **space-occupying hematoma** causing mass effect and herniation, not CSF accumulation.

Question 1

In a patient of head injury, the following sign is noted on his handkerchief. Which is the next test to confirm the diagnosis? (AIIMS Nov 2017)

Accepted Answer

Beta trace protein

Answer

Beta 2 micro-globulin

Answer

Beta amyloid

Answer

Beta glucuronidase

Question 2

A 62-year-old diabetic female patient presented with history of progressive right sided weakness of a month duration. The patient also had speech difficulty. Fundus examination showed papilledema. 2 months ago she also had a fall in her bathroom and struck her head against the wall. The most like diagnosis based on the image given below could be?

Accepted Answer

Left chronic subdural hematoma

Answer

Alzheimer's

Answer

Left parietal glioma

Answer

Left MCA territory stroke

Question 3

A 25 -year-old patient presents in coma with GCS of 5 and extensor posturing after a bike accident. Which of the following will be the best immediate management of the patient?

Accepted Answer

Burr hole surgery

Answer

Hypertonic saline

Answer

Thrombolysis

Answer

Pentobarbital coma

Question 4

A 30-year-old young male who met with a road traffic accident was brought to trauma center. On admission his BP was 90/50 mmHg, pulse rate is 150/min, SpO₂ is 80% and GCS is 8. He has multiple injuries and FAST reveals presence of blood in all quadrants. He was operated upon and his postoperative pictures are given below. Which of the following options best describe these pictures? (AIIMS Nov 2016)

Accepted Answer

Damage control surgery and temporary mesh closure of abdomen

Answer

Midline laparotomy and meshplasty

Answer

Abdominothoracic surgery and abdominal zipping

Answer

Abdominoplasty and primary closure of abdomen

Question 5

Which of the following regions marked in the picture represents zone 4 of retroperitoneal hemorrhage? (AIIMS Nov 2016)

Accepted Answer

D

Answer

A

Answer

B

Answer

C

Question 6

Which is the best method to secure airway and administer oxygen in case of burns shown below?

Accepted Answer

Elective intubation

Answer

Mask

Answer

Nasal prongs

Answer

Tracheostomy

Question 7

A soldier was airlifted from Siachen glacier after being trapped in an avalanche. All of the following are done in this condition except:

Accepted Answer

Slow rewarming

Answer

Analgesia

Answer

Surgery to be postponed till demarcation appears

Answer

Rapid rewarming

Question 8

A 28-year-old male is brought to the emergency department following a road traffic accident with left-sided chest pain and breathlessness. On examination, there is decreased air entry on the left side and tracheal deviation to the right. Heart sounds are normal. The chest X-ray is shown below. What is the most appropriate immediate management?

Accepted Answer

Chest tube insertion

Answer

Needle aspiration

Answer

Pericardiocentesis

Answer

Immediate thoracotomy

Question 9

A mixed martial arts boxer lost his match by knockout. One week later, he is having daily headaches, vomiting and disorientation. On arrival in casualty $\mathrm{GCS}=7$ and fundus shows presence of papilledema. Urgent CT scan head shows?

Accepted Answer

Subdural bleed

Answer

Lobar bleeding

Answer

Intraparenchymal bleeding

Answer

Subarachnoid bleed

Question 10

A 25-year-old patient presents in coma with GCS of 5 and extensor posturing after a bike accident. CT head was performed. Which of the following will be the best management of the patient?

Accepted Answer

Burr hole surgery

Answer

Hypertonic saline

Answer

Thrombolysis

Answer

Ventriculoperitoneal shunting

Trauma — MCQs

Trauma — MCQs

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