Trauma Practice Questions

Q: A car accident patient complains of breathlessness. On examination BP is $110 / 70 \mathrm{mmHg}$ with GCS of 15/15. On examination, trachea is deviated to the right side, with reduced breath sounds in left infra-axillary area and inframammary areas. $S_{1}$ and $S_{2}$ are normal in intensity and splitting. CXR is shown below. What is the best step in management of the patient?

Chest tube insertion. ***Chest tube insertion*** - The patient's symptoms (breathlessness, tracheal deviation to the right, reduced breath sounds in the left infra-axillary and inframammary areas) combined with the CXR findings indicate a **left-sided hemothorax or pneumothorax** causing mediastinal shift. - A chest tube will **drain the accumulated air or fluid**, re-expand the lung, and relieve the mediastinal shift, thereby improving breathing. - This is **NOT a tension pneumothorax** (patient is hemodynamically stable with BP 110/70 mmHg), so definitive chest tube insertion is preferred over needle decompression. *Needle aspiration* - Needle thoracostomy is indicated for **tension pneumothorax**, which presents with hemodynamic instability, severe respiratory distress, and requires immediate decompression. - This patient is **hemodynamically stable** (normal BP, GCS 15/15), indicating a simple pneumothorax or hemothorax that requires **chest tube** for definitive drainage rather than temporary needle aspiration. *Pericardiocentesis* - **Pericardiocentesis** is indicated for **cardiac tamponade**, which presents with muffled heart sounds, hypotension, and distended neck veins (Beck's triad). - The patient's **normal blood pressure, normal heart sounds** (S₁ and S₂ normal), and clinical findings pointing to pleural pathology rule out cardiac tamponade. *Immediate thoracotomy* - **Immediate thoracotomy** is reserved for massive hemothorax with **>1500 mL initial drainage** or **>200 mL/hour persistent bleeding** after chest tube insertion, or for major vessel/cardiac injuries. - Initial management should be **chest tube insertion** for drainage and assessment before proceeding to thoracotomy.

Q: Which of the following statements are correct regarding ABCDE of trauma care ? I. A stands for Airway with cervical spine protection II. B stands for Breathing and ventilation III. C stands for Control of massive external haemorrhage IV. D stands for Disability (Neurological status) Select the answer using the code given below :

I, II and IV. ***I, II and IV*** - All statements I, II, and IV accurately describe components of the **ABCDE approach in trauma care**. - **A** is for **Airway maintenance with cervical spine protection**, **B** for **Breathing and ventilation**, and **D** for **Disability (neurological status)**. - These are the core components as per **ATLS (Advanced Trauma Life Support) guidelines**. *I, II and III* - This option is incorrect because statement III is **incomplete and inaccurate**. - In the standard ATLS primary survey, **C stands for Circulation with hemorrhage control**, not just "Control of massive external haemorrhage." - While controlling hemorrhage is a critical part of 'C', the primary focus is on assessing and managing **circulation** (shock, perfusion, bleeding). - Note: ATLS 10th edition introduced ** for catastrophic hemorrhage** in tactical settings, but this is a separate step before A, not a replacement for C. *II, III and IV* - This option is incorrect as it omits statement I, which correctly describes **A as Airway with cervical spine protection**, the first and most critical step in trauma management. - Statement III also incorrectly describes what 'C' represents in the ABCDE approach. *I, III and IV* - This option is incorrect because it omits statement II, which correctly identifies **B as Breathing and ventilation**, an essential assessment following airway management. - Statement III is incomplete as it fails to mention that **C primarily stands for Circulation** (with hemorrhage control as one component).

Q: A patient with head injury with a Glasgow Coma Scale of 10 is classified as :

Moderate injury. ***Moderate injury*** - A Glasgow Coma Scale (GCS) score between **9 and 12** is classified as a **moderate head injury**. - Patients in this range often present with initial loss of consciousness, post-traumatic amnesia, or neurological deficits. *Mild injury* - A **mild head injury** is characterized by a GCS score of **13-15**. - These patients typically have a brief or no loss of consciousness and may experience symptoms like headache or dizziness. *Severe injury* - A **severe head injury** is indicated by a GCS score of **3-8**. - Patients with severe head injuries are often comatose and require urgent medical intervention. *Minor injury* - "Minor injury" is not a standard medical classification for head trauma based on the GCS. - The closest GCS classification would be for **mild head injury**.

Q: In seat belt syndrome the most common site of bleeding is from :

Mesentery. ***Mesentery*** - In **seat belt syndrome**, the **mesentery** is the **most common site of bleeding** due to the unique mechanism of injury. - Sudden deceleration causes **shearing forces** at fixed points where the small bowel and mesentery are compressed against the posterior abdominal wall and spine by the lap belt. - This results in **mesenteric tears**, **hematomas**, and **vascular injuries** (mesenteric vessels are particularly vulnerable), leading to significant intra-abdominal hemorrhage. - **Mesenteric injury** occurs in approximately **20-30%** of seat belt syndrome cases, making it the predominant source of bleeding. *Bowel* - While **bowel injuries** (perforation, transection, intramural hematoma) do occur in seat belt syndrome and are clinically significant, they are typically **second in frequency** to mesenteric injuries. - Bowel perforation occurs in about 15-20% of cases and may present with delayed symptoms. - The bowel injury often occurs in conjunction with mesenteric tears due to the same deceleration mechanism. *Spleen* - Splenic injury is less commonly associated with the specific compression mechanism of seat belt syndrome. - The spleen is more typically injured in direct blunt trauma to the left upper quadrant from side impacts or direct blows. - Not the characteristic injury pattern seen with lap belt restraint. *Liver* - Liver injuries are more often associated with direct forceful impacts to the right upper quadrant or generalized severe blunt abdominal trauma. - The typical seat belt mechanism with lap belt compression does not preferentially injure the liver. - Less common in the classical seat belt syndrome presentation.

Q: A 30-year-old motorbike rider is brought to the emergency with history of a road traffic accident and altered consciousness. On secondary survey, the doctor notices presence of a bruise over the left mastoid process. The finding indicates

fracture of the skull base. ***fracture of the skull base*** - A bruise over the mastoid process, known as **Battle's sign**, is a classic indicator of a **basilar skull fracture**. It signifies extravasation of blood from fracture lines in the skull base, typically involving the **temporal bone**. - This sign develops several hours to days after the injury as blood tracks subcutaneously, indicating severe trauma given the patient's altered consciousness. *injury to the external auditory meatus* - While head trauma can cause injury to the **external auditory meatus (EAM)**, a bruise over the mastoid process specifically points to deeper bone involvement, not just the EAM. - Injuries to the EAM might present with bleeding from the ear canal or local pain, but a mastoid bruise suggests a more extensive underlying fracture. *fracture of mastoid process* - Although Battle's sign is located on the mastoid process, it primarily indicates a fracture of the **skull base** (often involving the temporal bone, which includes the mastoid). - A fracture limited to the mastoid process itself might not necessarily cause the characteristic diffuse bruising pattern associated with Battle's sign, which results from blood tracking from deeper structures. *soft tissue injury to the neck* - A bruise over the mastoid process is anatomically distinct from the neck and does not directly indicate a **soft tissue injury to the neck**. - While neck injuries can accompany head trauma, Battle's sign is specific to a **cranial fracture**.

Q: A 30-year-old road traffic accident victim is being taken up for emergency laparotomy for haemoperitoneum and suspected multiorgan trauma. Which one of the following will be an indication for performing damage control surgery?

Acidosis with pH < 7.32. ***Acidosis with pH < 7.32*** - This represents **severe metabolic acidosis** and is a specific, measurable component of the **"lethal triad"** (acidosis, hypothermia, coagulopathy) that mandates damage control surgery. - pH < 7.32 provides a **defined threshold** indicating severe physiological derangement where prolonged definitive repair becomes dangerous and abbreviated surgery is required. *Blood pressure < 100 mm Hg* - While **hypotension** indicates shock requiring aggressive resuscitation, blood pressure < 100 mmHg alone is not a specific criterion for damage control surgery. - Damage control surgery is indicated by the **lethal triad** components, not by isolated blood pressure thresholds. *Hypothermia < 36 °C* - While **hypothermia** is part of the lethal triad, the standard threshold for damage control surgery is **core temperature 1.5, PT > 16-19 seconds) that would make it a definitive, measurable criterion compared to the specific pH threshold.

Q: Which of the following are stages of damage control surgery? 1. Patient selection 2. Control of haemorrhage 3. Resuscitation in ICU 4. Preventive surgery Select the correct answer using the code given below.

1, 2 and 3. ***1, 2 and 3*** - **Damage control surgery** (DCS) is a multi-stage approach for critically injured patients, involving initial stabilization, followed by definitive repair. - The stages include **patient selection** (for those who would benefit), **initial hemorrhage and contamination control**, and subsequent **resuscitation in the ICU** before a final operation. *1, 3 and 4* - This option incorrectly includes **preventive surgery** as a stage of damage control surgery. - While patient selection and ICU resuscitation are crucial, preventive surgery is not a distinct stage within the standard damage control protocol, which focuses on immediate life-saving measures and delayed definitive repair. *1, 2 and 4* - This option incorrectly includes **preventive surgery** and omits **resuscitation in the ICU**, which is a critical phase of damage control. - After initial surgical control of bleeding and contamination, the patient undergoes aggressive resuscitation and optimization in the ICU before the next surgical stage. *2, 3 and 4* - This option omits **patient selection**, which is the crucial first step in determining who is a candidate for damage control surgery. - It also incorrectly includes **preventive surgery**, as outlined previously.

Q: Which among the following are complications of liver trauma? 1. Liver abscess 2. Biliary fistula 3. Portal thrombosis 4. Liver failure Select the correct answer using the code given below.

1, 2 and 4. ***1, 2 and 4*** - **Liver abscess** is a well-recognized complication resulting from infected devitalized tissue, hematoma, or bile contamination following liver trauma. - **Biliary fistula** is a common complication occurring when bile leaks from damaged intrahepatic or extrahepatic bile ducts, potentially forming external fistulas or bilomas. - **Liver failure** may result from extensive parenchymal damage, massive blood loss causing hepatic ischemia, coagulopathy, and metabolic derangements. - These three represent the **most common and clinically significant** complications of liver trauma encountered in clinical practice. *1, 2 and 3* - While **portal thrombosis** can theoretically occur after portal vein injury in liver trauma, it is a **rare complication** compared to liver abscess, biliary fistula, and liver failure. - This option incorrectly prioritizes portal thrombosis over the more common and clinically significant complication of liver failure. *2, 3 and 4* - This option incorrectly omits **liver abscess**, which is one of the most important delayed complications of liver trauma. - Abscess formation from infected hematomas or devitalized tissue is far more commonly encountered than portal thrombosis. *1, 3 and 4* - This option incorrectly omits **biliary fistula**, which is one of the most frequent complications of liver trauma. - Bile duct injury with subsequent bile leakage occurs in a significant proportion of liver trauma cases, making biliary fistula more clinically relevant than portal thrombosis.

Q: Hypotension in an unconscious head injury patient is most commonly due to

associated injuries of abdomen or chest. ***associated injuries of abdomen or chest*** - **Hypotension** in an unconscious head injury patient is rarely caused by the head injury itself, as the brain cannot lose enough blood to cause systemic hypotension. - Therefore, other concurrent injuries, such as **intra-abdominal or intrathoracic hemorrhage**, are the most common cause of hypotension in this setting, requiring a thorough secondary survey. *intracerebral haemorrhage* - While intracerebral hemorrhage can lead to increased intracranial pressure and neurological deterioration, it generally does not cause **systemic hypotension** on its own. - The volume of bleeding within the brain is typically insufficient to result in clinically significant **blood loss** leading to shock. *extradural haemorrhage* - An extradural hematoma involves bleeding between the **dura mater** and the skull, often from a ruptured middle meningeal artery. - It primarily causes increased intracranial pressure and **neurological symptoms**, but like other cranial hemorrhages, it's not a common cause of **systemic hypotension**. *pontine haemorrhage* - A pontine hemorrhage is a severe form of stroke affecting the **brainstem**, leading to rapid neurological decline and often coma. - While devastating, its effect on blood pressure is typically through **autonomic dysfunction**, which can cause hypertension or profound bradycardia, but not usually **hypotension** due to blood loss.

Question 1

A car accident patient complains of breathlessness. On examination BP is $110 / 70 \mathrm{mmHg}$ with GCS of 15/15. On examination, trachea is deviated to the right side, with reduced breath sounds in left infra-axillary area and inframammary areas. $S_{1}$ and $S_{2}$ are normal in intensity and splitting. CXR is shown below. What is the best step in management of the patient?

Accepted Answer

Chest tube insertion

Answer

Needle aspiration

Answer

Pericardiocentesis

Answer

Immediate thoracotomy

Question 2

Which of the following statements are correct regarding ABCDE of trauma care ?
I. A stands for Airway with cervical spine protection
II. B stands for Breathing and ventilation
III. C stands for Control of massive external haemorrhage
IV. D stands for Disability (Neurological status)
Select the answer using the code given below :

Accepted Answer

I, II and IV

Answer

I, II and III

Answer

II, III and IV

Answer

I, III and IV

Question 3

Which of the following statements are correct regarding primary survey/management of traumatic head injury patient?
I. Ensure adequate oxygenation and circulation
II. Exclude hypoglycaemia
III. Check for mechanism of injury
IV. Check pupil size and response

Select the answer using the code given below :

Accepted Answer

I, II and IV

Answer

II, III and IV

Answer

I, III and IV

Answer

I, II and III

Question 4

A patient with head injury with a Glasgow Coma Scale of 10 is classified as :

Accepted Answer

Moderate injury

Answer

Mild injury

Answer

Severe injury

Answer

Minor injury

Question 5

In seat belt syndrome the most common site of bleeding is from :

Accepted Answer

Mesentery

Answer

Bowel

Answer

Spleen

Answer

Liver

Question 6

A 30-year-old motorbike rider is brought to the emergency with history of a road traffic accident and altered consciousness. On secondary survey, the doctor notices presence of a bruise over the left mastoid process. The finding indicates

Accepted Answer

fracture of the skull base

Answer

injury to the external auditory meatus

Answer

fracture of mastoid process

Answer

soft tissue injury to the neck

Question 7

A 30-year-old road traffic accident victim is being taken up for emergency laparotomy for haemoperitoneum and suspected multiorgan trauma. Which one of the following will be an indication for performing damage control surgery?

Accepted Answer

Acidosis with pH < 7.32

Answer

Blood pressure < 100 mm Hg

Answer

Coagulopathy

Answer

Hypothermia < 36 °C

Question 8

Which of the following are stages of damage control surgery?

1. Patient selection
2. Control of haemorrhage
3. Resuscitation in ICU
4. Preventive surgery
Select the correct answer using the code given below.

Accepted Answer

1, 2 and 3

Answer

1, 3 and 4

Answer

1, 2 and 4

Answer

2, 3 and 4

Question 9

Which among the following are complications of liver trauma?

1. Liver abscess
2. Biliary fistula
3. Portal thrombosis
4. Liver failure

Select the correct answer using the code given below.

Accepted Answer

1, 2 and 4

Answer

1, 2 and 3

Answer

2, 3 and 4

Answer

1, 3 and 4

Question 10

Hypotension in an unconscious head injury patient is most commonly due to

Accepted Answer

associated injuries of abdomen or chest

Answer

intracerebral haemorrhage

Answer

extradural haemorrhage

Answer

pontine haemorrhage

Trauma — MCQs

Trauma — MCQs

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