Trauma Practice Questions

Q: A 45 year old man sustains trauma in a road traffic accident and develops engorgement of neck veins, pallor, rapid pulse rate, and chest pain. What is the most likely diagnosis?

Cardiac tamponade. ***Cardiac tamponade*** - The classic triad of **Beck's triad** (engorged neck veins, muffled heart sounds, and hypotension) along with **tachycardia** and **pallor** in a trauma setting is highly indicative of cardiac tamponade [1]. - **Chest pain** due to pressure on the heart and surrounding structures further supports this diagnosis. *Haemothorax* - While blunt trauma can cause **haemothorax**, it typically presents with **diminished or absent breath sounds** on the affected side and **respiratory distress**, not prominently with engorged neck veins unless it's very large and significantly compromises venous return. - The primary sign would be **hypotension** and **tachycardia** from hypovolemia, but without the JVD. *Pulmonary laceration* - A pulmonary laceration would primarily cause **pneumothorax** or **haemothorax**, leading to signs like **dyspnea**, **chest pain**, and potentially **subcutaneous emphysema**. - **Engorged neck veins** are not a primary feature unless the resulting pneumothorax is tension type, which would also present with tracheal deviation. *Rupture of spleen* - A ruptured spleen causes **internal bleeding** (hypovolemic shock) presenting as **abdominal pain**, **left upper quadrant tenderness**, **tachycardia**, and **hypotension**. - **Engorged neck veins** are not a characteristic symptom of splenic rupture because it is a source of blood loss leading to hypovolemia.

Q: An electrical contact burn is considered to be:

Full thickness burn. ***Full thickness burn*** - Electrical contact burns are characterized by **high heat** generated at the point of contact, leading to **deep tissue destruction** that extends through the entire dermis and often into subcutaneous fat, muscle, or bone - The current pathway through the body causes additional damage internally, but the contact point itself typically reflects a **third-degree (full thickness) injury** due to intense localized heat - Entry and exit wounds from electrical burns characteristically show **charred, dry tissue** with central necrosis *Superficial partial thickness burn* - This type of burn involves only the **epidermis and superficial portion of the dermis**, typically presenting with blistering and redness - Electrical burns, especially contact burns, rarely result in such shallow injury due to the **intense and deep nature** of the energy transfer - The high voltage and current density at contact points cause damage far beyond superficial layers *Superficial scalding with blisters* - **Scald burns** are caused by hot liquids or steam and are typically **superficial or superficial partial thickness** - An electrical contact burn is distinct in its mechanism (electrical current) and the **severity of tissue damage** it causes, which extends far beyond the superficial layers - The mechanism of injury is fundamentally different from thermal scalding *Deep partial thickness burn* - Deep partial thickness burns extend into the **deeper dermis**, causing fluid-filled blisters and often mottled or waxy white areas - While electrical burns can involve deeper structures, the direct point of contact in an electrical contact burn usually causes damage that is **full thickness or beyond**, going past just the deep dermis - The concentrated heat and current flow at entry/exit sites result in complete destruction of all skin layers

Q: Traumatic haemothorax is best managed by:

Intercostal tube drainage. ***Intercostal tube drainage*** - **Intercostal tube drainage** is the most effective initial management for traumatic haemothorax as it allows continuous evacuation of blood and re-expansion of the lung. - It helps in quantifying blood loss, preventing clot formation, and improving respiratory mechanics by reducing pleural space compression. *Use of streptokinase* - **Streptokinase** is a fibrinolytic agent used to break down clots, but its primary role is in established, organized haemothoraces (fibrothorax) and is not the acute management for traumatic haemothorax. - Administering streptokinase in acute bleeding can worsen haemorrhage and is contraindicated in the immediate post-traumatic period. *Open drainage* - **Open drainage**, typically via thoracotomy, is reserved for massive haemothorax (e.g., >1500 mL initially or >200 mL/hr for 2-4 hours) or ongoing severe bleeding that cannot be controlled by tube thoracostomy. - It is a more invasive procedure with higher risks and is not the first-line management for all traumatic haemothoraces. *Aspiration of blood from pleural cavity* - **Aspiration of blood from the pleural cavity** (thoracentesis) can be diagnostic but is often insufficient for adequately draining a traumatic haemothorax, especially if there is ongoing bleeding or significant clot formation. - It is often reserved for small, uncomplicated haemothoraces or for diagnostic purposes, not as the definitive management in trauma.

Q: Which of the following are contraindications to salvaging accidentally injured spleen during operation? 1. Labile blood pressure 2. Presence of intraperitoneal infection 3. Pre-existing splenic disease 4. Age below 50 years Select the correct answer using the code given below:

1, 2 and 3. ***1, 2 and 3*** - **Labile blood pressure** (1) indicates ongoing hemodynamic instability, making splenic salvage risky due to the potential for further hemorrhage and the need for immediate control. - **Presence of intraperitoneal infection** (2) makes splenic salvage dangerous as the injured spleen provides a niche for bacterial proliferation, increasing the risk of abscess formation and sepsis. - **Pre-existing splenic disease** (3) such as lymphoma or significant architectural changes, can compromise the spleen's integrity and function, making successful and safe salvage unlikely. *1, 3 and 4* - This option incorrectly includes age below 50 years as a contraindication. **Age below 50 years** (4) is generally not a contraindication to splenic salvage; in fact, younger patients, especially children, often have a greater imperative for splenic preservation due to higher risks of **overwhelming post-splenectomy infection (OPSI)**. - While choices 1 and 3 are correct contraindications, choice 4 is not. *2, 3 and 4* - This option incorrectly includes age below 50 years as a contraindication. **Labile blood pressure** (1) is a critical contraindication but is omitted. - Choices 2 and 3 are valid contraindications, but excluding the crucial factor of hemodynamic instability makes this option incomplete. *1, 2 and 4* - This option correctly identifies **labile blood pressure** (1) and **intraperitoneal infection** (2) as contraindications but incorrectly includes **age below 50 years** (4). - It also omits **pre-existing splenic disease** (3), which is another significant reason to avoid salvage.

Q: Regarding haemorrhagic shock, which one of the following statements is correct?

Loss of 40% of circulating volume is life threatening. ***Loss of 40% of circulating volume is life threatening*** - A loss of **40% or more** of circulating blood volume corresponds to **Class IV haemorrhagic shock**, which is a severe, life-threatening condition requiring immediate and aggressive resuscitation. - At this stage, the body's compensatory mechanisms are overwhelmed, leading to profound systemic hypoperfusion, **organ dysfunction**, and a high risk of mortality. *Tachycardia presents in 100% of hypovolemic patients* - While **tachycardia** is a common compensatory mechanism in hypovolemia, it is not present in 100% of patients due to factors such as **beta-blocker use** or **pacemaker rhythm**. - In some early stages of blood loss, especially in young, healthy individuals, sufficient compensatory mechanisms may delay the onset of significant tachycardia. *Clinically manifested when > 10% of loss of total blood volume occurs* - Haemorrhagic shock is typically **clinically manifest** when there is a blood loss greater than **15%** (Class I shock), which represents approximately 750 mL in an average adult. - A loss of **less than 10%** often does not produce overt clinical signs as the body's compensatory mechanisms can effectively maintain vital signs within normal ranges. *In acute stage of shock, systemic vasodilation becomes evident* - In the acute stage of hemorrhagic shock, the body's primary compensatory mechanism is **systemic vasoconstriction**, not vasodilation, to maintain central blood pressure and perfuse vital organs. - **Vasodilation** can occur in the later, decompensated stages of shock, particularly in instances of **septic or neurogenic shock**, leading to a further drop in blood pressure.

Q: A 30 year old lady sustained chest injury in an accident and presented with massive haemothorax on right side. Tube thoracostomy drained 1800 ml of blood. What is the most appropriate treatment?

Resuscitation and prepare for urgent thoracotomy. ***Resuscitation and prepare for urgent thoracotomy*** - A **massive hemothorax**, defined as draining >1500 ml of blood initially or >200 ml/hour for 2-4 hours, indicates significant ongoing bleeding requiring surgical intervention. - Urgent **thoracotomy** is necessary to identify and control the source of hemorrhage in such cases. *Clamp the chest tube to cause the tamponade* - Clamping the chest tube in a massive hemothorax can lead to **cardiac tamponade** or worsening **respiratory distress** by trapping blood in the pleural space. - This action would dangerously increase **intrathoracic pressure** and is contraindicated as it prevents proper drainage and exacerbates hypovolemic shock. *Put one more chest tube* - While additional chest tubes might be considered for inadequate drainage in certain situations, a massive hemothorax (1800 ml) signifies a major vascular injury, making multiple tubes insufficient to control the bleeding. - The priority is to stop the bleeding surgically, not just to drain more blood, which would only accelerate **exsanguination**. *Correction of hypovolemic shock* - **Resuscitation** is a critical initial step, but it is not the definitive treatment for a massive hemothorax with ongoing bleeding. - Without addressing the source of the bleeding via **thoracotomy**, simply managing the **hypovolemic shock** would be futile as the patient would continue to bleed out.

Q: Glasgow coma scale (GCS) score ranges between:

3 and 15. **3 and 15** * The **Glasgow Coma Scale (GCS)** is a neurological scale that aims to give a reliable and objective way of recording the conscious state of a person [2]. * A score of **3 represents the lowest possible level of consciousness**, indicating a severe injury [1], while **15 represents full consciousness** [1]. * *1 and 15* * The GCS assesses three components: **eye opening, verbal response, and motor response** [2]. Each component has a minimum score of 1. * Therefore, a total score of 1 is not possible as the minimum score for any individual component is 1, and there are three components. * *2 and 15* * The lowest possible score for any single component in the GCS is 1 (e.g., no eye opening, no verbal response, no motor response). * With three components, the sum of the minimum scores (1+1+1) is 3, making a total score of 2 impossible. * *0 and 15* * The GCS is designed with a minimum score of 1 for each of its three categories. * A score of 0 is not used in the GCS scoring system; the lowest possible score for any component is 1, even in an unresponsive state.

Q: A young boy riding a motorcycle met with a road traffic accident. On examination he had maxillofacial trauma with paraesthesia of the lower lip. Most likely underlying fracture he has is:

Fracture of the mandibular body. ***Fracture of the mandibular body*** - **Paraesthesia of the lower lip** is a classic symptom of injury to the **inferior alveolar nerve**, which runs within the mandibular canal through the body of the mandible. - A fracture in the mandibular body can directly damage or compress this nerve, leading to altered sensation. *Fracture involving infraorbital foramen* - A fracture involving the **infraorbital foramen** would affect the **infraorbital nerve**, causing paraesthesia in the midface region, including the cheek, upper lip, and side of the nose, not the lower lip. - This nerve is a branch of the **trigeminal nerve (V2)**, whereas the nerve supplying the lower lip is a branch of **V3**. *Fracture of temporal bone* - A **temporal bone fracture** is more likely to cause symptoms related to the **facial nerve (cranial nerve VII)**, leading to facial paralysis, or hearing/balance issues due to damage to the inner ear structures. - It does not typically cause isolated paraesthesia of the lower lip. *Fracture involving floor of orbit* - A fracture of the floor of the orbit, often a **blowout fracture**, can entrap the **inferior rectus** or **inferior oblique muscles** and cause **diplopia** (double vision). - It may also involve the **infraorbital nerve**, leading to paraesthesia of the cheek, upper lip, and upper teeth, but not specifically the lower lip.

Q: A 70-year-old man on anticoagulants due to some heart disease suffered a minor head injury. One month later he has severe headache with slowly developing neurological signs. The probable diagnosis is:

Chronic subdural haematoma. ***Chronic subdural haematoma*** - This diagnosis fits the clinical picture of a **minor head injury** followed by a **delayed** presentation (one month later) of **slowly developing neurological signs** and headache, especially in an **elderly patient on anticoagulants**. - **Anticoagulation** increases the risk for bleeding, and the elderly are more susceptible due to brain atrophy, which stretches and makes bridging veins more vulnerable to tearing from minor trauma. *Acute subdural haematoma* - An acute subdural haematoma typically presents within **72 hours** of the initial trauma, with **rapidly progressive neurological deficits**, unlike the delayed and gradual onset described. - While anticoagulation increases risk, the **timeframe** of symptom onset is inconsistent with an acute presentation. *Extradural haematoma* - Extradural haematomas are usually associated with a **lucid interval** followed by rapid deterioration due to arterial bleeding, often from the **middle meningeal artery**, and rarely occur in the elderly or from minor trauma. - It would present much **sooner** after the injury, typically within hours, and is less common in this age group without significant impact. *Subarachnoid haemorrhage* - Subarachnoid haemorrhage typically presents with a **sudden onset**, **"thunderclap" headache**, often described as the "worst headache of my life," and is not typically associated with a minor head injury followed by a delayed, slowly progressive course. - While anticoagulants could worsen bleeding, the **temporal profile** and **gradual neurological decline** are not characteristic of a subarachnoid haemorrhage.

Q: Diaphragmatic injury is suspected in a 50 year old gentleman with history of blunt abdominal trauma, having a normal chest X-ray. He is best managed by:

Diagnostic laparoscopy. ***Diagnostic laparoscopy*** - **Diagnostic laparoscopy** is the **most sensitive and specific method** for detecting diaphragmatic injuries, especially when initial imaging like X-ray is normal but suspicion remains high after blunt trauma. - It allows **direct visualization** of the diaphragm for tears, herniation of abdominal contents, and associated visceral injuries, enabling simultaneous repair. *CECT abdomen* - While a **CECT abdomen** can show some diaphragmatic injuries, its sensitivity is **limited, especially for small tears**. - It may identify associated organ damage but might miss non-displaced diaphragmatic ruptures, particularly in the acute phase. *Diagnostic peritoneal lavage and proceed* - **Diagnostic peritoneal lavage (DPL)** is primarily used to detect intra-abdominal hemorrhage or viscus perforation, not specifically diaphragmatic injury. - A positive DPL (indicating bleeding) does not directly localize diaphragmatic trauma. *Upper GI contrast study* - An **Upper GI contrast study** is useful for diagnosing a **herniated stomach or small bowel** into the thoracic cavity in chronic or delayed presentations of diaphragmatic injury. - It is **less effective for acute detection** of diaphragmatic tears without significant herniation and does not allow for direct visualization or repair.

Question 1

A 45 year old man sustains trauma in a road traffic accident and develops engorgement of neck veins, pallor, rapid pulse rate, and chest pain. What is the most likely diagnosis?

Accepted Answer

Cardiac tamponade

Answer

Haemothorax

Answer

Pulmonary laceration

Answer

Rupture of spleen

Question 2

An electrical contact burn is considered to be:

Accepted Answer

Full thickness burn

Answer

Superficial partial thickness burn

Answer

Superficial scalding with blisters

Answer

Deep partial thickness burn

Question 3

Traumatic haemothorax is best managed by:

Accepted Answer

Intercostal tube drainage

Answer

Use of streptokinase

Answer

Open drainage

Answer

Aspiration of blood from pleural cavity

Question 4

Which of the following are contraindications to salvaging accidentally injured spleen during operation?

1. Labile blood pressure
2. Presence of intraperitoneal infection
3. Pre-existing splenic disease
4. Age below 50 years

Select the correct answer using the code given below:

Accepted Answer

1, 2 and 3

Answer

1, 3 and 4

Answer

2, 3 and 4

Answer

1, 2 and 4

Question 5

Regarding haemorrhagic shock, which one of the following statements is correct?

Accepted Answer

Loss of 40% of circulating volume is life threatening

Answer

Tachycardia presents in 100% of hypovolemic patients

Answer

Clinically manifested when > 10% of loss of total blood volume occurs

Answer

In acute stage of shock, systemic vasodilation becomes evident

Question 6

A 30 year old lady sustained chest injury in an accident and presented with massive haemothorax on right side. Tube thoracostomy drained 1800 ml of blood. What is the most appropriate treatment?

Accepted Answer

Resuscitation and prepare for urgent thoracotomy

Answer

Clamp the chest tube to cause the tamponade

Answer

Put one more chest tube

Answer

Correction of hypovolemic shock

Question 7

Glasgow coma scale (GCS) score ranges between:

Accepted Answer

3 and 15

Answer

1 and 15

Answer

2 and 15

Answer

0 and 15

Question 8

A young boy riding a motorcycle met with a road traffic accident. On examination he had maxillofacial trauma with paraesthesia of the lower lip. Most likely underlying fracture he has is:

Accepted Answer

Fracture of the mandibular body

Answer

Fracture involving infraorbital foramen

Answer

Fracture of temporal bone

Answer

Fracture involving floor of orbit

Question 9

A 70-year-old man on anticoagulants due to some heart disease suffered a minor head injury. One month later he has severe headache with slowly developing neurological signs. The probable diagnosis is:

Accepted Answer

Chronic subdural haematoma

Answer

Acute subdural haematoma

Answer

Extradural haematoma

Answer

Subarachnoid haemorrhage

Question 10

Diaphragmatic injury is suspected in a 50 year old gentleman with history of blunt abdominal trauma, having a normal chest X-ray. He is best managed by:

Accepted Answer

Diagnostic laparoscopy

Answer

CECT abdomen

Answer

Diagnostic peritoneal lavage and proceed

Answer

Upper GI contrast study

Trauma — MCQs

Trauma — MCQs

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