Trauma Practice Questions

Q: What is flail chest?

Fracture of three or more ribs at 2 or more places. ***Fracture of three or more ribs at 2 or more places*** - **Flail chest** is defined by a segment of the thoracic wall that has lost its **bony continuity** with the rest of the rib cage. - This typically occurs when **three or more adjacent ribs** are fractured in **two or more places**, creating an isolated segment. *Fracture of 2 ribs at three places* - This definition does not meet the criteria for flail chest as it specifies only **two ribs**, whereas the condition requires at least three adjacent ribs. - While significant, fractures of only two ribs usually do not result in the paradoxical segment movement characteristic of a flail chest. *Ventilator associated pneumonia* - **Ventilator-associated pneumonia (VAP)** is a lung infection acquired by patients on mechanical ventilation, unrelated to chest wall trauma. - VAP is an **infectious complication** of critical care, not a structural injury to the chest wall. *Transfusion associated lung injury* - **Transfusion-associated acute lung injury (TRALI)** is a serious complication of blood transfusions, characterized by acute respiratory distress. - TRALI is an **immune-mediated inflammatory response** affecting the lungs, not a physical injury to the ribs.

Q: Most commonly injured organ in blunt trauma of abdomen is -

Liver. ***Liver*** - The **liver** is the **most commonly injured solid organ** in blunt abdominal trauma according to current trauma databases and modern surgical literature. - This is due to its **large size** (largest solid abdominal organ), **fixed position** beneath the rib cage, and **anterior-superior location** making it vulnerable to direct impact forces. - Liver injuries can range from minor subcapsular hematomas to severe lacerations with major hemorrhage, often requiring operative or angiographic intervention. *Spleen* - The **spleen** is the **second most commonly injured** solid organ in blunt abdominal trauma. - Its superficial location in the left upper quadrant and highly vascularized parenchymal structure make it vulnerable to injury. - Historically, splenic injuries were considered most common, but modern trauma registries consistently show liver injuries are more frequent. *Small intestine* - **Small intestine** injuries from blunt trauma are less common than solid organ injuries (liver and spleen). - They typically occur with deceleration injuries, seatbelt injuries, or severe direct blows causing compression against the spine. - The intestine's mobility and mesenteric suspension provide some protection from blunt forces. *Pancreas* - The **pancreas** is a retroperitoneal organ well-protected by overlying structures, making it one of the **least commonly injured** organs in blunt abdominal trauma. - Pancreatic injury typically requires severe direct impact compressing the organ against the vertebral column (e.g., handlebar injury, steering wheel impact).

Q: In patient of head injuries with rapidly increasing intracranial tension without hematoma, the drug of choice for initial management would be :

20% Mannitol. ***20% Mannitol*** - **Mannitol** is an osmotic diuretic that reduces **intracranial pressure (ICP)** by creating an osmotic gradient, drawing water from the brain parenchyma into the intravascular space [1]. - Its rapid onset of action and significant ICP-reducing effects make it the drug of choice for acute management of elevated ICP in head injuries without hematoma. *Lasix* - **Furosemide (Lasix)** is a loop diuretic that can reduce ICP by decreasing cerebrospinal fluid production and promoting diuresis. - However, its effects are generally slower and less potent than mannitol for acute, rapidly increasing ICP. *Glycine* - **Glycine** is an amino acid and neurotransmitter; it has no direct role in the acute management of increased ICP. - It is sometimes used as an irrigating solution in urological procedures but is not indicated for brain injury. *Steroids* - **Steroids**, particularly **dexamethasone**, are effective in reducing vasogenic edema associated with brain tumors or abscesses. - They are generally **not recommended** for acute traumatic brain injury due to lack of benefit and potential for increased mortality or complications.

Q: A person had an accident and came to casualty with contusion on left precordium. There was decrease in breath sounds on left side, trachea deviated to right side and normal heart sounds. Which of the following is the first line of management?

Needle thoracocentesis. ***Needle thoracocentesis*** - The constellation of **decreased breath sounds** on the left, **tracheal deviation** to the right, and a history of trauma indicates a **tension pneumothorax**. - **Needle decompression** (thoracocentesis) is the immediate, life-saving intervention for tension pneumothorax to relieve pressure and restore cardiorespiratory function. *Chest tube thoracostomy* - While a **chest tube** (tube thoracostomy) is the definitive treatment for pneumothorax, it is not the *first-line* **emergency management** for a **tension pneumothorax** where immediate decompression is critical. - The delay in setting up and inserting a chest tube can be fatal in a **tension pneumothorax**. *Pericardiocentesis* - **Pericardiocentesis** is indicated for **cardiac tamponade**, which would typically present with muffled heart sounds, hypotension, and distended neck veins, none of which are noted here. - The presence of **tracheal deviation** and **decreased breath sounds** specifically points away from isolated cardiac tamponade. *Open surgery* - **Open surgery (thoracotomy)** is a major surgical procedure reserved for cases like massive hemorrhage or major airway injury, and not the initial rapid management for a tension pneumothorax. - Performing open surgery directly for a tension pneumothorax would be too slow and inappropriate as an initial intervention.

Q: A 19-year-old man is brought into the emergency department with a gunshot wound that occurred 4 hours before admission. At exploratory laparotomy, an injury is noted in the transverse colon with extensive tissue destruction. There is a large amount of fecal contamination. Management of this injury should include which of the following?

Resection with proximal colostomy and distal mucous fistula. ***Resection with proximal colostomy and distal mucous fistula*** - Extensive **tissue destruction** and significant **fecal contamination** in a gunshot wound to the colon necessitate diversion to prevent peritonitis and sepsis. - A **proximal colostomy** diverts the fecal stream, and a **distal mucous fistula** allows drainage of the distal segment, preventing a closed-loop obstruction and reducing the risk of anastomotic leak if a primary repair were attempted under septic conditions. *Resection of the wound with primary anastomosis and proximal cecostomy* - **Primary anastomosis** in the setting of extensive tissue destruction and heavy fecal contamination carries a high risk of **anastomotic leak** and peritonitis. - A **cecostomy** is generally insufficient for complete diversion of the fecal stream when dealing with injuries to the transverse colon or beyond. *Debridement and closure of wound with a proximal colostomy* - **Debridement and primary closure** are inadequate for extensive tissue destruction caused by a gunshot wound, as devitalized tissue will likely lead to breakdown and leak. - While a **proximal colostomy** provides diversion, inadequate management of the injury itself is prone to failure and complications. *Resection of the injured colon with primary anastomosis and proximal colostomy* - Although **resection** addresses the damaged tissue, performing a **primary anastomosis** in the presence of extensive **fecal contamination** significantly increases the risk of **anastomotic leak**. - A **proximal colostomy** would provide diversion, but the retained anastomosis remains a high-risk factor in this contaminated field.

Q: Commonest cause of death in penetrating injury of chest -

Cardiac and great vessel injury. ***Cardiac and great vessel injury*** - **Cardiac and great vessel injuries** are the most common cause of death in penetrating chest trauma, accounting for the majority of immediate fatalities. - Injuries to the **heart** (ventricles, atria), **aorta**, **pulmonary artery**, and **vena cava** lead to rapid **exsanguination** and **cardiac tamponade**. - Most patients with these injuries die at the scene or within minutes of arrival to the hospital due to massive hemorrhage and hemodynamic collapse. - Emergency **resuscitative thoracotomy** may be required but has limited success in severe cardiac/great vessel trauma. *Pulmonary laceration* - While **pulmonary lacerations** are common in penetrating chest injuries, they are often manageable with tube thoracostomy. - Most pulmonary injuries stop bleeding spontaneously due to the low-pressure pulmonary circulation. - Massive hemorrhage from pulmonary injuries is less common than from cardiac or great vessel injuries. *Oesophageal rupture* - **Oesophageal rupture** is relatively rare in penetrating chest trauma and typically presents with mediastinitis rather than immediate death. - Death from oesophageal rupture usually occurs later due to **sepsis** and multi-organ failure, not immediate exsanguination. *Tracheobronchial injury* - **Tracheobronchial injuries** are uncommon in penetrating chest trauma and often present with **tension pneumothorax** or persistent air leak. - While life-threatening, these injuries allow more time for intervention compared to cardiac/great vessel injuries.

Q: Glasgow coma scale -moderate includes

9-12. ***9-12*** - A **Glasgow Coma Scale (GCS)** score between 9 and 12 is classified as **moderate head injury** or **moderate coma** [1]. - This range indicates significant impairment of consciousness, often requiring medical intervention and close monitoring. * 12* - A GCS score of **greater than 12** typically falls into the category of **mild head injury** (13-15) [1]. - Patients in this range usually have a better prognosis and less severe neurological deficits. *3-8* - A GCS score between **3 and 8** is indicative of **severe head injury** or **severe coma** [1]. - Patients in this range often require immediate critical care, including intubation and ventilatory support due to compromised airway reflexes.

Q: Hemostasis in scalp wound is best achieved by -

Direct pressure over the wound. ***Direct pressure over the wound*** - Initial and most effective method for immediate **hemostasis** in scalp wounds due to the rich vascular supply and the ability to compress vessels against the underlying bone. - Applying **firm, sustained pressure** directly to the bleeding site helps to tamponade the vessels and promote clot formation. *Catching and crushing the bleeders by hemostats* - While hemostats can be used for individual vessels, it is often impractical and time-consuming for the numerous small vessels in a scalp wound and can cause **tissue damage**. - This method is typically reserved for **identified, larger arterial bleeders** once initial control has been achieved. *Coagulation of bleeders* - **Electrocautery** can be effective for smaller bleeders but risks **thermal injury** to surrounding tissues of the scalp, which has a relatively thin overlying skin. - It is often used after direct pressure has controlled the bulk of the bleeding and individual vessels need precise control. *Eversion of galea aponeurotica* - **Eversion of the galea** is a technique used during wound closure to ensure proper anatomical apposition, but it does not directly achieve hemostasis. - This step is for facilitating wound closure and preventing dead space rather than immediate bleeding control.

Q: Battle's sign is:

Ecchymosis in the mastoid region. **Ecchymosis in the mastoid region** - **Battle's sign** refers to **retroauricular ecchymosis**, appearing as bruising over the mastoid process, typically seen hours to days after a **basilar skull fracture**. - It is caused by the extravasation of blood from the fracture site into the tissues overlying the mastoid bone, often indicative of a fracture extending into the **posterior cranial fossa**. *Sub-lingual ecchymosis* - While any ecchymosis indicates bleeding, **sub-lingual ecchymosis** is not specifically referred to as Battle's sign and is not a typical indicator of a basilar skull fracture. - It could be seen in various other conditions but lacks the diagnostic specificity of mastoid ecchymosis for head trauma. *Sub-conjunctival ecchymosis* - This involves bleeding under the conjunctiva of the eye, often referred to as a **sub-conjunctival hemorrhage**. - While ocular manifestations can occur with head trauma (e.g., **raccoon eyes**), **sub-conjunctival ecchymosis** alone is not Battle's sign. *Palatal ecchymosis* - **Palatal ecchymosis** refers to bruising on the roof of the mouth. - This is not a recognized sign of a basilar skull fracture and is not known as Battle's sign.

Question 1

What is flail chest?

Accepted Answer

Fracture of three or more ribs at 2 or more places

Answer

Fracture of 2 ribs at three places

Answer

Ventilator associated pneumonia

Answer

Transfusion associated lung injury

Question 2

Most commonly injured organ in blunt trauma of abdomen is -

Accepted Answer

Liver

Answer

Spleen

Answer

Small intestine

Answer

Pancreas

Question 3

A 35-year-old smoker is involved in a house fire and receives a 45% total surface area burn. One half of the burned surface appears to be third degree. On the third post-burn day, the patient is noted to have bloody drainage from a nasogastric tube and a decrease of 5% in his hematocrit. Appropriate management should include which of the following?

Accepted Answer

Urgent esophagogastroduodenoscopy to diagnose the cause of bleeding

Answer

Urgent upper gastrointestinal contrast study to delineate site of bleeding

Answer

Urgent intravenous infusion of vasopressin at 0.2-0.4 IU/min

Answer

Immediate selective angiography of the left gastric artery to diagnose and treat presumed stress ulceration

Question 4

In patient of head injuries with rapidly increasing intracranial tension without hematoma, the drug of choice for initial management would be :

Accepted Answer

20% Mannitol

Answer

Lasix

Answer

Glycine

Answer

Steroids

Question 5

A person had an accident and came to casualty with contusion on left precordium. There was decrease in breath sounds on left side, trachea deviated to right side and normal heart sounds. Which of the following is the first line of management?

Accepted Answer

Needle thoracocentesis

Answer

Chest tube thoracostomy

Answer

Pericardiocentesis

Answer

Open surgery

Question 6

A 19-year-old man is brought into the emergency department with a gunshot wound that occurred 4 hours before admission. At exploratory laparotomy, an injury is noted in the transverse colon with extensive tissue destruction. There is a large amount of fecal contamination. Management of this injury should include which of the following?

Accepted Answer

Resection with proximal colostomy and distal mucous fistula

Answer

Resection of the wound with primary anastomosis and proximal cecostomy

Answer

Debridement and closure of wound with a proximal colostomy

Answer

Resection of the injured colon with primary anastomosis and proximal colostomy

Question 7

Commonest cause of death in penetrating injury of chest -

Accepted Answer

Cardiac and great vessel injury

Answer

Oesophageal rupture

Answer

Pulmonary laceration

Answer

Tracheobronchial injury

Question 8

Glasgow coma scale -moderate includes

Accepted Answer

9-12

Answer

<3

Answer

>12

Answer

3-8

Question 9

Hemostasis in scalp wound is best achieved by -

Accepted Answer

Direct pressure over the wound

Answer

Catching and crushing the bleeders by hemostats

Answer

Coagulation of bleeders

Answer

Eversion of galea aponeurotica

Question 10

Battle's sign is:

Accepted Answer

Ecchymosis in the mastoid region

Answer

Sub-lingual ecchymosis

Answer

Sub-conjunctival ecchymosis

Answer

Palatal ecchymosis

Trauma — MCQs

Trauma — MCQs

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