Trauma Practice Questions

Q: To which category will you classify this wound?

Degloving. ***Degloving*** - A **degloving injury** is a severe type of avulsion where a large section of skin and subcutaneous tissue is torn completely off the underlying fascia, muscle, or bone. - This type of injury often occurs in high-energy trauma, such as motor vehicle accidents or industrial incidents, and can lead to significant tissue loss, devitalization, and potential for infection. *Puncture wounds* - **Puncture wounds** are caused by a sharp, pointed object penetrating the skin, creating a small entry hole but deep damage to underlying tissues. - Unlike degloving injuries, they typically do not involve extensive tearing or avulsion of large skin sections. *Bites* - **Bites** involve tissue damage caused by animal or human teeth, often resulting in puncture marks, lacerations, or crush injuries. - While bites can be severe, they are distinct from degloving injuries, which involve the shearing off of a large segment of skin and soft tissue. *Hematoma* - A **hematoma** is a localized collection of blood outside of blood vessels, typically resulting from trauma that causes bleeding into tissues. - It is a collection of blood, not a type of wound where tissue is torn away from its underlying structures like a degloving injury.

Q: A 22-year-old woman is found in a comatose condition, having lain for an unknown length of time on the tile floor of the courtyard. She is found in possession of cocaine. The patient is transported to the hospital while EMT personnel receive instructions for treatment of drug overdose. During the physical examination the patient's gluteal region shows signs of ischemia. After regaining consciousness, she exhibits paralysis of knee flexion and dorsal and plantar flexion and sensory loss in the limb. What is the most likely diagnosis?

Gluteal crush injury. ***Gluteal crush injury*** - Prolonged pressure on the gluteal region, especially in a comatose state on a hard surface, can lead to **muscle necrosis** and **compartment syndrome**, causing secondary nerve damage. - The symptoms, including **paralysis of knee flexion** (hamstrings, supplied by sciatic/tibial) and **dorsal/plantar flexion** (peroneal and tibial nerves), along with sensory loss in the limb, are consistent with sciatic nerve damage resulting from a crush injury in the gluteal region. *Tibial nerve loss* - While damage to the tibial nerve would cause **paralysis of plantar flexion** and sensory loss, it would not explain the **paralysis of dorsal flexion** (peroneal nerve) or knee flexion (hamstrings). - This option represents a partial injury pattern and does not fully encompass all the described neurological deficits. *Piriformis entrapment syndrome* - This syndrome primarily involves compression of the **sciatic nerve** by the piriformis muscle, causing gluteal pain and paresthesias, often exacerbated by activities. - It typically does not result in a global loss of motor function in the entire lower limb, especially in the context of a crush injury. *S1-2 nerve compression* - Compression at the S1-S2 level would primarily affect **plantar flexion** (S1-S2), **eversion** of the foot, and sensation along the posterior leg and sole of the foot. - It would not explain the **paralysis of knee flexion** (L5-S2, predominantly L5-S1) or **dorsal flexion** (L4-S1, predominantly L4-L5).

Q: Fluid of choice for resuscitation of a burn patient:

Ringer lactate. ***Ringer lactate*** - **Ringer's lactate**, a **balanced crystalloid solution**, is the fluid of choice for initial resuscitation in burn patients due to its electrolyte composition closely mimicking that of plasma. - It helps to restore **fluid volume** and **electrolyte balance** effectively, reducing the risks associated with large-volume resuscitation. *Dextrose 5%* - **Dextrose 5%** is primarily used for providing **free water** and is not suitable for initial volume resuscitation due to its hypotonicity and tendency to distribute into the intracellular space quickly. - Its use in large volumes for burn resuscitation can lead to **hyponatremia** and exacerbate **cerebral edema**. *Human albumin solution* - **Albumin solutions** are colloids and are generally not recommended for initial burn resuscitation as they do not significantly reduce mortality or fluid requirements in the first 24 hours and can be more expensive. - In the initial phases of burn injury, capillaries become leaky, and administered albumin can extravasate into the interstitial space, potentially worsening **edema**. *Hypertonic saline* - While hypertonic saline can reduce the total volume required for resuscitation, its use is complex and carries a higher risk of **hypernatremia** and **hyperchloremic acidosis**. - It is not the standard first-line fluid and typically reserved for specific situations or in centers with extensive experience and close monitoring capabilities.

Q: A patient presents to the ER after an RTA. What is the best way to differentiate cardiac tamponade from tension pneumothorax?

Presence of breath sounds. **Presence of breath sounds** - In **tension pneumothorax**, breath sounds will be **absent** or severely diminished on the affected side due to lung collapse and air trapping. - In **cardiac tamponade**, breath sounds will typically be **present and symmetrical** as lung function is not directly impaired. *Raised JVP* - Both **cardiac tamponade** and **tension pneumothorax** can cause a **raised JVP** due to impaired venous return to the heart [1]. - Therefore, raised JVP on its own is **not a differentiating factor** between these two conditions. *Increased heart rate* - **Tachycardia** is a common compensatory mechanism in both **cardiac tamponade** and **tension pneumothorax** due to decreased cardiac output and hypovolemia/shock. - This symptom will not help distinguish between the two emergencies. *Tracheal shift* - **Tracheal deviation away** from the affected side is a classic, but often late, sign of **tension pneumothorax** as the mediastinum is pushed by the accumulating air. - **Cardiac tamponade** typically does **not cause tracheal shift**, as the pressure is localized to the pericardium and does not directly displace the trachea.

Q: When resuscitating a patient in shock which of the following is not an adequate parameter to predict end point of resuscitation?

Blood pressure. ***Blood pressure*** - While essential for initial assessment and guiding treatment, **blood pressure** can be maintained within normal limits even in significant shock states due to compensatory mechanisms [1]. - Blood pressure alone does not reflect **tissue perfusion** or cellular oxygenation, which are the true endpoints of resuscitation [1]. *Mixed venous oxygen saturation* - **Mixed venous oxygen saturation (SvO2)** reflects the balance between oxygen delivery and consumption, providing insight into global tissue oxygenation. - A low SvO2 indicates inadequate oxygen delivery relative to demand, making it a valuable target for guiding resuscitation. *Base deficit* - **Base deficit** is a measure of metabolic acidosis and reflects the severity of tissue hypoperfusion and anaerobic metabolism. - Normalization of base deficit indicates correction of metabolic derangements and improved tissue perfusion. *Lactate* - **Lactate** is a product of anaerobic metabolism, which occurs when tissues are not adequately perfused or oxygenated. - Elevated lactate levels indicate tissue hypoperfusion, and serial measurements are crucial for monitoring the effectiveness of resuscitation and predicting outcomes.

Q: A man comes to the emergency department with stab injury to left flank. He has stable vitals. What would be the next step in management?

CECT. ***CECT*** - A **Contrast-Enhanced Computed Tomography (CECT)** scan is the preferred initial diagnostic step for a hemodynamically stable patient with a stab wound to the flank. - It effectively assesses the **depth of penetration** and identifies potential internal organ injuries in the abdomen or retroperitoneum, guiding further management. *Diagnostic peritoneal lavage* - **Diagnostic peritoneal lavage (DPL)** is less commonly used for stab wounds in hemodynamically stable patients due to its **invasiveness** and lower specificity compared to CT scans. - While it can detect peritoneal penetration or significant hemorrhage, it often leads to **unnecessary laparotomies** and is not as precise in identifying specific organ injuries. *Laparotomy* - **Laparotomy** (surgical exploration) is indicated for **hemodynamically unstable** patients or those with definitive signs of peritonitis or evisceration. - Since the patient has **stable vitals**, immediate laparotomy is not the next step, as diagnostic imaging is needed first. *Laparoscopy* - **Laparoscopy** is a minimally invasive surgical procedure that can be used diagnostically or therapeutically in stable patients. - However, in the initial assessment of a flank stab wound, a **CECT scan** is typically performed first to get a comprehensive view of potential organ damage before considering a more invasive procedure like laparoscopy.

Q: What is the % Body surface area involved in burns of the perineum?

1%. ***1%*** - The perineum, along with the **genitalia**, constitute approximately **1%** of the total body surface area in adults according to the **Rule of Nines**. - This value is crucial for quickly estimating burn size to guide fluid resuscitation and initial management. *9%* - **9%** typically represents the entire head and neck, or one whole arm, according to the adult **Rule of Nines**. - It does not correspond to the perineum alone, which is a much smaller area. *5%* - **5%** is not a standard percentage assigned to any specific body region in the adult **Rule of Nines**. - In clinical practice, smaller irregular burn areas may be estimated using the **palm method** (patient's palm ≈ 1% TBSA), where 5% would represent approximately 5 palm-sized areas. *3%* - **3%** is also not a standard percentage for a single body region in the adult **Rule of Nines**. - Like 5%, this would typically be used when estimating smaller, irregular burn areas using the palm method (approximately 3 palm-sized areas).

Q: Which of the following is false regarding first degree burns

Blisters form in first-degree burns. ***Blisters form in first-degree burns*** - This statement is **false**. **First-degree burns** only affect the **epidermis** and are characterized by **redness** and **pain** without blister formation. - **Blisters** (vesicles or bullae) are characteristic of **second-degree** (partial thickness) **burns**, where damage extends into the **dermis**. *No residual scarring occurs* - This statement is **true** for first-degree burns. Because only the **epidermis** is affected, the skin fully regenerates, leaving **no residual scarring**. - **Scarring** typically occurs when the injury extends into the **dermis**, as seen in deeper burns. *Pain is the chief symptom* - This statement is **true**. **First-degree burns** primarily present with **pain** due to irritation of **nerve endings** in the epidermis, along with **erythema** (redness). - The **nerve endings** are still intact and highly sensitive in first-degree burns. *Protective functions of skin remain intact* - This statement is **true**. In **first-degree burns**, the **epidermis** is damaged but largely intact, meaning the skin’s **barrier function** against infection and fluid loss is maintained. - The **stratum corneum**, the outermost protective layer of the epidermis, is not severely disrupted.

Q: Which is not an indication for thoracotomy?

Pulmonary contusion. ***Pulmonary contusion*** - **Pulmonary contusion** typically refers to bruising of the lung tissue, which is usually managed **conservatively** with supportive care, such as oxygen and pain control. - While severe cases might require intubation, surgery like **thoracotomy** is generally not indicated unless there are associated injuries requiring surgical intervention. *Esophageal rupture* - **Esophageal rupture** is a serious condition that leads to leakage of gastrointestinal contents into the mediastinum, causing **mediastinitis** and sepsis. - Urgent **thoracotomy** is often necessary for direct repair of the tear or diversion, given the high morbidity and mortality associated with this condition. *Massive pneumothorax* - A **massive pneumothorax** indicates a complete or near-complete collapse of the lung due to air in the pleural space, often associated with significant **respiratory distress** and mediastinal shift. - If conservative measures like chest tube insertion fail, or if it's a recurrent or tension pneumothorax, **thoracotomy** (or VATS) may be required for surgical repair or pleurodesis. *Bleeding more than 200 ml/hr in thoracostomy tube* - Persistent **major bleeding** from a chest drain, especially if exceeding **200 ml/hr for 2-4 consecutive hours** or totaling more than 1500 ml initially, is an indication for immediate surgical exploration. - This level of bleeding suggests ongoing **intrathoracic hemorrhage** that may stem from large vessels or the heart, requiring **thoracotomy** to identify and control the source.

Question 1

To which category will you classify this wound?

Accepted Answer

Degloving

Answer

Puncture wounds

Answer

Bites

Answer

Hematoma

Question 2

Bullet wounds near major blood vessels should be explored only if -

Accepted Answer

There are hard signs of vascular injury (active hemorrhage, expanding hematoma, absent distal pulses, palpable thrill/bruit)

Answer

The wound is in close proximity to a major blood vessel

Answer

There is any suspicion of possible vascular involvement

Answer

Routine exploration is indicated for all penetrating wounds near vessels

Question 3

A 22-year-old woman is found in a comatose condition, having lain for an unknown length of time on the tile floor of the courtyard. She is found in possession of cocaine. The patient is transported to the hospital while EMT personnel receive instructions for treatment of drug overdose. During the physical examination the patient's gluteal region shows signs of ischemia. After regaining consciousness, she exhibits paralysis of knee flexion and dorsal and plantar flexion and sensory loss in the limb. What is the most likely diagnosis?

Accepted Answer

Gluteal crush injury

Answer

Tibial nerve loss

Answer

Piriformis entrapment syndrome

Answer

S1-2 nerve compression

Question 4

Fluid of choice for resuscitation of a burn patient:

Accepted Answer

Ringer lactate

Answer

Dextrose 5%

Answer

Human albumin solution

Answer

Hypertonic saline

Question 5

A patient presents to the ER after an RTA. What is the best way to differentiate cardiac tamponade from tension pneumothorax?

Accepted Answer

Presence of breath sounds

Answer

Raised JVP

Answer

Increased heart rate

Answer

Tracheal shift

Question 6

When resuscitating a patient in shock which of the following is not an adequate parameter to predict end point of resuscitation?

Accepted Answer

Blood pressure

Answer

Mixed venous oxygen saturation

Answer

Base deficit

Answer

Lactate

Question 7

A man comes to the emergency department with stab injury to left flank. He has stable vitals. What would be the next step in management?

Accepted Answer

CECT

Answer

Diagnostic peritoneal lavage

Answer

Laparotomy

Answer

Laparoscopy

Question 8

What is the % Body surface area involved in burns of the perineum?

Accepted Answer

1%

Answer

9%

Answer

5%

Answer

3%

Question 9

Which of the following is false regarding first degree burns

Accepted Answer

Blisters form in first-degree burns

Answer

No residual scarring occurs

Answer

Pain is the chief symptom

Answer

Protective functions of skin remain intact

Question 10

Which is not an indication for thoracotomy?

Accepted Answer

Pulmonary contusion

Answer

Esophageal rupture

Answer

Massive pneumothorax not responding to chest tube

Answer

Bleeding more than 200 ml/hr for 3-4 hours in thoracostomy tube

Trauma — MCQs

Trauma — MCQs

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