Trauma Practice Questions

Q: Which of the following is false about diaphragmatic injury?

No respiratory distress. ***No respiratory distress*** - Diaphragmatic injury often leads to **respiratory distress** due to the herniation of abdominal contents into the thoracic cavity, compressing the lung and displacing the mediastinum. - The immediate consequence of a diaphragmatic tear can include **dyspnea**, **tachypnea**, and **chest pain**, all indicative of respiratory compromise. - This statement is **FALSE** - respiratory distress is a common presentation. *Primary repair is preferred* - **Primary repair** of diaphragmatic tears with non-absorbable sutures is the preferred method for surgical correction of acute injuries. - This is a **TRUE statement** - primary repair using interrupted non-absorbable sutures (like silk or prolene) is the standard approach. - Mesh repair is reserved for very large defects or chronic hernias, not acute injuries. *Left side is common* - The left hemidiaphragm is more frequently injured than the right, largely due to the **protective effect** of the liver on the right side. - The liver acts as a **buffer**, absorbing some of the impact from trauma and preventing tearing of the right hemidiaphragm. - This is a **TRUE statement**. *Delayed presentation* - Diaphragmatic injuries can often have a **delayed presentation**, with symptoms developing weeks, months, or even years after the initial trauma. - This is because the abdominal viscera can gradually **herniate** through a small tear, leading to chronic symptoms like intermittent pain, bowel obstruction, or respiratory issues. - This is a **TRUE statement**.

Q: Which of the following is the safest initial approach to open the airway in a patient with maxillofacial trauma?

Jaw thrust technique. ***Jaw thrust technique*** - This technique is preferred in cases of **maxillofacial or suspected cervical spine trauma** as it minimizes neck movement, thereby reducing the risk of further injury. - It involves grasping the angles of the mandible and **lifting the jaw anteriorly**, which moves the tongue away from the posterior pharynx to clear the airway. *Head tilt-chin lift* - This maneuver is contraindicated in trauma settings where a **cervical spine injury** is suspected, as it can extend the neck and exacerbate spinal cord damage. - While effective for opening the airway in non-trauma patients, it involves **significant neck movement** which is unsafe in maxillofacial trauma. *Head lift-neck lift* - This is not a recognized or safe technique for airway management, especially in trauma patients, as it would cause **unnecessary and potentially harmful movement** of the head and neck. - There is no clinical scenario where this technique would be recommended over established airway maneuvers. *Heimlich procedure* - The Heimlich procedure (abdominal thrusts) is used to relieve **severe foreign body airway obstruction** and is not an initial approach to open an airway due to general trauma. - It is an intervention for choking, not for managing an airway in a patient with maxillofacial trauma where the primary concern is often **tongue prolapse** or significant structural injury causing obstruction.

Q: Neurogenic shock is characterized by:

Hypotension and bradycardia. ***Hypotension and bradycardia*** - **Neurogenic shock** results from the loss of **sympathetic vascular tone**, leading to widespread vasodilation and subsequent **hypotension**. - The interruption of sympathetic innervation to the heart can also cause **bradycardia**, as parasympathetic tone becomes unopposed. *Hypotension and tachycardia* - This presentation is typical of other forms of shock, such as **hypovolemic** or **septic shock**, where the body attempts to compensate for low blood pressure with an increased heart rate. - In neurogenic shock, the sympathetic nervous system, which usually causes tachycardia, is dysfunctional. *Hypertension and tachycardia* - This combination is not characteristic of any form of shock; rather, it often indicates a **hyperadrenergic state** or certain types of **hypertensive crisis**. - Shock is fundamentally a state of inadequate tissue perfusion, which typically involves hypotension. *Hypertension and bradycardia* - This combination can be seen in conditions like **Cushing's reflex** (due to increased intracranial pressure) but is not a feature of neurogenic shock [1]. - Neurogenic shock is defined by a loss of sympathetic tone, which leads to vessel dilation and reduced blood pressure.

Q: In cases of severe head trauma, at what GCS is endotracheal intubation advised?

<=8. ***<=8*** - A **Glasgow Coma Scale (GCS) score of 8 or less** indicates significantly impaired consciousness, putting the patient at high risk for **airway compromise** and **aspiration**. - **Endotracheal intubation** is advised to protect the airway, ensure adequate ventilation, and facilitate neurological assessment and management in these critically ill patients. - This is the standard **"rule of 8"** used in trauma management protocols worldwide. *12* - A GCS score of 12, while indicating some level of altered consciousness, is generally **not low enough** to mandate immediate endotracheal intubation solely based on GCS criteria. - Patients with this GCS may still be able to **maintain their airway** and have a **gag reflex** intact, though close monitoring is crucial. *10* - A GCS score of 10 suggests moderate head injury and **altered mental status**, but generally, the patient can still **protect their airway** adequately. - While careful monitoring is essential, intubation is usually not indicated unless there are **other signs of respiratory compromise** or impending deterioration. *<=3* - A GCS score of 3 is the **lowest possible score**, indicating **deep coma** and severe neurological impairment, which would certainly warrant intubation. - However, this option is **too restrictive** as it would exclude patients with **GCS 4-8 who also require intubation** for airway protection. - The correct threshold is **GCS ≤8**, not just the most severe cases.

Q: Ten days after Splenectomy for blunt abdominal trauma, a 23-year-old man complains of upper abdominal and lower chest pain exacerbated by deep breathing. He is anorectic but ambulatory and otherwise making satisfactory progress. On examination his temperature is 38.2°C and he has decreased breath sounds at left lung base. His abdominal wound appears to be healing well, bowel sounds are active and there are no peritoneal signs. Digital rectal examination is negative. WBC 12,500/mm³ with a shift to left. CXR show 'plate like' atelectasis of the left lung field. Abdominal radiograph shows a non-specific gas pattern in bowel and an air-fluid level in LUQ. Serum Amylase is 150 Somogyi units per dL. The most likely diagnosis is:

Subphrenic abscess. ***Subphrenic abscess*** - The combination of **fever**, **leukocytosis**, **left upper quadrant (LUQ) pain**, an **air-fluid level in the LUQ**, and **basilar atelectasis** or pleural effusion following splenectomy is highly suggestive of a subphrenic abscess. - The spleen is located in close proximity to the diaphragm, and splenic injuries or surgery like splenectomy can lead to complications such as fluid collection and infection in the subphrenic space. *Pancreatitis* - While **upper abdominal pain** can be a symptom of pancreatitis, the serum amylase level of 150 Somogyi units/dL (normal range usually up to ~200 Somogyi units/dL) is **not significantly elevated** to suggest acute pancreatitis. - The patient's primary symptoms and radiological findings (air-fluid level in LUQ, basilar atelectasis) are more indicative of a localized fluid collection rather than diffuse pancreatic inflammation. *Subfascial wound infection* - A subfascial wound infection would typically present with signs of **localized inflammation** at the wound site, such as erythema, warmth, severe pain, and possibly purulent discharge. - The question states that the "abdominal wound appears to be **healing well**" and there are **no peritoneal signs**, making a subfascial wound infection less likely to be the primary cause of the patient's systemic symptoms and LUQ findings. *Pulmonary embolism* - Pulmonary embolism (PE) would typically present with **sudden onset dyspnea**, **pleuritic chest pain**, and potentially **hemoptysis** or hypoxemia, which are not described. - Although PE can cause chest pain exacerbated by deep breathing and atelectasis, the presence of **LUQ pain** and an **air-fluid level in the LUQ** points away from PE as the most likely diagnosis.

Q: Chronic subdural hematoma refers to collection present for a period of

21 days. ***21 days*** - A **chronic subdural hematoma (CSDH)** is medically defined as a subdural collection of blood that has been present for **at least 3 weeks or 21 days** [1]. - This time frame allows for the blood products to undergo significant degradation, leading to the characteristic appearance on imaging and specific clinical presentations [1]. *7 days* - A subdural hematoma present for 7 days would typically be classified as **subacute**, not chronic [1]. - At this stage, the hematoma is undergoing early changes, but has not reached the chronic phase of organization and liquefaction [1]. *1 year* - While a hematoma present for 1 year would certainly be chronic, the definition for **chronic subdural hematoma** is established much earlier than this, at 21 days. - A 1-year duration implies a very long-standing, often stable or slowly progressing lesion. *6 months* - A subdural hematoma present for 6 months is undeniably chronic, however, the medical classification for **chronic status** begins at 21 days. - This period is well past the threshold for calling it chronic, but not the earliest point of classification.

Q: Which of the following statements is true with reference to the Glasgow Coma Scale:

An overall score of less than 9 indicates a poor prognosis.. An overall score of less than 9 indicates a poor prognosis. * A Glasgow Coma Scale (GCS) score of 8 or less is generally considered a severe head injury [2] and an indicator of a poor neurological prognosis [1], often necessitating intubation and aggressive management. * This threshold is widely used to determine the severity of altered consciousness and guides critical care decisions. *Gives an accurate impression of the neurological status.* * The GCS provides a snapshot of consciousness at a specific time, but it does not fully encompass the entire neurological status, as it lacks information about pupillary responses, motor deficits, or brainstem reflexes [3]. * Its utility lies in assessing the level of consciousness and monitoring trends, rather than providing a comprehensive neurological examination [1]. *Cannot be assessed in an unconscious patient.* * The GCS is specifically designed to assess and monitor changes in the level of consciousness, including in patients who are unconscious [1]. * While some components, like verbal response, might be unassessable, the motor and eye opening components can still be evaluated and contribute to the total score. *In the first 24 hours following a head injury, an overall score of 11 indicates a good prognosis.* * While a GCS of 11 is considered a moderate head injury [2], a definitive "good prognosis" cannot be immediately concluded within the first 24 hours due to the risk of secondary brain injury and potential deterioration. * Prognosis in head injury is complex and depends on multiple factors, including imaging findings, age, and duration of coma, beyond just the initial GCS score.

Q: After rupture of middle meningeal artery bleeding occurs in which region?

Extradural bleed. ***Extradural bleed*** - A rupture of the **middle meningeal artery** is the classic cause of an **extradural (epidural) hematoma**. - This type of bleed occurs between the **dura mater** and the **inner surface of the skull**. *Subdural bleed* - A **subdural bleed** typically results from tearing of **bridging veins**, not arteries. - This bleeding occurs between the **dura mater** and the **arachnoid mater**. *Subarachnoid bleed* - A **subarachnoid bleed** most commonly results from the rupture of an **aneurysm** or arteriovenous malformation. - This bleed occurs in the space between the **arachnoid mater** and the **pia mater**, where cerebrospinal fluid circulates. *Intracerebral bleed* - An **intracerebral bleed** involves bleeding directly into the **brain parenchyma**. - This is often caused by **hypertension**, trauma, or an underlying vascular malformation, not typically a ruptured meningeal artery.

Q: IV fluid replacement (volume & rate) in a trauma patient is determined by:

Urine output. ***Urine output*** - **Urine output** is a sensitive indicator of **renal perfusion** and overall **hemodynamic stability**, reflecting adequate tissue perfusion and fluid resuscitation in trauma patients. - Maintaining a urine output of **0.5-1.0 mL/kg/hour** is a common target during fluid resuscitation, demonstrating effective restoration of circulating volume. *Chest condition* - The **"chest condition"** (interpreted as respiratory status or thoracic trauma) primarily guides management of ventilatory support and thoracic interventions, not directly IV fluid rates. - While significant chest trauma can impact hemodynamics, it does not alone determine the specific **volume and rate** of IV fluid resuscitation. *BP* - **Blood pressure (BP)** can be a delayed and insensitive indicator of **hypovolemia** in trauma, as compensatory mechanisms can maintain BP until significant blood loss has occurred. - Relying solely on BP may lead to inadequate resuscitation or fluid overload, especially in patients with pre-existing hypertension. *CVP* - **Central Venous Pressure (CVP)** reflects **right atrial pressure** and can be influenced by multiple factors, including cardiac function, intrathoracic pressure, and venous tone, making it an unreliable sole indicator of fluid status in trauma. - CVP measurements can be misleading in situations like **cardiac tamponade** or **tension pneumothorax**, which are common in severe trauma.

Q: True about Aortic transection:

All of the options. ***All of the options*** - All three statements about aortic transection are medically accurate, making this the correct answer. - **Aortic transection** is typically caused by **deceleration injury** (especially in motor vehicle accidents), has **extremely high mortality if untreated** (approaching 90% within 24 hours), and requires **urgent surgical or endovascular repair** as definitive management. - The injury occurs when sudden deceleration causes **shearing forces** at the **aortic isthmus** (near the ligamentum arteriosum), where the mobile aortic arch meets the fixed descending aorta. *Surgical repair is the definitive treatment - Incomplete alone* - While this statement is true, selecting only this option would miss the critical information about etiology and prognosis. - Treatment options include **open surgical repair** or **TEVAR (thoracic endovascular aortic repair)**, with endovascular approaches increasingly preferred when anatomically feasible. *Associated with high mortality if untreated - Incomplete alone* - This is accurate but doesn't capture the mechanism of injury or treatment approach. - Without treatment, **80-90% of patients die within 24 hours** due to free rupture and exsanguination. *Most commonly caused by deceleration injury in motor vehicle accidents - Incomplete alone* - True regarding mechanism, but omits the critical prognostic and therapeutic information. - **High-speed MVA** and **falls from height** are classic causes, with the descending aorta tethered by intercostal arteries while the heart and arch continue moving forward.

Question 1

Which of the following is false about diaphragmatic injury?

Accepted Answer

No respiratory distress

Answer

Left side is common

Answer

Delayed presentation

Answer

Primary repair is preferred

Question 2

Which of the following is the safest initial approach to open the airway in a patient with maxillofacial trauma?

Accepted Answer

Jaw thrust technique

Answer

Head tilt-chin lift

Answer

Head lift-neck lift

Answer

Heimlich procedure

Question 3

Neurogenic shock is characterized by:

Accepted Answer

Hypotension and bradycardia

Answer

Hypotension and tachycardia

Answer

Hypertension and tachycardia

Answer

Hypertension and bradycardia

Question 4

In cases of severe head trauma, at what GCS is endotracheal intubation advised?

Accepted Answer

<=8

Answer

12

Answer

10

Answer

<=3

Question 5

Ten days after Splenectomy for blunt abdominal trauma, a 23-year-old man complains of upper abdominal and lower chest pain exacerbated by deep breathing. He is anorectic but ambulatory and otherwise making satisfactory progress. On examination his temperature is 38.2°C and he has decreased breath sounds at left lung base. His abdominal wound appears to be healing well, bowel sounds are active and there are no peritoneal signs. Digital rectal examination is negative. WBC 12,500/mm³ with a shift to left. CXR show 'plate like' atelectasis of the left lung field. Abdominal radiograph shows a non-specific gas pattern in bowel and an air-fluid level in LUQ. Serum Amylase is 150 Somogyi units per dL. The most likely diagnosis is:

Accepted Answer

Subphrenic abscess

Answer

Pancreatitis

Answer

Subfascial wound infection

Answer

Pulmonary embolism

Question 6

Chronic subdural hematoma refers to collection present for a period of

Accepted Answer

21 days

Answer

7 days

Answer

1 year

Answer

6 months

Question 7

Which of the following statements is true with reference to the Glasgow Coma Scale:

Accepted Answer

An overall score of less than 9 indicates a poor prognosis.

Answer

Gives an accurate impression of the neurological status.

Answer

Cannot be assessed in an unconscious patient.

Answer

In the first 24 hours following a head injury, an overall score of 11 indicates a good prognosis.

Question 8

After rupture of middle meningeal artery bleeding occurs in which region?

Accepted Answer

Extradural bleed

Answer

Subdural bleed

Answer

Subarachnoid bleed

Answer

Intracerebral bleed

Question 9

IV fluid replacement (volume & rate) in a trauma patient is determined by:

Accepted Answer

Urine output

Answer

Chest condition

Answer

BP

Answer

CVP

Question 10

True about Aortic transection:

Accepted Answer

All of the options

Answer

Surgical repair is the definitive treatment

Answer

Associated with high mortality if untreated

Answer

Most commonly caused by deceleration injury in motor vehicle accidents

Trauma — MCQs

Trauma — MCQs

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