Trauma Practice Questions

Q: Patient was in an accident and put on mechanical ventilation. He is opening his eyes on verbal command and follows motor commands with all four limbs. What is his GCS score?

10. ***10*** - **Eye-opening on verbal command scores 3 points** on the GCS (E3). - **Following motor commands with all four limbs scores 6 points** on the GCS (M6). - The patient is on **mechanical ventilation, meaning verbal response is untestable** and scores **1 point (V1T)** for intubated patients. - **Total GCS score: E3 + V1T + M6 = 10T** *12* - This score would incorrectly assume a verbal response of 5 (oriented), which is impossible for an intubated patient. - Would require: E3 + V5 + M4 or similar incorrect combinations that don't match the clinical presentation. *11* - This score would result from incorrect component assignment. - For example, E3 + V2 + M6 = 11, but verbal response cannot be 2 in an intubated patient (must be 1T). - Does not align with the untestable verbal response due to mechanical ventilation. *9* - This score underestimates the patient's neurological status. - Would require: E2 + V1 + M6 = 9, which contradicts the finding that the patient opens eyes on verbal command (E3, not E2). - Incorrectly assigns lower eye-opening score than the clinical presentation indicates.

Q: A man is brought to casualty who met with an accident. He sustained multiple rib fractures with paradoxical movement of chest. Management is

Intermittent positive pressure ventilation. ***Intermittent positive pressure ventilation*** - **Paradoxical movement of the chest** (flail chest) indicates instability of the chest wall, impairing effective ventilation. - **Intermittent positive pressure ventilation (IPPV)** helps to stabilize the chest wall internally by applying positive pressure, improving oxygenation and reducing the work of breathing. *Consult cardiothoracic surgeon* - While a cardiothoracic surgeon might be involved for severe cases or surgical fixation, **immediate management for respiratory compromise due to flail chest** is focused on ventilation support. - Consulting a surgeon would be part of a broader management plan, but not the primary immediate intervention for ventilatory failure. *Tracheostomy* - **Tracheostomy** is a surgical procedure to create an airway, typically considered for long-term ventilation or upper airway obstruction. - It is not the immediate intervention for acute flail chest, as **endotracheal intubation** for IPPV would be performed first if needed. *Strapping* - **Strapping** the chest (e.g., with tape or bandages) is **contraindicated** in flail chest. - It restricts chest wall movement unnecessarily, **impairs ventilation**, and can exacerbate respiratory distress and atelectasis.

Q: Initial fluid of choice in treatment of hypovolemia in patients presenting after trauma is

Crystalloid. ***Crystalloid*** - **Crystalloids** such as normal saline or lactated Ringer's solution are the initial fluid of choice for **hypovolemia in trauma patients** due to their ready availability, low cost, and effectiveness in rapidly expanding the intravascular volume. - They freely distribute across the extracellular space, effectively compensating for fluid loss and supporting organ perfusion. *Blood* - While essential for significant **hemorrhage**, blood products are typically reserved for patients who do not respond to crystalloid resuscitation or have documented severe blood loss. - Transfusion carries risks such as **transfusion reactions**, and blood preparation and cross-matching take time, making them less suitable for initial, rapid fluid replacement. *Colloid* - **Colloids** (e.g., albumin, starches) are larger molecules that theoretically remain in the intravascular space longer, but their benefits over crystalloids in trauma are controversial and they are significantly more expensive. - Some colloids have been associated with adverse effects like **renal dysfunction** or **coagulopathy**, making crystalloids a safer initial option. *Plasma expanders* - **Plasma expanders** is a broad term that includes both colloids and some hypertonic crystalloid solutions, but it is not commonly used as a primary, specific category for initial fluid resuscitation. - The potential benefits of these agents are still debated, and they are typically not recommended as the first-line choice in the acute management of **traumatic hypovolemic shock**.

Q: A 25-year-old male college student presents to emergency after road traffic accident. Patient is in state of shock and breath sounds are decreased on the side of chest trauma (left side). Normal heart sounds, no elevated JVP and dull note on percussion. What is the diagnosis?

Massive Hemothorax. ***Massive Hemothorax*** - The combination of **shock**, **decreased breath sounds**, and **dullness to percussion** on the injured side is highly indicative of massive hemothorax. - A massive hemothorax involves rapid accumulation of a large volume of blood (typically >1500 mL) in the pleural space, leading to significant **hypovolemic shock** and **respiratory compromise**. *Cardiac tamponade* - Characterized by **Beck's triad**: **hypotension**, **muffled heart sounds**, and **elevated JVP**, none of which are fully present here (heart sounds are normal, JVP is not elevated). - While it can cause shock, the lung findings (decreased breath sounds, dullness) point away from a primary cardiac issue. *Flail chest* - Defined by **paradoxical chest wall movement** due to fractures of multiple adjacent ribs in two or more places, which is not mentioned in the presentation. - Although it can lead to respiratory distress, it typically presents with crepitus and localized pain, not necessarily with dullness to percussion or profound shock from blood loss. *Tension pneumothorax* - Presents with **absent or decreased breath sounds** and **hyperresonance to percussion** on the affected side, along with **tracheal deviation** away from the affected side and distended neck veins. - The key differentiating factor here is the **dullness to percussion**, which is inconsistent with the air accumulation seen in tension pneumothorax.

Q: A patient is brought to the emergency as a case of head injury, following a head on collision road traffic accident. Patient is unconscious and his right pupil is dilated. CT scan is not available. What's the next step in management

Burrhole right side. ***Burrhole right side*** - A unilaterally dilated pupil in a head injury patient indicates **herniation syndrome** due to increasing intracranial pressure, often from an **epidural hematoma** on the same side. - In the absence of a CT scan, an urgent **burr hole** on the side of the dilated pupil (right side in this case) is a life-saving measure to evacuate the hematoma and decompress the brain. - The dilated pupil confirms **ipsilateral oculomotor nerve compression**, guiding the side for surgical intervention. *Craniotomy right side* - A **craniotomy** is a more extensive procedure typically performed after diagnostic imaging (CT scan) has confirmed the exact location and size of the hematoma. - In an emergency setting with an unconscious patient and no CT, a burr hole is a faster, less invasive, and potentially life-saving initial intervention. *Burrhole left side* - Performing a burr hole on the **left side** would be incorrect because the dilated pupil is on the right side, indicating the probable location of the brain compression on the **ipsilateral** side. - This could lead to a delay in addressing the actual pathology and worsen the patient's neurological outcome. *Craniotomy left side* - A craniotomy on the **left side** would be inappropriate for the same reasons as a burr hole on the left side: the dilated pupil points to a lesion on the **right side**. - Furthermore, a craniotomy is generally not the initial emergency procedure without imaging in such a critical situation.

Q: Feature of third-degree burn:

Whole dermis destroyed. ***Whole dermis destroyed*** - A **third-degree burn** involves the complete destruction of the **epidermis** and **dermis**, extending into the subcutaneous tissue. - This extensive damage results in a leathery, stiff, and often waxy white, brown, or charred black appearance. *Pain present* - Third-degree burns typically cause **no pain** in the burned area itself because the nerve endings in the dermis have been completely destroyed. - While there may be pain surrounding a third-degree burn due to less severe burn areas, the core third-degree area is numb. *Transudation of fluid present* - **Transudation of fluid** (blister formation and significant edema) is a prominent feature of **second-degree burns**, where the epidermis separates from the dermis. - In third-degree burns, the skin is destroyed, and the protein-rich fluid tends to **coagulate** within the damaged tissues rather than forming blisters or freely transuding. *Erythematous in appearance* - **Erythema** (redness) is characteristic of **first-degree burns** and **superficial second-degree burns**, due to vasodilation in the intact dermis. - Third-degree burns are typically **waxy white, leathery, charred black, or brown**, not red, due to the destruction of blood vessels and tissue necrosis.

Q: What is the investigation of choice for blunt abdominal trauma in an unstable patient?

USG. ***USG (FAST Exam)*** - In an **unstable patient** with blunt abdominal trauma, **Focused Assessment with Sonography for Trauma (FAST) exam** is the investigation of choice. - It is **rapid, non-invasive, and bedside**, allowing immediate detection of **free fluid** (blood) in the peritoneal cavity, pericardium, and pleural spaces without transporting the patient. - Guides immediate decision for **laparotomy** in hemodynamically unstable patients. - **Note:** In **stable patients**, **CT abdomen** is the gold standard as it provides detailed anatomical information, but it requires patient transport and time. *X-ray abdomen* - Provides limited information in blunt trauma, primarily showing **free air** (bowel perforation) or **bony fractures**. - **Not sensitive** for detecting intraperitoneal bleeding, which is the primary concern in unstable patients. *MRI* - Offers excellent soft tissue detail but is **time-consuming** and requires the patient to be **hemodynamically stable**. - **Impractical** for unstable trauma patients requiring rapid assessment and intervention. *Diagnostic Peritoneal Lavage (DPL)* - An **invasive procedure** that is sensitive for detecting intra-abdominal hemorrhage. - Has largely been **replaced by FAST exam** in most trauma centers due to FAST being non-invasive, rapid, and repeatable. - DPL has a **higher false-positive rate** and cannot identify the source of bleeding.

Q: A third degree circumferential burn in the arm and forearm region, which of the following is most important for monitoring -

Peripheral pulse and circulation. ***Peripheral pulse and circulation*** - **Circumferential third-degree burns** can act as a tourniquet, leading to **compartment syndrome** and critically impaired blood flow to the distal limb due to edema accumulating beneath the inelastic burn eschar. - Monitoring **peripheral pulses** and assessing **capillary refill** and skin color are crucial to detect early signs of **ischemia** and prompt intervention like escharotomy. *Blood gases* - While important in severely burned patients for assessing **respiratory status** and overall metabolic acid-base balance, it is not the *most immediate and critical* concern for a localized circumferential burn. - **Hypoxemia** or **acidosis** can result from extensive burns or smoke inhalation, but the primary threat from a circumferential limb burn is **limb viability**. *Carboxy-oxygen level* - This likely refers to **carboxyhemoglobin (COHb) levels**, which are vital for detecting **carbon monoxide poisoning**, especially in burn patients exposed to smoke inhalation. - While important for systemic toxicity, it doesn't directly address the immediate threat of vascular compromise to the limb from a circumferential burn. *Urine output* - Monitoring **urine output** is essential in extensive burn management as part of **fluid resuscitation** protocols (e.g., Parkland formula), targeting 0.5-1 mL/kg/hr to ensure adequate tissue perfusion. - However, for a **localized circumferential limb burn**, the immediate priority is preventing **limb ischemia** and potential loss, making peripheral pulse monitoring more critical than systemic fluid balance indicators.

Q: Escharotomies are required in which degree/type of burns:

3rd degree (full thickness). ***3rd degree (full thickness)*** - **Full-thickness burns** destroy all layers of the skin, including nerve endings, making the burn site **insensate** and forming a tough, non-elastic eschar. - This **rigid eschar** can impair circulation, especially in circumferential burns, and restrict ventilation in thoracic burns, necessitating **escharotomies** to relieve pressure and restore blood flow or breathing. *1st degree* - **First-degree burns** only affect the epidermis, causing redness and mild pain without blistering; they do not form a constricting eschar. - These burns heal spontaneously within a few days and do not require surgical intervention like **escharotomies**. *Electrical* - **Electrical burns** can cause deep tissue damage and internal organ injury, but the primary concern is often cardiac arrhythmias and deep tissue necrosis rather than a constricting eschar that requires escharotomy. - While they can lead to full-thickness skin damage, **escharotomy** is performed if a full thickness burn with constricting eschar. The primary reason for escharotomy is the nature of the burn not its cause. *2nd degree superficial* - **Superficial partial-thickness burns** involve the epidermis and superficial dermis, causing blisters, pain, and redness, but the skin remains pliable and does not form a constricting eschar. - These burns typically heal without scarring and do not require **escharotomies**.

Question 1

Patient was in an accident and put on mechanical ventilation. He is opening his eyes on verbal command and follows motor commands with all four limbs. What is his GCS score?

Accepted Answer

10

Answer

12

Answer

11

Answer

9

Question 2

A male patient has a sucking stab wound to the chest. Which action should the nurse take first?

Accepted Answer

Applying a dressing over the wound and taping it on three sides

Answer

Preparing to start an I.V. line

Answer

Preparing a chest tube insertion tray

Answer

Drawing blood for a hematocrit and hemoglobin level

Question 3

A man is brought to casualty who met with an accident. He sustained multiple rib fractures with paradoxical movement of chest. Management is

Accepted Answer

Intermittent positive pressure ventilation

Answer

Consult cardiothoracic surgeon

Answer

Tracheostomy

Answer

Strapping

Question 4

Initial fluid of choice in treatment of hypovolemia in patients presenting after trauma is

Accepted Answer

Crystalloid

Answer

Blood

Answer

Colloid

Answer

Plasma expanders

Question 5

A 25-year-old male college student presents to emergency after road traffic accident. Patient is in state of shock and breath sounds are decreased on the side of chest trauma (left side). Normal heart sounds, no elevated JVP and dull note on percussion. What is the diagnosis?

Accepted Answer

Massive Hemothorax

Answer

Cardiac tamponade

Answer

Flail chest

Answer

Tension pneumothorax

Question 6

A patient is brought to the emergency as a case of head injury, following a head on collision road traffic accident. Patient is unconscious and his right pupil is dilated. CT scan is not available. What's the next step in management

Accepted Answer

Burrhole right side

Answer

Craniotomy right side

Answer

Burrhole left side

Answer

Craniotomy left side

Question 7

Feature of third-degree burn:

Accepted Answer

Whole dermis destroyed

Answer

Pain present

Answer

Transudation of fluid present

Answer

Erythematous in appearance

Question 8

What is the investigation of choice for blunt abdominal trauma in an unstable patient?

Accepted Answer

USG

Answer

X-ray abdomen

Answer

MRI

Answer

Diagnostic Peritoneal Lavage (DPL)

Question 9

A third degree circumferential burn in the arm and forearm region, which of the following is most important for monitoring -

Accepted Answer

Peripheral pulse and circulation

Answer

Blood gases

Answer

Carboxy-oxygen level

Answer

Urine output

Question 10

Escharotomies are required in which degree/type of burns:

Accepted Answer

3rd degree (full thickness)

Answer

1st degree

Answer

Electrical

Answer

2nd degree superficial

Trauma — MCQs

Trauma — MCQs

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