Trauma Practice Questions

Q: All are true about Flail chest, except:

Paradoxical movement is never seen in flail chest. ***Paradoxical movement is never seen in flail chest*** - A definitive characteristic of a **flail chest** is the **paradoxical movement** of the chest wall segment. - This occurs because the **detached segment** moves inward during inspiration and outward during expiration, opposite to the rest of the chest. *If overlapping of fractured ribs with severe displacement is seen then patients are treated surgically with open reduction and fixation* - **Surgical fixation** is indicated for **severely displaced** or overlapping rib fractures in flail chest to stabilize the chest wall and improve respiratory mechanics. - This intervention aims to reduce pain, shorten ventilator time, and prevent long-term pulmonary complications. *Pa02 < 60 treated with intubation and PEEP* - **Hypoxemia** with a **PaO2 persistently below 60 mmHg** in a flail chest patient despite supplemental oxygen is a strong indication for **endotracheal intubation** and **positive end-expiratory pressure (PEEP)**. - PEEP helps to re-expand collapsed alveoli, improve oxygenation, and stabilize the flail segment internally. *Fracture of atleast 3 ribs* - A flail chest is defined as a fracture of **three or more adjacent ribs** in **two or more places**, creating a segment of the chest wall that is no longer continuous with the rest of the thoracic cage. - This discontinuity is what causes the characteristic paradoxical motion and compromises ventilatory mechanics.

Q: A patient met with an accident and presents with paralysis of both upper and lower limbs. The patient has not passed urine and tenderness is elicited in the cervical region. What is the most appropriate immediate management?

The patient should not be shifted and portable x-ray machine should be used after neck stabilization. ***The patient should not be shifted and portable x-ray machine should be used after neck stabilization*** - This approach minimizes movement of a potentially unstable cervical spine fracture, preventing further neurological damage and optimizing patient safety. - **Spinal immobilization** (e.g., with a cervical collar and backboard) is the first priority before any diagnostic imaging to protect the spinal cord. - Using a **portable X-ray** avoids the need to transport the patient to radiology, adhering to trauma management principles. *The doctor will instruct the radiographer to take cervical and chest x-ray* - While cervical and chest X-rays are appropriate investigations, this option lacks the critical detail of **neck stabilization** and the need for a **portable X-ray** to avoid patient movement. - Moving the patient to a radiology suite for standard X-rays can exacerbate a spinal injury, especially without proper immobilization. *The doctor should order a cervical x-ray and shift the patient from the trolley by himself* - Shifting the patient from the trolley without adequate assistance and proper technique carries a high risk of causing further **spinal cord damage** due to uncontrolled movement. - This approach directly violates principles of **spinal precautions** in trauma management and requires at least 4-5 trained personnel for safe log-rolling. *The doctor will instruct the radiographer to take cervical x-ray AP and lateral view without any cervical support* - Taking X-rays without **cervical support** or immobilization is extremely dangerous in a patient with suspected cervical spine injury and paralysis. - Lack of support during imaging can lead to increased spinal instability and potentially irreversible **neurological deficits** or even death.

Q: Steering wheel injury on chest of a young man reveals multiple fractures of ribs and paradoxical movement with severe respiratory distress. X-ray shows pulmonary contusion on right side without pneumothorax. What is the initial treatment of choice?

Endotracheal intubation and mechanical ventilation. ***Endotracheal intubation and mechanical ventilation*** - The presence of **paradoxical chest wall movement** (flail chest) with **severe respiratory distress** indicates compromised ventilation and impending respiratory failure. - **Mechanical ventilation** provides **internal pneumatic stabilization** of the chest wall, restores adequate oxygenation, and supports breathing in patients with severe flail chest and pulmonary contusion. - In the setting of **severe respiratory distress**, immediate airway control and ventilatory support take priority. *Thoracic epidural analgesia and O2 therapy* - **Epidural analgesia** with oxygen therapy is an effective strategy for flail chest management and may be adequate for patients **without severe respiratory distress**. - However, in the presence of **severe respiratory distress** as described in this scenario, more definitive airway management is required first. - This approach alone is insufficient when ventilatory failure is imminent or present. *Immediate internal fixation* - While surgical rib fixation can be considered for severe flail chest, it is typically a **delayed intervention** performed after initial stabilization and resuscitation. - **Immediate surgery** for rib fixation is not the priority in an acutely distressed patient requiring urgent airway management. *Stabilization with towel clips* - **External stabilization** methods like towel clips or weighted sandbags were historically used but are **no longer recommended** due to poor effectiveness and potential complications. - These methods do not address the underlying ventilatory failure and can impede respiratory mechanics further.

Q: A patient who met with an accident presented to the emergency department, he lost 25% of his total blood volume approximately, blood pressure is normal. He/she will be classified under which class of hypovolemic shock?

Class II. ***Class II*** - A 25% blood loss (within the **15-30% range**), with **blood pressure remaining normal**, categorizes this patient into **Class II hypovolemic shock**. - In Class II, compensatory mechanisms such as increased **heart rate** and **peripheral vasoconstriction** maintain systolic blood pressure despite significant volume loss. - Patients typically present with **tachycardia (100-120 bpm)**, **narrowed pulse pressure**, mild **anxiety**, and **normal systolic BP**. *Class I* - Class I shock involves **minimal blood loss** (up to 15%), with blood loss <750 mL in adults. - Patients in Class I typically present with **normal vital signs** and minimal to no clinical symptoms. - The 25% blood loss exceeds the threshold for Class I classification. *Class III* - Class III shock is characterized by blood loss of **30-40%** (1500-2000 mL in adults). - This level of loss typically results in **decreased systolic blood pressure**, **marked tachycardia (120-140 bpm)**, **confusion**, and clinical instability. - The patient's normal blood pressure and 25% loss are **below the threshold** for Class III shock. *Class IV* - Class IV shock involves massive blood loss of **greater than 40%** (>2000 mL in adults). - Presents with profound **hypotension**, **severe tachycardia (>140 bpm)**, **altered consciousness**, and **imminent cardiovascular collapse**. - This patient's normal blood pressure and stable condition are inconsistent with Class IV shock.

Q: Which of the following is the most common cause of hypotension in fractures of the lower ribs (ribs 10-12)?

Abdominal solid visceral organ injury. ***Abdominal solid visceral organ injury*** - Fractures of the **lower ribs (T10-T12)** are highly suggestive of associated injury to **intra-abdominal solid organs**, such as the **spleen, liver, or kidneys**. - These organs are highly vascular, and trauma can lead to significant **hemorrhage** into the abdominal cavity, causing **hypotension** and hypovolemic shock. *Injury to aorta* - While an aortic injury is life-threatening and causes severe hypotension, it is less commonly associated with **isolated lower rib fractures (T10-T12)**. - Aortic injuries are more often linked to severe blunt trauma with **deceleration forces** or fractures of the **upper ribs** and sternum. *Intercostal artery damage* - Damage to intercostal arteries can cause bleeding and contribute to hematomas, but the volume of blood loss is usually **insufficient** to cause severe systemic **hypotension** alone. - Intercostal artery hemorrhage is typically localized and does not quickly lead to hypovolemic shock unless multiple vessels are involved or combined with other injuries. *Pulmonary contusion* - A pulmonary contusion is bruising of the lung tissue that can impair gas exchange and potentially lead to **respiratory distress** and hypoxemia. - While it can be serious, a pulmonary contusion generally does not directly cause significant **blood loss** or severe **hypotension** as its primary effect.

Q: In splenic injury, conservative management is done in which of the following?

Young patient. ***Young patient*** - **Conservative management** of splenic injury is often favored in **younger patients** due to their greater capacity for healing and the desire to preserve splenic function. - The risk of **overwhelming post-splenectomy infection (OPSI)** is higher in children, making splenic preservation a priority. *Extreme pallor and hypotension* - **Extreme pallor** and **hypotension** are signs of significant blood loss and **hemodynamic instability**, which typically necessitate surgical intervention. - **Conservative management** is usually contraindicated in such cases as the patient is actively bleeding. *Shattered spleen* - A **shattered spleen** indicates a severe, often **grade IV or V** splenic injury, where the spleen is extensively fragmented. - This level of injury is associated with uncontrollable bleeding and almost always requires **splenectomy**. *Hemodynamically unstable* - **Hemodynamic instability**, characterized by persistent hypotension, tachycardia, or inadequate organ perfusion, is a **contraindication** to conservative management. - Patients who are **hemodynamically unstable** need immediate surgical exploration to control bleeding.

Q: Wallace rule is better known as?

Rule of 9 in burn assessment. ***Rule of 9 in burn assessment*** - The **Wallace rule**, also known as the **Rule of Nines**, is a standardized clinical tool used to estimate the total body surface area (TBSA) affected by burns in adults. - It divides the body into sections that are roughly 9% or multiples of 9% of the total body surface area to guide fluid resuscitation. *Rule of 10% in pheochromocytoma* - The **Rule of 10%** in pheochromocytoma describes that approximately **10% of pheochromocytomas** are extra-adrenal, bilateral, malignant, or familial. - This rule is not referred to as the Wallace rule. *Rule of 90% in pheochromocytoma* - This term is **not a recognized medical rule** or mnemonic. - It does not correspond to any established clinical guidelines for pheochromocytoma. *None of the options* - This option is incorrect because the **Rule of 9 in burn assessment** is the correct alternative name for the Wallace rule.

Q: The cause of systemic secondary insult to injured brain include all of the following except :

Therapeutic hypothermia. Therapeutic hypothermia - This is a treatment strategy used to mitigate secondary brain injury by reducing metabolic demand and inflammation, thus it is not a cause of secondary insult. [1] - Therapeutic hypothermia aims to improve neurological outcomes after initial brain injury. [1] Hypercapnia - Elevated arterial CO2 causes cerebral vasodilation, leading to increased cerebral blood volume and intracranial pressure (ICP). [2] - Increased ICP can compromise cerebral perfusion pressure and exacerbate secondary brain injury in an already vulnerable brain. Hypoxemia - Reduced oxygen delivery to the brain can lead to further neuronal damage and cell death, especially in an injured brain with compromised metabolic needs. [1], [2] - This directly contributes to ischemic injury and worsens the neurological outcome. Hypotension - Low blood pressure reduces cerebral perfusion pressure (CPP), directly decreasing blood flow to the brain. - This can cause or worsen cerebral ischemia, leading to further secondary brain injury and poorer patient outcomes.

Question 1

A 45-year-old with trauma presents after 4 hours with cheek swelling and has not passed urine. On examination, crepitus is palpated with periorbital swelling. What is your diagnosis?

Accepted Answer

Base of skull fracture

Answer

Lung laceration

Answer

Renal shut down

Answer

Gas gangrene

Question 2

All are true about Flail chest, except:

Accepted Answer

Paradoxical movement is never seen in flail chest

Answer

If overlapping of fractured ribs with severe displacement is seen then patients are treated surgically with open reduction and fixation

Answer

PaO2 < 60 treated with intubation and PEEP

Answer

Fracture of at least 3 ribs

Question 3

A patient met with an accident and presents with paralysis of both upper and lower limbs. The patient has not passed urine and tenderness is elicited in the cervical region. What is the most appropriate immediate management?

Accepted Answer

The patient should not be shifted and portable x-ray machine should be used after neck stabilization

Answer

The doctor will instruct the radiographer to take cervical and chest x-ray

Answer

The doctor should order a cervical x-ray and shift the patient from the trolley by himself

Answer

The doctor will instruct the radiographer to take cervical x-ray AP and lateral view without any cervical support

Question 4

Steering wheel injury on chest of a young man reveals multiple fractures of ribs and paradoxical movement with severe respiratory distress. X-ray shows pulmonary contusion on right side without pneumothorax. What is the initial treatment of choice?

Accepted Answer

Endotracheal intubation and mechanical ventilation

Answer

Immediate internal fixation

Answer

Thoracic epidural analgesia and O2 therapy

Answer

Stabilization with towel clips

Question 5

A patient who met with an accident presented to the emergency department, he lost 25% of his total blood volume approximately, blood pressure is normal. He/she will be classified under which class of hypovolemic shock?

Accepted Answer

Class II

Answer

Class I

Answer

Class III

Answer

Class IV

Question 6

Which of the following is the most common cause of hypotension in fractures of the lower ribs (ribs 10-12)?

Accepted Answer

Abdominal solid visceral organ injury

Answer

Injury to aorta

Answer

Intercostal artery damage

Answer

Pulmonary contusion

Question 7

In splenic injury, conservative management is done in which of the following?

Accepted Answer

Young patient

Answer

Extreme pallor and hypotension

Answer

Shattered spleen

Answer

Hemodynamically unstable

Question 8

Wallace rule is better known as?

Accepted Answer

Rule of 9 in burn assessment

Answer

Rule of 10% in pheochromocytoma

Answer

Rule of 90% in pheochromocytoma

Answer

None of the options

Question 9

The cause of systemic secondary insult to injured brain include all of the following except :

Accepted Answer

Therapeutic hypothermia

Answer

Hypercapnia

Answer

Hypoxaemia

Answer

Hypotension

Question 10

Following road traffic accident, a patient with vague abdominal pain was immediately taken to the operation theatre for emergency laparotomy. On examination, a large, contained, stable, non-pulsatile retroperitoneal hematoma was found on the right side. One-shot IVU shows a barely discernible nephrogram on the right side and prompt uptake and excretion on the left side. What should be the next step to be done?

Accepted Answer

Isolate the proximal renal vessels, open the Gerota's fascia and explore the kidney

Answer

Nephrectomy

Answer

Perform on table retrograde pyelography

Answer

Perform on table angiography

Trauma — MCQs

Trauma — MCQs

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