Trauma Practice Questions

Q: A 40 year old male driver had a car accident in which he got wedged in between. He complained of severe abdominal pain with radiation to the back. The initial CT on admission was negative except for minimal retroperitoneal hematoma. The diagnosis is

Pancreatic injury. ***Pancreatic injury*** - Severe **abdominal pain radiating to the back** after blunt trauma is a classic presentation for **pancreatic injury**, especially with a crushing mechanism as described. - Initial CT scans can be deceptively negative, as pancreatic injuries, particularly **ductal disruptions**, may not be immediately obvious, but a **minimal retroperitoneal hematoma** can be an early subtle sign. *Liver injury* - While liver injury is common in blunt abdominal trauma, it typically presents with right upper quadrant pain and is usually visible on initial CT scans, often with signs of **hemoperitoneum** or a clear parenchymal laceration. - **Pain radiation to the back** is less characteristic of an isolated liver injury compared to pancreatic pathology. *Bowel rupture* - Bowel rupture can cause significant abdominal pain, but it often leads to signs of **peritonitis** and may show **free air** on imaging or significant fluid collections not typically described as a "minimal retroperitoneal hematoma." - The mechanism of injury (wedged in between) can cause bowel injury, but the radiating back pain without peritonitis makes other diagnoses more likely. *Duodenal perforation* - **Duodenal perforation**, similar to pancreatic injury, can be subtle and cause retroperitoneal signs due to its retroperitoneal location. - However, the description of "minimal retroperitoneal hematoma" is less specific for a perforation, which often leads to **extravasation of gastric/duodenal contents** and more extensive inflammatory changes.

Q: Treatment of choice in traumatic facial nerve injury with delayed onset or incomplete paralysis is -

Masterly inactivity. ***Masterly inactivity*** - In traumatic facial nerve injuries with **delayed onset or incomplete paralysis**, the prognosis for **spontaneous recovery** is excellent (up to 90%). - This approach involves careful observation with serial clinical examinations, allowing time for nerve recovery without the risks of surgical intervention. - **Surgical exploration** is reserved for immediate complete paralysis or when electrodiagnostic tests (electromyography, electroneuronography) show >90% degeneration. *Facial decompression* - This surgical procedure is considered only in cases of **immediate complete paralysis** with temporal bone fractures and confirmed severe nerve degeneration on testing. - It is **not indicated** for delayed-onset or incomplete injuries, as these have excellent spontaneous recovery rates. - Carries risks of further nerve damage, CSF leak, and hearing loss. *Facial sling* - A facial sling is a **late reconstructive procedure** used for permanent facial paralysis when nerve recovery has failed after 1-2 years. - It is a palliative measure to improve facial symmetry and eye protection, not a treatment for acute nerve injury. *Systemic corticosteroid* - While corticosteroids have a role in **Bell's palsy** (idiopathic facial paralysis), their benefit in **traumatic facial nerve injury is unproven**. - The primary pathology in trauma is mechanical disruption, not inflammatory edema that would respond to steroids. - Some clinicians use steroids empirically, but evidence does not support this as standard treatment.

Q: To calculate the initial fluid requirement in a burn patient, the best approach is:

Estimate body surface area (burn). ***Estimate body surface area (burn)*** - The primary determinant for initial fluid resuscitation in burn patients is the **total body surface area (TBSA)** affected by the burn. Formulas like the **Parkland formula** use TBSA to calculate initial fluid requirements. - Accurate estimation of TBSA is crucial for preventing both under-resuscitation (leading to shock) and over-resuscitation (leading to complications like compartment syndrome or ARDS). *CVP* - **Central venous pressure (CVP)** is generally not a reliable indicator for guiding fluid resuscitation in burn patients due to its poor correlation with cardiac output and tissue perfusion in this specific patient population. - Changes in CVP can be influenced by many factors, including intrathoracic pressure and right ventricular function, making it an insensitive marker for systemic fluid status in significant burns. *Urine output* - While **urine output** is an essential parameter for monitoring the adequacy of fluid resuscitation in burn patients *after* initial fluid administration, it is not used to *investigate* or *calculate* the initial fluid requirement. - It serves as a real-time indicator of organ perfusion and helps in titrating fluid rates but does not determine the initial bolus or 24-hour fluid volume. *Blood volume measurement* - **Direct measurement of blood volume** is a complex and often invasive procedure that is not practical or readily available for emergency assessment and initial fluid calculation in burn patients. - It is not a standard method for calculating initial fluid requirements in acute burn care.

Q: A 19 year old girl sustained blunt abdominal trauma. She was diagnosed of having splenic rupture. Her pulse is 110/min and BP is normal. She is tachypneic with respiratory rate of 22/min and she is anxious. Her approximate blood loss is -

750 - 1500ml. ***750 - 1500ml*** - The patient's **pulse of 110/min**, **normal blood pressure**, tachypnea (22/min), and anxiety are indicative of **Class II hemorrhage**, which typically involves a blood loss of 750-1500 ml. - In Class II hemorrhage, the body's compensatory mechanisms maintain blood pressure, but **tachycardia** (pulse >100 bpm) is a primary sign, often accompanied by **anxiety** and increased respiratory rate. *1500 - 2000ml* - A blood loss of 1500-2000 ml (Class III hemorrhage) would typically present with **significant hypotension** (systolic BP 120 bpm), and altered mental status. - The patient's **normal blood pressure** rules out this extent of blood loss. * 2000ml* - A blood loss of more than 2000 ml (Class IV hemorrhage) is a life-threatening condition presenting with **profound hypovolemic shock**, including severe hypotension, marked tachycardia (>140 bpm), and usually unresponsiveness. - The patient's **normal blood pressure** and only moderate tachycardia do not align with this massive blood loss.

Q: In an unconscious patient, spinal injury is assessed by:

All of the options. ***All of the options*** In an unconscious patient, spinal cord injury assessment relies on a **comprehensive clinical examination** using multiple findings, as the patient cannot provide history or cooperate with neurological examination. All three assessment methods are used: - **Absence of response to painful stimulus below a certain level** indicates sensory pathway disruption and helps localize the level of spinal injury - **Abdominal (diaphragmatic) respiration** occurs when intercostal muscles are paralyzed due to high cervical/thoracic spinal cord injury (typically C3-C5), forcing the diaphragm to compensate - this is a key clinical sign - **Absence of deep tendon reflexes** below the injury level indicates spinal shock or complete spinal cord lesion, as neural pathways for reflexes are interrupted Since the patient is unconscious and cannot communicate, clinicians must use **objective physical findings** - all three signs together help assess for potential spinal injury and guide urgent management including spinal immobilization and imaging. *Why individual findings alone would be insufficient:* Each sign can have other causes, so comprehensive assessment using all findings together increases diagnostic accuracy and prevents missed injuries in this high-risk scenario.

Q: What is the fluid of choice in burns?

Ringer lactate. ***Ringer lactate*** - **Ringer lactate** is the fluid of choice in burn resuscitation because its electrolyte composition is similar to that of extracellular fluid, helping to maintain **fluid and electrolyte balance**. - It also contains **lactate**, which is metabolized in the liver to bicarbonate, helping to correct the **metabolic acidosis** often seen in burn patients. *Fresh frozen plasma* - **Fresh frozen plasma (FFP)** is a blood product that contains clotting factors and plasma proteins, primarily used for patients with significant **coagulopathy** or **massive transfusions**. - It is not the initial fluid of choice for routine burn resuscitation, as its primary role is not volume expansion. *Dextrose 5% in water (D5W)* - **D5W** is primarily a source of free water and provides minimal electrolytes or volume expansion compared to crystalloids. - Administering large volumes of D5W in burn patients can lead to **hyponatremia** and exacerbate cerebral edema. *Normal saline* - While **normal saline** is a crystalloid and can be used for volume expansion, high volumes can cause **hyperchloremic metabolic acidosis** due to its high chloride content. - Ringer lactate is preferred due to its balanced electrolyte profile and ability to buffer acidosis.

Q: A 25-year-old man is brought to the emergency department by ambulance after falling 20 ft from a ladder. He was placed on a backboard for spinal stabilization. Intravenous access was obtained en route, and he received infusion of crystalloids. The patient is unconscious upon arrival. His blood pressure is 91/44 mm Hg, pulse is 129/min, and respirations are 8/min. Pulse oximetry is at 85%. Evaluation shows several superficial facial lacerations, a depressed temporal skull fracture, and a forearm fracture. There are no periorbital or periauricular hematomas, and there is no significant neck edema. Which of the following is the most appropriate next step in management of this patient?

Orotracheal intubation. ***Orotracheal intubation*** - This patient is **unconscious**, has a traumatic brain injury (depressed temporal skull fracture), and is experiencing **respiratory depression** (respirations 8/min, SpO2 85%). This indicates a need for **definitive airway management**. - **Orotracheal intubation** using an **RSI (rapid sequence intubation)** approach with **manual in-line stabilization** of the cervical spine is the preferred method for airway control in trauma patients with suspected cervical spine injury. *Nasotracheal intubation* - This method is **contraindicated** in patients with suspected **basilar skull fracture** or **midface trauma**, which is a concern given the depressed temporal skull fracture. - It also carries a higher risk of **epistaxis** and can be more difficult to perform in an emergency setting. *Needle cricothyroidotomy* - This is primarily used as a **rescue airway** when intubation is impossible or has failed (a "cannot ventilate, cannot intubate" scenario). - While it provides an airway, it is not the **definitive method of choice** when orotracheal intubation is feasible. *Laryngeal mask placement* - A laryngeal mask airway (LMA) is a **supraglottic airway device** that does not protect the airway from aspiration as effectively as an endotracheal tube. - It is generally not recommended for patients with **head trauma** or those at high risk of aspiration, and it is not a definitive airway solution for prolonged ventilation.

Q: You evaluate an 18 yrs old male who sustained a right sided cervical laceration during a gang fight. Which of the following is a relative rather than an absolute indication for neck exploration?

Pneumothorax. ***Pneumothorax*** - A pneumothorax, while concerning, can often be managed with a **chest tube** insertion without immediate surgical exploration, making it a relative indication. - Its presence suggests potential compromise to structures in the neck/chest but doesn't always mandate direct surgical wound exploration as a first step. *Dysphonia* - **Hoarseness or difficulty speaking** after a neck injury suggests potential direct laryngeal, tracheal, or recurrent laryngeal nerve injury, warranting exploration to assess and repair. - This symptom implies a direct compromise of the **airway or critical nerves**, making exploration more immediate. *Expanding hematoma* - An **expanding hematoma** indicates active, potentially life-threatening bleeding and/or mass effect, which can compromise the airway or blood supply to the brain. - This is an **absolute indication for immediate surgical exploration** to control hemorrhage and prevent airway obstruction. *Dysphagia* - **Difficulty swallowing** post-neck trauma suggests injury to the pharynx or esophagus. - Such injuries carry a significant risk of **mediastinitis** or sepsis if not promptly identified and repaired via surgical exploration.

Question 1

A 40 year old male driver had a car accident in which he got wedged in between. He complained of severe abdominal pain with radiation to the back. The initial CT on admission was negative except for minimal retroperitoneal hematoma. The diagnosis is

Accepted Answer

Pancreatic injury

Answer

Liver injury

Answer

Bowel rupture

Answer

Duodenal perforation

Question 2

Treatment of choice in traumatic facial nerve injury with delayed onset or incomplete paralysis is -

Accepted Answer

Masterly inactivity

Answer

Facial decompression

Answer

Facial sling

Answer

Systemic corticosteroid

Question 3

To calculate the initial fluid requirement in a burn patient, the best approach is:

Accepted Answer

Estimate body surface area (burn)

Answer

CVP

Answer

Urine output

Answer

Blood volume measurement

Question 4

A 19 year old girl sustained blunt abdominal trauma. She was diagnosed of having splenic rupture. Her pulse is 110/min and BP is normal. She is tachypneic with respiratory rate of 22/min and she is anxious. Her approximate blood loss is -

Accepted Answer

750 - 1500ml

Answer

1500 - 2000ml

Answer

< 750 ml

Answer

> 2000ml

Question 5

Which of the following burn cases requires IMMEDIATE referral to a specialized burn center?

Accepted Answer

25% deep burn in adult

Answer

25% superficial burn in adult

Answer

Burn in palm

Answer

10% superficial burn in child

Answer

5% superficial scald in adult

Question 6

In an unconscious patient, spinal injury is assessed by:

Accepted Answer

All of the options

Answer

Absence of response to painful stimulus

Answer

Abdominal respiration

Answer

Absence of deep tendon reflexes

Question 7

What is the fluid of choice in burns?

Accepted Answer

Ringer lactate

Answer

Fresh frozen plasma

Answer

Dextrose 5% in water (D5W)

Answer

Normal saline

Question 8

A young patient presents with a massive injury to proximal duodenum, head of pancreas and distal common bile duct requiring definitive surgical management. The procedure of choice in this patient should be

Accepted Answer

Pancreaticoduodenectomy (Whipple's operation)

Answer

Lateral tube jejunostomy

Answer

Roux-en-Y anastomosis

Answer

Retrograde jejunostomy

Question 9

A 25-year-old man is brought to the emergency department by ambulance after falling 20 ft from a ladder. He was placed on a backboard for spinal stabilization. Intravenous access was obtained en route, and he received infusion of crystalloids. The patient is unconscious upon arrival. His blood pressure is 91/44 mm Hg, pulse is 129/min, and respirations are 8/min. Pulse oximetry is at 85%. Evaluation shows several superficial facial lacerations, a depressed temporal skull fracture, and a forearm fracture. There are no periorbital or periauricular hematomas, and there is no significant neck edema. Which of the following is the most appropriate next step in management of this patient?

Accepted Answer

Orotracheal intubation

Answer

Nasotracheal intubation

Answer

Needle cricothyroidotomy

Answer

Laryngeal mask placement

Question 10

You evaluate an 18 yrs old male who sustained a right sided cervical laceration during a gang fight. Which of the following is a relative rather than an absolute indication for neck exploration?

Accepted Answer

Pneumothorax

Answer

Dysphonia

Answer

Expanding hematoma

Answer

Dysphagia

Trauma — MCQs

Trauma — MCQs

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