Trauma Practice Questions

Q: All may be seen in deep burns except

Hyperthermia. ***Hyperthermia*** - While burns can initially cause a slight elevation in body temperature due to the inflammatory response, **deep burns** typically lead to **hypothermia** due to massive heat loss from the damaged skin barrier. - The body's ability to regulate temperature is severely impaired, making **hyperthermia** an unlikely persistent finding. *Vasodilatation* - **Vasodilation** occurs in response to the inflammatory mediators released after a burn injury. - This increased blood flow contributes to **edema** and fluid shifts in the affected areas. *Fluid loss by evaporation* - **Deep burns** destroy the protective skin barrier, leading to significant and continuous **evaporative fluid loss**. - This can quickly result in **hypovolemia** and is a major concern in burn management. *Increase vascular permeability* - Burn injury causes the release of inflammatory mediators like histamine and bradykinin, leading to a marked **increase in vascular permeability**. - This allows plasma proteins and fluid to leak from the capillaries into the interstitial space, contributing to **edema** and potential **shock**.

Q: In hypovolemic shock, the percentage of fluid depletion is:

15-45%. 15-45% - This range represents the **fluid depletion** levels that can lead to hypovolemic shock, with higher percentages associated with more severe shock categories. - Shock is typically classified into four classes (I-IV), where Class I (minimal shock) involves up to 15% fluid loss, and Class IV (severe shock) can involve over 40% fluid loss. 70% - A **70% fluid depletion** would represent an **extremely severe and likely fatal** fluid loss, far beyond the typical range described for hypovolemic shock. - Such a massive loss would invariably lead to **irreversible organ damage** and death. 10-15% - A **10-15% fluid depletion** generally corresponds to **Class I hypovolemic shock**, which is usually compensated and often does not present with the overt signs of shock unless other factors are contributing. - While it is a form of fluid depletion, it is at the **lower end** and typically not considered the full spectrum of established hypovolemic shock. 43-63% - While a depletion of **over 40%** would certainly cause severe hypovolemic shock (Class IV) [1], defining the overall range as 43-63% is **too narrow** and does not encompass the full spectrum, including the lower classes of shock. - This range represents an **extremely high and critical level** of fluid loss, indicating very severe shock, but not the entire classification of hypovolemic shock.

Q: Which of the following is commonest source of Extradural haemorrhage -

Middle meningeal artery. ***Middle meningeal artery*** - The **middle meningeal artery** is the most common source of **extradural (epidural) hemorrhage**, typically due to a traumatic skull fracture that lacerates the vessel. - This arterial bleed leads to a rapid accumulation of blood between the dura mater and the inner table of the skull, often forming a **lenticular (lens-shaped) hematoma** on CT scans. *Anterior ethmoidal artery* - The anterior ethmoidal artery is generally associated with hemorrhage in the frontal sinuses or orbits, rather than the epidural space. - While it can be injured in facial trauma, it is not a typical source for an intradural or extradural intracranial hemorrhage. *Posterior meningeal artery* - The posterior meningeal artery is a much smaller vessel compared to the middle meningeal artery and is a less common source of extradural hemorrhage. - When involved, it typically contributes to smaller, less extensive hematomas in the posterior cranial fossa. *Diploic veins* - **Diploic veins** are located within the spongy bone of the skull and drain into dural sinuses or intracranial veins. - While they can bleed, hemorrhage from diploic veins usually results in venous bleeding, which is slower and rarely causes a large, clinically significant extradural hematoma.

Q: Most sensitive investigation for abdominal trauma in a hemodynamically stable patient is-

CT Scan (Computed Tomography). ***CT Scan (Computed Tomography)*** - **CT scans** offer superior anatomical detail and can accurately detect organ damage, hemorrhage, and other injuries in **hemodynamically stable** patients with abdominal trauma. - It is considered the **most sensitive** and specific imaging modality for evaluating blunt and penetrating abdominal trauma when the patient can tolerate the study. *Ultrasonography (FAST)* - While effective for detecting **free fluid** (blood) in specific abdominal areas, **Focused Assessment with Sonography for Trauma (FAST)** has lower sensitivity for solid organ injuries or bowel perforations. - Its primary role is rapid assessment for **hemoperitoneum** to guide immediate management in unstable patients, not detailed injury characterization. *Diagnostic peritoneal lavage (DPL)* - **DPL** is an invasive procedure with high sensitivity for detecting **intraperitoneal bleeding**, but it does not identify specific organ injuries or retroperitoneal hemorrhage. - It is rarely used in hemodynamically stable patients due to its invasiveness and the availability of more detailed imaging techniques. *MRI (Magnetic Resonance Imaging)* - **MRI** provides excellent soft tissue contrast but is typically too **time-consuming** and less accessible in urgent trauma settings compared to CT. - It's generally not the first-line investigation for acute abdominal trauma due to motion artifacts and limited utility in detecting air or bone injuries.

Q: A trauma patient was brought to emergency. On evaluation, patient was found to have metabolic acidosis and coagulopathy with liver and duodenal injury. Next step:

Damage control surgery. ***Damage control surgery*** - A patient with significant trauma, including **liver** and **duodenal injury**, experiencing **metabolic acidosis** and **coagulopathy**, indicates profound physiological derangement, necessitating immediate **damage control surgery**. - This approach prioritizes **bleeding control** and contamination management in a rapid initial operation, followed by patient stabilization and definitive repair in a subsequent surgery once physiological parameters improve. *Whipples procedure* - A **Whipple procedure** (pancreaticoduodenectomy) is a complex and lengthy operation typically performed for pancreatic, duodenal, or distal bile duct cancers. - It is **contraindicated** in an unstable trauma patient with acute metabolic derangements due to its extensive nature and the patient's compromised physiological state. *Observation and supportive care only* - Given the severity of injuries (liver and duodenal) and the presence of **metabolic acidosis** and **coagulopathy**, **observation alone** is insufficient and would lead to rapid deterioration and death. - These injuries require **immediate surgical intervention** to control bleeding and prevent further complications like peritonitis. *Liver repair* - While **liver repair** is part of the overall surgical management for liver injury, focusing solely on this specific repair immediately, without addressing the overall patient physiology and other injuries in the context of damage control, would be inappropriate. - A **planned, definitive repair** of the liver might occur during a later stage of damage control surgery, after initial stabilization.

Q: A comatose 28-year-old woman sustained a depressed skull fracture in an automobile collision. She has been unconscious for 6 weeks. Her vital signs are stable and she breathes room air. Following her initial decompressive craniotomy, she has returned to the operating room twice due to intracranial bleeding. Select the best method of physiologic monitoring necessary for the patient.

Intracranial pressure monitoring. ***Intracranial pressure monitoring*** - This patient has a history of **depressed skull fracture**, **decompressive craniotomy**, and **intracranial bleeding**, all of which significantly increase the risk of elevated **intracranial pressure (ICP)**. - Monitoring ICP is crucial for detecting and managing cerebral edema or hematoma expansion, preventing secondary brain injury in a comatose patient. *Central venous catheterization* - While useful for monitoring **central venous pressure (CVP)** and administering fluids/medications, it does not directly assess cerebral perfusion or intracranial dynamics. - CVP alone is a poor indicator of ICP, and changes in CVP do not reliably reflect changes in cerebral perfusion pressure (CPP). *Pulmonary artery catheterization* - This provides detailed hemodynamic information including **cardiac output**, **pulmonary artery pressure**, and **pulmonary capillary wedge pressure**, primarily for assessing cardiac function and fluid status. - It is overly invasive and unnecessary for a patient with stable vital signs whose primary concern is neurological status. *Blood-gas monitoring* - **Arterial blood gas (ABG)** analysis assesses **oxygenation**, **ventilation**, and **acid-base balance**, which are important for overall patient management. - While important, ABG monitoring does not directly provide information about ICP or cerebral perfusion, which is the most critical parameter in this specific neurological injury scenario.

Q: Glasgow coma scale of a patient with head injury who is confused, localizes to pain on the right side but shows abnormal flexion on the left side, and opens eyes only to painful stimuli on sternum:

11. ***11*** - The Glasgow Coma Scale (GCS) score is calculated by summing the scores for **Eye Response**, **Verbal Response**, and **Motor Response**. - In this case: **Eye Response = 2** (opens eyes to painful stimuli), **Verbal Response = 4** (confused), and **Motor Response = 5** (localizes to pain on the right side). - **Key principle**: When there is **asymmetric motor response**, the **best motor response** is used for GCS calculation, not the worse response or an average. - Right side localizes to pain (M5) and left side shows abnormal flexion (M3), so we use M5. - **Total GCS = E2 + V4 + M5 = 11** *12* - This score would require a better response in at least one GCS component than what is described. - For a GCS of 12, the patient would need either: eyes opening to voice (E3), or obeys commands for motor (M6), or no confusion (V5). - The given patient has E2 + V4 + M5, which totals to 11, not 12. *6* - A score of 6 indicates **severe neurological impairment**, much worse than the described patient. - A GCS of 6 might include: no eye opening (E1) + incomprehensible sounds (V2) + abnormal flexion (M3) = 6. - This is significantly worse than the patient's current state with localizing response and confused speech. *7* - A GCS of 7 also represents **severe neurological deficit**, though not as profound as a score of 6. - This score would typically involve lower responses such as: E1 + V2 + M4 (withdrawal to pain) = 7, or E2 + V1 + M4 = 7. - The described patient has better responses (E2 + V4 + M5 = 11) than this would indicate.

Q: Periorbital ecchymosis without direct orbital trauma (raccoon eyes) is most commonly associated with injury to:

Base of skull. ***Base of skull*** - **Periorbital ecchymosis** (raccoon eyes) is a classic sign of a **basilar skull fracture**, particularly one involving the **anterior cranial fossa**. - The fracture allows blood to leak from the cranial cavity and track along fascial planes into the periorbital soft tissues. - The key feature is that ecchymosis occurs **without direct trauma to the orbit or eye**, indicating the primary injury is to the **skull base**. - Often associated with CSF rhinorrhea and requires CT imaging for diagnosis. *Eye* - The question specifically states the ecchymosis occurs "**without direct orbital trauma**," meaning the eye/orbit is NOT the site of injury. - The eye region is where the sign **manifests** (blood tracks to this area), but it is not the site of the underlying injury. - Direct eye trauma would cause immediate localized periorbital swelling, not the delayed bilateral "raccoon eyes" pattern. *Pinna* - Pinna (ear) injury can be associated with head trauma, and Battle's sign (retroauricular ecchymosis) indicates temporal bone fracture. - However, pinna injury does not cause periorbital ecchymosis; these are separate findings. *Scalp* - Scalp injuries cause localized bleeding and swelling at the impact site. - While scalp trauma may accompany basilar skull fracture, the scalp itself is not the source of periorbital ecchymosis. - Blood from scalp wounds tracks superficially, not into deep fascial planes leading to the orbits.

Question 1

All may be seen in deep burns except

Accepted Answer

Hyperthermia

Answer

Vasodilatation

Answer

Fluid loss by evaporation

Answer

Increase vascular permeability

Question 2

In hypovolemic shock, the percentage of fluid depletion is:

Accepted Answer

15-45%

Answer

70%

Answer

10-15%

Answer

43-63%

Question 3

Which of the following is commonest source of Extradural haemorrhage -

Accepted Answer

Middle meningeal artery

Answer

Anterior ethmoidal artery

Answer

Posterior meningeal artery

Answer

Diploic veins

Question 4

A 17-year-old boy is admitted to the hospital after a road traffic accident. Per abdomen examination is normal. After adequate resuscitation, his pulse rate is 80/min and BP is 110/70 mm Hg. Abdominal CT reveals a laceration in the left lobe of the liver extending from the dome more than half way through the parenchyma. Appropriate management at this time would be:

Accepted Answer

Conservative treatment

Answer

Abdominal exploration and packing of hepatic wounds

Answer

Abdominal exploration and ligation of left hepatic artery

Answer

Left hepatectomy

Question 5

Most sensitive investigation for abdominal trauma in a hemodynamically stable patient is-

Accepted Answer

CT Scan (Computed Tomography)

Answer

Ultrasonography (FAST)

Answer

Diagnostic peritoneal lavage (DPL)

Answer

MRI (Magnetic Resonance Imaging)

Question 6

A trauma patient was brought to emergency. On evaluation, patient was found to have metabolic acidosis and coagulopathy with liver and duodenal injury. Next step:

Accepted Answer

Damage control surgery

Answer

Whipples procedure

Answer

Observation and supportive care only

Answer

Liver repair

Question 7

A comatose 28-year-old woman sustained a depressed skull fracture in an automobile collision. She has been unconscious for 6 weeks. Her vital signs are stable and she breathes room air. Following her initial decompressive craniotomy, she has returned to the operating room twice due to intracranial bleeding. Select the best method of physiologic monitoring necessary for the patient.

Accepted Answer

Intracranial pressure monitoring

Answer

Central venous catheterization

Answer

Pulmonary artery catheterization

Answer

Blood-gas monitoring

Question 8

Glasgow coma scale of a patient with head injury who is confused, localizes to pain on the right side but shows abnormal flexion on the left side, and opens eyes only to painful stimuli on sternum:

Accepted Answer

11

Answer

12

Answer

6

Answer

7

Question 9

A 20 year old boy is brought to the emergency following a RTA (Road Traffic Accident) with respiratory distress and hypotension. He has subcutaneous emphysema and no air entry on the right side. What is the next best step in the management?

Accepted Answer

Needle decompression in the 5th intercostal space in the mid-axillary line

Answer

Start IV fluids after insertion of a wide-bore IV line

Answer

Shift the patient to the ICU and perform intubation

Answer

Initiate positive pressure ventilation

Question 10

Periorbital ecchymosis without direct orbital trauma (raccoon eyes) is most commonly associated with injury to:

Accepted Answer

Base of skull

Answer

Pinna

Answer

Scalp

Answer

Eye

Trauma — MCQs

Trauma — MCQs

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