RRM's Next - Trauma

Trauma
NEET SS MCh
01 Oct 2021
Dr Pradeep Dhanasekaran
M.S., (Gen Surgery), MRCS (Edinburgh),
M.Ch., Surgical Oncology
TRAUMA TOPICS
1. Trauma Basics
2. ATLS
3. Trauma scoring
4. Damage Control principles
5. Management of specific
injuries – Brain,
Faciomaxillary, Neck and
Spine, Chest, Abdomen,
Pelvis, Retroperitoneum
6. Vascular and Limb Injuries
7. Disaster and Mass casualty
Incidents
8. Blast Injuries
TRAUMA BASICS
ATLS
TRAUMA SCORING
Qn.1
Based on Timeline concept in trauma management, which of the

following has the shortest critical time window to intervene, before
leading to death or irretrievable damage?
A. Intra abdominal bleeding

B. Extradural hematoma
C. Airway obstruction
D. Ischemic limb
Ans.
Answer is C (Bailey & Love 27th ed; pg.312)

Qn.2
Most common cause of death in trauma due to
A. Hemorrhage
B. Traumatic brain injury
C. Multiple organ failure
D. Bleeding and brain injury
Ans.
Answer is B (Bailey & Love 27th ed; pg. 364)

Qn.3
True statement regarding Overt Injuries is all EXCEPT
A. Trauma Equation is right

B. Head injury in an RTA is an example
C. The injury is someway hidden
D. Lateral compression of pelvis from left sided impact in RTA is an
example
Ans.
Answer is C (Bailey & Love 27th ed; pg.314)
Overt Injuries Covert Injuries

Obvious injuries These are someway hidden
Trauma Equation is right If the equation does not add up, Think of Covert
injuries
Clear cut idea regarding the mechanism be it Patients usually tell truth, but may not if
Blunt or penetrating should be known, allows criminal activity is involved
potential pattern of injury to be imagined
Exposure in ATLS is to expose the injuries and Fear of abuse prevent vulnerable patients telling
look for clues the truth
Each patient respond differently to mechanical If Non Accidental Injury is suspected, you have
insults responsibility to take action
Qn.4
Which of the following is an example of Covert Injury?
A. Singed nasal hair in Facial burns

B. Chance fracture in a lap belt injury
C. Posterior dislocation of hip in a dashboard impact injury
D. Fracture ulna in a patient with fall on outstretched hand
Ans.

Qn.5
Regarding Motor Vehicle Accidents, FALSE statement is
A. Most common cause is blunt trauma

B. Seat belt injuries reduces risk of injury in vehicle by 45%
C. Patients with seat belt marks have increased incidence of chest
trauma than abdomen
D. Airbags in vehicles provide reduced risk of about 30%
Ans.
Answer is C
• Seatbelts reduce the risk of injury in a vehicle by 45%

• Patients with seatbelt marks have been found to have 4-fold
increase in thoracic trauma and 8-fold increase in abdominal
trauma than those who do not.
• Airbags provide reduced risk of fatality of about 30%.
Qn.6
All of the following are included in Primary survey of Trauma in

ATLS, EXCEPT
A. History about mode of injury

B. C spine immobilisation
C. Control of hemorrhage
D. Exposure
Ans.
Answer is A (Bailey & Love 27th ed; pg. 326)

Qn.7
A patient met with a road traffic accident with paralysis of both

upper and lower limb. Patient has not passed urine and tenderness
elicited in the cervical region. What will you advise?
A. The doctor should order a cervical X ray and shift the patient
from the trolley by himself
B. The doctor will instruct the radiographer to take cervical X ray
AP and Lateral view without any cervical support
C. The doctor will instruct the radiographer to take Cervical and
chest X ray
D. The patient should not be shifted and portable X-ray machine
should be used after neck stabilisation.
Ans.
Answer is D (Bailey & Love 27th ed; pg.323 and 340)
All patients spine should initially be immobilised using full spinal

precautions on the assumption that every trauma patient has a spinal
injury until proven otherwise.
Qn.8
Regarding Emergency surgical airway creation, FALSE statement is
A. Cricothyroidotomy is the treatment procedure

B. Vertical incision is made in the skin
C. Vertical incision is made in the cricothyroid membrane
D. Emergency tracheostomy is also an option during emergency
surgical airway
Ans.
Answer is C (Schwartz 11th ed; pg 185)

Qn.9
45 male had sustained civilian gunshot wound to the neck with

bleeding. What is the first step in the management?
A. Airway with Cervical spine stabilization

B. Control of bleeding
C. Breathing and ventilation
D. IV fluid and blood product resuscitation
Ans.

Qn.#
FALSE regarding Moderate Hemorrhagic Shock is
A. Decreased Blood pressure

B. Increased Heart rate
C. Base deficit >6mEq/L
D. Blood loss is approximately 15-30%
Ans.
Answer is D (Sabiston 21st ed; pg. 394)

Qn.10
Which of the following statement is WRONG regarding trauma

resuscitation?
A. IV Crystalloid bolus of 1.5 to 2 litres to be given when the patient

is hemodynamically unstable
B. Tranexamic acid to be given immediately in hemodynamically
unstable patients
C. Target systolic BP is >70mm Hg
D. PRBC : Platelet : Plasma ratio 1 : 1 : 1
Ans.
• Permissive hypotension (Maintain SBP 70 – 90mmHg)

• IV fluid small bolus 250ml
• Excess IV fluids avoided as they cause hemodilution, increase
coagulopathy and increase risk of ARDS
• Tranexamic acid reduces mortality after severe trauma if given
within 3 hours of injury
• Severely hypovolemic patients should be resuscitated using blood
and blood products in the ratio of 1:1:1.
Qn.#
Which of the following Evidence Statements related to Trauma

resuscitation is WRONG?
A. Permissive hypotension is more appropriate for blunt trauma and

Traumatic brain injury
B. Pre hospital plasma transfusion alone is safe and not have
additional survival benefit
C. Prehospital plasma and PRBC has survival benefit in patients not
requiring Massive transfusion protocol
D. Early Tranexamic acid infusion decreased mortality in severe
hemorrhagic shock patients
Ans.
Answer is A (Bailey & Love 27th ed; pg. 324, Schwartz 11th ed;
pg.193-195; Sabiston 21st ed; pg. 395-396)
Permissive hypotension
PAMPer trial
COMBAT trial
CRASH-2 trial
Qn.11
Log Roll during Primary survey – FALSE statement is
A. Should be avoided in patients with or suspected pelvic fracture

B. Done by 4 personnel
C. Gives useful clinical information of posterior torso by keeping
spine stabilised
D. Must in patients with blunt trauma
Ans.
Answer is D (Bailey & Love 27th ed; pg. 325-326)
For exposure, Per rectal examination, examine torso to find exit

wounds in penetrating trauma
Not in blunt trauma, must in penetrating trauma
Qn.12
A person met with an accident and came to casualty with contusion

on left precordium. His vitals are BP 120/80 mm Hg, RR –
16/minute. Normal heart sounds heard but there was decreased
breath sounds on left side and trachea deviated to right. Which of
the following is the first line of management?
A. Needle thoracocentesis
B. Chest tube insertion
C. Pericardiocentesis
D. Open surgery
Ans.
Answer is B (Schwartz 11th ed; pg.186)

It is Simple Pneumothorax and not tension pneumothorax
Hypotension is the defining feature of Tension pneumothorax
Qn.13
Which of the following statement regarding Whole body CT in

trauma assessment is WRONG.
A. Picks up injuries early

B. Decreases mortality
C. Risk of malignancy with one scan is 0.08%
D. One WBCT equates to 76 chest xrays
Ans.
Effect on survival is controversial

Only retrospective studies show benefit
Prospective High quality evidence suggests no survival benefit.
REACT 2 trial.
Rapid Fire
• Earliest indicator of blood loss?

• After ____ amount of blood loss, hypotension occurs?
• For a radial pulse to be palpable, the SBP should be
• Where will you do saphenous vein cut down?
• Amount of blood loss in a tibial fracture?
• Contraindications to cricothyroidotomy?
• How will you differentiate Tension pneumothorax from
Tamponade?
• Tension from Massive Hemothorax?
• Beck’s Triad?
• How will you treat Air embolism?
Qn.14
Expand FAST
A. Focussed Abdominal Sonar in Trauma

B. Focussed Abdominal Splenic Trauma
C. Focussed Assessment with Sonography for Trauma
D. First Assessment of Splenic Trauma
Ans.
Answer is C (Schwartz 11th ed; pg. 186-187)
FAST (FOCUSSED ASSESSMENT WITH SONOGRAPHY for

TRAUMA)
Used in all abdominal trauma patients whether hemodynamically

stable or unstable.
It is a rapid bedside diagnostic procedure to identify any free fluid in
abdomen (could not tell blood or ascitic fluid)
It is not 100% sensitive.
Qn.15
REBOA is an alternative for
A. Emergency Resuscitative Thoracotomy

B. ICD
C. Fracture fixation
D. Pelvic packing
Ans.
Answer is A (Sabiston 21st ed; pg. 395)
REBOA – Resuscitative Endovascular Balloon Occlusion of the

Aorta – quicker, less invasive method of achieving aortic occlusion
during initial resuscitation, providing another tool to combat early
exsanguinating blood loss.
Qn.16
Regarding Emergency Resuscitative thoracotomy, FALSE statement

is
A. Cross clamp of aorta done distal to inferior pulmonary ligament

B. Manual massage of heart done with single hand
C. Done in the Trauma bay itself and not in OR
D. Always uses a Left anterolateral thoracotomy incision in 5th ICS
Ans.
Answer is B (Schwartz 11th ed; pg.189-190)
Regarding Emergency Resuscitative Thoracotomy, it is done in the

trauma bay itself, by making left anterolateral thoracotomy.
It is done to evacuate blood clot from pericardium, manually
massage the heart using clap hand technique (not single hand which
cause perforation of atrium) and cross clamping of aorta done distal
to inferior pulmonary ligament.
Qn.17
Contraindication for Emergency Resuscitative Thoracotomy is
A. Refractory hypotension due to Air embolism

B. Refractory hypotension due to intraabdominal bleed
C. Patients sustaining witnessed blunt trauma with 15 minutes of
prehospital CPR
D. Refractory hypotension due to Cardiac tamponade
Ans.
Answer is C (Schwartz 11th ed; pg. 189)

Qn.18
After Primary survey, during secondary survey done & history is

elicited and AMPLE mnemonic is used. E stands for
A. Evidence
B. Exposure
C. Events
D. Environment
Ans.
Answer is C (Bailey & Love 27th ed; pg. 381)
A – Allergies
M – Medication
P – Past medical and surgical history, Pregnancy
L – last time meal
E – Events that led to injury
Qn.#
Regarding Trauma systems, FALSE is
A. Triage reduces the burden in Level I trauma centres

B. 20% reduction in in-hospital mortality noted when patients are
treated in trauma centre compared to non trauma centres
C. Prehospital care and Post injury rehabilitation are components of
trauma system
D. None of the above
Ans.
Answer is D (Sabiston 11th ed; pg.387-388)

Qn.19
All of the following are anatomical scoring systems in Trauma

EXCEPT
A. Abbreviated Injury Scale

B. Injury Severity Score
C. New Injury Severity Score
D. Revised Trauma Score
Ans.

Revised Trauma Score, Glasgow coma scale, TRISS – physiological
Anatomical – AIS, ISS, New ISS, Organ Injury scale
INJURY SEVERITY SCORE (ISS) – developed in 1974.

•Calculated by summing the squares of the AIS severity codes for the three most severely
injured body regions.
•Calculated based on Injuries to six Body regions from AIS and each region is graded a
severity based on AIS severity code. Among these, 3 most severely injured regions selected.
•Ranges from 1 – 75.
Severity Injury Severity Scores
of Injury
Minor Less than 9
Moderate Between 9 and 16
Serious Between 16 and 25

Severe More than 25
Qn.20
Post dot Code in AIS represents
A. Body region
B. Type of anatomic structure
C. Specific Anatomic structure
D. Injury Severity
Ans.
Answer is D
AIS – Abbreviated injury scale
Post dot Code (7th digit) describes the severity code ranges from 1 to
6 as follows
1 Minor
2 Moderate
3 Serious
4 Severe
5 Critical
6 Maximum (fatal)
Qn.21
Scoring system calculated on summing squares of AIS severity codes

of 3 worst injuries regardless of region is
A. Injury Severity Score

B. TRISS
C. New Injury Severity Score
D. MESS
Ans.
Answer is C
New Injury Severity Score - Score calculated based on sum of

squares of 3 worst injuries (with severity codes) regardless of the
region.
Injury Severity Score - Calculated by summing the squares of the

AIS severity codes for the three most severely injured body regions.
Calculated based on Injuries to six Body regions from AIS and each
region is graded a severity based on AIS severity code. Among
these, 3 most severely injured regions selected.
Qn.22
Parameter that raise suspicion of Non Accidental Injury EXCEPT:
A. Anterior rib fractures

B. External signs not consistent with mechanisms reported
C. Unusual behaviour of care takers at interview
D. Long bone fractures in preambulatory child
Ans.
Parameters that alert NAI

1, external signs of injuries not consistent with mechanism reported
2, long bone fractures in preambulatory child
3, inconsistent or changing history
4, aggressive or unusual behaviour of carers at interview
5, posterior rib fractures
Qn.23
Which of the following should the clinician be thoughtful of, in

circumstances where trauma equation is inconsistent?
A. Criminal activity
B. Non accidental injury
C. Unknown pre-existing condition
D. All of the above
Ans.
Mechanism + Patient = Injury

Equation not right in
1. Non accidental injury
2. Criminal activity
3. Unknown preexisting condition
DAMAGE CONTROL
PRINCIPLES
Qn.24
Lethal Triad in trauma is
A. Hypoxia, Coagulopathy and Acidosis

B. Hypothermia, Acidosis and Hypoxemia
C. Acidosis, Coagulopathy and Hypothermia
D. Hypothermia, Coagulopathy and Hypoxia
Ans.
Answer is C (Bailey & Love, 27th ed; pg. 326)

Qn.#
Assessment of Blood Consumption (ABC) score for massive

transfusion includes all EXCEPT
A. Pulse
B. Blood Pressure
C. Mechanism of Injury
D. Temperature
Ans.
Penetrating mechanism
Systolic BP <90
HR >120
FAST positive
0–4
Scores <2, less likely to require MTP
Scores >2, more likely to require MTP (SS 75%-90%; SP 86%)
Delaying every minute associated with 5% increase in mortality
Qn.25
38 male sustained RTA, on primary survey – airway adequate, chest

right side air entry decreased, pulse 110/mt, Spo2 94%, BP 90/60
mm Hg on inotrope, abdomen soft and deformed extremities
suggesting possible left femoral fracture and right humeral fracture.
Upon resuscitation, he requires transfusion with multiple blood
products, ABG pH 7.26, Lactate 5 mmol/L and Temperature 34 C.
Urine output 30ml/hour. Which of the following is the most
appropriate management?
A. Fracture splintage, Trauma evaluation

B. Chest trauma resuscitation & IM nail of femur and humerus
C. Bicarb infusion, Blood transfusion and External fixator
D. Fracture splintage, chest resuscitation, ICU care
Ans.

Qn. 26
Damage control surgery does not include the following component
A. Revascularisation of limb
B. Decontamination
C. Surgical Decompression
D. Reconstruction
Ans.
Answer is D (Bailey & Love, 27th ed; pg. 326)

Qn.27
FALSE statement regarding Venous lactate levels in Trauma setting
A. Marker of resuscitation
B. Helps in decision making
C. Indicator of tissue perfusion
D. Lactate >2mmol/L – indication for Damage control surgery
Ans.

Qn. 28
Damage control Resuscitation is all EXCEPT
A. Permissive hypotension
B. Crystalloid bolus infusion
C. Hemostatic resuscitation
D. Correction of Acute Traumatic Coagulopathy
Ans.
Answer is B (Bailey & Love, 27th ed; pg. 427)
DCR – should occur concurrent with DCS

1. Permissive hypotension for limited period
2. Avoid large volume crystalloid
3. Hemostatic resuscitation
4. Manage acute Traumatic coagulopathy
Qn. 29
Damage control approach – TRUE is
A. Aims to restore anatomy

B. Used in all patients with trauma
C. Ease the management of OT and ICU resources
D. Abbreviated laparotomy is done in Phase 2 of Damage control
approach
Ans.
DCS – 1st described by Rotondo et al

a.k.a Abbreviated Laparotomy
• In complex trauma patients with combined vascular and visceral
injuries
• Restore physiology over anatomy
• Phase 1 – injury severity recognition, early resuscitation, shift to
OT
• Phase 2 – Damage control surgery
• Phase 3 – ICU care ongoing resuscitation
• Phase 4 – Re surgery (Definitive repair)
• Heavy toll on theatre and ICU resources.
Qn.30
Goals of Damage Control Surgery are all EXCEPT
A. Correction of Acidosis
B. Control Contamination
C. Control Hemorrhage
D. Do Maximum Surgery to control Damage
Ans.
Answer is D.
Qn. 31
Damage control resuscitation is all EXCEPT
A. Treat coagulopathy
B. Permissive hypotension
C. Rapid hemostasis with early balanced transfusion
D. Bolus crystalloid infusion
Ans.

Qn.32
True about Point of Care Viscoelastic assays in Traumatic

coagulopathy treatment is all except
A. Conserve blood products

B. Costly
C. Takes longer time (1 hour)
D. Survival benefit
Ans.
Answer is C (Sabiston 21st ed; pg. 396)
TEG Thromboelastrography
• Provides real time graphical dynamic representation of clot
generation
• Rapid results
• Conserve overall products
• TEG based resuscitation during Massive Transfusion protocol
• Survival benefit with fewer deaths due to hemorrhagic shock
noted.
MANAGEMENT OF
SPECIFIC INJURIES
1. BRAIN,
FACIOMAXILLARY
INJURIES
Qn.33
What’s this?
Qn.34
Which of the following herniation numbered in the picture

manifests cushing’s triad?
A. 4
B. 5
C. 3
D. 2
Ans.
Answer is B (Bailey & Love 27th ed; pg.329)
3 is uncal herniation – causes anisocoria

5 is cerebellar tonsillar herniation – compress medullary vasomotor
and respiratory centres – Cushing triad of hypertension, bradycardia
and irregular respiration.
Qn.35
A trauma patient with history of Loss of consciousness and post

resuscitation GCS score of 14 will be categorized as
A. Mild head injury

B. Minor head injury
C. Moderate head injury
D. Severe head injury
Ans.
Severity – based on post resuscitation GCS (particulary motor – best

predictor of neurological outcome)
Qn.36
45 male in RTA sustained head injury has no loss of consciousness,

no vomiting, GCS 15 and has ecchymoses near mastoid. What is the
next step?
A. He has minor head injury and can be discharged

B. He can be discharged after observing for 6 hours
C. CT Brain to be done within one hour
D. CT Brain to be done only when GCS deteriorates
Ans.

Qn.37
45 male brought himself to the trauma ward after sustaining minor

head injury after fall from 2 wheeler, GCS 15 and no focal deficits,
no LOC/Seizures/Vomiting and not under the influence of alcohol
or drugs. Ideal next step is
A. Patient should be observed for 8 hours and seek for attender

B. Patient can be discharged
C. Patient can be discharged if CT Brain is normal
D. CT Brain is mandatory
Ans.

Qn.38
Concussion is defined by all features EXCEPT
A. No imaging abnormality
B. Loss of consciousness at time of injury is a key feature
C. Confusion and Amnesia
D. Headache and somnolence
Ans.
Answer is B (Bailey & Love 27th ed; pg. 329-330)
Concussion is alteration of consciousness as a result of closed head

injury
Mild head injury without imaging abnormalities, LOC at injury is
not prerequisite.
Confusion, amnesia, headache & somnolence are typical features
Gait disturbance and incoordination can be seen.
Qn.39
A 30 year old female was admitted to casualty with history of head

trauma in a RTA. Her Eye opens to pain, moans, localises towards
the pain on left-hand and away from the pain on right hand, both the
legs in extended posture. Calculate her GCS
A. 11
B. 3
C. 7
D. 9
Ans.
Answer is D (Bailey & Love 27th ed; pg. 331)

Score – represents the best performance elicited
Qn.40
Which is FALSE regarding Extradural hematoma?
A. Low energy mechanism of injury is sufficient

B. Associated with fracture of skull on the opposite side of bleed
C. Bleeding due to rupture from an artery or vein or venous sinus
D. Associated with underlying brain injury at the site of impact
Ans.

Qn.41
Goals in the treatment to prevent secondary brain injury in Neuro

Intensive Care Unit all except
A. ICP <20 mm Hg
B. CPP at least 70mm Hg
C. MAP around 90mm Hg
D. Pco2 <25 mm Hg
Ans.

MEASURES (TO DO) AVOIDED (NOT RECOMMENDED)
Keep HOB elevated to 20 -30’ or reverse Hypotonic fluids to be avoided
trendelenberg position
Intubation & Optimal Ventilation with Pao2 >11kPa; Steroids avoided or contraindicated
pCO2 = 4.5-5 kPa
Monitor ICP with ICP bolt monitor or External Hyperventilation not in first 24 hours
ventricular drain (advantage of therapeutic drainage due to risk of hypocapnia induced
of CSF) cerebral vasoconstriction
Mannitol as temporizing measure (100ml of 20% Pyrexia should be avoided
mannitol as bolus)
Sedation and paralysis with barbiturates
Finally Decompressive Craniectomy if all measures
fail
Qn.#
Following statements regarding neurological outcomes after

Traumatic brain injury are True EXCEPT
A. In Extradural hematoma, underlying brain and axonal injury

predicts the outcome
B. Motor response in GCS is the best predictor of neurological
outcome
C. Neurological outcome depends on how well the secondary brain
injury is prevented
D. Permissive hypotension worsen outcome in Traumatic brain
injury
Ans.

Qn.#
Indications for operative intervention in the setting of traumatic

brain injury are all EXCEPT
A. Depressed skull fracture

B. Small Epidural hematoma in posterior cranial fossa
C. Subdural hematoma with midline shift
D. Diffuse cerebral edema with ICP 18mm Hg
Ans.
Answer is D (Schwartz 11th ed; pg. 217-219)

Qn.43
Persistent vegetative state in a Glasgow outcome score is
a. 5
b. 4
c. 3
d. 2
Ans.

Qn.44
Most common site of Mandibular fracture is
A. Angle
B. Parasymphyseal along canine
C. Symphyseal
D. Condylar Neck
Ans.

Qn.45
22 male brought to ER with history of squash ball hitting the eye

causing severe pain, decreased vision and proptosis. Pupils not
reacting. Primary survey done and no other life threatening injuries
suspected. What is the next step in management?
A. CT Head with axial and coronal cuts

B. Emergency surgery with lateral canthotomy
C. Delayed definitive treatment after 1 week
D. CT Brain, CT Facial bones and CT Cervical spine
Ans.
Retrobulbar hemorrhage is a surgical emergency – as it can lead to

blindness.
Presents with decreasing visual acuity, increasing pain, loss of
pupillary response and tense proptosis.
If suspected – treatment initiated with acetazolamide, mannitol and
steroids and immediate surgical lateral canthotomy and cantholysis
to be done prior to any imaging.
Qn.46
Most common site of craniofacial fracture is
A. Posterior wall of frontal sinus

B. Ethmoidal sinus
C. Sphenoid sinus
D. Anterior cranial fossa
Ans.

Qn.47
A Patient following a Motor vehicle accident sustained a

faciomaxillary injury with lacerations over the left chin and cheek.
O/E he has Subconjunctival hemorrhage Right eye with swollen
eyelids with diplopia and paraesthesia over right cheek and
associated Facial palsy on Right side. All of the following are
possibility EXCEPT
A. Fracture Temporal Bone Right side

B. Fracture Right Zygoma
C. Fracture Right Maxilla
D. Fracture Right Floor of orbit
Ans.
Answer is C
FINDINGS DIAGNOSIS
Tenderness over sites Fracture suspected
CSF Rhinorrhea Le Fort I and II fractures
Subconjunctival haemorrhage with no Fracture zygoma
posterior limit
Dental occlusion lost or irregular Fracture of Jaws
Hematoma in floor of mouth Fracture mandible
Step defects in alveolus/teeth alignment Fracture of underlying bone
Jaw deviation to one side Ipsilateral fracture
Springing movement at fracture site Mandibular fracture
Degloving injuries Labial sulcus and body of mandible
Paresthesia of cheek and upper lip Fracture orbital floor
Paresthesia of lower lip Fracture body of mandible
Facial palsy Fracture temporal bone
Check for Diplopia to rule out Fracture floor of orbit or damage to III,
IV and VI cranial nerves
Qn.48
Pterygoid plate is not involved in which of the following fractures?
A. Le Fort III fracture

B. Le Fort II fracture
C. Le fort I fracture
D. None of the above
Ans.
Answer is A
FRACTURES DIAGNOSIS MANAGEMENT

Le Fort I Fracture line passes from Through gingival sulcus incision.
Separates the nasal piriform aperture and Dental arch is restored with
Alveolus and palate posteriorly through dental arch bars, intermaxillary
from facial skeleton maxillary sinus to include fixation screws or eyelet wires
above pterygoid plates
Le Fort II Fracture line Bridge of Approach through Bicoronal
Pyramidal in shape Nose, cribriform plate, incision
infraorbital rim & foramen Fractures fixed with mini or
to end at pterygoid plates microplates or stainless steel wire
Le Fort III Fracture line- Nasal bridge, Same as above
Craniofacial through orbital bones to
disjunction frontozygomatic suture and
zygomatic arch fracture
Qn.#
All of the following are TRUE regarding management of

faciomaxillary injuries except
A. Steroids are recommended

B. More prone for airway obstruction due to bleeding
C. Nursed in semirecumbent position
D. Depressed facial fractures requires fixation in the acute care
setting
Ans.
Answer is C (Sabiston 21st ed; pg. 401-402)

MANAGEMENT OF
SPECIFIC INJURIES
2. NECK & SPINE

Qn.49
Severity of spinal cord injury is given by
A. ASIA neurological evaluation

B. Frankel classification
C. MRC grading
D. Dermatomal maps
Ans.
Neurological examination using ASIA neurological evaluation

system (motor using MRC grading and sensory using dermatomal
maps, along with anal tone) – helps us to find the level
Severity of spinal cord injury by Frankel classification
A – Complete spinal cord injury
B – Sensation present; motor absent
C – Sensation present; motor present but not useful (MRC
grade<3/5)
D – Sensation present; motor present (MRC grade >/= 3/5)
E – Normal function.
Qn.50
Whole spine screening is mandatory in a patient with an identified

spinal fracture is based on the grounds that the incidence of further
spinal fracture is
A. 15%
B. 5%
C. 33%
D. 67%
Ans.
Treat all patients with full spinal precautions unless ruled out with
imaging
Spinal examination after spinal log roll – look for swelling,
tenderness or palpable defects or steps.
Second spinal injury at a remote level is seen in 10% to 15% which
can be missed with plain radiographs.
Qn.51
Principles in the management of spinal cord injury are all EXCEPT
A. Early steroids are indicated and shown to improve recovery

B. Spinal realignment and stabilization are the goal
C. Surgery indicated in cases of deteriorating neurological function
D. Decompression of neural elements in expanding hematoma or
bone fragments needed
Ans.
Answer is A (Bailey & Love 27th ed; pg. 344-345)
Steroids are no longer indicated in acute spinal cord injury because

of lack of evidence.
Cervical Spinal realignment by using skull tongs or halo brace
Qn.
Jefferson # - Fracture of C1 ring

Hangman # - Spondylolisthesis of C2 on C3
Chance # - flexion distraction injury of thoracolumbar junction
Spinal cord injury is more common with subaxial cervical spine #
Cervicothoracic and thoracolumbar junction – more prone for injury
Three types of shock occur in spinal trauma – Spinal, Neurogenic
and Hypovolemic shock
Bulbocavernosus reflex is the first to return once spinal shock recover
Qn.52
Zone of neck involving great vessels at thoracic inlet?
A. Zone I
B. Zone II
C. Zone III
D. Zone IV
Ans.
Answer is A
ZONES EXTENT CONTENTS
Zone I From thoracic inlet to Large vascular structures,

cricoid trachea and esophagus
Zone II From cricoid to angle Carotids, IJV, vertebral

of mandible arteries and trachea,
esophagus
Zone III From angle of Least surgically accessible

mandible to base of
skull
Qn.53
Denver’s criteria is used in
A. Penetrating Neck injury

B. Blunt cerebrovascular injury
C. Cervical spine injury
D. Blast Injuries
Ans.
Answer is B
Qn.54
25 male was assaulted by his neighbor for fidelity issues and

sustained stab injury to the middle of neck. On receiving, there is
airway compromise. Airway is secured with endotracheal
intubation. What to be done next?
A. Emergency Bronchoscopy
B. Emergency CT Neck
C. CT Neck with CT Angiogram
D. Shift to OR for Exploration
Ans.
In penetrating trauma to neck, If the patient is unstable, Immediate

Exploration in OR
If the patient is stable, Additional Imaging like CT angiogram
needed to rule out vascular injury and
Esophagogram/Bronchoscopy to rule out aerodigestive tract
injuries.
But in Zone II injuries even when stable, if there is expanding
hematoma or impending airway compromise, exploration should be
undertaken.
Qn.55
Regarding Management of Neck Injuries, FALSE statement is
A. Tracheostomy is the surgical airway of choice in Upper airway

injuries
B. Expanding Hematoma in Zone 2 needs Exploration immediately
even when hemodynamically stable
C. Surgical access is very difficult in Zone 1
D. Antiplatelet therapy forms the mainstay in management of blunt
cerebrovascular injuries
Ans.
Answer is C (Sabiston 21st ed; pg. 402-404)

Surgical access is very difficult in Zone 3 and not in Zone 1
Qn.#
True regarding Neck exploration for penetrating neck trauma

EXCEPT
A. Incision made anterior to anterior border of SCM

B. Distal internal carotid exposure is difficult
C. Most common nerve injured is ansa cervicalis
D. External carotid transposition is done when internal carotid is
not primarily repairable
Ans.
Answer is C (Schwartz 11th ed; pg. 209-215)

MANAGEMENT OF
SPECIFIC INJURIES
3. CHEST AND ABDOMEN

Qn.56
What are the physiological indicators of potential ongoing bleeding

EXCEPT?
A. Visible bleeding
B. Increasing respiratory rate
C. Rising serum lactate
D. Rising pulse rate
Ans.

Qn.58
Potentially life threatening injury of the chest is
A. Tension pneumothorax
B. Massive hemothorax
C. Pericardial tamponade
D. Tracheobronchial injuries
Ans.

Qn.#
35 female presented with gun shot injury to the chest over the
cardiac box area. Airway adequate. Breath sounds normal. SpO2
92% Pulse 130. BP 80/50 mm Hg. What is the next step along with
ongoing resuscitation?
A. eFAST
B. Chest X ray
C. Emergency thoracotomy
D. MD CT chest with angiogram
Ans.
Answer is A (Sabiston 21st ed; pg. 405-407)

Qn.57
Management of sucking chest wound following penetrating trauma

to chest is
A. Closed with sterile occlusive plastic dressing at three sides

B. Closed with sutures
C. Intercostal drainage tube insertion at the same site of wound
D. Intercostal drainage tube insertion remote from the wound
Ans.
Answer is A and D (Bailey & Love 27th ed; pg. 366, 368)
Qn.59
The only differentiating feature of Tension pneumothorax from

Simple Pneumothorax is
A. Hyperresonant on percussion
B. Hypotension
C. Tachypnea
D. Tracheal shift to opposite side
Ans.
Answer is B (Schwartz 11th ed; pg. 185-187)
Tension Pneumothorax – clinical diagnosis. Treatment should never

be delayed.
Qn.60
Feature of Massive hemothorax is all except
A. Absence of breath sounds

B. Dullness on percussion
C. Hypotension
D. Dilated neck veins
Ans.

Qn.61
FALSE about management of hemothorax is
A. Use of second drain in case of clot occlusion

B. Clamping a chest drain to cause tamponade to arrest bleeding
C. Low pressure 5cm H2O suction if lung fails to reinflate
D. Using larger tube 32 Fr ICD drain
Ans.

Qn.62
Most common location of aortic disruption following a deceleration

injury is
A. proximal to diaphragmatic opening

B. proximal to brachiocephalic artery
C. distal to left subclavian artery origin
D. proximal to left common carotid origin
Ans.

Qn.63
Sites of Aspiration in Bronchovenous Air embolism all EXCEPT
A. Apex of Left ventricle

B. Apex of Right ventricle
C. Right coronary artery
D. Aortic root
Ans.
Answer is B
Trendelenberg position and ERT and apply Pulmonary hilar clamp

on the side of injury. Then Air Aspirated from left ventricle, aortic
root and RCA and finally Repair of injury.
Qn.#
Indication for immediate thoracotomy after penetrating thoracic

trauma is all EXCEPT
A. Tube thoracostomy drainage of 1500ml after insertion and

further ongoing drainage 50ml/hour but hemodynamically stable
B. Pericardial FAST positive
C. Massive air leak from tube drainage
D. Turbid drainage through chest tube
Ans.
Answer is A (Sabiston 21st ed; pg. 405-407)

INDICATIONS FOR OPERATIVE MANAGEMENT OF THORACIC
INJURIES:
• Initial thoracostomy drainage of more than 1L (in penetrating) or >1.5L in blunt
trauma patients
• Ongoing thoracostomy drainage more than 200ml/hr for 3 consecutive hours in
noncoagulopathic patients
• Pericardial tampanode
• Caked hemothorax
• Great vessel injuries
• Massive air leak
• Esophageal or gastric contents in chest tube
• Air Embolism
• Cardiac herniation
Qn.64
Trap door thoracotomy is needed for
A. Left lung injuries

B. Left subclavian artery injury
C. Trachea
D. Distal esophagus
Ans.
• Answer is B (Sabiston 21st ed; pg. 407)
• Left Posterolateral thoracotomy at 5th ICS for lungs, pulmonary vasculature and hemidiaphragm
• Right – this also exposes proximal and mid esophagus and trachea with bilateral mainstem bronchi
• Median sternotomy – exposure of heart, ascending aorta, aortic arch with right sided arch vessels
and pulmonary vasculature
• Left thoracotomy – distal esophagus, left lung, left ventricle, descending aorta and left subclavian
artery
• Anterolateral thoracotomy – most versatile incision for emergent thoracic exploration in the 5th
ICS. Heart, lungs, descending aorta, pulmonary hilum and esophagus are accessible
• Clam shell Incision – if exploration needed in both cavities
• Trapdoor thoracotomy needed for left subclavian arterial repairs
• Median sternotomy with cervical extension need for exposure of proximal subclavian, innominate
and carotid vessels
Qn.65
Right posterolateral thoracotomy addresses all of the following

injuries EXCEPT
A. Descending thoracic aorta

B. Left mainstem bronchi
C. Trachea
D. Right airways
Ans.
Left Posterolateral thoracotomy at 5th ICS for lungs, pulmonary vasculature and
hemidiaphragm
Right – this also exposes proximal and mid esophagus and trachea with bilateral
mainstem bronchi
Left thoracotomy – distal esophagus, left lung, left ventricle, descending aorta and
left subclavian artery
Anterolateral thoracotomy – most versatile incision for emergent thoracic
exploration in the 5th ICS. Heart, lungs, descending aorta, pulmonary hilum and
esophagus are accessible
Qn.66
Ventricular lacerations near the Coronary vessels are repaired by
A. Continuous non locking fashion

B. Pledgeted continuous non locking fashion
C. Pledgeted intermittent suture
D. Pledgeted horizontal mattress sutures
Ans.
Answer is D
Atrial lacerations are grasped with satinsky clamp and closed with
running monofilament permanent sutures. Ventricular lacerations
needs closure by horizontal mattress sutures with reinforcement of
pledgets to prevent cut through. (2/3-0 prolene)
Abdomen
Abdomen
Qn.67
What is the first investigation to be done in any blunt trauma

abdomen patients?
A. FAST
B. CECT Abdomen
C. X ray Abdomen
D. Pelvic X ray
Ans.
Answer is A
FAST is the first investigation to be done in blunt trauma abdomen

patients irrespective of the hemodynamic status. It does not dictate
laparotomy in such patients.
Qn.68
Ideally in a FAST, how many views are done?
A. Two
B. Three
C. Four
D. Six
Ans.
Answer is C
Traditional four views

Sub Xiphoid Transverse view – assess pericardial fluid
Right Upper quadrant Longitudinal view – Collection in Morrison
pouch or any liver/renal injuries
Left Upper quadrant Longitudinal view – Collection in perisplenic
region or any splenic injuries
Suprapubic Longitudinal and transverse view – Collection in pelvis;
assess bladder and POD
Qn.69
Parameters recorded in Diagnostic Peritoneal Lavage all EXCEPT
A. Serum Amylase
B. Serum bilirubin
C. Serum LDH
D. Serum ALP
Ans.
Answer is C
Criteria for Positive finding on DPL

Abdominal trauma Thoracoabdominal stabs
RBC count >100,000/ml >10,000/ml
WBC count >500/ml >500/ml
Amylase level >19 IU/l >19 IU/l
Alkaline phosphatase >2 IU/l >2 IU/l
Bilirubin level >0.01 mg/dl >0.01 mg/dl
Qn.70
Latent period of Baudet is seen in
A. EDH
B. Splenic Trauma
C. Pelvic trauma
D. Genitourinary trauma
Ans.
Answer is B
Grading of Splenic injuries based on American Association for the

Surgery of Trauma (AAST) guidelines from Grade I to Grade V. In
low grade injuries, there will be initial bleeding and stops. But there
will be delayed initiation of hemorrhage which can occur up to
weeks after injury (Latent Period of Baudet)
The rate of rebleeding is 10.6%.
Qn.71
Bleeding despite Pringle’s maneuver in liver trauma is due to
A. Portal vein injury

B. Hepatic artery injury
C. Hepatic arteriole injury
D. Retrohepatic IVC injury
Ans.
Answer is D
Pringle’s maneuver is by applying digital compression or clamp over

the lesser omentum, which occludes portal vein and hepatic artery.
Hence, bleeding despite pringle’s could be due to bleed from hepatic
vein or Retrohepatic IVC injuries.
Qn.72
Patient with anterior stab wound with omentum protruding out

through the wound site. Management is
A. Do FAST and CECT Abdomen

B. Local Wound Exploration and reduce omentum and suture it
C. Exploratory laparotomy
D. Resection of omentum and closure of wound site after giving
wash
Ans.
Answer is C
Patient with anterior stab wound if presents with Shock, peritonitis

or evisceration, should be shifted to OT for Emergency Laparotomy.
Qn.73
Regarding management of Duodenal hematoma following Trauma,

FALSE is
A. NG tube insertion and TPN to be initiated

B. Do gastric emptying studies a week later
C. Explore hematoma and do a seromuscular stitch
D. They do often cause Gastric outlet obstruction
Ans.
Answer is C
Management of Duodenal Hematoma

Hematomas not need exploration
NG tube insertion and TPN started
Evaluation of gastric emptying by contrast studies after 1 week
Resolve within 2 weeks as evident by marked drop in NG tube
collection
If it does not, requires Surgery
Qn.74
Injury to Lower third of rectum which is inaccessible to repair

require
A. Proximal fecal diversion with sigmoid loop colostomy

B. Hartmann procedure
C. Proctoscopy and primary repair
D. Hartmann procedure + Presacral drainage
Ans.
Answer is D
Injury to Lower third of rectum includes proximal diversion

colostomy and primary repair, if possible. If not possible, Just a
presacral drainage is kept through incision in the perineum.
Qn.75
Management of Grade I Small bowel injuries can be mostly

managed with
A. Seromuscular reinforcement suture

B. Debridement and primary repair
C. Exteriorisation of bowel
D. Resection and anastomoses
Ans.
Answer is A
Grade I injury needs seromuscular reinforcement with sutures.

MANAGEMENT OF
SPECIFIC INJURIES
4. DIAPHRAGM,
RETROPERITONEUM,
PELVIS
Qn.76
False statement regarding Diaphragmatic injuries is
A. Most common injury mechanism is Penetrating injury to chest

B. Any penetrating injury below the level of 5th ICS raises suspicion
of diaphragmatic injury
C. Defect in diaphragm due to penetrating mechanism is larger than
blunt mechanism.
D. All penetrating diaphragmatic injuries should be explored
through abdomen and not through chest.
Ans.
Answer is C (Sabi 21st; pg. 411; Schwartz 11th ed; pg. 225)
Penetrating injury 67% vs Blunt 33%

Mortality due to blunt higher 19.8% than penetrating 8.8%
Any penetrating injury to chest below the level of nipples should
raise suspicion of diaphragmatic injury and explored from abdomen
and not chest.
Blunt mechanism causes larger tear than penetrating mechanism.
Qn.77
What is the safest incision in Phrenotomy needed in repair of severe

diaphragmatic injuries?
A. Radial
B. Central circumferential
C. Peripheral Circumferential
D. Oblique
Ans.
Answer is C
In Phrenotomy, ie, diaphragmatic incision, incision must be planned
not to injury the phrenic nerve. In such cases, peripheral
circumferential is the most preferred one which won’t injure phrenic
nerve and also helpful in escalating the diaphragm to spaces above to
relieve the tension during primary closure of tears due to trauma.
Qn.78
Blunt trauma to Portal Vein or Retrohepatic IVC considered under
A. Zone I retroperitoneum
B. Zone II
C. Zone III
D. Zone IV
Ans.
• Answer is D
ZONE PENETRATING BLUNT INJURY

INVOLVED INJURY
ZONE I Explore Explore
ZONE II Explore Not Explore Hematoma
unless it is ruptured, pulsatile
or rapidly expanding
ZONE III Explore Not explore unless pulsatile
or expanding or iliac pulse
absent
ZONE IV Explore Not Explore, Pack the
surrounding area
Qn.79
Fullen’s Zone I SMA Injury is best approached with
A. Through lesser sac

B. Right sided medial visceral rotation
C. Left sided medial visceral rotation
D. Cattel Braasch maneuver
Ans.
Answer is C
All supracolic injuries and arterial injuries in the retroperitoneum are best approached by Mattox
maneuver or Left sided Medial visceral rotation. Here we can take proximal and distal control and
then subjected to repair.
Aorta, Celiac trunk, SMA injuries - Left sided medial visceral rotation
IVC injuries – Right sided medial visceral rotation or Cattel Braasch maneuver
ZONE I Beneath the pancreas

ZONE II Between PD artery and
Middle colic
ZONE III Beyond middle colic

ZONE IV Enteric branches
Qn #
28 male sustained RTA brought to ER with hemorrhagic shock and

suspected Pelvic fracture received on Pelvic compression device.
Primary survey and resuscitation efforts with blood products on the
go. FAST negative and thorax clear. Patient still hemodynamically
unstable. What NEXT?
A. Emergency Laparotomy
B. Emergency Pelvic ExFIX and Pelvic packing
C. Shift for Angioembolization
D. Continue resuscitation and Pelvic CT
Ans.
Answer is B (Schwartz 11th ed; pg. 234)

VASCULAR AND
LIMB INJURIES
Qn.80
All of the following vascular injuries needs Immediate Exploration

EXCEPT
A. Pulsatile bleeding
B. Palpable Thrill or Bruit
C. Wounds in proximity to major vessels
D. Absent distal pulse
Ans.

HARD SIGNS SOFT SIGNS
 Pulsatile bleeding  H/o moderate haemorrhage
 Expanding Hematoma  Dimnished but palpable pulse
 Palpable thrill or audible bruit  Proximity fracture/dislocation/
 Evidence of Limb Ischemia (Pain, penetrating wound
Pallor, Pulselessness, Paraesthesia,  Level of peripheral nerve deficit in
Paralysis and Poikilothermia) proximity to major vessel
 Wounds in proximity to major vessels in
patients with unexplained hemorrhagic
shock
THESE INDICATE NEED FOR THESE INDICATE FURTHER IMAGING
IMMEDIATE INTERVENTION FOR AND EVALUATION TO RULE OUT
VASCULAR INJURY VASCULAR INJURY
Qn.81
Which of the following vessel can be ligated if injured?
A. External Iliac artery

B. Proximal axillary artery
C. Popliteal artery
D. Superior mesenteric artery
Ans.
Answer is B (Sabiston 21st ed; pg. 1794-98)

Qn.82
Management of Crush Syndrome is all EXCEPT
A. Aggressive volume loading even before extrication

B. Alkaline diuresis
C. Mannitol infusion
D. Fasciotomy
Ans.

CRUSH SYNDROME:
• After rescuing the patient from prolonged period of crushing, reperfusion to the
tissues causes Reperfusion Injury in the form of allowing toxic metabolites like
Myoglobins from damaged muscle and vasoactive mediators into circulation.
• This causes Intravascular volume reduction, renal vasoconstriction,
Myoglobulinuria and Acute Renal Failure.
• Management includes Aggressive fluid resuscitation with about 1 to 1.5L per
hour till proper urine output is achieved. Then alkanisation of urine along with
Alkaline mannitol diuresis is carried until there is no myoglobin in urine.
• Late Fasciotomy will only worsen the condition and not have benefit.
Qn.83
Regarding Compartment syndrome, FALSE statement is
A. Early clinical sign is loss of sensory innervation of the nerve in

compartment
B. Fasciotomy to be done only when the distal pulse disappears
C. Volkmann’s ischemic contracture can occur in later stages
D. STIC catheter is used for monitoring compartmental tissue
pressure
Ans.
Answer is B (Bailey 27th ed; pg. 422, Sabiston 21st ed; pg 461-464)
FASCIOTOMY INCISION TO RELIEVE THE PRESSURES
In calf compartment syndrome – Two incisions
Anterolateral incision – to release the anterior and lateral compartments
Medial incision posterior to tibia – to release superficial and deep posterior compartments.
Wound should not be closed with sutures. Closed after 3 to 5 days once the muscle bulge and edema decreases.
CAUSES CLINICAL SIGNS DIAGNOSIS

Trauma (open or closed 1st sign – loss of light touch Tissue pressure measurements
fractures) sensation in distribution of nerve in using Wick cathether or Side
Arterial Injury the compartment. (1st interdigital port needle (Stryker pressure
Gunshot wounds webspace sensation loss in calf monitoring system)
Snake bites compartment syndrome) Normal tissue
Crush injuries to limb Pain on passive stretch Compartment pressure from 0 to
Burns Pallor, pulselessness, paralysis and 9 mm Hg
Constrictive dressings poikilothermia are later Fasciotomy to be done when
Tight casts manifestations pressure >25-30mm Hg
Qn.84
Extremity injuries that are notorious for being missed are all
EXCEPT
A. Intertrochanteric fracture
B. Scaphoid fracture
C. Posterior dislocation of shoulder
D. Compartment syndrome
Ans.

Qn.85
Rule of 2 in limb radiography does not include
A. 2 views in orthogonal planes

B. 2 joints
C. 2nd X ray 2 days later
D. 2 sides
Ans.
2 views
2 joints
2 occasions (2 weeks apart)
2 sides to compare (paediatric)
Qn.86
Name of the classification for open fracture is
A. Tscherne classification
B. Seddon classification
C. Salter and Harris classification
D. Gustilo and Anderson classification
Ans.

Qn.87
A patient with compound supracondylar femur fracture with a defect

of 2cm and vascular injury is classified under Gustilo Anderson
A. Type II
B. Type IIC
C. Type IIIC
D. Type IIIB
Ans.

Qn.88
Regarding Salter & Harris growth plate injury classification, TRUE

is
A. Growth affected in Type III injury

B. Fracture line crossing physis and metaphysis is Type IV
C. Fracture line is intraarticular in Type III and IV
D. Growth disturbance is not seen in Type V
Ans.

Qn.89
True regarding Intramedullary nailing is
A. Used in fixing intra articular fractures

B. More chance of infection
C. Direct reduction of fractures
D. Limited soft tissue disruption
Ans.

Qn.90
All are true regarding Open fracture management except
A. Antibiotics to be given within 3 hours of ER admission

B. Gustilo Type II & III require combination antibiotics
C. Upper extremity injuries are treated definitively at initial
debridement
D. Tibial and periarticular fractures of leg require EX FIX
Ans.
Qn.91
Specific Indication for External fixator use are all EXCEPT
A. Damage control orthopaedics

B. Fracture with bone loss
C. Fracture with infection
D. Closed Long bone fracture in polytrauma setting
Ans.
Specific Indications
1. Emergency stabilization of long bone # in polytrauma setting
where unstable hemodynamically (DCO)
2. Stabilize dislocated joint after reduction, allowing time for
vascular repair
3. Fractures with bone loss and infection
4. Complex periarticular #
Qn.92
Absolute indication for Primary amputation over limb salvage are all
EXCEPT
A. Missing extremity
B. Warm ischemia > 1 hour
C. Severe crush injury
D. Mangled stump or distal tissue not amenable for repair
Ans.
Answer is B (Sabiston 21st ed; pg. 460)
MESS score, Limb salvage Index – validated scores

Qn.93
Evidence based statements regarding Amputation versus Limb

Salvage in Trauma is True or False
1. Functional outcomes similar between amputation & Salvage

limb
2. Pain, Return to work and disability – similar between both
3. Treatment cost higher with Limb salvage
4. MESS score, Limb Salvage Index scores have low sensitivity and
high specificity
Ans.
Sabiston 21st ed; pg. 460
True
True Based on LEAP and METALS study
False (Prosthetics cost higher)
True (Hence high score cannot reliability predict need for
amputation, ie, MESS 7 or more not a definite indication for
amputation)
MESS – Skeletal and Soft tissue injury, Limb ischemia, Shock, Age
Scores 2 to 14
Qn.94
Principle of debridement include all EXCEPT
A. High pressure wound wash to clear the debris

B. Excise all dead and devitalized tissue
C. Leave wound open and delay primary closure
D. Repair major vessels and not nerves and tendons
Ans.
Answer is A (Bailey & Love 27th ed; pg. 415-416)

DISASTER AND MASS
CASUALTY INCIDENTS
BLAST INJURIES
Qn.95
Differences of War surgery from Civilian trauma surgery are all

EXCEPT
A. Logistic and Personnel restrictions

B. Mass casualty situation & Triage
C. Early Total care
D. Hostile and dangerous to personnel in War
Ans.
War Surgery
• Hostile and dangerous environment
• Limited resources, no sophisticated infrastructure
• Mass casualty situation always
• Triage – do the best for most and not everything for everyone
• Staged treatment – Damage control surgery commonly practiced
• Careful planning, coordination and communication essential
Qn.96
Regarding Tiers of Medical Support in War Surgery, TRUE is
A. Role 1 support provides primary first aid and Triage

B. Role 4 means definitive hospital care
C. Role 3 support is an intermediate unit providing damage control
resuscitation
D. Role 2 support provides facility for short term holding of
casualties
Ans.
Medical Support Role:

R1 – unit level medical care including first aid, triage and
resuscitation
R2 – intermediate unit for resuscitation, damage control and
stabilization, limited holding facility
R3 – deployed hospital care with multi speciality capability and
diagnostic support
R4 – full spectrum of definitive hospital care within home or allied
nation.
Qn.97
Cavitation impact are seen with what mode of injury vector?
A. Inhalation injuries
B. Firearm injury
C. Sharp object injury
D. Blunt trauma to chest
Ans.

Qn.98
Which of the following statement is WRONG regarding permanent

wound cavity due to firearm?
A. Localised area of definitive tissue injury caused by direct contact

B. Cavity size determined by the size and trajectory of projectile
C. Dependent on amount of energy transferred by bullet and
material properties of tissue
D. Military rifle cause larger and irregular permanent wound cavity
Ans.
Permanent wound cavity Temporary Wound cavity

Direct contact with projectile Indirect contact
Crushing and laceration of tissue in the Lateral displacement of tissue
pathway (localized definitive tissue
injury)
Depends on size and trajectory of Depends on amount of energy
projectile transferred by bullet and material
properties of tissue
Pistol – low energy Skin, muscle, lung, bowel wall – good
elastic strength – minimal damage
Military rifle – high energy Liver, Brain, spleen – shatter
Qn.99
Correct sequence of Relief efforts after a DISASTER is
A. Damage assessment, rescue operation, Evacuation, Emergency

treatment
B. Damage assessment, resource mobilization, Rescue operation
and Triage casualties
C. Damage assessment, Resource mobilization, Triage and
emergency treatment and rescue operation
D. Set up communication, Mobilize resource, Triage and emergency
treatment
Ans.
Sequence of Relief effort in major disasters

1. Establish chain of command
2. Set up lines of communication
3. Damage assessment
4. Mobilise resources
5. Initiate rescue operation
6. Triage casualties
7. Emergency treatment
8. Evacuation
9. Definitive treatment
Qn.100
Following a mass casualty incident, you see a patient with

compound fracture of lower limb with degloving injury. You will
triage him to what category?
A. Red
B. Yellow
C. Green
D. Black
Ans.

Qn.101
Field hospitals give the following treatment except
A. First aid
B. Damage control surgery
C. Replantation of amputated limb
D. Amputation of devitalized limb
Ans.
Answer is C (Bailey & Love 27th ed; pg. 413-415)

Qn.102
True statement regarding MASCAL is
A. Always Triage is required

B. Emergency Department and Hospital infrastructure
overwhelmed
C. Standards of Care maintained for all severe injuries
D. Number of casualties is less than Emergency department
Ans.

MASCAL – Mass Casualty Incident
Disaster Class Total number of Implications for

casualties Trauma Care
Multiple Casualty Less than ED Standards of care
capacity maintained for all
severe casualties
Mass Casualty More than ED Care of some severe
capacity casualties delayed or
suboptimal
Major Medical ED and Hospital Most severely injured
Disaster overwhelmed patients die or
survive without any
medical care
Qn.103
Among various validated Triage methods, SALT Triaging denotes
A. Secondary Assessment and Live Transport

B. Sort Assess Life saving intervention and Transport
C. Simple Assessment and Rapid Transport
D. SAcco Life Triage
Ans.
Answer is B (Sabiston 21st ed; pg. 561

Qn.104
Which of the following organ is not affected in Primary Blast

Injury?
A. Lung
B. Tympanic membrane
C. Intestine
D. Skin
Ans.

Qn.105
Primary Blast lung injury is
Most common site of intestinal blast injury is
Most common operative findings of intestinal blast injury is
Most common organ injured in immersion Blast is
Most common organ injured in urban bombings is

Ans.
1. Alveolar capillary rupture and intrapulmonary bleed and oedema

2. Terminal Ileum & Cecum
3. Subserosal hemorrhage, perforation
4. GIT
5. Ear drum > Lungs
Qn.106
Regarding Blast Injury Classification, FALSE statement is
A. Blunt traumas caused by propulsion are called Tertiary Injuries

B. Patients at close proximity are more prone for Quarternary
injuries
C. Blast Lung Injury is a Secondary Blast Injury
D. Terminal Ileum and cecum are commonly affected regions in
GIT
Ans.

Qn.107
FALSE statement regarding Blast injury is
A. Secondary blast injuries are lower in enclosed blast

B. Tertiary blast injuries are higher and severe in enclosed blast
C. Adding radioactive material to IED is Quarternary blast injury
D. Underbody blast contributes to more severe injury
Ans.

Class Mechanism Organs injured
Primary Wounding of air filled viscera as a TM perforation

direct result of blast wave
Blast Lung Injury – DAH to ARDS
GIT – Subserosal hemorrhage to Perforation
Secondary Penetrating trauma from bomb Superficial skin laceration to lethal visceral wounds.
fragments and other projectiles of Helical CT scan to local multiple projectile and
varying mass and velocity trajectories
Tertiary Casualties propelled by blast wind, Usually combined with other types of blast injuries
resulting in standard patterns of
blunt trauma
Quarternary Burns, crush and all other trauma Superficial flash burns. Inhalation injury. Usually
mechanisms not included above found dead at the scene.
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Trauma

Based on Timeline concept in trauma management, which of the

A. Intra abdominal bleeding

Answer is C (Bailey & Love 27th ed; pg.312)

Most common cause of death in trauma due to

Answer is B (Bailey & Love 27th ed; pg. 364)

True statement regarding Overt Injuries is all EXCEPT

A. Trauma Equation is right

Overt Injuries Covert Injuries

Which of the following is an example of Covert Injury?

A. Singed nasal hair in Facial burns

Answer is B (Bailey & Love 27th ed; pg. 314)

Regarding Motor Vehicle Accidents, FALSE statement is

A. Most common cause is blunt trauma

• Seatbelts reduce the risk of injury in a vehicle by 45%

All of the following are included in Primary survey of Trauma in

A. History about mode of injury

Answer is A (Bailey & Love 27th ed; pg. 326)

A patient met with a road traffic accident with paralysis of both

Answer is D (Bailey & Love 27th ed; pg.323 and 340)

All patients spine should initially be immobilised using full spinal

Regarding Emergency surgical airway creation, FALSE statement is

A. Cricothyroidotomy is the treatment procedure

Answer is C (Schwartz 11th ed; pg 185)

45 male had sustained civilian gunshot wound to the neck with

A. Airway with Cervical spine stabilization

Answer is B (Bailey & Love 27th ed; pg. 326)

FALSE regarding Moderate Hemorrhagic Shock is

A. Decreased Blood pressure

Answer is D (Sabiston 21st ed; pg. 394)

Which of the following statement is WRONG regarding trauma

A. IV Crystalloid bolus of 1.5 to 2 litres to be given when the patient

Answer is A (Bailey & Love 27th ed; pg. 324)

• Permissive hypotension (Maintain SBP 70 – 90mmHg)

Which of the following Evidence Statements related to Trauma

A. Permissive hypotension is more appropriate for blunt trauma and

Log Roll during Primary survey – FALSE statement is

A. Should be avoided in patients with or suspected pelvic fracture

Answer is D (Bailey & Love 27th ed; pg. 325-326)

For exposure, Per rectal examination, examine torso to find exit

A person met with an accident and came to casualty with contusion

Answer is B (Schwartz 11th ed; pg.186)

Which of the following statement regarding Whole body CT in

A. Picks up injuries early

Answer is B (Bailey & Love 27th ed; pg. 317)

Effect on survival is controversial

• Earliest indicator of blood loss?

A. Focussed Abdominal Sonar in Trauma

Answer is C (Schwartz 11th ed; pg. 186-187)

FAST (FOCUSSED ASSESSMENT WITH SONOGRAPHY for

Used in all abdominal trauma patients whether hemodynamically

REBOA is an alternative for

A. Emergency Resuscitative Thoracotomy

Answer is A (Sabiston 21st ed; pg. 395)

REBOA – Resuscitative Endovascular Balloon Occlusion of the

Regarding Emergency Resuscitative thoracotomy, FALSE statement

A. Cross clamp of aorta done distal to inferior pulmonary ligament

Answer is B (Schwartz 11th ed; pg.189-190)

Regarding Emergency Resuscitative Thoracotomy, it is done in the

Contraindication for Emergency Resuscitative Thoracotomy is

A. Refractory hypotension due to Air embolism

Answer is C (Schwartz 11th ed; pg. 189)

After Primary survey, during secondary survey done & history is

Answer is C (Bailey & Love 27th ed; pg. 381)

RRM's Next - Trauma

RRM's Next - Trauma