MCQ bank · 38 questions · free
Trauma surgery MCQs with answers
38 single-best-answer questions on the primary survey, chest, abdominal, pelvic and head trauma, and massive transfusion. Try each one, then open the answer to see the explanation, why the other options are wrong, and the guideline or trial behind it.
After a road traffic collision, a man has a pulse of 130 and a blood pressure of 80/50 despite 1 litre of fluid. FAST shows free fluid in Morison’s pouch. What is the next step?
- Immediate laparotomy, with blood products and damage-control principles
- CT of the abdomen and pelvis
- Diagnostic peritoneal lavage
- Admit for observation
- Repeat FAST in 30 minutes
Show the answer and explanation
Answer: A. Immediate laparotomy, with blood products and damage-control principles. A haemodynamically unstable patient with a positive FAST needs immediate surgical control of haemorrhage. CT is only for patients who are stable or have responded to resuscitation.
Why not the others? Taking an unstable patient to CT is dangerous: “the tunnel of death”.
References
A stabbed patient is hypotensive and hypoxic, with absent breath sounds and a hyper-resonant left chest. What do you do first?
- Chest X-ray to confirm
- Immediate decompression: needle or finger thoracostomy in the 4th–5th intercostal space at the mid-axillary line
- Intubate and ventilate first
- CT of the chest
- Pericardiocentesis
Show the answer and explanation
Answer: B. Immediate decompression: needle or finger thoracostomy in the 4th–5th intercostal space at the mid-axillary line. Tension pneumothorax is a clinical diagnosis treated immediately. ATLS 10th edition recommends needle decompression at the 4th–5th intercostal space in the mid-axillary line in adults, because the chest wall there is thinner, followed by a chest drain.
Why not the others? Waiting for imaging can be fatal. Positive-pressure ventilation worsens a tension pneumothorax.
References
A trauma patient is bleeding heavily, and the massive transfusion protocol has been activated 1 hour after injury. Which approach is supported by trial evidence?
- Crystalloid until the haemoglobin falls below 70 g/L
- Colloid as first-line resuscitation
- Red cells only until clotting results return
- Tranexamic acid only after 6 hours
- Balanced transfusion of plasma, platelets and red cells (about 1:1:1) and tranexamic acid within 3 hours of injury
Show the answer and explanation
Answer: E. Balanced transfusion of plasma, platelets and red cells (about 1:1:1) and tranexamic acid within 3 hours of injury. Early balanced transfusion improves haemostasis and reduces death from exsanguination (PROPPR). Tranexamic acid within 3 hours of injury reduces mortality from bleeding (CRASH-2); given after 3 hours, it may cause harm.
Why not the others? Large volumes of crystalloid dilute clotting factors and worsen coagulopathy.
References
A 24-year-old man has a grade III splenic laceration after blunt trauma. He is haemodynamically stable, with no other injury needing surgery. What is the preferred management?
- Splenorrhaphy
- Splenectomy
- Discharge home
- Non-operative management with monitoring in a unit able to operate, with angioembolisation if there is a contrast blush
- Diagnostic laparoscopy
Show the answer and explanation
Answer: D. Non-operative management with monitoring in a unit able to operate, with angioembolisation if there is a contrast blush. Haemodynamically stable patients with splenic injury, regardless of grade, should have non-operative management where monitoring, angiography and theatre are available. Angioembolisation increases success when there is active contrast extravasation.
Why not the others? Splenectomy is for unstable patients. Discharge without observation is unsafe.
References
A motorcyclist is hypotensive. Pelvic X-ray shows an open-book pelvic fracture, and FAST is negative. What is the immediate step?
- Examine the pelvis repeatedly by springing it
- Laparotomy
- Apply a pelvic binder centred on the greater trochanters, and activate the massive transfusion protocol
- Insert a urinary catheter first
- Send for CT before any other action
Show the answer and explanation
Answer: C. Apply a pelvic binder centred on the greater trochanters, and activate the massive transfusion protocol. A binder closes the pelvic volume and reduces venous bleeding. With a negative FAST, the bleeding is likely to be pelvic, so the next steps are angioembolisation or preperitoneal packing, followed by external fixation.
Why not the others? Springing the pelvis disturbs clots and increases bleeding. A urethral injury must be excluded before catheterisation. Unstable patients should not go to CT.
References
A man has a stab wound to the left side of the neck. He has an expanding haematoma and active bleeding. His airway is intact. What do you do?
- Direct pressure, secure the airway early, and take him straight to theatre for neck exploration
- Observe for 24 hours
- Barium swallow
- CT angiography first
- Probe the wound in the emergency department
Show the answer and explanation
Answer: A. Direct pressure, secure the airway early, and take him straight to theatre for neck exploration. “Hard signs” of vascular or aerodigestive injury (expanding or pulsatile haematoma, active bleeding, bruit or thrill, shock, air bubbling through the wound, stridor) mean immediate operation. Patients without hard signs are assessed with CT angiography, whatever zone the wound is in.
Why not the others? Probing a neck wound can dislodge clot and cause catastrophic bleeding.
References
A 70-kg man has deep partial- and full-thickness burns of 30% of his body surface area. Using the Parkland formula, how much crystalloid should he receive in the first 8 hours after the burn?
- 12 600 mL
- 1400 mL
- 8400 mL
- 4200 mL
- 2100 mL
Show the answer and explanation
Answer: D. 4200 mL. Parkland: 4 mL × weight (kg) × %TBSA = 4 × 70 × 30 = 8400 mL in 24 hours, half of it in the first 8 hours from the time of the burn (4200 mL) and the rest over the next 16 hours. Many centres now start at 2 mL/kg/%TBSA in adults. Whatever the formula, the rate is adjusted to a urine output of about 0.5 mL/kg/h to avoid over-resuscitation.
Why not the others? 8400 mL is the 24-hour total. Superficial (erythema only) burns are not counted in the %TBSA.
References
A 74-year-old taking warfarin for atrial fibrillation fell and hit her head. She is fully alert (GCS 15), with no vomiting, no amnesia and no neurological signs. What is the correct plan?
- Skull X-ray
- MRI brain in 2 weeks
- No imaging, because she has no symptoms
- Discharge with head injury advice only
- CT of the head within 8 hours of the injury, and check the INR
Show the answer and explanation
Answer: E. CT of the head within 8 hours of the injury, and check the INR. Anticoagulated patients have a much higher risk of intracranial bleeding after even minor head injury. NICE recommends CT within 8 hours for people on anticoagulants who have no other indication for an immediate scan; any red-flag feature means CT within 1 hour.
Why not the others? The absence of symptoms does not exclude a bleed in anticoagulated patients. Skull X-ray has no role.
References
A chest drain is inserted for a right haemothorax after a stab wound. It immediately drains 1700 mL of blood, and the patient remains hypotensive. What is the next step?
- Insert a second drain
- Thoracotomy
- Clamp the drain and observe
- CT of the chest
- Fibrinolytic therapy through the drain
Show the answer and explanation
Answer: B. Thoracotomy. An initial drainage of more than 1500 mL, continued bleeding of more than about 200 mL per hour for 2–4 hours, or ongoing transfusion need indicates a massive haemothorax requiring thoracotomy to control the bleeding source.
Why not the others? Clamping the drain only hides the bleeding. An unstable patient should not go to CT.
References
A 72-year-old woman fell down the stairs. She is alert and complains of mild neck pain. There is no neurological deficit. Does she need cervical spine imaging?
- Only if she cannot rotate her neck
- No: she is alert with no deficit
- A plain lateral X-ray only
- Yes: CT of the cervical spine, because age 65 or over is a high-risk factor
- MRI only if pain persists for 6 weeks
Show the answer and explanation
Answer: D. Yes: CT of the cervical spine, because age 65 or over is a high-risk factor. Under the Canadian C-spine rule, age 65 or over, a dangerous mechanism or paraesthesia in the limbs makes a patient high risk, so imaging is required without testing neck rotation. CT is the first-line imaging in adults. Older people can fracture the spine after relatively minor falls.
Why not the others? Plain films miss many fractures, especially in older people with degenerative spines.
References
A 78-year-old man has four left rib fractures after a fall. He cannot take a deep breath or cough because of pain, despite paracetamol and oral morphine. What do you offer?
- Discharge home
- More opioids and strict bed rest
- Strapping the chest
- Antibiotics
- Regional analgesia (thoracic epidural or a paravertebral or erector spinae catheter), physiotherapy and incentive spirometry
Show the answer and explanation
Answer: E. Regional analgesia (thoracic epidural or a paravertebral or erector spinae catheter), physiotherapy and incentive spirometry. Older patients with multiple rib fractures are at high risk of pneumonia and death. Good analgesia, often regional, lets them breathe deeply and cough. Early mobilisation and chest physiotherapy reduce complications. Surgical rib fixation is considered for flail chest or failure of these measures.
Why not the others? Chest strapping restricts breathing and increases pneumonia.
References
A 30-year-old has a single stab wound to the left upper abdomen. He is haemodynamically stable, has no peritonitis and no evisceration, and is alert. What is an accepted approach?
- Discharge home immediately
- Mandatory laparotomy for every stab wound
- Probe the wound with a finger in the department and discharge if shallow
- Selective non-operative management with CT and serial examinations by a surgeon
- Diagnostic peritoneal lavage in every patient
Show the answer and explanation
Answer: D. Selective non-operative management with CT and serial examinations by a surgeon. In stable patients without peritonitis or evisceration, selective non-operative management with serial examination avoids unnecessary laparotomy in many. Any deterioration, peritonitis or haemodynamic change leads to surgery. Laparoscopy is useful for left thoracoabdominal wounds to exclude a diaphragm injury.
Why not the others? Shock, peritonitis or evisceration mean immediate laparotomy.
References
Twelve hours after a tibial shaft fracture was put in a cast, a young man has severe pain not relieved by morphine. Passive stretching of his toes makes it much worse. Foot pulses are present. What do you do?
- Apply a tighter cast
- Doppler ultrasound and review in the morning
- Split the cast and padding down to the skin, then urgent fasciotomy if pain does not settle quickly
- Wait until the pulses disappear
- More morphine and elevate the leg high
Show the answer and explanation
Answer: C. Split the cast and padding down to the skin, then urgent fasciotomy if pain does not settle quickly. Pain out of proportion and pain on passive stretch are the earliest signs of compartment syndrome. Loss of pulses is a late sign, and pulses are usually present. Release all dressings and keep the limb at heart level; if signs persist, decompress with fasciotomy of all four compartments urgently.
Why not the others? Elevating the limb high reduces arterial inflow and worsens compartment perfusion.
References
A man has a stab wound just left of the sternum. He is hypotensive with distended neck veins and muffled heart sounds. FAST shows fluid around the heart. What is the definitive treatment?
- Surgical decompression and repair through a thoracotomy or sternotomy; needle pericardiocentesis is only a temporary measure
- Pericardiocentesis and discharge
- Chest drain
- CT angiography first
- Intravenous fluids and observation
Show the answer and explanation
Answer: A. Surgical decompression and repair through a thoracotomy or sternotomy; needle pericardiocentesis is only a temporary measure. Beck’s triad (hypotension, raised venous pressure, muffled heart sounds) with pericardial fluid after penetrating trauma means cardiac tamponade from a cardiac wound. Definitive treatment is surgical. Needle aspiration may buy time if surgery is not immediately possible.
Why not the others? Blood in the pericardium often clots and cannot be aspirated effectively.
References
After a car crash, a 55-year-old has a flail segment of the right chest from multiple rib fractures and needs mechanical ventilation. Which treatment may reduce ventilator days and pneumonia?
- Surgical stabilisation of the rib fractures
- Chest strapping
- Prophylactic antibiotics only
- Bed rest for 6 weeks
- Avoiding analgesia to protect breathing
Show the answer and explanation
Answer: A. Surgical stabilisation of the rib fractures. In adults with flail chest, surgical stabilisation of rib fractures is associated with fewer days on the ventilator, less pneumonia and fewer tracheostomies. It is combined with good analgesia and pulmonary care.
Why not the others? Underlying lung contusion, not the flail segment itself, often drives respiratory failure.
References
A haemodynamically stable woman has a grade IV liver laceration after blunt trauma, with a small contrast blush on CT. There is no peritonitis. What is the management?
- Non-operative management with angioembolisation, in a monitored setting where theatre is available
- Liver transplantation
- Immediate laparotomy and liver resection
- Diagnostic peritoneal lavage
- Discharge home
Show the answer and explanation
Answer: A. Non-operative management with angioembolisation, in a monitored setting where theatre is available. Haemodynamically stable patients with liver injury of any grade are managed non-operatively where monitoring and intervention are available. Angioembolisation treats active arterial bleeding. Complications such as bile leaks are managed with drainage and ERCP. Instability means laparotomy.
Why not the others? Non-operative management succeeds in most stable patients.
References
A stable 25-year-old has a stab wound in the left lower chest, at the level of the costal margin. CT is unremarkable and there is no peritonitis. What is a recommended next step?
- Chest X-ray in 6 months
- Laparotomy in every case
- Discharge home
- MRI
- Diagnostic laparoscopy to look for an injury to the left hemidiaphragm
Show the answer and explanation
Answer: E. Diagnostic laparoscopy to look for an injury to the left hemidiaphragm. Penetrating left thoracoabdominal wounds have a significant rate of diaphragm injury that CT can miss. Undetected injuries can lead to later herniation and strangulation of abdominal organs. Laparoscopy diagnoses and repairs them. The right side is protected by the liver.
Why not the others? Missed diaphragm injuries may present years later with a strangulated hernia.
References
A 30-year-old has a severe traumatic brain injury (GCS 7). Which two factors most worsen the outcome and must be avoided in the first hours?
- Hypothermia and tachycardia
- Hypertension and fever
- Hyperglycaemia and anaemia
- Hypocalcaemia and hyperkalaemia
- Hypotension and hypoxia
Show the answer and explanation
Answer: E. Hypotension and hypoxia. Secondary brain injury from hypotension (systolic below about 100–110 mmHg) and hypoxia sharply increases mortality after head injury. Early airway protection, oxygenation, ventilation to normal CO₂, and blood pressure support are the priorities, together with urgent CT and neurosurgical input.
Why not the others? Routine hyperventilation reduces brain blood flow and is avoided except as a brief bridge.
References
A motorcyclist has an open tibial fracture with a contaminated wound. What should be done in the emergency department?
- Delay antibiotics until surgery
- Wash the wound out with a bucket of saline and discharge
- Close the wound in the department
- Intravenous antibiotics as soon as possible (ideally within 1 hour), tetanus prophylaxis, photograph and cover the wound, splint, then surgical debridement
- Remove all bone fragments in the department
Show the answer and explanation
Answer: D. Intravenous antibiotics as soon as possible (ideally within 1 hour), tetanus prophylaxis, photograph and cover the wound, splint, then surgical debridement. Early antibiotics are the most important measure to prevent deep infection in open fractures. The wound is photographed and covered to limit repeated exposure, the limb is splinted, and formal debridement is done in theatre by orthopaedic and plastic surgeons together.
Why not the others? Repeated exposure and examination of the wound increase contamination.
References
A woman who is 30 weeks pregnant is hypotensive after a car crash. She is lying flat on a spinal board. What simple step improves her circulation?
- Raise her legs only
- No change of position, because of spinal precautions
- Give a vasopressor first
- Lie her prone
- Manual displacement of the uterus to the left (or tilting the board to the left)
Show the answer and explanation
Answer: E. Manual displacement of the uterus to the left (or tilting the board to the left). After about 20 weeks, the uterus compresses the inferior vena cava when the woman lies flat, reducing venous return and cardiac output. Displacing the uterus to the left, or tilting the board while keeping spinal precautions, relieves this. The best treatment for the fetus is resuscitation of the mother.
Why not the others? Rhesus-negative mothers also need anti-D, and fetal monitoring is started early.
References
After a high-speed crash, a stable driver has a widened mediastinum on chest X-ray. CT angiography shows a contained injury of the descending thoracic aorta just beyond the left subclavian artery. What is the management?
- Thrombolysis
- Chest drain
- Strict blood pressure and heart rate control, and endovascular repair (TEVAR) for significant injuries, timed with other injuries
- Discharge home
- Open thoracotomy immediately for every injury
Show the answer and explanation
Answer: C. Strict blood pressure and heart rate control, and endovascular repair (TEVAR) for significant injuries, timed with other injuries. Blunt aortic injury is managed with anti-impulse therapy (beta-blockers to lower blood pressure and heart rate) and, for significant injuries, TEVAR, which has lower mortality and paraplegia rates than open repair. Minimal injuries can be managed medically with imaging follow-up.
Why not the others? Thrombolysis or anticoagulation without assessment is dangerous.
References
A child fell onto bicycle handlebars. He is stable. CT shows a complete transection of the pancreas in the body, left of the superior mesenteric vessels, with main duct disruption. What is the definitive treatment?
- Total pancreatectomy
- Distal pancreatectomy (spleen-preserving if possible)
- External drainage only for every case
- Observation alone
- Pancreatoduodenectomy
Show the answer and explanation
Answer: B. Distal pancreatectomy (spleen-preserving if possible). Pancreatic injuries with main duct disruption to the left of the superior mesenteric vessels are best treated with distal pancreatectomy. Injuries without duct disruption are usually managed with drainage or non-operatively. Head injuries are more complex and often managed with drainage.
Why not the others? Pancreatoduodenectomy is rarely needed in trauma.
References
During a trauma laparotomy, the patient is cold (34 °C), acidotic (pH 7.1) and coagulopathic, with ongoing bleeding from multiple injuries. What is the best strategy?
- Complete all definitive repairs now, however long it takes
- Stop surgery and give crystalloid
- Damage control: control bleeding and contamination quickly (packing, ligation, stapling), use temporary abdominal closure, resuscitate in intensive care, and return for definitive repair later
- Close the abdomen tightly and transfer
- Perform all anastomoses immediately
Show the answer and explanation
Answer: C. Damage control: control bleeding and contamination quickly (packing, ligation, stapling), use temporary abdominal closure, resuscitate in intensive care, and return for definitive repair later. The lethal triad of hypothermia, acidosis and coagulopathy worsens with prolonged surgery. Damage control surgery stops bleeding and contamination, then the patient is warmed, resuscitated and corrected in intensive care, returning for definitive repair in 24–48 hours.
Why not the others? Tight closure risks abdominal compartment syndrome.
References
After a diving accident, a man has a complete cervical spinal cord injury. His blood pressure is 80/45 and his heart rate is 52, with warm peripheries. Bleeding has been excluded. What is the likely cause and treatment?
- Septic shock; antibiotics
- Haemorrhagic shock; massive transfusion
- Neurogenic shock; vasopressors (and atropine for bradycardia) after cautious fluid, aiming for a mean arterial pressure of about 85–90 mmHg
- Cardiogenic shock; inotropes only
- Normal finding; no treatment
Show the answer and explanation
Answer: C. Neurogenic shock; vasopressors (and atropine for bradycardia) after cautious fluid, aiming for a mean arterial pressure of about 85–90 mmHg. High spinal cord injury interrupts sympathetic outflow, causing hypotension with bradycardia and warm skin. After excluding haemorrhage, vasopressors maintain spinal cord perfusion; guidelines suggest a mean arterial pressure of 85–90 mmHg for the first 7 days.
Why not the others? Hypotension in trauma is bleeding until proven otherwise; neurogenic shock is a diagnosis of exclusion.
References
A 30-year-old has an emergency splenectomy for trauma. What must be arranged before discharge?
- Steroids
- Lifelong warfarin
- Nothing; the spleen is not important in adults
- Vaccination against pneumococcus, Haemophilus influenzae type b and meningococcus (ideally about 14 days after surgery), annual influenza vaccine, antibiotic advice and patient education
- Monthly blood transfusions
Show the answer and explanation
Answer: D. Vaccination against pneumococcus, Haemophilus influenzae type b and meningococcus (ideally about 14 days after surgery), annual influenza vaccine, antibiotic advice and patient education. Asplenic patients are at lifelong risk of overwhelming post-splenectomy infection, mainly from encapsulated organisms. They need vaccination, a supply of antibiotics or prophylaxis according to local policy, and an alert card and education to seek urgent help for fever.
Why not the others? The risk of overwhelming infection is lifelong, highest in the first years.
References
A man has a bomb blast injury with torrential bleeding from a mangled lower leg. What is the first action?
- Start intravenous fluids first
- Apply a tourniquet high on the limb immediately, tightened until the bleeding stops, and note the time
- Check the airway before controlling the bleeding
- Elevate the leg and wait
- Apply a loose bandage
Show the answer and explanation
Answer: B. Apply a tourniquet high on the limb immediately, tightened until the bleeding stops, and note the time. Catastrophic external haemorrhage is controlled first, before airway and breathing (the “x” in xABCDE). Early tourniquet use for extremity bleeding saves lives. It is left in place until definitive surgical control, with the time recorded.
Why not the others? Fluids before bleeding control dilute clotting factors and increase blood loss.
References
An 80-year-old on apixaban has a pelvic fracture with life-threatening bleeding. Which treatment helps reverse the anticoagulant effect?
- Fresh frozen plasma alone as the main reversal
- Andexanet alfa if available, or prothrombin complex concentrate, along with tranexamic acid and bleeding control
- Protamine
- Platelet transfusion
- Vitamin K
Show the answer and explanation
Answer: B. Andexanet alfa if available, or prothrombin complex concentrate, along with tranexamic acid and bleeding control. Factor Xa inhibitors are reversed with andexanet alfa or, more widely available, prothrombin complex concentrate. Vitamin K reverses warfarin; protamine reverses heparin. Tranexamic acid and early surgical or radiological haemorrhage control remain essential.
Why not the others? Dabigatran is reversed with idarucizumab.
References
Four days after a chest drain was placed for a traumatic haemothorax, CT shows 500 mL of retained clotted blood despite the drain. What is recommended?
- Antibiotics alone
- Early video-assisted thoracoscopic surgery (VATS) to evacuate the clot
- Wait 6 weeks for it to resolve
- Insert a third drain
- Thoracotomy only after empyema develops
Show the answer and explanation
Answer: B. Early video-assisted thoracoscopic surgery (VATS) to evacuate the clot. Retained haemothorax increases the risk of empyema and fibrothorax. Early VATS, ideally in the first week, removes the clot with fewer complications and a shorter stay. Intrapleural fibrinolytics are an alternative in some patients.
Why not the others? Waiting allows the clot to organise, making later decortication more difficult.
References
A man has a stab wound to the chest with air bubbling in and out of the wound and increasing breathlessness. What is the first treatment?
- Leave the wound open
- Cover the wound with a vented chest seal (or a dressing taped on three sides), then insert a chest drain away from the wound
- Close the wound with sutures immediately
- Thoracotomy in the department
- Insert a chest drain through the wound
Show the answer and explanation
Answer: B. Cover the wound with a vented chest seal (or a dressing taped on three sides), then insert a chest drain away from the wound. An open (“sucking”) chest wound allows air to enter the pleural space with each breath. A vented seal lets air out but not in, preventing a tension pneumothorax. A chest drain is then placed through a separate incision, followed by definitive closure.
Why not the others? A fully occlusive dressing without a chest drain can create a tension pneumothorax.
References
A 10-year-old has bilious vomiting 1 day after a handlebar injury to the upper abdomen. He is stable. CT shows an intramural duodenal haematoma narrowing the lumen, with no free air. What is the management?
- Gastrojejunostomy now
- Oral diet immediately
- Immediate laparotomy and drainage
- Pancreatoduodenectomy
- Non-operative treatment: nasogastric decompression and nutritional support (parenteral if needed) until the haematoma resolves
Show the answer and explanation
Answer: E. Non-operative treatment: nasogastric decompression and nutritional support (parenteral if needed) until the haematoma resolves. Duodenal haematomas usually resolve over 1–3 weeks with decompression and nutrition. Surgery is reserved for perforation or failure to resolve. Associated pancreatic injury should be looked for.
Why not the others? Free air or extravasation of contrast would indicate perforation.
References
A stab wound to the medial thigh has no active bleeding, haematoma or bruit, but the ankle–brachial index on that side is 0.8. What is the next step?
- Compression bandage only
- Discharge home
- Immediate exploration in every case
- CT angiography of the limb
- Repeat ABI in a month
Show the answer and explanation
Answer: D. CT angiography of the limb. Hard signs of arterial injury (active bleeding, expanding or pulsatile haematoma, absent pulses, bruit or thrill) mean immediate surgery. Without hard signs, an injured-limb ABI below 0.9 suggests an arterial injury and warrants CT angiography.
Why not the others? A normal ABI (0.9 or more) with no hard signs makes significant arterial injury unlikely.
References
A man trapped under rubble for 8 hours has crushed legs, dark urine and a CK of 60,000 U/L. What is the main treatment to protect the kidneys?
- Potassium supplements
- Fluid restriction
- Early, generous intravenous isotonic fluid aiming for a high urine output, monitoring potassium and fluid balance, with dialysis if needed
- Wait until creatinine rises
- NSAIDs for pain
Show the answer and explanation
Answer: C. Early, generous intravenous isotonic fluid aiming for a high urine output, monitoring potassium and fluid balance, with dialysis if needed. Muscle breakdown releases myoglobin, which damages the kidneys, and potassium, which causes arrhythmias. Fluids should start as early as possible, ideally before release from entrapment. Compartment syndrome must also be checked.
Why not the others? NSAIDs worsen kidney injury.
References
Which four areas are examined in the standard FAST scan in trauma?
- Kidneys, bladder, aorta and liver
- Lungs only
- Pericardium, right upper quadrant (hepatorenal), left upper quadrant (splenorenal) and pelvis
- Both legs and arms
- Brain, neck, chest and pelvis
Show the answer and explanation
Answer: C. Pericardium, right upper quadrant (hepatorenal), left upper quadrant (splenorenal) and pelvis. FAST looks for free fluid (blood) around the heart and in the dependent areas of the abdomen. Extended FAST (eFAST) adds views of both lungs to look for pneumothorax. FAST does not reliably exclude retroperitoneal or hollow organ injury.
Why not the others? A negative FAST does not exclude injury in a stable patient; CT is used.
References
Where is the safe site for inserting a chest drain?
- The “safe triangle”: anterior border of latissimus dorsi, lateral border of pectoralis major, a line at the level of the nipple (5th intercostal space), and the apex below the axilla
- The second intercostal space in the mid-clavicular line for all drains
- Below the 8th rib
- Through the breast tissue
- Posteriorly near the spine
Show the answer and explanation
Answer: A. The “safe triangle”: anterior border of latissimus dorsi, lateral border of pectoralis major, a line at the level of the nipple (5th intercostal space), and the apex below the axilla. The safe triangle avoids major vessels, the internal mammary artery, the diaphragm and breast tissue. The drain goes just over the top of the rib to avoid the neurovascular bundle running beneath it.
Why not the others? Drains placed too low risk injury to the liver or spleen.
References
An 80-year-old falls from standing height. His blood pressure is 120/70 and his heart rate is 85. He takes a beta-blocker. Which statement is correct?
- Falls from standing height never cause serious injury
- Normal vital signs exclude serious injury
- Beta-blockers make shock easier to detect
- Older patients should not have CT
- Older trauma patients are often under-triaged: normal vital signs can hide shock, so a lower threshold for trauma team activation and CT is appropriate
Show the answer and explanation
Answer: E. Older trauma patients are often under-triaged: normal vital signs can hide shock, so a lower threshold for trauma team activation and CT is appropriate. In older patients, beta-blockers blunt tachycardia, and their usual blood pressure may be higher, so “normal” readings can mask shock. Low-energy falls cause significant injuries, especially with anticoagulants. Guidelines recommend a lower threshold for activation and imaging.
Why not the others? A systolic pressure below 110 may represent shock in an older patient.
References
A man has a gunshot wound to the abdomen and is hypotensive. What is the management?
- Diagnostic peritoneal lavage before deciding
- Observation
- CT first
- Immediate laparotomy
- Local wound exploration
Show the answer and explanation
Answer: D. Immediate laparotomy. Gunshot wounds carry a high rate of significant intra-abdominal injury, and an unstable patient goes straight to theatre. Selective non-operative management of gunshot wounds is limited to carefully selected stable patients in experienced centres.
Why not the others? Taking unstable patients to CT delays haemorrhage control.
References
A stable patient has a stab wound just medial to the left nipple. Bedside ultrasound of the pericardium is equivocal. Which procedure can confirm or exclude cardiac injury?
- Chest drain only
- Discharge
- Thrombolysis
- Needle pericardiocentesis as definitive treatment
- Subxiphoid pericardial window (or repeat focused imaging/CT if appropriate), proceeding to sternotomy if blood is found
Show the answer and explanation
Answer: E. Subxiphoid pericardial window (or repeat focused imaging/CT if appropriate), proceeding to sternotomy if blood is found. Wounds in the “cardiac box” (between the nipples, from the clavicles to the costal margins) may injure the heart. In stable patients with uncertain imaging, a subxiphoid pericardial window directly examines the pericardium. Unstable patients go straight to surgery.
Why not the others? A haemothorax can make pericardial ultrasound falsely negative by decompressing blood into the pleura.
References
A severely injured, hypotensive patient has no peripheral venous access after two attempts. What is the fastest alternative for giving fluids and blood?
- Oral fluids
- Subcutaneous fluids
- Rectal fluids
- Intraosseous access, for example in the proximal humerus or tibia
- Wait for a central line in theatre
Show the answer and explanation
Answer: D. Intraosseous access, for example in the proximal humerus or tibia. Intraosseous needles can be placed in seconds, and all resuscitation drugs and blood products can be given through them. The proximal humerus allows higher flow rates than the tibia. Avoid fractured bones and bones with a previous IO attempt.
Why not the others? Delays in access delay resuscitation.
References