A 35-year-old man with a head injury is being observed on the neurosurgical ward. Two hours later, the nurse records BP 188/104 mmHg (earlier 130/80), pulse 48/min and irregular, slow breathing, and his GCS has fallen from 12 to 8. What do these vital signs indicate?

Pain from an undetected fracture

Hypovolaemia from hidden bleeding

Neurogenic shock from cord injury

A 74-year-old woman on aspirin and clopidogrel after a coronary stent fell in her bathroom 6 hours ago. GCS is 11. Non-contrast CT shows a crescent-shaped hyperdense collection over the whole left cerebral convexity, crossing the suture lines, with 7 mm of midline shift. What is the most likely source of the bleeding?

Bridging veins between cortex and dural sinuses

Lenticulostriate branches of the middle cerebral artery

A 68-year-old retired teacher on metoprolol for hypertension fell from his scooter onto the left side. In casualty, his pulse is 76/min and BP 98/64 mmHg (his usual BP is 150/90 mmHg). He is pale and sweaty, and his hands are cold. The left 9th and 10th ribs are tender, and FAST shows fluid in the splenorenal recess. What is the most likely explanation of his findings?

Haemorrhagic shock masked by beta-blockade

Normal blood pressure for his age after a fall

Vasovagal reaction to the pain of fractures

Neurogenic shock from a thoracic cord injury

A 34-year-old woman fell from the back of a moving tempo. In casualty her pulse settles from 112 to 88/min and BP stays 122/78 mmHg after 1 litre of crystalloid. She has left upper abdominal tenderness, and FAST shows a thin rim of fluid in the splenorenal recess. What is the best next step?

Contrast-enhanced CT of the abdomen

Discharge with a review next day

Immediate exploratory laparotomy

ATLS, head injury and abdominal trauma

46 NEET-PG practice questions on ATLS, head injury and abdominal trauma, part of General Surgery. The first 25 are below; the first 5 with answers and explanations (tap Show answer after you have chosen), the rest in Learn with a free account.

Question 1 · Medium
After a highway collision, a 27-year-old pillion rider is brought to casualty gasping, with pulse 128/min, BP 82/50 mmHg and SpO2 85% on oxygen. The trachea is shifted to the left, the neck veins are full, and the right chest is hyper-resonant with absent breath sounds. The casualty medical officer considers four actions: 1. Chest X-ray to confirm the diagnosis before any procedure. 2. Immediate needle or finger decompression of the right pleural space. 3. An intercostal chest drain after decompression. 4. Intubation and positive-pressure ventilation before decompression. Which actions are correct?
1. A1, 2, 3 and 4
2. B1, 2 and 3 only
3. C2, 3 and 4 only
4. D2 and 3 only
Show answerHide answer
Answer: D · 2 and 3 only
Only actions 2 and 3 are correct. Hypotension, distended neck veins and tracheal shift away from a silent, hyper-resonant hemithorax is tension pneumothorax, a clinical diagnosis treated in the breathing step of the primary survey by immediate decompression (in adults, ATLS 10th edition advises the 5th intercostal space just anterior to the mid-axillary line), followed by an intercostal chest drain. Action 1 is wrong because waiting for an X-ray in a shocked patient can be fatal. Action 4 is wrong because positive pressure forces more air into the pleural space and can precipitate cardiac arrest.
- A: Includes both the delaying X-ray and intubation before decompression.
- B: Includes the confirmatory X-ray, which delays life-saving decompression.
- C: Includes intubation before decompression, which worsens the tension.
Question 2 · Easy
A 35-year-old man with a head injury is being observed on the neurosurgical ward. Two hours later, the nurse records BP 188/104 mmHg (earlier 130/80), pulse 48/min and irregular, slow breathing, and his GCS has fallen from 12 to 8. What do these vital signs indicate?
1. APain from an undetected fracture
2. BHypovolaemia from hidden bleeding
3. CRising intracranial pressure
4. DNeurogenic shock from cord injury
Show answerHide answer
Answer: C · Rising intracranial pressure
Hypertension, bradycardia and irregular respiration is the Cushing response, a late sign of rising intracranial pressure with brainstem compression. As ICP rises, the body raises arterial pressure to keep cerebral perfusion, and baroreceptors slow the heart. With a falling GCS, this needs urgent airway control, measures to lower ICP and an immediate repeat CT, often followed by surgery. Waiting for the full triad is unwise, because it appears only shortly before herniation.
- A: Pain causes tachycardia and hypertension, not bradycardia with a falling GCS.
- B: Hypovolaemia gives tachycardia and falling BP.
- D: Neurogenic shock gives hypotension with bradycardia, not hypertension.
Question 3 · Medium
A 74-year-old woman on aspirin and clopidogrel after a coronary stent fell in her bathroom 6 hours ago. GCS is 11. Non-contrast CT shows a crescent-shaped hyperdense collection over the whole left cerebral convexity, crossing the suture lines, with 7 mm of midline shift. What is the most likely source of the bleeding?
1. ALenticulostriate branches of the middle cerebral artery
2. BMiddle meningeal artery
3. CRupture of a berry aneurysm
4. DBridging veins between cortex and dural sinuses
Show answerHide answer
Answer: D · Bridging veins between cortex and dural sinuses
A crescentic hyperdense collection that crosses sutures (but not the falx) is an acute subdural haematoma. It comes from tearing of the bridging veins that cross the subdural space to the dural sinuses, which are stretched in the elderly by brain atrophy, and antiplatelet drugs worsen the bleeding. With midline shift and a reduced GCS, it needs urgent craniotomy and evacuation. Platelet transfusion may be considered before surgery after discussion with the cardiology team.
- A: Lenticulostriate bleeding is a hypertensive intracerebral bleed in the basal ganglia.
- B: Arterial extradural bleeding gives a biconvex collection limited by sutures.
- C: An aneurysm bleeds into the subarachnoid space and basal cisterns.
Question 4 · Hard
A 68-year-old retired teacher on metoprolol for hypertension fell from his scooter onto the left side. In casualty, his pulse is 76/min and BP 98/64 mmHg (his usual BP is 150/90 mmHg). He is pale and sweaty, and his hands are cold. The left 9th and 10th ribs are tender, and FAST shows fluid in the splenorenal recess. What is the most likely explanation of his findings?
1. ANormal blood pressure for his age after a fall
2. BHaemorrhagic shock masked by beta-blockade
3. CVasovagal reaction to the pain of fractures
4. DNeurogenic shock from a thoracic cord injury
Show answerHide answer
Answer: B · Haemorrhagic shock masked by beta-blockade
Beta-blockers blunt the tachycardic response to bleeding, so a normal pulse in an elderly patient can hide significant blood loss. His BP is a third lower than usual, his skin is cold and sweaty, he has lower left rib fractures (which overlie the spleen) and FAST shows free fluid, all pointing to haemorrhage from a splenic injury. He needs blood products and, depending on his response, CT or laparotomy. Older patients have less reserve, so a low threshold for treating shock is needed.
- A: A BP far below his usual is relative hypotension, not normal.
- C: A vasovagal reaction causes bradycardia and warm peripheries, not free fluid and cold skin.
- D: Neurogenic shock gives warm, dry peripheries and no free fluid.
Question 5 · Medium
A 34-year-old woman fell from the back of a moving tempo. In casualty her pulse settles from 112 to 88/min and BP stays 122/78 mmHg after 1 litre of crystalloid. She has left upper abdominal tenderness, and FAST shows a thin rim of fluid in the splenorenal recess. What is the best next step?
1. ADischarge with a review next day
2. BDiagnostic peritoneal lavage
3. CImmediate exploratory laparotomy
4. DContrast-enhanced CT of the abdomen
Show answerHide answer
Answer: D · Contrast-enhanced CT of the abdomen
A patient who responds to resuscitation and stays stable can have the injury defined before deciding on treatment, and contrast-enhanced CT is the investigation of choice. It grades solid-organ injuries, shows active contrast extravasation, and looks at the retroperitoneum, which FAST cannot see. Most stable splenic injuries are then managed without surgery. Laparotomy is kept for instability or peritonitis.
- A: Free fluid after trauma must be explained before any discharge.
- B: DPL is invasive, cannot grade the injury and is largely replaced by FAST and CT.
- C: Laparotomy in a stable patient with possible minor splenic injury is often unnecessary.
Question 6 · Easy
A 23-year-old man is brought to casualty 20 minutes after a knife stab just left of the sternum in the 4th intercostal space. BP is 78/56 mmHg, pulse 128/min, the neck veins are distended and the heart sounds are faint. The trachea is central and breath sounds are equal on both sides. What is the most likely diagnosis?
1. AMyocardial contusion
2. BMassive left haemothorax
3. CCardiac tamponade
4. DTension pneumothorax
Answer and explanation in LearnFree account
Question 7 · Hard
A 38-year-old man with multiple stab wounds has a laparotomy at a district hospital after 8 units of blood. The surgeon finds a deep liver laceration and two small bowel perforations. After 90 minutes, his core temperature is 34.2 °C, pH 7.12, lactate 7 mmol/L, INR 2.0, and there is diffuse ooze from all raw surfaces. What is the most appropriate surgical strategy now?
1. APrimary closure of the fascia, then transfer
2. BFormal liver resection and bowel anastomosis now
3. CPack the liver, close off the bowel, temporary closure, ICU
4. DContinue definitive repair with warmed fluids
Answer and explanation in LearnFree account
Question 8 · Medium
A 31-year-old man with a right temporal contusion becomes drowsy on the ward 8 hours after admission. His right pupil is now dilated and sluggish, and he has weakness of the left arm and leg. Which part of the brain has most likely herniated?
1. AUncus of the right temporal lobe through the tentorial notch
2. BCerebellar vermis upwards through the tentorial notch
3. CCerebellar tonsils through the foramen magnum
4. DRight cingulate gyrus under the falx cerebri
Answer and explanation in LearnFree account
Question 9 · Medium
A 28-year-old man with a pelvic fracture after a road traffic accident needs urine output monitoring in casualty. On examination, there is blood at the external urethral meatus and a scrotal swelling. What should be done before any attempt at urethral catheterisation?
1. ACystoscopy under anaesthesia
2. BRetrograde urethrogram
3. CIntravenous urogram
4. DUltrasound of the bladder
Answer and explanation in LearnFree account
Question 10 · Medium
A 30-year-old woman had a splenectomy for a splenic injury 2 months ago. Her peripheral smear shows small, round, dark purple inclusions near the edge of many red cells, and the platelet count is 6.2 lakh/µL. What are these inclusions?
1. AHeinz bodies
2. BHowell-Jolly bodies
3. CBasophilic stippling
4. DPappenheimer bodies
Answer and explanation in LearnFree account
Question 11 · Hard
Two days after a damage-control laparotomy with liver packing and 14 litres of fluids and blood, a 30-year-old man in the trauma ICU has a tense, distended abdomen. His urine output has fallen to 10 mL/h despite a normal BP, the ventilator's peak airway pressure has risen, and the bladder pressure is 30 mmHg. What is the most appropriate management?
1. ADecompressive laparotomy
2. BFurosemide infusion
3. CFluid bolus and higher PEEP
4. DUrgent haemodialysis
Answer and explanation in LearnFree account
Question 12 · Medium
A 27-year-old man is brought to casualty after a fall from a bus. His GCS is 7 (E1 V2 M4). He is breathing spontaneously with SpO2 95% on a face mask, pulse 98/min and BP 132/82 mmHg. What is the most appropriate airway management?
1. ANasopharyngeal airway with high-flow oxygen
2. BRapid sequence intubation with in-line stabilisation
3. CCT of the head before deciding on the airway
4. DOropharyngeal airway and continued observation
Answer and explanation in LearnFree account
Question 13 · Medium
A 70-kg man is brought to casualty after his car overturned. He is anxious and confused, with pulse 134/min, BP 86/60 mmHg, respiratory rate 32/min and cold, pale peripheries. A catheter drains 8 mL of urine in the first hour. Using the ATLS classes of haemorrhagic shock, how much blood has he most likely lost?
1. AOver 2,000 mL (over 40%)
2. B1,500-2,000 mL (31-40%)
3. C750-1,500 mL (15-30%)
4. DUp to 750 mL (under 15%)
Answer and explanation in LearnFree account
Question 14 · Medium
A 22-year-old man was hit in the left flank by a cricket ball. He is stable, with pulse 90/min and BP 124/80 mmHg, and has no peritonitis. Contrast CT shows a 2 cm deep splenic laceration with a small amount of blood around the spleen, no contrast blush and no other injury. What is the most appropriate management?
1. ASplenorrhaphy through an upper midline incision
2. BLaparoscopic splenectomy within 24 hours
3. CSplenic artery embolisation as a precaution
4. DNon-operative care with monitoring and serial haemoglobin
Answer and explanation in LearnFree account
Question 15 · Medium
A 36-year-old restrained front-seat passenger is brought to a tertiary casualty after a head-on collision. He has a band of bruising across the lower abdomen along the lap belt and back pain. Contrast CT shows a flexion-distraction fracture of L1, a small amount of free fluid, and no injury to the liver, spleen or kidneys. Which injury must be specifically suspected?
1. ALeft diaphragmatic rupture
2. BSplenic capsular tear
3. CRenal pedicle avulsion
4. DSmall bowel or mesenteric tear
Answer and explanation in LearnFree account
Question 16 · Easy
A 30-year-old man hit his forehead on the windscreen in a car crash. The next morning on the surgical ward he has bilateral periorbital bruising that stops at the orbital margins, and a clear, watery discharge drips from his nose when he bends forward. Which bone is most likely fractured?
1. ASquamous part of the temporal bone
2. BCribriform plate of the ethmoid
3. CBasilar part of the occipital bone
4. DPetrous part of the temporal bone
Answer and explanation in LearnFree account
Question 17 · Easy
A 26-year-old motorcyclist is brought to the casualty of a district hospital after a collision. He is drowsy, with noisy snoring breathing and blood in the mouth. Pulse is 116/min, BP 104/70 mmHg, and his right thigh is swollen and deformed with no external bleeding. What should be done first?
1. ASuction and jaw thrust with manual in-line neck stabilisation
2. BTwo large-bore IV cannulae and warmed crystalloid
3. CTraction splint for the deformed right thigh
4. DNon-contrast CT of the head and cervical spine
Answer and explanation in LearnFree account
Question 18 · Medium
A passer-by brings an unconscious 35-year-old man to a private hospital casualty after a road accident. He is in shock with free fluid on FAST and needs an emergency laparotomy. No relatives can be traced, and the police have not yet arrived. What should the surgeon do?
1. ARefer him to a government hospital as a police case
2. BWait for the police before starting treatment
3. CWait until relatives give written consent
4. DOperate now in his best interest and inform the police
Answer and explanation in LearnFree account
Question 19 · Medium
A 29-year-old man stabbed in the epigastrium during a quarrel is brought to casualty. Pulse is 92/min and BP 126/80 mmHg. A loop of omentum protrudes through the 3 cm wound, and the abdomen is soft away from the wound. What is the most appropriate management?
1. AReplace the omentum and suture the wound
2. BLocal wound exploration under local anaesthesia
3. CExploratory laparotomy
4. DContrast CT and observation in the ward
Answer and explanation in LearnFree account
Question 20 · Medium
A 28-year-old man is brought to casualty after a lorry hit his motorcycle. His airway is clear and the chest is normal on examination and X-ray, and the pelvis is stable. BP is 78/50 mmHg after 1 litre of warmed crystalloid and the first unit of blood. FAST shows free fluid in the hepatorenal pouch. What is the next best step?
1. AContrast-enhanced CT of the abdomen
2. BRepeat FAST after 30 minutes
3. CDiagnostic peritoneal lavage
4. DEmergency laparotomy
Answer and explanation in LearnFree account
Question 21 · Medium
A 25-year-old man with a right-sided stab wound has an intercostal drain placed in casualty, which drains 1,600 mL of blood at once. He has received 2 units of blood and BP is still 84/56 mmHg. What is the next step?
1. AInsert a second chest drain
2. BCT angiography of the chest
3. CClamp the drain to tamponade the bleeding
4. DUrgent thoracotomy
Answer and explanation in LearnFree account
Question 22 · Medium
A 20-year-old car passenger is unconscious from the moment of a high-speed crash, with GCS 5 and no lucid interval. Non-contrast CT shows a few small haemorrhages at the grey-white junction and in the corpus callosum, without a mass lesion or midline shift. What is the mechanism of his brain injury?
1. AGlobal hypoxic damage from cardiac arrest
2. BContusion of the frontal and temporal poles
3. CArterial bleeding compressing the brain
4. DShearing of axons from rotational acceleration
Answer and explanation in LearnFree account
Question 23 · Easy
A 19-year-old man was kicked in the left upper abdomen during a street fight. In casualty he complains of pain at the tip of his left shoulder, which is worse when he lies flat with the foot end raised. There is no shoulder injury. What is this sign called?
1. ABallance sign
2. BGrey Turner sign
3. CKehr sign
4. DCullen sign
Answer and explanation in LearnFree account
Question 24 · Medium
A 45-year-old pedestrian is hit by a bus. Airway and breathing are secure, but BP is 80/52 mmHg and pulse 132/min. Chest X-ray is normal and FAST shows no free fluid. Pelvic X-ray shows a pubic symphysis gap of 4 cm with widened sacroiliac joints. What is the most appropriate next step?
1. APelvic binder placed around the iliac crests
2. BPelvic binder centred over the greater trochanters
3. CRepeated compression of the pelvis to test stability
4. DEmergency laparotomy to find the bleeding
Answer and explanation in LearnFree account
Question 25 · Medium
After a bus overturns on a highway, the first doctor at a district hospital triages patients using START. Casualties: 1. A man walking around with a deformed forearm. 2. A woman who cannot walk and breathes at 36/min. 3. A youth who cannot walk, breathes at 22/min and has no radial pulse. 4. A woman with a fractured leg who cannot walk, breathes at 20/min, has a radial pulse and follows commands. Which casualties should be tagged red (immediate)?
1. A3 and 4 only
2. B2 and 3 only
3. C2, 3 and 4 only
4. D1, 2 and 3 only
Answer and explanation in LearnFree account

21 more ATLS, head injury and abdominal trauma questions

Answer them one by one, keep your score and see your weak topics in Learn. Signed-out visitors try 25 per exam; sign in with Google to see them all.

Study General Surgery

ATLS, head injury and abdominal trauma

A 35-year-old man with a head injury is being observed on the neurosurgical ward. Two hours later, the nurse records BP 188/104 mmHg (earlier 130/80), pulse 48/min and irregular, slow breathing, and his GCS has fallen from 12 to 8. What do these vital signs indicate?

A 34-year-old woman fell from the back of a moving tempo. In casualty her pulse settles from 112 to 88/min and BP stays 122/78 mmHg after 1 litre of crystalloid. She has left upper abdominal tenderness, and FAST shows a thin rim of fluid in the splenorenal recess. What is the best next step?

A 31-year-old man with a right temporal contusion becomes drowsy on the ward 8 hours after admission. His right pupil is now dilated and sluggish, and he has weakness of the left arm and leg. Which part of the brain has most likely herniated?

A 28-year-old man with a pelvic fracture after a road traffic accident needs urine output monitoring in casualty. On examination, there is blood at the external urethral meatus and a scrotal swelling. What should be done before any attempt at urethral catheterisation?

A 30-year-old woman had a splenectomy for a splenic injury 2 months ago. Her peripheral smear shows small, round, dark purple inclusions near the edge of many red cells, and the platelet count is 6.2 lakh/µL. What are these inclusions?

A 27-year-old man is brought to casualty after a fall from a bus. His GCS is 7 (E1 V2 M4). He is breathing spontaneously with SpO2 95% on a face mask, pulse 98/min and BP 132/82 mmHg. What is the most appropriate airway management?

A 30-year-old man hit his forehead on the windscreen in a car crash. The next morning on the surgical ward he has bilateral periorbital bruising that stops at the orbital margins, and a clear, watery discharge drips from his nose when he bends forward. Which bone is most likely fractured?

A 26-year-old motorcyclist is brought to the casualty of a district hospital after a collision. He is drowsy, with noisy snoring breathing and blood in the mouth. Pulse is 116/min, BP 104/70 mmHg, and his right thigh is swollen and deformed with no external bleeding. What should be done first?

A passer-by brings an unconscious 35-year-old man to a private hospital casualty after a road accident. He is in shock with free fluid on FAST and needs an emergency laparotomy. No relatives can be traced, and the police have not yet arrived. What should the surgeon do?

A 29-year-old man stabbed in the epigastrium during a quarrel is brought to casualty. Pulse is 92/min and BP 126/80 mmHg. A loop of omentum protrudes through the 3 cm wound, and the abdomen is soft away from the wound. What is the most appropriate management?

A 25-year-old man with a right-sided stab wound has an intercostal drain placed in casualty, which drains 1,600 mL of blood at once. He has received 2 units of blood and BP is still 84/56 mmHg. What is the next step?

A 19-year-old man was kicked in the left upper abdomen during a street fight. In casualty he complains of pain at the tip of his left shoulder, which is worse when he lies flat with the foot end raised. There is no shoulder injury. What is this sign called?

A 45-year-old pedestrian is hit by a bus. Airway and breathing are secure, but BP is 80/52 mmHg and pulse 132/min. Chest X-ray is normal and FAST shows no free fluid. Pelvic X-ray shows a pubic symphysis gap of 4 cm with widened sacroiliac joints. What is the most appropriate next step?