Q1. In a trauma patient with torrential external bleeding from a limb, the correct FIRST action is: A. Secure the airway B. Control the catastrophic haemorrhage C. Obtain intravenous access D. Perform a chest X-ray ANSWER: B. Why: catastrophic external haemorrhage precedes the airway in the modern sequence, because an open major artery kills faster than an unmanaged airway. Direct pressure first, tourniquet if that fails. LEARNING POINT: the order of the primary survey is a ranking by speed of death.

Q2. Absent breath sounds on one side with a HYPERRESONANT percussion note and distended neck veins indicates: A. Massive haemothorax B. Tension pneumothorax C. Flail chest D. Pulmonary contusion ANSWER: B — tension pneumothorax. Why: air trapped under pressure gives hyperresonance and obstructs venous return. A massive haemothorax gives the same absent breath sounds but is DULL to percussion. LEARNING POINT: percussion separates the two great absent-breath-sound diagnoses.

Q3. A 22-year-old after a fall has pulse 122, systolic 118, cool peripheries, capillary refill 4 seconds and agitation. The correct interpretation is: A. Normotensive — no significant blood loss B. Significant haemorrhage with intact compensation C. Anxiety related to the accident D. Head injury alone ANSWER: B. Why: tachycardia, a narrow pulse pressure, poor peripheral perfusion and agitation are compensated haemorrhagic shock. Young patients maintain systolic pressure until a large volume is lost, then decompensate abruptly. LEARNING POINT: hypotension is a late sign — do not wait for it before treating.

Q4. A patient with blunt abdominal trauma responds only transiently to fluid and has free fluid on FAST. The next step is: A. Repeat the fluid bolus and observe B. CT abdomen C. LAPAROTOMY D. Admit for serial examination ANSWER: C — laparotomy. Why: a transient responder is still bleeding. Haemodynamic instability with free intraperitoneal fluid after blunt trauma is an indication for operative control, and an unstable patient should not be taken to the scanner. LEARNING POINT: fluid buys time; only stopping the bleeding treats the bleeding.

Q5. In a severe head injury with oxygen saturation 88% and systolic 84 mmHg, the single most effective neuroprotective measure is: A. Correcting the hypoxia and hypotension B. Immediate mannitol C. Hyperventilation D. Waiting for the CT report ANSWER: A. Why: hypoxia and hypotension are the two great causes of SECONDARY brain injury, which — unlike the primary injury — is preventable. Resuscitation is the neuroprotection. LEARNING POINT: fix oxygenation and perfusion while imaging and neurosurgical referral are arranged.

Q6. Which patient may NOT show the expected tachycardia despite significant haemorrhage? A. A young athlete B. A patient taking a beta-blocker C. A patient with a limb fracture D. A patient with a head injury ANSWER: B — a patient on a beta-blocker. Why: beta-blockade blunts the compensatory tachycardia, so a deceptively normal heart rate can accompany serious blood loss. Older patients may also fail to mount a tachycardia, and their "normal" pressure may be low for them. LEARNING POINT: absence of tachycardia never excludes haemorrhage.

Q7. Why are large volumes of crystalloid avoided in haemorrhagic trauma? A. They cause hypernatraemia B. They dilute clotting factors, carry no oxygen and cool the patient — worsening the lethal triad C. They raise intracranial pressure D. They are contraindicated in fractures ANSWER: B. Why: hypothermia, acidosis and coagulopathy each worsen the other two, and dilutional coagulopathy from large-volume crystalloid feeds directly into that cycle. Replace blood with blood, and keep the patient warm. LEARNING POINT: the lethal triad explains why warming and early blood products are treatment, not comfort measures.