FREEMEDSITE MRCS ACADEMY · ARTICLE 19 · TRAUMA & EMERGENCY SURGERY

Trauma, Shock and Burns Made Easy for MRCS Part A

Learn to recognise life-threatening injuries, interpret shock, prioritise haemorrhage control, understand head and spinal trauma, and safely assess burns. Work through 12 clear lessons, save your 52-topic checklist and master 40 original clinical single-best-answer questions.

12Teaching modules

52Saved objectives

40Original SBAs

MRCS Paper 2Clinical cABCDEFive options A–ESaved locally

Learn → apply → test. Read the modules, tick each topic once understood, answer one question at a time, check your answer and read the explanation. All progress is saved on this device without a login.

Who is this article for?

MRCS Part A candidates, junior doctors and trauma trainees who want a beginner-friendly but examination-level explanation of priorities, physiology and dangerous distractors. Exam-style scenarios are original rather than reproduced recalls.

Clinical note: this educational material is not a replacement for local trauma/major-haemorrhage pathways, burn-centre guidance or supervised procedural training.

On this page

1. Primary survey: cABCDE and immediate intervention2. Airway, cervical spine and safe oxygenation3. Breathing assessment and immediately fatal chest injuries4. Circulatory shock: recognise mechanism and physiology5. Haemorrhage control, transfusion and TXA6. Pelvic and abdominal trauma: binder, FAST and CT7. Traumatic brain injury, GCS and cerebral perfusion8. Spinal trauma and neurological assessment9. Limb-threatening trauma: fractures, vessels and compartments10. Thermal burns: depth, size and initial first aid11. Major burns: airway, fluids and specialist referral12. Secondary survey, imaging, handover and examiner traps52-topic saved revision checklist40 clinical MRCS SBA questionsFrequently asked questionsReferences and related lessons

1. Primary survey: cABCDE and immediate intervention

In major trauma, activate the trauma team and use a structured catastrophic haemorrhage, Airway, Breathing, Circulation, Disability, Exposure (cABCDE) approach. Some pathways write XABCDE. Stop immediately life-threatening external bleeding while another team member protects the airway. Repeat the primary survey whenever physiology changes; treatment and assessment are simultaneous, not strictly sequential.

Identify external bleeding needing direct pressure, haemostatic dressing or a limb tourniquet where appropriate. Evaluate airway patency, ventilation, haemodynamic status, pupils and Glasgow Coma Scale. Prevent hypothermia, inspect the whole patient and preserve dignity. Normal blood pressure does not exclude compensated shock.

Clinical example: a hypotensive motorcycle casualty with brisk femoral bleeding needs immediate haemorrhage control, resuscitation and a rapid search for other injury—not transport to CT before stabilisation.

Clinical application

Clinical example: a hypotensive motorcycle casualty with brisk femoral bleeding needs immediate haemorrhage control, resuscitation and a rapid search for other injury—not transport to CT before stabilisation.

Exam pearl

In major trauma, activate the trauma team and use a structured catastrophic haemorrhage, Airway, Breathing, Circulation, Disability, Exposure (cABCDE) approach.

Original FreeMedSite diagram. The steps are iterative; immediate catastrophic bleeding is controlled without delaying airway management.

2. Airway, cervical spine and safe oxygenation

An obstructed or threatened airway takes priority. Listen for stridor, gurgling, altered phonation or absent airflow; inspect the mouth for blood, vomitus or foreign material. Suction, basic airway manoeuvres and prompt expert airway support take priority over a long examination.

Maintain in-line spinal protection when cervical injury is suspected, without compromising oxygenation. Some patients with facial injury, burns, reduced consciousness or progressive swelling require definitive airway management early. A GCS of 8 or lower is an important warning sign, but airway decisions depend on actual protection/ventilation rather than a number alone.

Clinical example: after a neck injury the patient develops expanding haematoma and new stridor. Call expert airway/trauma help urgently; waiting for CT before airway planning may be unsafe.

Clinical application

Clinical example: after a neck injury the patient develops expanding haematoma and new stridor. Call expert airway/trauma help urgently; waiting for CT before airway planning may be unsafe.

Exam pearl

An obstructed or threatened airway takes priority.

3. Breathing assessment and immediately fatal chest injuries

Determine respiratory rate, work of breathing, oxygenation, chest expansion, breath sounds and percussion as clinically useful. Life-threatening lesions include tension pneumothorax, massive haemothorax, open pneumothorax, flail chest with respiratory failure and cardiac tamponade.

Tension pneumothorax is a clinical diagnosis in an unstable patient. Severe respiratory distress, unilateral reduced air entry and hypotension after chest trauma demand immediate decompression by a trained clinician; radiography must not delay treatment. A ventilated patient may deteriorate rapidly.

Clinical example: following blunt chest trauma a patient develops profound shock, worsening hypoxia and unilateral absent breath sounds. Treat suspected tension pneumothorax immediately while the team continues resuscitation.

Clinical application

Clinical example: following blunt chest trauma a patient develops profound shock, worsening hypoxia and unilateral absent breath sounds. Treat suspected tension pneumothorax immediately while the team continues resuscitation.

Exam pearl

Determine respiratory rate, work of breathing, oxygenation, chest expansion, breath sounds and percussion as clinically useful.

4. Circulatory shock: recognise mechanism and physiology

Classify shock by physiology: haemorrhagic/hypovolaemic (loss of preload), obstructive (e.g., tension pneumothorax or tamponade), cardiogenic (pump failure) and distributive (vasodilatation). Trauma often involves more than one mechanism.

Assess heart rate, skin perfusion, pulse pressure, mental state, capillary refill, lactate trend and urine output as appropriate. Tachycardia or cool peripheries can precede hypotension. The shock index, heart rate divided by systolic pressure, above approximately 1 may raise concern but is nonspecific.

Clinical example: after major pelvic trauma a tachycardic patient with cold peripheries and falling conscious level may have severe blood loss even before the first low systolic-pressure reading.

Clinical application

Clinical example: after major pelvic trauma a tachycardic patient with cold peripheries and falling conscious level may have severe blood loss even before the first low systolic-pressure reading.

Exam pearl

Classify shock by physiology: haemorrhagic/hypovolaemic (loss of preload), obstructive (e.

Classify the mechanism first. Trauma patients may have several mechanisms simultaneously.

5. Haemorrhage control, transfusion and TXA

Identify where blood can collect: outside the body, chest, abdomen/retroperitoneum, pelvis or long-bone fractures. Activate major haemorrhage protocol as needed. Early definitive source control may require surgery, interventional radiology or both. Blood products and guided correction of coagulopathy matter; crystalloid alone does not replace lost oxygen-carrying capacity.

NICE NG39 and European guidance recommend IV tranexamic acid as soon as possible and within 3 hours for major trauma with active or suspected active bleeding (unless a specialist indication modifies decisions). In adults, a frequently cited European regimen is 1 g over 10 minutes followed by 1 g over 8 hours; follow local protocols.

Traumatic coagulopathy is worsened by hypothermia, acidosis and hypocalcaemia. Blood-gas chemistry, ionised calcium, fibrinogen and viscoelastic or laboratory testing support goal-directed resuscitation. Permissive hypotension must not compromise cerebral perfusion in traumatic brain injury.

Clinical application

Traumatic coagulopathy is worsened by hypothermia, acidosis and hypocalcaemia. Blood-gas chemistry, ionised calcium, fibrinogen and viscoelastic or laboratory testing support goal-directed resuscitation. Permissive hypotension must not compromise cerebral perfusion in traumatic brain injury.

Exam pearl

Identify where blood can collect: outside the body, chest, abdomen/retroperitoneum, pelvis or long-bone fractures.

6. Pelvic and abdominal trauma: binder, FAST and CT

An unstable pelvic ring injury can cause catastrophic retroperitoneal haemorrhage. Apply a purpose-made pelvic binder around the greater trochanters when indicated; positioning at the waist or iliac crests is too high. Avoid repeated vigorous pelvic springing, which can disrupt clot.

Focused assessment with sonography in trauma (FAST/eFAST) can detect free fluid, pleural fluid and pneumothorax. A negative FAST cannot exclude all intra-abdominal injury or retroperitoneal bleeding. CT is most informative in appropriately stable patients; haemodynamically unstable patients may need immediate haemorrhage control rather than delayed imaging.

Clinical example: with suspected unstable pelvis, apply a binder, activate major bleeding support and organise urgent definitive haemorrhage control while maintaining systematic reassessment.

Clinical application

Clinical example: with suspected unstable pelvis, apply a binder, activate major bleeding support and organise urgent definitive haemorrhage control while maintaining systematic reassessment.

Exam pearl

An unstable pelvic ring injury can cause catastrophic retroperitoneal haemorrhage.

7. Traumatic brain injury, GCS and cerebral perfusion

Glasgow Coma Scale combines eye opening (E1–4), verbal response (V1–5) and motor response (M1–6), giving a total 3–15. Document the separate components, pupils and any confounders such as intubation, sedation, hypoxia, intoxication and shock.

Brain physiology: cerebral perfusion pressure = mean arterial pressure − intracranial pressure. Avoid hypoxia and hypotension because both worsen secondary brain injury. Raised ICP may present with worsening consciousness, headache, vomiting, asymmetrical pupils or late Cushing physiology; do not wait for the full triad.

Use NICE NG232 imaging criteria and consult appropriate services for patients at risk, including those on anticoagulants/antiplatelets (excluding aspirin monotherapy in the specific additional consideration). Trauma imaging decisions depend on clinical findings and guidance, not every minor impact.

Clinical application

Use NICE NG232 imaging criteria and consult appropriate services for patients at risk, including those on anticoagulants/antiplatelets (excluding aspirin monotherapy in the specific additional consideration). Trauma imaging decisions depend on clinical findings and guidance, not every minor impact.

Exam pearl

Glasgow Coma Scale combines eye opening (E1–4), verbal response (V1–5) and motor response (M1–6), giving a total 3–15.

8. Spinal trauma and neurological assessment

Suspect spinal injury with high-energy mechanisms, neurological symptoms, distracting injuries or impaired assessment. Document limb power, sensation, reflexes and any sacral neurological features; immobilisation/spinal motion restriction should be risk-assessed and regularly reviewed, following NICE NG41.

Neurogenic shock after high spinal injury reflects loss of sympathetic vascular tone, often with hypotension and relative bradycardia. Distinguish it from spinal shock, which refers to transient suppression of reflexes and motor/sensory function below acute cord injury.

Clinical example: hypotension and bradycardia after cervical trauma suggest possible neurogenic shock, but occult haemorrhage must still be excluded before assuming a neurogenic cause.

Clinical application

Clinical example: hypotension and bradycardia after cervical trauma suggest possible neurogenic shock, but occult haemorrhage must still be excluded before assuming a neurogenic cause.

Exam pearl

Suspect spinal injury with high-energy mechanisms, neurological symptoms, distracting injuries or impaired assessment.

9. Limb-threatening trauma: fractures, vessels and compartments

Following long-bone fracture, examine skin integrity, distal pulses, capillary refill, motor/sensory function and developing compartment syndrome, and document results before and after reduction or immobilisation. Major arterial injury may exist even with a palpable distal pulse because collateral flow can mislead.

Acute compartment syndrome is a clinical emergency: severe escalating pain, pain on passive stretch and a tense compartment are concerning; paraesthesia and weakness may follow. Pulselessness is late and is not required for diagnosis. Urgent surgical evaluation/fasciotomy is needed when the diagnosis is established.

Open fractures require prompt antibiotics, sterile wound coverage, appropriate splinting and specialist debridement/fixation planning. Do not repeatedly probe or irrigate aggressively on an unsupervised emergency-department basis.

Clinical application

Open fractures require prompt antibiotics, sterile wound coverage, appropriate splinting and specialist debridement/fixation planning. Do not repeatedly probe or irrigate aggressively on an unsupervised emergency-department basis.

Exam pearl

Following long-bone fracture, examine skin integrity, distal pulses, capillary refill, motor/sensory function and developing compartment syndrome, and document results before and after reduction or immobilisation.

10. Thermal burns: depth, size and initial first aid

Burn depth: superficial burns are painful, erythematous and blanch; superficial partial-thickness burns are moist and often blister; deep partial-thickness burns have reduced capillary response; full-thickness burns are leathery and may be relatively insensate at the centre.

Estimate total body surface area (TBSA) using adult Rule of Nines or age-adjusted Lund–Browder charts. Exclude superficial erythema from TBSA used for formal burn resuscitation. Adult Rule of Nines: head/neck 9%, each arm 9%, anterior trunk 18%, posterior trunk 18%, each leg 18%, perineum 1%.

Cool a thermal burn under cool running tap water for 20 minutes as soon as possible, ideally within 3 hours. Remove jewellery and constricting items; cover with an appropriate clean dressing and prevent systemic hypothermia. Avoid ice, ointments and household remedies during emergency first aid.

Clinical application

Cool a thermal burn under cool running tap water for 20 minutes as soon as possible, ideally within 3 hours. Remove jewellery and constricting items; cover with an appropriate clean dressing and prevent systemic hypothermia. Avoid ice, ointments and household remedies during emergency first aid.

Exam pearl

Burn depth: superficial burns are painful, erythematous and blanch; superficial partial-thickness burns are moist and often blister; deep partial-thickness burns have reduced capillary response; full-thickness burns are leathery and may be relatively insensate at the centre.

Original FreeMedSite proportional reference. Use Lund–Browder for age-adjusted assessment in children.

11. Major burns: airway, fluids and specialist referral

Consider inhalation injury after enclosed-space fires, soot, facial burns, hoarseness, stridor or respiratory distress. Carbon monoxide exposure can produce severe toxicity even with apparently normal pulse oximetry: standard pulse oximetry does not reliably differentiate oxyhaemoglobin from carboxyhaemoglobin.

Major burns produce capillary leak and intravascular fluid loss. Formal fluid resuscitation uses a protocol-based initial estimate and frequent reassessment using physiology and urine output rather than blind adherence to a formula. In adults an approximate urine-output target often used is 0.5 mL/kg/h, modified for the clinical context.

American Burn Association guidance supports immediate consultation/consideration of transfer for full-thickness burns, partial-thickness burns ≥10% TBSA, deep burns in special functional regions, suspected inhalation injury and other high-risk patterns. Electrical/chemical mechanisms require specific assessment.

Clinical application

American Burn Association guidance supports immediate consultation/consideration of transfer for full-thickness burns, partial-thickness burns ≥10% TBSA, deep burns in special functional regions, suspected inhalation injury and other high-risk patterns. Electrical/chemical mechanisms require specific assessment.

Exam pearl

Consider inhalation injury after enclosed-space fires, soot, facial burns, hoarseness, stridor or respiratory distress.

12. Secondary survey, imaging, handover and examiner traps

Once immediate threats are controlled, perform head-to-toe secondary survey including back, perineum and neurovascular examination, relevant history (AMPLE: Allergies, Medications, Past illnesses/Pregnancy, Last meal, Events), and targeted imaging. Revisit the primary survey if the patient deteriorates.

Chest and pelvic radiography, eFAST and CT are tools that complement physiology and examination; they are not substitutes for life-saving resuscitation. Immobilise suspected fractures, give analgesia, record tetanus status for relevant wounds and coordinate with orthopaedics, surgery, neurosurgery or burns teams as indicated.

Communicate a structured trauma handover: mechanism, suspected injuries, treatment given, response, current physiology, outstanding investigations and immediate risks. Clear documentation reduces missed injuries and repetition.

Clinical application

Communicate a structured trauma handover: mechanism, suspected injuries, treatment given, response, current physiology, outstanding investigations and immediate risks. Clear documentation reduces missed injuries and repetition.

Exam pearl

Once immediate threats are controlled, perform head-to-toe secondary survey including back, perineum and neurovascular examination, relevant history (AMPLE: Allergies, Medications, Past illnesses/Pregnancy, Last meal, Events), and targeted imaging.

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Primary survey

Catastrophic external haemorrhage firstAirway assessment and suctionBreathing: inspection and auscultationCirculation and perfusion markersGCS/pupils and exposure with warmingRepeated primary survey after intervention

Airway & cervical spine

Stridor and threatened airway signsProtecting C-spine without delaying oxygenationEarly expert airway planningGCS components and airway caveat

Chest trauma

Tension pneumothorax clinical featuresDecompression before radiographyMassive haemothorax and source controlOpen chest wound and appropriate chest sealCardiac tamponade recognitionFlail chest respiratory compromise

Haemorrhagic shock

Compensated shock and shock indexSites of concealed bleedingMajor haemorrhage pathwayTXA within three hoursCoagulopathy, hypothermia and ionised calciumBalanced blood-product resuscitation and definitive source control

Pelvic & abdominal

Binder position at greater trochantersAvoid repeated pelvic springingFAST/eFAST limitationsStable versus unstable CT decisionsInterventional versus operative haemorrhage control

Brain & spine

GCS eye, verbal and motor componentsCPP = MAP minus ICPPrevent secondary brain injurySpinal shock versus neurogenic shockSpinal motion restriction and reassessment

Limb trauma

Document distal neurovascular findingsCompartments: disproportionate painPulses may remain present in compartment syndromeOpen-fracture immediate principlesTetanus prophylaxis after contaminated injury

Burn basics

Burn depth and blanchingExclude superficial erythema from TBSAAdult Rule of NinesLund–Browder in childrenCool running water 20 minutesElectrical and chemical injury specific dangers

Burn resuscitation

Inhalation injury red flagsCarbon monoxide/pulse oximetry trapFluid resuscitation guided by physiologyABA specialist referral triggers

Trauma completion

AMPLE history and secondary surveyRepeat primary survey after deteriorationStructured handover and missed-injury preventionRecognise time-critical referral thresholdsContinue warming and monitoring during transfers

40 original MRCS trauma, shock and burns SBAs

Examination-format practice: five options, one best answer, clinical reasoning and explanations for each distractor. This is an original educational question bank, not a copied recall paper.

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Question 1 of 40

Question 1 of 40 · Immediate bleeding control

Q01. A 27-year-old motorcyclist is brought to the resuscitation bay with a spurting thigh wound and weak radial pulses. His airway is patent. What should occur immediately?

A. Control catastrophic external haemorrhage with direct pressure or a limb tourniquet when indicatedB. Obtain a whole-body CT before touching the woundC. Finish a detailed secondary surveyD. Give an oral antibiotic and dischargeE. Check a formal neurological score before stopping the blood loss

View detailed explanation, examiner trap and viva

Correct answer: A. Control catastrophic external haemorrhage with direct pressure or a limb tourniquet when indicated

Why correct: Uncontrolled external haemorrhage is an immediately reversible cause of death; address it while the team continues cABCDE.

Why the other options are incorrect:

B. Obtain a whole-body CT before touching the wound: Imaging must not delay immediate haemorrhage control.

C. Finish a detailed secondary survey: Secondary survey follows control of immediate life threats.

D. Give an oral antibiotic and discharge: The patient has active life-threatening bleeding and needs resuscitation.

E. Check a formal neurological score before stopping the blood loss: Disability assessment is important but must not delay stopping exsanguination.

Exam pearl: The initial letter c (or X) signals catastrophic bleeding before routine airway checks.

Examiner trap: Do not interpret ABCDE as a reason to ignore obvious massive external bleeding.

Viva extension: Viva: Name the main concealed bleeding sites. Chest, abdomen, pelvis/retroperitoneum and long bones.

Question 2 of 40 · Compensated shock

Q02. A 23-year-old trauma patient has HR 132/min, BP 118/76, cold hands and increasing anxiety. What is the most accurate interpretation?

A. Normal pressure excludes significant blood lossB. Haemorrhagic shock remains possible despite a normal systolic pressureC. Anxiety is always the sole reason for tachycardiaD. A stable BP means CT is always the first priorityE. Urine output always rises during hypoperfusion

View detailed explanation, examiner trap and viva

Correct answer: B. Haemorrhagic shock remains possible despite a normal systolic pressure

Why correct: Tachycardia, peripheral vasoconstriction and altered mental status may precede hypotension in compensated shock.

Why the other options are incorrect:

A. Normal pressure excludes significant blood loss: Sympathetic compensation can maintain pressure until late.

C. Anxiety is always the sole reason for tachycardia: Anxiety cannot safely explain all perfusion abnormalities after trauma.

D. A stable BP means CT is always the first priority: Physiology must be evaluated and bleeding addressed.

E. Urine output always rises during hypoperfusion: Hypoperfusion generally decreases renal perfusion and urine output.

Exam pearl: Normal BP does not exclude haemorrhagic shock.

Examiner trap: Recognise shock by perfusion, not an isolated systolic reading.

Viva extension: Viva: What is shock index? Heart rate divided by systolic BP.

Question 3 of 40 · Airway rescue

Q03. A patient with blunt facial trauma develops gurgling respirations, blood in the mouth and deteriorating oxygenation. The cervical spine is potentially injured. Which initial action is most appropriate?

A. Delay airway care until cervical CT confirms stabilityB. Force active neck extension without needC. Clear the airway using suction and appropriate manoeuvres with spinal protectionD. Complete an orthopaedic skeletal survey before suctionE. Give oral fluids to clear the blood

View detailed explanation, examiner trap and viva

Correct answer: C. Clear the airway using suction and appropriate manoeuvres with spinal protection

Why correct: Oxygenation and clearance of obstructing material take priority, with inline spinal protection when indicated.

Why the other options are incorrect:

A. Delay airway care until cervical CT confirms stability: Imaging must not defer immediate oxygenation.

B. Force active neck extension without need: Unnecessary neck movement can worsen cervical injury.

D. Complete an orthopaedic skeletal survey before suction: Threatened airway is immediately life-threatening.

E. Give oral fluids to clear the blood: Oral fluids in an obtunded patient increase aspiration risk.

Exam pearl: Protect the C-spine without sacrificing the airway.

Examiner trap: C-spine concern does not mean never moving to establish oxygenation.

Viva extension: Viva: When is definitive airway considered? Failure to protect airway, ventilate, oxygenate or an anticipated rapidly worsening airway.

Question 4 of 40 · Tension pneumothorax

Q04. After blunt chest trauma a ventilated patient suddenly becomes hypotensive and hypoxaemic; the right chest is silent. Which action is the priority?

A. Wait for a portable chest radiographB. Give diuretics for suspected pulmonary oedemaC. Transfer to CT as the first investigationD. Immediate decompression of clinically suspected tension pneumothoraxE. Reassure and repeat auscultation in an hour

View detailed explanation, examiner trap and viva

Correct answer: D. Immediate decompression of clinically suspected tension pneumothorax

Why correct: An unstable patient with classical tension physiology needs rapid decompression by a trained clinician before imaging.

Why the other options are incorrect:

A. Wait for a portable chest radiograph: Imaging delay can be fatal.

B. Give diuretics for suspected pulmonary oedema: The abrupt unilateral findings are not explained by pulmonary oedema.

C. Transfer to CT as the first investigation: CT cannot supersede life-saving intervention.

E. Reassure and repeat auscultation in an hour: Progressive obstructive shock demands immediate treatment.

Exam pearl: Unstable tension pneumothorax is a clinical diagnosis.

Examiner trap: Tracheal deviation is late/inconsistent; do not wait for it.

Viva extension: Viva: What type of shock is caused by tension pneumothorax? Obstructive shock.

Question 5 of 40 · Open pneumothorax

Q05. A penetrating chest wound produces a sucking sound with inspiration while the patient remains conscious. What is the initial wound-management principle while arranging definitive chest care?

A. Apply a circumferential rigid, non-venting seal and ignore deteriorationB. Push a finger deeply through the wound to assess depthC. Delay all management until CT is availableD. Simply give oral analgesia and dischargeE. Apply an appropriate vented chest seal and reassess breathing closely

View detailed explanation, examiner trap and viva

Correct answer: E. Apply an appropriate vented chest seal and reassess breathing closely

Why correct: A purpose-designed vented seal helps manage an open chest wound while ongoing assessment and definitive treatment continue.

Why the other options are incorrect:

A. Apply a circumferential rigid, non-venting seal and ignore deterioration: Trapped pleural air can worsen tension physiology.

B. Push a finger deeply through the wound to assess depth: This can cause harm and does not treat ventilation.

C. Delay all management until CT is available: Open pneumothorax requires immediate clinical treatment.

D. Simply give oral analgesia and discharge: Penetrating chest injury needs urgent trauma evaluation.

Exam pearl: Reassess for evolving tension pneumothorax after sealing a wound.

Examiner trap: Traditional three-sided dressings are not the only or universally preferred approach; vented commercial seals are commonly recommended.

Viva extension: Viva: What other intervention may be needed? Pleural decompression/drainage when indicated.

Question 6 of 40 · Shock index

Q06. A casualty has heart rate 120/min and systolic BP 100 mmHg. What is the shock index?

A. 1.2B. 0.12C. 0.83D. 12E. 220

View detailed explanation, examiner trap and viva

Correct answer: A. 1.2

Why correct: Shock index is pulse divided by systolic blood pressure: 120/100 = 1.2.

Why the other options are incorrect:

B. 0.12: This is not the result of HR divided by SBP.

C. 0.83: That is the reciprocal of the actual ratio.

D. 12: That is ten times the correct ratio.

E. 220: Adding pulse and pressure is not a shock index.

Exam pearl: Shock index above about 1 can increase concern for bleeding.

Examiner trap: Interpret the ratio clinically; beta blockers, pain and age change its performance.

Viva extension: Viva: What is the formula? HR/SBP.

Question 7 of 40 · Tranexamic acid

Q07. A patient with major active traumatic haemorrhage arrives 70 minutes after injury. In addition to bleeding control and resuscitation, which pharmacological intervention is indicated according to major trauma guidance?

A. Give oral iron as the priorityB. Give intravenous tranexamic acid promptly according to trauma protocolC. Wait until four hours after injuryD. Give prophylactic heparin for active haemorrhageE. Give aspirin to prevent microthrombosis

View detailed explanation, examiner trap and viva

Correct answer: B. Give intravenous tranexamic acid promptly according to trauma protocol

Why correct: NICE NG39 supports early IV TXA in major trauma with active or suspected active bleeding, with a three-hour treatment window.

Why the other options are incorrect:

A. Give oral iron as the priority: Oral iron cannot control acute haemorrhage.

C. Wait until four hours after injury: Delay beyond three hours is generally not recommended without evidence of hyperfibrinolysis/specialist indication.

D. Give prophylactic heparin for active haemorrhage: Anticoagulation is inappropriate during uncontrolled significant bleeding.

E. Give aspirin to prevent microthrombosis: Antiplatelet therapy increases bleeding and does not treat trauma-induced haemorrhage.

Exam pearl: Give TXA early in major bleeding within three hours.

Examiner trap: TXA does not replace definitive haemorrhage control.

Viva extension: Viva: Typical adult European guideline regimen? 1 g IV over 10 minutes followed by 1 g over 8 hours.

Question 8 of 40 · Late TXA

Q08. A casualty with suspected major bleeding is seen 5 hours after injury, with no laboratory evidence of hyperfibrinolysis. What is the appropriate interpretation of routine TXA timing?

A. TXA should always be given regardless of elapsed timeB. Delay bleeding control until drug administrationC. Do not routinely start TXA beyond three hours solely for traumatic haemorrhageD. Give twice the usual TXA dose because of the delayE. Use oral TXA as a substitute for surgery

View detailed explanation, examiner trap and viva

Correct answer: C. Do not routinely start TXA beyond three hours solely for traumatic haemorrhage

Why correct: NICE advises against routine TXA beyond three hours after injury unless there is evidence of hyperfibrinolysis.

Why the other options are incorrect:

A. TXA should always be given regardless of elapsed time: Late routine administration lacks demonstrated benefit and can be harmful.

B. Delay bleeding control until drug administration: Source control is urgent and independent of TXA use.

D. Give twice the usual TXA dose because of the delay: Dose doubling is not an evidence-based timing correction.

E. Use oral TXA as a substitute for surgery: Oral administration cannot replace definitive haemostasis.

Exam pearl: Time from injury—not time from ED arrival—matters.

Examiner trap: The three-hour restriction is easy to miss in emergency stems.

Viva extension: Viva: What if hyperfibrinolysis is demonstrated? Follow specialist/local guidance on exceptional late use.

Question 9 of 40 · Trauma coagulopathy

Q09. A massively transfused injured patient becomes hypothermic, acidotic and develops increasing diffuse oozing. What is the most appropriate concept?

A. Only an isolated vitamin B12 deficiencyB. The normal physiological response that needs no correctionC. A purely surgical-site infection within minutesD. Trauma-associated coagulopathy worsened by physiological derangementE. Only platelet excess

View detailed explanation, examiner trap and viva

Correct answer: D. Trauma-associated coagulopathy worsened by physiological derangement

Why correct: Hypothermia, acidosis, poor perfusion and loss/consumption of coagulation components impair haemostasis; resuscitate and correct causes.

Why the other options are incorrect:

A. Only an isolated vitamin B12 deficiency: It cannot account for acute diffuse coagulopathy after major haemorrhage.

B. The normal physiological response that needs no correction: Ongoing bleeding indicates a clinically important problem.

C. A purely surgical-site infection within minutes: The temporal pattern is characteristic of bleeding/coagulopathy.

E. Only platelet excess: Increased platelet count alone is not the characteristic mechanism.

Exam pearl: Prevent the lethal spiral of hypothermia, coagulopathy and acidosis.

Examiner trap: Modern trauma teaching also tracks hypocalcaemia.

Viva extension: Viva: Why measure ionised calcium? Citrate in blood components can reduce biologically active calcium.

Question 10 of 40 · Hypocalcaemia during transfusion

Q10. After massive transfusion the patient develops prolonged QT and hypotension. Ionised calcium is low. Which mechanism best explains this?

A. Calcium is always raised after transfusionB. Fibrinogen is converted into calciumC. Platelet transfusion routinely releases sufficient free calciumD. TXA directly supplies ionised calciumE. Citrate contained in transfused blood products binds ionised calcium

View detailed explanation, examiner trap and viva

Correct answer: E. Citrate contained in transfused blood products binds ionised calcium

Why correct: Citrate anticoagulant chelates calcium; rapid product delivery can precipitate clinically relevant hypocalcaemia.

Why the other options are incorrect:

A. Calcium is always raised after transfusion: Massive transfusion can lower ionised calcium.

B. Fibrinogen is converted into calcium: These are unrelated substances.

C. Platelet transfusion routinely releases sufficient free calcium: There is no such predictable corrective effect.

D. TXA directly supplies ionised calcium: TXA inhibits fibrinolysis; it is not a calcium replacement.

Exam pearl: Monitor ionised calcium during major haemorrhage resuscitation.

Examiner trap: Normal total calcium does not guarantee normal ionised calcium.

Viva extension: Viva: Which calcium measurement matters acutely? Ionised calcium.

Question 11 of 40 · Pelvic binder

Q11. A 35-year-old pedestrian has haemodynamic instability and suspected pelvic ring disruption. Where should a pelvic binder be centred?

A. At the level of the greater trochantersB. Around the umbilicusC. Across the lower ribsD. Around the anterior superior iliac spines onlyE. Across the proximal thighs well below the hip joints

View detailed explanation, examiner trap and viva

Correct answer: A. At the level of the greater trochanters

Why correct: Binder compression at greater trochanters stabilises the pelvis more effectively than positioning at iliac crests.

Why the other options are incorrect:

B. Around the umbilicus: This is too high for appropriate pelvic ring compression.

C. Across the lower ribs: This does not stabilise the pelvic ring.

D. Around the anterior superior iliac spines only: The pelvic binder should not sit high over the iliac wings.

E. Across the proximal thighs well below the hip joints: This sits too low to provide intended pelvic compression.

Exam pearl: Binder over greater trochanters—not the waist.

Examiner trap: An incorrectly positioned binder can be ineffective despite appearing tight.

Viva extension: Viva: What is the immediate goal? Temporary stabilisation and mitigation of pelvic haemorrhage while definitive care is arranged.

Question 12 of 40 · FAST interpretation

Q12. FAST is negative in a hypotensive patient with suspected unstable pelvic fracture. What conclusion is best?

A. All intra-abdominal and pelvic bleeding is excludedB. Retroperitoneal bleeding remains possible despite a negative FASTC. CT is always safe regardless of haemodynamic statusD. Pelvic binder can be removed immediatelyE. The patient must have only neurogenic shock

View detailed explanation, examiner trap and viva

Correct answer: B. Retroperitoneal bleeding remains possible despite a negative FAST

Why correct: FAST is not sufficiently sensitive to exclude pelvic retroperitoneal haemorrhage and several solid-organ injuries.

Why the other options are incorrect:

A. All intra-abdominal and pelvic bleeding is excluded: FAST has known anatomical and sensitivity limitations.

C. CT is always safe regardless of haemodynamic status: Unstable patients may need immediate haemorrhage control.

D. Pelvic binder can be removed immediately: A negative FAST does not rule out pelvic bleeding.

E. The patient must have only neurogenic shock: Traumatic haemorrhage remains a major consideration.

Exam pearl: Negative FAST does not rule out traumatic bleeding.

Examiner trap: A negative FAST is not a discharge test.

Viva extension: Viva: What does FAST chiefly seek? Free intraperitoneal/pericardial fluid; eFAST adds chest assessment.

Question 13 of 40 · Imaging and stability

Q13. A haemodynamically unstable blunt-trauma patient remains hypotensive despite initial resuscitation, and intra-abdominal bleeding is strongly suspected. What is the key decision principle?

A. Transfer to CT before any further clinical interventionB. Wait for normal haemoglobin before any operationC. Prioritise immediate haemorrhage control rather than delaying treatment for CTD. Repeat FAST indefinitely instead of treatmentE. Give oral contrast and discharge if no vomiting

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Correct answer: C. Prioritise immediate haemorrhage control rather than delaying treatment for CT

Why correct: In persistent physiological instability, definitive source control may be life-saving and supersede CT when the cause is sufficiently likely.

Why the other options are incorrect:

A. Transfer to CT before any further clinical intervention: CT may be unsafe and delay intervention in refractory instability.

B. Wait for normal haemoglobin before any operation: Initial haemoglobin can be misleading, and normalisation is not a prerequisite.

D. Repeat FAST indefinitely instead of treatment: Additional imaging without action delays haemorrhage control.

E. Give oral contrast and discharge if no vomiting: This is inappropriate for shock.

Exam pearl: Physiology drives immediate CT versus theatre/IR decisions.

Examiner trap: Do not assume a negative early haemoglobin rules out catastrophic bleeding.

Viva extension: Viva: What influences CT appropriateness? Haemodynamic stability, response to resuscitation and local resources.

Question 14 of 40 · Glasgow coma scale

Q14. A head-injured patient opens eyes to pain (E2), uses inappropriate words (V3), and localises painful stimulus (M5). What is the GCS total?

A. 7B. 8C. 12D. 10E. 15

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Correct answer: D. 10

Why correct: GCS = E2 + V3 + M5 = 10. Document the three component scores in addition to the total.

Why the other options are incorrect:

A. 7: The provided components add to 10, not 7.

B. 8: This omits or undervalues a component.

C. 12: This overestimates one or more responses.

E. 15: Normal maximum GCS is 15; the patient has impaired responses.

Exam pearl: Always report E/V/M components, not only total.

Examiner trap: An intubated verbal score should not be guessed; document not testable.

Viva extension: Viva: What is the component range? Eye 1–4, verbal 1–5, motor 1–6.

Question 15 of 40 · Cerebral perfusion pressure

Q15. A patient with severe traumatic brain injury has MAP 82 mmHg and intracranial pressure 22 mmHg. What is the cerebral perfusion pressure?

A. 104 mmHgB. 22 mmHgC. 82 mmHgD. 3.7 mmHgE. 60 mmHg

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Correct answer: E. 60 mmHg

Why correct: CPP = MAP − ICP = 82 − 22 = 60 mmHg.

Why the other options are incorrect:

A. 104 mmHg: This incorrectly adds MAP and ICP.

B. 22 mmHg: That is the ICP alone.

C. 82 mmHg: That is the MAP alone.

D. 3.7 mmHg: Dividing MAP by ICP is not CPP.

Exam pearl: CPP is a pressure difference: MAP minus ICP.

Examiner trap: A numerically acceptable CPP does not negate other causes of brain injury.

Viva extension: Viva: Why avoid hypotension in severe TBI? It reduces cerebral perfusion and increases secondary injury.

Question 16 of 40 · Head injury priorities

Q16. A patient with a significant head injury develops severe hypoxaemia and hypotension. What is most important to prevent secondary brain injury?

A. Rapid restoration of adequate oxygenation and perfusionB. Delay oxygen until CT is completedC. Induce profound systemic hypotension to reduce bleedingD. Treat only scalp swellingE. Avoid assessment of pupils until after transfer

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Correct answer: A. Rapid restoration of adequate oxygenation and perfusion

Why correct: Hypoxia and low cerebral perfusion exacerbate secondary neuronal damage; immediately stabilise oxygenation and circulation.

Why the other options are incorrect:

B. Delay oxygen until CT is completed: Oxygenation is an immediate priority.

C. Induce profound systemic hypotension to reduce bleeding: Systemic hypotension risks catastrophic cerebral ischaemia.

D. Treat only scalp swelling: Superficial swelling may not reflect intracranial physiology.

E. Avoid assessment of pupils until after transfer: Pupil changes can guide urgent recognition of deterioration.

Exam pearl: Prevent hypoxia and hypotension in TBI.

Examiner trap: Do not apply permissive hypotension uncritically to brain-injured patients.

Viva extension: Viva: Write CPP formula. MAP minus ICP.

Question 17 of 40 · Head CT and anticoagulation

Q17. An older patient on apixaban sustains a minor head injury and is alert with no focal deficit. No other CT indications are present. What is the appropriate approach under NICE NG232?

A. Discharge without discussing anticoagulationB. Consider CT imaging because anticoagulant use modifies risk assessmentC. Perform lumbar puncture instead of head imagingD. Treat with routine prophylactic heparinE. Only scan if both pupils are fixed

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Correct answer: B. Consider CT imaging because anticoagulant use modifies risk assessment

Why correct: NICE NG232 recommends considering CT for certain anticoagulant or antiplatelet exposure (excluding aspirin monotherapy), even without other CT indications.

Why the other options are incorrect:

A. Discharge without discussing anticoagulation: Anticoagulant use matters to intracranial bleeding risk.

C. Perform lumbar puncture instead of head imaging: LP is not the routine evaluation of traumatic intracranial bleeding.

D. Treat with routine prophylactic heparin: This is not an appropriate response to possible intracranial bleeding.

E. Only scan if both pupils are fixed: Severe pupillary abnormalities are not required to consider imaging.

Exam pearl: Head injury plus anticoagulation deserves careful CT consideration.

Examiner trap: The aspirin-monotherapy exclusion in the specific NICE additional CT recommendation is often overlooked.

Viva extension: Viva: Which specific class is apixaban? Direct oral factor Xa inhibitor.

Question 18 of 40 · Neurogenic shock

Q18. After cervical spinal trauma a patient has hypotension, warm skin and HR 48/min; imaging suggests cord injury. Which physiological cause may contribute?

A. Uncomplicated anxietyB. Acute myocardial erythropoietin excessC. Loss of sympathetic vasomotor toneD. Pure bronchospasm in a normal airwayE. High serum cholesterol

View detailed explanation, examiner trap and viva

Correct answer: C. Loss of sympathetic vasomotor tone

Why correct: High spinal cord injury can cause vasodilatation with relative bradycardia due to sympathetic disruption.

Why the other options are incorrect:

A. Uncomplicated anxiety: Anxiety usually increases pulse rather than creating this pattern.

B. Acute myocardial erythropoietin excess: This is not a recognised acute shock mechanism.

D. Pure bronchospasm in a normal airway: Bronchospasm does not explain the autonomic findings.

E. High serum cholesterol: Cholesterol does not cause acute neurogenic shock.

Exam pearl: Neurogenic shock = haemodynamic autonomic failure.

Examiner trap: Do not assume neurogenic shock until occult haemorrhage has been evaluated.

Viva extension: Viva: How is spinal shock different? Temporary loss of reflexes and neurological function below injury.

Question 19 of 40 · Compartment syndrome

Q19. A patient 3 hours after tibial fracture fixation has rapidly escalating pain despite analgesia, pain on passive toe stretch and intact distal pulses. What is the major concern?

A. No serious injury because pulses are presentB. A routine uncomplicated postoperative courseC. A simple superficial haematoma that never requires assessmentD. Acute compartment syndrome requiring immediate surgical assessmentE. Immediate discharge after analgesia

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Correct answer: D. Acute compartment syndrome requiring immediate surgical assessment

Why correct: Disproportionate pain and passive-stretch pain are major early clues; preserved pulses do not exclude compartment syndrome.

Why the other options are incorrect:

A. No serious injury because pulses are present: Pulses commonly remain detectable before very late disease.

B. A routine uncomplicated postoperative course: Escalating pain and stretch response are concerning.

C. A simple superficial haematoma that never requires assessment: A dangerous deep pressure problem is possible.

E. Immediate discharge after analgesia: Urgent reassessment is necessary.

Exam pearl: Do not wait for pulselessness in compartment syndrome.

Examiner trap: Classic six Ps occur late or are variably present; early clinical trend matters.

Viva extension: Viva: Definitive intervention? Urgent fasciotomy when indicated.

Question 20 of 40 · Open fracture

Q20. A farm worker has an open tibial shaft fracture contaminated with soil. After life threats are managed, what initial care best reduces later complications?

A. Repeated bedside probing of the woundB. Immediate primary closure without inspection or debridementC. Apply a tight circumferential cast without neurovascular checksD. Delay antibiotics until all culture results returnE. Early IV antibiotics, sterile covering, splinting and urgent orthopaedic care

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Correct answer: E. Early IV antibiotics, sterile covering, splinting and urgent orthopaedic care

Why correct: Prompt antimicrobial administration, appropriate wound protection, tetanus assessment and timely operative management are key.

Why the other options are incorrect:

A. Repeated bedside probing of the wound: This increases contamination and tissue injury risk.

B. Immediate primary closure without inspection or debridement: Contaminated wounds require specialist assessment and planned surgery.

C. Apply a tight circumferential cast without neurovascular checks: Swelling and neurovascular compromise must be considered.

D. Delay antibiotics until all culture results return: Early antibiotics are time-sensitive in open fractures.

Exam pearl: Open fractures require early antibiotics and specialist debridement planning.

Examiner trap: Do not confuse superficial laceration near a fracture with confirmed simple closed fracture.

Viva extension: Viva: What should be documented around splinting? Distal pulse, motor/sensation, wound and perfusion.

Question 21 of 40 · Hard vascular signs

Q21. A patient with penetrating popliteal injury has active pulsatile bleeding and an expanding haematoma. What is the next key decision?

A. Urgent vascular/trauma surgical evaluation for definitive haemorrhage controlB. Observe without reassessment for 24 hoursC. Treat only with oral analgesiaD. Assume an intact distal pulse excludes arterial injuryE. Delay all treatment until elective Doppler next week

View detailed explanation, examiner trap and viva

Correct answer: A. Urgent vascular/trauma surgical evaluation for definitive haemorrhage control

Why correct: Hard signs of vascular injury such as pulsatile bleeding and expanding haematoma demand urgent action and source control.

Why the other options are incorrect:

B. Observe without reassessment for 24 hours: Major arterial injury can cause fatal haemorrhage or limb ischaemia.

C. Treat only with oral analgesia: Analgesia does not address the injured artery.

D. Assume an intact distal pulse excludes arterial injury: Collaterals may preserve a pulse despite injury.

E. Delay all treatment until elective Doppler next week: Vascular emergency needs prompt assessment.

Exam pearl: Hard signs include pulsatile bleeding and expanding haematoma.

Examiner trap: A detectable distal pulse does not rule out major vascular injury.

Viva extension: Viva: Other hard signs? Bruit/thrill or signs of acute limb ischaemia.

Question 22 of 40 · Burn depth

Q22. A child spills hot liquid over the forearm. The wound is moist, very painful, blistered and blanches to pressure. What depth is most consistent?

A. Full-thickness burnB. Superficial partial-thickness burnC. Superficial epidermal erythema onlyD. Subcutaneous fat necrosis without skin injuryE. Primary electrical muscle injury

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Correct answer: B. Superficial partial-thickness burn

Why correct: Moist blisters, marked pain and preserved brisk capillary refill suggest superficial dermal injury.

Why the other options are incorrect:

A. Full-thickness burn: Full-thickness injuries are typically dry/leathery with little blanching at the centre.

C. Superficial epidermal erythema only: Simple epidermal burns usually do not form deep blisters.

D. Subcutaneous fat necrosis without skin injury: The described skin findings indicate a dermal burn.

E. Primary electrical muscle injury: The mechanism is a scald and the signs fit partial-thickness injury.

Exam pearl: Blistered, moist, painful and blanching = superficial partial thickness.

Examiner trap: Reduced pain can reflect deeper tissue loss, not necessarily less severe injury.

Viva extension: Viva: Why are full-thickness centres less painful? Destruction of cutaneous nerve endings.

Question 23 of 40 · TBSA calculation

Q23. An adult has partial-thickness burns over the entire anterior trunk and the entire right upper limb. Using Rule of Nines, what is estimated TBSA?

A. 9%B. 18%C. 27%D. 36%E. 45%

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Correct answer: C. 27%

Why correct: Adult anterior trunk is 18% and each whole upper limb is 9%, totaling 27%.

Why the other options are incorrect:

A. 9%: This includes only the arm.

B. 18%: This includes only the anterior trunk.

D. 36%: This overcounts the burned regions.

E. 45%: This overcounts by a substantial amount.

Exam pearl: Adult anterior torso 18% + whole arm 9% = 27%.

Examiner trap: Only involved areas are counted; do not automatically include posterior trunk.

Viva extension: Viva: Head and neck contribution in an adult? Approximately 9%.

Question 24 of 40 · TBSA exclusions

Q24. A patient has red painful sunburn over the back with no blistering and a small partial-thickness patch elsewhere. What should be counted in formal burn TBSA?

A. All red skin regardless of depthB. Only charred tissueC. Only skin that does not hurtD. Only partial- and full-thickness injured areasE. All body surfaces by default

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Correct answer: D. Only partial- and full-thickness injured areas

Why correct: Simple superficial epidermal erythema is excluded from %TBSA used for formal burn resuscitation estimates.

Why the other options are incorrect:

A. All red skin regardless of depth: Including epidermal erythema leads to overestimation.

B. Only charred tissue: Partial-thickness burns also contribute to TBSA.

C. Only skin that does not hurt: Pain is not a valid exclusion test.

E. All body surfaces by default: TBSA describes burned surface, not entire body size.

Exam pearl: Do not count simple superficial redness for burn TBSA.

Examiner trap: A large red area may not justify fluid-resuscitation formula use if superficial only.

Viva extension: Viva: Best paediatric method for body-region adjustment? Lund–Browder chart.

Question 25 of 40 · Burns first aid

Q25. A woman sustains a thermal scald 15 minutes ago. She is stable and there are no airway concerns. What first aid best limits burn progression?

A. Apply ice directly for 20 minutesB. Cover with butter immediatelyC. Leave hot clothing and jewellery firmly in placeD. Scrub the burn using strong disinfectantE. Cool with cool running tap water for approximately 20 minutes while preventing hypothermia

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Correct answer: E. Cool with cool running tap water for approximately 20 minutes while preventing hypothermia

Why correct: British burn guidance supports prompt cool running water, ideally within three hours, avoiding overall heat loss.

Why the other options are incorrect:

A. Apply ice directly for 20 minutes: Ice causes vasoconstriction and secondary tissue injury.

B. Cover with butter immediately: Household oils/ointments interfere with care and are not first aid.

C. Leave hot clothing and jewellery firmly in place: Constriction can worsen swelling; remove items not adhered to skin.

D. Scrub the burn using strong disinfectant: Aggressive cleaning can damage the injured dermis.

Exam pearl: Cool the burn, warm the patient.

Examiner trap: Twenty minutes of water does not mean immersing the whole patient in cold water.

Viva extension: Viva: Timing window? As soon as possible, ideally within three hours.

Question 26 of 40 · Burn inhalation

Q26. A patient rescued from an enclosed house fire has soot in the mouth, new hoarseness and facial burns. What is the priority?

A. Urgent airway assessment and early expert planning for progressive oedemaB. Wait for stridor to become severe before informing an airway expertC. Reassure because SpO2 is 100%D. Give only topical antibiotic creamE. Allow oral intake before airway assessment

View detailed explanation, examiner trap and viva

Correct answer: A. Urgent airway assessment and early expert planning for progressive oedema

Why correct: Inhalation injury can evolve rapidly; hoarseness and soot are red flags for threatened airway.

Why the other options are incorrect:

B. Wait for stridor to become severe before informing an airway expert: Delay risks difficult airway access.

C. Reassure because SpO2 is 100%: Pulse oximetry can mislead in carbon monoxide exposure and does not assess airway oedema.

D. Give only topical antibiotic cream: This does not manage respiratory risks.

E. Allow oral intake before airway assessment: Possible airway compromise needs prioritisation.

Exam pearl: Enclosed fire + soot/hoarseness = potential inhalation injury.

Examiner trap: Normal saturation does not exclude carbon monoxide poisoning.

Viva extension: Viva: Which test detects CO burden? Co-oximetry measurement of carboxyhaemoglobin.

Question 27 of 40 · CO poisoning

Q27. A smoke-inhalation patient appears hypoxic and confused but a conventional pulse oximeter reads 99%. Which statement is most accurate?

A. CO poisoning always causes a low SpO2 numberB. Pulse oximetry may appear normal despite significant carboxyhaemoglobinC. Carboxyhaemoglobin is identified by standard finger oximeterD. Confusion excludes toxic inhalationE. Giving oxygen is contraindicated in carbon monoxide exposure

View detailed explanation, examiner trap and viva

Correct answer: B. Pulse oximetry may appear normal despite significant carboxyhaemoglobin

Why correct: Ordinary two-wavelength pulse oximeters cannot reliably discriminate COHb from oxyhaemoglobin.

Why the other options are incorrect:

A. CO poisoning always causes a low SpO2 number: Conventional SpO2 can be falsely reassuring.

C. Carboxyhaemoglobin is identified by standard finger oximeter: Direct measurement needs co-oximetry.

D. Confusion excludes toxic inhalation: Neuropsychiatric symptoms are consistent with CO exposure.

E. Giving oxygen is contraindicated in carbon monoxide exposure: High-concentration oxygen is part of initial management.

Exam pearl: Measure COHb with co-oximetry when indicated.

Examiner trap: Normal SpO2 does not rule out CO poisoning.

Viva extension: Viva: Initial treatment? Remove from exposure, provide high-concentration oxygen and seek toxicology/burns input as indicated.

Question 28 of 40 · Burn resuscitation

Q28. A patient with extensive partial-thickness burns requires formal fluid resuscitation. What is the most defensible strategy?

A. Give no fluid because burns do not cause capillary leakB. Give an identical fixed 10 litres to every adultC. Start protocol-based fluid estimation and titrate to physiology and urine outputD. Continue a formula rate even when pulmonary oedema occursE. Use oral water alone for any large burn regardless of shock

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Correct answer: C. Start protocol-based fluid estimation and titrate to physiology and urine output

Why correct: Formulae are starting points; repeated clinical assessment and urine output help avoid under- and over-resuscitation.

Why the other options are incorrect:

A. Give no fluid because burns do not cause capillary leak: Major burns induce capillary leakage and significant fluid shifts.

B. Give an identical fixed 10 litres to every adult: Fluid needs vary by body size, TBSA, injury and response.

D. Continue a formula rate even when pulmonary oedema occurs: Clinical response must guide titration.

E. Use oral water alone for any large burn regardless of shock: Major burns may require monitored IV resuscitation.

Exam pearl: Burn formulas initiate therapy; they do not replace reassessment.

Examiner trap: Blind “fluid creep” can worsen oedema and complications.

Viva extension: Viva: Typical adult urine output target? Around 0.5 mL/kg/hour, adjusted as indicated.

Question 29 of 40 · Burn referral

Q29. An adult sustains deep partial-thickness burns of the hand and wrist extending over a joint. What is the best referral decision?

A. Manage with home remedies without reassessmentB. Refer only if total burn size exceeds 40% TBSAC. Delay review until mature scar appearsD. Immediate burns-specialist consultation with consideration of transferE. Ignore burn depth because it is painful

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Correct answer: D. Immediate burns-specialist consultation with consideration of transfer

Why correct: Deep burns of the hands or over joints meet American Burn Association specialist referral criteria because of functional consequences.

Why the other options are incorrect:

A. Manage with home remedies without reassessment: Special-function areas carry functional and contracture risk.

B. Refer only if total burn size exceeds 40% TBSA: Anatomic depth/location can prompt referral even when total area is small.

C. Delay review until mature scar appears: Early expert care may influence function and healing.

E. Ignore burn depth because it is painful: Depth and function matter in referral decisions.

Exam pearl: Special sites: face, hands, feet, genitalia, perineum and joints.

Examiner trap: A small deep hand burn may need referral despite low TBSA.

Viva extension: Viva: Give another transfer criterion. Suspected inhalation injury or full-thickness burn.

Question 30 of 40 · Electrical burn

Q30. After a high-voltage electrical accident a worker has a tiny hand entry wound but severe muscle pain. What is the critical concern?

A. Small skin wounds guarantee minor injuryB. Only superficial moisturiser is neededC. There can be no risk of compartment syndromeD. ECG has no relevance after electrical injuryE. Deep muscle injury and cardiac complications out of proportion to skin appearance

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Correct answer: E. Deep muscle injury and cardiac complications out of proportion to skin appearance

Why correct: Electrical current can injure deep tissues and conduction systems even with limited cutaneous lesions.

Why the other options are incorrect:

A. Small skin wounds guarantee minor injury: External wound size can underestimate internal injury.

B. Only superficial moisturiser is needed: Potential deep injury, rhabdomyolysis and arrhythmia require assessment.

C. There can be no risk of compartment syndrome: Deep muscle oedema may threaten compartments.

D. ECG has no relevance after electrical injury: Cardiac evaluation may be important depending on exposure and symptoms.

Exam pearl: Electrical injury depth can exceed visible burn.

Examiner trap: Do not use skin TBSA alone to grade electrical injury.

Viva extension: Viva: Which laboratory marker may reflect muscle breakdown? Creatine kinase with renal/electrolyte monitoring.

Question 31 of 40 · Chemical burn

Q31. A lab worker splashes a corrosive liquid on the forearm. What is the safest general first response after ensuring scene safety?

A. Remove contaminated clothing and irrigate copiously, following substance-specific safety adviceB. Apply a neutralising chemical without knowing the agentC. Cover the chemical with greaseD. Delay decontamination until blistering startsE. Scrape all damaged skin with an instrument

View detailed explanation, examiner trap and viva

Correct answer: A. Remove contaminated clothing and irrigate copiously, following substance-specific safety advice

Why correct: Rapid removal/decontamination and appropriate irrigation reduce ongoing exposure, with exceptions for substances requiring specialised protocols.

Why the other options are incorrect:

B. Apply a neutralising chemical without knowing the agent: Uncontrolled reactions can generate heat and worsen injury.

C. Cover the chemical with grease: This may trap the agent against tissue.

D. Delay decontamination until blistering starts: Continued contact increases injury.

E. Scrape all damaged skin with an instrument: This is traumatic and not standard first aid.

Exam pearl: Chemical burns need rapid decontamination and agent-specific advice.

Examiner trap: Brush off dry chemical powders before irrigation when indicated; not all agents are managed identically.

Viva extension: Viva: What extra information matters? Chemical identity, concentration, contact time and safety data.

Question 32 of 40 · Secondary survey

Q32. After successful initial resuscitation of a multiply injured patient, what is the appropriate next systematic step?

A. Discharge simply because the blood pressure normalisedB. A thorough head-to-toe secondary survey including AMPLE historyC. Repeat the same single limb X-ray and stop further assessmentD. Assume CT identifies every ligament, tendon and nerve injuryE. Avoid examining the back or perineum to save time

View detailed explanation, examiner trap and viva

Correct answer: B. A thorough head-to-toe secondary survey including AMPLE history

Why correct: After primary threats are controlled, secondary survey identifies additional injuries with focused history, examination and imaging.

Why the other options are incorrect:

A. Discharge simply because the blood pressure normalised: Missed injuries remain possible.

C. Repeat the same single limb X-ray and stop further assessment: A full examination is needed.

D. Assume CT identifies every ligament, tendon and nerve injury: Clinical examination and reassessment remain essential.

E. Avoid examining the back or perineum to save time: These are components of a proper trauma assessment.

Exam pearl: Secondary survey follows stabilisation and can be repeated.

Examiner trap: Return to primary survey with any deterioration.

Viva extension: Viva: Expand AMPLE. Allergies, Medications, Past history/Pregnancy, Last meal, Events.

Question 33 of 40 · Missed injuries

Q33. A conscious trauma patient has a normal initial chest exam but later develops increasing abdominal pain and guarding. What principle is most appropriate?

A. The normal initial exam permanently excludes injuryB. Guarding after trauma is always due to anxietyC. Serial examination and reassessment for evolving or initially missed injuryD. Discharge without reassessmentE. Ignore pain if FAST was negative earlier

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Correct answer: C. Serial examination and reassessment for evolving or initially missed injury

Why correct: Some abdominal injuries become clinically apparent after the primary survey, especially as physiology evolves.

Why the other options are incorrect:

A. The normal initial exam permanently excludes injury: Early findings may be subtle.

B. Guarding after trauma is always due to anxiety: Peritonism requires careful assessment.

D. Discharge without reassessment: Worsening abdominal signs merit investigation.

E. Ignore pain if FAST was negative earlier: FAST cannot exclude every abdominal injury.

Exam pearl: Serial examinations matter even after initial imaging.

Examiner trap: Negative early FAST or CT cannot replace reassessment when clinical state changes.

Viva extension: Viva: What helps communicate evolving injury? Structured handover with trends and responses.

Question 34 of 40 · Spinal shock versus neurogenic

Q34. A patient with acute spinal cord injury has initial flaccid paralysis and absent deep tendon reflexes below the lesion. Which concept best explains this?

A. Only haemorrhagic shockB. Neurogenic shock aloneC. Isolated peripheral neuropathy from diabetesD. Spinal shockE. A chronic upper motor neuron syndrome

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Correct answer: D. Spinal shock

Why correct: Acute spinal shock is a transient loss of reflexes and neurological function below the lesion, distinct from haemodynamic neurogenic shock.

Why the other options are incorrect:

A. Only haemorrhagic shock: Bleeding cannot by itself explain a clear lesion-level areflexic neurological syndrome.

B. Neurogenic shock alone: Neurogenic shock refers to hypotension and vasodilatation due to sympathetic interruption.

C. Isolated peripheral neuropathy from diabetes: The onset immediately after cord trauma makes this unlikely.

E. A chronic upper motor neuron syndrome: Early cord injury can be flaccid before later spasticity emerges.

Exam pearl: Spinal shock = neurological areflexia; neurogenic shock = haemodynamic dysautonomia.

Examiner trap: Do not interchange these terms.

Viva extension: Viva: Later long tract features? Spasticity and hyperreflexia may emerge after spinal shock resolves.

Question 35 of 40 · Tamponade

Q35. Following penetrating thoracic trauma a patient develops shock with a distended neck and muffled heart sounds. What lesion is particularly concerning?

A. Isolated minor rib contusionB. Chronic essential hypertensionC. Uncomplicated bronchitisD. Simple stable pneumothorax without pressureE. Traumatic cardiac tamponade

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Correct answer: E. Traumatic cardiac tamponade

Why correct: Pericardial accumulation limits filling, producing obstructive shock; emergency trauma/cardiothoracic input is indicated.

Why the other options are incorrect:

A. Isolated minor rib contusion: A simple rib contusion does not explain obstructive shock signs.

B. Chronic essential hypertension: No acute explanation for shock.

C. Uncomplicated bronchitis: This would not produce the haemodynamic constellation.

D. Simple stable pneumothorax without pressure: That usually does not cause tamponade physiology.

Exam pearl: Tamponade is an obstructive cause of trauma shock.

Examiner trap: Classic Beck triad may be absent during concurrent blood loss.

Viva extension: Viva: What immediate imaging can help when available without delay? Bedside cardiac ultrasound.

Question 36 of 40 · Hypothermia prevention

Q36. A multiply injured bleeding patient is cool (34 C) after wet clothes were removed. What is a key supportive intervention alongside haemorrhage control?

A. Active prevention and treatment of hypothermiaB. Leave the patient uncovered for prolonged examinationC. Give ice-cold fluids routinelyD. Wait for body temperature to normalise spontaneouslyE. Avoid recording temperature

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Correct answer: A. Active prevention and treatment of hypothermia

Why correct: Hypothermia worsens coagulopathy, reduces drug performance and is associated with poorer trauma outcomes.

Why the other options are incorrect:

B. Leave the patient uncovered for prolonged examination: Exposure without warming promotes hypothermia.

C. Give ice-cold fluids routinely: Cold fluids exacerbate heat loss.

D. Wait for body temperature to normalise spontaneously: Active warming is often required.

E. Avoid recording temperature: Temperature is a relevant resuscitation parameter.

Exam pearl: Expose to examine; re-cover and warm immediately.

Examiner trap: Cold trauma patients bleed more due to impaired haemostasis.

Viva extension: Viva: What else is monitored during haemostatic resuscitation? pH/lactate and ionised calcium.

Question 37 of 40 · Secondary injury from hypotension

Q37. Why is uncontrolled hypotension especially dangerous in a patient with traumatic brain injury?

A. It always decreases intracranial pressure enough to protect the brainB. It lowers mean arterial pressure and may reduce cerebral perfusion pressureC. It invariably raises oxygen deliveryD. It rules out extra-cranial blood lossE. It only damages the scalp

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Correct answer: B. It lowers mean arterial pressure and may reduce cerebral perfusion pressure

Why correct: CPP depends on MAP minus ICP; systemic hypotension increases risk of ischaemic secondary brain injury.

Why the other options are incorrect:

A. It always decreases intracranial pressure enough to protect the brain: A low MAP can critically reduce CPP.

C. It invariably raises oxygen delivery: Poor perfusion reduces oxygen transport.

D. It rules out extra-cranial blood loss: Hypotension may reflect extracranial haemorrhage.

E. It only damages the scalp: Global brain perfusion is at stake.

Exam pearl: Do not apply permissive hypotension indiscriminately to TBI.

Examiner trap: Secondary brain injury prevention is as important as identifying primary lesions.

Viva extension: Viva: What two values define CPP? MAP and ICP.

Question 38 of 40 · Haemorrhage from long bones

Q38. A patient has a displaced femoral shaft fracture and progressive tachycardia with no visible external bleeding. What is the key diagnostic consideration?

A. A normal skin surface means no bleedingB. Femoral fractures never cause haemodynamic consequencesC. Significant concealed bleeding into the thighD. Only hyperventilation can cause tachycardiaE. Bleeding is excluded unless haemoglobin immediately decreases

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Correct answer: C. Significant concealed bleeding into the thigh

Why correct: Long-bone fractures, especially femoral fractures, can conceal substantial blood loss and contribute to shock.

Why the other options are incorrect:

A. A normal skin surface means no bleeding: Haemorrhage can be internal to tissue compartments.

B. Femoral fractures never cause haemodynamic consequences: They can contribute to major bleeding.

D. Only hyperventilation can cause tachycardia: Blood loss is important to assess.

E. Bleeding is excluded unless haemoglobin immediately decreases: Early haemoglobin can lag behind true blood loss.

Exam pearl: Remember long bones as potential bleeding compartments.

Examiner trap: Do not assume all shock in pelvic injury comes only from the pelvis.

Viva extension: Viva: What other hidden spaces bleed? Chest, abdomen and retroperitoneum.

Question 39 of 40 · Tetanus assessment

Q39. After stabilisation, a patient has a contaminated open wound from farm equipment. Which preventive aspect should be reviewed?

A. Routine influenza vaccination as the only wound prophylaxisB. Antibiotics replace tetanus assessmentC. Tetanus is impossible after orthopaedic injuryD. Tetanus immunisation status and need for prophylaxisE. No action if the injury looks small

View detailed explanation, examiner trap and viva

Correct answer: D. Tetanus immunisation status and need for prophylaxis

Why correct: Contaminated wounds require immunisation history assessment and local protocol for booster and immunoglobulin as indicated.

Why the other options are incorrect:

A. Routine influenza vaccination as the only wound prophylaxis: This does not target tetanus.

B. Antibiotics replace tetanus assessment: Antibiotics do not reliably prevent tetanus.

C. Tetanus is impossible after orthopaedic injury: Contaminated traumatic wounds can pose risk.

E. No action if the injury looks small: Wound depth and contamination, not surface length alone, determine risk.

Exam pearl: Open wounds require tetanus status review.

Examiner trap: Do not confuse systemic antibiotic coverage with tetanus prophylaxis.

Viva extension: Viva: What influences prophylaxis? Wound classification, vaccination history and immune status.

Question 40 of 40 · Massive haemothorax

Q40. A patient after penetrating chest trauma is shocked, with dullness to percussion and markedly reduced left breath sounds. What potentially life-threatening diagnosis must be considered?

A. Simple asthma exacerbationB. Isolated chronic obstructive pulmonary diseaseC. Uncomplicated rib bruisingD. Small stable pericardial effusionE. Massive haemothorax

View detailed explanation, examiner trap and viva

Correct answer: E. Massive haemothorax

Why correct: Pleural blood loss can cause hypovolaemic shock with impaired ventilation; urgent pleural and haemorrhage management is required.

Why the other options are incorrect:

A. Simple asthma exacerbation: Does not fit unilateral dullness and haemorrhagic shock.

B. Isolated chronic obstructive pulmonary disease: Acute unilateral findings after penetrating trauma are more concerning.

C. Uncomplicated rib bruising: Usually insufficient to explain profound shock.

D. Small stable pericardial effusion: Would not cause unilateral pleural dullness.

Exam pearl: Tension pneumothorax tends toward hyperresonance; massive haemothorax may produce dullness.

Examiner trap: Physical signs are supportive and may be obscured by noise, body habitus or simultaneous injuries.

Viva extension: Viva: What shock type dominates massive haemothorax? Hypovolaemic/haemorrhagic.

Frequently asked questions

Are these actual MRCS examination recalls?

No. These questions are newly authored educational SBAs based on published syllabus concepts and clinical reference guidance.

Is tension pneumothorax a clinical diagnosis?

Yes when the patient is unstable and the clinical picture fits. Urgent decompression must not wait for imaging.

Can major trauma cause shock with normal blood pressure?

Yes. Compensated shock can present with tachycardia, cool extremities, anxiety and decreased perfusion before hypotension.

How is shock index calculated?

Heart rate divided by systolic blood pressure, using the numeric values in beats/minute and mmHg.

When is tranexamic acid recommended in major bleeding?

As early as possible within 3 hours of injury for major trauma with active or suspected active bleeding, following protocols and local specialist guidance.

Do we count first-degree burns when estimating TBSA?

No. Simple superficial epidermal erythema is not included in TBSA for burn-resuscitation calculations.

When should a patient be referred to a burn centre?

Examples include full-thickness burns, partial-thickness burns of at least 10% TBSA, certain deep burns in functional regions, or suspected inhalation injury; follow published ABA guidance.

Will quiz and checklist progress sync across devices?

No. Data is stored with localStorage in the current browser. Clearing website data or changing device can remove access to saved progress.

References and related MRCS lessons

Independent medical education. For real patients follow current local resuscitation, trauma, burns and major-haemorrhage protocols; consult specialists promptly.

1. Intercollegiate MRCS candidate guidance
2. NICE NG39 — Major trauma assessment and initial management
3. NICE NG232 — Head injury assessment and early management
4. NICE NG41 — Spinal injury assessment and initial management
5. European guideline: major bleeding and coagulopathy following trauma, sixth edition (2023)
6. American Burn Association — Burn centre referral guidelines
7. NHS — Burns and scalds first aid

Published MRCS Academy articles

Article 01
Start MRCS HereArticle 02
Complete SyllabusArticle 03
Books and ResourcesArticle 04
12-Week Study PlanArticle 05
SBA Question StrategyArticle 06
Common Preparation MistakesArticle 07
Surgical Anatomy OverviewArticle 08
Upper Limb AnatomyArticle 09
Inguinal & Abdominal WallArticle 10
Head & Neck Surgical AnatomyArticle 11
Cardiovascular & Respiratory PhysiologyArticle 12
Renal & Acid–Base PhysiologyArticle 13
GI, Endocrine & NeurophysiologyArticle 14
Lower Limb Surgical Anatomy Made Easy for MRCS Part AArticle 15
Thoracic, Pelvic and Visceral Surgical AnatomyArticle 16
Surgical Pathology, Inflammation and Wound Healing Made Easy for MRCS Part AArticle 17
Surgical Pharmacology and Microbiology Made Easy for MRCS Part AArticle 18
Perioperative Care, Anaesthesia and Surgical Complications Made Easy for MRCS Part A

Previous lesson: Article 18 — Perioperative Care and Anaesthesia

Next planned: Article 20 — Acute Abdomen and Emergency Surgical Conditions. This link will be added after publication.

FreeMedSite MRCS independent education · Reviewed 16 October 2026 · References are for topics, not for reproducing actual exam questions.