Airway management techniques US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Airway management techniques. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Airway management techniques US Medical PG Question 1: A 45-year-old man was a driver in a motor vehicle collision. The patient is not able to offer a medical history during initial presentation. His temperature is 97.6°F (36.4°C), blood pressure is 104/74 mmHg, pulse is 150/min, respirations are 12/min, and oxygen saturation is 98% on room air. On exam, he does not open his eyes, he withdraws to pain, and he makes incomprehensible sounds. He has obvious signs of trauma to the chest and abdomen. His abdomen is distended and markedly tender to palpation. He also has an obvious open deformity of the left femur. What is the best initial step in management?
- A. Emergency open fracture repair
- B. Packed red blood cells
- C. Exploratory laparotomy
- D. Intubation (Correct Answer)
- E. 100% oxygen
Airway management techniques Explanation: ***Intubation***
- The patient's **Glasgow Coma Scale (GCS) score is 7** (E=1, V=2, M=4), which is below 8 and indicates a severe head injury needing **airway protection** via intubation.
- A GCS ≤ 8 mandates **definitive airway management** to prevent aspiration and ensure adequate ventilation.
*Emergency open fracture repair*
- While the patient has an open femur fracture, it is not the most immediate life-threatening concern after a major trauma; **airway and breathing** take precedence.
- **Hemorrhage control** and **stabilization** often precede definitive orthopedic repair in polytrauma.
*Packed red blood cells*
- Although the patient is likely in **hemorrhagic shock** (tachycardia, hypotension, obvious trauma), administering blood products without first securing the airway is not the initial priority.
- **Circulation** management, including fluid resuscitation and blood products, follows **airway and breathing** establishment.
*Exploratory laparotomy*
- The patient's distended and tender abdomen strongly suggests intra-abdominal injury, but this is a **diagnostic and therapeutic procedure** that comes after initial resuscitation and stabilization.
- **Emergent laparotomy** for abdominal trauma is considered once the patient's airway, breathing, and circulation are secured.
*100% oxygen*
- Administering 100% oxygen is part of initial resuscitation, but it does not address the fundamental problem of an unsecured airway and the risk of **hypoventilation** or **aspiration** in a patient with a GCS of 7.
- Oxygen supplementation helps improve saturation in spontaneously breathing patients but cannot protect a compromised airway.
Airway management techniques US Medical PG Question 2: A 9-year-old boy presents for incision and drainage of a small abscess on his left thigh. No significant past medical history. No current medications. Before the procedure, the patient is allowed to inhale colorless, sweet-smelling gas. After the procedure, the patient receives 3–4 minutes of high flow oxygen through a nasal mask. The pulse oximetry shows an oxygen saturation of 94%. This patient was oxygenated at the end of the procedure to prevent which of the following complications?
- A. Malignant hyperthermia
- B. Hepatotoxicity
- C. Raised intracranial pressure
- D. Cardiac arrhythmias
- E. Diffusion hypoxia (Correct Answer)
Airway management techniques Explanation: ***Diffusion hypoxia (Correct)***
- **Nitrous oxide** rapidly diffuses from the blood into the alveoli after discontinuation, displacing oxygen and carbon dioxide.
- This creates the **"Fink effect"** - a dilution of alveolar oxygen that can lead to transient **hypoxemia**.
- Administering **high-flow oxygen for 3-5 minutes** prevents this complication by maintaining adequate alveolar oxygen concentration during the N2O washout period.
*Malignant hyperthermia (Incorrect)*
- This is a pharmacogenetic disorder triggered by **volatile anesthetics** (e.g., halothane, sevoflurane) and **succinylcholine**, not nitrous oxide.
- Characterized by **muscle rigidity, hyperthermia, and hypermetabolism**.
- While oxygen is part of supportive treatment, post-procedure oxygenation doesn't prevent its onset.
- Treatment requires **dantrolene**, not just oxygen.
*Hepatotoxicity (Incorrect)*
- Not prevented by post-procedure oxygenation.
- Typically associated with **halothane** (rare with modern anesthetics), not nitrous oxide.
- Nitrous oxide is not a primary cause of hepatotoxicity.
*Raised intracranial pressure (Incorrect)*
- While nitrous oxide can increase **cerebral blood flow** and potentially raise ICP, post-procedure oxygen doesn't specifically prevent this effect.
- Management of elevated ICP involves **hyperventilation, head elevation, osmotic diuretics**, and avoiding N2O in at-risk patients.
- The oxygen administration here targets diffusion hypoxia, not ICP control.
*Cardiac arrhythmias (Incorrect)*
- While hypoxia can cause arrhythmias, the primary purpose of post-N2O oxygen is to prevent **diffusion hypoxia**.
- Preventing hypoxemia secondarily reduces arrhythmia risk, but this is not the direct indication.
- Arrhythmias from anesthetics are more commonly associated with **halogenated agents** sensitizing the myocardium to catecholamines.
Airway management techniques US Medical PG Question 3: A 5-year-old boy is brought to the emergency department by his grandmother because of difficulty breathing. Over the past two hours, the grandmother has noticed his voice getting progressively hoarser and occasionally muffled, with persistent drooling. He has not had a cough. The child recently immigrated from Africa, and the grandmother is unsure if his immunizations are up-to-date. He appears uncomfortable and is sitting up and leaning forward with his chin hyperextended. His temperature is 39.5°C (103.1°F), pulse is 110/min, and blood pressure is 90/70 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 95%. Pulmonary examination shows inspiratory stridor and scattered rhonchi throughout both lung fields, along with poor air movement. Which of the following is the most appropriate next step in management?
- A. Nebulized albuterol
- B. Direct laryngoscopy and pharyngoscopy
- C. Immediate nasotracheal intubation in the emergency department
- D. Prepare for emergency airway management in the operating room with anesthesia and ENT backup (Correct Answer)
- E. Intravenous administration of antibiotics
Airway management techniques Explanation: ***Prepare for emergency airway management in the operating room with anesthesia and ENT backup***
- The constellation of **hoarseness**, **muffled voice**, **drooling**, **inspiratory stridor**, **fever**, and the classic **tripod position** (sitting up, leaning forward, hyperextended chin) in an unimmunized child strongly indicates **epiglottitis**.
- Given the risk of **complete airway obstruction**, securing the airway in a controlled environment like the **operating room** with specialized personnel (**anesthesia**, **ENT**) is the safest and most appropriate immediate step.
*Nebulized albuterol*
- This medication is a **bronchodilator** primarily used for conditions like **asthma** or **bronchiolitis** that involve bronchospasm.
- It would not alleviate airway obstruction caused by supraglottic swelling in epiglottitis and could potentially worsen the child's distress.
*Direct laryngoscopy and pharyngoscopy*
- Performing a direct laryngoscopy or pharyngoscopy in the emergency department, especially without immediate intubation capabilities, could precipitate **laryngospasm** and **complete airway obstruction** in a child with suspected epiglottitis.
- Visualization of the airway should only be attempted in a controlled setting where immediate intubation or tracheostomy can be performed.
*Immediate nasotracheal intubation in the emergency department*
- While intubation is necessary, attempting it immediately in the emergency department without the controlled environment of an operating room and without the full support of anesthesia and ENT specialists carries significant risks.
- The swelling can make intubation extremely difficult and increase the likelihood of failed attempts or trauma, further compromising the airway.
*Intravenous administration of antibiotics*
- Although antibiotics are a crucial part of epiglottitis treatment (typically **ceftriaxone** or **cefotaxime** to cover *Haemophilus influenzae* type b), they are not the immediate priority.
- The most urgent threat is airway compromise; therefore, securing the airway takes precedence over initiating antibiotic therapy.
Airway management techniques US Medical PG Question 4: A 36-year-old male with fluctuating levels of consciousness is brought to the emergency department by ambulance due to a fire in his home. He currently opens his eyes to voice, localizes painful stimuli, responds when asked questions, but is disoriented and cannot obey commands. The patient’s temperature is 99°F (37.2°C), blood pressure is 86/52 mmHg, pulse is 88/min, and respirations are 14/min with an oxygen saturation of 97% O2 on room air. Physical exam shows evidence of soot around the patient’s nose and mouth, but no burns, airway obstruction, nor accessory muscle use. A blood lactate is 14 mmol/L. The patient is started on intravenous fluids.
What is the next best step in management?
- A. Methylene blue
- B. Hyperbaric oxygen
- C. Sodium thiosulfate and sodium nitrite
- D. Intravenous epinephrine
- E. 100% oxygen, hydroxycobalamin, and sodium thiosulfate (Correct Answer)
Airway management techniques Explanation: ***100% oxygen, hydroxycobalamin, and sodium thiosulfate***
- This patient presents with signs of both **carbon monoxide poisoning** (fire exposure, disoriented, altered mental status) and **cyanide poisoning** (fire exposure, very high lactate, normal oxygen saturation despite altered mental status). This combination therapy directly addresses both.
- **100% oxygen** competes with carbon monoxide for hemoglobin binding and helps clear it, while **hydroxycobalamin** and **sodium thiosulfate** are antidotes for cyanide poisoning, converting cyanide into less toxic compounds.
*Methylene blue*
- **Methylene blue** is used to treat **methemoglobinemia**, a condition where iron in hemoglobin is oxidized, leading to impaired oxygen transport.
- The patient's symptoms (fire exposure, altered mental status, and a high lactate with normal SpO2) are not characteristic of methemoglobinemia, but rather strong indicators of carbon monoxide and cyanide poisoning.
*Hyperbaric oxygen*
- **Hyperbaric oxygen** is a treatment for severe carbon monoxide poisoning, but it is not the initial or sole treatment for a patient with suspected co-existing cyanide poisoning.
- While recommended for **severe CO poisoning**, it doesn't directly address cyanide toxicity, which is suggested by the metabolic acidosis with a high lactate level despite normal oxygen saturation.
*Sodium thiosulfate and sodium nitrite*
- This combination (the **Lilly kit**) is traditionally used to treat **cyanide poisoning**, with sodium nitrite inducing methemoglobinemia to sequester cyanide, and sodium thiosulfate aiding its excretion.
- The patient also requires treatment for **carbon monoxide poisoning**, and hydroxycobalamin is generally preferred over sodium nitrite as it does not induce methemoglobinemia, which can worsen hypoxia in CO poisoning.
*Intravenous epinephrine*
- **Epinephrine** is a powerful vasoconstrictor and bronchodilator primarily used to treat **anaphylaxis** or **cardiac arrest**.
- There is no indication of anaphylaxis or cardiac arrest in this patient, and epinephrine would not be an appropriate treatment for carbon monoxide or cyanide poisoning.
Airway management techniques US Medical PG Question 5: A 5-year-old is brought into the emergency department for trouble breathing. He was at a family picnic playing when his symptoms began. The patient is currently struggling to breathe and has red, warm extremities. The patient has an unknown medical history and his only medications include herbs that his parents give him. His temperature is 99.5°F (37.5°C), pulse is 112/min, blood pressure is 70/40 mmHg, respirations are 18/min, and oxygen saturation is 82% on 100% O2. Which of the following is the best initial step in management?
- A. Intubation
- B. Albuterol
- C. Cricothyroidotomy
- D. Albuterol, ipratropium, and magnesium
- E. Epinephrine (Correct Answer)
Airway management techniques Explanation: ***Epinephrine***
- This patient is exhibiting signs of **anaphylactic shock** (difficulty breathing, red/warm extremities, hypotension) likely triggered by an allergen at the picnic. **Epinephrine** is the first-line treatment for anaphylaxis due to its alpha and beta-adrenergic effects that counteract vasodilation, bronchoconstriction, and histamine release.
- The rapid onset of symptoms and cardiovascular collapse (hypotension) necessitate immediate administration of epinephrine to stabilize the patient.
*Intubation*
- While the patient is in respiratory distress, intubation is a more invasive procedure and not the *initial* best step for anaphylactic shock. **Epinephrine** should be administered first to address the underlying physiological derangements.
- Airway management, including intubation, may be necessary if epinephrine fails to improve respiratory status, but it is secondary to addressing the systemic allergic reaction.
*Albuterol*
- **Albuterol** is a bronchodilator that helps with bronchospasm, but it does not address the widespread vasodilation, hypotension, or other systemic effects of anaphylaxis.
- While it might provide some symptomatic relief for breathing, it is insufficient as a standalone treatment for anaphylactic shock and would not prevent cardiovascular collapse.
*Cricothyroidotomy*
- **Cricothyroidotomy** is an emergency airway procedure used when conventional intubation is impossible due to upper airway obstruction.
- In this scenario, the primary issue is systemic anaphylaxis causing bronchospasm and shock, not an isolated upper airway obstruction, making epinephrine the more appropriate initial intervention.
*Albuterol, ipratropium, and magnesium*
- This combination is typically used for severe asthma exacerbations, focusing on bronchodilation and smooth muscle relaxation.
- Like albuterol alone, this combination does not address the underlying systemic vasodilation and hypotension characteristic of anaphylactic shock, which requires **epinephrine**.
Airway management techniques US Medical PG Question 6: A 23-year-old man is brought to the emergency department by ambulance following a motor vehicle accident. He was pinned between 2 cars for several hours. The patient has a history of asthma. He uses an albuterol inhaler intermittently. The patient was not the driver, and admits to having a few beers at a party prior to the accident. His vitals in the ambulance are stable. Upon presentation to the emergency department, the patient is immediately brought to the operating room for evaluation and surgical intervention. It is determined that the patient’s right leg has a Gustilo IIIC injury in the mid-shaft of the tibia with a severely comminuted fracture. The patient’s left leg suffered a similar injury but with damage to the peroneal nerve. The anesthesiologist begins to induce anesthesia. Which of the following agents would be contraindicated in this patient?
- A. Halothane
- B. Propofol
- C. Etomidate
- D. Succinylcholine (Correct Answer)
- E. Neostigmine
Airway management techniques Explanation: ***Succinylcholine***
- Given the history of the patient being pinned between two cars for several hours, there is a significant risk of **rhabdomyolysis** and subsequent hyperkalemia.
- **Succinylcholine**, a depolarizing neuromuscular blocker, can cause a sudden and significant release of potassium from muscle cells, leading to **life-threatening hyperkalemia** in patients with rhabdomyolysis or crush injuries.
*Halothane*
- While **halothane** has been associated with **malignant hyperthermia**, the patient's history does not directly suggest an increased risk for this condition here.
- It also has a bronchodilating effect, which could be beneficial for a patient with a history of **asthma**.
*Propofol*
- **Propofol** is a commonly used intravenous anesthetic for induction and maintenance, providing rapid onset and recovery.
- There are generally no specific contraindications for propofol in a patient with a crush injury or asthma.
*Etomidate*
- **Etomidate** is an intravenous anesthetic agent known for its **cardiovascular stability**, making it a good choice for hemodynamically unstable patients.
- It can cause adrenal suppression, but this is usually a concern with prolonged infusions, not a single induction dose.
*Neostigmine*
- **Neostigmine** is an acetylcholinesterase inhibitor used to reverse the effects of non-depolarizing neuromuscular blockers.
- It is not an induction agent and would not be used at the beginning of anesthesia induction.
Airway management techniques US Medical PG Question 7: A 28-year-old soldier is brought back to a military treatment facility 45 minutes after sustaining injuries in a building fire from a mortar attack. He was trapped inside the building for around 20 minutes. On arrival, he is confused and appears uncomfortable. He has a Glasgow Coma Score of 13. His pulse is 113/min, respirations are 18/min, and blood pressure is 108/70 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 96%. Examination shows multiple second-degree burns over the chest and bilateral upper extremities and third-degree burns over the face. There are black sediments seen within the nose and mouth. The lungs are clear to auscultation. Cardiac examination shows no abnormalities. The abdomen is soft and nontender. Intravenous fluid resuscitation is begun. Which of the following is the most appropriate next step in management?
- A. Insertion of nasogastric tube and enteral nutrition
- B. Intravenous antibiotic therapy
- C. Intubation and mechanical ventilation (Correct Answer)
- D. Immediate bronchoscopy
- E. Intravenous corticosteroid therapy
Airway management techniques Explanation: ***Intubation and mechanical ventilation***
- The patient exhibits several signs of impending **airway compromise** due to **inhalation injury**, including perioral burns, black sediments in the nose and mouth, and being trapped in a fire.
- While current oxygen saturation is 96%, **airway edema** can rapidly worsen, leading to respiratory failure. **Early intubation** is crucial to secure the airway before it becomes obstructed.
*Insertion of nasogastric tube and enteral nutrition*
- A nasogastric tube is often placed in burn patients to decompress the stomach and provide nutritional support, but it is **not the immediate priority** when there is a risk of airway obstruction.
- **Enteral nutrition** is important but should be initiated only after airway control is established and the patient is stable for feeding.
*Intravenous antibiotic therapy*
- **Prophylactic antibiotics** are generally **not recommended** in the immediate management of burn patients unless there is clear evidence of infection, which is not present here.
- Unnecessary antibiotic use can lead to **antibiotic resistance** and fungal infections.
*Immediate bronchoscopy*
- While **bronchoscopy** can confirm the extent of inhalation injury, it is not the primary immediate step. **Securing the airway** through intubation takes precedence over diagnostic procedures when airway compromise is imminent.
- Bronchoscopy can be considered *after* intubation to assess the lower airway for damage and guide further management.
*Intravenous corticosteroid therapy*
- **Corticosteroids** are typically **contraindicated** in the management of inhalation injury because they can **impair immune function** and increase the risk of infection in burn patients.
- Evidence does not support the routine use of corticosteroids to reduce inflammation in inhalation injury, and they may worsen outcomes.
Airway management techniques US Medical PG Question 8: A 63-year-old man is brought to the emergency department, 30 minutes after being involved in a high-speed motor vehicle collision. He is obtunded on arrival. He is intubated and mechanical ventilation is begun. The ventilator is set at a FiO2 of 60%, tidal volume of 440 mL, and positive end-expiratory pressure of 4 cm H2O. On the third day of intubation, his temperature is 37.3°C (99.1°F), pulse is 91/min, and blood pressure is 103/60 mm Hg. There are decreased breath sounds over the left lung base. Cardiac examination shows no abnormalities. The abdomen is soft and not distended. Arterial blood gas analysis shows:
pH 7.49
pCO2 29 mm Hg
pO2 73 mm Hg
HCO3- 20 mEq/L
O2 saturation 89%
Monitoring shows a sudden increase in the plateau airway pressure. An x-ray of the chest shows deepening of the costophrenic angle on the left side. Which of the following is the most appropriate next step in management?
- A. CT scan of the chest
- B. Administer levofloxacin
- C. Close observation
- D. Increase the PEEP
- E. Insertion of a chest tube (Correct Answer)
Airway management techniques Explanation: ***Insertion of a chest tube***
- The sudden increase in **plateau airway pressure**, decreased breath sounds over the left lung base, worsening hypoxemia (O2 sat 89%) despite high FiO2, and **deepening of the costophrenic angle on the left side** indicate a **traumatic hemothorax**.
- Deepening of the costophrenic angle on chest X-ray is a classic sign of **pleural fluid accumulation** (hemothorax or pleural effusion), not pneumothorax.
- In a trauma patient (high-speed motor vehicle collision) on day 3 of mechanical ventilation, this represents a **delayed hemothorax** requiring immediate drainage.
- **Chest tube insertion** is the definitive management to evacuate blood, re-expand the lung, and improve ventilation and oxygenation.
*CT scan of the chest*
- While CT scan would provide detailed anatomical information, the clinical presentation with sudden respiratory decompensation and clear chest X-ray findings of hemothorax requires **immediate intervention**.
- Delaying treatment to obtain CT imaging in an unstable ventilated patient could worsen hypoxemia and lead to cardiovascular compromise.
- CT scan may be obtained later if needed to evaluate for ongoing bleeding or other injuries.
*Administer levofloxacin*
- Antibiotics would be appropriate for **pneumonia or empyema**, but the patient has no clear signs of infection (afebrile at 37.3°C, acute presentation over hours not days).
- The primary problem is **mechanical compression** from pleural fluid accumulation, not infection.
- Antibiotics do not address the life-threatening respiratory compromise from hemothorax.
*Close observation*
- Close observation is inappropriate given the acute deterioration with increased plateau pressures and worsening hypoxemia.
- The patient requires urgent intervention to prevent further respiratory failure and potential cardiovascular collapse.
- Expectant management would be negligent in this clinical scenario.
*Increase the PEEP*
- Increasing **Positive End-Expiratory Pressure (PEEP)** would worsen the situation by increasing intrathoracic pressure against an already compressed lung.
- Higher PEEP could impair venous return, decrease cardiac output, and potentially convert a simple hemothorax to a tension physiology.
- PEEP adjustments do not address the underlying problem of pleural space fluid accumulation requiring drainage.
Airway management techniques US Medical PG Question 9: An obese 52-year-old man is brought to the emergency department because of increasing shortness of breath for the past 8 hours. Two months ago, he noticed a mass on the right side of his neck and was diagnosed with laryngeal cancer. He has smoked two packs of cigarettes daily for 27 years. He drinks two pints of rum daily. He appears ill. He is oriented to person, place, and time. His temperature is 37°C (98.6°F), pulse is 111/min, respirations are 34/min, and blood pressure is 140/90 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 89%. Examination shows a 9-cm, tender, firm subglottic mass on the right side of the neck. Cervical lymphadenopathy is present. His breathing is labored and he has audible inspiratory stridor but is able to answer questions. The lungs are clear to auscultation. Arterial blood gas analysis on room air shows:
pH 7.36
PCO2 45 mm Hg
PO2 74 mm Hg
HCO3- 25 mEq/L
He has no advanced directive. Which of the following is the most appropriate next step in management?
- A. Comfort care measures
- B. Cricothyroidotomy (Correct Answer)
- C. Tracheostomy
- D. Intramuscular epinephrine
- E. Tracheal stenting
Airway management techniques Explanation: ***Correct: Cricothyroidotomy***
- This patient has **impending complete airway obstruction** evidenced by inspiratory stridor, severe tachypnea (34/min), hypoxia (O2 sat 89%), and a large obstructing laryngeal mass
- **Cricothyroidotomy** is the emergent surgical airway procedure of choice when there is **imminent or actual complete upper airway obstruction** and endotracheal intubation cannot be safely performed
- The subglottic mass makes endotracheal intubation **extremely dangerous** - instrumentation could precipitate complete obstruction and inability to ventilate
- Cricothyroidotomy provides **immediate airway access** (can be performed in 30-60 seconds) below the level of obstruction, making it life-saving in this emergency
- In the "cannot intubate, cannot ventilate" scenario, cricothyroidotomy is the definitive emergency intervention per ATLS and airway management guidelines
*Incorrect: Tracheostomy*
- While tracheostomy provides definitive airway management, it is a **controlled, elective procedure** typically performed in the OR that takes 20-30 minutes
- This patient requires **immediate airway access** - waiting for OR setup and performing tracheostomy risks complete airway collapse and death
- Tracheostomy may be performed later as a planned procedure once the airway is secured with cricothyroidotomy
- The presence of stridor indicates **critical airway narrowing** requiring emergency intervention, not elective surgery
*Incorrect: Comfort care measures*
- The patient is **alert and oriented** without an advanced directive indicating wishes for comfort care only
- This is an **acute, reversible condition** with appropriate emergency airway intervention
- Presumed consent applies in life-threatening emergencies when the patient cannot formally consent but intervention would be life-saving
- Comfort care would be inappropriate without documented patient wishes or irreversible terminal condition
*Incorrect: Intramuscular epinephrine*
- Epinephrine is indicated for **anaphylaxis** or angioedema causing airway edema from allergic/inflammatory mechanisms
- This patient has **mechanical obstruction** from a solid tumor mass, which will not respond to epinephrine
- Epinephrine causes vasoconstriction and reduces mucosal edema but cannot reduce tumor mass
- Would delay definitive airway management and not address the underlying problem
*Incorrect: Tracheal stenting*
- Tracheal stenting requires **bronchoscopy** in a controlled setting and is used for palliation of tracheal narrowing
- Cannot be performed emergently in an unstable patient with impending airway obstruction
- The obstruction is at the **laryngeal/subglottic level**, not typically amenable to emergency stenting
- Requires time for procedure setup and sedation, which this patient cannot afford given the critical airway emergency
Airway management techniques US Medical PG Question 10: A 24-year-old man is brought to the emergency department 30 minutes after being involved in a high-speed motor vehicle collision in which he was a restrained driver. On arrival, he is alert and oriented. His pulse is 112/min, respirations are 29/min, and blood pressure is 100/60 mm Hg. The pupils are equal and reactive to light. There is a 3-cm laceration over the forehead and multiple bruises over the trunk. The lungs are clear to auscultation. Cardiac examination shows no abnormalities. The abdomen is soft and nontender. The right knee is swollen and tender; range of motion is limited by pain. Infusion of 0.9% saline is begun and intravenous acetaminophen is administered. Two hours later, blood-tinged fluid spontaneously drains from both nostrils, and is made worse by leaning forward. On a piece of gauze, it shows up as a rapidly-expanding clear ring of fluid surrounding blood. Further evaluation of this patient is most likely to show which of the following?
- A. Numbness of upper cheek area
- B. Retroauricular ecchymosis
- C. Bilateral periorbital ecchymosis (Correct Answer)
- D. Cranial nerve XII palsy
- E. Carotid artery dissection
Airway management techniques Explanation: **Bilateral periorbital ecchymosis**
- The clinical presentation, including head trauma from a **high-speed motor vehicle collision**, neurological symptoms like **blood-tinged fluid draining from both nostrils with a halo sign**, and hemodynamic instability (tachycardia and hypotension), points towards a **basilar skull fracture**.
- **Bilateral periorbital ecchymosis** (raccoon eyes) is a classic sign of a basilar skull fracture, particularly one involving the **anterior cranial fossa**, indicating extravasation of blood into the periorbital tissues.
*Numbness of upper cheek area*
- **Numbness of the upper cheek area** is associated with injury to the **infraorbital nerve**, which often occurs with **maxillary (Le Fort II or III) fractures** or **orbital floor fractures**.
- While midface fractures can occur in severe trauma, the **halo sign** from the nostrils is more indicative of a **CSF leak** associated with a **basilar skull fracture**, rather than isolated maxillary injury.
*Retroauricular ecchymosis*
- **Retroauricular ecchymosis** (Battle's sign) is also a sign of a **basilar skull fracture**, but it specifically indicates a fracture involving the **middle cranial fossa** and the **temporal bone**.
- While possible, the spontaneous draining of CSF from the nostrils (rhinorrhea) is more directly linked to an **anterior cranial fossa fracture** and involvement of the **cribriform plate**, making bilateral periorbital ecchymosis a more likely and specific finding in this context.
*Cranial nerve XII palsy*
- **Cranial nerve XII (hypoglossal) palsy** would result in **tongue deviation** and weakness, typically associated with injuries to the **posterior cranial fossa** or the **neck**.
- This is not a common finding with the presented symptoms of **rhinorrhea with a halo sign**, which points to an **anterior cranial fossa fracture**.
*Carotid artery dissection*
- **Carotid artery dissection** can occur after significant trauma and may present with headaches, neck pain, and focal neurological deficits such as **hemiparesis** or **cranial nerve deficits (e.g., Horner's syndrome)**.
- While trauma increases the risk, the specific symptom of **CSF rhinorrhea with a halo sign** is not characteristic of a carotid dissection but rather indicative of a **communication between the subarachnoid space and the nasal cavity** due to a skull base fracture.
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