Anesthesia for Vascular Emergencies — MCQs
A cardiovascular parameter helpful in diagnosis of anaphylaxis during anaesthesia:
Which of the following statements is NOT true regarding rapid induction of anesthesia?
A comatose 28-year-old woman sustained a depressed skull fracture in an automobile collision. She has been unconscious for 6 weeks. Her vital signs are stable and she breathes room air. Following her initial decompressive craniotomy, she has returned to the operating room twice due to intracranial bleeding. Select the best method of physiologic monitoring necessary for the patient.
A patient is on follow-up for recurrent abdominal pain. USG reveals an aortic aneurysm of 40 mm. What should be the next immediate step?
All of the following are indicators of adequacy of pre-operative resuscitation except
A 58-year-old male with a history of hypertension and smoking presents with sudden severe back pain and hypotension. A CT scan reveals a 7 cm ruptured abdominal aortic aneurysm (AAA). What are the key factors in deciding whether to proceed with endovascular aneurysm repair (EVAR) or open surgical repair?
Steps in review of patient's history during secondary survey of trauma care can be summarised as
On the 4th postoperative day of laparotomy a patient presents with bleeding & oozing from the wound. Management is :
Patient shows ST depression, troponin rise 6h post-surgery. Next best step is:
Child with aspiration risk needs emergency surgery. Best induction sequence is:
Anesthesia for Vascular Emergencies Indian Medical PG Practice Questions and MCQs
Question 1: A cardiovascular parameter helpful in diagnosis of anaphylaxis during anaesthesia:
- A. Bradycardia
- B. Dysrhythmia
- C. Increased peripheral vascular resistance
- D. Hypotension (Correct Answer)
Explanation: ***Hypotension*** - **Hypotension** is a hallmark cardiovascular sign of anaphylaxis, occurring due to widespread **vasodilation** and increased vascular permeability. - This symptom is often profound and unresponsive to initial fluid resuscitation due to the ongoing systemic release of inflammatory mediators. *Bradycardia* - While bradycardia can occur in some rare cases of anaphylaxis (e.g., **vasovagal response**), **tachycardia** is the more common cardiac response due to compensatory mechanisms. - It is not a primary or consistent indicator of anaphylaxis, making it less helpful for diagnosis in this context. *Dysrhythmia* - **Dysrhythmias** can occur during anaphylaxis due to myocardial ischemia or electrolyte imbalances, but they are not a direct or consistent diagnostic feature. - Their presence often reflects severe compromise or co-existing conditions rather than being a primary anaphylactic sign. *Increased peripheral vascular resistance* - Anaphylaxis is characterized by a significant **decrease in peripheral vascular resistance** due to mast cell and basophil degranulation releasing vasodilatory mediators like histamine. - Therefore, an increase in peripheral vascular resistance would contradict the pathophysiology of anaphylaxis.
Question 2: Which of the following statements is NOT true regarding rapid induction of anesthesia?
- A. Suxamethonium is often used.
- B. Mechanical ventilation is typically avoided before intubation.
- C. Pre-oxygenation is mandatory
- D. Sellick's maneuver is always required. (Correct Answer)
Explanation: ***Sellick's maneuver is always required.*** - **Sellick's maneuver**, or cricoid pressure, is applied to compress the esophagus against the vertebrae, aiming to prevent **gastric regurgitation** and aspiration during rapid sequence intubation (RSI). - While historically considered a standard component of RSI, its routine use has been increasingly questioned due to a lack of strong evidence supporting its efficacy and potential to impede glottic visualization and intubation. It is not "always" required; its application is often at the discretion of the anesthetist based on patient factors and risk assessment. *Pre-oxygenation is mandatory* - **Pre-oxygenation** is a critical step in rapid sequence induction, involving administering 100% oxygen for several minutes prior to induction. - This denitrogenates the functional residual capacity (FRC), creating an oxygen reservoir that extends the safe apnea time, thus preventing **hypoxemia** during the intubation attempt. *Suxamethonium is often used.* - **Suxamethonium** (succinylcholine) is a depolarizing neuromuscular blocker primarily used in rapid sequence intubation due to its **ultra-rapid onset** (30-60 seconds) and short duration of action (5-10 minutes). - Its rapid action facilitates quick muscle relaxation for tracheal intubation, which is crucial for minimizing the risk of aspiration in patients with a full stomach or other risk factors. *Mechanical ventilation is typically avoided before intubation.* - During rapid sequence induction, **positive pressure ventilation** with a bag-valve mask is typically avoided before intubation to prevent gastric insufflation. - Gastric insufflation can increase the risk of **regurgitation** and pulmonary aspiration of gastric contents, which is a major concern in patients undergoing RSI.
Question 3: A comatose 28-year-old woman sustained a depressed skull fracture in an automobile collision. She has been unconscious for 6 weeks. Her vital signs are stable and she breathes room air. Following her initial decompressive craniotomy, she has returned to the operating room twice due to intracranial bleeding. Select the best method of physiologic monitoring necessary for the patient.
- A. Central venous catheterization
- B. Pulmonary artery catheterization
- C. Intracranial pressure monitoring (Correct Answer)
- D. Blood-gas monitoring
Explanation: ***Intracranial pressure monitoring*** - This patient has a history of **depressed skull fracture**, **decompressive craniotomy**, and **intracranial bleeding**, all of which significantly increase the risk of elevated **intracranial pressure (ICP)**. - Monitoring ICP is crucial for detecting and managing cerebral edema or hematoma expansion, preventing secondary brain injury in a comatose patient. *Central venous catheterization* - While useful for monitoring **central venous pressure (CVP)** and administering fluids/medications, it does not directly assess cerebral perfusion or intracranial dynamics. - CVP alone is a poor indicator of ICP, and changes in CVP do not reliably reflect changes in cerebral perfusion pressure (CPP). *Pulmonary artery catheterization* - This provides detailed hemodynamic information including **cardiac output**, **pulmonary artery pressure**, and **pulmonary capillary wedge pressure**, primarily for assessing cardiac function and fluid status. - It is overly invasive and unnecessary for a patient with stable vital signs whose primary concern is neurological status. *Blood-gas monitoring* - **Arterial blood gas (ABG)** analysis assesses **oxygenation**, **ventilation**, and **acid-base balance**, which are important for overall patient management. - While important, ABG monitoring does not directly provide information about ICP or cerebral perfusion, which is the most critical parameter in this specific neurological injury scenario.
Question 4: A patient is on follow-up for recurrent abdominal pain. USG reveals an aortic aneurysm of 40 mm. What should be the next immediate step?
- A. Establish surveillance protocol with repeat imaging in 6-12 months. (Correct Answer)
- B. Initiate medical management with beta-blockers.
- C. Perform surgical intervention immediately.
- D. Start antihypertensive therapy immediately.
Explanation: ***Establish surveillance protocol with repeat imaging in 6-12 months.*** - A **40mm abdominal aortic aneurysm (AAA)** is below the threshold for elective surgical repair (typically **55mm for men, 50mm for women**). - The **immediate next step** is to establish a **surveillance protocol** with repeat imaging at appropriate intervals (every **6-12 months** for 40-44mm AAAs). - Surveillance allows monitoring of aneurysm growth rate and timely intervention if it expands to surgical threshold or becomes symptomatic. - **Risk factor modification** (smoking cessation, BP control, statin therapy) should accompany surveillance but is secondary to establishing the monitoring plan. *Initiate medical management with beta-blockers.* - **Beta-blockers are NOT recommended** for AAA management and may actually be harmful by reducing aortic wall stress detection. - Current guidelines do not support routine pharmacological therapy specifically to prevent AAA expansion, though **statins** may have some benefit. *Perform surgical intervention immediately.* - A **40mm AAA is well below surgical threshold** and does not require immediate intervention. - Surgery is considered when AAA reaches **≥55mm (men) or ≥50mm (women)**, growth rate **>10mm/year**, or when **symptomatic/ruptured**. *Start antihypertensive therapy immediately.* - While **blood pressure control is important** in AAA management, it is not the immediate next step without first establishing a surveillance protocol. - Antihypertensive therapy should be part of overall cardiovascular risk management but assumes the patient is hypertensive (not specified in the question).
Question 5: All of the following are indicators of adequacy of pre-operative resuscitation except
- A. Hematocrit level
- B. Consciousness level
- C. C-reactive protein level (Correct Answer)
- D. Urine output
Explanation: ***C-reactive protein level*** - **C-reactive protein (CRP)** is an inflammatory marker and is not a direct indicator of the adequacy of pre-operative fluid and hemodynamic resuscitation. An elevated CRP suggests ongoing inflammation or infection, not necessarily a deficit in perfusion or hydration. - While inflammation can coincide with critical illness requiring resuscitation, CRP itself does not provide real-time information about **organ perfusion**, **oxygen delivery**, or **fluid status**. *Hematocrit level* - **Hematocrit** levels are crucial for assessing factors like **blood loss** and **hemoconcentration**, which directly impact the need for and adequacy of resuscitation. An increasing hematocrit can indicate hemoconcentration, while a decreasing hematocrit may suggest blood loss. - It helps guide decisions regarding **blood product transfusions** and overall fluid management. *Consciousness level* - The **level of consciousness** is a vital clinical indicator of **cerebral perfusion** and overall brain oxygenation. Deterioration can signal inadequate resuscitation and poor cerebral blood flow. - Improvements in consciousness level after interventions suggest improved **systemic perfusion** and oxygen delivery to the brain. *Urine output* - **Urine output** is a sensitive and widely used indicator of **renal perfusion** and overall systemic hydration status. Adequate urine output (e.g., >0.5 mL/kg/hr) suggests sufficient renal blood flow. - Low or absent urine output can indicate **hypovolemia**, **poor cardiac output**, or **renal hypoperfusion**, highlighting the need for further resuscitation.
Question 6: A 58-year-old male with a history of hypertension and smoking presents with sudden severe back pain and hypotension. A CT scan reveals a 7 cm ruptured abdominal aortic aneurysm (AAA). What are the key factors in deciding whether to proceed with endovascular aneurysm repair (EVAR) or open surgical repair?
- A. Patient's hemodynamic stability, anatomy of the aneurysm, and access to EVAR equipment (Correct Answer)
- B. Patient's hemodynamic stability and anatomy of the aneurysm
- C. Access to EVAR equipment and patient's age
- D. Surgeon's experience with EVAR procedures
Explanation: ***Patient's hemodynamic stability, anatomy of the aneurysm, and access to EVAR equipment*** - **Hemodynamic stability** is crucial; unstable patients may benefit from more rapid intervention, potentially open repair, or require stabilization before EVAR. - The **anatomy of the aneurysm** (e.g., neck length, angulation, iliac artery access) dictates suitability for EVAR, as specific morphological criteria must be met for stent-graft placement. - **Access to EVAR equipment and trained personnel** is also a practical consideration for emergency intervention. *Patient's hemodynamic stability and anatomy of the aneurysm* - While **hemodynamic stability** and **aneurysm anatomy** are critical factors, access to specialized EVAR equipment and facilities is also a practical determinant of whether EVAR can even be attempted, especially in an emergent setting. - This option overlooks the logistical requirements necessary for performing an **EVAR procedure**. *Access to EVAR equipment and patient's age* - **Access to EVAR equipment** is important, but **patient's age** is generally less critical than factors like physiological status, comorbidities, and aneurysm morphology when deciding between EVAR and open repair for ruptured AAAs. - Younger patients may tolerate open surgery better, but age alone does not preclude EVAR if anatomy is suitable. *Surgeon's experience with EVAR procedures* - While **surgeon experience** is important for procedural success and outcomes, it is considered secondary to the immediate patient-centered and anatomical factors. - In emergency settings, the decision primarily hinges on the **patient's hemodynamic status**, **aneurysm anatomical suitability**, and **immediate availability of EVAR resources**, rather than being driven by surgeon preference based on experience alone. - Institutional protocols typically guide whether EVAR or open repair should be attempted based on the factors in the correct answer.
Question 7: Steps in review of patient's history during secondary survey of trauma care can be summarised as
- A. TRIAGE
- B. ABCDE
- C. AMPLE (Correct Answer)
- D. None of the options
Explanation: ***AMPLE*** - The **AMPLE history** is a mnemonic used during the **secondary survey** in trauma care to gather crucial patient information - It stands for **Allergies, Medications, Past medical history/Pregnancy, Last meal, and Events** surrounding the injury. *TRIAGE* - **Triage** is the process of prioritizing patients based on the severity of their condition and the likelihood of benefit from immediate treatment. - It is an initial assessment done to determine the urgency of care, not a detailed historical review for a single patient. *ABCDE* - The **ABCDE approach** (**Airway, Breathing, Circulation, Disability, Exposure**) is part of the **primary survey** in trauma care. - It focuses on identifying and managing immediate life-threatening conditions. *None of the options* - This option is incorrect because **AMPLE** specifically describes the historical review process during the secondary survey.
Question 8: On the 4th postoperative day of laparotomy a patient presents with bleeding & oozing from the wound. Management is :
- A. Send for USG abdomen
- B. Start treatments for peritonitis
- C. IV fluids
- D. Dressing of wound & observe for dehiscence (Correct Answer)
Explanation: ***Dressing of wound & observe for dehiscence*** - **Bleeding and oozing from the wound** on the 4th postoperative day could indicate early wound dehiscence or a seroma/hematoma. - **Dressing the wound** provides local control, while diligent observation is crucial to detect progressive dehiscence requiring surgical intervention. *Send for USG abdomen* - An **ultrasound (USG) abdomen** would be useful for assessing intra-abdominal collections such as abscesses or hematomas, or to detect an incisional hernia, but not the immediate bleeding and oozing from the wound site itself. - While it might provide additional information, it's not the **first-line management** for local wound issues like bleeding and oozing. *Start treatments for peritonitis* - **Peritonitis** presents with signs of severe abdominal infection, such as fever, generalized abdominal pain, rigidity, and rebound tenderness, which are not described in the patient's presentation of only local wound bleeding and oozing. - Initiating peritonitis treatment without signs of widespread infection would be **inappropriate** and delay appropriate wound care. *IV fluids* - **Intravenous (IV) fluids** are used to manage dehydration, electrolyte imbalances, or hypovolemia, but the patient's primary complaint is localized wound bleeding and oozing, not systemic signs of instability requiring fluid resuscitation at this stage. - While **fluid balance** is always important postoperatively, it is not the specific management for the described wound issue.
Question 9: Patient shows ST depression, troponin rise 6h post-surgery. Next best step is:
- A. 12-lead ECG
- B. Echocardiogram
- C. Cardiology consult (Correct Answer)
- D. Start heparin
Explanation: ***Cardiology consult*** - A cardiology consult is the most appropriate next step given the presence of **ST depression** and a **troponin rise** post-surgery, indicating a likely myocardial infarction (MI). - This allows for prompt comprehensive evaluation, risk stratification, and initiation of specialized cardiac management by an expert. *12-lead ECG* - While a 12-lead ECG is an important diagnostic tool, the patient's existing **ST depression** suggests it has already been performed or noted. - A repeat ECG might be useful for tracking changes, but it doesn't replace the need for expert cardiac evaluation and management. *Echocardiogram* - An echocardiogram can assess **cardiac function**, wall motion abnormalities, and valvular issues, which are relevant in MI. - However, it's a diagnostic test that should be ordered and interpreted in the context of a broader cardiac workup, which a cardiologist can best coordinate. *Start heparin* - **Heparin** is an anticoagulant that may be part of the management for an MI, especially in certain types or for prevention of clot extension. - However, initiating anticoagulation should be done after a thorough assessment of the patient's cardiac status, bleeding risk post-surgery, and in consultation with cardiology, rather than as the immediate next best step.
Question 10: Child with aspiration risk needs emergency surgery. Best induction sequence is:
- A. Preoxygenation-ketamine-succinylcholine
- B. Sevoflurane-propofol-succinylcholine
- C. Midazolam-propofol-rocuronium
- D. Preoxygenation-propofol-succinylcholine (Correct Answer)
Explanation: ***Preoxygenation-propofol-succinylcholine*** - This sequence describes a **rapid sequence intubation (RSI)**, which is the preferred method for patients at high risk of aspiration, including children needing emergency surgery with an unknown fasting status. - **Preoxygenation** provides an oxygen reserve during the apneic period, **propofol** offers rapid induction with good hemodynamic stability, and **succinylcholine** provides fast-onset, short-acting neuromuscular blockade, crucial for preventing aspiration. *Preoxygenation-ketamine-succinylcholine* - While preoxygenation and succinylcholine are appropriate for RSI, **ketamine** may not be the optimal choice for a child with aspiration risk due to its potential to increase secretions and maintain laryngeal reflexes, which could complicate intubation. - Ketamine can also cause **emergence delirium** in some children, making it less favorable for a smooth anesthetic course compared to propofol. *Sevoflurane-propofol-succinylcholine* - **Sevoflurane** is an inhaled anesthetic often used for mask induction in children due to its non-pungent odor and rapid onset. However, it is generally **not suitable for RSI** in patients with aspiration risk as it has a slower induction time compared to intravenous agents and can cause coughing or laryngospasm. - Using both sevoflurane and propofol for induction in an RSI scenario is redundant and prolongs the induction phase, increasing aspiration risk. *Midazolam-propofol-rocuronium* - **Midazolam** is a benzodiazepine used for anxiolysis and sedation but has a **slower onset** and longer duration of action compared to propofol for rapid induction. - **Rocuronium** is a non-depolarizing neuromuscular blocker with a slower onset of action than succinylcholine, making it less ideal for RSI where immediate paralysis for intubation is critical to prevent aspiration.
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