Trauma Anesthesia Principles — MCQs

10 questions

In an accident case, after the arrival of medical team, all should be done in early management except;

According to ATLS classification of hemorrhagic shock, a patient with decreased blood pressure, decreased urine output and decreased circulatory volume of 30-40% is managed by?

The inducing agent of choice in shock -

What is the first-line fluid to be administered in a patient presenting with acute hemorrhagic shock?

In a patient with multiple fractures, what is the most important initial management step?

Which is not a component of Lethal Triad in trauma?

A 60-year-old man underwent cardiac bypass surgery 2 days ago. He has now started forgetting things and is unable to recall names and phone numbers of his relatives. What is the probable diagnosis?

A patient is admitted following a road traffic accident. He has sustained significant blunt injury to his head, chest and abdomen and has a Glasgow Coma Scale score of 8/15. His saturations are poor at 89% on 15 L of oxygen a rebreathing mask. You note bruising around both eyes and blood-stained fluid issuing from his left ear, which forms concentric circles when dripped on a white sheet. You wish to support his airway to improve oxygenation. The first choice of airway adjunct would be

Q9Easy

What is the dose of adrenaline given intravenously in a cardiac arrest victim?

Q10Medium

What is the alternative drug for epinephrine in Advanced Cardiac Life Support (ACLS)?

Trauma Anesthesia Principles Indian Medical PG Practice Questions and MCQs

Question 1: In an accident case, after the arrival of medical team, all should be done in early management except;

A. Glasgow coma scale
B. Check BP (Correct Answer)
C. Stabilization of cervical vertebrae
D. Check Respiration

Explanation: ***Check BP*** - In the **immediate/early management** of trauma (primary survey), while circulation assessment is crucial, the **initial assessment of circulation** focuses on: - **Pulse rate and quality** (radial, carotid) - **Capillary refill time** - **Skin color and temperature** - **Active hemorrhage control** - **Formal blood pressure measurement** with a cuff, while important, is typically recorded during or after these rapid initial assessments, as it takes more time to obtain an accurate reading. - In the context of this question, among the four options listed, BP measurement is relatively less immediate compared to the other life-saving priorities (airway protection, breathing assessment, C-spine stabilization, and GCS). - **Note:** This is a nuanced distinction - BP is assessed during primary survey, but the other three options have more immediate life-threatening implications if not addressed. *Glasgow coma scale* - **GCS assessment** is part of the **"D" (Disability)** step in the ATLS primary survey. - It is performed early to assess neurological status and level of consciousness. - GCS <8 indicates need for **definitive airway protection** (intubation). - This is a critical early assessment that guides immediate management decisions. *Stabilization of cervical vertebrae* - **C-spine immobilization** is part of the **"A" (Airway)** step - "Airway with cervical spine protection." - It is performed **simultaneously** with airway assessment using a **rigid cervical collar**. - This is the **first priority** in trauma management to prevent secondary spinal cord injury. - All trauma patients should be assumed to have C-spine injury until proven otherwise. *Check Respiration* - **Respiratory assessment** is part of the **"B" (Breathing)** step in the ATLS primary survey. - This involves checking: - **Respiratory rate and pattern** - **Chest wall movement** - **Air entry bilaterally** - **Signs of tension pneumothorax or flail chest** - This is an immediate life-saving priority and must be assessed early.

Question 2: According to ATLS classification of hemorrhagic shock, a patient with decreased blood pressure, decreased urine output and decreased circulatory volume of 30-40% is managed by?

A. blood transfusion alone
B. crystalloids infusion
C. crystalloids+blood transfusion (Correct Answer)
D. plasma therapy

Explanation: ***Correct: crystalloids+blood transfusion*** - A 30-40% blood volume loss, indicated by **decreased blood pressure** and **decreased urine output**, corresponds to ATLS **Class III hemorrhagic shock**. - Management for Class III shock requires both **intravenous crystalloids** to restore circulatory volume and **blood transfusion** to replace lost red blood cells and improve oxygen-carrying capacity. - The initial approach follows the **3:1 crystalloid replacement rule**, followed by or concurrent with **packed red blood cells** to address ongoing hemorrhage and maintain oxygen delivery. *Incorrect: blood transfusion alone* - While blood transfusion is crucial for Class III hemorrhagic shock, administering it **alone** without initial crystalloid resuscitation may not adequately address the immediate need for **intravascular volume expansion**. - **Crystalloids** are typically administered first or concurrently to rapidly restore circulating volume and support perfusion before packed red blood cells can be prepared and transfused. *Incorrect: crystalloids infusion* - **Crystalloids alone** would be insufficient for Class III hemorrhage as the patient has experienced significant **red blood cell loss** (30-40% circulating volume) which requires direct replacement to improve oxygen delivery. - While initial crystalloid resuscitation is vital, continuing with crystalloids alone will lead to **dilutional coagulopathy** and failure to correct oxygen-carrying capacity. *Incorrect: plasma therapy* - **Plasma therapy** (e.g., fresh frozen plasma) is primarily used for the correction of **coagulopathy** in actively bleeding patients or those with anticipated massive transfusion. - Although it may be part of a massive transfusion protocol for severe hemorrhage, it is not the primary or sole initial treatment strategy for volume resuscitation and red blood cell replacement in Class III shock.

Question 3: The inducing agent of choice in shock -

A. Isoflurane
B. Ketamine (Correct Answer)
C. Desflurane
D. Thiopentone

Explanation: **Ketamine** * **Ketamine** is preferred in shock due to its sympathomimetic properties, which maintain or increase blood pressure and heart rate, thus preserving **cardiovascular stability**. * It also has minimal respiratory depression and bronchodilatory effects, making it safer for patients with compromised respiratory function. * The cardiovascular stimulating effects of ketamine helps maintain haemodynamic stability in shocked patients. It maintains cerebral autoregulation and perfusion of vital organs. *Isoflurane* * **Isoflurane** is an inhaled anesthetic that typically causes **dose-dependent myocardial depression** and **vasodilation**, which can worsen hypotension in a shock state. * It can significantly decrease systemic vascular resistance, thereby exacerbating the already compromised cardiovascular status of a shock patient. *Desflurane* * **Desflurane** is an inhaled anesthetic known for its rapid onset and offset but can cause a **significant increase in heart rate and blood pressure** upon rapid concentration changes, which may be detrimental in an unstable patient. * Like isoflurane, it also causes dose-dependent peripheral vasodilation and myocardial depression, which can worsen hypotension in patients in shock. *Thiopentone* * **Thiopentone** is a barbiturate that causes significant **myocardial depression** and **peripheral vasodilation**, leading to a substantial drop in blood pressure. * Its use in shock would further compromise cardiovascular stability and is generally contraindicated due to its potent hemodynamic depressant effects.

Question 4: What is the first-line fluid to be administered in a patient presenting with acute hemorrhagic shock?

A. PRBC
B. Crystalloid (Correct Answer)
C. Colloid
D. Whole blood

Explanation: ***Crystalloid*** - Initial fluid resuscitation in **hemorrhagic shock** prioritizes **crystalloids** (e.g., normal saline or lactated Ringer's) to restore intravascular volume rapidly and maintain perfusion. - This approach is based on their immediate availability, cost-effectiveness, and ability to expand the extracellular fluid compartment. *PRBC* - While **packed red blood cells (PRBCs)** are crucial for replacing oxygen-carrying capacity in significant hemorrhage, they are typically administered *after* or *concurrently* with initial crystalloid resuscitation once the need for blood products is established. - Administering PRBCs as the *first-line* fluid might delay volume expansion and could be less effective for initial circulatory support. *Colloid* - **Colloid solutions** (e.g., albumin, dextran) remain controversial in initial hemorrhagic shock resuscitation due to concerns about their cost, potential side effects, and lack of clear superiority over crystalloids in improving patient outcomes. - They are also not as readily available as crystalloids in all emergency settings. *Whole blood* - **Whole blood** is the ideal resuscitation fluid as it contains all components of blood but is generally not readily available for initial emergency resuscitation in most civilian settings. - Its use is often limited to specific trauma centers or military combat scenarios due to logistical challenges.

Question 5: In a patient with multiple fractures, what is the most important initial management step?

A. Intravenous fluids
B. Open reduction of fractures
C. Blood transfusion
D. Airway maintenance (Correct Answer)

Explanation: ***Airway maintenance*** - In any trauma patient, ensuring a **patent airway** is the absolute priority to prevent hypoxia and brain damage. - This is part of the primary survey (**ABCDE**) in trauma management, where life-threatening issues are addressed first. *Intravenous fluids* - While essential for managing **hypovolemia** due to blood loss in polytrauma, fluid resuscitation comes after securing the airway and ensuring adequate breathing. - Administering fluids to a patient who cannot breathe effectively will not resolve the primary issue. *Blood transfusion* - **Blood transfusion** is necessary for significant hemorrhage and can be life-saving, but it is not the *initial* management step. - Airway, breathing, and circulation (which includes addressing significant hemorrhage) collectively precede the decision and initiation of blood transfusions. *Open reduction of fractures* - **Open reduction of fractures** is a definitive treatment for musculoskeletal injuries that is performed much later, after the patient has been stabilized. - It is an elective procedure in the context of initial trauma management and is not a life-saving measure in the acute phase.

Question 6: Which is not a component of Lethal Triad in trauma?

A. Hypothermia
B. Coagulopathy
C. Acidosis
D. Hypoxia (Correct Answer)

Explanation: ***Hypoxia*** - The **lethal triad** of trauma consists of **hypothermia, acidosis, and coagulopathy**, which are critical factors that worsen outcomes in severely injured patients. - While **hypoxia** is a serious complication in trauma and can contribute to other elements of the triad, it is not considered one of the three direct components of the **lethal triad** itself. *Hypothermia* - **Hypothermia** contributes to the lethal triad by impairing enzyme function and exacerbating coagulopathy, leading to increased bleeding. - It results in decreased platelet function and reduced activity of clotting factors. *Coagulopathy* - **Coagulopathy** is a central component, as uncontrolled bleeding due to impaired coagulation is a major cause of death in severe trauma. - It can be induced by massive blood loss, resuscitation with crystalloids, and consumption of clotting factors. *Acidosis* - **Acidosis**, often due to hypoperfusion and shock, impairs myocardial function and further inhibits the clotting cascade. - It is often worsened by inadequate tissue oxygenation and lactate accumulation.

Question 7: A 60-year-old man underwent cardiac bypass surgery 2 days ago. He has now started forgetting things and is unable to recall names and phone numbers of his relatives. What is the probable diagnosis?

A. Cognitive dysfunction (Correct Answer)
B. Alzheimer's disease
C. Post traumatic psychosis
D. Depression

Explanation: ***Cognitive dysfunction*** - **Postoperative cognitive dysfunction (POCD)** is a common complication after cardiac surgery, especially in older patients, marked by memory impairment and difficulty with concentration. - The onset of **forgetfulness** and inability to recall names and phone numbers within days of cardiac bypass surgery is highly suggestive of POCD. *Alzheimer's disease* - Alzheimer's is a **neurodegenerative disease** with a gradual onset, characterized by progressive cognitive decline over months to years [1], not sudden changes post-surgery. - While age is a risk factor, the acute presentation immediately following an operation makes Alzheimer's less likely as the primary cause [2]. *Post traumatic psychosis* - Post-traumatic psychosis typically occurs after a severe traumatic event and involves symptoms like **hallucinations, delusions, and disorganized thinking**, which are not described in this patient. - The patient's symptoms are focused on **memory and recall deficits**, not florid psychotic symptoms. *Depression* - Depression can cause cognitive symptoms like **poor concentration and memory problems**, often referred to as "pseudodementia." - However, the abrupt onset specifically linked to surgery, without other prominent depressive symptoms like low mood, anhedonia, or sleep disturbances, makes depression less likely as the sole immediate cause.

Question 8: A patient is admitted following a road traffic accident. He has sustained significant blunt injury to his head, chest and abdomen and has a Glasgow Coma Scale score of 8/15. His saturations are poor at 89% on 15 L of oxygen a rebreathing mask. You note bruising around both eyes and blood-stained fluid issuing from his left ear, which forms concentric circles when dripped on a white sheet. You wish to support his airway to improve oxygenation. The first choice of airway adjunct would be

A. Nasopharyngeal tube
B. Intubation
C. Laryngeal mask
D. Oropharyngeal airway (Correct Answer)

Explanation: ***Oropharyngeal airway*** - An **oropharyngeal airway (OPA)** is the most appropriate initial airway adjunct in a patient with a **depressed GCS (8/15)** and poor oxygenation, as it helps to relieve **upper airway obstruction** caused by the tongue falling back. - Given the potential for a **basal skull fracture** (bruising around eyes, blood-stained fluid from ear forming concentric circles), a **nasopharyngeal airway (NPA)** is contraindicated due to the risk of intracranial insertion. *Nasopharyngeal tube* - A **nasopharyngeal airway (NPA)** is contraindicated in this patient due to signs suggestive of a **basal skull fracture**, which include **raccoon eyes (periorbital bruising)** and **Battle's sign (bruising behind the ear)**, as well as the **halo sign (concentric circles of blood and CSF)** from the ear. - Inserting an NPA in such a scenario risks inadvertently entering the **cranial cavity**, leading to further neurological damage or infection. *Intubation* - While **intubation** may eventually be necessary given the patient's low GCS and poor oxygenation, it is not the *first choice* of airway adjunct. - The immediate priority is to establish a **patent airway** quickly and safely, which an OPA can achieve while preparations for definitive intubation are made. *Laryngeal mask* - A **laryngeal mask airway (LMA)** could be considered for airway management, but it is typically a more advanced adjunct than an OPA. - Its insertion requires a certain level of skill and might be more time-consuming than an OPA, which is crucial in an emergency setting.

Question 9: What is the dose of adrenaline given intravenously in a cardiac arrest victim?

A. 10 ml of 1 in 10,000 solution (Correct Answer)
B. 1 ml of 1 in 10,000 solution
C. 2 ml of 1 in 1000 solution
D. 10 ml of 1 in 1000 solution

Explanation: **Explanation:** In the management of cardiac arrest (as per ACLS guidelines), the standard intravenous dose of Adrenaline (Epinephrine) is **1 mg every 3–5 minutes**. To ensure rapid systemic distribution and minimize local irritation during emergency administration, a dilute concentration is used. **Why Option A is correct:** Adrenaline is available in two standard strengths: 1:1,000 and 1:10,000. * **1:10,000 concentration** means 1 gram in 10,000 ml, which equals **0.1 mg/ml**. * Therefore, **10 ml** of a 1:10,000 solution provides exactly **1 mg** of Adrenaline, which is the gold-standard dose for Advanced Cardiac Life Support (ACLS). **Analysis of Incorrect Options:** * **Option B (1 ml of 1:10,000):** This provides only 0.1 mg, which is a sub-therapeutic dose for cardiac arrest (though sometimes used in pediatric cases or for severe anaphylaxis). * **Option C (2 ml of 1:1,000):** This provides 2 mg. While the 1:1,000 concentration is used for IM injections in anaphylaxis, giving it IV in this volume is incorrect and potentially arrhythmogenic. * **Option D (10 ml of 1:1,000):** This provides 10 mg, which is a massive overdose and can cause severe hypertension and fatal arrhythmias post-resuscitation. **High-Yield Clinical Pearls for NEET-PG:** * **Route:** IV/IO is preferred. If given via **Endotracheal tube**, the dose is doubled (2–2.5 mg). * **Mechanism:** Its primary benefit in arrest is **$\alpha$-1 agonist** activity, which causes vasoconstriction, increasing coronary and cerebral perfusion pressure. * **Anaphylaxis Dose:** 0.5 mg (0.5 ml of 1:1,000) **Intramuscularly**. * **Shockable vs. Non-shockable:** In VF/pVT, give after the 2nd shock. In PEA/Asystole, give as soon as possible.

Question 10: What is the alternative drug for epinephrine in Advanced Cardiac Life Support (ACLS)?

A. Amiodarone infusion
B. Atropine
C. High dose vasopressin (Correct Answer)
D. Adenosine

Explanation: **Explanation:** In the management of cardiac arrest (VF, pulseless VT, Asystole, or PEA), **Epinephrine** is the primary vasopressor used for its $\alpha$-adrenergic effects, which increase coronary and cerebral perfusion pressure. According to ACLS guidelines, **Vasopressin (40 units IV/IO)** can be used as an alternative to the first or second dose of Epinephrine. **Why Vasopressin?** Vasopressin is a potent non-adrenergic peripheral vasoconstrictor that acts on $V_1$ receptors. Unlike Epinephrine, it remains effective in the presence of metabolic acidosis (common during prolonged arrest) and does not increase myocardial oxygen consumption, as it lacks $\beta$-adrenergic effects. **Analysis of Incorrect Options:** * **A. Amiodarone:** This is an anti-arrhythmic drug, not a vasopressor. It is indicated for shock-refractory VF or pulseless VT, but it does not replace Epinephrine. * **B. Atropine:** Previously used for asystole/PEA, it has been removed from the routine ACLS cardiac arrest algorithm because it showed no therapeutic benefit in these scenarios. * **D. Adenosine:** This is the drug of choice for stable Supraventricular Tachycardia (SVT). It causes a transient AV nodal block and has no role in the management of cardiac arrest. **High-Yield Pearls for NEET-PG:** * **Dose:** Vasopressin is given as a single one-time dose of **40 units** (High dose). * **Half-life:** Vasopressin has a longer half-life (10–20 mins) compared to Epinephrine (3–5 mins). * **Current Status:** While the 2015/2020 AHA updates simplified the algorithm by focusing primarily on Epinephrine to reduce complexity, Vasopressin remains the classic "textbook" alternative in exam questions. * **Endotracheal Route:** If IV/IO access is unavailable, drugs like **L**idocaine, **E**pinephrine, **A**tropine, and **N**aloxone (**LEAN**) can be given via the ET tube at 2–2.5 times the IV dose.

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