Anesthesia for Cardioversion — MCQs
A person was brought to emergency department and was diagnosed with Supra ventricular tachycardia and suddenly he became unstable. What is the next line of management?
In which clinical scenario would you find a patient requiring the vital signs assessment technique shown in the image?
During rapid sequence intubation in a child after taking brief history and clinical examination next step is:
A patient presents with palpitations, consciousness, fast pulse, and BP of 80/50 mmHg. After failed vagal maneuver and maximum dose of adenosine, what is the next step in management?
A patient scheduled for elective inguinal hernia surgery has a history of myocardial infarction (MI) and underwent coronary artery bypass grafting (CABG). What should be included in the preoperative assessment?
Which of the following drugs produces dissociative anesthesia?
Which IV anesthetic does not cause cardiac depression?
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
Which of the following is used for day care surgery?
A hospital is designing a protocol for anesthesia services in the interventional radiology suite. Cases include hepatic chemoembolization, biliary interventions, and vascular procedures. Which combination of factors makes general anesthesia more appropriate than conscious sedation?
Anesthesia for Cardioversion Indian Medical PG Practice Questions and MCQs
Question 1: A person was brought to emergency department and was diagnosed with Supra ventricular tachycardia and suddenly he became unstable. What is the next line of management?
- A. Intravenous ibutilide
- B. Intravenous Diltiazem
- C. DC Cardioversion (Correct Answer)
- D. Intravenous Flecainide
Explanation: ***DC Cardioversion*** - For **unstable supraventricular tachycardia (SVT)**, immediate **direct current (DC) cardioversion** is the definitive treatment to restore sinus rhythm. - Instability in SVT includes symptoms like hypotension, altered mental status, signs of shock, ischemic chest discomfort, or acute heart failure. *Intravenous ibutilide* - **Ibutilide** is an antiarrhythmic drug used for pharmacological cardioversion of recent-onset atrial fibrillation or flutter, but not typically for unstable SVT. - While it can convert certain supraventricular arrhythmias, it is generally reserved for **stable patients** and takes longer to act than immediate electrical cardioversion. *Intravenous Diltiazem* - **Diltiazem** is a calcium channel blocker used to control ventricular rate in **stable SVT**, atrial fibrillation, or flutter [1]. - It is contraindicated in unstable patients as it can further depress cardiac contractility and worsen hypotension [2]. *Intravenous Flecainide* - **Flecainide** is a class Ic antiarrhythmic drug used to maintain sinus rhythm in patients with supraventricular arrhythmias, including SVT. - It also takes time to act and is used in **stable patients** without structural heart disease, not in emergency unstable situations where immediate rhythm conversion is required.
Question 2: In which clinical scenario would you find a patient requiring the vital signs assessment technique shown in the image?
- A. Pulse absent, breath present
- B. Pulse and breath both not present
- C. Pulse and breath present
- D. Pulse present, breath absent (Correct Answer)
Explanation: ***Pulse present, breath absent*** - The image depicts a **mouth-to-mouth resuscitation** technique, specifically rescue breaths being administered by one person to another. - This technique is applied when a person has a **detectable pulse** but is **not breathing** or is only gasping, indicating respiratory arrest while the heart is still circulating blood. *Pulse absent, breath present* - This scenario would represent **cardiac arrest** where the heart has stopped, but the person is still attempting to breathe. This is a rare, transient state. - In such a case, the primary intervention would be **chest compressions**, not just rescue breathing, as circulation is the immediate priority. *Pulse and breath both not present* - This describes **cardiopulmonary arrest (CPA)**, where both the heart and lungs have ceased functioning. - The appropriate intervention is **cardiopulmonary resuscitation (CPR)**, which involves a combination of **chest compressions and rescue breaths (30:2 ratio)**, not just rescue breaths alone. *Pulse and breath present* - If both vital signs are present, the person is **conscious and breathing adequately**, or unconscious but breathing normally. - No advanced respiratory intervention like mouth-to-mouth resuscitation is needed; the priority would be maintaining their airway and monitoring their condition.
Question 3: During rapid sequence intubation in a child after taking brief history and clinical examination next step is:
- A. Administer oxygen (Correct Answer)
- B. Analgesic injection with Fentanyl
- C. Preanaesthetic medication with atropine and lignocaine
- D. IV anesthetic Diazepam/Ketamine
Explanation: ***Administer oxygen*** - Pre-oxygenation with 100% oxygen is critical before **rapid sequence intubation (RSI)** to maximize **oxygen reserves** and extend the safe apnea time. - This step helps prevent **hypoxemia** during the intubation procedure, especially in children who have lower functional residual capacity. *Analgesic injection with Fentanyl* - While fentanyl is often used in RSI for its **analgesic** and **sedative properties**, it typically follows pre-oxygenation and is administered as part of the **induction phase**, often concurrently with a paralytic. - Administering fentanyl alone without prior oxygenation or other induction agents would not be the immediate next step in a structured RSI protocol. *Preanaesthetic medication with atropine and lignocaine* - **Atropine** may be used in children to prevent **bradycardia** during intubation, particularly in infants, but it's not the immediate next step after initial assessment; pre-oxygenation is more critical. - **Lidocaine** can be used to blunt the sympathetic response to intubation or to suppress cough, but it's not universally required and comes after pre-oxygenation and other induction medications. *IV anesthetic Diazepam/Ketamine* - **Diazepam** and **ketamine** are **induction agents** that cause sedation and loss of consciousness, but they are administered after pre-oxygenation and often just before the paralytic agent. - Administering an induction agent without adequate pre-oxygenation would increase the risk of **hypoxemia** during the subsequent apnea.
Question 4: A patient presents with palpitations, consciousness, fast pulse, and BP of 80/50 mmHg. After failed vagal maneuver and maximum dose of adenosine, what is the next step in management?
- A. Amiodarone
- B. Repeat adenosine
- C. Defibrillation
- D. Cardioversion (Correct Answer)
Explanation: ***Cardioversion*** - The patient presents with **symptomatic tachycardia** (palpitations, decreased consciousness, hypotension) refractory to **vagal maneuvers** and **adenosine**, indicating hemodynamic instability. - In such cases, **synchronized cardioversion** is the definitive treatment to restore sinus rhythm promptly and prevent further deterioration [1]. *Amiodarone* - **Amiodarone** is an antiarrhythmic drug used for stable wide complex tachycardia or as a second-line agent for unstable tachycardia after cardioversion. - It is not the immediate next step for an unstable patient who has failed adenosine, as its onset of action is slower than cardioversion [2]. *Repeat adenosine* - The question states that the patient has already received the **maximum dose of adenosine** and it has failed. - Administering more adenosine would be ineffective and delay definitive treatment for a hemodynamically unstable patient. *Defibrillation* - **Defibrillation** is used for **pulseless ventricular tachycardia/fibrillation** where there is no organized electrical activity [1]. - This patient has a pulse and an organized (though fast) rhythm, making synchronized cardioversion the appropriate electrical therapy.
Question 5: A patient scheduled for elective inguinal hernia surgery has a history of myocardial infarction (MI) and underwent coronary artery bypass grafting (CABG). What should be included in the preoperative assessment?
- A. History + c/e + routine labs + V/Q scan
- B. History + c/e + routine labs
- C. History + c/e + routine labs + stress test (Correct Answer)
- D. History + c/e + routine labs + angiography to assess graft patency
Explanation: ***History + c/e + routine labs + stress test*** - A **stress test** is crucial in patients with a history of MI and CABG to assess **myocardial ischemia** and functional capacity, guiding perioperative management. - This evaluation helps determine the patient's **cardiac risk** for non-cardiac surgery and the need for further cardiac optimization. *History + c/e + routine labs + angiography to assess graft patency* - **Coronary angiography** is an invasive procedure and is generally not indicated as a routine preoperative assessment unless there are new, significant cardiac symptoms or signs of **graft dysfunction**. - Assessing graft patency through angiography carries risks and would only be justified if there were strong clinical indications suggesting acute or severe **cardiac ischemia**. *History + c/e + routine labs* - While critical for any preoperative assessment, **routine history, physical examination, and basic laboratory tests** are insufficient for a patient with a significant cardiac history like MI and CABG. - This approach would **underestimate the cardiac risk** and might miss undetected ischemia, leading to adverse perioperative cardiac events. *History + c/e + routine labs + V/Q scan* - A **ventilation-perfusion (V/Q) scan** is primarily used to diagnose **pulmonary embolism** or assess regional lung function. - It does not provide information about myocardial ischemia or cardiac functional capacity, making it **irrelevant** for assessing cardiac risk in this clinical scenario.
Question 6: Which of the following drugs produces dissociative anesthesia?
- A. Ketamine (Correct Answer)
- B. Propofol
- C. Thiopentone
- D. Enflurane
Explanation: ***Ketamine*** - **Ketamine** is a **dissociative anesthetic** that causes a trance-like state characterized by profound analgesia, amnesia, and catatonia, with the patient appearing to be awake but unresponsive. - It works by antagonizing the **NMDA receptor**, leading to a functional dissociation between the limbic and cortical systems. *Propofol* - **Propofol** is a short-acting intravenous anesthetic that produces a rapid loss of consciousness and has sedative-hypnotic properties. - It functions primarily by enhancing the activity of the **GABA-A receptor**, leading to central nervous system depression, not dissociation. *Thiopentone* - **Thiopentone** (Thiopental) is a barbiturate that induces rapid anesthesia and is used for induction and short procedures. - Its mechanism involves potentiation of the **GABA-A receptor**, causing global central nervous system depression without dissociative effects. *Enflurane* - **Enflurane** is an inhaled halogenated ether anesthetic that provides excellent muscle relaxation and analgesia. - It primarily acts by enhancing **GABAergic inhibition** and inhibiting excitatory neurotransmission, producing general anesthesia rather than a dissociative state.
Question 7: Which IV anesthetic does not cause cardiac depression?
- A. Propofol
- B. Etomidate (Correct Answer)
- C. Thiopentone
- D. Methohexital
Explanation: **Etomidate** - **Etomidate** is known for its **minimal cardiovascular effects**, making it a preferred choice in patients with **pre-existing cardiac disease** or hemodynamic instability. - Unlike other IV anesthetics, it causes very little change in **heart rate**, **blood pressure**, or **cardiac output**. *Propofol* - **Propofol** frequently causes **dose-dependent myocardial depression** and **vasodilation**, leading to significant decreases in blood pressure. - Its cardiovascular effects can be problematic in patients with compromised cardiac function. *Thiopentone* - **Thiopentone**, a barbiturate, typically causes **dose-dependent cardiovascular depression**, including reduced **myocardial contractility** and **vasodilation**. - This can result in a decrease in **blood pressure** and **cardiac output**. *Methohexital* - **Methohexital**, another barbiturate, also causes **cardiovascular depression** similar to thiopentone. - It can lead to decreased **blood pressure** due to both **myocardial depression** and **peripheral vasodilation**.
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: Which of the following is used for day care surgery?
- A. Thiopentone
- B. Ketamine
- C. Etomidate
- D. Propofol (Correct Answer)
Explanation: ***Propofol*** - **Propofol** is favored for **day care surgery** due to its **rapid onset** and **rapid recovery** profile, allowing patients to be discharged quickly. - It produces a **clear-headed recovery** with less postoperative nausea and vomiting compared to other agents. *Thiopentone* - **Thiopentone** has a **longer recovery time** and greater potential for **postoperative sedation** and **nausea**, making it less suitable for day care surgery. - Its use often leads to a **delayed discharge** from the recovery unit. *Ketamine* - **Ketamine** can cause **psychomimetic effects** (e.g., hallucinations, vivid dreams) and **delirium** during emergence, which are undesirable for day care procedures. - It also leads to **increased heart rate** and **blood pressure**, which may prolong recovery and observation time. *Etomidate* - **Etomidate** is known to cause **adrenocortical suppression** and can be associated with **pain on injection** and **myoclonus**, which are not ideal for routine day care use. - While it has a relatively **stable cardiovascular profile**, these side effects limit its widespread use in short procedures where rapid, smooth recovery is paramount.
Question 10: A hospital is designing a protocol for anesthesia services in the interventional radiology suite. Cases include hepatic chemoembolization, biliary interventions, and vascular procedures. Which combination of factors makes general anesthesia more appropriate than conscious sedation?
- A. Expected moderate pain, advanced age, and multiple comorbidities
- B. Patient anxiety, lack of IV access, and obesity
- C. Duration >90 minutes, prone positioning, and need for breath-holding (Correct Answer)
- D. Contrast allergy, renal dysfunction, and coagulopathy
Explanation: ***Duration >90 minutes, prone positioning, and need for breath-holding*** - Prolonged procedures and **prone positioning** carry a high risk of **airway obstruction** and restricted access to the patient, making a secured airway via **general anesthesia** necessary. - Precise imaging during vascular or biliary interventions often requires **controlled apnea** (breath-holding), which is only reliably achieved through **neuromuscular blockade** and mechanical ventilation. *Expected moderate pain, advanced age, and multiple comorbidities* - **Moderate pain** can often be managed with **monitored anesthesia care (MAC)** or regional techniques rather than requiring full general anesthesia. - **Advanced age** and **comorbidities** represent increased perioperative risk, but they are not specific indications for general anesthesia; in fact, avoiding GA may be preferred in certain fragile patients. *Patient anxiety, lack of IV access, and obesity* - While **obesity** increases the risk of airway compromise, it does not mandate general anesthesia unless the specific procedural requirements or patient anatomy make **conscious sedation** unsafe. - **Anxiety** is typically manageable with appropriate **anxiolytic sedation**, and **IV access** is a fundamental requirement for both sedation and general anesthesia. *Contrast allergy, renal dysfunction, and coagulopathy* - These factors are related to **radiological risk** and procedural safety rather than the choice of anesthetic technique. - **Coagulopathy** is a contraindication for certain **regional anesthesia** techniques but does not specifically dictate a shift from sedation to **general anesthesia**.
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