Acute Pain Management — MCQs

10 questions

All of the following can be routes of opioid administration except:

Which agent is used to reverse opioid overdose?

A 50-year-old patient with renal insufficiency was recently operated on for pyelolithotomy. Which drug is the most appropriate choice for post-operative analgesia?

Intravenous regional anesthesia is suitable for :

A patient selected for surgery was induced with Thiopentone iv through one of the antecubital veins and complained of severe pain of the whole hand. The next line of management is:

Which of the following anesthetic agents have good analgesic property? a) Ketamine b) Nitrous oxide c) Thiopentone d) Propofol e) Midazolam

Which approach of brachial plexus block targets cords of the brachial plexus:-

A two month old infant has undergone a major surgical procedure. Regarding postoperative pain relief which one of the following is recommended:

Celiac plexus block all the following is true Except

Q10

Which of the following statements about acute retropharyngeal abscess is true?

Acute Pain Management Indian Medical PG Practice Questions and MCQs

Question 1: All of the following can be routes of opioid administration except:

A. Intramuscular
B. Oral
C. Intravenous
D. Intradermal (Correct Answer)

Explanation: ***Intradermal*** - **Intradermal administration** involves injecting medication into the dermis, the layer between the epidermis and the subcutaneous tissue, and is typically used for **allergy testing** or **tuberculosis screening (PPD test)**, not for systemic opioid delivery. - The **slow absorption rate** and **small volume capacity** of the dermal layer make it unsuitable for achieving therapeutic opioid concentrations quickly or effectively. *Intramuscular* - **Intramuscular (IM)** injection allows for **rapid absorption** of opioids into the bloodstream from the muscle tissue. - It is a common route for administering **analgesics**, including opioids, especially in settings where oral administration is not feasible or faster onset is desired. *Oral* - **Oral (PO) administration** is a common and convenient route for many opioid formulations, allowing for **systemic absorption** through the gastrointestinal tract. - Opioids like **oxycodone**, **hydrocodone**, and **morphine** are often prescribed as oral tablets or solutions for pain management. *Intravenous* - **Intravenous (IV) administration** provides the **fastest onset of action** for opioids, as the medication is directly introduced into the bloodstream. - This route is critically important in **acute pain management**, surgical settings, and emergency situations where immediate pain relief is necessary.

Question 2: Which agent is used to reverse opioid overdose?

A. Atropine
B. Protamine
C. Naloxone (Correct Answer)
D. Flumazenil

Explanation: ***Naloxone*** - **Naloxone** is an **opioid receptor antagonist** that competitively binds to opioid receptors, reversing the effects of opioid agonists. - It rapidly restores respiratory function and consciousness in individuals experiencing an **opioid overdose**. *Atropine* - **Atropine** is an **anticholinergic agent** used to treat bradycardia, organophosphate poisoning, and as a pre-anesthetic medication. - It does not have any direct action on opioid receptors and is ineffective in reversing an opioid overdose. *Protamine* - **Protamine** is a **heparin antagonist** used to reverse the anticoagulant effects of heparin. - It acts by forming a stable complex with heparin, thereby neutralizing its activity, and is unrelated to opioid overdose. *Flumazenil* - **Flumazenil** is a **benzodiazepine receptor antagonist** used to reverse the sedative effects of benzodiazepines. - While it reverses the effects of another class of central nervous system depressants, it has no activity on opioid receptors and is not indicated for opioid overdose.

Question 3: A 50-year-old patient with renal insufficiency was recently operated on for pyelolithotomy. Which drug is the most appropriate choice for post-operative analgesia?

A. Diclofenac sodium
B. Naproxen
C. Indomethacin
D. Acetaminophen (Correct Answer)
E. Ketorolac

Explanation: ***Acetaminophen*** - **Acetaminophen** is primarily metabolized in the liver, with minimal renal excretion, making it a safer option for patients with **renal insufficiency**. - It provides effective **analgesia** without the adverse renal effects associated with NSAIDs. *Diclofenac sodium* - **Diclofenac** is a non-steroidal anti-inflammatory drug (**NSAID**) that can impair renal function, especially in patients with pre-existing **renal insufficiency**, by inhibiting prostaglandin synthesis. - Its use can lead to further **kidney damage** or exacerbate existing renal impairment. *Naproxen* - **Naproxen** is an **NSAID** that carries a significant risk of causing acute kidney injury in patients with **compromised renal function**. - It reduces renal blood flow and glomerular filtration rate, making it unsuitable for this patient. *Indomethacin* - **Indomethacin** is a potent **NSAID** known for its adverse renal effects, including acute renal failure. - It should be avoided in patients with **renal insufficiency** due to its potential to further decline kidney function. *Ketorolac* - **Ketorolac** is a potent **NSAID** commonly used for post-operative pain but is **contraindicated** in patients with renal insufficiency. - It has significant nephrotoxic potential and can cause acute renal failure, especially in patients with pre-existing kidney disease.

Question 4: Intravenous regional anesthesia is suitable for :

A. Caesarian section
B. Head and neck surgery
C. Orthopedic manipulation on the upper limb (Correct Answer)
D. Vascular surgery on the lower limb

Explanation: ***Orthopedic manipulation on the upper limb*** - **Intravenous regional anesthesia (IVRA)**, also known as a Bier block, is ideal for **short-duration procedures on the extremities**, especially the upper limb. - The technique involves isolating the limb with a **tourniquet** and injecting a local anesthetic intravenously, making it suitable for procedures like **orthopedic manipulations** that are typically less than an hour. *Caesarian section* - A Caesarian section requires **widespread anesthesia** to the lower abdomen and uterus, which cannot be achieved with IVRA. - It is typically performed under **spinal or epidural anesthesia**, or general anesthesia. *Head and neck surgery* - **IVRA** is a regional technique limited to the extremities below the tourniquet; it cannot provide anesthesia for the **head and neck region**. - Procedures in this area usually require **general anesthesia** or sometimes regional blocks like cervical plexus blocks. *Vascular surgery on the lower limb* - While IVRA can be used on the lower limb, **vascular surgery** often involves **longer durations** and may require more profound muscle relaxation and sensory blockade than IVRA can reliably provide. - Additionally, the use of a **tourniquet for extended periods** in vascular surgery patients can be contraindicated due to potential ischemic complications.

Question 5: A patient selected for surgery was induced with Thiopentone iv through one of the antecubital veins and complained of severe pain of the whole hand. The next line of management is:

A. Leave it alone
B. IV ketamine through same needle
C. Give IV propofol through same needle
D. IV lignocaine through same needle (Correct Answer)

Explanation: **_IV lignocaine through same needle_** - **Lignocaine** (lidocaine) is a **local anesthetic** that can alleviate the severe pain caused by the extravasation or intra-arterial injection of thiopentone by **vasodilatation** and nerve block. - This immediate intervention helps to mitigate the consequences of thiopentone injection outside the vein or into an artery, which can include **vasoconstriction**, tissue necrosis, and **compartment syndrome**. *Leave it alone* - Ignoring the patient's complaint of severe pain, especially after thiopentone administration, could lead to **severe tissue damage**, including **vasoconstriction**, necrosis, and potential limb loss. - Doing nothing is a **negligent approach** that fails to address a potentially serious complication of intravenous drug administration. *IV ketamine through same needle* - **Ketamine** is a dissociative anesthetic and analgesic, but it is not the primary drug for managing local pain and potential vascular complications from thiopentone extravasation or intra-arterial injection. - Administering ketamine in this scenario would **not address the underlying vascular injury** or tissue irritation caused by thiopentone and might only mask the pain without resolving the issue. *Give IV propofol through same needle* - **Propofol** is an intravenous anesthetic that generally causes less pain on injection than thiopentone and has some vasodilatory properties, but it is not the immediate or primary treatment for managing the severe pain and potential vascular injury caused by thiopentone outside the vein or in an artery. - While it may offer some comfort, propofol does not have the **specific local anesthetic action** or immediate **vasodilatory effect** needed to reverse the harmful effects of thiopentone in this situation.

Question 6: Which of the following anesthetic agents have good analgesic property? a) Ketamine b) Nitrous oxide c) Thiopentone d) Propofol e) Midazolam

A. Ketamine and Nitrous oxide (Correct Answer)
B. Ketamine only
C. Nitrous oxide and Thiopentone
D. Ketamine and Propofol
E. Midazolam only

Explanation: ***Ketamine and Nitrous oxide*** - **Ketamine** is a dissociative anesthetic with potent **analgesic properties** secondary to its action as an **NMDA receptor antagonist**. - **Nitrous oxide** is an inhalational anesthetic known for its mild to moderate **analgesic effects**, making it useful for sedation and pain relief. *Ketamine only* - While **ketamine** has excellent analgesic properties, this option is incomplete as **nitrous oxide** also contributes significant analgesia among the choices. - Excluding other agents with analgesic properties makes this option less comprehensive than the correct answer. *Ketamine and Propofol* - **Ketamine** possesses strong analgesic effects, but **propofol** is a sedative-hypnotic agent with no significant intrinsic **analgesic properties**. - Propofol provides anesthesia and sedation but typically requires co-administration with opioids for pain control. *Nitrous oxide and Thiopentone* - **Nitrous oxide** provides analgesia, but **thiopentone** (a barbiturate) is primarily an anesthetic and sedative with **no significant analgesic properties**. - Thiopentone can induce unconsciousness rapidly but does not relieve pain. *Midazolam only* - **Midazolam** is a benzodiazepine primarily used for sedation, anxiolysis, and amnesia, with **no intrinsic analgesic properties**. - Its effects can reduce stress and perception of pain, but it does not directly act as an analgesic.

Question 7: Which approach of brachial plexus block targets cords of the brachial plexus:-

A. Infraclavicular (Correct Answer)
B. Supraclavicular
C. Axillary
D. All of the options

Explanation: ***Infraclavicular*** - The **infraclavicular approach** targets the brachial plexus at the level of the **cords**, which lie deep to the pectoralis muscles and medial to the coracoid process. - This block is particularly useful for surgeries involving the **distal upper limb**, as it blocks all divisions of the cords. *Supraclavicular* - The **supraclavicular approach** targets the brachial plexus at the level of the **trunks**, specifically where they emerge between the anterior and middle scalene muscles. - While it provides good anesthesia for the entire upper limb, it is proximal to the cord level. *Axillary* - The **axillary approach** targets the terminal nerves (e.g., median, ulnar, radial, musculocutaneous) after the brachial plexus has divided into individual nerves in the **axilla**. - This block is distal to the cords and is often used for surgeries of the forearm and hand. *All of the options* - This option is incorrect because only the **infraclavicular approach** specifically targets the cords of the brachial plexus. - The other approaches target either the trunks (supraclavicular) or the terminal nerves (axillary).

Question 8: A two month old infant has undergone a major surgical procedure. Regarding postoperative pain relief which one of the following is recommended:

A. Spinal narcotics intrathecal route
B. Intravenous narcotic infusion in lower dosage (Correct Answer)
C. Only paracetamol suppository is adequate
D. No medication is needed as infant does not feel pain after surgery due to immaturity of nervous system

Explanation: ***Intravenous narcotic infusion in lower dosage*** - **Intravenous narcotic infusion** provides continuous pain relief and allows for careful titration of the dose, which is crucial in infants due to their developing metabolism and increased sensitivity to opioids. - Lower dosages are recommended because infants have a **reduced capacity for drug metabolism** and excretion, making them more susceptible to side effects like respiratory depression. *Spinal narcotics intrathecal route* - While effective, the **intrathecal route** carries risks such as neurotoxicity and spinal cord injury, which are particularly concerning in infants due to their small size and developing neural structures. - The **pharmacokinetics** of intrathecal narcotics can also be unpredictable in infants, leading to potential for delayed respiratory depression. *Only paracetamol suppository is adequate* - For **major surgical procedures**, a single agent like **paracetamol** is typically insufficient to manage severe postoperative pain effectively. - While paracetamol is a useful adjunct, it lacks the potent analgesic effects of opioids needed for comprehensive pain control after significant surgery. *No medication is needed as infant does not feel pain after surgery due to immaturity of nervous system* - This statement is **incorrect** and a dangerous misconception; infants, even neonates, have a **fully developed pain pathway**, perceive pain, and require appropriate analgesia. - The **pain response** in infants can be more exaggerated due to an immature inhibitory pain system, necessitating careful and effective pain management.

Question 9: Celiac plexus block all the following is true Except

A. Cause hypotention
B. Can be used to provide anesthesia for intra abdominal surgery
C. Relieved pain from gastric malignancy
D. Can be given only by retrocrural (classic) approach (Correct Answer)

Explanation: ***Can be given only by retrocrural (classic) approach*** - The celiac plexus block can be performed using various approaches, including **retrocrural (classic)**, **transcrural**, **anterior**, and **endoscopic ultrasound (EUS)-guided** techniques. - The choice of approach depends on patient anatomy, desired outcome, and the physician's expertise, making the statement of "only" a specific approach incorrect. *Cause hypotension* - **Hypotension** is a common side effect of celiac plexus block due to the blockade of **sympathetic innervation** to the splanchnic circulation, leading to vasodilation. - This effect is often managed with intravenous fluids and vasopressors if necessary. *Can be used to provide anesthesia for intra abdominal surgery* - Celiac plexus blocks are primarily used for **analgesia** in patients with chronic abdominal pain, particularly from **visceral malignancies**, not as the sole anesthetic for major intra-abdominal surgery. - While it can provide significant pain relief, it does not induce the level of muscle relaxation or unconsciousness required for surgical anesthesia. *Relieved pain from gastric malignancy* - The celiac plexus innervates many abdominal organs, including the stomach, pancreas, and liver, making its blockade effective in relieving **visceral pain** originating from these structures. - It is a well-established intervention for managing severe **pain associated with gastric** and pancreatic malignancies.

Question 10: Which of the following statements about acute retropharyngeal abscess is true?

A. Treatment often involves incision and drainage.
B. Acute retropharyngeal abscess is common in adults.
C. Swelling typically occurs unilaterally.
D. Acute retropharyngeal abscess is often due to lymphadenitis. (Correct Answer)

Explanation: ***Acute retropharyngeal abscess is often due to lymphadenitis.*** - The **retropharyngeal lymph nodes** (nodes of Rouviere) are prominent in children and drain the nasopharynx, oropharynx, and paranasal sinuses. Infection in these areas can lead to **suppurative lymphadenitis**, which can then progress to an abscess. - **Lymphadenitis** following an upper respiratory tract infection is the **most common etiology** in children, who represent the majority of cases. This is a characteristic pathophysiological mechanism specific to retropharyngeal abscesses. - While other causes exist (trauma, foreign bodies, odontogenic infections in adults), this statement best captures the typical presentation and etiology. *Acute retropharyngeal abscess is common in adults.* - **Retropharyngeal abscesses** are far more common in **children**, especially those under 6 years of age, due to the presence of prominent retropharyngeal lymph nodes that typically atrophy by age 5-6. - In adults, retropharyngeal abscesses are rarer and usually result from trauma, foreign bodies, or odontogenic infections rather than lymphadenitis. *Swelling typically occurs unilaterally.* - The **retropharyngeal space** is a **midline structure**, and infection typically causes **bilateral** or central swelling. - **Edema and inflammation** affect the entire space, leading to generalized posterior pharyngeal wall bulging rather than true unilateral presentation. - While some asymmetry may be visible, describing the swelling as "typically unilateral" is inaccurate. *Treatment often involves incision and drainage.* - While this statement is technically true for **mature abscesses**, it is **incomplete** as a characterizing statement about retropharyngeal abscesses. - Treatment depends on stage: **early phlegmon or cellulitis** may respond to **intravenous antibiotics alone**, while a **mature abscess** requires both **I&D and antibiotics**. - The statement lacks the important context that **antibiotics are the cornerstone** of treatment, with surgical drainage reserved for established abscesses. - This is a treatment modality rather than a defining characteristic of the condition, making it a less complete answer than the etiology-based statement.

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