Surgical Airway Management — MCQs
Road traffic accident (RTA) with multiple fractures - initial treatment would be:
What is the most common complication occurring in tracheostomy in children? (March 2004)
Best management for an inhaled foreign body in an infant is?
What is the correct sequence of management in a patient who presents to the casualty with an RTA? 1. Cervical spine stabilization 2. Intubation 3. IV cannulation 4. CECT
High tracheostomy is done in which one of the following conditions?
A 5-year old boy while having dinner suddenly becomes aphonic and is brought to the casualty with the complaint of respiratory distress. Immediate management should be:
What is the most reliable indicator to prevent esophageal intubation?
Identify the maneuver being performed.
During rapid sequence intubation in a child after taking brief history and clinical examination next step is:
Which of the following is an ideal method to prevent aspiration pneumonia?
Surgical Airway Management Indian Medical PG Practice Questions and MCQs
Question 1: Road traffic accident (RTA) with multiple fractures - initial treatment would be:
- A. Management of shock
- B. Splinting of limbs
- C. Airway management (Correct Answer)
- D. Cervical spine protection
Explanation: ***Airway management*** - In trauma, **establishing and maintaining a patent airway** is the absolute priority, as compromised breathing can lead to rapid deterioration and death. - The **ABCs (Airway, Breathing, Circulation)** of trauma care dictate that airway intervention precedes other life-saving measures. *Management of shock* - While crucial, **managing shock (C)** follows **airway (A)** and **breathing (B)** in the primary survey of trauma care. - Addressing profound shock without a patent airway can be ineffective and leads to irreversible damage. *Splinting of limbs* - **Splinting fractures** is important for pain control, preventing further injury, and minimizing blood loss in open fractures, but it is not an immediate life-saving intervention. - This falls under the **secondary survey** or definitive management, after life-threatening issues have been addressed. *Cervical spine protection* - **Cervical spine protection** is essential in trauma to prevent further neurological injury and is performed simultaneously with airway management (often with in-line stabilization). - However, a patent airway is the **most immediate life-sustaining intervention** if the airway is compromised.
Question 2: What is the most common complication occurring in tracheostomy in children? (March 2004)
- A. Infection (Correct Answer)
- B. Difficult decannulation
- C. Difficult weaning
- D. Stenosis
Explanation: ***Infection*** - **Infection** is among the most frequent complications in pediatric tracheostomy, occurring in the immediate postoperative period and throughout the tracheostomy course. - Can manifest as **stoma infections** (cellulitis, wound breakdown), **tracheitis**, **pneumonia**, or **mediastinitis**. - The constant presence of an open wound, bypassed upper airway defenses, and need for frequent suctioning create ongoing infection risk. - **Clinical significance**: While some studies cite difficult decannulation as more common, infection remains the most clinically significant early complication requiring active management. *Difficult decannulation* - A very common complication in pediatric tracheostomy, with some studies suggesting it may be the **most frequent** long-term issue. - Children's airways are more prone to **granulation tissue formation**, **suprastomal collapse**, and **tracheomalacia**. - Occurs in **prolonged tracheostomy** cases, often requiring multiple attempts or surgical intervention. - Frequency varies by underlying indication and duration of cannulation. *Difficult weaning* - Refers to challenges in **ventilator weaning** rather than a direct tracheostomy complication. - More related to the **underlying respiratory or neurological condition** necessitating tracheostomy. - A management challenge rather than a procedural complication. *Stenosis* - **Tracheal or subglottic stenosis** is a serious **late complication** occurring in 10-15% of pediatric cases. - Results from **chronic irritation**, **granulation tissue**, cartilage injury, or improper tube size. - While severe when it occurs, its overall incidence is **lower than infection or decannulation issues**.
Question 3: Best management for an inhaled foreign body in an infant is?
- A. IPPV
- B. Tracheostomy
- C. Corticosteroids
- D. Bronchoscopy (Correct Answer)
Explanation: ***Bronchoscopy*** - **Bronchoscopy** is the definitive and most effective procedure for both diagnosing and removing an inhaled foreign body in an infant. - It allows direct visualization of the airways and the precise retrieval of the foreign object, preventing complications like **atelectasis** or **pneumonia**. *Tracheostomy* - **Tracheostomy** is an emergency procedure to create a surgical airway, usually reserved for severe upper airway obstruction that cannot be managed by less invasive means. - It is not the primary line of treatment for removing an inhaled foreign body, which is typically found further down in the **bronchial tree**. *Corticosteroids* - **Corticosteroids** are used to reduce inflammation and edema in the airways, but they do not remove the foreign body itself. - While they might be used as an adjunct in managing airway inflammation after removal, they are not the definitive treatment for the foreign body. *IPPV* - **Intermittent Positive Pressure Ventilation (IPPV)** is a method of respiratory support used for patients with respiratory failure. - It does not address the physical obstruction caused by an inhaled foreign body and may even push the object further into the airway or cause **pneumothorax**.
Question 4: What is the correct sequence of management in a patient who presents to the casualty with an RTA? 1. Cervical spine stabilization 2. Intubation 3. IV cannulation 4. CECT
- A. 2,1,4,3
- B. 1,3,2,4
- C. 2,1,3,4
- D. 1,2,3,4 (Correct Answer)
Explanation: ***1,2,3,4*** - This sequence follows the **ATLS (Advanced Trauma Life Support)** protocol, prioritizing immediate life threats in order. - **Cervical spine stabilization** is the **first action upon patient contact** to prevent secondary neurological injury in any trauma patient. - **Airway management (intubation)** is then performed **with maintained in-line c-spine stabilization** - these occur nearly simultaneously but c-spine protection is instituted first. - **IV cannulation (circulation)** follows to establish vascular access for resuscitation and medications. - **CECT (imaging)** is performed last, once the patient is stabilized after addressing immediate life threats. - This follows the **ATLS Primary Survey: Airway (with c-spine protection) → Breathing → Circulation → Disability → Exposure**. *2,1,4,3* - This incorrectly places intubation **before** cervical spine stabilization is initiated. - In ATLS, **c-spine protection must be applied immediately upon patient contact** before any airway manipulation. - Delaying IV cannulation until after CECT is inappropriate as circulatory access is critical for early resuscitation. *1,3,2,4* - While this correctly starts with cervical spine stabilization, it incorrectly places **IV cannulation before intubation**. - In the ATLS primary survey, **Airway comes before Circulation** - securing the airway takes priority over establishing IV access. - This sequence could delay critical airway management in a patient with respiratory compromise. *2,1,3,4* - This sequence places **intubation before cervical spine stabilization**, which violates ATLS principles. - **C-spine stabilization must be the first action** upon approaching any trauma patient to prevent secondary spinal cord injury. - While intubation with in-line stabilization is possible, the c-spine protection must be instituted first, not after beginning airway manipulation.
Question 5: High tracheostomy is done in which one of the following conditions?
- A. Laryngeal cancer
- B. Tracheal stenosis (Correct Answer)
- C. Severe asthma exacerbation
- D. Vocal cord dysfunction
Explanation: ***Tracheal stenosis*** - A **high tracheostomy** is performed when there is **lower tracheal stenosis** or obstruction, requiring placement of the tracheostomy stoma **above the stenotic segment**. - This approach ensures that the **tracheostomy tube** bypasses the narrowed portion of the trachea and provides a patent airway. - The level of tracheostomy is chosen based on the location of the pathology - high tracheostomy for lower pathology, and vice versa. *Laryngeal cancer* - In **laryngeal cancer**, a **low tracheostomy** is typically preferred, not a high one. - A high tracheostomy in laryngeal malignancy is generally **contraindicated** due to the risk of tumor seeding and interference with surgical planning. - The tracheostomy should be placed **away from the tumor site** and below the pathology, especially if laryngectomy is planned. *Severe asthma exacerbation* - **Severe asthma exacerbation** rarely requires a tracheostomy; endotracheal intubation and mechanical ventilation are the standard initial management. - If prolonged ventilatory support is needed, a **standard tracheostomy** (not high) would be performed. - There is no specific indication for high tracheostomy placement in asthma. *Vocal cord dysfunction* - **Vocal cord dysfunction (VCD)** involves paradoxical vocal cord movement and is typically managed with **conservative measures** including speech therapy and breathing exercises. - VCD does not cause structural obstruction requiring surgical airway intervention. - Tracheostomy, especially high tracheostomy, has no role in the management of VCD.
Question 6: A 5-year old boy while having dinner suddenly becomes aphonic and is brought to the casualty with the complaint of respiratory distress. Immediate management should be:
- A. Emergency tracheostomy
- B. Humidified oxygen
- C. Heimlich maneuver (Correct Answer)
- D. Cricothyroidotomy
Explanation: ***Heimlich maneuver*** - The sudden onset of **aphonia** and **respiratory distress** during dinner indicates **foreign body airway obstruction** (FBAO). - The **Heimlich maneuver** is the immediate, life-saving intervention for conscious individuals with complete airway obstruction. *Emergency tracheostomy* - This is an invasive surgical procedure performed when other methods to clear the airway have failed or are not possible due to severe obstruction or trauma. - It is not the **first-line intervention** for a conscious child with FBAO. *Humidified oxygen* - While supportive of respiratory function, humidified oxygen alone will not resolve an **acute foreign body obstruction** causing aphonia and severe distress. - It does not address the underlying mechanical blockage of the airway. *Cricothyroidotomy* - This is an emergency procedure to establish an airway, typically used in adults when other methods of intubation or airway clearance have failed. - It is generally **contraindicated in children under 12** due to the risk of damaging the cricoid cartilage, which is a major part of the child's airway.
Question 7: What is the most reliable indicator to prevent esophageal intubation?
- A. Oxygen saturation on pulse oximeter
- B. Direct visualization of passing tube beneath vocal cords
- C. Auscultation over chest
- D. Measurement of CO2 in exhaled air (EtCO2). (Correct Answer)
Explanation: ***Measurement of CO2 in exhaled air (EtCO2)*** - The presence of **carbon dioxide** in exhaled air confirms tracheal intubation as the esophagus does not contain CO2. - This method provides a **real-time**, objective assessment of tube placement that is highly reliable because even small amounts of CO2 are detected. *Oxygen saturation on pulse oximeter* - This indicator measures **oxygenation**, which can remain adequate for several minutes after esophageal intubation due to pre-oxygenation. - A **delayed drop in saturation** might indicate esophageal intubation, but it's not immediate and therefore not the most reliable early indicator. *Direct visualization of passing tube beneath vocal cords* - While helpful, **direct visualization** can sometimes be misleading due to difficult airways or poor visibility, where the tube might appear to pass correctly but enter the esophagus. - This method is **operator-dependent** and its reliability can vary based on the intubator's experience and the patient's anatomy. *Auscultation over chest* - **Auscultation** can detect breath sounds; however, sounds can be transmitted from the stomach or surrounding tissues, leading to false positives. - It is also very difficult to reliably distinguish between **esophageal and tracheal sounds**, especially in noisy environments or with inexperienced personnel, making it less reliable than EtCO2.
Question 8: Identify the maneuver being performed.
- A. Head tilt, chin lift (Correct Answer)
- B. Jaw thrust maneuver
- C. Head extension technique
- D. In-line manual stabilization
Explanation: ***Head tilt, chin lift*** - This maneuver is performed by placing one hand on the patient's forehead and tilting the head back while simultaneously using the fingers of the other hand to lift the chin, thereby opening the airway. - It is a primary technique to establish an **open airway** in an unconscious patient who does not have suspected cervical spine injury. *Jaw thrust maneuver* - The jaw thrust maneuvers involves placing fingers behind the angles of the patient's mandible and displacing the jaw forward, which can be done without extending the neck. - This maneuver is preferred for patients with suspected **cervical spine injuries** to open the airway while minimizing neck movement. *Head extension technique* - This term describes the **head tilt component** of the head tilt, chin lift maneuver, but it doesn't encompass the chin lift aspect, making it an incomplete description of the depicted action. - Simply extending the head without lifting the chin might not adequately open the airway by lifting the tongue off the posterior pharynx. *In-line manual stabilization* - This technique involves manually holding the patient's head and neck to prevent movement, typically used when a **cervical spine injury** is suspected. - It is a **supportive measure** often performed *in conjunction* with airway maneuvers like the jaw thrust, not an airway maneuver itself.
Question 9: 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 10: Which of the following is an ideal method to prevent aspiration pneumonia?
- A. Full stomach
- B. Increase the intra abdominal pressure
- C. Inhalational anesthetic
- D. Endotracheal tube (cuffed) (Correct Answer)
Explanation: ***Endotracheal tube (cuffed)*** - A cuffed endotracheal tube forms a **seal** in the trachea, effectively preventing aspiration of gastric contents or oral secretions into the lungs. - This method is particularly crucial before and during surgical procedures involving general anesthesia, where normal airway protective reflexes are abolished. *Full stomach* - A **full stomach** significantly increases the risk of aspiration, as there is more gastric content available to be regurgitated into the airway. - This is a contraindication for immediate induction of general anesthesia and often necessitates a rapid sequence intubation. *Increase the intra abdominal pressure* - Increasing **intra-abdominal pressure** (e.g., due to obesity, insufflation for laparoscopy) can push gastric contents towards the esophagus, thereby increasing the risk of reflux and aspiration. - This effect is undesirable and directly contributes to aspiration risk rather than preventing it. *Inhalational anesthetic* - **Inhalational anesthetics** depress airway reflexes, making the patient more susceptible to aspiration. - While they are essential for maintaining anesthesia, they do not prevent aspiration; rather, other measures like intubation are necessary to counteract their effects.
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