Airway Management in Trauma — MCQs

10 questions

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

The safest initial approach to open the airway of a patient with maxillofacial trauma is:

What is to be addressed first in case of polytrauma -

All are used in the management of head injury patient except?

A construction worker met with an accident when a cement block fell on his face. He sustained severe maxillofacial and laryngeal injury. He was not able to open his mouth and is having jaw fracture with obstruction in nasopharynx and oropharynx. To stabilize his airway, the following procedure was done on him. Which option describes the procedure done on him?

What is the primary purpose of Sellick's maneuver?

Endotracheal tube in the esophagus is best assessed by:

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?

Q10

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

Airway Management in Trauma Indian Medical PG Practice Questions and MCQs

Question 1: 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 2: The safest initial approach to open the airway of a patient with maxillofacial trauma is:

A. Head tilt-chin lift
B. Jaw thrust technique (Correct Answer)
C. Head lift-neck lift
D. Heimlich procedure

Explanation: ***Jaw thrust technique*** - This technique is preferred in cases of **maxillofacial or suspected cervical spine trauma** as it minimizes neck movement, thereby reducing the risk of further injury. - It involves grasping the angles of the mandible and **lifting the jaw anteriorly**, which moves the tongue away from the posterior pharynx to clear the airway. *Head tilt-chin lift* - This maneuver is contraindicated in trauma settings where a **cervical spine injury** is suspected, as it can extend the neck and exacerbate spinal cord damage. - While effective for opening the airway in non-trauma patients, it involves **significant neck movement** which is unsafe in maxillofacial trauma. *Head lift-neck lift* - This is not a recognized or safe technique for airway management, especially in trauma patients, as it would cause **unnecessary and potentially harmful movement** of the head and neck. - There is no clinical scenario where this technique would be recommended over established airway maneuvers. *Heimlich procedure* - The Heimlich procedure (abdominal thrusts) is used to relieve **severe foreign body airway obstruction** and is not an initial approach to open an airway due to general trauma. - It is an intervention for choking, not for managing an airway in a patient with maxillofacial trauma where the primary concern is often **tongue prolapse** or significant structural injury causing obstruction.

Question 3: What is to be addressed first in case of polytrauma -

A. Circulation
B. Neurology
C. Blood Pressure
D. Airway (Correct Answer)

Explanation: ***Airway*** - Maintaining a **patent airway** is the absolute first priority in polytrauma management according to the **ATLS (Advanced Trauma Life Support)** protocol. - Failure to secure an airway can lead to **hypoxia** and **brain damage** within minutes, regardless of other injuries. *Circulation* - While critical, addressing **circulation** (C in ABCDE) comes after establishing a secure airway and adequate breathing (A and B). - Uncontrolled hemorrhage would be the focus of circulation management, but only after guaranteeing proper oxygenation. *Neurology* - Neurological assessment (D in ABCDE for Disability) follows the primary survey of airway, breathing, and circulation. - Initial neurological evaluation focuses on **level of consciousness** using the **GCS (Glasgow Coma Scale)**. *Blood Pressure* - **Blood pressure** is an indicator of circulatory status but is not the first thing to be addressed. - It falls under the "C" for circulation in the ATLS protocol, which is secondary to airway and breathing.

Question 4: All are used in the management of head injury patient except?

A. Neuromuscular paralysis
B. Norepinephrine
C. Glucocorticoids (Correct Answer)
D. Sedation

Explanation: ***Glucocorticoids*** - **Glucocorticoids** are generally **not recommended** for the routine management of head injury patients due to a lack of proven benefit and potential for harm. - Studies have shown that their use in **traumatic brain injury (TBI)** can be associated with increased mortality and other adverse outcomes. *Neuromuscular paralysis* - **Neuromuscular paralysis** (e.g., with vecuronium or cisatracurium) is often used in severe head injury to facilitate **endotracheal intubation**, control intractable intracranial pressure (ICP), or prevent self-extubation. - It helps in reducing metabolic demands and ensuring proper ventilation and oxygenation in critically ill patients. *Norepinephrine* - **Norepinephrine** is a potent **vasopressor** frequently used to maintain adequate cerebral perfusion pressure (CPP) by increasing mean arterial pressure (MAP) in head injury patients. - Maintaining **CPP** is crucial to prevent secondary brain injury from ischemia. *Sedation* - **Sedation** (e.g., with propofol or midazolam) is essential in head injury management to reduce **agitation**, prevent increases in ICP, and facilitate mechanical ventilation. - It helps in patient comfort and ensures stability of vital signs and neurological parameters.

Question 5: A construction worker met with an accident when a cement block fell on his face. He sustained severe maxillofacial and laryngeal injury. He was not able to open his mouth and is having jaw fracture with obstruction in nasopharynx and oropharynx. To stabilize his airway, the following procedure was done on him. Which option describes the procedure done on him?

A. Cricothyroidotomy
B. Subcutaneous tracheostomy
C. Tracheostomy (Correct Answer)
D. Submental insertion of ET

Explanation: ***Tracheostomy*** - A tracheostomy creates a surgical opening in the **trachea** to establish a direct airway, bypassing the upper airway. This is crucial when the **nasopharynx and oropharynx are obstructed** due to severe maxillofacial and laryngeal injuries, as described in the case. - The procedure allows for ventilation and prevents aspiration, making it the most suitable long-term solution for definitive airway management in patients with extensive facial and jaw trauma preventing oral or nasal intubation. *Cricothyroidotomy* - This procedure involves making an incision through the **cricothyroid membrane** into the trachea. It is typically a **rapid, emergency airway** procedure. - While it provides an immediate airway, it is generally considered a temporary measure due to potential complications like **subglottic stenosis** with prolonged use, and not ideal for the described severe, multifocal obstruction requiring a more stable, long-term solution. *Subcutaneous tracheostomy* - This term is **not a recognized medical procedure** for establishing an airway. - Tracheostomies are performed with direct access to the trachea, not subcutaneously. *Submental insertion of ET* - This technique involves passing an endotracheal tube through a submental incision into the oropharynx, bypassing the mouth in cases of **maxillofacial trauma** and securing the airway. - However, the question describes **obstruction in both the nasopharynx and oropharynx**, and also a laryngeal injury, which would likely preclude the passage of an endotracheal tube even via a submental approach, making a direct tracheal access (tracheostomy) a more appropriate and definitive solution.

Question 6: What is the primary purpose of Sellick's maneuver?

A. Prevention of hypertension
B. Prevention of alveolar collapse
C. Prevention of aspiration of gastric contents (Correct Answer)
D. Prevention of bradycardia

Explanation: ***Prevention of aspiration of gastric contents*** - **Sellick's maneuver**, also known as **cricoid pressure**, involves applying pressure to the cricoid cartilage. - This pressure occludes the **esophagus**, thereby preventing the regurgitation and aspiration of gastric contents into the airway, especially during rapid sequence intubation. *Prevention of alveolar collapse* - **Alveolar collapse** (atelectasis) is typically prevented by maintaining positive end-expiratory pressure (PEEP) or using lung recruitment maneuvers during mechanical ventilation. - Sellick's maneuver has no direct role in maintaining **alveolar patency**. *Prevention of hypertension* - **Hypertension** during intubation can be managed with specific medications like opioids or beta-blockers, or by optimizing anesthetic depth. - Sellick's maneuver does not influence **blood pressure regulation**. *Prevention of bradycardia* - **Bradycardia** can occur during intubation due to vagal stimulation and is often managed with anticholinergic drugs like atropine. - Sellick's maneuver does not affect **heart rate** directly.

Question 7: Endotracheal tube in the esophagus is best assessed by:

A. Direct laryngoscopy
B. Auscultation
C. CO2 Exhalation (Correct Answer)
D. Chest wall movement

Explanation: ***CO2 Exhalation*** - Measuring **CO2 exhalation** (capnography) is the most reliable method to confirm endotracheal tube placement, as CO2 is present in the trachea but not in the esophagus. - A persistent **waveform on the capnograph** indicates proper tracheal intubation. *Direct laryngoscopy* - While helpful for initial visualization during intubation, **direct laryngoscopy** cannot confirm continuous tracheal placement after the tube is advanced. - It only confirms the tube passing through the vocal cords, not its final position in the trachea versus esophagus. *Auscultation* - **Auscultation** can be misleading because stomach sounds can be transmitted to the chest, and breath sounds can be heard in the epigastrium even with esophageal intubation. - It relies on subjective interpretation and is less definitive than capnography. *Chest wall movement* - Observing **chest wall movement** is not a definitive sign, as the chest can still rise with esophageal intubation due to air entering the stomach. - This method is unreliable and can be mistaken for proper ventilation, leading to dangerous delays in correcting tube misplacement.

Question 8: 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 9: 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.

Question 10: 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.

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