Pain Management in Emergency — MCQs
A female was given morphine sulphate during labour for pain but she developed respiratory distress. Which of the following will be the correct antidote?
Which of the following anesthetic drugs is contraindicated in chronic renal failure?
For comparison grading of pain the scale used is -
Which of the following is not done in the primary survey of trauma?
A young male was administered regional anesthesia with 0.25% bupivacaine. The patient became unresponsive, and the pulse became unrecordable. What is the best management in this situation?
Which of the following anesthetic agents have good analgesic property? a) Ketamine b) Nitrous oxide c) Thiopentone d) Propofol e) Midazolam
A 35-year-old with migraines needs prophylaxis. Which is suitable?
What is an absolute indication for surgery in disc prolapse?
Emergency management of Ulcerative colitis is by:
A pregnant lady with persistent variable decelerations with cervical dilatation of 6 cm is planned for emergency LSCS. Which of the following is NOT done in management while preparing patient for surgery
Pain Management in Emergency Indian Medical PG Practice Questions and MCQs
Question 1: A female was given morphine sulphate during labour for pain but she developed respiratory distress. Which of the following will be the correct antidote?
- A. Naloxone (Correct Answer)
- B. Epinephrine
- C. Pralidoxime
- D. Atropine
Explanation: ***Naloxone*** - **Naloxone** is a pure opioid antagonist that rapidly reverses the effects of **opioid overdose** [1, 3], including **respiratory depression** [2], by competitively binding to opioid receptors [1]. - Its short half-life may necessitate repeated doses, especially with longer-acting opioids like morphine, to prevent recurrence of respiratory depression [1]. *Epinephrine* - **Epinephrine** is an adrenergic agonist used to treat **anaphylaxis** and severe allergic reactions, as it causes **vasoconstriction** and **bronchodilation**. - It is not an antidote for opioid-induced respiratory depression, which primarily results from central nervous system effects rather than allergic reactions. *Pralidoxime* - **Pralidoxime** is a **cholinesterase reactivator** used to treat poisoning by **organophosphates**, which inhibit acetylcholinesterase, leading to cholinergic crisis. - It works by restoring the function of the enzyme, thereby breaking down excess acetylcholine, and is not indicated for opioid overdose. *Atropine* - **Atropine** is an **anticholinergic agent** that blocks muscarinic acetylcholine receptors, used to treat **bradycardia** and **organophosphate poisoning**. - It would not reverse opioid-induced respiratory depression, as it primarily affects the parasympathetic nervous system and does not antagonize opioid receptor effects.
Question 2: Which of the following anesthetic drugs is contraindicated in chronic renal failure?
- A. Atracurium
- B. Fentanyl
- C. Pethidine (Correct Answer)
- D. Morphine
Explanation: ***Pethidine*** - **Pethidine** is contraindicated in chronic renal failure due to its active metabolite, **normeperidine**, which is eliminated renally. - Accumulation of **normeperidine** can lead to **central nervous system (CNS) toxicity**, including seizures, tremors, and hyperreflexia. *Atracurium* - **Atracurium** undergoes **Hofmann elimination** and **ester hydrolysis**, which are independent of renal or hepatic function. - This makes it a relatively safe choice for patients with **renal impairment**. *Fentanyl* - **Fentanyl** is primarily metabolized by the liver, with its metabolites being inactive. - While some dose adjustment may be considered in severe renal failure, it is generally **safe** for use in patients with chronic renal impairment as its metabolites are inactive. *Morphine* - **Morphine** is metabolized in the liver to **morphine-3-glucuronide (M3G)** and **morphine-6-glucuronide (M6G)**, both of which are renally excreted. - **M6G** is an active metabolite with potent analgesic effects, and its accumulation in renal failure can cause **prolonged sedation** and **respiratory depression**. While significant caution and dose reduction are needed, it's not strictly contraindicated in the same way pethidine is due to the more neurotoxic nature of normeperidine.
Question 3: For comparison grading of pain the scale used is -
- A. Visual scale (Correct Answer)
- B. Face's scale
- C. CHEOPS
- D. Numerical charts
Explanation: ***Visual scale*** - The **Visual Analog Scale (VAS)** is a psychometric response scale used to measure subjective characteristics, like pain intensity, that cannot be directly measured. - Patients mark a point on a **10-cm line** between "no pain" and "worst pain imaginable," allowing for continuous comparison. *Face's scale* - The **Wong-Baker FACES Pain Rating Scale** is primarily used in children or adults with communication difficulties. - It uses **facial expressions** to depict different levels of pain intensity, making it easier for individuals to express their pain. *CHEOPS* - **CHEOPS** stands for the Children's Hospital of Eastern Ontario Pain Scale and is specifically designed for assessing **postoperative pain in infants and young children**. - It observes **behavioral indicators** such as crying, facial expression, and verbal cues, rather than direct self-reporting [1]. *Numerical charts* - **Numerical Rating Scales (NRS)** ask patients to rate their pain intensity on a scale from 0 (no pain) to 10 (worst pain possible). - While commonly used, NRS provides discrete values rather than a continuous visual representation for comparison like the VAS.
Question 4: Which of the following is not done in the primary survey of trauma?
- A. Intubation
- B. NCCT head (Correct Answer)
- C. ICD drainage
- D. CXR
Explanation: ***NCCT head*** - A **Non-Contrast CT (NCCT) head** is typically performed during the **secondary survey** once the patient is hemodynamically stable and life-threatening conditions have been addressed. - The primary survey focuses on immediate **life-saving interventions** for airway, breathing, circulation, disability, and exposure. *Intubation* - **Intubation** is a critical intervention during the primary survey, specifically under the **'A' (Airway)** component, to establish and secure a patent airway in a compromised patient. - Failure to establish an airway can rapidly lead to **hypoxia** and death. *ICD drainage* - **Intercostal drain (ICD) drainage** is an urgent intervention in the primary survey, falling under **'B' (Breathing)**, to manage conditions like **tension pneumothorax** or massive hemothorax. - These conditions can severely compromise ventilation and circulation, requiring immediate relief. *CXR* - A **Chest X-ray (CXR)** is a rapid and essential diagnostic tool in the primary survey, also under **'B' (Breathing)**, to identify life-threatening thoracic injuries such as pneumothorax, hemothorax, or mediastinal shift. - It provides quick information crucial for immediate management decisions.
Question 5: A young male was administered regional anesthesia with 0.25% bupivacaine. The patient became unresponsive, and the pulse became unrecordable. What is the best management in this situation?
- A. ECPR with calcium
- B. ECPR with dobutamine
- C. ECPR with 20% intralipid (Correct Answer)
- D. ECPR with sodium bicarbonate
Explanation: ***ECPR with 20% intralipid*** - The scenario describes **Local Anesthetic Systemic Toxicity (LAST)**, likely due to bupivacaine, leading to cardiovascular collapse. - **Intralipid 20%** is the first-line treatment for LAST-induced cardiovascular toxicity, as it acts as a lipid sink for the lipophilic local anesthetic. *ECPR with calcium* - While calcium may be used in certain cardiac arrest scenarios, it is **not the primary treatment for bupivacaine-induced cardiovascular collapse** and LAST. - Calcium might offer some cardiac support but does not directly neutralize the local anesthetic's toxic effects. *ECPR with dobutamine* - **Dobutamine is an inotropic agent** used to improve cardiac contractility but is not indicated as a primary rescue therapy for severe LAST. - It would not address the underlying toxicity caused by bupivacaine and could potentially worsen the situation by increasing myocardial oxygen demand without reversing toxin effects. *ECPR with sodium bicarbonate* - **Sodium bicarbonate** is used to treat metabolic acidosis and can be beneficial in certain drug overdoses to enhance excretion or stabilize cardiac membranes. - However, it is **not the primary or most effective treatment for bupivacaine-induced LAST** and cardiovascular collapse compared to lipid emulsion therapy.
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: A 35-year-old with migraines needs prophylaxis. Which is suitable?
- A. Acetaminophen
- B. Sumatriptan
- C. Verapamil (Correct Answer)
- D. Tramadol
Explanation: ***Verapamil*** - **Verapamil**, a calcium channel blocker, is often used off-label for **migraine prophylaxis**, particularly in cases where other first-line agents are contraindicated or ineffective. - While not a first-line treatment, it can reduce the frequency and severity of migraine attacks by modulating **vasoconstriction** and **vasodilation**. *Acetaminophen* - **Acetaminophen** is an analgesic used for **acute pain relief**, but it does not have properties that prevent migraine attacks from occurring. - It is unsuitable for long-term **prophylactic management** of migraines. *Sumatriptan* - **Sumatriptan** is a **triptan** medication used for **acute migraine treatment**, meaning it is taken to stop a migraine attack once it has started. - It is not indicated for **migraine prophylaxis** and should not be used regularly to prevent migraines. *Tramadol* - **Tramadol** is an **opioid analgesic** used for moderate to severe pain, and it carries risks of dependence and side effects. - It is not recommended for **migraine prophylaxis** due to its addictive potential and lack of evidence for preventing migraine attacks.
Question 8: What is an absolute indication for surgery in disc prolapse?
- A. Recurrent episodes of sciatica
- B. Cauda equina syndrome (Correct Answer)
- C. Pain not relieved by complete rest
- D. Progressive motor weakness despite conservative management
Explanation: ***Cauda equina syndrome*** - **Cauda equina syndrome** is a neurological emergency characterized by compression of the cauda equina nerves, leading to symptoms like **saddle anesthesia**, bowel/bladder dysfunction, and severe neurological deficits, necessitating immediate surgical decompression. - Delay in surgery for **cauda equina syndrome** can result in permanent neurological damage, making it an *absolute indication* for surgical intervention within **48 hours**. *Recurrent episodes of sciatica* - While recurrent **sciatica** can be debilitating and may eventually warrant surgery, it is typically managed conservatively initially and is not considered an *absolute emergency* for surgery. - Surgical intervention in recurrent **sciatica** is usually considered when conservative treatments fail over 6-12 weeks, but it is a *relative indication*, not an immediate requirement. *Progressive motor weakness despite conservative management* - **Progressive motor weakness** is a serious concern and represents a *relative indication* for surgery, especially if documented over serial examinations. - Unlike **cauda equina syndrome**, which requires immediate surgery, progressive weakness allows for a brief period of conservative management and surgical planning, though surgery should not be unduly delayed if weakness continues to progress. *Pain not relieved by complete rest* - **Pain not relieved by rest** is a common symptom of disc prolapse and can be an indication for surgery after failed conservative management, but it is not an *absolute emergency* like **cauda equina syndrome**. - This type of pain often indicates discogenic pain or nerve root compression but can often be managed with medications, physical therapy, or injections before surgical consideration.
Question 9: Emergency management of Ulcerative colitis is by:
- A. Subtotal colectomy with end ileostomy (Correct Answer)
- B. Right hemicolectomy
- C. Total proctocolectomy with end ileostomy
- D. Left hemicolectomy
Explanation: ***Subtotal colectomy with end ileostomy*** - This is the **standard emergency procedure** for fulminant ulcerative colitis, toxic megacolon, perforation, or massive hemorrhage - Involves removal of the **entire colon** (from ileocecal junction to upper rectum) while **preserving the rectal stump** as a Hartmann's pouch - Creates an **end ileostomy** for fecal diversion - **Proctectomy is avoided** in the emergency setting due to higher morbidity, risk of pelvic sepsis, and technical difficulty in acutely ill patients - The rectal stump can be removed later (2nd stage) with consideration for **ileal pouch-anal anastomosis (IPAA)** after patient stabilization - This staged approach allows for optimization of the patient's condition and future reconstructive options *Total proctocolectomy with end ileostomy* - This involves removal of both the **colon and rectum** with permanent ileostomy - **NOT recommended in emergency settings** as proctectomy adds significant morbidity in critically ill patients - Requires pelvic dissection in inflamed tissues, increasing risk of complications - May be performed electively as a **second-stage procedure** or in patients not candidates for reconstructive surgery *Right hemicolectomy* - Removes only the **right side of the colon** (cecum, ascending colon, and part of transverse colon) - Inappropriate for ulcerative colitis, which is a **pan-colonic disease** that always involves the rectum and extends proximally - Inadequate resection would leave diseased colon in place *Left hemicolectomy* - Removes only the **left side of the colon** (descending colon and part of transverse colon) - Inadequate for ulcerative colitis as it doesn't address the **entire diseased colon** - Would leave inflamed segments and the **always-involved rectum** in place
Question 10: A pregnant lady with persistent variable decelerations with cervical dilatation of 6 cm is planned for emergency LSCS. Which of the following is NOT done in management while preparing patient for surgery
- A. O2 inhalation
- B. I.V. fluid
- C. Foley catheterization
- D. Supine position (Correct Answer)
Explanation: ***Supine position*** - Maintaining a **supine position** in a pregnant woman can lead to **aortocaval compression**, reducing **venous return** and **cardiac output**, which compromises uterine blood flow and fetal oxygenation. - To prevent this, the patient should be placed in a **left lateral tilt** (wedge under the right hip) to displace the uterus off the great vessels. *O2 inhalation* - Administering **oxygen via face mask** increases the mother's partial pressure of oxygen (PaO2), which can improve **fetal oxygenation** and potentially alleviate fetal distress. - This is a standard and safe intervention to maximize oxygen delivery to the fetus, especially in cases of **fetal compromise** indicated by variable decelerations. *I.V. fluid* - Administering **intravenous fluids** helps maintain maternal hydration and **circulatory volume**, crucial for adequate uterine perfusion. - This can improve **placental blood flow**, potentially reducing the frequency or severity of variable decelerations by increasing amniotic fluid volume and relieving **cord compression**. *Foleys catheterisation* - **Foley catheterization** is essential before a Cesarean section to **decompress the bladder**, preventing injury during surgery and improving surgical exposure. - A full bladder can obstruct the surgical field and increases the risk of accidental incision, therefore, it is a routine pre-operative step.
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