Cardiopulmonary Resuscitation

CARDIOPULMONARY RESUSCITATION

Q. 1 Bag and mask ventilation in newborn resuscitation is contraindicated in:
 A Diaphragmatic hernia
 B Pulmonary hypoplasia
 C Tracheo-oesophageal fistula
 D Laryngomalacia
Q. 1 Bag and mask ventilation in newborn resuscitation is contraindicated in:
 A Diaphragmatic hernia
 B Pulmonary hypoplasia
 C Tracheo-oesophageal fistula
 D Laryngomalacia
Ans. A

Explanation:

Bag and mask ventilation is contraindicated in suspected or confirmed diaphragmatic hernia. It is done in:

•    If the infant is apnoeic/gasping

•    Respiration is spontaneous but heart rate is below 100/min. The capacity of the bag is 240 to 750 ml. It should be attached to O2 source (5 to 6 litres/min) so as to deliver 90-

100% oxygen.


Q. 2

Which of the following is NOT used in a preterm infant to assess need for resuscitation?

 A

Color

 B

Heart rate

 C

Rate of respiration

 D

Muscle tone

Q. 2

Which of the following is NOT used in a preterm infant to assess need for resuscitation?

 A

Color

 B

Heart rate

 C

Rate of respiration

 D

Muscle tone

Ans. C

Explanation:

Respiratory effort is used instead respiratory rate in APGAR scoring system for resuscitation in neonates.
 
Apgar scoring system:
 
Apgar scores are a numerical expression of a newborn infant’s physical condition. Usually determined 1 min after birth and again at 5 min, the score is the sum of points gained on assessment of color, heart rate, reflex irritability, muscle tone, and respirations. The total score, based on the sum of the five components.

 

Signs

0

1

2

Heartbeats per minute

Absent

Slow (<100)

>100

Respiratory effort

Absent

Slow, irregular

Good, crying

Muscle tone

Limp

Some flexion of extremities

Active motion

Reflex irritability

No response

Grimace

Cry or cough

Color

Blue or pale

Body pink, extremities blue

Completely pink

 

If the score is

 

Ref: Raab E.L., Kelly L.K. (2013). Chapter 9. Normal Newborn Assessment & Care. In A.H. DeCherney, L. Nathan, N. Laufer, A.S. Roman (Eds), CURRENT Diagnosis & Treatment: Obstetrics & Gynecology, 11e.


Q. 3

One of the patients in paediatric ICU has developed VF and the staff have started CPR. You are the physician on call. You want to try DC shock so as to revert to it to normal rhythm. What is the energy you would use in this scenario? The child is 3 years old, weight – 15 kg, SPO2 – 88, BP unrecordable, RR – 40/minute.

 A

60 J

 B

280 J

 C

250 J

 D

320 J

Q. 3

One of the patients in paediatric ICU has developed VF and the staff have started CPR. You are the physician on call. You want to try DC shock so as to revert to it to normal rhythm. What is the energy you would use in this scenario? The child is 3 years old, weight – 15 kg, SPO2 – 88, BP unrecordable, RR – 40/minute.

 A

60 J

 B

280 J

 C

250 J

 D

320 J

Ans. A

Explanation:

In this case a single shock of 4 J/kg can be given. This should be immediately followed by CPR – 15:2 for 2 minutes. During CPR make sure you correct the reversible causes of arrhythmia like hypoxia, hypovolemia, metabolic disturbance etc.

Ref: Oxford Handbook of Clinical Specialities, 8th Edition, Page 239


Q. 4

A lady with placenta previa delivered a baby. She had excessive bleeding and shock. After resuscitation most likely complication would be:

 A

Galactorrhoea

 B

Diabetes insipidus

 C

Loss of menstruation

 D

Cushing’s syndrome

Q. 4

A lady with placenta previa delivered a baby. She had excessive bleeding and shock. After resuscitation most likely complication would be:

 A

Galactorrhoea

 B

Diabetes insipidus

 C

Loss of menstruation

 D

Cushing’s syndrome

Ans. C

Explanation:

Sheehan syndrome refers to panhypopituitarism.

It classically follows massive postpartum hemorrhage and associated hypotension. Abrupt, severe hypotension leads to pituitary ischemia and necrosis.

In its most severe form, these patients develop shock due to pituitary apoplexy.

In less severe forms, loss of gonadotrope activity in the pituitary leads to anovulation and subsequent amenorrhea.

Damage to the other pituitary cell types may present as failure to lactate, loss of sexual and axillary hair, and manifestation of hypothyroidism and adrenal insufficiency symptoms.
 
Ref: Hoffman B.L., Schorge J.O., Schaffer J.I., Halvorson L.M., Bradshaw K.D., Cunningham F.G., Calver L.E. (2012). Chapter 16. Amenorrhea. In B.L. Hoffman, J.O. Schorge, J.I. Schaffer, L.M. Halvorson, K.D. Bradshaw, F.G. Cunningham, L.E. Calver (Eds), Williams Gynecology, 2e.

Q. 5

All of the following are indications for giving intravenous calcium gluconate during cardiopulmonary resuscitation, EXCEPT:

 A

Hypocalcemia

 B

Calcium channel blockers toxicity

 C

Cardiac arrest due to hyperkalemia

 D

Routinely after 1 min of cardiac arrest

Q. 5

All of the following are indications for giving intravenous calcium gluconate during cardiopulmonary resuscitation, EXCEPT:

 A

Hypocalcemia

 B

Calcium channel blockers toxicity

 C

Cardiac arrest due to hyperkalemia

 D

Routinely after 1 min of cardiac arrest

Ans. D

Explanation:

Calcium gluconate is not routinely administered during cardiopulmonary resuscitation, because calcium administration may worsen post ischemic hypoperfusion.

Ref: Recent Advances in Pediatric Anesthesia By Kirti N. Saxena, Page 75

Q. 6

Mechanism of action of epinephrine in cardiopulmonary resuscitation is –

 A

Increase myocardical demand

 B

Increase SA node activity

 C

Peripheral vasoconstriction and directing blood flow to heart

 D

Ratio of blood flow to epicardium and endocardium decreases

Q. 6

Mechanism of action of epinephrine in cardiopulmonary resuscitation is –

 A

Increase myocardical demand

 B

Increase SA node activity

 C

Peripheral vasoconstriction and directing blood flow to heart

 D

Ratio of blood flow to epicardium and endocardium decreases

Ans. B

Explanation:

Ans. is ‘b i.e., Increase S.A. node activity [Ref: Goodman Gilman ll’h/e p. 245; Katzung 116/e p. 139] “Epinephrine speeds the heart by accelerating the slow depolarization of SA nodal cells that takes place during diastole, i.e., during phase 4 of the action potential. Consequently, the transmembrane potential of the pacemaker cells rises more rapidly to the threshold level of action potential initiation. The amplitude the action potential and the maximal rate of depolarization (phase 0) also are increased.”


Q. 7

Naloxone is not used during resuscitation of a child whose mother is on –

 A

Methadone

 B

Phenylcyclidine

 C

Amphetamine

 D

Cocain

Q. 7

Naloxone is not used during resuscitation of a child whose mother is on –

 A

Methadone

 B

Phenylcyclidine

 C

Amphetamine

 D

Cocain

Ans. A

Explanation:

Ans. is ‘a’ i.e., Methadone

o Naloxone is used to reverse neonatal respiratory depression due to opioid use during labour.

o It should not be used in cases where mother is opioid dependent. It can result in withdraw! syndrome.

o When the mother is on opioids, fetus becomes opioid dependent in-utero and the use of naloxone in respiratory resuscitation may result in severe withdraw! symptoms.

“In subjects who are dependent on morphine like opioids (e.g. methadone) small cutaneous doses of naloxone precipitate a moderate to severe withdrawl syndrome that is very similar to that seen after withdrawl of opioids, except that syndrome appears within minutes after administration and subsides in about 2 hours”.


Q. 8

Components of neonatal resuscitation –

 A

Maintenance of temprature

 B

Maintenance of respiration

 C

Maintenance of circulation

 D

All

Q. 8

Components of neonatal resuscitation –

 A

Maintenance of temprature

 B

Maintenance of respiration

 C

Maintenance of circulation

 D

All

Ans. D

Explanation:

Ans. is All

Resuscitation of newborn

o The goal of pediatric resuscitation is to maintain adequate oxygenation and perfusion of blood throughout the body while steps are taken to stabilize the child and establish long term hemostasis.

o The most common indication for neonatal resuscitation is asphyxia.

o Second most common indication is extreme prematurity.

o The components of neonatal resuscitation are TABC ‑

Maintenance of temprature                                        B – Initiate breathing

A- Establish an open airway                                       C – Maintain circulation

Maintenance of temprature

o Newborn baby is susceptible for hypothermia.

o Therefore maintenance of temprature is very important.

o Temprature is maintained by –

i)    Radiant heat source

ii)  Drying the baby and removing wet linen.

Establish an open airway

o Neonate is placed on his back with neck slightly extended by elevating the shoulder 3/4 or 1 inch off the mattress with the help of a rolled blanket or towel.

o Suction of mouth, nose and in some instance trachea.

o If necessary, insert an endotracheal tube (ET) to ensure an open airway. Initiate breathing

o Tactile stimulation can be given to initiate breathing.

o When necessary bag and mask ventilation or ET tube can be used. Maintain circulation

o This is done by chest compression and/or medications.


Q. 9

Meconium aspiration is done for 3 times but no breathing occurs. Next step in resuscitation would be-

 A

Chest compression

 B

O2 inhalation

 C

Bag & mask intubation

 D

Trikling of sole

Q. 9

Meconium aspiration is done for 3 times but no breathing occurs. Next step in resuscitation would be-

 A

Chest compression

 B

O2 inhalation

 C

Bag & mask intubation

 D

Trikling of sole

Ans. D

Explanation:

Ans. is ‘d’ i.e., Trikling of sole

To solve this question, one should know the resuscitation protocol of newborn.

Resuscitation protocol

o As soon as the baby is delivered, five signs are assessed ‑

  1. Clearance of meconium
  2. Active breathing or crying
  3. Good muscle tone (flexed posture and active movement of baby).
  4. Pink color (look at tougue and lips)
  5. Term gestation (delivery between 37-42 weeks of pregnancy).

o If all signs are positive no active resuscitation is required.

o If any of the 5 signs is absent, baby requires resuscitation.

o The baby should be placed under the heat source (radiant warmer) and subjected to a set of intervention known as initial steps.

Initial steps of resuscitation

1. Positioning

The neonate should be placed on her back or side with the neck slightly extended.

This can be achieved by putting a rolled blanket or towel under the shoulders, elevating them 3/4 or 1 inch off the mattress.

2. Suctioning

The mouth and nose should be suctioned

The mouth is suctioned first to ensure that there is nothing for the infant to aspirate when the nose is suctioned.

One should not insert the catheter very deep in mouth or nose for suction -4 Stimulation of posterior pharynx during the first few minutes after birth can produce a vagal responce, causing severe bradycardia or apnea.

3. Dry, stimulate and reposition

After suctioning, the baby should be dried by using pre-warmed linen to prevent heat loss.

A brief tactile stimulation in the form of flicking the soles or rubbing the back may be provided in case of non-establishment of good respiratory efforts.

4. Free flow of oxygen

 If the baby continues to be depressed, provide free flow of oxygen using a facemask.

  • After providing initial steps, the baby should be evaluated for three signs ‑

Respiration

  1. Heart rate (HR)
  2. Color
  • If baby has good breathing, HR >100 and pink color, he should be given supportive care.
  • If the baby is not breathing well or HR <100 then bag and mask ventilation is needed.

o After the infant has received 30 seconds of ventilation with 100% oxygen by bag and mask, evaluation of heart rate should be done –

HR >100        —->           Discontinue ventilation if spontaneous respiration is present

HR 60 to 100  —>            Continue ventilation

Below 60         —>          Continue ventilation + chest compressions

  • After 30 seconds of chest compressions, the heart rate is checked.

HR <60                           Continue chest compression and bag & mask ventilation + initiate medications.

HR> 60                          Discontinue chest compression but continue bag & mask ventilation until the heart rate is above 100.


Q. 10

True regarding neonatal resuscitation-

 A

Ist nasal suctioning done

 B

1st mouth suctioning done

 C

Max. length of nasal suctioning is upto 3 cm and mouth suctioning is upto 5 cm

 D

b and c

Q. 10

True regarding neonatal resuscitation-

 A

Ist nasal suctioning done

 B

1st mouth suctioning done

 C

Max. length of nasal suctioning is upto 3 cm and mouth suctioning is upto 5 cm

 D

b and c

Ans. D

Explanation:

Ans is ‘b i.e., 1st mouth suctioning done & ‘c’ i.e., Max. length of nasal suctioning is upto 3 cm and mouth suctioning is upto 5 cm

Suctioning during resuscitation

o The mouth and nose should be suctioned

o The mouth is suctioned first to ensure that there is nothing for the infant to aspirate when the nose is suctioned.

o One should not insert the catheter very deep in mouth or nose for suction Stimulation of posterior pharynx during the first few minutes after birth can produce a vagal responce, causing severe bradycardia or apnea.

o Therefore, during oral suctioning, a suction tube is gently introduced into the baby’s mouth until the 5 cm mark is at the baby’s lip.

o During nasal suctioning, a suction tube is introduced upto 3 cm mark into each nostril.


Q. 11

Dose of i.v. adrenaline in term infant is during neonatal resuscitation –

 A

0.1 – 0.3 ml/kg in 1:1000

 B

0.3 – 0.5 ml/kg in 1:1000

 C

0.1-0.3 ml/kg in 1:10,000

 D

0.3 – 0.5 ml/kg in 1:10,000

Q. 11

Dose of i.v. adrenaline in term infant is during neonatal resuscitation –

 A

0.1 – 0.3 ml/kg in 1:1000

 B

0.3 – 0.5 ml/kg in 1:1000

 C

0.1-0.3 ml/kg in 1:10,000

 D

0.3 – 0.5 ml/kg in 1:10,000

Ans. C

Explanation:

Ans. is c i.e., 0.1-0.3 mUkg in 1:10,000

Dose or adrenlaine ‑

0.1 ml/kg to 0.3 inlikg diluted (1: I0,000)

Routs : (1) Intravenous (umbilical vein) or

(2) Endotracheal

Indication ‑

HR < 60/min after 30 sec. of positive pressure ventilation & chest compression


Q. 12

The outcome following resuscitation of cardiac arrest is worsened if during resuscitation patient is given:

 A

Ringer’s lactate

 B

Colloids

 C

5% Dextrose

 D

Whole blood transfusion

Q. 12

The outcome following resuscitation of cardiac arrest is worsened if during resuscitation patient is given:

 A

Ringer’s lactate

 B

Colloids

 C

5% Dextrose

 D

Whole blood transfusion

Ans. C

Explanation:

C i.e. 5% Dextrose

  • Glucose containing solutions should not be used in I.V. lines during treatment of shock or cardiac arrestQ because the amount needed to maintain B.P. would cause pulmonary edema and congestive heart failure d/t volume overload.
  • In high risk patients, I.V. glucose solutions should be avoided Q or used judiciously and blood glucose concentration should be maintained within the normoglycemic range until the patients have passed the period of high risk for hemodynamic compromise.

Q. 13

First step in CPR (cardio pulmonary resuciatation) should be :

 A

IV adrenaline

 B

Intracardic atropine

 C

Airway maintainance

 D

Hystrectomy

Q. 13

First step in CPR (cardio pulmonary resuciatation) should be :

 A

IV adrenaline

 B

Intracardic atropine

 C

Airway maintainance

 D

Hystrectomy

Ans. C

Explanation:

C i.e. Airway maintenance


Q. 14

True about adrenaline in CPR :

 A

Can be given intratracheally

 B

I.V. route better than intracardiac

 C

Intracardiac route better than IV

 D

a and b

Q. 14

True about adrenaline in CPR :

 A

Can be given intratracheally

 B

I.V. route better than intracardiac

 C

Intracardiac route better than IV

 D

a and b

Ans. D

Explanation:

A & B i.e. Can be given intra tracheally & I.V. route is better than intracardiac

Cardiopulmonary Resuscitation (CPR)

  • ABCD of CPR are – Airway, Breathing, Circulation & Defibrillation
  • Central (internal jugular or subclavian) venous line is ideal for CPRQ
  • If there is no central line access, then one should attempt to establish peripheral venous line either in antecubital or external jugular vein.
  • If intravenous cannulation is difficult, an intraosseous infusion can provide emergency vascular access in children.
  • Some drugs are well absorbed following administration through an endotracheal tube (eg. epinephrine, atrophine, vasopressin, lidocaine but not sodium bicarbonate)
  • During CPRadrenaline converts fine fibrillation to coarse oneQ

Basic life support – summary

 

Infant (<12 month)

Child (>12month)

Adult

Breathing rate

20 breaths/min

20 breaths/min

10-12 breaths/min

Compression rate

>100/min

100/min

100/min

Compression method

push hard & fast and

allow complete recoil

Two-Three fingersQ or two

thumbs encircling hands

Heel of one hand

Hands interlacedQ

Compression-ventilation

ratio

5:1Q

5:1Q

15 : 2Q

5 : 1 if tracheal tube is used

Compresison depth

Approximately 1/3 – 1/2 of de th of chest

1.5-2 inches

Pulse check

Brachial/Femoral

Carotid

Carotid

Foreign body obstruction

Back blows & Chest thursts

Hemlich maneuver

Hemlich maneuverQ

* CPR in newborn should deliver 90 compressions and 30 ventilation (3:1) per minute.Q


Q. 15

According to 2005 AHA guidelines true about no of chest compression in CPR:

 A

80/min including neonate

 B

90/min including neonate

 C

100/min excluding neonate

 D

120/min including neonate

Q. 15

According to 2005 AHA guidelines true about no of chest compression in CPR:

 A

80/min including neonate

 B

90/min including neonate

 C

100/min excluding neonate

 D

120/min including neonate

Ans. B

Explanation:

B i.e., 90/min including neonates

American heart association (AHA) guidelines for CPR

 

New born

Infant

Children

Adult

Compression rate

90/minQ

Aprox 100/min

Aprox 100/min

Aprox 100/min

Compression

Ventilation ratio

3 : 1

15: 2

(2 rescuer)

30: 2 (or 15:1)

(Single rescuer)

30:2 (or 15: 1)

(1 or 2 rescuer)


Q. 16

During cardiac resuscitation, the follwing can occur except :

 A

Rupture of Lungs

 B

Rupture of liver

 C

Rupture of Stomach

 D

Disseminated intravascular coagulation occurs

Q. 16

During cardiac resuscitation, the follwing can occur except :

 A

Rupture of Lungs

 B

Rupture of liver

 C

Rupture of Stomach

 D

Disseminated intravascular coagulation occurs

Ans. D

Explanation:

D i.e. Disseminated intravenous coagulation

  • During CPR following may occur

Fracture rib, sternumQ or vertebrae

Rupture of lung, liver, spleen, stomachQ

DIC is usually seen in massive trauma, burn & surgery.


Q. 17

The 2010 AHA Guidelines for CPR during Basic Life Support Recommend:

 A

Airway – Breathing – Compression (A-B-C)

 B

Compression – Breathing- Airway ( C-B-A)

 C

Compression- Airway – Breathing (C-A-B)

 D

Breathing – Airway – Compression (B –A-C )

Q. 17

The 2010 AHA Guidelines for CPR during Basic Life Support Recommend:

 A

Airway – Breathing – Compression (A-B-C)

 B

Compression – Breathing- Airway ( C-B-A)

 C

Compression- Airway – Breathing (C-A-B)

 D

Breathing – Airway – Compression (B –A-C )

Ans. C

Explanation:

Answer is C (Compression- Airway – Breathing (C-A-B)

The major Highlight of the 2010 AHA Guidelines for CPR is the Change from “A-B-C” to “C-A-B”

The newest development in the 2010 AHA Guidelines for CPR and ECC is a change in the basic life support (BLS) sequence of steps from “A-B-C (Airway, Breathing, Chest compressions) to “C-A-B” (Chest compressions, Airway, Breathing) for adults and paediatric patients (children and infants, excluding new-born)

Summary of Key BLS Components for Adults, Children, and Infants

(Excluding the new-born, in whom the etiology of an arrest is nearly always asphyxia)

 

 

Recommendations

Component

Adults

Children

Infants

 

Unresponsive (for all ages)

Recognition

No breathing or no normal

breathing (i.e. Only

gasping )

No breathing or only gasping

 

No pulse palpated within 10 seconds for all ages (HCP only)

CPR sequence

C-A-B

Compression rate

At least 100/min

Compression depth

At least 2 inches (5cm)

At least 1/3 AP diameter

About 2 inches (5cm)

At least 1/3 AP diameter

About 1 /2 inches (4cm )

Chest wall recoil

Allow complete recoil between compressions

HCP s rotate compressors every 2minutes

Compression interruptions

Minimize interruptions in chest compressions

Attempt to limit interruptions to < 10 seconds

Airway

Head tilt- chin lift

(If HCP suspects trauma use Jaw Thrust)

Compression-to –ventilation

ratio (until advanced airway

placed)

3:2

1 or 2 rescuers

30;2 Single rescuer

15:2 21-1CP rescuers

Ventilations; when rescuer untrained or trained and not proficient

Compressions only

Ventilations with advanced

airway (HCP)

1 breath every 6-8 seconds (8-10 breaths/min) Asynchronous with chest compressions about 1 second per breath visible chest rise

Defibrillation

Attach and use AED as soon as available. Minimize interruptions in chest compressions before and after shock; Resume CPR beginning with compressions immediately after each shock.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AED, automated external defibrillator; AP. Anterior-posterior; CPR, cardiopulmonary resuscitation; HCP. healthcare provider. .


Q. 18

Key issues and major changes in the 2010 AHA Guidelines for CPR for lay rescuer in adult C ‘R include all of the following Except:

 A

Change in CPR Sequence: C-A-B Rather than A­B-C

 B

Emphasis on “Look, Listen, and Feel’ for Breathing

 C

Chest Compression Rate: At Least 100 per Minute

 D

Chest Compression Depth to at least 2 inches (5 cm).

Q. 18

Key issues and major changes in the 2010 AHA Guidelines for CPR for lay rescuer in adult C ‘R include all of the following Except:

 A

Change in CPR Sequence: C-A-B Rather than A­B-C

 B

Emphasis on “Look, Listen, and Feel’ for Breathing

 C

Chest Compression Rate: At Least 100 per Minute

 D

Chest Compression Depth to at least 2 inches (5 cm).

Ans. B

Explanation:

Answer is B (Emphasis on “Look, Listen, and Feel’ for Breathing)

According to the new 2010 AHA Guidelines “Look, listen, and feel” has been removed from the CPR sequence.

Key issues and major changes in the 2010 AHA Guidelines for CPR for lay rescuer in adult CPR include:

(Emphasis on Chest Compressions)

  • Change in CPR Sequence to C-A-B Rather than A-B-C
  • Chest Compression Rate of at least 100 per Minute
  • Chest Compression Depth to at least 2 inches (5 cm)
  • Elimination of “Look, Listen, and Feel for Breathing”

Q. 19

The 2010 AHA Guidelines for CPR during Basic Life Support for neonates Recommends:

 A

Airway – Breathing – Compression (A-B-C)

 B

Compression – Breathing- Airway (C-B-A)

 C

Compression- Airway – Breathing (C-A-B)

 D

Breathing – Airway – Compression (B –A-C)

Q. 19

The 2010 AHA Guidelines for CPR during Basic Life Support for neonates Recommends:

 A

Airway – Breathing – Compression (A-B-C)

 B

Compression – Breathing- Airway (C-B-A)

 C

Compression- Airway – Breathing (C-A-B)

 D

Breathing – Airway – Compression (B –A-C)

Ans. A

Explanation:

Answer is A (Airway – Breathing – Compression (A-B-C))

The A-B-C (Airway – Breathing – Compression) sequence is still retained for neonates since cardiac arrests in neonates are nearly always from asphyxia.

The major Highlight of the 2010 AHA Guidelines for CPR is the Change from “A-B-C” to “C-A-B”. The newest development in the 2010 AHA Guidelines for CPR and ECC is a change in the basic life support (BLS) sequence of steps from “A-B-C” (Airway, Breathing, Chest compressions) to “C-A-B” (Chest compressions, Airway, Breathing) for adults and paediatric patients (children and infants, excluding new-borns). However the A-B-C (Airway – Breathing –Compression) sequence is still retained for neonates since cardiac arrests in neonates are nearly always from asphyxia.


Q. 20

True regarding cardio pulmonary resuscitation is:

 A

Most common presentation in ECG is asystole

 B

Compression to ventilation ratio is 5:1

 C

Adrenaline is given if cardioversion fails

 D

Calcium gluconate is given immediately

Q. 20

True regarding cardio pulmonary resuscitation is:

 A

Most common presentation in ECG is asystole

 B

Compression to ventilation ratio is 5:1

 C

Adrenaline is given if cardioversion fails

 D

Calcium gluconate is given immediately

Ans. C

Explanation:

Answer is C (Adrenaline is given if cardioversion fails)

During cardiopulmonary rescuscitation (CPR), administration of Adrenaline is recommended only after attempts at cardioversion fail.

Adrenaline (Epinephrine) is given if cardioversion fails

Cardioversion is a brief procedure where an electric shock is given to the heart to convert an abnormal heart rhythm back to a normal rhythm (Defibrillation)

Cardioversion/Defibrillation is recommended as the immediate step during cardiopulmonary resuscitation. Adrenalene/Epinerphrine is recommended only after Jailed defibrillation/cardioversion

‘Epinephrine 1 mg intravenously is given after failed defibrillation’

Most common presentation on ECG is ventricular fibrillation (VF) and not Asystole (H17th/1708)

`The most common electrical mechanism for true cardiac arrest is ventricular fibrillation (VF) Which is responsible for 65 to 80% of cardiac arrest Harrison

‘Asystole, Pulseless Electrical Activity and Severe Bradyarrhythmias cause the remaining 20 to 30%’

Calcium gluconate is not recommended for routine administration (H17th/1712)

Intravenous calcium gluconate is no longer considered necessary or safe for routine administration It is now only recommended for certain specific indications

Indications for calcium gluconate administration

Acute hyperkalemia (Known to be the triggering event for resistant VF) HypocakemiaQ

Patients who have received toxic doses of calcium channel antagonisitsQ


Q. 21

The best chances of recovery after successful cardiopulmonary resuscitation are seen in:

 A

Ventricular Tachycardia

 B

Ventricular Fibrillation

 C

Asystole

 D

Electromechanical dissociation

Q. 21

The best chances of recovery after successful cardiopulmonary resuscitation are seen in:

 A

Ventricular Tachycardia

 B

Ventricular Fibrillation

 C

Asystole

 D

Electromechanical dissociation

Ans. A

Explanation:

Answer is A (Ventricular Tachycardia)

The outcome after cardiac arrest is hest if the mechanism k ventricular tachycardia-

Outcome after cardiac arrest in decreasing order of success

Ventricular tachycardia (Best)

Ventricular fibrillation (Second Best)

Asystole

Pulseless Electrical activity (Electromechanical dissociation)


Q. 22

Resuscitation time of the human retina following ischaemia is:

 A

30 minutes

 B

45 minutes

 C

1 to 2 hours

 D

15 to 20 minutes

Q. 22

Resuscitation time of the human retina following ischaemia is:

 A

30 minutes

 B

45 minutes

 C

1 to 2 hours

 D

15 to 20 minutes

Ans. C

Explanation:

Ans. 1 to 2 hours


Q. 23

Ratio of chest compression to breathing during cardiopulmonary resuscitation in newborn patient admitted in ICU is:

March 2012, March 2013

 A

3:1

 B

5:1

 C

15:2

 D

30:2

Q. 23

Ratio of chest compression to breathing during cardiopulmonary resuscitation in newborn patient admitted in ICU is:

March 2012, March 2013

 A

3:1

 B

5:1

 C

15:2

 D

30:2

Ans. A

Explanation:

Ans: A 3:1

CPR

  • In newborn, compression ventilation ratio is 3:1 with pause for ventilation (synchronized; 90 compressions in 30 breaths) without advanced airway (ventilation by mouth to mouth or nose, bag and mask ventilation) and also with advanced airway in place (endotracheal tube, combitube, tracheostomy tube)
  • 15:2 is the ratio for two resuscitators in case of infants and childrens
  • 30:2 is ratio for single resuscitator in infant and child and in adults (irrespective of number of resuscitators)

Q. 24

Endotracheal Concentration of adrenaline in CPR for pediatric is:       

September 2012

 A

1:10 lakhs

 B

1: 1 lakh

 C

1:10,000

 D

1: 1,000

Q. 24

Endotracheal Concentration of adrenaline in CPR for pediatric is:       

September 2012

 A

1:10 lakhs

 B

1: 1 lakh

 C

1:10,000

 D

1: 1,000

Ans. D

Explanation:

Ans. D.)1:1000

Dose of Epinephrine during CPR

 Adult: 1 mg IV/IO every 3–5 minutes

Pediatric:

  • IV/IO dose: 0.01 mg/kg (0.1 mL/kg of 1:10,000 solution) every 3 to 5 min
  • ET dose (if no IV or IO): 0.1 mg/kg (0.1 mL/kg of 1:1,000 solution)

Q. 25

Chest compression during CPR depth:

March 2013 (a, c, d, g)

 A

1 inch

 B

2 inches

 C

3 inches

 D

4 inches

Q. 25

Chest compression during CPR depth:

March 2013 (a, c, d, g)

 A

1 inch

 B

2 inches

 C

3 inches

 D

4 inches

Ans. B

Explanation:

Ans. B i.e. 2 inches


Q. 26

Which of the following is not widely used in cardiopulmonary resuscitation:     

September 2006

 A

Adrenaline

 B

Calcium

 C

Atropine

 D

Vasopressin

Q. 26

Which of the following is not widely used in cardiopulmonary resuscitation:     

September 2006

 A

Adrenaline

 B

Calcium

 C

Atropine

 D

Vasopressin

Ans. B

Explanation:

Ans. B: Calcium

Calcium is contraindicated in CPR

Despite the fact that extracellular calcium enhances the contractile force of cardiac muscle, there is no evidence to indicate that calcium administration during CPR improves cardiac performance.

In fact ischemia promotes intracellular calcium accumulation, leading to membrane disruption and uncoupling of oxidative phosphorylation.

Because of the risk of calcium accumulation and subsequent cell injury during periods of tissue ischemia, it is indicated when the patient exhibits acute calcium channel blocker toxicity or if there is evidence of ionized hypocalcemia or hyperkalemia.


Q. 27

During cardiopulmonary resuscitation in adult, chest compressions are given at the rate of:        

September 2011

 A

72 compressions/ min

 B

90 compressions/ min

 C

100 compressions/min

 D

120 compressions/min

Q. 27

During cardiopulmonary resuscitation in adult, chest compressions are given at the rate of:        

September 2011

 A

72 compressions/ min

 B

90 compressions/ min

 C

100 compressions/min

 D

120 compressions/min

Ans. C

Explanation:

Ans. C: 100 compressions/min

Compression rate for infant, child and adult is 100 compressions/min


Q. 28

All of the following are true regarding fluid resuscitation in burn patients except:

 A

Consider intravenous resuscitation in children with burns greater than 15% TBSA

 B

Oral fluids must contain salts

 C

Most preferred fluid is Ringer’s lactate

 D

Half of the calculated volume of fluid should be given in first 8 hours

Q. 28

All of the following are true regarding fluid resuscitation in burn patients except:

 A

Consider intravenous resuscitation in children with burns greater than 15% TBSA

 B

Oral fluids must contain salts

 C

Most preferred fluid is Ringer’s lactate

 D

Half of the calculated volume of fluid should be given in first 8 hours

Ans. A

Explanation:

Ans. A: Consider intravenous resuscitation in children with burns greater than 15% TBSA

In children with burns over 10% TBSA and adults with 15% TBS, consider the need for intravenous fluid resuscitation.

If oral resuscitation is to be commenced, it is important that the water given is not salt free.

Preferred fluid: Lactated Ringer’s Solution, because it is:

  • Isotonic
  • Cheap
  • Easily stored

Resuscitation formulas: Parkland formula most commonly used

Fluid calculation: 4 x weight in kg x %TBSA burn

Give 1/2 of that volume in the first 8 hours. Give other 1/2 in next 16 hours

TBSA: Total burns surface area.


Q. 29

Best fluid for resuscitation in burns:

FMGE 11; Punjab 12

 A

Dextran

 B

Ringer lactate

 C

Albumin

 D

Hartmann’s solution

Q. 29

Best fluid for resuscitation in burns:

FMGE 11; Punjab 12

 A

Dextran

 B

Ringer lactate

 C

Albumin

 D

Hartmann’s solution

Ans. B

Explanation:

Ans. Ringer lactate


Q. 30

Identify the purpose of the pulse palpated as shown in the picture below ? 

 A

To assess rate and rhythm.

 B

At resuscitation (CPR).

 C

To assess peripheral vascular disease.

 D

To detect aneurysmal swelling

Q. 30

Identify the purpose of the pulse palpated as shown in the picture below ? 

 A

To assess rate and rhythm.

 B

At resuscitation (CPR).

 C

To assess peripheral vascular disease.

 D

To detect aneurysmal swelling

Ans. B

Explanation:

Ans:B.)At resuscitation (CPR).

Carotid pulse is shown to be palpated in the image.

Systematic examination of pulses
Which and what order? Where and how? Why?
1. Radial artery
  • Radial side of wrist.
  • With tips of index and middle fingers.
  • To assess rate and rhythm.
  • Simultaneously with femoral to detect delay.
  • Not good for pulse character.
2. Brachial artery
  • Medial border of humerus at elbow medial to biceps tendon.
  • Either with thumb of examiner’s right hand or index and middle of left hand.
  • To assess pulse character.
  • To confirm rhythm.
3. Carotid artery
  • Press examiner’s left thumb against patient’s larynx.
  • Press back to feel carotid artery against precervical muscles.
  • Alternatively from behind, curling fingers around side of neck.
  • Best for pulse character and, to some extent, left ventricular function.
  • To detect carotid stenosis.
  • At resuscitation (CPR).
4. Femoral artery
  • Patient lying flat and undressed.
  • Place finger directly above pubic ramus and midway between pubic tubercle and anterior superior iliac spine.
  • To assess cardiac output.
  • To detect radiofemoral delay.
  • To assess peripheral vascular disease.
5. Popliteal artery
  • Deep within the popliteal fossa.
  • Compress against posterior of distal femur with knee slightly flexed.
  • Mainly to assess peripheral vascular disease.
  • In people with diabetes.
6. Dorsalis pedis (DP) and tibialis posterior (TP) arteries (foot)
  • Lateral to extensor hallucis longus (DP).
  • Posterior to medial malleolus (TP).
  • As above.
7. The abdominal aorta
  • With the flat of the hand per abdomen, as body habitus allows.
  • In peripheral vascular disease.
  • To detect aneurysmal swelling

Q. 31

During resuscitation, fractured ribs most commonly involve:

 A

2nd –4th ribs

 B

3rd –5th ribs

 C

4th 6th ribs

 D

5th –7th ribs

Q. 31

During resuscitation, fractured ribs most commonly involve:

 A

2nd –4th ribs

 B

3rd –5th ribs

 C

4th 6th ribs

 D

5th –7th ribs

Ans. C

Explanation:

Ans. c. 4th — 6th ribs

Reasonable conclusions to be drawn from the literature in relation to rib fractures in adults

  • Rib fractures following CPR in adults are quite common – 30 to 60% of prospective post-mortem studies.
  • Post-CPR rib fractures are often bilateral.
  • The site of rib fracture is dependent on: the position of the hands; force used; and method of chest compression (manual or device-assisted).
  • The vast majority (90%+) offractures occur in ribs 2 to 7; fractures in the bony parts of rib numbers 1 and 8 to 10 are possible but probably very rare; it is difficult to see how fractures can occur in rib numbers 11 and 12 following standard manual CPR.
  • The vast majority of fractures (90%+) occur in the anterior third of the bony part of the rib, some occur in the middle third but – following standard manual CPR – none in the posterior third of the bony part of the rib.
  • Posterior rib fractures occur following automated band-type CPR.
  • Lateral fractures i.e. those occurring between the anterior and posterior axillary lines, do occur after standard CPR. If a fracture is noted in rib numbers 10 to 12 or in the posterior third of the bony part of a rib, then non-resuscitation trauma should be suspected.
  • Chest x-ray is unreliable as a diagnostic tool for detecting rib fractures.
  • CT is better than x-ray and may complement the post-mortem detection of rib fractures.

Fractures are more common

  • On the left side of the chest
  • With increasing age of the patient
  • In females
  • With increasing length of time of resuscitation attempts Following the involvement of untrained persons
  • With the use of ACD-CPR

Q. 32

Drug used in neonatal resuscitation

 A

Adrenaline

 B

Soda bi carbonate

 C

Naloxone

 D

All of above

Q. 32

Drug used in neonatal resuscitation

 A

Adrenaline

 B

Soda bi carbonate

 C

Naloxone

 D

All of above

Ans. D

Explanation:

Ans. is ‘d’ i.e., All of above

Drug used during neonatal resuscitation

  • Epinephrine./Adrenalin
  • NS or RL
  • Naloxone
  • Sodium-by-carbonate

Q. 33

The ideal parameters for cardiac massage in cardiopulmonary resuscitation are all except ‑

 A

Force should depress sternum by 11/2 inches

 B

Ratio of compression to ventilation should be 15:2

 C

Compressions to be given over lower third of sternum

 D

Force should depress sternum approximately 1/3 of chest wall diameter

Q. 33

The ideal parameters for cardiac massage in cardiopulmonary resuscitation are all except ‑

 A

Force should depress sternum by 11/2 inches

 B

Ratio of compression to ventilation should be 15:2

 C

Compressions to be given over lower third of sternum

 D

Force should depress sternum approximately 1/3 of chest wall diameter

Ans. B

Explanation:

Ans. is `b,’ i.e., Ratio of compression to ventilation should be 15:2


Q. 34

Machine used noninvasively to monitor an external chest compression during cardio­pulmonary resuscitation is ‑

 A

Zoll AED – plus automatic external defibrillator

 B

Zoll depth synchronizer

 C

Zoll strength sensor

 D

Zoll pA02 monitor

Q. 34

Machine used noninvasively to monitor an external chest compression during cardio­pulmonary resuscitation is ‑

 A

Zoll AED – plus automatic external defibrillator

 B

Zoll depth synchronizer

 C

Zoll strength sensor

 D

Zoll pA02 monitor

Ans. A

Explanation:

Ans. is ‘a’ i.e., Zoll automatic external defibrillator

Monitor for chest compressions in cardio pulmonary resuscitation

  • A novel monitor for the chest compressions is a device incorporated into the chest compression pad of the ZOLL AED – PLUS automatic external defeibrillator.
  • The sternal compression pad located between the stick on defibrillating electrodes includes an accelerometer.
  • The signal from this device is doubly integrated to produce a measure of compression depth monitored by the device.
  • Auditory feedback can be provided to the rescuer if chest compression depth so monitored falls outside the recommended range.
  • Such technical aids improve the efficacy of external chest compressions and thus the rescue of patients.

Q. 35

This 29-year-old obese diabetic man presented in a state of septic shock, requiring resuscitation in the Intensive Care Unit.On examination,following picture was seen.What can be the most possible diagnosis?

 A

Scrotal abscess

 B

Testicular torsion

 C

Acute epididymo-orchitis

 D

Fournier gangrene

Q. 35

This 29-year-old obese diabetic man presented in a state of septic shock, requiring resuscitation in the Intensive Care Unit.On examination,following picture was seen.What can be the most possible diagnosis?

 A

Scrotal abscess

 B

Testicular torsion

 C

Acute epididymo-orchitis

 D

Fournier gangrene

Ans. D

Explanation:

Ans:D.)Fournier gangrene.

Fournier gangrene

  • It is defined as a polymicrobial necrotizing fasciitis of the perineal, perianal, or genital areas.
  • It is usually caused by a mixed infection of both aerobic and anaerobic bacteria.
  • They present with systemic toxicity and pain over the perineum. Cellulits is seen in the patient but they may present with crepitance and extensive necrosis under relative normal skin.
  •  Synergistic flora of the anorectal and urogenital area (streptococcus, clostridia, and non-hemolytic streptococcus).
  • Immuno-compromised patients (e.g. diabetics, alcoholics and malnourished patients).
  •  They are associated with high morbidity and mortality. Aggressive surgical debridement and broad spectrum antibiotics is necessary.


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