Intubation

INTUBATION

Q. 1 In  a  patient with Le-fort II,  Le-fort III,  & naso-ethmoid #, what is the choice of intubation?
 A Oral
 B Oral & nasal
 C Nasal
 D Submental
Q. 1 In  a  patient with Le-fort II,  Le-fort III,  & naso-ethmoid #, what is the choice of intubation?
 A Oral
 B Oral & nasal
 C Nasal
 D Submental
Ans. D

Explanation:

Submental

  • Surgical repair of maxillofacial trauma requires modification of the standard anesthesia technique.
  • Nasal endotracheal intubation is often contraindicated in the presence of fracture of base of he skull. Comminuted midfacial fractures cause physical obstruction to the passage of nasotracheal tube. Further, the presence of  nasotracheal tube can interfere with surgical reconstruction of fractures of  the naso- orbital ethmoid (NOE) complex.
  • Surgical reconstruction often involves maxillo-mandibular fixation in the intra operative period to restore patient’s dental occlusion. This precludes the use of oral endotracheal intubation in such cases. In these conditions tracheostomy may be indicated but it carries a significant morbidity.
  • Submental endotracheal intubation has been described as an useful alternative totracheostomy

Q. 2 Difficult oral intubation may be associated with all except:
 A Receding lower jaw
 B Poor mobility of mandible
 C Protruding upper incisor tooth
 D Decreased alveolar mental distance
Q. 2 Difficult oral intubation may be associated with all except:
 A Receding lower jaw
 B Poor mobility of mandible
 C Protruding upper incisor tooth
 D Decreased alveolar mental distance
Ans. D

Explanation:

Oral tracheal intubation is commonly employed in the administration of general anesthesia.

Difficult intubation is expected in:

1. Limited neck extension.

2.   Limited  temporomandibular  joint   range   of motion.

3. Massive obesity.

4. Prominent maxillary teeth.

5. Broken or loose maxillary teeth.

6. Fragile maxillary dental work.

7. Macroglossia.

8. Tonsillar pillars not visualized.

9. Anterior larynx

10. Rheumatoid involvement of larynx

11. Airway edema.

12. Intrinsic or  extrinsic pathology eg. Tumor, abscess, hematoma, or foreign body

13. Active bleeding in airway.


Q. 3

Mallampatti classification is used for?

 A Inspection of oral cavity before intubation 
 B Size of the airway 
 C Size of the ET tube
 D Tracheostomy tube
Q. 3

Mallampatti classification is used for?

 A Inspection of oral cavity before intubation 
 B Size of the airway 
 C Size of the ET tube
 D Tracheostomy tube
Ans. A

Explanation:

Inspection of oral cavity before intubation REF: Morgan 3′ ed p. 82

In anaesthesiology, the Mallampatti score, also Mallampatti classification is used to predict the ease of intubation. It is determined by looking at the anatomy of the oral cavity; specifically, it is based on the visibility of the base of uvula, faucial pillars (the arches in front of and behind the tonsils) and soft palate.

Modified Mallampati Scoring is as follows:

Class 0

Visibility of Epiglottis

No difficulty

Class 1

Full visibility of tonsils, uvula and soft palate

No difficulty

Class 2

Visibility of hard and soft palate, upper portion of tonsils and uvula

No difficulty

Class 3

Soft and hard palate and base of the uvula are visible

Moderate difficulty

Class 4

Only Hard Palate visible

Severe difficulty


Q. 4 Blind nasal intubation is not indicated in? 
 A

TM joint ankylosis

 B Impossible laryngoscopy 
 C

CSF otorrhea

 D

Base of skull fracture

Q. 4 Blind nasal intubation is not indicated in? 
 A

TM joint ankylosis

 B Impossible laryngoscopy 
 C

CSF otorrhea

 D

Base of skull fracture

Ans. D

Explanation:

Base of skull fracture REF: Miller 6th ed p. 1628-1645

Contraindications for nasal intubation:

  • Base of skull fracture
  • CSF rhinorrhoea
  • Adenoids
  • Nasal polyps
  • Bleeding disorder
  • Previous nasal surgery

Indications for blind nasal intubation

  • Impossible laryngoscopy
  • TM joint problems
  • Trismus due to any cause
  • Neck contracture

Q. 5

A 40 year old man who met with a motor vehicle catastrophe came to the casualty hospital in an hour with severe maxillofacial trauma. His Pulse rate was 120/min, BP was 100/70 mm Hg, Sp0280% with oxygen. What would be the immediate management 

 A

Nasotracheal intubation

 B

Orotracheal intubation

 C

Intravenous fluid

 D

Tracheostomy

Q. 5

A 40 year old man who met with a motor vehicle catastrophe came to the casualty hospital in an hour with severe maxillofacial trauma. His Pulse rate was 120/min, BP was 100/70 mm Hg, Sp0280% with oxygen. What would be the immediate management 

 A

Nasotracheal intubation

 B

Orotracheal intubation

 C

Intravenous fluid

 D

Tracheostomy

Ans. B

Explanation:

Orotracheal intubation [Ref: Morgan’s Anaesthesia 4/e p. 112; Schwartz surgery 9/e p. 137]

  • Patients with severe maxillofacial trauma and with low Sp02 even on oxygen suggests severe airway compromise or obstruction.
  • In these cases emergency airway management is essential.
  • The patient require immediate oxygen.

– These patients needs to be intubated immediately.

But an important point to note is that severe maxillofacial trauma makes intubation very difficult.

-Some believe that nasotracheal intubation is contraindicated in patients with severe maxillofacial injury because

nasotracheal intubation in these patients can result in nasocranial intubation or severe nasal hemorrhage.

– Nasotracheal intubation is absolutely contraindicated in patients with midfacial injury and C.S.F.

rhinorrhoea.

Orotracheal intubation in patients with severe maxillofacial injury

  • In patients with severe maxillofacial injuries orotracheal intubation is also difficult.
  • Presence of blood clots, .fractures make the passage of the tube quite difficult.
  • Moreover when the surgeons perform operation for mandibular or maxillary fractures they wires both these together.
  • If surgery is required with severe maxillofacial injury surgeons usually prefer nasotracheal intubation or tracheostomy.

Tracheostomy in patient with severe maxillofacial injury : ?

  • Tracheostomy does not have much role in “emergency airways management”.

– Tracheostomy is a time taking procedure compared to intubation.

If the airways of the patient is severely compromised and he requires immediate oxygenation, tracheostomy has no role.

Immediate oxygenation can only be delivered by rapid intubation.

  • In case, intubation is impossible, cricothyroidotomy is an alternative.

In emergency management of the airway, cricothyroidotomy is done if intubation is not possible.

  • Tracheostomy is only done when immediate oxygen requirements are taken care of and a surgical procedure is planned.
  • In the question the Sp02 of the patient is 80% when on oxygen. He requires immediate emergency management of the
    airway which can be achieved through intubation, If intubation is impossible, cricothyroidotomy is an alternative.

The better option of intubation in this patient is orotracheal intubation.

  • The ideal management in this patient is cricothyroidotomy.
  • Since that is not mentioned in the question intubation in the next best option. “Orotracheal intubation would be preferred over nasotracheal intubation in these cases”

Q. 6

Merits of nasotracheal intubation is

 A Good oral hygiene
 B Less infection
 C Less miscosal damage and bleeding
 D More movement or displacement of endotracheal t ube
Q. 6

Merits of nasotracheal intubation is

 A Good oral hygiene
 B Less infection
 C Less miscosal damage and bleeding
 D More movement or displacement of endotracheal t ube
Ans. A

Explanation:

Good oral hygine

Intubation can be done in two ways :

  • Orotracheal intubation
  • Nasotracheal intubation
  • Orotracheal intubation is the preferred technique in most cases. It is most suited to emergency situation (nasotracheal intubation requires a little extra time.
  • Orotracheal intubation under direct laryn goscopy is generally the easier route and the one of choice in unstable patients when rapid re-establishment of the airway is essential.
  • Nasatracheal intubation is better tolerated during pralonged mechanical ventilation.
  • Nasotracheal intubation has certain drawbacks 😕

– Increased risk of nosocomial sinusitis

– Increased risk of mensal damage and bleeding therefore nasotracheal intubation should be avoided in coagulopathies

– Restricted movement of the endotracheal tube

Complications of orotracheal tube occurs due to

– Occlusion or displacement of the tube and airway trauma.


Q. 7

All of the following are related to difficult intubation, EXCEPT:

 A

Miller’s sign

 B

TMJ ankylosis

 C

Increased thyromental distance

 D

Micrognathia

Q. 7

All of the following are related to difficult intubation, EXCEPT:

 A

Miller’s sign

 B

TMJ ankylosis

 C

Increased thyromental distance

 D

Micrognathia

Ans. C

Explanation:

Tracheal intubation is best achieved in the classic “sniffing the morning air” position

in which the neck is flexed and there is extension at the cranio-cervical (atlanto-axial) junction.

This aligns the structures of the upper airway in the optimum position for laryngoscopy and

permits the best view of the larynx when using a curved blade laryngoscope.

Abnormalities of the bony structures and the soft tissues of the upper airway will result in difficult intubation.

Signs of difficult intubation:

  • Thyromental distance < 7cms
  • Mallampatti grade III or IV
  • Micrognathia
  • Macroglossia
  • High arched palate with narrow dental arch
  • TMJ limitation
  • Limited cervical vertebrae extension
  • Miller sign
  • Growth in oral cavity

The modified Mallampati, thyromental distance, ability to protrude the mandible and craniocervical movement are probably the most reliable.


Q. 8

An anaesthetist is using Mallampati classification for which of the following purpose?

 A

Inspection of oral cavity before intubation

 B

Size of the airway

 C

Size of the ET tube

 D

Tracheostomy tube

Q. 8

An anaesthetist is using Mallampati classification for which of the following purpose?

 A

Inspection of oral cavity before intubation

 B

Size of the airway

 C

Size of the ET tube

 D

Tracheostomy tube

Ans. A

Explanation:

Mallampati classification is based on the structures seen with maximal mouth opening and tongue protrusion without phonation in the sitting position.

The observer’s eye should be at the level of the patient’s mouth. This classification correlates with intubation difficulty. 

Mallampati classification (Modified by Samsoon and Young):

Mallampati Class Intraoral structures visible
Class I Soft palate, fauces, uvula, pillars
Class II Soft palate, fauces, portion of uvula
Class III Soft palate, base of uvula
Class IV Hard palate only (later added by Samsoon and Young)

Q. 9

In a case of road traffic accident, emergency nasotracheal intubation is done. Advantage of nasotracheal intubation is:

 A

Good oral hygiene

 B

Less infection

 C

Less mucosal damage and bleeding

 D

More movement or displacement of endotracheal tube

Q. 9

In a case of road traffic accident, emergency nasotracheal intubation is done. Advantage of nasotracheal intubation is:

 A

Good oral hygiene

 B

Less infection

 C

Less mucosal damage and bleeding

 D

More movement or displacement of endotracheal tube

Ans. A

Explanation:

Nasotracheal intubation is mainly used when access to the trachea through the oropharynx is difficult and
emergency cricothyrotomy is not indicated.
The advantages of nasotracheal intubation are
.good oral hygiene,
.greater comfort for the patient and
.greater ease in communicating with the intubated patient through lip reading. 
 
Disadvantages include need for a smaller airway, which results in increased airway resistance;
need for a more skilled operator, because the tube is usually inserted without direct vision;
possible bleeding caused by passage of the nasotracheal tube through the nasopharynx;
and sinusitis that may result owing to obstruction of the ostia of the sinuses.
 
Ref: Partin W.R., Dorroh C. (2011). Chapter 7. Emergency Procedures. In R.L. Humphries, C. Stone (Eds), CURRENT Diagnosis & Treatment Emergency Medicine, 7e.

Q. 10

Which of the following is not an indication for endotracheal intubation?

 A

Pneumothorax

 B

Pulmonary toilet

 C

Maintenance of a patent airway

 D

To provide positive pressure ventilation

Q. 10

Which of the following is not an indication for endotracheal intubation?

 A

Pneumothorax

 B

Pulmonary toilet

 C

Maintenance of a patent airway

 D

To provide positive pressure ventilation

Ans. A

Explanation:

Endotracheal intubation is the gold standard method used to establish an airway.

It is indicated to maintain a patent airway in case of obstruction,

to provide positive pressure ventilation and for pulmonary toilet. 

Patients with secondary pneumothorax, large pneumothorax or tension pneumothorax should undergo chest tube placement (tube thoracostomy) not endotracheal intubation.
 
Ref: Respiratory Care: Principles And Practice By Dean Hess, 2nd Edition, Page 383; CURRENT Medical Diagnosis and Treatment, 2012, Chapter 9.

Q. 11

A man presented with fractures of 4th to 10th ribs and respiratory distress after a Road Traffic Accident (RTA). He is diagnosed to have flail chest and a PaO2, of

 A

Tracheostomy

 B

IPPV with oral intubation

 C

Fixation of ribs

 D

Strapping of chest

Q. 11

A man presented with fractures of 4th to 10th ribs and respiratory distress after a Road Traffic Accident (RTA). He is diagnosed to have flail chest and a PaO2, of

 A

Tracheostomy

 B

IPPV with oral intubation

 C

Fixation of ribs

 D

Strapping of chest

Ans. B

Explanation:

Flail chest occurs when three or more contiguous ribs are fractured in at least two locations.

Paradoxical movement of this free-floating segment of chest wall may be evident in patients with spontaneous ventilation, due to the negative intrapleural pressure of inspiration.

The decreased compliance and increased shunt fraction caused by the associated pulmonary contusion that is typically the source of postinjury pulmonary dysfunction.

Pulmonary contusion often progresses during the first 12 hours.

Resultant hypoventilation and hypoxemia may require presumptive intubation and mechanical ventilation.

 
Ref: Cothren C., Biffl W.L., Moore E.E. (2010). Chapter 7. Trauma. In F.C. Brunicardi, D.K. Andersen, T.R. Billiar, D.L. Dunn, J.G. Hunter, J.B. Matthews, R.E. Pollock (Eds), Schwartz’s Principles of Surgery, 9e.

Q. 12

During intubation of a child, type of endotracheal tube and blade of laryngoscope is –

 A

Uncuffed tube with curved blade

 B

Uncuffed tube with straight blade

 C

bladeCuffed tube with straight blade

 D

Cuffed tube with curved blade

Q. 12

During intubation of a child, type of endotracheal tube and blade of laryngoscope is –

 A

Uncuffed tube with curved blade

 B

Uncuffed tube with straight blade

 C

bladeCuffed tube with straight blade

 D

Cuffed tube with curved blade

Ans. B

Explanation:

Ans. is ‘b’ i.e., Uncuffed tube with straight blade

o During intubation of a child the endotracheal tube should be uncuffed and straight.


Q. 13

A child presented in the casuality with fever, unconcous & papilloedema. What next to the done ‑

 A

Intubation

 B

Oxygenation

 C

CT scan

 D

All

Q. 13

A child presented in the casuality with fever, unconcous & papilloedema. What next to the done ‑

 A

Intubation

 B

Oxygenation

 C

CT scan

 D

All

Ans. D

Explanation:

Ans. is ‘a’ i.e., lntubation; `b’ i.e., Oxygenation; ‘c’ i.e., CT Scan

o The child in question with fever, unconsciousness & papilloedema, probably suffering from complicated meningitis/ encephalitis. Papilloedema is uncommon in uncomplicated meningitis & should suggest a more chronic process, such as the presence of an intracranial abscess, subdural empyema or occlusion of a dural venous sinus.

Emergency & critical care management of a comatose child with intracranial hypertension :

The main goals of care include optimizing cerebral blood flow, cerebral perfusion pressure & minimizing factors that can aggravate neurological injury or trigger intracranial pressure elevation. General measures are :

1)         Assess the Airway, Breathing & Circulation (ABC) -* Intubation, oxygen etc.

2)         Assess & treat for immediately correctable causes of coma, like hypoglycemia, dyselectrolytemia etc.

3)         Assess the depth of coma with Glassgow coma scale.

4)         Assess & treatment of raised intracranial pressure with Mannitol, Hypertonic saline solutions.

5)         Antiseizure medications.

Neuroimaging : A CT scan may provide information about the cause of altered mental status & the presence of intracranial hypertension, however a normal CT scan does not rule out raised ICP. MRI is also helpful for early changes.

7)         Lumber puncture helpful for diagnosis & treatment of CNS infective causes. In an unconscious child with potential raised ICP, the decision is controversial with some authors stating that the risks of herniation for outweighs the benefit of knowing the pathogen from an early lumber puncture.

8)         Choice of empiric broad-spectrum antibiotic, till confirmatory tests available.

9)         Dextrose containing hypotonic IVF should be avoided & enteral feed started at the earliest.

10)        Others like steroids, Barbiturates etc.


Q. 14

True about endotracheal intubation is:

 A

It reduces normal anatomical dead space

 B

It produces decrease in resistance to respiration

 C

Subglottic edema is most common complication

 D

All of the above

Q. 14

True about endotracheal intubation is:

 A

It reduces normal anatomical dead space

 B

It produces decrease in resistance to respiration

 C

Subglottic edema is most common complication

 D

All of the above

Ans. A

Explanation:

A i.e. It reduces the normal anatomical dead space 

–  Endotracheal tube decreases the anatomical dead space (150 ml) to as less as 25 ml.

– Endotracheal intubation increases the resistance to respiration; obstruction from kinking, foreign body or secretions further increase resistance.

Subglottic edema, though a complication, is not the most common one.


Q. 15

True about LMA (Laryngeal Mask Airway): 

 A

Available in 8 sizes

 B

Intubation can be done

 C

Size 1 for neonates

 D

b and c

Q. 15

True about LMA (Laryngeal Mask Airway): 

 A

Available in 8 sizes

 B

Intubation can be done

 C

Size 1 for neonates

 D

b and c

Ans. D

Explanation:

Ans:D.)b and c  : B. i.e. Intubation can be done; C i.e. Size 1 for neonates

– Laryngeal mask airway (LMA)  is an alternative airway intermediate between the face mask and endotracheal tube in terms of anatomical position, invasiveness, reliability & security to protect airway & facilitate gas exchange.

– LMA does not require any laryngoscope, visualization-muscle relaxants or specific position of cervical spine.

– It is used if difficult intubation  is indicated, for difficult airway management during CPR, in emergency and to facilitate ventilation & passage of ETT in patient with difficult airway.

–  Size 1 LMA is used in neonates and size 3 in children & small adults (30-50 kg) .

– Oropharyngeal abscess or mass and risk of gastric regurgitation & aspiration is a contraindication to the use of laryngeal mask airway.


Q. 16

During laryngoscopy and endo-tracheal intubation which of the maneuver is not performed:

 A

Flexion of the neck

 B

Extension of Head at the atlanto-occipital joint.

 C

The laryngoscope is lifted upwards levering over the upper incisors.

 D

In a straight blade laryngoscope, the epiglottis is lifted by the tip.

Q. 16

During laryngoscopy and endo-tracheal intubation which of the maneuver is not performed:

 A

Flexion of the neck

 B

Extension of Head at the atlanto-occipital joint.

 C

The laryngoscope is lifted upwards levering over the upper incisors.

 D

In a straight blade laryngoscope, the epiglottis is lifted by the tip.

Ans. C

Explanation:

Ans:C i.e. The laryngoscope is lifted upward levering over the upper incisiors.

Procedure of Endotracheal Intubation:

  • The correct position is with the lower part of the cervical spine flexed (by placing a pillow or other suitable pad under the patient’s occiput), and the atlanto-occipital joint extended(by tilting the head back) – the so-called “sniffing position”. This position aligns the axes of the mouth, pharynx and trachea, and will give the best visualization of the cords during laryngoscopy.
  • In a Straight Blade Laryngoscope,lift the epiglottis with the tip of the blade.

Q. 17

Malampatti grading is for

 A

Mobility of cervical spine

 B

Mobility of atlanto axial joint

 C

Assessment of free rotation of neck before intubation

 D

Inspection of oral cavity before intubation

Q. 17

Malampatti grading is for

 A

Mobility of cervical spine

 B

Mobility of atlanto axial joint

 C

Assessment of free rotation of neck before intubation

 D

Inspection of oral cavity before intubation

Ans. D

Explanation:

D i.e. Inspection of oral cavity before intubation

Malampatti grading is for assessment of difficult air way (inspection of oral cavity for intubation)Q


Q. 18

Nasal intubation is contra indicated in

 A

CSF Rhinorrhea

 B

Fracture cervical spine

 C

Fracture mandible

 D

Short neck

Q. 18

Nasal intubation is contra indicated in

 A

CSF Rhinorrhea

 B

Fracture cervical spine

 C

Fracture mandible

 D

Short neck

Ans. A

Explanation:

A i.e. CSF Rhinorrhea

Nasal (naso-tracheal) intubation is required when oral (orotracheal) tube will interfere with surgery (eg intraoral surgery) and may be indicated when oral intubation is difficult (eg inability to open month). It provides good oral hygiene and more secure fixation with less chances of displacement and extubation. But it is more commonly a/w significant nasaVmucosal bleeding, submucosal placement, transient bacteremia (infection), sinusitis and otitis mediaQ. These side effects make nasotracheal intubation contraindicated in base of skull fracture, CSF rhinorrheaQ, nasal abnormalities and trauma and coagulopathy.


Q. 19

A 40 year old man who met with a motor vehicle catastrophe came to the casualty hospital in an hour with severe maxillofacial trauma. His Pulse rate was 120/min, BP was 100/70 mm Hg, Sp02 – 80% with oxygen. What would be the immediate management – 

 A

Nasotracheal intubation

 B

Orotracheal intubation

 C

Intravenous fluid

 D

Tracheostomy

Q. 19

A 40 year old man who met with a motor vehicle catastrophe came to the casualty hospital in an hour with severe maxillofacial trauma. His Pulse rate was 120/min, BP was 100/70 mm Hg, Sp02 – 80% with oxygen. What would be the immediate management – 

 A

Nasotracheal intubation

 B

Orotracheal intubation

 C

Intravenous fluid

 D

Tracheostomy

Ans. B

Explanation:

B i.e. Orotracheal intubation

– ABCDE of trauma care includes Airway maintenance and cervical spine protection, Breathing and ventilation, Circulation with haemorrhage control, Disability and neurological assessment and Exposure (undress) to assess for other injures. So option C is excluded. And decreased 02 saturation (80%) with oxygen (most probably through mask or nasal tube) indicate that patient needs tracheal intubation. The tube in trachea can be put via nose (nasotracheal), via oral cavity (orotracheal) or trachea itself (tracheostomy).

–  Ideally tracheostomy should be performed under GA. And technically tracheostomy with an awake local anesthetic in a patient with severe airway compromise is difficult because the ideal positioning with an extended head and supine is often not tolerated by patient, and the procedure is to be undertaken in a semi upright sitting position. Because tracheostomy is a relatively time taking procedure in comparison to intubation, it does not have much role in emergency airway managementQ. Tracheostomy is usually done when immediate 02 requirements are taken care of by rapid intubation and prolonged intubation is plannedQ (>1 to 2-3 weeks). However, if intubation is impossible, cricothyroidotomy is an emergency procedure. So option D is excluded.

Orotracheal intubation using rapid sequence induction is the technique of choice for resuscitationQ. And nasotracheal intubation is preferred in awake patients. But it is important to understand that in case of maxillary fracture, awake intubation is not possible. Nasotrached intubation is contraindica in severe mid facial injuryQ. So for maxillary fracture, orotracheal intubation is method of choice for immediate management of hypoxia.


Q. 20

Both Oral and Nasal intubation are C/I

 A

Laryngeal endema

 B

CSF – Rhinorrhoea

 C

Comastose patient

 D

Acute Tracheo – Laryngo – bronchitis

Q. 20

Both Oral and Nasal intubation are C/I

 A

Laryngeal endema

 B

CSF – Rhinorrhoea

 C

Comastose patient

 D

Acute Tracheo – Laryngo – bronchitis

Ans. D

Explanation:

D i.e. Acute Tracheo – Laryngo – bronchitis


Q. 21

True about endotracheal intubation (during the process) is all except:

 A

Hypertension & tachycardia

 B

Raised IOT

 C

Raised ICT

 D

Increased esophageal peristalsis

Q. 21

True about endotracheal intubation (during the process) is all except:

 A

Hypertension & tachycardia

 B

Raised IOT

 C

Raised ICT

 D

Increased esophageal peristalsis

Ans. D

Explanation:

D i.e. Increased esophageal peristalsis


Q. 22

A 27 year old female was brought to emergency department for acute abdominal pain following which she was shifted to the operation theatre for Laparotomy. A speedy intubation was performed but after the intubation, breath sounds were observed to be decreased on the left side and a high end tidal CO2 was recorded.

The likely diagnosis is:

 A

Endotracheal tube blockage

 B

Bronchospasm

 C

Esophageal intubation

 D

Endobronchial intubation

Q. 22

A 27 year old female was brought to emergency department for acute abdominal pain following which she was shifted to the operation theatre for Laparotomy. A speedy intubation was performed but after the intubation, breath sounds were observed to be decreased on the left side and a high end tidal CO2 was recorded.

The likely diagnosis is:

 A

Endotracheal tube blockage

 B

Bronchospasm

 C

Esophageal intubation

 D

Endobronchial intubation

Ans. D

Explanation:

D i.e. Endobronchial intubation 


Q. 23

Intubation dose of pancuronium

 A

0.02 mg/Kg

 B

0.04 mg/Kg

 C

0.06 mg/Kg

 D

0.08 mg/Kg

Q. 23

Intubation dose of pancuronium

 A

0.02 mg/Kg

 B

0.04 mg/Kg

 C

0.06 mg/Kg

 D

0.08 mg/Kg

Ans. D

Explanation:

D i.e. 0.08 mg/Kg 

Pancuronium is commonly used MR. d/t lack of S/E like flushing, bronchospasm as it causes less histamine release. It causes hypertension by releasing Noradrenaline and is safe in malignant hyperpyrexia. Dose for intubation is 0.08-0.12 mg/kgQ


Q. 24

In a young patient who had extensive soft tissue and muscle injury, which of these muscle relaxants used for endotracheal intubation might lead to cardiac arrest :

 A

Atracurium

 B

Suxamethonium.

 C

Vecuronium

 D

Pancuronium

Q. 24

In a young patient who had extensive soft tissue and muscle injury, which of these muscle relaxants used for endotracheal intubation might lead to cardiac arrest :

 A

Atracurium

 B

Suxamethonium.

 C

Vecuronium

 D

Pancuronium

Ans. B

Explanation:

B i.e. Suxamethonium


Q. 25

During endotracheal intubation, unilateral breath sounds, no air heard entering the stomach and no gastric distension is suggestive of entry of the endotracheal tube into –

 A

Right main bronchus

 B

Oesophagus

 C

Mid-trachea

 D

Left main bronchus

Q. 25

During endotracheal intubation, unilateral breath sounds, no air heard entering the stomach and no gastric distension is suggestive of entry of the endotracheal tube into –

 A

Right main bronchus

 B

Oesophagus

 C

Mid-trachea

 D

Left main bronchus

Ans. A

Explanation:

Ans. is ‘a’ i.e., Right main bronchus


Q. 26

In a one-year-old child intubation is done using:

 A

Straight blade with uncuffed tube

 B

Curved blade with uncuffed tube

 C

Straight blade with cuffed tube

 D

Straight curved blade with cuffed tube

Q. 26

In a one-year-old child intubation is done using:

 A

Straight blade with uncuffed tube

 B

Curved blade with uncuffed tube

 C

Straight blade with cuffed tube

 D

Straight curved blade with cuffed tube

Ans. A

Explanation:

 

Pediatric Airway Management – Equipment                               .

  • Tracheal intubation remains the standard for airway maintenance during many procedures.
  • Generally, a tracheal tube of the largest possible internal diameter should be chosen to minimize resistance to gas flow and avoid an excessive leak around the tube. It is important, however, to avoid inserting too large tube, which may cause mucosal damage.

The length of the tube is calculated as:

Length =+ 12 cm For orotracheal intubation Length = + 15 cm For nasotracheal intubation

  • Uncuffed tubes are used in children – as there is potential for mucosal damage with the cuffed tubes (with high volume, low pressure cuffs)
  • In older children approaching puberty – Cuffed endotracheal tubes are used, reflecting the anatomical development of the airway.
  • Endotracheal tubes are available in a variety of materials although the use of PVC and silicone rubber is now almost universal.
  • As far as blades are concerned – A huge range of laryngoscopes blades are available. Anatomical considerations and to some extent personal choice, determine the most appropriate blade to use. In general, position of the infant larynx and the long epiglottis makes intubation easier with a straight blade and are often used in children under 6 months of age. So from above description, it is clear that in children straight blade with uncuffed tube is the best for intubation.

Q. 27

Proper technique of endotracheal intubation involves:

March 2012

 A

Flexion of neck

 B

Flexion of the neck and extension of the atlanto­occipital joint

 C

Extension of the neck

 D

Extension of the neck and flexion of the atlanto­occipital joint

Q. 27

Proper technique of endotracheal intubation involves:

March 2012

 A

Flexion of neck

 B

Flexion of the neck and extension of the atlanto­occipital joint

 C

Extension of the neck

 D

Extension of the neck and flexion of the atlanto­occipital joint

Ans. B

Explanation:

Ans: B i.e. Flexion of the neck and extension of the atlanto-occipital joint

Optimal head and neck positioning while intubation is obtained by flexion of the neck and extension of the atlanto-occipital joint


Q. 28

Which of the following is the most common complication related to intubation: 

March 2009

 A

Bleeding

 B

Malposition

 C

Sore throat

 D

Abductor paralysis

Q. 28

Which of the following is the most common complication related to intubation: 

March 2009

 A

Bleeding

 B

Malposition

 C

Sore throat

 D

Abductor paralysis

Ans. C

Explanation:

Ans. C: Sore Throat

Complications after intubation:

  • Trauma to the lips, teeth, and soft tissues of the airway.
  • Bronchial injury
  • Laryngospasm

– Common when extubation is done when the patient is in a semiconscious state

– Extubation should be done in a relatively deep anaesthesia or when the protective laryngeal reflex has returned

Postintubation hoarseness and sore throat

– It is the most common post-operative complication

– Due to mechanical presence of the tracheal tube


Q. 29

Which of the following is the most common postoperative complication related to intubation:

March 2011

 A

Malposition

 B

Bleeding

 C

Sore throat

 D

Abductor Paralysis

Q. 29

Which of the following is the most common postoperative complication related to intubation:

March 2011

 A

Malposition

 B

Bleeding

 C

Sore throat

 D

Abductor Paralysis

Ans. C

Explanation:

Ans. C: Sore throat

Sore throat (pharyngitis, laryngitis) is the most common post-operative complication of intubation It usually subsides within 2-3 days without any treatment


Q. 30

Which of the following is contraindicated during endotracheal intubation:                         

March 2011

 A

Head elevation

 B

Preoxygenation with 100% oxygen

 C

Introduction of blade toward the right side of oropharynx

 D

Neck flexion at atlanto-occipital joint

Q. 30

Which of the following is contraindicated during endotracheal intubation:                         

March 2011

 A

Head elevation

 B

Preoxygenation with 100% oxygen

 C

Introduction of blade toward the right side of oropharynx

 D

Neck flexion at atlanto-occipital joint

Ans. D

Explanation:

Ans. D: Neck flexion at atlanto-occipital joint

Technique of intubation includes: Patient should be supine and there should be extension at the Atlanto-occipital joint and flexion at the cervical spine


Q. 31

Injury resembling endotracheal intubation injuries ‑

 A

Smothering

 B

Hanging

 C

Manual strangulation

 D

None of the above

Q. 31

Injury resembling endotracheal intubation injuries ‑

 A

Smothering

 B

Hanging

 C

Manual strangulation

 D

None of the above

Ans. C

Explanation:

Ans. is ‘c’ i.e., Manual strangulation

Artefacts introduced between death and autopsy due to introduction of artificial airway – endotracheal tube/ laryngoscope:

  1. Damage to mouth, lips, gums, palate, teeth, pharynx and larynx – especially in difficult, hurried, emergency situations.
  2. Injuries to the larynx, fracture of the hyoid and thyroid corneae – may be difficult to distinguish from manual strangulation.

Q. 32

Classification showed in the image is used for assessment of ?

 A

Stages of Anesthesia

 B

Stage of Oral Carcinoma

 C

Grading of Trismus

 D

Ease of intubation

Q. 32

Classification showed in the image is used for assessment of ?

 A

Stages of Anesthesia

 B

Stage of Oral Carcinoma

 C

Grading of Trismus

 D

Ease of intubation

Ans. D

Explanation:

Ans:D.)Ease of intubation

Modified Mallampattic Classification is shown in the image.

Modified Mallampati classification

  • In Anesthesia, the Mallampati classification, is used to predict the ease of endotracheal intubation.
  • The test comprises a visual assessment of the distance from the tongue base to the roof of the mouth, and therefore the amount of space in which there is to work.
  • It is an indirect way of assessing how difficult an intubation will be; this is more definitively scored using the Cormack-Lehane classification system, which describes what is actually seen using direct laryngoscopy during the intubation process itself.
  • A high Mallampati score (class 3 or 4) is associated with more difficult intubation as well as a higher incidence of sleep apnea.
  • Modified Mallampati score is a good predictor of difficult direct laryngoscopy and intubation, but poor at predicting difficult bag mask ventilation.
  • The score is assessed by asking the patient, in a sitting posture, to open his or her mouth and to protrude the tongue as much as possible. The anatomy of the oral cavity is visualized.

Modified Mallampatti Scoring.

  • Class I: Soft palate, uvula, fauces, pillars visible.
  • Class II: Soft palate, uvula, fauces visible.
  • Class III: Soft palate, base of uvula visible.
  • Class IV: Only hard palate visible.

Q. 33

An infant with respiratory distress was intubated. The fastest and accurate method to confirm intubation

 A

Capnography

 B

Clinically by auscultation

 C

Chest radiography

 D

Airway pressure measurement

Q. 33

An infant with respiratory distress was intubated. The fastest and accurate method to confirm intubation

 A

Capnography

 B

Clinically by auscultation

 C

Chest radiography

 D

Airway pressure measurement

Ans. A

Explanation:

Ans. a. Capnography

  • Capnography is the surest confirmatory sign of correct intubationQ
  • So, the fastest and accurate method to confirm intubation in the above mentioned infant is capnography

Capnography

  • Capnography is the continuous measurement of end tidal carbon dioxide (ETCO,) and its waveform.
  • Normal: 32 to 42 mmHe (3 to 4 mmHg less than arterial pCO, which is 35 to 45 mmHg)
  • Principle: Infrared light is absorbed by carbon dioxide

Uses of Capnography

  • It is the surest confirmatory sign of correct intubation  (esophageal intubation will yield ETCO2=0)
  • Intraoperative displacement of endotracheal tube° (ETCO2 will become zero)
  • Diagnosis of malignant hyperthermie (ETCO, may rise to more than 100 mm Hg)
  • For detecting obstructions and disconnections of endotracheal tubes (ETCO, will fall)

Capnography

Uses of Capnography

  • Diagnosing pulmonary embolism by air, fat or thrombus (sudden fall of ETCO2 occurs. It may
  • become zero if embolus is large enough to block total pulmonary circulation)
  • Exhausted sodalime or defective valves of closed circuit will show high ETCO2 values.
  • To control level of hypocapnia during hyperventilation in neurosurgery
  • Indicator of cardiac output. In cardiac arrest ETCO, is zero.

Q. 34

The laryngoscope shall be held in which hand by a right handed person for the purpose of intubation?

 A

Right hand

 B

Left hand

 C

Either

 D

Neither

Q. 34

The laryngoscope shall be held in which hand by a right handed person for the purpose of intubation?

 A

Right hand

 B

Left hand

 C

Either

 D

Neither

Ans. B

Explanation:

Ans. b. Left hand

laryngoscope should be held in left hand by a right-handed person, for the purpose of intubation.

“Laryngoscope used for intubation is also called as Macintosch’s laryngoscope. It has to be held in the anesthetist’s or surgeon’s left hand for purpose of intubation so that the endotracheal tube can be held in right hand to insert in in trachea. Dexterity of surgeon or anesthetist does not matter in conventional laryngoscope as the curvature of blade is in such a manner that it has to be held in left hand.”

“Laryngoscopes are a left-handed instrument, with the operator’s right hand used to pass the tube. Ever since the early pioneers described the procedure it was appreciated that tongue displacement to one side would facilitate reaching the larynx. Since an operator would want their dominant hand free for instrumentation, the laryngoscope became, by default, a left-handed instrument (appropriate since 85% of the population is right hand dominant).”- http://www. airwaycam.com/laryngoscope-blade-design.html


Q. 35

The first priority in management of a case of head injury with open fracture of shaft of femur is:

 A

Neurosurgery consultation

 B

Give IV fluids

 C

Intubation

 D

Splintage of fracture

Q. 35

The first priority in management of a case of head injury with open fracture of shaft of femur is:

 A

Neurosurgery consultation

 B

Give IV fluids

 C

Intubation

 D

Splintage of fracture

Ans. C

Explanation:

Ans. c. Intubation


Q. 36

Alternative to succinylcholine which muscle relaxant can be used while endotracheal intubation

 A

Atracurium

 B

Pancuronium

 C

Mivacurium

 D

Vecuronium

Q. 36

Alternative to succinylcholine which muscle relaxant can be used while endotracheal intubation

 A

Atracurium

 B

Pancuronium

 C

Mivacurium

 D

Vecuronium

Ans. C

Explanation:

Ans. is ‘c’ i.e., Mivacurium


Q. 37

Drug used for emergency intubation is ‑

 A

Propofol

 B

Ketamine

 C

Eomidate

 D

None

Q. 37

Drug used for emergency intubation is ‑

 A

Propofol

 B

Ketamine

 C

Eomidate

 D

None

Ans. A

Explanation:

Ans. is ‘a’ i.e., Propofol

  • Emergency intubation in anaesthesia refers to rapid sequence anaesthesia (or rapid sequence intubation).
  • Any inducing agent can be used, but thiopental and propofol are the preferred agent.

 


Q. 38

Infra ocular pressure rises in ‑

 A

 Intubation & laryngoscopy

 B

 LMA

 C

 Infusion of IV propofol

 D

 Bag and mask ventilation

Q. 38

Infra ocular pressure rises in ‑

 A

 Intubation & laryngoscopy

 B

 LMA

 C

 Infusion of IV propofol

 D

 Bag and mask ventilation

Ans. A

Explanation:

Ans. is ‘a’ i.e., Intubation & laryngoscopy 

  • Laryngoscopy and intubation of trachea can dramatically increase intraocular pressure to a values as high as 40 mm Hg.
  • Administration of intravenous lignocaine prior to intubation has been found to prevent an increase in IOR
  • IOP changes with LMA insertion are less than those following tracheal intubation.


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