AMERICAN INTERNATIONAL UNIVERSITY OF WEST AFRICA

NURSE ANAESTHESIA PROGRAM

PRINCIPLES & PRACTICES OF ANAESTHESIA IV

MIDTERM EXAMS NS 7 ANSWERS

EACH STATEMENT MUST BE ANSWERED EITHER BY WRITING ‘T’ FOR ‘TRUE’ OR ‘F’ FOR
‘FALSE’ BESIDES IT.

Anesthesia for Eye , ENT, & Dental surgery

1) Anatomy
a) The Orbit has the shape of a regular pyramid F
b) The base is located at the front and the Axis points posterio-medially towards
skull T
c) The depth of orbit is from the rear surface of eyeball to apex , about 25mm T
d) The Globe lies in the posterior part of orbit and sits high and posteriorly. F

2) Orbital fat : divided into 2 compartments by cone of recti muscles

a) Central (retrobulbar, intracone) T
b) Lateral (peribulbar, pericone) F
c) Four rectus muscles arise from the back of orbit T
d) And these muscles insert into the globe just forward of equator to form a cone T

3) Within the cone are the following structures:

a) Optic nerve T
b) Ciliary ganglion T
c) Frontal Nerve F
d) Lacrimal Nerve F
4) Within the Peripheral space contains are the following structures:
a) Trochlear n. T
b) Abducen Nerve F
c) Oculomotor nerve F
d) Infraorbital n T

5) IOP could be increased by:

a) Laryngoscopy T
b) Intubation T
c) Supine position F
d) Trendelenburg position T

6) Anatomy
 Parasympathetic supply
a) Edinger Westphal nu. accompanys III cranial nerve to synapse with short ciliary
nerve in ciliary ganglion T

Sympathetic supply

b) T1 (First thoracic sympathetic outflow) synapses in the superior cervical

ganglion before joining only the short ciliary nerves F
c) Trigeminovagal reflex Triggers traction on EOM (Extra Ocular Muscles) / pressure
on globe T
d) The effect of this traction causes: Bradycardia, AV block, ventricular ectopy, or
asystole. T
7) Oculocardiac reflex
a) Occurs more often with procedures under topical anesthesia. T
b) Retrobulbar blocks do prevent reflex. F
c) Orbital injections cannot trigger response. F
d) Exacerbated by hypercapnia or hypoxemia T

8) Mx of Oculocardiac reflex
a) Ask surgeon to stop manipulations and Ventilatory status is assessed. T
b) If significant bradycardia persists or recurs, i.v atropine in 7 µg/kg increments. T
c) Pretreatment with intravenous atropine or glycopyrrolate may not be effective. F
d) In pt. with h/o conduction block, vasovagal responses, or β-blocker t/t T

9) Intra-ocular Pressure
a) Blood supply to retina and optic nerve depends on intraocular perfusion
pressure. T
b) Intraocular perfusion pressure = MAP + IOP. F
c) High IOP impairs blood supply leading to loss of optic nerve function T
d) After incision in globe, increase IOP can cause prolapse and loss of intraocular
contents thus permanent vision loss. T

10) Inhaled anesthetics

a) Inhalational anesthetics decrease IOP in proportion to depth of anesthesia T
b) They cause a drop in blood pressure reduces choroidal volume T
c) Relaxation of EOM (Extra Ocular Muscles) increases wall tension F
d) Pupillary constriction facilitrates aqueous outflow. T

11) Intravenous Anaesthetics

 a) Intravenous anesthetics drugs decrease IOP T
b) Exception is ketamine, which usually raises arterial blood pressure T

Muscle relaxants

c) Succinylcholine increases IOP by 6—12 mm Hg for 5—10 minutes principally

through prolonged contracture of EOMs (Extra Ocular Muscles). T
d) Nondepolarizing muscle relaxants also increase IOP. F

12) Drugs used: Echothiophate Iodide

a) A cholinesterase inhibitor, echothiophate iodide is used as a miotic agent
(causing constriction of the pupil). T
b) It has no prolong effect of both succinylcholine & ester-type local anesthetics. F
c) Levels of pseudocholinesterase decrease by 30% after 2 weeks on drug. F
d) Succinyicholine and ester-type local anesthetics should be avoided. T

13) Acetazolamide
a) Carbonic anhydrase inhibitor decrease chronically elevated IOP. T
b) Reduces alkaline diuresis - potassium depletion. F
c) Electrolytes should be checked preoperatively T
d) Enhances GA F

14) Complications of retrobulbar block

a) Retrobulbar hemorrhage (MC) : due to inadvertent puncture of vessels within
retrobulbar space T
b) Sign: proptosis (protrusion of the eye ball) & palpable increase in IOP T
c) Subconjunctival ecchymosis (haematoma of the eye) - if extend anteriorly
d) IOP increased - lateral canthotomy - decompress orbit. T
e) Bleeding outside muscle cone - subconjunctival ecchymosis without proptosis. T

15) Management of Foreign body aspiration

a) Common, but a life threatening problem. T
b) Cause of morbidity and mortality. T
c) Can cause chronic lung injury. T
d) Not challanging for anaesthetist. F
16) Foreign body aspiration: Toddlers
a) Oral exploration T
b) Lack posterior dentition T
c) Easy distractibility T
d) Cognitive development (edible?) T

17) Involuntary safety muscular mechanics in adults.

 a) Soft palate is pulled up and posteriorly to prevent reflux of food into nasal
cavities T
b) Palatopharangeal folds move medially to form a slit, allow only chewed food to
pass. T
c) Epiglottis moves down and close to glottis T
d) The tongue does not play a part in this process F

18) Foreign Body Aspiration

a) Vegetable matter in 70-80% T
b) Peanuts & other nuts (20%) F
c) Carrot pieces, beans, sunflower & watermelon seeds T
d) Metallic objects & Plastic objects T

19) Foreign Body Aspiration

a) Organic f.b are more liable to evoke larangospasm T
b) Patients do not often present present with fever, tracheobronchitis and lung
infection. F
c) Vegetable FB are slippery, hard to grip and friable. T
d) They usually get swollen, stuck at the subglottis and may lead to complete
obstruction. T
20) Pathophysiology
a) Most Fb’s are stuck at the bronchi 45 - 50% F
b) Right mainstem most common at the carina T
c) At the more divergent angle F
d) The more divergent angle has the greater diameter F
21) Types of Obstruction
a) Check valve: air can be exhaled but not inhaled.[emphysema]. F
b) Ball valve: air can be inhaled but not exhaled.[broncho pul segment collapse]. F
c) Bypass valve: FB partially obstructs both in insp. and exp. T
d) Stop valve: total obstruction, airway collapse and consolidation. T

22) Presentation
In general, aspiration of foreign bodies produces the following 3 phases:
a) Initial phase - Choking and gasping, coughing, or airway obstruction at the time
of aspiration T
b) Asymptomatic phase - Subsequent lodging of the object with relaxation of
reflexes that often results in a reduction or cessation of symptoms. T
c) This reduction lasts for hours only. F
d) Complications phase - Foreign body producing erosion or obstruction leading to
pneumonia, atelectasis, or abscess. T
23) Foreign Body Aspiration:signs & symptoms include;
 a) Tachepnia, rib and sternal retraction T
b) Cyanosis T
c) Hypoxic seizures T
d) Arrest T

24) Foreign Body Aspiration:signs & symptoms include also;

a) hypoxic brain damage T
b) Asymptomatic interval T
c) 20-50% not detected for one month F
d) Hypertension F

25) Inflammation and Complications are as follows:

a) Cough T
b) Emphysema T
c) Hyperventilation F
d) Obstructive atelectasis T

26) As well as:

a) Hemoptysis T
b) Pneumonia T
c) Lung abscess T
d) Fever T

27) Airway & Chest Injuries

Definition:
a) Airway trauma is any injury that directly involves the airway. T
b) This excludes the location from nasopharynx to the oro-pharynx F
c) It may involve actual damage to the airway or injure bony T
d) This may not include vascular structure that distort airway anatomy. F

28) Incidence:
a) Laryngotracheal trauma(LTT): 0.03% - 2.8% T
b) 40 – 50% die before reaching medical care F
c) Of those who reach tertiary care, 21% die in the first two hours of admission. T
d) Age: 26 – 34 years & Sex: More common in males (75%) T
29) Anatomy
a) Larynx well protected on 2 sides F
b) Posteriorly: vertebral column T
c) Sides: Strap muscles& Sternomastoid T
d) Mandible to sternum is not protected F
30) Anatomy
 a) The entire airway is a fairly free & mobile structure T
b) It is attached inferiorly to the hyoid & intra-thoracically to the lungs. F
c) Platysma key muscle to define penetrating trauma, cervical fascia unyielding. T
d) Cricotracheal ligament – weak & most likely point of airway separation. T

31) Mechanisms of Injury

a) Trauma – Penetrating & Blunt T
b) Thermal & Inhalational injuries T
c) Iatrogenic/ Intubation injuries T
d) Aspiration of foreign body T

32) Penetrating Trauma

a) Complicate 10-15% of trauma cases. F
b) Mortality: 30% F
c) Usually apparent T
d) Causes: Stab, firearm, blast injury and fall on sharp objects T

33) Penetrating Trauma

a) May be high or low velocity injuries T
b) Airway injuries are more common in stab than missile injuries F
c) More common in Zone 2 penetrating injury of the neck T
d) May not be a source of major bleeding F

34) Zones of penetrating injury

Zone 1:

a) Cephalad border of clavicle to cricoid cartilage including the thoracic inlet 3- 7%

T
b) Associated with great vessel injuries, (subclavian vs, jugular vs, common carotid
artery, aortic arch), as well as that of trachea, thyroid, esophagus & pulmonary
contusion. T
Zone 2:
c) cricoid to the angle of the mandible T
d) 60% F

35) Zones of penetrating injury

a) Airway compromise is most likely to occur if wound involves this area. 33%
require emergency airway management. Most require surgical exploration. T
b) Associated with injury to carotid artery, vertebral artery, jugular vein, larynx,
pharynx, cranial nerve X, XI, XII, cervical spine T
Zone 3 :
 c) Angle of the mandible to the skull base and is associated with injury to internal
& external carotid arteries, pharynx, cranial nerves VII, IX, X, XI, XII. T
d) 20% F

36) Blunt Trauma

a) 1 in 30,000 of Emergency Department admissions T
b) Mortality : 40% T
c) Causes: Motor vehicle accidents(MVA), direct blows, crush injuries, clothesline
injuries, strangulation injuries. T
d) Frontal impact MVA: The victim’s head is forced back, neck is hyperextended &
the exposed larynx makes contact with the dashboard & is crushed against the
cervical spine. T

37) Blunt Trauma

a) Direct blows usually cause fractures of the laryngeal cartilages. T
b) Mc- Thyroid(47%) , follollowed by arytenoid(24%) and cricoid(22%). T
c) Tear of the cricotracheal ligament, resulting in complete laryngotracheal
disruption forms (30%). F
d) Intrathoracic airway is prone to injury in blunt trauma chest. These tears are
usually found within 2.5cm of the carina at the junction of the membranous &
cartilaginous portion of the airway. T
38) Blunt Trauma

Associated injuries:

a) Cervical spine( 10 – 50 %) T
b) Esophageal injury T
c) Pulmonary contusion/pneumothorax T
d) Sublingual trauma F

39) Anaesthetic Management of Burns (The rehabilitative management)

Acute phase. Prevention of:
a) Articular limitations T
b) Muscle or tendon contractures T
c) No breathing complications T
d) oedema T

40) The rehabilitative management of burns

 Post-acute phase. Aims:
a) Recovery of muscular tone trophism T
b) Return of patient to normal overall condition T
c) Restoration of patient’s autonomy in 1 year F
d) Skin grafting F
Chronic phase (sequelae). Aims:
a) Scar prevention T
b) Treatment of orthopaedic sequelae T
c) Ttreatment of neurological sequelae T
d) Return of patient to social environment, family, and working life T

41) Various procedures of kinesitherapy

a) Assisted active mobilisation T
b) Active mobilization T
c) Mobilization against resistance T
d) Dynamic proprioceptive re-education T

42) Various procedures of kinesitherapy also include:

a) Stretching & Splinting T
b) Postural sequences T
c) Recommencement of standing (orthostatism) should not be done F
d) Re-education for the recommencement of walking T

43) Respiratory Burns

a) Explosion in distant environment F
b) Flame burns to the face T
c) Shoot in mouth or nostrils T
d) Hoarse and stridor T
44) Electrical Burn
a) Few are flash burns F
b) Flash may reach 40000c T
c) Don’t occur by electrical conduction T
d) Low tension current causes small thickness burns F

45) Electrical Burn

 a) High tension burn causes entry and exit wound T
b) Current passes through the path of highest resistance F
c) Extent of tissue destruction is underestimated but could cause Myonecrosis and
myoglobinuria T
d) High tension burns-arrhythmias T

46) The Degree of Tissue Injury is Dependent on:

a) Voltage of the source T
b) Amperage of current passing through the tissues is irrelevant F
c) Resistance of tissue traversed by current causes less tissue damage F
d) Duration of contact and Pathway of the current T

47) Treatment
a) Moist dressing T
b) Cooling cream T
c) Antiphlogistics T
d) Topical Corticosteroids T

48) Chemical burn

Factors that determine the severity are:
a) Type of chemical and its concentration T
b) Temperature T
c) Contact time T
d) Environment F

49) Chemical burn

a) Acid burns may penetrate deeply down to the bone T
b) Alkali can cause deep dermal or full thickness burn T
c) Acid burns may heal slower than alkalis F
d) Alkali burns tend to have an affinity for staphylococci bacilli F

50) Treatment
a) At scene, cool the tar with cool water. T
b) Removal of the tar is best done using an emulsifying agent such as Tween 80
found in neosporin ointment. Neosporin applications, using a closed dressing,
will soften the tar so it can be gently removed. T
c) Wound management is that for a deep burn is by surgery. F
d) Calcium gluconate T