FACEM Clinical Procedures and Protocols 3 — Questions and Answers
Question 1: When performing a lumbar puncture, which maneuver best confirms correct needle placement in the subarachnoid space before fluid collection?
- Free flow of CSF upon stylet removal (Correct answer)
- Ability to aspirate fluid with a syringe
- Loss of resistance technique
- Fluoroscopic confirmation
Correct answer: Free flow of CSF upon stylet removal
Free flow of CSF upon stylet removal confirms placement in the subarachnoid space; aspiration with a syringe can cause nerve root trauma and collapse the space.
Question 2: A patient requires cardioversion for unstable atrial flutter. What is the appropriate initial synchronized energy setting using a biphasic defibrillator?
- 50–100 J (Correct answer)
- 200 J
- 360 J
- 10–20 J
Correct answer: 50–100 J
Atrial flutter is very sensitive to cardioversion and typically converts with 50–100 J biphasic, making it the appropriate starting energy.
Question 3: During intraosseous access placement in the proximal tibia, needle insertion should occur at which specific site?
- 2 cm below the tibial tuberosity on the anteromedial flat surface (Correct answer)
- Directly over the tibial tuberosity
- Lateral aspect of the tibial head
- 3 cm above the medial malleolus
Correct answer: 2 cm below the tibial tuberosity on the anteromedial flat surface
The proximal tibial IO site is 2 cm below the tibial tuberosity on the flat anteromedial surface, avoiding the growth plate and epiphysis in children.
Question 4: In a patient with massive pulmonary embolism and cardiac arrest, which intervention is an absolute contraindication to thrombolysis?
- Active internal bleeding from an organ (Correct answer)
- Prior CPR lasting >10 minutes
- Blood pressure <90 mmHg
- Age >75 years
Correct answer: Active internal bleeding from an organ
Active internal bleeding from an organ is an absolute contraindication to thrombolysis; CPR alone is not an absolute contraindication in arrest from PE.
Question 5: When using a Seldinger technique for arterial line insertion, after initial arterial puncture and guidewire advancement, resistance is felt. What is the most appropriate next step?
- Withdraw the guidewire and re-flush, confirming pulsatile flow before reattempting (Correct answer)
- Advance the catheter over the wire with additional force
- Remove everything and apply direct pressure for 5 minutes
- Dilate the tract with a scalpel before advancing the wire
Correct answer: Withdraw the guidewire and re-flush, confirming pulsatile flow before reattempting
Resistance to wire advancement suggests vessel wall or valve obstruction; withdrawing and confirming pulsatile flow before reattempting prevents vessel injury.
Question 6: Which depth of endotracheal tube insertion (measured at the lips) is the standard starting point in an average adult male after orotracheal intubation?
- 23 cm (Correct answer)
- 18 cm
- 27 cm
- 15 cm
Correct answer: 23 cm
An initial depth of 23 cm at the lips in adult males places the tube tip approximately 3–4 cm above the carina, confirmed by clinical assessment and chest X-ray.
Question 7: In an obtunded patient with suspected C-spine injury requiring airway management, which technique maintains best cervical spine immobilization during intubation?
- Video laryngoscopy with manual in-line stabilization (Correct answer)
- Blind nasotracheal intubation
- Standard direct laryngoscopy alone
- Fibreoptic intubation with the patient awake
Correct answer: Video laryngoscopy with manual in-line stabilization
Video laryngoscopy combined with manual in-line stabilization (MILS) reduces cervical movement while providing superior glottic visualization in obtunded patients.
FACEM Clinical Procedures and Protocols 3
When performing a lumbar puncture, which maneuver best confirms correct needle placement in the subarachnoid space before fluid collection?