2009 A April Mcq Stu

Front 1

Doing an awake CEA. Patient becomes confused & combative after carotid clamped and opened. Priority is...

a) tell surgeon to release clamp
b) tell surgeon to place shunt
c) induce GA
d) give midazolam

Back 1

Ans B

If the patient becomes confused and restless, stops responding to commands, or simply ceases to communicate, these are all signs of cerebral ischaemia and shunt insertion is indicated.

Howell. Carotid endarterectomy BJA 2007 99(1): 119-31

Front 2

AT28 You intubate a young male patient for a left thoracotomy with a 39FG Robert Shaw tube. When you inflate both cuffs and ventilate the bronchial lumen you get left sided ventilation. When you attempt to ventilate the tracheal lumen the pressures are very high and you get no air entry. Yet when you deflate both cuffs you can ventilate the patient through the tracheal lumen. The most appropriate step to take next is:
A. Change to a 41FG tube
B. Change to a 37FG tube
C. Deflate both cuffs and insert further cm and recheck
D. Deflate both cuffs and withdraw a few cm and recheck
E. Pull ETT out and start again.

Back 2

Ans C
With no air entry, bronchial cuff herniation is likely.
Seymour et al. An audit of Robertshaw double lumen tube placement using the fibreoptic bronchoscope. BJA 2002

Front 3

AT A patient comes to see you in clinic for a pneumonectomy for SCLS. His spirometry shows an FEV1 of 2.5L (>40% predicted). What do you advise about his fitness for surgery?
A. He is not fit for the procedure
B. He is fit for the procedure
C. He needs referral for formal exercise testing
D. He needs a blood gas

Back 3

Answer is B
CEACCP Vol.6 No3, 2006,

Front 4

On bypass, for mitral stenosis repair immediately after cardioplegia the following happens:
MAP to 25
SvO2 80%
CVP1
Next step in management:
A) metaraminol
B) give volume
C) increase pump flows
D) adrenaline infusion
E)

Back 4

Answer A

Initiation of CPB is often associated with a period of hypotension, which can be managed with the administration of an -agonist into the venous reservoir of the ECC circuit. Any hypotension and hypertension that occur despite adequate flow and SvO2 can be treated by adjusting the patient’s SVR with vasoconstrictors or vascodilators.

Miller Anesthesia Chapter 60 Anesthesia for cardiac surgical procedures

Front 5

Redo CABG following median sternotomy surgeon states he has accidentally cut a vein graft, immediately followed by ST elevation on ECG and VF, next action.
A) External defibrillation 200J (Biphasic)
B) Heparin IV then femoral cutdowns for bypass
C) Hand ventilate with 100% oxygen
D) GTN infusion
E) metaraminol

Back 5

Patients undergoing “redo” cardiac surgery (i.e., those who have previously had a median sternotomy) warrant special concern about the possibility of sudden massive hemorrhage. Frequently, the surgeon will elect to use an oscillating saw in these patients, but mediastinal structures adherent to the underside of the sternum may nevertheless be injured. If the RA, right ventricle, great vessels, or an existing coronary graft is cut, the surgeon may elect to initiate CPB on an emergency basis. Therefore, the anaesthesiologist should have a systemic dose of heparin prepared. As soon as the patient is heparinized, the femoral or aortic arterial cannula is inserted, and the cardiotomy suckers may be used to create venous return (the so-called sucker bypass). At least 2 units of blood should also be immediately available for all redo cases.

Miller Anesthesia Chapter 60 Anesthesia for cardiac surgical procedures

Front 6

Mitral valve replacement for Mitral stenosis. Pulmonary artery catheter in situ. Following separation from bypass, copious frank haemoptysis via ETT. Next step in management"
A) Insert double lumen tube
B) Go back on bypass
C) Give protamine
D) Deflate and pull back PAC
E) Perform fibreoptic bronchoscopy

Back 6

Answer B
Chauhan et al Exsanguinating endotracheal hemorrhage during cardiopulmonary bypass. Journal of cardiothoracic and vascular anesthesia Vol15 No3 2001 p377-380

Front 7

Young man on the ward post ORIF # tib/fib. On morphine PCA, high demands/bolus given ratio, used 40mg morphine in last 2 hours (or something else high). Is a bit drowsy but has severe constant leg pain. Next step in management
A. admit to intensive care
B. increase bolus dose morphine PCA
C. decrease lockout interval of PCA
D. organise urgent orthopaedic review
E. give more morphine until comfortable (or something else rubbish)

Back 7

Answer D,
to exclude compartment syndrome

Front 8

Patient with IV in right arm, has mediastinal mass and SVC compression undergoing mediastinal biopsy, suddenly uncontrolled surgical bleeding in mediastinum. Next step in management prior to thoractomy:
A. insert femoral cannulae and place on bypass
B. insert IV in left arm
C. insert IV into foot
D. insert jugular CVC

Back 8

Answer C
Anesthetic Management of Mediastinoscopy Hemorrhage
1. Stop surgery ad pack the wound. There is a serious risk that the patient will get too close to the point of hemodynamic collapse if the surgery anesthesia team does not admit soon enough that there is a problem.
2. Begin the resuscitation and call for help, both anesthetic and surgical
3. Obtain large bore vascular access in the lower limbs.
4. Place an arterial line
5. Prepare for massive hemorrhage with blood warmers and rapid infusers
6. Obtain cross matched blood in the operating room
7. Place a double lumen tube or bronchial blocker if the surgeon believes thoractomy is a possibility
8. Once the patient’s condition is stabilised and all the preparation are made, the surgeon can re-explore the cervical incision
9. Convert to sternotomy or thoracotomy if indicated.

Millers Anesthesia Chapter 59 Anesthesia of thoracic surgery

Front 9

AZ ASA grading was introduced to
A. predict intraop anaesthetic risk
B. Predict intraop surgical and anaesthetic risk
C. Standardise the physical status classification of patients
D. Predict periop anaesthetic risk
E. Predict periop anaesthetic and surgical risk

Back 9

Ans C
Categorization system for statistical studies. Operative risk is not included in the classification system as it is altered by the nature of the surgical procedure.

Ref Saklad Grading of patients for surgical procedures Anesthesiology 1941: 2: 281-4

Front 10

(Shown a CT slice of the neck with a massive tumour that is causing left sided tracheal deviation) The thing that is the most concern to the anaesthetist is:

A. Difficult intubation due to tracheal deviation to the left
B. Difficult intubation due to tracheal deviation to the right.

Back 10

A?

Front 11

Why does a proseal LMA provide a better airway seal?
A. More stable position due to oesophageal tube
B. Doral cuff pushes ventral cuff...?
C. Presence of oesophageal lumen
D. Higher cuff pressure
E. ?

Back 11

Ans B
A dorsal cuff (pushes the ventral cuff into the periglottic tissues to improve the seal).
Keller et al. Does the proseal laryngeal mask airway prevent aspiration of regurgitated fluid? Anesth Analg 2000;91;1017

Front 12

Which of the following is the most frequent complication after use of LMA?
A. dysphagia
B. dysarthria
C. sore throat
D. hoarse voice
E. dry mouth

Back 12

Ans E

McHardy et al. Postopeartive sore throat: cause, prevention and treatment. Anesthesia 1999, 54 pg 444-453

Front 13

What is true regarding arterial pressure transducer systems
A. Underdamping overestimates systolic BP
B. Underdamping underestimates MAP
C. Compliant tubing?

Back 13

Ans A

Front 14

MM Features of eaton lambert include all EXCEPT...
a) Associated with SCLC
b) improvement with exercise
c) defect in ACh release from motor end plate
d) dry mouth
e) Fatigue with exercise

Back 14

Ans E
Eaton-Lambert syndrome (myasthenic syndrome) is proximal myopathy associated with small cell carcinoma. Reduction in acetylcholine released from presynaptic motor nerve terminals in these patients causes increased sensitivity to all neuromuscular blocking drugs. In contrast to myasthenia gravis, the muscle weakness improves with exercise and is not reversed by acetyl cholinesterase inhibitor therapy.

Ahmed-Nusrath et al. Anaesthesia for mediastinoscopy. CEACCP 2007. 7:1:6-9

Front 15

MC 60 year old vascular patient. ECG given.
Showed large positive R waves in lateral leads, large negative S waves in anterior leads. ST depression laterally  ie LVH with strain; bicuspid p waves
A. LVH with strain
B. Enlarged RA
C. Lateral ischaemia
D. LBBB
E. L posterior hemiblock

Back 15

Depend on ECG
A

Front 16

Pulsus paradoxus is:
A. Reduced BP on inspiration unlike normal (ie normally increased on insp)
B. Reduced BP on inspiration exaggerated from normal
C. Reduced BP on expiration unlike normal
D. Reduced BP on expiration exaggerated from normal
E. ?

Back 16

answer B
> 10 mmHg

Front 17

What antibiotics are required for bacterial endocarditis prophylaxis in a woman with MV prolapse for cholecystectomy.
A. None
B. gentamicin
C. ampicillin and gentamicin
D. ampicillin
E. cephazolin

Back 17

answer - A- gb
Agree with none, so A. This is the link to the new guidelines, http://circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.108.190377

Front 18

Male 60’s sudden onset of chest pain , L arm weakness and hoarse voice, ECG is unchanged from old (T inversion laterally), CXR normal, BP135/80, Pulse 110/min. Next step in management:

A)Aspirin
B)SNP infusion
C)GTN infusion
D)Metoprolol
E)Heparin

Back 18

Ans D
Assuming aortic dissection without aortic regurgitation
recurrent Laryngeal nerve involvement on L side is a relatively common feature.

Oxygen (ABC as indicated)
Detailed medical history and complete physical examination (whenever possible)
HR, BP, and SpO2 monitoring
i.v. line, bloods (Cross match, CK, Troponin, FBC, U & Es, Myoglobin, D-dimer, LDH)
12-lead ECG: documentation of ischaemia
Pain relief (morphine sulphate)
Careful i.v. fluid infusion
BP titration to about 110–120 mm Hg systolic with i.v. esmolol, metoprolol, or labetalol first.
Sodium nitroprusside for further control of blood pressure (calcium channel blockers
if beta-blockers are contraindicated)
Imaging studies at the earliest opportunity
Transfer to theatre/regional cardiothoracic centre/intensive care unit as appropriate

Artery occlusion of left limb may be causing weakness.
Hebballi et al Diagnosis and management of aortic dissection CEACCP 2009 9;1;14-18

Front 19

Plasma glucose level compared to blood glucose level
a)32% higher
b)14% higher
c)same
d)14%lower
e)32% lower

Back 19

Ans B
10-15% higher

Front 20

You are called for a labour epidural. The woman is extremely distressed and in the middle of your consent process states “Just take my pain away” . You:
A. Place epidural then when calmed return to advise her of risks and complications
B. Explain she has to hear all the potential complications and refuse to place epidural without consent
C. Take consent from partner
D. Perform spinal to relieve pain, then consent her for epidural
E. Go away and return when she is more cooperative

Back 20

Ans A

Ref Paech "Just put it in!" Consent for epidural analgesia in labour. Anaesthesia and Intensive Care 2006.34(2)147-9. He clearly states that A is the correct answer. While this is not necessarily what most of us are comfortable with, I suspect this question references that article

Front 21

You are on call for a maternity hospital. Your junior registrar calls you after having inserted a labour epidural in an extremely anxious 19 yo parturient, and obtained blood in the catheter. He informs you the epidural space was found by LOR at 6cm and the catheter has been inserted to 12 cm. Your first instruction should be:
A. Flush with saline and secure and use
B. Aspirate again for blood
C. Give 3mls 2% lidnocaine with 1:200 000 adrenaline
D. Pull back 2cm and check again for blood
E. Remove epidural and start again

Back 21

Ans D
6% of epidural catheters had initial intravenous placement but 46% were made functional by simple manipulations without higher subsequent failure.

ANZCA Management of Regional Anaesthesia for Labour 2008

Front 22

Pre-eclamptic woman BP 180/110. Aim to drop BP to
a) 150-160
b) 140-150
c) 120-130
d) 110-120
e) 100-110

Back 22

Ans B.
ANZCA Management of Pre-eclampsia and Eclampsia 2008

Front 23

Highest likelihood of motor block with labour epidural analgesia:
A)Nurse initiated epidural topups
B)Anaesthetist initiated epidural topups
C)PCEA
D)Continuous epidural infusion
E)All associated with same motor block

Back 23

Ans D
ANZCA Management of Regional Anaesthesia for Labour 2008
PCEA without background infusion reduce local anaesthetic use and motor block when compared with continuous epidural infusion
ANZCA pain book page 189: comparison with continuous epidural (vs PCEA) first study quoted found higher incidence motor block with continuous (but also better pain scores), next paragraph muddies the waters and states that more recent studies have found no difference in side effects (including motor block) ANZCA doesnt give a key message summary here, so I'm going for D. Very nice of them to ask a MCQ when even they are not sure of the answer.
British Journal of Anaesthesia, 2002, Vol. 89, No. 3 459-465 "Patient-controlled epidural analgesia versus continuous infusion for labour analgesia: a meta-analysis" demonstrated the PCEA was associated with less motor block cf CEI.

Front 24

Trauma pregnant patient (?32wks) BP 70/40, P 50, intubated in emergency department, next management step:
A)L tilt pelvis
B)IV fluid bolus
C)Arrange urgent caesarean section
D)Vasopressor options (?Adrenaline, Metaraminol)

Back 24

Ans A.
Basics first, then fluid, then pressor.

Front 25

Emergency caesarean section for foetal distress (and foetal acidosis on scalp probe?). what is best option to raise gastric pH preop:
A)Oral Na Citrate
B)Ranitidine IV
C)Ranitidine oral
D)Omeprazole IV
E)Omeprazole oral
F)Metoclopramide 20 IV

Back 25

A - citrate is best agent to raise pH in an emergency C-section.
Similar questions in future versions have also asked for reduced gastric volume. IV Ranitidine is best single agent for raising pH and lowering volume.

Ref: ANZCA Aspiration prophylaxis for Pregnant Patients Requiring Anaesthesia 2008

Non EM CS it is Combi of NaCitrate po and Ranitidine iv. ANZCA OBS Bible pg 59

Front 26

70 year old man having lung resection for SCC of left lung FEV1 2.3L (? % predicted), FVC 3.5L (? % predicted). Do you...
A. Accept for lobectomy or pneumonectomy
B. Decline pneumonectomy, proceed to lobectomy
C. Cardiopulmonary exercise testing
D. Differential V/Q scan
E. Decline both pneumonectomy and lobectomy

Back 26

Ans A

if the FEV1 is >2L then they are fit for a pneumonectomy as you'd leave them with and FEV1 of >1L.
Anatomy

Front 27

NU Which distinguishes C8-T1 from an ulnar nerve lesion at elbow?
A. Paraethesia of the 5th digit
B. Paraesthesia over index finger
C. Flexor carpi ulnaris function
D. Paraesthesia/sensory loss over medial forearm
E. Adductor pollicis function

Back 27

Ans D
Ulnar Nerve C7-T1
Contains the motor supply to all the small muscles of the hand (except for lateral two lumbricals, opponens pollicis, abductor pollicis brevis, flexor pollicis brevis which is supplied by the median nerve), flexor carpi ulnaris and ulnar half of flexor digitorum profundus.

Answer is D. The medial cutaneous nerve of the forearm arises from the medial cord of the brachial plexus which is prior to the formation of the ulnar nerve.

Front 28

RH Asking the patient to look up and in during a retrobulbar block increases the risk of injury to:
A. Inferior oblique
B. Superior oblique
C. optic nerve
D. globe
E. ophthalmic artery

Back 28

C
When the globe was in the Atkinson “up and in” position, the optic nerve was displaced downward and outward, and a 35 mm needle inserted through the lower eyelid would be in immediate proximity to the optic nerve, and would pass near the ophthalmic artery, superior ophthalmic vein, and the posterior pole of the globe.

Wong, Regional anaesthesia for intraocular surgery CJA 1993 40:7 pp 625-57

The Atkinson “up and in” position of the gaze was abandoned when Liu et al. and Unsöld et al. confirmed that it increased the risk of optic nerve injury. From “regional anaesthesia for eye surgery” Regional Anesthesia and Pain Medicine, Vol 30, No 1 (January–February), 2005: pp 72–82

Front 29

RL A man presents for an ankle fusion. Which of the following combinations will provide the best block:
A. Sciatic nerve
B. Common peroneal and saphenous
C. Tibial and saphenous
D. ?Sural and tibial
E. Ankle block

Back 29

Ans A

A Sciatic nerve would be probably be the best option - it splits into the common peroneal and tibial somewhere in the popliteal fossa and is indicated for surgery involving lower leg, ankle foot. You might miss part of the saphenous nerve innervation but you might get away with it.

Front 30

RN18 Stellate ganglion block associated with all except:
A. Ptosis
B. Miosis
C. Sweating
D. Facial flushing
E. Nasal stuffiness

Back 30

Ans C
Sympathetic denervation to the head is documented easily by the presence of a Horner’s syndrome: miosis (pinpoint pupils), ptosis (drooping of the upper eyelid), and enophthalmos (sinking of the eyeball). Associated finding include conjunctival injection, facial anhidrosis, and nasal congestion.

Rauck. Stellate Ganglion block. Techniques in Regional Anesthesia and Pain Management, Vol5 no 3 July 2001 pp 88-93

Front 31

Spinal anaesthesia, T3 level
a) bradycardia due to unapposed vagus
b) autonomic response more if lever higher

Back 31

A

Front 32

18yo patient in a psych unit, being treated for frequent vomiting. Collapses and found unconscious.
ABG's:
pH 7.22
CO2 40
PO2 100
HCO3 16
Na 138
K 4.0
Cl 105
Diagnosis is:
A. anorexia nervosa
B. diabetic ketoacidosis
C RTA
D. Normal saline administration
E) Gastric outlet obstruction

Back 32

Ans B
The gas definitely showed a metabolic acidosis with AG 21; pO2 was safe.
High anion gap metabolic acidosis with normal chloride - only one that fits is DKA. B
Anion gap = Na – (Cl + HCO3) (ref range 8-16 average 12 mmol/L)
Delta ratio = (Anion gap – normal (12))/(normal bicarb (24) – bicarb)

Front 33

60yo with history of hypertension. Presents with chest pain, hoarse voice, left arm weakness. Has lateral T-wave changes on ECG, also present on an old ECG. Heart rate 110, BP 130/80 (definitely this value), SpO2 96% or something. First drug to give:
A. aspirin
B. metoprolol
C. GTN
D. nitroprusside
E. Heparin

Back 33

B

Front 34

Trauma patient with GCS 6 with hard collar. HR and BP unstable. What is the best way of clearing neck?
A. CT
B. Cervical spine trauma series
C. MRI
D. Leave had collar indefinitely??
E. Clinically

Back 34

Ans D
Not indefinitely, until patient is stable enough to have a CT
Harrison et al. Clearing the cervical spine in the unconscious patient CEACCP 2008 8;4 pp 117-120

Front 35

Patient (?48h post) SAH following bloods:
Na 155
Plasma osmolality 350
urine osmolality 250
Management includes:
A)DDAVP (?nasally)
B)Water restriction

Back 35

Ans A
After brain injury hypernatraemia is most commonly related to the development of central diabetes insipidus or the overzealous use of osmotic diuretics such as mannitol.

In the context of brain injury the diagnosis of DI is made in the presence of
1. Increased uine volume (usually >3000 mL per 24 hour
2. High serum sodium (>145 mmol/L)
3. High serum osmolality (>305 mmol/kg)
4. Abnormally low urine osmolality (<350 mmol/kg)

There are two aims in the management of DI
1. Replacement and retention of water
2. Replacement of ADH

In unconscious patients fluid replacement is achieved with water administered via a nasogastric tube or iv 5% dextrose. Excessive fluid input is a risk in unconscious patient and treatment should be guided by accurate assessment of volume status. If urine output continues >250 ml/hr, synthetic ADH should be administered. This is usually in the form of small titrated doses of 1-deamino-8-D-arginine vasopressin which can be given intranasally (100-200 mg) or iv (0.4 mcg).

Bradshaw et al. Disorders of sodium balance after brain injury CEACCP 2008 8;4;129-33

Front 36

Alt 6 hour post pituitary surgery, Serum Na 153, next step in management
a)Dext 5%
b)Normal saline
c)DDAVP
cant remember other options

Back 36

Ans A or C depend on situation

When the diagnosis of diabetes insipidus is established, an appropriate fluid management regimen is hourly maintenance fluids plus two thirds of the previous hour’s urine output. (An acceptable alternative is previous hour’s urine output minus 50 ml plus maintenance.) The choice of fluid is dictated by the patient’s electrolyte picture. Generally, the patient is losing fluid that is hypo-osmolar and relatively low in sodium. Half-normal saline and 5% dextrose in water are commonly used as replacement fluids. Hyperglycaemia is a risk when large volumes of 5% dextrose in water are employed. An unacceptable fluid regimen that has been employed calls for maintenance fluid plus previous hour’s urine output. This has the potential to put the anaesthesiologist and the patient in a “chase your tail” situation. Should the patient become iatrogenically fluid overloaded, this regimen precludes his or her returning to isovolemia, and when the maintenance fluid allowance is generous, it guarantees that the patient will become increasingly hypervolemic. If the hourly requirement exceeds 350 to 400 mL, desmopressin (DDAVP) is usually administered.

Miller’s Anesthesia Chapter 63 Neurosurgical Anesthesia

Front 37

Neonate if febrile with rash and periodic breathing. which is likely ABG?
a) metab acidosis resp acidosis
b) metab acidosis compensated
c) resp acidosis
d) alkalosis
e) alkalosis

Back 37

Ans B
Khan et al. Measurement of the CO2 apneic threshold innewborn infants: possible relevance for periodic breathing and apnea J, Appl Physiol 98: 1171-1176, 2005

Neonates breathe very close to their PCO2 apneic threshold. We speculate that this closeness of eupneic and apneic PCO2 thresholds confers great vulnerability to the respiratory control system in neonates, because minor oscillations in breathing may bring eupneic PCO2 below threshold, causing apnea.

Periodic breathing may be observed for 2-6% of the breathing time in healthy term neonates and as much as 25% of the breathing time in preterm neonates. The occurrence of periodic breathing is directly proportional to the degree of prematurity.

Kelly and co-workers observed periodic breathing in 78% of neonates examined at 0-2 weeks of age. The incidence substantially declined to 29% at postconceptual ages of 39-52 weeks.

Front 38

2 month old systolic murmur heard at apex no change with posture, now on 5th percentile for weight after being on 30th at birth, mother states has difficulty feeding. Peripheral pulses reduced femoral more than upper body. Most likely cause:
A. HOCM
B. VSD
C. PDA
D. venous hum
E. ASD

Back 38

Answer C

Best answer. Continuous murmur classically but can be systolic only. Unequal pulses however are more commonly associated with coarctation of the aorta.

PDA - collapsing pulse with sharp upstroke from ejection of large volume of blood into empty aorta during systole, low diastolic pressure due to rapid decompression of aorta, hyperkinetic apex, single S2 if large or even reversed splitting of S2, continuous loud "machinery murmur at 1st LIC space. sometimes associated with flow murmur through left heart eg. mitral mid diastolic murmur. (Talley + O'Connor 3rd Ed.)

If the pulmonary-to-systemic blood ratio approaches or exceeds 2:1, an apical flow rumble, caused by high flow into the left ventricle, is frequently present. Also, because flow through the left ventricle into the aorta is increased, an aortic ejection murmur may be present. History of difficulty feeding, low birth wt or poor growth, prematurity. www.emedicine.medscape.com

Front 39

4 yr old presents for elective surgery, otherwise fit healthy, murmur at left sternal edge on auscultation heard in systole and diastole, disappears on lying down. Most likely cause:
A. HOCM
B. VSD
C. PDA
D. venous hum
E. ASD

Back 39

Answer : D
Venous Hum - systolic + diastolic components, not really a murmur. Benign medical condition where 20% of the blood flows to the brain and back to the heart. Due to the large amount of blood it can move quite fast causing the vein walls to vibrate which can create a humming noise to be heard by the patient. The murmur disappears when the patient is in the supine position. Tally&O'connor 3rd Ed p79-83

Continuous murmur PDA, aorticopulmonary window defect, aortic or pulmonary stenosis combined with insufficiency (to and fro murmur).

Front 40

18/12 old undergoing routine SV GA under LMA. Sudden onset SVT with HR 220 BP 84/60 ETCO2 32 SpO2 98.Management:
A. Adenosine 100mcg
B. DCR 2J/kg
C. DCR 4J/kg
D. Amiodarone 5mg/kg
E. CPR

Back 40

Ans A, but suspect it should be 100mcg/KG
ARC Management of specific arrhythmias in paediatric advanced life support. 2006

Pt is maintaining a good BP and sats. Cardioversion not indicated. 1st line treatment would be adenosine 100 mcg/kg

Front 41

What is the appropriate LMA size for an 8kg child:
A. 1
B. 1.5
C. 2
D. 2.5
E. 3

Back 41

Ans B

LMA sizes (Drug Doses Frank Shann Book)
<5kg = 1,
5-10kg = 1.5,
10-20kg = 2,
20-30kg = 2.5,
30-50kg = 3.0,
50-70kg = 4.0,
70-100kg = 5.0,
>100kg = 6

Front 42

Neonate born to known drug abusing mother brought to emergency department by grandmother, unwell lethargic, slightly jaundiced, ABG shows following:
pH 7.52
Na 135
Cl 87
K 3
pCO2 38
Which of the following is the Diagnosis?
A) Septicaemia
B) Hepatitis
C) Pyloric stenosis
D) Pneumonia
E) Opioid withdrawl

Back 42

Ans C
Hypokalaemic, hypochloraemic metabolic alkalosis; classic for pyloric stenosis.

Front 43

15kg child found fitting on paeds ward ?24h ?48h postop while on infusion of 60ml/h ½ NS + Dextrose. Now intubated. Na is 119, next management step:
A) frusemide
B) hypertonic saline
C) Normal saline at 20ml/hr
D) Water restrict
E) Phenytoin

Back 43

Ans B.
Symptomatic hyponatraemia = hypertonic saline.

The hyponatraemic child with seizure or CNS depression
 Notify ICU urgently
 Resuscitation ABC and iv anticonvulsants as clinically indicated. Hyponatraemic seizures often respond poorly to conventional anticonvulsants, and sodium correction should not be delayed. The sodium should be raised until it reaches 125 mmol/L or until seizures stop, whichever occurs first.
 IV 3% NaCl solution. It is stored in the resuscitation trolleys on the wards, in the ICU and ED. Give 4 mL/kg of 3% NaCl. Give over 15-30 minutes. This will raise the serum sodium by 3 mmol/L and will usually stop the seizures. 3% saline is hypertonic and should be given through a central venous line where possible. However do not delay administration in a fitting child to put in a central line. Careful use of a peripheral IV line is suitable in an emergency.
 Measure the serum Na after the first bolus. Ongoing seizures and persistent hyponatraemia will require more 3% NaCl.
 Many children with hyponatraemia and seizures will have other reasons for seizures (fever, meningitis, hypoglycaemia), and these should also be addressed.
 After the seizures have resolved the total sodium correction (including the bolus) should not exceed 8 mmol/L/day. (e.g. 122-130 mmol/L)
 Measure electrolytes every 2 hours until stable, then every 4-6 hours until the serum sodium is normal and the child is off iv fluid.

RCH Clinical Practice Guidelines

Front 44

PN: A man on PCA controlled with 2 mg morphine bolus is having a lot of pruritus. You decide to switch him to fentanyl. Which dose is the most appropriate bolus to be equi-analgesic with morphine 2mg:
A. 10mcg
B. 20mcg
C. 40mcg
D. 60mcg
E. 80mcg

Back 44

Ans B

Front 45

A patient with chronic pain using morphine PCA after lower limb orthopaedic surgery. Daily usage of IV morphine works out at about 400mg/day. What dose of oral methadone would you start him on to replace the morphine?
A. 60mg/day
B. 120mg/day
C. 400mg/day
D. 600mg/day
E: 1200mg/day

Back 45

Ans A
400 mg iv = 1200 mg po
>1000 morphine  20:1
60 mg methadone po

Methadone replacement depends on dose of oral morphine
Daily Dose : Conversion Ratio
<100mg 3:1
100 - 300mg 5:1
300 - 600mg 10:1
600mg - 800mg 12:1
800mg - 1000mg 15:1
>1000mg 20:1

Front 46

PR For muscle relaxant,placing the nerve stimulator to stimulate FPB (Flexor pollicis brevis) compared to Abductor pollicis brevis is likely to
A. show a slower recovery to NMB
B. show the same recovery
C. show a faster recovery to NMB Cannot remember other options

Back 46

Ans B
Likely flexor hallicus brevis. That would make a lot more sense as when you stimulate the ulnar nerve both APB and FPB can be stimulated but no one actually monitors FPB. On the other hand FHB would make sense as you may not have access to the arm (or can't see it).

Monitoring neuromuscular block: an update Anaesthesia Volume 64, Issue s1, Pages 82-89
It has been show that quantitative measurement of neuromuscular recovery at this site (flexor hallucis brevis) does not differ significantly from measurements made at the ulnar nerve-adductor pollicis muscle.

Front 47

EM66 Aneursym clipping, BEST monitor of depth of block during this is
A. TOFR
B. TOFC
C. DBS
D. PTC

Back 47

D

Front 48

Closed circuit anaesthesia with 70%N2O,70kg man (low flow i think) what is the uptake of N2O after 90 mins anaesthesia:
A. less than 50ml/min
B. 100ml/min
C. 200ml/min
D. 500ml/min
E. 1000 ml/minut

Back 48

Ans B
The average rate of uptake of N2O in six subjects was described approximately by the equation:
Rate= 1000/t (ml/min)

Uptake in the first minute = blood gas partition coefficient x cardiac output x MAC as a fraction of 1 atm
Severinghaus equation
uptake = solubility x CO x A-V difference x proportion of inspired gas mix.
Miller Anaesthesia
Severinghaus. The rate of uptake of nitrous oxide in man. The journal of clinical investigations 1954. 1183-9

Front 49

Rapid infusion of mannitol IV initially causes:
A. Raised ICP
B. Reduced CBF
C. Reduced K
D. Reduced Na
E. ?

Back 49

Ans A
A. The physical bolus of Mannitol causes an initially transient increase in patient with normal ICP due to transient increase in cerebral blood flow and volume, then decreases as interstitial water is drawn out.
Abou-Madi Does a bolus of mannitol initially aggravate intracranial hypertension? BJA vol 59;5;pp 630-639
C. increase potassium through solvent drag and passive potassium efflux through potassium channels in cell membranes because of water loss.
D. Increase mannitol in plasma creates apparent hyponatraemia
Mannien et al The effect of high dose mannitol on serum and urine electrolytes and osmolality in neurosurgical patients Canadian Journal of Anaesthesia 1987 34:5 pp 442-6

Front 50

Granisitron, which is incorrect:
A) Decreased serotonin release
B) Metabolism by carbamoyl ?...
C) 5HT3 antagonism

Back 50

A
westmead page 242

Front 51

Who has got minimum effect on ICP at 1 MAC
a)isoflurane
b)sevoflurane
c)desflurane
d)enflurane
e)halothane

Back 51

B

The important clinical consequences of administration of volatile anesthetics are derived from the increases in CBF and CBV and consequently ICP that can occur. Of the commonly used volatile anaesthetics, the order of vasodilating potency is approximately
Halothane>>enflurane>desflurane~isoflurane>sevoflurane
Miller’s anaesthesia Chapter 13 Cerebral Physiology and the Effects of Anesthetic Drugs

Front 52

PH An ABG showing a raised anion gap. Which of the following would explain this ABG?
A. Salicylate poisoning
B. DKA
C. Lactic acidosis
D. 6L of normal saline (or did this option belong to another Q?)

Back 52

A,B,C can all cause an raised anion gap but salicylate poisoning is the weird one that causes a respiratory alkalosis beyond what is expected in compensation.

Front 53

Young woman with subarachnoid haemorrhage, hyponatraemia and increased urinary sodium (did not specify if high sodium concentration or total amount lost). What is likely cause?
A. cerebral salt wasting syndrome
B. SIADH
C. HHH therapy
D. Excess NS administration
E. diabetes insipidus

Back 53

Ans A or B
CSWS is usually caused by brain injury/trauma or cerebral lesion, tumor, or hematoma. CSWS is a diagnosis of exclusion and may be difficult to distinguish from the syndrome of inappropriate antidiuretic hormone (SIADH), which develops under similar circumstances and also presents with hyponatremia. The main clinical difference is that of total fluid status of the patient: CSWS leads to a relative or overt hypovolemia whereas SIADH is consistent with a normal to hypervolemic range. Random urine sodium concentrations tend to be lower than 100 mEq/L in CSWS and greater in SIADH . If blood-sodium levels increase when fluids are restricted, SIADH is more likely. [3]

Front 54

Which of the following can be used to describe the spread of non-parametric data?
A. standard deviation
B. interquartile range
C. confidence interval
D. standard error
E. variance coefficient

Back 54

B
(CEACCP 7(4): 127-130, answer on p129). Jo, Aug 09.