Anzca Final 2013 August

Front 1

AUG2013
1. You are called to see a 30 year old man with rapidly deteriorating asthma. Following appropriate medical management an endotracheal tube is inserted and he is ventilated with a mechanical ventilator with a tidal volume of 600ml and a rate of 12 breaths per minute. Five minutes later the blood pressure is unrecordable and external cardiac massage is commenced. Arterial blood is taked and shows ph 7.08, pCO2 96 mmHg, pO2 36 mmHg, SpO2 46% and bicarbonate 27 mmol/L. He is administered adrenaline, salbutamol, pancuronium, bicarbonate and calcium gluconate. The ECG shows sinus rhythm at a rate of 60 beats per minute. The patient remains pulseless and cyanosed with fixed dilated pupils and distended neck veins. The most appropriate management is to
A. cease resuscitation
B. administer further adrenaline
C. insert bilateral intercostal drains
D. cease ventilation for 30 seconds and resume at a slower rate
E. increase peak inspiratory pressure

Back 1

Answer: D

From Oh's:

Circulatory arrest with apparent electromechanical dis- sociation is a recognised complication that may occur within 10 minutes of intubation and can lead to death or severe cerebral ischaemic injury if not managed cor- rectly.112–114 Standard mechanical ventilation recommen- dations (minute ventilation 115 ml/kg per min) have been estimated to be safe for 80% of patients requiring mechanical ventilation for acute severe asthma, with the remaining 20% requiring a small to moderate reduction in minute ventilation to return DHI to a safe level.97 A small percentage of patients with unusually severe asthma can rapidly develop excessive DHI during initial uncontrolled mechanical ventilation, leading to electro- mechanical dissociation, sometimes despite ‘safe’ levels of minute ventilation. If the cause of this is not immediately recognised, it can lead to prolonged and unnecessary cardiopulmonary resuscitation, unsafe procedures such as intercostal vascular access needles or pericardial taps and risk cerebral injury and death.112–114 When this occurs, immediate disconnection from the ventilator for 60–90 seconds (the ‘apnoea test’; see above) or profound hypoventilation (2–3 breaths/min)54 will diagnose and improve this situation. An even smaller percentage of patients may remain hypotensive despite profound hypo- ventilation with marked hypercapnia, fluid loading and inotropes. These patients may require Heliox delivered by the mechanical ventilator115 or extracorporeal mem- brane oxygenation.

Front 2

AUG 2013
2. A patient known to have porphyria is inadvertently administered thiopentone on induction of anaesthesia. In recovery the patient complains of abdominal pain prior to having a seizure and losing consciousness. Which drug should NOT be given
A. Pethidine
B. Diazepam
C. Haematin
D. Suxamethonium
E. Pregabalin

Back 2

ANSWER: A

No clinical reason to give pethidine. Also could make seizures worse.

Symptoms: severe abdominal pain, N+V, tachycardia, confusion, seizures, hyponatremia. May develop respiratory failure or bulbar palsy (CrN IX, X, XI, XII -> aspiration risk, dysphagia / dysphasia etc)

Diagnosis: Urine PBG levels (does not diagnose ALA dehydratase deficiency, which is rare.

Treatment: IV haem arginate, carbohydrate load

Drugs:

Only IV induction agent: Propofol
Only UNSAFE volatile: Sevoflurane
Bupivicaine and lignocaine are safe. Ropivacaine undetermined.
Morphine and fentanyl are safe. Oxycodone is not.
Ephedrine is unsafe. Metaraminol undetermined. Phenylephrine is safe.
Diclofenac is unsafe. Ibuprofen is safe.

Front 3

AUG 2013 3. A 42 year old lady presents for right pneumonectomy with a left sided double-lumen tube. She is 132kg and 160cm. What depth, measured at the incisors, is likely to give the ideal position?
A. 24cm
B. 26cm
C. 28cm
D. 30cm
E. 32cm

Back 3

Answer: C

29cm depth for 170cm tall.

+/- 1cm for every +/- 10cm of height.

Good correlation between height and depth of insertion.
Poor correlation between height and size of DLETT

DLETT Size: (from Miller 6th ed)
137-165cm: 35-37 Fr
165-178cm: 37-39 Fr
180-193cm: 39-41 Fr

Airways tend to be larger than would be predicted by height in COPD / bronchiectasis

Front 4

AUG 2013
4.What is the most effective method of minimizing acute kidney injury following an elective open abdominal aortic aneurysm repair?
A. give IV crystalloid as a ‘preload’ before cross-clamp
B. give IV mannitol before cross-clamp
C. give IV frusemide before cross-clamp
D. give preoperative N-acetylcysteine
E. minimize aortic cross-clamp time

Back 4

Answer: E

CEACCP

The main cause of renal complications after AAA repair is the decrease in renal blood flow, decreased renal perfusion pressure (outside autoregulation) augmented by the increasing renal vascular resistance (by 30%) associated with aortic clamping. Myoglobin release from ischaemic tissues may contribute to acute tubular necrosis by decreasing local nitric oxide release. Acute kidney injury (AKI) may also be linked to ischaemic – reperfusion injury, decreased renal cortical blood flow, prostaglandin imbal- ance, and increased activity of renin – angiotensin system.10 Postoperative dialysis rates are similar in patients who have under- gone either suprarenal or infra-renal aortic cross-clamping.10 Intraoperative urine output does not correlate with the degree of decrease in glomerular filtration rate (GFR) or the incidence of postoperative AKI.

Front 5

5. [New] Features of severe pre-eclampsia include:
A. Foetal growth retardation
B. Peripheral oedema
C. Systolic BP more than 160
D. Thrombocytopenia
E. Severe proteinuria

Back 5

Answer: C as written.

However, likely poorly remembered, and should be 'all of these except', in which case B.
CEACCP eclampsia article 2003

Severe pre-eclampsia is defined as any one of the following occurring after the 20th week of pregnancy: (i) severe hypertension (systolic blood pressure > 160 mmHg or diastolic blood pressure > 110 mmHg); (ii) proteinuria > 5 g per 24 h; (iii) oliguria < 400 ml per 24 h; (iv) cerebral irritability; (v) epigastric or right upper quadrant pain (liver capsule distension); or (vi) pulmonary oedema.

NICE Guidelines:
If considering magnesium sulphate* treatment, use the following as features of severe pre-eclampsia:

severe hypertension and proteinuria or

mild or moderate hypertension and proteinuria with one or more of the following:
symptoms of severe headache
problems with vision, such as blurring or flashing before the eyes
severe pain just below the ribs or vomiting
papilloedema
signs of clonus (≥3 beats)
liver tenderness
HELLP syndrome
platelet count falling to below 100 x 109 per litre
abnormal liver enzymes (ALT or AST rising to above 70 iu/litre).

Front 6

6. [Repeat] Earliest sign of a high block in a neonate post awake caudal:
A. Increased HR
B. Increased BP
C. Reduced HR
D. Desaturation
E. Loss of consciousness

Back 6

D

Haemodynamic changes are minimal in total spinals in neonates, mainly due to immature SNS. Case reports in literature often list apnoea as first sign of total spinal and the need for ventilation and occasional pharmacologic intervention for blockade of cardiac acceleratory fibres.
Smith’s Anaesthesia for infants and children, p465

Front 7

7.A 20 year old man was punched in the throat 3 hours ago at a party. He is now complaining of severe pain, difficulty swallowing, has a hoarse voice and had has some haemoptysis. What is your next step in his management?
A. Awake Fibreoptic Intubation
B. CT scan for laryngeal fractures
C. Direct laryngoscopy after topicalising with local anaesthetic
D. Nasopharyngoscopy by an ENT surgeon
E. Soft tissue xray of the neck

Back 7

ANSWER: D

A - Blood in airway, likely difficult
B - Patient sounds stable. This would facilitate identification of sub-glottic injuries prior to airway intervention
C - LA may be dangerous. ETT may disrupt trachea
D - As per blue book 2005 article
E - useful for suspected radio opaque foreign bodies. May be useful in epiglottitis.


See UB ‘Blunt Upper Airway Injuries’, which is a blue book article from 2005.

Front 8

8.A 60 year old man with normal LV function is having coronary artery bypass grafting. After separation from the bypass machine he becomes hypotensive with ST elevation in leads II and aVF. The Swan Ganz Catheter showed a PCWP of 25 and CVP of 15 with normal PVR and SVR. The TOE is likely to show:
A. Early mitral inflow > inflow during atrial systole
B. Inferior wall hypokinesis
C. Severe MR
D. TR and RV dilatation
E. LV cavity obliteration at the end of systole

Back 8

ANSWER: B

Consistent with inferior MI and acute LVF

Front 9

11.You are working in a theatre with a line isolation monitor, which is working. You touch a wire. What is going to happen?
A. equipotent earth
B. the theatre floor won't conduct
C. ?
D. ?
E. the RCD will protect you from shock

Back 9

ANSWER: B

From CEACCP:

Isolated (floating) circuits
Isolated or floating circuits (Fig. 2) provide a circuit whereby a connection between the electrical source and earth does not allow current to flow. They are created by the use of an isolat- ing transformer which consists of 2 coils electrically insulated from each other. When alternating current flows through the mains or primary coil, it produces a changing electromagnetic field around it. This induces a current in the patient or sec- ondary coil. The mains circuit is earthed but, importantly, the patient circuit is not earthed (hence floating). Therefore, to form part of this circuit one must connect wires A and B (Fig. 2). Even if you are earthed, contact with wire A or B alone does not complete a circuit and so current cannot flow.
These floating circuits can be used to isolate an entire operat- ing theatre. However, if a fault occurs in one piece of equipment, power may be lost to the entire theatre. In the UK, a floating cir- cuit is generally used to isolate individual instruments.

Front 10

12.What is the test is decreased in Iron deficiency anaemia?
A. microcytosis
B. serum feritin
C. serum iron
D. transferin
E. total iron binding capacity

Back 10

ANSWER B

A. Increased microcytosis
B. Most specific marker. Ferritin below 15g/L is diagnostic. Is an acute phase protein, and can be elevated in inflammation, infection, malignancy and liver disease.
C. Not reliable. Significant diurnal variation. Low in both infection and deficiency.
D. Transferrin goes up
e. TIBC Goes up

Front 11

13. A full size C oxygen cyclinder (size A in New Zealand) has pressure regulated from
A. 16000kpa to 400kpa
B. 16000kpa to 240kpa
C. 11000kpa to 400kpa
D. 11000kpa to 240kpa
E. 7600kpa to 240kpa

Back 11

Answer: A

(Confirmed with Biomed)

16000 x 85% = 13600

Cylinders for gases are filled to 13,700 kPa (2/3 of rated pressure).

Cylinders for liquids are filled by weight so that (in Aust) a cylinder at 65°C reaches 85% of rated pressure. For both CO2 and N2O this means, in practice, filling to about 2/3 of the cylinder's water capacity in kg. The filling ratio is the weight of nitrous usually added compared to the water capacity of the cylinder. 1.87 kg of N20 in the 2.8 kg C size cylinder gives a filling ratio of about 2/3. In cooler climates e.g. UK the filling ratio is 75%. A C size nitrous cylinder holds about twice as much nitrous as oxygen (in litres of gas).

Front 12

14.MRI Telsa 3, least likely to cause harm
A. Cochlear implant
B. mechanical heart valve
C. Implanted intrathecal pump
D. Recently placed aortic stent
E. shrapnel fragment

Back 12

Answer: B

From MRI safety.com
‘because the actual attractive forces exerted on these implants are deemed minimal compared to the force exerted by the beating heart, MR procedures at 3-Tesla are not considered to be hazardous for patients or individuals that have these devices’

Front 13

15-What happens when you place a magnet over a biventricular internal cardiac defibrillator
A. Switch to asynchronous pacing
B. Damage the internal programming
C. Nothing
D. Switch off antitachycardia function
E. Switch of rate responsiveness

Back 13

Answer: D

Front 14

16-You are performing an awake fibreoptic intubation, through the nose, on an adult patient. In order, the fibrescope will encounter structures with sensory innervation from the following nerves
A. facial, trigeminal, glossopharyngeal
B. facial, trigeminal, vagus
C. glossopharyngeal, trigeminal, vagus
D. trigeminal, glossopharyngeal, vagus
E. trigeminal, vagus, glossopharyngeal

Back 14

Answer: D

1 Olfactory
2 Optic
3Oculomotor levator palbebrae, miosis, all movements except lateral
4 Trochlear: supplies superior oblique (rotates eye out and down)
5 Trigeminal:
V1 (opthalmic) entirely sensory: eyeball, upper lid, lacrimal glands, forehead, nose, scalp to vertex, mucous membrane of medial and lateral walls of the anterior nose and frontal plus ethmoid sinuses.
V2 (maxillary) sensory + sympathetic only, cheek, temple, upper lip, lower lid, nose, upper teeth, posterior nasal septum and roof, nasopharyngeal mucosa, superior and middle conchae
V3 (mandibular) sensory to temple, tragus, mandbile, lower lip, anterior 2/3 of tongue and floor of mouth
Motor: mastication, tensor tympanii, tensor palatii (lifts soft palate), digastric (lifts hyoid)
6 Abducens: lateral recuts
7 Facial: Facial movements, lacrimation, submandibular and sublingual salivation, taste from anterior 2/3 of the tongue
8 Vestibulocochlear: Hearing, balance
9 Glossopharyngeal: sensation of pharynx, tonsils, posterior 1/3 of the tongue sensation + taste. Stylopharngeus motor (elevates pharynx and larynx, + involved in swallowing), carotid body and sinus
10 Vagus:
Motor: larynx, bronchial muscles, alimentary tract to splenic flexure, heart (cardioinhibitory)
Superior laryngeal nerve
Recurrent laryngeal nerve splits at subclavian artery on R and arch of aorta on L
Sensory: Dura, external auditory meatus, respiratory tract, alimentary tract to ascending colon, heart, epiglottis
Superior laryngeal nerve supplies larynx as far as the vocal cords
Recurrent laryngeal nerve supplies laryngeal mucosa inferior to the vocal cords
Secretomotor to bronchial mucous glands and alimentary tract.
In neck runs in carotid sheath, between internal jugular and carotid
11 Accessory: sternocleidomastoid and trapezius
12 Hypoglossal: intrinsic and extrinsic muscles of the tongue

Front 15

19Electrocardiogram in the Cs5 configuration. What are you looking at when monitoring lead I.
A. anterior ischaemia
B. atrial
C. inferior
D. lateral
E. septal

Back 15

ANSWER: A

Lead I: anterior ischaemia

Lead II: Inferior ischaemia and arrhythmias

"The central subclavicular (CS5) lead is particularly well suited for the detection of anterior myocardial wall ischemia. The right arm (RA) electrode is placed under the right clavicle, the left arm (LA) electrode is placed in the V5position, and the left leg electrode is in its usual position to serve as a ground. Lead I is selected for detection of anterior wall ischemia, and lead II can be selected for monitoring inferior wall ischemia or for the detection of arrhythmias. If a unipolar precordial electrode is unavailable, this CS5 bipolar lead is the best and easiest alternative to a true V5 lead for monitoring myocardial ischemia."

Front 16

20 Lowest extension of thoracic paravertebral space
A. t10
B. t12
C. l2
D. l4
E. s1

Back 16

ANSWER: B

From CEACCP - Paravertebral block

Anatomy of the thoracic paravertebral space

The thoracic paravertebral space begins at T1 and extends caudally to terminate at T12. Although PVBs can be performed in the cervical and lumbar regions, there is no direct communication between adjacent levels in these areas. Most PVBs are therefore performed at the thoracic level.
The thoracic paravertebral space is wedge shaped in all three dimensions. The bodies of the vertebrae, intervertebral discs, and intervertebral foraminae form the medial wall. Anterolaterally, the space is bounded by the parietal pleura and the innermost intercostal membrane. Posteriorly, it is bounded by the transverse processes (TPs) of the thoracic vertebrae, heads of the ribs, and the superior costotransverse ligament.

Front 17

21.20 yr old male presents to ED with 30% burns from a fire. His approx weight is 80kg. Based on the Parkland formula, how much fluid is required in the first 8hrs from time of injury?
A. 2.4L N/S
B. 3.6L N/S
C. 3.6L Hartmann's
D. 4.8L N/S
E. 4.8L CSL

Back 17

Answer: E

4 x 80 x 30 = 9600

Parkland formula is 4ml/(kg)*(%burn) - to be given over 24 hours. Half given over the first 8 hours, the other half over the remaining 16 hours.

CEACCP:

I.V. fluid resuscitation is required in adults if the burn involves more than 15% BSA or 10% with smoke inhalation. The Parkland formula is the most widely used resuscitation guideline and is 4 ml kg21 (%burn)21 which predicts the fluid requirement for the first 24 h after the burn injury. Starting from the time of burn injury (not time of presentation), half of the fluid is given in the first 8 h and the remaining half is given over the next 16 h. The fluid of choice is Hartmann’s solution. Any fluid already given should be deducted from the calculated requirement. A urinary catheter A urinary catheter should be inserted and the hourly urine output should be used as a guide to resuscitation. In adults, at least 0.5mg/kg/h should be passed.

Front 18

22 In regards to systemic sclerosis, what is the least likely cardiac manifestation?
A. accelerated coronary artery disease
B. atrioventricular conduction block
C. myocarditis
D. pericardial effusion
E. valvular regurgitation

Back 18

Answer: E

Although accelerated coronary artery disease is NOT a feature (vasospastic lesions occur), myocardial infarction is a greater risk than in the general population. (UTD)

Summary:

A -

Potentially difficult - small mouth / stiff tissues

B -

Fibrosing alveolitis & restrictive lung disease

Pulmonary hypertension (2e pulmonary vascular disease)

Lung cancer

Pulmonary thrombosis (late)

C -

(Most common is 2e to pulmonary disease, but primary cardiac disease does occur)

Right sided heart failure (2e pulmonary vascular disease)

MI

Raynauds

Pericarditis

Myocardial fibrosis and diastolic dysfunction

Myocarditis

Conduction disturbances (includes fatal ventricular dysrhythmias)

Arrhythmias

D -

Fatigue

Nerve entrapment

Headaches

Seizures

Stroke

E -

Lower esophageal sphincter

Dilated hypomotile stomach

GORD

High aspiration risk

F -

Chronic kidney disease - may abruptly go into ARF

HT 2e kidney disease

Front 19

23 (repeat) The reason that desflurane requires a heated vapour chamber can be best explained by its:
A. Low saturated vapour pressure
B. High saturated vapour pressure
C. High boiling point
D. Low molecular weight
E. Very low solubility

Back 19

Answer: B

The main problem with desflurane is that it has a high saturated vapor pressure at room temperature (700mmHg at 20°C). It boils at just 22.8°C (if you’ve ever spilled any you’ll know how quickly it disappears as it evaporates) compare with sevoflurane at 58.5°C or isoflurane at 48.5°C. What this means is that small changes in ambient temperature will cause marked changes in the performance of a vaporizer and great difficulty in controlling the delivered concentration of desflurane.

Front 20

24 (New but on a repeated theme)A 30 year old lady has a vaginal forceps delivery without neuroaxial blockade. The next day she is noted to have loss of sensation over the anteriolateral aspect of her left thigh. There are NO motor symptoms. The is best explained by damage to the left sided:
A. Lumbosacral trunk
B. Lateral cutaneous nerve of the thigh
C. Pudendal nerve
D. L2/3 Nerve root
E. Sciatic nerve

Back 20

ANSWER: B.

Lateral femoral cutaneous nerve arises from L2+L3 is a direct branch of the lumbar plexus. It supplies sensation to the lateral and anterior aspects of the thigh

Neurologic Complications of Regional Anesthesia in Obstetrics: A Current Review

Peripheral nerve injuries may occur.
1) Common peroneal nerve is prone to compression at the fibular head during positioning in stirrups. Symptoms include lateral calf paresthesia, dorsal sensory loss between the 1st and 2nd toes, along with foot drop and inversion.
2) Pressure on the lateral femoral cutaneous nerve as it passes under the inguinal ligament produces numbness along the lateral aspect of the thigh. This usually recovers spontaneously within 6 weeks.
3) The femoral nerve may be compressed by the inguinal ligament during flexion of the hip. Symptoms include quadriceps weakness and hyperalgesia in the thigh and calf.
4) The lumbosacral trunk may be injured within the pelvis by the fetal head (especially with forceps or occiput postero-lateral position). Symptoms may be unilateral (75%) or bilateral (25%) and may affect the quadriceps, hip adduction and cause foot drop.

Front 21

25.->AZ84 When performing laryngoscopy using a Macintosh blade, your best view is of the patient's epiglottis touching the posterior pharyngeal wall. Using the Cormack and Lehane scale this is grade
A. 1
B. 2
C. 3a
D. 3b
E. 4

Back 21

ANSWER: D

Front 22

26. A healthy 20 year old patient undergoing nasal surgery under general anaesthesia has the nose packed with gauze soaked in 0.5% phenylephrine and a submucosal injection of lignocaine with 1:100,000 adrenaline. Over the next 10 minutes the blood pressure rises from 130/80 to 220/120 mmHg and the heart rate from 60 to 100 beats per minute. The LEAST appropriate management of this situation would be to
A. administer glyceryl trinitrate
B. administer esmolol
C. administer labetalol
D. administer sodium nitroprusside
E. deepen anaesthesia with isoflurane

Back 22

ANSWER:B

esmolol -B blockade gives unoposed alpha stimulation
Labetalol half life = 5.5 hours

Phenylephrine dose should not exceed 20mcg/kg, to a maximum of 500mcg.
Severe hypertension should be treated with agents that are direct vasodilators (GTN, SNP), or alpha antagonists (phentolamine, prazosin)

Alpha stimulation raises PVR, and therefore shifts blood into the pulmonary circulation. This increases LVEDV. Afterload is also increased.
In this context, the ability to increase heart rate and contractility are important compensatory mechanisms to maintain cardiac output.

Administration of beta-blocker will decrease contractility and heart rate, and will increase SVR as arteriolar beds supplying striated muscle are blocked. It may also cause bronchoconstriction, which will further elevate pulmonary pressures.

Of patients treated for severe hypertension following phenylephrine +/- adrenaline administration, most of the patients who developed pulmonary edema in the below series were given beta blocking agents. All of the patients who experienced cardiac arrests and death were given beta-blockers immediately before the arrest.

Front 23

27.An 8 year old 30kg girl presents for resection of a Wilms tumour. Her starting haematocrit is 35% and you decide that your trigger for transfusion will be 25%. The amount of blood that she will need to lose prior to transfusion is
A. 400mL
B. 500mL
C. 600mL
D. 700mL
E. 800mL

Back 23

Answer = C

Maximum allowable blood loss = EBV * (HctS - HctT)/HctS

= (Estimated blood volume) x [(Starting Hct) - (Target Hct)] / (Starting Hct)
OR
= (EBV) x Starting Hb - Target Hb/Starting Hb
If bleeds more than 1EBV, then start FFP

Front 24

28. An adult male preoperatively complains of pain similar to his angina. Initial treatment is all below except:
A. Aspirin
B. heparin
C. morphine
D. nitrates
E. oxygen

Back 24

Answer = B

ANGINA NOT NSTEMI, for NSTEMI need to stratify to high or intermediate risk to get clexane, STEMI are the ones who get heparin.

Front 25

29. What cannot be used for tocolysis in a 34/40 pregnant woman:
A. Clonidine
B. Indomethacin
C. Magnesium
D. Salbutamol
E. Nifedipine

Back 25

ANSWER: A

A. Does not have tocolytic actions
B. Is tocolytic, but should not be given after 34/40 as it may close the fetal ductus arteriosis
C. Magnesium is tocolytic but doesn't prolong gestation
D. Salbutamol is second line
E. Nifedipine is first line

Other agents:

GTN
Oxytocin receptor antagonists (not available in Australia, include Atosiban)

Front 26

30. Pringles procedure for life threatening liver haemorrhage includes clamping of:
A. Hepatic artery
B. Hepatic vein
C. Portal pedicle
D. Aorta
E. Splenic Artery

Back 26

ANSWER: C

Note: "includes". Hepatic pedicle includes hepatic artery and portal vein.

Portal pedicle appears to be made up.

(But Hepatic pedicle aka hepatoduodenal ligament would be technically more correct if it were offered as an option)


BJA 2004. 93 (2): 204. Effects of Pringle manoeuvre and ischaemic preconditioning on haemodynamic stability in patients undergoing elective hepatectomy: a randomized trial
“During hepatic resection, the risk of severe intraoperative bleeding represents a major risk. To avoid massive blood loss, continuous or intermittent vascular clamping of the hepatic artery and portal vein (‘Pringle manoeuvre’) is an efficient method to reduce haemorrhage.”
Portal pedicle contains Hep Artery and Portal vein therefore D is correct. Also referred to as portal triad, which is Hep a., Portal v. and bile duct.

Front 27

31. Your patient has smoked cannabis prior to arrival in the OT. Pt taking cannabis might lead to:
A. Intraoperative Bradycardia
B. Decreased anaesthetic requirement
C. Increased nausea and vomiting
D. Increased risk of awareness
E. Decreased BIS reliability

Back 27

ANSWER: A

A. This happens with higher cannabis doses
B. Anaesthetic requirement may be increased (despite potentiation of drugs by THC)
C. Wrong
D. Wrong
E. Can't find anything about this in the literature

When administering anesthesia to cannabis users, one can expect dose-dependent cardiovas- cular changes. With low or moderate doses, there is an increase in sympathetic activity accompanied by a drop in parasympathetic activity, leading to tachycardia and increased cardiac output. With high doses, sympathetic activity is inhibited and parasympathetic activ- ity increases, followed by bradycardia, as well as hypotension.8 Hypotension secondary to the use of cannabis responds well to fluids. On ECG, reversible changes in P and T waves, as well as ST segment changes, have been described. Yet, it is not clear if these modifications in the ECG are due to the cannabis itself or rather to reflex tachycardia. Despite the presence of ectopic supraventricular and ventricular beats, no fatal arrhythmias have been documented.

Front 28

32. MVA trauma patient arrives in ED BP100/60 HR 100 with the following CXR (‘’I thought it looked like an aortic dissection/rupture with a widened mediastinum’’). The most appropriate next investigation would be:
A. Aortography
B. CT Chest
C. MRI
D. TOE
E. TTE

Back 28

Answer: D

A CT scan is relatively rapid and non-invasive and with con- trast image enhancement the extent of the dissection along with the true and false lumens can be identified. This technique is not appropriate if the patient is haemodynamically unstable.

Transthoracic echocardiography (TTE) is easily available and the ascending aorta and aortic arch can be visualized well. In obese or chest trauma patients, image quality may be inadequate due to poor echo windows. Transoesophageal echocardiography (TOE) has become more popular as experience and availability increase. It is useful perioperatively in the haemodynamically unstable patient. TOE images the entire thoracic aorta except for the most distal ascending aorta and a part of the arch obscured by the trachea or right main bronchus. Echocardiography can be used with high accuracy for decision-making in acute dissection.

Front 29

33. A 70 year old man with slow atrial fibrillation is reviewed for insertion of a permanent pacemaker. He is otherwise well. He is on warfarin with an INR of 2.2. Prior to PPM insertion do you
A. Cease warfarin and commence dabigatran
B. Cease warfarin and commence Enoxaparin
C. Cease warfarin and recommence post procedure
D. cease warfarin and commence heparin
E. Continue warfarin

Back 29

Answer: C

Should give bridging anticoagulation for any patient with a CHADS2 score of 3 or more.

Front 30

34. A 40 year old man with Marfan's has undergone a thoracoabdominal aneurysm repair. 48 hours post procedure there is blood noted in his CSF drain and he is obtunded. Your next course of action is:
A. Coagulation studies
B. CSF microscopy and culture
C. CT Head
D. MRI Head
E. MRI Spine

Back 30

ANSWER: C

Drainage should stop when there is evidence ‘bloody’ or ‘blood-tinged’ CSF and coagulopathy should be corrected. Radiographic CT-testing should be done to exclude intracranial bleeding or a spinal haematoma.

Further dangers that are present whenever a spinal drain is in place are: (1) the introduction of infection into the subarachnoid or epidural space; (2) the development of spi- nal haematoma from the combination of an indwelling line in a potentially coagulopathic patient; (3) the risk of inad- vertent injection of drugs down the line if it is mistaken for an intravenous line.

Front 31

36. You are anaesthetising a fit 50 year old woman for an elective laparoscopic cholecystectomy. In her pre operative assessment she has a normal cardiovascular exam and her BP is 115/75. You induce anaesthesia with 100mcg fentanyl, 100mg propofol and 50 mg rocuronium. Soon after induction her ECG looks like this (showed narrow complex tachycardia around 180-200/min – ie SVT). Her BP is now 95/50. What is the most appropriate management?
A. adenosine
B. amiodarone
C. DC cardioversion
D. GTN
E. metaraminol

Back 31

ANSWER: A

Could be C.

?Tachycardia, rate >150
Unclear whether there is myocardial ischaemia or signs of shock
Therefore synchronised cardioversion.

If awake and symptom free, could give adenosine.

http://www.resus.org.au/policy/guidelines/section_11/managing_acute_dysrhythmias.htm

Front 32

37. The electrical requirement that distinguishes a "cardiac protected area" from a "body protected area" is the
A. isolation transformer
B. line isolation monitor
C. equipment has a maximum leakage current of 500 microamperes
D. residual current device
E. equipotentiality

Back 32

Answer: E

A. This is a way of preventing shock in theatres that cannot have interruptions to their power from an RCD. By not earthing the neutral wire, a person who is themselves earthed will not complete the circuit. Both wires need to be touched in order to get a shock.
B. This is a monitor to check for faults in the connected devices. You would need a double fault in order to expose both parts of the circuit and allow shock
C - Microshock is 100uA or above. Macroshock is 10mA or above. Cardiac protected areas must protect against microshock
D- This is a circuit breaker that trips if there is a fault which allows leakage of current to earth over a set threshold (usually 10mA with a 40ms response time)
E. All conductive surfaces have low resistance (thick short wiring) connections to earth. This prevents the build-up of charge, and provides a lower resistance return circuit than that provided by a person.

From Hitchhiker's Guide to Electrical Safety:

Equipotential earthing

Front 33

38. After ingestion of 500mg/kg aspirin, the most efficient therapy to enhance the elimination is
A. normal saline infusion
B. bicarbonate infusion
C. mannitol
D. frusemide
E. haemodialysis

Back 33

Answer: E

From Oh's:

"Extracorporeal techniques are very effective in removing salicylates and correcting acid–base disturbance. "

From CEACCP

Salicylates
Patients with salicylate poisoning may present with tinnitus, deaf- ness, hyperventilation, epigastric pain, vomiting, hyperthermia, sweating, dehydration, respiratory alkalosis, metabolic acidosis, and electrolyte disturbances. Agitation and confusion may indicate the development of cerebral oedema which can be fatal. Treatment includes rehydration, treatment of acid – base disturbance, and close monitoring of plasma levels. AC should be administered as soon as possible even in delayed presentations. The use of multidose AC is debatable, but should be considered if the plasma salicylate level continues to increase or if a slow release preparation has been taken. Alkalinization of the urine may increase the elimination of salicylate and should be considered in patients with signs of toxicity or in patients with plasma levels more than 300 mg litre21. In patients with levels more than 700 mg litre21, haemodialysis should be considered.

Front 34

39. Most cephalic interspace in neonate to perform spinal while minimising the possibility of spinal cord puncture
A. L1-L2
B. L2-L3
C. L3-L4
D. L4-L5
E. L5-S1

Back 34

Answer: C

Adults: L1-2
Neonates: L3

From anatomy for the anaesthetist:

The relations of the cord to the vertebral column differ greatly in foetal, infant and adult life (Fig. 98). Up to the third fetal month, the cord extends the length of the vertebral canal. The vertebrae then grow considerably faster than the cord, so that the cord terminates in the newborn at the lower border of the 3rd lumbar vertebra and, in the adult, on average, at the disc between the 1st and 2nd lumbar vertebral bodies. However, there is considerable variation in this level (Fig. 99); frequently the cord ends opposite the body of L1 or 2, or, rarely T12 or even L3.

Front 35

40. A 6 week old is planned for an elective Right inguinal hernia repair. What is the most apprioate advice you give about fasting times.
A. 2 hours breast milk
B. 4 hours formula
C. 5 hours for formula and breast milk
D. Solids for 6 hours
E. 8 hours for solids and 4 hours for fluids

Back 35

Answer: B

From ANZCA PS15

Healthy adults
solids 6 hours
clear fluids <200mL up to 2 hours

Healthy children > 6/52 for elective
Solid food and formula up to 6 hours
Breast milk up to 4 hours
Clear fluids up to 2 hours

Healthy infants <6/52 for elective
Formula and breast milk up to 4 hours
Clear fluids up to 2 hours
Consider PPI for patients with GORD

Front 36

41. What is the best method of detecting early respiratory depression when a person is using a PCA
A. Something about looking at PCA settings
B. Pupil size
C. Sedation
D. Respiratory Rate
E. Number of Bolus doses used.

Back 36

ANSWER: C

(Confirmed in ANZCA blue book)

It is harder to compare the incidence of respiratory depression between PCA and conventional methods of opioid analgesia. This is partly because the risk is small and, therefore, most, if not all, studies would have inadequate numbers of patients in each group to be able to show a significant difference. In addition, the definitions of respiratory depression vary widely. Many authors choose to define respiratory depression as a respiratory rate of less than 8 or 10 breaths min–1, even though a decrease in respiratory rate is known to be an unreliable indicator of the presence or absence of respiratory depression.26 62 101 A better clinical indicator of early respiratory depression is sedation, and many centres routinely monitor patient sedation using sedation scores.62Better estimates of the risk of respiratory depression with PCA are obtained from results of larger audits (see later).

Front 37

42. A reduction in DLCO can be caused by;
A. Asthma
B. COPD
C. Left to right shunt
D. Pulmonary haemorrhage
E. Bronchitis

Back 37

Answer: B

A. Asthma - normal or high DLCO
B. Low with emphysema
C. Increased
D. Increased
E. See A.

Older textbooks suggest that thickening of the alveolar-capillary membrane (in interstitial lung disease) and loss of alveolar membrane surface area (in emphysema) are the primary causes of a low DLCO. However, subsequent experimental data suggest these and most other diseases that influence the DLCO do so by reducing the volume of red blood cells in the pulmonary capillaries. The total volume of blood in the lungs in healthy adults at rest is less than 150 mL; the volume of blood in the pulmonary capillaries and the DLCO are increased in the following circumstances:

When pulmonary capillaries are recruited, as occurs during exercise
When the patient is in the supine position
During a Mueller (reverse Valsalva) maneuver
When a left-to-right cardiac shunt is present.

Front 38

43. You place a thoracic epidural for a patient having an elective open AAA repair. There are 4cm in the epidural space and you aspirate blood. What is the most appropriate management plan:
A. inject 5 mL of saline, and if you can no longer aspirate blood, leave in place and use
B. inject 5 mL lignocaine 2% with adrenaline. If there is no rise in HR be happy that it is not intravascular and secure in place and use
C. Remove and postpone surgery for 24 hours
D. Remove and place epidural 1 level higher
E. Remove and postpone surgery for 4 hours

Back 38

ANSWER: C

Difficult to find good reference for this, but some documents on web specify that bloody tap should necessitate postponement of elective case

Front 39

44. You are anaethetising a lady for elective laparoscopic cholecystectomy, who apparently had an anaphylactic reaction to rocuronium in her last anaesthetic. There has not been sufficient time for her to undergo cross-reactivity testing. What would be the most appropriate drug to use:
A. rocuronium
B. suxamethonium
C. pancuronium
D. atracurium
E. cisatracurium

Back 39

ANSWER: E

A. No
B. Most common anaphylactic trigger
C. Shares rocuronium's aminosteroid structure
D. Benzylisoquinolone. Less allergic reactions than rocuronium, but causes direct histamine release
E. Least cross-reactivity with rocuronium. Benzylisoquinolone. Also: See Anaphylaxis to neuromuscular blocking drugs: incidence and cross-reactivity in Western Australia from 2002 to 2011 BJA

Front 40

45 Patient with subdural haematoma, on warfarin. INR 4.5. Needs urgent craniotomy. Vit K given already by ED resident. What further do you give for urgent reversal of this patient's INR?
A. Factor VII
B. Cryoprecipitate
C. FFP
D. Prothrombinex
E. FFP + prothrombinex

Back 40

Answer: E

MJA:

INR > 1.5 and life-threatening bleeding
Vit K 5-10mg
Prothrombinex-VF 50u/kg
FFP 150-300mL
(FFP 15mL/kg if prothrombinex unavailable)

INR > 2 and critically significant bleeding
Vit K 5-10mg
Prothrombinex-VF 35-50u/kg based on INR
(FFP 15mL/kg if prothrombinex unavailable)

Any INR with minor bleeding
Vit K 0.5-1mg

Front 41

46 Regarding endotracheal tubes used in laser surgery:
A. They are more resistant to combustion when the cuff is covered in blood
B. Resistant to ignition from electrocautery
C. The cuff is resistant to ignition if hit by the laser
D. Have an external diameter which is larger than a normal PVC endotracheal tube (compared to the internal diamater)
E. Have 2 cuffs which are resistant to combustion

Back 41

Answer: D

Endotracheal tubes for laser surgery
There are two basic designs of endotracheal tube for use in laser surgery. First, silicone rubber tubes with metal links incorporated into the tube wall with either a sponge cuff (Bivona Fome cuff) or a double cuff (Mallinckrodt ‘Laser flex’) are available. If the cuff bursts in the former, the sponge will maintain a sealed airway; in the latter, the second cuff can be used. Second, foil wrapped tubes with an outer Teflon coat (Sheridan ‘Laser Trach’) can be used. The cuff is filled with methylene blue crystals so that, if the laser bursts the cuff, this will be detected quickly by the surgeon. The main problem with laser tubes is that they have a narrow internal diameter because they have thick outer walls. This can make spontaneous ventilation difficult, and airway pressures can be high in the ventilated patient.
A variety of anaesthetic techniques have been advocated for laser airway surgery. Some centres paralyse and ventilate using a laser endotracheal tube, others utilise a jet ventilator device attached to a rigid laryngoscope. However, some centres employ a spontaneous respiration technique using an air/oxygen mixture with a volatile agent administered via a laser tube or a nasopha- ryngeal airway. Good topical anaesthesia of the airway is also used to minimise the risk of coughing and straining.

Front 42

50 During an elective thyroidectomy a patient develops symptoms consistent with the diagnosis of “thyroid storm” which of the following treatment options in NOT appropriate
A. Carbimazole
B. Beta-blocker
C. Propythiouracil
D. Plasmaphoresis
E. Hydrocortisone

Back 42

Answer: D

ANSWER: D (has been used in some cases, but not first line, not practical in OT)

OHA:
Weight loss, HT, sweating, arrhythmias

Treatment from UTD:

●A beta-blocker to control the symptoms and signs induced by increased adrenergic tone
●A thionamide to block new hormone synthesis
●An iodine solution to block the release of thyroid hormone
●An iodinated radiocontrast agent (if available) to inhibit the peripheral conversion of T4 to T3
●Glucocorticoids to reduce T4-to-T3 conversion, promote vasomotor stability, and possibly treat an associated relative adrenal insufficiency


Thyroid storm:
Can be triggered by surgery, trauma, infection, parturition

Signs:
A - goitre
B - nil
C - tachycardia (AF), CHF, other arrhythmias, hypotension
D - Agitation, delirium, tremor
E - abdominal pain, N+V, hepatic failure
F - may be dry or overloaded in heart failure
G - Marked weight loss, proximal myopathy. Lid lag, exophthalmos (with grave's), warm moist skin

Front 43

53 Two days post upper spinal surgery, patient notices parathesia of the right arm, surgeon thinks this is an ulnar nerve palsy due to poor positioning. What sign will distinguish a C8-T1 nerve root lesion from an ulnar nerve neuropathy?
A. parasthesia in little finger
B. parasthesia in the distribution of the interscalene nerve
C. weakness in adductor digiti minimi
D. weakness in abductor pollicis brevis
E. weakness in lateral interosseus

Back 43

ANSWER: D

A. ulna nerve will produce this
B. no such nerve
C. ?poorly remembered. No such muscle. ABductor digiti minimi is supplied by the ulna and abducts the little finger
D. Abductor pollicis brevis is innervated by the median nerve (C5-T1)
E. no such muscle

The ulnar nerve (C7, 8, T1), shown in Figs 117 and 121, is the continuation of the medial cord after this has given off the medial head of the median nerve. The ulnar nerve is usually composed of fibres from C7, 8 and T1, but in some 15% of cases there is no C7 contribution.

1 Muscular branches - to flexorcarpiulnaris,the medial half of flexor digitorum profundus, and all the intrinsic muscles of the hand apart from the lateral two lumbricals and the three muscles of the thenar eminence. 2 Cutaneous branches - to the dorsal and palmar aspects of the medial side of the hand and of the medial 1.5 fingers. 3 Articular branches - to elbow and wrist.

Front 44

54 A 54 year old man, is on warfarin for atrial fibrillation, has a history of alcohol abuse and liver failure with an albumin of 30 and a bilirubin of 28. What is his CHADS 2 score?
A. 0
B. 1
C. 2
D. 3
E. 4

Back 44

ANSWER: A


Congestive heart failure (any history)1
Hypertension (prior history)1
Age ≥75 years1
Diabetes mellitus1
Secondary prevention in patients with a prior ischemic stroke or a transient ischemic attack; most experts also include patients with a systemic embolic event 2 CHAD

Risk of stroke per year by score:

0: 2%
1: 3%
2: 4%
3: 6%
4: 8.5%
5: 12.5%
6: 18%

Front 45

57 You are 2 hours into an operation. 3L of IV Crystalloid has been given. There has been minimal blood loss. The dilutional anaemia is compensated by:
A. Cellular anaerobic metabolism
B: Capillary vasodilation
C: Increased cardiac output
D: Increased tissue oxygen extraction
E: Rightwards shift of the Oxygen – Haemoglobin dissociation curve

Back 45

Answer: C

"From Miller, Ch 57. The hypervolumetric haemodilution will lower PaO2 but compensatory mechanisms occur to ensure surplus Oxygen delivery to the tissues continues. A sudden reduction of [RBC] – reduction in viscosity – reduced peripheral resistance- and so increased VR with increased CO results."

Front 46

58 You are putting in an Internal Jugular CVC. Which manoeuvre will cause maximum venous distension of the jugular vein?
A. Continuous Positive Airway Pressure (No value given)
B: Breath hold at end-expiration
C: Manual compression at the base of the neck
D: Trendelenburg position
E: Patient performs a valsalva

Back 46

ANSWER: D

A. 10cmH20 PEEP = 7mmHg. Constant, controllable.
B. End-expiratory pressure will be -4 in spontaneously ventilating patients, and likely equal to PEEP in positive pressure ventilation. CVP is quoted as being 0-5 in spent venting and up to 10mmHg in PPV by Oh's.
C. Not practical to occlude the internal jugular with manual compression during central line insertion
D. Roughly 5.5 cm from sternal angle to right atrium. Say another 5cm to insertion point. Therefore 10cmH2O difference if upside down (=7mmHg). HOWEVER, I think the column of blood actually runs from the feet to the jugular, and is therefore longer than this calculation would imply.
E. This will produce a large increase in pressure while it is held.

Front 47

59. What is approximately the systolic blood pressure in an awake neonate (mmHg)
A. 55
B. 70
C. 85
D. 100
E. 115

Back 47

Answer: B

From http://www.expertconsultbook.com/expertconsult/ob/book.do?method=display&type=bookPage&decorator=none&eid=4-u1.0-B978-0-7020-3479-4..00053-2--bib1&isbn=978-0-7020-3479-4

Front 48

60. The volatile agent most likely to be associated with carbon monoxide production when used with a soda lime scrubber is:
A. Desflurane
B. Isoflurane
C. Sevoflurane
D. Halothane
E. Enflurane

Back 48

ANWER: A

http://www.biomedcentral.com/1471-2253/5/6

Peak concentrations of CO were very high with desflurane and enflurane (14262 and 10654 ppm respectively). It was lower with isoflurane (2512 ppm). We also measured small concentrations of CO for sevoflurane and halothane. No significant temperature increases were detected with high CO productions.

Front 49

61. A 40yo female with primary pulmonary hypertension is to have a laparoscopic cholecystectomy. Her preoperative pulmonary artery pressure is 80/60mmHg. During the procedure she suddenly desaturates to 87%, BP 80/40mmHg, and ETCO2 45mmHg. Likely findings on TOE will include:
A: Increased LV wall thickness, abnormal septal wall motion, TR, RA dilation
B: Increased RV:LV area, abnormal septal wall motion, increased LV wall thickness, RA dilation
C: Increased RV:LV area, abnormal septal wall motion, TR, RA dilation
D: Increased RV:LV area, abnormal septal wall motion, TR, PR
E: Increased RV:LV area, TR, PR, RA dilation

Back 49

Answer: C

From UTD:

"Patients with PH may have echocardiographic signs of right ventricular pressure overload, including paradoxical bulging of the septum into the left ventricle during systole and hypertrophy of the right ventricular free wall and trabeculae (image 4 and movie 3). As the right ventricle fails, there is dilation and hypokinesis, septal flattening, right atrial dilation, and tricuspid regurgitation (image 5 and movie 4). The tricuspid regurgitation is not due to an intrinsic abnormality of the tricuspid valve; it is a secondary manifestation of dilation of the tricuspid annulus and right ventricle (ie, functional tricuspid regurgitation) (movie 5 and image 6) [17]. Other findings associated with pulmonary hypertension are pulmonic insufficiency and midsystolic closure of the pulmonic valve [18,19]. The echocardiographic findings of PH are summarized in the figure (figure 2)."

Front 50

62 The principal resistance to airflow in an ETT is:

A: density of the gas
B: diameter of the tube
C: length of the tube
D: temperature of the gas
E: viscosity of the gas

Back 50

Answer: B

F = ΔP.r^4
η.L

Front 51

65. A new antiemetic decreases the incidence of PONV by 33% compared with conventional treatment. 8% who receive the new treatment still experience PONV. The no of patients who must receive the new treatment instead of the conventional before 1 extra patient will benefit is
A. 3
B. 4
C. 8
D. 25
E. 33

Back 51

Answer: D

NNT = 1/probability(with intervention) - probability(control)

Front 52

66. According to guidelines endorsed by ANZCA, the label of an intra-osseous infusion should be
A. beige
B. blue
C. Pink
D. Red
E. yellow

Back 52

Answer: C

From http://www.safetyandquality.gov.au/wp-content/uploads/2012/03/Labelling-Recommendations-2nd-edition-February-2012.pdf

Front 53

69. During apnoeic oxygenation under light anaesthesia, the expected rise in PaCO2 would be:
A. 0.5 mmHg per min
B. 1 mmHg per min
C. 2 mmHg per min
D. 3 mmHg per min
E. 5 mmHg per min

Back 53

Question as remembered makes no sense.

If it should have read PaCO2, answer would be D

Oxygen flow rates of 0.1 L/kg/min provide adequate oxygenation during prolonged apnea. Apneic oxygenation for up to 55 mins does not lead to hypoxaemia, but severe hypercapnia and acidemia can occur. Catecholamine concentrations increase and arrhythmias can occur.

Reference: The rate of rise of PACO2 in apneic anaesthetised man. Eger et al. Anaesthesiology 1961.

Front 54

70. In the Revised Trauma Score, the initial assessment parameters include Glascow Coma Scale, Blood Pressure, and :
A. Heart Rate
B. Saturation
C. Respiratory Rate
D. Urine Output
E. Temperature

Back 54

Answer: C

http://www.trauma.org/archive/scores/rts.html

RR, GCS, SBP

Front 55

72. Absolute Contraindication to ECT
A. Cochlear implants
B. Epilepsy
C. Pregnancy
D. Raised intracranial pressure
E. Myocardial infarction

Back 55

ANSWER: D

Royal College of Psychiatry
(although quite a few references say there are no absolute contraindications, raised ICP seems to be the strongest relative contraindication)

In the presence of raised ICP (for eg secondary to large tumour) ECT may precipitate acute uncal herniation

Relative contraindications:
1) within 3/12 of MI / CVA
2) uncontrolled CHF
3) DVT prior to anticoagulation
4) Untreated cerebral aneurysm
5) Unstable major fracture
6) Severe osteoporosis
7) Phaeochromocytoma
8) Retinal detachment
9) Glaucoma
10) Cochlear implant (unilateral has been used)

http://www.ect.org/resources/apa/3.html

Front 56

73. 80 year old female for open reduction and internal fixation of a fractured neck of femur. Fit and well. You notice a systolic murmur on examination. Blood pressure normal. On transthoracic echo, she has a calcified aortic valve, with aortic stenosis with a mean gradient of 40mmHg. How do you manage her:
A. Instigate low dose beta blockade
B. Defer, and refer to a cardiologist
C. Perform a transoesophageal echo to get a better look at the valve
D. Proceed to surgery with no further investigation
E. Perform a dobutamine stress echo

Back 56

ANSWER: D

Not symptomatic. Mean gradient < 50mmHg. Therefore no need for intervention pre-op.
Slow, full, sinus, tight. Spinal/epidural probably not optimal.

Mean gradient (Note that this will become less sensitive as the ventricle starts to fail)
Normal: <12
Mild: 12-25
Moderate: 25-40
Severe: 40-50
Critical: >50

Front 57

75 A 25 y.o. male has a traumatic brain injury on a construction site. GCS 7. Intubated on site and transported 1 hour to hospital. Haemodynamically stable and no other injuries. Most appropriate pre hospital fluid:
A. 4% albumin
B. Dextran 70 in 0.9%N/saline
C. 6% hydroxyethyl starch
D. Ringers lactate
E. 0.9% N/saline

Back 57

ANSWER: E

Must give isotonic solution

Front 58

76 A 40 y.o. female newly diagnosed ITP. Retinal detachment for surgery in 2 days. Platelets 40 and blood group A+. Management of her ITP:
A. Administer Anti-D antibodies 6 hrs pre op
B. Admister desmopressin one hour pre op
C. Administer methylpred and IVIg 2 days pre op
D. Recheck platelet count morning of surgery and if not dropped continue
E. Platelet transfusion morning of surgery

Back 58

Up To Date:

Answer: C

A. Wrong
B. This works for vWD by increasing FVIII and vWF
C. IVIG (1 g/kg, repeated the following day if the platelet count remains <50,000/microL)
Pulse methylprednisolone (1 g intravenously, repeated daily for three doses)
D. Plt 40 too low for eye surgery / neurosurgery.
E. They will be rapidly inactivated, administration during or immediately before surgery would be ideal. OHA says that this should be reserved for major haemorrhage only.

Oxford handbook says:
Lumbar puncture, epidurals, brain and eye surgery need platelet count over 100.
Count > 50 for everything else.

Front 59

77. (Rpt) A neonate will desaturate faster than an adult at induction because
A. FRC decreased more
B. Faster onset of induction agents
C. More difficult to pre-oxygenate
D.
E.

Back 59

ANSWER: A

(increased oxygen consumption compared to an adult might be a better answer)

From Michael Dobbie:
FRC 28 ml/kg vs adult 30-35ml/kg
Oxygen consumption 4-6ml/kg vs adult 2-3mL/kg
Alveolar ventilation 100-150ml/kg vs 50-60ml/kg for an adult

Front 60

78. (Rpt Jul 07) Isoflurane is administered in a hyperbaric chamber at 3 atmospheres absolute pressure using a variable bypass vaporizer. At a given dial setting and constant fresh gas flow, vapour will be produced at:
A. the indicated vapour concentration
B. three times the indicated vapour concentration
C. one third the partial pressure obtained at 1 atmosphere
D. the same partial pressure as is obtained at 1 atmosphere
E. three times the partial pressure obtained at 1 atmosphere

Back 60

Answer D

(Partial pressure and therefore anaesthetic effect is the same, but percentage delivered falls, note your measured end-tidal will fall)

A. Output is about 26% of indicated vapour concentration
B. See A
C. See D
D. Partial pressure reduction is about 20%. This is closest to D.
E. See D

Front 61

80. 37 female presents to ED with headache and confusion. She is otherwise neurological normal and haemodynamically stable. Urine catheter and bloods takes. UO > 400ml/hr for 2 consecutive hours, Serum Na 123 mmol/l, Serum Osmolality 268, Urine Osmolality 85 The most likely diagnosis is
A. Central diabetes insipidus
B. Nephrogenic diabetes insipidus
C. Psychogenic polydipsia
D. Cerebral salt wasting
E. SIADH

Back 61

ANSWER: C

Hyponatraemic
Hyposmolar
Large urine output
Dilute urine

A. Central diabetes insipidus: caused by inadequate secretion of ADH. Polyuria, hypernatremia, hyperosmolarity, dilute urine
B. Nephrogenic diabetes insipidus: Resistance to action of ADH on the kidneys. Polyuria, high normal or hypernatraemia, high normal or hyperosmolarity, dilute urine
C. Hyponatraemia, hyposmolarity, low urine osmolarity, increased urine output.
D. Cerebral salt wasting follows CNS injury, and is like SIADH except that there is evidence of hypovolaemia
E. Hyponatraemia, hyposmolarity, urine osmolarity >100 (normal minimum 40-100). Urine output determined usually by water intake, but given SIADH causes fixed ADH secretion urine output instead becomes dependant on salt intake (and excretion) only.

Front 62

83 A 45 year old obese man complains of headache, lower limb weakness and polyuria. On examination, his blood pressure is 150/70mmHg. He has a displaced apex beat. Bloods revealed Na145, K2.8, Cl101, HCO3 27. What is the most likely diagnosis
A. Cushings
B. Diabetes
C. Primary hyperaldosteronism
D. Hypothyroidism
E. Phaeochromocytoma

Back 62

Answer: c

A. Causes obesity, proximal muscle weakness, hypokalemia, hypertension. (also thin, easily bruised skin, osteopenia, glucose intolerance, heart failure, coronary artery disease, CVA, AMI, thromboembolic events, agitation, anxiety, paranoia, infections, headache)
B. Unlikely.
C. Increased Na resorption and K excretion. Hypertension: headaches, facial flushing. Hypokalemia: muscle weakness, polyuria and polydipsia, constipation, dysrhythmias. Cardiomegaly.
D. Does not cause obesity, marked HT, nor hypokalemia
E. Causes hypertension, but not electrolyte disturbances etc

Front 63

84 Which of the following is the best predictor of a difficult intubation in a morbidly obese patient
A. Pretracheal tissue volume
B. Mallampati score
C. Thyromental distance
D. BMI
E. Severity of OSA

Back 63

Answer: A

In 50 morbidly obese patients, we quantified the soft tissue of the neck from the skin to the anterior
aspect of the trachea at the vocal cords using ultrasound. Thyromental distance, mouth opening,
limited neck mobility, modified Mallampati score, abnormal upper teeth, neck circumference and
sleep apnoea were assessed as predictors of difficult laryngoscopy. Of the nine (18%) cases of difficult
laryngoscopy, seven (78%) had a history of obstructive sleep apnoea, compared with two of the
41 patients (5%) in whom laryngoscopy was easy (p < 0.001). Patients in whom laryngoscopy was
difficult had more pretracheal soft tissue (mean (SD) 28 (2.7) mm vs. 17.5 (1.8) mm; p< 0.001) and a
greater neck circumference (50 (3.8) vs. 43.5 (2.2) cm; p < 0.001). None of the other predictors
correlated with difficult laryngoscopy. We conclude that an abundance of pretracheal soft tissue at
the level of the vocal cords is a good predictor of difficult laryngoscopy in obese patients.

Front 64

85. You wish to compare a new method of BP measurement with the gold standard. The best way to do this is:
A. CUSUM analysis
B. Friedman's test
C. ?
D. Pearson’s correlation
E. Bland-Altman plot

Back 64

Answer: E

Bland and Altman plots are extensively used to evaluate the agreement among two different instruments or two measurements techniques. Bland and Altman plots allow us to investigate the existence of any systematic difference between the measurements (i.e., fixed bias) and to identify possible outliers. The mean difference is the estimated bias, and the SD of the differences measures the random fluctuations around this mean.

Front 65

86. After intubating for an elective case you connect up the circuit and notice that you are unable to ventilate and observe high airway pressures. The next most appropriate step is to:
A. Auscultate the lungs
B. Release the APL valve
C. Remove the endotracheal tube and bag mask ventilate
D. Turn on the ventilator
E. Low positive end expiratory pressure

Back 65

Answer: A

Clinically seems like the best first step. ?wheeze from reactive airways disease / allergy.

Front 66

87. You insert a thoracic epidural in a patient for a liver resection with an upper abdominal incision. You have recently topped it up. On waking the patient appears weak, despite adequate reversal. He can breathe spontaneously and can flex his biceps but is not able to extend triceps. The level of the block is most likely to be:
A. C5
B. C6
C. C7
D. C8
E. T1

Back 66

Answer: C

From http://www.neurosurgical.com/neuro_medical_info/neuro_exam.htm

List of Myotomes of Commonly Injured Nerve Roots
Myotome distributions of the upper and lower extremity are:
C1/C2-neck flexion/extension
C3-neck lateral flexion
C4-shoulder elevation
C5-shoulder abduction
C6-elbow flexion/wrist extension
C7-elbow extension/wrist flexion
C8-thumb extension
T1-finger abduction
L2-hip flexion
L3-knee extension
L4-ankle dorsi-flexion
L5-great toe extension
S1-ankle plantar-flexion
S2-knee flexion

Front 67

88. (repeat) You are anaesthetizing a pregnant woman for neuro-radiological coiling. At what gestation is it important to monitor uteroplacental sufficiency?
A. 22 weeks
B. 24 weeks
C. 26 weeks
D. 28 weeks
E. 32 weeks

Back 67

Answer: B

From CEACCP Anaesthesia for non-obstetric surgery during pregnancy
Fetal monitoring
Once fetal viability is assumed (24–26 weeks), the fetal heart rate (FHR) should be monitored. This may be difficult in the obese patient or during abdominal surgery. Inhalation agents typically cause a reduction in FHR variability, one of the changes indicative of fetal hypoxaemia. Intra-operative FHR monitoring requires skilled interpretation and an obstetrician with a plan of action should fetal distress be diagnosed. Uterine manipulation should be minimized in order to avoid pre-term labour. Ketamine increases uterine tone in early pregnancy and should not be used. While some advocate the prophylactic use of tocolytic agents, they are not without risk themselves and there is no proof of efficacy.

Front 68

89 During the neurosurgical management of a cerebral aneurysm. The drug to administer to facilitate permanent clip placement is?
A. Nimodipine
B. Adenosine
C. Mannitol
D. Hypertonic Saline
E. Thiopentone

Back 68

Answer: B

Produces transient asystole.

Front 69

90. Prior to seeking consent from family/relatives for DCD, it is important to confirm which of the following?
A. Not a coroners case
B. Pt will have a cardiac death within 90 minutes in the absence of life-support
C. Potential organ recipient's identified and are available
D. Patient's wishes have been considered
E. Decision confirmed by an external committee

Back 69

Answer: B

1.need medical suitability -includes fulfilling criteria

2. consider wishes of pt

3. formal consent

Australian National Protocol DCD 2010

Front 70

91. You see a young man prior to surgery. He describes a history of throat swelling and difficulty breathing both spontaneously and in association with minor dental procedures. His brother has had similar episodes. The most likely mechanism is:
A. C1-esterase deficiency
B. Factor V deficiency
C. Low bradykinin levels
D. Mast cell degranulation
E. Tryptase release

Back 70

Answer: A
(actually C1-esterase inhibitor deficiency)

Hereditary angioedema (HAE)
Deficiency in C1-esterase inhibitor
Usually autosomal dominant inheritance, although recessive and new mutations can occur
Mechanism: Uncontrolled complement activation. Results in localized non-histamine mediated angioedema.
So: acute, localised, non-pitting, non-pruritic, non-erythematous and demarcated edema.

Can occur anywhere: face / larynx / GIT tract cause most issues. Can be incorrectly diagnosed as appendicitis, gall bladder spasm, diverticulitis, irritable bowel syndrome.

Diagnosis: Normal C3 and low C4 (C4 is cleaved by C1), either low-antigenic and low functional C1-INH (for type I HAE: deficiency of C1-esterase inhibitor), or normal antigenic and low functional C1-INH (for type II HAW: dysfunctional C1-INH)

Treatment of acute attacks AND surgical prophylaxis for both elective and emergency surgery:
Infusion of plasma-derived C1-esterase inhibitor concentrate
B. Factor V deficiency: very rare bleeding disorder, recessive inheritance. Treated with FFP. Does not cause angioedema.

C. Bradykinin levels can be high in ACE-I treatment related angioedema, or in C1-esterase inhibitor deficiency.
ACE-I angioedema is treated with nebulised / SC adrenaline and airway interventions as required.

D. This occurs in IgE and non-IgE mediated anaphylaxis. Treatment is with removal of trigger, fluids, adrenaline, steroids, bronchodilators and supportive measures.

E. This also occurs in IgE mediated anaphylaxis. Testing as soon as practical, then at 2/24 and 24/24 to confirm cause.

Honorable mention to idiopathic angioedema, 2nd most common cause, diagnosis of exclusion. Can rarely affect the airway. Treat with anti-histamines and steroids.

Front 71

92. A 5 year-old child with recently diagnosed Duchenne muscular dystrophy has an inhalation induction with sevoflurane for closed reduction of a distal forearm fracture. No other drugs have been given. 10 minutes later the child suffers a cardiac arrest. After a further 5 minutes a venous blood sample shows a potassium level of 8.5mmol/L. The most likely mechanism for the hyperkalaemia is:
A. Acute renal failure
B. Cardiomyopathy
C. Crush injury
D. Malignant hyperthermia
E. Rhabdomyolisis

Back 71

Answer: E

CEACCP
No association between duchenne muscular dystrophy and MH.

What is the risk of rhabdomyolysis?
The muscular dystrophies with an absence of dystrophin in the muscle cell have an unstable and more permeable sarcolemma. Inhalation agents and succinylcholine may increase the underlying instability and permeability of the sarcolemma, resulting in increased intracellular calcium levels and leakage of potassium and CK into the serum.
Succinylcholine is contraindicated in DMD. It has been impli- cated in producing intraoperative cardiac arrests secondary to rhab- domyolysis and hyperkalaemia.
There continue to be reports of children suffering hyperkalaemic cardiac arrests after the use of inhalation anaesthetic agents. These sometimes occur in patients during the recovery period, and may be related to emergence shivering.8 Although this can occur at any age, the most ‘at risk’ group are children aged ,8 yr of age, where there is less muscle fibrosis and still some muscle regeneration.
Although only a small proportion of patients with DMD develop hyperkalaemia and rhabdomyolysis after exposure to vola- tile anaesthetics, the outcome is often fatal. The trend in recent lit- erature is to recommend avoidance of volatile agents in patients with DMD, and rely instead on total i.v. anaesthesia (TIVA).2
The rhabdomyolysis and hyperkalaemia that develop in DMD is unrelated to that which develops in MH, with a distinct differ- ence in pathophysiology. This has given rise to the term AIR (Anaesthesia induced rhabdomyolysis).2 In AIR, it is the instability of the sarcolemma that results in ‘leak’ of potassium and CK from necrotic and regenerating muscle cells into the serum.

Front 72

95. You are anaesthetising a 6 month-old infant for repair of a VSD. You perform an inhalational induction with 8% sevoflurane and 50% nitrous oxide. Several minutes later, whilst trying to secure IV access, the infant’s oxygen saturations fall to 85%. The most appropriate next step in management:
A. give a fluid bolus
B. change from sevoflurane to isoflurane
C. apply CPAP
D. reduce the FiO2
E. reduce sevoflurane

Back 72

Answer: E

CEACCP ‘Anaesthetic management of children with congential heart disease for non cardiac surgery’
In regards to large VSD... ‘large doses of induction agent may reduce SVR so much that shunt flow is reversed causing desaturation’.
So, we need to increase SVR and decrease PVR.
Avoid hypoxia (reduce HPV)
Achieve normocarbia
Minimise vasodilatation
Consider vasopressors
Minimise lung inflation pressure, aim for spontaneous ventilation

Front 73

96. A 30-year old patient, who takes paroxetine, has suffered a traumatic amputation. The most appropriate medication to reduce her developing chronic post-operative pain is:
A. amitriptyline
B. dextromethorphan
C. gabapentin
D. tramadol
E. pethidine

Back 73

Answer: C

(interactions between all other agents and SSRI may cause serotonin syndrome)

Front 74

97. A 3 year old child has suffered a fractured arm. What is the most appropriate way to assess her pain?
A. the reported severity from the child
B. the reported severity from the parent
C. the reported severity from the nursing staff
D. using the FLACC scale
E. the Wong-Baker Faces scale

Back 74

Answer: ?E
Online consensus is D

(If unable to use E, would use D as 2nd option. D might be more practical in a young child with severe pain)

FLACC - face, legs, activity, cry, consolabilty. (similar use to CHEOPS - cry, face, verbal, torso, touch, leg position)

From 4 years of age self-report becomes more viable. Wong-Baker faces visual analogue scale listed as working from 3-8.

Front 75

98 buprenorphine patch removed morning of surgery. What time till PLASMA reaches half original level
A. 12 hours
B. 18 hours
C. 24 hours
D. 30 hours
E. 36 hours

Back 75

Answer: A

Reference: Acute pain management scientific evidence 2010 p163.

Front 76

101. [Repeat - 2013A Q48] The clinical sign that a lay person should use to decide whether to start CPR is:
A. Absent central pulse
B. Absent peripheral pulse
C. Loss of consciousness
D. Obvious airway obstruction
E. Absence of breathing

Back 76

Answer: E

Danger?

Response?
-> Send for help.

-> Open airway.

Breathing?

-> CPR.

-> Attach AED

Front 77

102. [Similar to 2013A Q38] Central sensitization, resulting in prolongation of post-operative pain, is caused by:
A. Increased intra-cellular gene expression
B. Increased intra-cellular magnesium
C. Low frequency activation of A-delta fibres
D. Primary activation of N-methyl-D-aspartate receptor
E. Increased glycine as a major neurotransmitter

Back 77

Answer: A

See: When does acute pain become chronic?

Front 78

103. [New] A 15yo girl with a newly diagnosed mediastinal mass presents for lymph node biopsy under general anaesthesia. The most important investigation to perform preoperatively is.
A. CXR
B. CT chest
C. MRI chest
D. PET scan
E. Transthoracic echocardiogram

Back 78

Answer: B

Anaesthesia for mediastinoscopy

Pre-op:
Spirometry, CXR, CT scan. Tracheal narrowing > 50%, PEFR < 40%, combined obstructive and restrictive picture, or cardiopulmonary signs and symptoms at presentation all make perioperative respiratory compromise more likely.

A: Potential for tracheobronchial compression. Airway may be difficult, but most lesions will be able to be passed with an ETT.
Flexible ETT preferred. Difficult ventilation may require rescue with rigid bronchoscope and jet ventilation.
B: IPPV may precipitate loss of airway. Inhalational induction and maintenance of spontaneous breathing ideal.
C: Massive haemorrhage rare but serious. May need to use lower limb IV access, as SVC may be compromised. Place art line in R arm ideally, to monitor for R brachiocephalic compression and subsequent possible CVA if inadequate collateral circulation.
D: Ideally, avoid muscle relaxants in those with signs of myasthenic syndromes.
Myasthenia gravis: muscle weakness and fatigability, more sensitive to NDNMBDs, may be resistant to sux.
Eaton-Lambert syndrome - (antibodies to voltage gated calcium channels, inhibit ACh release) proximal muscle weakness that improves with exercise and is not improved by anticholinesterases. Also more sensitive to NDNMBDs.

Post-op:
CXR check for PTx
Dyspnea / stridor may indicate recurrent laryngeal nerve injury or pretracheal haematoma.

Front 79

104. [New] A 63yo woman with chronic AF has a history of hypertension, Type 2 Diabetes Mellitus and has previously had a CVA. What is her annual risk of stroke without anticoagulation?
A. <1%
B. 1.9%
C. 2.8%
D. 4%
E. 8.5%

Back 79

Answer: E

C - 0

H - 1

A - 0

D - 1

S - 2

Score = 4
Risk = 8.5%

Congestive heart failure
Hypertension
Age > 75
Diabetes
Secondary prevention for CVA/TIA - 2 points

Risk of stroke per year by score:

0: 2%
1: 3%
2: 4%
3: 6%
4: 8.5%
5: 12.5%
6: 18%

Front 80

105. [New] A 30 year old multi trauma patient one week post injury has severe ARDS. He is currently ventilated at 6ml/kg tidal volume, PEEP of 15cm H20 and pa02/Fi02 is less than 150. The next step to improve oxygenation is:
A. increase PEEP to 20cmH20
B. increase tidal volume to 10mls/kg
C. initiate nitrous oxide therapy
D. commence high flow oscillatory ventilation
E. ventilate in the prone position

Back 80

Answer: E

(i) plateau inspiratory pressure between 25 and 30 cm H2O,
(ii) FIO2 /PEEP combinations varying between 0.3/5 mm Hg and
1.0/24 mm Hg to maintain SpO2 >88%, PaO2>55mmHg
(iii) I:E ratios between 1:1 and 1:3,
(iv) respiratory rate of up to 35 bpm to minimize hypercapnia, and
(v) bicarbonate to maintain pH >7.15.

See ARDSnet

Front 81

106. [Repeat 2013A] The incidence and severity of vasospasm post sub arachnoid haemorrhage is greatest at:
A. 0 -24 hours
B. 2 - 4 days
C. 6 - 8 days
D. 10 - 12 days
E. greater than 2 weeks

Back 81

Answer: C

CEACCP says greatest days 4-10

Front 82

107. [Repeat 2013A] The insulation on the power cord of a piece of class 1 equipment is faulty such that the active wire is in contact with the equipment casing. What will happen when the power cord is plugged in and the piece of equipment is turned on
A. The double insulation of the device will prevent macroshock when the outer casing is touched
B. The electrical fuse will immediately break and disconnect the device from the power supply
C. Equipotential earthing will prevent microshock from anyone who touches it.
D. The Line Isolation Monitor will alarm and disconnect power to the device
E. The RCD will immediately disconnect the device from the power supply

Back 82

Answer: B

Class I: Have fuses installed before the device. Casing is earthed.


A. Double insulated devices are Class II.
B. Fuses and circuit breakers protect wiring from excessive current, but not personal injury. Would expect RCD to trip first.
C. This is only true in cardiac protected areas.
D. Line isolation monitors do not disconnect power, they merely alarm to alert you to a current imbalance between L1 and L2 (implying a leak)
E. This will happen if the device is plugged into a socket with an RCD

Front 83

108. [Repeat 2013A] In adult cardiopulmonary resuscitation in the community include all of the following EXCEPT:
A. Allow equal time for chest compression and relaxation
B. Chest compression at 100bpm
C. Chest compression should be at least 5cm depth
D. Give 2 rescue breath before commencement of CPR
E. Chest compression to breaths ratio at 30:2

Back 83

Answer: D

CPR first

Front 84

109. [New] Regarding intra-osseous cannulation in paediatric during resus for shock/cardio arrest, a correct statement is:
A. distal tibial above medial malleolus is preferred due to easy access
B. drug reaction time is the same as central venous route
C. 12G used to ensure adequate flow
D. bicarbonate cannot be infused due to bone damage
E. fat embolism is common complication

Back 84

Answer: B

A. Proximal tibia or proximal humerus are preferred

B. More equivalent to IV route.
C.EZ-IO needles are 15g. Some other brands are 18g. (http://www.vidacare.com/files/M-119-Product-Spec-Sheet.pdf)
D. UTD: Fluid and drug administration — Any intravenous drug or routine resuscitation fluid can be administered safely by the intraosseous (IO) route including epinephrine, dopamine, dobutamine, adenosine, antibiotics, digitalis, heparin, lidocaine, atropine, sodium bicarbonate, phenytoin, neuromuscular blocking agents, crystalloids, colloids, and blood products [8,10,27,30-33]. Drug and fluid dosing is the same as for intravenous administration [17,32]. However, the IO route may not be as effective as upper extremity peripheral intravenous access for the treatment of supraventricular tachycardia with adenosine in some young infants

E. Fat embolism can occur: From UTD Microscopic fat and bone marrow emboli were found in the pulmonary autopsy specimens of two children who received intraosseous infusion during resuscitation attempts and in 100 percent of study subjects in several animal studies of intraosseous infusion [44,45]. However, the clinical relevance of these emboli is not clear. No significant alterations in arterial oxygenation or intrapulmonary shunting occurred during a four-hour study period, despite the universal finding of fat and bone marrow emboli.

Front 85

110. [New] During endovascular aneurysm repair, GA is preferred due to:
A. risk of uncontrolled haemorrhage
B. renal ischaemia is painful
C. aorta traction is painful
D. long duration of apnoea is needed
E. contrast used can cause CVS instability

Back 85

Answer: probably A

GA is not generally preferred for EVAR. Local practice is LA / RA, and CEACCP supports this.
A. Can happen, needs GA
B. No
C. No
D. Patient is asked to hold their breath, but normally for short periods during image acquisition
E. No

Front 86

111. [Repeat 2013A Q26] A 35yo G1P0 with a dilated cardiomyopathy presents for a Caesarean section. She has an ejection fraction of 35%. The benefits of a regional anaesthetic over a general anesthetic in this patient may include:
A. decreased heart rate
B. decreased systolic blood pressure
C. increased ejection fraction
D. decreased preload
E. increased myocardial contractility

Back 86

Answer: C

Regional anaesthesia used alone or in combination with general anaesthesia has the advantage of reducing after load which can improve cardiac output. However, hypotension must be prevented to avoid myocardial hypoperfusion. Treatment of arterial pressure changes should be considered if a 10% decrease in systolic pressures occurs.

Aims: avoid tachycardia;

† avoid/minimize the effects of negative inotropic agents, in
particular anaesthetic drugs;
† prevent increases in afterload;
† maintain adequate preload in the presence of elevated LVEDP.

Front 87

112. [New] In attempting to make a precise diagnosis of parathyroid adenoma, you would expect all of the following are found in hyperparathyroid disease EXCEPT:
A. decreased urinary calcium
B. extraosseous calcifications
C. increased plasma calcium
D. increased urinary phosphate
E. renal calculi

Back 87

Answer: A

Bones, stones, abdominal moans, psychic groans and thrones from hypercalcaemia.
Osteitis fibrosis cystica - excessive osteoclast activity which can cause pathological fractures. Also osteoporosis, osteomalacia, and extra-osseous calcifications.
Stones: kidney stones
Abdominal groans: constipation, indigestion, N+V
Psychic groans: lethargy, fatigue, depression, memory loss, psychosis, ataxia, delirium, and coma
Thrones: Polyuria and constipation

Front 88

116. Which general anaesthetic agent contributes the most to green house gas? (Now I'm not 100% sure on the stem recall, but I got the impression it was asking for the agent that is the absolute worse for green house gases (desflurane), not so much which one do we use the most and thus ends up contributing the most to the total green house gas volume (iso or sevo)
A. Desflurane
B. Isoflurane
C. Sevoflurane
D. Propfol
E. N2O

Back 88

Answer: A

Honorable mention: N2O is worse as a greenhouse gas than sevofluarne and isoflurane, and destroys the ozone layer.

Front 89

119. [New] A patient's competence to give informed consent is determined by all the following EXCEPT:
A. Ability to communicate a choice
B. Ability to apply reasoning
C. Ability to understand consequences
D. The provision of significant information
E. ??

Back 89

Answer: ?D

Understand
Retain
Use

Front 90

120. [Repeat] A patient undergoes a femoral-popliteal bypass and has a mildly elevated troponin on day 1 post-operatively. They are otherwise asymptomatic with no other signs/symptoms of myocardial infarction and have an uneventful recovery. What do you do?
A. Arrange for a cardiology follow-up and outpatient angiogram because he is at increased risk of future myocardial infarction
B. Arrange coronary angiogram as an inpatient prior to discharge
C. Inform the patient that while the result is real the significance is questionable
D. Repeat in one week’s time as a second troponin is a better indicator of long-term myocardial infarction risk
E. Ignore the result as it is likely a laboratory error

Back 90

Answer: A

For a diagnosis of MI, require:
1) Typical increase and gradual decrease of troponin
AND ONE OF
1) Ischaemic symptoms
2) development of pathological Q waves
3) ECG changes indicative of ischaemia
4) Coronary artery intervention.

However, according to the CEACCP article below, "Up to 60% of patients undergoing vascular procedures have severe coronary artery disease and fewer than 10% have normal coronary arteries. The cause of cTn increase in this subset of surgical patients is therefore likely to be MI (a high pre-test prob- ability)."

"The majority occur in the first 3 postoperative days, when patients may be affected by sedation or residual anaes- thesia, be receiving strong analgesics which mask ischaemic chest pain or have a distracting painful surgical incision."

The symptoms of angina could have been masked by anaesthetic / analgesic agents. So for this patient, with a high pre-test probability of coronary artery disease, and therefore significant increased mortality in the intermediate term, angiography seems reasonable. If this is going to happen, it should probably happen as an inpatient.

Front 91

121. St John's wort will reduce the effect of
A. aspirin
B. clopidogrel
C. dabigatran
D. heparin
E. warfarin

Back 91

Answer: E

It is also a potent inducer of hepatic cytochrome P450 CYP3A4 isoform. Hence, it may significantly increase the metabolism of many concomitantly administered drugs such as alfentanil, mida- zolam, and lidocaine. It also induces the P450 2C9 isoform that results in the reduction in effect of warfarin and NSAIDs.
The sedative properties of St John’s Wort may potentiate or prolong anaesthetic agents’ effect.

Pharmacokinetic data suggest that St John’s Wort should be stopped for at least 5 days before surgery. This discontinuation is especially important for patients awaiting organ transplant and hence requires immunosuppressants and patients who may require oral anticoagulation.

Potentiates clopidogrel. (clopidogrel is a prodrug, and St John's Wort induces the enzyme that activates it)

Front 92

122. The most important effect of Lugol's iodine administration before thyroid surgery is
A. reduce incidence of thyroid storm
B. reduce incidence of vocal cord palsy
C. increase likelihood to identify and preserve parathyroid glands
D. pigmentation of thyroid gland to help identify thyroid gland
E. reduce vascularity of thyroid gland.

Back 92

Answer: E

Antithyroid drugs make the thyroid more vascular. Giving iodine for 10 days pre-op reduces the vascularity of the thyroid and reduces bleeding. Not commonly done any more, as the thyroid is now usually resected whole - ie: without being transected.

From BJA thyroid disease

Front 93

123. Performed a brachial plexus block. Normal sensation still remains in medial forearm. Which part of brachial plexus is most likely to have been missed
A. Inferior trunk
B. Ulnar nerve
C. Median brachial cutaneous nerve
D. Anterior division
E. Posterior cord

Back 93

Answer: C

(Actually Medial antebrachial cutaneous nerve)

Front 94

124. You are pre assessing A 70 year old patient treated for congestive cardiac failure. They are able to shower themselves and complete other ADLs but get dyspneoa on mowing the lawn. They are New York Heart Association classification
A. Class 1
B. Class 2
C. Class 3a
D. Class 3b
E. Class 4

Back 94

Answer: B

I : no symptoms and no limitations in ordinary physical activiy
II: Mild symptoms and slight limitations in ordinary daily activity
III: Marked limitation
IV: SOBAR

Front 95

126 Fluoroscopy in the operating theatre increases the exposure of theatre personnel to ionising radiation. Best method to minimise one's exposure to such radiation is to
A. have dosimeter checked at least 6-monthly
B. limit exposure time to radiation
C. maximal distance from radiation source
D. stand behind transmitter of C arm
E. wear protective garments

Back 95

Answer: C

From Miller:Because the intensity of scattered radiation is inversely proportional to the square of the distance from the source, the best protection is physical separation. A distance of at least 3 feet from the patient is recommended. Six feet of air provides protection the equivalent of 9 inches of concrete or 2.5 mm of lead.

Front 96

127 Prothrombinex VF useful in perioperative period to correct the coagulopathic defect of all except
A. Isolated factor II deficiency
B. Isolated factor VII deficiency
C. Isolated factor IX deficiency
D. Isolated factor X deficiency
E. Warfarin

Back 96

Answer: B

From MIMS, full Pi precautions: "Prothrombinex VF is not recommended for the management of patients with isolated factor V or factor VII deficiency because of the low levels of factors V and VII in the product."

Has a short half life and is not present in useful quantities in prothrombinex.

From the Red Cross and the PI from CSL
When reconstituted as recommended, each vial of PROTHROMBINEX-VF contains 500 IU of factor IX, approximately 500 IU of factor II, 500 IU of factor X, 25 IU of antithrombin III, 192 IU of heparin sodium and ≤ 500mg of plasma proteins (which includes low levels of factor V & VII.) Other ingredients include sodium citrate, sodium phosphate and sodium chloride.
The coagulation factors II, VII, IX and X, which are synthesised in the liver with the help of vitamin K, are commonly called the prothrombin complex.
PROTHROMBINEX–VF is indicated for the treatment and perioperative prophylaxis of bleeding in acquired deficiency of prothrombin complex factors, such as deficiency caused by treatment with vitamin K antagonists, or in case of overdose of vitamin K antagonists, when rapid correction of the deficiency is required. PROTHROMBINEX–VF is also indicated for the treatment and prophylaxis of bleeding in patients with single or multiple congenital deficiencies of factor IX, II or X when purified specific coagulation factor product is not available.

Front 97

133. The organ that is least tolerant of ischaemia, after removal for transplant, is:
A. Cornea
B. Heart
C. Kidney
D. Liver
E. Pancreas

Back 97

Answer: B

Heart4 : 6 : 12 : 18 hours

Front 98

134. 75yo woman with an ejection systolic murmur presents for elective total knee joint replacement. Focussed transthoracic echocardiogram is performed. The feature most consistent with severe aortic stenosis is:
A. Mean gradient across aortic valve of 30mmHg
B. Peak gradient across aortic valve of 40mmHg
C. Peak velocity across aortic valve of 4.2m/s
D. Aortic valve area of 1.2cm2
E. Calcification and restriction of the aortic valve

Back 98

Answer: C


Severe AS:
AVA <1.0
Mean gradient 40-50
Peak gradient > 65

From AHA guidelines:
Symptomatic AS: need AVR before any elective non-cardiac surgery
Severe AS without symptoms: must have valve evaluated within last year

Front 99

135. Which of the following statements regarding patients with ankylosing spondylitis is FALSE?
A. amyloid renal infiltration is rarely seen
B. cardiac complications occur in less than 10% of cases
C. normochromic anaemia occurs in over 85% of cases
D. sacroileitis is an early sign of presentation
E. uveitis is the most common extra-articular manifestation

Back 99

Answer C

A – Yes, about 4%
B – Yes, about 10%. 2.5% AR, 1%MR, 0.5% mitral valve prolapse, 0.5% pericarditis, 4.5% AV block, 3% BBB
C – No, anaemia of chronic disease/inflammation in 15%
Anemia of chronic disease is often a mild normocytic anemia, but can sometimes be more severe, and can sometimes be a microcytic anemia;thus, it often closely resembles iron-deficiency anemia.
In response to inflammatory cytokines, increasingly IL-6,the liver produces increased amounts of hepcidin. Hepcidin in turn causes increased internalisation of ferroportin (iron transporter) molecules on cell membranes which prevents release of iron stores, and decreased plasma iron levels.
D – Yes
E – Yes

Front 100

136. A healthy 25 year old woman is 18 weeks pregnant. Her paternal uncle has had a confirmed episode of malignant hyperthermia. She has never had susceptibility testing. Her father and siblings have not been tested either. The best test to exclude malignant hyperthermia susceptibility before she delivers is
A. Genetic test father
B. Genetic test woman
C. Muscle biopsy sibling
D. Muscle biopsy father
E. Muscle biopsy woman

Back 100

Answer: D

Genetic testing can be helpful if it is positive, but does not rule out MH.
Testing requires live muscle samples, so muscle biopsy needs to be performed on-site, usually 'under regional' according to the below article - i.e.: nerve block, not local infiltration as this may interfere with muscle function

From BMHA (http://www.bmha.co.uk/screening.html): Not all patients can have a biopsy, these include children less than 10-12yrs (30kgs), pregnant women, and patients on prolonged steroid therapy. If the proband cannot be tested, eg a young child or deceased, then the nearest most appropriate relative is tested. In the case of a young child this would be the parents.

??because of hormonal state of mother
Can't do it under LA because it alters the test
Paternal uncle specified in question

Front 101

139. During the first stage of labour, pain from uterine contractions + cervical dilatation is from nerve roots: A.-E. ( multiple options of thoracic - lumbar roots (sorry can't remember the exact ones, thought it was a repeat question so didn't write it all down)

Back 101

Uterus: T10-L2
Cervix, vagina, perineum: S2,3,4

(Peritoneum as high as T4)

Front 102

140. A test has a sensitivity + specificity of 90% for a disease with a prevalence of 10%. What is the positive predictive value?
A. 10%
B. 50%
C. 82%
D. 90%
E. 99%

Back 102

Answer: B

PPV = probability of having a disease, given a positive test
=TP/TP+FP

Front 103

141. A female with type 1 von Willebrand disease presents for a dilation and curettage. She is a Jehovah’s Witness. In regards to desmopression to prevent haemorrhage in this patient all of the following are true EXCEPT:
A. It is a synthetic substance and therefore acceptable to Jehovah's Witnesses
B. It is likely to reduce haemorrhage in this patient
C. It should be given as an infusion 30 minutes prior to surgery
D. The effect will last 5 days
E. The dose is 0.3μg/kg

Back 103

Answer: D

(8-20 hours)

OHA mainly. Also Miller, the PI, and UB ‘How treat von Willebrands Disease Blood 2001’
von Willebrand's disease is divided into three subtypes. After subtyping (type 2B is non-responsive) a therapeutic trial of desmopressin with before-and-after levels of von Willebrand factor is performed. Responders should have desmopressin for bleeding or prophylactically prior to surgery. Non-responders can have intermediate purity factor VIII concentrate (which includes von Willebrand factor) or cryoprecipitate.
Desmopressin infusion of 0.3µg/kg in 50–100ml 0.9% sodium chloride over 30min, 20-30 minutes before surgery.
A – Yes, desmopressin is a synthetic analogue of vasopressin.
B – Yes, type I is a quantitative vWF deficiency, desmopressin increases plasma vWF in patients with type I and some patients with type II disease.
C – Yes, above
D – No, In general, high VIII–vWF concentrations last in plasma for at least 8 to 10 hours. Infusions can be repeated every 12 to 24 hours, if necessary. Tachyphylaxis is likely with repeated infusions within 48 hours.
E – Yes, above

From UpToDate

Type 1 — Type 1, an autosomal dominant disease, is the most common, accounting for approximately 70 percent of patients. It reflects a quantitative deficiency of von Willebrand factor (VWF). The clinical presentation varies from mild to moderately severe, as determined by bleeding symptoms.

Type 2 — Type 2, which is usually an autosomal dominant disease, accounts for 25 to 30 percent of cases. It is characterized by several qualitative abnormalities of VWF (ie, altered size ratios or biologic properties).

Type 3 — Type 3 VWD, an autosomal recessive disorder, leads to severe disease with extremely reduced or undetectable levels of VWF. These patients present with severe bleeding involving both the skin and mucous membrane surfaces (due to decreased VWF) and soft tissues and joints (due to the low concentration of factor VIII) (table 2). They may initially be diagnosed as having hemophilia A before the results of VWF testing are available. Replacement therapy with VWF is usually required.

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142. A 25 week post conceptual age infant is being ventilated in the Neonatal Intensive Care Unit. To reduce the risk of retinopathy of prematurity, they are being ventilated to a target oxygen saturation of 85-89% instead of 91-95%. This is associated with:
A. Increased acute lung injury
B. Increased mortality
C. Increased sepsis
D. Reduced intracerebral haemorrhage
E. Reduced necrotizing enterocolitis

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Answer: B

BOOST 2
SpO2 85-89% reduced retinopathy of prematurity, increases mortality
International randomized controlled trial 2500 premature infants

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144. An 80 year old man undergoes a unilateral lumbar sympathectic blockade. THe most likely side effect that he experiences is:
A. Genitofemoral neuralgia
B. Haematuria
C. Postural hypotension
D. Lumbar radiculopathy
E. Psoas haematoma

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Answer: A

ANZCA Book ‘Pain Management, 2ed (ClinicalKey) Waldman’
Similar to all regional anesthetic blocks, sympatholysis may result in intravascular injection; however, the chance of intravenous injection should be negligible if fluoroscopic guidance is used throughout the injection. The most common complication associated with lumbar sympatholysis is neuralgia of the genitofemoral nerve, particularly for the lateral approach.The incidence of genitofemoral neuralgia has been reported to be 15%, but it may be only 4% with a single- needle technique. Most cases are transient and resolve with nonprescription analgesics, but the condition may last 6 weeks. A repeat local anesthetic sympathetic block commonly produces immediate remission. Similarly, intravenous lidocaine may be used in a dose of 1 to 2 mL/kg, or transcutaneous nerve stimulation may be employed over the thigh for genitofemoral neuralgia. Other complications are necrosis of the psoas muscle and sloughing of the ureter (D. Reed, personal communication, 1985). Bleeding may occur in a patient with a clotting deficiency, which, in any case, would be a contraindication to sympathetic block. Otherwise, any bleeding from needle puncture should be self-limiting. Patients should be warned that they may have some hypotension immediately after sympatholysis, and men should be apprised that they may experience impotence or failure of ejaculation, particularly if a neurolytic procedure is undertaken.

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145. Regarding Le Fort fractures:
A. External signs correlate with internal skeletal damage
B. Le Fort fractures don't usually occur in combination (for example I and II)
C. Patients with a Le Fort I fracture should NOT undergo nasal intubation
D. Patients with a Le Fort II fracture should have evaluation of the base of skull prior to nasal intubation
E. Le Fort III fracture is associated with fracture of the cribiform plate

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Answer: E

A-False
B-False: the Le Fort classification is a gross oversimplification. In high speed MVA, the fractures can occur in combination
C-False: Le Fort I is a fracture of the mandible from the rest of the mid face, and does not involve the base of skull. It is usually stable.
D - False
E - Yes. Cribiform plate is in the ethmoid bone.

Le Fort I: Maxilla detached
Le Fort II: Maxilla and nose detached
Le Fort III: Through orbits and along the base of skull. Craniofacial dysjunction.

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?145. Greatest predictor of AF post CPB
A. advanced age
B. history of hypertension
C. history of CVA
D. history of CCF
E. prolonged CPB

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Answer: A

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146. 2yr child post op following stabismus surgery. ETT 4.5 used. Awake, stridor and tracheal tug. Immediate action?
A. inhalational induction
B. CPAP with facemask
C. propofol 1mg/kg
D. dexamethasone 0.4mg/kg
E. adrenaline nebuliser 1:1000 05ml/kg

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Answer: B

Laryngospasm:

CPAP, jaw thrust, stop painful stimulus

Consider sux 0.5mg/kg IV or 2-4mg/kg IM.

Low dose propofol.

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149. Transient neurological (radicular) syndrome ONLY occurs with
A. Hyperbaric local anaesthetics
B. Intrathecal lignocaine
C. Lithotomy positioning
D. Following complete resolution of motor blockade
E. When there has been a dense motor block with spinal anaesthetic

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Answer: D

By definition: Transient neurological symptoms have been defined as pain in the lower extremities (buttocks, thighs and legs) after an uncomplicated spinal anesthesia and after an initial full recovery during the immediate postoperative period (less than 24 h).

TNS rate lignocaine > mepivacaine > prilocaine and bupivacaine

More common after lithotomy positioning.
Mechanism unclear.
Distinct from the cauda equine syndrome reported following continuous spinal anaesthesia via catheters with hyperbaric 5% lignocaine. Lignocaine is more toxic to unsheathed nerves, and hyperbaric lignocaine appears to pool when infused slowly via a catheter.

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150. 50yo lady, attempted suicide attempt, jumped from 5th floor building. She does not open her eyes or vocalise and there is no response to pressure on her nail-bed. What is her GCS?
A. 2
B. 3
C. 5
D. 8
E. 12

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Answer: B