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102 Cards in this Set
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Child with murmur- what would make it more likely for you to investigate if you heard the murmur
A. persist in supine position B. louder or softer with various manouveres |
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TMP-Mar11-045
How far to insert PICC line in a kid beyond the carina A: At the carina B: 1cm below C: 1cm above |
A: At the carina
- see wiki link re Coroner's report on child death secondary to PICC line -> cardiac tamponade. ----------- |
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[May09][Oct09][Sep11]
Neonate born to known drug abusing mother brought to emergency department by grandmother, unwell lethargic, slightly jaundiced, ABG shows following: pH 7.52 Na 135 Cl 87 K 3 pCO2 38 Which of the following is the Diagnosis? A) Septicaemia B) Hepatitis C) Pyloric stenosis D) Pneumonia E) Opioid withdrawal |
C. Pyloric stenosis
From eMedicine: Jaundice occurs in ~2% of infants with pyloric stenosis. Cause is uncertain and though to reflect decrease in hepatic glucoronosyltransferase activity associated with starvation, as occurs in high GI obstruction. The jaundice resolves spontaneously and rapidly after pyloromyotomy. ----------- |
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PP07 [1985] [1986] [Apr96]
The APGAR score of a neonate who is blue in colour with weak respirations, weak cry, pulse of 84, floppy with slight flexion to stimulation is: A. 1 B. 2 C. 3 D. 4 E. 5 |
D. 4
APGAR = Appearance (skin colour), Pulse, Grimace (Reflex irritability), Activity (muscle tone), Respiration (A =0, P=1, G=1, A=1, R=1) ----------- Appearance 0 = blue or pale; 1= pink body with blue extremities; 2 = completely pink Pulse (HR) 0=absent; 1= <100; 2= >100 Grimace (reflex irritability) 0=no response; 1=grimace; 2=cough or sneeze Activity (muscle tone) 0=limp; 1=some flexion; 2=active movement Respirations 0=absent; 1=slow, irregular; 2=good, crying |
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PP10 ANZCA version [2001-Apr] Q51, [2005-Apr] Q57, [Jul05] [Mar06]
The passage of an appropriately sized endotracheal tube in a neonate suffering from the idiopathic respiratory distress syndrome (hyaline membrane disease) will A. impair oxygenation by making grunting impossible B. impair oxygenation by increasing airway resistance C. improve oxygenation by reducing dead space D. improve oxygenation by eliminating laryngeal obstruction E. have no effect on oxygenation |
A. impair oxygenation by making grunting impossible
Respiratory Distress Syndrome also (called Idiopathic Respiratory Distress Syndrome, or Hyaline Membrane Disease) ➮ Result of lack of surfactant at birth ➮ Risk factors ➟Prematurity ➟Diabetic mothers ➮ Lack of surfactant implies that alveoli are more prone to collapse as surfactant decreases work of breathing and helps promote alveolar stability. Hence neonates with HMD have requirements for high PEEP when ventilated, as well as higher pressures due to decreases ventilatory compliance. Neonates will classically grunt at the end of expiration in order to apply some self-PEEP and hence keep alveoli open. ----------- |
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PP16
The condition of a neonate deteriorates twelve hours after repair of a diaphragmatic hernia. The most likely cause for deterioration: A. Hypoglycaemia B. Gastric dilatation C. Tension pneumothorax D. Haemorrhage E. None of the above |
E. None of the above.
----------- Quote out of Stoelting 5E "The postoperative course, after surgical reduction of congenital diaphragmatic hernias, is often characterized by rapid improvement, followed by sudden deterioration with profound arterial hypoxemia, hypercapnia, and acidosis, resulting in death. The mechanism for this deterioration is the reappearance of fetal circulation patterns, with right-to-left shunting through the foramen ovale and ductus arteriosus. If shunting occurs through the ductus arteriosus, there is a 20-mm Hg or more difference in the PaO2 measured in samples obtained simultaneously from preductal and postductal arteries. If the shunting is predominantly through the foramen ovale, no such gradient exists. Proper sedation is necessary as any stressful stimulus can further exacerbate already elevated pulmonary pressures with resultant increases in shunt flow and further desaturation." |
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PP25 ANZCA version [2003-Aug] Q115 (Similar question reported in [1989] [Aug96])
In an infant suffering from persistent vomiting: A. a plain x-ray of the abdomen is NOT likely to provide diagnostic help B. duodenal atresia is less likely if the child has Down's syndrome C. pyloric stenosis often presents with hypokalaemic, hypochloraemic, metabolic acidosis D. surgery is urgent to prevent dehydration E. the presence of bile in the vomitus favours the diagnosis of pyloric stenosis |
A. a plain x-ray of the abdomen is NOT likely to provide diagnostic help
B. FALSE Associated with Down's syndrome in 20-30% of cases (300 times more likely in Down's) C. FALSE alkalosis D. FALSE surgery is urgent to prevent gut infarction in the case of volvulus, dehydration can be managed with intravenous fluids E. FALSE the presence of bile in the vomitus suggests the stricture is distal to the ampulla, this sign is serious ----------- |
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PP31 ANZCA version [2005-Apr][Jul05] [Jul07][Mar10][Mar12]
In congenital diaphragmatic hernia A. there is hyperplasia of pulmonary arterioles in the hypoplastic lung B. right-sided lesions are more pathologically significant C. vasodilator drugs are contraindicated D. right-sided lesions through the foramen of Bochdalek are the most common E. intrapulmonary shunts are the major cause of cyanosis |
A. there is hyperplasia of pulmonary arterioles in the hypoplastic lung
~~ Congenital Diaphragmatic Hernia (CDH) --------------------------------- ➭ 1:2000-4000 live births ➭ 80% left sided through the foramen of Bochdalek ➭ The affected lung is intrinsically abnormal, all stages of lung development being affected - underdeveloped airways - abnormal differentiation of type II pneumocytes - reduced number of pulmonary arteries per unit lung volume - intrapulmonary arteries excessively muscularized with thickened adventitia and media (hyperplasia) - display an abnormal response to vasoactive substances ➭ ALL have pulmonary hypertension - Echo features: flattening of the interventricular septum, tricuspid regurgitation, and a right-to-left or bidirectional shunt at the ductus arteriosus ➭ Inhaled NO improves oxygenation but not ned for ECMO ➭ ECMO used for stabilisation pre-surg and rescue post-op - improved survival BUT greater long term morbidity Continuing Education in Anaesthesia, Critical Care & Pain | Volume 5 Number 5 2005 ➭ Intrapulmonary shunt is now thought not to be main cause of hypoxia, but rather ductal shunt due to pulmonary hypertension ----------- "The diaphragmatic defect may be small and slitlike or include the entire hemidiaphragm. Both lungs are small compared with those of age- and weight-matched controls, with the lung on the side of the defect more severely affected. There is a decrease in the number of alveoli and bronchial generations. The pulmonary vasculature is abnormal, with a decrease in volume and marked increase in muscular mass in the arterioles. Although there is some evidence that the pulmonary abnormalities are due to compression by the intrathoracic abdominal viscera, it is not accepted that physical compression is the sole or primary cause." |
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PP33 ANZCA version [Aug93] [2003-Aug] Q101
A 26 year old primigravida at 39 weeks is delivering by the vertex after a protracted labour. She has received 250mg of pethidine over the previous 8 hours. The head is delivered and the neonate has thick meconium on its face and in its mouth. The most important step in the management of this neonate is A. administration of naloxone via the umbilical vein B. intubation of the trachea immediately on delivery C. lavage of the trachea with sterile normal saline D. oropharyngeal suction with a sterile catheter immediately following delivery of the head E. oxygen by mask with intermittent positive pressure |
D. oropharyngeal suction with a sterile catheter immediately following delivery of the head
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PP36 ANZCA version [2001-Aug] Q32, [2002-Mar] Q50, [2003-Aug] Q84, [2004-Apr] Q74, [Mar06] (Similar question reported in [Aug94] [Apr96] [Apr98] [Jul98])
A two year old child sustains a simple fracture of the lower end of the forearm one hour after having a full meal. The most appropriate approach is to A. postpone surgical reduction for 12 hours and treat as an elective case B. allow immediate reduction using a rapid sequence induction, cricoid pressure and intubation C. allow immediate reduction using a regional technique D. allow immediate reduction, after gastric emptying with a tube followed by rapid sequence induction, cricoid pressure and intubation E. wait 4 hours and treat as elective |
A. postpone surgical reduction for 12 hours and treat as an elective case
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PP37 [Aug94] [Apr96][Mar12]
A child with an inhaled foreign body. What is the characteristic radiological sign? A. Hyperinflation of the affected lung on expiration B. Opacity in the right upper lobe C. Evidence of interstitial oedema D. Collapse of the affected lobe E. Right middle lobe collapse F. Radiopaque shadow superimposed on bronchi G. Mediastinal shift |
A. Hyperinflation of the affected lung on expiration
-- A. Hyperinflation of the affected lung on expiration - true and has best detail: "If the chest is normal, a ball-valve phenomenon may still exist, and on the expiration view, air will be trapped on the affected side, whereas the unaffected lung will decrease in volume." (Mettler: Essentials of Radiology 2E Ch 9) B. Opacity in the right upper lobe - likely false C. Evidence of interstitial oedema - likely false D. Collapse of the affected lobe - true: "In this case (of a completely impacted foreign body), the air distally will become resorbed, and postobstructive atelectasis or a focal infiltrate with associated volume loss will be found." (Mettler: Essentials of Radiology 2E Ch 9) E. Right middle lobe collapse - possible but not a cardinal feature of the CXR F. Radiopaque shadow superimposed on bronchi - false: "Most foreign bodies consist of vegetable material (such as peanuts) or plastic. Remember that vegetable and plastic items are usually not visible on a plain x-ray." (Mettler: Essentials of Radiology 2E Ch 9) G. Mediastinal shift - true but only on expiratory film: "If the chest is normal, a ball-valve phenomenon may still exist, and on the expiration view, air will be trapped on the affected side, whereas the unaffected lung will decrease in volume. When this happens, a resultant shift of the mediastinum toward the normal unaffected side will be seen." (Mettler: Essentials of Radiology 2E Ch 9) ----------- |
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PP46b ANZCA version [2001-Apr] Q17, [2003-Apr] Q104, [2003-Aug] Q57, [Mar06][Aug10][Mar12]
The average expected depth of insertion of an oral endotracheal tube, from the lip, in a normal newborn infant is A. 7.5 cm B. 8.5 cm C. 9.5 cm D. 10.5 cm E. 11.5 cm |
C. 9.5 cm
Miller: Premature 6-7 Term 8-10 Infants (Age/2) + 12 In neonates of various weights (ie to include prems) the formula to remember is weight plus 6. Thus average newborn weight is 3.5 kg so average length is 9.5 cm. The approximate depth of insertion measured from the centre of the lips for an oral tube: in a newborn is 9.5 cm, 11.5 cm for a 6 months old infant 12 cm for a 1 year old. Thereafter, the approximate depth of oral insertion is given by the formula: age (years)/2 + 12 cm. ----------- Table 3. ETT Size and Measurement at Lip According to Infant Weight Weight ETT size ETT measurement at lip <1000g 2.5 7 cm at the lip 1000-2000 g 2.5-3 8 cm at the lip 2000-3000 g 3-3.5 9 cm at the lip >3000 g 3.5-4 10 cm at the lip |
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PP49 [Apr99] [Mar00]
A 5kg baby loses 65mls of blood at operation. Which of the following is correct? A. Transfuse as blood loss >20% B. Don't transfuse as loss is <10% C. Transfuse if further blood loss anticipated D. >25% blood volume lost E. Definitely do not give blood |
C. Transfuse if further blood loss anticipated
Weight = 5kg Blood volume = 80 mls/kg = 80 x 5 = 400mls Blood loss = 65/400 = 16% ----------- |
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PP51 [Jul00]
At what age in children is the Hb level at its lowest? A. Neonate B. 3 months C. 6 months D. 12 months E. 24 months |
B. 3 months
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PP52 ANZCA version [2001-Aug] Q66, [2002-Mar] Q34
A 16 kilogram, 3 year old boy for unilateral inguinal herniotomy has general anaesthesia and a caudal with 8 mls of 0.25% plain bupivacaine. The LEAST correct statement regarding this anaesthetic management is that A. the required level of the block is T12 B. the volume of local anaesthetic used is inadequate C. the block duration is the same for all segments D. peripheral nerve blocks are safer than neural axis blocks in children E. use of adrenaline in the local anaesthetic would prolong the block |
C. the block duration is the same for all segments -- most false answer therefore the one to choose
----------- A. the required level of the block is T12 -- Moderately incorrect T11 B. the volume of local anaesthetic used is inadequate -- Partially incorrect May be adequate but not ideal volume… should be 1ml/kg so need more volume C. the block duration is the same for all segments F Highly incorrect D. peripheral nerve blocks are safer than neural axis blocks in children ?no idea seems true so not the answer to choose. E. use of adrenaline in the local anaesthetic would prolong the block F Evidence suggest it may or may not have an effect |
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PP53a ANZCA version [2001-Aug] Q85
Intra-operative hypoglycaemia in children is LEAST likely in A. small-for-age children B. Beckwith-Wiedeman Syndrome C. infants following an overnight fast D. infants on propranolol peri-operatively E. intra-operative interruption of pre-operative total parenteral nutrition (TPN) |
C. infants following an overnight fast
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PP53c ANZCA version [2001-Apr] Q82
The most correct statement regarding intra-operative glucose management in children is that A. 5% dextrose should be used B. there is a higher incidence of hypoglycaemia in children following overnight fasting than in children fasting during the daytime C. blood glucose monitoring is mandatory D. hyperglycaemia is harmless E. most children do not require glucose intra-operatively |
E. most children do not require glucose intra-operatively
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PP54 ANZCA version [2001-Aug] [Oct09]
Obstructive sleep disorder in children A. is associated with pulmonary hypertension and dysfunction of left and right ventricles B. has obesity as a major risk factor C. is rarely seen in children less than 8 years old D. is four times more prevalent in boys than girls E. does NOT usually require tonsillectomy for its management |
A. is associated with pulmonary hypertension and dysfunction of left and right ventricles
On wiki B. is debated however studies are heterogenous in definition of 'obese'… ----------- |
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PP55 ANZCA version [2001-Apr] Q91, [2002-Mar] Q83, [2002-Aug] Q69, [2005-Apr] Q89, [Jul05] [Jul07] [Apr08]
A 4-year-old child with obstructive sleep disorder presenting for tonsillectomy A. is likely to suffer from daytime somnolence B. is unlikely to have a history of snoring C. is suitable for day-case surgery D. has a 40% chance of postoperative vomiting without antiemetic treatment E. is likely to lose 5% of their blood volume during surgery |
E. is likely to lose 5% of their blood volume during surgery
For a 4 year old: Weight = 2x(Age + 4) = 2x(4 + 4) = 16kg Blood volume of child = 80mls/kg = 80x16 = 1280mls 5% blood volume = 0.05 x 1280 = 64 mls higher than 40% emesis risk ----------- |
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PP56 ANZCA version [2002-Mar] Q143
The Pierre Robin syndrome is characterised by 1. smaller than normal mandible 2. cervical spine synostosis 3. cleft palate 4. maxillary hypoplasia |
1. smaller than normal mandible
3. cleft palate Pierre Robin syndrome has mandibular hypoplasia. There are no cervical spine abnormalities. Cleft palate in 50% of cases. Maxillary hypoplasia is a feature of Treacher Collins syndrome Klippel Feil: cervical spine synostosis. ----------- |
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PP57 ANZCA version [2002-Mar] Q148 type K MCQ
Anaesthesia-related cardiac arrest in children 1. associated with overdose of a volatile agent, is more likely to occur at induction than at any other time period of anaesthesia 2. has an incidence which is unrelated to the age of the child 3. has an outcome which is related to ASA physical status 4. is unlikely to be due to cardiovascular depression from volatile agents in patients with ASA physical status 1or |
1. associated with overdose of a volatile agent, is more likely to occur at induction than at any other time period of anaesthesia
3. has an outcome which is related to ASA physical status ----------- |
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PP58a ANZCA version [2002-Mar] Q74
Spinal anaesthesia in infants A. often causes hypotension if the infant is awake B. has a lower failure rate than in adults C. eliminates the risk of postoperative apnoea D. lasts for a longer time than in adults E. may be performed at a higher spinal level than in adults |
ALL FALSE
A. often causes hypotension if the infant is awake - probably false B. has a lower failure rate than in adults - false: There is a high failure rate. "This technique is for the expert only and there is a failure rate of around one in five even in expert hands." C. eliminates the risk of postoperative apnoea - false: lower incidence but not eliminated (think of a high spinal). "Postoperative monitoring should be in a neonatal high-dependency or intensive care unit. Using this technique, there is a proven reduced incidence of postoperative apnoea and episodes of bradycardia and hypoxaemia when compared with general anaesthesia with tracheal intubation." D. lasts for a longer time than in adults - false: "The onset time is 5–10 min but the duration of useful surgical anaesthesia may be very short at 20–60 min. This makes the single injection subarachnoid block less suitable for bilateral procedures, complex hernias or prolonged procedures." E. may be performed at a higher spinal level than in adults - false - spinal cord is relatively longer in infants. ----------- |
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PP58b ANZCA version [2003-Aug] Q114, [2004-Apr] Q32, [2005-Apr] Q24, [2005-Sep] Q38, [Jul07]
Spinal anesthesia in infants A. eliminates the risk of postoperative apnea B. has a lower failure rate than in adults C. lasts for a shorter time than in adults D. may be performed at a higher level than in adults E. often causes hypotension if the infant is awake |
C. lasts a shorter time than in adults
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PP59 ANZCA version [2002-Mar] Q95, [2002-Aug] Q35
A child weighing 8 kg would be expected to need a Laryngeal Mask Airway of size: A. 0 B. 1 C. 1.5 D. 2 E. 2.5 |
C. 1.5
1-5 Kg 1.0 5-10 1.5 10-20 2.0 – remember that up to 20, needs 2.0. 10 kg increments above and below this per half size 20-30 2.5 30-50 3.0 50-70 4.0 >70 5.0 ----------- |
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PP60 ANZCA version [2002-Aug] Q116
A one-month-old infant requires analgesia following simple inguinal hernia repair. The most appropriate paracetamol dosing regimen for the first 48 hours is Route Loading Subsequent Maximum daily dose doses dose (mg.kg-1) (mg.kg-1) (mg.kg-1.day-1) A. Oral 20 15 45 B. Oral 20 20 90 C. Oral 20 20 60 D. Rectal 20 20 90 E. Rectal 40 20 90 |
C. Oral 20 20 60
According to ANZCA APM (2nd ed) p210: Max daily dose for infants less than 6 months is 60mg/kg/day - so answer is C Over 6 months: 90 mg/kg/day Under 6 months: 60 mg/kg/day 34 wk prem: 45 mg/kg/day ----------- |
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PP61a ANZCA version [2002-Aug] Q119
The peak effect of oral midazolam as a premedication in children occurs after A. 10 - 20 minutes B. 20 - 30 minutes C. 30 - 40 minutes D. 40 - 50 minutes E. 50 - 60 minutes |
B. 20 - 30 minutes
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PP61b ANZCA version [2003-Aug] Q124, [Apr07] Q124, [Jul07]
The peak effect of oral midazolam as a premedication in children occurs after A. 10 - 15 minutes B. 20 - 30 minutes C. 35 - 45 minutes D. 50 - 60 minutes E. 65 - 75 minutes |
B. 20 - 30 minutes
The disadvantages of oral administration are that a relatively large dose (0.5-1.0 mg·kg–1) of midazolam is required because of first-pass metabolism in the portal circulation yet the peak effect is seen in about 30 min and children dislike its bitter taste. Furthermore, the peak effect of oral transmucosal midazolam of 10 min compares favourably with 30 min after an oral dose. CJA - Oral Transmucosal Premedication for Preschool Children ----------- |
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PP61c ANZCA version [2004-Apr] Q131
Satisfactory sedation after 0.5 mg.kg-1 of oral midazolam as a premedication in children usually occurs after A. 5 minutes B. 15 minutes C. 25 minutes D. 35 minutes E.45 minutes |
C.25 minutes
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PP61d ANZCA version [2004-Aug] Q141, [2005-Apr] Q61
Which of the following statements regarding pre-operative oral midazolam in children (in appropriate dosage) is INCORRECT? A. Distress at induction is reduced by approximately one half B. Peak effect is at 20 - 30 minutes C. Pre-operative anxiety is reduced D. Post-operative maladaptive behaviour is reduced E. Significantly delays recovery and discharge |
E. Significantly delays recovery and discharge - FALSE so answer to choose.
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PP62 ANZCA version [2002-Aug] Q113, [2003-Apr] Q74
Propofol for induction and maintenance of anaesthesia in healthy children, compared to healthy adults, has A. a larger central volume of distribution B. a lower total body clearance C. the same context sensitive half-time D. a more rapid awakening time E. a lower infusion rate requirement |
A. a larger central volume of distribution
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PP63a ANZCA version [2002-Aug] Q117, [2003-Apr] Q44, [2004-Aug] Q42 [Oct08]
A six-week-old baby is booked for elective right inguinal hernia repair. The gestational age is 38 weeks. An appropriate fasting time is A. 6 hours for breast and formula milk B. 4 hours for solids C. 2 hours for formula milk D. 3 hours for breast milk E. 6 hours for solids and 3 hours for all fluids |
D. 3 hours for breast milk
As was the practice at Adelaide WCH. ----------- |
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PP63b ANZCA version [2002-Aug] Q117, [2003-Apr] Q44, [2004-Aug] Q42, [Jul05] [Apr07] [Oct08]
A six-week-old baby is booked for elective right inguinal hernia repair. An appropriate fasting time is A. 2 hours for formula milk B. 2 hours for clear fluids C. 5 hours for breast and formula milk D. 6 hours for solids E. 6 hours for solids and 3 hours for all fluids |
B. 2 hours for clear fluids
College guidelines from PS15: 4.5.2.2 For healthy children over 6 weeks of age having an elective procedure, limited solid food and formula milk may be given up to six hours, breast milk may be given up to four hours and clear fluids up to two hours prior to anaesthesia. 4.5.2.3 For healthy infants under 6 weeks of age having an elective procedure, formula or breast milk may be given up to four hours and clear fluids up to two hours prior to anaesthesia. ----------- |
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PP64 ANZCA version [2002-Aug] Q131, [2003-Apr] Q78
Changes in the fetal circulation following birth include A. an immediate increase in pulmonary vascular resistance B. functional closure of the foramen ovale at one hour C. physical closure of the foramen ovale at several weeks D. a decrease in systemic vascular resistance E. closure of the ductus arteriosus in the first few hours |
B. functional closure of the foramen ovale at one hour
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PP65 ANZCA version [2003-Apr] Q130
In a child with NO history of epilepsy the commonest cause of post-operative convulsions is A. hyperthermia B. hyponatraemia C. hypoxia D. local anaesthetic toxicity E. pethidine toxicity |
C. hypoxia
what a stupid f-ing question. ----------- |
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PP66 ANZCA version [2003-Apr] Q108, [2003-Aug] Q56, [Mar06] [Jul06] [Mar10] [Aug12]
In infants with congenital pyloric stenosis A. dehydration is associated with early hyponatremia B. plasma chloride levels seldom fall below 85 mmol.1-I C. renal conservation of hydrogen and potassium ions occurs D. the urine is initially alkaline, then may become acidic E. vomiting causes a loss of potassium ions |
D. the urine is initially alkaline, then may become acidic
Initially: vomit acid, compensate by alkaline urine. As volume becomes contracted, retain Na+ and HCO3 and lose K and H. Develop a ketoacidosis from starvation and lactic acidosis from shock. ----------- |
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PP67 ANZCA version [2003-Apr] Q126, [2003-Aug] Q75
The most appropriate intravenous fluid volume to administer to a one-year-old 10 kilogram infant, fasted for five hours having minor peripheral surgery of two hours duration (with minimal blood loss) is A. 200 ml B. 260 ml C. 320 ml D. 410 ml E. 490 ml |
C. 320 ml
10kg child 7hr x 40ml/hr = 280ml Third space losses = 0-2ml/kg/hr for relatively atraumatic surgery or 6-8ml/kg/hr for traumatic procedures, so 2ml/kg/hr x 10kg x 2hr = 40ml Total = 320ml = C Fluid requirements per hour: ➭ 4ml/hr first 10 kg ➭ 2ml/hr next 10 kg ➭ 1ml/hr each further kg Third space losses: ➭ 0-2ml/kg/hr for relatively atraumatic surgery ➭ 6-8ml/kg/hr for traumatic procedures ----------- |
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PP68b ANZCA version [2004-Apr] Q139, [Mar06]
Separation anxiety in most infants begins at A. 2 - 4 months B. 4 - 6 months C. 6 - 8 months D. 8 - 10 months E. 10 - 12 months |
C. 6 - 8 months
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PP69 ANZCA version [2003-Aug] Q93, [2004-Apr] [Mar10]
The commonest congenital cardiac defect is A. coarctation of the aorta B. patent ductus arteriosus C. pulmonic stenosis D. transposition of the great vessels E. ventricular septal defect |
E. ventricular septal defect
VSD is the most common paediatric congenital condition (over 40% of the total) - (Ref: Stoelting's Anesthesia & Co-Existing Disease - 5th edn; p.44) ACYANOTIC defects: VSD=35%, ASD=9%, PDA=8%, Pulm. stenosis=8%, Aortic stenosis=6%, Coarctation=6%, Atrioventricular septal defect=3% CYANOTIC defects: Tetralogy=5%, Transposition=4% ----------- |
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PP70 ANZCA version [2003-Aug] Q140, [2004-Apr] Q82
The normal haemoglobin (g.dl-1) for age during infancy is A. 16 at 3 months B. 12 at 3 months C. 10 at 3 months D. 8 at 3 months E. 9 at 12 months |
C. 10 at 3 months
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PP72 ANZCA version [2004-Apr] Q97, [2004-Aug] Q92, [Mar06] [Jul06]
Ventricular fibrillation in children A. if resistant to defibrillation, should be treated with amiodarone 5 mg.kg-1 B. is not associated with tricyclic antidepressant overdose C. is often associated with respiratory arrest D. is the commonest arrhythmia associated with cardiac arrest E. should be immediately defibrillated with a 5 J.kg-1 shock |
A. if resistant to defibrillation, should be treated with amiodarone 5 mg.kg-1
VF is relatively uncommon, may complicate hypothermia, TCA poisoning and those with pre-existing cardiac disease. DC shock is 4j/kg x3. Asystole and bradycardia more common in asphyxia. ----------- |
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PP73 ANZCA version [2004-Apr] Q133, [Mar06] [Jul06]
Conditions which are more commonly associated with exomphalos, compared to gastroschisis include A. amniotic fluid peritonitis B. cardiac abnormalities C. fluid and electrolyte disturbances D. hypothermia E. prematurity |
B. cardiac abnormalities
Gastroschisis involves a defect in the anterior abdominal wall (usually on the right) causing herniation of the abdominal contents without a covering sac In exomphalos there is a failure of the gut to return to the abdominal cavity during fetal embryonic development, resulting in persistent herniation through the extra embryonal part of the umbilical cord which covers it. other abdominal organs may be included. there is also an increased incidence of associated abnormalities including cardiac disease. ----------- |
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PP74 ANZCA version [2004-Apr] Q148, [2004-Aug] Q62, [Mar06] Q69, [Jul06] Q36, [Jul07]
A 20 kilogram child has a haemoglobin of 60 g.l-1. The child is normovolaemic and there is no on-going blood loss. The volume of packed cells required to increase the haemoglobin level to 100 g.l-1 is A. 80 ml B. 160 ml C. 320 ml D. 500 ml E. 750 ml |
C. 320mls
see wiki. A simple solution is to use Frank Shann's equation: 4ml/kg of packed cells will increase Hb by 10g/L. Thus 4x20x4 = 320 mls (which is option C). ----------- |
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PP75 ANZCA version [2004-Apr] Q101
In the management of pain for children A. a linear analogue scale is rarely used in assessment of pain B. non-steroidal anti-inflammatory drugs (NSAIDS) often cause renal dysfunction C. opioids are contraindicated under one month of age D. paracetamol is effective orally at a dose of 10 mg.kg-1 E. rectal paracetamol is recommended at doses of 20-30 mg.kg-1 |
E. rectal paracetamol is recommended at doses of 20-30 mg.kg-1
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PP76 ANZCA version [2004-Apr] Q134, [2004-Aug] Q57
Post-operative nausea and vomiting in children A. is more common in females (than males) before puberty B. is more common in children under two years of age (than older) C. is rare following orchidopexy D. is twice as frequent in children over the age of three, compared to adults E. should not be treated with ondansetron |
D. is twice as frequent in children over the age of three, compared to adults
The incidence of PONV above preschool age is higher than in adults. It depends on age: ➭ 34-50% in school children ➭ 20% in preschool children ➭ 5% (lowest incidence) in infants ----------- |
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PP77 ANZCA version [2004-Aug] Q118
The median body mass index (BMI) for a Caucasian boy (in a developed country) is A. 16 kg.m-2 B. 22 kg.m-2 C. 25 kg.m-2 D. 28 kg.m-2 E. 33 kg.m-2 |
A. 16 kg.m-2
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PP78 ANZCA version [2004-Apr] Q150, [2004-Aug] Q4
In children with upper respiratory tract infections (URTIs) presenting for general anaesthesia A. airway events are less likely if an endotracheal tube is used B. oxygen desaturation to under 90% is more likely (compared to children without URTIs) C. parental smoking does NOT affect the incidence of airway events D. peri-operative breath holding is NOT more likely (compared to children without URTIs) E. the site of surgery has no effect on the incidence of airway events |
B. oxygen desaturation to under 90% is more likely (compared to children without URTIs)
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PP79a ANZCA version [2004-Aug] Q103, [Jul05] [Jul07]
Pneumonia in children A. if bacterial is commonly associated with a pleural effusion B. is often caused by Mycoplasma Pneumoniae in infants C. is rarely caused by Chlamydia Trachomatis in neonates D. is rarely fatal in developed countries E. often presents as lethargy without fever or cough |
D. is rarely fatal in developed countries
(some have argued for A). From Nelson Paediatrics Ch.392 - "Mortality from community-acquired pneumonia in developed nations is rare…" ~~ ----------- Surely pneumonia is RARELY fatal (how many children have you seen die from pneumonia?) - I would go for D Once again the candidates are disappointed in how badly the examiners have worded this question. However, I thought these were the points they were trying to make, with quotes from Rudolph's Pediatrics: "Pneumococcal pneumonia...small, sterile pleural effusions are common" -could this be what they are after? "Mycoplasma ... over 5 years of age" therefore, NOT infants. "Chlamydia trachomatis is commonly found in the female genital tract...and infants born to infected mothers have a 10 to 20% chance of developing pneumonia." therefore NOT rare. Pneumonia is still one of the major infective presentations in children, especially those with disabilities, but I agree, rarely fatal in previously well. Often presents as lethagy AND fever, but not necessarily cough.Loum 04:14, 11 Nov 2007 (EST) My study group has shouted down my choice of pleural effusion and endorsed the rarely fatal option, pointing out the emphasis on developed countries.Loum 07:12, 24 Nov 2007 (EST) |
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PP79b ANZCA version [2005-Sep] Q143, [Jul07] [Apr 07]
Pneumonia in children A. if staphylococcal, is commonly associated with a pleural effusion B. is commonly caused by mycoplasma pneumoniae in young children C. is most commonly caused by streptococcus pneumoniae D. is rarely caused by chlamydia trachomatis in neonates E. often presents as lethargy without fever or cough |
A. if staphylococcal is commonly associated with a pleural effusion
see wiki debate Viral pathogens 45% of pneumonia (Nelson's Paediatrics); Strep pneumoniae most common bacterial pathogen from 3wks-4yo. Myco pneumoniae most common 5yo and older (bacterial pathogen). Need to consider chlamydia trachomatis as a cause in neonates. ----------- |
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PP80 ANZCA version [2005-Apr] Q123
A three-week-old infant presents with vomiting for 3 days and a diagnosis of pyloric stenosis. The most correct statement concerning resuscitation is that A. alkalosis should be treated with dilute hydrochloric acid B. 5% albumin is an appropriate fluid for initial treatment of shock C. fluid deficit should be completely replaced with 5% dextrose D. hyponatraemia should be treated with 2N (twice normal) saline E. potassium replacement should begin immediately |
B. 5% albumin is an appropriate fluid for initial treatment of shock
or E. Potassium replacement should begin immediately. See wiki debate. essentially 5% Dectrose with 0.45% saline is ideal fluid of choice. Some argue to start potassium straight away or once urine output is being passed. ----------- |
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PP81 ANZCA version [2005-Apr] Q137
An eight-year-old boy presents with bleeding one week after a tonsillectomy. When you see him in the emergency room, he is conscious but restless, tachypnoeic, pale and cool peripherally, with a pulse rate of 135 and blood pressure of 80/60. What percentage of his blood volume is he most likely to have lost? A. 10 -15% B. 15-25% C. 25 - 45% D. 45-55% E. more than 55% |
C. 25-45%
(prev grp chose B.) BP is low -- indicating uncompensated shock or moderate blood loss. Other signs indicate lower degree of blood loss though (see wiki debate) ----------- An 8 yr old is expected to have a syst BP= 80 + (2 x age in yrs). So for this child expect sys BP=95 The APLS guidelines suggest that a child with greater than 40% blood loss will be "responsive only to pain", clearly not this child. In fact, an agitated child falls into the <25% blood loss group. Also of note is that HR=135. A child of 8 years will have a HR in the range of 80-120. |
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PP82 ANZCA version [2004-Aug] Q143
Post dural puncture headaches (PDPH) in children A. are less effectively treated by a blood patch (compared to adults) B. are rare in children under 10 years of age C. have an incidence of approximately 5% to 12% following spinal anaesthesia D. have an incidence which is independent of needle gauge E. presents with signs which are not posturally related |
B. are rare in children under 10 years of age
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PP83 [Mar06] [Jul06] [Jul07]
Regarding endotracheal tubes for paediatric patients A. a 2.5 mm endotracheal tube is the appropriate size for a term neonate B. armoured (wire spiral) endotracheal tubes have the same outside diameter as non-armoured endotracheal tubes (of the same internal diameter) C. the outside diamter (in mm) of an appropriately sized tube is given by the formula (Age/4) +4 D. the same diameter tube is used for nasal and oral intubation in a child E. uncuffed, paediatric endotracheal tubes do NOT have a Murphy's eye |
D. the same diameter tube is used for nasal and oral intubation in a child
~~ Use the same size tube for nasal as oral intubation because narrowest part is the cricoid. Tube size selection in children: ➭ Cole's formula = 4 + age/4 for kids over 2 years ➭ Neonates: 3.5kg 3.5 tube, 3.0kg 3.0 tube. Downsize to 2.5 when < 1.0kg ➭ Cluf's ETTs for children 3 - for a "a standard lookin' newborn" half a year old == 3 and a half one year old == 4, then Age/4 +4 until 10 - 12 2.5 for 2.5 kilo 2 for 2 kilo ----------- A. False - term neonate would be 3.0-3.5 - preterms would be 2.5 tubes B. False - armoured tubes are thinner, so for the same internal diameter, armoured tubes are smaller C. False - this formula refers to the INTERNAL diameter. D. TRUE - albeit at different lengths of insertion E. False - they do have a Murphy eye! |
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PP84a [2004-Aug] Q102, [Jul05][Sep11]
Tracheo-oesophageal Fistula (TOF) A. is associated with cardiac anomalies in approximately 60% of cases B. is associated with oesophageal atresia in approximately 20% of cases C. is more common in males than females D. is usually left sided E. occurs in approximately 1 in 3500 live births |
E. occurs in approximately 1 in 3500 live births
" The incidence of OS/TOF is 1 in 3500 live births." (doi:10.1093/bjaceaccp/mkl062 Continuing Education in Anaesthesia, Critical Care & Pain | Volume 7 Number 1 2007) ----------- A. is associated with cardiac anomalies in approximately 60% of cases - false Approx 27% (Table 2) B. is associated with oesophageal atresia in approximately 20% of cases - false: Higher association approx 96% C. is more common in males than females - false D. is usually left sided |
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PP84b ANZCA version [2005-Sep] Q141, [Mar06][Sep11]
Tracheo-oesophageal Fistula (TOF) A. is associated with cardiac anomalies in approximately 60% of cases B. is associated with oesophageal atresia in approximately 20% of cases C. is more common in males than females D. is usually left sided E. does not usually require contrast studies for diagnosis |
E. does not usually require contrast studies for diagnosis - contrast studies may pose risk of aspiration
Diagnosis: Classically failure to pass soft NG tube. However tube may coil up - so imaging without contrast may be required ----------- A. is associated with cardiac anomalies in approximately 60% of cases - false Approx 27% (Table 2) B. is associated with oesophageal atresia in approximately 20% of cases - false: Higher association approx 96% |
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PP85 [2004-Aug] Q149
Signs of severe dehydration in an infant include each of the following EXCEPT A. elevated pulse rate B. marked oliguria C. pale skin colour D. parched mucous membranes E. reduced blood pressure |
C. pale skin colour
From BJA review, ref below on assessment of dehydration Appearance: Mild - Thirsty, restless, alert. Moderate - Thirsty, restless or lethargic but rousable, pale (BP - Normal/low) Severe - Drowsy to comatose, limp, cold, sweaty, grey, cyanosed ( BP - Low) ----------- |
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PP86 ANZCA version [2005-Sep] Q118 | Aug10
A three-week old infant presents with pyloric stenosis and 3 days of vomiting. A typical electrolyte profile would be A. Na+ 130 mmol.l-1 K+ 5.8 mmol.l-1 Cl- 98 mmol.l-1 HCO3- 17 mmol.l-1 B. Na+ 148 mmol.l-1 K+ 4.1 mmol.l-1 Cl- 108 mmol.l-1 HCO3- 13 mmol.l-1 C. Na+ 135 mmol.l-1 K+ 4.5 mmol.l-1 Cl- 90 mmol.l-1 HCO3- 30 mmol.l-1 D. Na+ 130 mmol.l-1 K+ 2.8 mmol.l-1 Cl- 90 mmol.l-1 HCO3- 28 mmol.l-1 E. Na+ 130 mmol.l-1 K+ 3.9 mmol.l-1 Cl- 98 mmol.l-1 HCO3- 17 mmol.l-1 |
D. Na+ 130 mmol.l-1 K+ 2.8 mmol.l-1 Cl- 90 mmol.l-1 HCO3- 28 mmol.l-1
- Hyponatraemic, hypochloraemic, hypokalaemic metabolic alkalosis. Bilirubin may be elevated. (Na can be low OR high). Vomiting -> loss of Chloride and H+ -> metabolic alkalosis The initial renal response is excretion of HCO3- -> alkaline urine With persistent vomiting and volume depletion, the renal response changes to preferentially conserve Na in exchange for H+ ions therefore get -> acid urine (paradoxic aciduria) -> worsening metabolic alkalosis Just a reminder that if the condition has persisted for some time, the baby might be severely dehydrated and under-nourished so a metabolic lactic acidosis may also be present or at least offset some of the metabolic alkalosis. See 2001 CEACCP Review - excellent summary. ----------- |
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PP87 ANZCA Version [Jul06][Oct09][Sep11]
The weight of a child can be estimated using the formula A. (age + 2) x 3 B. (age + 4) x 2 C. (age x 2) + 4 D. (age x 3) + 2 E. age x 4 |
B. (age+4)x2
The "standard" anaesthetic formula are: From age 1-8: wt= (age in years x 2) + 8 [which is equal to (age+4)x2] From age 8-12 wt = (age in years) x 3 ----------- |
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PP88 [Jul06] [Jul07] [Apr08]
At what age does the GFR equal adult GFR (ml/min/m2) A. 1 month B. 6 month C. 2 years D. 4 years E. 6 years |
C. 2 years
Oxford handbook Nephron formation is complete at term, but renal function is immature Adult GFR (per BSA) by 2 years and tubular function by 6-8 months. RBF is reduced due to high renal vascular resistance ~~ ----------- Miller Glomerular filtration rate (mL/min/1.72 m2) 2–8 days 39 (range, 17–60) 6–12 mo 103 (range, 49–157) 2–12 yr 127 (range, 89–165) |
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PP89 [Jul06]
8 year old boy with cerebral palsy, mental retardation. Scheduled for urgent MRI for assessment of increased seizure frequency/rapidly worsening epilepsy. On arrival (no premed) he is agitated, uncooperative and distressed. His immediate management should include: A. Cancel case until seizures better controlled B. Cancel and return with oral premed C. Oral or im ketamine induction now D. Immediate gas induction with caretaker present E. Long/detailed discussion with his parent/caregiver re anaesthetic options |
E. Long/detailed discussion with his parent/caregiver re anaesthetic options
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PP90 [Jul06] [Apr07] Q8
Child having multiple lower limb osteotomies. He has frequent painful muscle spasm and cerebral palsy. Best analgesia: A. continuous epidural infusion with bupivacaine and clonidine B. regular NSAID plus tramadol C. morphine PCA D. paracetamol and oxycodone E. spinal morphine |
A. continuous epidural infusion with bupivacaine and clonidine
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PP91 [Jul06] [Apr07] Q2
An 7-year old girl is having an anaesthetic. At laryngoscopy she is noted to have clear secretions around her larynx/in her pharynx. After the tube is placed, clear fluid is suctioned. There is a short period of wheeze on chest auscultation. At the end of the case she is saturating at 96% on an FiO2 of 0.30. There is no wheeze. The best management for this child is: A. give IV steroids, wait 1 hr and if stable extubate B. pull the tube, place her on oxygen via a Hudson mask, and observe in recovery for 4-6 hrs C. organise an on-table CXR, treat accordingly D. order an urgent pH of the suctioned fluid and base further management on the result E. start antibiotic |
C. organise an on-table CXR, treat accordingly
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PP92 [Apr07][Apr08][Aug12]
5yo 35kg child having repair of leg laceration. Gas induction with sevoflurane, N2O and oxygen. Can't get in drip. Put in LMA and immediately get stridor and airway obstruction and desaturate to 90%. Next step after increase FiO2 to 100% is: A. Remove LMA and deepen with sevoflurane B. Leave LMA and deepen with sevoflurane C. Intralingual Suxamethonium D. IM Atropine E. IM Suxamethonium |
A. Remove LMA and deepen with sevoflurane
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PP93 [Apr07] Q124
The Neonatal Facial Coding Scale (NFCS) used to assess pain in neonates includes all of the following except A. Brow bulge B. Chin quiver C. Closed mouth D. Deep nasolabial fold E. Eyes squeezed shut |
C. Closed mouth
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PP94 [Apr07]
A 25kg child is having liver resection and is rapidly given 1 unit of blood. Her CVP is 8. The cause most likely to be responsible for any haemodynamic instability she experiences is: A. coagulopathy B. hyperkalaemia C. ABO incompatability D. Hypocalcaemia E. Hypothermia |
D. Hypocalcaemia
?C. ABO incompatability ----------- |
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PP95 [Jul07][Apr08]
1 y.o. arrest with VT. Has had 2x DC shocks, and 100 mcg adrenaline. Further 1x DC shock given. What is next step: A. 20 J DC shock B. 40 J DC shock C. 50 mg amiodarone D. 100 mcg adrenaline E. 1000 mcg adrenaline |
C. 50 mg amiodarone
----------- Weight in kg === (Age in months + 9)*2 (3 - 12m) Weight over 1 === 2 * Age + 9 Why 9 ? Because kilogram has Almost 9 letters. |
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PP96 [Jul07]
Newborn with diaphragmatic hernia. Initially sats 95% on RA. Now beginning to develop respiratory distress. Next appropriate step: A. Awake intubation B. Trial NO prior to intubation and ventilation C. Rapid sequence induction D. Mask ventilation throughout case with CPAP E. Gas down with CPAP |
A. Awake intubation
Miller pg 2396 "Anesthesia management of patients with diaphragmatic hernia includes the following: an awake intubation without bag and mask ventilation prevents overdistention of the stomach and herniation across the midline.....". ----------- |
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PP97 ANZCA Version [Jul07][Apr08]
You are commencing general anaesthesia for a 2-year-old child to allow biopsy of an anterior mediastinal mass, A pre-operative CT scan demonstrated compression of the lower trachea and the carina by Ihe mass. During inhalational induction, the child desaturates to 70% due to airway compression by the mass. You should A. apply continuous positive airway pressure (CPAP) via facemask B. arrange urgent median sternotomy C. intubate the patient and allow spontaneous ventilation D. intubate the patient and provide positive pressure ventilation E. place the patient in the prone position |
E. place the patient in the prone position
- awaken if you can - reposition the patient - rigid bronchoscopy - median sternotomy "Development of airway or vascular compression requires that the patient be awakened as rapidly as possible and then other options for surgery can be explored. Intraoperative life-threatening airway compression has usually responded to one of two therapies:either repositioning of the patient (it should be determined before induction if thereis one side or position that causes less symptomatic compression) or rigid bronchoscopy and ventilation distal to the obstruction (this means that an experienced bronchoscopist and rigid bronchoscopy equipment must always be immediately available in the operating room during these cases). For patients with life-threatening cardiovascular compression after induction that does not respond to lightening the anesthetic the only therapy is immediate sternotomy and surgical elevation of the mass off the great vessels." Current Opinion in Anaesthesiology 2007, 20:1–3 Slinger Miller says: "The operating room team should retain the capability of changing the patient's position rapidly to the lateral or prone position. " "If general anesthesia is required, maintain spontaneous ventilation." ----------- |
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PP98 [ANZCA Version [Jul07]
With respect to gastric volumes and fasting in children, A. casein-predominant milks empty faster than whey-predominant milks B. children have a higher incidence of aspiration than adults C. solids rely on first order kinetics for gastric emptying but liquids follow zero order kinetics D. the rate of gastric emptying is NOT related to the energy content of the meal E. unlimited clear fluid ingestion 2 hours before surgery does NOT affect volume, but does affect the pH of stomach contents |
B. Paediatric aspiration more common than in adults
1 per 1200–2600 compared to 1 per 2000–3000 in adults - there may be an increase in pH with clear fluids up to 2 hrs - human milk and whey predominant formula empty faster than casein predominant formular and cow's milk. Probably due to lower protein content in human and whey based milk - solids follow zero order (linear decay) kinetics and liquids first order (exponentail decay), in regards to stomach emptying ----------- |
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TMP-107 [Mar10][Aug10][Sep11]
Baby with TracheoOesophageal Fistula found by bubbling saliva and nasogastric tube coiling on xray. Best immediate management? A. Bag and mask ventilate B. Intubate and ventilate C. position head up, insert suction catheter in oesophagus (or to stomach?) D. Place prone, head down to allow contents to drain E. Insert gastrostomy |
C. position head up, insert suction catheter in oesophagus (or to stomach?)
-- A - FALSE. Not unless the baby is in respiratory distress and/or hypoxic. May inflate stomach by ventilating through fistula. B - FALSE. Just because the baby has been diagnosed with TOF is not an immediate indication for intubation in and of itself. C - TRUE. Neonates with TOF should have a "nasogastric" tube inserted into the oesophageal stump to drain secretions and prevent accumulation in the blind-end pouch. The NGT should be connected to continuous suction. The infant should be nursed prone or in the lateral position with 30 degrees head up tilt to decrease the risk of aspiration. See A Practice of Anesthesia for Infants and Children - 4th edition by Cote, Lerman, Todres; p.755. Saunders (2009) D - FALSE. Can nurse prone, but lateral with head up tilt seems to be the recommended and most commonly cited method. E - FALSE. Initial management as above (see C - TRUE), and then repair. Gastrostomy may be performed, but not best immediate management. ----------- |
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TMP-Jul10-020 [Aug12]
Thermoneutral zone in 1 month old infant ? A. 26 – 28 degrees Celcius B. 28 – 30 degrees Celcius C. 30 – 32 degrees Celcius D. 32 – 34 degrees Celcius E. 34 - 46 degrees Celcius |
D. 32 – 34 degrees Celcius
- From wiki The thermoneurtral zone is didined as the environmental temperature range over which metabolic rate is kept at a minimum and within which temperature regulation is achieved by non-evaporative physical processes alone. This zone is much higher in the naked neonate (32-36 deg C) than in name adults. ----------- |
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TMP-Sep11-021
Repeat Neonate intubation - at lips |
APLS formula for insertion depth for children >1 yr old
insertion depth (cm) for orotracheal intubation = age/2+12 insertion depth (cm) for nasotracheal intubation = age/2+15 From Paediatric Anaesthesia article: for children below 1 yr Length of orotracheal tube = weight/2+8 From "A Practical Approach to Pediatric Anesthesia" (online book via ANZCA site) Table 6.3 - Age = Teeth to mid-trachea Premie = 7-8cm Birth = 9 6 mo = 11 1yr = 12 ----------- |
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TMP-Sep11-025
LSCS for foetal distress, meconium stained liquor. Management of baby A. Intrapartum suctioning B. Intrapartum suctioning and post partum tracheal suction C. Post partum tracheal suctioning D. Routine neonatal care E. Intubate |
D. routine care
----- A - Incorrect: no advantage over post-partum suctioning and not recommended B - Incorrect: as above C - Correct IF BABY NON-VIGOROUS: no evidence to recommend change in current practice which is "endotracheal suctioning of non-vigorous infants who have been exposed to meconium stained fluid" D - Correct IF BABY VIGOROUS: "Routine endotracheal suctioning of babies who have meconium stained liqour, and who are vigorous, is discouraged" E - Incorrect: only done to facilitate suctioning followed by removal of ETT ----------- |
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TMP-Sep11-030
Post delivery neonate did not breath post stimulation by midwife, not vigorous, heart rate drop from 140 to 90bpm. Next step of action A. 100% oxygen B. Positive pressure ventilation C. Intubation D. CPR E. Adrenaline |
B. Positive pressure ventilation
-- from ARC guidelines A - Incorrect: insufficient on its own if apnoea present B - Correct: if apnoea present commence IPPV C - Incorrect: not indicated at this stage as HR > 60 and no need for chest compressions D - Incorrect: HR > 60 E - Incorrect: HR > 60 ----------- |
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TMP-Sep11-050
NEW Most common cause of paediatric post anaesthesia cardiac arrest A. Drug error B. Respiratory cause C. Multifactorial D. Cardiac problem (?) |
B or D
contentious - I vote D though "Cardiovascular" cause mainly due to hypovolaemia associated with bloodless and electrolyte imbalance. Cardiac arrest not the same as Mortality! POCA registry 2007 - less drug errors as a cause compared to earlier review. Cardiovascular cause during anaesthesia more likely (52%). Respiratory cause on induction or emergence or in PACU 50%. No deaths due to laryngospasm leading to arrest... ----------- |
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TMP-Sep11-104
new Neonate desaturate faster than adult at induction because A. FRC decrease more B. Faster onset of induction agents C. More difficult to pre-oxygenation |
consumption or closing capacity issues
- Neonates have closing volume (volume at which alveoli being to close, producing a shunt) within range of normal tidal volumes - thus small changes in lung volume can lead to shunting and desaturations (which can be RAPID) -- openanesthesia.org ----------- |
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TMP-Sep11-106
NEW Suxamethonium dosage higher in neonates compare to adult because A. Increased volume of distribution B. Increased pseudocholinesterase activity C. More receptors D. Higher cardiac output (?) E. Decreased sensitivity of nicotinic ACH receptors to suxamethonium F. Faster diffusion away from neuromuscular junction |
A. Increased volume of distribution
- From "Neuromuscular blocking drugs in infants and children" CEACCP 2007: The increased dose requirement of succinylcholine in younger patients is thought to result from its rapid distribution into an enlarged volume of ECF rather than an altered response to the action of the drug at post junctional AChRs. ----------- |
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TMP-Mar12-019
An infant is born with meconium stained liquor and is apnoeic and floppy… your first step should be a. Stimulate and dry b. Positive pressure ventilation c. Suction the trachea |
c. Suction the trachea
-- From www.resus.org guideline 13.5 INTUBATION UNDER SPECIFIC CIRCUMSTANCES Meconium stained liquor (See also Guideline 13.4). Routine intrapartum oropharyngeal and nasopharyngeal suctioning is not recommended for infants born with either clear or meconium-stained amniotic fluid [Class A, LOE II8, 9] There is insufficient evidence to recommend a change in the current practice of endotracheal suctioning of non-vigorous infants born through meconium-stained amniotic fluid [Class B, expert consensus opinion10-12]. If it is done, it should be performed only: • Immediately after birth. • If an experienced practitioner and all needed equipment are immediately available. • Before the onset of breathing or crying and in infants with decreased muscle tone. It should not be done if the infant is vigorous and breathing or crying. It should be done once, and then any subsequent resuscitation that is needed should be commenced expeditiously [Class B, expert consensus opinion]. ----------- |
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TMP-Mar12-029
In an infant, the intercristine line is at the level of a. L1-L2 b. L2-L3 c. L3-L4 d. L4-L5 e. L5-S1 |
e. L5-S1
-- From 04 CEACCP article: Most local anaesthetic techniques are performed on the anaesthetized infant. Anatomical relationships and landmarks may be different and absolute distances are very small. For example, the distance from skin to epidural space in infants >6 months is ~1 mm/kg. The intercristal line is at L5/S1 (L4 in adults), the termination of the spinal cord is at L3 (L1/2 in adults) and the termination of the dura is at S3/4 (S2 in adults). The technique for accessing the epidural space must be adapted to avoid inadvertent dural puncture or spinal cord damage in infants. The younger the patient, the lower the approach is a sound general principle. ----------- |
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TMP-Mar12-035 [Aug12]
The features of Pierre Robin sequence include cleft palate, micrognathia and: A. Glossoptosis B. Craniosynostosis C. Macroglossia D. Microstomia |
A. Glossoptopsis
From Stoelting Anaesthesia and Coexisting disease "Pierre Robin syndrome consists of micrognathia usually accompanied by glossoptosis (posterior displacement of the tongue) and cleft palate. Mandibular hypoplasia may be responsible for displacement of the tongue into the pharynx, which subsequently prevents fusion of the palate. Acute upper airway obstruction can occur in neonates or infants with Pierre Robin syndrome. Feeding problems, failure to thrive, and cyanotic episodes are other early complications of this syndrome. Associated congenital heart disease is frequent. Fortunately, sufficient mandibular growth during early childhood markedly reduces the degree of airway problems in later years." ----------- |
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TMP-Mar12-043
What is the most accurate method of determining fetal heart rate in a neonate a. Palpation of an umbilical vein pulse b. Auscultation with a stethoscope c. Palpation of femoral pulse d. Pulse oximetry |
b. Auscultation with a stethoscope
> d. pulse oximetry -- Guideline 13-3 from Aust Resus Council Dec2010 Heart rate can be determined by listening to the heart with a stethoscope (most reliable) or in the first few minutes after birth, by feeling for pulsations at the base of the umbilical cord [Class A, expert consensus opinion]. The base of the umbilical cord is preferable to other palpation locations, but if a pulse is not felt at the base of the cord this is not a reliable sign that the heart rate is absent. Other central and peripheral pulses are difficult to feel in newborn infants making the absence of these pulses an unreliable sign.4-6 Pulse oximetry can provide an accurate and continuous display of the heart rate within about a minute of birth [LOE IV 7, 8]. -- From 2010 International Consensus on CPR Part 11: Neonatal Resus - Of clinical assessments, auscultation of the heart is the most accurate, with palpation of the umbilical cord less so. However, both are relatively insensitive (LOE 2 and 4). - Several studies have addressed the accuracy of pulse oximetry in measuring heart rate in the delivery room and have shown the feasibility of pulse oximetry during newborn resus, but none of these studies examined impact of these measurements on resus outcomes (LOE 4) - Pulse oximetry (SpO2) and HR can be measured reliably after 90s from birth with a pulse oximeter designed to reduce movement artefact and a neonatal probe (LOE 4). - Preductal values, obtained from the R wrist or hand, are higher than post ductal values. Applying the oximeter probe to the subject before connecting it to the instrument will produce reliable results more quickly (LOE 4). ----------- |
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++41. An infant with failure to thrive is noted to have an apical systolic murmur weak pulses, with the femoral felt most easily. They most likely have
a. Patent ductus arteriosis b. Ventriculoseptal defect c. Coarcation of the aorta |
x
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TMP-Mar12-048
An inpatient becomes hyponatraemic 48 hours post op and has a seizure. The most appropriate treatment is a. Fluid restriction b. Normal saline ?ml/hr c. Hypertonic saline d. Salt tables |
c. Hypertonic saline
-- From 'The Treatment of Hyponatremia'. Seminars in Nephrology Vol 29, No3, May 2009 pp282-299: 'The Second International Exercise-Associated Hyponatremia Consensus Development Conference recommended that any athlete with hyponatremia and encephalopathy should be treated immediately with a bolus infusion of 100 mL of 3% NaCl to acutely reduce brain edema, with up to 2 additional 100-mL 3% NaCl bolus infusions that should be given at 10-minute intervals if there is no clinical improvement. We believe that this is a reasonable regimen for all symptomatic patients with acute hyponatremia, for hyponatremia associated with underlying neurologic or neurosurgical conditions, and for all hyponatremic patients with seizures or coma regardless of the duration of the electrolyte disturbance. This regimen translates to a maximum of 6 mL/kg of 3% saline in a 50-kg woman, enough to increase the serum sodium concentration by 5 to 6 mmol/L. Once the bolus therapy has been completed, further treatment with hypertonic saline may be unnecessary.' ----------- |
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[May09][Mar12][Aug12]
2 yo 15kg child following seizure on surgical ward. Admitted with appendicitis and perforation. 60ml/hr of ½ N. Saline 5% dextrose Na+ 119 K+ 4.5 HCO3- 19 Cl- 90 Best treatment would be A. Desmopressin B. Frusemide C. 3% saline (hypertonic) D. Normal Saline E. Fluid restrict (some stems have give phenytoin) |
C. 3% Saline (or 3% NaCl - NOT 3% normal saline)
-- ref: http://www.rch.org.au/clinicalguide/guideline_index/Hyponatraemia/ Main causes of hypoNa in children are - administration of hypotonic fluids (IV or enteral) - conditions with impaired free H2O excretion and high ADH levels - Relative excess fluid intake in a child receiving exogenous anti-diuretic agents (e.g. Desmopressin for nocturnal enuresis) - GI fluid losses Less common but more important causes are: - adrenal insufficiency - defect in renal tubular absorption, including obstructive uropathy - psychogenic polydipsia Management - Ideal rate of Na correction depends on presence and severity of symptoms. Rapid correction (>8mmol/L Na+/24h) can result in cerebral demyelination - especially if hypoNa has been present for >5 days and rapidly corrected. In children with seizures or CNS depression - Notify ICU - ABC resus and IV anticonvulsants as indicated. HypoNa seizures often respond poorly to conventional anticonvulsants and Na correction should not be delayed. The Na should be raised until it reaches 125mmol/L or until seizures stop - whichever occurs first - Use IV 383aCl solution - 4ml/kg over 15-30 minutes. This will raise serum Na by 3mmol/L and will usually stop the seizures. Give thru a CVC where possible but do not delay administration in a fitting child to insert the CVC. - Measure serum Na after first bolus. Ongoing seizures and persistent hypoNa will require more 3% NaCl - Many children with hypoNa and seizures will have other reasons for seizures (fever, meningitis, hypoglycaemia) and these should be addressed - After the seizures have resolved the total sodium correction (including the bolus) should not exceed 8mmol/L per day (e.g. from 122-130mmol/L) - Measure electrolytes every 2 hours until stable, then every 4-6 hours until the serim sodium is normal and the child is off IV fluids. If the child has no symptoms of hypoNa - Management depends on volume status and active correction with 3% NaCl is not needed. ----------- |
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[Aug12] New: Regarding pyloric stenosis:
see also PP66 A. More common in females B. Occurs most commonly in premmies C. Acidic urine (or urinary acidification) D. Cause of hypokalemia is vomiting (also remembered as hyperkalaemic metabolic alkalosis from GI losses) |
C. Acidic urine (or urinary acidification)
- Mostly male Not more in premature Hypokalaemia metabolic alkalosis The excess loss of Cl depletes extracellular chloride and with the luminal loss of Hydrogen ions produces a metabolic alkalosis. The kidney tries to initially maintain blood pH by excreting an alkaline urine. HCO3 is excreted with Na and K until the overall volume deficit triggers an expansion of the extracellular volume rather than maintenance of pH. Na is resorbed, but K is lost via an aldosterone mediated mechanism and this leads to excretion of H ion resulting in "paradoxical aciduria" in an alkalotic patient. ----------- |
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TMP-Oct09-035 [Aug12]
(NEW) Emergence delirium in a kid in recovery. To treat a. Fentanyl 1mc/kg b. Midazolam 0.1 mg/kg c. Propofol d. Clonidine 1mc/kg e. Sucrose |
e. Sucrose
- See wiki debate. There are studies regarding PREVENTION but not so much on TREATMENT. EA is self limited and usually resolves without pharmacological intervention. studies- fentanyl, propofol, midazolam but best is to reunite with parent. ----------- |
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TMP-Sep11-004 [Aug 12]
Child with murmur- what would make it more likely for you to investigate if you heard the murmur A. persist in supine position B. louder or softer with various manouveres [aug12] A. 4/6 loudness B. ????vibratory/flutter sound |
A. 4/6 loudness (Aug12 version)
-- From http://www.aafp.org/afp/1999/0801/p558.html "Characteristics of pathologic murmurs include a sound level of grade 3 or louder, a diastolic murmur or an increase in intensity when the patient is standing". Also from Am J Cardiol. 2008 Oct 15;102(8):1107-10. Samuel A. Levine and the history of grading systolic murmurs: "Of 19 subjects with grade 3 or 4 murmurs, all were determined to have organic heart disease or anemia. Thus, louder systolic murmurs were found to be a significant finding, as were the cause location and effects of posture". 1/6: very soft and not heard at first 2/6: soft, but can be detected almost immediately by an experienced auscultator 3/6: moderate; no thrill 4/6: loud; thrill just palpable 5/6: very loud; thrill easily palpable 6/6: very very loud; can be heard without placing stethoscope on the chest! See Table 1 CEACCP article: Innocent - Asymptomatic, early systolic or continuous (venous hum), blowing/musical/vibratory in quality, No precordial thrill, often varies with posture Pathological - symptomatic (hx recurrent chest infections, cyanosis, tachypnoea, sweating, feeding difficulties, failure to thrive), Diastolic, pan systolic or late systolic Variable/harsh in quality precordial thrill sometimes present Rarely varies with posture (HOCM murmur increases with standing) ALSO - Most CHD is identified before 3 months old but any child under 1 yr with a murmur should be referred to a paediatric cardiologist before anaesthesia, even if asymptomatic as significant lesions may be slow to present. Be suspicious of children with syndromes assoc with CHD - Down's syndrome - CHARGE (coloboma of eye, heart defects, atresia of choanae, retardation, genital/urinary abnormalities, ear abnormalities/deafness) - VATER (vertebral anomalies, anal atresia, TOF, radial dysplasia) - Turner's - DiGeorge In older children watch for decreased extol, squatting during play (tet spells), syncope -- serious heart disease Family history of sudden death -- suspect HOCM, has autosomal dominant inheritance but often asymptomatic. ECG - look for ventricular hypertrophy In an asymptomatic child over 1 yr old with an innocent murmur and normal ECG -- probably safe to proceed with surgery and refer for investigation after operation ----------- |
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TMP-Mar11-031
[Sep11][Mar12][?Aug12] NEW. Which of the following causes the most heat loss in a neonate? A. vasodilatation B. radiation C. convection D. conduction E. evaporative |
B. radiation
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PP ANZCA version [Apr08][Oct09][Aug10][Aug12]
A 12-year-old boy presents at 11 pm having fallen and dislocated his hip at 4 pm. One hour after the injury he ate a meal. He will require closed reduction of the dislocation. The BEST anaesthesia option is to: A. defer the case until the next morning and keep him fasted B. perform a femoral nerve block C. perform an inhalational induction and then maintain spontaneous ventilation using a face mask D. perform a rapid sequence induction with cricoid pressure and intubate the trachea E. provide intravenous sedation |
D. perform a rapid sequence induction with cricoid pressure and intubate the trachea
- Procedure needs to be done urgently, child ate after injury = NON-fasted "Dislocation of the hip requires immediate reduction to avoid injury to the femoral head and to relieve patient discomfort." Textbook of Pediatric Emergency Procedures Christopher King 2007, p978 ----------- |
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[May09][Oct09][Mar10] 4 yr old presents for elective surgery, otherwise fit healthy, murmur at left sternal edge on auscultation heard in systole and diastole, disappears on lying down. Most likely cause:
A. HOCM B. VSD C. PDA D. venous hum E. ASD |
D. Venous hum (previous grp answer)
- A. HOCM - false. From UTD - Among children with familial hypertrophic cardiomyopathy (HCM), LVH can develop in infancy and childhood, but for the vast majority increases in LV wall thickness typically occur during puberty, with little change in adulthood. Children and adolescents are often asymptomatic and diagnosed during family screening. An exception can occur in infants diagnosed in the first year of life. Detection of a heart murmur is often the initial sign of heart disease. Death is primarily due to heart failure rather than sudden death. From Talley O'connor - Late systolic murmur at lower left sternal edge and apex (due to the obstruction) and a pan systolic murmur at the apex (due to MR); S4. B. VSD - False. UTD - Systolic murmurs — The character and duration of the systolic murmur are helpful in evaluating the size of the defect. The murmur of a small defect is classically described as a 2 to 3/6 low-pitched harsh holosystolic murmur best heard at the left mid- to lower-sternal border; subpulmonic defects are best heard at the left upper sternal border. During spontaneous closure the holosystolic murmur may shorten, occurring only in early systole, before disappearing altogether. The murmur of small muscular or perimuscular VSDs may occur only in early systole since the contraction of the septum during systole may close the defect. The murmur of moderate defects, usually evident within two to three days of birth, is holosystolic, high frequency, grade 2/6 or louder, and heard best in the 3rd or 4th LICS; the quality of the murmur may change as PVR falls. In infants who have large VSDs, as PVR approaches systemic levels, the holosystolic murmur shortens and softens before disappearing altogether. Diastolic murmurs — The presence of diastolic murmurs in infants usually indicates increased left-to-right shunting. A diastolic rumble due to increased flow across the mitral valve may be heard at the apex in infants with moderate to large VSDs and Qp:Qs >2:1. A high-frequency decrescendo murmur beginning with the first component of the second heart sound and best heard at the mid- to-lower sternal border suggests the development of aortic regurgitation secondary to prolapse of an aortic cusp through either a perimembranous or a subpulmonic defect. Patients with such murmurs usually require early surgery. An early diastolic decrescendo murmur at the mid- left sternal border in patients with elevated pulmonary artery pressures suggests pulmonary regurgitation. Patients with such murmurs should be evaluated for elevated pulmonary vascular resistance. C. PDA - false. From UTD - A small PDA (Qp:Qs <1.5 to 1) that restricts excessive blood flow to lungs may go undetected with no identifiable symptoms. These patients are commonly identified incidentally by the detection of the characteristic continuous flow murmur noted during a routine primer care visit - usually heard in L infraclavicular area. Moderate - large PDA - pt would have presented sooner with symptoms of exercise intolerance, heart failure, failure to thrive etc. D. Venous hum - true? except for where murmur is heard. From UTD: A venous hum, which results from altered flow in the veins can cause an innocent continuous murmur. It is hear with the patient is in the sitting position (usually IN THE SUPRACLAVICULAR FOSSA) and frequently disappears with the patient MOVES TO THE SUPINE POSITION. The hum tends to be louder in diastole and can be completely abolished by compression of the ipsilateral IJV. A lid left sided venous hum transmitted BELOW THE CLAVICLE SHOULD NOT BE MISTAKEN FOR THE MURMUR OF PDA. Venous hum is not heard in the supine position and pressure on the IJV abolishes it. In contrast, the murmur of PDA PERSISTS IN THE SUPINE POSITION and despite pressure on the IJV. E. ASD - false. UTD - Heart murmurs — The low velocity shunt flow across the ASD produces insufficient turbulence to be audible, although it can be demonstrated by intracardiac phonocardiography. However, several other murmurs may be heard. (See "Auscultation of cardiac murmurs".) A midsystolic pulmonary flow or ejection murmur, resulting from the increased blood flow across the pulmonic valve, is classically present with moderate to large left-to-right shunts and may be louder than that attributed to the usual functional murmur. In the previously mentioned series of Japanese schoolchildren, an ejection systolic murmur was audible in 94 percent [31]. This murmur is loudest over the second intercostal space and is usually not associated with a thrill. The presence of a thrill typically indicates a very large shunt or pulmonic stenosis. A systolic crescendo-decrescendo murmur audible over the lung fields and not prominent over the second intercostal space results from rapid flow through the peripheral pulmonary arteries. A murmur of mitral regurgitation may accompany these findings due to a cleft mitral valve in ostium primum defects and mitral valve prolapse in secundum defects. In the latter setting, an apical late or holosystolic murmur of mitral regurgitation radiating to the axilla may be heard. A mid-diastolic murmur of low to medium frequency is commonly audible with an ASD and a left-to-right shunt greater than 2:1. It results from high flow across the tricuspid valve and does not increase with inspiration. A low-pitched diastolic murmur of pulmonic regurgitation may result from dilatation of the pulmonary artery. ----------- |
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TMP-Mar10-121
Paediatric VF arrest. Which is true? A. if resistant to defibrillation should give amiodarone 5mg/kg B. C. commonly associated with respiratory arrest D. is the most common form of arrest in this patient group E. should defibrillate with 5J/kg |
A. if resistant to defibrillation should give amiodarone 5mg/kg
- A. True - amiodarone io/iv dose: 5mg/kg. May repeat 2 times for REFRACTORY VF/pulseless VT. C. false. VF is usually the result of an underlying cardiac problem. Bradycardia is the usual result from respiratory arrest. D. False. VF or pulseless VT is the initial cardiac rhythm in 5-15% of paediatric in and out of hospital cardiac arrest. The incidence increases with age. E. false. First shock 2j/kg, second shock 4J/kg, subsequent shocks >or=4J/kg. Max 10J/kg or adult dose. ----------- |
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TMP-Oct09-015
Paediatric ALS – 20 kg, VF has had 2 shocks only. Next step a. Adrenaline b. Amiodarone c. Shock 50J d. Shock 100J |
a. Adrenaline 10mcg/kg after 2nd shock then every second loop. See guideline 12.3 and 12.5 on resus.org.au website.
- b. Amiodarone - false - too soon. Consider it after next cycle. c. Shock 50J - false - too low. d. Shock 100J - false - 3 stacked shocks are only in special circumstances. As per resus.org.au: Witnessed onset of monitored VF/pulseless VT 3 stacked shocks (all 4J/kg) may be given when the onset of a shockable rhythm is witnessed with monitoring in special circumstances such as: 1) In the cardiac catheter lab 2) In ICU or cardiac ward post cardiac surgery 3) In other circumstances when defib is ALREADY attached AEDs are UNSUITABLE for this purpose ----------- |
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TMP-Oct09-036
Pain in 3 year old, best objective tool a. FLACC (crying limbs activity consolability) b. Wong baker Faces pain c. Self reporting d. Mum reporting e. Nurse reporting |
a. FLACC (crying limbs activity consolability)
- b. Wong baker faces - ?3-8 years, however self reporting not reliable until over 4 (see wiki) ----------- |
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[May09][Oct09]
What is the appropriate LMA size for an 8kg child: A. 1 B. 1.5 C. 2 D. 2.5 E. 3 |
B. 1.5
- I always remember LMA 4 for females and 5 for males if going by RECOMMENDED weight. 5 = 70-100kg 4= 50-70kg 3 = 30-50kg 2.5 = 20-30kg 2 = 10-20kg 1.5 = 5-10kg 1 = <5kg ----------- |
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[May09] 2 month old systolic murmur heard at apex no change with posture, now on 5th centile for weight after being on 30th at birth, mother states has difficulty feeding. Peripheral pulses reduced femoral more than upper body. Most likely cause:
A. HOCM B. VSD C. PDA D. venous hum E. ASD |
C. PDA
- Asked again in Mar12 paper - but had coarctation listed as an option. Could not find anything related to weaker femoral pulses and above conditions. From wiki May09 page: PDA - collapsing pulse with sharp upstroke from ejection of large volume of blood into empty aorta during systole, low diastolic pressure due to rapid decompression of aorta, hyperkinetic apex, single S2 if large or even reversed splitting of S2, continous loud "machinary murmur at 1st LIC space. sometimes associated with flow murmur through left heart eg. mitral mid diastolic murmur. (Talley + O'Connor 3rd Ed.) If the pulmonary-to-systemic blood ratio approaches or exceeds 2:1, an apical flow rumble, caused by high flow into the left ventricle, is frequently present. Also, because flow through the left ventricle into the aorta is increased, an aortic ejection murmur may be present. History of difficulty feeding, low birth wt or poor growth, prematurity. www.emedicine.medscape.com ----------- |
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[Mar12] NEW Young infant with Failure to Thrive. Born on the 20th percentile now is on the 5th percentile. Found to have a systolic murmur, tachynpnea with weak femoral pulse. The most likely diagnosis is
a. Coarctation b. HOCM c. PDA d. AS |
a. Coarctation
- nb May 09 version did not have Coarctation in remembered version. ----------- |
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EZ79 [May09][Mar12] [Aug12]
An infant is anaesthetised and ventilated using an endotracheal tube and circle breathing system with C02 absorber. The item which causes the most resistance to breathing is the A. airway pressure limiting (APL) valve B. circuit hosing C. endotracheal tube D. heat and moisture exchange filter E. inspiratory and expiratory valves |
C. endotracheal tube
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(Q90 Aug 2008) A 6 month old baby is booked for an elective right inguinal hernia repair. An apropriate fasting time is
A 2 hours breast milk B 4 hours formula milk C 5 hours breast and formula milk D 6 hours solids E 8 hours solids, 4 hours all fluids |
B 4 hours formula milk
D 6 hours from solids D>B? - RCH guidelines For children less than 6 months: - breast milk 3 hours - formula/cow's milk 4 hours BUT ANZCA PS15 guidelines 4.5.2.2 For healthy children over 6 weeks of age having an elective procedure, limited solid food and formula milk may be given up to six hours, breast milk may be given up to four hours and clear fluids up to two hours prior to anaesthesia. 4.5.2.3 For healthy infants under 6 weeks of age having an elective procedure, formula or breast milk may be given up to four hours and clear fluids up to two hours prior to anaesthesia. ----------- |
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(Q139 Aug 2008) Arrest in a 10 year old. Has ventricular tachycardia after a near drowning accident. Patient is intubated and is being ventilated with 100% O2 and has IV access. A single DC monophasic shock of 60J has been given. The next step is to give
A adrenaline 10mcg/kg and DC shock 60J B adrenaline 10mcg/kg and DC shock 120J C amiodarone 5mg/kg D DC shock 60J E DC shock 120J |
E DC shock 120J
- See ARC guidelines. 4J/kg every shock in infants and children, adrenaline is given every 2nd loop. ----------- |
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(Q150 Aug 2008) 6 month old baby for VSD repair. Induced with 50% N2O, O2, sevoflurane 8%. While obtaining IV access, the patient desaturates to 85%. The manouevre to increase the O2 saturations is to
A give a fluid bolus B change from sevoflurane to isoflurane C institute CPAP D decrease the FiO2 E reduce the sevoflurane concentration [edit] |
E reduce the sevoflurane concentration
- Desaturation likely due to reduced SVR and R->L shunt. A - no IV access! B - false no difference C - CPAP increases PVR and worsens shunt D - decreasing FiO2 increases PVR and worsens shunt E - Increases SVR and FiO2 and reverses shunt :) (Stan's notes:) The ratio of PVR to SVR is normally 1:10-1:20, VSDs generally result in production of L-R shunt. In some instances, however, the ratio of PVR to SVR may be higher, resulting in near-normal pulmonary blood flow or, in extreme cases, production of R-L shunt. Large VSDs predispose the development of PVOD (pulmonary Veno-Occlusive Disease) during the first few years of life due to exposure of the pulm vasculature to high flows and systemic Bps. The increases in PVR that accompany PVOD will ultimately produce bidirectional and R-L shunts. Pts with advanced PVOD and markedly increased PVR (Eisenmenger's) generally are not candidates for VSD closure, because closure will result in an enormous increase in RV after load and RV after load mis-match. For this reason, large VSDs (Qp:Qs>2:1) are corrected early in childhood. Anaes Mx goals in pts with ASDs, VSDs, Atrioventricular canal defect and PDAs: 1. Maintain HR, contractility and preload to maintain CO. Reduction in CO will compromise systemic perfusion despite a relatively high pulm blood flow 2. Avoid decreases in PVR:SVR ratio. Increase in pulmonary blood flow that accompanies reduced PVR:SVR ratio necessitates an increase in CO to maintain systemic blood flow 3. Avoid large increases in the PVR:SVR ratio. An increase may result in production of a R-L shunt 4. In instances in which a R-L shunt exists, ventilatory measures to decrease PVR should be used. In addition, SVR must be maintained or increased. These measures will reduce the magnitude of the R-L shunt ----------- |
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PP [Apr08][Oct08]
A 4 year-old girl with recurrent otitis media is scheduled for insertion of grommets. Prior to the commencement of the operating list you assess her and you notice that she has a clear runny nose. Her mother says that she has had a dry cough for a few days but has been otherwise well. She is afebrile and her chest is clear on auscultation. You should: A. arrange a full blood count and chest X-ray B. postpone the case for 1 week C. postpone the case for 2 weeks D. proceed with the case using an anaesthesia face mask E. proceed with the case using endotracheal intubation |
D. crack on with face mask
Afebrile, no chest signs, otherwise well = crack on Avoidance of intubation / LMA will decreased risk of reactive bronchoconstriction Grommets are elective = fasted patient ----------- |
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PP100 ANZCA version [Jul07] [Apr08]
Regarding the normal term infant A. foetal haemoglobin (HbF) comprises approximately one-third the total haemoglobin at birth and falls to negligible levels by 3 months of age B. foetal haemoglobin (HbF) comprises approximately 70% of the total haemoglobin at birth and falls to negligible levels by 6 months of age C. haemoglobin level below 90g.l-1 at 9-12 weeks (physiological anaemia) is common and does NOT require investigation D. normal haemoglobin at birth should be greater than 200g.l-1 unless there has been delay in umbilical cord clamping E. total blood volume is approximately 70 ml.kg-1 body weight |
B. foetal haemoglobin (HbF) comprises approximately 70% of the total haemoglobin at birth and falls to negligible levels by 6 months of age
- From Power and Kam, Wikipedia; A. foetal haemoglobin (HbF) comprises approximately one-third the total haemoglobin at birth and falls to negligible levels by 3 months of age - 75% to 80% at birth, falls to negligible levels by 6 months B. foetal haemoglobin (HbF) comprises approximately 70% of the total haemoglobin at birth and falls to negligible levels by 6 months of age - TRUE - close to above values C. haemoglobin level below 90g.l-1 at 9-12 weeks (physiological anaemia) is common and does NOT require investigation - This is the lower limit of the reference range in the online reference below - therefore not common though probably not all that unusual; most would likely investigate D. normal haemoglobin at birth should be greater than 200g.l-1 unless there has been delay in umbilical cord clamping - Upper limit of normal E. total blood volume is approximately 70 ml.kg-1 body weight - More like 80-85 ml.kg-1 ----------- |
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PP101 ANZCA version [Apr08] q124
You are about to anaesthetise a 20kg infant. For this patient, advantages of a T-piece breathing system include each of the following EXCEPT: A. ability to assess lung compliance B. ability to assess tidal volume C. ability to use low gas flows D. ability to vary CPAP (continuous positive airway pressure) E. low resistance |
C. ability to use low gas flows
Requires high gas flows (3-8 L/min) ----------- |
