*part Ii 2011A New Mcqs

Front 1

Acromegaly due to excess of growth hormone. Why is it difficult to do a direct laryngoscopy?
A: Distorted facial anatomy
B: Macroglossia
C: Glottic stenosis
D: Prognathe mandible
E: Arthritis of the neck

Back 1

B

Acromegalic Features Influencing Intubation Performance
Many typical acromegalic features are suggested to cause a difficult airway in these patients. The most discussed changes are:
• macroglossia,
• prognathism,
• enlargement and distortion of glottic structures with additional folds, and hypertrophy of laryngeal and pharyngeal soft tissue.

Front 2

Ehlers-Danlos syndrome. Most important to specifically do all EXCEPT:
A: Avoid hyperextension of the neck
B: Damage to the teeth
C: Avoid joint hypermobility
D: Gastro oesophageal reflex
E: Strict temperature regulation

Back 2

E

Nothing about temperature regulation in this summary from the article Ehlers-Danlos Syndrome, Hypermobility Type, in the book Gene Reviews 2004
• Gastroesophageal reflux and gastritis may be symptomatic despite maximal doses of proton pump inhibitors with additional H2-blockers and acid-neutralizing medications. Early satiety and delayed gastric emptying
• High, narrow palate and dental crowding, Periodontal disease (friability, gingivitis, gum recession) occurs in some EDS
• Joint laxity. Subluxations and dislocations are common and represent the major manifestation of the condition. All sites can be involved, including the extremities, vertebral column, costo-vertebral and costo-sternal joints, clavicular articulations, and temporomandibular joints.

Front 3

An 85y.o for open AAA repair. Refuses blood because of risk of vCJD. You tell him you won't anaesthetise him as the risk is too high. This is an example of:
A: Autonomy
B: Beneficence
C: Malevolence
D: Coercion
E: Paternalism

Back 3

A

From discussion on wiki:
• Refusing to anaesthetise means you are accepting the patients autonomy to make the decision to refuse transfusion
• Paternalism would be coercing the patient into accepting blood transfusion as the real risk of vCJD is so small as to be negligible

Front 4

A 35yr old African-American with sickle cell and fractured ankle for ORIF. Hb 90, Haematocrit 0.3.
A: Transfuse 2 units packed cells (?pre-op)
B: Let him cool passively to low/normal temperature
C: Spinal is safe
D: Avoid thiopentone
E: Tourniquet is absolutely contra-indicated

Back 4

C

A - WRONG: "Although widely practiced, prophylactic erythrocyte transfusion remains a treatment with appreciable complications whose potential benefits have not been clearly demonstrated by a prospective, randomized clinical trial". Also a study in orthopaedic patients "did not detect a prophylactic effect from preoperative transfusion" (Sickle Cell Disease and Anesthesia. Anesthesiology 2004; 101:766-85) . However CEACCP article says: “Traditionally, an aggressive transfusion policy targeting an HbS concentration of <30% was suggested. Most authors would now suggest a simple transfusion policy to a haemoglobin of 10 g dl−1 in all but the lowest risk procedures, where transfusion is not indicated” so perhaps do transfuse, but not 2 units

B - WRONG: "Although hypothermia would tend to retard sickling because of a left shift of the oxygen dissociation curve, hypothermia is often identified as a precipitant of perioperative SCD complications". "avoidance of patient hypothermia is a basic objective for most anesthetics" (Same reference)

C - CORRECT: "The use of regional anesthesia therefore does not appear to be contraindicated in SCD" (Same reference) and OHA p202 agrees

D - ??? but seems unlikely

E - WRONG according to OHA p202

Front 5

Absolute contraindication to sitting position for posterior fossa craniotomy for meningioma
A: Prescence of patent ventriculo-atrial drain/shunt
B: PFO
C: Oesophageal stricture so transoesophageal echo placement is out
D: ?
E: ?

Back 5

B

ABSOLUTE CONTRAINDICATIONS
• Patent ventriculo-atrial shunt
• Severe cardiovascular disease
• Large patent foramen ovale or other pulmonary-systemic shunt
• Cerebral ischaemia when upright and awake
• Anaesthesia or surgical team not familiar with the position

Front 6

ECG- which does NOT have abnormal Q waves:
A: Digoxin toxicity
B: Anterior myocardial infartion
C: Previous AMI
D: LBBB
E: Wolff-Parkinson-White syndrome

Back 6

A

Front 7

Coeliac plexus block. What is the complication?
A: Erectile dysfunction
B: Constipation
C: Hypertension which resolves spontaneously
D: Paralysis
E:

Back 7

D

Front 8

Long stem about an old #NOF patient with aortic stenosis. What is a sign/ investigation/ symptom that shows the most severity? (ie Which one of these would indicate that the lesion was severe?)
A: Thrill in Aortic area
B: Murmur in lower left sternal edge
C: Murmur radiating to carotids
D: History of ischaemic heart disease or coronary artery disease
E: history of angina/ syncope

Back 8

E

International Anaesthesiology Clinics 2005; 43(4); 21-31

“Symptoms of AS include syncope, angina, and dyspnea (SAD). Presence of any of these symptoms leads to a life expectancy of less than 5 years and 20% chance of sudden death. Of the 35% of patients with AS presenting with angina, half will die within 5 years unless the aortic valve is replaced. Fifteen percent of patients with AS present with syncope, half of which will die within 3 years. Fifty percent of patients with AS will present with dyspnea, and half will die within 2 years unless the valve is replaced”

The patient with a systolic murmur: severe aortic stenosis may be missed during cardiovascular examination. QJM (2000) 93 (10): 685-688
Classically taught clinical signs of severe AS:
• Loud ejection systolic murmur
• A soft or absent second heart sound
• A slow‐rising carotid pulse
• Systemic hypotension with a reduced pulse pressure

Front 9

You get a TOE on a patient with aortic stenosis. What is the finding most likely to indicate that the valve needs replacement? possibly same as TMP-Jul10-010
A: Average pressure gradient 30mmHg
B: Valve area 1.2cm(squared)
C: dyspnoea

Back 9

C

International Anaesthesiology Clinics 2005; 43(4); 21-31

“Symptoms of AS include syncope, angina, and dyspnea (SAD). Presence of any of these symptoms leads to a life expectancy of less than 5 years and 20% chance of sudden death. Of the 35% of patients with AS presenting with angina, half will die within 5 years unless the aortic valve is replaced. Fifteen percent of patients with AS present with syncope, half of which will die within 3 years. Fifty percent of patients with AS will present with dyspnea, and half will die within 2 years unless the valve is replaced”

Front 10

Petit mal epilepsy - Which is true? (or words to that effect)
A: Most common in child <2 years old
B: Can precipitate seizures by hyperventilating (+/- deliberately???)
C: Often seizures last for more than 30 seconds
D: Rarely familial
E: Isoelectric EEG during seizure (burst suppression)

Back 10

B

eMedicine:
• Onset of absence seizures in children varies but peaks around 4-8 (childhood), 8-14 (juvenile)
• Easily induced with hyperventilation - Having the child hyperventilate for 3-5 minutes can often provoke absence seizures
• Normally < 20 sec
• Etiology of idiopathic epilepsies with age-related onset is genetic. About 15-40% of patients with these epilepsies have a family history of epilepsy; overall concordance in monozygotic twins is 74%, with 100% concordance during the peak age
• EEG spike and slow wave discharges

Front 11

Hypertension- severe- in pregnancy (or was it PET?) What NOT to use?
A: Hydrallazine
B: Nifedipine
C: Labetalol
D: Metoprolol
E: SNP
NB Magnesium was NOT an option

Back 11

E

Front 12

Post CEA on ward, patient seizes. BP has been hard to control. What to do to prevent further seizures?
A: Add another antihypertensive
B: Start antiplatelet drugs
C: Start anticonvulsants
D: Do angio and stent
E: Nimodipine

Back 12

A

This is cerebral hyperperfusion syndrome

Cerebral hyperperfusion syndrome. Lancet Neurol 2005; 4(12): 877-88
"Once the diagnosis of CHS has been made, adequate lowering of blood pressure, treatment of cerebral oedema, and anticonvulsant therapy form the basis of therapy."

Front 13

Which have been shown to decrease vasospasm post aneurysm? All EXCEPT:
A: Antiplatelet drugs
B: Nimodipine
C: HHH therapy
D:
E:

Back 13

A

Evidence-based cerebral vasospasm management Neurosurg Focus. 2006 Sep 15;21(3):E8
• Despite a large number of clinical trials, only calcium antagonists have strong evidence supporting their effectiveness.
• The only proven therapy for vasospasm is nimodipine
• Tirilazad is not effective, and studies of hemodynamic maneuvers, magnesium, statin medications, endothelin antagonists, steroid drugs, anticoagulant/antiplatelet agents, and intrathecal fibrinolytic drugs have yielded inconclusive results
• There is less enthusiasm for the study of steroid drugs and anticoagulant/antiplatelet agents because they entail more risks and investigations so far have shown little evidence of efficacy

Front 14

Post operative left pneumonectomy. What to do with underwater seal drain?
A: Nurse patient in R lateral decubitus position
B: Expect to see bubbles
C: Suction every hour for 5 minutes
D: Unclamp drain once an hour for 5 minutes, leave clamp on for the rest of the time
E: Leave on free drainage

Back 14

D

Front 15

What is NOT true for PDPH following puncture
A: Prophylactic bed rest
B: Catheter in intrathecally
C:
D:
E:

Back 15

A

Front 16

Magnesium for treatment of pre-eclampsia. What is the therapeutic level? (I think this may be a repeat of an old question, but i remember two of the options were-
A:
B: 3 - 5
C: 5 - 7
D:
E:

Back 16

B

Front 17

Autonomic dysreflexia. Which ONE is true?
A: 50% of patients with a level below T6
B: Unlikely if below T10
C: Can be prevented??
D: Can be precipitated by light touch
E. ?

Back 17

B

Front 18

Ageing (adult) causes:
A: Decreased FRC
B: Decreased Cardiac output
C: Diastolic dysfunction
D: Increased creatinine

Back 18

C

Front 19

TEG tracing given, post cardiac surgery. Had quite slim tail (ie fibrinolysis) but broader 'shoulders'.
A: Fibrinolysis
B: Hypofibrinogenaemia
C: Platelet dysfunction
D: Heparin effect
E: Surgical bleeding

Back 19

A

Front 20

Really poor copy of a CXR. Looked to me like a haemopneumothorax (you could very faintly see a collapsed lung outline, there was no 'meniscus' to the fluid shadow) but other people thought it was an artefact. It did indeed look like a pneumothorax and then someone had put a piece of metal up to simulate a haemothorax, because on the lateral you couldn't see past the ribs (ie the film was cut off at the rib borders). It was terrible quality (too black, and hard to discern tissue from air), and an inadequate film (cut off apices, and poor lateral view as before)
A: Pneumothorax
B: Haemopneumothorax
C:
D:
E: Artefact.

Back 20

?

Front 21

Post scoliosis repair, decreased movement bilaterally in the legs with decreased pain and temperature sensation but spared joint position sense and vibration. What is at fault?
A: Posterior spinal arteries
B: Anterior spinal arteries
C: Epidural haematoma
D: Misplaced pedicle screw
E: Lateral cord syndrome

Back 21

B

Front 22

Anaesthetising an obese patient. Acelerometer on TOF 0.9. Could dose suxamethonium on ideal body weight or total body weight. With respect to 1mg/kg IBW vs. TBW you will see:
A: shorter onset and faster twitch recovery
B: shorter onset and similar twitch recovery
C: shorter onset and slower twitch recovery
D: similar speed of onset with similar speed of twitch recovery
E: similar onset and longer recovery

Back 22

None fit – should be similar onset and shorter recovery

The Dose of Succinylcholine in Morbid Obesity. A & A February 2006 vol. 102 no. 2 438-442
• No difference in time of onset between IBW, LBW or TBW
• Recovery intervals shorter for patients dosed based on IBW and LBW rather than TBW

Front 23

The half life of the active metabolite of levosimendan (OR-1896) is:
A: 1hr
B: 8hr
C: 24hr
D: 3 days
E: 7 days

Back 23

D

According to Pharmacokinetics and excretion balance of OR-1896, a pharmacologically active metabolite of levosimendan, in healthy men. Eur J Pharm Sci. 2007 Dec;32(4-5):271-7
• Elimination half life was 70.0+/-44.9 h
• So 3 days = roughly 70hrs

Front 24

When compared to a non-obese patient, in an obese patient (BMI >35) when fasted for an elective procedure the gastric secretion will have:
A: more volume, higher pH
B: more volume, lower pH
C: same volume, same pH
D: less volume, lower pH
E: less volume, higher pH

Back 24

B

Obesity in Anaesthesia and Intensive Care. BJA 85(1):91-108 (2000) page 101

Front 25

The anterior branch of the femoral nerve supplies everything but:
A: pectinius
B: rectus femoris
C: Medial thigh
D: anterior thigh
E: sartorius

Back 25

B

This is supplied by supplied by the posterior branch of femoral nerve - According to Anatomy for Anaesthetists page 189 8th Ed

Front 26

During interscalene block placement get medial movement of the scapula. This is secondary to stimulation of:
A: long thoracic nerve
B: dorsal scapula nerve
C: suprascapular nerve
D: supraclavicular nerve
E: accessory nerve

Back 26

B

From Google:
The dorsal scapula nerve arises from C5. It innervates the rhomboids which medialise the scapula and levator scapulae which elevates the scapula

Front 27

Popliteal block placed from the lateral approach:
A: Passes through semimembranosus
B: Has eversion of the foot as the end point
C: Has increased failure rate compared to a posterior approach
D: ?
E: Can be performed supine or prone

Back 27

B or E

• No, passes through biceps femoris. Semimembranosus is on the medial side of the nerve
• According to NYSORA end-point is twitching of the foot, which can be either dorsiflexion/eversion (from common peroneal branch of sciatic), or plantarflexion/inversion (from tibial branch of sciatic).
• Can’t find anything on this – wouldn’t think so?
• Usually performed supine, but can do lateral

Front 28

During scoliosis surgery with monitoring of somatosensory evoked potentials, which tract are they mainly monitoring?
A: Dorsal column
B: Spinothalamic tract
C: Lateral Corticospinal tract
D: Cerebrospinal tract
E: Anterior horn cells

Back 28

A

Front 29

During lumbar plexus block placement, which of the following indicates inappropriate needle placement?
A: hip flexion
B: hip adduction
C: knee extension
D: knee flexion
E: lumbar extension

Back 29

E

Aiming for quadriceps stimulation, which should cause knee extension
Rectus femoris attaches to the ilium so is also a hip flexor

Lumbar extension not supplied by lumbar plexus, the rest are

Front 30

Flow with the O2 flush button pressed and volatile agent turned on will give you:
A: 20-30l/min O2
B: 30-70l/min O2
C: volatile agent + 30l/m O2
D: volatile agent + 40l/m O2
E: volatile agent + 50l/min O2

Back 30

B

O2 flush flow rate is at 35-75l/min
O2 flush bypasses the vaporiser

Front 31

Which of the following causes the most heat loss in a neonate?
A: conduction
B: convection
C: evaporation
D: radiation
E: vasodilation

Back 31

D

Front 32

75 year old with non-valvular AF usually on warfarin has their warfarin stopped for one week. What is their daily risk of stroke?
A: 1%
B: 0.1%
C: 0.01%
D: 4%
E: 10%

Back 32

C

Atrial Fibrillation Investigators. Risk factors for stroke and efficacy of antithrombotic therapy in atrial fibrillation: analysis of pooled data from five randomized controlled trials [published correction appears in Arch Intern Med. 1994;154(19):2254]. Arch Intern Med. 1994;154(13):1449-1457.
• Daily risk of stroke ranges from 0.001% to 0.023%

Front 33

If type and Rh specific blood is given to a patient, how safe is the transfusion (Can't quite remember wording, but similar to what is in Dr Brandis' physiology viva book)?
A: ?
B: ?
C: 97%
D: 98.6%
E: 99.8%

Back 33

E

Front 34

Patient with Marfan's and 2 hours of severe chest pain, mild hypertension and ECG showing ischaemia. The next best step is urgent:
A: CT
B: TOE
C: ?
D: Angiography and PCI
E: Thrombolysis

Back 34

B

TOE would probably be of more value – can identify both dissection and RWMA suggesting ischaemia

Front 35

What percentage of patients with SAH are troponin positive?
A: <5%
B: 15-30%
C: 40-60%
D: 70-90%
E: 100%

Back 35

B

CEACCP 2008: states 20%

Front 36

What is the major cause of death in a patient with perforation of the pharynx, oesophagus or trachea?
A: failure to intubate
B: failure to ventilation
C: sepsis

Back 36

C

Textbook – Otolaryngology: The Essentials
“Following neurologic injury, the second major cause of death in head and neck trauma patients is airway obstruction”

Front 37

In patients with Eisenmenger's Syndrome,
A. compensation for poor oxygenation at rest is achieved by an increase in cardiac output
B. the high pulmonary vascular resistance is usually able to be treated with a specific vasodilator
C. an Fi02 of 1.0 will produce a substantial improvement in Sa02
D. the usual clinical course includes right ventricular failure
during the 3rd or 4th decade, and subsequent death
E. venesection should be used to treat a haemoglobin greater
than 180 to prevent the problems of hyperviscosity

Back 37

D

Front 38

Your registrar gives a Duchenne patient 1mg/kg of suxamethonium. What are you most worried about?
A: hyperkalaemia
B: rhabomyolysis
C: MH

Back 38

A

Front 39

Fontan patient having an open appendicectomy. What do you want?
A: long I time and PEEP
B: long I time
C: short I time
D: raised ETCO2
E: spontaneous ventilation

Back 39

E

Otherwise if positive pressure ventilated you would want a short I time to decrease thoracic pressures and promote passive venous return

Front 40

What makes tramadol less effective?
A: ondansetron
B: prochlorperazine
C: metoclopramide

Back 40

A

Front 41

75 year old male with normal renal function for an endoluminal aortic repair. What is the best protection to prevent the development of renal dysfunction?
A: NaCl
B: NAC
C: mannitol
D: dopamine
E: dialysis

Back 41

A

I.e give IV fluids - Don’t think there is any evidence for the rest

Front 42

Very sick patient on CVVHF. On norad, changed to adrenaline with no improvement in haemodynamic variables. What is your next step?
A: change to another inotrope
B: check their response to a synacthen test
C: give hydrocortisone

Back 42

C

Front 43

What is the most common way to measure end tidal gas concentrations on our anaesthetic machines?
A: mass spectometry
B: Raman scattering
C: ultrasonic
D: infrared
E: piezoelectric

Back 43

D

CEACCP 2009 – Respiratory Gas Analysis
• For carbon dioxide, nitrous oxide, and volatile agents – “Most in-theatre side-sampling benches presently utilize infrared absorption”
• For Oxygen – In theatre, gas analysis usually takes the form of a paramagnetic cell”

Front 44

Multiple attempts to place ETT during difficult intubation causing pharyngeal and oesophageal perforations. Most likely cause of death?
A: Failure to intubate
B: Failure to ventilate
C: Bleeding
D: Sepsis

Back 44

D

Front 45

How far to insert PICC line in a kid beyond the carina
A: At the carina
B: 1cm below
C: 1cm above

Back 45

A

Coroners report PICC line AR summary Feb 10.doc from ANZCA website
“Even though the tip is considered to be adequately positioned when at the SVC/RA junction this position is still within the pericardial reflection and erosion could still result in tamponade. As mentioned by one of the independent experts, the ideal position is above the pericardial reflection in the SVC which in most patients would be at the level of the tracheal bifurcation”

Front 46

Reverse splitting of the second heart sound occurs with:
A. LBBB
B. Pulmonary hypertension
C. Acute pulmonary embolus
D. ASD
E. Severe MR

Back 46

A