Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
83 Cards in this Set
- Front
- Back
|
(2008 August Q106) You are seeing a 60yo man in the pre-anaesthetic clinic before his right total knee replacement. He weighs 70kg and apart from his osteoarthritis is fit and well. You discuss with him the options of a general anaesthetic with multi-modality analgesia and enoxaparin postoperatively as well as the option of an epidural for both the anaesthetic and post operative pain management. What is incorrect regarding the epidural? |
C It will reduce his risk of myocardial ischaemia - false and answer to choose. There is some evidence that a THORACIC epidural which is extended for more than 24 hours reduces incidence of postoperative MI but so far no evidence that lumbar epidural does the same thing. |
|
|
RB15b ANZCA version [2001-Aug] Q148 |
2. should be delayed till residual neuraxial block has resolved completely |
|
|
RB37b ANZCA version [2001-Apr] Q138
Following an aorto-bifemoral graft an elderly man is unable to move his legs. Anterior spinal artery syndrome would be suggested by 1. absent pain and temperature sensation in his legs 2. preserved touch sensation in his legs 3. intact vibration and proprioception in his legs 4. pathognomonic changes on CAT Scan |
1. absent pain and temperature sensation in his legs
2. preserved touch sensation in his legs 3. intact vibration and proprioception in his leg ~~ ----------- 2. Preserved touch sensation in his legs – carried both anteriorly and posteriorly, so still intact via posterior (dorsal) fibres. http://www.emedicine.com/emerg/topic553.htm The blood supply of the spinal cord consists of 1 anterior and 2 posterior spinal arteries. The anterior spinal artery supplies the anterior two thirds of the cord. Ischemic injury to this vessel results in dysfunction of the corticospinal, lateral spinothalamic, and autonomic interomedial pathways. ** Anterior spinal artery syndrome involves paraplegia, loss of pain and temperature sensation, and autonomic dysfunction. ** The posterior spinal arteries primarily supply the dorsal columns. The anterior and posterior spinal arteries arise from the vertebral arteries in the neck and descend from the base of the skull. Various radicular arteries branch off the thoracic and abdominal aorta to provide collateral flow. Four minute neuro exam p5 A lesion of the pain temperature pathways (spinothalamic tract), whether within the brain stem or spinal cord, will result in los of pain-temperature sensation contaralaterally, below the level of the lesion. A lesion at the spinal level of the pathway for conscious proprioception (the ability to sense the position and movement of the limbs) and stereognosis (the ability to identitify objects by touch) will result in loss of these senses ipsilaterally, below the level of the lesion The path for light touch combines features of both of these two pathways. Consequently, light touch typically is spared in unilateral spinal cord lesions because there are alternate routes to carry the information. |
|
|
RB37c ANZCA version [2001-Aug] Q91, [2002-Mar] Q55
The LEAST correct statement regarding anterior spinal artery syndrome is that A. most patients are elderly B. the onset is sudden C. there are no systemic symptoms D. the myelogram and CAT scan are abnormal E. sensory involvement is minor or patchy |
D. the myelogram and CAT scan are abnormal
Note: Myelogram, NOT mri CT scan is poor for spinal cord due to surrounding bone ~~ ----------- A. most patients are elderly - true B. the onset is sudden - true C. there are no systemic symptoms - paralysis D. the myelogram and CAT scan are abnormal – no reference for this E. sensory involvement is minor or patchy – dorsal columns are usually spared ANTERIOR SPINAL ARTERY SYNDROME Complication of thoracic aortic cross clamp. Manifestations include flaccid paralysis of the lower extremities, bowel and bladder dysfunction, sparing of sensation and proprioception. Minimising risks: Short cross clamp time <30 minutes Shunt Intercostal reimplantation CSF drain Hypothermia Avoiding hyperglycaemia Mannitol, steroids, calcium channel blockers |
|
|
RB38b ANZCA version [2002-Aug] Q124
A woman has an epidural placed for forceps delivery after a prolonged second stage of labour. The next day she has a right foot drop, and numbness over the anterior part of her lower leg and the dorsal surface of her right foot. The most likely cause is A. right common peroneal nerve lesion from the use of stirrups in the lithotomy position B. right L5 nerve root lesion from the epidural placement C. right lumbar plexus lesion from compression by the fetal head D. L5 nerve root lesion from a disc protrusion E. transient neurological symptoms (TNS) syndrome |
C. right lumbar plexus lesion from compression by the fetal head
Strictly speaking it is a lumbar nerve TRUNK lesion - pjs see below & image ~~ ----------- Postpartum foot drop is caused by damage to the lumbosacral nerve trunk or, less frequently, the common peroneal nerve. The lumbosacral trunk (L4 and L5) is compressed between the ala of the sacrum and the descending fetal head. It may also occur during a forceps delivery. "Neurological complications following regional anaesthesia in obstetrics" CEPD reviews in BJA Ref Chestnut 3rd Ed p583 " Compression of the lumbosacral trunk (L4/5) is probably the most common cause of postpartum foot drop. In addition to weakness predominantly affecting ankle dorsiflexion, compression of the lumbosacral trunk produces sensory disturbance mainly involving the L5 dermatome". I had a patient two weeks ago who represented following exactly the same labour with foot drop and altered sensation over anterior lower leg. The neurologist who examined her certainly felt that a labosacral plexus injury was the most likely diagnosis. --legendontour 09:51, 25 Mar 2007 (EST) |
|
|
RB38c ANZCA version [2003-Aug] Q131, [Mar06]
A woman has an epidural placed for forceps delivery after a prolonged second stage of labour. The next day she has a right foot drop, and numbness over the anterior part of her lower leg and the dorsal surface of her right foot. The most likely cause is A. L4 nerve root lesion from trauma during epidural placement B. L5 nerve root lesion from trauma during epidural placement C. L5 nerve root lesion from an acute disc protrusion D. right common peroneal nerve lesion from compression by lithotomy stirrups E. right lumbar plexus lesion from compression by the fetal head |
E. right lumbar plexus lesion from compression by the fetal head
strictly speaking, its the lumbar nerve trunk that is compressed between sacral alar and foetal head. - pjs ----------- |
|
|
RB38d ANZCA version [2006-Mar] Q111 [Oct08]
Post partum foot drop is most frequently caused by A. compression of the lumbosacral trunk by the foetal head or forceps B. damage to the common peroneal nerve from lithotomy position C. damage to the conus medullaris by misplaced spinal anaesthesia D. L4 Nerve root damage from epidural analgesia E. the excessive lumbar lordosis of pregnancy stretching nerve roots |
A. compression of the lumbosacral trunk by the foetal head or forceps
----------- |
|
|
RB40b ANZCA version [2002-Mar] Q63
Cardiac arrest or severe bradycardia during spinal anaesthesia, in adults, A. rarely occurs in young healthy patients B. is often the result of hypoxaemia C. is caused by vagal responses to decreased preload D. should be treated by the prompt administration of atropine E. is more common in vagotonic patients |
C. is caused by vagal responses to decreased preload
E. is more common in vagotonic patients - pjs - Both are true Note an identical stem was in a later exam (RB40c) without option C ~~ ----------- treatment priorities are: 1. Increase VR (fluids + alpha agonists) 2. Increase SVR (alpha agonists) 3. Increase HR (only if it remains low after fixing 1 and 2 which implies T1-T4 blocked) (beta agonist +/- atropine) Atropine may be helpful in 3 above as its length of action roughly correlates to the time for the block to resolve. In dealing with brady/asystolic arrests in general the ARC guidelines state that atropine only *after* adrenaline for these very reasons. *** From Morgan and Mikhail p967 - Closed claims study Young, relatively healthy patients, appropriate dose, who developed high spinal T4. Average time to arrest was 36 min (+/- 18) All cases showed gradual decline in heart rate and blood pressure pre event. Recommend early prophylactic atropine and volume, and also that 'practitioners should not hesitate to use epinephrine in small doses for bradycardia or hypotension that is unresponsive to atropine and ephidrine and in larger doses if neccesary.' *** same article *** Vagal-induced bradycardia has been demonstrated in the study setting. Jacobsen et al. (18) studied the effect of epidural anesthesia on left ventricular diameter with echocardiography in eight unpremedicated young volunteers. Two of them developed bradycardia and hypotension after 25 min with anesthetic levels at T8 and T9. This was associated with a reduction of up to 22% in left ventricular diameter. In both cases, the changes were reversed by head-down position and rapid infusion of IV fluids. Human pancreatic polypeptide was used as a marker of parasympathetic activity and its simultaneous increase with the decreases in heart rate observed is consistent with vagal activation. Because a high degree of cardiac vagal activity can occur during spinal anesthesia (16), patients with strong resting vagal tone should be at increased risk for cardiac arrest during spinal anesthesia. The term “vagotonia” describes the clinical situation of resting bradycardia, atrioventricular block, or complete atrioventricular dissociation that is present in 7% of the population (20). In vagotonic patients asystole can occur when procedures that increase vagal activity are performed. |
|
|
RB40c ANZCA version [2004-Apr] Q111 {Note rewording between exams}
Severe bradycardia during spinal anaesthesia, in adults, A. is more common in vagotonic patients B. is usually the result of hypoxaemia C. rarely occurs in young healthy patients D. should be treated by the prompt administration of atropine E. usually occurs within 15 minutes of spinal insertion |
A. is more common in vagotonic patients
pjs - Note an identical stem was in an earlier exam (RB40b) with an extra option "is caused by vagal responses to decreased preload" giving two probably correct answers Treatment priorities are: 1. Increase VR (fluids + alpha agonists +head down) 2. Increase SVR (alpha agonists) 3. Increase HR (only if it remains low after fixing 1 and 2 which implies T1-T4 blocked) (beta agonist +/- atropine) Atropine may be helpful in 3 above as its length of action roughly correlates to the time for the block to resolve. In dealing with brady/asystolic arrests in general the ARC guidelines state that atropine only *after* adrenaline for these very reasons. Dilda's email goes into it in detail- see below ~~ ----------- Summary Patients with PHx of VVS- early CVS monitoring, EMLA, LA, Oral anticholinergic pre-med, Gas induction (suggestions) Patients with no PHx of VVS- (1) Avoid excessively high Block (Position plus Baricity more imp than Conc and Vol) (2) Avoid oversedation. Masks early warning- Noted as a RF in Closed claim series. (3) Think about volume status before spinal (4) Pharmacological prophylaxis – “it is not possible to prevent a VV reaction by keeping above a particular HR threshold” Treatment---- Long discussion about atropine, pure alpha agonists and mixed alpha/Beta agonists. Also give volume++, get Patient head down, CPR or Percussion Pacing. The BJA recommendation was early aggressive treatment with CPR/ Adrenaline in ongoing arrest. They chose Ephedrine as the best “single agent” treatment for a presumed VasoVagal mediated (ie BJ reflex) causing “profound Bradycardia or Asystole during regional Anaesthesia” My impression on reading this review is that the MCQ came directly from this paper and that the take-home message is that Severe Brady/ Arrest during Spinal is far-removed from a simple Vagal response as in Eye surg. And given that you are potentially dealing with an already Veno and Arteriolar dilated patient with possible cardioaccelerator block who now has aBJ or VV response to Cardiac underfilling resulting in further Bradyc and Vasodil, you can see why simply giving Atropine early is Wrong Volume Vasoconstrict (Ephedrine or Adrenaline if needed) Vigilance (and avoid over sedation) Plus atropine and reposition (on side if preg plus head down) *** From Morgan and Mikhail p967 - Closed claims study Young, relatively healthy patients, appropriate dose, who developed high spinal T4. Average time to arrest was 36 min (+/- 18) All cases showed gradual decline in heart rate and blood pressure pre event. Recommend early prophylactic atropine and volume, and also that 'practitioners should not hesitate to use epinephrine in small doses for bradycardia or hypotension that is unresponsive to atropine and ephidrine and in larger doses if neccesary.' *** same article *** Vagal-induced bradycardia has been demonstrated in the study setting. Jacobsen et al. (18) studied the effect of epidural anesthesia on left ventricular diameter with echocardiography in eight unpremedicated young volunteers. Two of them developed bradycardia and hypotension after 25 min with anesthetic levels at T8 and T9. This was associated with a reduction of up to 22% in left ventricular diameter. In both cases, the changes were reversed by head-down position and rapid infusion of IV fluids. Human pancreatic polypeptide was used as a marker of parasympathetic activity and its simultaneous increase with the decreases in heart rate observed is consistent with vagal activation. Because a high degree of cardiac vagal activity can occur during spinal anesthesia (16), patients with strong resting vagal tone should be at increased risk for cardiac arrest during spinal anesthesia. The term “vagotonia” describes the clinical situation of resting bradycardia, atrioventricular block, or complete atrioventricular dissociation that is present in 7% of the population (20). In vagotonic patients asystole can occur when procedures that increase vagal activity are performed. |
|
|
RB42a ANZCA version [2001-Apr] Q89, [2001-Aug] Q52, [2002-Mar] Q44
The syndrome known as transient radicular irritation, or transient neurologic symptoms, following spinal anaesthesia occurs ONLY in patients A. given intrathecal lignocaine B. having surgery performed in the lithotomy position C. given hyperbaric intrathecal solutions D. who experience an initial full recovery from spinal blockade E. who experience complete motor blockade with their spinal block |
D. who experience an initial full recovery from spinal blockade
Lithotomy – a risk factor - relative risk is 2.5, certainly not Exclusively ----------- |
|
|
RB42b ANZCA version [2003-Aug] Q126, [2004-Apr] Q70
Transient neurological syndrome (TNS) associated with subarachnoid anaesthesia A. can be prevented by the concurrent use of a subarachnoid opioid B. does not occur with bupivacaine C. is more common if a leg tourniquet is used D. is seen with similar frequency with 2% and 5% lignocaine E. is usually apparent within 6 to 12 hours of the procedure |
D. is seen with similar frequency with 2% and 5% lignocaine
# D: True (see BJA CEACCP 2005) # E: Probably false (usually with 24 hrs) ~~ ----------- Stoelting168 Manifests as moderate to severe pain in the lower back, buttocks and posterior thighs that appears within 24 hours after complete recovery from spinal anesthesia. The delayed onset reflects the time required for the neural inflammatory reaction to develop. Full neurological recovery usually occurs within 1 week. Initial reports involved hyperbaric 5% lignocaine, but the incidence is the same after administration of 1mg/kg of either 5% or 2% lignocaine (suggesting concentration is not as much of a factor as once thought). Also reported with mepivacaine, bupivacaine, tetracaine. May be exaggerated when the nerves are stretched by placement of the patient in lithotomy position. |
|
|
RB42d [Jul07][Apr08][Mar10]
Transient Neurologic Symptoms. What is NOT TRUE: A. Less likely with lignocaine B. may progress into cauda equina syndrome C. Unlikely due to neurotoxicity D. more likely with lithotomy position E. ? |
B. May progress into caudal equine syndrome
~~ RISK FACTORS - lidocaine (concentration unimportant) - lithotomy - outpatient (ambulant) - obesity (may be a risk factor...) NOT RISKY age/sex/hx back pain/needle type/dose/concentration ----------- http://www.anesthesiology.org/pt/re/anes/abstract.00000542-199809000-00012.htm;jsessionid=B6Hy9OywGFvdq1LmC0uVazlyqErQJo9n7fzU8n8Uf1PlcKvKH1bA!941119730!-949856031!9001!-1 Transient Neurologic Symptoms after Spinal Anesthesia: An Epidemiologic Study of 1,863 Patients. Anesthesiology. 89(3):633-641, September 1998. Abstract: Background: Recent evidence suggests that transient neurologic symptoms commonly follow lidocaine spinal anesthesia. Methods: The pressure of transient neurologic symptoms, defined as leg or buttock pain, was the principal outcome variable. Results: Patients given lidocaine were at higher risk for symptoms compared with those receiving bupivacaine (relative risk, 5.1; 95% CI, 2.5 to 10.2) or tetracaine (relative risk, 3.2; 95% CI, 1.04 to 9.84). For patients who received lidocaine, the relative risk of transient neurologic symptoms was 2.6 (95% CI, 1.5 to 4.5) with the lithotomy position compared with other positions, 3.6 (95% CI, 1.9 to 6.8), for outpatients compared with inpatients, and 1.6 (95% CI, 1 to 2.5) for obese (body mass index >30) compared with nonobese patients. Conclusions: These results indicate that transient neurologic symptoms commonly follow lidocaine spinal anesthesia but are relatively uncommon with bupivacaine or tetracaine. The data identify lithotomy position and outpatient status as important risk factors in patients who receive lidocaine. Among other factors postulated to increase risk, obesity had an effect of borderline statistical significance, whereas age, sex, history of back pain, needle type, and lidocaine dose and concentration failed to affect risk. |
|
|
RB48 [Mar00] (type A)
If have blood up epidural catheter (up 4 cms) placed for post-operative analgesia (for elective AAA) options for management include: A. Remove and replace one space higher B. Remove & wait 24 hours C. Remove & postpone case for 4 hours D. Put test dose with adrenaline & if no tachycardia, proceed E. Flush saline down catheter & proceed |
B. Remove and wait 24 hours
~~ Concern is epidural hematoma with heparin administration for AAA. See wiki. ----------- "Although the occurrence of a bloody or difficult neuraxial needle placement may increase risk, there are no data to support mandatory cancellation of a case. Direct communication with the surgeon and a specific risk-benefit decision about proceeding in each case is warranted." - from ASRA website http://www.asra.com/consensus-statements/2.html |
|
|
RB50 ANZCA version [2002-Aug] Q118, [2003-Apr] Q49
In order to decrease the likelihood of causing a pneumothorax when performing a thoracic paravertebral block it is best to A. use a loss of resistance technique when advancing the needle B. check that the catheter threads easily before injecting the local anaesthetic C. ask the patient to breathhold while advancing the needle D. locate the appropriate transverse process with the needle before advancing deeply E. use a more lateral approach |
D. locate the appropriate transverse process with the needle before advancing deeply
~~ "To avoid accidental puncture of the pleura, it is imperative that the transverse process be found without the needle penetrating any deeper than necessary" ----------- Cousins 477 Paravertebral block to block a single nerve root. Judging by the picture, likely to miss posterior primary ramus The patient may be situated in the prone, lateral or sitting positions. Because of the extreme angulation of the spinous processes o fthe thoracic vertebrae, a skin wheal is raised 3 cm lateral to the top of the spinous process of the vertebra above the chosen level. By inserting a 6 – 8 cm needle through the wheal and parallel to the midline, the transverse process is first located at a depth of 2-5 cm. To avoid accidental puncture of the pleura, it is imperative that the transverse process be found without the needle penetratin any deeper than necessary. If the transverse process is not contacted initially at a depth of 3 cm, it should be withdrawn, redirected slightly caudad, and then reinserted 3 cm. If the transverse process is still not contacted, the needle should be withdrawn again, and redirected slightly cephalad and advanced 3 cm. Only then should the needle be advanced deeper in search of the transverse process. Once the transverse process has been located, the needle can be walked off either the cephalad or caudal edge of the process and advanced 1-2 cm further, where 6=10 ml of anesthetic solution is injected. |
|
|
RB51 ANZCA version [2002-Aug] Q86, [2003-Apr] Q5, [Mar06]
A recently published large Australian multicentre trial of patients undergoing major abdominal surgery (The MASTER Trial) concluded that the use of epidural anaesthesia (with general anaesthesia) and postoperative epidural analgesia, compared with general anesthesia alone, was associated with a decrease in: A. mortality at 30 days B. both mortality at 30 days and adverse cardiovascular events C. both mortality at 30 days and respiratory failure D. adverse cardiovascular events E. respiratory failure |
E. respiratory failure
----------- |
|
|
RB52a ANZCA version [2002-Aug] Q80, [Mar06]
Twenty-four hours following a vaginal hysterectomy, a 48-year-old obese female complains of severe pain that radiates down both buttocks and thighs. She had received a spinal anaesthetic with hyperbaric lignocaine. The most likely explanation for these complaints is A. transient neurological symptoms syndrome B. lumbar disc herniation C. a spinal abscess D. trauma due to improper positioning E. a spinal haematoma |
A. transient neurological symptoms syndrome
----------- |
|
|
RB52b ANZCA version [2003-Apr] Q97 Note how this has been SLIGHTLY reworded!!
Twenty-four hours following a vaginal hysterectomy, a 48-year-old obese female complains of severe pain that radiates down both buttocks and thighs. She had received a spinal anaesthetic with hyperbaric lignocaine. A likely explanation for these complaints includes all of the following EXCEPT A. a spinal abscess B. a spinal haematoma C. lumbar disc herniation D. transient neurological symptoms syndrome E. trauma due to improper positioning |
A. a spinal abscess
generally takes more than 2-3 days for an abcess. also, lumbar disc herniation is described with bilateral pain. ~~ ----------- http://bja.oxfordjournals.org/cgi/content/full/96/3/292. Have found evidence saying that lumbar disc herniation can cause bilateral leg pain - "The pain associated with a lumbar disc herniation is characterized by a sharp, burning, or stabbing sensation, which radiates down one or both legs. The symptoms associated with a herniated disc are sometimes referred to and confused with the condition of sciatica." *** The following quotes from 'Transient Neurologic Symptoms After Spinal Anesthesia with Lidocaine Versus Other Local Anesthetics:A Systematic Review of Randomized, Controlled Trials' Dusanka Zaric, Christian Christiansen, Nathan L. Pace, and Yodying Punjasawadwong, Anesth Analg 2005;100:1811–6: * TNS incidence is low overall, but not in the subpopulation of lignocaine spinal: "Approximately one of seven patients who received spinal anesthesia with lidocaine developed TNS" * "Neurologic sequelae related to regional anesthesia are very rare. Possible causes are intrathecal hematoma due to the use of anticoagulants, including low-molecular-weight heparins; spinal cord ischemia; mechanical trauma; and neurotoxicity. The incidence of this serious complication varies, depending upon whether studies are retrospective or prospective, from 1:10,000 in the older literature to more recent reports in which the most frequent incidence is cited as approximately 1 in 3,000 spinal anesthesias." |
|
|
RB53a ANZCA version [2001-Apr] Q64, [2003-Aug] Q136, [2004-Apr] Q38
Post-dural puncture headache A. does NOT recur following discharge from hospital B. may be associated with hearing loss C. is more likely if a catheter has entered the subarachnoid space D. is reduced in incidence by prophylactic bed rest for 24 hours E. is worse if the patient is nursed in the prone position |
B. may be associated with hearing loss
A – may be problematic up to 6 months, case reports of headaches up to 8 years C – not true – less likely especially if the catheter is left in situ D – no proven benefit to bed rest E – prone is better, if anything, due to increased intraabdominal pressure ~~----------- http://bja.oupjournals.org/cgi/content/full/91/5/718 British Journal of Anaesthesia, 2003, Vol. 91, No. 5 718-729 Post-dural puncture headache: pathogenesis, prevention and treatment Duration The largest follow-up of post-dural puncture headache is still that of Vandam and Dripps in 1956.132 They reported that 72% of headaches resolved within 7 days, and 87% had resolved in 6 months (Table 3). The duration of the headache has remained unchanged since that reported in 1956.26 In a minority of patients the headache can persist.133 Indeed, case reports have described the persistence of headache for as long as 1–8 yr after dural puncture.80 It is interesting to note that even post-dural puncture headaches of this duration have been successfully treated with an epidural blood patch.72 Symptoms Headache is the predominant, but not ubiquitous presenting complaint.83 * The headache is described as severe, ‘searing and spreading like hot metal’.133 * The common distribution is over the frontal and occipital areas radiating to the neck and shoulders. The temporal, vertex and nuchal areas are reported less commonly as the site of discomfort, although neck stiffness may be present. * The pain is exacerbated by head movement, and adoption of the upright posture, and relieved by lying down. An increase in severity of the headache on standing is the sine qua non of post-dural puncture headache. * Other symptoms associated with dural puncture headache include nausea, vomiting, hearing loss,78 tinnitus, vertigo, dizziness and paraesthesia of the scalp, and upper108 and lower limb pain. * Visual disturbances such as diplopia or cortical blindness have been reported. * Cranial nerve palsies are not uncommon. * Two cases of thoracic back pain without headache have been described. * Neurological symptoms may precede the onset of grand mal seizures. Intracranial subdural haematomas, cerebral herniation and death,39 have been described as a consequence of dural puncture. Unless a headache with postural features is present, the diagnosis of post-dural puncture headache should be questioned, as other serious intracranial causes for headache must be excluded. * The prone position has been advocated, but it is not a comfortable position for the post-partum patient. The prone position raises the intra-abdominal pressure, which is transmitted to the epidural space and may alleviate the headache. A clinical trial of the prone position following dural puncture failed to demonstrate a reduction in post-dural puncture headache.55* The role of CSF in terms of its replacement capacity14 is extremely important (500 ml per 24 hr, or more) in providing the closing force on the valvular opening of tangential dural puncture. It is interesting to note that Brocker's observation of 195815 was rediscovered by others,16,17 and cited a decreased incidence of PDPH when the patient remained in a prone position for 2-4 hours after dural puncture. This phenomenon correlates with this author's study, i.e., that persistent CSF escape after a probable perpendicular puncture will stop and the forthcoming pressure equilibrium will constitute the most important prerequisite for "wound-healing". Actually, a dural defect closure is very similar to a vein or artery puncture where mild pressure of a split second or a couple of minutes, respectively, secures healing, in spite of the bevel piercing in the "wrong" position (Figure 5B). Enlarging the valvular opening by using a large needle will increase the CSF pressure on the valve surface and close the valve forcefully (Figure 5C). Of course, the larger needle will deviate less and allow greater control and more accurate placement of the puncture |
|
|
RB53b ANZCA version [2003-Apr] Q134
Post-dural puncture headache A. does NOT recur following discharge from hospital B. is NOT associated with hearing loss C. is mediated by the glossopharyngeal and vagus nerves D. is reduced in incidence by prophylactic bed rest for 24 hours E. is worse if the patient is nursed in the prone position |
C. is mediated by the glossopharyngeal and vagus nerves
* A False - onset can be minutes to 12 days - usually 12-24 hrs or when first ambulates * B false - CAN CERTAINLY be associated with hearing loss (VIII) or diplopia (VII) * C TRUE - Traction on pain-sensitive intracranial and meningeal structures, particularly cranial nerves V, VII, IX, and X, the upper three cervical nerves, and bridging veins is thought to cause headache and some of the associated symptoms. * D False - no evidence that bed rest helps other than symptomatic relief (although 90% improve spontaneously within 10 days) * E False - some people have suggested removing the needle prone would reduce incidence, but doesn't ~~ ----------- There are few experimental studies of the response of the dura to perforation.70 In 1923, it was noted that deliberate dural defects in the cranial dura of dogs took approximately one week to close. The closure was facilitated through fibroblastic proliferation from the cut edge of the dura. Work published in 195970 dismissed the notion that the fibroblastic proliferation arose from the cut edge of the dura. This study maintained that the dural repair was facilitated by fibroblastic proliferation from surrounding tissue and blood clot. The study also noted that dural repair was promoted by damage to the pia arachnoid, the underlying brain and the presence of blood clot. It is therefore possible that a spinal needle carefully placed in the subarachnoid space does not promote dural healing, as trauma to adjacent tissue is minimal. Indeed, the observation that blood promotes dural healing agrees with Gormley’s original observation that bloody taps were less likely to lead to a post-dural puncture headache as a consequence of a persistence CSF leak. VERY GOOD ARTICLE --> http://bja.oxfordjournals.org/cgi/content/full/91/5/718 |
|
|
RB54 ANZCA version [2002-Mar] Q134
When performing spinal anaesthesia in adults important considerations include that 1. although the cord commonly ends opposite the lower border of L1 or the L1-2 interspace, it may extend as low as L3 2. the cord reaches L2 more commonly in females than males 3. anaesthetists are more likely to err by performing their spinal at a higher level, as opposed to lower, than the level they assume they are entering 4. the level of the line joining the iliac crests is reliably at the lower border of L4 to the L4-5 interspace |
1. although the cord commonly ends opposite the lower border of L1 or the L1-2 interspace, it may extend as low as L3
?2. the cord reaches L2 more commonly in females than males 3. anaesthetists are more likely to err by performing their spinal at a higher level, as opposed to lower, than the level they assume they are entering "Cases of conus damage following spinal anaesthesia have been reported, as the conus medullaris does not always terminate at the lower border of L1. In 2–20% of individuals it ends at the lower border of L2, more commonly in women. Even senior anaesthetists may underestimate the interspace where injection occurs. Tuffier’s line may cross the midline at L3/L4 not L4/L5 and is not a reliable indicator. Therefore, before attempting spinal anaesthesia, it is prudent to choose the lowest possible interspace and avoid using the L2/L3 interspace (or higher)." Neurological Complications following regiional anaesthesia in obstetrics - CEACP ----------- |
|
|
RB55 ANZCA version [2002-Mar] Q140
Complications following an effective thoracic paravertebral block include 1. urinary retention. 2. pneumothorax. 3. profound hypotension 4. ipsilateral Horner's syndrome |
2. pneumothorax.
4. ipsilateral Horner's syndrome does "effective" mean "perfect"? proximity to dura mean it can track and become intrathecal, hence 1 & 3 as well - pjs ----------- |
|
|
RB56 [Jul05]
In patients who have sustained a dural puncture headache following a dural puncture during epidural catheter placement (18G or greater), the percentage of patients achieving persistent relief of headache with blood patching (performed after 24 hours) is A. less than 30% B. 30 - 45 % C. 45 - 60 % D. 60 - 75% E. more than 75% |
E. more than 75%
~~ ranges different in Apr 08 exam Acute pain management guidelines: Although common practice, further high quality trials are required to determine the efficacy of epidural blood patch administration in the treatment of PDPH (Sudlow & Warlow 2001b, Level I). However significant symptomatic relief was obtained in 75–95% of patients who received a 15mL blood patch (Safa-Tisseront et al 2001, Level IV; Wu et al 1994, Level IV; Abouleish et al 1975, Level IV).----------- (wiki) It may in fact be C. This is what Mike Paech reckons in his article CJA 2005 52:6 ppR1-R5, assuming we are talking from an Epidural PDPH and not a spinal. The figures usually quoted lump spinals & epidurals in together. If it was spinal then more than 75% is OK. Oh & by the way did you know Dr Paech is an examiner for the college? ===== The blood patch Using either radiolabelled red cells124 or an MRI scan,7 several studies have reported the degree of spread of the epidural blood patch. After injection, blood is distributed caudally and cephalad regardless of the direction of the bevel of the Tuohy needle. The blood also passes circumferentially around to the anterior epidural space. The thecal space is compressed and displaced by the blood. In addition, the blood passes out of the intervertebral foramina and into the paravertebral space. The mean spread of 14 ml of blood is six spinal segments cephalad and three segments caudad. Compression of the thecal space for the first 3 h, and a presumed elevation of subarachnoid pressure, may explain the rapid resolution of the headache. Compression of the thecal sac is not, however, sustained and maintenance of the therapeutic effect is likely to be attributable to the presence of the clot eliminating the CSF leak. It has been observed that CSF acts as a procoagulant, accelerating the clotting process.24 At 7–13 h, there is clot resolution leaving a thick layer of mature clot over the dorsal part of the thecal sac. Animal studies have demonstrated that 7 days after the administration of an epidural blood patch, there is widespread fibroblastic activity and collagen formation.34 74 Fortunately, the presence of blood does not initiate an inflammatory process and there is no evidence of axonal oedema, necrosis or demyelination. Outcome The technique has a success rate of 70–98% if carried out more than 24 h after the dural puncture.1 If an epidural blood patch fails to resolve the headache, repeating the blood patch has a similar success rate. Failure of the second patch and repeating the patch for a third or fourth time has been reported. However, in the presence of persistent severe headache, an alternative cause should be considered. |
|
|
RB56b [Apr08]
In patients who have sustained a dural puncture headache following a dural puncture during epidural catheter placement (18G or greater), the percentage of patients achieving persistent relief of headache with blood patching (performed after 24 hours) is A. less than 30% B. 30 - 45 % C. 45 - 60 % D. 60 - 80% E. more than 80% |
D. 60-80%
Note this question does not specify if this is for the obstetric population! - From Chestnut's Obstetric Anesthesia Ch 31: In early case series, the reported success rate of epidural blood patch therapy for PDPH was between 89% and 91%.[162,164] Subsequent studies have not confirmed this high rate of success. Taivainen et al.[165] studied 81 patients with PDPH after spinal needle puncture. Initially symptoms were relieved in 88% to 96% of patients; however, a permanent cure was achieved in only 61%. Safa-Tisseront et al.[166] reviewed the experience with blood patch therapy at their institution over a 12-year period (n = 504, including 78 obstetric patients). Complete relief of PDPH was obtained in 75%, partial relief occurred in 18%, and treatment failed in 7% of patients. The investigators noted a significantly higher failure rate of blood patch after large-gauge needle puncture of the dura. The difference in early reports and more modern audits of PDPH and epidural blood patch therapy success may be related to differences in the duration of follow-up, or perhaps to other differences in management after blood patch therapy, such as delayed mobilization. In studies limited to obstetric patients, the published success rates of the epidural blood patch have been even less encouraging. Stride and Cooper[62] noted complete and permanent relief of PDPH in 64% of patients after one blood patch procedure. Williams et al.[94] reported that only 33% of their patients obtained complete and permanent relief from the first blood patch. Banks et al.[167] prospectively monitored 100 patients with unintentional dural puncture. Fifty-eight patients received a therapeutic blood patch; the treatment completely failed in 3 patients, and 17 patients had recurrence of moderate or severe headache requiring further therapy. These observational studies also describe the use of repeated epidural blood patch procedures for parturients with a recurrence of PDPH. ----------- |
|
|
RB57 [Mar06]
Epidural blood patch for severe post-dural puncture headache A. is contraindicated in patients with Acquired Immunodeficiency Syndrome (AIDS) B. has NOT been shown to be associated with a higher success rate if performed more than 24 hours after dural puncture C. is associated with a higher success rate if more than 20 ml of blood is used D. is rarely associated with back pain during injection E. is most effective when given immediately following accidental dural puncture |
C. is associated with a higher success rate if more than 20 ml of blood is used
- A. is contraindicated in patients with AIDS - this is FALSE. It has been demonstrated that there is early CNS penetration of the HIV virus, and that there is no "seeding" of the CNS by the act of patching. It states that it's only contraindicated if there are other active bacterial or viral illnesses. B. has NOT been shown to be associated with a higher success rate if performed more than 24 hours after dural puncture headache - this is FALSE. There is a higher success rate; it is hypothesised that local anaesthetic has a very small antiplatelet action and may inhibit clot formation over the dural hole). C. is associated with a higher success rate if more than 20ml of blood is used - possibly true by elimination? perhaps they mean that if you didn't get back pain and you stopped at less than 20mL you're less likely to be successful as if you had pain after <20mL the rate of success is no less. D. is rarely associated with backpain during injection - this must be FALSE as the end point of injection prior to getting to 30mL is back and radicular pain. E. is most effective when given immediately following accidental dural puncture - False - see answer B ----------- Contraindications Contraindications include those that normally apply to epidurals, but include a raised white cell count, pyrexia and technical difficulties. Limited experience with HIV+ patients suggest that it is acceptable providing no other bacterial or viral illnesses are active. Epidural blood patch following diagnostic lumbar puncture in the oncology patient raises the potential for seeding the neuroaxis with neoplastic cells. One case has been reported of a successful patch without complications, and one case11 where the risks of central nervous system (CNS) seeding of leukaemia were considered to outweigh the benefits of an epidural blood patch. |
|
|
RB58 [Jul06][Aug10]
Which ONE of the following is NOT a feature of high spinal? A. tachycardia B. dyspnoea C. weak hand grip strength D. difficulty with phonation E. ?hypotension |
A. tachycardia
• The first signs of high spinal block are hypotension, bradycardia and difficulty in breathing. Before hypotension is detected, the patient often complains of nausea or “not feeling well”. Tingling in the fingers indicates a high block at the level of T1 (occasionally anxious patients who are hyperventilating may complain of this). • Hypotension is due to venous and arterial vasodilation resulting in a reduced venous return, cardiac output and systemic vascular resistance. It should be treated with volume infusion and vasopressors. The head-down (Trendelenburg) position should be used with caution because it may raise further the level of blockade. A better alternative is to raise the legs. • Bradycardia is caused by several factors. Extensive spread results in a widespread sympathetic block leading to unopposed vagal tone and blockade of the cardio-accelerator fibres arising from T1-T4. Heart rate may also decrease as a result of a fall in right atrial filling. Bradycardia can be treated with anticholinergic agents, like atropine, or ß-adrenergic agonists, like ephedrine. • Cardiac output is the product of heart rate and stroke volume. As we have seen, heart rate and stroke volume decrease. The most important reason for the decrease in stroke volume is the decreased volume of blood in the ventricle at the end of diastole (end-diastolic volume), often called “preload”. This is due to a reduction in venous return because of marked venous dilatation following spinal anaesthesia and compression of the vena cava by the pregnant uterus. Venous return is reduced further, if the patient is ventilated, due to the increase in intra-thoracic pressure during the inspiratory phase. Any bleeding which reduces blood volume is poorly tolerated, (see Cardiovascular Physiology and also the Pharmacology of Inotropes and Vasopressors in Update in Anaesthesia No 10). • Respiratory difficulty is caused by loss of chest wall sensation caused by paralysis of the intercostal muscles. Patients often describe their breathing as feeling abnormal, but can demonstrate a good inspiration and can cough and speak normally. When a total spinal occurs the nerve supply to the diaphragm (cervical roots 3-5) is blocked and respiratory failure develops rapidly. Early warning signs include poor respiratory effort, whispering and an inability to cough. Sudden respiratory arrest is usually caused by hypoperfusion of the respiratory centres in the brainstem. • Cardiac arrest may occur due to hypotension and hypoxaemia. Prevent this by adequate ventilation and use of vasopressors. • Other symptoms of total spinal are upper extremity weakness, loss of consciousness and pupillary dilatation. • Pregnant patients in this situation are at risk of aspiration and severe reductions in placental blood flow. ----------- |
|
|
RB59 [Jul06]
At what sensory level do you know a high epidural has blocked all cardiac accelerator fibres? A. Little finger B. Apex of axilla C. Xiphoid process D. Medial upper arm E. Nipple line |
A. Little finger
little finger = C8 cardiac accelerator fibres T1-4 apparently sympathetic block can be 1-2 levels higher, so maybe B, but A you would KNOW FOR SURE - pjs ----------- |
|
|
RB60 ANZCA Version [Jul07] Q146
An 85-year-old woman requires an emergency repair of an obstructed inguinal hernia. She has recently suffered a pulmonary embolus and is taking warfarin. You elect to perform an inguinal field block. Which of the following nerves does NOT need to be blocked? A. iliohypogastric B. ilioinguinal C. ilioinguinal of the contralateral side D. femoral E. subcostal |
D. Femoral
Block of month: Inguinal Hernia Surgery (http://www.anaesthesia-az.com/sites/156/imagebank/typeArticleparam509662/9539.pdf) This article implies the following nerves need to be blocked: * Ilioinguinal nerve * Iliohypogastric nerve * Genitofemoral nerve * Subcostal & thoracic nerves --- i can't see this in the article - pjs **** Need to block innervation from the contralateral side -- nor this... So maybe, it's all-EXCEPT question, in which case D is answer. ----------- |
|
|
RB61 [Jul07]
Block Height required for orchidectomy: A. xiphisternum B. nipple C. umbilicus D. midway between pubis and umbilicus E. pubis |
C. umbilicus
T10 Those boys migrate down (to be covered by scrotum which is S2 dermatome) ----------- |
|
|
RB62 ANZCA Version [Jul06] [Aug10]
Recommendations for the inital management of post dural puncture headache include A. ensuring adequate analgesia B. intravenous caffeine infusion C. oral sumatriptan D. prolonged bed rest E. prophylactic blood patching |
A. ensuring adequate analgesia - true
- Summary of recommendations in Section 9.6.5 Acute Pain Management: Scientific Evidence (2005) and Update (2007) Incidence of headache following dural puncture 0.4-24% postural in nature commoner in patients under 50 yrs commoner in parturients significanntly less common in males than non-pregnant females (level 1 evidence - 2007 update) 90% resolve spontaneously within 10 days Incidence may be reduced by using: (level I) 26 gauge or smaller needle (NNT=13) use of needle with a non-cutting bevel (NNT=27) orienting the cutting bevel parallel to the spinal saggital plane (dural fibres)(2010 update) No evidence that bed rest is beneficial in preventing PDPH (Level I) PDPH may causes difficulty mobilising, and headache may then subside with bed rest Non-opioid and opioid analgesics may provide temoporary relief Preventive role of fluid therapy unclear (Level I) No evidence to support the use of: Sumatriptan (Level II) ACTH Epidurally administered saline, dextran, fibrin glue or neuraxial opioids IV and oral caffeine (both level II) are: effective in treating PDPH do not reduce blood patch rate Epidural blood patches: are common practice but further high quality trials are required to determine efficacy (level I) significant symptomatic relief obtained in 75-95% of patients given a 15 mL blood patch (level IV, three studies) (2010 update) significantly reduced the intensity of the pdph at 24 hours (level II) and also reduced the incidence and severity of the headache at 1 week (level II) conflicting evidence regarding use of prophylactic blood patches - one trial showed decreased incidence of PDPH (level III) Autologous epidural blood patches may be contra-indicated in: leukaemia coagulopathy infection, including HIV ----------- |
|
|
RB63 [Aug08][Aug10]
When hearing loss occurs following spinal anaesthesia it is usually in which of the following frequency ranges: A. 125 - 1000 Hz B. 1500 - 3000 Hz C. 3500 - 5500 Hz D. 6000 - 10000Hz E. > 11000Hz |
A. 125 - 1000 Hz
- See wiki for references. Basically low frequency sensorineural hearing loss occurs. ----------- |
|
|
RB64b ANZCA version [Apr08 Q121][Oct08]
Regarding thoracic epidural analgesia for acute post-operative pain: A. it has NO role in improving preservation of total body protein after upper abdominal surgery B. opioids alone via the thoracic epidural provide significantly better analgesia than systemic opioids alone C. there is NO effect on the incidence of postoperative myocardial infarction D. the addition of adrenalin (epinephrine) to a local anaesthetic mixture has NO measurable benefit E. using local anaesthetics improves bowel recovery after abdominal surgery |
E. using local anaesthetics improves bowel recovery after abdominal surgery
Medscape http://www.medscape.com/viewarticle/464150_5 In summary, the data demonstrated that intraoperative TEA and postoperative thoracic epidural analgesia with regimens containing local anesthetics results in more rapid recovery of bowel function. It is emphasized that there are several prerequisites for achieving this result. First, the epidural must be placed and activated prior to the surgical stress and nociceptive afferent stimulation. Second, the epidural catheter should include the T5-L2 dermatomes, and the solution administered into the catheter should include local anesthetics to affect a sympathetic blockade of the gut. Third, the epidural local anesthetics need to be administered postoperatively until bowel function returns (usually 2-3 days) to achieve the full benefits of the technique. In summary, 4 large studies involving high-risk (eg, aortic reconstruction) surgery patients have reported significant reductions in cardiac morbidity associated with use of intraoperative and postoperative epidural anesthesia/analgesia using local anesthetics plus opioids. In addition, intraoperative epidural administration of local anesthetics blunts the physiologic hypercoagulable surgical stress response and modifies the perioperative hypercoagulable state. This occurs via several mechanisms, such as blockade of sympathetic efferent signals, enhanced fibrinolytic activity, and systemic absorption of local anesthetics. The clinical relevance of these phenomena are confirmed by convincing data that intraoperative epidural anesthesia improves graft patency in lower extremity vascular reconstruction patients. ------------------------------ Epidural analgesia reduces postoperative myocardial infarction: a meta-analysis. Anesth Analg. 2001 Oct;93(4):853-8.Click here to read Postoperative epidural analgesia, especially thoracic epidural analgesia, continued for more than 24 h reduces postoperative myocardial infarctions. -- From wiki: A - Has a role together with NSAIDs and IV nutritional support (so false) B - Seems to be false; epidural better than PCA except when epidural using hydrophilic opioids only C - Possibly a decreased incidence (paper referenced in APM) D - Improved block (p134) E - true - reduced duration of ileus after colorectal surgery. ----------- |
|
|
RB65 [Mar11]
Coeliac plexus block. What is the complication? A: Erectile dysfunction B: Constipation C: Hypertension which resolves spontaneously D: Paralysis E: |
D
due to possibly injection into spinal arteries- Adamkiewitz ----------- |
|
|
RH26a ANZCA version [2003-Apr] Q131, [2003-Aug] Q26
The LEAST likely complication of a peribulbar regional block for cataract surgery is A. bradycardia B. damage to the optic nerve C. globe perforation D. ocular muscle palsy E. peribulbar haemorrhage |
B. damage to the optic nerve
?? D. ocular muscle palsy ----------- |
|
|
RH26b ANZCA version [2004-Apr] Q126, [Jul07][Apr08][Sep11]
To achieve maximum anaesthesia with minimal risk of trauma to veins, the tip of a needle used for a medial peribulbar injection should be advanced no further past the equator of the globe than A. 5 mm B. 10 mm C. 15 mm D. 20 mm E. 25 mm |
B. 10 mm
----------- |
|
|
RH33 [Apr08][Mar11]
Globe perforation with eye blocks is most likely with: A. Axial length <25mm B. Medial canthus peribulbar injection C. Inferotemperal peribulbar injection D. Age < 40 years E. Sub-Tenons |
B. Medial canthus peribulbar injection
- A. false - globe perforation is more likely in patients with elongated myopic eyes (>27mm axial length) C. The classical first insertion point ----------- |
|
|
RH35 [Mar10][Sep11][Mar12]
Most safe side to insert subtenon block or Best approach to STB (nb previous versions had WORST side) A. Inferonasal B. Inferotemporal C. Medial D. Superonasal E. Superotemporal |
A. Inferonasal
----------- |
|
|
RL11 [Apr07]
A patient requires forefoot amputation. You wish to block the most peripheral nerves to give complete anaesthesia for the procedure. Best nerves to be blocked include A. Medial and lateral plantar B. common peroneal and tibial C. sciatic and saphenous D. sural and sciatic E. deep peroneal and superficial peroneal |
C. sciatic and saphenous
You need deep peroneal (web space), superficial peroneal (dorsum foot), sural (lateral foot - tibial n), med & lat plantars (sole of foot - tibial) _____________ Sciatic -> Tibial -> Sural -> Medial & Lateral Plantar -> Common Peroneal -> Deep Peroneal -> Superficial Peroneal Femoral -> Saphenous ----------- A. Medial and lateral plantar - only gets the sole of the foot B. common peroneal and tibial - YES but you still need Sural (from saphenous from femoral) C. sciatic and saphenous - TRUE D. sural and sciatic - WRONG - sciatic gets tibial which gets sural E. deep peroneal and superficial peroneal - only gets dorsum and web space ----------- |
|
|
RN11b ANZCA version [Mar00] [2001-Apr] Q117, [2001-Aug] Q120
Following successful superficial and deep cervical plexus blockade (i.e. complete blockade of C2, C3 and C4) for carotid endarterectomy under local analgesia, supplementary local anaesthetic may still be required for 1. pain at the upper pole of the incision 2. pain on entering the carotid sheath 3. pain at the lower pole of the incision 4. bradycardia |
all of the above
* A - TRUE - Mandibular branch CN V * B - TRUE - Blocks CN IX & X - glossopharyngeal & vagus * C - TRUE - 2nd thoracic nerve fibres cover (recall C5-T1 brachial plexus hence covers the arm, therefore next dermatome down from C4 is T2 * D - TRUE - LA to Carotid Sinus branch of CN IX blocks Baroreceptor response ----------- DEEP CERVICAL PLEXUS BLOCK: Aiming to block nerve roots of C2-4 as they emerge from the foramina in the cervical bertebrae. Position the head to the side. Draw a line from the mastoid process to Chassaignac’s tubercle of C6, which is palpated lateral to the sternomastoid at the level of the cricoid cartilage. C4 is at the lower border of the mandible. C2 and C3 are located by dividing the distance from C4 to the mastoid into thirds. Needles are directed slightly medial and slightly caudad to contact the gutter of the cervical vertebra The caudad direction is to avoid inadvertently entering the intervertebral foramen and producing a spinal or epidural block The endpoint is the bony landmark of the transverse process, and parethesias are obtained. Injection of 3-4 ml are generally adequate for anesthesia. |
|
|
RN12 ANZCA version [Apr97] [2002-Mar] Q85
The stellate ganglion A. is the middle cervical ganglion B. is blocked 1 cm lateral to the cricoid process C. is blocked on the right side to treat intractable angina D. may be blocked unilaterally to treat sudden deafness E. when blocked, results in exophthalmos |
D. may be blocked unilaterally to treat sudden deafness
* A - FALSE - its the fusion of INFERIOR Cx ganglion & 1st THORACIC ganglion * B - FALSE - 2cm lateral to midline at this level - well of the cricoid - what is the cricoid PROCESS??? * C - FALSE - Some success with LEFT Stellate ganglion blocks * D - TRUE - "for idiopathic sudden deafness" * E - FALSE - Enophthalmos (i.e. Horner's) McClure295 – Stellate ganglion block for Bell’s palsy, quinine toxicity, retinal artery occlusion, and certain types of acute hearing loss ~~ ----------- Arch Otolaryngol. 1976 Jan;102(1):5-8. Fifty-six patients, treated with a series of anesthetizing blocks of the stellate ganglion for idiopathic sudden sensorineural loss, were compared with 20 patients of similar diagnosis who were treated by other means as to amount of pure-tone gain, speech discrimination improvement, nature of symptoms, and delay in start of surgery. Seventy percent of the stellate-ganglion-block-treated patients achieved substantial hearing improvement. |
|
|
RN15 ANZCA version [Jul00] [2003-Apr] Q81, [2003-Aug] Q90 [Mar06]
Following superficial and deep cervical plexus blockade for carotid endarterectomy, the incidence of ipsilateral phrenic nerve block is A. less than 10% B. 20-30% C. 50-60% D. 80-90% E. nearly 100% |
C. 50-60%
This article says 55% incidence with deep Cx plexus block. 100% is for interscalene. http://www.anesthesia-analgesia.org/cgi/content/full/95/3/746 ----------- |
|
|
RN16 ANZCA version [2002-Mar] Q87
Complications of attempted cervical plexus block include all of the following EXCEPT A. ipsilateral diaphragmatic paralysis B. total spinal anaesthesia C. Horner's syndrome D. vocal cord paralysis E. pneumothorax |
E. pneumothorax
You'd have to be way off track to do that. Vocal cord paralysis may occur from LA tracking down to recurrent laryngeal nerve. ----------- |
|
|
RN17 ANZCA version [2003-Apr] Q53, [2003-Aug] Q27, [2004-Apr] [Oct08]
A sympathetic block could be effective in treating all of the following conditions EXCEPT A. chronic tinnitus B. quinine poisoning C. post-cardiac-surgery pain syndrome D. phantom limb pain E. compartment syndrome |
E. compartment syndrome - that would be silly.
==== B. Is used for acute quinine toxicity causing blindness - vascular spasm of the retinal artery is the mechanism of blindness http://bja.oxfordjournals.org/cgi/reprint/35/11/728.pdf ~~ ----------- Stellate Ganglion Block (cervicothoracic sympathetic block) Indications Pain Syndromes Complex Regional Pain Syndrome Type I and II Refractory Angina Phantom Limb Pain Vascular Insufficiency Raynaud's Syndrome Scleroderma Frostbite Obliterative vascular disease vasospasm trauma emboli S/P vascular reconstruction, limb reimplatation Edema local edema s/p surgery |
|
|
RN18 [May09][Aug10][Sep11][Mar12]
Stellate ganglion block is associated with all EXCEPT: A. Ptosis B. Miosis C. Sweating D. Facial flushing E. Nasal stuffiness |
C. Sweating
-- Stellate ganglion block produces horner's syndrome (sympathetic block). Anhydrosis is the result as sweating is sympathetically mediated. ----------- |
|
|
RU12 ANZCA version [1986] [Aug93] [Mar94] [Apr96] [2002-Aug][2003-Apr][2005-Apr][Jul05][Mar12][Aug12]
If a patient experiences parasthesia in the little finger during supraclavicular brachial plexus block, the needle is in proximity to the A. posterior cord B. middle trunk C. ulnar nerve D. lower trunk E. medial cord |
D. lower trunk
*Anatomy of this area is such that you block trunks at a supraclavicular level C. Ulnar nerve – same effect, but doesn’t form until well below the clavicle (see EF157) E. Medial cord – formed at the apex of the axilla, well below the clavicle ~~ ----------- * Anatomy of this area is such that you block trunks at a supraclavicular level. * NYSORA site says that supraclavicular targets the trunks. Divisions are behind the clavicle and cords are infraclavicular. OHA (1st Ed) p 1014 implies supraclavicular is at the root/trunk level.--Phil 03:40, 25 Jul 2007 (EDT) http://www.backpain-guide.com/Chapter_Fig_folders/Ch05_Anatomy_Folder/Ch5_Images/05-9_Brachial_Plexus.jpg |
|
|
RU18 [Jul06]
Which of the following manoeuvres/strategies reduce the incidence of pneumothorax in when performing a subclavian axillary block? A. not having air in the needle/syringe? B. putting the patient head down C. asking the patient to take a deep breath as you advance the needle D. using a short fine gauge needle E. CXR after procedure |
D. using a short fine gauge needle
----------- |
|
|
RU19 [Mar10] [Aug10]
The intercostobrachial nerve: A. Arises from T2 trunk B. Is usually blocked in brachial plexus block C. Supplies antecubital fossa D. can be damaged by torniquet E. Arises from inferior trunk |
D. can be damaged by torniquet
or ?A... - A - ?False. Arises from lat. cut. branch of 2nd intercostal nerve (from T2 originally, but not directly from the trunk) Though depends on how it is worded. There is no such thing as 'trunk'. T2 root is true. B - False. It joins the medial cutaneous nerve of the arm which comes from the medial cord, but does not form part of the brachial plexus, and is not blocked in brachial plexus blocks. C - False. Supplies medial side of upper arm, and joins medial cutaneous nerve of arm which supplies medial side of upper arm down to the elbow. D - TRUE. Any nerve compressed by a tourniquet can be damaged. Would have to be high up the arm/close to axilla to compress it. But cannot find anything on pubmed search. It IS typically damaged in breast surgery (Mastectomy, axillary clearance) E - False. Not part of brachial plexus, or a branch from it. Arises from lat. cut. branch of 2nd intercostal nerve. ----------- |
|
|
TMP-102 [Mar10][Aug10][Sep11]
Interscalene block, patient hiccups...where do you redirect your needle? A. Anterior B. Posterior C. Caudal D. Cranial E. Superficial |
B. Posterior
(see Oxford handbook of Anaesthesia, 2nd Edn, p. 1077). Phrenic nerve stimulation occurs if you are too anterior. ----------- |
|
|
TMP-144 [Apr08] Q127
You are performing epidural anaesthesia on an adult patient. To minimize the chance of inserting the epidural catheter into a blood catheter into a blood vessel you could: A. avoid using a combined spinal-epidural technique B. establish loss-of-resistance with saline rather than air C. inject saline prior to threading the catheter D. perform the procedure in the sitting rather than the lateral position E. use a midline rather than a paraspinous (paramedian) approach |
C. inject saline prior to threading the catheter
- C - True - injecting fluid through the epidural needle before catheter insertion decreases risk (OR 0.49) D - Sitting increases the risk of epidural vein cannulation vs lateral position (OR 0.53) References [Anesth Analg 2009;108:1232–42] ----------- |
|
|
TMP-Jul10-012
How do you minimise risk of intravenous cannulation with epidural insertion ? A. Injection saline through epidural needle before catheter insertion B. Lie patient lateral C. Do CSE D. Thread catheter slowly E. |
A. Injection saline through epidural needle before catheter insertion
- From wiki: A Systematic Review of Randomized Controlled Trials That Evaluate Strategies to Avoid Epidural Vein Cannulation During Obstetric Epidural Catheter Placement. Anesth Analg 2009;108:1232–42. RESULTS: Of 90 trials screened, 30 trials were included (n = 12,738 subjects). Five strategies reduce the risk of epidural vein cannulation: the lateral as opposed to sitting position (six trials, mean (sd) quality score = 35% [11%], odds ratio (OR) 0.53 [95% confidence interval (CI) 0.32–0.86]), fluid administered through the epidural needle before catheter insertion (8 trials, quality score 48% [18%], OR 0.49 [95% CI 0.25–0.97]), single rather than multiorifice catheter (5 trials, quality score 30% [6%], OR 0.64 [95% CI 0.45–0.91]), a wire-embedded polyurethane compared with polyamide epidural catheter (1 trial, 31%, plus 4 unscored abstracts, OR 0.14 [95% CI 0.06–0.30]) and catheter insertion depth <=6 cm (2 trials, 47% [11%], OR 0.27 [95% CI 0.10–0.74]). The paramedian as opposed to midline needle approach and smaller epidural needle or catheter gauges do not reduce the risk of epidural vein cannulation. ----------- |
|
|
TMP-Jul10-013
Timing of peak respiratory depression post intrathecal 300 mcg morphine: A. < 3.5 hours (think it was one hour) B. 3.5 – 7.5 hours (then three hours) C. 7 - 12.5 hours (then 7.5 - 12.5 hrs) D. 12.5 -18 hours E. > 18 hours |
B. 3.5 – 7.5 hours (then three hours)
- ANZCA Acute Pain: Scientific Evidence 3rd ed p195: "Respiratory depression occurs in up to 1.2% to 7.6% of patients (Meylan et al, 2009 Level I) given intrathecal morphine. When measured in opioid-naive volunteers, respiratory depression peaked at 3.5 to 7.5 hours following intrathecal morphine at 200 to 600 mcg doses (Bailey et al, 1993 Level IV). Volunteers given 600 mcg had significant depression of the ventilatory response to carbon dioxide up to 19.5 hours later. ----------- |
|
|
TMP-Jul10-019
Stellate ganglion block. Needle entry next to SCM muscle at C6. Which direction to advance needle ? A. C3 B. C4 C. C5 D. C6 E. C7 |
D. C6
-- From FRCA site: The stellate ganglion is formed by the fusion of the inferior cervical and the first thoracic ganglion as they meet anterior to the vertebral body of C7. It is present in 80% of subjects and usually lies on or above the neck of the first rib. Chassaignac's tubercle is the anterior tubercle of the TP of C6, which lies lateral to and slightly higher level than the posterior tubercle and against which the carotid artery may be compressed by the finger. Technique Pt is supine with neck slightly extended and facing away from the block with jaw open. Point of needle puncture is between trachea and carotid sheath at the level of the cricoid cartilage and chassaignac's tubercle. Although the ganglion lies at C7 vertebral body, the needle is inserted at C6 TO AVOID PIERCING PLEURA. Inject LA to skin. SCM and carotid artery are retracted laterally as index and middle fingers palpate chassaignac's tubercle. The skin and subcut tissue are pressed firmly on to the tubercle to reduce distance between skin and bone and in an attempt to push dome of lung out of needle path. When done properly, this is uncomfortable for the pt. Needle is directed onto the tubercle then redirected medially and inferiorly toward C6 body. After the body is contacted, the needle is withdrawn 1-2 mm. This brings the needle out of the belly of the longus colli muscle, which sits posterior to the ganglion and runs along the anterolateral surface of the cervical vertebral bodies. The needle is then held immobile. Needle position is confirmed by fluoroscopy. Spread of radiocontrast is confirmed by both anteroposterior and lateral views. Failure of the solution to spread cephalad and caudad between tissue planes suggests intramuscular injection into the longus colli muscle. Immediate dissipation of the solution indicates intravascular placement of the needle orifice. ----------- |
|
|
TMP-Jul10-024
[Mar11] A 78 year old man with past difficult intubation for arm surgery. Supraclavicular block with 25 mls 0.5% bupivacaine. Shortly after begins convulsing. INITIAL management? A. Midazolam 5mg B. Intralipid 20% 1.5 ml/kg C. Thiopentone 150mg D. Suxamethonium 50mg E. Propofol 50mg |
A. Midazolam 5mg
- From Practice Advisory on Treatment of Local Anesthetic Systemic Toxicity: - Initial Focus -- Airway: Ventilate with 100% oxygen -- Seizure suppression: benzodiazepines are preferred -- Basic and Advanced Cardiac Life Support: May require prolonged effort - Infuse intralipid ----------- |
|
|
TMP-Jul10-027
Post accidental dural puncture with epidural needle. Which does not fit? A. Epidural blood patch 30-50% effective B. Unlikely to be related to epidural if purely occipital headache C. caffeine mildly effective in reducing headache D. subdural haematoma can rarely occur with PDPH E. ?Something about photophobia?? |
A. Epidural blood patch 30-50% effective - false so answer to choose
blood patch effective in 80% at 24 hrs - see my comment on wiki. ----------- |
|
|
TMP-Jul10-033
[Mar11][Sep11] Subtenon’s block. What is the worst position to insert block? A. Inferonasal B. Inferotemporal C. Superonasal D. Supertemporal E. Medial / canthal |
E or C?
no consensus as articles have described this block being performed in all 4 quadrants. Though it is ideal to avoid insertion of rectus muscle (i.e. E as the answer) - medial approach has been described as safe in the literature. I think I would lean towards E. -- ----------- |
|
|
TMP-Jul10-052
[Sep11][?Aug12] Nerve block for anaesthesia over anterior 2/3 of ear? A. C2 B. Mandibular nerve C. Maxillary nerve D. Ophthalmic nerve E. Vagus |
B. Mandibular nerve [?Auriculotemporal nerve in Aug12 stem]
Mandibular n. is largest division of the trigeminal n. with sensory roots from the trigeminal ganglium and motor roots from the pons and medulla. Sensory nerves from posterior division include - AURICULOTEMPORAL n. which is sensory to EXTERNAL AUDITORY MEATUS and external surface of the tympanic membrane. - Lingual n. - provides sensation to ant 2/3 of tongue, floor of the mouth and lingual gingiva ----------- |
|
|
TMP-Mar11-015
New? What is NOT true for PDPH following puncture A: Prophylactic bed rest B: Catheter in intrathecally C: D: E: |
A: Prophylactic bed rest
----------- |
|
|
TMP-Mar11-026
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 |
B: Dorsal scapular nerve
?needle is too posterior? - A: LTN supplies serratus anterior muscle which pulls the scapula forward around the thorax B: Dorsal scapular nerve supplies rhomboids which pulls scapula medially C: Suprascapular n. supplies supraspinatous and infraspinatous muscles which abduct and laterally rotate the arm. D. Supraclavicular n. - has three branches - medial, intermedial and lateral E. Accessory nerve - CNXI supplies trapezius and sternocleidomastoid muscles. ----------- |
|
|
TMP-Mar11-027
[Mar12][Aug12] Popliteal block placed from the lateral approach: A: Passes through semimembranosus B: Has eversion of the foot as the end point for nerve stimulation C: Has increased failure rate compared to a posterior approach D: Adequate for ankle surgery (Aug12) E: Can be performed supine or prone |
E: Can be performed supine or prone
-- A: false - semimembranous is medial (see nysora website on popliteal block) B: false - common peroneal nerve stimulation results in dorsiflexion and eversion. stimulation of the tibial nerve results in plantar flexion and inversion; From Reg Anesth Pain Med 2010;35: S16-S25: "dorsiflexion or eversion indicating common perineal nerve stimulation, plantar flexion indicating TN stimulation, and INVERSION indicating simultaneous stimulation of both branches). It has been demonstrated that inversion may be the optimal single evoked motor response to maximise the onset and success of sciatic nerve block" C: false i think - it would depend if using nerve stimulator or US. D: false - ?need to block saphenous n. as well especially if tourniquet is used (see frca.co.uk) E: can be performed supine or prone - definitely true. (especially with US, prone with nerve stimulator so can see twitches better) ----------- |
|
|
TMP-Mar11-029
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 |
D: knee flexion
- From NYSORA on Lumbar Plexus Block Hamstring muscle twitches causes knee flexion which is the result of stimulation of the roots of the sciatic plexus. .. As the needle is advanced, local twitches of the paravertebral muscles are obtained first at a depth of a few cm. The needle is then advanced further until twitches of the quadriceps muscle are obtained (usually at 6-8 cm). After twitches are obtained, the current should be lowered to obtain stimulation between 0.5-1.0mA. Inject local slowly. ----------- |
|
|
TMP-Mar12-022
[Aug12] An epidural in a healthy individual causes all EXCEPT a. Raised Co2 b. Bradycardia c. Vasodilation d. Dyspnea e. reduced circulating catecholamines [in Aug12] |
a. Raised Co2 - ?false and answer to choose
-- a. From Textbook of regional anaesthesia and acute pain management Ch 14 - epidural blockage - see Table 14-5. Significant REDUCTION in PaCO2 AFTER thoracic epidural. b. and c. - From above reference: Block below T4 - vasomotor tone is maintained by sympathetic fivers from T5-L1 that innervate vascular smooth muscle. Blockade of these fibers causes venodilation and arterial vasodilation with decreased SVR. This leads to reduced venous return, RAP and subsequently reduced CO. However upper body vasoconstriction with baroreceptor activation can lead to increased vagal tone, causing bradycardia DESPITE the decrease in venous return. (Bezold-Jarisch) Block above T4: high sympathetic block, cardiac symp fibers arise from T1-T4 so when blocked, profound hypotension and bradycardia can occur. ----------- |
|
|
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. ----------- |
|
|
TMP-Mar12-046
Stellate ganglion blockade causes a. Conjunctival injection b. Dry eyes c. Decreased axillary sweating |
a. Conjunctival injection
-- From 'Pain-Relieving Procedures: The Illustrated Guide' by P. Prithvi Raj, Serdar Erdine. - Horner's syndrome: myosis, ptosis, enophthalmos (sinking of the eyeball) is in a way a documentation of the stellate ganglion block. Associated findings include CONJUNCTIVAL INJECTION, facial anhidrosis, and nasal congestion. b. ? c. false. Stellate ganglion is too high. Sympathetic block can be used to treat excessive axillary sweating - however a 'complication' of this is inadvertant stellate ganglion block which may result in a hornet's syndrome. ----------- |
|
|
TMP-Oct09-027
As per ANZCA Acute Pain Guidelines (2nd ed update), after a prophylactic subcutaneous dose of heparin, minimum time before you can remove epidural catheter is a. 2 hours b. 4 hours c. 6 hours d. 8 hours e. 10 hours |
c. 6 hours
- Unchanged in 3rd edition. See p198 Chapter 7 Section 4. ----------- |
|
|
TMP-Sep11-035
Post epidural and LSCS, the next day patient have persistent paraesthesia anterior thigh. What other injuries would indicate more of nerve roots instead of peripheral nerve injuries A. Weakness on hip flexion and thigh adduction B. Weakness on knee flexion and plantar flexion C. Urinary incontinence D. Foot drop |
A. Weakness on hip flexion and thigh adduction
Paraesthesia anterior thigh is supplied by L3 nerve. L2/3 - hip flexion. L3 - hip adduction. ----------- |
|
|
TMP-Sep11-069
NEW Interscalene block after injection of 2ml bupivacaine- patient seizure. Most likely injected to A. Dural cuff B. Vertebral arteries C. Internal carotid arteries D. Jugular veins E. Subarachnoid (?) |
B. Vertebral arteries
-- various online resources have stated vertebral artery (rather than ICA) ----------- |
|
|
TMP-Sep11-075
Compared to retrobulbar block, peribulbar block is associated with A. More bleeding B. More risk to optic nerve C. More akinetic eye D. Less block to orbicularis oculi |
none of above, maybe more block to OO
-- Orbicularis oculi is supplied by CNVII - Miller describes performing a separate block in order to prevent patient closing eye and straining (increasing ocular pressure). From "Regional Anaesthesia and Eye Surgery" Anaesthesiology 113(5)1236-42 regarding peribulbar anaesthesia "as much as 12 mL LA is injected and spreads into the entire corpus adpisum of the orbit, including the intraconal space. In addition, this large volume allows anterior spread to the eyelids, providing a block of the orbicular is muscle of the eyelids". Can also get block of Orbicularis with STB (described in same article). ----------- |
|
|
RB42c ANZCA version [2004-Aug] Q150, [2005-Apr] Q78 [Oct08]
Transient neurological symptoms (TNS) syndrome is characterised by pain and/or dysaesthesia in the buttocks or lower extremities following spinal anaesthesia. Clinical features of this syndrome include A. a reduction in symptoms with lower doses of lignocaine B. a significantly decreased risk with 2% lignocaine compared to 5% lignocaine C. increased risk with early ambulation D. increased risk with prone positioning E. similar incidence with lignocaine and bupivacaine |
C. increased risk with early ambulation
TNS is a rare (0.01% - 0.7% incidence) syndrome characterised by aching/burning pain in back, lower buttocks and thighs which may radiate into lower legs. It is usually bilateral, usually occurs within 12-36hrs post spinal/epidural and is more common with lidocaine, lithotomy position, obesity and knee arthroscopy. It can occur with all local anaesthetics but is more common with lidocaine where concentration does not make a difference to incidence. It cannot be prevented by subarachnoid opioids but can be treated with NSAIDs, systemic opioids and trigger point local anaesthetic injections. It is of short duration, resolving within 6hrs to 4days and has never been reported to cause motor weakness or an abnormal neurological examination. Ref Best Pract & Res Clinical Anaesth 2003, 17(3) pg 471-484 The risk is higher in early ambulation according to this article: Journal of Clinical Anesthesia, Volume 13, Issue 7, Pages 521-523 "The symptoms of TNS can appear from within a few hours until approximately 24 h after a full recovery from uneventful spinal anesthesia." from 'Transient Neurologic Symptoms After Spinal Anesthesia with Lidocaine Versus Other Local Anesthetics: A Systematic Review of Randomized, Controlled Trials' Dusanka Zaric, Christian Christiansen, Nathan L. Pace, and Yodying Punjasawadwong,Anesth Analg 2005;100:1811–6 ----------- |
|
|
RH34 [Apr08]
Retrobulbar block is least likely to block which muscle? A. Lateral rectus B. Superior oblique C. Levator palpebrae superioris D. Inferior rectus E. Medial rectus |
B. Superior oblique
NYSORA http://nysora.com/techniques/eye-surgery/index.shtml#retrobulbar "Because of its extraconal motor control, the superior oblique muscle may frequently remain functional, precluding total akinesia of the globe." Note: Superior Oblique supplied by the Trochlear nerve ----------- |
|
|
RH31 [Apr07] Q70
In performing a retrobulbar block, the complication of brainstem anaesthesia: A. Is not associated with contralateral amaurosis B. Has an incidence of approximately 1 in 2000 blocks C. Becomes clinically apparent within 2 to 15 minutes D. Usually takes 4 to 6 hours to resolve E. Is associated with increased auditory acuity |
C. Becomes clinically apparent within 2 to 15 minutes
----------- |
|
|
RH32 or TMP-142 [Apr08] Q110
A 75-year-old male presents for a cataract extraction and insertion of intra-ocular lens. He has a history of stable angina, non-insulin dependant diabetes mellitus and hypertension. The surgeon says the operation cannot be done under topical anaesthesia alone. You perform an uneventful block - on the wrong eye. Following explanation and apology, the most appropriate course of action is to: A. convince the surgeon to perform the surgery on the correct side, under topical anaesthesia, on the same list B. perform an eye block on the correct side and proceed with surgery on the same list C. postpone surgery to another day which is convenient for the patient D. provide general anaesthesia for correct side cataract surgery to be performed on the same list E. write an incident report and postpone surgery until the outcome of the subsequent enquiry is known |
C. postpone surgery to another day which is convenient for the patient
----------- |
|
|
RH30 [2005-Apr] Q112
The recommended concentration of hyaluronidase as an aid for local anaesthesia in peribulbar injection for ophthalmic surgery is A. 25 IU (International Units).ml-l of local anaesthetic solution B. 50 IU.ml-I of local anaesthetic solution C. 100 IU.ml-I of local anaesthetic solution D. 150 IU.ml-I of local anaesthetic solution E. 1500 IU.ml-l of local anaesthetic solution |
A. 25 IU (International Units).ml-l of local anaesthetic solution
- In practice I use 15IU.ml-l ----------- |
|
|
RH29 ANZCA version [2005-Apr] Q118, [Jul05]
A sub-Tenon's eye block is absolutely contraindicated in A. a severely myopic patient B. a warfarinised patient C. previous glaucoma surgery D. previous retinal detachment repair E. none of the above |
E. none of the above
previous retinal detatchment is a relative contraindication ----------- |
|
|
RH28 ANZCA version [2004-Aug] Q104, [Jul07]
Following a retrobulbar block of the eye which of the following features would suggest brainstem spread of the local anaesthetic? A. an atonic pupil B. blindness in the blocked eye C. blindness in the contralateral eye D. difficulty in swallowing E. diplopia |
D. difficulty in swallowing
A & B Shoudl happen anyway C. blindness in the other eye – may occur, but the chiasm is closer than the brainstem. Cousins 549 The protean CNS signs may include violent shivering, contralateral amaurosis, eventual loss of consciousness, apnea, and hemplegia, paraplegia, quadriplegia or hyperreflexia. Blockade of the 8th to 12th cranial nerves will result in deafness, vertigo, vagolysis, dysphagia, aphasia, and loss of neck muscle power ----------- |
|
|
RH25 ANZCA version [2002-Aug] Q82, [Jul05] [Jul06]
Of the following situations, the strongest contraindication to retrobulbar anaesthesia is A. an operative eye axial length of 24 mm B. a staphyloma of the operative eye C. warfarin for embolism prophylaxis in a patient in atrial fibrillation D. treated glaucoma E. a vitreous humour biopsy for diagnosis and treatment of enophthalmitis |
B. a staphyloma of the operative eye
----------- |
|
|
RH24 ANZCA version [Mar00] [2001-Aug] Q124, [2002-Mar]
In performing retrobulbar blocks, important considerations are that the 1. ophthalmic artery passes from lateral to medial inferior to the optic nerve in approximately 20% of patients 2. globe is normally approximately 26mm in antero-posterior diameter 3. needle should NOT be inserted deeper than 32mm from the plane of the iris 4. safest eye position during block performance is gazing superomedially |
1. ophthalmic artery passes from lateral to medial inferior to the optic nerve in approximately 20% of patients
3. needle should NOT be inserted deeper than 32mm from the plane of the iris (previous grps answer) ----------- |
|
|
RH23 ANZCA version [Apr99] [Aug99] [2001-Aug] Q12, [2002-Mar] Q30, [2003-Aug] Q29, [2005-Apr] Q44, [Apr07]
Advantages of local anaesthesia for middle ear surgery compared with general anaesthesia do NOT include A. avoidance of problems with middle ear pressure B. a drier surgical field C. ability to monitor facial nerve integrity D. ability to monitor hearing E. substantial reduction in post-operative nausea and vomiting |
E. substantial reduction in post-operative nausea and vomiting
- Huge debate vs C. Previous grp, Stan said E. see wiki. ----------- |
|
|
RH22 ANZCA version [Apr98] [Jul98] [Apr99] [2001-Apr] Q55, [2001-Aug] Q56 (A-type with only 4 options)
Complications of an intra-orbital local anaesthetic block are minimised if A. the eye is oriented in a supero-medial direction for an inferolateral injection B. the anaesthetic solution is placed posteriorly where the nerves are close together C. a shallow bevel (Atkinson-type) rather than a sharp intravenous type needle is used D. the injection site is medial rather than supero-medial |
D. the injection site is medial rather than supero-medial
- Superomedial (superonasal) - has lots of blood vessels, therefore should be avoided (2005 CEACCP article) ----------- |
|
|
RH21 ANZCA version [Apr98] [2001-Aug] Q39, [2002-Mar] Q38, [2003-Apr] Q29, [2003-Aug] Q53, [Jul05] [Mar06]
Regional anaesthesia for modified radical mastoidectomy requires blockade of the following nerves EXCEPT A. greater auricular B. auriculotemporal C. auricular branch of vagus D. facial E. tympanic branch of glossopharyngeal |
D. facial
The facial nerve leaving the stylomastoid foramen is entirely motor. The sensory components leave within the petrous temporal bone. They are are a mess of petrosal nerves, nervus intermedius, chorda tympani and so on. Certainly, blocking the facial nerve at any extracranial point will not help. The auricular branches of vagus and tympanic branches of the glossopharyngeal all cross with the branches of VII. ----------- |
|
|
RH17 [Mar93] [Apr07]
Block of the maxillary nerve in the pterygopalatine fossa causes ipsilateral analgesia of: A. Upper molar teeth B. Upper incisor teeth C. Hard palate D. The posterior part of the lateral wall of the nose E. Nasal septum |
A. Upper molar teeth…
Crappy question. NOT Nasal Septum The maxillary nerve: sensation from dura, nasal mucosa, soft palate, skin of lower eyelid and beneath the eye, side of nose, cheek, lip, upper teeth, hard palate ----------- |
|
|
RH11 [Apr05]
In order to remove a lesion from the skin of the external auditory meatus one would have to block: A. Auriculotemporal nerve B. Greater occipital nerve C. Lesser occipital nerve D. Great auricular nerve E. Auricular branch of vagus |
D. Great auricular nerve
----------- |
|
|
RH14b ANZCA version [2002-Mar] Q131
Potential complications and unwanted side-effects of blockade of the Gasserian ganglion and the trigeminal nerve include 1. corneal anaesthesia 2. activation of herpes labialis and herpes zoster 3. Horner's syndrome 4. ocular subscleral haematoma |
All of the Above
Apparently Lennard "Pain Procedures in Clinical Practice" 2nd edition, lists these four complications 'word-for-word'. • Neural blockade of the trigeminalis ganglion is usually reserved for those with trigeminal neuralgia that do not respond to pharmacologic therapy. • Local anesthetic block of the trigeminal ganglion and its primary divisions is often used as a diagnostic test to predict response to neural blockade prior to proceeding with neurolysis Technique: Trigeminal (gasserian) ganglion block. (1) The needle is placed through the skin 2–3 cm lateral to the lateral margin of the mouth and advanced toward the mandibular condyle and toward the ipsilateral pupil until bone is contacted. (2) The needle is then withdrawn and redirected more posteriorly until the foramen ovale is entered. Complications associated with local anesthetic block of the trigeminal ganglion include direct intravascular injection into the carotid artery, persistent paresthesia, and total spinal anesthesia due to local anesthetic deposition within the cerebrospinal fluid over the ventral surface of the brainstem. Complications associated with neurolysis are more common. Facial numbness occurs in nearly all patients and may be profound. Other complications include anesthesia dolorosa (pain and numbness), reduced corneal reflex, abolition of the corneal reflex, keratitis, and masticatory weakness. Percutaneous trigeminal neurolysis (using either glycerol or radiofrequency lesioning) remains an effective, minimally invasive treatment for patients with trigeminal neuralgia. ----------- |
|
|
RL05 ANZCA version [2001-Apr] Q95, [2001-Aug] Q99, [2002-Mar] Q109
Regional analgesia for the excision of a skin lesion on the medial side of the mid-calf can be obtained by 1. sciatic nerve block 2. caudal epidural block reaching L5 3. obturator nerve block 4. femoral nerve block |
4. femoral nerve block
• sciatic nerve block – post thigh, lateral lower lg and dorso-laeral foot • dermatome covering medial calf is L4 • obturator nerve block – patch on medial thigh • femoral nerve block - coverage of ant thigh and medial side lower leg (Saphenous nerve is a branch of the femoral nerve) ----------- |
|
|
RU07 [1985] [1987]
Nerve commonly left unblocked in the axillary approach to the brachial plexus: A. Medial cutaneous nerve of the arm B. Medial cutaneous nerve of the forearm C. Circumflex nerve D. Lateral cutaneous nerve of the forearm E. Nerve to serratus anterior |
D. Lateral cutaneous nerve of the forearm
- Branch of musculocutaneous. ----------- |
