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98 Cards in this Set

  • Front
  • Back
Bleeding patient. What is relative contraindication to Prothrombinex?
A. History of HITS
B. Von Willebrands
C. Haemophilia B
D. Warfarin overdose
E. Renal failure
F. Overdose vit K (not warfarin)
A

Prothrombinex it contains 192 IU heparin per vial
Indication for percutaneous closure of ASD
A. Ostium primum < 3cm
B. Ostium primum > 3cm
C. Ostium secundum < 3 cm
D. Ostium secundum > 3cm
E. Sinus venosus ASD
C

CEACCP 2008
"Of these, only an ostium secundum ASD is suitable for percutaneous closure..."

"If the defect is very large (>3 cm) or complicated (associated with other abnormalities), or an incomplete rim is detected, referral for surgical closure is indicated." – I.e. if <3cm then percutaneous rather than surgical closure
Methylene blue given intravenously has the effect:
A. Pulse oximetry goes down
B. Blood Gas Pa02 decrease
C. Hypotension
D. Metabolic acidosis
E. Increased heart rate
A
Essential diagnostic criteria on ECG for LBBB
A. Loss of septal Q's in V5 and V6
B. RSR in V1
C. Large slurred S in V6
D. T-waves opposite to direction of QRS
E. QRS duration minimum 0.2 s
A

Diagnostic criteria for LBBB:
• 1) Total QRS duration >0.12 s.
• 2) No secondary R wave in V1 to indicate RBBB. 

• 3) No septal q wave in V5, V6 or in leads further to the left (lead I and aVL in horizontal hearts).
Patient over-warfarinised and is for surgery. Prothrombinex 50U/kg may NOT reverse an INR of 5.5 because it contains:
A. Citrate
B. Heparin
C. Anti-thrombin III
D. Not enough Factor VII
E. Not enough Factor X
D

Prothrombinex use for the reversal of warfarin: is fresh frozen plasma needed? Med J Aust 2006; 184 (7): 365-366.
“Current Australian guidelines for urgent warfarin reversal recommend withholding warfarin, and giving vitamin K as well as factor replacement (Prothrombinex HT; PTX) with or without fresh frozen plasma (FFP). PTX administration without FFP is recommended only when FFP is unavailable, as PTX factor VII levels are low and unquantified.”
Ventricular fibrillation (VF) following caudal anaesthesia in 20kg six year old child. The recommended dose of of Intralipid 20% is:
A. 10mls
B. 20mls
C. 30mls
D. 40mls
E. 50mls
C

Recommended dose Intralipid 20% = 1.5ml/Kg = 30 ml
Regarding College Professional Document PS9 – sedation for colonoscopy – the following equipment must be present (NB: The wording was 'present', not 'ready access to' as used for defib in PS9)
a. Defibrillator
b. Mechanical ventilator
c. Anaesthetic machine
d. Suxamethonium
e. Dantrolene
A

Need “ready access to defib” – doesn’t state present but the others are not mentioned.
6. FACILITIES AND EQUIPMENT
The procedure must be performed in a location which is adequate in size, and staffed and equipped to deal with a cardiopulmonary emergency. This must include:
6.1 Adequate room to perform resuscitation should this prove necessary.
6.2 Appropriate lighting.
6.3 An operating table, trolley or chair which can be tilted head down readily.
6.4 An adequate suction source, catheters and handpiece.
6.5 A supply of oxygen and suitable devices for the administration of oxygen to a spontaneously breathing patient.
6.6 A means of inflating the lungs with oxygen (e.g. a self-inflating bag) together with a range of equipment for advanced airway management (e.g. masks, oropharyngeal airways, laryngeal mask airways, laryngoscopes, endotracheal tubes).
6.7 Appropriate drugs for cardiopulmonary resuscitation and a range of intravenous equipment and fluids (See Appendix II).
6.8 Drugs for reversal of benzodiazepines and opioids.
6.9 A pulse oximeter.
6.10 A sphygmomanometer, or other device for measuring blood pressure.
6.11 Ready access to an ECG and a defibrillator.
6.12 A means of summoning emergency assistance.
6.13 Within the facility there should be access to devices for measuring expired carbon dioxide.
(See College Professional Documents T1 Recommendations on Minimum Facilities for Safe Administration of Anaesthesia in Operating Suites and Other Anaesthetising Locations, PS15 Recommendations for the Perioperative Care of Patients Selected for Day Care Surgery.)
APPENDIX II
Emergency drugs should include at least the following:
adrenaline
atropine
dextrose 50%
lignocaine
naloxone
flumazenil
portable emergency O2 supply
According to PS9 for sedation with Propofol for colonscopy, the staff required is/are:
a. Medical practitioner other than proceduralist
b. Nurse other than proceduralist
c. Anaesthetist in addition to the proceduralist
d. Assistant
e. Proceduralist alone
A

Propofol may be used by a medical practitioner with airway and resuscitation skills, and training in sedation for conscious sedation in ASA P 1-2 patients.

Intravenous anaesthetic agents such as propofol must only be used by a second medical practitioner trained in their use because of the risk of unintentional loss of consciousness. These agents must not be administered by the proceduralist.

5.1 There must be a minimum of three appropriately trained staff present: the proceduralist, the practitioner administering sedation and monitoring the patient, and at least one additional staff member to provide assistance to the proceduralist and/or the practitioner providing sedation as required
Duration of Troponin elevation
A. 12-24 hours
B. 24-48 hours
C. 2-5 days
D. 5-14 days
E. 2-4 weeks
D

Emedicine
For early detection of myocardial necrosis, sensitivity of this laboratory test is superior to that of the creatine kinase-MB (CK-MB). Troponin I is detectable in serum 3-6 hours after an AMI and its level remains elevated for 14 days.
Laparoscopic cholecystectomy patient with hyperparathyroidism and ionised calcium of 2.0 mmol/l. The BEST initial treatment is:
A. Calcitonin
B. Magnesium
C. Dialysis
D. IV fluids
E. Frusemide
D

OHA:
• Initial management should be rehydration; as Ca++ inhibits ADH. Promotion of a diuresis also increases excretion of Calcium.
• Texts then defer as to the next treatment; OHA says Pamidronate IV, but also states a saline diuresis is frusemide is 2nd line. Calcitonin is temporary.
Your patient given thiopentone by mistake has a porphyric (acute intermittent) crisis with abdominal pain and then seizures. What drug is contraindicated?
a. Phenytoin
b. Morphine
c. can't remember others
d. ?
e. ?
A

Definitely unsafe commonly used drugs (OHA):
• Barbiturates
• Ropivacaine
• Metoclopramide
• Hydralazine
• Phenoxybenzamine
• Aminophylline
• OCP
• Phenytoin

Treatment of Acute Porphyric Crises
1. Withdraw drugs which may have precipitated the crises
2. Treat symptoms with ‘safe’ drugs
3. Treat infection, dehydration, electrolyte imbalance, give glucose
4. Reverse factors which inc. ALA synthetase – give Haem arginate 3mg/kg iv daily for 4 days.
5. Monitor – ICU or HDU, invasive BP monitoring
Fit lady for elective laparoscopic cholecystectomy seen in PreAdmission Clinic. ECG shows LAD, RSR in V1, wide slurred S in V6 and QRS duration 0.2 msec. Your options
a. Refer to cardiology
b. Crack on
c. Place permanent pacemaker
d. Place temporary pacing wires
e. Give atropine premedication
B

ECG descrption: LAD + RBBB i.e Bifascicular block

OHA: “BBB, bi- or tri-fascicular block will rarely progress to complete heart block during anaesthesia – so not insert pacing wire unless episodes of syncope.”
All these nerves provide some sensation to upper arm EXCEPT
a. Musculocutaneous
b. Intercostobrachial
c. Radial
d. Circumflex
e. Median antebrachial?
A

Musculocutaneous nerve is:
• motor ABOVE the elbow THEN
• sensory (as lateral cutaneous nerve of the forearm) BELOW the elbow -ie NO sensory above elbow.
Advantage if supraclavicular over interscalene nerve block for shoulder surgery
a. Less phrenic nerve block
b. Easier landmarks in obese patient
c. Arm can be in any position for block
d. Less risk pneumothorax
e. Better cover for shoulder surgery?
A

NYSORA
Phrenic nerve palsy:
• interscalene 100%
• up to 80% supraclavicular
The basilic vein
a. Arises from the dorsum of the hand
b. Follows the superficial radial artery
c. Pierces the clavipectoral fascia
d. Becomes the brachial vein at the cubital fossa
e. Arcs around the radial side of the forearm
A

• A=True.
• B=False.
• C=False - cephalic vein does
• D=False - becomes the Axillary vein
• E=False - runs on the ulnar/lateral side
Long duration of surgery, arms stretched out, head turned 30 degrees to right. On waking patient has a neurological deficit. Sensory loss over ventral lateral palm and 3 fingers, some weakness of the hand, weakness of the wrist, some paraesthesia of the forearm and weak elbow flexions. Most likely injury is
A. Median nerve
B. Ulnar nerve
C. C5 nerve root
D. Upper cervical trunk
E. Musculocutaneous
D

• A false- Ventral lateral palm and 3 fingers - median nerve distribution but not motor to elbow flexors
• B. false - sensory loss doesn't match
• C. false - sensory loss doesn't match
• D. true - upper cervical trunk (C5, C6) forms musculocutaneous and median
• E. false - no motor supply to fingers
Paediatric ALS – 20 kg, VF has had 2 shocks only. Next step
a. Adrenaline
b. Amiodarone
c. Shock 50J
d. Shock 100J
A
Patient with known severe aortic regurgitation. Auscultation reveals loud mid diastrolic murmur in aortic area. You also hear a quiet mid diastolic murmur in the apex. This is
a. Functional mitral stenosis
b. Mitral valve incompetence
c. Impaired LV function
d. Papillary muscle dysfunction
A

'The Austin Flint rumble is a mid-diastolic, low frequency murmur that is best heard at the apex with little radiation. It mimics rheumatic mitral stenosis in its characteristics and physiology. The murmur is the result of competition between the regurgitant jet of the aortic valve and the attempt to fill the left ventricle from the left atrium—in essence, functional mitral stenosis. It differs in that it occurs in the presence of a murmur of aortic valve insufficiency and in the absence of the rheumatic, mitral opening snap."
Hetastarch 130/0.4. The 0.4 means:
A. 40 mg/l
B. 40 g/l
C. 4 hydroxylations of every 10 glucose molecule
D. every 4the glucose is hydroxyethylated
E. ?
C

The 130 is the molecular weight of the starch, while the 0.4 is the molar substitution
A Hetastarch of intermediate plasma expansion and intermediate plasma duration is
A. 10% HES 250/0.6
B. 10% HES 200/0.5
C. 6% HES 450/0.7
D. 6% HES 130/0.4
E. 3% HES 200/0.5
D
Maternal collapse post-delivery. What is NOT consistent with Amniotic fluid embolism?
a. Seizure
b. Petechial rash
c. Hypotension
d. Coagulopathy
e. Cardiac arrest
B
B
Trauma with # pelvis and femur. Has a splenectomy. Day 2 patient thrombocytopenia, confused and hypoxic. Diagnosis is
a. fat embolism syndrome
b. pneumcoccal pneumonia
c. thromboembolism
A

Fat Embolism Syndrome (FES) is distinct from the presence of fat emboli. Symptoms usually occur 1-3 days after the injury, and are predominantly: pulmonary (shortness of breath, hypoxemia), neurological (agitation, delirium, or coma), dermatological (petechial rash), and haematological (anaemia, low platelets). The syndrome manifests more frequently in closed fractures of the pelvis or long bones. The petechial rash, which usually resolves in 5-7 days is said to be pathognomonic of the syndrome; however, it occurs in only 20-50% of cases.
Indications for steroids in neurosurgery
a. Cerebral abscess
b. Subdural haematoma
c. Meningioma
d. SAH
e. Traumatic brain injury
A

And potentially meningioma also

From CEACCP – Current controversies in neuroanaesthesia, head injury management and neuro critical care:

“Steroids are very effective in reducing ICP in cerebral tumours and infective intracranial lesions. Trials on the early use of high dose methylprednisolone in traumatic spinal cord injury have demonstrated significant benefits, though the efficacy has been questioned, particularly in patients with penetrating trauma of the cord. Most studies examining the role of steroids in head injury have shown no substantial benefit with respect to clinical outcome, decreasing ICP, or both. The Brain Trauma Foundation does not recommend the use of steroids for improving outcome or reducing ICP in patients with severe head injury. However, a meta-analysis of 13 trials indicated a marginal pooled
risk reduction of 1.8% in patients who received steroids. This prompted a multicentre controlled study—the CRASH (Corticosteroid Randomization after Severe Head Injury) study—on the role of methylprednisolone in acute head injury. Though this international trial was designed to investigate 20 000 patients, it was stopped after recruiting 10 008 patients as the data monitoring committee found an increased risk of early death in the steroid group.”
Rate of phenytoin administration:
a. 50 mg/min
b. 70 mg/min
c. 100 mg/min
d. Over 5 minutes
e. As fast as possible
A

Admin by slow IVI (max 50 mg/min) into large vein via catheter (from MIMS)
Hypothetical anaesthetic agent. Flows 2 L oxygen and 2L nitrous. Copper kettle vaporiser flow 0.5 L. Volatile with SVP 380 mmHg. Inspired volatile concentration (no numbers were exactly correct)
a. 2%
b. 5%
c. 10%
d. 11%
3. 15%
C

Old Question:
EV08 [1986] [1987] [1988] [Mar93] [Aug93] [Aug95] [Apr96] [Aug96] [Apr99] [Aug99]
A hypothetical volatile anaesthetic agent with a saturated vapour pressure of 380 mmHg at 20C is placed in a copper kettle vaporiser. The flow meters are set at oxygen 2 l/min & nitrous oxide 2 l/min. Flow into kettle 0.5 l/min. At 20C the concentration of the volatile anaesthetic agent delivered in the gas is:
A. 1%
B. 2%
C. 5%
D. 10%
E. 11%
Answer here: E
Concentration in vaporiser = 380/760 = 50%. Flow into kettle is 500 ml/min, and this will pick up additional 500ml/min of vapour to maintain SVP at 50%.
Final concentration:
= vapour flow x concentration/ total flow
= 1000 x 50%/4500 = 11.1%
You are performing a Level 2 check on the anaesthetic machine. The suction bulb at
the common gas outlet does not stay compressed after 10 seconds. The cause of this could be:
A. leak in CO2 absorber
B. loosely seated vaporiser
C. leak in pipeline O2
D. leak in cylinder attachment to anaesthetic machine
E. malfunction in one of the valves of the ventilator circuit
E

• A - False. Part of the high pressure system.
• B - False. Not proximal to the CGO - part of the circle. See below.
• C - False. Part of the high pressure system.
• D - False. Part of the circle.
• E - True. See below
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

From APMSE guidelines :
“Unfractionated SC heparin — thromboprophylaxis with SC heparin given twice-daily is not a contraindication to neuraxial blockade. To identify heparin-induced thrombocytopenia, a platelet count should be done prior to removal of an epidural catheter in patients who have had more than 4 days of heparin therapy. Epidural catheters should be removed a minimum of 6 hours after the last heparin dose and not less than 2 hours before the next dose. Safety in patients receiving total daily doses of greater than 10 000 units, or if doses are given more often than twice a day, has not yet been established.”
Utility of BNP (brain naturietic peptide) is for
a. Dyspnoea after pneumonectomy
b. Loss of consciousness after ..
c. Confusion after CABG
A

From Wiki:
Both BNP and NT-proBNP levels in the blood are used for screening, diagnosis of acute congestive heart failure (CHF) and may be useful to establish prognosis in heart failure and in Anesthesiology, preoperative BNP independently predicts in-hospital ventricular dysfunction, hospital length of stay (HLOS) and mortality up to 5 years after primary CABG surgery. So hard to know without the real question. Other things I've read suggest that BNP can help differentiate dyspnoea due to cardiac failure from other causes. After pneumonectomy, there is a sudden increase in PVR, so perhaps this is indicative of whether the right heart is coping. I think the key is dyspnoea; when the real answers appear (in the next exam no doubt) its utility is to suggest whether the dyspnoea is related to cardiac failure or something else.
The BNP test is used as an aid in the diagnosis and assessment of severity of congestive heart failure (also referred to as heart failure). The BNP test is also used for the risk stratification of patients with acute coronary syndromes.
Which patients do not get pulmonary hypertension
a. ASD
b. Chronic thromboembolism
c. Tetralogy
d. MR
e. MS
C

The obstruction is in the RVOT in Fallot’s, so the PA pressure would be low if anything
Drug LEAST likely to cause hypoxia in ARDS
a. Noradrenaline
b. Milrinone
c. Isoprenaline
d. Isoflurane
e. SNP
A

i.e. norad should enhance HPV
Pulmonary hypertension, which will affect PVR the most
a. Isoflurane
b. Sevoflurane
c. Desflurane
d. Propofol
e. Remifentanil
C

Not clear, though discussion on wiki quotes this article (Management of Pulmonary Hypertension: Physiological and Pharmacological Considerations for Anesthesiologists. A&A June 2003 vol. 96 no. 6 1603-1616) which seems to suggest that propofol doesn't change PVR much, Des may raise it, and Sevo and Iso both decreased it with Sevo decreasing it to a greater amount than Iso.
In body protected OR with a Line Isolation Monitor reading 0 mA. If you touch one active wire what will happen.
a. nothing, because no connection to earth is completed
b. you get shocked
c. nothing because the floor is insulated
d. nothing because your shoes are nonconductive
e. RCD trips
A

Line Isolation Monitor (LIM)
• Alarms at 5mA (loss of floating power supply)  does not protect against microshock
• Mains supply is not interrupted - only alarm sounds must take steps to identify offending equipment.
• Continually checks that the floating supply is not earth-referenced, and indicates on a dial how much current could flow to earth if there was an earth connection
• It does this by intermittently connecting one of the two active wires to ground through a very large resistance. If the other wire is connected to ground a circuit will be formed and current will flow, and this indicates how much current would flow through the circuit if either of the two active wires are connected to ground
From Wiki:
“0mA means everything is fine and properly isolated so the circuit is not earth referenced. “
Best way prevent first phase of heat loss after induction
a. Prewarming the patient with forced air warming
b. Warm blankets
c. Warm fluids
d. Warm theatre
e. Humidified gases
A

“Pre-warming eliminates the gradient between core and peripheries thus the redistribution phase does not occur.”
Best way to assess fluid resuscitation after burns is
a. Urine output
b. mixed venous sats
c. blood pressure
d. cvp
e. capillary refill
A

From TRAUMA - Emergency Resuscitation, Perioperative Anesthesia, Surgical Management
Ongoing Needs/Endpoints of Resuscitation

Endpoints of resuscitation continue to be studied to determine the ideal resuscitation fluids and volumes (intravascular vs. total body) as well as the ideal blood pressures and intravascular osmolality, protein levels, and urine output. Under-resuscitation leads to tissue ischemia and rapid progression of burn depth, a hypercoagulable state, renal failure, and ultimately MODS. Over-resuscitation has other obvious complications resulting from edema, including decreased tissue perfusion and compromised pulmonary oxygenation.

Urine output has been the gold standard for resuscitation endpoints for many years. A volume of 0.5 cc/kg/hr in adults and l.0 cc/kg/hr in children is used to guide fluid resuscitation volume adjustments. Urine output may not accurately reflect the volume status in patients who are diuresing secondary to osmotic loads (e.g., hyperglycemia, ethanol, or mannitol). The presence of smoke inhalation greatly increases the amount of fluid required to maintain intravascular volume
Emergence delirium in a kid in recovery. To treat
a. Fentanyl 1mc/kg
b. Midazolam 0.1 mg/kg
c. Propofol
d. Clonidine 1mc/kg
e. Sucrose
A or D

?supposed to be an ‘except’ question
Otherwise clonidine or fentanyl would be my first choice
Pain in 3 year old, best objective tool
a. FLACC (crying limbs activity consolability)
b. Wong baker Faces pain
c. Self reporting
d. Mum reporting
e. Nurse reporting
A

Though could potentially be D also according to below
APMSE:
Based on current data the following
observational / behavioural measurement tools were recommended for pain measurement
in infants 1 year and above (McGrath et al, 2008 Level I), children and adolescents (von Baeyer &
Spagrud, 2007 Level I) (see Table 10.2).

• acute procedural pain — Face Legs Activity Cry and Consolability (FLACC) and Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS);
• postoperative pain — FLACC;
• postoperative pain managed by parents at home — Parents Postoperative Pain Measure (PPPM); and
• intensive care — COMFORT.

Self-report of pain is preferred when feasible, and is usually possible by 4 years of age, but
this will depend on the cognitive and emotional maturity of the child.

At 4 to 5 years of age, children can differentiate ‘more’, ‘less’ or ‘the same’, and can use a Faces Pain Scale (Figure 10.1) if it is explained appropriately and is a relatively simple scale with a limited number of options.
ECG given. No scale, poor copy, can just make out large and small squares in the upper part, is blurry down low, in absence of scale the squares look bigger than 1mm! Shows anterolateral T inversion, maybe subtle ST sag, no Q's. At first glance looks like big negative QRS's in V2 and big positive QRS's in V5 to suggest LVH, but having struggled to make out squares as above, total pos & neg deflection adds up to approx 5 big squares. (In summary, voltage criteria for LVH with lateral strain pattern - no BBB)
a. longstanding hypertension
b. anterolateral infarct
c. some sort of BBB?
A
ECG given. P pulmonale, Tall R V1, T inversion V1-3
a. Primary pulmonary hypertension.
b. post. Infarct
A

From GPTrainingNet – ECG Reporting:
Right Atrial Enlargement
Diagnostic Criteria
• The P wave in leads II, II and aVF is peaked with a height greater than 2.5mm. "P pulmonale"
• The P wave axis is +75o or greater.
• The positive aspect of the P wave in lead V1 or V2 is >1.5mm in height.
Differential Diagnosis
• Valvular Disease
o Tricuspid stenosis
o Tricuspid regurgitation
• Pulmonary Hypertension
o COPD
o Pulmonary emboli
o Interstitial lung disease
o Sleep apnea
o Mitral valve disease
o Left ventricular systolic dysfunction
• Congenital Heart Disease
• Ebstein's anomaly
Best time to collect serum tryptase after suspected anaphylaxis
a. within 15 minutes
b. 1 - 3 hours
c. 3 - 6 hours
d. 12 - 24 hours
e. greater than 36 hours
B

Peak tryptase is at 1hr
Patient with Hemophilia A with known high titres of inhibitors to factor 8. What would you give to prevent bleeding in the patient for ot
a. FVIIa
b. High dose FVIII concentrate
c. FFP
d. Cryo
e. Platelets
A

From BLOOD, 1 JANUARY 2009, VOLUME 113, NUMBER 1 - How we treat a hemophilia A patient with a factor VIII inhibitor:

“However, as a consequence of treatment patients with HA may develop inhibitory IgG antibodies to fVIII, termed inhibitors. Inhibitors bind fVIII and prevent its hemostatic action. When this occurs, treatment becomes more costly and morbidity increases”

“How do we treat patients with an inhibitor? … Currently available agents include recombinant activated factor VII”

“fVIIa facilitates hemostasis by activating factor X directly on the platelet surface thereby bypassing the tenase complex.”
Pregnant women whose paternal uncle has MH. Nobody has been tested. What's the best test to exclude MH in this patient?
a. Genetic test lady
b. genetic test dad of lady
c. muscle biopsy lady
d. muscle biopsy dad
D

From British Malignant Hyperthermia Association (BMHA):
“Not all patients can have a biopsy, these include children less than 10-12yrs (30kgs), pregnant women, and patients on prolonged steroid therapy. If the proband cannot be tested, eg a young child or deceased, then the nearest most appropriate relative is tested. In the case of a young child this would be the parents.”

Although Stoelting says:
"No longer can the inheritance of human MH be considered solely autosomal dominant with variable penetrance, because more than one genetic locus has been identified in some families."
A woman is being treated for pre-eclampsia. She is given 10 grams Magnesium sulphate in 1 h, instead of 1 gr per 1 h, Mg level 5-6, and patient is hyporeflexia. The best treatment is:
a. calcium
b. IV fluid
c. Furosemide
d. ?
A

From Wiki:
Was there an option of waiting to repeat the level a few hours later? Cos with that level but not cardiovascular instability often you'd just hold off until reflexes are normal. In many countries where serum Mg levels aren't so widely available when the original Magpie trial was done, decreased DTR was the end point in developing countries. Otherwise its A, Ca Gluconate 1g over 10 minutes
Disease associated with malignant hyperthermia
a. central core disease
b. myasthenia gravis
c. myotonia congenita
d. ?
A

From British Malignant Hyperthermia Association (BMHA):
Conditions associated with MH
The only truly associated condition is central core disease (CCD) which is also inherited and located close to the RYR1 gene. It should be emphasised that the vast majority of MH patients do not have CCD and not all CCD patients have MH
Endotracheal tube to circuit connectors
a. 15/22 mm
b. lots of other wrong combo's
A
Appropriate infection control measures when anaesthetising a patient with suspected variant-CJD, the airway equipment should be
a.thrown away
b.plastic sheath, reuse
c.sterilization with ethylene oxide
d. sterilization with heat at 134 degrees for 3 minutes
e. Autoclave
A

Stoelting on Variant Creutzfeldt-Jakob Disease:
“Management of anesthesia includes the use of universal infection precautions, disposable equipment, and sterilization of any reusable equipment (laryngoscope blades) using sodium hypochlorite”
Mechanism of action of antiepileptics in chronic pain, which is false?
a. Phenytoin workes at Na channels
b. Gabapentin increases gaba in cns
c. Carbamazepine works at Na channels
d. Valproate increases GABA in the CNS
e. lamotrogine acts at Ca channel
E

From CEACCP - Treatment of chronic pain: antidepressant, antiepileptic and antiarrhythmic drugs:
Mechanism of action
• Antiepileptic drugs work in a number of different ways, all of which have relevance to their effect on pain. Some drugs have more than one mechanism of action…
• Older antiepileptic drugs such as phenytoin and carbamazepine reduce neuronal excitability by means of frequency-dependent blockade of sodium channels.
• Lamotrigine also has action at sodium channels and probably by this mechanism suppresses the neuronal release of glutamate, an excitatory amino acid involved in central neuronal hyperexcitability and persisting pain.
• Sodium valproate probably elevates levels of the inhibitory amino acid GABA in the central nervous system and by potentiation of GABAergic functions, particularly in the brain, inhibits pain.
• Gabapentin is an antiepileptic drug that, despite its name, has no interaction with GABA receptors or GABA metabolism.
Timing of worst coagulopathy after liver transplant
a. 1-2 days
b. 3-4 days
c. 5-6 days
A

Postoperative Changes in Prothrombin Time following Hepatic Resection: Implications for Perioperative Analgesia - Anaesth Intensive Care. 2006 Aug;34(4):438-43
"This study demonstrates that maximal disturbances in the PT occur on the first and second postoperative days."
Anaesthetic management in patient with cardiac tamponade
a. bradycardia for the ventricle filling time
b. inotropes
c. volume loading
d. ?
C

From Miller:
In patients who are severely hemodynamically compromised, one surgical option is to perform pericardiocentesis or subxiphoid exploration under local anesthesia and induce general anesthesia after the tamponade has been partially relieved. If general anesthesia is planned, watchwords in the management of cardiac tamponade are fast, full, and strong. It is important to administer intravenous fluids before induction to optimize preload. Increasing intravascular volume helps increase the effective filling pressure of the heart, restore the gradient between the chambers, and increase arterial pressure.
Any manipulation that can decrease venous return to the heart should be avoided, including controlled positive-pressure ventilation with large tidal volumes, which may significantly decrease preload and cardiac output. Instead, if general anesthesia is required, one option is to allow the patient to breathe spontaneously until the pericardial sac is opened. Alternatively, a ventilation pattern of high rate and low tidal volume can be used to minimize mean airway pressure.
Drugs that may cause myocardial depression should be avoided. Additionally, bradycardia should be avoided because tachycardia is the most important compensatory mechanism for preserving cardiac output. The use of ketamine to induce general anesthesia for creation of a pericardial window has been described.
When cardiac tamponade is relieved, endogenously generated and exogenously administered catecholamines may cause sudden, severe increases in blood pressure and heart rate. This phenomenon should be anticipated and treated.
Doing an awake CEA. Patient becomes confused & combative after carotid clamped and opened. Priority is...
a) tell surgeon to release clamp
b) tell surgeon to place shunt
c) induce GA
d) give midazolam
B

From OHA:
Attentive monitoring of the patient is vital, particularly during crossclamping. If neurological deficit develops, a shunt should be inserted immediately, although you may have to use considerable tact/skill to reassure the patient, maintaining the airway whilst the shunt is being inserted. Recovery should be rapid once the shunt is in place—if it is not, convert to general anaesthesia.
You intubate a young male patient for a left thoracotomy with a 39FG Robert Shaw tube. When you inflate both cuffs and ventilate the bronchial lumen you get left sided ventilation. When you attempt to ventilate the tracheal lumen the pressures are very high and you get no air entry. Yet when you deflate both cuffs you can ventilate the patient through the tracheal lumen. The most appropriate step to take next is:
A. Change to a 41FG tube
B. Change to a 37FG tube
C. Deflate both cuffs and insert further cm and recheck
D. Deflate both cuffs and withdraw a few cm and recheck
E. Pull ETT out and start again.
C

From wiki:
If you can ventilate BOTH lungs when cuffs are down (assume that is what they mean when they say you can ventilate the patient) then, when the bronchial cuff is inflated, it must be blocking the passage of air via the tracheal lumen, ie bronchial cuff is at the carina and tube needs to go in further.
Patient with IV in right arm, has mediastinal mass and SVC compression undergoing mediastinal biopsy, suddenly uncontrolled surgical bleeding in mediastinum. Next step in management prior to thoractomy: A. insert femoral cannulae and place on bypass
B. insert IV in left arm
C. insert IV into foot
D. insert jugular CVC
E. trendelenburg
C

OHA:
• Insert a 14 or 16G cannula in lower leg vein after induction (see below).
• There is the potential for massive haemorrhage from the great vessels—the risk is increased in patients with SVC obstruction (hence the cannula in the leg): may require immediate median sternotomy.
ASA grading was introduced to
A. predict intraop anaesthetic risk
B. Predict intraop surgical and anaesthetic risk
C. Standardise the physical status classification of patients
D. Predict periop anaesthetic risk
E. Predict periop anaesthetic and surgical risk
C

ASA
"In attempting to standardize and define what has heretofore been considered 'Operative Risk', it was found that the term ... could not be used. It was felt that for the purposes of the anesthesia record and for any future evaluation of anesthetic agents or surgical procedures, it would be best to classify and grade the patient in relation to his physical status only."
What is true regarding arterial pressure transducer systems
A. Underdamping overestimates systolic BP
B. Underdamping underestimates SBP
C. Compliant tubing?
D. wide range of damping coefficient associated with good performance if system has high natural frequency
A
60 year old vascular patient. ECG given.
Showed large positive R waves in lateral leads, large negative S waves in anterior leads. ST depression laterally  ie LVH with strain; bicuspid p waves
A. LVH with strain
B. Enlarged RA
C. Lateral ischaemia
D. LBBB
E. L posterior hemiblock
A
Pulsus paradoxus is:
A. Reduced BP on inspiration unlike normal (ie normally increased on insp)
B. Reduced BP on inspiration exaggerated from normal
C. Reduced BP on expiration unlike normal
D. Reduced BP on expiration exaggerated from normal
E. ?
B

Miller's, 7th ed.:
Pulsus paradoxus is an exaggerated inspiratory fall in systolic arterial pressure that exceeds 10 to 12 mm Hg during quiet breathing (see Fig. 40-16B).The term is confusing because a small inspiratory reduction in blood pressure is a normal phenomenon and pulsus paradoxus is not truly paradoxical, but rather an exaggeration of the normal inspiratory decline in blood pressure
What antibiotics are required for bacterial endocarditis prophylaxis in a woman with MV prolapse for cholecystectomy.
A. None
B. gentamicin
C. ampicillin and gentamicin
D. ampicillin
E. cephazolin
A

From ACC/AHA Focused Update on Infective Endocarditis
Plasma glucose level compared to blood glucose level
a)32% higher
b)14% higher
c)same
d)14%lower
e)32% lower
B
You are called for a labour epidural. The woman is extremely distressed and in the middle of your consent process states “Just take my pain away” . You:
A. Place epidural then when calmed return to advise her of risks and complications
B. Explain she has to hear all the potential complications and refuse to place epidural without consent
C. Take consent from partner
D. Perform spinal to relieve pain, then consent her for epidural
E. Go away and return when she is more cooperative
A
Pre-eclamptic woman BP 180/110. Aim to drop BP to
a) 150-160
b) 140-150
c) 120-130
d) 110-120
e) 100-110
B
4 yr old presents for elective surgery, otherwise fit healthy, murmur at left sternal edge on auscultation heard in systole and diastole, disappears on lying down. Most likely cause:
A. HOCM
B. VSD
C. PDA
D. venous hum
E. ASD
D

Talley&O'connor 3rd Ed p79-83 and wikipaedia
Venous Hum - systolic + diastolic components, not really a murmur. Benign medical condition where 20% of the blood flow travels to the brain and back to the heart. Due to the large amount of blood it can move quite fast causing the vein walls to vibrate which can create a humming noise to be heard by the patient. The murmur disappears when the patient is in the supine position.
Neonate born to known drug abusing mother brought to emergency department by grandmother, unwell lethargic, slightly jaundiced, ABG shows following:
pH 7.52
Na 135
Cl 87
K 3
pCO2 38
Which of the following is the Diagnosis?
A) Septicaemia
B) Hepatitis
C) Pyloric stenosis
D) Pneumonia
E) Opioid withdrawal
C
Which of the following can be used to describe the spread of non-parametric data?
A. standard deviation
B. interquartile range
C. confidence interval
D. standard error
E. variance coefficient
B
A patient has a suspected anaphylactic reaqction under GA. What is the best time to perform the tryptase test?
A><1 hour
B>1 to 3 hours
C>3 to 6 hours
D>numerous other options
B
You are anaesthetising a patient with multiple sclerosis. The best way to avoid a flare up of this patients multiple sclerosis following the anaesthetic is to
A. Avoid dehydration
B. Avoid overheating the patient
C. ?
D. ?
B

"...increases in body temperature should be avoided. Demyelinated fibres are extremely sensitive to increases in temperature; an increase of as little as 0.5 C may completely block conduction"...Morgan and Mikhail p588
70 y old patient with AF (rate 80/min) in pre-admission clinic booked for ant resection. (it was not mentioned if AF was old or new or if on patient was on any medication) What management?
A. Crack on
B. Echocardiography and Cardioversion
C. Immediate Cardioversion
D. ?
E. ?
A
Ketamine for acute pain relief
A. an appropriate dose is 0.5 -1 mg/kg
B. Midazolam does not help in unpleasant dreams / delirium
C. Morphine is contraindicated
D. Hallucinations are common
E. Subcut is better than IV
D

A. FALSE - Usual dose is 0.1 - 0.3mg/kg/hour (or as an initial bolus)
B. FALSE - Midazolam is useful
C. FALSE - Need an opioid for best effect
D. TRUE - Don't know about it being common, but...
E. FALSE - S/c is not better than; but can be used instead of IV. "however SC infusion is also used, especially in palliative care, with a bioavailability (similar to IM) of approximately 90% (Clements et al, 1982)." From APMSE
TRALI most likely after transfusion of
A. Red Blood Cells
B. Platelets
C. FFP
D. ?
E. ?
C
What is the appropriate LMA size for an 8kg child:
A. 1
B. 1.5
C. 2
D. 2.5
E. 3
B

LMA sizes (Drug Doses Frank Shann Book)

<5kg = 1
5-10kg = 1.5
10-20kg = 2
20-30kg = 2.5
30-50kg = 3.0
50-70kg = 4.0
70-100kg = 5.0
100kg = 6
Aneurysm clipping. Best monitor of depth of block during this is:
A. TOFR
B. TOFC
C. DBS
D. PTC
D
Which volatile has the minimum effect on ICP at 1 MAC
A. Isoflurane
B. Sevoflurane
C. Desflurane
D. Enflurane
E. Halothane
B
Blunt abdo trauma, liver injury, for conservative management if
a) haemodynamically stable
b) blood <500 ml in the peritonium
c) low grade injury on CT
A
The absorption of fluid into the circulation during transurethral prostatectomy (TURP) is NOT related to
A. prostate size
B. height of the irrigation fluid bag
C. duration of surgery
D. surgical technique
E. type of irrigation fluid
E

The Internet Journal of Anesthesiology 1999; Vol3: "Several factors contribute to the rapid volume expansion, namely the intravesicular pressure (governed by the height of the irrigation bag above the prostatic sinuses), the number of prostatic sinuses opened and maybe most important the duration of the surgical procedure“

Transurethral Resection of the Prostate (TURP) Syndrome: A Review of the Pathophysiology and Management. Anesth & Analg 1997: “using continuous irrigating resectoscopes or suprapubic trocar drainage can minimize absorption”
In patients undergoing thoracotomy, techniques which reduce the incidence of intraoperative atrial fibrillation include
A. hyperventilation
B. pre-operative loading with digoxin
C. rocuronium, rather than pancuronium
D. thoracic epidural bupivacaine
E. thoracic epidural morphine
D
During laparoscopic surgery, pneumoperitoneum usually results in a fall in cardiac output when intra-abdominal pressure exceeds
A 10mmHg
B 20mmHg
C 30mmHg
D 40mmHg
E 50mmHg
A
A fourteen-year-old girl is scheduled to have a termination of pregnancy. With regard to consent for this procedure, which of the following statements most truly reflects the law in Australasia?
A. A fourteen-year-old girl is able to give consent independently of her parents/guardians if she is considered, by her treating doctors, to be of sufficient maturity to understand the issues.
B. A fourteen-year-old girl is able to give consent independently of her parents/guardians, only if a court deems her sufficiently mature.
C. Minors are not able to give consent, independently of parents/guardians, until sixteen years of age.
D. Minors are not able to give consent, independently of parents/guardians, until eighteen years of age.
E. Only life-saving treatment may be administered to a fourteen-year-old without parental/guardian consent.
A
A multi-trauma patient opens his eyes and withdraws to painful stimuli, but does not respond to voice. He is moaning but makes no comprehensible sounds. His Glasgow Coma Score is
A. 5
B. 6
C. 7
D. 8
E. 9
D
Respiratory function in quadriplegics is improved by
A. abdominal distension
B. an increase in chest wall spasticity
C. interscalene nerve block
D. the upright position
E. unilateral compliance reduction
B
An INCORRECT statement regarding the autonomic nervous system is that
A. autonomic dysfunction is a predictor for worse long term survival after myocardial infarction
B. heart rate responses are primarily mediated through the sympathetic nervous system
C. inhalation anaesthetics all impair autonomic reflex responses
D. autonomic dysfunction is a predictor for haemodynamic instability following anaesthetic induction
E. low heart rate variability is associated with worse cardiac outcomes following non-cardiac surgery
B

Anesthesiology: Volume 90(3) March 1999 pp 651-653:
- There also is strong evidence in patients that autonomic balance and vagal reflexes influence morbidity and mortality after MI. Patients surviving MI who had either low HRV or low baroreflex sensitivity had an increased risk of subsequent sudden cardiac death
- The sympathetic component is primarily involved in adjusting peripheral vascular tone and plays a lesser role in the reflex regulation of HR and cardiac output. The vagal component is primarily involved in regulating HR.
- it is well documented that patients with impaired autonomic reflexes (e.g., patients with diabetes) have greater intraoperative BP lability compared with autonomically intact patients. [2,3] In addition, it now is clear that many of the sedative, hypnotic drugs used for induction of anesthesia and all of the potent inhaled anesthetic gases in clinical use impair autonomic reflex responses.
- low HR variability (HRV), an index of impaired cardiac-vagal tone, is an independent predictor of mortality after non-cardiac surgery
Correct statements regarding expiratory-inspiratory flow-volume loops include all of the following EXCEPT
A. in obstructive disease the expiratory curve has a scooped out or concave appearance
B. in restrictive disease expiratory flows are usually decreased in relation to lung volume
C. in restrictive disease the expiratory curve has a convex appearance
D. the expiratory curve is largely effort independent
E. the inspiratory curve is effort dependent
A
Obstructive sleep disorder in children
A. is associated with pulmonary hypertension and dysfunction of left and right ventricles
B. has obesity as a major risk factor
C. is rarely seen in children less than 8 years old
D. is four times more prevalent in boys than girls
E. does NOT usually require tonsillectomy for its management
A

 A. "Children with long-standing OSA syndrome who become chronically hypoxaemic and hypercarbic may develop acute respiratory failure and right ventricular failure." (Anaesthesia 1998; 53:571-579)
 B. partly true: Definitely a risk factor in the fat kiddies, but is it a major risk factor?
 "Obesity, a typical feature of adults with OSA, is uncommon in children but if observed, may be associated with reduced daytime activity. More typically these children have poor weight gain and small stature." (Anaesthesia 1998; 53:571-579)
 C. "Children usually present between 3 and 7 years of age" (Anaesthesia 1998; 53:571-579)
 D "In contrast with adult OSA, in children there is an equal prevalence of affected boys and girls" (Anaesthesia 1998; 53:571-579)
 E. "In most cases the definitive treatment of children with OSA syndrome is surgical by adenotonsillectomy" (Anaesthesia 1998; 53:571-579)
Factors associated with post-operative ulnar nerve palsy include all of the following EXCEPT
A. male gender
B. sternal retraction for cardiac surgery
C. cardiopulmonary bypass for cardiac surgery
D. internal jugular vein catheterisation
E. diabetes mellitus
C

• A=False - this is a risk factor : Anesthesiology Clin N Am 20:(2002) 589– 603:
This bony prominence is at least 50% larger in males, consistent with their greater susceptibility to perioperative ulnar nerve damage
• B=False - this is a risk factor : Miller 6th ed. Pg. 1154:
“Brachial plexus injuries occur primarily in cardiothoracic procedures requiring median sternotomy. Mechanisms for injury during median sternotomy include stretch or compression of the plexus during sternal separation, direct trauma from fractured 1st ribs, stretching related to internal mammary dissection and trauma or haematoma related to internal jugular vein cannulation. “
• C=?True – whilst is associated with cardiac surgery it is not related to the CPB per se
• D=False – as per above quote from miller – haematoma from IJ cannulaion could cause brachial plexus injury
• E=False – this is a risk factor apparently (pre-existing neuropathy)
32 year old with early acute liver failure (not paracetamol related). Management includes
A. prophylactic antibiotics
B. N-acetyl cysteine as general liver protection
C. avoid early intubation so can assess for encephalopathy
D. INR> 3 means should be considered for transplant??
E. avoid saline as resuscitation fluid
B
Carcinoid syndrome - finding on examining heart:
A. Fine inspiratory crepitations
B. Systolic murmur at apex
C. Systolic murmur at left sternal edge
D. Murmur at apex with opening snap
E. Pericardial rub
C
Central anticholinergic syndrome, which is NOT true:
A. Will improve with neostigmine
B. Peripheral anticholinergic symptoms
C. Caused by Anti-Parkinson drugs
D. CNS depression
E. Associated with agitation, delirium, and ???
A
The intraoperative hypothermia for aneurysm surgery trial (IHAST) showed that cooling to a target temperature of 33°C
A. did NOT improve neurological outcome in WFNS (World Federation of Neurosurgical Surgeons) in grade I-III patients
B. did NOT improve neurological outcome in WFNS grade IV-V patients
C. improved neurological outcome in WFNS grade I-III
D. improved neurological outcome in WFNS grade III
E. improved neurological outcome in WFNS grade IV-V
A
12 year old child with hip dislocation at 4pm. Ate something 1 hour after injury. Now 11 pm. Best anaesthetic:
A. RSI with ETT
B. delay until next day then treat elective
C. inhalational induction and continue with face mask
D. Reduce immediately with iv sedation
E. inhalational induction and continue with face mask
A
What is 1 MET uptake of oxygen DUKE'S ?
A. 1-2 ml O2/kg/min
B. 2-3 ml O2/kg/min
C. 3-4 ml O2/kg/min
D. 5-6 ml O2/kg/min
E. 7-8mls O2/kg/min
C
Anaemia in chronic renal failure is characteristically
A. due to haemolysis in the renal vascular bed
B. normochromic and microcytic
C. due to defective haemoglobin synthesis
D. responsive to ion and folate therapy
E. associated with increased 2,3-DPG levels in blood cells
E
Histamine release in anaphylaxis does NOT cause:
A. Tachycardia
B. Myocardial depression
C. Coronary artery vasodilatation
D. Prolonged PR interval
E. Decreased impulse conduction
B
Pre-ganglionic sympathetic fibres pass to the
A. otic ganglion
B. carotid body
C. ciliary ganglion
D. coeliac ganglion
E. all of the above
D
Codeine phosphate
A. is converted by the liver to its active metabolite, oxycodone
B. is not associated with tolerance on chronic use
C. is not effective as an analgesic in approximately 20% of Causcasians
D. is poorly absorbed from the gastrointestinal tract
E. when given orally has approximately 5% of the analgesic potency of intramuscular morphine
E
Branches of the mandibular nerve do NOT include the
A. auriculotemporal nerve
B. long buccal nerve
C. lingual nerve
D. great auricular nerve
E. chorda tympani nerve
D

The great auricular nerve (C2, 3) is the largest cutaneous branch of the cervical plexus. It hooks around the mid-point of the posterior border of sternocleidomastoid, then passes across it in the direction of the angle of the mandible. On this muscle it breaks up into three terminal branches.
1 Auricular - supplying the lower two-thirds of the medial aspect of the external ear and the lateral surface of the lobule.
2 Mastoid - to the skin over the mastoid process.
3 Facial - to the skin over the masseter and the parotid gland
Preoperative assessment shows a Mallampati (ML) score of III and thyromental distance (TMD) of < 6cm. A grade 3 to 4 on Cormark and Lehane is predicted. Compared to the ML score, the TMD is
A less sensitive, less specific
B less sensitive, more specific
C more sensitive, less specific
D more sensitive, more specific
E equal sensitivity an specificity
B
The innervation of the human larynx is such that
A. the internal laryngeal branch of the superior laryngeal branch of the vagus supplies the lingual surface of the epiglottis
B. in the cadaveric position the cords are fully abducted
C. the recurrent laryngeal nerve supplies all the intrinsic muscles of the larynx
D. the glossopharyngeal nerves are sensory to the laryngeal mucous membrane above the level of the vocal cords
E. cord paralysis can be produced by a distended endotracheal cuff in the larynx compressing a branch of the recurrent laryngeal nerve against the thyroid cartilage
E
Max Sedation time post oral midazolam 0.5mg/kg
a. 10min
b. 20min
c. 30min
d. 40min
e. 50min
C

"The dose of oral midazolam... usually results in a satisfactorily sedated child in approximately 10-15 min with a peak effect occurring at approximately 20-30 min, with minimal to no delay in recovery, even for brief procedures." (Cote, Preoperative preparation and premedication, BJA 1999, 83:16-28)
Art line system
a. Overdamped exaggerates mean
b. Underdamping increases mean
c. Underdamping underestimates systolic
d. Long random option about multiple damping coefficients in an optimal system
e. Compliant tubing is good
D
The tapered connector between the ETT and machine is
a.12-20mm
b. 15-22mm
c. 20-30mm
d. 22-30mm
e. 25-35mm
B
Which drug is an example of a specific PDE III inhibitor:
a. Aminophyline
b. Sildenafil
c. Milrinone
d. Dipyridamole
e. ?
C