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134 Cards in this Set

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  • Back
TMP-Jul10-001 Pre-eclamptic woman, BP 170/110, headache, proteinuria 1.2g. Which of the following NOT to use for control of her hypertension:
A. Magnesium
D. Hydralazine
E. Metoprolol
A. Magnesium - not for control of HTN

Severe PET as > 160/110 + headache and proteinuria.
Management of PET:
- early diagnosis, control of BP, prevention of convulsions and timely delivery, strict fluid balance

BP control:
Maintain MAP 100-140 (130/90-170/110). Sudden drop can compromise placental perfusion. Drugs used:
- Hydralazine 5mg increments or infusion
- Labetalol 50mg increments IV or 100mg PO q30min
- Methyldopa 1-3g PO per day
- Nifedipine 20mg PO (drops BP ++ with magnesium)
- SNP infusion - may cause excessive hypotension, good for emergencies, risk of cyanide toxicity to fetus
- GTN - as above, risk of methaemoglobinaemia

Magnesium is NOT for control of BP. It is for prevention of fits and treatment. 4g loading + 1g/h infusion
TMP-Jul10-002 Male with a Haemoglobin of 8G% and reticulocyte count 10%. Possible diagnosis:
A. Untreated pernicious anaemia
B. Aplastic anaemia
C. Acute leukaemia
D. Anaemia of chronic disease
E. Hereditary spherocytosis
Ans E Spherocytosis
Only this have increased reticulocyte count
TMP-Jul10-003 Commonest organism causing meningitis post spinal:
A. Staph epidermidis
B. Staph salivarius
C. Staph aureus
D. Strep pneumoniae
E. ?
B. Staph salivarius
Baer, Post Dural Puncture Bacterial meningitis, Anaesth 2006
Most of the organisms that cause PDPM are commensals of the mouth and upper airway. These observations support the droplet mechanism for the pathogenesis of most cases of PDPM. That is, the aerosolized organism that enters the CSF during dural puncture originates in the upper airway of medical personnel.
Order of most to least common
Staph salivarius
Strep viridians
Staph aures
Pseudomonas aeruginosa
Exponential decline / definition of time constant (with various options)
A. time for exponential process to reach log(e) of its initial value
B. Time until exponential process reaches zero
C. Time to reach 37% of initial value
D. Time to reach half if its initial value
E. 69% of half life
Ans: C
(Time constant = Time to reach 1/e of its initial value)
(This is a very old repeat) Relative humidity – air fully saturated at 20 degree. What is the relative humidity at 37 degrees ?
Ans C
Saturated vapour pressure of water at 20 degree 17.3 mmHg 37 degree 47 mmHg
17.3/47 = 36.8%
A 50 year old man with multiple fractures. The BEST parameter to monitor volume resuscitation is:
A. Heart rate
E. Changes in R atrial pressure during inspiration
LVEDV would be best if it were easily measureable.

If stem suggests 'most useful' or 'most practical' then perhaps C - PCWP
Anaphylaxis to rocuronium. Which is most likely to cause coss-reactivity ?
A. Vecuronium
B. Pancuronium
C. Atracurium
D. Cisatracurium
E. None of the above -cross reactivity too variable to predict
A. Vecuronium
From part 2 course, Vec and Roc have highest cross-reactivity
Hypotension post propofol induction in elderly patient. More pronounced / profound than in younger patient. Reason ?

A. Concentric LVH associated with ageing and therefore preload dependent
B. Because of increased lean body mass
C. Decreased cardiac output with ageing
D. Increased sensiticity to all anaesthetic agents, thus relative overdose is common
E. Decreased liver blood flow with ageing, decrease drug clearance and increased drug concentration
C or D, as per group discussion

A, B and E we are all sure are wrong.
Predictive factors for mortality in elderly patient (except):
A. Aortic stenosis
B. Diabetes mellitus
C. Elevated Creatinine
D. Cognitive dysfunction
E. Type of surgery
Ans: D

Ref Minimising perioperative adverse events in the elderly BJA 2001
All are mentioned except cognitive dysfunction
The best clinical indicator of SEVERE AS
A. Presence of thrill
B. Mean Gradient 30mmHg
C. Area 1.2 cm2
D. Slow rising pulse and ESM radiating to carotids
E. Shortness of breath
Ans A
CEACCP 2005 Aortic stenosis and non-cardiac surgery
However, symptoms do not correlate well to the severity of the stenosis and some patients with small valve areas can be asymptomatic.

50% of pts with angina with have CAD too.
Examination: arterial pulse slow rising and of low volume - if severe low systolic and pulse pressures.
Lag may be felt between apex and carotid - presence of precordial thrill is reasonably specific for severe AS.
Elderly patient. Indications for coronary angiogram before Femoro-Popliteal Bypass surgery include all EXCEPT:

A. Severe heart failure
B. Suspicion of L main disease
C. Symptomatic tachyarrhythmia
D. Unstable angina
E. Stable angina with positive thallium
Ans: C
ABD they are all straight forward indications for coronary angio. Positive thallium suggest patient may require revascularisation and coronary anatomy is required.
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
D. Thread catheter slowly
Ans A
Detection of intravascular epidural catheter placement A review 2007
The injection of saline into the epidural space prior to threading the catheter is reported to decrease the incidence of intravascular placement
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
Ans B
Morphine-induced late onset respiratory depression occurs between 3.5 and 12 h after injection with a peak at 6 h
TMP-Jul10-014 Patient with aortic dissection. Blood pressure 150/90. Best drug to control BP:
A. Captopril
B. Esmolol
D. Hydralazine
Ans B
The primary goal is to reduce the force of left ventricular con-traction without compromising perfusion, thus reducing shear forces and preventing further extension of the dissection or possible rupture. Beta-blockers (e.g. esmolol, metoprolol) and labetalol (beta- and alpha-blocker) can be used. If further reduction in BP is required, sodium nitroprusside, glyceryl trinitrate, or hydralazine are appropriate. Beta-blockers should be given first before vasodilators, as the reflex catecholamine release due to vasodilatation may increase left ventricular contractions.
TMP-Jul10-015 Type of dissection – which is classically for NON-operative management:
A. DeBakey Type I
B. DeBakey Type II
C. Stanford A
D. Stanford B
E. Stanford C
Ans D
In acute type B aortic dissections, surgical intervention is only indicated if there is persistent or recurrent intractable pain, aneur-ysm expansion, peripheral ischaemic complications, and rupture.
This is because surgical repair has no proven superiority over non-surgical treatment in stable type B dissection patients.
Stanford A involves ascending aorta but may extend into arch and descending aorta
Type B involves descending aorta only, dissection distal to left subclavian artery origin
DeBakey -
Type I involves ascending aorta, arch, descending aorta
Type II - confined to ascending aorta
Type III - descending aorta distal to left subclavian artery (IIIa up to diaphragm, IIIb beyond)
TMP-Jul10-016 TURP – patient under spinal. Confused. ABG: Na+ 117 / normal gas exchange. Treatment ?
A. 10 ml 20% Saline as fast push IV
B. 3% NS 100 ml/h
C. Normal saline 200 ml/h
D. Frusemide 40 mg IV
E. Fluid restrict 500 ml/day
Ans B
Hypertonic saline (3%) is indicated to correct severe hyponatraemia, if serum sodium ,120 mmol litre-1 or if severe symptoms develop.
Correction should be no more than 2 mmol/L per hour initially for 3 to 4 hours, then about 1 mmol/L per hour afterwards. In 24 hours, correction should be no more than 12 mmol/L.
-use frusemide
-fluid restriction
TMP-Jul10-017 Male undergoing trans-sphenoidal surgery. Now Na+ 155mmol/l and thirsty with polydypsia. Treatment:
A. Desmopressin (DDAVP)
B. Fluid restrict
C. Aldosterone
Ans A
DDAVP for diabetes insipidus

Results from absolute or relative lack of ADH in response to normal physiologic triggers such as hyperosmolarity
Central or nephrogenic
Typically polyuria is compensated for by thirst and excess consumption of fluid to match output

Usual features are:
Hypertonic plasma with hypotonic urine
Plasma ~ high normal > 290 – 300
Urine 50 – 200 mosm/L
High Volume Urine output:
> 4 – 6 L/day or > 3ml/kg for 4 - 6 consecutive hours

Determines if central or nephrogenic
• 10mcg DDAVP nasally
• 1mcg DDAVP S/C or IV
Central will be associated with 50% increase in urine osmolality

1 – 4 mcg/hr IV continuous
10 – 40 mcg intranasal
Duration 12 – 24 hr intranasal
TMP-Jul10-018 The STRONGEST stimulus for ADH secretion:
A. High serum osmolality
B. Low serum osmolality
C. Hypovolaemia
D. High serum Na
C. Volume wins - sensitive to 1-2% change in osmolarity or 10% change in volume, but volume response is STRONGER
TMP-Jul10-019 Stellate ganglion block. Needle entry next to SternoCleidoMastoid muscle at C6. Which direction to advance needle ?
A. C3
B. C4
C. C5
D. C6
E. C7
D. C6
Ref: Anaesthesia UK site


Pain syndromes
Complex regional pain syndrome type I and II
Refractory angina
Phantom limb pain
Herpes zoster
Shoulder/hand syndrome

Vascular insufficiency
Raynaud's syndrome
Obliterative vascular disease

Although the ganglion lies at the level of the C7 vertebral body, the needle is inserted at the level of C6 to avoid the piercing the pleura.
TMP-Jul10-020 20. Thermoneutral zone in 1 month old infant ?
A. 26 – 28 degrees Celcius
B. 28 – 30 degrees Celcius
C. 30 – 32 degrees Celcius
D. 32 – 34 degrees Celcius
E. 34-46 degrees celcius
Ans D
Neonatal Physiology, AICU 2008

Thermal stress is the extra energy required to maintain normothermia. It can occur with a normal core temperature as the neonate uses extra energy to maintain normothermia. Thermal stress can also occur if a baby is overheated because energy must be used to lose heat. The thermoneutral environment therefore minimizes neonatal energy requirements in maintaining a normal core temperature of 36.5–37.5°C rectal (axilla is 0.5–1.0°C lower). The thermoneutral temperature range varies with age and whether the baby is wearing clothes or not. The range for a naked term baby at 1 week is 32.0–33.5°C and 24.0–27.0°C when the baby is clothed. In comparison, a 30-week gestation baby’s range is 34.0–35.0°C naked and 28.0–30.0°C clothed. The point at which an increase in metabolic rate is required to maintain normothermia is defined as the critical temperature.
TMP-Jul10-021 A 60 year old man describes orthopnoea. On examination: pansystolic murmur (at Left Sternal Edge)/ displaced apex beat. Likely diagnosis ?
A. Mitral regurgitation
B. Aortic stenosis
C. Mitral stenosis
Ans A
Other options weren't recalled and have just been guessed at.
TMP-Jul10-022 A 4 year old child with VSD (repaired when 2 years old) for dental surgery. What antibiotic prophylaxis do the guidelines recommend?
A. Amoxycillyn orally
B. Amoxycillin IV
C. Cephazolin IV
D. Amoxycillin / gentamicin
E. No antibiotics required
E. AHA guidelines say after 6 months nil required if no leak

+ Anaesthetic implications of CHD (AIC 2003)
TMP-Jul10-023 A 4 year old child with Arthrogrophysis multiplex congenita for dental surgery. Jaw rigidity post induction. Likely cause ?
A. Temporomandibular joint involvement/ TMJ rigidity
B. Inadequate depth of anaesthesia
C. Inadequate muscle relaxation/ inadequate sux
D. Masseter spasm
E. ?
No increased risk MH.
Arthrogryposis multiplex congenita refers to a variety of conditions that involve congenital limitation of joint movement. Intelligence is relatively normal except when the arthrogryposis is caused by a disorder or syndrome that also affects intelligence.
There are two major types of arthrogryposis multiplex congenita (AMC):
Amyoplasia (classic arthrogryposis): Multiple symmetric contractures occur in the limbs.
Distal arthrogryposis: The hands and feet are involved, but the large joints are spared.
Any condition that impairs in utero movement for > 3 wk can result in AMC. Causes may involve
Physical limitation of movement (eg, due to uterine malformations, multiple gestations, oligohydramnios)
Maternal disorders (eg, multiple sclerosis, impaired uterine vascularity)
Fetal disorders (eg, neuropathies; myopathies, including muscular dystrophies; connective tissue abnormalities; impaired fetal vascularity; anterior horn cell disease)
More than 35 specific genetic disorders (eg, spinal muscular atrophy type I, trisomy 18) have been linked to AMC.
Symptoms and Signs
Deformities are prominent at birth. AMC is not progressive; however, the condition that causes it (eg, muscular dystrophy) may be. Affected joints are contracted in flexion or extension. In classic AMC, shoulders are sloped, adducted, and internally rotated; the elbows are extended; and the wrists and digits are flexed. Hips may be dislocated and are usually slightly flexed. Knees are extended; feet are often in the equinovarus position. Leg muscles are usually hypoplastic, and limbs tend to be tubular and featureless. Soft-tissue webbing sometimes occurs over ventral aspects of the flexed joints. The spine may be scoliotic. Except for slenderness of the long bones, the skeleton appears normal on x-rays. Physical disabilities may be severe. As noted, some children may have primary CNS dysfunction, but intelligence is usually unimpaired.
Endotracheal intubation during surgery may be difficult because children have small immobile jaws. Other abnormalities that rarely accompany arthrogryposis include microcephaly, cleft palate, cryptorchidism, and cardiac and urinary tract abnormalities.
TMP-Jul10-024 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
TMP-Jul10-025 Advantages of bronchial blockers over double lumen tubes:
A. Able to achieve lobar isolation
B. Lower cuff pressure
C. Quicker deflation of isolated lung
D. Pneumonectomy
E. Lower incidence of malposition
Campos, Thoracic Anaesthesia, DLT versus bronchial blockers
Therefore, the use of a bronchial blocker is more advantageous than the DLTs for difficult airways (nasal and
oral), rapid sequence induction, or in patients with an
existing tracheostomy who require lung isolation [15].
In contrast, the depth of insertion of a bronchial blocker is
not an issue as long as the tip of the single-lumen
endotracheal tube is at least 2cm above the tracheal
carina, so the bronchial blocker can be manipulated into
the desired bronchus.
For an absolute lung separation or sleeve pneumonectomy, the use of a right or left-sided DLT is the best choice.
Bronchial blockers are a better choice for patients with
difficult airways, for selective lobar ventilation, or
wherever postoperative mechanical ventilation is contemplated
TMP-Jul10-026 Patient for pneumonectomy. Pre op FEV1 2.4. (Predicted 4.5L) FVC given as well. For R lower lobectomy. Postoperative predicted FEV1 ?
A. 1.3
B. 1.5
C. 1.7
D. 1.9
E. 2.2
C. Because of how many segments there follow.

CEACCP article (2006), we can calculate a predicted post-op FEV1 (ppoFEV1) by calculating how many broncho-pulmonary segments of lung will remain after surgery. The starting number varies depending on the text/classification you use, but this article suggests 19 lung segments in total - 10 on the right (RUL=3, RML=2, RLL=5), and 9 on the left (LUL=3, Lingula=2, LLL=4). Given that the right lung is physically and functionally larger than the left this makes sense. Therefore for a right lower lobectomy we will be removing 5 segments, and therefore be left with 14 segments. The ppoFEV1 will be 14/19 x 2.4L = 0.7368 x 2.4L = 1.77L.
TMP-Jul10-027 Post accidental dural puncture with epidural needle. Headache. 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)
TMP-Jul10-028 Cell saver. Which does NOT get filtered ?
A. Foetal cells
B. Free Hb
C. Platelets
D. Clotting factors
E. Microaggregates of leukocytes
A. Fetal cells. But they've shown it's no worse than labour/delivery and the UK College recommends for LSCS now.

Red cells are retained, while the plasma, platelets, heparin, free haemoglobin, and inflammatory mediators are discarded with the wash solution.
Cell salvage is increasingly used in the UK in obstetrics in the
management of major obstetric haemorrhage. Concerns about amniotic fluid embolism, fetal debris contamination, and rhesus sensitization previously limited such use. However to date, there have been no proven cases of amniotic fluid embolism caused by reinfusion of salvaged blood in the literature. There is increasing evidence supporting the safety of cell salvage in obstetrics, and this has been approved by NICE.7 In pregnancies involving an Rh-negative mother and an Rh-positive fetus, a Kleihauer test should be performed in the immediate post-partum period. This will allow the calculation of the appropriate dose of anti-D immunoglobulin (usually 125 IU ml21 of fetal blood) if required.
TMP-Jul10-029 You are on a humanitarian aid mission in the developing world. Drawover vaporiser apparatus described being used. Given 400 mm tubing, OMV or diamedica vaporiser, 200mm tubing attached to self-inflating bag. Which other ONE piece of equipment is ESSENTIAL to make this system functional?
A. Halothane
B. In-line Waters' Cannister [1]
C. Non-rebreathing valve
D. Oxygen source
E. Ventilator
A. Doesn't have to be haolthane
B. ?
C. TRUE - see reference below
D. Not essential. Certainly desireable
E. False. Supplied with self-inflating bag as stated.
TMP-Jul10-030 Regarding post craniotomy pain:
A. Local infiltration proven to reduce long-term pain
B. Local more painful than discrete nerve blocks
C. Local infiltration more efficacious than discrete nerve blocks
D. Local infiltration more efficacious than opioid analgesia
E. Local infiltration more efficacious with clonidine included
Ans A
Acute pain management - scientific evidence - third edition 2010 p247

Local anaesthetic scalp block

A comparison between scalp nerve block and morphine showed no relevant differences in any analgesic parameters (Ayoub et al, 2006 Level II). Scalp infiltration was also no more effective than IV fentanyl (Biswas & Bithal, 2003 Level II)
However, comparisons of scalp blocks with bupivacaine or ropivacaine and placebo showed better analgesia with the local anaesthetic blocks in a number of trials.
Scalp infiltration with ropivacaine also reduced the incidence of persistent pain 2 months after craniotomy, from 56% to 8 %
A comparison between SC local anaesthetic infiltration and occipital/supraorbital nerve block showed no difference between groups in the postoperative period, but nerve blocks were less painful than infiltration analgesia
TMP-Jul10-031 A 60 year old female is undergoing hysterectomy. Gabapentin reduces postoperative:
A. Nausea
B. Vomiting
C. Sedation
D. Pruritus
E. Constipation
Ans A
Acute pain management - scientific evidence - third edition 2010 p91

After hysterectomy and spinal surgery specifically, gabapentin improved pain relief and was opioid-sparing, nausea was less in patients after hysterectomy, and there was no difference in sedation.
TMP-Jul10-032 Burns dressings. The following is proven to be of analgesic benefit:
A. Morphine gel
B. Biosynthetic dressings
C. Dexmedetomidine IV
D. Lignocaine IV
E. Cognitive/Distraction technique
Ans B
Acute pain management - scientific evidence - third edition 2010 p250

The choice of dressing has an effect on time to healing and pain during dressing change; biosynthetic dressings have been found to be superior.
Nitrous oxide (N2O), ketamine and IV lignocaine infusions (Jonsson et al, 1991 Level IV) have also been used to provide analgesia for burn procedures (see Sections 4.3.1, 4.3.2 and 4.3.5), however a Cochrane review reported that more trials were required to determine the efficacy of lignocaine (Wasiak & Cleland, 2007 Level I).
TMP-Jul10-033 Subtenon’s block. What is the worst position to insert block?
A. Inferonasal
B. Inferotemporal
C. Superonasal
D. Supertemporal
E. Medial / canthal
Ans: ?E
Any spot really okay but apparently more muscle insertion points medially
TMP-Jul10-034 Liposuction. Infiltration of lignocaine with 1:200,000 adrenaline. Peak plasma concentration of lignocaine occurs at:
A. 1 hour
B. 3 hours
C. 18 hours
D. 24 hours
E. 30 mins
Ans C
CAECCP Novel techniques of LA infiltration

Tumescent analgesia
The high hydrostatic pressure within the tissues is also thought to be responsible for the delayed systemic absorption and hence delayed and reduced peak plasma concentrations of local anaesthetic, despite the very large doses being used. Doses as high as 22–57 mg kg-1 of lidocaine.

Tumescent technique for regional anesthesia permits lidocaine doses of 35 mg/kg for liposuction.
J Dermatol Surg Oncol 1990
Peak plasma lidocaine levels occurred 12-14 hours after beginning the infiltration.
TMP-Jul10-035 Child-Pugh score. Components ?

A. Bilirubin, INR, creatinine
B. Bilirubin, albumin, INR, AST, encephalopathy
C. Bilirubin, albumin, INR, ascites, encephalopathy
D. Bilirubin, INR, creatinine, ascites, encephalopathy
E. INR, creatinine, ascites, encephalopathy
C - Bilirubin, albumin, INR, ascites, encephalopathy

Other choice not recalled, made up subsequently.

Clinical or biochemical variable
Points scored for increasing abnormality 1 / 2 / 3
The Pugh modification of Child’s classification is used to estimate the risk of mortality in patients with liver disease undergoing surgery. Points from each variable are added to make the total score. A total score of 5 or 6 is considered Child’s class A and is associated with a low operative mortality risk (<5%); a total score of 7–9 (Child’s class B) carries a moderate risk (25%) and total score of 10–15 (Child’s class C) carries a high risk (>50%).
Although this classification was originally used in patients undergoing portosystemic shunts, the variables included have been shown to be predictive of outcome for all types of abdominal surgery in patients with liver disease. Other predictors of poor outcome include malnutrition, emergency surgery, sepsis, and blood loss.
TMP-Jul10-036 Which is NOT a disadvantage of drawover vaporiser versus plenum vaporiser:
A. Temperature compensation
B. Cannot use sevoflurane
C. Small volume reservoir
D. Flow compensation
Ans B
TMP-Jul10-037 Acute renal failure. Which is not an indication for dialysis ?
A. Hyperkalaemia
B. Metabolic alkalosis
C. Hypernatraemia
D. Uraemic pericarditis
Ans C
TMP-Jul10-038 Chronic alcohol use. Which is not an associated complication ?
B. hypertriglyceridemia
C. Macrocytosis
D. Nephrotic syndrome
E. Pancreatic Ca
Ans D
CEACCP Alcohol and the Anaesthetist
TMP-Jul10-039 Chest xray shown of patient post Left pneumonectomy with heart swung to left side. Management:
A. Increase PEEP
B. Roll onto right side
C. Turn on suction to left pleural catheter
D. Lung biopsy
Ans B.
Drain has been left open for too long probably, causing mediastinal shift.
TMP-Jul10-040 Salicylate poisoning:
A. Respiratory acidosis
B. Metabolic acidosis
C. Increased CO2 (production)
D. High output renal failure
E. Hyperthermia
TMP-Jul10-041 New onset atrial fibrillation in a 10 week pregnant lady. BP 150/90, HR 160, SaO2 92%. Moderate mitral stenosis on TTE, no thrombus seen. Emergency doctor gave her anticoagulant (not specified what). Most appropriate management:
A. Verapamil
B. Labetalol 20mg iv to 300mg
C. Amiodarone 300mg IV
D. Synchronised biphasic cardioversion with 70-100 Joule
E. Oral digoxin -1000mcg then 500mcg 6 hrs later
Same managment principles as anyone else. DC shock won't harm baby (?).
TMP-Jul10-042 Patient post anterior cervical fusion. Patient in recovery. Confused and combative. Nurse concerned about haematoma Taken to theatre: Most appropriate way of securing airway:
A. Gas induction / laryngoscopy / intubate
B. Awake tracheostomy
C. Awake fibreoptic intubation using minimal sedation
D. Thiopentone, suxamethonium, direct laryngoscopy and intubation
E. retrograde intubation
Ans A
CEACCP V7 No3 2007
Re-intubation may be difficult. The patients must be managed in a semi-sitting posture. Awake fibreoptic intubation is sometimes a good option, but direct laryngoscopy after sevoflurane and oxygen induction (with judicious doses of propofol) may be easier. The gum-elastic bougie is often vital and an LMA (+fibrescope,+gum elastic bougie or Aintree catheter) or an ILMA-guided technique may save the day. The use of succinylcholine in myelopathic patients is hazardous because of abnormal potassium shifts.
TMP-Jul10-043 Young asthmatic male in emergency department. RR 26, pCO2 27, SAO2 92%, struggling talking in sentences. Given nebulised salbutamol, and ipratropium, 200mg IV hydrocortisone. After 30 minutes - no improvement. Further management:
A. IV salbutamol
B. IV aminophylline
C. IV magnesium
D. Intubate and ventilate
E. ?
TMP-Jul10-044 Called to emergency department to review a 20 y/o male punched in throat at a party. Some haemoptysis / hoarse / soft voice. Next step in management:
A. CT to rule out thyroid cartilage fracture
B. XR to rule out fractured hyoid
C. Rapid sequence induction / laryngoscopy / intubation
D. Awake fibreoptic intubation
E. Nasendoscopy by ENT in emergency department
TMP-Jul10-045 How quickly does the CO2 rise in the apnoeic patient ?
A. 1 mmHg per min
B. 2 mmHg per min
C. 3 mmHg per min
D. 4 mmHg per min
E. 5 or ?8 mmHg per min
ournal of clinical Anaesthesia 1989 328 3.4 mmHg every minute
TMP-Jul10-046 Long-standing T6 paraplegia. All present EXCEPT ?
A. Flaccid paralysis
B. Poikilothermia
C. Autonomic hypereflexia
D. Labile BP
E. Hyperkalaemia with suxamethonium

OHA p240
Return of muscle tone and reflexes after perhaps 3 days to 8 weeks
Rest are longer term (i.e. 9 months)
TMP-Jul10-047 Young female patient for tonsillectomy with history of bleeding tendency. Which is the most likely cause?
A. Factor V Leiden
B. Protein C deficiency
C. Haemophilia B (Christmas disease)
D. Antithrombin III deficiency
E. Lupus anticoagulant
Rest are pro-coagulant and she would clot clot clot.


Bleeding disorders
• Haemophilia A, B, C
• von Willebrand disease
• Factors II, V, VII, X deficiency (common pathway proteins)
• Factor XIII and fibrinogen deficiency

Hypercoagulable diseases
• A ntithrombin III deficiency
• Protein C and S deficiency

• L iver diseases
• Drugs: vitamin K deficiency, warfarin, heparin
• Haemodilution and massive transfusion
• Disseminated intravascular coagulation
• Hyperfibrinolysis
• Venom-induced coagulopathy

• Heparin-induced thrombocytopenia
• Antiphospholipid antibody syndrome (‘lupus anticoagulant’)
• Microvascular thrombosis: thrombotic microangiopathy,
coumarin-induced skin necrosis
TMP-Jul10-048 Amniotic fluid embolism. Cause of death in first half hour ?
A. Pulmonary hypertension
B. Malignant arrhythmia
C. Pulmonary oedema
D. Hypovolaemic shock
TMP-Jul10-049 Hypocalcaemia – earliest sign:
A. Tingling of face and hands
B. Chvostek’s sign
C. Carpopedal spasm

CATS go numb (Convulsions, Arrythmias, Tetany and numbness/parasthesias in hands, feet, around mouth and lips)
Oral, perioral and acral paresthesias, tingling or 'pins and needles' sensation in and around the mouth and lips, and in the extremities of the hands and feet. This is often the earliest symptom of hypocalcaemia.
TMP-Jul10-050 Elderly COAD patient. On home oxygen. 24 hours of worsening condition. Various blood gases given:
A. paO2 > 50, paCO2 70 HCO3 30
B. paO2 > 80, paCO2 55 HCO3 29
C. paO2 > 50, paCO2 70 HCO3 27
A - worst hypoxia and respiratory acidosis with biggest chronic change.

Other options not recalled, made up subsequently.
TMP-Jul10-051 Visual loss with pupillary reflexes retained. Likely cause ?
A. Retinal detachment
B. Occipital mass
C. Frontal mass
D. Chiasmal mass
E. Optic neuritis
Cortical blindess = visual loss but with retained pupillary reflexes and normal fundoscopy. Caused by pathology in the occipital lobes.
This damage is most often caused by loss of blood flow to the occipital cortex from either unilateral or bilateral posterior cerebral artery blockage (ischemic stroke). A patient with cortical blindness often has little or no insight that they have lost vision, a phenomenon known as Anton's Syndrome or Anton-Babinski syndrome.
Retinal detachment – an extensive retinal detachment involving the macular area would produce acute visual loss and this patient will complain of flashing lights followed by a large number of floaters and then a shade or blind covering the visual field. An afferent pupillary defect is usually present. The diagnosis is confirmed by ophthalmoscopy through a dilated pupil, and retina appears elevated with folds and the choroidal background is indistinct.
Optic Neuritis: Optic Neuritis is inflammation of the optic nerve and is usually associated with multiple sclerosis in a significant number. The visual acuity is markedly reduced and an afferent pupillary defect is present. The optic disc initially appears hyperemic and swollen. The visual acuity usually recovers; however, repeated episodes of optic neuritis may lead to permanent loss of
TMP-Jul10-052 Nerve block for anaesthesia over anterior 2/3 of ear?
A. C2
B. Mandibular nerve
C. Maxillary nerve
D. Ophthalmic nerve
E. Vagus
Four sensory nerves supply the external ear: (1) greater auricular nerve, (2) lesser occipital nerve, (3) auricular branch of the vagus nerve, and (4) auriculotemporal nerve. (Emedicine)
The greater auricular nerve is a branch of the cervical plexus. It innervates the posteromedial, posterolateral, and inferior auricle.
The lesser auricular nerve innervates a small portion of the helix.
The auricular branch of the vagus nerve innervates the concha and most of the area around the auditory meatus.
The auriculotemporal nerve is a branch of the mandibular branch of the trigeminal nerve. It innervates the anterosuperior and anteromedial aspect of the auricle.
The external auditory canal and tympanic membrane have separate innervation.
TMP-Jul10-053 Complex regional pain syndrome. What proportion of patients have motor involvement ?
A. 0 %
B. 25 %
C. 50 %
D. 75 %
E. 95 %

CRPS type I (previously called reflex sympathetic dystrophy) is diagnosed where there is no evidence of a precipitating nerve injury
CRPS Type II (previously called causalgia) where a nerve injury is present.

Motor / trophic changes
- motor dysfunction 57-98%
- weakness 75-95%
- limited range of movement 80-88%
- incoordination 47%
- tremor 48%
- spasm 13%
- dystonia 14%
- myoclonus 4-20%
TMP-Jul10-054 Malignant hyperthermia. The number of people in the community at any given time with a predisposition is called the:
A. Prevalence
B. Incidence
C. Occurance
D. Rate
E. Denominator
Prevalence = measures how much of some disease or condition there is in a population at a particular point in time.
Incidence = the rate of occurrence of new cases of a disease or condition.

Incidence of MH (per wiki) is 1:15000 anaesthetics for children and adolescents and 1:50-150000 anaesthetics for adults.
Prevalence for susceptabiity may be as high as 1:2000
TMP-Jul10-055 Patient with Hx COAD and suspected pneumonia – clinical findings supporting R pneumonia on examination:
A. R Dull percussion note & increased vocal resonance
B. R Dull percussion note & decreased vocal resonance
C. R Decreased air entry
D. Tracheal deviation to left
E. Tracheal deviation to right
Pneumonia = dull percussion note (drum effect of hollow viscera is lost), decreased breath sounds, may be bronchial breath sounds, increased vocal resonance (through consolidated lung)
TMP-Jul10-056 Thallium scan:
A. High negative predictive value
B. High positive predictive value
C. Not as good as a dobutamine stress echocardiography
AHA/ACCHA Guidelines:
The 2 main techniques used in preoperative evaluation of
patients undergoing noncardiac surgery who cannot exercise
are to increase myocardial oxygen demand (by pacing or
intravenous dobutamine) and to induce hyperemic responses
by pharmacological vasodilators such as intravenous dipyridamole
or adenosine. The most common examples presently
in use are DSE and intravenous dipyridamole/adenosine
myocardial perfusion imaging with both thallium-201 and
From the 2007 AHA guidelines,
'because of a very high sensitivity of abnormal stress nuclear imaging studies for detecting patients at risk for perioperative cardiac events, the negative predictive value of a normal scan has remained uniformly high at approximately 99% for MI or cardiac death'.
Thallium scanning in coronary artery disease (CAD) using radioactive thallium-201(201-Tl) is a widely available technique which is sensitive, accurate and noninvasive. It detects CAD accurately in patients with:
atypical chest pain and a positive exercise ECG or
typical chest pain and a negative exercise ECG.
TMP-Jul10-057 A 50 y/o male diabetic admitted to intensive care with pneumonia. Intubated and ventilated. Extensive results given. BP 80/-, HR 120, CVP 4, PCWP 6, SvO2 69% PaO2 80, BE -4 pH 7.2. Management:
A. Blood transfusion
B. Bicarbonate infusion
C. Fluid resuscitation
D. Adrenaline infusion
E. Insulin infusion
C. Fluids.
Low CVP, hypotensive, tachycardic, low PCWP.
Acidosis could be diabetic or lactate .

No reason for Blood unless low Hb.
Bicarb contraindicated in DKA as need to breathe off excess CO2
Adrenaline - if non-responsive to fluid
Insulin - depends if hyperglycaemic
TMP-Jul10-058 Young female having cholecystectomy. Venous air embolus:
A. Mechanical ventilation and PEEP is part of treatment strategy
B. Most likley to occur at initial gas insufflation, but can occur at any time
C. Inert gas (argon, xenon) is safer
B. Classically due to insufflation of CO2 via a hasson cannula, but cut surfaces e.g. of liver may permit entry of gas. "This complication develops principally during the induction of pneumoperitoneum, particularly in patients with previous abdominal surgery." Miller 7th ed. p. 2188.

Two preconditions must exist for venous air embolism to occur: (1) a direct communication between a source of air and the vasculature and (2) a pressure gradient favoring the passage of air into the circulation. Severity depends on volume of gas (20ml/kg, or 2-3ml into cerebral circulation), rate of accumulation (rapid entry puts a strain on RV, and if increases PAP can lead to RV outflow obstruction), and patient's position at time of event.

Tachyarrhythmias common; bradyarrhythmias can occur, + "Mill wheel" murmur - A temporary loud, machinerylike, churning sound due to blood mixing with air in the right ventricle, best heard over the precordium (a late sign)

Positioning: Generally, if the patient is in a sitting position, gas will travel retrograde via the internal jugular vein to the cerebral circulation, leading to neurologic symptoms secondary to increased intracranial pressure. In a recumbent position, gas proceeds into the right ventricle and pulmonary circulation, subsequently causing pulmonary hypertension and systemic hypotension.

Incidence - 10% for cervical laminectomy (prone) - 80% in posterior fossa (Fowler's (sitting)).
VAE pose a risk whenever wound is > 5cm about RA
Inert gases NOT safer - CO2 safest as dissolves fastest

TREATMENT = ABC; place patient in left lateral and trendeleburg position; remove air from CVC if possible (see VAE CEACCP)
TMP-Jul10-059 LUSCS for failure to progress. Spinal is inserted uneventfully. Next day the patient has foot drop. The most likely cause is?
A. epidural haematoma
B. lumbosacral palsy
C. sciatic nerve palsy
D. common peroneal palsy
B. It's never us ;) CEACCP 2003:
"Postpartum foot drop is caused by damage to the lumbosacral trunk or, less frequently, the common peroneal nerve. The lumbosacral trunk (L4, L5) is compressed between the ala of the sacrum and the descending fetal head. It may also occur during a forceps delivery. The result is a unilateral foot drop with loss of sensation and/or paraesthesia along the lateral calf and foot."
"Common peroneal nerve damage may occur due to improper or prolonged positioning during lithotomy and the sensory deficit may be limited to the dorsum of the foot."
Epidural haematomas extremely rare (1:168,000 from review in Anaesthesiology 2006; 105: 394)and obstetric palsies are much more common than complications related to neuraxial blocks.
Sciatic nerve injury would cause a foot drop but would also affect knee flexion (hamstrings) and all muscles in lower leg and foot.
Common peroneal nerve palsy less likely in this case as there is no mention of stirrups or 'excessive knee holding'
TMP-Jul10-061 Severe pre-eclampsia. WORST treatment option:
A. Magnesium
B. Nifedipine
C. Metoprolol
Ans D
Magnesium if questions say about hypertension
Beta blockers could tip into LVF and APO however SIG says some B blockers (metoprolol, pindolol, propranolol) are ok.
SNP is rarely used and not recommended due to hypotension, paradoxical bradycardia with severe PET and unknown risk of fetal cyanide toxicity
TMP-Jul10-062 In pregnancy the dural sac ends at:
A. T12
B. L2
C. L4
D. S2
E. S4
Ans D
TMP-Jul10-064 Another pregnant woman with ?MS. Develops SVT. Try vagal manouveres without success.
A. Adenosine
B. ?
C. ?
A. Adenosine or shock if unstable
BJA 2004 "SVT in Pregnancy"
Drug use in labour or LSCS can precipitate SVT. Careful with synto, and ephedrine.
Regional anaesthesia --> decreased filling and may precipitate. Ensure aortocaval tilt is used.
Adenosine, a naturally occurring purine nucleotide, transiently depresses sinus node activity and slows atrioventricular conduction, and is effective in terminating SVT.
It is rapidly metabolized with an elimination half-life of less than 10 s, making it ideally suitable for use in pregnancy.

If adenosine fails, other antiarrhythmics may be indicated and the risk of their use should be weighed against the risk of continuing SVT. Beta-blockers have been used extensively in pregnancy, to treat maternal hypertension and cardiac problems, and are generally well tolerated. They are the agents of choice in Wolf-Parkinson-White syndrome, where AV nodal blocking drugs may lead to acceleration of conduction through the accessory pathway and the arrhythmia being sustained.

Verapamil, a calcium channel-blocking agent, is as effective as adenosine in converting an SVT to sinus rhythm. Peripheral vasodilation and negative inotropy are unwanted side-effects. There are reports of its safe use in pregnancy for treatment of SVT.

Digoxin has been used in all stages of gestation for maternal and fetal indications without causing harm.

Amiodarone is best avoided because of its potential teratogenic effects and reports of fetal toxicity, but again there are reports of its safe use during pregnancy.

Synchronized electrical cardioversion may necessary for SVT resistant to pharmacological therapy, particularly if hypotension develops. Direct current electrical shock has been used at all stages in pregnancy without significant complication. The current reaching the fetus is thought to be negligible. However, transient fetal dysrhythmia has been described, and monitoring of fetal heart rate during maternal cardioversion is advisable. Implantable devices have been successfully used during pregnancy for malignant tachyarrhythmias. Both temporary and permanent endocardial pacing has been used in pregnancy, although mainly in the treatment of bradyarrhythmias.
TMP-Jul10-064 Pregnant woman presents with narrow complex tachycardia HR 190, stable BP 100/60. No response to vagal manoevures. Management?
A. Adenosine 6mg
B. Magnesium
C. Amiodarone
D. Atenolol
E. DC shock
A Adenosine

A. Adenosine or shock if unstable
BJA 2004 "SVT in Pregnancy"
Drug use in labour or LSCS can precipitate SVT. Careful with synto, and ephedrine.
Regional anaesthesia --> decreased filling and may precipitate. Ensure aortocaval tilt is used.

If adenosine fails, other antiarrhythmics may be indicated and the risk of their use should be weighed against the risk of continuing SVT. Beta-blockers have been used extensively in pregnancy, to treat maternal hypertension and cardiac problems, and are generally well tolerated. They are the agents of choice in Wolf-Parkinson-White syndrome, where AV nodal blocking drugs may lead to acceleration of conduction through the accessory pathway and the arrhythmia being sustained.

Verapamil, a calcium channel-blocking agent, is as effective as adenosine in converting an SVT to sinus rhythm. Peripheral vasodilation and negative inotropy are unwanted side-effects. There are reports of its safe use in pregnancy for treatment of SVT.

Digoxin has been used in all stages of gestation for maternal and fetal indications without causing harm.

Amiodarone is best avoided because of its potential teratogenic effects and reports of fetal toxicity,

Synchronized electrical cardioversion may necessary for SVT resistant to pharmacological therapy, particularly if hypotension develops. Direct current electrical shock has been used at all stages in pregnancy without significant complication. The current reaching the fetus is thought to be negligible. However, transient fetal dysrhythmia has been described, and monitoring of fetal heart rate during maternal cardioversion is advisable.
TMP-Jul10-065 Which gives the BEST seal?
A LMA classic
B Proseal
C Intubating LMA
D. ?
E. ?
According to anesth analg 2008 A Comparison of Seal in Seven Supraglottic Airway Devices Using a Cadaver Model of Elevated Esophageal Pressure
B according to product info
CEACCP Supraglottic Airway Deices - Recent Advancements
From the LMA website / product information:
LMA Classic - Seal pressure up to 20cm H20
LMA Supreme™ - measured oropharyngeal leak pressures up to 37 cm H2O
LMA Flexible™ - oropharyngeal seal pressures up to 20 cm H2O
LMA Fastrach - Seal pressures up to 20 cm H2O
LMA ProSeal™ - leak pressures up to 32 cm H2O

(Oesophageal seat = ILMA; Concerning the risk of aspiration, the use of devices with an additional esophageal drainage lumen might be superior for use in patients with an increased risk of aspiration. The Combitube, Easytube, and intubating laryngeal mask Fastrach showed the best capacity to withstand an increase of esophageal pressure.)
TMP-Jul10-067 Peak plasma lignocaine level after epidural lignocaine.

A. 10 min
B. 30 min
C. 1 hour
D. 2 hours
E. 3 hours
Br J Clin Pharmacol 1996; 42: 242245
Peak lignocaine concentration ~30 mins
TMP-Jul10-068 ?possible repeat Lady on citalopram. Which drug is relatively contraindicated?
A Tramadol
B. Clonidine
C. Ondansetron
D. Metaraminol
Ans A Serotonin syndrome
AC158 A 30yo Male. 5 hour operation. Arms abducted to 60 degrees. Head turned slightly to left side. Post op numb palm/thumb/index finger/middle finger and lateral half of ring finger. Numb ventral forearm. Weak finger grip. Weak elbow flexion. Most likely nerve injured?
A. median nerve
B. musculocutanous nerve
C. upper trunk of brachial plexus
D. ?brachial plexus stretch
A. Median nerve doesn't supply elbow flexion (this is upper arm - brachialis (musculocutaneous), brachioradialis (radial), biceps (musculocutaneous)
B. coracobrachialis, brachialis and biceps brachi but not median nerve sensory
C. Think it must be to encompass m/cutaneous + median
D. ?
MC77 [Aug10] Repeat Q Diastolic dysfunction is NOT caused by:
A Adrenaline
B Aortic stenosis
C Hypertension
D myocardial fibrosis
E ?
A. Adrenaline

Left ventricular (LV) diastolic dysfunction refers to abnormalities of diastolic distensibility, filling, or relaxation, regardless of whether LV ejection fraction (LVEF) is normal or abnormal and whether the patient is symptomatic or not.
The major causes of diastolic dysfunction include:
chronic hypertension
hypertrophic cardiomyopathy
aortic stenosis
coronary artery disease
restrictive cardiomyopathy (a rare condition in which the heart muscle is infiltrated, and made stiff, by abnormal cells, protein, or scar tissue. The most common cause of restrictive cardiomyopathy is amyloidosis, a disease in which protein-like substance is deposited within the body's tissues. Other causes include sarcoidosis and haemochromatosis.)
aging (Whether age alone causes stiffening of the ventricles, or whether such stiffening is related to "subclinical hypertension" or some other definable medical condition, is not yet worked out.)
MC157 An 18 yo with Fontan circulation undergoing exploratory laparotomy. On ICU vent, sats 70%. Which ventilator parameter would you INCREASE to improve his sats?
A. Bilevel pressure
B. Expiratory time
C. Inspiratory time
D. Peak inspiratory pressure
B. Expiratory time

Low respiratory rates, short inspiratory times, low PEEP,
and tidal volumes of 5–6 ml kg21 usually allow adequate pulmonary
blood flow, normocarbia, and a low PVR.
SC33 A 7 kg Infant with tetralogy of fallot, post BT-shunt. Definitive repair at later date. Paralysed and ventilated. Sats 85% baseline, now 70%, best treatment:
A. Increase FiO2 from 50 - 100%
B. Esmolol 70 mcg
C. Phenylephrine 35 mcg
D. Morphine 1 mg
E. 1/2 NS with 2.5% dex 70 mls
C. Phenylephrine - will increase SVR and L pressures, reducing R-L shunt.

(increase FiO2 won't change if big shunt)

Frank Shann's dose recommendation for phenylephrine is 2-10 mcg/kg as a bolus, which would fit nicely with C (5mcg/kg).
MN41 Von Hippel-Lindau disease is associated with:
A. increased risk of malignant hyperthermia
B. meningiomas
C. peripheral neuropathy
D. pheochromocytomas
E. poor dentition
D. Pheo
"Management of anesthesia in patients with von Hippel-Lindau disease must consider the possible presence of pheochromocytomas" (Stoelting)
von Hippel-Lindau disease (VHL) is a rare, genetic multi-system disorder characterized by the abnormal growth of tumors in certain parts of the body (angiomatosis).
The tumors of the central nervous system (CNS) are benign and are comprised of a nest of blood vessels and are called hemangioblastomas (or angiomas in the eye). Hemangioblastomas may develop in the brain, the retina of the eyes, and other areas of the nervous system.
Other types of tumors develop in the adrenal glands, the kidneys, or the pancreas.
Symptoms of VHL vary among patients and depend on the size and location of the tumors. Symptoms may include headaches, problems with balance and walking, dizziness, weakness of the limbs, vision problems, and high blood pressure. Cysts (fluid-filled sacs) and/or tumors (benign or cancerous) may develop around the hemangioblastomas and cause the symptoms listed above. Individuals with VHL are also at a higher risk than normal for certain types of cancer, especially kidney cancer.
Inheritance = Familial Autosomal dominant
Features= Retinal angiomas, Haemangioblastomas, Cerebellar and visceral tumours (usually benign but can cause pressure effects)
Associations = An increased incidence of Phaeochromocytoma - apparently 20%, Renal cysts, Renal cell carcinoma

Anaesthesia= Treat hypertension occurring with phaeochromocytoma, Haemangioblastoma of spinal cord may limit use of spinal although epidural has been used for LSCS, Exagerrated hypertension with surgical stimulation or laryngoscopy = Treat with β blockers and/or SNP

From recollection, Phaeos are associated with the Diseases of Von- Ie. Von Recklinghausen and Von Hippel Lindau.
MH59 70 year old post TKJR. On sub-cut heparin. Develops clinical DVT and platelets 40 (sounds like HITS type-II). Management
A. Enoxaparin
B. Fondoparinux
C. Heparin by infusion
D. Lepirudin
E. Warfarin
D - no other direct thrombin inhibitors on list.
MC161 Drug eluting stent 6 months old. On aspirin and prasugrel 10mg. Elective lap cholecystectomy for biliary colic.
A. Do case while taking both.
B. Do case while stopping both.
C. Stop Prasugrel for 7 days, keep taking aspirin.
D. Stop Prasugrel for some other different time
E. Post-pone for 6 months

ACC/AHA Pre-op:
Thrombosis of DES may occur late and has been reported up to 1.5 years after implantation, particularly in the context of discontinuation of antiplatelet agents before noncardiac surgery.

Discontinuation of antiplatelet therapy in the early-surgery group resulted in a 30.7% incidence of MACE (all fatal) versus a 0% incidence in early-surgery patients who continued dual antiplatelet therapy perioperatively. Overall, there was no difference in MACE between patients with bare-metal stents and those with DES. The study reported that all patients with MACE had discontinued antiplatelet therapy before surgery, whereas only 46% without MACE had done so. The study also stated there was no difference in surgical risk between patients in whom antiplatelet agents were discontinued and those in whom they were not. Excessive blood loss occurred in 2 patients, 1 of whom was receiving antiplatelet agents and 1 of whom was not.

** The panel concurred with the AHA/ACC guideline recommendation for 12 months of dual-antiplatelet therapy after DES implantation in patients who are not at high risk for bleeding.
**1. Before implantation of a stent, the physician should discuss the need for dual-antiplatelet therapy. In patients not expected to comply with 12 months of thienopyridine therapy, whether for economic or other reasons, strong consideration should be given to avoiding a DES.

A thienopyridine (ticlopidine or clopidogrel) is generally administered with aspirin for 4 weeks after bare-metal stent
placement. The thienopyridines and aspirin inhibit platelet aggregation and reduce stent thrombosis but increase the risk of bleeding. Rapid endothelialization of bare-metal stents makes late thrombosis rare, and thienopyridines are rarely needed for more than 4 weeks after implantation of baremetal stents. For this reason, delaying surgery 4 to 6 weeks after bare-metal stent placement allows proper thienopyridine use to reduce the risk of coronary stent thrombosis; then, after the thienopyridine has been discontinued, the noncardiac surgery can be performed. However, once the thienopyridine is stopped, its effects do not diminish immediately. It is for this reason that some surgical teams request a 1-week delay after thienopyridines are discontinued before the patient proceeds to surgery. In patients with bare-metal stents, daily aspirin antiplatelet therapy should be continued perioperatively. The risk of stopping the aspirin should be weighed against the benefit of reduction in bleeding complications from the planned surgery. In the setting of noncardiac surgery in patients who have recently received a bare-metal stent, the risk of stopping dual-antiplatelet agents prematurely (within 4 weeks of implantation) is significant compared with the risk of major bleeding from most commonly performed surgeries.
MZ80 Arterial blood gases (ABGs): pH 7.12, PO2 100, PCO2 65, HCO3 20.3, BE -10. Consistent with?
A. Chronic renal failure
B. Malignant hyperthermia
C. Diabetic ketoacidosis
D. End-stage respiratory failure
E. Ethylene glycol toxicity
Combined metabolic and respiratory acidosis = MH!
a. CRF wouldn't have high CO2
c. DKA = low CO2 to breathe off
d. Would be metabolic compensation i.e. high bicarb
e. Would try to breathe off CO2 to compensate for non-anion gap metabolic acidosis
TMP-100 Compared to lignocaine, bupivacaine is
A. Twice as potent
B. Three times as potent
C. Four times as potent
D. Five times as potent
E. Same potency
Ans C
TMP-101 Aneurysm sugery. Propofol/remifentanil/NMDR. Depth of anaesthesia monitoring (Entropy) is being used. MAP 70 , HR 70/min, State entropy 50, Response entropy 70. What do you do?

A. ?
B. Metaraminol
C. Check TOF
D. Nothing
E. Increase TCI.
RE of 70 compared to SE of 50 means paralysis is wearing off
TMP-102 Interscalene block, patient hiccups...where do you redirect your needle?
A. Anterior
B. Posterior
C. Caudal
D. Cranial
E. Superficial
It is stimulating the phrenic nerve
TMP-103 What is the SVR in a patient with MAP 100mmHg, CVP 5, PCWP 15, CO 5L/min?
A. 20 dynes.sec/cm-5
B. 19 dynes.sec/cm-5
C. 520 dynes.sec/cm-5
D. 1280 dynes.sec/cm-5
E. 1520 dynes.sec/cm-5
Ans E
SVR=constant * (MAP-CVP)/CO
TMP-104 Stellate ganglion is:
A. Anterior to scalenius anterior
B. Posterior to scalanius anterior
C. Medial to scalanius medial
D. Inferior to scalanius posterior
E. Intraabdominal
Ans A

Other answers not recalled, have been made up since.

The inferior cervical ganglion lies at the level of the disc space between the 7th cervical and 1st thoracic vertebrae; in 80% of subjects it is fused with the 1st thoracic ganglion to form the stellate ganglion. It represents the coalescence of the 7th and 8th cervical ganglia.
Relations of stellate ganglion

Anterior: The structures anterior to the ganglion include the skin and subcutaneous tissue, the sternocleidomastoid and the carotid sheath. The dome of the lung lies anterior and inferior to the ganglion.

Medial: The prevertebral fascia, vertebral body of C7, oesophagus and thoracic duct lie medially.

Posterior: Structures posterior to the ganglion include the longus colli muscle, anterior scalene muscle, vertebral artery, brachial plexus sheath and neck of the first rib.
TMP-105 The median nerve
A. can be blocked at the elbow immediately medial to the brachial artery
B. can be blocked at the wrist between palmaris longus and flexor carpi ulnaris
C. can be blocked at the wrist medial to flexor carpi ulnaris
D. is formed from the lateral, medial, and posterior cords of the brachial plexus
E. provides sensation to the ulnar half of the palm
Ans A - median nerve lies medial to brachial artery.

B false - lies between palmaris longus and flexor carpi RADIALIS.
TMP-106 A 75yo male with moderate aortic stenosis (valve area 1.1cm2).. Gets mild dyspnoea on exertion but otherwise asymptomatic. Needs hip replacement.
A. Continue with surgery
B. Beta block then continue
C. Get myocardial perfusion scan
D. Postpone surgery awaiting AVR
E. Postpone surgery awaiting balloon valvotomy
ACC AHA 2007

In symptomatic aortic stenosis, elective noncardiac surgery should generally be postponed or canceled. Such patients require aortic valve replacement before elective but necessary noncardiac surgery.

If the aortic stenosis is severe but asymptomatic, the surgery should be postponed or cancelled if the valve has not been evaluated within the year.

On the other hand, in patients with severe aortic stenosis who refuse cardiac surgery or are otherwise not candidates for aortic valve replacement, noncardiac surgery can be performed with a mortality risk of approximately 10%.
If a patient is not a candidate for valve replacement, percutaneous balloon aortic valvuloplasty may be reasonable as a bridge to surgery in hemodynamically unstable adult patients with aortic stenosis who are at high risk for aortic valve replacement surgery and may be reasonable in adult patients with aortic stenosis in whom aortic valve replacement cannot be per-formed because of serious comorbid conditions.
TMP-107 Baby with Tracheo-oesophageal fistula found by bubbling saliva and nasogastric tube coiling on Xray. Best immediate management?
A. Bag and mask ventilate
B. Intubate and ventilate
C. position head up, insert suction catheter in oesophagus (or to stomach?)
D. Place prone, head down to allow contents to drain
E. Insert gastrostomy
TMP-108 A 60yo man with anterior mediastinal mass, during induction for mediastinoscopy....lose cardiac output, decreased saturations, drop in ETCO2. Management:
A. Adrenaline
D. Place prone
Ans D
Management of the patient with a large anterior mediastinal mass: recurring myths
Curr Opin Anaesthesiol 20:1-3 2007

Should try wake up the patient.
Intraoperative life-threatening airway compression has usually responded to one of two therapies:
1. Repositioning of the patient (it should be determined before induction if there is one side or position that causes less symptomatic compression)
2. Rigid bronchoscopy and ventilation distal to the obstruction (this means that an experienced bronchoscopist and rigid bronchoscopy equipment must always be immediately available in the operating room during these cases).

For patients with life-threatening cardiovascular compression after induction that does not respond to lightening the anesthetic the only therapy is immediate sternotomy and surgical elevation of the mass off the great vessels.
TMP-109 The MAIN indication for biventricular pacing is
A. complete heart block
B. congestive cardiac failure

The standard indications for biventricular pacing which initially included patients with advanced HF and evidence of systolic dysfunction (EF ≤35%), with conduction tissue disease and marked cardiac symptoms [New York Heart Association (NYHA) classes III and IV] have now expanded to include even the mildly symptomatic patient (NYHA classes I and II).
EM66 What's the most appropriate mode for neuromuscular monitoring during aneurysm clipping?
A. TOF count
B. TOF ratio
C. Post tetanic count
D. ?
E. ?
Ans C
Anaesthesia for cerebral aneurysm repair Roger Traill
TOF 0 PTC >10
TMP-118 What's the area burnt in the following man? Half of left upper arm, all of left leg and anterior abdomen.
A. 27%
B. 32%
C. 42%
Ans B
Arm is 9% half an arm is 4.5
Leg 18%
Anterior abdomen 9%
4.5 + 18 + 9 = 31.5%
MC59b Torsades, what's not useful?
A. Amiodarone
B. Isoprenaline
C. Magnesium
RU19 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
Ans D
A- False. Arise from la. Cut. Branch of 2nd intercostal nerve (originally from T2 but not from the trunk. )
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 he arm close to axilla to compress it.
E- False. Not part of the brachial plexus, or a branch from it. Arises from lat. Cut. Branch of 2nd intercostal nerve.
SF87 Labour epidurals increase maternal and foetal temperature. This results in neonatal
A. Increased sepsis
B. Increased investigations for sepsis
C. increased non shivering thermogenesis
D. Increased need for resuscitation
E. Cerebral palsy
A great core temperature is tolerated with an epidural block
SF88 Maternal cardiac arrest. In making the diagnosis of amniotic fluid embolism, large amount of PMNs surrounding foetal squamous cells are
A. Pathognomonic
B. Supportive
C. Only found at postmortem
D. Irrelevant
E. Incidental
PC50 Half life of tirofiban:
A. 2hrs
B. 8hrs
C. 12hrs
D. 24hrs
E. 15 minutes
A 2 hours
PN48 Why is codeine not used in paediatrics?
A. Poor taste
B. High inter-individual pharmacokinetic variability
C. Not licensed for <10 year old
D. not as effective as adult when given in ?weight adjusted dose?
E. ?
TMP-113 Best agent to decrease gastric volume AND increase gastric pH before semi-urgent procedure
A. Omeprazole
B. Cimetidine
C. Ranitidine
D. Sodium citrate
AM28c Myaesthenia gravis - features predicting need for post op ventilation EXCEPT
A. Prolonged disease
B. High dose Rx
C. Previous respiratory crisis
D. Increased sensitivity to NMB's
E. bulbar dysfunction
FVC < 2.9L
Hx of resp disease
Grade 3-4 MG
>6 years of disease
Dose > 750mg/day Pyridostigmine
NN13b Innervation of larynx
A. The internal branch of the superior laryngeal nerve supplies the lingual surface of the epiglottis
B. In cadaveric position the cords are fully abducted
C. The RLN supplies all intrinsic muscles of the larynx
D. The glossopharyngeal nerves are sensory to the laryngeal mucous membrane above the level of the cords
E. Cuff compression of recurrent laryngeal nerve against thyroid can cause palsy
Ans E
Regional and topical anesthesia for endotracheal intubation
Airway innervations

Nasal cavity: greater and lesser palatine nerves and anterior ethmoidal nerve.
Trigeminal nerve  palatine nerves innervates: nasal turbinates and most of the nasal septum.
Olfactory nerve  anterior ethmoidal nerve innervates: nares and anterior third of the nasal septum.

Oropharynx: vagus, facial and glossopharyngeal nerves
Trigeminal nerve: lingual branch of the mandibular division supply the anterior 2/3 of tongue
Glossopharyngeal: travels anteriorly along the lateral surface of the pharynx with 3 branches
1. Lingual branch: sensory posterior 1/3 of tongue, vallecula, anterior surface of the epiglottis
2. Pharyngeal branch: wall of the pharynx
3. Tonsillar branch: tonsils
1. Internal branch of superior laryngeal nerve: This branch originates from superior laryngeal nerve lateral to the greater cornu of the hyoid bone
a. Sensation: base of the tongue, posterior epiglottis, aryepiglottic folds and arytenoids.
b. Motor: Cricothyoid
2. Recurrent laryngeal nerve:
a. Sensation: vocal folds and trachea sensation
b. Motor: All intrinsic laryngeal muscles except cricothyroid
NA15 The nerve supplying area of skin between greater trochanter and iliac crest:
A. subcostal nerve
B. ilioinguinal nerve
C. genitofemoral nerve
D. femoral nerve
E. lat cutaneous femoral nerve.

Fundamentals of Regional Anaesthesia
A. Subcostal: sends fibre to the first lumbar nerve and its lateral cutaneous branch runs over the iliac crest to innervate the skin of the lateral aspect of the buttock as far as the greater trochanter
B. Ilioinguinal: enters the inguinal canal accompanies the spermatic cord and supplies the skin of the rrot of the penis and anterior part of the scrotum, mons pubis and labium majorum.
C. Genitofemoral: two branches.
a. Genital branch enters the inguinal canal and supply the spermatic cord and innervate the same cutaneous area as the ilioinguinal nerve.
b. Femoral branch: skin over the femoral triangle.
D. Femoral: supplies the muscles and the skin of the anterior compartment of the thigh
E. Lateral cutaneous nerve:
a. Anterior branch: supplies the skin over the antero-lateral aspect of the thigh down to the knee
b. Posterior branch: the skin of the lateral aspect of the leg from the greater trochanter to the mid-thigh
Iliohypogastric nerve innervate skin overlying the lateral aspect of the buttock and runs medially and superficial to the inguinal canal to innervate the skin over the pubis.
PZ103 IV paracetamol:
A. late plasma levels around the same as oral
B. highly protein bound
C. ?30%? renally excreted
D. VD 10L/kg
Ans A
MC77 Patient with diastolic dysfunction. Is it caused by:
A. Restrictive cardiomyopathy
B. Dilated cardiomyopathy
AC90 Most likely to result in myocardial infarction:
A. intraop myocardial ischaemia
B. post op myocardial ischaemia.
C. intraop junctional rhythm
D. postop atrial fibrillation

Options C,D not recalled, have been made up.
TMP-128 Indication for percutaneous closure of ASD
A. Primun < 3cm
B. Primun > 3cm
C. Secundum < 3 cm
D. Secundum > 3cm
E. sinus venosus ASD
Ans C
CEACCP Anaesthesia for percutaneous closure of atrial septal defects 2008
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.
MN38 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
Allows diaphragm to expand chest without chest wall collapsing inward
SF53 Carbon dioxide is the most common gas used for insufflation for laparoscopy because it
A. is cheap and readily available
B. is slow to be absorbed from the peritoneum and thus safer
C. is not as dangerous as some other gases if inadvertently given intravenously
D. provides the best surgical conditions for vision and diathermy
E. will not produce any problems with gas emboli as it dissolves rapidly in blood
AA04 Histamine release in anaphylaxis does NOT cause:
A. Tachycardia
B. Myocardial depression
C. Coronary artery vasodilatation
D. Prolonged PR interval
E. Decreased impulse conduction
EZ88 [Aug10] A device that detects a 10mA difference in active and neutral leads and causes turning off of the circuit within 40 ms. This is a:
A. Class 1 device
B. Equipotential earthing
C. Line isolation monitor
D. Residual Current Device
E. Fuse
Ans D
CEACCP electrical safety in the operating theatre

A. Class 1 Device: Any conducting part of Class I equipment accessible to the user, such as the metal casing, is connected to earth by an earth wire. If a fault occurs, this allows the live supply to come into contact with an accessible part, current flows down the earth wire. This new circuit has a lower resistance, resulting in an increased current which melts the protective fuses and breaks the circuit, removing the source of potential electrocution.
B. Equipotential earthing: the terminals of each piece of equipment in a stack can be connected to each other bringing them all to the same potential.
C. Line isolation monitor: measures the potential for current flow from the isolated power supply to the ground. i.e. active and neutral should have the same current. If there is a fault, a device is grounded then the current through to neutral would decrease. There is then a current able to flow through the line isolation monitor and sounds an alarm.
D. Residual current device: If the current in the live and neutral conductors is the same, the magnetic fluxes cancel themselves out. However, if they are different (due to excessive current leakage) there is a resultant magnetic field. This induces a current in the third winding causing the relay to break the circuit.
E. Fuse: a material that melts with increased current and breaks the circuit.
AZ80 Which of the following is NOT an absolute contra-indication for MRI?
A. cochlear implant
B. heart valve prosthesis
D. pacemaker
E. intracranial clips
Ans B
CAECCP Anaesthesia for magnetic resonance imaging 2003
Absolute contra-indications to MRI include implanted surgical devices such as cochlear implants, cardiac pacemakers or implanted defibrillators, intra-ocular metallic foreign bodies or ferromagnetic neuro-vascular surgical clips.
Many implanted prosthetic devices are non-ferromagnetic. General surgical clips, joint prostheses, artificial heart valves and sternal wires are generally safe as they are fixed by fibrous tissue
AT08c [Aug10] One lung ventilation and hypoxaemia. After 100% O2 and FOB next step is:
A. CPAP 5cm top lung
B. CPAP 10cm top lung
C. PEEP 5cm bottom lung
D. CPAP 5cm top + PEEP 5cm bottom
E. ?
As always much debate.
CAECCP prefer CPAP to non-ventilated lung first
Miller is the reverse.
AC158 [Aug09] [Aug10] 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
ME23 Plasma glucose level compared to blood glucose level
A. 32% higher
B. 14% higher
C. Same
D. 14%lower
E. 32% lower
Wiki: Glucose levels in plasma (one of the components of blood) are generally 10%–15% higher than glucose measurements in whole blood (and even more after eating).
MZ71 With regards to obstructive sleep apnoea (OSA), which of the following statements is INCORRECT?
A. hypoxaemia is the main stimulus to arousal
B. the main method of treating this syndrome is with Continuous Positive Airway Pressure (CPAP)
C. this syndrome is the most likely diagnosis in patients presenting with excessive daytime sleepiness
D. this syndrome occurs in up to 5% of adults
E. this syndrome rarely has an obstructive component
Ans E
SZ14b Management of rhabdomyolysis – best option?
A. Haemodialysis
B. Bicarbonate
C. Frusemide
D. IV fluids
Ans D
EZ76 Residual current devices:
A. Compare current between active and neutral lines
D. Must be fitted in cardiac protected areas
E. Must be fitted in operating theatres
If there is a difference, then current must be 'leaking' somewhere, ie through a person perhaps.

All operating theatres and ICU are cardiac protected and must have either line isolation monitor or residual current device, and have equipotential earthing junctions.
PZ86d Serotonin syndrome has been reported following SSRI coadministration with:
A. Gingko
B. Garlic
C. Ginger
D. St John’s wort
E. Vallerian
PP86 Child with ?pyloric stenosis and 3 days of vomiting. Which bloods would you expect? [Not given pH]
A. Na 130 K 4.5 Cl 90 Bic 17
B. Na 130 K 2.5 Cl 87 Bic 24
MZ51 Why is tachycardia bad in mitral stenosis?
A. Increased oxygen demand
B. Increases transvalvular pressure gradient
C. Leads to hypetension
D. Risk of sudden cardiac death

Other options not recalled, have been made up since
AT28 You intubate a young male patient for a left thoracotomy with a 39FG Robertshaw 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 BRONCHIAL cuff you can ventilate BOTH left and right lungs 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.
bronchial cuff in the trachea
PP46b ANZCA version [2001-Apr] Q17, [2003-Apr] Q104, [2003-Aug] Q57, [Mar06], [Aug10]
The average expected depth of insertion of an oral endotracheal tube, from the lip, in a normal newborn infant is
A. 7.5 cm
B. 8.5 cm
C. 9.5 cm
D. 10.5 cm
E. 11.5 cm
weight + 6
RB58 What is NOT a feature of high spinal block?
A. Hypotension
C. Hard to speak
D. Numb hands
E. Tachycardia
RN18 Stellate ganglion block is associated with all EXCEPT:
A. Ptosis
B. Miosis
C. Sweating
D. Facial flushing
E. Nasal stuffiness
AM16 Recognised clinical associations with dystrophia myotonica include
A. development of diabetes mellitus
B. abnormal intestinal motility
C. cardiomyopathy
D. ovarian dysfunction
E. all of the above
MC110 Left bundle branch block (LBBB) is associated with:
A. Right axis deviation
B. Marfan's syndrome
C. left heart disease occasionally
D. Relative contraindication to Centra Venous Line insertion

Other options not recalled, have been made up since.
RB63 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

Does spinal anesthesia cause hearing loss in the obstetric population? Anesth analg 2002
No it does not
Does hearing loss after spinal anesthesia differ between young and elderly patients Anesth analg 2002
Hearing loss in low frequencies 125-500 Hz in young patient after spinal
116. 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
117. 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
118. 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 ???
119. 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
Pulmonary stenosis (90%), tricuspid insufficiency (47%), and tricuspid stenosis (42%) are encountered most commonly.
SZ11 Lowering intra-ocular pressure by applying pressure to the globe (e.g. Honan balloon) is typically contraindicated in a patient having
A. a revision corneal graft
B. a revision trabeculectomy
C. an extra-capsular lens extraction
D. a redo vitrectomy
E. repeat retinal cryotherapy
121. Troponin is elevated post-infarct
A. 1-2 days
B. 2-5 days
C. 5-14 days
D. 7-21 days
122. Myotome of C6-7
A. Shoulder flexion
B. Shoulder extension
C. Elbow flexion
D. Wrist flexion and extension
E. Finger flexion and extension
123. Head Trauma patient with unilateral dialated pupil, whats the diagnosis ?
A.Global injury
B.Optic nerve injury
C.Horners syndrome
D.Transtentorial herniation
124. The PREDOMINANT pathophysiological effect of restrictive cardiomyopathy is:
A. Systolic dysfunction
B. Diastolic dysfunction
C. Valvular dysfuntion
D. Conduction dysfunction

Other options not remembered, have been made up since.
PZ65b When does effect of diclofenac on platelets wear off?
A. 6 hours
B. 12 hours
C. 24 hours
D. 48 hours
NL04 Muscle NOT supplied by sciatic nerve:
A. biceps femoris
B. gluteus maximus
C. semimembranosus
D. semitendinosus
E. addutor magnus
Gluteus maximus: innervated by inferior gluteal nerve L5,S1,2

Other options not recalled, have been made up since.
ST37 [Aug10] Negative predictive value is best described as:
A. Probability of a negative test in people without a disease
B. Probability that a negative test means a patient does not have the disease
C. Probability of a negative test in patients with a disease
D. Probability that a positive test means a patient does have the disease

Original stem had no correct answers at all. I have made up some possible answers including one that is correct - Stu
PL31 Aug10 Time to reach peak plasma concentration after injection of 2% lignocaine with adrenaline into epidural space
A. 20 min
B. 30 min
C. 40 min
D. 50 min
E. 60 min
Br J Clin Pharmacol 1996; 42: 242245
Peak lignocaine concentration ~30 mins