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68 Cards in this Set

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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
E. PEEP

B

From CEACCP: Fontan circulation:
“Low respiratory rates, short inspiratory times, low PEEP, and tidal volumes of 5–6 ml/ kg usually allow adequate pulmonary blood flow, normocarbia, and a low PVR. Hyperventilation tends to impair pulmonary blood flow, despite the induced respiratory alkalosis, because of the increased mean intrathoracic pressure”

A 7 kg Infant with tetralogy of Fallot, post BT-shunt. Definitive repair at later date. Paralysed and vetilated. line, 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

Increasing FiO2 to 100% would be 1st thing to do – as will decrease HPV and decrease pulmonary pressures. I guess may make little difference if it is due to infundibulum spasm though

However phenylephrine may be the ‘best treatment’ as increases SVR and reduces gradient for right-to-left shunt

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

Management of HIT:
• First task is to discontinue unfractionated heparin from ALL sources (including heparin-coated lines, etc). LMWH can also cause HIT, therefore not suitable as a replacement. Fondaparinux is an indirect Factor-Xa inhibitor (synthetic pentasaccharide), and there are some reports of it being used in HIT successfully. Warfarin (Vit K antagonist) is contraindicated in acute HIT (or if suspected HIT), as it can cause skin necrosis or venous limb gangrene.
• Current recommendations are to treat with DTI's (lepirudin, argatroban, bivalirudin) or danaparoid. Although danaparoid is a LMW heparinoid, there is an extremely low cross-reactivity rate with HIT antibodies, and this is rarely clinically significant.
• As danaparoid is not an option, the best answer is therefore a direct thrombin inhibitor (DTI), and lepirudin is the only one listed, so answer is D.

Hypercalcaemia
A. Chovostek's sign
B.
C.
D.
E. Short QT

E

From Miller: “Hypercalcemia shortens and hypocalcemia prolongs phase 2 of the action potential duration, thus leading to abbreviation or prolongation of the QT interval, respectively. Severe hypercalcemia (e.g., total serum Ca2+ >15 mg/dL) causes a decrease in T-wave amplitude or T-wave inversion, and hypercalcemia may produce a high-takeoff ST segment in leads V1 and V2 simulating acute ischemia.”
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
E

• Prasugrel = same class of drug as clopidogrel.
• As per AHA/ACC Guidelines, recommended to continue dual anti-platelet therapy for 365 days with DES, and I would consider prasugrel the same as clopidogrel.
• Given that this is an elective procedure, and the potential for blood loss (while usually minimal) is significant (especially given dual anti-platelet therapy), the procedure should be delayed for another 6 months (i.e. 12 months from time of stent placement. The risk of an in-stent thrombosis is high if both anti-platelet drugs are not continued for the full 12 months

For a person newly diagnosed as MH susceptible, which is true?
A. ?
B. Can have had an uneventful 'triggering' anaesthetic
C. Recommended to use an anaesthetic machine which has not had volatiles through it
D. ?
E. There have been case reports of MH occurring up to 48 h post op

B
ABG 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
B
Cocaine overdose. What is false? (rpt Q)
A. Euphoria
B. ?
C. ?
D. ?
E. Miosis
E
Maximum dose (with low risk of toxicity) of lignocaine (with adrenaline 1:100000) for liposuction with tumescence technique
A. 3 mg/kg
B. 7 mg/kg
C. 15 mg/kg
D. 25 mg/kg
E. 35 mg/kg
E

Tumescent technique for regional anesthesia permits lidocaine doses of 35 mg/kg for liposuction. JA Klein - Dermatol Surg, 1990

Tumescent Anesthesia
A technique of local anesthesia most commonly used by plastic surgeons during liposuction procedures involves the subcutaneous injection of large volumes of dilute local anesthetic in combination with epinephrinee and other agents. Total doses of lidocaine ranging from 35 to 55 mg/kg have been reported to produce safe plasma concentrations, which may peak more than 8 to 12 hours after infusion. Despite these seemingly huge doses, very good outcomes have been reported in several case series.http://www.expertconsultbook.com/expertconsult/b/linkTo?type=bookPage&isbn=978-0-443-06959-8&eid=4-u1.0-B978-0-443-06959-8..00030-3--bib77&appID=NGE
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
C

• If procaine =1, then lignocaine potency=2, and bupivacaine potency =8. Therefore bupivacaine is 4 times as potent as lignocaine - (Foundations of Anesthesia: Basic Sciences for Clinical Practice by Hemmings & Hopkins, 2nd edn, p.394)
• Other recommended texts (Primary exam pharm texts) give differing values compared to procaine, but all give a ratio of 4x potency for buipvacaine:lignocaine (Stoelting and Katzung)
• E.g for epi top-up for LCSC use 20ml 0.5% Bupivacaine or 20ml 2% lignocaine (ie need 4x more lignocaine for same effect).

Aneurysm sugery. Propofol / remifentanil / NMDR. DOA monitoring (Entropy). 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

C

Millers (7 ed p 1253) suggests: SE should be in range 40-60, if RE is more than 10 greater, then should give more analgesia. Increasing TCI covers both options (hypnosis&analgesia)

However increased response entropy could mean increased frontalis muscle activity hence inadequate paralysis

GE Healthcare Entropy Product Information
• Entropy monitoring is based on acquisition and processing of raw EEG and FEMG (frontalis muscle EMG) signals by using the Entropy algorithm
• Response Entropy (RE) is sensitive to the activation of facial muscles, i.e. FEMG. Its response time is very fast; less than two seconds. FEMG is especially active during awake state but may also activate during surgery. Activation of Response Entropy to painful stimuli may be interpreted as a sign of inadequate analgesia. Facial muscles may also give an early indication of recovery, and this can be seen as a quick rise in RE
• State Entropy (SE) value is always less than or equal to Response Entropy. Estimation of the hypnotic effect of anesthetic drugs in the brain during general anesthesia may be based on the State Entropy number. State Entropy is not aff ected by sudden reactions of the facial muscles because it is based on the EEG signal. Neuromuscular blocking agents (NMBA), administered in surgically appropriate doses are not known to affect the EEG
• Interpretation:
o 100 = Fully awake and responsive
o 60-40 = Clinically meaningful anesthesia with low probability of consciousness.
o 0 = Suppression of cortical electrical activity
Paralysed with atracurium. TOF is 1(25%). You give a dose of 0.1 mg/kg mivacurium to close the abdomen. When will you be back to TOF 1(25%)?
A. 5 min
B. 10 min
C. 30 min
D. 60 min
E. 90 min
C

The duration of action of mivacurium is prolonged if preceded by atracurium or vecuronium. Acta Anaesthesiologica Scandinavica. Volume 39, Issue 7, pages 912–915, October 1995
We studied 45 patients (ASA I-II) during propofol-alfentanil-N2O-O2 anaesthesia to determine if recovery from neuromuscular block induced by mivacurium is influenced differently by prior injection of atracurium or vecuronium. Neuromuscular function was monitored by adductor pollicis EMG. Patients were randomized to receive two dosesof either mivacurium (150 and 70 μg kg-1), atracurium (350 and 75 μg kg-1) or vecuronium (70 and 15 μg kg-1) followed by a final dose of mivacurium 70 μg kg-1. The second and third doses of the muscle relaxants were administered at 25–30% recovery of the E1 (first EMG response in the train-of-four series). Following the final dose of mivacurium, the EMG response recovered to 25 and 95% in 10.4±3.9 and 19.7±5.7 min (mean±SD), respectively, if mivacurium was the only muscle relaxant. Respective times were 100% longer if mivacurium had been preceded by atracurium (23.8 ± 3.3 and 39.8±6.9 mm) or vecuronium (22.6±3.5 and 44.1 ±7.9 min) (P=0.000l). The 25–75% recovery times in the three groups were 4.9±1.0, 8.7±2.4 and 10.5±2.5 min, respectively (P=0.0001). Our results indicate that there is no benefit in giving mivacurium at the end of surgery after peroperative use of atracurium or vecuronium.
Plenum Vaporiser
A.? something with fresh gas flows
B. Relies on a constant flow of pressurised gas
C. Out of circle
D. Not temperature compensated
E. volatile injected into fresh gas flow?
B

Or perhaps C

World Anaesthesia Online:
“Plenum vaporisers are designed for use with continuous flow of pressurised gas, and have high internal resistance”

“Normal plenum vaporisers, with high internal resistance, cannot be used within the circle and a low internal resistance type vaporiser (such as the Goldman) is required”

CEACCP – Understanding Vaporisers
“Plenum vaporizers are high resistance, unidirectional, agent-specific, variable bypass vaporizers designed to be used outside the breathing system.”

“Plenum vaporizers have a much higher internal resistance, requiring fresh gas at above atmospheric pressure”
Interscalene block, patient hiccups...where do you redirect your needle?
A. Anterior
B. Posterior
C. Caudal
D. Cranial
E. Superficial
B

Oxford handbook of Anaesthesia, 2nd Edn, p. 1077:
Phrenic nerve stimulation occurs if you are too anterior
What is the SVR in a patient with MAP 100mmHg, CVP 5, PCWP 15, CO 5L/min?
A. ?0.8
B. ?3
C. 520
D. 1280
E. 1520 dynes.sec/cm-5
E

• SVR = (Systemic A-V Pressure difference) / Flow
• Therefore SVR = (100-5)/5 = 95/5 = 19 mmHg/L/min
• To convert to dynes.sec/cm-5 then multiply by 80; this gives us 1520 dynes.sec/cm-5
Accidentally cannulate carotid artery with 5 lumen 7 Fr CVC preop for a semi urgent CABG. Most appropriate next response is to
A. Get vascular surgeon to repair it and continue with surgery and heparin
B. Leave it in. Do CABG. Pull it out post op.
C. Pull it out, compress. Delay surgery for 24hrs
D. Pull it out compress. Continue with surgery + heparin.
E. Pull it out. Compress. Continue with surgery no heparin.
A

Eckhardt WF, et al Inadvertent Carotid Artery Cannulation During Pulmonary Artery Catheter Insertion. J Cardiothorac Vasc Anesth 1996, 283-290
On the basis of present evidence, we recommend the following management plan for inadvertent carotid cannulation (with a large bore cannula) should it occur:
• Initially, leave the cannula or sheath in the vessel and consider the options.
• If the patient is judged to be at low risk of complication, remove the cannula and apply firm pressure for ten minutes. Monitor the neurological, haemodynamic and airway state during this time and be prepared for emergency intubation. Contemplate proceeding to surgery according to the considerations outlined above.
• If the patient is judged to be at high risk of complication, consider intubating the patient (in order to prevent airway compression) before removing the sheath. Removal of the sheath can then be performed, or, on the recommendation of some authors 11, can be carried out at an exploratory operation.
• If the sheath is removed, apply carotid pressure for ten minutes, being mindful that this may not be successful due to a coagulopathic state, extensive damage to the vessel or bleeding from a site distal to the puncture site
• Remember that pressure on the carotid artery can in itself precipitate a neurological event. This is a powerful argument for recommending that pressure only be applied in a conscious, cooperative patient.
• Monitor the general state of the patient. - Bleeding can occur proximal to the puncture site producing a rapid deterioration in the susceptible patient.
• Consult a vascular surgeon as soon as is practical to determine if surgical exploration or repair is warranted. Indications for exploration may include an enlarging haematoma, airway compression, pre-existing carotid artery disease, a neurological event or cardiovascular instability. Some authors advise exploration in all patients who have had puncture with 17-gauge or larger needle. Caution is strongly recommended in the patient group more prone to complications. The reader is again reminded that damage to other vessels beyond the puncture site has been reported. Hence vigilance is still advised even if exploration of the puncture site has been undertaken.

Whilst this article: Arterial misplacement of large-caliber cannulas during jugular vein catheterization: case for surgical management Journal of the American College of SurgeonsVolume 198, Issue 6, Pages 939-944 (June 2004), showed lowest rate of compliations with surgical repiar
Patient for total knee replacement under spinal anaesthetic. Continous femoral nerve catheter put in for post op pain relief. Good analgesia and range of motion 18hrs post op. 24hrs post op, patchy decreased sensation in leg and unable flex knee. What is the cause?
A. Compression neurapraxia (i think it said due to torniquet)
B. DVT
C. Muscle ischaemia
D. Damage to femoral nerve
E. Spinal cord damage

A

Knee flextion – due to hamstring muscles - Biceps Femoris, semitendinosis and semimembranosis muscles – all supply from Sciatic nerve (L4,5, S1,2,3) before bifurcation in popliteal fossa.
• A. True – sciatic nerve compression is possible if torniquet applied in upper thigh.
• B. False – assuming Femoral DVT or iliac thrombrosis - unlikely to occur at 24hours post-op and cause such significant localised neurological injury – may expect other extension weakness.
• C. Possible – again why so localised, would also expect hamstring injury too. Unilkely to develop after 24hours (?tournequet time)
• D. False – femoral nerve injury would not cause injury to Quadreceps muscles.
• E. False – Neuroaxial technique complicated by spinal cord damage would give bilateral motor and sensory signs, not localised to a unilateral weakness.

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

A

AHA guidelines would suggest AVR given patient is symptomatic. Though does this sill apply to moderate AS?

Going by the flow chart – non-urgent surgery, no active cardiac conditions (as valve dysfunction is not severe), intermediate risk surgery, ?presumably >4METS, no risk factors = proceed with surgery

ACC/AHA Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery
Section 3.5 Valvular Heart Disease
"if the aortic stenosis is symptomatic, elective noncardiac surgery should generally be postponed or cancelled. 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%”
Patient for fempop bypass (i believe it said "angioplasty"), history of CCF. Also has diabetes on oral hypoglycaemics, controlled hypertension and atrial fibrillation at rate of 80bpm .
A. Medium risk surgery, medium risk patient
B. Medium risk surgery, high risk patient
C. High risk surgery low risk patient
D. High risk surgery, medium risk patient
E. High risk surgery, high risk patient.
D

• Vascular surgery (Fem-pop bypass) = HIGH RISK SURGERY.
• MEDIUM RISK PATIENT - 2 intermediate risk factors: a history of prior CCF, and diabetes. The controlled HT and AF<80bpm are minor risk factors.
ACC/AHA Guidelines Stratifies patient risk into 3 groups. There is "a group of active cardiac conditions that when present indicate major clinical risk". Intermediate risk is denoted by the presence of "clinical risk factors". They also mention MINOR PREDICTORS:
1. High risk pt = An "active cardiac condition"
- Unstable coronary syndromes
- Unstable or severe angina (CCS class III or IV)
- Recent MI
- Decompensated HF
- NYHA class IV
- Worsening or new-onset HF
- Significant arrhythmias
- High-grade A-V block
- Mobitz type II A-V block
- 3rd degree A-V block
- Symptomatic ventricular arrhythmias
- SVT (incl AF) with uncontrolled ventricular rate (HR>100bpm @ rest)
- Symptomatic bradycardia
- Newly recognised VT
- Severe valvular disease
- Severe AS (mean P gradient > 40mmHg; valve area < 1.0cm2; symptomatic)
- Symptomatic mitral stenosis (progressive SOBOE, exertional presyncope, or HF)

2. Medium risk pt = Presence of "clinical risk factors" (presumably 1 or more)
- ischaemic heart disease
- compensated or prior heart failure
- diabetes mellitus
- renal insufficiency (creatinine >2mg/dL, which is >177umol/L)
- cerebrovascular disease

3. Low risk pt = Minor predictors
- Age >70
- Abnormal ECG (LVH; LBBB; ST-T abnormalities)
- Rhythm other than sinus
- Uncontrolled systemic hypertension
Best Approach for a Sub-Tenon's block?
A. inferonasal
b. inferotemporal
c. medial canthus
d. superior nasal
e. superior temporal
A

Inferonasal quadrant is described as the approach for Sub-tenon’s Block:
A blunt sub-Tenon’s anesthesia cannula 1.10 × 25 mm or 19-gauge × 1 in. (BD-Visitec, Sarasota, FL) was used in all cases. The technique for STB is briefly described as follows. After topical anesthesia and asepsis of the eye, a suitable lid speculum is inserted. The patient is then asked to gaze upwards and laterally. The conjunctiva and Tenon’s fascia is lifted with forceps in a place 5 mm away from the corneal limbus in the infero-nasal quadrant, creating a small tent of conjunctiva and adherent Tenon’s capsule. A small nick incision into the side of the conjunctival tent is made with blunt-tipped Westcott scissors. The closed scissors are then slid through the nick in the conjunctiva and used to create a path in Tenon’s capsule and the intermuscular fascia. The blunt and curved anesthesia cannula is then inserted onto bare sclera and glided along the path created by the Westcott scissors, following the contour of the globe, until posterior to the equator. The forceps should maintain fixation of the eye during dissection and insertion of the needle. The needle can be advanced to a depth of approximately 2 cm depending upon globe size. A total volume of 3–4 mL of LA is then injected slowly. It effectively irrigates the retrobulbar space. Digital massage or an orbital pressure device is sometimes applied to disperse the LA
Baby with TracheoOesophageal Fistula found by bubbling saliva and nasogastric tube coiling on xray. Best immediate management?
A. Bag and mask ventilate
B. Intubate and ventilate
C. position head up, insert suction catheter in oesophagus (or to stomach?)
D. Place prone, head down to allow contents to drain
E. Insert gastrostomy
C

• A - FALSE. Not unless the baby is in respiratory distress and/or hypoxic. May inflate stomach by ventilating through fistula.
• B - FALSE. Just because the baby has been diagnosed with TOF is not an immediate indication for intubation in and of itself.
• C - TRUE. Neonates with TOF should have a "nasogastric" tube inserted into the oesophageal stump to drain secretions and prevent accumulation in the blind-end pouch. The NGT should be connected to continuous suction. The infant should be nursed prone or in the lateral position with 30 degrees head up tilt to decrease the risk of aspiration. See A Practice of Anesthesia for Infants and Children - 4th edition by Cote, Lerman, Todres; p.755. Saunders (2009)
• D - FALSE. Can nurse prone, but lateral with head up tilt seems to be the recommended and most commonly cited method.
• E - FALSE. Initial management as above (see C - TRUE), and then repair. Gastrostomy may be performed, but not best immediate management.
A 60yo Man with anterior mediastinal mass, during induction for mediastinoscopy....lose cardiac output, decreased saturations, drop in ETCO2. Management
A. Adrenaline
B. CPR
C. CPB
D. Place prone
D

• A. Adrenaline ineffective – no circulation
• B. CPR – ineffective – mechanical obstruction impeding flow
• C. CPB – ideally femoral lines placed and ready if large mass.
• D. Prone position – allows relief from mechanical obstruction from the mass and therefore hopefully improves output – especially if CPB not available.
Post thyroidectomy patient, patient in PACU for 30 minutes. Develops respiratory distress. Most likely cause?
A. Hypercalcemia from taking parathyroids
B. Bilateral laryngeal nerve palsies
C. bleeding and haematoma
D. Tracheomalacia
E.
C

A. False - parathyroids you get HYPOcalcaemia, not HYPERcalcaemia
B. False - Bilateral laryngeal nerve palsies and vocal cord paralysis are possible, but less likely than bleeding and haematoma. Usually recognise issues initially on extubation.
C. True: slow accumulation of haematoma in neck – develops respiratory distress. Most likely cause.
D. False – if significantly large thyroid, usually problems intra-op with ventilation
Best way to prevent hypothermia in patient undergoing a general anaesthetic (Repeat question)
A. Prewarming of patient
B.
C.
D. Warm IV fluids
A
MAIN indication for biventricular pacing is
A. complete heart block
B. congestive cardiac failure
c. VF
D.
B

Yao & Artusio (6th edn, p.236-7):
• Biventricular pacing is defined as a lead in the RV to pace the interventricular septum, and a lead in the coronary sinus which can pace the LV lateral free wall. This is apparently most commonly used in patients with LBBB which can cause dyssynchronous contraction of the LV leading to impaired systolic function. The biventricular pacing "resynchronises" LV contraction and improves systolic function.
• Indications:
o severe cardiomyopathy (EF<35%)
o LBBB with NYHA class III or IV symptoms despite maximal medical therapy

Desflurane TEC6 vaporiser, unable to turn dial on. This is NOT because
A. vapouriser is tilted
B. Hotter than 39C
C. On battery power
D. Interlock not engaged, or not seated properly (or something like that)
E. other vapouriser is already on

B

• A – False – vaporiser will cut out if tilted
• B – True – internal switches will cut out above 57 degrees C (A-Z Anaesthesia & Intensive care)
• C – False – will not work on battery power
• D – False – will not work if not locked into selectatec mount
• E – False – will not run multiple vaporisers at once
Desflurane vaporiser, heated because of
A. High SVP
B. High boiling poing
C. Low SVP
D. High MAC
E. Low MAC
A

• A – True. Vaporizer heated because of the high SVP. Heated to well above boiling point to ensure reliable concentration of desflurane gas mixture.
• B – False. 23.5°C.
• C – False.
• D – False.
• E – False.

Most common cause of maternal cardiac arrest
A. PE
B. AFE
C. Haemorrhage
D. Preeclampsia
E. cardiomyopathy

B

2009 blue book:
In Australia, amniotic fluid embolism has been the leading cause of direct maternal death during the previous two triennia (Table 4). This differs from the UK CEMACH reports, which most commonly identify thromboembolic disease as the leading cause of death.2,4 Nevertheless, the leading causes of direct maternal death in developed countries are thromboembolic disease, amniotic fluid embolism, haemorrhage, hypertensive disorders and sepsis. Cardiac disease and psychiatric disease are the leading causes of indirect maternal death, with suicide the overall leading cause of death amongst pregnant women in the UK.4 In contrast to the sudden cardiac arrest that is seen in the non-pregnant population, the majority of causes are non-cardiac in origin, and resuscitation follows the “non-shockable” or “pulseless electrical activity” pathway of the advanced cardiac life support algorithm (Figure 1).

Most likely change on CTG with anaesthesia for non-obstetric surgery at 32 wks
A. Loss of beat to beat variability
B. No change
C. Late decels
D. Variable Deccels
E. uterine contractions
B

From Chestnut:
CTG can be used from about 18-20 weeks gestation. Fetal heart rate (FHR) variability is present by 25-27 weeks. The most likely thing in non-obstetric surgery during pregnancy is that the CTG will not change (assuming all goes well with the surgery, and the mother's physiology is maintained close to normal). However, the most common signs of fetal distress will be a change in the baseline FHR, and loss of beat-to-beat variability. If this occurs you should assess and correct any maternal physiologic parameters that are abnormal.
What's the most appropriate mode for neuromuscular monitoring during aneurysm clipping? (repeat question)
A. TOFC
B. TOFratio
C. Post tetanic count
C

What's the area burnt in man? Half of left upper arm, all of left leg and anterior abdomen (repeat qu).
A. 27%
B. 32%
C. 42%
D.
E.

B



4.5 + 9 + 18 = 31.5 = B



Head 9%
Torso 18% front and 18% back
UL 9% each
LL 18% each
Groin 1%

Torsades, what's not useful? (Repeat question)
A. Amiodarone
B. Isoprenaline
C. ?
D. ?
E. ?

A
HOCM, VF arrest on induction, what's the first priority in management?
A. defibrillate
B. amiodarone
C. Intubate and ventilate
D. Pre-cordial thump
E. adrenaline
A

From most recent Aus Resus Council guidelines on pre-cordial thump:
• The precordial thump may be considered for patients with monitored, pulseless ventricular tachycardia if a defibrillator is not immediately available. [Class B; LOE IV]
• The precordial thump is relatively ineffective for ventricular fibrillation, and it is no longer recommended for this rhythm.
• There is insufficient evidence to recommend for or against the use of the precordial thump for witnessed onset of asystole caused by AV-conduction disturbance.
• The precordial thump should not be used for unwitnessed cardiac arrest.
• A precordial thump should not be used in patients with a recent sternotomy (eg. for coronary artery grafts or valve replacement), or recent chest trauma
Pregnant woman presents with narrow complex tachycardia HR 190, stable BP 100/60. No response to vagal manoevures. Management?
A. adenosine 6mg
B. DCR
C. amiodarone
D. Atenolol
E. ?
A
The intercostobrachial nerve:
A. Arises from T2 trunk
B. Is usually blocked in brachial plexus block
C. Supplies antecubital fossa
D. can be damaged by torniquet
E. Arises from inferior trunk
D

• A - False. Arises from lat. cut. branch of 2nd intercostal nerve (from T2 originally, but not directly 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 the arm/close to axilla to compress it.
• E - False. Not part of brachial plexus, or a branch from it. Arises from lat. cut. branch of 2nd intercostal nerve.
From Anatomy For Anaesthetists:
The lateral cutaneous branch of the 2nd intercostal is atypical; it forms the intercostobrachial nerve which arches over the roof of the axilla to supply the skin of the medial aspect of the upper arm as far as the elbow. As it is not part of the brachial plexus, it is not affected by brachial plexus blocks, a point of importance when an upper arm tourniquet is used on the awake patient. Local anaesthetic needs to be deposited subcutaneously at the axilla along the medial border of the upper arm in order to provide analgesia for the tourniquet.
Post dural puincture headache (PDPH) -(thoracic epidural) of "low pressure type". Features NOT consistent
A. headache Immediately after procedure
B. Frontal headache only
C. Starts 24hrs post
D. Auditory symptoms
E. Neck stiffness
A

• A=FALSE. Usually starts 24-48 hrs after dural puncture.
• B=True. Typically fronto-occipital, but can be frontal, occipital or nuchal (Evidence-Based Obstetric Anaesthesia, Halpern & Douglas, BMJ Books; Blackwell, 2005; p.192)
• C=True. Most commonly starts 24-48 hrs later.
• D=True. Hearing loss and/or tinnitus are features.
• E=True. Neck stiffness and photophobia are common.
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
B

Chestnut's Obstetric Anesthesia: Principles and Practice
Labour epidural analgesia is associated with an increase in maternal core body temperature, but also with an increased neonatal temperature and fetal heart rate. Several studies have shown that labour epidural analgesia is associated with increased neonatal neonatal sepsis evaluations, but no increase in neonatal sepsis.
Maternal cardiac arrest. In making the diagnosis of amniotic fluid embolism, large amount of PMNs surrounding foetal squamous cells are
A. Pathonomonic
B. Supportive
C. Only found at postmortem
D. Irrelevant
E. Incidental
B

• A = False. No finding is pathognomonic of AFE. It is a diagnosis of exclusion.
• B = True. This finding (whether at post-mortem, or whether aspirated from pulmonary artery catheter in a surviving patient) is suggestive, but not pathognomonic. Fetal squames have been found in pulm. art. catheter aspirates in women with no evidence of AFE, and conversely there are reports where they have been unable to detect fetal squames in women diagnosed with AFE. The finding is suggestive/supportive only.
• C = False. Can be found in pulmonary artery aspirates in women still alive, and even with no symptoms.
• D = False. This finding is not irrelevant, but not diagnostic. It needs to be considered with all other clinical information.
• E = ? Given the less than ideal specificity of the test, one could argue that it is incidental, although the BJA CEACCP article states that it is suggestive of AFE, which implies it is more than an incidental finding.
Jehovah's witness patient refusing blood products. The ethical principle you are honouring if you continue with elective hip operation
A. Autonomy
B. Nonmaleficience
C. Justice
D. Paternalism
A

From Ethics in the Hospital:

Another commonly used method is a balancing of the physician’s ethical responsibilities based on the six values of medical ethics:
• To act on principles of Beneficence (act in the best interest of the patient – salus aegroti suprema) vs. Non-maleficence ("first, do no harm"- primum non nocere)
• To uphold patient autonomy (the right to refuse or choose treatment – voluntas aegroti suprema), by promoting patient’s ability to make an informed decision
• To ensure equality of care/Justice: are all patients being treated equally? Keep in mind that this is different than fairness. This concerns the distribution of scarce health resources.
• To ensure the patient’s and provider’s right to dignity
• Encourage honesty and truthfulness. This concept encompasses the important field of informed consent
An 86yo with severe dementia and multiple medical problems.. Surgeons want to operate for faecal peritonitis/bowel perforation, and believe he will die without the surgery. Your decision NOT to proceed with surgery is supported by which ethical principle?
A. Dignity
B. Competence
C. Non-maleficience
D. Paternalism
E. Futility
E
Inserted DLT. FOB down tracheal lumen. What feature is most helpful in identifying Left vs Right main bronchus
A. Trachealis muscle
B. "there are 3 lobes in right lung"
C. LMB longer than right
D. Angle of RMB vs left
E. Three segments of RUL
E

• A – False/?true. Trachealis muscle divides at carina and continues in each main bronchus, so not particularly helpful. BUT - trachealis is only located posteriorly connecting the ends of the C-shaped cartilage. If you know whats the front and whats the back wouldnt this make it easy to figure out L from R ?
• B - False. While there are indeed 3 lobes in the right lung, that fact is not helpful to determine which is right or left main bronchus.
• C - True. The LMB is about 5cm long before it gives off any subsequent lobar bronchi, whereas the RMB gives off a lobar bronchus (the RUL bronchus) about 2.5cm from the carina. This can help to determine between RMB and LMB.
• D - ? False. While there is a difference in the angle (from the vertical) of the LMB and RMB, I don't know if this would be significantly appreciable bronchoscopically. Anyone?
• E - True. The RUL bronchus has a trifurcation for each of the RUL segments, and this may also be useful in determining which side you are on.

You are performing a bronchoscopy, but are unsure of your location. Then you see trifurcation of bronchi. Most likely location is:
A. Right upper lobe
B. RML
C. RLL
D. LUL
E. Lingula

A
Elimination Half life of Tirofiban (woohoo... closed my eyes and pointed!)
A. 2hrs
B. 8hrs
C. 12hrs
D. 24hrs
E. 15 minutes
A

From Medpedia:
The half-life of tirofiban, the time required for the concentration in the body to be reduced by half, is approximately two hours. Most of tirofiban is excreted in the urine. Tirofiban is not metabolized to a large extent, therefore, the drug is unlikely to affect the metabolism of other drugs.
POISE trial showed
A. Increase CVA
B. Anaphylaxis
C. renal failure
D. Increased AMI
A

POISE Trial Summary – Lancet 2008
For every 1000 patients with a similar risk profile: metoprolol would prevent 15 MIs, but there would be 8 extra deaths, 5 disabling strokes and 53 patients needing treatment for hypotension and 42 for bradycardia.
Why is codeine not used in paeds
A. Poor taste
B. High inter-individual pharmacokinetic variability
C. Not licensed for <10yo
D. not as effective as adult when given in ?weight adjusted dose?
B

Patient on table for phaeochromocytoma with GA and epidural insitu. Pt on phenoxybenzamine and metoprolol preop, high dose nitroprusside and phentolamine. BP still high ?250/-. Next step
A. IV hydralazine
B. IV Magnesium
C. Propofol
D. Epidural lignocaine bolus
E. Esmolol

B

From Stoelting AACD:
Virtually all patients exhibit increases in systolic arterial pressure in excess of 200 mm Hg for periods of time intraoperatively irrespective of preoperative α-blockade. A number of antihypertensive drugs must be prepared and ready for immediate administration. Sodium nitroprusside, a direct vasodilator, is the agent of choice because of its potency, immediate onset of action, and short duration of action. Phentolamine, a competitive α-adrenergic blocker and a direct vasodilator, is effective, although tachyphylaxis and tachycardia are associated with its use. Nitroglycerin is effective but is required in large doses to control significant hypertensive episodes and may also cause tachycardia. Labetalol, with more β- than α-blocking properties, is preferred for predominantly epinephrine-secreting tumors. Magnesium sulfate inhibits release of catecholamines from the adrenal medulla and peripheral nerve terminals, reduces sensitivity of α-receptors to catechols, is a direct vasodilator, and is an antiarrhythmic. However, like all antihypertensive medications, it is suboptimal in controlling hypertension during tumor manipulation. Mixtures of antihypertensive drugs such as nitroprusside, esmolol, diltiazem, and phentolamine have been recommended to control refractory hypertension. Increasing the depth of anesthesia is also an option, although this approach may accentuate the hypotension accompanying tumor vein ligation.
25 yo primip ?38/40 gestation with beta thalassemia trait for epidural. BP 140/95, mild proteinuria ...something else... Best test before you will put in epidural
A. Coagulation screen
B. Hb
C. Platelet count
D. skin bleeding time
E.
C
Another pregnant lady ?39/40 with BP185/115 , 4+proteinuria, clonus. IDC placed, 10mLs of dark coloured urine only for the last few hours. Initial management
A. 500mL Crystalloid bolus
B. IV hydralazine
C. IV Magnesium
D. insert epidural
B

This is severe pre-eclampsia. Blood pressure control takes precedence.

From ANZCA SIG Obstetrics:
Elevated blood pressure should be lowered to levels of systolic blood pressure 140-150 mmHg and diastolic blood pressure 90-100 mmHg at a rate of 10-20 mmHg every 10-20 minutes. Reducing severe levels of hypertension decreases the risk of death (Level IV).

There is extensive experience with the safety and efficacy of intravenous hydralazine. This is usually administered by intermittent bolus of 5mg intravenously (IV) or intramuscularly (IM) and repeated as necessary; it has an onset of action of 10-15 minutes. Continuous infusion of 0.5-10.0 mg/hr is also typically employed in more refractory cases. The use of hydralazine is often accompanied by maternal tachycardia. It has been noted however that there is an absence of robust trials comparing hydralazine with intravenous labetalol or oral nifedipine. These latter agents may be preferable due to reduced maternal and fetal complications (Magee et al 2003, Level I).

MgSO4 should be used for seizure prophylaxis in women with severe pre-eclampsia (Level I).

MgSO4 does not reverse or prevent the progression of the disease, nor does it significantly lower blood pressure and it is not recommended as an antihypertensive agent (Abalos et al 2007, Level I; Duley et al 2006, Level I; Podymow & August 2008; Rowe 2008).

In observational studies the use of either crystalloid or colloid solutions has been associated with transient improvements in maternal cardiovascular system parameters. However in one large trial (Ganzevoort et al 2005, Level II) and a systematic review (Duley et al 1999, Level I), volume expansion demonstrated no advantages compared with no plasma volume expansion
The BEST agent to decrease gastric volume AND increase gastric pH before semi-urgent procedure
A. Omeprazole
B. Cimetidine
C. Ranitidine
D. Sodium citrate
E. ?
C

• A – False. Reduces pH, but volume ? See below.
• B – False. See below.
• C – True. Reduces volume and increases pH.
• D – False. Increases volume as well as pH.
Most common congenital heart disease (repeat)
A. VSD
B. PDA
C. ?
D. ?
A

Acetylcholine receptors are down regulated in
A. Guillain-Barre syndrome
B. Organophosphate poisoning
C. Spinal cord injury
D. Stroke
E. Prolonged NMBD use

B

• A - False. Effectively a denervation injury which causes UP-regulation.
• B - TRUE. Organophosphate poisoning causes increases in miniature-end-plate potential (MEPP), and thus can cause DOWN-regulation of ACh receptors. Apparently continuous exposure to organophosphates can cause degeneration of pre-junctional and post-junctional structures.
• C - False. Denervation causes UP-regulation.
• D - False. As for spinal cord injury.
• E - Prolonged NMBD use can cause UP-regulation of ACh receptors.
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
D

According to Oxford Handbook:
Preoperative predictors of postoperative need for ventilation:
• duration of disease of greater than 6 years
• history of coexisting chronic respiratory disease
• dose requirements of pyridostigmine > 750 mg/day less than 48 H prior to surgery
• preoperative VC < 2.9L

Miller pg 1098-9:
"postop ventilation ....... is especially important in cases involving myasthenia gravis of more than 6 years' duration, chronic obstructive lung disease, daily pyridostigmine requirement of 750 mg in association with significant bulbar weakness, and vital capacity of less than 40 mL/kg"
Diagnositic Utility of BNP best in (repeat)
A. SOB post pneumonectomy dyspnoea
B. Confusion post CABG
A
Innervation of Larynx (repeat)
A. the ineternal branch of the superior branch of the...
B.
C.
D.
E. Cuff compression of recurrent laryngeal nerve against thryoid can cause palsy
E
Most distant anatomy seen on grade III laryngoscopy
A. soft palate
B. hard palate
C. Epiglottis
D. arytenoid cartillage
E. opening to ?
C
Regarding anticholinesterases:
A. pyridostigmine has slow onset of effect
B. physostigmine does not rely on renal metabolism/excretion
C. neostigmine cannot reverse centrally acting cholinergics
D. edrophonium is less reliable in reversal?
A, B and C all correct - ?an ‘except’ question

A. True. Has a slower onset of action than neostigmine and its duration of action is longer.
B. True. “Physostigmine is hydrolysed at its ester linkage and renal excretion is of minor importance” (Stoelting)
C. True. It contains “a quaternary ammonium group… poorly lipid soluble and thus do not easily penetrate lipid cell membranes barriers such as… blood brain barrier” (Stoelting)
D. False. Edrophonium produces “reversible inhibition of acetylcholinesterase through its electrostatic attachment to the anionic site on the enzyme…further stabilized by hydrogen bonding on the esteratic site on the enzyme… duration of action considered to be brief, reflecting its reversible binding” (Stoelting)
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
A

Which can deliver minute ventilation of greater than 5L/min using a 14 G cannula used for needle cricothyroidotomy
A. jet ventilation using pressure 400KPA
B. oxygen flush button on anaesthetic machine
C. oxygen tubing on oxygen port on anaesthetic machine at 12L/min
D.
E. none of the above

A

Flint NJ, Russell WC, Thompson JP. Comparison of different methods of ventilation via cannula cricothyroidotomy in a trachea–lung model. Br J Anaesth 2009; 103: 891–5
MVs increased with increasing cannula diameter. In the absence of a proximal const
A

Flint NJ, Russell WC, Thompson JP. Comparison of different methods of ventilation via cannula cricothyroidotomy in a trachea–lung model. Br J Anaesth 2009; 103: 891–5
MVs increased with increasing cannula diameter. In the absence of a proximal constriction, MVs delivered via a 20 G cannula were <1 litre/min with all devices; only the Manujet delivered MV >2 litre/min, at cannula sizes of 16 G. MVs were greater in the presence of a proximal constriction, but did not exceed 4 litre/min using the low-pressure devices.
IV paracetamol
A. late plasma levels around the same as oral
B. highly protein bound
C. ?30%? renally excreted
D. VD 10L/kg
A

A. True. “plasma concentrations of intravenous propacetamol were significantly higher and obtained earlier, compared to oral administration, however after the first hour and up to 24 hours the plasma concentrations remained similar” MIMS
B. False. It is not extensively protein bound.
C. False. 90% excreted in 24 hours.
D. False. VD 1L/kg
Head Trauma patient with unilateral dialated pupil, wahts the diagnosis ?
A.Global injury
B.Optic nerve injury
C.Horners syndrome
D.Tenstentorial herniation
E.....
D

Trauma.org
If there are signs of impending transtentorial herniation (unilateral posturing and/or unilateral dilated pupil) or if there is rapid progressive neurological deterioration (without extracranial cause), then there is significant intracranial hypertension and measures should be instituted to control ICP immediately.
Question about CO2 Laser. Does not cause deep tissue damage because
a. High Frequency
b. Penumbra effect
c. ? Dissipation of energy
d
e.
C

The extinction length of a particular laser beam refers to the depth of tissue penetration when 90% absorption of the laser beam has occurred
Patient with diastolic dysfunction. Is it caused by:
a. Restrictive cardiomyopathy
b. Dilated cardiomyopathy
c.
d.
e.

A

Diastolic dysfunction/increased myocardial diastolic stiffness
▪ Ischemia
▪ Ventricular hypertrophy
▪ Restrictive cardiomyopathy
▪ Consequence of prolonged hypovolemic or septic shock
▪ Ventricular interdependence
▪ External compression by pericardial tamponade

What term means the number of people who are correctly identified as not having a disease:
A. Sensitivity
B. Specificity
C. Positive predictive value
D. Negative predictive value

B



Asking for true negative rate



Sensitivity = True positive rate


Specificity = True negative rate

If a test is negative, what proportion will not have the disease:
A. Sensitivity
B. Specificity
C. Positive Predictive Value
D. Negative Predisctive Value
D

Awake patient with diabetes insipidus
A. Euvolaemic
B.
C.
D.
E. urinary Na <20

A

Harrison’s:
Clinical Characteristics Decreased secretion or action of AVP usually manifests as DI, a syndrome characterized by the production of abnormally large volumes of dilute urine. The 24-h urine volume is >50 mL/kg body weight and the osmolarity is <300 mosmol/L. The polyuria produces symptoms of urinary frequency, enuresis, and/or nocturia, which may disturb sleep and cause mild daytime fatigue or somnolence. It is also associated with thirst and a commensurate increase in fluid intake (polydipsia). Clinical signs of dehydration are uncommon unless fluid intake is impaired

Symptoms of hypercalcaemia include: (see Q5)
A.
B.
C. seizures
D. short ST segment

D

Symptoms of hypercalcaemia:
"Bones, stones, groans and psychic moans"
Abdominal pain
vomiting, constipation
polyuria, polydipsia
depression
anorexia
weight loss
tiredness
weakness
hypertension
confusion
pyrexia
renal stones
renal failure
corneal calcification
cardiac arrest
ECG: shortened ST segment
Symptoms of HYPOcalcaemis:
Tetany, depression
perioral paraesthesia
carpo-pedal spasm (Trousseau's sign)
neuromuscular excitability (Chvostek's sign)
Cataract
Increased QT interval
Paediatric VF arrest. Which is true?
A. if resistant to defibrillation should give amiodarone 5mg/kg
B.
C. commonly associated with respiratory arrest
D. is the most common form of arrest in this patient group
E. should defibrillate with 5J/kg
A
Intercostobrachial nerve
A. Is often damaged by torniquet
B. supplies sensation to cubital fossa
C. is blocked by interscalene brachial plexus block
D. ?
E. ?
A