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61 Cards in this Set

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When hearing loss occurs following spinal anaesthesia it is usually in which of the following frequency ranges:

A 125 - 1000 Hz
B 1500 - 3000 Hz
C 3500 - 5500 Hz
D 6000 - 10000Hz
E > 11000Hz

A

Gultekin et al. Does Hearing loss after spinal anesthesia differ between young and elderly patients? Anesth Analg 2002;94;1318-20
Each of the following drugs act at the DOP (delta receptor) EXCEPT:

A. diamorphine
B. fentanyl
C. morphine
D. naloxone
E. pethidine
Ans B

Ref McDonald et al Opioid receptors. CEACCP 2005 5:1:22-5
Patient burns during MRI can be associated with each of the following EXCEPT

A high intensity changing magnetic fields
B looped monitoring lines ...
C non ferromagnetic material in contact with the patient
D cosmetics worn by the patient (which do not contain metals)
E temperature monitoring with thermister probes
Ans D

Tattoos and make-up: Some tattoos and make-up contain metal pigments. These can cause image artefact or heat, causing skin discomfort, although burns have not been reported

Ref Olive. Don’t get sucked in: Anaesthesia for Magnetic Resonance Imaging. Australian Anaesthesia 2005
AZ (Q120 Aug 2008) Preoperative assessment shows a malampati (ML) score of III and thyromental distance (TMD) of < 6cm. A grade 3 to 4 on Cormark and Lehanes is predicted. Compared to the ML score, the TMD is:

A less sensitive, less specific
B less sensitive, more specific
C more sensitive, less specific
D more sensitive, more specific
E equal sensitivity an specificity
Ans B

Ref: Shiga et al. Predicting Difficult Intubation in Apparently Normal Patients. Anesthesiology 205; 103:429-37
Lee et al. A systematic review (Met-Analysis) of the accuracy of the Mallampati Tests to Predict the Difficult Airway. Anesth Analg 2006;102:1867-78
AZ In performing an awake fibreoptic intubation it is MOST important that care is taken to avoid:

a. Causing any bleeding that will obstruct view
b. Oversedation as leads to posterior pharyngeal wall collapse
c. Trauma to nasal turbinates
d. Touching vocal cords as will induce coughing
e. Oral route as may bite the fibreoptic scope
Ans B

Over-sedation should be avoided, especially in those who have a difficult airway

Ref: Sudheer et al. Anaesthesia of awake intubation CEPD 2003 3:4:120-3
CT reprint showing large MNG. Uppermost concerns to anaesthetist is

a. Involvement of the Right carotid artery
b. Tracheal deviation to the left
c. Tracheal deviation to the right
d. Malignant involvement of the paratracheal nodes
e. compression of upper lobe of rt.lung
Ans D

Thyroidectomy - malignancy - cord palsies likely. Distortion and rigidity of surrounding structures. Possibility of intraluminal spread. Larynx may be displaced. Tumour can produce obstruction anywhere from glottis to carina.
OHA page 555 2nd edition.

The presence of cancerous goiter is a major factor predicting difficult endotracheal intubation.

Ref: Bouaggad et al. Prediction of Difficult Tracheal Intubation in Thyroid surgery. Anesth Analg 2004;99:603-6
Disputed by Amathieu et al. Difficult Intubation in Thyroid Surgery: Myth or Reality? Anesth Analg 2006;103:965-8
PAC seeing patient with thyroid disease. Most reassuring factor for normal thyroid function is:

A. Absence of 'hot' nodules on nuclear scan
B.?
C. Normal heart rate
D. Normal temperature
E. Absence of any antithyroid medications
Ans C.

Thyroid function: check patient is euthyroid- heart rate of <80 bpm and no had tremor. Delay surgery if possible until this is achieved.
OHA 2nd ed pp 158
T1 injury. Patient now 4 weeks post and going to theatre for sacral pressure area debridement. Feature most unlikely to reflect autonomic dysreflexia

B. Bradycardia
C. Severe hypotension
E. Goose bumps below T1 level
Ans C

Autonomic dysreflexia is characterised by massive, disordered automonic response to stimulation below the level of the lesion. It is rare in lesions lower than T7. Incidence increases with higher lesions. It may occur within 3wk of the original injury but is unlikely to be a problem after 9 months. The dysreflexia and its effects are thought to arise because of a loss of descending inhibitory control on regenerating presynaptic fibres.
Hypertension is the most common feature but is not universal. Other features include headache, flushing, pallor ( may be manifest above the level of lesion, nausea, anxiety, sweating, bradycardia and penile erection. Less commonly pupillary changes or Horner’s syndrome.
Dysreflexia may be complicated by seizures, pulmonary oedema, coma or death and should be treated as a medical emergency.

Stimuli to trigger
Urological: bladder distension,
UTI, catheter insertion
Obstetric
Bowel obstruction
Acute abdo
Fractures

From OHA page 240
With regard to fire in OT

A. Mainly caused by laser surgery
B. Decreased incidence since cessation of use of cyclopropane and ether
C. Need fuel, ignition source and oxidizing agent
Ans C

Ref: ASA Practice Advisory for the prevention and management of operating room fires. Anesthesiology 2008; 108:786-801
Visual loss post-operatively

a. more common after external ocular compression
b. incidence 1 in 200,000
c. most common after spinal surgery
d. incidence independent of duration of surgery
e. more common after isovolaemic haemodilution
C

External compression does not cause ischemic optic neuropathy (85% visual loss)
Incidence 1:125000
Spinal Sx > Cardiac Sx
>6h major factor
Cause for hoarse voice after anterior spinal surgery

a. glossopharyngeal nerve palsy or lesion
b. recurrent laryngeal nerve palsy or lesion
c. superior laryngeal nerve or lesion
d. airway oedema
e. prolonged intubation
Ans B
Features most suspicious for myocardial ischaemia

a. ST depression 2mm during fem pop bypass in 60 yo man under spinal
b. T wave inversion in fem pop bypass in 60yo under spinal
c. 0.7mm ST elevation in fem pop bypass in 60 yo man under spinal
d. SAH in young man
e. 32 yo woman during LSCS
Ans A

ECG manifestations of acute myocardial ischaemia (in the absence of LVH and LBBB)

ST elevation
New ST elevation at the J-point in two contiguous leads with the cut-off points: 0.2 mV (2mm) in men or 0.15 mV (1.5 mm) in women in chests leads and/or 0.1 mV in limb leads.

ST depression and T-wave changes
New horizontal or down sloping ST depression 0.05 mV (0.5 mm) in two contiguous leads and/or T inversion 0.1 mV in two contiguous leads with prominent R-wave or R/S ratio >1

SAH ECG changes
Primarily reflect repolarization abnormalities involving the ST segment, T wave, U wave and QTc interval.
Sommargren Electrocardiographic Abnormalities in Patients With Subarachnoid Hemorrhage. Am J Crit Care. 2002;11:48-56
The Line Isolation Transformer

c. Provides low current to the line isolation monitor
d. Separates earth from the OT electrical supply (similar wording)
Ans D

1. When the transformer output in ungrounded, no electric shock occurs to the person at the right if an isolated power line is touched.
2. An electric shock does take place if the person touches the circuit after occurrence of the ground fault shown at the bottom. In the potentially injurious electricity path, shown in red, current comes up from ground through the fault circles around and returns to ground by travelling throught person’t body.
3. The person suffering the electric shock has been replaced by a current meter and a large resistance to ground. This is the basis for detection of the “first fault” by the line isolation monitor.
DC cardioversion - LEAST likely indicated for

A atrial fibrillation
B atrial flutter
C multifocal atrial tachycardia
D paroxysmal atrial tachycardia
E ventricular tachycardia
Ans C

Cardioversion is contraindicated in MAT. Due to the multiple atrial foci, direct current (DC) cardioversion is not effective in restoring normal sinus rhythm and can precipitate more dangerous arrhythmias.

Diagnosis of MAT requires the following electrocardiographic criteria:
1. P waves with at least three different morphologies (including the normal sinus P wave). P wave morphology is generally best seen in lead II, III and V1.
2. An atrial rate of over 100 beats/min is the classic definition of MAT. However, based upon data from a series of patients with chronic obstructive pulmonary disease (COPD), a threshold of 90 bpm has been proposed,.
3. The P waves are separated by isoelectric intervals.
4. The P-P intervals, the P-R duration, and the R-R intervals vary.
Hypercalcaemia due to hyperparathyroidism is associated with

A an elevated GFR
B prolonged QT
C short PR interval
D polyuria polydipsia
E skeletal muscle rigidity
D

HyperCa: Prolonged PR, QRS intervals, shortened QT, T wave flattening, CHB

HypoCa: Prolonged QT
Suprapubic prostatectomy bleeding excessively. Need to exclude primary hyperfibrinolysis. Most useful test would be

A clot retraction time
B plasma fibrinogen estimation
C prothrombin time
D thromboelastography
E whole blood clotting time
D
While of the following statements regarding patients with ankylosing spondylitis are FALSE

A amyloid renal infiltration is rarely seen
B cardiac complications occur in <10% of cases
C normovolaemia anaemia occurs in over 85% of cases
D sacroileitis is an early sign of presentation
E uveitis is the most common extra articular manifestation
Ans C

A TRUE Amyloidosis is a very rare complication of ankylosing spondylitis in patients with severe, active, and long-standing disease. These patients generally have active spondylitis, active peripheral joint involvement, and an elevated erythrocyte sedimentation rate (ESR) and C-reactive protein level. This may result in renal dysfunction with proteinuria and renal insufficiency or failure.[5]
B TRUE Cardiovascular involvement of clinical significance occurs in fewer than 10% of patients, typically those with severe long-standing disease. However, subclinical disease can be detected in many patients and may occur as an isolated clinical entity in association with HLA-B27[6]
C FALSE Approximately 15% of patients may present with a normochromic normocytic anemia of chronic disease.
E TRUE Uveitis is the most common extra-articular manifestation, occurring in 20-30% of patients with ankylosing spondylitis. Of all patients with acute anterior uveitis, 30-50% have or will develop ankylosing spondylitis. The incidence is much higher in individuals who are HLA-B27–positive (84-90%).
COPD patient with pulmonary hypertension and acute RHF. Treatment

a. 100% oxygen will decrease the pulmonary artery pressure
b. Sildenafil will be useful for treating RHF
c. Noradrenaline is an appropriate inotrope for this patient
Ans A

Fischer et al. Management of Pulmonary Hypertension: Physiological and Pharmacological Considerations for Anesthesiologists. Anesth Analg 2003;96:1603-16
Post op patient (surgery 3/7 ago). Patient dyspnoeic. V/Q scan organized which shows non segmental matched perfusion/ventilation defects. This is consistent with

a. Atelectasis
b. COPD (multiple, segmental, peripheral, bilateral, matched)
c. Pulmonary embolus (mismatched)
d. Pneumonia (reverse mismatch)
e. Pulmonary infarction (mismatched)
Ans B

3 type of defects
V/Q MM = Normal V, dec Q eg. PE, pulmonary infarction
V/Q match = Dec V and Q eg. atelectasis, pneumonia, COPD
V/Q Reverse MM = Dec V, normal Q eg. pneumonia
A 25yo primipara with an uncomplicated pregnancy presents to delivery suite in labour at term. Her membranes spontaneously rupture soon after, and it is blood-stained. At the same time, a severe foetal bradycardia appears on the CTG. What is the most likely cause of this?

A. Placenta accreta
B. Placental abruption
C. Uterine rupture
D. Vasa praevia
E. True knot in the umbilical cord
D

Classic triad = membrane rupture followed immediately by painless vaginal bleeding and fetal bradycardia

Vasa praevia = fetal vessels crossing inner cervical os

The bleeding in vasa previa is fetal rather than maternal in origin; only a small amount of blood loss may result in fetal demise unless the problem is recognised quickly and an emergency caesarean section can be performed immediately.

Miller Anaesthesia chapter 69 Anesthesia for obstetrics.
Patient with placenta accreta. Surgical management MOST likely to save her life

A B lynch suture around the uterus for external tamponade
B Rusch balloon in the uterus for internal tamponade
C ligation of the internal iliac arteries
D ligation of the uterine arteries
E subtotal or total hysterectomy
Answer E

B-lynch suture = uterine atony
Balloon tamponade = atony or lower segment bleeding
Iliac artery ligation = buy time
After a difficult thyroidectomy for thyroid carcinoma, a 63 year old woman develops stridor immediately following extubation. The most likely cause is

A hypocalcaemia
B neck oedema
C recurent laryngeal nerve palsies
D tracheomalacia
E vocal cord oedema
Ans C

A: False removal of parathyroid causes hypocalcaemia which usually presents symptomatically after 24 hours.
B neck oedema is possible
C The incidence temporary unilateral vocal cord paralysis resulting from damage to the recurrent laryngeal nerve is 3-4%. Permanent unilateral vocal cord paralysis occurs in <1% of patients and bilateral vocal cord paralysis should be extremely rare. Should present immediately in any case.
D Tracheomalacia very rare according to CEACCP 2007
E Vocal cord oedema possible.

Malhotra et al. Anaesthesia for thyroid and parathyroid surgery CEACCP 2007 7:2:55-9
Farling Thyroid disease. BJA 2000 85:15-28
Patient with traumatic brain injury has the following readings. Global CSF flow measured at 15ml/100gm/min while the CMRO2 is measured at 3.5ml/100gm/min. There is

A appropriate coupling of cerebral perfusion and cerebral metabolism
B autoreguation of cerebral vasodilation
C cerebral hypoperfusion
D cerebral ischaemia
E reperfusion injury
Ans D

Normal CBF is ~ 50 mL/100g/min
Oxygen consumption is ~ 3 mL/100g/min

The critical threshold of CBF for the development of irreversible tissue damage is 15 mL/100g/min in patients with TBI compared with 5-8.5 mL/100g/min in patients with ischaemic stroke.

Low flow with normal or high metabolic rate represents an ischaemic situation whereas high CBF with normal or reduced metabolic rate represents cerebral hyperaemia. In contrast, low CBF with a low metabolic rate or high CBF with high metabolic rates represents coupling between flow and metabolism, a situation that does not necessarilty reflect a pathological condition.
55 year old subarachnoid haemorrhage secondary to aneurysm. Patient is confused with a oculomotor (3rd cranial nerve) palsy, complains of a severe headache. This patient is in Hunt and Hess class:

A 0
B 1
C 2
D 3
E 4
Answer is D

Hunt and Hess Classification
1. Asymptomatic, mild headache, slight nuchal rigidity
2. Moderate to severe headache, nuchal rigidity, no neurologic deficit other than cranial nerve palsy
3. Drowsiness / confusion, mild focal neurologic deficit
4. Stupor, moderate-severe hemiparesis
5. Coma, decerebrate posturing

NB any neurological deficit other than CN palsy is 3 or more
Traumatic brain injury with central diabetes insipidus. Can be managed with

A democlocydine
B desmopressin
C fludrocortisone
D fluid restriction
E frusemide
Answer B

There are two aims in the management of DI: replacement and retention of water and replacement of ADH.

If urine output continues > 250 mL/hour, synthetic ADH should be administered. This is usually in the form of small titrated doses of 1-deamino-8-D-arginine vasopressin which can be given intranasally (100-200 mcg) or iv (0.4 mcg).

Bradshaw et al. Disorders of sodium balance after brain injury. CEACCP 2008 8:4:129-33
Called to ward for Postoperative thyroidectomy bleeding in ward. SpO2 92% on 6L, tachycardic and ?hypertensive and neck haematoma. What is the least appropriate management:

a. call and arrange CT scan of his neck
b. call OT and arrange urgent surgery
c. release staples
d. increase oxygen supply
Answer A.

A sudden loss of airway in remote setting leaves this as a dangerous option. Lying flat may also compromise airway.
Hypertensive female at 38 weeks gestation BP 180/110. CTG shows no foetal distress. First Hb 110 and second is 109. First plt count 90 then drops to 40. AST increases from 50 to ? 120. Most appropriate management is

a. deliver the baby
b. various antihypertensive medication options
c. 20mg frusemide
Ans B

The management of severe pre-eclampsia is based on careful assessment, stabilisation, continued monitoring and delivery at the optimal time for the mother and her baby. This means controlling blood pressure and if necessary convulsions. Ref: Royal college of obstetricians and Gynaecologists. The management of severe pre-eclampsia/eclampsia. March 2006

Elevated blood pressure should be lowered to levels of systolic blood pressure 140-150 mmHg. Reducing severe levels of hypertension decreases the risk of death.

Antihypertensive drugs that can be safely used include labetalol, nifedipine and hydralazine. The choice should be made on clinician familiarity and experience with a particular agent.

Drugs that should be avoided for the reduction of blood pressure are diazoxide, ketanserin, nimodipine, MgSO4 and sodium nitroprusside.

ANZCA. Management of pre-eclampsia and eclampsia 2008

Once pre-eclampsia is diagnosed, the goal of therapy is prevention and reduction of further complications by taking into account both maternal and fetal factors. Although the only definitive cure is deliver, management of maternal hemodynamics and prevention of the development of eclampsia are key to a favourable outcome for the mother and infant.

The mainstay of therapy in pre-eclampsia is control hypertension, prevention of seizures, and delivery of the fetus.

Miller’s Anaesthesia. Chapter 69- Anesthesia for Obstetrics.
Post bypass 3 vessel CABG. Hypotensive and ECG shows ST elevation in II, aVF CVP 15mmHg PAP 25mmHg with normal SVR and PVR. What is most likely to be seen on TOE
a. early diastolic augmented flow ct atrial systolic flow
b. Inferior hypokinesis (of the left ventricle)
c. RV failure and TR
d. Empty left ventricle following systole
e. Mitral regurgitation
Ans B

ST elevation in II aVF suggests inferior ischaemic changes. CVP (normal 1-10) high PAP (normal systolic 15-30 diastolic 0-8 Mean pulmonary arterial pressure 10-20)

Inferior ischaemia suggest LV involvement. High PAP also suggests LV involvement. Increased CVP likely due to transmitted pressure.
The left recurrent laryngeal nerve

A hooks around the arch of the aorta anterior to the attachment of the ligamentum arteriosum
B passes under cover of the lower border of the inerior constrictor muscle before entering the larynx
C supplies the cricothyroid muscle
D supplies sensation to the whole of the laryngeal mucosa on the left side
E contains motor fibres derived from the spinal root of the accessory nerve
B
The ascending aorta

A has no branches
B begins at the semilunar valve
C arises from right ventricle
D occupies the superior mediastinum
E lies inferior to the SVC
Answer is B
The nerve providing sensory supply to the airway muscle below (inferor) to the vocal cords is the

A phrenic nerve
B posterior thyroid nerve
C recurrent laryngeal nerve
D superior laryngeal nerve
E tracheal nerve
C
Ciliary ganglion

A sympathetic from inferior cervical ganglion
B located inferiorly within orbit
C may be damaged during a peribulbar block
D preganglionic parasympathetic supply from the supra trochlear nerve
E preganglionic parasympathetic originates from the Edinger Westpal nucleus
E
Ciliary ganglion

Parasymp root: From the Edinger Westphal part of the oculomotor nucleus via CN III
Symp root: From the SCG via internal carotid nerve.
Sensory root: From a branch of the nasociliary nerve, with cell bodies in the trigeminal ganglion.

Branches: Short ciliary nerve to the eye.
You are seeing a 60yo man in the pre-anaesthetic clinic before his right total knee replacement. He weighs 70kg and apart from his osteoarthritis is fit and well. You discuss with him the options of a general anaesthetic with multi-modality analgesia and enoxaparin postoperatively as well as the option of an epidural for both the anaesthetic and post operative pain management. What is incorrect regarding the epidural?

A. It will shorten his hospital stay and accelerate his rehabilitation
B. It will give him better pain relief particularly for the CPM machine (the continuous pain machine)
C. It will reduce his risk of myocardial ischaemia
D. There will be little difference in his risk of thromboembolism.
E. If he has no sedation, his risk of post-operative delirium and cognitive impairment will be reduced
Ans C

Acute Pain management:scientific evidence(ANZCA) summary and pg 110-115 (2nd edition)
A)- True
B- True “After hip or knee replacement, epidural analgesia provides better pain relief than parental opioid in particular with movement. Acute pain management scientific evidence 3rd ed
C- False( correct answer): only true for thoracic epidurals extended for more than 24hrs, not lumbar epidural for TKR
D- True, only difference is with graft occlusion in peripheral vascular surgery, not orthopaedics and DVT where DVT prophylaxis has been used.
E- ?true
Effect of Injecting 5 mL of saline into the epidural space:

a. increase incidence of patchy block
b. decreased risk of epidural vein catheterisation
c. no effect
d. increased ease of threading catheter
e. ? decreased effectiveness of block
Ans B

Evron et al. Predistention of the epidural space before catheter insertion reduces the incidence of intravascular epidural catheter insertion. Anesth Analg 2007;105:460-4
PDPH

a. IV caffeine treatment used to relieve symptoms.
b. Is usually frontal headache
c. Bed rest for 24 hrs is beneficial
d. no use if blood patch done after 48 hrs.
e. usually manifests within first 4 hrs.
A

A Although caffeine is often prescribed to prevent or treat PDPH, evidence for its efficacy is limited and conflicting. Administration of caffeine combined with paracetamol for 3 days following spinal anaesthesia did not redice the incidence of PDPH (or associated symptoms such as nausea and photophobia) compared with placebo. IV caffeine administered during spinal anaesthesia reduced pain scores analgesia requirements and the incidence of moderate to severe PDPH for up to 5 days. Acute pain management.
B False usually occipital and frontal
C There was evidence of benefit with bed rest in the treatment or prevention of PDPH.
D Observational studies suggest that failure is more likely if the blood patch is performed within 24 hours of the dural puncture.
E Headache typically occurs on the first or second day after dural puncture it must appear within 5 days of dural puncture.
A terrorist attack has taken place involving the nerve gas "VX". Some victims have arrived in the emergency department. The most appropriate management of this situation is to:

A. Strip them off and hose them down
B. Strip them off, scrub them with a brush, and hose them down
C. Leave their clothes on and hose them down
D. Leave their clothes on, scrub them with a brush, and hose them down
E. Take them to the resuscitation area and put in an IV
Ans A

Priority is given to life saving treatment over decontamination. It is preferable for patients to decontaminate themselves. Clothes and jewellery should be removed and the patient washed from head to toe with soap and water, but gently enough to avoid skin trauma.

Victorian Government. Decontamination guidance for hospital 2004. White et al. Chemical and biological weapons. Implications for anaesthesia and intensive care. BJA 2002 89;2;306-24
GCS question – open eyes to command, withdrawing from pain, confused conversation:

A. 8
B. 9
C. 10
D. 11
E. 7
Ans D

Eyes 3/4 Movement 4/6 Verbal 4/5
Young man in trauma, had been drinking,alcohol level >300. Multiple fractures. Initial lactate 10 then post fluid resus lactate 5.

a. 2nd lactate more important than first for prognosis
b. initial lactate high due to alcohol
d. The initial lactate result carries a mortality exceeding 20%
Ans A

A. True in that increased lactate or no reduction in high lactate is prognostic of very poor outcome (mortality 100% in haemorrhagic trauma with patients with no improvement in lactate after 48 hours of resuscitation.
Manikis et al correlation of serial blood lactate levels to organ failure and mortality after trauma. Am J Emerg Med 1995;13;619-622

B. False Alcohol may increase lactate levels slightly but lactic acidosis (and a lactate of 10!!! extremely unlikely without protein malnutrition and still this is very rare.

D. False. In this group of patients, we found similar results, with the best positive predictive value of 20% when the admission lactate was >20 mmol/l Ref Pal et al. Admission serum lactate levels do not predict mortality in the acute injured patient. J Trauma. 2006;60;583-589.
Depends on reference - Multiple articles claim > 20% mortality in SIRS/sepsis however for trauma unlikely to predict outcome.
A 6 month old baby is booked for an elective right inguinal hernia repair. An apropriate fasting time is

A 2 hours breast milk
B 4 hours formula milk
C 5 hours breast and formula milk
D 6 hours solids
E 8 hours solids, 4 hours all fluids
D

2 4 6 rule for clear fluids/breast milk/solids (includes formula)
Therefore D (breast milk at 4 hours would be ideal)

This question may well be from the ANZCA document on day surgery which includes fasting guidelines - They are as stated above (2 hours clear fluids, 4 hours breast milk for any age child, 4 hrs for formula for <6 week old, or 6hrs for formula/solids for >6 weeks old, and of course 6 hrs adult solids).
Arrest in a 10 year old. Has ventricular tachycardia after a near drowning accident. Patient is intubated and is being ventilated with 100% O2 and has IV access. A single DC monophasic shock of 60J has been given. The next step is to give

A adrenaline 10mcg/kg and DC shock 60J
B adrenaline 10mcg/kg and DC shock 120J
C amiodarone 5mg/kg
D DC shock 60J
E DC shock 120J
Ans E

VT in child algorithm from Australian Resuscitation Guidelines on ANZCA website [21]

Next step after CPR for 2 min is 1 shock at 4 J /kg. 10 year old should be 28 kg therefore 120J

AUSTRALIAN RESUSCITATION COUNCIL The recommended initial monophasic or biphasic shock treatment of VF or pulseless VT is a single shock of 2 joules per kilogram (J/kg) followed by 2 minutes of CPR and then by a monophasic or biphasic shock of 4J/kg 1,2,3 [Class A; LOE IV]. All subsequent shocks should be 4 J/kg 1 [Class A; LOE IV].

F'ailure to revert to sinus rhythm is treated with adrenaline 10mcg/kg IV or IO or 100mcg/kg ETT. Adrenaline administration should be followed with a subsequent single DC shock (4J/kg monophasic or biphasic shock).

Persistent or refractory VF or VT may be treated with antiarrhythmics such as amiodarone 5 mg/kg IV 7 [Class A; LOE II] or IO as a bolus followed by additional DC shock. This may be repeated. A less efficacious antiarrhythmic for DC- shock resistant VF or VT is lignocaine 8 [Class B; LOE II] in a dose of 1 mg/kg IV or IO or 2- 3 mg/kg via ETT1.
6 month old baby for VSD repair. Induced with 50% N2O, O2, sevoflurane 8%. While obtaining IV access, the patient desaturates to 85%. The manouevre to increase the O2 saturations is to

A give a fluid bolus
B change from sevoflurane to isoflurane
C institute CPAP
D decrease the FiO2
E reduce the sevoflurane concentration
Ans E

↑SVR and FiO2 (↓PVR) reverses right to left shunt back to normal.

The ratio of PVR and SVR is normally 1:10-1:20, VSDs generally result in production of a L-R shunt. In some instances, however, the ratio of PVR to SVR may be higher, resulting in near normal pulmonary blood flow or in extreme cases, production of a R-L shunt.

Large VSDs predispose the development of PVOD (pulmonary Veno-Occlusive Disease) during the first few years of life due to exposure of the pulmonary vasculature to high flows and systemic blood pressures. The increases in PVR that accompany PVOD will ultimately produce bidirectional and R-L shunts. Patients with advanced PVOD and markedly increased PVR (Eisenmenger’s complex) generally are not candidates for VSD closure, because closure will result in an enormous increase in RV afterload and RV afterload mis-match. For this reason, large VSD (Qp:Qs > 2:1) are corrected early in childhood.
The active metabolite of ketamine is:

a. Hydroxyketamine
b. Hydroxynorketamine
c. Ketamine glucuronide
d. Ketamine sulphonamide
e. Norketamine
E

Metabolites of ketamine are norketamine and dehydronorketamine
Antidepressants are not effective/recommended for

a. Chronic headache
b. Chronic back pain
c. Chronic pain post mastectomy
d. Chronic pain post acute herpes zoster
e. Trigeminal neuralgia
Ans B C E

B There is no good evidence that antidepressants are effective in the treatment of chronic low back pain.
C No longer true as the information and evidence supporting it has been withdrawn.
E Published guideline identified insufficient evidence for the effectiveness of any IV medication in this setting. The same guidelines rate carbamazepine as effective and oxcarbazepine as probably effective in this condition and suggest that baclofen, lamotrigen and pimozide may be considered if the first line medications are ineffective. Topical ophthalmic anaesthesia is described as probably ineffective.

ANZCA
Acute pain management
NNT is the number of patient who need to be treated to prevent 1 additional bad outcome. The NNT is the reciprocal of the

A. absolute odds of a bad outcome
B. absolute risk of a bad outcome
C. absolute risk reduction in the bad outcome (due to the treatment)
D. odds ratio of the bad outcome (due to the treatment)
E. relative risk of the bad outcome (due to the treatment)
Answer is C

ie new antiemetic reduces risk of vomiting by 1/5th. Thus absolute risk reduction of bad outcome is 1/5th. Thus NNT is 5 inorder for 1 patient to not vomit
In a Jehovah's Witness patient undergoing a revision of a total hip replacement, the most effective technique to minimise post-operative anaemia would be

A. epidural anaesthesia
B. induced hypotension
C. intra-operative cell saving
D. intra-operative intentional normovolaemic haemodilution
E. pre-operative administration of recombinant erythropoietin
C
When providing anaesthesia for a patient who is a Jehovah's Witness, it is NOT acceptable to use

A. erythropoietin
B. albumin and clotting factors
C. cardio-pulmonary bypass
D. isovolaemic haemodilution
E. blood products for children, if parents insist that they be witheld
B

Accept NOT- whole blood, plasma, RBCs, PLT, FFP, autologous transfusion not in connection w/ circ

Accept may- Ig, individual clotting factors, albumin

Accept will- EPO, autologous blood kept in circuit eg. hemodilution, CPB, dialysis,
Recognised clinical associations with Dystrophia myotonia include:

A. development of diabetes mellitus
B. abnormal intestinal motility
C. cardiomyopathy
D. ovarian dysfunction
E. all of the above
E

"Myotonia dystrophica usually manifests as facial weakness (expressionless facies), wasting and weakness of the sternocleidomastoid muscles, ptosis, dysarthria, dysphagia, and inability to relax the handgrip (myotonia). Other characteristic features include the triad of mental retardation, frontal baldness, and cataracts. Endocrine gland involvement may be indicated by gonadal atrophy, diabetes mellitus, hypothyroidism, and adrenal insufficiency."
"Delayed gastric emptying and intestinal pseudo-obstruction may be present."
"Death from pneumonia or heart failure often occurs by the sixth decade of life. This reflects progressive involvement of skeletal muscle, cardiac muscle, and smooth muscle. Perioperative morbidity and mortality rates are high due principally to cardiopulmonary complications."
In elderly patients

A. opioid requirements are decreased, primarily due to age-related changes in physiology
B. pain thresholds are decreased
C. self-rated pain scores are lower than in younger patients
D. there is a decrease in the density of unmyelinated but not myelinated nerve fibres
E. there is impairment of pain inhibitory systems
E

Pain book
A 70-yr-old man is to undergo removal of cataract and intraocular lens implantation. He has long-standing atrial fibrillation and is on warfarin. He has no other health problems. He has never had a stroke. A sub-tenon’s block is planned for the procedure. His INR is 2.5. What should be the perioperative management of his warfarin therapy and anticoagulant status?

A. Interrupting warfarin therapy is optional for this procedure. If warfarin is interrupted for 5 days to allow normalisation of INR (< 1.5) no other perioperative anticoagulant prophylaxis is necessary
B. Warfarin therapy should be ceased 5 days preoperatively and no other perioperative anticoagulant prophylaxis is necessary. Surgery should proceed if INR is < 1.5
C. Warfarin therapy should be ceased 5 days preoperatively. He should commence daily low molecular weight heparin, omitting the dose on the day of surgery. Surgery should proceed if INR is < 1.5
D. Warfarin therapy should be ceased 5 days preoperatively. He should take daily clopidogrel till surgery. Surgery should proceed if INR is < 1.5
E. Warfarin therapy should be ceased 5 days preoperatively. He should take daily low dose aspirin till surgery. Surgery should proceed if INR is < 1.5
A

From the frca.co.uk site: "Patients taking anti-coagulant medication such as aspirin, clopidogrel or warfarin can still safely receive a sub-Tenon’s block as the risk of significant or problematic bleeding is negligible.
The question as to whether the surgical procedure should proceed or not in the face of abnormal clotting will depend on the nature of the surgery
and the clinical judgment of the surgeon."
A sympathetic block could be effective in treating all of the following conditions EXCEPT

A. Chronic Tinnitus
B. Quinine Poisoning
C. Post Cardiac Surgery Pain Syndrome
D. Phantom limb pain
E. Compartment Syndrome
E
The earliest sign in the development of malignant hyperthermia is

A. acidosis
B. hyperthermia
C. increased end-tidal carbon dioxide concentration
D. muscle rigidity
E. myoglobinuria
C
Chronic post-operative pain

A. in a phantom limb is reduced in incidence by administration of chemotherapy
B. after thoracotomy has an incidence of approximately 50%
C. following thoracotomy does NOT have its severity predicted by the severity of acute post-operative pain
D. following mastectomy combined with implantation of a prosthesis is LESS likely to occur than following mastectomy alone
E. following cholecystectomy is MORE likely if there is a history of classic gallbladder pain pre-operatively
B

"Administration of chemotherapy increases the incidence of phantom limb pain."
"Long-term pain after thoracotomy, the postthoracotomy pain syndrome (PTPS), may have an incidence of more than 50%."
"The intensity of acute postoperative pain is a statistically significant predictor of post-thoracotomy pain syndrome (PTPS) (36 vs. 56% PTPS for minor vs. moderate to severe acute pain)."
"......found that mastectomy combined with implantation of a breast prosthesis yielded a higher incidence of pain (53%) than did mastectomy alone (31%)."
"A history of classic gallbladder attack symptoms is associated with reduced risk of chronic pain and symptoms."

Incidence of chronic pain post surgery
Amputation 30-85%
Thoracotomy 5-67%
Mastectomy 11-57%
Cholecystecomy 5-56%
Inguinal hernia 0-63%
Correct statements regarding medical laser hazards include all of the following EXCEPT

A. carbon dioxide lasers can cause corneal opacification
B. carbon dioxide laser energy is readily absorbed by most tissues
C. in general, the shorter wavelength lasers are more strongly absorbed by tissues and the longer wavelength lasers are more scattered
D. Nd:YAG (neodymium:yttrium-aluminium-garnet) lasers can injure the retina
E. the effect that a particular laser beam has on tissue depends on its wavelength and power density
C- other way around

Carbon dioxide lasers can cause corneal opacification (Zuclich et al, Corneal damage induced by pulsed CO2 laser radiation. Health Phys. 1984 Dec;47(6):829-35.)

Carbon dioxide lasers operate at 10600nm and are preferentially absorbed by water which is the main constituent of most cells. Tissue damage can be observed directly. (Oxford Handbook Anaesthesia, pg 677)

Nd:YAG lasers can injure the retina. (Multiple reports, just do a Google search for Nd:YAG laser retinal injury).

The effect of a laser on tissue depends on its wavelength, power density (read size of beam). (Oxford handbook Anaesthesia, pg 675).
The most appropriate investigation to diagnose Type A aortic dissections in potentially unstable patients is
A. angiography
B. CAT scan
C. magnetic resonance imaging (MRI)
D. transoesophageal echocardiography
E. transthoracic echocardiography
D
Post partum foot drop is most frequently caused by

A. compression of the lumbosacral trunk by the foetal head or forceps
B. damage to the common peroneal nerve from lithotomy position
C. damage to the conus medullaris by misplaced spinal anaesthesia
D. L4 Nerve root damage from epidural analgesia
E. the excessive lumbar lordosis of pregnancy stretching nerve roots
A

"Two women, aged 27 and 28 years, presented with an isolated dropping foot developed during labour and the third trimester of pregnancy, respectively. Lumbosacral plexopathy was diagnosed in both cases. Of the relatively rare maternal obstetric complications, lumbosacral plexopathy is the most common. It is caused by compression of the truncus lumbosacralis against the sacral ala by the foetal head. Symptoms are often misdiagnosed as peroneal or ischiadic neuropathy or lumbosacral radiculoopathy. Therefore for a correct diagnosis, a consultation with a neurologist is indicated. The prognosis for lumbosacral plexopathy is excellent."
When intravenous magnesium sulphate is administered in the management of severe pre-eclampsia, deep tendon reflexes are lost at a serum Mg2+ level of

A. 2 mmol.1-1
B. 3.5 mmol.1-1
C. 5 mmol.1-1
D. 8 mmol.1-1
E. 12 mmol.l-1
B

Normal 0.7-1.0mmol/L
Therapeutic 2-3.5
Loss of patellar reflexes 3.5-5
Skeletal muscle relaxation 6
SA, AV block, respiratory paralysis 6-7.5
Cardiac arrest >12
Anatomical features of the spinal cord do NOT include

A. an anterior median fissure and a posterior median septum
B. thirty-two pairs of spinal nerves
C. a filum terminale ending at the coccyx
D. four to six spinal arteries arising from the posterior inferior cerebellar arteries
E. the anterior spinal artery arising from the vertebral arteries
B and D

"The spinal cord presents an anterior median fissure and a shallow posterior median sulcus from which a glial posterior median septum extends about halfway into the substance of the cord."

"31 pairs of spinal nerves- 8 cervical, 12 thoracic, 5 lumbar, 5 sacral and 1 coccygeal. Each is formed by the fusion of an anterior and posterior spinal root."

"Below, the spinal cord tapers into the conus medullaris, from which a glistening thread, the filum terminale, continues down to become attached to the coccyx."

"The anterior spinal artery is a midline vessel lying on the anterior median fissure and is formed at the foramen magnum by the union of a branch from each vertebral artery."
Transient neurological symptoms (TNS) syndrome is characterised by pain and/or dysaesthesia in the
buttocks or lower extremities following spinal anaesthesia. Clinical features of this syndrome
include

A. a reduction in symptoms with lower doses of lignocaine
B. a significantly decreased risk with 2% lignocaine compared to 5% lignocaine
C. increased risk with early ambulation
D. increased risk with prone positioning
E. similar incidence with lignocaine and bupivacaine
C
Codeine phosphate

A. is converted by the liver to its active metabolite, oxycodone
B. is not associated with tolerance on chronic use
C. is not effective as an analgesic in approximately 20% of Causcasians
D. is poorly absorbed from the gastrointestinal tract
E. when given orally has approximately 5% of the analgesic potency of intramuscular morphi
E

Metabolites = codeine-6-glucuronide, norcodeine, morphine
CYP2D6 polymorphism 10% Caucasians
PO B/A >50%
Correct statements regarding fondaparinux include each of the following EXCEPT

A. it has a structure unrelated to heparin
B. it is administered once daily
C. it is a synthetic, selective Factor Xa inhibitor
D. it is recommended for DVT prophylaxis in major orthopaedic surgery
E. the dosage does NOT need to be adjusted for age and sex
A

derived from the factor Xa-binding moeity of unfractionated heparain
A diagnostic test has a sensitivity of 90% and a specificity of 99% in detecting a certain disease.
From this we can conclude that

A. the false positive rate of this test is 1%
B. the false negative rate of this test is 1%
C. the positive predictive value of this test is 90%
D. the negative predictive value of this test is 90%
E. this test would be a useful screening test for this disease
A