Anzca Mcq 2008 B

Front 1

RB63 (Q133 Aug 2008) 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

Back 1

Ans A
Gultekin et al. Does Hearing loss after spinal anesthesia differ between young and elderly patients? Anesth Analg 2002;94;1318-20

Front 2

AP (Q126 Aug 2008) Each of the following drugs act at the DOP (delta receptor) EXCEPT:
A. diamorphine
B. fentanyl
C. morphine
D. naloxone
E. pethidine

Back 2

Ans B
Ref McDonald et al Opioid receptors. CEACCP 2005 5:1:22-5

Front 3

AZ (Q26 Aug 2008) 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

Back 3

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

Front 4

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

Back 4

C - more sensistive, less specific
Anaesthesia, 2002, 57, pages 105±109

Alternative view:
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

Front 5

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

Back 5

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

Front 6

AZ-12. CT reprint showing large Multi Nodular Goitre . 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

Back 6

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

Front 7

AZ26. 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

Back 7

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

Front 8

AZ. T1 injury. Patient now 4 weeks post injury and going to theatre for sacral pressure area debridement. Feature most UNLIKELY to reflect autonomic dysreflexia
A. ?
B. Bradycardia
C. Severe hypotension
D. ?
E. Goose bumps below T1 level

Back 8

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

Front 9

AC. 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
D. ?
E. ?

Back 9

Ans C
Ref: ASA Practice Advisory for the prevention and management of operating room fires. Anesthesiology 2008; 108:786-801

Front 10

AZ. 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

Back 10

A. Possibly True: Increased IOP would not result in ION without also causing retinal damage. Further support is that sustained increases in IOP significantly decreased both retinal and choroidal blood flows, and even small increases in IOP damaged the retinal ganglion cells, which are sensitive to pressure alterations.
B. False incidence 1 in 60 000 to 125 000
C. False spine 0.03% and cardiac surgery 0.086% Shen et al The prevalence of perioperative visual loss in the united states: A 10 year study from 1996 to 2005 of spinal, orthopediac cardiac and general surgery. Anesth Analg 2009;109:1534-45
D. False In the patients with ION, the highest risk group included patients who had anesthetics lasting more than 6 hours and estimated blood loss of greater than 1L. Ref: Warner. Postoperative visual loss. Anesthesiology 2006; 105:641-2
E. There are no clinical studies examining the optic nerve, but in healthy volunteers very deep levels of haemodilu-tion (haemoglobin, 50 g litre-1) were tolerated without any disturbance in systemic O2 delivery, 100 and in a multicentre prospective study, allowing a lower haematocrit in critically ill patients did not worsen out-comes. 45 It is not known whether any of these results can be extended to patients undergoing surgery such as spine surgery.

Front 11

AZ. 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

Back 11

Ans B
BCDE are all possible. End point is the RLN
Since the duration of surgery is not related to RLN injury in our series, we suggest that the most important factor was excessive retractor pressure than duration of pressure. We suggest that the possible etiologies for this complication are sharp dissection, pinching of the RLN by retractors, stretching of the nerve with retraction, postoperative edema, and nerve involvement in suture, direct trauma to the cricoarytenoid joint and reoperation in the same level. Properly endotracheal intubation, careful blunt dissection and surgical technique, correct retractor placement beneath the bodies of longus colli muscles away from the tracheoesophageal groove, are critical to preventing direct surgical trauma to the nerve.

S Kahraman et al Is dysphonia permanent or temporary after anterior cervical approach? Eur Spine J 2007 16:2092-2095

Front 12

EM 65 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

Back 12

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

Front 13

EM. The Line Isolation Transformer
a. ?
b. ?
c. Provides low current to the line isolation monitor
d. Separates earth from the OT electrical supply (similar wording)
e. ?

Back 13

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.

Front 14

MC (Q132 Aug 2008) DC cardioversion - LEAST likely indicated for
A atrial fibrillation
B atrial flutter
C multifocal atrial tachycardia
D paroxysmal atrial tachycardia
E ventricular tachycardia

Back 14

Ans C
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.
Uptodate.
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. http://emedicine.medscape.com/article/155825-overview#a30

Front 15

ME (Q83 Aug 2008) 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

Back 15

D

Front 16

MH (Q100 Aug 2008) 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

Back 16

D

Front 17

MZ (Q96 Aug 2008) Which 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

Back 17

C is false and answer to choose

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.[7]
D TRUE
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%).

Front 18

MZ-16 MR48 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
d. ?
e. ?

Back 18

? All correct

Ref for A:
Fischer et al. Management of Pulmonary Hypertension: Physiological and Pharmacological Considerations for Anesthesiologists. Anesth Analg 2003;96:1603-16

Front 19

MZ-25 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
c. Pulmonary embolus
d. Pneumonia
e. Pulmonary infarction

Back 19

Ans B

3 type of defects
Ventilation-perfusion (V-P) mismatch: Perfusion defect without corresponding ventilatory abnormality
V-P match: perfusion defect with corresponding ventilatory abnormality
Reversed V-P mismatch: ventilation abnormality with either no or with much less severe corresponding perfusion abnormality.
Suggest a shunt
COPD: matched areas with defects in ventilation and perfusion are observed. Ventilation defects are commonly more prominent than those of perfusion which leads to a pattern called reversed mismatch.
COPD is characterized on V/Q scan by matched ventilation and perfusion defects. Frequently ventilation defects are more pronounced than perfusion defects. This is known as reverse mismatch
Bajc et al. EANM guidelines for ventilation/perfusion scintigraphy. Eur J Nucl Med Mol Imaging 2009 36:1356-1370

Pneumonia: pneumonic regions lack ventilation while perfusion may partly be upheld. The most frequent finding is a matched defect. Reverse mismatch also can happen.

Front 20

SF (Q105 August 2008) 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

Back 20

D - Vasa Praevia

Vasa previa is an uncommon placental condition that carries with it high fetal mortality. It occurs in pregnancies with a velamentous insertion of the umbilical vessels so that they run through amniotic membranes traversing between the fetal presenting part and the cervical os. These vessels have little support and are very susceptible to trauma during labor. A diagnosis of vasa previa is suspected when vaginal bleeding occurs immediately on rupture of the amniotic membranes and is accompanied by FHR abnormalities. 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.

Front 21

SF (Q141 Aug 2008) Patient with placenta acreta. 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

Back 21

Answer E
Page 731 2nd edition OHA B-lynch suture is for uterine atony after caesarean. Balloon tamponade can be used for atony or lower segment bleeding, arterial ligation does not appear to be that helpful due to collateral supply (anecdotal from obstetricians I work with), and hysterectomy is surgical last resort. kom.
Agree, iliac artery ligation seems to be something done to buy time for further treatment.

From Chestnut Obstetric Anaesthesia....."Most patients with placenta accreta require hysterectomy. This condition is currently one of the two most common indications for peripartum hysterectomy; a prompt decision to proceed to hysterectomy without delay enhances the likelihood of an optimal outcome.[55] Attempts to separate and detach the placenta frequently result in massive hemorrhage. Therefore, in cases in which the diagnosis was made before delivery, the obstetrician may proceed directly to hysterectomy without attempting to separate the placenta. Unfortunately, some obstetricians have little or no experience with the performance of peripartum hysterectomy. The presence of two obstetricians for cesarean delivery in women at high risk for placental accreta is recommended. Blood loss in these cases can be substantial. The importance of delivering large amounts of blood products to the operating room quickly cannot be overstated."

Front 22

SG (Q103 Aug 2008) 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

Back 22

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

Front 23

SN (Q114 Aug 2008) Patient with traumatic brain injury has the following readings. Global Cerebral blood flow 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

Back 23

Ans D - cerebral ischaemia

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.

Front 24

SN (Q108 Aug 2008) 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

Back 24

Answer is D - grade 3 (from 1-5, not 0-4)

Hunt and Hess Classification (NB any neurological deficit other than CN palsy is 3 or more)
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[11]

Front 25

SN (Q131 Aug 2008) Traumatic brain injury with central diabetes insipidus. Can be managed with
A democlocydine
B desmopressin
C fludrocortisone
D fluid restriction
E frusemide

Back 25

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

Front 26

SG2. 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

Back 26

Answer A. A sudden loss of airway in remote setting leaves this as a dangerous option. Lying flat may also compromise airway. Although will > 6 L of O2 benefit someone on a hudson mask.

Front 27

SF4. 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
d.?
e.?

Back 27

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.

Front 28

SC15]] 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

Back 28

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.

Front 29

NN (Q85 Aug 2008) 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

Back 29

A false posterior to ligamentum arteriosum
B TRUE
C False innervates all intrinsic muscles of the larynx except the cricothyroid
D False supplies sensation to mucosa BELOW the cords (Superior laryngeal nerve above cords)
E False Vagus nerve.

Front 30

NT (Q62 Aug 2008) 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

Back 30

Answer is B

Front 31

NN (Q102 Aug 2008) 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

Back 31

C

Front 32

NH (Q138 Aug 2008) 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

Back 32

E
Ciliary ganglion
Parasympathetic root: From the Edinger Westphal part of the oculomotor nucleus by a branch from the nerve to the inferior oblique muscle from the inferior division of the oculomotor nerve.
Sympathetic root: From the superior cervical ganglion by branches of the 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.

Front 33

RB (2008 August Q106) You are seeing a 60yo man in the pre-anaesthetic clinic before his right total knee replacement. He weighs 70kg and apart from his osteoarthritis is fit and well. You discuss with him the options of a general anaesthetic with multi-modality analgesia and enoxaparin postoperatively as well as the option of an epidural for both the anaesthetic and post operative pain management. What is incorrect regarding the epidural?
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) <--- really?? I thought CPM was continuous passive motion?
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

Back 33

Ans C

The question asks for the incorrect answer. Taken from 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 RTKJReplacement.
D- True, only difference is with graft occlusion in peripheral vascular surgery, not orthopaedics and DVT where DVT prophylaxis has been used.
E- ?true

Front 34

RB 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

Back 34

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

Front 35

RB 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.

Back 35

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.

Front 36

IC (2008 August Q104) 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

Back 36

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

VX or S-[2-(diisopropylamino)ethyl]-O-ethyl methylphosphonothioate] is able to be lethal on skin contact therefore patient must be cleaned before touched!

Front 37

IC Another GCS question – open eyes to command, withdrawing from pain, confused conversation:
A. 8
B. 9
C. 10
D. 11
E. 7

Back 37

Ans D
Eyes 3/4 Movement 4/6 Verbal 4/5

Front 38

IC 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 c. ?
d. The initial lactate result carries a mortality exceeding 20% e. ?

Back 38

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. See reference [19]

Front 39

IC. Patient has anterior cervical spine fusion. Most likely cause of hoarse voice
a. RLN injury
b. Swelling
c. ?
d. ?
e. ?

Back 39

A. RLN injury

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PP (Q90 Aug 2008) 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

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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).

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PP (Q139 Aug 2008) 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

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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
Answer E.--SG 12:22, 26 Oct 2008 (EDT)

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.

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PP (Q150 Aug 2008) 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

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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.

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PZ. The active metabolite of ketamine is:
a. Hydroxyketamine
b. Hydroxynorketamine
c. Ketamine glucuronide
d. Ketamine sulphonamide
e. Norketamine

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E
norketamine Metabolites of ketamine are norketamine and dehydronorketamine

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PZ19. 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

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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

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ST (Q23 Aug 2008) 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)

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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