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85 Cards in this Set

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Pre-eclamptic woman, BP 170/110, headache, proteinuria 1.2g. Which of the following NOT to use for control of her hypertension:

A. Magnesium
B. SNP
C. GTN
D. Hydralazine
E. Metoprolol

A. Magnesium - not for control of HTN

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

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

Magnesium is NOT for control of BP. It is for prevention of fits and treatment. 4g loading + 1g/h infusion

Male with a Haemoglobin of 8G% and reticulocyte count 10%. Possible diagnosis:

A. Untreated pernicious anaemia
B. Aplastic anaemia
C. Acute leukaemia
D. Anaemia of chronic disease
E. Hereditary spherocytosis

Ans E Spherocytosis

Only this have increased reticulocyte count
Normal range 0.5-1.5%

Commonest organism causing meningitis post spinal:

A. Staph epidermidis
B. Staph salivarius
C. Staph aureus
D. Strep pneumoniae

B. Staph salivarius

Baer, Post Dural Puncture Bacterial meningitis, Anaesth 2006
Most of the organisms that cause PDPM are commensals of the mouth and upper airway. These observations support the droplet mechanism for the pathogenesis of most cases of PDPM. That is, the aerosolized organism that enters the CSF during dural puncture originates in the upper airway of medical personnel.

Order of most to least common
Staph salivarius
Strep viridians
Staph aureus
Pseudomonas aeruginosa
Exponential decline / definition of time constant

A. time for exponential process to reach log(e) of its initial value
B. Time until exponential process reaches zero
C. Time to reach 37% of initial value
D. Time to reach half if its initial value
E. 69% of half life
Ans: C
Relative humidity – air fully saturated at 20 degree. What is the relative humidity at 37 degrees ?

A. 20
B. 30
C. 40
D. 50
E. 60%
Ans C

Absolute vapour of water at 20 deg = 17.3 mmHg
37 degree = 47 mmHg

17.3/47 = 36.8%
A 50 year old man with multiple fractures. The BEST parameter to monitor volume resuscitation is:

A. Heart rate
B. LVEDV
C. PCWP
D. RVEDV
E. Changes in R atrial pressure during inspiration
B
Anaphylaxis to rocuronium. Which is most likely to cause coss-reactivity ?

A. Vecuronium
B. Pancuronium
C. Atracurium
D. Cisatracurium
E. None of the above -cross reactivity too variable to predict
Ans E

Ref: AAGBI Anaphylaxis 2009
60% of anaphylaxis in anaesthesia = NBMD
Miv- and atracurium are associated with histamine / non-allergy reaction
Sux is most likely, Roc close behind
Cross sensitivity is relatively common, probably because of their quaternary ammonium group.
If anaphylaxis to an NMBA is suspected, the patient should undergo skin prick testing with all the NMBAs in current use. If a patient demonstrates a positive skin prick test (SPT) to an NMBA, the patient should be warned against future exposure to all NMBAs if possible. If it is mandatory to use an NMBA during anaesthesia in the future, it would seem appropriate to permit the use of an NMBA which has a negative skin test, accepting that a negative skin test does not guarantee that anaphylaxis will not occur.
Hypotension post propofol induction in elderly patient. More pronounced / profound than in younger patient. Reason ?

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

Overdose often due to slow circulation time and lower Vd but the agents are vasodilatory and hence the hypotension
Predictive factors for mortality in elderly patient (except):

A. Aortic stenosis
B. Diabetes mellitus
C. Elevated Creatinine
D. Cognitive dysfunction
E. Type of surgery
Ans: D

Ref Minimising perioperative adverse events in the elderly BJA 2001
All are mentioned except cognitive dysfunction
The best clinical indicator of severe AS

A. Presence of thrill
B. Mean Gradient 30mmHg
C. Area 1.2 cm2
D. Slow rising pulse and ESM radiating to carotids
E. Shortness of breath
Ans A

CEACCP 2005 Aortic stenosis and non-cardiac surgery
However, symptoms do not correlate well to the severity of the stenosis and some patients with small valve areas can be asymptomatic.

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

A. Severe heart failure
B. Suspicion of L main disease
C. Symptomatic tachyarrhythmia
D. Unstable angina
E. Stable angina with positive thallium
E

ACC/AHA guidelines - stable angina not an active cardiac condition. Also refer CARP trial.


Class I: Patients With Suspected or Known CAD
1. Evidence for high risk of adverse outcome based on noninvasive test results.
2. Angina unresponsive to adequate medical therapy.
3. Unstable angina, particularly when facing intermediate- risk* or high-risk* noncardiac surgery.
4. Equivocal noninvasive test results in patients at high clinical risk† undergoing high-risk* surgery.

Class IIa
1. Multiple markers of intermediate clinical risk† and planned vascular surgery (noninvasive testing should be considered first).
2. Moderate to large ischemia on noninvasive testing but without high-risk features and lower left ventricular ejection fraction.
3. Nondiagnostic noninvasive test results in patients at intermediate clinical risk† undergoing high-risk* noncardiac surgery.
4. Urgent noncardiac surgery while convalescing from acute MI.
How do you minimise risk of intravenous cannulation with epidural insertion ?

A. Injection saline through epidural needle before catheter insertion
B. Lie patient lateral
C. Do CSE
D. Thread catheter slowly
Ans A
Timing of peak respiratory depression post intrathecal 300 mcg morphine:

A. < 3.5 hours (think it was one hour)
B. 3.5 – 7.5 hours (then three hours)
C. 7 - 12.5 hours (then 7.5 - 12.5 hrs)
D. 12.5 -18 hours
E. > 18 hours

Ans B

CEACCP
Morphine-induced late onset respiratory depression occurs between 3.5 and 12 h after injection with a peak at 6 h

Patient with aortic dissection. Blood pressure 150/90. Best drug to control BP:

A. Captopril
B. Esmolol
C. GTN
D. Hydralazine
E. SNP
Ans B

CEACCP 2009
The primary goal is to reduce the force of left ventricular contraction without compromising perfusion, thus reducing shear forces and preventing further extension of the dissection or possible rupture. Beta-blockers (e.g. esmolol, metoprolol) and labetalol (beta- and alpha-blocker) can be used. If further reduction in BP is required, sodium nitroprusside, glyceryl trinitrate, or hydralazine are appropriate. Beta-blockers should be given first before vasodilators, as the reflex catecholamine release due to vasodilatation may increase left ventricular contractions.
Type of dissection – which is classically for NON-operative management:

A. DeBakey Type I
B. DeBakey Type II
C. Stanford A
D. Stanford B
E. Stanford C
Ans D

CEACCP 2009
In acute type B aortic dissections, surgical intervention is only indicated if there is persistent or recurrent intractable pain, aneur-ysm expansion, peripheral ischaemic complications, and rupture.
This is because surgical repair has no proven superiority over non-surgical treatment in stable type B dissection patients.

Stanford A involves ascending aorta but may extend into arch and descending aorta

Type B involves descending aorta only, dissection distal to left subclavian artery origin

DeBakey -
Type I involves ascending aorta, arch, descending aorta
Type II - confined to ascending aorta
Type III - descending aorta distal to left subclavian artery (IIIa up to diaphragm, IIIb beyond)
TURP – patient under spinal. Confused. ABG: Na+ 117 / normal gas exchange. Treatment ?

A. 10 ml 20% Saline as fast push IV
B. 3% NS 100 ml/h
C. Normal saline 200 ml/h
D. Frusemide 40 mg IV
E. Fluid restrict 500 ml/day
Ans B

Normal gas exchange = not fluid overloaded

CEACCP 2009
Hypertonic saline (3%) is indicated to correct severe hyponatraemia, if serum sodium ,120 mmol litre-1 or if severe symptoms develop.

Correction should be no more than 2 mmol/L per hour initially for 3 to 4 hours, then about 1 mmol/L per hour afterwards. In 24 hours, correction should be no more than 12 mmol/L.
-use frusemide
-fluid restriction
Male undergoing trans-sphenoidal surgery. Now Na+ 155mmol/l and thirsty with polydypsia. Treatment:

A. Desmopressin (DDAVP)
B. Fluid restrict
C. Aldosterone
Ans A
DDAVP for diabetes insipidus

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

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

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

DDAVP
1 – 4 mcg/hr IV continuous
10 – 40 mcg intranasal
Duration 12 – 24 hr intranasal
The STRONGEST stimulus for ADH secretion:

A. High serum osmolality
B. Low serum osmolality
C. Hypovolaemia
D. High serum Na
C.

Volume wins - sensitive to 1-2% change in osmolarity or 10% change in volume, but volume response is STRONGER
Stellate ganglion block. Needle entry next to SCM muscle at C6. Which direction to advance needle ?

A. C3
B. C4
C. C5
D. C6
E. C7
D. C6

Ref: Anaesthesia UK site
http://www.frca.co.uk/article.aspx?articleid=100538

Indications:

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

Vascular insufficiency
Raynaud's syndrome
Scleroderma
Frostbite
Obliterative vascular disease
Vasospasm
Trauma
Emboli

Although the ganglion lies at the level of the C7 vertebral body, the needle is inserted at the level of C6 to avoid the piercing the pleura.
Thermoneutral zone in 1 month old infant ?

A. 26 – 28 degrees Celcius
B. 28 – 30 degrees Celcius
C. 30 – 32 degrees Celcius
D. 32 – 34 degrees Celcius
E. 34 - 46 degrees celcius
Ans D
Neonatal Physiology, AICU 2008

Thermal stress is the extra energy required to maintain normothermia. It can occur with a normal core temperature as the neonate uses extra energy to maintain normothermia. Thermal stress can also occur if a baby is overheated because energy must be used to lose heat. The thermoneutral environment therefore minimizes neonatal energy requirements in maintaining a normal core temperature of 36.5–37.5°C rectal (axilla is 0.5–1.0°C lower). The thermoneutral temperature range varies with age and whether the baby is wearing clothes or not. The range for a naked term baby at 1 week is 32.0–33.5°C and 24.0–27.0°C when the baby is clothed. In comparison, a 30-week gestation baby’s range is 34.0–35.0°C naked and 28.0–30.0°C clothed. The point at which an increase in metabolic rate is required to maintain normothermia is defined as the critical temperature.
A 60 year old man describes orthopnoea. On examination: pansystolic murmur (at LSE)/ displaced apex beat. Likely diagnosis ?

A. Mitral regurgitation
Ans A

A VSD can also have a pansystolic murmur but there will be signs of growth retardation, respiratory infection, pulmonary HTN, LV + RV failure
A 4 year old child with VSD (repaired when 2 years old) for dental surgery. What antibiotic prophylaxis do the guidelines recommend?

A. Amoxycillyn orally
B. Amoxycillin IV
C. Cephazolin IV
D. Amoxycillin / gentamicin
E. No antibiotics required
E.

AHA guidelines say after 6 months nil required if no leak

+ Anaesthetic implications of CHD (AIC 2003)
A 4 year old child with Arthrogrophysis multiplex congenita for dental surgery. Jaw rigidity post induction. Likely cause ?

A. Temporomandibular joint involvement/ TMJ rigidity
B. Inadequate depth of anaesthesia
C. Inadequate muscle relaxation/ inadequate sux
D. Masseter spasm
A.

No increased risk MH.
Arthrogryposis multiplex congenita refers to a variety of conditions that involve congenital limitation of joint movement. Intelligence is relatively normal except when the arthrogryposis is caused by a disorder or syndrome that also affects intelligence.
There are two major types of arthrogryposis multiplex congenita (AMC):
Amyoplasia (classic arthrogryposis): Multiple symmetric contractures occur in the limbs.
Distal arthrogryposis: The hands and feet are involved, but the large joints are spared.
Etiology
Any condition that impairs in utero movement for > 3 wk can result in AMC. Causes may involve
Physical limitation of movement (eg, due to uterine malformations, multiple gestations, oligohydramnios)
Maternal disorders (eg, multiple sclerosis, impaired uterine vascularity)
Fetal disorders (eg, neuropathies; myopathies, including muscular dystrophies; connective tissue abnormalities; impaired fetal vascularity; anterior horn cell disease)
More than 35 specific genetic disorders (eg, spinal muscular atrophy type I, trisomy 18) have been linked to AMC.
Symptoms and Signs
Deformities are prominent at birth. AMC is not progressive; however, the condition that causes it (eg, muscular dystrophy) may be. Affected joints are contracted in flexion or extension. In classic AMC, shoulders are sloped, adducted, and internally rotated; the elbows are extended; and the wrists and digits are flexed. Hips may be dislocated and are usually slightly flexed. Knees are extended; feet are often in the equinovarus position. Leg muscles are usually hypoplastic, and limbs tend to be tubular and featureless. Soft-tissue webbing sometimes occurs over ventral aspects of the flexed joints. The spine may be scoliotic. Except for slenderness of the long bones, the skeleton appears normal on x-rays. Physical disabilities may be severe. As noted, some children may have primary CNS dysfunction, but intelligence is usually unimpaired.
Endotracheal intubation during surgery may be difficult because children have small immobile jaws. Other abnormalities that rarely accompany arthrogryposis include microcephaly, cleft palate, cryptorchidism, and cardiac and urinary tract abnormalities.
A 78 year old man with past difficult intubation for arm surgery. Supraclavicular block with 25 mls 0.5% bupivacaine. Shortly after begins convulsing. INITIAL management?

A. Midazolam 5mg
B. Intralipid 20% 1.5 ml/kg
C. Thiopentone 150mg
D. Suxamethonium 50mg
E. Propofol 50mg
A
Advantages of bronchial blockers over double lumen tubes:

A. Able to achieve lobar isolation
B. Lower cuff pressure
C. Quicker deflation of isolated lung
D. Pneumonectomy
E. Lower incidence of malposition
A

Campos, Thoracic Anaesthesia, DLT versus bronchial blockers
Therefore, the use of a bronchial blocker is more advantageous than the DLTs for difficult airways (nasal and oral), rapid sequence induction, or in patients with an existing tracheostomy who require lung isolation [15].
In contrast, the depth of insertion of a bronchial blocker is not an issue as long as the tip of the single-lumen
endotracheal tube is at least 2cm above the tracheal
carina, so the bronchial blocker can be manipulated into
the desired bronchus.
For an absolute lung separation or sleeve pneumonectomy, the use of a right or left-sided DLT is the best choice.
Bronchial blockers are a better choice for patients with
difficult airways, for selective lobar ventilation, or
wherever postoperative mechanical ventilation is contemplated
Patient for pneumonectomy. Pre op FEV1 2.4. (Predicted 4.5L) FVC given as well. For R lower lobectomy. Postoperative predicted FEV1 ?

A. 1.3
B. 1.5
C. 1.7
D. 1.9
E. 2.2
C.

Based on the numbers used in Miller there are 42 segments in total: 22 segments (or subsegments) in the right lung (RUL=6, RML=4, RLL=12), and 20 in the left lung (LUL=10, LLL=10).

A right lower lobectomy will remove 12 segments, and we will be left with 30. Therefore ppoFEV1 will be 30/42 x 2.4L = 0.7143 x 2.4L = 1.71L
Post accidental dural puncture with epidural needle. Headache. Which does NOT fit ?

A. Epidural blood patch 30-50% effective
B. Unlikely to be related to epidural if purely occipital headache
C. Caffeine mildly effective in reducing headache
D. Subdural haematoma can rarely occur with PDPH
B

Early studies of the efficacy of EBP (up to 90%) were overstated probably because of inadequate patient follow up and inclusion of patients who had PDPH resulting from dural puncture by different types and gauge of needles. Reported success rates have fallen over time and current data suggest that permanent cure by a single blood patch can be expected in 50% of patients. About 40% of patients require a second blood patch.
Cell saver. Which does NOT get filtered ?

A. Foetal cells
B. Free Hb
C. Platelets
D. Clotting factors
E. Microaggregates of leukocytes
A.

Fetal cells. But they've shown it's no worse than labour/delivery and the UK College recommends for LSCS now.

Cell salvage filters the following substances:
Free haemoglobin
White blood cells
Plasma
Platelets
Heparin
Clotting factors
Complement
You are on a humanitarian aid mission in the developing world. Drawover vaporiser apparatus described being used. Given 400 mm tubing, OMV or diamedica vaporiser, 200mm tubing attached to self-inflating bag. Which other ONE piece of equipment is ESSENTIAL to make this system functional?

A. Halothane
B. In-line Waters' Cannister
C. Non-rebreathing valve
D. Oxygen source
E. Ventilator
C.

Can use air instead of O2
Regarding post craniotomy pain:

A. Local infiltration proven to reduce long-term pain
B. Local more painful than discrete nerve blocks
C. Local infiltration more efficacious than discrete nerve blocks
D. Local infiltration more efficacious than opioid analgesia
E. Local infiltration more efficacious with clonidine included
A

Acute pain management - scientific evidence - third edition 2010 p247

Local anaesthetic scalp block

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

A. Nausea
B. Vomiting
C. Sedation
D. Pruritus
E. Constipation
Ans A

Acute pain management - scientific evidence - third edition 2010 p91

After hysterectomy and spinal surgery specifically, gabapentin improved pain relief and was opioid-sparing, nausea was less in patients after hysterectomy, and there was no difference in sedation.
Burns dressings. The following is proven to be of analgesic benefit:

A. Morphine gel
B. Biosynthetic dressings
C. Dexmedetomidine IV
D. Lignocaine IV
E. Cognitive/Distraction technique
Ans B

Acute pain management - scientific evidence - third edition 2010 p250

The choice of dressing has an effect on time to healing and pain during dressing change; biosynthetic dressings have been found to be superior.
Nitrous oxide (N2O), ketamine and IV lignocaine infusions (Jonsson et al, 1991 Level IV) have also been used to provide analgesia for burn procedures (see Sections 4.3.1, 4.3.2 and 4.3.5), however a Cochrane review reported that more trials were required to determine the efficacy of lignocaine (Wasiak & Cleland, 2007 Level I).
Subtenon’s block. What is the worst position to insert block?

A. Inferonasal
B. Inferotemporal
C. Superonasal
D. Supertemporal
E. Medial / canthal
Ans: E

Any spot really okay but apparently more muscle insertion points medially
Infiltration of lignocaine with 1:200,000 adrenaline. Peak plasma concentration of lignocaine occurs at:

A. 1 hour
B. 3 hours
C. 18 hours
D. 24 hours
E. 30 mins
Ans C
CAECCP Novel techniques of LA infiltration

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

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

A. Bilirubin / albumen / INR, ascites, encephalopathy
B. Various other options including AST/ALT, GGT, PT
A. Child-Pugh:

The Pugh modification of Child’s classification is used to estimate the risk of mortality in patients with liver disease undergoing surgery. Points from each variable are added to make the total score. A total score of 5 or 6 is considered Child’s class A and is associated with a low operative mortality risk (<5%); a total score of 7–9 (Child’s class B) carries a moderate risk (25%) and total score of 10–15 (Child’s class C) carries a high risk (>50%).
Which is NOT a disadvantage of drawover vaporiser versus plenum vaporiser:

A. Temperature compensation
B. Cannot use sevoflurane
C. Small volume reservoir
D. Flow compensation
Ans B

Advantages: simplicity of concept and assembly, no need for pressurised gas supply regulators and flow meters, minimum FiO2 is 18-21%, Robust reliable and easily serviced, low cost, portable.

Disadvantages: decreasing familiarity with technique/equipment, vaporiser limitations, filling systems not agent specific (can be an advantage), basic temperature compensation affecting performance at extremes (>1 to <50 degrees they maintain their accuracy), less easy to observe spontaneous ventilation with self inflating bag, cumbersome in paediatric use.
Acute renal failure. Which is not an indication for dialysis ?

A. Hyperkalaemia
B. Metabolic alkalosis
C. Hypernatraemia
D. Uraemic pericarditis
E. APO
B
Chronic alcohol use. Which is not an associated complication ?

A. AF
B. hypertriglyceridemia
C. Macrocytosis
D. Nephrotic syndrome
E. Pancreatic Ca
Ans D

CEACCP Alcohol and the Anaesthetist
Chest xray shown of patient post Left pneumonectomy with heart swung to left side. Management:

A. Increase PEEP
B. Roll onto right side
C. Turn on suction to left pleural catheter
D. Lung biopsy
Ans B
Salicylate poisoning:

A. Respiratory acidosis
B. Metabolic acidosis
C. Increased CO2 (production)
D. High output renal failure
E. Hyperthermia/hypothermia
B

a. uncoupling of oxidative phosphorylation (mainly in skeletal muscle) increases oxygen consumption, and carbon dioxide production, thus decreasing PaO2 & increasing PaCO2
b. hyperventilation via direct effect, and increased PaCO2, leads to respiratory alkalosis, with renal compensation
c. with even larger doses,
-depress respiratory centre, causing further CO2 accumulation, resulting in uncompensated respiratory acidosis
-metabolic acidosis with accumulation of pyruvic, lactic and aceto-acetic acid, and absorption of salicylic acid
-hyperpyrexia due to increased metabolic rate
-initial CNS stimulation, then later coma
New onset atrial fibrillation in a 10 week pregnant lady. BP 150/90, HR 160, SaO2 92%. Moderate mitral stenosis on TTE, no thrombus seen. Emergency doctor gave her anticoagulant (not specified what). Most appropriate management:
A. Verapamil
B. Labetalol 20mg iv to 300mg
C. Amiodarone 300mg IV
D. Synchronised biphasic cardioversion with 70-100 Joule
E. Oral digoxin -1000mcg then 500mcg 6 hrs later
D
Patient post anterior cervical fusion. Patient in recovery. Confused and combative. Nurse concerned about haematoma. Taken to theatre: Most appropriate way of securing airway:
A. Gas induction / laryngoscopy / intubate
B. Awake tracheostomy
C. Awake fibreoptic intubation using minimal sedation
D. Thiopentone, suxamethonium, direct laryngoscopy and intubation
E. retrograde intubation
Ans A

CEACCP V7 No3 2007
Re-intubation may be difficult. The patients must be managed in a semi-sitting posture. Awake fibreoptic intubation is sometimes a good option, but direct laryngoscopy after sevoflurane and oxygen induction (with judicious doses of propofol) may be easier. The gum-elastic bougie is often vital and an LMA (+fibrescope,+gum elastic bougie or Aintree catheter) or an ILMA-guided technique may save the day. The use of succinylcholine in myelopathic patients is hazardous because of abnormal potassium shifts.
Young asthmatic male in emergency department. RR 26, pCO2 27, SAO2 92%, struggling talking in sentences. Given nebulised salbutamol, and ipratropium, 200mg IV hydrocortisone. After 30 minutes - no improvement. Further management:

A. IV salbutamol
B. IV aminophylline
C. IV magnesium
D. Intubate and ventilate
C
Called to emergency department to review a 20 y/o male punched in throat at a party. Some haemoptysis / hoarse / soft voice. Next step in management:
A. CT to rule out thyroid cartilage fracture
B. XR to rule out fractured hyoid
C. Rapid sequence induction / laryngoscopy / intubation
D. Awake fibreoptic intubation
E. Nasendoscopy by ENT in emergency department
E
How quickly does the CO2 rise in the apnoeic patient ?

A. 1 mmHg per min
B. 2 mmHg per min
C. 3 mmHg per min
D. 4 mmHg per min
E. 5 or ?8 mmHg per min
C

PaCo2 rises by 5-6mmHg within the first few minutes as arterial levels come to match venous (because there is no removal of CO2 in the lungs). After this initial rise, the value quoted is 3mmHg/min.
Long-standing T6 paraplegia. All present EXCEPT ?

A. Flaccid paralysis
B. Poikilothermia
C. Autonomic hypereflexia
D. Labile BP
E. Hyperkalaemia with suxamethonium
A

OHA p240
Return of muscle tone and reflexes after perhaps 3 days to 8 weeks
Rest are longer term (i.e. 9 months)
Young female patient for tonsillectomy with history of bleeding tendency. Which is the most likely cause?

A. Factor V Leiden
B. Protein C deficiency
C. Haemophilia B (Christmas disease)
D. Antithrombin III deficiency
E. Lupus anticoagulant
C

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

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

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

Prothrombotic
• Heparin-induced thrombocytopenia
• Antiphospholipid antibody syndrome (‘lupus anticoagulant’)
• Microvascular thrombosis: thrombotic microangiopathy,
coumarin-induced skin necrosis
Amniotic fluid embolism. Cause of death in first half hour-

A. Pulmonary hypertension
B. Malignant arrhythmia
C. Pulmonary oedema
D. Hypovolaemic shock
A

'Amniotic fluid and fetal cells cause an increase in both systemic and pulmonary vascular resistances resulting in acute pulmonary hypertension. Survivors of this response develop left ventricular failure and pulmonary oedema '
CEACCP 2007
Hypocalcaemia – earliest sign:

A. Tingling of face and hands
B. Chvostek’s sign
C. Carpopedal spasm
A

CATS go numb (Convulsions, Arrhythmias, Tetany and numbness/parasthesias in hands, feet, around mouth and lips)
Visual loss with pupillary reflexes retained. Likely cause ?

A. Retinal detachment
B. Occipital mass
C. Frontal mass
D. Chiasmal mass
E. Optic neuritis
B

Cortical blindess = visual loss but with retained pupillary reflexes and normal fundoscopy. Caused by pathology in the occipital lobes.
This damage is most often caused by loss of blood flow to the occipital cortex from either unilateral or bilateral posterior cerebral artery blockage (ischemic stroke). A patient with cortical blindness often has little or no insight that they have lost vision, a phenomenon known as Anton's Syndrome or Anton-Babinski syndrome.
http://www.iveyeye.ca/pdfs/acute_visual_loss.pdf

Retinal detachment – an extensive retinal detachment involving the macular area would produce acute visual loss and this patient will complain of flashing lights followed by a large number of floaters and then a shade or blind covering the visual field. An afferent pupillary defect is usually present. The diagnosis is confirmed by ophthalmoscopy through a dilated pupil, and retina appears elevated with folds and the choroidal background is indistinct.

Optic Neuritis: Optic Neuritis is inflammation of the optic nerve and is usually associated with multiple sclerosis in a significant number. The visual acuity is markedly reduced and an afferent pupillary defect is present. The optic disc initially appears hyperemic and swollen. The visual acuity usually recovers; however, repeated episodes of optic neuritis may lead to permanent loss of
vision.
Nerve block for anaesthesia over anterior 2/3 of ear?

A. C2
B. Mandibular nerve
C. Maxillary nerve
D. Ophthalmic nerve
E. Vagus
B

Four sensory nerves supply the external ear: (1) greater auricular nerve, (2) lesser occipital nerve, (3) auricular branch of the vagus nerve, and (4) auriculotemporal nerve. (Emedicine)
Complex regional pain syndrome. What proportion of patients have motor involvement ?

A. 0 %
B. 25 %
C. 50 %
D. 75 %
E. 95 %
D

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

Motor / trophic changes
- motor dysfunction 57-98%
- weakness 75-95%
- limited range of movement 80-88%
- incoordination 47%
- tremor 48%
- spasm 13%
- dystonia 14%
- myoclonus 4-20%
Malignant hyperthermia. The number of people in the community at any given time with a predisposition is called the:

A. Prevalence
B. Incidence
A

Prevalence = measures how much of some disease or condition there is in a population at a particular point in time.
Incidence = the rate of occurrence of new cases of a disease or condition.

Incidence of MH (per wiki) is 1:15000 anaesthetics for children and adolescents and 1:50-150000 anaesthetics for adults.
Prevalence for susceptabiity may be as high as 1:2000
Patient with Hx COAD and suspected pneumonia – clinical findings supporting R pneumonia on examination:

A. R Dull percussion note & increased vocal resonance
B. R Dull percussion note & decreased vocal resonance
C. R Decreased air entry
D. Tracheal deviation to left
E. Tracheal deviation to right
A
Thallium scan:
A. High negative predictive value
B. High positive predictive value
C. Not as good as a dobutamine stress echocardiography
A.

AHA/ACCHA Guidelines:
The 2 main techniques used in preoperative evaluation of patients undergoing noncardiac surgery who cannot exercise are to increase myocardial oxygen demand (by pacing or intravenous dobutamine) and to induce hyperemic responses by pharmacological vasodilators such as intravenous dipyridamole or adenosine. The most common examples presently in use are DSE and intravenous dipyridamole/adenosine myocardial perfusion imaging with both thallium-201 and
technetium-99m.

From the 2007 AHA guidelines,
'because of a very high sensitivity of abnormal stress nuclear imaging studies for detecting patients at risk for perioperative cardiac events, the negative predictive value of a normal scan has remained uniformly high at approximately 99% for MI or cardiac death'.

Thallium scanning in coronary artery disease (CAD) using radioactive thallium-201(201-Tl) is a widely available technique which is sensitive, accurate and noninvasive. It detects CAD accurately in patients with:
atypical chest pain and a positive exercise ECG or
typical chest pain and a negative exercise ECG.
A 50 y/o male diabetic admitted to intensive care with pneumonia. Intubated and ventilated. Extensive results given. BP 80/-, HR 120, CVP 4, PCWP 6, SvO2 69% PaO2 80, BE -4 pH 7.2. Management:

A. Blood transfusion
B. Bicarbonate infusion
C. Fluid resuscitation
D. Adrenaline infusion
E. Insulin infusion
C. Fluids.
Low CVP, hypotensive, tachycardic, low PCWP.
Acidosis could be diabetic or lactate .

No reason for Blood unless low Hb.
Bicarb contraindicated in DKA as need to breathe off excess CO2
Young female having cholecystectomy. Venous air embolus:

A. Mechanical ventilation and PEEP is part of treatment strategy
B. Most likley to occur at initial gas insufflation, but can occur at any time
C. Inert gas (argon, xenon) is safer
B.

Classically due to insufflation of CO2 via a hasson cannula, but cut surfaces e.g. of liver may permit entry of gas. "This complication develops principally during the induction of pneumoperitoneum, particularly in patients with previous abdominal surgery." Miller 7th ed. p. 2188.

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

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

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

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

TREATMENT = ABC; place patient in left lateral and trendeleburg position; remove air from CVC if possible (see VAE CEACCP)
LUSCS for failure to progress. Spinal is inserted uneventfully. Next day the patient has foot drop. The most likely cause is?

A. epidural haematoma
B. lumbosacral palsy
C. sciatic nerve palsy
D. common peroneal palsy
B.

CEACCP 2003:
"Postpartum foot drop is caused by damage to the lumbosacral trunk or, less frequently, the common peroneal nerve. The lumbosacral trunk (L4, L5) is compressed between the ala of the sacrum and the descending fetal head. It may also occur during a forceps delivery. The result is a unilateral foot drop with loss of sensation and/or paraesthesia along the lateral calf and foot."
"Common peroneal nerve damage may occur due to improper or prolonged positioning during lithotomy and the sensory deficit may be limited to the dorsum of the foot."
Epidural haematomas extremely rare (1:168,000 from review in Anaesthesiology 2006; 105: 394)and obstetric palsies are much more common than complications related to neuraxial blocks.
Sciatic nerve injury would cause a foot drop but would also affect knee flexion (hamstrings) and all muscles in lower leg and foot.
Common peroneal nerve palsy less likely in this case as there is no mention of stirrups or 'excessive knee holding'
Severe pre-eclampsia. WORST treatment option:

A. Magnesium
B. Nifedipine
C. Metoprolol
D. SNP
Ans D
In pregnancy the dural sac ends at:

A. T12
B. L2
C. L4
D. S2
E. S4
Ans D
Which gives the BEST seal?

A LMA classic
B Proseal
C Intubating LMA
B

From the LMA website / product information:
LMA Classic - Seal pressure up to 20cm H20
LMA Supreme™ - measured oropharyngeal leak pressures up to 37 cm H2O
LMA Flexible™ - oropharyngeal seal pressures up to 20 cm H2O
LMA Fastrach - Seal pressures up to 20 cm H2O
LMA ProSeal™ - leak pressures up to 32 cm H2O
A 30yo male- 5 hour operation. Arms abducted to 60 degrees. Head turned slightly to left side. Post op numb palm/thumb/index finger/middle finger and lateral half of ring finger. Numb ventral forearm. Weak finger grip. Weak elbow flexion. Most likely nerve injured?

A. median nerve
B. musculocutanous nerve
C. upper trunk of brachial plexus
D. ?brachial plexus stretch
C
Which of the following does NOT cause diastolic dysfunction

A. Hypertension
B. Ischaemic heart disease
C. Aortic stenosis
D. Adrenaline
E. Myocardial fibrosis
D

The major causes of diastolic dysfunction include:
chronic hypertension
hypertrophic cardiomyopathy
aortic stenosis
coronary artery disease
restrictive cardiomyopathy (a rare condition in which the heart muscle is infiltrated, and made stiff, by abnormal cells, protein, or scar tissue. The most common cause of restrictive cardiomyopathy is amyloidosis, a disease in which protein-like substance is deposited within the body's tissues. Other causes include sarcoidosis and haemochromatosis.)
A 7 kg Infant with tetralogy of fallot, post BT-shunt. Definitive repair at later date. Paralysed and ventilated. Sats 85% baseline, now 70%, best treatment:

A. Increase FiO2 from 50 - 100%
B. Esmolol 70 mcg
C. Phenylephrine 35 mcg
D. Morphine 1 mg
E. 1/2 NS with 2.5% dex 70 mls
C. Phenylephrine - will increase SVR and L pressures, reducing R-L shunt.

(increase FiO2 won't change if big shunt)
http://lifeinthefastlane.com/2010/04/cardiovascular-curveball-009/

Frank Shann's dose recommendation for phenylephrine is 2-10 mcg/kg as a bolus, which would fit nicely with C (5mcg/kg).
70 year old post TKJR. On sub-cut heparin. Develops clinical DVT and platelets 40 (sounds like HITS type-II). Management

A. Enoxaparin
B. Fondoparinux
C. Heparin by infusion
D. Lepirudin
E. Warfarin
D - no other direct thrombin inhibitors on list.
Arterial blood gases (ABGs): pH 7.12, PO2 100, PCO2 65, HCO3 20.3, BE -10. Consistent with?

A. Chronic renal failure
B. Malignant hyperthermia
C. Diabetic ketoacidosis
D. End-stage respiratory failure
E. Ethylene glycol toxicity
B

Combined metabolic and respiratory acidosis = MH!
a. CRF wouldn't have high CO2
c. DKA = low CO2 to breathe off
d. Would be metabolic compensation i.e. high bicarb
e. Would try to breathe off CO2 to compensate for non-anion gap metabolic acidosis
Aneurysm sugery. Propofol/remifentanil/NMDR. DOA monitoring (Entropy). MAP 70 , HR 70/min, State entropy 50, Response entropy 70. What do you do?

B. Metaraminol
C. Check TOF
D. Nothing
E. Increase TCI.
C

RE of 70 compared to SE of 50 means paralysis is wearing off
Interscalene block, patient hiccups...where do you redirect your needle?

A. Anterior
B. Posterior
C. Caudal
D. Cranial
E. Superficial
B
It is stimulating the phrenic nerve
What's the most appropriate mode for neuromuscular monitoring during aneurysm clipping?

A. TOF count
B. TOF ratio
C. Post tetanic count
Ans C

Anaesthesia for cerebral aneurysm repair Roger Traill
TOF 0 PTC >10
With regards to obstructive sleep apnoea (OSA), which of the following statements is INCORRECT?

A. hypoxaemia is the main stimulus to arousal
B. the main method of treating this syndrome is with Continuous Positive Airway Pressure (CPAP)
C. this syndrome is the most likely diagnosis in patients presenting with excessive daytime sleepiness
D. this syndrome occurs in up to 5% of adults
E. this syndrome rarely has an obstructive component
Ans E
Management of rhabdomyolysis – best option?

A. Haemodialysis
B. Bicarbonate
C. Frusemide
D. IV fluids
E.
Ans D
Residual Current Devices (also known as Safety Switches)

A. detect differences in current between the active and neutral wires of a circuit
B. isolate the patient from earth
C. monitor the isolation of the power line
D. must be fitted to all Cardiac Protection areas
E. must be fitted to all operating theatres
A

All operating theatres and ICU are cardiac protected and must have either line isolation monitor or residual current device, and have equipotential earthing junctions.
Serotonin syndrome has been reported following SSRI co-administration with:

A. Gingko
B. Garlic
C. Ginger
D. St John’s wort
E. Vallerian
D
A three-week old infant presents with pyloric stenosis and 3 days of vomiting. A typical electrolyte
profile would be

A. Na+ 130 K+ 5.8 Cl- 98 HCO3- 17
B. Na+ 148 K+ 4.1 Cl- 108 HCO3- 13
C. Na+ 135 K+ 4.5Cl- 90 HCO3- 30
D. Na+ 130 K+ 2.8 Cl- 90 HCO3- 28
E. Na+ 130 K+ 3.9 Cl- 98 HCO3- 17
D
You intubate a young male patient for a left thoracotomy with a 39FG Robertshaw tube. When you inflate both cuffs and ventilate the bronchial lumen you get left sided ventilation. When you attempt to ventilate the tracheal lumen the pressures are very high and you get no air entry. Yet when you deflate BRONCHIAL cuff you can ventilate BOTH left and right lungs through the tracheal lumen. The most appropriate step to take next is:

A. Change to a 41FG tube
B. Change to a 37FG tube
C. Deflate both cuffs and insert further cm and recheck
D. Deflate both cuffs and withdraw a few cm and recheck
E. Pull ETT out and start again.
C
bronchial cuff in the trachea
The average expected depth of insertion of an oral endotracheal tube, from the lip, in a normal newborn infant is

A. 7.5 cm
B. 8.5 cm
C. 9.5 cm
D. 10.5 cm
E. 11.5 cm
C

weight + 6
What is NOT a feature of high spinal block?

A. Hypotension
C. Hard to speak
D. Numb hands
E. Tachycardia
E
Stellate ganglion block is associated with all EXCEPT:

A. Ptosis
B. Miosis
C. Sweating
D. Facial flushing
E. Nasal stuffiness
C
Recognised clinical associations with dystrophia myotonica include

A. development of diabetes mellitus
B. abnormal intestinal motility
C. cardiomyopathy
D. ovarian dysfunction
E. all of the above
E
Left bundle branch block (LBBB) on the ECG is

A. commonly a normal variant
B. associated with a delay in atrio-ventricular conduction
C. demonstrated by a notched R wave in chest lead V1
D. associated with right axis deviation
E. a relative contra-indication to flotation of a pulmonary artery catheter
E
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

Does spinal anesthesia cause hearing loss in the obstetric population? Anesth analg 2002
No it does not
Does hearing loss after spinal anesthesia differ between young and elderly patients Anesth analg 2002
Hearing loss in low frequencies 125-500 Hz in young patient after spinal
Troponin is elevated post-infarct

A. 1-2 days
B. 2-5 days
C. 5-14 days
D. 7-21 days
E.
C
The sciatic nerve supplies the following muscles EXCEPT

A. biceps femoris
B. semitendinosus
C. semimembranosus
D. gluteus maximus
E. adductor magnus
D

Gluteus maximus: innervated by inferior gluteal nerve L5,S1,2
Time to reach peak plasma concentration after injection of 2% lignocaine with adrenaline into epidural space

A. 20 min
B. 30 min
C. 40 min
D. 50 min
E. 60 min
A
In a patient undergoing a femoro-popliteal bypass, the most predictive independent risk factor for the development of post-operative myocardial infarction would be

A. an acute myocardial infarct 3 months ago
B. an episode of intra-operative myocardial ischaemia
C. an episode of post-operative myocardial ischaemia
D. 50% blood volume blood loss intra-operatively
E. poorly controlled diabetes mellitus
C