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54 Cards in this Set

  • Front
  • Back
EZ93 What is the chemical used in sodalime to indicate exhaustion?
A. ethyl violet
B. potassium permanganate
C. ?

Ethylviolet is a pH-sensitive triarylmethane dye used as an indicator in CO2-absorbents. It changes from colorless to blue/violet
2. Repeat- Main heat loss in anaesthetic for neonate
A. vasodilatation
B. radiation
C. convection
D. conduction
E. evaporative
Child with murmur- what would make it more likely for you to investigate if you heard the murmur
A. persist in supine position
B. louder or softer with various manouveres

Murmur that changes with position is more likely innocent, however I would think getting louder (or softer) with certain manoeuvres means it is more likely due to a valve pathology rather than just a flow murmur
9. Patient with aortic stenosis, the signs indicate poor prognosis
A. Palpitation
B. Radiation to carotid arteries
C. Something about characteristic of murmur
None quite right

International Anaesthesiology Clinics 2005; 43(4); 21-31

“Symptoms of AS include syncope, angina, and dyspnea (SAD). Presence of any of these symptoms leads to a life expectancy of less than 5 years and 20% chance of sudden death. Of the 35% of patients with AS presenting with angina, half will die within 5 years unless the aortic valve is replaced. Fifteen percent of patients with AS present with syncope, half of which will die within 3 years. Fifty percent of patients with AS will present with dyspnea, and half will die within 2 years unless the valve is replaced”
Which is the best predictor of poor prognosis with aortic stenosis?
A. chest pain
B. paroxysmal nocturnal dyspnoea
C. syncope

Evaluation and Management of Patients With Aortic Stenosis. Circulation. 2002; 105: 1746-1750
“Survival is nearly normal until the classic symptoms of angina, syncope, or dyspnea develop.1 However, only 50% of patients who present with angina survive 5 years, whereas 50% survival is 3 years for patients who present with syncope and 2 years for patients who present with dyspnea or other manifestation of congestive heart failure”
10. New- Patient indicated for prophylaxis of infective endocardititis
A. amoxicillin orally 2 hours prior
B. amoxicillin IV 1 hourly prior
C. amoxicillin IV just before incision
D. cefazolin IV 1 hour prior

Standard oral prophylaxis from the 2007 AHA guidelines is Amoxycillin 2g orally 30-60 minutes prior to dental procedure.

Cephalzolin 1g IM or IV 30-60 minutes prior is an alternative if oral route not possible
Given the timing of the oral amoxicillin dose is wrong this would leave D
72 year old has had hip replacement surgery and 3 days postop has a pulmonary embolus. He is fully heparinised, but still dyspnoeic, clammy, BP 80/40, pulse 120 and CVP 18. The most appropriate next step is
A. IVC filter
B. Refer him for a pulmonary embolectomy
C. Supportive (fluids and inotropes)
D. Thrombolysis
E. Warfarin

Supportive therapy would be appropriate, but this guy sounds pretty sick and I’m assuming thrombolysis is contraindicated given recent surgery

UpToDate – Treatment of Acute Pulmonary Embolism
“If the patient presents with systemic hypotension, prompt hemodynamic support should be instituted. Intravenous fluid administration may be beneficial; however, clinicians should be wary of administering more than 500 to 1000 mL during the initial resuscitation period”

“For patients whose hypotension does not resolve with intravenous fluids, we recommend prompt vasopressor therapy (Grade 1B). We suggest using norepinephrine as the initial agent (Grade 2C). Dopamine, epinephrine, or a combination of dobutamine plus norepinephrine may also be effective”

“For patients with acute PE in whom thrombolysis is indicated, but who fail thrombolysis or have contraindications to thrombolysis, we suggest catheter or surgical embolectomy if the necessary resources and expertise are available (Grade 2C). The decision of whether to pursue one of these approaches should be based upon local expertise.”
LSCS for foetal distress, meconium stained liquor. Management of baby
A. Intrapartum suctioning
B. Intrapartum suctioning and post partum tracheal suction
C. Post partum tracheal suctioning
D. Routine neonatal care
E. Intubate

Depends on whether or not the baby is well
Routine ETT and suctioning no longer indicated if baby is vigorous. Otherwise answer is C
An elderly lady has a closed neck of femur fracture and presents to ED. She is in chronic AF and on warfarin. INR is 2.6 and she is not bleeding. It is 9am and she is scheduled for repair the following day. According to current guidelines, how should her warfarin be reversed?
A. Prothrombinex 25IU/kg immediately and then 2 units FFP immediately prior to surgery
B. No immediate treatment then 2 units FFP immediately prior to surgery
C. Vitamin K 1mg IV immediately
D. Vitamin K 10mg IV immediately
E. Withhold warfarin

The Australian Consensus guidelines (Warfarin reversal: consensus guidelines, on behalf of the Australasian Society of Thrombosis and Haemostasis. MJA 2004) don’t seem to specifically mention reversal for emergency surgery

This is from UK blood and Tissue service (www.transfusionguidelines.co.uk):
Subarachnoid haemorrhage patient. What percentage rebleed in the first 24hours
A. <5%
B. 5-10%
C. 10-15%
D. 15-20%
E. >20%

According to OHA 2nd Ed p408 - 4% risk of rebleed in 1st 24 hours
Post delivery neonate did not breath post stimulation by midwife, not vigorous, heart rate drop from 140 to 90bpm. Next step of action
A. 100% oxygen
B. Positive pressure ventilation
C. Intubation
E. Adrenaline
The safe maximal pressure for endotracheal cuff at the lateral side of the trachea
A. 0-10 cm water
B. 10-20 cm water
C. 20-30 cm water
D. 30-40 cm water
E. 40-50 cm water

A Comparison of Endotracheal Tube Cuff Pressures Using Estimation Techniques and direct Intracuff Measurement. Journal of American Association of Nurse Anaesthetists. Dec 2003
“While there is no single number, the consensus regarding an acceptable maximum cuff pressure ranges from 25-40cmH20”

“The pressure limit is determined in part by the capillary blood pressure supplying the trachea, which is approximately 48cmH20”

“An intra-cuff pressure greater than 34cmH20 can result in decreased perfusion to the trachea, wheras total obstruction to trachea blood flow occurs at approximately 50cmH20”
Patient with mastocytosis. Intraop would probably be:
A. Severe hypotension

Anaesthesia and Uncommon Diseases
• Mastocytosis is caused by mast cell hyperplasia in the liver, spleen, bone marrow, lymph nodes, skin, and gastrointestinal tract.
• Mast cells easily degranulate and symptoms related to release of mediators are common, including urticaria, flushing, abdominal pain, bone pain, diarrhea, nausea, and vomiting.
• Preoperative Considerations
o Gastric hypersecretion should be suspected in all mastocytosis patients. Gastric acid blockade and increased gastric emptying with metoclopramide should be considered.
o Anxiolysis may decrease mast cell activation. If chronic corticosteroids are used for treatment, stress-dose corticosteroids should be ordered for the perioperative period
• Intraoperative Consideration.
o Vasodilation makes hypothermia more likely, and active temperature support should be planned
o Release of mediators is increased by manipulation of lesions, which should be kept to the absolute minimum.
o Bone pain indicates a risk of fracture, which should be considered during positioning.
o Hemodynamic instability may occur from mast cell mediator release. Sudden, profound, intraoperative hypotension has been reported and epinephrine may be the intervention of choice. As a result, invasive monitoring and immediate availability of vasoactive drugs is often required.
o Histamine release with transfusion can be massive; pretreatment with diphenhydramine should be routine.
o Regional anesthesia is acceptable, but vasodilation may accentuate the consequences of neuraxial sympathetic block. Specific agents for general anesthesia should be selected to avoid further histamine release
o Light anesthesia may trigger histamine release.
Post epidural and LSCS, the next day patient have persistent paraesthesia anterior thigh. What other injuries would indicate more of nerve roots instead of peripheral nerve injuries
A. Weakness on hip flexion and thigh adduction
B. Weakness on knee flexion and plantar flexion
C. Urinary incontinence
D. Foot drop

Anterior thigh = L2/3
Hip flexion = L2/3, Hip adductors = L3
After transfusion of 5 unit of FFP what is least likely to occur
A. Haemolytic reaction
B. Hypocalcaemia
C. Infection
D. Hyperkalaemia
There is evidence to avoid BIS <40 for more than 5minutes because
A. Safe cost
B. Increase incident of hypotension
C. Increase post op mortality
D. Decrease volatile (?) for poor cardiac output patient
E. Decrease the incidence of awareness

Sessler DI. Duration of a “Triple Low” of Blood Pressure, BIS & Anesthetic Concentration Predicts Poor Outcomes. Anesthesiology 2009; 111: A880.
“Patients who are sensitive to anesthesia do poorly. The combination of low MAC and low MAP was a strong and highly statistically significant predictor for mortality. When combined with low BIS, mortality was even greater. The combination of low MAC, low MAP, and low BIS is thus an ominous “Triple Low” which is associated with a tripled risk of mortality at 30 days, and doubled risk of mortality at one year”
Most common cause of paediatric post anaesthesia cardiac arrest
A. Drug error
B. Respiratory cause
C. Multifactorial
D. Cardiac problem (?)
Post cervical spine op, there is bulging noted under the incision sit:E. Patient desaturated, combative, keep pulling off the oxygen facemask. Next course of action
A. Rapid sequence induction
B. Gas induction
C. Needle aspiration of the bulge at the neck
What drug known to cause prolong QT and risk of Torsades de Pointes
A. Metoclopramide
B. Droperidol
C. Tranexamic acid
During cardiac catheterisation (?) patient become BP 80/60, HR 110, CVP 16. What is the next most important investigation
A. Echocardiogram
C. Electrocardiogram
Intraop hyperfibrinolysis- how to diagnose (euglobulin lysis time NOT an option in the answer)
75yo patient seen for femoral bypass surgery, no significant cardiac risk factor. He will be admitted 3 days prior to operation. You decided NOT to start on beta blocker and you are justified because:
A. There is increase mortality and morbidity
B. There is not enough time to safely start beta blocker
C. The beta blocker may make the patient claudication worst
D. ?
You see a man in his 60s in clinic 1 week prior to laparoscopic cholecystectomy. He has dilated cardiomyopathy with an ejection fraction of 30%, but does not get dyspnoeic with normal activities of daily living. What is the most appropriate management of his heart failure?
A. amiodarone 100mg bd
B. digoxin 250mcg daily
C. enalapril 2.5mg bd
D. metoprolol 100mg bd
E. diltiazem slow release 240mg daily
A line isolation monitor protects against microshock
A. only if the warning current is set at 10mA
B. only if the warning current is set at 30mA
C. under no circumstances
D. only if the equipment used is grounded
E. only if it monitors all the equipment in the region
Patient ingested 500mg/kg aspirin. In ICU, the most effective method to remove aspirin
A. IV fluid
B. Haemodialysis
C. Sodium bicarbonate infusion
D. Frusemide

Sodium Bicarbonate Infusion to alkalinate urine is "treatment of choice" according to Oh's Intensive Care Manual 6th Ed. p905
The below would increase A-a oxygen gradient Except
A. Increase FIO2
B. Decrease FIO2
C. Decrease cardiac output
D. Increase shunt

Decreased CO leads to decreased shunt flow
Interscalene block after injection of 2ml bupivacaine- patient seizure. Most likely injected to
A. Dural cuff
B. Vertebral arteries
C. Internal carotid arteries
D. Jugular veins
E. Subarachnoid (?)

The Anaesthesia Science Viva Book (on Interscalene block):
“Complications: These include intravascular injection (particularly into the vertebral artery), central spread via inadvertent dural puncture leading to a total spinal, phrenic nerve palsy (which almost invariably accompanies an effective block), Horner’s syndrome (cervical sympathetic block, which is
usually innocuous), vagal and recurrent laryngeal nerve block which may cause hoarseness, but is usually benign, and pneumothorax. (There are also the generic complications such as systemic toxicity and neurapraxia.)”
Post intubation, you manual ventilate and noted patient high airway pressure. What would you do next
A. Open the APL valve
B. Auscultate the lung
C. Switch to ventilator
Modified Cormack and Lehane grade - You cannot see beyond the epiglottis and there is a little space between the epiglottis and the posterior pharyngeal wall (? remembered as epiglottis touching posterior pharyngeal wall)
A. 2a
B. 2b
C. 3a
D. 3b
E. 4
Compared to retrobulbar block, peribulbar block is associated with
A. More bleeding
B. More risk to optic nerve
C. More akinetic eye
D. Less block to orbicularis oculi
These are all false
There is less bleeding, less risk to optic nerve, no difference in akinesia and orbicularis oculi is blocked with peribulbar (unlike retrobulbar)
Lumbarsacral nerve does not supply:
A. Subcostal nerve
B. Ilioinguinal n
C. Iliohypogastric n
D. Femoral n
E. Genitofemoral n (?)

If talking about not supplied by lumbar nerves?
Subcostal = T12
Ilioinguinal/Iliohypogastric = L1
Genitofemoral = L1-2
Femoral = L2-4
Trauma patient best indicator of good resuscitation (?)-
A. Lactate level
B. Heart rate
C. Blood pressure
D Acidosis (?)
Pregnant patient seatbelt, driver- involved in car accident. Suddenly developed severe central chest pain, HR 110, BP 154/80, RR 26, Sat 100%. The most likely cause?
A. Sternal fracture
B. Aortic dissection
C. Pneumothorax
D. Rib fracture
E. Myocardial infarction
ASD murmur heard at
B. Tricuspid valve
C. Pulmonary valve
D. Mitral valve
E. Aortic valve

Pulmonary systolic murmur with fixed splitting of second heart sound according to Talley
Apnoeic oxygenation in obese patient can be increased by
A. Sniffing position
B. Prone
C. Supine
D. Lateral
E. Head up

Pre-oxygenation in the obese patient: effects of position on tolerance to apnoea. BJA 2005
“Pre-oxygenation in sitting position significantly extends the tolerance to apnoea in obese patients when compared with the supine position”
Post partum sudden collapse, suspected amniotic fluid embolism. The consistent finding is:
A. Low C3, C4
B. Increase complement
C. Increase tryptase
D. Increase histamine?
E. petechial rash
Which is supportive of a diagnosis of amniotic fluid embolism?
A. decreased C3 & C4 levels
B. hyperfibrinogenaemia
C. thrombocytosis
D. markedly elevated tryptase
E. ?

Current Concepts of Immunology and Diagnosis in Amniotic Fluid Embolism. Clinical and Developmental Immunology Volume 2012 (2012)
• Complement levels are decreased associated with complement activation
• Tryptase can be elevated, but not always
Young pregnant patient with moderate mitral stenosis, normal LV function. The best delivery method
A. Epidural anaesthesia LSCS
B. Spinal with LSCS
C. Epidural analgesia and normal vaginal delivery
E. Normal vaginal delivery with remifentanil PCA

Referenced in Chestnut:
Clark SL, Phelan JP, Greenspoon J, et al: Labor and delivery in the presence of mitral stenosis: Central hemodynamic observations. Am J Obstet Gynecol 1985; 152:984-988
1 Give supplemental oxygen during labor and delivery, and maintain left uterine displacement.
2. Place a pulmonary artery catheter before induction of labor or during early labor.
3. Restrict fluids and maintain a PCWP of approximately 14 mm Hg.
4. Prevent tachycardia. Treat severe tachycardia with intravenous administration of a beta-adrenergic receptor antagonist.
5. Give epidural anesthesia during active labor, and maintain epidural anesthesia during the immediate postpartum period to reduce preload and prevent postpartum pulmonary edema.
6. Reserve cesarean section for obstetric indications.
Neonate desaturate faster than adult at induction because
A. FRC decrease more
B. Faster onset of induction agents
C. More difficult to pre-oxygenation

None quite right, but I guess C is kind of true
Neonates desaturate faster because of:
• Higher O2 consumption
• Higher closing volume
• Higher MV:FRC (ie have to maintain elevated RR
The cause of hypoxia in one lung ventilation
A. Blood flow through non ventilated lung
B. Impairment of hypoxic pulmonary vasoconstriction
C. Ventilation perfusion mismatched (?)
Suxamethonium dosage is higher in neonates compared to adults because:
A. Increased volume of distribution
B. Increased pseudocholinesterase activity
C. More receptors
D. Higher cardiac output (?)
E. Decreased sensitivity of nicotinic ACH receptors to suxamethonium
F. Faster diffusion away from neuromuscular junction
Indicates autonomic neuropathy EXCEPT:
A. Sinus arrthymias
B. Gastric reflux
C. Postural hypotension

Do get gastric dysmotility, but doesn’t directly cause reflux.
A and C are certainly manifestations of autonomic neuropathy
Best indicator of return of function of laryngeal muscles is:
A. Sustained head lift 5 sec
B. Sustained leg lift 5 sec
C. TOF 0.9
D. DBS no fade
E. Tetanus 50Hz
A nulliparous woman in labour for 8 hours with epidural analgesia has a fever 37.6 degrees. The most likely reason for this is
A. altered thermoregulation
B. chorioamnionitis
C. urinary tract infection
D. inflammatory response
E. neuraxial infection

Epidural does cause fever by altered thermoregulation, but most common cause in this setting is inflammation (according to CEACCP article)
Supply of sensation above the vocal cord- internal branch of superior laryngeal nerve
The superior laryngeal nerve (SLN) has 2 divisions: internal and external.
 The internal branch provides sensory innervation to the larynx. It enters the larynx through the thyrohyoid membrane and therefore should not be at risk during thyroidectomy.
• The external branch provides motor function to the cricothyroid muscle and is at risk during thyroidectomy. This muscle is involved with elongation of the vocal folds. Trauma to the nerve results in an inability to lengthen a vocal fold and thus to create a higher-pitched sound. The external branch of the SLN is probably the most commonly injured nerve in thyroid surgery. The rate of injury to the external branch of the SLN has been estimated at 0-25%. This rate is probably underestimated, because the diagnosis is frequently missed
Pre eclamptic patient post LSCS continue on Mg infusion in ICU. Found to be in respiratory depressed. Next management
A. Calcium gluconate
B. IV fluid
C. Frusemide
Periop clinic reviewing a patient with chronic/ end stage renal failure. Her calcium found to be low. He most certainly have
A. Primary hyperparathyroidism
B. Secondary hyperparathyroidism
C. Tertiary hyperparathyroidism
When stimulating the ulnar nerve with a nerve stimulator, which muscle do you see twitch?
A. opponens abducens
B. abductor pollicis brevis
C. adductor pollicis brevis
D. extensor pollicis
E. flexor pollicis brevis

Medscape: Peripheral Nerve Stimulator - Train of Four Monitoring
“If stimulating the ulnar nerve, observe for twitches of the thumb (adductor pollicis muscle)”
When intubating over a bougie / awake fibreoptic, which direction do you rotate the tube to stop it catching on structures in the glottis
A. no change from normal
B. 90 degrees clockwise
C. 90 degrees counterclockwise
D. 180 degrees
E. try either direction
Advantages of off-pump CABG over on-pump CABG
A. decreased transfusion rate
B. decreased mortality
C. decreased cost
D. increased graft patency
E. less cognitive impairment
F. less stroke
A, E, F

Cochrane Review 2012 Mar
• No difference in mortality
• Off pump associated with les stroke, atrial fibrillation, transfusion requirements, respiratory infection, ventilation time, inotropic agent requirements, and length of hospital stay

Advantages from University of Maryland Medical Centre Website:
• Reduced need for blood transfusions
• Reduced risk of bleeding, stroke and kidney failure
• Potential for reduced psychomotor and cognitive problems
After coronary artery bypass graft surgery, the FRC is
A. increased 40%
B. increased 20%
C. unchanged
D. decreased 20%
E. decreased 40%
?Probably D or E
A 60 year old man 24 hours post CABG is confused, oliguric, with BP 80/40, pulse 120. The most appropriate and useful investigation is
A. electrocardiogram
B. echocardiogram
C. chest x-ray
D. arterial blood gas
E. coronary angiogram
Why should NSAIDs be avoided in pregnant women >30 weeks gestation?
A. cause neonatal acute renal failure
B. increased antepartum haemorrhage
C. increased rate of pre-eclampsia
D. cause closure of the fetal ductus arteriosus
E. increase preterm labour

“While relatively safe in early and mid pregnancy, they can precipitate fetal cardiac and renal complications in late pregnancy, as well as interfere with fetal brain development and the production of amniotic fluid; they should be discontinued in the 32nd gestational week (Ostensen & Skomsvoll, 2004). Fetal exposure to nsNSAIDs has been associated with persistent pulmonary hypertension in the neonate (Alano et al, 2001 Level III-2) and an increased risk of premature closure of the ductus arteriosus (Koren et al, 2006 Level I)”
A 62 year old man has chronic renal failure. You notice his total serum calcium is 2.05 mmol/L. This is because he has
A. high serum vitamin D
B. hypoparathyroidism
C. primary hyperparathyroidism
D. secondary hyperparathyroidism
E. tertiary hyperparathyroidism