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56 Cards in this Set

  • Front
  • Back

Acromegaly due to excess of growth hormone. Why is it difficult to do a direct laryngoscopy?

A: Distorted facial anatomy
B: Macroglossia
C: Glottic stenosis
D: Prognathe mandible
E: Arthritis of the neck

B- macroglossia
Ehlers-Danlos syndrome. Most important to specifically do all EXCEPT:

A: Avoid hyperextension of the neck
B: Damage to the teeth
C: Avoid joint hypermobility
D: Gastro oesophageal reflex
E: Strict temperature regulation
E- strict temperature regulation

1. GORD and gastritis
2. Early satiety and delayed gastric emptying
3. High, narrow palate and dental crowding
4. Peridontal disease (friability, gingivitis, gum recession)
5. Joint laxity. Subluxations and dislocations are common and represent the major manifestation of the condition. All sites can be involved, including the extremities, vertebral column, costo-vertebral and costo-sternal joints, clavicular articulations, and temporomandibular joints.
An 85y.o for open AAA repair. Refuses blood because of risk of vCJD. You tell him you won't anaesthetise him as the risk is too high. This is an example of:

A: Autonomy
B: Beneficence
C: Malevolence
D: Coercion
E: Paternalism
E- Paternalism
A 35yr old African-American with sickle cell and fractured ankle for ORIF. Hb 90, Haematocrit 0.3.

A: Transfuse 2 units packed cells (?pre-op)
B: Let him cool passively to low/normal temperature
C: Spinal is safe
D: Avoid thiopentone
E: Tourniquet is absolutely contra-indicated
C- spinal is safe

A - WRONG: "Although widely practiced, prophylactic erythrocyte transfusion remains a treatment with appreciable complications whose potential benefits have not been clearly demonstrated by a prospective, randomized clinical trial". Also a study in orthopaedic patients "did not detect a prophylactic effect from preoperative transfusion" (Sickle Cell Disease and Anesthesia. Anesthesiology 2004; 101:766-85)

B - WRONG: "Although hypothermia would tend to retard sickling because of a left shift of the oxygen dissociation curve, hypothermia is often identified as a precipitant of perioperative SCD complications". "avoidance of patient hypothermia is a basic objective for most anesthetics" (Same reference)

C - CORRECT: "The use of regional anesthesia therefore does not appear to be contraindicated in SCD" (Same reference) and OHA p202 agrees
Absolute contraindication to sitting position for posterior fossa craniotomy for meningioma

A: Prescence of patent ventriculo-atrial drain/shunt
C: Oesophageal stricture so transoesophageal echo placement is out
A or B


* Patent ventriculo-atrial shunt
* Severe cardiovascular disease
* Large patent foramen ovale or other pulmonary-systemic shunt
* Cerebral ischaemia when upright and awake
* Anaesthesia or surgical team not familiar with the position

ECG- which does NOT have abnormal Q waves:

A: Digoxin toxicity
B: Anterior myocardial infartion
C: Previous AMI
E: Wolff-Parkinson-White syndrome

ANSWER A- digoxin toxicity

Q waves: transmural MI, LBBB, hyperkalaemia, WPW, amyloid, HOCM, cardiac contusion, myocarditis, dextrocardia, reverse limb leads.
Coeliac plexus block. What is the complication?

A: Erectile dysfunction
B: Constipation
C: Hypertension which resolves spontaneously
D: Paralysis
ANSWER D- paralysis

* 3 common transient adverse effects
1. Local pain (96%)
2. Diarrhoea (44%)
3. Hypotension (38%)
* Other complications include
o Lower extremity weakness
o Paraplegia
o Parasthesia
o Adjacent organ puncture
o Infection
o Bleeding → retroperitoneal haematoma
o Epidural injection
o Subarachnoid injection
o Intravascular injection
o Pneumothorax
o Chylothorax

* Neurology caused by
o Direct injury to spinal cord or somatic nerves
o Spinal cord ischaemia
+ Spasm or thrombosis of the artery of Adamkiewicz → spinal cord ischaemia T8 to L4

Long stem about an old #NOF patient with aortic stenosis. What is a sign/ investigation/ symptom that shows the most severity?

A: Thrill in Aortic area
B: Murmur in lower left sternal edge
C: Murmur radiating to carotids
D: History of ischaemic heart disease or coronary artery disease
E: history of angina/ syncope

ANSWER A- thrill in aortic area

A - True - "A precordial thrill may be felt, especially on leaning forward in expiration. Its presence is reasonably specific for severe aortic stenosis"

Symptoms not specific for severity- can have with mild stenosis


You get a TOE on a patient with aortic stenosis. What is the finding most likely to indicate that the valve needs replacement?

A: Average pressure gradient 30mmHg
B: Valve area 1.2cm(squared)
C: dyspnoea

C- dyspnoea

In symptomatic aortic stenosis, elective noncardiac surgery should generally be postponed or canceled. Such patients require aortic valve replacement before elective but necessary noncardiac surgery. If the aortic stenosis is severe but asymptomatic, the surgery should be postponed or canceled if the valve has not been evaluated within the year.

Petit mal epilepsy - Which is true?

A: Most common in child <2 years old
B: Can precipitate seizures by hyperventilating
C: Often seizures last for more than 30 seconds
D: Rarely familial
E: Isoelectric EEG during seizure (burst suppression)
ANSWER B- preicipitate seizures by hyperventilating

Absence seizures
-abrupt and sudden onset of impairment of consciousness (blank stare, possible upward rotation of eyes)
-usually brief <20sec
-EEG generalised spike and slow wave discharges
-hyperventilation triggers in 90%
-treatment mainly valproate (second line lamotrigine)
-should not use carbamazepine, vigabatrin, tiagabine, phenytoin, gabapentin and pregabalin --> not effective in treatment
Hypertension- severe- in pregnancy. What NOT to use?

A: Hydralazine
B: Nifedipine
C: Labetalol
D: Metoprolol
D- metoprolol or E- SNP

Not mentioned in CEACCP 2003
Likely causes heart failure in face of raised afterload

SNP good for HT emergencies but requires arterial monitoring and risk of cyanide toxicity to fetus
Which have been shown to decrease vasospasm post aneurysm? All EXCEPT:

A: Antiplatelet drugs
B: Nimodipine
C: HHH therapy
A- antiplatelet drugs
Post operative left pneumonectomy. What to do with underwater seal drain?

A: Nurse patient in R lateral decubitus position
B: Expect to see bubbles
C: Suction every hour for 5 minutes
D: Unclamp drain once an hour for 5 minutes, leave clamp on for the rest of the time
E: Leave on free drainage
D- unclamp drain once an hour for 5 minutes

If cardiac herniation nurse with operative side up
What is NOT true for PDPH following puncture

A: Prophylactic bed rest
B: Catheter in intrathecally
A- prophylactic bed rest

in Section 9.6.5 Acute Pain Management: Scientific Evidence (2005) and Update (2007)

Incidence of headache following dural puncture 0.4-24%

* postural in nature
* commoner in patients under 50 yrs
* commoner in parturients
* significanntly less common in males than non-pregnant females (level 1 evidence - 2007 update)
* 90% resolve spontaneously within 10 days

Incidence may be reduced by using: (level I)

* 26 gauge or smaller needle (NNT=13)
* use of needle with a non-cutting bevel (NNT=27)

No evidence that bed rest is beneficial in preventing PDPH (Level I)

* PDPH may causes difficulty mobilising, and headache may then subside with bed rest
* Non-opioid and opioid analgesics may provide temoporary relief
* Preventive role of fluid therapy unclear (Level I)

NO evidence to support the use of:

* Sumatriptan (Level II)
* Epidurally administered saline, dextran, fibrin glue or neuraxial opioids

IV and oral caffeine (both level II) are:

* effective in treating PDPH
* do not reduce blood patch rate

Epidural blood patches:

* are common practice but further high quality trials are required to determine efficacy (level I)
* significant symptomatic relief obtained in 75-95% of patients given a 15 mL blood patch (level IV, three studies)
* conflicting evidence regarding use of prophylactic blood patches - one trial showed decreased incidence of PDPH (level III)

Autologous epidural blood patches may be contra-indicated in:

* leukaemia
* coagulopathy
* infection, including HIV
Magnesium for treatment of pre-eclampsia. What is the therapeutic level?

B: 3 - 5
C: 5 - 7

Normal serum level 0.75-1.0
Therapeutic level 2-3.5
Loss of patellar reflexes 3.5-5
Skeletal muscle relaxation, SA/AV block, respiratory paralysis 6-7.5
Cardiac arrest > 12
Autonomic dysreflexia. Which ONE is true?

A: 50% of patients with a level below T6
B: Unlikely if below T10
D: Can be precipitated by light touch
B- unlikely if below T10

During adulthood, ageing results in

A. a decline in resting cardiac output
B. a decrease in functional residual capacity (FRC)
C. an increase in hypoxic ventilatory drive
D. an increase in serum creatinine
E. an increase in ventricular wall stiffness

E- increase in ventricular wall stiffness

A also correct- decreases 1%/yr
TEG tracing given, post cardiac surgery. Had quite slim tail but broader 'shoulders'.

A: Fibrinolysis
B: Hypofibrinogenaemia
C: Platelet dysfunction
D: Heparin effect
E: Surgical bleeding
A- fibrinolysis
Post scoliosis repair, decreased movement bilaterally in the legs with decreased pain and temperature sensation but spared joint position sense and vibration. What is at fault?

A: Posterior spinal arteries
B: Anterior spinal arteries
C: Epidural haematoma
D: Misplaced pedicle screw
E: Lateral cord syndrome
B- anterior spinal arteries

Anterior Spinal Cord Syndrome
# Complete motor paralysis below the level of the lesion due to interruption of the corticospinal tract
# Loss of pain and temperature sensation at and below the level of the lesion due to interruption of the spinothalamic tract
# Retained proprioception and vibratory sensation due to intact dorsal columns

Typical causes include acute disc herniation or ischemia from anterior spinal artery occlusion.

Anaesthetising an obese patient. Acelerometer on TOF 0.9. Could dose suxamethonium on ideal body weight or total body weight. With respect to 1mg/kg IBW vs. TBW you will see:

A: shorter onset and faster twitch recovery
B: shorter onset and similar twitch recovery
C: shorter onset and slower twitch recovery
D: similar speed of onset with similar speed of twitch recovery
E: similar onset and longer recovery

E- similar onset and longer recovery if comparing TBW to IBW

i.e. TBW similar speed onset but longer recovery cf. IBW but better intubating conditions

A & A February 2006 vol. 102 no. 2 438-442

The half life of the active metabolite of levosimendan (OR-1896) is:

A: 1hr
B: 8hr
C: 24hr
D: 3 days
E: 7 days

D- 3 days

Clin Pharmacokinet. 2007;46(7):535-52.

Levosimendan has been developed for the treatment of decompensated heart failure and is used intravenously when patients with heart failure require immediate initiation of drug therapy. It increases cardiac contractility and induces vasodilatation. The pharmacokinetics of levosimendan are linear at the therapeutic dose range of 0.05-0.2 microg/kg/minute. The short half-life (about 1 hour) of the parent drug, levosimendan, enables fast onset of drug action, although the effects are long-lasting due to the active metabolite OR-1896, which has an elimination half-life of 70-80 hours in patients with heart failure (New York Heart Association functional class III-IV).
When compared to a non-obese patient, in an obese patient (BMI >35) when fasted for an elective procedure the gastric secretion will have:

A: more volume, higher pH
B: more volume, lower pH
C: same volume, same pH
D: less volume, lower pH
E: less volume, higher pH
B- more volume, lower pH

Study in Anesthesiology 1975 and reviews in BJA 2000 and CEACCP 2008

Note later study in 1998 demonstrated same volume and same pH
The anterior branch of the femoral nerve supplies everything but:

A: pectinius
B: rectus femoris
C: Medial thigh
D: anterior thigh
E: sartorius
B- rectus femoris

Supplied by posterior branch of femoral nerve
During interscalene block placement get medial movement of the scapula. This is secondary to stimulation of:

A: long thoracic nerve
B: dorsal scapula nerve
C: suprascapular nerve
D: supraclavicular nerve
E: accessory nerve
B- dorsal scapula nerve


Needle contacts bone at 102cm depth, no twitches
-needle stopped by transverse process
-insertion point is too posterior
-reinsert needle more anteriorly

Twitches the diahragm
-stimulation of phrenic nerve
-needle inserted anteriorly
-reinsert more posteriorly

Arterial blood
-carotid artery puncture
-angled too anterior
-withdraw and apply pressure
-redirect posteriorly

Twitch of scapula
-direct stim of serratus anterior muscle
-direct stim of thoracodorsal nerve (supplied lat dorsi)
-direct stim of dorsal scapular nerve (supplies rhomboid muscles and levator scapulae)
-re-direct needle anteriorly

Popliteal block placed from the lateral approach:

A: Passes through semimembranosus
B: Has eversion of the foot as the end point
C: Has increased failure rate compared to a posterior approach
E: Can be performed supine or prone

E- can be performed supine or prone

A FALSE, semimembranosus is muscle on the back of thigh

Common peroneal : dorsiflesion and eversion
Tibial nerve: plantar flexion and inversion

Want to get inversion for PNS as this is supplied by both common peroneal (tib anterior) and tibial n (tib posterior)

C FALSE intermediate block, easier to perform, higher success rate
During scoliosis surgery with monitoring of somatosensory evoked potentials, which tract are they mainly monitoring?

A: Dorsal column
B: Spinothalamic tract
C: Lateral Corticospinal tract
D: Cerebrospinal tract
E: Anterior horn cells
A- dorsal column

SSEPs- monitor passage of sensory information through posterior columns to cerebral cortex.

Apply repeated electrical stimuli to a peripheral nerve and measure response over cerebral cortex. Low amplitude to distinguish from background noise and EEG.

Increase in latency of 10-15% or decrease in amplitude > 50% = problem

During lumbar plexus block placement, which of the following indicates inappropriate needle placement?

A: hip flexion
B: hip adduction
C: knee extension
D: knee flexion
E: lumbar extension

E- lumbar extension

1. Mark out midline over spinus processes
2. Mark out perpendicular line, line connect iliac spines
3. Needle insertion 4cm from midline along interiliac spine, aim perpendicular, parallel to spine
4. 6-8 cm depth
5. aim is for twitch of quadraceps (femoral nn), but twitch of any of the lumbar nerves possible
6. Nerve stimulation from 1mA to 0.5mA
7. aspirate and inject 20-25ml of solution (0.5-0.75% ropivacaine)
Flow with the O2 flush button pressed and volatile agent turned on will give you:

A: 20-30l/min O2
B: 30-70l/min O2
C: volatile agent + 30l/m O2
D: volatile agent + 40l/m O2
E: volatile agent + 50l/min O2
B- 30-70L/mnin O2
75 year old with non-valvular AF usually on warfarin has their warfarin stopped for one week. What is their daily risk of stroke?

A: 1%
B: 0.1%
C: 0.01%
D: 4%
E: 10%
C- 0.01% is closest answer

Divide annual risk by 365

Score 0 = low risk, 1 = low-moderate (consider antiplatelet or anticoagulation), > 1 = moderate-high (anticoagulate)

CHF, HT, DM, Vasc disease, Age 64-75, female = 1
Age > 75, CVA/TIA/TE = 2

Score Annual Risk
1 1
2 2
3 3
4 4
5 6
6-8 10- requires bridging
9 15
If type and Rh specific blood is given to a patient, how safe is the transfusion

C: 97%
D: 98.6%
E: 99.8%
E- 99.8%

ABO-Rh type = 99.8%.
+ Ab screening = 99.94%
Crossmatch = 99.95%
Patient with Marfan's and 2 hours of severe chest pain, mild hypertension and ECG showing ischaemia. The next best step is urgent:

D: Angiography and PCI
E: Thrombolysis
A- CT if stable

If unstable and going to OT- TOE
What percentage of patients with SAH are troponin positive?

A: <5%
B: 15-30%
C: 40-60%
D: 70-90%
E: 100%
B- 15-30%

Contin Educ Anaesth Crit Care Pain (2008) 8 (2): 62-66. states 20%
What is the major cause of death in a patient with perforation of the pharynx, oesophagus or trachea?

A: failure to intubate
B: failure to ventilation
C: sepsis
C- sepsis
Eisenmenger's syndrome:

A: decrease Hb to <180 with venesection
B: Give high FiO2
C: Pulmonary vasodilators will treat the pulmonary hypertension
D: terminal RV failure usually occurs in the 3rd-4th decade
A- venesection

Aim HCT < 65

Therapeutic methods used in patients with Eisenmenger syndrome. Cardiol J 2009
Your registrar gives a Duchenne patient 1mg/kg of suxamethonium. What are you most worried about?

A: hyperkalaemia
B: rhabdomyolysis
A- hyperkalemia
Fontan patient having an open appendicectomy. What do you want?

A: long I time and PEEP
B: long I time
C: short I time
D: raised ETCO2
E: spontaneous ventilation
E- spontaneous ventilation
What makes tramadol less effective?

A: ondansetron
B: prochlorperazine
C: metoclopramide
A- ondansetron
75 year old male with normal renal function for an endoluminal aortic repair. What is the best protection to prevent the development of renal dysfunction?

A: NaCl
C: mannitol
D: dopamine
E: dialysis
A- saline

Methods to reduce AKI after contrast (?is this adaptable to EVAR)
-Witholding nephrotoxic drugs: NSAIDs, aminoglycosides, metformin etc

Volume expansion
-well established in AKi
-evidence indicated normal saline or CSL is more effective than half normal saline
-consider bicarbonate solutions
-maintain UO>2ml/kg

Dialysis or hemofiltration
-no evidence for prophylactic dialysis with normal renal function
-evidence in CRI
-may be confounded by hemofiltration ensures adequate intravascular volume

-no approved agents for prevention of AKI
-Ascorbic acid 3g nocte before and 2g bd
-multicentre RCT, placebo controlled showed reduced incidence
-NAC not consistently shown to be effect, meta analysis showed no effect

Fenoldopam, dopamine, calcium-channel blockers, atrial natriuretic peptide, and L-arginine have not been shown to be effective in the prevention of contrast-induced AKI. Furosemide, mannitol, and an endothelin receptor antagonist are potentially detrimental

Very sick patient on CVVHF. On norad, changed to adrenaline with no improvement in haemodynamic variables. What is your next step?

A: change to another inotrope
B: check their response to a synacthen test
C: give hydrocortisone

C- hydrocortisone
What is the most common way to measure end tidal gas concentrations on our anaesthetic machines?

A: mass spectometry
B: Raman scattering
C: ultrasonic
D: infrared
E: piezoelectric
D- infrared

Dorsch and Dorsch
Multiple attempts to place ETT during difficult intubation causing pharyngeal and oesophageal perforations. Most likely cause of death?

A: Failure to intubate
B: Failure to ventilate
C: Bleeding
D: Sepsis
D- Sepsis
How far to insert PICC line in a kid beyond the carina

A: At the carina
B: 1cm below
C: 1cm above
A- at the carina

The ideal position is above the pericardial reflection in the SVC
In a patient with porphyria, the drug most likely to cause an acute episode is

A. morphine
B. propofol
C. propanidid
D. phenytoin
E. atropine
D- phenytoin
Transfusion related acute lung injury (TRALI)

A. can be caused by all homologous blood components, but particularly FFP (fresh frozen plasma)
B. is associated with significantly elevated pulmonary artery pressure
C. is the commonest cause of morbidity associated with blood transfusion
D. should be treated with high dose steroids
E. typically presents 24 hours following transfusion
C- commonest cause of morbidity
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- midazolam
Subtenon’s block. What is the worst position to insert block?

A. Inferonasal
B. Inferotemporal
C. Superonasal
D. Supertemporal
E. Medial / canthal
C- superonasal

Potentially more hazardous due to vascular, neuronal and muscular contents in this area

Ophthalmol Clin N Am 2006
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
B- cannot use sevo
Thallium scan:

A. High negative predictive value
B. High positive predictive value
C. Not as good as a dobutamine stress echocardiography
A- High NPV

NPV 95%
PPV 30%

Probably the same as dobutamine stress echo
Correct statements regarding fondaparinux include each of the following EXCEPT

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

As per Yentis pg 214

* A - derived from the factor Xa-binding moeity of unfractionated heparain (FALSE, hence ANSWER)
* B - single daily dose (TRUE)
* C - "It is a synthetic and specific inhibitor of activated Factor X (Xa)" [1] (TRUE)
* D - only licensed for DVT prophylaxis in orthopaedic surgery (TRUE)
* E - implies standard dose for all (TRUE)
Exponential decline / definition of time constant (with various options)

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
C- time to reach 37% of initial value
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
B- 3% NS

Patient is symptomatic
-3% Saline at 1-2ml/kg/hr (stop as soon as symptoms resolve)

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

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

A- gas induction/laryngoscopy/intubate
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
E. IV adrenaline?
C- IV Mg
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- 3mm Hg per min

6mm Hg per min 1st minute then 3mm Hg per min after
Visual loss with pupillary reflexes retained. Likely cause ?

A. Retinal detachment
B. Occipital mass
C. Frontal mass
D. Chiasmal mass
E. Optic neuritis
B- occipital mass
In pregnancy the dural sac ends at:

A. T12
B. L2
C. L4
D. S2
E. S4
D- S2