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87 Cards in this Set
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List the MET equalents.
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IC34 ANZCA version [2005-Sep] Q73
Urinary osmolality A. in the presence of oliguria is a good indicator of renal function B. will increase more than specific gravity with an osmotic dieresis due to glucose C. is measured by elevation of the freezing point D. is expressed in milliosmol.l-1 E. in severely ill patients gives an indication of the effectiveness of frusemide |
ANSWER A
A : True ATN leads to tubular dysfunction and inability to conc. urine B : False disproportionate increase in specific gravity compared to osmolality if larger molecules (e.g glucose), are present (i.e in glucosuria in uncontrolled DM, and the administration of radiocontrast media) (Up to Date) C : False depression D : False mOsmol/kg E : False |
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IC71 ANZCA version [2003-Apr] Q141, [2003-Aug] Q40, [Mar06]
The first priority in managing a witnessed ventricular fibrillation cardiac arrest is A. defibrillation times 3 B. endotracheal intubation C. establishment of intravenous access D. external cardiac massage E. mask ventilation with 100% oxygen |
ANSWER A
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IC73 ANZCA version [2005-Apr] Q126, [Mar06] Q86
In a haemodynamically stable 20-year-old male presenting with blunt chest trauma, the best screening test for diagnosis of cardiac injury requiring treatment is A. chest X-Ray B. serum CK-MB levels C. serum Troponin levels D. standard 12 lead ECG E. transthoracic echocardiography |
ANSWER D
An admission 12 lead ECG should be performed on all patients in whom there is suspected BCI. If the admission ECG is normal, the risk of having a BCI that requires treatment is insignificant, and no further testing is indicated. Echocardiography is the diagnostic method of choice in patients with ECG abnormalities or unexplained cardiovascular instability following blunt cardiac trauma. If the patient is hemodynamically unstable, a TTE should be obtained. If an optimal TTE cannot be performed, then the patient should have a TOE. Neither creatine phosphokinase with isoenzyme analysis nor measurement of circulating cardiac troponin T are useful in predicting which patients have or will have complications related to BCI. |
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IC79 ANZCA version [2005-Sep] Q117, [Mar06] Q92
The patient most likely to sustain blunt cardiac trauma (cardiac contusion) is a A. back seat passenger in a motor vehicle which crashes at a speed of 60 km.hr-1 B. motor bike rider who falls from his bike on a bend travelling at 50 km.hr-1 C. painter who falls 10 metres on to grass D. seventy-year-old patient who had cardiopulmonary rescusitation (CPR) performed by a passerby in the street E. water skier who falls from his skis travelling at a speed of 40 km.hr-1 |
ANSWER
By far, the most important cause of significant blunt chest trauma is motor vehicle accidents (MVAs). MVAs account for 70-80% of such injuries. As a result, preventive strategies to reduce MVAs have been instituted in the form of speed limit restriction and the use of restraints. Pedestrians struck by vehicles, falls, and acts of violence are other causative mechanisms. Blast injuries can also result in significant blunt thoracic trauma. |
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SO05 ANZCA version [1988] [Mar93] [2002-Aug] Q9, [2003-Apr] Q6, [2005-Sep] Q31 [Mar06] Q5
A patient with a central dislocation of the hip following a motor car accident is noted to be shocked on admission, one hour after the accident. The most likely cause is A. Ruptured bladder B. Fat embolism C. Ruptured urethra D. Neurogenic shock E. None of the above |
ANSWER E
Trauma haemorrhage 750mls in tibia or humerus 1500mls in femur >2000mls retroperitoneal haematoma in pelvic fractures |
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MN33a ANZCA version [2002-Mar] Q17, [2002-Aug] Q23, [2005-Apr] Q3 (Similar reported question in [Jul98] [Apr99] [Aug99] [Mar00])
A patient with a head injury who has eye opening to speech, no verbal responses and withdrawal motor responses would have a Glasgow Coma Scale score of A. 4 B. 5 C. 6 D. 7 E. 8 |
ANSWER E
E=3/4 V=1/5 M=4/6 Eye Opening (E) 4=Spontaneous 3=To voice 2=To pain 1=None Verbal Response (V) 5=Normal conversation 4=Disoriented conversation 3=Words, but not coherent 2=No words (sounds only) 1=None Motor Response (M) 6=Normal 5=Localizes to pain 4=Withdraws to pain (Normal flexion) 3=Decorticate posture (Abnormal flexion) 2=Decerebrate (ie Extension) 1=None |
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IC80 ANZCA Version [Jul06] Q105, [Apr07] Q3
A 30-year-old man presents to the Emergency Department following a high speed motor vehicle accident. He has marked abdominal distenson, a pulse rate of 130 and a blood pressure of 80/50 mmHg. The most appropriate initial investigation would be A. abdominal angiogram B. abdominal paracentesis C. CAT scan of the abdomen D. plain X-ray of the abdomen E. FAST (focussed abdominal sonography for trauma) scan |
ANSWER E
FAST : Focused Abdominal Sonography in Trauma 4 Windows 1. Perihepatic : Pouch of Rutherford-Morison, most dependent abdominal compartment supine, looking at hepatorenal space Found at right mid-axillary line between 11th and 12th rib 2. Perisplenic : found left midaxillary line in 11th and 12th rib 3. Pelvis : visualise the cul de sac : Pouch of Douglas in women and rectovesicular pouch in men, midline superior to pubic symphysis 4. Pericardium : looking for pericardial effusion/haemorrhage, left xiphisternum angled cranially. |
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IC81 ANZCA Version [Jul06] Q123
A 16-year-old arrives in your Emergency Department having fallen from, and been trampled by, a horse. The ambulance officers report that this initial GCS (Glasgow Coma Scale) was 15 and is now 11. His pulse is 120 and blood pressure 80/60 mmHg. SpO2 is 97% when breathing on a Hudson mask. On auscultation his chest is clear. He has facial bruising and a tender abdomen. Your first priority now is to A. administer an IV (intravenous) fluid bolus B. arrange an urgent CT scan of the head C. administer mannitol D. perform a FAST (focussed assessment with sonography for trauma) examination E. secure the airway by intubation |
ANSWER A
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IC82 ANZCA Version [Jul06] Q102
A 30-year-old man presents to the Emergency Department following a high speed motor vehicle accident. He has a Glasgow Coma Score of 7 and arrives with a cervical collar in situ and an 18 gauge intravenous cannula in his right hand. You first priority in managing this patient would be to A. insert a large bore intravenous cannula B. perform a CAT scan of the brain C. perform a cervical spine X-ray D. perform a plain chest and pelvic X-ray E. secure the airway with an endotracheal tube |
ANSWER E
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IC83a ANZCA Version Jul06 Q65
A patient suddenly collapses 36 hours after gastrectomy. His blood pressure is 80/30 mmHg, his pulse rate 100/minute, his central venous pressure +2 cm (from the sternal angle) and his temperature 39C. The most likely diagnosis is A. acute dilataton of the stomach B. anastomotic disruption C. haemorrhage D. pulmonary embolismm E. Septicaemia |
ANSWER E
Haemorrhage possible but less likely with fever 39° PE: - with temp 39°C less likely as mentioned above. - with sysBP 80 and HR 130, I'd expect a higher JVP due to R heart failure - no mention of resp symptoms/signs, chest pain or else in the stem Gastric dilatation: vagus response would result in bradycardia and hypotension Anastomotic breakdown: Will often cause sepsis, prob. more likely with colo-rectal surgery. Also, needs some time to develop sepsis. Septicaemia: Low BP, tachycardia, high temperature are all signs in sepsis, plus there's a good reason to be septic 2d postop. A CVP 2cm above sternal angle is not unusual, the fact that the CVP is not lower can have various reasons, eg sepsis-associated myocardial dysfunction, low RV compliance in high-CO state, incr PVR due to pulm pathology. |
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IC84 ANZCA Version [Jul06] Q145, [Jul07]
A 32-year-old patient is admitted with early acute liver failure (unrelated to paracetamol ingestion). Management should include: A. avoidance of intubation to monitor encephalopathic progress B. consideration for liver transplant if the INR (international normalised ratio) is over 3 C. limited use of sodium containing fluids during acute resuscitation D. N-acetyl-cysteine as a generall hepatoprotective agent E. prophylactic antibiotics |
ANSWER E
A. FALSE : partly true, but if you need to intubate, you intubate B. FALSE : King's College Hospital criteria for liver transplantation in acute liver failure: Patients with paracetamol toxicity * pH <7.3 or * Prothrombin time >100 seconds and * serum creatinine level >3.4 mg/dL (>300 μmol/l) * if in grade III or IV encephalopathy Other patients * Prothrombin time > 100 seconds or * Three of the following variables: * Age <10 yr or >40 yr * Cause: o non-A, non-B hepatitis o halothane hepatitis o idiosyncratic drug reaction * Duration of jaundice before encephalopathy >7 days * prothrombin time >50 seconds * Serum bilirubin level >17.6 mg/dL (>300 μmol/l) C. FALSE : only in CLD D. TRUE : Studies have shown that NAC may work in non-paracetamol related liver failure as many cases are due to drug toxicity; and its role as an anti-oxidant may help. E. TRUE : reduces risk of sepsis/encephalopathy, increased success of transplantation, no different in survival |
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IC85 [Apr07] Q115
A young woman has an MVA when driving home from a nightclub. She was known to have moderate MDMA (ecstasy) consumption. Which of the following complications is least likely to be due to MDMA? A. Hyponatraemia B. Hypotension C. Pneumothorax D. Sweating E. Tachycardia |
Minor clinical symptoms and signs seen with MDMA
Tachycardia Elevated mood Hypertension Confusion Mydriasis Ataxia Dry mouth Nystagmus Sweating Bruxism (jaw clenching) |
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IC86 ANZCA Version [Apr07] [Jul07]
A 25-year-old man, involved in a motor vehicle crash, presented with a GCS (Glasgow Coma Score) of 5. He was intubated and ventilated, and CT scan of his head was consistent with diffuse axonal injury. An ICP (intra-cranial pressure) monitor has been placed. The patient's ICP has ranged between 15 and 25 mmHg over the last 2 hours, despite intravenous mannitol and moderate hypocapnia. He has stable haemodynamics with a mean arterial pressure of 95-100 mmHg. He now requires general anaesthesia to manage his orthopaedic injuries. The most appropriate agents for maintenance of anaesthesia would be A. isoflurane / remifentanil B. propofol and fentanyl C. propofol and nitrous oxide D. sevoflurane and nitrous oxide E. sevoflurane and remifentanil |
ANSWER B
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ANZCA Version [Jul07][mar10]
A 30-year-old man presents to the emergency department following a high speed motor vehicle accident. His blood pressure is 70/50 mmHg with a strongly positive FAST (focused abdominal sonography for trauma). His chest X-¬ray shows a widened mediastinum. The most appropriate method to assess the widened mediastinum in this patient is A. aortogram B. CT angiogram of the chest C. repeat chest X-ray D. intraoperative TOE (transoesophageal echocardiography) E. transthoracic echocardiography |
ANSWER D
Grade 3-4 haemorrhagic shock with positive FAST : needs to go to theatre ASAP. The widen mediastinum can be evaluated intraoperatively with TOE |
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ANZCA Version [Jul07]
A 50-year-old female patient presents with a 12 hour history of feeling unwell and is found to fulfill the criteria for Systemic Inflammatory Response Syndrome. Her blood pressure is 80/45 mmHg, her pulse rate is 90 beats.min1 and her central venous pressure is 12 mmHg. The hypotension is most appropriately managed with A. adrenaline B. dobutamine C. dopamine D. ephedrine E. noradrenaline |
ANSWER D
SIRS = vasodilated with hyperdynamic heart. Resusitation Goal from Surviving Sepsis Guidelines 1. CVP 8-12 2 MAP >65 3. UO >0.5ml/kg/hr 4. CVP O2 sat>70% or mixed venous >65% |
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IC89 ANZCA version [Apr08]
Which one of the following is most likely to be associated with a high mixed venous oxygen saturation (SvO2)? A. acute myocardial infarction B. acute pulmonary embolism C. cardiac tamponade D. sepsis E. severe liver disease |
ANSWER D
Other causes for high mixed venous sat sepsis A-V fistulae cirrhosis left-to-right cardiac shunts cyanide poisoning hypothermia unintentional PA catheter wedging |
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IC90 ANZCA version [Jul07] Q144
The best indicator of adequate fluid resuscitation in the trauma patient is: A arterial pH B blood pressure C core temperature D pulse rate E serum lactate level |
ANSWER E
Urine output is the best answer but is not available |
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IC91 ANZCA version [Jul07] Q143
When optimising patients for surgery using goal-directed therapy, which of the following parameters is LEAST useful? A. blood pressure B. cardiac index C. oxygen saturation of blood aspirated from a central venous catheter D. oxygen saturation of blood aspirated from the distal port of a pulmonary artery catheter E. stroke volume variability |
ANSWER A
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ANZCA Version [Apr08]
Each of the following statements regarding cardiac tamponade as a complication of central venous lines is true, EXCEPT: A. catheters with multiple lumens carry greater risk B. for a left sided catheter, placement of the tip at the mid-point of the brachiocephalic vein is safe C. it usually occurs within the first week following insertion D. placement of the catheter tip above the junction of the right atrium and superior vena cava will avoid this complication E. visceral chest pain with drug infusion is an early symptom |
ANSWER D
A: TRUE..."Stiffer catheters are more likely to perforate. Stiffness is a function of the composition of the catheter (Silastic probably being safest) and the number of the lumen (a function of the greater diameter and presence of ‘septa’ within the catheter)." B: TRUE..."Zone C (mid‐point, left innominate vein). This is a suitable site for the tip when the catheter is introduced from the left internal jugular or subclavian vein, and reduces the risk of SVC perforation." (In reference to a diagram of the heart and great vessels showing various "zones" for the CVC tip) C: TRUE..."Most cases occur in the first week after insertion" D: FALSE (and answer to choose)..."the pericardium may ascend alongside the medial wall of the SVC by up to 5 cm (mean 3 cm). Thus, placement just proximal to the atrium does not obviate the risk of tamponade". E: TRUE..."This results in two warning signs: visceral‐type chest pain on infusion of drugs or parenteral nutrition solutions and a curved appearance of the distal catheter seen on chest x‐ray" |
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IC93 ANZCA version [Apr08]
When using osmotic agents to reduce intracranial pressure (ICP), the patient's serum osmolality should not be allowed to exceed: A. 280 mosmol/L B. 300 mosmol/L C. 320 mosmol/L D. 340 mosmol/L E. 360 mosmol/L |
ANSWER C
http://www.trauma.org/archive/neuro/icpcontrol.html Controlling ICP for intensive treatment of traumatic brain injury -maintenance of adequate cerebral perfusion pressure vs raised ICP Ventilation -carbon dioxide dilates the cerebral blood vessels, increasing the volume of blood in the intracranial vault, increasing ICP -aim for normocapnia -no studies have shown improved outcome with hyperventilation -however, hyperventilation can be used for short periods when immediate ICP control is necessary : eg acute deterioration, CT scanning, surgical intervention -transcranial doppler and PET have shown excessive vasoconstriction which may reduce cerebral blood flow to below ischaemic threshold -extended periods of hyperventilation maybe instituted with intensive neuromonitoring : jugular venous oxygen saturation and transcranial doppler assessments Intravenous therapy -should be normovolaemic, hypovolaemia inceases risk of decreased cerebral perfusion -use isotonic fluids to maintain volume -osmolality is most important -avoid all free water -hypertonic solutions and osmotic diuretics : mannitol Mannitol -6 carbon sugar, works via 2 mechanisms 1. expands circulating volume 2. decreases blood viscosity -therefore increasign creebral flow and oxygen delivery -takes 15-30 minutes to draw fluid from brain -mannitol itself directly breakdown BBB -wholly excreted in the urine and will cause rise in serum and urine osmolality -osmolality > 320mOsm are at risk of ATN Anaesthesia -TBI should be intubated -intubation mat induce a rise in ICP especially in those on the cusp of the pressure volume curve -RSI is indicated -continued sedation to allow ventilation and avoid coughing or fighting the ventilator -avoid PEEP |
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IC93 ANZCA version [Apr08] Q126
A patient is ventilated and invasively monitored in intensive care following a traumatic brain injury. Systemic arterial blood pressure is 140/80 mmHg with a mean pressure of 100 mmHg. Central venous pressure is 8 mmHg and intracranial pressure is 15 mmHg. The cerebral perfusion pressure (CPP) for this patient is: A. 72 mmHg B. 85 mmHg C. 92 mmHg D. 125 mmHg E. 132 mmHg |
ANSWER B
CPP = MAP - (ICP or CVP (whichever is greater)) |
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[Apr08]
Patient on ward, collapsed. Nurse calls code blue when finds pt unresponsive. No signs of life. After ensuring airway is clear, 1st action A. DCR x3 200J B. DCR x1 200J C. precordial thump D. CPR E. Adrenaline 1mg |
ANSWER D
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ANZCA Version [Apr08]
Improved neurological outcome has been demonstrated with the use of hypothermia soon after:: A. asystolic cardiac arrest B. Cerebrovascular accident C. Perinatal complications causing ischaemic encephalopathy D. rupture of an inracranial aneurysm E. traumatic brain injury |
ANSWER C (maybe E)
A: False * For VF arrest B: False * There is currently no evidence from randomised trials to support routine use of physical or pharmacological strategies to reduce temperature in patients with acute stroke. Large randomised clinical trials are needed to study the effect of such strategies...[1] (http://www.cochrane.org/reviews/en/ab001247.html) C: True * There is evidence that induced hypothermia (cooling) of newborn babies who may have suffered from a lack of oxygen at birth reduces death or disability, without increasing disability in survivors....Cooling for newborns with hypoxic ischaemic encephalopathy (http://www.cochrane.org/reviews/en/ab003311.html) D: False * No evidence E:False * The jury is still out on TBI... * Reductions in risk of mortality were greatest and favorable neurologic outcomes much more common when hypothermia was maintained for more than 48 h. However, this evidence comes with the suggestion that the potential benefits of hypothermia may likely be offset by a significant increase in risk of pneumonia...Journal of Neurotrauma |
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60. Following a cadaveric renal transplant under general anaesthesia, your patient's plasma K+ increases to 6.0 mmol.I-1 in recovery after being 5.0 mmol.I-1 pre and intra-- operatively. This patient requires
A. an intravenous infusion of CaCl2 (10 mls over 20 minutes) B. arterial blood gases to ascertain the acid/base status C. potassium exchange resins rectally D. sodium bicarbonate infusion (50-10O mEq over 5-10 minutes) E. urgent haemodialysis |
ANSWER B
This patient is likely to have chronically elevated K+ and hence be at low risk of arrythmias with a K+ 6.0. An ABG is reasonable to evaluate. However : * If cardiac changes (ie emergent treatment) –> CaCl2 or CaGluconate (up to 0.5ml/kg) * If acidosis & urgent treatment required –> NaHCO3 * If urgent treatment required – Insulin dextrose or urgent dialysis. I generally avoid salbutamol infusions. * If it can wait or using other treatments in the meantime –> resonium (sodium polystyrene sulphonate) |
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79. The most important factor in reducing peri-operative morbidity in diabetic patients undergoing peripheral vascular surgery is
A. tight control of blood sugar level in the peri-operative period B. frequent blood sugar level estimations C. the use of regional rather than general anaesthesia D. stabilisation of co-existing disease the use of an insulin infusion rather than a E. subcutaneous sliding scale regimen |
ANSWER D
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111. Which one of the following is most likely to be associated with a high mixed venous oxygen saturation (SvO2)?
A. acute myocardial infarction B. acute pulmonary embolism C. cardiac tamponade D. sepsis E. severe liver disease |
ANSWER D
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143. When optimising patients for surgery using goal-directed therapy, which of the following parameters is LEAST useful?
A. blood pressure B. cardiac index C. oxygen saturation of blood aspirated from a central venous catheter D. oxygen saturation of blood aspirated from the distal port of a pulmonary artery catheter E. stroke volume variability |
ANSWER A
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ANZCA 2007 Q148
The LEAST desirable position for the tip of a central venous catheter which has been inserted into the left internal jugular vein is A. mid-way along the left brachiocephalic vein B. at the junction of the left brachiocephalic vein and the superior vena cava (SVC) C. in the SVC at the level of the carina D. at the junction of the SVC and the right atrium E. in the right atrium |
ANSWER E>B
B. catheter tip will be against vessel wall and erode : causing mediastinal or pleural haemorrhage and drug deposition E. catheter tip erode into pericardium: causing pericardial haemorrhage and drug deposition |
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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 |
ANSWER A
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MC159 ANZCA Version [Apr 07]
The American Heart Association guidelines for pre-operative cardiac risk assessment define poor functional capacity as being only able to exercise at a level of less than 4 METS. An exercise capacity of 4 METS would correspond to: A. Light housework such as dishwashing B. heavy work around the house such as moving heavy objects C. jogging for 2 kms D. walking briskly on level ground (6kph) E. walking slowly on level ground (3kph) |
ANSWER D
From AHA exercise standards Table 1. Clinically Significant Key Metabolic Equivalents for Maximum Exercise 1 MET = resting 2 METs = level walking at 2 mph 4 METs = level walking at 4 mph (6.4 kmph) <5 METs = poor prognosis; usual limit immediately after MI; peak cost of basic activities of daily living 10 METs = prognosis with medical therapy as good as coronary artery bypass surgery 13 METs = excellent prognosis regardless of other exercise responses 18 METs = elite endurance athletes 20 METs = world class athletes |
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AC93 ANZCA version [2001-Apr] Q8, [2002-Aug] Q10, [2003-Aug] Q55, [2004-Apr] Q60, [Apr07] Q55, [Jul07] (Similar question reported in [Apr99] [Jul00])
The most important factor in reducing peri-operative morbidity in diabetic patients undergoing peripheral vascular surgery is A. tight control of blood sugar level in the peri-operative period B. frequent blood sugar level estimations C. use of regional rather than general anaesthesia D. stabilisation of co-existing disease E. the use of an insulin infusion rather than a subcutaneous sliding scale regimen |
ANSWER D
NICE SUGAR tight control in ICU does worse |
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IC89 ANZCA version [Apr08]
Which one of the following is most likely to be associated with a high mixed venous oxygen saturation (SvO2)? A. acute myocardial infarction B. acute pulmonary embolism C. cardiac tamponade D. sepsis E. severe liver disease |
ANSWER D
* MIXED VENOUS pO2 (pVO2):"A normal or high pVO2 can also coexist with tissue dysoxia especially in high flow states such as sepsis". * MIXED VENOUS ARTERIAL SATURATION: "SvO2 values exceeding 0.8 are genserally seen in nhigh flow states such as sepsis, hyperthyroidism and severe liver disease". |
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IC91 ANZCA version [Jul07] Q143
When optimising patients for surgery using goal-directed therapy, which of the following parameters is LEAST useful? A. blood pressure B. cardiac index C. oxygen saturation of blood aspirated from a central venous catheter D. oxygen saturation of blood aspirated from the distal port of a pulmonary artery catheter E. stroke volume variability |
ANSWER A
CEACCP Volume 2 Number 6 2002 Pre-operative care of the high-risk surgical patient "In order to target therapy, markers of tissue oxygen delivery are required. Vital signs such as heart rate and blood pressure are known to be unreliable, whereas assessment of cardiac index (CI), and subsequent calculation of global O2 delivery index (DO2I) and O2 consumption index (VO2I), provides meaningful physiological end points for resuscitation" Which goals should we target? Apparently adequate tissue oxygen delivery is the key physiological variable. We're going with answer A ANZCA version: blood pressure. Goal directed therapy • insert IABP and CVP • fill to CVP 8 - 12mmHg • if MAP remains < 65mmHg commence Noradrenaline • if high dose NA required, insert non-invasive CO monitor (PiCCO) and commence inotrope (Dobutamine) • guide management using mixed or central venous oxygen (aim > 70%) • consider: - levosimendan - milrinone - vasopressin (0.01 – 0.05U/min) - Activated Protein C |
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ANZCA Version [Jul07]
A 50-year-old female patient presents with a 12 hour history of feeling unwell and is found to fulfill the criteria for Systemic Inflammatory Response Syndrome. Her blood pressure is 80/45 mmHg, her pulse rate is 90 beats.min1 and her central venous pressure is 12 mmHg. The hypotension is most appropriately managed with A. adrenaline B. dobutamine C. dopamine D. ephedrine E. noradrenaline |
ANSWER E
* "Norepinephrine raises SVRI, MAP, regional blood flow, oxygen extraction and urine output and is the usual agent of first choice." * "Epinephrine may have undesirable effects on the splanchnic circulation" * "If norepinephrine maintains an adequate MAP but CI remains low, then a separate infusion of dobutamine maylead to improvement." |
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ANZCA Version [Apr08]
Each of the following statements regarding cardiac tamponade as a complication of central venous lines is true, EXCEPT: A. catheters with multiple lumens carry greater risk B. for a left sided catheter, placement of the tip at the mid-point of the brachiocephalic vein is safe C. it usually occurs within the first week following insertion D. placement of the catheter tip above the junction of the right atrium and superior vena cava will avoid this complication E. visceral chest pain with drug infusion is an early symptom |
ANSWER E
A: TRUE..."Stiffer catheters are more likely to perforate. Stiffness is a function of the composition of the catheter (Silastic probably being safest) and the number of the lumen (a function of the greater diameter and presence of ‘septa’ within the catheter)." B: TRUE..."Zone C (mid‐point, left innominate vein). This is a suitable site for the tip when the catheter is introduced from the left internal jugular or subclavian vein, and reduces the risk of SVC perforation." (In reference to a diagram of the heart and great vessels showing various "zones" for the CVC tip) C: TRUE..."Most cases occur in the first week after insertion" D: FALSE (and answer to choose)..."the pericardium may ascend alongside the medial wall of the SVC by up to 5 cm (mean 3 cm). Thus, placement just proximal to the atrium does not obviate the risk of tamponade". E: TRUE..."This results in two warning signs: visceral‐type chest pain on infusion of drugs or parenteral nutrition solutions and a curved appearance of the distal catheter seen on chest x‐ray" |
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IC93 The maximum osmolality to go up to when managing raised ICP when using osmotic diuretics:
A. 300 B. 320 C. 340 D. 360 E. 280 |
ANSWER B
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IC93 ANZCA version [Apr08] Q126
A patient is ventilated and invasively monitored in intensive care following a traumatic brain injury. Systemic arterial blood pressure is 140/80 mmHg with a mean pressure of 100 mmHg. Central venous pressure is 8 mmHg and intracranial pressure is 15 mmHg. The cerebral perfusion pressure (CPP) for this patient is: A. 72 mmHg B. 85 mmHg C. 92 mmHg D. 125 mmHg E. 132 mmHg |
ANSWER B
CPP = MAP - (ICP or CVP (whichever is greater)) |
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IC95 [Apr08]
Patient on ward, collapsed. Nurse calls code blue when finds pt unresponsive. No signs of life. After ensuring airway is clear, 1st action A. DCR x3 200J B. DCR x1 200J C. precordial thump D. CPR E. Adrenaline 1mg |
ANSWER D
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IC96 ANZCA Version [Apr08]
Improved neurological outcome has been demonstrated with the use of hypothermia soon after:: A. asystolic cardiac arrest B. Cerebrovascular accident C. Perinatal complications causing ischaemic encephalopathy D. rupture of an inracranial aneurysm E. traumatic brain injury |
ANSWER C
A: False * For VF arrest B: False * There is currently no evidence from randomised trials to support routine use of physical or pharmacological strategies to reduce temperature in patients with acute stroke. Large randomised clinical trials are needed to study the effect of such strategies...[1] C: True * There is evidence that induced hypothermia (cooling) of newborn babies who may have suffered from a lack of oxygen at birth reduces death or disability, without increasing disability in survivors....Cooling for newborns with hypoxic ischaemic encephalopathy D: False * No evidence E:False * The jury is still out on TBI... * Reductions in risk of mortality were greatest and favorable neurologic outcomes much more common when hypothermia was maintained for more than 48 h. However, this evidence comes with the suggestion that the potential benefits of hypothermia may likely be offset by a significant increase in risk of pneumonia. |
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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 |
ANSWER A
VX = S-[2-(diisopropylamino)ethyl]-O-ethyl methylphosphonothioate] known nerve-agent exposure or who exhibits definite signs or symptoms of nerve-agent exposure should immediately have the nerve agent antidote drugs atropine, pralidoxime (2-PAM), and diazepam Immediate first aid is to remove pt from the area of danger to a well-ventilated area before removal of clothing and decontamination of the skin |
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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. ? |
ANSWER A
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Black Bank March 2009
18yo patient in a psych unit, being treated for frequent vomiting. Collapses and found unconscious. ABG's: pH 7.22 CO2 40 PO2 100 HCO3 16 Na 138 K 4.0 Cl 105 Diagnosis is: A. anorexia nervosa B. diabetic ketoacidosis C RTA D. Normal saline administration E) Gastric outlet obstruction |
ANSWER B
the gas definitely showed a metabolic acidosis with AG 21; pO2 was safe. High anion gap metabolic acidosis with normal chloride - only one that fits is DKA. |
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lack Bank March 2009
60yo with history of hypertension. Presents with chest pain, hoarse voice, left arm weakness. Has lateral T-wave changes on ECG, also present on an old ECG. Heart rate 110, BP 130/80 (definitely this value), SpO2 96% or something. First drug to give: A. aspirin B. metoprolol C. GTN D. nitroprusside E. Heparin |
ANSWER B
The question is whether this represents dissection or AMI. Didn't think hoarse voice and left arm weakness are typically associated with AMI; thus I think the question is getting at dissection. The history of HTN is also associated. The first drug to give would be a beta-blocker of some description; thus B |
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Black Bank March 2009
Trauma patient with GCS 6 with hard collar. HR and BP unstable. What is the best way of clearing neck? A. CT B. Cervical spine trauma series C. MRI D. Leave had collar indefinitely?? E. Clinically |
ANSWER C
NEXUS CRITERIA • National Emergency X-Radiography Utilization Study • NPV 99.9% and PPV 2.7% • Presence of any one of these findings requires radiological evaluation 1. Midline tenderness C-spine 2. Focal neurological deficit 3. Decreased level of alertness 4. Evidence of intoxication 5. Distracting injury CANADIAN C-SPINE • NPV 100%, PPV 40% • Includes 20 clinical findings and 5 demographic variables • High-Risk YES? → Radiography o Age>65 o Dangerous mechanism • Fall from elevation 3m • Axial load to head • MVA>100km/hr rollover ejection • Motorized recreational vehicles • Bicycle struck or collision o Paresthesia in extremities • Low Risk NO? → Radiography o Simple rearend MVA o Sitting position in ED o Ambulatory at any time o Delayed onset of neck pain o Absence of midline C-spine tenderness • Able to actively rotate neck 45° left or right NO? → Radiography RADIOLOGICAL EVAULATION • Plain radiographs 1. Cross table lateral view 2. Anteriorposterior view 3. Open mouth view of odontoid 4. Swimmer view • CT or MRI for obtunded patients • CT unable to define unstable ligmentus injury in less than 5% of cases • MRI is no better than CT |
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Black Bank March 2009
Patient (?48h post) SAH following bloods: Na 155 Plasma osmolality 350 urine osmolality 250 Management includes: A)DDAVP (?nasally) B)Water restriction |
ANSWER A
basically hypernatremia with high plasma osmolality N=280 and low urine osmolality (ranges from 50-1400, but average is 500-800), suggests DI ie inadequate ADH secretion - therefore treatment DDVAP |
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Black Bank August 2009
30. (NEW) Drug LEAST likely to cause hypoxia in ARDS a. Noradrenaline b. Milrinone c. Isoprenaline d. Isoflurane e. SNP |
Answer: A
Wiki: “All the others would bugger up your HPV.” |
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Black Bank August 2009
31. PI82 (NEW) Pulmonary hypertension, which will affect PVR the most a. Isoflurane b. Sevoflurane c. Desflurane d. Propofol e. Remifentanil |
ANSWER B
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Black Bank March 2010
39.HOCM, VF arrest on induction, what's the first priority in management? A. defibrillate B. amiodarone C. Intubate and ventilate D. Pre-cordial thump E. adrenaline |
ANSWER A
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lack Bank March 2010
58.Myaesthenia gravis - features predicting need for post op ventilation EXCEPT A. Prolonged disease B. High dose Rx C. Previous respiratory crisis D. Increased sensitivity to NMB's E. bulbar dysfunction |
ANSWER D
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TMP-Jul10-006 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 |
ANSWER E
Traditionally "volume status" is assessed by a clinician considering a range of relevant clinical information and making a "clinical assessment". The relevant factors are generally: 1. heart rate (generally a high pulse rate of 100-160/min, esp if weak & "thready"(?) supports hypovolaemia); not specific so, for exanmple, tachycardia due to pain and anxiety in trauma patients. 2. arterial BP (including checking for postural drop) - low supports hypovolaemia, but of course can be other causes; also maintained by compensatory processes - tachycardia, vasoconstriction in certain vascular beds such as skin, renal, GIT) - so BP normal until volume loss exceeds as certain critical amount. 3. JVP - (Not useful for picking hypovolaemia) 4. urine output (The only "external non-invasive quantifier of tissue perfusion"; requires cathetisation for precise & serial measurements 5. peripheral perfusion assessed by warmth & colour of extremities - Cold & pale suggests "shutdown" - i.e. extreme vasoconstriction suggesting compensation for hypovolaemia). [NB: "Shutdown" = "peripheral circulatory failure"] Such clinical assessment is easy to do in the extreme cases. With invasive monitoring, the above is supplanted by a quantitative assessment of the preload of the ventricles, and this is traditionally assessed as "filling pressure" (and with of course the unstated assumption that ventricular compliance is unchanging). Cerebral perfusion is mostly not useful. Brain blood flow tends to be preferentially maintained (due metaboliccontrol and pressure autoregulation) so a volume depleted patient (assuming no head injury which confuses things) can still be talking with a BP of 50 systolic. Of course, less rousable as BP sinks from there. The right heart filling pressure (generally as CVP, or RAP measured using a central venous line) is useful in most patients, but is considered potentially misleading as an indicator of left heart filling pressures in certain situations. Then the emphasis is on an assessment of "left heart filling pressure" (thus PCWP, PAOP, LAP) but these require a balloon flotation catheter. Ultrasound (in suitable hands) allows a non-invasive assessment of LV volume. As LV volume is a better index of LV preload than LV filling pressure, and can be obtained non-invasively this can be very useful. |
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TMP-Jul10-037 Acute renal failure. Which is not an indication for dialysis ?
A. Hyperkalaemia B. Metabolic alkalosis C. Hypernatraemia D. Uraemic pericarditis E. APO |
ANSWER B
A = acidosis E = electrolytes inc hyperkalaemia, hyper/hyponatraemia when assoc with ARF (see google books ref below) I = Ingestion toxins/drugs O = oedema U = uraemia |
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TMP-Jul10-057
A 50 year old diabetic man is 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 |
ANSWER C
He's hypotensive, tachycardiac, has low CVP and PCWP consistent with hypovolaemia. Acidosis and BE might be related to DM or lactate. Some intitial thoughts: * You wouldn't give blood unless indicated by low [Hb] or active bleeding * A bicarbonate infusion is contraindicated in DKA; or at least it doesn't help * Fluid resuscitation - Hypotension and tachycardia consistent with need to give fluids. If DKA, then expect significant fluid deleted. * Adrenaline infusion - not initially. * Insulin - Definitely if hyperglycaemia & DKA (Infection is major cause of "metabolic decompensation" - i.e. DKA - in diabetics. No plasma glucose in results above. The pH and BE result don't indicate a severe DKA so check blood for glucose. Also urine for glucose and ketones. |
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MZ80 [Mar10][Jul10]
Arterial blood gases in a patient: pH 7.12, PO2 100, PCO2 65, HCO3 20.3, BE -10. These results are consistent with? A. Chronic renal failure B. Malignant hyperthermia C. Diabetic ketoacidosis D. End-stage respiratory failure E. Ethylene glycol toxicity |
ANSWER B
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TMP-Jul10-063 [Aug10]
Septic elderly man. (Given lots of results but essentially mixed venous oxygen sat 65%, lactate 4, MAP low) Management? A. Transfuse B. Fluid bolus C. Noradrenaline D. ? E. ? |
ANSWER B
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Management of rhabdomyolysis – best option?
A. Haemodialysis B. Bicarbonate C. Frusemide D. IV fluids E. |
ANSWER D
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42 NEW. 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 |
ANSWER C
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IC05 [1987] [Mar91]
The treatment of carbon monoxide poisoning in the unconscious patient includes: A. Dexamethasone B. Mannitol C. Hyperbaric oxygen D. Methylene blue E. Bicarbonate |
ANSWER C
Hyperbaric Oxygenation Displaces CO from Hb, after which it can be expelled through the lungs. The half-life of carboxyhemoglobin is reduced from ~ 240 mins on Room Air to ~ 75 to 80 ms at an FIO2 of 100% and to 20 mins with Hyperbaric oxygen (HBO) at 2.0 atmospheres * Controversial as to whether it reduces neurologic sequelae, and obvious problems with Mx of critically ill, often with other injuries , so if mild / no neurologic sequelae – probably not indicated * If > 40% burns don’t delay Mx of other more life-threatening problems – i.e airway compromise or haemodynamic instability CO Poisoning Smokers may have up to 10% 'normally'; Coma or levels > 40% always indicate severe poisoning * Impaired oxygen delivery to tissues esp brain and heart * Neuro signs vary from mild confusion to fitting or coma * ECG : may see ST segment changes * PaO2 is normal (in absence of hypoventilation/aspiration) * Cherry-pink skin and mucosa is RARELY seen, cyanosis is more common Management 1. 100% O2 – elimination depends more on alveolar partial pressure of O2 and less on alveolar ventilation – therefore O2 as soon as possible 2. Hyperbaric Oxygen : probably beneficial for those with coma, neuro deficits, or carboxyHb > 30% |
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IC06 [1988] [Mar91] [Aug91]
Carbon monoxide halflife in a person who has stopped smoking: A. 1 hour B. 4 hours C. 12 hours D. 24 hours E. 72 hours |
ANSWER B
* The half-life of carboxyhemoglobin is reduced from ~ 240 mins on Room Air to ~ 75 to 80 mins at an FIO2 of 100% and to 20 mins with Hyperbaric oxygen (HBO) at 2.0 atmospheres |
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IC10 ANZCA version [1988] [Aug91] [Mar92] [Aug93] [Mar94] [2001-Apr] Q20, [2001-Aug] Q24, [2002-Mar] Q16
In a patient who has a plasma tricyclic antidepressant level greater than 1000 ng.mL-1 the most likely E.C.G. finding is A. a prolonged PR interval B. deepened Q waves C. a prolonged QRS duration D. a prolonged ST segment E. the appearance of U waves |
ANSWER C
With increasing TCA dose, the ECG changes are: 1. prolonged QRS and QT 2. prolonged PR 3. VT/VF "The tricyclic antidepressants (TCAs) are probably the leading cause of life-threatening overdoses worldwide Signs and symptoms suggestive of TCA overdose include: * tachycardia, * characteristic QRS widening on EKG, * orthostatic hypotension, * dry mouth, * dilated pupils, * hyperthermia, * hypertonicity, * seizures, * ataxia, and * delirium. The preponderance of anticholinergic findings best may be remembered as: "Hot as a Hare, Blind as a Bat, Dry as a Bone, Red as a Beet, Mad as a Hatter." |
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IC09 [Aug91]
Features of tricyclic anti-depressant (?amitriptyline) overdosage: A. Cardiac arrhythmias B. Convulsions C. Hypertension D. Metabolic acidosis E. Coma |
ANSWER D
The toxic manifestation of the tricyclic antidepressants result primarily from their anticholinergic actions and their ability to block the reuptake of neurotransmitters such as norepinephrine. * CNS: Early manifestations include fever, agitation and pupillary dilatation. Advanced cases are characterised by delerium, coma, and generalised seizures. The neurotoxic manifestations are attributed to anti-cholinergic effects * Cardiovascular: Early signs include tachycardia and hypertension, which are attributed to blockade of norepinephrine reuptake. Depletion of norepinephrine in nerve terminals leads to postural and supine hypotension. Cardiac conduction abnormalitis (prolonged QRS interval), arrhythmias and a decreased cardiac output are seen in advanced cases. No mention of metabolic acidosis. |
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IC12 A young man following a motor vehicle accident is lying in respiratory distress on the roadside. He has a penetrating chest wound. Which ONE of the following measures would most benefit the man?
A. Mouth to mouth respiration B. Tracheostomy C. Seal the wound during expiration D. Lie the man in a lateral posture with the wounded thorax lowermost |
ANSWER C
"Treatment of sucking chest wounds in the field begins with coverage using a sterile occlusive dressing. The dressing is taped on three sides so that it can act as a one-way valve, allowing air to exit the chest during exhalation, but preventing air entrainment during inhalation. Alternatively, commercially manufactured “Heimlich valves” can be placed. If the patient’s state deteriorates after placing the dressing, it must be removed immediately. In the case of a large open wound that cannot be occluded, the patient must be intubated and ventilated to survive the injury"...Trama, Vol 1, p 143 |
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IC13b ANZCA version [2004-Apr] Q104, [2004-Aug] Q55
A dock-worker is extricated from beneath a fallen lift platform and has signs of respiratory distress. He has a jagged wound of the chest wall with blood-stained froth alternately oozing from, and sucking back into the wound. The best initial treatment at the scene should be to A. apply 100% oxygen B. apply a CPAP (continuous positive airway pressure) mask C. apply a sterile dressing and seal the wound completely with adhesive tape D. apply a sterile dressing to the wound and seal on three sides only E. insert a 14G cannula in the 2nd intercostal space at the mid-clavicular line |
ANSWER D
Management of an open pneumothorax ("sucking chest wound") 100% oxygen should be delivered via a facemask. Consideration should be given to intubation where oxygenation or ventilation is inadequate. Intubation should not delay placement of a chest tube and closure of the wound. The definitive management of the open pneumothorax is to place an occlusive dressing over the 'wound and immediately place an intercostal chest drain. Rarely, if a chest drain is not available and the patient is far from a definitive care facility, a bandage may be applied over the wound and taped on 3 sides. This, in theory, acts as a flap-valve to allow air to escape from the pneumothorax during expiration, but not to enter during inspiration. This dressing may be difficult to apply to a large wound and it's effect is very variable. As soon as possible a chest drain should be placed and the wound closed. from Trauma.org. (Also has a video of an open pneumothorax) In summary: 1. Occlude wound 2. Place intercostal catheter (with seal i.e. underwater seal if in a hospital) |
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IC15b [Mar91]
Regarding tracheobronchial disruption following chest trauma - Which of the following is true? A. Haemoptysis is the most common symptom B. Should all have double lumen tubes C. Dyspnoea is the most common symptom D. Stridor is the most common symptom E. Mediastinal emphysema on CXR confirms diagnosis if suspected |
ANSWER C
* A: "Haemoptysis occurs in 25% of cases and is usually due to mucosal tear" * B: "Several choices of endotracheal tubes can be used for isolation of TBI" (tracheobronchial injury). Double lumen tubes have the remote possibility of extending the lesion because of their size * C: "Dyspnoea occurs in more than 60% or patients". * D: "Stridor, however, is not a prominent feature of TBI" * E: "Radiological findings in TBI are mostly non specific", "Direct inspection of the tracheobronchial tree is the most definitive method to diagnose TBI" Trauma divided into penetrating vs non-penetrating (ie blunt) Usual mechanism of TBI is a shearing force, with blunt trauma to the chest. This would typically occur with a deceleration type injury. Clinical signs of TBI: * Dyspnoea * Cough * Haemoptysis * Cyanosis * Subcutaneous emphysema * Tracheal shift * Persistent pneumothorax following successful placement of ICC * Signs of airway obstruction |
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IC17 ANZCA version [2005-Sep] Q33 (Similar question reported in [1988][Mar91][Mar94][Aug94])
A widened mediastinum after a chest injury is suggestive of a ruptured aorta especially if associated with A. displacement of the mid-oesophagus to the right B. right haemothorax C. elevated left main bronchus D. fractured left third rib E. left pneumothorax |
ANSWER A
A widened mediastinum ALWAYS arouses suspicion of a ruptured aorta. In one series, mediastinal width greater than 8cm at the level of the aortic arch was present in all 10 patients with ruptured thoracic aorta. Diagnosis is enhanced by ONE or more of the following radiological features: * Left haemothorax * Depressed left main bronchus * Blurred outline of the arch or descending aorta * Fractured first rib or left apical haematoma * Displacement of the mid-oesophagus to the right (easily detectable with a nasogastric tube in situ) |
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IC18 Which of the following does NOT occur in response to trauma?
A. Rise in urinary nitrogen B. Rise in urinary sodium C. Water retention D. Sodium retention E. Rise in serum sodium |
ANSWER B
* A. Rise in urinary nitrogen Effect - Catabolic * B. Rise in urinary sodium Effect – Increased vasopressin and water retention * C. Water retention Effect – Increased vasopressin * D. Sodium retention Effect – Increased renin, Angiotensin II, and Aldosterone * E. Rise in serum sodium Occurs with DI from head trauma |
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IC19 Which is the first sign of deterioration in a patient with head injury? Change in:
A. Level of consciousness B. Pupil size C. Pulse rate D. Respiratory rate |
ANSWER A
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IC20 A patient is suffering from a head injury. The first sign of an increase in intracranial pressure is:
A. Bradycardia B. Increase in BP C. Decrease in level of consciousness D. Tachycardia E. Vomiting F. Pupil size increase |
ANSWER C
Bradycardia and hypertension (ie Cushings response) are late stages of a raised ICP. Pupil size increase is usually due to uncal herniation so is a sign of serious injury with ICP high enough to cause herniation. Decreased level of consciousness is a serious sign but is not typically considered the "first" or even an early sign. Vomiting is a common symptom in patients with raised pressure but is pretty non-specific in trauma patients. If an HI patient in ICU vomited then they should be neurologically assessed via GCS and decisions based on that. No point is rushing off for an emergency CT or to OT on the basis of some vomiting alone. |
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IC24c ANZCA version [2004-Aug] Q112, [2005-Apr] Q53
Each of the following findings is consistent with brain death EXCEPT A. absence of diabetes insipidus i.e. continued vasopressin secretion B. Babinski's reflex C. focal EEG (electroencephalogram) activity D. limb movement in response to touch E. nystagmus on injection of cold water into the ear canal |
ANSWER E
A - False * Absence of diabetes insipidus is consistent with a diagnosis of brain death. B - False * Presence of Babinski reflex is compatible with a diagnosis of brain death. C - False * EEG not part of the criteria in Australia. Has been used in the US. D - False * See IC24b - 2 and 4. E - True * An intact vestibulo-ocular reflex excludes brain death. Importantly: The following observations are compatible with the diagnosis of brain death: * spontaneous “spinal” movements of the limbs (not to be confused with a pathological flexion or extension response) * respiratory-like movements (shoulder elevation and adduction, back arching or intercostal expansion) without significant tidal volume * sweating, blushing, tachycardia. * normal blood pressure without pharmacological support * absence of diabetes insipidus (normal osmolar control mechanism) * deep tendon reflexes. * Babinski’s reflex |
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IC28 ANZCA version [Aug94] [Mar95] [Aug95] [Apr97] [Jul97] [Aug99] [2001-Apr] Q93, [2001-Aug] Q93, [2002-Mar] Q100
Prolonged inhalation of 100% oxygen (at one atmosphere pressure) leads to 1. convulsions 2. retrosternal pain 3. visual disturbances 4. atelectasis |
ANSWER 2 and 4
From Yentis "Tracheobronchial irritation and substernal discomfort is noticed by healthy volunteers after 12-24 h breathing 100% O2. Reduced vital capacity, compliance and diffusing capacity and increased arteriovenous shunt and dead space may occur after 24-36 h. |
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IC36 [# ] [Apr96]
Man in MVA is hypotensive with distended neck veins. Possible causes: A. Tension pneumothorax B. Cardiac tamponade C. Myocardial contusion D. Air embolus |
ANSWER ALL
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IC47 ANZCA version [Mar95] [Aug95] [Apr97] [Apr98] [2001-Apr] Q42, [2001-Aug] Q25, [2004-Apr] Q19
You are called to see a 30 year old man with rapidly deteriorating asthma. Following appropriate medical management an endotracheal tube is inserted and he is ventilated with a mechanical ventilator with a tidal volume of 600 ml and a rate of 12 breaths per minute. Five minutes later the blood pressure is unrecordable and external cardiac massage is commenced. Arterial blood is taken and shows pH 7.08, pCO2 96 mmHg, pO2 36 mmHg, oxygen saturation 46% and bicarbonate 27 mmol.L-1. He is administered adrenaline, salbutamol, pancuronium, bicarbonate and calcium gluconate. The ECG shows sinus rhythm at a rate of 60 beats per minute. The patient remains pulseless and cyanosed with fixed dilated pupils and distended neck veins. The most appropriate continuing management is A. cease resuscitation B. administer further adrenaline C. insert bilateral intercostal drains D. cease ventilation for 30 seconds and resume at a slower rate E. increase peak inspiratory pressure |
ANSWER D
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IC39 [1989]
In aspirin overdose, which is common: A. Respiratory acidosis B. Increased bleeding due to fibrinolysis C. Hypothermia D. Increased CO2 production E. Renal failure |
ANSWER D
A - FALSE * "Common: Respiratory alkalosis (subsequently complicated by a metabolic acidosis)." Peck, Hill & Williams, 2nd. ed., p.140. o Respiratory Alkalosis [2ndry to Resp Centre stimulation] o Metabolic Acidosis - increase in pyruvate and lactate that causes a elevated anion gap metabolic acidosis B - FALSE * "Rare: Coagulopathy" Peck, Hill & Williams, 2nd. ed., p.140. * laboratory abnormalities may include a prolonged prothrombin time, thrombocytosis...Current Critical Care (but not common) * ↓ Plt Function C - FALSE * "Common: Pyrexia" Peck, Hill & Williams, 2nd. ed., p.140. D - TRUE * Uncouples oxidative phosphorylation which leads to an increased metabolic rate with a resulting increase in glucose utilization, oxygen consumption, and heat production. Clinical effects of this uncoupling include hypoglycemia and fever...Current Critical Care, 2008 * Also...Inhibition of enzymatic components of the Krebs cycle occurs, leading to an increase in pyruvate and lactate that causes a elevated anion gap metabolic acidosis. As a result of their stimulatory effects on lipid metabolism, salicylates increase ketone formation...Current Critical Care, 2008 o Does uncouple ox-phos but also inhibits krebs cycle. So CO2 production should be reduced. (Yes, but overall increased...Kingfed) * "Aspirin also has effects on the metabolic state, which are usually of little significance but in overdose become significant. It uncouples oxidative phosphorylation, thereby increasing oxygen consumption and carbon dioxide production." Peck, Hill & Williams, 2nd. ed., p.140. E - FALSE |
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IC84 [Jul06] [Jul07]
32 year old with early acute liver failure (not paracetamol related). Management includes A. prophylactic antibiotics B. N-acetyl cysteine as general liver protection C. avoid early intubation so can assess for encephalopathy D. INR> 3 means should be considered for transplant?? E. avoid saline as resuscitation fluid |
ANSWER A
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IC86 [Apr07] [Jul07]
A young boy sustains a head injury and CT scan shows diffuse axonal injury. He is intubated and ventilated in the ICU and is going to theatre due to rising ICP’s (20 to 30) despite mannitol and cooling. The best anaesthetic to give is: A. propofol and fentanyl B. sevoflurane and remifentanil C. isoflurane and remifentanil D. option including nitrous oxide E. ? |
ANSWER
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IC85 [Apr07] Q115
A young woman has an MVA when driving home from a nightclub. She was known to have moderate MDMA (ecstasy) consumption. Which of the following complications is least likely to be due to MDMA? A. Hyponatraemia B. Hypotension C. Pneumothorax D. Sweating E. Tachycardia |
ANSWER B
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IC83 [Jul06]
Sudden cardiovascular collapse 48 hours post gastrectomy, Temp 39C, HR 130/min, BP 80 systolic, CVP 2cm above sternal angle. Cause? A. Anastomotic breakdown B. Acute gastric dilatation C. septicaemia D. haemorrhage E. PE |
ANSWER C
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IC81 ANZCA Version [Jul06] Q123
A 16-year-old arrives in your Emergency Department having fallen from, and been trampled by, a horse. The ambulance officers report that this initial GCS (Glasgow Coma Scale) was 15 and is now 11. His pulse is 120 and blood pressure 80/60 mmHg. SpO2 is 97% when breathing on a Hudson mask. On auscultation his chest is clear. He has facial bruising and a tender abdomen. Your first priority now is to A. administer an IV (intravenous) fluid bolus B. arrange an urgent CT scan of the head C. administer mannitol D. perform a FAST (focussed assessment with sonography for trauma) examination E. secure the airway by intubation |
ANSWER A
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IC74 ANZCA version [2005-Apr] Q132, [2005-Sep] Q21
The equivalent shock energy with a biphasic defibrillator, to that of a 360 joule monophasic defibrillator shock is A. 90 joules B. 180 joules C. 360 joules D. 450 joules E. 720 joules |
ANSWER B
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IC77 ANZCA version [2005-Sep] Q115, [Apr07] [Jul07]
The signs of exposure to a nerve agent such as Sarin or VX include A. bronchodilation B. dry skin C. muscle fasciculation D. pupillary dilatation E. tetany |
ANSWER C
# People exposed to a low or moderate dose of VX by inhalation, ingestion (swallowing), or skin absorption may experience some or all of the following symptoms within seconds to hours of exposure: * Runny nose * Watery eyes * Small, pinpoint pupils * Eye pain * Blurred vision * Drooling and excessive sweating * Cough * Chest tightness * Rapid breathing * Diarrhea * Increased urination * Confusion * Drowsiness * Weakness * Headache * Nausea, vomiting, and/or abdominal pain * Slow or fast heart rate * Abnormally low or high blood pressure # Even a tiny drop of nerve agent on the skin can cause sweating and muscle twitching where the agent touched the skin. # Exposure to a large dose of VX by any route may result in these additional health effects: * Loss of consciousness * Convulsions * Paralysis * Respiratory failure possibly leading to death |
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IC76 ANZCA version [2004-Aug] Q26
When pulmonary oedema is due to raised capillary hydrostatic pressure, the most reliable radiological evidence of this aetiology is derived from A. heart size B. mediastinal width C. upper lobe vascular markings D. the presence of basal effusions E. oedema migration with postural change |
ANSWER C
Pulmonary edema may be classified as: * increased hydrostatic pressure edema, * permeability edema with diffuse alveolar damage (DAD), * permeability edema without DAD, or * mixed edema. Pulmonary edema has variable manifestations: * Postobstructive pulmonary edema typically manifests radiologically as septal lines, peribronchial cuffing, and, in more severe cases, central alveolar edema. * Pulmonary edema with chronic pulmonary embolism manifests as sharply demarcated areas of increased ground-glass attenuation. * Pulmonary edema with veno-occlusive disease manifests as large pulmonary arteries, diffuse interstitial edema with numerous Kerley lines, peribronchial cuffing, and a dilated right ventricle. * Stage 1 near drowning pulmonary edema manifests as Kerley lines, peribronchial cuffing, and patchy, perihilar alveolar areas of airspace consolidation; stage 2 and 3 lesions are radiologically nonspecific. * Pulmonary edema following administration of cytokines demonstrates bilateral, symmetric interstitial edema with thickened septal lines. * High-altitude pulmonary edema usually manifests as central interstitial edema associated with peribronchial cuffing, ill-defined vessels, and patchy airspace consolidation. * Neurogenic pulmonary edema manifests as bilateral, rather homogeneous airspace consolidations that predominate at the apices in about 50% of cases. * Reperfusion pulmonary edema usually demonstrates heterogeneous airspace consolidations that predominate in the areas distal to the recanalized vessels. * Post-reduction pulmonary edema manifests as mild airspace consolidation involving the ipsilateral lung, whereas pulmonary edema due to air embolism initially demonstrates interstitial edema followed by bilateral, peripheral alveolar areas of increased opacity that predominate at the lung bases. |
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IC75 ANZCA version [2004-Apr] Q93
The main rationale for using CPAP (continuous positive airway pressure) in the management of acute left ventricular failure is to A. increase the inspired concentration of oxygen (FiO2) B. recruit alveoli C. reduce the afterload D. reduce the preload E. reduce the work of breathing |
ANSWER C
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IC70 ANZCA version [2003-Apr] Q138
Management of an overdose of paracetamol could include all of the following EXCEPT A. activated charcoal B. alkalinisation of the urine C. gastric lavage D. hepatic transplantation E. N-acetylcysteine |
ANSWER B
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IC69 ANZCA version [2001-Aug] Q78, [2002-Mar] Q2
The most common complication of blunt cardiac trauma is A. myocardial ischaemia B. valve rupture C. right ventricular rupture D. arrhythmias E. tamponade |
ANSWER D
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IC68b ANZCA version [2003-Apr] Q85, [2003-Aug] Q82
The incidence of vertebral artery injury in patients with cervical fractures or dislocations is A. 1% B. 5% C. 15% D. 40% E. 70% |
ANSWER D
40% The association between cervical spine fractures and vertebral artery injury is well documented, although the true incidence of the condition and its significance remains unclear. Imaging of the vertebral artery is not routine in cervical spine trauma, so those case reports in the literature tend to report only those patients presenting with neurologic deficits, as with this patient. Four studies have prospectively evaluated cervical spine injuries using conventional or magnetic resonance angiography. The incidence of vertebral artery injury with cervical spine fracture ranged between 24% and 46%. However only about one quarter of these patient will have neurological deficits. |
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MZ71 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 |
ANSWER E
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TMP-108 A 60yo man with anterior mediastinal mass, during induction for mediastinoscopy....lose cardiac output, decreased saturations, drop in ETCO2. Management:
A. Adrenaline B. CPR C. CPB D. Place prone E. |
ANSWER D
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