Ite Questions

Front 1

The need for increased doses of nondepolarizing muscle relaxants in patients with extensive burns is best explained by
(A) increased protein binding
(B) hypermetabolism
(C) increased glomerular filtration rate
(D) proliferation of receptors on burned muscle
(E) decreased volume of distribution

Back 1

(D) If pt has burns > 25% of their body surface they req increased doses of NDMRs. The effect is 2/2 proliferation of AChR’s (pharmacodynamic change). Giving these pt’s sux >24hrs after burn will elicit hyperkalemia. Some other NDMR stuff to know: autoimmune disorders (ie. Lupus, dermatomyositis, etc) hypersensitize, myasthenia gravis causes resistance to sux and hypersensitivity to NDMRs (fewer AChRs), myasthenic syndrome (aka Lambert Eaton) causes hypersensitivity to sux and NDMRs. Hypothermia prolongs NDMRs.

Front 2

Which of the following parts of the infant's airway determines the appropriate diameter of a nasotracheal tube?
(A) Nares
(B) Glottis
(C) Vocal cords
(D) Cricoid cartilage
(E) Third tracheal ring

Back 2

(D) Cricoid ring is narrowest part of kids AW, in adults it’s glottis. 4 other differences bet babies and adults: 1) big tongue, 2) floppy omega shaped epiglottis, 3) larynx more cephalad (C3-4 instead of C4-5), 4) vocal cords are angulated more downwards (ie not exactly perpendicular to the trachea like in adults).

Front 3

Administration of 200 mEq of sodium bicarbonate during cardiopulmonary resuscitation is associated with
(A) CSF alkalosis
(B) hypercalcemia
(C) hypercarbia
(D) hyperkalemia
(E) shift of the oxyhemoglobin dissociation curve to the right

Back 3

(C) Acidosis during cardiac arrest decreases the chance of cardiac function returning (decreased contractility and some also say pressors don’t work as well). Sodium bicarb can raise the extracellular pH. NaHC03 + H <-→ Na+ + H2C03 <→ Na+ + H20 + C02 (basically sodium bicarb binds loose H’s to make water and CO2). pCO2 goes up as does pH. Remember lots of sodium in sodium bicarb too, that’s why it’s typically mixed with D5 for infusions. Standard bicarb amp is 50 meq in 50 ml, equivalent to 8.4 grams/dl or 4.2 grams Na

Front 4

When compared with diazepam, midazolam
(A) metabolites contribute more significantly to the sedative effect
(B) elimination is less dependent on hepatic metabolism
(C) has more predictable action after intramuscular administration
(D) produces less respiratory depression
(E) produces less hypotension during induction of anesthesia with opioids

Back 4

(C) Midazolam typical dose IM is 5mg (about ½ the effect of IV and takes 15 minutes). Valium in notoriously unreliable IM, is it however, given as a rectal gel. Midaz 3mg ~ Diazepam 10mg ~ ativan 1.5mg

Front 5

Which of the following statements concerning a patient who has been receiving nitroprusside for several days is true?
(A) Biotransformation of cyanide requires a sulfur donor
(B) Formation of methemoglobin increases cyanide toxicity
(C) Increased serum thiocyanate concentrations are innocuous
(D) Mixed venous P 0 2 decreases as cyanide toxicity develops
(E) Serum thiocyanate concentrations reflect the degree of cyanide toxicity

Back 5

(A) SNP is a potent vasodilator of veins and arteries. SNP breaks down in circulation to release nitric oxide (NO). NO activates guanylate cyclase in vascular smooth muscle and increases intracellular production of cGMP. It inactivates myosin light chains involved in muscle contraction. The end result is vascular smooth muscle relaxation. Decreases preload and afterload. SNP breakdown releases cyanide ions, can be detoxified with a sulfur donor like thiosulfate making thiocyanate. SNP can cause methemoglobinemia (that is caused by oxidizing drugs making Fe3+ from normal Hb Fe2+) – remember LAs (cepacaine aka benocaine is for top. in awake fiber). Tx metHb with methylene blue 1-2mg/kg over 5min.

Front 6

"Which of the following increases the cephalad spread of hyperbaric intrathecal local anesthetics?
(A) Cephalad-directed needle bevel
(B) Coughing
(C) Lithotomy position
(D) Obesity
(E) Rapid injection"

Back 6

(D) Cephalad spread on hyperbaric LA in spinal can occur with increased abdominal pressure which decreases CSF volume – mainly obesity and pregnancy. Coughing has not been shown to have an effect. Obvi any position with head down will make hyperbaric go up.

Front 7

"Compared with a patient without liver disease, a patient with cirrhosis will have
(A) greater accumulation of vecuronium with infusion
(B) increased unbound plasma vecuronium concentration
(C) more frequent occurrence of phase II block after succinylcholine administration
(D) prolonged elimination half-life of atracurium
(E) unchanged volume of distribution for pancuronium"

Back 7

(A) People with ESLD has a increased volume of dist so doses of NDMR will be increased. Only pancuronium and vecuronium have a significant hepatic metabolism (rocuronium is excreted in bile). Pseudocholinesterase is often low in these pts so sux may last longer

Front 8

"Intrathecally administered opioids exert their analgesic effects primarily in the
(A) brain stem
(B) fourth ventricle
(C) spinal nerve roots
(D) spinothalamic tracts
(E) substantia gelatinosa"

Back 8

(E) Intrathecal opioids act primarily on the substantia gelatinosa in the SC Rexed lamina 2. It is where C fibers terminate and there are a bunch of my receptors. The opioids also work in the brain and systemically as well. The more lipophilic the drug (ie fentanyl) the fast it is cleared from the CSF (morphine is less so and lasts longer and brain effect because it travels around all the CSF.

Front 9

"During laser excision of vocal cord polyps in a 5-year-old boy, dark smoke suddenly appears in the surgical field. The trachea is intubated and anesthesia is being maintained with halothane, nitrous oxide, and oxygen. The most appropriate initial step is to
(A) change from oxygen and nitrous oxide to air
(B) fill the oropharynx with water
(C) instill water into the endotracheal tube
(D) remove the endotracheal tube
(E) ventilate with carbon dioxide"

Back 9

(D) “In the case of an airway fire immediately, without hesitation, halt the procedure and remove the tracheal tube. Stop the flow of all airway gases. Remove sponges or any other flammable material from the airway, and pour saline into the airway. Once the fire is extinguished, re-establish ventilation either with the circuit or a self-inflating resuscitation bag. If possible, ventilate with room air. Examine the integrity of tracheal tube to make sure no fragments may have been left in the airway. Consider bronchoscopy (preferably rigid) to assess injury and, especially, to locate and remove tracheal tube fragments and other debris. Assess the patient and then devise a management plan.”

Front 10

"During craniotomy in the sitting position, end-tidal carbon dioxide tension suddenly decreases. Ventilatory excursion of the chest is normal. Further evaluation is most likely to show a decrease in
(A) alveolar-to-arterial oxygen tension difference
(B) alveolar-to-arterial carbon dioxide tension difference
(C) dead space ventilation
(D) pulmonary artery pressure
(E) pulmonary artery occlusion pressure"

Back 10

(E) High risk for VAE in pts sitting upright for crani. Air lodges in RV or in PA and obstructs RV outflow – you get big drop in ETCO2 and increased PA pressures. With no cardiac output to LA and LV wedge pressure (LVEDV) will drop. Dx with TEE. Notify surgeon to flood/pack surgical field, jugular compression, lower head, aspirate RA-cath, 100% FiO2, pressors

Front 11

"Which of the following is a cardiorespiratory effect of epidural block to a T4 sensory level?
(A) Decreased expiratory reserve volume
(B) Decreased tidal volume
(C) Increased circulating catecholamine concentrations
(D) Increased heart rate
(E) Unchanged vital capacity"

Back 11

"Which of the following is a cardiorespiratory effect of epidural block to a T4 sensory level?
(A) Decreased expiratory reserve volume
(B) Decreased tidal volume
(C) Increased circulating catecholamine concentrations
(D) Increased heart rate
(E) Unchanged vital capacity"

Front 12

"A 67-year-old man undergoes spinal anesthesia with hyperbaric tetracaine 10 mg for transurethral resection of the pros- tate. At the end of the 50-minute procedure, the level of anesthesia is T6 and blood pressure is 120/70 mmHg. Within two minutes after transfer to a stretcher, the patient has nausea and blood pressure decreases to 76/42 mmHg. Which of the following is the most likely cause of the acute hypotension?
(A) Acute congestive heart failure
(B) Decreased venous return
(C) Dilutional hyponatremia
(D) Progression of sympathetic block
(E) Unrecognized bladder perforation"

Back 12

(B) Tetracaine is usually 0.5% given 6-10mg, with 0.2mg epi it is the longest block you can get (~3hrs). FYI adding 0.1mg of 0.1% (1mg/cc or 1:1000) epi to 10cc gives 1:100,000, adding 0.1mg to 20cc gives 1:200,000, 0.1 to 30cc gives 1:300,000 etc. As far as this answer it seems to be that moving the pt to a stretcher from the lithotomy position after a spinal 1 hour earlier just decreased his venous return severely.

Front 13

"Compared with intermittent positive pressure ventilation (IPPV), intermittent mandatory ventilation (IMV)
(A) better maintains cardiac output
(B) provides less than full mechanical ventilatory support
(C) requires a greater level of sedation
(D) requires a higher PI02
(E) requires a lower inspiratory flow rate"

Back 13

(A) Intermittent mandatory ventilation typically gives less positive pressure than IPPV as long as the pt is meeting the desired MV goal, less PPV is less decreased preload and less low BP.

Front 14

"Which of the following findings would be considered normal in the EEG of an adult?
(A) Decreased frequency during induction with halogenated anesthetics
(B) Decreased frequency in frontal areas with administration of nitrous oxide 50%
(C) Dominance of beta rhythm at 20 to 30 Hz during the awake relaxed state
(D) Electrical silence with administration of isoflurane 2.5 MAC
(E) The presence of burst-suppression during natural sleep"

Back 14

(D) Question 16 is a little archaic but the focus is on the neurologic properties of isoflurane. Iso increased CBF and ICP at 1MAC (as do all the volatiles, 2/2 cerebral vasodilation). Iso also decreases CMO2 requirements and at 2MAC produces a silent EEG (protects brain during ischemia). Burst suppression is an EEG finding significant for deep coma characterized by jagged portions followed by flat portions. It is usually achieved with propofol and indicated the brain is using a lot less O2.