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123 Cards in this Set

  • Front
  • Back
AA22 [Sep11][Mar12][?Mar13]
The commonest initial presenting feature in anaphylaxis is

A. coughing

B. desaturation

C. hypotension

D. rash

E. wheeze
C. hypotension

AT20c [Jul07][Apr08][Aug12][Mar13]

All of the following are major complications of mediastinoscopy EXCEPT:

A. Cardiac laceration

B. Air embolism

C. Pneumothorax

D. Major haemorrhage

E. Recurrent laryngeal nerve damage
A. Cardiac laceration

Continuing Education in Anaesthesia, Critical Care & Pain | Volume 7 Number 1 2007
NA15 ANZCA version [Mar92] [Aug92] [Mar93] [Aug93] [2002-Mar] Q18, [2002-Aug] [Mar10] [Aug10] [Aug12] [Mar13]

The skin of the anterolateral part of the gluteal region, between the iliac crest and the greater trochanter, is supplied by the

A. Ilioinguinal nerve

B. Genitofemoral nerve

C. Superior gluteal nerve

D. Subcostal nerve

E. Lateral cutaneous nerve of the thigh

F. Femoral nerve
D. Subcostal nerve

Subcostal nerve = T12 intercostal = MUFFIN TOPS (see picture below)

Each nerve from T7 to T12 also gives off a lateral cutaneous branch (with anterior and posterior branches), which divides in the mid-axillary line. These branches supply the skin of the flank and back in the relevant distribution. The iliohypogastric and subcostal nerves, however, do not have a divided lateral cutaneous nerve, but continue down to supply the skin over the upper lateral buttock. The ilioinguinal nerve has no lateral cutaneous branch.

Concise Anatomy for Anaesthesia

"supplies sensory innervation to the skin over the hip."
A. ilioinguinal nerve - false
B. genito-femoral nerve - false
C. superior gluteal nerve - false: "The superior gluteal nerve (L4, 5, S1) accompanies the superior gluteal vessels as the only structures that pass through the upper compartment of the greater sciatic foramen (above piriformis). It supplies gluteus medius and minimus and tensor fasciae lata." (Ellis)
D. subcostal nerve - true: "The 12th thoracic (subcostal) nerve runs along the lower border of the 12th rib below the subcostal vessels, passes behind the lateral arcuate ligament to run in front of quadratus lumborum behind the kidney and colon. The nerve then passes between transversus abdominis and internal oblique and then has a course and distribution which are similar to the lower intercostal nerves. However, there is one point of difference: the lateral cutaneous branch of the 12th nerve descends without branching to supply the skin over the lateral aspect of the buttock" (Ellis)
E. lateral cutaneous nerve of thigh - false: "The anterior branch supplies the skin over the antero-lateral aspect of the thigh down to the knee, where it links up with twigs from the intermediate cutaneous nerve of the thigh and the infrapatellar branch of the saphenous nerve to form the patellar plexus. The posterior branch penetrates the fascia lata to innervate the skin of the lateral aspect of the leg from the greater trochanter to the mid-thigh."

NH31 ANZCA version [Apr08][Mar13]

You are performing an awake fibreoptic intubation, through the nose, on an adult patient. In order, the fibrescope will encounter structures with sensory innervation from the following nerves:

A. facial, trigeminal, glossopharyngeal
B. facial, trigeminal, vagus
C. glossopharyngeal, trigeminal, vagus
D. trigeminal, glossopharyngeal, vagus
E. trigeminal, vagus, glossopharyngeal
D. trigeminal, glossopharyngeal, vagus
* Three major neural pathways supply sensation to airway structures (see Figure 1).
* Terminal branches of the ophthalmic and maxillary divisions of the trigeminal nerve supply the nasal cavity and turbinates.
* The oropharynx and posterior third of the tongue are supplied by the glossopharyngeal nerve.
* Branches of the vagus nerve innervate the epiglottis and more distal airway structures.

➚ Internal Branch
● SENSORY above cords
Superior + inferior epiglotis
➚ Laryngeal N.
➘ External Branch
● MOTOR to cricothyroid 'eee'

➘ Recurrent
Laryngeal N.
● ALL intrinsic muscles EXCEPT cricothyroid

SG30 ANZCA version [1985] [1987] [Mar93] [Aug96] [Apr97] [Jul00] [2001-Apr][Mar12][Aug12][Mar13]

A patient has suffered flash burns of the upper half of the left upper limb, all of the left lower limb and the anterior surface of the abdomen. The approximate percentage of the body surface which has been burned is:

A. 18%

B. 23%

C. 32%

D. 41%

E. 48%
C. 32%

Upper half of the left upper limb = 0.5 × 9 = 4.5%
All of the left lower limb = 18%
Anterior surface of the abdomen = 0.5 × 18 = 9%
TOTAL ≈ 32%
ST32 [Apr07][Mar13]

If a new test is developed for a particular disease, the best way to determine its SPECIFICITY is to:

A. find a sample of people, some of whom have the disease and some who do not

B. find a sample of people, all of whom do not have the disease

C. find a sample of people, all of whom do not have the disease, and compare to the estimate of population prevalence

D. find a sample of people, all of whom have the disease

E. find a sample of people, all of whom have the disease, and compare to the estimate of population prevalence
B. find a sample of people, all of whom do not have the disease

Specificity is looking for the rate of false positive for a new test, ie. true negative. Therefore, if we have a population who do not have the disease, as far as we can tell, then if any "positives" come up, then they will be false positives, so we can calculate specificity as TN/FP+TN, since we know TN from the sample.

(Q96 Aug 2008) [?Aug12] [Mar13]

While of the following statements regarding patients with ankylosing spondylitis are FALSE

A amyloid renal infiltration is rarely seen

B cardiac complications occur in <10% of cases

C normovolaemia anaemia occurs in over 85% of cases

D sacroileitis is an early sign of presentation

E uveitis is the most common extra articular manifestation
C normovolaemia anaemia occurs in over 85% of cases
From wiki:
A TRUE Amyloidosis is a very rare complication of ankylosing spondylitis in patients with severe, active, and long-standing disease. These patients generally have active spondylitis, active peripheral joint involvement, and an elevated erythrocyte sedimentation rate (ESR) and C-reactive protein level. This may result in renal dysfunction with proteinuria and renal insufficiency or failure.[5]

B TRUE Cardiovascular involvement of clinical significance occurs in fewer than 10% of patients, typically those with severe long-standing disease. However, subclinical disease can be detected in many patients and may occur as an isolated clinical entity in association with HLA-B27[6]

C FALSE Approximately 15% of patients may present with a normochromic normocytic anemia of chronic disease.[7]


E TRUE Uveitis is the most common extra-articular manifestation, occurring in 20-30% of patients with ankylosing spondylitis. Of all patients with acute anterior uveitis, 30-50% have or will develop ankylosing spondylitis. The incidence is much higher in individuals who are HLA-B27–positive (84-90%).[8] --SG 10:37, 23 Oct 2008 (EDT)

New: Patient with subdural hematoma and PPM for ?AV ablation. PPM technician >1 hour away. Surgeon wishes to proceed immediately. Do you?

A. Postpone and await a cardiologist review
B. Postpone and await arrival of PPM technician
C. Postpone and insert a transvenous temporary PM
D. Proceed after institution of transcutaneous pacing.
E. Proceed with a magnet handy.
B. Postpone and await arrival of PPM technician


D. Proceed after institution of transcutaneous pacing
see ANZCA webinar on pacemakers (part 3); You cannot assume that a magnet will automatically switch it to asynchronous mode - the magnet function depends on what it was programmed to do. You would need to interrogate it to find out. The majority of the time it will switch it to asynchronous mode, HOWEVER some PPM have been programmed to ignore the magnet!

You are asked by an Obstetrician to help relax a uterus in labour and deliver for manual removal of placenta. What is a safe and effective dose of IV GTN to be delivered?

a. 5 mcg
b. 50 mcg
c. 250 mcg (or 200mcg in Aug12, 250mcg in Mar13 exam)
d. 400 mcg
e. 500 mcg
b. ?50mcg (safe) - tend to give in 50mcg boluses.

c. 200mcg? quoted dose sometimes is 100-200mcg
++[Mar12][Aug12][Mar13] NEW:Middle-aged male with severe mitral stenosis {MS) having general anaesthesia for repair of fractured ulna / radius. 10 minutes into the case you notice a tachyarrythmia with his HR 130 and BP 70. He is normally in sinus. What do you do?

A. Adenosine
B. Amiodarone
C. Shock
D. :Volume
E. Metaraminol
c. Shock
Unsure if it is SVT or VT so shock!

a. Adensine - but if VT useless
b. Amiodarone - takes too lung
d. Volume - ?
e. metaraminol - ?if you think tachyarrhytmia is due to hypotension?

Depends on how this question is interpreted overall.
++TMP-Jul10-036 [Aug10][Mar11][Sep11][Aug12][Mar13]

Which is NOT a disadvantage of drawover vaporiser versus plenum vaporiser:

A. Temperature compensation (Basic temperature compensation)
B. Cannot use sevoflurane
C. Small volume reservoir
D. Flow compensation (Basic flow compensation)
E. ?

i.e. assuming what is NOT a disadvantage of the drawover (see wiki re: wording)

C. Small volume reservoir ?

or B. Cannot use sevoflurane? (u can but need two vaporisers - hence does this make B. 'false' and 'not' the answer???)
A. false - draw over vaporiser only has basic temperature compensation therefore performance is affected at extreme temperatures
b. false - can use sevoflurane HOWEVER output (max concentration) is limited so cannot induce with sevoflurane unless two vaporisers are used
c. small volume reservoir - true - "The fractional oxygen concentrate delivered to a patient is dependent on O2 output of the concentrator, MV of the pt and presence of the OET (oxygen economiser tube, aka reservoir). FiO2 conc is in depended of the ventilation pattern with the OET (reservoir) in place. Without an OET, performance is impaired and final FiO2 conc depends on flow of O2, MV and ventilation pattern. 1m length of tubing (internal vol 415ml) will produce an FiO2 of 30% with O2 at 1.0l/min and 60% with 4L/min. at normal MV. USING A LARGER INFLOW RESERVOIR CAN BE CUMBERSOME."
d. flow compensation - flow is determined by the patent
Basic principles behind draw-over vaporiser are same as for the plenum. However, draw-over (pullover) has a low resistance to flow and is relatively INEFFICIENT in comparison to plenum (pushover).

Plenum is used outside the circuit.

Draw-over may be used inside the breathing circuit, usually as part of a draw-over anaesthetic system. If used inside a circle breathing system, the expired vapour builds up to high concentration, hence close end tidal agent monitoring is recommended.

Fresh gas is drawn through the vaporiser because of a negative pressure generated downstream by the pt or ventilator. Flow is governed by pt's minute volume. Output varies with flow, decreasing as flow increases - calibration needs to cover a wide range of minute volumes (less accurate at high or low flows). Advantage is that they are portable and can be used where compressed gas is unavailable
++TMP-Oct09-030 [Mar13]
Drug LEAST likely to cause hypoxia in ARDS
a. Noradrenaline
b. Milrinone
c. Isoprenaline
d. Isoflurane
e. SNP
a. Noradrenaline
41) Comparing New instrument of BP measurement with gold std - choice of test
Bland-Altman plot
From wikipedia
'Bland and Altman make the point that any two methods that are designed to measure the same parameter (or property) should have good correlation when a set of samples are chosen such that the property to be determined varies considerably. A high correlation for any two methods designed to measure the same property is thus in itself just a sign that one has chosen a wide spread sample. A high correlation does not automatically imply that there is good agreement between the two methods.

One primary application of the Bland Altman plot is to compare two clinical measurements that each provide some errors in their measure. it can also be used to compare a new measurement technique or method with a gold standard even so the interest of the Bland-Altman plot is contested in this particular case because the error pertains to the sole new measure.'
54 yo for operation. Is on warfarin for AF. History of alcohol abuse, bilirubin is ?, albumin is 30. History of DVT following flight.
What is CHADS2 score?

A 0
B 1
C 2
D 3
E ?
8 year old, 30kg girl for major operation. Haematocrit is 35%, you decide you will transfuse if haematocrit falls below 25%

What blood volume must she lose to trigger transfusion?

A 400mls
B 500mls
C 600mls
D 700mls
E ?
Pulsus paradoxus is:

A. Reduced BP on inspiration unlike normal (ie normally increased on insp)

B. Reduced BP on inspiration exaggerated from normal

C. Reduced BP on expiration unlike normal

D. Reduced BP on expiration exaggerated from normal

E. ?

(also asked Pulsus paradoxes in constrictive pericarditis:)
B. Reduced BP on inspiration exaggerated from normal

By definition greater than 10mmHg fall.

Ciliary ganglion

A sympathetic from inferior cervical ganglion

B located inferiorly within orbit

C may be damaged during a peribulbar block

D preganglionic parasympathetic supply from the supra trochlear nerve

E preganglionic parasympathetic originates from the Edinger Westpal nucleus
E preganglionic parasympathetic originates from the Edinger Westpal nucleus
Ciliary ganglion
- parasymp root - from Edinger Westphal part of oculomotor nucleus by a branch from the herve to the inferior oblique muscle from the inferior division of the oculomotor n.
- symp root - from superior cervical ganglion by branches of the internal carotid nerve
- sensory root - from a branch of the nasociliary nerve, with cell bodies in the trigeminal ganglion
- branches - short ciliary nerves to the eye

Absolute CI for ECT -

A Increased ICP
B Recent MI
C Pregnancy
A Increased ICP - Clinical memorandum 12 RANZCP
From Clinical Memorandum #12 Royal Australian New Zealand College of Psychiatrists:
3.1 With the exception of raised intracranial pressure, there ar eno absolute contraindications to ECT…
Situations of high risk:
- Hypertension
- MI
- Bradyarrhythmias
- Cardiac pacemakers
- Intracranial pathology
- Aneurysms
- Epilepsy
- Osteoporosis
- Skull defect
- Retinal Detachment
- Concurrent medical illness

Most effective way to reduce renal failure in AAA surgery

A Minimize cross clamp time

NEW: What gestation to monitor uteroplacental flow

A 20 weeks

B 24 weeks

C 28 weeks

D 32 weeks

E 36 weeks
A 20 weeks
From Chestnut's Ch17: 'Continuous FHR monitoring (using transabdominal Doppler ultrasonography) is feasible beginning at approximately 18-20 weeks gestation. However, technical problems may limit the use of continuous FHR monitoring between 18 and 22 weeks gestation. Transabdominal monitoring may not be possible during abdominal procedures or when the mother is very obese; use of transvaginal Doppler ultrasonography may be considered in selected cases.

FHR variability, which is typically a good indicator of feral well-being, is present by 25-27 weeks gestation. Changes in the baseline FHR and FHR variability caused by anaesthetic agents or other drugs must be distinguished from changes that result from feral hypoxia. Persistent severe feral bradycardia typically indicates true fetal compromise.

Intraop FHR monitoring requires someone who can interpret the tracing. A pal should be in place that addresses how to proceed in the event of persistent non reassuring feral status, including whether to perform emergency caesarean delivery. The greatest value of intraop FHR monitoring is that it allows for optimisation of the maternal condition if the fetes shows sign of compromise.'

Peak incidence of vasospasm post SAH -

A 0-2 days
B 3-5 days
C 6-8 days
D ?
C 6-8 days
From UpToDate
'Vasospasm causes symptomatic ischaemia and infarction in ~20-30% of patients with aneurysmal SAH - it is the leading cause of death and disability after aneurysm rupture. It typically begins no earlier than day 3 after haemorrhage, reaching a peak at days seven to eight. The onset of clinical vasospasm is characterised by a decline in neurologic status, including the onset of focal neurologic abnormalities.'

Perform a brachial plexus block however the medial forearm is NOT numb. Which nerve has been missed?

A. Medial brachial cutanous nerve
B. Lower trunk
C. Ulnar nerve
D. ?
E. ?

Medial ANTEbrachial cutaneous nerve (C8,T1) supplies the medial forearm.
C8,T1 join to form the LOWER TRUNK -> divides to anterior and posterior division -> ANTERIOR division forms the MEDIAL CORD. From the Medial cord -> medial pectoral nerve, medial cutaneous nerve of arm (or medial brachial cutaneous nerve) and MEDIAL ANTEBRACHIAL CUTANEOUS NERVE (or medial cutaneous nerve of the forearm.


Rpt: A Full Size C oxygen cylinder has pressure downregulated from?

A. 16,000 kPa to 400 kPa
B. 16,000 kPa to 240 kPa
C. 11,000 kPa to 400 kPa
D. 11,000 kPa to 240 kPa
A. 16000 kPa to 400 kPa
See RAH presentation.

What is the incidence of fat embolism following a unilateral closed femoral fracture?

A 1-3%
B 4-7%
C 8 - ?%
Patients with a single long bone fracture have a 1-3% chance of developing the syndrome, but it has been reported in up to 33% of patients with bilateral femoral fractures. CEACCP 2007 article
New: Thoracodorsal nerve arises from?

A Inferior trunk
B Lateral cord
C dorsal scapular n
D posterior cord
Thoracodorsal (middle subscapular) nerve arises from the posterior cord and receives innervation from C6,7,8. It innervates the Latissimus dorsi muscle.


What drug should NOT be used for tocolysis in 32/40 female?

A. Indomethacin
B. Magnesium
C. Nifedipine
D. Salbutamol
E. Clonidine (in Mar13 exam)
B. Magnesium and
A. Indomethacin even ?D. salbutamol
B>A and D?

See Chestnut. Table 34-4.

Cochrane review on Magnesium in preterm labour (2002) found 'no evidence of a clinically important tocolytic effect for magnesium sulphate; it did not have any substantial effect of the proportion of women delivering within 48 hours, either overall, or in any subgroup analysis. Moreover, there was no evidence of any substantial improvements in neonatal morbidity. IN CONTRAST, MgSO4 was associated with an INCREASE IN FETAL AND PAEDIATRIC DEATHS. The higher death rate was present in the SUBGROUP where the maintenance dose of MgSO4, as in the study's protocol, was high, rather than low.'

Indomethacin can cause premature closure of ductus arteriosus in the fetus if given in 3rd trimester

Depends on reference. NSW health policy directive states that BEFORE 34/40 there are 5 classes of tocolytic agents available in Australia currently: CCB, Beta-agonists, nitric oxide donors, prostaglandin synthetase inhibitors and magnesium sulphate. The evidence to support the use of magnesium sulphate as a first line tocolytic is poor so it is not recommended.

The use of beta-agonists (like salbutamol) or multiple tocolytics is associated with a high incidence of serious adverse drug reactions. Both nitric oxide donors (like GTN) and prostaglandin synthetase inhibitors (like indomethacin) MAY HAVE A ROLE PRIOR TO 28 WEEKS.

You are performing a bronchoscopy, but are unsure of your location. Then you see trifurcation of bronchi. Most likely location is:
A. Right upper lobe
E. Lingula <br
A. Right upper lobe
see wiki Mar10 exam
(similar to TMP-Mar10-079 but more info/different info?)

Head Trauma patient with unilateral dilated pupil, no direct (?and consensual) response to light whats the diagnosis ?

A.Global injury
B.Optic nerve injury
C.Horners syndrome
D.Transtentorial herniation
E. Injury to Pons (?)
D. Transtentorial herniation


18/12 old undergoing routine SV GA under LMA. Sudden onset SVT with HR 220 BP 84/60 ETCO2 32 SpO2 98.Management:
A. Adenosine 100mcg
B. DCR 2J/kg
C. DCR 4J/kg
D. Amiodarone 5mg/kg
D. Amiodarone 5mg/kg
See www.resus.org.au Guideline 12.5
A. False - incorrect dose. at 18/12 estimated weight is ~11kg (2(age+4)). Dose is 0.1-0.3mg/kg. Otherwise adenosine is FIRST LINE, with amiodarone being second line.
B. False - Patient is not severely hypotensive yet! From above ref: 'SVT may cause severe hypotension or pulseless in which case synchronised DC shock should be given immediately in a dose of 0.5-1.0 J/kg (mono phasic shock or biphasic shock) but up to 2J/kg if necessary'.
C. False - see B
D. TRUE. see A.
E. False - bit premature...
AA24 ANZCA Version [Jul07][Apr08][Mar13]

Investigation of a suspected anaphylactic reaction requires measurement of tryptase levels. Correct statements regarding tryptase include all except:

A. 99% of body tryptase is in mast cells

B. a concentration of greater than 20 ng/mL suggests an anaphylactic reaction

C. blood samples should be repeated 24 to 48 hours after the reaction

D. maximum blood concentrations occur within 1 hour of the reaction

E. tryptase concentrations rise after both anaphylactic and anaphylactoid reactions
C - False and answer to choose;

Samples should be taken immediately, 1 hour after reaction and 6 or up to 24 hours after reaction

ref 2004 CEACCP article

The CEACCP article from Aug 04 answers these questions, it states

A. 8% cross reactivity between cephlasporins and penicillin
B. Colloids can precipitate histamine release and make the situation worse and are recommend to avoid
C. Tryptase is elevted in both- making this option incorrect
D. Collect blood immediately, at 1hr and a third sample between 6 and 24 hrs

AM09e ANZCA version [Apr08] [Mar12-Q122][Aug12][Mar13]

The diagnosis of neuroleptic malignant syndrome requires the presence of:

A. Diaphoresis
B. elevated plasma creatinine kinase (some recalled just ↑ CK)
C. hypertension
D. muscle rigidity
E. tachycardia
D. Muscle rigidity
and possibly B. ↑ CK if CK = creatine kinase NOT creatinine kinase (only using Levenson's crier for dx of NMS)
DSM IV-TR criteria: Severe muscle rigidity and elevated temperature associated with use of neuroleptic medication as well as two or more of the following -
- diaphoresis
- dysphagia
- tremor
- incontinence
- changes in level of consciousness ranging from confusion to coma
- mutism
- tachycardia
- elevated or labile BP
- leukocytosis
- laboratory evidence of muscle injury

Levenson's criteria (3 major, or 2 major and 4 minor criteria are needed for dx)
Major criteria
- fever
- rigidity
- elevated creatine kinase (CK)
Minor criteria
- tachycardia
- abnormal BP
- altered consciousness
- diaphoresis
- leukocytosis
AM49 ANZCA Version [Apr 08][Mar13]

Definitive evaluation of malignant hyperthermia (MH) susceptibility does NOT include observing:

A. abnormalities on magnetic resonance imaging (MRI) spectroscopy
B. calcium release from B lymphocytes in response to caffeine stimulation
C. certain mutations in the ryanodine receptor gene
D. myofibrillar necrosis on muscle biopsy
E. plasma creatine kinase (CK) levels above 800 units.l-1
D. myofibrillar necrosis on muscle biopsy
false hence answer
A. MRI spectroscopy - true - Nuclear magnetic resonance spectroscopy measures the concentrations of ATP, phosphocreatine and other phosphomonoesters, along with pH, both in vivo and non invasively, in muscle and other tissue. Several studies have shown delayed reconstitution of pH, ATP, and increased phosphocreatine in MH patients during and after graded exercise. A recent study reports 100% concordance between abnormalities in adenosine triphosphate and high-energy phosphates produced by a specific exercise protocol and the results of muscle biopsy.
B. Ca release from B lymphocytes in response to caffeine stimulation- true - Recently, Sei et al.22 have shown RYR-1 receptors on B lymphocytes in humans. This implied that these cells might demonstrate changes in calcium flux similar to those demonstrated in muscle. They found that lympho- cytes from MH patients, when incubated with 4-chloro- m-cresol, showed increased intracellular calcium con- centrations. However, halothane did not affect intracellular calcium concentrations.
C. mutations in ryanodine receptor gene - true - Most recently, the demonstration that a mutation in the gene that encodes the calcium release channel (the ryanodine receptor, RYR-1) underlies porcine MH in- creased the expectation of a simple DNA-based test for MH in humans as well.
D. myofibrillar necrosis on muscle biopsy - false
E. plasma creatine kinase levels above 800 u/L - true- Creatine kinase concentrations are chronically in- creased in perhaps 50% of MH patients.

"Another approach has been the use of nuclear magnetic resonance spectroscopy to measure ATP, pH, creatine phosphate and other high-energy phosphates non-invasively. With exercise, MH susceptibles demonstrate a greater depletion of high-energy phosphates and fall in pH, compared to normals."

Caffeine stimulated release of calcium from B Lymphocytes
- "The B lymphocytes from MH patients also display exaggerated changes in cellular calcium levels upon exposure to caffeine and other calcium-release agents compared to normals."

Resting CK >800

Muscle contraction on exposure to halothane
- caffeine/halothane contracture test (CHCT) continues to be the gold standard

Myofibrillary necrosis on histology

ASA Abstracts 2001

Histopathological Examination Does Not Improve Differentiation between Malignant Hyperthermia Susceptible and Normal Patients

Frank Wappler, M.D.; Franziska von Breunig, M.D.; Marko Fiege, M.D.; Ralf Weisshorn, M.D.; Jochen Schulte am Esch, M.D. Department of Anesthesiology, University Hospital Eppendorf, Hamburg, Germany

In contrast to the results of recent investigations in a small population of MH patients, histological differences between MHS and MHN could not be demonstrated. Histological investigations can neither improve MH diagnosis nor contribute to a better definition of the MHE status. Therefore, the IVCT remains the only reliable test method in diagnosis of MH susceptibility. However, histological examinations might be helpful to determine unknown neuromuscular diseases (e. g. central core disease, carnitine deficiency syndrome) in patients undergoing IVCT.
Anorexic patient admitted for treatment. She is commenced on a normal diet. She because progressively dyspnoeic and ?admitted to ICU shortly after??

What must derangement do you correct?

A potassium
B sodium
C phosphate
D magnesium?
AZ03 [Jul07][Apr08][Aug12][Mar13]

The BEST indication of a difficult intubation in morbid obesity:

A. Mallampatti Score

B. Neck circumference

C. Limited neck movement


E. Body weight

F. Increased pretracheal soft tissue
B. Neck circumference

F. for Mar13 exam

JB Brodsky, HJM Lemmens, JG Brock-Utne, MVierra, LJ Saidman, Morbid Obesity and Tracheal Intubation. Anesth Analg 2002;94:732–6

➮ Factors looked at included: "height, weight, neck circumference, width of mouth opening, sternomental distance, thyromental distance and Mallampati score"

➮ "Logistic regression identified neck circumference as the best single predictor of problematic intubation. Mallampati score inclusion did not further improve the model in our limited study with only 12 problematic intubations. In patients with a large neck, the view during direct laryngoscopy was poorer."

Can't intubate, can't ventilate situation after giving rocuronium (1.2mg/kg)

What does of sugammadex do you give?

A 2mg/kg
B 4mg/kg
Carcinoid tumour resection. Patient is hypotensive and octreotide commenced. Patient remains hypotensive. Next treatment option?

A adrenaline
B levosimendan
C milronone
D vasopressin
E ?
Class I device. There is a fault which leads to an active wire touching the outside casing. What will happen when the power switches on?

A nothing because of double insulation (or something about double insulation)
B RCD will interrupt power supply
Drug NOT to use to treat hypertension in pregnancy

A aspirin
B …
During pregnancy all of which of the following respiratory mechanics decrease?

A minute ventilation
B tidal volume
C functional residual capacity
D ??
E ??
C ? B
Eaton lambert syndrome feature

A initial improvement with repeated exercise
ECG lead placement (3-lead)

- combination of red white black and green in various places.
- white over right, smoke over fire.
EM16b ANZCA version [2002-Mar] Q68, [2002-Aug] Q64, [2005-Apr] Q94, [2005-Sep] [Apr08] [Sep11] [Mar12] [Aug12] [?Mar13]

Circuit disconnection during spontaneous breathing anaesthesia

A. will be reliably detected by a fall in end-tidal carbon dioxide concentration

B. will be detected early by the low inspired oxygen alarm

C. will be most reliably detected by spirometry with minute volume alarms

D. may be detected by an unexpected drop in end-tidal volatile anaesthetic agent concentration

E. can be prevented by using new, single-use tubing
D. may be detected by an unexpected drop in end-tidal volatile anaesthetic agent concentration

CJA 48:847-849 (2001)
A breathing circuit disconnection detected by anaesthetic agent monitoring
EM68 [May09][Aug09][Mar13]

In an arterial line system
A. Overdamping exaggerates mean
B. Underdamping increases mean
C. Underdamping underestimates systolic
D. wide range of damping coefficient associated with good performance if system has high natural frequency
E. Compliant tubing is good
D. wide range of damping coefficient associated with good performance if system has high natural frequency.

However from Miller: Most catheter-transducer systems are underdamped but have an acceptable natural frequency that exceeds 12 Hz. If the system's natural frequency is lower than 7.5 Hz, the pressure waveform is often distorted, and no amount of damping adjustment can restore the monitored waveform to adequately resemble the original waveform.[47] If, on the other hand, the natural frequency can be increased sufficiently (e.g., 24 Hz), damping will have minimal effect on the monitored waveform, and faithful reproduction of intravascular pressure is achieved more easily (Figs. 40-6 and 40-7). In other words, the lower the natural frequency of the monitoring system, the more narrow the range of damping coefficients that can be tolerated to ensure faithful reproduction of the pressure wave. For example, if the monitoring system's natural frequency is 10 Hz, the damping coefficient must be between 0.45 and 0.6 for accurate monitoring of the pressure waveform. If the damping coefficient is too low, the monitoring system will be underdamped, resonate, and display factitiously elevated systolic blood pressure; if the damping coefficient is too high, the system will be overdamped, systolic pressure will be falsely decreased, and fine detail in the pressure trace will be lost.

ie. The higher the natural frequency of the system it will tolerate a wider range of damping… not the other way around… so does that make D false too? poorly remembered.
by exclusion.
A. false - From Common Errors in Clinical Measurement. Anaes Int Care Med 05 Vol 6 Issue 12: "Damping of the pressure waveform due to poor positioning of the cannula, or the use of overly compliant tubing, underestimates systolic pressure and overestimates diastolic pressure. The mean pressure is still reasonably accurate."
B. false - see A
C. false - see A.
E. False - see A.
ET02 [Mar11] [Mar13]
An 85y.o for open AAA repair. Refuses blood because of risk of vCJD. Despite explanation trying to convince him he still refuses. You tell him you won't anaesthetise him as the risk is too high (and that it is not in his best interest - this was in Mar 13 exam). This is an example of:

A: Autonomy
B: Beneficence
C: Malevolence
D: Coercion
E: Paternalism
E or A - see wiki
n 'J Med Ethics 2004;30:286–290' - not available through ANZCA so here is the relevant part:

"Consider the case of a patient, Mr A, who is due to undergo surgical repair of a 10 cm abdominal aortic aneurysm, but who refuses intraoperative blood transfusion, because he is worried about the infinitesimally small risk of contracting variant Jakob-Creutzfeld disease (vCJD) through transfusion. The anaesthetist may explore these fears in a preoperative visit, and may discuss alternative methods of fluid replacement or conservation during this potentially very bloody operation. If the patient still refuses blood transfu-sion, however, the anaesthetist is faced with a conundrum— it would be morally and professionally very difficult to justify proceeding without potential recourse to transfusion, because of the markedly greater risk of severe patient morbidity or mortality. This example differs from the problems posed by blood refusing Jehovah's Witnesses, in that such patients refuse blood on the basis of a strongly held religious belief, a belief that to them, forms a core value, and is therefore to be respected. Mr A, however, although making an autonomous decision about an admittedly possible but realistically negligible risk is undoubtedly making a poor decision, and one that may be viewed as being at odds with his normal beliefs and values. The easiest course is to respect Mr A's decision, and proceed. Alternatively, the anaesthetist may respect Mr A's decision, but refuse to anaesthetise him because of the substantially increased perioperative risk to Mr A. Hard cases make hard decisions, however, and in this case, the anaesthetist would be justified in coercing Mr A into accepting blood; untreated, a 10 cm aneurysm would be likely to rupture within a year, with a 90% mortality if this occurred outside hospital, an occurrence that the anaesthetist may decide does not conform with Mr A's values (Mr A being an otherwise happy family man). The anaesthetist may feel that Mr A has attached undue weight to the risk of vCJD, and may continue to try and convince Mr A to accept blood."
EZ98 [Mar12][Mar13]

A machine with a soda lime absorber was left on overnight with oxygen running at 6 litres per minute. In the morning a desflurane vaporiser is connected. What toxic substance may be produced?

A. Substance A
B. Carbon monoxide
C. Carbon dioxide
D. Calcium hydroxide
E. Substance B
B. Carbon monoxide
From Stoelting:
'Carbon monoxide formation reflects degradation of volatile anaesthetics that contain a CHF2 moiety (des, enf and iso) by the sting bases in desiccated CO2 absorbents. Factors which influence magnitude of carbon monoxide production from volatile anaesthetics include:
- dryness of CO2 absorbent with hydration preventing formation
- high temperatures of CO2 absorbent as during low fresh gas flows and/or increased metabolic production of CO2
- type of absorbent

Desflurane produces the highest carbon monoxide concentration (then enf and iso).
Female patient requires DLT, she weighs ?kg and is 160cm tall. What mark would best correspond at the teeth to indicate correct placement?

A 24cm
B 26cm
? A?
Intraosseous infusion (according to ANZCA guidelines) should be labelled:

A beige
B red
C pink
D blue
E yellow
Management that is least useful in SEVERE anaphylaxis?

A cardiopulmonary bypass
B nebulized salbutamol
C IV vasopressin
D corticosteroids
E subcutaneous adrenaline
MC30b ANZCA version [2004-Aug] Q128, [2005-Apr][Sep11][?Mar13]

A patient with pulmonary hypertension secondary to lung disease presents for a laparotomy.
Regarding this patient's anaesthetic management

A. an alpha-agonist is the inotrope of choice

B. hypothermia is protective against rises in pulmonary artery pressure

C. isoflurane will tend to decrease pulmonary artery pressure

D. ketamine is an appropriate anaesthetic agent

E. right heart failure is not a concern
A. an alpha-agonist is the inotrope of choice
A. an alpha-agonist is the inotrope of choice - probably true and best answer:
there are No α-1 adrenergic receptors are present in the pulmonary circulation (Blaise, Anaesthesiology, 2003, 99(6):1421) so α-1 agonists are fine and may assist RV function by increasing coronary perfusion pressure (although some prefer dobutamine initially becuase it increases contractility and may pulmonary vasodilate)
the wording is confusing and might subequently change now. Both the Blaise article and Stoelting 5th ed. suggest that causes of hypotension are multifactorial and should be treated accordingly. Specifically pulm HTN crisis requiring inotropy, the 'inotrope' of choice might be milrione (or possibly dobutamine), however R heart ischaemia and low SVR (with fixed PVR) are important causes of hypotension specifically treated with noradrenaline
B. hypothermia is protective against rises in pulmonary artery pressure - false
Hypothermia increases PVR (A & A ,Volume 96(6), June 2003, pp 1603-1616)
C. isoflurane will tend to decrease pulmonary artery pressure - false
PVR does not change with volatiles except N2O which does increase PVR (Stoelting Pharmacology p47)
Isoflurane has no effect on baseline pulmonary vessel tone. (Blaise, Anaesthesiology, 2003, 99(6):1421)
D. ketamine is an appropriate anaesthetic agent - false
'In patients who have pulmonary artery pressure, ketamine seems to cause a more pronounced increase in pulmonary than systemic vascular resistance' (Miller, p348)
'The sympathomimetic properties of ketamine may preclude use in the setting of pulmonary hypertension (Yao, p96)
In-vitro ketamine increases PVR in rat lung...(and)...ketamine attenuates endothelium-dependent pulmonary vasorelaxation in response to acetylcholine and bradykinin ...(and)...sympathetic innervation of the pulmonary circulation does exist (Blaise, Anaesthesiology, 2003, 99(6):1421)
E. right heart failure is not a concern - false
MC42 ANZCA version [apr04][Mar11][Sep11][Aug12][Mar13]

Abnormal Q waves are NOT a feature of the ECG in

A. an old myocardial infarction

B. left bundle branch block

C. recent transmural myocardial infarction

D. digitalis toxicity

E. Wolff-Parkinson-White syndrome
D. digitalis toxicity

Digoxin is associated with ST depression and other arrhythmias and calcium channel blockers with AV conduction disturbances. (harrison’s 1267-70) Q waves: transmural MI, LBBB, hyperkalaemia, WPW, amyloid, HOCM, cardiac contusion, myocarditis, dextrocardia, reverse limb leads. Epstein page 52.
MC59 [Aug12][Mar13]

The treatment LEAST likely to be useful for torsades de pointes is

A. defibrillation

B. procainamide

C. magnesium

D. electrical pacing

E. isoprenaline
B. procainamide

Avoid Class I anti-arrhythmics, mexilitine & sotalol (in renal failure)

Magnesium – first line treatment according to emedicine
Isoprenaline – second line treatment according to emedicine
Lignocaine – has been used to treat resistant TDP
Phenytoin – useful, as it shortens the QTc – according to Harrisons

β blockade is the mainstay for congenital prolonged QT (Lown Ganong Levine)
– remember that fat Med Reg in Dunedin on his first on call night in Nelson

Torsades de pointes, which may mimic VF or VT, is a life threatening arrhythmia that occurs in the presence of disturbed repolarisation (hence its association with prolonged QT interval). Discontinuation of drugs that predispose to QT interval prolongation and correction of electrolyte abnormalities are essential in the treatment of torsades de pointes. Acute therapy may include defibrillation, 1 to 2g of intravenous magnesium sulfate, amiodarone (n.b not considered a good therapy in most texts ), isoprenaline and overdrive pacing.

By mechanisms that are poorly understood, mexiletine
may exacerbate existing arrhythmias and may evoke torsades de

AMIODARONE - prolongation of the QT interval is commonly
observed during chronic treatment but induction of torsades de
pointes is seen only rarely.

The most important unwanted effect of sotalol may be its
arrhythmogenic activity, which includes provoking torsades
de pointes. The likelihood of this effect is increased by hypokalaemia,
and is greater in women than in men. Since sotalol
is eliminated mainly by excretion, unchanged in the urine, the
danger of torsades de pointes is also increased where there is
renal dysfunction.

Adverse Effects of procainamide
o arrhythmias: ventricular tachycardia or fibrillation, Torsades de Pointes (associated with high levels of procainamide and/or NAPA (N-acetyl procainamide); secondary to prolonged QT interval)
o heart block
o prolongation of PR, QRS, QT intervals (up to 50%)
o bradycardia, asystole
o decreased BP, decreased
ME47 [Mar12][Aug12][Mar13]

Which of the following are feature of Conn’s syndrome?

A. Normoglycaemia, hypernatremia , hypokalemia
B. Hypoglycaemia, hypernatremia, hypokalemia
C. Hyperglycaemia, hyponatremia, hyperkalemia
D. Normoglycaemia, hyponatremia, hyperkalemia
E. Hypoglycaemia, hyponatremia, hyperkalemia
A. Normoglycaemia, hypernatremia , hypokalemia
see wiki (tendency for impaired glucose tolerance…)
Also tend to have low magnesium.
MG05 [Jul07][Mar10][Aug12][Mar13]

All of the following may be associated with ulcerative colitis EXCEPT

A. cirrhosis

B. iritis

C. psoriasis

D. arthritis

E. sclerosing cholangitis
C. psoriasis

get psoriasis with crohns but not UC
Monitoring ECG during anaesthesia. You choose lead II to monitor for

A Inferior ischaemia
B Anterior ischaemia
C Lateral ischaemia
D Septal ischaemia..
Most cephalad level a safe spinal in a neonate would be?

A L2-3
B L3-4
C L4-5
D L5-S1
Patient for urgent surgery. On warfarin and INR is 4.5 - he has been given vitamin K 2mg by intern. How would you reverse INR?

B prothrombin complex concentrate
C prothrombin complex concentrate and FFP
Patient has biventricular internal cardiac defibrillator. What happens if you place a magnet over it?

A switch to asynchronous
B damage internal programming
C nothing
D switch of antitachycardic function
E ?
Patient has operation and has mildly raised troponin post op. Otherwise uneventful recovery. Do you

A arrange for cardiology follow-up as he is at increased risk for future blah blah
B arrange coronary angiography etc etc
C inform him and say the significance is unknown
D repeat in a week's time
A ?

Patient has terminal cancer, his family does not want him to be informed because they don't think he would be able to handle the news. You inform patient anyway, ethical principle?

A Autonomy
B beneficence
C non-maleficence
D confidentiality
E utilitarism (or something like that)
Patient having EP study and ablation. Suddenly becomes hypotensive.
Most important investigation?

A Echocardiogram
B Coronary angiography
C ..
Patient in clinic with cardiac failure. No dyspnoea on showering, but gets short of breath mowing the lawn. NYHA classification is?

Patient on methadone 150mg/day. What do you expect to find on her ECG?

A prolonged (?or short) PR
B prolonged QTc
C peaked T wave
D ?u wave
Patient presents confused and unwell. BP 100/60 HR110 Temp 35.8
Infected foot ulcer

Na 125
BSL 55!!
Cr 180

what do you give urgently?

A antibiotics
B normal saline
C insulin
D potassium
This patient has pseudohyponatraemia secondary to hyperglycaemia. Most likely he is septic given clinical picture. I chose antibiotics over insulin as delay for antibiotics increases mortality. realistically you would treat both give IV fluids and resuscitate. I hate mcqs.
Patient with Parkinson's disease. Which drug is best to treat PONV?

A droperidol
B metoclopramide
C ondansetron
D ?
E ?
Performing a regional block when patient has a seizure and loses consciousness. Your immediate management is.

A administer intralipid 1.5mL/kg
C establish an airway and administer 100% oxygen
D give midazolam
PI83 [Mar10][Aug12][Mar13]

Desflurane vaporiser, heated because of

A. High SVP

B. High boiling point

C. Low SVP

D. High MAC

E. Low MAC
A. High SVP

see wiki.
Des also has a low BP not high BP.
PiCCO determines cardiac output using

A thermodilution
B pulse contour analysis
C thermodilution and pulse contour analysis
Poise trial showed decrease

A cardiovascular mortality
B myocardial infarction
C hypotension
D stroke
E bradycardia?
(but increase in everything else!)
PP87 ANZCA Version [Jul06][Oct09][Sep11][Mar13]

The weight of a child can be estimated using the formula

A. (age + 2) x 3

B. (age + 4) x 2

C. (age x 2) + 4

D. (age x 3) + 2

E. age x 4
B. (age+4)x2

The "standard" anaesthetic formula are:
From age 1-8: wt= (age in years x 2) + 8 [which is equal to (age+4)x2]
From age 8-12 wt = (age in years) x 3
PP92 [Apr07][Apr08][Aug12][Mar13]

5yo 35kg child having repair of leg laceration. Gas induction with sevoflurane, N2O and oxygen. Can't get in drip. Put in LMA and immediately get stridor and airway obstruction and desaturate to 90%. Next step after increase FiO2 to 100% is:

A. Remove LMA and deepen with sevoflurane

B. Leave LMA and deepen with sevoflurane

C. Intralingual Suxamethonium

D. IM Atropine

E. IM Suxamethonium
A. Remove LMA and deepen with sevoflurane
Risk factor which would increase likelihood of atrial fibrillation when coming of cardiopulmonary bypass? (cannot recall if it was for cardiac surgery or other type of surgery)

A history of congestive heart failure
B history of cerebrovascular accident
C prolonged cardiopulmonary bypass time
D ?
E ?
Rpt: Intraoperative pediatric arrest during scoliosis surgery most likely due to?

A. Underappreciated degree of blood loss
?A. Underappreciated degree of blood loss
difficult to find references. From Anaesth Intensive Care 2010;38:1088-1084:
'Fourteen cardiac arrests were recalled and details were specified for four: hyperkalaemia, major haemorrhage and CVS collapse in one patient with cerebral palsy and three DMD patients. Ten deaths were recalled, detail specified for six: three associated with major haemorrhage or transfusion (one DMD in the arrest group and one DMD with TRALI, one idiopathic scoliosis patient), one AMI in a pt with cardiomyopathy but no other myopathy, one brainstem stroke (with thoracic spin bifid a) and one due to sepsis. Closed questions on venous/arterial thrombosis, infection (wound or instrumentation), failed fusion rates, awareness or intraoperative recall during wake-up tests were not included.'

SG65 ANZCA version [Apr08][Mar12][Aug12][Mar13]

During prolonged trendelenburg positioning there is:

a. No change in ICP
b. No change in IOP
c. Increased pulmonary compliance
d. Increased myocardial work
e. No increased pulmonary venous pressures
d. Increased myocardial work
a. false - increases ICP (Miller)
b. false - increases IOP (Miller)
c. false - decreases pulmonary compliance (Miller)
d. ?true - presumably increased preload and venous return results in increased cardiac output and therefore myocardial work.
e. ?false - presumably increased preload and venous return translates to increased pulmonary venous flow and pressure if resistance is unchanged
SN18 [Mar11][Aug12][Mar13]

Absolute contraindication to sitting position for posterior fossa craniotomy for meningioma

A: Presence of patent ventriculo-atrial drain/shunt
C: Oesophageal stricture so transoesophageal echo placement is out
D: ?
E: ?
A: Presence of patent ventriculo-atrial drain/shunt
B: PFO if large!
From Anaesth Int Care 2005; 33:323-331
Table 3
Absolute contraindications to the sitting position
- Severe CVS disease
- LARGE PFO or other pulmonary-systemic shunt
- Cerebral ischaemia when upright and awake
- Anaesthesia or surgical team unfamiliar with position
- small PFO
- extremes of age
- uncontrolled HT
- COAD (may not tolerate VAE as well if it occurs)
St John's wort interacts with which anticoagulant drug?
(can't recall if question was interacts or caused increased bleeding…)

A warfarin
B ?
The following are all part of adult? life support algorithm except

A chest compression ratio 30:2
B allow equal time for for chest compression and relaxation
C depth of ?5cm each compression
D aim for ?bpm
E 2 rescue breaths prior to commencing CPR
TMP-108 [Mar10][Aug10][Mar13]

A 60yo man with anterior mediastinal mass, during induction for mediastinoscopy....lose cardiac output, decreased saturations, drop in ETCO2. Management:

A. Adrenaline
D. Place prone
D. Place prone
TMP-130 [Oct09][Aug12][Mar13]

Essential diagnostic criteria on ECG for LBBB

A. Loss of septal Q's in V5 and V6
B. RSR in V1
C. Large slurred S in V6
D. T-waves opposite to direction of QRS
E. QRS duration minimum 0.2 s
A. Loss of septal Q's in V5 and V6
Diagnostic Criteria
- QRS duration of 120 ms
- Dominant S wave in V1
- Broad monophasic R wave in lateral leads (I, aVL, V5-V6)
- Absence of Q waves in lateral leads (I, V5-V6; small Q waves are still allowed in aVL)
- Prolonged R wave peak time > 60ms in left precordial leads (V5-6)

TMP-Jul10-010 [Mar11][Mar13]

The best clinical indicator of SEVERE AS

A. Presence of thrill

B. Mean Gradient 30mmHg

C. Area 1.2 cm2

D. Slow rising pulse and ESM radiating to carotids

E. Shortness of breath
A. Presence of thrill

see wiki. Dyspnoea may or may not be present in severe AS (though 50% of patients with severe AS will have dyspnoea).

From "Aortic Stenosis and Non Cardiac Surgery" CEACCP 2005; 5(1):1-4

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

B - False - Severe AS mean gradient 40-50mmHg

C - False - Severe AS valve area 0.6-0.8cm2

D - ? False - may be present in other grades of AS

E - False - "There are three cardinal symptoms in aortic stenosis; angina, syncope and dyspnoea. However, symptoms do not correlate well to the severity of the stenosis"
TMP-Jul10-015 [Aug12][Mar13]

Which type of aortic dissection is classically for NON-operative management:
A. DeBakey Type I
B. DeBakey Type II
C. Stanford A
D. Stanford B
E. Stanford C
D. Stanford B
Stanford A involves ascending aorta (DeBakey types I and II);
Stanford B involves the descending aorta below the subclavian artery (DeBakey III) and has traditionally been managed with medication.

Stanford C does not exist?
TMP-Jul10-020 [Aug12][Mar13]

Thermoneutral zone in 1 month old infant ?
A. 26 – 28 degrees Celcius
B. 28 – 30 degrees Celcius
C. 30 – 32 degrees Celcius
D. 32 – 34 degrees Celcius
E. 34 - 46 degrees Celcius
D. 32 – 34 degrees Celcius
From wiki
The thermoneurtral zone is didined as the environmental temperature range over which metabolic rate is kept at a minimum and within which temperature regulation is achieved by non-evaporative physical processes alone. This zone is much higher in the naked neonate (32-36 deg C) than in name adults.
TMP-Jul10-025 [Mar13]

Advantages of bronchial blockers over double lumen tubes:
A. Able to achieve lobar isolation
B. Lower cuff pressure
C. Quicker deflation of isolated lung
D. Pneumonectomy
E. Lower incidence of malposition
A. Able to achieve lobar isolation

Bronchial Blockers
Easy recognition of anatomy if the tip of a single lumen tube is above carina
Best device for pt with difficult airway
No cuff damage during intubation
No need to replace ETT if post-op ventilation required
Selective lobar isolation is possible (mentioned at end of article, not in table)
Small channel for suctioning
Conversion from 1- to 2- then to 1-lung ventilation (problematic for novice)
High maintenance device (dislodgement or seal loss during surgery)

Double-Lumen ETT's
Large lumen facilitates suctioning
Best device for absolute lung separation
Conversion from 2 to 1-lung ventilation easy and reliable
Difficulty selecting proper size
Difficult to place during laryngoscopy
Damage to tracheal cuff
Major tracheo-bronchial injuries
TMP-Jul10-026 [Mar13]

Patient for pneumonectomy. Pre op FEV1 2.4. (Predicted 4.5L) FVC given as well. For R lower lobectomy. Postoperative predicted FEV1 ?
A. 1.3
B. 1.5
C. 1.7
D. 1.9
E. 2.2
C. 1.7
The objective is to establish that after surgical resection of the lung for a tumor, there will be sufficient pulmonary reserve to keep the patient comfortable, and will not become a respiratory cripple.

To answer the question we can refer to the BJA CEACCP article from 2006, or Miller (7th edition). Basically they have the same concept, although the numbers used differ, but the end results are similar. These can be used for pneumonectomy or lobectomy, but I assume this question is referring to a right lower lobectomy rather than the introductory suggestion of a pneumonectomy (initially a bit confusing).

Based on the CEACCP article (2006), we can calculate a predicted post-op FEV1 (ppoFEV1) by calculating how many broncho-pulmonary segments of lung will remain after surgery. The starting number varies depending on the text/classification you use, but this article suggests 19 lung segments in total - 10 on the right (RUL=3, RML=2, RLL=5), and 9 on the left (LUL=3, Lingula=2, LLL=4). Given that the right lung is physically and functionally larger than the left this makes sense. Therefore for a right lower lobectomy we will be removing 5 segments, and therefore be left with 14 segments. The ppoFEV1 will be 14/19 x 2.4L = 0.7368 x 2.4L = 1.77L.

Based on the numbers used in Miller there are 42 segments in total: 22 segments (or subsegments) in the right lung (RUL=6, RML=4, RLL=12), and 20 in the left lung (LUL=10, LLL=10). The calculation is the same, but with different numbers: A right lower lobectomy will remove 12 segments, and we will be left with 30. Therefore ppoFEV1 will be 30/42 x 2.4L = 0.7143 x 2.4L = 1.71L.

The numbers used in Miller obviously give an answer that is closer to one of the options in the remembered question, so based on this I would say ANSWER=C.
TMP-Jul10-027 [Mar13]
Post accidental dural puncture with epidural needle. Which does not fit?

A. Epidural blood patch 30-50% effective
B. Unlikely to be related to epidural if purely occipital headache
C. caffeine mildly effective in reducing headache
D. subdural haematoma can rarely occur with PDPH
E. ?Something about photophobia??
A. Epidural blood patch 30-50% effective - false so answer to choose

blood patch effective in 80% at 24 hrs
see my comment on wiki.
TMP-Jul10-043 [Mar11][Sep11][Aug11][Aug12][Mar13]

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?
?helium/oxygen mixture also option in other stem? (heliox was an option in Mar13)
C. IV magnesium

See Global Initiative for Asthma 2012 update figure 4.4-2 Management of Asthma exacerbations in acute care setting. Intravenous magnesium is part of treatment for severe episode (along with oxygen, inhaled b2 agonist and inhaled anticholinergic and systemic glucocorticosteroids.)

TMP-Jul10-047 [Mar13]

Young female patient for tonsillectomy with history of bleeding tendency. Which is the most likely cause?
A. Factor V Leiden
B. Protein C deficiency
C. Haemophilia B (Christmas disease)
D. Antithrombin III deficiency
E. Lupus anticoagulant
C. Haemophilia B (Christmas disease)
All others make her hypercoagulable
Factor V Leiden confers resistance to breakdown by protein C & S system. It results in hypercoagulability, and is therefore the wrong answer.

Protein C deficiency results in reduced FV & VIII breakdown and hypercoagulability, and is therefore the wrong answer.

Haemophilia B, is X-linked but the phenotype in females is variable. It does cause increased bleeding. And is the answer to choose.

ATIII deficiency is associated with a hypercoagulable state, and is the wrong answer.

Lupus anticoagulant, causes in vitro prolongation of the APTT but in vivo, results in hypercoagulability, and is the wrong answer.
Amniotic fluid embolism. Cause of death in first half hour ?
A. Pulmonary hypertension
B. Malignant arrhythmia
C. Pulmonary oedema
D. Hypovolaemic shock
A. Pulmonary hypertension
From CEACCP article on AFE 7(5) p 152
' Amniotic fluid and fetal cells cause an increase in both systemic and pulmonary vascular resistances resulting in acute pulmonary hypertension. Survivors of this response develop left ventricular failure and pulmonary oedema '

Thallium scan:
A. High negative predictive value
B. High positive predictive value
C. Not as good as a dobutamine stress echocardiography
A. High negative predictive value
Thallium scanning in coronary artery disease (CAD) using radioactive thallium-201(201-Tl) is a widely available technique which is sensitive, accurate and noninvasive. It detects CAD accurately in patients with:

atypical chest pain and a positive exercise ECG or
typical chest pain and a negative exercise ECG.

In known CAD, it determines the severity, extent and haemodynamic significance of a stenosis.

In patients with recurrent chest pain following coronary artery graft surgery (CAGS) or angioplasty, scanning can detect the presence and severity of any ischaemia, when graft occlusion or restenosis has occurred.

201-Tl has important prognostic value in predicting cardiac complications (death and acute myocardial infarction) in patients undergoing major surgery - usually vascular.

In patients with acute myocardial infarction, it may contribute to risk stratification.

-from Aust Prescr 1994;17:57-61

Possibly 'A' depending on the stem. In the recent vascular surgery webinar/podcast Dr Machlin emphasised that, in the context of using perfusion scans to predict perioperative ischaemic events, a negative study was of much more benefit i.e. they have a high NPV but a low PPV. No one perfusion scan was any better than the others, it just depended what was available in your institution.SGB

From the 2007 AHA guidelines,

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

TMP-Mar-025b [Mar13]

What is the immediate compensation for the dilutional anaemia when 3 litres of normal saline is given at the start of a case?
(Mar13 version - unsure if it said 'immediate')

a. Increased cardiac output
b. Capillary dilatation
c. Increased oxygen delivery
d. Right shift in the oxygen dissociation curve
a. Increased cardiac output
Example of Hypervolemic hemodilution.
a. Increased CO occurs - not sure if it is immediate?!
b. Capillary dilatation - unsure though theoretically can occur due to non-anion gap metabolic acidosis that would result from 3L of NS!
c. Increased O2 delivery - unsure… again if CO increases and acidosis is result of NS infusion then ODC is shifted right… all things point to increased O2 delivery
d. Right shift in ODC - true if acidosis occurs from NS. Not sure if it is immediate?
From Miller Ch 57:
Withdrawal of whole blood and replacement with crystalloid or colloid solution decreases arterial O2 content but compensatory hemodynamic mechanisms and the existence of surplus O2-delivery capacity make acute normovolemic hemodilution safe. A sudden decrease in RBC concentration decreases blood viscosity, thereby decreasing peripheral resistance and increasing cardiac output. If CO can effectively compensate, O2 delivery to the tissues at a hct of 25-30% is as good as, but no better than O2 delivery at a HCT 30-35%.
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
From www.scoliosisjournal.com/content/5/1/8
"Somatosensory evoked potentials (SSEP) measure the integrity of the sensory pathways in the dorsal columns of the spinal cord, by stimulating a peripheral sensory nerve and measuring the electrical response in the brain. The introducetion of SSEP monitoring to spinal surgery has significantly reduced the rate of intraoperative injury."
[Aug12] [Mar13]
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%
CHADS2 (CCF, Hypertension, Age ≥75 years, DM, Stroke/TIA or Thromboembolism)
- pts score would be 1 which gives annual stroke risk of 2.8%
- does that translate to a daily stroke risk of ~0.01% ?
CHA2DS2-VASc (CCF, HT, Age ≥75 years, DM, Stroke/Tia or thromboembolism, Vascular disease (IHD, PVD etc), Age 65-74, Sex category (female))
- pts score would be 3 - scores 2 for being 75 - so his annual stroke risk would be 2.2%
What is the major cause of death in a patient with perforation of the pharynx, oesophagus or trachea?
(Or: Major cause of death following difficult intubation with perforated oesophagus)

A: failure to intubate
B: failure to ventilation
C: sepsis
D: bleeding
C: Sepsis
(though previous grp said B)
From AANA Journal/June 2005/Vol 73 (3):
'The AANA and ASA closed claims analysis underscores seriousness of pharyngoesophageal perforation. Despite the relatively rare occurrence of this type of injury compared to other airway injuries, pharyngoesophageal perforation, especially when diagnosis and treatment were delayed, was associated with the poorest outcome. The late sequelae of undiagnosed pharyngoesophageal perforation are mediastinitis, retropharyngeal abscess, pneumonia, pericarditis, and death. Earlier signs are pneumothorax and pneumomediastinum (Table 1).'
TMP-Mar12-019 [Mar13]

An infant is born with meconium stained liquor and is apnoeic and floppy… your first step should be

a. Stimulate and dry

b. Positive pressure ventilation

c. Suction the trachea
c. Suction the trachea
From www.resus.org guideline 13.5


Meconium stained liquor (See also Guideline 13.4).

Routine intrapartum oropharyngeal and nasopharyngeal suctioning is not recommended for infants born with either clear or meconium-stained amniotic fluid [Class A, LOE II8, 9]

There is insufficient evidence to recommend a change in the current practice of endotracheal suctioning of non-vigorous infants born through meconium-stained amniotic fluid [Class B, expert consensus opinion10-12]. If it is done, it should be performed only:
• Immediately after birth.
• If an experienced practitioner and all needed equipment are immediately available.
• Before the onset of breathing or crying and in infants with decreased muscle tone.

It should not be done if the infant is vigorous and breathing or crying.

It should be done once, and then any subsequent resuscitation that is needed should be commenced expeditiously [Class B, expert consensus opinion].
TMP-Mar12-020b [Mar13]

What is the mechanism of central sensitisation?

A. Increased intracellular magnesium
B. Antagonism of the NMDA receptor
C. Glycine is the major neurotransmitter involved
D. Recurrent a-delta fibre activation
E. Alteration in gene expression
E. Alteration in gene expression
A. false. Magnesium inhibits calcium ions from entering cells by blocking NMDA receptors, which causes an antinociceptive effect. Furthermore, this antinociceptive effect is related to its prevention of central sensitisation caused by peripheral tissue injury.
Increased intracellular CALCIUM levels seem to play a role in initiation of central sensitisation, and the build-up of intracellular Ca is associated with various receptors on postsynaptic neurone of the spinal dorsal horn such as NMDA, AMPA, and glutamate receptors. Of these, NMDA receptor activation has been demonstrated to be essential for initiating and maintaining central sensitization.
Extracellular magnesium blocks NMDA receptor in a voltage-dependent manner.
Ref: Magnesium in the Central Nervous System 2011 (University of Adelaide Press)
B. false. see above reference
C. false. Glutamate is the major neurotransmitter. (See The Journal of Pain, Vol 10, No 9 (September), 2009: pp 895-926)
D. false. C-fiber activity is responsible.
E. true.
TMP-Mar12-027 [Aug12][Mar13]

The time constant of the lung is calculated by

a. Compliance x resistance

b. Compliance plus resistance

c. Compliance /resistance

d. Resistance/compliance
a. compliance x resistance

Compliance - measurement of lung distensibility and expressed as change in volume divided by change in pressure. Normal lung+thorax compliance is 0.1L/cmH2O. Low compliance - more pressure will be needed to deliver given volume (e.g. ARDS). Emphysema is typical of increased lung compliance

Resistance - pressure needed to deliver flow of gas and expressed as change in pressure divided by flow. Normal is 0.5-1.5 cmH2O/L/sec.

Time Constant of the lung is a phenomenon whereby a given percentage of passively exhaled breath will require a constant amount of time to be exhaled regardless of the starting volume given constant lung mechanics. Mathematically is compliance multiplied by airway resistance and resulting value has units of seconds.

TMP-Mar12-028 [Mar13]

The commonest post operative complication in a patient with a # NOF is

a. UTI

b. Pneumonia

c. Delirium

d. Myocardial infarction [?this was NOT an option in Mar 13]
b. Pneumonia
heart failure came in 2nd
TMP-Mar12-031 [Mar13]

What is the commonest symptomatic cardiac condition in pregnancy

a. Mitral stenosis
b. Aortic stenosis
c. Eisenmengers
d. Tetralogy of fallot
e. ?
a. Mitral stenosis
source - dr google.
TMP-Mar12-032 [Aug12][Mar13]

What is the ratio of MAC awake:MAC of sevoflurance

a. 0.2
b. 0.34
c. 0.5
b. 0.34
ref: 'Cerebral Awakening Concentration of Sevoflurane and Isoflurane Predicted during Slow and Fast Alveolar washout' Anesthesia and Analgesia 1993.
Mac awake for sevo was the same for both slow and fast washout.
TMP-Mar12-033 [Mar13]

A man presents to ED after a fight with his son in law in which he is punched in the head- calculate the GCS.

He is confused
He obeys commands and opens his eyes when you ask him to.

6= obey commands
5= localizes pain
4= flexion withdrawal from pain
3= abnormal flexion (decorticate)
2= abnormal extension (decerebrate)
1= nada
5= alert and orientated
4= confused
3= inappropriate words
2= incomprehensible sounds
1= nada
4= open
3= to voice
2= pain
1 = nada
TMP-Mar12-035 [Aug12][Mar13]

The features of Pierre Robin sequence include cleft palate, micrognathia and:

A. Glossoptosis
B. Craniosynostosis
C. Macroglossia
D. Microstomia
A. Glossoptopsis

From Stoelting Anaesthesia and Coexisting disease
"Pierre Robin syndrome consists of micrognathia usually accompanied by glossoptosis (posterior displacement of the tongue) and cleft palate. Mandibular hypoplasia may be responsible for displacement of the tongue into the pharynx, which subsequently prevents fusion of the palate. Acute upper airway obstruction can occur in neonates or infants with Pierre Robin syndrome. Feeding problems, failure to thrive, and cyanotic episodes are other early complications of this syndrome. Associated congenital heart disease is frequent. Fortunately, sufficient mandibular growth during early childhood markedly reduces the degree of airway problems in later years."
TMP-Mar12-037 [Mar13]

A patient having a craniotomy has the CVP/arterial transducers at the level of the right atrium. The head is 13cm above the level of the heart. If the MAP is 80mmHg and the CVP is 5mmHg what is the cerebral perfusion pressure in mmHg

a. 60
b. 62
c. 65
d. 70
e. 75
d. 70
1mmHg = 1.36 cmH2O
13/1.36 = 10mmHg

CPP = MAP - ICP or CVP whichever is greater (normally)

In head up/sitting position with a craniotomy -
Need to take into consideration hydrostatic pressure (ρgh)

ICP is open to atmosphere therefore ICP = zero

CVP corrected for height is negative due to subtraction of the hydrostatic gradient (-5)

Thus CPP = (MAP - ρgh) - the maximum of (ICP-ρgh), (CVP-ρgh) or Patm, where ρgh is hydrostatic pressure at height from skull to BP measurement site, Patm =0

ref: http://www.apsf.org/newsletters/html/2008/summer/11_modified_calculation.htm
TMP-Mar12-038b [Aug12][Mar13]

Patient complains of numbness of the anterior third of his tongue following GA with LMA. Which nerve is involved?
(lingual n. was NOT an option)

A. Glossopharyngeal
B. Facial nerve
C. Superior vagus
D Mandibular n.
B. Facial nerve
Just before entering this foramen, the FACIAL nerve gives off the chorda tympani, which pierces the posterior wall of the tympanic cavity close to the deep surface of the ear drum. It runs forward over the pars flaccida of the tympanic membrane and the neck of the malleus, lying immediately beneath the mucous membrane throughout its course. It passes out through the front of the middle ear by piercing the bone at a canaliculus at the inner end of the petrotympanic fissure. It emerges from this fissure to join the LINGUAL nerve about 2.5 cm below the base of the skull. Through the chorda tympani, taste fibres are conveyed from the anterior two-thirds of the tongue and secretomotor fibres reach the submandibular ganglion.

The literature only speaks of damage to LINGUAL nerve (as strictly speaking this is the nerve that is damaged though it carries fibers from the FACIAL nerve). Other nerves that may be damaged is hypoglossal or recurrent laryngeal. The facial nerve is 'INVOLVED' - depends how question was actually worded!

TMP-Mar12-043 [?Mar13]

What is the most accurate method of determining fetal heart rate in a neonate

a. Palpation of an umbilical vein pulse
b. Auscultation with a stethoscope
c. Palpation of femoral pulse
d. Pulse oximetry
b. Auscultation with a stethoscope
> d. pulse oximetry
Guideline 13-3 from Aust Resus Council Dec2010
Heart rate can be determined by listening to the heart with a stethoscope (most reliable) or in the first few minutes after birth, by feeling for pulsations at the base of the umbilical cord [Class A, expert consensus opinion]. The base of the umbilical cord is preferable to other palpation locations, but if a pulse is not felt at the base of the cord this is not a reliable sign that the heart rate is absent. Other central and peripheral pulses are difficult to feel in newborn infants making the absence of these pulses an unreliable sign.4-6 Pulse oximetry can provide an accurate and continuous display of the heart rate within about a minute of birth [LOE IV 7, 8].
From 2010 International Consensus on CPR Part 11: Neonatal Resus
- Of clinical assessments, auscultation of the heart is the most accurate, with palpation of the umbilical cord less so. However, both are relatively insensitive (LOE 2 and 4).
- Several studies have addressed the accuracy of pulse oximetry in measuring heart rate in the delivery room and have shown the feasibility of pulse oximetry during newborn resus, but none of these studies examined impact of these measurements on resus outcomes (LOE 4)
- Pulse oximetry (SpO2) and HR can be measured reliably after 90s from birth with a pulse oximeter designed to reduce movement artefact and a neonatal probe (LOE 4).
- Preductal values, obtained from the R wrist or hand, are higher than post ductal values. Applying the oximeter probe to the subject before connecting it to the instrument will produce reliable results more quickly (LOE 4).
Your patient given thiopentone by mistake has a porphyric (acute intermittent) crisis with abdominal pain and then seizures. What drug is contraindicated?
a. Phenytoin
b. Morphine
c. Pethidine
d. ?
e. ?
a. Phenytoin
from wiki: "Treatment of seizures in porphyriacs is a difficult situation given that most anticonvulsants are contraindicated (such as phenytoin, carbamazepine, thiopentone) because they induce hepatic P450 enzymes. (This consumes heme and thus reduces the negative feedback on ALA synthesase which is then free to generate heme/porphyrins products.) Drugs considered safe to use in convulsing porphyriacs include: midazolam, propofol, gabapentin and magnesium."

Also, from UTD 'Management of acute intermittent porphyria':
- Seizures are treated by carefully correcting hyponatremia, if present. Almost all anticonvulsant drugs have at least some potential for exacerbating acute porphyries. Clonazepam may be less harmful than phenytoin, barbiturates or valproic acid. Bromides, gabapentin and vigabatrin are safe.
TMP-Sep11-004 [Aug 12][Mar13]

Child with murmur- what would make it more likely for you to investigate if you heard the murmur
A. persist in supine position
B. louder or softer with various manouveres

A. 4/6 loudness
B. ????vibratory/flutter sound
A. 4/6 loudness (Aug12 version)
From http://www.aafp.org/afp/1999/0801/p558.html
"Characteristics of pathologic murmurs include a sound level of grade 3 or louder, a diastolic murmur or an increase in intensity when the patient is standing".

Also from Am J Cardiol. 2008 Oct 15;102(8):1107-10. Samuel A. Levine and the history of grading systolic murmurs:
"Of 19 subjects with grade 3 or 4 murmurs, all were determined to have organic heart disease or anemia. Thus, louder systolic murmurs were found to be a significant finding, as were the cause location and effects of posture".

1/6: very soft and not heard at first
2/6: soft, but can be detected almost immediately by an experienced auscultator
3/6: moderate; no thrill
4/6: loud; thrill just palpable
5/6: very loud; thrill easily palpable
6/6: very very loud; can be heard without placing stethoscope on the chest!

See Table 1 CEACCP article:

Innocent - Asymptomatic, early systolic or continuous (venous hum), blowing/musical/vibratory in quality, No precordial thrill, often varies with posture

Pathological -
symptomatic (hx recurrent chest infections, cyanosis, tachypnoea, sweating, feeding difficulties, failure to thrive),
Diastolic, pan systolic or late systolic
Variable/harsh in quality
precordial thrill sometimes present
Rarely varies with posture (HOCM murmur increases with standing)

Most CHD is identified before 3 months old but any child under 1 yr with a murmur should be referred to a paediatric cardiologist before anaesthesia, even if asymptomatic as significant lesions may be slow to present.
Be suspicious of children with syndromes assoc with CHD
- Down's syndrome
- CHARGE (coloboma of eye, heart defects, atresia of choanae, retardation, genital/urinary abnormalities, ear abnormalities/deafness)
- VATER (vertebral anomalies, anal atresia, TOF, radial dysplasia)
- Turner's
- DiGeorge
In older children watch for decreased extol, squatting during play (tet spells), syncope -- serious heart disease
Family history of sudden death -- suspect HOCM, has autosomal dominant inheritance but often asymptomatic.
ECG - look for ventricular hypertrophy

In an asymptomatic child over 1 yr old with an innocent murmur and normal ECG -- probably safe to proceed with surgery and refer for investigation after operation
Which is the best predictor of poor prognosis with aortic stenosis?
A. chest pain
B. paroxysmal nocturnal dyspnoea
C. syncope
D. palpitations
E. fatigue
B. paroxysmal nocturnal dyspnoea

Patients die within an average of 5 yrs after onset of angina, 3 yrs after onset of syncope and 2 years after onset of heart failure symptoms.
You see a man in his 60s in clinic 1 week prior to laparoscopic cholecystectomy. He has dilated cardiomyopathy with an ejection fraction of 30%, but does not get dyspnoeic with normal activities of daily living. What is the most appropriate management of his heart failure?
A. amiodarone 100mg bd
B. digoxin 250mcg daily
C. enalapril 2.5mg bd
D. metoprolol 100mg bd
E. diltiazem slow release 240mg daily
C. Enalapril 2.5mg BD

See AHA 2007 CVS evaluation for non cardiac surgery AND AHA 2009 update for treatment of heart failure.

Dose of metoprolol is extremely high to start with but he should also be started on a beta blocker.
TMP-Sep11-069 [Mar13]

Interscalene block after injection of 2ml bupivacaine- patient seizure. Most likely injected to
A. Dural cuff
B. Vertebral arteries
C. Internal carotid arteries
D. Jugular veins
E. Subarachnoid (?)
B. Vertebral arteries
various online resources have stated vertebral artery (rather than ICA)

Modified Cormack and Lehane grade - You cannot see beyond the epiglottis and there is a little space between the epiglottis and the posterior pharyngeal wall (? remembered as epiglottis touching posterior pharyngeal wall - this was definitely in MARCH 13 exam)
A. 2a
B. 2b
C. 3a
D. 3b
E. 4
C or ?D (prev grp answer)
D - for March13
From Evidence Based Practice Anaesthesiology Ch17:
- 2a - partial view of glottis visible
- 2b - only arytenoids visible (2b is associated with greater difficulty)
- 3a - epiglottis can be seen and lifted
- 3b - epiglottis seen but CANNOT be lifted

6 grades and 3 functional classes:
easy: laryngeal inlet visible and indubitable under direct vision (1 and 2a)
restricted: posterior glottic structures visible or epiglottis visible and can be lifted (2b and 3a) these views likely to benefit from indirect intubation methods
difficult: epiglottis cannot be lifted or when no laryngeal structures are visible - likely need specialist methods for intubation and may need to be performed blindly (3b and 4)
TMP-Sep11-081 [?Mar13]

Pregnant patient seatbelt, driver- involved in car accident. Suddenly developed severe central chest pain, HR 110, BP 154/80, RR 26, Sat 100%. The most likely cause?
A. Sternal fracture
B. Aortic dissection
C. Pneumothorax
D. Rib fracture
E. Myocardial infarction
B. Aortic Dissection
TMP-Sep11-082 [Mar12][Aug12][Mar13]

Atrial Septal Defect (ASD) murmur is due to flow through which valve?
B. Tricuspid valve
C. Pulmonary valve
D. Mitral valve
E. Aortic valve
C. Pulmonary valve

(where is the ASD spot?)
From Talley O'Connor 5th ed.
- Ostia secundum (90%) where defect does not involve AV valves and ostia primum where defect involves AV valves
- Auscultation: fixed splitting of S2, defect produces no direct murmur but increased flow through R side of heart can produce low pitched diastolic tricuspid flow murmur and more often a pulmonary systolic ejection murmur louder on inspiration.
From emedicine:
- Findings on examination depend on degree of L-R shunt and hemodynamic consequences.
- Hyperdynamic RV impulse due to increased diastolic filling and stroke volume.
- Palpable pulsation of PA and ejection click can be detected because of a dilated pulmonary artery
- S1 is typically split and second component may be increased in intensity due to forceful RV contraction and delayed closure of TV
- S2 is often widely split and fixed due to reduced respiratory variation from delayed PV closure (only seen if PAP is normal and PVR is low). This is the CHARACTERISTIC abnormality found in almost ALL pts with large L-R shunts.
- blood flow across ASD does not cause a murmur at site of shunt because no substantial pressure gradient exists between the atria.
- however ASD with moderate-large L-R shunts -> pulmonary systolic ejection murmur (crescendo-decrescendo) due to increased stroke volume rather than any valvular problems.
- large L-R shunts often have rumbling mid diastolic murmur at TV because of increased flow.

Auscultatory findings may resemble those of mild valvular or infundibular pulmonic stenosis and idiopathic dilation of pulmonary artery.
- these all produce a systolic ejection murmur but DIFFER from ASD by movement of S2 with respiration, a pulmonary ejection click or absence of a tricuspid flow murmur.

The cause of hypoxia in one lung ventilation
A. Blood flow through non ventilated lung
B. Impairment of hypoxic pulmonary vasoconstriction
C. Ventilation perfusion mismatched (?)
A. Blood flow through non ventilated lung

"The major cause of hypoxemia is the shunt of de-oxygenated blood through the non-ventilated lung. " - from www.thoracic-anesthesia.com by Peter Slinger
When stimulating the ulnar nerve with a nerve stimulator, which muscle do you see twitch?

A. opponens abducens

B. abductor pollicis brevis

C. adductor pollicis brevis

D. extensor pollicis

E. flexor pollicis brevis
C. adductor pollicis brevis

When intubating over a bougie / awake fibreoptic, which direction do you rotate the tube to stop it catching on structures in the glottis

A. no change from normal

B. 90 degrees clockwise

C. 90 degrees counterclockwise

D. 180 degrees

E. try either direction
C. 90 degrees counterclockwise

Counter clockwise rotation turns bevel inferiorly. Tip passes under epiglottis, gap is closed and tube enters larynx symmetrically.
Treatment for thyroid storm includes the following EXCEPT

A. propranolol
B. carbimazole
C. plasmapheresis
D. propylthiouracil
E. corticosteroids?
What is the first sign of a total spinal in an AWAKE neonate?

A bradycardia
B hypotension
C loss of consciousness
D ?
What must bystanders ascertain before starting CPR?

A loss of pulse
B loss of breathing
C loss of consciousness
D ..
E ..
What percentage of postdural puncture headaches will resolve in 10 days?

A 90%
B 70%
C 50%
D 30%
E 10%
What would exclude patient from having lung reduction surgery?

A. ?
B. FEV1 <25% predicted
Which has the WEAKEST evidence for prevention of postoperative infection?

A. Intraoperative low fraction inspired oxygen
B. Blood transfusion
C. Intraoperative hypothermia
D. Intraoperative hyperglycaemia
E .?
Which piece of equipment is designed for use with a fibre optic bronchoscope?

A Aintree
B Frovea?
C Cook's airway exchange catheter
TMP-Mar12-042 [Mar13]

Which radiological finding is most consistent with atlantoaxial instability in a patient with rheumatoid arthritis

a. A 9mm gap between the anterior arch of C1 and the odontoid peg
B. Increased sagittal diameter
C. Posterior atlantodental interval >14
D. Midpart of C1 over C2
E. Tear drop sign of C2
all these options seem wrong.
a. false! - 9mm gap is excessive. Diagnosis of atlantoaxial instability can be made with gap > 3-4 mm (depending on reference) ?with flexion extension views.
c. posterior atlantodental interval>14mm - false. From medicine Rheumatoid Arthritis spine imaging: 'Studies suggest PADI is a better method of assessment because it directly measures the spinal canal and therefore shows how much is narrowed by the subluxation. PADI is the distance between posterior surface of the odontoid and the anterior margin of the posterior ring of the atlas. At all cervical levels cord requires minimum canal width f 10mm; CSF 2mm, dura 2mm. Thus, minimum PADI of 14mm is needed to avoid cord compression. Normal spinal canal measures 17-29mm at C1. Boden et al 93 study -> PADI < 14mm 97% ability to detect patients with neuro deficit. Neuro recovery from surgery unlikely if <10mm, more likely if >14mm.
e. tear drop sign of C2 - false. Tear drop sign refers to C2 vertebral body fracture see on the lateral film as a small avulsion on the anteroinferior part of C2. Occurs with hyperextension injuries - Anterior longitudinal ligament attached to C2 vertebral body causes an avulsion fracture.
from http://www.learningradiology.com/archives06/COW%20214-Atlantoaxial%20subluxation/atlantoaxialcorrect.htm:

- Distance between the anterior surface of the dens and the posterior surface of the tubercle of C1 is usually 3 mm or less in adults and 5 mm or less in children
This space is called by many names: predentate space, predental space, atlantodental distance
- The distance may increase slightly on flexion in children but is usually unchanged between flexion and extension in adults
- Forward movement of the atlas on the axis is normally restricted by the transverse ligament
The transverse ligament is the primary restraint against atlantoaxial, anteroposterior movement
- Atlantoaxial instability is defined by an increase in the predentate space of greater then 3 mm in adults and 5 mm in children
- Symptoms will be present when the atlas moves far enough forward on the axis to narrow the spinal canal and impinge on the spinal cord
- The spinal canal is typically widest at the level of C2 and should not be less than 18 mm in ins widest AP dimension

From CEACCP 2006 Anasthesia for adult pt with RA:
- Atlanto-axial joint commonly affected in RA due to attenuation of transverse ligament and erosion of odontoid peg -> leads to instability in 25% of patients with RA. Two main categories of c-spine instability: atlanto-axial subluxation and sub axial subluxation. The latter is uncommon and occurs below C2 and leads to earlier symptoms of nerve compression.
- Anterior (in 80%). C1 vertebra moves forward on C2 due to transverse ligament destruction -> risk of spinal cord compression by odontoid peg. Subluxation exists when distance between atlas and odontoid peg exceeds 4mm in pts >44yo and 3mm in younger pts. Anterior AAS is worsened by neck flexion
- Posterior (in 5%). Destruction of peg may cause backward movement of C1 on C2 - may be seen on lateral extension views. Worsened by neck extension.
- Vertical (10-20%). Destruction of lateral mass of C1 -> sublimation of peg through foramen magnum and compression of the cervico-medullary junction.
- Lateral or rotatory subluxation. Results from degenerative changes in C1/C2 facet joints. It can lead to spinal nerve compression and vertebral artery compression.
Neurosurgeon about to clip a large cerebral aneurysm - what drug can you give just prior to clipping that will assist him?

A Mannitol
B Frusemide
C Adenosine