*part Ii 2004A New Mcqs

Front 1

150. In children with upper respiratory tract infections (URTIs) presenting for general anaesthesia
A. airway events are less likely if an endotracheal tube is used
B. oxygen desaturation to under 90% is more likely (compared to children without URTIs)
C. parental smoking does NOT affect the incidence of airway events
D. peri-operative breath holding is NOT more likely (compared to children without URTIs)
E. the site of surgery has no effect on the incidence of airway events

Back 1

B


Anaesthesia & Analgesia 2005; 100:59-65 - "Anaesthesia for the child with an upper respiratory tract infection: still a dilemma?"

Parnis et al. (2), in a study of 2051 pediatric surgical patients, identified 8 clinical predictors of anesthetic complications. These predictors included airway management (endotracheal tube [ETT] > laryngeal mask airway [LMA] >face mask), the parents’ statement that the child had a “cold,” a history of snoring, passive smoking, induction anesthetic (thiopental>halothane>sevoflurane >propofol), presence of sputum, presence of nasal congestion, and use of an anticholinesterase (muscle relaxant not reversed>reversed).

Tait et al. (3) examined the incidence of and risk factors for adverse respiratory events in 1078 children undergoing a variety of surgical procedures. Results showed that children with active and recent URIs (in the last 4 wk) had significantly more episodes of overall respiratory events, breath-holding, major arterial oxygen desaturation (Spo2 < 90%), and severe coughing compared with children with no URTIs.

Front 2

149. The electrical requirement that distinguishes a "cardiac protected area" from a "body protected area" is the
A. equipotential earth
B. isolation transformer
C. line isolation monitor
D. maximum leakage current to patient limit of 500 microamperes
E. residual current device

Back 2

A


Body Protected Area
These areas are designed for procedures in which patients are connected to equipment that lowers the natural resistance of the skin. Applied parts such as electrode gels, conductive fluids entering the patient, metal needles and catheters provide an easy pathway for current to flow.
The main occurrence of injury from Body-Type procedures is from high current levels causing electric shock. A direct connection to the patient's heart is not present so the risk of 'Microelectrocution' - fibrillation from minute current levels - is reduced.
Residual Current Devices (RCD) or Isolation Transformers and Line Isolation Monitors (LIMís), are used in Body Protected areas to provide protection against electrocution from high leakage currents. Body-Protected Areas are identified with this sign.

Cardiac Protected Area
Where the procedure involves placing an electrical conductor within or near the heart, protection against fibrillation induced from small leakage currents is required. Electrical conductors used in these procedures include cardiac pacing electrodes, intracardiac ECG electrodes and intracardiac catheters.
Equipotential earthing in conjunction with RCD's or LIM's provides protection against microelectrocution in Cardiac-Type procedures.
Fault currents are reduced to magnitudes that are unlikely to induce fibrillation. Used in conjunction with RCD's or LIM's, the magnitude and duration of any fault currents sourced from equipment are limited.
Cardiac-Protected Areas are identified with this sign.

http://www.rch.org.au/bme_rch/safety.cfm?doc_id=4698 - body

Front 3

148. A 20 kilogram child has a haemoglobin of 60 g.l-1. The child is normovolaemic and there is no on-going blood loss. The volume of packed cells required to increase the haemoglobin level to 100 g.l-1 is
A. 80 ml
B. 160 ml
C. 320 ml
D. 500 ml
E. 750 ml

Back 3

C


A simple solution is to use Frank Shann's equation:
4ml/kg of packed cells will increase Hb by 10g/L.
Thus 4x20x4 = 320 mls

Front 4

147. The output of a diathermy machine does NOT cause patient electrocution because the
A. current is too low
B. current travels on the surface of the body
C. frequency is too high
D. return electrode is never placed between the heart and the operating site
E. voltage is too low

Back 4

C


Rosewarne Anaesthetic Equipment:
A. False – typical current 200mA up to 500mA, macroshock (VF) occurs at 100mA, microshock occurs at 100A
B. False – travels through the tissue, producing intense local heating of the tissue
C. True – “Very high frequency currents (0.25-3MHz) will produce intense local heating, whereas the tendancy for the heart to fibrillate declines as the applied frequency increases”
D. ?True – preferable. The return (dispersive, indifferent) electrode should be placed close to the operative site
E. False – typical diathermy apparatus produces cutting voltage of 200 and coagulation voltage of 8500 at 750kHz

Front 5

146. In patients with myasthenia gravis
A. aminoglycosides have no effect on the skeletal muscle weakness
B. corticosteroids are useful as first line therapy
C. myocarditis can result in heart block
D. regular plasmapheresis produces long term benefits
E. thyroid function is not altered

Back 5

C

Front 6

145. When considering prophylactic anti-emetic therapy in adults, which of the following statements is FALSE?
A. Constipation is a side-effect of ondansetron treatment.
B. Hypnosis before surgery has NOT been shown to be beneficial.
C. Intramuscular ephedrine has been shown to be effective.
D. Prophylactic doses of 5HT3 antagonists are approximately four times those needed to treat vomiting.
E. Transdermal scopolamine is effective if given early.

Back 6

B


A - True
" The number-needed-to-harm with a single dose of ondansetron is 36 for headache, 31 for elevated liver enzymes, and 23 for constipation."
B - False in 2004
" Hypnosis has been found to be effective when compared with placebo"
but in the 2007 guideline, clearly states:
" There is inadequate evidence to suggest that hypnosis is a promising modality for PONV prophylaxis."
C - True
" Similarly, it was suggested that the phenylethylamine, ephedrine, 0.5 mg/kg IM, may have an antiemetic effect when administered at the end of surgery."
D - True
" In general, treatment doses of the 5-HT3 antagonists are about a quarter of those used for prophylaxis."
E- True
" A systematic review of transdermal scopolamine shows that it is useful as an adjunct to other antiemetic therapies . The patch effectively prevents nausea and vomiting postoperatively (NNT = 6). It is applied the evening before surgery or 4 h before the end of anesthesia due to its 2–4 h onset of effect, which may be problematic in some centers. "

Front 7

144. The optimal patient position for anaesthetising a woman at term with an umbilical cord presenting externally is
A. knee-chest (i.e. on hands and knees)
B. left lateral (i.e. on side with left side down)
C. supine with head down (and lateral tilt)
D. supine with head elevated (and lateral tilt)
E. supine and level (with lateral tilt)

Back 7

E

Front 8

143. Clinical features of hepatitis C include
A. a sustained response rate of 60% with interferon treatment
B. availability of pre and post exposure prophylaxis
C. a chronic infection rate of approximately 10%
D. chronic sequelae which may be dependent on HCV genotype
E. protective immunity after infection

Back 8

D


A – false. “Antiviral treatment with pegylated interferon monotherapy for 12–24 weeks is effective in
achieving SVR rates over 80%”. Lancet.
B – false. “The development of effective pre- and postexposure prophylaxis is complicated because of the genetic diversity of HCV. No effective post-exposure prophylaxis (immune globulin, antiviral agents) is available for hepatitis C”. WHO GAR.
C – false. Chronic infection approx 85-90%. Lancet.
D – true. “Viral genotype and baseline hepatitis C virus RNA levels seem to be the most important
predictors of response. More than 80% of patients infected with genotype 2 or 3 can be expected to eradicate the virus after six months of therapy. Unfortunately, genotype 1 infection predominates in developed countries.
E – false. “The absence of a clearly defined protective immune response after natural infection complicates the prospects of ultimately developing a vaccine against HCV infection”. WHOGAR.

Front 9

142. Multiple sclerosis in pregnancy is
A. a contraindication for epidural anaesthesia in labour
B. a contraindication for the use of suxamethonium
C. associated with an increased caesarean section rate
D. associated with an increase in relapse rate postpartum
E. associated with a worse fetal outcome

Back 9

D


• A - False. "Epidural anaesthesia during labor is considered safe for women with MS, (Achiron et al. 2004;Confavreux et al. 1998) and is preferred to spinal anaesthesia due to presumed neurotoxic effects to demyelinised spinal neurons with a potential postoperative worsening of the disease. This preference is not supported by robust studies." MS and pregnancy: pregnancy, delivery and birth outcome in woman with multiple sclerosis
• B – False – though could be true if the patient was significantly debilitated and immobile
• C - Historically No, but apparently new data suggests true: "MS also increased the duration of the second stage of labor and increased the need for induction and operative intervention during birth. The increased rate of planned caesarean section might be justified, since we found that forceps and vacuum extraction occurred with high frequency despite the increased planned caesarean section rate in MS women compared to the references." MS and pregnancy: pregnancy, delivery and birth outcome in women with multiple sclerosis.
• D - True. "The rate of relapse may decrease during pregnancy and the latter is usually well tolerated, although the rate of relapse may increase in the first three months postpartum before returning to the basal rate." Analgesia, Anaesthesia and Pregnancy: A Practical Guide By Steve Yentis, Anne May, Surbhi Malhotra, David Bogod
• E - False. "There are few large-scale studies on the effect of MS on pregnancy, delivery and birth outcome. Prospective data from the PRIMS study showed no effect of MS on the risk of miscarriage, stillbirth and congenital malformations“ Multiple sclerosis and pregnancy: pregnancy, delivery and birth outcome in woman with multiple sclerosis.

Front 10

141. All of the following may be useful in the treatment of ventricular fibrillation due to bupivacaine cardiotoxicity EXCEPT
A. adrenaline
B. diazepam
C. intralipid
D. propofol
E. vasopressin

Back 10

B


From OHA 2nd ed p1071:
• CPR
• bretylium no longer available and amiodarone is antiarrhythmic of choice
• Vasopressors such as adrenaline and vasopressin should be used
• Propofol "may" decrease cardiotoxicity, supress bupivacaine induced seizures, reduce the effective tissue levels of bupivacaine and act as an antioxidant to improve recovery from tissue hypoxia

Front 11

140. Concerning backache in obstetrics
A. gestational backache occurs in 10-20% of pregnant women
B. posterior pelvic pain is much more common than lumbar pain during pregnancy
C. relaxin production is decreased during pregnancy
D. risk factors include smoking history and ethnicity
E. the principal diagnostic tool is magnetic resonance imaging (MRI)

Back 11

B & D


Curr Opin Anaesthesiol. 2003 Jun;16(3):269-73
A – False. Incidence 40-90%
B – True. The locations of backache can be thoracic or the low back. The pain occurring in the low back can further be classified into lumbar pain (LP) and posterior pelvic pain (PPP). PPP is four times more common than LP during pregnancy.
C – False. The etiology of GBP is multifactorial. The most widely accepted explanations relate to the secretion of relaxin, a hormone that facilitates the loosening of the supporting structure, tendons, and ligaments, making the spine and sacroiliac joints (SIJs) ‘less stable’, and the expansion of the uterus causing pregnant women to shift their center of gravity resulting in back strain.
D – True. The risk factors that contribute to the development of GBP are: a history of backache, ethnic background, smoking, parity, type of work, age, fetal weight, and rapid weight gain over a short period of time. Other pathological changes such as lumbosacral disc herniation, spondylolisthesis, coccydynia can also cause GBP
E – False. The evaluation of pregnancy-induced backache begins with an in-depth history and a thorough physical examination. Once a medical history has been completed, a physical examination, with emphasis on the back and a detailed neurological examination, should be performed. It is a relative contraindication to utilize radiographs as part of a backache work-up during early pregnancy. Magnetic resonance imaging is a safe means of assessing the spine and pelvis. And only if red flags: bladder or bowel dysfuntion, saddle anaesthesia, progressive neurological deficit etc.

Front 12

139. Separation anxiety in most infants begins at
A. 2 - 4 months
B. 4 - 6 months
C. 6 - 8 months
D. 8 - 10 months
E. 10 - 12 months

Back 12

C


A & A 2001 93 (1): 98-105. The Management of Preoperative Anxiety in Children: An Update
Mary Ellen McCann, MD, FAAP* and Zeev N. Kain, MD, FAAP.

In the first weeks of life, infants are able to discriminate among people, but will accept care and comfort from adults other than their parents (14). By 3 mo of age, however, infants begin to respond differently to familiar and unfamiliar people. Older infants smile more at familiar people and may even try to engage their attention Separation anxiety usually begins at 7–8 mo of age and peaks around 1 yr of age.

Front 13

138. The following statements regarding prolonged QT syndrome are true EXCEPT
A. all patients with the syndrome have a prolonged QTc (QT interval corrected for heart rate)
B. a QTc greater than 500 msec is considered prolonged
C. exercise testing may provoke a prolongation of the QTc
D. T and U wave abnormalities are common
E. T wave alternans is pathognomonic of the syndrome

Back 13

A


Booker PD, Whyte SD, Ladusans EJ. Long QT syndrome and anaesthesia. Br J Anaesth. 2003 Mar;90(3):349-66
A - False (therefore answer) --> "6% of patients with symptomatic LQTS have a normal QTc interval."
B - True --> "QTc interval of >440 ms is considered prolonged", therefore > 500 msec is definitely prolonged
C - True --> "Exercise testing of patients with LQTS may provoke prolongation of the QTc"
D - True --> "T wave and U wave abnormalities are common in LQTS"
E - True --> "A pathognomonic feature of LQTS is so-called T wave alternans, where there is beat- to-beat variation in T wave amplitude."

Front 14

137. Intra-nasal topical cocaine used in nasal surgery
A. has a duration of action of the order of 6 hours
B. is metabolised more quickly by the liver if the patient is using ecothiopate eye drops
C. is typically used in a dose of approximately 5 ml of 5% solution in an adult
D. may be metabolised more slowly in patients with liver disease
E. reaches a peak plasma concentration in 3 hours

Back 14

D


A false
• Duration for topical use, lasts only 20-30min (OHA)
B false.
• Metabolised quantitatively more by liver b/c plasma esterases inhibited by ecothiopate. But not necessarily faster by the liver.
C false
• Most hospitals stock only 4%
• Goodman + Gillman says max dose is 150mg for 70kg male, comes in 1-4%
o Dose is 1-3mg/kg (in paediatric) OHA p.1116
o OHA p.606 says Cocaine can be used 4-10% and maximum dose of 1.5mg/kg
 Moffet solution
• 2ml Cocaine 8%
• 1ml adrenalin 1:1000
• 2mL sodium bicarbonate 1%
D true
• "Cocaine is metabolised by plasma and liver cholinesterases to water-soluble metabolites that are excreted in urine. Plasma choliesterase activity is decreased in parturients, neonates, the elderly, and patients with severe underlying hepatic disease." Stoelting
E false
• 2-5 minutes for peak effect in topical anaesthesia

Front 15

136. In hemiplegic patients
A. neuromuscular blockade should be monitored on the affected side
B. suxamethonium may cause a hyperkalaemic response 3 months to one year after the stroke
C. there is resistance to non-depolarizing muscle relaxants in the unaffected muscle groups
D. the response to non-depolarizing muscle relaxants is similar to that seen in paraplegic patients
E. ventricular fibrillation after suxamethonium has been documented

Back 15

E

Not that clear about the rest, but E is true

Front 16

135. Which of the following statements regarding C1-esterase deficiency is FALSE ?
A. Attacks can be identified by low C4 complement levels.
B. Estrogen receptor blocking drugs help prevent attacks.
C. Severe abdominal pain can be a presenting complaint.
D. Specific plasma extract can be used prophylactically.
E. The condition is a purely inherited trait.

Back 16

E


o A - False. Emedicine: "The C4 concentration is almost always decreased during attacks and is usually low between attacks."
o B - False. From Stoelting: " Androgens such as danazol and stanozolol have been the mainstay of prophylactic therapy, both long term and prior to surgery or dental manipulation”
o C - False. Emedicine: Abdominal attacks usually present with excruciating pain, nausea, vomiting, and/or diarrhea
o D - False. "C1 INH concentrate offers specific rapid therapy and can be used to treat acute attacks. It may also be used for acute prophylaxis”
o E - True. Emedicine: "The most common hereditary form of angioedema results from an autosomal dominant deficiency or dysfunction of C1 esterase inhibitor. . however... C1 esterase inhibitor deficiency can be acquired by patients with lymphoproliferative disorders”

Front 17

134. Post-operative nausea and vomiting in children
A. is more common in females (than males) before puberty
B. is more common in children under two years of age (than older)
C. is rare following orchidopexy
D. is twice as frequent in children over the age of three, compared to adults
E. should not be treated with ondansetron

Back 17

D

From Concensus guidelines: >3 yrs incidence 40% (almost twice adults)

Front 18

133. Conditions which are more commonly associated with exomphalos, compared to gastroschisis include
A. amniotic fluid peritonitis
B. cardiac abnormalities
C. fluid and electrolyte disturbances
D. hypothermia
E. prematurity

Back 18

B


CEACCP Poddar and Hartley 9 (2): 48. (2009). Exomphalos and gastroschisis
Up to 72% of neonates born with exomphalos will have an associated congenital anomaly. Approximately 20% of these are cardiac in origin, most commonly tetralogy of Fallot or atrial septal defect.

Other associated anomalies include:
• Chromosomal trisomies—trisomies 13, 14, 15, 18, or 21;
• Beckwith–Wiedemann syndrome— macroglossia, giantism, and pancreatic islet cell hyperplasia;
• pentalogy of Cantrell—exomphalos, dia- phragmatic hernia, sternal defect, cardiac anomaly (commonly ventricular septal defect), and pericardial defect. This should be suspected if an infant with exomphalos presents with cyanosis.
• lower midline syndrome—bladder or cloacal exstrophy, imperforate anus, colonic atresia, vertebral anomalies, and meningomyelocele.

Front 19

132. The drug most likely to cause an increase in intra-ocular pressure is
A. ketamine
B. propofol
C. pancuronium
D. diazepam
E. etomidate

Back 19

A

Front 20

131. Satisfactory sedation after 0.5 mg.kg-1 of oral midazolam as a premedication in children usually occurs after
A. 5 minutes
B. 15 minutes
C. 25 minutes
D. 35 minutes
E. 45 minutes

Back 20

B

"The dose of oral midazolam... usually results in a satisfactorily sedated child in approximately 10-15 min with a peak effect occurring at approximately 20-30 min, with minimal to no delay in recovery, even for brief procedures." (Cote, Preoperative preparation and premedication, BJA 1999, 83:16-28)

Front 21

130. Osteogenesis imperfecta is associated with
A. blindness
B. cleft palate
C. hypothermia
D. mitral stenosis
E. thrombocytopaenia

Back 21

B


• A. False - deafness not blindness
• B. True - assoc. with cleft palate
• C. False - HYPERthermia
• D. False - Aortic and mitral regurgitation NOT stenosis
• E. False - Platelet count is usually normal, but defect is qualitative

Front 22

129. The herbal medicine associated with enhanced bleeding is
A. echinacae
B. ginko
C. golden seal
D. kava-kava
E. St. John's wort

Back 22

B


Blue book AA 2003 Herbal Medicine and PerioperativeCare — An Australian Perspective. GRAUER, R
Adverse Coagulation Effects
Ginger, Garlic, Gingko, Ginseng, and Feverfew: all possess antiplatelet activity and there have been reports of unanticipated excessive surgical bleeding with them

Front 23

128. During surgery to repair an aneurysm of the aortic arch using circulatory arrest, the most effective method to minimise cerebral injury is
A. antegrade cerebral perfusion via the carotid arteries during the arrest period
B. retrograde cerebral perfusion via the internal jugular veins during the arrest period
C. intravenous methyl prednisolone prior to the arrest period
D. intravenous thiopentone prior to the arrest period
E. systemic hypothermia to 20oC during the arrest period

Back 23

E


Ultimately it is the hypothermia providing the best neuroprotection, but as suggested in E below other methods may also be required (i.e. A)
Ann Thorac Surg. 2007 Feb;83(2)
A - True
Initial results with normothermic or mildly hypothermic cerebral perfusion were disappointing, but the combination of hypothermia with selective ACP has been very successful in providing cerebral protection both in laboratory studies and in clinical practice If the total time necessary for aortic arch repair requiring arrest of the antegrade circulation is moderately long, between 40 and 80 minutes, the incidence of temporary neurologic dysfunction, which reflects the adequacy of cerebral protection, is clearly lower with ACP than with any other alternative. 11 Thus, ACP is the technique of choice when the need for prolonged arrest of antegrade circulation is anticipated. However, in a large series of patients, even ACP was shown not to be safe indefinitely: in patients with very prolonged ACP (>80 minutes), an increased duration of ACP was a risk factor for adverse outcome, defined as permanent stroke or death.”
“Aortic arch surgery necessitates interrupted brain perfusion and carries a risk of brain injury. Various brain protective techniques have been advocated to reduce risk including hypothermic arrest and retrograde or selective antegrade perfusion. Knowledge of the pathophysiologic consequences of deep hypothermia, may aid the surgeon in deciding when to initiate circulatory arrest and for how long. Retrograde cerebral perfusion use was advocated to prolong safe arrest durations but may not improve outcomes. Selective antegrade cerebral perfusion appears to have become the preferred method of brain protection.”
B – false
“long durations of RCP are associated not only with high rates of temporary neurologic dysfunction, but also, in some studies, with an increased risk of stroke and death after aortic surgery”
C, D – false (though thio may temporarily ↓O2 consumption)
E – True
Best answer as this is combined with all answers
“Hypothermic circulatory arrest (HCA) was the first technique to gain wide acceptance for use in surgery of the aortic arch. It has the virtue of simplicity, permitting a field essentially free of blood and cannulas, allowing thorough inspection of the aneurysm and a careful open distal anastomosis. However, awareness of a relatively high incidence of neurologic complications after aortic arch surgery with HCA led to the gradual recognition that the safety of HCA depends on very careful implementation and that HCA cannot be relied on to protect the brain completely during prolonged procedures.

Front 24

127. A fourteen-year-old girl is scheduled to have a termination of pregnancy. With regard to consent for this procedure, which of the following statements most truly reflects the law in Australasia?
A. A fourteen-year-old girl is able to give consent independently of her parents/guardians if she is considered, by her treating doctors, to be of sufficient maturity to understand the issues.
B. A fourteen-year-old girl is able to give consent independently of her parents/guardians, only if a court deems her sufficiently mature.
C. Minors are not able to give consent, independently of parents/guardians, until sixteen years of age.
D. Minors are not able to give consent, independently of parents/guardians, until eighteen years of age.
E. Only life-saving treatment may be administered to a fourteen-year-old without parental/guardian consent.

Back 24

A


The common law position relating to a minor's competency to consent to treatment was established by the English House of Lords decision in Gillick v West Norfolk and Wisbech Area Health Authority [1986] AC 112, which was approved by the High Court of Australia in Secretary, Department of Health and Community Services v JWB and SMB (Marion's case) (1992) 175 CLR 218. In Gillick, it was held that the authority of a parent decreases as their child becomes increasingly competent. Gillick prescribes that the parental right to determine their child's treatment terminates once a child under the age of 16 is capable of fully understanding the medical treatment proposed. Whether a particular child has the requisite intelligence and understanding to give a valid consent is a question of fact.

While Gillick holds that a minor who has a requisite level of understanding may consent to treatment, this does not amount to a corresponding right to refuse treatment. Hence, an adolescent who is competent according to the principles established by Gillick, will generally lack the capacity to refuse life-saving treatment if his/her parents are prepared to consent to it.

Front 25

126. To achieve maximum anaesthesia with minimal risk of trauma to veins, the tip of a needle used for a medial peribulbar injection should be advanced no further past the equator of the globe than
A. 5 mm
B. 10 mm
C. 15 mm
D. 20 mm
E. 25 mm

Back 25

B



Total globe length should be less than 25mm for this block, and the equator is therefore at 12.5mm. So the tip of the needle shouldn't be more than 12.5mm past the equator

Front 26

125. Post-operative ischaemic optic neuropathy
A. has a good visual prognosis if optic nerve decompression is performed within 24 hours
B. is an uncommon cause of post-operative blindness
C. is commonly due to emboli to the ophthalmic artery
D. is not associated with hypotension and low haematocrit
E. may present as a confusional state

Back 26

E


A. false. Poor prognosis and not associated with compression of nerve
B. false, most common cause
C. false due to hypotension/haemorrhage
D. false, is associated with hypotension and low hct
E. true, 'the loss of vision itself may lead to a confusional state' "Postoperative ischaemic optic neuropathy" (Anes Analg 1995 (80)1018-29 )

Front 27

124. Respiratory function in quadriplegics is improved by
A. abdominal distension
B. an increase in chest wall spasticity
C. interscalene nerve block
D. the upright position
E. unilateral compliance reduction

Back 27

B

Increased muscular tone promotes rib cage stability - reduce paradoxical chest wall movement.

Front 28

123. Intubation of patients with acute C5 spinal cord injury
A. can only be safely performed using awake fibreoptic intubation
B. is necessary in most patients for secretion clearance
C. is necessary in most patients to avoid atelectasis
D. is associated with a low risk of aspiration
E. may be safely facilitated by the use of suxamethonium

Back 28

E


From the BJA CEPD review 2002:
• options for intubation are:
o (i) direct laryngoscopy and intubation in the presence of manual in-line immobilisation
o (ii) blind nasal intubation if there is no compromise to the cribiform plate
o (iii) blind oral intubation using the intubating laryngeal mask airway (ILMA)
o (iv) awake fibre-optic intubation
o (v) surgical airway if intubation is not possible
• 'Awake fibre-optic intubation (...) requires skill and specialist equipment and is often impractical in the acute situation, particularly if intubation is required urgently. The choice depends on the situation and experience of the individual.'
• 'Direct laryngoscopy with in-line immobilisation is a safe and acceptable method'
• 'Succinylcholine is the muscle relaxant of choice. The release of potassium associated with the use of succinylcholine in spinal cord injury has not been shown to be a problem until 3 days post-injury at the earliest.'"

Front 29

122. The peri-operative use of beta-adrenergic antagonists
A. exerts a cardioprotective effect entirely by reduction of heart
rates
B. is best started intra-operatively
C. is contraindicated in patients with chronic airways
limitation
D. is contraindicated in patients receiving angiotensin
converting enzyme inhibiting drugs (ACE inhibitors)
E. is safe in patients with moderately impaired ventricular
function

Back 29

E


A – False.
• beta-blocker beneficial in preserving myocardial oxygen supply and demand, both from a reduction in heart rate and also reduction in myocardial contractility. Also anti-arrhythmic properties. And decreased haemodynamic triggers which influence plaque rupture.
B – False
• Optimal timing of B-blocker administration is not known. Most of the well known studies start B-blocker preop close to time of surgery. Mangano – atenolol 30 minutes preop, Poldermans - bisoprolol 1 week preop, POISE – metoprolol 2-4 hours preop
C – False
• Only a relative contraindication in presence of COAD
D – False
E – True

Front 30

121. Induced mild hypothermia (core temperatures of 32 - 34oC) following ventricular fibrillation and successful cardiopulmonary resuscitation in adults
A. does not improve neurological outcomes, but may improve
other outcomes
B. is contraindicated because despite improvement in
neurological outcomes, it is associated with major complications
C. is contraindicated because it worsens all outcomes
D. should only be established using cardio-pulmonary bypass
E. will significantly improve neurological outcomes

Back 30

E


NEJM 2002. 346 (8):549-556
The Hypothermia after Cardiac Arrest Study Group (2000) [1] in NEJM compared the outcomes of patients treated with mild hypothermia or normothermia following cardiac arrest from ventricular fibrillation. Neurologic outcome (using a disability scale) and death were measured at 6 months. Patients were randomly assigned to hypothermia (n = 137) or normothermia (n = 138).
Seventy-five patients in the hypothermia group had a favorable neurologic outcome, as compared with 54 patients in the normothermia group (p = .009). It was estimated that to prevent one unfavorable neurologic outcome, 6 patients would require hypothermia treatment. Similarly, to prevent one death, 7 patients would need treatment. Patients in the normothermia group were more likely to have diabetes, coronary heart disease, or have received basic life support at the onset of the cardiac arrest. There was no change in the outcome results after adjustment for these parameters. Sepsis was slightly more likely to occur among patients receiving hypothermia, but the total number of complications was not significantly higher in the hypothermia group. Patients receiving hypothermia following cardiac arrest had an improved chance of survival and favorable neurologic outcome at 6 months.

Front 31

120. Amniotic fluid embolism is associated with
A. augmentation of labour
B. history of allergy
C. maternal age
D. method of delivery
E. parity

Back 31

B & C


RWH Handbook – Higher rates of AFE with:
• Multiple Births
• Medical induction of labour
• Increasing maternal age
• Caesarian section or instrumental delivery
• Polyhydramnios
• Uterine rupture
• Cervical lacerations
• Placenta praevia/abruptions
• Pre-eclampsia
• Mothers with multiple allergies
• Male fetuses

Parity is not a risk factor – though in one analysis by Morgan, 88% of cases were multiparous women

Front 32

119. The most important operating theatre hazard during the use of laser for ophthalmic procedures is
A. burns to the skin of theatre personnel
B. combustion of patient drapes
C. combustion of surgical tubing
D. eye damage to theatre personnel
E. unintended burns to patient retina

Back 32

D

D probably most true given it specifically asks for OT hazard

Front 33

118. A patient is requiring 70 mg per day of morphine by continuous subcutaneous infusion, for the treatment of cancer pain. You are asked to change the patient to oral morphine. An appropriate initial order for slow release oral morphine would be
A. 35 mg twice a day
B. 70 mg twice a day
C. 100 mg twice a day
D. 200 mg twice a day
E. 300 mg once a day

Back 33

C


Equianalgesic dose of oral morphine is 3x parenteral = 210mg
Twice daily dosing = 100mg

Front 34

116. In a patient with aortic stenosis,
A. aortic regurgitation is rarely seen
B. loss of sinus rhythm is poorly tolerated
C. presentation is usually with a cerebrovascular accident
D. the characteristic compensation of the left ventricle is dilatation
E. the most common aetiology is rheumatic calcification

Back 34

B

Front 35

115. One hundred vomiting patients receive ondansetron. If 25 patients, who would not have stopped vomiting had they received a placebo, stop vomiting, then the number needed to treat (NNT) for ondansetron to stop vomiting is
A. 1.3
B. 4
C. 25
D. 100
E. can't be calculated without information on placebo success rate

Back 35

B


NNT = 1/absolute risk
Absolute risk = 25/100
NNT = 100/25 =4

Front 36

114. The amount of fluid drawn into the vascular space when 100 ml of 25% albumin is administered intravenously is approximately
A. 100 - 200 ml
B. 200 - 300 ml
C. 300 - 400 ml
D. 400 - 500 ml
E. 500 - 600 ml

Back 36

C


Almost REPEAT
Stoelting:
"Administration of hypertonic albumin will draw 3 to 4 ml of fluid from the interstitial space into the intravascular space for every 1ml of albumin administered".

Front 37

113. In patients with carcinoid syndrome
A. bradykinin causes bronchodilation
B. heart disease develops in 5-10% of patients
C. symptoms are produced by over 15 active compounds
D. tricuspid stenosis is a common pathological feature
E. treatment with octreotide may lead to hypoglycaemia

Back 37

C


A – False. Bradykinin causes bronchoconstriction
B – False. 50%. About 10% have left sided disease, but right sided disease is far more common.
C – True. About 20 vasoactive substances all up.
D – False. TR and PR are the most common. PS less so, and TS very uncommon
E – False. UpToDate Drug information states that octreotide treatment leads to hyperglycaemia in 15-27% of people

Front 38

112. The observed fall in cardiac output induced by carbon dioxide pneumoperitoneum (with intra-abdominal pressures below 12 mmHg), during laparoscopic cholecystectomy is primarily a result of
A. a fall in venous return to the heart
B. an increase in systemic vascular resistance
C. increased pressure transmitted to intra-thoracic baro¬receptors
D. increased pulmonary vascular resistance
E. reflex bradycardia

Back 38

A


Pneumoperitoneum:
- increased SVR >> drop in CO, thus MAP increases.
- increased VR if IAP<15; else decreased VR.
- decreased CO due to decreased VR, increased SVR.
- increased CVP due to increased ITP.

Front 39

111. Severe bradycardia during spinal anaesthesia, in adults,
A. is more common in vagotonic patients
B. is usually the result of hypoxaemia
C. rarely occurs in young healthy patients
D. should be treated by the prompt administration of atropine
E. usually occurs within 15 minutes of spinal insertion

Back 39

A


Almost REPEAT
Cardiac Arrest During Spinal Anesthesia: Common Mechanisms and Strategies for Prevention, in Anesth Analg 2001;92:
• "Although many factors can contribute to cardiac arrest during spinal anesthesia, vagal responses to decreases in preload often play a key role. Patients with risk factors for bradycardia or overt vagal symptoms during spinal anesthesia appear to be at increased risk for cardiac arrest during spinal anesthesia."
• "Because a high degree of cardiac vagal activity can occur during spinal anesthesia , patients with strong resting vagal tone should be at increased risk for cardiac arrest during spinal anesthesia. The term “vagotonia” describes the clinical situation of resting bradycardia, atrioventricular block, or complete atrioventricular dissociation that is present in 7% of the population. In vagotonic patients asystole can occur when procedures that increase vagal activity are performed”

Front 40

110. An elective surgical patient with hypertrophic obstructive cardiomyopathy becomes hypotensive (systolic pressure 70 mmHg and heart rate 60 beats.min-1) during intravenous induction of anaesthesia. The most appropriate initial therapy would be aimed at increasing
A. blood volume
B. degree of myocardial depression
C. heart rate
D. myocardial contractility
E. vasoconstriction

Back 40

E


Between A and E – E seems more appropriate given the decrease in afterload that is occurring with induction
Stoelting p 118
• Management is directed towards minimising LVOT obstruction, any drug that decreases myocardial contractility or increases preload/afterload reduces LVOT obstruction.
OHA:

Front 41

109. A patient with pulmonary hypertension secondary to lung disease presents for laparotomy. The anaesthetic technique LEAST likely to exacerbate the pulmonary hypertension is endotracheal intubation and controlled ventilation with
A. high dose opioids, N2O and O2
B. isoflurane and O2 / air
C. isoflurane, N2O and O2
D. ketamine and O2 / air
E. propofol and O2 / air

Back 41

B

Answer: B>E (propofol does not inhibit HPV, iso inhibits HPV)

Front 42

108. Features of an attack of acute intermittent porphyria include each of the following EXCEPT
A. abdominal pain
B. acute left heart failure
C. convulsions
D. hyponatraemia
E. peripheral neuropathy

Back 42

B


No mention of LVF in references.
Stoelting Anesthesia and Coexisting Disease p315
Acute attacks of porphyria are characterised by:
• Severe abdominal pain
• Autonomic nervous system instability
• Electrolyte disturbances
• Neuropsychiatric manifestations

Front 43

107. Femoral artery cannulation for arterial pressure monitoring
A. is associated with more major complications than radial artery cannulation
B. is frequently unreliable in the immediate post-bypass period
C. should be performed with an approach from above the inguinal ligament
D. should be performed with a large bore cannula to avoid erosion of the vessel wall
E. should not be used for over 24 hours because of the risk of infection

Back 43

A


Not clear:
Clinical review: Complications and risk factors of peripheral arterial catheters used for haemodynamic monitoring in anaesthesia and intensive care medicine. Critical Care June 2002:
• "Incidence rates for major complications such as permanent ischaemic damage, sepsis and pseudoaneurysm formation are low and similar for the radial, femoral and axillary arteries”
Whilst Miller:
• "The femoral artery is the largest artery commonly selected for pressure monitoring, and it appears to have a safety record comparable to that of other sites... Although some investigators have shown an increase in infectious complications with femoral artery catheters, others have not shown an increased risk."

Front 44

106. Codeine phosphate
A. is converted by the liver to its active metabolite, oxycodone
B. is not associated with tolerance on chronic use
C. is not effective as an analgesic in approximately 20% of Causcasians
D. is poorly absorbed from the gastrointestinal tract
E. when given orally has approximately 5% of the analgesic potency of intramuscular morphine

Back 44

E


AMH opioid comparative table 200mg codeine oral = 10 mg im morph i.e. 5%
• A - False, mostly to codeine-6-glucuronide, some to norcodeine, morphine, normorphine and hydrocodone.
• B - False, tolerance does occur like all other opioids
• C - False,CYP2D6 exhibits genetic polymorphism in 9% UK and 30% Hong Kong population.
• D - False, oral bioavailability of at least 50%.

Front 45

105. Hepatotoxicity from paracetamol overdose is enhanced in
A. chronic renal failure
B. concomitant ingestion of benzopdiazepines
C. conditions associated with glutathione deficiency
D. obese patients
E. patients with hepatitis C antibody

Back 45

C


Goodman & Guilman
“Conditions of CYP induction (e.g., heavy alcohol consumption) or GSH depletion (e.g., fasting or malnutrition) increase the susceptibility to hepatic injury, which has been documented, albeit uncommonly, with doses in the therapeutic range.”

Front 46

104. A dock-worker is extricated from beneath a fallen lift platform and has signs of respiratory distress. He has a jagged wound of the chest wall with blood-stained froth alternately oozing from, and sucking back into the wound. The best initial treatment at the scene would be to
A. apply 100% oxygen
B. apply a CPAP (continuous positive airway pressure) mask
C. apply a sterile dressing and seal the wound completely with adhesive tape
D. apply a sterile dressing to the wound and seal on three sides only
E. insert a 14G cannula in the 2nd intercostal space at the mid-clavicular line

Back 46

A


Almost REPEAT
D is the best option for management of an open pneumothorax – but surely applying 100% which takes only seconds is an appropriate thing to do

Front 47

103. In the recovery room, following general anaesthesia for renal transplant surgery, your patient is found to have a serum potassium concentration of 6 mmol.l-1, despite having a normal potassium concentration pre-operatively. His oxygen saturation is 96% on approximately 40% oxygen via a Hudson mask. He is still unconscious, but breathing spontaneously at 8 breaths per minute. The most likely cause of his hyperkalaemia is
A. beta-blockers which he received peri-operatively
B. catabolic stress of surgery
C. opioid induced narcosis causing carbon dioxide retention
D. renal graft failure
E. washed red blood cell transfusion, which he received intra-operatively

Back 47

C

C is more likely given the long spill about patient being unconscious with a resp rate of 8. This suggests the patient is hypoventilating with resultant hypercapnoea. K can increase by 0.5mmol/L for every 0.1 decrease in pH in patient with renal failure

Front 48

102. Factors which contribute to the increased risk of aspiration pneumonitis during pregnancy include all the following EXCEPT
A. a tendency for the stomach to be pushed up against the left diaphragm
B. decreased secretion of the hormone motilin
C. increased acidity of gastric secretion
D. increased gastrin production
E. increased volume of gastric secretion

Back 48

D


Almost REPEAT
Do have increased gastric secretions and acidity, and it’s not related to gastrin production

Front 49

101. In the management of pain for children
A. a linear analogue scale is rarely used in assessment of pain
B. non-steroidal anti-inflammatory drugs (NSAIDS) often cause renal dysfunction
C. opioids are contraindicated under one month of age
D. paracetamol is effective orally at a dose of 10 mg.kg-1
E. rectal paracetamol is recommended at doses of 20-30 mg.kg-1

Back 49

E


A. false - VAS useful in school aged children (oxford handbook)
B. false - commonly used
C. false - "caution in infants under 6 months of age, as dose reduction may be required". Premature infants listed as CI in MIMS
D. false - "A dose of 10mg/kg is no more effective than placebo for minor pain in children" analgesic therapeutic guidelines
E. true - "The recommended dose in children is...20mg/kg rectally every 6 hours" analgesic therapeutic guidelines

Front 50

100. According to the American Heart Association Guidelines on Perioperative Cardiac Evaluation for Noncardiac Surgery, which of the following operations has a high risk (>5%) of cardiac death or non-fatal myocardial infarct?
A. carotid endarterectomy
B. trans-urethral resection of the prostate (TURP)
C. total knee joint replacement
D. femoral-popliteal bypass
E. right hemicolectomy

Back 50

D


• Active cardiac conditions require investigation and likely intervention unless the surgury is an emergency.
1. Unstable coronary Sx
2. Decompensated heart failure
3. Significant arrythmias
4. Severe valvular disease
• Clinical Risk Factors to stratify other patients
1. Hx of heart disease
2. Prior heart failure
3. Cerebrovascular disease
4. Diabetes mellitus
5. Chronic renal impairment
• Procedure related risk
1. Vascular (>5% risk of MI and/or death). Includes all vascular surgery except carotid endarterectomy
2. Intermediate (Less than 5%, more than 1%). Carotid endarterectomy, abdominal, thoracic, neuro, head and neck, major orthopaedic, prostatic, etc.
3. Low risk (less than 1%). Ambulatory, eyes, superficial, endoscopy, breast

Front 51

99. The best predictor of poor outcome for a peri-operative ulnar nerve injury is
A. a delay in symptom onset to more than 48 hours post¬operatively
B. association with anaesthesia lasting more than 2 hours
C. association with a brachial plexus block
D. presence of bilateral injury
E. presence of mixed sensory and motor deficit

Back 51

E


• D=False - Miler 6th ed.pg. 1155 - this occurs in about 9% of cases
• E=True - Miller 6th ed. Pg. 1155 - Only 35% of patients with a mixed sensory and motor deficit recovered completely in 1 year

Front 52

98. The most commonly reported cause of awareness during general anaesthesia for a non-obstetric procedure is
A. equipment failure
B. human error
C. lack of premedication
D. recreational drug use
E. the use of total intravenous anaesthesia

Back 52

B


Almost REPEAT
CEACCP 2005: “Awareness is frequently associated with poor
anaesthetic technique”

Front 53

97. Ventricular fibrillation in children
A. if resistant to defibrillation, should be treated with amiodarone 5 mg.kg-1
B. is not associated with tricyclic antidepressant overdose
C. is often associated with respiratory arrest
D. is the commonest arrhythmia associated with cardiac arrest
E. should be immediately defibrillated with a 5 J.kg-1 shock

Back 53

A


• “ Failure to revert to SR is treated with Adrenaline 10mcg/kg…persistent or refractory VF or VT may be treated with antiarrthymic such as amiodarone”
• CAN be treated with amiodarone, not SHOULD (5mg/kg is right)
• The rest are certainly false

Front 54

2006 ACC/AHA guidelines for management AF:

TABLE 8. Risk Factors for Ischemic Stroke and Systemic
Embolism in Patients With Nonvalvular Atrial Fibrillation
Risk Factors Relative Risk
Previous stroke or TIA 2.5
Diabetes mellitus 1.7
History of hypertension 1.6
Heart failure 1.4
Advanced age (continuous,perdecade)1.4

Medi C, Hankey GJ, Freedman SB (2007) Atrial fibrillation. Med J Aust. 2007 Feb 19;186(4):197-202
• Hypertension, poor LV function, age = all risk factors for stroke --> so A, B, E true
• Cardioversion: anticoag for 3 wk prior and 4-6 wk post --> C true
• Warfarin reduces stroke by 62% --> D false (i.e not up to 50%, but greater than 50%)

Back 54

D


2006 ACC/AHA guidelines for management AF:

TABLE 8. Risk Factors for Ischemic Stroke and Systemic
Embolism in Patients With Nonvalvular Atrial Fibrillation
Risk Factors Relative Risk
Previous stroke or TIA 2.5
Diabetes mellitus 1.7
History of hypertension 1.6
Heart failure 1.4
Advanced age (continuous,perdecade)1.4

Medi C, Hankey GJ, Freedman SB (2007) Atrial fibrillation. Med J Aust. 2007 Feb 19;186(4):197-202
• Hypertension, poor LV function, age = all risk factors for stroke --> so A, B, E true
• Cardioversion: anticoag for 3 wk prior and 4-6 wk post --> C true
• Warfarin reduces stroke by 62% --> D false (i.e not up to 50%, but greater than 50%)

Front 55

95. A 32 year-old man has a four day history of progressive weakness in the extremities. He has been well apart from an upper respiratory tract infection 10 days ago. His temperature is 37.8oC and respiratory rate 42 breaths.min-1 and shallow. He has symmetric weakness on both sides of his face and the proximal and distal muscles of the extremities. Sensation is intact. His most likely diagnosis is
A. acute disseminated encephalomyelitis
B. Guillain-Barré syndrome
C. myasthenia gravis
D. poliomyelitis
E. polymyositis

Back 55

B


• A - false, this is a demyelinating disease of brain and spinal cord, possibly triggered by vaccination or viral infection. Expect more brain disturbance (personality change, seizure, coma, headache, N/V). Can present as MS. Children more likely than adults.
• B. Guillain-Barre syndrome
• Half have preceding URTI or GIT symptoms
• More than 50% of patients have facial palsies
• Bulbar involvement can be present (note another MCQ asks about pseudobulbar palsy)
• Intact sensation (or mild impairment) is a feature of GBS
• Usually afebrile at onset of symptoms
• Myasthenia gravis – certainly false
• D. Poliomyelitis – False
• 7-14 days incubation → acute febrile illness with URTI or GIT symptoms (90% infections subclinical)
• Ventilation required in acute illness in 30%
• Asymetrical LMN weakness in 1%
• E. Polymyositis - False
• Weakness of proximal muscle groups (shoulders, hips, neck)
• Dysphagia and pulmonary aspiration
• ↑ CK
• Heart block

Front 56

94. An adult requiring defibrillation for the treatment of ventricular fibrillation, should receive an initial monophasic shock across the chest with an energy of
A. 50 - 74 joules
B. 75 - 99 joules
C. 100 - 199 joules
D. 200 - 399 joules
E. 400 - 500 joules

Back 56

D

Answer is 360J for monophasic; 200J for biphasic.

Front 57

93. The main rationale for using CPAP (continuous positive airway pressure) in the management of acute left ventricular failure is to
A. increase the inspired concentration of oxygen (FiO2)
B. recruit alveoli
C. reduce the afterload
D. reduce the preload
E. reduce the work of breathing

Back 57

E


Oh's ICU p232
"CPAP...the benefits result from improved oxygenation and reducing or eliminating the work of breathing, which may account for up to 30% of oxygen consumption. This reduction in oxygen consumption reduces LV workload and alleviates myocardial ischaemia”

Executive summary of the guidelines on the diagnosis and treatment of acute heart failure.' The Task Force on Acute Heart Failure of the European Society of Cardiology, European Heart Journal (2005) 26, 384–416
Application of CPAP can cause pulmonary recruitment and is associated with an increase in the functional residual capacity. The improved pulmonary compliance, reduced transdiaphragmatic pressure swings, and decreased diaphragmatic activity can lead to a decrease in the overall work of breathing and therefore a decreased metabolic demand from the body

Front 58

92. Correct statements regarding intravenous phenylephrine include all the following EXCEPT
A. A reasonable bolus dose for hypotension is 250 micrograms.
B. Associated reflex bradycardia should NOT be treated with atropine.
C. It acts directly on alpha-adrenergic receptors.
D. It increases systolic and diastolic pressures.
E. It is metabolised by Monoamine Oxidase

Back 58

B


A. 0.1-0.5mg increments according to OHA (although I would start with lower dose)
B. atropine can be used
C. true
D. true
E. true - in the liver

Front 59

91. Correct statements regarding confidence intervals (CI) include all the following EXCEPT
A. CI are derived from the standard error (of the mean).
B. CI can be used to assess the precision of population
parameter estimates.
C. The width of the CI depends on the degree of confidence required.
D. The width of the CI depends on the sample size.
E. The width of the CI depends on the mean value of the sample.

Back 59

E


From Myles and Gin:
"Confidence intervals are derived from the SE and define a range of values that are likely to include a population parameter. The width of the CI depends on the SE (and thus sample size) and the degree of confidence required." pp10-11
"CI can be used to indicate the precision of any estimate" p.23

Front 60

75. 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

Back 60

D


MD Consult:
TABLE 12-9 -- Differential Diagnosis of Noninfarction Q Waves (with Selected Examples)
Physiological or Positional Factors
Normal variant “septal” Q waves
Normal variant Q waves in V1 and V2, III, and aVF
Left pneumothorax or dextrocardia: loss of lateral R wave progression
Myocardial Injury or Infiltration
Acute processes—myocardial ischemia without infarction, myocarditis, hyperkalemia (rare cause of transient Q waves)
Chronic myocardial processes—idiopathic cardiomyopathies, myocarditis, amyloid, tumor, sarcoid
Ventricular Hypertrophy/Enlargement
Left ventricular (slow R wave progression)
Right ventricular (reversed R wave progression or poor R wave progression, particularly with chronic obstructive lung disease)
Hypertrophic cardiomyopathy (can simulate anterior, inferior, posterior, or lateral infarcts)
Conduction Abnormalities
Left bundle branch block (slow R wave progression)
Wolff-Parkinson-White patterns

Front 61

73. Histamine release during anaphylaxis does not cause
A. tachycardia
B. decreased myocardial contractility
C. coronary vasodilatation
D. a shift in the pacemaker site
E. an increased PR interval

Back 61

B

Front 62

71. A unit of Human Platelet Concentrate obtained from a healthy blood donor
A. usually contains a very small number of lymphocytes
B. may lead to immunisation of the recipient against red cell antigens
C. is best stored at 4ºC and constantly agitated
D. increases the platelet count of a typical 70 kg adult by about 20 109.l-1 of whole blood
E. is obtained from pooled blood donors with the same ABO blood group

Back 62

B


A - true UpToDate: "Platelet concentrates, like red cells, contain contaminating leukocytes that may cause adverse reactions in some recipients and may elaborate inflammatory cytokines during storage." Note routine leucocyte depletion of platelets has only occurred since 2008. So perhaps this was false at the time of the exam
B - true “Immunisation to donor red cell antigens may occur because of the presence of small but variable numbers of red cells in platelet units.” www.transfusion.com.au - Blood component information
C - false, room temp and constant agitation
D - false - Miller - 7000 - 10000 platelets /mm3 (although note that the tranfusion website states this 'One unit of platelets (either pooled or apheresis) would be expected to increase the platelet count of a 70kg adult by 20 - 40 x 10^9/L. '
E - false - single unit is from single donor although can also get pooled platelets in some places

Front 63

63. A 65 year old female commenced hydrochlorothiazide two weeks earlier for mild hypertension, and has now been admitted to hospital with confusion. Serum electrolytes are:
sodium 110 mmol.l-1
potassium 3.3 mmol.l-1
chloride 85 mmol.l-1
creatinine 0.06 mmol.l-1

Correct statements regarding this clinical situation include all the following EXCEPT
A. dilutional hyponatreamia related to the thiazide is the most likely cause of this presentation
B. generalized seizures may occur
C. intravenous frusemide and hypertonic saline (twice normal) will rapidly and safely normalize her serum sodium
D. stopping hydrochlorothiazide and water restriction ( 600 mls.day-1) is indicated
E. the serum ADH level will be elevated

Back 63

C


• A – true – get Na / K loss, then water retention by ADH
• B – true
• C – most wrong – as chronic want to slowly increase Na – otherwise get central pontine myelinosis.
o “In summary, rapid correction is indicated for patients with acute (<48 hr) and symptomatic hyponatremia. This should probably aim to raise serum Na+ concentrations by approximately 1 to 2 mEq/L/hr until seizures subside. This correction can be achieved by administration of hypertonic saline with the concomitant administration of furosemide, which impairs free water reabsorption and lowers urine osmolality, induces excretion of Na+ in a much larger volume of urine, and leads to a much greater negative water balance. This allows more rapid correction of the plasma Na+ concentration.”
o Brenner: Brenner and Rector's The Kidney, 8th ed
• D – true
• E – true – “Thiazide diuretics induce hyponatremia by impairment of urinary dilution, renal loss of sodium and potassium, stimulation of antidiuretic hormone (ADH), and perhaps from a dipsogenic effect.” The American journal of the medical sciences 2004, vol. 327, no2, pp. 109-111

Front 64

56. The estimated risk of infection following percutaneous exposure (needlestick injury) to human immunodeficiency virus (HIV) is approximately
A. 1 in 30
B. 1 in 300
C. 1 in 3,000
D. 1 in 30,000
E. 1 in 300,000

Back 64

B


Miller 6th E,d p 3156
= 0.3% or 1 in 300
• HIV - 0.3%
• Hepatitis C - 3%
• Hepatitis B - 30%

Front 65

51. The term "base" of the heart refers to the
A. diaphragmatic surface of the heart
B. left ventricle and left atrium
C. right ventricle and right atrium
D. left and right atrium
E. roots of the great vessels and intervening heart walls

Back 65

D


Anatomy for Anaethetists p. 85
The base, or posterior surface, is quadri- lateral in shape and is formed mainly by the left atrium with the openings of the pulmonary veins and, to a lesser extent, by the right atrium.

Front 66

50. Fresh frozen plasma
A. is produced from pooled blood
B. needs to be cross matched before it is used
C. does not cause or transmit hepatitis
D. contains all the coagulation proteins except Factor VIII
E. has a shelf life of at least one year if stored below -32oC

Back 66

E


FFP has a shelf life of 12 months if stored <-25 deg C.

From ARCBS site:

• A – False
o Produced from one unit of whole blood.
• B – False.
o Does not NEED to be crossmatched, but use group specific (esp restrict O FFP for O recipient)
• C – False.
• D - False.
o FFP which is thawed has 200 units of FFP but FFP which has been thawed and then not used for more than a few hours has no F8. This is false as stated-as per ARCBS 'FFP contains all coagulation factors including 200 units of F8 and the other labile clotting factor (F5).'
• E – True.
o Elsewhere in the world "In 1995 the European 'Guide to the preparation, use and quality assurance of blood components' extended the shelf-life of FFP from 12 to 24 months and concurrently reduced the storage temperature from -30 to -40 °C." In Australia -25C.

Front 67

45. The median nerve
A. provides sensation to the radial side of the palm and radial
three fingers
B. can be blocked at the elbow with the arm abducted, and
injecting immediately lateral to the brachial artery on the intercondylar line
C. at the wrist is blocked 2 cm proximal to the distal crease
between palmaris longus and flexor carpi ulnaris
D. lies medial to the flexor carpi ulnaris if palmaris longus is
absent
E. is formed from fibres from the lateral, medial and posterior
cords of the brachial plexus

Back 67

A


• A=True (Moores pg. 519/520/603/605  the median nerve sends cutaneous sensory fibres to the lateral palmar surface, sides of the 1st 3 digits, lateral ½ of the 4th digit and the dorusm of the distal halves of these digits).
• B=False (Moore’s pg. 552  the median nerve lies medial to the brachial artery at the cubital fossa beneath the bicipital aponeurosis).
• C=False (Typically block at the proximal skin crease, between PL and FCR  can block between PL and FCU but need larger volume and takes longer to work).
• D=False (Normally lies deep to PL, between FDS and FCR. If PL is absent, the nerve is still lateral to FCU).
• E=False (Lasts pg. 68  formed from the lateral cord (lateral root of the median nerve  is the continuation of the lateral cord (C5,6,7) AND is joined by the medial root of the median nerve (is the continuation of the medial cord (C8,T1)).

Front 68

44. A lesion of the right recurrent laryngeal nerve
A. results in an inability to tense the right vocal cord
B. results in a complete failure of adduction of the right vocal
cord
C. results in a complete failure of abduction of the right vocal
cord
D. may occur during surgical exposure of the superior thyroid vessels
E. always results in hoarseness

Back 68

C


• A = wrong: cricothyroid mm. are the only tensor of the cords, and is innervated by ext. laryngeal n.
• B = wrong: cricothyroid mm. are spared, and may tense the cord
• C = correct: post. cricoarytenoid mm. are the only abductors, and are paralysed
• D = wrong: inf. thyroid vessels
• E = wrong: not always, because there is compensation from the other side

Front 69

43. Haemoptysis would be LEAST likely to occur with
A. pulmonary tuberculosis
B. viral pneumonias
C. bronchial adenomas
D. bronchiectasis
E. mitral stenosis

Back 69

E


Either c OR e – Leaning towards E
From Uptodate:
There are numerous causes of massive hemoptysis originating from the lower respiratory tract, the most common and important of which will be discussed here. The literature from the 1940s through the 1960s supports three major etiologies accounting for 90 percent of cases: tuberculosis (TB), bronchiectasis, and lung abscess.


"Less commonly (< 10% of cases), pulmonary venous hypertension (eg, mitral stenosis, pulmonary embolism) causes hemoptysis." (Current Medical Dx and Tx, Ch2)

Front 70

41. The segmental nerve supply to the renal pelvis and the ureter gives an anatomical basis for the surface representation of the pain of renal colic. The segments concerned are
A. T11 and T12
B. L1
C. L1 and L2
D. T11, T12, L1 and L2
E. T12 and L1

Back 70

D


Gray's Anatomy 39e, p1288
"Excessive distension of the ureter or spasm of its muscle may be caused by a stone (calculus) and provokes severe pain (ureteric colic, which is commonly, but mistakenly, called renal colic). The pain, spasmodic and agonizing, particularly if the obstruction is gradually forced down the ureter by the muscle spasm, is referred to cutaneous areas innervated from spinal segments which supply the ureter, mainly T11-L2. It shoots down and forwards from the loin to the groin and scrotum or labium majus and may extend into the proximal anterior aspect of the thigh by projection to the genitofemoral nerve (L1, 2). The cremaster, which has the same innervation, may reflexly retract the testis."

Front 71

40. The congenital arterial abnormality of the upper limb which is most likely to lead to accidental arterial puncture at the antecubital fossa is
A. high bifurcation of the brachial artery
B. superficial radial artery
C. superficial ulnar artery
D. ulnar recurrent artery
E. radial recurrent artery

Back 71

C

Front 72

33. Following major surgery, there is an increased risk of thrombosis, associated with a decrease in
A. fibrinogen
B. factor VIII coagulant
C. factor VIII; Ag (von Willebrand related antigen)
D. interleukin 6
E. protein C

Back 72

E


Thrombophillias:
- PrC, PrS deficiency
- Antithrombin III deficiency
- F5 Leiden mutation
- Prothrombin gene mutation
- Lupus anticoagulant = Antiphospholipid syndrome

PLUS:
- polycythemia
- OCP
- malignancy
- thrombocythemia, HITTS

Front 73

28. Scleroderma is commonly associated with
A. macroglossia
B. obstructive pulmonary disease
C. restrictive pulmonary disease
D. pernicious anaemia
E. thrombocytopenia

Back 73

C


Scleroderma (Clinical Anaesthesia / 5mcc Palm)
• Autoimmune collagen vascular disease
• 2 types
o Diffuse – distal and mascimal extremity and tuncal skin thickening
o Limited – restricted to hand / face – CREST
• CREST = Calsinosis, Raynaud, oesophageal dismotility, Sclerodactalyly, telangiectasia
• Affects: skin (thickened swollen), joints & visceral organs (interstitial fibrosis and impaired DLCO, pericardial effusion, renal dysnfunction, decreased GIT motility)
• Raynaud’s in 95%
• Beware aspiration
• Beware difficult intubation – taut skin limits mouth opening / TMJ joint limitation
• Hypoxaemia – restrictive lung disease and impaired DLCO
• Difficult IV access
• Skeletal muscle involvement may increase sensitivity to muscle relaxants (proximal weakness)

Front 74

26. The earliest sign in the development of malignant hyperthermia is
A. acidosis
B. hyperthermia
C. increased end-tidal carbon dioxide concentration
D. muscle rigidity
E. myoglobinuria

Back 74

D


Answer C – Though note that below seems to suggest acidosis is also early, but hypercapnia probably is contributing to acisosis
British Journal of Anaesthesia. 85(1):118-28, 2000 Jul.

Front 75

21. Iron deficiency is characterised by
A. high serum ferritin level and low serum iron
B. high serum ferritin level and absent bone marrow iron
C. increased serum ferritin level and normal serum iron
D. low serum ferritin level and low serum iron
E. low serum iron level and lowered total iron binding capacity

Back 75

D

Front 76

16. In staphylococcal bronchopneumonia one would commonly expect
A. abscess formation
B. resolution to begin on the third day
C. bacteraemia
D. characteristic intra-alveolar fibrosis
E. none of the above

Back 76

A


Pathological Basis of Disease: Kumar
Staphylococcus aureus is an important cause of secondary bacterial pneumonia in children and healthy adults following viral respiratory illnesses (e.g., measles in children and influenza in both children and adults). Staphylococcal pneumonia is associated with a high incidence of complications, such as lung abscess and empyema. Intravenous drug abusers are at high risk of developing staphylococcal pneumonia in association with endocarditis. It is also an important cause of hospital-acquired pneumonia, as will be discussed later.
“Like staph infections elsewhere, staph pneumonia is characterized by abcess development”

Front 77

15. Complications of diabetes mellitus in the pregnant patient include each of the following EXCEPT
A. increased risk of oligohydramnios
B. greater risk of fetal death in the third trimester
C. retinopathy and retinal detachment
D. potentiation of hypotension when regional anaesthesia is administered to assist delivery
E. reduced fetal oxygen delivery

Back 77

A


Polyhydramnios with pregnancy not oligohydramnios
Complications of Diabetes mellitus for baby:
1. increased fetal malformations, persists despite better treatment of T1DM. two- to sixfold increase in major malformations. Mainly neurological (neural tube), cardiac and sacral.
2. supply demand relationship affects: maternal vasculopathy, preeclampsia, hyperglycaemia and DKA causing poor placental perfusion AND the fetus has increased metabolic needs due to hyperinsulinism and macrosomia.
3. stillbirth previously occurred in 10-30% of T1DM, usually after 36weeks, thought to be due to chronic intrauterine hypoxia.
4. fetal umbilical cord blood samples from pregnant women with type 1 diabetics have demonstrated "relative fetal erythremia and lactic acidemia."
5. macrosomic children: birth trauma, obesity when older
6. neonatal hypoglycaemia
7. respiratory distress syndrome
8. polycythaemia and jaundice
9. Ca and Mg metabolic changes

Front 78

12. Branches of the mandibular nerve do NOT include the
A. auriculotemporal nerve
B. long buccal nerve
C. lingual nerve
D. great auricular nerve
E. chorda tympani nerve

Back 78

D


The great auricular nerve (C2, 3) is the largest cutaneous branch of the cervical plexus. It hooks around the mid-point of the posterior border of sternocleidomastoid, then passes across it in the direction of the angle of the mandible. On this muscle it breaks up into three terminal branches.
1 Auricular - supplying the lower two-thirds of the medial aspect of the external ear and the lateral surface of the lobule.
2 Mastoid - to the skin over the mastoid process.
3 Facial - to the skin over the masseter and the parotid gland

Front 79

11. Malignant hyperpyrexia
A. may be confirmed by a muscle biopsy showing contracture in response to halothane, caffeine and calcium
B. is an autosomal recessive disorder
C. should be treated with an initial dose of dantrolene of 2.5 mg.kg-1
D. had a mortality as high as 50% prior to dantrolene
F. is consistently associated with a rapidly rising temperature as one of the early signs

Back 79

C


A - halothane, caffeine. Not calcium.
B - dominant.
D - 80% mortality
E - temperature is not early sign.

Front 80

6. The pudendal nerve does NOT
A. give off the inferior haemorrhoidal nerve
B. cross the greater sciatic foramen
C. cross the lesser sciatic foramen
D. arise from L2-3-4
E. give off the dorsal nerve of the penis

Back 80

D


Anatomy for Anaesthetis:
The pudendal nerve (S2–4) provides the principal innervation of the perineum; its course is complex, passing from the pelvis, briefly through the gluteal region, along the side wall of the ischiorectal fossa and through the deep perineal pouch to end by supplying the skin of the external genitalia (see Figs 138 & 147). Arising as the lower main division of the sacral plexus (although dwarfed by the giant sciatic nerve), the pudendal nerve leaves the pelvis through the greater sciatic foramen below piriformis. It appears briefly in the buttock region, accompanied laterally by the internal pudendal vessels, merely to cross the dorsum of the ischial spine and straightaway disappear through the lesser sciatic foramen into the perineum. The nerve now traverses the lateral wall of the ischiorectal fossa, accompanied by the internal pudendal vessels, and lies within a distinct fascial compartment on the medial aspect of obturator internus termed the pudendal canal (Alcock’s canal). Within the canal, it first gives off the inferior rectal nerve which crosses the fossa to innervate the external anal sphincter and the perianal skin, then divides into the perineal nerve and the dorsal nerve of the penis or clitoris

Front 81

5. In cadaveric donor renal transplantation the intra-operative measure most likely to improve immediate graft function and transplant outcome is
A. administration of 200 mg frusemide intravenously prior to unclamping of the newly grafted kidney
B. aggressive intra-operative volume expansion to central venous pressures of 10-15 mmHg
C. administration of 50 g mannitol intravenously prior to unclamping of the newly grafted kidney
D. use of a low dose dopamine infusion (2 microgram.kg-1. min-1) peri-operatively
E. administration of 0.8 g.kg-1 albumin intravenously prior to unclamping of the newly grafted kidney

Back 81

B