1
Q
- A patient undergoing liver surgery has a venous air embolism, what is the most appropriate position to place them in:
a. Reverse trendelenburg, right side up
b. Reverse trendelenburg left side up
c. Reverse trendelenburg, neutral
d. Trendelenburg right side up
e. Trendeleburg left side up
A
A. Reverse Trendelenburg, right side up
CEACCP - Gas embolism in anaesthesia (2002)
Treatment goals:
- Resuscitation
- Prevent further air entry
- Reduce the size of the embolism
- Overcome any mechanical obstruction caused by the embolism
Preventing further air entry:
- Immediately eliminate high pressure gas source if in use (e.g. pneumoperitoneum)
- The surgeon should flood the operative site with saline
- Venous pressure at the procedural site should be elevated by: (i) positioning it below the level of the right atrium (if possible); (ii) IV volume loading; and (iii) increasing intrathoracic pressure with a Valsalva manoeuvre, thus reducing venous return.
Reducing the size of the embolus:
- Discontinue N2O if in use
- 100% O2 (+/- hyperbaric)
- Aspirate from RA lumen of CVC/PAC
Overcoming the mechanical obstruction
- The left lateral decubitus position described by Durant may help overcome the airlock within the RV by positioning it superior to the RVOT. The Trendelenburg position has a similar effect
2
Q
- Which of the following is NOT a side effect of cyclosporine
a. Alopecia
b. Hypertension
c. Renal impairment
d. Gum hyperplasia
A
A. Alopecia
3
Q
- What is the half life of clopidogrel?
a. 6 hours
b. 14 hours
c. 24 hours
d. 7 days
A
A. 6 hours
although not clinically relevant given irreversible effect on platelet function
4
Q
- When administering adrenaline and atropine via ETT dose compared with IV should be
a. Same dose
b. Double
c. Quadruple
d. Six times
A
D. Six times
ARC 2010
endotracheal administration of some medications is possible, although the absorption is variable and plasma concentrations are substantially lower than those achieved when the same drug is given by the intravenous route (increase in dose 3-10 times may be required).
Neonatal formulary
Tracheal administration is of doubtful efficacy and should only be tried if IV access is unavailable - a higher dose (50 to 100 microgram/kg) is suggested.
5
Q
EV14 What splitting ratio gives a 3% concentration of isoflurane?
a. 1/5
b. 1/9
c. 1/13
d. 1/20
e. 1/23
A
C. 1/13
6
Q
- What transfusion related complication is the commonest cause of mortality
a. Bacterial infection
b. TRALI
c. ABO incompatibility
d. ?
e.
A
B. TRALI
Blood journal:
Today, the leading causes of allogeneic blood transfusion (ABT)–related mortality in the United States—in the order of reported number of deaths—are transfusion-related acute lung injury (TRALI), ABO and non-ABO hemolytic transfusion reactions (HTRs), and transfusion-associated sepsis (TAS).
7
Q
- Which of the following is not included in the CHADS2 AF thromboembolic risk scoring system
a. Age
b. Gender
c. Diabetes
d. Heart failure
e. Previous TIA
A
B. Gender
8
Q
- What is the ratio of breaths to compressions in neonatal resuscitation
a. 1:3
b. 1:5
c. 2:15
d. 2:30
A
A. 1:3
9
Q
- What is the innervation of the hard palate
a. Greater palatine and nasopalatine nerves
A
A. Greater palatine and nasopalatine nerves
10
Q
- Which of the following is suggesting of an inhaled foreign body in a child on chest x ray
a. Foreign body visible in front of airway
b. Hyper-expanded hemithorax
c. Collapse
A
B. Hyper-expanded hemithorax
Sims and Johnson:
Air trapping with hyperinflation might be seen on expiratory film due to a ‘ball valve effect’, but while this is classical, it is not common.
11
Q
- What is the distance from the lips to the carina in an 70kg adult male in cm
a. 21
b. 23
c. 25
d. 27
e. 29
A
D. 27 cm
Tube tip should be 5 cm above carina. Average distance at the lips in an adult male is 22 cm.
12
Q
- What colour is the label for subcutaneously administered drugs
a. Pink
b. Yellow
c. Brown
d. Red
e. Blue
A
C. Brown
13
Q
- What is the maximum volume of air (in mL) that should be used to inflate a 5 LMA classic cuff
a. 15
b. 20
c. 25
d. 40
e. 45
A
D. 40 mL
Size 3 - 20 mL
Size 4 - 30 mL
Size 5 - 40 mL
14
Q
- Where should the tip of an IABP lie
a. 2cm distal to the left subclavian
b. 2 cm proximal to the left subclavian
c. 2cm proximal to the renal artery
d. 2 cm distal to the renal artery
A
A. 2 cm distal to the left subclavian artery
15
Q
- A 60kg female is given 50 mg of rocuronium, she is unable to be intubated or ventilated, what dose of sugamadex is required to reverse the rocuronium
a. 240
b. 800
c. 960
A
C. 960 mg (16 mg/kg)
16
Q
IC67 In a penetrating chest injury what part of the heart is most likely to be injured
a. Left ventricle
b. Right ventricle
c. Right coronary artery
d. Right atrium
e. Sinus node
A
B. Right ventricle
17
Q
- What is the maximum recommended dose of Intralipid in local anesthetic toxicity (ml/kg)
a. 6
b. 8
c. 10
d. 12
e. 14
A
D. 12 mL/kg
18
Q
- What is a contraindication to an IABP?
A. Aortic regurgitation
B. Aortic stenosis
A
A. Aortic regurgitation
19
Q
- 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
A
C. Suction the trachea
suction from mouth and pharynx then CPAP, or intubate then suction from trachea
20
Q
- Central sensitization occurs due to
a. Primary events mediated by the NMDA receptor
b. Alterations in gene expression
c. Increased magnesium
A
B. Alterations in gene expression
Central sensitization represents an enhancement in the function of neurons and circuits in nociceptive pathways caused by increases in membrane excitability and synaptic efficacy as well as to reduced inhibition and is a manifestation of the remarkable plasticity of the somatosensory nervous system in response to activity, inflammation, and neural injury. The net effect of central sensitization is to recruit previously subthreshold synaptic inputs to nociceptive neurons, generating an increased or augmented action potential output: a state of facilitation, potentiation, augmentation, or amplification. Central sensitization is responsible for many of the temporal, spatial, and threshold changes in pain sensibility in acute and chronic clinical pain settings and exemplifies the fundamental contribution of the central nervous system to the generation of pain hypersensitivity. Because central sensitization results from changes in the properties of neurons in the central nervous system, the pain is no longer coupled, as acute nociceptive pain is, to the presence, intensity, or duration of noxious peripheral stimuli. Instead, central sensitization produces pain hypersensitivity by changing the sensory response elicited by normal inputs, including those that usually evoke innocuous sensations.
21
Q
- What volume of FFP is required to increase fibrinogen level by 1g/L (I think it was FFP or did it say cryoprecipitate?)
a. 10-15ml/kg
b. 30ml/kg
A
B. 30 mL/kg (for FFP)
22
Q
- An epidural in a healthy individual causes all EXCEPT
a. Raised Co2
b. Bradycardia
c. Vasodilation
d. Dyspnea
A
A. Raised CO2
23
Q
- The Revised Trauma Score includes GCS, Blood pressure and what other parameter?
a. HR
b. Saturation
c. Respiratory rate
d. Urine output
A
C. Respiratory rate
The Revised Trauma Score is made up of a three categories: Glasgow Coma Scale, Systolic blood pressure, and respiratory rate. The score range is 0-12. In START triage, a patient with an RTS score of 12 is labeled delayed, 11 is urgent, and 10-3 is immediate. Those who have an RTS below 3 are declared dead and should not receive certain care because they are highly unlikely to survive without a significant amount of resources.[citation needed]
24
Q
- Autologous transfusion results in less
a. Cost
b. Blood waste
c. Incompatible transfusion
d. Unrequired transfusion
A
C. Incompatible transfusion
CEACCP - Autologous blood transfusion (2006)
Controversies:
The evidence-base proving that cell salvage saves allogenic blood transfusion and is cost-effective is limited. A recent Cochrane review of 49 randomized controlled trials over a 24-yr period showed that the use of cell salvage reduced the rate of exposure to allogenic blood transfusion by 40%. It did not adversely affect mortality or complications such as bleeding, infection, myocardial infarction, thrombosis and stroke. The review concluded that better quality research specifically designed to assess the cost-effectiveness of cell salvage across a range of surgical procedures is required.
In surgery for malignancy there is concern because of potential systemic dissemination of tumour cells from salvaged blood. Malignant cells may be removed by filtration and further reductions achieved by irradiation. This remains an area of much research. The use of cell salvage during caesarean section remains controversial because of concerns regarding amniotic fluid embolism and rhesus sensitisation resulting from reinfusion of foetal cells in salvaged blood. There are a small number of studies indicating that it can be used without these complications, but larger safety studies are required.
25
25. After an infusion of normal saline causing isovolumetric haemodilution what occurs?
a. Increased cardiac output
b. Increase oxygen extraction
c. Capillary vasodilatation
A. Increased cardiac output
26
IC97 Bleeding in trauma has been shown to be reduced by
```
A. Tranexamic acid
B. Recombinant factor VIIa
C. DDAVP
D. Prothrombinex
E. Aprotinin
```
A. Tranexamic acid
CRASH-2 trial (Lancet 2010):
Tranexamic acid safely reduced the risk of death in bleeding trauma patients in this study. On the basis of these results, tranexamic acid should be considered for use in bleeding trauma patients.
27
27. 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
28
28. The commonest post operative complication in a patient with a # NOF is
a. UTI
b. Pneumonia
c. Delirium
d. Myocardial infarction
C. Delirium
29
29. In an infant, the intercristine line is at the level of
a. L1-L2
b. L2-L3
c. L3-L4
d. L4-L5
e. L5-S1
E. L5-S1
Intercristal line is the imaginary line drawn between the two superior iliac crests
CEACCP - Local and regional anaesthesia in infants (2004):
The intercristal line is at L5/S1 (L4 in adults), the termination of the spinal cord is at L3 (L1/2 in adults) and the termination of the dura is at S3/4 (S2 in adults).
30
30. Which of the following is a contra-indication to a left DLT
a. Left pneumonectomy
b. Tumour in the left main stem bronchus
B. Tumour in the left main stem bronchus
31
31. 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
32
32. What is the ratio of MAC awake:MAC of sevoflurance
a. 0.2
b. 0.34
c. 0.5
B. 0.34
33
34. Pain from the uterus during labour is transmitted via
a. From the anterior roots of T10-L1
b. Parasympathetic fibres
c. The inferior hypogastric plexus
d. Via grey rami communicantes
C. The inferior hypogastric plexus
34
NEW: The features of Pierre Robin sequence include cleft palate, micrognathia and:
A. Glossoptosis
B. Craniosynostosis
C. Macroglossia
D. Microstomia
A. Glossoptosis (posterior displacement of the tongue)
35
36. A size C oxygen cylinder that reads 5000kpa contains approximately how many litres of oxygen
a. 100
b. 150
c. 200
d. 350
e. 600
B. 150 L
P1V1 = P2V2
Full size C is 440 L at 13,700 kPa
If pressure is 5000 kPa, volume of O2 is ([5000/13,700] x 440), = 160 L
36
37. 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
C. 65 mmHg
CPP = MAP (at level of tragus) - CVP
= (80-10) - 5
= 65
(13 cm H2O = 10 mmHg)
37
38. After a procedure with an LMA in situ a patient complains of loss of sensation to the anterior part of the tongue. What nerve is likely damaged?
a. Facial
b. Lingual
c. Greater palatine
d. Glossopharyngeal
B. Lingual nerve (branch of trigeminal - supplies somatic afferent to anterior 2/3 of tongue)
(Glossopharyngeal supplies posterior 1/3 of tongue)
38
39. What statistical test would be best to evaluate the effects of ? 2 drugs in patients at ? 3 different points in time
a. ANOVA
b. Mantel Hantzel
c. Kruskall Wallis
d. Students t test
A. (Repeated measures) ANOVA
When to use a Repeated Measures ANOVA:
We can analysis data using a repeated measures ANOVA for two types of study design. Studies that investigate either (1) changes in mean scores over three or more time points, or (2) differences in mean scores under three or more different conditions. For example, for (1), you might be investigating the effect of a 6-month exercise training programme on blood pressure and want to measure blood pressure at 3 separate time points (pre-, midway and post-exercise intervention), which would allow you to develop a time-course for any exercise effect. For (2), you might get the same subjects to eat different types of cake (chocolate, caramel and lemon) and rate each one for taste, rather than having different people flavour each different cake. The important point with these two study designs is that the same people are being measured more than once on the same dependent variable (i.e., why it is called repeated measures).
In repeated measures ANOVA, the independent variable has categories called levels or related groups. Where measurements are repeated over time, such as when measuring changes in blood pressure due to an exercise-training programme, the independent variable is time. Each level (or related group) is a specific time point. Hence, for the exercise-training study, there would be three time points and each time-point is a level of the independent variable
Performing lots of 2 sample t-tests on the serial measurements between different time or dosage points and/or between different groups at each time point and/or between each time point and baseline is statistically unsound, rendering the p-values invalid unless adjusted for multiple testing. Even if multiple testing were not invalid, such an approach is not designed to answer any useful research question.
39
40. A man is working with electrical appliances at home with a residual current device. If he touches the active and the neutral (was it neutral or earth) wire he will suffer
a. A microshock
b. A macroshock
c. Nothing happens because the fuse blows
d. The RCD will protect him from macroshock
D. The RCD will protect him from macroshock
Wiki
A residual-current device (RCD), or residual-current circuit breaker (RCCB) or residual twin-direct current couplet (R2D2), is an electrical wiring device that disconnects a circuit whenever it detects that the electric current is not balanced between the energized conductor and the return neutral conductor. Such an imbalance may indicate current leakage through the body of a person who is grounded and accidentally touching the energized part of the circuit. A lethal shock can result from these conditions. RCCBs are designed to disconnect quickly enough to prevent injury caused by such shocks. They are not intended to provide protection against overcurrent (overload) or all short-circuit conditions.
40
41. An infant with failure to thrive is noted to have an apical systolic murmur weak pulses, with the femoral felt most easily. They most likely have
a. Patent ductus arteriosis
b. Ventriculoseptal defect
???
PDA - differential cyanosis, i.e. cyanosis of the lower extremities but not of the upper body.
VSD - Pansystolic murmur along lower left sternal border (depending upon the size of the defect) +/- palpable thrill (palpable turbulence of blood flow). Heart sounds are normal. Larger VSDs may cause a parasternal heave, a displaced apex beat (the palpable heartbeat moves laterally over time, as the heart enlarges). An infant with a large VSD will fail to thrive and become sweaty and tachypnoeic (breathe faster) with feeds.
41
42. 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
A. A 9 mm gap between the anterior arch of C1 and the odontoid peg
42
43. 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
43
44. In acute liver injury what causes the highest risk of bleeding
a. Thrombocytopenia
b. Coagulopathy
c. Portal hypertension
d. Platelet dysfunction
B. Coagulopathy
44
45. A patient in recovery post op total hip replacement develops crushing central chest pain, ECG shows ST segment elevation (NB- no BP etc given, beta blockade was not an option). The most appropriate action is to give
a. Aspirin
b. IV GTN
c. IV heparin
d. Calcium channel blocker
e. T/L
A. Aspirin
AHA/ACC guidelines
Therapy with aspirin, a beta blocker, and an ACE inhibitor, particularly for patients with low ejection fractions or anterior infarctions, may be beneficial, whether or not the patients are rapidly taken to the catheterization laboratory.
45
46. Stellate ganglion blockade causes
a. Conjunctival injection
b. Dry eyes
c. Decreased axillary sweating
All of the above (conjunctival injection, dry eyes and decreased axillary sweating)
Horners syndrome is caused by sympathetic blockade and produces the following features on the ipsilateral side of the face:
- drooping of the eyelid (ptosis)
- constriction of the pupil (miosis)
- decreased sweating of the face on the same side (anhydrosis)
- redness of the conjunctiva of the eye
- impression of an apparently sunken eyeball (enophthalmos)
This may also lead to increased amplitude of accommodation, paradoxical contralateral eyelid retraction, transient decrease in intraocular pressure and changes in tear viscosity. Although it may be considered a complication, the presence of Horner’s syndrome is a confirmatory sign of successful stellate ganglion blockade.
46
47. Features of ventricular tachycardia DO NOT include
a. Absence of p waves
b. Monophasic waves
c. Prominent R wave in V1
d. A-V dissociation
A. Absence of P waves
ECG features of VT - LITFL
- Very broad complexes (>160ms).
- Absence of typical RBBB or LBBB morphology.
- Extreme axis deviation (“northwest axis”) — QRS is positive in aVR and negative in I + aVF.
- AV dissociation (P and QRS complexes at different rates).
- Capture beats — occur when the sinoatrial node transiently ‘captures’ the ventricles, in the midst of AV dissociation, to produce a QRS complex of normal duration.
- Fusion beats — occur when a sinus and ventricular beat coincide to produce a hybrid complex of intermediate morphology.
- Positive or negative concordance throughout the chest leads, i.e. leads V1-6 show entirely positive (R) or entirely negative (QS) complexes, with no RS complexes seen.
- Brugada’s sign – The distance from the onset of the QRS complex to the nadir of the S-wave is > 100ms.
- Josephson’s sign – Notching near the nadir of the S-wave.
- RSR’ complexes with a taller “left rabbit ear”. This is the most specific finding in favour of VT. This is in contrast to RBBB, where the right rabbit ear is taller.
47
48. An inpatient becomes hyponatraemic 48 hours post op and has a seizure. The most appropriate treatment is
a. Fluid restriction
b. Normal saline ?ml/hr
c. Hypertonic saline
d. Salt tablets
C. Hypertonic saline
48
49. A patient has a laparotomy for an acute abdomen, nothing in found intra-operatively. ABG reveals
?
??
49
50. A child with 10% dehydration is likely to have
a. Bradycardia
b. Rapid deep breathing
B. Rapid deep breathing
50
1. REPEAT Sep 11 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
D. extensor pollicis
E. flexor pollicis brevis
```
C. Adductor pollicis
51
ST39 When analyising a study containing a control and two test groups, the best statistical method to use is....
```
A. Analysis of variance
B. Chi squared with Bonnferoni correction
C. ?
D.
E.
```
A. Analysis of variance
52
3. REPEAT Sep 2011 20. Really poor copy of a CXR. Looked to me like a haemopneumothorax (you could very faintly see a collapsed lung outline, there was no 'meniscus' to the fluid shadow) but other people thought it was an artefact. It did indeed look like a pneumothorax and then someone had put a piece of metal up to simulate a haemothorax, because on the lateral you couldn't see past the ribs (ie the film was cut off at the rib borders). It was terrible quality (too black, and hard to discern tissue from air), and an inadequate film (cut off apices, and poor lateral view as before)
```
A: Pneumothorax
B: Haemopneumothorax
C:
D:
E: Artefact.
```
???
53
4. REPEAT ME46 Acromegaly due to excess of growth hormone. Why is it difficult to do a direct laryngoscopy?
```
A: Distorted facial anatomy
B: Macroglossia
C: Glottic stenosis
D: Prognathe mandible
E: Arthritis of the neck
```
B. Macroglossia
54
AC159 REPEAT Mar 2011 Post CEA on ward, patient seizes. BP has been hard to control. What to do to prevent further seizures?
```
A: Add another antihypertensive
B: Start antiplatelet drugs
C: Start anticonvulsants
D: Do angio and stent
E: Nimodipine
```
A. Add another antihypertensive
55
6. Repeat Sep 2011 - Main heat loss in anaesthetic for neonate
```
A. vasodilatation
B. radiation
C. convection
D. conduction
E. evaporative
```
B. Radiation
56
7. REPEAT - Sep 2011 Patient with aortic stenosis, the signs indicate poor prognosis
```
A. Palpitation
B. Radiation to carotid arteries
C. Paroxysmal nocturnal dyspnoea
D. Angina
E. Syncope
```
E. Syncope
57
8. REPEAT Sep 2011 - EM16 ANZCA version [2002-Mar] Q68, [2002-Aug] Q64, [2005-Apr] Q94, [2005-Sep] Q75 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
58
9. REPEAT PZ130 Which drugs below does not need dose adjustment in renal failure patient
```
A. Buprenorphine
B. Morphine
C. Tramadol
D. ?
E. ?
```
A. Buprenorphine
59
```
10. Repeat- Fat: blood coefficient- N2O, Desflurane, Sevoflurane, Isoflurane
A. N2O ~ D > S > I
B. S > I > D > N2O
C. D > N2O > S > I
D. N2O > D > S ~ I
E . D > N2O > I > S
```
B. Sevo (48) > Iso (45) > Des (27) > N2O (2.3)
| Uptake and distribution of inhaled anesthetics - Shafer
60
11. REPEAT PP46 The average expected depth of insertion of an oral endotracheal tube, from the lip, in a normal newborn infant is
```
A. 7.5 cm
B. 8.5 cm
C. 9.5 cm
D. 10.5 cm
E. 11.5 cm
```
C. 9.5 cm
Distance at lips = 3 x tube size
(size 3.0 uncuffed tube for at term neonate)
61
NEW: What is the average distance from the lips to carina in an average 70kg adult male?
```
21 cm
23 cm
25 cm
27 cm
29 cm
```
D. 27 cm
Tube tip should be 5 cm above carina - this usually corresponds to 22 cm at the lips for an average 70 kg adult male.
62
NEW: Q51 Patient with severe Rheumatoid arthritis. Has C1/C2 instability. Most likely C-spine Xr finding would be
```
A. Anterior Atlantoodental interval >9
B. Increased sagittal diameter
C. Posterior atlantodental interval >14
D. Midpart of C1 over C2
E. Tear drop sign of C2
```
A. Anterior atlantodental interval > 9
Anaesthesia in treating rheumatoid arthritis CEACCP
Cervical spine
The atlanto-axial joint is commonly affected in RA because of attenuation of the transverse ligament and erosion of the odontoid peg. This can lead to atlanto-axial instability in about 25% of patients suffering from RA. Acute subluxation may cause spinal cord compression and/or compression of the vertebral arteries leading to quadriparesis or sudden death. There are two main categories of cervical spine instability - atlanto-axial subluxation and subaxial subluxation.
Atlanto-axial subluxation:
Four subtypes have been described.
i. Anterior (affecting up to 80% of patients with atlanto-axial subluxation). The C1 vertebra moves forward on C2 because of destruction of the transverse ligament and there is a risk of spinal cord compression by the odontoid peg. Views of the lateral cervical spine in flexion may demonstrate subluxation. Subluxation exists when the distance between the atlas and the odontoid peg exceeds 4 mm in patients older than 44 yr and 3 mm in younger patients. Anterior atlanto-axial subluxation is worsened by neck flexion.
ii. Posterior (affecting about 5% of patients with atlanto-axial subluxation). Destruction of the odontoid peg may cause backward movement of C1 on C2, which may be evident on lateral extension views of the neck. Posterior atlanto-axial subluxation is worsened by neck extension.
iii. Vertical (accounts for about 10–20% of atlanto-axial subluxation). Destruction of the lateral mass of C1 can lead to subluxation of the odontoid peg through the foramen magnum and compression of the cervico-medullary junction.
iv. Lateral or rotatory subluxation results from degenerative changes in the C1/C2 facet joints. It can lead to spinal nerve compression and vertebral artery compression.
63
NEW NH32 (Similar to NH11): Which nerves need to blocked to anaesthetise the hard palate:
A. Superior labial nerve and greater palatine nerve
B. Greater palatine nerve and nasopalatine nerve
C. Inferior orbital nerve and nasopalatine nerve
D. Glossopharyngeal nerve and…
E. Anterior ethmoidal nerve and…
B. Greater palatine nerve and nasopalatine nerve
64
NEW: Patient complains of numbness of the anterior third of his tongue following GA with LMA. Which nerve is involved?
A. Glossopharyngeal
B. Facial nerve
C. Superior vagus
D Mandibular nerve
D. Mandibular nerve
| lingual branch V3 - the mandibular division of the trigeminal nerve
65
NEW: CHADS2 score. Which is not a feature?
```
A. Age
B. Gender
C. Diabetes mellitus
D. Stroke
E. CCF
```
B. Gender
66
NEW: Increased risk of post-partum haemorrhage in:
A. Nulliparous patient
B. Patient
E. Prolonged labour
67
NEW: Chest Xray findings in a child who has inhaled a foreign body:
```
A. Opaque mass overlying the airway
B. Hyper-expanded lung fields
C. Unilateral pulmonary oedema
D. Collapsed lung base
E. Mediastinal shift
```
B. (Unilateral) hyperexpanded lung field
68
ME47Which 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, hypernatraemia, hypokalaemia
Conn's syndrome = mineralocorticoid excess
Excess aldosterone promotes active reabsoprtion of sodium and excretion of potassium through renal tubules.
Clinical features: refractory hypertension, hypervolaemia, metabolic alkalosis, hypokaelmia, hypernatremia.
69
REPEAT: MR47Unequal consolidation on CXR can be caused by all except:
```
A. Pleural effusion
B. Pulmonary infarction
C. Pulmonary haemorrhage
D. APO
E. Pneumonia
```
A. Pleural effusion
Consolidation refers to lung fields, not the pleural space
70
NEW: 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
71
NEW: What is the resus dose of atropine and adrenaline when given via ETT compared to IV
```
A. x 0.5
B. No change
C. x 2
D. x 4
E. x 6
```
E. x 6
ARC ALS guidelines 2010
Endotracheal route:
If IV/IO access cannot be attained and an endotracheal tube is present, endotracheal administration of some medications is possible, although the absorption is variable and plasma concentrations are substantially lower than those achieved when the same drug is given by the intravenous route (increase in dose 3-10 times may be required). There are no benefits from endobronchial injection compared with injection of the drug directly into the tracheal tube. Dilution with water instead of 0.9% saline may achieve better drug absorption. Adrenaline, lignocaine and atropine may be given via endotracheal tube, but other cardiac arrest drugs should NOT be given endotracheally as they may cause mucosal and alveolar damage.1 This route cannot be used if a laryngeal mask airway is present. [Class A; Expert consensus opinion]
72
NEW: EZ94A home handyman leaves his electricity turned on whilst fiddling with wires [repairing a power outlet]. He has a RCD. What happens if he touches the neutral and ground wires?
```
A. Nothing will happen
B. Receives macroshock
C. Protected from macroshock by RCD
D. Protected from microshock by domestic fuse
E Receives microshock
```
A. Nothing will happen
RCD protects by constantly monitoring the current flowing in the live and neutral wires supplying a circuit or an individual item of equipment. Under normal circumstances, the current flowing in the two wires is equal. When an earth leakage occurs due to a fault in the circuit or an accident with the equipment, an imbalance occurs and this is detected by the RCD, which automatically cuts off the power before injury or damage can result.
What an RCD will not protect:
If a user was to touch both active and neutral at the same time, then current flow would be even through both circuits, there is no imbalance so the RCD WON’T TRIP
A: Nothing will happen, Neutral and Ground are connected at the fuse box so they are essentially the same wire so no potential difference between them. RCD will not trip in this case as no current is leaking out of system
73
REPEAT: RU12 If a patient experiences parasthesia in the little finger during supraclavicular brachial plexus block, the needle is in proximity to the
```
A. posterior cord
B. middle trunk
C. Ulnar nerve
D. lower trunk
E. medial cord
```
D. Lower trunk
74
NEW: What is the best predictor of severe bleeding in cirrhosis?
```
A. Thrombocytopaemia
B. Hypofibrinogenaemia
C. Prolonged PT
D. Hypoalbuminaemia
E. Pulmonary hypertension
```
C. Prolonged PT
75
NEW: What is the dose of FFP required to increase fibrinogen levels by 1 g/L
```
A. 2 ml/kg
B. 5 ml/kg
C. 10 ml/kg
D. 20 ml/kg
E. 30 ml/kg
```
E. 30 mL/kg
ASA transfusion practice 2011
Each unit of cryoprecipitate per 10 kg body weight increases plasma fibrinogen by approximately 50 mg/dL (i.e. 0.1 unit/kg cryo will raise fibrinogen by 0.5 g/L) when there is no ongoing bleeding, whereas 30 ml/kg of FFP is required to raise plasma fibrinogen level by 1 g/L (4, 5).
76
EZ95 What is the oxygen concentration in a standard bottle of heliox?
A. 21%
B. 25%
C. 30%
D. 33%
A. 21%
| Available as helium with both 21% and 28% O2 in Australia
77
NEW: EZ96 A C size oxygen cylinder (A size in New Zealand) reads 5000kPa. How much oxygen remains?
```
A. 50 litres
B. 150 litres
C. 500 litres
D. 750 litres
E. 1500 litres
```
B. 150 L
Full size C has 440 L (at 13700 kPa)
Pressure of 5000 kPa equates to volume of 440 x (5000/13700) = 160 L
78
NEW: Patient undergoing partial hepatic resection develops Venous Air Embolism.
Best position should be
A. Head down left side up
B. Head down right side up
C. Head up right side up
D. Head up left side up
C. Head up, right side up
79
NEW: What is the ratio of compressions to breaths in neonatal resus?
A. 3:1
B. ?
A. 3:1
80
REPEAT: SF27 The pain of the first stage of labour is transmitted by:
```
A. Grey rami communicantes
B. T10-L1 anterior roots
C. The hypogastric plexus
D. Inhibitory nerves to the internal vesical sphincter
E. Parasympathetic nerves
```
C. The hypogastric plexus
81
NEW: 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
D. 400 mcg
E. 500 mcg
```
B. 50 mcg
82
NEW:Middle-aged male with severe 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
83
NEW: The ratio of MAC to MAC Awake for sevoflurane is:
A. 0.22
B. 0.33
B. 0.33
84
NEW: A lady with a Fontan’s circulation for tricuspid atresia presents for caesarian section. What is the best way of maintaining her cardiac output?
```
A. Trendelenburg
B. Epidural contraindicated
C. Allow pCO2 to rise to 50 to vasodilate her
D. Short inspiratory time
E. Allow hypovolaemia
```
D. Short inspiratory time
CEACCP - The Fontan Circulation (2008)
Mechanical ventilation:
For relatively short procedures, Fontan patients are probably better off breathing spontaneously, as long as severe hypercarbia is avoided. For major surgery, or when prolonged anaesthesia is required, control of ventilation and active prevention of atelectasis is usually advisable. Potential disadvantages of mechanical ventilation in Fontan patients relate to the inevitable increase in mean intrathoracic pressure. This causes decreased venous return, decreased pulmonary blood flow, and hence, decreased cardiac output. Low respiratory rates, short inspiratory times, low PEEP, and tidal volumes of 5–6 ml kg−1 usually allow adequate pulmonary blood flow, normocarbia, and a low PVR. Hyperventilation tends to impair pulmonary blood flow, despite the induced respiratory alkalosis, because of the increased mean intrathoracic pressure.
85
NEW:What is the cerebral perfusion pressure if MAP 80, CVP 5, both at the level of the RA with the tragus 13 cm above the RA?
A. 62 mmHg
B. 65 mmHg
C. 75 mmHg
D. 80 mmHg
B. 65 mmHg
CPP = MAP - CVP
= (80 - 10) - 5
13 cm H2O = 10 mmHg
86
NEW: What is the best way to measure neonatal heart rate during resus?
A. Palpate a femoral artery
B. Palpate a carotid artery
C. Auscultate the precordium
D. Palpate the umbilical stump
C. Auscultate the praecordium
87
NEW: A term primip with meconium-stained liquor has a caesarian section. On initial assessment the neonate if pale and floppy with a heart rate of 90 bpm. Initial treatment should be:
A. Positive pressure ventilation
B. Dry and stimulate
C. Suction the trachea
D. Start CPR
C. Suction the trachea
88
NEW: The Revise Trauma Score includes the first measures of GCS, BP and:
```
A. HR
B. RR
C. SpO2
D. Temp
E. CVP
```
B. RR
89
NEW: The most common clinically significant valvular lesion in pregnancy is:
```
A. MS
B. MR
C. AS
D. AR
E. TR
```
A. MS
90
NEW: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
91
NEW: How do you calculate the inspiratory time constant for lungs
```
A. resistance multiplied by compliance
B. resistance divided by compliance
C. compliance divided by resistance
D. resistance minus compliance
E. resistance plus compliance
```
A. Resistance x compliance
A lung unit can be considered to be an airway with the alveoli it supplies. If an airway has higher resistance than normal, then the movement of air into it or out of that lung unit will be slower. If a lung unit has a lower compliance than normal, then the flow of air into that unit will cease sooner than in other units.
The resistance and compliance of a lung unit therefore affect the time-dependent filling or emptying of that unit.
This can be expressed by the time constant of the lung unit, which is the product of the resistance and compliance.
As air flows into lung unit, 95% is complete after 3 time constants.
Resistance = change in pressure/flow = 2 cmH2O/L per second
Compliance = change in volume/change in pressure = 0.1 L/cmH2O
Time constant = R x C = (2 cmH2O x 1 sec)/1 L x 0.1 L/1 cmH2O
= 2 x 1 sec x 0.1
= 0.2 secs
92
NEW: What is the best indicator of impending respiratory depression when using a morphine
PCA
A. Respiratory rate
B. Sedation score
C. Reduced saturations
B. Sedation score
93
NEW: A 60kg 17 year old female given 50 mg rocuronium for RSI. You can’t intubate or ventilate. What is the appropriate dose of sugammadex?
A. 300mg
B. 600mg
C. 960mg
D. 1300mg
C. 960 mg (16 mg/kg)
94
NEW: What is the maximum dose of Intralipid during LA toxicity resus?
A. 8 mL/kg
B. 10 mL/kg
C. 12 mL/kg
D. 16 mL/kg
C. 12 mL/kg
95
NEW: What is the maximum volume of air the can be placed in a size 5 classic LMA?
```
A. 30ml
B. 35ml
C. 40ml
D. 45ml
E. 50ml
```
C. 40 mL
Size 3 - 20 mL
Size 4 - 30 mL
Size 5 - 40 mL
96
NEW: What is the immediate compensation for the dilutional anaemia when 3 litres of normal saline is given at the start of a case?
A. Increased CO
B. Capillary dilatation
C. Increased oxygen delivery
D. Right shift in the oxygen dissociation curve
A. Increased cardiac output
97
```
NEW Alcoholic patient undergoes unremarkable anaesthesia for exploratory laparotomy for investigation of abdominal pain. No pathology is found. However, in recovery the following electrolyte disturbances found:
Na 140
K 5.0
CL 115
HCO 18
```
What is the most likely cause?
```
A. Acute renal failure
B. Lactatic acidosis
C. Methanol ingestion
D. Normal saline resuscitation
E. DKA
```
D. Normal saline resuscitation
| hyperchloraemic acidosis
98
The plasma half-life of clopidogrel is:
```
A. 6 hrs
B. 14 hrs
C. 24 hrs
D. 7 days
E. 14 days
```
A. 6 hours
99
NEW: Isoflurane vaporiser giving 3%. What is the splitting ratio?
```
A. 1:3
B. 1:9
C. 1:13
D. 1:20
E. 1:27
```
C. 1:13
100
NEW: The line between the iliac crests in a neonate corresponds to:
```
A. L2/3
B. L3/4
C. L4/5
D. L5/S1
E. S1/2
```
D. L5/S1
A line connecting the top of the iliac crests crosses the spinal axis at the L5-S1 level in neonates and infants up to one year of age and at the L4-L5 level in older children. (Update in anaesthesia)
101
REPEAT: EZ79 In a neonate the main resistance in a circle system with CO2 absorber
```
A. APL valve
B. Expiratory and inspiratory unidirectional valves
C. Tubing
D. ETT
E. HME filter
```
D. ETT
102
NEW: Blood flow across which of the following is used to estimate pulmonary artery pressures during echocardiography?
A. Tricuspid valve
B. Pulmonary valve
C. Mitral Valve
A. Tricuspid valve (regurgitant flow)
103
REPEAT: AT16 Which patient do you not put a left-sided Robert-Shaw DLT into?
```
A. Left pneumonectomy
B. Left main bronchial lesion
C. There is a right-sided broncho-pleural fistula
D. The patient has shunt > 10%
E. The left lung is to be collapsed
```
B. Left mainstem bronchial lesion
104
NEW: An infant born at 32 weeks gestational age comes at 6 weeks for elective bilateral inguinal hernia repair. The parents expect to take him home that day. What do you tell them?
A. He cannot have surgery until he is 3 months old
B. They can take him home that day
C. They can take him home with apnoea monitoring overnight
D. He needs to stay in hospital for apnoea monitoring
D. He needs to stay in hospital for apnoea monitoring
Overnight admission for any ex-preterm infant less than 52 weeks PCA, or any term infant
105
NEW: EZ98A 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
106
REPEAT: {Apr09], [Mar 12] A post-op child being given 2.5%D + 1/2NS on the ward seizes, is intubated and ventilated and transferred to ICU. Sodium is 116. What do you do?
```
A. Give phenytoin
B. Give hypertonic saline
C. Give normal saline
D. Give frusemide
E. Give normal saline
```
B. Give hypertonic saline
107
NEW: Which two nerves are most reliably blocked in a fascia iliaca block?
Various combinations of femoral, obturator, lateral cutaneous and sciatic
Femoral > lateral cutaneous nerve of thigh > obturator
108
NEW: Which is not a side effect of cyclosporine?
A. Alopecia
B. Gingival hyperplasia
C. Hypertension
D. Renal impairment
A. Alopecia
ADRs can include gingival hyperplasia, convulsions, peptic ulcers, pancreatitis, fever, vomiting, diarrhea, confusion, hypercholesterolemia, dyspnea, numbness and tingling particularly of the lips, pruritus, high blood pressure, potassium retention possibly leading to hyperkalemia, kidney and liver dysfunction, burning sensations at finger tips and an increased vulnerability to opportunistic fungal and viral infections.
In short, it is nephrotoxic, neurotoxic, causes hypertension (due to renal vasoconstriction and increased sodium reabsorption), increases the risk of squamous cell carcinoma and infections. It also causes gingival hypertrophy and hirsutism which is not seen with tacrolimus (another calcineurin inhibitor).
109
NEW: New national labelling standards endorsed by ANZCA. What colour should the label on a subcutaneous ketamine infusion be?
```
A. Red
B. Blue
C. Beige
D. Yellow
E. Pink
```
C. Beige
110
NEW ANZCA professional documents, ketamine labels should be
```
A. Pink
B. Green
C. Grey
D. Yellow
E. Black
```
C. Yellow
111
REPEAT Q121. Poor prognosis of AS
```
A. PND
B. Chest pain
C. Palpitation
D. Syncope
E. Malaise
```
D. Syncope
112
NEW Q122. Required for diagnosis of Neuroleptic Malignant Syndrome
```
A. Diaphoresis
B. ↑ CK
C. Rigidity
D. Hypertension
E. ↑ HR
```
C. Rigidity
113
```
NEW Q143. 2 yo 15kg child following seizure on surgical ward. Admitted with appendicitis and perforation. 60ml/hr of ½ N. Saline 5%dextrose
Na+ 119
K+ 4.5
HCO3- 19
Cl- 90
```
Best treatment would be
```
A. Desmopressin
B. Frusemide
C. 3% normal saline
D. Normal Saline
E. Fluid restrict
```
C. 3% normal saline
114
NEW Atrial septal defect, where is the murmur heard the loudest?
```
A. PV
B. MV
C. ASD
D. AV
E. TV
```
A. Over the pulmonary valve area
Talley and oconnor:
The defect itself produces no murmur directly, but increased flow through the right side of the heart can produce a low pitched diastolic tricuspid flow murmur and more often a pulmonary systolic ejection murmur
115
NEW Young infant with Failure to Thrive. Born on the 20th percentile now is on the 5th percentile. Found to have a systolic murmur, tachynpnea with weak femoral pulse. The most likely diagnosis is
a. Coarctation
b. HOCM
c. PDA
d. AS
e. VSD
C. PDA
116
NEW Myasthenia gravis, Eaton Lambert Syndrome What happens with exercise?
a. MG better, EL worse
b. EL better, MG worse
c. Both EL and MG get worse
d. Both EL and MG get better
B. EL better, MG worse
117
REPEAT Cephalothin doesn't cover:
a. Proteus
b. E coli
c. Staph
d. Strep
e. Pseudomonas
E. Pseudomonas
118
NEW:Regarding PS9 safe provision of anaesthesia for Colonoscopy:
```
A. Medical Practitioner providing sedation with a skilled assistant who is not assisting the proceduralist.
B. Medical practitioner alone
C. Specialist Anaesthetist
D. Skilled nurse with airway experience
E. Skilled bogan
```
A. (Appropriately skilled) medical practitioner + assistant
Assistant may be shared between the proceduralist and the medical practitioner providing the sedation but the sedationneur must have exclusive access to the assistant during induction and emergence
119
NEW: 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. Frusemide
b. Amiodarone
c. ACE inhibitor
d. Digoxin
e. Biventricular pacemaker
C. ACE inhibitor
'...For this reason, angiotensin converting enzyme (ACE) inhibitors are the mainstays of treatment in patients with idiopathic dilated cardiomyopathy, irrespective of the severity of heart failure'
120
Young child with WPW undergoes general anaesthesia. Intraoperatively developed tachycardia. HR 220, BP 80/40.
Best drug to cardiovert
A. Adenosine
B. Amiodarone
C.
Depends...
Unstable --> shock
Stable:
Narrow complex regular - give adenosine
Narrow complex irregular - probably AF with WPW, adenosine may precipitate VT/VF, give beta blocker or amiodarone
121
REPEAT Finding on haemophilia A patient
A. Female haemarthrosis
B. Male haemarthrosis
C. Normal PT, abnormal APTT
D. Abnormal PT, normal APTT
C. Normal PT, abnormal aPTT
Haemophilia
- Prolonged aPTT, normal platelet count, bleeding time and prothrombin time
- Presents with bleeding spontaneously (often into weight-bearing joints) or after trauma
122
NEW: 32 y/o male. Weakness distal and prox muscles, infection 10 days ago, no sensory involvement, temp 37.8, facial weakness. Cause:
```
A. Guillian Barre
B. Myasthenia Gravis
D. Poliomyelitis
E. ?Acute encephalitis
F. ?Polymyositis
```
A. Guillain Barre
123
NEW: What gestation to monitor uteroplacental flow
```
A. 20 weeks
B. 24 weeks
C. 28 weeks
D. 32 weeks
E. 36 weeks
```
B. 24 weeks (minimum gestation for fetal viability)
124
REPEAT: Cause of hypoxia in 1 lung ventilation?
A Blood to non-ventilated lung
B V/Q mismatch in ventilated lung
C ?hypoxic pulm vasoconstriction
A. Blood flow to non-ventilated lung
125
NEW: Endocarditis prophylaxis
```
A Bicuspid valve
B Congenital repair > 12 months ago
C Rheumatic heart valve
D Uncorrected cyanotic heart disease
E MVP + ?MR
```
D. Uncorrected cyanotic heart disease
Antibiotic prophylaxis is only recommended for the small group of patients with cardiac conditions that place them at high risk of adverse outcomes associated with endocarditis (see below), and only for certain procedures.
High risk group:
- Prosthetic cardiac valve (or valve repaired with prosthetic material)
- Previous IE
- Congenital heart defect, but only if it involves:
o Unrepaired cyanotic defects (including palliative shunts and conduits)
o Completely repaired defects with prosthetic material or devices during the first 6/12 after the procedure (after which the prosthetic material is likely to have been endothelialised)
o Repaired defects w/ residual defects at or adjacent to the site of a prosthetic patch or device (which inhibit endothelialisation)
- RHD in high risk groups (Aboriginal, or non-Indigenous from low socioeconomic background)
- (Consider for post-cardiac transplant pts)
126
REPEAT: Air bubble in arterial line. Causes decreased:
A Damping
B Resonant freq of system
B. Resonant frequency of the system
127
REPEAT: Area burnt in adult male - upper half of upper limb, anterior abdo, whole left leg:
A 23% [changed figure compared to prev years]
B 32%
B. 32%
Upper limb = 4.5% anterior + 4.5% posterior
(half of upper limb = 4.5%)
Abdomen = 9% (anterior)
Leg = 9% anterior + 9% posterior
4.5 + 9 + 18 = 31.5%
128
REPEAT: Contraindication to Intra-aortic Balloon pump:
A AR
B AS
C MR
A. AR
129
NEW: Best position for tip of IABP is 1-2 cm:
A Distal to Left subclavian artery
B Proximal to Left subclavian artery
A. Distal to left subclavian artery
130
NEW: VT features:
A monophasic V6
B QRS > 0.14
C Right axis deviation
B. QRS > 0.14
131
NEW: 70 y/o postop in recovery following hip surgery. Develops severe chest pain, ST elevation. Immediate mx:
A Beta blocker
B Aspirin
C GTN infusion
D Heparin infusion
B. Aspirin
MCQs
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