1
Q
- Given the following diagram, what does X represent? (diagram of underwater seal drain apparatus)
A. Amount of drainage since system was connected to patient
B. Level of resistance to drainage of pleural cavity
C. Level of underwater seal applied to pleural cavity
D. Maximum pressure ?in/against pleural cavity on expiration
E. Maximum suction that can be applied to pleural cavity
A
?
2
Q
- Retrobulbar block. Sign of brainstem spread
A. Atonic pupil B. Unilateral blindness in blocked eye C. Contralateral blindness D. Diplopia- past papers remembered this as dysphagia E. Nystagmus
A
C. Contralateral blindness
Caused by back-spread of LA to the optic chiasm
Drowsiness/Vomiting/Convulsions/Respiratory Depression/Arrest
http://bja.oxfordjournals.org/content/75/1/93.full.pdf
3
Q
- Otherwise healthy 20 yo male undergoes surgery for an ORIF tibia for open tib fracture. The limb is exanguinated and the tourniquet correctly applied at 250mmHg. His SBP is 120. When the surgeons go to start there is a small amount of bleeding. Do you..
A. Accept that a small amount of bleeding may occur with a tourniquet
B. Reinflate at a higher pressure
C. Check coags
D. Take tourniquet down, rexanguinate and reinflate
E. Something else
A
A. Accept a small amount of bleeding
4
Q
- This was the CXR showing a widened mediastinum with an otherwise normal CXR, there was an electronic circuit thing at the bottom right but nothing else obvious. Aortic dissection was the answer (at least I think!)
A
Aortic dissection
5
Q
- Fatigue during night shifts can be minimized by:
A. Avoiding daylight B. not sleeping during day C short naps during shift D use of caffeine or stimulants E. using benzodiazepines for sleep during the day
A
C
CEACCP - fatigue and the anaesthetist (2013)
6
Q
6.Patient with Acute Intermittent Porphyria presents to hospital with abdominal pain and requires a general anaesthetic. Which drug for PONV would you avoid?
A. Metoclopramide B. Prochlorperazine C. Tropisetron D. Ondansetron E. Droperidol
A
A. Metoclopramide
Oxford handbook
7
Q
- A 65 year old man having a total hip placement under general anaesthetic has continued to take his moclobemide. He becomes hypotensive shortly after induction. The best treatment would be judicious use of
A. adrenaline B. dobutamine C. ephedrine D. metaraminol E. phenylephrine
A
E. Phenylephrine
Moclobemide- reversible MAOI
Most dangerous - indirect sympathomimetics (Ephedrine/Metaraminol/Amphetamine/Cocaine)
Direct sympathomimetics - exaggerated effect
Serotonin Syndrome - Pethidine/Tramadol
Pancuronium - releases stored NA
Oxford Handbook
8
Q
- The following capnography trace was observed in an intubated and ventilated patient (low/false plateau, then true plateau just prior to inspiration). The most likely explanation for this respiratory pattern is
A. endobronchial intubation B. endotracheal cuff leak C. gas sampling line leak D. obstructive airways disease E. spontaneous ventilatory effort
A
C. Gas sampling line leak
9
Q
- When topping up a labour ward epidural to an epidural for lower segment caesarean section, the optimum level of block when assessed for light touch is to:
A. T2 B. T4 C. T6 D. T8 E. T10
A
B. T4
10
Q
- You are in the pre-admission clinic assessing a 60 year old male who is due to undergo total knee replacement in 10 days time. He is taking dabigatran 150mg BD for chronic atrial fibrillation. He has no other past medical history and normal renal function. He is planned for a spinal anaesthetic. The most appropriate management for his anticoagulation is:
A. Cease dabigatran 7 days prior
B. Cease dabigatran 3 days prior
C. Cease dabigatran 3 days prior and give bridging anticoagulation
D. Cease dabigatran 24 hours prior and measure INR on day of surgery
E. Continue dabigatran and withhold on day of surgery
A
B. Cease dabigatran 3 days, prior. No bridging required (low risk for thromboembolism).
Darbigatran - factor Xa inhibitor
At least 48 hours for spinal
MIMS
11
Q
- A 15 yo girl with newly diagnosed mediastinal mass presents for supraclavicular lymph node biopsy under GA. The most important investigation to perform preoperatively
A. CXR B. CT chest C. MRI chest D. PET scan E. TOE
A
CT or MRI to determine presence/extent of airway compression. ?MRI better for 15 year-old to minimise radiation.
If she could tolerate it, would do this procedure under LA (if any concerns about airway compression or SVC syndrome).
12
Q
- A CTG recording with late prolonged decelerations. Cause:
A. GA B. Head compression C. Uteroplacental insufficiency D. Acute asphyxia E. Umbilical cord compression.
A
C. Uteroplacental insufficiency
Late decelerations begin at peak of uterine contraction and recover when the contraction ends.
Caused by:
Maternal Hypotension
Pre-Eclampsia
Uterine Hyperstimulation
Head compression- Early deceleration
Umbilical cord compression- Variable deceleration
http: //geekymedics.com/2011/05/29/how-to-read-a-ctg/
http: //ceaccp.oxfordjournals.org/content/3/2/38.full.pdf+html
13
Q
- A new antiemetic decreases the incidence of PONV by 33% compared with conventional treatment. 8% who receive the new treatment still experience PONV. The number of patients who must receive the new treatment instead of the conventional before 1 extra patient will benefit is
A. 3 B. 4 C. 8 D. 25 E. 33
A
D. 25
1/ARR
1/Probability (with intervention)-Probablity (Control)
1/0.12-0.08=1/0.04 = 25
14
Q
- You are anaethetising a lady for elective laparoscopic cholecystectomy, who apparently had an anaphylactic reaction to rocuronium in her last anaesthetic. There has not been sufficient time for her to undergo cross-reactivity testing. What would be the most appropriate drug to use:
A. vecuronium B. cisatracurium C. pancuronium D. atracurium E. suxamethonium
A
B Cisatracurium
60-70% of all anaphylaxis
Anaphylaxis to suxamethonium - 60% to all others NMBD
Benzylisoquinolonium
Less potential for histamine release
Cisatracurium less histamine release
Peck + Hill
…If it’s elective, the safest thing to do is to defer the case until she has had allergy testing.
15
Q
- Increase in period bleeding EXCEPT
A. Gingko B. Garlic C. Ginger D. Fish Oil E. Echinacea
A
E. Echinacea
16
Q
- Post op hip ORIF, commonest periop complication
A. UTI B. PE C. Delirium D. AMI E. Pneumonia
A
C. Delirium
Anaesthesia UK - tutorial of the week: neck of femur fracture; perioperative management (2013)
17
Q
- You are anaesthetizing a 50 year old man who is undergoing liver resection for removal of metastatic carcinoid tumour. He has persistent intraoperative hypotension despite fluid resuscitation and intravenous octreotide 50 ug. The treatment most likely to be effective in correcting the hypotension is:
A. Adrenaline B. Dobutamine C. Levosimenden D. Milrinone E. Vasopressin
A
E. Vasopressin
CEACCP - carcinoid: the disease and its implications for anaesthesia (2011):
A significant proportion of the surgery related to carcinoid will be for the removal of metastases by hepatic resection. Here, the need to try to maintain a relatively low CVP, during clamping of the hepatic artery and portal vein to avoid backflow into the liver and venous bleeding, will further exacerbate the risk of hypotension. The response to inotropic and vasopressor agents is unpredictable and, in general, drugs such as norepinephrine and epinephrine can be hazardous in carcinoid patients. Norepinephrine has been shown to activate kallikrein in the tumour and can even lead to the syn- thesis and release of bradykinin resulting paradoxically in further vasodilatation and worsening hypotension, although exaggerated hypertensive responses may be seen. Indeed, any pharmacological stimulation of the autonomic nervous system has the potential to provoke further problems with vasoactive hormone release. In practice, cautious administration of small doses of phenylephrine has been found helpful in some patients.
Vasoactive hormone release intra-operatively is best treated with intravenous boluses of 20 – 50 mg of octreotide, titrated to haemodynamic response. Vasopressin as an alternative vasocon- strictor that may be useful if prolonged vasoconstriction is required; however, the evidence base is small.
It must be borne in mind that concomitant fluid losses, especially bleeding, may be responsible for intra-operative instabil- ity rather than hormone excess and that fluid resuscitation may be the answer rather than further octreotide therapy. Monitoring of fluid losses, especially bleeding, is very important in these patients.
18
Q
- 80 year old female for open reduction and internal fixation of a fractured neck of femur. Fit and well. You notice a systolic murmur on examination. Blood pressure normal. On transthoracic echo, she has a calcified aortic valve, with aortic stenosis with a mean gradient of 40mmHg. How do you manage her:
A. Instigate low dose beta blockade
B. Defer, and refer to a cardiologist
C. Perform a transoesophageal echo to get a better look at the valve
D. Proceed to surgery with no further investigation
E. Perform a dobutamine stress echo
A
D. Crack on
CEACCP - anaesthetic management of patients with hip fractures: an update (2013):
No study has so far shown that ‘preoptimization’ improves outcome among hip fracture patients, whereas two large meta-analyses of 275,000 patients have shown that delay to surgery beyond 48 h is associated with increased 30 day post- operative mortality, complications, and length of inpatient stay…
…The management of patients with hip fracture in whom a systolic murmur [indicating aortic stenosis (AS)] is heard remains conten- tious. Traditionally, anaesthetists have been reluctant to administer anaesthesia without additional echocardiographic information con- cerning aortic valve area, transvalvular gradient, and left ventricular contractility (indicated by ejection fraction), for fear of producing cerebral and coronary hypotension and ischaemia through arteriolar relaxation in patients with a relatively fixed, stenotic cardiac output, consequent to spinal (and general ) anaesthesia.
Guidelines have consistently stated that echocardiography is indicated if it has not been performed recently. However, despite the prevalence of AS being higher in the population with hip frac- ture (20–40% vs 3% in the over 75s, possibly contributing to the aetiology of the fall), several studies have found that early postoperative mortality among patients with AS undergoing hip fracture is similar to hip fracture patients without AS, although higher mortality has been noted in other studies. Insistence on pre- operative echocardiography has declined in recent years; however, as this can delay surgery, and the information yielded rarely changes management, which should be to treat patients with an audible ejection systolic murmur as if they had at least moderate AS, and administer anaesthesia accordingly, that is: using invasive arterial pressure monitoring and vasopressors to maintain coronary and cerebral perfusion pressure, and delivering anaesthesia sympa- thetically to the patients age and co-morbidities.
19
Q
19 (Repeat) Electrocardiogram in the Cs5 configuration. What are you looking at when monitoring lead I.
A. anterior ischaemia B. atrial C. inferior D. lateral E. septal
A
D. Lateral
20
Q
- (Repeat) Pringles procedure for life threatening liver haemorrhage includes clamping of:
A. Aorta B. Hepatic artery C. Hepatic vein D. Portal pedicle E. Splenic Artery
A
D. Portal pedicle
both hepatic artery and portal vein
21
Q
- A 60 y.o. diabetic man has below knee amputation for ischaemic leg. His neuropathic pain is treated with oxycodone 40mg BD and paracetamol 1g QID. He is also on omeprazole 20mg BD for reflux. You decide to start him on gabapentin. Before choosing a dosing regime and starting treatment it is most important that you:
A. cease his omeprazole B. check his hepatic transaminase level C. check his renal function D. CHeck his QT interval on a resting ECG E. Decrease his oxycodone
A
C. Check his renal function
22
Q
- The anterior and posterior borders of the ‘triangle of safety’, the preferred insertion site for an intercostal catheter, are pec major and:
A. Coracobrachialis B. Deltiod C. Lat Dorsi D. Serratius Anterior E. Trapezius
A
C. Lat dorsi
23
Q
- A 39 yo male brought into ED with a compound fracture of his forearm. Has a history of schizophrenia and depression with nucertain medication compliance. He is confused and agitated wuth generalised rigidity but no hyperreflexi:A. Obs - HR 120, BP 160/90, RR 18, Sats 98 Temp 38.8 Likely Dx?
A. Heat stress from anticholinergics B. Hypoxic ischaemic encephalopathy C. Neuroleptic malignant syndrome D. Serotonin syndrome E. Pain from fracture
A
C. Neuroleptic malignant syndrome
24
Q
- CO2 laser penetrates surface tissue so well with little damage to underlying tissue because
A) Well absorbed by Hb B) Poorly absorbed by H20 C) Widely disseminated in tissue D) Long infrared wavelength E) Short infrared wavelength
A
D. Long infrared wavelength
25
25. (NEW) An 80yo man is having a transuretheral bladder resection, the surgeon is using diathermy close to the lateral bladder wall which results in patient thigh adduction. The nerve involved is:
```
A. Inferior gluteal
B. Obturator
C. Pudendal
D. Scaitic
E. Superior gluteal
```
B. Obturator
Obturator - adductor muscles of the hip
Inferior gluteal - gluteus maximus
Pudendal - sensation to genitals + anal canal, pelvic floor muscles, sphincters
Sciatic - posterior thigh and leg
26
26. (New) You are involved in research and as part of data collection you collect ASA scores. This type of data is:
```
A. Ratio
B. Nominal
C. Non-parametric
D. Numerical
E. Ordinal
```
E. Ordinal
27
27. An otherwise healthy man presents with anaemia. The test that most reliably indicates iron deficiency is decreased:
```
A. MCV
B. serum ferritin
C. serum iron
D. serum transferrin
E. total iron binding capacity
```
B. serum ferritin
Iron deficiency anaemia:
```
MCV Low
Ferritin Low
Serum Iron Low
Transferrin Low
Total Iron Binding Capacity High
```
Ferritin intracellular protein - stores and releases iron
28
30. The maximal allowable atmospheric concentration of nitrous oxide in Australian and New Zealand operating theatres (in parts per million) is
```
A. 5
B. 25
C. 50
D. 100
E. 200
```
B. 25
29
31. What is associated with down regulation of nicotinic acetylcholine receptors:
```
A. Guillain-Barre syndrome
B. Organophospate overdose
C. Spinal cord injury
D. Stroke
E. Prolonged neuromuscular blockade
```
B. Organophosphate overdose
nAchR Down-regulation:
- Myasthenia Gravis
- Anticholinesterase poisoning
- Organophosphate poisoning
nAchR Up-Regulation:
- Spinal cord injury
- Stroke
- Burns
- Prolonged immobility
- Prolonged exposure to NMD
- Multiple Sclerosis
- Guillain Barre
Miller page 900 (table 29-1)
30
35. A reduction in DLCO can be caused by:
```
A. Asthma
B. Emphysema
C. Left to right shunt
D. Pulmonary haemorrhage
E. Bronchitis
```
B. Emphysema
Increased DLCO (120-140% predicted):
- Asthma
- Pulmonary haemorrhage
- Polycythaemia
- Left to Right shunt
Rate of Diffusion = A (C1-C2)/D
31
36. A healthy 25 year old woman is 18 weeks pregnant. Her paternal uncle has had a confirmed episode of malignant hyperthermia. She has never had susceptibility testing. Her father and siblings have not been tested either. The best test to exclude malignant hyperthermia susceptibility before she delivers is
```
A. Genetic test father
B. Genetic test woman
C. Muscle biopsy sibling
D. Muscle biopsy father
E. Muscle biopsy woman
```
E. Muscle biopsy woman
If you want the best test to exclude MH for this patient, you have to muscle biopsy her.
In real life though, a better approach might be to muscle biopsy her father (and not expose her to the risks of GA, including fetal loss). If he is negative, she will almost certainly be negative (unless there is MH on her mother's side).
32
37. (New) The size (in French gauge) of the largest suction catheter which can be passed through a size 8 endotracheal tube which will take up not greater than half the internal diameter is size:
```
A. 6
B. 8
C. 10
D. 12
E. 14
```
D. 12
French size is the circumference in mm
Diameter of suction catheter must be = 4
Circ = 2 x pi x r, = pi x diam, = 3.14 x 4, = 12
33
38. (Repeat) Pneumoperitoneum causes a decrease in cardiac output at what pressure (or possibly ABOVE what pressure)
```
A. 10mmHg
B. 20mmHg
C. 30mmHg
D. 40mmHg
E. 50mmHg
```
A. 10 mmHg
Miller says >10
CEACCP - Laparascopic abdominal surgery (2004)
20 mmHg - decreased VR, decreased CO, decreased MAP.
34
39. 60yo male had total knee replacement. 7 days post-operatively diagnosed with deep venous thrombosis on ultrasound. Was on LMWH. PLT dropped from 300 immediately post-op and now 150x10^9/L. All the following are acceptable treatments EXCEPT
```
A. Argabotran
B. Lepirudin
C. Fondaparinax
D. Danaparoid
E. Warfarin
```
C. Fondaparinux
Synthetic Xa inhibitor, chemically related to low molecular weight heparins (Wiki)
35
40. [Repeat] Maximum dose (with low risk of toxicity) of lignocaine (with adrenaline 1:100000) for liposuction with tumescence technique:
```
A. 3 mg/kg
B. 7 mg/kg
C. 15 mg/kg
D. 25 mg/kg
E. 35 mg/kg
```
E. 35 mg/kg
CEACCP - Novel techniques of local anaesthetic infiltration (2011)
Another method to increase the effectiveness and duration of local anaesthetics at the site of infiltration is a technique known as tumescent analgesia. A high volume but low concentration of a local anaesthetic (lidocaine 0.05 – 0.1%) together with dilute epi- nephrine is infiltrated at the site of incision, causing the tissues to become firm. Analgesia and anaesthesia are thought to be pro- longed by the increase in hydrostatic pressure in the tumescent tissues causing blood vessel compression and therefore reduction in local anaesthetic removal from the site of injection. The local anaesthetic effect is also prolonged by both the presence of epi- nephrine, which causes vasoconstriction, and sequestration of the local anaesthetic in fat due to its lipophilicity. The high hydrostatic pressure within the tissues is also thought to be responsible for the delayed systemic absorption and hence delayed and reduced peak plasma concentrations of local anaesthetic, despite the very large doses being used. Doses as high as 22–57 mg kg21 of lidocaine7 – 9 have been used in the context of tumescent techniques and have been shown to have safe plasma concentration profiles.
36
43. Drug to facilitate clip placement during cerebral aneurysm surgery
```
A. nimodipine
B. mannitol
C. adenosine
D. hypertonic saline
E. thiopentone
```
C. Adenosine
37
44. Which drug should be avoided both intra- and post operatively in a woman having surgery who is breast feeding a 6 week old baby?
```
A. codeine
B. morphine
C. paracetamol
D. parecoxib
E. tramadol
```
A. Codeine
Mothers may be ultra-rapid metabolisers, leading to higher than normal morphine concentrations (which then appear in breast milk).
Another version of this question has pethidine as an option - pethidine is also bad, as neonates excrete norpethidine slowly and so are more vulnerable to toxicity.
38
45. A three year old girl for an elective hernia repair is seen immediately prior to surgery. It is revealed she had 100mL of apple juice 2 hours ago. The best course of action is to:
```
A. Postpone surgery for 2 hours
B. Postpone surgery for 4 hours
C. Postpone surgery for 6 hours
D. Cancel surgery
E. Continue with surgery
```
E. Crack onski
Apple juice = clear fluid
39
46. In accordance with their belief that blood transfusion is wrong, a Jehovah's Witness may consent to all of the following except:
```
A. Cryoprecipitate
B. Immunoglubulins
C. Fresh Frozen Plasma
D. Factor VIIa
E. Prothrombinex
```
C. FFP
Unacceptable:
- Pre-op autologous blood donation
- Transfusion of the 'primary components' of blood, namely whole blood, packed red cells, plasma, platelets and white cells.
May be acceptable (not banned by the church, up to the patient):
- Fractions of all the primary components (incl. albumin, cry, clotting factors, immunoglobulins, recombinant human EPO, interferon, interleukins, haemoglobin-based blood substitutes or oxygen carriers).
40
47. 80 year old lady with fractured NOF needing ORIF. On examination had a systolic murmur. Arranged TTE which showed a calcific aortic valve with peak velocity of 4 m/s. Using the simplified Bernoulli equation, what is the peak pressure gradient across the valve:
```
A. 16 mmHg
B. 32 mmHg
C. 48 mmHg
D. 64 mmHg
E. 80 mmHg
```
D. 64 mmHg
Bernoulli principle - an increase in the flow velocity of an ideal fluid will be accompanied by a simultaneous reduction in its pressure
Simplified equation:
P1 - P2 = 4V^2
41
48. You have developed a new cardiac output monitor called WaCCO. You want to compare the readings with the gold standard, a pulmonary artery catheter. What is the best statistical method to present the data/results:
```
A. Funnel plot
B. Bland-Altman plot
C. Forest plot
D. Galbraith plot
E. Partial regression plot
```
B. Bland-Altman plot
CEACCP - Minimally invasive cardiac output monitors 2011
'The accuracy of these devices has been researched in a number of different settings. The most consistently used method of assessing their accuracy has been to measure their mean bias in comparison with another method of cardiac output measurement using the Bland-Altman method.'
42
50. A 60 year old, triple vessel disease normal LV. Hypotensive post CABG, ST elevation in II and avF, CVP 15 PCWP 25. Normal SVR
```
A. Early diastolic mitral inflow dynamic with atrial systole
B. Left inferior hypokinesis
C. Left ventricle collapse in systole
D. Right ventricle dilation and TR
E. Severe Mitral Regurg
```
B. ST elevation in II and aVF indicates inferior infarct. Elevation of both CVP and PCWP suggests hypokinesis of both RV and LV.
43
51. Maximum amplitude from TEG or ROTEM decreased give
```
A. Cryoprecipitate
B. FFP
C. Platelets
D. Prothrombinex
E. Tranexamimic acid
```
C. Platelets
| see video on lifeinthefastlane, TEG
44
52. Young male, previous IVDU, now on 100mg Methadone per day has a laparotomy with an effective epidural. Amount of IV Morphine needed per HOUR:
```
A. 1mg
B. 2mg
C. 4mg
D. 8mg
E. 16mg
```
B. 2 mg/h
Using the conversion ratios from the CJA article below, 100 mg oral methadone --> 2.78 mg/h IV morphine. 2 mg/h may be underdosing, but is the more conservative option, out of 2 mg/h and 4 mg/h.
Review article: perioperative pain management of patients on methadone (CJA 2005)
When converting methadone to other opioids in the postoperative period, two issues need to be con- sidered. The first is the incomplete tolerance between opioids, the second is that the conversion ratio between opioids is not bi-directional. Conversion of methadone to other opioids appears to be more problematic and is associated with worsening pain and dysphoria. Since there is no uniformly accepted conversion ratio for substituting methadone with another opioid, a conservative approach should be adopted. In the authors’ experience, a conservative methadone to morphine ratio (4 or 5:1) is used. For instance, a patient previously on 30 mg methadone per day will be equivalent to roughly 120 mg oral morphine per day. Factoring the oral bioavailability (33%) and a 50% cross-tolerance, the hourly morphine requirement is approximately 1 mg·hr–1 intravenously.
On the first day, the maximum background infusion rate of morphine should not exceed 3 mg·hr–1 due to the highly unpredictable nature of the equianalgesic conversion. A PCA device is used separate from the iv infusion if there is an underlying pain condition. After the patient is loaded with adequate amounts of mor- phine, reassessments of pain, sedation and respiratory rate are made at least once every two hours as the patient approaches a steady state with the morphine and as the methadone continues to clear from their system. The ward nurses and clinicians looking after the patient are informed of the patient’s unique requirements.
45
54. Fluoroscopy in the operating theatre increases the exposure of theatre personnel to ionising radiation. Best method to minimise one's exposure to such radiation is to
A. have dosimeter checked at least 6-monthly
B. limit exposure time to radiation
C. maximal distance from radiation source
D. stand behind transmitter of C arm
E. wear protective garments
C. Maximal distance from radiation source
Intensity of radiation = 1/distance sqaured
At least 3 feet from source
6 feet or air provides 9 inches of concrete or 2.5mm lead
CEACCP - Radiation safety for anaesthetists (2012)
46
57. Ibuprofen dose for one year old child tds regular post-op dose
```
A. 5mg/kg
B. 10
C. 15
D. 20
E. 25
```
B. 10 mg/kg
5-10 mg/kg (MIMS)
10 mg/kg (RCH)
47
58. AICD, what does a magnet do
A. Maintain defib activity & activate asynchronous pacing
B. maintain anti tachycardia pacing & deactivate asynchronous pacing
C. Deactivate anti tachycardia pacing & activate asynchronous pacing
D. Deactivate defib & activate asynchronous pacing
E. Deactivate defib & deactivate asynchronous pacing
? It will always deactivate the defib, but the response of the pacemaker is less predictable.
BJA 2011 - Perioperative management of patients with cardiac implantable electronic devices
Even when the ICD has been deactivated by a magnet, pacemaker function of an ICD is not affected. Thus, in a patient with an ICD, the magnet response will always be to deactivate the ICD and the pacing behaviour will not change to an asynchronous mode.
48
60. A 35yo man collapses in shopping mall and is resuscitated by bystanders using an AE:D. On admission to hospital his ECG was as below;
ECG - sinus, rate ~60, normal axis, borderline PR interval, RSR' in V1 and V2 with ST elevation and inverted T waves (Brugada sign)
```
A. Acute pericarditis
B. Brugada
C. Cocaine intoxication
D. Coronary artery spasm
E. Long QT syndrome
```
B
Brugada syndrome is due to a mutation in the cardiac sodium channel gene.
Clinical Criteria:
Documented ventricular fibrillation (VF) or polymorphic ventricular tachycardia (VT).
Family history of sudden cardiac death at
49
61. A 58yo with solitary hepatic metastasis from colon cancer scheduled for resection of R lobe of liver. Inorder to manage the risk of intra-operative haemorrhage, it is most important to maintain:
A. High CVP in anticipation of heavy blood loss
B. Decreased MAP to reduce arterial bleeding
C. Decreased CVP to reduce venous bleeding
D. Normal MAP in anticipation of heavy blood loss
E. Normal CVP to ensure adequate filling of the heart.
C. Low CVP ( 5 mmHg significantly increases bleeding. However, the risks of maintaining a low CVP include cardiovascular instability and air embolism, but the theoretical risk of increasing postoperative renal dysfunction does not appear to be clinically important. Some patients require a CVP of > 5 mm Hg for cardiovascular stability, and in these patients an individually tailored compromise needs to be achieved.
50
63. A man is admitted to ICU with a Sodium of 105 mmol/L. What is the maximum his sodium should be raised in the next 24 hours
```
A. 5 mmol
B. 10 mmol
C. 15 mmol
D. 20 mmol
E. 25 mmol
```
B. 10 mmol
Pontine Myelinolysis
Rapid correction of sodium in hyponatremia would cause the extracellular fluid to be relatively hypertonic. Free water would then move out of the brain cells to decrease this relative hypertonicity. This leads to a central pontine myelinolysis, manifesting as the paralysis. The brain appears to shrink.
The demyelination of the axons (nerve fibers in the brain) damages them.
51
64. What is the distance from lips to carina in a 70 Kg man?
```
A. 21 cm
B. 23 cm
C. 25 cm
D. 27 cm
E. 29cm
```
D. 27 cm
Lee's Synopsis of Anaesthesia:
Central Incisors to Carina
Male 27cm/Female 23cm
15cm from teeth to cords, 12 cm from cords to carina
52
65. The action of which laryngeal laryngeal muscle opens the cords?
```
A. Cricothyroid
B. Posterior cricoarytenoid
C. Lateral Cricoarytenoid
D. Thyroarytenoid
E. Vocalis
```
B. Posterior cricoarytenoid
```
Cricothyroid muscles - tense cords
Posterior cricoarytenoids - open glottis
Lateral cricoarytenoids - close glottis
Interarytenoids - close glottis
Thyroarytenoids - relax cords
Vocalis - relax cords
```
53
66. Induction of a 4yr old child with Arthrogrophysis multiplex congenita, however you find it difficult to place the laryngoscope. What is the concern? (paraphrased question here, can’t remember all possible answers)
```
A. MH
B. Neuroleptic malignant syndrome
C. ?
D. opioid induced rigidity
E. TMJ rigidity
```
E. TMJ rigidity
Skin and soft connective tissue abnormalities, contracture deformities, micrognathia, cervical spine and jaw stiffness, congenital heart disease (10%), hypermetabolic response is probably NOT MH. Difficult airway and venous access, sensitive to thiopental.
Oxford handbook page 298
54
70. A patient is suffering from aortic dissection with acute aortic regurgitation. BP 160/90, HR 100 & evidence of acute pulmonary oedema. What is your immediate management?
```
A. Beta-blockers
B. Dopamine
C. Dobutamine
D. Sodium nitroprusside
E. Intra-aortic Balloon Pump
```
D. Sodium nitroprusside
Cardiac bosses all agree. No great evidence.
Rationale would be that you want to decrease afterload (to reduce regurgitant fraction, and also to decrease shear stress on the aorta) but you don't want to decrease HR (fast forward for regurgitant lesions), and you definitely don't want to decrease inotropy in someone with cardiogenic pulmonary oedema - i.e. not beta blockers.
55
71. Presented are a femoral arterial line trace & a central venous line (JVP) trace - looked like it was demonstrating elevated right atrial pressures... What is demonstrated by these pressure waveforms?
```
A. Aortic Stenosis
B. Aortic Regurgitation
C. Pulmonary Regurgitation
D. Tricuspid Regurgitation
E. Mitral Regurgitation
```
D. Triscupid regurgitation
56
72. The MELD score is calculated using INR, Bilirubin & what?
```
A. Creatinine
B. Albumin
C. Urea
D. AST
E. Ammonia
```
A. Creatinine
Med Calc
Model End Stage Liver Disease
Disease severity scoring system applied to ADULT livers to improve organ allocation in transplants
MELD + MELD-Na
* 40 or more — 71.3% mortality
* 30–39 — 52.6% mortality
* 20–29 — 19.6% mortality
* 10–19 — 6.0% mortality
*
57
73. In resuscitating a newborn infant after delivery, the time at which you would like to achieve arterial oxygen saturation of 85-90%:
```
A. 2mins
B. 3mins
C. 4mins
D. 5mins
E. 10mins
```
E. 10 mins
Australian Resuscitation Council
Target sats
- ------ 60-70 @1min
- ------ 65-85 @2min
- ------ 70-90 @3min
- ------ 75-90 @4min
- ------ 80-90 @5min
- ------ 85-90 @10min
58
74. (repeat): You inserted a central venous line and peripheral arterial line for a patient who is having a tumour removed via craniotomy. The transducers of both the lines were placed at the level of the right atrium 13cm below the level of the external auditory meatus. MAP is 80mmHg, CVP 5mmHg. What is the CPP?
```
A. 62mmHg
B. 65mmHg
C. 70mmHg
D. 75mmHg
E. 80mmHg
```
B. 65 mmHg
13 cmH20 = 10 mmHg --> MAP at level of external auditory meatus = 80-10 = 70.
CPP = MAP - CVP = 70-5 = 65.
Arterial pressure transducer should be at the level of the tragus.
Kirkman MA, BJA 2014: 'Intracranial pressure monitoring, cerebral perfusion pressure estimation, and ICP/CPP-guided therapy: a standard of care or optional extra after brain injury?'
59
75. What proportion of the population are heterozygous for plasma cholinesterase deficiency?Having a Dibucaine number of 30-80.
```
A. 0.04
B. 0.4
C. 4
D. 14
E. 40
```
C. 4%
Peck & Hill page 183
60
76. You are putting in a internal jugular central venous line. Which maneuvre causes maximal distension of the internal jugular vein?
```
A. CPAP
B. Breath hold at end expiration
C. Manual compression at the base of the neck
D. Trendelenberg position
E. Valsalva manoeuvre
```
E. Valsalva manoeuvre
61
82. A 40 yo woman for laparotomy to remove phaeochromocytoma under combined epidural and general anaesthesia. Pre-operatively treated with phenoxybenzamine and metoprolol. Intra-operatively, blood pressure is 250/130 despite high dose phentolamine and SNP. HR is 70/min and SaO2 are 98%. The next most appropriate treatment is:
```
A. Epidural Lignocaine
B. IV Esmolol
C. IV Hydralazine
D. IV Magnesium
E. IV Propofol
```
D. IV magnesium
CEACCP - Phaeochromocytoma (2003)
Such agents include boluses of phentolamine 1–5 mg and labetalol 5–10 mg or sodium nitroprusside, GTN and nicardipine infusions. Sodium nitroprusside has a rapid onset and offset of action; it is not associated with toxicity when used in recommended doses. Nicardipine is a calcium chan- nel blocker which has been used as an infusion for fast titration of blood pressure. The use of isoflurane as an antihypertensive agent is a practical alternative. Magnesium sulphate infusions have recently been described (inhibits catecholamine release, exerts a direct vasodilator effect and reduces α-receptor sensitivity).
62
83. Best option to reduce risk of Ventilator induced pneumonia?
```
A. Nurse in supine position
B. Early spontaneous ventilation through ETT
C. Oral hygiene
D. Use antacids
E. Regularly change breathing circle
```
C. Oral hygiene
BJA education - Ventilator-associated pneumonia (2015)
The main pathogenic factor in the development of VAP is biofilm formation within the tracheal tube (TT) and microaspiration of secretions. The presence of a TT interferes with the normal protective upper airway reflexes and prevents effective coughing. The oropharynx becomes rapidly colonized by aerobic gram-negative bacteria after illness, antibiotic administration, and hospital admission. These contaminated secretions pool above the TT cuff and slowly gain access to the lower airway through a fold in the wall of the cuff. A bacterial biofilm, which is impervious to antibiotics, gradually forms on the inner surface of the tube and serves as a nidus for infection. This pathogen-rich biofilm is pushed into the distal airways by ventilator cycling and in the setting of immunosuppression associated with critical illness causes pneumonia. The longer the duration of ventilation, the greater the risk of developing VAP. Nursing patients in a supine position increases the risk of microaspiration and enteral feeding via a nasogastric tube increases the risk of aspiration of gastric contents. It follows that attempts to prevent VAP would focus on measures to reduce biofilm formation and micro aspiration.
... In 2007, the Department of Health launched ‘Saving Lives; reducing infection, delivering clean and safe care’, a campaign to prevent and control hospital-acquired infection. This included ‘High Impact Intervention No 5—Care bundle for ventilated patients’, the aim of which was to reduce VAP. The original document consisted of daily sedation holds, bed head elevation, gastric ulcer prophylaxis, and oral care. It was updated in 2010 to include oral hygiene with adequate strength anti-septics, subglottic aspiration, and TT cuff pressure monitoring in addition to the initial four care interventions.
63
85. A 37 year old female presents to ED with headache and confusion. She is otherwise neurologically normal and haemodynamically stable. Urine catheter and bloods taken. UO > 400ml/hr for 2 consecutive hours, Serum Na 123 mmol/l, Serum Osmolality 268, Urine Osmolality ???. The most likely diagnosis is
```
A. Central diabetes insipidus
B. Nephrogenic diabetes insipidus
C. Psychogenic polydipsia
D. Cerebral salt wasting
E. SIADH
```
Hard to say without knowing urine sodium and osmolality.
```
Psychogenic Polydipsia:
Increased H20 intake due to dry mouth (caused by drugs)
Hyponatraemia (serum)
Hyposmolar (serum)
Polyuria
Dilute Urine (urine osmolality
Normovolaemic
```
```
CDI (Inadequate ADH Secretion):
Hypernatraemia
Hyperosmolar
Polyuria
Dilute Urine (urine osmolality
Responsive to ADH
```
```
NDI (Kidney resistant to ADH):
Normal to high Na
Normal to high osmolality
Polyuria
Dilute urine (urine osmolality
Non-responsive to ADH
```
Cerebral Salt Wasting:
Excessive Na secretion by Kidneys due to brain trauma/tumour)
Hyponatraemia
Hyposmolar
Polyuria
Elevated urinary Na (urine osmolality>plasma osmolality)
Hypovolaemic
```
SIADH (Inappropriate ADH secretion):
Hyponatraemia
Hyposmolar
Oliguria Elevated urinary Na (urine osmolality>plasma osmolality)
Normal to expanded volume
```
64
86.
Photograph of an Arndt bronchial blocker multiport airway adapter. Orifice labelled 'X'. What connects to 'X'?
A. Bronchoscope
B. Bronchial blocker
C. Breathing circuit
D. ETT
???
65
91. The American Heart Association (AHA) guidelines for preoperative cardiac risk assessment define a poor functional capacity as only able to exercise at a level of less than 4 metabolic equivalents (METs). Exercise capacity of 4 METs corresponds to:
A. light housework such as dishwashing
B. heavy work around the house such as moving heavy objects
C. jogging 2km
D. brisk walking on level ground (6km/hr)
E. slow walking on level ground (3km/hr)
D. Brisk walking on level ground (6 km/h)
Light housework, climbing a flight of stairs, and brisk walking on level ground are all clustered around 4 METs in ascending order (probably better to be conservative and investigate further if a patient can do light housework but not walk briskly/climb stairs, esp. as patients often overestimate what they can do).
66
92. Pneumoperitoneum for laparoscopy is commonly associated with a change in each of the following EXCEPT
```
A. arterial pressure
B. vasopressin secretion
C. inotropic action
D. systemic vascular resistance
E. venous resistance
```
C. Inotropic action
CEACCP - Anaesthesia for laparoscopic surgery 2011
67
93. 7 year old with closed head injury. Intubated and ventilated in ICU. Serum sodium 142. Most appropriate maintenance fluid is:
```
A. 0.3% saline plus 3% glucose
B. 0.45% saline plus 5% glucose
C. 0.9% Saline
D. Hartman's solution
E. Hartman's plus 5% glucose
```
C. 0.9% saline
Use isotonic fluid with brain injury - risk of cerebral oedema with hypotonic fluid. If Na > 142, consider 0.45% saline.
Ref: Ch 99 Oh's Intensive Care Manual 2009
68
94. Patient with Marfan's syndrome. Thoracoabdominal aortic aneurysm repair. 24 hours later in ICU noted to be blood in CSF drain and patient obtunded. Most appropriate urgent management:
```
A. CT head
B. Coagulation screen
C. CSF culture
D. MRI brain
E. MRI spine
```
A. CT head (exclude SAH)
69
99. (new) The respiratory pattern most likely seen in an acute C5 spinal cord injury:
```
A. increased respiratory rate
B. arterial hypoxaemia
C. chest wall immobility
D. ?
E. ?
```
A. Increased respiratory rate
C3-C5 partial phrenic nerve weakness/paralysis of diaphragm. Reduced VC to 10-30%, weak cough, 80% require ventilation w/in 48hrs. No intercostal function. Diaphragmatic breathing w collapse of chest initially (until intercostal paralysis develops in few days).
Ref: CEACCP July 2013 initial mx of acute spinal cord injury
70
100. something about pharmacologically induced reduction in afterload (? which condition would not benefit from this)
```
A. aortic stenosis
B. tetralogy of fallot
C. cardiac tamponade
D. Mitral incompetence
E. aortic incompetence
```
A. aortic stenosis
71
101. (repeat) A 20 year old man was punched in the throat 3 hours ago at a party. He is now complaining of severe pain, difficulty swallowing, has a hoarse voice and had has some haemoptysis. What is your next step in his management?
```
A. Awake Fibreoptic Intubation
B. CT scan for laryngeal fractures
C. Direct laryngoscopy after topicalising with local anaesthetic
D. Nasopharyngoscopy by an ENT surgeon
E. Soft tissue xray of the neck
```
D. Nasopharyngoscopy by an ENT surgeon
72
102. Preferred method for treating raised INR
```
A. FFP
B. FFP + prothrombinex
C. FFP + vitamin K
D. prothrombinex
E. prothrombinex + vitamin K
```
E. Prothrombinex and vitamin K
Tran et al, MJA 2013 - 'An update of consensus guidelines for warfarin reversal':
For immediate reversal, prothrombin complex concentrates (PCC) are preferred over fresh frozen plasma (FFP). Prothrombinex-VF is the only PCC routinely used for warfarin reversal in Australia and New Zealand. It contains factors II, IX, X and low levels of factor VII. FFP is not routinely needed in combination with Prothrombinex-VF. FFP can be used when Prothrombinex-VF is unavailable. Vitamin K1 is essential for sustaining the reversal achieved by PCC or FFP.
73
103. Regarding PS31, Level II check includes:
| Multiple options, can’t remember exactly
Level 2 check (before each list):
- Service label
- High pressure system
- Low pressure system (check for leaks, check vaporisers, oxygen failure warning system, flow controls)
- Ventilator (incl. disconnection and high pressure alarm)
- Emergency ventilation system
- Scavenging
- IV and LA administration devices (power supply/battery life, occlusion pressure alarms)
- Other apparatus (airway equipment, suction, gas analysis devices, monitoring equipment, IV infusion devices, humidifiers, filters)
- Final check (make sure vaporisers are turned off and breathing system is purged with air or oxygen)
- Documentation
74
104. Anaphylaxis, when to check tryptase
```
A. Within 15 minutes of event
B. Between 1 hour and 3 hour
C. Between 4 hour and 6 hour
D. Between 6 hour and 12 hour
E. After 24 hour
```
B and E correct.
As soon as possible after initial resuscitation, then at 1-2 hours, then any time after 24 hours (to get baseline level).
Australian and New Zealand Anaesthetic Allergy group say check at 1, 4 and > 24 hours
75
107.(New) A 50 yo man with a Deep Brain Stimulator (DBS) secondary to Parkinson's disease is scheduled for elective surgery. What is the best management regarding this device?
A. Place diathermy pad as far away from DBS as possible
B. Turn off DBS and commence with oral Levodopa
C. Turn off DBS during surgery and turn on prior to extubation
D. Use Bipolar diathermy
D. Use bipolar diathermy
CEACCP - Anaesthesia and deep brain stimulation (2009)
Surgical diathermy (electrocautery) can damage the DBS leads and can also cause temporary suppression of the neurostimulator, reprogramming of the neurostimulator, or both, but is not contraindicated.
When diathermy is necessary, the following precautions should be followed:
use bipolar diathermy where possible;
if unipolar diathermy is necessary:
use only a low-voltage mode;
use the lowest possible power setting;
keep the current path (ground plate) as far from the neurostimulator and leads as possible (usually located in the subclavicular space with the leads running up the neck, posterior to the ear, to the crown of the head).
After using diathermy, confirm that the neurostimulator is functioning as intended.
External defibrillation
If a patient requires external defibrillation, the first consideration should obviously be the patient's survival. Safety for the use of external defibrillators on patients with a DBS has not been established. External defibrillation may damage a neurostimulator. If external defibrillation is necessary, the following precautions should be followed:
position defibrillation paddles as far from the neurostimulator as possible;
position defibrillation paddles perpendicular to the implanted neurostimulator-lead system;
use the lowest clinically appropriate energy output.
Confirm that the DBS is functioning correctly after any external defibrillation.
76
108. (New) Fit and well G1P0 post epidural complaining of loss of sensation over posterior leg, lateral thigh and foot with weak flexion of knee. Which best explains the findings? (Not remembered quite correctly.)
```
A. Femoral neve
B. Obturator nerve
C. Sciatic nerve
D. Lumbosacral plexus
E. Peroneal nerve
```
???
Posterior leg sensation - branches of sciatic nerve (common peroneal and sural nerves) + saphenous nerve (continuation of femoral)
Lateral thigh sensation - lat cutaneous nerve of thigh (L2, 3)
Lateral foot sensation - sural nerve (L4 to S4), superficial peroneal nerve (L4 to S1)
Knee flexion - hamstrings (biceps femoris, semimembranosus, semitendinosus) - L5/S1, and to a lesser extent gracilis, sartorius, popliteus, gastrocnemius and plantaris.
77
109 Patient with metastatic cancer. What's not useful to increase Ca excretion?
A. Bisphosphonates.
B. ?
Bisphosphonates reduce the resorption of bone.
78
110. (New, long stem taking up half the page) Male in 60's one day post laparotomy. Management includes: IV fluids @40ml/hr, 2L oxygen via nasal prongs, and a morphine PCA. Observations: t38.8C, RR14, Sats 88% Examination: mildly sedated, bibasal creps. In addition to increasing the FiO2 what would be your initial management?
```
A. Incentive spirometry
B. Diuresis
C. Broad spectrum ABs
D. Naloxone 100mcg increments
E. ?
```
A and C.
Combination of low sats and fever in the setting of recent laparotomy suggest atelectasis +/- LRTI.
79
111. A patient is coming for an operation on his upper limb. 5mls of 0.75% ropivacaine is placed around the structure seen below. What is the most likely consequence of this?
```
A. Unable to abduct fingers
B. Unable to extend wrist
C. Unable to oppose little finger and thumb
D. Unable to pronate arm
E. Unable to [unsure of 5th option]
```
???
80
112. A 40 year old man suffered a traumatic brain injury 2 days ago. He does not meet the criteria to be certified brain dead. What investigation will be most useful to assess cerbral function prior to organ donation.
```
A. Electroencephalogram
B. Somatosensory evoked potentials
C. Auditory evoked potentials
D. Motor evoked potentials
E. BIS
```
? E. EEG. Angiography would be a better answer if this was an option.
CEACCP - Diagnosis of death (2011):
Ancillary tests:
The UK Code recognizes that there may be circumstances where clinicians feel unable to confirm death using neurological criteria based on clinical assessment alone. Such circumstances include:
- episodes where a comprehensive neurological examination cannot be carried out, for example, after severe maxillofacial trauma;
- when the influence of residual sedation cannot be excluded;
- high cervical cord injury where a distinction between central apnoea and the effects of cervical cord injury cannot be distinguished.
Provision is made in the guidelines for a number of confirmatory tests to be performed in order to confirm the clinical suspicion of brainstem death. These tests are generally aimed at confirming the presence or absence of cerebral blood flow or cerebral function. EEG is the most popular and best validated ancillary test worldwide, but is of little value in cases of drug intoxication since sedative drugs suppress neuronal and therefore EEG activity. Confirmation of the absence of cerebral blood flow by angiography establishes the irreversibility of coma in such circumstances, but may be more difficult to organize. CT angiography may be more readily available, but has yet to be properly validated. Expert advice should be sought from a local neuroscience unit if necessary.
81
113. Isoflurane is administered in a hyperbaric chamber at 3 atmospheres using a variable bypass vapouriser, at a constant fresh gas flow and vapour dial setting, the vapour produced will be:
A the indicated vapour concentration
B three times the indicated vapour concentration
C one third the partial pressure obtained at 1 atmosphere
D the same partial pressure as is obtained at 1 atmosphere
E three times the partial pressure obtained at 1 atmosphere
D. Same partial pressure, 1/3 the concentration
| partial pressure is what influences pharmacodynamics so the same concentration can be dialled
82
114. What is most likely to occur if the earth/grounding plate that is attached to a patient for use with monopolar diathermy malfunctions?
```
A electrocution
B electrical interference with monitors
C electrical burns
D ignition of gases/volatiles
E microshock
```
C. Electrical burns (assuming there is still some contact of the neutral plate with the patient).
CEACCP - Injury during anaesthesia (2006)
Monopolar surgical diathermy uses high frequency alternating current which can generate local temperatures of up to 1000°C. Current passes from the active electrode, held by the surgeon (high current density), through the body, returning via the patient plate electrode (low current density) to the generator. If the return pathway is interrupted by incorrect placement of the patient plate electrode, any points of contact between metal and skin (e.g. ECG electrodes) will provide an alternate return pathway resulting in burns. The patient plate electrode should have good contact with dry, shaved skin. The contact surface area should be at least 70 cm2 and should be away from bony prominences, scar tissue and metal implants. Incorrect placement of the patient plate electrode is the most common cause of accidental diathermy burns. However, careless surgical technique can also cause local burns. The local concentration of high density currents will cause skin burns if the active electrode touches skin. Any pools of spirit-based skin preparation fluids can heat up and even ignite during diathermy use. Bipolar diathermy, in which current passes only between the two points of the diathermy forceps, is inherently safer. It should be used on appendage surgery (e.g. digits and penis); monopolar diathermy can lead to large currents persisting beyond the operative site, causing tissue burns.
83
115. A 24yo primigravida, 25/40 gestation, BP 150/90 on 4 occasions. No signs of pre-eclampsia. Which antihypertensive is inappropriate?
```
A. diazoxide
B. metoprolol
C. enalapril
D. hydralazine
E. nifedipine
```
C. Enalapril
ACE inhibitors cause fetal malformations if given 2nd & 3rd trimesters
(Ref: Williams Obstetrics, 23rd Ed, p989)
84
116. Post-spinal surgery, patient notices paraesthesia of R arm, surgeon thinks this is an ulnar nerve palsy due to poor positioning. What sign will distinguish a C8-T1 nerve root lesion from ulnar nerve neuropathy?
A. paraesthesia in little finger
B. paraesthesia in the distribution of the interscalene nerve
C. weakness in adductor digiti minimi
D. weakness in the abductor pollicis brevis
E. weakness in lateral interosseus
D. Weakness in the abductor pollicis brevis (innervated by median nerve)
"The ulnar nerve innervates all intrinsic hand muscles, except the abductor and flexor pollicis brevis, opponens pollicis, and lateral two lumbricals, which are innervated by C8 and T1 via the median nerve. By examining these five muscles, one can clinically differentiate cubital tunnel syndrome from C8-T1 radiculopathies."
Ref: Global Spine J. 2014 Feb;4(1):1-6.
Differentiating c8-t1 radiculopathy from ulnar neuropathy: a survey of 24 spine surgeons.
85
119. According to PS09, the minimum requirement for administering propofol for conscious sedation is
A. Medical practitioner with a skilled assistant that is separate from the assistant to the proceduralist
B. Medical practitioner
C. Nurse supervised by proceduralist with recent ALS training
D. Specialist anaesthetist
E. Nurse with advanced airway skills
A. Medical practitioner with a skilled assistant that is separate from the assistant to the proceduralist
PS09 p8: "Intravenous anaesthetic agents such as propofol must only be used by a second medical or dental practitioner trained in their use because of the risk of unintentional loss of consciousness. These agents must not be administered by the proceduralist." But also see Scenario 2 of Appendix 1 of PS09: the assistant can be shared between both ends for conscious sedation in ASA 1-2 patients only. Therefore best answer would be a medical or dental practitioner trained in its use with an assistant who may be shared with the procedurals.
86
122. Reasons infants desaturate faster than adults on induction (?did it say rapid sequence?)
```
A. More difficult to preoxygenate
B. More rapid detection of hypoxia
C. FRC decreased more than adults
D. Drugs work more rapidly
E. Persistent L->R shunt (or was it right to left?)
```
? A best answer
Better answer would be closing volume encroaches on FRC.
Neonatal oxygen consumption (per kg) is 2-3 times that of the adult. Unfortunately, their closing volume (the volume at which alveoli begin to close, producing a shunt) is within the range of normal tidal volumes, thus small changes in lung volume (ex. laryngospasm) can lead to shunting and desaturations. Desaturation in the infant can be EXTREMELY rapid.
N.B.: alveolar closing can occur even while intubated. If a neonate drops its lung volume enough to lead to alveolar closing, it may appear that the infant has been extubated or main-stemmed, because resistance to ventilation will be so high. In fact, the infant remains intubated – the only successful treatment is often either lidocaine (do not exceed 1.5 mg/kg) or paralysis.
Infant tidal volume is actually the same as adults (7 cc/kg),it is their respiratory rate that makes up for a high VO2. As RR is 30-50, infant induction and recovery are much more rapid than with adults. Infants also fatigue more quickly than adults because they have a lower fraction of Type 1 muscle in their diaphragm, and their chest walls, which are highly compliant, are less efficient.
(from openanaesthesia.org)
87
125. Adenosine would be useful for terminating which arrhythmia?
```
A. AF
B. Atrial Flutter with variable block
C. Torsades
D. VT
E. WPW
```
Best answer E, although WPW is not an arrhythmia, it is a syndrome. Patients with WPW develop two different supra ventricular tachyarrhythmias: AF and re-entrant tachycardia. Management depends on which arrhythmia is present. For AF, use beta blockers or amiodarone. For re-entrant tachycardia, use adenosine.
Adenosine preferentially blocks the AV node, therefore it should not be used in AF.
Verapamil and digoxin are also contraindicated as they both preferentially block AV conduction, thereby increasing conduction through the accessory pathway.
(The Clinical Anaesthesia Viva Book).
--------------------------------------
Oxford Emergencies in Anaesthesia pg 506 - Adenosine slows conduction through the AV node, therefore is useful in terminating SVTs including WPW. May differentiate between SVT and VT.
----------------------------------------
CEACCP - Supraventricular tachyarrhythmias and their management in the perioperative period (2014):
The term Wolff–Parkinson–White (WPW) syndrome is a specific form of AVRT and is applied to the patient with both preexcitation manifest on an ECG and symptomatic arrhythmias (orthodromic or antidromic AVRT) involving the accessory pathway. The term WPW pattern is applied to the patient with preexcitation manifest on an ECG in the absence of symptomatic arrhythmias. The classic ECG pattern of preexcitation in sinus rhythm has two major features:
A short PR interval (
88
126. Induction with thio 5mg/kg, suxamethonium 2mg/kg, Difficult to open mouth, Finally intubated. Next step:
A. Continue surgery with propofol TIVA
B. Abandon surgery
C. Wait for co2 to rise restart surgery after 30 min
D. Continue with inhalational agents
E. Give calcium as potassium may have raised
A. Continue surgery with propofol TIVA
89
127. In a patient with an intra-orbital haemorrhage, following local anaesthetic injection, the adequacy of ocular perfusion is best assessed by:
```
A. angiography
B. direct ophthalmoscopy
C. indirect ophthalmoscopy
D. intra-ocular pressure tonometry
E. palpation of the globe by an experienced clinician
```
B. Indirect ophthalmoscopy
Royal college of anaesthetists and opthalmologists consensus document
http://www.rcoa.ac.uk/system/files/LA-Ophthalmic-surgery-2012.pdf
Document page 26
"Indirect ophthalmoscopy should be performed to look for evidence of central retinal artery perfusion compromise"
90
128. A patient is in Class IV Haemorrhagic Shock, secondary to a gunshot wound to the abdomen. He is clinically coagulopathic 30 minutes later. He has received intravenous Hartmann's 1L. The coagulopathy is likely related to:
```
A. acidosis
B. dilution of clotting factors
C. hypothermia
D. systemic release of tissue factor
E. tissue hypoperfusion
```
E. Tissue hypoperfusion
Acidosis, hypothermia and trauma induced coagulopathy are the lethal triad of major haemorrhage following trauma but Acute Trauma Coagulopathy is independent of resuscitation efforts
CEACCP - Management of haemorrhage in major trauma (2014) - “Trauma patients were coagulopathic on arrival at the emergency department (ED) and the incidence of coagulopathy increased with severity of injury independent of the volume of pre-hospital resuscitation fluid. Those who arrived coagulopathic had an increased mortality compared with non-coagulopathic patients. This coagulopathy is termed acute trauma coagulopathy (ATC) and is another mechanism of coagulopathy under the umbrella term of TIC. The mechanisms of ATC are yet unproven but appear to be related to tissue hypoperfusion, leading to up-regulation of the vascular endothelium and subsequent alterations in coagulation pathways. This coincides with massive activation of coagulation with consumption of clotting factors, noticeably factor V and fibrinogen, activation of the Protein C pathway, and increased fibrinolysis”
91
129. (Repeat) A 20 kilogram child suffered 15% full thickness burns 6 hours ago. Optimum crystalloid resuscitation for the first hour is:
```
A. 160ml
B. 260ml
C. 360ml
D. 460ml
E. 660ml
```
C. 360 mL
Parkland formula = 4ml/kg x %BSA with half in first 8 hours (CSL) from time of burn
4 x 20 x 15 = 1200ml / 2 = 600mL in 8 hours, but only 2hrs remaining so 300ml/hr
Mainentance IVF = 4ml/kg/hr for 1st 10kg, 2mL/kg/hr for next 10kg, 1ml/kg/hr for remaining kg (N/2 + 5%)
40 + 20 = 60ml/hr
Total = 360ml/hr
92
130. You’re anaesthetizing an otherwise well 40 yo male for a craniotomy. Propofol and remifentanil TIVA. Using entropy. The MAP is 70 mmHg, heart rate is 70 bpm, Sats are 98%, state entropy is 50 and the response entropy 70. Most appropriate next step is
```
A. give 0.5 mg metaraminol iv
B. use NMT to assess train of four ratio
C. change to volatile anaesthetic
D. do nothing
E. increase propofol TCI concentration by 0.5
```
B. Check neuromuscular monitor (hopefully you are checking the TOF count rather than the TOF ratio!)
(from forum on gasexchange.com)
The 2 numbers provided by the Entropy monitor are the State Entropy (SE) and Response Entropy (RE). SE is calculated over frequencies from 0.8 to 32 Hz while RE is calculated over frequencies from 0.8 to 47 Hz. The significance of this difference is that frequencies below 32 Hz are dominated by the EEG signal while EMG signal from facial muscles dominate above 32 Hz. In theory, SE reflects the cortical state of the patient (and hence depth of anaesthesia) while RE additionally incorporates facial muscle EMG signals. The idea is that if there is a significant difference between SE and RE, this reflects inadequate analgesia (which increases facial muscle tone – apparently).
Just like with BIS, the manufacturer recommends increasing depth of anaesthesia if the SE is above 60 as this represents a possibility of awareness. Unlike BIS, they also recommend giving additional analgesia if the RE is more than 5-10 above the SE.
There are several papers comparing BIS and Entropy and the short answer seems to be that the BIS and the SE correlate reasonably well with only occasional disagreement. None of these trials are large enough to demonstrate a difference in the ability of either monitor to detect awareness (and quite frankly, the jury is still out on whether BIS is useful for this – awareness is just too rare an event to study easily). I am not aware of any trials demonstrating the usefulness of the RE for guiding analgesic administration.
reference: Bein B. Entropy. Best Pract Res Clin Anaesthesiol. 2006 Mar;20(1):101-9
93
131. The normal physiological response following ECT is:
A. transient tachycardia followed by bradycardia and hypotension
B. transient bradycardia followed by tachycardia and hypertension
C. unpredictable
D. transient tachycardia followed by bradycardia and hypertension
E. tachycardia and hypotension
B. Transient bradycardia followed by tachycardia and hypertension
94
132 (repeat) Aspirin Overdose > 500 mg/kg. What will enhance her elimination most effectively?
```
A. Mannitol
B. Haemodialysis
C. lignocaine
D. ?
E. BIcarbonate infusion
```
B. Haemodialysis
Ingestion of > 500 mg/kg is a potentially lethal dose, according to the risk assessment table in the Toxicology Handbook.
(from the Toxicology Handbook):
Urinary alkalinisation is indicated in patients with symptomatic salicylate poisoning.
Haemodialysis effectively removes salicylate but is rarely required if early decontamination and urinary alkalinisation are implemented. Consider HDx in the following circumstances:
- Urinary alkalinisation not feasible
- Serum salicylate levels rising to >4.4 mmol/L (>60 mg/dL) despite decontamination and urinary alkalinisation
- Severe toxicity as evidenced by altered mental status, acidaemia or renal failure
- Very high serum salicylate levels:
- Acute poisoning >7.2 mmol/L (>100 mg/dL)
- Chronic poisoning >4.4 mmol/L (>60 mg/dL)
- The threshold to dialyse is lower in the elderly (>60 mg/dL)
95
133. A 50 year old male is having an aortic valve replacement for aortic stenosis. He is stable on bypass initially but after the first dose of cardioplegia his MAP falls to 25mmHg, CVP 1 and his mixed venous oxygen saturation is 80%. What is the best management in this situation?
```
A. Metaraminol bolus
B. Commence an adrenaline infusion
C. Increase oxygen flow rate
D. Increase pump flow rate
E. IV crystalloid bolus
```
A. Metaraminol bolus
Cardioplegia induces transient hypotension secondary to K-related vasodilation, best managed with alpha agonist.
Miller 7th ed pg 1916 - "Initiation of CPB is often associated with a period of hypotension, which can be managed with the administration of an alpha-agonist into the venous reservoir of the ECC circuit. Any hypotension and hypertension that occur despite adequate flow and SvO2 can be treated by adjusting the patient’s SVR with vasoconstrictors or vasodilators”
Should be on full flows so D is incorrect
96
134. An eighty year old man presents to the emergency department with two hours of severe abdominal pain. On examination he has a tender pulsatile 8cm mass. His GCS is 12, heart rate 104, blood pressure 80/49, Temp 35 degrees, SpO2 92%, respiratory rate is 30/min. What is the next appropriate step.
A. Commence a vassopressor to support the circulation and improve end organ perfusion.
B. Obtain IV access and crossmatch
C. Intubate to secure the airway and prevent aspiration
D. Perform an abdominal ultrasound to confirm diagnosis
E. Ventilate with a bag valve mask to improve saturations
B. IV access and cross-match
97
137. A PiCCO monitor may be used to measure cardiac output through use of:
A. Lithium Dilution Cardiac Output (LiDCO)
B. Pulse contour analysis
C. Pulse contour analysis and thermodilution
D. Thermodilution
E. Thermodilution and aortic flow doppler
C. Pulse contour analysis and thermodilution (thermodilution for calibration)
98
138. A tablet containing OxyContin 40mg and naloxone 20mg offers the following advantage over OxyContin alone.
```
A. Less potential for abuse
B. Less constipation
C. Less sedation
D. Less respiratory depression
E. Less pruritus
```
B. Less constipation
Targin product information, although there is less potential for abuse given antagonist activity when administered IV
99
141. Immunity to Hepatitis B is demonstrated by the presence of:
```
A. Hepatits B core antibodies
B. Hepatits B core antigens
C. Hepatits B surface antibodies
D. Hepatits B surface antigens
E. Any of the above
```
C. HBsAb
HBsAb +ve = immunity via immunisation or exposure
HBsAg +ve = active infection
HBcAb = suggests previous exposure
100
142. In an adult with advanced liver cirrhosis, the best predictor of bleeding is:
```
A. Dysfibrinogenaemia
B. Hypoalbuminaemia
C. Prolonged Prothrombin time
D. Portal Hypertension
E. Thrombocytopaenia
```
? C. Prolonged prothrombin time
Mansour 1997 Abdominal operations in patients with cirrhosis: Still a major surgical challenge - “Three factors that contributed to increased morbidity and mortality in their patients: a prolongation ofthe prothrombin time longer than 2.5 seconds, the presence of ascites, and the need for an emergency operation. In our group of patients, we found that the presence of ascites, encephalopathy, prolonged prothrombin time, and elevated blood urea nitrogen level as independent variables were predictors of mortality."
Also, Child Pugh score predicts surgical complications (including haemorrhage), and includes PT/INR but not platelet count.
101
143. 65 year old lady with acute cholecystitis presenting for cholecystectomy. Has known hyperparathyroidism. Calcium 3.2mmol/L (normal 2.2 -2.6). Initial treatment with:
```
A. calcitonin
B. frusemide
C. intravenous fluids
D. magnesium
E. mythramycin
```
C. IV fluids
102
144. SG67 20 year old male 80kg presents post house fire with 30% burns. Using the Parkland formula how much fluid should he have replaced in the first 8 hours?
```
A. 2.6L N/saline
B. 3.6L N/saline
C. 3.6L CSL
D. 4.8L N/saline
E. 4.8L CSL
```
E. 4.8L CSL
BJA 2001 - A burn greater than 15% of the total body surface in adults and 10% in children requires intravenous fluid resuscitation. The Parkland formula, developed in 1971 and now widely used in the UK, predicts a total fluid requirement of 3-4 ml/kg1 x (% burn). The resulting volume of fluid is given over the 24 h from the time of the burn (not from the time of presentation) with half the volume given in the first 8 h and the remaining half in the subsequent 16 h. Lactated Ringer’s solution is the fluid of choice.
Parkland formula = 4 x 30 x 80 = 9600mL = 4.8L in first 8hrs.
Some debate over whether to use 4 mL/kg or 3mL/kg (modified Parkland) however, question specifically asks for Parkland.
Hilton, Peter John, and Martin Hepp. "The Immediate Care of the Burned Patient." BJA CEPD Reviews 1, no. 4 (2001): 113-116.
Hettiaratchy, Shehan, and Remo Papini. "Initial Management of a Major Burn: IIassessment and Resuscitation." Bmj 329, no. 7457 (2004): 101-103.
103
145. The thoracic paravertebral space is continuous down to:
```
A. T10
B. T12
C. L2
D. L4
E. S1
```
B. T12
CEACCP - Paravertebral block (2010) - "The thoracic paravertebral space begins at T1 and extends caudally to terminate at T12"
104
28. 54 year old radical prostatectomy with ongoing blood loss during the procedure. Surgeon complains of ooze and asks if the patient is on aspirin. Thromboelastograph shown below. Most appropriate therapy:
A. rFVII
B. cryoprecipitate
C. FFP
D. platelets
E. tranexamic acid
???
105
32. Rheumatoid arthritis. Most common C-spine abnormality is anterior subluxation. What is next most common direction of subluxation in RA
A. lateral
B. oblique
C. posterior
D. rotated
E. vertical
F. subaxial
C. Posterior
106
33. MS patient requires GA. Most likely precipitant of deterioration:
A. hyperthermia
B. hypocarbia
C. Non-depolarising muscle relaxant
D. TIVA
E. volatile anaesthetic agent
A. Hyperthermia
107
41. 6 year old 20kg anaesthetised and paralaysed for appendicectomy. First attempt- vocal cords seen. Size 5.5 uncuffed unsuccessful. 2nd attempt with 4.5 unsuccessful. Next appropriate step
A. administer nebulised adrenaline
B. attempt 4.0 tube
C. examine trachea with fibreoptic bronchoscope
D. LMA
E. soften 4.5 tube and attempt reinsertion
???
This is probably an RSI (for appendicectomy) so you need to secure the airway to protect against aspiration.
I would check that I could ventilate by hand (if not --> LMA as rescue), then try a size 4.0 tube (B).
This child obviously has abnormal subglottic anatomy and will need endoscopic examination at some point, but the immediate priority would be to secure the airway and complete the surgery.
108
49. 40 year old, pulmonary artery hypertension 80/60 pre-op. Lap cholecystectomy. Sudden SPO2 87, sBP 80/40, etPCO2 45. Cause?
A. gas emboli
B. Left heart failure
C. myocardial ischaemia
D. pneumothorax
E. right heart failure
E. Right heart failure
109
55. 10L/min via facemask. Cylinder C 15 000kP lasts
A. 10min
B. 15min
C. 30min
D. 45min
E. 60 min
D. 45 mins
(from BOC healthcare website)
Size C cylinder lasts:
- 81 mins at 6 L/min
- 49 mins at 10 L/min
- 32 mins at 15 L/min
110
59. ?To prevent transmission of CJD? Airway-contaminated equipment
A. autoclave
B. protected plastic covers
C. sterilise in ethylene oxide
D. 134 degrees C for 3 min
E. thrown away
E. Thrown away
111
89. A 63 year old woman with chronic AF has a history of HTN, T2DM and has had a previous CVA. Her annual risk of stroke without anticoagulation is
A.
D. 4%
CHA2DS2-VAS score:
- HTN (1)
- T2DM (1)
- Female (1)
- Previous CVA (2)
= 5
2-3 points = moderate risk: 2.2-3.2% risk of stroke per year without anticoagulation
4-5 points = high risk: 4.0-6.7% per year
6 or more points = very high risk: 9.8% per year
112
An 85y.o for an open AAA repair. Refuses blood because of risk vCJD. You tell him you won't anaesthetise him as the risk is too high. This is an example of
A. Autonomy
B. Beneficence
C. Justice
D. Coercion
E. Paternalism
E. Paternalism
113
149 (?repeat -not sure) You have administered a regional anaesthetic to a primiparous woman for an emergency caesarean section. Soon after delivery of the baby, the woman complains of chest pain and dyspnoea, then loses consciousness. What is the most likely cause of her loss of consciousness?
A. Administration of suxamethonium
B. Anaphylaxis to oxytocin
C. Amniotic fluid embolus
D. Pulmonary Embolus
E. Eclamptic seizure
C. AFE
114
150. The faster rate to desaturation observed in morbidly obese patients is due to:
A. Decreased residual volume
B. Decreased functional residual capacity
C. Decreased diffusion capacity
D. Increased closing capacity
E. Increased pulmonary blood volume
B. Decreased FRC
115
In preadmission clinic with patient with a tracheostomy. To enable patient to talk you would:
A. Deflate tracheostomy cuff, insert one-way valve, insert fenestrated piece
B. Deflate tracheostomy cuff, remove one-way valve, insert fenestrated piece
C. Inflate tracheostomy cuff, remove one-way valve, insert fenestrated piece
D. Inflate tracheostomy cuff, insert one-way valve, insert fenestrated piece
E. ?
A. Deflate cuff, insert one-way valve, insert fenestrated piece
See lifeinthefastlane - Fenestrated tracheostomy tube, for diagrams:
Components:
- comes with an outer cannula, inner cannula, obturator, cuff and plug
- outer cannula = keeps stoma from closing
- inner cannula = can be removed for cleaning
- obturator is used when putting the outer cannula into the stoma
- fenestrations are holes on the posterior part of the tube above the cuff
- with the cuff up and a non-fenestrated inner cannula there is no air leak
Vocalisation:
- need to remove inner cannula or use a fenestrated inner cannula
- need to occlude the outer cannula opening with a plug, speaking valve or finger
- on expiration with the cuff deflated, air passes upwards through the cords through the fenestration and around the tube enabling vocalisation
116
Which is least likely fraudulent research reduction strategy?
A. Published in a peer review journal
B. Multiple authors
C. Departmental director sole author
D. Research findings similar to other published studies
E. Backing of a major research institute
C. Departmental director sole author
117
Trauma patient undergoes delayed ORIF FEMUR. Induction consists of suxamethonium, propofol and an ETT. Cephalozin is given and rocuronium Femoral Nerve Block, turned lateral. Suddenly BRADYCARDIC, ETCO2 45, MAP 50mmHg. This is most likely to be ..?
A. PE
B. Fat embolism
C. Anaphylaxis
D. LA Toxicity
E. ?
D. LA toxicity. C also possible (and is more common) but more likely to be tachycardic than bradycardic.
Incidence of anaphylaxis - 1:5000
Incidence of LAST - 1:12,000 (when ultrasound is used)
Would be unusual to see bradycardia with anaphylaxis but a sudden increase in venous capacitance could cause a Bezold-Jarisch reflex-induced bradycardia (especially when compounded by a sudden change in position).
LA toxicity - CVS effects (from the Toxicology Handbook): bradycardia, hypotension, atrial and ventricular dysrhythmias, cardiovascular collapse and asystole.
MCQs
flashcards
Decks in class (18)
# Cards
