2 Rakesh Flashcards
1
Q
- A 70-year-old patient is complaining of feeling heaviness in the chest, lightheadedness and breathlessness. She has a blood pressure of 100/60
mmHg, pulse of 35/min and is getting oxygen by mask.
What is the most appropriate next management of this patient?
A. Call the intensive care team for review.
B. Give 500 mcg of IV atropine.
C. Arrange for transcutaneous pacing.
D. IV isoprenaline 5 mcg/min.
E. IV adrenaline 2–10 mcg/min.
A
B
- Answer: B
The 2010 ALS Bradycardia algorithm suggests 500 mcg IV atropine as the fi rst line of management
in patients with symptomatic bradycardia with adverse features. The other options mentioned form
part of the subsequent management of this patient.
2
Q
- A 72-year-old male patient is in recovery after an aorto-femoral bypass surgery under general anaesthesia, which was fairly uneventful.
His past medical history includes COPD, ischaemic heart disease, hypertension, and extensive atherosclerosis. A few hours in, the recovery nurse calls you to tell that the patient’s heart rate has gone up to 140. The 12-lead
ECG shows a narrow complex regular tachycardia with minimal new ST segment depression. The patient is talking to you, is feeling fine and does not seem to be in any pain or discomfort. Which of the following is
not appropriate for subsequent management of the patient?
A. Vagal manoeuvres such as carotid sinus massage.
B. IV adenosine.
C. IV β -blockers.
D. Preparation for synchronized cardioversion.
E. High fl ow oxygen.
A
c
- Answer: A
All the above mentioned steps are part of the adult algorithm for management of narrow complex
tachycardia, so will be appropriate in any other situation. Cardioversion is not recommended in
stable narrow complex tachycardia unless the patient has adverse signs or symptoms but, given this
patient’s medical history and the onset of ST depression on ECG, it would be sensible to be ready
for cardioversion if pharmacological treatment does not work.
However, this particular patient has signifi cant atherosclerosis and carotid sinus massage might
therefore not be very safe because of the risk of embolization from an undiagnosed atheromatous
plaque present in the carotid artery. High-fl ow oxygen should be given even in a COPD patient who
is unwell post-operatively and in an acute situation.
3
Q
- While doing a routine urology list on the day surgery unit, one of the patients develops pulseless ventricular tachycardia. Which of the following steps is recommended?
A. First priority is defi brillation before chest compression.
B. Initial 2 min of chest compression is recommended before fi rst shock.
C. The fi rst shock is delivered at 150–360 J biphasic, with escalating energy for subsequent
shocks.
D. The interval between stopping compression and delivering shock should be less than 10 s.
E. Give both adrenaline and amiodarone after the third shock.
A
d
- Answer: E
Even for a shockable rhythm, chest compression should be started while waiting for the defi brillator
to be attached and/or charged, but once ready, the fi rst shock should delivered without delay. The
fi rst shock is delivered at 150–200 J biphasic, with subsequent shocks at 200–360 J biphasic. The
time between stopping chest compressions and shock delivery should ideally be less than 5 s. The
new guidelines suggest both adrenaline and amiodarone should be given after the third shock.
4
Q
4. You have just transferred a 10-year-old boy to recovery after tonsillectomy. Within how many hour(s) of the surgery is the highest risk of post-tonsillectomy haemorrhage? A. 1 h. B. 6 h. C. 12 h. D. 24 h. E. 48 h.
A
d
- Answer: B
Seventy-fi ve per cent of post-tonsillectomy haemorrhage occurs within the fi rst 6 h, and the rest
occurs within the fi rst 24 h. The most common cause of early haemorrhage is the pain, which
causes hypertension and re-bleeding.
Haemorrhage occurring after a few days is secondary to infection.
5
Q
- Which of the following statements is true regarding children with upper respiratory tract infection (URTI):
A. Incidence of laryngospasm and bronchospasm is same in children with concurrent URTI
compared to children who had URTI 4 weeks ago.
B. Children of parents who smoke do not have increased risk of adverse airway events.
C. Children with recent URTI should be postponed for elective surgery.
D. There is same incidence of adverse airway events if LMA is used instead of endotracheal
tube.
E. The risk is the same if children have non-productive cough compared to those having
productive cough.
A
a
- Answer: A
There is no diff erence in laryngospasm or bronchospasm during elective surgery when children had
active URTI or URTI in the last few weeks. Independent risk factors for adverse respiratory events
in children with URTI include history of reactive airway disease, history of prematurity, parental
smoking, airway surgery, use of endotracheal tube, productive cough, and nasal congestion. If a
patient has normal appetite and activities, no fever, and does not look systemically unwell, it is
probably safe to proceed with the surgery.
6
Q
- You have just given a spinal anaesthetic for an elective caesarean
section. Which of the following would you fi nd most useful to decrease the incidence of hypotension for caesarean section under regional
anaesthesia?
A. Preloading with IV fl uids.
B. Metaraminol bolus.
C. Prophylactic phenylephrine infusion.
D. Prophylactic ephedrine bolus.
E. Low-dose spinal.
A
- Answer: C
Historically the recommended fi rst-line drug treatment for hypotension associated with regional
anaesthesia in obstetrics is ephedrine. This is because early animal studies suggested that ephedrine,
which is a predominantly β -adrenergic agonist, was better at increasing maternal arterial pressure
while preserving uterine blood fl ow than other vasopressors. However, the use of ephedrine
to prevent or treat hypotension associated with regional anaesthesia might even worsen foetal
acidosis.
Metaraminol is a mixed α - and β -adrenergic agonist that has predominant α eff ects at doses
used clinically. When used by infusion to maintain arterial pressure during spinal anaesthesia for
caesarean section, metaraminol was associated with less neonatal acidosis and more closely
controlled titration of arterial pressure than ephedrine.
There is evidence that the metaraminol and phenylephrine are safe and are associated with better
foetal acid–base status. If infusions of phenylephrine or metaraminol are used, umbilical cord blood
gases are signifi cantly better than with ephedrine, but decreases in maternal heart rate are more
common with metaraminol. The bradycardia is usually a baroreceptor-mediated event and resolves
on stopping the infusion.
Prophylactic infusion of phenylephrine 100 mcg/min decreased the incidence, frequency, and
magnitude of hypotension, with equivalent neonatal outcome, compared with a control group
receiving IV bolus phenylephrine.
7
Q
- The recent RCOA audit on central neuraxial blocks (CNBs) has shown that the incidence of major complications after CNBs is rare. However,
in which one of the following is the risk of neurological complications
highest when doing a CNB?
A. Labour combine spinal epidural. B. Paediatric patients under general anaesthesia. C. General surgical patients. D. Chronic pain patients. E. Spinal for orthopaedic procedures.
A
c
- Answer: C
National Audit Project 3 showed the highest incidence of complications in epidurals performed in
adult patients undergoing general surgical procedures, which refl ects the co-morbidities that these
patients have as well as the fact that they usually have thoracic epidurals, which are technically more
diffi cult and challenging.
8
Q
- Which one of the following is an absolute contraindication for doing a
central neuraxial block during pregnancy?
A. Platelet count of 80 000. B. Severe PET with BP 160/100. C. HELLP syndrome. D. Grade 4 anterior placenta praevia. E. Type-3 von Willebrand’s disease.
A
e
- Answer: E
Von Willebrand’s disease Type 3 results in a complete absence of von Willebrand’s factor, platelet
dysfunction, and severe coagulopathy, so regional techniques are contraindicated.
All others situations mentioned are amenable to regional techniques. You can still give a single-shot
spinal in pre-eclampsia with platelet count of 80 000, or in a patient with severe PET or HELLP
syndrome if the coagulation is normal and the risk of giving GA is considered to be high when
assessed by an experienced anaesthetist.
Von Willebrand’s disease (vWD) is characterized by either a shortage or defect (or both) in a
protein in the blood called von Willebrand factor (vWF), which helps to make blood clot. It thus
takes longer with vWD for the blood to clot and for bleeding episodes to stop. vWD is the most
common of bleeding disorders, aff ecting 1 % to 2 % of the population nationwide, and is named after
the Finnish haematologist who fi rst reported it. It varies in severity, and in its milder form often goes
undetected, unless unusual bleeding occurs during tooth extraction, surgery, or an accident. Most
people with vWD live completely normal lives.
Symptoms can also change over time and include: z prolonged bleeding from minor skin cuts z easy bruising z frequent epitasis nose bleeds z unusual bleeding from mouth or gums z bleeding in the gastrointestinal tract z bleeding into muscles and joints z excessive haemorrhage after injury, dental work, or surgery The diff erent types of vWD are: z Type 1 A z Type 2: 2A, 2B, 2M and 2N z Type 3
9
Q
- All of the following are proven benefi ts of epidural analgesia except:
A. Early hospital discharge. B. Decreased incidence of ileus. C. Improved quality of analgesia. D. Decreased mortality. E. Decreased post-operative pulmonary complications.
A
d
- Answer: D
Epidural analgesia as a part of enhanced recovery programme has been shown to shorten hospital
stay. It also has been shown to decrease ileus, provide better analgesia, and improve pulmonary
function. However, none of the epidural studies or systematic reviews has shown long-term survival
benefi ts.
10
Q
- A 26-year-old primipara in labour had epidural for labour analgesia. Two hours later she was fi ne but there was sudden foetal bradycardia
on the CTG monitor. With regards to foetal resuscitation, which of the
following is the least eff ective measure?
A. Stopping the epidural infusion.
B. Subcutaneous terbutaline.
C. Intravenous fl uids.
D. Oxygen by mask.
E. Lateral position.
A
B
- Answer: A
In-utero resuscitation consists of steps taken to improve the placental perfusion in a compromised
foetus. Lateral position removes aorto-caval compression. Terbutaline causes tocolysis. Oxytocin
should be stopped as well if being used. IV fl uids and oxygen also improve placental perfusion.
Epidural infusion is generally stopped during the resuscitation but it does not help in immediate in-
utero resuscitation.
11
Q
- An 83-year-old man who slipped and had fracture neck of femur. Based
on the NCEPOD recommendations regarding the management of
fracture neck of femur in the elderly, the following will improve the
outcome except:
A. Spinal anaesthesia over GA.
B. Pre-operative regional analgesia.
C. Regular input from the geriatric medicine specialists.
D. Careful fl uid management.
E. Adequate nutritional support.
A
A
- Answer: A
There is no evidence that using spinal or GA in management of fracture of neck of femur makes
a diff erence to the overall outcome of the patients. The other points are recommended in the
NCEPOD report.
Pre-operative regional anaesthesia by doing fascia–iliaca block is recommended to relieve the pain
of the fracture and operation within 24 h. A systematic review found no robust evidence that
spinal/epidural anaesthesia confers any benefi t over general anaesthesia with regards to overall
mortality at 3, 6 and 12 months following surgical repair of hip fracture in older people (6.9 % versus
10 % ; relative risk, 0.69; confi dence interval, 0.5–0.95).
12
Q
- You have given an interscalene block for a patient undergoing shoulder
surgery. However, about 30 min after the block, the patient fi nds that
his voice is getting hoarse and he is fi nding it diffi cult to speak. Which of
the following is the most likely cause?
A. Cervical sympathetic block.
B. Phrenic nerve block.
C. LA toxicity.
D. Horner’s syndrome.
E. Recurrent laryngeal nerve block.
A
D
- Answer: E
Recurrent laryngeal nerve block is a well-known complication after interscalene block, which
can cause hoarseness of voice due to ipsilateral paralysis of vocal cord. The other mentioned
complications are possible but are unlikely to be responsible for change in voice.
13
Q
- A 35-year-old patient with idiopathic cardiomyopathy is pregnant. When is the highest risk of her developing congestive cardiac failure?
A. Between 30 and 32 weeks’ gestation.
B. During fi rst stage of labour.
C. At term, near 40 weeks’ gestation.
D. Immediately after third stage of labour.
E. At the peak of uterine contractions in the second stage of labour.
A
A
- Answer: D
The maximum increase in cardiac output occurs at the end of the third stage of labour, when
the placenta separates and there is autotransfusion of blood from placental circulation back into
maternal circulation. This is the time when the risk of congestive cardiac failure is highest.
14
Q
- A 25-year-old primipara has an accidental dural tap (ADT) with a 16-G tuohy needle while the anaesthetist was attempting labour epidural
analgesia. A day after the ADT, the patient is complaining of severe
positional frontal and occipital headache. Which of the following is not
appropriate for management?
A. Prophylactic bed rest.
B. Simple analgesics.
C. Caff eine.
D. Liberal fl uid intake.
E. Epidural blood patch.
A
A
- Answer: A
There is no evidence for prophylactic bed rest in post-dural puncture headache. All the other
mentioned treatments have some benefi t, with the blood patch having the best results.
Management of PDPH
Conservative management approaches include:
z bed rest
z encouraging intake of oral fl uids and/or intravenous hydration
z reassurance.
A recent Cochrane review concluded that routine bed rest after dural puncture is not benefi cial and
should be abandoned.
Pharmacological approaches include:
z caff eine — either intravenous (e.g. 500 mg caff eine in 1 L saline) or orally
z synacthen (synthetic ACTH )
z regular analgesia: paracetamol, diclofenac etc.
z other drugs with insuffi cient evidence in the literature are:
5HT agonists (e.g.sumatriptan)
gabapentin, DDAVP
theophyline
hydrocortisone.
Interventional approaches include:
z immediate:
insertion of long-term intrathecal catheter placement (15 % ) and epidural saline bolus (13 % )
epidural morphine
15
Q
- A 75-year-old patient is to undergo an emergency laparotomy for sub- acute bowel obstruction. He suff ers from chronic atrial fi brillation and is
on warfarin. The patient’s INR is 2.0 on admission. What would be the
best course of his management?
A. Wait for the INR to correct on its own.
B. Carry on with the surgery with FFP transfused intra-operatively.
C. Correct INR pre-operatively with FFP.
D. Correct INR pre-operatively with vitamin K.
E. Correct INR pre-operatively with vitamin K and prothrombin concentrate.
A
B
- Answer: E
Warfarin is a coumarin derivative, which inhibits synthesis of the vitamin-K-dependent clotting
factors (factors II, VII, IX and X) in the liver, by preventing the reduction of oxidized vitamin K
required for carboxylation of clotting factor precursors. The management of patients on warfarin
for emergency surgery requires administration of prothrombin complex concentrate (PCC), which
contains the necessary factors, although fresh frozen plasma at 15 mL/kg can be administered, but
this presents a risk of anaphylaxis and transmission of blood-borne pathogens, and is the most
common cause of transfusion-related acute lung injury (TRALI).The best course of management for
this patient would be to correct INR with vitamin K and PCC if the surgery is not very urgent. FFP
is to be given only if there is signifi cant ongoing bleeding or PCC is not available.
