2006.1 Flashcards
- MZ39 ANZCA version [2002-Mar] Q51, [2002-Aug] Q51, [2005-Apr] Q8, [2005-Sep] Q5, [2006-Mar] Q1
Epidermolysis bullosa may be associated with
A. oesophageal stricture B. anaemia C. amyloidosis D. porphyria E. all of the above
E. all of the above
- Causes of inverted P waves in lead II of the electrocardiogram include
A. transposed lower limb leads B. junctional rhythm C. hypothermia D. left axis deviation E. Inferior myocardial infarction
B. junctional rhythm
hypothermia: prolonged QRS, prolonged QT, Osborne waves
MH36c ANZCA version [2004-Apr] Q32, [2004-Aug] Q1, [Mar06]
15. Following major surgery there is an increased risk of thrombosis, associated with a decrease in
A. fibrinogen B. factor VIII coagulant C. factor VIII; Ag (von Willebrand related antigen) D. interleukin 6 E. protein C
E. protein C
Yentis A-Z Anesthesia 3rd ed p124 Oxford Hand Book of Medicine 6th Edition p672
[1] Ital J Surg Sci. 1984;14(1):9-12. Study about Post-op Protein C. Levels decreased by day 3 in all groups (Minor, Major and oncology surgery)
There is an increased risk of thrombosis with: ▪ Protein C deficiency ▪ Protein S deficiency ▪ Antithrombin III deficiency ▪ Lupus anticoagulant and/or anticardiolipin antibody ▪ Factor V Leiden mutation ▪ Thrombocytosis ▪ Polycythemia ▪ Hyperhomocysteinemia
- AM16 ANZCA Version [Mar06] Q23, [Aug10]
Recognised clinical associations with myotonia dystrophica include
A. development of diabetes mellitus B. abnormal intestinal motility C. cardiomyopathy D. ovarian dysfunction E. all of the above
E. all of the above
Stoelting
• Myotonia dystrophica usually manifests as facial weakness (expressionless facies), wasting and weakness of the sternocleidomastoid muscles, ptosis, dysarthria, dysphagia, and inability to relax the handgrip (myotonia). Other characteristic features include the triad of mental retardation, frontal baldness, and cataracts
• Endocrine gland involvement may be indicated by gonadal atrophy, diabetes mellitus, hypothyroidism, and adrenal insufficiency
• Delayed gastric emptying and intestinal pseudo-obstruction may be present
• Death from pneumonia or heart failure often occurs by the sixth decade of life. This reflects progressive involvement of skeletal muscle, cardiac muscle, and smooth muscle. Perioperative morbidity and mortality rates are high due principally to cardiopulmonary complications
- The most correct statement concerning the respiratory changes of morbid obesity is that
A. alveolar hypoventilation is characteristic of Pickwickian obesity
B. The functional residual capacity (FRC) is unchanged
C. The residual volume (RV) is decreased
D. The weight of the torso is responsible for increased chest wall compliance
E. The work of breathing is unchanged
A.
FRC decreased. RV preserved. Reduced chest wall compliance in obesity. WOB increased.
PZ113 ANZCA version [2004-Aug] Q110, [Mar06]
34. Following acute subarachnoid haemorrhage, the use of anti-fibrinolytic agentsis associated with a decreased
A. incidence of hydrocephalus B. incidence of rebleeding C. incidence of pulmonary embolus D. mortality from all causes E. mortality from ischaemic neurological events
B. decreased incidence of rebleeding
The Lancet Volume 369, Issue 9558, 27 January 2007-2, Pages 306-318 Seminar-Subarachnoid haemorrhage
Antifibrinolytic drugs prevent rebleeding after aneurysmal rupture, but because they increase the risk of cerebral ischaemia, they have no useful effect on overall outcome.
- MC148 ANZCA Version [Mar06] Q46
The most useful finding to confirm the diagnosis of aortic stenosis in an adult with a systolic murmur is
A. increasing murmur intensity with inspiration
B. decreasing murmur intensity with passive leg elevation
C. increased second heart sound
D. effort syncope
E. a slow rate of rise of the carotid pulse
E. slow rate of rise of the carotid pulse
Effort syncope nonspecific (also common in HOCM)
ACC/AHA Guidelines for the Management of Patients With Valvular Heart Disease (JACC 1998)
• Midsystolic (systolic ejection) murmurs, often crescendo decrescendo in configuration, occur when blood is ejected across the aortic or pulmonic outflow tracts. The murmurs start shortly after S1, when the ventricular pressure rises sufficiently to open the semilunar valve. As ejection increases, the murmur is augmented, and as ejection declines, it diminishes
• Left-sided murmurs usually are louder during expiration
• With prompt squatting, most murmurs become louder, (but those of HCM and MVP usually soften and may disappear). Passive leg raising usually produces the same results as prompt squatting
• A soft or absent A2 or reversed splitting of S2 may denote severe AS
• A slow-rising, diminished arterial pulse suggests severe AS in a patient with a grade 2/6 midsystolic murmur at the upper intercostal spaces
- Prior to surgical stimulation, which of the following drugs, when added to propofol or volatile anaesthesia, will decrease the BIS?
A. 70% nitrous oxide B. ketamine (0.5mg/kg) C. midazolam (0.2mg/kg) D. remifentanil infusion (0.25mcg/kg/min) E. all of the above
C. midazolam 0.2 mg/kg
AZ63 ANZCA version [2002-Aug] Q123, [Mar06] Q59 [Apr07] Q10
59. Regarding extracorporeal shockwave lithotripsy (ESWL) for renal calculi in patients with a permanent pacemaker in situ,
A. ESWL is contraindicated
B. ESWL pulses should be timed to coincide with the ST interval
C. rate modulation of the pacemaker should be deactivated during the ESWL procedure
D. there is a risk that the ESWL pulse will reprogramme the pacemaker
E. Regional anaesthesia is relatively contraindicated
C. rate modulation of the pacemaker should be deactivated during the ESWL procedure.
Pacemakers are a relative contraindication to ESWL
▪ Dual chamber pacemakers:
reprogram to VVI, turn rate response off
▪ Continuous ECG monitoring
▪ Keep lithotripter more than 15cm from pacemaker
Time shock wave with R wave
EZ87 ANZCA version [2005-Sep] Q142 [2006-Mar] Q79
79. With regard to accidental electrocution, which of the following statements is true?
A. all electrical equipment in the operating theatre should be earthed
B. risk if ventricular fibrillation increases with increasing current frequency
C. risk of ventricular fibrillation is greater with alternating current (c.f. direct)
D. risk of electrocution is reduced by earthing the patient
E. use of battery operated equipment avoids the risk of ventricular fibrillation
C. risk of VF is greater with AC (cf direct current)
A - equipment supplied by an isolated circuit is not earthed
B - diathermy does not cause electrocution because of its very high frequency
- NL08 ANZCA Version [Mar06] Q80
The sural nerve
A. is a branch of the posterior tibial nerve
B. supplies the skin of the anterior two thirds of the sole of the foot
C. lies anterior to the lateral malleolus at the ankle
D. reaches the foot in contact with the short saphenous vein
E. supplies the small muscles of the foot
D. reaches the foot in contact with the short saphenous vein - the sural nerve runs with the short saphenous vein, while the saphenous nerve runs with the long saphenous vein.
A - Sural nerve is made up of branches of the tibial nerve (not posterior tibial nerve!) and common peroneal nerve.
B - Supplies the postero-lateral calf, and the lateral foot to the 5th toe
C - Passes posterior to the lateral malleolus
E - Sensory only
Nerve blocks at the ankle
Five nerves pass the malleoli at the ankle: the posterior tibial nerve, the sural nerve, the deep peroneal nerve, the superficial peroneal nerve and the saphenous nerve (see Figs 143, 144 & 146). All can be blocked with local anaesthetic, although the choice of nerves to be blocked for an individual patient will depend upon the site of surgery.
The posterior tibial nerve is blocked immediately posterior to the medial mal- leolus as it runs just behind the posterior tibial artery. An injection of 7–10 ml of local anaesthetic at this point will provide anaesthesia, although a smaller volume can be injected if paraesthesiae are elicited during the insertion of the needle. The sural nerve is blocked with a subcutaneous infiltration of local anaesthetic between the lateral malleolus and the tendo achilles. The deep peroneal nerve is blocked with an injection just lateral to the extensor hallucis tendon. The super- ficial peroneal nerve is blocked by a subcutaneous injection between the extensor hallucis tendon and the lateral malleolus. The saphenous nerve is blocked by a subcutaneous infiltration between the extensor hallucis tendon and the medial malleolus, taking care not to inject local anaesthetic into the saphenous vein.
- The signs of exposure to a nerve agent such as Sarin or VX include
A. bronchodilatation B. dry skin C. muscle fasciculation D. pupillary dilatation E. tetany
C. muscle fasciculation (cholinergic agent)
90 PP54 ANZCA version [2001-Aug] Q69 [2006-Mar] Q90, [Jul06] Q87
Obstructive sleep disorder in children
A. is associated with pulmonary hypertension and dysfunction of left and right ventricles
B. has obesity as a major risk factor
C. is rarely seen in children less than 8 years old
D. is four times more prevalent in boys than girls
E. does NOT usually require tonsillectomy for its management
A. is associated with pulmonary hypertension and dysfunction of left and right ventricles
Cardiac Remodeling and Dysfunction in Children with Obstructive Sleep Apnea - A Community Based Study Thorax (BMJ) 2009
Conclusions: OSA is an independent risk factor for subclinical RV and LV dysfunction, and improvement in AHI is associated with reversibility of these abnormalities.
RCH website OSA:
▪ The most common cause of OSA in childhood is enlargement of the tonsils in the back of the throat and the adenoids in the back of the nose. Tonsils and adenoids grow most quickly when a child is 2-7 years old. Having the tonsils and adenoids taken out cures OSA in 80-90% of children. Sometimes, the adenoids grow back again. If the symptoms return, your child may need more surgery.
▪ Obesity is another cause of childhood OSA.
▪ Long-term allergy or hay fever may also cause OSA. This can usually be treated.
▪ Children with certain medical conditions associated with weak muscles or low muscle tone, such as Down syndrome, are more likely to have OSA.
▪ Sometimes children with very small jaws or flat faces may also be at risk.
“Most younger children with OSA are not overweight, however if a child is overweight this might contribute. Weight loss is therefore important for overweight children with OSA.” Symptoms of Sleep Apnea in Children, about.com
AFP 2006:
“true OSA results in detrimental clinical sequelae such as failure to thrive, behaviour problems, enuresis and cor pulmonale.”
It seems that most children with OSA are small, with failure to thrive. However, obese children are more likely to have OSA. The mechanism of LV dysfunction is described by Americal Academy of Paeds: Preop assessment, OSA
• Hypoxaemia and hypercapnia secondary to OSA lead to pulm HT (vasoconstriction causes structural remodeling of pulm vascular bed)
• PHT results in RV dysfunction, remodeling and hypertrophy
• Progressive tricuspid regurg and movement of the inter-ventricular septum lead to LVOT obstruction
• LVOT obstruction results in LV dysfunction and pulmonary oedema, which exacerbates the hypoxia.
Anaesthesia 1998 says “In contrast with adult OSA, in children there is an equal prevalence of affected boys and girls”
Argument on BB is between A and B; I’m going A.
- The patient most likely to sustain blunt cardiac trauma (cardiac contusion) is a
A. back seat passenger in a motor vehicle which crashes at a speed of 60km/h
B. motor bike rider who falls from his bike on a bend travelling at 50km/hr
C. painter who falls 10m onto grass
D. 70 year old patient who had CPR performed by a passerby on the street
E. water skier who falls from his skis at speed of 40km/hr
A. back seat passenger in a motor vehicle which crashes at a speed of 60 kph
95 MR47 ANZCA Version [Mar06]
The differential diagnosis of asymmetric consolidation on a CXR includes each of the following EXCEPT
A. Pleural effusion B. Pneumonia C. Pulmonary Haemorrhage D. Pulmonary Infarction E. Pulmonary Oedema
A. pleural effusion
(consolidation refers to the airspaces, a pleural effusion is fluid in the pleural space).
N.B. pulmonary oedema can be unilateral e.g. due to extrinsic pulmonary vein compression, rapid re-expansion of a collapsed lung
Note – badly worded question, as you don’t see “consolidation” on CXR (which implies aetiology), you see areas of opacification…
- Each of the following herbal treatments is associated with an increased risk of perioperative bleeding EXCEPT
A. garlic B. ginger C. ginko D. ginseng E. St. Johns wort
E. St John’s wort (no direct effect on bleeding; may cause decreased warfarin effect due to cytochrome P450 enzyme induction)
- PR56 ANZCA version [March 2006] Q97
The duration of action of suxamethonium may be increased by
A. betamethasone B. bleomycin C. carvedilol D. neostigmine E. all of the above
D. neostigmine
True - neostigmine is a cholinesterase inhibitor
98 SO20 ANZCA Version [Mar 06] Q98 [Jul06] Q53
In anaesthetised patients undergoing controlled ventilation, release of a lower-limb arterial tourniquet after sixty minutes will
A. cause no change in end-tidal CO2 tension
B. decrease central venous pressure for more than 30 minutes before returning to baseline
C. decrease oxygen consumption
D. increase cerebral blood flow
E. increase core body temperature transiently
D. increased cerebral blood flow
From Kam, P. et al (2001), The arterial tourniquet: pathophysiological consequences and anaesthetic implications. Anaesthesia, 56: 534–545 (excellent article)
“Deflation is associated with a transient increase in ETCO2, peaks in 1min and returns to baseline in 10-13min.
“After deflation of the tourniquet, CVP and arterial BP decrease for 15 min as a result of a shift of blood volume back into the limb and post-ischaemic reactive hyperaemia associated with a decrease in peripheral vascular resistance”
“the rapid increase in ETCO2 after deflation is associated with a 50% increase in middle cerebral artery blood flow velocity… the resulting increase in cerebral blood volume may contribute to secondary brain injury in pts with increased ICP.
- SC25 ANZCA version [Mar06]
When anaesthetising a patient with a ventricular assist device (VAD) for non-cardiac surgery
A. Anticoagulation should be temporarily discontinued during surgery
B. Electrocautery is well tolerated by these devices
C. Malignant arrhythmias should be treated with defibrillation if indicated
D. The most important causes of decreased pump output are hypovolaemia and increased afterload
E. Volatile anaesthetic agents should be avoided
D. The most important causes of decreased pump output are hypovolaemia and increased afterload. As is the case with the diseased native heart, normal or slightly increased intravascular volume and normal or slightly decreased vascular resistance are necessary for VADs to function optimally. Hypovolemia will delay VAD filling with each pump cycle, which may decrease overall pump output and lead to hypotension. Significantly increased vascular resistances may impede VAD ejection, resulting in prolonged or incomplete chamber emptying, and will also decrease overall pump output. Additionally, incomplete chamber emptying results in stasis of blood in the pump, potentially increasing the risk of thrombotic complications.
A ventricular assist device (VAD) is a mechanical circulatory device that is used to partially or completely replace the function of a failing heart. Some VADs are intended for short term use, typically for patients recovering from heart attacks or heart surgery, while others are intended for long-term use (months to years and in some cases for life), typically for patients suffering from advanced congestive heart failure.
A - With the exception of the Heartmate, maintenance of therapeutic levels of anticoagulation is imperative for extracorporeal circulation through these devices (because of the risk of thromboembolism).
B - Extracorporeal devices (the Abiomed and the Thoratec) and the well shielded Novacor will not be affected by defibrillation or electrocautery. Unfortunately, the Heartmate is not well shielded and may be reset to a fixed-rate mode by the electrocautery and potentially damaged by external defibrillation. When feasible, the use of bipolar electrocautery is recommended. Extracorporeal – insulated, implanted – not so.
C - Standard Advanced Cardiac Life Support (ACLS) protocols (with the exception of chest compressions that could cause potential dislodgement of intracardiac cannulae) should be used when needed, and malignant arrhythmias should be electrically or pharmacologically terminated.
E - There are no specific drugs that are contraindicated because of the VAD itself, although excessive doses of any anaesthetic will decrease preload and potentially drop cardiac output
100 The following measures have been shown to reduce intraoperative blood loss in some surgical situations, EXCEPT
A. arterial hypotension (MAP = 50 mmHg) B. controlled ventilation C. hypothermia (less than 34°C) D. maintenance of a low central venous pressure E. regional anaesthesia
C. Hypothermia
(promotes coagulopathy)
Controlled ventilation gives greater control over respiratory parameters such as PO2 and PCO2; avoiding hypoxia and hypercapnia minimises sympathetic activation which reduces bleeding. However IPPV also leads to higher venous pressure, which tends to favour bleeding.
101 EZ83 ANZCA Version [Mar06] Q101
Regarding perioperative use of processed salvaged red blood cells,
A. malignant cells are removed by the washing process
B. storage of salvaged cells should be limited to 6 hours
C. the high free Hb levels are associated with renal failure
D. the salvaged cells have lower oxygen carrying capacity than banked blood
E. the survival of the salvaged red blood cells is significantly impaired
C. The high free Hb levels are associated with renal failure.
A: false – CEACCP: “malignant cells may be removed by filtration and further reductions achieved by irradiation.” It is not guaranteed that malignant cells will be removed with a leukocyte filter.
B: false – Miller: if stored at room temp, salvaged blood can be stored for 4 hours.
C: true: Miller and CEACCP refer to renal damage from free Hb.
D, E: false – Miller: “the oxygen-transport properties of recovered RBCs are equivalent to those of stored allogenic RBCs. The survival of recovered RBCs appears to be at least comparable to that of transfused allogenic RBCs.”
102 SZ23 [Mar06] Q102
Regarding decontamination of anaesthetic equipment
A. alcohol is sporicidal
B. disinfection is sporicidal
C. phenol is sporicidal
D. sterilisation with ethylene oxide requires 5-12 hours to work
E. sterilisation with glutaraldehyde requires 5-8 exposure hours to work
D. Sterilisation with ethylene oxide requires 5-12 hours to work
CEACCP 2004 “Decontamination of anaesthetic equipment”
• Decontamination: process that removes or destroys contaminants; it always involves cleaning followed by disinfection and/or sterilization
• Disinfection: A process that eliminates many or all pathogenic organisms except bacterial spores. Agents include alcohol.
• High-level disinfection: A chemical agent that can kill bacteria, viruses and spores. It is only sporicidal under certain conditions. Eg gluteraldehyde, hydrogen peroxide, chlorine.
• Sterilisation: Process that renders an object completely free of all viable infectious agents by eliminating all forms of microbial life.
Disinfection, alcohol and phenol are not sporicidal (ie A, B, C false)
High-level disinfection is sporicidal (but must be specified as such)
Ethylene oxide requires 5-12 hours
Gluteraldehyde requires immersion in 2% solution for 10 hours to sterilize. (20 minutes is adequate to disinfect endoscopes) - used for cystoscopes, bronchoscopes as it is non-corrosive and doesn’t damage the lens
MZ76 ANZCA Version [Mar06] Q103
In patients with chronic renal failure there is
A. increased calcium absorption B. increased phosphate excretion C. increased vitamin D3 production D. increased osteoclastic activity E. decreased osteoblastic activity
D. Increased osteoclast activity
Stoelting: Renal osteodystrophy is a complication of chronic renal failure, reflecting the complex interaction of secondary hyperparathyroidism and decreased vit D production by the kidneys. As GFR falls, there is a parallel decrease in phosphate clearance and increase in serum phosphate concentration which results in a reciprocal decrease in serum calcium. Hypocalcaemia stimulates PTH secretion, which leads to bone resorption and calcium release. Due to decreased renal production of Vit D by the kidneys, intestinal absorption of calcium is impaired, which also leads to hypocalcaemia, stimulation and PTH release and bone resorption.
BB: hypocalcaemia develops primarily from decreased intestinal Ca absorption because of low plasma calcitriol levels and possibly from Ca binding to serum PO4.
Ganong: there is increased activity of both osteoblast and osteoclasts, with osteoclasts dominant so overall Ca is mobilized from the bones.
