2011.2 Flashcards
EZ93 What is the chemical used in sodalime to indicate exhaustion?
A. ethyl violet
B. potassium permanganate
C. ?
A. Ethyl violet
Chemical reaction is;
H20 + CO2 → H2CO3
H2CO3 + 2NaOH → Na2CO3 + 2H2O
Na2CO3 + Ca(OH)2 → CaCO3 + 2NaOH
Indicators for SodasorbTM (such as ethyl violet) are colorless when fresh, and purple when exhausted, because of pH changes in the granules.
- Repeat- Main heat loss in anaesthetic for neonate
A. vasodilatation B. radiation C. convection D. conduction E. evaporative
B. Radiation
Radiation if > 28/40 PCA
Evaporation if
- Repeat- One lung ventilation- FIO2 1.0, desaturate
Management of hypoxaemia during OLV:
o Increased FiO2 to 1.0
o Confirm adequate lung isolation by talking to surgeon and checking positioning of DLT with bronchoscope
o Manually ventilate to assess compliance (?upper airway obstruction ?PTX, ?APO) - if poor compliance, suction down tube (down ventilated side) to exclude partial tube obstruction
o Ensure adequate muscle relation
o Optimise cardiac output (may need inotropes)
o Interventions to ventilated lung:
- Alveolar recruitment manoeuvre + increase PEEP (up to 10 cmH2O)
o Interventions to nonventilated lung (bearing in mind that these will interfere with surgery to varying extents)
- Alveolar recruitment manoeuvre followed by CPAP (e.g. 5-10 cmH2O) via an auxillary circuit
- Intermittent two lung ventilation
- Surgical clamping of the pulmonary artery on the operative side to decrease shunt (depending on surgery)
- Child with murmur- what would make it more likely for you to investigate if you heard the murmur
A. persist in supine position
B. louder or softer with various manouveres
??
Likely to be innocent:
- Asymptomatic
- Soft, no associated thrill
- Ejection systolic
- Lower sternal edge, does not radiate
Likely to be pathological:
- Child has chromosomal abnormality or syndrome
- Cardiac symptoms, frequent respiratory symptoms, e.g. cough, wheeze, recurrent respiratory infections
- Failure to thrive
- Family history of congenital heart diseaseInfant
- Repeat- Single lumen intubation after multiple attempts of difficult intubation, you put in a bronchoscope after and the tip is in the trachea. The structure B you see corresponds to?
??
- Repeat- CXR correspond to-
A. right side hydropneumothorax
??
- Repeat- Neonate to drug addicts found by grandmother in the house, brought into ed, mildly jaundice, slight tachycapnic. ABG PH 7.54, PaCO2 46, pO2 74, HCO 13
A. Septicaemic B. Pyloric stenosis C. Opiod overdose D. Meningitis E. Hepatitis
?? This ABG is impossible - ?incorrectly remembered
ET03 [Repeat] Jehovah’s witness refused blood- you have told him you refuse to do the surgery/anaesthesia for his own good. Ethical principle:
A. Paternalism
B. Maleficience
C. Autonomy
D. Beneficience
A. Paternalism
- Patient with aortic stenosis, the signs indicate poor prognosis
A. Palpitation
B. Radiation to carotid arteries
C. Something about characteristic of murmur
Poor prognosis:
- Angina: 5 year 50% survival
- Syncope: 3 year 50% survival
- Heart failure: 2 year 50% survival
Which is the best predictor of poor prognosis with aortic stenosis?
A. chest pain B. paroxysmal nocturnal dyspnoea C. syncope D. E.
B. Paroxysmal nocturnal dyspnoea
Poor prognosis:
- Angina: 5 year 50% survival
- Syncope: 3 year 50% survival
- Heart failure: 2 year 50% survival
- New- Patient indicated for prophylaxis of infective endocardititis
A. amoxicillin orally 2 hours prior
B. amoxicillin IV 1 hour prior
C. amoxicillin IV just before incision
D. cefazolin IV 1 hour prior
B. Amoxycillin IV 1 hour prior (best answer of the ones given)
TGA 2014
For standard prophylaxis, use:
amoxycillin 2 g (child: 50 mg/kg up to 2 g) orally, 1 hour before the procedure
OR
amoxy/ampicillin 2 g (child: 50 mg/kg up to 2 g) IV, within the 60 minutes (ideally 15 to 30 minutes) before the procedure
OR
amoxy/ampicillin 2 g (child: 50 mg/kg up to 2 g) IM, 30 minutes before the procedure.
- Repeat- Spontaneously breathing patient under GA, what would detect the breathing tube disconnection
Loss of anaesthetic agent waveform/decrease in end-tidal agent
(may still have capnography trace if disconnection is proximal to the sampling line)
- Repeat- Plenum and flow over vaporiser- what is not the disadvantage of flow over vaporiser
Wiki:
- Not temperature compensated (drawback)
- Not flow compensated - output concentration depends on flow
The drawover vaporizer is driven by negative pressure developed by the patient, and must therefore have a low resistance to gas flow. Its performance depends on the minute volume of the patient: its output drops with increasing minute ventilation.
The design of the drawover vaporizer is much simpler: in general it is a simple glass reservoir mounted in the breathing attachment. Drawover vaporizers may be used with any liquid volatile agent (including older agents such as diethyl ether or chloroform, although it would be dangerous to use desflurane). Because the performance of the vaporizer is so variable, accurate calibration is impossible. However, many designs have a lever which adjusts the amount of fresh gas which enters the vaporising chamber.
The drawover vaporizer may be mounted either way round, and may be used in circuits where re-breathing takes place, or inside the circle breathing attachment.
Drawover vaporizers typically have no temperature compensating features. With prolonged use, the liquid agent may cool to the point where condensation and even frost may form on the outside of the reservoir. This cooling impairs the efficiency of the vaporizer. One way of minimising this effect is to place the vaporizer in a bowl of water.
The relative inefficiency of the drawover vaporizer contributes to its safety. A more efficient design would produce too much anaesthetic vapour. The output concentration from a drawover vaporizer may greatly exceed that produced by a plenum vaporizer, especially at low flows. For safest use, the concentration of anaesthetic vapour in the breathing attachment should be continuously monitored.
PZ130 Which drugs below does not need dose adjustment in renal failure patient
A. Buprenorphine B. Morphine C. Tramadol D. ? E. ?
A. Buprenorphine
- Repeat- Child after gas induction, LMA insertion without IV cannula- desaturate to 90%. Next step of action?
A. Bag with LMA insitu
B. Bag without LMA insitu
B. Remove LMA and provide CPAP via mask
PZ128 Patient on cisapride. What drug NOT to give in recovery?
A. Tramadol
B. ?
C. ?
?? - Avoid QT prolonging drugs, also avoid serotonergic drugs
As a prokinetic agent that increases gastrointestinal motility, cisapride acts as a selective serotonin agonist in the 5-HT 4 receptor subtype. Cisapride also relieves constipation-like symptoms by indirectly stimulating the release of acetylcholine in the muscarinic receptors
Most data on cisapride interactions are derived from case reports. However, current prescribing information warns against the coadministration of cisapride and any medications known to prolong the QT interval, such as class IA or III antiarrhythmic drugs, tricyclic antidepressants, erythromycin, clarithromycin and phenothiazines.
- Repeat- Which herbal supplement reacts with tramadol?
A. Ephedra
B. St John’s wort
B. St John’s wort
Similar to more conventional antidepressants, its effects are thought to be because of the inhibition of serotonin, norepinephrine, and dopamine re-uptake by neurones.
- Repeat- Fat: blood coefficient- N2O, D, S, I
Fat:blood coefficients:
- N2O: 2.3
- Des: 27
- Iso: 45
- Sevo: 48
- Repeat- Immunology mediated heparin induced thrombocytopenia
? Answer was intravascular thrombosis
- Repeat- Half life or tirofiban?
A. 2 hours
A. 2 hours
Time to normal platelet function = 4-8 hours (can perform neuraxial block at 8 hours)
TMP-131 Repeat- Troponin can be detected for how long:
A. 5-14 days
B. ?
A. 5-14 days
- Repeat- Neonate intubation- at lips
~ 9 cm
Distance at the lips:
- There are lots of formulas, but they don’t take into account natural variation, or head position (e.g. needs to go in further if head flexed).
- Look at the child: you want the tip of the tube to be half-way between the cords and the carina - this half-way point corresponds to the heads of the clavicles in most children –> so the distance between the heads of the clavicles and the cricoid cartilage is the length of tube you want past the cords.
- Phil Ragg reckons this ‘length of tube past the cords’ also corresponds to the internal diameter of the tube (but obviously in cm, not mm)
- Another useful formula is ‘distance at the lips = 3 x ETT size (ID)’
- New - 72 year old has had hip replacement surgery and 3 days postop has a pulmonary embolus. He is fully heparinised, but still dyspnoeic, clammy, BP 80/40, pulse 120 and CVP 18. The most appropriate next step is
A. IVC filter B. Refer him for a pulmonary embolectomy C. Supportive (fluids and inotropes) D. Thrombolysis E. Warfarin
C. Supportive (fluids and inotropes) - and if this fails, then consideration of pulmonary embolectomy.
Stoelting:
Treatment options for acute pulmonary embolism include anticoagulation, thrombolytic therapy, inferior vena caval filter placement, and surgical embolectomy.
Heparin remains the cornerstone of treatment for acute pulmonary embolism.
Patients who cannot undergo anticoagulation, experience significant bleeding while being treated with anticoagulants, or have recurrent pulmonary emboli despite receiving anticoagulant therapy may require insertion of a vena cava filter to prevent lower-extremity thrombi from becoming pulmonary emboli. The use of vena cava filters should be reserved for patients with contraindications to anticoagulant treatment.
Thrombolytic therapy may be considered to hasten dissolution of pulmonary emboli, especially if there is hemodynamic instability or severe hypoxemia. Hemorrhage is the principal adverse effect of thrombolytic therapy, and so this treatment is contraindicated in patients at high risk of bleeding.
The hypotension caused by a pulmonary embolism may require treatment with inotropes such as dopamine and dobutamine or a vasoconstrictor such as norepinephrine. A pulmonary vasodilator may be needed to help control pulmonary hypertension.
Pulmonary artery embolectomy is reserved for patients who have a massive pulmonary embolism that is unresponsive to medical therapy and who cannot receive thrombolytic therapy.
- Repeat- The test to diagnose pulmonary embolism
A. CT pulmonary angiogram
B. Echocardiogram
C. Electrocardiogram
D. Ventilation-perfusion scan
A. CTPA
- Repeat- Finding on haemophilia A patient
A. Female haemarthrosis
B. Male haemarthrosis
C. Normal PT, abnormal APTT
D. Abnormal PT, normal APTT
B. Male haemarthrosis
C. Normal PT, abnormal APTT
Haemophilia A and B
- X-linked recessive
- Bleeding into weight-bearing joints (spontaneously or after trauma) - e.g. knees, ankles, elbows
- Normal PT, prolonged APTT
25.tmp11b25 New- LSCS for foetal distress, meconium stained liquor. Management of baby
A. Intrapartum suctioning B. Intrapartum suctioning and post partum tracheal suction C. Post partum tracheal suctioning D. Routine neonatal care E. Intubate
Depends on tone/respiratory effort.
If floppy/apnoeic –> intubate immediately and suction once down ETT
If vigorous, routine neonatal care
- Repeat- 36yo male with sickle cell anaemia Hct 0.3 with close foot fracture, what is true
A. Transfusion 2 pint packed cell preop
B. Spinal can be done
B. Spinal can be done
- New- An elderly lady has a closed neck of femur fracture and presents to ED. She is in chronic AF and on warfarin. INR is 2.6 and she is not bleeding. It is 9am and she is scheduled for repair the following day. According to current guidelines, how should her warfarin be reversed?
A. Prothrombinex 25IU/kg immediately and then 2 units FFP immediately prior to surgery
B. No immediate treatment then 2 units FFP immediately prior to surgery
C. Vitamin K 1mg IV immediately
D. Vitamin K 10mg IV immediately
E. Withhold warfarin
Vitamin K 3 mg IV immediately
(+ withhold warfarin… then check INR again the next day)
MJA 2013:
Check INR day before surgery: If INR 2–3, administer 3 mg vitamin K1IV
Day of surgery:
• If INR = 1.5, surgery can proceed(GPP);
If INR > 1.5, defer surgery or if urgent, dose Prothrombinex-VF according toBox 4
- Repeat- Marfan syndrome. All EXCEPT-
A. Aortic stenosis
A. Aortic stenosis
- New- Subarachnoid haemorrhage patient. What percentage rebleed in the first 24hours
A. 20%
A.
30.TMP11B30 New- Post delivery neonate did not breath post stimulation by midwife, not vigorous, heart rate drop from 140 to 90bpm. Next step of action
A. 100% oxygen B. Positive pressure ventilation C. Intubation D. CPR E. Adrenaline
B. Positive pressure ventilation
- New- The safe maximal pressure for endotracheal cuff at the lateral side of the trachea
A. 0-10 cm water B. 10-20 cm water C. 20-30 cm water D. 30-40 cm water E. 40-50 cm water
C. 20-30 cmH2O
BMC anaesthesiology:
It is thus essential to maintain cuff pressures in the range of 20–30 cm of H2O
- New- Patient with mastocytosis. Intraop would probably be:
A. Severe hypotension
A. Severe hypotension
- Repeat- Complication of celiac plexus block
A. Hypertension B. Failure of erection C. Constipation D. Paraplegia E. L3,4 lumbar pain
D. Paraplegia
- New- Post epidural and LSCS, the next day patient has persistent paraesthesia anterior thigh. What other deficits would indicate a nerve root lesion rather than a peripheral nerve injury
A. Weakness on hip flexion and thigh adduction
B. Weakness on knee flexion and plantar flexion
C. Urinary incontinence
D. Foot drop
A. Weakness of hip flexion and thigh adduction
With a femoral nerve lesion, there would be sensory loss over the anterior thigh and weakness of hip flexion, but hip adduction would be preserved (obturator nerve).
Knee flexion is L5/S1
Ankle plantar flexion is S1/2
Ankle dorsiflexion (or lack of dorsiflexion with foot drop) = L4/5
Urinary incontinence = sacral nerve roots
- Repeat- Nerve supply to the upper eyelid-
A. ophthalmic branch of trigeminal and sympathetic from superior collicus ganglion
A. Ophthalmic branch of trigeminal and sympathetic from superior colliculus
- Repeat- Post LSCS foot drop-
A. Common peroneal nerve
??
- Repeat- Post op cervical- patient complaint arm weakness. Differentiate C8, T1 versus ulnar nerve injuries
A. Abductor pollicis brevis
Weakness of abductor policies braves would indicate a C8/T1 lesion rather than an ulnar nerve lesion, as this muscle is innervated by the median nerve (from C8/T1 roots)
- Repeat-Absent of Q waves-
A. Digitalis toxicity
A. Digitalis toxicity
- Repeat- What can prolong QT interval except-
A. Magnesium
A. Magnesium
used to treat torsades so definitely wouldn’t prolong it
- Repeat- Post carotidenderactomy in the ward, patient seizure. Noted patient operation side is more severe stenosis and post op difficult to control blood pressure. What would prevent seizure most
A. Add on antihypertensive
B. Start anti convulsant
A. Add antihypertensive
- Repeat- Post local anaesthetic block in difficult intubate patient- patient seizure. What would you give?
A. Midazolam 5mg
B. thiopentone
C. propofol
D. Suxamethonium
A. Midazolam 5 mg
- Repeat- Carcinoid patient intraop hypotension-
A. octreotide
A. Octreotide
- Repeat- Allergic question, which is true
A. Collect tryptase 8hours
B. RAST test most sensitive/ specific
C. Absent of trytase exclude anaphylactic
D. Skin and intradermal test- sensitivity, specificity
Collect tryptase immediately after resuscitation, at 1 hour, 4 hours and 24 hours. Normal result does not exclude anaphylaxis.
RAST is highly specific but has poor sensitivity.
Skin testing:
- Comprises skin prick testing and intradermal test
- Skin prick testing highly sensitive for NMBAs and gelatins, but insensitive for barbiturates, benzos and opioids
- Intradermal testing is indicated if there is clinical suspicion but negative SPT. The AAGBI suggests that IDT is more sensitive but less specific than SPT (some drugs, e.g. morphine, have a direct histamine-releasing action, and may lead to false positives with IDT)
- Skin prick testing is safe, but intradermal injections may rarely precipitate systemic reactions
- Repeat- What more likely to cause TRALI?
A. FFP
A. FFP
- New- After transfusion of 5 unit of FFP what is least likely to occur
A. Haemolytic reaction
B. Hypocalcaemia
C. Infection
D. Hyperkalaemia
D. Hyperkalaemia
- Severe asthmatic- tachycapnia, HR120, speaking in words, pH 7.45, pCO2 46, pO2 96, HCO3 24. Then given nebulised salbutamol continuously, nebulised ipratropium bromide, and hydrocortisone- The next step:
A. ?
B. ?
IV magnesium 50 mg/kg over 20 mins, followed by 30 mg/kg/h
- Repeat- Most common cause of awareness-
A. human error
A. Human error
- New- There is evidence to avoid BIS
C. Increased post-op mortality
Monitoring with BIS and absence of BIS values 5 min were associated
with improved survival and reduced morbidity in patients enrolled in the B-Aware Trial
- New- Most common cause of paediatric post anaesthesia cardiac arrest
A. Drug error
B. Respiratory cause
C. Multifactorial
D. Cardiac problem (?)
B. Respiratory cause
- New- Post cervical spine op, there is bulging noted under the incision site. Patient desaturated, combative, keep pulling off the oxygen facemask. Next course of action
A. Rapid sequence induction
B. Gas induction
C. Needle aspiration of the bulge at the neck
B. Gas induction
- New- What drug known to cause prolong QT and risk of Torsades de pointes
A. Metoclopramide
B. Droperidol
C. Tranexamic acid
B. Droperidol (probably only at high doses, e.g. 5-10 mg)
- New- During cardiac catheterisation (?) patient become BP 80/60, HR 110, CVP 16. What is the next most important investigation
A. Echocardiogram
B. CXR
C. Electrocardiogram
A. Echo - to exclude tamponade
- Intraop hyperfibrinolysis- how to diagnose (euglobulin lysis time NOT an option in the answer)
A. TEG
B. PT
C. APTT
A. TEG
- New- 75yo patient seen for femoral bypass surgery, no significant cardiac risk factor. He will be admitted 3 days prior to operation. You decided NOT to start on beta blocker and you are justified because:
A. There is increase mortality and morbidity
B. There is not enough time to safely start beta blocker
C. The beta blocker may make the patient claudication worst
D. ?
A. Increased mortality and morbidity
POISE - fewer MIs, but more stroke/death/bradycardia
- New- You see a man in his 60s in clinic 1 week prior to laparoscopic cholecystectomy. He has dilated cardiomyopathy with an ejection fraction of 30%, but does not get dyspnoeic with normal activities of daily living. What is the most appropriate management of his heart failure?
A. amiodarone 100mg bd B. digoxin 250mcg daily C. enalapril 2.5mg bd D. metoprolol 100mg bd E. diltiazem slow release 240mg daily
C. Enalapril 2.5 mg bd
Medical management
Systolic dysfunction is the major pathological component of dilated cardiomyopathy; medical therapy is as for chronic heart failure. A preoperative history of heart failure is an important risk factor for postoperative
cardiac complications, and risk increases when clinical signs are present before surgery. Optimal management of this heart failure
should occur before an operation.
The effect of medical therapy including angiotensin-converting enzyme inhibitors (ACEIs), angiotensin II inhibitors, and diuretics
should be determined. Other therapies include b-blockers, spironolactone, digoxin, biventricular pacing, and anticoagulants.
57.EZ80 Repeat- A line isolation monitor protects against microshock
A. only if the warning current is set at 10mA
B. only if the warning current is set at 30mA
C. under no circumstances
D. only if the equipment used is grounded
E. only if it monitors all the equipment in the region
C. Under no circumstances
- Repeat- Post pneumonectomy patient care- clamp chest tube with intermittent release
Clamp chest tube, release intermittently (for no longer than 5 mins)
59.RB53 Repeat- Post dural punture headache
A. 24hour bed rest
B. Prone position worst
C. Increase incidence with insertion of spinal
D. Hearing loss
D. May be associated with hearing loss
- New- Patient ingested 500mg/kg aspirin. In ICU, the most effective method to remove aspirin
A. IV fluid
B. Haemodialysis
C. Sodium bicarbonate infusion
D. Frusemide
B. Haemodialysis
- Repeat- The most effective method of decrease renal impairment in AAA surgery
Maintain adequate renal perfusion (keep patient euvolaemic, minimise clamp time)
62.SZ18 Repeat- What happen after infra-renal clamping in AAA- decrease renal blood flow
Decreased renal blood flow (even with infra-renal clamp)
- Repeat- The most effective method for cerebral protection in aortic arch aneurysm repair
A. Systemic hypothermia 20degrees B. Antegrade perfusion to carotid arteries C. Retrograde perfusion to jugular veins D. Thiopentone E. Steroid (?)
Combination of hypothermia to 20 degrees and antegrade perfusion to carotid arteries. Would probably say hypothermia if had to pick one.
- Repeat- CO2 used in pneumoperitoneum because-
A. less adverse effect in embolism
A. Less adverse effect in embolism
- Repeat- Most common signs of malignant hyperthermia-
A. tachycardia
A. Tachycardia
- New- The below would increase A-a oxygen gradient Except
A. Increase FIO2
B. Decrease FIO2
C. Decrease cardiac output
D. Increase shunt
B. Decreased FiO2
A-a gradient = PAo2- Pa02
= (Fi02 (Patm-PH2O) – PaCO2/0.8) – PaO2
The direct mathematical cause of a large value is that the blood has a low PO2, a low PCO2, or both
- Repeat- Stellate ganglion-
A. anterior to scalenus anterior
A. Anterior to scalenus anterior
- Repeat- Patient cough during interscalene block- insertion needle should be directed- posteriorly
Posteriorly
- New- Interscalene block after injection of 2ml bupivacaine- patient seizure. Most likely injected to
A. Dural cuff B. Vertebral arteries C. Internal carotid arteries D. Jugular veins E. Subarachnoid (?)
B. Vertebral arteries
Complications can occur due to the proximity of other anatomical structures. Blockade of the stellate ganglion can occur with resultant Horner’s syndrome (triad of myosis, ptosis, and anhidrosis). The phrenic nerve can be blocked with resultant dyspnea. This block is not done bilaterally to avoid accidental bilateral blockade of the phrenic nerves. The recurrent laryngeal nerve can be blocked with resultant hoarseness. Accidental injection into the vertebral artery can lead to rapid seizures and CNS toxicity. Accidental injection into the cervical epidural, subarachnoid, or subdural space can lead to epidural anesthesia or a high spinal. Advancement of the needle to far lateral can result in pneumothorax. Hematoma can occur from accidental puncture of the vertebral or subclavian artery or the subclavian vein. Direct nerve injury can occur due to needle trauma. It should be noted that most complications can be avoided by remaining “superficial”. 1-1.5 cm should be adequate to reach the brachial plexus and illicit parasthesia.
- New- Post intubation, you manual ventilate and noted patient high airway pressure. What would you do next
A. Open the APL valve
B. Auscultate the lung
C. Switch to ventilator
B. Auscultate the lung
- Repeat- Acromegaly- difficult intubation because-
A. Macroglossia
A. Macroglossia
72.->AZ84 New- Modified Cormack and Lehane grade - You cannot see beyond the epiglottis and there is a little space between the epiglottis and the posterior pharyngeal wall (? remembered as epiglottis touching posterior pharyngeal wall)
A. 2a B. 2b C. 3a D. 3b E. 4
C. 3a
3a - visualization of only the epiglottis, with space between epiglottis and posterior pharyngeal wall (‘bougieable’)
3b - visualization of only the epiglottis adherent to the posterior pharyngeal wall
- Repeat- Stellate ganglion block associated with all except- sweating of face
Sweating of face
Sympathoplegia causes Horner’s syndrome - ptosis, miosis, anhidrosis
- Repeat- Most safe side to insert subtenon block
A. Inferonasal B. Inferotemporal C. Medial D. Superonasal E. Superotemporal
B. Inferonasal
- Compared to retrobulbar block, peribulbar block is associated with
A. More bleeding
B. More risk to optic nerve
C. More akinetic eye
D. Less block to orbicularis oculi
D. Less block to orbicularis oculi
- Repeat- Diastolic dysfunction Not caused by
A. Adrenaline
B. Myocardial fibrosis
C. Aortic stenosis
D. Hypertension
A. Adrenaline
- Repeat- Reversed splitting of second heart sound associated with-
A. LBBB
A. LBBB
Talley:
A split second heart sound is normal, with A2 preceding P2
Increased normal splitting (wider on inspiration):
- RBBB
- Pulmonary stenosis
- VSD
- MR (earlier A2)
Fixed splitting:
- ASD
Reversed splitting (P2 first):
- LBBB
- AS (severe)
- Coarctation
- PDA (large)
- Lumbarsacral plexus does not supply:
A. Subcostal nerve B. Ilioinguinal n C. Iliohypogastric n D. Femoral n E. Genitofemoral n (?)
A. Subcostal nerve
The 12th thoracic (subcostal) nerve runs along the lower border of the 12th rib below the subcostal vessels, passes behind the lateral arcuate ligament to run in front of quadratus lumborum behind the kidney and colon. The nerve then passes between transversus abdominis and internal oblique and then has a course and distribution which are similar to the lower intercostal nerves. However, there is one point of difference: the lateral cutaneous branch of the 12th nerve descends without branching to supply the skin over the lateral aspect of the buttock (see Fig. 210). (Note that the subcostal nerve is the motor supply to the pyramidalis which lies within the lowest part of the rectus sheath.)
- Repeat- Relative humidity of fully saturated air at 20degree and 37 degrees-
A. 40%
A. 40%
Absolute humidity of fully saturated air at 20 degrees = 18 mg/L
Absolute humidity of fully saturated air at 37 degrees = 44 mg/L
Relative humidity 20 compared to 37 = 18/44, = 40%
80.IC90 Repeat- Trauma patient best indicator of good resuscitation (?)-
A. Lactate level
B. Heart rate
C. Blood pressure
D Acidosis (?)
A. Lactate level
- New- Pregnant patient seatbelt, driver- involved in car accident. Suddenly developed severe central chest pain, HR 110, BP 154/80, RR 26, Sat 100%. The most likely cause?
A. Sternal fracture B. Aortic dissection C. Pneumothorax D. Rib fracture E. Myocardial infarction
B. Aortic dissection
- New- ASD murmur heard at
A. ASD B. Tricuspid valve C. Pulmonary valve D. Mitral valve E. Aortic valve
C. Pulmonary valve
Because the pressure in the left atrium initially exceeds that in the right, the blood flows in a left to right shunt. This high volume of blood next passes into the right ventricle, and the ejection of the excess blood through a normal pulmonary valve produces a prominent mid-systolic flow murmur. This murmur is best heard over the “pulmonic area” of the chest, and may radiate into the back as with the murmur of pulmonary stenosis.
The most characteristic feature of an atrial septal defect is the fixed split S2. With an atrial septal defect, the right ventricle can be thought of as continuously overloaded because of the left to right shunt, producing a widely split S2.
- Repeat- Chronic alcohol is not associated with- nephritic syndrome
True
- Repeat- Blunt throat trauma- next step- nasoendoscopy
True
- Repeat- Rate of CO2 rise in apnoeic oxygenation
3-4 mmHg/min
- New- Apnoeic oxygenation in obese patient can be increased by
A. Sniffing position B. Prone C. Supine D. Lateral E. Head up
E. Head up
It is important to maintain a patent airway if a patient is apnoeic, even if no ventilation is being attempted.
Time to critical hypoxaemia for an apnoeic obese patient is extended by preoxygenation in a head-up position.
- Repeat- Long standing T6 paraplegia, except- flaccid paralysis
True
89. Repeat- Amniotic fluid embolism- cause of early death- Pulmonary hypertension
True
- New- Post partum sudden collapse, suspected amniotic fluid embolism. The consistent finding is:
A. Low C3, C4 B. Increase complement C. Increase tryptase D. Increase histamine? E. petechial rash
A. Low C3, C4
The suggestion that AFE may be related to anaphylaxis led Nishio and colleagues to measure tryptase concentrations. They reported concentrations of 67.2 ng ml−1 (normal
Which is supportive of a diagnosis of amniotic fluid embolism?
A. decreased C3 & C4 levels B. hyperfibrinogenaemia C. thrombocytosis D. markedly elevated tryptase E. ?
A. Decreased C3 and C4 levels
- Repeat- Earliest sign of hypocalcaemia- tingling
?
- Repeat- Nerve block anterior 2/3 of ear- mandibular
(Auricolotemporal branch of V3)
- Repeat- the no of people in the population with a predisposition of a disease- prevalence
True
- Repeat- sensitivity 90%, specificity 99%- False positive rate?
1%
- Repeat- Levosimendin-
A. alteration of calcium binding
True
- Repeat- In pregnancy dural sac end at – S2
True
- Repeat- ? Stable narrow complex tachycardia not responding to vagal maneuvres- adenosine
True
- Repeat- Which does not have pulmonary hypertension- Tetralogy of Fallot
True (pulmonary circulation is protected form high pulmonary pressures by the large non-restrictive VSD)
- Repeat- Fontan circulation-
A. short inspiratory time
B. prolong inspiratory time with positive pressure ventilation
A. Short inspiratory time
to minimise percentage of the respiratory cycle where venous return is compromised
- Repeat- SVRI = SVR x BSA
True
- New- Young pregnant patient with moderate mitral stenosis, normal LV function. The best delivery method
A. Epidural anaesthesia LSCS
B. Spinal with LSCS
C. Epidural analgesia and normal vaginal delivery
D. GA LSCS
E. Normal vaginal delivery with remifentanil PCA
C. Epidural analgesia and normal vaginal delivery
Indian J Anaesth. 2010 Sep-Oct; 54(5): 439–444.
Most reports have recommended vaginal delivery under epidural anaesthesia, unless obstetrically contraindicated. Caesarean section is indicated for obstetric reasons only.
Sartain J, O&G Magazine 2008 - Obstetric patients with rheumatic heart disease
Most patients can be delivered vaginally, though a low threshold for obstetric intervention is reasonable. Assisted delivery is recommended in higher-risk patients to avoid straining and to shorten the second stage. The major indications for caesarean delivery are obstetric. However, it may also be appropriate either to expedite delivery for a mother whose condition is deteriorating, or if there is a perceived need to deliver a precarious patient in daylight hours.
- Repeat- Tracheo-oesophageal fistula, correct statement
A. Usually does not need contrast for diagnosis B. Mainly left side
C. Associated with cardiac lesion 60% of the time
D. ..?.. 20%
A. Usually does not need contrast for diagnosis
Diagnosis of TOF (except H-type - 4% of cases) can be confirmed by placing a catheter in the esophagus and visualizing it in a blind upper esophageal pouch on chest radiograph.
Associated with cardiac lesion 25-35% of the time.
- Repeat- Pulmonary hypertension secondary to lung disease
A. Alpha agonist can be used B. Isoflurane will decrease the pulmonary pressure significantly C. N2O D. Ketamine E. Spontaneous breathing
A. Alpha agonist can be used
Effects of volatiles on pulmonary vasculature:
Miller - In contrast with their direct vasodilatory actions, halothane, isoflurane, enflurane, and desflurane attenuate KATP channel– and endothelin-mediated pulmonary vasodilation in chronically instrumented dogs.
- New- Neonate desaturate faster than adult at induction because
A. FRC decrease more
B. Faster onset of induction agents
C. More difficult to pre-oxygenate
C. More difficult to pre-oxygenate
They also have a more unstable FRC and higher VO2
- New- The cause of hypoxia in one lung ventilation
A. Blood flow through non ventilated lung
B. Impairment of hypoxic pulmonary vasoconstriction
C. Ventilation perfusion mismatched (?)
A. Blood flow through non-ventilated lung
www.thoracic-anaesthesia.com
The major cause of hypoxemia is the shunt of de-oxygenated blood through the non-ventilated lung. Factors which influence this shunt are hypoxic pulmonary vasoconstriction (HPV), gravity, the pressure differential between the thoraces and physical lung collapse.
- New- Suxamethonium dosage is higher in neonates compared to adults because:
A. Increased volume of distribution
B. Increased pseudocholinesterase activity
C. More receptors
D. Higher cardiac output (?)
E. Decreased sensitivity of nicotinic ACH receptors to suxamethonium
F. Faster diffusion away from neuromuscular junction
A. Increased volume of distribution
CEACCP 2007
The increased dose requirement of succinylcholine in younger patients is thought to result from its rapid distribution into an enlarged volume of extracellular fluid rather than an altered response to the action of the drug at postjunctional AChRs. The fact that expressing the dose of succinylcholine in mg m−2 abolishes the differences in dose requirements between the age groups supports this suggestion, as extracellular fluid volume and surface area bear a close relationship throughout life
The duration of action of these doses is the about the same or somewhat less than that of the standard 1 mg kg−1 intubating dose in adults (6–8 min).
- Repeat- Baby with trache-oesophageal fistula management- head up, drainage tube in oesophagus
True
- Repeat- C6/7- wrist flexion and extension
True
- Repeat- CTG for pregnant patient under anaesthesia for non-obstetric surgery- loss of beat to beat variability
?
- New- Indicates autonomic neuropathy EXCEPT:
A. Sinus arrhythmia
B. Gastroparesis
C. Postural hypotension
A. Sinus arrhythmia
- Repeat- Best indicator of return of function of laryngeal muscles is:
A. Sustained head lift 5 sec B. Sustained leg lift 5 sec C. TOF 0.9 D. DBS no fade E. Tetanus 50Hz
C. TOF ratio > 0.9
- Repeat- Torsades not useful-
A. Amiodarone
B. ?
A. Amiodarone
- New- A nulliparous woman in labour for 8 hours with epidural analgesia has a fever 37.6 degrees. The most likely reason for this is
A. altered thermoregulation B. chorioamnionitis C. urinary tract infection D. inflammatory response E. neuraxial infection
D. Inflammatory response
Although exactly how epidurals cause fever and how fever causes adverse neonatal outcomes remain unknown, inflammation may play a role.
Pediatrics. Published online January 30, 2012.
- Repeat- Supply of sensation above the vocal cord- external branch of superior laryngeal nerve
False - internal branch of the superior laryngeal nerve
- Repeat- Supply of carotid sinus- Glossopharyngeal nerve
True
- ? Post op pneumonectomy short of breath- investigation
? CXR
- Repeat- COAD on home oxygen, submandibular lymph nodes biopsy under LA. How to prevent airway fires- Bipolar instead of unipolar diathermy
True (also use lowest possible FiO2 and avoid ‘oxygen pockets’)
- Repeat- ? Respiratory function in quadriplegic- A. improve with chest wall spasticity
True
- Repeat- Pulsus paraxodus-
A. exaggeration of normal decrease in systolic pressure on inspiration
True
- New- Pre eclamptic patient post LSCS continue on Mg infusion in ICU. Found to be in respiratory depressed. Next management
A. Calcium gluconate
B. IV fluid
C. Frusemide
A. Calcium gluconate
- New- Periop clinic reviewing a patient with chronic/ end stage renal failure. Her calcium found to be low. He most certainly have
A. Primary hyperparathyroidism
B. Secondary hyperparathyroidism
C. Tertiary hyperparathyroidism
B. Secondary hyperparathyroidism
Decreased calcium levels (due to decreased renal production of vit D3) causes increased secretion of PTH
- Repeat- How to estimate weight in child-
A. (age+4) x2
True
- Repeat- Post trauma with liver laceratioNew- would not be operated
A. Haemodynamically stable
True
- Repeat- Compare to Mallampati Score, thyromental distance is- less sensitive more specific
True
- New- Compare to Myasthenia gravis, which symptoms is more likely to be Eaton Lambert syndrome?
Eaton Lambert - weakness improves with use
- Repeat- Acute malignant hyperthermia- muscle rigidity 75% in cases
True
- Repeat- Medial peribulbar block advance no further past the equator than-
A. 10mm
True
- Repeat- What proportion of the population are heterozygous for pseudocholinesterase deficiency, i.e. have a dibucaine number 30-70?
A. 0.04% B. 0.4% C. 4% D. 14% E. 40%
C. 4%
- Repeat- Systematic review weakness is
Weaknesses of systematic review:
- Publication bias
- Heterogeneity
- Inclusion of outdated studies
- Repeat- Commonest presenting features of anaphylaxis- hypotension
True
Cardiovascular signs - 78.6%
Cutaneous signs - 66.4%
Bronchospasm - 39.9%
- New - When stimulating the ulnar nerve with a nerve stimulator, which muscle do you see twitch?
A. opponens abducens B. abductor pollicis brevis C. adductor pollicis D. extensor pollicis E. flexor pollicis brevis
C. Adductor pollicis
- New - When intubating over a bougie / awake fibreoptic, which direction do you rotate the tube to stop it catching on structures in the glottis
A. no change from normal B. 90 degrees clockwise C. 90 degrees counterclockwise D. 180 degrees E. try either direction
C. 90 degrees counterclockwise
- New - Advantages of off-pump CABG over on-pump CABG
A. decreased transfusion rate B. decreased mortality C. decreased cost D. increased graft patency E. less cognitive impairment F. less stroke
?A. Decreased transfusion rate
(medscape)
Two large-scale studies—first results from the German Off-Pump CABG in Elderly Trial (GOPCABE) and 12-month results from the CORONARY study—showed similar findings with nonsignificant differences between the two procedures at 30 days and 12 months. A third, much smaller, single-center Czech study—PRAGUE-6—did show a benefit of off-pump, but with only 200 patients, it is difficult to draw conclusions from these data.
Fewer off-pump patients received blood transfusions (56% vs 63%).
Anaesthesia and Intensive Care Medicine (2015) - Anaesthesia for off-pump coronary artery bypass grafting surgery:
Based on the Cochrane systematic review and meta-analyses - Compared to off-pump, on-pump CABG surgery has lower mortality. The incidence of AF is significantly lower in off- than on-pump CABG surgery, but the heterogeneity is high so limiting interpretation of the finding. All other important adverse outcomes from CABG surgery (including MI, stroke, renal insufficiency, coronary reintervention) are not significantly different if undertaken on- or off-pump.
- New - After coronary artery bypass graft surgery, the FRC is
A. increased 40% B. increased 20% C. unchanged D. decreased 20% E. decreased 40%
D. Decreased 20%
- New - A 60 year old man 24 hours post CABG is confused, oliguric, with BP 80/40, pulse 120. The most appropriate and useful investigation is
A. electrocardiogram B. echocardiogram C. chest x-ray D. arterial blood gas E. coronary angiogram
B. Echocardiogram
will give an indication of LV and RV function, valvular function, and will help exclude tamponade
- Iron deficiency
A. decreased serum ferritin, increased serum iron
B. decreased serum ferritin, absence of bone marrow iron
C. decreased serum ferritin, normal serum iron
D. increased serum ferritin, decreased serum iron
E. increased serum ferritin, decreased total iron binding capacity
Decreased serum ferritin, decreased serum iron, increased transferrin/TIBC, decreased transferrin saturation.
Interpretation of serum iron: considerable variation occurs within a day in individuals and assessment of serum iron alone provides little helpful clinical information.
- New - Why should NSAIDs be avoided in pregnant women >30 weeks gestation?
A. cause neonatal acute renal failure B. increased antepartum haemorrhage C. increased rate of pre-eclampsia D. cause closure of the fetal ductus arteriosus E. increase preterm labour
D. Cause closure of metal ductus arteriosus
- A 62 year old man has chronic renal failure. You notice his total serum calcium is 2.05 mmol/L. This is because he has
A. high serum vitamin D B. hypoparathyroidism C. primary hyperparathyroidism D. secondary hyperparathyroidism E. tertiary hyperparathyroidism
Low serum vitamin D
Chronic kidney failure is the most common cause of secondary hyperparathyroidism. Failing kidneys do not convert enough vitamin D to its active form, and they do not adequately excrete phosphate. When this happens, insoluble calcium phosphate forms in the body and removes calcium from the circulation. Both processes lead to hypocalcemia and hence secondary hyperparathyroidism. Secondary hyperparathyroidism can also result from malabsorption (chronic pancreatitis, small bowel disease, malabsorption-dependent bariatric surgery) in that the fat-soluble vitamin D can not get reabsorbed. This leads to hypocalcemia and a subsequent increase in parathyroid hormone secretion in an attempt to increase the serum calcium levels.
