2012.1 Flashcards
- A patient undergoing liver surgery has a venous air embolism, what is the most appropriate position to place them in:
a. Reverse trendelenburg, right side up
b. Reverse trendelenburg left side up
c. Reverse trendelenburg, neutral
d. Trendelenburg right side up
e. Trendeleburg left side up
A. Reverse Trendelenburg, right side up
CEACCP - Gas embolism in anaesthesia (2002)
Treatment goals:
- Resuscitation
- Prevent further air entry
- Reduce the size of the embolism
- Overcome any mechanical obstruction caused by the embolism
Preventing further air entry:
- Immediately eliminate high pressure gas source if in use (e.g. pneumoperitoneum)
- The surgeon should flood the operative site with saline
- Venous pressure at the procedural site should be elevated by: (i) positioning it below the level of the right atrium (if possible); (ii) IV volume loading; and (iii) increasing intrathoracic pressure with a Valsalva manoeuvre, thus reducing venous return.
Reducing the size of the embolus:
- Discontinue N2O if in use
- 100% O2 (+/- hyperbaric)
- Aspirate from RA lumen of CVC/PAC
Overcoming the mechanical obstruction
- The left lateral decubitus position described by Durant may help overcome the airlock within the RV by positioning it superior to the RVOT. The Trendelenburg position has a similar effect
- Which of the following is NOT a side effect of cyclosporine
a. Alopecia
b. Hypertension
c. Renal impairment
d. Gum hyperplasia
A. Alopecia
- What is the half life of clopidogrel?
a. 6 hours
b. 14 hours
c. 24 hours
d. 7 days
A. 6 hours
although not clinically relevant given irreversible effect on platelet function
- When administering adrenaline and atropine via ETT dose compared with IV should be
a. Same dose
b. Double
c. Quadruple
d. Six times
D. Six times
ARC 2010
endotracheal administration of some medications is possible, although the absorption is variable and plasma concentrations are substantially lower than those achieved when the same drug is given by the intravenous route (increase in dose 3-10 times may be required).
Neonatal formulary
Tracheal administration is of doubtful efficacy and should only be tried if IV access is unavailable - a higher dose (50 to 100 microgram/kg) is suggested.
EV14 What splitting ratio gives a 3% concentration of isoflurane?
a. 1/5
b. 1/9
c. 1/13
d. 1/20
e. 1/23
C. 1/13
- What transfusion related complication is the commonest cause of mortality
a. Bacterial infection
b. TRALI
c. ABO incompatibility
d. ?
e.
B. TRALI
Blood journal:
Today, the leading causes of allogeneic blood transfusion (ABT)–related mortality in the United States—in the order of reported number of deaths—are transfusion-related acute lung injury (TRALI), ABO and non-ABO hemolytic transfusion reactions (HTRs), and transfusion-associated sepsis (TAS).
- Which of the following is not included in the CHADS2 AF thromboembolic risk scoring system
a. Age
b. Gender
c. Diabetes
d. Heart failure
e. Previous TIA
B. Gender
- What is the ratio of breaths to compressions in neonatal resuscitation
a. 1:3
b. 1:5
c. 2:15
d. 2:30
A. 1:3
- What is the innervation of the hard palate
a. Greater palatine and nasopalatine nerves
A. Greater palatine and nasopalatine nerves
- Which of the following is suggesting of an inhaled foreign body in a child on chest x ray
a. Foreign body visible in front of airway
b. Hyper-expanded hemithorax
c. Collapse
B. Hyper-expanded hemithorax
Sims and Johnson:
Air trapping with hyperinflation might be seen on expiratory film due to a ‘ball valve effect’, but while this is classical, it is not common.
- What is the distance from the lips to the carina in an 70kg adult male in cm
a. 21
b. 23
c. 25
d. 27
e. 29
D. 27 cm
Tube tip should be 5 cm above carina. Average distance at the lips in an adult male is 22 cm.
- What colour is the label for subcutaneously administered drugs
a. Pink
b. Yellow
c. Brown
d. Red
e. Blue
C. Brown
- What is the maximum volume of air (in mL) that should be used to inflate a 5 LMA classic cuff
a. 15
b. 20
c. 25
d. 40
e. 45
D. 40 mL
Size 3 - 20 mL
Size 4 - 30 mL
Size 5 - 40 mL
- Where should the tip of an IABP lie
a. 2cm distal to the left subclavian
b. 2 cm proximal to the left subclavian
c. 2cm proximal to the renal artery
d. 2 cm distal to the renal artery
A. 2 cm distal to the left subclavian artery
- A 60kg female is given 50 mg of rocuronium, she is unable to be intubated or ventilated, what dose of sugamadex is required to reverse the rocuronium
a. 240
b. 800
c. 960
C. 960 mg (16 mg/kg)
IC67 In a penetrating chest injury what part of the heart is most likely to be injured
a. Left ventricle
b. Right ventricle
c. Right coronary artery
d. Right atrium
e. Sinus node
B. Right ventricle
- What is the maximum recommended dose of Intralipid in local anesthetic toxicity (ml/kg)
a. 6
b. 8
c. 10
d. 12
e. 14
D. 12 mL/kg
- What is a contraindication to an IABP?
A. Aortic regurgitation
B. Aortic stenosis
A. Aortic regurgitation
- An infant is born with meconium stained liquor and is apnoeic and floppy… your first step should be
a. Stimulate and dry
b. Positive pressure ventilation
c. Suction the trachea
C. Suction the trachea
suction from mouth and pharynx then CPAP, or intubate then suction from trachea
- Central sensitization occurs due to
a. Primary events mediated by the NMDA receptor
b. Alterations in gene expression
c. Increased magnesium
B. Alterations in gene expression
Central sensitization represents an enhancement in the function of neurons and circuits in nociceptive pathways caused by increases in membrane excitability and synaptic efficacy as well as to reduced inhibition and is a manifestation of the remarkable plasticity of the somatosensory nervous system in response to activity, inflammation, and neural injury. The net effect of central sensitization is to recruit previously subthreshold synaptic inputs to nociceptive neurons, generating an increased or augmented action potential output: a state of facilitation, potentiation, augmentation, or amplification. Central sensitization is responsible for many of the temporal, spatial, and threshold changes in pain sensibility in acute and chronic clinical pain settings and exemplifies the fundamental contribution of the central nervous system to the generation of pain hypersensitivity. Because central sensitization results from changes in the properties of neurons in the central nervous system, the pain is no longer coupled, as acute nociceptive pain is, to the presence, intensity, or duration of noxious peripheral stimuli. Instead, central sensitization produces pain hypersensitivity by changing the sensory response elicited by normal inputs, including those that usually evoke innocuous sensations.
- What volume of FFP is required to increase fibrinogen level by 1g/L (I think it was FFP or did it say cryoprecipitate?)
a. 10-15ml/kg
b. 30ml/kg
B. 30 mL/kg (for FFP)
- An epidural in a healthy individual causes all EXCEPT
a. Raised Co2
b. Bradycardia
c. Vasodilation
d. Dyspnea
A. Raised CO2
- The Revised Trauma Score includes GCS, Blood pressure and what other parameter?
a. HR
b. Saturation
c. Respiratory rate
d. Urine output
C. Respiratory rate
The Revised Trauma Score is made up of a three categories: Glasgow Coma Scale, Systolic blood pressure, and respiratory rate. The score range is 0-12. In START triage, a patient with an RTS score of 12 is labeled delayed, 11 is urgent, and 10-3 is immediate. Those who have an RTS below 3 are declared dead and should not receive certain care because they are highly unlikely to survive without a significant amount of resources.[citation needed]
- Autologous transfusion results in less
a. Cost
b. Blood waste
c. Incompatible transfusion
d. Unrequired transfusion
C. Incompatible transfusion
CEACCP - Autologous blood transfusion (2006)
Controversies:
The evidence-base proving that cell salvage saves allogenic blood transfusion and is cost-effective is limited. A recent Cochrane review of 49 randomized controlled trials over a 24-yr period showed that the use of cell salvage reduced the rate of exposure to allogenic blood transfusion by 40%. It did not adversely affect mortality or complications such as bleeding, infection, myocardial infarction, thrombosis and stroke. The review concluded that better quality research specifically designed to assess the cost-effectiveness of cell salvage across a range of surgical procedures is required.
In surgery for malignancy there is concern because of potential systemic dissemination of tumour cells from salvaged blood. Malignant cells may be removed by filtration and further reductions achieved by irradiation. This remains an area of much research. The use of cell salvage during caesarean section remains controversial because of concerns regarding amniotic fluid embolism and rhesus sensitisation resulting from reinfusion of foetal cells in salvaged blood. There are a small number of studies indicating that it can be used without these complications, but larger safety studies are required.
- After an infusion of normal saline causing isovolumetric haemodilution what occurs?
a. Increased cardiac output
b. Increase oxygen extraction
c. Capillary vasodilatation
A. Increased cardiac output
IC97 Bleeding in trauma has been shown to be reduced by
A. Tranexamic acid B. Recombinant factor VIIa C. DDAVP D. Prothrombinex E. Aprotinin
A. Tranexamic acid
CRASH-2 trial (Lancet 2010):
Tranexamic acid safely reduced the risk of death in bleeding trauma patients in this study. On the basis of these results, tranexamic acid should be considered for use in bleeding trauma patients.
- The time constant of the lung is calculated by
a. Compliance x resistance
b. Compliance plus resistance
c. Compliance /resistance
d. Resistance/compliance
A. Compliance x resistance
- The commonest post operative complication in a patient with a # NOF is
a. UTI
b. Pneumonia
c. Delirium
d. Myocardial infarction
C. Delirium
- In an infant, the intercristine line is at the level of
a. L1-L2
b. L2-L3
c. L3-L4
d. L4-L5
e. L5-S1
E. L5-S1
Intercristal line is the imaginary line drawn between the two superior iliac crests
CEACCP - Local and regional anaesthesia in infants (2004):
The intercristal line is at L5/S1 (L4 in adults), the termination of the spinal cord is at L3 (L1/2 in adults) and the termination of the dura is at S3/4 (S2 in adults).
- Which of the following is a contra-indication to a left DLT
a. Left pneumonectomy
b. Tumour in the left main stem bronchus
B. Tumour in the left main stem bronchus
- What is the commonest symptomatic cardiac condition in pregnancy
a. Mitral stenosis
b. Aortic stenosis
c. Eisenmengers
d. Tetralogy of fallot
e. ?
A. Mitral stenosis
- What is the ratio of MAC awake:MAC of sevoflurance
a. 0.2
b. 0.34
c. 0.5
B. 0.34
- Pain from the uterus during labour is transmitted via
a. From the anterior roots of T10-L1
b. Parasympathetic fibres
c. The inferior hypogastric plexus
d. Via grey rami communicantes
C. The inferior hypogastric plexus
NEW: The features of Pierre Robin sequence include cleft palate, micrognathia and:
A. Glossoptosis
B. Craniosynostosis
C. Macroglossia
D. Microstomia
A. Glossoptosis (posterior displacement of the tongue)
- A size C oxygen cylinder that reads 5000kpa contains approximately how many litres of oxygen
a. 100
b. 150
c. 200
d. 350
e. 600
B. 150 L
P1V1 = P2V2
Full size C is 440 L at 13,700 kPa
If pressure is 5000 kPa, volume of O2 is ([5000/13,700] x 440), = 160 L
- A patient having a craniotomy has the CVP/arterial transducers at the level of the right atrium. The head is 13cm above the level of the heart. If the MAP is 80mmHg and the CVP is 5mmHg what is the cerebral perfusion pressure in mmHg
a. 60
b. 62
c. 65
d. 70
e. 75
C. 65 mmHg
CPP = MAP (at level of tragus) - CVP
= (80-10) - 5
= 65
(13 cm H2O = 10 mmHg)
- After a procedure with an LMA in situ a patient complains of loss of sensation to the anterior part of the tongue. What nerve is likely damaged?
a. Facial
b. Lingual
c. Greater palatine
d. Glossopharyngeal
B. Lingual nerve (branch of trigeminal - supplies somatic afferent to anterior 2/3 of tongue)
(Glossopharyngeal supplies posterior 1/3 of tongue)
- What statistical test would be best to evaluate the effects of ? 2 drugs in patients at ? 3 different points in time
a. ANOVA
b. Mantel Hantzel
c. Kruskall Wallis
d. Students t test
A. (Repeated measures) ANOVA
When to use a Repeated Measures ANOVA:
We can analysis data using a repeated measures ANOVA for two types of study design. Studies that investigate either (1) changes in mean scores over three or more time points, or (2) differences in mean scores under three or more different conditions. For example, for (1), you might be investigating the effect of a 6-month exercise training programme on blood pressure and want to measure blood pressure at 3 separate time points (pre-, midway and post-exercise intervention), which would allow you to develop a time-course for any exercise effect. For (2), you might get the same subjects to eat different types of cake (chocolate, caramel and lemon) and rate each one for taste, rather than having different people flavour each different cake. The important point with these two study designs is that the same people are being measured more than once on the same dependent variable (i.e., why it is called repeated measures).
In repeated measures ANOVA, the independent variable has categories called levels or related groups. Where measurements are repeated over time, such as when measuring changes in blood pressure due to an exercise-training programme, the independent variable is time. Each level (or related group) is a specific time point. Hence, for the exercise-training study, there would be three time points and each time-point is a level of the independent variable
Performing lots of 2 sample t-tests on the serial measurements between different time or dosage points and/or between different groups at each time point and/or between each time point and baseline is statistically unsound, rendering the p-values invalid unless adjusted for multiple testing. Even if multiple testing were not invalid, such an approach is not designed to answer any useful research question.
- A man is working with electrical appliances at home with a residual current device. If he touches the active and the neutral (was it neutral or earth) wire he will suffer
a. A microshock
b. A macroshock
c. Nothing happens because the fuse blows
d. The RCD will protect him from macroshock
D. The RCD will protect him from macroshock
Wiki
A residual-current device (RCD), or residual-current circuit breaker (RCCB) or residual twin-direct current couplet (R2D2), is an electrical wiring device that disconnects a circuit whenever it detects that the electric current is not balanced between the energized conductor and the return neutral conductor. Such an imbalance may indicate current leakage through the body of a person who is grounded and accidentally touching the energized part of the circuit. A lethal shock can result from these conditions. RCCBs are designed to disconnect quickly enough to prevent injury caused by such shocks. They are not intended to provide protection against overcurrent (overload) or all short-circuit conditions.
- An infant with failure to thrive is noted to have an apical systolic murmur weak pulses, with the femoral felt most easily. They most likely have
a. Patent ductus arteriosis
b. Ventriculoseptal defect
???
PDA - differential cyanosis, i.e. cyanosis of the lower extremities but not of the upper body.
VSD - Pansystolic murmur along lower left sternal border (depending upon the size of the defect) +/- palpable thrill (palpable turbulence of blood flow). Heart sounds are normal. Larger VSDs may cause a parasternal heave, a displaced apex beat (the palpable heartbeat moves laterally over time, as the heart enlarges). An infant with a large VSD will fail to thrive and become sweaty and tachypnoeic (breathe faster) with feeds.
- Which radiological finding is most consistent with atlantoaxial instability in a patient with rheumatoid arthritis
a. A 9mm gap between the anterior arch of C1 and the odontoid peg
A. A 9 mm gap between the anterior arch of C1 and the odontoid peg
- What is the most accurate method of determining fetal heart rate in a neonate
a. Palpation of an umbilical vein pulse
b. Auscultation with a stethoscope
c. Palpation of femoral pulse
d. Pulse oximetry
B. Auscultation with a stethoscope
- In acute liver injury what causes the highest risk of bleeding
a. Thrombocytopenia
b. Coagulopathy
c. Portal hypertension
d. Platelet dysfunction
B. Coagulopathy
- A patient in recovery post op total hip replacement develops crushing central chest pain, ECG shows ST segment elevation (NB- no BP etc given, beta blockade was not an option). The most appropriate action is to give
a. Aspirin
b. IV GTN
c. IV heparin
d. Calcium channel blocker
e. T/L
A. Aspirin
AHA/ACC guidelines
Therapy with aspirin, a beta blocker, and an ACE inhibitor, particularly for patients with low ejection fractions or anterior infarctions, may be beneficial, whether or not the patients are rapidly taken to the catheterization laboratory.
- Stellate ganglion blockade causes
a. Conjunctival injection
b. Dry eyes
c. Decreased axillary sweating
All of the above (conjunctival injection, dry eyes and decreased axillary sweating)
Horners syndrome is caused by sympathetic blockade and produces the following features on the ipsilateral side of the face:
- drooping of the eyelid (ptosis)
- constriction of the pupil (miosis)
- decreased sweating of the face on the same side (anhydrosis)
- redness of the conjunctiva of the eye
- impression of an apparently sunken eyeball (enophthalmos)
This may also lead to increased amplitude of accommodation, paradoxical contralateral eyelid retraction, transient decrease in intraocular pressure and changes in tear viscosity. Although it may be considered a complication, the presence of Horner’s syndrome is a confirmatory sign of successful stellate ganglion blockade.
- Features of ventricular tachycardia DO NOT include
a. Absence of p waves
b. Monophasic waves
c. Prominent R wave in V1
d. A-V dissociation
A. Absence of P waves
ECG features of VT - LITFL
- Very broad complexes (>160ms).
- Absence of typical RBBB or LBBB morphology.
- Extreme axis deviation (“northwest axis”) — QRS is positive in aVR and negative in I + aVF.
- AV dissociation (P and QRS complexes at different rates).
- Capture beats — occur when the sinoatrial node transiently ‘captures’ the ventricles, in the midst of AV dissociation, to produce a QRS complex of normal duration.
- Fusion beats — occur when a sinus and ventricular beat coincide to produce a hybrid complex of intermediate morphology.
- Positive or negative concordance throughout the chest leads, i.e. leads V1-6 show entirely positive (R) or entirely negative (QS) complexes, with no RS complexes seen.
- Brugada’s sign – The distance from the onset of the QRS complex to the nadir of the S-wave is > 100ms.
- Josephson’s sign – Notching near the nadir of the S-wave.
- RSR’ complexes with a taller “left rabbit ear”. This is the most specific finding in favour of VT. This is in contrast to RBBB, where the right rabbit ear is taller.
- An inpatient becomes hyponatraemic 48 hours post op and has a seizure. The most appropriate treatment is
a. Fluid restriction
b. Normal saline ?ml/hr
c. Hypertonic saline
d. Salt tablets
C. Hypertonic saline
- A patient has a laparotomy for an acute abdomen, nothing in found intra-operatively. ABG reveals
?
??
- A child with 10% dehydration is likely to have
a. Bradycardia
b. Rapid deep breathing
B. Rapid deep breathing
- REPEAT Sep 11 When stimulating the ulnar nerve with a nerve stimulator, which muscle do you see twitch?
A. opponens abducens B. abductor pollicis brevis C. adductor pollicis D. extensor pollicis E. flexor pollicis brevis
C. Adductor pollicis
ST39 When analyising a study containing a control and two test groups, the best statistical method to use is….
A. Analysis of variance B. Chi squared with Bonnferoni correction C. ? D. E.
A. Analysis of variance
- REPEAT Sep 2011 20. Really poor copy of a CXR. Looked to me like a haemopneumothorax (you could very faintly see a collapsed lung outline, there was no ‘meniscus’ to the fluid shadow) but other people thought it was an artefact. It did indeed look like a pneumothorax and then someone had put a piece of metal up to simulate a haemothorax, because on the lateral you couldn’t see past the ribs (ie the film was cut off at the rib borders). It was terrible quality (too black, and hard to discern tissue from air), and an inadequate film (cut off apices, and poor lateral view as before)
A: Pneumothorax B: Haemopneumothorax C: D: E: Artefact.
???
