2014.1 Flashcards

Question

25. (NEW) An 80yo man is having a transuretheral bladder resection, the surgeon is using diathermy close to the lateral bladder wall which results in patient thigh adduction. The nerve involved is: ``` A. Inferior gluteal B. Obturator C. Pudendal D. Scaitic E. Superior gluteal ```

Answer 1

B. Obturator Obturator - adductor muscles of the hip Inferior gluteal - gluteus maximus Pudendal - sensation to genitals + anal canal, pelvic floor muscles, sphincters Sciatic - posterior thigh and leg

Answer 2

E. Ordinal

Answer 3

B. serum ferritin Iron deficiency anaemia: ``` MCV Low Ferritin Low Serum Iron Low Transferrin Low Total Iron Binding Capacity High ``` Ferritin intracellular protein - stores and releases iron

Answer 4

B. Organophosphate overdose nAchR Down-regulation: - Myasthenia Gravis - Anticholinesterase poisoning - Organophosphate poisoning nAchR Up-Regulation: - Spinal cord injury - Stroke - Burns - Prolonged immobility - Prolonged exposure to NMD - Multiple Sclerosis - Guillain Barre Miller page 900 (table 29-1)

Answer 5

B. Emphysema Increased DLCO (120-140% predicted): - Asthma - Pulmonary haemorrhage - Polycythaemia - Left to Right shunt Rate of Diffusion = A (C1-C2)/D

Answer 6

E. Muscle biopsy woman If you want the best test to exclude MH for this patient, you have to muscle biopsy her. In real life though, a better approach might be to muscle biopsy her father (and not expose her to the risks of GA, including fetal loss). If he is negative, she will almost certainly be negative (unless there is MH on her mother's side).

Answer 7

D. 12 French size is the circumference in mm Diameter of suction catheter must be = 4 Circ = 2 x pi x r, = pi x diam, = 3.14 x 4, = 12

Answer 8

A. 10 mmHg Miller says >10 CEACCP - Laparascopic abdominal surgery (2004) 20 mmHg - decreased VR, decreased CO, decreased MAP.

Answer 9

C. Fondaparinux Synthetic Xa inhibitor, chemically related to low molecular weight heparins (Wiki)

Answer 10

E. 35 mg/kg CEACCP - Novel techniques of local anaesthetic infiltration (2011) Another method to increase the effectiveness and duration of local anaesthetics at the site of infiltration is a technique known as tumescent analgesia. A high volume but low concentration of a local anaesthetic (lidocaine 0.05 – 0.1%) together with dilute epi- nephrine is infiltrated at the site of incision, causing the tissues to become firm. Analgesia and anaesthesia are thought to be pro- longed by the increase in hydrostatic pressure in the tumescent tissues causing blood vessel compression and therefore reduction in local anaesthetic removal from the site of injection. The local anaesthetic effect is also prolonged by both the presence of epi- nephrine, which causes vasoconstriction, and sequestration of the local anaesthetic in fat due to its lipophilicity. The high hydrostatic pressure within the tissues is also thought to be responsible for the delayed systemic absorption and hence delayed and reduced peak plasma concentrations of local anaesthetic, despite the very large doses being used. Doses as high as 22–57 mg kg21 of lidocaine7 – 9 have been used in the context of tumescent techniques and have been shown to have safe plasma concentration profiles.

Answer 11

C. Adenosine

Answer 12

A. Codeine Mothers may be ultra-rapid metabolisers, leading to higher than normal morphine concentrations (which then appear in breast milk). Another version of this question has pethidine as an option - pethidine is also bad, as neonates excrete norpethidine slowly and so are more vulnerable to toxicity.

Answer 13

E. Crack onski Apple juice = clear fluid

Answer 14

C. FFP Unacceptable: - Pre-op autologous blood donation - Transfusion of the 'primary components' of blood, namely whole blood, packed red cells, plasma, platelets and white cells. May be acceptable (not banned by the church, up to the patient): - Fractions of all the primary components (incl. albumin, cry, clotting factors, immunoglobulins, recombinant human EPO, interferon, interleukins, haemoglobin-based blood substitutes or oxygen carriers).

Answer 15

D. 64 mmHg Bernoulli principle - an increase in the flow velocity of an ideal fluid will be accompanied by a simultaneous reduction in its pressure Simplified equation: P1 - P2 = 4V^2

Answer 16

B. Bland-Altman plot CEACCP - Minimally invasive cardiac output monitors 2011 'The accuracy of these devices has been researched in a number of different settings. The most consistently used method of assessing their accuracy has been to measure their mean bias in comparison with another method of cardiac output measurement using the Bland-Altman method.'

Answer 17

B. ST elevation in II and aVF indicates inferior infarct. Elevation of both CVP and PCWP suggests hypokinesis of both RV and LV.

Answer 18

C. Platelets | see video on lifeinthefastlane, TEG

Answer 19

B. 2 mg/h Using the conversion ratios from the CJA article below, 100 mg oral methadone --> 2.78 mg/h IV morphine. 2 mg/h may be underdosing, but is the more conservative option, out of 2 mg/h and 4 mg/h. Review article: perioperative pain management of patients on methadone (CJA 2005) When converting methadone to other opioids in the postoperative period, two issues need to be con- sidered. The first is the incomplete tolerance between opioids, the second is that the conversion ratio between opioids is not bi-directional. Conversion of methadone to other opioids appears to be more problematic and is associated with worsening pain and dysphoria. Since there is no uniformly accepted conversion ratio for substituting methadone with another opioid, a conservative approach should be adopted. In the authors’ experience, a conservative methadone to morphine ratio (4 or 5:1) is used. For instance, a patient previously on 30 mg methadone per day will be equivalent to roughly 120 mg oral morphine per day. Factoring the oral bioavailability (33%) and a 50% cross-tolerance, the hourly morphine requirement is approximately 1 mg·hr–1 intravenously. On the first day, the maximum background infusion rate of morphine should not exceed 3 mg·hr–1 due to the highly unpredictable nature of the equianalgesic conversion. A PCA device is used separate from the iv infusion if there is an underlying pain condition. After the patient is loaded with adequate amounts of mor- phine, reassessments of pain, sedation and respiratory rate are made at least once every two hours as the patient approaches a steady state with the morphine and as the methadone continues to clear from their system. The ward nurses and clinicians looking after the patient are informed of the patient’s unique requirements.

Answer 20

C. Maximal distance from radiation source Intensity of radiation = 1/distance sqaured At least 3 feet from source 6 feet or air provides 9 inches of concrete or 2.5mm lead CEACCP - Radiation safety for anaesthetists (2012)

Answer 21

B. 10 mg/kg 5-10 mg/kg (MIMS) 10 mg/kg (RCH)

Answer 22

? It will always deactivate the defib, but the response of the pacemaker is less predictable. BJA 2011 - Perioperative management of patients with cardiac implantable electronic devices Even when the ICD has been deactivated by a magnet, pacemaker function of an ICD is not affected. Thus, in a patient with an ICD, the magnet response will always be to deactivate the ICD and the pacing behaviour will not change to an asynchronous mode.

Answer 23

B Brugada syndrome is due to a mutation in the cardiac sodium channel gene. Clinical Criteria: Documented ventricular fibrillation (VF) or polymorphic ventricular tachycardia (VT). Family history of sudden cardiac death at

Answer 24

C. Low CVP ( 5 mmHg significantly increases bleeding. However, the risks of maintaining a low CVP include cardiovascular instability and air embolism, but the theoretical risk of increasing postoperative renal dysfunction does not appear to be clinically important. Some patients require a CVP of > 5 mm Hg for cardiovascular stability, and in these patients an individually tailored compromise needs to be achieved.

Answer 25

B. 10 mmol Pontine Myelinolysis Rapid correction of sodium in hyponatremia would cause the extracellular fluid to be relatively hypertonic. Free water would then move out of the brain cells to decrease this relative hypertonicity. This leads to a central pontine myelinolysis, manifesting as the paralysis. The brain appears to shrink. The demyelination of the axons (nerve fibers in the brain) damages them.

Answer 26

D. 27 cm Lee's Synopsis of Anaesthesia: Central Incisors to Carina Male 27cm/Female 23cm 15cm from teeth to cords, 12 cm from cords to carina

Answer 27

B. Posterior cricoarytenoid ``` Cricothyroid muscles - tense cords Posterior cricoarytenoids - open glottis Lateral cricoarytenoids - close glottis Interarytenoids - close glottis Thyroarytenoids - relax cords Vocalis - relax cords ```

Answer 28

E. TMJ rigidity Skin and soft connective tissue abnormalities, contracture deformities, micrognathia, cervical spine and jaw stiffness, congenital heart disease (10%), hypermetabolic response is probably NOT MH. Difficult airway and venous access, sensitive to thiopental. Oxford handbook page 298

Answer 29

D. Sodium nitroprusside Cardiac bosses all agree. No great evidence. Rationale would be that you want to decrease afterload (to reduce regurgitant fraction, and also to decrease shear stress on the aorta) but you don't want to decrease HR (fast forward for regurgitant lesions), and you definitely don't want to decrease inotropy in someone with cardiogenic pulmonary oedema - i.e. not beta blockers.

Answer 30

D. Triscupid regurgitation

Answer 31

A. Creatinine Med Calc Model End Stage Liver Disease Disease severity scoring system applied to ADULT livers to improve organ allocation in transplants MELD + MELD-Na * 40 or more — 71.3% mortality * 30–39 — 52.6% mortality * 20–29 — 19.6% mortality * 10–19 — 6.0% mortality *

Answer 32

E. 10 mins Australian Resuscitation Council Target sats - ------ 60-70 @1min - ------ 65-85 @2min - ------ 70-90 @3min - ------ 75-90 @4min - ------ 80-90 @5min - ------ 85-90 @10min

Answer 33

B. 65 mmHg 13 cmH20 = 10 mmHg --> MAP at level of external auditory meatus = 80-10 = 70. CPP = MAP - CVP = 70-5 = 65. Arterial pressure transducer should be at the level of the tragus. Kirkman MA, BJA 2014: 'Intracranial pressure monitoring, cerebral perfusion pressure estimation, and ICP/CPP-guided therapy: a standard of care or optional extra after brain injury?'

Answer 34

C. 4% Peck & Hill page 183

Answer 35

E. Valsalva manoeuvre

Answer 36

D. IV magnesium CEACCP - Phaeochromocytoma (2003) Such agents include boluses of phentolamine 1–5 mg and labetalol 5–10 mg or sodium nitroprusside, GTN and nicardipine infusions. Sodium nitroprusside has a rapid onset and offset of action; it is not associated with toxicity when used in recommended doses. Nicardipine is a calcium chan- nel blocker which has been used as an infusion for fast titration of blood pressure. The use of isoflurane as an antihypertensive agent is a practical alternative. Magnesium sulphate infusions have recently been described (inhibits catecholamine release, exerts a direct vasodilator effect and reduces α-receptor sensitivity).

Answer 37

C. Oral hygiene BJA education - Ventilator-associated pneumonia (2015) The main pathogenic factor in the development of VAP is biofilm formation within the tracheal tube (TT) and microaspiration of secretions. The presence of a TT interferes with the normal protective upper airway reflexes and prevents effective coughing. The oropharynx becomes rapidly colonized by aerobic gram-negative bacteria after illness, antibiotic administration, and hospital admission. These contaminated secretions pool above the TT cuff and slowly gain access to the lower airway through a fold in the wall of the cuff. A bacterial biofilm, which is impervious to antibiotics, gradually forms on the inner surface of the tube and serves as a nidus for infection. This pathogen-rich biofilm is pushed into the distal airways by ventilator cycling and in the setting of immunosuppression associated with critical illness causes pneumonia. The longer the duration of ventilation, the greater the risk of developing VAP. Nursing patients in a supine position increases the risk of microaspiration and enteral feeding via a nasogastric tube increases the risk of aspiration of gastric contents. It follows that attempts to prevent VAP would focus on measures to reduce biofilm formation and micro aspiration. ... In 2007, the Department of Health launched ‘Saving Lives; reducing infection, delivering clean and safe care’, a campaign to prevent and control hospital-acquired infection. This included ‘High Impact Intervention No 5—Care bundle for ventilated patients’, the aim of which was to reduce VAP. The original document consisted of daily sedation holds, bed head elevation, gastric ulcer prophylaxis, and oral care. It was updated in 2010 to include oral hygiene with adequate strength anti-septics, subglottic aspiration, and TT cuff pressure monitoring in addition to the initial four care interventions.

Answer 38

Hard to say without knowing urine sodium and osmolality. ``` Psychogenic Polydipsia: Increased H20 intake due to dry mouth (caused by drugs) Hyponatraemia (serum) Hyposmolar (serum) Polyuria Dilute Urine (urine osmolality Normovolaemic ``` ``` CDI (Inadequate ADH Secretion): Hypernatraemia Hyperosmolar Polyuria Dilute Urine (urine osmolality Responsive to ADH ``` ``` NDI (Kidney resistant to ADH): Normal to high Na Normal to high osmolality Polyuria Dilute urine (urine osmolality Non-responsive to ADH ``` Cerebral Salt Wasting: Excessive Na secretion by Kidneys due to brain trauma/tumour) Hyponatraemia Hyposmolar Polyuria Elevated urinary Na (urine osmolality>plasma osmolality) Hypovolaemic ``` SIADH (Inappropriate ADH secretion): Hyponatraemia Hyposmolar Oliguria Elevated urinary Na (urine osmolality>plasma osmolality) Normal to expanded volume ```

Answer 39

D. Brisk walking on level ground (6 km/h) Light housework, climbing a flight of stairs, and brisk walking on level ground are all clustered around 4 METs in ascending order (probably better to be conservative and investigate further if a patient can do light housework but not walk briskly/climb stairs, esp. as patients often overestimate what they can do).

Answer 40

C. Inotropic action CEACCP - Anaesthesia for laparoscopic surgery 2011

Answer 41

C. 0.9% saline Use isotonic fluid with brain injury - risk of cerebral oedema with hypotonic fluid. If Na > 142, consider 0.45% saline. Ref: Ch 99 Oh's Intensive Care Manual 2009

Answer 42

A. CT head (exclude SAH)

Answer 43

A. Increased respiratory rate C3-C5 partial phrenic nerve weakness/paralysis of diaphragm. Reduced VC to 10-30%, weak cough, 80% require ventilation w/in 48hrs. No intercostal function. Diaphragmatic breathing w collapse of chest initially (until intercostal paralysis develops in few days). Ref: CEACCP July 2013 initial mx of acute spinal cord injury

Answer 44

A. aortic stenosis

Answer 45

D. Nasopharyngoscopy by an ENT surgeon

Answer 46

E. Prothrombinex and vitamin K Tran et al, MJA 2013 - 'An update of consensus guidelines for warfarin reversal': For immediate reversal, prothrombin complex concentrates (PCC) are preferred over fresh frozen plasma (FFP). Prothrombinex-VF is the only PCC routinely used for warfarin reversal in Australia and New Zealand. It contains factors II, IX, X and low levels of factor VII. FFP is not routinely needed in combination with Prothrombinex-VF. FFP can be used when Prothrombinex-VF is unavailable. Vitamin K1 is essential for sustaining the reversal achieved by PCC or FFP.

Answer 47

Level 2 check (before each list): - Service label - High pressure system - Low pressure system (check for leaks, check vaporisers, oxygen failure warning system, flow controls) - Ventilator (incl. disconnection and high pressure alarm) - Emergency ventilation system - Scavenging - IV and LA administration devices (power supply/battery life, occlusion pressure alarms) - Other apparatus (airway equipment, suction, gas analysis devices, monitoring equipment, IV infusion devices, humidifiers, filters) - Final check (make sure vaporisers are turned off and breathing system is purged with air or oxygen) - Documentation

Answer 48

B and E correct. As soon as possible after initial resuscitation, then at 1-2 hours, then any time after 24 hours (to get baseline level). Australian and New Zealand Anaesthetic Allergy group say check at 1, 4 and > 24 hours

Answer 49

D. Use bipolar diathermy CEACCP - Anaesthesia and deep brain stimulation (2009) Surgical diathermy (electrocautery) can damage the DBS leads and can also cause temporary suppression of the neurostimulator, reprogramming of the neurostimulator, or both, but is not contraindicated. When diathermy is necessary, the following precautions should be followed: use bipolar diathermy where possible; if unipolar diathermy is necessary: use only a low-voltage mode; use the lowest possible power setting; keep the current path (ground plate) as far from the neurostimulator and leads as possible (usually located in the subclavicular space with the leads running up the neck, posterior to the ear, to the crown of the head). After using diathermy, confirm that the neurostimulator is functioning as intended. External defibrillation If a patient requires external defibrillation, the first consideration should obviously be the patient's survival. Safety for the use of external defibrillators on patients with a DBS has not been established. External defibrillation may damage a neurostimulator. If external defibrillation is necessary, the following precautions should be followed: position defibrillation paddles as far from the neurostimulator as possible; position defibrillation paddles perpendicular to the implanted neurostimulator-lead system; use the lowest clinically appropriate energy output. Confirm that the DBS is functioning correctly after any external defibrillation.

Answer 50

??? Posterior leg sensation - branches of sciatic nerve (common peroneal and sural nerves) + saphenous nerve (continuation of femoral) Lateral thigh sensation - lat cutaneous nerve of thigh (L2, 3) Lateral foot sensation - sural nerve (L4 to S4), superficial peroneal nerve (L4 to S1) Knee flexion - hamstrings (biceps femoris, semimembranosus, semitendinosus) - L5/S1, and to a lesser extent gracilis, sartorius, popliteus, gastrocnemius and plantaris.

Answer 51

Bisphosphonates reduce the resorption of bone.

Answer 52

A and C. Combination of low sats and fever in the setting of recent laparotomy suggest atelectasis +/- LRTI.

Answer 53

? E. EEG. Angiography would be a better answer if this was an option. CEACCP - Diagnosis of death (2011): Ancillary tests: The UK Code recognizes that there may be circumstances where clinicians feel unable to confirm death using neurological criteria based on clinical assessment alone. Such circumstances include: - episodes where a comprehensive neurological examination cannot be carried out, for example, after severe maxillofacial trauma; - when the influence of residual sedation cannot be excluded; - high cervical cord injury where a distinction between central apnoea and the effects of cervical cord injury cannot be distinguished. Provision is made in the guidelines for a number of confirmatory tests to be performed in order to confirm the clinical suspicion of brainstem death. These tests are generally aimed at confirming the presence or absence of cerebral blood flow or cerebral function. EEG is the most popular and best validated ancillary test worldwide, but is of little value in cases of drug intoxication since sedative drugs suppress neuronal and therefore EEG activity. Confirmation of the absence of cerebral blood flow by angiography establishes the irreversibility of coma in such circumstances, but may be more difficult to organize. CT angiography may be more readily available, but has yet to be properly validated. Expert advice should be sought from a local neuroscience unit if necessary.

Answer 54

D. Same partial pressure, 1/3 the concentration | partial pressure is what influences pharmacodynamics so the same concentration can be dialled

Answer 55

C. Electrical burns (assuming there is still some contact of the neutral plate with the patient). CEACCP - Injury during anaesthesia (2006) Monopolar surgical diathermy uses high frequency alternating current which can generate local temperatures of up to 1000°C. Current passes from the active electrode, held by the surgeon (high current density), through the body, returning via the patient plate electrode (low current density) to the generator. If the return pathway is interrupted by incorrect placement of the patient plate electrode, any points of contact between metal and skin (e.g. ECG electrodes) will provide an alternate return pathway resulting in burns. The patient plate electrode should have good contact with dry, shaved skin. The contact surface area should be at least 70 cm2 and should be away from bony prominences, scar tissue and metal implants. Incorrect placement of the patient plate electrode is the most common cause of accidental diathermy burns. However, careless surgical technique can also cause local burns. The local concentration of high density currents will cause skin burns if the active electrode touches skin. Any pools of spirit-based skin preparation fluids can heat up and even ignite during diathermy use. Bipolar diathermy, in which current passes only between the two points of the diathermy forceps, is inherently safer. It should be used on appendage surgery (e.g. digits and penis); monopolar diathermy can lead to large currents persisting beyond the operative site, causing tissue burns.

Answer 56

C. Enalapril ACE inhibitors cause fetal malformations if given 2nd & 3rd trimesters (Ref: Williams Obstetrics, 23rd Ed, p989)

Answer 57

D. Weakness in the abductor pollicis brevis (innervated by median nerve) "The ulnar nerve innervates all intrinsic hand muscles, except the abductor and flexor pollicis brevis, opponens pollicis, and lateral two lumbricals, which are innervated by C8 and T1 via the median nerve. By examining these five muscles, one can clinically differentiate cubital tunnel syndrome from C8-T1 radiculopathies." Ref: Global Spine J. 2014 Feb;4(1):1-6. Differentiating c8-t1 radiculopathy from ulnar neuropathy: a survey of 24 spine surgeons.

Answer 58

A. Medical practitioner with a skilled assistant that is separate from the assistant to the proceduralist PS09 p8: "Intravenous anaesthetic agents such as propofol must only be used by a second medical or dental practitioner trained in their use because of the risk of unintentional loss of consciousness. These agents must not be administered by the proceduralist." But also see Scenario 2 of Appendix 1 of PS09: the assistant can be shared between both ends for conscious sedation in ASA 1-2 patients only. Therefore best answer would be a medical or dental practitioner trained in its use with an assistant who may be shared with the procedurals.

Answer 59

? A best answer Better answer would be closing volume encroaches on FRC. Neonatal oxygen consumption (per kg) is 2-3 times that of the adult. Unfortunately, their closing volume (the volume at which alveoli begin to close, producing a shunt) is within the range of normal tidal volumes, thus small changes in lung volume (ex. laryngospasm) can lead to shunting and desaturations. Desaturation in the infant can be EXTREMELY rapid. N.B.: alveolar closing can occur even while intubated. If a neonate drops its lung volume enough to lead to alveolar closing, it may appear that the infant has been extubated or main-stemmed, because resistance to ventilation will be so high. In fact, the infant remains intubated – the only successful treatment is often either lidocaine (do not exceed 1.5 mg/kg) or paralysis. Infant tidal volume is actually the same as adults (7 cc/kg),it is their respiratory rate that makes up for a high VO2. As RR is 30-50, infant induction and recovery are much more rapid than with adults. Infants also fatigue more quickly than adults because they have a lower fraction of Type 1 muscle in their diaphragm, and their chest walls, which are highly compliant, are less efficient. (from openanaesthesia.org)

Answer 60

Best answer E, although WPW is not an arrhythmia, it is a syndrome. Patients with WPW develop two different supra ventricular tachyarrhythmias: AF and re-entrant tachycardia. Management depends on which arrhythmia is present. For AF, use beta blockers or amiodarone. For re-entrant tachycardia, use adenosine. Adenosine preferentially blocks the AV node, therefore it should not be used in AF. Verapamil and digoxin are also contraindicated as they both preferentially block AV conduction, thereby increasing conduction through the accessory pathway. (The Clinical Anaesthesia Viva Book). -------------------------------------- Oxford Emergencies in Anaesthesia pg 506 - Adenosine slows conduction through the AV node, therefore is useful in terminating SVTs including WPW. May differentiate between SVT and VT. ---------------------------------------- CEACCP - Supraventricular tachyarrhythmias and their management in the perioperative period (2014): The term Wolff–Parkinson–White (WPW) syndrome is a specific form of AVRT and is applied to the patient with both preexcitation manifest on an ECG and symptomatic arrhythmias (orthodromic or antidromic AVRT) involving the accessory pathway. The term WPW pattern is applied to the patient with preexcitation manifest on an ECG in the absence of symptomatic arrhythmias. The classic ECG pattern of preexcitation in sinus rhythm has two major features: A short PR interval (

Answer 61

A. Continue surgery with propofol TIVA

Answer 62

B. Indirect ophthalmoscopy Royal college of anaesthetists and opthalmologists consensus document http://www.rcoa.ac.uk/system/files/LA-Ophthalmic-surgery-2012.pdf Document page 26 "Indirect ophthalmoscopy should be performed to look for evidence of central retinal artery perfusion compromise"

Answer 63

E. Tissue hypoperfusion Acidosis, hypothermia and trauma induced coagulopathy are the lethal triad of major haemorrhage following trauma but Acute Trauma Coagulopathy is independent of resuscitation efforts CEACCP - Management of haemorrhage in major trauma (2014) - “Trauma patients were coagulopathic on arrival at the emergency department (ED) and the incidence of coagulopathy increased with severity of injury independent of the volume of pre-hospital resuscitation fluid. Those who arrived coagulopathic had an increased mortality compared with non-coagulopathic patients. This coagulopathy is termed acute trauma coagulopathy (ATC) and is another mechanism of coagulopathy under the umbrella term of TIC. The mechanisms of ATC are yet unproven but appear to be related to tissue hypoperfusion, leading to up-regulation of the vascular endothelium and subsequent alterations in coagulation pathways. This coincides with massive activation of coagulation with consumption of clotting factors, noticeably factor V and fibrinogen, activation of the Protein C pathway, and increased fibrinolysis”

Answer 64

C. 360 mL Parkland formula = 4ml/kg x %BSA with half in first 8 hours (CSL) from time of burn 4 x 20 x 15 = 1200ml / 2 = 600mL in 8 hours, but only 2hrs remaining so 300ml/hr Mainentance IVF = 4ml/kg/hr for 1st 10kg, 2mL/kg/hr for next 10kg, 1ml/kg/hr for remaining kg (N/2 + 5%) 40 + 20 = 60ml/hr Total = 360ml/hr

Answer 65

B. Check neuromuscular monitor (hopefully you are checking the TOF count rather than the TOF ratio!) (from forum on gasexchange.com) The 2 numbers provided by the Entropy monitor are the State Entropy (SE) and Response Entropy (RE). SE is calculated over frequencies from 0.8 to 32 Hz while RE is calculated over frequencies from 0.8 to 47 Hz. The significance of this difference is that frequencies below 32 Hz are dominated by the EEG signal while EMG signal from facial muscles dominate above 32 Hz. In theory, SE reflects the cortical state of the patient (and hence depth of anaesthesia) while RE additionally incorporates facial muscle EMG signals. The idea is that if there is a significant difference between SE and RE, this reflects inadequate analgesia (which increases facial muscle tone – apparently). Just like with BIS, the manufacturer recommends increasing depth of anaesthesia if the SE is above 60 as this represents a possibility of awareness. Unlike BIS, they also recommend giving additional analgesia if the RE is more than 5-10 above the SE. There are several papers comparing BIS and Entropy and the short answer seems to be that the BIS and the SE correlate reasonably well with only occasional disagreement. None of these trials are large enough to demonstrate a difference in the ability of either monitor to detect awareness (and quite frankly, the jury is still out on whether BIS is useful for this – awareness is just too rare an event to study easily). I am not aware of any trials demonstrating the usefulness of the RE for guiding analgesic administration. reference: Bein B. Entropy. Best Pract Res Clin Anaesthesiol. 2006 Mar;20(1):101-9

Answer 66

B. Transient bradycardia followed by tachycardia and hypertension

Answer 67

B. Haemodialysis Ingestion of > 500 mg/kg is a potentially lethal dose, according to the risk assessment table in the Toxicology Handbook. (from the Toxicology Handbook): Urinary alkalinisation is indicated in patients with symptomatic salicylate poisoning. Haemodialysis effectively removes salicylate but is rarely required if early decontamination and urinary alkalinisation are implemented. Consider HDx in the following circumstances: - Urinary alkalinisation not feasible - Serum salicylate levels rising to >4.4 mmol/L (>60 mg/dL) despite decontamination and urinary alkalinisation - Severe toxicity as evidenced by altered mental status, acidaemia or renal failure - Very high serum salicylate levels: - Acute poisoning >7.2 mmol/L (>100 mg/dL) - Chronic poisoning >4.4 mmol/L (>60 mg/dL) - The threshold to dialyse is lower in the elderly (>60 mg/dL)

Answer 68

A. Metaraminol bolus Cardioplegia induces transient hypotension secondary to K-related vasodilation, best managed with alpha agonist. Miller 7th ed pg 1916 - "Initiation of CPB is often associated with a period of hypotension, which can be managed with the administration of an alpha-agonist into the venous reservoir of the ECC circuit. Any hypotension and hypertension that occur despite adequate flow and SvO2 can be treated by adjusting the patient’s SVR with vasoconstrictors or vasodilators” Should be on full flows so D is incorrect

Answer 69

B. IV access and cross-match

Answer 70

C. Pulse contour analysis and thermodilution (thermodilution for calibration)

Answer 71

B. Less constipation Targin product information, although there is less potential for abuse given antagonist activity when administered IV

Answer 72

C. HBsAb HBsAb +ve = immunity via immunisation or exposure HBsAg +ve = active infection HBcAb = suggests previous exposure

Answer 73

? C. Prolonged prothrombin time Mansour 1997 Abdominal operations in patients with cirrhosis: Still a major surgical challenge - “Three factors that contributed to increased morbidity and mortality in their patients: a prolongation ofthe prothrombin time longer than 2.5 seconds, the presence of ascites, and the need for an emergency operation. In our group of patients, we found that the presence of ascites, encephalopathy, prolonged prothrombin time, and elevated blood urea nitrogen level as independent variables were predictors of mortality." Also, Child Pugh score predicts surgical complications (including haemorrhage), and includes PT/INR but not platelet count.

Answer 74

C. IV fluids

Answer 75

E. 4.8L CSL BJA 2001 - A burn greater than 15% of the total body surface in adults and 10% in children requires intravenous fluid resuscitation. The Parkland formula, developed in 1971 and now widely used in the UK, predicts a total fluid requirement of 3-4 ml/kg1 x (% burn). The resulting volume of fluid is given over the 24 h from the time of the burn (not from the time of presentation) with half the volume given in the first 8 h and the remaining half in the subsequent 16 h. Lactated Ringer’s solution is the fluid of choice. Parkland formula = 4 x 30 x 80 = 9600mL = 4.8L in first 8hrs. Some debate over whether to use 4 mL/kg or 3mL/kg (modified Parkland) however, question specifically asks for Parkland. Hilton, Peter John, and Martin Hepp. "The Immediate Care of the Burned Patient." BJA CEPD Reviews 1, no. 4 (2001): 113-116. Hettiaratchy, Shehan, and Remo Papini. "Initial Management of a Major Burn: IIassessment and Resuscitation." Bmj 329, no. 7457 (2004): 101-103.

Answer 76

B. T12 CEACCP - Paravertebral block (2010) - "The thoracic paravertebral space begins at T1 and extends caudally to terminate at T12"

Answer 77

C. Posterior

Answer 78

A. Hyperthermia

Answer 79

??? This is probably an RSI (for appendicectomy) so you need to secure the airway to protect against aspiration. I would check that I could ventilate by hand (if not --> LMA as rescue), then try a size 4.0 tube (B). This child obviously has abnormal subglottic anatomy and will need endoscopic examination at some point, but the immediate priority would be to secure the airway and complete the surgery.

Answer 80

E. Right heart failure

Answer 81

D. 45 mins (from BOC healthcare website) Size C cylinder lasts: - 81 mins at 6 L/min - 49 mins at 10 L/min - 32 mins at 15 L/min

Answer 82

E. Thrown away

Answer 83

D. 4% CHA2DS2-VAS score: - HTN (1) - T2DM (1) - Female (1) - Previous CVA (2) = 5 2-3 points = moderate risk: 2.2-3.2% risk of stroke per year without anticoagulation 4-5 points = high risk: 4.0-6.7% per year 6 or more points = very high risk: 9.8% per year

Answer 84

E. Paternalism

Answer 85

B. Decreased FRC

Answer 86

A. Deflate cuff, insert one-way valve, insert fenestrated piece See lifeinthefastlane - Fenestrated tracheostomy tube, for diagrams: Components: - comes with an outer cannula, inner cannula, obturator, cuff and plug - outer cannula = keeps stoma from closing - inner cannula = can be removed for cleaning - obturator is used when putting the outer cannula into the stoma - fenestrations are holes on the posterior part of the tube above the cuff - with the cuff up and a non-fenestrated inner cannula there is no air leak Vocalisation: - need to remove inner cannula or use a fenestrated inner cannula - need to occlude the outer cannula opening with a plug, speaking valve or finger - on expiration with the cuff deflated, air passes upwards through the cords through the fenestration and around the tube enabling vocalisation

Answer 87

C. Departmental director sole author

Answer 88

D. LA toxicity. C also possible (and is more common) but more likely to be tachycardic than bradycardic. Incidence of anaphylaxis - 1:5000 Incidence of LAST - 1:12,000 (when ultrasound is used) Would be unusual to see bradycardia with anaphylaxis but a sudden increase in venous capacitance could cause a Bezold-Jarisch reflex-induced bradycardia (especially when compounded by a sudden change in position). LA toxicity - CVS effects (from the Toxicology Handbook): bradycardia, hypotension, atrial and ventricular dysrhythmias, cardiovascular collapse and asystole.