2018.2 Flashcards
You’re performing an infraclavicular block (Identify part of the brachial plexus)
A) Lateral Cord
B) Posterior Trunk
C) Posterior Cord
With Cephalad on left of screen, caudal to right
9 o’clock position = lateral cord
7 o’clock position = posterior cord
5 o’clock position = medial cord
Pec major and pec minor on top
Diabetes Insipidus treatment - ??
- Desmopressin (preferred option) ADH Analogue
- Other drugs: carbamazepine, NSAIDS, thiazides
- Low solute diet
Cause of D.I
- decreased release of ADH
- sodium may be normal or high Normal
Coiling aneurysm. Surgeons tells you there is a rupture. What is an inappropriate immediate management? o decrease BP o give protamine o Urgent transfer to theatre o Continue coiling o Mild hyperventilation
Urgent transfer to theatre
Flow volume loop
We got fixed upper airway obstruction
Expiratory flat = intrathoracic problem
Inspiratory flat = extrathoracic problem
Fixed will be small and flat both sides
Preferred gas for IABP inflation
- air
- CO2
- Oxygen
- Nitrogen
- Helium
Helium
Severe spinal cord injury. How long before reflexes return?
50 -150 days (roughly, this was the longest)
Patient complains of pain after attempted IV induction. You realise cannula is intra-arterial. What is NOT indicated?
Use heparin Maybe LA CCB anti thromboxane eg aspirin ilprost Papervine Sympatholysis
Patient with FiO2 of 1.0, at sea level. PaO2 is 260mmHg, PaCO2 is 40mmHg, respiratory quotient is 0.8. What is the approximate A- gradient?
- 220mmHg
- 400mmHg
- 663mmHg
400
PAO2 - PaO2
Normal is 5-10mmhg
Lower 3rd molar incision/extraction. Which nerve should be blocked/Which nerve injured?
- Inferior alveolar
- Mental
- Lingual
- Superior petrosal
Inferior alveolar nerve
Medical cylinder – grey shoulders, white body. What gas does it contain?
- nitrogen
- air
- oxygen
- carbon dioxide
- helium
Co2 1,6
Oxygen white 2,5
N2O blue white 3,5
Air black and white 1,5
Helium brown 4,6
5 yo child in cardiorespiratory arrest. Intubated. Rate of cardiac compressions
a) 80-100
b) 100-120
c) 120-140
d) 140-150
e) 150-160
B - 100-120
Rate of Compressions
Rescuers should perform chest compressions for all ages at a rate of 100 to 120 compressions per minute (almost 2 compressions/second).2 [CoSTR 2015, strong recommendation, very- low-quality evidence]
There is some evidence that compressions rates less than 100 or greater than 140 compressions per minute are associated with lower rates of survival.2,4,5 [CoSTR 2015, Values and Preferences Statement]
MRSA nose swab. TKR. What reduces joint infections (Alternative - Which intervention would NOT help reduce infection?
- Mupiricin nose ointment for ?2 weeks or 5 days
- Chlorhex (2 or 4%) body wash for 5 days
- Vancomycin 15mg/kg 1 hour pre-tourniquet
- Teicoplainin 800mg 30 mins pre-tourniquet
Mupiricin ointment for 5 days
Drug of choice and very effective
Patient on Dabigatran. Normal renal function. How long after last dose can you do a neuraxial block without checking direct thrombin time?
- 24 hours
- 48 hours
- 72 hours
- 96 hours
?72
ASRA guidelines say 120 hours (5d) prior to neuroaxial but If normal renal function and no other risk factors for bleeding then more graded approach
72 hours if Cr cL 80ml/min
96 hours if CrCl 50-80 ml/min
120 hours if CrCl 30-50 ml/min
Smallest size bronchoscope/ fibreoptic scope that will fit with Aintree catheter?
? 3.7mm
Aintree catheter has 4.7mm internal diameter.
Use smallest tube that will fit over aintree: size 6.5 or 7
When to medically intervene in seizure post ECT? a) 30s b) 60s c) 90s d) 120s e) 150s
120s
Patient for eye block. Average axial length as determined by ultrasound? A) 20mm B) 23 C) 26 D) 29 E) 32 BJA
The globe lies anteriorly in the bony cavity. It is approximately spherical in shape, with an average axial length (distance between cornea and retinal pigment epithelium) of 25 mm. Myopic eyes with an axial length of >26 mm are at increased risk of perforation during retrobulbar or peribulbar injection. This risk is increased by the associated likelihood of staphylomas (scleral outpouches), which typically lie posteriorly or inferiorly.
Tenon’s fascia surrounds the eyeball. It arises from the corneo-scleral junction (the limbus), fuses posteriorly with the dural sheath of the optic nerve and separates the globe from the intra- and extra-conal fat which surrounds the ocular muscles. The extra-ocular muscles and nerves penetrate this fascia. Tenon’s fascia creates a potential space around the eye into which local anaesthetic can be placed, allowing diffusion of drugs to nerves that innervate the eye and its muscles as they pass through the fascia.
https://bjaed.org/article/S2058-5349(17)30060-4/fulltext
Other sources say 23mm average
MELD Score: Creatinine, INR and?
Bilirubin
inr
Bilirubin
Creatinine
New MELD add
Na
Dialysis twice in past week
Anterior mediastinal mass in a child. 70% tracheal compression near carina. Inhalational induction and child desaturates to 70%. What do you do?
A) Turn prone
B) Intubate and spontaneous ventilation
C) Positive pressure ventilation
D) Intubate and positive pressure ventilation
E) Sternotomy
Turn prone
During (2012-2014) - what was the commonest cause of anaesthetic death?
(Possibly the same questions?)
NAP 4 – most common cause of direct anaesthetic death?
- Aspiration
- Myocardial infarction
- Inability to oxygenate and ventilate
- Stroke
- Anaphylaxis
Anaphylaxis was the single commonest cause of death in anaesthesia events (NAP 4)
Treatment for dyspnoea and chest pain in HOCM?
- GTN
- Metoprolol
- Morphine
- Salbutamol
Metoprolol
Aortic pressure wave with LV pressure wave. What is this trace consistent with?
- aortic dissection
- aortic coarctation
- AR
- AS
- MS
AS
LV pressure much much higher than aortic pressure
Airway device in this picture? A. Arndt bronchial blocker B. Cohen bronchial blocker – was this one C. Microlaryngoscopy tube D. Hunsaker tube E. Parker Flex tip ETT
Picture of Cohen tube
https://www.cookmedical.com/critical-care/endobronchial-blockers-for-one-lung-ventilation/
Patient on prophylactic heparin post op. Calf swelling 7 days post surgery (DVT)
- Heparin infusion
- Warfarin
- Enoxaparin
- Fondaparinux
- Bivalirudin
F- Fondaparinux or lepirudin ( I think it’s lepirudin because it’s mentioned in bja article and Fonda isn’t)
From bja 2003
Danaparoid: long half life, not great in pt high risk of bleeding or needing OT. Doesn’t affect INR So can be given with warfarin. Also not licensed.
Ilprost: short half life, good for csurg and in Icu pt on dialysis
Lepirudan, argatroban- irreversible thrombin inhibitors: good. Can be monitored with aptt, etc
Bivalirudin: not licensed in 2003 when article written
HIT should also be suspected if the platelet count decreases by 30–50% after 5 days of heparin treatment The occurrence of thromboembolic complications during heparin therapy is another strong marker of HIT.
2Regardless of the degree of thrombocytopenia, the predominant clinical feature is thrombosis and not bleeding.
HIT/HITT (heparin‐induced thrombocytopenia and heparin‐induced thrombocytopenia with thrombosis syndrome) is an immune‐mediated adverse reaction to heparin that is often underdiagnosed and can result in venous and arterial thrombosis.
The alternative name of HITT, white clot syndrome, refers to the gross pathology of the clots. The platelet–platelet adhesion without erythrocyte involvement gives a classic appearance of a white clot.
Patients with HITT may suffer from venous thrombosis, most often deep venous thrombosis (DVT), which can be extensive and complicated by pulmonary embolism. Adrenal vein thrombosis and cerebral sinus thrombosis are other unusual venous thromboses that complicate HIT. Arterial thromboses associated with HITT may result in ischaemic limb damage that often requires amputation. Myocardial infarction, ischaemic stroke and end‐organ thromboses, such as mesenteric, renal, brachial, splenic and hepatic arterial thromboses, can also occur.
HIT develops in 3% of patients treated with unfractioned heparin for more than 4 days.
7Without treatment, mortality in HIT patients with new thromboembolic complications is about 20–30%, with equal morbidity caused by arterial and venous thrombosis.
Thrombin inhibitors currently available for the management of HIT and HITT are:
(i) lepirudin (Refludan®);
(ii) argatroban (Argatroban®, Novastan®);
(iii) hirulog and bivalirudin (Angiomax®) and
(iv) desirudin (ReVase®).
Also
Warfarin - don’t start for HIT as will be procoagulant first and risk of limb ischaemia
In patients with remote HIT who require venous thromboembolism treatment or prophylaxis, the panel recommends administration of a non-heparin anticoagulant (e.g. apixaban, dabigatran, edoxaban, fondaparinux, rivaroxaban, vitamin K antagonist) rather than UFH or LMWH. (Strong recommendation, very low certainty in the evidence)
Factor that is first to fall in coagulopthy?
a) I
b) II
c) V
d) VII
e) VIII
? I
Patient for elective LSCS. Has amoxicillin allergy, limited to rash. What do you give?
- Cephazolin
- Ceftriaxone
- Clindamycin
Cephazolin
It’s just a rash?
Cell salvage – leukodepletion filters do not protect against?
a) Vernix b) Alpha fetoprotein c) Foetal RBC d) Amniotic fluid e) Foetal squamous cell
Fetal RBC
Leukocyte filters Remove products such as fetal squamous cells lipids, amniotic fluid and vernix to produce levels are the lower than or similar to those seen in maternal central blood samples at the time of uteroplacental separation. studies have shown that products that can cause amniotic fluid syndrome can be completely illuminated by using a liquid depletion filter
Can’t stop fetal RBC because can’t tell the difference, allo -immunization may occur if antigen incompatibility A
40 yo M following MVA. He opens his eyes to pain, speaking incomprehensible words and flexes appropriately to pain. What is his GCS? A) 5 B) 6 C) 7 D) 8 E) 9 F) 10
E4V5M6
Eyes Opens spontaneously 4 Opens to voice 3 Opens to pain 2 No eye opening 1
Voice Normal 5 Confused 4 Inappropriate 3 Incomprehensible 2 No verbal response 1
Motor Obeys commands 6 Purposeful response to pain 5 Withdraws from pain 4 Flexes to pain (decorticate posture) 3 Extends to pain (Decerebrate posture) 2 No motor response 1
Capnography trace (answer was leak in sample line)
Triangle shaped co2 trace
What is first line treatment for trigeminal neuralgia?
- carbamazepine
- lamotrigine
Carbamazepine
From BJA education Trigeminal neuralgia “Many patients respond to pharmacological therapy and carbamazepine remains the first-line drug.”
SGLT2 – what can you use to exclude ketoacidosis?
a) BSL
b) Urinary ketones
c) Plasma ketones
Plasma ketones
Patient for urgent bypass surgery. HITS antibodies
- plasmapheresis then heparin
- Bivalirudin
- Enoxaparin
- Fondaparinux
Bivalirudin
Bivalirudin, tirofiban, ilprost have all been used without VTE or bleeding complications.
From Another article
- If urgent surgery use Bivalirudin
- if possible wait three months for antibodies to clear out then use unfractionated heparin
- evidence for plasma exchange not strong enough to recommend
- platelet inhibition too unpredictable or risky
Thoracic wall block for mastectomy. Most likely to miss?
Terminal branches of the supraclavicular nerves (C3-4) innervate the upper part of the breast and this should be taken into account when the surgical procedure involves this area (e.g. Portacaths and Hickman lines) because Pecs blocks will not block the supraclavicular nerve. Breast surgery however, is rarely performed at this level.
The innervation of the breast is supplied mainly by the anterior branches of the 4th, 5th and 6th intercostal nerves which arise from the thoracic spinal nerves (T4-6).
The apex of the axilla is supplied by the intercostobrachialis nerve; this is a cutaneous branch of the second intercostal nerve (T2).
The pectoral major and minor muscles are innervated by the lateral pectoral nerve (C5-7) and medial pectoral nerve (C8-T1). (PECS 1 block)
The long thoracic nerve (C5-7) supplies the serratus anterior muscle. (PECS 2 block)
The thoracodorsal nerve (C6-8) supplies latissimus dorsi and this is relevant for more extensive procedures.
What decreases effectiveness of methadone?
- grapefruit juice
- citalopram
- phenytoin
Phenytoin
Top of page
Status of interaction: Clinically important.
Effects: Reduced methadone levels.
Mechanism: Phenytoin stimulates hepatic enzymes involved in methadone metabolism.
Citalopram : inhibits CYP450, therefore increases levels.
Grapefruit juice: inhibits CYP450 and therefore increases levels
http://www.health.gov.au/internet/publications/publishing.nsf/Content/drugtreat-pubs-meth-toc~drugtreat-pubs-meth-app~drugtreat-pubs-meth-app1
Most effective intervention to prevent emergence delirium after sevoflurane GA?
a) Parental presence
b) Premedication with midazolam
c) Slow emergence in a quiet room
d) Switch to propofol at end of case
e) Switch to isoflurane at end of case
S The efficacy of propofol is dependent on the timing of administration. Due to the rapid pharmacokinetics of propofol, a bolus of 1 mg kg−1 given at the end of the procedure or continuous infusion used during maintenance of anaesthesia results in increased concentrations during emergence resulting in a decreased incidence of ED.6
While sevoflurane is a very effective induction agent, the use of isoflurane or propofol for the maintenance of anaesthesia may reduce the risk of ED. Studies have shown positive effects for propofol, pain prevention, ketamine, and α2-adrenoreceptor agonists with no evidence of effectiveness for midazolam or 5-HT3 antagonists.6
Woman comes in to ED confused and combative. Otherwise well. Na 143 Low serum osmolality Low urine osmolality Urine output 400mls/hr for past 2 hours. What is this most consistent with?
D.I
Although ? Low osm
3) The adductor canal (pictured). What is this? (pointed to Vastus Medialis)
a) Adductor longus
b) Adductor magnus
c) Gracilis
d) Sartorius
e) Vastus medialis
https://www.nysora.com/wp-content/uploads/2018/09/33Ex03AB.jpg
SUPERFICIALLY: Sartorius
POST: AM (Adductor magnus)
saphenous nerve, femoral artery on top of femoral vein
VM ( vastus medialus) : ANT
Which of the following drugs has the LEAST effect on thrombin time?
a) bivalirudin,
b) dabigatran,
c) heparin,
d) clexane,
e) warfarin
Warfarin
TT (thrombin time/ thrombin clotting time)
- assesses fibrin formation from fibrinogen and formation of clot
- will be low if fibrinogen is low, if impairment of fibrin formation such as DIC, thrombin inhibitory drugs eg: heparin
PT
- is a measure of the extrinsic pathway and common pathway
- measures factors II (prothrombin), V, VII, X and fibrinogen
- prolonged PT: warfarin use, vit k deficiency, fibrin abnormality, massive transfusion and dilution of products
During endovascular repair of ruptured aneurysm the proceduralist expresses concern about perforation of intracranial vessel following passage of a micro catheter. Each of the following could be part of your management except?
a) Mannitol
b) Protamine
c) Thiopentone
d) Vasopressor
e) Mild hyperventilation
Vasopressin
Left temporal and right nasal visual field loss. Location of lesion?
- Left optic nerve
- Right optic nerve
- Optic chiasm
- Left optic tract
- Right optic trac
Right optic tract
Nerve, chiasm , tract
FFP dose to increase fibrinogen by 1g/L
- 5ml/kg
- 10ml/kg
- 20ml/kg
- 30ml/kg
- 50ml/kg
?
Fibrinogen replacement options
- FFP (low levels of fibrinogen so not recommended for replacement)
- CRYO 15g/L if fibrinogen, std dose is 10u
- Fibrinogen concentrates 4g inc by 1g/L
Peribulbar block - Safest approach?
Inferolateral
5) Which cardiac condition has the “highest mortality” in pregnancy
A) HOCM with hypertrophied septum
B) Bicuspid AV with significantly dilated aortic root
C) Severe MR
D) PDA
WHO I
- Uncomplicated small or mild: pulmonary stenosis PDA, MVP
- Successfully repaired simple lesions ( ASD, VSD, PDA)
- atrial or ventricular ectopic
WHO II
- unoperated ASD, VSD
- Repaired TOF
- Most arrythmias
WHO II-III
- Mild LVH impairment
- HOCM
- Native or tissue valvular heart disease not considered WHO I or IV
- Marfan syndrome without aortic dilation
- Aorta <45 mm in aortic disease associated with bicuspid aortic valve
- Repaired coarctation
WHO III
- Mechanical valve
- single right ventricle
- Fontan circulation
- cyanotic heart disease unrepaired
- Aortic dilatation 40-45mm in Marfan syndrome
- Aortic dilatation 45-50mm in pt with Bicuspid aortic valve
WHO IV
- PAH
- Severe systemic ventricular dysfunction LVEF <30%
- Previous peripartum cardiomyopathy with any residual impairment of left ventricular function
- Severe mitral stenosis, severe symptomatic aortic stenosis
- Marfan syndrome with aorta dilated >45 mm
- Aortic dilatation >50 mm in aortic disease with bicuspid aortic valve
- severe coarctation
High grade staphyloma. Safest way to do a single injection peribulbar block?
- Medial canthus
- Lateral canthus
- Inferotemperal
Medial I think
myopic staphyloma, an anatomical anomaly that represents a risk factor for perforation, is infrequently encountered on the nasal side of the globe.
Moreover, staphyloma was more frequently found at the posterior pole of the globe (accounting for perforations after RBA) or in the inferior area of the globe (accounting for perforations after inferior and temporal punctures, both peri and retrobulbar).
Induction of labour at 35/40 for pre-eclampsia. Has eclamptic seizure. What dose of Mg should be given?
A) 1g over 20 minutes, followed by 1 g/hour
B) 1g over 20 minutes, followed by 2g/hour
C) 2g over 20 minutes, followed by 0.5g/hour
D) 4g over 20 minutes followed by 0.5g/hr
E) 4g over 20 minutes followed by 1g/hr
Prophylaxis:
• Severe pre-eclampsia (NNT 60).
•MgSO4 50%®4g(8ml)over15minutes+1g/hr
(2 ml/hr) until 24 hours post-delivery. Can to 1.5
g/hr if sub therapeutic levels.
• Target level 2-3.5 mmol/L (normal 0.8-1 mmol/L).
Treatment of eclampsia: •MgSO4 50%®4g(8ml) over 5 min + commence/continue infusion 1g/hr for 24 hours • recurrent seizures 2g boluses +/- thiopentone/propofol.
Treatment of magnesium toxicity:
• 10 ml (1 g) calcium gluconate 10% over 10
minutes.
Crash 2 trial (Very specific question - Dan might remember)
What happened to the death rate?
Results:
- > all cause mortality reduced in the TXA2 group
- > decreased mortality due to bleeding (RR 0.85) (which was 35% of deaths)
- > trend toward more vascular occlusive events in placebo group
- > no difference in transfusion and need for surgery
- > trend towards early treatment being more effective
- > NNT 65, ARR 1.5%, RR 0.91
Bottomline
ARR in mortality is very small, also didn’t reduce blood products administered. However TXA unlikely to cause harm so will continue to be part of practice for bleeding trauma patient
104) Incidence of HCV infection post needle stick form a HCV positive patient
HIV 0.3%
HBV 0% with post exposure prophylaxis
HCV 1.8%
Not sure about my resource
Transport cylinder. Water capacity 2L. Pressure gauge reads 150 Bar. Flows - O2 10L/min – longest it can last?
15min
30min
45min
60min
2hrsMaybe 15min
Portable oxygen tank D/E : 10l/min has 15 mins of oxygen supply
Transport vehicle tank H or K or M = 30 mins
According to Australian and New Zealand Resuscitation Guidelines, the minimum
distance the defibrillator pads have to be from the generator box of a PPM/AICD is?
a) 4cm
b) 8cm
c) 12cm
d) 16cm
e) 20cm
8cm
Which blood product is contraindicated in DIC from an AFE?
a) Prothrombinex
b) Tranexamic aci
A) Prothrombinex-VF
Prothrombinex-VF contraindicated as it may potentate existing thrombotic tendency which is a feature of DIC.
Role of heparin is controversial Blood products to use are: - FFP 10 u/kg - Cryo aim fibrinogen >1 - platelets 1-2 adult doses - antithrombin replacement but discuss with haem
Asystolic arrest. 1mg of adrenaline given.
When to give next dose?
2 minutes
1 minute
5 minutes
After 1st loop of CPR
After 2nd loop of CPR
After second loop
Contraindications for TOE
Absolute:
- Perforated viscus
- Esophageal stricture
- Esophageal tumor
- Esophageal perforation, laceration
- Esophageal diverticulum
- Active upper GI bleed
Relative: - History of radiation to neck and mediastinum - History of GI surgery - Recent upper GI bleed - Barrett’s esophagus - History of dysphagia - Restriction of neck mobility (severe cervical arthritis, atlantoaxial joint disease) - Symptomatic hiatal hernia - Esophageal varices - Coagulopathy, thrombocytopenia - Active esophagitis Active peptic ulcer disease
What structure are you most likely to damage in elective tracheostomy in a 4 yo?
- vertebral artery
- phrenic nerve
- vagus nerve
- left brachiocephalic vein
- thoracic duct
Don’t know
Tracheostomy Cx
Early
- pneumothorax, pneumomediastinum, subcutaneous emphysema
Sherlock ECG guided PICC insertion trace.
When is PICC in the right spot?
Pulses from the Sinoatrial Node are detected by the PICC as it enters the Superior Vena Cava. The impulse grows stronger as the tip advances down the vein, signified by an enlarged p-wave visible on the ECG. Passing the node causes a deflection in the wave, communicating to the inserter that the tip is positioned beyond the Cava-Atrial Junction (CAJ) i.e. into the right atrium, and should be retracted. The ideal tip position for a PICC line is between the distal SVC and within one centimetre of the right atrium. This method of insertion is not suitable for all patient groups. It is well documented that obese, the young or patients with AF will not obtain a clear p-wave rise. Also the presence of a pacemaker will mean that the p-wave size is not affected by the PICC tip position.
60 year old man in ICU. Aim for SBP (missing rest of stem)
- 100mHg
- 110mHg
- 120mHg
?
T1DM / other version said T2DM . Fasting. BSL 7. Give insulin to prevent hyperglycaemia. What’s the mechanism
- Increased glucose uptake into liver - Increased glucose uptake into muscle - Inhibits glycogenolysis - Prevent/decrease proteolysis
Inhibits glycogenolysis
Insulin effects
- Inhibits glycogenolysis and gluconeogenesis
- inc glucose transport into muscle and fat GLUT 4
- increased glycolysis in fat and muscle
- Stimulating glycogen production
CRASH II trial – multiple stems/ versions recalled
- What happened to the death rate from bleeding (¯/)? What happened to overall mortality(¯/)??
Tranexamic acid resulted in higher/lower
- death from bleeding
- overall transfusion requirements
- overall mortality
Decreased death from bleeding but otherwise overall mortality stayed the same
Outcome
Primary outcome: death in hospital within 4 weeks of injury
Significant reduction in intervention group
Secondary outcomes: no significant difference in intervention and control groups
Receipt of a blood-products transfusion
Surgical intervention
Occurrence of vascular occlusive episodes (stroke, myocardial infarction, pulmonary embolism, clinical evidence of deep vein thrombosis)
Unit of blood products transfused
Dependency at hospital discharge or at day 28 if still in hospital
NAP 6 – Commonest allergen/ Worst antibiotic?
-Teicoplainin
Teicoplanin
See NAP 6 results
46 yo F with menorrhagia is booked for an abdominal hysterectomy. Her blood results are as followed (normal ranges were provided)
Creatinine 55
Ca2+ 2.2
PO43- 0.34
What is the cause? A. Diuretic use B. Fanconi syndrome C. Vitamin D use D. Vit D deficiency E. Iron transfusion F. Hyperparathyroidism
Hyperparathyroidsyndrome
Primary hyperparathyroid Syndrome causes:
- high calcium
- low phosphate
Secondary
You are performing an interscalene block with a nerve stimulator. You notice the patient’s abdomen is moving in time with the stimulator. Where should you move the needle? A. Withdraw completely B. Posterior C. Anterior D. Lateral E. Cephalad F. Caudad
Twitch of Diaphragm
- result of phrenic nerve stimulation
- needle is too anterior and medial
- withdraw needle and reinsert 15 Deg posterior and lateral
Commonest cause of peri-operative stroke
- Hypotensive
- Embolic
- Thrombotic
- Hypertensive
- Haemorrhagic
- Commonest cause of stroke
Ischaemic primarily
Post CSURG = emboli
Post non CSURG: both embolic and thrombotic
Intra op hypotension has been associated with stroke in the non cardiac surgical population but the effect size is minimal and clinical significant not yet clear
Desmopressin is relatively contraindicated in what subtype of vWD?
- a) 2a
- b) 2b
- c) 3
- d) Relax!! You can give it to all of them
2B non responsive
Injury during intubation with laryngoscope (WTF … have no idea what this questions about!)
- Left carotid incision - Right carotid incision
?
Facemask
- corneal abrasion
LMA
- sore throat
- pressure on cranial nerves, lingual (loss of taste), hypoglossal ( dysphagia), RLN ( voice changes)
- usually resolves spontaneously.
- RF N20 and small LMA
- need to warn singers of voice changes with LMA even though it is preferable to intubation.
ETT
- Pressure greater than 30cmh20 high risk
- VC haematoma
- Mucosal Odema
- Laceration of vocalis
- Arytenoid subluxation
- RLN palsy
Risk factor for cement syndrome
- male
- previous cement syndrome
- diuretic use
- pre-existing cardiovascular conditions
Preexisting CVs conditions
TURP patient, hyponatraemic. Treatment?
3% nsaline
(0.6 x TBWeight kg) x 2= mls of 3% normal saline per hour to increase by 1 moo
Blue urticaria is a complication of which? A. Anaphylaxis B. Methhaemoglobinaemia C. Patent blue dye D. Methylene blue
C - patent blue dye
The authors report a severe anaphylactic reaction to Patent Blue V dye used in sentinel node biopsy for lymphatic mapping during breast cancer surgery to stage the axilla. Patent Blue dye is the most widely used in the UK; however, adverse reactions have been reported with the blue dye previously. This case highlights that reactions may not always be immediately evident and to be vigilant in all patients that have undergone procedures using blue dye. If the patients are not responding appropriately particularly during an anaesthetic, one must always think of a possible adverse reaction to the dye. All surgical patients should give consent for adverse reactions to patent blue dye preoperatively. Alternative agents such as methylene blue are considered.
Blue acute urticaria is one of the clinical manifestations of immediate hypersensitivity reactions to patent blue dye. Skin tests must be performed 6 weeks after the reaction in order to confirm the diagnosis and formally contra-indicate this substance.
https://www.ncbi.nlm.nih.gov/pubmed/26372548
Neonatal resuscitation. Neonate handed to midwife. Blue and apneic despite stimulation. HR drops from 140 to 90. Next step in resuscitation?
- Intubate
- CPR
- Adrenaline
- PPV
PPV
- If HR below 100 or
gasping or apnea
Start PPV
Targeted pre ductal sats 1 min = 60% -70% 2 min = 65% - 75% 3 min = 70% - 90% 4 min = 75% - 90% 5 mins = 80% -90% 10 mins = 85 - 90%
ADrenaline 1:10,000
23-26 0.1ml
27-37 0.25 ml
38-43 0.5 mls
10/30mcg/kg (0.1-0.3ml/kg)
sats
4) Refuse to do high risk JW bleeding patient. Which ethical principle?
- non-maleficence
- beneficence
- autonomy
- paternalism
Beneficence: Obligation to do good
Non-maleficence: obligation to do no harm
Autonomy: Patient’s right to self-determination
Paternalism: overriding the patient’s choice where the patient’s choice is not in his/her best interest. Autonomy overrides this.
Doctrine of double effect: Action with both good and harmful effects are justified if the intention is good. Eg: morphine for end-of-life care
NDMR least likely to cause anaphylaxis
– (cisatracurium not on list)
Sux> roc> Vec> atrac> cisatracurium > panc
I think
Worst greenhouse gas effect/ Alternative: Volatile with greatest Global Warming Potential?
- nitrous oxide
- sevoflurane
- desflurane
- isoflurane
GWP100
DES 1526
SEVO 575
ISO 350
N20 296
But n20 contribution is most because of high consumption
What needle is this?
a) Quincke
b) Sprotte
c) Tuohy
d) Whitacre
e) Pitkin
Tuohy
https://aneskey.com/epidural-and-spinal-anesthesia-2/
Hand wash. Antibiotic kill rate
70% isopropyl alcohol ?
Alcohol kills bacteria. Mixed with water as the alcohol disrupts cell membranes and then water moves in and causes osmotic shock.
Autoclave kills spores
What opioid side effect do you NOT get tolerance to? A. Nausea and vomiting B. Constipation C. Respiratory depression D. Sedation
Not sure
Tolerance highest for analgesia> respiratory > g.i effects
What is an apnoea?
- stop breathing 10 seconds
- stop breathing 20 seconds
- stop breathing 30 seconds
- stop breathing 10 seconds with 3% desat
- stop breathing 20 seconds with 3% desat
Apnea = stop breathing for 10 seconds
Patient with signs of retrobubar haematoma (proptosis). How does a lateral canthotomy work?
- Allow globe to continue to swell
- Drain blood from behind eyeball
Allows eyeball to come forward in compartment syndrome
Intraorbital pressure of 40+
Cut into lateral canthal ligament (2 parts).
Allows globe to come forward
Subdural haemorrhage. Surgeon wants to proceed urgently. Patient has DDD pacemaker. Technician over one hour away. What do you do?
- Wait for technician
- Proceed once transcutaneous pacing established
- Proceed with magnet available
Proceed with magnet available
Most effective prevention of post herpetic neuralgia
- Amitriptyline used (low dose) for 90 days from onset of herpes zoster rash Reduces incidence of post herpetic neuralgia
- Topical aspirin, topical lignocaine patch or controlled release oxycodone provide analgesia an acute pain due to herpes zoster
- Provision of early and appropriate analgesia is an important component of herpes zoster and have benefits in reducing the incidence of post herpetic neuralgia
Lowest possible spinal cord injury without getting spinal shock?
- C something
- T5
- T9
- T12
- L something
Spinal shock usually T7 and above
Neurogenic shock is classically characterised by hypotension, bradycardia and peripheral vasodilatation. Neurogenic shock is due to loss of sympathetic vascular tone and happens only after a significant proportion of the sympathetic nervous system has been damaged – as may occur with lesions at the T6 level or higher.
Spinal shock is not a true form of shock. It refers to the flaccid areflexia that may occur after spinal cord injury, and may last hours to weeks. It may be thought of as ‘concussion’ of the spinal cord and resolves as soft tissue swelling improves. Priapism may be present.
RBF during cross clamp?
- Increase by 20%
- Increase by 40%
- Decrease by 20%
- Decrease by 40%
? By about 30%
The main cause of renal complications after AAA repair is the decrease in renal blood flow, decreased renal perfusion pressure (outside autoregulation) augmented by the increasing renal vascu- lar resistance (by 30%) associated with aortic clamping.
Postoperative dialysis rates are similar in patients who have under- gone either suprarenal or infra-renal aortic cross-clamping
Post blood transfusion clinical scenario
(No actual question given)
- TRALI
- APO
- Haemolytic reactionTRALI - AbAg reaction
- fever and chills, desat, inc hr, hypotension, in rr
Haemolytic reaction
- immune and non immune
- ABO incompatibility
- alloAB from previous sensitization
What is a marker of iron deficiency anaemia?
- increased/decreased TIBC
- increased/decreased transferrin
Iron def anaemia
- Ferritin decreases
- transferrin/TBIC increases
- transferrin sats decrease
ECG axis question - left axis deviation/ Alternative: calculate axis. (Positive lead 1 , negative lead 2, avF negative)
- -90
- -45
- -15
- 15
- 45
- 90
- 12
27) An ECG that only had a left axis deviation – what did it shown (? The correct recollection)
A. Left anterior fascicular block – was this one
B. Left posterior fascicular block
C. Right bundle branch block
D. Left bundle branch block
LAD need positive lead 1, negative lead 2 & AVF.
If just lead avf negative could still be normal axis deviation
Left ant hemiblock: left axis deviation
Left post hemiblock: right axis deviation
Gold classes A-D for COPD severity are determined by:
Exertional dyspnoea
Exertional dyspnoea and FEV1
Exertional dyspnoea and number of exacerbations per year
Spirometry FEV1 only
Number of exacerbations per year only
Exacerbation sand dyspnoea
GOLD 1234 = FEV1
Gold ABCD = exac + mmrc
Components of Prothrombinex (? Except)
- antithrombin III
- Protein C
- Heparin
- Factor X
No protein C in Prothrombinex-VF.
Contains: 2, 9, 10, ATIII, HEparin, low levels of 5&7
Each vial of Prothrombinex®-VF contains 500 IU of factor IX 500 IU each of factors II and X. 25 IU of antithrombin III 192 IU of heparin sodium.
Other ingredients include =500 mg of human plasma proteins (which includes low levels of factors V and VII), sodium citrate, sodium phosphate and sodium chloride. T
Which anaesthetic agent invalidates the OCP
- Sugammadex
Suggamadex
Female 32 weeks pregnant (also remembered as 35wks). AST 400, INR 2.1 (alternative 2.3). Most likely diagnosis? A. Acute cholestasis of pregnancy B. HELLP syndrome C. Severe pre-eclampsia D. Acute fatty liver of pregnancy E. Hyperemesis gravidarum F. Choledocholithiasis G. Pre-eclampsia with HELLP
Acute fatty liver of pregnancy
Although the cause is unknown, it is believed to occur secondary to an abnormality in the β-oxidation of fatty acids in mitochondria.149 Patients present with vague abdominal symptoms that include pain, jaundice, vomiting, and anorexia.150 Laboratory signs may include hyperbilirubinaemia, transaminitis, elevated serum creatinine, and coagulopathy
What does the Pringle manoeuvre involve?
- clamping the hepatic artery and portal vein (duodenal ligament
Where does the Glenn Shunt attach to
GT = SVC to RPA
Hypoplastic left heart
- Norwood procedure
- aim is to make right ventricle the main pumping chamber
- 1st 2 weeks of life
- aorta made larger
- PA and aorta connected to allow all blood to reach the body
- BT shunt = right subclavian to PA artery
Glenn shunt
- 4-12 months of age
- blalock-taussig shunt is removed
- SVC connected to right pulmonary artery
- now that blood passes passively into pulmonary artery to be oxygenated.
- child will still remain cyanosis at this stage because the deoxygenated blood from the IVC will mix
-
Fontan procedure
- 18-36 months
- IVC connected to Right PA
Patient with headache that gets worse standing, relieved lying down. Neurologist suspects spontaneous intracranial hypotension and asks for blood patch. What do you do?
- refuse to do blood patch
- Do blood patch with no further investigations
- Order CT myelogram and MRI to confirm CSF leak and then do lumbar epidural blood patch
- Order CT myelogram and MRI to confirm CSF
?
Maybe ct first then lumbar epidural patch?
Patient had a proven anaphylactic reaction to suxamethonium, which of the following drugs is at most risk to cause cross-reactivity?
a) pancuronium
b) vecuronium
c) atracurium
d) rocuronium
Anaphylaxis to Sux
- Roc > vec > cisatracurium > atracurium/panc
Anaphylaxis to Roc
Sux> Vec»_space; atrac > panc» cisatracium
Anaphylaxis to Vec
Sux=roc=panc»_space; atracurium
Anaphylaxis to Atracurium
Cisatracurium > sux
Vec= anaphylaxis to AS
Atracurium = anaphylaxis to BSQ
If anaphylaxis to anything except atracurium, give cisatracurium
Dental procedure. What needs IE antibiotic prophylaxis?
a) mitral ring annuloplasty
b) previous aortic balloon dilatation
c) patch VSD repair in childhood
Mitral ring annuloplasty
Antibiotic prophylaxis is indicated for the following high-risk cardiac conditions:
Prosthetic cardiac valve
History of infective endocarditis
Congenital heart disease (CHD) (except Antibiotic prophylaxis is indicated for the following high-risk cardiac conditions:
Prosthetic cardiac valve
History of infective endocarditis (see image below)
Congenital heart disease (CHD) (except for the conditions listed, antibiotic prophylaxis is no longer recommended for any other form of CHD): (1) unrepaired cyanotic CHD, including palliative shunts and conduits; (2) completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first 6 months after the procedure; and (3) repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device (which inhibits endothelialization)
Cardiac transplantation recipients with cardiac valvular disease Antibiotic prophylaxis is indicated for the following high-risk cardiac conditions:
Prosthetic cardiac valve
History of infective endocarditis (see image below)
Congenital heart disease (CHD) (except for the conditions listed, antibiotic prophylaxis is no longer recommended for any other form of CHD): (1) unrepaired cyanotic CHD, including palliative shunts and conduits; (2) completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first 6 months after the procedure; and (3) repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device (which inhibits endothelialization)
Cardiac transplantation recipients with cardiac valvular disease for the conditions listed, antibiotic prophylaxis is no longer recommended for any other form of CHD): (
- 1) unrepaired cyanotic CHD, including palliative shunts and conduits;
- 2) completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first 6 months after the procedure; and
- 3) repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device (which inhibits endothelialization)
Cardiac transplantation recipients with cardiac valvular disease
You’re gassing a 4yo with an URTI. What’s good for reducing laryngospasm?
a. ETT is better than LMA
b. IV induction is better than inhalational
c. Deep extubation is better than awake
d. Desflurane is better than sevoflurane
e. Thiopentone is better than propofol
B IV induction
The RELIEF Trial showed that a liberal fluid strategy compared to a restrictive fluid strategy resulted in?
Also remembered as… What happened to the AKI risk in the liberal fluid group?
A. Decreased acute kidney injury
B. Increased mortality
Restrictive fluid regime does NOT improve survival and leads to more AKI, SSI, RRT
No difference in disability free survival at 1 year
2yo child, 12kg for orchidopexy. You perform a caudal and use 0.2% ropivocaine. How much do you give to provide post-op analgesia?
a) 3ml
b) 6ml
c) 12ml
d) 18ml
e) 24ml
12
1ml/kg 0.2% ropivacaine
Patient post spinal surgery. Loss of pain and temperature sensation. Preservation of proprioception and vibratory sensation. Likely diagnosis?
- anterior spinal artery syndrome
- posterior spinal artery syndrom
Anterior spinal cord syndrome
- Paralysis and loss of pain and temperature with Preservation of Proprioception, fine touch, and Vibration
- anterior spinal artery runs as a single artery anterior to the cord and supplies the anterior 2/3 of the cord. Transection therefore produces sparing of the dorsal columns
Which tooth is most damaged with intubation/laryngoscopy?
Maxillary incisors
- thinner
- single roots
- esp left side
Most damage at intubation 3/4
Extubation 1/3
Suction and Guedel insertion
11% if medicolegal claims
