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
