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