2024.1 MCQ Flashcards

Question

#25. The intrinsic muscles of the larynx do NOT include a) cricothyroid b) suprahyoid c) thyroaretenoid d) transverse arytenoid

Answer 1

Intrinsic muscles of the larynx: cricothyroid thyroaretenoid posterior cricoarytenoid lateral cricoarytenoid transverse arytenoid NO hyoid Use “PLAT VCO” to recall all intrinsic muscles: • Posterior cricoarytenoid • Lateral cricoarytenoid • Aryepiglotticus • Transverse arytenoid • Vocalis • Cricothyroid • Oblique arytenoid

Answer 2

HAGMA LTKR lactate toxin - salicylate ketone renal failure

Answer 3

UGIB SAH (WFNS GCS and motor- survival and Fisher rad- vasospasm)

Answer 4

Neuraxial- spinal abolishes ADR and spasms, epidural reduces ADR, spinal blunts SNS when inflating bladder ## Footnote https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/full/10.1046/j.1365-2044.1998.00337.x

Answer 5

Things that affect it: MRI Diathermy ?Maybe ECT TENS Machine Gamma radiation Defibrillation/external shocks Peripheral nerve stimulator lithotripsy ## Footnote https://academic.oup.com/europace/article/24/9/1512/6562768?login=false

Answer 6

do nothing: goal sats in prematurity 91% ## Footnote https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/oxygen_delivery/#:~:text=91%20%2D%2095%25%20for%20premature%20and,bronchiolitis%20(link%20to%20Bronchiolitis%20CPG) The neonate's current oxygen saturation of 92% falls within the recommended target range (90–95% for preterm infants) during laser therapy and mechanical ventilation. Maintaining the current ventilator settings is appropriate, as adjusting parameters risks destabilizing oxygenation or increasing hyperoxia-related complications. ### Key Considerations: 1. **Oxygen Saturation Targets**: - Preterm infants require tight SpO₂ regulation to avoid **retinopathy of prematurity (ROP) progression** while preventing hypoxia. - Current guidelines recommend **SpO₂ 90–95%** for preterm neonates receiving oxygen therapy[2][7][28][50]. 2. **Ventilator Settings**: - **FiO₂ 0.4** with SpO₂ 92% indicates adequate oxygenation without excessive oxygen exposure. - **PEEP 5 cmH₂O** and **rate 24 breaths/min** are within typical neonatal ventilation parameters[24][28]. 3. **Anesthesia Context**: - General anesthesia during ROP laser therapy carries risks of postoperative ventilatory dependence[1][15]. - Stability in oxygenation (avoiding fluctuations) is prioritized over aggressive weaning during the procedure. ### Conclusion: **No changes to ventilator settings are needed.** The current configuration achieves optimal balance between oxygenation safety and ROP risk mitigation. Adjustments should only occur if SpO₂ trends outside the 90–95% range or clinical deterioration arises. Sources [1] Anaesthesia modalities during laser photocoagulation for ... https://pmc.ncbi.nlm.nih.gov/articles/PMC5278276/ [2] Oxygen saturation SpO2 level targeting in neonates https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/oxygen_saturation_spo2_level_targeting_premature_neonates/ [3] High or Low Oxygen Saturation and Severe Retinopathy of Prematurity https://pmc.ncbi.nlm.nih.gov/articles/PMC4016714/ [4] Supplemental oxygen for the treatment of prethreshold retinopathy ... https://pmc.ncbi.nlm.nih.gov/articles/PMC7017219/ [5] Anaesthesia for the laser treatment of neonates with retinopathy of ... https://www.nature.com/articles/6702502 [6] Strategies to Prevent Severe Retinopathy of Prematurity: A 2020 ... https://publications.aap.org/neoreviews/article-abstract/21/4/e249/88504/Strategies-to-Prevent-Severe-Retinopathy-of?redirectedFrom=fulltext%3Fautologincheck%3Dredirected [7] Target Ranges of Oxygen Saturation in Extremely Preterm Infants https://pmc.ncbi.nlm.nih.gov/articles/PMC2891970/ [8] Graded oxygen saturation targets and retinopathy of prematurity in ... https://www.nature.com/articles/pr201698 [9] Laser treatment in infants with retinopathy of prematurity using sub ... https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/full/10.1111/j.1365-2044.2006.04945_4.x [10] [PDF] A uthor Manuscript - Minerva Access https://minerva-access.unimelb.edu.au/bitstreams/bbe392c3-2dc8-54c2-a583-ce71d87c1e5d/download [11] Anesthesia in retinopathy of prematurity - PMC https://pmc.ncbi.nlm.nih.gov/articles/PMC9583347/ [12] Current update on retinopathy of prematurity: screening and treatment https://pmc.ncbi.nlm.nih.gov/articles/PMC3319383/ [13] Ophthalmology : Treatment of ROP - The Royal Children's Hospital https://www.rch.org.au/ophthal/patient_information/Treatment_of_ROP/ [14] Technical aspects of laser treatment for acute retinopathy of ... https://pmc.ncbi.nlm.nih.gov/articles/PMC2993981/ [15] Anaesthesia for the laser treatment of neonates with retinopathy of ... https://www.nature.com/articles/6703083 [16] neonatal services division - Pulse Oximetry Screening of Newborns https://www.seslhd.health.nsw.gov.au/sites/default/files/groups/Royal_Hospital_for_Women/Neonatal/Medical/nccretinopathy2019.pdf [17] The practice of general anesthesia for the retinopathy of prematurity ... https://journals.lww.com/ejanaesthesiology/fulltext/2014/06001/the_practice_of_general_anesthesia_for_the.461.aspx [18] Screening Examination of Premature Infants for Retinopathy of ... https://publications.aap.org/pediatrics/article/142/6/e20183061/37478/Screening-Examination-of-Premature-Infants-for?autologincheck=redirected [19] [PDF] Our General Anesthesia Experiences in Premature Patients ... https://app.mevlanamedsci.org/uploads/makale-pdf/our-general-anesthesia-experiences-in-premature-patients-undergoing-laser-photocoagulation-DrnUn2.pdf [20] Inadequate laser coagulation is an important cause of treatment ... https://onlinelibrary.wiley.com/doi/10.1111/aos.14406 [21] Anaesthesia modalities during laser photocoagulation ... - BMJ Open https://bmjopen.bmj.com/content/bmjopen/7/1/e013344.full.pdf [22] Ventilator Management - StatPearls - NCBI Bookshelf https://www.ncbi.nlm.nih.gov/books/NBK448186/ [23] [PDF] DRAFT #1 AARC - Neonatal ALI Guideline Page 1 of 5 American ... https://www.aarc.org/wp-content/uploads/2020/03/neonatal_ventilation_000.pdf [24] Setting the Ventilator in the NICU - PMC https://pmc.ncbi.nlm.nih.gov/articles/PMC7122498/ [25] [PDF] Respiratory Support https://www.ucsfbenioffchildrens.org/-/media/project/ucsf/ucsf-bch/pdf/manuals/6_respsupport.pdf?rev=2bb223b4b25f4ef6a92abfd429c20c96 [26] Oxygen therapy in children - Starship Hospital https://starship.org.nz/guidelines/oxygen-therapy [27] [PDF] Neonatal Clinical Practice Guidelines 2018-2021 https://platform.who.int/docs/default-source/mca-documents/policy-documents/guideline/blz-mn-32-02-guideline-2018-eng-neonatal-clinical-guidelines-2018-2021.pdf [28] Respiratory Support in Neonates and Infants - MSD Manuals https://www.msdmanuals.com/professional/pediatrics/respiratory-problems-in-neonates/respiratory-support-in-neonates-and-infants [29] Accuracy of the spontaneous breathing trial using a combined CPAP ... https://pmc.ncbi.nlm.nih.gov/articles/PMC9632075/ [30] Nursing guidelines : Oxygen delivery - The Royal Children's Hospital https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/oxygen_delivery/ [31] [PDF] Newborn Critical Care Center (NCCC) Clinical Guidelines https://www.med.unc.edu/pediatrics/cccp/wp-content/uploads/sites/1156/2021/04/UNC-CDH-Pathway-NCCC-PICU.pdf [32] Oxygen saturation targets for children with respiratory distress https://pmc.ncbi.nlm.nih.gov/articles/PMC10577592/ [33] Retinopathy of prematurity and oxygen therapy: A changing ... https://www.analesdepediatria.org/en-retinopathy-prematurity-oxygen-therapy-a-articulo-13070181 [34] [PDF] Nasal High-Flow Therapy during Neonatal Endotracheal Intubation https://medicine.unimelb.edu.au/__data/assets/pdf_file/0009/4114854/Kate_SHINE_nejmoa2116735.pdf [35] [DOC] Retinopathy of Prematurity (ROP) in Neonates, Screening and ... https://www.canberrahealthservices.act.gov.au/__data/assets/word_doc/0006/1981644/Retinopathy-of-Prematurity-ROP-in-Neonates,-Screening-and-Treatment.docx [36] Comparative cohorts of retinopathy of prematurity outcomes of ... https://bmjophth.bmj.com/content/6/1/e000626 [37] Oxygen saturation screening for newborns - Safer Care Victoria https://www.safercare.vic.gov.au/best-practice-improvement/clinical-guidance/neonatal/oxygen-saturation-screening-for-newborns [38] Retinopathy of prematurity (ROP) - Safer Care Victoria https://www.safercare.vic.gov.au/best-practice-improvement/clinical-guidance/neonatal/retinopathy-of-prematurity-rop [39] [PDF] Retinopathy of prematurity and oxygen therapy - Anales de Pediatría https://analesdepediatria.org/index.php?p=revista&tipo=pdf-simple&pii=13070181 [40] Perioperative use of oxygen: variabilities across age | BJA https://academic.oup.com/bja/article/113/suppl_2/ii26/227567 [41] Oxygen care and treatment of retinopathy of prematurity in ocular ... https://www.nature.com/articles/s41598-021-04221-8 [42] High rate and large intercentre variability in retreatment of ... https://bmjophth.bmj.com/content/6/1/e000695 [43] Retinal vascular development in an immature retina at 33–34 weeks ... https://www.nature.com/articles/s41598-020-75151-0 [44] Twelve-year outcomes of bedside laser photocoagulation for severe ... https://www.frontiersin.org/journals/pediatrics/articles/10.3389/fped.2023.1189236/full [45] [PDF] Royal Hospital for Women (RHW) NEONATAL BUSINESS RULE ... https://www.seslhd.health.nsw.gov.au/sites/default/files/groups/Royal_Hospital_for_Women/Neonatal/Medical/RHW%20CLIN083%20Retinopathy%20of%20Prematutity%20(ROP).pdf [46] [PDF] Airway Management and Mask Ventilation of the Newborn https://www.anzcor.org/assets/anzcor-guidelines/guideline-13-4-airway-management-and-mask-ventilation-of-the-newborn-288.pdf [47] [PDF] Guideline: Neonatal resuscitation - Queensland Health https://www.health.qld.gov.au/__data/assets/pdf_file/0011/140600/g-resus.pdf [48] [PDF] Respiratory Support in Neonates - GCNIC - CHW https://resources.schn.health.nsw.gov.au/policies/policies/pdf/2007-0005.pdf [49] [PDF] National Guideline on Management of Oxygen Therapy in Neonates https://health.gov.mv/storage/uploads/5oBvMkoG/pzqwvjv2.pdf [50] Safe oxygen saturation targeting and monitoring in preterm infants https://pmc.ncbi.nlm.nih.gov/articles/PMC4225465/ [51] Oxygen Saturation Monitoring for the Preterm Infant - Nature https://www.nature.com/articles/pr200973 [52] Oxygen Saturation guidelines Oxygen titration guidelines April 2020 ... https://fn.bmj.com/content/fetalneonatal/early/2022/08/23/archdischild-2022-324160/DC1/embed/inline-supplementary-material-1.pdf?download=true

Answer 7

MVP ## Footnote https://journals.physiology.org/doi/full/10.1152/advan.00128.2011

Answer 8

**platelets prior to pRBCs** n the setting of massive/rapid transfusion when platelets and plasma are both required, they may be transfused sequentially through the same blood administration set." Platelets must be transfused through a new blood administration set. In the setting of massive/rapid transfusion when platelets and plasma are both required, they may be transfused sequentially through the same blood administration set. Platelets must not be transfused through a blood administration set which has previously been used for red cells, as red cell debris in the in-line filter may trap infused platelets. Red cells may follow platelets through the same blood administration set, but not precede platelets. ## Footnote https://www.lifeblood.com.au/health-professionals/clinical-practice/transfusion-process/administration The most appropriate order for sequential transfusion of blood products through the same administration set is **platelets first, followed by red cells, then plasma**. This sequence minimizes risks of platelet trapping and ensures safe product compatibility with the administration set. ### Key Rationale: 1. **Platelets first**: - Platelets **must not be transfused through a blood administration set previously used for red cells**, as residual red cell debris can trap platelets and reduce efficacy[10][16]. - Transfusing platelets first allows subsequent products (red cells or plasma) to safely use the same set[7][10]. 2. **Red cells second**: - Red cells can follow platelets through the same administration set without issues[10]. - Studies like the PROPPR trial prioritized platelet transfusion in massive hemorrhage protocols, followed by alternating red cells and plasma[1][5]. 3. **Plasma last**: - Plasma is compatible with the same administration set used for red cells or platelets[7]. - Plasma units often follow red cells in transfusion sequences to maintain ratio-based resuscitation strategies (e.g., 1:1:1)[1][5]. ### Why Other Sequences Are Incorrect: - **Red cells → platelets**: Risks platelet entrapment in red cell debris[10][16]. - **Plasma → red cells → platelets**: Exposes platelets to red cell debris if the same set is reused. - **Red cells → plasma → platelets**: Fails to prioritize platelets and risks contamination of the set for subsequent platelet transfusions. This order aligns with clinical guidelines emphasizing platelet-first protocols in transfusion medicine[3][7][10]. Sources [1] Transfusion of Plasma, Platelets, and Red Blood Cells in a 1:1:1 vs a ... https://pmc.ncbi.nlm.nih.gov/articles/PMC4374744/ [2] Blood administration | Professional Education https://professionaleducation.blood.ca/en/transfusion/clinical-guide/blood-administration [3] Transfusion Medicine - Pathology - University of Michigan https://www.pathology.med.umich.edu/blood-bank/faq [4] [PDF] Safety Blood filters & giving sets Common blood products https://www.rch.org.au/uploadedFiles/Main/Content/bloodtrans/BLOOD_PRODUCT_ADMINISTRATION.pdf [5] Transfusion of Plasma, Platelets, and Red Blood Cells in a 1:1:1 vs a ... https://jamanetwork.com/journals/jama/fullarticle/2107789 [6] Single Unit Transfusion Guide | National Blood Authority https://www.blood.gov.au/blood-products/blood-product-management/single-unit-transfusion-guide [7] [PDF] Blood Components and Blood Products Administration https://cahs.health.wa.gov.au/~/media/HSPs/CAHS/Documents/Health-Professionals/Neonatology-guidelines/Blood-Components-and-Blood-Products-Administration.pdf?thn=0 [8] [PDF] Ordering Fresh Blood and Albumin - Quick Reference Guide (QRG) https://emrmonashhealth.org/wp-content/uploads/2020/04/Ordering-a-Blood-Transfusion-QRG-v3.pdf [9] ANZSBT Guidelines https://anzsbt.org.au/guidelines-standards/anzsbt-guidelines/ [10] Administration | Lifeblood https://www.lifeblood.com.au/health-professionals/clinical-practice/transfusion-process/administration [11] Plasma, Platelets and Whole Blood | Red Cross Blood Services https://www.redcrossblood.org/donate-blood/how-to-donate/types-of-blood-donations/blood-components.html [12] Blood Management Standard https://www.safetyandquality.gov.au/standards/nsqhs-standards/blood-management-standard [13] Blood administration - The Royal Children's Hospital https://www.rch.org.au/bloodtrans/blood_administration/Blood_administration/ [14] Massive Transfusion - StatPearls - NCBI Bookshelf https://www.ncbi.nlm.nih.gov/books/NBK499929/ [15] Blood and blood products clinical tool | Emergency Care Institute https://aci.health.nsw.gov.au/networks/eci/clinical/tools/blood [16] 3.15 Blood Administration Sets and Filters https://www.nzblood.co.nz/healthcare-professionals/transfusion-medicine/transfusion-medicine-handbook/3-guide-to-good-transfusion-practice/3-15-blood-administration-sets-and-filters/ [17] Types of transfusion - Lifeblood https://www.lifeblood.com.au/patients/types-of-transfusions [18] Transfusion process | Lifeblood https://www.lifeblood.com.au/health-professionals/clinical-practice/transfusion-process [19] Transfusion Guidelines https://www.vet.cornell.edu/animal-health-diagnostic-center/laboratories/comparative-coagulation/clinical-topics/transfusion-guidelines [20] Clinical Practice Guidelines : Blood product prescription https://www.rch.org.au/clinicalguide/guideline_index/Blood_product_prescription/

Answer 9

| Mapleson circuits

Answer 10

sBP < 50 mmHg ## Footnote ANZAAG

Answer 11

Adductor pollicis ## Footnote https://pubs.asahq.org/anesthesiology/article/138/1/13/137379/2023-American-Society-of-Anesthesiologists

Answer 12

**No difference in PONV** Although both 4 mg and 8 mg have consistently been shown to provide effective prophylaxis (and treatment) for postoperative nausea and vomiting, the higher dose (8 mg) almost certainly provides additional benefits for both analgesia and QoR, and perhaps earlier hospital discharge. ## Footnote https://pubs.asahq.org/anesthesiology/article/135/5/895/116641/Benefits-and-Risks-of-Dexamethasone-in-Noncardiac

Answer 13

"**Psoas Tendon (This)** Iliacus Sartorius " The anterior hip capsule is innervated by the articular branches from the 1. femoral, (AIIS IPE) 2. obturator, (pericap spread) 3. accessory obturator nerves (AIIS IPE) while the posterior capsule is innervated by branches from the sacral plexus ## Footnote https://www.asra.com/news-publications/asra-newsletter/newsletter-item/asra-news/2023/08/01/how-i-do-it-pericapsular-nerve-group-%28peng%29-block

Answer 14

CO2 - covers both class A and E Extra: PASS point, aim, squeeze, sweep RACE remove/rescue alert contain evacuate ## Footnote PS 55A - appendix 3 - minimum safe facility FireExtinguishersInformationSheet

Answer 15

**Maxillary incisors** are the most commonly injured under GA. Representing 50% of cases, theyare particularly prone to fracture, being small-rooted, of narrow cross-sectional area with a slight anterior axis. The **left central maxillary incisor** is most vulnerable to damage from the flange of the laryngoscope blade if used as a fulcrum, usually when attempting to improve the view during a difficult intubation." ## Footnote BJA Education Dental Knowledge for Anaesthetists 2016

Answer 16

Body - white | Shoulder - blue and white ## Footnote BOC medical cylinder chart

Answer 17

0.1-0.3ml/kg 1:10,000 ## Footnote https://www.apls.org.au/algorithm-newborn-life-support

Answer 18

mParkland 3mL/kg x TBW x %TBSA 3-4ml so B

Answer 19

a 4 second/1000mL (250x60, /1000)= A 15L/m) initial rescue breath, followed by 2 second/500mL subsequent breaths guided by SpO2 measurement. These volumes are suggested for an “average adult”. ## Footnote EMAC CICO

Answer 20

840mL 840mL/70kg = 12ml/kg 1.5mL/kg bolus over 2-3 mins 15mL/kg/hr to 30mL/kg/h ## Footnote AAGBI

Answer 21

10 years old (30kg) (need quadraceps bulk) MH AD Early/developing/later signs Most freq CO2 high tachy masseter spasm temp abn | MH ## Footnote MH ANZ - https://malignanthyperthermia.org.au/mh-for-anaesthetists/

Answer 22

**Aspirin** NSAIDs - displaces thyroxine from TBP

Answer 23

- **Myo injury** - cTn > 99th percentile URL Acute if rise or fall **- Myo INFARCTION** Myo Injury +clinical evidence of AMI + at least 1 of 1. MI sx 2. New ischaemia ECG changes 3. Path Q waves 4. Imaging - new loss myo or RWMA 5. ID cor thrombus by angio/autopsy A rise and fall of cardiac troponin above the 99th percentile upper reference limit with clinical evidence of ischemia demonstrated by at least one of the following: symptoms of ischemia, new ECG changes, or imaging evidence of a new regional wall motion abnormality1. The absence of thrombus on angiography is a critical distinguishing feature that virtually eliminates Type 1 MI from the differential diagnosis1. ## Footnote https://www.sciencedirect.com/science/article/pii/S0735109718369419?via%3Dihub#sec6 Fourth Universal Definition of Myocardial Infarction (2018) ESC

Answer 24

Higher in females despite same dose propofol Responses consistent with connected consciousness occurred in 37 of 338 subjects (11%), and were twice as likely to occur in female (13%) than in male (6%) subjects. There were no differences in medical comorbidity, **dosing of anaesthetic drugs**, or performance of tracheal intubation to explain why some subjects experienced connected consciousness. ## Footnote Lennertz Connected consciousness after tracheal intubation in young adults: an international multicentre cohort study Br J Anaesth. 2023 Feb; 130(2): e217–e224.

Answer 25

Chronic pain after thoracotomy afflicts up to 57% of patients at 3 months and 47% at 6 months.8 This incidence has not improved since the 1990s despite improvements in perioperative care.8 Patients present to the pain clinic describing a burning, numbness, or a cutting sensation along the thoracotomy scar, which may be constant or intermittent, and may be evoked by non-painful stimuli such as changes in temperature or donning clothing. ALLODYNIA Pain due to a **stimulus** that does not normally provoke pain. **DYSESTHESIA** An unpleasant abnormal sensation, whether spontaneous or evoked. Paraesethsia An abnormal sensation, whether spontaneous or evoked (not unpleasant) HYPERALGESIA Increased pain from a stimulus that normally provokes pain. ## Footnote https://www.iasp-pain.org/resources/terminology/

Answer 26

12mo ## Footnote PS50 https://www.anzca.edu.au/fellowship/fellows-toolkit/taking-a-career-break-and-returning-to-anaesthesia

Answer 27

## Footnote Advanced airway assessment techniques https://www.bjaed.org/article/S2058-5349(21)00056-1/pdf

Answer 28

**GOn** LOGAn SCTC Cervical roots **C2-4** Plexus branches = great auricular n, lesser occipital, supraclavicular, transverse cervical. ## Footnote https://www.nysora.com/topics/regional-anesthesia-for-specific-surgical-procedures/head-and-neck/ultrasound-guided-cervical-plexus-block/

Answer 29

Oral corticosteroids probably do not significantly diminish the skin test reaction even after prolonged use ## Footnote https://www.allergy.org.au/images/stories/pospapers/ASCIA_SPT_Manual_March_2016.pdf

Answer 30

**10-20 mins nap** (ideal) appendix 7 Minimisation Effects may be minimised by: Naps **2 hour nap prior to night duty** ** 30 minute nap during night duty** - Naps are followed by a period of “sleep inertia” - 15-30 minute period of impaired performance after waking. ## Footnote PG43A 2020 Fatigue Minimising the effects of night-time shift work may be achieved by taking a 60- 90 minute afternoon sleep prior to the night duty, taking a 20-30 minute nap during the shift, eating proper meals, and sleeping as soon as possible after completing their shift.9,10

Answer 31

Atrac Miv ## Footnote https://pubs.asahq.org/anesthesiology/article/120/3/753/13713/Perioperative-Management-of-Patients-with For a 39-year-old patient with mastocytosis undergoing laparoscopic cholecystectomy, **atracurium and mivacurium** are the non-depolarizing muscle relaxants to avoid due to their high potential to trigger mast cell degranulation and hypersensitivity reactions[1][4][5][6]. These benzylisoquinolinium compounds directly activate mast cells, increasing the risk of severe perioperative complications like anaphylaxis[1][4]. Safer alternatives include **rocuronium**, **vecuronium**, and **cisatracurium**, which have minimal mast cell activation effects[1][5][6]. For laparoscopic procedures, cisatracurium combined with rocuronium has demonstrated stable muscle relaxation with reduced dosing requirements[3]. Prophylactic H1/H2 antihistamines and corticosteroids are recommended preoperatively to mitigate mast cell mediator release[1][5]. Sources [1] [PDF] Mastocytosis and Anaesthesia Advice for patients https://www.rcoa.ac.uk/sites/default/files/documents/2020-09/Mastocytosis2014.pdf [2] Mast cell activation syndrome—anesthetic challenges in two ... https://pmc.ncbi.nlm.nih.gov/articles/PMC9724157/ [3] Effects of Combined Rocuronium and Cisatracurium in ... https://pmc.ncbi.nlm.nih.gov/articles/PMC5332119/ [4] [PDF] NAP6 Chapter 6 - Summary of main findings.pdf https://www.nationalauditprojects.org.uk/downloads/NAP6%20Chapter%206%20-%20Summary%20of%20main%20findings.pdf [5] [PDF] Anaesthesia recommendations for Systemic mastocytosis https://www.orphananesthesia.eu/en/rare-diseases/published-guidelines/systemic-mastocytosis/1710-systemic-mastocytosis-2/file.html [6] Surgery and Anesthesia - Mastocytosis.ca https://www.mastocytosis.ca/en/treatment/surgery-and-anesthesia [7] Succinylcholine Chloride - StatPearls - NCBI Bookshelf https://www.ncbi.nlm.nih.gov/books/NBK499984/ [8] Neuromuscular physiology and pharmacology: an update https://academic.oup.com/bjaed/article/12/5/237/289170 [9] Anaesthesia in a patient with mastocytosis - PMC https://pmc.ncbi.nlm.nih.gov/articles/PMC9511845/ [10] [PDF] Neuromuscular blocking agents and reversal agents - ? Heading 16 https://www.nationalauditprojects.org.uk/downloads/NAP6%20Chapter%2016%20-%20Neuromuscular%20blocking%20agents%20and%20reversal%20agents.pdf [11] Perioperative Management - TMS - The Mast Cell Disease Society, Inc https://tmsforacure.org/perioperative-management/ [12] Neuromuscular Blocking Agents - StatPearls - NCBI Bookshelf https://www.ncbi.nlm.nih.gov/books/NBK537168/ [13] Muscle Relaxants Allergy - Sage Journals https://journals.sagepub.com/doi/pdf/10.1177/03946320110240S306 [14] Mastocytosis: anaphylaxis following emergency anaesthesia https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/pdf/10.21466/ac.MAFEA2.2015 [15] atracurium journal articles from PubMed - Unbound Medicine https://www.unboundmedicine.com/medline/research/atracurium [16] Challenges in Drug and Hymenoptera Venom Hypersensitivity ... https://www.mdpi.com/2075-4418/14/2/123 [17] Is Muscle Relaxant Necessary for Cardiac Surgery? - ResearchGate https://www.researchgate.net/publication/8215133_Is_Muscle_Relaxant_Necessary_for_Cardiac_Surgery [18] Successful Management of Hypothermic Cardiopulmonary Bypass https://journals.lww.com/aoca/fulltext/2020/23030/successful_management_of_hypothermic.28.aspx [19] Selecting Neuromuscular-Blocking Drugs for Elderly Patients https://www.researchgate.net/publication/10945622_Selecting_Neuromuscular-Blocking_Drugs_for_Elderly_Patients [20] [PDF] A Practical Guide for Treatment of Pain in Patients with Systemic ... https://www.painphysicianjournal.com/current/pdf?article=NDYxNQ%3D%3D&journal=107

Answer 32

2 ## Footnote https://www.asahq.org/standards-and-practice-parameters/statement-on-asa-physical-status-classification-system

Answer 33

? Cephlosporins? not specifically told not to use them? ------- aminoglycosides: pre and post NMJ blockade. Fluroquinolones: umnask and worsen MOA ?. Fluroquinolones: avoid. macrolides and telithromycin: avoid. Based on the available information, the antibiotic considered safest to be administered to a patient with myasthenia gravis in the perioperative period is: **Amoxicillin** Rationale: While no antibiotic is completely without risk in myasthenia gravis (MG) patients, amoxicillin appears to have the lowest risk profile among the options discussed in the search results: 1. **Penicillins, including amoxicillin, are generally considered low-risk antibiotics for MG patients[2][4].** 2. Amoxicillin is used as a reference antibiotic "not associated with MG risk" in comparative studies[6]. 3. Other antibiotic classes have higher reported risks of exacerbating MG: - Aminoglycosides have a high risk and should be used cautiously, if at all[1][2][5]. - Fluoroquinolones have a high risk and carry a black box warning against use in MG patients[2][5]. - Macrolides have a moderate risk and should be used cautiously, if at all[2][5]. 4. While there are rare case reports of MG exacerbations with amoxicillin, the overall risk appears lower compared to other antibiotic classes[4]. It's important to note that any antibiotic can potentially cause issues in MG patients, so close monitoring is always recommended regardless of the antibiotic chosen[4][5]. Citations: [1] https://periop-handbook.ukclinicalpharmacy.org/drug/pyridostigmine/ [2] https://www.aliem.com/antibiotics-and-myasthenia-gravis/ [3] https://www.neurologyadvisor.com/features/guidance-for-antibiotic-use-in-myasthenia-gravis/ [4] https://pubmed.ncbi.nlm.nih.gov/32296986/ [5] https://pmc.ncbi.nlm.nih.gov/articles/PMC8520038/ [6] https://consultqd.clevelandclinic.org/myasthenia-gravis-exacerbation-with-quinolone-and-macrolide-antibiotics-what-is-the-risk [7] https://www.myaware.org/abn-guidelines [8] https://www.orphananesthesia.eu/en/rare-diseases/published-guidelines/myasthenia-gravis/730-myasthenia-gravis-2/file.html [9] https://pmc.ncbi.nlm.nih.gov/articles/PMC8038781/ [10] https://www.neurology.org/doi/10.1212/WNL.0000000000011124 [11] https://myasthenia.org/wp-content/uploads/Portals/0/Cautionary%20Drugs.pdf [12] https://www.ncbi.nlm.nih.gov/books/NBK572091/ [13] https://academic.oup.com/ofid/article/4/suppl_1/S342/4294794 [14] https://www.ccjm.org/content/90/2/81 [15] https://rightdecisions.scot.nhs.uk/nhs-dumfries-galloway-antimicrobial-handbook/additional-resources-incl-dosing-generaldrug-specific-advice-pils-sapg-guidance/general-antimicrobial-prescribing/myasthenia-gravis-and-antibiotics/ [16] http://www.scielo.org.mx/scielo.php?script=sci_arttext&pid=S2524-177X2019000200098 [17] https://www.safetyandquality.gov.au/sites/default/files/migrated/3.8-Surgical-Antibiotic-Prophylaxis.pdf [18] https://ccmsfiles.tg.org.au/s5/PDFs/ABG16-Surgical-antibiotic-prophylaxis-Collated-table-v4.pdf?type=Surgical+prophylaxis+-+summary+tables

Answer 34

"a) argon **weakest, used in retinal surgery** b) Nd:YAG **strongest laser** c) Er:YAG d) CO2 e) holmium *lithotrypsy**" | Laser danger is proportional to penetration. Penetration inversely prop ## Footnote Based on comprehensive analysis of the available evidence, the ranking of these lasers from least to greatest tissue penetration is: Er:YAG laser (least penetration) CO₂ laser Holmium lithotripsy laser Argon laser Nd:YAG laser (greatest penetration)

Answer 35

"a) Frailtyee b) Age ** c) GA vs neuraxial** d) male"

Answer 36

"a) ketone production b) intravasc volume ** c) serum Cr d) " ## Footnote https://www.tga.gov.au/sites/default/files/auspar-empagliflozin-171026-pi.pdf

Answer 37

Patients may need to be transitioned to oral naltrexone for this period, which can then be stopped **72 hours prior to surgery** ## Footnote Blue book 2023 P.106 107

Answer 38

Volatile appears safe Avoid propofol infusion. Can give propofol bolus for induction if thio and etomidate not available Beta agonism reduce STE Isoprenaline (b1 and b1 AGONIST) Note: Medications that worsen STE in the precordial leads (V1–V3) consistent with Brugada pattern indicate a pro-arrhythmogenic state. ## Footnote https://www.brugadadrugs.org/ Miller's 10e P.879

Answer 39

Anterior triangle borders 1. midline of neck 2. anterior border of SCM, 3. inferior border of mandible Posterior 1. A: posterior SCM 2. P: anterior traps 3. Inferior: mid 1/3 clavicle EJV, SCV, SCA ## Footnote https://teachmeanatomy.info/neck/areas/anterior-triangle/

Answer 40

Hyperkalemia, hyponatremia Occasionalhypoglycemia Hypercalcemia KaCa high Salt and sugar low ## Footnote Miller's 10e P. 895 OHA P. 229

Answer 41

Bup ## Footnote "Avoid due to methaemaglobinaemia: benzocaine, lidocaine, articaine, prilocaine; https://accessanesthesiology.mhmedical.com/content.aspx?bookid=572§ionid=42543607 Bupivacaine - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9658825/ "

Answer 42

IV fluid bolus (50mL/kg), norad infusion +/- vasopressin +/- metaraminol/phenylephrine, glucagon (1-2mg Q5m) Refrac BRONCHOSPASM - salbutamol - Mag - Inh - Ketamine

Answer 43

HypoK Long QT--> TdP (polymorphic VT) Monomorphic VT ## Footnote https://ecgwaves.com/topic/ecg-electrolyte-imbalance-electrolyte-disorder-calcium-potassium-magnesium/

Answer 44

(probably classic, anything with aperture bars)

Answer 45

Dialysis, Cr, Bili, INR, Na

Answer 46

Sheehan Post–dural puncture headache is associated with a substan- tially increased risk of **cerebral venous thrombosis and sub- dural hematoma** (composite adjusted odds ratio [aOR] 19.0 [95% confidence interval (CI) 11.2–32.1]) and **bacterial meningitis** (aOR 39.7 (95% CI 13.6–115.1)]. Therefore rec- ognizing, treating and monitoring patients who suffer PDPH is vitally important.384 In addition to the acute, severe symptoms associated with a PDPH, new studies have shown an increased risk of long-term adverse effects such as ** - chronic back pain, - chronic headache, - decreased breast- feeding, postpartum depression, and posttraumatic stress disorder.218–220** ## Footnote Miller's

Answer 47

BP ok < 34w Fetal neuroprotection - red incidence of CP ## Footnote OHA P 870

Answer 48

not safe "NSAIDS cat c except celecoxib B3 APMSE 2020"

Answer 49

b) CTG persistent foetal brady The most common sign of uterine rupture during attempted vaginal birth after cesarean (VBAC) is **abnormal fetal heart rate tracing**, particularly prolonged deceleration or fetal bradycardia. This is consistently reported across multiple clinical guidelines and studies as the most reliable and frequently observed indicator[1][2][4][6][7][11][12]. ### Key Findings: 1. **Abnormal fetal heart rate (FHR) patterns** - Present in 55–87% of uterine rupture cases[2][6]. - Prolonged fetal bradycardia (sudden drop in heart rate) is the most consistent finding[7][11]. - Occurs due to placental separation or compromised uteroplacental circulation during uterine tearing[4][14]. 2. **Other supporting signs** - **Severe abdominal pain** persisting between contractions, though this may be masked by epidural analgesia[2][3][6][12]. - **Loss of fetal station** (recession of the baby’s head into the birth canal)[1][4][6]. - Maternal tachycardia, hypotension, or signs of shock[1][3][6]. ### Clinical Context: - While uterine rupture is rare (<1% in VBAC attempts)[1][5], prompt recognition is critical. Abnormal FHR often precedes maternal symptoms[4][11]. - Continuous electronic fetal monitoring is mandatory during VBAC due to this risk[4][12]. For example, a study cited by *BJA Education* notes that FHR abnormalities were the first sign in 66–76% of uterine rupture cases[4][12]. UpToDate similarly highlights FHR changes as the most common initial indicator[11]. In summary, vigilance for **fetal bradycardia or prolonged deceleration** on cardiotocography is paramount, as delayed intervention beyond 10–40 minutes significantly increases neonatal mortality[5][7]. Sources [1] Uterine Rupture: Causes, Symptoms, and Treatment https://www.healthline.com/health/pregnancy/complications-uterine-rupture [2] Anaesthetic Considerations for Vaginal Birth After Caesarean Delivery https://resources.wfsahq.org/atotw/anaesthetic-considerations-for-vaginal-birth-after-caesarean-delivery/ [3] Uterine rupture https://patient.info/doctor/uterine-rupture [4] [PDF] Birth After Previous Caesarean Section - WA Health https://www.kemh.health.wa.gov.au/~/media/HSPs/NMHS/Hospitals/WNHS/Documents/Clinical-guidelines/Obs-Gyn-Guidelines/Birth-After-Previous-Caesarean-Section.pdf?thn=0 [5] Uterine Rupture | Childbirth complications | Treatment https://www.drshivahk.com/uterine-rupture/ [6] [PDF] Guideline for the Management of Uterine Rupture - WISDOM https://wisdom.nhs.wales/health-board-guidelines/cwm-taf-maternity-file/uterine-rupture-management-guideline/ [7] Ruptured Uterus https://www.birthinjuryhelpcenter.org/birth-injuries/delivery-complications/uterine-rupture/ [8] Uterine Rupture - Risk Factors - Management - Surgery - TeachMeObGyn https://teachmeobgyn.com/labour/emergencies/uterine-rupture/ [9] Uterine Rupture - StatPearls - NCBI Bookshelf https://www.ncbi.nlm.nih.gov/books/NBK559209/ [10] What Is Uterine Rupture? https://www.webmd.com/baby/what-is-uterine-rupture [11] Vaginal Birth After Cesarean Delivery - StatPearls - NCBI Bookshelf https://www.ncbi.nlm.nih.gov/books/NBK507844/ [12] 1 https://www.barnsleyhospital.nhs.uk/sites/default/files/2023-07/uterine-rupture.pdf [13] [PDF] Anaesthetic Considerations for Vaginal Birth After Caesarean Delivery https://resources.wfsahq.org/wp-content/uploads/atow-450-00-1-6.pdf [14] Uterine Rupture: Signs, Symptoms, Risks & Treatment https://my.clevelandclinic.org/health/diseases/24480-uterine-rupture [15] [PDF] Supporting Women in their Next Birth After Caesarean Section (NBAC) https://www1.health.nsw.gov.au/pds/ActivePDSDocuments/GL2014_004.pdf [16] Uterine Rupture: What Family Physicians Need to Know https://www.aafp.org/pubs/afp/issues/2002/0901/p823.html [17] [PDF] Birth after Caesarean Section - SA Health https://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/resources/policies/birth+after+caesarean+section+-+sa+perinatal+practice+guidelines [18] [PDF] Guideline for the Management of Uterine Rupture - WISDOM https://wisdom.nhs.wales/health-board-guidelines/cwm-taf-maternity-file/guideline-for-the-management-of-uterine-rupture/

Answer 50

crack on and do blood patch at lumbar level!! ## Footnote "UTD ""Dx and Tx of spontaneous intracranial hypotension"" - Want brain MRI AND spine MRI but spine MRI is not to visualise CSF --> Seems to be to image spinal in case there's a tumor etc or something else prohibiting you from doing an epidural blood patch"

Answer 51

Anterior spinal artery syndrome Lateral spinothalamic tract ## Footnote "Deranged phys Power, pain, temp = anterior tracts priop + vibration = posterior "

Answer 52

0.9% NS ## Footnote "Maintain serum Na >140mmol/L Aim isotonic solution Starship kids hospital guideline NZ"

Answer 53

Dec/short Insp time Inc Exp time ## Footnote Blue book - 2021 Maintian pulm bf: Lim peak insp pressure to < 20cmH2o, short insp time, avoid excesive PEEP, reduce RR to < 20

Answer 54

C In this scenario of sudden hypoxemia and difficult ventilation during tonsillectomy in an intubated asthmatic child, **option C (ask surgeon to release gag)** is the correct next step. Here's why: 1. **Mechanical obstruction from gag placement** is the most likely immediate cause of difficult ventilation during tonsillectomy surgery. The mouth gag used for surgical exposure can compress the endotracheal tube (ETT) against the hard palate or teeth, particularly in pediatric patients with smaller airways. 2. **First-line intervention** should focus on relieving reversible iatrogenic causes before addressing bronchospasm (option B) or tube obstruction (option D). Releasing the gag often immediately improves ventilation by relieving ETT compression. 3. **Sequence of action**: - Release gag → reassess ventilation - If persists → suction ETT (option D) - If still problematic → consider bronchospasm treatment (option B) This approach follows the ASA difficult airway algorithm's emphasis on addressing positional/mechanical causes first in OR emergencies. While bronchospasm (option B) is important in asthmatics, it wouldn't typically cause sudden onset of difficult ventilation during gag manipulation. Sources

Answer 55

>60mmHg Note * 50 mmHg start compress in **anaphylaxis** ## Footnote CALS Bedside Notebook

Answer 56

wean from bypass and ventilate ## Footnote ??Failure of oxygenation via oxygenator

Answer 57

Temperatures measured at the nasopharyngeal, esophageal, bladder, rectal, or skin surface sites underestimate jugular bulb temperature during rewarming.314,315 Because monitoring **jugular bulb temperature** is not usually feasible, monitoring the temperature of the **blood in the arterial line of the CPB circuit** is considered the closest surrogate for brain temperature.315,317 Temperature measured in the **PA or the nasopharynx** (class IIa, Level C) are also reasonable sites to monitor during weaning from CPB. ## Footnote Miller 10e P. 1620

Answer 58

In TOE 4 chamber view, leaflet closest to septum is **anterior mitral leaflet **

Answer 59

BMS 6/12 DAPT DES 6-12/12 DAPT If surg mandatory, cease clopid 5/7, cont aspirin Cease P2Y12 inhibitor - In high or intermediate risk surgery - Restart and reload after 24-72 hours ## Footnote Bedside Notebook

Answer 60

Adenosine then B blocker ## Footnote ACLS/AL2 tachycardia algorithm ? blue book 2021

Answer 61

1:8000 with muscle relaxant b) 1:670 GA LSCS a) 1:8600 CTS c) 1:8200 volatile + NMBD b) Overall 1:19,000 d) e)

Answer 62

Laparotomy and R thoracotomy Ivor Lewis Esophagectomy In the Ivor Lewis esphagectomy, the esophageal tumor is removed through an abdominal incision and a right thoracotomy (a surgical incision of the chest wall). The esophagogastric anastomosis (reconnection between the stomach and remaining esophagus) is located in the upper chest. The first stage consisted of a **laparotomy** and mobilization of the stomach, and the second stage performed 10 to 15 days later was a **right thoracotomy**, resection of the esophagus, and esophagastric anastomosis. ## Footnote https://stanfordhealthcare.org/medical-treatments/e/esophagectomy/types/ivor-lewis-esophagectomy.html https://www.optechtcs.com/article/S1522-2942(09)00058-0/fulltext

Answer 63

e) decreased AKI RELIEF Trial: Key Findings Summary - **Study Design**: Large international RCT with 3,000 patients across 47 hospitals in 7 countries undergoing major abdominal surgery. - **Fluid Protocols**: Liberal strategy (10 mL/kg bolus at induction + 8 mL/kg/hr intraoperatively) vs. Restrictive strategy (5 mL/kg bolus + 5 mL/kg/hr intraoperatively). - **Total Fluid Volumes**: Liberal group received median 6.1L vs. restrictive group 3.7L (p<0.001). - **Acute Kidney Injury**: Liberal strategy resulted in significantly lower AKI rates (5.0%) compared to restrictive strategy (8.6%), p<0.001. - **Renal Replacement Therapy**: Trend toward lower requirement in liberal group (0.3% vs 0.9%, p=0.048), not significant after adjustment. - **Disability-free Survival**: No significant difference at 1 year (82.3% liberal vs 81.9% restrictive). - **Surgical Site Infections**: Lower in liberal group (13.6% vs 16.5%, p=0.02), not significant after adjustment. - **Anastomotic Leak**: No statistically significant difference (2.4% liberal vs 3.3% restrictive). - **Conclusion**: Liberal fluid strategy in major abdominal surgery decreased AKI compared to restrictive strategy. --- Answer from Perplexity: pplx.ai/share ANZCA study! The bottom line: Primary outcome: No difference in disability-free survival up to 1 year after surgery --> Acute kidney injury at 30 days occurred more commonly in the restrictive fluid group - Liberal group - decreased AKI No difference in mortality or major septic complications ## Footnote https://www.thebottomline.org.uk/summaries/relief/

Answer 64

**Allow eye to proptose** Retrobulbar haemorrhage reduces orbital compartment pressure Vision treatment requires prompt intervention with immediate decompression of the expanding hematoma by dissection of the lateral canthus (lateral canthotomy) and disinsertion of at least the inferior crus of the lateral canthal tendon (inferior cantholysis). This will allow for the globe to prolapse anteriorly relieving the pressure within the orbit. ## Footnote https://surgeryreference.aofoundation.org/cmf/trauma/midface/further-reading/retrobulbar-hemmorage

Answer 65

Irregular narrow-complex tachycardia In the acute care setting the simplest approach to managing this condition is to control the rate of ventricular response. This can be achieved with agents such as **oral or intravenous beta blockers (metoprolol 5mg IV) (contraindications would include a history of bronchospasm or evidence of decompensated heart failure)** or **digoxin (250 mcg to 500mcg IV or PO)**. In cases of paroxysmal (intermittent) atrial fibrillation many patients revert to a normal heart rhythm spontaneously. The common symptoms of tachycardia include syncope (fainting), shortness of breath, dizziness, chest pain or palpitations. The following adverse features suggest a need for immediate treatment (see tachycardia algorithm): - sBP < 90 mmHg; - HR > 150/min; - chest pain; - heart failure; or - drowsiness or confusion Add: Regular broad complex tachy = amiodarone 300mg then 900 Irregular broad complex tachy = AF = BBB = avoid adeno/dig/verap/diltiazem TdP VT = mag 5mmol over 10min; repeated x1; infusion 20mmmol over 4 hrs TdP from HB and brady = pacing, sync DC Avoid amiodarone ## Footnote https://www.anzcor.org/home/adult-advanced-life-support/guideline-11-9-managing-acute-dysrhythmias/ + AHA guideline

Answer 66

18mL Local anaesthetic for the block: - Dilute lidocaine (lignocaine) 1% with an equal quantity of normal saline to make a 0.5% solution - Lidocaine (lignocaine) dose: 3 mg/kg **(0.6 mL/kg of 0.5%; max 200 mg or 40 mL) ** ## Footnote RCH guidelines - Rec dilute lig to 0.5% https://www.rch.org.au/clinicalguide/guideline_index/Bier_block/

Answer 67

"Chewing gum and boiled sweets should be discarded prior to inducing anaesthesia to avoid them being inhaled as a foreign body but **do not constitute an indication for delaying any procedure unless they have been ingested."** ## Footnote PG07

Answer 68

Intercristal line in NEONATES = L5/S1

Answer 69

70mmHg ## Footnote Oxford Handbook

Answer 70

Midaz 0.15mg/kg ## Footnote https://www.apls.org.au/algorithm-status-epilepticus

Answer 71

IM Ad (paeds) 0-**6yo** = 150mcg **6**-12yrs = 300mcg q5m in lateral thigh

Answer 72

4mg/kg 60mg

Answer 73

**Reduced due to incr VD and Cl** The pharmacokinetic characteristics of a propofol bolus administered in patients with major burns were enhanced clearance and expanded volume of distribution. BURN and WT were the important covariates. Population pharmacokinetics of a propofol bolus administered in patients with major burns - 2010

Answer 74

sail sign | Probably LLL collapse? Look for sail sign or double R heart border

Answer 75

ANZCOR - 1L 2.1.5L "LITFL: Massive hemothorax is defined by the need for thoracotomy — the indications are: Blood loss > 1,500 mL or 1/3rd of blood volume Blood loss >200 mL/h (3 mL/kg/h) for 2-4 hours"

Answer 76

pneumothorax or lung apex ## Footnote https://academic.oup.com/bjaed/article/16/2/39/2897763

Answer 77

incr risk non fatal cardiac arrest ## Footnote POISE2 trial: Conclusions: Administration of low-dose clonidine in patients undergoing noncardiac surgery did not reduce the rate of the composite outcome of death or nonfatal myocardial infarction; it did, however, increase the risk of clinically important hypotension and nonfatal cardiac arrest.

Answer 78

esmolol **Answer:** **a) esmolol** **Rationale:** In acute aortic dissection, the primary therapeutic goals are to reduce systolic blood pressure (target <120 mmHg) and lower the rate of pressure rise (dP/dt) to minimize aortic wall stress. Beta-blockers like **esmolol** are first-line agents because they achieve both objectives by reducing heart rate and myocardial contractility[1][2][5][7]. Esmolol’s ultra-short half-life (9 minutes) allows precise titration, making it ideal for unstable patients[1][2]. Vasodilators like sodium nitroprusside (SNP) or hydralazine are contraindicated as monotherapy due to reflex tachycardia, which increases dP/dt and propagation risk[2][8]. Guidelines explicitly state hydralazine should not be used in aortic dissection[3][6][8]. SNP may be added *after* beta-blockade for additional blood pressure control[2][7]. HTN (hypertension) is not a medication. Thus, esmolol is the optimal initial choice[1][5][7][10]. Citations: [1] https://pubmed.ncbi.nlm.nih.gov/32354528/ [2] https://emedicine.medscape.com/article/2062452-medication [3] https://www.bhs.org.au/bhsapps/govdoc/gdhtml/GDDRG0034-25949-63479.pdf [4] https://nyulangone.org/conditions/aortic-dissection/treatments/medication-for-aortic-dissection [5] https://institutionalrepository.aah.org/cgi/viewcontent.cgi?article=1077&context=sciday [6] https://www.ahajournals.org/doi/10.1161/ATVBAHA.118.310956 [7] https://journals.sagepub.com/doi/10.1177/17511437231162219 [8] https://www.uhbw.nhs.uk/assets/1/22-201_aortic_dissection_redacted.pdf [9] https://aci.health.nsw.gov.au/networks/eci/clinical/tools/cardiology/aortic-dissection [10] https://litfl.com/acute-aortic-dissection/ [11] https://www.annalscts.com/article/view/4188/pdf [12] https://pmc.ncbi.nlm.nih.gov/articles/PMC10726980/ [13] https://www.emra.org/emresident/article/thoracic-aortic-dissection [14] https://www.ncbi.nlm.nih.gov/books/NBK518965/ [15] https://coreem.net/core/aortic-dissection/ [16] https://academic.oup.com/bjaed/article/9/1/14/465697 [17] https://www.ahajournals.org/doi/10.1161/CIR.0000000000001106 [18] https://www.ncbi.nlm.nih.gov/books/NBK470296/ [19] https://www.bloodpressureclinic.ed.ac.uk/sites/default/files/atoms/files/type_b_aortic_dissection.pdf [20] https://emcrit.org/ibcc/htn/ [21] https://www.ncbi.nlm.nih.gov/books/NBK441963/ [22] https://www.ahajournals.org/doi/10.1161/CIRCRESAHA.118.312436 ## Footnote "Up TO Date Initial treatment consists typically of an intravenous beta blocker to reduce the heart rate to 60 to 80 beats/minute [75]. Esmolol is useful in the acute setting due to its short half-life and ability to titrate to effect --> Then SNP"

Answer 79

Catastrophising ## Footnote APMSE p24

Answer 80

Amitriptyline 3.6 Tramadol (NNT 4.4) ## Footnote APMSE p 137

Answer 81

RCH guidelines Wong-baker by age 4 Visual analogue scale by age 8

Answer 82

Tranexamic Acid Efficacy in Different Clinical Scenarios Tranexamic acid (TXA) is an antifibrinolytic agent that inhibits the enzymatic breakdown of fibrinogen and fibrin by plasmin. While it has proven beneficial in several clinical scenarios involving hemorrhage, its efficacy is not universal across all bleeding conditions. Evaluation of Tranexamic Acid Across Clinical Settings Cardiac Surgery Applications TXA demonstrates significant benefit in cardiac surgery settings. The ATACAS trial, which examined tranexamic acid use in patients undergoing coronary artery surgery, found that TXA was "associated with a lower risk of bleeding than was placebo, without a higher risk of death or thrombotic complications within 30 days after surgery"[3]. While TXA did increase the risk of postoperative seizures, its hemostatic benefits were clear, with significantly reduced blood product transfusion requirements and fewer reoperations for bleeding[3][8]. Neurotrauma Management In traumatic brain injury (TBI), the CRASH-3 trial demonstrated that timely TXA administration reduces mortality in specific patient groups. Particularly beneficial effects were observed "in patients with reactive pupils and those with a mild to moderate GCS at baseline"[4]. The trial emphasized that treatment delay reduces benefit, highlighting the importance of early administration[4][9]. Postpartum Hemorrhage The WOMAN trial provided compelling evidence for TXA in postpartum hemorrhage (PPH). Results showed that when administered within 3 hours of birth, TXA "can reduce the risk of death due to bleeding by one-third and the need for surgery to stop bleeding by over one-third"[5][10]. With PPH being a leading cause of maternal mortality worldwide, this represents a significant clinical advance in obstetric care. Trauma-Related Hemorrhage The landmark CRASH-2 trial established TXA's role in trauma management. This international study demonstrated mortality benefits when TXA was administered to bleeding trauma patients, particularly when given early after injury[6][11]. The evidence has been robust enough to influence trauma protocols globally. Gastrointestinal Bleeding In stark contrast to the aforementioned scenarios, the HALT-IT trial found that TXA provides no mortality benefit in gastrointestinal bleeding. This international, randomized, double-blind, placebo-controlled trial involving 12,009 patients conclusively demonstrated that "tranexamic acid did not reduce death from gastrointestinal bleeding"[16]. The trial reported "death due to bleeding within 5 days of randomisation occurred in 222 (4%) of 5956 patients in the tranexamic acid group and in 226 (4%) of 5981 patients in the placebo group (risk ratio [RR] 0·99, 95% CI 0·82-1·18)"[16]. More concerning, the study found that TXA was "associated with an increased risk of venous thromboembolic events (deep vein thrombosis or pulmonary embolism)"[16]. The trial investigators explicitly concluded that "tranexamic acid should not be used for the treatment of gastrointestinal bleeding outside the context of a randomised trial"[16]. Conclusion Based on the comprehensive evidence from major clinical trials, tranexamic acid has proven beneficial in cardiac surgery, traumatic brain injury, postpartum hemorrhage, and general trauma management. However, the HALT-IT trial clearly establishes that TXA is not useful in the management of upper gastrointestinal bleeding, where it shows no benefit and potential harm. Therefore, the correct answer is e) UGI bleed. Citations: [1] https://pmc.ncbi.nlm.nih.gov/articles/PMC6668177/ [2] https://txacentral.lshtm.ac.uk/gi-bleeding/ [3] https://pubmed.ncbi.nlm.nih.gov/27774838/ [4] https://pubmed.ncbi.nlm.nih.gov/32076783/ [5] https://www.thebottomline.org.uk/summaries/icm/woman-trial/ [6] https://pubmed.ncbi.nlm.nih.gov/23477634/ [7] https://bmjopen.bmj.com/content/bmjopen/13/2/e059982.full.pdf [8] https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.124.069606 [9] https://pmc.ncbi.nlm.nih.gov/articles/PMC3481366/ [10] https://txacentral.lshtm.ac.uk/post-partum-haemorrhage/ [11] https://onlinelibrary.wiley.com/doi/10.1155/2015/874920 [12] https://www.thebottomline.org.uk/summaries/halt-it/ [13] https://bmjopen.bmj.com/content/13/2/e059982 [14] https://www.theresusroom.co.uk/courses/txa-in-gi-bleeds/ [15] https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)308485/fulltext [16] https://pubmed.ncbi.nlm.nih.gov/32563378/ [17] https://ashpublications.org/ashclinicalnews/news/5319/Tranexamic-Acid-for-Gastrointestinal-Bleeding-Time [18] https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30975-2/fulltext [19] https://pubmed.ncbi.nlm.nih.gov/7793735/ [20] https://txacentral.lshtm.ac.uk/wp-content/uploads/2021/03/CRASH-3_neuroprotective-effect-of-tranexamic-acid.pdf [21] https://pmc.ncbi.nlm.nih.gov/articles/PMC2864262/ [22] https://www.journalslibrary.nihr.ac.uk/hta/HTA17100 [23] https://jamanetwork.com/journals/jama/fullarticle/2794565 [24] https://www.thebottomline.org.uk/summaries/crash-3/ [25] https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)30638-4/fulltext [26] https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)60835-5/fulltext [27] https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)32233-0/fulltext [28] https://pubmed.ncbi.nlm.nih.gov/28456509/ [29] https://www.ncbi.nlm.nih.gov/books/NBK260390/ [30] https://www.thelancet.com/article/S0140-6736(19)32312-8/fulltext --- Answer from Perplexity: pplx.ai/share "Multiple trials with TXA - CRASH-2 showed reduction in 28-day mortality in patients who received TXA within 3 hours of injury - CRASH-3 was a trial of TXA in head injured patients. The group with mild-moderate head injury benefited from TXA, but overall there was no significant effect - TRAAP2 showed the use of prophylactic TXA for caesarean delivery reduces the rates of PPH as defined by an estimated blood loss of > 1000ml or red cell transfusion by day 2 - HALT-IT showed TXA does not reduce death from GI bleeding and should not be used as part of a uniform approach to treat GI bleeding + harm shown - ATACAS 2017 showed the use of TXA was associated with a lower risk of bleeding post-operatively and was not associated with increased risk of death or thrombotic effects when compared to the administration of a placebo"

Answer 83

Prothrombinex - contains heparin "Bivalirudin is the non-heparin agent of choice for anticoag in HIT - UTD Danaparoid is a non-heparin anticoagulant used to treat HIT - NSW Guideline"

Answer 84

Reduced time to resumption of oral intake

Answer 85

"250mcg IM Q15min, up to 2mg "

Answer 86

rocuronium (24% - fig 4) ## Footnote NAP6

Answer 87

SST/serum tube (Gold top) ## Footnote https://www.rcpa.edu.au/Manuals/RCPA-Manual/Pathology-Tests/T/Tryptase

Answer 88

4 hrs ## Footnote https://www.lifeblood.com.au/health-professionals/clinical-practice/transfusion-process/administration

Answer 89

TRALI ## Footnote https://www.lifeblood.com.au/health-professionals/clinical-practice/adverse-events/TRALI

Answer 90

longer length ## Footnote https://aam.ucsf.edu/microlaryngoscopy-tube-mlt%C2%AE

Answer 91

30cmH20 ## Footnote 30cmh20 - thats the top of the green zone

Answer 92

"Two defibrillators with pads in 2 different planes (AL, AP) note - DSED better neurologic outcomes and survival to d/c vs standard defib in refractory VF < 1 sec" ## Footnote "https://www.nejm.org/doi/full/10.1056/NEJMoa2207304 ""two near-simultaneous defibrillation shocks provided by two defibrillators"""

Answer 93

Cold saline irrigation ## Footnote SMACC quick reference guidelines #9

Answer 94

"a) Hypoxia b) Alkalaemia c) High alpha1-acid glycoprotein d) Hypocarbia e) Increased carnitine levels" ## Footnote hypoxia (decreases protein binding as per BJA) "https://litfl.com/local-anaesthetic-toxicity-ccc/ risk factors: type of LA and dose, site of injection, the patient’s comorbidities, extremes of age, and small size or limited muscle mass, organ dysfunction (cardiac, hepatic, renal), the serum level of the binding proteins, and age. Worse with hypoxia, hypercarbia, acidosis. Carnitine deficiency may predispose to toxicity - https://pubmed.ncbi.nlm.nih.gov/21537157/ alpha 1 GP binds amide LA. Lower levels -> increased toxicity risk"

Answer 95

Non-inferiority is not demonstrated

Answer 96

comparisons of means between three groups (unpaired) in normally distr data ## Footnote BJA

Answer 97

Pregnancy - 3rd heart sound reflects rapid LV distension along with increased AV flow

Answer 98

Adductor Canal ## Footnote adductor canal block - https://www.bjanaesthesia.org/article/S0007-0912(18)30572-5/pdf

Answer 99

Critical appraisal

Answer 100

RCA - inferior - II III aVF LAD - anterior - V3 V4 OM - LCx - lateral - I aVL V5 V6 Post - RCA/RCx - V7 V8 V9 (reciprocal STD V1-V3)

Answer 101

Give IV iron ** Serum ferritin level < 30 μg.l−1 is the most sensitive and specific test used for the identification of absolute iron deficiency. However, in the presence of inflammation (C-reactive protein > 5 mg.l−1) and/or transferrin saturation < 20%, a serum ferritin level < 100 μg.l−1 is indicative of iron deficiency. Hb 110 (< 130) = anaemia CRP 10mg/L = inflammation Ferritin < 100 = iron deficiency 10 days pre op ( < 6 weeks dx) = IV iron ## Footnote https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.13773 International consensus statement on the peri-operative management of anaemia and iron deficiency Sufficient data exist to support intravenous iron as efficacious and safe. Intravenous iron should be used as front-line therapy in patients who do not respond to oral iron or are not able to tolerate it, or if surgery is planned for < 6 weeks after the diagnosis of iron deficiency. Ferritin < 30 = PO iron Ferritin 30-100 = IV iron

Answer 102

Unstable angina (no trop rise) (NSTEMI and MINS will both have trop rise)

Answer 103

Normal 0 to 90 deg LAD 0 to - 90 extreme axis -90 to 180

Answer 104

65 Norad first line ## Footnote Surviving sepsis guidelines 2021

Answer 105

octreotide bolus ## Footnote https://academic.oup.com/bjaed/article/11/1/9/285683

Answer 106

Vasoplegia Hemodynamic Profile in Cardiac Surgery: Low-Normal CVP, Hypotension, and Hyperdynamic Heart Hemodynamic monitoring during cardiac surgery provides critical information about a patient's cardiovascular status. When confronted with a pattern of low-normal central venous pressure (CVP), low blood pressure, and a hyperdynamic heart, clinicians must correctly identify the underlying pathophysiology to implement appropriate treatment strategies. This specific hemodynamic profile strongly suggests vasoplegia, but it's important to understand why this is the case and rule out other potential conditions. Vasoplegia as the Correct Answer Vasoplegia is defined as hypotension and low systemic vascular resistance (SVR) despite normal or elevated cardiac index, a complication frequently following cardiac surgery[1]. This hemodynamic profile perfectly matches the scenario described: low blood pressure (hypotension) with a hyperdynamic heart (indicating normal or elevated cardiac output) and a low-normal CVP. The pathophysiology of vasoplegia involves profound vasodilation leading to increased vascular capacitance. This excessive vasodilation results in relative hypovolemia despite potentially normal total blood volume, explaining the low-normal CVP[8]. The heart attempts to compensate for this decreased vascular resistance by increasing cardiac output, resulting in the hyperdynamic state described in the question. Vasoplegia is a common complication following cardiovascular surgery with cardiopulmonary bypass (CPB), with an incidence varying from 5% to 44%[4]. It represents a distributive form of shock characterized by a significant drop in vascular resistance. The pathophysiology involves multiple mechanisms, including activation of inflammatory pathways, excessive nitric oxide production, and vascular smooth muscle cell hyperpolarization through potassium channel activation[6][8]. Why Hypovolemia is Incorrect Hypovolemia refers to a decreased intravascular volume state. While hypovolemia can certainly cause low blood pressure and low CVP, it doesn't typically maintain a hyperdynamic cardiac state when severe enough to cause hypotension[5]. In significant hypovolemia, the heart initially becomes hyperdynamic as a compensatory mechanism, but as volume depletion continues, cardiac output eventually decreases due to inadequate preload. The extreme hyperdynamic state (EHS) described in one study is characterized by SVR below 450 dynes × s/cm^5 and a cardiac output above 7 L/min/m^2, but this was observed in conditions like cirrhosis and sepsis rather than pure hypovolemia[5]. In cardiac surgery, persistent hyperdynamic circulation with hypotension despite adequate volume replacement strongly points toward vasoplegia rather than simple hypovolemia. Why LV Dysfunction is Incorrect Left ventricular dysfunction presents with a fundamentally different hemodynamic profile than the one described. LV dysfunction typically causes: 1. Elevated CVP (not low-normal) due to backward failure and congestion in the venous system 2. Low blood pressure due to reduced forward flow 3. Reduced cardiac output (not hyperdynamic)[2] Heart failure with reduced ejection fraction is actually a risk factor for developing vasoplegia, with studies showing increased incidence of vasoplegia up to 74% in patients with poor LV function (EF < 37%) exposed to prolonged CPB duration[4]. This suggests that the hyperdynamic state described in the question cannot be attributed to LV dysfunction. Why Cardiomyopathy is Incorrect Cardiomyopathy, particularly dilated cardiomyopathy, presents with hemodynamics similar to LV dysfunction: 1. Elevated filling pressures, including increased CVP 2. Low blood pressure from decreased forward flow 3. Reduced cardiac output The hemodynamic profile would show a failing heart unable to generate adequate cardiac output, not the hyperdynamic state described in the question[7]. Like LV dysfunction, cardiomyopathy is characterized by impaired contractility, which is inconsistent with the hyperdynamic heart mentioned in the scenario. Conclusion The combination of low-normal CVP, low blood pressure, and a hyperdynamic heart in cardiac surgery most strongly suggests vasoplegia. This distributive shock state commonly occurs after cardiopulmonary bypass due to systemic inflammatory response, nitric oxide overproduction, and vasopressin deficiency, leading to pathologic vasodilation[1][4]. The other options—hypovolemia, LV dysfunction, and cardiomyopathy—each have hemodynamic profiles that differ significantly from the pattern described in the question, making vasoplegia the correct diagnosis. Citations: [1] https://www.eajm.org/Content/files/sayilar/221/92-100.pdf [2] https://litfl.com/cvp-measurement/ [3] https://www.ahajournals.org/doi/10.1161/JAHA.117.008377 [4] https://pmc.ncbi.nlm.nih.gov/articles/PMC9658078/ [5] https://pmc.ncbi.nlm.nih.gov/articles/PMC29017/ [6] https://www.mdpi.com/2077-0383/11/21/6407 [7] https://onlinelibrary.wiley.com/doi/10.1111/jocs.15805 [8] https://pmc.ncbi.nlm.nih.gov/articles/PMC6035427/ [9] https://www.ncbi.nlm.nih.gov/books/NBK519493/ [10] https://pmc.ncbi.nlm.nih.gov/articles/PMC10402787/ [11] https://www.racgp.org.au/afp/2014/may/dizziness [12] https://www.medintensiva.org/en-how-use-echocardiography-manage-patients-articulo-S217357272300200X [13] https://www.mdpi.com/1648-9144/60/12/2064 [14] https://onlinelibrary.wiley.com/doi/10.1111/liv.13589 [15] https://criticalcarenow.com/vasoplegia/ [16] https://academic.oup.com/ejcts/article/25/3/327/379777 [17] https://emcrit.org/pulmcrit/mythbusting-empty-ivc-hyperkinetic-heart-%E2%89%A0-volume-depletion/ [18] https://jeccm.amegroups.org/article/view/5248/html [19] https://www.medintensiva.org/en-factors-associated-with-vasoplegic-shock-articulo-S217357272400081X [20] https://www.ahajournals.org/doi/10.1161/circulationaha.108.803965 --- Answer from Perplexity: pplx.ai/share

Answer 107

O2 consumption at rest

Answer 108

8cm ## Footnote https://www.resus.org.nz/assets/Uploads/ANZCOR-Guideline-11.4-Elect-Jan16.pdf

Answer 109

Incr pulmonary vascular resistance | - ## Footnote "UTD - decrease in cardiac output up to 60% therefore decrease in cardiac index - Increased SVR due to vasopressin - increased hep bf only after 48h"

Answer 110

Desat In an awake neonate experiencing inadvertent total spinal anaesthesia, desaturation due to respiratory compromise is most likely to be the first observable clinical sign, followed by cardiovascular changes and eventually loss of consciousness if the condition progresses without intervention. (Perplexity) ## Footnote Cote's Practice of Anaes for Infants

Answer 111

More serious injury results from neuropraxia associated with pressure on cranial nerves from the tube (lingual nerve), or cuff (hypoglossal and recurrent laryngeal nerves) of the SAD have been reported in small case series. Injury to the lingual nerve usually presents as loss of taste and sensation to the tip of the tongue,hypoglossal nerve as dysphagia, and recurrent laryngeal nerve as altered voice and rarely, stridor. ## Footnote Iatrogenic airway injury BJA Education, 18(10): 310e316 (2018)

Answer 112

hypovolaemia Normal ED cm = 3.5-5.6cm

Answer 113

ΔP = Pplat – PEEP Clinical need Protective lung ventilation strategies and ‘open lung’ approaches are associated with less ventilator-induced lung injury (VILI), improved oxygenation and improved outcomes Important components of these strategies all decrease stress on the lung: lower tidal volumes lower plateau pressure higher PEEP Conclusion: 1. Titrating VT to prevent ΔP >13 cmH2O, if has minimal costs in terms of CO2 clearance, appears to be a reasonable adjunct to a protective lung ventilation approach 2. However, the use of driving pressure is yet to be subjected to a high quality randomised controlled trial confirming its clinical utility and safety 3. Optimal threshold for ΔP, if any, is unknown (various studies suggests targets in the range of 10-15 cmH2O). ## Footnote "https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7280884/ https://litfl.com/driving-pressure/"