21.1 Flashcards

Question 1

Q

21.1 The optimal position, under ultrasound guidance, to place a catheter tip to provide continuous erector
spinae plane block for post-thoracotomy analgesia is

a. Between the fascial plane of erector spinae and rhomboids
b. Posterior to both erector spinae and spinous process
c. Anterior to erector spinae and posterior to transverse process 5th rib
d. Superficial to the infraspinatus fossa
e .Superficial to the lamina

Answer

A

c. Anterior to erector spinae and posterior to transverse process 5th rib

Place anterior to transverse process and posterior to erector spine

Midpoint between T5-6
(Usual Incision T4-5, ICC T6)

Source - Blue book 2019

Question 2

Q

21.1 A structure that is NOT clamped during a Pringle manoeuvre is the

a. Hepatic artery
b. hepatic vein
c. Portal vein
d. Bile duct
e. Hepato-duodenal ligament

Answer

A

b. hepatic vein

Pringle Manoeuvre = clamping hepatoduodenal ligament (clamps hepatic artery, portal vein, CBD)

Question 3

Q

21.1 The muscle or muscle group with the greatest sensitivity to the action of non-depolarising neuromuscular blocking agents is/are the

a. Abdominal muscles
b. Adductor pollicis
c. Pharyngeal muscles
d. Diaphragm

Answer

A

b. Adductor pollicis

see combined deck/millers

Question 4

Q

21.1 The most common cause of mortality in children with diabetic ketoacidosis is

a. Cerebral oedema
b. Septic shock
c. Central pontine myelinolysis

Answer

A

a. Cerebral oedema

Cerebral Oedema

Source: UpToDate

Question 5

Q

21.1 The intubating dose of atracurium in a patient with post-polio syndrome should be

a. 10 %
b. 20
c. 50
d. 100
e. 200

Answer

A

0.25mg/kg (Half)

Source: PolioSA

Question 6

Q

21.1 In the morbidly obese the induction dose of propofol should be calculated based on

a. Lean body weight
b. Total body weight
c. Ideal body weight
d. Ideal body weight + 70%

Answer

A

Lean Body Weight

For infusion: Adjusted body weight
NDMB: Lean Body weight
Sux: Total body weight

Source: SOBA UK

Question 7

Q

21.1 All of the following conditions are associated with acromegaly EXCEPT

a. Myocardial fibrosis
b. biventricular enlargement
c. Arrhythmia
d. Left ventricular enlargement
e. AAA

Answer

A

e. AAA

Osteoarthritis
nerve compression syndrome due to bony overgrowth, and carpal tunnel syndrome
Hypertension
Diabetes mellitus
Cardiomyopathy/HF
Colorectal cancer
Sleep Apnea
Thyroid nodules and thyroid cancer
Hypogonadism
Compression of the optic chiasm

Source: BJA

Question 8

Q

21.1 The composition of blood returned to the patient from intraoperative cell salvage shows

A. No evidence of haemolysis
B. Normal 2,3 DPG
C. Nil evidence of bone cement or some embolism type
D. Normal levels of coagulation factors

Answer

A

B. Normal 2,3 DPG

higher Hct-60%
No immunimodulation
require reinfusion within 6hrs
pause with sement, caution metal fragments

Question 9

Q

21.1 When performing a brachial plexus block at the level of the axilla, the structure indicated by the arrow
is the (ultrasound image shown)

a. Musculocutaneous nerve
b. Median
c. Radial
d. Ulnar

Answer

A

Ultrasound view of right axillary brachial plexus AA = axillary artery AV = axillary vein McN = musculocutaneous nerve RN = radial nerve UN = ulnar nerve MN = median nerve CoBM = coracobrachialis muscle CT = conjoint tendon

Question 10

Q

21.1 Severe obstructive sleep apnoea in a 6-year-old child is confirmed if during polysomnography the
apnoea/hypopnea index (AHI) is greater than or equal to

A >5
B >10
C >15
D >20
E >30

Question 11

Q

21.1 Predictors of successful awake extubation after volatile anaesthesia in infants include

a. 2mL/kg tidal volume,
b. grimacing
c. coughing
d. RR > 20

Answer

A

b. grimacing

conjugate gaze
facial grimace
eye opening
purposeful movement
tidal volume greater than 5 ml/kg
suitable for age upto 7

Source: SPANZA 2019 article

Question 12

Q

21.1 Major international guidelines recommend maintaining the core body temperature between 32°C and
36°C in comatose patients after

A. SAH
B. Stroke
C. Cardiac Arrest

Answer

A

Cardiac Arrest

Source: LITFL

Question 13

Q

21.1 A man presents with a fractured tibia. He has increasing pain in his leg, loss of sensation on the plantar surface of his foot and weakness of toe flexion. This is most consistent with a compartment syndrome of the leg in the

A. Anterior
B. Lateral
C. Superficial Posterior
D. Deep posterior

Answer

A

Deep Posterior Compartment

Source: UpToDate

Question 14

Q

21.1 The coagulopathy that can result from intrahepatic cholestasis of pregnancy is due to

a. Platelet dysfunction
b. All clotting factors made by the liver
c. Thrombocytopenia
d. 2/7/9/10
e. Fibrinolysis

Answer

A

d. 2/7/9/10

Hypovitaminosis of Vitamin K

(Bile required for absorption)

Source: BMC Article
https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-022-04875-w

Question 15

Q

21.1 The best patient position to evaluate the gastric contents with ultrasound is

a. Right lateral
b. Trendelburg
c. Supine
d. Left lateral
e. Reverse trendelenberg

Answer

A

Right lateral Decubitus

BJA: ultrasound

Question 16

Q

21.1 A 50-year-old man is seen prior to his hip revision surgery. His blood results are (FBE and Iron
Studies shown). The most likely diagnosis is

Hb 110 (130-170 normal range)
Ferritin 31 (30-100 range)
Transferrin saturation 21% (normal 20-80)
CRP 10 (0.1-10 normal)

Answer

A

Anaemia of chronic inflamation with iron deficiciency

Question 17

Q

21.1 Of the following, allergy based on cross reaction to penicillin sensitivity is most likely with

A) Cephazolin
B) ceftriaxone
C) cefapime
D) cefaclor
E) cefoxatin

Answer

A

D) Cefaclor

Cephalexin? More so than Cephazolin (no B-lactam)
Cefaclor
cefapime

Source: UpToDate

Question 18

Q

21.1 In maternal cardiac arrest the most common arrhythmia is

a) PEA
b) VT
c) VF
d) Asystole
e) SVT

Answer

A

a) PEA

I couldn’t find a great article on this anywhere. BJAED hasn’t got much either

Question 19

Q

21.1 You are performing a regional block for analgesia following knee surgery. You have an ultrasound
probe scanning the anterior mid-thigh. The muscle indicated by the arrow in the ultrasound image
below is the

Question 20

Q

21.1 The recommended antibiotic prophylaxis for insertion of an intrauterine device is

a. cephalexin PO
b. cefazolin IV
c. doxycycline PO
d. none

Answer

A

d. none

Increase in presence of mycobacterium vaginosis, doxycylcine will kill commensal bacteria

Doxycycline is used for copper IUD in the setting of emergency insertion with PID

Question 21

Q

21.1 The independent predictors for severe bone cement implantation syndrome (BCIS) in cemented
hemiarthroplasty for hip fracture do NOT include

a. Male
b. GA
c. severe cardiopulmonary disease
d. Diuretic use
e. Age

Answer

A

b. GA

Independent predictors for severe BCIS were:
ASA grade III—IV
chronic obstructive pulmonary disease
medication with diuretics or warfarin

Source: BJA 2014 Article
https://academic.oup.com/bja/article/113/5/800/2920080

Question 22

Q

21.1 The 12 lead ECG shown is most consistent with acute total occlusion of the
ECG with ST depression V1-V5, perhaps 1mm ste in lead 3.

A. Posterior descending
B. RCA
C. LAD
D. OM

Question 23

Q

A 45 Year old man has poor oxygenation in the post anaesthesia care unit after a low anterior resection. His chest xray is below. The most likely diagnosis is

a. LLL collapse
b. Pneumothorax
c. L pleural effusion

Answer

A

The lungs are hyperinflated with relatively flat diaphragms - a sign of pulmonary emphysema. There is a dense triangular opacity overlying the cardiac shadow with increased lucency of the left upper zone relative to the right upper zone. This is the “sail sign” of left lower lobe collapse with subsequent left upper lobe hyper-expansion.

Question 24

Q

According to National Audit Project (NAP) 5, the incidence of awareness during general anaesthesia using a non relaxant technique with a volatile agent is
a. 1:700
b. 1:8000
c. 1:10000
d. 1:19000
e. 1:136,000

Answer

A

e. 1:136,000

1/670 E-LSCS
1/8000 with muscle relaxation
1/8600 CTS
Overall 1:19000

Question 25

Q

21.1 The drug which has the LEAST impact on somatosensory evoked potentials (SSEPs) monitored in a 15-year-old patient undergoing scoliosis surgery is

A) propofol
B) fentanyl
C) desflurane
D) Midazolam
E) sevoflurane

Answer

A

B) fentanyl

Drugs which have the least impact on SSEPs
1. Ketamine
2. Opioids
3. Dexmedetomidine

Article in Anaesthesiology
https://pubs.asahq.org/anesthesiology/article/99/3/716/40407/Pharmacologic-and-Physiologic-Influences-Affecting

Question 26

Q

21.1 Toxicity of methylene blue is likely to be seen after single bolus dose (in mg/kg) greater than

a. 1mg/kg
b. 2mg/kg
c. 5mg/kg
d. 0.5mg/kg
e. 0.1mg/kg

Answer

A

c. 5mg/kg

Methylene blue due to its monoamine oxidase(MAO) inhibiting property may precipitate potentially fatal serotonin toxicity at doses >5mg/kg.

Question 27

Q

21.1 A woman is having a potentially curative primary breast cancer resection. Compared with a
sevoflurane and opioid technique, using a regional anaesthesia-analgesia technique with paravertebral block and a propofol infusion will result in

a. Decreased cancer recurrence
b. Decreased chronic pain and recurrence
c. Decreased incision pain at 6 months
d. Decreased neuropathic pain at 6 months
e. Decreased neuropathic pain at 12 months

Answer

A

e. Decreased neuropathic pain at 12 months

ANZCA pain book

Question 28

Q

21.1 A normal 75 kg term parturient may be expected to have a total blood volume of

a. 5250
b. 6000
c. 6750
d. 7500

Answer

A

d. 7500

7.5L (Average increase around 48%)

BJAed

Question 29

Q

21.1 A patient undergoing robotic prostatectomy with controlled mandatory volume ventilation has the
following measurements:

plateau pressure 32 cmH2O, PEEP 8 cmH2O, autoPEEP 4 cmH2O, peak pressure 38 cmH2O, tidal volume 600mL

The static compliance is

20 ml/cmH20
23 ml/cmH2O
25 ml/cmH20
30 ml/cm H20

Answer

A

25ml/cm H2O

600/32-8 = 25

The answer is 30ml/cmH20 because total PEEP is 8+4=12

Static lung compliance (Cstat), mL/cm H2O = TV / (Plateau pressure (Pplat) – PEEP)

Question 30

Q

21.1 A 30-year-old professional athlete who underwent a knee arthroscopy under general anaesthesia becomes tachycardic in the recovery room. His non-invasive systolic blood pressure is 90 mmHg. A 12-lead ECG is obtained. The most appropriate therapy is

a. Adenosine 6mg (or 60mg remembered by other cohort)
b. valsalva
c. 50J
d. 200J

Answer

A

b. valsalva

Fluid and magnesium - fixes all.

But could also be conscious VT or something stupid….

Question 31

Q

21.1 A patient requiring an elective joint replacement has had a recent stroke. The minimum time to wait after the stroke before proceeding with surgery is

a. 3
b. 6
c. 9
d. 12 months

Answer

A

c. 9
AHA guidelines

12 Months
But 12 weeks minimum

Question 32

Q

21.1 The direct physiological effects of electroconvulsive therapy include

a) reduced contractility
b) initial htn
c) initial bradycardia
d) initial tachycardia
e) reduced ICP

Answer

A

c) initial bradycardia

ANS Stimulation (PNS first, then SNS)
- Bradycardic/Tachycardic
- Hypertensive
Neuro
- Increased CMR/CBF/ICP
- Increased IOP
Increased Gastric pressure

Question 33

Q

21.1 A man is brought into hospital after a motor vehicle accident 45 minutes ago. His chest x-ray is shown.
This is most consistent with a left-sided

Answer

A

?? XR Reviews

Question 34

Q

21.1 A common electrolyte disturbance following the administration of ferric carboxymaltose is

a. hypophosphatemia
b. hypocalicaemia
c. hypokalaemia
d. hypercalicaemia
e. hypernatraemia

Answer

A

Hypophosphataemia

Question 35

Q

21.1 Globe perforation during eye block is more common in myopic eyes because

Answer

A

Best answer? Staphylopias?

But also reduced space between globe and orbit

Question 36

Q

21.1 A five-year-old child weighing 25 kg is to be strictly nil by mouth overnight following a laparotomy. The
most appropriate fluid prescription is

a. 65ml/hr N Saline
b. 45ml/hr N saline w 5% dex
c. 45ml/hr N Saline w 2.5% dex
d. 65ml/hr .45% saline w 2.5% dex
e. 65ml/hr .45% saline w 5% dex

Answer

A

b. 45ml/hr N saline w 5% dextrose

A guide to paediatric anaesthesia fluid management
-421 rule overestimates fluid resus
-due to stress response from ADH release
-post-op fluid maintenace is 2/3rds calculated
-never use hypotonic solution
-unlikely to need glucose as not a neonate

Question 37

Q

21.1 A four-year-old boy with a history of waddling gait, larger than normal calves and frequent falls
receives a spontaneously breathing volatile-based anaesthetic with sevoflurane.

One hour into the case he develops peaked T waves and then the end-tidal CO2 begins to rise. The most appropriate immediate treatment is to

a. Temp probe, and go from there
b. Cool + dantrolene
c. Stop volatile, cool + dantrolene
d. Stop volatile, calcium
e. Stop volatile

Answer

A

d. Stop volatile, calcium

?Duchenne muscular dystrophy?

Immediate MH Management:
Stop administering Sevo, flush machine (or new), charcoal filters. Dantrolene.

Question 38

Q

21.1 The substance that should be avoided in a patient with history of anaphylaxis to MMR vaccine is

a. Protamine
b. Gelofusine
c. Sulphonamides
d. Penicilins

Answer

A

b. Gelofusin
Gelatin

Question 39

Q

21.1 A patient with a history of hereditary angiooedema requires an appendectomy for acute appendicitis.
The most effective therapy for the prevention of an acute attack in the perioperative period is

a) FFP
b) Icatibant
c) Hydrocortisone
d) Danazole
e) cetirizine

Answer

A

b) Icatibant

https://www.allergy.org.au/hp/papers/hereditary-angioedema

Question 40

Q

21.1 Sensory innervation of the cornea is by the

A. ophthalmic division of the Trigeminal nerve
B. Nasocilliary Nerve
C. Frontal Nerve
D. Oculomotor

Answer

A

B. Nasocilliary Nerve
a branch of Ophthalmic division of trigeminal

Question 41

Q

21.1 Local anaesthetic-induced myotoxicity is most likely to be associated with

A. Biers
B. Interscalene
C. Sciatic
D. Adductor Canal

Answer

A

D. Adductor Canal

unclear phenomonenon
prolonged exposure and high concentrations of local anaesthetic

Question 42

Q

21.1 The minimum microshock current required to elicit ventricular fibrillation is

A) 0.1 mA
B) 1 mA
C) 10 mA
D) 100 mA

Answer

A

0.05-0.1mA

Source: LITFL

Question 43

Q

21.1 You give a dose of intravenous indocyanine green to facilitate videoangiography during cerebral
aneurysm surgery. The displayed pulse oximetry (SpO2) and cerebral oxygen tissue saturation
(SctO2) changes you expect to see are

a. Increases NIRS , decreases peripheral
b. Decreases NIRS, decreases peripheral
c. No change NIRS, decreases peripheral
d. Increases NIRS and peripheral
e. Decreases NIRS, increases peripheral

Answer

A

a. Increases NIRS , decreases peripheral

SctO2 up, SpO2 down.

Source: Korean Journal Anaesthesia
https://www.researchgate.net/publication/274570990_Effects_of_intravenously_administered_indocyanine_green_on_near-infrared_cerebral_oximetry_and_pulse_oximetry_readings

Question 44

Q

21.1 Non-anaesthetist practitioners wishing to provide procedural sedation should have training in sedation
and/or anaesthesia for a minimum of

6 weeks
3 months
6 months
12 months

Answer

A

3 months full time

Source: ANZCA PG 09

Question 45

Q

21.1 Of the following classes of medication for diabetes mellitus, the most likely to cause hypoglycaemia in the fasted patient are the

A. Biguanides
B. Sulphonylureas
C. Acarbose
D. SGLT2 inhibitors
E. DPP4 inhibitors

Answer

A

Absolute most = Insulin, but probably not an option.

Sulphonylureas most likely

Question 46

Q

21.1 A 25-year-old ASA I patient develops ongoing seizures five minutes after receiving a brachial plexus block with ropivacaine. Of the following, the most suitable initial intravenous treatment is

a) Midazolam
b) Intralipid
c) Propofol
d) Levetiracetam
e) Phenytoin

Answer

A

Control seizures first
a) Midazolam if an option
or
c) propofol
or

treat seizures 1st followedLAST
- ABCD
- Intralipid 1.5mL/kg

Question 47

Q

21.1 A 50 year old man has the following pulmonary function test result. The most consistent diagnosis is

FEV1 - test result - predicted - % predicted 68%
FVC - test result - predicted - % predicted 68%
DLCO 46%

a) Asthma
b) Myasthenia Gravis
c) Emphysema
d) Sarcoidosis
e) Pulmonary Hypertension

Answer

A

d) Sarcoidosis

Time to loof at PFTs

Question 48

Q

21.1 The nerve labelled with the arrow in the diagram is the (diagram of a nerve plexus shown)

Question 49

Q

21.1 You have been asked to anaesthetise a patient with a history of severe depression which has been
well controlled on moclobemide. The most appropriate medications in combination with propofol are

a. Sevoflurane, morphine, phenylephrine
b. Sevoflurane, pethidine, phenylephrine
c. Midazolam, fentanyl, ephedrine
d. sevoflurane, oxycodone, ephedrine

Answer

A

a. Sevoflurane, morphine, phenylephrine

Moclobemide = MAOi

Question 50

Q

21.1 Infection control management of patients with carbapenemase-producing Enterobacteriaceae (CPE)
infection should include all of the following EXCEPT
a) isolation
b) contact precautions
c) droplet precautions
d) screening at risk patients with rectal swab and urine mcs

Answer

A

c) droplet precautions

https://www.safetyandquality.gov.au/sites/default/files/migrated/Recommendations-for-the-control-of-Carbapenemase-producing-Enterobacteriaceae.pdf

Question 51

Q

21.1 Blocking the sciatic nerve results in loss of function of all of the following EXCEPT

Answer

A

The sciatic nerve block results in anesthesia of the posterior aspect of the knee, hamstring muscles, and entire lower limb below the knee, both motor and sensory block, with the exception of skin on the medial leg and foot (supplied by the saphenous nerve). The skin of the posterior aspect of the thigh is supplied by the posterior femorocutaneous nerve, which deviates away from in the sciatic nerve proximal to the level of the anterior approach, and is therefore not blocked.

NYSORA

Question 52

Q

21.1 21.2 Benztropine ameliorates the side effects of drugs that antagonize

a) Dopamine receptor
b) Nicotinic Ach receptor
c) Muscarinic Ach receptor
d) Serotonin
e) Noradrenaline

Answer

A

a) Dopamine receptor

MOA: central acting anticholinergic

Question 53

Q

21.1 You are anaesthetising a 35-year-old woman undergoing a laparoscopic appendectomy. She uses a
levonorgestrel-releasing intrauterine device (Mirena®) for contraception and you have used sugammadex for reversal of neuromuscular blockade at the end of the procedure. Your postoperative advice to her regarding contraception should state that

a. Barrier protection for a week
b. Barrier protection until the next period.
c. The mirena is sufficient
d. OCP for a week
e. OCP until next period

Answer

A

a. Barrier protection for a week

Question 54

Q

21.1 You are resuscitating a 60 kg man in cardiac arrest secondary to severe hyperkalaemia. You decide to
give intravenous sodium bicarbonate. Australian and New Zealand resuscitation guidelines state the initial dose of 8.4% sodium bicarbonate should be

a. 30ml
b. 40 ml
c. 50 ml
d. 60 ml
e. 70ml

Answer

A

60 mmol
1mmol/kg

Question 55

Q

21.1 Regarding healthcare research, the SQUIRE guidelines describe

a) Standards for RCTs
b) Standards for meta-analysis
c) Standards for observational studies
d) Standards for systematic reviews
e) Standards of quality improvement

Answer

A

e) Standards of quality improvement

Quality Improvement

(Standards for QUality Imporvement and Reporting Excellence)

CONSORT: randomised trials
PRISMA: systematic reviews and meta-analysis (Preferred Reporting Items for Systematic reviews and meta-analysis).
STROBE: observational studies

Question 56

Q

21.1 A 30-year-old woman is administered an anaesthetic for a laparoscopic cholecystectomy for acute
cholecystitis. She is breastfeeding her six-week-old infant. During anaesthesia she receives the following drugs: propofol, fentanyl, sevoflurane, rocuronium, oxycodone, parecoxib, ondansetron, sugammadex and cefuroxime. The best advice regarding breastfeeding after anaesthesia is to

a) Discard 12 hours post procedure
b) discard 24 hours post procedure
c) discard 1st feed
d) discard first 2 feeds
e) discarding not required

Answer

A

Disregard not required

Question 57

Q

21.1 The most common cause of postoperative visual loss after spinal surgery is
a. Central retinal artery occlusion
b. Central retinal vein occlusion
c. Ischemic optic neuropathy
d. Haemorrhage
e. corneal abrasion

Answer

A

c. Ischemic optic neuropathy

Cardiac: Anterior
Spinal: Posterior
ION

Question 58

Q

21.1 A baby is brought to the emergency department three days after a term home birth. It has not been feeding well and has had few wet nappies. The child is grey in appearance and femoral pulses are difficult to palpate. You note an enlarged liver and marked tachycardia. Pulse oximetry reveals
saturations of 75% despite oxygen being administered. You suspect a duct-dependent circulation. The best initial management is

Answer

A

Prostaglandin

Baby needs fluids first and prostaglandins case hypotension esp in acidaemic infants

Question 59

Q

21.1 A patient with a history of restless leg syndrome is experiencing significant agitation in the post-anaesthesia care unit. After excluding other precipitating causes, the best treatment of the agitation in this patient is

a. Midazolam
b. Olanzepine
c. Haloperidol
d. Clozapine
e. Droperidol

Answer

A

midazolam

Question 60

Q

21.1 During trauma resuscitation in adults, contraindications to blind nasogastric tube insertion include all of
the following EXCEPT

a) High C-spine injury
b) Recent nasal surgery
c) Oesophageal fracture
d) Base of skull fracture
e) oesophageal varices

Answer

A

a) High C-spine injury

Question 61

Q

21.1 Cardiovascular effects of hyperthyroidism include

a. Decreased PVR
b. Increased SVR
c. Decreased diastolic relaxation
d. Decreased SVR
e. Increased diastolic blood pressure

Answer

A

decreased SVR

Question 62

Q

21.1 Effective pharmacotherapy options to support smoking cessation in the perioperative period include all of the following EXCEPT

a) bupropion
b) clonidine
c) nortoptyline
d) Varenicicline
e) fluoxetine

Answer

A

Fluoxetine

Question 63

Q

21.1 The main advantage of using norepinephrine (noradrenaline) over phenylephrine for the prevention of
hypotension as a result of spinal anaesthesia for elective caesarean section is

A. Better APGAR
B. Better foetal acid/base
C. Less nausea/vomiting
D. Less maternal bradycardia

Answer

A

less maternal bradycardia

Question 64

Q

21.1 The atmospheric lifetime of nitrous oxide (in years) is approximately

1yr
10 yr
50 yrs
100years

Answer

A

100 years
Desflurane: 10yrs
Sevoflurane 1yr

Answer 61

A

history of eczema

Answer 62

A

increased incidence of major bleeding

Answer 63

A

sucrulfate or honey

Answer 64

A

obturator nerve

Answer 65

A

no difference

Answer 66

A

neurological damage due to methionine deficit

Answer 67

A

high level of education

Answer 68

A

adenosine

Answer 69

A

supraclavicular

Answer 70

A

no need for monitoring

Answer 71

A

renal tubular acidosis-> NAGMA

Answer 72

A

urine osmolality <100

Answer 73

A

decompress the bladder

Answer 74

A

suxamethonium

Answer 75

A

neostigmine

Answer 76

A

hypoCALCEMIA

Answer 77

A

comet tails

Answer 78

A

multiple sclerosis.

Answer 79

A

midline laparotomy and left cervical incision

Answer 80

A

pain score

Answer 81

A

labetaolol

Answer 82

A

doing an epidural on a patient who is labouring with normal pregnancy and no comorbidities

Answer 83

A

NTEMI vs MINS

Answer 84

A

54 weeks

46 weeks if term infant

Answer 85

A

less time in aged care and reduced mortality

Answer 86

A

low resistance

Answer 87

A

Bolus 1 IU oxytocin; start oxytocin infusion at 2.5–7.5IU.h1(0.04–0.125 IU.min1)

EmLSCS; 3 IU oxytocinover≥30 s; start oxytocininfusion at 7.5–15 IU.h1(0.125–0.25 IU.min1).

Answer 88

A

anaesthetic consent implied in surgical consent - this is specifically incorrect as per anzca doc ps26. Must be misremembered options.

Answer 89

A

oxygen administration/ low fio2
assumed bleomycin

Answer 90

A

1000mls/hr

Answer 91

A

I:E ration 1:3

aim 1:1

Answer 92

A

e) tachycardia

Answer 93

A

low potassium diet

Answer 94

A

increased SVR/ increased PVR

Answer 95

A

anaemia

Iron deficiency can be caused by depletion of total Iron stores or a chronic loss of blood.

Metabolism of Iron is also influenced by disease states including inflammation and malignancy.

Raised Iron stores and inflammation upregulate the production of HEPCIDIN, a hormone responsible for the inhibition of enteral Iron absorption

HEPCIDIN degrades iton trans-membrane transporter ferroportin on duodenal enterocyte membranes. it also inhibits the transport of stored iron from hepatocytes and macrophages into plasma in a similar manner.

Upregulation of HEPCIDIN can produce functional iron deficiency, lading to what has been tradionally known as the anaemia of chronic disease

HEPCIDIN deficiency is the cause of iron overload in hereditary hemochromatosis, iron-loading anemias, and hepatitis C

HEPCIDIN is suppressed in iron deficiency, allowing increased absorption of dietary iron and replenishment of iron stores. Increased erythropoietic activity also suppresses HEPCIDIN production.

HEPCIDIN is decreased in iron deficiency anemia, hemolytic anemia, and anemias with ineffective erythropoiesis

Answer 96

A

bottle A = fluid trap or collection bottle, can be independently emptied and allows accurate record of drainage amount
- first tube connecting drain to drainage bottles must be wide to decreased resistance
- volume capacity of this tube should exceed ½ of patient’s maximum inspiratory volume (otherwise H2O may enter chest)

bottle B = underwater seal drain, maintained at a predetermined level whilst still allowing for drainage of pleural fluid (if bubbling continuously -> bronchopleural fistula)
- volume of H2O in bottle B should exceed ½ patient’s maximum inspiratory volume to prevent indrawing of air during inspiration

bottle C = manometer or pressure-regulating bottle allows suction to be attached and should bubble continuously
- The maximum negative pressure (in cm H2O) generated by suction equals to the distance (in cm) the vent tube is below the water line (this can be adjusted)
-The negative pressure generated by the vent tube is independent of the amount of pleural drainage that is collected in the trap bottle
- If suction is turned off then tubing must be unplugged -> so air can escape into atmosphere

Answer 97

A

age

Domains:
1. Cognition
2. General health status
3. Functional independance
4. social support
5. Medication use
6. Nutrition
7. Mood ?interpreted as mental illness in stem?
8. Continence
9. Functional performance

Scoring
0-5= Not frail
6-7= Vulnerable
8-9= Mild Frailty
10-11= Moderate Frailty
12-17= Severe Frailty

Answer 98

A

b. Thoracodorsal

Thoracodorsal nerve (C6-C8) is a branch of the posterior cord of the brachial plexus. Its primary function is motor innervation of the latissimus dorsi muscle. Its blockade is relevant in more extensive breast reconstruction procedures.

The Pecs I, Pecs II and Serratus Plane blocks are superficial thoracic wall blocks which through blockade of the
1. Pectoral N.
2. Intercostal N.
3. Thoracodorsal N.
3. Long thoracic N.
It can be used to provide analgesia for breast surgery and other procedures/surgery involving the anterior chest wall.

Answer 99

A

A. Reduced RR

BJA HFNOT

It has been demonstrated that patients with acute hypoxaemic respiratory failure experience improved comfort and tolerance with HFNOT compared with humidified oxygen via a facemask, and traditional non-invasive ventilation masks. Subjective feelings of dyspnoea AND RESPRIATORY RATES are REDUCED as is airway dryness.

Answer 100

A

D. Cerebral Abscess

HBOT Indications:
- air or gas embolism
- arterial insufficiencies
(central retinal artery occlusion, enhancement of healing in wound problems)
- Carbon monoxide poisoning
- Clostridium myonecrosis (gas gangrene)
- Compromised grafts and flaps
- Acute traumatic ischaemia
- Decompression sickness
- Delayed radiation injuries
- Sudden sensorineural hearing loss
- Intracranial abscess
- Necrotising soft tissue infections
- Refractory osteomyelitis
- Severe Anaemia
- Thermal burns

Absolute Contraindications to HBOT:
- untreated PTx
- Premature Infants
- Bleomycin
- Disulfiram (antabuse)
- Cisplatin

Relative contraindications:
- Pregnancy
- Asthma
- Thoracic Surgery
- Emphysema with CO2 retention
- upper respiratory tract infections
- History of middle ear surgery or disorder
- History of seizures
- Fevers
- Congenital spherocytosis
- Optic neuritis

Answer 101

A

BMI >35 kg m−2

Contraindications:
- Inflammatory disease of GI tract (ulcers, oesophagitis, Crohn’s)
- Upper GI bleeding
- Portal Htn
- Liver Cirrhosis
- Chronic Pancreatitis
- Laparascopic surgery may be technically difficult in patients weighing >180kg and may be considered a relative contraindication

Answer 102

A

a. Tricuspid regurg

Regurgitant CV waves: tricuspid regurgitation

In tricuspid regurgitation, the backflow of blood out of the right ventricle obliterates the normal x descent. The c wave becomes accentuated and fuses with the v wave, as both are the results of right ventricular contraction (and the v wave peak pressure is often the same as the right ventricular peak systolic pressure).

the reality is that they usually fuse completely to produce huge mutant waves, as seen here:

Answer 103

A

e. Peripheral RICC line, 8.5 Fr

Answer 104

A

b) conscious state

No mention of BP or HR in ANZCA OIVI monitoring document

In many published reports of patient deaths resulting from OIVI, undue reliance has been placed on respiratory rate as a unidimensional measure of OIVI, either without formal assessment of patient sedation, or without recognising the significance of excessive sedation

Respiratory rate and oxygen saturation levels are not direct measures of adequacy of ventilation.

Sedation scores should be assessed repeatedly at intervals that are appropriate to the route of opioid administration

Continuous measurement of a patient’s carbon dioxide concentrations is more likely to identify OIVI than continuous pulse oximetry

Answer 105

A

L hypoglossal

The hypoglossal nerve innervates all the extrinsic and intrinsic muscles of the tongue, except the palatoglossus which is innervated by the vagus nerve.

Injury to the hypoglossal nerve causes ipsilateral tongue deviation (pathognomonic), with dysarthria and dysphagia in severe cases. The tongue deviates towards the side that is affected due to the unopposed action of the contralateral genioglossus

The symptoms and signs of hypoglossal neurapraxia are often self-limiting and 43% of diagnosed patients achieve resolution within 6 weeks of surgery and an additional 40% are symptom free within 6 months after surgery

Nerves injured by SAD
- Lingual nerve (2ry to tube)
- Hypoglossal nerve (2ry to cuff)
- Recurrent laryngeal nerve (2ry to cuff)

Presenting symptoms and signs
Lingual nerve:
- loss of taste and sensation to tip of tongue

Hypoglossal nerve:
- dysphagia
- dysarthria
- tongue deviation in unilateral injury

Recurrent laryngeal nerve:
- altered voice
- rarely: stridor

Risk factors for injury:
- use of nitrous oxide-> over inflation
- selection of SAD that is too small-> over inflation
- LMA maximum inflation pressure 60cmH2O

Answer 106

A

b. 18ml

3mg/kg max dose as per RCH guidelines
3mg x 30kg = 90mg
90mg/5mg/ml = 18ml

or

0.6ml/kg of 0.5% Lignocaine
0.6ml x 30kg = 18ml

Answer 107

A

After LA administration, any abnormal cardiovascular or neurological symptoms and signs, including isolated cardiac arrest, should raise suspicion of LAST

Presenting features of LAST vary widely. Cardiovascular collapse may occur without preceding neurological changes.

Clinical features of LAST:

CNS
- 2 stage process of excitatory phase followed by a depressive phase
- early signs:
1. perioral tingling
2. tinnitus
3. slurred speech
4. lightheadedness
5. tremor
6. change in mental state: confusion and agitation

excitatory phase culminates in generalised convulsions
-Depressive phase:
1. Coma
2. Respiratory depression

CVS
- 3 phases:
- initial phase:
Htn and tachycardia

intermediate phase:
myocardial depression and hypotension
terminal phase:
peripheral vasodialtion
severe hypotension

arrhythmias:
1. sinus bradycardia
2. conduction blocks
3. VT
4. Asystole

Answer 108

A

a. Diclofenac

LIthium perioperative concerns:
- Prolongation of NMB
- Reduction in anaesthetic agent requirement
- Avoid NSAIDs
- No withdrawl symptoms
- Discontinue 24hrs before surgery

BJA: perioperative advice for psychotropic drugs

Answer 109

A

b. 0.5% Chlorhexidine/ETOH

For skin preparation, 0.5 per cent chlorhexidine in alcohol, where available, is recommended for neuraxial techniques although it should be noted that very small quantities of neuraxial chlorhexidine have been implicated in cases of severe neurotoxicity

Answer 110

A

f)Cricothyroid

Nerve supply of larynx:
1. Superior laryngeal nerve:
- Cricothyroid muscle
- sensory supply to the interior of larynx down to vocal cords
2. internal laryngeal nerve
-
3. Recurrent laryngeal nervs
- motor supply to the intrinsic muscles of the larynx apart from cricothyroid
- sensory supply to laryngeal mucosa inferior to the cords

Intrinsic muscles of the larynx
a) Posterior Cricoarytenoid
- abducts the cords, opens the glottis
- only muscle to open glottis
b) Lateral Cricoarytenoid
- adducts the cords and closes the glottis
c) Interarytenoid
- only unpaired muscle
- closes the glottis
- continues upwards to form the aryepiglottic muscle which acts as a weak sphincter
d) Thyroarytenoid
- relaxes vocal cords
e) Vocalis
-adjusts tension in the cords
f) Cricothyroid
- only intrinsic muscle that lies outside the cartilagenous framework
- only tensor of the vocal cords

actions of intrinsic laryngeal muscles
1. Abductor of the cords: posterior cricoarytenoids
2. Adductors of the cords: lateral cricoarytenoids, interarytenoids
3. Sphincter to the vestibule: aryepiglottics, thyroepiglotics
4. Tension regulators of the cords: Cricothyroids (tensors), Thyroarytenoids (relaxors), Vocales (fine adjustment)

Answer 111

A

Dependence

Answer 112

A

1st a) atorvastatin
2nd c) Digoxin

All of the DOACs are avid substrates for the excretory P-gp system of the gastrointestinal epithelial cells, and drugs that inhibit or induce the P-gp system may affect plasma DOAC levels

Dabigatran and edoxaban are substrates for P-glycoprotein (P-gp)

Apixaban and rivaroxaban are metabolised by cytochrome P450 enzyme CYP3A4 and are substrates for P-gp

There is study evidence that among patients taking DOACs for non-valvular atrial fibrillation, concurrent use of amiodarone, fluconazole, rifampicin, and phenytoin compared with the use of DOACs alone, was associated with increased risk of major bleeding

It is unlikely that clinically significant interactions occur between dabigatran and other drugs that are merely substrates for P-gp-mediated excretion. When dabigatran was coadministered with digoxin neither digoxin nor dabigatran plasma levels were significantly altered

Rivaroxaban and apixaban are metabolised to an extent of 40–50 % in the liver to variable degrees by CYP3A4 and may interact with drugs that inhibit this enzyme.

The metabolism of Apixaban and rivaroxaban can be decreased when combined with Atorvastatin which is also metabolised by CYP3A4

Answer 113

A

Chronic obstructive pulmonary disease (COPD) is the most common cause of cor pulmonale

leads to an increase in RV afterload secondary to changes in pulmonary vascular structure and mechanics, and lung hyperinflation.

Patients with COPD who subsequently develop RV dysfunction have an increased risk of admission to hospital and mortality

Answer 114

A

b. adrenaline 1mg boluses

The risk of administering adrenaline in conventional doses is with profound hypertension, bleeding, or tearing of vessel anastomoses on return of spontaneous circulation (ROSC), which can precipitate catastrophic harm or further cardiac arrest.
Adrenaline remains a useful drug in peri-arrest situations in smaller doses.

Answer 115

A

d) pregnancy

A third heart sound reflects rapid left ventricular distention along with an increased atrioventricular flow

Heard in Congestive heart failure

Associated with Dilated Cardiomyopathy with dilated ventricles

Less commonly valvular regurgitation and left to right shunts

May be normal physiological finding in patients less than 40yrs old

Answer 116

A

a. Cholecystitis

Example and explanation taken from RACGP:
The raised AlP relative to Alt suggests cholestasis and the high GGt confirms liver origin. The mild hyperbilirubinaemia confirms the clinical impression of jaundice. Biliary disease is highly likely with gallstones the most likely differential diagnosis. however, this clinical picture may also occur in drug reactions or infiltrative conditions. After a careful history, abdominal ultrasound is the most appropriate next investigation.

Answer 117

A

no observed beneficial effect of sevoflurane on the composite endpoint of prolonged ICU stay, mortality, or both in patients undergoing high-risk cardiac surgery

Answer 118

A

d) myasthenia gravis

In contrast to other neuromuscular disorders, succinylcholine may be used in myasthenia gravis. The required dose may need to be increased by up to two-fold, as those with the disease show a relative resistance to the drug.

Sux is not recommended in patients with neuromuscular disease due to:
1. presence of extrajunctional receptors and risk of hyperkalaemia and rhabodmyolysis
2. fasiculations causing temperomandibular muscle spasm preventing intubation

Answer 119

A

b) Thumb abduction
(flexor pollicis brevis)

D. Paraesthesia/sensory loss over medial forearm
(medial antebrachial cutaneous)

Severing Ulnar nerve alone results in numbness of the 4th (ring) and 5th (little) fingers alone

C8 and T1 supply the medial antebrachial cutaneous nerve

Muscles weak in C8-T1 radiculopathy but intact in ulnar neuropathy

flexor pollicis brevis
abductor pollicis brevis
opponens pollicis
lateral lumbricals

AbOF the Law may be useful—the abductor (Ab) and flexor (F) pollicis brevis, opponens pollicis (O), and lateral lumbricals (Law) are “above the law” that intrinsic hand muscles are ulnar-innervated

Answer 120

A

c) Wipe with detergent

Laryngoscope handles:
-non-critical devices
-should be cleaned with
detergent and water between each patient use.
-If contaminated with blood, they should be washed and disinfected.

Laryngoscope blades:
-considered critical equipment because they may penetrate skin or mucous membranes, require sterilisation.

Bougies:
-Re-use of these items has been associated with cross-infection.
-It is preferable that alternative single-use intubation aids are employed when possible

Face Masks:
-In contact with intact skin, these items are frequently contaminated by secretions
-considered semi-critical, requiring cleaning and
thermal disinfection

Answer 121

A

a) Brachiocephalic artery

Major vessels, most commonly the brachiocephalic artery, traverse the anterior tracheal wall in up to 53% patients at the suprasternal notch

Answer 122

A

d) contraindicated as it won’t work

Type 1:
-Quantitative defect of VWF

Type 2:
-Qualitative Defect of VWF
-Type 2 subclassification depending on plt binding function, F8 binding capcacity, number of high molecular weight VWF multimers

Type 3:
- complete absence of VWF

Treatment:
- do not need blood components to control haemorrhage
-F8 plasma concentration >100 for major surgery and >50 for minor surgery
-DDAVP approved for use in Type 1, no use in type 3, discuss its use with haematology in type 2 due to its variable effect
-DDAVP given atleast 90mins before operation
-TXA may be useful
-VWF/F8 concentrates indicated in severe cases, type 3 and qualitiative defects in VWF
-Plt infusions should be considered in persistent bleeding
-Cryo has an unpredictable effect, only used if other treatments have failed

Answer 123

A

a) LUSCS

Rates of VAE by surgical procedure:
LUSCS: 10%-97%

Neurosurgery:
Posterior Fossa: 76%
Cervical Laminectomy: 7-25%
Lateral/Prone Neurosurgery: 15-25
%
Total Hip Replacement: 30%
Lap Cholecystectomy: 69%

Answer 124

A

Hunsaker Mon-jet ventilation tube for microlarnygeal surgery

Description:
-Laser-safe
-fluoroplastic
-self-centring catheter

Uses:
-subglottic ventilation during microlaryngeal surgery

Components:
- proximal end for attaching to jet insufflation system
-proximal end allows passage of stylet to aid insertion
-Side port at proximal end for monitopring airway pressure and ETCO2
-Outer diameter 4.3mm for maintaining good surgical access
-Green basket to keep the centre port at its tip away from tracheal mucosa and avoiding potential damage from jet ventilation

Answer 125

A

EXCEPT C) RV dilation

Echo findings in Aortic Dissection:
1. Intimal flap

Type A dissection:
- Aortic regurgitation
-Acute dilation of aortic root
-Aortic leaflet prolapse
-Dissection flap prolapse
-Pre-existing disease
-Pericardial Effusion/Tamponade
-RWMA
Colour flow doppler
-identifies true and false lumen
-aortic branch occlusion/dissection

Answer 126

A

A. 100mg QID

42mg IV Morphine = 126mg Oral Morphine

126/8= 15.75
15.75 x 25 = 393.75 (*400mg/day Tapentadol)

Oral Tapentadol 25mg = 8mg Oral Morphine

Oral Oxycodone 5mg = 8mg Oral Morphine

Oral Tramadol 25mg = Oral Morphine 5mg

Oral Hydromorphone 4mg = Oral Morphine 20mg

S/L Buprenorphine 200mcg = 8mg Oral Morphine

IV Oxycodone 5mg = Oral Morphine 15mg

IV Morphine 5mg = Oral Morphine 15mg

IV Hydromorphone 1mg = Oral Morphine 15mg

Answer 127

A

B. 29

PaCO2= 1.5 x 14 + 8
PaCO2= 21 + 8
PaCO2= 29

Winter’s formula: expected PaCO2 = [1.5 x (serum HCO3)] + [8±2]
if PaCO2 lower, there is a concomitant primary respiratory alkalosis
if PaCO2 higher, there is a concomitant primary respiratory acidosis

Answer 128

A

RLL
1.Superior (apical bronchus 6)
-> most common site for foreign body or secretions to collect if patient laying flat in bed

Brainscape's Knowledge GenomeTM

21.1 Flashcards

Brainscape's Knowledge Genome^TM