4 Rakesh Flashcards
- Acromegaly is a clinical syndrome causing the over-production and under-regulation of growth hormone.
Which of the following features
does not increase the diffi
culty on direct laryngoscopy?
A. Distorted facial anatomy.
B. Macroglossia.
C. Glottic stenosis.
D. Prognathe mandible.
E. Arthritis of the neck.
C
- Answer: C
Whilst glottic stenosis is a feature of acromegaly and increases the difficulty of tracheal intubation,
it does not increase the diffi culty of the process of direct laryngoscopy.
Acromegaly is a rare clinical
syndrome caused by the overproduction and under-regulation of growth hormone (GH) from the
anterior pituitary.
It can be an insidious and potentially life-threatening condition for which there is good, albeit incomplete, treatment that can augment life by many years of high-quality.
It is often associated with a GH-secreting somatotroph pituitary tumour. Other causes of increased and
unregulated GH production, all very rare, include increased growth hormone-releasing hormone
(GHRH) from hypothalamic tumours, ectopic GHRH from non-endocrine tumours, and ectopic
GH secretion by non-endocrine tumours.
In acromegaly the symptoms develop slowly, taking years to decades to become apparent and the
mean duration of symptom onset to diagnosis is 12 years. Excess GH produces a myriad of signs
and symptoms and signifi cantly increases morbidity and mortality rates. Additionally, the mass eff ect
of the pituitary tumour itself can cause symptoms.
- Brachial plexus injury in the course of anaesthesia and critical care episodes is not an uncommon occurrence.
Which of the following statements below is not correct?
A. Brachial plexus catheter insertion is associated with increased risk of injury.
B. Arm abduction with lateral rotation of the head to the opposite side can cause excessive
stretch.
C. Lesions affecting the upper nerve roots are more common.
D. Damage to the long thoracic nerve causes winging of the scapula.
E. Upward movement of the clavicle and sternal retraction can cause a compression injury to
the nerve.
C
- Answer: A
Injury to peripheral nerves is a recognized complication of surgery and anaesthesia.
It is also largely preventable if careful attention is paid to high-risk positioning and measures are undertaken to minimize compression by padding the pressure areas.
Brachial plexus injury varies in incidence
between 1 in 15,000 and 1 in 30 000 patients having a brachial plexus block, and the incidences
are, perhaps, under-reported.
Broadly, injury to the brachial plexus can to avoided by ensuring that there is no stretching (due to contralateral twisting of the head with the arm in abduction),
compression (particularly in the axilla in the prone position), and by the introduction of nerve-
location techniques (ultrasound and peripheral nerve stimulation) to reduce injury to the plexus
during regional anaesthesia. There is no evidence that nerve catheter techniques are associated with
a specifi c increase in the risk of injury.
- You are called to see a 32-year-old primiparous woman on the postnatal
ward following caesarean section.
The caesarean was done 8 h ago,
under spinal anaesthesia as the top up epidural failed.
The midwives in ward are now concerned that the patient is drowsy, with a respiratory
rate of 6/min. What is the most likely cause?
A. Fentanyl 100mcg, administered via the labour epidural at the start of the caesarean
section, acting on the local spinal receptors.
B. Exhaustion due to long latent phase of labour.
C. Diamorphine 300 mcg, administered via the spinal at the start of the caesarean section,
acting by the cephalad spread of drug by the bulk fl ow of CSF.
D. L-bupivacaine 0.5 % , 20 mL, administered via the labour epidural at the start of the
caesarean section, causing high regional anaesthetic block.
E. Fentanyl 100 mcg, administered via the labour epidural at the start of the caesarean
section, acting by the lipophilic systemic absorption of opioid.
C
- Answer: C
Neuraxial anaesthesia describes the use of spinal, epidural, and caudal techniques.
Neuraxial adjuvants are often used to decrease the adverse effects associated with high doses of a single local anaesthetic agent, increase the speed of onset of neural blockade, and improve the quality and
prolong the duration of neural blockade.
Neuraxial adjuvants include opioids, sodium bicarbonate,
vasoconstrictors, α 2-adrenoceptor agonists, cholinergic agonists, N-methyl- d -aspartate (NMDA)
antagonists, and γ -aminobutyric acid (GABA) receptor agonists.
After epidural administration of opioids, variable quantities will diffuse across the dura and
arachnoid mater into the subarachnoid space to bind opioid receptors in the dorsal horn of the
spinal cord.
Lipid solubility is the most important factor aff ecting the rate of diff usion and the
subsequent onset and duration of analgesia. Lipophilic opioids such as fentanyl diff use rapidly across
the dura into the CSF to give rapid onset of action with relatively short acting analgesia. This is
compared to hydrophilic opioids such as diamorphine, which have a slower onset of action but a
prolonged duration of action.
Respiratory depression is potentially the most serious adverse eff ect caused by neuraxial opioids.
The incidence after neuraxial administration is similar to that of parenterally administered opioids.
Early respiratory depression generally develops within 2 h of epidural administration of lipophilic
opioids such as fentanyl. It is due to systemic absorption from the epidural space. Delayed
respiratory depression usually develops between 6–12 h after intrathecal administration of poorly
lipid-soluble opioids such as diamorphine. This is due to cephalad migration of the opioid in the
CSF, which reaches opioid receptors in the respiratory centre. It is uncommon with lipophilic
opioids because they rapidly penetrate the spinal cord, leaving minimal free opioid in the CSF.
- The report by the UK’s Centre for Maternal and Child Enquiries,
entitled ‘Saving mothers’ lives’, was published in 2010, and highlighted
the leading causes of maternal death. Which of the complications below
was the leading cause of direct maternal deaths?
A. Venous thromboembolism.
B. Genital tract sepsis.
C. Haemorrhage.
D. Amniotic fluid embolism.
E. Pre-eclampsia and eclampsia.
B
- Answer: B
Overall, the latest triennial CMACE report has shown a reduction in maternal mortality. In the
2006–2008 report, it was concluded that genital tract sepsis, particularly from streptococcal A
acquired in the community, was the leading cause of direct maternal death. .
This partly reflects the
reduced incidence of venous thrombo-embolism and haemorrhage in the obstetric population,
following increased awareness of the complications in the previous report.
- Trigeminal neuralgia is a chronic facial pain syndrome. Select the most reliable initial treatment from the list below.
A. Pregabalin.
B. Carbamazepine.
C. Gabapentin.
D. Amitriptyline.
E. Lamotrigene.
D
- Answer: B
Anticonvulsant drugs reduce the excitability of gasserian ganglion neurons, preventing anomalous
discharges and related lancinating volleys of pain.
Thus these agents may help control paroxysmal
pain by limiting the aberrant transmission of nerve impulses and reducing the fi ring of nerve
potentials in the trigeminal nerve.
Carbamazepine is the standard in the medical management of trigeminal neuralgia and is considered
fi rst-line therapy.
Lamotrigine and baclofen are second-line therapy.
Other treatments are third line and the evidence for their effi cacy is scant.
Carbamazepine acts by inhibiting the neuronal sodium channel activity, thereby reducing the
excitability of neurons. A 100-mg tablet may produce significant and complete relief within 2 h,
and for this reason it is a suitable agent for initial trial, although the eff ective dose ranges from
600–1200 mg/day, with serum concentrations between 40–100 mcg/mL.
Indeed, serum levels of carbamazepine (but not necessarily phenytoin) in ranges appropriate for epilepsy may be necessary,
at least to control initial symptoms.
Anticonvulsants, tricyclic antidepressants, skeletal muscle relaxants, and botulinum toxin have all
been trialled with, at best, moderate success.
- You are working on the trauma list and an 11-year-old boy presents to the anaesthetic room for an ORIF of his radius.
You notice that he has bruising on his arms that looks like finger prints, scratches to his face,
and is very withdrawn. He comes to theatre alone with a paediatric nurse. During the preparation for anaesthesia you ask him what
happened and he bursts into tears and says that he is too frightened to
go home as his mother’s boyfriend was beating him up. What is your
next action?
A. Proceed with the anaesthesia as quickly as possible.
B. Postpone the operation and send the patient back to the ward.
C. Ask the nurse to talk to the patient and report back to the ward.
D. Briefl y explain to the surgeon that there will be a short delay and listen to and observe the
child, allowing him to talk and document the conversation. Proceed with surgery.
E. Briefl y explain to the surgeon that there will be a short delay and listen to and observe the
child, allowing him to talk and document the conversation. Postpone surgery.
D
- Answer: D
It is the responsibility of all professionals who come into contact with children to be familiar with
the guidelines produced by NICE, When to suspect child maltreatment . Online training modules
are available and are a requirement if your practice involves the care of children. The process for
dealing with suspected maltreatment is:
z Listen and observe: the child should be allowed to explain in their own words any obvious
external signs such as bruising, burns, bite marks, and signs of neglect, which should be
carefully documented.
z Seek an explanation from the parent/carer and the child in an open and non-judgemental
manner; beware of unsuitable explanations, including those that are implausible, inadequate,
inconsistent, or based on cultural practice.
z Record all areas of concern and report to the person nominated as responsible for child
protection within your trust.
In this case postponing the surgery would potentially put the patient at more risk of harm, but the
small amount of time needed to listen to the child’s concerns is a justifi able delay.
- A 41-year-old man has been induced for a laparoscopic cholecystectomy
with fentanyl 100 mcg, propofol 200 mg, and atracurium 40 mg.
On direct laryngoscopy it is not possible to pass the back of the tongue
and no epiglottis is seen. The patient is oxygenated with 100 %oxygen, repositioned, and a further attempt at direct laryngoscopy is made with
no improvement in the view.
What is the next management strategy?
A. One further attempt at direct laryngoscopy with a McCoy blade laryngoscope.
B. One further attempt at direct laryngoscopy with a bougie.
C. Abandon further direct laryngoscopy and insert a laryngeal mask airway.
D. Abandon further direct laryngoscopy and intubate with asleep fi breoptic technique.
E. Abandon further direct laryngoscopy and establish an airway with an emergency cannula
cricothyroidotomy.
C
- Answer: C
The Diffi cult Airway Society has produced guidelines on the management of failed intubation during
routine laryngoscopy.
Plan A involves the process of direct laryngoscopy and tracheal intubation.
Should this not be possible, the patient should be ventilated manually to ensure adequate
oxygenation.
The position should then be optimized and a second attempt at direct laryngoscopy
performed.
If this is unsuccessful, plan B should involve the insertion of a laryngeal mask (LMA) or
intubating laryngeal mask to establish a controlled airway and oxygenation maintained.
As intubation is required in this setting, intubation via a fi breoptic technique through the LMA is indicated.
Should intubation fail or LMA not establish an airway, plan C is followed with manual ventilation with a
mask and waking the patient. Should ventilation not be achieved, plan D is activated, and ventilation
is attempted with an LMA. If this is not achieved, an emergency technique such as a cannula or
surgical cricothyroidotomy must be performed. All anaesthetists should be familiar with, and drilled
in, emergency airway procedures.
- The recovery nurse calls you to see a 35-year-old African-American woman who has had an ORIF for a fractured medial malleolus.
She is known to have a positive Sickledex test.
The patient is complaining of severe abdominal pain, which is not resolving with morphine intravenously.
She has Hb 10.4 g/dL, oxygen saturation 94 %on air, HR 110 bpm, BP 138/62, tympanic temperature 36.9 ° C. What is the most
appropriate initial management strategy?
A. Oxygen 2 L/min via nasal cannulae.
B. Oxygen 4 L/min via Hudson mask.
C. Oxygen 15 L/min via non-rebreathe mask.
D. Morphine 5 mg bolus IV.
E. Diclofenac 7 5mg IV.
C
- Answer: C
Sickle cell crises can be precipitated by a number of factors: hypoxia, pain, anaemia, cold,
tourniquet use, incorrect positioning.
Whilst analgesia is important in this case, it is possible that the mild degree of hypoxia suggested by the lowered oxygen saturation has precipitated an abdominal sickle-cell crisis.
Sickle-cell disease is a congenital haemoglobinopathy with a high incidence of perioperative
complications.
Traditional anaesthetic management, based largely on extrapolation from biochemical models, has emphasized avoidance of red cell sickling to prevent exacerbations of the disease.
Sickle-cell disease is characterized by deformed red blood cells, acute episodic attacks of pain and
pulmonary compromise, widespread organ damage, and early death.
The central pathological event has traditionally been assumed to be an increase in sickling or
deformation of erythrocytes, as a result of the insolubility of the deoxygenated mutant sickle
haemoglobin, haemoglobin S. While acute pain and pulmonary complications often have no clearly
identifi able triggers in the community setting, the perioperative period is a well-recognized and
predictable time of disease exacerbations. As these problems occur in an environment of close
patient management and observation, the perioperative period can off er a unique insight into the
origins of acute and chronic complications of sickle cell disease.
- A fit and well 71-year-old man has undergone total knee replacement under a general anaesthetic,
spontaneously ventilating on a laryngeal
mask and with opioid analgesia combined with a femoral nerve block.
Before closure of the wound, the surgeon requests that you release the surgical tourniquet, which has been inflated for 68 min. What is the first
clinical parameter that you will see change?
A. An increase in the respiratory rate.
B. A decrease in the blood pressure.
C. A decrease in the heart rate.
D. An increase in the serum potassium.
E. An increase in the end-tidal carbon dioxide.
E
- Answer: E
Arterial tourniquets are used to provide a bloodless field to the surgeon for operative procedures
on the extremities. Inflation of the tourniquet renders the tissues beyond the tourniquet
temporarily ischaemic and can cause direct pressure injuries to underlying structures. Release of
the tourniquet will result in rapid reperfusion of the ischaemic limb, and result in physiological
changes to counteract the subsequent release of anaerobic metabolic by-products, especially
lactate, which rises by 2 mmol/L.
The immediate consequence of this is a rapid increase in end tidal carbon dioxide (metabolic by-product) and a reduction in serum pH. This will initially cause a
compensatory tachycardia and possibly a transient hypotension. The increase in carbon dioxide will
cause an increase in the respiratory rate to aid in returning the blood pH to normal limits. Although
the serum potassium levels do increase, these do not peak until 3 min (an increase of 0.3 mmol/L).
- A 60-year-old is diagnosed with sciatica. Which of the following do not increase or decrease the risk of having this condition?
A. Gender.
B. Age.
C. Genetic predisposition.
D. Smoking.
E. Height.
.D
- Answer: A
Sciatic neuralgia is a chronic pain condition characterized by pain in the distribution of the sciatic
nerve.
Sciatica is associated with pathology of the sciatic nerve.
The main risk factors include:
z height: increasing height increases risk, especially in patients aged 50–64 years
z age: the peak incidence is seen between 50 and 64 years
z patients are thought to have a genetic predisposition
z walking and jogging increases the incidence in patients with history of this condition
z occupation: associated with driving or physical activity
z smoking.
Note: gender and body mass index have no infl uence.
- A young female patient presents with recurrent severe right side pulsating headache.
The attacks last for about 5 h. These are
accompanied by photophobia and nausea. Which of the following is true about this condition?
A. Must occur with aura.
B. NSAIDs are not useful in its treatment.
C. Triptans (5-HT agonists) are the most potent abortive agents in migraine attacks.
D. Triptans should be taken on daily basis to prevent recurrent migraine attacks.
E. Sumatriptan can be safely used in patients suffering from ischaemic heart disease.
.B
- Answer: C
Migraine is one of the most common primary headache disorders, which presents as periodic
unilateral headache.
It invariably develops before the age of 30.
It results from an overactivity and
amplification in pain and sensory pathways.
Neurovascular symptoms usually predominate in this
condition.
Central sensitization of C-fi bres in the trigeminal system is thought to take place. The C-fi bres
release calcitonin gene-related peptide (CGRP), substance P, glutamate, etc. This sensitization
results in increased excitability of neurons.
Clinical presentation Migraine has a female preponderance, with a female to male ratio of 3:1. It has a prevalence of
approximately 18 % in females and 5 % males. The highest prevalence is between ages 25 and 55 years.
Migraine headache has the following characteristics:
z unilateral
z usually peri-orbital or retro-orbital
z headache is severe and pounding in nature
z headache may be associated with nausea, vomiting, and photophobia..
Aura
About one in five migraine sufferers experience aura before the onset of headache.
Aura is mostly visual but can also be olfactory or auditory.
Decrease in cerebral blood flow is thought
to be the cause of the phenomenon.
The aura typically precedes the headache by 30–60 min.
Characteristically, the aura is completely reversible. Neurological symptoms usually last for less
than 1 h.
Aura followed by a headache that does not fulfil diagnostic criteria for migraine must
be investigated for organic lesions like transient ischemic attack and multiple sclerosis.
The aura symptoms may present as scotoma, an arc of zigzag scintillating lights. Aura may be associated
with sensory symptoms like pins and needles, numbness, and dysphasia. Some elderly patients may
present with typical aura but without the headache as the disease progresses.
Migraine can occur with or without aura.
Treatment
Pharmacological treatment includes abortive, preventive, and symptomatic treatment.
Abortive medications should be taken at the earliest on the onset of the attack and should not be
administered daily.
Triptans are the most potent drugs in this group.
They are powerful vasoconstrictors and should
not be given to patients with unstable hypertension and ischaemic heart conditions.
The anti-infl ammatory eff ect of NSAIDs makes them useful in treatment of migraine attacks.
Prophylactic treatment includes treatment with non-selective β -blockers such as propranolol,
calcium channel blockers such as verapamil, and antidepressants such as amitriptyline and
anticonvulsants.
- A 17-year-old male is admitted for elective scoliosis surgery to insert Harrington rods.
The procedure is undertaken in the prone position.
Which of the following methods of intra-operative monitoring of neurological function should be used to aid in the instrumentation of the spine?
A. Bispectral index.
B. Somato-sensory evoked potentials.
C. Wake the patient from general anaesthesia.
D. Peripheral nerve stimulation.
E. Invasive blood pressure monitoring.
B
- Answer: B
Although the ‘wake-up’ test was originally used in scoliosis surgery, it has been superseded by more
modern techniques. It involved lightening the plane of anaesthesia for a short period of time so that
the patient can complete simple tasks on command. This is impractical with modern anaesthetic
techniques and with intubation. Bispectral index is a monitor of depth of anaesthesia and does not
indicate neurological injury. Invasive blood pressure monitoring and peripheral nerve stimulation are
important components of a safe anaesthetic technique, but, again, do not monitor for neurological
injury.
Somato-sensory evoked potentials involve stimulating peripheral nerves and determining a response
in scalp electrodes.
It is required that the patient not be under the eff ects of neuromuscular blockade for this method to work.
The introduction of remifentanil has made this a more
acceptable technique in modern scoliosis surgery.
- A 62-year-old man presents to A&E with an acute onset of severe central upper abdominal pain.
It radiates through to his back, and he has been vomiting all day. He is known to have gallstones and has had a recent course of oral antibiotics and steroids for an infective exacerbation of COPD.
On examination he is found to have rebound
epigastric tenderness, pyrexia, and discolouration of his flanks.
Which of the following blood tests is most specifi c for the diagnosis of acute pancreatitis?
A. Serum transaminases.
B. Serum trypsinogen.
C. Serum amylase.
D. Serum lipase.
E. Serum calcium.
D
- Answer: D
Classically it was taught that a raised serum amylase was consistent with acute pancreatitis, but it is
also elevated in bowel perforation, obstruction and ischaemia, diabetic ketoacidosis, pneumonia,
and neoplasms. Serum lipase levels are both more sensitive and specifi c in acute pancreatitis and
remain elevated for up to 14 days.
- A 67-year-old male is undergoing minimally invasive oesophagectomy, requiring one-lung anaesthesia.
Which of the following is least likely to
occur during one-lung anaesthesia?
A. Hypoxia.
B. Hypercarbia.
C. Hypoxic pulmonary vasoconstriction.
D. Ventilation-perfusion mismatch.
E. Intrapulmonary shunt.
C
- Answer: B
Patients undergoing minimally invasive oesophagectomy are in the lateral decubitus position.
During surgery non-dependent (upper) lung is collapsed on the dependent (lower) lung.
Ventilation is ceased to the non-dependent lung. However, blood supply to the non-dependent lung is
maintained, and therefore ventilation–perfusion mismatch, shunt, and subsequent hypoxia may
occur.
Carbon dioxide exchange is not aff ected to the same degree, so there is less of a problem
with hypercarbia.
- A 27-year-old male motorcyclist is admitted to the orthopaedic ward following a road traffic collision involving a lorry.
He suffered a crush injury and tibia/fibula fracture to his right leg and is admitted for
observation.
The nurses are concerned that he may be developing acute limb compartment syndrome.
What is the earliest cardinal feature of
compartment syndrome?
A. Pain disproportionate to the injury in the affected compartment.
B. Paralysis of the limb.
C. Pain aggravated by passive stretching of the involved muscles.
D. Pulselessness of the vessels in the aff ected compartment.
E. Paraesthesia to two-point discrimination in the nerves of the aff ected compartment.
C
- Answer: A
Compartment syndrome is a serious limb-threatening, and potentially life-threatening, condition
that requires a high index of suspicion for diagnosis.
Acute limb compartment syndrome refers to
acutely raised pressures in an osseofascial compartment of a limb, associated with injury or surgery
to that compartment. It can be caused internally by an increase in tissue volume or externally
by a compressive force. The most common cause is trauma, usually after a fracture, in male
patients under 35 years of age. Severe pain that is disproportionate to the injury in the aff ected
compartment is the cardinal symptom. Paralysis, pulselessness, and paraesthesia are later signs. Pain
is aggravated by passive stretching of the involved muscles, but this is less specifi c.
