Anaesthetics

Question 1

Regarding migraines which is incorrect in its treatment a) Chlorpromazine can have a success rate of up to 95% b) Metoclopramide has extrapyramidal side effects in approx. 1% of patients c) Promethazine, chlorpromazine and prochlorperazine can have extrapyramidal effects in up to 45% of patients d) Opioids have good performance for acute migraine treatments

Answer 1

D (Opioids have poor performance for migraines)

Question 2

Which is incorrect about analgesia in children a) Adolescence: behaviors can regress when anxious or in pain b) Stranger anxiety is no longer an issue in primary school aged children c) Children less than 9 months will adversely react to subsequent painful procedures after the initial exposure to pain d) Toddlers should always be examined initially with a parental presence

Answer 2

C

Question 3

Which is an appropriate dose for analgesia in children a) Sucrose 3 ml orally for neonates b) Intranasal fentanyl 1.5 mcg/kg c) Morphine 0.5 mg/kg intravenous d) Oxycodone 0.5 mg/kg orally

Answer 3

B

(sucrose 0.1 to 0.5 ml orally max 5ml, IN fentanyl 1.5 mcg/kg up to 3 mcg/kg, morphine IV and oxycodone 0.1 to 0.2 mg/kg max 10mg. (RCH analgesia and sedation guidelines 2016)

Question 4

Which of the following is correct regarding procedural sedation of children in the ED a) Aspiration risk is 5% in a non-fasted child receiving procedural sedation outside theater b) Vomiting is more likely in the recovery phase than during sedation phase c) The risk of vomiting cannot be decreased with pre-treatment including use of ondansetron d) Laryngospasm cannot be overcome with airway manipulation maneuvers including pressure at ‘Larson’s point’

Answer 4

B

(Aspiration risk is 1 in 30,000 in a non-fasted pediatric sedation outside ED, risk of vomiting may be decreased with ondansetron depending on sedation drugs used, laryngospasm can be overcome with pressure at Larson’s point bilaterally whilst performing a jaw thrust. LITFL laryngospasm 2016)

Question 5

Regarding local anaesthetics which is correct

a) Prilocaine can cause oxidation of haemaglobin and create methemoglobin
b) The use of local anaesthesia with adrenaline often cause problems when given in end arterial fields such as fingers, toes
c) True allergic reactions to local anaesthetics is common
d) Ropivocaine has significantly more cardiotoxicity compared to lignocaine and bupivocaine

Answer 5

A

LA with adrenaline appears to be safe for use in end arteries but should be avoided in the presence of vascular diseases such as Raynaulds or Bergers and in vascular surgery, true allergy is uncommon and usual allergy is to preservatives: alternatives to amides and esters are
diphenhydramine and benzyl alcohol with adrenaline. Ropivocaine has significantly less
cardiotoxicity compared to lignocaine and bupivocaine

Question 6

Which maximal safe dose of local anaesthetic is incorrect

a) Bupivacaine 3 mg/kg
b) Ligocaine 4 mg/kg
c) Ropivacaine 3 mg/kg
d) Prilocaine 7 mg/kg

Answer 6

D (Prilocaine 5 mg/kg)

Question 7

Regarding median nerve blocks which is correct

a) It passes between flexor digitorum profundus and palmaris longis at the proximal wrist crease.
b) It provides sensation to the palmar and dorsum of thumb, index, long and half of ring fingers
c) It provides innervation to the thenar muscles as well as 1 st and second lumbricals
d) The palmar cutaneous branch lies deep to the recurrent branch of the median nerve

Answer 7

C

It lies between palmaris longis and flexor carpi radialis, it does not provide sensation to dorsum of thumb, the palmar cutaneous branch lies superficial to the recurrent nerve and to the flexor retinaculum so is spared in carpal tunnel syndrome.

Question 8

Radial nerve innervates which of the following

a) Medial two Lumbricals
b) All of the extensor muscles of the forearm
c) Sensation of dorsum thumb, index, middle and ring fingers
d) All of the interossei muscles

Answer 8

B

Radial nerve provides sensation to dorsum thumb, index and half of middle fingers, innervates all of the extensor muscles of posterior forearm.

Question 9

Regarding Ulnar nerve blocks which is incorrect

a) The ulnar nerve travels deep to the flexor carpi ulnaris
b) It innervates flexor pollicis brevis, adductor pollicis and all digiti minimi muscles except extensor, medial two lumbricals and all interossei.
c) It innervates the medial two lumbricals and all of the interossei muscles
d) Skin innervation includes all of the 4 th and 5 th digit as well as the hypothenar eminence

Answer 9

D

Ulnar skin innervation: hypothenar, all of 5 th digit and medial half of 4 th digit.

Muscle innervations: flexor pollicis brevis, adductor pollicis, palmaris brevis, all digiti minimi except
extensor, medial two lumbricals and all interossei)

Question 10

Which is not a branch of the sciatic nerve that is anaesthetized in a full ankle block

a) Saphenous nerve
b) Peroneal nerves
c) Tibial nerve
d) Sural nerve

Answer 10

A (Saphonous nerve a branch of the femoral)

Question 11

Regarding ankle blocks which is not true.

a) The deep nerves are posterior tibial and deep peroneal
b) The superficial nerves need to be blocked by depositing local anaestheisa as a field block in subcutaneous space.
c) A complete ankle block anaesthetizes four individual nerves that innervate the foot
d) The landmarks for performing an ankle block includes extensor halluces longis, tibialis anterior tendon, Achilles and the malleoli.

Answer 11

C

A complete ankle block anaesthetizes five nerves: superficial and deep peroneal, posterior tibial, sural and saphenous.

Question 12

Which is correct regarding skin innervation of the ankle nerves

a) 1 st web space is innervated by superficial peroneal nerve
b) Majority of plantar surface is innervated by sural nerve
c) Saphenous nerves innervates the lateral aspect of the ankle
d) Posterior tibial nerve innervates the heel

Answer 12

D

Saphenous nerve innervates medial aspect of ankle.

Posterior tibial innervates heel and majority of plantar.

Sural nerve innervates lateral plantar and lateral ankle.

Superficial peroneal innervates majority of dorsum of foot.

Deep peroneal innervates 1 st web space.

Question 13

Which of these is not one of the 6 ‘A’s of anaesthesia.

a) Anaesthesia
b) Amnesia
c) Analgesia
d) Anxiolysis
e) Airway control

Answer 13

E

The 6 A’s are:

Anaesthesia

Anxiolysis

Amnesia

Areflexia (muscle relaxation - not always required)

Autonomic stability

Analgesia

Question 14

Which of the following is part of the LEMON evaluation when assesing for a difficult airway?

a) Look
b) Enlarged tongue
c) Mouth opening
d) Obvious airway swelling
e) Nasty dentition

Answer 14

A

Look - obesity, beard, dental/facial abnormalities, neck and facial trauma.

Evaluate 3-3-2 rule

Mallampati score

Obstruction - stridor, foreign bodies

Neck mobility

Question 15

When considering the 3-3-2 rule during the evaluation of a difficult airway. Which of the following statements is true?

a) 3 applies to mouth opening, if the patient can not fit 3 of their own fingers in their mouth it will be a difficult intubation.
b) 1 finger breadth is the thyromental distance.
c) The thyromental distance is the distance of the lower mandible in midline from the mentum to the base of the thyroid.
d) 2 fingers should fit from the base of the mouth to the thyroid notch.
e) The hyoid bone to the base of the mouth should fit at least 2 fingers.

Answer 15

A

3 - of the patients fingers should fit vertically between the incisors (any less could be a difficult airway)

3 - of the patients fingers should fit horizotally from the tip of the chin to the hyoid bone (this is the thyromental distance, from the mentum to the thyroid notch - or hyoid bone)

2 - of the patients fingers should fit from the top of the hyoid bone to the top of the thyroid cartilage.

Question 16

A difficult bag valve mask can be remembered by the mneumonic BONES. Which of the following is correct?

a) Bad teeth
b) Overbite
c) No sedation
d) Elderly
e) Short chin

Answer 16

D

Beard

Obese

No teeth

Elderly

Sleep apnoea / snoring

Question 17

Which of the following is included in the ‘RODS’ mneumonic for a difficult LMA?

a) Restricted mouth opening
b) Restricted tongue protrusion
c) Restricted anterior jaw dislocation
d) Systolic BP <80
e) Salivation (excess)

Answer 17

A

Restricted mouth opening

Obstruction

Distorted Airway

Stiff lungs or c-spine

Question 18

Which of the following is included in the mneumonic ‘SHORT’ for a difficult surgical airway?

a) Shotgun wound
b) Hair
c) Obvious infection at site
d) Raised / extended neck
e) Tumour

Answer 18

E

Apart from the extended neck all the others would technically make things trickier. However, the mnuemonic is:

Surgery

Haematoma

Obesity

Radiation distortion or other deformity

Tumour

Question 19

Which one of the following is correct from the Mallampati classification?

a) IV only the base of the uvula can be seen
b) II All the tonsillar pillars are seen
c) I Base of uvula is seen
d) IV Only the tongue and hard palate is visable
e) III partial view of the tonsillar pillars

Answer 19

D

I - Everything is seen (Uvula - body and base, tonsils and tonsilar pillars)

II - Uvula is seen but you start losing site of the tonsils and tonsilar pillars

III - Only the base of the uvula is seen

IV - Only the hard palate can be seen

Question 20

In relation to the American Society of Anesthesiology Classification (ASA) which one of the following is correct?

a) ASA 6 is declared brain dead.
b) ASA 2 is a fit person but not fasted.
c) ASA 4 is a moribound patient not expected to survive 24 hours without surgery.
d) ASA 3 a patient with mild systemic disease.
e) ASA 5 a patient with incapacitating disease this is a constant threat to life.

Answer 20

A

ASA 1 = a healthy fit person

ASA 2 = a patient with a mild systemic disease (T2DM, controlled HTN)

ASA 3 = a patient with severe systemic disease that limits activity e.g. stable CAD, COPD

ASA 4 = a patient with incapacitating disease this is a constant life threat e.g. unstable angina

ASA 5 = a moribund patient not expected to survivie 24 hours without surgery e.g. ruptured AAA

ASA 6 = declared brain dead, a patient whose organs are being removed for donation purposes.

For emergency operation, add the letter E after the classification (e.g. ASA 3E)

Question 21

Regarding facial nerve blocks which is correct?

a) Supraorbital nerve blocks will anaesthetize forehead and bridge of nose.
b) Infraorbital nerve blocks can be done through mucosa superior to maxilla canine.
c) Mental nerve block also anaesthetizes the teeth.
d) Auricular field blocks need only to infiltrate the area superior to the external ear.

Answer 21

B (Supraorbital nerve only supplies forehead, supratrochlear nerve supplies bridge of nose, mental nerve innovates gingiva but not teeth, auricular field block needs both superior and
inferior injections around the external ear)

Question 22

Regarding intercostal nerve blocks which is correct?

a) The scapula and rhomboid muscles will only make blocking to ribs 1 to 3 difficult
b) The order from superior to inferior within the subcostal groove of a rib goes: nerve, artery, vein)
c) Blocking posterior to the midaxillary line ensures analgesia to the lateral cutaneous and anterior branch of the intercostal nerve
d) Pneumothorax occurs in 20% of patients or about 5% for each individual intercostal block

Answer 22

C (Scapula and rhomberg muscles make blocking ribs 1 to 6 difficult, subcostal groove of rib from superior to inferior runs vein – artery – nerve, pneumothorax rate is 8-9% or about 1.4%
for each individual intercostal block)

Question 23

With respect to femoral nerve blocks and fascia iliaca blocks which is incorrect?

a) “3 in 1” blocks target the femoral, obturator and sciatic nerves
b) Ideal injuries for these blocks are neck of femur and proximal femur fractures
c) Fascia iliaca block technique will have two “pops” where the needle infiltrates the fascia lata and fascia iliaca
d) Ropivocaine 0.75% is used as it is less cardiotoxic and usual dose should be 1-3 mg/kg maximal dose of 300mg (40ml)

Answer 23

• *A** (3 in 1: femoral, lateral fem cutaneous and obturator. Ozemed and ASEM websites 2016: http://www.ozemedicine.com/wiki/doku.php?id=fasciailiacusblock. AND
  http: //www.asem.org.au/document.php/gbcokgx/Guidelines+for+use+in+the+ED.pdf.)

Question 24

Which is not a typical contraindication for Bier’s Blocks

a) Sickle cell disease
b) Raynaud’s disease
c) Poorly controlled epilepsy
d) Children

Answer 24

• *D** (contraindicated for children under 5 yo, RCH and RCEM websites 2016 and 2014:
  http: //www.rch.org.au/clinicalguide/guideline_index/Biers_Block/. AND
  secure. rcem.ac.uk/code/document.asp?ID=5360.)

Question 25

Which of the following is least useful score or scale for assessing depth of procedural sedation or sedation in the intubated patient?

a) Richmond Agitation Sedation Scale
b) Glasgow Coma Scale
c) Ramsay Sedation Scale
d) Observer’s assessment of alertness/sedation scale

Answer 25

B (GCS especially Verbal can be a poor score for intubated patients LITFL GCS rev 2 Aug 2014)

Question 26

Which sedation agent property is true?

a) Nitrous oxide is relatively contraindicated in patients with pulmonary Hypertension
b) Entonox is 30:70 mixture of oxygen:nitrous oxide
c) Paradoxical agitation to midazolam has been reported in less than 1% of patients
d) Rigid chest syndrome occurrences in fentanyl administration usually occurs as a late complication.

Answer 26

A. N2O is a pulmonary vasoconstrictor, entonox is 50:50 oxygen:N2O, paradoxical agitation to midaz occurs 1% to 15% of patients, rigid chest syndrome spasm of resp muscles occurs mostly in small children given high doses >5mcg/kg at a rapid IV bolus and usually requires intubation as opioid receptor antagonists does not reverse condition.

Question 27

Which sedation agent property is not true?

a) Ketamine has degrees of dissociation depending on dose
b) Laryngospasm is more common in children given ketamine sedation
c) Egg or soy protein allergy is a contraindication for propofol
d) Ketamine should be avoided in patients with eye injuries or glaucoma

Answer 27

A Ketamine has a threshold for dissociation but it cannot be ‘deepened’ by additional doses, ketamine associated laryngospasm occurs in 1% to 2.5% primarily in children, ketamine is not absolutely contraindicated in head injury but has been shown to increase intraocular pressure (controversial). Propofol is formulated in egg and soybean oil.

Question 28

Which is not typical of the chronic pain types?

a) Myofascial headaches and chronic tension headaches are similar in their trigger point activation of pain
b) Chronic migraine (15 or more migraine days in a month) can lead to transformed migraine
c) Sciatica causes greater degrees of pain in the back than the corresponding dermatome distribution in the leg
d) Risk factors for chronic back pain includes male gender, advanced age and evidence of nonorganic disease

Answer 28

C (Sciatica causes greater leg pain than back pain)

Question 29

Which is typical of the chronic pain types?

a) Diabetic neuropathy is unrelated to glycemic control
b) Post herpetic neuralgia occurs in 8% to 70% of acute episodes of herpes zoster
c) Ocular symptoms such as tearing of eyes or red eyes should not occur with trigeminal neuralgia
d) Phantom limb pain is rare and occurs in <20% of amputations

Answer 29

B Diabetic neuropathy can be prevented or slowed by glycemic control, ocular symptoms can occur with trigeminal neuralgia, phantom limb pain occurs in 30% to 81% of amputations.

Question 30

Regarding Complex Regional Pain Syndrome CRPS which is correct?

a) CRPS Type I occurs post peripheral nerve injury ie post fractured limb
b) Myocardial infarction is an unusual cause of CRPS
c) CRPS can cause oedema, localized sweating and rubor that can mimic wound infection or osteomyelitis
d) Steroids have no role in the treatment of CRPS

Answer 30

C CRPS type I also known as reflex sympathetic dystrophy is due to prolonged immobilization or disuse eg AMI or stroke, type II AKA causalgia due to peripheral nerve injury, early steroid use may reduce ongoing symptoms.

Question 31

Which of the following is less predictive of drug seeking behavior compared to the others?

a) Factitious illness, requests opioids
b) Has current illicit drug addiction
c) Uses aliases
d) Abusive when refused

Answer 31

D

Question 32

Which of the following is a risk factor for aspiration when giving an anaesthetic?

a) Trauma
b) GCS 15
c) meals within 2 hours
d) anorexia
e) Endotracheal tube

Answer 32

A.

There is increased risk of aspiration with:

Decreased LOC

Trauma

Meals within 8 hours

Suspected sphincter incompetence (GERD, hiatus hernia, nasogastric tube)

Increased abdominal pressure (pregnancy, obesity, bowel obstruction, acute abdomen)

Laryngeal mask.

Question 33

Which of the following is an indication of excessive anaesthetic dose?

a) Hypertension
b) Bradycardia
c) Tachycardia
d) Sweating
e) Blink reflex present when eye lashes lightly touched

Answer 33

B.

The others are signs of inadequate anaesthetic. Hypotension and bradycardia are signs of excessive anaesthetics dosing.

Question 34

Which of the following is the correct formula for sizing an uncuffed ETT tube for a paediatric patient?

a) age/4 + 2
b) age/2 +4
c) age + 4
d) age/4 + 4
e) age/2 + 2

Answer 34

D.

Question 35

Which of the following drugs can be given down the endotracheal tube?

a) Dobutamine
b) Amiodarone
c) Lidocaine
d) Sugammadex
e) Ketamine

Answer 35

C.

A mneumonic that may be useful is: NAVEL

Naloxone

Atropine

Ventolin

Epinephrine

Lidocaine/Lignocaine

Question 36

With regards to the mneumonic DOPES for hypoxia post intubation. Which of the following is correct?

a) Deep tube
b) Oesphageal intubation
c) Pierced balloon
d) ETT kinked
e) Stacked breaths

Answer 36

E.

Displacement of the endotracheal tube (ETT)

Obstruction of the ETT

Patient — especially pneumothorax; also: pulmonary embolism, pulmonary edema, collapse, bronchospasm

Equipment — ventilator problems

‘Stacked breaths’ — a reminder about bronchospasm and ventilator settings.

Question 37

With regards to MAC when talking about volatile anaesthetic agents, which of the following statements is true?

a) MAC stands for Maximal Alveolar Concentration.
b) A MAC of 1.0 will prevent movement in 75% of the population to a surgical stimulus.
c) A MAC of 1.5 will ablate a response to a surgical stimuli in 100% of the population.
d) A MAC of 2.0 will block any adrenergic response to a noxious stimuli.
e) A MAC of 1.3 is required to intubate a patient.

Answer 37

E.

MAC is the minimum alveolar concentration. A MAC of 1.0 will prevent movement in 50% of the population with a surgical stimuli and a MAC of 1.2-1.3 will work for most of the population. MAC 1.3 is ideal for intubation and a MAC of 1.5 will block an adrenergic response to noxious stimuli.

Question 38

A short duration of blockade by succinylcholine occurs with?

a) High levels of plasma cholinesterase
b) Pregnancy
c) Malignancy
d) Hypothyroidism
e) Liver disease

Answer 38

A.

All the others cause a prolonged duration of blockade as well as malnutrition, collagen vascular disease and poor quality plasma cholinesterase (usually due to a genetic abnormality in the enzyme function).

Question 39

Which of the following patients would succinylcholine be a good choice?

a) 3rd degree burns
b) Severe closed head injury
c) Upper motor neuron lesions
d) Patient undergoing ECT
e) A patient with traumatic paralysis

Answer 39

D.

The other patients are at risk is there is a massive relase of potassium. In addition, patients with a neuromuscular disease and severe intra-abdominal infection should also avoid succinylchloine

Contrindications include allergy, history of malignant hyperthermia, myotonia anf high risk for hyperkalamic response.

Relative contraindications include cholinesterase deficiency, myasthenia gravis, myastenic syndrome, familial periodic paralysis and an open eye injury.

Question 40

Which of the following patients are at risk of post-op nausea and vomiting?

a) Elderly
b) Males
c) Non-smoker
d) Anaesthetised with TIVA
e) Orthopaedic surgery

Answer 40

C.

Risk factors for PONV include:

Young age; female, history of PONV, non-smokers, use of N20, opioids and volitile agents and finally the type of surgery (ENT, ophthal, abdo/pelvic and plastics).

Question 41

With regards to anaesthetic use in pregnancy which of the following is true?

a) Pregnant women have an increased FRC.
b) The upper airway is oedematous.
c) They have decreased O2 consumption.
d) Decreased SVR proportionally greater than decreased CO results in decreased BP.
e) Increased MAC due to hormonal effects.

Answer 41

B.

In labour the upper airway is more oedematous and friable. There is a decreased FRC and increased O2 consumption. They have an increased blood volume that is greater than the increased RBC mass resulting in a mild anaemia. Decreased SVR proportionally greater than increased CO results in decreased BP. They are also prone to decreased BP from an aortocaval compression.

Decreased MAC due to hormonal effects and an increased block height due to engorged epidural veins.

Question 42

In regards to pregnancy which of the following is true?

a) They have increased gastric emptying.
b) Decreased acidity in the stomach.
c) Increased lower oesophageal tone.
d) Increased risk of aspiration.
e) Decreased abdominal pressure.

Answer 42

D.

Pregnant women have; delayed gastric emptying, increased volume and acidity of gastric fluid, decreased lower oesophageal sphincter tone, increased abdominal pressure and an increased risk of aspiration.

Question 43

Which of the following statement sis correct with ETT sizing in paediatrics?

a) Diameter (mm) = (age/4) + 4
b) Diameter (mm) = (age/2) + 4
c) Length in cm = (age/4) + 10
d) Length in cm = (age/2) + 10
e) Length in cm = (age/2) + 8

Answer 43

A.

Diameter (mm) = (age/4) + 4

Length (cm) = (age/2) + 12

Question 44

Which of the following is seen in malignant hyperthermia?

a) Hypothermia
b) Bradycardia
c) Increased minute ventilation
d) Static or falling ETCO2
e) Paralysis

Answer 44

C.

Signs of malignant hyperthermia include an unexplained rise in ETC02, increase in minute ventilation and oxygen consumption, tachycardia, hypertension, rigidity and hyperthermia (late sign).

The first signs of muscle spasm is usually trismus (masseter spasm) although this can occur in 1% of children given succinylcholine therefore it is not specific for MH.

Question 45

Which of the following is true in regards to malignant hyperthermia?

a) Hypermetabolic disorder of smooth muscle.
b) Due to uncontrolled release of potassium.
c) Autosomal recessive inheritance.
d) Triggered by the use of rocuronium.
e) Incidence of 1-5 in 100,000.

Answer 45

E.

MH is a hypermetabolic disorder of skeletal muscle, due to uncontrolled increase in intracellular Ca2+. Autosomal dominant inheritance and is triggered by all inhalational anaesthetic except nitrous oxide, and can be caused by depolarising muscle relaxants.

Question 46

Which of the following can be used in the management of malignant hyperthermia?

a) Sugammadex
b) Bromocriptine
c) Sodium bicarbonate
d) Warm fluids
e) Hypoventilation

Answer 46

C.

The main treatment is to stop surgery and discontinue any volatile agents, hyperventilate and administer dantrolene 2.5mg/kg IV every 5 minutes until there are signs of control. The patient also needs to be cooled. Other complications include hyperkalaemia and acidosis which respond to sodium bicarbonate, glucose/insulin and sometime calcium chloride or gluconate is required for severe hyperkalaemia.

Some Hot Dudes Better Get Iced Fluids Fast:

Stop all triggering agents

Hyperventilate

Dantrolene

Bicarbonate

Glucose and insulin

IV fluids, cool patient to 38

Fluid output, consider frusemide

Tachycardia; be prepared to treat VT