Health Assessment 2 Practice ?s Flashcards
What does the internal nasal cavity primarily consist of?
A) Septum
B) Epiglottis
C) Vocal cords
D) Cricoid cartilage
A) Septum
Divided by septum
Cribriform plate
Turbinates
The hard and soft palates are part of which anatomical structure?
A) Larynx
B) Pharynx
C) Mouth
D) Trachea
C) Mouth
Mouth
Roof
Maxilla and palatine bones
Hard palate
Soft palate
Teeth
What type of cartilage is the cricoid?
A) Paired
B) Unpaired
C) Flexible
D) Inverted
B) Unpaired
Unpaired
Thyroid
Cricoid - complete ring
Epiglottis
Paired
Arytenoid
Corniculate
Cuneiform
How long is the adult trachea typically?
A) 5-10 cm
B) 10-15 cm
C) 15-20 cm
D) 20-25 cm
B) 10-15 cm
Trachea
Extends from inferior cricoid membrane to carina
10 to 15 cm - adult
C-shaped cartilage
Closed posteriorly by longitudinal trachealis muscle
Anteriorly bounded by tracheal rings
What is the primary purpose of airway assessment?
A) Diagnosing infections
B) Planning surgery
C) Evaluating intubation possibilities
D) Assessing vocal abilities
C) Evaluating intubation possibilities
What factor is most predictive of a difficult intubation?
A) History of snoring
B) Past difficult intubation
C) High BMI
D) Beard presence
B) Past difficult intubation
History Concerns
Past difficult intubation – most predictive factor
Report of excessive sore throat
Report of cut lip/broken tooth
Recent onset of hoarseness
History of OSA
Lesions intra-orally…. base of tongue, lingual tonsils
What is considered an adequate inter-incisor distance for intubation?
A) > 3 cm
B) > 4 cm
C) > 5 cm
D) > 6 cm
D) > 6 cm
Prefer > 6 cm (3 finger breadths)
However, An inter-incisor distance of less than 3 cm (or 2 fingerbreadths), as measured from the upper to the lower incisors with maximal mouth opening, can suggest the possibility of difficult intubation
What is the preferred sternal notch to chin distance in the context of airway assessment?
A) >10.5 cm
B) >11.5 cm
C) >12.5 cm
D) >13.5 cm
C) >12.5 cm
Head and neck mobilitysternomental distance
Distance between sternal notch and chin
Head in full extension
Mouth closed
>12.5 cm preferred
The Mallampati score ranges from:
A) I to II
B) I to III
C) I to IV
D) I to V
C) I to IV
Which condition is NOT typically associated with difficult mask ventilation?
A) Obesity
B) Snoring
C) Beard
D) Youth
D) Youth
“BOOTS” – predictor difficult BMV and potentially airway
Beard – gel
Obesity
Older
Toothless – “gather” cheek, 2 people
Sounds – snoring, stridor
Inability to maintain O2 saturations >90% with BMV
What is the ideal sniffing position intended to align?
A) Oral, pharyngeal, and laryngeal axes
B) Nasal, oral, and tracheal pathways
C) Oral, bronchial, and diaphragmatic areas
D) Pharyngeal, laryngeal, and bronchial axes
A) Oral, pharyngeal, and laryngeal axes
Sniffing position
Cervical flexion and atlanto-occipital extension
Aligns oral, pharyngeal, and laryngeal axis
Ears level with the chest (sternal notch)..
What does the “BOOTS” acronym stand for in predicting difficult airway management?
A) Beard, Obesity, Older, Toothless, Snoring
B) Breathing, Obstruction, Oropharyngeal, Trauma, Surgery
C) Blood, Oxygen, Opacity, Tumors, Swelling
D) Beard, Overbite, Occlusion, Tonsils, Speech
A) Beard, Obesity, Older, Toothless, Snoring
What contributes to the LEMONS score for difficult intubation?
A) Length, Evaluation, Mouth, Obstruction, Neck, Saturation
B) Look, Evaluate, Mallampati, Obstruction, Neck Mobility
C) Look, Evaluate, Mouth opening, Obstruction, Neck mobility, Saturation
D) Larynx, Edema, Mallampati, Obesity, Neck mobility, Surgery
B) Look, Evaluate, Mallampati, Obstruction, Neck Mobility
LEMONS
L- Look – abnormal face, trauma, unusual anatomy
Evaluate – 3-3-2 rule (3 finger mouth opening, fingers along the floor of the mandible, 2 fingers between the space between the superior notch of the thyroid cartilage, and neck/mandible junction
Mallampati score – I-IV, relates mouth opening to size of tongue
Obstruction/obesity – tumor, infection
Neck mobility
What is the primary reason for conducting an airway assessment before anesthesia?
A) To decide on the type of anesthesia
B) To prepare the patient mentally
C) To ensure proper medication is chosen
D) To identify potential intubation and ventilation challenges
D) To identify potential intubation and ventilation challenges
Which of the following is NOT a paired laryngeal cartilage?
A) Arytenoid
B) Thyroid
C) Corniculate
D) Cuneiform
B) Thyroid
In the context of airway assessment, what does a thick neck indicate?
A) Increased risk of hypoxemia
B) Decreased risk of laryngeal injury
C) Increased risk of difficult intubation
D) Decreased need for sedatives
C) Increased risk of difficult intubation
Facial deformities
Head and neck cancers
Burns
Goiter
Short or thick neck
>43 cm = difficulty w/ intubation
More predictive than high BMI
Receding mandible
Beard
C-collar
The presence of what condition increases the complexity of airway management?
A) High blood pressure
B) Diabetes
C) Obstructive Sleep Apnea (OSA)
D) Hyperthyroidism
C) Obstructive Sleep Apnea (OSA)
Difficult Mask Vent
O: Obesity
BMI > 30 kg/m2
B: Beard
E: Edentulous
S: Snorer, OSA
E: Elderly, male
Age > 55
Mallampati 3 or 4
What is indicated by the Mallampati Class IV?
A) Full visibility of tonsils, uvula, and soft palate
B) Visibility of only the hard palate
C) Full visibility of the soft palate only
D) Partial visibility of the uvula
B) Visibility of only the hard palate
Which anatomical measurement is preferred to be greater than 6.5 cm for intubation?
A) Inter-incisor distance
B)Thyromental distance
B) Sternomental distance
C) Head extension distance
D) Neck rotation distance
B)Thyromental distance
Submandibular compliance
Prefer > 6.5 cm (3 finger breadths)
Tip of chin to thyroid notch
What are the typical consequences of dental injuries during intubation?
A) High recovery rates without intervention
B) Low insurance claim rates
C) High percentage during tracheal intubation
D) No significant medical costs
C) High percentage during tracheal intubation
25% of closed insurance claims against anesthesia providers
75% occur during tracheal intubation
Difficult or emergency airway management
Laryngoscope blade
Rigid suction catheters
Oropharyngeal airway placement
Rigorous removal of airways
Biting down on ETT/LMA/airways during emergence
Incisor on right highest potential for injury
Also a slide that says left so who knows
Which Mallampati class is characterized by visibility of the entire uvula and soft palate?
A) Class I
B) Class II
C) Class III
D) Class IV
A) Class I
Fauces, pillars, entire uvula, and soft palate
What is the primary purpose of the sniffing position during airway management?
A) Comfort for the patient
B) Alignment of the pharyngeal axes
C) Prevention of aspiration
D) Reduction of neck strain
B) Alignment of the pharyngeal axes
In the LEMONS score for difficult intubation, what does ‘E’ stand for?
A) Evaluate
B) Edema
C) Extension
D) Elevation
Evaluate – 3-3-2 rule (3 finger mouth opening, fingers along the floor of the mandible, 2 fingers between the space between the superior notch of the thyroid cartilage, and neck/mandible junction
What anatomical characteristic is assessed by the thyromental distance?
A) Distance from the thyroid cartilage to the chin
B) Distance between the sternum and the chin
C) Distance from the thyroid cartilage to the mandible
D) Distance from the top of the thyroid gland to the base of the neck
A) Distance from the thyroid cartilage to the chin
Submandibular compliance
Prefer > 6.5 cm (3 finger breadths)
Tip of chin to thyroid notch
For airway assessment, what is the significance of a high-arched palate?
A) Easier intubation
B) Indicator of robust health
C) Associated with difficult laryngoscopy
D) Reduces the risk of aspiration
C) Associated with difficult laryngoscopy
Identify pathologic characteristics
Tumor
Palate deformities
High arched palate, cleft palate
Macroglossia
What does the “CORMACK-LEHANE classification” assess?
A) Severity of sleep apnea
B) Level of consciousness
C) Visibility of laryngeal structures during laryngoscopy
D) Ability to open the mouth
C) Visibility of laryngeal structures during laryngoscopy
Classification of laryngeal view
Trying to achieve the best view during DL
Grade I-IV
Procedure note we put this down
How does obesity impact airway management?
A) Lowers risk of difficult ventilation
B) Increases risk of easy intubation
C) Increases risk of difficult mask ventilation
D) Has no impact on airway management
C) Increases risk of difficult mask ventilation
What is the primary treatment for angioedema affecting airway management?
A) Immediate fluid resuscitation
B) Administration of antihistamines
C) Rapid sequence intubation
D) High-flow nasal oxygen
C) Rapid sequence intubation
then
Angioedema- FFP, TXA, steroids..
What is the preferred action if the patient cannot be intubated and ventilated?
A) Wait for spontaneous recovery
B) Immediate administration of steroids
C) Preparation for cricothyrotomy
D) Increase sedative dosage
C) Preparation for cricothyrotomy
Best option for given choices
The “BURP” maneuver in laryngoscopy stands for:
A) Backward, Upward, Rightward Pressure
B) Breathe, Unwind, Relax, Position
C) Backward, Upward, Rotate, Push
D) Breathe, Up, Right, Pressure
A) Backward, Upward, Rightward Pressure
Optimal external laryngeal manipulation (OELM)
What is the key consideration when using a bougie during intubation?
A) Color of the device
B) Length corresponding to depth of insertion
C) Shape of the tip
D) Material it’s made from
B) Length corresponding to depth of insertion
essential
small tube for small hole strategically designed deflection at the tip
self-confirming
can intubate epiglottis-only views leave the laryngoscope in
lubricate the tube, pull back and rotate if you get stuck black stripe is 25 cm - at lips, mid trachea in an adult male the bougie is your friend
The onset time for good intubating conditions with rocuronium compared to succinylcholine is:
A) Faster with rocuronium
B) The same for both
C) Slower with rocuronium
D) Not relevant to intubation success
B) The same for both
Succinylcholine possesses the fastest onset (45sec) and produces the shortest period of muscle relaxation (6 – 10min) compared to all other paralytic agents at standard doses. However, Rocuronium dosed at 1.6mg/kg IV, gives the same onset of muscle relaxation as succinylcholine [7] and gives a longer safe apnea time [8] making it the preferred paralytic of choice in the critically ill.
The use of succinylcholine is contraindicated in patients with:
A) Low blood sugar
B) A history of fast recovery
C) A predisposition to malignant hyperthermia
D) Previous administration of atropine
C) A predisposition to malignant hyperthermia
rhabdomyolysis existing hyperkalemia multiple sclerosis ALS
muscular dystrophies / inherited myopathies
denervating injuries > 72 hours old (e.g. stroke, spinal cord injury) burns > 72 hours old
crush injury > 72 hours old
tetanus, botulism, and other exotoxin infections
severe infections >72 hours old (esp. intra-abdominal infections) immobilization (including patients found down)
predisposition to malignant hyperthermia bradycardia
fasciculations – increased ICP, myalgias, hastened desaturation masseter spasm
What is the significance of “can’t intubate, can’t ventilate” scenario in airway management?
A) It indicates an easy airway
B) It is a common, non-urgent situation
C) It represents a critical emergency requiring immediate action
D) It suggests the patient should be awakened and the procedure postpone
C) It represents a critical emergency requiring immediate action
Emergency Pathway- Limit attempts and be aware of the passage of time. Call for help/For Invasive access.
Try an alternative approach as you prepare an invasive access.. If that attempt fails proceed with the invasive access.
Based on the ASA Difficult Airway Algorithm for Adult Patients:
Before attempting intubation, if there is a significant increased risk of aspiration, the clinician should:
A) Proceed with a post-induction airway strategy.
B) Proceed with intubation with the patient awake.
C) Postpone the case immediately.
D) Use supraglottic airway devices.
B) Proceed with intubation with the patient awake.
Based on the ASA Difficult Airway Algorithm for Adult Patients:
When intubation attempt after induction of general anesthesia fails, the next step should be to:
A) Wake the patient up immediately.
B) Limit attempts and consider calling for help.
C) Proceed with a non-emergency pathway.
D) Attempt mask ventilation with adequate confirmation by CO2.
D) Attempt mask ventilation with adequate confirmation by CO2
Also, consider calling for help
Based on the ASA Difficult Airway Algorithm for Adult Patients:
In the case of adequate mask ventilation but unsuccessful intubation, what should be considered?
A) Immediate surgical airway.
B) Limit attempts and consider awakening the patient.
C) Continue attempts without limiting.
D) Proceed with emergency invasive access.
B) Limit attempts and consider awakening the patient.
Based on the ASA Difficult Airway Algorithm for Adult Patients:
If supraglottic airway ventilation is not adequate, what is the advised action?
A) Continue with repeated attempts.
B) Transition immediately to awake intubation.
C) Limit attempts and be aware of the passage of time.
D) Attempt a different supraglottic device.
C) Limit attempts and be aware of the passage of time.
You are now in the emergency pathway..
Emergency Pathway- Limit attempts and be aware of the passage of time. Call for help/For Invasive access.
Try an alternative approach as you prepare an invasive access.. If that attempt fails proceed with the invasive access.
Based on the ASA Difficult Airway Algorithm for Adult Patients:
In the algorithm, when should you consider calling for help or invasive access?
A) Only if mask ventilation is adequate.
B) After a single failed intubation attempt.
C) When supraglottic airway ventilation is not adequate and mask ventilation fails.
D) As soon as the patient arrives in the operating room.
C) When supraglottic airway ventilation is not adequate and mask ventilation fails.
(cannot intubate, cannot ventilate)
Cannot intubate is implied
Which component is NOT included in the Mallampati classification?
A) Visibility of the uvula
B) Tongue size
C) Pharyngeal pillars
D) Nasal patency
D) Nasal patency
Rationale: The Mallampati classification involves visibility of intra-oral structures, not nasal structures.
However,
The lateral wall of the nasal passages is characterized by the presence of three turbinates (or conchae) that divide the nasal passage into three scroll-shaped meatuses: inferior meatus, between the inferior turbinate and the floor of the nasal cavity, is the preferred pathway for passage of nasal airway devices
What is a contraindication for using a laryngeal mask airway (LMA)?
A) Elective surgery
B) Full stomach
C) Patient comfort
D) Short procedures
B) Full stomach
Rationale: LMAs are not recommended for patients at risk of aspiration, such as those with a full stomach.
What differentiates a ‘difficult airway’ from a ‘failed airway’?
A) Difficult airway implies successful intubation after multiple attempts
B) Failed airway indicates successful mask ventilation
C) Difficult airway is a situation where the patient is conscious
D) Failed airway means multiple unsuccessful intubation attempts and unsuccessful mask ventilation
D) Failed airway means multiple unsuccessful intubation attempts and unsuccessful mask ventilation
Rationale: A ‘failed airway’ scenario indicates both unsuccessful intubation and mask ventilation, posing an immediate risk to patient safety.
Awake fiberoptic intubation is recommended in patients with:
A) No risk of aspiration
B) Anticipated difficult airway
C) Stable cardiovascular status
D) Previous history of easy intubation
B) Anticipated difficult airway
Which is NOT a key feature of the ASA Difficult Airway Algorithm?
A) Use of supraglottic airway devices
B) Immediate cricothyrotomy
C) Awake intubation
D) Pharmacological induction before airway assessment
B) Immediate cricothyrotomy
Rationale: Immediate cricothyrotomy is not a key feature but a last resort in the ASA Difficult Airway Algorithm.
Patient could be combative and need ketamine to calm down before a good assessment can be made.
Which medication is NOT typically used to break a laryngospasm?
A) Succinylcholine
B) Propofol
C) Atropine
D) Lidocaine
C) Atropine
Rationale: Atropine is not used to break a laryngospasm; it is used to reduce secretions. Succinylcholine, Propofol, and Lidocaine can be used for laryngospasm.
Signs of inadequate mask ventilation include all EXCEPT:
A) Rising CO2 levels
B) Cyanosis
C) Chest movement
D) Squeaking noises from the mask
C) Chest movement
Rationale: Adequate mask ventilation is confirmed by visible chest movement; its presence indicates effective ventilation.
The “BURP” maneuver in laryngoscopy is used to:
A) Prevent vomiting
B) Optimize vocal cord visualization
C) Increase speed of intubation
D) Reduce patient discomfort
B) Optimize vocal cord visualization
Rationale: The “BURP” maneuver is used to improve the visualization of the vocal cords during laryngoscopy.
The Brachial Plexus is formed by the anterior rami of which spinal nerves?
A) C1-C4
B) C5-C8 and T1
C) L1-L4
D) S1-S4
Answer: B) C5-C8 and T1
Which muscle is NOT innervated by the Musculocutaneous Nerve?
A) Biceps Brachii
B) Coracobrachialis
C) Brachialis
D) Teres Major
Answer: D) Teres Major
Nerve roots–C5-C7.
Motor functions– muscles in the anterior compartment of the arm (coracobrachialis, biceps brachii and the brachialis).
Sensory functions– gives rise to the lateral cutaneous nerve of forearm, which innervates the lateral aspect of the forearm
The Axillary Nerve provides motor innervation to which of the following muscles?
A) Pectoralis Major
B) Deltoid
C) Latissimus Dorsi
D) Biceps Brachii
Answer: B) Deltoid
Spinal roots: C5 and C6.
Sensory functions: Gives rise to the upper lateral cutaneous nerve of arm, which innervates the skin over the lower deltoid (‘regimental badge area’).
Motor functions:Innervates the teres minor and deltoid muscles.
Axillary nerve- and nerve block.. Shoulder pain.. Lateral area of the arm.. Axillary nerve block from tourniquet pain..
The Median Nerve does NOT innervate which of the following muscles?
A) Flexor Carpi Radialis
B) Palmaris Longus
C) Flexor Carpi Ulnaris
D) Pronator Teres
Answer: C) Flexor Carpi Ulnaris - Just remember it doesn’t innervate your pinky which is ulnar side. First three fingers and the palm of your hand.
Nerve roots:C6 – T1 (also contains fibers from C5 in some individuals).
Motor functions:Innervates the flexor and pronator muscles in theanterior compartment of the forearm(except the flexor carpi ulnaris and part of the flexor digitorum profundus, innervated by theulnar nerve). Also supplies innervation to the thenar muscles and lateral two lumbricals in the hand.
Sensory functions:Gives rise to the palmar cutaneous branch, which innervates the lateral aspect of the palm, and the digital cutaneous branch, which innervates the lateral three and a half fingers on the anterior (palmar) surface of the hand.
Tracks all the way down the arm.. Radial thumb, ulnar pinky, median is the middle
Sensory innervation of the lateral aspect of the forearm is provided by which nerve?
A) Ulnar Nerve
B) Radial Nerve
C) Median Nerve
D) Musculocutaneous Nerve
Answer: D) Musculocutaneous Nerve
Axillary is high lateral
Radial is Inferior lateral - just above forearm, and the posterior side of your arm.
Ulnar is basically just your pinky.
Which of the following is NOT a branch of the Lumbar Plexus?
A) Femoral Nerve
B) Obturator Nerve
C) Genitofemoral Nerve
D) Axillary Nerve
Answer: D) Axillary Nerve
The Radial Nerve innervates all of the following except:
A) Triceps Brachii
B) Extensor Carpi Radialis
C) Flexor Carpi Ulnaris
D) Anconeus
Answer: C) Flexor Carpi Ulnaris
It basically innervates the whole backside of your arm and the back side of your hand.
Nerve roots– C5-T1.
Sensory– Innervates most of the skin of the posterior forearm, the lateral aspect of the dorsum of the hand, and the dorsal surface of the lateral three and a half digits.
Motor–Innervates the triceps brachii and the extensor muscles in the forearm.
Radial nerve near the radial artery..
The Sacral Plexus gives rise to which major nerve of the lower limb?
A) Femoral Nerve
B) Sciatic Nerve
C) Tibial Nerve
D) Common Peroneal Nerve
Answer: B) Sciatic Nerve
The sacral plexus, L4-S4
Which nerve is primarily involved in the wrist drop condition?
A) Ulnar Nerve
B) Radial Nerve
C) Median Nerve
D) Axillary Nerve
Answer: B) Radial Nerve
The sacral plexus is formed by the anterior rami of which sacral spinal nerves?
A) S1-S4
B) S2-S4
C) S1-S3
D) S2-S5
A) S1-S4
Which nerve is known as the largest nerve in the body and originates from the sacral plexus?
A) Femoral Nerve
B) Sciatic Nerve
C) Ulnar Nerve
D) Median Nerve
Answer: B) Sciatic Nerve
What is the primary function of the musculocutaneous nerve?
A) Innervates the posterior compartment of the arm
B) Innervates the anterior compartment of the thigh
C) Innervates muscles in the anterior compartment of the arm
D) Provides sensory innervation to the posterior thigh
Answer: C) Innervates muscles in the anterior compartment of the arm
The femoral nerve arises from which spinal roots?
A) L1-L3
B) L2-L4
C) L1-L4
D) L2-L3
Answer: B) L2-L4
Which of the following muscles is NOT innervated by the axillary nerve?
A) Deltoid
B) Teres Minor
C) Teres Major
D) Biceps Brachii
Answer: D) Biceps Brachii
The obturator nerve provides sensory innervation to which area?
A) The medial thigh
B) The lateral thigh
C) The anterior thigh
D) The posterior thigh
Answer: A) The medial thigh
Roots: L2, L3, L4.
Motor Functions: Innervates the muscles of the medial thigh – the obturator externus, adductor longus, adductor brevis, adductor magnus and gracilis.
Sensory Functions: Innervates the skin over the medial thigh.
What is the sensory function of the lateral femoral cutaneous nerve?
A) Innervates the medial aspect of the thigh
B) Innervates the anterior and lateral thigh down to the knee
C) Provides sensation to the heel and sole of the foot
D) Provides sensation to the back of the thigh
Answer: B) Innervates the anterior and lateral thigh down to the knee
This nerve has a purely sensory function. It enters the thigh at the lateral aspect of the inguinal ligament, where it provides cutaneous innervation to the skin there.
Roots: L2, L3
Motor Functions:None.
Sensory Functions: Innervates the anterior and lateral thigh down to the level of the knee.
Which of the following is not a typical function or characteristic of the lumbar plexus?
A) Innervating the muscles of the anterior thigh
B) Originating from the anterior rami of L1-L4 spinal nerves
C) Contributing to the formation of the sciatic nerve
D) Providing sensory innervation to the lower leg and foot
Answer: C) Contributing to the formation of the sciatic nerve
The anterior rami of the L1-L4 spinal roots divide into several cords. These cords then combine together to form the six major peripheral nerves of the lumbar plexus. These nerves then descend down the posterior abdominal wall to reach the lower limb, where they innervate their target structures.
A usefulmemory aid for the branches of the lumbar plexus is:I,IGetLeftoversOnFridays. This stands for theIliohypogastric,Ilioinguinal,Genitofemoral,Lateral cutaneousnerve of the thigh,ObturatorandFemoral.
The iliohypogastric nerve innervates which of the following?
A) The internal oblique and transversus abdominis muscles
B) The quadriceps femoris muscle
C) The muscles of the posterior thigh
D) The adductor muscles of the thigh
Answer: A) The internal oblique and transversus abdominis muscles
And sits above the ilioinguinal nerve.
The iliohypogastric nerve is the first major branch of the lumbar plexus. It runs to the iliac crest, across the quadratus lumborum muscle of the posterior abdominal wall. It then perforates the transversus abdominis, and divides into its terminal branches.
Roots: L1 (with contributions from T12).
MotorFunctions: Innervates the internal oblique and transversus abdominis.
SensoryFunctions: Innervates the posterolateral gluteal skin in the pubic region.(Tip: an easy way to remember that the IlioHypogastric comes before the IlioInguinal is thatH comes beforeIin the alphabet!)
The obturator nerve originates from which spinal roots?
A) L2, L3, L4
B) L4, L5, S1
C) L1, L2, L3
D) S1, S2, S3
Answer: A) L2, L3, L4
Roots: L2, L3, L4.
Motor Functions: Innervates the muscles of the medial thigh – the obturator externus, adductor longus, adductor brevis, adductor magnus and gracilis.
Sensory Functions: Innervates the skin over the medial thigh.
Where is the stellate ganglion typically located?
A) Anterior to the neck of the first rib and occasionally extending to being anterior to the transverse process of the C7 cervical vertebra
B) Directly on the surface of the heart
C) Inside the thoracic vertebral column
D) Within the cranial cavity
Answer: A) Anterior to the neck of the first rib and occasionally extending to being anterior to the transverse process of the C7 cervical vertebra
Which symptom is NOT typically alleviated by a stellate ganglion block?
A) Craniofacial hyperhidrosis
B) Refractory angina
C) Postherpetic neuralgia
D) Acute appendicitis
Answer: D) Acute appendicitis
The stellate ganglion provides sympathetic fibers to all of the following EXCEPT:
A) The anterior rami of C7, C8, and T1.
B) The inferior cardiac nerve contributing to the cardiac plexus.
C) The lumbar plexus.
D) The brachial plexus.
Answer: C) The lumbar plexus.
Which is NOT an indication for a stellate ganglion block?
A) Phantom limb pain
B) Chronic post-surgical pain
C) Hyperthyroidism
D) Meniere’s syndrome
Answer: C) Hyperthyroidism
Which nerve is closely associated with the stellate ganglion and may be affected during a stellate ganglion block?
A) Median Nerve
B) Ulnar Nerve
C) Phrenic Nerve
D) Femoral Nerve
Answer: C) Phrenic Nerve
What is a common symptom that might develop after a stellate ganglion block due to disruption in sympathetic nerve supply?
A) Tachycardia
B) Hyperhidrosis
C) Horner’s syndrome
D) Hypertension
Answer: C) Horner’s syndrome (including partial ptosis, miosis, and facial anhidrosis)
What gene is associated with Malignant Hyperthermia (MH)?
A) RYR1
B) BRCA1
C) MYH7
D) CFTR
A) RYR1
What is the primary treatment for scleroderma renal crisis?
A) NSAIDs
B) ACE inhibitors
C) Beta-blockers
D) Antimalarials
B) ACE inhibitors
Renal: Decreased renal blood flow and systemic HTN
Renal crisis – precipitated by corticosteroids, treatment ACE-I
Which is NOT a component of CREST syndrome?
A) Calcinosis
B) Raynaud’s phenomenon
C) Esophageal dysmotility
D) Tricuspid regurgitation
D) Tricuspid regurgitation
T= Telangiectasis- dilation of capillaries causing red marks on surface of skin
Duchenne Muscular Dystrophy (DMD) is caused by mutations in what gene?
A) Dystrophin
B) Hemoglobin
C) Collagen
D) Insulin
A) Dystrophin
What is the typical initial symptom of Duchenne Muscular Dystrophy?
A) Cataracts
B) Waddling gait
C) Skin rash
D) Hearing loss
B) Waddling gait
Mutation in the dystrophin gene
Fatty infiltration =pseudohypertrophic
2-5 y/o boys
Initial symptoms: waddling gait, frequent falling, difficulty climbing stairs
In Myasthenia Gravis, what is decreased at the neuromuscular junction?
A) Sodium channels
B) Acetylcholine receptors
C) Dopamine receptors
D) Potassium channels
B) Acetylcholine receptors
Chronic autoimmune disorder
NMJ - Decreased functional post-synaptic AChreceptors
Muscle weakness w/ rapid exhaustion of voluntary muscles
Partial recovery with rest
ACh receptor-bindingantibodies andthymusabnormalities
What is the primary symptom of Myasthenia Gravis?
A) Muscle stiffness
B) Muscle weakness
C) Numbness
D) Pain
B) Muscle weakness
Ptosis, diplopia, and dysphagia – initial
Ocular, pharyngeal, and laryngeal muscle involvement
Dysarthria (Problems with the muscles that help produce speech, difficulty pronouncing words)
Pulmonary: isolated respiratory failure – occasional presenting manifestation- isolated respiratory failure as presentaion
MS: Arm, leg, or trunk muscle weakness – asymmetric
CV: Myocarditis – A Fib, heart block, or cardiomyopathy
Autoimmune diseases associated – RA, SLE, pernicious anemia, hyperthyroidism
Which medication is preferred in Myasthenia Gravis for symptom control?
A) Pyridostigmine
B) Acetaminophen
C) Ibuprofen
D) Neostigmine
A) Pyridostigmine
Anticholinesterases
First line of treatment
Pyridostigmine > neostigmine
Thymectomy
Induces remission
Reduced use of immunosuppressives
Reduces ACh receptor antibody levels
Full benefit delayed
Osteoarthritis is characterized by degeneration of what?
A) Muscles
B) Articular cartilage
C) Blood vessels
D) Nerve cells
B) Articular cartilage
Degenerative process affecting articular cartilage
Minimal inflammation
Joint trauma
Biomechanical stresses
Joint injury
Abnormal joint loading
Neuropathy
Ligament injury
Muscle atrophy
Obesity
Pain present with motion,relieved by rest
The involvement of which joints is typical in Rheumatoid Arthritis?
A) Hip and shoulder
B) Spinal
C) Proximal interphalangeal and metacarpophalangeal
D) Distal interphalangeal
C) Proximal interphalangeal and metacarpophalangeal
Autoimmune-mediated, systemic inflammatory disease
Proximal interphalangeal and metacarpophalangeal joints
Rheumatoid nodules at pressure points
Rheumatoid factor
What is the main characteristic of Systemic Lupus Erythematosus (SLE)?
A) Increased platelet count
B) Chronic inflammation
C) Muscle hypertrophy
D) Bone enlargement
B) Chronic inflammation
Multisystem chronic inflammatory
Antinuclear antibody production
Typical manifestations:
Antinuclear antibodies
Characteristic malarrash
Thrombocytopenia
Serositis
Nephritis
What symptom is NOT associated with Systemic Lupus Erythematosus?
A) Malar rash
B) Butterfly-shaped rash
C) Thrombocytopenia
D) Hyperglycemia
D) Hyperglycemia
Which medication is NOT commonly used to treat Systemic Lupus Erythematosus?
A) NSAIDs
B) Antimalarials
C) Corticosteroids
D) ACE inhibitors
D) ACE inhibitors
NSAIDs or ASA
Anti-malarial
Hydroxychloroquine and quinacrine
Corticosteroids
Immunosuppressants
Methotrexate, azathioprine
What is a potential complication of Rheumatoid Arthritis in the cervical spine?
A) Atlantoaxial subluxation
B) Lumbar disc herniation
C) Thoracic kyphosis
D) Sacroiliac joint dysfunction
A) Atlantoaxial subluxation
Atlantoaxial subluxation
Odontoid process protrudes into the foramen magnum
Pressure on the spinal cord or impairs vertebral artery blood flow
Cricoarytenoid arthritis
Acute – hoarseness, dyspnea, and stridor w/ tenderness over the larynx; swelling and redness of arytenoids
Chronic – asymptomatic or variable degrees of hoarseness, dyspnea, and upper airway obstruction
Osteoporosis
NM: Weakened skeletal muscles
Peripheral neuropathies
What is the key factor in diagnosing Malignant Hyperthermia?
A) High blood pressure
B) Elevated end-tidal CO2
C) Decreased heart rate
D) Low blood sugar
B) Elevated end-tidal CO2
What is NOT a feature of the Duchenne Muscular Dystrophy?
A) Cardiomyopathy
B) Increased CK levels
C) Bone deformities
D) Cognitive impairment
E) None of the above
E) None of the above
CNS: Intellectual disability
MS: Kyphoscoliosis, skeletal muscle atrophy, serum CK 20-100x normal
CV: Sinus tachycardia, cardiomyopathy, EKG abnormalities
Pulmonary: weakened respiratory muscles and cough, OSA
GI: Hypomotility, gastroparesis
Which symptom is least associated with Myasthenia Gravis?
A) Ptosis
B) Diplopia
C) Muscle rigidity
D) Dysphagia
C) Muscle rigidity
Ptosis, diplopia, and dysphagia
Dysarthria and difficulty handling saliva
Isolated respiratory failure
Arm, leg, or trunk muscle weakness
Myocarditis
Autoimmune diseases associated
RA, SLE, pernicious anemia, hyperthyroidism
What is the first line of treatment for Rheumatoid Arthritis?
A) Corticosteroids
B) NSAIDs
C) Antimalarials
D) Biologics
D) Biologics
DMARDs (Disease-modifying antirheumatic drugs)
Halt or slow disease progression
Methotrexate
Tumor necrosis factor (TNF-alpha) inhibitors and interleukin(IL-1) inhibitors
TNF-alpha inhibitors > DMARDs
IL-1 inhibitors – slower onset and less effective
Surgery
Intractable pain, impairment ofjoint function, jointstabilization
Total replacement
What is NOT a common side effect of systemic steroids used in SLE treatment?
A) Osteoporosis
B) Hypertension
C) Hyperglycemia
D) Hypothyroidism
D) Hypothyroidism - This is not a common side effect of systemic steroids used in SLE treatment.
NSAIDs or ASA – arthritis and serositis
Anti-malarial – dermatologic and arthritic manifestations (hydroxychloroquine and quinacrine)
Corticosteroids – tx for severe symptoms; thrombocytopenia and anemia
Suppresses glomerulonephritis and CV abnormalities effectively
Major cause of morbidity
Immunosuppressants – better alternative than high-dose steroids (methotrexate, azathioprine)
Which of the following is not a characteristic of osteoarthritis?
A) Morning stiffness
B) Joint swelling
C) Neuropathy
D) Pain relieved by rest
C) Neuropathy - Neuropathy is not a characteristic of osteoarthritis.
Most common joint disease, leading chronic diseases ofthe elderly,and a major cause of disability
Degenerative process that affects articular cartilage w/ minimal inflammatory reaction in the joints
Joint trauma
Biomechanical stresses
Joint injury
Abnormal joint loading
Neuropathy
Ligament injury
Muscle atrophy
Obesity
Pain present with motion,relieved by rest
Morning Stiffness disappears with movement
Steroids – increase the rate of breakdown. PT – prehab- pain management before the replacement maybe..
For Myasthenia Gravis, the Edrophonium/Tensilon Test is used for which purpose?
A) Confirm Rheumatoid Arthritis
B) Diagnose Myasthenic Crisis
C) Identify Cholinergic Crisis
D) Improve symptoms in Myasthenic Crisis
B) it’s a diagnostic test, positive if symptoms improve
Myasthenic crisis
Drug resistance or insufficient drug therapy
S/S: severe muscle weakness and respiratory failure
Cholinergic crisis
Excessive anticholinesterase treatment
S/S: muscarinic side effects – profound muscle weakness, salivation, miosis, bradycardia, diarrhea, abdominal pain
Edrophonium/Tensilon Test
1-2 mg IVP
Improves myasthenic crisis, makes cholinergic crisis worse
Which is NOT a sign or symptom of Malignant Hyperthermia?
A) Hypercapnia
B) Hypotension
C) Muscle rigidity
D) Tachycardia
B) Hypotension
What is the primary pathological process in Scleroderma?
A) Muscle atrophy
B) Vasculitis leading to fibrosis
C) Neurodegeneration
D) Inflammatory myopathy
B) Vasculitis leading to fibrosis - This is the primary pathological process in Scleroderma.
Duchenne Muscular Dystrophy primarily affects which demographic?
A) Elderly men
B) Young women
C) Boys aged 2-5 years
D) Girls aged 2-5 years
C) Boys aged 2-5 years
Mutation in the dystrophin gene
Fatty infiltration =pseudohypertrophic
2-5 y/o boys
Initial symptoms: waddling gait, frequent falling, difficulty climbing stairs
In patients with Systemic Lupus Erythematosus, what is NOT typically found?
A) Antinuclear antibodies
B) Thrombocytopenia
C) Elevated white blood cell count
D) Serositis
C) Elevated white blood cell count - This is not typically found in patients with Systemic Lupus Erythematosus.
Polyarthritis and dermatitis
Symmetrical arthritis
No spinal involvement
Avascular necrosis of femoral head or condyle
CNS: Cognitive dysfunction, psychological changes
CV: Pericarditis, coronary atherosclerosis, Raynaud’s
Pulmonary: Lupus pneumonia, restrictive lung disease, vanishing lung syndrome
Renal: Glomerulonephritis, decreased GFR
What does the treatment for Systemic Lupus Erythematosus NOT commonly include?
A) NSAIDs
B) ACE inhibitors
C) Antimalarials
D) Corticosteroids
B) ACE inhibitors
Alleviating symptoms…
ACE-I for scleroderma
What triggers a Malignant Hyperthermia crisis?
A) Exposure to cold temperatures
B) Inhaled anesthetics and succinylcholine
C) Antibiotics
D) Nonsteroidal anti-inflammatory drugs
B) Inhaled anesthetics and succinylcholine
What are Heberden’s nodes associated with?
A) Rheumatoid Arthritis
B) Osteoarthritis
C) Systemic Lupus Erythematosus
D) Myasthenia Gravis
B) Osteoarthritis
Weight-bearing and distal interphalangeal joints
Heberden nodes
Distal interphalangeal joints
Degenerative disease – vertebral bodies and intervertebral disks
Protrusion of the nucleus pulposus
Compression of nerve roots
Middle to lower c-spine andl-spine
Which of the following is NOT associated with Rheumatoid Arthritis?
A) Morning stiffness
B) Symmetrical joint involvement
C) Spinal cord compression
D) Rheumatoid nodules
A) morning stiffness
The presence of what antibody is most associated with Systemic Lupus Erythematosus?
A) Rheumatoid factor
B) Antinuclear antibodies
C) Bence Jones protein
D) Anti-cyclic citrullinated peptide
B) Antinuclear antibodies
What is NOT a recommended management practice for Malignant Hyperthermia?
A) Discontinue all triggering agents
B) Administer dantrolene
C) Increase room temperature
D) Hyperventilate with 100% oxygen
C) Increase room temperature
Scleroderma affects the body by:
A) Decreasing muscle mass
B) Thickening and hardening the skin
C) Increasing bone density
D) Reducing cardiac output
B) Thickening and hardening the skin
Which is NOT a symptom of Duchenne Muscular Dystrophy?
A) Difficulty climbing stairs
B) Frequent falling
C) Joint hypermobility
D) Waddling gait
C) Joint hypermobility
Which treatment is not typically used for managing symptoms of Myasthenia Gravis?
A) Cholinesterase inhibitors
B) Corticosteroids
C) Antimalarials
D) Thymectomy
C) Antimalarials
In the management of Osteoarthritis, what is NOT a recommended therapy?
A) Joint replacement surgery
B) High-impact exercises
C) Physical therapy
D) Pain relief medications
B) High-impact exercises
Which feature is not associated with Rheumatoid Arthritis?
A) Osteoporosis
B) Fusiform swelling
C) Atlantoaxial subluxation
D) Heberden’s nodes
D) Heberden’s nodes
Atlantoaxial subluxation
Odontoid process protrudes into the foramen magnum
Pressure on the spinal cord or impairs vertebral artery blood flow
Cricoarytenoid arthritis
Acute – hoarseness, dyspnea, and stridor w/ tenderness over the larynx; swelling and redness of arytenoids
Chronic – asymptomatic or variable degrees of hoarseness, dyspnea, and upper airway obstruction
Osteoporosis
NM: Weakened skeletal muscles
Peripheral neuropathies
The primary cause of death in Systemic Lupus Erythematosus is often related to:
A) Liver failure
B) Renal failure
C) Cardiac arrest
D) Malignant hyperthermia
C) Cardiac Arrest
Death during the course of SLE may be due to coronary atherosclerosis. The development and progression of coronary atherosclerosis is accelerated by treatment with corticosteroids
What is NOT a symptom of SystemLupus Erythematosus?
A) Malar rash
B) Increased red blood cell count
C) Photosensitivity
D) Raynaud’s phenomenon
B) Increased red blood cell count
Rationale: SLE typically involves hematological changes like anemia (low red blood cell count), not an increased red blood cell count.
Which condition is characterized by muscle weakness following repeated activities?
A) Osteoarthritis
B) Rheumatoid Arthritis
C) Myasthenia Gravis
D) Systemic Lupus Erythematosus
C) Myasthenia Gravis
What is NOT a common complication of Systemic Lupus Erythematosus?
A) Glomerulonephritis
B) Pulmonary hypertension
C) Malignant hyperthermia
D) Thrombocytopenia
Answer: C) Malignant hyperthermia
Rationale: Malignant hyperthermia is a rare life-threatening condition usually triggered by certain anesthesia medications, not associated with SLE.
What triggers Myasthenic Crisis?
A) Excessive anticholinesterase treatment
B) Insufficient anticholinesterase treatment
C) High doses of corticosteroids
D) Overuse of NSAIDs
Answer: B) Insufficient anticholinesterase treatment
Rationale: Myasthenic crisis can occur due to inadequate treatment with anticholinesterase medications, leading to severe muscle weakness.
What is not a sign of a cholinergic crisis?
A) Muscle weakness
B) Salivation
C) Miosis (constricted pupils)
D) Hypercalcemia
Answer: D) Hypercalcemia
Rationale: Hypercalcemia is not a symptom of cholinergic crisis; typical signs include muscle weakness, salivation, and miosis (constricted pupils).
Which medication is avoided in patients with Myasthenia Gravis due to risk of exacerbation?
A) Dantrolene
B) Succinylcholine
C) Pyridostigmine
D) Neostigmine
Answer: B) Succinylcholine
Rationale: Succinylcholine can exacerbate symptoms of Myasthenia Gravis and should be avoided due to its effect on neuromuscular transmission.
What is not a part of the SHADE protocol for Malignant Hyperthermia?
A) Stop triggering agents
B) Hypothermia treatment
C) Dantrolene
D) Electrolyte correction
Answer: B) Hypothermia treatment
SHADE
Stop, heat control, activated charcoal, dantrolene, electrolyte (hyperkalemia)
Which statement about Duchenne Muscular Dystrophy is FALSE?
A) Caused by a deficiency of dystrophin
B) Typically presents in early adulthood
C) Leads to progressive muscle weakness
D) Involves cardiomyopathy as a common complication
Answer: B) Typically presents in early adulthood
Rationale: Duchenne Muscular Dystrophy typically presents in early childhood, not adulthood.
In scleroderma, what is not a typical feature?
A) Microvascular changes
B) Increased deposition of collagen
C) Autoimmune-mediated vasculitis
D) Hyperactive immune response leading to increased white blood cell count
Answer: D) Hyperactive immune response leading to increased white blood cell count
Rationale: Scleroderma involves autoimmune-mediated changes but does not typically feature a hyperactive immune response leading to increased white blood cell count.
What percentage of surgical patients have Ischemic Heart Disease (IHD)?
A) 10%
B) 20%
C) 30%
D) 40%
C) 30%
Which of these is NOT a first manifestation of IHD?
A) Angina pectoris
B) Acute Myocardial Infarction
C) Sudden death
D) Hypertension
Answer: D) Hypertension
What are the two most important risk factors for the development of atherosclerosis involving the coronary arteries?
A) Female gender and decreasing age
B) Male gender and increasing age
C) Smoking and high cholesterol
D) Diabetes and sedentary lifestyle
Answer: B) Male gender and increasing age
What type of angina develops in the setting of partial occlusion of a coronary artery?
A) Unstable angina
B) Prinzmetal angina
C) Stable angina
D) Microvascular angina
Answer: C) Stable angina
Stable angina typically develops in the setting of partial occlusion or significant (>70%) chronic narrowing of a segment of coronary artery.
What leads to the typical chest pain of angina pectoris?
A) Increase in coronary blood flow
B) Balance between myocardial oxygen supply and demand
C) Stimulation of cardiac nociceptive and mechanosensitive receptors
D) Increase in cardiac contractility
Answer: C) Stimulation of cardiac nociceptive and mechanosensitive receptors
These substances stimulate cardiac nociceptive and mechanosensitive receptors whose afferent neurons converge with the upper five thoracic sympathetic ganglia and somatic nerve fibers in the spinal cord and ultimately produce thalamic and cortical stimulation that results in the typical chest pain of angina pectoris.
Which condition is NOT commonly associated with angina pectoris?
A) Myocardial hypertrophy
B) Severe aortic stenosis
C) Aortic regurgitation
D) Pulmonary hypertension
Answer: D) Pulmonary hypertension
What does chronic stable angina refer to?
A) Chest pain that changes in frequency or severity over a 2-month period
B) Chest pain that does not change appreciably in frequency or severity over 2 months
C) Increasing chest pain with physical activity
D) Chest pain relieved by nitroglycerin within 5 minutes
Answer: B) Chest pain that does not change appreciably in frequency or severity over 2 months
Unstable angina is characterized by:
A) Chest pain that decreases in frequency without any treatment
B) Chest pain increasing in frequency and/or severity without an increase in cardiac biomarkers
C) Chest pain that only occurs at rest
D) Chest pain that is relieved by rest and medications
Answer: B) Chest pain increasing in frequency and/or severity without an increase in cardiac biomarkers
Which of the following is a typical symptom of angina pectoris?
A) Retrosternal chest pain that radiates to the right shoulder
B) Retrosternal chest pain that does not change with physical activity
C) Retrosternal chest pain, pressure, or heaviness that may radiate to the neck, left shoulder, left arm, or jaw
D) Retrosternal chest pain accompanied by a high fever
Answer: C) Retrosternal chest pain, pressure, or heaviness that may radiate to the neck, left shoulder, left arm, or jaw
What substance is released during stable angina that can slow atrioventricular conduction and decrease cardiac contractility?
A) Dopamine
B) Adenosine
C) Epinephrine
D) Acetylcholine
B) Adenosine
Also bradykinin
What is considered the most common cause of stable angina?
A) Myocardial infarction
B) Atherosclerosis
C) Cardiomyopathy
D) Valvular heart disease
Answer: B) Atherosclerosis
Which of the following is NOT a symptom of chronic stable angina?
A) Chest pain that does not change in frequency
B) Chest pain increasing in frequency or severity
C) Shortness of breath
D) Pain lasting several minutes
Answer: B) Chest pain increasing in frequency or severity
At what percentage of occlusion does stable angina typically develop?
A) 50%
B) 60%
C) 70%
D) 80%
Answer: C) 70%
What does the release of adenosine and bradykinin in the heart result in?
A) Increased heart rate
B) Decreased blood pressure
C) Chest pain
D) Increased cardiac contractility
C) Chest pain
Release of adenosine and bradykinin
Cardiac nociceptors
Afferent neurons
T1-T5 sympathetic ganglia
Slow AV conduction
Decrease cardiac contractility
Which of the following is NOT a classic sign of angina pectoris?
A) Retrosternal chest pressure
B) Pain radiating to the neck and left arm
C) Lasts less than 5 min
D) Shortness of breath
Answer: C) Lasts less than 5 min
What distinguishes unstable angina at rest?
A) Lasts less than 5 minutes
B) Typically lasting more than 10 minutes
C) Accompanied by a decrease in cardiac biomarkers
D) Resolves with physical activity
Answer: B) Typically lasting more than 10 minutes
What is the main diagnostic tool for identifying Ischemic Heart Disease?
A) MRI scan
B) 12 lead ECG
C) Blood pressure measurement
D) Cholesterol levels
Answer: B) 12 lead ECG
Which ECG change is NOT associated with myocardial ischemia?
A) ST-segment depression
B) T wave inversion
C) ST elevation
D) P wave enlargement
Answer: D) P wave enlargement
Troponin levels increase within how many hours after myocardial injury?
A) 1 hour
B) 3 hours
C) 6 hours
D) 12 hours
Answer: B) 3 hours
Which of the following is a major risk factor for Ischemic Heart Disease?
A) Low cholesterol
B) Young age
C) Smoking
D) Low blood pressure
Answer: C) Smoking
What is NOT a goal of drug treatment in patients with clinical atherosclerosis?
A) Lowering LDL cholesterol below 70 mg/dL
B) Increasing HDL cholesterol above 160 mg/dL
C) Stabilizing plaque
D) Reducing inflammation
Answer: B) Increasing HDL cholesterol above 160 mg/dL
What is the primary mechanism of action of statins in the context of IHD?
A) Blood thinning
B) Coronary plaque stabilization
C) Vasodilation
D) Increasing heart rate
Answer: B) Coronary plaque stabilization
Which medication class is uniquely effective for treating Prinzmetal’s angina?
A) Beta-blockers
B) Calcium channel blockers
C) Nitrates
D) ACE inhibitors
Answer: B) Calcium channel blockers
What is the significance of a patient’s ability to climb 2-3 flights of stairs in the context of cardiac reserve?
A) Indicates poor cardiac reserve
B) Suggests good cardiac reserve
C) Indicates risk of ventricular tachycardia
D) Suggests need for immediate surgery
Answer: B) Suggests good cardiac reserve
Which diagnostic feature is characteristic of stable angina on an ECG?
A) ST segment elevation
B) Pathological Q waves
C) ST segment depression
D) Complete heart block
Answer: C) ST segment depression
1mm
Troponin levels after myocardial injury remain elevated for how long?
A) 1-2 days
B) Up to 2 weeks
C) 24 hours
D) 5-7 days
Answer: B) Up to 2 weeks
Which of the following is NOT a typical symptom of myocardial ischemia?
A) Sweating
B) Dyspnea
C) Skin pallor
D) Hyperglycemia
Answer: D) Hyperglycemia
Percutaneous coronary intervention (PCI) is preferred over thrombolytic therapy when:
A) The patient has a history of bleeding disorders
B) There are no available cardiac catheterization facilities
C) The symptoms have been present for more than 12 hours
D) The patient has a contraindication to thrombolytic therapy
Answer: D) The patient has a contraindication to thrombolytic therapy
can’t do active bleeding
Which medication class is only recommended to prolong life in patients with coronary artery disease (CAD)?
A) Calcium channel blockers
B) Nitrates
C) β-blockers
D) ACE inhibitors
Answer: C) β-blockers
What is the primary mechanism of action for Calcium Channel Blockers in the management of ischemic heart disease?
A) Increase heart rate
B) Dilate coronary arteries
C) Increase oxygen consumption
D) Increase blood clotting
Answer: B) Dilate coronary arteries
ACE inhibitors are used in cardiac therapy primarily because they:
A) Decrease myocardial hypertrophy
B) Increase coronary vasoconstriction
C) Promote interstitial myocardial fibrosis
D) Induce inflammatory responses
Answer: A) Decrease myocardial hypertrophy
Angiotensin converting enzyme converts angiotensin I to angiotensin II
Prevent ventricular remodeling, stabilize electrical activity of re-perfused heart and prevent the occurrence of reperfusion arrhythmias
Reduce myocardial workload and decrease myocardial oxygen demand
Does some things we might not want.. Good for aberrant conduction..
Patient might have exaggerated response, hypotensive..
Infusions for these patients – vasodilator and a constrictor
The primary indication for revascularization in ischemic heart disease is:
A) Less than 30% occlusion of coronary arteries
B) Failure of medical therapy
C) Improved ejection fraction (EF) above 40%
D) Preference of the patient
Answer: B) Failure of medical therapy
Failure of medical therapy
> 50% L main coronary artery
> 70% epicardial coronary artery
Impaired EF <40%
CABG > PCI
Which of the following is NOT typically part of the initial management for Unstable Angina/NSTEMI?
A) Bed rest and oxygen
B) Thrombolytic therapy
C) Sublingual nitroglycerin
D) β-blocker therapy
Answer: B) Thrombolytic therapy
Dual Antiplatelet Therapy (DAPT) consists of:
A) ASA and P2Y12 inhibitor
B) Statins and beta-blockers
C) ACE inhibitors and statins
D) Nitrates and calcium channel blockers
Answer: A) ASA and P2Y12 inhibitor
The recommended time to wait before surgery after PCI with a drug-eluting stent is:
A) 2 weeks
B) 6 weeks
C) 1 year
D) 5 days
Answer: C) 1 year
Minimum is 6 months but most of the slides say 1 year
According to the Revised Cardiac Risk Index (RCRI), what is considered low risk for cardiac complications?
A) More than three RCRI risk factors
B) Less than one RCRI risk factor
C) Exactly two RCRI risk factors
D) More than one percent risk
Answer: B) Less than one RCRI risk factor
Low risk - <1%
≤1 RCRI risk factor
Elevated risk - >1%
>2 RCRI risk factors
For patients undergoing elective major noncardiac surgery, poor functional capacity is indicated by:
A) Ability to climb more than 3 flights of stairs
B) METs greater than 4
C) METs less than 4
D) High rate of energy consumption at rest
Answer: C) METs less than 4
The urgency of surgery classification “Emergency” means:
A) Surgery can be delayed without significant risk
B) Surgery is required within 6 to 24 hours
C) Surgery is needed within 6 hours or less
D) Surgery can be scheduled routinely
Answer: C) Surgery is needed within 6 hours or less
Which medication is recommended to continue throughout the peri-operative period for cardiac risk patients?
A) ACE inhibitors
B) Statins
C) β-blockers
D) Glycopyrrolate
Answer: C) β-blockers
After percutaneous coronary intervention (PCI), the minimum waiting period before surgery without stenting is:
A) 1 year
B) 6 weeks
C) 2 weeks
D) 5 days
Answer: C) 2 weeks
Active cardiac conditions increasing perioperative risk include all EXCEPT:
A) Stable angina
B) Decompensated heart failure
C) Severe valvular heart disease
D) Significant dysrhythmias
Answer: A) Stable angina
What is the result of an imbalance between coronary blood flow and myocardial oxygen consumption?
A) Hypertension
B) Ischemia
C) Tachycardia
D) Bradycardia
Answer: B) Ischemia
Which type of angina is characterized by chest pain that does not change in frequency or severity over a two-month period?
A) Unstable angina
B) Chronic stable angina
C) Prinzmetal angina
D) Microvascular angina
Answer: B) Chronic stable angina
Statins are primarily prescribed for their ability to:
A) Increase lipid oxidation
B) Reduce mortality in non-cardiac and vascular surgery
C) Promote inflammation
D) Increase matrix metalloproteinase activity
Answer: B) Reduce mortality in non-cardiac and vascular surgery
They decrease lipid oxidation
When discontinuing P2Y12 inhibitors before surgery, what is the minimum discontinuation period for clopidogrel to reduce bleeding risk?
A) 24 hours
B) 5 days
C) 7 days
D) 12 hours
Answer: B) 5 days
In dual antiplatelet therapy, discontinuation of P2Y12 inhibitors significantly increases the risk of:
A) Hypertension
B) Stent thrombosis
C) Hyperlipidemia
D) Diabetes
Answer: B) Stent thrombosis
When is Percutaneous Coronary Intervention (PCI) preferred over thrombolytic therapy?
A) When patients have a history of severe bleeding
B) When a mature clot is present
C) When symptoms have been present for less than 1 hour
D) All of the above
Answer: B) When a mature clot is present
In the context of drug therapy for ischemic heart disease, which medication class directly addresses the imbalance between myocardial oxygen supply and demand by slowing the heart rate?
A) Statins
B) Nitrates
C) Beta-blockers
D) ACE inhibitors
Answer: C) Beta-blockers
Which condition is least likely to be directly improved by the administration of nitrates?
A) Angina pectoris
B) Ventricular tachycardia
C) Myocardial oxygen consumption
D) Preload on the heart
Answer: B) Ventricular tachycardia
In the context of ischemic heart disease, why might patients with diabetes exhibit atypical symptoms?
A) Enhanced pain sensitivity
B) Lowered threshold for myocardial oxygen demand
C) Neuropathy affecting chest pain perception
D) Increased collateral coronary circulation
Answer: C) Neuropathy affecting chest pain perception
What does the presence of new Q waves on an ECG typically indicate?
Answer: Myocardial infarction
When is CABG preferred over PCI in the context of ischemic heart disease?
Answer: In patients with significant left main coronary artery disease
What is an essential factor to consider before prescribing beta-blockers to patients with ischemic heart disease?
Answer: The presence of heart failure w/ bradycardia or reactive airway diseases
For which type of angina is the decrease in peripheral vascular resistance particularly beneficial?
Answer: Stable angina due to decreased afterload and myocardial oxygen consumption
Wall motion abnormalities in an echocardiogram may indicate:
A) Valvular heart disease
B) Ischemic heart disease
C) Pericarditis
D) Atrial fibrillation
Answer: B) Ischemic heart disease
Rationale: Wall motion abnormalities often indicate ischemic heart disease, as regions of the heart affected by inadequate blood supply due to blocked coronary arteries may move abnormally.
CK-MB is a cardiac marker used to diagnose:
A) Rheumatic fever
B) Myocardial infarction
C) Heart failure
D) Hypertension
Answer: B) Myocardial infarction
Rationale: CK-MB (Creatine Kinase-MB) is an enzyme found in the heart muscle and is used as a marker to diagnose myocardial infarction. Levels rise 4-6 hours after a heart attack and peak at 12-24 hours.
Not as effective as Troponin
What intervention is indicated to manage decreased blood pressure and prevent perioperative myocardial injury?
A) Administer β-Blockers
B) Administer α₂-Agonists
C) Administer Nitroglycerin
D) Administer Statins
E) Administer Fluids
E) Administer Fluids
Prevent hypotension
What intervention is indicated to manage surgical stress on the neuroendocrine response?
A) Administer β-Blockers
B) Administer α₂-Agonists
C) Administer Nitroglycerin
D) Administer Statins
B) Administer α₂-Agonists
Analgesia
What 2 leads give you the best whole view of the heart?
V5- anterior lateral, lead 2 inferior
What is an indicative feature of vanishing lung syndrome often seen in systemic lupus erythematosus (SLE) patients?
A) Expansion of lung volumes and lowered diaphragm.
B) Elevated diaphragm and decreased lung volumes.
C) Symmetrical arthritis in the spine.
D) Increased GFR and proteinuria.
Answer: B) Elevated diaphragm and decreased lung volumes.
High diagram and mediastinum shift towards the effective lung
Rationale: Vanishing lung syndrome, as mentioned in the context of systemic lupus erythematosus (SLE), is characterized by decreased lung volumes and an elevated diaphragm, which can be identified through imaging techniques such as X-rays. This condition contrasts with conditions like pneumothorax, where there’s an increase in the space within the chest cavity. The syndrome may present with symptoms like dry cough, dyspnea, and recurrent atelectasis due to diaphragmatic weakness or phrenic neuropathy, which are not typical of standard pulmonary issues in SLE but represent a rare and severe manifestation.
What is the most common hereditary bleeding disorder according to the text?
A) Hemophilia A
B) Hemophilia B
C) Von Willebrand Disease (vWD)
D) Factor V Leiden
Answer: C) Von Willebrand Disease (vWD)
Which treatment is specifically noted for type 1 von Willebrand Disease?
A) Blood transfusions
B) Desmopressin (DDAVP)
C) Direct factor VIII infusion
D) Corticosteroids
Answer: B) Desmopressin (DDAVP)
When analyzing vWF Disease, what lab result is typically prolonged?
A) PT
B) aPTT
C) Bleeding Time (BT)
D) ACT
Answer: C) Bleeding Time (BT)
What factor concentrates are used for a Type 3 vWD?
A) Factor IX
B) Factor X
C) Factor VIII
D) Factor VII
Answer: C) Factor VIII
DDAVP stimulates the release of vWF from which type of cells?
A) Red blood cells
B) White blood cells
C) Endothelial cells
D) Platelets
Answer: C) Endothelial cells
Which side effect is NOT listed for DDAVP in the treatment of vWD?
A) Headache
B) Rubor
C) Hyponatremia
D) Hypernatremia
Answer: D) Hypernatremia
The side effects of DDAVP
Headache, rubor (flush), hypotension, tachycardia, hyponatremia, and water intoxication
In order to decrease water intoxication, hyponatremia, and consequent seizures, the administration of water, orally or intravenously, should be restricted for 4 to 6 hours after the use of the drug
For managing hyponatremia, what restriction is recommended post-DDAVP administration?
A) Fluid restriction for 4 to 6 hours
B) Complete fasting for 12 hours
C) High salt diet
D) Unlimited fluid intake
Answer: A) Fluid restriction for 4 to 6 hours
What is a critical value increase after administering one unit of cryoprecipitate?
A) Hematocrit by 10%
B) Hemoglobin by 1 g/dL
C) Fibrinogen levels by 50 mg/dL
D) Platelet count by 30,000/mm³
Answer: C) Fibrinogen levels by 50 mg/dL
Can be used for vWF disease if unresponsive to DDAVP
1 unit raises the fibrinogen levels by 50 mg/dL
Factor VIII concentrate differs from cryoprecipitate in terms of:
A) Infection risk
B) Fibrinogen content
C) vWF content
D) Preparation method
In common preparation, the cryoprecipitate is not submitted to viral attenuation and, therefore, poses an increased risk of infection
Factor VIII concentrate is prepared from the pool of plasma from a large number of donors
It undergoes viral attenuation
Contains F VIII and vWF
Given preoperatively and during surgery
What is the recommended time frame for DDAVP administration before surgery?
A) 15 minutes
B) 30 minutes
C) 45 minutes
D) 60 minutes
Answer: D) 60 minutes
Prior evaluation by a hematologist
When indicated, DDAVP should be infused 60 minutes before the surgery
Normalization of the bleeding time and improved levels of F VIII should be confirmed before the surgery in patients
Why is general anesthesia a concern for patients with coagulopathies regarding specific blocks?
A) Risk of hematoma and neurological compression
B) Immediate allergic reactions
C) Ineffective pain management
D) Prolonged recovery time
Answer: A) Risk of hematoma and neurological compression
Patients with coagulopathies undergoing neuroaxial block = increased risk of developing a hematoma and compression of neurological structures
In the context of anticoagulation and anesthesia, why should arterial punctures be avoided?
A) Risk of infection
B) Risk of hematoma formation
C) Inadequate blood withdrawal
D) Misinterpretation of arterial gases
Answer: B) Risk of hematoma formation
Avoid traumas during the anesthesia
Arterial puncture is not recommended
Laryngeal trauma during tracheal intubation may cause hematoma = postoperative obstruction of the airways
IM avoided
Heparin’s anticoagulant effect can be neutralized by which substance?
A) Vitamin K
B) Protamine
C) Warfarin
D) DDAVP
Answer: B) Protamine
Monitor PTT and ACT
Heparin’s anticoagulant effect is rapidly reversible by protamine (+ polypeptide forming a stable complex neutralizing heparin)
LMWHs -effective at VTE prophylaxis compared to UFH
LMWHs have a more predictable pharmacokinetic response, fewer effects on platelet function, and a reduced risk for heparin-induced thrombocytopenia (HIT)
Monitoring of LMWHs is not performed routinely
How does heparin primarily exert its anticoagulant effect?
A) Inhibiting vitamin K
B) Inhibiting Thrombin
C) Activating antithrombin III
D) Directly dissolving clots
B) Inhibiting Thrombin - Primarily
This should be b and c
Doesn’t work with anti-thrombin 3 deficiencies.. You can give FFP that has antithrombin 3 in it
Negatively charge, CHO containing glucuronic acid residues
Unfractionated heparin (UFH), LMWH
Heparin inhibits thrombin (thrombin needed to convert fibrinogen to fibrin)
Heparin derives its anticoagulant effect by activating antithrombin III
What is the hallmark finding in heparin-induced thrombocytopenia (HIT)?
A) Platelet count < 150,000/mm³
B) Platelet count < 100,000/mm³
C) Increased PTT
D) Decreased fibrin degradation products
E) Increased ACT
Answer: B) Platelet count < 100,000/mm³
HIT describes an autoimmune-mediated drug reaction occurring in as many as 5% of patients after exposure to unfractionated heparin or (rare cases) LMWH
Thrombocytopenia occurring 5 -14 days after initial therapy
The hallmark of findings is a decrease in PLT < 100,000
HIT results in platelet activation and potential for venous and arterial thromboses
In patients with vWD, what are the usual results of PT and aPTT tests?
A) Prolonged PT only
B) Prolonged aPTT only
C) Both prolonged PT and aPTT
D) Both are often normal
Answer: D) Both are often normal
PT and aPTT are often normal in patients with vWD
BT is prolonged
Hematologist to analyze labs
What is the initial dose of DDAVP administered intravenously for vWD?
A) 0.1 µg/kg
B) 0.2 µg/kg
C) 0.3 µg/kg
D) 0.4 µg/kg
Answer: C) 0.3 µg/kg
A synthetic analogue of vasopressin and stimulates the release of vWF by endothelial cells
It can be administered intravenously at a dose of 0.3 µg/kg in 50 mL of normal saline over 15 to 20 minutes
The maximal effect in 30 minutes and lasts from 6 to 8 hours
For how long should water intake be restricted after administering DDAVP to prevent water intoxication?
A) 1-2 hours
B) 2-4 hours
C) 4-6 hours
D) 6-8 hours
Answer: C) 4-6 hours
What is the main risk associated with using cryoprecipitate in treating vWD?
A) Low fibrinogen increase
B) Increased risk of infection
C) Ineffective in Type 1 vWD
D) Causes hypernatremia
Answer: B) Increased risk of infection
In the context of heparin-induced thrombocytopenia (HIT), what is the typical time frame for thrombocytopenia to occur after initial heparin therapy?
A) 1-3 days
B) 3-5 days
C) 5-14 days
D) 15-21 days
Answer: C) 5-14 days
What is the main treatment strategy for HIT?
A) Continue heparin at a lower dose
B) Switch to warfarin immediately
C) Discontinue heparin and start a non-heparin anticoagulant
D) Administer vitamin K
Answer: C) Discontinue heparin and start a non-heparin anticoagulant
A diagnosis of HIT should be entertained for any patient experiencing thrombosis or thrombocytopenia during or after heparin administration
In suspected HIT cases, D/C heparin STAT (i.e., including unfractionated heparin, heparin-bonded catheters, heparin flushes, LMWH)
Alternative non-heparin anticoagulation must be administered concurrently
In most cases, a direct thrombin inhibitor (i.e., bivalirudin, lepirudin, argatroban) is substituted for heparin
What factor does Fondaparinux target for anticoagulation?
A) Factor IIa (Thrombin)
B) Factor V
C) Factor VIII
D) Factor Xa
Answer: D) Factor Xa
Fondaparinaux - to treat VTE. Off labelled use. A synthetic Factor Xa inhibitor.
What is the main clinical concern when using general anesthesia in patients with Factor V Leiden mutation?
A) Decreased risk of bleeding
B) Increased risk of developing DVT and PE
C) Reduced effect of local anesthetics
D) Enhanced sensitivity to anesthetics
Answer: B) Increased risk of developing DVT and PE
Factor V Leiden is associated with an increased risk of developing an episode of DVT (with or without a PE)
Because of high risks of DVT and PE, patients are on anticoagulants
What is the standard treatment approach for a patient diagnosed with heparin-induced thrombocytopenia (HIT)?
A) Continue heparin but monitor platelet levels more frequently.
B) Switch to non-heparin anticoagulation such as bivalirudin, argatroban, or fondaparinux.
C) Increase the dose of unfractionated heparin.
D) Administer vitamin K antagonist.
Answer: B) Switch to non-heparin anticoagulation such as bivalirudin, argatroban, or fondaparinux.
How does Desmopressin (DDAVP) act to correct bleeding disorders?
A) By converting fibrinogen to fibrin.
B) By inhibiting platelet function.
C) By stimulating the release of von Willebrand factor and factor VIII from endothelial cells.
D) By activating antithrombin III.
Answer: C) By stimulating the release of von Willebrand factor and factor VIII from endothelial cells.
What is the primary action of unfractionated heparin in blood coagulation?
A) Converts prothrombin to thrombin.
B) Inhibits thrombin and factor Xa via antithrombin III activation.
C) Directly converts fibrinogen to fibrin.
D) Induces platelet aggregation.
Answer: B) Inhibits thrombin and factor Xa via antithrombin III activation.
What is the consequence of administering heparin to a patient with antithrombin III deficiency?
A) Increased risk of bleeding.
B) No anticoagulant effect.
C) Enhanced anticoagulant effect.
D) Immediate reversal of anticoagulation.
Answer: B) No anticoagulant effect.
Give FFP first, has antithrombin 3 in it.
How does von Willebrand factor (vWF) primarily function in hemostasis?
A) By degrading fibrinogen to prevent clot formation.
B) By facilitating platelet adhesion to damaged endothelium.
C) By activating factor X to convert prothrombin to thrombin.
D) By catalyzing the conversion of plasminogen to plasmin.
Answer: B) By facilitating platelet adhesion to damaged endothelium.
vWF critical role in platelet adherence/adhesion
Most common hereditary bleeding disorders
Clinical features varies
Different types and classification
Easy bruising
Recurrent epistaxis
Menorrhagia
Patients usually unaware until questionnaire/surgery
Which statement best describes the management of disseminated intravascular coagulation (DIC)?
A) Primarily involves administering high-dose antifibrinolytics.
B) Focuses on treating the underlying cause and replacing consumed coagulation factors.
C) Involves lifelong administration of vitamin K antagonists.
D) Requires the exclusive use of unfractionated heparin.
Answer: B) Focuses on treating the underlying cause and replacing consumed coagulation factors.
What is a common trigger for the development of disseminated intravascular coagulation (DIC)?
A) Chronic hypertension.
B) Mild allergic reactions.
C) Trauma, malignancy, sepsis, or amniotic fluid embolus.
D) Long term fibrinolytic use
C) Trauma, malignancy, sepsis, or amniotic fluid embolus.
Systemic activation of the coagulation system simultaneously leads to thrombus formation and exhaustion of platelets and coagulation factors
Numerous underlying disorders may precipitate DIC, including trauma, amniotic fluid embolus, malignancy, sepsis, or incompatible blood transfusions
What lab findings are indicative of DIC?
A) Increased platelet count
B) Shortened PT/PTT
C) Reduction in platelets, prolonged PT/PTT
D) Elevated RBC count
Answer: C) Reduction in platelets, prolonged PT/PTT
Labs
Reductions in PLT, prolongation PT, PTT, and thrombin time (TT), and elevated concentrations of soluble fibrin degradation products
Management of DIC requires alleviating the underlying condition precipitating hemostatic activation
Treatment includes blood component transfusions to replete coagulation factors and platelets consumed in the process
Antifibrinolytic therapy generally is contraindicated in DIC owing to potential for catastrophic thrombotic complications
The primary goal in the management of DIC is:
A) To start antifibrinolytic therapy immediately
B) To replace coagulation factors and platelets
C) To prescribe long-term anticoagulation therapy
D) To administer high doses of vitamin K
Answer: B) To replace coagulation factors and platelets
Which is NOT a recommended treatment approach for DIC?
A) Blood component transfusions
B) Antifibrinolytic therapy
C) Immediate administration of heparin
D) Alleviating the underlying condition
Answer: B) Antifibrinolytic therapy
Antifibrinolytic agents–tranexamic acid, ε–aminocaproic acid, and aprotinin
inhibits the conversion of plasminogen to plasmin
Factor V Leiden
Factor V Leiden is an abnormal version of factor V that is resistant to the action of activated protein C
Activated protein C cannot easily stop factor V Leiden from making more fibrin
What is a common symptom of severe hyponatremia?
A) Hyperactivity
B) Seizures
C) Tachycardia
D) Hypertension
Answer: B) Seizures
The treatment for acute symptomatic hyponatremia includes:
A) Administering hypotonic saline
B) Restricting fluid intake
C) Administering hypertonic saline
D) Increasing sodium intake orally
Answer: C) Administering hypertonic saline
Seizures, coma, death
NPO and hypertonic 3%- bag, bolus it in
Can give 23% syringe -
What CNS changes are expected when the serum sodium level drops to 120 mEq/L?
A) Somnolence and Nausea
B) Seizures and Coma
C) Confusion and Restlessness
D) Headache and Dizziness
Answer: C) Confusion and Restlessness
At which serum sodium level are elevated ST segments and widened QRS typically observed?
A) 120 mEq/L
B) 115 mEq/L
C) 110 mEq/L
D) 130 mEq/L
Answer: B) 115 mEq/L
Severe hyponatremia is indicated by a serum sodium level of:
A) 120 mEq/L
B) 125 mEq/L
C) 110 mEq/L
D) 130 mEq/L
Answer: C) 110 mEq/L
Vtach or Vfib
Which of the following ECG changes is not associated with a serum sodium level of 115 mEq/L?
A) Elevated ST segments
B) Narrow QRS
C) Vtach or Vfib
D) Normal sinus rhythm
A) Elevated ST segments
Also see a Widened QRS
Vtach or Vfib (This is associated with a serum sodium level of 110 mEq/L)
What are the CNS changes associated with a serum sodium level of 110 mEq/L?
A) Confusion and Restlessness
B) Somnolence and Nausea
C) Seizures and Coma
D) Headache and Irritability
Answer: C) Seizures and Coma
What is the correct sequence of exam procedures?
Inspection, palpation, percussion, auscultation
Which of the following if considered allergic reaction to Lidocaine with Epi?
Pruritus (Tachycardia, HTN, and LA side effects not reactions)
Late stage burn healing would be Ann example of what type of pain?
Inflammatory
Acetaminophen- “tylenol”
IV (Ofirmev®) - Dose
Kid PO Tylenol 15 mg/kg
IV 15 mg/kg IV q 6 h or 12.5 mg/kg q4
Tension Test with Edrophonium improves what type of crisis?
Myasthenic (gets worse w/ Cholinergic crisis)
Rheumatoid Arthritis results inn increased pain at what time of day?
-Morning (OA is worse later in day)
Airway concerns in RA include which of the following 2?
-Atlantoaxial subluxation & TMJ movement limitation (also decreased Cricoarytenoid Laxity)
*NO increased risk of aspiration
Which off the following is not a common manifestation of SLE?
Asymmetric Arthritis
The mortality rate of MH is?
-50%
Which of the following agents are triggers for MH?
Isoflurane & Anectine (aka Succinylcholine)
Ryanodex is treatment
Horners syndrome occurs as a result of which blockade?
Stellate Ganglion
-may be inadvertent d/t Scalene block
Which of the following is the most sensitive indicator of left ventricular myocardial ischemia?
Wall motion abnormalities on the echo
Cardiac Tamponade is associated with?
A: Pulsus paradoxus
The MAP in a patient with a blood pressure of 180/60 mmHg is?
Dr. Schmidt Method: DBP + 1/3 (SBP- DBP)= 99.96
Which of the following would be the best intraoperative TEE view to monitor for myocardial ischemia?
-A: Transgastric mid-papillary left ventricular short axis view
Which of the following medications blocks angiotensin at the receptor?
Lorsartan (ARB)
Sildenafil belongs to the same class of drug as which of the following?
-A: Milrinone
PDE3 inhibitor
What is the minimum amount of time after angioplasty with a drug elut. Stent that DAPT is continued elective surgery?
-A: 1 yr.
The effects of clopidogrel can be reversed with?
A: None of the above»_space;> Plts.
You made an infusion of dopamine with 200 mg dopamine in 250mL 800 mcg/mL. What is the rate for 5 mcg/kg/min in 70 kg pt?
A: 26 mL/hr
-(70 kg x 5 mcg/kg x 60 minutes)/ 800 mcg/mL
Severe aortic stenosis is associated with a valve area less then __ cm2?
-A: 1 cm2
What makes up the largest component of whole blood?
-A: Plasma
Which is more predominant, Rh+ or Rh- ?
A: Rh+
Von Willebrand disease could be treated (initial) with all of the following but?
Factor VIII
TREATMENT
Correct the deficiency of vWF
Using desmopressin
By the transfusion of the specific factor
Cryoprecipitate
Patients with what factor deficiency may require FFP prior to Heparin administration?
A: ATIII
Which blood type offers the most compatibility?
-A: O
Which chemical is added to blood products as preservative?
A: CPDA-1
Which product increases the O2 carrying capacity?
A: RBCs
What is the standard dosing for plasma?
-A: 10-15 mL/kg
One unit of platelets will increase your platelet count by?
A: 5-10K
Which blood product is most likely to cause TRALI?
A: Plasma (high protein)
What is the likely TEG result in a patient taking Plavix after cardiac stent placement?
-A: Normal TEG (doesn’t determine if Plt. Is functional itself —> use Plt. Mapping
Which product contains the largest amount of Fibrinogen?
-A: Cryoprecipitate
Administration of which product type may cause incompatibility later requiring treatment with Rhogram?
A: O+
Which TEG measures fibrinolysis?
A: LY30
Which product contain the most elemental calcium?
-A: Calcium Chloride
What is the typical timing in the cardiac cycle for aortic stenosis?
A) Holosystolic
B) Midsystolic crescendo-decrescendo
C) Mid-diastolic
D) Early diastolic
B) Midsystolic crescendo-decrescendo
Systolic or midsystolic murmur – right upper sternal border
Crescendo–decrescendo pattern
Radiates to neck, mimics carotid bruit
Critical AS
Angina pectoris
Increased risk of peri-op mortality and MI
Syncope
Dyspnea on exertion
Symptoms correlate with an average time to death of 5, 3, and 2 years
75% of symptomatic pts die w/in 3 years w/o valve replacement
Where is the murmur of mitral regurgitation best heard?
A) Right upper sternal border
B) Left sternal border
C) Apex
D) Lower left sternal border
C) Apex
Holosystolic murmur that is heard
Best at the apex and radiates to the axilla suggests mitral regurgitation
Which of the following is a symptom of aortic stenosis?
A) Cyanosis
B) Orthopnea
C) Syncope
D) Palpitations
C) Syncope
Critical AS
Angina pectoris
Increased risk of peri-op mortality and MI
Syncope
Dyspnea on exertion
What does the presence of a mid-systolic click indicate?
A) Mitral valve prolapse
B) Aortic regurgitation
C) Tricuspid stenosis
D) Mitral regurgitation
A) Mitral valve prolapse
In which condition is the Valsalva maneuver likely to decrease the intensity of the murmur?
A) Hypertrophic cardiomyopathy
B) Mitral valve prolapse
C) Aortic stenosis
D) Tricuspid regurgitation
C) Aortic stenosis
Increases with squatting, decreases with Valsalva and standing
What is the most common cause of mitral stenosis worldwide?
A) Infective endocarditis
B) Rheumatic heart disease
C) Degenerative disease
D) Congenital malformation
B) Rheumatic heart disease
Rare in the US
Rheumatic heart disease
Primarily affects women
Asymptomatic for 20-30 years
Which of the following diagnostic tools is most useful for assessing valve areas and transvalvular pressure gradients?
A) EKG
B) Chest X-ray
C) Echocardiogram
D) MRI
C) Echocardiogram
What is the main treatment approach for severe symptomatic aortic stenosis?
A) Beta-blockers
B) Valve repair
C) Transcatheter aortic valve replacement (TAVR)
D) Diuretics
C) Transcatheter aortic valve replacement (TAVR)
Prevention/avoidance of hypotension and decreased CO
Maintain NSR
Avoid bradycardia or tachycardia
Optimize intravascular fluid volume
Aggressive treatment of hypotension
CPR is typically not effective
Which condition is characterized by a holosystolic murmur that increases with inspiration?
A) Mitral regurgitation
B) Tricuspid regurgitation
C) Aortic stenosis
D) Mitral valve prolapse
B) Tricuspid regurgitation
Prominent jugular venous distention, signs of right heart failure.
What is the typical effect of exercise on functional murmurs?
A) Increase
B) Decrease
C) No change
D) Variable
A) Increase
In which condition is the murmur best heard at the lower left sternal border?
A) Aortic stenosis
B) Mitral regurgitation
C) Tricuspid regurgitation
D) Mitral valve prolapse
C) Tricuspid regurgitation
Which valve disorder is likely to show prominent jugular venous distension as an associated finding?
A) Mitral stenosis
B) Aortic regurgitation
C) Tricuspid regurgitation
D) Hypertrophic cardiomyopathy
C) Tricuspid regurgitation
What is the initial medical treatment for mitral stenosis?
A) ACE inhibitors
B) Rate control with beta-blockers
C) Immediate surgery
D) High-dose diuretics
B) Rate control with beta-blockers
Rate control
β-blockers, calcium channel blockers, digoxin
Left atrial pressure
Diuretics
Anticoagulation - risk of stroke 7-15% per year
Arterial thromboembolism vs venous thrombosis
Surgical correction
Percutaneous valvotomy
Surgical commissurotomy
Valve replacement
What is the risk of stroke per year without anticoagulation in mitral stenosis?
A) 1-3%
B) 7-15%
C) 20-25%
D) 30-35%
B) 7-15%
Which murmur is described as “blowing” in character?
A) Aortic stenosis
B) Mitral regurgitation
C) Tricuspid stenosis
D) Mitral stenosis
A) Aortic stenosis
What is the main concern with the use of mechanical valves in younger patients?
A) Durability
B) Risk of infection
C) Necessity for lifelong anticoagulation
D) High failure rate
C) Necessity for lifelong anticoagulation
Which condition is associated with a midsystolic click followed by a late systolic murmur?
A) Aortic regurgitation
B) Mitral valve prolapse
C) Tricuspid regurgitation
D) Aortic stenosis
B) Mitral valve prolapse
In which condition would you expect to find a diastolic decrescendo murmur?
A) Aortic regurgitation
B) Mitral stenosis
C) Tricuspid stenosis
D) Mitral regurgitation
A) Aortic regurgitation
Early diastole
What diagnostic feature is most indicative of left atrial enlargement on an echocardiogram?
A) Notched T Wave
B) Elongated P Wave
C) Tall P Wave
D) Inverted T Wave
B) Elongated P Wave
Rumbling diastolic murmur at apex, radiates to left axilla
EKG
Notched P waves - longer
AF
Which condition is often managed with diuretics to reduce left atrial pressure?
A) Aortic stenosis
B) Mitral regurgitation
C) Tricuspid stenosis
D) Mitral stenosis
D) Mitral stenosis
Left atrial pressure
Diuretics
What is the main goal in the management of patients with aortic regurgitation?
A) Increase afterload
B) Decrease heart rate
C) Maintain forward flow
D) Reduce preload
C) Maintain forward flow
Goal: maintain forward LV SV
Avoid bradycardia
HR: > 80 bpm
Avoid increased SVR
Minimize myocardial depression
Vasodilator to reduce afterload
Inotrope to increase contractility
Which 2 murmurs would likely increase with the handgrip maneuver or with a BP cuff?
A) Aortic stenosis
B) Mitral regurgitation
C) Aortic regurgitation
D) Tricuspid regurgitation
C) Aortic regurgitation
B) Mitral regurgitation
In the context of valvular heart disease, what does the presence of an opening snap suggest?
A) Aortic stenosis
B) Mitral stenosis
C) Aortic regurgitation
D) Mitral regurgitation
B) Mitral stenosis
Opening snap after S2, Loud S1, radiation to left axilla
What is the primary effect of tachycardia on aortic regurgitation?
A) Increases regurgitant volume
B) Decreases regurgitant volume
C) No effect on regurgitant volume
D) Increases forward flow
B) Decreases regurgitant volume
Decreased CO d/t regurgitant SV
Combined LV pressure and volume overload
Usually slow onset
Magnitude of regurgitation depends on:
Time available for regurgitant flow (HR)
Pressure gradient across the aortic valve (SVR)
Have an increased SV with a decreased EF
Which is a common finding in patients with advanced mitral stenosis?
A) Atrial fibrillation
B) Ventricular tachycardia
C) Bradycardia
D) Complete heart block
A) Atrial fibrillation
MS: Symptoms
Dyspnea on exertion
Orthopnea
Paroxysmal nocturnal dyspnea
Pulmonary edema
Pulmonary HTN
Atrial fibrillation
What is the incidence of valvular heart disease in the US population?
A) 1%
B) 2.5%
C) 5%
D) 10%
Answer: B) 2.5%
Which condition is often associated with mitral regurgitation due to ischemic heart disease?
A) Aortic stenosis
B) Tricuspid regurgitation
C) Pulmonary hypertension
D) Increased mortality
Answer: D) Increased mortality
Valvular heart disease and ischemic heart disease frequently co-exist
50% of pt with aortic stenosis >50 years have ischemic heart disease
CAD pt with mitral or aortic valve disease worsens the long-term prognosis
Mitral regurgitation d/t ischemic heart disease > mortality
What is the main compensatory mechanism in the presence of cardiac disease?
A) Decreased sympathetic nervous system activity
B) Myocardial atrophy
C) Increased sympathetic nervous system activity
D) Decreased heart rate
C) Increased sympathetic nervous system activity
Recognition of compensatory mechanisms for maintaining cardiac output, such as increased sympathetic nervous system activity and cardiac hypertrophy, as well as consideration of current drug therapy, are important
What defines a functional murmur?
A) Results from structural heart disease
B) Primarily due to physiologic conditions outside the heart
C) Always pathologic
D) Causes decreased cardiac output
Answer: B) Primarily due to physiologic conditions outside the heart
What is the normal mitral valve orifice area?
A) 1–2 cm²
B) 2–3 cm²
C) 4–6 cm²
D) 7–8 cm²
Answer: C) 4–6 cm²
Mechanical obstruction to LV filling d/t decrease in size of mitral valve orifice
Normal mitral valve orifice area is 4–6 cm2
Symptoms develop - < 2 cm2
Diffuse thickening and fibrosis of mitral leaflet cusps, subvalvular apparatus, and commissural fusion
Calcification of the annulus and leaflets
Left atrial volume and pressure
LV contractility
SV
Which murmur is associated with stenosis of the aortic or pulmonic valves?
A) Diastolic murmur
B) Decrescendo murmur
C) Systolic murmur
D) Late systolic murmur
Answer: C) Systolic murmur
Stenosis of the aortic or pulmonic valves
Incompetence of the mitral or tricuspid valves
Midsystolic or holosystolic
During which cardiac phase do the mitral and tricuspid valves open?
A) Systole
B) Diastole
C) Both A and B
D) Neither A nor B
Answer: B) Diastole
What is the significance of a midsystolic murmur heard best at the right upper sternal border?
A) Mitral regurgitation
B) Tricuspid stenosis
C) Aortic stenosis
D) Pulmonic stenosis
C) Aortic stenosis
Systolic or midsystolic murmur – right upper sternal border
Crescendo–decrescendo pattern
Radiates to neck, mimics carotid bruit
Which diagnostic tool is most useful for evaluating cardiomegaly?
A) EKG
B) CXR (Chest X-Ray)
C) MRI
D) Blood tests
Answer: B) CXR (Chest X-Ray)
Which type of heart valve is very durable and lasts 20-30 years?
A) Biological
B) Mechanical
C) Homograft
D) Autograft
Answer: B) Mechanical
Mechanical
Metal or carbon alloy
Very durable… 20-30 years
Highly thrombogenic
Young pts
Bioprosthetic
Porcine or bovine
Shorter lasting… 10-15 years
Low thrombogenic potential
Elderly pts
What is a key goal in the anesthetic management of patients with mitral stenosis?
A) Increase heart rate
B) Decrease systemic vascular resistance
C) Maintain normal heart rate
D) Increase preload
C) Maintain normal heart rate
Goal: normal HR, normal volume, normal afterload
Prevention and treatment of decreased cardiac output or pulmonary edema
Excessive pre-op IV fluid or trendelenburg position
Control HR
AF w/ RVR
Cardioversion or IV administration of amiodarone,β-blockers, or calcium channel blockers
Control of the heart rate is critical because tachycardia impairs left ventricular filling and increases left atrial pressure.
What is the primary cause of mitral regurgitation in the US?
A) Infective endocarditis
B) Rheumatic heart disease
C) Mitral valve prolapse
D) Congenital mitral valve anomalies
Answer: C) Mitral valve prolapse
More common than MS
2% of the US population
Associated with
IHD
Ruptured papillary muscle
Endocarditis
Mitral valve prolapse
Cardiomyopathy
What is a common cause of acute mitral regurgitation?
A) Degenerative valve disease
B) Calcification of the mitral valve
C) Ruptured papillary muscle
D) Aortic dissection
Answer: C) Ruptured papillary muscle
What is the treatment of choice for severe mitral regurgitation when surgery is indicated?
A) Mitral valve repair
B) Balloon valvuloplasty
C) Mitral valve replacement
D) Transcatheter mitral valve repair (MitraClip)
Answer: A) Mitral valve repair
Asymptomatic vs symptomatic pts
MV repair > MV replacement
EF < 30% little improvement with surgery
Transcatheter mitral valve repair
MitraClip
Vasodilators, biventricular pacing
ACE-I, β-blockers (carvedilol)
What is the primary goal in the management of aortic regurgitation?
A) Increase heart rate
B) Decrease afterload
C) Increase preload
D) Reduce regurgitant volume
Answer: B) Decrease afterload
A) is more important. Keeps pressure head moving forward
Goal: maintain forward LV SV
Avoid bradycardia
HR: > 80 bpm
Avoid increased SVR
Minimize myocardial depression
Vasodilator to reduce afterload
Inotrope to increase contractility
What are the common symptoms of aortic stenosis?
A) Syncope, angina pectoris, and dyspnea on exertion
B) Fever, weight loss, and night sweats
C) Palpitations, flushing, and dizziness
D) Cough, frothy sputum, and wheezing
Answer: A) Syncope, angina pectoris, and dyspnea on exertion
Which procedure is often performed simultaneously with aortic valve replacement in patients with significant coronary artery disease?
A) Coronary artery bypass grafting (CABG)
B) Mitral valve repair
C) Pulmonary thromboendarterectomy
D) Left ventricular assist device implantation
Answer: A) Coronary artery bypass grafting (CABG)
The risk of sudden death is associated with which condition even when asymptomatic?
A) Mitral valve prolapse
B) Aortic stenosis
C) Tricuspid regurgitation
D) Pulmonary hypertension
Answer: B) Aortic stenosis
What is the recommended heart rate for patients with aortic regurgitation under anesthesia?
A) Less than 60 bpm
B) 60-70 bpm
C) 70-80 bpm
D) More than 80 bpm
Answer: D) More than 80 bpm
Goal: maintain forward LV SV
Avoid bradycardia
HR: > 80 bpm
Avoid increased SVR
Minimize myocardial depression
Vasodilator to reduce afterload
Inotrope to increase contractility
What is a key goal in the anesthetic management of patients with aortic stenosis?
A) Increase heart rate
B) Decrease heart rate
C) Maintain normal sinus rhythm
D) decrease preload
Answer: C) Maintain normal sinus rhythm
Prevention/avoidance of hypotension and decreased CO
Maintain NSR
Avoid bradycardia or tachycardia
Optimize intravascular fluid volume
Aggressive treatment of hypotension
CPR is typically not effective
In patients with mitral stenosis, what condition increases the risk of arterial thromboembolism?
A) Increased Left Ventricle filling time
B) Decreased left atrial pressure
C) Stasis of blood in the distended left atrium
D) Increased turbulent flow across the stenotic valve.
C) Stasis of blood in the distended left atrium
Which murmur is characterized by a low-pitched diastolic rumble at the left sternal border, also known as the Austin-Flint murmur?
A) Tricuspid Stenosis
B) Mitral Stenosis
C) Aortic Regurgitation
D) Pulmonic regurgitation
C) AR
Early or mid-diastolic murmur, at the left sternal border
Low-pitched diastolic rumble (Austin-Flint murmur)
Hyperdynamic circulation
Widened pulse pressure
Decreased DBP
Bounding pulses
LV failure (end stage)
Dyspnea, orthopnea, fatigue and coronary ischemia
Acute AR – severe LV volume overload
Coronary ischemia, rapid deterioration LV function, and HF
EKG and CXR
LV enlargement and hypertrophy
Echocardiogram
Leaflet prolapse or perforation
Associated aortic abnormalities
What is the approximate specific gravity of red blood cells?
A) 1.08-1.09
B) 1.03-1.04
C) 1.00-1.01
D) 1.05-1.06
Answer: A) 1.08-1.09
Based on different specific gravities
RBC : 1.08-1.09
Platelet : 1.03-1.04
RBCs most dense, sink to bottom
Fresh Frozen Plasma should be prepared from W.B within how many hours of collection?
A) 24 hours
B) 8 hours
C) 12 hours
D) 48 hours
B) 8 hours
Prepared by removing plasma from W.B w/in 8H of collection.
Source of antithrombin III
One bag = 200-250 mL
Expires 12 months after donation
Dose 10-15 mL/kg
Stored at –18C or below.
Each unit of FFP=increase the level of each clotting fx by 2-3% in adults.
Therapeutic dose: 10-15ml/kg.
Contains:
Water, carbohydrates, fats, minerals
Proteins(all labile & stable clotting fx).
What is the primary reason for administering cryoprecipitate?
A) Increase oxygen-carrying capacity
B) Increase blood volume
C) Replace clotting factors
D) Counteract anticoagulation
C) Replace clotting factors
K time >3 : “Kinetic time” for fibrin cross linkage to reach 20 mm clot strength
Protein fraction taken off the top of the FFP when being thawed
Then refrozen for up to 1 year
Contains:
Factor VIII: C
Factor VIII: vWF
Factor XIII
Fibrinogen
Stored at –18C & below.
Which of the following is a primary component of Cryoprecipitate?
A) Hemoglobin
B) Fibrinogen
C) Immunoglobulins
D) Albumin
B) Fibrinogen
Has the most
LTOWB-1000mg
FFP-400mg
Cryo-2500mg
What is the typical storage temperature for whole blood?
A) 1-6°C
B) 10-15°C
C) 20-25°C
D) 30-35°C
Answer: A) 1-6°C
The addition of which substance extends the storage time of blood from 21 to 35 days?
A) Glucose
B) Adenine
C) Calcium
D) Citrix acid
Answer: B) Adenine
Storage of blood is achieved by adding Citrate phosphate dextrose adenine (CPDA-1)
Citrate for chelation of calcium to prevent clotting
Phosphate as a buffer
Dextrose as a fuel source
Adenine as a substrate for the synthesis of ATP extending storage time from 21 to 35 days
What does the transfusion of one unit of Packed Red Blood Cells typically increase?
A) Hemoglobin by 1g/dL
B) Platelet count by 50,000/mL
C) Hct 5%
D) Plasma volume
A) Hemoglobin by 1g/dL
Prepared by removing 200-250ml of plasma from a unit of W.B.
200-350 ml
Do not contain functional platelets or granulocytes
Have the same O2 carrying capacity with W.B
Intended to increase the O2 carrying capacity in anemic pt who require an increase in their red cell mass w/out increase in their blood volume.
1 unit: increase Hb level about 1g/dL (10g/L)& Hct by 3%.
At what temperature should Fresh Frozen Plasma be stored?
A) Room temperature
B) 1-6°C
C) –18°C or below
D) 22-24°C
Answer: C) –18°C or below
Prepared by removing plasma from W.B w/in 8H of collection.
Source of antithrombin III
One bag = 200-250 mL
Expires 12 months after donation
Dose 10-15 mL/kg
Stored at –18C or below.
Each unit of FFP=increase the level of each clotting fx by 2-3% in adults.
Therapeutic dose: 10-15ml/kg.
Contains:
Water, carbohydrates, fats, minerals
Proteins(all labile & stable clotting fx).
What is the typical dose of Fresh Frozen Plasma?
A) 5-10 mL/kg
B) 10-15 mL/kg
C) 20-25 mL/kg
D) 30-35 mL/kg
Answer: B) 10-15 mL/kg
How does the storage of blood affect levels of 2,3-DPG?
A) Increases over time
B) Decreases over time
C) Remains constant
D) Initially decreases then increases
Answer: B) Decreases over time
The longer blood is stored, the lower are the levels of 2,3-DPG, shifting the oxyhemoglobin dissociation curve to the left, which impairs oxygen delivery
Packed red blood cells (PRBCs) are derived from whole blood from which the plasma has been removed
PRBCs contain leukocytes unless they have been specifically leukoreduced
Which factor is primarily associated with Hemolytic Transfusion Reactions?
A) IgG antibodies
B) IgM antibodies
C) IgA antibodies
D) IgE antibodies
Answer: B) IgM antibodies
Hemolytic transfusion reactions
Mediators: IgM A/b (usually ABO), complement.
S/S: fever, chill, hemoglobinemia, hemoglobinuria, hypotension, dyspnea.
Treatment and Prevention: decrease opportunities for error, treat ARF & DIC.
The TRALI syndrome is associated with which of the following components?
A) Red blood cells
B) Platelets
C) Fresh Frozen Plasma
D) All of the above
Answer: D) All of the above
It is typically associated with plasma components such as platelets and Fresh Frozen Plasma, though cases have been reported with packed red blood cells since there is some residual plasma in the packed cells.
Which of the following is a common cause of post-transfusion purpura?
A) Platelet specific antibodies
B) Red blood cell antibodies
C) White blood cell antibodies
D) Plasma protein antibodies
Answer: A) Platelet specific antibodies
3 Post-transfusion purpura
MOA: platelet specific A/b.
S/S: thrombocytopenia, clinical bleeding.
Treatment and Prevention: IV Ig, plasma exchange, corticosteroids.
Which component of blood is most likely to cause TRALI?
A) Cryoprecipitate
B) Packed Red Blood Cells
C) Platelets
D) Fresh Frozen Plasma
Answer: D) Fresh Frozen Plasma
What is the standard ratio of blood components provided in the Massive Transfusion Protocol (MTP)?
A) 1:1:2 (Plasma:Platelets:RBCs)
B) 1:2:1 (Plasma:Platelets:RBCs)
C) 1:1:1 (Platelets:Plasma:RBCs)
D) 2:1:1 (Plasma:Platelets:RBCs)
Answer: C) 1:1:1 (Platelets:Plasma:RBCs)
Which product is typically used to manage circulatory overload (TACO)?
A) Diuretics
B) Antihistamines
C) Corticosteroids
D) Calcium gluconate
Answer: A) Diuretics
Big difference is the circulatory overload and the fever..
2 Circulatory overload (TACO)
Mediators : fluid volume.
S/S: coughing, cyanosis, orthopnea, severe headache, peripheral edema, diff breathing.
Treatment and Prevention: administer subsequent Tx slowly & in a small volume.
What is the main reason for leukoreducing blood products?
A) Increase oxygen capacity
B) Reduce risk of febrile non-hemolytic transfusion reactions
C) Increase platelet count
D) Reduce the risk of HIV transmission
B) Reduce risk of febrile non-hemolytic transfusion reactions
Nonhemolytic febrile transfusion reactions
Mediators: A/b to HLA Class I Ag.
S/S: fever, chill.
Treatment and Prevention: antipyretics, leukocyte reduced.
In the setting of a massive transfusion, when is calcium typically replaced?
A) After 1 unit of blood has been transfused
B) After 2 units of blood have been transfused
C) After 4 units of blood have been transfused
D) Only if symptoms of hypocalcemia appear
Answer: C) After 4 units of blood have been transfused
CALCIUM: Hypocalcemia, long QTc, decreased cardiac output, coagulopathy, seizures, etc.
97.4% of trauma MTP patients hypocalcemic (<1.12mmol/L)
50-70% severe (<0.8-0.9mmol/L)
More coagulopathy
More blood transfused
Double mortality (49% vs. 24%)
Calcium replacement after 4U, but never resolved (still <1.12mmol/L)
One unit of citrated blood product drops iCa
1 unit of Platelets will increase your count how much?
A) 5,000-7,000
B) 3,000-5,000
C) 5,000- 10,000
D) 250- 300
C) 5,000- 10,000
Prepared by cytapheresis/by separating PRP from a unit of W.B w/in 8H of collection & recentrifuged to remove plasma.
Contains PLT only
One bag = random value
One bag pheresis = 250-300 mL
One unit increases PLT by 5,000 - 10,000
What is a critical variable in determining mortality in patients requiring massive transfusion?
A) Hypocalcemia
B) Hypernatremia
C) Hypokalemia
D) Hyponatremia
Answer: A) Hypocalcemia
What is the threshold INR value for considering Fresh Frozen Plasma transfusion?
A) Greater than 1.2
B) Greater than 1.5
C) Greater than 1.8
D) Greater than 2.0
Answer: B) Greater than 1.5
The transfusion of which component is usually indicated for treatment of a bleeding patient with a fibrinogen level below 100 mg/dL?
A) Platelets
B) Red Blood Cells
C) Fresh Frozen Plasma
D) Cryoprecipitate
Answer: D) Cryoprecipitate
Which of the following best describes the effect of a long R time on a Thromboelastogram (TEG)?
A) Indicates a need for platelets
B) Suggests a deficit in clotting factors
C) Shows enhanced fibrinolysis
D) Represents accelerated clot formation
Answer: B) Suggests a deficit in clotting factors
“Reaction time” to initial fibrin formation
5.0 - 10.0 min
clotting factors (intrinsic pathway)
Long R time, give FFP
When using a Massive Transfusion Protocol, what is a common trigger for initiating transfusion?
A) Hemoglobin less than 7 g/dL
B) Blood loss of 180 mL/min
C) Platelet count below 50,000/mL
D) Blood Loss of 15% Total Blood Volume
Answer: B) Blood loss of 180 mL/min
MTP in Adults
1) Total blood volume is replaced within 24 hours
2) 50% of total blood volume is replaced in 3 hours
3) Rapid bleeding rate = 4 units RBCS transfused within 4 hours or 150 mL/min blood loss
MTP in Children = >40 mL/kg transfusion
Current standard of care in level 1 trauma centers = balanced resuscitation
1:1:1 ratio (platelets:plasma:RBC)
Multiple blood components ”reconstituted” whole blood
Actively bleeding pt>20% of body blood volume.
What is the blood loss range for Class I Hemorrhage?
A) 0-750 ml
B) 750-1500 ml
C) 1500-2000 ml
D) >2000 ml
Answer: A) 0-750 ml
In which class of hemorrhage does the pulse rate typically exceed 100 bpm?
A) Class I
B) Class II
C) Class III
D) Class IV
Answer: B) Class II
Which class of hemorrhage is associated with a blood loss of more than 40% volume?
A) Class II
B) Class III
C) Class IV
D) None of the above
Answer: C) Class IV
An R time of 8 minutes in a TEG suggests deficiency in:
A) Platelets
B) Clotting factors
C) Fibrinogen
D) None of the Above
D) None of the Above
Normal time : 5.0 - 10.0 min
Reaction time” to initial fibrin formation
clotting factors (intrinsic pathway)
What is the normal range for the TEG-ACT value?
A) 50-70 sec
B) 80-140 sec
C) 5-10 min
D) 1-3 min
Answer: B) 80-140 sec
“Activated clotting time” to initial fibrin formation
Measures
clotting factors (extrinsic/intrinsic pathways
Which TEG value indicates the need for Fresh Frozen Plasma (FFP) transfusion?
A) TEG-ACT > 140
B) MA < 50
C) LY30 > 3%
D) Alpha angle < 53
Answer: A) TEG-ACT > 140
MA < 50: Platelets
LY30 > 3%:Tranexamic Acid
Alpha angle < 53: Cryoprecipitate +/- Platelets
The maximum amplitude (MA) in TEG reflects:
A) Clot lysis
B) Clotting factor activity
C) Platelet number and function
D) Fibrinolysis
Answer: C) Platelet number and function
What does a MA amplitude of 80.0 mm on a TEG indicate?
A) Hypercoagulability
B) Hypocoagulability
C) Normal coagulation function
D) Platelet dysfunction
A) Hypercoagulability
MA
50.0 - 70.0 mm
Maximum amplitude of tracing
platelet number and function
In the “Drinker’s Guide to Viscoelastic Testing”, what is recommended for a decreased LY 30 time?
A) FFP
B) Platelets
C) TXA
D) No action
Answer: C) TXA (Tranexamic Acid)
Normal: 0 - 3%
An increase in LY30 time in thromboelastography (TEG) analysis indicates more fibrinolysis than normal. The LY30 value measures the percentage of clot lysis 30 minutes after the maximum amplitude, reflecting the body’s natural process to break down blood clots. A higher LY30 value means there is more breakdown of the clot, which can indicate increased fibrinolytic activity.
What is the fluid replacement strategy for Class I Hemorrhage?
A) Crystalloid and blood
B) Crystalloid only
C) Crystalloid (3:1 rule)
D) Blood only
Answer: C) Crystalloid (3:1 rule)
A LY30 value greater than 3% in TEG analysis suggests treatment with:
A) FFP
B) Platelets
C) Cryoprecipitate
D) Tranexamic Acid
Answer: D) Tranexamic Acid
At what percentage of blood volume loss does the heart rate typically begin to rise?
A) Up to 15%
B) 15%-30%
C) 30%-40%
D) >40%
Answer: B) 15%-30%
The normal alpha angle in TEG, indicating clot strength, ranges between:
A) 20-40 degrees
B) 40-55 degrees
C) 53-72 degrees
D) 72-90 degrees
Answer: C) 53-72 degrees
a angle
53.0 - 72.0 degrees
Angle from baseline to slop of tracing that represents clot formation
fibrinogen, platelet number
Alpha angle <53
Cryoprecipitate +/- Platelets
For which condition is cryoprecipitate transfusion recommended according to TEG?
A) TEG-ACT > 140
B) K time > 3
C) MA < 50
D) Alpha angle < 53
Answer: D) Alpha angle < 53
The TEG value indicating entire coagulation cascade strength is:
A) Alpha angle
B) MA
C) G value
D) LY30
Answer: C) G value
G value
5.3 - 12.4 dynes/cm2
Calculated value of clot strength
entire coagulation cascade
Hemodynamic instability due to hemorrhage generally starts in which class?
A) Class I
B) Class II
C) Class III
D) Class IV
Answer: C) Class III
In a patient with an alpha angle less than 53 degrees, you would consider transfusing:
A) Platelets
B) FFP
C) Cryoprecipitate +/- Platelets
D) None of the above
Answer: C) Cryoprecipitate +/- Platelets
In the context of hemorrhage, mental status changes to confusion or lethargy in which class?
A) Class I
B) Class II
C) Class III
D) Class IV
Answer: D) Class IV
An MA value less than 50 mm in TEG suggests a requirement for:
A) Platelets
B) FFP
C) Cryoprecipitate
D) Tranexamic Acid
Answer: A) Platelets
What TEG value assesses the clot lysis at 30 minutes?
A) MA
B) K time
C) LY30
D) Alpha angle
Answer: C) LY30
What is the recommended treatment for a patient with a TEG K time greater than 3 minutes?
A) FFP
B) Platelets
C) Cryoprecipitate
D) Tranexamic Acid
Answer: C) Cryoprecipitate
K time
1.0 - 3.0 min
“Kinetic time” for fibrin cross linkage to reach 20 mm clot strength
fibrinogen, platelet number
K time >3
Cryoprecipitate
