Mega MCQ Flashcards
Kick those MCQs in the butt!
What is the maximum pressure delivered by Manujet? A. 1.5 atm
B. 2.5 atm
C. 3.5 atm
D. 4.5 atm
E. 5.5 atm
Answer: C (according to product info table)
Manujet:
Emergency use:
- Life-saving manoeuvre in “can’t intubate, can’t ventilate” situation for oxygenation to avoid severe desaturation of the patient
Elective use:
- Microlaryngeal surgery
- Rigid bronchoscopy
- ENT surgery
- Assist in difficult fiberoptic intubation
Consists of:
- Manujet jet ventilator
- Luer lock connecting tubing
- Endojet-adapter with endojet-catheter - Bronchoscope adapter
- 4m pressure hose
- Jet ventilating catheters
– Infant (16G cannula, 37mm long)
– Child (14G cannula, 49mm long)
– Adult (13G cannula, 63mm long)
Technical data:
- Operating pressure: 4 - 10 bar/58 - 145 PSI
- Pressure range of gauge: 0 - 4 bar/0 - 58 PSI
Use:
- Designed for use with O2 or compressed air
- Needs operating pressure of 4 - 10 bar
- 4m pressure hose is attached to Manujet
Operating instructions:
- Connect Manujet to Oxygen or compressed air supply with appropriate adapter
- Pull out pressure regulator knob and turn counter-clockwise until pointer on 0 bar/PSI. Release pressure in system by activation of the trigger
- Connect Manujet to pt via Leur Lock connecting tubing
- Adjust ventilation pressure by turning pressure regulator knob clockwise. Start with lowest pressure and increase pressure slowly. Push in pressure regulator knob to lock pressure.
- Activation of trigger allows pt to be ventilated.
http: //p-h-c.com.au/doc/Manujet_111_Manual.pdf
Healthy pt on escitalopram. Which drug is NOT relatively contraindicated?
A. Clonidine
B. Omeprazole
C. Metoprolol
D. Pethidine
E. Tramadol
Answer: A (clonidine) - enhances sedative effects of esitalopram
Interactions (MIMS):
Escitalopram is an inhibitor of CYP2D6
- Clonidine- additive toxicity of clonidine. Isolated case of drowsiness to pt almost becoming unconscious
- Omeprazole - escitalopram may increase serum concentration of omeprazole via inhibition of CYP2C19. Can lead to prolonged QT in elderly pts.
- Metoprolol - escitalopram may increase serum concentration of metoprolol due to inhibition of CYP2D6 (up to 2-fold increase in metoprolol)
- Tramadol - risk of serotonin syndrome
-
Pethidine - serotonergic activity, which can increase risk of serotonin syndrome.
https: //www.nps.org.au/medical-info/medicine-finder/escitalopram-an-tablets
Drugs details:
Escitalopram: SSRI, Rx depression
Clonidine: Alpha-2 agonist >> decreases noradrenaline release from smpathetic nerve terminals and decreases sympathetic tone. Increases vagal tone.
Omeprazole: PPI. Inhibition of basal and stimulated gastric secretion via irreversibl, non-competative blockade of parietal cell H+-K+-ATPase>> resulting in inhibition of final common pathway of H+ secretion into gastric juices
Metoprolol: non-selective B-blocker
Pethidine: Mu and kappa receptor agonist >> increase intracellular Ca2+ and K+ conductance >> hyperpolarisation of cell membranes. Anticholinergic effect (causes tachycardia)
Tramadol: non-selective mu, kappa, delta opioid receptor agonist (higher affinity for mu). Inhibits neuronal uptake of noradrenaline and serotonin; inhibition of pain pathways due to activation of descending noradrenergic and serotonergic pathways
Intra-arterial propofol 10ml. Extreme pain. Most appropriate immediate management:
A. 30ml normal saline intra-arterial
B. Heparin 500IU
C. Lignocaine 50mg
D. Papaverine 50mg
E. Observe
Answer: ?C (or A?)
OHA:
Intra-arterial injection: chemical end-arteritis with arterial vasospasm, local release of nordrenaline, crystal deposiiton in distal arteries >> thrombosis and necrosis
Rx:
- Aiming to dilute irritant, reverse vasospasm, prevent thrombosis
1. Stop injection
2. Leave IVC in-situ
3. 50mg 1% lignocaine (to prevent vasospasm and provide analgesia)
4. Papavarine 40mg (vasodilator)
5. Injection of heparinised saline (anticoagulant + dilution)
6. If drug is high irritant >> isotonic saline or hepsal flush
Propofol intra-arterial injection = hyperemia and blanching
https://academic.oup.com/bjaed/article/10/4/109/381097
Where should lead V4 of ECG be positioned?
A. Right sternal edge 4th ICS
B. Left sternal edge 4th ICS
C. Left mid clavicular line 4th ICS
D. Left mid clavicular line 5th ICS
E. Left Mid axillary line 5th ICS
Answer: D
V1 - (R) 4th ICS
V2 - (L) 4th ICS
V3 - midway between V2 and V4
V4 - (L) 5th ICS, mid-clavicular line
V5 - anterior axillary line, in line with V4
V6 - (L) 5th ICS, mid-axillary line
What do A lines on lung ultrasound represent?
A. Pneumonia
B. Pleural effusion
C. Pulmonary oedema
D. Pneumothorax
E. Normal lung
Answer: E
A-line - horizontal artifact = normal lung surface
B-line - comet-tail artifact = subpleural interstitial oedema; artefact generated by juxtaposition of alveolar air & septal thickening. Arise from pleural line, long, vertical, hyperechoic, erase A lines, move with lung sliding. Caused by interstitial or pulmonary oedema
https://academic.oup.com/bjaed/article/16/2/39/2897763
“Air below the pleural line reflects most US back to the transducer. This is itself a reflector, meaning some of the US waves will bounce back and forth between the pleura and transducer generating artifacts called A-lines. They are horizontal lines below the pleura with the same spacing as the distance between the probe and the pleural line. Because they demonstrate the presence of air below the pleura, they are present both in normal lungs and in pneumothorax. Turning the probe transversely will abolish the rib shadows so more of the pleural line can be seen. The danger of this is that an inexperienced user may interpret a rib as the pleural line and incorrectly diagnose absent lung sliding”
https://www.sciencedirect.com/science/article/pii/S0012369209605997
“The A-line is a horizontal artifact indicating a normal lung surface. The B-line is a kind of comet-tail artifact indicating subpleural interstitial edema. The relationship between anterior interstitial edema detected by lung ultrasound and the pulmonary artery occlusion pressure (PAOP) value was investigated.”
Aspirin efficacy is reduced with
A. Parecoxib
B. Diclofenac
C. Ibuprofen
D. Naproxen
E. Celecoxib
Answer: C
“Regular use of ibuprofen may inhibit the cardioprotective effects of aspirin…COX2 inhibitors (i.e. celecoxib) do not affect platelet function and do not appear to impair the antiplatelet effects of aspirin…Diclofenac 75mg BD did not influence the antiplatelet effects of aspirin”
https: //www.pharmacytimes.com/publications/issue/2004/2004-07/2004-07-8036
https: //www.pharmacytimes.com/publications/issue/2004/2004-07/2004-07-8036
Original study findings (2001, Catella-Lawson)
“Serum thromboxane B2 levels (an index of cyclooxygenase-1 activity in platelets) and platelet aggregation were maximally inhibited 24 hours after the administration of aspirin on day 6 in the subjects who took aspirin before a single daily dose of any other drug, as well as in those who took rofecoxib or acetaminophen before taking aspirin. In contrast, inhibition of serum thromboxane B2 formation and platelet aggregation by aspirin was blocked when a single daily dose of ibuprofen was given before aspirin, as well as when multiple daily doses of ibuprofen were given. The concomitant administration of rofecoxib, acetaminophen, or diclofenac did not affect the pharmacodynamics of aspirin”
https://www.nejm.org/doi/full/10.1056/NEJMoa003199
Risk of thromboembolic effect is lowest with
A. Parecoxib
B. Diclofenac
C. Ibuprofen
D. Naproxen
E. Celecoxib
Answer: D (followed by ibuprofen)
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3676195/
Use of Schnider rather Marsh model TCI Pharmacokinetics in a adult patient of normal weight for longer than 15minutes procedure will result in
A) Smaller loading dose and smaller overall dose
B) Smaller loading dose but larger overall dose
C) A larger loading dose and larger overall dose
D) A larger loading dose but smaller overall dose
E) A larger/? Smaller loading dose and overall dose dependent
Answer: A
Marsh:
- 1st propofol TCI model developed
- Takes into account weight only (but requires age input to pump to allow it to work)
- Used for PLASMA targeting
– When used for effect-site targeting, will give HIGH initial dose >> can cause instability in unstable or elderly patients
- Risk of overdosing in obese patients if actual weight used >> need to input ideal body weight
- VD 15.9L
Schneider:
- Requires weight, height, age, gender >> to calculate lean body mass
- Used for effect-site targeting
- Gives lower doses of propofol cf Marsh protocol (both at induction and maintenance) due to lower value for central compartment
- VD 4.27L
- Better for elderly with lower lean body mass
Lean body mass:
Male = 1.07 x wt - 148 (wt/ht)2
Female = 1.1 x wt - 128 (wt/ht)2
What is the maximum time to pause CPR for intubation during ALS
A. 5 sec
B. 10 sec
C. 20 sec
D. 30 sec
E. 45 sec
Answer: A
ANZCOR Guidelines (2016)
However, if endotracheal intubation is attempted, ongoing CPR must be maintained, laryngoscopy should be performed during chest compressions and attempts at intubation should not interrupt cardiac compressions for more than 5 seconds [Class A; Expert consensus opinion].
Warm ischaemic time for lung
A. 30 min
B. 45 min
C. 60 min
D. 90 min
E. 120 min
Answer: D
LITFL
- Donation after circulatory death (DCD) - refers to organ donation taking place once circulatory arrest has occurred following treatment withdrawal
Warm ischaemic time:
- Time from withdrawal of treatment to cold perfusion
- Most important phase occurs when SBP <60mmHg
– Liver <30mins
– Kidney and pancreas <60mins
– Lung <90mins
How long to stop ticagrelor prior to neuraxial?
A. 2 days
B. 3 days
C. 5 days
D. 7 days
E. 10 days
Answer: C
European Society of Anaesthesiology 2018 Guidelines
What is the initial IV magnesium bolus dose for treatment of torsades?
A. 1 - 2g
B. 2 – 3g
C. 3 – 4g
D. 4 – 5g
E. 5 – 6g
Answer: ?
Torsades de pointes (UTD):
- Polymorphic ventricular tachycardia (PVT)
- HR >100bpm with frequent variations of QRS axis, morphology or both
- Occurs in setting of acquired or congenital QT prolongation
- Characterised by progressive, sinusoidal and cyclic alteration of QRS axis, HR 160 - 250bpm, irregular RR intervals, cycling of QRS axis through 180degrees every 4 - 20beats
OpenAnaesthesia:
“Magnesium sulfate is the treatment of choice to prevent recurrence. Patients should receive an initial bolus of 30 mg/kg intravenously, followed by an infusion of 2– 4 mg/min. The bolus may be repeated after 15 min”
How long to start transfusion of pRBC after it has left the fridge?
A. within 15 min
B. within 30 min
C. within 60 min
D. within 120 min
E. within 240 min
Answer: B
What pregnancy category is propofol?
A. A.
B. B1
C. B2
D. C
E. D
Answer: D
MIMS“All general anaesthetics cross the placenta and carry the potential to produce central nervous system and respiratory depression in the newborn infant. In routine practice this does not appear to be a problem; however, in the compromised fetus, careful consideration should be given to this potential depression, and to the selection of anaesthetic drugs, doses and techniques.
Diprivan should not be used in pregnancy. Teratology studies in rats and rabbits show some evidence of delayed ossification or abnormal cranial ossification with an increase in the incidence of subcutaneous haematomas. Reproductive studies in rats suggest that administration of Diprivan to the dam adversely affects perinatal survival of the offspring”
For emergency surgery, the minimum effective prothrombinex dose to reduce an INR from 2.0 to 1.5 is:
a) 5
b) 15
c) 25
d) 35
e) 50
Answer: B
Prothrombinex:
- Dried prothrombin complex
- Prepared from human plasma
- Contains factor IX + variable amounts of factors II, VII, X
- Indications: Rx/prophylaxis of congenital or aquired factor deficiency (F2, 7, 9, 10; such as warfarin Rx)
- Contraindications: angina, recent MI, h/o heparin-induced thrombocytopaenia
- S/Es: thrombosis, hypersensitivity, anaphylaxis
https: //www.mja.com.au/system/files/issues/tra10614_web_fm_0.pdf
What is the IM adrenaline dose for anaphylaxis in 14 year old?
A. 100 mcg
B. 300 mcg
C. 500 mcg
D. 700 mcg
E. 1000 mcg
Answer: C
Adult ANZAAG guidelines (>12yo use adult guidelines)
Children (<12yo)
- Initial IV adrenaline bolus = dilute 1mg in 50ml = 20mcg/ml
- Moderate (grade 2) = 0.1ml/kg (2mcg/kg)
- Life threatening (grade 3) = 0.2 - 0.5ml/lg (4 - 10mcg/kg)
Grading: SEVERITY OF ANAPHYLAXIS
For the purposes of these guidelines and management cards, the following grading scale for severity of anaphylaxis is used.
3.1. Mild (Grade 1) anaphylaxis is typified by mucocutaneous signs only, such as erythema, urticaria, and peripheral angioedema. Although the focus of these anaphylaxis management resources is on moderate to severe anaphylaxis, mild anaphylaxis (Grade 1) must also be recognised and monitored carefully in order to promptly detect the development of any multi- organ manifestations which would then reclassify the reaction to a higher grade and thus warrant treatment with adrenaline.
3.2. Moderate (Grade 2) anaphylaxis has multi-organ manifestations typically mucocutaneous signs combined with hypotension and/or bronchospasm.
Grade 2 anaphylaxis is more likely than Grade 3 anaphylaxis to have mucocutaneous signs facilitating the diagnosis of anaphylaxis over other causes of moderate hypotension and/or bronchospasm. Anaphylaxis during general anaesthesia most commonly presents with hypotension
Moderate hypotension is a common sign during anaesthesia and is mostly due to causes other than anaphylaxis. The diagnosis of anaphylaxis should be considered where there is hypotension out of proportion to that which could be expected for the stage of the operation in a particular patient and/or where there has been a lack of response to usual vasopressors and restorative measures. While tachycardia is more common, bradycardia may be observed
The reported rate of bronchospasm during anaesthesia varies widely and has a reported incidence between 1.7 percent and 16 percent of anaesthetics. Moderate bronchospasm and/or high airway pressure during anaesthesia are frequently caused by conditions other than anaphylaxis. The diagnosis of anaphylaxis should be suspected where bronchospasm and difficulty with ventilation are resistant to the commonly employed treatment manoeuvres.
Grade 2 anaphylaxis may also have additional respiratory, gastrointestinal or central nervous system symptoms and signs in patients who are conscious or minimally sedated. These include rhinorrhoea, cough, dyspnoea, circumoral tingling, difficulty swallowing, nausea, abdominal pain, irritability, confusion or a sense of impending doom.
3.3. Life threatening (Grade 3) anaphylaxis is a clinical presentation of life threatening hypotension and/or high airway pressure. Immediate treatment is required in this situation in order to avoid progression from inadequate tissue perfusion to cardiac arrest or significant hypoxia. The airway pressures are elevated to levels where oxygenation and ventilation are rapidly compromised. In up to 20 percent of patients only one of the signs of anaphylaxis is present.
Unlike Grade 2 anaphylaxis, cutaneous signs are frequently absent initially due to the low cardiac output and may appear only when circulation is restored.
3.4. Cardiac arrest (Grade 4) anaphylaxis is characterised by either absence of a palpable central pulse or a grossly inadequate blood pressure as assessed via direct arterial measurement.
Drug that is NOT recommended in ANZCA endorsed anaphylaxis guidelines:
A. Noradrenaline
B. Metaraminol
C. Glucagon
D. Vasopressin
E. Promethazine
E: promethazine
ANZAAG Guidelines
Resistant hypoTN:
- Continue adrenaline infusion
- Additional IV fluid bolus 50ml/kg
- Add 2nd vasopressor
- Consider CVC
- Cardiac bypass/ECMP if available
Vasopressor recommendations:
- Noradrenaline infusion 3 - 40mcg/min (0.05-0.5mcg/kg/min) +/-
- Vasopressin bolus 1 - 2units then 2units per hour
If neither available, use metaraminol or phenylephrine infusion
- Glucagon 1 - 2mg IV Q5min until response; draw up and administer IV (to counteract b-blockers)
Most sensitive test for dabigatran effect:
A. International normalized ratio
B. Activated partial thromboplastin time
C. Activated clotting time
D. Thrombin clotting time
E. Thromboelastogram
Answer: D
Minimum time before deflation of cuff after Bier block?
A. 5 min
B. 10 min
C. 20 min
D. 30 min
E. 40 min
Answer: C
OHA:
- 15mins for prilocaine
- 20mins for lignocaine
- Tourniquet not to be released prior to this due to large systemic volume of LA being released prior to being metabolised or bound
Cardiac output achieved with effective CPR
A. Lessthan10%
B. 10-20%
C. 20-30%
D. 30-40%
E. 40-50%
Answer: C
Source: ANZCOR Guidelines
“BLS is a temporary measure to maintain ventilation and circulation. Effective external compressions provide cardiac output 20 - 30% pre-arrest value and expired air resuscitation provides ventilation with FiO2 15 - 18%
[ALTERNATE VERSION] Bier’s block with 3% prilocaine. Minimum time until cuff deflation:
A. 15min
B. 30min
C. 45min
D. 60min
E. 75min
Answer: A
OHA:
- 15mins for prilocaine
- 20mins for lignocaine
- Tourniquet not to be released prior to this due to large systemic volume of LA being released prior to being metabolised or bound
TURP with sudden drop in level of consciousness. BP 120/70 and heart rate 80. Sodium is 119.
Most appropriate management is:
A. 20% saline as abolus
B. 3% saline at 100ml/hr
C. Normal saline at maintenance rate
D. Frusemide 40mg IV
Answer: B
OHA:
- TURP Sydrome
- For hypertonic saline due to neurological findings (loss of consciouness) and acute hyponatraemia
- Rx with 1.2 - 2.4ml/kg/hr hypertonic saline
Procedure which is contraindicated with deep brain stimulator is:
A. Electrical stimulation of facial nerve
B. Elective cardioversion of supraventricular arrhythmia
C. Emergent cardioversion
D. ECT
E. MRI
Answer:
Most effective drug for smoking cessation, in combination with counselling is
A. Zyban (buproprion)
B. Varenicline
C) Nicotine patch
D) Nicotine inhaler
Answer: B (Champix)
Quit.com.au
