Perioperative Mock Flashcards
What is the least likely examination finding in patients with Le Fort II fractures?
Excessive mobility of the palate
Paraesthesia in the region supplied by the inferior alveolar nerve
Malocclusion of the teeth
Enopthalmos
Parasthesia in the region supplied by the infraorbital nerve
Le Fort II fractures have a pyramidal shape. The fracture line involves the orbit and extends to involve the bridge of the nose and the ethmoids. In continues to involve the infraorbital rim and usually through the infraorbital foramen. As a result infraorbital parasthesia, palatal mobility and malocclusion are common findings. Severe fractures may result in enopthalmos. However, the fracture does not, by definition, involve the inferior alveolar nerve.
A 10 year old child is admitted to the emergency department after a fall. On examination, the blood pressure is 100/55mmHg, pulse rate 90, abdomen soft but tender on the left. Abdominal imaging demonstrates a grade III splenic laceration. What is the most appropriate course of action?
Undertake an immediate laparotomy and splenectomy
Undertake a laparoscopy and laparoscopic splenectomy
Admit the child to the high dependency unit for close monitoring
Arrange splenic artery embolisation
Undertake a laparotomy and splenic repair
ADMIT HIM! ONLY GRADE 3
Splenic trauma is nearly always managed conservatively. Hilar injuries (grade IV) are less amenable to this and will tend to come to surgery.
A 20 year old man falls over and bangs his head whilst intoxicated. On arrival in the emergency department he opens his eyes in response to speech, and is able to speak, although he is disorientated. He obeys motor commands. What is his Glasgow coma score?
E=3, V=4, M=6.
A 49-year-old male sustained a severe blunt injury just below the bridge of the nose with industrial machinery. Imaging demonstrates a fracture involving the superior orbital fissure. On examination an ipsilateral pupillary defect is present and loss of the corneal reflexes. In addition to these examination findings, which of the following will not be present?
Altered cutaneous sensation from the forehead to the vertex Ptosis Complete opthalmoplegia Nystagmus Ipsilateral visual loss
OPHTHALMOPLEGIA =! NYSTAGMUS
Orbital apex syndrome
This is an extension of superior orbital fissure syndrome and includes compression of the optic nerve passing through the optic foramen. It is indicated by features of superior orbital fissure syndrome and ipsilateral afferent pupillary defect.
This type of injury will result in the orbital apex syndrome (See above). As such opthalmoplegia will be present and nystagmus cannot occur.
A 25 year old cyclist is hit by a bus traveling at 30mph. He was not wearing a helmet. He arrives with a GCS of 3/15 and is intubated. A CT scan shows evidence of cerebral contusion but no localising clinical signs are present. What is the most appropriate course of action?
Burr hole decompression Decompressive craniotomy Insertion of intra cranial pressure monitoring device Administration of intravenous mannitol Parietotemporal craniotomy
This patient may well develop raised ICP over the next few days and intracranial pressure monitoring will help with management.
A 45 year old man is undergoing a small bowel resection. The anaesthetist decides to administer an intravenous fluid which is electrolyte rich. Which of the following most closely matches this requirement?
Dextrose / Saline Pentastarch Gelofusine Hartmans 5% Dextrose with added potassium 20mmol/ L
Hartmans solution is the most electrolyte rich. However, both pentastarch and gelofusine have more macromolecules.
A 23 year old man is reviewed on the ward 10 days following a laparotomy. The wound is inspected and is healing well. Which of the following processes is least likely to be occurring in the wound at this stage?
Angiogenesis Synthesis of collagen Necrosis of fibroblasts Secretion of matrix metalloproteinases by fibroblasts Proliferation of fibroblasts
NECROSIS
Vasculogenesis vs Angiogenesis
Vascu is new. Angi is pre
Vasculogenesis is new vessels developing in situ from existing mesenchyme.
Angiogenesis is vessels develop from sprouting off pre-existing arteries.
Fibroblasts are an important cell type in healing wounds. They typically proliferate in the early phases of wound healing. They release matrix metalloproteinases and these facilitate in the remodelling of the matrix within the healing wound. Necrosis in a healing wound would be unusual as wounds will tend to show clinical evidence of angiognesis by this time.
A 45 year old man is undergoing a small bowel resection. The anaesthetist decides to administer an intravenous fluid which is electrolyte rich. Which of the following most closely matches this requirement?
Dextrose / Saline Pentastarch Gelofusine Hartmans 5% Dextrose with added potassium 20mmol/ L
Hartmans solution is the most electrolyte rich. However, both pentastarch and gelofusine have more macromolecules.
A 55 year old man requires a flexible sigmoidoscopy to investigate bright red rectal bleeding. What is the most appropriate preparation?
Single phosphate enema the day prior to the procedure
Single phosphate enema 30 minutes pre procedure
Oral sodium picosulphate the day prior to the procedure
Oral sodium picosulphate 30 minutes prior to the procedure
Rectal lavage with saline 1 hour pre procedure
For a limited endoscopy a simple enema will suffice.
SIGMOIDOSCOPY - JUST ENEMA 30 MIN PRIOR
A 48 year old lady has a metallic heart valve and requires a paraumbilical hernia repair. Perioperatively she is receiving intra venous unfractionated heparin. To perform the surgery safely a normal coagulation state is required. Which of the following strategies is routine standard practice?
Administration of 10 mg of vitamin K the night prior to surgery and stopping the heparin infusion 6 hours pre operatively
Stopping the heparin infusion 6 hours pre operatively
Stop the heparin infusion on induction of anaesthesia
Stopping the heparin infusion 6 hours pre operatively and administration of intravenous protamine sulphate on commencing the operati
None of the above
No need for protamine!
Patients with metallic heart valves will generally stop unfractionated heparin 6 hours pre operatively. Unfractionated heparin is generally cleared from the circulation within 2 hours so this will allow plenty of time and is the method of choice in the elective setting. Protamine sulphate will reverse heparin but is associated with risks of anaphylaxis and is thus not generally used unless immediate reversal of anticoagulation is needed, e.g. coming off bypass.
Which of the agents listed below can be administered via the peripheral intra venous route in the non cardiac arrest setting?
Milrinone Noradrenaline Adrenaline Metaraminol Dobutamine
METADONE - METARAMINOL - PERIPH IV
Metaraminol is an alpha receptor agonist.
As a general rule, inotropes and vasopressors can only be administered via a central vein. Metaraminol is an exception to this as it can be administered via a peripheral line.
Which statement is false about pethidine?
It is thirty times more lipid soluble than morphine
Structurally similar to morphine
Pethidine has a toxic metabolite (norpethidine) which is cleared by the kidney
Pethidine is metabolized by the liver
Can be given intramuscularly
PETHIDINE IS… OTHER THAN MORPHINE
It has a different structure. It is much more lipid soluble than morphine. It produces less biliary tract spasm than morphine.
Which of the anaesthetic agents below is most likely to induce adrenal suppression?
Sodium thiopentone Midazola Propofol Etomidate Ketamin
OUTOMIDATE - YOUR ADRENALS OUT
Etomidate is a recognised cause of adrenal suppression, this has been associated with increased mortality when used as a sedation agent in the critically ill.
You are the cardiothoracic surgical registrar reviewing a patient referred for an aortic valve replacement. The 40-year-old man is being investigated for progressive breathlessness in a previous respiratory clinic. The notes show he has smoked for the past 25 years. Pulmonary function tests reveal the following:
FEV1 1.4 L
FVC 1.7 L
FEV1/FVC 82%
What is the most likely explanation?
Asthma Bronchiectasis Kyphoscoliosis Chronic obstructive pulmonary disease Laryngeal malignancy
TIFFNO > 70 = RESTRICTIVE = SCOLIOSIS
These results show a restrictive picture, which may result from a number of conditions including kyphoscoliosis. The other answers cause an obstructive picture.
We note that most people have chosen COPD as the answer. In COPD the FEV1/FVC would show an obstructive picture with the FEV1/FVC value being low (approximately less than 70%). In restrictive conditions the FEV1/FVC is normal or increased (greater than 70%). With the FEV1/FVC being over 70% the most likely answer is kyphoscoliosis.
Which of the following muscle relaxants is an agent that is degraded by hydrolysis and may produce histamine release?
Atracurium Panciuronium Curare Suxamethonium Vecuronium
ATRACURIUM - AANAAPHYLAXIS - HISTAMINE
Atracurium is degraded by a process of ester hydrolysis. This uses non specific plasma esterases.
