Pharm Exam 4: LA rescue

Question 1

Allergic reactions to local anesthetics are:
A. Common, occurring in more than 10% of administrations.
B. Rare, occurring in less than 1% of administrations.
C. Most often caused by the anesthetic agent itself rather than additives.
D. Usually due to cross-sensitivity between esters and amides.

Answer 1

Correct Answer: B. Rare, occurring in less than 1% of administrations.
Rationale: Allergic reactions to local anesthetics are rare and often related to excess plasma levels or additives like methylparaben, which is similar in structure to PABA, a known allergen.

Question 2

Which class of local anesthetics is more likely to produce an allergic reaction due to a structural similarity to para-aminobenzoic acid (PABA)?
A. Amides
B. Esters
C. Both equally
D. Neither; allergic reactions are not related to structural similarity to PABA

Answer 2

Correct Answer: B. Esters
Rationale: Esters have a higher likelihood of causing allergic reactions compared to amides because of their structural similarity to PABA, a known allergen.

Question 3

When testing for an allergy to local anesthetics, what type of local anesthetic should be used?
A. Any local anesthetic with a preservative.
B. A local anesthetic with methylparaben.
C. A preservative-free local anesthetic.
D. The exact local anesthetic suspected to have caused a previous reaction.

Answer 3

Correct Answer: C. A preservative-free local anesthetic.
Rationale: To reduce the risk of reacting to additives that may cause allergies, a preservative-free local anesthetic should be used for intradermal allergy testing.

Question 3

What immunoglobulin is typically involved in the hypersensitivity reaction seen with some local anesthetic allergic reactions?
A. IgA
B. IgE
C. IgG
D. IgM

Answer 3

Correct Answer: B. IgE
Rationale: Hypersensitivity reactions, particularly immediate-type hypersensitivity or anaphylaxis, are usually mediated by IgE antibodies. These reactions can result in symptoms such as rash, urticaria, and laryngeal edema, and can also include systemic manifestations like hypotension and bronchospasm.

Question 4

A 12-year-old patient presents for elective surgery requiring local anesthesia. The patient has a history of atopic dermatitis but no prior surgeries or known allergies. The anesthesia team is considering using lidocaine for a peripheral nerve block. Given the patient’s history, they are cautious about potential hypersensitivity reactions.

Question:
Which of the following factors should be most carefully considered when selecting a local anesthetic for this patient?

A) The patient’s history of atopic dermatitis.
B) The concentration of the local anesthetic to be used.
C) The history of exposure to local anesthetics.
D) The type of surgery being performed.

Answer 4

Answer and Rationale:
C) The history of exposure to local anesthetics.

Rationale: While all the options listed are important considerations, the patient’s history of exposure to local anesthetics is particularly pertinent in this scenario. According to the information provided, repeated exposure to local anesthetics can increase the risk of hypersensitivity reactions, especially in pediatric patients. Given that this is the patient’s first surgery, it would be essential to determine if they had been exposed to local anesthetics through other routes, such as dental procedures. If the patient had previous exposures with no adverse reactions, lidocaine could be considered safer. However, if there is a history of multiple exposures, especially if any were associated with reactions, an alternative agent might be preferable. The patient’s history of atopic dermatitis (A) does increase the overall risk of allergic reactions,

Question 5

What is the immediate action to take if a patient’s heart rate increases significantly after a test dose of local anesthetic with epinephrine for an epidural block?

A) Proceed with surgery as planned
B) Administer an additional dose of local anesthetic
C) Check for signs of systemic toxicity due to possible intravascular injection
D) Increase the rate of IV fluids

Answer 5

Answer:
C) Check for signs of systemic toxicity due to possible intravascular injection

Question 6

Local anesthetic systemic toxicity is most directly related to which of the following?

A) The speed of local anesthetic injection
B) The volume of local anesthetic used
C) The plasma concentration of the local anesthetic
D) The type of surgery being performed

Answer 6

Answer:
C) The plasma concentration of the local anesthetic

Question 7

Question 3:
What is a critical step before injecting a local anesthetic during a peripheral nerve block?

A) Administering a bolus of IV fluids
B) Aspirating to ensure the needle is not in a vein or artery
C) Applying a tourniquet
D) Checking the patient’s blood pressure

Answer 7

Answer:
B) Aspirating to ensure the needle is not in a vein or artery

Question 8

Which patient factor contributes to the risk of developing LAST during regional anesthesia?

A) Previous surgeries
B) Protein binding capacity of the drug and dose
C) Time of day when the procedure is performed
D) The patient’s preferred language

Answer 8

B) Protein binding capacity of the drug and dose

Question 9

Which of the following symptoms should alert a healthcare provider to the potential onset of a seizure due to local anesthetic systemic toxicity?

A) Hypertension and bradycardia
B) Drowsiness and facial twitching
C) Polyuria and polydipsia
D) Fever and chills

Answer 9

Answer:
B) Drowsiness and facial twitching

Rationale:
Drowsiness followed by facial twitching can precede a seizure, which is a manifestation of CNS toxicity from local anesthetics.

Question 10

When monitoring for systemic toxicity of lidocaine during an epidural, what plasma level is critical to observe?

A) Above 500 mg
B) Above 900 mg
C) Above 200 mg
D) Above 700 mg

Answer 10

Answer:
B) Above 900 mg

Rationale:
Monitoring plasma levels of lidocaine is important, especially when the epidural dose exceeds 900 mg, as this may indicate a higher risk of systemic toxicity.

Question 11

In the context of local anesthetic systemic toxicity, hyperkalemia is known to promote which of the following conditions?

A) Hypotension
B) Seizures
C) Hyperglycemia
D) Respiratory alkalosis

Answer 11

Answer:
B) Seizures

Rationale:
Hyperkalemia can exacerbate the CNS effects of local anesthetics, potentially increasing the risk of seizures.

Question 12

What cardiac changes can be seen with high plasma concentrations of local anesthetics due to their effect on sodium channels?

A) Increased heart rate and QT shortening
B) Bradycardia and ST elevation
C) Slow conduction of cardiac impulses and QRS widening
D) Tachycardia and PR shortening

Answer 12

Answer:
C) Slow conduction of cardiac impulses and QRS widening

Rationale:
Local anesthetics block cardiac sodium channels, which can result in slowed conduction of cardiac impulses leading to a prolonged PR interval and widening of the QRS complex on an electrocardiogram

Question 13

Which of the following is a potential cardiovascular effect of an accidental intravenous injection of bupivacaine?

A) Mild hypertension
B) Ventricular tachycardia
C) Decreased QT interval
D) Decreased PR interval

Answer 13

Answer:
B) Ventricular tachycardia

Rationale:
Accidental IV injection of bupivacaine can lead to severe cardiovascular complications including ventricular tachycardia. It can also cause precipitous hypotension and atrioventricular (AV) block.

Question 14

At what concentration of lidocaine can patients experience circumoral numbness with minimal potential cardiovascular toxicity?

A) 1 µg/mL
B) 2 µg/mL
C) 5 µg/mL
D) 10 µg/mL

Answer 14

Answer:
C) 5 µg/mL

Rationale:
Patients can experience circumoral numbness, which may be a sign of systemic toxicity, when plasma levels of lidocaine reach around 5 µg/mL. This concentration is not typically associated with cardiovascular system effects.

Question 15

Which local anesthetic is associated with the highest risk of cardiotoxicity?
A. Lidocaine
B. Ropivacaine
C. Bupivacaine
D. Mepivacaine

Answer 15

Answer: C. Bupivacaine
Rationale: Bupivacaine has a higher affinity for cardiac sodium channels than ropivacaine or lidocaine, making it more cardiotoxic, especially in cases of systemic toxicity.

Question 16

In the context of systemic toxicity of local anesthetics, why might pregnant women be at increased risk?
A. Increased blood volume
B. Decreased plasma proteins
C. Enhanced renal clearance
D. Decreased sensitivity to local anesthetics

Answer 16

Answer: B. Decreased plasma proteins
Rationale: During pregnancy, the decrease in plasma proteins results in a higher fraction of free local anesthetic in the bloodstream, increasing the risk of systemic toxicity.

Question 17

What cardiovascular change can predispose a patient to increased local anesthetic systemic toxicity?
A. Hypertension
B. Hypercarbia
C. Tachycardia
D. Hypokalemia

Answer 17

Answer: B. Hypercarbia
Rationale: Hypercarbia, along with hypoxemia and acidosis, can worsen the effects of local anesthetic systemic toxicity by reducing the body’s ability to tolerate the additional stress from the local anesthetic.

Question 18

Why should epinephrine and phenylephrine be used with caution as additives to local anesthetics?
A. They can cause prolonged nerve blockade.
B. They can reduce the onset time of local anesthetics.
C. They may increase the risk of systemic toxicity.
D. They are incompatible with most local anesthetics.

Answer 18

Answer: C. They may increase the risk of systemic toxicity. w/ cardiovascular effects.
Rationale: While epinephrine and phenylephrine are often added to local anesthetics to prolong their effect and reduce systemic absorption, in the event of systemic toxicity, they can further stress the cardiovascular system, particularly if there is an accidental intravascular injection.

Question 19

What is the primary initial step in managing local anesthetic systemic toxicity (LAST)?
A. Administering benzodiazepines
B. Hyperventilation
C. Airway management
D. Intravenous fluid administration

Answer 19

Answer: C. Airway management
Rationale: The immediate goal in treating systemic toxicity is to ensure adequate oxygenation and ventilation, thus airway management is the primary initial step.

Question 20

Which medication is most appropriate for treating seizures induced by local anesthetic systemic toxicity?
A. Epinephrine
B. Barbiturates
C. Benzodiazepines
D. Beta-blockers

Answer 20

Answer: C. Benzodiazepines
Rationale: Benzodiazepines are the first-line treatment for seizures caused by local anesthetic toxicity due to their anticonvulsant properties.

Question 21

Why is hyperventilation used in the treatment of CNS systemic toxicity from local anesthetics?
A. To increase cerebral perfusion
B. To induce metabolic alkalosis
C. To increase carbon dioxide levels
D. To reduce intracranial pressure

Answer 21

Answer: B. To induce metabolic alkalosis
Rationale: Hyperventilation is used to induce a respiratory alkalosis, which can help to reduce the toxicity of local anesthetics on the CNS.

Question 22

Why should epinephrine be used cautiously as an additive in the treatment of systemic toxicity of local anesthetics?
A. It can worsen hypotension.
B. It can cause vasodilation.
C. It can prolong the local anesthetic effect.
D. It can exacerbate arrhythmias.

Answer 22

Answer: D. It can exacerbate arrhythmias.
Rationale: While epinephrine is often added to local anesthetic solutions to prolong their effect and reduce systemic absorption, its use must be cautious in the setting of systemic toxicity, as it can potentially exacerbate arrhythmias, especially in a toxic state.

Question 23

What is the role of hyperventilation in the treatment of CNS systemic toxicity from local anesthetics?
A. To decrease the seizure threshold
B. To increase cerebral perfusion
C. To correct metabolic acidosis
D. To induce respiratory alkalosis

Answer 23

Answer: D. To induce respiratory alkalosis
Rationale: Hyperventilation induces respiratory alkalosis, which can help control CNS toxicity by increasing the seizure threshold and countering acidosis that may potentiate toxicity.

Question 24

Which of the following medications is not typically used in the treatment of systemic toxicity from local anesthetics?
A. Barbiturates
B. Benzodiazepines
C. Epinephrine
D. Muscle relaxants

Answer 24

Answer: D. Muscle relaxants
Rationale: While barbiturates, benzodiazepines, and epinephrine can be used for specific symptoms or to mitigate the effects of toxicity, muscle relaxants are not typically employed in the treatment of systemic toxicity. Instead, they are used for their neuromuscular blockade properties in different contexts.

Question 25

Which substance is used as a “rescue” therapy for severe systemic local anesthetic toxicity?
A. Barbiturates
B. Benzodiazepines
C. Propofol
D. Intralipid emulsion

Answer 25

Answer: D. Intralipid emulsion
Rationale: Intralipid emulsion is used as a “rescue” therapy for severe systemic local anesthetic toxicity because it can bind to the lipophilic local anesthetics, reducing their plasma concentration and potentially reversing the toxicity.

Question 26

What is the initial bolus dose of 20% lipid emulsion used in the treatment of systemic toxicity due to local anesthetics?
A. 0.25 mL/kg
B. 1.5 mL/kg
C. 3.8 mL/kg
D. 10 mL/kg

Answer 26

Answer: B. 1.5 mL/kg
Rationale: The slide indicates that the initial bolus dose for the treatment of systemic toxicity with Intralipid (20% lipid emulsion) is 1.5 mL/kg.

Question 27

If a patient does not respond to initial Intralipid therapy for local anesthetic systemic toxicity, which of the following is the most aggressive next step?
A. Increase the Intralipid dose
B. Start an epinephrine infusion
C. Administer a benzodiazepine
D. Initiate cardiopulmonary bypass (CPB)

Answer 27

Answer: D. Initiate cardiopulmonary bypass (CPB)
Rationale: The slide mentions that cardiopulmonary bypass is considered if there is no response to Intralipid therapy, suggesting it as an aggressive next step in treatment.

Question 28

During the continuous infusion of lipid emulsion for local anesthetic systemic toxicity, what is the initial recommended rate?
A. 0.25 mL/kg/minute
B. 0.5 mL/kg/minute
C. 1 mL/kg/minute
D. 1.5 mL/kg/minute

Answer 28

Answer: A. 0.25 mL/kg/minute
Rationale: According to the slide, after the initial bolus, the continuous infusion rate should be 0.25 mL/kg/minute for at least 10 minutes.

Question 29

Which mechanism is primarily responsible for the efficacy of Intralipid in the treatment of local anesthetic systemic toxicity?
A. Provides a lipid compartment for the fat-soluble local anesthetic
B. Acts as a direct antidote to the local anesthetic
C. Accelerates the renal excretion of the local anesthetic
D. Neutralizes the local anesthetic with a chemical reaction

Answer 29

Answer: A. Provides a lipid compartment for the fat-soluble local anesthetic
Rationale: Intralipid creates a lipid compartment that sequesters the lipophilic local anesthetics, reducing their plasma concentration and thereby mitigating toxicity.Provides for fat for myocardial metabolism?

Question 30

If a patient with LAST is not responding to initial Intralipid therapy, how often should the bolus be repeated?
A. Every 1-2 minutes
B. Every 3-5 minutes
C. Every 10 minutes
D. Every 15 minutes

Answer 30

Answer: B. Every 3-5 minutes
Rationale: According to the slide, if the patient is unresponsive to the initial Intralipid therapy, the bolus should be repeated every 3-5 minutes up to a maximum bolus dose of 3 mL/kg until circulation is restored. Max total dose is 8mL/kg

Question 31

In the treatment of LAST with Intralipid, when should the infusion rate be increased?
A. If the patient’s blood pressure declines
B. If the patient’s blood pressure increases
C. After 10 minutes of the initial bolus
D. Immediately after the first bolus

Answer 31

Answer: A. If the patient’s blood pressure declines
Rationale: The instructions on the slide indicate that the infusion should be increased to 0.5 mL/kg/minute if the patient’s blood pressure declines.

previous slide suggests otherwise but we go Tex Wes

The kind of annoying fucking questions they do w/ 2 right answers.

Question 32

What is the maximum total dose of Intralipid for the treatment of LAST?
A. 3 mL/kg
B. 8 mL/kg
C. 10 mL/kg
D. 12 mL/kg

Answer 32

Answer: B. 8 mL/kg
Rationale: The slide clearly states that the maximum total dose of Intralipid in the treatment of LAST is 8 mL/kg.

Question 33

Which medication is not recommended during the cardiac arrest that occurs as a result of LAST?
A. Epinephrine
B. Vasopressin
C. Calcium channel blockers
D. Amiodarone

Answer 33

Answer: B. Vasopressin
Rationale: According to the guidelines, vasopressin is not recommended if cardiac arrest occurs due to LAST.

Question 34

How long should you continue the infusion of lipid emulsion after circulatory stability is attained?
A. Until the patient is hemodynamically unstable
B. For at least 10 minutes
C. Until lipid emulsion is no longer effective
D. For 30 minutes as the upper limit

Answer 34

Answer: B. For at least 10 minutes
Rationale: The text advises to continue the infusion of lipid emulsion at 0.25 mL/kg/minute for at least 10 minutes after circulatory stability is achieved.

Question 35

What is the infusion adjustment if circulatory stability is not achieved during lipid emulsion therapy for LAST?
A. Increase the infusion to 0.5 mL/kg/minute
B. Decrease the infusion to 0.1 mL/kg/minute
C. Stop the lipid emulsion infusion
D. Maintain the same rate of infusion

Answer 35

Answer: A. Increase the infusion to 0.5 mL/kg/minute
Rationale: The instructions state that if circulatory stability is not attained, consider rebolus and increasing infusion to 0.5 mL/kg/minute.

Question 36

Upon suspecting local anesthetic systemic toxicity, the first immediate action is to:
A) Airway, Breathing, Circulation
B) Call for help and initiate life support measures if needed
C) Give a bolus of lipid emulsion therapy
D) Provide benzodiazepines for seizures

Answer 36

Correct Answer: B) Call for help and initiate life support measures if needed.
Rationale: Prompt recognition and calling for help are critical initial steps in the management of LAST. Life support measures may include airway management, breathing support, and circulation assistance, depending on the patient’s condition.

Question 37

During the management of LAST, after administering a bolus of lipid emulsion and starting the infusion, what is the primary focus of assessment?
A) Evaluating the patient for allergic reactions to the lipid emulsion
B) Monitoring for cardiovascular stability and reassessing the need for further intervention
C) Assessing the patient’s pain level to determine if additional analgesia is required
D) Checking the infusion site for signs of infection

Answer 37

Correct Answer: B) Monitoring for cardiovascular stability and reassessing the need for further intervention.
Rationale: The ‘Assess’ step in the LAST treatment algorithm is critical for determining the patient’s response to the initial lipid emulsion therapy. Continuous monitoring of cardiovascular stability, including heart rate, blood pressure, and rhythm, as well as mental status and oxygenation, is essential to guide further treatment decisions. If there is no improvement or if cardiovascular instability persists, adjustments in therapy, including additional boluses of lipid emulsion, may be needed.

Question 38

A 45-year-old man undergoing a brachial plexus block with bupivacaine suddenly experiences seizures. Immediate administration of intralipid 20% 1.5 mL/kg bolus is carried out, followed by a 0.25 mL/kg/min infusion. After 10 minutes, the patient’s seizures stop, but he remains hypotensive and bradycardic.

What is the most appropriate next step in the management of this patient?
A) Discontinue intralipid infusion as the seizures have stopped.
B) Repeat the intralipid bolus and double the infusion rate if hypotension persists.
C) Start an immediate cardiopulmonary bypass.
D) Double the Infusion rate

Answer 38

Correct Answer: B) Repeat the intralipid bolus and consider doubling the infusion rate if hypotension persists.

Rationale: According to the LAST treatment algorithm, this patient presents with cardiac instability and hypotension so it would be reasonable to repeat the 1.5mL/kg bolus and double the Infusion rate to 0.5mL/kg/min

Question 39

During a liposuction procedure, a patient is given a local anesthetic, and shortly after, they exhibit signs of LAST with tinnitus, perioral numbness, and signs of CNS excitation. An intralipid 20% 1.5 mL/kg bolus is administered immediately, followed by an infusion. The patient’s mental status improves, but they are still experiencing tachycardia and hypertension.

What should the healthcare provider do next?
A) Initiate a repeat 1.5mL/kg bolus due to persistent tachycardia.
B) Stop the lipid emulsion therapy as the CNS symptoms have improved.
C) Continue the lipid emulsion infusion and monitor the patient closely for any signs of deterioration.
D) Administer a vasodilator to control the hypertension.

Answer 39

C) Continue the lipid emulsion infusion and monitor the patient

even though the patient has hypertension and tachycardia, technically he is stable.. the infusion should be continued for another 10 min and the patient monitored for the next 12 hours.

Question 40

A patient reports moderate to severe pain in the lower back and buttocks 24 hours after receiving a single-shot spinal anesthetic with lidocaine for a minor procedure. The patient has no history of back problems, and the procedure was uneventful. What is the most likely diagnosis?

A) Cauda Equina Syndrome
B) Transient Neurologic Symptoms (TNS)
C) Anterior Spinal Artery Syndrome
D) Muscular strain unrelated to the anesthetic procedure

Answer 40

Correct Answer: B) Transient Neurologic Symptoms (TNS)
Rationale: TNS is characterized by moderate to severe pain in the lower back, buttocks, and thighs typically occurring within 6 to 36 hours after a spinal anesthetic and resolving within 1 to 7 days. It is more commonly associated with lidocaine than other local anesthetics.

Question 41

Which of the following treatment options is appropriate for a patient diagnosed with Transient Neurologic Symptoms (TNS) after a spinal anesthetic?

A) Emergency decompressive laminectomy
B) Administration of intravenous corticosteroids
C) Trigger point injections and nonsteroidal anti-inflammatory drugs (NSAIDs)
D) Immediate re-administration of a spinal anesthetic to counteract symptoms

Answer 41

Correct Answer: C) Trigger point injections and nonsteroidal anti-inflammatory drugs (NSAIDs)
Rationale: TNS is typically managed conservatively, often with the use of NSAIDs for pain control. Trigger point injections may also be utilized to alleviate muscle spasms and discomfort. More invasive procedures or re-administration of anesthetics are not indicated for TNS.

Question 42

A 55-year-old male patient presents with urinary retention and perianal numbness several days following a spinal anesthetic for knee surgery. Upon examination, he is found to have decreased sensation in the saddle area and bilateral lower extremity weakness. What is the most urgent step in managing this patient?

A) Immediate referral to a neurologist
B) Administration of high-dose corticosteroids
C) MRI of the lumbar spine
D) Observation and reassessment in 24 hours

Answer 42

Correct Answer: C) MRI of the lumbar spine
Rationale: The presentation is suggestive of Cauda Equina Syndrome (CES), which is a surgical emergency. An MRI is the diagnostic modality of choice to confirm the diagnosis and determine the cause, such as a herniated disc or other mass effect causing nerve compression. Early diagnosis and treatment are critical to prevent permanent nerve damage and improve outcomes. While referral to a neurologist is important for long-term management, the immediate concern should be to confirm the diagnosis and proceed with surgical decompression if necessary.

Question 43

A 65-year-old patient with a history of severe hypotension during a recent vascular surgery develops sudden onset of flaccid paralysis of the lower extremities and loss of pain and temperature sensation below the level of the umbilicus, but retains proprioception and vibratory sense. Which of the following is the most likely diagnosis?

A) Cauda Equina Syndrome
B) Transient Neurologic Symptoms
C) Anterior Spinal Artery Syndrome
D) Spinal Epidural Abscess

Answer 43

Correct Answer: C) Anterior Spinal Artery Syndrome
Rationale: The patient’s clinical presentation of motor paralysis with a loss of pain and temperature sensation while preserving proprioception and vibration suggests a spinal cord infarction affecting the anterior two-thirds of the spinal cord, which is supplied by the anterior spinal artery. This pattern is consistent with Anterior Spinal Artery Syndrome (ASAS). The key to distinguishing ASAS from other spinal cord pathologies is the preservation of proprioception and vibration, which are mediated by the posterior columns of the spinal cord and are typically not affected in ASAS. Prompt imaging and neurosurgical evaluation for potential reversible causes such as a hematoma are crucial.

Question 44

Which clinical finding is most indicative of Anterior Spinal Artery Syndrome in a patient after a spinal procedure?
A) Hyperreflexia in the upper extremities
B) Loss of proprioception in the lower extremities
C) Lower extremity paresis with a variable sensory deficit
D) Intact pain and temperature sensations in the lower extremities

Answer 44

C) Lower extremity paresis with a variable sensory deficit

Question 45

A patient post-operatively presents with preserved dorsal column function but impaired pain and temperature sensation following aortic surgery. This clinical picture is suggestive of a hematoma compression on which artery?
A) Posterior Spinal Artery
B) Anterior Radicular Artery
C) Anterior Spinal Artery
D) Segmental Spinal Artery

Answer 45

Correct Answer: C) Anterior Spinal Artery
Rationale: The anterior spinal artery supplies the anterior two-thirds of the spinal cord, including areas responsible for pain and temperature sensation. The dorsal columns are supplied by the posterior spinal arteries and are not affected.

Question 46

In managing a suspected case of Anterior Spinal Artery Syndrome, what is the most immediate course of action?
A) Administer high-dose corticosteroids
B) Initiate hypothermic spinal cord protection
C) Conduct MRI imaging for confirmation
D) Start aggressive blood pressure management

Answer 46

Correct Answer: D) Start aggressive blood pressure management
Rationale: In Anterior Spinal Artery Syndrome, maintaining adequate perfusion pressure to the spinal cord is critical. Hypotension can exacerbate spinal cord ischemia, and aggressive blood pressure management is essential to support the potentially reversible spinal cord injury.

Question 47

Which of the following is a less common cause of Anterior Spinal Artery Syndrome but should be considered in at-risk patients -select all?
A) Spinal cord trauma
B) Prolonged hypotension
C) Infectious myelitis
D) PVD
E) Epidural Abscess

Answer 47

Answer: B) Prolonged hypotension, D) PVD, E) Epidural Abscess

The 2 main causes are thrombosis and artery spasm

Question 48

A patient presents with cyanosis and chocolate-colored blood after receiving a local anesthetic. Which of the following drugs is most likely to have caused these symptoms due to inducing methemoglobinemia?
A) Lidocaine
B) Prilocaine
C) Bupivacaine
D) Ropivacaine

Answer 48

Correct Answer: B) Prilocaine

Causes: Prilocaine, benzocaine > lidocaine, nitroglycerine, phenytoin, & sulfonamides

Rationale: Prilocaine is known to have a higher propensity to induce methemoglobinemia compared to other local anesthetics. Methemoglobinemia can result in cyanosis and chocolate-colored blood due to an increased level of methemoglobin, which poorly releases oxygen to tissues.

Question 49

Which treatment is indicated for a patient with a methemoglobin level of 20% without signs of hemodynamic instability?
A) Immediate blood transfusion
B) Methylene blue 1 mg/kg over 5 minutes
C) Methylene blue 20 mg/kg over 10 minutes
D) Supportive care with oxygen

Answer 49

Correct Answer: B) Methylene blue 1 mg/kg over 5 minutes
Rationale: Methylene blue is the treatment of choice for methemoglobinemia, as it helps to reduce methemoglobin back to hemoglobin. It is indicated for levels above 15% or in cases with symptomatic patients.

Question 50

A patient diagnosed with methemoglobinemia is about to be treated with methylene blue. What is the expected time frame for clinical improvement after initiating treatment?
A) Immediate reversal within 5 minutes
B) Reversal within 20 to 60 minutes
C) Gradual improvement over several hours
D) Full recovery expected in 1-2 days

Answer 50

Correct Answer: B) Reversal within 20 to 60 minutes
Rationale: The conversion of methemoglobin (Fe³⁺) back to hemoglobin (Fe²⁺) typically occurs within 20 to 60 minutes after administration of methylene blue, which is the standard of care for significant methemoglobinemia.

Question 51

Which patient population is most at risk for a decreased ventilatory response to hypoxia when given lidocaine?
A) Asthmatics
B) COPD patients
C) Patients with renal insufficiency
D) Young healthy adults

Answer 51

Correct Answer: B) COPD patients who are CO2 retainers
Rationale: Lidocaine can depress the ventilatory response to arterial hypoxemia, posing a particular risk to patients with conditions like COPD, where there is a pre-existing challenge in maintaining adequate gas exchange.

Question 52

What is the likely outcome when the infusion of a local anesthetic implicated in hepatotoxicity is stopped?
A) Worsening of liver function
B) No change in liver enzyme levels
C) Normalization of liver transaminase enzymes
D) Immediate resolution of neurological symptoms

Answer 52

Correct Answer: C) Normalization of liver transaminase enzymes
Rationale: Hepatotoxicity caused by local anesthetics like bupivacaine can be reversed upon discontinuation of the drug, leading to normalization of liver enzymes. This indicates recovery from the drug-induced liver injury.

Question 53

A patient receiving an epidural infusion of bupivacaine for postherpetic neuralgia develops elevated liver enzymes. What should be the first step in management?
A) Order a liver ultrasound
B) Increase the dosage of bupivacaine to overcome potential tolerance
C) Discontinue the bupivacaine infusion
D) Start antibiotic therapy for suspected hepatobiliary infection

Answer 53

Correct Answer: C) Discontinue the bupivacaine infusion
Rationale: If hepatotoxicity is suspected as a result of bupivacaine infusion, the first step is to stop the infusion to prevent further liver damage and assess if there is a subsequent normalization of liver enzymes.

Question 54

What is the primary mechanism of action for the systemic effects of cocaine?
A) It stimulates the parasympathetic nervous system.
B) It blocks the presynaptic uptake of norepinephrine and dopamine.
C) It provides direct stimulation to the myocardium.
D) It acts as a calcium channel blocker.

Answer 54

Correct Answer: B) It blocks the presynaptic uptake of norepinephrine and dopamine.
Rationale: Cocaine’s stimulatory effects on the sympathetic nervous system are primarily due to its blockade of the presynaptic reuptake of norepinephrine and dopamine, increasing their postsynaptic levels and activity.

Question 55

Which cardiovascular effect is not commonly associated with cocaine toxicity?
A) Hypertension (HTN)
B) Bradycardia
C) Tachycardia
D) Coronary vasospasm

Answer 55

Correct Answer: B) Bradycardia
Rationale: Cocaine typically causes sympathetic stimulation leading to increased heart rate (tachycardia), not decreased heart rate (bradycardia).

Question 56

In parturients, what adverse effect is of particular concern with cocaine toxicity?
A) Increased uterine blood flow (UBF)
B) Decreased uterine blood flow leading to fetal hypoxemia
C) Maternal hypoglycemia
D) Fetal bradycardia

Answer 56

Correct Answer: B) Decreased uterine blood flow leading to fetal hypoxemia
Rationale: Cocaine can cause vasoconstriction leading to decreased uterine blood flow, which may result in fetal hypoxemia.

Question 57

Cocaine toxicity can lead to hyperpyrexia, which in turn may cause:
A) Hypotension
B) Seizures
C) Hypoglycemia
D) Respiratory alkalosis

Answer 57

Correct Answer: B) Seizures
Rationale: Hyperpyrexia or an extremely high body temperature is a serious complication of cocaine toxicity that can lead to central nervous system manifestations such as seizures.

Question 58

Which medication is recommended for immediate management of cocaine-associated chest pain?
A) Acetaminophen
B) Aspirin (ASA)
C) Metoprolol
D) Amiodarone

Answer 58

Correct Answer: B) Aspirin (ASA)
Rationale: Aspirin is the standard of care for acute chest pain and is also recommended for cocaine-associated chest pain due to its antiplatelet effects.

Question 59

For patients with persistent hypertension after cocaine use, which treatment is preferred?
A) Beta-blockers
B) Calcium channel blockers
C) IV nitroglycerin (NTG) or nitroprusside
D) ACE inhibitors

Answer 59

Correct Answer: C) IV nitroglycerin (NTG) or nitroprusside
Rationale: IV NTG and nitroprusside are preferred treatments for persistent hypertension in the context of cocaine use because they do not have the adverse effects associated with beta-blockers in this scenario.

Question 60

What is the recommended course of action for a patient with a high risk of cocaine-associated STEMI?
A) Administration of clopidogrel and immediate discharge
B) Primary Percutaneous Coronary Intervention (PCI)
C) Observation in Chest Pain Unit (CPU)
D) Immediate administration of a beta-blocker

Answer 60

Correct Answer: B) Primary Percutaneous Coronary Intervention (PCI)
Rationale: For a high-risk patient with cocaine-associated STEMI, primary PCI is the recommended course of action to restore blood flow to the affected myocardium.

Question 61

In the context of cocaine-associated cardiovascular complications, why should beta-blockers be avoided acutely?
A) They increase the risk of seizures.
B) They can cause unopposed alpha-adrenergic effects.
C) They do not affect the heart rate.
D) They are not effective in reducing chest pain.

Answer 61

Correct Answer: B) They can cause unopposed alpha-adrenergic effects.
Rationale: Acute administration of beta-blockers in the context of cocaine use is avoided due to the potential for unopposed alpha-adrenergic effects, which can worsen hypertension and coronary vasoconstriction.

Question 62

Tiene preguntas?

Answer 62

NO, senor Castillo.. you have made me a master pharmacist.. I thought this fool was filipino ?