Regional and local anaesthesia Flashcards
A stellate ganglion block is NOT indicated in the management of:
a) AV block
b) Resistant ventricular arrhythmia
c) PTSD
d) Scleroderma
e) Hyperhidrosis
AV block
CI in
- cardiac conduction block
- Glaucoma
- Anticoagulation
Indications
Complex regional pain syndrome of the head and upper limbs
Peripheral vascular disease
Upper extremity embolism
Postherpetic neuralgia
Chronic post-surgical pain
Hyperhidrosis
Raynaud disease
Scleroderma
Orofacial pain
Phantom limb
Atypical chest pain
A cluster or a vascular headache
Post-traumatic stress disorder
Meniere syndrome
Intractable angina
Refractory cardiac arrhythmias
The local anaesthetic with the lowest CCCNS ratio (ratio of the drug dose required
to cause cardiac collapse to the drug dose required to cause seizure) is:
a) Levobupivacaine
b) Bupivacaine
c) Lignocaine
d) Ropivacaine
B) Bupivacaine
CC/CNS Ratio: the ratio of the dose required to cause CVS collapse and the dose required to cause CNS toxicity (indicates the CNS is more vulnerable than CVS)
Lignocaine: 7.1
Ropivacaine: 5.0
Bupivacaine: 3.7
Levobupivacaine: **not listed
Petkov
Ropivacaine and levobupivacaine, for example, have higher CC/CNS ratios than racemic bupivacaine; therefore, it seems logical to preferentially use these drugs when long-acting LAs are desired.
Pubmed
You are undertaking an ultrasound guided pericapsular nerve group (PENG) block
for hip surgery. In the accompanying image, the structure labelled with the arrow is
the:
a) Psoas Tendon (This)
b) Iliacus
c) Sartorius
Add picture of peng block (can’t from my account)
a) Psoas Tendon (This)
In this ultrasound image, the cricothyroid membrane is at the position marked
A
B
C
D
E
C
A superficial cervical plexus block will block all of the following nerves EXCEPT the:
a) Lesser occipital
b) Greater occipital
c) Greater auricular
d) Transverse cervical
e) Supraclavicular
Greater occipital
The accompanying image is obtained while doing an ultrasound guided erector spinae plane block at the level of the transverse process of the fourth thoracic vertebra. The muscle marked by the arrow is the:
a) Traps
b) Rhomboids
c) Erector spinae
d) Latissimus Dorsi
NAOMI
Steph Borders of the anterior triangle of the neck DO NOT include the:
a) Inferior angle of mandible
b) Middle third of clavicle
c) Sternocleidomastoid muscle
d) Midline neck
b) Middle third of clavicle
Anterior triangle contains IJ
Superiorly: inferior border of the mandible.
Laterally: anterior border of the sternocleidomastoid.
Medially: sagittal line down the midline of the neck.
Posterior triangle contains EJ
Anterior: posterior border SCM
Posterior: anterior border trapezius
Inferior: middle third clavicle
StatPearls
Anatomy, Head and Neck, Neck Triangle
Steph A local anaesthetic agent that is considered safe to use in a patient with glucose-6-phosphate dehydrogenase deficiency is:
a) Articaine
b) Bupivacaine
c) Lignocaine
d) Prilocaine
e) Benzocaine
Bupiv
Also avoid methylene blue (prev Q)
Could only find
- don’t give lignocaine
- can give bupivacaine
Also found don’t give articaine, prilocaine or benzocaine
https://cdho.org/factsheets/glucose-6-phosphate-dehydrogenase/#:~:text=Local%20anaesthetic%20agents%20(e.g.%2C%20prilocaine,9%20in%20G6PD%20deficient%20persons.
A 50-year-old has had a headache for the last month which is relieved by lying flat. They have had no medical procedure to their spine such as epidural, spinal or lumbar puncture. Their brain magnetic resonance (MR) imaging scan shows diffuse
meningeal enhancement and brain sagging. The neurologist suspects spontaneous intracranial hypotension and asks you to do an epidural blood patch. No spinal imaging has been performed to confirm a cerebrospinal fluid (CSF) leak. You should
A do LP to measure pressure if low do lumbar patch
B do blood patch at lumbar level with no further investigation
C do spine imaging if CSF leak present do blood patch at level
D do spine imaging if CSF leak present do lumbar blood patch
E refuse to do blood patch
REPEAT
B do blood patch at lumbar level with no further investigation
A 69-year-old patient is dyspnoeic and complains of right shoulder tip pain while in the post-anaesthesia care unit after a laparoscopic-assisted anterior resection. A focused thoracic ultrasound is performed and an image of the right lung is shown below. This represents:
a) Pneumothorax
b) Pulmonary Oedema
c) Normal Lung
d) Consolidated Lung
REPEAT
c) Normal Lung
Normal lung = A lines (pleura) + batwing appearance + sliding
Soon after a peribulbar block, the patient’s eye rapidly becomes proptosed and tense, and the visual acuity is markedly decreased. A lateral canthotomy is indicated to:
a) Allow globe to continue to swell
b) Drain blood from behind eyeball
c) Allow the eye to proptose
d) Reduce pressure on the optic nerve
REPEAT
c) Allow the eye to proptose
Orbital Compartment Syndrome
The orbital compartment is a fixed space with limited capacity for expansion. If something like blood fills part of that space the pressure increases and may result in ischaemia of the optic nerve or the retina. A lateral canthotomy is a way of releasing this pressure.
You have up to approximately 2 hours before irreversible visual loss occurs. It may occur in less than 2 hours however, so speed is of the essence.
use local anesthetic but warn the patient that they may feel pain
Perform the canthotomy:
place the scissors across the lateral canthus and incise the canthus full thickness
Perform cantholysis:
Grasp the lateral lower eyelid with toothed forcepsPull the lower eyelid anteriorlyPoint the scissors toward the patient’s nose, place the blades either side of the lateral canthal tendon, and cut.
By cutting the canthal tendon,the counter pressure of the eyelid on the is relieved and the eye is allowed to proptose and pressure is relieved.
LITFL Goal of procedure: to release pressure on the globe & to decrease intraocular pressure enough to reinstitute retinal artery blood flow.
The canthotomy allows trhe eye to move forward and open up the space, reducing pressure. The globe itself should not swell.
NP B lines (comet tails) in lung ultrasound are NOT observed in:
a) ARDS
b) Interstitial
c) Normal lung
d) Pneumothorax
D) pneumothorax
From BJA 2016 lung US article
The features of a pneumothorax are abolished sliding, absence of B lines, absence of the lung pulse, and presence of the lung point
A risk factor which increases the likelihood of developing local anaesthetic systemic toxicity is:
a) Hypoxia
b) Alkalaemia
c) High alpha1-acid glycoprotein
d) Hypocarbia
e) Increased carnitine levels
AT
REPEAT
b) Hypoxia
Hypoxia
Local anaesthetics are bases with pKa above physiological pH. The more alkalaemic the environment the more unionionised (B) form there is – which will speed diffusion across plasma membrane = can exert Na+ channel blockade.
https://www.bjanaesthesia.org/article/S0007-0912(17)38238-7/pdf
https://academic.oup.com/bjaed/article/15/3/136/279390
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6087022/
Hypoxia – metabolic acidosis = ion trapping = increased toxicity
Alkalaemia = prevents ion trapping in tissues (intralipid can work) = reduced toxicity
High a1GP = reduced free fraction (a1gp high affinity, low capacity) = reduced toxicity
Low CO2 = alkalosis = prevents ion trapping in tissues (intralipid can work) = reduced toxicity
Carnitine deficiency = increased toxicity, therefore increased carnitine will reduce toxicity https://pubmed.ncbi.nlm.nih.gov/19849674/
a. Hypoxia - Yes
b. Alkalemia - No - acidosis causes increased ionised fraction due to its weak base properties
c. High α1-acid glycoprotein - No, normally bound to alpha-1 acid glycoprotein
d. Hypocarbia < (decreased seizure threshold) - No - hypercarbia increases CNS blood flow and increases risk of seizures due to more LA delivered to CNS
e. Increased carnitine levels -s - Never heard of it
Local anaesthetic-induced myotoxicity is most likely to be associated with:
A. Biers
B. Interscalene
C. Sciatic
D. Adductor Canal
REPEAT
D. Adductor Canal
unclear phenomonenon
prolonged exposure and high concentrations of local anaesthetic
When inadvertent total spinal anaesthesia occurs in an awake neonate, the first sign is most likely to be
MAYANK
? Options
Bronchospasm
Desaturation
Hypotension
Apnea
Bradycardia
Loss of consciousness
Kate
A 54-year-old has a laryngeal mask airway inserted for a surgical procedure. The
following day it is noted that the tongue is deviated to the right. The most likely site
of nerve injury is the right:
a) Hypoglossal
REPEAT
Hypoglossal (deviates to the affected side)
Nerve injuries : (pressure neuropraxia)
Lingual nerve injury (most common)
RLN (most serious)
Hypoglossal
Glossopharyngeal
Inferior alveolar
Infra orbital
Usually self resolve except for RLN
Kate The nerve marked by the arrow is the:
REPEAT
Axillary Nerve
22.2 The nerve labelled by the arrow marked P in the diagram is the
- Ulnar Nerve
- Axillary Nerve
- Median Nerve
- Medial Cutaneous nerve of the forearm
- Long Thoracic Nerve
- Dorsal Scapular Nerve
- Radial Nerve
- Suprascapular nerve
- Musculocutaneous Nerve
- Long Thoracic Nerve
21.1 The lung ultrasound finding most consistent with atelectasis is three or more
A. B lines
B. A lines
C. Comet tails
D. Z lines
E. Lung Pulse
comet tails or B-lines
useful resource: https://academic.oup.com/bjaed/article/16/2/39/2897763
Comet Tail artefact:
- a short path reverberation artefact that weakens with each reverberation, resulting in a vertical echogenic artefact that rapidly fades as it continues in to the ultrasound image.
https://litfl.com/comet-tail-artefact/
Short path reverberation artefact
- The ultrasound appearance of this artefact is a thin vertical bright or echogenic line that passes from the point of origin, to the deepest part of the ultrasound image.
- When appearing deep to the pleural line these are known as B-lines.
- Elsewhere in the body the identical artefact is known as ring down artefact.
- Where these artefacts fade quickly they are called comet tail artefacts
https://litfl.com/short-path-reverberation-artefact/
Radiopedia “B-line distribution corresponds with sub-pleural thickened interlobular septa” - more consistent with homogenous atelectasis
Following a severe spinal cord injury, return of reflexes is usually seen after
a. <1 day
b. 1-3 days
c. 7 days
d. 1-4 weeks
e. >1 month
Answer: b, 1-3 days
BJA 2013 Initial Management of Acute Spinal Cord Injury
Spinal shock is the loss of reflexes below the level of SCI resulting in the clinical signs of flaccid areflexia and is usually combined with hypotension of neurogenic shock.
There is a gradual return of reflex activity when the reflex arcs below redevelop, often resulting in spasticity, and autonomic hyperreflexia.
This is a complex process and a recent four-phase classification to spinal shock has been postulated:
areflexia (Days 0 – 1),
initial reflex return (Days 1 – 3),
early hyperreflexia (Days 4 – 28), and
late hyperreflexia (1 – 12 months)
21.1 The most common cause of postoperative visual loss after spinal surgery is
a. Central retinal artery occlusion
b. Central retinal vein occlusion
c. Ischemic optic neuropathy
d. Haemorrhage
e. corneal abrasion
c. Ischemic optic neuropathy
Cardiac: Anterior
Spinal: Posterior
ION
21.2 You have been asked to provide general anaesthesia for a complex thoracic endovascular aortic aneurysm repair. After the placement of a lumbar drain the recommended safe time before the administration of intravenous heparin is
a) 1 hour
b) 4 hours
c) 6 hours
d) 12 hours
1 hour
ASRA: 1 hour
Although the occurrence of a bloody or difficult neuraxial needle placement may increase risk, there are no data to support mandatory cancellation of a case. Direct communication with the surgeon and a specific risk-benefit decision about proceeding in each case are warranted.
Currently, insufficient data and experience are available to determine if the risk of neuraxial haematoma is increased when combining neuraxial techniques with the full anticoagulation of cardiac surgery. We suggest postoperative monitoring of neurologic function and selection of neuraxial solutions that minimise sensory and motor block to facilitate detection of new/progressive neurodeficits.
NYSORA:
Administration of intravenous heparin intraoperatively should be delayed for at least 1 hour after epidural placement; a delay before administration of subcutaneous heparin is not required. In cases of full heparinization for CPB, additional precautions include delaying surgery for 24 hours in the event of a traumatic tap, tightly controlling the heparin effect and reversal, and removing catheters when normal coagulation is restored.
19.1, 20.1 Soon after a peribulbar block, the patient’s eye rapidly becomes proptosed and tense, and the visual acuity is markedly decreased. A lateral canthotomy is indicated to:
a) Allow globe to continue to swell
b) Drain blood from behind eyeball
c) Allow the eye to proptose
d) Reduce pressure on the optic nerve
c) Allow the eye to proptose
Orbital Compartment Syndrome
The orbital compartment is a fixed space with limited capacity for expansion. If something like blood fills part of that space the pressure increases and may result in ischaemia of the optic nerve or the retina. A lateral canthotomy is a way of releasing this pressure.
You have up to approximately 2 hours before irreversible visual loss occurs. It may occur in less than 2 hours however, so speed is of the essence.
use local anesthetic but warn the patient that they may feel pain
Perform the canthotomy:
place the scissors across the lateral canthus and incise the canthus full thickness
Perform cantholysis:
Grasp the lateral lower eyelid with toothed forcepsPull the lower eyelid anteriorlyPoint the scissors toward the patient’s nose, place the blades either side of the lateral canthal tendon, and cut.
By cutting the canthal tendon,the counter pressure of the eyelid on the is relieved and the eye is allowed to proptose and pressure is relieved.
A 50-year-old woman has had a headache for the last month which is relieved by lying flat. She has had no medical procedure to her spine such as epidural, spinal or lumbar puncture. Her brain magnetic resonance imaging (MRI) scan shows diffuse meningeal enhancement and brain sagging. Her neurologist suspects spontaneous intracranial hypotension and asks you to do an epidural blood patch. No spinal imaging has been performed to confirm a cerebrospinal fluid (CSF) leak. You should
A do LP to measure pressure if low do lumbar patch
B do blood patch at lumbar level with no further investigation
C do spine imaging if CSF leak present do blood patch at level
D do spine imaging if CSF leak present do lumbar blood patch
E refuse to do blood patch
B do blood patch at lumbar level with no further investigation
22.2 Despite an interscalene block being performed preoperatively for arthroscopic rotator cuff repair, a patient wakes up with posterior shoulder pain. The most appropriate procedure to consider would be a nerve block of the
a. Supraclavicular nerve
b. Suprascapular nerve
c. Medial pectoral
d. Vagus nerve
b. Suprascapular nerve
Suprascapula nerve (C5,6)
- innervates supra and infraspinatus
- comes off superior trunk of the brachial plexus, and is usually anaesthetised by an interscalene block
- sensory innervation to 70% posterior-superior shoulders and portion of the anterior axilla and the ACJ
Supraclavicular nerve (C3,4)
- provides sensory to the ‘cape’ of the shoulder
- component of the cervical plexus block
- lies outside the brachial plexus
- commonly missed during supraclavicular brachial plexus blocks
Subscapular nerve:
- subscapularis
- medial rotation shoulder
Dorsal scapular nerve:
- branch of the brachial plexus
- supplies rhomboid major muscle, rhomboid minor muscle, and levator scapulae muscle
- causes the scapula to be moved medially towards the vertebral column
- Dorsal scapular nerve syndrome can cause a winged scapula, with pain and limited motion
Thoracodorsal nerve:
- thoracodorsal nerve also branches from the posterior division of the brachial plexus
- this nerve innervates the latissimus dorsi muscle.
https://resources.wfsahq.org/atotw/the-shoulder-block/
21.2 The main advantage of using noradrenaline (norepinephrine) over phenylephrine for the prevention of hypotension as a result of spinal anaesthesia for elective caesarean section is
a) Better APGAR
b) Better foetal acid-base balance
c) Less nausea & vomiting
d) Less maternal bradycardia
less bradycardia
21.2 Stellate ganglion block is NOT contraindicated in patients with
a) Contralateral phrenic nerve palsy
b) Glaucoma
c) Recent MI
d) Arrhythmia
d) Arrhythmia
- caution if conduction disease however
Contraindications are current coagulopathy (or anticoagulated), recent myocardial infarction, pathologic bradycardia, and glaucoma.
Source Radiopaedia
Contralateral stellate ganglion/phrenic nerve block/neuropathy
20.1 You want to position a internal jugular CVL with a CXR at the caval-atrial junction. Where is this?
a) 2 vertebral bodies superior to carina
b) 1 vertebral body superior to carina
c) At the carina
d) 1 vertebral body inferior to carina
e) 2 vertebral bodies inferior to carina
e) 2 vertebral bodies inferior to carina
21.2 A patient has numbness and weakness in her hand postoperatively. You are trying to distinguish between an ulnar nerve lesion and a C8-T1 radiculopathy. You can diagnose a C8-T1 radiculopathy if she has weakness
A. Parasthesia in little finger
B. Parasthesia in the distribution of the interscalene nerve
C. Weakness in adductor digiti minimi
D. Weakness in abductor pollicis brevis
E. Weakness in lateral interosseus
Muscles weak in C8-T1 radiculopathy but intact in ulnar neuropathy
- flexor pollicis brevis
- abductor pollicis brevis
- opponens pollicis
- lateral lumbricals
AbOF the Law may be useful—the abductor (Ab) and flexor (F) pollicis brevis, opponens pollicis (O), and lateral lumbricals (Law) are “above the law” that intrinsic hand muscles are ulnar-innervated
20.1 What is the arrow pointing to?
a. Ilioinguinal
b. Psoas
c. Iliacus
d. Lateral cutaneous nerve of thigh
e. Obturator
b. Psoas
21.1 A woman is having a potentially curative primary breast cancer resection. Compared with a sevoflurane and opioid technique, using a regional anaesthesia-analgesia technique with paravertebral block and a propofol infusion will result in
a. Decreased cancer recurrence
b. Decreased chronic pain and recurrence
c. Decreased incision pain at 6 months
d. Decreased CPSP pain at 6 months
e. Decreased CPSP pain at 12 months
Fuck this question
e. Decreased CPSP pain at 12 months
or it could be updated with an option that says makes no difference
most likely they will just remove the question and this is a big waste of time
https://pubs.asahq.org/anesthesiology/article/135/6/1091/117748/Preoperative-Paravertebral-Block-and-Chronic-Pain
—>This says it makes no difference in 2021
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007105.pub4/full
—-> this says weak evidence but it helps prevent persistent post surgical pain at 3-12months in 2018
—-> ANZCA pain book references this article
ANZCA pain book
https://www.bjaed.org/article/S2058-5349(18)30101-X/fulltext
A recent review showed that, whilst there was little effect on intra- and postoperative opioid consumption and PONV, patients receiving either both single-shot injections or placement of paravertebral catheters had less acute pain in the first 72 h after surgery.
There is also a suggestion that the use of TPVB for acute postsurgical pain may protect against the development of chronic postsurgical pain after breast surgery at 6 months.
For breast cancer surgery any form of regional anaesthesia (18 RCTs, n=1,297) reduces CPSP 3 to 12 months after surgery compared with systemic analgesia (OR 0.43; 95%CI 0.28 to 0.68) (NNT 7); specifically paravertebral block (PVB) (6 RCTs, n=419) is effective (OR 0.61; 95%CI 0.39 to 0.97) (NNT 11).
In our study population, regional anaesthesia-analgesia (paravertebral block and propofol) did not reduce breast cancer recurrence after potentially curative surgery compared with volatile anaesthesia (sevoflurane) and opioids. The frequency and severity of persistent incisional breast pain was unaffected by anaesthetic technique. Clinicians can use regional or general anaesthesia with respect to breast cancer recurrence and persistent incisional pain.
https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(19)32313-X.
20.1, 22.2 Your patient underwent a stellate ganglion block 2 hours ago. Prior to discharge you are asked to review the patient in recovery because of a droopy upper eyelid. The patient would also be expected to have ipsilateral
a) Pupillary constriction and reaction to light
b) Pupillary constriction and no response to light
c) Pupillary dilation and response to light
d) Pupillary dilation and no response to light
a) Pupillary constriction and reaction to light
Stellate ganglion block causes ipsilateral Horner’s Syndrome:
Ptosis (eyelid droop)
Miosis (constricted pupils)
Anhydrosis (loss of sweating)
Enophthalmos (sinking of eyeball into the bony cavity that protects the eye)
*Pupillary constriction in response to light is controlled by the Edinger-Westphal nucleus of CN3, which will remain intact.
21.1 A patient has numbness and weakness in her hand postoperatively. You are trying to distinguish between an ulnar nerve lesion and a C8-T1 radiculopathy.
You can diagnose a C8-T1 radiculopathy if she has weakness
a) Thumb adduction
b) Thumb abduction
c) Fingers adduction
d) Fingers Abduction
e) Little finger flexion
b) Thumb abduction
(flexor pollicis brevis)
D. Paraesthesia/sensory loss over medial forearm
(medial antebrachial cutaneous)
Severing Ulnar nerve alone results in numbness of the 4th (ring) and 5th (little) fingers alone
C8 and T1 supply the medial antebrachial cutaneous nerve
Muscles weak in C8-T1 radiculopathy but intact in ulnar neuropathy
- flexor pollicis brevis
- abductor pollicis brevis
- opponens pollicis
- lateral lumbricals
AbOF the Law may be useful—the abductor (Ab) and flexor (F) pollicis brevis, opponens pollicis (O), and lateral lumbricals (Law) are “AbOF the Law” that intrinsic hand muscles are ulnar-innervated
22.2 The nerve labelled by the arrow marked H in the diagram is the
- Ulnar Nerve
- Axillary Nerve
- Median Nerve
- Medial Cutaneous nerve of the forearm
- Long Thoracic Nerve
- Dorsal Scapular Nerve
- Radial Nerve
- Suprascapular nerve
- Musculocutaneous Nerve
- Median Nerve
21.1 A patient has numbness and weakness in her hand postoperatively. You are trying to distinguish between an ulnar nerve lesion and a C8-T1 radiculopathy.
You can diagnose a C8-T1 radiculopathy if she has
A. Paraethesia of the 5th digit
B. Paraesthesia over index finger
C. Flexor carpi ulnaris function
D. Paraesthesia/sensory loss over medial forearm
E. Adductor pollicis function
Remembered answers don’t help differentiate.
[A. Paraethesia of the 5th digit - can be ulnar only
B. Paraesthesia over index finger - will be median only
C. Flexor carpi ulnaris function - can be ulnar only
D. Paraesthesia/sensory loss over medial forearm - can be ulnar only
E. Adductor pollicis function - can be ulnar only
C8-T1 radiculopathy
Will cause:
Loss of Thumb and finger abduction
(flexor pollicis brevis - suppled by both ulnar deep branch (C8-T1) and median nerve lateral terminal branch C6-T1)
Severing Ulnar nerve alone results in numbness of the 4th (ring) and 5th (little) fingers alone, and potentially medial forearm sensation (C8 and T1 supply the medial antebrachial cutaneous nerve), although loss of forearm sensation is more common in C6 radiculopathies.
All intrinsic muscles of the hand are innervated by the ulnar nerve, except for 4 muscles supplied by the median nerve. These muscles may be weak in C8-T1 radiculopathy but intact in ulnar neuropathy.
- flexor pollicis brevis
- abductor pollicis brevis, in part.
- opponens pollicis
- lateral lumbricals
AbOF the Law
may be useful—the abductor (Ab) and flexor (F) pollicis brevis, opponens pollicis (O), and lateral lumbricals (Law) are “above the law”
Or
LOAF
21.1 You are performing a regional block for analgesia following knee surgery. You have an ultrasound probe scanning the anterior mid-thigh. The muscle indicated by the arrow in the ultrasound image below is the
A: Sartorius
B: Vastus Medialis
C: Adductor Longus
D: Gracilis
E: Rectus femoris
A: Sartorius
20.2 You are performing a regional block for analgesia following knee surgery. You have an ultrasound probe scanning the anterior mid-thigh. The muscle indicated by the arrow in the ultrasound image below is the
A. biceps femoris
B. Sartorius
C. Gracillis
D. Adductor longus
E. Adductor magnus
Sartorius
repeat
22.1 The abnormality shown in this image (image of shoulder shown) is LEAST likely to be caused by
an injury to the
a. Accessory nerve N
b. Long thoracic N
c. Dorsal scapular N
d. Suprascapular N
Picture in Q shows medial winging of right shoulder
Answer = b
Can be caused by injury to long thoracic nerve (serratus ant’) or serratus itself
a. Accessory nerve (Trapezius paralysis, causing lateral winging)
b. Long thoracic N- (Serratus anterior paralysis, causing medial winging)
c. Dorsal scapular N (Rhomboids paralysis, causing lateral winging)
d. Suprascapular nerve (Infra and supraspinatus – doesn’t affect scapula)
In addition, here is an example of lateral winging
22.2 The nerve labelled by the arrow marked B in the diagram is the
- Ulnar Nerve
- Axillary Nerve
- Median Nerve
- Medial Cutaneous nerve of the forearm
- Long Thoracic Nerve
- Dorsal Scapular Nerve
- Radial Nerve
- Suprascapular nerve
- Musculocutaneous Nerve
- Suprascapular nerve
21.1 Sensory innervation of the cornea is by the
A. Ophthalmic division of the Trigeminal nerve
B. Nasocilliary Nerve
C. Frontal Nerve
D. Oculomotor
B. Nasocilliary Nerve
a branch of Ophthalmic division of trigeminal
20.1 You are planning to perform an adductor canal block for a patient prior to a total knee arthroplasty. The principal advantage of this approach compared to a conventional femoral nerve block below the inguinal ligament is :
a) better block of infrapatellar nerve
b) better analgesia
c) lower dose of LA needed for same analgesia
d) less motor block to quads
d) less motor block to quads
APMSE 5th edition:
Other regional and local analgesic techniques
“Adductor canal block results in similar postoperative pain outcomes following total knee arthroplasty versus femoral nerve block with less quadriceps weakness, earlier mobilisation and better functional recovery
23.1 In subarachnoid block for caesarean section, hyperbaric local anaesthetic compared to regular local anaesthetic has been shown to reduce the
a. Risk of total spinal
b. Analgesic properties
c. Onset of anaesthetic
d. Offset of anaesthetic
e. Chance of inadequate anaesthetic
reduce onset time
c) faster onset of anaesthetic
https://pubmed.ncbi.nlm.nih.gov/28708665/ agrees with faster onset but for non obstetric surgery
UTD
hyperbaric bupivacaine because of its rapid onset and the option to modify the spinal level by changing the position of the operating table. Plain bupivacaine (ie, slightly hypobaric, prepared in saline) may also be used for spinal anesthesia for CD. The literature comparing safety and efficacy of hyperbaric with isobaric bupivacaine for CD is inconclusive
20.1 What is the arrow pointing to?
a. Ilioinguinal
b. Iliohypogastric
c. Genitofemoral
d. Accessory Obturator
e. Obturator
e. Obturator
21.1 A 25-year-old ASA I patient develops ongoing seizures five minutes after receiving a brachial plexus block with ropivacaine. Of the following, the most suitable initial intravenous treatment is
a) Midazolam
b) Intralipid
c) Propofol
d) Levetiracetam
e) Phenytoin
Control seizures first
a) Midazolam if an option
or
c) propofol
or
treat seizures 1st followedLAST
- ABCD
- Intralipid 1.5mL/kg
22.2 When used for prolonged analgesia in a healthy adult, the recommended maximum dose of ropivacaine via continuous infusion or bolus dosing in a 24-hour period is
a) 450mg
b) 600mg
c) 770mg
d) 1200mg
c) 770mg
Product info: Fresenius-Kabi
When prolonged epidural blocks are used, either by continuous infusion or repeated bolus administration, the risks of reaching a toxic plasma concentration or inducing local neural injury must be considered. Cumulative doses of up to 800 mg ropivacaine for surgery and postoperative analgesiaadministered over 24 hours were well tolerated in adults, as were postoperative continuous epidural infusions at rates up to 28 mg/hour for 72 hours.
product info: pfizer
When prolonged blocks are used, either through continuous infusion or through repeated bolus administration, the risks of reaching a toxic plasma concentration or inducing local neural injury must be considered. Experience to date indicates that a cumulative dose of up to 770 mg ropivacaine hydrochloride administered over 24 hours is well tolerated in adults when used for postoperative pain management: i.e., 2016 mg. Caution should be exercised when administering ropivacaine for prolonged periods of time, e.g., > 70 hours in debilitated patients
20.2 You are called to assist in the resuscitation of a 75-year-old female patient in the emergency department who is hypotensive and hypoxaemic in extremis. The image shown is of a focused transthoracic echocardiogram, parasternal short axis view. The most likely diagnosis is
a) Pulmonary embolism
b) Anterior MI
c) Cardiac tamponade
d) Pneumothorax
a) Pulmonary embolism
A bit about the RV in PE:
The right ventricle drapes around the LV. In response to an acute Pulmonary Embolus (PE) it first dilates. The RV can’t generate much force without training, sowhen the Pulmonary Vascular Resistance (PVR) first rises with a PE, thepulmonary arterypressures don’t actually rise substantially because the RV can’t generate largepressures.
Looking at the ventricle in short axis, the septum maybow towardstheLV which will form aD shape indiastole,producing a“volumeoverloaded right ventricle” appearance.
Only later whenthe RV has beentrainedwill it be able togenerate higher pressures. If the LV is D shaped insystole, this is a “pressureoverloaded right ventricle”.
Acute cor pulmonale with bothpressureANDvolumeoverload (D shape insystoleANDdiastole)is often absent.
22.2 The nerve labelled by the arrow marked A in the diagram is the
- Ulnar Nerve
- Axillary Nerve
- Median Nerve
- Medial Cutaneous nerve of the forearm
- Long Thoracic Nerve
- Dorsal Scapular Nerve
- Radial Nerve
- Suprascapular nerve
- Musculocutaneous Nerve
- Dorsal Scapular Nerve
20.1 Best resolution US probe for median nerve visualisation:
d) 5-10mHz
e) 6-13mHz
High frequency probe at 90 degrees to the skin
- to best visualise superficial structures have the probe at 90 degrees to the skin with a high frequency transducer
it is best to use high-frequency transducers (up to 10–15 MHz range) to image superficial structures (such as for stellate ganglion blocks) and low-frequency transducers (typically 2–5 MHz) for imaging the lumbar neuraxial structures that are deep in most adults.
23.1 The nerve labelled with the arrow in the diagram is the (diagram of the brachial
plexus shown)
a. Musculocutaneous
b. Median
c. Radial
d. Ulnar
e. Axillary
a) muscolocutaneous
21.1 The main advantage of using norepinephrine (noradrenaline) over phenylephrine for the prevention of
hypotension as a result of spinal anaesthesia for elective caesarean section is
A. Better APGAR
B. Better foetal acid/base
C. Less nausea/vomiting
D. Less maternal bradycardia
less maternal bradycardia
21.1 The muscle or muscle group with the greatest sensitivity to the action of non-depolarising neuromuscular blocking agents is/are the
a. Abdominal muscles
b. Adductor pollicis
c. Pharyngeal muscles
d. Diaphragm
c. Pharyngeal muscles
Millers Anaesthesia:
Reference artyicle from Millers: https://pubs.asahq.org/anesthesiology/article/92/4/977/710/The-Incidence-and-Mechanisms-of-Pharyngeal-and
An adductor pollicis TOF ratio of 0.90 or less was associated with impaired pharyngeal function and airway protection, resulting in a four- to fivefold increase in the incidence of pharyngeal dysfunction causing misdirected swallowing. Moreover, pharyngeal function and airway protection may be impaired, even if the adductor pollicis muscle has recovered to a TOF ratio of more than 0.90.
21.2 The nerve labelled by the arrow in the diagram below is the
a) Obturator
b) Accessory obturator
c) Genitofemoral
d) Ilioinguinal
e) Iliohypogastric
c) Genitofemoral
20.1 What is the arrow pointing to?
a. Psoas
b. Femoral
c. Genitofemoral
d. Lumbosacral trunk
e. Obturator
d. Lumbosacral trunk
21.1 Considering emergency front-of-neck airway access, the major blood vessel that is most likely to lie anterior to the trachea above the sternal notch is the
a) Brachiocephalic artery
b) Brachiocephalic Vein
c) Superior thyroid artery
d) Inferior thyroid artery
e) Carotid artery
a) Brachiocephalic artery
Major vessels, most commonly the brachiocephalic artery, traverse the anterior tracheal wall in up to 53% patients at the suprasternal notch
22.1 The sensory innervation to the larynx above the vocal cords is provided by the
a) External SLN
b) Internal SLN
c) RLN
b) Internal SLN
22.2 The nerve labelled by the arrow marked F in the diagram is the
- Ulnar Nerve
- Axillary Nerve
- Median Nerve
- Medial Cutaneous nerve of the forearm
- Long Thoracic Nerve
- Dorsal Scapular Nerve
- Radial Nerve
- Suprascapular nerve
- Musculocutaneous Nerve
- Axillary Nerve
22.2 The nerve labelled by the arrow marked E in the diagram is the
- Ulnar Nerve
- Axillary Nerve
- Median Nerve
- Medial Cutaneous nerve of the forearm
- Long Thoracic Nerve
- Dorsal Scapular Nerve
- Radial Nerve
- Suprascapular nerve
- Musculocutaneous Nerve
- Musculocutaneous Nerve
21.1 21.2 The breast does NOT receive sensory innervation from the
a. Long thoracic
b. Thoracodorsal
c. Anterior intercostals
d. Posterior intercostals
e. Supraclavicular
b. Thoracodorsal
Thoracodorsal nerve (C6-C8) is a branch of the posterior cord of the brachial plexus. Its primary function is motor innervation of the latissimus dorsi muscle. Its blockade is relevant in more extensive breast reconstruction procedures.
The Pecs I, Pecs II and Serratus Plane blocks are superficial thoracic wall blocks which through blockade of the
1. Pectoral N.
2. Intercostal N.
3. Thoracodorsal N.
3. Long thoracic N.
It can be used to provide analgesia for breast surgery and other procedures/surgery involving the anterior chest wall.
21.2 The number of segments in the lower lobe of the left lung is
a) 3
b) 4
c) 5
d) 10
e) 12
b) 4
Right lung:
RUL: APA
RML: LM
RLL: SMALP
Left lung:
LUL: ASIA (S&I form the lingular lobe)
LLL: ALPS
Subsegments (total of 42)
Left: 10 + 10
Right: 6 + 4 + 12
22.2 Blockade of the superficial cervical plexus includes the
a. C1 dermatome
b. C5
c. phrenic nerve
d. transverse cervical
e. greater occipital
d. transverse cervical
Supraclavicular nerve block. An initial injection of 3 mL local anesthetic is deposited at the midpoint of the sternocleidomastoid muscle, followed by 7 mL injected subcutaneously in a caudad and cephalad direction along the posterior border of the muscle.
complications:
1.Infection
2.Hematoma
3.Phrenic nerve block
4.Local anesthetic toxicity
5.Nerve injury
https://www.nysora.com/techniques/head-and-neck-blocks/cervical/cervical-plexus-block/
21.1 Local anaesthetic-induced myotoxicity is most likely to be associated with
A. Biers
B. Interscalene
C. Sciatic
D. Adductor Canal
D. Adductor Canal
unclear phenomonenon
prolonged exposure and high concentrations of local anaesthetic
22.2 A thoracic regional technique that will NOT provide analgesia for sternal fractures is a
a. PECS I
b. PECS II
c. Parasternal intercostal nerve block?
d. Transfascial muscle block (can’t remember wording)
e. transverse thoracic plane block
b. PECS I
(PECS II Covers SA and will extend to the sternum)
20.2 When performing an infraclavicular block of the brachial plexus under ultrasound guidance, the structure indicated by the arrow is the (ultrasound image shown
a) Musculocutaneous nerve
b) Lateral cord
c) Medial cord
d) Superior trunk
e) Inferior trunk
c) Medial cord
21.1 Local anaesthetic systemic toxicity does NOT manifest as
a) hypoxaemia
b) severe agitation
c) sinus bradycardia
d) VF
e) seizures
a) hypoxaemia
After LA administration, any abnormal cardiovascular or neurological symptoms and signs, including isolated cardiac arrest, should raise suspicion of LAST
Presenting features of LAST vary widely. Cardiovascular collapse may occur without preceding neurological changes.
Clinical features of LAST:
CNS
- 2 stage process of excitatory phase followed by a depressive phase
- early signs:
1. perioral tingling
2. tinnitus
3. slurred speech
4. lightheadedness
5. tremor
6. change in mental state: confusion and agitation
- excitatory phase culminates in generalised convulsions
-Depressive phase:
1. Coma
2. Respiratory depression
CVS
- 3 phases:
- initial phase:
Htn and tachycardia
- intermediate phase:
myocardial depression and hypotension - terminal phase:
peripheral vasodialtion
severe hypotension
arrhythmias:
1. sinus bradycardia
2. conduction blocks
3. VT
4. Asystole
22.2 The nerve labelled by the arrow marked G in the diagram is the
- Ulnar Nerve
- Axillary Nerve
- Median Nerve
- Medial Cutaneous nerve of the forearm
- Long Thoracic Nerve
- Dorsal Scapular Nerve
- Radial Nerve
- Suprascapular nerve
- Musculocutaneous Nerve
- Radial Nerve
(
21.1 A 10-year-old boy (weight 30 kg) has a displaced distal forearm fracture that requires manipulation and application of plaster. The volume of 0.5% lidocaine (lignocaine) that should be used for intravenous regional anaesthesia (Bier block) is
a. 12 ml
b. 18ml
c. 30 ml
d. 42 ml
b. 18ml
3mg/kg max dose as per RCH guidelines
3mg x 30kg = 90mg
90mg/5mg/ml = 18ml
or
0.6ml/kg of 0.5% Lignocaine
0.6ml x 30kg = 18ml
https://www.rch.org.au/clinicalguide/guideline_index/Bier_block/
21.1 You are performing a regional block for analgesia following knee surgery. You have an ultrasound probe scanning the anterior mid-thigh. The muscle indicated by the arrow in the ultrasound image below is the
A: Sartorius
B: Vastus Medialis
C: Adductor Longus
D: Gracilis
E: Rectus femoris
B: Vastus Medialis
22.1 You are planning to perform a peribulbar block and wish to check the axial length of the eye prior to proceeding. The average axial length of the globe in adults as measured by ultrasound is
a. 20mm
b. 23mm
c. 26mm
d. 29mm
e. 32mm
B 23mm
20.2 The structure labelled A shows (gastric ultrasound image shown)
a. Empty stomach
b. Full stomach with Solids
c. Full stomach with liquids and Air
d. Gall Bladder
e. Abdominal Aorta
c. Full stomach with liquids and Air
22.2 The nerve labelled by the arrow marked J in the diagram is the
- Ulnar Nerve
- Axillary Nerve
- Median Nerve
- Medial Cutaneous nerve of the forearm
- Long Thoracic Nerve
- Dorsal Scapular Nerve
- Radial Nerve
- Suprascapular nerve
- Musculocutaneous Nerve
- Medial Cutaneous nerve of the forearm
23.1 Following the insertion of a peripherally inserted central catheter (PICC) into the cephalic vein in the upper arm, the patient complains of numbness in their forearm. It is likely that during insertion the operator has injured the
A. Median cutaneous antebrachial
B. Median antebrachial
C. Lateral antebrachial
D. Posterior brachial
E. Posterior cutaneous nerve (of the forearm)
c) lateral antebrachial
https://anatomytool.org/content/radiopaedia-drawing-contents-superficial-cubital-fossa-english-labels
double check - no reference
21.2 A 65 year old woman is dyspnoeic after a total hip replacement. A lung ultrasound is performed in the post-anaesthesia care unit, with a still image shown below. The likely cause of the dyspnoea is
a) Effusion
b) PE
c) Pneumothorax
d) Pneumonia
PTx
Commented from example image:
The stratosphere sign. Absent lung sliding on M-mode in a patient with a pneumothorax. Notice the absence of T lines (the lung pulse)
LITFL
The ultrasound appearance of pneumothorax
1. Loss of lung sliding and the movement artefact deep to the pleural line
- A pneumothorax lies deep to the smooth parietal pleural surface.
- The gas interface creates a highly reflective surface reflecting all ultrasound energy.
- This prevents imaging of structures lying below the pneumothorax. The movement of the lung, deep to the pneumothorax is completely hidden – lung sliding is lost.
- Loss of characteristic B-lines
- B-lines (vertical short path reverberation artefacts) are created by alveolar and interstitial fluid or fibrosis at the lung surface.
- In the same way that pneumothorax hides lung sliding it also hides any B-lines lying below. - Increased clarity of A-lines
- A-lines (horizontal long path reverberation artefacts) are echogenic horizontal artifactual lines deep to the pleural surface that are characteristic of pneumothorax.
- The mirror like, flat parietal pleura overlying the pneumothorax reflects the ultrasound which often then reverberates between the pleural surface and other horizontal reflecting surfaces above. These include fascial planes and the transducer surface itself.
- Multiple reflections cause horizontal linear artefacts mirroring the flat surfaces above the pleural surface, deep to the pleural surface. - Lung Point
- Pneumothorax separates the visceral and parietal pleural surfaces.
- The point at which these surfaces meet is known as the lung point
23.1 A nerve that does NOT provide sensory innervation to the shoulder joint is the
A. Axillary
B. Lateral pectoral
C. Subscapular
D. Supraclavicular
E. Suprascapular
d) Supraclavicular
Axillary nerve innervates skin to inferior deltoid (regimental badge)+ motor to terres minor and deltoid.
Lateral pectoral nerve innervates the anterosuperior part of the glenohumeral joint.
Subscapular nerves - upper subscapular nerve serves the upper portion of the subscapularis muscle; the middle subscapular nerve (thoracodorsal nerve) innervates latissiumus dorsi; lower subscapular nerve innervates subscapularis and terres major.
Supraclavicular nerve - sensory only and innervates skin across entire shoulder and trapezius in a ‘cape-like’ fashion - sometimes missed in interscalene block.
Suprascapular nerve sensory innervation to glenohumeral joint and acromiovlavicular joint + motor to supraspinatus/infraspinatous (rotator cuff)
https://pubmed.ncbi.nlm.nih.gov/32712453/
20.2 The part of the lung that is typically divided into superior and inferior segments is the
a) RUL
b) RML
c) RLL
d) LUL
e) Left lingula
e) Left lingula
LEFT LUNG: ASIA ALPS
Apical Posterior
Superior lingula
Inferior lingula
Apical Anterior
Anterior basal
Lateral basal
Posterior basal
Superior
RIGHT LUNG: A PALM Seed Makes Another little Palm
RUL:
Apical
Posterior
Anterior
RML:
Lateral
Medial
RLL
Superior
Medial basal
Anterior basal
Lateral basal
Posterior basal
20.2 This lung ultrasound shows
a) Normal lungs
b) Pulmonary odema
c) Pneumothorax
d) Pleural effusion
e) Pneumonia
b) Pulmonary oedema
B-lines
> Vertical echogenic short path reverberation artefacts originating at the pleural line and extending to the deepest part of the ultrasound image.
They interrupt any horizontal A-lines.
Occasional B-lines are considered normal.
More than 3 B-lines in any single view is considered pathological.
Where there are numerous B-lines in close proximity they become confluent.
B-lines move with lung movement.
They are caused by ultrasound energy reverberating in a fluid filled focus that is surrounded by air. These foci may be interstitial or alveolar.
Cardiogenic and noncardiogenic oedema may have very similar appearances.
Interstitial thickening due to fibrosis or lymphangitis can also create the sonographic appearance of diffuse B-lines.
20.1 What is the arrow pointing to?
a. Ilioinguinal
b. Iliohypogastric
c. Iliacus
d. Lateral Femoral Cutaneous
e. Obturator
d. Lateral Femoral Cutaneous
20.2 When performing an infraclavicular block of the brachial plexus under ultrasound guidance, the structure indicated by the arrow is the (ultrasound image shown
a) Posterior Cord
b) Lateral cord
c) Median nerve
d) Superior trunk
e) Inferior trunk
a) Posterior Cord
20.1 What is the arrow pointing to?
a. Psoas
b. Femoral
c. Genitofemoral
d. Lateral cutaneous nerve of thigh
e. Lumbosacral trunk
b. Femoral
20.2 This lung ultrasound shows
a) Normal lungs
b) Pulmonary odema
c) Pneumothorax
d) Pleural effusion
e) Pneumonia
a) Normal lungs
M-mode image demonstrating seashore sign seen with normal lung sliding.
20.2 A patient has a peripherally inserted central catheter (PICC) inserted. The follow-up chest X-ray shows the tip positioned in the (Chest X-Ray shown)
a) Azygos vein
b) Coronary sinus
c) SVC
d) R atrium
e) L atrium
a) Azygos vein
Correct positioning in image
22.1 A 50-year-old man is admitted with a stroke and undergoes cerebral angiography. The artery
marked by the arrow on the angiogram is the
a. Vertebral
b. Basilar
c. PCA
d. PICA
e. Anterior cerebral artery
21.1 A patient had prolonged surgery with a laryngeal mask airway in situ. The following day he reports a problem with his tongue. You examine him and see the following when he protrudes his tongue: The most likely cause of the abnormality is
a. R hypoglossal nerve injury
b. L hypoglossal
c. R glossopharyngeal
d. L glossopharyngeal
L hypoglossal
The hypoglossal nerve innervates all the extrinsic and intrinsic muscles of the tongue, except the palatoglossus which is innervated by the vagus nerve.
Injury to the hypoglossal nerve causes ipsilateral tongue deviation (pathognomonic), with dysarthria and dysphagia in severe cases. The tongue deviates towards the side that is affected due to the unopposed action of the contralateral genioglossus
The symptoms and signs of hypoglossal neurapraxia are often self-limiting and 43% of diagnosed patients achieve resolution within 6 weeks of surgery and an additional 40% are symptom free within 6 months after surgery
Nerves injured by SAD
- Lingual nerve (2ry to tube)
- Hypoglossal nerve (2ry to cuff)
- Recurrent laryngeal nerve (2ry to cuff)
Presenting symptoms and signs
Lingual nerve:
- loss of taste and sensation to tip of tongue
Hypoglossal nerve:
- dysphagia
- dysarthria
- tongue deviation in unilateral injury
Recurrent laryngeal nerve:
- altered voice
- rarely: stridor
Risk factors for injury:
- use of nitrous oxide-> over inflation
- selection of SAD that is too small-> over inflation
- LMA maximum inflation pressure 60cmH2O
20.2 You are performing a regional block for analgesia following knee surgery. You have an ultrasound probe scanning the anterior mid-thigh. The muscle indicated by the arrow in the ultrasound image below is the
Vastus Medialis
21.2 When performing cannulation of the median cubital vein the structure that is LEAST likely to be inadvertently punctured or damaged is the
a) Ulnar artery
b) Radial nerve
c) Median nerve
d) Brachial artery
e) Ulnar nerve
E) ulnar nerve
20.2 You are performing a regional block for analgesia following knee surgery. You have an ultrasound probe scanning the anterior mid-thigh. The muscle indicated by the arrow in the ultrasound image below is the
Sartorius
23.1 A 40-year-old woman is administered a nerve block for extraction of her right lower wisdom tooth. The nerve that should be blocked is the
A. Mental
B. Lingual
C. Inferior alveolar
c) inf alveolar
The conventional inferior alveolar nerve block is the most commonly used nerve block technique in dentistry
The nerves anesthetized are the inferior alveolar, incisor, mental, and lingual nerves. The mandibular teeth to the midline, the body of the mandible, the lower part of the mandibular ramus, buccal periosteum and mucous membrane to the premolars, anterior 2/3 of the tongue, oral floor, lingual soft tissue, and the periosteum are all anesthetized
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6218392/
22.2 The nerve labelled by the arrow marked I in the diagram is the
- Ulnar Nerve
- Axillary Nerve
- Median Nerve
- Medial Cutaneous nerve of the forearm
- Long Thoracic Nerve
- Dorsal Scapular Nerve
- Radial Nerve
- Suprascapular nerve
- Musculocutaneous Nerve
- Ulnar Nerve
21.2 Performing a superficial cervical plexus block will block all of the following nerves EXCEPT the
a) Greater occipital
b) Greater auricular
c) Lesser occipital
d) Supraclavicular
e) Transverse cervical
a) Greater occipital
20.2 When performing an infraclavicular block of the brachial plexus under ultrasound guidance, the structure indicated by the arrow is the (ultrasound image shown
a) Posterior Cord
b) Lateral cord
c) Medial cord
d) Superior trunk
e) Inferior trunk
b) Lateral cord
20.2 You are performing a regional block for analgesia following knee surgery. You have an ultrasound probe scanning the anterior mid-thigh. The muscle indicated by the arrow in the ultrasound image below is the
Adductor Magnus
23.1 A 69-year-old man is dyspnoeic and complains of right shoulder tip pain whilst in the postanaesthesia care unit after a laparoscopic-assisted anterior resection. A focused thoracic ultrasound is performed and an image of the right lung is shown below. This represents
a) Pneumothorax
b) Pulmonary Oedema
c) Normal Lung
d) Consolidated Lung
Normal Lung
A patient has undergone a laparotomy with a central line inserted intra-operatively. In the PACU, the patient is dyspnoeic and a lung ultrasound is performed. The ultrasound, shown below, is consistent with
A. Pneumonia
B. Effusion
C. Normal lung
D. Pneumothorax
E. Pleural odema
C. Normal lung
- shows sandy shore sign of normal lung sliding
Alternative: Absent sliding & PTx: Stratosphere sign
20.1 The structure labelled A shows
a. Empty stomach
b. Clear fluids
c. Solids, early stage
d. Solids, late stage
a. Empty stomach
20.1 You are using ultrasound with colour flow Doppler to scan a patient’s neck prior to placing an internal jugular line. In the short axis view of the carotid artery, the colour Doppler image will be
A. Red because blood is going away from the probe
B. Blue because blood is going away from the probe
C. Blue when the blood is coming to the probe, red when the blood is going away from the probe
D. Red when the blood is coming toward the probe, blue when the blood is going away from the probe
E. The colour depends on the angle you hold the probe at
E. The colour depends on the angle you hold the probe at
Radiopaedia article: change of wording may change the answer to the question
20.1 What is the arrow pointing to?
a. Ilioinguinal
b. Iliohypogastric
c. Genitofemoral
d. Psoas
e. Obturator
b. Iliohypogastric
20.1 A patient has prolonged surgery with a laryngeal mask airway. The following day she reports a problem with her tongue. You examine her and see the following when she protrudes her tongue. The most likely cause of the abnormality is (facial picture shown)
a. Left hypoglossal nerve
b. Left glossopharyngeal
c. Right hypoglossal
d. Right glossopharyngeal
e. Right recurrent laryngeal
C
Ipsilateral deviation
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4308816/
21.1 The abnormality shown in this image is LEAST likely to be caused by an injury to the
a) Accessory nerve
b) Dorsal scapular nerve
c) Long thoracic nerve
d) Supraclavicular nerve
Supraclavicular nerve – it is a superficial sensory nerve arising from C3/C4.
Long thoracic nerve innervates serratus anterior muscle. Paralysis of this leads to medial winging of scapula (weakness of shoulder abduction).
Lateral winging of scapula (where lateral side protrudes) is due to weakness of trapezius or rhomboid muscles which are innervated by spinal accessory nerves and dorsal scapular nerve respectively.
Dorsal scapular nerve -> winging
Accessory nerve -> winging S
uprascapular nerve -> maybe
Subscapular nerve - > maybe
22.2 The rate of drainage of cerebrospinal fluid via a lumbar drain is NOT influenced by the
a. Height of bed
b. Height of drainage chamber
c. Height of highest part of drainage system
d. Position of patient
e. Spinal level of drain
e. Spinal level of drain
According to AANN2 and SNACC4 Guidelines:
* Patient positioning and leveling is crucial to prevent complications from lumbar drainage
* The head of the bed, height of drainage chamber, and changes in patient positioning must be monitored closely to prevent sudden overdrainage
* While making changes to the patient’s positioning, the lumbar drainage device should be clamped so that overdrainage does not occur
https://www.integralife.com/file/general/1604065981.pdf
(manufacturer’s instructions)
20.2 The nerve(s) that need to be blocked with local anaesthetic to achieve complete anaesthesia for amputation of the fifth toe is/are
a) Posterior tibial and sural
b) Posterior tibial and superficial peroneal
c) Sural and superficial peroneal
d) Deep and superficial peroneal
e) Sural, deep peroneal, and posterior tibial
b) Posterior tibial and superficial peroneal
If answer includes:
Posterior Tibial, Sural and superficial peroneal this would be the most appropriate
Or
Posterior Tibial + Sciatic nerve as Sural, deep and superficial peroneal are all branches of the sciatic nerve
The needle tip pictured is called a
a Sprotte
b Whittacre
c Quincke
d Trocar
e Tuohy
c Quincke
Needles for spinal anesthesia or lumbar puncture can be classified according to the needle tip.
Cutting-tip, or Quincke, needles have sharp, cutting tips, with the hole at the end of the needle.
Whitacre and Sprotte needles are two types of pencil point, or noncutting tip needles. They have a closed tip shaped like a pencil, with the hole on the side of the needle near the tip.
Pencil point needles are designed to minimize leak of cerebrospinal fluid after puncture and reduce the chance of postdural puncture headache.
20.1 To perform regional anaesthesia suitable for a fourth toe amputation, it is essential to block the:
a) posterior tibial
b) superficial peroneal
c) deep peroneal
d) sciatic
d) sciatic
Sciatic best answer given dermatomes and osteotomes
23.1 To provide anaesthesia to the medial malleolus, the key nerve to block is the
a. Saphenous
b. Deep peroneal
c. Superficial peroneal
d. Tibial
a) saphenous
21.2 A peripheral intravenous cannula is being inserted in the forearm of a man having a hemicolectomy. The skin asepsis preparation NOT suitable for this procedure is
a) Povidone iodine
b) Chlorhexidine 2%
c) Alcohol 70%
d) Chlorhexidine 0.5% with alcohol
e) Tincture of iodine
c) Alcohol 70%
- only suitable for short-term cannulation (<24 hours)
23.1 The glossopharyngeal nerve does NOT supply sensory innervation to the
a. Anterior third of tongue
b. Walls of pharynx
c. Motor to stylopharyngeal muscle
d. Pharyngeal plexus
a) anterior third of the tongue
Prior to neuraxial block in a patient with normal renal function, apixaban should be ceased for
a. 1 day
b. 2 days
c. 3 days
d. 5 days
e. 7 days
c. 3 days
22.1 You inadvertently place a 7.5Fr central venous catheter into the carotid artery of a patient undergoing an emergency laparotomy for peritonitis. The best course of management is to
a) Leave in, call vascular to repair at end of case
b) Heparin, remove, apply pressure
Leave in situ and contact vascular surgeons
21.1 When performing a brachial plexus block at the level of the axilla, the structure indicated by the arrow is the (ultrasound image shown)
a. Musculocutaneous nerve
b. Median
c. Radial
d. Ulnar
Ultrasound view of right axillary brachial plexus AA = axillary artery AV = axillary vein McN = musculocutaneous nerve RN = radial nerve UN = ulnar nerve MN = median nerve CoBM = coracobrachialis muscle CT = conjoint tendon
The part of the lung that is typically divided into medial and lateral segments is the
a. Left upper lobe
b. Lingula
c. Right upper lobe
d. Right middle lobe
e. Right lower lobe
d. Right middle lobe
23.1 In order to provide anaesthesia of the scalp for awake craniotomy, it is necessary to
block branches of the
a. Greater and lesser occipital and greater auricular nerves
b. Trigeminal, greater and lesser occipital nerves
c. Trigeminal, greater occipital and greater auricular nerves
d. Facial, trigeminal and greater occipital nerves
e. Facial, greater and lesser occipital nerves
b) Trigeminal, greater and lesser occipital nerves
2005 blue book article: six nerves need to be blocked bilaterally
- supratrochlear
- supraorbital
- zygomaticotemporal
- auriculotemporal
- lesser occipital nerve
- greater occipital nerve
Minor contributions from the greater auricular nerve and third occipital nerve rarely encroach into the surgical field
21.1 You are performing a regional block for analgesia following knee surgery. You have an ultrasound probe scanning the anterior mid-thigh. The muscle indicated by the arrow in the ultrasound image below is the
A: Sartorius
B: Vastus Medialis
C: Adductor Longus
D: Gracilis
E: Rectus femoris
C: Adductor Longus
22.2 This ultrasound image is acquired in preparation for a thoracic erector spinae plane block. The structure indicated by the arrow is the
a) Errector Spinae
b) Latismus Dorsi
c) Trapezius
d) Rhomboid
e) Psoas
d) Rhomboid
20.2 In order to provide adequate anaesthesia for operation on the earlobe, the following nerve/s need to be blocked
a) Greater auricular
b) Auriculotemporal
c) Vagal auricular branch
d) Lesser occiptal nerve
e) Zygomaticotemporal
a) Greater auricular
23.1 A central venous catheter is recognised as being inadvertently placed in the common carotid artery five hours after insertion. The most appropriate management is
A. Open repair
B. Percutaneous repair
C. Remove and put pressure on it.
a) Open repair
Flow chart from Blue book
https://jamanetwork.com/journals/jamasurgery/fullarticle/1741862
23.1 The sensory supply of the external nose is provided by all of the following nerves EXCEPT the
A. Lacrimal
B. Supratrochlear
C. Infratrochlear
D. Infraorbital
E. Anterior ethmoidal
Lacrimal
20.2 When performing an infraclavicular block of the brachial plexus under ultrasound guidance, the structure indicated by the arrow is the
a) Musculocutaneous nerve
b) Lateral Cord
c) Medial Cord
d) Superior trunk
e) Inferior trunk
c) Medial Cord
20.1 What is the arrow pointing to?
a. Ilioinguinal
b. Psoas
c. Genitofemoral
d. Lateral cutaneous nerve of thigh
e. Obturator
c. Genitofemoral
21.1 The nerve labelled with the arrow in the diagram is the (diagram of a nerve plexus shown)
22.1 A 54-year-old woman has a laryngeal mask airway inserted for a surgical procedure. The following day she complains of tongue numbness and abnormal taste over the posterior third of the tongue.
The most likely site of the nerve injury is the
a) Glossopharyngeal nerve
b) Lingual nerve
c) Facial nerve
d) Vagus nerve
Glossopharyngeal
20.2 This lung ultrasound shows
a) Normal lungs
b) Pulmonary odema
c) Pneumothorax
d) Pleural effusion
e) Pneumonia
a) Normal lungs
Probe selection
Linear probe (8–12 MHz)
These high-frequency probes give good resolution of superficial structures. As the anterior pleura is relatively superficial, excellent images of the pleura and lung sliding can be obtained. The poor penetration of high-frequency US and the narrow sector width mean deeper structures are poorly imaged.
Curvilinear probe (3–5 MHz)
This is the best all-round probe for LU. Lung sliding can be easily visualized as can IS. Effusions, consolidated lung, and the diaphragm are also well imaged because of the good penetration and large sector width. The large footprint of the probe means some angulation is needed to avoid the ribs when scanning postero-laterally.
Phased array (3–4.5 MHz)
These probes have a useful footprint for getting in between the ribs. They can be used to demonstrate all the signs of LU but the clarity of the images is not as good.
General points
The clearest images are obtained by having the image as shallow as possible with the focus point at the level of interest. The frequency can be adjusted to enhance the image, depending on the depth. Increasing the frequency on a curvilinear probe will improve the appearance of lung sliding whilst worsening the appearance of a consolidated lung base.
20.1 A postpartum woman presents with numbness over the anterior thigh, and weakness on flexion of the hip and extension of the knee. An epidural was sited for labour and she underwent an instrumental delivery. The most likely site of the injury is the:
a) Femoral nerve
b) Lateral femoral cutaneous nerve
c) Lumbosacral plexus
d) Obturator nerve
e) Sciatic nerve
a) Femoral nerve
Nerve roots: L2-L4
Motor functions: Innervates the anterior thigh muscles that flex the hip joint (pectineus, iliacus, sartorius) and extend the knee (quadriceps femoris: rectus femoris, vastus lateralis, vastus medialis and vastus intermedius),
Sensory functions: Supplies cutaneous branches to the anteromedial thigh (anterior cutaneous branches of the femoral nerve) and the medial side of the leg and foot (saphenous nerve).
20.1 What is the arrow pointing to?
b. Psoas
c. Iliacus
c. Genitofemoral
d. Lateral cutaneous nerve of thigh
e. Lumbosacral trunk
c. Iliacus
21.1 The optimal position, under ultrasound guidance, to place a catheter tip to provide continuous erector spinae plane block for post-thoracotomy analgesia is
a. Between the fascial plane of erector spinae and rhomboids
b. Posterior to both erector spinae and spinous process
c. Anterior to erector spinae and posterior to transverse process 5th rib
d. Superficial to the infraspinatus fossa
e .Superficial to the lamina
c. Anterior to erector spinae and posterior to transverse process 5th rib
Midpoint between T5-6
(Usual Incision T4-5, ICC T6)
Source - Blue book 2019
20.1 What is the arrow pointing to?
a. Ilioinguinal
b. Iliohypogastric
c. Genitofemoral
d. Accesory Obturator
e. Obturator
d. Accessory Obturator
23.1 Reviewing the below image (ultrasound image shown), in order to safely perform an erector spinae block the probe needs to be moved
(exact exam image)
A. Move inferiorly
B. Move laterally
C. Move superiorly
D. Move medially
A. Move medial
20.1 What is the arrow pointing to?
a. Ilioinguinal
b. Iliohypogastric
c. Genitofemoral
d. Lateral cutaneous nerve of thigh
e. Obturator
a. Ilioinguinal
The shoulder joint receives sensory innervation from all of the following nerves EXCEPT the
a) Axillary
b) Long thoracic
c) Lateral pectoral nerve
d) Supra scapular
e) Sub scapularis
b) Long thoracic
The needle whose tip is pictured is a
a) Sprotte
b) Quinke
c) Touhy
d) Whitacre
c) Touhy
