Resus, Trauma, Crisis Flashcards
In an anaesthetised patient with anaphylaxis, cardiac compression should be
initiated at a systolic blood pressure of less than:
a) 40
b) 60
c) 80
d) 100
e) 120
a) 40
40; if 50 was there the answer would be 50
NAP 6 says CPR if SBP<50mmHg
ANZAAG says 50mmHg
During resuscitation of a newborn, the heart rate is noted to be 50 beats per minute
despite optimal ventilation and chest compressions. The next step in management
is to give intravenous adrenaline:
a) 0.1-0.3ml/kg 1:1000
b) 0.5-1ml/kg 1:10000
c) 0.1-0.3ml/kg 1:10000
d) 0.1-0.3ml/kg 1:100000
C
Anaphylaxis
Less than 6 - 0.15ml 1:1000
6-12 - 0.3ml 1:1000
Moderate allergy - 0.1ml/kg
Life threatening - 0.2 to 0.5ml/kg
(1mg in 50ml - 20mcg/ml)
An adult weighing 80 kg has sustained full-thickness burns to 40% of their body.
The recommended volume of fluid resuscitation in the first 24:
a) 9600ml
b) 16000ml
c) 6400ml
3 * 40 * 80 = 9600
4 * 40 * 80 = 12800
Parkland seems to be trending toward 3ml these days rather than 4
Deranged physiology key points
Urine output as end goal - risk of fluid creep with same
Albumin reduces total volume of resus but not difference to survival
Hypertonic fluids - increased mortality and AKI
Other formula
Brooke
Evan’s
Monafo
Shriner’s -paeds
Galvestons - paeds
In a can’t intubate, can’t oxygenate (CICO) scenario when using a 14G cannula
and a Rapid-O2 oxygen delivery device, the initial rescue breath should be:
a) 2 seconds, 10L O2
b) 4 seconds, 10L O2
c) 2 secs 15L
d) 4 secs 15L
d) 4 secs 15L
Initial breath 4 seconds @ 15L (rate is 250ml/s i.e. total delivered in 4 seconds = 1L)
If no improvement in SpO2 after 30 seconds give another 2 second breath
Subsequent breaths once sats fall by 5% from maximum Spo2 achieved with initial jet ventilation breath = 2 secs (I.e. 500ml)
Kate The maximum recommended cumulative dose of Intralipid 20% for the treatment of
local anaesthesia systemic toxicity is:
a) 8ml/kg
b) 9ml/kg
c) 12ml/kg
c) 12ml/kg
Intralipid 20% treatment
Initial bolus 1.5ml/kg (repeat up to Max 3 times 5 mins apart
Infusion 15ml/kg /hr
Max cumulative dose = 12 ml/kg
A patient with a perioperative troponin rise above normal, chest pain, left ventricular
anterior regional wall motion abnormality, and atheroma without thrombus
occluding 70% of the left anterior descending coronary artery has had a/an
NSTEMI
STEMI
Unstable angina
Acute myocardial injury
Chronic myocardial injury
Type 1 MI
Type 2 MI
NSTEMI
MINS: MI/ischemic myocardial injury that doesn’t fulfill MI defn
MI: Myocardial injury with rise/fall cTn above 99th percentile of upper ref limit within 30 days post op plus at least one of:
Ischemic symptoms
New ischemic ECG changes
New path Q waves on ECG
Imaging evidence of myocardial ischemia
Angiographic/autopsy evidence of coronary thrombus
Steph The ANZAAG-ANZCA guideline for management of resistant hypotension during perioperative refractory anaphylaxis in an adult includes all of the following
EXCEPT:
1) Fluid bolus 20ml/kg
2) Continue adrenaline
3) Norad infusion
4) Vaso bolus
5) Glucagon
LINDON a) its 50ml/kg bolus
You are called to assist with a patient in the intensive care unit who has had cardiac surgery three days ago and is now in cardiac arrest. External cardiac massage should aim for a systolic blood pressure of
a. 40
b. 60
c. 80
d. 100
e. 120
REPEAT
b. 60
BJA Article - Management of cardiac arrest following cardiac surgery - BJA Education
In the CICU, the effectiveness of ECC is confirmed by monitoring the arterial pressure trace with a target compression rate and depth to achieve a systolic impulse of > 60 mm Hg to maintain a mean perfusion pressure, preventing ventricular distension, LV wall stress, and ischaemia.
An 85-year-old is scheduled for open reduction and internal fixation of a fractured neck of femur today. They have no significant past medical history. Preoperative review including physical examination, full blood count, electrolyte profile and electrocardiogram performed yesterday were normal. In the anaesthetic bay, the monitor shows the patient to be in atrial fibrillation with a ventricular rate of 110 to 145 beats per minute. The blood pressure is 130/80 mmHg. The best initial treatment for the atrial fibrillation is:
A) Amiodarone
B) Metoprolol
C) Digoxin
D) Induce then cardiovert
E) Calcium Channel Blocker
B) Metoprolol
Guidelines from the American College of Cardiology/American Heart Association (ACC/AHA) and the European Society of Cardiology (ESC) recommend beta-blockers as a first-line therapy for rate control in atrial fibrillation.
Reference: January CT, Wann LS, Calkins H, et al. 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation. 2019;140(2)
In a patient who sustained significant burn injury, the blood concentration of propofol is:
a) Increased due to reduced cardiac output
b) Increased due to dehydration and reduced circulating volume
c) Reduced due to increased volume of distribution and clearance
d) Increased due to reduced renal clearance
e) Reduced due to increased inflammatory cytokines
REPEAT
c) Reduced due to increased volume of distribution and clearance
2010 Paper on major burns
The pharmacokinetic characteristics of a propofol bolus administered in patients with major burns were enhanced clearance and expanded volume of distribution.
BURN and WT were the important covariates. For sedation or anesthesia induction, a higher than recommended dose of propofol may be required to maintain therapeutic plasma drug concentrations in patients with severe burns.
Vigilance regarding the burned individual and careful titration of hypnotics to the desired effect cannot be overemphasized.
https://pubmed.ncbi.nlm.nih.gov/20510522/
NP Once a unit of fresh packed red blood cells has been removed from controlled refrigeration the transfusion should be completed within
a) 2.5 hours
b) 3 hours
c) 3.5 hours
d) 4 hours
REPEAT
4 hours
As per Lifeblood
Start the transfusion as soon as possible after removing the blood component from approved temperature-controlled storage. Transfusion of each pack should be completed prior to the labelled expiry or within four hours, whichever is sooner.
Redcross: “Transfusion of each pack should be completed prior to the labelled expiry or within four hours, whichever is sooner. “
Shelf life of platelets: 5 days (Stored at 20-24 degrees, must be agitated gently and continuously)
FFP: Once FFP is thawed, must use within 24 hours.
Albumin administration: At RCH we allow the product to be administered within 6 hours of piercing the bottle. (from RCH.org)
Cryoprecipitate
Thawed cryoprecipitate should be maintained at 20°C to 24°C until transfused.
Once thawed, should be used within six hours if it is a closed single unit, or within four hours if it is an open system or units have been pooled.
A previously healthy 22-year-old man is involved in an altercation and sustains a ruptured spleen. During splenectomy he is transfused with packed red blood cells. One hour into the transfusion his SpO2 rapidly decreases, his ventilator pressures
increase, frothy sputum appears in the endotracheal tube and he is febrile. The likely cause is:
a) TRALI
b) TACO
AT
a) TRALI
Both TACO and TRALI are characterised by:
- hypoxia
- acute dyspnoea
- diffuse bilateral infiltrates
However, presence of fever is more in keeping with TRALI.
Reference:
Distinguishing between transfusion related acute lung injury and transfusion associated circulatory overload Robert C. Skeatea and Ted Eastlund
Double sequential external defibrillation is performed by applying two shocks from:
a. Single set of pads, <1 second apart
b. Single set of pads, <5 seconds apart
c. Two sets of pads, <1 second apart
d. Two sets of pads, <5 seconds apart
e. Two sets of pads, simultaneously
AT
- Two sets of pads, <1 second apart
(OR
- Two sets of pads, <5 seconds apart)
Following 3 standard shocks for refractory VF
Two defibrillators are used to provide sequential defibrillation with pads oriented in anterio-lateral and anterior posterior
The shocks are delivered near-simultaneously
- Anteriolateral first
- Then Anterioposterior
DOuble SEquential External Defibrillation for Refractory Ventricular Fibrillation (DOSE VF): study protocol for a randomized controlled trial
DSED: For paramedic services randomized to DSED, paramedics will apply a second set of defibrillation pads in the anterior-posterior configuration (Fig. 1) Application of the second set of defibrillation pads for the second defibrillator will occur during the 2-min cycle of CPR following the third defibrillation attempt, minimizing any interruptions in CPR. All subsequent defibrillation attempts will be carried out by sequential defibrillation shocks provided by two defibrillators. To ensure that shocks are not administered at the exact same moment, we will employ a short (less than 1 s) delay to provision of the second defibrillator shock. This will be accomplished by having a single paramedic pressing the “shock” button on each defibrillator in rapid succession as opposed to simultaneously. This technique will be performed across all sites when randomized to the DSED arm to maintain consistency in application within the trial.
NOTES ON PREVIOUS QUESTION 23.1
For DSED, to avoid possible defibrillator damage caused by shocks applied at the same instant, a short delay (<1 second) between shocks was created by having a single paramedic depress the “shock button” on each defibrillator in rapid sequence (anterior–lateral followed by anterior–posterior)
Among patients with refractory ventricular fibrillation, survival to hospital discharge occurred more frequently among those who received DSED or VC defibrillation than among those who received standard defibrillation.
https://www.nejm.org/doi/full/10.1056/NEJMoa2207304
The initial management for a seizure during an awake craniotomy is:
a. Cold saline irrigation
b. Midazolam
c. Propofol
Nikki
A) cold saline irrigation
Intraoperative seizures have a higher incidence of transient motor deterioration and longer hospital stays.[10] First-line treatment should be irrigation of the brain with sterile iced saline. Propofol bolus (10 to 20 mg IV) or midazolam (1 to 2 mg IV) should be administered to terminate the seizure if iced saline is ineffective.
https://www.ncbi.nlm.nih.gov/books/NBK572053/
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
In septic shock, the recommended target mean arterial pressure in an adult is:
a) 50 mmHg
b) 55 mmHg
c) 60 mmHg
d) 65 mmHg
VICTORIA
Screen shot sent to JJ
D
Kate According to the Australian and New Zealand Committee on Resuscitation guidelines, the minimum distance a defibrillation pad should be placed away from a pacemaker or implantable cardiac defibrillator generator is:
a) 8cm
b) 12cm
c) 16cm
A) 8cm
ANZCOR:
In patients with an ICD or a permanent pacemakerthe defibrillator pad/paddle is placed on the chest wall ideally at least 8 cm from the generator position
Kate A bleeding patient has ROTEM results including: [table attached]. The most
appropriate treatment is:
a) Fibrinolysis
LINDON
20.1 A patient has foam sclerotherapy to treat a number of varicose veins. Following the procedure she stands, immediately loses consciousness and develops a unilateral limb weakness. The most likely mechanism is
a. Anaphylaxis
b. Intracranial bleed
c. Paradoxical gas embolus
d. Thromboembolic stroke
c. Paradoxical gas embolus
Although liquid-injection sclerotherapy is the criterion standard, foam sclerotherapy is becoming a popular alternative because of its efficacy and success rate.1 A potential complication of foam sclerotherapy is the formation of gas microemboli in the brain, which can lead to neurologic deficits.
https://www.degruyter.com/document/doi/10.7556/jaoa.2016.063/html?lang=en
20.2 If group A Rh-ve fresh frozen plasma is not available for use in an A Rh-ve patient, of the following your next best choice should be
a. A+
b. B-
c. AB+
d. O+
e. O-
a. A+
Group A Plasma component preference
1st choice: A
2nd Choice: AB
3rd Choice: B
[a] If the patient is a female of childbearing potential, O RhD negative red cells should be used until the patient’s blood group is established.
[b] Group A platelets with the A2 subgroup don’t express significant amounts of A antigen and are therefore preferable to other group A platelets when transfusing group O and B recipients.
[c] Apheresis platelets that have a low titre anti-A/B or pooled platelets pose a lower risk of haemolysis when transfusing ABO incompatible components.
[d] Plasma components that have low titre anti-A/B pose a lower risk of haemolysis when transfusing ABO incompatible components.
[e] Group A plasma may be used as per local institutional policies.
If no A, use AB Rh + cryo (Ie; no anti A or anti B)
Cryo incompatible can be given, but large volumes are high risk for DIC
https://litfl.com/cryoprecipitate/
20.1 In the treatment of diabetic ketoacidosis, the most important initial therapeutic intervention is to
a) Electrolyte correction
b) Insulin
c) IV hydration
d) Bicarbonate
IV hydration
Fluid first (hartmanns or saline w k+) then insulin
BJA Developments in the management of diabetic ketoacidosis 2015
Diabetic ketoacidosis (DKA) is a medical emergency and bedside capillary ketone testing allows timely diagnosis and identification of successful treatment.
> 0.9% saline with premixed potassium chloride should be the main resuscitation fluid on the general wards and in theatre; this is because it complies with National Patient Safety Agency recommendations on the administration of potassium chloride.
> Weight-based fixed rate i.v. insulin infusion (FRIII) is now recommended rather than a variable rate i.v. insulin infusion (VRIII).
> The blood glucose must be kept above 14 mmol litre−1 with the FRIII.
> Precipitating factor(s) needs to be identified and treated. Surgery and also critical care may be indicated to manage the patient presenting with DKA.
23.1 A man has symptomatic carbon monoxide poisoning. His pulse oximetry (SpO2) and arterial blood gas (PaO2) would be expected to show
a. Normal SpO2, Normal PaO2
b. Normal SpO2, reduced PaO2
c. Reduced SpO2, normal PaO2
d. Reduced SpO2, reduced PaO2
a. Normal - Normal
A normal or high oximetry reading should be disregarded because saturation monitors cannot differentiate between carboxyhaemoglobin and oxyhaemoglobin, owing to their similar absorbances.
The blood gas PO2 will also be normal in these cases (despite the presence of tissue hypoxia).
file:///Users/newuser/Downloads/BTS%20Guideline%20for%20oxygen%20use%20in%20adults%20in%20healthcare%20and%20emergency%20settings.pdf
22.1 A four-year-old boy is in refractory ventricular fibrillation. The recommended dose of amiodarone is
80mg
Age + 4 x 2-> 4 + 4 x 2 =16kg
5 x 16mg =80mg
22.2 A four-year-old boy is in refractory ventricular fibrillation. The recommended dose of amiodarone is
a) 40mg
b) 80mg
c) 120mg
d) 160mg
80mg
Age + 4 x 2-> 4 + 4 x 2 =16kg
5 x 16mg =80mg
16kg x 5mg/kg = 80mg
An awake patient in the post-anaesthesia care unit complains of breathlessness. The FiO2 through the patient’s rebreather mask is 40%. An arterial blood gas taken at the time shows (ABG shown). The alveolar-arterial gradient (in mmHg) is approximately
Blood gas shows:
PaO2 135
PaCO2 48
SpO2 100%
The A-a gradient is:
A. 5
B. 30
C. 60
D. 90
E. 110
D 90
A-a = PAO2 - PaO2
Alveolar air equation gives PAO2
PAO2 = PiO2 - PaCO2 / R
PAO2 = 0.4 x (760 - 47) - 48 / 0.8
so, as PaO2 given as 135
A-a = 228 - 135 = 93
21.1 A baby is brought to the emergency department three days after a term home birth. It has not been feeding well and has had few wet nappies. The child is grey in appearance and femoral pulses are difficult to palpate. You note an enlarged liver and marked tachycardia. Pulse oximetry reveals
saturations of 75% despite oxygen being administered. You suspect a duct-dependent circulation. The best initial management is
a) Intubation and controlled ventilation
b) 20ml/kg crystalloid bolus
c) Alprostadil (PGE1)
d) Stop administration of oxygen
c) Alprostadil (PGE1)
From Paediatric BASIC on CHD:
- Resuscitation of an infant or newborn in shock should follow a standard approach regardless of the aetiology.
- Any patient with a duct dependent lesion either for pulmonary blood flow, or systemic output, will require PGE1. The problem is that whether or not a duct dependent lesion is present is unclear in most cases. If CHD has been diagnosed antenatally, PGE1 should be started.
- The cyanosed neonate presenting with severe cyanosis (O2 <75) and/or in extremis should be started on PGE1; the assumption being that the duct has closed and needs to be reopened.
19.2 An 80-year-old woman is admitted to hospital with respiratory failure. Her arterial blood gas on oxygen 4 litres per minute via a Hudson mask is as follows: (ABG shown) Which of the following most accurately describes this blood gas result?
pH 7.2, pO2 91, pCO2 84, BE 16, HCO3- 43, Na 145
a) Metabolic alkalosis, acute resp acidosis + normal AG
b) Metabolic alkalosis resp acidaemia + abnormal AG
c) Mixed acidaemia
d) Respiratory Acidosis with incomplete compensation
e) Compensated Respiratory acidosis
d) Respiratory Acidosis with incomplete compensation
Uncertain of this answer, not enough info to calculate anion gap
pH 7.2 = acidaemia
pCO2 84 = respiratory acidosis
HCO3 43 = metabolic alkalosis as compensation
BE 16 = metabolic alkalosis
Boston rules:
Chronic fully compensated Respiratory acidosis
Expected compensation is 3-4 mmol/L rise for every 10mmHg rise in PCO2.
Expected metabolic compensation therefore is
HCO3 = 24 + 4 x ((84-40)/10)
= 24 + 4x (44/10)
= 24 + 4 x (4.4)
= 24 + 17.6
= 41.6
Metabolic acidosis
PaCO2 should be 1.5 x HCO3 + 8
= 72.5
Rules (from K.Brandis Acid-base rules anaesthesia mcq):
- 1 for 10 (acute resp acidosis), 4 for 10 (chronic resp acidosis)
- 2 for 10 (acute resp alkalosis), 5 for 10 (chronic resp alkalosis)
- 1.5xHCO + 8 = expected pCO2 in a metabolic acidosis
- 0.7xHCO3 + 22 = expected pCO2 in a metabolic alkalosis
https://www.anaesthesiamcq.com/AcidBaseBook/ab9_3.php
21.1 The management of a patient who has experienced a cardiac arrest within 10 days of cardiac surgery
should NOT routinely include
a. Atropine 3mg
b. adrenaline 1mg boluses
c. 3 stacked shocks
d. amiodarone 300
e. 1L fluid
b. adrenaline 1mg boluses
The risk of administering adrenaline in conventional doses is with profound hypertension, bleeding, or tearing of vessel anastomoses on return of spontaneous circulation (ROSC), which can precipitate catastrophic harm or further cardiac arrest.
Adrenaline remains a useful drug in peri-arrest situations in smaller doses.
21.1 During trauma resuscitation in adults, contraindications to blind nasogastric tube insertion include all of
the following EXCEPT
a) High C-spine injury
b) Recent nasal surgery
c) Oesophageal fracture
d) Base of skull fracture
e) oesophageal varices
High C-Spine injury
22.1 A normal sized six-year-old girl has a haemoglobin of 70 g/L following surgery. The volume of packed red blood cells that you would plan to infuse to raise her haemoglobin to 80 g/L is
a. 80ml
b. 100ml
c. 120ml
d. 180ml
e. 200ml
b. 100ml
Paediatric weight estimation:
Luscombe: Weight (kg) = (age x 3) + 7
RCH: Weight (kg) = (age + 4) x 2
Formula for calculating transfusion volume (mL)
Children <20 kg:
PRBC (mL) = wt (kg) x Hb (g/L) rise (desired Hb – actual Hb) x 0.5 (transfusion factor)
Children >20 kg: 1 unit PRBC
Example:
6 + 4 x 2 = 20kg
20kg x 10g/l x 0.5 = 100ml
23.1 According to Australian and New Zealand Anaesthetic Allergy Group (ANZAAG) anaphylaxis guidelines for adults, cardiopulmonary resuscitation should commence at a systolic blood pressure of less than
a. 70
b. 60
c. 50
d. 40
c) 50mmHg
The initial management for a seizure during an awake craniotomy is
a. Cold saline irrigation
b. Midazolam
c. Propofol
a) Cold Saline Irrigation
22.2 A patient presents with sepsis-induced hypoperfusion or septic shock. The minimum suggested volume of intravenous crystalloid to be administered over the first three hours as outlined in the Surviving Sepsis Guideline is
a) 10ml/kg
b) 20ml/kg
c) 30ml/kg
d) 40ml/kg
e) 50ml/kg
30ml/kg
https://journals.lww.com/ccmjournal/Fulltext/2021/11000/Executive_Summary__Surviving_Sepsis_Campaign_.14.aspx
22.1 In comparison with fresh frozen plasma, cryoprecipitate contains an increased concentration of factor
a. II
b. VII
c. XI
d. XIII
d. XIII
But Fibrinogen (I) is the most significant factor that
20.2 The composition of Plasma-Lyte 148 (in mmol/l) includes
a Na 140 Mg 1.0 K 5.0 acetate 27 lactate 0
b Na 140 Mg 1.5 K 5.0 acetate 0 lactate 27
c Na 140 Mg 1.0 K 4.0 acetate 24 lactate 0
d Na 140 Mg 1.0 K 4.0 acetate 0 lactate 24
e Na 140 Mg 1.5 K 5.0 acetate 27 lactate 0
e Na 140 Mg 1.5 K 5.0 acetate 27 lactate 0
22.2 The initial management for a seizure during an awake craniotomy is
a. GA and tube
b. Cold saline irrigation of brain
c. IV keppra
d. IV propofol
e. IV midazolam
b. Cold saline irrigation of brain
Seizures, either focal or generalized, are most likely to occur during cortical mapping. They are treated by irrigating the brain tissue with ice-cold saline. They usually cease with this treatment alone, but occasionally benzodiazepines, anti-epileptic drugs, or re-sedation with airway control are required.
An emergency plan for airway control has to be in place at all times and this can be challenging as the patient’s head is fixed in head pins and often away from the ventilator. The options include the insertion of an LMA which may be easier than oro-tracheal intubation.
Awake craniotomy is generally a well-tolerated procedure with a low rate of conversion to general anaesthesia and a low rate of complications. One of the most frequent complications is patient intolerance of the procedure, often because of the urinary catheter or prolonged positioning and intra-operative seizures.
22.1 A patient is undergoing treatment for a malignant hyperthermia crisis. Active cooling should be ceased when the patient’s core temperature has dropped to
a. 35
b. 36
c. 37
d. 38
38
22.2 According to the ANZICS Statement on Death and Organ Donation 2021, circulatory determination of death in the context of organ donation requires the absence of evidence of circulation for at least
a. 2min
b. 3min
c. 5 min
d. 10 min
c. 5 min
Circulatory determination of death in the context of organ donation
12 Circulatory determination of death in the context of organ donation requires the absence of spontaneous movement, breathing and circulation. Absence of circulation is evidenced by absent arterial pulsatility for 5 minutes, using intra-arterial pressure monitoring and confirmed by clinical examination (absent heart sounds and/or absent central pulse). In cases without an arterial line, electrical asystole should be observed for 5 minutes on the electrocardiogram and confirmed by clinical examination.
13 For the purposes of organ donation, circulatory determination of death should be documented using a specific form (see Appendix E) to demonstrate explicitly that all criteria set out in this Statement are met. The same criteria should be listed in local hospital forms
22.1 The most clinically useful indicator of effective ventilation during neonatal resuscitation is an improvement in
a. HR increases
b. Grimace
c. Resp rate
a. HR increases
20.1 You are asked to review a previously well 48-year-old woman two hours after hysteroscopic myomectomy and endometrial ablation under general anaesthesia. Her observations are: Heart rate 70 /minute, blood pressure 130/80 mmHg, SpO2 98% on 2 litres per minute of oxygen via nasal prongs. She is drowsy but rousable, oriented to person but not to time and place. Her electrolytes show: (List of electrolytes given) The most appropriate treatment is
Na 118, K 3.0, Cr 56, Ur normal.
What is your management?
A. 500ml 0.9% NaCl
B. 3% NaCl 100ml
C. 10mmol KCl
D. Fluid restriction
a) 3% saline 100ml
100ml bolus of 3% saline (should raise serum Na by 2-3
meq/L). If no improvement in neurological symptoms, can
repeat bolus 1-2 more times at 10 minute intervals.
Frusemide only recommended if APO
22.2 The medication most strongly associated with an acute primary hypotensive reaction following transfusion of blood products is
a. aspirin
b. celecoxib
c. hydralazine
d. metoprolol
e. labetalol
f. perindopril
f. perindopril
Hypotensive transfusion reactions, which account for almost 3% of all transfusion reactions, are associated with patients treated with angiotensin-converting enzyme inhibitors. The current hypothesis suggests that they are caused by bradykinin-induced vasodilation in the absence of allergic, hemolytic, or septic mechanisms. The hypotension observed frequently is unresponsive to conventional therapy with catecholamines. The suggested intraoperative management includes cessation of transfusion and washing red blood cells before blood replacement.
Hypotensive reactions to transfusion may not always be recognized. To prevent these reactions, clinicians have several options: they may discontinue the ACE inhibitor (elective transfusion), not use a leukoreduction filter (if the patient has no absolute requirement for leukoreduced blood components), use washed cellular components, or use components that have undergone leukoreduction at the collection facility or the hospital blood bank before transfusion (since bradykinin is degraded during storage).
23.1 A 24-year-old man has been brought into the emergency department with a traumatic fracture of the femur. His observations are: heart rate 90 beats per minute; blood
pressure 120/80 mmHg; respiratory rate 25 breaths per minute. A peripheral VENOUS blood gas sample shows a pH of 7.29. The arterial blood pH can be estimated to be
A. 7.29
B. 7.32
C. 7.35
D. 7.4
B. 7.32
https://emj.bmj.com/content/18/5/340
The values of pH on arterial and venous samples were highly correlated (r=0.92) with an average difference between the samples of −0.4 units. There was also a high level of agreement between the methods with the 95% limits of agreement being −0.11 to +0.04 units.
https://litfl.com/vbg-versus-abg/
pH
- Good correlation
- pooled mean difference: +0.035 pH units
22.1 A drug which does NOT increase the defibrillation threshold in a patient with an implanted cardioverter defibrillator is
a. Amiodarone
b. Atropine
c. B-blocker
d. Flecainide
e. Sotalol
e. Sotalol
Drugs that INCREASE defibrillation threshold:
+ Amiodarone (Chronic)
+ Atropine
+ lignocaine
+ Diltiazem
+ Flecainide
+ Verapamil
+ Venlafaxine
+ Anaesthetic agents.
Drugs that DECREASE defibrillation threshold:
- Sotalol
- Amiodarone (acute)
- Nifekalant
Drugs with No Change in DFT
= B- blocker
= Disopyramide
= Procainamide
= Propafenone
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6304797/
21.1, 21.2 In maternal cardiac arrest the most common arrhythmia is
a) PEA
b) VT
c) VF
d) Asystole
e) SVT
a) PEA
I couldn’t find a great article on this anywhere. BJAED hasn’t got much either
23.1 Findings associated with massive pericardial tamponade include
a. Electrical alternans
b. Exaggerated collapsible IVC on ECHO during respiratory cycle
c. Pulses alternans
d. Kussmaul breathing
a) electrical alternans
Physical findings in Tamponade:
- A number of findings may be present on physical examination, depending upon the type and severity of cardiac tamponade
- None of the findings alone are highly sensitive or specific for the diagnosis.
Beck’s triad
1. Low arterial blood pressure
2. Dilated neck veins
3. Muffled heart sounds
- Are present in only a minority of cases of acute cardiac tamponade.
Diagnosis:
Clinical diagnosis is usually suspected based on the history and physical examination findings, which may include:
●Chest pain
●Syncope or presyncope
●Dyspnea and tachypnea
●Hypotension
●Tachycardia
●Peripheral edema
●Elevated jugular venous pressure
●Pulsus paradoxus
A 65-year-old woman has presented with a grade 2 subarachnoid haemorrhage equally suitable for treatment with surgical clipping or endovascular coiling. The factor shown to most effectively reduce mortality in early subarachnoid haemorrhage treatment is
a) Nimodipine
b) Tranexamic acid
c) Early repair
d) Atorvastatin
e) EVD placement
c) Early repair
Coil within 24 hours
Early repair - the outcome in terms of survival free of disability at 1 year is significantly better with endovascular coiling. Preferably within 24 hours
20.1 IgE-related penicillin anaphylaxis crossover rate with cephazolin
a. 0.1%
b. 1%
c. 5%
d. 10%
1%
BJA ED
23.1 According to the Australian and New Zealand Anaesthetic Allergy Group (ANZAAG) guidelines for the investigation of a suspected anaphylactic reaction, serum tryptase should be measured at
a. 0, 4, 12
b. 0, 2, 4, 24
c. 0, 1, 4, 24
d. 0, 4 , 6, 24
e. 1, 6, 24
c) 0, 1, 4, 24
Serum tryptase levels are recommended to be collected as soon as possible after the onset of symptoms and then at 1 hour, 4 hours and after 24 hours.
https://www.anzca.edu.au/resources/professional-documents/endorsed-guidelines/anaphylaxis-guideline-2022.pdf
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
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.
20.1 You are inserting a pulmonary artery catheter in an intubated patient prior to cardiac surgery, and a significant amount of blood appears in the endotracheal tube. The most appropriate specific initial management is to:
A. Remove PAC and insert DLT
B. Wedge PAC and insert DLT
C. Wedge PAC and insert bronchial blocker
D. Withdraw PAC 2 cm and insert DLT
E. Withdraw PAC and insert bronchial blocker
F. Inflate balloon
D. Withdraw PAC 2 cm and insert DLT
LITFL: Pulmonary haemorrhage after PAOP measurement
a life threatening time-critical emergency pulmonary artery rupture caused by inflation of the pulmonary artery catheter (PAC) balloon during ‘wedging’ (measurement of the pulmonary artery occlusion pressure) some experts advise against measuring PAWP because of the risk of pulmonary artery rupture 0.2% risk, 30% mortality
RISK FACTORS
pulmonary hypertension mitral valve disease anticoagulants age >60 years
MANAGEMENT
Goals
prevent further pulmonary haemorrhage stop bleeding resuscitate
Call for help
ICU consultant anaesthetist/ OT cardiothoracic surgeon interventional radiology
Resuscitation
A
may have to be emergently intubated if not already
B
FiO2 1.0
controlled ventilation
if able to recognize which lung is haemorrhaging may be able to perform lung isolation (insert single lumen tube into unaffected side, exchange for a double lumen tube or use bronchial blocker with bronchoscopic assistance)
apply PEEP to tamponade wound
C
large bore IV cannulae, fluids, blood products, inotropes
Specific therapy
Lay the patient ruptured side down withdraw pulmonary catheter 2-3 cm with balloon down then refloat PAC with balloon inflated to occlude pulmonary artery (to try to tamponade bleeding) stop antiplatelet agents and anticoagulants give reversal agents: — protamine for heparin — platelets for anti-platelet agents give blood products as indicated by FBC, coags and clinical state interventions — angiogram or bronchoscopy to isolate pulmonary vessel involved — if bleeding doesn’t settle will require lobectomy
21.2, 22.2 A patient has blunt chest trauma. A thoracotomy is indicated if the immediate blood drainage after closed thoracostomy is greater than
a) 500mL
b) 750mL
c) 1L
d) 1.2L
e) 1.5L
1,500 mL immediately
OR
200 mL/hr in the first 2-4 hours
21.2, 22.2 You are involved in the care of a two-year-old child who ingested a button battery within the last 4 hours. You should consider giving
a. milk,
b. sodium bicarbonate
c. Pantoprazole
d. sucralfate
Honey (or sucralfate) - 10 mL every 10 minutes (maximum 6 times) while awaiting surgical retrieval
Source QCH guidelines
23.1 Of the following drugs, the LEAST suitable for managing atrial arrhythmias in a patient with a left ventricular assist device is
A. Metoprolol
B. Amiodarone
C. Digoxin
D. Diltiazem
d) diltiazem
Nondihydropyridine calcium channel blockers should be used cautiously in patients with HFrEF because of their negative inotropic effects, and the role of these agents in LVAD recipients remains unclear
https://www.ahajournals.org/doi/10.1161/CIR.0000000000000673
Should also avoid sotolol
23.1 A patient with severe abdominal trauma develops acute respiratory distress syndrome. A diagnosis of abdominal compartment syndrome is confirmed if the patient also has a sustained intraabdominal pressure greater than
A. 10mmHg
B. 16mmHg
C. 20mmHg
D. 24mmHg
c) 20mmHg
Intra-abdominal hypertension is defined as a sustained intra-abdominal pressure of >12 mm Hg, and abdominal compartment syndrome occurs at a pressure >20 mm Hg in association with new organ dysfunction.
Intra-abdominal hypertension is graded as follows: Grade 1=12–15 mm Hg; Grade 2=16–20 mm Hg; Grade 3=21–25 mm Hg; and Grade 4 >25 mm Hg.
https://academic.oup.com/bjaed/article/12/3/110/258792
20.1Of the following, the LEAST appropriate treatment in the management of severe acute respiratory distress syndrome (ARDS) is
a) High PEEP
b) Recruitment maneuvers
c) Neuromuscular blockade
d) Prone
e) Negative fluid balance
Muscle relaxation or Recruitment maneuvers
A, D and E are all appropriate for ARDS.
Muscle relaxation and lung recruitment are controversial.
Best answer is probably A muscle relaxation (not recommended unless there is dyssynchrony).
Recruitment and higher PEEP are conditional.
UP TO DATE: RE: Muscule relaxation: “ Until a clear benefit is demonstrated, we suggest not routinely administering NMBs to patients with moderate to severe ARDS, unless other indications are present (eg, severe ventilator dyssynchrony, particularly if it leads to double triggering, or unwanted motor movement refractory to ventilator adjustment and sedation). “
Recruitment manoeuvres – no positive influence on survival.
https://derangedphysiology.com/main/required-reading/respiratory-medicine-and-ventilation/Chapter%20512/ventilation-strategies-ards
Does this strategy improve survival? Probably not, according to this Cochrane review. In fact, in the ART trial (Cavalcanti et al, 2017) they probably caused harm. But, they can improve oxygenation temporarily.
One can see the benefit of recruitment manoeuvres in patients who have accidentally become disconnected from the ventilator.
The 2017 ATS guidelines were published in May of 20117, whereas the ART trial came out in September that year, and so the ATS guidelines still recommend recruitment manoeuvres whereas the rest of the world probably does not.
In fact, in their answer to Question 8 from the first paper of 2018 the college remarked that if any trainee who confesses to the routine use of recruitment manouvres, “they were should be marked down” by the examiners.
22.1 A man has symptomatic carbon monoxide poisoning. His pulse oximetry (SpO2) and arterial blood gas (PaO2) would be expected to show
a. Normal SpO2, Normal PaO2
b. Normal SpO2, reduced PaO2
c. Reduced SpO2, normal PaO2
d. Reduced SpO2, reduced PaO2
a. Normal SpO2, Normal PaO2
ABG
HbCO (elevated levels are significant, but low levels do not rule out exposure) lactate (tissue hypoxia) PaO2 should be normal, SpO2 only accurate if measured (not calculated from PaO2) MetHb (exclude)
https://litfl.com/carbon-monoxide-poisoning/
22.1 The first-line drug recommended by both the Australian Resuscitation Council and the New Zealand Resuscitation Council to treat severe cyanide poisoning is
a. Methylene blue
b. Hydroxycobalamine
c. Sodium thiosulfate
hydroxycobalamin
20.1 A 25-year-old man suffers a 30% total body surface area burn. A physiological change expected within the first 24 hours is
a) Increase PVR
b) Decreased SVR
c) Increased cardiac index
d) Increased stroke volume
a) Increase PVR
UTD:
Low cardiac output “ebb,” phase (resuscitative phase) –
In the first 48 hours after a major burn, cardiac output (CO) is reduced up to 60 percent from baseline due to:
1. hypovolemia from permeability-induced plasma loss
2. reduced myocardial response to catecholamines
3. increased systemic vascular resistance due to elevated vasopressin levels
4. depressed myocardial contractility
5. possible myocardial ischemia due to decreased coronary blood flow
The large volumes that these patients require can sometimes result in over-resuscitation, leading to pulmonary edema and right heart failure.
High cardiac output “flow,” phase (recovery phase)
During the recovery phase 72 to 96 hours postburn, hyperdynamic and hypermetabolic responses result in:
1. increased CO
2. Tachycardia
3. increased myocardial oxygen consumption
4. decreased systemic vascular resistance
Elevation of catecholamines in major burns produces:
1. hyperdynamic circulation
2. augments energy expenditure
3. romotes protein catabolism in skeletal muscle.
Nonselective beta blocker therapy is sometimes used to block catecholamine receptors, treat cardiac dysfunction, and modulate the hyperdynamic response during this phase
21.1 A 100 kg 32-year-old male presents two hours after suffering a 30% total body surface area electrical burn. He has had no resuscitation fluids. The infusion rate of isotonic crystalloid resuscitation fluid required for this man for the next six hours is
a. 500 ml/hr
b. 750 ml/hr
c. 1000 ml/hr
d. 1200 ml/hr
c. 1000 ml/hr
30% x 100kg x 4ml= 12000ml
50% in first 8hrs = 6000ml
pt presents 2hrs late = 6000ml/6hrs = 1000ml/hr
or
30% x 100kg x 3ml= 9000ml
50% in 1st 8 hrs= 4500ml
pt presents 2hrs late= 4500ml/6hrs= 750ml/hr
750mls/hr
EMSB recommends 3ml/kg, BJA recommends 4ml/kg
-> go with 4ml/kg because electrical burn and more likely to require increased fluids anyway
22.1 Preperitoneal pelvic packing is a surgical treatment of haemorrhage from a/an
a) pelvic fracture
Haemodynamically unstable pelvic fracture
20.1 Perioperative hypothermia down to 35degrees - effect on bleeding:
a) More bleeding with normal INR and APTT
b) More bleeding with normal INR and raised APTT
c) More bleeding with raised INR and normal APTT
d) Unchanged bleeding and normal INR and APTT
e) Unchanged bleeding and elevated INR and APTT
More bleeding with normal INR and APPT
https://academic.oup.com/bja/article/117/suppl_3/iii18/2664400
Bleeding observed at reduced temperatures (33 – 37 °C) often occurs because of defects in platelet adhesion, while at temperatures below 33 °C, both reduced platelet function and coagulation enzyme activity contribute
Also lab INR and APTT are not temperature corrected
20.1 What is the level below which we need to replace fibrinogen in a pregnant patient with a PPH
A. <1 g/L
B. <1.5 g/L
C. <2 g/L
D. <2.5 g/L
E. <3 g/L
<2g/L
23.1 A patient with long-term severe anorexia nervosa is commenced on a normal diet. Three days later she develops cardiac failure and exhibits a decreased level of consciousness. The most important parameter to assay and normalise is the plasma
a. Phosphate
b. Potassium
c. Magnesium
d. Sodium
e. Calcium
a) Phosphate
hypophosphate: Clinical symptoms range from muscle weakness and paraesthesia to severe cardiac failure, seizures and diaphragmatic paralysis
Refeeding malnourished patients with anorexia nervosa can be associated with hypophosphatemia, cardiac arrhythmia and delirium. Phosphorus repletion should be started early with and serum levels maintained above 3 mg/dL
weakness and fatigue, in the context of a recent history of starting a regular diet while in a state of chronic malnutrition, are concerning for refeeding syndrome, which typically occurs 2 to 5 days after beginning nutritional repletion. Depleted phosphate stores due to prolonged starvation, hypocalcemia, and hypokalemia can lead to impaired muscle contractility and subsequently weakness, myalgia, and tetany.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4168120/
21.1 The risk of major bleeding in patients taking direct oral anticoagulants (DOACs) is NOT significantly increased by commencing administration of
a) Atorvastatin
b) Amiodarone
c) Digoxin
d) Diltiazem
e) Fluconazole
1st a) Atorvastatin
2nd c) Digoxin
source of Atorvastatin > Digoxin
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5818856/
All of the DOACs are avid substrates for the excretory P-gp system of the gastrointestinal epithelial cells, and drugs that inhibit or induce the P-gp system may affect plasma DOAC levels
Dabigatran and edoxaban are substrates for P-glycoprotein (P-gp)
Apixaban and rivaroxaban are metabolised by cytochrome P450 enzyme CYP3A4 and are substrates for P-gp
There is study evidence that among patients taking DOACs for non-valvular atrial fibrillation, concurrent use of amiodarone, fluconazole, rifampicin, and phenytoin compared with the use of DOACs alone, was associated with increased risk of major bleeding
It is unlikely that clinically significant interactions occur between dabigatran and other drugs that are merely substrates for P-gp-mediated excretion. When dabigatran was coadministered with digoxin neither digoxin nor dabigatran plasma levels were significantly altered
Rivaroxaban and apixaban are metabolised to an extent of 40–50 % in the liver to variable degrees by CYP3A4 and may interact with drugs that inhibit this enzyme.
The metabolism of Apixaban and rivaroxaban can be decreased when combined with Atorvastatin which is also metabolised by CYP3A4
23.1 You are called to assist in the resuscitation of a 75-year-old patient in the emergency
department who is in extremis with severe hypotension and hypoxaemia. The image
shown is of a focused transthoracic echocardiogram, parasternal short axis view.
The most likely diagnosis is
a. PE
b. Tamponade
a) PE
D-shaped left ventricle
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)
21.1 A patient with a purely metabolic acidosis has a serum bicarbonate of 14 mmol/L and a lactate of 3.8 mmol/L. The expected PaCO2 is
a. 24
b. 29
c. 35
d. 40
B. 29
PaCO2= 1.5 x 14 + 8
PaCO2= 21 + 8
PaCO2= 29
Winter’s formula: expected PaCO2 = [1.5 x (serum HCO3)] + [8±2]
if PaCO2 lower, there is a concomitant primary respiratory alkalosis
if PaCO2 higher, there is a concomitant primary respiratory acidosis
22.2 A 47-year-old man is anaesthetised for an elective laparoscopic cholecystectomy. Three minutes after induction, he is noted to have a heart rate of 130 bpm and systolic blood pressure of 60 mmHg. The most appropriate initial dose of adrenaline is
a) 100mcg IM Adr
b) 200mcg IM Adr
c) 20mcg Adr IV
d) 100mcg Adr IV
e) 50mcg Adr IV
c) 20mcg Adr IV
ANZAAG use Ring and Mesmer scale for anaphylactic reactions as a base for classifying anaphylaxis grade (see image)
From sunny coast QH document
With PAGS ‘Life Threatening Anaphylaxis’ can be distinguished from
‘Moderate Anaphylaxis’ in an adult by the presence of any
one of these signs:
* systolic blood pressure of <60 mmHg
* life-threatening tachy- or bradyarrhythmia
* oxygen saturation <90%
* inspiratory pressures of >40 cmH2
Life-threatening anaphylaxis
23.1 A patient is suffering an acute myocardial infarction. Australian and New Zealand
guidelines recommend the threshold for the use of supplemental oxygen is when the
SpO2 falls below
a. 88%
b. 90%
c. 93%
d. 97%
e. 100%
c) 93%
ANZCOR suggests against the routine administration of oxygen in persons with chest pain.13 [2015 COSTR, weak recommendation, very-low certainty evidence]
For persons with heart attack, routine use of oxygen is not recommended if the oxygen saturation is >93% [National Heart Foundation of Australia & Cardiac Society of Australia and New Zealand: practice advice].9
21.2 Cryoprecipitate contains all of the following EXCEPT
a) Factor I
b) Factor VII
c) Factor VIII
d) VWF
e) Fibronectin
b) Factor VII
Redcross:
Cryoprecipitate contains most of the following found in fresh frozen plasma:
1. factor VIII
2. fibrinogen
3. factor XIII
4. von Willebrand factor
5. fibronectin
Prothrombinex-VF® is a lyophilised concentrate of human coagulation factors it contains:
Factors:
II
IX
X
small amount of factor VII.
Also contains:
plasma proteins (human)
Antithrombin III (human)
Heparin sodium (porcine)
Sodium
Phosphate
Citrate
Chloride
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
23.1 Cryoprecipitate contains coagulation factors
A. 2, 8, 13, von willebrands
B. 1, 7, 13 , von willebrands.
C. 1, 8, 13, von willebrands.
D. 2, 7, 13, von willebrands.
C.
Cryoprecipitate contains Factor VIII, XIII, fibrinogen (factor I), fibronectin, vWF
https://www.lifeblood.com.au/health-professionals/products/blood-components/cryoprecipitate
21.1 A 40-year-old man suffers a hydrofluoric acid burn to 60% of his total body surface area in an industrial accident. An expected electrolyte disturbance is:
a. Hypocalcemia
b. Hyponatremia
c. Hypophosphatemia
d. Hypomagnesemia
hypoCALCEMIA
Hydrofluoric acid: highly corrosive inorganic aacid of element fluorine
- used in glass etching, electronics industry and cleaning solutions for metals, stone and marble
- dilute solutions can rapidly penetrate the skin and exposure of even a small area can be fatal (2%TBSA)
Fluoride ions bind with calcium and magnesium ions in the tissues
-> significant hypocalcaemia and hypomagnesaemia
-> Hyperkalaemia may also be seen
Direct cardiotoxic effects of fluoride ions can lead to cardiac arrhythmias that are difficult to treat
20.1 What is the abnormality in this CXR?
a. Pneumonectomy
b. Pleural effusion
c. Pneumonia
d. Unilateral pulmonary oedema
c. Pneumonia
Complete white-out of left lung with air bronchogram sign consistent with total consolidation. Patchy areas of ground glass opacities in right lung. There is silhouetting of the left heart border and left hemi-diaphragm. There is no rib crowding to suggest atelectasis.
Complete white-out of the hemithorax with air bronchograms and trachea in a central position is consistent with consolidation secondary to pneumonia. The patient is on linezolid, micafungin, and piperacillin-tazobactam pending culture and susceptibility studies.
Differential diagnosis of hemithorax white-out with a midline trachea include:
- consolidation
- pulmonary edema/ARDS
- pleural mass
- chest wall mass
21.1 The composition of blood returned to the patient from intraoperative cell salvage shows
A. No evidence of haemolysis
B. Normal 2,3 DPG
C. Nil evidence of bone cement or some embolism type
D. Normal levels of coagulation factors
B. Normal 2,3 DPG
higher Hct-60%
No immunimodulation
require reinfusion within 6hrs
pause with sement, caution metal fragments
21.2 A bleeding patient has ROTEM results including (results displayed) . The most appropriate treatment is
a) Cryoprecipitate
b) FFP
c) Platelets
d) TXA
e) Protamine
e) Protamine
The interpretation of this graph is not especially laborious. The cardinal abnormality is the massively prolonged CT and CF of the INTEM graph, which suggests that something has killed the intrinsic pathway of the clotting cascade. The CT returns to normal in the HEPTEM graph, which is essentially just an INTEM test with adde heparinase. The presence of heparinase seems to have reversed all of the coagulopathy - the CFT, alpha-angle and MCF have all returned to normal. Therefore, this patient has no coagulation problems other than the heparin.
https://derangedphysiology.com/main/required-reading/haematology-and-oncology/Chapter 1.2.0.1/intepretation-abnormal-rotem-data
21.2 The power board on the back of the anaesthesia machine has caught fire during an elective case. This should be extinguished with
a) CO2
b) Fire blanket
c) Wet chemical powder
d) Foam
e) Water
a) CO2
20.1 According to the Australian and New Zealand Resuscitation Guidelines the immediate treatment for an adult conscious victim with a severe airway obstruction due to a foreign body inhalation is
a) a single back blow
b) two back blow
c) up to 5 blows to back, then up to 5 chest thrusts
d) up to 5 chest thrusts
e) sweep mouth
c) 5 back, 5 chest
4.1 Assess Severity
The simplest way to assess severity of a FBAO is to assess for effective cough.
4.2 Effective Cough (Mild Airway Obstruction)
The person with an effective cough should be given reassurance and encouragement to keep coughing to expel the foreign material. If the obstruction is not relieved the rescuer should call an ambulance.
4.3 Ineffective Cough (Severe Airway Obstruction) Conscious person
If the person is conscious send for an ambulance and perform up to five sharp, back blows with the heel of one hand in the middle of the back between the shoulder blades. Check to see if each back blow has relieved the airway obstruction. The aim is to relieve the obstruction with each blow rather than to give all five blows. An infant may be placed in a head downwards position prior to delivering back blows, i.e. across the rescuer’s lap [Class B; LOE IV].1,2
If back blows are unsuccessful the rescuer should perform up to five chest thrusts. To perform chest thrusts, identify the same compression point as for CPR and give up to five chest thrusts. These are similar to chest compressions but sharper and delivered at a slower rate. The infant should be placed in a head downwards and on their back across the rescuer’s thigh, while children and adults may be treated in the sitting or standing position [Class B; LOE IV].1,2
With each chest thrust, check to see whether the airway obstruction has been relieved. The aim is to relieve the obstruction rather than deliver all five chest thrusts. If the obstruction is still not relieved and the person remains responsive, continue alternating five back blows with five chest thrusts.
Unconscious person
If the person becomes unresponsive a finger sweep can be used if solid material is visible in the airway.1,2 [Class A; LOE IV] Call an ambulance and start CPR.
23.1 A multitrauma patient is being managed with a resuscitative endovascular balloon occlusion device of the aorta (REBOA) as part of damage control resuscitation. The
balloon has been inserted for intractable pelvic bleeding. The most appropriate location for the device placement is between the
A. Between artery of adamkiewicz to coeliac artery
B. Between coeliac artery to renal artery
C. Between lowest renal artery to bifurcation of aorta
D. Between coeliac and bifurcation
C. Between lowest renal artery to bifurcation of aorta
https://litfl.com/reboa-in-resuscitation/
Anatomy:
The aorta is divided into three separate zones for the purposes of REBOA (aortic length varies between individuals)
Zone I of the aorta extends from the origin of the left subclavian artery to the coeliac artery (approx 20cm long in a young adult male)
Zone II extends from the coeliac artery to the most caudal renal artery (approx 3cm long)
Zone III extends distally from the most caudal renal artery to the aortic bifurcation (approx 10cm long)
REBOA location based on injury:
> suspected or diagnosed intra-abdominal haemorrhage due to blunt trauma or penetrating torso injuries (Zone I REBOA), or
> blunt trauma patients with suspected pelvic fracture and isolated pelvic haemorrhage (Zone III REBOA), or
> patients with penetrating injury to the pelvic or groin area with uncontrolled haemorrhage from a junctional vascular injury (iliac or common femoral vessels) (Zone III REBOA)
Simplistic rendering of aorta. Zone 1 (from left subclavian artery to the upper border of the celiac trunk), Zone 2 (the upper border of the celiac trunk to the lower border of the distal take-off of the renal arteries), and Zone 3 (from the lower border of the lower renal artery to the aortic bifurcation). Zone 1 is occluded in the case of cardiac arrest or life-threatening intra-abdominal hemorrhage; Zone 2 has no current indication; and Zone 3 is occluded in the case of life-threatening pelvic or lower limb haemorrhage7. REBOA Resuscitative Endovascular Balloon Occlusion of the Aorta.
23.1 A drug that is NOT useful for the treatment of vasoplegic shock is
A. Hydroxycobalamin
B. Methylene blue
C. Dobutamine
D. vasopressin
E. Dopamine
c. dobutamine
UTD
Indications for the use of hyperbaric oxygen therapy in the treatment of acute carbon monoxide toxicity include all of the following EXCEPT
a. Pregnancy
b. COHb level 10%
c. Difficult to examine patient as likely concomitant drug overdose
d. Myocardial ischaemia
e. Reduced GCS
b. COHb level 10%
22.1 The 2012 Berlin definition of the Acute Respiratory Distress Syndrome (ARDS) defines moderate disease as one with a PaO2 / FiO2 ratio (in mmHg) of
100 < PaO2/FiO2 ≤ 200 with PEEP ≥5 cmH2O
https://link.springer.com/article/10.1007/s00134-012-2682-1/tables/3
23.1 The Sequential Organ Failure Assessment (SOFA) score is used in intensive care for the assessment of sepsis. This score does NOT include the
a. Bilirubin
b. Platelets
c. PaO2/FiO2
d. GCS
e. Hypoglycaemia
e) hypoglycaemia
A patient in the intensive care unit has ventricular fibrillation two hours after her coronary artery bypass graft procedure. Recommended immediate management does NOT include
a) Atropine
b) Adrenaline
c) 3 stacked shocks
d) Amiodarone
b) Adrenaline
-You do not use full dose adrenaline (rather, give smaller doses)
-You do three “stacked shocks”
-You try pacing (rate of 90, DDD) in asystole if pacing wires are available
-If they are already paced and in PEA, you turn off the pacing to “unmask” VF.
-These shocks and attempted pacing are all measures you take before starting CPR, which is a departure from the ACLS norms.
-If you can’t control a shockable rhythm with three stacked shocks, you give amiodarone immediately rather than after three cycles.
-Amiodarone is the only drug in the protocol, which makes it easy to remember. -
-After five minutes of unsuccessful resuscitation the chest should be re-opened. —External CPR is pointless in all of the common causes of arrest in this scenario. Therefore, CPR is something you do while waiting to re-open the chest.
-Non-surgical staff are encouraged to re-open the chest in an emergency
https://derangedphysiology.com/main/required-reading/cardiac-arrest-and-resuscitation/Chapter%20221/cardiac-arrest-following-cardiac-surgery
23.1 You are called to an airway emergency in the intensive care unit. A 40-year-old woman with morbid obesity and pneumonia had an elective percutaneous tracheostomy inserted eight hours previously. She is sedated, paralysed and ventilated. After being turned for pressure care, she desaturates and there is no clear CO2 trace on capnography.
The tracheostomy tube is still in the neck but you are concerned it has been displaced. Your immediate management should be to:
a. Reintubate from the mouth
b. Bronch via Trache
c. ?
a) reintubate from the mouth
? couldn’t find other recalled answers ? Will depend on the remembered answers ?
The key principles of the algorithm are:
1.Waveform capnography has a prominent role at an early stage in emergency management.
2.Oxygenation of the patient is prioritised.
3.Trials of ventilation via a potentially displaced tracheostomy tube to assess patency are avoided.
4.Suction is only attempted after removing a potentially blocked inner tube.
5.Oxygen is applied to both potential airways.
6.Simple methods to oxygenate and ventilate via the stoma are described.
7.A blocked or displaced tracheostomy tube is removed as soon as this is established and not as a ‘last resort’
BJA: Update on management of tracheostomy
https://www.bjaed.org/article/S2058-5349(19)30125-8/fulltext
https://www.tracheostomy.org.uk/storage/files/Patent%20Airway%20Algorithm.pdf
22.1 Under the NEXUS criteria, requirements to clear the cervical spine of trauma patients without radiographic imaging include all of the following EXCEPT
a. No midline tenderness
b. No distracting injury
c. No altered level of consciousness
d. Able to turn head 45 deg
e. No focal neurological deficit
d. Able to turn head 45 deg
NEXUS criteria:
One easy mnemonic for these criteria is NSAID:
Neuro Deficit Spinal Tenderness (Midline) Altered Mental Status/Level of Consciousness Intoxication Distracting Injury
22.1 In a 5-year-old child with severe life-threatening anaphylaxis and no intravenous access, the recommended initial dose of intramuscular adrenaline is
a. 100mcg
b. 150mcg
c. 300mcg
d. 500mcg
e. 600mcg
150mcg IM
Then commence adrenaline infusion 0.1mcg/kg/min to 2mcg/kg/min
Refractory management:
Additional IV fluid 20-40ml/kg,
Noradrenaline infusion 0.1- 2mcg/kg/min
Vasopressin infusion 0.02-0.06 units/kg/hr, glucagon 40mcg/kg IV
21.2 Of the following, the LEAST likely cause of high anion gap metabolic acidosis is
a) Pancreatic fistula
b) DKA
c) Cardiac failure
d) Anti-retroviral
e) Methanol
pancreatic fistula
-> should cause NAGMA
HAGMA:
Lactate
Toxins
Ketones
Renal failure
NAGMA
Chloride
Addison’s, adrenal insuffiency, acetazolamide
GI loss (pancreatic fistula)
Extra: RTA
Anion gap:
- Anion Gap = Na+ – (Cl- + HCO3-)
- The Anion Gap (AG) is a derived variable primarily used for the evaluation of metabolic acidosis to determine the presence of unmeasured anions
- The normal anion gap is assumed to be 12, and the normal HCO3 is assumed to be 24
Delta ratio:
- can check delta ratio in the presence of a high anion gap metabolic acidosis (HAGMA) to determine if it is a ‘pure’ HAGMA or if there is coexistant normal anion gap metabolic acidosis (NAGMA) or metabolic alkalosis.
21.1 Of the following, the incidence of venous air embolism is considered highest for
a) LUSCS
b) Prostatectomy
c) Coronary artery surgery
d) Spinal surgery
e) Gastric endoscopy
a) LUSCS
Rates of VAE by surgical procedure:
LUSCS: 10%-97%
Neurosurgery:
Posterior Fossa: 76%
Cervical Laminectomy: 7-25%
Lateral/Prone Neurosurgery: 15-25
%
Total Hip Replacement: 30%
Lap Cholecystectomy: 69%
20.2 Prothrombinex VF is a factor concentrate. It is indicated for the management of bleeding caused by
a Von Willebrand disease
b Haemophilia a
c Haemophilia b
d Haemophilia c
e Congenital fibrin deficiency
c Haemophilia b
21.2 A ten year old child (weight 30 kg) presents to the emergency department in status epilepticus. He has received one dose of 15 mg midazolam buccally prior to his arrival. According to Advanced Paediatric Life Supprt, Australia (APLS) guidelines the next drug treatment should be intravenous
a) Midazolam
b) Propofol
c) Levetiracetam
d) Phenytoin
a) Midazolam 0.15mg/kg
1st line: Midazolam IV/IO/IM –> 0.15mg/kg
2nd line: Midazolam IV/IO/IM –> 0.15mg/kg
3rd line: Keppra 40mg/kg (max 3g)
4th line: Phenytoin 20mg/kg or phenobarbitone
5th line: Intubation and deep sedation with midazolam, propofol +/- phenobarbitone
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
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
20.1, 21.2 A patient with a history of paroxysmal atrial fibrillation and chronic obstructive airways disease develops a wheeze intraoperatively which resolves with administration of salbutamol via the endotracheal tube.
Soon after, he develops rapid atrial fibrillation with a ventricular rate of 120 beats per minute, a BP of 90/60 and an ETCO2 of 40mmHg. His regular medications are
inhaled salbutamol, inhaled salmeterol and digoxin 125mcg daily. The next most suitable treatment is
a) Amiodarone 150mg over 30minutes, then 1mg/min for 6 hours
b) Esmolol 500mcg/kg and infusion
c) Direct cardioversion with 50J
d) Metoprolol 2.5mg IV up to 3 doses
a) Amiodarone 150mg over 30minutes, then 1mg/min for 6 hours
UP TO DATE: Arrhythmias in COPD
For patients with atrial fibrillation and COPD, we suggest using verapamil or diltiazem rather than metoprolol in patients who require ventricular rate control (Grade 2C).
Metoprolol is reserved for patients who do not respond to the calcium channel blockers and do not have uncontrolled bronchoconstriction. For those with an accessory pathway or heart failure, amiodarone or digoxin may be preferred as outlined in the table (table 3).
Addition of Digoxin in this answer stem could be prefered over Amiodarone
21.2 Intraoperative cell salvage is contraindicated in
a) LSCS
b) Revision of infected THR
c) Heparin allergy
d) Severe coagulopathy
e) Phaeochromocytoma
phaeochromatoma
23.1 Anaesthesia-induced rhabdomyolysis differs from malignant hyperthermia in that it is NOT
a. Reduced Myoglobinaemia
b. Less increase in ETCO2
C. Less muscle rigidity
a. Reduced Myoglobinaemia
Repeat but its not myoglobinuria it was myoglobinaemia
- There is NOT reduced myoglobinuria with AIR compared to MH (both have myoglobinuria)
- There IS less increase in ETCO2
- There IS less muscle rigidity
In the management of anaphylaxis in a 5-year-old with no intravenous or intra-osseous access, the correct dose of intramuscular adrenaline is
A. 20mcg
B. 50mcg
C. 100mcg
D. 150mcg
E. 300mcg
D. 150mcg
23.1 Under the NEXUS criteria, requirements to clear the cervical spine of trauma patients without radiographic imaging include all of the following EXCEPT
A. No distracting injury
B. No limitation in neck movement
C. No midline tenderness
D. No focal neurological deficit
E. No altered level of consiousness
b) no limitation in neck movement
23.1 A 35-year-old woman is brought to the emergency department following a suspected amitriptyline overdose. She has a Glasgow Coma Scale score of 6 and her blood pressure is 90/46 mmHg. Her electrocardiogram is most likely to show
A. AF
B. CHB
C. Sinus tachy with prolonged QRS
D. Sinus brady with prolonged QRS
E. VT
c. sinus tachy with prolonged QRS
A bleeding patient has ROTEM results including (ROTEM results shown). The most
appropriate treatment is
a) Plts
b) FFP
c) Cryo
d) TXA
c) Cryo
Cryo or TXA,
TXA first line treatment however patient has low fibrinogen and requires fibrinogen replacement.
The recommended dose of IV adrenaline in a 15 kg, 5 year old child with grade 2 (moderate) perioperative anaphylaxis is
a) 15mcg
b) 30mcg
c) 50mcg
d) 100mcg
e) 150mcg
b) 30mcg
Moderate = 2mcg/kg
Life threatening = 4-10mcg/kg
file:///Users/jbjon/Downloads/Australian_and_New_Zealand_Anaesthetic_Allergy_Gro.pdf
