True Learn: Neuroscience & Neuromuscular Flashcards
A 25-year-old, 75-kg presents for a craniotomy after a motor vehicle accident 2 hours ago and sustaining a traumatic brain injury. An external ventricular drain was placed in the emergency department. Currently, his intracranial pressure is reading 40 mmHg. Which of the following anesthetic techniques is MOST appropriate in this patient?
A. 1.0 MAC of isoflurane
B. Controlled hypotension with mean arterial pressure between 60 and 70 mmHg
C. Hyperventilation to an EtCO2 of 25 mmHg
D. Total intravenous anesthesia with propofol and fentanyl
D. Total intravenous anesthesia with propofol and fentanyl
During a knee arthroplasty revision under general anesthesia, the thigh tourniquet is left inflated uninterrupted for over 4 hours. The lower leg is then found to be swollen and painful the next morning after surgery. The urinary catheter is draining dark urine. What is a possible consequence of this syndrome?
A. Hypercalcemia
B. Hypoalbuminemia
C. Hyponatremia
D. Metabolic alkalosis
B. Hypoalbuminemia
Which of the following is the MOST appropriate in the anesthetic management of a patient with an intracerebral arteriovenous malformation undergoing general anesthesia for embolization of the lesion?
A. Avoidance of all glucose containing solutions
B. Ensuring a slow emergence from anesthesia
C. Permissive hypertension during intubation
D. Use of a depolarizing muscle relaxant for paralysis
A. Avoidance of all glucose containing solutions
Which of the following is TRUE regarding intraoperative neuromonitoring (IONM) during aortic surgery?
A. Loss of cortical potentials from tibial nerve stimulation implies spinal cord ischemia during aortic repair
B. Several randomized controlled trials support the routine use of intraoperative neuromonitoring for aortic surgery
C. Somatosensory evoked potentials (SSEPs) have quicker responses than motor evoked potentials (MEPs)
D. Volatile anesthetics suppress motor evoked potentials (MEPs) to a lesser degree than somatosensory evoked potentials (SSEPs)
A. Loss of cortical potentials from tibial nerve stimulation implies spinal cord ischemia during aortic repair
Which of the following statements regarding spinal cord blood supply is CORRECT?
A. One posterior spinal artery supplies the posterior spinal cord
B. Radicular arteries supplement the anterior but not the posterior spinal cord blood supplies
C. The anterior spinal artery supplies the anterior two thirds of the spinal cord
D. The artery of Adamkiewicz most commonly originates in the T5-T8 region
C. The anterior spinal artery supplies the anterior two thirds of the spinal cord
A 36-year-old man with amyotrophic lateral sclerosis, hyperlipidemia, urinary retention, and chronic urinary tract infections presents for cystoscopy and suprapubic urinary catheter placement. He is wheelchair bound with progressive weakness, dysphagia, and dysphonia. He has had two incidents of occult aspiration pneumonia in the past two years. He has never seen a cardiologist and has no preoperative cardiac testing. Which of the following anesthetic plans would be the most reasonable for this patient?
A. Delaying the surgery for a cardiac catheterization
B. Modified rapid sequence induction with propofol and rocuronium
C. Rapid sequence induction with propofol and succinylcholine
D. Subarachnoid block with lidocaine
B. Modified rapid sequence induction with propofol and rocuronium
Which of the following MOST likely interferes with acetylcholine release?
A. Hypocalcemia
B. Myasthenia gravis
C. Nifedipine
D. Potassium channel blockers
A. Hypocalcemia
A 33-year-old woman has developed acute inflammatory demyelinating polyradiculopathy (Guillain-Barré syndrome) following an acute gastrointestinal illness. Due to the severity of her condition, the decision has been made to intubate the patient and provide mechanical ventilation for respiratory support. Which of the following is MOST TRUE regarding this patient’s care?
A. Muscle paralysis is typically maintained to facilitate mechanical intubation
B. Prior to intubation, this patient’s forced expiratory volume in one second will be decreased
C. The use of succinylcholine to facilitate intubation is recommended
D. Ventilator settings following intubation will demonstrate decreased lung compliance
B. Prior to intubation, this patient’s forced expiratory volume in one second will be decreased
A 45-year-old male post motor vehicle accident has a Glasgow Coma Scale score of 7, blood pressure of 85/60 mmHg, and a subdural hematoma seen on CT scan. What is the MOST accurate and useful method to assess his intracranial pressure?
A. Intraparenchymal catheter
B. Lumbar subarachnoid catheter
C. Optic nerve sheath diameter with ultrasound
D. Ventriculostomy catheter
D. Ventriculostomy catheter
A 39-year-old man with history of cervical spondylosis is diagnosed with anterior spinal artery syndrome after onset of symptoms. Which of the following is most likely intact?
A. Motor function
B. Temperature sensation
C. Pain sensation
D. Proprioception
D. Proprioception
Which of the following interventions is most likely to be effective for the prophylaxis of post-operative nausea and vomiting (PONV)?
A. Acupuncture
B. Isopropyl alcohol inhalation
C. Nicotine patch to non-smokers
D. Tetrahydrocannabinol
A. Acupuncture
Which of the following does NOT contribute to the termination of an action potential in a neuron?
A. Neuron membrane repolarization
B. Sodium channel inactivation
C. Calcium ion efflux
D. Potassium ion efflux
C. Calcium ion efflux
A 16-year-old girl is scheduled to undergo minimally invasive repair of pectus excavatum with the placement of two pectus bars. Analgesia is planned with the preoperative placement of bilateral paravertebral nerve catheters. Which of the following is the MOST reliable means of identifying vertebra prominens (C7) when determining the placement of the paravertebral catheters?
A. Palpation of the most cephalad stationary spinous process on neck flexion and extension
B. Palpation of the most prominent spinous process
C. The spinous process underlying the line connecting the roots of the bilateral scapular spines
D. The spinous process underlying the intercristal line
A. Palpation of the most cephalad stationary spinous process on neck flexion and extension
Which of the following statements regarding nitrous oxide and cerebral blood flow (CBF) is FALSE?
A. CBF is increased significantly when nitrous oxide is administered alone
B. CBF response to carbon dioxide is preserved with nitrous oxide use
C. IV anesthetics blunt the CBF changes seen with nitrous oxide
D. Substituting nitrous oxide for volatile anesthetic will not affect CBF as long as the MAC value is unchanged
D. Substituting nitrous oxide for volatile anesthetic will not affect CBF as long as the MAC value is unchanged
Which of the following statements regarding nitrous oxide and cerebral blood flow (CBF) is FALSE?
A. CBF is increased significantly when nitrous oxide is administered alone
B. CBF response to carbon dioxide is preserved with nitrous oxide use
C. IV anesthetics blunt the CBF changes seen with nitrous oxide
D. Substituting nitrous oxide for volatile anesthetic will not affect CBF as long as the MAC value is unchanged
D. Substituting nitrous oxide for volatile anesthetic will not affect CBF as long as the MAC value is unchanged
A 32-year-old woman with a history of myasthenia gravis presents for transsternal thymectomy. Which of the following preoperative risk factors MOST predicts the need for extended postoperative ventilation in this patient?
A. Dose of pyridostigmine greater than 750 mg daily
B. Duration of myasthenia gravis for more than 6 years
C. History of chronic respiratory disease other than myasthenia gravis
D. Preoperative vital capacity less than 2.9 liters
B. Duration of myasthenia gravis for more than 6 years
You are caring for an 18-year-old patient undergoing urgent exploratory laparotomy for small bowel obstruction secondary to adhesions. An airway cart is obtained prior to induction, which includes multiple airway modalities including jet ventilation, a fiberoptic scope, and a tracheostomy kit. The patient was given propofol and succinylcholine for induction. Following administration of induction medications, the patient develops severe trismus with no other muscle rigidity noted. Vital signs are BP 110/70 mmHg, HR 105 bpm, SpO2 100%, and temperature 37.1 degC. Of the following, which is the MOST appropriate?
A. Administer dantrolene immediately
B. Insert a nasal airway and mask ventilate until trismus resolves
C. Perform immediate tracheostomy
D. Perform nasal fiberoptic intubation with an apneic oxygenation technique
D. Perform nasal fiberoptic intubation with an apneic oxygenation technique
Which of the following is TRUE regarding congenital myasthenic syndromes (CMS)?
A. Inheritance is almost always autosomal dominant
B. Pathology is secondary to genetic mutations for proteins involved in neuromuscular transmission
C. Peri-operative plasmapheresis may be beneficial for crises
D. The most common defect is related to presynaptic acetylcholine release
B. Pathology is secondary to genetic mutations for proteins involved in neuromuscular transmission
With regard to myasthenia gravis and myasthenic syndrome, which of the following is correct?
A. Myasthenia gravis: weakness improves with repetition
Myasthenic syndrome: weakness worsens with repetition
B. Myasthenia gravis: circulating antibodies against voltage-gated calcium channels
Myasthenic syndrome: circulating antibodies against acetylcholine receptors
C. Myasthenia gravis: weakness most often involves bulbar muscles
Myasthenic syndrome: weakness most often involves the proximal extremities
D. Myasthenia gravis: More sensitive to succinylcholine
Myasthenic syndrome: Less sensitive to succinylcholine
C. Myasthenia gravis: weakness most often involves bulbar muscles
Myasthenic syndrome: weakness most often involves the proximal extremities
Which of the following changes will cause the GREATEST decrease in cerebral blood flow during otherwise normal physiologic conditions?
A. Decreasing PaO2 from 80 to 45 mm Hg
B. Decreasing mean arterial blood pressure from 100 to 70 mm Hg
C. Decreasing body temperature from 37 to 34 degrees Celsius
D. Increasing PaCO2 from 40 to 60 mm Hg
C. Decreasing body temperature from 37 to 34 degrees Celsius
Which of the following ions is MOST responsible for the maintenance of the resting neural membrane potential between -60 and -90 mV?
A. Calcium
B. Chloride
C. Potassium
D. Sodium
C. Potassium
A 43-year-old man with a history of ulcerative colitis just underwent an uncomplicated total proctocolectomy with ileostomy placement. Neuromuscular blockade was maintained throughout the case with a vecuronium infusion. Which of the following statements is MOST TRUE regarding the assessment of the recovery from neuromuscular blockade?
A. Tactile fade to train-of-four stimulation is superior to acceleromyography for detecting residual neuromuscular blockade
B. Presence of adequate unsupported tidal volumes precludes the need for further assessment of neuromuscular blockade
C. Train-of-four stimulation of the adductor pollicis more closely reflects blockade of the larynx when compared to the corrugator supercilii
D. Use of double-burst stimulation is more sensitive for the detection of fade when compared to standard train-of-four monitoring
D. Use of double-burst stimulation is more sensitive for the detection of fade when compared to standard train-of-four monitoring
Which of the following is the most correct regarding endovascular cerebral aneurysm repair compared to craniotomy and surgical clipping?
A. After open surgical repair, patients should remain intubated and after endovascular repair patients can be extubated at the end of the case
B. Avoiding coughing on emergence is primarily a concern with open repair
C. Hyperventilation should be avoided with endovascular repair, but not with open surgery
D. The complications associated with endovascular repair are less severe than those associated with open repair
C. Hyperventilation should be avoided with endovascular repair, but not with open surgery
Which of the following would be LEAST likely to result in an episode of autonomic hyperreflexia?
A. A patient with a C6 spinal cord lesion undergoing simple fecal disimpaction
B. A laboring patient with a prior T4 spinal cord injury
C. A patient with a T10 spinal cord lesion undergoing cystoscopy
D. Visceral stimulation below the spinal cord lesion in a patient with a T5 injury
C. A patient with a T10 spinal cord lesion undergoing cystoscopy
In what body temperature range is there typically transition to complete suppression of electroencephalogram (EEG) activity?
A. 10-13 degrees Celsius
B. 15-18 degrees Celsius
C. 23-25 degrees Celsius
D. 32-34 degrees Celsius
B. 15-18 degrees Celsius
A 67-year-old woman with a history of a chronic 90% right carotid artery occlusion presents with weakness and sensory loss in her left lower extremity and foot. She is found to have an acute thromboembolic occlusion of her right anterior cerebral artery. Which of the following is MOST LIKELY to improve blood flow downstream of the vascular occlusion when compared to the remainder of the cerebral circulation?
A. Clevidipine
B. Hypothermia
C. Respiratory alkalosis
D. Volatile anesthetic agents
C. Respiratory alkalosis
A 67-year-old woman with a history of a chronic 90% right carotid artery occlusion presents with weakness and sensory loss in her left lower extremity and foot. She is found to have an acute thromboembolic occlusion of her right anterior cerebral artery. Which of the following is MOST LIKELY to improve blood flow downstream of the vascular occlusion when compared to the remainder of the cerebral circulation?
A. Clevidipine
B. Hypothermia
C. Respiratory alkalosis
D. Volatile anesthetic agents
C. Respiratory alkalosis
A 53-year-old man presents with an acute thromboembolic stroke with subtotal occlusion of his right middle cerebral artery. He is emergently taken to the interventional radiology suite for mechanical thrombectomy. The periprocedural use of which of the following is MOST LIKELY to improve blood flow to the ischemic area of the brain relative to the collateral circulation?
A. Isoflurane for anesthetic maintenance
B. Permissive hypercapnea
C. Sodium nitroprusside for blood pressure maintenance
D. Therapeutic hyperventilation
D. Therapeutic hyperventilation
Which of the following is an indication for intracranial pressure (ICP) monitoring?
A. A 42-year-old patient presenting with head trauma, GCS 7, hypotension, and normal head CT scan on admission
B. A patient with a history of atrial fibrillation taking warfarin with head trauma and GCS score of 12
C. An elective multilevel laminectomy in an otherwise healthy 52-year-old male
D. During an awake craniotomy
A. A 42-year-old patient presenting with head trauma, GCS 7, hypotension, and normal head CT scan on admission
Which of the following findings is MOST LIKELY to be seen during generalized tonic-clonic convulsions on intraoperative electroencephalogram monitoring?
A. Beta waves
B. Burst suppression
C. K complexes
D. Spike and slow wave pattern
D. Spike and slow wave pattern
A 58-year-old female smoker with hypertension presented to the Emergency Department complaining of a severe headache, nausea, and photophobia. Computed tomography scans revealed a subarachnoid hemorrhage. She was taken to interventional radiology and saccular aneurysm at the left middle cerebral artery was coiled. She was transferred to the neuro intensive care unit. On day seven from admission, her neurologic status deteriorates. Which of the following diagnostic modalities is the BEST choice to diagnosis cerebral vasospasm?
A. Cerebral angiography
B. Computed tomography scan
C. Magnetic resonance imaging
D. Transcranial Doppler
A. Cerebral angiography
Which of the following statements about spinal cord anatomy is FALSE?
A. The dural sac in adults ends at L5
B. The dural sac in newborns ends at S3
C. The conus medullaris in adults ends at L1
D. The conus medullaris in newborns ends at L3
A. The dural sac in adults ends at L5
A 64-year-old man had a subarachnoid hemorrhage three days ago. Which of the following is NOT a treatment modality for cerebral vasospasm?
A. Chemical angioplasty
B. Hemodilution
C. Hypertension
D. Labetalol
D. Labetalol
Which of the following anesthetic techniques will reduce both cerebral metabolic rate of oxygen and cerebral blood flow?
A. Isoflurane at 1 MAC
B. Ketamine infusion titrated to EEG burst suppression
C. Nitrous oxide 50% and sevoflurane at 0.75 MAC
D. Propofol infusion titrated to EEG burst suppression
E. Sevoflurane at 1 MAC
D. Propofol infusion titrated to EEG burst suppression
Which type of frequency waves will MOST LIKELY dominate on an electroencephalogram of a patient experiencing prolonged hypoxia prior to the onset of burst suppression?
A. Alpha
B. Beta
C. Delta
D. Theta
C. Delta
A 6-year-old male with a past medical history of mitochondrial myopathy presents for a craniotomy for a temporal lobe mass. Which of the following would be appropriate?
A. Intraoperative hypothermia
B. Preoperative infusion of 5% dextrose in normal saline
C. Propofol infusion for maintenance of anesthesia
D. Rocuronium 1.2 mg/kg for intubation
B. Preoperative infusion of 5% dextrose in normal saline
Which of the following statements about thiopental is TRUE?
A. Cerebral autoregulation is unaffected
B. Cerebral metabolic rate is reduced 5% with IV induction doses
C. Increases cerebral blood flow and decreases cerebral metabolic rate
D. Uncouples cerebral blood flow and cerebral metabolic rate
A. Cerebral autoregulation is unaffected
Vecuronium use would be LEAST appropriate in which of the following patients?
A. Avocado allergy
B. Decreased dibucaine number
C. Myasthenia gravis
D. Renal disease
C. Myasthenia gravis
Which of the following anesthetic gases MOST significantly augments neuromuscular blockade?
A. Desflurane
B. Isoflurane
C. Sevoflurane
D. Nitrous oxide
A. Desflurane
A 60-year-old male with polycystic kidney disease, hypertension, and known anterior communicating artery cerebral aneurysm undergoes an endovascular thoracic aortic aneurysm repair. A lumbar drain is placed pre-operatively and blood pressure is maintained within 20% of baseline throughout the procedure. The operation goes well and the patient is extubated and following commands. Upon moving the patient to the hospital bed for transport, 50 mL of CSF is drained from the lumbar drain as the drain setup was not clamped. The patient received 0.2 mg of hydromorphone for pain control during transport. Upon arrival in the intensive care unit the patient has altered mental status. The patient is reintubated and a head CT scan is performed, showing acute subarachnoid hemorrhage. Which of the following is MOST likely responsible for the aneurysm rupture?
A. CSF drainage into the lumbar drain
B. Hypoventilation from opioid use
C. Poorly controlled hypertension intraoperatively
D. Spontaneous rupture
A. CSF drainage into the lumbar drain
Which of the following is TRUE regarding myotonic dystrophy?
A. Myotonic episodes are less likely to occur during pregnancy
B. Patients with myotonic dystrophy display resistance to the respiratory effects of benzodiazepines
C. Succinylcholine is the agent of choice for neuromuscular blockade in myotonic dystrophy
D. The majority of complications experienced are pulmonary related
D. The majority of complications experienced are pulmonary related
Which of the following is true regarding peripheral compartment syndrome?
A. A compartment pressure > 20 mmHg is an indication for emergent operative intervention
B. Arteriography is needed prior to operative intervention to identify the compartment at risk
C. Muscle weakness is a late symptom of compartment syndrome
D. Regional anesthesia effectively reduces the risk of compartment syndrome
C. Muscle weakness is a late symptom of compartment syndrome
A 60-year-old female is undergoing left carotid endarterectomy for 99% left common carotid artery stenosis. Which of the following statements regarding glucose management is applicable to this patient’s physiology?
A. Hyperglycemia aggravates lactic acidosis
B. Hyperglycemia induces aerobic glycolysis which is detrimental in acute cerebral ischemia
C. In contrast to hyperglycemia, hypoglycemia is associated with worse neurological outcomes
D. Intravenous fluid of choice is 5% dextrose in water
A. Hyperglycemia aggravates lactic acidosis
Somatosensory evoked potentials are LEAST effective for detecting vascular compromise of which of the following arterial blood supplies?
A. Anterior spinal artery
B. Posterior spinal artery
C. Internal carotid artery
D. Middle cerebral artery
E. Anterior cerebral artery
A. Anterior spinal artery
An otherwise healthy 23-year-old man was involved in a motorcycle collision where he sustained a closed head injury. The patient was intubated in transit to the hospital for a deteriorating mental status and on arrival, his heart rate was 41 bpm with a blood pressure of 194/111 mmHg. Which of the following is MOST responsible for these presenting vital signs?
A. Excess aldosterone release by the adrenal cortex
B. Excess release of corticotropin-releasing hormone from the hypothalamus
C. Parasympathetic activation via the trigeminal ganglion
D. Sympathetic activation via the medullary vasomotor center
D. Sympathetic activation via the medullary vasomotor center
Which of the following BEST describes how to administer neostigmine for treatment of succinylcholine apnea in a patient with atypical plasma cholinesterase?
A. 0.03 mg/kg with presence of phase I block
B. 0.03 mg/kg with presence of phase II block
C. 0.07 mg/kg with presence of phase I block
D. 0.07 mg/kg with presence of phase II block
B. 0.03 mg/kg with presence of phase II block
Which of the following therapies is contraindicated in the setting of increased intracranial pressure following traumatic head injury?
A. Barbiturate coma
B. Head elevation
C. High-dose glucocorticoids
D. Neuromuscular blockade
C. High-dose glucocorticoids
Which of the following BEST describes the clinical difference between global and focal cerebral ischemia?
A. Focal ischemia can be tolerated for a longer period of time than global ischemia
B. Focal ischemia will tend to result in neuronal depolarization while global ischemia results in neurons left in their resting state
C. Global ischemia can induce a flat EEG while focal ischemia cannot
D. Global ischemia may be attenuated by hypothermia while focal ischemia is not
A. Focal ischemia can be tolerated for a longer period of time than global ischemia
An 8-year-old male with a past medical history of Becker Muscular Dystrophy (BMD) undergoes induction of anesthesia with propofol, fentanyl, and succinylcholine. He is successfully and uneventfully intubated. An hour into the case he develops a wide QRS complex rhythm that degenerates into ventricular fibrillation with consequent loss of peripheral pulses, pulse oximetry, and ability to measure blood pressure via a non-invasive blood pressure cuff. No changes are noted in peak airway or plateau pressures and breath sounds are noted bilaterally. What is the MOST likely etiology of this rapid decline in hemodynamics?
A. Anaphylaxis
B. Malignant hyperthermia
C. Myocardial infarction
D. Rhabdomyolysis
D. Rhabdomyolysis
A 57-year-old male is undergoing transsphenoidal resection of a large pituitary adenoma. Prior to surgery, the patient’s symptoms consisted only of a hemianopsia. Eight hours after surgical incision, the anesthesiologist notes that the patient’s urine output has increased from 85 mL/hour to 600 mL/hour. Urine and plasma labs are sent and are notable for low urine specific gravity, low urine osmolarity, and high plasma osmolarity. Which is the MOST likely cause of this patient’s increased urine output?
A. Cerebral salt-wasting syndrome
B. Diabetes insipidus
C. Fluid overload
D. Syndrome of inappropriate antidiuretic hormone secretion
B. Diabetes insipidus
Which of the following is TRUE about cerebral metabolism?
A. Approximately 10 minutes after interruption of blood flow to the brain, ATP stores are depleted
B. Brain glucose metabolism in the brain is approximately 5 mg/100 g/min
C. The main metabolic substrate of the brain during starvation state is lactate
D. The majority of glucose in the brain is metabolized via anaerobic processes
B. Brain glucose metabolism in the brain is approximately 5 mg/100 g/min
Which of the following patients would be LEAST likely to have pronounced upregulation of nicotinic acetylcholine receptors?
A. 31-year-old male with acute severe spinal cord injury 10 hours ago
B. 38-year-old female intubated in the ICU for 18 days due to aspiration pneumonia
C. 45-year-old female undergoing skin grafting for 3rd degree burns that occurred a week prior
D. 56-year-old female with long-term multiple sclerosis
A. 31-year-old male with acute severe spinal cord injury 10 hours ago
What component of the brainstem plays the largest role in regulating balance and coordination?
A. Cerebellum
B. Medulla
C. Midbrain
D. Pons
D. Pons
A patient presents for elective neurointerventional repair of a wide-neck intracranial aneurysm. The neurosurgical interventionalist plans on first deploying a stent and then placing coils into the aneurysm sack. Which of the following would be your MOST significant concern regarding anesthetic management?
A. Antiplatelet and anticoagulant agent plan in the perioperative period
B. Deciding on a total intravenous anesthetic versus inhalational anesthetic plan
C. Determining which kind of coils the interventionalists plans to deploy
D. Determining what kind of embolization agent the interventionalist plans to use
A. Antiplatelet and anticoagulant agent plan in the perioperative period
An 18-year-old female has a sudden decline in mental status following a motor vehicle collision. Vital signs are as follows:
HR: 44 bpm
BP: 184/92 mm Hg
RR: 8 breaths/min
SpO2: 92%
Which of the following is the MOST appropriate initial management?
A. Mannitol
B. Endotracheal intubation
C. Nitroglycerin
D. CT scan of head
B. Endotracheal intubation
Which of the following is the most appropriate diagnostic test in a patient who is two years status post discectomy with acute onset back pain, fever, and lower extremity weakness?
A. Computed tomography
B. Magnetic resonance imaging
C. Plain lumbar radiograph
D. Three-phase bone scintigraphy
B. Magnetic resonance imaging
Which of the following is TRUE regarding Parkinson disease?
A. Levodopa cannot cross the blood brain barrier without the concomitant administration of carbidopa
B. Levodopa should be continued on the day of surgery
C. Parkinson disease is considered a trinucleotide repeat disorder
D. Treatment is aimed at increasing serotonin concentration
B. Levodopa should be continued on the day of surgery
Succinylcholine associated side effects are MOST LIKELY to be seen in which of the following patients?
A. A patient who suffered burns to 40% of their body 12 hours ago
B. A patient with an ischemic stroke 8 hours ago
C. A patient with multiple sclerosis and hyperreflexia
D. A patient with myasthenia gravis having an acute exacerbation
C. A patient with multiple sclerosis and hyperreflexia
You are called to evaluate an 18-year-old who delivered a healthy newborn at 40-weeks gestation yesterday. She underwent uneventful epidural anesthesia for labor and had a vaginal delivery. Today, she complains of severe headache especially when she flexes her neck. She has received caffeine and ibuprofen, but still has a headache. She reports photophobia, a stiff neck, and double vision. Vital signs reveal a new onset fever and confusion on neurologic exam. Which of the following is the MOST likely diagnosis?
A. Bacterial meningitis
B. Basilar migraine
C. Epidural hematoma
D. Post-dural puncture headache
A. Bacterial meningitis
Which of the following electroencephalography patterns are most associated with sleep and sedation?
A. Alpha waves
B. Beta waves
C. Gamma waves
D. Delta waves
D. Delta waves
Which of the following is TRUE regarding the use of intraoperative electroencephalogram (EEG) monitoring?
A. The electrodes used in EEG monitoring must be different from those used in ECG monitoring
B. The main frequencies captured are between 1 to 30 Hz
C. The primary indication is to monitor depth of anesthesia
D. Use of intraoperative EEG is contraindicated during epilepsy surgery
B. The main frequencies captured are between 1 to 30 Hz
Patients with myotonic dystrophy have an increased risk of aspiration due to several mechanisms. Which of the following is NOT one of those mechanisms?
A. Delayed gastric emptying
B. Pharyngeal muscle weakness
C. Intestinal hypomotility
D. Gastric spasticity
D. Gastric spasticity
What is a typical indication for the neurologic wake-up test (NWT) to assess brain function?
A. Complex intracranial surgery near verbal areas
B. Critical care patients with traumatic brain injury
C. Placement of a deep brain stimulator
D. Spinal cord surgery to evaluate for nerve function
B. Critical care patients with traumatic brain injury
A 55-year-old male is undergoing an open thoracoabdominal aortic aneurysm repair. The surgeon reports that there is sudden and significant bleeding at the surgical site. The surgeon has to hold pressure near the anterior radicular vessels at the lower thoracic and upper lumbar levels. What would be the expected finding as a result of this on evoked potential monitoring?
A. Decreased amplitude and increased latency on motor evoked potential
B. Decreased amplitude and increased latency on somatosensory evoked potential
C. Increased amplitude and increased latency on motor evoked potential
D. Increased amplitude and increased latency on somatosensory evoked potential
A. Decreased amplitude and increased latency on motor evoked potential
Which of the following is MOST TRUE regarding the subdivision of the upper airway?
A. The hypopharynx refers to the region between the base of the tongue and the true vocal cords
B. The larynx refers to the region between the base of the epiglottis and the carina
C. The nasopharynx refers to the region between the nares and the hard palate
D. The oropharynx refers to the region between the soft palate and the epiglottis
D. The oropharynx refers to the region between the soft palate and the epiglottis
Which of the following statements concerning the circle of Willis is the MOST correct?
A. The anterior inferior cerebellar artery is a branch off of the vertebral arteries
B. The basilar artery branches into the posterior communicating arteries
C. The internal carotid artery branches into the middle cerebral and posterior cerebral arteries
D. The posterior communicating arteries connect the anterior and posterior circulations
D. The posterior communicating arteries connect the anterior and posterior circulations
A 43-year-old woman scheduled for elective cholecystectomy has a history of hypertension well-controlled on amlodipine. Which of the following management options is BEST given the potential interaction of calcium channel blockers and neuromuscular blocking agents?
A. Avoid depolarizing neuromuscular blockers during the case
B. Proceed with usual management since clinical interaction between the drugs is minimal
C. Tell the patient to hold her amlodipine on the day of surgery
D. Use half the initial intubating dose of nondepolarizing neuromuscular blocker
B. Proceed with usual management since clinical interaction between the drugs is minimal
A 29-year-old male is brought in by paramedics from the scene of a motor vehicle accident. He experienced some blood loss in the field from a scalp laceration but is not actively bleeding. Traumatic brain injury (TBI) is diagnosed, but no other injuries are identified. His past medical history is only positive for Ménière disease, controlled with furosemide and a potassium supplement, but his basic metabolic panel is normal. He is hypotensive. Which of the following fluids would be most appropriate for resuscitation?
A. Albumin
B. D5NS
C. D5W
D. Hypertonic saline
D. Hypertonic saline
A 50-year-old female with small cell lung cancer presents to the Emergency Department with extreme proximal muscular weakness upon awakening which alleviates with movement. What is the likely mechanism of this weakness?
A. Antibodies directed at postsynaptic acetylcholine receptors
B. Antibodies directed at voltage gated calcium channels in presynaptic nerve terminals
C. Defect in the voltage gated calcium channel
D. Hypercalcemia induced weakness
B. Antibodies directed at voltage gated calcium channels in presynaptic nerve terminals
A young male, undergoing open reduction internal fixation of a pelvic fracture and external fixation of a tibial plateau fracture following a motorcycle accident, develops elevated creatinine phosphokinase (CPK) and altered renal function. The patient is an otherwise healthy professional body builder who weighs 135 kg. The surgical time is going on eight hours and the patient has been hemodynamically stable. Which of the following is MOST likely the cause of this finding?
A. Development of compartment syndrome
B. Prolonged immobilization
C. Succinylcholine administration
D. Tourniquet use
B. Prolonged immobilization
You are planning on using a wake-up technique during surgery for a deep brain stimulator placement for Parkinson disease. Which of the following will likely interfere the LEAST with the microelectrode recording portion of the electrode placement?
A. Desflurane
B. Dexmedetomidine
C. Midazolam
D. Propofol
B. Dexmedetomidine
Which choice BEST describes the effect that 1.5 MAC isoflurane has on cerebral blood flow (CBF) and cerebral metabolic rate (CMRO2) in a normal brain?
A. Increased CBF and increased CMRO2
B. Decreased CBF and decreased CMRO2
C. Increased CBF and decreased CMRO2
D. Decreased CBF and increased CMRO2
C. Increased CBF and decreased CMRO2
A 68-year-old male is undergoing a hemicolectomy for colon cancer. He is maintained on 1% isoflurane and fentanyl boluses. Rocuronium is used for paralysis and is titrated to a single twitch on the peripheral nerve stimulator. Intraoperatively the surgeon complains of inadequate paralysis and requests further relaxation. Assessment of which of the following muscles is the MOST representative of abdominal muscle paralysis?
A. Adductor pollicis muscle
B. Corrugator supercilii muscle
C. Flexor hallucis brevis muscle
D. Orbicularis oculi muscle
B. Corrugator supercilii muscle
Which of the following is a risk factor for the development of postoperative cognitive dysfunction in a patient having surgery?
A. Administration of general anesthesia
B. Lower educational level
C. Cardiac surgery
D. Inpatient surgery
B. Lower educational level
Following release from the sarcoplasmic reticulum, what does calcium bind to within myofibrils during the initiation of a muscle contraction?
A. F-actin
B. Myosin
C. Tropomyosin
D. Troponin C
D. Troponin C
A patient is five days post C4 spinal cord injury from a motorcycle crash. The patient was found to have spinal shock upon admission. Which of the following is the MOST important continued treatment to optimize outcome?
A. Insertion of a lumbar drain to maintain ICP < 20 mm Hg
B. Maintenance of mean arterial pressure greater than 85 mm Hg
C. Methylprednisolone 30mg/kg IV bolus
D. Transfusion of packed red blood cells to maintain hemoglobin above 12 g/dL
B. Maintenance of mean arterial pressure greater than 85 mm Hg
Which of the following should be AVOIDED in the perioperative management of a patient with hypokalemic periodic paralysis?
A. Dextrose-containing intravenous fluids
B. Low sodium meal
C. Postoperative opioid administration
D. Potassium-containing intravenous fluids
A. Dextrose-containing intravenous fluids
In which of the following patients would upregulation of the nicotinic acetylcholine receptors NOT occur?
A. A 26-year-old male with Guillain-Barré syndrome
B. A 57-year-old female with myasthenia gravis
C. A 72-year-old male immobilized in the intensive care unit for the past 16 days
D. An 18-year old male with a history of burns covering 60% of his body 8 months ago
B. A 57-year-old female with myasthenia gravis
Which of the following is true regarding the parasympathetic nervous system?
A. Cranial nerve VI is a preganglionic cell body
B. Ganglia are located adjacent to or within the innervated organ
C. Innervation of the heart maintains contractility
D. Postganglionic fibers are longer than preganglionic fibers
B. Ganglia are located adjacent to or within the innervated organ
A patient presents with electrical shooting pain from her neck to her left hand’s first three digits when turning her head. She exhibits weakness in her hand and a positive Hoffman sign. What is the most likely cause of this patient’s pain?
A. Brachial plexopathy
B. Carpal tunnel syndrome
C. Cervical spinal radiculitis
D. Cervical spinal myelopathy
D. Cervical spinal myelopathy
A 19-year-old male is brought to the trauma bay of the emergency room after a severe MVA. He was thrown several feet from his vehicle and currently has a GCS of 3. He will be intubated and brought to the OR for an emergency craniotomy. Which of the following drugs will increase ICP the most?
A. Dexmedetomidine
B. Etomidate
C. Methohexital
D. Nitrous oxide
D. Nitrous oxide
Which of the following is MOST TRUE regarding ion flow in neuromuscular transmission?
A. Binding of acetylcholine to nicotinic receptors in the motor end plate causes ion channels to open and exclusively allow sodium ions to flow across the membrane into the muscle cell
B. Calcium ions cause neurotransmitter-containing vesicles to fuse to the neuron cell membrane at the axon terminal resulting in exocytosis of acetylcholine
C. Ion shift prevents the electrical current across the cell membrane and ultimately muscle contraction
D. The flow of sodium ions across the membrane away from the muscle cell and potassium ions into the cell causes a local depolarization of the muscle cell referred to as an end plate potential
B. Calcium ions cause neurotransmitter-containing vesicles to fuse to the neuron cell membrane at the axon terminal resulting in exocytosis of acetylcholine
Preoperative administration of intravenous dextrose is MOST likely to benefit a patient with which of the following skeletal muscle channelopathies?
A. Hyperkalemic periodic paralysis
B. Hypokalemic periodic paralysis
C. Myotonia congenita
D. Thyrotoxic periodic paralysis
A. Hyperkalemic periodic paralysis
Which of the following patients has the HIGHEST risk of developing cognitive impairment in the postoperative period?
A. A 60-year-old who abuses alcohol but has been sober for 2 months who is having a total knee replacement
B. A 65-year-old man with dementia undergoing a laparotomy for small bowel obstruction that required 2 units of packed red blood cells
C. A 65-year-old woman with normal mentation who fell and broke her hip who is undergoing a hip arthroplasty
D. A 70-year-old retired male physician who is having an open cystectomy
B. A 65-year-old man with dementia undergoing a laparotomy for small bowel obstruction that required 2 units of packed red blood cells
Which of the following is TRUE regarding limb-girdle muscular dystrophy?
A. Cardiovascular complications may be associated with the disease
B. It is usually attributed to genetic defects in one particular gene
C. Patients often present with weakness in the extremities
D. Patients typically are able to live and function normally
A. Cardiovascular complications may be associated with the disease
Which of the following is TRUE regarding Becker Muscular Dystrophy (BMD)?
A. The clinical course is usually severe and debilitating
B. They have a reduced quantity of dystrophin
C. They may also have microglossia
D. Unlike Duchenne muscular dystrophy, cardiac involvement is uncommon
B. They have a reduced quantity of dystrophin
Which of the following anesthetic agents is paired correctly with its effect on cerebral metabolic rate of oxygen (CMRO2), cerebral blood flow (CBF), and intracranial pressure (ICP)?
A. Isoflurane: ↓ CMRO2, ↓ CBF, ↓ ICP
B. Sevoflurane: ↓CMRO2, ↑ CBF, ↑ ICP
C. Nitrous oxide ↑ CMRO2, ↓ CBF, ↓ ICP
D. Propofol ↓ CMRO2, ↑ CBF, ↓ ICP
