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102 Cards in this Set
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MH56 (NEW) Bleeding patient. What is relative contraindication to Prothrombinex?
A. History of HITS B. Von Willebrands C. Haemophilia B D. Warfarin overdose E. Renal failure F. Overdose vit K (not warfarin) |
Answer is A (it contains 192 IU heparin per vial)
PROTHROMBINEX-VF is a sterile lyophilised (freeze-dried) prothrombin complex concentrate (PCC) containing purified human coagulation factors II, IX, X and low levels of factor VII. PROTHROMBINEX-VF distributed in Australia, is prepared from plasma collected from voluntary and non remunerated Australian donors. When reconstituted as recommended, each vial of PROTHROMBINEX-VF contains 500 IU of factor IX, approximately 500 IU of factor II, 500 IU of factor X, 25 IU of antithrombin III, 192 IU of heparin sodium and ≤ 500mg of plasma proteins (which includes low levels of factor V & VII.) Other ingredients include sodium citrate, sodium phosphate and sodium chloride. PROTHROMBINEX–VF is manufactured using two dedicated pathogen inactivation/ reduction steps which contribute to the clearance of viruses: dry heat treatment at 80C for 72 hours, and nanofiltration. The nanofiltration step (size-based removal) is complementary to the dry heat treatment step. This increases the spectrum of pathogens that can potentially be eliminated and hence further enhances the safety profile of PROTHROMBINEX-VF. |
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TMP-128 [Aug09] Indication for percutaneous closure of ASD
A. Ostium primum < 3cm B. Ostium primum > 3cm C. Ostium secundum < 3 cm D. Ostium secundum > 3cm E. Sinus venosus ASD |
C
CEACCP Anaesthesia for percutaneous closure of atrial septal defects 2008 Only an ostium secundum ASD is suitable for percutaneous closure. If the defect is very large (>3 cm) or complicated (associated with other abnormalities), or an incomplete rim is detected, referral for surgical closure is indicated. |
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TMP-129 [Aug09] Methylene blue given intravenously has the effect:
A. Pulse oximetry goes down B. Blood Gas Pa02 decrease C. Hypotension D. Metabolic acidosis E. Increased heart rate |
A
Update in Anaesthesia Pulse Oximetry 1995 A source of light originates from the probe at two wavelengths (650nm and 805nm). Intravenous dyes such as methylene blue, indocyanine green, and indigo carmine can cause falsely low SpO2 readings [30], an effect that persists for up to 20 min [31] Methylene Blue Administration is associated with decreased cerebral oximetry values A&A 2007 Methylene blue has a dose- and time-dependent effect on plasma light absorbance, with a spectral absorption peak at 668 nm, resulting in falsely low pulse oximetry readings. B. False: no impact on PaO2 C. False: Methylene blue inhibits the enzyme guanylate cyclase, avoiding the cyclic guanosine 3'5'-monophosphate (cGMP)-dependent vasorelaxant effects of nitric oxide in the smooth muscle of vessels. methylene blue has been used to treatrefractory vasoplegia after cardiopulmonary bypass (CPB), anaphylaxis, and septic shock. (refractory hypotension) J Thorac Cardiovasc Surg 2003;125:426-427 D False: Methylene blue is indicated for methemoglobinaemia causing metabolic acidosis, cardiac ischaemia, dyspnea or methemoglobin level >30%. E. Heart rate, cardiac filling pressures, cardiac output, oxygen delivery and consumption did not change. Brazillian journal of medical and biological research 1999 |
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TMP-130 [Aug09] Essential diagnostic criteria on ECG for LBBB
A. Loss of septal Q's in V5 and V6 B. RSR in V1 C. Large slurred S in V6 D. T-waves opposite to direction of QRS E. QRS duration minimum 0.2 s |
A or D
Previously, stem has not included option D. Both appear to be correct. Diagnostic criteria for LBBB: 1. Total QRS duration >0.12 s. 2. No secondary R wave in V1 to indicate RBBB. 3. No septal q wave in V5, V6 or in leads further to the left (lead I and aVL in horizontal hearts). 4. T-waves in opposite direction to QRS (look for neg T where QRS is fully positive) |
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MH57 (NEW) Patient over-warfarinised and is for surgery. Prothrombinex 50U/kg may NOT reverse an INR of 5.5 because it contains:
A. Citrate B. Heparin C. Anti-thrombin III D. Not enough Factor VII E. Not enough Factor X |
D
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PL29 (NEW) Ventricular fibrillation (VF) following caudal anaesthesia in 20kg six year old child. The recommended dose of of Intralipid 20% is:
A. 10mls B. 20mls C. 30mls D. 40mls E. 50mls |
C
Weight = (Age(y) + 4) x 2 which is 20kg Dose of Intralipid 20% is 1.5 ml/kg = 30ml AAGBI guidelines 2010 - Immediately give iv 1.5ml/kg over 1 min and start and iv infulsion of 15 ml/kg/hr |
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7. (NEW) Regarding College Professional Document PS9 – sedation for colonoscopy – the following equipment must be present (NB: The wording was 'present', not 'ready access to' as used for defib in PS9)
a. Defibrillator b. Mechanical ventilator c. Anaesthetic machine d. Suxamethonium e. Dantrolene |
A
Ready access to a defibrillator A means of inflating the lung is "a self-inflating bag and advanced airway management. Emergency drugs that must be present did not include sux or dantrolene |
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8. (NEW) According to PS9 for sedation with Propofol for colonscopy, the staff required is/are:
a. Medical practitioner other than proceduralist b. Nurse other than proceduralist c. Anaesthetist in addition to the proceduralist d. Assistant e. Proceduralist alone |
Answer is A
PS9 Propofol may be used by a medical practitioner with airway and resuscitation skills, and training in sedation for conscious sedation in ASA P 1-2 patients. Intravenous anaesthetic agents such as propofol must only be used by a second medical practitioner trained in their use because of the risk of unintentional loss of consciousness. These agents must not be administered by the proceduralist |
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TMP-131 [Aug09] Troponin is elevated post-infarct
A. 1-2 days B. 2-5 days C. 5-14 days D. 7-21 days E ? |
C
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TMP-132 [Aug09] Laparoscopic cholecystectomy patient with hyperparathyroidism and ionised calcium of 2.0 mmol/l. The BEST initial treatment is:
A. Calcitonin B. Magnesium C. Dialysis D. IV fluids E. Frusemide |
D.
OHA - Initial management should be rehydration; as Ca++ inhibits ADH. Promotion of a diuresis also increases excretion of Calcium. Texts then defer as to the next treatment; OHA says Pamidronate IV, but also states a saline diuresis with frusemide is 2nd line. Calcitonin is temporary. |
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11. (NEW) Your patient given thiopentone by mistake has a porphyric (acute intermittent) crisis with abdominal pain and then seizures. What drug is contraindicated?
a. Phenytoin b. Morphine c. can't remember others d. ? e. ? |
A - can cause porhyric crisis on it's own
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*12. (NEW) Fit lady for elective laparoscopic cholecystectomy seen in PreAdmission Clinic. ECG shows LAD ?(LAFB), RSR in V1, wide slurred S in V6 and QRS duration 0.2 msec. Your options
a. Refer to cardiology b. Continue with surgery c. Place permanent pacemaker d. Place temporary pacing wires e. Give atropine premedication |
Ans B
OHA Preoperative management 1. First degree heart block in the absence of symptoms is common. No investigation or treatment is necessary is asymptomatic. 2. Second or third degree heart block may need pacemaker insertion. If surgery is urgent this may be achieved quickly by inserting a temporary transvenous wire prior to definitive insertion. 3. Bundle branch, bifascicular, or trifascicular block will rarely progress to complete heart block during anaesthesia and so it is not normal practice to insert pacing wire unless there have been episodes of syncope. Indications for preoperative pacing 1. symptomatic first degree heart block 2. symptomatic second degree Mobitz I heart block 3. Second degree Mobitz II heart block 4. Third degree heart block 5. Symptomatic bifascicular block or symptomatic first degree heart block plus bifascicular block (trifascicular block) 6. Slow rate unresponsive to drugs |
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13. (NEW) All these nerves provide some sensation to upper arm EXCEPT
a. Musculocutaneous b. Intercostobrachial c. Radial d. Circumflex e. Median antebrachial |
Ans A
NB: Musculocutaneous nerve is: musculo- (ie motor) ABOVE the elbow THEN sensory (as lateral cutaneous nerve of the forearm) BELOW the elbow -ie NO sensory above elbow. Innervates the coracobrachialis, biceps brachii, and brachialis muscles, Sensation to the lateral cutaneous aspect of the forearm. |
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14. (NEW) Advantage if supraclavicular over interscalene nerve block for shoulder surgery
a. Less phrenic nerve block b. Easier landmarks in obese patient c. Arm can be in any position for block d. Less risk pneumothorax e. Better cover for shoulder surgery? |
Ans A probably
Given that phrenic nerve block is an expected outcome of the interscalene block. Doesn't matter where the arm is, and in the fat patient both might be difficult. Closer to pleura with SCB ie higher risk of pneumothorax Might miss supraclavicular with SCB as it comes off early from the superior trunk. |
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15. (Variation of old question NV27) The basilic vein
a. Arises from the dorsum of the hand b. Follows the superficial radial artery c. Pierces the clavipectoral fascia d. Becomes the brachial vein at the cubital fossa e. Arcs around the radial side of the forearm |
Ans A
wiki A It arises from the medial (ulnar) side of the dorsal venous of plexus of veins; B False as above hence does not follow the superficial radial artery. C False Cephalic vein pierces clavipectoral fascia not basilic D False It joins the brachial vein to become the axillary vein in the axilla. E False it is the ulna side The cephalic vein does B,C and E. |
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AC158 [Aug09] [Aug10] Long duration of surgery, arms stretched out, head turned 30 degrees to right. On waking patient has a neurological deficit. Sensory loss over ventral lateral palm and 3 fingers, some weakness of the hand, weakness of the wrist, some paraesthesia of the forearm and weak elbow flexions. Most likely injury is
A. Median nerve B. Ulnar nerve C. C5 nerve root D. Upper cervical trunk E. Musculocutaneous |
D
Elbow flexors (Brachialis, Biceps, Coracobrachialis) and some parasthesia of forearm is in the distribution of the musculocutaneous nerve. Ventral lateral palm amd 3 fingers is median nerve distribution. So the lesion must be proximal to the formation of the terminal nerve roots; C5 and 6 nerve root, upper trunk or lateral cord (and upper trunk is the only option available). |
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17. You are attending a Paediatric arrest with a 20 kg child. The rhythym is VF and the patient has had 2 shocks. What is the next step?
a. Adrenaline b. Amiodarone c. Shock 50J d. Shock 100J |
A- Adrenalin
1st shock 2J/kg subsequent shocks 4J/kg 80 J is close enough to 100 J Adrenaline after 2 mins and reassess rhythm. |
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18. Patient with known severe aortic regurgitation. Auscultation reveals loud mid diastrolic murmur in aortic area. You also hear a quiet mid diastolic murmur in the apex. This is
a. Functional mitral stenosis b. Mitral valve incompetence c. Impaired LV function d. Papillary muscle dysfunction |
Ans A
Sounds like they're talking about the "Austin-Flint" murmur, where the regurgitant jet strikes the anterior leaflet of the mitral vale. A Austin Flint - Classically, it is described as being the result of mitral valve leaftlet displacement and turbulent mixing of antegrade mitral flow and retrograde aortic flow. Displacement: The blood jets from the aortic regurgitation strike the anterior leaflet of the mitral valve, which often results in premature closure of the mitral leaflets. This can be mistaken for mitral stenosis. (Wikipedia) Disco 27/6/10 |
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TMP-133 [Aug09] Hetastarch 130/0.4. The 0.4 means:
A. 40 mg/l B. 40 g/l C. 4 hydroxylations of every 10 glucose molecule D. every 4the glucose is hydroxyethylated E. ? |
C.
The 130 is the molecular weight of the starch, while the 0.4 is the molar substitution. To clarify, the MS (molar substitution) is the ratio of hydroxyethyl groups to glucose residues |
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TMP-134 A Hetastarch of intermediate plasma expansion and intermediate plasma duration is
A. 10% HES 250/0.6 B. 10% HES 200/0.5 C. 6% HES 450/0.7 D. 6% HES 130/0.4 E. 3% HES 200/0.5 |
D
I'm presuming they mean Voluven[1]. 130/0.4 |
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21. (NEW) Maternal collapse post-delivery. What is NOT consistent with Amniotic fluid embolism?
a. Seizure b. Petechial rash c. Hypotension d. Coagulopathy e. Cardiac arrest |
B - Petechial rash not consistent
Most common Symptoms Dyspnoea Cough Headache Chest pain Most common signs, in order: Hypotension Fetal distress Pulmonary oedema/ARDS Cardiopulmonary arrest Cyanosis Coagulopathy Seizures Uterine atony Bronchospasm Transient hypertension |
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22. (Repeat) Trauma with # pelvis and femur. Has a splenectomy. Day 2 patient thrombocytopenia, confused and hypoxic. Diagnosis is
a. fat embolism syndrome b. pneumcoccal pneumonia c. thromboembolism |
A
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23. (NEW) Indications for steroids in neurosurgery
a. Cerebral abscess b. Subdural haematoma c. Meningioma d. SAH e. Traumatic brain injury |
C
Treatment of cerebral oedema The neurologist 2006 Useful in tumours and radiation therapy Meningitis and abscess in adults steroid use is controversial Not recommended in head injury CRASH trial increased 2 week mortality rates No role in treatment of ischaemic stroke or intracerebral hemorrhage |
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24. (NEW) Rate of phenytoin administration:
a. 50 mg/min b. 70 mg/min c. 100 mg/min d. Over 5 minutes e. As fast as possible |
A
Admin by slow IVI (max 50 mg/min) into large vein via catheter (from MIMS) |
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25. EV08 Hypothetical anaesthetic agent. Flows 2 L oxygen and 2L nitrous. Copper kettle vaporiser flow 0.5 L. Volatile with SVP 380 mmHg. What is the approximate inspired volatile concentration?
a. 2% b. 5% c. 10% d. 11% |
Ans C - 10%
380mmHg/760mmHg=0.5, ie the saturated vapour pressure is half of the atmopsheric pressure, so any saturated air that comes out of the kettle will be 50% volatile Vaporiser outflow x (100%-%volatile) = vaporiser inflow Re-arrange for vaporiser outflow, = 1L/min Total gas outflows then are 2L/min O2 + 2L/min NOS + 1L/min volatile saturated air. Volatile flow is 0.5 L/min thus volatile concentration = 0.5/5 = 10% Note that in a copper kettle, the gas-inflow is a seperate flow, and not diverted from the fresh-gas flow. A variable bypass vaporiser, eg for sevo, would divert the 0.5 L/min so the correct sum above would be 0.5/4.5 = 11% |
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26. A (?failed) negative pressure leak test in a Boyles type machine. This means:
a. Vaporiser leak b. Circuit leak c. Brain leaking out of my ears by now d. Leak in non return valve |
A
Checking anaesthetic machine It is a low pressure system test. |
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27. (NEW) As per ANZCA Acute Pain Guidelines (2nd ed update), after a prophylactic subcutaneous dose of heparin, minimum time before you can remove epidural catheter is
a. 2 hours b. 4 hours c. 6 hours d. 8 hours e. 10 hours |
C.
ANZCA Acute Pain Guidelines 3rd ed p198 "Thromboprophylaxis with SC heparin is not a contraindication to neuraxial blockade. To identify heparin-induced thrombocytopenia, a platelet count should be done prior to removal of an epidural catheter in patients who have had more than 4 days of heparin therapy. Epidural catheters should be removed a minimum of 6 hours after the last heparin dose and not less than 2 hours before the next dose." Interestingly this does not correspond with most of the world wide guidelines who say 4 hours. also: LMWH - wait 12 hrs after dose to insert first dose 2hrs after removal |
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28. (NEW) Utility of BNP (brain naturietic peptide) is for
a. Dyspnoea after pneumonectomy b. Loss of consciousness after .. c. Confusion after CABG |
Likely A
Both BNP and NT-proBNP levels in the blood are used for screening, diagnosis of acute congestive heart failure (CHF) and may be useful to establish prognosis in heart failure and in Anesthesiology, preoperative BNP independently predicts in-hospital ventricular dysfunction, hospital length of stay (HLOS) and mortality up to 5 years after primary CABG surgery. So hard to know without the real question. Other things I've read suggest that BNP can help differentiate dyspnoea due to cardiac failure from other causes. After pneumonectomy, there is a sudden increase in PVR, so perhaps this is indicative of whether the right heart is coping. I think the key is dyspnoea; when the real answers appear (in the next exam no doubt) its utility is to suggest whether the dyspnoea is related to cardiac failure or something else. |
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29. (NEW) Which patients do not get pulmonary hypertension
a. ASD b. Chronic thromboembolism c. Tetralogy d. MR e. MS |
C
As you have some degree of RVOT obstruction thus pulmonary blood flow is decreased, and your mitral valve is competent so there is no increase in LA pressure. |
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30. (NEW) Drug LEAST likely to cause hypoxia in ARDS
a. Noradrenaline b. Milrinone c. Isoprenaline d. Isoflurane e. SNP |
A.
All the others would bugger up your Hypoxic Pulmonary Vasoconstriction. |
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31. PI82 (NEW) Pulmonary hypertension, which will affect PVR the most
a. Isoflurane b. Sevoflurane c. Desflurane d. Propofol e. Remifentanil |
Ans ?C
Anaesthesia and right ventricular failure AIC 2009 Inhaled anaesthetics All of the volatile anaesthetics may worsen RV dysfunction by reducing preload, afterload and contractility. Halothane, enflurane, isoflurane and sevoflurane do not adversely affect PVR. However, PVR is increased by both desflurane, and nitrous oxide, hence these agents should be avoided in patients who are at risk of RV decompensation. For example, while propofol has no effect on PVR normally, in the presence of α-adrenoreceptor activation it produces pulmonary vasoconstriction. Remifentanil produces minor pulmonary vasodilation, which is mediated by histamine release and opiate receptor pathways |
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32. (NEW) In body protected OR with a Line Isolation Monitor reading 0 mA. If you touch one active wire what will happen.
a. nothing, because no connection to earth is completed b. you get shocked c. nothing because the floor is insulated d. nothing because your shoes are nonconductive e. RCD trips |
A.
0mA means everything is fine and properly isolated so the circuit is not earth referenced. This link explains line isolation monitors nicely http://biomedgbis.com/line_isolation.htm |
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33. (NEW) Best way prevent first phase of heat loss after induction
a. Prewarming the patient with forced air warming b. Warm blankets c. Warm fluids d. Warm theatre e. Humidified gases |
A
Pre-warming eliminates the gradient between core and peripheries thus the redistribution phase does not occur. |
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34. (NEW) Best way to assess fluid resuscitation after burns is
a. Urine output b. mixed venous sats c. blood pressure d. cvp e. capillary refill |
A - urine output - from Blue Book 2005 –
"End points of resuscitation The optimal end points for burns resuscitation continue to generate much debate. Despite the administration of fluid therapy according to prescribed guidelines, problems frequently noted at the end of the burn resuscitation are generalized oedema, decreased efficiency of pulmonary gas exchange, hypoalbuminaemia and intermittent episodes of hypotension and oliguria. Some problems may indicate over resuscitation, whereas others are suggestive of ongoing hypovolaemia. Clinical examination, together with assessment of end organ perfusion (urine output 1⁄2 to 1 ml/kg/hr; intact sensorium), is the minimum assessment possible to guide burn resuscitation. Pulmonary artery catheters and other more invasive forms of monitoring of haemodynamic parameters have not been shown to improve outcome in surgical, medical or burns patients. Both subcutaneous and splanchnic oxygenation are sensitive indicators of evolving haemorrhagic shock, and have been used in burn care to monitor tissue oxygenation indices during burn shock and resuscitation.15 Recently, Rivers et al investigated the use of central venous oxygen saturation (ScvO2) as part of a package to guide therapy for severe sepsis, and showed an improvement in outcome when it was used in a single centre.16 However, the role of ScvO2 to guide resuscitation of burn shock is not established. A single centre Australasian study is planned. And from UpToDate 2009: Monitoring fluid status — Confirmation of adequate resuscitation is more important than strict adherence to Parkland or any fluid resuscitation formula. Monitoring urine output using an indwelling bladder catheter (eg, Foley catheter) is a readily available means of assessing fluid resuscitation. Hourly urine output should be maintained at 0.5 mL/kg in adults and 1.0 mL/kg in children who weigh less than 25 kg. Patients with minimal or no urine output following severe burns, despite fluid resuscitation, generally do not survive. |
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35. (NEW) Emergence delirium in a kid in recovery. To treat
a. Fentanyl 1mc/kg b. Midazolam 0.1 mg/kg c. Propofol d. Clonidine 1mc/kg e. Sucrose |
A - Fentanyl
Emergence agitation in children: an update - Current Opinion in Anaesthesiology 2005, 18:614–619 Possibly key is patient in recovery - fentanyl, midazalom and clonidine are referenced in above article for prevention. Not much is mentioned about PACU except..."all possible causes, such as physiologic compromise, physical discomfort or pain should be ruled out." Post anaesthesia excitation - Paediatric Anaesthesia 2002 12: 293–295 "In contrast with prevention, there is no scientific support for any method of treatment. Opioids are widely used and seem to be effective in most but not all cases" |
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36. (NEW) Pain in 3 year old, best objective tool
a. FLACC (crying limbs activity consolability) b. Wong baker Faces pain c. Self reporting d. Mum reporting e. Nurse reporting |
A.
Wong Baker faces (revised) for 4 to 12 years. Any form of self reporting usually not possible until the age of 4. From APMSE 3rd edition. |
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39. Best time to collect serum tryptase after suspected anaphylaxis
a. within 15 minutes b. 1 - 3 hours c. 3 - 6 hours d. 12 - 24 hours e. greater than 36 hours |
B
AAGBI safety guideline suppected anaphylactic reactions with anaesthesia 2009 Pg15 6 Take blood samples (5–10 ml clotted blood) for Mast Cell Tryptase as follows: A Initial sample as soon as feasible after resuscitation has started – do not delay resuscitation to take the sample. B Second sample at 1–2 h after the start of symptoms. C Third sample either at 24 h or in convalescence (for example in a follow-up allergy clinic). This is a measure of baseline tryptase levels as some individuals have a higher baseline level. D Ensure that the samples are labelled with the |
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40. Suspect drug cardiac toxicity (can't remember which drug - please help!) Auscultation findings which support this are
a. Bibasal crackles b. Systolic murmur LSE c. Systolic murmur Apex d. ? e. ? |
Don't know
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41.(NEW) Patient with Hemophilia A with known high titres of inhibitors to factor 8. What would you give to prevent bleeding in the patient for ot
a. FVIIa b. High dose FVIII concentrate c. FFP d. Cryo e. Platelets |
A
The whole reason why novoSeven exists in the first place. A particular therapeutic conundrum is the development of "inhibitor" antibodies against factor VIII due to frequent infusions. These develop as the body recognises the "normal form" factor VIII as foreign, as the body does not have its own "copy". The problem is that in these patients, factor VIII infusions are ineffective. Recently[update] activated factor VII (NovoSeven) has become available as a treatment for haemorrhage in patients with haemophilia and factor inhibitors. Wikipedia. Disco 28/6/10 |
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42. (Variation) Pregnant women whose paternal uncle has MH. Nobody has been tested. What's the best test to exclude MH in this patient?
a. Genetic test lady b. genetic test dad of lady c. muscle biopsy lady d. muscle biopsy dad |
Ans D
You never anaesthetise a pregnant woman unless you absolutely have to given the possibility of precipitating pre-term labour. The safest thing to do would be to do a muscle biopsy of the Dad. A genetic test can mean you are MHS if you have the same mutation but does not mean you're not sensitive if it's negative as you can have a different mutation. British Malignant Hyperthermia Association (BMHA) Not all patients can have a biopsy, these include children less than 10-12yrs (30kgs), pregnant women, and patients on prolonged steroid therapy. If the proband cannot be tested, eg a young child or deceased, then the nearest most appropriate relative is tested. In the case of a young child this would be the parents. Once the proband has been confirmed as MH susceptible, a blood sample taken at the time of the biopsy will be screened to see if they carry one of the genetic mutations that can be used to test for MH. At present only around 60% of families carry one of these mutations of which there are currently 27.From British Malignant Hyperthermia Association |
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43. A woman is being treated for pre-eclampsi. She is given 10 grams Magnesium sulphate in 1 h, instead of 1 gr per 1 h, Mg level 5-6, and patient is hyporeflexia. The best treatment is:
a. calcium b. IV fluid c. Furosemide d. ? |
Ans A
Was there an option of waiting to repeat the level a few hours later? Cos with that level but not cardiovascular instability often you'd just hold off until reflexes are normal. In many countries where serum Mg levels aren't so widely available when the original Magpie trial was done, decreased DTR was the end point in developing countries. Otherwise its A, Ca Gluconate 1g over 10 minutes, |
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44. Disease associated with malignant hyperthermia
a. central core disease b. myasthenia gravis c. myotonia congenita d. ? |
A Central core disease...kingfed
MH, CEA Vol 3, No 1 5-9 |
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45.Endotracheal tube to circuit connectors
a. 15/22 mm b. lots of other wrong combo's |
A
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46.Appropriate infection control measures when anaesthetising a patient with suspected variant-CJD, the airway equipment should be
a.thrown away b.plastic sheath, reuse c.sterilization with ethylene oxide d. sterilization with heat at 134 degrees for 3 minutes e. Autoclave |
Ans A
Reading a number of guidelines, it would suggest that options B through E is inadequate. Oral Tissues (unless you hit the tonsils, which are classed as medium risk) are generally low risk, and processing and reuse is acceptable. The process is particularly nasty and involved concentrated sodium hydroxide or 2% bleach heated up to various temperatures. Steam autoclave alone would mean 18 minutes at 134°C (hmm, wonder what would get through that unscathed). So A would probably be the right option. As they articles specifically state, covered items are still not guaranteed to be prion- free as there is always a bit of splashback. |
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47. Mechanism of action of antiepileptics in chronic pain, which is false?
a. Phenytoin workes at Na channels b. Gabapentin increases gaba in cns c. Carbamazepine works at Na channels d. Valproate increases GABA in the CNS e. lamotrogine acts at Ca channel |
Ans E
Just noting the controversial ones, while gabapentin is not a GABA precursor, agonist or antagonist, it does seem to have some effect on glutamate carboxylase which converts glutamate to GABA increasing CNS levels. Lamotrigine is definitely wrong as it acts on a Na+ Channel. E |
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48. (Repeat) Timing of worst coagulopathy after liver transplant
a. 1-2 days b. 3-4 days c. 5-6 days etc |
Ans A
Teik Oh 6E states "8-hourly for the first 24 hours, thereafter daily unless indicated. The fall in PT is more important than the actual value. FFP should be withheld to assess graft function although platelet support should be provided as usual". So that would imply the worse function is early. |
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49. Anaesthetic management in patient with cardiac tamponade
a. bradycardia for the ventricle filling time b. inotropes c. volume loading d. ? |
Ans B & C
Anesthestic management for suspected cardiac tamponade could include arterial monitoring and CVP. Keep the heart "fast, full, and strong". Minimize positive pressure ventilation, especially high-volumes. And avoid drugs that cause myocardial depression or bradycardia. Reference: Miller's Anesthesia, 7th ed. Ch 60. |
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50.(Repeat Apr 09) Doing an awake CEA. Patient becomes confused & combative after carotid clamped and opened. Priority is...
a) tell surgeon to release clamp b) tell surgeon to place shunt c) induce GA d) give midazolam |
B
OHA pg 436 |
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51. (Repeat) You intubate a young male patient for a left thoracotomy with a 39FG Robert Shaw tube. When you inflate both cuffs and ventilate the bronchial lumen you get left sided ventilation. When you attempt to ventilate the tracheal lumen the pressures are very high and you get no air entry. Yet when you deflate both cuffs you can ventilate the patient through the tracheal lumen. The most appropriate step to take next is:
A. Change to a 41FG tube B. Change to a 37FG tube C. Deflate both cuffs and insert further cm and recheck D. Deflate both cuffs and withdraw a few cm and recheck E. Pull ETT out and start again. |
C
The tube is not far in enough |
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52. (Repeat) Patient with IV in right arm, has mediastinal mass and SVC compression undergoing mediastinal biopsy, suddenly uncontrolled surgical bleeding in mediastinum. Next step in management prior to thoractomy: A. insert femoral cannulae and place on bypass
B. insert IV in left arm C. insert IV into foot D. insert jugular CVC E. trendelenburg |
C
Miller Mild mediastinal hemorrhage may respond to conservative measures: the patient can be placed in the head-up position, the systolic pressure kept in the 90s, and the wound tamponaded with surgical sponges. However, massive hemorrhage requires an emergent thoracotomy to stop the bleeding (Table 59-20). A bronchial blocker can be passed through the lumen of the existing lung-isolation device if lung isolation is required because it is often difficult to change to a DLT while the surgeon is tamponading the wound. An arterial line should be placed (if not placed previously) to measure arterial blood pressure. If hemorrhage originates from a tear in the superior vena cava, volume replacement and drug treatment may be lost into the surgical field unless they are administered through a peripheral intravenous line placed in the lower extremity. |
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53. (Repeat) ASA grading was introduced to
A. predict intraop anaesthetic risk B. Predict intraop surgical and anaesthetic risk C. Standardise the physical status classification of patients D. Predict periop anaesthetic risk E. Predict periop anaesthetic and surgical risk |
C - Specifically noted not to predict anaesthetic/surgical risk
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54. (Repeat) What is true regarding arterial pressure transducer systems
A. Underdamping overestimates systolic BP B. Underdamping underestimates SBP C. Compliant tubing? D. wide range of damping coefficient associated with good performance if system has high natural frequency |
Ans A
Physical principles of intra-arterial blood pressure measurement |
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55. 60 year old vascular patient. ECG given.
Showed large positive R waves in lateral leads, large negative S waves in anterior leads. ST depression laterally ie LVH with strain; bicuspid p waves A. LVH with strain B. Enlarged RA C. Lateral ischaemia D. LBBB E. L posterior hemiblock |
A
Sounds like LVH with strain; as long as the S waves in V1 or V2 and R waves in V5 or V6 added up to 35mm. Which lead were the bicuspid p waves in? With RA enlargement you'd get an enlarged P wave, but with LA enlargement you may see a secondary peak in the P wave. The normal situation is that you'd have a bicuspid p in V1 anyway. |
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56. Pulsus paradoxus is:
A. Reduced BP on inspiration unlike normal (ie normally increased on insp) B. Reduced BP on inspiration exaggerated from normal C. Reduced BP on expiration unlike normal D. Reduced BP on expiration exaggerated from normal E. ? |
B;
remember pulsus paradoxus is NOT a paradox in itself. The BP falls, but by greater than 10mmHg. The paradox in pulsus paradoxus is that, on clinical examination, one can detect beats on cardiac auscultation during inspiration that cannot be palpated at the radial pulse.[1] It results from an accentuated decrease of the blood pressure, which leads to the (radial) pulse not being palpable (Wikipedia) Disco 28/6/10 |
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57. What antibiotics are required for bacterial endocarditis prophylaxis in a woman with MV prolapse for cholecystectomy.
A. None B. gentamicin C. ampicillin and gentamicin D. ampicillin E. cephazolin |
A
Trickly wording! "Widely accepted indications for antibiotic prophylaxis are contaminated and clean-contaminated surgery and operations involving the insertion of an artificial device or prosthetic material." Australian Prescriber. So this patient would likely get cephazolin, but not for BE prophylaxis. The new guidelines state that the following patients should be given BE prophylaxis; Prosthetic valve or valve repair material pHx of BE Unrepaired cyanotic congenital heart disease Partially repaired cynanotic CHD with defect over the repair Repaired CHD within the 1st 6 months of repair Heart transplant with valvulopathy So the devil is in the detail! |
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58. (Repeat) Plasma glucose level compared to blood glucose level
a)32% higher b)14% higher c)same d)14%lower e)32% lower |
B
Because red blood cells (erythrocytes) have a higher concentration of protein (e.g., hemoglobin) than serum, serum has a higher water content and consequently more dissolved glucose than does whole blood. To convert from whole-blood glucose, multiplication by 1.15 has been shown to generally give the serum/plasma level. Wikipedia Disco 28/6/10 |
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59. You are called for a labour epidural. The woman is extremely distressed and in the middle of your consent process states “Just take my pain away” . You:
A. Place epidural then when calmed return to advise her of risks and complications B. Explain she has to hear all the potential complications and refuse to place epidural without consent C. Take consent from partner D. Perform spinal to relieve pain, then consent her for epidural E. Go away and return when she is more cooperative |
A as per group discussion
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60. Pre-eclamptic woman BP 180/110. Aim to drop BP to
a) 150-160 b) 140-150 c) 120-130 d) 110-120 e) 100-110 |
B
"Blood pressure should be lowered to levels of SBP 140-150/DBP 90-100 at a rate of 10-20 mmHg every 10-20 minutes" Management of Pre-eclampsia and Eclampsia ANZCA |
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61. 4 yr old presents for elective surgery, otherwise fit healthy, murmur at left sternal edge on auscultation heard in systole and diastole, disappears on lying down. Most likely cause:
A. HOCM B. VSD C. PDA D. venous hum E. ASD |
A FALSE Relieved with squatting and passive leg raise
B FALSE Relieved with Valsalva C FALSE A Continuous murmur D TRUE Characteristic E FALSE |
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62. Neonate born to known drug abusing mother brought to emergency department by grandmother, unwell lethargic, slightly jaundiced, ABG shows following:
pH 7.52 Na 135 Cl 87 K 3 pCO2 38 Which of the following is the Diagnosis? A) Septicaemia B) Hepatitis C) Pyloric stenosis D) Pneumonia E) Opioid withdrawal |
C
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63. Which of the following can be used to describe the spread of non-parametric data?
A. standard deviation B. interquartile range C. confidence interval D. standard error E. variance coefficient |
B
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64. A patient has a suspected anaphylactic reaqction under GA. What is the best time to perform the tryptase test?
A. <1 hour B. 1 to 3 hours C. 3 to 6 hours D. numerous other options |
B
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65. You are anaesthetising a patient with multiple sclerosis. The best way to avoid a flare up of this patients multiple sclerosis following the anaesthetic is to
A. Avoid dehydration B. Avoid overheating the patient C. Minimal neuromuscular blocker use D. Epidural |
B
Uhthoff's Phenomena "...increases in body temperature should be avoided. Demyelinated fibres are extremely sensitive to increases in temperature; an increase of as little as 0.5 C may completely block conduction"...Morgan and Mikhail p588 |
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66. 70 y old patient with AF (80/min) is in your pre-admission clinic booked for an anterior resection. How will you manage her AF peri-operatively?
A. Continue with case B. Echocardiography and Cardioversion C. Immediate Cardioversion D. ? E. ? |
A.
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67.(NEW) Regarding ketamine for acute pain relief
A. an appropriate dose is 0.5 -1 mg/kg B. Midazolam does not help in unpleasant dreams / delirium C. Morphine is contraindicated D. Hallucinations are common E. Subcut is better than IV |
D - relatively common side effect
A. FALSE Usual dose is 0.1 - 0.3mg/kg/hour (or as an initial bolus) B. FALSE Midazolam is useful C. FALSE Need an opioid for best effect D. TRUE Don't know about it being common, but... E. FALSE S/c is not better than; but can be used instead of IV. "however SC infusion is also used, especially in palliative care, with a bioavailability (similar to IM) of approximately 90% (Clements et al, 1982)." From APMSE |
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68. AB50 TRALI most likely after transfusion of
A. Red Blood Cells B. Platelets C. FFP D. Albumin E. Prothrombinex |
C
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69. What is the appropriate LMA size for an 8kg child:
A. 1 B. 1.5 C. 2 D. 2.5 E. 3 |
B - size 1.5
Under 5kg - size 1 5-10kg - size 1.5 10-20kg - size 2 20-30kg - 2.5 30-50kg - size 3 50-70kg - size 4 70-100kg - size 5 |
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EM66 Aneurysm clipping. Best monitor of depth of block during this is:
A. TOFR B. TOFC C. DBS D. PTC |
D - Post tetanic count (pt needs to be deeply paralysed/anaesthetised)
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71. PI81 Which volatile has the minimum effect on ICP at 1 MAC
A. Isoflurane B. Sevoflurane C. Desflurane D. Enflurane E. Halothane |
B
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72. Blunt abdo trauma, liver injury, for conservative management if
a) haemodynamically stable b) blood <500 ml in the peritonium c) low grade injury on CT d) no blood in urine |
A
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73.SZ10The absorption of fluid into the circulation during transurethral prostatectomy (TURP) is NOT related to
A. prostate size B. height of the irrigation fluid bag C. duration of surgery D. surgical technique E. type of irrigation fluid |
E - type of fluid
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74. In patients undergoing thoracotomy, techniques which reduce the incidence of intraoperative atrial fibrillation include
A. hyperventilation B. pre-operative loading with digoxin C. rocuronium, rather than pancuronium D. thoracic epidural bupivacaine E. thoracic epidural morphine |
D
Is there a role for prophylaxis against atrial fibrillation for patients undergoing lung surgery? Thus in summary digoxin and verapamil do not reduce the incidence of AF. Amiodarone may cause ARDS, and thus cannot be recommended, and flecainide and betablockers have been inadequately studied to make safe recommendations. Single randomized controlled trials have demonstrated evidence for bupivacaine epidural, magnesium and diltiazem for the prophylaxis of AF in patients undergoing non-cardiac thoracic surgery. |
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75. SG53 During laparoscopic surgery, pneumoperitoneum usually results in a fall in cardiac output when intra-abdominal pressure exceeds
A 10mmHg B 20mmHg C 30mmHg D 40mmHg E 50mmHg |
A
CEACCP Laparoscopic abdominal surgery IAP 10-20 mm Hg ↓VR → ↓CO ↑SVR → BP = ↓CO x ↑↑SVR → ↔/↑BP Venous return initially increases with intra-abdominal pressure below 10 mmHg, this paradox is due to reduction in the blood volume sequestrated in the splanchnic vasculature which increases cardiac output and arterial pressure. When intra-abdominal pressure exceeds 20 mmHg, the inferior vena cava is compressed. Venous return from the lower half of the body is impeded resulting in a fall in cardiac output. |
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77. A multi-trauma patient opens his eyes and withdraws to painful stimuli, but does not respond to voice. He is moaning but makes no comprehensible sounds. His Glasgow Coma Score is
A. 5 B. 6 C. 7 D. 8 E. 9 |
Ans D
E2V2M4 |
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78. Respiratory function in quadriplegics is improved by
A. abdominal distension B. an increase in chest wall spasticity C. interscalene nerve block D. the upright position E. unilateral compliance reduction |
B
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79. An INCORRECT statement regarding the autonomic nervous system is that
A. autonomic dysfunction is a predictor for worse long term survival after myocardial infarction B. heart rate responses are primarily mediated through the sympathetic nervous system C. inhalation anaesthetics all impair autonomic reflex responses D. autonomic dysfunction is a predictor for haemodynamic instability following anaesthetic induction E. low heart rate variability is associated with worse cardiac outcomes following non-cardiac surgery |
B
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80. Correct statements regarding expiratory-inspiratory flow-volume loops include all of the following EXCEPT
A. in obstructive disease the expiratory curve has a scooped out or concave appearance B. in restrictive disease expiratory flows are usually decreased in relation to lung volume C. in restrictive disease the expiratory curve has a convex appearance D. the expiratory curve is largely effort independent E. the inspiratory curve is effort dependent |
C
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81. Carbon dioxide is the most common gas used for insufflation for laparoscopy because it
A. is cheap and readily available B. is slow to be absorbed from the peritoneum and thus safer C. is not as dangerous as some other gases if inadvertently given intravenously D. provides the best surgical conditions for vision and diathermy E. will not produce any problems with gas emboli as it dissolves rapidly in blood |
C
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SZ11 Lowering intra-ocular pressure by applying pressure to the globe (e.g. Honan balloon) is typically contraindicated in a patient having:
A. a revision corneal graft B. a revision trabeculectomy C. an extra-capsular lens extraction D. a redo vitrectomy E. repeat retinal cryotherapy |
B
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SZ14b Following a cadaveric renal transplant under general anaesthesia, your patient's plasma K+ increases to 6.0 mmol.L-1 in recovery after being 5.0 mmol.L-1 pre and intra-operatively. This patient requires:
A. an intravenous infusion of CaCl2 (10 mls over 20 minutes) B. arterial blood gases to ascertain the acid/base status C. potassium exchange resins rectally D. sodium bicarbonate infusion (50- 100 mEq over 5- 10 minutes) E. urgent haemodialysis |
B
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84. Obstructive sleep disorder in children
A. is associated with pulmonary hypertension and dysfunction of left and right ventricles: B. has obesity as a major risk factor C. is rarely seen in children less than 8 years old D. is four times more prevalent in boys than girls E. does NOT usually require tonsillectomy for its management |
A
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85. Factors associated with post-operative ulnar nerve palsy include all of the following EXCEPT:
A. male gender B. sternal retraction for cardiac surgery C. cardiopulmonary bypass for cardiac surgery D. internal jugular vein catheterisation E. diabetes mellitus |
D
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86. 32 year old with early acute liver failure (not paracetamol related). Management includes:
A. prophylactic antibiotics B. N-acetyl cysteine as general liver protection C. avoid early intubation so can assess for encephalopathy D. INR> 3 means should be considered for transplant?? E. avoid saline as resuscitation fluid |
A
CAECCP 2004 Management of acute liver failure Prophylactic antimicrobials with broad-spectrum coverage of gram-positive and gram-negative activity including an anti-fungal (e.g. piperacillin with tazobactam and fluconazole) should be administered on admission, as this halves the incidence of infective episodes when compared with commencement at the time of suspected infection. However, this benefit must be balanced against the risk of developing multi-resistant pathogens. |
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87. Carcinoid syndrome - finding on examining heart:
A. Fine inspiratory crepitations B. Systolic murmur at apex C. Systolic murmur at left sternal edge D. Murmur at apex with opening snap E. Pericardial rub |
C
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88. Central anticholinergic syndrome, which is NOT true:
A. Will improve with neostigmine B. Peripheral anticholinergic symptoms C. Caused by Anti-Parkinson drugs D. CNS depression E. Associated with agitation, delirium, and ??? |
A
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89. The intraoperative hypothermia for aneurysm surgery trial (IHAST) showed that cooling to a target temperature of 33°C
A. did NOT improve neurological outcome in WFNS (World Federation of Neurosurgical Surgeons) in grade I-III patients B. did NOT improve neurological outcome in WFNS grade IV-V patients C. improved neurological outcome in WFNS grade I-III D. improved neurological outcome in WFNS grade III E. improved neurological outcome in WFNS grade IV-V |
A
IHAST |
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90. 12 year old child with hip dislocation at 4pm. Ate something 1 hour after injury. Now 11 pm. Best anaesthetic:
A. RSI with ETT B. delay until next day then treat elective C. inhalational induction and continue with face mask D. Reduce immediately with iv sedation E. inhalational induction and continue with face mask |
A
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91. What is 1 MET uptake of oxygen DUKE'S ?
A. 1-2 ml O2/kg/min B. 2-3 ml O2/kg/min C. 3-4 ml O2/kg/min D. 5-6 ml O2/kg/min E. 7-8mls O2/kg/min |
C
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92. Anaemia in chronic renal failure is characteristically
A. due to haemolysis in the renal vascular bed B. normochromic and microcytic C. due to defective haemoglobin synthesis D. responsive to ion and folate therapy E. associated with increased 2,3-DPG levels in blood cells |
E
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93. Histamine release in anaphylaxis does NOT cause:
A. Tachycardia B. Myocardial depression C. Coronary artery vasodilatation D. Prolonged PR interval E. Decreased impulse conduction |
B
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94. Pre-ganglionic sympathetic fibres pass to the
A. otic ganglion B. carotid body C. ciliary ganglion D. coeliac ganglion E. all of the above |
D
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95. Codeine phosphate
A. is converted by the liver to its active metabolite, oxycodone B. is not associated with tolerance on chronic use C. is not effective as an analgesic in approximately 20% of Causcasians D. is poorly absorbed from the gastrointestinal tract E. when given orally has approximately 5% of the analgesic potency of intramuscular morphine |
E - 5% potency of IM morphine - true
Slow metabolisers ~10% in Europe (ie caucasian), 20% in Africa. http://www.australianprescriber.com/magazine/34/5/133/5 |
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96. Branches of the mandibular nerve do NOT include the
A. auriculotemporal nerve B. long buccal nerve C. lingual nerve D. great auricular nerve E. chorda tympani nerve |
D
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97. Which of the following reduces the incidence of severe phantom limb pain following amputation
A. Use spinal anaesthesia B. Ketamine…? (can’t remember) |
B
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98. Preoperative assessment shows a Mallampati (ML) score of III and thyromental distance (TMD) of < 6cm. A grade 3 to 4 on Cormark and Lehane is predicted. Compared to the ML score, the TMD is
A less sensitive, less specific B less sensitive, more specific C more sensitive, less specific D more sensitive, more specific E equal sensitivity an specificity |
B
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99. The innervation of the human larynx is such that
A. the internal laryngeal branch of the superior laryngeal branch of the vagus supplies the lingual surface of the epiglottis B. in the cadaveric position the cords are fully abducted C. the recurrent laryngeal nerve supplies all the intrinsic muscles of the larynx D. the glossopharyngeal nerves are sensory to the laryngeal mucous membrane above the level of the vocal cords E. cord paralysis can be produced by a distended endotracheal cuff in the larynx compressing a branch of the recurrent laryngeal nerve against the thyroid cartilage |
E
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100. In a trial, 75 patients with an uncommon, newly described complication and 50 matched patients without this complication are selected for comparison of their exposure to a new drug.
The results show Complication present Complication absent Exposed to new drug 50 25 NOT exposed 25 25 |
A
Cohort studies: A longitudinal study where some cases are exposed and the others are not. They are followed up and the incidence of disease in each pup compared. Almost always prospective but it is possible to perform a cohort study entfre1y retrospectively. Risk analysis often with relative risk or odds ratio. Case control studies: The disease status is know and a retrospective analysis is made to determine whether there was a difference in exposure to risk factors. Risk analysis with odds ratio. Risk: the number with an even divided by the total number at risk of the event. Odds: the number with an even divided by the number without. Relative risk: ratio of the risk of an even between the two groups Above if it was a cohort study: RR: 50/75/(25/50)=1.333 OR: (50:25)/(25/25) = 2 This is a retrospective case control study. Patient with complication were identified and matched to look at the exposure. Therefore, you can’t define an incidence rate and therefore not able to calculate RR. However, you can still calculate an odds ratio. |
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101. (NEW) Max Sedation time post oral midazolam 0.5mg/kg
a. 10min b. 20min c. 30min d. 40min e. 50min |
C
If this means time to max sedation, then 30min. Pediatric Anesthesia 2007 17: 1143–1149 Different to previous question which gave a range of 20-30mins |
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102. (NEW) EM68 Art line system
a. Overdamped exaggerates mean b. Underdamping increases mean c. Underdamping underestimates systolic d. Long random option about multiple damping coefficients in an optimal system e. Compliant tubing is good |
D
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103. EM67 The tapered connector between the ETT and machine is
a.12-20mm b. 15-22mm c. 20-30mm d. 22-30mm e. 25-35mm |
B
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104. The best formula to determine the weight of an infant is
a. weight = (age+4) x 2 b. ? c. ? d. ? e. ? |
A
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105.(NEW) Which drug is an example of a specific PDE III inhibitor:
a. Aminophyline b. Sildenafil c. Milrinone d. Dipyridamole e. ? |
C
A non-selective PDE B selective PDE5 inhibitor C Selective PDE3 inhibitor D selective PDE5 inhibitor |
