MCQ 2010b

10. The best clinical indicator of SEVERE AS A. Presence of thrill B. Mean Gradient 30mmHg C. Area 1.2 cm2 D. Slow rising pulse and ESM radiating to carotids E. Shortness of breath

A

21. A 60 year old man describes orthopnoea. On examination: pansystolic murmur (at LSE)/ displaced apex beat. Likely diagnosis ? A. Mitral regurgitation B. ? C. D. E.

A

24. A 78 year old man with past difficult intubation for arm surgery. Supraclavicular block with 25 mls 0.5% bupivacaine. Shortly after begins convulsing. INITIAL management? A. Midazolam 5mg B. Intralipid 20% 1.5 ml/kg C. Thiopentone 150mg D. Suxamethonium 50mg E. Propofol 50mg

A

49. Hypocalcaemia - earliest sign: A. Tingling of face and hands B. Chvostek's sign C. Carpopedal spasm D. E.

A

55. Patient with Hx COAD and suspected pneumonia - clinical findings supporting R pneumonia on examination: A. R Dull percussion note & increased vocal resonance B. R Dull percussion note & decreased vocal resonance C. R Decreased air entry D. Tracheal deviation to left E. Tracheal deviation to right

A

64. Pregnant woman presents with narrow complex tachycardia HR 190, stable BP 100/60. No response to vagal manoevures. Management? A. Adenosine 6mg B. DCR C. Amiodarone D. Atenolol E. ?

A

67. Lady on citalopram. Which drug is relatively contraindicated? A Tramadol B. ?

A

69. Diastolic dysfunction is NOT caused by: A Adrenaline B Aortic stenosis C Hypertension D myocardial fibrosis E ?

A

99. Patient with diastolic dysfunction. Is it caused by: A. Restrictive cardiomyopathy B. Dilated cardiomyopathy C. D. E.

A

81. The median nerve A. can be blocked at the elbow immediately medial to the brachial artery B. can be blocked at the wrist between palmaris longus and flexor carpi ulnaris C. can be blocked at the wrist medial to flexor carpi ulnaris D. is formed from the lateral, medial, and posterior cords of the brachial plexus E. provides sensation to the ulnar half of the palm

A Ans B I think A. It is between PL and FCR Block at the wrist spares paralyzing the forearm muscles. http://www.sonoguide.com/median_plexus_block.html http://emedicine.medscape.com/article/1369028-overview

97. The nerve supplying area of skin between greater trochanter and iliac crest: A. subcostal nerve B. ilioinguinal nerve C. genitofemoral nerve D. femoral nerve E. lat cutaneous femoral nerve.

A Fundamentals of Regional Anaesthesia A. Subcostal: sends fibre to the first lumbar nerve and its lateral cutaneous branch runs over the iliac crest to innervate the skin of the lateral aspect of the buttock as far as the greater trochanter B. Ilioinguinal: enters the inguinal canal accompanies the spermatic cord and supplies the skin of the rrot of the penis and anterior part of the scrotum, mons pubis and labium majorum. C. Genitofemoral: two branches. a. Genital branch enters the inguinal canal and supply the spermatic cord and innervate the same cutaneous area as the ilioinguinal nerve. b. Femoral branch: skin over the femoral triangle. D. Femoral: supplies the muscles and the skin of the anterior compartment of the thigh E. Lateral cutaneous nerve: a. Anterior branch: supplies the skin over the antero-lateral aspect of the thigh down to the knee b. Posterior branch: the skin of the lateral aspect of the leg from the greater trochanter to the mid-thigh Iliohypogastric nerve innervate skin overlying the lateral aspect of the buttock and runs medially and superficial to the inguinal canal to innervate the skin over the pubis.

50. Elderly COAD patient. On home oxygen. 24 hours of worsening condition. Various blood gases given: A. paO2 > 50, paCO2 70 HCO3 30 etc... B. C. D. E.

A High HCO3 indicates chronic high CO2 (HCO3 is initially low because of respiratory compensation, but renal compensation increases HCO3)

54. Malignant hyperthermia. The number of people in the community at any given time with a predisposition is called the: A. Prevalence B. Incidence C. D. E.

A Incidence of MH - 1:15000 anaesthetics for children and adolescents and - 1:50,000-150,000 anaesthetics for adults. Prevalence for susceptibility may be as high as 1:2000

46. Long-standing T6 paraplegia. All present EXCEPT ? A. Flaccid paralysis B. Poikilothermia C. Autonomic hypereflexia D. Labile BP E. Hyperkalaemia with suxamethonium

A OHA p240 Return of muscle tone and reflexes after perhaps 3 days to 8 weeks Rest are longer term (i.e. 9 months)

98. IV paracetamol: A. late plasma levels around the same as oral B. highly protein bound C. ?30%? renally excreted D. Vd 10 L/kg E.

A Pb 10-25% Mainly hepatic metabolism Vd ~ 50 L ~ 1 L/kg Wiki

88. Torsades, what's not useful? A. Amiodarone B. Isoprenaline C. ? D. E.

A Why? ***

31. A 60 year old female is undergoing hysterectomy. Gabapentin reduces postoperative: A. Nausea B. Vomiting C. Sedation D. Pruritus E. Constipation

A Acute pain management - scientific evidence - third edition 2010 p91 After hysterectomy and spinal surgery specifically, gabapentin improved pain relief and was opioid-sparing, nausea was less in patients after hysterectomy, and there was no difference in sedation.

48. Amniotic fluid embolism. Cause of death in first half hour ? A. Pulmonary hypertension B. Malignant arrhythmia C. Pulmonary oedema D. Hypovolaemic shock E.

A CEACCP 2007

42. Patient post anterior cervical fusion. Patient in recovery. Confused and combative. Nurse concerned about haematoma Taken to theatre: Most appropriate way of securing airway: A. Gas induction / laryngoscopy / intubate B. Awake tracheostomy C. Awake fibreoptic intubation using minimal sedation D. Thiopentone, suxamethonium, direct laryngoscopy and intubation E. retrograde intubation

A CEACCP V7 No3 2007 Re-intubation may be difficult. The patients must be managed in a semi-sitting posture. Awake fibreoptic intubation is sometimes a good option, but direct laryngoscopy after sevoflurane and oxygen induction (with judicious doses of propofol) may be easier. The gum-elastic bougie is often vital and an LMA (+fibrescope,+gum elastic bougie or Aintree catheter) or an ILMA-guided technique may save the day. The use of succinylcholine in myelopathic patients is hazardous because of abnormal potassium shifts.

25. Advantages of bronchial blockers over double lumen tubes: A. Able to achieve lobar isolation B. Lower cuff pressure C. Quicker deflation of isolated lung D. Pneumonectomy E. Lower incidence of malposition

A Campos, Thoracic Anaesthesia, DLT versus bronchial blockers 1. Difficult airways (nasal and oral) 2. RSI 3. Existing tracheostomy requiring OLV 4. Selective lobar ventilation 5. Post-op ventilation required (but can exchange at end)

17. Male undergoing trans-sphenoidal surgery. Now Na+ 155mmol/l and thirsty with polydypsia. Treatment: A. Desmopressin (DDAVP) B. Fluid restrict C. Aldosterone D. E.

A DDAVP for diabetes insipidus Results from absolute or relative lack of ADH in response to normal physiologic triggers such as hyperosmolarity Central or nephrogenic Typically polyuria is compensated for by thirst and excess consumption of fluid to match output Usual features are: Hypertonic plasma with hypotonic urine Plasma ~ high normal > 290 - 300 Urine 50 - 200 mosm/L High Volume Urine output: > 4 - 6 L/day or > 3ml/kg for 4 - 6 consecutive hours TREATMENT Determines if central or nephrogenic • 10mcg DDAVP nasally • 1mcg DDAVP S/C or IV Central will be associated with 50% increase in urine osmolality DDAVP 1 - 4 mcg/hr IV continuous 10 - 40 mcg intranasal Duration 12 - 24 hr intranasal

12. How do you minimise risk of intravenous cannulation with epidural insertion ? A. Injection saline through epidural needle before catheter insertion B. Lie patient lateral C. Do CSE D. Thread catheter slowly E.

A Detection of intravascular epidural catheter placement A review 2007 The injection of saline into the epidural space prior to threading the catheter is reported to decrease the incidence of intravascular placement

30. Regarding post craniotomy pain: A. Local infiltration proven to reduce long-term pain B. Local more painful than discrete nerve blocks C. Local infiltration more efficacious than discrete nerve blocks D. Local infiltration more efficacious than opioid analgesia E. Local infiltration more efficacious with clonidine included

A Acute pain management - scientific evidence - third edition 2010 p247 Local anaesthetic infiltration 1. No different in short term (ie. same efficacy) 2. Less pain at 2 months (56% to 8%) 3. More painful than nerve blocks?

92. Half life of tirofiban: A. 2hrs B. 8hrs C. 12hrs D. 24hrs E. 15 minutes

A 2 hours Aggrastat IIb/IIIa-R antagonist Coagulation normalises in 4-8 hours

27. Post accidental dural puncture with epidural needle. Headache. Which does NOT fit ? A. Epidural blood patch 30-50% effective B. Unlikely to be related to epidural if purely occipital headache C. Caffeine mildly effective in reducing headache D. Subdural haematoma can rarely occur with PDPH E. (?something about photophobia)

A and B are both false? *** Paech, Epidural blood patch, CanJAnaes 2005 Therapeutic 95% Prophylactic 30-75% Women should be informed that - the chance of a "cure" (complete relief) with a single EBP is at best 50% - in up to 40% of cases a second EBP is required

56. Thallium scan: A. High negative predictive value B. High positive predictive value C. Not as good as a dobutamine stress echocardiography D. E.

A. High NPV = low FN High PPV = high FP Draw table

35. Child-Pugh score. Components ? A. Bilirubin / albumin / INR (yes INR, not PT), ascites, encephalopathy B. Various other options including AST/ALT, GGT, PT C. ? D. ? E. ?

A. 5 components. Lowest = 1, highest = 3 Albumin = 28 g/dL Ascites = moderate/severe Bilirubin = > 50 uM Coagulopathy = INR > 2.3 Encephalopathy = III/IV Childs A = 5/6 = low operative mortality risk (<5%) Childs B = 7-9 = moderate risk (25%) Childs C = 10-15 = high risk (>50%). Although this classification was originally used in patients undergoing portosystemic shunts, the variables included have been shown to be predictive of outcome for all types of abdominal surgery in patients with liver disease. Other predictors of poor outcome include malnutrition, emergency surgery, sepsis, and blood loss.

63. Another pregnant woman with ?MS. Develops SVT. Try vagal manouveres without success. A. Adenosine 6mg B. DCR C. Amiodarone D. Atenolol E. ?

A. Adenosine (Shock if unstable) BJA 2004 "SVT in Pregnancy" Drug use in labour or LSCS can precipitate SVT. Careful with synto, and ephedrine. Regional anaesthesia --> decreased filling and may precipitate. Ensure aortocaval tilt is used. Adenosine, a naturally occurring purine nucleotide, transiently depresses sinus node activity and slows atrioventricular conduction, and is effective in terminating SVT. It is rapidly metabolized with an elimination half-life of less than 10 s, making it ideally suitable for use in pregnancy. If adenosine fails, other antiarrhythmics may be indicated and the risk of their use should be weighed against the risk of continuing SVT. Beta-blockers have been used extensively in pregnancy, to treat maternal hypertension and cardiac problems, and are generally well tolerated. They are the agents of choice in Wolf-Parkinson-White syndrome, where AV nodal blocking drugs may lead to acceleration of conduction through the accessory pathway and the arrhythmia being sustained. *** Verapamil, a calcium channel-blocking agent, is as effective as adenosine in converting an SVT to sinus rhythm. Peripheral vasodilation and negative inotropy are unwanted side-effects. There are reports of its safe use in pregnancy for treatment of SVT. Digoxin has been used in all stages of gestation for maternal and fetal indications without causing harm. Amiodarone is best avoided because of its potential teratogenic effects and reports of fetal toxicity, but again there are reports of its safe use during pregnancy. Synchronized electrical cardioversion may necessary for SVT resistant to pharmacological therapy, particularly if hypotension develops. Direct current electrical shock has been used at all stages in pregnancy without significant complication. The current reaching the fetus is thought to be negligible. However, transient fetal dysrhythmia has been described, and monitoring of fetal heart rate during maternal cardioversion is advisable. Implantable devices have been successfully used during pregnancy for malignant tachyarrhythmias. Both temporary and permanent endocardial pacing has been used in pregnancy, although mainly in the treatment of bradyarrhythmias.

23. A 4 year old child with Arthrogrophysis multiplex congenita for dental surgery. Jaw rigidity post induction. Likely cause ? A. Temporomandibular joint involvement/ TMJ rigidity B. Inadequate depth of anaesthesia C. Inadequate muscle relaxation/ inadequate sux D. Masseter spasm E. ?

A. No increased risk MH. Arthrogryposis multiplex congenita refers to a variety of conditions that involve congenital limitation of joint movement. Intelligence is relatively normal except when the arthrogryposis is caused by a disorder or syndrome that also affects intelligence.

28. Cell saver. Which does NOT get filtered ? A. Foetal cells B. Free Hb C. Platelets D. Clotting factors E. Microaggregates of leukocytes

A. Fetal cells. But they've shown it's no worse than labour/delivery and the UK College recommends for LSCS now. CEACCP: Red cells are retained, while the plasma, platelets, heparin, free haemoglobin, and inflammatory mediators are discarded with the wash solution.

1. Pre-eclamptic woman, BP 170/110, headache, proteinuria 1.2g. Which of the following NOT to use for control of her hypertension: A. Magnesium B. SNP C. GTN D. Hydralazine E. Metoprolol

A. Magnesium - not for control of HTN Severe PET as > 160/110 + headache and proteinuria. Management of PET: - early diagnosis, control of BP, prevention of convulsions and timely delivery, strict fluid balance BP control: Maintain MAP 100-140 (130/90-170/110). Sudden drop can compromise placental perfusion. Drugs used: - Hydralazine 5mg increments or infusion - Labetalol 50mg increments IV or 100mg PO q30min - Methyldopa 1-3g PO per day - Nifedipine 20mg PO (drops BP ++ with magnesium) - SNP infusion - may cause excessive hypotension, good for emergencies, risk of cyanide toxicity to fetus - GTN - as above, risk of methaemoglobinaemia Magnesium is NOT for control of BP. It is for prevention of fits and treatment. 4g loading + 1g/h infusion

80. Stellate ganglion A. Anterior to scalenius anterior B. ? C. ? D. ? E. ?

Ans A Inferior cervical ganglion = fusion C7 and C8 ganglia = at level of C7/T1 In 80% patients, it is fused with the 1st thoracic ganglion = stellate ganglion.

76. Compared to lignocaine, bupivacaine is A. Twice as potent B. Three times as potent C. Four times as potent D. Five times as potent E. Same potency

Ans C How? *** Lignocaine 1% vs Bupivacaine 0.5% Lig 7mg/kg and Bupiv 2.5mg/kg toxicity

20. Thermoneutral zone in 1 month old infant ? A. 26 - 28 degrees Celcius B. 28 - 30 degrees Celcius C. 30 - 32 degrees Celcius D. 32 - 34 degrees Celcius E. 34-46 degrees celcius

Ans D Neonatal Physiology, AICU 2008 The range for a naked term baby at 1 week is 32.0-33.5°C and 24.0-27.0°C when the baby is clothed. In comparison, a 30-week gestation baby's range is 34.0-35.0°C naked and 28.0-30.0°C clothed.

79. What is the SVR in a patient with MAP 100mmHg, CVP 5, PCWP 15, CO 5L/min? A. ?0.8 B. ?3 C. 520 D. 1280 E. 1520 dynes.sec/cm-5

Ans E MAP = CO x SVR (really, (MAP-CVP) = CO x SVR as CVP isn't zero) 95 mmHg = 5 L/min x SVR SVR = 19 mmHg.min/L SVR = 1 PRU 1 mmHg.min/L = 1 PRU (peripheral resistance unit) 1 mmHg = 1,330 dynes/cm2 1 L/min = 16.67 cm3/sec 1 PRU = 80 dynes.sec/cm5 19 x 80 = 1520 dynes.sec/cm5

16. TURP - patient under spinal. Confused. ABG: Na+ 117 / normal gas exchange. Treatment ? A. 10 ml 20% Saline as fast push IV B. 3% NS 100 ml/h C. Normal saline 200 ml/h D. Frusemide 40 mg IV E. Fluid restrict 500 ml/day

B

36. Which is NOT a disadvantage of drawover vaporiser versus plenum vaporiser: A. Temperature compensation B. Cannot use sevoflurane C. Small volume reservoir D. Flow compensation E.

B

93. Why is codeine not used in paediatrics? A. Poor taste B. High inter-individual pharmacokinetic variability C. Not licensed for <10 year old D. not as effective as adult when given in ?weight adjusted dose? E. ?

B

85. The MAIN indication for biventricular pacing is A. complete heart block B. congestive cardiac failure C. VF D. E.

B LVEF < 35% BiV may improve this by 5-10% http://my.clevelandclinic.org/heart/services/procedures/biventricular_pm.aspx

100. Most likely to result in myocardial infarction: A. intraop myocardial ischaemia B. post op myocardial ischaemia. C. D. E.

B Postop: Preop ischaemia = 3:1 Postop: Intraop ischaemia = 5:1 In-hospital postoperative myocardial ischaemia preceded long-term adverse cardiac outcome in up to 70%. http://bja.oxfordjournals.org/content/93/1/9.full.pdf

40. Salicylate poisoning: A. Respiratory acidosis B. Metabolic acidosis (/ don't think this was an option - ak )(yep i think it was- mm) C. Increased CO2 (production) D. High output renal failure E. Hyperthermia (/ pretty sure this option was HYPOthermia - too late)

B Salicylic acid = HS HS <> H+ + S- H2O + CO2 <> H2CO3 <> H+ + HCO3 Increased CO2 too? ***

91. Maternal cardiac arrest. In making the diagnosis of amniotic fluid embolism, large amount of PMNs surrounding foetal squamous cells are A. Pathognomonic B. Supportive C. Only found at postmortem D. Irrelevant E. Incidental

B Squamous cells are in 21-100% of pregnant women without AFE http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3401570/

70. An 18 yo with Fontan circulation undergoing exploratory laparotomy. On ICU vent, sats 70%. Which ventilator parameter would you INCREASE to improve his sats? A. Bilevel pressure B. Expiratory time C. Inspiratory time D. Peak inspiratory pressure E. PEEP

B To improve BQ through pulmonary BV

90. Labour epidurals increase maternal and foetal temperature. This results in neonatal A. Increased sepsis B. Increased investigations for sepsis C. increased non shivering thermogenesis D. Increased need for resuscitation E. Cerebral palsy

B A great core temperature is tolerated with an epidural block

32. Burns dressings. The following is proven to be of analgesic benefit: A. Morphine gel B. Biosynthetic dressings (the answer per pain book) C. Dexmedetomidine IV D. Lignocaine IV E. Cognitive/Distraction technique

B Acute pain management - scientific evidence - third edition 2010 p250 The choice of dressing has an effect on time to healing and pain during dressing change; biosynthetic dressings have been found to be superior. Nitrous oxide (N2O), ketamine and IV lignocaine infusions (Jonsson et al, 1991 Level IV) have also been used to provide analgesia for burn procedures (see Sections 4.3.1, 4.3.2 and 4.3.5), however a Cochrane review reported that more trials were required to determine the efficacy of lignocaine (Wasiak & Cleland, 2007 Level I).

87. What's the area burnt in the following man? Half of left upper arm, all of left leg and anterior abdomen. A. 27% B. 32% C. 42% D. E.

B Arm is 9% half an arm is 4.5 Leg 18% Anterior abdomen 9% 4.5 + 18 + 9 = 31.5%

14. Patient with aortic dissection. Blood pressure 150/90. Best drug to control BP: A. Captopril B. Esmolol C. GTN D. Hydralazine E. SNP

B CEACCP 2009 Beta-blockers should be given first before vasodilators, as the reflex catecholamine release due to vasodilatation may increase left ventricular contractions.

75. Arterial blood gases (ABGs): pH 7.12, PO2 100, PCO2 65, HCO3 20.3, BE -10. Consistent with? A. Chronic renal failure B. Malignant hyperthermia C. Diabetic ketoacidosis D. End-stage respiratory failure E. Ethylene glycol toxicity

B Combined metabolic and respiratory acidosis = MH! a. CRF wouldn't have high CO2 c. DKA = low CO2 to breathe off d. Would be metabolic compensation i.e. high bicarb e. Would try to breathe off CO2 to compensate for non-anion gap metabolic acidosis Boston Rules *** Respiratory acidosis: excess CO2 = 65 - 40 = 25 mmHg Acute: 10 in 1 = 10 mmHg CO2 = HCO3 rises 1 = so, (25/10)x1 = 2.5 increase HCO3 Chronic = "10 to 4" = (25/10)x4 = 10 mmHg increase HOWEVER, the bicarb is LOW = metabolic acidosis too!

51. Visual loss with pupillary reflexes retained. Likely cause ? A. Retinal detachment B. Occipital mass C. Frontal mass D. Chiasmal mass E. Optic neuritis

B Cortical blindness = visual loss but with retained pupillary reflexes and normal fundoscopy. Caused by pathology in the occipital lobes. A patient with cortical blindness often has little or no insight that they have lost vision, a phenomenon known as Anton's Syndrome or Anton-Babinski syndrome. http://www.iveyeye.ca/pdfs/acute_visual_loss.pdf Retinal detachment - an extensive retinal detachment involving the macular area would produce acute visual loss and this patient will complain of flashing lights followed by a large number of floaters and then a shade or blind covering the visual field. An afferent pupillary defect is usually present. The diagnosis is confirmed by ophthalmoscopy through a dilated pupil, and retina appears elevated with folds and the choroidal background is indistinct. Optic Neuritis: Optic Neuritis is inflammation of the optic nerve and is usually associated with multiple sclerosis in a significant number. The visual acuity is markedly reduced and an afferent pupillary defect is present. The optic disc initially appears hyperaemic and swollen. The visual acuity usually recovers; however, repeated episodes of optic neuritis may lead to permanent loss of vision.

52. Nerve block for anaesthesia over anterior 2/3 of ear? A. C2 B. Mandibular nerve C. Maxillary nerve D. Ophthalmic nerve E. Vagus

B Four sensory nerves supply the external ear: (1) greater auricular nerve, (2) lesser occipital nerve, (3) auricular branch of the vagus nerve (CNX), and (4) auriculotemporal nerve (CNV3). (Emedicine) The greater auricular nerve is a branch of the cervical plexus. It innervates the posteromedial, posterolateral, and inferior auricle. The lesser auricular nerve innervates a small portion of the helix. The auricular branch of the vagus nerve innervates the concha and most of the area around the auditory meatus. The auriculotemporal nerve is a branch of the mandibular branch of the trigeminal nerve. It innervates the anterosuperior and anteromedial aspect of the auricle. The external auditory canal and tympanic membrane have separate innervation. http://emedicine.medscape.com/article/82698-overview

37. Acute renal failure. Which is not an indication for dialysis ? A. Hyperkalaemia B. Metabolic alkalosis C. Hypernatraemia D. Uraemic pericarditis E. APO

B I think C ***

13. Timing of peak respiratory depression post intrathecal 300 mcg morphine: A. < 3.5 hours (think it was one hour) B. 3.5 - 7.5 hours (then three hours) C. 7 - 12.5 hours (then 7.5 - 12.5 hrs) D. 12.5 -18 hours E. > 18 hours

B I think C? CEACCP Morphine-induced late onset respiratory depression occurs between 3.5 and 12 h after injection with a peak at 6 h http://ceaccp.oxfordjournals.org/content/8/3/81.full

78. Interscalene block, patient hiccups...where do you redirect your needle? A. Anterior B. Posterior C. Caudal D. Cranial E. Superficial

B It is stimulating the phrenic nerve (which is anterior to brachial plexus)

39. Chest xray shown of patient post Left pneumonectomy with heart swung to left side. Management: A. Increase PEEP B. Roll onto right side C. Turn on suction to left pleural catheter D. Lung biopsy E.

B Reference? ***

62. Septic elderly man. Given lots of obs but essentially mixed venous oxygen sat 65%, lactate 4, MAP low. Mx. A transfuse B fluid bolus C Noradrenaline

B SvO2 is low normal Inadequate perfusion? ***

65. Which gives the BEST seal? A LMA classic B Proseal C Intubating LMA D. ? E. ?

B C according to A+A 2008 A Comparison of Seal in Seven Supraglottic Airway Devices Using a Cadaver Model of Elevated Esophageal Pressure? B according to product info CEACCP Supraglottic Airway Deices - Recent Advancements From the LMA website / product information: LMA Classic - Seal pressure up to 20cm H20 LMA Supreme™ - measured oropharyngeal leak pressures up to 37 cm H2O LMA Flexible™ - oropharyngeal seal pressures up to 20 cm H2O LMA Fastrach - Seal pressures up to 20 cm H2O LMA ProSeal™ - leak pressures up to 32 cm H2O (Oesophageal seat = ILMA; Concerning the risk of aspiration, the use of devices with an additional esophageal drainage lumen might be superior for use in patients with an increased risk of aspiration. The Combitube, Easytube, and intubating laryngeal mask Fastrach showed the best capacity to withstand an increase of esophageal pressure.)

3. Commonest organism causing meningitis post spinal: A. Staph epidermidis B. Staph salivarius C. Staph aureus D. Strep pneumoniae E. ?

B. Baer, Post Dural Puncture Bacterial meningitis, Anaesth 2006 Staph salivarius Strep viridians Staph aures Pseudomonas aeruginosa

59. LUSCS for failure to progress. Spinal is inserted uneventfully. Next day the patient has foot drop. The most likely cause is? A. epidural haematoma B. lumbosacral palsy C. sciatic nerve palsy D. common peroneal palsy E.

B. Lumbosacral plexus > Lumbosacral trunk (L5/S1) > Sciatic N > Common peroneal N CEACCP 2003: "Postpartum foot drop is caused by damage to the 1. lumbosacral trunk or, 2. common peroneal nerve (less common). The lumbosacral trunk (L4, L5) is compressed between the ala of the sacrum and the descending fetal head. It may also occur during a forceps delivery. The result is a unilateral foot drop with loss of sensation and/or paraesthesia along the lateral calf and foot." Common peroneal nerve damage may occur due to improper or prolonged positioning during lithotomy and the sensory deficit may be limited to the dorsum of the foot." Epidural haematomas extremely rare (1:168,000 from review in Anaesthesiology 2006; 105: 394)and obstetric palsies are much more common than complications related to neuraxial blocks. Sciatic nerve injury would cause a foot drop but would also affect knee flexion (hamstrings) and all muscles in lower leg and foot. Common peroneal nerve palsy less likely in this case as there is no mention of stirrups or 'excessive knee holding'

58. Young female having cholecystectomy. Venous air embolus: A. Mechanical ventilation and PEEP is part of treatment strategy B. Most likely to occur at initial gas insufflation, but can occur at any time C. Inert gas (argon, xenon) is safer D. E.

B. Classically due to insufflation of CO2 via a hasson cannula, but cut surfaces e.g. of liver may permit entry of gas. "This complication develops principally during the induction of pneumoperitoneum, particularly in patients with previous abdominal surgery." Miller 7th ed. p. 2188. Two preconditions must exist for venous air embolism to occur: (1) a direct communication between a source of air and the vasculature and (2) a pressure gradient favoring the passage of air into the circulation. Severity depends on volume of gas (20ml/kg, or 2-3ml into cerebral circulation), rate of accumulation (rapid entry puts a strain on RV, and if increases PAP can lead to RV outflow obstruction), and patient's position at time of event. Tachyarrhythmias common; bradyarrhythmias can occur, + "Mill wheel" murmur - A temporary loud, machinerylike, churning sound due to blood mixing with air in the right ventricle, best heard over the precordium (a late sign) Positioning: Generally, if the patient is in a sitting position, gas will travel retrograde via the internal jugular vein to the cerebral circulation, leading to neurologic symptoms secondary to increased intracranial pressure. In a recumbent position, gas proceeds into the right ventricle and pulmonary circulation, subsequently causing pulmonary hypertension and systemic hypotension. Incidence - 10% for cervical laminectomy (prone) - 80% in posterior fossa (Fowler's (sitting)). VAE pose a risk whenever wound is > 5cm about RA Inert gases NOT safer - CO2 safest as dissolves fastest TREATMENT = ABC; place patient in left lateral and trendeleburg position; remove air from CVC if possible (see VAE CEACCP) Miller = not trendelenburg (keep embolus in RA where it won't create an air lock in RV, and might be amenable to aspiration from CVC. PEEP may increase risk of PAE and worsen HD instability http://web.squ.edu.om/med-Lib/MED_CD/E_CDs/anesthesia/site/content/v04/040125r00.HTM

4. Exponential decline / definition of time constant (with various options) A. time for exponential process to reach log(e) of its initial value B. Time until exponential process reaches zero C. Time to reach 37% of initial value D. Time to reach half if its initial value E. 69% of half life

C

43. Young asthmatic male in emergency department. RR 26, pCO2 27, SAO2 92%, struggling talking in sentences. Given nebulised salbutamol, and ipratropium, 200mg IV hydrocortisone. After 30 minutes - no improvement. Further management: A. IV salbutamol B. IV aminophylline C. IV magnesium D. Intubate and ventilate E. ?

C

45. How quickly does the CO2 rise in the apnoeic patient ? A. 1 mmHg per min B. 2 mmHg per min C. 3 mmHg per min D. 4 mmHg per min E. 5 or ?8 mmHg per min

C

94. Best agent to decrease gastric volume AND increase gastric pH before semi-urgent procedure A. Omeprazole B. Cimetidine C. Ranitidine D. Sodium citrate E.

C 50mg IV = needs 30 mins

83. Baby with Tracheo-oesophageal fistula found by bubbling saliva and nasogastric tube coiling on Xray. Best immediate management? A. Bag and mask ventilate B. Intubate and ventilate C. position head up, insert suction catheter in oesophagus (or to stomach?) D. Place prone, head down to allow contents to drain E. Insert gastrostomy

C I think head down may cause further leak

5. Relative humidity - air fully saturated at 20 degree. What is the relative humidity at 37 degrees ? A. 20 B. 30 C. 40 D. 50 E. 60%

C Absolute vapour of water - 20 degrees = 17.3 mmHg - 37 degree = 47 mmHg 17.3/47 = 36.8%

34. Liposuction. Infiltration of lignocaine with 1:200,000 adrenaline. Peak plasma concentration of lignocaine occurs at: A. 1 hour B. 3 hours C. 18 hours D. 24 hours E. 30 mins

C CAECCP Novel techniques of LA infiltration Tumescent analgesia The high hydrostatic pressure within the tissues is also thought to be responsible for the delayed systemic absorption and hence delayed and reduced peak plasma concentrations of local anaesthetic, despite the very large doses being used. Doses as high as 22-57 mg/kg of lidocaine. Tumescent technique for regional anesthesia permits lidocaine doses of 35 mg/kg for liposuction. J Dermatol Surg Oncol 1990 Peak plasma lidocaine levels occurred 12-14 hours after beginning the infiltration.

60. Severe pre-eclampsia. WORST treatment option: A. Magnesium B. Nifedipine C. Metoprolol D. SNP E.

C I think A? (Mg is more seizure prophylaxis) C. pure beta blockade may cause LVF due to -INO against high AL *** ?? Ans D Magnesium if questions say about hypertension Beta blockers could tip into LVF and APO however SIG says some B blockers (metoprolol, pindolol, propranolol) are ok. SNP is rarely used and not recommended due to hypotension, paradoxical bradycardia with severe PET and unknown risk of fetal cyanide toxicity

68. 30yo Male. 5 hour operation. Arms abducted to 60 degrees. Head turned slightly to left side. Post op numb palm/thumb/index finger/middle finger and lateral half of ring finger. Numb ventral forearm. Weak finger grip. Weak elbow flexion. Most likely nerve injured? A. median nerve B. musculocutanous nerve C. upper trunk of brachial plexus D. ?brachial plexus stretch E.

C Positioning problem. A. Median nerve too distal = doesn't supply elbow flexion (this is upper arm - brachialis (musculocutaneous), brachioradialis (radial), biceps (musculocutaneous) B. coracobrachialis, brachialis and biceps brachi but not median nerve sensory C. Think it must be to encompass m/cutaneous + median D. ?

77. Aneurysm sugery. Propofol/remifentanil/NMDR. DOA monitoring (Entropy). MAP 70 , HR 70/min, State entropy 50, Response entropy 70. What do you do? A. ? B. Metaraminol C. Check TOF D. Nothing E. Increase TCI.

C RE of 70 compared to SE of 50 means paralysis is wearing off DOA = depth of anaesthesia

47. Young female patient for tonsillectomy with history of bleeding tendency. Which is the most likely cause? A. Factor V Leiden B. Protein C deficiency C. Haemophilia B (Christmas disease) D. Antithrombin III deficiency E. Lupus anticoagulant

C Rest are pro-coagulant and she would clot clot clot. A8 B9

86. What's the most appropriate mode for neuromuscular monitoring during aneurysm clipping? A. TOF count B. TOF ratio C. Post tetanic count D. ? E. ?

C To ensure really deep block Anaesthesia for cerebral aneurysm repair Roger Traill TOF 0 PTC >10

11. Elderly patient. Indications for pre Femoro-Popliteal Bypass angiogram include all EXCEPT: A. Severe heart failure B. Suspicion of L main disease C. Symptomatic tachyarrhythmia D. Unstable angina E. Stable angina with positive thallium

C Would require other investigations.. ABD they are all straight forward indications for coronary angio. Positive thallium suggest patient may require revascularisation and coronary anatomy is required. AHA ACA

18. The STRONGEST stimulus for ADH secretion: A. High serum osmolality B. Low serum osmolality C. Hypovolaemia D. High serum Na E.

C ? *** Volume wins - sensitive to 1-2% change in osmolarity or 10% change in volume, but volume response is STRONGER

26. Patient for pneumonectomy. Pre op FEV1 2.4. (Predicted 4.5L) FVC given as well. For R lower lobectomy. Postoperative predicted FEV1 ? A. 1.3 B. 1.5 C. 1.7 D. 1.9 E. 2.2

C. Because of how many segments there are...to follow. 19 lung segments in total - 10 on the right (RUL=3, RML=2, RLL=5), and - 9 on the left (LUL=3, Lingula=2, LLL=4).

29. You are on a humanitarian aid mission in the developing world. Drawover vaporiser apparatus described being used. Given 400 mm tubing, OMV or diamedica vaporiser, 200mm tubing attached to self-inflating bag. Which other ONE piece of equipment is ESSENTIAL to make this system functional? A. Halothane B. In-line Waters' Cannister [1] C. Non-rebreathing valve D. Oxygen source E. Ventilator

C. Can use air instead of O2

57. A 50 y/o male diabetic admitted to intensive care with pneumonia. Intubated and ventilated. Extensive results given. BP 80/-, HR 120, CVP 4, PCWP 6, SvO2 69% PaO2 80, BE -4 pH 7.2. Management: A. Blood transfusion B. Bicarbonate infusion C. Fluid resuscitation D. Adrenaline infusion E. Insulin infusion

C. Fluids. Low CVP, hypotensive, tachycardic, low PCWP. Acidosis could be diabetic or lactate . No reason for Blood unless low Hb. Bicarb contraindicated in DKA as need to breathe off excess CO2 Adrenaline - if non-responsive to fluid Insulin - depends if hyperglycaemic Normal SvO2 = 65-70

71. A 7 kg Infant with tetralogy of fallot, post BT-shunt. Definitive repair at later date. Paralysed and ventilated. Sats 85% baseline, now 70%, best treatment: A. Increase FiO2 from 50 - 100% B. Esmolol 70 mcg C. Phenylephrine 35 mcg D. Morphine 1 mg E. 1/2 NS with 2.5% dex 70 mls

C. Phenylephrine - will increase SVR and LH pressures, reducing R-L shunt. (increase FiO2 won't change if big shunt) http://lifeinthefastlane.com/2010/04/cardiovascular-curveball-009/ Frank Shann's dose recommendation for phenylephrine is 2-10 mcg/kg as a bolus, which would fit nicely with C (5 mcg/kg). BT shunt = Blalock-Taussig shunt - aim = increase pulmonary BQ and reduce shunt (R-L) - SCA / CCA -> PA Sano shunt = RV -> PA = avoids reduced diastolic BQ to coronaries with BT

15. Type of dissection - which is classically for NON-operative management: A. DeBakey Type I B. DeBakey Type II C. Stanford A D. Stanford B E. Stanford C

D

61. In pregnancy the dural sac ends at: A. T12 B. L2 C. L4 D. S2 E. S4

D

95. Myasthenia gravis - features predicting need for post op ventilation EXCEPT A. Prolonged disease B. High dose Rx C. Previous respiratory crisis D. Increased sensitivity to NMB's E. bulbar dysfunction

D Disease in lungs = Hx of resp disease, FVC < 2.9 L Disease severity = Grade 3-4 MG Disease duration = >6 years of disease Treatment = Dose > 750mg/day Pyridostigmine

9. Predictive factors for mortality in elderly patient (except): A. Aortic stenosis B. Diabetes mellitus C. Elevated Creatinine D. Cognitive dysfunction E. Type of surgery

D Minimising perioperative adverse events in the elderly BJA 2001 http://www.ncbi.nlm.nih.gov/pubmed/11878732 All are mentioned except cognitive dysfunction

41. New onset atrial fibrillation in a 10 week pregnant lady. BP 150/90, HR 160, SaO2 92%. Moderate mitral stenosis on TTE, no thrombus seen. Emergency doctor gave her anticoagulant (not specified what). Most appropriate management: A. Verapamil B. Labetalol 20mg iv to 300mg C. Amiodarone 300mg IV D. Synchronised biphasic cardioversion with 70-100 Joule E. Oral digoxin -1000mcg then 500mcg 6 hrs later

D OK to cardiovert because new onset. DC more effective. Safe?

72. Von Hippel-Lindau disease is associated with: A. increased risk of malignant hyperthermia B. meningiomas C. peripheral neuropathy D. phaeochromocytomas E. poor dentition

D "Management of anesthesia in patients with von Hippel-Lindau disease must consider the possible presence of pheochromocytomas" (Stoelting) von Hippel-Lindau (VHL) disease - rare, AD genetic condition - predisposes individuals to benign and malignant tumours The most common tumours - CNS + retinal hemangioblastomas - clear cell renal carcinomas, - phaeochromocytomas - pancreatic neuroendocrine tumours - pancreatic cysts - endolymphatic sac tumors - epididymal papillary cystadenomas. Associations = An increased incidence of - Phaeochromocytoma - apparently 20% - Renal cysts - Renal cell carcinoma Anaesthesia 1. Treat hypertension occurring with phaeochromocytoma 2. Haemangioblastoma of spinal cord may limit use of spinal although epidural has been used for LSCS 3. Exaggerated hypertension with surgical stimulation or laryngoscopy = Treat with β blockers and/or SNP

89. The intercostobrachial nerve: A. Arises from T2 trunk B. Is usually blocked in brachial plexus block C. Supplies antecubital fossa D. can be damaged by torniquet E. Arises from inferior trunk

D A- False. Arise from lateral cutaneous branch of 2nd intercostal nerve (originally from T2 but not from the trunk. ) B- False. It joins the medial cutaneous nerve of the arm which comes from the medial cord, but does not form part of the brachial plexus, and is not blocked in brachial plexus blocks. C- False. Supplies medial side of upper arm, and joins medial cutaneous nerve of arm which supplies medial side of upper arm down to the elbow. D- True. Any nerve compressed by a tourniquet can be damaged. Would have to be high up he arm close to axilla to compress it. E- False. Not part of the brachial plexus, or a branch from it. Arises from lat. Cut. Branch of 2nd intercostal nerve.

38. Chronic alcohol use. Which is not an associated complication ? A. AF B. hypertriglyceridemia C. Macrocytosis D. Nephrotic syndrome E. Pancreatic Ca

D CEACCP Alcohol and the Anaesthetist

8. Hypotension post propofol induction in elderly patient. More pronounced / profound than in younger patient. Reason ? A. Concentric LVH associated with ageing and therefore preload dependent B. Because of increased lean body mass C. Decreased cardiac output with ageing D. Increased sensitivity to all anaesthetic agents, thus relative overdose is common E. Decreased liver blood flow with ageing, decrease drug clearance and increased drug concentration

D I think A too? *** ?? Ans A overdose often due to slow circulation time and lower Vd but the agents are vasodilatory and hence the hypotension

19. Stellate ganglion block. Needle entry next to SCM muscle at C6. Which direction to advance needle ? A. C3 B. C4 C. C5 D. C6 E. C7

D I think E *** Stellate ganglion = inferior cervical + T1 ganglia Although the ganglion lies at the level of the C7 vertebral body, the needle is inserted at the level of C6 to avoid the piercing the pleura. http://www.frca.co.uk/article.aspx?articleid=100538

84. A 60yo man with anterior mediastinal mass, during induction for mediastinoscopy....lose cardiac output, decreased saturations, drop in ETCO2. Management: A. Adrenaline B. CPR C. CPB D. Place prone E.

D Management of the patient with a large anterior mediastinal mass: recurring myths Curr Opin Anaesthesiol 20:1-3 2007 http://www.ncbi.nlm.nih.gov/pubmed/17211158 Should try wake up the patient. Intraoperative life-threatening airway compression has usually responded to one of two therapies: 1. Repositioning of the patient (it should be determined before induction if there is one side or position that causes less symptomatic compression) 2. Rigid bronchoscopy and ventilation distal to the obstruction (this means that an experienced bronchoscopist and rigid bronchoscopy equipment must always be immediately available in the operating room during these cases). For patients with life-threatening cardiovascular compression after induction that does not respond to lightening the anesthetic the only therapy is immediate sternotomy and surgical elevation of the mass off the great vessels.

82. 75yo male with moderate aortic stenosis (valve area 1.1cm2).. Gets mild dyspnoea on exertion but otherwise asymptomatic. Needs hip replacement. A. Continue with surgery B. Beta block then continue C. Get myocardial perfusion scan D. Postpone surgery awaiting AVR E. Postpone surgery awaiting balloon valvotomy

D SOB on exertion is NYHA 2. Don't get distracted by "otherwise" ACC AHA 2007 In patients with severe aortic stenosis who refuse cardiac surgery or are otherwise not candidates for aortic valve replacement, noncardiac surgery can be performed with a mortality risk of approximately 10%. *** What is mortality for symptomatic AS surgery

73. 70 year old post TKJR. On sub-cut heparin. Develops clinical DVT and platelets 40 (sounds like HITS type-II). Management A. Enoxaparin B. Fondoparinux C. Heparin by infusion D. Lepirudin E. Warfarin

D Fondaparinux has no affinity for PF4, lower risk of HITTS, but not zero. Lepirudin = direct thrombin inhibitor, different structure. Heparin-PF4 = hapten = induces immune response = IgG binds and causes platelet activation.

44. Called to emergency department to review a 20 y/o male punched in throat at a party. Some haemoptysis / hoarse / soft voice. Next step in management: A. CT to rule out thyroid cartilage fracture B. XR to rule out fractured hyoid C. Rapid sequence induction / laryngoscopy / intubation D. Awake fibreoptic intubation E. Nasendoscopy by ENT in emergency department

E

33. Subtenon's block. What is the worst position to insert block? A. Inferonasal B. Inferotemporal C. Superonasal D. Supertemporal E. Medial / canthal

E Any spot really okay but apparently more muscle insertion points medially

74. Drug eluting stent 6 months old. On aspirin and prasugrel 10mg. Elective lap cholecystectomy for biliary colic. A. Do case while taking both. B. Do case while stopping both. C. Stop Prasugrel for 7 days, keep taking aspirin. D. Stop Prasugrel for some other different time E. Post-pone for 6 months

E Prasugrel = ADP-R inhibitor = platelet inhibitor, similar to clopidogrel ACC/AHA Pre-op: DRUG ELUTING: Thrombosis of DES may occur late and has been reported up to 1.5 years after implantation, particularly in the context of discontinuation of antiplatelet agents before noncardiac surgery. Discontinuation of antiplatelet therapy in the early-surgery group resulted in a 30.7% incidence of MACE (all fatal) versus a 0% incidence in early-surgery patients who continued dual antiplatelet therapy perioperatively. BARE METAL: Rapid endothelialization of bare-metal stents makes late thrombosis rare, and thienopyridines are rarely needed for more than 4 weeks after implantation of baremetal stents. For this reason, delaying surgery 4 to 6 weeks after bare-metal stent placement allows proper thienopyridine use to reduce the risk of coronary stent thrombosis; then, after the thienopyridine has been discontinued, the noncardiac surgery can be performed. In patients with bare-metal stents, daily aspirin antiplatelet therapy should be continued perioperatively. The risk of stopping the aspirin should be weighed against the benefit of reduction in bleeding complications from the planned surgery.

7. Anaphylaxis to rocuronium. Which is most likely to cause cross-reactivity ? A. Vecuronium B. Pancuronium C. Atracurium D. Cisatracurium E. None of the above -cross reactivity too variable to predict

E Ref: AAGBI Anaphylaxis 2009 " 60% of anaphylaxis in anaesthesia = NBMD Cross sensitivity is relatively common, probably because of their quaternary ammonium group.

96. Innervation of larynx A. The internal branch of the superior laryngeal nerve supplies the lingual surface of the epiglottis B. In cadaveric position the cords are fully abducted C. The RLN supplies all intrinsic muscles of the larynx D. The glossopharyngeal nerves are sensory to the laryngeal mucous membrane above the level of the cords E. Cuff compression of recurrent laryngeal nerve against thyroid can cause palsy

E ***

22. A 4 year old child with VSD (repaired when 2 years old) for dental surgery. What antibiotic prophylaxis do the guidelines recommend? A. Amoxycillyn orally B. Amoxycillin IV C. Cephazolin IV D. Amoxycillin / gentamicin E. No antibiotics required

E Certain surgical factors (eg. dental surgery eg. extractions) need it if certain patient factors. See notes on endocarditis prophylaxis AHA guidelines say after 6 months nil required if no leak (ie. patient factor) + Anaesthetic implications of CHD (AIC 2003)

2. Male with a Haemoglobin of 8 g/dL and reticulocyte count 10%. Possible diagnosis: A. Untreated pernicious anaemia B. Aplastic anaemia C. Acute leukaemia D. Anaemia of chronic disease E. Hereditary spherocytosis

E Only this have increased reticulocyte count

66. Peak plasma lignocaine level after epidural lignocaine. (again various times similar to the tumesent lignocaine one) A 1 hour B 3 hours C 18 hours D 24 hours E 30 mins

E Epidural similar to Subcut Tumescent is different... EMJ 2004 http://emj.bmj.com/content/21/2/249.full Br J Clin Pharmacol 1996; 42: 242245 Peak lignocaine concentration ~30 mins

53. Complex regional pain syndrome. What proportion of patients have motor involvement ? A. 0 % B. 25 % C. 50 % D. 75 % E. 95 %

E / D / C *** Pain 2009 = 50% http://www.rsds.org/pdfsall/RajaSN_editorial.pdf AA 2005 = 75-95% http://www.anzca.edu.au/resources/college-publications/pdfs/books-and-publications/Australasian%20Anaesthesia/australasian-anaesthesia-2005/05_Visser.pdf CRPS type I (reflex sympathetic dystrophy) is diagnosed where there is no evidence of a precipitating nerve injury CRPS Type II (causalgia) where a nerve injury is present. Motor / trophic changes - motor dysfunction 57-98% - weakness 75-95% - limited range of movement 80-88% - incoordination 47% - tremor 48% - spasm 13% - dystonia 14% - myoclonus 4-20%

6. A 50 year old man with multiple fractures. The BEST parameter to monitor volume resuscitation is: A. Heart rate B. LVEDV C. PCWP D. RVEDV E. Changes in R atrial pressure during inspiration

E?*** http://www.ncbi.nlm.nih.gov/pubmed/21918726