Multichoice March 2010

1. MC157 [Mar10] New Q 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

Answer - B During IPPV a DECREASE in inspiratory time (which means an INCREASE in expiratory time) will improve pulmonary blood flow - despite the increased peak airway pressures.

[edit] References A. T. Lovell, Anaesthetic implications of grown-up congenital heart disease (British Journal of Anaesthesia 93 (1): 129-39, 2004)

2.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

A - While you would obviously increase the FiO2 to 100% if the sats were 70%, this will not make a great deal of difference due to the massive shunt, so not the best answer. B - Beta blocker may help slow heart rate and increase diastolic filling and preload, and MAY help to increase diameter of RVOT. C - Phenylephrine will increase SVR and therefore left-sided pressures, thereby reducing right-to-left shunt. BEST ANSWER D - Morphine will probably make little difference to a patient who is paralysed and ventilated, E - Crystalloid will increase preload if a big enough bolus is given, and this may dilate RVOT and decrease right-to-left shunt. BEST ANSWER = C (Ref: Yao & Artusio, 6th edn; page 411)

Reference: Practical Approach to Pediatric Anesthesia 2008 p354: Consider option A-Increase FiO2 to 100%: Giving 100% oxygen may reduce hypoxic pulmonary vasoconstriction, pulmonary vascular resistance and allow more blood to flow through the Blalock-Taussig aortopulmonary shunt where it can be oxygenated. Other PVR lowering strategies include sodium bicarbonate 1-2 mmol/kg, low inspiratory pressure ventilation with long expiratory times (although I suspect this may produce hypercapnoea) and general anaesthesia. Phenylephrine 35 mcg is quite a high dose in a 7kg infant (I have read here 0.5 - 2 mcg/kg) but is one of the methods cited to increase SVR along with knee-chest positioning and abdominal pressure on the aorta. Finally RV filling with reduction in RVOT obstruction can be facilitated by B-blockers which slow HR, likewise opioids (although morphine 1 mg to 7 kg child is excessive), general anaesthetics (particularly the inhaled ones) and fluid loading. Given that the question was remembered with doses, I wonder if the key to the question lies there rather than the choice of drug.

Frank Shann says: phenylephrine 2 10mcg/kg esmolol 0.5mg/kg So 70mcg of esmolol is pissing in the wind

3. MN41 Von Hippel-Lindau disease is associated with: A. increased risk of malignant hyperthermia B. meningiomas C. peripheral neuropathy D. pheochromocytomas E. poor dentition

D - Von Hippel Lindau disease (VHL) is a rare, autosomal dominant genetic condition[1]:555 in which hemangioblastomas are found in the cerebellum, spinal cord, kidney and retina. These are associated with several pathologies including renal angioma, renal cell carcinoma and phaeochromocytoma. VHL results from a mutation in the von Hippel Lindau tumor suppressor gene on chromosome 3p25.3 Wikipedia - Disco 28/6/10

4.70 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

Management of HIT: First task is to discontinue unfractionated heparin from ALL sources (including heparin-coated lines, etc). LMWH can also cause HIT, therefore not suitable as a replacement. Fondaparinux is an indirect Factor-Xa inhibitor (synthetic pentasaccharide), and there are some reports of it being used in HIT successfully. Warfarin (Vit K antagonist) is contraindicated in acute HIT (or if suspected HIT), as it can cause skin necrosis or venous limb gangrene. Current recommendations are to treat with DTI's (lepirudin, argatroban, bivalirudin) or danaparoid. Although danaparoid is a LMW heparinoid, there is an extremely low cross-reactivity rate with HIT antibodies, and this is rarely clinically significant. As danaparoid is not an option, the best answer is therefore a direct thrombin inhibitor (DTI), and lepirudin is the only one listed, so answer is D. References: Greinacher A. Heparin-induced thrombocytopenia, J Thromb Haemost 2009;7(Suppl. 1):9-12. Shantsila, et.al. Heparin-Induced Thrombocytopenia: A Contemporary Clinical Approach to Diagnosis and Management, Chest 2009; 135:1651-1664. Therapeutic Guidelines - Cardiovascular (electronic version), 2008.

5.Hypercalcaemia (repeat) A. Chovostek's sign B. C. D. E. Short QT

hypocalcaemia (or hypocalcemia) is the presence of low serum calcium levels in the blood, usually taken as less than 2.1 mmol/L or 9 mg/dl or an ionized calcium level mm of less than 1.1 mmol/L (4.5 mg/dL). It is a type of electrolyte disturbance. In the blood, about half of all calcium is bound to proteins such as serum albumin, but it is the unbound, or ionized, calcium that the body regulates. If a person has abnormal levels of blood proteins, then the plasma calcium may be inaccurate. The ionized calcium level is considered more clinically accurate in this case. In the setting of low serum albumin (frequently seen in patients with chronic diseases, hepatic disease or even long term hospitalization), the formula for corrected calcium is: CorrCa = Measured serum Ca + [(4.0 - measured serum albumin) * 0.8]. Thus, if the albumin is low, the measured calcium may appear low when in fact it is physiologically within normal limits.

Perioral tingling and paraesthesia, 'pins and needles' sensation over the extremities of hands and feet. This is the earliest symptom of hypocalcaemia. Tetany, carpopedal spasm are seen. Latent tetany Trousseau sign of latent tetany (eliciting carpal spasm by inflating the blood pressure cuff and maintaining the cuff pressure above systolic) Chvostek's sign (tapping of the inferior portion of the zygoma will produce facial spasms) Tendon reflexes are hyperactive Life threatening complications Laryngospasm Cardiac arrhythmias Hypocalcemia ECG-characteristics of hypocalcemia, low blood calcium: Narrowing of the QRS complex Reduced PR interval T wave flattening and inversion Prolongation of the QT-interval Prominent U-wave Prolonged ST and ST-depression

6.Drug eluting stent 6 months old. On aspirin and prasugrel 10mg. Elective lap chole 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

I had never heard of prasugrel until I read this question, but it is the same class of drug as clopidogrel (not surprising given the context). As per AHA/ACC Guidelines, recommended to continue dual anti-platelet therapy for 365 days, and I would consider prasugrel the same as clopidogrel. Continue dual therapy and delay elective surgery for 12 months after DES.

7.Person newly diagnosed as MH susceptible. Which is true? A. ? B. can have had an uneventful 'triggering' anaesthetic C. Recommended to use an anaesthetic machine which has not had volatiles through it D. ? E. there have been case reports of MH occurring up to 48 h post op

B is TRUE - may have had an uneventful trigger-type anaesthetic previously. (Oxford Handbook of Anaesthesia, 2nd Ed, p. 260) C is not strictly true (depending how you interpret the question). If a machine that has never had volatiles through it is available then that's great, but in practice you need to remove the vaporisers, change the circuit and CO2 absorber, and flush with high fresh gas flows for 20-30 minutes. (Oxford Handbook of Anaesthesia, 2nd Ed, p. 263) E is TRUE also. Oxford Handbook states that rarely it can develop 2-3 days post-op and manifest as massive myoglobinuria +/- renal failure secondary to rhabdomyolysis. (Oxford Handbook of Anaesthesia, 2nd Ed, p. 260)

8. MZ80 ABG 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 This is an acute mixed metabolic and respiratory acidosis. So A is out, D should be out given the PO2, Ethylene Glycol acutely causes a metabolic acidosis with hyperventilation so that should be out, DKA are usually Kussmaul breathing. The Gas also fits with MH. 29/6/10 Disco

9. Signs consistent with cocaine overdose include all of the following except A. arrhythmias B. dysphoria C. Hyperglycemia D. Hyperthermia E. Miosis

Cocaine DOES cause euphoria therefore A is true. Cocaine causes pupillary dilatation (mydriasis), not miosis. Therefore ANSWER is E.

10.Maximum dose (with low risk of toxicity) of lignocaine (with adrenaline 1:100000) for liposuction with tumescence technique A. 3 mg/kg B. 7 mg/kg C. 15 mg/kg D. 25 mg/kg E. 35 mg/kg

Apparently up to 35-55 mg/kg of lignocaine has been "safely" used in this technique, although you would have to have a low threshold for suspecting toxicity. I guess that means E is the answer (though my initial reaction was that 7mg/kg was going to be the answer - traditionally accepted max. dose with adrenaline) References: Miller's Anesthesia (7th edn) - p 930, and Clinical Anesthesia (6th edn) by Barash - Chapter 33 (? page...I was using online text)

11.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

If procaine =1, then lignocaine potency=2, and bupivacaine potency =8. Therefore bupivacaine is 4 times as potent as lignocaine - ANSWER is C (Foundations of Anesthesia: Basic Sciences for Clinical Practice by Hemmings & Hopkins, 2nd edn, p.394) Other recommended texts (Primary exam pharm texts) give differing values compared to procaine, but all give a ratio of 4x potency for buipvacaine:lignocaine (Stoelting and Katzung)

12.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
British Journal of Anaesthesia 97 (1): 85 94 (2006) GE healthcare product info

Entropy is a mathematical concept used to describe non-linear dynamics. Response entropy measures frequency range that includes EEG and EMG Rapid response to change in depth or pain (frontalis EMG) Some propose that sig rise in RE without SE occurs in pain and so should be treated with opiates (usually SE rises too, just slower) State entropy measures frequency range that should only include EEG (but does catch some EMG) SE meant to relate to hypnotic depth. Always lower or equal to RE NMB s don t effect SE as they do with RE A significant rise in RE and SE should be treated with propofol and remi together Numbers are the same as for BIS (100 =awake, 60 =anaesthetised, 40 =low probability consciousness, 0 = flat EEG)

With only limited information, a MAP of 70 seems OK (unless this is a cerebral aneurysm with raised ICP in which case you may want the MAP a little higher to maintain an acceptable CPP, and therefore B would be true - metaraminol would help.....but we are not given any more information) State entropy of 50 (if sustained) would cause me to increase the TCI (either propofol OR remifentanil) a little, and aim for 30-40. Response entropy: While there is not a lot of evidence that I know of that supports this concept the advice (from the manufacturer) is to increase the analgesic, and this could be done by increasing the remifentanil. Another take on this might be to do nothing and see what happens. We have all seen the BIS shoot up a little and grab our attention only to drop back to its normal acceptable level just as quickly if you wait 30 seconds or something like that. So maybe the answer is D - do nothing? However assuming it is not a fleeting temporary glitch in the monitoring I would probably go for E increase TCI as the best answer. Response entropy is a product of EMG & EEG. This implies that there is muscle activity & I would check TOF to see if more relaxant is required

13.Paralysed with atracurium. TOF is 1(25%). You give a dose of 0.1 mg/kg mivacurium to close the abdomen. When will you be back to TOF 1(25%)? A. 5 min B. 10 min C. 30 min D. 60 min E. 90 min

A study by Naguib et. al. showed that after an initial intubating dose of atracurium, and spontaneous recovery of the first twitch (T1) to 10% of its control height, a maintenance dose of 0.1mg/kg of mivacurium resulted in a time of 25 minutes to regain T1=10%. My guess would be the answer is C, but it's still a guess Reference: Naguib, et al. Interactions between Mivacurium and Atracurium. BJA 1994; 73:484-89

14.Plenum Vaporiser A.? something with fresh gas flows B. Relies on a constant flow of pressurised gas C. Out of circle D. Not temperature compensated E. volatile injected into fresh gas slow?

Plenum Vaporiser (wiki)

Driven by positive pressure from machine SV or IPPV make no difference Internal resistance is high Delivers reliable conc. Agent over wide range of FGF Splits incoming gas into two streams, one of which is fully saturated End percentage (or partial pressure) depends on the splitting ratio Cannot be placed in reverse position on machine One vaporiser per volatile (cannot interchange)

Plenum Vaporiser
SVP is temperature dependant so the vaporiser needs to compensate
Encased in 5kg metal jacket to insulate from cooling with evaporation Bimetallic strip at inlet to vaporiser chamber adjusts splitting ratio for temperature The vaporiser has a temp range within which it is reliable

A-? B - TRUE. Upstream gas source required to push fresh gas through the vaporizer (opposite to Draw-over vaporizer) C - ? FALSE. Don't exactly understand the question/stem. You can use a plenum vaporizer with OR without a circle (e.g. T-piece in paeds) D - FALSE. Most ARE temperature compensated E - FALSE. Not necessarily, although some can. Not true exclusively

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

Answer is B (see Oxford handbook of Anaesthesia, 2nd Edn, p. 1077). Phrenic nerve stimulation occurs if you are too anterior

16.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

SVR = (Systemic A-V Pressure difference) / Flow Therefore SVR = (100-5)/5 = 95/5 = 19 mmHg/L/min To convert to dynes.sec/cm-5 then multiply by 80; this gives us 1520 dynes.sec/cm-5. Therefore ANSWER is E.

17.Accidentally cannulate carotid artery with 5 lumen 7 Fr CVC preop for a semi urgent CABG. Most appropriate next response is to A. Get vascular surgeon to repair it and continue with surgery and heparin B. Leave it in. Do CABG. Pull it out post op. C. Pull it out, compress. Delay surgery for 24hrs D. Pull it out compress. Continue with surgery + heparin. E. Pull it out. Compress. Continue with surgery no heparin

From personal experience I can tell you that the services of a vascular surgeon are required for this situation. I m going for A

18.Stellate ganglion (Repeat Question) A. Anterior to scalenius anterior B. ? C. ? D. ? E. ? Perhaps:Stellate ganglion is where: (2007) A. at the level of the body of C6 (spine of C6) B. posterior to the brachial plexus sheath C. anterior to the dome of the pleura D. anterior to the thoracic duct E. anterior to scalenius anterior

The stellate ganglion lies ANTERIOR to the scalenius anterior muscle ("Anaesthesia UK" website - Stellate Ganglion Block Formed by fusion of lower cervical and upper thoracic ganglion in 80% of people. Anterior to body of C7, on or above neck of first rib Anterior relations: skin and subcut, SCM, carotid sheath. Lung apex ant and inf to ganglion Posterior: longus colli, ant scalene, vertebral artery, brachial plexus and 1st rib Medial: body of C7, oesophagus and thoracic duct

Stellate (cervicothoracic sympatetic) block

Indications: Pain (CRPS, phantom pain, angina), Vascular insufficiency (Reynauds, frosbite) Contraindications: recent MI, pathological bradycardia, coagulopathy, glaucoma Position: supine, neck extended, slightly away from side of block

Stellate block
Palpate TP of C6 at level of carina between trachea and carotid sheath Press down to displace sheath and lung apex (should be uncomfortable) Advance to bone then walk medially to body of C6, withdraw 1-2mm (out of lungus colli) and inject dye for AP and Lat views Test dose LA and adrenaline (NB aiming for C6 with inferior spread in plane, not C7 to avoid lung apex)

19.The median nerve (REPEAT) 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 ulna half of the palm

The median nerve is formed by a lateral and medial head (from the lateral and medial cords respectively), but has no contribution from the posterior cord (D=FALSE). It runs down the upper arm initally lateral to the brachial artery, but changes to be medial to the artery about halfway down the arm, and is therefore MEDIAL to the brachial artery at the elbow (A=TRUE). It can be blocked at the wrist between palmaris longus and flexor carpi radialis (B=FALSE). It is located LATERAL to the flexor carpi ulnaris at the wrist (C=FALSE), and provides sensation to the lateral 3 and a half fingers and corresponding lateral area of palm radial side (E=FALSE

20.Patient for total knee replacement under spinal anaesthetic. Continous femoral nerve catheter put in for post op pain relief. Good analgesia and range of motion 18hrs post op. 24hrs post op, patchy decreased sensation in leg and unable flex knee. What is the cause? A. Compression neurapraxia (i think it said due to torniquet) B. DVT C. Muscle ischaemia D. Damage to femoral nerve E. Spinal cord damage

Inability to flex the knee is not a femoral nerve problem - it is sciatic. This problem seems to have clinical onset at about 24 hours. It is unlikely to be femoral nerve damage (D=False) or DVT causing these findings (B=False). After a neuraxial technique one would have to consider 'spinal cord damage' due to epidural haematoma, although unilateral symptoms would make one think of other causes as being more likely (therefore, for the puropses of the MCQ I would say E=False). Of the 2 remaining options, muscle ischaemia is unlikely to develop after 24 hours in the case of a knee replacement, although no mention was made of the 'tourniquet time' (C=False), and the most likely cause would be compression neurapraxia secondary to the tourniquet (A=true).

21.A 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

The guidelines recommend that "if the aortic stenosis is symptomatic, elective noncardiac surgery should generally be postponed or cancelled. Such patients require aortic valve replacement before elective but necessary noncardiac surgery" (see p. e184, Section 3.5 Valvular Heart Disease). AHA/ACC D

22.similar to above, patient for fempop bypass (i believe it said "angioplasty"), history of CCF. Also has diabetes on oral hypoglycaemics, controlled hypertension and atrial fibrillation at rate of 80bpm . A. Medium risk surgery, medium risk patient B. Medium risk surgery, high risk patient C. High risk surgery low risk patient D. High risk surgery, medium risk patient E. High risk surgery, high risk patient.

Fem-pop bypass is HIGH risk surgery (although an angioplasty would not be if done under LA +/sedation). This patient has 2 intermediate risk factors: a history of prior CCF, and diabetes. The controlled HT and AF<80bpm are minor risk factors. Therefore D=TRUE.

23.Best Approach for a Sub-Tenon's block? A. inferonasal b. inferotemporal c. medial canthus d. superior nasal e. superior temporal

The typical approach for cataract surgery (phaecoemulsification & insertion of IOL) is infero-medially (aka infero-nasally). Presumably the question had more information as the best approach can vary with the operation. For cataract surgery the 2 surgical incisions are at the limbus - superolaterally & inferolaterally. A sub-Tenon's block is best done on the opposite sign so that any sub-conjunctival haemorrhage (& this is a very common minor complication) is mostly on ther other sidfe of the eye from the surgical incision. The 4 recti muscles penetrate the Tenon's capsule and insert into the sclera in the 4 compass positions of north, south, east & west. Hence to reach the poosterior sub-Tenon's space with your cannula, you need to avoid these 4 positions. For a removal of a pterygium, the surgical incision is medial, so a sub-Tenon's block is done laterally, either supero-laterally or infero-laterally. A sub-Tenon's block can be done in any of the 4 quadrants and will work. If there is no other issue, the inferonasal approach is by far the most frequent one used.

24.Baby with TracheoOesophageal 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

A - FALSE. Not unless the baby is in respiratory distress and/or hypoxic. May inflate stomach by ventilating through fistula. B - FALSE. Just because the baby has been diagnosed with TOF is not an immediate indication for intubation in and of itself. C - TRUE. Neonates with TOF should have a "nasogastric" tube inserted into the oesophageal stump to drain secretions and prevent accumulation in the blind-end pouch. The NGT should be connected to continuous suction. The infant should be nursed prone or in the lateral position with 30 degrees head up tilt to decrease the risk of aspiration. See A Practice of Anesthesia for Infants and Children - 4th edition by Cote, Lerman, Todres; p.755. Saunders (2009) D - FALSE. Can nurse prone, but lateral with head up tilt seems to be the recommended and most commonly cited method. E - FALSE. Initial management as above (see C - TRUE), and then repair. Gastrostomy may be performed, but not best immediate management.

25.60yo 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

I don't know if this was a bit of a trick question but setting aside the complexities and potential side-effects/complications of mediastinal masses, the answer may be that in the event of cardiac arrest you must perform CPR. If CPB has been organised pre-op and/or is available then that's great, but the first response would be to attempt to resuscitate the patient with CPR and look for/treat reversible causes. Answer=B. However - significant compression of vascular structures (including the heart) can occur secondary to large mediastinal masses, and changing patient position may improve things. Perhaps the answer should be to turn prone and see if there is improvement? Any ideas? Reference: Curr Opin Anesthesiology 2007 20:1-3 Consider D-Place prone Options are reposition (lateral or prone) vs emergency sternotomy and decompression great vessels

26.Post thyroidectomy patient, patient in PACU for 30 minutes. Develops respiratory distress. Most likely cause? A. Hypercalcemia from taking parathyroids B. Bilateral laryngeal nerve palsies C. bleeding and haematoma D. Tracheomalacia E.

Answer = C. Parathyroid problems would take longer to develop than that (from 2-3 days up to weeks according to Ganong, 23rd edn - p.368), besides if you take the parathyroids you get HYPOcalcaemia, not HYPERcalcaemia (A=FALSE). Bilateral laryngeal nerve palsies and vocal cord paralysis are possible, but less likely than bleeding and haematoma. Can occur after a variable time period post-operatively (B=FALSE). Tracheomalacia can also occur, but the money is on bleeding/haematoma as the MOST LIKELY CAUSE.

27.Best way to prevent hypothermia in patient undergoing a general anaesthetic (Repeat question) A. Prewarming of patient B. C. D. Warm IV fluids

28.Main indication for biventricular pacing is A. complete heart block B. congestive cardiac failure c. VF D.

According to Yao & Artusio (6th edn, p.236-7), biventricular pacing is defined as a lead in the RV to pace the interventricular septum, and a lead in the coronary sinus which can pace the LV lateral free wall. This is apparently most commonly used in patients with LBBB which can cause dyssynchronous contraction of the LV leading to impaired systolic function. The biventricular pacing "resynchronises" LV contraction and improves systolic function. They quote indications as: (i) severe cardiomyopathy (EF<35%), and (ii) LBBB with NYHA class III or IV symptoms despite maximal medical therapy. Based on that I would go for B=TRUE

29.Desflurane TEC6 vaporiser, unable to turn dial on. This is NOT because A. vapouriser is tilted B. Hotter than 39C C. On battery power D. Interlock not engaged, or not seated properly (or something like that) E. other vapouriser is already on

The TEC 6 desflurane vaporizer needs to warm up and the "operational" LED light needs to be illuminated before you can turn the dial to the ON position. If you try to turn it on before the "operational" light is on it will not work. I assume that any of the alarms which cause the "operational" light to go off (and subsequently halt delivery of desflurane) mean that if you turn the dial to 0% (i.e. OFF) then you will not be able to turn it back on, but I have not read that anywhere. According to Graham (BJA 1994; 72:470-73), causes of vaporizer shutdown include: a tilt of about 10 degrees or more - although extremely unlikely given the design (A WILL cause you to be unable to turn the dial, so A is not the answer) power failure. It will not work on battery power (C is not the answer) the vaporizer will not work unless locked into the selectatec mount, and the selectatec mount wil not allow the use of multiple vaporizers simultaneously (therefore D and E are true, and neither is the answer) Answer is therefore B.

30.Desflurane vaporiser, heated because of A. High SVP B. High boiling poing C. Low SVP D. High MAC E. Low MAC

Vaporizer heated because of the high SVP. Heated to well above boiling point to ensure reliable concentration of desflurane gas mixture. (Answer = A)

31.Myotome of C6-7 (Repeat Question) A. Wrist flexion and extension

Cervical Myotomes
Neck Flexion C1-2 Neck Side bend C3 Shoulder Elevation C4 Shoulder abduction C5 Elbow flexion and wrist extension C6 Elbow extension and wrist flexion C7 Thumb extension C8

32. SF86 Most common cause of maternal cardiac arrest A. PE B. AFE C. Haemorrhage D. Preeclampsia E. cardiomyopathy

A or C (take your pick)

I could not find any specific numbers about cardiac arrest in pregnancy, but the "Saving Mothers' Lives" (2003-2005) publication from the UK (the latest 'CEMACH' publication) gives figures for maternal deaths. Obviously not all women who have a cardiac arrest in pregnancy die, but I have based my answer on these numbers. If you are talking about direct deaths, then the most common cause would be thromboembolism (Answer=A). The order is: VTE>AFE>haemorrhage. For indirect deaths, "cardiac disease" is the main cause of death, and is higher in number than thromboembolism. Just found this article that gives some numbers...MI rate 25% due to haemorrhage; 20% due to comined AFE and PE...so am going with options C "Cardiac Arrest and Pregnancy"; Journal of Emergencies, Trauma and Shock: 2009; 2; p.34-42...Gabby

86. Cryoppt: insufficient (rpt) A. F9 B. F13

"One unit of cryoprecipitate derived from a unit of whole blood contains: a volume of 10-20 mL, * 80-100 units of factor VIII (which consists of both the procoagulant activity and the von Willebrand factor), * 150-250 mg of fibrinogen, * 50-100 units of factor XIII, and * 50-60 mg of fibronectin

87. Most likely to result in myocardial infarction (rpt): A. intraop myocardial ischaemia B. post op myocardial ischaemia In a patient undergoing a femoro-popliteal bypass, the most predictive independent risk factor for the development of postoperative myocardial infarction would be A. an acute myocardial infarct 3 months ago B. an episode of intra-operative myocardial ischaemia C. an episode of post-operative myocardial ischaemia D. 50% blood volume blood loss intra-operatively E. poorly controlled diabetes mellitus

From Landesberg G: The pathopysiology of peri-op MI: the facts and perspectives. J Cardiothoracic and Vasc Anaes 2003: 17(1): 90100 (http://download.journals.elsevierhealth.com/pdfs/journals/10530770/PIIS105307700247718X.pdf) -recommended review. [2] (http://www2.jcardioanesthesia.com/scripts/om.dll/serve?action=searchDB& searchDBfor=home&id=jcan) Peri-op myocardial ischeamia peaks in the early post-op period and is significantly associated with MI and cardiac complications. Intraop ischaemia is less common and infrequently associated with post-op MI. Peri-op MI is almost exclusively preceded by ST depression type ischaemia (STEMI is uncommon) Peri-op MI is mostly silent (only 50% have any Sx) and occur in first 24-48 hours post-op- pick up with cont. ECG monitoring and ST trend analysis and troponin. If you still need convincing that it is postoperative ischaemia try this BJA article from Jan 2005 (http://bja.oxfordjournals.org/cgi/content/full/95/1/3)

88.Awake patient with diabetes insipidus A. Euvolaemic B. C. D. E. urinary Na <20

DI
Neurogenic (not enough DH) or nephrogenic (reduced effect of ADH in kidneys) Awake patient with intact thirst will maintain euvolaemia unless very severe DI Plasma Na and Osm is high, urinary is low (Osm <300,didn t find anything for urinary Na) Diagnose with morning plasma/urine osmolarity or water deprivation test (dilute urine continues) Central DI treated with dDAVP, nephrogenic isn t

89.Indication for percutaneous closure of ASD a. Primun < 3cm b. Primun > 3cm c. Secundum < 3 cm d. Secundum > 3cm e. sinus venosus ASD

"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." Continuing Education in Anaesthesia, Critical Care & Pain 2008 8(1):16-20 I agree Answer C, size does matter, but also location: "sinus venosus type occurs at the junction of the superior vena cava and the right atrium and usually is associated with partial anomalus pulmonary venous return; and ostium primum defect occurs low in the septum and often is associated with a cleft mitral valve". A practical approach to cardiac anesthesia, third edition, pg410. So you do not want to pop patches on those without having a closer look. Andrew 13/01/10 "Of these, only an ostium secundum ASD is suitable for percutaneous closure..." CEACCP 2008 - Georgie 16/05/10

90.Timing of worst coagulopathy after liver transplant a. 1-2 days b. 3-4 days c. 5-6 days etc

A or B take your pick I think group gut feeling ended as B

91.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

Pulsus paradoxus is: (the Q was something like severe asthmatic - when take BP you would find) 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. ?

Under normal conditions, arterial blood pressure fluctuates throughout the respiratory cycle, falling with inspiration and rising with expiration. Therefore, during inspiration the fall in the left ventricular stroke volume is reflected as a fall in the systolic blood pressure. The converse is true for expiration. During quiet respiration, the changes in the intrathoracic pressures and blood pressure are minor. The accepted upper limit for fall in systolic blood pressure with inspiration is 10 mmHg. The paradox refers to the fact that heart sounds may be heard over the precordium when the radial pulse is not felt. This is due to an exaggeration of the normal mechanisms mentioned above. Moreover, the clinical method of assessment of this "pulse" is by measurement of the "systolic blood pressure".

92.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

93.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

94.Correct statements regarding expiratoryinspiratory 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

95.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

CO2 insufflation
It is cheap and readily available but from safety point of view going with C It can cause embolic side effects if given IV but is better than less soluble gasses He I think can also be used with good vision etc (prob best not to use H)

96. 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 (this is where i'm talking about figments of imagination - i'm pretty sure this paper had the version where RR 8/min, what is the most likely cause etc etc) 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

97. 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

Carcinoid Heart Disease This has generated a few MCQs over the years. Develops in 50% of patients with carcinoid syndrome hence in about 5% of people with a carcinoid tumour It results in fibrosis of myocardial tissues, especially on the Right side of the heart tricuspic regurgitation is the most common finding pulmonary regurg and/or stenosis also occurs less than 10% of patients with carcinoid have mitral or aortic regurg constrictive pericarditis has also been described

"Carcinoid syndrome is a disease consisting of a combination of symptoms, physical manifestations, and abnormal laboratory chemical findings caused by a carcinoid tumour. A carcinoid tumor is a tumor that secretes large amounts of the hormone serotonin. These tumors usually: * arise in the gastrointestinal tract and * from there may migrate (metastasize)to the liver. Carcinoid tumors also sometimes develop in the lung. Only about 10% of the people with carcinoid tumors will develop the carcinoid syndrome. Major symptoms of this syndrome include: * hot, red facial flushing, * diarrhea and * wheezing. The presence of carcinoid syndrome suggests: - the presence of liver secondaries - a non-GI carcinoid tumour - massive mediator release by tumour The liver normally breaks down the mediators (vasoactive compounds) secreted by the tumour. As most carcinoid tumours are in the GIT, the mediators are released into the portal veins, and broken down in the liver. To cause carcinoid syndrome then indicates the liver is being bypassed or overwhelmed

98.Histamine release in anaphylaxis does NOT cause: A. Tachycardia B. Myocardial depression C. Coronary artery vasodilatation D. Prolonged PR interval E. Decreased impulse conduction

H1 acting via phospholipase C coronary constriction; bronchoconstriction; slowing at AV node. release of prostacyclin [edit] H2 acting via cAMP inotropy; coronary dilation; bronchodilation; tachyarrythmias BJA Review p219: increased PR ventricular irritability decreased VF threshold shifts in pacemaker site CNS stimulation increased H+ secretion by parietal cells Both H1 & H2 increase capillary leak.

99.Pre-ganglionic sympathetic fibres pass to the A. otic ganglion B. carotid body C. ciliary ganglion D. coeliac ganglion E. all of the above

 Ciliary ganglion: PSNS ganglion in posterior orbit, pupillary constriction and ciliary accomodation Otic ganglion: small PSNS in infratemporal fossa (one of four PSNS ganglion of head and neck also ciliary, submandibular, pterygopalatine) Carotid chemoreceptor CNIX (?PSNS), aortic body is via CNX

100.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

The chorda tympani is a nerve that branches from the facial nerve (cranial nerve VII) inside the facial canal, just before the facial nerve exits the skull via the stylomastoid foramen. Chorda tympani is a branch of the facial nerve (the seventh cranial nerve) that serves the taste buds in the front of the tongue, runs through the middle ear, and carries taste messages to the brain. (Wikipedia) Disco 30/6/10

 The corda tympani is not really a branch of the mandibular nerve but it does join the lingual nerve (definitely a branch of mandibular) to supply taste to tongue The great auricular is a branch of the cervical plexus and has nothing to do with the mandibular I think my anaesthetic practice has improved astronomically with this new info

101. 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 From this data A. the relative risk of this complication with drug exposure CANNOT be determined B. the odds ratio of this complication with drug exposure CANNOT be determined C. the relative risk of this complication with drug exposure is 2 D. the odds ratio of this complication with drug exposure is 1.33 E. none of the above

This is a curly little question. If you just plug in the values into the formulae for RR and OR, you come up with: RR = (50/75)/(25/50) = 1.333333 OR = (50/25)/(25/25) = 2 Hence, you would expect the answer to be E. because you can happily calculate the values and they are both wrong. INCORRECT!!! As you will read below, you are not allowed to apply RR to a case-control study. I don't really understand why the OR is then considered kosher then (in my mind it is also invalid) but the books and articles seem to think it is legit. So, the answer is A.--lovethedrugs 00:42, 28 Jun 2008 (EDT) This is a retrospective case-control study. Patients with complication were identified and matched with controls (without the complication) and then their exposures were looked at. The answer is clearly A. When you define your sample size by identifying patients with the disease, you can't define an incidence rate and therefore can no-longer calculate a risk ratio (ie ratio of disease incidence in those exposed to those not - or a/(a+b)/c/(c+d). So you calculate an odds ratio (sort of a way of estimating risk ratio). This looks at how much greater the odds of having the disease are if you're exposed compared to if you're not. ie say the odds of having the outcome if you're exposed are 2 to 1, vs 1 to 1 if you weren't, then odds ratio is 2/1 or 2.

102.BP measurement - overestimates with: A. big (wide) cuff B. skinny arm C. severely peripherally vasoconstricted D. atherosclerosis (it was arteriosclerosis - yes indeed) E. slow cuff deflation

Extrinsic cuff compression (Auscultatory, NIBP). Overly rapid cuff deflation leading to BP underestimation (Auscultatory). Calcified, noncompressible arteries leading to BP overestimation (Auscultatory, NIBP). Intense vasoconstriction leading to BP underestimation (Auscultatory). Use of inappropriately small cuff leading to BP overestimation (Auscultatory, NIBP). Dysrhythmias (Auscultatory, NIBP). Shivering and patient movement (Auscultatory, NIBP). Beat-to-beat BP variations, as in pulsus alternans (Auscultatory, NIBP). Rapid BP changes not detected (Auscultatory, NIBP).

103. A device that detects a 10mA difference in active and neutral leads and causes turning off of the circuit within 40 ms. this is a : A. Class 1 device B. Equipotential earthing C. LIM D. Residual Current Device E. Fuse

A residual-current device (RCD), similar to a Residual Current Circuit Breaker (RCCB), is an electrical wiring device that disconnects a circuit whenever it detects that the electric current is not balanced between the energized conductor and the return neutral conductor. Such an imbalance is sometimes caused by current leakage through the body of a person who is grounded and accidentally touching the energized part of the circuit. A lethal shock can result from these conditions. RCDs are designed to disconnect quickly enough to mitigate the harm caused by such shocks although they are not intended to provide protection against overload or short-circuit conditions. (wiki)

104.Post-transfusion hepatitis in Australia is associated with A. jaundice in over 50% of patients B. development of chronic disease in less than 10% of patients C. hepatitis B in the majority of patients D. the presence of antigen or antibody to hepatitis C E. elevation of serum alkaline phosphatase

Someone has asked this question directly from the ARC in their Q&A section [2] (http://www.transfusion.com.au/QA/QA_A nswer.asp?qid=658) This would indicate that the answer is C - hep B is the most common

105.In a patient requiring FFP where the patient s blood group is unknown, it is ideal to give FFP of group A. A B. B C. AB D. O E. Blood group of FFP in this situation does not matter

 Plasma is the reverse to blood cells AB becomes the universal donor and O becomes the universal recipient Because someone with AB red cell antigens has no antibodies in their plasma

106.Features of the transurethral resection of the prostate (TURP) syndrome include all of the following EXCEPT A. agitation B. angina C. bradycardia D. nausea E. tinnitus

Cardiovascular - maybe the only features in the anaesthetised patient Initial hypertension and reflex bradycardia: due to initial fluid overload Hypotension Angina Dysrhythmias (including VT/VF), widened QRS, ST elevation: due to hyponatraemia CVS Collapse Neurological - primarily due to hyponatraemia and cerebral oedema Altered conscious state - agitation, confusion, lethargy Nausea and vomiting Convulsions (uncommon unless Na+<120mmol/L or falling rapidly) Coma Transient blindness, loss of dark/light discrimination, sluggish or fixed dilated pupils: specific complication of glycine toxicity. Resolves within 24 hours as level return to normal. Respiratory Dyspnoea Hypoxia Pulmonary oedema Other Haemolysis due to hypo-osmolality ARF - secondary to haemolysis

107.The most frequently reported clinical sign in malignant hyperpyrexia is A. arrhythmia B. cyanosis C. sweating D. tachycardia E. rigidity

108.Which of the following is not an absolute contra-indication for MRI? A. cochlear implant B. heart valve prosthesis C. ICD D. pacemaker E. intracranial clips

A or B, take your pick

Absolute Cardiac pacmakers ICD Metal in the orbit Metal in the CNS (some modern aneurysm clips are not ferromagnetic) ferromagnetic stapedial implants Relative Other electronic implants spinal stimulators insulin pumps lead wires prosthetic heart valves cochlear implants Metal in other parts of body (joint replacements and secure plates are OK) Tattoos

109.Reverse splitting of the second heart sound occurs with: A. LBBB B. Pulmonary hypertension C. Acute pulmonary embolus D. ASD E. Severe MR

 Reverse splitting of S2 occurs with delayed LV outflow (LBBB or severe AS) Normally the A2 precedes P2 because LV empties first NB A2 is normally louder than P2 which may change in PHTN

110.Atrial fibrillation: A. Cardioversion results in longer life expectency than rate control B. Need to stay on warfarin following cardioversion C. Pt with HR <80 generally do not require anticoagulation D.

 Warfarin 3 weeks prior and one month post Rate control has equal morbidity to cardioversion in those >65years Anticoagulation is required regardless of rate

111.Scoliosis surgery. what is incorrect A. one third of the blood loss occurs postoperatively B. major blood loss is frequently accompanied by a consumptive coagulopathy C. surgery will halt progression of the restrictive lung deficit D. the major neurological deficits that occur are usually due to damage to the posterior columns of the spinal cord E. the use of aprotinin reduces blood loss

I think the answer is D. The Gibson article (quoted below) says " ischaemic injury is most common and the areas of the cord most vulnerable to ischaemic injury are the motor pathways supplied by the anterior spinal artery." --Captainsnooze 00:20, 29 Mar 2008 (EST) I agree with the Captain. This is why Sensory Evoked Potentials can be unreliable in Scoliosis Surgery - hence the use of "wake up tests" and Motor Evoked Potentials (which can be quite a hassle)--Quark 02:48, 20 Aug 2008 (EDT) The question comes directly from the AIC article reference below. Most options are word for word in there. Rustymonkey [edit] References Gibson PR. Anaesthesia for correction of scoliosis in children. Anaesth Intensive Care. 2004 Aug;32(4):54859 (http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&Ter mToSearch=15675216&ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_R esultsPanel.Pubmed_RVDocSum) Entwistle, Patel Scoliosis surgery in children. CEACCP (http://ceaccp.oxfordjournals.org/cgi/reprint/6/1/13)

112.About transient neurological syndrome..?? Transient Neurological Syndrome A. comprises pain localised to the back B. diagnosis is confirmed by typical findings on neurological examination C. is associated with consistent abnormalities on magnetic resonance imaging and electrophysiological studies (EPS) D. is associated with long term deficits in 5% of cases E. may occur with lignocaine, bupivacaine, prilocaine and procaine

Twenty-four hours following a vaginal hysterectomy, a 48-year-old obese female complains of severe pain that radiates down both buttocks and thighs. She had received a spinal anaesthetic with hyperbaric lignocaine. The most likely explanation for these complaints is A. transient neurological symptoms syndrome B. lumbar disc herniation C. a spinal abscess D. trauma due to improper positioning E. a spinal haematoma Twenty-four hours following a vaginal hysterectomy, a 48-year-old obese female complains of severe pain that radiates down both buttocks and thighs. She had received a spinal anaesthetic with hyperbaric lignocaine. A likely explanation for these complaints includes all of the following EXCEPT A. a spinal abscess B. a spinal haematoma C. lumbar disc herniation D. transient neurological symptoms syndrome E. trauma due to improper positioning

A and A again

113. Epidural infection... Serious post-operative epidural infection A. is rarely due to Staphylococcal species B. is associated with epidural catheter disconnection C. occurs with an incidence in the range 1-2 per 10,000 D. is usually reported in obstetric cases E. mandates surgical drainage if an abscess is present

Regarding Epidural Abcess - which is WRONG A. Diagnosis is DEPENDENT on triad of back pain, fever, and paralysis B. Occurs at a rate of 1:1000-3000 (OR 1:2000 - 1:5000) C. Worse outcomes if advanced age D. Usually gram positive cocci E. Expectant management may be appropriate

A. Diagnosis is DEPENDENT on triad of back pain, fever, and paralysis - false and the ANSWER to CHOOSE: "The early signs and symptoms may be vague, the 'classic' triad of back pain, fever and variable neurological deficit occurred in only 13% of patients by the time of diagnosis, and contributed to diagnostic delay in 75%." (Grewal et al, Epidural Abscesses in BJA 2006 96(3):292-302) B. Occurs at a rate of 1:1000-3000 (OR 1:2000 - 1:5000) - true: "Estimating the true incidence of a rare complication from such disparate reports is not easy, but there is some suggestion that it might be of the order of 1 in 1000 in surgical, and 1 in 2000 in obstetric, patients." (Grewal et al, Epidural Abscesses in BJA 2006 96(3):292-302) C. Worse outcomes if advanced age - true: "With every decade increase in age, the likelihood of poor outcome doubled, presumably due to declining health and, possibly, reduced plasticity of the spinal cord." (Grewal et al, Epidural Abscesses in BJA 2006 96(3):292-302) D. Usually gram positive cocci - true: "In the developed world the organisms most frequently encountered are Staphylococcus aureus (57 93% of cases), Streptococci (18%) and a variety of Gram-negative bacilli (13%)." (Grewal et al, Epidural Abscesses in BJA 2006 96(3):292-302) E. Expectant management may be appropriate - true: "It might be assumed that every patient with an epidural abscess should undergo surgery, but 11% of those identified in a major review did not, and another report identified 38 such individuals in case series and reports published between 1970 and 1990... The neurological deficit was unchanged or improved in all these patients except two, who died from sepsis syndrome, suggesting that the results of medical and surgical treatment are equivalent." (Grewal et al, Epidural Abscesses in BJA 2006 96(3):292-302)

114. Difference between cardiac protected and body protected area A. Equipotential earthing The electrical requirement that distinguishes a "cardiac protected area" from a "body protected area" is the A. equipotential earth B. isolation transformer C. line isolation monitor D. maximum leakage current to patient limit of 500 microamperes E. residual current device

 Euipotential earth required for cardiac protected area to protect against microshock

115. Which hormone is not released during surgery? A. cortisol B. C. TSH D. growth hormone

Catecholamines, corticosteroids, GH, glucagon all increased. GH only anabolic hormone. TSH unchanged. Thyroxine may be increased by symathetic stimulation, but catabolic effects

116. Asystolic aortic arch repair. The best method for cerebral protection is: A. anterograde perfusion via coronary vessel B. retrograde perfusion via jugular vein C. thiopentone IV D. hypothermia to 20 degrees celcius

117. Specificity most closely means A. chance of a positive test in people with the disease B. chance of a negative test in people without disease C. chance of...

Sp = proportion of negatives correctly tested as such

118. Negative predictive value most closely means A. chance of a positive test in people with the disease B. chance of a negative test in people without disease C. chance of... (NB there were definitely two questions with identical options a. through e. (and each option was wordy and a bit confusing). The stems were definitely specificity and NPV)

 Proportion of people with negative tests results who are correctly diagnosed

119. Performing a bronchoscopy. The best way to orient the scope is: (see Q48) A. angle of the bronchus B. length of the bronchus c. RUL (NB there were definitely two new questions on bronchoscopy

 RUL bronchus is the only one with a trifurcation other options true but this seems like most definitive orientation

120. Symptoms of hypercalcaemia include: (see Q5) A. B. C. seizures D. short ST segment

Signs and symptoms There is a general mnemonic for remembering the effects of hypercalcaemia: "groans (constipation), moans (psychotic noise), bones (bone pain, especially if PTH is elevated), stones (kidney stones), and psychiatric overtones (including depression and confusion)." Other symptoms can include fatigue, anorexia, nausea, vomiting, pancreatitis and increased urination.[citation needed] Abnormal heart rhythms can result, and ECG findings of a short QT interval[2] and a widened T wave suggest hypercalcaemia. Finally, peptic ulcers may also occur. Symptoms are more common at high calcium blood values (12.0 mg/dL or 3 mmol/l). Severe hypercalcaemia (above 15 16 mg/dL or 3.75-4 mmol/l) is considered a medical emergency: at these levels, coma and cardiac arrest can result.

121. Paediatric VF arrest. Which is true? A. if resistant to defibrillation should give amiodarone 5mg/kg B. C. commonly associated with respiratory arrest D. is the most common form of arrest in this patient group E. should defibrillate with 5J/kg

Ventricular fibrillation in children A. if resistant to defibrillation, should be treated with amiodarone 5 mg.kg-1 B. is not associated with tricyclic antidepressant overdose C. is often associated with respiratory arrest D. is the commonest arrhythmia associated with cardiac arrest E. should be immediately defibrillated with a 5 J.kg-1 shock

DC shock is 2J/k then 4J/kg thereafter. The first line antiarrhythmic for shock-refractory VF/pulselessVT is amiodarone, 5mg/kg The most common arrest scenario in children is bradycardia proceeding to asystole - a response to severe hypoxia and acidosis. VF is relatively uncommon, but may complicate hypothermia, TCA poisoning, and those children with pre-existing cardiac disease So C is correct Addit: But severe bradycardia (ie post respiratory arrest) can detoriate to VF. Is this not more common? What is wrong with A as an answer? Note: The new NZRC guidelines for DC shock are 4J/Kg x3 (and for adults is 3 shocks at the defibs maximum setting, but no more than 360J) A has got my vote. C is definitely wrong according to 2005 AHA guidelines pp1012 and 1014. Most common ECG finding in infants and children in cardiac arrest are aystole and PEA. Asystole and bradycardia most common in asphyxia. VF is in the minority at 5-15% out of hospital and 20% in hospital at some point in arrest. Incidence of VF increases with age. DickO 2007

122. Intercostobrachial nerve (see Q41) A. Is often damaged by torniquet B. supplies sensation to cubital fossa C. is blocked by interscalene brachial plexus block Perhaps... Tourniquet pain is caused by: A. Intercostobrachial nerve B. Musculocutaneous nerve C. Circumflex nerve D. C5

The intercostobrachial and the medial brachial nerves originate in the lower neck and upper thorax and become cutaneous on medial upper arm. Both must be blocked proximal to the axilla for shoulder surgery or for any upper extremity procedure that involves use of a pneumatic tourniquet. The intercostobrachial nerve derives from T2, whereas the medial brachial cutaneous nerve derives from C8 and T1. I also think A. "Two areas of the arm are not supplied by nerves from the brachial plexus; branches of the superficial cervical plexus supply the skin on the shoulder, and the posteromedial aspect of the arm is innervated by the intercostobrachial nerve. This is of clinical relevance because the latter may need to be blocked to prevent tourniquet pain." http://www.anaesthesiauk.com/article.aspx?articleid=100446 Answer A

123. OLV hypoxaemia. After 100% O2 and FOB next step is: (rpt) A. CPAP 5cm top lung B. CPAP 10cm top lung C. PEEP 5cm bottom lung D. CPAP 5cm top + PEEP 5cm bottom

C
PEEP to ventilated lung, then CPAP to non-ventilated lung, then if you re really clever iPAP to non-ventilated lung Then apologise to surgeon and periodically reinflate