Finals MCQs-August 2008

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Finals Black Bank


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Contents

Anaesthesia

RB63 (Q133 Aug 2008) When hearing loss occurs following spinal anaesthesia it is usually in which of the following frequency ranges:

A 125 - 1000 Hz
B 1500 - 3000 Hz
C 3500 - 5500 Hz
D 6000 - 10000Hz
E > 11000Hz


AP (Q126 Aug 2008) Each of the following drugs act at the DOP (delta receptor) EXCEPT:

A. diamorphine
B. fentanyl
C. morphine
D. naloxone
E. pethidine

The affinity of Morphine for the m-receptor is apprx. 50 times higher than for the d-receptor. Naloxone is antagonist at DOP. "Pain Physician 2008 (11) S133-53: meperidine: agonist ?? Diamorphine?? Fentanyl seems best -- raccoon

Answer is B fentanyl. See CEACCP article Fentanyl only works on muMop and a little on Kop [1] --SG 07:03, 23 Oct 2008 (EDT)


AZ (Q26 Aug 2008) Patient burns during MRI can be associated with each of the following EXCEPT
A high intensity changing magnetic fields
B looped monitoring lines ...
C non ferromagnetic material in contact with the patient
D cosmetics worn by the patient (which do not contain metals)
E temperature monitoring with thermister probes

A Not sure attached from Neuro imaging group web site (don't know why examiners would look at sites like this but couldn't find anything in the regular sources) B definitely true C true cases of aluminium backed nicotine patches causing burns - aluminium is non ferromagnetic D unsure but tattoos have caused burns? E Thermistors contain ferromagnetic material thus may cause burn.

Undecided any ideas divided between A D or E Would appreciate any furthur input.

[2]--SG 07:03, 23 Oct 2008 (EDT)

I think answer is D. Various case reports of burns with tattoos and cosmetics which contain metal pigments( Pigments dont have to be ferrous). Ferromagnetic substances- get sucked in. Non-Ferromagnetic metal substances heat up. Reference Blue Book ANZCA 2005 pg 85. So no metals, no burns, hence D --Tsotsi 18:30, 28 Oct 2008 (EDT)



AZ (Q120 Aug 2008) Preoperative assessment shows a malampati (ML) score of III and thyromental distance (TMD) of < 6cm. A grade 3 to 4 on Cormark and Lehanes is predicted. Compared to the ML score, the TMD is:
A less sensitive, less specific
B less sensitive, more specific
C more sensitive, less specific
D more sensitive, more specific
E equal sensitivity an specificity

B - from Anesthesiology 2005 (103) 429-37: TMD sens 20, spec 94; Mall sens 49, spec 86% (numbers differ broadly depending which article you read..., but A&A 2005 (101) 1542-5 concurrs: TMD sens 52, spec 71; Mall sens 70, spec 60) --- raccoon

      A - from http://www.cja-jca.org/cgi/reprint/52/3/291, sens/spec MP 61.5/98.4, TMD 15.4/98.1, wonder which is right? happygas 


Sensitivity, specificity and positive predictive value of the five single airway predictors Predictive test Sensitivity (%) Specificity (%) Positive predictive value (%) Mallampati 61.5 98.4 57.1 Thyromental distance 15.4 98.1 22.2 Sternomental distance 0 100 0 Horizontal length of 30.8 76.0 4.3 the mandible Inter-incisor gap 30.8 97.3 28.6

Not evidence as such, but from previous examiners' report May 07 Q12 on airway assessment, accuracy of assessment listed as "good" for Mallampati but with comment high FP rate (therefore less specific) and also "good" for TMD. So maybe TMD more specific than Mallampati?

AZ In performing an awake fibreoptic intubation it is MOST important that care is taken to avoid:
a. Causing any bleeding that will obstruct view
b. Oversedation as leads to posterior pharyngeal wall collapse
c. Trauma to nasal turbinates
d. Touching vocal cords as will induce coughing
e. Oral route as may bite the fibreoptic scope


Either A or B. Oversedation annuls the safety of the AFI but posterior pharyngeal wall collapse?? Any suggestions. --SG 07:03, 23 Oct 2008 (EDT)

I reckon its B- Bleeding less of a problem if patient awake- they can cough. Oversedation and losing the airway in someone needing AFOB is tiger-country!--Tsotsi 12:14, 5 Nov 2008 (EST)

found this: Fig. 1B. —Fluoroscopic images from 1-year-old boy with pharyngeal collapse. Image obtained at another point during respiratory cycle shows collapse of pharynx with lack of aeration. Posterior pharyngeal wall has moved anteriorly, and posterior aspect of tongue has moved posteriorly and resulted in collapse of pharynx. So maybe answer B. Rocket

It's not an AFOI if you've over sedated the patient isn't it?

AZ-12. CT reprint showing large MNG. Uppermost concerns to anaesthetist is
a. Involvement of the Right carotid artery
b. Tracheal deviation to the left
c. Tracheal deviation to the right
d. Malignant involvement of the paratracheal nodes
e. compression of upper lobe of rt.lung

B.  ? Tracheal deviation to the L. Thus involvement of airway plus the risk of SVC obstruction. --SG 07:03, 23 Oct 2008 (EDT)

I've changed my opinion and am going with D. See OHA page 555 2nd edition on Thyroidectomy - malignancy - cord palsies likely. Distortion and rigidity of surrounding structures. Possibility of intraluminal spread. Larynx may be displaced. Tumour can produce obstructoin anywhere from glottis to carina.--SG 04:36, 4 Nov 2008 (EST)


D. no ref. but a workshop at the asanza conference assessing airway in ent surgery: summery malignancy is bad. a tracheal stenosis due to groiter can often eaesy be dillatated, in malignantcy the stenosis is often fixed and there is also the risk of bleeding

Our group concurs- malignant= invasion structures: concerning for anaesthetists and surgeons. Benign MNG are usually OK. You can always clamp a carotid artery( even if you do give the patient a stroke!)--Tsotsi 12:52, 5 Nov 2008 (EST)

That all sounds plausible and sensible but from memory I think what the CT actualy showed was tracheal deviation...


AZ26. PAC seeing patient with thyroid disease. Most reassuring factor for normal thyroid function is:

A. Absence of 'hot' nodules on nuclear scan

B.?

C. Normal heart rate

D. Normal temperature

E. Absence of any antithyroid medications

Answer is C. Normal HR. --SG 10:37, 23 Oct 2008 (EDT)


AZ. T1 injury. Patient now 4 weeks post and going to theatre for sacral pressure area debridement. Feature most unlikely to reflect autonomic dysreflexia

A. ?

B. Bradycardia

C. Severe hypotension

D. ?

E. Goose bumps below T1 level


Answer is C severe hypotension. Autonomic dysreflexia is characterised by massive, disordered automonic response to stimulation below the level of the lesion. It is rare in lesions lower than T7. Incidence increases with higher lesions. It may occur within 3wk of the original injury but is unlikely to be a problem after 9 months. The dysreflexia and its effects are thought to arise because of a loss of descending inhibitory control on regenerating presynaptic fibres.

Hypertension is the most common feature but is not universal. Other features include headache, flushing, pallor ( may be manifest above the level of lesion, nausea, anxiety, sweating, bradycardia and penile erection. Less commonly pupillary changes or Horner’s syndrome.

Dysreflexia may be complicated by seizures, pulmonary oedema, coma or death and should be treated as a medical emergency.

Stimuli to trigger

• Urological: bladder distension, UTI, catheter insertion • Obstetric • Bowel obstruction • Acute abdo • Fractures

From OHA page 240 --SG 08:56, 23 Oct 2008 (EDT)

Not sure that C is the answer, i'm leaning more towards B. Both the OHA and CEACCP articles (Cervical cord injury and criticial care) refer more to HYPERtension rather than HYPOtension, and the CEACCP article says "The clinical picture is one of malignant hypertension with reflex bradycardia" --Getafix 00:01, 24 Apr 2011 (EDT)



AC. With regard to fire in OT

A. Mainly caused by laser surgery

B. Decreased incidence since cessation of use of cyclopropane and ether

C. Need fuel, ignition source and oxidizing agent

D. ?

E. ?

c - Anesthesiology May 2008, 108(5): "fire triad", oxidizer, ignition source, fuel... raccoon



AZ. Visual loss post-operatively

a. more common after external ocular compression

b. incidence 1 in 200,000

c. most common after spinal surgery

d. incidence independent of duration of surgery

e. more common after isovolaemic haemodilution

E seems appropriate (having changed my mind from ? B) CEACCP says 1:125000.

[3] --SG 08:56, 23 Oct 2008 (EDT)

A False: Ischaemic optic neuropathy(ION) more common(89%), bilateral, systemic causes( atherosclerosis, antihypertensives); Central retinal artery occlusion(CRAO) less common 11% and there is an association with external compression but it occurs less often than ION B False 1:125 000 overall surgery( CEACCP) C False overall 0,0008%, spinal surgery 0,2% but cardiac 4,5%( Anesthesiology 2006, 105, 652) D False association with surgery> 6hrs or blood loss > 1L( above reference) E True Ass with large volumes of clear fluids ie isovolaemic haemodilution. --Tsotsi 12:52, 5 Nov 2008 (EST)


Disagree with above. Answers in this reference: Perioperative Visual Loss After Nonocular Surgeries, American Journal of Ophthalmology Volume 145, Issue 4 604-610

From above reference, A:False ext compression does not cause ION (casues central retinal occlusion) and ION most common cause 85% B:False 1:125 000 CCEAP C:True- Perioperative ION has been reported after a wide variety of nonocular surgeries, including spinal surgery, cardiac surgery, radical neck dissection, and vascular, abdominal, and orthopedic procedures.[13] and [16] In the ASA Registry, 73% of cases occurred in the setting of spine surgery. D: False- duration >6 hours a major factor E: False- Hct not a factor. -who is spooky

agree, answer C, from http://www.asahq.org/Newsletters/2003/06_03/lee.html --Happygas 03:58, 29 Nov 2008 (EST)happygas


I've changed my mind again given the above reference. Thanks Happygas.

"Preliminary analysis of the database indicates that the majority of cases are associated with spine operations (67 percent) followed distantly by cardiac bypass procedures (10 percent). The remaining 23 percent of cases are composed of liver transplants, thoracoabdominal aneurysm resections, peripheral vascular procedures, head and neck operations, prostatectomies and miscellaneous cases. Because spine operations comprised such a large percentage of the ASA POVL Registry, these cases were analyzed separately." --SG 23:01, 29 Dec 2008 (EST)

[4]

Related question: AC142

See discussion under this question (AC142). The problem is the editorial in Anesthesiology 2006; 105:641–2 states that ION is more common in cardiac surgery. There is no reference quoted at the end of this statement to support this. A reference quoted at the end of the next sentence refers to Anesth Analg 2001;93:1410–6, which is a retrospective case control study of ION following cardiac surgery between 1976 and 1994. They found a rate of 0.06% for developing ION after cardiopulmonary bypass surgery. So far the only figure I've found giving a rate for "visual loss" following spine surgery is 0.2% and comes from a retrospective study in Spine 1997; 22:1319–24 via BJA review of anaesthesia in the prone position Br J Anaesth 2008; 100: 165–83. Are there any other figures for rate of visual loss following prone spine surgery? Based on this I'd still have to go with C followed closely by E--Nomad 19:07, 10 Mar 2009 (EDT)

I think blood loss is a factor but there is no reference that directly quotes ANH.

Answer C This Reference: The Practice Advisory for Perioperative Vision loss in Spinal surgery states:

The Task Force believes that there is no documented
lower limit of hemoglobin concentration that has been
associated with the development of perioperative visual loss. --Drpeace 18:46, 6 June 2012 (CDT)

Dissenting opinion: I'm going with A. Sure, central artery occlusion is an uncommon cause (~10% of cases), but it's still responsible for a significant number. If you start pushing on people's eyeballs during surgery then surely your rate of blindness will be "more common" even if it doesn't go through the roof. The question only says "more common", not "heaps more common". --Farnsworth 02:27, 14 June 2014 (CDT)

AZ. Cause for hoarse voice after anterior spinal surgery

a. glossopharyngeal nerve palsy or lesion

b. recurrent laryngeal nerve palsy or lesion

c. superior laryngeal nerve or lesion

d. airway oedema

e. prolonged intubation

BDE seem to be correct, but many articles talk about the rec. laryngeal nerve, therefore I think B is most correct -- raccoon

I agree B, C, D, E correct, but most common cause is airway oedema and thus I would go for D.

See http://books.google.com.au/books?id=s-ZXPL_GvoMC&pg=PA23&lpg=PA23&dq=anterior+spinal+surgery+hoarse+voice&source=web&ots=kgOeF7OoMw&sig=eqRSjd0Q7EM_ItF0N3Qf-7U-Kn0&hl=en&sa=X&oi=book_result&resnum=1&ct=result#PPA24,M1 "Complications of Spine Surgery: Treatment and Prevention" by An, and Jenis. --Kom


Dysphonia and Dysphagia Following the Anterior Approach to the Cervical Spine Catherine P. WinslowArch Otolaryngol Head Neck Surg. 2001;127:51-55 archotol.ama-assn.org/cgi/reprint/127/1/51.pdf The incidence of hoarseness following this procedure is noted in the literature to occur in 0.06% to 21% of patients (mean, 3.6%).1,2 Injury to the recurrent laryngeal nerve, either from stretching or sectioning, is a well-known but rare source of hoarseness. Laryngeal injury from endotracheal intubation is also rare, with a 5% to 33% incidence.3,4 However, this may become more prevalent when significant retraction and consequent pressure occur during surgery. Infection is also rare but must remain in the differential diagnosis. Edema and fibrosis of the larynx is hypothesized to be a more common source of hoarseness and dysphonia following this procedure. This may occur as a result of retraction devices designed to provide adequate surgical exposure by displacing the larynx laterally. Our study showed a subjectiveincidence of 51%, much greater than that described in previous reports. Even more impressive is that the symptoms persisted for longer than 6 months in 38% of symptomatic patients. suggests D ... Speedy (I also saw another reference that now cant find suggesting risk nerve injury depends in site - upper cervical - superior laryngeal, lower cervical RLN)

Equipment

EM 65 Features most suspicious for myocardial ischaemia
a. ST depression 2mm during fem pop bypass in 60 yo man under spinal
b. T wave inversion in fem pop bypass in 60yo under spinal
c. 0.7mm ST elevation in fem pop bypass in 60 yo man under spinal
d. SAH in young man
e. 32 yo woman during LSCS


A St depression may be in reciprocal leads in ischaemia, elevation indicates early ischaemia

B may indicate ischaemia but not specific for ischaemia

C  ? C false ST elevation - ST segment elevation may indicate myocardial infarction. An elevation of >1mm and longer than 80 milliseconds following the J-point. This measure has a false positive rate of 15-20% (which is slightly higher in women than men) and a false negative rate of 20-30%.....From Wikipedia

D and E ???

Going with A on this. Most post op AMI's preceeded by ST depression. --SG 10:37, 23 Oct 2008 (EDT)

I reckon its A. BJA 2005, 95, Priebe( author) says 80% perioperative AMI occur in early post-op period and most commonly preceeded by ST depression and turn out to be non Q wave infarcts. The cummulative time of ST depression is significant. --Tsotsi 12:52, 5 Nov 2008 (EST)

I agree, after all ST depression = ischaemia, don't we learn that in medical school? --Kom 06:16, 27 Nov 2008 (EST)

I also agree A - see this reference from the EMAC website: http://anaesthesia.org.au/emac/cardio/ischaemia.html which states ST segment changes are the most specific ECG manifestation for myocardiardial ischaeamia. Specifically:

 ST depression: subendocardial ischaemia, poor localisation
     - Horizontal / downsloping depression > 0.1 mV (1 mm) at 60-80 msec after J point - consistent with A correct
     - Upsloping depression > 0.15 mV at 80 msec after J point
 ST Elevation: transmural ischaemia, good localisation
     > 0.1 mV at 60-80 msec after J point - implies C incorrect (only 0.7 mm ST elevation)

Note also ST changes possible on ECG without myocardial ischaemia in acute SAH, hence D false.--Tgr 23:01, 29 Nov 2008 (EST)


EM. The Line Isolation Transformer
a.  ?
b.  ?
c. Provides low current to the line isolation monitor
d. Separates earth from the OT electrical supply (similar wording)
e.  ?

D --SG 10:37, 23 Oct 2008 (EDT) nice talk about electrical safety in OR http://video.google.com/videoplay?docid=2179603385329770413 --Happygas 06:19, 29 Nov 2008 (EST)

See also Miller 6th Edition Chapter 87 (pp 3139-43) which confirms that the line isolation transformer supplies power sockets within the OT with an electrical supply which is isolated from ground - D correct. --Tgr 01:26, 30 Nov 2008 (EST)

Medicine

MC (Q132 Aug 2008) DC cardioversion - LEAST likely indicated for
A atrial fibrillation
B atrial flutter
C multifocal atrial tachycardia
D paroxysmal atrial tachycardia
E ventricular tachycardia

c - multifocal atrial tachycardia states as contraindication for cardioversion in emedicine -- raccoon from http://www.emedicine.com/EMERG/topic320.htm --Happygas 06:48, 29 Nov 2008 (EST)

According to the link you provided, the actual quote is "Due to the multiple atrial foci, cardioversion rarely is successful". I initially thought "D" due to the paroxysmal nature, then thought it's NOT likely to need DC cardioversion, rather than LEAST likely. Hence, I'll stick with C. -- ddt 1508h, 15 March 2009 (NZ)

Chest Jan 1998 states that MAT is "not responsive to cardioversion and that it may ppt hypotension due the underlying sepsis or PE"..answer is c. Rocket

Cardioversion is contraindicated in MAT. Due to the multiple atrial foci, direct current (DC) cardioversion is not effective in restoring normal sinus rhythm and can precipitate more dangerous arrhythmias. http://emedicine.medscape.com/article/155825-overview#a30 (((baci)))



ME (Q83 Aug 2008) Hypercalcaemia due to hyperparathyroidism is associated with
A an elevated GFR
B prolonged QT
C short PR interval
D polyuria polydipsia
E skeletal muscle rigidity

D - hypercalcaemia / hyperparathyroidism is accociated with impaired renal function, shorter QTc, prolonged PR and muscular weakness. -- raccoon

I agree D is correct. See OHA 2nd Ed p162-3. I am not sure that the PR interval is prolonged in hypercalcaemia - OHA p163 mentions prolonged PR interval in hypocalcaemia. The Anaesthesia UK webpage on Electrolyte disturbances and ECG changes only mentions QT changes (short QTc in hypercalcaemia and prolonged QTc in hypocalcaemia) and not changes in PR interval.--Tgr 02:25, 30 Nov 2008 (EST)

Westmead Pocket Anaesthetic Manual, 2nd. ed. / Hypercalaemia (in general): shortened QT interval, prolonged PR and QRS intervals, T wave flattening and widening, AV nodal blocking to complete heart block. QuizFizz 19:33, 30 Jan 2009 (EST)


MH (Q100 Aug 2008) Suprapubic prostatectomy bleeding excessively. Need to exclude primary hyperfibrinolysis. Most useful test would be
A clot retraction time
B plasma fibrinogen estimation
C prothrombin time
D thromboelastography
E whole blood clotting time

Answer is D Thromboelastography Google it TEG is very prominent --SG 10:37, 23 Oct 2008 (EDT)

  • Also see: Evaluation of rotation thrombelastography for the diagnosis of hyperfibrinolysis in trauma patients Br J Anaesth 2008; 100: 792–7

Levrat- Background. Blood loss and uncontrollable bleeding are major factors affecting survival in trauma patients. Because treatment with antifibrinolytic drugs may be effective, early detection of hyperfibrinolysis with rotation thrombelastography (ROTEMw) may be beneficial. Conclusions. ROTEMw provided rapid and accurate detection of hyperfibrinolysis in severely injured trauma patients.--Gord 15:39, 25 Nov 2008 (EST)

See also this AnaesthesiaUK article on Thromboelastometry.--Tgr 04:43, 1 Dec 2008 (EST)


MZ (Q96 Aug 2008) While of the following statements regarding patients with ankylosing spondylitis are FALSE
A amyloid renal infiltration is rarely seen
B cardiac complications occur in <10% of cases
C normovolaemia anaemia occurs in over 85% of cases
D sacroileitis is an early sign of presentation
E uveitis is the most common extra articular manifestation

Ankylosing spondylitis

A TRUE Amyloidosis is a very rare complication of ankylosing spondylitis in patients with severe, active, and long-standing disease. These patients generally have active spondylitis, active peripheral joint involvement, and an elevated erythrocyte sedimentation rate (ESR) and C-reactive protein level. This may result in renal dysfunction with proteinuria and renal insufficiency or failure.[5]


B TRUE Cardiovascular involvement of clinical significance occurs in fewer than 10% of patients, typically those with severe long-standing disease. However, subclinical disease can be detected in many patients and may occur as an isolated clinical entity in association with HLA-B27[6]


C FALSE Approximately 15% of patients may present with a normochromic normocytic anemia of chronic disease.[7]


D TRUE


E TRUE Uveitis is the most common extra-articular manifestation, occurring in 20-30% of patients with ankylosing spondylitis. Of all patients with acute anterior uveitis, 30-50% have or will develop ankylosing spondylitis. The incidence is much higher in individuals who are HLA-B27–positive (84-90%).[8] --SG 10:37, 23 Oct 2008 (EDT)


MZ6. This Chest Xray shows
a. left upper lobe collapse
b. right upper lobe collapse
c. right middle lobe collapse
d. right lower lobe collapse
e. left lower lobe

Useful guide to CXR changes seen in different lung lobes, with collapse and consolidation, in this Student BMJ article. --Tgr 05:37, 1 Dec 2008 (EST)


MZ-16 MR48 COPD patient with pulmonary hypertension and acute RHF. Treatment a. 100% oxygen will decrease the pulmonary artery pressure b. Sildenafil will be useful for treating RHF c. Noradrenaline is an appropriate inotrope for this patient d. ?
e. ?

MZ-25 Post op patient (surgery 3/7 ago). Patient dyspnoeic. V/Q scan organized which shows non segmental matched perfusion/ventilation defects. This is consistent with
a. Atelectasis

b. COPD (multiple, segmental, peripheral, bilateral, matched)

c. Pulmonary embolus (mismatched)

d. Pneumonia (reverse mismatch)

e. Pulmonary infarction (mismatched) --Happygas 05:35, 30 Nov 2008 (EST)

http://books.google.com/books?id=-dQA-yTsCD0C&pg=PA576&lpg=PA576&dq=V+Q+scan+matched+nonsegmental&source=web&ots=ZAv3mKtXwz&sig=EM6MBlFrQXCztYQyktJ_BmErSDg&hl=en&sa=X&oi=book_result&resnum=10&ct=result#PPA589,M1

Answer is A atelectasis. both compression of pulmonary vessels and alveoli (matched VQ defect plus non segmental) --SG 10:37, 23 Oct 2008 (EDT)

Got a reference?--Tsotsi 12:52, 5 Nov 2008 (EST)

the google books reference above states:

Reverse mismatch with Atelectasis (basically west zone3 with shunt), Asthma (generalised patchy), Pneumonia, Inhaled foreign body

Another article states: matched V/Q scan in patients with a pulmonary embolism, may result from lung consolidation induced by a pulmonary infarction, localized edema, or hemorrhage Zhonghua Yi Xue Za Zhi (Taipei). 1992 Jan;49(1):16-20. The predictability of matched ventilation perfusion scan in pulmonary embolism. Ok, so its a random chinese journal, but at least it makes sense!

I checked this question with my friend, a local Unclear Medicine-ologist. She said that of those options, the only two that would give a non-segmental MATCHED defect would be A: Atelectasis or D: pneumonia. I asked if atelectasis was more probable as the stem specified 'segmental' and she said that in the real world this isn't always the case (circular paediatric pneumonia, anyone?) but thinks that A: atelectasis is the answer the examiners are after. Gasmama 19:52, 13 Mar 2011 (EDT) (level of evidence 4.5. She is pretty clever)

However, Pulm infarct would be segmental & matched defect wouldn't it? A: No, because it would show ventilation (albeit reduced) but no perfusion.Gasmama 19:52, 13 Mar 2011 (EDT)

Surgery

SF (Q105 August 2008) A 25yo primipara with an uncomplicated pregnancy presents to delivery suite in labour at term. Her membranes spontaneously rupture soon after, and it is blood-stained. At the same time, a severe foetal bradycardia appears on the CTG. What is the most likely cause of this?
A. Placenta accreta
B. Placental abruption
C. Uterine rupture
D. Vasa praevia
E. True knot in the umbilical cord

Answer is D.

From WIKIPEDIA[9] Vasa praevia (vasa previa AE) is an obstetric complication defined as "fetal vessels crossing or running in close proximity to the inner cervical os. These vessels course within the membranes (unsupported by the umbilical cord or placental tissue) and are at risk of rupture when the supporting membranes rupture."[1]

These vessels may be torn at the time of labor, delivery or when the membranes rupture. It has a high fetal mortality because of the bleeding that follows. [2] The bblood lost is foetal not maternal blood hence the high mortality.

The classic triad are membrane rupture followed immediately by painless vaginal bleeding and fetal bradycardia.--SG 10:37, 23 Oct 2008 (EDT)


SF (Q141 Aug 2008) Patient with placenta acreta. Surgical management MOST likely to save her life
A B lynch suture around the uterus for external tamponade
B Rusch balloon in the uterus for internal tamponade
C ligation of the internal iliac arteries
D ligation of the uterine arteries
E subtotal or total hysterectomy


Answer E

Page 731 2nd edition OHA--SG 10:37, 23 Oct 2008 (EDT) B-lynch suture is for uterine atony after caesarean. Balloon tamponade can be used for atony or lower segment bleeding, arterial ligation does not appear to be that helpful due to collateral supply (anecdotal from obstetricians I work with), and hysterectomy is surgical last resort. kom.

Agree, iliac artery ligation seems to be something done to buy time for further treatment.

Answer A. From Chestnut Obstetric Anaesthesia....."Most patients with placenta accreta require hysterectomy. This condition is currently one of the two most common indications for peripartum hysterectomy; a prompt decision to proceed to hysterectomy without delay enhances the likelihood of an optimal outcome.[55] Attempts to separate and detach the placenta frequently result in massive hemorrhage. Therefore, in cases in which the diagnosis was made before delivery, the obstetrician may proceed directly to hysterectomy without attempting to separate the placenta. Unfortunately, some obstetricians have little or no experience with the performance of peripartum hysterectomy. The presence of two obstetricians for cesarean delivery in women at high risk for placental accreta is recommended. Blood loss in these cases can be substantial. The importance of delivering large amounts of blood products to the operating room quickly cannot be overstated." saraht Feb 2010


SG (Q103 Aug 2008) After a difficult thyroidectomy for thyroid carcinoma, a 63 year old woman develops stridor immediately following extubation. The most likely cause is
A hypocalcaemia
B neck oedema
C recurent laryngeal nerve palsies
D tracheomalacia
E vocal cord oedema

All are possible causes. Good summary in CEACCP article [10] ,

Yes all could happen post-operatively, but only RLN palsies, vocal cord oedema would realistically give stridor, (RLN palsies much more likely). Collapsing neck oedema, and tracheomalacia would certainly give dyspnoea is significant. I think answer is C QuizFizz 18:52, 30 Jan 2009 (EST)

As to most likely cause ?? B or C are my picks. Would be happy to be corrected. --SG 10:37, 23 Oct 2008 (EDT)

My pick would be C - difficult thyroidectomy for malgnancy suggests surgeons digging around a lot and nerves may have been involved... But agree, all are correct. In Surgeery 2003 137 (3): recurrent laryngeal nerve palsies are the most common complications, about 5 % , even 19.4% in cancer. Would need bilateral injury for stridor though... --- raccoon Yes, that's why the question says "RLN palsies", plural.


SN (Q114 Aug 2008) Patient with traumatic brain injury has the following readings. Global CSF flow measured at 15ml/100gm/min while the CMRO2 is measured at 3.5ml/100gm/min. There is
A appropriate coupling of cerebral perfusion and cerebral metabolism
B autoreguation of cerebral vasodilation
C cerebral hypoperfusion
D cerebral ischaemia
E reperfusion injury


15 ml of blood carries 0.015 X 200ml (normally about 200 ml of O2 per litre of blood) = 3 ml.

Delivery ~ 3 ml/100g/min : Requirement 3.5 mL/100g/min.

NB normal CBF is 750 ml/min or 50 ml/100g/min not 15.


C? Anyone else with ideas??--SG 10:37, 23 Oct 2008 (EDT)

I think D: almost normal o2-consumption but dramatic reduction in o2-delivery - clearly uncoupled and beyond just hypoperfusion -- raccoon I agree and this from wikipedia "Ischemia results if blood flow to the brain is below 18 to 20 ml per 100 g per minute" supports this. kom

My view on C vs D: We are told CBF is low therefore there is hypoperfusion. Ischaemia to me implies not enough o2 delivery. to know o2 delivery you really need to know sats and Hb to get o2 content as well as just flow (if Hb=200 or hyperbaric chamber could conceivably have enough o2 delivery with poor flow). Futhermore CMRo2 is measured as normal. If there is inadequate o2 supply you shoud rapidly see a consequent fall in measured CMRo2 since you can't consume oxygen that isn't there (The brain has very limited oxygen reserves). I think go for something you definitely have over something you probably or might have. If you also have ischaemia it doesn't make hypoperfusion any less correct - C. jamesj

I assume they mean global CBF, not CSF flow. I don't know how you can differentiate btw hypoperfusion and ischaemia without being able to calculate DO2 (as james said above), although I doubt 15ml/100g/min is going to supply enough. "CBF at which ischaemia becomes apparent on EEG is 20ml/100g/min" Yao&Artusio 6th Ed pg 555. Going with D but happy to be proven otherwise. --Tortis 20:26, 21 Feb 2009 (EST)

I'm going for D. BJA 2007 July Neuro Issue Pathophys TBI Top p.5 http://bja.oxfordjournals.org/cgi/reprint/99/1/4 "For example, low flow with normal or high metabolic rate represents an ischaemic situation whereas high CBF with normal or reduced metabolic rate represents cerebral hyperaemia. 5 30 43 In contrast, low CBF with a low metabolic rate or high CBF with high metabolic rates represents coupling between flow and metabolism, a situation that does not necessarily reflect a pathological condition." - --Damos 00:30, 17 Mar 2009 (EDT)

Strong work, Damos, cheers for that. Tortis

I'm kind of with jamesJ on this one...how is option C incorrect? Actual answer might depend on the exact wording of the question and options. Maybe you were given sats, Hb etc, or maybe it was hyper rather than hypoperfusion? --Getafix 03:10, 24 Apr 2011 (EDT)


SN20 (Q108 Aug 2008) 55 year old subarachnoid haemorrhage secondary to aneurysm. Patient is confused with a oculomotor (3rd cranial nerve) palsy, complains of a severe headache. This patient is in Hunt and Hess class:
A 0
B 1
C 2
D 3
E 4

Answer is D

Hunt and Hess Classification (NB any neurological deficit other than CN palsy is 3 or more)

  1. Asymptomatic, mild headache, slight nuchal rigidity
  2. Moderate to severe headache, nuchal rigidity, no neurologic deficit other than cranial nerve palsy
  3. Drowsiness / confusion, mild focal neurologic deficit
  4. Stupor, moderate-severe hemiparesis
  5. Coma, decerebrate posturing [11]

--SG 10:37, 23 Oct 2008 (EDT)

 I disagree, I think it's C, H&H states no neurological deficit other than cranial nerve palsy, this pat's got 3rd cn palsy, so therefore H&H 2. Andrew 31.03.09

I disagree: Confusion implies a neurological deficit other than CN palsy, Therefore D) 3. Shim 31/3/09


SN (Q131 Aug 2008) Traumatic brain injury with central diabetes insipidus. Can be managed with
A democlocydine
B desmopressin
C fludrocortisone
D fluid restriction
E frusemide

Answer B --SG 10:37, 23 Oct 2008 (EDT)



SG2. Called to ward for Postoperative thyroidectomy bleeding in ward. SpO2 92% on 6L, tachycardic and ?hypertensive and neck haematoma. What is the least appropriate management:
a. call and arrange CT scan of his neck
b. call OT and arrange urgent surgery
c. release staples
d. increase oxygen supply

Answer A. A sudden loss of airway in remote setting leaves this as a dangerous option. Lying flat may also compromise airway. Although will > 6 L of O2 benefit someone on a hudson mask?--SG 10:37, 23 Oct 2008 (EDT)


SF4. Hypertensive female at 38 weeks gestation BP 180/110. CTG shows no foetal distress. First Hb 110 and second is 109. First plt count 90 then drops to 40. AST increases from 50 to ? 120. Most appropriate management is
a. deliver the baby
b. various antihypertensive medication options
c. 20mg frusemide
d.?
e.?


Control BP first then deliver baby. No foetal distress. Delivery is definitve treatment but stabilising patient imperative. Drugs of choice

Antihypertensive drugs that can be safely used include labetalol, nifedipine and hydralazine. The choice should be made on clinician familiarity and experience with a particular agent (Level I).

Drugs that should be avoided for the reduction of blood pressure are diazoxide, ketanserin, nimodipine, MgSO4 (Level I) and sodium nitroprusside (Level IV). From new obstetric guidelines from ANZCA [12] --SG 10:37, 23 Oct 2008 (EDT)

I reckon its A- looks like HELLP syndrome developing- definitive management is delivery, you can manage BP whilst doing so.--Tsotsi 12:52, 5 Nov 2008 (EST)

Depends how the question is worded and if Initial management was used. I agree that delivery is the plan as you may not get control of her BP until the placenta is out.

This from WIlliams Manual of Obstetrics, 21st Edition: In most cases delivery is indicated because the platelet count continues
to decrease.  In general the lower the platelet count the greater the maternal and foetal morbidity and mortality.

I wonder if the O and G exam includes anaesthetic questions? --Kom 04:52, 30 Nov 2008 (EST)

Hb is stable so HELLP hasn't set in yet, but judging from the rising AST and massive plt drop it's imminent. The "no foetal distress" part makes me wonder about B, but going A anyway. Although clearly you'd be doing B whilst organising A and giving a bit of MgSO4 in the real world.--Tortis 00:46, 22 Feb 2009 (EST)


SC15]] Post bypass 3 vessel CABG. Hypotensive and ECG shows ST elevation in II, aVF CVP 15mmHg PAP 25mmHg with normal SVR and PVR. What is most likely to be seen on TOE
a. early diastolic augmented flow ct atrial systolic flow
b. Inferior hypokinesis (of the left ventricle)
c. RV failure and TR
d. Empty left ventricle following systole
e. Mitral regurgitation


Unsure ST elevation in II aVF suggests inferior ischaemic changes. CVP high PAP high (if PAP mean then pt has pulm HT)

D false

E more likely to get pulm HT in mitral stenosis--

My pick would be B SG 10:37, 23 Oct 2008 (EDT)

I would think B - sounds like a failing heart/ischaemia/graft failure --raccoon

Could also be RV signs from a failing RCA graft in face of pulm HT, therefore C?? TOrtis (PS how can PVR be normal in someone with pulm HT?)

Re above: If high right cardiac output can have pulm HT with normal PVR (BP= CO * Resistance). eg VSD with L->R shunt. Eventually get hypertrophy of pulm vessels in response to pressure load in this situation and PVR does go up tho. Don't think any that applies here tho. James J

Anatomy

NN (Q85 Aug 2008) The left recurrent laryngeal nerve
A hooks around the arch of the aorta anterior to the attachment of the ligamentum arteriosum
B passes under cover of the lower border of the inerior constrictor muscle before entering the larynx
C supplies the cricothyroid muscle
D supplies sensation to the whole of the laryngeal mucosa on the left side
E contains motor fibres derived from the spinal root of the accessory nerve



A false posterior to ligamentum arteriosum

B ? TRUE

C False innervates all intrinsic muscles of the larynx except the cricothyroid

D False supplies sensation to mucosa BELOW the cords (Superior laryngeal nerve above cords)

E False Vagus nerve.

--SG 11:11, 23 Oct 2008 (EDT)

Agree - B true--raccoon


NT (Q62 Aug 2008) The ascending aorta
A has no branches
B begins at the semilunar valve
C arises from right ventricle
D occupies the superior mediastinum
E lies inferior to the SVC

Answer is B--SG 11:11, 23 Oct 2008 (EDT)

--BassBoyDave 06:34, 3 Jul 2010 (EDT) No it's not. The answer is D (see CEACCP article on mediastinoscopy). The semilunar valve is the pulmonary valve, so B is wrong.

Googling reveals plenty of references to semilunar valves as being the pulmonary AND aortic valve. Also, first few pictures of superior mediastinum show that it is only the arch which is in this compartment. Ascending aorta appears to be in the Inferior mediastinum - Isoma - My answer will be B.

If this is the exact wording then there are 2 options B or D. The ascending aorta begins at the semilunar valve or aortic orifice or aortic vestibule. The ascending aorta absolutely definitely occupies the superior mediastinum according to Moore, Last etc. I'm going with D.

I'm also finding it hard to choose between B and D. If it says "the" semilunar valve rather than "a" semilunar valve, that would make me think they are referring to the pulmonary valve rather than aortic valve, but as mentioned above there are plenty of references with the aortic valve described as a semilunar valve, including Gray's Anatomy (the textbook not the TV show!!). There seems to be some debate about which part of the mediastinum the ascending aorta is in. Gray's doesn't even have a superior mediastinum, but lists the ascending aorta as being in the middle mediastinum. The CEACCP article doesn't explicitly refer to the ascending aorta in Fig 1, while wikipedia (for what it's worth) lists it as being in the middle mediastinum. Most references refer to the middle mediastinum as being the contents of the pericardium, and i have seen a few references talk about the ascending aorta being inside the pericardium. So it seems as though the aortic valve is definitely a semilunar valve, but it is not definitely within the superior mediastinum. Mind you, another thought i had was where does the aorta actually start? Could it be that the semilunar leaflets of the aortic valve are actually within the aorta rather than being its origin? Gray's says "It commences at the upper part of the left ventricle, in front of the left auriculoventricular orifice...". Quite rightly, Anatomy for Anaesthetists dedicates one paragraph to the mediastinum and doesn't go into the specifics of which bit contains which structures!!! --Getafix 06:37, 24 Apr 2011 (EDT)

http://radiographics.rsna.org/content/27/3/657.full - nice pics, 2nd paragraph states several different arbitary ways of dividing up the mediastinum, seems to indicate ascending aorta NOT in superior mediastinum... speedy


NN (Q102 Aug 2008) The nerve providing sensory supply to the airway muscle below (inferor) to the vocal cords is the
A phrenic nerve
B posterior thyroid nerve
C recurrent laryngeal nerve
D superior laryngeal nerve
E tracheal nerve


Answer is C see two questions above --SG 11:11, 23 Oct 2008 (EDT)


NH (Q138 Aug 2008) Ciliary ganglion
A sympathetic from inferior cervical ganglion
B located inferiorly within orbit
C may be damaged during a peribulbar block
D preganglionic parasympathetic supply from the supra trochlear nerve
E preganglionic parasympathetic originates from the Edinger Westpal nucleus


Answer is E[13] --SG 11:11, 23 Oct 2008 (EDT)

Regional Anaesthesia

RB (2008 August Q106) You are seeing a 60yo man in the pre-anaesthetic clinic before his right total knee replacement. He weighs 70kg and apart from his osteoarthritis is fit and well. You discuss with him the options of a general anaesthetic with multi-modality analgesia and enoxaparin postoperatively as well as the option of an epidural for both the anaesthetic and post operative pain management. What is incorrect regarding the epidural?
A. It will shorten his hospital stay and accelerate his rehabilitation
B. It will give him better pain relief particularly for the CPM machine (the continuous pain machine) <--- really?? I thought CPM was continuous passive motion?
C. It will reduce his risk of myocardial ischaemia
D. There will be little difference in his risk of thromboembolism.
E. If he has no sedation, his risk of post-operative delirium and cognitive impairment will be reduced


The question asks for the incorrect answer.Taken from Acute Pain management:scientific evidence(ANZCA)summary and pg 110-115(2nd edition)

A)- True

B- True Better analgesia with all techniques of epidural anaesthesia (in particular with movement) as compared to parenteral opioids

C- False( correct answer): only true for thoracic epidurals extended for more than 24hrs, not lumbar epidural for RTKJReplacement.

D- True, only difference is with graft occlusion in peripheral vascular surgery, not orthopaedics and DVT where DVT prophylaxis has been used.

E- true

C false therefore correct answer.--Tsotsi 09:12, 6 Nov 2008 (EST)

I agree with C being the best (i.e. most incorrect) answer, but does anyone have any evidence to support E as being correct? Most reviews seem to indicate that no difference has been demonstrated between regionals and GAs with regards to post-op delirium and cognitive impairment. (eg Anesthesiology 2007; 106:622–8). Apparently though most of these studies didn't control for sedation being given to the regionals group, so E seems plausible, but is there actually any paper that supports it as being true??--Nomad 22:17, 13 Mar 2009 (EDT)


Whoops - I agree --SG 07:07, 17 Nov 2008 (EST)

Why is E true? I thought there was no diff in rate of post-op cognitive dysfunction between regional vs general - anyone? Regional anaesthesia with no sedation reduces the risk of early, but not late POCD.

- he's 70 and otherwise healthy, low risk of POCD with TKR anyway!


RB Effect of Injecting 5 mL of saline into the epidural space:
a. increase incidence of patchy block
b. decreased risk of epidural vein catheterisation
c. no effect
d. increased ease of threading catheter
e. ? decreased effectiveness of block


This question most likely comes directly from this article in A and A [14]


a False (compared with 2 mls - less patchy block 91% vs 67%)

b True 5mls vs 2mls NS - 2% vs 16%)

c False

d False

e False

--SG 09:35, 26 Oct 2008 (EDT)



RB PDPH.

a. IV caffeine treatment used to relieve symptoms.
b. Is usually frontal headache
c. Bed rest for 24 hrs is beneficial
d. no use if blood patch done after 48 hrs.
e. usually manifests within first 4 hrs.


A True as per pain bible [15] page 166.

B False usually occipital and frontal

C  ? correctly remembered - as per pain bible not beneficial in preventing PDPH (symptomatic relief)

D BS!

E False usually manifest 24-36 hours post puncture


--SG 09:35, 26 Oct 2008 (EDT)

Intensive Care

IC (2008 August Q104) A terrorist attack has taken place involving the nerve gas "VX". Some victims have arrived in the emergency department. The most appropriate management of this situation is to:
A. Strip them off and hose them down
B. Strip them off, scrub them with a brush, and hose them down
C. Leave their clothes on and hose them down
D. Leave their clothes on, scrub them with a brush, and hose them down
E. Take them to the resuscitation area and put in an IV


VX or S-[2-(diisopropylamino)ethyl]-O-ethyl methylphosphonothioate] is able to be lethal on skin contact therefore patient must be cleaned before touched!

I'll go F. Stab them in the heart with a syringe and inject atropine. (Nicolas Cage, The Rock 1996)

FROM WIKIPEDIA

An individual who has received a known nerve-agent exposure or who exhibits definite signs or symptoms of nerve-agent exposure should immediately have the nerve agent antidote drugs atropine, pralidoxime (2-PAM), and diazepam injected. In several nations the nerve agent antidotes are issued for military personnel in the form of an autoinjector such as the United States military Mark I NAAK.[5]

Atropine works by binding and blocking a subset of acetylcholine receptors (known as muscarinic acetylcholine receptor, mAchR), so that the build up of acetylcholine produced by loss of the acetylcholinesterase function can no longer affect their target. The injection of pralidoxime regenerates bound acetylcholinesterase.[16]

Primary consideration should be given to removal of the liquid agent from the skin before removal of the individual to an uncontaminated area or atmosphere. After removal from the contaminated area, the casualty will be decontaminated by washing the contaminated areas with household bleach and flushing with clean water. After decontamination, the contaminated clothing is removed and skin contamination washed away. If possible, decontamination is completed before the casualty is taken for further medical treatment.[17]


--SG 09:35, 26 Oct 2008 (EDT)

Answer B

1) you'd be required to wear protective garments before approaching these victims

2) T. Oh Intensive care p807 "Immediate first aid is to remove pt from the area of danger to a well-ventilated area before removal of clothing and decontamination of the skin...."

3) certainly when I was working in ED at the Alfred Hosp, Melbourne during the Commonwealth Games 2006, there were laid-out plans in case of terrorist attacks with chemical agents during the games- Had bays to strip patients, wash and scrub them before taken into the dept.

4) you have to strip them otherwise there will be ongoing absorption of agent via the skin. Hosing them while they have clothes on is futile.-- spitfire 20:42, 9 Nov 2008 (EST)

You have to strip them off clothes, agree. Hose them down, yes. What about the scrubbing with brush?? It may increase the skin absorption!? I would almost think A (emedicine and A&A 2003 (96) 819-25 --raccoon

I agree it is A, as abrading the skin by scrubbing will increase absorption of these agents as per e-medicine and CDC website states priorities are removal from hot zone, cut off clothing, wash with soap and water or hypochlorite solution. http://www.emedicine.com/emerg/topic899.htm http://www.atsdr.cdc.gov/MHMI/mmg166.html#bookmark04 --Kom 05:07, 3 Dec 2008 (EST)


From Fink, Abraham, Textbook of Critical Care 2005 p2238, Nerve agents (eg VX) "the cardinal rule in decontaminating patients is to remove and dispose of all items of clothing." I'm going A. Jamesj

Answer is A, and probably comes from BJA article on terrorist attacks (British Journal of Anaesthesia, 2002, Vol. 89, No. 2 306-324), which highlights need to remove clothing, wash with soap and water, 0.5% sodium hypochloride, and GENTLE washing to avoid abrasion. saraht

IC Another GCS question – open eyes to command, withdrawing from pain, confused conversation:

A. 8 B. 9 C. 10 D. 11 E. 7


Eyes 3/4 Movement 4/6 Verbal 4/5

answer D --SG 09:35, 26 Oct 2008 (EDT)



IC young man in trauma, had been drinking,alcohol level >300. Multiple fractures. Initial lactate 10 then post fluid resus lactate 5.
a. 2nd lactate more important than first for prognosis
b. initial lactate high due to alcohol c. ?
d. The initial lactate result carries a mortality exceeding 20% e. ?


A. Truish in that increased lactate or no reduction in high lactate is prognostic of very poor outcome (mortality 100% in haemorrhagic trauma with patients with no improvement in lactate after 48 hours of resuscitation [18]

B. False Alcohol may increase lactate levels slightly but lactic acidosis (and a lactate of 10!!! extremely unlikely without protein malnutrition and still this is very rare.

D. Depends on reference - Multiple articles claim > 20% mortality in SIRS/sepsis however for trauma unlikely to predict outcome. See reference [19]


See link for good powerpoint/pdf on shock and lactate measurements and outcomes [20]



IC. Patient has anterior cervical spine fusion. Most likely cause of hoarse voice
a. RLN injury
b. Swelling
c. ?
d. ?
e. ?


A. RLN injury --SG 12:22, 26 Oct 2008 (EDT)

This is same as final AZ question and more completely recalled above.

Paediatrics

PP (Q90 Aug 2008) A 6 month old baby is booked for an elective right inguinal hernia repair. An apropriate fasting time is
A 2 hours breast milk
B 4 hours formula milk
C 5 hours breast and formula milk
D 6 hours solids
E 8 hours solids, 4 hours all fluids

2 4 6 rule for clear fluids/breast milk/solids (includes formula)

Therefore D (breast milk at 4 hours would be ideal)

Hold on isn't it: 2346? 2 = clear fluids, 3 = breast milk, 4 = formula and 6 = solids? So therefore B is the answer! Andrew, 11/01/10

At kids we use 2,4,6 - clear, breast (infants), formula/solids ; (if under 6weeks old: 2,4,4)


This question may well be from the ANZCA document on day surgery which includes fasting guidelines - They are as stated above (2 hours clear fluids, 4 hours breast milk for any age child, 4 hrs for formula for <6 week old, or 6hrs for formula/solids for >6 weeks old, and of course 6 hrs adult solids). D for me then - Cracker2011


PP (Q139 Aug 2008) Arrest in a 10 year old. Has ventricular tachycardia after a near drowning accident. Patient is intubated and is being ventilated with 100% O2 and has IV access. A single DC monophasic shock of 60J has been given. The next step is to give
A adrenaline 10mcg/kg and DC shock 60J
B adrenaline 10mcg/kg and DC shock 120J
C amiodarone 5mg/kg
D DC shock 60J
E DC shock 120J


VT in child algorithm from Australian Resuscitation Guidelines on ANZCA website [21]


Next step after CPR for 2 min is 1 shock at 4 J /kg. 10 year old should be 28 kg therefore 120J

Answer E.--SG 12:22, 26 Oct 2008 (EDT)

Disagree. While the algorithm at first glance looks like no role for adrenaline in VF/VT, the ARC website http://www.resus.org.au/ guideline 12.5 states should give adrenaline every 3 mins along with shocks for VF/ pulseless VT. Also has adrenaline in box of algorithm. Misleading algorithm. I vote B. jamesj

Have a look at the flowchart again dude.

the flow chart and the text on the ARC resus website describe 2j/kg shock....CPR 2 mins...4j/kg shock and the go on to talk about adrenaline. My answer is therefore E . Rocket

AUSTRALIAN RESUSCITATION COUNCIL The recommended initial monophasic or biphasic shock treatment of VF or pulseless VT is a single shock of 2 joules per kilogram (J/kg) followed by 2 minutes of CPR and then by a monophasic or biphasic shock of 4J/kg 1,2,3 [Class A; LOE IV]. All subsequent shocks should be 4 J/kg 1 [Class A; LOE IV]. .......... F'ailure to revert to sinus rhythm is treated with adrenaline 10mcg/kg IV or IO or 100mcg/kg ETT. Adrenaline administration should be followed with a subsequent single DC shock (4J/kg monophasic or biphasic shock). Persistent or refractory VF or VT may be treated with antiarrhythmics such as amiodarone 5 mg/kg IV 7 [Class A; LOE II] or IO as a bolus followed by additional DC shock. This may be repeated. A less efficacious antiarrhythmic for DC- shock resistant VF or VT is lignocaine 8 [Class B; LOE II] in a dose of 1 mg/kg IV or IO or 2- 3 mg/kg via ETT1.

December 2010 ARC algorithm for infants and children (http://www.resus.org.au/public/arc_paediatric_cardiorespiratory_arrest.pdf) indicates that ALL SHOCKS should be at 4j/kg.


PP (Q150 Aug 2008) 6 month old baby for VSD repair. Induced with 50% N2O, O2, sevoflurane 8%. While obtaining IV access, the patient desaturates to 85%. The manouevre to increase the O2 saturations is to
A give a fluid bolus
B change from sevoflurane to isoflurane
C institute CPAP
D decrease the FiO2
E reduce the sevoflurane concentration

E ? reduce sevo - attempt to regain some SVR to reduce shunt. Any other suggestions?? --SG 12:22, 26 Oct 2008 (EDT)

Sigh! Crap question, lots of wasted time looking for morsals of info.I agree its E, so does Troianos( Anaesthesia for the cardiac patient pg 289) excessive drop in SVR can lower SVR<PVR and promote transient R-L shunt.--Tsotsi 12:52, 5 Nov 2008 (EST)

Working this through from first principles. The infant is coming for VSD repair, therefore it must be a largish shunt. Typically a VSD would be a left to right shunt and thus the infant's normal sat would probably be relatively normal, unless there's a degree of pulmonary congestion from LV failure. Assuming there is not, then desaturation, other than the usual causes would be due to shunt reversal; either increased PVR or decreased SVR. I'd say the things that I would do is the usual stuff of increasing FiO2, turn off nitrous, and turn down the Sevo.


I disagree; Notes from Children's Hospital Westmead say that even in large VSDs, the shunt is L-> R (unlike in Tetralogy), and while pulm vasc changes begin at 6-12 months, change to R->L shunt does not develop until teens. In fact, surgical repair is contraindicated if PVR/SVR <0.5 or PHT with R->L shunt ! So increasing SVR will not help sats (in fact will promote more LVF). Given question states that desat occurs while stabbing child, it is more likely to be a standard laryngospasm, so CPAP will help - hence ?C

Really depends on the wording of the question doesn't it? Are the examiners trying to see whether "common things are common" or whether they're trying to test your understanding of physiological principles. I would have thought that given desaturation isn't likely to be the only thing you'll notice in a kid who's spasming (!) there's a bit more to the question than just that.

Have seen another edition of this question where it states "unable to get IV access" so desat not necessarily related to IV attempt, and so shunt reversal more likely to be a result of volatile and reduced SVR. Regarding above from Westmead, this is in reference to regular physiology, and not discussing the effects of anaesthesia. Flow direction is the key wrt dealing with shunts in anaesthesia - understanding the effects of the relationship between PVR and SVR, the effects of drugs we use, and how we can manipulate them. Kamquach

Pharmacology

PZ. The active metabolite of ketamine is:
a. Hydroxyketamine
b. Hydroxynorketamine
c. Ketamine glucuronide
d. Ketamine sulphonamide
e. Norketamine

E norketamine Metabolites of ketamine are norketamine and dehydronorketamine --SG 12:22, 26 Oct 2008 (EDT)


PZ19. Antidepressants are not effective/recommended for
a. Chronic headache
b. Chronic back pain
c. Chronic pain post mastectomy
d. Chronic pain post acute herpes zoster
e. Trigeminal neuralgia

E Trigeminal neuralgia --SG 12:22, 26 Oct 2008 (EDT)

  • It is also no use in acute herpes zoster but my reduce post herpetic neuralgia (PHN) and is usful in PHN. G
  • In the new edition of APMSE that's coming, they've reversed the finding about back pain. Now "There is no good evidence that antidepressants given to patients with chronic low back pain improve pain relief (Urquhart et al, 2008 Level I)." Wonder if they'll ask the question again.
  • They've also reversed the key message re mastectomy. "Antidepressants reduce the incidence of chronic neuropathic pain after breast surgery - This has been deleted as the information and evidence supporting it has been withdrawn."

Physiology

??

Statistics

ST (Q23 Aug 2008) NNT is the number of patient who need to be treated to prevent 1 additional bad outcome. The NNT is the reciprocal of the

A. absolute odds of a bad outcome

B. absolute risk of a bad outcome

C. absolute risk reduction in the bad outcome (due to the treatment)

D. odds ratio of the bad outcome (due to the treatment)

E. relative risk of the bad outcome (due to the treatment)


Answer is C

ie new antiemetic reduces risk of vomiting by 1/5th. Thus absolute risk reduction of bad outcome is 1/5th. Thus NNT is 5 inorder for 1 patient to not vomit.


--SG 12:22, 26 Oct 2008 (EDT)

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