1
Q
- The insulation on the power cord of a piece of class 1 equipment is faulty such that the active wire is in contact with the equipment casing. What will happen when the power cord is plugged in and the piece of equipment is turned on
A. The double insulation of the device will prevent macroshock when the outer casing is touched
B. The electrical fuse will immediately break and disconnect the device from the power supply
C. Equipotential earthing will prevent microshock
D. The Line Isolation Monitor will alarm and disconnect power to the device
E. The RCD will rapidly disconnect the device from the power supply
A
B. The electrical fuse will immediately break and disconnect the device from the power supply
2
Q
- EZ99 According to the current ANZCA approved standards for labeling, the appropriate colour label for an intraosseous infusion is (some remember it saying INTERosseous, not intraosseous… possibly typo, possibly trick question)
A. Yellow B. Beige C. Pink D. Blue E. Red
A
C. Pink
3
Q
3. PP102 An 8 year old 30kg girl presents for resection of a Wilms tumour. Her starting haematocrit is 35% and you decide that your trigger for transfusion will be 25%. The amount of blood that she will need to lose prior to transfusion is
A. 400mL B. 500mL C. 600mL D. 700mL E. 800mL
A
C. 600 mL
Miller:
Allowable blood loss = blood volume x (initial Hb - final Hb)/initial Hb
… or can substitute Hct for Hb
Blood volume = 70 mL/kg (2100 mL for 30 kg pt)
Allowable blood loss = 2100 x (35-25/35), = 600 mL
Stoelting has a slightly different formula, with the denominator being the average of initial Hb and final Hb –> using this formula you get 700 mL
4
Q
- A 30 year-old pregnant patient develops contractions at 30/40 weeks gestation which of the following cannot be used for tocolysis
A. Clonidine B. Indomethacin C. Magnesium D. Salbutamol E. Nifedipine
A
A. Clonidine - not tocolytic
Indomethacin is an appropriate (first-line) tocolytic for the pregnant patient in early preterm labor (up to 32/40)
5
Q
- A patient known to have porphyria is inadvertently administered thiopentone on induction of anaesthesia. In recovery the patient complains of abdominal pain, prior to having a seizure and losing consciousness. Which drug should NOT be given?
A. Pethidine B. Diazepam C. Haematin D. Suxamethonium E. Pregabalin
A
A. Pethidine
Assume pt has had porphyric crisis.
This is a controversial question - different sources classify diazepam as safe and unsafe. The CEACCP article does not even mention diazepam.
Pethidine safe - although lowers seizure threshold, so probably not the best drug in this circumstance
Sux safe
Haematin = treatment for porphyria
A small minority of patients will experience chronic neuropathic pain, associated with an ongoing level of disease activity. Gabapentin, pregabalin, and amitryptilline are safe drugs to treat neuropathic pain
Unsafe drugs in porphyria:
- Thiopentone
- Ketamine
- Sevoflurane
- Oxycodone
- Diclofenac
- Rifampicin
- Erythromycin
- Ephedrine
6
Q
- A patient with HOCM presents with dyspnoea and angina on exertion. Which of the following is the best agent to treat these symptoms
A. Glycerol trinitrate B. Metoprolol C. Morphine D. Hydrochlorthiazide E. Salbutamol
A
B. Metoprolol
7
Q
- A patient undergoes a femoral-popliteal bypass and has a mildly elevated troponin on day 1 post-operatively. They are otherwise asymptomatic with no other signs/symptoms of myocardial infarction and have an uneventful recovery. What do you do?
A. Arrange for a cardiology follow-up and outpatient angiogram because he is at increased risk of future mycocardial infarction
B. Arrange coronary angiogram as an inpatient prior to discharge
C. Inform the patient that while the result is real the significance is questionable
D. Repeat in a week’s time as a second troponin is a better indicator of long-term myocardial infarction risk
E. Ignore the result as it is likely a laboratory error
A
A. Arrange for cardiology follow-up and outpatient angiogram because he is at increased risk of future MI
Periop medicine short course
Metanalysis 2011 looking at vascular surgery patients found that an isolated troponin leak was strongly predictive of all-cause mortality at 30-days. The associated 30-day mortality in patients with no troponin elevation, an isolated troponin leak or PMI was 2.3%, 11.6% and 21.6%
Hence any patient with elevated perioperative troponin should be considered at risk for future adverse cardiac events.
8
Q
- A 40 year-old lady with a history of a bleeding diathesis presents for a tonsillectomy. What is the most likely cause?
A. Factor V Leiden B. Protein S deficiency C. Haemophilia B D. Antithrombin III deficiency E. Protein C deficiency
A
C. Haemophilia B
The others are prothrombotic conditions
Haemophilia B (or hemophilia B) is a blood clotting disorder caused by a mutation of the Factor IX gene, leading to a deficiency of Factor IX. It is the second most common form of haemophilia, rarer than haemophilia A. It is sometimes called Christmas disease
9
Q
- What is the most cephalad intervertebral space at which a spinal can be sited in a neonate where the risk of damage to the spinal cord is minimal
A. L1/2 B. L2/3 C. L3/4 D. L4/5 E. L5/S1
A
C. L3/4
Spinal cord ends at L3 in neonate
10
Q
- St John’s Wort (Hypericum perforatum) potentiates the effects of
A. Dabigatran B. Heparin C. Warfarin D. Aspirin E. Clopidogrel
A
E. Clopidogrel
St John’s Wort induces CYP3A4:
- Increases metabolism of Dabigatrin and warfarin
- Increases conversion of clopidogrel to active form (so will potentiate the effects of clopidogrel)
- No known interaction with aspirin or heparin
11
Q
- You are performing an awake fibreoptic intubation, through the nose, on an adult patient. In order, the fibrescope will encounter structures with sensory innervation from the following nerves
A. facial, trigeminal, glossopharyngeal B. facial, trigeminal, vagus C. glossopharyngeal, trigeminal, vagus D. trigeminal, glossopharyngeal, vagus E. trigeminal, vagus, glossopharyngeal
A
D. Trigeminal, glossopharyngeal, vagus
- The sensory innervation of the respiratory passage is provided by branches of the trigeminal, glossopharyngeal and vagus nerves:
- Nose/nasal passages: nasociliary branch of V1, and the nasopalatine and infraorbital branches of V2.
- Nasopharynx/oropharynx: overlapping supply, from glossopharyngeal nerve (IX), posterior palatine branch of V2, and lingual branch of V3
- Tongue: anterior two thirds – general sensation provided by lingual branch of V3 (taste from chorda tympani branch of VII); posterior third – general sensation and taste both provided by glossopharyngeal nerve (IX)
- Larynx: internal branch of the superior laryngeal nerve supplies sensation above the cords (including the superior surface of the cords); recurrent laryngeal nerve supplies sensation below the cords (including the inferior surface of the cords). Both of these nerves are branches of the vagus.
12
Q
- A patient is having an electrophysiological study and ablation for atrial fibrillation. Suddenly the blood pressure drops to 76/38 mmHg, with the heart rate at 110 in sinus rhythm. What is the best investigation to confirm the cause of hypotension?
A. Troponin B. ST-segment elevation C. Transoesophageal echocardiography D. Coronary Angiogram E. Electrocardiogram
A
C. TOE
13
Q
- Which is the most powerful predictor of atrial fibrillation post cardiac surgery.
A. Age B. History of hypertension C. History of CVA D. History of diabetes E. Time on Bypass
A
A. Age
‘ Post-op AF in the setting of coronary artery bypass graft surgery CABG has been associated with increases in health care costs estimated around $10000 per patient affected. Procedural risk factors of post-operative AF include valve surgery, pulmonary vein venting, bicaval venous cannulation, and longer cross-clamp times. Patient risk factors for post-op AF include male gender, renal dysfunction, congestive heart failure, and left atrial enlargement, the most powerful predictor, however, remains age.’
http://www.jafib.com/published/published.php?cont=abstract&id=482
14
Q
- A man with a history of Parkinsons disease has undergone uncomplicated general anaesthetic for a knee replacement but develops post-operative nausea and vomiting (PONV). He received 4mg dexamethsone intraoperatively as prophylaxis. What would you use to treat his PONV in recovery?
A. Dexamethasone B. Prochloperazine C. Metoclopramide D. Droperidol E. Ondansetron
A
E. Ondansetron
Dex has already been used. All others are dopamine antagonists.
15
Q
- Which of the following is of the least benefit in the treatment of severe anaphylaxis?
A. Cardiopulmonary bypass B. Nebulised salbutamol C. IV crystalloid D. IV vasopressin E. Subcutaneous adrenaline
A
E. subcutaneous adrenaline
Anaphylaxis during cardiac surgery: implications for clinicians A&A Feb 2008 vol 106 no 2 pp 392-403
All mentioned excepted E.
16
Q
- A 70 year old patient is being treated for congestive cardiac failure. They are able to shower themselves and complete other ADLs but get dyspneoa on mowing the lawn. They are New York Heart Association classification
A. Class 1 B. Class 2 C. Class 3a D. Class 3b E. Class 4
A
B. Class 2
NYHA Classification
Class I: Symptoms with more than ordinary activity
Class II: Symptoms with ordinary activity
Class III: Symptoms with minimal activity
Class IIIa: No Dyspnea at rest
Class IIIb: Recent Dyspnea at rest
Class IV: Symptoms at rest
17
Q
- The percentage of post dural puncture headaches that would resolve spontaneously by 1 week is closest to
A. 90% B. 70% C. 50% D. 30% E. 10%
A
B. 70%
BJA 2003 Post dural puncture headache: pathogenesis, prevention and treatment
The largest follow‐up of post‐dural puncture headache is still that of Vandam and Dripps in 1956. They reported that 72% of headaches resolved within 7 days, and 87% had resolved in 6 months. The duration of the headache has remained unchanged since that reported in 1956.
Ninety per cent of headaches will occur within 3 days of the procedure, and 66% start within the first 48 h. Rarely, the headache develops between 5 and 14 days after the procedure.
18
Q
18. Which piece of airway equipment is designed for use with a fibreoptic bronchoscope A. Aintree B. Cook’s airway exchange catheter C. Frova introducer D. ? E. ?
A
A. Aintree intubating catheter
19
Q
- A 50 year old lady is seen at the pre-operative assessment clinic, she is on 150mg/day methadone, what is the most likely ECG change to be found in her pre-op ECG?
A. Prolonged PR interval B. Prolonged QTc C. ST depression D. U wave E. Tented T-waves
A
B. Prolonged QTc
20
Q
- Current guidelines regarding cardiopulmonary resuscitation include all of the following EXCEPT
A. Allow equal time for chest compression and relaxation
B. Give 2 rescue breath before commencement of CPR
C. Chest compression at 100bpm
D. Chest compression should be at least 5cm depth
E. Chest compression to breath ratio at 30:2
A
B. Giving 2 rescue breaths before commencement of CPR
21
Q
- When a 3 lead ECG is applied correctly in the CS5 position, you will monitor lead II when you suspect which of the following conditions
A. Anterior ischemia B. Inferior ischemia C. Lateral ischemia D. Atrial ischemia E. Posterior ischemia
A
B. Inferior ischaemia
The central subclavicular (CS5) lead is particularly well suited for the detection of anterior myocardial wall ischemia. The right arm (RA) electrode is placed under the right clavicle, the left arm (LA) electrode is placed in the V5 position, and the left leg electrode is in its usual position to serve as a ground.
Lead I is selected for detection of anterior wall ischemia, and lead II can be selected for monitoring inferior wall ischemia or for the detection of arrhythmias. If a unipolar precordial electrode is unavailable, this CS5 bipolar lead is the best and easiest alternative to a true V5 lead for monitoring myocardial ischemia.
Thys DM, Kaplan JA: The ECG in Anesthesia and Critical Care. New York, Churchill Livingstone, 1987.
22
Q
- You are anaesthetizing a 50 year old man who is undergoing liver resection for removal of metastatic carcinoid tumour. He has persistent intraoperative hypotension despite fluid resuscitation and intravenous octreotide 50 ug. The treatment most likely to be effective in correcting the hypotension is:
A. Adrenaline B. Dobutamine C. Levosimenden D. Milrinone E. Vasopressin
A
E. Vasopressin
23
Q
- Using the American Heart Association specification, the colours of the electrodes in a 3-lead electrocardiographic is
A. Right arm = Black; Left arm = White; Left leg = Red
B. Right arm = White; Left arm = Black; Left leg = Green
C. Right arm = Black; Left arm = Green; Left leg = Red
D. Right arm = White; Left arm = Black; Left leg = Red
E. Right arm = Red; Left arm = White; Left leg = Green
A
D. Whitey righty, smoke over fire
24
Q
- AZ84 When performing laryngoscopy using a Macintosh blade, your best view is of the patient’s epiglottis touching the posterior pharyngeal wall. Using the Cormack and Lehane scale this is grade
A. 1 B. 2 C. 3a D. 3b E. 4
A
D. 3b
25
25. You are doing a supraclavicular brachial plexus block on an awake 35 year-old lady who is healthy with no significant past medical hsitory. Soon after injecting 20mLs of 0.375% ropivicaine she becomes agitated, has a seizure and loses consciousness. Your 1st step in management is
A. Intralipid 20% 1.5ml/kg bolus
B. Midazolam
C. Propofol
D. Establish airway and give 100% O2 via a facemask
E. Feel for radial pulse and give 100mcg adrenaline
D. Establish airway and give 100% O2 via a facemark
26
26. A G1P0 patient with a dilated cardiomyopathy and an ejection fraction (EF) of 35% presents for a caesarean section. The benefits of regional vs general anaesthesia are
```
A. Decreased heart rate
B. Decreased systolic blood pressure
C. Increased ejection fraction
D. Increased myocardial contractility
E. Decreased preload
```
C and D correct - general anaesthesia causes myocardial depression as well as a reduction in SVR, whereas spinal anaesthesia will only cause a decrease in SVR (provided the block does not extend above T4), which is advantageous in patients with cardiomyopathy.
CEACCP - Cardiomyopathy and anaesthesia
Regional anaesthesia used alone or in combination with general anaesthesia has the advantage of reducing after load which can improve cardiac output
CEACCP - Pregnant women with significant medical conditions: anaesthetic implications
The UK registry of high-risk obstetric anaesthesia on cardiac disease revealed slow incremental epidural anaesthesia and incremental combined spinal-epidural (CSE) (small intrathecal dose followed by careful incremental epidural top-ups) were both shown to be popular, combining the advantages of reduction of afterload with relative haemodynamic stability
PERIPARTUM CARDIOMYOPATHY
(definition: dilated cardiomyopathy of unknown aetiology occurring in the last month of pregnancy and up to 5 months post partum resulting in LV dysfunction)
- risks: advanced maternal age, obesity, multiparous, multiple gestation, gestational hypertension, African American race
- aims:
o Minimise Afterload (epidurals useful)
o Maintain low-normal HR to decrease oxygen demand
27
27. ET05 A patient has a terminal malignancy. His family doesn’t want you to tell the patient about his diagnosis and prognosis. Your decision to inform him is an example of:
```
A. Autonomy
B. Beneficence
C. Confidentiality
D. Non-maleficence
E. Utilitarianism
```
A. Autonomy
28
28. A septic patient has a CVP of 12mmHg, a blood pressure of 80/40mmHg and a pulse rate of 90/minute. Which is the best agent to treat their hypotension
```
A. Dopamine
B. Dobutamine
C. Noradrenaline
D. Adrenaline
E. Levosimenden
```
C. Noradrenaline
29
29. Which organ is least tolerant of ischaemia following removal for transplantation
```
A. Cornea
B. Heart
C. Liver
D. Kidney
E. Pancreas
```
B. Heart
BJA 2012 108 (51) i29-i42 Organ transplantation: historical perspective and current practice
Heart > Lung > liver = pancreas > kidney
4, 6, 12, 18 hours respectively
30
30. You are performing a TAP block. If the needle is correctly positioned where will you deposit the local anaesthetic
A. Beneath the peritoneum
B. Into the transverse abdominus muscle
C. Between the transverse adominus muscle and the internal oblique muscle
D. Between the transverse abdominus muscle and the external oblique muscle
E. Between the internal oblique and the external oblique muscle
C. Between transversus abdominis and external oblique
31
31. You are inserting a left sided double lumen tube into a 140kg 160cm woman. At what depth measured at the incisors is it most likely to be in the correct position
```
A. 25cm
B. 26cm
C. 27cm
D. 28cm
E. 29cm
```
D. 28 cm
OHA:
29 cm for 170 cm patient - add or subtract 1 cm for every 10 cm change in height
32
32. A patient is cooled to 33 degrees Celcius in an attempt to improve neurological outcome after out-of-hospital ventricular fibrillation cardiac arrest. The evidence for this treatment comes from
```
A. Case Reports
B. Case Control Studies
C. Systematic Review
D. Randomized Control Trial
E. Pseudo-randomized Trial
```
D. RCT
2010 AHA guidelines for CPR and emergency cardiovascular care Circulation 2010 122:S768-786
NEJM 2002 346:549-566 Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest (RCT)
Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. N Engl J Med. 2002;346:557–563 (Pseudo randomized trial)
33
33. Which of the following decrease during pregnancy?
```
A. Functional Residual Capacity
B. Forced Expiratory Volume in one second
C. Tidal Volume
D. Respiratory Rate
E. Vital Capacity
```
A. FRC
34
34. You are anaesthetizing a patient with chronic renal failure for removal of a Tenkoff catheter and have intubated using rocuronium at a dose of 1.2mg/kg. You are immediately unable to intubate or ventilate and you decide to reverse the patient with sugammadex. What dosage would you use
```
A. 2mg/kg
B. 4mg/kg
C. 8mg/kg
D. 12mg/kg
E. 16mg/kg
```
E. 16 mg/kg
35
35. During an elective thyroidectomy a patient develops symptoms consistent with the diagnosis of “thyroid storm” which of the following treatment options in NOT appropriate
```
A. Carbimazole
B. Beta-blocker
C. Propythiouracil
D. Plasmapheresis
E. Hydrocortisone
```
A. Carbimazole (takes too long to work)
36
36. A young female patient with anorexia nervosa, had just started eating again. After three days she develops dyspnea and is found to have cardiac failure. Which of the following is the most important to correct
```
A. Potassium
B. Chloride
C. Phosphate
D. Glucose
E. Sodium
```
E. Phosphate
Wiki - refeeding syndrome
Any individual who has had negligible nutrient intake for more than 5 consecutive days is at risk of refeeding syndrome. Refeeding syndrome usually occurs within four days of starting to feed. Patients can develop fluid and electrolyte disorders, especially hypophosphatemia, along with neurologic, pulmonary, cardiac, neuromuscular, and hematologic complications.
During prolonged fasting the body aims to conserve muscle and protein breakdown by switching to ketone bodies derived from fatty acids as the main energy source. The liver decreases its rate of gluconeogenesis thus conserving muscle and protein. Many intracellular minerals become severely depleted during this period, although serum levels remain normal. Importantly, insulin secretion is suppressed in this fasted state and glucagon secretion is increased.[4]
During refeeding, insulin secretion resumes in response to increased blood sugar; resulting in increased glycogen, fat and protein synthesis. This process requires phosphates, magnesium and potassium which are already depleted and the stores rapidly become used up. Formation of phosphorylated carbohydrate compounds in the liver and skeletal muscle depletes intracellular ATP and 2,3-diphosphoglycerate in red blood cells, leading to cellular dysfunction and inadequate oxygen delivery to the body's organs. Refeeding increases the basal metabolic rate. Intracellular movement of electrolytes occurs along with a fall in the serum electrolytes, including phosphate, potassium and magnesium. Glucose, and levels of the B1 vitamin thiamine may also fall. Cardiac arrhythmias are the most common cause of death from refeeding syndrome, with other significant risks including confusion, coma and convulsions and cardiac failure.
37
37. A pregnant woman is undergoing neuroradiological coiling of a cerebral aneurysm. At what gestational age should you monitor foetal heart rate to ensure adequate uteroplacental blood flow
```
A. 20 weeks
B. 24 weeks
C. 28 weeks
D. 30 weeks
E. 32 weeks
```
B. 24 weeks
38
38. What is the mechanism of central sensitisation?
```
A. Increased intracellular magnesium
B. Antagonism of the NMDA receptor
C. Glycine is the major neurotransmitter involved
D. Recurrent a-delta fibre activation
E. Alteration in gene expression
```
E. Alteration in gene expression
39
39. Which of the following is the best predictor of a difficult intubation in a morbidly obese patient
```
A. Pretracheal tissue volume
B. Mallampati score
C. Thyromental distance
D. BMI
E. Severity of OSA
```
? Mallampati score (I would go with this based on the paper below), ? pretracheal tissue volume
Myatt J, Trends in Anaesthesia and Critical Care (2010) - Airway management in obese patients
MP score:
In the study by Juvin et al. a Mallampati score of 3 or 4 was the only independent risk factor for difficult intubation in obese patients with a specificity and positive predictive value of 62% and 29% respectively. This reflected the findings of another study of 100 morbidly obese patients (BMI > 40 kg/m2), where the product of the graded laryngoscopy view and number of intubation attempts was used to define difficult intubation. Mallampati score of 3 or 4 was also significantly associated with difficult tracheal intubation in the study by Gonzalez et al.
Neck circumference:
Neck circumference is generally measured at the level of the superior border of the cricoid cartilage. Large-neck circumference has been shown in several studies to be a predictor of difficult intubation in morbidly obese patients. In the study by Brodsky et al., a neck circumference of 40 cm was associated with a 5% probability of problematic intubation (described as grade of laryngoscopy view multiplied by intubation attempts ≥3), whereas at 60 cm, the probability was 35% (P = 0.02). Furthermore, a large-neck circumference was significantly associated with male gender (P
40
40. A female patient with a history of COPD presents for lung volume reduction surgery, which of the following is a contraindication for surgery (? indicates a poor prognosis)
A. Age > 60 years
B. Chronic asthma
C. Evidence of bullous disease on CT scan
D. FEV
D. FEV
41
41. A patient with known metastatic lung cancer is found to have hypercalcaemia, all of the following would help excretion of calcium except
```
A. Bisphosphates
B. Calcitonin
C. Frusemide
D. Sodium Chloride
E. IV crystalloids
```
A. Bisphosphonates
Australian prescriber (bisphosphonates):
Pyrophosphate is a normal by-product of metabolism. Bisphosphonates are analogues of pyrophosphate which have potent inhibitory effects on bone resorption. They are effective drugs in bone disorders characterised by increased bone resorption, such as Paget’s disease, osteoporosis, hypercalcaemia of cancer, multiple myeloma and bony metastases.
Wiki (calcitonin):
The hormone participates in calcium (Ca2+) and phosphorus metabolism. In many ways, calcitonin counteracts parathyroid hormone (PTH).
More specifically, calcitonin lowers blood Ca2+ levels in four ways:
- Inhibits Ca2+ absorption by the intestines
- Inhibits osteoclast activity in bones
- Stimulates osteoblastic activity in bones.
- Inhibits renal tubular cell reabsorption of Ca2+ allowing it to be excreted in the urine.
However, effects of calcitonin that mirror those of PTH include the following:
- Inhibits phosphate reabsorption by the kidney tubules
42
42.What potentiates/interacts with adenosine
```
A. Aspirin
B. Warfarin
C. Clopidogrel
D. Dabigatran
E. Dipyridamole
```
E. Dipyridamole
Wiki - dipyridamole:
- Dipyridamole inhibits the phosphodiesterase enzymes that normally break down cAMP (increasing cellular cAMP levels and blocking the platelet aggregation response to ADP) and/or cGMP (resulting in added benefit when given together with nitric oxide [NO] or statins).
- It inhibits the cellular reuptake of adenosine into platelets, red blood cells and endothelial cells leading to increased extracellular concentrations of adenosine.
43
43. A 2 year-old child has just undergone strabismus surgery. They had an URTI 1/52 prior to surgery. They had an uneventful general anaesthetic with a 4.5mm cuffed ETT, was extubated and sent to recovery. 20 minutes later they develop respiratory distress. Their saturations are 96% on room air, and there is noticeable tracheal tug. What is the most appropriate initial management that will help with their respiratory distress
```
A. Apply CPAP via a facemask
B. Propofol 1mg/kg
C. Dexamethasone 0.4mg/kg
D. Gas induction and reintubate
E. Nebulized adrenaline (1:1000) 0.5mL/kg
```
E. Nebulised adrenaline (1:1000) 0.5 mL/kg
| Post-extubation stridor - dexamethasone 0.6 mg/kg + nebulised adrenaline 0.5 mL/kg 1:1000 is the usual treatment.
44
44. Which antihypertensive is not safe to use in pregnancy
```
A. Aspirin
B. Enalapril
C. Metoprolol
D. Hydralazine
E. Nifedipine
```
B. Enalapril
Also, aspirin is not an antihypertensive
45
45. Which of the following is least likely to contribute to postoperative infection?
```
A. Intraoperative low inspired O2
B. Intraoperative blood transfusion
C. Intraoperative hypothermia
D. Intraoperative hyperglycaemia
E. Cigarette smoking
```
A. Low FiO2
46
46. During a cerebral aneurysm clipping, the anaesthetist can assist with the placement of the clip by giving the patient which drug immediately prior to clipping
```
A. Nimodipine
B. Thiopentone
C. Hypertonic saline
D. Adenosine
E. Mannitol
```
D. Adenosine
Adenosine cardiac arrest is a relatively novel method for decompression of intracranial aneurysms to facilitate clip application. With appropriate safety precautions, it is a reasonable alternative method when temporary clipping of proximal vessels is not desirable or not possible.
47
47. The POISE trial showed that the perioperative administration of metoprolol XR resulted in decreased
```
A. Perioperative mortality
B. Hypotension
C. Congestive Cardiac Failure
D. Myocardial Infarction
E. Stroke
```
D. Myocardial infarction
| but increased strokes and death
48
48. In paediatric trauma, the Broselow tape is used to estimate
```
A. Blood loss
B. Weight and drug dosages
C. Urine output
D. Abdominal girth
E. Head circumference
```
B. Weight and drug dosages
49
49. Which of the following should be used by a lay person to indicate that they should commence CPR
```
A. Absence of central pulse
B. Absence of peripheral pulse
C. Loss of consciousness
D. Absence of breathing
E. Obvious airway obstruction
```
D. Absence of breathing
ARC 2010
Rescuers must start CPR if the victim is unresponsive and not breathing normally. Even if the victim takes occasional gasps, rescuers should start CPR.
50
50. A patient presents for dilation of a pharyngeal stenosis post laryngopharyngectomy 12 months earlier. After inducing anaesthesia you site a size 7 reinforced ETT in the stoma. Over the next 30 minutes the patient gradually desaturates. Despite hand bag ventilation and an increased FiO2 of 1 the saturations remain at 88%. This is due to
```
A. Endobronchial intubation
B. Aspiration
C. Tension Pneumothorax
D. Circuit leak
E. Blockage of ETT with secretions
```
A. Endobronchial intubation
51
51. PiCCO determines cardiac output utilizing
```
A. Thermodilution
B. Pulse contour analysis
C. Thermodilution and pulse contour analysis
D. ? Doppler
E. ?
```
C. Thermodilution and pulse contour analysis
PiCCO® enables continuous hemodynamic monitoring using a femoral or axillary artery catheter and a central venous catheter. Employing patented algorithms, PiCCO combines real-time continuous monitoring through pulse contour analysis with intermittent thermodilution measurement via the transpulmonary method.
52
52. During scoliosis surgery with monitoring of somatosensory evoked potentials, which tract are they mainly monitoring
```
A. Anterior horn
B. Anterior corticospinal tract
C. Dorsal column
D. Spinothalamic tract
E. Lateral corticospinal tract
```
C. Dorsal column
53
53. A patient has suffered flash burns of the upper half of the left upper limb, all of the left lower limb and the anterior surface of the abdomen. The approximate percentage of the body surface which has been burned is
```
A. 18%
B. 23%
C. 32%
D. 41%
E. 48%
```
C. 32%
Half of L. upper limb = 4.5 (assuming front and back = 2.25 + 2.25)
Lower limb = 18 (9+9 - front and back)
Anterior abdomen = 9
54
54. Complications of mediastinoscopy include all of the following except
```
A. Air embolism
B. Cardiac laceration
C. Pneumothorax
D. Recurrent laryngeal nerve palsy
E. Tracheal compression
```
B. Cardiac laceration
| theoretically possible but the least likely of the options
55
55. A 70 year old man with severe mitral stenosis and normally in sinus rhythm, is going for an ORIF of fractured radius and ulna. Soon after induction of GA, he develops a tachyarrhythmia with BP 70/40mmHg and HR 130bpm. The most appropriate immediate action is
```
A. Amiodarone
B. Adenosine
C. IV fluid bolus
D. Adrenaline
E. Direct cardioversion
```
E. Direct cardioversion
56
56. The time constant of the alveoli is
```
A. Resistance multiplied by compliance
B. Resistance divided by compliance
C. Resistance plus compliance
D. Resistance minus compliance
E.
```
A. Resistance multiplied by compliance
57
57. The MAC awake:MAC ratio of sevoflurane is closest to
```
A. 0.22
B. 0.34
C. 0.45
D. 0.76
E. 1.00
```
B. 0.34
58
58.Abnormal Q waves occur in all the following EXCEPT
```
A. Digitalis toxicity
B. LBBB
C. Recent transmural MI
D. Wolff-Parkinson-White
E. Previous MI
```
A. Digitalis toxicity
LITFL - WPW:
Pseudo-infarction pattern can be seen in up to 70% of patients – due to negatively deflected delta waves in the inferior / anterior leads (“pseudo-Q waves”), or as a prominent R wave in V1-3 (mimicking posterior infarction).
LITFL - LBBB:
QRS duration of > 120 ms
Dominant S wave in V1
Broad monophasic R wave in lateral leads (I, aVL, V5-V6)
Absence of Q waves in lateral leads (I, V5-V6; small Q waves are still allowed in aVL)
Prolonged R wave peak time > 60ms in left precordial leads (V5-6)
59
59. Patient complains of numbness in the anterior 2/3 of tongue after GA with LMA. Most likely nerve injured is
```
A. Glossopharyngeal
B. Facial nerve
C. Mandibular
D. Superior vagus
E. Maxillary nerve
```
C. Mandibular nerve
60
60. A 70 year old man with non-valvular atrial fibrillation is taken off his warfarin for 7 days prior to surgery and has no bridging therapy. His daily risk of stroke is
```
A. 0.001%
B. 0.01%
C. 0.1%
D. 4%
E. 10%
```
B. 0.01%
61
61. In patient with ankylosing spondylitis which of the following is INCORRECT
A. Amyloid renal infiltration is rarely seen
B. Cardiac complications occur in
C. Normocytic anaemia occurs in 85% of cases
Australian family physician - ankylosing spondylitis: an update (2013)
Patients with AS are at risk of developing apical pulmonary fibrosis (up to 15%) and aortic valve incompetence (up to 10%). These features usually develop late in the disease and are often asymptomatic.
Uniocular anterior uveitis occurs in about 40% of patients.
Many but not all patients with early presentations have active sacroiliitis on MRI scan.
No mention of amyloid renal infiltration or normocytic anaemia in this paper. Other sources say renal involvement is rare and prevalence of anaemia is around 30%.
62
62. Which of the following are NOT useful in the management of Torsades de Pointes
```
A. Isoprenaline
B. Procainamide
C. DC cardioversion
D. Electrical pacing
E. Magnesium
```
B. Procainamide
Magnesium, cardioversion and overdrive pacing (either electrical or pharmacological) are all used.
63
63. Compared with a plenium vaporizer what is NOT a disadvantage of draw-over vaporizer (repeat but still not quite remembered correctly)
```
A. Basic temperature compensation
B. Basic flow compensation
C. Cannot use sevoflurane
D. Small volume reservoir
E. ?
```
B. Basic flow compensation
64
64. The desflurane vaporizer is heated because of desflurane's
```
A. High SVP
B. High boiling point
C. Low SVP
D. High MAC
E. Low MAC
```
A. High SVP
65
65. The thermoneutral zone in a neonate in degrees celcius is
```
A. 26-28
B. 28-30
C. 30-32
D. 32-34
E. 34-36
```
D. 32-34 C
66
66. Which of the following is most effective way to reduce renal failure in AAA surgery
```
A. Fluid bolus prior to aortic clamping
B. Fluid bolus after aortic clamp release
C. Frusemide
D. Minimize cross-clamp time
E. Mannitol
```
D. Minimise clamp time
67
67. Which type of aortic dissection can be managed conservatively/non-operatively
```
A. Debakey 1
B. Debakey 2
C. Stanford A
D. Stanford B
E. Stanford C
```
D. Standford B
DeBakey 1 - ascending and descending
DeBakey 2 - ascending only
DeBakey 3 - descending only
Standford A - involves aortic arch, needs surgical repair
Stanford B - distal to subclavian artery, medical management
(Standford C does not exist)
68
68. The most likely cause of death after pharyngeal, esophageal or tracheal perforation is
```
A. Air embolus
B. Hemorrhage
C. Failure to intubate
D. Failure to ventilate
E. Sepsis
```
E. Sepsis
69
69. An essential criteria for diagnosis of left bundle branch block (LBBB) on ECG is
```
A. RSR in V1
B. Minimum duration QRS of 0.2 secs
C. Deep slurred S wave in V6
D. Loss of septal Q waves in V5 and V6
E. T waves opposite direction to main direction of QRS
```
D. Loss of septal Q waves in V5 and V6
LITFL
Diagnostic Criteria
- QRS duration of > 120 ms
- Dominant S wave in V1
- Broad monophasic R wave in lateral leads (I, aVL, V5-V6)
- Absence of Q waves in lateral leads (I, V5-V6; small Q waves are still allowed in aVL)
- Prolonged R wave peak time > 60ms in left precordial leads (V5-6)
70
70. If a patient experiences parasthesia in the little finger during supraclavicular brachial plexus block, the needle is in proximity to the
```
A. Posterior cord
B. Middle trunk
C. Ulnar nerve
D. Lower trunk
E. Medial cord
```
D. Lower trunk
71
71. Which of the following are feature of Conn's syndrome?
A. Hypoglycaemia, hyponatremia, hyperkalemia
B. Hypoglycaemia, hypernatremia, hypokalemia
C. Normoglycaemia, hypernatremia , hypokalemia
D. Normoglycaemia, hyponatremia, hyperkalemia
E. Hyperglycaemia, hyponatremia, hyperkalemia
C. Normoglycaemia, hypernatraemia, hypokalaemia
72
72 Commonest valvular heart disease seen in pregnancy is
```
A. Aortic stenosis
B. Aortic regurgitation
C. Mitral Stenosis
D. Mitral regurgitation
E. Tricuspid reguritation
```
C. Mitral stenosis
73
73. Incidence and severity of vasospasm following sub-arachnoid haemorrhage is seen maximally at
```
A. 0-24 hrs
B. 2-4 days
C. 6-8 days
D. 7-10 days
E. 2 weeks
```
C. 6-8 days
74
74. The predominant pathology seen in restrictive heart disease is
```
A. Diastolic dysfunction
B. Systolic dysfunction
C. Valvular dysfunction
D. ?
E. ?
```
A. Diastolic dysfunction
75
75. What is the first sign/symptom seen with an inadvertent total spinal whilst performing caudal anaesthesia in a neonate
```
A. Hypotension
B. Bradycardia
C. Desaturation
D. Tachycardia
E. Loss of consciousness
```
C. Desaturation
76
76. Which of the following is an absolute contraindication to electroconvulsive therapy
```
A. Cochlear implant
B. Epilepsy
C. Pregnancy
D. Raised Intracranial Pressure
E. Recent myocardial infarct
```
D. Raised ICP
CEACCP - Anaesthesia for ECT (2010)
Particular conditions which may be a contraindication to ECT should be identified. None is absolute, but the physiological responses to ECT make it particularly hazardous;
• within 3 months of either a myocardial infarction
• or cerebrovascular accident,
• or where raised intracranial pressure exists.
Further relative contraindications include;
• uncontrolled cardiac failure,
• deep venous thrombosis (until anticoagulated),
• untreated cerebral aneurysm,
• unstable major fracture or severe osteoporosis,
• phaeochromocytoma,
• retinal detachment
• or glaucoma.
• Cochlear implants are also a contraindication, although unilateral ECT has successfully been used.
In all cases, risks of untreated depression must be balanced against risks of anaesthesia and ECT, remembering that ECT is quicker in onset than other treatment modalities and potentially life-saving in states of catatonia when, for example, there is no oral intake.
77
77. Prolonged Trendelenburg (head-down) positioning causes which of the following
```
A. No change in intracranial pressure
B. No change in intraocular presssre
C. No change in pulmonary venous pressure
D. Increased myocardial work
E. Increased pulmonary compliance
```
D. Increased myocardial work
78
78. Performed a brachial plexus block. Normal sensation still remains in medial forearm. Which part of brachial plexus is most likely to have been missed
```
A. Posterior cord
B. Anterior division
C. Median brachial cutaneous nerve
D. Ulnar nerve
E. Inferior trunk
```
None correct
Medial antebrachial cuteneous nerve (medial cutaneous nerve of forearm) from the medial cord of the brachial plexus supplies sensation to the medial forearm
79
79. A 29 year old female undergoes craniotomy for posterior fossa tumour. Which of the following is an absolute contraindication to the sitting position
```
A. Patent ventriculo-atrial shunt
B. Previous back surgery
C. Pacemaker
D. Small patent foramen ovale
E. Oesophageal stricture contraindicated for transoesophageal echocardiogram
```
A and D both contraindications.
A ventriculo-atrial shunt (for the treatment of hydrocephalus) increases the risk of VAE, whereas a PFO will increase the risk of paradoxical embolus should VAE occur.
80
80. A 4 year old child booked for minor surgery is seen in pre-admission clinic where a murmur is detected. Which feature will warrant further investigation
A. Loudness 4/6
B. Decreases on inspiration (implies not left sided lesion)
C. Vibratory quality
D. Ejection systolic murmur (late are generally pathological)
E. Louder on supine (increased preload, but doesn’t necessarily exclude pathology)
A. Loudness 4/6
Adam Skinner notes
• Heart
o Palpation: Hyperdynamic circulation due to increase pulmonary blood flow or RVH or LVH will cause prominence of the RV and/or LV impulses. Thrills = pathological. Displaced apex.
o Auscultation:
• Murmurs: Harsh murmurs indicate pathology. All diastolic murmurs and all pansystolic murmurs are pathological. Generally murmurs >3/6 are pathological, however some venous hums (innocent) can be a high grade. Late systolic murmurs is considered pathological. A practical hint however, is that even paediatric cardiac anaesthetists don’t spend all their time listening to hearts. Most people would find it difficult to exclude pathology 100% with confidence.
• Heart Sounds: First heart sound should be audible. Second heart sound should split in inspiration and become single in expiration. Single second heart sound, or variation in splitting such as fixed splitting or reverse splitting, i.e. split in expiration and single in inspiration indicate pathology. A loud P2 indicates pulmonary hypertension. S4 is pathological. S3 may be normal. Widely split S2 may indicate RV overload, PHT or RVOT Obstruction.
The seven S's - key features of innocent murmurs:
- Sensitive (changes with child's position or with respiration)
- Short duration (not pansystolic)
- Single (no associated clicks or gallops)
- Small (murmur limited to a small area and not radiating)
- Soft (low amplitude)
- Sweet (not harsh sounding)
- Systolic (occurs during and is limited to systole)
81
81. The autonomic supply of the ciliary ganglion is such that it
A. Receives its sympathetic nerve supply from the cervical ganglion
B. Receives its parasympathetic nerve supply from the trochlear nerve
C. Is located inferiorly in the orbit
D. Is at risk from injury during peribulbar nerve block
E. Receives parasympathetic nerve supply from the Edinger Westphal Nucleus
E. Receives parasympathetic nerve supply from the Edinger Westphal nucleus
The ciliary ganglion is a parasympathetic ganglion located in the posterior orbit. Preganglionic axons from the Edinger-Westphal nucleus travel along the oculomotor nerve and form synapses with these cells. The postganglionic axons run in the short ciliary nerves and innervate two eye muscles:
1. the sphincter pupillae constricts the pupil, a movement known as Miosis. The opposite, Mydriasis, is the dilation of the pupil.
2. the ciliaris muscle contracts, releasing tension on the Zonular Fibers, making the lens more convex, also known as accommodation.
82
82. Regarding Thallium Stress Testing in predicting perioperative cardiac events
A. A positive result requires further investigation with a pulmonary artery catheter
B. It has a high negative predictive value
C. It has a low negative predictive value
D. It has a high positive predictive value
E. Thallium Stress testing is considered inferior to Dobutamine Stress Echo
B. It has a high negative predictive value
83
83. An elderly gentleman on warfarin has suffered a subdural haematoma. His INR on admission was 4.5. The resident in Ed has already given him 2.5mg of Vit K. To reverse his coagulopathy prior to urgent surgery you should give him
```
A. Factor VIIa
B. FFP
C. Cryoprecipitate
D. Prothrominex
E. Prothrombinex and FFP
```
E. Prothrombinex and FFP
INR > 1.5 with life-threatening (critical organ) bleeding:
- Cease warfarin therapy
- Vitamin K 5-10 mg IV
- Prothrombinex-VF 50 IU/kg
- FFP 150-300 mL
(if Prothrombinex-VF is unavailable, administer FFP 15 mL/kg)
INR > 2.0 with clinically significant bleeding (not life-threatening):
- Cease warfarin therapy
- Vitamin K 5-10 mg IV
- Prothrombinex 35-50 IU/kg IV
Any INR with minor bleeding:
- Omit warfarin, repeat INR the following day and adjust warfarin dose to maintain INR in the target therapeutic range
- If bleeding risk is high or INR > 4.5, consider vitamin K 1-2 mg orally or 0.5-1 mg IV
84
84. During caesarean section a meconium stained floppy apnoeic baby is delivered. When the midwife gives you the baby, it is apnoeic, cyanotic with heart rate of 90 bpm. What do you do next
```
A. Give naloxone
B. Dry and stimulate
C. Start chest compressions
D. Give positive pressure ventilation
E. Suction the trachea
```
E. Suction the trachea
85
85. A 70 year old lady suffered a subdural haematoma. She is currently confused and the neurosurgeon wants to take her to theatre for urgent decompression. She is a vague historian, but from notes you find out she had ablation and pacemaker put in 7 months ago - DDD mode. Cardiac technician is 1 hour away and the surgeon wants to proceed. What do you do
A. Postpone until cardiology review
B. Postpone until pacemaker checked by technician
C. Postpone until temporary pacemaker inserted
D. Proceed after having implemented external pacing
E. Proceed with magnet available
E. Proceed with magnet available
Response of pacemakers to magnet is unpredictable, cf. AICDs which are reliably deactivated by magnets.
Indication for pacemaker not clear from stem (previous ablation suggests PHx tachyarrhythmia, although doesn't indicate whether this is related to indication for pacemaker).
Worst case scenario - pt is pacemaker dependent and pacemaker inappropriately senses signal from diathermy (leading to inhibition of pacing).
Condition needs urgent surgery and it is inappropriate to wait for a cardiology review/pacemaker tech. Should proceed with:
- magnet available (worth a shot in the event of inappropriate sensing --> asystole; may revert pacemaker to asynchronous mode which would be useful)
- facilities for external pacing the room (don't need to implement it prophylactically, in fact this may even damage the pacemaker unnecessarily)
86
86. New blood pressure measuring device is developed. Best was to compare it to the current gold standard
```
A. SCUSUS
B. Bland Altman Plot
C. Kendall Coefficient of Concordance
D. Pearsons coefficient
E. Friedmans ??
```
B. Bland Altman Plot
Wiki
One primary application of the Bland–Altman plot is to compare two clinical measurements that each provide some errors in their measure. It can also be used to compare a new measurement technique or method with a gold standard. However the interest of the Bland–Altman plot is contested in this particular case because the error pertains to the sole new measure.
87
87. What happens when you place a magnet over a biventricular internal cardiac defibrillator
```
A. Switch to asynchronous pacing
B. Damage the internal programming
C. Nothing
D. Switch off antitachycardia function
E. Switch of rate responsiveness
```
D. Switches off antitachycardia function
AICD and PPM (CEACCP)
In older devices, magnets would disable the defibrillation and anti-tachycardia functions, however this cannot be guaranteed for newer devices.
Stoelting
Application of a magnet to a pacemaker often results in asynchronous pacemaker function at a fixed rate.
Application of a magnet to a cardioverter-defibrillator rarely alters the antibradycardia pacing capabilities, but most often suspends anti-tachycardia therapy (defibrillation). But, depends on device, and some it will permanently disable it!
88
88. A 54 year-old patient is on warfarin for AF. They have a history of alcohol abuse and liver failure with a bilirubin of 28 and an albumin of 30. He also has a history of DVT following a flight. What is his CHADS2 score
```
A. 0
B. 1
C. 2
D. 3
E. 4
```
C. 2
```
CCF – no
HTN – no
Age>75 – no
DM – no
CVA/TIA/VTE – yes x2=2
```
89
89. A full size C oxygen cyclinder (size A in New Zealand) has pressure regulated from
```
A. 16000kpa to 400kpa
B. 16000kpa to 240kpa
C. 11000kpa to 400kpa
D. 11000kpa to 240kpa
E. ?
```
A. 16,000 to 400 kPa
90
90. What is approximately the systolic blood pressure in an awake neonate
(mmHg)?
```
A. 55
B. 70
C. 85
D. 100
E. 115
```
B. 70
| 60-70 mmHg for term neonate
91
91. A 25 year male with a history of asthma who is usually on fluticonasone and salbutamol nebs presents with an acute exacerbation. On examination you see he is distressed, RR 26 bpm. On auscultation: poor air entry and polyphonic wheeze bilaterally. ABG: pH 7.45, pCO2 27, pO2 75, HCO3 24. He has been treated with salbutamol and ipratropium nebules and intravenous hydrocortisone. What is the next step in his treatment
```
A. Inhaled helium/oxygen
B. IV aminophylline
C. IV magnesium
D. IV salbutamol
E. Intubation and ventilation
```
IV magnesium
(magnesium 50 mg/kg IV over 30 mins followed by 30 mg/kg/h - similar to pre-eclampsia protocol... for 70 kg pt works out to be 3.5 g load, then ~ 2 g/h)
92
92. You are doing an fibreoptic bronchoscopy and having difficulty identifying the anatomy of where you are. Then you observe a trifurcation. The lobe of the lung to which this airway is conected is
```
A. LUL
B. Lingula
C. RUL
D. RML
E. RLL
```
C. RUL
```
Right Lung
o RUL
• Apical
• Posterior
• Anterior
o RML
• Lateral
• Medial
o RLL
• Superior
• Medial Basal
• Anterior basal
• Lateral basal
• Posterior basal
```
```
Left Lung
o LUL
• Superior division
- Apical-posterior
- Anterior
• Inferior (Lingular) division
- Superior
- Inferior
o LLL
• Superior
• Anterior medial basal
• Lateral basal
• Posterior basal
```
93
93. A 35kg 5 year old girl is having elective surgery for suturing of a superficial leg laceration. After induction with N2O/Sevoflurane/O2 and in absence of any visible veins you have placed an appropriately sized LMA. Following this her SpO2 immediately drop to 90%. What is your initial management
A. Remove LMA and increase inspired Sevoflurane concentration
B. Increase inspired Sevoflurane concentration through the LMA
C. Give sublingual Suxamethonium
D. Give intramuscular Atropine
E. Give intramuscular Suxamethonium
A. Remove LMA and increase inspired sevoflurane concentration
(although early consideration of IM sux if sats drop below 90%)
94
94. Ulcerative colitis is associated with all of the following EXCEPT:
```
A. Cirrhosis
B. Iritis
C. Psoriasis
D. Arthritis
E. Sclerosing cholangitis
```
C. Psoriasis
95
95. Regarding rotameters
A. The bobbin is contained in a tube with parallel sides
B. There is laminar flow at high flows
C. The height of the bobbin is directly proportionate to the pressure drop across the bobbin.
D. There is a constant pressure difference across the bobbin at all flows.
E. Resistance increases at high flows
D. There is a constant pressure difference across the bobbin at all flows.
(Constant pressure, variable orifice)
96
96. You see a man in his 60s in clinic 1 week prior to laparoscopic cholecystectomy. He has dilated cardiomyopathy with an ejection fraction of 30%, but does not get dyspnoeic with normal activities of daily living. What is the most appropriate management of his heart failure?
```
A. Amiodarone 100mg bd
B. Digoxin 250mcg daily
C. Enalapril 2.5mg bd
D. Metoprolol 100mg bd
E. Diltiazem slow release 240mg daily
```
C. Enalapril 2.5 mg bd
97
97. The best clinical indicator of severe aortic stenosis is
```
A. Presence of a thrill
B. Mean pressure gradient of 30mmHg
C. Area 1.2cm2
D. Slow rising pulse
E. ESM radiating to the carotids
```
A. Presence of a thrill
98
98. Atrial Septal Defect murmur is heard due to blood flow through
```
A. Tricuspid valve
B. Pulmonary valve
C. Mitral valve
D. Aortic valve
E. Atrial Septal Defect
```
B. Pulmonary valve
ASD
Because the pressure in the left atria initially exceeds that in the right, the blood flows in a left to right shunt. This high volume of blood next passes into the right ventricle, and the ejection of the excess blood through a normal pulmonary valve produces a prominent mid-systolic flow murmur. This murmur is best heard over the pulmonic area of the chest, and may radiate into the back as with the murmur of pulmonary stenosis.
The most characteristic feature of an atrial septal defect is the fixed split S2. A split S2 is caused physiologically during inspiration because the increase in venous return overloads the right ventricle and delays the closure of the pulmonary valve. With an atrial septal defect, the right ventricle can be thought of as continuously overloaded because of the left to right shunt, producing a widely split S2. Because the atria are linked via the defect, inspiration produces no net pressure change between them, and has no effect on the splitting of S2. Thus, S2 is split to the same degree during inspiration as expiration, and is said to be “fixed.”
99
99. At what valve area do you begin to get symptoms at rest, with mitral stenosis?
```
A. 4.5 cm2
B. 3.5 cm2
C. 2.5 cm2
D. 1.5 cm2
E. 1.0 cm2
```
E. 1.0 cm2
100
100. Nitrous oxide anaesthesia may cause all of the following EXCEPT
A. An increased incidence of myocardial ischaemia
B. Decreased leukocyte chemotactic response
C. Elevation of plasma homocysteine levels
D. Megaloblastic anaemia
E. Reversible inhibition of methionine synthetase
E. Reversible inhibition of methionine syntheses
| inhibition is irreversible
101
101. The diagnosis of neuroleptic malignant syndrome requires the presence of
```
A. Diaphoresis
B. Elevated plasma creatine kinase
C. Hypertension
D. Muscle rigidity
E. Tachycardia
```
D. Muscle rigidity
102
102. Regarding tryptase level testing for suspected anaphylaxis, all are true EXCEPT:
A. Levels peak within 1 hour
B. Increased with anaphylactoid and anaphylactic reactions
C. 99% of the body’s stores are found in mast cells
D. Levels of > 20ng/mL are suggestive of anaphylaxis
E. Test should be repeated at 24-48 hours
?? C? - tryptase is also found in basophils, not sure how much though...
A, B and D definitely correct.
E correct too - a repeat test is done at 24 h or any time in convalescence to determine the patient's baseline tryptase level.
103
103. An 18 month old boy presents for surgery for an incarcerated inguinal hernia. On examination you note that he has had an URTI for approximately one week. Your advice regarding surgery should be
A. Postpone the surgery for two weeks
B. Proceed with surgery under spinal anaesthetic
C. Proceed with surgery with a full course of antibiotics to treat the URTI
D. Undertake surgery, but avoid the use of an ETT
E. Proceed with surgery with careful monitoring
E. Proceed with surgery with careful monitoring
104
104. The incidence of fat embolism syndrome following a unilateral closed femoral fracture is
```
A. 0 -3%
B. 4 – 7%
C. 8 -11%
D. 12 – 15%
E. 16 - 19%
```
A. 0-3%
| 1-3% - CEACCP - Fat embolism
105
105. The thoracodorsal nerve arises from
```
A. A Medial cord of brachial plexus
B. Lateral cord of brachial plexus
C. Posterior cord of brachial plexus
D. Dorsal scapular nerve
E. Long thoracic nerve
```
C. Posterior cord of brachial plexus
106
106. Neurosurgery operation in the sitting position. MAP 80mmHg, CVP 5mmHg, the transducers are located 13cm below the external auditory meatus. What is the CPP
```
A. 62 mmHg
B. 65 mmHg
C. 67 mmHg
D. 72 mmHg
E. 75 mmHg
```
B. 65 mmHg
13 cmH2O = 10 mmHg (approx)
so MAP at level of external auditory meatus will be 80-10 = 70.
CPP = MAP - CVP, = 65 (assuming ICP = 5)
107
107. A man attending his daughter's wedding is involved in fight with his son-in-law. He does not know where he is, opens eyes to voice, but removes tie when instructed. What is his GCS?
```
A. 10
B. 11
C. 12
D. 13
E. 14
```
D. 13
E3, V4, M6
108
108. Which of the following drugs is least likely to cause hypoxia in ARDS
```
A. Noradrenaline
B. Milrinone
C. Isoprenaline
D. Isoflurane
E. Sodium nitroprusside
```
A. Noradrenaline.
All of the others are vasodilators, which have the potential to blunt HPV (and worsen V/Q mismatch)
109
109. What is the best predictor of poor prognosis with aortic stenosis?
```
A. Chest pain
B. Paroxysmal nocturnal dyspnoea
C. Syncope
D. Palpitations
E. Fatigue
```
B. Paroxysmal nocturnal dyspnoea (indicates heart failure)
110
110. Pierre-Robin sequence is characterized by cleft palate, micrognathia and
```
A. Craniosynostosis
B. Macroglossia
C. Glossoptosis
D. Microstomia
E. ?
```
C. Glossoptosis
111
111. After 3 litres of normal saline, the dilutional anaemia is initially offset by
```
A. Increased cardiac output
B. Increased oxygen extraction
C. Capillary vasodilation
D. ?
E. ?
```
A. Increased cardiac output
112
112. Anaesthetic Machine is left on all weekend with flow rate of oxygen at 6 litres/min. A Desflurane vaporiser is placed on it on Monday morning without changing the CO2 absorber. What is the most likely toxic product produced?
```
A. Ca(OH)2
B. Carbon dioxide
C. Carbon monoxide
D. Compound A
E. Compound B
```
C. Carbon monoxide
113
113. 2ml of 0.75% ropivacaine is injected for an interscalene block. Soon after the patient loses consciousness. The most likely place of inadvertent injection is
```
A. Subdural
B. Internal jugular vein
C. Common carotid artery
D. External jugular vein
E. Vertebral artery
```
E. Vertebral artery
114
114. An 18 month old infant is undergoing a routine spontaneously breathing GA with an LMA. They have a sudden onset of SVT with a heart rate of 220 and a BP of 84/60 with an ETCO2 of 32 and SpO2 of 98. The best management strategy is
A. Adenosine 100mcg/kg
B. DCR 2J/kg
C. DCR 4J/kg
D. Amiodarone 5mg/kg
A. Adenosine 100 mcg/kg
115
115. When stimulating the ulnar nerve with a nerve stimulator, which muscle do you see twitch
```
A. Opponens abducens
B. Abductor pollicis brevis
C. Adductor pollicis
D. Extensor pollicis
E. Flexor pollicis brevis
```
C. Adductor pollicis
116
116. A middle-aged male with severe mitral stenosis having general anaesthesia for repair of fractured ulna/radius. Ten minutes into the case you notice a tachyarrythmia with his HR 130 and BP 70/-. He is normally in sinus rhythm. What do you do
```
A. Adenosine
B. Amiodarone
C. Shock
D. Volume
E. Metaraminol
```
C. Shock
MS
Avoid low SVR (fixed max CO)
Avoid high HR (decreased LV filling time)
Not too full or dry (APO vs. decreased LV filling)
Treat AF!
117
117. Circuit disconnection during spontaneous breathing anaesthesia
A. Will be reliably detected by a fall in end-tidal carbon dioxide concentration
B. Will be detected early by the low inspired oxygen alarm
C. Will be most reliably detected by spirometry with minute volume alarms
D. May be detected by an unexpected drop in end-tidal volatile anaesthetic agent concentration
E. Can be prevented by using new, single-use tubing
D. May be detected by an unexpected drop in end-tidal volatile anaesthetic agent
? C also correct
118
118. ET04 An 85 year old patient with a bleeding disorder (? haemophilia) suffers a fractured neck of femur (#NOF). You discuss the possibility of a needing a blood transfusion but despite your explanation they refuse because they are scared of CJD infection post transfusion. Subsequently you decide not to proceed with the case because of the high risk of bleeding. The ethical principle that this is an example of is
```
A. Paternalism
B. Coercion
C. Justice
D. Beneficience
E. Autonomy
```
A. Paternalism
119
119. A type I diabetic is fasting pre-operatively and you decide to place them on an IV insulin infusion to optimize their perioperative glycaemic control. Their BSL is 7 mmol/L. By what mechanism does the insulin infusion decrease their BSL
A. Stimulates glucose uptake into the liver
B. Stimulates glucose uptake into skeletal muscle
C. Inhibits glucose production in the liver
D. Decreases glucose absorption from the gastrointestinal tract
E. Inhibit glucagon release
C. Inhibits glucose production in the liver
(B also correct)
Insulin: understanding its action in health and disease (BJA 2000)
The use of tracer glucose infusions has shown not only that hyperglycaemia in the face of insulin deficiency is the result of over‐production of glucose by the liver but also that insulin infusion lowers blood glucose by inhibiting hepatic glucose production
120
120. Patient has undergone a bilateral lung transplant. All of following are impaired EXCEPT
```
A. Mucociliary clearance
B. Cough reflex distal to anastomosis
C. Hypoxic pulmonary vasoconstriction
D. Response to CO2
E. Lymphatic drainage
```
C. Hypoxic pulmonary vasoconstriction
121
121. Patient with history of long QT syndrome treated with long term propranolol. How do you know the treatment is effective
```
A. Normal QTc
B. No further prolongation of QT in response to valsalva manoeuvre
C. ?
D. ?
E. ?
```
B. No further prolongation of QT in response to Valsalva
Long QT syndrome and anaesthesia (BJA 2003)
The dose of β‐blocker is determined by ensuring a reduction in maximal heart rate on treadmill exercise testing to 130 beats/min or less; further reduction in symptomatic events does not occur if the dose is increased. Propranolol is the most widely used drug at a daily dose of 2–3 mg/kg, although β‐blockers with longer half‐lives may increase compliance. Patients who develop marked bradycardia or prolonged sinus arrest on treatment may require back up permanent pacing. The QTc is unchanged despite efficacy of treatment, although QTD is higher in patients who do not respond to β‐block.
Patients with known LQTS
Preoperatively, all patients with known LQTS should be on maintenance β‐blocker therapy, which must be continued up to and including the day of surgery. Preoperative assessment of its adequacy should determine that the heart rate does not exceed 130/min during exercise; where exercise testing is impractical, there should ideally be no change in the QT interval in response to a Valsalva manoeuvre in a fully β‐blocked individual.
122
```
122. A neonate is born with meconium stained liquor but is vigorous and crying. The reason for not suctioning the pharynx is
A. Hypertension
B. Hypotension
C. Bradycardia
D. Tachycardia
E. ?
```
C. Bradycardia (vagal response to suctioning)
123
123. What organism most commonly causes meningitis post spinal anaesthesia
```
A. Staphylococcus epidermidis
B. Staphylococcus aureus
C. Streptococcus pneumonia
D. Streptococcus salivarius
E. Escherichia coli
```
D. Strep salivarius
124
124. A male patient has a haemoglobin of 8g/dL and reticulocyte count 10%. The most likely diagnosis is
```
A. Untreated pernicious anaemia
B. Aplastic anaemia
C. Acute leukaemia
D. Anaemia of chronic disease
E. Hereditary spherocytosis
```
E. Hereditary spherocytosis
Elevated reticulocyte count suggests increased destruction of red cells (the other options are all associated with decreased production)
125
125. An advantage of supraclavicular block over an interscalene nerve block for shoulder surgery
```
A. Less phrenic nerve block
B. Easier landmarks in obese patient
C. Arm can be in any position for block
D. Less risk pneumothorax
E. Better cover for shoulder surgery
```
A. Less phrenic nerve block
126
126. A patient with a head injury is found to have a unilateral dilated pupil with no direct or consensual response to light. What is the most likely diagnosis
```
A. Global injury
B. Optic nerve injury
C. Horners syndrome
D. Transtentorial herniation
E. Injury to the pons
```
D. Transtentorial herniation
127
127. EM68 In an arterial line system
A. Overdamping exaggerates mean pressure
B. Underdamping increases mean pressure
C. Underdamping underestimates systolic pressure
D. Wide range of damping coefficient associated with good performance if system has high natural frequency
E. Compliant tubing is good
D. Wide range of damping coefficient associated with good performance if system has high natural frequency.
Blackbank:
resonant frequency is high, then accurate values of systolic and diastolic pressure can be recorded at almost any value of the damping coefficient
128
128. The commonest postoperative complication in a patient with a neck of femur fracture (#NOF) is
```
A. UTI
B. Pneumonia
C. Myocardial Infarction
D. Delirium
E. ?
```
D. Delirium
129
129. Which of the following is an advantage of a bronchial blocker over a double lumen tube
A. Able to isolate separate lobes
B. Significantly easier to deflate non-ventilated lung
C. Better suited to pneumonectomy
D. Less pressure on bronchial tissue
E. Lower incidence of tube malpositioning
A. Able to isolate separate lobes
130
130. Laser endotracheal tubes
A. More resistant to ignition when covered in blood
B. Resistant to electrosurgical cautery
C. Wont ignite when touched by laser
D. Have larger external diameter for same internal diameter relative to standard PVC tubes
E. Have double cuffs which are resistant to puncture by laser
D. Have large external diameter for same internal diameter relative to standard PVC tubes.
LASERS - CEACCP
Endotracheal tubes for laser surgery
There are two basic designs of endotracheal tube for use in laser surgery. First, silicone rubber tubes with metal links incorporated into the tube wall with either a sponge cuff (Bivona Fome cuff) or a double cuff (Mallinckrodt ‘Laser flex’) are available. If the cuff bursts in the former, the sponge will maintain a sealed airway; in the latter, the second cuff can be used. Second, foil wrapped tubes with an outer Teflon coat (Sheridan ‘Laser Trach’) can be used. The cuff is filled with methylene blue crystals so that, if the laser bursts the cuff, this will be detected quickly by the surgeon. The
main problem with laser tubes is that they have a narrow internal diameter because they have thick outer walls. This can make spontaneous ventilation difficult, and airway pressures can be high in the ventilated patient.
A variety of anaesthetic techniques have been advocated for laser airway surgery. Some centres paralyse and ventilate using a laser endotracheal tube, others utilise a jet ventilator device attached to a rigid laryngoscope. However, some centres employ a spontaneous respiration technique using an air/oxygen mixture with a volatile agent administered via a laser tube or a nasopharyngeal airway. Good topical anaesthesia of the airway is also used to minimise the risk of coughing and straining.
131
131. Pulsus paradoxus in cardiac tamponade, the blood pressure decreases
A. Every second beat
B. In expiration when increase is normal
C. In expiration more than normal subjects
D. In inspiration when increase is normal
E. In inspiration more than normal subjects
E. In inspiration more than normal subjects
132
132. You are anesthetizing a patient for a laparotomy who has a history of pulmonary hypertension. Regarding the patients anaesthetic management
A. An alpha-agonist is the inotrope of choice
B. Hypothermia is protective against a rise in pulmonary artery pressure
C. Isoflurane will tend to decrease pulmonary artery pressure
D. Ketamine is an appropriate anaesthetic agent
E. ? RHF
A. An alpha-agonist is the inotrope of choice
133
133. In a patient with severe rheumatoid arthritis, which radiological finding is most consistent with severe atlantoaxial instability (? C1/C2 instability)
A. A 9mm gap between the anterior arch of C1 and the odontoid peg
B. Increased saggital diameter
C. Posterior atlantodental interval of > 14mm
D. Midpart of C1 over C2
E. Tear drop sign of C2
A. A 9 mm gap between the anterior arch of C1 and the odontoid peg
Anaesthesia in treating rheumatoid arthritis CEACCP
Cervical spine
The atlanto-axial joint is commonly affected in RA because of attenuation of the transverse ligament and erosion of the odontoid peg. This can lead to atlanto-axial instability in about 25% of patients suffering from RA. Acute subluxation may cause spinal cord compression and/or compression of the vertebral arteries leading to quadriparesis or sudden death. There are two main categories of cervical spine instability - atlanto-axial subluxation and subaxial subluxation.
Atlanto-axial subluxation:
Four subtypes have been described.
i. Anterior (affecting up to 80% of patients with atlanto-axial subluxation). The C1 vertebra moves forward on C2 because of destruction of the transverse ligament and there is a risk of spinal cord compression by the odontoid peg. Views of the lateral cervical spine in flexion may demonstrate subluxation. Subluxation exists when the distance between the atlas and the odontoid peg exceeds 4 mm in patients older than 44 yr and 3 mm in younger patients. Anterior atlanto-axial subluxation is worsened by neck flexion.
ii. Posterior (affecting about 5% of patients with atlanto-axial subluxation). Destruction of the odontoid peg may cause backward movement of C1 on C2, which may be evident on lateral extension views of the neck. Posterior atlanto-axial subluxation is worsened by neck extension.
iii. Vertical (accounts for about 10–20% of atlanto-axial subluxation). Destruction of the lateral mass of C1 can lead to subluxation of the odontoid peg through the foramen magnum and compression of the cervico-medullary junction.
iv. Lateral or rotatory subluxation results from degenerative changes in the C1/C2 facet joints. It can lead to spinal nerve compression and vertebral artery compression.
134
134. You are called to the labour ward to assist in the manual removal of a retained placenta in a healthy woman. The obstetrician asks you to administer intravenous glycerol trinitrate. An initial safe dose, that you would expect to be effective, would be
```
A. 5mcg
B. 50mcg
C. 250mcg
D. 500mcg
E. 1000mcg
```
B. 50 mcg
135
135. What is the most accurate method of determining foetal heart rate in a neonate
```
A. Palpation of an umbilical vein pulse
B. Auscultation with a stethoscope
C. Palpation of the femoral artery
D. Pulse oximetry
E. ?
```
B. Auscultation with a stethoscope
Mercy Neonatal Resuscitation Presentation
• Listen to the heart with a stethoscope or feel the base of the cord for pulsations.
• If pulsations in the cord are not present it is important to confirm the heart rate with auscultation
• Central and peripheral pulses are difficult to feel
• Pulse oximetry can provide an accurate and continuous display of the heart rate within one minute of birth and should be applied as soon as possible.
• ECG monitoring should be commenced by the NICU response team as soon as possible
136
136. Definitive evaluation of malignant hyperthermia (MH) susceptibility does NOT include observing
A. Abnormalities on magnetic resonance imaging (MRI) spectroscopy
B. Calcium release from B lymphocytes in response to caffeine stimulation
C. Certain mutations in the ryanodine receptor gene
D. Myofibrillar necrosis on muscle biopsy plasma
E. Creatine kinase (CK) levels above 800 units/L
E. CK levels above 800 units/L
137
137. A 60 year-old man with anterior mediastinal mass, is having a mediaastinoscopy. During induction they lose cardiac output, desaturate and drop their ETCO2. What is the best management strategy
```
A. Adrenaline
B. CPR
C. CPB
D. Place prone
E. ?
```
D. Place prone
138
138. Which is true of Eaton-Lambert syndrome that differentiates it from myasthenia gravis?
A. Immune antibodies against post-synaptic ion channels
B. Associated with thymoma
C. Repeated exercise causes weakness to initially improve
D. Good response to edrophonium
E. Resistant to non-depolarizing muscle relaxants
C. Repeated exercise causes weakness to initially improve.
139
139. A 55 year-old man presents to the emergency department with an obviously infected heel ulcer - BP 100/60, PR 110/minute, temperature 35.8, Na 125, K 2.7, BSL 55, Creatinine 180. Which do you give first/most urgently?
```
A. Antibioitcs
B. Crystalloid
C. Insulin
D. Potassium
E. Adrenaline
```
B. Crystalloid
Hyperglycaemia/hyperosmolar state is a bigger concern than sepsis in this man. Crystalloid resuscitation should help to restore circulating volume, decrease BSL and osmolality, and will probably tend to normalise the sodium (likely pseudohyponatraemia). Potassium may need to be replaced later, but should be done cautiously once an adequate urine output has been established.
140
140. A new test has been developed to diagnose a disease. To determine the SPECIFICITY of this new test it should be administered to
A. A mixed series of patients i.e. some known to be suffering from the disease and some known to NOT be suffering from it
B. A series of patients known to NOT be suffering from the disease
C. A series of patients known to NOT be suffering form the disease and an estimate of the prevalence of the disease in the population obtained
D. A series of patients known to be suffering from the disease
E. A series of patients known to be suffering from the disease and an estimate of the prevalence of the disease in the population obtained
B. A series of patients known to not be suffering from the disease.
Specificity = TN/(TN+FP)
141
141. During one lung ventilation, hypoxaemia can occur. The cause for this is:
A. Loss of hypoxic pulmonary vasoconstriction
B. Perfusion of the unventilated lung
C. Ventilation perfusion mismatch of the ventilated lung
D. Atelectasis of the ventilated lung
E. Upper lobe collapse of the ventilated lung
B. Perfusion of the unventilated lung (shunt)
142
142. A child with intra-operative blood loss. A cardiac arrest is most likely because of
A. A delay in delivery of blood from the blood bank
B. Inadequate intravenous access
C. Underestimated intra-operative blood loss
D. Underestimated pre-operative hypovolaemia
E. Complication of transfusion
C. Underestimated intraoperative blood loss
Anesthesia-related cardiac arrest in children: update from the Pediatric Perioperative Cardiac Arrest Registry 2007
Cardiovascular causes of cardiac arrest were the most common (41% of all arrests), with hypovolemia from blood loss and hyperkalemia from transfusion of stored blood the most common identifiable cardiovascular causes
143
143. The lumbar plexus supplies all of the following EXCEPT:
```
A. Subcostal nerve
B. Obturator nerve
C. Lateral cutaneous femoral nerve
D. Long saphenous nerve
E. Iliohypogastric nerve
```
D. Long saphenous nerve (doesn't exist)
The lumbar plexus is a nervous plexus in the lumbar region of the body which forms part of the lumbosacral plexus. It is formed by the divisions of the first four lumbar nerves (L1-L4) and from contributions of the subcostal nerve (T12), which is the last thoracic nerve.
Anterior divisions form:
- Iliohypogastric
- Ilioinguinal
- Genitofemoral
- Obturator
- Accessory obturatory
- Lumbosacral trunk
Posterior divisions form:
- Lateral femoral cutaneous
- Femoral (sensory component continues as saphenous nerve)
144
145. A 50 year old male in recovery after an anterior cervical fusion, developing increasing respiratory distress, bulge under original incision, combative, repeatedly removing oxygen mask, SpO2 96%. What is the most appropriate management?
A. Aspirate the collection with a 19G needle and syringe
B. Awake fibreoptic intubation with minimal sedation
C. Direct laryngoscopy and intubation after sevoflurane/O2 gaseous induction
D. Direct laryngoscopy and intubation after propofol/suxamethonium induction
E. Intubation via intubating LMA
C. Direct laryngoscopy and intubation after sevoflurane/O2 gaseous induction.
145
146. Regarding post dural puncture headache, all of the following are true, EXCEPT:
A. If puncture with the tuohy needle during epidural insertion, subsequent blood patch is 30-50% effective
B. Caffeine is often used to treat mild headache
C. Subdural haemorrhage can occur rarely
D. ?
E. Unlikely to be post dural puncture headache if the headache is only in the occipital area
E. Unlikely to be post-dural puncture headache if the headache is only in the occipital area (false)
146
147. A 70 year-old male presents for right lower lobectomy. Preoperative spirometry shows FEV1 2.4L (4.2L predicted), FVC 4L (5L predicted). The predicted post-operative FEV1 is:
```
A. 1.0L
B. 1.3L
C. 1.7L
D. 1.9L
E. 2.2L
```
C. 1.7 L
ppoFEV1 = pre-op FEV1 x (1 - [12/42])
= 2.4 x (30/42)
= 1.7 L
147
148. What is the most important immediate treatment for a cardiac arrest due to ventricular fibrillation in a patient with hypertrophic obstructive cardiomyopathy?
```
A. Adrenaline
B. Amiodarone
C. Defibrillation
D. Intubation, ventilation and oxygenation
E. Precordial thump
```
C. Defibrillation
```
HOCM
Worse under any conditions that decrease LV chamber size at End Diastole
- decreased LV filling
- decreased afterload
- increased contractility
Avoid positive inotropes (worsen dynamic obstruction)
Avoid veno- and arteriodilators
Optimise filling
GA>Epidural>Spinal
Vasoconstrictors the pressor of choice
```
148
149. Hypercalcaemia due to hyperparathyroidism is associated with
```
A. A shortened PR interval
B. A prolonged QTc interval
C. Muscle rigidity
D. Polyuria and polydipsia
E. Increased glomerular filtration rate
```
D. Polyuria and polydipsia
149
150. The cause of early mortality (early - within 30 minutes) in a pregnant women with amniotic fluid embolism is
```
A. Bronchospasm
B. Hypovolaemia
C. Malignant arrhythmia
D. Pulmonary hypertension
E. Pulmonary oedema
```
D. Pulmonary hypertension
MCQs
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