21.1 Flashcards

Question

21.1 The drug which has the LEAST impact on somatosensory evoked potentials (SSEPs) monitored in a 15-year-old patient undergoing scoliosis surgery is A) propofol B) fentanyl C) desflurane D) Midazolam E) sevoflurane

Answer 1

"b - fentanyl ^SSEP amplitude - ketamine, low dose etomidate decrease SSEP - volatiles > N2O, barbituates > propofol Minimal change - opioids, low dose benzo, dexmedetomidine, lidocaine No affect - muscle relxant https://www.uptodate.com/contents/neuromonitoring-in-surgery-and-anesthesia#H3106240"""B) fentanyl Drugs which have the least impact on SSEPs 1. Ketamine 2. Opioids 3. Dexmedetomidine Article in Anaesthesiology https://pubs.asahq.org/anesthesiology/article/99/3/716/40407/Pharmacologic-and-Physiologic-Influences-Affecting

Answer 2

c. 5mg/kg Methylene blue due to its monoamine oxidase(MAO) inhibiting property may precipitate potentially fatal serotonin toxicity at doses >5mg/kg.

Answer 3

e. Decreased neuropathic pain at 12 months ANZCA pain book

Answer 4

d. 7500 7.5L (Average increase around 48%) pregant = 100ml/kg , neonate 90ml/kg, adult 70ml/kg , paeds 80ml/kg """

Answer 5

30ml/cm H2O The answer is 30ml/cmH20 because total PEEP is 8+4=12 Static lung compliance (Cstat), mL/cm H2O = TV / (Plateau pressure (Pplat) – PEEP)

Answer 6

d) modified valsalva HD stable: narrow QRS - likely SVT – vagal manouvres, adenosine 6 , 12, 12 Unstable.- HR>150, sBP <90 (in conscious and lower in anaesthetised pt) - synchrnised DCCV 1J/kg and can be increased to 2J/kg "conscious VT or something stupid....

Answer 7

"3 mths AHA Guidelines. ""we suggest that elective noncardiac surgery be deferred at least 6 months after a prior stroke, and possibly as long as 9 months to reduce the risk of perioperative stroke in patients undergoing noncardiac surgery. Alternatively, patients who stand to gain significant improvements in quality of life with elective surgery may consider waiting only 6 months after a prior stroke."" https://www.ahajournals.org/doi/10.1161/CIR.0000000000000968 https://www.bjaed.org/article/S2058-5349(20)30123-2/fulltext"

Answer 8

c) initial bradycardia PSNS during seizure 10-15sec - brady/hypotension followed by SNS (5mins) - tachycardia/ hypertension/ dysrhythmia, ^myocardial oxygen requirement seziure --> ^ICP and ^CMRO2 --> ^CBF Other - hypersalivation, ^gastric pressure, ^IOP, incontinence absolute CI - recent MI or CVA, phaeochromocytoma, intracranial mass lesion, intracranial or aortic aneurysm Oxford handbook pg 273-274"

Answer 9

?? XR Reviews

Answer 10

"a) hypophosphataemia - due to renal wasting of phosphate - usually transient and asymptomatic "osphataemia

Answer 11

"a) staphyloma BJA - regional anaesthesia for ophthalmic surgery - Myopic eyes with an axial length of > 26mm are at increased risk of perforation with retrobulbar / peripulbar . This risks is increased in by the associated likelyhood of staphylomas (sclera outputting), which are typically posterior or inferior"

Answer 12

b. 45ml/hr N saline w 5% dextrose A guide to paediatric anaesthesia fluid management -421 rule overestimates fluid resus -due to stress response from ADH release -post-op fluid maintenace is 2/3rds calculated -never use hypotonic solution -unlikely to need glucose as not a neonate

Answer 13

"c.Stop volatile and calcium Duchenne muscular dystrophy -> rhabdomyolysis and hyperkalemia. Calcium for cardiac stabilization The only conditions shown to have a definite linkage with malignant hyperthermia (MH) are King–Denborough syndrome, central core disease, and Evans myopathy.7 Patients with other neuromuscular disorders have shown MH-type symptoms under general anaesthesia, but the link between these symptoms and true MH remains unclear. There is no association between DMD and MH; previously described ‘normothermic MH’ reports were almost certainly rhabdomyolysis https://academic.oup.com/bjaed/article/10/5/143/274799#3357763"

Answer 14

"b) gelofusine (succinylated gelatin) 25% of children suffering anaphylaxis to MMR is due to gelatin gelatin also found in Haemaccel and Gelofusine https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/full/10.1111/j.1365-2044.2005.04529.x"

Answer 15

"b) berinert another remembered option had icatibant instead of berinert. ?give FFP in this instance as icatibant wont have time to work Tx of acute flare: – C1 inhibitor concentrate eg Berinert, Cinryze – Recombinant C1 inhbitor (conestat alfa) – bradykinin B2 receptor antagonist (Icatibant – FFP - 2units initially- repeated Q2-4H HAE - causes recurrent episodes of angioedema in the upper respiratory tract , GIT or subcut tissue Due to C1 esterase inhibitor deficiency. Rare autosominal dominat condition 2 types (type1 - reduced, type 2 poorly functional C1 esterase inhibitor) Triggers - infection, stress, menstruation, surgery, dental work, trauma, medicine (COCP and ACEi) or may have no clear trigger Pre-op prevention: 1st line - Danazol 10mg/kg/day for 5-10days before and 2-5days after procedur) (androgen increase C1 esterase inhibitor synthsis) Emergency or high risk procedures - 25u/kg infusion of C1 esterase inhibitor concentrate (Berinert) given 1hr prior to procedure **antihistamines and cortiocsteroids have no role in management of HAE related angiodema. Role of adrenaline not well established https://www.rch.org.au/clinicalguide/guideline_index/C1_Esterase_inhibitor_deficiency/ "

Answer 16

"a. Nasociliary. It is a branch of the Trigeminal nerve (V1) https://academic.oup.com/bjaed/article/17/7/221/3800526 V1 (Ophtlamic) divides into Fronal, lacrimal, nasocillary Frontal (largest of V1 branches) branches into supraorbita (innervates upper eyelid and contiva and scalPl and supratrochlear (innervavtes upper eyelid, conjunctiva, forehead) Lacrimal (smallest of V1 branches and receive branch from V2 containing parasympathetic fibres) - lacrimal gland, upper eyelid, conjunctiva Nasocillary (4 branches - ant ethmoid, post ethmoid, infratrochlea, long ciliary nerves) - sensatotion to sinuses, nasal cavity, external nose. Long ciliary - sensory innervation to eye (CORNEA, ciliary bodies, iris) sympathetic fibres to dilator pupillae muscle Occulomtor - CN III - innervates all extraoccular muscles EXCEPT - SO4 and LR6 Optic CN II - sight"

Answer 17

"d - Adductor canal. Opthalmic blocks> Addutor canal. Adductor canal specifically for lower limb blocks Rare complication Myotoxicity after regional anaesthesia defined as: occurance of symptoms related to muscle damage, including muscle paralysis/wekaness, occurence of dipolpia/ptosis/hypertropia and hypotropia after catarcht surgery, enzymatic changes indicateive of muscle damage (such as elevated CK) Myotoxic damage appeared to occur independent of needle size and LA concentration. https://www.bjanaesthesia.org/article/S0007-0912(18)30572-5/pdf"""

Answer 18

"a) 100microamp Microshock - enters body through internal devices close to heart - 10micramp - unsafe - 100microamp - can induce VF macroshock - current through 2 points of body – 1mA - pain - 10mA - tetany (unsafe) -100mA - VF"

Answer 19

a. Increases NIRS , decreases peripheral SctO2 up, SpO2 down. Source: Korean Journal Anaesthesia https://www.researchgate.net/publication/274570990_Effects_of_intravenously_administered_indocyanine_green_on_near-infrared_cerebral_oximetry_and_pulse_oximetry_readings

Answer 20

no longer has time frame

Answer 21

"insulin and sulfonylureas (eg. Gliclazide) high risk of hypoglycaemia when fasting (stimulates pancreatic cells to make more insulin) "

Answer 22

Control seizures first a) Midazolam if an option or c) propofol or treat seizures 1st followedLAST - ABCD - Intralipid 1.5mL/kg

Answer 23

"d) DLCO low MG won't affect DLCO Pulmonary HTN won't show restrictive pattern Emphsema/asthma - high DLCO Other causes of ^DLCO: asthma, polycythemia, pulmonary haemorrhage, large lung volumes, high altitude, left to right cardiac shunt, exercise prior to test (^CO) Emphsema, ILD, sarcoid --> decreased DLCO "

Answer 24

"a) sevo, morph, phenyl moclobemide - MAO-Ai - AVOID indirect acting sympathomimetics (ephedrine, metaraminol -->hypertensive crisis) - AVOID serotonin crisis precipitants (including pethidine) MAO-A - involved in breakdown of norad and serotonin MAO-B- involved in breakdown of tyraime and phenyethyamine https://academic.oup.com/bjaed/article/10/6/177/299579 "

Answer 25

C) droplet "Standard + contact precuations: Standard - hand hygiene, PPE, effective cleaning of all equipment/enivronment Contact: - single room isolation - PPE - glove + gowns - dedicated equipment to patients – enahnced cleaning + disinfection - x2 / day https://www.safetyandquality.gov.au/sites/default/files/2020-09/cpe_for_clinicians_sept_2020.pdf"

Answer 26

b? The sciatic nerve block results in anesthesia of the posterior aspect of the knee, hamstring muscles, and entire lower limb below the knee, both motor and sensory block, with the exception of skin on the medial leg and foot (supplied by the saphenous nerve). The skin of the posterior aspect of the thigh is supplied by the posterior femorocutaneous nerve, which deviates away from in the sciatic nerve proximal to the level of the anterior approach, and is therefore not blocked. NYSORA

Answer 27

"c) Dopamine 2 antagonist Indicatoins: Parkinson, drug induced EPSE, acute dystonia MOA: antimuscurinic - reduction of relative excess of cholinergic activity that accompanies dopamine deficienc in PD. partially blocks cholinergic activity in basal ganglia and has been shown to increase availability of dopamine by blocking its reuptake and storage in central sites https://www.sciencedirect.com/topics/pharmacology-toxicology-and-pharmaceutical-science/benzatropine#:~:text=Benzatropine%20partially%20blocks%20cholinergic%20activity,of%20Parkinson%27s%20disease%20and%20dystonia."

Answer 28

a. Barrier protection for a week

Answer 29

60 mmol 1mmol/kg 1mmol/kg given over 2-3minutes as guided by ABG 8.4% sodium bicarb 100mmol = 1mmol/ml Routine use not recommended for cardiac arrest Consider if: - hyperkalaemia - tx of documented metabolic acidosis - overdose with TCA - protracted arrest (>15mins) https://www.resus.org.nz/assets/Uploads/ANZCOR-Guideline-11.5-Medications-Aug16.pdf"

Answer 30

e) Standards of quality improvement Quality Improvement (Standards for QUality Imporvement and Reporting Excellence) Quality improvement - SQUIRE RCT - CONSORT Observational studies - STROBE Systematic review - PRISMA Study protocols - SPIRIT Clinical practice guidelines - AGREE Qualitative research - SRQR Research question - PICO"

Answer 31

e. Disregard not required "Conitnue to breast feed as per usual. Do not need to express and discard. Monitor infant for signs of respiratory depression and drowsiness especially if multiple doses of opioids/bzd AVOID codeine in breastfeeding https://anaesthetists.org/Home/Resources-publications/Guidelines/Anaesthesia-and-sedation-in-breastfeeding-women-2020"

Answer 32

c. Ischemic optic neuropathy post op ischaemic optic neuropathy - most common cause of POVL after nonocular surgery - ^risk with cardiac, spine, orthopaedic, steep trendelenberg positions - anterior ION - more common with cardiac - posterior ION - more common with prone procedures, steep trendelenberg, cardiac - presents with painless b/l vision loss - risk factors for POVL with spine surgery - male, ^BMI, wilson frame, long duration, ^ blood loss - PION more common however only AION has fundoscopic changes -- AION - fundoscopy - swollen disc - can be uni or bilateral -- AION onset usually immediate after awakening but can also have onset a day or so afterwards - sudden unilateral or bilateral, progressive vision loss Central retinal artery occlusion - most common retinal cause of POVL - usually unilateraly and immediately after awakening from anaesthesia - fundoscopy - ischaemic retina + cherry red spot at macula https://www.uptodate.com/contents/postoperative-visual-loss-after-anesthesia-for-nonocular-surgery#H437018973 """

Answer 33

Prostaglandin RCH say give 10ml/kg bolus rather than 20ml/kg https://www.safercare.vic.gov.au/best-practice-improvement/clinical-guidance/neonatal/cyanosed-neonate-assessment low threshold to give Most frequent side effects include: fever 12 per cent apnoea 12 per cent flushing 10 per cent hypotension tachycardia. Apnoea rarely occurs at 10 ncg/kg/min and is not an indication to decrease the dose if the infant is responding clinically. Ensure adequate respiratory support. The likelihood of apnoea is very high at a dose of 100 ncg/kg/min and most infants on this dose should have ventilatory support.

Answer 34

a) High C-spine injury - at high risk of passive regurgitation and then aspiration due to loss of gag and cough response https://trauma.reach.vic.gov.au/guidelines/spinal-trauma/primary-survey Absolute Contraindications: midface injury, basal skull fracture, recent nasal surgery Relative Contraindications: coagulation abnormality, eosophageal varices or stricture, recent banding of varices, alkaline ingestion https://iem-student.org/nasogastric-tube-placement/"

Answer 35

decreased SVR High CO state (+/- failure -- LVEF does not ^ appropriately during exercise suggesting presence of cardiomyopathy) - ^CO state due to ^ peripheral oxygen needs and ^ cardiac contractility - increased HR, contractiliity, sBP (widened pulse pressure), pulmnoary artery pressure, myocardial oxygen https://www.uptodate.com/contents/cardiovascular-effects-of-hyperthyroidism?search=cardiovascular%20effects%20of%20hyperthryod&topicRef=7833&source=see_link in HYPOthryoid - opposite occurs - decreased CO - decreased contractility, HR, diastolic relaxation (so decreased compliance and diastolic filling), peripheral tissue oxygen utilisation - blunted response to catecholamine mediated ^ in inotropy - ^ SVR, ^Qtc"

Answer 36

Fluoxetine All other effective NRT, buproprion, nortriptyline, clonidine, nicotine receptor patial agonists (varenicline -(champix)) Individual counselling, group behaviour therapy, rapid smoking aversive therapy https://www.anzca.edu.au/getattachment/a3591188-1d7d-41cf-807a-b3b2f0226109/PS12BP-Guideline-on-smoking-as-related-to-the-perioperative-period-Background-Paper"

Answer 37

less maternal bradycardia b) less maternal bradycardia - nil pt required anticholinergic so clinical significance unclear no difference in N/V norad non inferior to phenyl in terms of acid base profiles and APGAR at 1min and 5mins https://www.bjanaesthesia.org.uk/article/S0007-0912(20)30442-6/fulltext

Answer 38

100 years Desflurane: 10yrs Sevoflurane 1yr

Answer 39

A. expereince of anaesthetist assuming they are implying that an experienced anaesthetist is operating (as inexperienced anaesthetists operating increase risk PRAE). APRICOT doesnt mention snoring but BJA does https://www.bjanaesthesia.org/article/S0007-0912(24)00497-5/fulltext

Answer 40

increased incidence of major bleeding APREE trial 2018 (NEJM) - low dose aspirin as primary prevention in pts>70 --> ^ risk of major haemorrhage (mostly GI bleed) and DID NOT lower risk of CVS disease compared to placebo. Primary prevention of CVD with aspirin among pts 40-59yo who have a 10% or grater 10yr CVD risk - has a small net benefit. https://jamanetwork.com/journals/jama/fullarticle/2791399"

Answer 41

"d) sucralfate or honey - give within 12hrs of ingestion - don't give honey to <12mth old"""sucrulfate or honey

Answer 42

c) lateral bladder wall resection obturator nerver - responsible for hip adduction - obturator nerve (L2-4) travels alongside the posterolateral bladdder wall before exiting the pelvis - stimulation of obturator nerve during TURBT --> adductor spasm --> ^risk of bladder perf spinal does not prevent unintended stimulation of obturator nerve - need Neuromuscular blocker or obturator nerve block decreased riks with lower diathermy current https://karger.com/cur/article/12/1/1/103204/Avoiding-the-Obturator-Jerk-during-TURBT"

Answer 43

no difference TARGET trial 2019 energy dense vs routine enteral nutrition in critically ill ventillated Conclusion - no differenc in 90day survival (primary outcome) - ^ GI effects in high caloric group - ^ gastric residual volumes, regugitation, ^use of insulin and prokineitc drugs https://www.thebottomline.org.uk/summaries/target/"

Answer 44

neurological damage due to methionine deficit chronic exposure --> deplete B12 stores through oxidation of cobalt --> inactivation of methionine synthase --> decreuased methionine synthesis --> megaloblastic anaemia, peripheral neuropathy, memory loss Potetntially teratogenic (in Rats) Acutely Resp - ^PVR - avoid in pulmonary HTN - expansion of existing air filled spaces - diffusion hypoxia CNS ^CBF --> ^ICP"

Answer 45

high level of education Risk factors for CPSP Demographic: young adults, low level of education, seeking compensation, smokers Psychological: fear, anxiety, depression Pain related: pre-existing pain, stronger post-op intensity and duration Clincal: greater prior disability Surgery: longer operative time, increased complication rate Blue Book 2019 pg 176 "

Answer 46

adenosine Denervated heart. Only drugs that act directly on the heart will be effective. Loss of predominant parasympathetic outflow - so SA node rate now 90-100. Preload dependent - frank starling mechanism. alpha and beta receptors remain intact but attenuated response to catechoamines. Dopamine/isoprenaline - effective Norad/adrenaline,dobutamine - exagerrated effect - depends on intrinsic stores of catehcolamines and degree of reinnervation metaraminol - effective but no reflex brady Pheynlephrine - effective ephedrine - less effective glyco/atropine - not effective No autonomic innervation of the heart -> lack of reflex bradycardia. Adenosine - exaggerated bradycardia - receptors present on heart b-blocker - effective - but caution with use as CO dependent on catechoamines digoxin - usually ineffective due to parasympathetic dennervation ANZCA blue book 2019 pg 69"

Answer 47

4 hours RBC out of temperature controlled storage for <30mins can be returned to blood bank. Once RBC out of tempeature controlled storage for 30mins, transfusion of the unit must be completed within 4hrs and NO LONGER than 4.5hrs. Blood components must be transfused using a set that has a standard filter to remove clots and small clumps of debris. Recommended filter pore size is 170-200micron. https://anzsbt.org.au/wp-content/uploads/2018/06/ANZSBT_Guidelines_Administration_Blood_Products_3rdEd_Jan_2018.pdf"

Answer 48

supraclavicular or suprascap Intrinsic muscles = rotator cuff muscles - supraspinatus, infraspinatus, subscapularis, teres minor Innervated by suprascapula, subscapular and axillary nerves (Branches off C5/C6/C7) Stabilisation scapula and rotational movements - levator sacpuale, trapezius, rhomboid, serratus anterior Innervation - axillary, spinal accessory (inn trapezius), dorsal scapula (inn rhomboid and levator scap), long thoracic (inn. serratus) Damge = winged scapula "

Answer 49

c Rivaroxaban or apixaban are generally favoured over dabigatran or warfarin as they do not require a period of parenteral anticoagulation or routine laboratory monitoring. EXCEPT - if active cancer or pregnancy - LMWH - CKD 4 or 5, extreme body weight (/=120) or antiphospholipid syndrome - LMWH followed by warfarin Initial dose rivaroxaban 15mg BD for 21 days. Maintenaince 20mg OD for up to 6mths Apixaban 10mg BD for 7 days. Maintenaince 5mg BD for up to 6mths Rivaroxaban contraindicated if CrCl <30ml/min and Apixaban CI if CrCl<25ml/min Dabigatran - not on PBS. Also needs parenteral anticoagulant (eg clexane) for the first 5 days before starting dabigatran. Surgically provoked or distal DVT: (low risk recurrence at 12mths) Proximal DVT or PE - at least 3mths anticoag Distal DVT (ie. distal to popliteal vein) - 6weeks to 3mths. If high risk bleeding - surveillance uss x 2 over 2 weeks to monitor extension. If extension - anticoagulate Non surgically provoked (ie travel or COCP) or unprovoked - intermediate risk for recurrence - onggoing low dose apixaban (2.5mg BD) or rivaroxaban (10mg OD) commonly used https://australianprescriber.tg.org.au/articles/venous-thromboembolism-current-management.html"

Answer 50

3 Appearance - pink > peripherial cyanosis > cyanotic Pulse - 100-140 > (<100) > 0 Grimace - cry > grimace > no response Activity - well flexed > some flexion > limp Respiration - strong cry > irregular breathing > apnoea "

Answer 51

renal tubular acidosis-> NAGMA

Answer 52

"a. Urine osmol <100 High ADH -> Highly concentrated urine. Cortisol Suppressed ADH release - likely to be low but not necessarily BJA education: Criteria for diagnosing SIADH include: clinical euvolaemia, serum osmolality <275 mOsm/kg urine osmolality >100 mOsm/kg urinary Na >30 mmol/litre normal thyroid/adrenal function, no use of diuretics within a week of testing"

Answer 53

"a) empty bladder - suspect autonomic dysreflexia Treatment 1. Declare emergency and make surgical team aware of issues * Sit patient up if possible to reduce pressure to the head 2. Remove stimulus * Stop surgical insult * Check catheter is draining unblocked * May be able to check for constipation but less likely to be possible while on operating table mid surgery * Remove tight clothing 3. Drugs * Vasodilators ○ GTN bolus and subsequent infusion ○ Hydralazine ○ Mg, phentolamine, clonidine * Be careful with betablockers as may cause heart failure due to very high SVR and addition of betablocker may cause loss of contractility * Analgesia (opioids etc.) to reduce afferent nociceptive stimulation * Treat any arrythmias that may occur 4. Prevention of this by spinal anaesthesia * This can be done pre-op and prevents transmission of afferents which cannot then go on to cause ↑SNS outflow Not a treatment as such, more preventative in patients who are high risk"

Answer 54

"c. Sux - degraded by plasma cholineserase -- may result in prolonged paralysis Likely organophosphate poisoning. Covalent bonding with inactvation of acetylcholinesterase - cholinergic crisis - Long duration of effect + worsening side effects SLUDGE BBB - salivation, lacrimation, urination, diarrhoea, gastric emesis, bronchorroea, bronchospasm, bradycardia Nicotinic effects --> muscle fasiculations, weakness, parlysis --? similar to depolarising effects of sux Tx - atropine (20mcg/kg boluses) + pralidoxime (30mg IV than 8mg/kg/hr) (treats nicotinic effects) BZD for seizures activated charcoal if within 2hrs https://litfl.com/organophosphate-poisoning/"

Answer 55

"c) neostigmine or fluid Ogilvie syndrome - colonic pseudo-obstruction '3 , 6, 9 ' rule 10% related to O&G cases small bowel >/=3cm, large bowel >/=6cm, caecum >/=9cm caecum >/= 9cm -- ^ risk of perforation tx - first line (if <12cm) - correction of serum electrlytes, fluid resuscitation, avoid/minimize narcotics, avoid anticholinergic, trat infection if present, ambulation, bowel rest, alternating position to promote GI motility, decompression with NG or rectal tube. Avoid osmotic or stimulant laxatives -- can worsen dilation IF not resolved with above - neostigmine is indcated https://www.uptodate.com/contents/approach-to-acute-abdominal-pelvic-pain-in-pregnant-and-postpartum-patients?search=ogilvie&source=search_result&selectedTitle=2~50&usage_type=default&display_rank=2#H39 https://fascrs.org/getattachment/Healthcare-Providers/Education/Clinical-Practice-Guidelines/2021-Colonic-Volvulus-CPG.pdf?lang=en-US"

Answer 56

"hypocalcaemia hypocalcaemia --> tetany hypomagnaesaemia --> QT prolongation HYPERkalaemia acidosis ALL can lead to life threatening arrythmia HF - F- bind directly with calcium and magnesium and disrupts potassium channels --> cell dysfunction and death Tx - ALS. I+V. Cacium Chloride 10% 20mL repeat every 5mins until calcium >1mmol/L Sodium bicarb 100mmol Mag 10mmol https://litfl.com/hydrofluric-acid/ "

Answer 57

B lines (AKA comet tails) - a lines and z lines both normal - pulse is movement of pleura with cardiac pulsation - also normal A-lines - horizontal lines below the pleura with the same spacing as the distance between the probe and the pleura - indicates air - so it is seen in NORMAL lung and PTX B-lines - (aka comet tails) - artifacts generated by juxtaposition of alveolar air and septal thickening (from fluid or fibrosis) – up to 2 between ribs is normal – 3+ pathological - any disease affecting interstitium - pulmonary oedema (cardiac or ARDS) – B lines occur with interstitial oedema (before alveolar oedema) Atelectasis and consolidation difficult to differentiate on USS – see bronchograms - air bronchograms are white and fluid brochograms are black - atelectasis - no or static air borchograms - large consolidation - appears like liver Z-lines - artifact - looks like b lines but are ill-defined https://www.pocus101.com/lung-ultrasound-made-easy-step-by-step-guide/#Consolidations https://academic.oup.com/bjaed/article/16/2/39/2897763 "

Answer 58

"a) A group (or AB) - has no plasma antibodies Plasma compatibility - should be combatible with ABO group of recipient to prevent haemolytic reaction. ANY RhD subtype can be given Pt group: A --> compatible with A, AB plasma B --> compatible with B, AB plasma AB --> compatible with AB plasma O --> compatible with all "

Answer 59

"c) multiple sclerosis - temperature monitoring important. Pyrexia to be avoided and treated aggressively. - demyelinated axons more sensitvie to heat - hypothermia may dlay recovery from anaesthesia OXFORD handbook pg 248"s NB overheating can precipitate myasthenic crisis also

Answer 60

"c) Transhiatal - laparotomy + neck (L) incision Ivor lewis – laparotomy + R thoracotomy McKeown/ tri-incision - laparotomy + R thoracotomy + L cervica Transdiaphgramatic - thoracolaparotomy - incision from thoracotomy site to umbilicus https://academic.oup.com/bjaed/article/17/2/68/2907833l"

Answer 61

"normal PCWP 4-12mmHg. need other values. Likely either COPD or PE acute suggests PE "

Answer 62

"e) pain Aldreate scoring system used for PACU discharge criteria - activity, respiration, circulation, consciousness, colour (O2 sat) (Score >= 9 for discharge A- SpO2 > 92% on RA (2pts) B - deep breath/cough (2pts) C - BP within 20% baseline (2pts) D - conscious and fully alert (2pts) move 4 limbs (2pts) "

Answer 63

"1st line - labetolol 2nd line - nifedipine 3rd line - methyldopa NICE guideline if severe sBP>160 - than nifedipine QLD guideline says follow local prefernce/protocol https://www.health.qld.gov.au/__data/assets/pdf_file/0034/139948/g-hdp.pdf?back=%2Fsearch%3Fkeywords%3Dpre%2Beclampsia%2C%2C%2Fcondition%2Fhypertensive-emergency%3Fsearch%3Dpre%2Beclampsia%23view%2F728%2F1410"

Answer 64

doing an epidural on a patient who is labouring with normal pregnancy and no comorbidities 1. Avoid routinely performing preoperative blood investigations, chest X-ray or spirometry prior to surgery, but instead order in response to patient factors, symptoms and signs, disease, or planned surgery. 2. Avoid ordering cardiac stress testing for asymptomatic patients prior to undergoing low to intermediate risk non-cardiac surgery. 3. Avoid administering packed red blood cells (blood transfusion) to a young healthy patient with a haemoglobin of ≥70g/L who does not have on-going blood loss, unless the patient is symptomatic or hemodynamically unstable. 4. Avoid initiating anaesthesia for patients with limited life expectancy, at high risk of death or severely impaired functional recovery, without discussing expected outcomes and goals of care. 5. Avoid initiating anaesthesia for patients with significant co-morbidities without adequate, timely preoperative assessment and postoperative facilities to meet their needs. 6. Avoid routine prescription of SR opioids for acute pain unless demonstrated need, close follow up & cessation plan. https://www.choosingwisely.org.au/recommendations/anzca

Answer 65

NSTEMI MINS includes myocardial infarction and ischemic myocardial injury that do not fulfill the Universal Definition of Myocardial Infarction (myocardial injury with a rise or fall of cTn above the 99th percentile of the upper reference limit and at least 1 of the following: ischemic symptoms, new ischemic electrocardiographic changes, development of new pathological Q waves on ECG, imaging evidence of myocardial ischemia, or angiographic or autopsy evidence of coronary thrombus). https://www.ahajournals.org/doi/10.1161/CIR.0000000000001024 This history meets the diagnosis of type 1 MI and given there are no ST changes is a NSTEMI. https://www.ahajournals.org/doi/10.1161/CIR.0000000000000617 If the patient had a supply/demand mismatch it would be a type 2 MI and be a type 2 NSTEMI

Answer 66

"d) 54weeks PMA well children ASA 1 or 2 Term infants >46weeks PMA (so 6 weeks old) Ex Preterm infants >54weeks PMA (they are more at risk of post-op apnoea) When discharged should travel home by car with 2 adults (1 to drive and 1 to watch the child) https://www.anzca.edu.au/getattachment/568bad2d-7517-4eea-9c5d-cb7aa1c60c01/PG29(A)-Guideline-for-the-provision-of-anaesthesia-care-to-children-(PS29)"

Answer 67

who bloody knows recent Meta analysis shows that delerium may be reduced https://journals.plos.org/plosone/article?id=10.1371%2Fjournal.pone.0306308#abstract0 recent systematic review with cochrane 2022: no effect on mortality or LOS, might stop unplanned hospital readmission https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD012705.pub2/full from 2021: probably reduces LOS and mortality https://www.bjaed.org/article/S2058-5349(21)00034-2/fulltext cochrane review from 2018: no evidence of mortality benefit, might influence LOS https://www.cochrane.org/evidence/CD006211_comprehensive-geriatric-assessment-older-adults-admitted-hospital

Answer 68

"Maple E Pros: low resistance, valveless, low dead space, light weight, compact, easy to transport/clean/sterilise Cons: require 2-3MV to prevent rebreathe, no bag – no tactile feedback or ability to ventilate or provide CPAP, difficult to scavenge, inefficient"

Answer 69

Bolus 1 IU oxytocin; start oxytocin infusion at 2.5–7.5IU.h1(0.04–0.125 IU.min1) EmLSCS; 3 IU oxytocinover≥30 s; start oxytocininfusion at 7.5–15 IU.h1(0.125–0.25 IU.min1).

Answer 70

"a) son The medical treatment decision maker is the first person in the list below who is reasonably available, and willing and able to make the decision: 1) a medical treatment decision maker appointed by the patient 2) a guardian appointed by VCAT to make decisions about medical treatment 3)the first person in the list below who is in a close and continuing relationship with the patient: - the patient's spouse or domestic partner - the patient's primary carer (not a paid service provider) - an adult child of the patient - a parent of the patient - an adult sibling. If there are two or more relatives who are first on this list, it is the eldest person. https://www.publicadvocate.vic.gov.au/your-rights/your-healthcare/appointing-a-medical-treatment-decision-maker "

Answer 71

"Bleomycin - oxygen toxicity -lifelone risk of bleomycin induced lung injury from oxygen - aim O2sats 88-92% if hypoxic - pulmonary fibrosis in lower lobes "

Answer 72

NSW course - give 4ml/kg for electrical burns "Parkland = 4 x TBSA% x weight = 400 x 30 = 12 000mL 50% in first 8hrs so 6L in 6hrs so 1000mL /hr " https://www.vicburns.org.au/severe-burns/early-management-of-severe-burns/fluid-resuscitation/

Answer 73

"d - IE ratios - no evidence Consensus recommendations 2019 : - Vt 6-8ml/kg IBW - PEEP at least 5cmH20 and individualised - 30deg headup if possible - FiO2 lowest possible (aim SpO2 >94%) - alveolar recruitment manouvres beneficial - machine better than bag - minimise PEEP lost between transitioning - lowest effective pressure for shortest effective time Hyperoxia - ^ oxidateive stress, peripheral and coronary vascular vasoconstrictuion, decrease CO, ^ resoption atelectasis, ^postop pulmonary complications, masking effect of O2 therapy --> delayed diagnosis of gas-exchange impairment. https://www.bjanaesthesia.org/article/S0007-0912(19)30647-6/fulltext"

Answer 74

"a - resting tachycarida They are usually bradycardic CVS: hypotension, bradycardia, MV prolapse, impaired myocardial contractility, cardiomyopathy, ^ arrythmia (AV block. ST depression, TWI, QT prolongation) Resp: metabolic alkalosis, decreased lung compliance, aspiration pneumonia, PTX, pneumomediastinum Renal: proteinuria, reduced GFR, hypo - all electrolytes and renal stones GI: dental caries, periodontis, mallory-weiss tears, oesophgeal stricture, gastritis, delayed gastric emptying, risk of refeeding, fatty liver, hepatomegaly, cirrhosis, ^amylase, abnormal LFT, enlarged salivary gland Endocrine: delayed onset puberty, ^ cortisol/ GH, decreased glucose/insulin, impaired thermoregulation Immune: leucopenia, thrombocytopenia, haemolytic anaemia, poor wound healing Haem: bone marrow hypoplasia Neuro: decreased cognitive function, coma EEG abnromalities, seizures, neuropathy, ^pain threshold MSK: myalgia, myopathy, rhabdo, osteopenia, stress fracture https://academic.oup.com/bjaed/article/9/2/61/299563"

Answer 75

"a) low K diet High K diet, etoh reduction, exercise, low Na diet, smoking cessation https://www.nps.org.au/australian-prescriber/articles/lifestyle-management-of-hypertension:"

Answer 76

"b) increased SVR Early CVS changs (max at 24hrs bost burns) - mimics hypovolamic shock - intravascular volume depletion, ^ SVR (by up to 200%), CO halved, ^ciruclationg vasopression - decreased oxygen delivery, ^ PVR - ^ Hct Late CVS changes (hyperdynamic circulation 2-5days post burn) - driven by catecholamine surge - ^ CO proportional to size of burn (part of hypermetabolic response, most commonly seen in patients with>40% burn) - ^HR, decreased SVR http://khcanaesthesia.com/onewebmedia/peri%20operative%20Mx%20BURNS.pdf "

Answer 77

"d) anaemia Hepcidin - peptide hormone produced in liver. degrades transport protein for iron. Hepcidin REDUCES oral absorption of iron and INHIBIT iron release from cellular storage. Decreases when anaemic - want to absorb more iron. Increased in infection and inflammation (hepcidin is an acute phase reactant --> ^ hepcidin --> decreased transport of iron out of cells --> decrease in serum iron), anaemia of chronic disease cancer deficiency in hepcidin production --> iron overload (hereditary haemachromatosis) https://www.ncbi.nlm.nih.gov/books/NBK538257/#:~:text=Hepcidin%20is%20a%20peptide%20hormone,and%20the%20electron%20transport%20chain. "

Answer 78

bottle A = fluid trap or collection bottle, can be independently emptied and allows accurate record of drainage amount - first tube connecting drain to drainage bottles must be wide to decreased resistance - volume capacity of this tube should exceed ½ of patient’s maximum inspiratory volume (otherwise H2O may enter chest) bottle B = underwater seal drain, maintained at a predetermined level whilst still allowing for drainage of pleural fluid (if bubbling continuously -> bronchopleural fistula) - volume of H2O in bottle B should exceed ½ patient’s maximum inspiratory volume to prevent indrawing of air during inspiration bottle C = manometer or pressure-regulating bottle allows suction to be attached and should bubble continuously - The maximum negative pressure (in cm H2O) generated by suction equals to the distance (in cm) the vent tube is below the water line (this can be adjusted) -The negative pressure generated by the vent tube is independent of the amount of pleural drainage that is collected in the trap bottle - If suction is turned off then tubing must be unplugged -> so air can escape into atmosphere

Answer 79

age Domains: 1. Cognition 2. General health status 3. Functional independance 4. social support 5. Medication use 6. Nutrition 7. Mood ?interpreted as mental illness in stem? 8. Continence 9. Functional performance Scoring 0-5= Not frail 6-7= Vulnerable 8-9= Mild Frailty 10-11= Moderate Frailty 12-17= Severe Frailty

Answer 80

"a) supine, trendelenbergy, increased chest wall rgidity all improve ventilation in tetraplegic assume C3-5 injury --> diaphragm and accessory muscles involved --> expiration is difficult --> head down allows passive excursion https://www.bjaed.org/article/S2058-5349(17)30152-X/fulltext"

Answer 81

b. Thoracodorsal Thoracodorsal nerve (C6-C8) is a branch of the posterior cord of the brachial plexus. Its primary function is motor innervation of the latissimus dorsi muscle. Its blockade is relevant in more extensive breast reconstruction procedures. The Pecs I, Pecs II and Serratus Plane blocks are superficial thoracic wall blocks which through blockade of the 1. Pectoral N. 2. Intercostal N. 3. Thoracodorsal N. 3. Long thoracic N. It can be used to provide analgesia for breast surgery and other procedures/surgery involving the anterior chest wall.

Answer 82

"a) reduce RR HFNP - reduce RR, increase end expiratory lung volume, PEEP up to 7cmH2) with closed mouth, reduced airway surface dehydration, decrease atelectasis, improve secretion clearance, CO2 washout, reduction in anatomical dead space https://www.bjaed.org/article/S2058-5349(17)30029-X/fulltext"

Answer 83

D. Cerebral Abscess HBOT Indications: - air or gas embolism - arterial insufficiencies (central retinal artery occlusion, enhancement of healing in wound problems) - Carbon monoxide poisoning - Clostridium myonecrosis (gas gangrene) - Compromised grafts and flaps - Acute traumatic ischaemia - Decompression sickness - Delayed radiation injuries - Sudden sensorineural hearing loss - Intracranial abscess - Necrotising soft tissue infections - Refractory osteomyelitis - Severe Anaemia - Thermal burns Absolute Contraindications to HBOT: - untreated PTx - Premature Infants - Bleomycin - Disulfiram (antabuse) - Cisplatin Relative contraindications: - Pregnancy - Asthma - Thoracic Surgery - Emphysema with CO2 retention - upper respiratory tract infections - History of middle ear surgery or disorder - History of seizures - Fevers - Congenital spherocytosis - Optic neuritis

Answer 84

" 35 according to new guideline (ANZMOSS 2022) (MBS is recommended for individuals with BMI >35 kg/m2, regardless of presence, absence, or severity of comorbidities and for patients with type 2 diabetes and BMI>30 kg/m2.) https://anzmoss.com.au/ifso-guidelines/ Diabetes Aus guideline 2011 or BMI >35 with co-morbidities secondary to obesity (ie. Poorly controlled diabetes despite lifestyle and optimal medical therapy) BMI 30-35 - can consider bariatric surgery if uncontrolled hyperglycaemia despite optimal medical therapy https://www.diabetesaustralia.com.au/wp-content/uploads/Position-statement-Bariatric-Surgery.pdf "

Answer 85

a. Tricuspid regurg Regurgitant CV waves: tricuspid regurgitation In tricuspid regurgitation, the backflow of blood out of the right ventricle obliterates the normal x descent. The c wave becomes accentuated and fuses with the v wave, as both are the results of right ventricular contraction (and the v wave peak pressure is often the same as the right ventricular peak systolic pressure). the reality is that they usually fuse completely to produce huge mutant waves, as seen here: -------------------------------------- "cardiac tamponade - sawtooth W or M pattern with all pressures raised (can't pump out blood so all pressures elevated) - pulsus parodoxus (>10mmHg fall in sBP with inspiration) - tachycardia - low QRS voltage trace - electrical alternans (alternating high and low QRS complexes) - associated with large pericardial effusion to the extent that the pericardial effusion is associated with tamponade https://derangedphysiology.com/main/required-reading/cardiac-arrest-and-resuscitation/Chapter%20221/cardiac-tamponade Other abnormal CVP trace: AF - loss of a waves (a wave = atrial contraction) Retrograde conduction of ventricular deplarisation (VT, junctional rhythm, ventricular pacing)/ Asynchronous atrial activity (reversal of atrial and ventricular pacing wires, complete heart block) - cannon a waves (fusion of a and c waves) - due to atrial contraction ocurring at the same time as ventricular contraction (so atrium contracting against closed TV with force of this contraction being reflected off the valve --> cannon a wave) TR - fused c and v waves - c wave due to tricuspid cusp protruding into RA. with regurg - loss of x decent due to backflow of blood Tricuspid stenosis / PS / Pulmonary HTN or reduced RV compliance (pericardial disease) - prominent a wave (contraction) Pericardial constriction - bifid CVP waveform (steep and aburpt x and y descent), raised CVP. -- different from cardiac tamponade because y-descent usually prolonged https://derangedphysiology.com/main/cicm-primary-exam/required-reading/cardiovascular-system/Chapter%20784/abnormal-central-venous-pressure-waveform-patterns "

Answer 86

e. Peripheral RICC line, 8.5 Fr RICC > 14g cannula > MLC > Swan sheath > 14G cannula with large volume extension > 16g cannula > 18g cannula > 14g cannula with bung > central line so if want quick infusion, don't use central line and don't put on bung"

Answer 87

b) conscious state No mention of BP or HR in ANZCA OIVI monitoring document In many published reports of patient deaths resulting from OIVI, undue reliance has been placed on respiratory rate as a unidimensional measure of OIVI, either without formal assessment of patient sedation, or without recognising the significance of excessive sedation Respiratory rate and oxygen saturation levels are not direct measures of adequacy of ventilation. Sedation scores should be assessed repeatedly at intervals that are appropriate to the route of opioid administration Continuous measurement of a patient’s carbon dioxide concentrations is more likely to identify OIVI than continuous pulse oximetry

Answer 88

"c) right hypoglossal Deviation to side of LMN lesion as that side has decreased power. Tongue Motor: Vagus (CN10) does palatoglossus; Hypoglossal (CN12) dose all other muscle. Tongue Sensory: Glossopharyngeal (CN9) does taste/sensory posterior 1/3; Lingual (CN5) sensory ant. 2/3; Chordaie tympani (CN7) taste anterior 2/3."

Answer 89

b. 18ml 3mg/kg max dose as per RCH guidelines 3mg x 30kg = 90mg 90mg/5mg/ml = 18ml or 0.6ml/kg of 0.5% Lignocaine 0.6ml x 30kg = 18ml

Answer 90

a) hypoxaemia After LA administration, any abnormal cardiovascular or neurological symptoms and signs, including isolated cardiac arrest, should raise suspicion of LAST Presenting features of LAST vary widely. Cardiovascular collapse may occur without preceding neurological changes. Clinical features of LAST: CNS - 2 stage process of excitatory phase followed by a depressive phase - early signs: 1. perioral tingling 2. tinnitus 3. slurred speech 4. lightheadedness 5. tremor 6. change in mental state: confusion and agitation - excitatory phase culminates in generalised convulsions -Depressive phase: 1. Coma 2. Respiratory depression CVS - 3 phases: - initial phase: Htn and tachycardia - intermediate phase: myocardial depression and hypotension - terminal phase: peripheral vasodialtion severe hypotension arrhythmias: 1. sinus bradycardia 2. conduction blocks 3. VT 4. Asystole

Answer 91

a. Diclofenac LIthium perioperative concerns: - Prolongation of NMB - Reduction in anaesthetic agent requirement - Avoid NSAIDs - No withdrawl symptoms - Discontinue 24hrs before surgery BJA: perioperative advice for psychotropic drugs

Answer 92

b. 0.5% Chlorhexidine/ETOH For skin preparation, 0.5 per cent chlorhexidine in alcohol, where available, is recommended for neuraxial techniques although it should be noted that very small quantities of neuraxial chlorhexidine have been implicated in cases of severe neurotoxicity

Answer 93

f)Cricothyroid Nerve supply of larynx: 1. Superior laryngeal nerve: - Cricothyroid muscle - sensory supply to the interior of larynx down to vocal cords 2. internal laryngeal nerve - 3. Recurrent laryngeal nervs - motor supply to the intrinsic muscles of the larynx apart from cricothyroid - sensory supply to laryngeal mucosa inferior to the cords Intrinsic muscles of the larynx a) Posterior Cricoarytenoid - abducts the cords, opens the glottis - only muscle to open glottis b) Lateral Cricoarytenoid - adducts the cords and closes the glottis c) Interarytenoid - only unpaired muscle - closes the glottis - continues upwards to form the aryepiglottic muscle which acts as a weak sphincter d) Thyroarytenoid - relaxes vocal cords e) Vocalis -adjusts tension in the cords f) Cricothyroid - only intrinsic muscle that lies outside the cartilagenous framework - only tensor of the vocal cords actions of intrinsic laryngeal muscles 1. Abductor of the cords: posterior cricoarytenoids 2. Adductors of the cords: lateral cricoarytenoids, interarytenoids 3. Sphincter to the vestibule: aryepiglottics, thyroepiglotics 4. Tension regulators of the cords: Cricothyroids (tensors), Thyroarytenoids (relaxors), Vocales (fine adjustment)

Answer 94

"b. physical dependance - Presence of withdrawal symptoms. Tolerance - predictable physiological decrease in effect of drug over time (more drug to achieve same effect Abuse - intentional use of opioid for non medical purose, such as euphoria or altering one's state of consciousness Addiction - pattern of continued use with experience of or demonstrated potential for harm. Pain book page 806"

Answer 95

1st a) atorvastatin 2nd c) Digoxin All of the DOACs are avid substrates for the excretory P-gp system of the gastrointestinal epithelial cells, and drugs that inhibit or induce the P-gp system may affect plasma DOAC levels Dabigatran and edoxaban are substrates for P-glycoprotein (P-gp) Apixaban and rivaroxaban are metabolised by cytochrome P450 enzyme CYP3A4 and are substrates for P-gp There is study evidence that among patients taking DOACs for non-valvular atrial fibrillation, concurrent use of amiodarone, fluconazole, rifampicin, and phenytoin compared with the use of DOACs alone, was associated with increased risk of major bleeding It is unlikely that clinically significant interactions occur between dabigatran and other drugs that are merely substrates for P-gp-mediated excretion. When dabigatran was coadministered with digoxin neither digoxin nor dabigatran plasma levels were significantly altered Rivaroxaban and apixaban are metabolised to an extent of 40–50 % in the liver to variable degrees by CYP3A4 and may interact with drugs that inhibit this enzyme. The metabolism of Apixaban and rivaroxaban can be decreased when combined with Atorvastatin which is also metabolised by CYP3A4

Answer 96

Chronic obstructive pulmonary disease (COPD) is the most common cause of cor pulmonale leads to an increase in RV afterload secondary to changes in pulmonary vascular structure and mechanics, and lung hyperinflation. Patients with COPD who subsequently develop RV dysfunction have an increased risk of admission to hospital and mortality

Answer 97

b) atropine Priority is to correct reversible caues of arrest followed by immediate chest re-opening if these measures fail - stop sedative infusions if on any - VF coomon 25-50% of cases - bleeding and tampoande also common (non shockable rhythm usually) CALS (cardiac ALS) 1) Ax rhythm 2) Start BLS 3) emergency re-sternotomy (should happen within 5mins to facilitate interncal cardiac massage or defib at 20J) - VF/VT - DC shock - 3 attempts 150J --> amiodarone 300mg --> continue CPR with single DC shock every 2mins until resternotomy - asystole or severe brady - PACE if wires available (DDD 80bpm, max stimulation threshold) --> external pacing if no wires --> CPR until resternotomy - PEA - if paced, turn off pacing to identify underlying rhythm ---> if VF follow VF path otherwise contiue CPR until resternotomy * ATROPINE not recommended ** Adrenaline to be given by senior clinician in small doses (apparently this is going to be someone like us eventually) https://www.bjaed.org/action/showPdf?pii=S2058-5349%2817%2930182-8

Answer 98

d) pregnancy A third heart sound reflects rapid left ventricular distention along with an increased atrioventricular flow Heard in Congestive heart failure Associated with Dilated Cardiomyopathy with dilated ventricles Less commonly valvular regurgitation and left to right shunts May be normal physiological finding in patients less than 40yrs old

Answer 99

"c) PCA left 70% of stroke in anterior circulation (MCA (90%) > ICA, ACA) PCA stroke - occipital lobe - contralateral homonymous hemianopia , cortical blindness (if bilateral lesions) - medial temporal lobe - deficits in memory, behaviour alteration - thalamic infarct - contralateral sensory loss, aphasia (if dominant side involved), executive dysfunction, memory impairment, decreaed LOC ---- PRESERVED MOTOR ACA stroke - contalateral leg weakness (>arm weakness) and executive dysfunction MCA stroke - contralateral hemiparesis (variable involvement of face/UL/LL) and sensory loss in pattern similar to motor deficit - contralateral homonymous hemianopia - dysarthria - aphasia, aflexia, agraphia, aclaculia, apraxia (if dominant side) - neglet if not dominant side IN SUMMARY - if sensory loss and homonymous hemianopia without motor deficit - PCA https://www.strokenetworkseo.ca/sites/default/files/files/stroke_school_brockville_part_3.pdf"

Answer 100

a. Cholecystitis Example and explanation taken from RACGP: The raised AlP relative to Alt suggests cholestasis and the high GGt confirms liver origin. The mild hyperbilirubinaemia confirms the clinical impression of jaundice. Biliary disease is highly likely with gallstones the most likely differential diagnosis. however, this clinical picture may also occur in drug reactions or infiltrative conditions. After a careful history, abdominal ultrasound is the most appropriate next investigation. ------------------------------------------------------------- Not acute hep C - not significant rise, Not Alcoholic Liver disease - AST not >ALT. Paracetamol OD should mainly affect ALT and coags ALP > 3 x ALT suggest cholestasis picture ^ALT and ^AST suggest hepatocellular injury - >10x upper limit suggest acute severe insult - hepatitis or hypoxia - mildly elevate suggest infection, alcohol, fatty liver or medication AST high - S = shit faced cholestatic picture = ^ GGT and ^ ALP Elevated AST: ALT = 1 --> associated with ischaemia (CCF, ischaemic necrosis, hepatitis) AST: ALT >2.5 --> alcoholic hepatitis, AST: ALT <1 --> high rise in ALT specific for hepatocellular damage - paracetamol OD with hepatocellular necrosis, viral hipatitis, ischaemic necrosis, toxic hepatitis ^ALP - primarily associated with cholestasis and malignant hepatic inflitration (marker of rapid bone turnover and extensive bone mets) ^GGT - sensitive to alcohol ingetsion, marker of hepatocellular damage but non-specific, sharpest rise associated with biliary and hepatic obstruction https://litfl.com/liver-function-tests/ https://www.racgp.org.au/getattachment/36d1c5e0-9c1d-43fc-a8a0-b323e3ed8fbe/Liver-function-tests.aspx"

Answer 101

"a) no difference VA vs TIVA for cardiac surgery NEJM 2019 - multicentre single blinded RCT - specific for elective CABG https://sci-hub.hkvisa.net/10.1056/NEJMoa1816476"

Answer 102

d) myasthenia gravis In contrast to other neuromuscular disorders, succinylcholine may be used in myasthenia gravis. The required dose may need to be increased by up to two-fold, as those with the disease show a relative resistance to the drug. Sux is not recommended in patients with neuromuscular disease due to: 1. presence of extrajunctional receptors and risk of hyperkalaemia and rhabodmyolysis 2. fasiculations causing temperomandibular muscle spasm preventing intubation MS - if significant decreased mobility --> hyperK Neuromuscular disease (dystrophies) - increased sensitivity to NDMB. ethonium / volatiles or cholinesterase inhibitors can induce mytonia - can induce MH or anaesthsia induced rhabdomyoliysis --> hyperkalaemia --> cardiac arrest GBS - also contraindicated as can cause hyperK HypoPP - sux / anticholinesterases and K causes severe muscle stiffnesss "

Answer 103

b) Thumb abduction (flexor pollicis brevis) D. Paraesthesia/sensory loss over medial forearm (medial antebrachial cutaneous) Severing Ulnar nerve alone results in numbness of the 4th (ring) and 5th (little) fingers alone C8 and T1 supply the medial antebrachial cutaneous nerve Muscles weak in C8-T1 radiculopathy but intact in ulnar neuropathy 1. flexor pollicis brevis 2. abductor pollicis brevis 3. opponens pollicis 4. lateral lumbricals AbOF the Law may be useful—the abductor (Ab) and flexor (F) pollicis brevis, opponens pollicis (O), and lateral lumbricals (Law) are “above the law” that intrinsic hand muscles are ulnar-innervated

Answer 104

PG 28 4.2.2.2 Laryngoscopes Reusable laryngoscope blades are considered semi-critical medical devices owing to their contact with the mucous membranes of the oropharynx and require sterilisation or high-level disinfection between uses. Reusable laryngoscope handles are non-critical devices and should be cleaned then undergo low-level disinfection, as a minimum, following use.

Answer 105

a) Brachiocephalic artery Major vessels, most commonly the brachiocephalic artery, traverse the anterior tracheal wall in up to 53% patients at the suprasternal notch

Answer 106

"D Type 1: -Quantitative defect of VWF Type 2: -Qualitative Defect of VWF -Type 2 subclassification depending on plt binding function, F8 binding capcacity, number of high molecular weight VWF multimers Type 3: - complete absence of VWF Treatment: - do not need blood components to control haemorrhage -F8 plasma concentration >100 for major surgery and >50 for minor surgery -DDAVP approved for use in Type 1, no use in type 3, discuss its use with haematology in type 2 due to its variable effect -DDAVP given atleast 90mins before operation -TXA may be useful -VWF/F8 concentrates indicated in severe cases, type 3 and qualitiative defects in VWF -Plt infusions should be considered in persistent bleeding -Cryo has an unpredictable effect, only used if other treatments have failed

Answer 107

a) LUSCS Rates of VAE by surgical procedure: LUSCS: 10%-97% Neurosurgery: Posterior Fossa: 76% Cervical Laminectomy: 7-25% Lateral/Prone Neurosurgery: 15-25 % Total Hip Replacement: 30% Lap Cholecystectomy: 69%

Answer 108

Hunsaker Mon-jet ventilation tube for microlarnygeal surgery Description: -Laser-safe -fluoroplastic -self-centring catheter Uses: -subglottic ventilation during microlaryngeal surgery Components: - proximal end for attaching to jet insufflation system -proximal end allows passage of stylet to aid insertion -Side port at proximal end for monitopring airway pressure and ETCO2 -Outer diameter 4.3mm for maintaining good surgical access -Green basket to keep the centre port at its tip away from tracheal mucosa and avoiding potential damage from jet ventilation

Answer 109

EXCEPT C) RV dilation Echo findings in Aortic Dissection: 1. Intimal flap 2. Type A dissection: - Aortic regurgitation -Acute dilation of aortic root -Aortic leaflet prolapse -Dissection flap prolapse -Pre-existing disease -Pericardial Effusion/Tamponade -RWMA 3. Colour flow doppler -identifies true and false lumen -aortic branch occlusion/dissection RWMAs with possible MI, AR due to involvement of the root pericardial effusion/tamponade severe proximal aortic dilatation intimal flap https://academic.oup.com/ehjcimaging/article/10/1/i31/2465433#41562550"

Answer 110

A. 100mg QID 42mg IV Morphine = 126mg Oral Morphine 126/8= 15.75 15.75 x 25 = 393.75 (*400mg/day Tapentadol) Oral Tapentadol 25mg = 8mg Oral Morphine Oral Oxycodone 5mg = 8mg Oral Morphine Oral Tramadol 25mg = Oral Morphine 5mg Oral Hydromorphone 4mg = Oral Morphine 20mg S/L Buprenorphine 200mcg = 8mg Oral Morphine IV Oxycodone 5mg = Oral Morphine 15mg IV Morphine 5mg = Oral Morphine 15mg IV Hydromorphone 1mg = Oral Morphine 15mg

Answer 111

B. 29 PaCO2= 1.5 x 14 + 8 PaCO2= 21 + 8 PaCO2= 29 Winter’s formula: expected PaCO2 = [1.5 x (serum HCO3)] + [8±2] if PaCO2 lower, there is a concomitant primary respiratory alkalosis if PaCO2 higher, there is a concomitant primary respiratory acidosis

Answer 112

RLL 1.Superior (apical bronchus 6) -> most common site for foreign body or secretions to collect if patient laying flat in bed A PA LM Seed Makes Another Little Palm (R Side) ASIA ALPS (L side) "

21.1 Flashcards

(141 cards)