23.1 Flashcards

Question

23.1 A 75-year-old man has this right heart catheter trace as part of his investigation of dyspnoea. His pulmonary capillary wedge pressure is 24 mmHg. The most likely diagnosis is: A. Idiopathic Pulmonary Arterial Hypertension B. Portopulmonary Syndrome C. Left Heart Failure D. Pulmonary Embolism E. Pulmonary Fibrosis

Answer 1

C. Left heart failure causing PulmHTN Normal PAPs/d is 25/7. This would be classed as severe (55) - (if image is correct) PAWP >15 means ‘ post-capillary’ cause or combined pre- and post. This is either group 2 or 5. A PVR might help differentiate. All other options (group 1,3,4 and 5) would likely have a isolated ‘pre-capillary’ PAWP of <15 LITFL and blue book 2015 article

Answer 2

a) anterior third of the tongue

Answer 3

a) over-expansion https://www.respiratorytherapyzone.com/ventilator-waveforms/#:~:text=Note%3A%20A%20pressure%2Dvolume%20loop,hand%2C%20indicates%20increased%20lung%20compliance.

Answer 4

D. Amitriptyline Amitriptyline (used in low doses for 90 days from onset of the herpes zoster rash) reduces the incidence of postherpetic neuralgia N.B Antiviral agents started within 72 hours of onset of the herpes zoster rash accelerate the resolution of acute pain (U) (Level I) but **do not reduce** the incidence, severity and duration of postherpetic neuralgia UTD Both Gabapentinoids and TCAs are effective at TREATING postherpetic neuralgia. The former have lower risk of discontinuation due to adverse side effects. For moderate or severe pain, use gabapentinoids.

Answer 5

e) hypoglycaemia

Answer 6

A Massive bronchopleural fistula. Nick Chrimes 2022 - Journal of Anaesthesia ‘Preventing unrecognised oesophageal intubation: a consensus guideline from the Project for Universal Management of Airways and international airway societies’ Causes of exhaled carbon dioxide detection despite oesophageal intubation No alveolar ventilation occurring -Prior ingestion of carbonated beverages or antacids -Gastric insufflation of CO2 for upper gastrointestinal endoscopy -Prolonged ventilation with facemask or poorly positioned supraglottic airway before attempting tracheal intubation -Bystander rescue breaths Some alveolar ventilation potentially occurring -Tracheo-oesophageal fistula with tube tip proximal to fistula -Proximal oesophageal intubation with uncuffed tube in a paediatric patient

Answer 7

c. Two sets of pads, <1 second apart For DSED, to avoid possible defibrillator damage caused by shocks applied at the same instant, a short delay (<1 second) between shocks was created by having a single paramedic depress the “shock button” on each defibrillator in rapid sequence (anterior–lateral followed by anterior–posterior) Among patients with refractory ventricular fibrillation, survival to hospital discharge occurred more frequently among those who received DSED or VC defibrillation than among those who received standard defibrillation. https://www.nejm.org/doi/full/10.1056/NEJMoa2207304

Answer 8

e. Hypotension https://www.safetyandquality.gov.au/sites/default/files/2022-06/sepsis_clinical_care_standard_2022.pdf | SIRS criteria: 2 or more Temp >38 or <36 HR >90 RR >20 or PaCo2 <32 WBC

Answer 9

c. inc extracellular fluid https://derangedphysiology.com/main/required-reading/electrolytes-and-fluids/Chapter%20531/hyponatremia-lazy-mans-classification ECF/fluid status differentiates the two ECF = Plasma volume + ISF; Key feature: CSWS - dehydrated w/ high urine output - ↓plasma volume SIADH - euvolaemic (or hypervolaemic) w/ low urine output ->↑ADH in both (appropriately 2o to hypovolaemia in CSWS, inappropriate in SIADH) ∴ -> hyponatraemia and low uric acid level in both https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2912080/#:~:text=The%20key%20differentiation%20is%20that,CSW%2C%20despite%20correction%20of%20hyponatremia"

Answer 10

b. AR https://litfl.com/oesophageal-doppler/

Answer 11

c) 50mmHg Initial Fluid bolus/adrenaline Gr 2: 500mL; 10-20mcg, then 50mcg if no response Gr 3: 1L; 50mcg-100mcg, then 200mcg if no response Gr 4: 2L >3 boluses of adrenaline -> start infusion (can be peripheral) Give 100% FiO2

Answer 12

E. Urine output For adults with sepsis or septic shock, we suggest using dynamic measures to guide fluid resuscitation over physical examination or static parameters alone. Weak recommendation, very low-quality evidence. Remarks: Dynamic parameters include response to a passive leg raise or a fluid bolus, using stroke volume (SV), stroke volume variation (SVV), pulse pressure variation (PPV), or echocardiography, where available. https://journals.lww.com/ccmjournal/Fulltext/2021/11000/Surviving_Sepsis_Campaign__International.21.aspx

Answer 13

a) electrical alternans Physical findings in Tamponade: - A number of findings may be present on physical examination, depending upon the type and severity of cardiac tamponade - None of the findings alone are highly sensitive or specific for the diagnosis. Beck's triad 1. Low arterial blood pressure 2. Dilated neck veins 3. Muffled heart sounds - Are present in only a minority of cases of acute cardiac tamponade. Diagnosis: Clinical diagnosis is usually suspected based on the history and physical examination findings, which may include: ●Chest pain ●Syncope or presyncope ●Dyspnea and tachypnea ●Hypotension ●Tachycardia ●Peripheral edema ●Elevated jugular venous pressure ●Pulsus paradoxus - most common ECG finding is sinus tachy, electrical alternans in severe"" Pulsus alternans = arterial pulse with alternating strong and weak beats. Indicative of severe LV dysfunction (HF, cardiomyopathy) Kussmaul breathing: deep, laboured breathing in MA (DKA)

Answer 14

a) musculocutaneous RT - DCB; Read That Damn Cadaver Book Roots - Interscalene Trunks - Superior trunk Divisions - Supraclav Cords - Infraclav Branches - Axillary""

Answer 15

e) ensure leads securely attached https://journals.lww.com/nursing/Citation/2006/11000/Cables_and_electrodes_can_burn_patients_during_MRI.12.aspx#:~:text=The%20radiofrequency%20fields%20that%20occur,enough%20to%20require%20plastic%20surgery. https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.107.187256#d1e281 bullshit question. the radiographers in MRI had no clue

Answer 16

b. FFP or recombinant ATIII concentrates (better) >600IU/kg heparin = heparin resistance (if cannot achieve ACT >480s) - may be due to ATIII deficiency or ^protein binding of heparin - aquired defiiciency can be due to recent heparin administration Heparin resistance: ACT >480s using 300-400IU/kg; generally up to 600IU/kg acceptable - can be due to AT deficiency (e.g. prior heparin), AT-independent or pseudoresistance"

Answer 17

c) 93% ANZCOR suggests against the routine administration of oxygen in persons with chest pain.13 [2015 COSTR, weak recommendation, very-low certainty evidence] For persons with heart attack, routine use of oxygen is not recommended if the oxygen saturation is >93% [National Heart Foundation of Australia & Cardiac Society of Australia and New Zealand: practice advice]. AHA go with 90%

Answer 18

e. Obstructive w/ reduced FEV1 Mucous narrowing airways = obstructive Parenchymal damage = restrictive Obstructive PFP remains the most common pulmonary function pattern in adult CF and is associated with -decrease FEV1 & FVC/FEV1 For patients with CF, an obstructive pattern is generally seen, with a decrease in forced expiratory volume in 1 s (FEV1), and forced vital capacity (FVC) to FEV1 ratio. https://academic.oup.com/bjaed/article/11/6/204/263786 can have mixed pattern also

Answer 19

b) 4yo 4 yo = wong baker faces score 3-18. 8 yo = Visual analogue scale. https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Pain_assessment_and_measur ement/ APMSE 5 also

Answer 20

c. 200mg hydrocortisone 200mg Hydrocortisone or 25mg Prednisolone Dex:pred:hydrocort conversion 4:25:100 8:50:200"

Answer 21

a) inhalational anaesthesia https://resources.wfsahq.org/atotw/emergence-delirium-in-pediatric-patients/ occurs in 9-18% paeds - eye and ENT surgery at higher risk - higher incidence in preschool 2-5 years old (male), anxious patients, negative behaviour on induction TIVA better than Sevo in decreasing PoD https://academic.oup.com/bja/article/118/3/335/2999642 2017 review"

Answer 22

c) 0, 1, 4, 24 Serum tryptase levels are recommended to be collected as soon as possible after the onset of symptoms and then at 1 hour, 4 hours and after 24 hours. https://www.anzca.edu.au/resources/professional-documents/endorsed-guidelines/anaphylaxis-guideline-2022.pdf

Answer 23

a) saphenous To block foot/ankle completely, need saphenous to complement popliteal sciatic nerve block"

Answer 24

d. Augments Cardiac output in patients with LV failure Airway pressure release ventilation (APRV) is an open-lung mode of invasive mechanical ventilation mode, in which spontaneous breathing is encouraged. APRV uses longer inspiratory times; this results in increased mean airway pressures, which aim to improve oxygenation. Brief releases at a lower pressure facilitate carbon dioxide clearance. The terminology and methods of initiation, titration, and weaning are distinct from other modes of mechanical ventilation. The use of APRV is increasing in the UK despite a current paucity of high-quality evidence high intrathoracic pressure decreases the transmural left ventricular pressure, reducing the work of contraction and increasing cardiac output. In the context of hypoxaemia, a mode of mechanical ventilation that improves arterial oxygenation will improve myocardial oxygen delivery, myocardial function and cardiac output. As APRV is a spontaneous breathing mode, in addition to the benefits of spontaneous ventilation, reduced doses of sedative drugs can often be used, with subsequent reduction of requirement for vasoactive drugs and improvement in haemodynamic state. Airway pressure release ventilation (APRV) is an open-lung mode of invasive mechanical ventilation mode, in which spontaneous breathing is encouraged. APRV uses longer inspiratory times; this results in increased mean airway pressures, which aim to improve oxygenation https://www.bjaed.org/article/S2058-5349(19)30178-7/fulltext https://derangedphysiology.com/main/required-reading/respiratory-medicine-and-ventilation/Chapter%20518/airway-pressure-release-ventilation-aprv-ards

Answer 25

c) DOO The pacing mode will be DOO when the programmed pacing mode is a dual chamber mode, VOO when the programmed pacing mode is a single chamber ventricular mode, and AOO when the programmed pacing mode is a single chamber atrial mode.

Answer 26

a) 10 Paeds: 1-5 mild, 5-10 mod, 10+ severe (i.e. 1+ = OSA); 1 - 5 - 10 https://www.sleepfoundation.org/sleep-apnea/ahi ADULT (note scale always inclusive of lower number); 5 - 15 - 30 normal <5 mild 5-15 moderate 15-30 severe > 30 Apnoea = breathing stop or reduce to 10% of normal levels for 10 secs Hypopnea = airflow decreases by more than 30% for 10 seconds AHI = total apnoea+hypopnoea / total no. of hours asleep"

Answer 27

a) methylene blue "a) methylene blue G6PD deficiency most common enzymatic disorder of RBC --> enzyme G6PD generateds NADPH --> protects RBC from oxidative stress. G6PD deficiency -->haemolytic anaemia https://www.uptodate.com/contents/diagnosis-and-management-of-glucose-6-phosphate-dehydrogenase-g6pd-deficiency?search=G6PD%20deficiency&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H5" Drugs to avoid: Antibiotics Sulphonamides (check with your doctor) Co-trimoxazole (Bactrim, Septrin) Dapsone Chloramphenicol Nitrofurantoin Nalidixic acid Antimalarials Chloroquine Hydroxychloroquine Primaquine Quinine Mepacrine Chemicals Moth balls (naphthalene) Methylene blue Foods Fava beans (also called broad beans) Other drugs Sulphasalazine Methyldopa Large doses of vitamin C Hydralazine Procainamide Quinidine Some anti-cancer drugs

Answer 28

(base rate is 10%, experimental group is 8% (20% below 10%) therefore 100/ 2 = 50 or 1 divided by risk reduction population risk = 10/100 patients get PONV population risk + new antiemetic = 8/100 patients get PONV (8/100 as reduction by 20% with new drug) RR= 0.10-0.08=0.02 NNT= 1/RR =1/0.02 =50

Answer 29

a) case control https://www.cdc.gov/csels/dsepd/ss1978/lesson3/section5.html

Answer 30

a. Drugs that absolutely must not be used for pregnancy. (absolute contraindication) https://www.tga.gov.au/australian-categorisation-system-prescribing-medicines-pregnancy

Answer 31

c. Decreased amplitude, increased latency SSEP used for spine, intracranial, endovascular, carotid surgeries - stimulate peripheral nerves (ulnar/median/posterior tibial) Brainstem auditory evoked potential - post fossa surgery https://www.bjaed.org/article/S2058-5349(19)30019-8/fulltext 2019 BJA intraop neuromonitoring in paed spinal surgery"

Answer 32

a) Cold Saline Irrigation 1st line: Irrigation of the brain with sterile iced saline. 2nd line:Propofol bolus (10 to 20 mg IV) or midazolam (1 to 2 mg IV) to terminate seizure https://www.ncbi.nlm.nih.gov/books/NBK572053/"

Answer 33

b) severe dermatographia ABSOLUTE CONTRAINDICATIONS to skin testing - no healthy skin (at all) - severe dermatographism - hx of severe non-immediate hypersensitivity - erythema multiforme, stevens johnson syndrome, toxic epidermal necrolysis, lucocytoclastic vasculitis, DRESS RELATIVE contraindication: - recent antihistamine use - severe asthma – b-blocker /ACEI (may worsen severe reaction - usually still continued) - should not be carried out on limbs affected by lymphoedema, paralysis, neurogenic abnormalities - pregnancy"

Answer 34

a) turn left lateral "suspect cardiac herniation - turn pt to non-operative side down and then return to OT ASAP https://www.bjaed.org/article/S2058-5349(19)30078-2/fulltext#secsectitle0135 2019 - mortality >50%; can occur in R - acute hypotension, shock, cyanosis, w/ SVC obstruction (chest pain/dyspnoea) PS: chest drains removed for 1min every hour to assess for haemorrhage (if unclamped for prolonged periods -> risk of acute mediastinal shift into empty hemithorax -> circulatory collapse" UTD: Cardiac herniation is usually seen within three days of surgery, presenting as sudden onset of hypotension and shock, cyanosis, chest pain, and superior vena cava syndrome. The acute event is usually preceded immediately by coughing, moving the patient, vomiting, or extubation. Treatment involves emergent surgery to reposition the heart and close the pericardial defect to prevent recurrence. ?bleeding Rapid filling of the PPS with blood can occur within 24 hours of surgery. This complication is more common after pleuropneumonectomy or pneumonectomy for suppurative lung disease. The clinical presentation may be with hypotension and shock due to the loss of intravascular blood volume. The mainstay of treatment is surgical reexploration and control of bleeding sources.

Answer 35

b) vasoplegia Vasoplegia - vasodilatory shock post cardiac bypass - normal or high cardiac output state with low SVR causing organ hypoperfusion - within 24hrs if CI >2.2 AND SVR <800dynes - criteria non specific and found in other diseased states like adrenal insufficiency, sepsis, liver failure - main distintion being aetiology (ie. post bypass - likely vasoplegia, infection - sepsis) - ^ risks of vasoplegia if on ACEI / b-blockers / CCB; also w/ vasodilatory inotropes (e.g. dobumatine, milrinone)"

Answer 36

b) flaccid paralysis Guillain–Barré syndrome (GBS) is an inflammatory disease of the PNS and is the most common cause of acute flaccid paralysis

Answer 37

a. Dysaesthesia Chronic pain that may involve itchiness, burning, electric shock, or a general tightening in any part of the body. Allodynia Pain from stimuli which are not normally painful. The pain may occur other than in the area stimulated. Hyperalgesia is an abnormally increased sensitivity to pain Hyperesthesia is a condition that involves an abnormal increase in sensitivity to stimuli of the sense https://www.iasp-pain.org/resources/terminology/#:~:text=DYSESTHESIA,sen

Answer 38

d. 65 to 85 per hundred Risk of acquiring CMV through a leucodepleted blood product is estimated at around 1 in 13,575,000. This compares to a community acquired risk where 85% of Australian adults are infected by the age of 40. 85% of australians are CMV positive by the age of 40 https://www.blood.gov.au/system/files/documents/cmv-blood-components.pdf CMV negative blood recommended for: pregnant women. May be considered for: transplant recipeints, chemotherapy, intrauterine RBC transfusion, premature or immunocompromised neonates,.

Answer 39

d) diltiazem Nondihydropyridine calcium channel blockers should be used cautiously in patients with HFrEF because of their negative inotropic effects, and the role of these agents in LVAD recipients remains unclear https://www.ahajournals.org/doi/10.1161/CIR.0000000000000673 Should also avoid sotolol Atrial arrythmia mx: - already on anticoagulation of LVAD - rate control: b-blocker (carvedilol, bisoprolol, metoprolol approved for HFrEF) + digoxin ↓hospitalisations -> NON-dihydropyridine CCB usually avoided due to negative inotropy effects (e.g. verapamil, diltiazem) (note amloDIPINE is a dihydropyriDINE) - rhythm control w/ amiodarone, sotalol (caution -ve introopy) - controversial if works. Ventricular arrhythmia: no antiarrhythmic drug better than ICD therapy for survival Amiodarone probably good (but beware SEs) AFlutter: ablation first-line (>95% success rate)"

Answer 40

a) Accurate delivery of volatile concentration from vaporiser PS31 Level two check should be performed at the start of each anaesthetic list. 4.2.3.2 Inhalational anaesthesia delivery devices (vapouriser) 4.2.3.2.1 Ensure electricity is connected to vapourisers that require it. 4.2.3.2.2 Check the anaesthetic liquid level is within marked limits. 4.2.3.2.3 Ensure all filling ports are sealed. 4.2.3.2.4 Check correct seating, locking and interlocking of detachable vapourisers or casettes. 4.2.3.2.5 Test for circuit leaks with a cassette installed or for each vapouriser in the “on” and “off” state. 4.2.3.3 Check for machine leaks upstream from the common gas outlet or breathing system, using a protocol appropriate for the anaesthesia delivery system. One: detailed check (by trained personnel) of all systems (new or after service/repair) Two: at start of every anaesthetic list Three: prior to each pt (all anaesthesia personnel should be trained and accredited for two/three)"

Answer 41

b) diclofenac LIthium perioperative concerns: - Prolongation of NMB - Reduction in anaesthetic agent requirement - Avoid NSAIDs - No withdrawl symptoms - Discontinue 24hrs before surgery NSAIDs differentially alter lithium concentrations by multiple mechanisms, and one of these is to reduce prostaglandin E2 BJA: perioperative advice for psychotropic drugs

Answer 42

a. <110ml leak with cuff deflated approach is to use 110 mL or 10% of tidal volume as the cut-off https://litfl.com/cuff-leak-test/ "Normal cuff leak is >110ml (cuff leak volume = between inspiratory TV pre-deflation and average expiratory TV (after deflation) - average three lowest values over next six breathing cycles post-deflation - if <110mL associated with increased post extubation stridor - >110mL difference in exp TV before and after cuff down has NPV 98% for post extubation stridor (essentially rules it out in original study from 1996) - 2009 meta-analyses: absence of leak -> higher risk airway obstruction presence of a leak -> low predictive value; does NOT rule out obstruction absence of a leak should alert the clinician to a higher risk of upper airway obstruction; however, the presence of a leak has a low predictive value and does not rule out the occurrence of upper airway obstruction 2017 BJA postop mx difficult airway We define a ‘failed CLT’ as the RT being unable to identify air leak during auscultation. 2019 BMJ The positive cuff-leak test can, in a high percentage, predict post-extubation airway obstruction. However, due to its low to moderate sensitivity, a negative test cannot exclude potential complications after the patient has been extubated. GE cuff leak "

Answer 43

b) no limitation in neck movement One of the most commonly used mnemonics is “NSAID” which stands for: N eurological deficit S pinal tenderness A ltered mental status I ntoxication D istracting injury

Answer 44

e) haloperidol Bluebook - suggest antipsychotics with caution Mx - treat underlying cause - infection, pain, dehydration, metabolic derangement, constipation, urinary retention - antipsychotics (e.g. haloperidol 0.5mg-1 PO/IM/IV, quetiapine 25mg PO STAT = preferred w/ PD or demential w/ Lewy bodies) is first line for agitation but does not alter time course of delirium or modify its prognosis - avoid benzo - may worsen symptoms NOF surgery - 70% risk of post op delirium Post-op (usually days 2-5) - non pharm mx - re-orientation, sleep optimisation, mobilisation, nutrition - prophylactic antipsychotic (risperidone, olanzapine), melatonin"

Answer 45

d) loss of pain and temperature Brown Sequard - lateral damage to the cord with ipsilateral loss of motor function, proprioception, light touch and contralateral loss of pain and temperature below level of injury

Answer 46

A. Pecs 1 - between pecs major and pecs minor - blocks lateral and medial pectoral nerves Stenum innervated by interocostal nerves. All 3 options below can be used for sternal fracture PECS 2 - between pecs minor and serratous ant - blocks intercostal brachial, long throacic, intercostal III - VI nerve Subpectoral interfascial plane block - between pec major and interocstal Transverus thoracic plane block = parasternal plane block https://www.asra.com/news-publications/asra-newsletter/newsletter-item/asra-news/2020/05/01/how-i-do-it-transversus-thoracic-plane-and-pecto-intercostal-fascial-block "

Answer 47

C. 3 Appearance - pink > peripherial cyanosis > blue/pale Pulse - >100 > (<100) > absent Grimace - cry/active withdrawal > grimace > no response Activity - active motion (flexed arms/legs resisting extnesion) > some flexion > limp Respiration - strong cry/good breathing > irregular/shallow breathing, weak cry > apnoea "

Answer 48

Category GFR ml/min/1.73 m2 Terms G1 ≥90 Normal or high G2 60-89 Mildly decreased* G3a 45-59 Mildly to moderately decreased G3b 30-44 Moderately to severely decreased G4 15-29 Severely decreased G5 <15 Kidney failure Assign Albuminuria category as follows: Albuminuria categories in CKD Category ACR (mg/g) Terms A1 <30 Normal to mildly increased A2 30-300 Moderately increased* A3 >300 Severely increased** Abbreviations: ACR, albumin-to-creatinine ratio; CKD, chronic kidney disease. *Relative to young adult level. **Including nephrotic syndrome (albumin excretion ACR >2220 mg/g) **Collectively referred to as “CGA Staging” REPEAT

Answer 49

E. distance from anterior surface of dens to posterior surface of anterior arch of atlas The atlantodental interval is used in the diagnosis of atlanto-occipital dissociation injuries and injuries of the atlas and axis. The anterior atlantodental interval is the horizontal distance between the posterior cortex of the anterior arch of the atlas (C1) and the anterior cortex of the dens in the median (midsagittal) plane Normal values for anterior atlantodental interval are: radiographs: adults: males: <3 mm females: <2.5 mm 1 (although most authors describe <3 mm ref) children: <5 mm ref CT: adults: <2 mm Atlantoaxial subluxation ~25% of patients with severe RA - ~80 % ant subluxation (so atlas (C1) moves forward on axis (C2) - due to destruction of transverse ligament (>3mm distance is signficant) - worsened by neck flexion

Answer 50

A. Move medial

Answer 51

d) myasthenia gravis or d) Cerebral palsy ->sux and volatiles are not contraindicated -> presence of extrajunctional receptors may cause hyperkalaemia if responses remembered incorrectly but of this list CP is probably the answer a. Becker muscular dystrophy -> essentially milder Duchenne's (see duchenne response to Sux) b. Cerebral palsy -> Sux and volatiles not contraindicated -> reduced MAC requirement -> increased sensitivity to muscle relaxants c. Guillain Barre -> sux contraindicated due to risk of hyperkalaemia -> increased sensitivity to Non depolarising NB d. Frederich’s ataxia -> sux should be avoided due to risk of hyperkalaemia e. Duchenne muscular dystrophy -> sux and volatiles contraindicated due to rick of hyperkalaemia and rhabdomyolysis 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 REPEAT

Answer 52

B. 7.32 https://emj.bmj.com/content/18/5/340 The values of pH on arterial and venous samples were highly correlated (r=0.92) with an average difference between the samples of −0.4 units. There was also a high level of agreement between the methods with the 95% limits of agreement being −0.11 to +0.04 units. https://litfl.com/vbg-versus-abg/ VBG vs ABG pH + 0.035 PCO2 - mean difference +6mmHg; good correlation in normocapnoea (unreliable when PaCO2>45mmHg) Correlate well: HCO3-, Base Excess, Lactate - dissociation above 2mmol/L https://litfl.com/vbg-versus-abg/ "

Answer 53

D. Substance P Development of aprepitant, the first neurokinin-1 receptor antagonist for the prevention of chemotherapy-induced nausea and vomiting (2011) https://www.ncbi.nlm.nih.gov/pubmed/21434941 Aprepitant acts centrally at NK-1 receptors in vomiting centres within the central nervous system to block their activation by substance P released as an unwanted consequence of chemotherapy. REPEAT

Answer 54

c) 110 Brain trauma foundation Level III recommendation. To decrease mortality and improve outcomes: Maintain SBP at >100mmHg for patients 50 - 69 Maintain SBP at >110 for patients 15 - 49 Maintain SBP at >110 for patients 70 or older

Answer 55

A. AION Answer is more likely ‘A - Anterior Ischaemic Optic Neuropathy, because: 1. Most common 2. One or two days post - up to 12 3. Optic disc oedema (CRAO - fundoscopic appearance is that retina appears pale with cherry red central spot). PION fundoscopy is normal at first but has late developing oedema. It is less common than AION. https://eyewiki.aao.org/Non-Arteritic_Anterior_Ischemic_Optic_Neuropathy_(NAION) Symptoms: The classic description of patients with AION presenting with acute, painless unilateral vision loss that is often described as a blurring or cloudiness of vision, often inferiorly, has been expanded. Although the majority of patients do not have accompanying pain, headache or periocular pain is reported in 8-12% of patients, which can make it difficult to differentiate from optic neuritis 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 56

a. 3 months is the minimum time period for delay (one could argue that a major joint can wait 9 months but they specified minimum) Elective surgery should preferably be delayed for 9 months after a previous stroke; emergency surgery should not be delayed. - <3 months high risk (68-fold increase) cf. 9 months - ↓stroke/MI/death risk at 9 months

Answer 57

C. Between lowest renal artery to bifurcation of aorta https://litfl.com/reboa-in-resuscitation/ Anatomy: The aorta is divided into three separate zones for the purposes of REBOA (aortic length varies between individuals) Zone I of the aorta extends from the origin of the left subclavian artery to the coeliac artery (approx 20cm long in a young adult male) Zone II extends from the coeliac artery to the most caudal renal artery (approx 3cm long) Zone III extends distally from the most caudal renal artery to the aortic bifurcation (approx 10cm long) REBOA location based on injury: >suspected or diagnosed intra-abdominal haemorrhage due to blunt trauma or penetrating torso injuries (Zone I REBOA), or >blunt trauma patients with suspected pelvic fracture and isolated pelvic haemorrhage (Zone III REBOA), or >patients with penetrating injury to the pelvic or groin area with uncontrolled haemorrhage from a junctional vascular injury (iliac or common femoral vessels) (Zone III REBOA) Simplistic rendering of aorta. Zone 1 (from left subclavian artery to the upper border of the celiac trunk), Zone 2 (the upper border of the celiac trunk to the lower border of the distal take-off of the renal arteries), and Zone 3 (from the lower border of the lower renal artery to the aortic bifurcation). Zone 1 is occluded in the case of cardiac arrest or life-threatening intra-abdominal hemorrhage; Zone 2 has no current indication; and Zone 3 is occluded in the case of life-threatening pelvic or lower limb haemorrhage7. REBOA Resuscitative Endovascular Balloon Occlusion of the Aorta.

Answer 58

D. Withholding information to the patient if you think it will cause harm https://www.sciencedirect.com/topics/medicine-and-dentistry/therapeutic-privilege “Therapeutic privilege,” also known as “therapeutic nondisclosure,” is defined as the withholding of relevant health information from the patient if nondisclosure is believed to be in the best interests of the patient (President’s Commission, 1982; Berger, 2005). The two most common justifications for such nondisclosure are that the disclosure would create incapacitating emotional distress and that disclosure would violate a patient’s personal, cultural, or other social requirements (Crawley et al., 2001; Berger, 2005). ANZCA PG 67 - Therapeutic privilege - in an emergency, consent does not need to be obtained for treatment that will save a person's life or prevent sigfnicant harm or distress to the patient. - this applies WHEN patients lack decision-making capacity and their substitute decision maker is unavailable in a reasonable time frame to provide consent. - Advance care directives, where known, can be used to guide treatment."

Answer 59

a) Open repair Flow chart from Blue book https://jamanetwork.com/journals/jamasurgery/fullarticle/1741862 - recommended when injury is recognised >4hrs after cannulation or where no endovascular treatment service available Other options - percutaneous closure device, temporary balloon tamponade with concurrent external mannual pressure or external pressure alone (in palpable artery like common carotid) Current ASA guidelines - leave catheter in place (note all adult CVCs are ≥7 Fr) and contact general or vascular surgeon or interventional radiologist. Postpone elective surgery https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9503793/ 2022"

Answer 60

a) delayed gastric emptying

Answer 61

e. 45ml/hr 0.9% NS 5% dextrose Total fluid requirement = maintenaince + replacement of deficit + replacement of ongoing losses - replace deficit over 24-48hrs (first 5% over 24hrs, then rest over next 24hrs). -> deficit (L) = weight change in kg (most accurate) ->Deficit (mL) = weight (kg) x % dehydration x 10 - ongoing losses replaced over 4hr period (or hourly if significant) Maintenance fluid = 4,2,1 rule (4mL/kg/hr for 1st 10kg, 2mL/kg/hr for 2nd 10kg, then 1mL/kg/hr after that; max 100mL/hr) = 65ml/hr - in all unwell children (acute CNS/pulmonary conditions, post op & trauma) - **2/3 maintenance rate due to ^ADH secretion (risk fluid overload/hyponatraemia)**

Answer 62

B. Cardiac hernation https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.109.896829

Answer 63

a) day of and 2 days prior For surgery/procedures requiring 1 or more days in hospital / colonoscopy requiring bowel prep - omit SGLT2i for at least 3 days (2 days pre-procedure and day of procedure) For day stay procedures (including gastroscopy) that does not require bowel prep - SGLT2i can be stopped just for day of procedure. Limit fasting before/after procedure https://www.diabetessociety.com.au/wp-content/uploads/2023/05/ADS-ADEA-ANZCA-NZSSD_DKA_SGLT2i_Alert_Ver-May-2023.pdf

Answer 64

d) Supraclavicular Axillary nerve innervates skin to inferior deltoid (regimental badge)+ motor to terres minor and deltoid. Lateral pectoral nerve innervates the anterosuperior part of the glenohumeral joint. Subscapular nerves - upper subscapular nerve serves the upper portion of the subscapularis muscle; the middle subscapular nerve (thoracodorsal nerve) innervates latissiumus dorsi; lower subscapular nerve innervates subscapularis and terres major. Supraclavicular nerve - sensory only and innervates skin across entire shoulder and trapezius in a ‘cape-like’ fashion - sometimes missed in interscalene block. Suprascapular nerve sensory innervation to glenohumeral joint and acromiovlavicular joint + motor to supraspinatus/infraspinatous (rotator cuff) https://pubmed.ncbi.nlm.nih.gov/32712453/

Answer 65

A. Aspirin 150mg daily (option was definitely 150mg not 100mg) or D. Ca Aspirin should be given at a dose between 75 and 150 mg per day, started preferably before 16 weeks, possibly taken at night, and continued until delivery; https://www.somanz.org/content/uploads/2023/06/SOMANZ_Hypertension_in_Pregnancy_Guideline_2023.pdf Calcium supplementation (1.5g/day) should therefore be offered to women with moderate to high risk of preeclampsia, particularly those with a low dietary calcium intake (247) - 100-150mg /day for moderate to high risk groups ideally before 16weeks gestation to K36 - NNT 61 Calcium 1.2-1.5g/day in high risk women where there is deficient calcium intake (<600mg/day) Mg, Zinc, salt restriction and antioxidants not supported https://www.health.qld.gov.au/__data/assets/pdf_file/0034/139948/g-hdp.pdf "

Answer 66

c) Foetal RBC All others removed with leukodepletion filter Leucocyte depletion filters are adhesive filters (removes 98-100% bacteria) - removes plasma phase elements of amniotic fluid, AFP (plasma protein in fetus), vernix and squamous cells, but RBCs still present - can cause bradykinin mediated hypotension - removes most cancer cells but not all (no evidence of increased recurrence of metastatic disease) No absolute contraindications to cell salvage. Relative contraindications - potential contamination of aspirated blood with bowel contents, infection or tumor cells (specific consent for latter).

Answer 67

b. Insufficient fludrocortisone replacement In Primary Adrenal Insufficency, cortisol deficiency results in decreased feedback to the HPA axis, leading to increased secretion of ACTH to stimulate the adrenal cortex. Simultaneously, MCs deficiency causes increased release of renin by the juxtaglomerular apparatus of the kidneys.

Answer 68

c. Pain at site 1 month prior to surgery Pain itself is a risk factor: the strongest predictors of CPSP are chronic preoperative pain and the severity of acute postoperative pain https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5741327/#:~:text=Pain%20its CPSP - pain develoing or increasing in intesnity after a surgical procedure, in the area of the surgery, persisting beyond the healing process (~3mths) and not better explained by another rcause such as infection, malignancy or pre-exisiting pain condition.

Answer 69

b) 1 or more RF Risk factors - female (MC), age<50, post-op opioids, hx PONV, non-smoker recommendation from new consensus guideline - 2 forms of prophylaxis for patients with 1-2 risk factors and 3-4 for more risk factors https://www.ashp.org/-/media/assets/policy-guidelines/docs/endorsed-documents/endorsed-documents-fourth-consensus-guidelines-postop-nausea-vomiting.pdf "

Answer 70

D. 4 WFNS (based on GCS) (survival; based on GCS); FND = morbidity I – GCS 15 (70%) II – GCS 13-14 w/o focal neurological deficit (60%) III – GCS 13-14, focal neurological deficit (e.g. hemiparesis, aphasia) (50%) IV – GCS 7-12 (20%) V – GCS 3-6 (10%) * alternatively her Fisher score is: grade 2 (diffuse thin (<1 mm) SAH, no clots; which estimates an incidence of symptomatic vasospasm of 25%) Note the new modified Fischer scale. G0 No SAH or IVH (0%) G1 Focal or diffuse thin SAH but no IVH (6-24%) G2 Focal or diffuse thin SAH with IVH (15-33%) G3 Thick SAH no IVH (33-35%) G4 Thicc SAH with IVH (34-40%) The main differences between the Fisher scale and modified Fisher scale are: 1) Fisher scale, no SAH is grade 1, but 0 in modified Fisher scale 2) Fisher scale, thin SAH & no IVH is grade 2, but 1 in modified Fisher scale 3) Fisher scale, thick SAH with no IVH is grade 3 and the same 3 in modified Fisher scale 4) Fisher scale, any IVH is grade 4, irrespective of the presence of SAH but in modified Fisher scale it is either 2 if thin or no SAH, or grade 4 if thick SAH REPEAT

Answer 71

2-3weeks if asymptomatic PG68(A) If not symptomatic: 2-3 weeks for major surgery. No delay if minor surgery (must be beyond infectious period as per local guidelines) If symptomatic: delay 7 weeks for major surgery clock starts from first symptoms or first positive test For most patients, it is safe to proceed with surgery TWO TO THREE WEEKS post SARS-CoV-2 infection provided no ongoing symptoms are present. For high-risk patients, it is recommended to perform an individualised risk assessment and utilise Shared Decision Making to determine optimal timing of surgery post SARS-CoV-2 infection. Patients who are asymptomatic, have returned back to baseline, are vaccinated, aged <70 years and without comorbidity can proceed with non-urgent elective minor surgery (day case) and endoscopy procedures without delay beyond the infectious period (timeframe as per local guideline and expertise ALL patient with ongoing symptoms, especially those who have not returned to baseline function and those patients with a history of moderate or more severe25 SARS-CoV-2 infection: recommended delay for non-urgent elective surgery is still 7 weeks

Answer 72

c. sinus tachy with prolonged QRS TCA overdose - toxicity develops 30mins post overdose, peaks 2-6hrs post. - 4 receptors antagonsim invovled - central and peripheral Ach receptors, alpha adrenergic receptors, norad and srototnin reuptake, fast sodium channels in myocardial cells - anticholinergic symptoms - agitation, restless, delirium, mydriasis (big pupils), warm skin, tachycardia, ileus, urinary retention (SLUDGE) - CVS toxicity - tachycardia, arrythmia, HTN, Hypotension (due to alpha blockade), broad complex tachy but can also develop bradycardia pre arrest) - CNS toxcicity - delirium, agitation, sedation, seizures, coma (often precedes CVS signs) - metabolic acidosis https://litfl.com/another-tca-overdose/"

Answer 73

a) NT ProBNP Sacubitrilat inhibits the enzyme neprilysin, which is responsible for the degradation of atrial and brain natriuretic peptide, two blood pressure–lowering peptides that work mainly by reducing blood volume. In contrast, in comparison with enalapril, patients receiving LCZ696 had consistently lower levels of NTproBNP (reflecting reduced cardiac wall stress) and troponin (reflecting reduced cardiac injury) throughout the trial. ## Footnote https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.114.013748?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed

Answer 74

c. dobutamine - causes dose dependent vasodilation --> hypotension Vasodilatory shock - norad, vasopressin, methylene blue, angiotensin II, vitamin C, hydroxycobalamin (vit B12) (UpToDate) - norad, adrenaline, dopamine, terlipressin, angiotensin II, methylene blue (BJA) https://docs.google.com/document/d/1aIYS372hPVynvKXATrMBakn4T43vi2OoWqW-Vi4cjKw/edit?usp=sharing " ## Footnote UTD

Answer 75

a. Normal - Normal A normal or high oximetry reading should be disregarded because saturation monitors cannot differentiate between carboxyhaemoglobin and oxyhaemoglobin, owing to their similar absorbances. The blood gas PO2 will also be normal in these cases (despite the presence of tissue hypoxia). SpO2 (pulse ox can't differentiate COHb and OxyHb) -> SpO2 not useful PaO2 (PaO2 reflects dissolved O2 in blood - not affected by CO) - only SaO2 (Hb-bound O2) is reduced (in presence of CO binding) https://www.uptodate.com/contents/carbon-monoxide-poisoning#:~:text=Diagnosis%20–%20The%20diagnosis%20of%20CO,in%20smokers%20confirms%20the%20diagnosis. " ## Footnote file:///Users/newuser/Downloads/BTS%20Guideline%20for%20oxygen%20use%20in%20adults%20in%20healthcare%20and%20emergency%20settings.pdf

Answer 76

A. Lupus anticoagulant (normal PT, raised APTT) Lupus anticoagulant (more likely to be associated with thrombosis than bleeding) "Lupus anticoagulant (i.e. antiphospholipid syndrome) - cause prolonged APTT, and is associated w/ thrombosis. BJA 2007 - Abs that block phospholipids important for coagulation Haemophilia A (VIII deficiency) and B can cause isolated prolonged APTT, but associated with bleeding (repeat MCQ 2017B – guy with dental bleeding). Cold agglutinins prolongs PT and APTT -> (IgM autoantiboidies against RBC antigens that bind at cold temperature --> haemolytic anaemia) Factor VII deficiency prolongs PTs w/ normal APTT " ## Footnote https://www.uptodate.com/contents/image?imageKey=HEME%2F79969

Answer 77

b. high HDL-C 3 or more of: (5 H's) 1) Heavy: central obesity: waist >94cm men, >80cm women 2) HTN (>140/90) 3) High levels of triglycerides 4) HDL - low levels 5) High blood surgar (impaired fasting glucose or diabetes)" ## Footnote https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.105.169405

Answer 78

a. medial cutanous brachial nerve C8/T1 roots are often missed. Therefore, interscalene blocks tend to fail on the ulnar side of the arm Medial brachial cutaneous nerve (C8-T1, arises from the medial cord of the brachial plexus): upper medial arm ## Footnote NYSORA

Answer 79

D. Albumin MELD-Na score components: (BICS) Bilirubin INR Creatinine Sodium (serum) Low serum sodium is an independent predictor of mortality in patients with cirrhosis estimates 90 day survival >15 - listed for deceased donor transplant. TIPS best if MELD <15" ## Footnote https://www.tamingthesru.com/blog/r1-diagnostics/labs-in-hepatic-failure

Answer 80

"d) lateral antebrachila cutaneous N (continuation of musculocutaenous nerve) tracks behind cephalic vein in upper forarm and provides cutaneous innervation to forearm"

Answer 81

d) 120s Optimal seizure duration somewhere between 10-120seconds. https://academic.oup.com/bjaed/article/10/6/192/299664 Apparently Oxford Handbook says 60 secs (MCQ TL) ""It is recommended that motor and/or EEG seizures lasting more than 120 seconds be terminated pharmacologically by a benzodiazepine (for example, diazepam or midazolam) or anaesthetic agent in consultation with the anaesthetist."" QLD Health ECT guidelines"

Answer 82

Dopamine - least likely to cause pulmonary vasodilation (all the others do to my knowledge) - From UP TO DATE: > At low doses of 1 to 3 mcg/kg per min, dopamine acts primarily on dopamine-1 receptors to dilate the renal and mesenteric artery beds > At 3 to 10 mcg/kg per min (and perhaps also at lower doses), dopamine also stimulates beta-1 adrenergic receptors and increases cardiac output, predominantly by increasing stroke volume with variable effects on heart rate. > At medium-to-high doses, dopamine also stimulates alpha-adrenergic receptors, although a small study suggested that renal arterial vasodilation and improvement in cardiac output may persist as the dopamine dose is titrated up to 10 mcg/kg per min *clinically, the haemodynamic effects of dopamine demonstrate individual variability Dobutamine (inodilator): - selective β1-agonist that increases cardiac contractility and reduces pulmonary vascular and systemic vascular resistances Vasopressin: - vasopressin may have pulmonary vasodilatory effects in addition to a systemic vasoconstrictive effect Milrinone (inodilator): - the phosphodiesterase-3 inhibitors, milrinone and enxoimone, have positive inotropic effects combined with the capacity to reduce RV afterload (‘inodilators’) without significant chronotropic effect, but they can be associated with significant systemic hypotension ## Footnote https://pubs.asahq.org/anesthesiology/article/121/5/914/13855/VasopressinThe-Perioperative-Gift-that-Keeps-on

Answer 83

C. 3 lap chole, insulin, stroke Not originally specified as open verse lap. One of the big critiques of the RCRI. https://www.bjaed.org/article/S2058-5349(18)30128-8/fulltext ## Footnote UTD

Answer 84

C. Cryoprecipitate contains Factor VIII, XIII, fibrinogen (factor I), fibronectin, vWF Cryo - volume 10-20mL - fibrinogen (i.e. Factor I, 150-250mg) , F VIII, vWF, fibronectin, FXIII -> Cryo -> think VolksWagen (lucky unlucky one) - vWF, fibronectin - eight, thirteen, one). - not used to replace factors as factor concentrates and recombinant products are safer and better FFP - volume 250-300mL - fibrinogen (700-800mg) - all coag factors including II, VII, VIII, IX, X, XI, vWF" ## Footnote https://www.lifeblood.com.au/health-professionals/products/blood-components/cryoprecipitate

Answer 85

a) 15 mins 50UI/kg, Prothrombinex-VF is able to completely reverse a supratherapeutic INR within 15 minutes however, vitamin K is also required to sustain the reversal effect as the half-lives of the infused clotting factors are similar to endogenous factors. ## Footnote https://www.mja.com.au/journal/2013/198/4/update-consensus-guidelines-warfarin-reversal#:~:text=Prothrombinex%2DVF%20is%20able%20to,similar%20to%20endogenous%20clotting%20factors.

Answer 86

Longer length Different cuff size/ length: The MLT® has a cuff size/ length that would be typical for an adult-sized 'standard' ETT. A 'standard' pediatric 5.0 endotracheal tube has a smaller cuff made for a pediatric-sized trachea (see picture below). Distance of cuff from tube tip: In an MLT® the cuff is further away from the tube tip which is acceptable as the adult trachea is obviously longer than the pediatric one (see picture below). - same diameters and larger cuff size (i.e. 5.0 MLT cuff would be typical for adult-sized standard ETT) - MLT cuff further away from tube tip - size of tube is internal diameter MLT = Massively Long Tube - for vocal cord surgery - beware high AWR -> high airway pressures - gas flow slow in expiration -> may need lower I:E ratio for complete expiration" ## Footnote https://aam.ucsf.edu/microlaryngoscopy-tube-mlt%C2%AE

Answer 87

d. pregnancy "S3 at apex normal in children, pregnant females, well trained athletes, but disappears before middle age. Can also be systolic heart failure (if re-emerges later in life) - during passive ↑LV filling (when blood strikes compliant LV) 'ventricular gallop' - can be severe MR/TR https://www.healio.com/cardiology/learn-the-heart/cardiology-review/topic-reviews/s3-heart-sound "

Answer 88

d. 54 Ex-preterm infants at risk of post-operative apnoea should not be considered for same day discharge unless they are medically fit and have reached a postmenstrual age of 54 weeks. Term infants should not be considered for same day discharge unless they are medically fit and have reached a postmenstrual age of 46 weeks.d) 54 weeks ## Footnote https://www.anzca.edu.au/getattachment/568bad2d-7517-4eea-9c5d-cb7aa1c60

Answer 89

B. Aphasia All can happen in pts with MS but aphasia is less common (more commonly associated with disease of grey matter) - only a handful of case reports in literature https://jamanetwork.com/journals/jamaneurology/fullarticle/777200 " ## Footnote UTD

Answer 90

c) 20mmHg Intra-abdominal hypertension is defined as a sustained intra-abdominal pressure of >12 mm Hg, and abdominal compartment syndrome occurs at a pressure >20 mm Hg in association with new organ dysfunction. Intra-abdominal hypertension is graded as follows: Grade 1=12–15 mm Hg; Grade 2=16–20 mm Hg; Grade 3=21–25 mm Hg; and Grade 4 >25 mm Hg. ## Footnote https://academic.oup.com/bjaed/article/12/3/110/258792

Answer 91

B. distal to LSCA The appropriate performance of the IABP is dependent on proper position. Ideally, the tip of the balloon should be positioned 2–3 cm distal to the origin of the left subclavian artery (LSCA) https://radiopaedia.org/articles/intra-aortic-balloon-pump - femoral artery sheath extends to proximal descending aorta ~1cm below subclavian artery -> if left radialpulse lost -> balloon is too high - radio-opaque tip lies in 2nd intercostal space just above left main bronchus -> lower end of balloon cephalad to renal arteries" ## Footnote https://academic.oup.com/bja/article/110/2/316/228037

Answer 92

E. Upper GI bleed Incompressible sites, large volume blood loss and mortality risk are a few of the things that made GI bleeds seem like a natural fit for TXA administration. Early research seemed promising, but trials were small. The HALT-IT trial examined over 15,000 patients to see if TXA reduced death [14]. Not only did TXA have no effect on mortality, it increased the risk of seizure and thromboembolic events. Take home: No demonstrated benefit with TXA in GI bleeding ## Footnote https://www.ems1.com/research-reviews/articles/understanding-txa-AFkqRLajUv46X7xV/

Answer 93

c) inf alveolar The conventional inferior alveolar nerve block is the most commonly used nerve block technique in dentistry The nerves anesthetized are the inferior alveolar, incisor, mental, and lingual nerves. The mandibular teeth to the midline, the body of the mandible, the lower part of the mandibular ramus, buccal periosteum and mucous membrane to the premolars, anterior 2/3 of the tongue, oral floor, lingual soft tissue, and the periosteum are all anesthetized Mental nerve is terminal branch of inf alveolar and exits mental foramen - innervates skin over lower lip and chin region ## Footnote https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6218392/

Answer 94

"50J UK resus - defib Internal defib requires less energy. Biphasic more effective than monophasic. For biphasic shocks, use 10- 20 J, delivered directly to the myocardium through internal paddles. Monophasic shocks require approximately double these energy levels. Do not exceed 50 J when using internal defibrillation - failure to defibrillate at these energy levels requires myocardial optimisation before defibrillation is attempted again. Energy selection is automatically limited to a range of 2—50 joules when internal paddles are connected. Stryker PDI Make sure the maximum energy available is 50 Joules. Product PDI " ## Footnote https://www.ncbi.nlm.nih.gov/books/NBK499899/

Answer 95

Pre-ductal -> right "d) Right hand/wrist (pre-ductal): avoids right to left shunt of ductus arteriosus - reliable 90 secs after birth Post-ductal = either foot (preductal higher immediately after birth) Time after birth (mins) / targets: 1 / 60-70% 2 / 65 - 85% 3 / 70-90% 4 / 75-90% 5 / 80-90% 10 / 85-90%"

Answer 96

A A - Alcohol is a common cause of macrocytosis and macrocytic anemia. (UpToDate) B - No - normally nomrocytic chronic disease anaemia C - No - microcytic D - I can't find anything on macrocytosis with thyrotoxicosis, but hypothyroidism definitely does E - Possibly.... https://hemonc.mhmedical.com/content.aspx?bookid=1783§ionid=121720217 Causes of macrocytic anaemia: (lacking vit/B12, Thyroid/BM function, liver from alcohol) Vitamin B12 deficiency, folate deficiency Liver disease (↑cholesterol/phospholipids deposit on RBC -> ↑size), alcoholism Hypothyroidism Myelodysplastic disease Medication - for cancer, seizure, autoimmune disorrder ↑ RBC production to correct anaemia post blood loss "

Answer 97

B - prevention of electrocution. BJA Education

Answer 98

A The situation in adults is straightforward: there is convincing evidence that propofol is safe in patients who are allergic to peanut and/or soy and/or egg. BJA Ed https://academic.oup.com/bja/article/116/1/11/2566111 safe in egg anaphlaxis (and soy/peanuts). Shellfish/contrast allergy no ↑risk to povidone iodine ""Current literature supports the administration of propofol in patients allergic to egg, soy and peanuts. Patients with shellfish allergy or allergy to contrast material have the same risk of allergy to povidone iodine as the general population"". ANZCA 2021 bulletin Risk of anaphylaxis 1:10 000"

Answer 99

A Apnea is defined as the cessation of airflow for ten or more seconds. Hypopnea is defined as a recognizable, transient reduction, but not a complete cessation of, breathing for ten or more seconds. Hypopnea requires a 4% fall in SpO2 https://www.ncbi.nlm.nih.gov/books/NBK441909/#:~:text=Obstructive%20Sleep%20Apnea%20(OSA)%2C,for%20ten%20or%20more%20seconds.

Answer 100

C. Foetal neuroprotection (Mg infusion for 4g over 20 mins, then 1g/hr for 24hrs - further 2g over 5 mins if seizure during load) <30 weeks GA = fetal neuroprotection https://www.bjaed.org/article/S2058-5349(20)30114-1/fulltext 2020 BJA on pre-eclampsia https://www.health.qld.gov.au/__data/assets/pdf_file/0034/139948/g-hdp.pdf " https://www.kemh.health.wa.gov.au/~/media/HSPs/NMHS/Hospitals/WNHS/Documents/Clinical-guidelines/Obs-Gyn-Guidelines/Preterm-Labour-Magnesium-Sulphate-for-Neuroprotection-of-the-Fetus.pdf?thn=0#:~:text=MgSO4%20is%20only%20given%20to,4%20hours%20prior%20to%20delivery.

Answer 101

"d) paracetamol, ibuprofen, tramadol PRN PROSPECT guideline - Paracetamol + NSAIDS (pre op, intraop and postop) - single dose IV dexamethasone (For pain and antiemetic) - note ↑risk of reoperation but not ↑risk of bleeding - opioids for rescue in post op - preop gabapentinoids or intra op (peritonsillar) ketamine (for children) or intraop dexmed when basic analgesia contraindicated - adjuncts - dextramorphan, magnesium, acupuncture, honey - both work https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/full/10.1111/anae.15299 " "DO NOT use codeine after andenotonsillectomy due to risk of apnoea/death (ANZCA pain) Note ibuprofen may ↑severity of haemorrhage post tonsillectomy Aspirin/ketorlac ↑risk of reop in adults, but not children Celecoxib optimal (selective) Note giving peritonsillar ketamine/tramadol or parenterally were similar in Pain Book"

Answer 102

B. 20% 25% (a few studies have higher ranges but typically around 20-25%) https://doi.org/10.1192/bjp.bp.115.165498 Oral - 20% Subling - 30% IN - 40-50% IM - 93%

Answer 103

C) Cease clopidogrel for 5 days, continue aspirin WFSA update document https://resources.wfsahq.org/wp-content/uploads/uia29-Perioperative-management-of-patients-with-coronary-stents-for-non-cardiac-surgery.pdf "b) cease clopidogrel for 5 days (high risk), continue aspirin 2016 AHA 1) Elective noncardiac surgery should be delayed 30 days after BMS implantation and optimally 6 months after DES implantation - if P2Y12 needs to stop, can consider surgery 3 months after DES if risk of further delay > risk of stent thrombosis -> Do NOT perform surgery <3 months post DES 1st year DES = riskiest; 1% risk after 6 mths of adverse cardiac events 2) If pts on DAPT (post PCI), and P2Y12 needs to stop -> continue with aspirin -> Spanish (European) guidelines say switch clopidogrel only to aspirin 2023 CHEST (see top right) - Elective surgery, DAPT for Stents within last 3-12 months, stop P2Y12 inhibitor (without bridging) "

Answer 104

A. Inhalational anesthesia or b. Clonidine Prospect: two studies focused on tonsillectomy, and those did not show any additional analgesic effect of clonidine when used on top of adequate baseline medication after tonsillectomy. PROSPECT https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.15299#:~:text=The%20basic%20analgesic%20regimen%20should,analgesic%20and%20anti%2Demetic%20effects.

Answer 105

d. Hyalase/hyaluronidase reaction/allergy https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4850816/ " retrobulbar haemorrhage - will have ^IOP and decreased VA https://pubmed.ncbi.nlm.nih.gov/16362314/ 12-72hrs post cataract surgery: - axial proptosis, - periorbital erythema with swelling. Periorbital pain/itch - extraocular muscle (EOM) function restriction (5/5) - conjunctival chemosis (4/5). Retrobulbar haemorrhage: 2-3 hrs severe orbitalpain, periorbital ecchymosis, eyelid hematoma, ophthalmoplegia, proptosis, subconjunctival hemorrhage. Visual loss and RAPD +ve in orbital compartment syndrome Periorbital cellulitis = infection of eyelid and surrounding skin (swelling/pain/erythema)"

Answer 106

E Can't remember if this was the exact ECG but it had LAD

Answer 107

D - AB Group AB plasma or group A plasma that is high-titre negative can be given in an emergency when the blood group is unknown. Group AB plasma is universal but in short supply. Our guidelines say type A is appropriate as type AB is very rare. In neonates, infants under 1 use group AB. FFP - volume 250-300mL - fibrinogen (700-800mg) - all coag factors including II, VII, VIII, IX, X, XI, vWF - Deranged: preferably ABO-typed, as donor plasma may contain anti-ABO antibodies. Crossmatch/RhD not necessary"

Answer 108

E - SSRIs ANZCA PG12 Background Paper

Answer 109

Cefazolin A first-generation cephalosporin is recommended, such as 2g intravenous cefazolin. The dose should be increased to 3g for women weighing over 120kg. Consideration should also be given to a repeat dose if the procedure is prolonged (over 3 hours). * For women with a history of immediate or delayed nonsevere hypersensitivity to penicillins, cefazolin, as above, remains appropriate. * For women with a history of immediate or delayed severe hypersensitivity to penicillins, use Clindamycin 600mg iv plus Gentamicin 2mg/kg iv. * For women colonised with Methicillin-resistant Staphylococcus aureas (MRSA) or at increased risk of being colonised with MRSA, add Vancomycin 15mg/kg iv. * Azithromycin may be considered at caesarean sections performed during labour or at least four hours after rupture of membranes (2). Administration of azithromycin 500mg has been shown to reduce a composite outcome of endometritis, wound infection or other infection (3). However, a strong recommendation in favour of routine use is not yet warranted given the concerns around the external validity of the paper, inducing resistance to azithromycin and possible effects on the establishment of the indigenous microbiome. According to MSH guidelines - alternate therapy If severe hypersensitivity - Teicoplanin 400mg IV (800mg if >80kg) + tobramycin 2mg/kg IV Lincomycin 600mg in practice"

Answer 110

"a) c/s rate Epidural does not affect c/s rate (with either type of epidural, compared to those without) Assoc/ decrease in instrumental deliveries in nulliparous females with intermittent bolus with no difference in C-section rate Lower concentration LA decreased rate of instrumental delivery (w/ less motor blockade & improved fetal outcomes) with similar levels of analgesia ANZCA blue book 2021 pg 195 PCEA vs continuous epidural infusion: - Decreased motor blockade - decreased total LA consumption - decreased workload - similar obstetric outcomes and analgesia

Answer 111

repeat a) Less transfusion, same thrombosis 2020 Cochrane review: Moderate-quality evidence suggests that preoperative rHuEPO + iron therapy for anaemic adults prior to non-cardiac surgery reduces the need for RBC transfusion and, when given at higher doses, increases the haemoglobin concentration preoperatively. The administration of rHuEPO + iron treatment did not decrease the mean number of units of RBC transfused per patient. There were no important differences in the risk of adverse events or mortality within 30 days, nor in length of hospital stay. Further, well-designed, adequately powered RCTs are required to estimate the impact of this combined treatment more precisely. https://www.cochrane.org/evidence/CD012451_use-erythropoietin-plus-iron-correct-anaemia-surgery-reduce-risk-blood-transfusion

Answer 112

a. Reduced Myoglobinaemia Repeat but its not myoglobinuria it was myoglobinaemia - There is NOT reduced myoglobinuria with AIR compared to MH (both have myoglobinuria) - There IS less increase in ETCO2 - There IS less muscle rigidity

Answer 113

"d) rocuronium (as severe) - diazepam if mild #Hyperthermia in SS - mostly mediated by muscle hyperactivity - paracetamol, dantrolene ineffective - mild: topical cooling and benzos to ↓muscle activity - severe (>41.1 degrees) -> rhabdo, metabolic acidosis, DIC -> Rx = sedation, NDMB necessary (avoid suxamethonium due to hyperkalaemia) https://www.medsafe.govt.nz/profs/PUArticles/Dec2012Neuroleptic.htm#:~:text=However%2C%20NMS%20is%20characterised%20by,are%20indicative%20of%20serotonin%20syndrome "#Agitation/anxiety -> benzos #Autonomic instability - IV fluids for hypotension (helps with rhabdo as well) +/- direct acting (phenyl/norad/Adr) - HTN/Tachycardia -> esmolol and GTN (short-acting as unpredictable); dexmedetomidine also an option -> avoid hydralazine (inhibits MAO) and indirect (e.g. ephedrine, dopamine) -> unpredictable) Consider cyproheptadine (H1 antagonist) -> helps w/ symptoms and in severe presentations Algorithm on right from BJA 2020 https://www.bjaed.org/article/S2058-5349(19)30153-2/fulltext "

Answer 114

A. High frequency

Answer 115

* D. perindopril isolated hypotension is rare - most likely due to excess bradykinin, especially when bradykinin metabolism is inhibited (eg. In patients on ACEi) https://www.lifeblood.com.au/health-professionals/clinical-practice/adverse-events/hypotension " Acute hypotensive transfusion reaction (AHTR) is characterized by the abrupt onset of hypotension immediately after the start of transfusion and usually resolves when transfusion ceases. Recent studies have shown an association with pre-operative treatment with an angiotensin-converting enzyme (ACE) inhibitor https://www.lifeblood.com.au/health-professionals/clinical-practice/adverse-events/hypotension

23.1 Flashcards

(144 cards)