25.2 Flashcards

Question

What is the lowest figure at which pulse pressure variation suggests fluid responsiveness? a) 8% b) 13% c) 5% d) 20%

Answer 1

13% Pulse pressure (difference between systolic and diastolic pressure) is directly proportional to LV stroke volume and inversely related to arterial compliance. The respiratory changes seen in LV stroke volume determine changes in the peripheral pulse pressure during the respiratory cycle Pulse pressure variation (PPV) can be expressed as a percentage using the equation PPV (%) = (PPmax − PPmin)/PPmean. Measurement of PPV can be used to predict preload non-responders in those with a PPV <13%. Also, high baseline PPV values correlate well with subsequent increase in cardiac index. In addition, the decrease in PPV after fluid therapy correlates well with the resulting increase in cardiac index. As PPV is also subject to arterial compliance, in theory patients with reduced arterial compliance (e.g. elderly patients with peripheral vascular disease), there may be a big change in pulse pressure for only a small change in LV stroke volume. BJA

Answer 2

Same as aortic stenosis: crescendo decrescendo

Answer 3

a. reduced splanchnic blood flow Octreotide acts on splanchnic blood flow by causing vasoconstriction via inhibition of nitric oxide synthesis and inhibition of glucagon release, both of which cause splanchnic vasodilation The resulting fall in splanchnic blood flow is felt to be responsible for reducing portal pressures and thereby reducing variceal bleeding as a bridge to more definitive therapy.

Answer 4

c. 30 Start at peak inspiratory pressure (PIP) of 30 cm H2O for a term neonate (20-25 cm H2O preterm neonate) and positive end expiratory pressure (PEEP) of 5 cm H2O at 40-60 breaths/minute https://www.seslhd.health.nsw.gov.au/sites/default/files/documents/Neoresusdelivery20.pdf

Answer 5

"b) thumb abduction Ulnar nerve orginate from C8/T1 Median nerve originate C5-T1 Ulnar nerve innervates: (essentially all of pinky and also adduct and flex thumb) hand muscles: ADDuctor pollicis, deep head of flexor pollics, Opponens digiti minimi and abductor digiti minii and flexor digitiminimi, 3rd and 4th lumbricals Median nerve innervates: (all of thumb action except for adduction) hand muscles: 1st and 2nd lumbricals, Oppones pollicis, abductor pollicis, flexor pollicis brevis Radial nerve - extensors of hand "

Answer 6

Unstable angina

Answer 7

Upper GI bleed "Glasgow-Blatchford Bleeding Score (GBS) Stratifies upper GI bleeding patients who are ""low-risk"" and candidates for outpatient management."

Answer 8

2Kgs Neonate/infant/small paed/larg paed/ small-med-large adult 1: 2-5kg 1.5: 5-12kg 2: 10-25kg 2.5: 25-35kg 3: 30-60kg 4: 50-90kg 5: 90+kg "

Answer 9

https://radiopaedia.org/cases/implantable-loop-recorder-device was photo

Answer 10

Coronary Sinus + RA and RV leads + https://www.bjaed.org/article/S2058-5349%2817%2930025-2/fulltext similar to fig

Answer 11

b) Comparison between 2 or more means

Answer 12

Mechanism, Injury, Signs, Treatment - investigations/symptoms in there as decoys

Answer 13

2018 BJA emergence delirium lists MALE as RF. I think N2O is answer for what is NOT a risk factor. Child "temperament" is risk factor so ASD likely contributes. 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" "A slow washout with nitrous oxide after a sevoflurane anaesthetic has also been shown to decrease EA"

Answer 14

30min as per PS03

Answer 15

d) reduced morphine requirements Vitamin C reduces postoperative opioid requirements (N) (Level I [PRISMA] and postoperative pain compared to placebo (N) (Level IV SR [PRISMA]). APMSE

Answer 16

a) probably sural

Answer 17

a) anterior Anterior compartment - dorsiflexion of foot and ankle Lateral compartment.- plantarflexion and eversion of foot Deep posterior compartment - plantarflexion and inversion of foot Superficial posterior compartment - plantarflexion https://www.orthobullets.com/trauma/1001/leg-compartment-syndrome

Answer 18

Confounder

Answer 19

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 "

Answer 20

4-10 days DCI - The occurrence of focal neurological impairment … or a decrease of at least 2 points on the Glasgow Coma Scale … This should last for at least 1 hour, is not apparent immediately after aneurysm occlusion, and cannot be attributed to other causes by means of clinical assessment, CT or MRI scanning of the brain, and appropriate laboratory studies. DCI affects approximately 30% of patients who survive the initial hemorrhage. Prophylactic treatment, such as nimodipine, is typically started at admission and continued for 21 days to cover this high-risk period. cause unknown but vasospasm contributes to

Answer 21

https://www.ahajournals.org/doi/10.1161/strokeaha.110.602888 Coil within 24hrs Treatment of ruptured aneurysms within 24 hours is associated with improved clinical outcomes compared with treatment at >24 hours. The benefit is more pronounced for coiling than clipping.

Answer 22

e. Tetralogy of fallot Occurs with prada willi, DMD, DS https://pmc.ncbi.nlm.nih.gov/articles/PMC4454627/ and with Spina Bifida https://thorax.bmj.com/content/71/Suppl_3/A184.1

Answer 23

Plasma https://esmed.org/citrate-toxicity-and-hypocalcemia-in-massive-transfusion/#:~:text=Table_title:%20Citrate%20content%20in%20blood%20products%20Table_content:,%7C%20Estimated%20citrate%20content%20(mmol):%201.49%20%7C Highest content Whole blood > FFP whole blood > Platelets > FFP apapharesis > pRBC apapharesis >cryo > pRBC (whole blood) FFP Plasma products and Platelets have higher Citrate than PRBC (as PRBC recons. In SAGM) When donated, whole blood has CPD added (26g/L citrate), plt apheresis has ACD added (22g/L citrate) and Plasma apheresis has straight citrate at 40g/L added Other numbers have found FFP - 20mmol/L Platelets - 15-20mmol/L Plasma - 13-15mmol/L Red cells 5-7.5mm/L Cryo 13-15mmol/L Fib conc - nil

Answer 24

For patients requiring immediate surgery (e.g. from major trauma admission to the Emergency Department), any anaesthetic workstation can be prepared within 3 min with the use of ACFs. https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.14407

Answer 25

b. hypocalcaemia injured muscle --> rhabdo. Rhabdomyolysis can lead to metabolic acidosis, hyperkalemia, hypocalcemia, and disseminated intravascular coagulation. Myoglobin-induced renal failure can be prevented with intravascular fluid expansion, alkalinization of the urine by intravenous administration of bicarbonate, and osmotic diuresis. (ATLS) Hypocalcaemia. https://www.acep.org/imports/clinical-and-practice-management/resources/ems-and-disaster-preparedness/disaster-preparedness-grant-projects/cdc---blast-injury/cdc-blast-injury-fact-sheets/crush-injury-and-crush-syndrome

Answer 26

b) methylene blue

Answer 27

d. 12hr https://rapm.bmj.com/content/early/2025/10/16/rapm-2024-105766

Answer 28

Dabigatran (50-60% removed in 4hour run). Others have very high protein binding and difficult to dialyse off.

Answer 29

https://litfl.com/wolff-parkinson-white-syndrome-ccc/ Likely electricity Acute unstable -> synchronised DC shock stable -> anti-arrhythmics (prolongation of accessory pathway: sotalol, amiodarone, flecanide, procanamide) drugs that shorten refractory period are contraindicated (digoxin) drugs that increase ventricular rate avoid (verapamil and lignocaine) drugs that have no effect on refractory period of accessory pathway are useless (beta-blockers)

Answer 30

ventricular arrhythmias according to this meta-analysis https://pmc.ncbi.nlm.nih.gov/articles/PMC8990315/#:~:text=A%20total%20of%203%2C396%20studies,that%20still%20needs%20further%20confirmation.

Answer 31

c) reduced time to motor/sensory onset USS: reduced the proportion of participants who required additional analgesia or anaesthesia when compared with electrical stimulation alone reduced the proportion of patients experiencing pain during needle manipulation reduced the time to the onset of sensory block reduced the proportion of patients with accidental vascular puncture https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.13098

Answer 32

c. septic shock Conditions where PPV is less reliable: False +ve - spont breathing - cardiac arrhythmias - increased intra abdominal pressure - RV dysfunction False -ve - Low vT - low lung compliance - very high resp rate https://www.atsjournals.org/doi/10.1164/rccm.201801-0088CI

Answer 33

d. Withdraw ETT 1-2cm "Anesthesiology 2019 (https://pubs.asahq.org/anesthesiology/article/131/3/666/17826/Lung-Pulse-with-PneumothoraxExamine-the-Thoracic): The lung pulse, is the rhythmic movement of the pleura in synchrony with the cardiac rhythm. Its presence indicates that the parietal and visceral pleura oppose one another; its presence rules out a pneumothorax." Ddx no lung sliding = PTX (-ve if lung pulse present), atelectasis, prior pneumonectomy, one-lung ventilation on opposite side (intentional or unintentional primary bronchus intubation), large consolidation.

Answer 34

a. Hb IO samples show a good correlation with venous samples for: Hemoglobin / haematocrit Chloride Glucose Urea Creatinine Albumin IO samples poorly correlate with venous samples for: WBCs Platelets Serum CO2 Sodium Potassium Calcium

Answer 35

Carbamazepine APMSE: Topiramate is as effective as carbamazepine at 1 mth after treatment commencement and slightly more effective at the 2 mth endpoint in trigeminal neuralgia (RR 1.20; 95%CI 1.04 to 1.39) (Wang 2011 Level I, 6 RCTs, n=354). All included RCTs were of poor methodological quality; this is also an issue for carbamazepine trials, which show probable effectiveness over placebo (Wiffen 2014 Level I [Cochrane], 10 RCTs, n=480). Duloxetine has been shown to have an effect in trigeminal neuralgia https://www.bjanaesthesia.org/article/S0007-0912(19)30430-1/pdf

Answer 36

Multisite pacing

Answer 37

b) cardioversion

Answer 38

Amiodarone

Answer 39

defibrillate as per ACLS you do also switch them to BMV to confirm can ventilate manually but would not delay defibrillation with 3 stacked shocks firs

Answer 40

a) IV insulin/dextrose Calcium (if ecg changes) - onset <3mins, duration - 30mins Insulin/dextrose - onset 15mins, peak 60mins, duration 2-3hrs Renal association Salbutamol - onset 30 mins, peak 120mins duration 2-3hrs Bicarb (in acidosis) - onset 30-60mins, duration 2-3hrs Resonium - onset 60mins (PR) and 4hrs (PO), duration variable (remember via CIS-BR 3-15-30-30/60 min onset; 30 for calcium, 2-3hrs for middle 3)"

Answer 41

a) mixing studies When an initial PTT is prolonged, a second PTT test is performed by mixing the person’s plasma with pooled normal plasma (a collection of plasma from a number of normal donors). If the PTT time returns to normal (“corrects”), it suggests a deficiency of one or more of the coagulation factors in the person’s plasma. If the time remains prolonged, then the problem may be due to the presence of an abnormal factor-specific factor inhibitor (autoantibody) or nonspecific inhibitor, such as lupus anticoagulant. https://www.testing.com/tests/partial-thromboplastin-time-ptt-aptt/#:~:text=To%20detect%20nonspecific%20autoantibodies%20(antiphospholipid,be%20used%20for%20this%20purpose.

Answer 42

c) variable extrathoracic - if inspiration affected -> extrathoracic - if expiration affected -> intrathoracic - if both affected -> large airway obstruction Flow-volume loops "

Answer 43

Factor 8 4 factor Beriplex - 2, 7, 9, 10, protein C and S Excipients Antithrombin III (human), albumin (human), Heparin sodium (porcine), Sodium+ Phosphate+ Citrate+ Chloride+ (Present as sodium citrate, sodium phosphate and sodium chloride)

Answer 44

VA ECMO Femoral and preserved cardiac function Blood is drained from the inferior vena cava, passes through the oxygenator and is then returned to the descending aorta in a retrograde fashion. In peripheral V-A ECMO any residual native cardiac output passes through the patient’s lungs. If the lungs are badly affected by pathology or mechanical ventilation is inadequate the blood of the residual cardiac output may remain significantly hypoxic as it enters the systemic circulation. Anatomically, this blood is preferentially delivered to the circulation of the heart, head and neck and right arm. Therefore, when there is residual native cardiac output and the lungs are not ventilated normally, potential exists for delivery of hypoxic blood to the coronary, cerebral and right arm circulations. This is termed differential hypoxia or harlequin syndrome. https://ecmo.icu/va-ecmo-differential-hypoxia/

Answer 45

Type 3 always ineffective https://www.rch.org.au/clinicalguide/guideline_index/Von_Willebrand_Disease_vWD/ DDAVP for type 1 (relative deficiency) and 2a (qualitative problem). vWF and FVIII (Biostate) replacement for Type 2b and Type 3 (absolute deficiency). Platelets - second line option if ongoing bleeding https://www.uptodate.com/contents/von-willebrand-disease-vwd-treatment-of-major-bleeding-and-major-surgery#H3081086338 "

Answer 46

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"ting tachycardia

Answer 47

a) Severity of air leak

Answer 48

50mg When using both agents together, follow this approach: Calculate the fraction of maximum dose for each drug: Lidocaine fraction = (actual dose used ÷ maximum dose) Bupivacaine fraction = (actual dose used ÷ maximum dose) Add these fractions together: Ensure the total fraction does not exceed 1 (100%) So given lignocaine = 100 ÷ 200 = 0.5 can give 0.5 of bupe dose = 50mg

Answer 49

90mg 30mg oxy IV = 30mg morphine IV 30mg morphine IV = 90mg morphine PO

Answer 50

SGLT2 inhibitor inhibiting glucose reabsorption within the proximal renal tubules, resulting in glucosuria, modest weight loss, and blood pressure reduction.

Answer 51

RUL "Bronchopulmonary segments: 3/2/5, 4/4 3 RUL: Apical, Posterior, Anterior 2 RML: Lateral, Medial 5 RLL: Superior, Medial, Anterior, Lateral, Posterior 4 LUL: Apicoposterior, Superior, Inferior, Anterior (lingula italicised) 4 LLL: Anteromedial, Lateral, Posterior, Superior RL: A PALM Seed Makes Another Little Plam LL: ASIA ALPS"

Answer 52

"b) Long throacic The shoulder receives sensory innervation from the cervical (C3,4) and brachial plexuses (C5,6). Shoulder nerve supply: - Major sensation (motor & sensory) = **suprascapular** nerve (upper trunk of the brachial plexus) and **axillary nerve** (posterior cord of the brachial plexus). - Minor sensation = SLaM: **subscapular, lateral pectoral, musculocutaneous** - Rotator cuffs are supplied by: axillary, suprascapular & subscapular nerves SA-SLaM the scapula (supra and sub)" other option has been supraclav which innervates skin of upper chest/shoulder

Answer 53

110 Brain trauma foundation guidelines: - SBP>100 for ages 50-69, - SBP>110 for ages 15-49 and above 70 years https://emcrit.org/ibcc/tbi/ TBI guideline for everything"

Answer 54

b. intrahepatic cholestsasis of pregnancy www.ranzcog.edu.au/wp-content/uploads/Management-Obesity-Pregnancy.pdf

Answer 55

PECS 1 - between pecs major and pecs minor - blocks lateral and medial pectoral nerves Stenum innervated by interocostal nerves. All 3 options belwo 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 "

Answer 56

"MELD-Na score components: (BICS) Bilirubin INR Creatinine Sodium (serum) estimates survival over next 3 months >15 - listed for deceased donor transplant "

Answer 57

1 - Buccal/intranasal Midaz 0.3mg/kg (max 10mg) if no IV access OR IV/IM midazolam 0.15mg/kg (max 10mg) 2 - IV/IO midaz 0.15mg/kg 3 - Levetiracetam 40-60mg/kg (over 5mins; max 4.5g) or phenytoin 20mg/kg (over 20mins) - provided pt NOT taking that med 4 - Give whichever was not given or phenobarbitone 5 - RSI Each step preceded by 5 mins (1 -> 5 mins after seizure onset, 2/3 = after midaz given, 4/5 = after infusion finished"

Answer 58

"IQR For skewed data: dispersion/spread/variability: interquartile range (or other percentile-based ranges). Measure central tendency=median. For normal distributed data: dispersion = standard deviation central tendency = mean. " Measures of central tendency = mean, median, mode

Answer 59

d) norad > 0.25mcg/kg/min for at least 4 hours For adults with septic shock and an ongoing requirement for vasopressor therapy, we suggest using IV corticosteroids. Quality of evidence: Moderate The typical corticosteroid used in adults with septic shock is IV hydrocortisone at a dose of 200 mg/d given as 50 mg intravenously every 6 hours or as a continuous infusion. It is suggested that this is commenced at a dose of norepinephrine or epinephrine ≥ 0.25 mcg/kg/min at least 4 hours after initiation. https://www.sccm.org/clinical-resources/guidelines/guidelines/surviving-sepsis-guidelines-2021

Answer 60

Non-inferior

Answer 61

S/C phentolamine https://www.rch.org.au/clinicalguide/guideline_index/Peripheral_extravasation_injuries__Initial_management_and_washout_procedure/

Answer 62

c. major haemorrhage The most common causes of perioperative cardiac arrest were major haemorrhage (17%), bradyarrhythmia (9.4%) and cardiac ischaemia (7.3%) but varied by surgical specialty. Anaphylaxis was likely overestimated as a cause of cardiac arrest in our survey of anaesthetists

Answer 63

Grimacing "1) Eye opening 2) Eyes - conjugate gaze 3) Facial grimace 4) Laryngeal stimulation test +ve 5) Low ET anaesthetic concentration <0.2% sevo, <1% des and <0.15% isoflurane 6) Movement (except coughing) 6) Movement - purposeful 7) SpO2 >97% Preop (baseline) target if cyanotic congenital heart disease 8) TV >5mL/kg"

Answer 64

Metoprolol Results in unopposed alpha stimulation - unopposed vasoconstriction. Worsen HTN, coronary spasm, ischaemia.

Answer 65

low frequency probe

Answer 66

c. justice “Justice in medical ethics emphasises fair, equitable and appropriate treatment and distribution of healthcare resources, ensuring no unfair disadvantage based on socioeconomic status, location or other factors”

Answer 67

"Ans: Salicylate toxicity ^Cl -> NAGMA Low albumin -> Masks HAGMA, (AG reduces by 1 for every drop of albumin from 4o by 4g/L) Litium & ^Ca2+-> Low AG metabolic acidosis (Extra unmeasured cations) Lithium: Low AGMA"24.1

Answer 68

a. ibuprofen "NSAIDS/aspirin should be avoided as it displaces thyroxine from protein and subsequently increases free T3 and T4 levels. Thyroid storm General measures Cooling IVF +/- glucose Paracetamol Propranolol Specific Hydrocortisone 200 mg QID IV PTU after PTU sodium iodide/lugols iodine"

Answer 69

"b) Nd:yag Modified Question: this question asks Greatest, old asks least Least = Er:yag (or CO2)? Most = Nd:Yag Er:yag (Erbrium-Yag) used in dermatology which is the least penetrative CO2 laser has very little penetration (~ 10micrometres), as it has a wavelength of 10 600nm. Helium-Neon laser also has very little penetration. Nd:YAG is the most powerful, with a penetration of 2-6mm, as it has a wavelength of 1064nm. Argon penetration of 0.5mm"

Answer 70

"72 hours ANZCA Blue Book 2023 Oral naltrexone should be stopped at least 24 hours and ideally 72 hours prior to elective surgery. And there is a lack of instruction re Contrave(naltrexone/buproprion for weight loss)- so best to stop 72 hours prior. And limited evidence re low dose naltrexone for chronic pain - so for consistency blue book says 72 hours. Caution increased opioid sensitivity in patients using perioperative naltrexone."

Answer 71

d. proprioception Anterior spinal artery syndrome usually includes tracts in the anterior two-thirds of the spinal cord, which include the CSTs, the spinothalamic tracts, and descending autonomic tracts to the sacral centers for bladder control. CST involvements produce weakness and reflex changes. A spinothalamic tract deficit produces the bilateral loss of pain and temperature sensation. Tactile, position, and vibratory sensation are normal. Urinary incontinence is usually present.

Answer 72

"d. 1:136,000 https://www.bjanaesthesia.org/article/S0007-0912%2817%2930746-8/fulltext 1/670 E-LSCS 1/8000 with muscle relaxation 1/8600 CTS 1/8200 Volatile + neuromuscular blocking Overall 1:19000"

Answer 73

"d) Proceed ANZCA PG07 appendix 1 - Chewing gum and boiled sweets should be discarded prior to inducing anaesthesia to avoid them being Inhaled as a foreign body but do not constitute an indication for delaying any procedure unless they have been ingested. Therefore D"

Answer 74

c. elderly "RFs for CPSP: Preop: mod-severe pain >1mth, repeat surgery - young, female, anxiety, opioids (ineffective) Intraop: high-risk surgeries, nerve damage Postop: Acute pain (mod-severe), anxiety/depression"

Answer 75

Titrate to pain scores alone Should use FAS https://www.anzca.edu.au/getContentAsset/136f5a83-d1d0-4f34-be72-87b62b721d14/80feb437-d24d-46b8-a858-4a2a28b9b970/PS41(G)-Acute-pain-2023.pdf

Answer 76

"REPEAT reconsidered as Amitriptyline a) Amitriptyline By order of favourable NNT: TCAs (amitriptyline) NNT: 3.6, NNH: 9 Strong opioids NNT 4.3 NNH 11.7 Tramadol NNT: 4.7, NNH 12.6 SNRIs (duloxetine and venlafaxine) NNT 6.4, NNH 11.8 Gabapentin NNT: 7.2 NNH 25.6 Pregabalin NNT:7.7, NNH 13.9 ANZCA Pain book Treatment of chronic neuropathic pain after SCI (Guy 2016 GL). These guidelines recommend: First line: pregabalin, gabapentin and amitriptyline; Second line: tramadol and lamotrigine (in incomplete SCI); Third line: Transcranial direct current stimulation (tDCS) alone and combined with visual illusion; Fourth line: TENS, oxycodone and dorsal root entry zone lesions."

Answer 77

Dysaesthesia Ans = allodynia – normal touch = painful Dysaesthesia = normal touch or even just spontaneous pain. Unpleasant, abnormal sense of touch (e.g. burning, wetness, can be pain) Paraesthesia = abnormal sensation (or loss of sensation) Hyperalgesia = pain out of proportion Hyperaesthesia = stimulus required"

Answer 78

e) distance from anterior margin of dense to posterior surface of anterior arch of atlas be aware of wording Normal interval <3mm adult, <5mm child Widening indicates potential instability can also measure PADI (posterior atlantodental interval) or SAC (space available for cord) . Posterior cortex of dens and anterior arch C1. normal is >15mm. Less than this - increased risk of AAI and spinal cord injury Antlantoaxial instability Loss of transverse ligament + erosion of odontoid peg → atlanto-occipital instability in ~25% of patients *Acute subluxation can cause spinal cord compression and/or compression of vertebral arteries Two main categories of cervical spine instability: Atlanto-axial subluxation *Anterior: C1 moves forward on C2 *Posterior: C1 moves backward on C2 *Vertical: odontoid process subluxes through foramen magnum *Lateral/rotatory subluxation: C1/C2 rotation Subaxial subluxation *Occurs less commonly *More likely to involve neurological symptoms

Answer 79

"Decreased urine output (alternative is Residual sedation) - Dexmed can be a diuretic (increase GFR and UO) Loading infusion: Transient HTN (α2B receptors agonism), bradycardia, hypotension Intaop dexmed associated with PACU: ↓ PONV, shivering, cough, emergence agitation, pain scores Decreased BP (hypotension) No change bradycardia and sedation and PACU LOS No change - BSL - bradycardia/sedation/LoS PACU Decreased everything else incl. BP (PONV, shivering, cough, agitation, pain)" "BJA 2020 RCT: 24hrs post-induction dexmed reduces AKI post aortic surgery requiring CPB. No differences in HR/BP/sedation https://www.bjanaesthesia.org.uk/article/S0007-0912(20)30001-5/pdf "

Answer 80

"Increasing MV -> avoid hypocapnoea is part of algorithm If desat >20% from baseline - check head position - ensure neutral - check ETT ties - exclude venous/arterial obstruction – Optimise O2 delivery - HR/SV/ MAP (vasopressors/ ^FiO2 (treat hypoxia), optimise ventilation (clear CO2), tranfusion if anaemic – Optimise O2 consumption - ensure adequate depth of anaesthesia, avoid hyperthermia, exclude seizures- antiepileptics

Answer 81

" >120sec Optimal seizure duration somewhere between 10-120seconds. https://academic.oup.com/bjaed/article/10/6/192/299664

Answer 82

a) initial sympathetic stimulation Beginning with the electrical stimulus, there is an initial parasympathetic discharge lasting 10–15 s. This can result in bradycardia, hypotension, or even asystole. A more prominent sympathetic response follows during which time cardiac arrhythmias occasionally occur. Systolic arterial pressure may increase by 30–40% and heart rate may increase by 20% or more, generally peaking at 3–5 min Left ventricular systolic and diastolic function can remain decreased up to 6 h after ECT. Cerebral oxygen consumption, blood flow, and intracranial pressure all increase https://www.bjaed.org/article/S1743-1816(17)30338-4/fulltext

Answer 83

A) 30 day mortality MINS study n=15,065 patients. >45 y/o undergoing non cardiac surgery. Had troponins measured for 3 days post op. Elevated trop independently predicted 30 day mortality.

Answer 84

a) Propofol for LMA + PPV alternative could be e but significance of transphenoid surgery and potential pneumocephalus... Placing cpap on this patient even with an OPA is likely going to increase risk of this. an LMA gives a better seal (and its a glorified OPA anyway). If you're able to stick an OPA in someone you can use an LMA (Answer e suggests the pt is so obtunded that they will tolerate an OPA as no suggestion of deepening with props)

Answer 85

d. Adductor brevis "Boundaries: - Medial wall - sartorius - Posterior wall - adductor longus, adductor magnus - Anterior - vastus medialis Contents: subsartorial artery/vein, saphenous nerve and nerve to vastus medialis (both branches of femoral nerve)"

Answer 86

a. inferotemporal The inferotemporal approach offers more physical space between the globe and the orbital walls, providing safer access away from the extraocular muscles compared with a medial or off-centered (“two thirds/one third”) inferotemporal approach.Citation8

Answer 87

40mL/kg Massive transfusion (prevent hypothermia/acidosis/coagulopathy) Children- (pRBC) transfusion i.e. replacement of: >1 blood volume in 24hours OR >50% TBV in <3-4hours OR >10% TBV over 10 minutes (OR 40mL/kg blood) Adults - replacement of >1 blood volume in 24hours OR >50% blood volume in 4hrs 10mL/kg pRBC increases Hb 20g/L; (cGPT); 1 unit pRBC ~300mL"

Answer 88

Aprepitant barrier contraception for 28 days https://www.merck.com/product/usa/pi_circulars/e/emend/emend_pi.pdf https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5809356/ 2 months in UK (28 days in USA) Works as a centrally acting NK1 receptor antagonist by blocking actions of Substance P - also ↑activity of dexamethasone & ondansetron (in chemo)"

Answer 89

c. Phenoxybenzamine Phentolamine used intraop (short action/reversible cf phenoxybenzamine which is irreversible and has a lasts 3-4 days as need to make new receptors) Preop objectives: (note orthostatic hypotension and ST/T wave changes of Roizen criteria now questionable) 1) BP control (<130/80 seated): α blockade >7days (e.g. doxazosin or phenoxybenzamine, latter stopped 24-48hrs preop due to postop hypotension), +/- CCB (nicardipine SR) 2) HR/arrhythmia control: selective β1 antagonists (metoprolol/atenolol) avoids hypertensive crisis (if β2-vasodilation stopped and unopposed α vasoconstriction) 3) High Na+/fluid intake -> restores blood volume 4) Optimise myocardial function: ECG (ventricular hypertrophy, tachycarrhythmia, myocardial ischaemia). TTE mandatory (majority pts have diastolic dysfunction) Beware HOCM (MCC, due to HTN), and atypical Takutsubo 5) Reverse glucose/electrolyte disturbances (hyperglycaemia, and hypercalcaemia)"

Answer 90

d. Basilar

Answer 91

Desufflation: wont increase SVR insufflation IAP<10mmHg - ↑ VR/CO (from splanchnic/GI cirulcation) IAP 10-20mmHg (MC) - ↓VR/CO, ↑SVR (also ↑catecholamines), <->or ↑BP IAP>20mmHg - ↓↓ VR/CO --> ↓ BP (starts to impede VR seriously) https://academic.oup.com/bjaed/article/4/4/107/308013 2004 Resp: ↓ FRC, ↑AWR + ↓compliance. Barotrauma risk

Answer 92

a. add 0.03 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 93

a. decreased renal blood flow Should enhance CO and increase renal blood flow

Answer 94

"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 "

Answer 95

a high frequency Frequencies above 100 kHz (and specifically in the radiofrequency range of 0.5-3 MHz) avoid causing neuromuscular stimulation and cardiac excitation, unlike lower, mains-level frequencies (50-60 Hz), which can cause ventricular fibrillation.

Answer 96

"Cohort "Prospective: - Observational cohort studies: observes exposure, then observes the development of risk. Uses relative risk (i.e. who develops the illness) - Randomised and non-randomised (cohort) interventional controlled trials. RCTs gold standard - only study that can establish casuation by evaluating intervention https://www.bjaed.org/article/S1743-1816(17)30475-4/fulltext#seccestitle70 " Retrospective: - case reports (and case series (a collection of case reports) - cross-sectional studies/surveys: no control group, merely a large series of case reports -> e.g. can determine prevalence of a disease - case-control studies: identified risk factors assoc/ w/ outcomes. -> compare case w/ control to identify RFs or causative agents implicated in aetiology of disease -> Use odds ratios"

Answer 97

"c - IE ratios - no recommendations (lack of evidence for a specific I:E ratio) * The ventilator should initially be set to deliver VT ≤6–8 ml kg–1 PBW and PEEP=5 cm H2O. * Individualised PEEP can prevent progressive alveolar collapse. Recruitment manoeuvres can reverse alveolar collapse, but have limited benefit without sufficient PEEP * An I:E ratio of 1:1, which has been characterised as providing a ‘balanced stress to time product’, was associated with attenuation of lung damage. Evidence for specific I:E ratio lacking -> no recommendation. (^ mean airway P but reduces peak airway P) * high ventilator driving pressure (ΔP=plateau pressure [Pplat]–PEEP) has been recognised as a significant determinant of lung injury and is linked to PPCs"

Answer 98

"a) 1% PPV = TP / TP + FP For example For prevalence of 1:1000 the number of TP = 1 False positives = 999 x 10% FP = 99 PPV = 1 / 1+99 PPV = 1% PPV = TP / TP + FP NPV = TN/ (TN + FN) Sensitivity = TP / (TP+FN) Specificity = TN / (TN+FP)"

Answer 99

"a) pupil constriction (horner syndrome) and reaction to light Loss of SNS, so would have relative miosis. Still has PSNS and optic nerve (CNII) intact so intact pupillary light reflex - anhidrosis (decreased sweating), enopthalmos (sunken eyeball), bloodshot conjunctiva, facial flushing on affected side Also possible: VC paralysis, RLN injury, phrenic n injury, brachial plexus injury, pneumothorax, indavertent epidural"

Answer 100

"a) More bleeding, normal INR and APTT - also more transfusions' - INR and APTT done at room temp Mild hypothermia (<1degC) ^ blood loss by 16% & tranfusion risk by 22% Anaesthesiology 2008 effects mild periop hypothermia"

Answer 101

Hydroxycobalamin "IV hydroxocobalamin (B12) 5mg with repeat dosing upt to 15mg sodium thiosulfate used in case series also appears affective with no AE https://www.resuscitationskills.com/library/algorithms/all-adult-als-guidelines-june-2017.pdf "

Answer 102

"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 103

Sagittal, subxiphoid

Answer 104

"a) AB group - 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 " https://www.lifeblood.com.au/health-professionals/products/component-compatibility

Answer 105

FB BJA 2hrs if in oesophagus, or symptomatic in stomatch

Answer 106

"90min - the lungs take 90 mins ""In Australia it is usual to stand down the DCDD process if the agonal period has exceeded 90 minutes"" https://www.donatelife.gov.au/sites/default/files/2022-01/ota_bestpracticeguidelinedcdd_02.pdf

Answer 107

"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 108

B or D (?D misremembered) b. ocoulocephalic reflex is an inferior test compared to the vestibulo-ocular reflex (tests same nerves) and may exacerbate pre-existing spinal injury pre-conditions for test - temp >35 - normotension - exclusion of sedatieves - absence of electrolyte abnormalities/ Liver faliure - absence of NMBD a minimum 4-hour observation period prior to neurological determination of death using clinical examination alone. Throughout this observation period, all preconditions are met, the patient has a Glasgow Coma Scale of 3, with pupils nonreactive to light, absent cough/tracheal reflex and apparent apnoea on a ventilator. Following an acute hypoxic-ischaemic encephalopathy or hypothermia (<35°C) of duration greater than 6 hours, there should be a waiting period of 24 hours before determination of death using clinical examination alone.

Answer 109

b) 1 hourly https://www.diabetessociety.com.au/wp-content/uploads/2023/03/ADS-ANZCA-Perioperative-Diabetes-and-Hyperglycaemia-Guidelines-Adults-November-2022-v2-Final.pdf Continue hourly BGL monitoring until the person leaves the recovery area. If the BGL has been stable (and within target range) while in the recovery area, BGL monitoring can be decreased to 2 hourly if type 1 diabetes, or 2-4 hourly if type 2 diabetes. If BGLs have been unstable or if VRII, hourly monitoring is required.

Answer 110

"c) Normal Lung Normal lung = A lines (pleura) + batwing appearance + sliding" "A lines horizontal - may be normal or pneumothorax B lines vertical - can be interstitial fluid e.g. pulmonary oedema -> (After Hours, Batman is Vigilant) Pneumothorax features: - abscence of B lines & sliding (on highest point of anterior chest) - absence of lung pulse - presence of lung point"

Answer 111

d) NAGMA non-anion gap metabolic acidosis (NAGMA), often specifically referred to as hyperchloremic metabolic acidosis.

Answer 112

c. fibrinogen <2 https://www.bjanaesthesia.org.uk/article/S0007-0912(17)31590-8/pdf platelets < 150 Giga/L (OR 2.98, 95%CI 1.63, 5.46), fibrinogen < 4.5 g/l (OR 1.86, 95%CI 1.21, 2.87) and APTT ratio ≥ 1.1 https://www.sciencedirect.com/science/article/abs/pii/S2468784721001069

Answer 113

"a) 6 hrs 6hr and 24hrs hypocalcaemia—ionized calcium <0.9mmol/L, total calcium (corrected for albumin) <2.2mmol/L. Trough level usually occurs at 20hr following parathyroidectomy and typically normalizes by days 2–3."

25.2 Flashcards

(148 cards)