25.2 Flashcards

Question

Q25: Risks associated with peribulbar block Safest approach for peribulbar if short eye length? a) Inferotemporal b) superior temporal c) medial canthal d) lateral canthal e) Other approaches

Answer 1

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 2

Place the probe in the epigastrium in a sagittal plane, slightly left of the midline. Below xiphisternum aiming for antrum.

Answer 3

A multi-site pacing

Answer 4

Gold standard of diagnosis is the totally unrealistic manoeuvre of sucking some amniotic fluid debris out of a distal port of the PA catheter. Foetal debris in maternal sputum is a more civilised alternative, but again unlikely to be game-changing if you already strongly suspect AFE. Foetal antigen serology looking for TKH-2 antibodies ( or insulin-like growth factor binding protein-1) are apparently not well validated Supporting investigations Bloods: FBC (thrombocytopenia) Coags/fibrinogen (DIC) Troponin (cardiac strain) ABG (hypoxia, lactic acidosis) Imaging etc: TTE/TOE (right heart strain, evidence of obstructive shock) ECG (RV strain) CXR (pulmonary oedema)

Answer 5

? C Benztropine is a muscarinic antagonist, however it is used to treat extrapyramidal symptoms in dopaminergic agents.

Answer 6

Core Ventilation Principles 1. Reduce Airway Pressure: The primary goal is to minimize peak inspiratory pressure (PIP) and mean airway pressure. 2. Low Tidal Volume (4-6ml/kg): Use smaller, pressure-controlled, or volume-controlled breaths to reduce the pressure gradient driving air through the fistula. 3. Minimal PEEP: Use the lowest possible PEEP to maintain oxygenation without forcing air through the fistula. 4. Short Inspiratory Time: A shorter Ti reduces the time for air leakage during the breath. 5. Permissive Hypercapnia: Allowing CO2 levels to rise can be necessary to reduce minute ventilation requirements. Specialized Techniques 1. High-Frequency Jet Ventilation (HFJV): Effective in reducing air leaks by providing small, high-frequency, low-pressure breaths. 2. Independent Lung Ventilation (ILV): Uses two ventilators or a double-lumen tube to ventilate the healthy lung with standard parameters while minimizing pressure in the affected lung. 3. Double-Lumen Tube (DLT) or Bronchial Blocker: Used to isolate the affected lung. 4. ECMO: Venovenous ECMO can be used for refractory cases to allow the lungs to rest and the fistula to heal. Key Management Considerations 1. Avoid Excessive Suction: Keep chest tube suction to the minimum necessary to maintain lung inflation. 2. Underlying Disease: Addressing the root cause (e.g., pneumonia, infection) is critical, as BPF usually seals once the underlying lung condition improves. 3. Monitor Leak: Large leaks (>500 mL/breath) are associated with higher mortality, but conventional strategies can manage most

Answer 7

Top Risk Factors for Severe PPH Obstetric History: Previous severe PPH (highest risk factor), grand multiparity (5+ deliveries).Placental Issues: Placenta previa, placenta accreta, or placental abruption.Uterine Overdistension: Multiple pregnancy (twins/triplets), macrosomia (large baby >4500g), or polyhydramnios (excess amniotic fluid).Labour and Delivery Management: Prolonged labour (especially second stage), instrumental vaginal delivery (forceps/vacuum), in-labour (emergency) caesarean section, and induction/augmentation of labour.Maternal Conditions: Anaemia, obesity (BMI \(\ge \) 30), severe pre-eclampsia, HELLP syndrome, coagulation disorders, or uterine fibroids.Other Factors: Infection (chorioamnionitis), smoking (nicotine abuse), and the use of magnesium sulfate or anticoagulants

Answer 8

C Hyperthermia triggered by muscle hyperactivity. Therefore no role for paracetamol. Initial management for hyperthermia is sedation with benzodiazepines followed by muscle relaxation via non-depolarising agents. If all supportive care, specific serotonin antagonists (cyproheptadine) should be given

Answer 9

The pharmacological strategy is often summarized by the "5 B's": Block synthesis Block release Block conversion Beta-blockade Block enterohepatic circulation. Thionamides (Block Synthesis): Propylthiouracil (PTU) is preferred due to its ability to inhibit the peripheral conversion of T4 to T3, in addition to blocking new hormone synthesis. Recommended loading doses are high (e.g., 500-1000 mg PTU), followed by 250 mg every 4 hours. Iodine Compounds (Block Release): Inorganic iodine (e.g., Lugol’s solution, SSKI) stops the release of preformed thyroid hormones. Critically, this should be administered at least one hour after the thionamide loading dose to prevent the iodine from being used to create more hormone Beta-Blockers (Adrenergic Blockade): Propranolol is the preferred agent for symptomatic control (tachycardia, tremors, agitation) because it not only provides beta-adrenergic blockade but also reduces the peripheral conversion of T4 to T3 at high doses. Esmolol is an alternative for critically ill patients requiring rapid titration. Glucocorticoids (Conversion Block & Adrenal Support): Hydrocortisone or dexamethasone is given to inhibit T4 to T3 conversion, treat potential associated adrenal insufficiency (a,c,c), and stabilize hemodynamics. Bile acid sequestrants (e.g., Cholestyramine) can be used to reduce the enterohepatic circulation of thyroid hormones. In cases resistant to medical therapy, therapeutic plasma exchange (TPE) can be used to remove excess hormones.

Answer 10

Answer: A Stellate ganglion block causes ipsilateral Horner’s Syndrome: Ptosis (eyelid droop) Miosis (constricted pupils) Anhydrosis (loss of sweating) Enophthalmos (sinking of eyeball into the bony cavity that protects the eye) *Pupillary constriction in response to light is controlled by the Edinger-Westphal nucleus of CN3, which will remain intact.

Answer 11

Coronary Sinus Lead in CRT Device

Answer 12

Answer: Radial Nerve

Answer 13

A anterior compartment Dorsiflexion = tibialis anterior. Numbness pattern = deep peroneal nerve. Both in the anterior compartment

Answer 14

? A. Amitriptyline Many variations of this question. Not sure 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

Answer 15

Answer B: 1 hour

Answer 16

Probably misremembered and not so good now
MELD original does not use Albumin or Na
MELD-Na does not use Albumin
MELD 3.0 (more contemporary) uses all of the options

Answer 17

a. 1% i.e. what is the positive predictive value (PPV) for this test PPV= TP/ TP +FP Negative Predictive Value = TN / TN + FN Prevalence of 1/1000 Sensitivity of 100% Specificity of 90% Of patients that are disease positive in population of 1000 TP = 1 FN = 0 -> 100% sensitivity Of patients that are disease negative in population of 1000 FP = 99 TN = 900 -> 90% Specificity PPV= 1/ 1 + 99 = 1/100 =1% NPV= 900/ 900 + 0 = 1/1 = 100%

Answer 18

A. Reduced RR BJA HFNOT It has been demonstrated that patients with acute hypoxaemic respiratory failure experience improved comfort and tolerance with HFNOT compared with humidified oxygen via a facemask, and traditional non-invasive ventilation masks. Subjective feelings of dyspnoea AND RESPRIATORY RATES are REDUCED as is airway dryness

Answer 19

C. Increased minute ventilation

Answer 20

D 120 seconds

Answer 21

b. Procainamide BJA: Perioperative cardiac arrhythmias https://academic.oup.com/bja/article/93/1/86/265716 Note in NZ Procainamide is not even approved by medsafe.

Answer 22

Aortic Regurgitation

Answer 23

Answer quantifies degree of air leak

Answer 24

>50% blood loss after 3 hours (RCH) is defined as massive haemorrhage As to when you should activate it…

Answer 25

Answer: C In anterior spinal artery syndrome (anterior two-thirds cord infarction), you lose: Motor (corticospinal tracts) Pain and temperature (spinothalamic tracts) You typically spare dorsal column modalities because the posterior columns (proprioception, vibration, discriminative touch) are supplied predominantly by the posterior spinal arteries.

Answer 26

Answer: Amiodarone

Answer 27

?? Variations of this question, sometimes maximum is **60 cmH2O** Presumably the answer for this question is 30mL ? | (Hol) I think key here = "volume" 30ml = max vol, 60cmH2O = max pressure

Answer 28

?painless ?due to ischaemia (in anaesthesia anyway) ?early optic disc edema (delayed in PION ?more commonly associated with cardiac surgery (vs posterior spinal surgery for PION)

Answer 29

Answer C 72 hours

Answer 30

examples include - range - variance - standard deviation (square root variance) - IQR

Answer 31

?failure rate ~30%? Risk factors for failure: migraine hx, accidental dural puncture at higher lumbar levels, EBP <48h after accidental dural puncture

Answer 32

VF/VT --> 3 x shocks, then start BLS, DC shock every 2 minutes until chest opening Asystole/severe bradycardia --> pace if wires in situ, attempt transcutaneous pacing, if unsuccessful cor until chest opening PEA--> turn off pacing if on to exclude underlying VF, continue cor until resternotomy

Answer 33

Answer: A or B The makers of the GCS say you should use paediatric GCS if ≤2 years as the patient needs to be able to speak to score the verbal response I note that RCH paediatric trauma guideline has this at 4 years old https://www.rch.org.au/trauma-service/manual/Head_injury

Answer 34

Causes haemolytic anaemia

Answer 35

A. 1, 5 Air: 1, 5 Oxygen: 2, 5 N2O: 3,5 CO2: 2, 6 He: 2, 4 Cyclopropane 3, 6 Entonox 7

Answer 36

For selected surgeries, a short period of invasive EEG monitoring may be required during surgery: EEG electrodes are placed directly on the cortical surface and epileptiform activity is identified, and this can guide the extent of a resection. If ECoG is required, then benzodiazepines should not be given on induction because they suppress EEG activity. During ECoG, pharmacoactivation may be required in order to activate IEAs. Potent short-acting μ-agonists can be used to increase IEAs and alfentanil, remifentanil, fentanyl and sufentanil can be used for this. Alfentanil is the most specific and consistent activator of IEAs and is administered at doses of 20–100 μg kg−1 for this purpose. It is generally accepted that the depth of anaesthesia should be reduced during ECoG, and the patient should be advised of the small risk of awareness during this period. It should be noted that laudanosine, a metabolite of atracurium and cisatracurium, is potentially epileptogenic.

Answer 37

Answer D (PG07)

Answer 38

- get a ESM due to LVOTO. Generally no radiation to carotids though. quieter w increase in preload e.g. squatting or increase in after load (hand grip), louder w valsalva (decr preload) - sometimes may get MR like murmur due to SAM

Answer 39

LITFL: Long-acting somatostatin analogue Reduces splanchnic blood flow and portal venous pressure by unknown mechanisms (hence reduces variceal pressures) Inhibits endocrine and paracrine factor secretion, including insulin, glucagon, gastrin, GH and TSH As a long-acting somatostatin analog, it binds with high affinity to somatostatin receptors (specifically subtypes 2 and 5). Splanchnic Vasoconstriction: Octreotide suppresses the release of vasodilatory peptides, most notably glucagon, which are responsible for splanchnic hyperemia in cirrhosis.

Answer 40

ECG - sinus brady /first degree, Mobitz Type I / Type II, CHB

Answer 41

Group A+ Rhesus status not important Reserve AB+ for emergencies

Answer 42

c) comparisons of means between three groups in normally distributed data ANOVA (analysis of variance): comparisons of means between more than two groups or between several measurements in the same group is called analysis of variance and is frequently cited by the acronym ANOVA

Answer 43

Mechanism of injury Injuries Signs and symptoms Treatment

Answer 44

a) Deepen with propofol and insert LMA https://academic.oup.com/bjaed/article/11/4/133/266875#3195876

Answer 45

A. Inhalational anaesthesia

Answer 46

Answer: ? C I think long thoracic goes to ser ant m? although subscap primarily motor to its muscle and teres major

Answer 47

Answer: A PG03 2.9 In addition to monitoring for any specific patient needs, monitoring during establishment of major regional analgesia should include frequent and regular blood pressure measurement, respiratory rate, and conscious state evaluation. An electrocardiograph and pulse oximeter should be available. Oxygen should be administered in the presence of sedation. **This level of monitoring should be continued for at least 30 minutes or until the patient’s vital signs are stable. ** Subsequent monitoring depends on the block and drugs used and the clinical circumstances (see item 3.3.1). Institutional protocols must be applied. In general this should include regular assessment of heart rate, blood pressure, sedation, pain, and motor block as indicated by the clinical circumstances.

Answer 48

Obturator Nerve

Answer 49

?? Brief review of online - Has modest opioid sparing benefit when used IV (less evidence for oral) Some signal that it can prevent CRPS after a distral radius fracture (Hol) quick search through APMSE - "vitamin C reduces post pain and has mod evidence for reduction in post morphine consumption. - RCT (1g/day)- PO vit C decreased postop pain score and rescue analgesia needs for foot and ankle surgery, major abdominal surgery (2g/day PO) - no pain relief for herpes zoster (5g IV)

Answer 50

A lung pulse suggests that there is intact pleura and therefore no pneumothorax or haemothorax. Absence of lung sliding suggests no movement on that side and perhaps this is pointing to an endobronchial intubation? I am unsure Blue book 2025 - likely endobronchial ETT

Answer 51

c. Pain at site 1 month prior to surgery

Answer 52

Sural Nerve

Answer 53

120 seconds

Answer 54

Laryngectomy "J" tube

Answer 55

a. increased bleeding and normal aptt and inr Bleeding because cold = we know this (ok) Haemtology analyzer in labs warms blood to 37.2 degrees (fixes hypothermia on sample)

Answer 56

a) 30 min If the anaesthesia machine requires electrical power for normal operation, a backup power supply must be a part of the machine and permit normal operation for at least 30 minutes after a mains power supply failure. An alarm must be activated at the time of the mains failure and the state of the reserve power supply must be indicated while it is in use. https://www.anzca.edu.au/getattachment/f05e02ec-2023-4c50-b57f-9549ea0c4183/PS54(A)-Position-statement-on-the-minimum-safety-requirements-for-anaesthesia-machines-and-workstations-for-clinical-practice-2021#page=

Answer 57

Mapleson C

Answer 58

Metabolic Acidosis?

Answer 59

? Presumably something catecholamine secreting related

Answer 60

E. distance from anterior surface of dens to posterior surface of anterior arch of atlas

Answer 61

b. grimacing conjugate gaze facial grimace eye opening purposeful movement tidal volume greater than 5 ml/kg Source: SPANZA 2019 article

Answer 62

Like.. all of them? Down syndrome Craniofacial anomalies (PRS/craniosynostosis syndromes) Skeletal dysplasia (achondroplasia) Prader–Willi Mucopolysaccharidoses Congenital neuromuscular disorders

Answer 63

Answer: A This seems to vary depending on what source you look at. One interpretation https://resources.wfsahq.org/atotw/understanding-and-establishing-intraosseous-access/

Answer 64

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/ pH - Good correlation - pooled mean difference: +0.035 pH units

25.2 Flashcards

(150 cards)