Bundles

Question 1

AS

Answer 1

Slow sinus
Adequately filled
High after load

Art line
Metaraminol
5 lead ECG
Slow titrated induction

Question 2

Regurgitant lesions

Answer 2

Rate 80-100
High normal preload
Low after load and PVR

Art line, 5 lead ECG
Bolus fluid prior to induction
Consider neuraxial
Ephedrine

Question 3

MS

Answer 3

Low normal preload
Aggressively treat arrhythmia
Maintain after load
Anticipate pulmonary HTN
Manage anticoagulation

Question 4

Pulmonary HTN

Answer 4

Previous increase in PVR (excess SNS, acidosis, hypercapnia, hypoxia, hypothermia)

Maintain RV function and perfusion

Consider active reduction in PVR

Question 5

Raised ICP

Answer 5

Maintain cerebral perfusion and oxygenation
- Optimise supply: MAP > 80, Sats >95, Hb >100 in TBI
- Minimising demand: hypothermia, euglycaemia, antiepiletics, deep anaesthesia, analgesia

Prevent increase in ICP
- Head up, low normal CO2, low PEEP, short inspiratory time.
- Mannitol, hypertonic saline
- Prevent cough (paralysis)

Question 6

On table STEMI

Answer 6

Confirm diagnosis
Communicate to team and cardiology -> revascularise

Temporise
- Increase myocardial O2 supply
–> FiO2 100%
–> Maintain MAP > 65
–> Hb >80

• Reduce demand
  –> Reduce SNS activity (pain, cough)
  –> Consider beta-block/GTN

Question 7

Anaphylaxis

Answer 7

Confirm diagnosis.
Call for help.
CVC, art line, ICU, report.

Pharm
- IV fluid 20ml/kg, repeat as needed
- Adrenaline IM 500mic then infusion 1-10mic / min, or IV adrenaline 10-40mic titrated
- Dexamethasone 8mg
- Resistant: glucagon 2mg Q5min, vasopressin / norad

Bronchospasm
- Neb salbutamol 5mg (IV dose 250microg in 70kg)
- Neb adrenaline 3-5mg
- Ketamine, MgSO4

Tryptase 1,4,24

Question 8

Trauma

Answer 8

Mobilise resource, assign team leader, allocate roles (airway, procedure, assessment, eFAST, runner, scribe)

Priorities
Exclude any immediate life threatening injuries via a primary suvery as per EMST protocol

Facilitate imaging to diagnose significant major cavity or limb injuries

Prepare patient for safe transfer to theatre for definitive managemnet

Question 9

Autism

Answer 9

Behavioural planning - anticipate communication difficulty, engage carer early, preserve routine

Pre-medication

Review of past anaesthetic records

Question 10

Cerebral palsy

Answer 10

Airway difficulties - contractures, scoliosis, limited neck extension

Aspiration risk

Post-op analgesia - pain, muscle spasm, related respiratory issues.

Question 11

Epilepsy

Answer 11

Continue anticonvulsants

Avoid pro-convulsant drugs

Consider underlying causes

Question 12

Major trauma - how do you approach the clinical assessment?

Answer 12

I will perform a structured primary survey using the A-E approach, addressing life-threatening issues as I find them

A - I will assess the patency and protect the cervical spine. I will look for obstruction, and suction, jaw thrust, or prepare for intubation if compromised.

B - I will assess the respiratory rate, chest movement, oxygen sats, auscultate and percussion the chest.

C - I will assess patients’ haemodynamics, insert large bore cannulas, send bloods, commence fluid resuscitation. I will place pressure on major source of bleeding, and transfuse if shock.

D - I will perform a rapid GCS assessment and assess pupil size and symmetry.

E - I will fully expose the patients to assess for injuries.

To complete the survey, I will keep the patient warm, check BSL, and perform a eFAST scan.

Question 13

How do you perform an AFOI?

Answer 13

My steps are
One, Preparation
- Explain, consent, ensure full monitoring.
- Prepare equipment, including fiberoptic scope, oxygen delivery (cut Hudson or nasal prongs), appropriately sized ETT, difficult airway trolley for backup plans.

Two, Topicalisation
- 200microg glycopyrulate.
- Topicalise with lignocaine in the form of sprays and atomiser, with total dose not exceeding 9mg/kg

Three, Sedation
- Remifentanil

Four, procedure
- Stand in front of patient, insert scope.
- Spray as you go lignocaine as needed
- Confirm landmark, beware of cork-in-bottle phenomenon
- Railroad ETT into trachea. Confirm position with EtCO2
- Proceed to induction.