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116 Cards in this Set

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1. Given the following diagram, what does X represent?
[three container chest drain diagram]
A. ?
B. Maximum pressure against the pleural cavity on expiration
C. Maximimum suction available
D. ?
E. ?

(Question 1 had the picture of the three container chest drain, with the suction limiting outlet the answer to the question)
2. RH28 Retrobulbar block. Sign of brainstem spread
A. Atonic pupil
B. Unilateral blindness in blocked eye
C. Contralateral blindness
D. Diplopia- past papers remembered this as dysphagia
E. Nystagmus
C

Ref: BJA article: Complications of local anaesthesia for opthalmic surgery

3. Something like: Otherwise healthy 20 yo male undergoes surgery for an ORIF tibia for open tib fracture. The limb is exanguinated and the tourniquet correctly applied at 250mmHg. His SBP is 120. When the surgeons go to start there is a small amount of bleeding. Do you..
A. Accept that a small amount of bleeding may occur with a tourniquet
B. Reinflate at a higher pressure
C. Check coags
D. Take tourniquet down, rexanguinate and reinflate
E. Something else

A

ref: ceaccp tourniquets
4. What's this?
4. What's this?
Aortic dissection
5. Fatigue during night shifts can be minimized by:
A. Avoiding daylight
B. not sleeping during day
C short naps during shift
D use of caffeine or stimulants
E. using benzodiazepines for sleep during the day

C

Ref: ANZCA PS43

Many individuals find it difficult to reset their body time clocks to allow for effective
daytime sleep after night duties. Daytime sleep is typically shorter and of inferior
quality compared with sleep at night
(13)
. Minimising the effects of night-time shift
work may be achieved by taking a two hour afternoon sleep prior to the night duty,
taking a 20-30 minute nap during the duty time, ensuring proper meals, and sleeping
as soon as possible after the duty(14)

6. [New] Patient with Acute Intermittent Porphyria presents to hospital with abdominal pain and requires a general anaesthetic. Which drug for PONV would you avoid?
A. Metoclopramide
B. Prochlorperazine
C. Tropisetron
D. Ondansetron
E. Droperidol
A
7. A 65 year old man having a total hip placement under general anaesthetic has continued to take his moclobemide. He becomes hypotensive shortly after induction. The best treatment would be judicious use of
A. adrenaline
B. dobutamine
C. ephedrine
D. metaraminol
E. phenylephrine
F. noradrenaline
E

Ref: OHA
8. The following capnography trace was observed in an intubated and ventilated patient. The most likely explanation for this respiratory pattern is
A. endobronchial intubation
B. endotracheal cuff leak
C. gas sampling line leak
D. obstructive ...
8. The following capnography trace was observed in an intubated and ventilated patient. The most likely explanation for this respiratory pattern is
A. endobronchial intubation
B. endotracheal cuff leak
C. gas sampling line leak
D. obstructive airways disease
E. spontaneous ventilatory effort
C
9. When topping up a labour ward epidural to an epidural for lower segment caesarean section, the optimum level of block when assessed for light touch is to:
A. T2
B. T4
C. T6
D. T8
E. T10
B
10. You are in the pre-admission clinic assessing a 60 year old male who is due to undergo total knee replacement in 10 days time. He is taking Dabigatran 150mg BD for chronic atrial fibrillation. He has no other past medical history and normal renal function. He is planned for a spinal anaesthetic. The most appropriate management for his anticoagulation is:
A. Cease dabigatran 7 days prior
B. Cease dabigatran 3 days prior
C. Cease dabigatran 3 days prior and give bridging anticoagulation
D. Cease dabigatran 24 hours prior and measure INR on day of surgery
E. Continue dabigatran and withhold on day of surgery
B

"The Central European Journal of Medicine - Dabigatran in patients with atrial fibrillation: perioperative and peri-interventional management. For Major procedures ie TKR
A preoperative laboratory testing is usually not meaningful (Recommendation 3C). A dabigatran-sensitive coagulation test (Hemoclot test or ECT) may help to determine whether haemostasis is still impaired.
Dabigatran should be paused the day before the intervention (Day – 1; Recommendation 1C). The therapy should be discontinued 2 days in case of creatinine clearance 50–80 ml/min or interventions associated with a high risk of bleeding. The therapy should be paused 3–4 days before the intervention if creatinine clearance is < 50 ml/min (Recommendation 1C)."
11. A 15 yo girl with newly diagnosed mediastinal mass presents for supra-clavicular lymph node biopsy under GA. The most important investigation to perform pre-operativel
A. CXR
B. CT chest
C. MRI chest
D. PET scan
E. TOE
B

Can't find a reference, but need to assess trachea pre-induction
12. A CTG recording with late prolonged decelerations. Cause:
A. GA
B. Head compression
C. Uteroplacental insufficiency
D. Acute asphyxia
E. Umbilical cord compression.

D

Head compression: early decels
Umbilical cord compression: variable decels

Late decelerations occur when a fall in the level of oxygen in the fetal blood triggers chemoreceptors in the fetus to cause reflex constriction of blood vessels in nonvital peripheral areas in order to divert more blood flow to vital organs such as the adrenal glands, heart, and brain. Constriction of peripheral blood vessels causes hypertension that stimulates a baroreceptor mediated vagal response which slows the heart rate. The time consumed in this two step process accounts for the delay in the timing of the deceleration relative to the contraction

13. A new antiemetic decreases the incidence of PONV by 33% compared with conventional treatment. 8% who receive the new treatment still experience PONV. The no of patients who must receive the new treatment instead of the conventional before 1 extra patient will benefit is
A. 3
B. 4
C. 8
D. 25
E. 33

D

NNT = 1/probability(with intervention) - probability(control)
8% with new treatment. Therefore 12% without.
So NNT = 1/0.12-0.08
= 1/0.04
= 25
14. You are anaethetising a lady for elective laparoscopic cholecystectomy, who apparently had an anaphylactic reaction to rocuronium in her last anaesthetic. There has not been sufficient time for her to undergo cross-reactivity testing. What would be the most appropriate drug to use:
A. vecuronium
B. cisatracurium
C. pancuronium
D. atracurium
E. suxamethonium

B

15. Increase in period bleeding EXCEPT
A. Gingko
B. Garlic
C. Ginger
D. Fish Oil
E. Echinacea
Answer: E

Garlic, ginger, ginko and ginseng: increase bleeding
Fish oil: increases bleeding

Echinachea: no change

16. Post op hip ORIF, commonest periop complication
A. UTI
B. PE
C. Delirium
D. AMI
E. Pneumonia

C
17. You are anaesthetizing a 50 year old man who is undergoing liver resection for removal of metastatic carcinoid tumour. He has persistent intraoperative hypotension despite fluid resuscitation and intravenous octreotide 50 ug. The treatment most likely to be effective in correcting the hypotension is:
A. Adrenaline
B. Dobutamine
C. Levosimenden
D. Milrinone
E. Vasopressin
E
18. 80 year old female for open reduction and internal fixation of a fractured neck of femur. Fit and well. You notice a systolic murmur on examination. Blood pressure normal. On transthoracic echo, she has a calcified aortic valve, with aortic stenosis with a mean gradient of 40mmHg. How do you manage her:
A. Instigate low dose beta blockade
B. Defer, and refer to a cardiologist
C. Perform a transoesophageal echo to get a better look at the valve
D. Proceed to surgery with no further investigation
E. Perform a dobutamine stress echo

D

This is moderate aortic stenosis. Needs emergency surgery.

Mean gradient (Note that this will become less sensitive as the ventricle starts to fail)
Normal: <5
Mild: <25
Moderate: 25-40
Severe: 40-50
Critical: >50

19 (Repeat) Electrocardiogram in the Cs5 configuration. What are you looking at when monitoring lead I.
A. anterior ischaemia
B. atrial
C. inferior
D. lateral
E. septal
A

For Cs5:
RA placed under R clavicle, LA placed at V5, LL placed as normal
Lead ONE is for anterior ischaemia, lead TWO is for inferior / arrhythmia detection
20. (Repeat) Pringles procedure for life threatening liver haemorrhage includes clamping of:
A. Aorta
B. Hepatic artery
C. Hepatic vein
D. Portal pedicle
E. Splenic Artery
D


BJA 2004. 93 (2): 204. Effects of Pringle manoeuvre and ischaemic preconditioning on haemodynamic stability in patients undergoing elective hepatectomy: a randomized trial
“During hepatic resection, the risk of severe intraoperative bleeding represents a major risk. To avoid massive blood loss, continuous or intermittent vascular clamping of the hepatic artery and portal vein (‘Pringle manoeuvre’) is an efficient method to reduce haemorrhage.”
Portal pedicle contains Hep Artery and Portal vein therefore D is correct. Also referred to as portal triad, which is Hep a., Portal v. and bile duct.

21. A 60 y.o. diabetic man has below knee amputation for ischaemic leg. His neuropathic pain is treated with oxycodone 40mg BD and paracetamol 1g QID. He is also on omeprazole 20mg BD for reflux. You decide to start him on gabapentin. Before choosing a dosing regime and starting treatment it is most important that you:
A. cease his omeprazole
B. check his hepatic transaminase level
C. check his renal function
D. CHeck his QT interval on a resting ECG
E. Decrease his oxycodone

C

Renal excretion - must dose reduce.
22. The anterior and posterior borders of the 'triangle of safety', the preferred insertion site for an intercostal catheter, are pec major and:
A. Coracobrachialis
B. Deltiod
C. Lat Dorsi
D. Serratius Anterior
E. Trapezius

C

Formed anteriorly by the lateral border of the pectoralis major, laterally by the lateral border of the latismus dorsi, inferiorly by the line of the 5th intercostal space and superiorly by the base of the axilla.

23. A 39 yo male brought into ED with a compound fracture of his forearm. Has a history of schizophrenia and depression with nucertain medication compliance. He is confused and agitated wuth generalised rigidity but no hyperreflexia. Obs - HR 120, BP 160/90, RR 18, Sats 98 Temp 38.8 Likely Dx?
A. Heat stress from anticholinergics
B. Hypoxic ischaemic encephalopathy
C. NEM
D. Serotonin syndrome
E. Pain from fracture
If C is supposed to read Neuroleptic Malignant Syndrome, then C

From DSM-IV
Severe muscle rigidity and hyperthermia associated with the use of antipsychotic medication
Two or more of the following: diaphoresis, HT, tachycardia, incontinence, dysphagia, mutism, tremor, confusion or altered GCS, leukocytosis, elevated CK.
24. CO2 (laser??) penetrates surface tissue so well with little damage to underlying tissue because:
A. Well absorbed by Hb
B. Poorly absorbed by H20
C. Widely disseminated in tissue
D. Long infrared wavelength
E. Short infrared wavelength

D

Long wavelength, low frequency. Well absorbed by water.

The CO2 laser emits light at a wavelength of 10 600 nm, i.e., in the infrared part of the spectrum. As the beam is not visible, a separate aiming helium- neon laser has to be set up so that its visible red dot hits the target at the same point as the CO2 beam. This laser must always be tested before use on a patient, to ensure proper alignment. The main beam will not totally internally reflect, so to guide it mirrors have to be used. As a consequence it can only be used where a rigid system can be deployed, either with an operating microscope or with a bronchoscope with a mirrored array at the top. Tissue is vaporized by the energy of the beam and because of its wavelength there is very little absorption of energy by deep tissues. Modern CO2 lasers can be controlled to very fine limits, for example setting the beam to ablate to a depth of 0.2 mm. Haemostasis however is quite poor.

25. (NEW) An 80yo man is having a transuretheral bladder resection, the surgeon is using diathermy close to the lateral bladder wall which results in patient thigh adduction. The nerve involved is:
A. Inferior gluteal
B. Obturator
C. Pudendal
D. Scaitic
E. Superior gluteal
B
26. (New) You are involved in research and as part of data collection you collect ASA scores. This type of data is:
A. Categorical
B. Nominal
C. Non-parametric
D. Numerical
E. Ordinal

E

A. Categorical = qualitative
B. Subtype of categorical data where the groups can be arbitrarily assigned numbers, but the groups cannot be ranked meaningfully
C. To use parametric tests, the data must be quantitative and follow a normal distribution
D. Data that can be measured
E. Subtype of qualitative data, where the subgroups can be ranked

27. An otherwise healthy man presents with anaemia. The test that most reliably indicates iron deficiency is decreased
A. MCV
B. serum ferritin
C. serum iron
D. serum transferrin
E. total iron binding capacity
B
30. The maximal allowable atmospheric concentration of nitrous oxide in Australian and New Zealand operating theatres (in parts per million) is
A. 5
B. 25
C. 50
D. 100
E. 200

B

Recommended maximum concentrations in operating theatre (National Occupational Health and Safety Comission, Australia)
• 25 ppm for nitrous oxide
• 0.5 ppm for volatile agents when nitrous oxide is used, 2 ppm when it is not

31. What is associated with down regulation of nicotinic acetylcholine receptors:
A. Guillain-Barre syndrome
B. Organophospate overdose
C. Spinal cord injury
D. Stroke
E. Prolonged neuromuscular blockade

B

• A - False. Effectively a denervation injury which causes UP-regulation.
• B - TRUE. Organophosphate poisoning causes increases in miniature-end-plate potential (MEPP), and thus can cause DOWN-regulation of ACh receptors. Apparently continuous exposure to organophosphates can cause degeneration of pre-junctional and post-junctional structures.
• C - False. Denervation causes UP-regulation.
• D - False. As for spinal cord injury.
• E - Prolonged NMBD use can cause UP-regulation of ACh receptors.

35. A reduction in DLCO can be caused by:
A. Asthma
B. Emphysema
C. Left to right shunt
D. Pulmonary haemorrhage
E. Bronchitis

B

36. A healthy 25 year old woman is 18 weeks pregnant. Her paternal uncle has had a confirmed episode of malignant hyperthermia. She has never had susceptibility testing. Her father and siblings have not been tested either. The best test to exclude malignant hyperthermia susceptibility before she delivers is
A. Genetic test father
B. Genetic test woman
C. Muscle biopsy sibling
D. Muscle biopsy father
E. Muscle biopsy woman
D

From BMHA Not all patients can have a biopsy, these include children less than 10-12yrs (30kgs), pregnant women, and patients on prolonged steroid therapy. If the proband cannot be tested, eg a young child or deceased, then the nearest most appropriate relative is tested. In the case of a young child this would be the parents.
37. (New) The size (in French gauge) of the largest suction catheter which can be passed through a size 8 endotracheal tube which will take up not greater than half the internal diameter is size:
A. 6
B. 8
C. 10
D. 12
E. 14
Answer: D

Endotracheal tube size refers to internal diameter in mm.
French gauge requires a conversion: Fr 1 = 1/3 mm. Therefore Fr 3 = 1 mm

So, Fr12 = 4 mm

38. (Repeat) Pneumoperitoneum cases a decrease in cardiac output at what pressure (or possibly ABOVE what pressure)
A. 10mmHg
B. 20mmHg
C. 30mmHg
D. 40mmHg
E. 50mmHg

A

<10 mmHg: increased CO
10-20: decreased CO (unlikely to cause BP effects)
>20: greatly decreased CO

Miller says > 10.

ref: CEACCP Laparoscopic abdominal surgery

Initially, owing to autotransfusion of pooled blood from the splanchnic circulation, there is an increase in the circulating blood volume, resulting in an increase in venous return and cardiac output. However, further increases in the IAP result in the compression of the inferior vena cava, reduction in venous return and subsequent decrease in cardiac output.

39. 60yo male had total knee replacement. 7 days post-operatively diagnosed with deep venous thrombosis on ultrasound. Was on LMWH. PLT dropped from 300 immediately post-op and now 150x10^9/L. All the following are acceptable treatments EXCEPT-
A. Argabotran
B. Lepirudin
C. Fondapurinax
D. Danaparoid
E. Warfarin

Answer: E

Warfarin (Vit K antagonist) is contraindicated in acute HIT (or if suspected HIT), as it can cause skin necrosis or venous limb gangrene.

Management of HIT:
• First task is to discontinue unfractionated heparin from ALL sources (including heparin-coated lines, etc). LMWH can also cause HIT, therefore not suitable as a replacement. Fondaparinux is an indirect Factor-Xa inhibitor (synthetic pentasaccharide), and there are some reports of it being used in HIT successfully.
• Current recommendations are to treat with DTI's (lepirudin, argatroban, bivalirudin) or danaparoid. Although danaparoid is a LMW heparinoid, there is an extremely low cross-reactivity rate with HIT antibodies, and this is rarely clinically significant.

40. [Repeat] Maximum dose (with low risk of toxicity) of lignocaine (with adrenaline 1:100000) for liposuction with tumescence technique:
A. 3 mg/kg
B. 7 mg/kg
C. 15 mg/kg
D. 25 mg/kg
E. 35 mg/kg
E

"Tumescent technique for regional anesthesia permits lidocaine doses of 35 mg/kg for liposuction. JA Klein - Dermatol Surg, 1990"

CEACCP: "Doses as high as 22–57 mg kg−1 of lidocaine7–9 have been used in the context of tumescent techniques and have been shown to have safe plasma concentration profiles. Addition of non-steroidal anti-inflammatory drugs and steroids has also been used to try to improve the quality and length of analgesia."
43. Drug to facilitate clip placement during cerebral aneurysm surgery;
A. nimodipine
B. mannitol
C. adenosine
D. hypertonic saline
E. thiopentone
C
44. Which drug should be avoided both intra- and post operatively in a woman having surgery who is breast feeding a 6 week old baby?
A. codeine
B. morphine
C. paracetamol
D. parecoxib
E. tramadol
??F. pethidine
Probably A

-can cause deaths. Pethidine not included in some remembered sets of options.

From Acute Pain Management Scientific Evidence 2010:

A. There has been a death in a child of a rapid metaboliser, and other babies have shown decreased alertness, poor feeding, and lethargy
B. Morphine: Safe (The recommended opiod for use in breastfeeding mothers)
C. Paracetamol: Safe
D. Parecoxib not specifically mentioned. Celecoxib and most other NSAIDs: Safe (Ibuprofen safest)
E. Tramadol is concentrated in breast milk, but appears to be safe
F. (If this was even an option): Infants are detectably more drowsy, and norpethidine excretion in neonates is slow. Pethidine is not recommended.

Aspirin: Unsafe
Indomethacin: Associated with maternal psychosis in the post-natal period.
Fentanyl, Midaz, propofol: so safe that mothers probably don't need to discard breast milk after a GA.
45. A three year old girl for an elective hernia repair is seen immediately prior to surgery. It is revealed she had 100mL of apple juice 2 hours ago. The best course of action is to:
A. Postpone surgery for 2 hours
B. Postpone surgery for 4 hours
C. Postpone surgery for 6 hours
D. Cancel surgery
E. Continue with surgery
E

From ANZCA PS15

Healthy adults
* solids 6 hours
* clear fluids <200mL up to 2 hours

Healthy children > 6/52 for elective
* Solid food and formula up to 6 hours
* Breast milk up to 4 hours
* Clear fluids up to 2 hours

Healthy infants <6/52 for elective
* Formula and breast milk up to 4 hours
* Clear fluids up to 2 hours

Consider PPI for patients with GORD
46. In accordance with their belief that blood transfusion is wrong, a Jehovah's Witness may consent to all of the following except:
A. Cryoprecipitate
B. Immunoglubulins
C. Fresh Frozen Plasma
D. Factor VIIa
E. Prothrombinex
C

Blue Book 2011: Acceptable: cryo, Hb, Ig, Albumin, clotting factors, EPO, interferon.
47. 80 year old lady with fractured NOF needing ORIF. On examination had a systolic murmur. Arranged TTE which showed a calcific aortic valve with peak velocity of 4 m/s. Using the simplified Bernoulli equation, what is the peak pressure gradient across the valve:
A. 16 mmHg
B. 32 mmHg
C. 48 mmHg
D. 64 mmHg
E. 80 mmHg
D

P1-P2 = 4V^2

4 * 16 = 64 mmHg
48. You have developed a new cardiac output monitor called WaCCO. You want to compare the readings with the gold standard, a pulmonary artery catheter. What is the best statistical method to present the data/results:
A. Funnel plot
B. Bland-Altman plot
C. Forest plot
D. Galbraith plot
E. Partial regression plot
B
50. A 60 year old, triple vessel disease normal LV Post CABG hypotensivem ST elevation II, avF, CVP 15 PCWP 25. Normal SVR. Echo shows:
A. A early diastolic mitral inflow dynamic with atrial systole
B. Left inferior hypokinesis
C. Left ventricle collapse in systole
D. Right ventricle dilation and TR
E. Severe Mitral Regurg
B

51. Maximum amplitude from TEG or ROTEM decreased give
A. Cryoprecipitate
B. FFP
C. Platelets
D. Prothrombinex
E. Tranexamimic acid

C
52. Young male, previous IVDU, now on 100mg Methadone per day has a laparotomy with an effective epidural. Amount of IV Morphine needed per HOUR:
A. 1mg
B. 2mg
C. 4mg
D. 8mg
E. 16mg

E

Med Calc:
100mg methadone = 400 mg morphine
400/24 = 16

PO Morph <100 ----- 1:4
PO Morph 100-300 -- 1:8
PO Morph >300 -----1:12

53. A healthy 25 year old woman is 18 weeks pregnant. Her paternal uncle has had a confirmed episode of malignant hyperthermi:A. She has never had susceptibility testing. Her father and siblings have not been tested either. The best test to exclude malignant hyperthermia susceptibility before she delivers is
A. Genetic test father
B. Genetic test woman
C. Muscle biopsy sibling
D. Muscle biopsy father
E. Muscle biopsy woman
D
54. Fluoroscopy in the operating theatre increases the exposure of theatre personnel to ionising radiation. Best method to minimise one's exposure to such radiation is to
A. have dosimeter checked at least 6-monthly
B. limit exposure time to radiation
C. maximal distance from radiation source
D. stand behind transmitter of C arm
E. wear protective garments

C

Because the intensity of scattered radiation is inversely proportional to the square of the distance from the source, the best protection is physical separation. A distance of at least 3 feet from the patient is recommended. Six feet of air provides protection the equivalent of 9 inches of concrete or 2.5 mm of lead.

57. Ibuprofen dose for one year old child tds regular post-op dose
A. 5mg/kg
B. 10
C. 15
D. 20
E. 25

B

MIMS 5-10mg/kg Q6-8H

58. AICD, what does a magnet do
A. Maintain defib activity & activate asynchronous pacing
B. maintain anti tachycardia pacing & deactivate asynchronous pacing
C. Deactivate anti tachycardia pacing & activate asynchronous pacing
D. Deactivate defib & activate asynchronous pacing
E. Deactivate defib & deactivate asynchronous pacing

?D

I think they actually turn off the defibrillator, but maintain the usual pacing mode?

"With the ICD, approximately 99% of them are programmed to have their anti-tachycardia function disabled in the presence of a magnet without affecting their bradycardia pacing."
60. A 35yo man collapses in shopping mall and is resuscitated by bystanders using an AED. On admission to hospital his ECG was as below;
ECG - sinus, rate ~60, normal axis, borderline PR interval, RSR' in V1 and V2 with ST elevation and inverted T waves (Brugada sign)
A. Acute pericarditis
B. Brugada
C. Cocaine intoxication
D. Coronary artery spasm
E. Long QT syndrome
B

Incomplete RBBB, ST elevation V1-V3. T-wave inversion. Positive family history. More common in SE Asians.
61. A 58yo with solitary hepatic metastasis from colon cancer scheduled for resection of R lobe of liver. Inorder to manage the risk of intra-operative haemorrhage, it is most important to maintain:
A. High CVP in anticipation of heavy blood loss
B. Decreased MAP to reduce arterial bleeding
C. Decreased CVP to reduce venous bleeding
D. Normal MAP in anticipation of heavy blood loss
E. Normal CVP to ensure adequate filling of the heart.

C

Mortality ~3% in selected population (otherwise healthy patients with resections <50% of non-cirrhotic livers)
Child-Pugh B+C contraindicated
Pre-existing cirrhosis confers 32% chance of post-operative liver failure
Hepatic pedicle clamping - warm ischaemic time max 60 mins. If intermittent (15 on 5 off) then up to 90 mins.
Clamping makes BP go up.

Theoretical concerns re: epidurals given post-op coagulopathy

Use tranexamic acid
CVP and IABP monitoring
Temp and NMB monitoring
Monitor closely for hypoglycaemia

Aim CVP < 5 (May cause low BP and air embolism but reduces bleeding)
Minimise mean airway pressure and PEEP
Beware of IVC compression with posterior tumours -> profound hypotension

N-acetylcysteine infusions might help liver recover. Evidence is equivocal.

Avoid paracetamol until liver dysfunction has resolved post-op.
May develop ascites transiently post-op and become intravascularly dry - consider 20% albumin.
Likely to need FFP

63. A man is admitted to ICU with a Sodium of 105 mmol/L. What is the maximum his sodium should be raised in the next 24 hours
A. 5 mmol
B. 10 mmol
C. 15 mmol
D. 20 mmol
E. 25 mmol
Answer: B

OHA: Says <12mmol in 24 hours.

Because a 4 to 6 meq/L increase in serum sodium concentration appears to be sufficient to reverse the most severe manifestations of acute hyponatremia and because actual correction often exceeds what is intended, an increase of 4 to 6 meq/L in 24 hours is a reasonable therapeutic goal for all patients. Every effort should be made so that the increase in serum sodium is less than 9 meq/L in any 24-hour period.

For patients with severe symptoms, the first day's goal may be achieved in the first few hours since the daily rate rather than the hourly rate of correction is associated with osmotic demyelination.
64. What is the distance from lips to carina in a 70 Kg man?
A. 21 cm
B. 23 cm
C. 25 cm
D. 27 cm
E. 29cm

D

15cm from teeth to cords. 12 from cords to carina.

Lee's Synopsis of Anaesthesia: The average distance from the central incisors and the carina is 27cm in an adult male and 23cm in a female. The tip of the tube moves about 4cm caudad as the neck moves from full extension to full flexion.



There are other answers going around that reference an Indian paper. These are wrong - the Indian paper was done to demonstrate the difference between the caucasian values given in Miller, and the general Indian population.

65. The action of which laryngeal laryngeal muscle opens the cords?
A. Cricothyroid
B. Posterior cricoarytenoid
C. Lateral Cricoarytenoid
D. Thyroarytenoid
E. Vocalis

B

Lee's synopsis:

Posterior cricoarytenoids: open glottis
Lateral cricoarytenoids: close glottis
Interarytenoid: close glottis
Cricothyroid: tense cords
Thyroarytenoid: Relax cords
Vocales: relax cords

66. Induction of a 4yr old child with Arthrogrophysis multiplex congenita, however you find it difficult to place the laryngoscope. What is the concern? (paraphrased question here, can’t remember all possible answers)
A. MH
B. Neuroleptic malignant syndrome
C. ?
D. opioid induced rigidity
E. TMJ rigidity

E

OHA: Arthrogryposis
Skin and SC tissue abnormalities, contracture deformities, micrognathia, cervical spine and jaw stiffness, congenital heart disease (10%), difficult airway and venous access, sensitive to thiopental, hypermetabolic response is probably not MH

70. A patient is suffering from aortic dissection with acute aortic regurgitation. BP 160/90, HR 100 & evidence of acute pulmonary oedema. What is your immediate management?
A. Beta-blockers
B. Dopamine
C. Dobutamine
D. Sodium nitroprusside
E. Intra-aortic Balloon Pump

D

Because of the APO and AR. If there was no AVR and APO then A would be a better answer.

The primary goal is to reduce the force of left ventricular con- traction without compromising perfusion, thus reducing shear forces and preventing further extension of the dissection or poss- ible rupture. Beta-blockers (e.g. esmolol, metoprolol) and labetalol (beta- and alpha-blocker) can be used. If further reduction in BP is required, sodium nitroprusside, glyceryl trinitrate, or hydralazine are appropriate. Beta-blockers should be given first before vasodi- lators, as the reflex catecholamine release due to vasodilatation may increase left ventricular contractions.

71. Presented are a femoral arterial line trace & a central venous line (JVP) trace - looked like it was demonstrating elevated right atrial pressures... What is demonstrated by these pressure waveforms?
A. Aortic Stenosis
B. Aortic Regurgitation
C. Pulmonary Regurgitation
D. Tricuspid Regurgitation
E. Mitral Regurgitation
71. Given the following femoral AL and CVP traces, what is the most likely cause? [diagram]
A. Pulmonary stenosis
B. Left Ventricular Failure
C. Tricuspid Regurgitation
D. Aortic Stenosis
E. Mitral Stenosis
71. Trace of an Arterial line and RA venous pressure. The venous pressure started escalating prior to the onset of the arterial pressure rise (all 4 regurg options, one stenotic option)
Who knows, but probably tricuscpid regurg?
72. The MELD score is calculated using INR, Bilirubin & what?
A. Creatinine
B. Albumin
C. Urea
D. AST
E. Ammonia
A

INR, bilirubin and creatinine
73. In resuscitating a newborn infant after delivery, the time at which you would like to achieve arterial oxygen saturation of 85-90%:
A. 2mins
B. 3mins
C. 4mins
D. 5mins
E. 10mins
73. Aim for saO2 of 85-90% in neonatal resuscitation by-
A. 1min
B. 2min
C. 3min
D. 5min
E. 10min

E

ARC guidelines: 10 mins

Measured off R arm because of PDA

74. (repeat): You inserted a central venous line and peripheral arterial line for a patient who is having a tumour removed via craniotomy. The transducers of both the lines were placed at the level of the right atrium 13cm below the level of the external auditory canal. MAP is 80mmHg, CVP 5mmHg. What is the CPP?
A. 62mmHg
B. 65mmHg
C. 70mmHg
D. 75mmHg
E. 80mmHg

B

75. What proportion of the population are heterozygous for plasma cholinesterase deficiency?Having a Dibucaine number of 30-80.
A. 0.04
B. 0.4
C. 4
D. 14
E. 40

C



Peck & Hill p183

76. You are putting in a internal jugular central venous line. Which maneuvre causes maximal distension of the internal jugular vein?
A. CPAP
B. Breath hold at end expiration
C. Manual compression at the base of the neck
D. Trendelenberg position
E. Valsalva manoeuvre

E



Valsalva - probably gives maximal distention

82. A 40 yo woman for laparotomy to remove phaeochromocytoma under combined epidural and general anaesthesia. Pre-operatively treated with phenoxybenzamine and metoprolol. Intra-operatively, blood pressure is 250/130 despite high dose phentolamine and SNP. HR is 70/min and SaO2 are 98%. The next most appropriate treatment is:
A. Epidural Lignocaine
B. IV Esmolol
C. IV Hydralazine
D. IV Magnesium
E. IV Propofol

Answer: D



CEACCP: Adequate pre-operative care aims to limit the severity of these episodes but vasodilators must be prepared and close at hand. Such agents include boluses of phentolamine 1–5 mg and labetalol 5–10 mg or sodium nitroprus- side, GTN and nicardipine infusions. Sodium nitroprusside has a rapid onset and offset of action; it is not associated with toxicity when used in recommended doses. Nicardipine is a calcium chan- nel blocker which has been used as an infusion for fast titration of blood pressure. The use of isoflurane as an antihypertensive agent is a practical alternative. Magnesium sulphate infusions have recently been described (inhibits catecholamine release, exerts a direct vasodilator effect and reduces α-receptor sensitivity).

83. Best option to reduce risk of Ventilator induced pneumonia?
A. Nurse in supine position
B. Early spontaneous ventilation through ETT
C. Oral hygiene
D. Use antacids
E. Regularly change breathing circle



A - 30 degrees head up


B - Avoiding intubation, limiting time


C - Yes


D - Increasing pH increases bacteria in GIT theoretically: ?increases pneumonia


E - Leave connected

85. 37 female presents to ED with headache and confusion. She is otherwise neurological normal and haemodynamically stable. Urine catheter and bloods takes. UO > 400ml/hr for 2 consecutive hours, Serum Na 123 mmol/l, Serum Osmolality 268, Urine Osmolality 85 The most likely diagnosis is A. Central diabetes insipidus B. Nephrogenic diabetes insipidus C. Psychogenic polydipsia D. Cerebral salt wasting E. SIADH

C



Hyponatraemic
Hyposmolar
Large urine output
Dilute urine

A. Central diabetes insipidus: caused by inadequate secretion of ADH. Polyuria, hypernatremia, hyperosmolarity, dilute urine
B. Nephrogenic diabetes insipidus: Resistance to action of ADH on the kidneys. Polyuria, high normal or hypernatraemia, high normal or hyperosmolarity, dilute urine
C. Hyponatraemia, hyposmolarity, low urine osmolarity, increased urine output.
D. Cerebral salt wasting follows CNS injury, and is like SIADH except that there is evidence of hypovolaemia
E. Hyponatraemia, hyposmolarity, urine osmolarity >100 (normal minimum 40-100). Urine output determined usually by water intake, but given SIADH causes fixed ADH secretion urine output instead becomes dependant on salt intake (and excretion) only.

91. The American Heart Association (AHA) guidelines for preoperative cardiac risk assessment define a poor functional capacity as only able to exercise at a level of less than 4 metabolic equivalents (METs). Exercise capacity of 4 METs corresponds to
A. light housework such as dishwashing
B. heavy work around the house such as moving heavy objects
C. jogging 2km
D. brisk walking on level ground (6km/hr)
E. slow walking on level ground (3km/hr)

A

92. Pneumoperitoneum for laparoscopy is commonly associated with each of the following EXCEPT
A. arterial pressure
B. vasopressin secretion
C. inotropic action
D. systemic vascular resistance
E. venous resistance

C



Miller table



A - Up


B - Up


C - Correct - decreases


D - Up


E - Up

93. 7 year old with closed head injury. Intubated and ventilated in ICU. Serum sodium 142. Most appropriate maintenance fluid is:
A. 0.3% saline plus 3% glucose
B. 0.45% saline plus 5% glucose
C. 0.9% Saline
D. Hartman's solution
E. Hartman's plus 5% glucose

C



(Because head injury -> want isotonic solution)

94. Patient with Marfan's syndrome. Thoracoabdominal aortic aneurysm repair. 24 hours later in ICU noted to be blood in CSF drain and patient obtunded. Most appropriate urgent management:
A. CT head
B. Coagulation screen
C. CSF culture
D. MRI brain
E. MRI spine

A

99. (new) The respiratory pattern most likely seen in an acute C5 spinal cord injury:
A. increased respiratory rate
B. arterial hypoxaemia
C. chest wall immobility
D. ?
E. ?

C

100. (new) Afterload reduction is most useful in which of the following:


A. aortic stenosis
B. tetralogy of fallot
C. cardiac tamponade
D. Mitral incompetence
E. aortic incompetence

AS - worse


Tetralogy of fallot - reduced afterload increases R => L shunt


AR + MR - benefit


Tamponade - benefit

101. A 20 year old man was punched in the throat 3 hours ago at a party. He is now complaining of severe pain, difficulty swallowing, has a hoarse voice and had has some haemoptysis. What is your next step in his management?
A. Awake Fibreoptic Intubation
B. CT scan for laryngeal fractures
C. Direct laryngoscopy after topicalising with local anaesthetic
D. Nasopharyngoscopy by an ENT surgeon
E. Soft tissue xray of the neck

D

102. Preferred method for treating raised INR
A. FFP
B. FFP + prothrombinex
C. FFP + vitamin K
D. prothrombinex
E. prothrombinex + vitamin K

E



Prothrombinex + vit K for all


Add FFP if life-threatening severe bleeding

103. Regarding PS31, Level II check includes:
(Multiple options, can’t remember exactly)

Service Label


High pressure system - O2 cylinder, pipeline supply


Low pressure system - rotatmeters, vaporizers


Leak Test


CO2 absorbtion


Ventilator


Scavenging


Emergency ventilation



Level three:


Changed circuit


Changed vaporizer


IV anaesthetic devices


Intubation / LMA gear


Suction


Gas analysis


Monitoring and alarms


Humidifiers


Filters



107.(New) A 50 yo man with a Deep Brain Stimulator (DBS) secondary to Parkinson's disease is scheduled for elective surgery. What is the best management regarding this device?
A. Place diathermy pad as far away from DBS as possible
B. Turn off DBS and commence with oral Levodopa
C. Turn off DBS during surgery and turn on prior to extubation
D. Use Bipolar diathermy

D

108. (New) Fit and well G1P0 post epidural complaining of loss of sensation over posterior leg, lateral thigh and foot with weak flexion of knee. Which best explains the findings? (Not remembered quite correctly.)
A. Femoral neve
B. Obturator nerve
C. Sciatic nerve
D. Lumbosacral plexus
E. Peroneal nerve

D

41. A patient with known metastatic lung cancer is found to have hypercalcaemia, all of the following would help excretion of calcium except
A. Bisphosphates
B. Calcitonin
C. Frusemide
D. Sodium Chloride
E. IV crystalloids

Answer: A


A. Inhibit bone resorption and reduce serum calcium levels, but do not enhance excretion
B. Promotes urinary calcium excretion
C. Reduce calcium resorption in loop of Henle
D. Increases urinary calcium excretion
E. Increases excretion

110. (New, long stem taking up half the page) Male in 60's one day post laparotomy. Management includes: IVH @40ml/hr, 2L oxygen via nasal prongs, and a morphine PCA. Observations: t38.8C, RR14, Sats 88% Examination: mildly sedated, bibasal creps. In addition to increasing the FiO2 what would be your initial management?
A. Incentive spirometry
B. Diuresis
C. Broad spectrum ABs
D. Naloxone 100mcg increments
E. ?

C

111. A patient is coming for an operation on his upper limb. 5mls of 0.75% ropivacaine is placed around the structure seen below. What is the most likely consequence of this?
A. Unable to abduct fingers
B. Unable to extend wrist
C. Unable to oppose little finger and thumb
D. Unable to pronate arm
E. Unable to [unsure of 5th option]
[Also please note that the picture was very poorly produced. You could make out a triangle structure and the humerus but nothing else]



Picture was of probe on posterior upper arm

??radial nerve block



B

112. A 40 year old man suffered a traumatic brain injury 2 days ago. He does not meet the criteria to be certified brain dead. What investigation will be most useful to assess cerbral function prior to organ donation.
A. Electroencephalogram
B. Somatosensory evoked potentials
C. Auditory evoked potentials
D. Motor evoked potentials
E. BIS

A

113. Isoflurane is administered in a hyperbaric chamber at 3 atmospheres using a variable bypass vapouriser, at a constant fresh gas flow and vapour dial setting, the vapour produced will be:
A the indicated vapour concentration
B three times the indicated vapour concentration
C one third the partial pressure obtained at 1 atmosphere
D the same partial pressure as is obtained at 1 atmosphere
E three times the partial pressure obtained at 1 atmosphere

D

114. What is most likely to occur if the earth/grounding plate that is attached to a patient for use with monopolar diathermy malfunctions?
A electrocution
B electrical interference with monitors
C electrical burns
D ignition of gases/volatiles
E microshock

C

115. A 24yo primigravida, 25/40 gestation, BP 150/90 on 4 occasions. No signs of pre-eclampsia. Which antihypertensive is inappropriate?
A. diazoxide
B. metoprolol
C. enalapril
D. hydralazine
E. nifedipine

C

116. Post-spinal surgery, patient notices paraesthesia of R arm, surgeon thinks this is an ulnar nerve palsy due to poor positioning. What sign will distinguish a C8-T1 nerve root lesion from ulnar nerve neuropathy?
A. paraesthesia in little finger
B. paraesthesia in the distribution of the interscalene nerve
C. weakness in adductor digiti minimi
D. weakness in the abductor pollicis brevis
E. weakness in lateral interosseus

D

119. According to PS09, the minimum requirement for administering propofol for conscious sedation is
A. Medical practitioner with a skilled assistant that is seperate from the assistant to the proceduralist
B. Medical practitioner
C. Nurse supervised by proceduralist with recent ALS training
D. Specialist anaesthetist
E. Nurse with advanced airway skills

A

122. Reasons infants desaturate faster than adults on induction (?did it say rapid sequence?)
A. More difficult to preoxygenate
B. More rapid detection of hypoxia
C. FRC decreased more than adults
D. Drugs work more rapidly
E. Persistent L->R shunt (or was it right to left?)

C

125. Adenosine can be used to treat
A. Atrial fibrillation
B. Atrial flutter with variable block
C. WPW syndrome
D. Ventricular tachycardia
E. Torsades

D

126. Induction with thio 5mg/kg, scoline 2mg/kg, Difficult to open mouth, Finally intubated. Next step
A. Continue surgery with tiva propofol
B. Abandon surgery
C. Wait for co2 to rise restart surgery after 30 min
D. Continue with inhalational agents
E. Give calcium as potassium may have raised.

Answer: A



OHA:



Switch to MH safe anaesthetic


Wait 15 mins and monitor for increasing heart rate / CO2

127. In a patient with an intra-orbital haemorrhage, following local anaesthetic injection, the adequacy of ocular perfusion is best assessed by
A. angiography
B. direct ophthalmoscopy
C. indirect ophthalmoscopy
D. intra-ocular pressure tonometry
E. palpation of the globe by an experienced clinician

C



Royal college of anaesthetists and opthalmologists consensus document

128. A patient is in Class IV Haemorrhagic Shock, secondary to a gunshot wound to the abdomen. He is clinically coagulopathic 30 minutes later. He has received intravenous Hartmann's 1L. The coagulopathy is likely related to:
A. acidosis
B. dilution of clotting factors
C. hypothermia
D. systemic release of tissue factor
E. tissue hypoperfusion

E



Causes of coagulopathy:


Tissue injury / hypoperfusion


Consumption of clotting factors


Acidosis


Hypothermia


Dilution of clotting factors


Hyperfibrinolysis

129. (Repeat) A 20 kilogram child suffered 15% full thickness burns 6 hours ago. Optimum crystalloid resuscitation for the first hour is:
A. 160ml
B. 260ml
C. 360ml
D. 460ml
E. 660ml

C



4 * 20 * 15 = 1200 mL


So 600mL first 8 hours, 600mL next 16


So 300mL/h for next 2 hours, then 600/16.



40+20 = 60mL/h maintenance.



4ml/kg * BSA burns over 24/hours, with 1/2 in the first 8 hours and the rest over the next 16, plus maintenance.

130. You’re anaesthetizing an otherwise well 40 yo male for a craniotomy. Propofol and remifentanil TIVA. Using entropy. The MAP is 70 mmHg, heart rate is 70 bpm, Sats are 98%, state entropy is 50 and the response entropy 70. Most appropriate next step is
A. give 0.5 mg metaraminol iv
B. use NMT to assess train of four ratio
C. change to volatile anaesthetic
D. do nothing
E. increase propofol TCI concentration by 0.5

B

Patient is likely not paralysed.
B seems appropriate. Other options: increase analgesia.

BiS: bispectral index: analyses EEG

Entropy:
Sate entropy: 0.8-32Hz (primarily EEG)
Response entropy: 0.8-47Hz (Includes EMG dominant frequencies)

RE - SE difference indicates upper facial EMG activation in response to an external stimulus.
Usually pain. Requires a non-paralysed patient.

Elevations in RE are generally followed by elevations in SE.

From CEACCP article:
"During anaesthesia, state entropy and response entropy normally have the same value, but if response entropy diverges by more than 10 points from the state entropy value the ‘analgesic’ component of the anaesthetic may be inadequate."

131. The normal physiological response following ECT is
A. transient tachycardia followed by bradycardia and hypotension
B. transient bradycardia followed by tachycardia and hypertension
C. unpredictable
D. transient tachycardia followed by bradycardia and hypertension
E. tachycardia and hypotension

B



From CEACCP:

"The cardiovascular response is secondary to activation of the autonomic nervous system. Beginning with the electrical stimulus, there is an initial parasympathetic discharge lasting 10 – 15 s. This can result in bradycardia, hypo- tension, 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.2 Myocardial oxygen consumption, as deter- mined by the rate – pressure product (RPP), therefore increases. RPP increases are more marked with bilateral ECT, in older patients and during hyperventilation-induced hypocap- nia. Simultaneously, seizure activity increases tissue oxygen consumption, potentially redu- cing myocardial oxygen supply. Myocardial ischaemia and infarction can therefore occur, particularly with pre-existing disease. Left ven- tricular systolic and diastolic function can remain decreased up to 6 h after ECT. Cardiac rupture has also been described."

132 (repeat) ->also recalled as Q148 so one must be a mistake –see below Aspirin Overdose. What will enhance her elimination most effectively?
A. Mannitol
B. Haemodialysis
C. lignocaine
D. ?
E. BIcarbonate infusion

B



From Oh's

SALICYLATES (ASPIRIN) Moderate toxicity occurs with serum concentrations 500– 750 mg/l (3600–5500 mmol/l) and severe toxicity with concentrations > 750 mg/l. Serum concentrations alone do not determine prognosis. The elimination half-life increases significantly with increasing concentrations. Small reductions in pH produce large increases in non- ionised salicylate, which then penetrates tissues. CLINICAL FEATURES Tinnitus, deafness, diaphoresis, pyrexia, hypoglycaemia, haematemesis, hyperventilation and hypokalaemia may all occur. Coma, hyperpyrexia, pulmonary oedema and acidaemia are reported as more common in fatal cases, which present late. TREATMENT Multiple-dose AC may be effective but is not established. Vitamin K and glucose are used to correct hypoprothrombi- naemia and hypoglycaemia. Urinary alkalinisation (see above) will decrease the amount of non-ionised drug available to enter tissues, but is hazardous and should only be used for the most severely ill patients. Extracorporeal techniques are very effective in removing salicylates and correcting acid–base disturbance. Although indications for their use are yet to be defined, they should be considered for severe cases.

133. A 50 year old male is having an aortic valve replacement for aortic stenosis. He is stable on bypass initially but after the first dose of cardioplegia his MAP falls to 25mmHg, CVP 1 and his mixed venous oxygen saturation is 80%. What is the best management in this situation.
A. Metaraminol bolus
B. Commence an adrenaline infusion
C. Increase oxygen flow rate
D. Increase pump flow rate
E. IV crystalloid bolus

D



Can't find reference, but this seems right?

134. An eighty year old man presents to the emergency department with two hours of severe abdominal pain. On examination he has a tender pulsatile 8cm mass. His GCS is 12, heart rate 104, blood pressure 80/49, Temp 35 degrees, SpO2 92%, respiratory rate is 30/min. What is the next appropriate step.
A. Commence a vassopressor to support the circulation and improve end organ perfusion.
B. Obtain IV access and crossmatch
C. Intubate to secure the airway and prevent aspiration
D. Perform an abdominal ultrasound to confirm diagnosis
E. Ventilate with a bag valve mask to improve saturations

B



Likely leaking AAA


Needs emergency laparotomy


PPV may worsen venous return and BP


Increasing BP may result in more bleeding


Ideally do as little as possible until in OT


137. A PiCCO monitor may be used to measure cardiac output through use of:
A. Lithium Dilution Cardiac Output (LiDCO)
B. Pulse contour analysis
C. Pulse contour analysis and thermodilution
D. Thermodilution
E. Thermodilution and aortic flow doppler

C



Swan-Ganz pulmonary artery catheter (PAC) - gold standard, but also most invasive. Uses thermodilution

PiCCO: Thermistor tipped arterial line placed in central artery (usually femoral, can use axillary), calibrated using CVL + thermodilution. Inaccurate if intracardiac shunts, pneumonectomy, IABP, aortic aneurysm or stenosis, AR, arrhythmia

Vigileo: Standard arterial line. Absolute values less accurate than PiCCO as not calibrated. Same things make it inaccurate as PiCCO. Often underestimates CO on absolute values, but trends reasonably accurate.

LiDCO: Uses lithium dilution and standard arterial line. Pulse power analysis. Quite accurate.

USCOM: Suprasternal USS doppler. Assumes normal aortic valve cross-sectional area using a nomogram. Inaccurate if beam misaligned. Poor accuracy in low or high output states.

TOE: Poorly tolerated without intubation. CO = CSA x VTI x HR (CSA: aortic cross sectional area. VTI: area under the curve across the aortic valve.)

138. A tablet containing OxyContin 40mg and naloxone 20mg offers the following advantage over OxyContin alone.
A. Less potential for abuse
B. Less constipation
C. Less sedation
D. Less respiratory depression
E. Less pruritus

B



MIMS: "The naloxone component in a fixed combination with oxycodone is indicated for the therapy and/or prophylaxis of opiod induced constipation."

141. Immunity to Hepatitis B is demonstrated by the presence of
A. Hepatits B core antibodies
B. Hepatits B core antigens
C. Hepatits B surface antibodies
D. Hepatits B surface antigens
E. Any of the above

C



http://www.cdc.gov/hepatitis/hbv/pdfs/serologicchartv8.pdf

142. In an adult with advanced liver cirrhosis, the best predictor of bleeding is
A. Dysfibrinogenaemia
B. Hypoalbuminaemia
C. Prolonged Prothrombin time
D. Portal Hypertension
E. Thrombocytopaenia

E

Ref: OHA p140. Bleeding: Prothrombin time is usually prolonged and can be improved by daily vitamin K injections. Thrombocytopenia is also common, as is defective platelet function. Bleeding is more likely to be due to thrombocytopenia than clotting factor deficiency. Clotting studies and FBC must be checked perioperatively and adequate provision must be made for the crossmatch of blood, FFP and platelets.

143. 65 year old lady with acute cholecystitis presenting for cholecystectomy. Has known hyperparathyroidism. Calcium 2.2mmol/L (normal values given). Initial treatment with:
A. calcitonin
B. frusemide
C. intravenous fluids
D. magnesium
E. mythramycin

Answer: C

From up to date:

Mild hypercalcemia (<3mmol/L): Avoid diuretics. Adequate hydration
Moderate hypercalcemia (3-3.5mmol/L): NS and bisphosphonates if develop delirium
Severe hypercalcemia: (>3.5mmol/L): NS 200-300ml/h, aim UO 100-150mL/h, calcitonin, bisphosphonates

144. SG67 20 year old male 80kg presents post house fire with 30% burns. Using the Parkland formula how much fluid should he have replaced in the first 8 hours.
A. 2.6L N/saline
B. 3.6L N/saline
C. 3.6L CSL
D. 4.8L N/saline
E. 4.8L CSL

E



4 * 80 * 30 = 9600 over 24 hours.


4.8L CSL in first 8 hours.

145 The thoracic paravertebral space is continuous down to
A. T10
B. T12
C. L2
D. L4
E. S1

B

146. To best visualise a superficial peripheral nerve you should use a
A. low frequency probe at 90 degrees to the skin
B. high frequency probe at 90 degrees to the skin
C. low frequency probe at 45 degrees to the skin
D. high frequency probe at 45 degrees to the skin
E. low frequency probe at 75 degrees to the skin

B



USRA http://www.usra.ca/transducer.php



For superficial structures (e.g. nerves in the interscalene, supraclavicular and axillary regions), it is ideal to use high frequency transducers greater than or equal to 7 MHz. Transducers in the range of 10-15 MHz are preferred but depth of penetration is often limited to 2-3 cm below the skin surface.

For visualization of deeper structures (e.g. in the infraclavicular and popliteal regions), it may be necessary to use a lower frequency transducer (less than or equal to 7 MHz) because it offers ultrasound penetration of 4-5 cm or more below the skin surface. However, the image resolution is often inferior to that obtained with a higher frequency transducer.

149 You have administered a regional anaesthetic to a primiparous woman for an emergency caesarean section. Soon after delivery of the baby, the woman complains of chest pain and dyspnoea, then loses consciousness. What is the most likely cause of her loss of consciousness?
A. Administration of suxamethonium
B. Anaphylaxis to oxytocin
C. Amniotic fluid embolus
D. Pulmonary Embolus
E. Eclamptic seizure

C



There are a few papers that mention AFE occuring within 30 minutes of delivery.

(Rina says PE. This is the most common cause of maternal death after haemorrhage. It can occur immediately following delivery, as the decompression of the IVC results in increased flow through central veins. She can't find a reference though)

150. The faster rate to desaturation observed in morbidly obese patients is due to:
A. Decreased residual volume
B. Decreased functional residual capacity
C. Decreased diffusion capacity
D. Increased closing capacity
E. Increased pulmonary blood volume

B

[Nonum 1] In preadmission clinic with patient with a tracheostomy. To enable patient to talk you would-
A. Deflate tracheostomy cuff, insert one-way valve, insert fenestrated piece
B. Deflate tracheostomy cuff, remove one-way valve, insert fenestrated piece
C. Inflate tracheostomy cuff, remove one-way valve, insert fenestrated piece
D. Inflate tracheostomy cuff, insert one-way valve, insert fenestrated piece

A



CEACCP management of tracheostomy:



If the tube is cuffed, the fenestration lies above the cuff. Deflation of the cuff during spontaneous respiration (with the fenestrated inner tube in place) allows air to pass caudally through the tracheostomy lumen and fenestration, as well as around the tracheostomy tube, and up through the larynx. This encourages maximal airflow through the upper airways during speech. A one-way speaking valve can also be used with the tracheostomy tube to maximize speech. This allows air to be entrained through the tube during inspiration. The valve then closes during expiration such that exhaled air must pass through the natural airway and vocal cords to exit the lungs, thus aiding phonation.

[Nonum 2] Rheumatoid arthritis. Most common C-spine abnormality is anterior subluxation. What is next most common?
A. Posterior
B. Vertical
C. Lateral
D. Subaxial
E. ?

B



CEACCP http://ceaccp.oxfordjournals.org/content/6/6/235.full.pdf+html



Anterior 80%


Vertical 10-20%


Posterior 5%


Lateral no number, presumably rare

[Nonum 3] A 13kg child booked for elective procedure. Has had 100mL of clear fluid 2 hours ago. Management?
A. Delay surgery for 2hours
B. Delay surgery for 4hours
C. Delay surgery for 6hours
D. Proceed with surgery
E. Cancel surgery

D



PS15

[Nonum 4] Radical prostatectomy. Long operation and constant ooze. Surgeon asks if patient on 'aspirin'. You do a TEG. Shown TEG- fibrinolysis but also long r time. What treatment?
A. FFP
B. Cryoprecipitate
C. Desmopressin
D. Tranexamic acid
TEG, think it was picture of low fibrinogen

Check TEG pictures



if long r time = give FFP, if hyperfibrinolysis = give TXA

[Nonum 5] Which is least likely to fraudulent research reduction strategy?
A. Published in a peer review journal
B. Multiple authors
C. Departmental director sole author
D. Research findings similar to other published studies
E. Backing of a major research institute

???A

[Nonum 6] With respect to the triangle of safety and intercostal chest drain (ICC) insertion, if pectoralis major and the 4th - 5th intercostal space form two borders what forms the other?
A. Latissimus dorsi
B. Serratus anterior
C. Midaxillary Line (maybe wasn't an option)
D. Posterior Axillary Line (maybe wasn't an option)
E. Trapezius

A



http://thorax.bmj.com/content/58/suppl_2/ii53.full



Insertion should be in the “safe triangle” illustrated in fig 3⇓. This is the triangle bordered by the anterior border of the latissimus dorsi, the lateral border of the pectoralis major muscle, a line superior to the horizontal level of the nipple, and an apex below the axilla.

[Nonum 7] Small picture trying to show USS probe on inferio-posterior R arm of a teenager's arm with an associated USS image of a very triangular looking peripheral nerve between two muscle fascia (radial N).
Blockade of this nerve would result in?
A. Reduced pronation
B. Reduced hand grip.
C. Reduced elbow flexion
D. Reduced wrist extension

D

[Nonum 8] USS picture of an axillary brachial plexus nerve block with all four nerve unlabelled, the humerus, brachioradialis and biceps brachii marked.
(Good quality image provided)
What is the structure labelled 1.?
A. Musculocutaneous nerve (answer)
B. was Radial N
C. was Ulnar N
D. was Median N

Review images

[Nonum 9] Patient with known PAH with pulmonary pressures of 80/60 undergoing a lap cholecystectomy. About 20mins into case there is a sudden acute drop in SpO2 88%, hypotension. This is most likely to be?
A. Pulmonary embolism
B. Venous air embolism
C. Acute right heart failure
D. ?
E. ?

C



Pulmonary Hypertension is defined as a mean pulmonary artery pressure (PAP) >25mmHg at rest with a pulmonary capillary wedge pressure <12mmHg. Pulmonary hypertension is considered moderately severe when mean PAP >35mmHg. Right ventricular failure is unusual unless mean PAP is >50mmHg.


Raised pulmonary vascular resistance (PVR) places an additional pressure load on the right ventricle. The right heart is poorly designed to deal with these increases in afterload. A rise in PVR and hence right ventricular afterload can put the right heart into failure. Left ventricular failure can then ensue, due to both reduced volume reaching the left heart, and septal interdependence.
Factors which can raise PVR include hypoxia, hypercarbia, hypothermia, acidaemia, and pain. Anaesthetic technique is aimed at preventing these occurrences.

[Nonum 10] Paediatric intubation of 20kg, 5.5 doesnt fit, 4.5 doesn't fit, what next?
A. 4.0 tube
B. LMA
C. flex bronch
D. ?
E. ?

?A



Pedisafe estimates 5mm tube should fit



ETT size (age/4)+4


Weight = (age+4) x 2

[Nonum 11] Trauma patient undergoes delayed ORIF tibia. Nerve block given. Induction consists of suxamethonium, propofol and an ETT. Cephalozin is given and rocuronium also given (long stem to confuse us). Suddenly bradycardic, ETCO2 45, MAP 50mmHg. This is most likely to be?
A. PE
B. Fat embolism
C. Anaphylaxis
D. ?
E. LA toxicity

E



(Bradycardia not likely with other causes)