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  • Question 1 - You are preparing to conduct rapid sequence induction. What clinical observation, typically seen...

    Correct

    • You are preparing to conduct rapid sequence induction. What clinical observation, typically seen after administering suxamethonium, is not present when rocuronium is used for neuromuscular blockade?

      Your Answer: Muscle fasciculations

      Explanation:

      When suxamethonium is administered for neuromuscular blockade during rapid sequence induction, one of the clinical observations typically seen is muscle fasciculations. However, when rocuronium is used instead, muscle fasciculations are not present.

      Further Reading:

      Rapid sequence induction (RSI) is a method used to place an endotracheal tube (ETT) in the trachea while minimizing the risk of aspiration. It involves inducing loss of consciousness while applying cricoid pressure, followed by intubation without face mask ventilation. The steps of RSI can be remembered using the 7 P’s: preparation, pre-oxygenation, pre-treatment, paralysis and induction, protection and positioning, placement with proof, and post-intubation management.

      Preparation involves preparing the patient, equipment, team, and anticipating any difficulties that may arise during the procedure. Pre-oxygenation is important to ensure the patient has an adequate oxygen reserve and prolongs the time before desaturation. This is typically done by breathing 100% oxygen for 3 minutes. Pre-treatment involves administering drugs to counter expected side effects of the procedure and anesthesia agents used.

      Paralysis and induction involve administering a rapid-acting induction agent followed by a neuromuscular blocking agent. Commonly used induction agents include propofol, ketamine, thiopentone, and etomidate. The neuromuscular blocking agents can be depolarizing (such as suxamethonium) or non-depolarizing (such as rocuronium). Depolarizing agents bind to acetylcholine receptors and generate an action potential, while non-depolarizing agents act as competitive antagonists.

      Protection and positioning involve applying cricoid pressure to prevent regurgitation of gastric contents and positioning the patient’s neck appropriately. Tube placement is confirmed by visualizing the tube passing between the vocal cords, auscultation of the chest and stomach, end-tidal CO2 measurement, and visualizing misting of the tube. Post-intubation management includes standard care such as monitoring ECG, SpO2, NIBP, capnography, and maintaining sedation and neuromuscular blockade.

      Overall, RSI is a technique used to quickly and safely secure the airway in patients who may be at risk of aspiration. It involves a series of steps to ensure proper preparation, oxygenation, drug administration, and tube placement. Monitoring and post-intubation care are also important aspects of RSI.

    • This question is part of the following fields:

      • Basic Anaesthetics
      7.8
      Seconds
  • Question 2 - You are caring for a pediatric patient in the resuscitation bay. Your attending...

    Correct

    • You are caring for a pediatric patient in the resuscitation bay. Your attending physician notices you selecting an oropharyngeal airway adjunct (OPA) and recommends using a laryngeal mask airway (LMA) instead. Which of the following statements about the advantages and disadvantages of using a laryngeal mask airway (LMA) is correct?

      Your Answer: Greater risk of inducing laryngospasm using LMA compared to endotracheal intubation

      Explanation:

      The use of a laryngeal mask airway (LMA) carries a higher risk of inducing laryngospasm compared to endotracheal intubation. However, LMAs are still considered excellent alternatives to bag masks as they reduce the risk of gastric inflation and aspiration. While they do decrease the risk of aspiration, they are not as protective as endotracheal tubes. Complications associated with LMA use include laryngospasm, nausea and vomiting, and a low risk of aspiration. LMAs have advantages over bag-mask ventilation, such as more effective ventilation, less gastric inflation, and a lower risk of aspiration. However, they also have disadvantages, including the risk of hypoventilation due to air leak around the cuff, greater gastric inflation compared to endotracheal intubation, and a very low risk of aspiration.

      Further Reading:

      Techniques to keep the airway open:

      1. Suction: Used to remove obstructing material such as blood, vomit, secretions, and food debris from the oral cavity.

      2. Chin lift manoeuvres: Involves lifting the head off the floor and lifting the chin to extend the head in relation to the neck. Improves alignment of the pharyngeal, laryngeal, and oral axes.

      3. Jaw thrust: Used in trauma patients with cervical spine injury concerns. Fingers are placed under the mandible and gently pushed upward.

      Airway adjuncts:

      1. Oropharyngeal airway (OPA): Prevents the tongue from occluding the airway. Sized according to the patient by measuring from the incisor teeth to the angle of the mandible. Inserted with the tip facing backwards and rotated 180 degrees once it touches the back of the palate or oropharynx.

      2. Nasopharyngeal airway (NPA): Useful when it is difficult to open the mouth or in semi-conscious patients. Sized by length (distance between nostril and tragus of the ear) and diameter (roughly that of the patient’s little finger). Contraindicated in basal skull and midface fractures.

      Laryngeal mask airway (LMA):

      – Supraglottic airway device used as a first line or rescue airway.
      – Easy to insert, sized according to patient’s bodyweight.
      – Advantages: Easy insertion, effective ventilation, some protection from aspiration.
      – Disadvantages: Risk of hypoventilation, greater gastric inflation than endotracheal tube (ETT), risk of aspiration and laryngospasm.

      Note: Proper training and assessment of the patient’s condition are essential for airway management.

    • This question is part of the following fields:

      • Basic Anaesthetics
      13.9
      Seconds
  • Question 3 - A 28-year-old patient has arrived at the emergency department following an accident at...

    Correct

    • A 28-year-old patient has arrived at the emergency department following an accident at a construction site. The skin has been lacerated by a dropped piece of stainless steel sheeting with a sharp edge. The plan is to suture the wound after infiltrating the area with local anesthesia. In the suture room, you find Lidocaine 1% with Adrenaline (Epinephrine) 1:200,000 and Bupivacaine 0.5% available. What is a contraindication to using local anesthesia combined with adrenaline?

      Your Answer: Area to be infiltrated is in periphery

      Explanation:

      Adrenaline is known to cause vasoconstriction, which is the narrowing of blood vessels. As a result, it is not recommended to use adrenaline in areas such as the peripheries, end arteries, and flap lacerations because it can increase the risk of ischemia, which is a lack of blood supply to tissues. Additionally, there are certain contraindications to using adrenaline locally, including conditions like pheochromocytoma, hypertension, and arteriosclerosis. It is important to be cautious of these factors as adrenaline’s vasoconstrictive effects can also lead to an elevation in blood pressure.

      Further Reading:

      Local anaesthetics, such as lidocaine, bupivacaine, and prilocaine, are commonly used in the emergency department for topical or local infiltration to establish a field block. Lidocaine is often the first choice for field block prior to central line insertion. These anaesthetics work by blocking sodium channels, preventing the propagation of action potentials.

      However, local anaesthetics can enter the systemic circulation and cause toxic side effects if administered in high doses. Clinicians must be aware of the signs and symptoms of local anaesthetic systemic toxicity (LAST) and know how to respond. Early signs of LAST include numbness around the mouth or tongue, metallic taste, dizziness, visual and auditory disturbances, disorientation, and drowsiness. If not addressed, LAST can progress to more severe symptoms such as seizures, coma, respiratory depression, and cardiovascular dysfunction.

      The management of LAST is largely supportive. Immediate steps include stopping the administration of local anaesthetic, calling for help, providing 100% oxygen and securing the airway, establishing IV access, and controlling seizures with benzodiazepines or other medications. Cardiovascular status should be continuously assessed, and conventional therapies may be used to treat hypotension or arrhythmias. Intravenous lipid emulsion (intralipid) may also be considered as a treatment option.

      If the patient goes into cardiac arrest, CPR should be initiated following ALS arrest algorithms, but lidocaine should not be used as an anti-arrhythmic therapy. Prolonged resuscitation may be necessary, and intravenous lipid emulsion should be administered. After the acute episode, the patient should be transferred to a clinical area with appropriate equipment and staff for further monitoring and care.

      It is important to report cases of local anaesthetic toxicity to the appropriate authorities, such as the National Patient Safety Agency in the UK or the Irish Medicines Board in the Republic of Ireland. Additionally, regular clinical review should be conducted to exclude pancreatitis, as intravenous lipid emulsion can interfere with amylase or lipase assays.

    • This question is part of the following fields:

      • Basic Anaesthetics
      8.3
      Seconds
  • Question 4 - You are summoned to the resuscitation bay to provide assistance with a patient...

    Correct

    • You are summoned to the resuscitation bay to provide assistance with a patient who has experienced cardiac arrest. The team is getting ready to administer amiodarone. What is the mechanism of action of amiodarone in the context of cardiac arrest?

      Your Answer: Blockade of potassium channels

      Explanation:

      Amiodarone functions by inhibiting voltage-gated potassium channels, leading to an extended repolarization period and decreased excitability of the heart muscle.

      Further Reading:

      In the management of respiratory and cardiac arrest, several drugs are commonly used to help restore normal function and improve outcomes. Adrenaline is a non-selective agonist of adrenergic receptors and is administered intravenously at a dose of 1 mg every 3-5 minutes. It works by causing vasoconstriction, increasing systemic vascular resistance (SVR), and improving cardiac output by increasing the force of heart contraction. Adrenaline also has bronchodilatory effects.

      Amiodarone is another drug used in cardiac arrest situations. It blocks voltage-gated potassium channels, which prolongs repolarization and reduces myocardial excitability. The initial dose of amiodarone is 300 mg intravenously after 3 shocks, followed by a dose of 150 mg after 5 shocks.

      Lidocaine is an alternative to amiodarone in cardiac arrest situations. It works by blocking sodium channels and decreasing heart rate. The recommended dose is 1 mg/kg by slow intravenous injection, with a repeat half of the initial dose after 5 minutes. The maximum total dose of lidocaine is 3 mg/kg.

      Magnesium sulfate is used to reverse myocardial hyperexcitability associated with hypomagnesemia. It is administered intravenously at a dose of 2 g over 10-15 minutes. An additional dose may be given if necessary, but the maximum total dose should not exceed 3 g.

      Atropine is an antagonist of muscarinic acetylcholine receptors and is used to counteract the slowing of heart rate caused by the parasympathetic nervous system. It is administered intravenously at a dose of 500 mcg every 3-5 minutes, with a maximum dose of 3 mg.

      Naloxone is a competitive antagonist for opioid receptors and is used in cases of respiratory arrest caused by opioid overdose. It has a short duration of action, so careful monitoring is necessary. The initial dose of naloxone is 400 micrograms, followed by 800 mcg after 1 minute. The dose can be gradually escalated up to 2 mg per dose if there is no response to the preceding dose.

      It is important for healthcare professionals to have knowledge of the pharmacology and dosing schedules of these drugs in order to effectively manage respiratory and cardiac arrest situations.

    • This question is part of the following fields:

      • Basic Anaesthetics
      7.7
      Seconds
  • Question 5 - A 15 year old male is brought to the emergency department by his...

    Correct

    • A 15 year old male is brought to the emergency department by his parents after he fell while climbing over a fence and sustained a deep cut to the arm where the metal spike pierced the skin. An X-ray reveals no bone damage. You opt to examine and cleanse the wound under sedation as the patient is extremely upset. You choose to sedate the patient with Ketamine. What is the main way in which Ketamine works?

      Your Answer: NMDA receptor antagonist

      Explanation:

      Ketamine primarily works by blocking NMDA receptors, although its complete mechanism of action is not yet fully comprehended. Ongoing research is exploring its impact on various other receptors.

      Further Reading:

      Procedural sedation is commonly used by emergency department (ED) doctors to minimize pain and discomfort during procedures that may be painful or distressing for patients. Effective procedural sedation requires the administration of analgesia, anxiolysis, sedation, and amnesia. This is typically achieved through the use of a combination of short-acting analgesics and sedatives.

      There are different levels of sedation, ranging from minimal sedation (anxiolysis) to general anesthesia. It is important for clinicians to understand the level of sedation being used and to be able to manage any unintended deeper levels of sedation that may occur. Deeper levels of sedation are similar to general anesthesia and require the same level of care and monitoring.

      Various drugs can be used for procedural sedation, including propofol, midazolam, ketamine, and fentanyl. Each of these drugs has its own mechanism of action and side effects. Propofol is commonly used for sedation, amnesia, and induction and maintenance of general anesthesia. Midazolam is a benzodiazepine that enhances the effect of GABA on the GABA A receptors. Ketamine is an NMDA receptor antagonist and is used for dissociative sedation. Fentanyl is a highly potent opioid used for analgesia and sedation.

      The doses of these drugs for procedural sedation in the ED vary depending on the drug and the route of administration. It is important for clinicians to be familiar with the appropriate doses and onset and peak effect times for each drug.

      Safe sedation requires certain requirements, including appropriate staffing levels, competencies of the sedating practitioner, location and facilities, and monitoring. The level of sedation being used determines the specific requirements for safe sedation.

      After the procedure, patients should be monitored until they meet the criteria for safe discharge. This includes returning to their baseline level of consciousness, having vital signs within normal limits, and not experiencing compromised respiratory status. Pain and discomfort should also be addressed before discharge.

    • This question is part of the following fields:

      • Basic Anaesthetics
      3.7
      Seconds
  • Question 6 - A 45 year old presents to the emergency department after a fall onto...

    Correct

    • A 45 year old presents to the emergency department after a fall onto their outstretched left hand. An X-ray confirms a displaced fracture of the distal radius. Your consultant recommends reducing it under conscious sedation. What is the best description of conscious sedation?

      Your Answer: Level of sedation where patient responds purposefully to verbal commands

      Explanation:

      Conscious sedation involves a patient who can respond purposefully to verbal commands. It is different from deeper levels of sedation where the patient may only respond to painful stimuli or not respond at all. In conscious sedation, the patient can usually maintain their own airway and does not need assistance with breathing or cardiovascular support.

      Further Reading:

      Procedural sedation is commonly used by emergency department (ED) doctors to minimize pain and discomfort during procedures that may be painful or distressing for patients. Effective procedural sedation requires the administration of analgesia, anxiolysis, sedation, and amnesia. This is typically achieved through the use of a combination of short-acting analgesics and sedatives.

      There are different levels of sedation, ranging from minimal sedation (anxiolysis) to general anesthesia. It is important for clinicians to understand the level of sedation being used and to be able to manage any unintended deeper levels of sedation that may occur. Deeper levels of sedation are similar to general anesthesia and require the same level of care and monitoring.

      Various drugs can be used for procedural sedation, including propofol, midazolam, ketamine, and fentanyl. Each of these drugs has its own mechanism of action and side effects. Propofol is commonly used for sedation, amnesia, and induction and maintenance of general anesthesia. Midazolam is a benzodiazepine that enhances the effect of GABA on the GABA A receptors. Ketamine is an NMDA receptor antagonist and is used for dissociative sedation. Fentanyl is a highly potent opioid used for analgesia and sedation.

      The doses of these drugs for procedural sedation in the ED vary depending on the drug and the route of administration. It is important for clinicians to be familiar with the appropriate doses and onset and peak effect times for each drug.

      Safe sedation requires certain requirements, including appropriate staffing levels, competencies of the sedating practitioner, location and facilities, and monitoring. The level of sedation being used determines the specific requirements for safe sedation.

      After the procedure, patients should be monitored until they meet the criteria for safe discharge. This includes returning to their baseline level of consciousness, having vital signs within normal limits, and not experiencing compromised respiratory status. Pain and discomfort should also be addressed before discharge.

    • This question is part of the following fields:

      • Basic Anaesthetics
      12.8
      Seconds
  • Question 7 - A 32-year-old man that has been involved in a car crash develops symptoms...

    Correct

    • A 32-year-old man that has been involved in a car crash develops symptoms of acute airway blockage. You determine that he needs intubation through a rapid sequence induction. You intend to use etomidate as your induction medication.
      Etomidate functions by acting on what type of receptor?

      Your Answer: Gamma-aminobutyric acid (GABA)

      Explanation:

      Etomidate is a derivative of imidazole that is commonly used to induce anesthesia due to its short-acting nature. Its main mechanism of action is believed to involve the modulation of fast inhibitory synaptic transmission within the central nervous system by acting on GABA type A receptors.

    • This question is part of the following fields:

      • Basic Anaesthetics
      8
      Seconds
  • Question 8 - A 28-year-old with a past of opioid misuse is brought into the ER...

    Correct

    • A 28-year-old with a past of opioid misuse is brought into the ER after being discovered in a collapsed state with decreased level of consciousness. You are worried about the patient's airway. Your consultant recommends using a nasopharyngeal airway adjunct instead of an oropharyngeal airway adjunct. Why is a nasopharyngeal airway preferred in this scenario?

      Your Answer: Less likely to provoke the gag reflex

      Explanation:

      When a patient is semi-conscious, it is less likely for the nasopharyngeal airway adjuncts (NPA’s) to trigger the gag reflex compared to oropharyngeal airways. Therefore, NPA’s are typically the preferred option in these cases.

      Further Reading:

      Techniques to keep the airway open:

      1. Suction: Used to remove obstructing material such as blood, vomit, secretions, and food debris from the oral cavity.

      2. Chin lift manoeuvres: Involves lifting the head off the floor and lifting the chin to extend the head in relation to the neck. Improves alignment of the pharyngeal, laryngeal, and oral axes.

      3. Jaw thrust: Used in trauma patients with cervical spine injury concerns. Fingers are placed under the mandible and gently pushed upward.

      Airway adjuncts:

      1. Oropharyngeal airway (OPA): Prevents the tongue from occluding the airway. Sized according to the patient by measuring from the incisor teeth to the angle of the mandible. Inserted with the tip facing backwards and rotated 180 degrees once it touches the back of the palate or oropharynx.

      2. Nasopharyngeal airway (NPA): Useful when it is difficult to open the mouth or in semi-conscious patients. Sized by length (distance between nostril and tragus of the ear) and diameter (roughly that of the patient’s little finger). Contraindicated in basal skull and midface fractures.

      Laryngeal mask airway (LMA):

      – Supraglottic airway device used as a first line or rescue airway.
      – Easy to insert, sized according to patient’s bodyweight.
      – Advantages: Easy insertion, effective ventilation, some protection from aspiration.
      – Disadvantages: Risk of hypoventilation, greater gastric inflation than endotracheal tube (ETT), risk of aspiration and laryngospasm.

      Note: Proper training and assessment of the patient’s condition are essential for airway management.

    • This question is part of the following fields:

      • Basic Anaesthetics
      13.7
      Seconds
  • Question 9 - A 32-year-old man with a history of severe asthma is brought to the...

    Correct

    • A 32-year-old man with a history of severe asthma is brought to the Emergency Department by his girlfriend. He is experiencing extreme shortness of breath and wheezing, and his condition worsens rapidly. After receiving back-to-back nebulizer treatments, hydrocortisone, and IV magnesium sulfate, he is taken to resus, and the intensive care team is called for consultation. He is now severely hypoxic and has developed confusion. It is decided that the patient needs to be intubated.
      Which of the following medications would be the most appropriate choice for inducing anesthesia in this patient?

      Your Answer: Ketamine

      Explanation:

      Intubation is rarely necessary for asthmatic patients, with only about 2% of asthma attacks requiring it. Most severe cases can be managed using non-invasive ventilation techniques. However, intubation can be a life-saving measure for asthmatic patients in critical condition. The indications for intubation include severe hypoxia, altered mental state, failure to respond to medications or non-invasive ventilation, and respiratory or cardiac arrest.

      Before intubation, it is important to preoxygenate the patient and administer intravenous fluids. Nasal oxygen during intubation can provide additional time. Intravenous fluids are crucial because patients with acute asthma exacerbations can experience significant fluid loss, which can lead to severe hypotension during intubation and positive pressure ventilation.

      There is no perfect combination of drugs for rapid sequence induction (RSI), but ketamine is often the preferred choice. Ketamine has bronchodilatory properties and does not cause hypotension as a side effect. Propofol can also be used, but it carries a risk of hypotension. In some cases, a subdissociative dose of ketamine can be helpful to facilitate the use of non-invasive ventilation in a hypoxic or combative patient.

      Rocuronium and suxamethonium are commonly used as paralytic agents. Rocuronium has the advantage of providing a longer period of paralysis, which helps avoid ventilator asynchrony in the early stages of management.

      Proper mechanical ventilation is essential, and it involves allowing the patient enough time to fully exhale the delivered breath and prevent hyperinflation. Therefore, permissive hypercapnia is typically used, and the ventilator settings should be adjusted accordingly. The recommended settings are a respiratory rate of 6-8 breaths per minute and a tidal volume of 6 ml per kilogram of body weight.

    • This question is part of the following fields:

      • Basic Anaesthetics
      11.3
      Seconds
  • Question 10 - A 28 year old female presents at the emergency department with a circular...

    Correct

    • A 28 year old female presents at the emergency department with a circular saw laceration. You opt to examine the wound using local anesthesia. What is the maximum dosage of Prilocaine that can be administered?

      Your Answer: 6 mg/Kg

      Explanation:

      The highest amount of Prilocaine that can be administered without adrenaline is 6 mg per kilogram of body weight. However, if Prilocaine is used in combination with adrenaline, the maximum dose increases to 8mg per kilogram.

      Further Reading:

      Local anaesthetics, such as lidocaine, bupivacaine, and prilocaine, are commonly used in the emergency department for topical or local infiltration to establish a field block. Lidocaine is often the first choice for field block prior to central line insertion. These anaesthetics work by blocking sodium channels, preventing the propagation of action potentials.

      However, local anaesthetics can enter the systemic circulation and cause toxic side effects if administered in high doses. Clinicians must be aware of the signs and symptoms of local anaesthetic systemic toxicity (LAST) and know how to respond. Early signs of LAST include numbness around the mouth or tongue, metallic taste, dizziness, visual and auditory disturbances, disorientation, and drowsiness. If not addressed, LAST can progress to more severe symptoms such as seizures, coma, respiratory depression, and cardiovascular dysfunction.

      The management of LAST is largely supportive. Immediate steps include stopping the administration of local anaesthetic, calling for help, providing 100% oxygen and securing the airway, establishing IV access, and controlling seizures with benzodiazepines or other medications. Cardiovascular status should be continuously assessed, and conventional therapies may be used to treat hypotension or arrhythmias. Intravenous lipid emulsion (intralipid) may also be considered as a treatment option.

      If the patient goes into cardiac arrest, CPR should be initiated following ALS arrest algorithms, but lidocaine should not be used as an anti-arrhythmic therapy. Prolonged resuscitation may be necessary, and intravenous lipid emulsion should be administered. After the acute episode, the patient should be transferred to a clinical area with appropriate equipment and staff for further monitoring and care.

      It is important to report cases of local anaesthetic toxicity to the appropriate authorities, such as the National Patient Safety Agency in the UK or the Irish Medicines Board in the Republic of Ireland. Additionally, regular clinical review should be conducted to exclude pancreatitis, as intravenous lipid emulsion can interfere with amylase or lipase assays.

    • This question is part of the following fields:

      • Basic Anaesthetics
      5.7
      Seconds
  • Question 11 - You examine the X-ray of a 55-year-old male who has fallen onto his...

    Correct

    • You examine the X-ray of a 55-year-old male who has fallen onto his extended right hand. The X-ray confirms a fracture of the distal radius with dorsal displacement. Your plan is to perform a reduction of the fracture using intravenous regional anesthesia (Bier's block). While conducting the procedure, you take note of the duration of cuff inflation. What is the maximum duration the cuff should remain inflated?

      Your Answer: 45 minutes

      Explanation:

      According to the RCEM, the minimum time for cuff inflation during Bier’s block is 20 minutes, while the maximum time is 45 minutes.

      Further Reading:

      Bier’s block is a regional intravenous anesthesia technique commonly used for minor surgical procedures of the forearm or for reducing distal radius fractures in the emergency department (ED). It is recommended by NICE as the preferred anesthesia block for adults requiring manipulation of distal forearm fractures in the ED.

      Before performing the procedure, a pre-procedure checklist should be completed, including obtaining consent, recording the patient’s weight, ensuring the resuscitative equipment is available, and monitoring the patient’s vital signs throughout the procedure. The air cylinder should be checked if not using an electronic machine, and the cuff should be checked for leaks.

      During the procedure, a double cuff tourniquet is placed on the upper arm, and the arm is elevated to exsanguinate the limb. The proximal cuff is inflated to a pressure 100 mmHg above the systolic blood pressure, up to a maximum of 300 mmHg. The time of inflation and pressure should be recorded, and the absence of the radial pulse should be confirmed. 0.5% plain prilocaine is then injected slowly, and the time of injection is recorded. The patient should be warned about the potential cold/hot sensation and mottled appearance of the arm. After injection, the cannula is removed and pressure is applied to the venipuncture site to prevent bleeding. After approximately 10 minutes, the patient should have anesthesia and should not feel pain during manipulation. If anesthesia is successful, the manipulation can be performed, and a plaster can be applied by a second staff member. A check x-ray should be obtained with the arm lowered onto a pillow. The tourniquet should be monitored at all times, and the cuff should be inflated for a minimum of 20 minutes and a maximum of 45 minutes. If rotation of the cuff is required, it should be done after the manipulation and plaster application. After the post-reduction x-ray is satisfactory, the cuff can be deflated while observing the patient and monitors. Limb circulation should be checked prior to discharge, and appropriate follow-up and analgesia should be arranged.

      There are several contraindications to performing Bier’s block, including allergy to local anesthetic, hypertension over 200 mm Hg, infection in the limb, lymphedema, methemoglobinemia, morbid obesity, peripheral vascular disease, procedures needed in both arms, Raynaud’s phenomenon, scleroderma, severe hypertension and sickle cell disease.

    • This question is part of the following fields:

      • Basic Anaesthetics
      2.7
      Seconds
  • Question 12 - A 55 year old female patient is brought into the emergency department with...

    Correct

    • A 55 year old female patient is brought into the emergency department with urosepsis. It is decided to intubate her pending transfer to ITU. Your consultant requests you prepare propofol and suxamethonium for rapid sequence intubation (RSI). What is the recommended dose of suxamethonium for RSI in adults?

      Your Answer: 1.5 mg/kg

      Explanation:

      The appropriate dosage of suxamethonium for rapid sequence intubation (RSI) in adults is between 1 and 1.5 milligrams per kilogram of body weight.

      Further Reading:

      Rapid sequence induction (RSI) is a method used to place an endotracheal tube (ETT) in the trachea while minimizing the risk of aspiration. It involves inducing loss of consciousness while applying cricoid pressure, followed by intubation without face mask ventilation. The steps of RSI can be remembered using the 7 P’s: preparation, pre-oxygenation, pre-treatment, paralysis and induction, protection and positioning, placement with proof, and post-intubation management.

      Preparation involves preparing the patient, equipment, team, and anticipating any difficulties that may arise during the procedure. Pre-oxygenation is important to ensure the patient has an adequate oxygen reserve and prolongs the time before desaturation. This is typically done by breathing 100% oxygen for 3 minutes. Pre-treatment involves administering drugs to counter expected side effects of the procedure and anesthesia agents used.

      Paralysis and induction involve administering a rapid-acting induction agent followed by a neuromuscular blocking agent. Commonly used induction agents include propofol, ketamine, thiopentone, and etomidate. The neuromuscular blocking agents can be depolarizing (such as suxamethonium) or non-depolarizing (such as rocuronium). Depolarizing agents bind to acetylcholine receptors and generate an action potential, while non-depolarizing agents act as competitive antagonists.

      Protection and positioning involve applying cricoid pressure to prevent regurgitation of gastric contents and positioning the patient’s neck appropriately. Tube placement is confirmed by visualizing the tube passing between the vocal cords, auscultation of the chest and stomach, end-tidal CO2 measurement, and visualizing misting of the tube. Post-intubation management includes standard care such as monitoring ECG, SpO2, NIBP, capnography, and maintaining sedation and neuromuscular blockade.

      Overall, RSI is a technique used to quickly and safely secure the airway in patients who may be at risk of aspiration. It involves a series of steps to ensure proper preparation, oxygenation, drug administration, and tube placement. Monitoring and post-intubation care are also important aspects of RSI.

    • This question is part of the following fields:

      • Basic Anaesthetics
      5.4
      Seconds
  • Question 13 - A 35-year-old woman is brought in by ambulance following a car accident where...

    Correct

    • A 35-year-old woman is brought in by ambulance following a car accident where her car was hit by a truck. She has sustained severe facial injuries and shows signs of airway obstruction. Her cervical spine is immobilized. She has suffered significant midface trauma, and the anesthesiologist decides to secure a definitive airway by intubating the patient.

      Which of the following does NOT indicate proper placement of the endotracheal tube?

      Your Answer: Presence of borborygmi in the epigastrium

      Explanation:

      The presence of borborygmi in the epigastrium can indicate that the endotracheal tube (ETT) is incorrectly placed in the esophagus. There are several ways to verify the correct placement of the endotracheal tube (ETT).

      One method is through direct visualization, where the ETT is observed passing through the vocal cords. Another method is by checking for fogging in the ETT, which can indicate proper placement. Auscultation of bilateral equal breath sounds is also a reliable way to confirm correct ETT placement.

      Additionally, the absence of borborygmi in the epigastrium is a positive sign that the ETT is in the correct position. Capnography or using a CO2 detector can provide further confirmation of proper ETT placement. Finally, chest radiography can be used to visually assess the placement of the endotracheal tube.

    • This question is part of the following fields:

      • Basic Anaesthetics
      15.1
      Seconds
  • Question 14 - A 52 year old male is brought to the emergency department with severe...

    Correct

    • A 52 year old male is brought to the emergency department with severe head and chest injuries. As his Glasgow Coma Scale (GCS) continues to decline, it is determined that intubation is necessary. You begin preparing for rapid sequence induction (RSI). Before administering sodium thiopentone, the patient's blood pressure is measured and found to be 88/58 mmHg. What is the most suitable course of action?

      Your Answer: Use half normal dose

      Explanation:

      In patients with pre-existing hypovolaemia, the amount of sodium thiopentone administered should be reduced by half. This is because sodium thiopentone can cause venodilation and myocardial depression, which can result in significant hypovolaemia. Alternatively, an induction agent that does not cause hypotension, such as Etomidate, can be used instead. It is important to note that both propofol and thiopentone are known to cause hypotension.

      Further Reading:

      There are four commonly used induction agents in the UK: propofol, ketamine, thiopentone, and etomidate.

      Propofol is a 1% solution that produces significant venodilation and myocardial depression. It can also reduce cerebral perfusion pressure. The typical dose for propofol is 1.5-2.5 mg/kg. However, it can cause side effects such as hypotension, respiratory depression, and pain at the site of injection.

      Ketamine is another induction agent that produces a dissociative state. It does not display a dose-response continuum, meaning that the effects do not necessarily increase with higher doses. Ketamine can cause bronchodilation, which is useful in patients with asthma. The initial dose for ketamine is 0.5-2 mg/kg, with a typical IV dose of 1.5 mg/kg. Side effects of ketamine include tachycardia, hypertension, laryngospasm, unpleasant hallucinations, nausea and vomiting, hypersalivation, increased intracranial and intraocular pressure, nystagmus and diplopia, abnormal movements, and skin reactions.

      Thiopentone is an ultra-short acting barbiturate that acts on the GABA receptor complex. It decreases cerebral metabolic oxygen and reduces cerebral blood flow and intracranial pressure. The adult dose for thiopentone is 3-5 mg/kg, while the child dose is 5-8 mg/kg. However, these doses should be halved in patients with hypovolemia. Side effects of thiopentone include venodilation, myocardial depression, and hypotension. It is contraindicated in patients with acute porphyrias and myotonic dystrophy.

      Etomidate is the most haemodynamically stable induction agent and is useful in patients with hypovolemia, anaphylaxis, and asthma. It has similar cerebral effects to thiopentone. The dose for etomidate is 0.15-0.3 mg/kg. Side effects of etomidate include injection site pain, movement disorders, adrenal insufficiency, and apnoea. It is contraindicated in patients with sepsis due to adrenal suppression.

    • This question is part of the following fields:

      • Basic Anaesthetics
      6.2
      Seconds
  • Question 15 - You are managing a 62-year-old woman with a dorsally displaced fracture of the...

    Correct

    • You are managing a 62-year-old woman with a dorsally displaced fracture of the distal radius. Your plan is to perform a reduction of the fracture using intravenous regional anesthesia (Bier's block). Following the administration of the local anesthetic, you observe a change in the patient's skin color to a grayish-blue hue. What complication is most likely to have occurred?

      Your Answer: Methaemoglobinaemia

      Explanation:

      In this case, the administration of the local anesthetic used for the Bier’s block may have caused the patient’s blood to convert hemoglobin into methemoglobin, resulting in the observed skin color change.

      Further Reading:

      Bier’s block is a regional intravenous anesthesia technique commonly used for minor surgical procedures of the forearm or for reducing distal radius fractures in the emergency department (ED). It is recommended by NICE as the preferred anesthesia block for adults requiring manipulation of distal forearm fractures in the ED.

      Before performing the procedure, a pre-procedure checklist should be completed, including obtaining consent, recording the patient’s weight, ensuring the resuscitative equipment is available, and monitoring the patient’s vital signs throughout the procedure. The air cylinder should be checked if not using an electronic machine, and the cuff should be checked for leaks.

      During the procedure, a double cuff tourniquet is placed on the upper arm, and the arm is elevated to exsanguinate the limb. The proximal cuff is inflated to a pressure 100 mmHg above the systolic blood pressure, up to a maximum of 300 mmHg. The time of inflation and pressure should be recorded, and the absence of the radial pulse should be confirmed. 0.5% plain prilocaine is then injected slowly, and the time of injection is recorded. The patient should be warned about the potential cold/hot sensation and mottled appearance of the arm. After injection, the cannula is removed and pressure is applied to the venipuncture site to prevent bleeding. After approximately 10 minutes, the patient should have anesthesia and should not feel pain during manipulation. If anesthesia is successful, the manipulation can be performed, and a plaster can be applied by a second staff member. A check x-ray should be obtained with the arm lowered onto a pillow. The tourniquet should be monitored at all times, and the cuff should be inflated for a minimum of 20 minutes and a maximum of 45 minutes. If rotation of the cuff is required, it should be done after the manipulation and plaster application. After the post-reduction x-ray is satisfactory, the cuff can be deflated while observing the patient and monitors. Limb circulation should be checked prior to discharge, and appropriate follow-up and analgesia should be arranged.

      There are several contraindications to performing Bier’s block, including allergy to local anesthetic, hypertension over 200 mm Hg, infection in the limb, lymphedema, methemoglobinemia, morbid obesity, peripheral vascular disease, procedures needed in both arms, Raynaud’s phenomenon, scleroderma, severe hypertension and sickle cell disease.

    • This question is part of the following fields:

      • Basic Anaesthetics
      11
      Seconds
  • Question 16 - A 65 year old female patient has been brought into the department after...

    Correct

    • A 65 year old female patient has been brought into the department after being hit by a car in a vehicle-pedestrian accident. The patient needs CT imaging to evaluate the complete scope of her injuries. What are the minimum monitoring requirements for transferring a critically ill patient?

      Your Answer: ECG, oxygen saturations, blood pressure and temperature monitoring

      Explanation:

      It is crucial to continuously monitor the oxygen saturation, blood pressure, ECG, and temperature of critically ill patients during transfers. If the patient is intubated, monitoring of end-tidal CO2 is also necessary. The minimum standard monitoring requirements for any critically ill patient during transfers include ECG, oxygen saturation, blood pressure, and temperature. Additionally, if the patient is intubated, monitoring of end-tidal CO2 is mandatory. It is important to note that the guidance from ICS/FICM suggests that monitoring protocols for intra-hospital transfers should be similar to those for interhospital transfers.

      Further Reading:

      Transfer of critically ill patients in the emergency department is a common occurrence and can involve intra-hospital transfers or transfers to another hospital. However, there are several risks associated with these transfers that doctors need to be aware of and manage effectively.

      Technical risks include equipment failure or inadequate equipment, unreliable power or oxygen supply, incompatible equipment, restricted positioning, and restricted monitoring equipment. These technical issues can hinder the ability to detect and treat problems with ventilation, blood pressure control, and arrhythmias during the transfer.

      Non-technical risks involve limited personal and medical team during the transfer, isolation and lack of resources in the receiving hospital, and problems with communication and liaison between the origin and destination sites.

      Organizational risks can be mitigated by having a dedicated consultant lead for transfers who is responsible for producing guidelines, training staff, standardizing protocols, equipment, and documentation, as well as capturing data and conducting audits.

      To optimize the patient’s clinical condition before transfer, several key steps should be taken. These include ensuring a low threshold for intubation and anticipating airway and ventilation problems, securing the endotracheal tube (ETT) and verifying its position, calculating oxygen requirements and ensuring an adequate supply, monitoring for circulatory issues and inserting at least two IV accesses, providing ongoing analgesia and sedation, controlling seizures, and addressing any fractures or temperature changes.

      It is also important to have the necessary equipment and personnel for the transfer. Standard monitoring equipment should include ECG, oxygen saturation, blood pressure, temperature, and capnographic monitoring for ventilated patients. Additional monitoring may be required depending on the level of care needed by the patient.

      In terms of oxygen supply, it is standard practice to calculate the expected oxygen consumption during transfer and multiply it by two to ensure an additional supply in case of delays. The suggested oxygen supply for transfer can be calculated using the minute volume, fraction of inspired oxygen, and estimated transfer time.

      Overall, managing the risks associated with patient transfers requires careful planning, communication, and coordination to ensure the safety and well-being of critically ill patients.

    • This question is part of the following fields:

      • Basic Anaesthetics
      15.7
      Seconds
  • Question 17 - You examine the X-ray of a 70 year old male who has fallen...

    Correct

    • You examine the X-ray of a 70 year old male who has fallen onto his outstretched right hand. The X-ray confirms a fracture of the distal radius with dorsal displacement. Your plan is to perform a reduction of the fracture using intravenous regional anesthesia (Bier's block). The patient's blood pressure is 145/90 mmHg and his pulse rate is 75 bpm. What inflation pressure would you use when inflating the cuff?

      Your Answer: 250 mmHg

      Explanation:

      During Bier’s block, the cuff is inflated to a pressure that is 100 mmHg higher than the patient’s systolic blood pressure. For example, if the systolic blood pressure is 150 mmHg, the cuff would be inflated to 250 mmHg. It is important to note that Bier’s block should not be performed if the systolic blood pressure is greater than 200 mmHg, as this is considered a contraindication. Therefore, the maximum pressure ever used during Bier’s block is 300mmHg.

      Further Reading:

      Bier’s block is a regional intravenous anesthesia technique commonly used for minor surgical procedures of the forearm or for reducing distal radius fractures in the emergency department (ED). It is recommended by NICE as the preferred anesthesia block for adults requiring manipulation of distal forearm fractures in the ED.

      Before performing the procedure, a pre-procedure checklist should be completed, including obtaining consent, recording the patient’s weight, ensuring the resuscitative equipment is available, and monitoring the patient’s vital signs throughout the procedure. The air cylinder should be checked if not using an electronic machine, and the cuff should be checked for leaks.

      During the procedure, a double cuff tourniquet is placed on the upper arm, and the arm is elevated to exsanguinate the limb. The proximal cuff is inflated to a pressure 100 mmHg above the systolic blood pressure, up to a maximum of 300 mmHg. The time of inflation and pressure should be recorded, and the absence of the radial pulse should be confirmed. 0.5% plain prilocaine is then injected slowly, and the time of injection is recorded. The patient should be warned about the potential cold/hot sensation and mottled appearance of the arm. After injection, the cannula is removed and pressure is applied to the venipuncture site to prevent bleeding. After approximately 10 minutes, the patient should have anesthesia and should not feel pain during manipulation. If anesthesia is successful, the manipulation can be performed, and a plaster can be applied by a second staff member. A check x-ray should be obtained with the arm lowered onto a pillow. The tourniquet should be monitored at all times, and the cuff should be inflated for a minimum of 20 minutes and a maximum of 45 minutes. If rotation of the cuff is required, it should be done after the manipulation and plaster application. After the post-reduction x-ray is satisfactory, the cuff can be deflated while observing the patient and monitors. Limb circulation should be checked prior to discharge, and appropriate follow-up and analgesia should be arranged.

      There are several contraindications to performing Bier’s block, including allergy to local anesthetic, hypertension over 200 mm Hg, infection in the limb, lymphedema, methemoglobinemia, morbid obesity, peripheral vascular disease, procedures needed in both arms, Raynaud’s phenomenon, scleroderma, severe hypertension and sickle cell disease.

    • This question is part of the following fields:

      • Basic Anaesthetics
      5.2
      Seconds
  • Question 18 - A 45 year old male patient is brought into the emergency department with...

    Correct

    • A 45 year old male patient is brought into the emergency department with a suspected massive pulmonary embolism. It is decided to intubate him pending transfer to ITU. Your consultant requests you prepare the patient for rapid sequence intubation. You start pre-oxygenating the patient. What is the gold standard evaluation for ensuring sufficient pre-oxygenation?

      Your Answer: End tidal O2 > 85%

      Explanation:

      The blood gas measurement of pO2 should be equal to or greater than 18 kilopascals (kPa) at a level of 10.

      Further Reading:

      Rapid sequence induction (RSI) is a method used to place an endotracheal tube (ETT) in the trachea while minimizing the risk of aspiration. It involves inducing loss of consciousness while applying cricoid pressure, followed by intubation without face mask ventilation. The steps of RSI can be remembered using the 7 P’s: preparation, pre-oxygenation, pre-treatment, paralysis and induction, protection and positioning, placement with proof, and post-intubation management.

      Preparation involves preparing the patient, equipment, team, and anticipating any difficulties that may arise during the procedure. Pre-oxygenation is important to ensure the patient has an adequate oxygen reserve and prolongs the time before desaturation. This is typically done by breathing 100% oxygen for 3 minutes. Pre-treatment involves administering drugs to counter expected side effects of the procedure and anesthesia agents used.

      Paralysis and induction involve administering a rapid-acting induction agent followed by a neuromuscular blocking agent. Commonly used induction agents include propofol, ketamine, thiopentone, and etomidate. The neuromuscular blocking agents can be depolarizing (such as suxamethonium) or non-depolarizing (such as rocuronium). Depolarizing agents bind to acetylcholine receptors and generate an action potential, while non-depolarizing agents act as competitive antagonists.

      Protection and positioning involve applying cricoid pressure to prevent regurgitation of gastric contents and positioning the patient’s neck appropriately. Tube placement is confirmed by visualizing the tube passing between the vocal cords, auscultation of the chest and stomach, end-tidal CO2 measurement, and visualizing misting of the tube. Post-intubation management includes standard care such as monitoring ECG, SpO2, NIBP, capnography, and maintaining sedation and neuromuscular blockade.

      Overall, RSI is a technique used to quickly and safely secure the airway in patients who may be at risk of aspiration. It involves a series of steps to ensure proper preparation, oxygenation, drug administration, and tube placement. Monitoring and post-intubation care are also important aspects of RSI.

    • This question is part of the following fields:

      • Basic Anaesthetics
      4.5
      Seconds
  • Question 19 - A 68 year old has been brought to the emergency department by ambulance...

    Correct

    • A 68 year old has been brought to the emergency department by ambulance with a history of collapsing shortly after complaining of severe chest pain and difficulty breathing. It has been determined that the patient needs rapid sequence induction after pre-oxygenation. What is the best position for the patient to be in during pre-oxygenation?

      Your Answer: 20-30 degrees head up tilt

      Explanation:

      Several studies have shown that elevating the head by 20-30 degrees is beneficial for increasing oxygen levels compared to lying flat on the back.

      Further Reading:

      Rapid sequence induction (RSI) is a method used to place an endotracheal tube (ETT) in the trachea while minimizing the risk of aspiration. It involves inducing loss of consciousness while applying cricoid pressure, followed by intubation without face mask ventilation. The steps of RSI can be remembered using the 7 P’s: preparation, pre-oxygenation, pre-treatment, paralysis and induction, protection and positioning, placement with proof, and post-intubation management.

      Preparation involves preparing the patient, equipment, team, and anticipating any difficulties that may arise during the procedure. Pre-oxygenation is important to ensure the patient has an adequate oxygen reserve and prolongs the time before desaturation. This is typically done by breathing 100% oxygen for 3 minutes. Pre-treatment involves administering drugs to counter expected side effects of the procedure and anesthesia agents used.

      Paralysis and induction involve administering a rapid-acting induction agent followed by a neuromuscular blocking agent. Commonly used induction agents include propofol, ketamine, thiopentone, and etomidate. The neuromuscular blocking agents can be depolarizing (such as suxamethonium) or non-depolarizing (such as rocuronium). Depolarizing agents bind to acetylcholine receptors and generate an action potential, while non-depolarizing agents act as competitive antagonists.

      Protection and positioning involve applying cricoid pressure to prevent regurgitation of gastric contents and positioning the patient’s neck appropriately. Tube placement is confirmed by visualizing the tube passing between the vocal cords, auscultation of the chest and stomach, end-tidal CO2 measurement, and visualizing misting of the tube. Post-intubation management includes standard care such as monitoring ECG, SpO2, NIBP, capnography, and maintaining sedation and neuromuscular blockade.

      Overall, RSI is a technique used to quickly and safely secure the airway in patients who may be at risk of aspiration. It involves a series of steps to ensure proper preparation, oxygenation, drug administration, and tube placement. Monitoring and post-intubation care are also important aspects of RSI.

    • This question is part of the following fields:

      • Basic Anaesthetics
      3.6
      Seconds
  • Question 20 - A 45 year old male patient is brought into the emergency department with...

    Correct

    • A 45 year old male patient is brought into the emergency department with a suspected severe pulmonary embolism. It is decided to intubate him pending transfer to the intensive care unit. Your consultant requests you prepare the patient for rapid sequence intubation. You start pre-oxygenating the patient. What is the recommended minimum duration for sufficient pre-oxygenation?

      Your Answer: 3 minutes

      Explanation:

      Inspired oxygen primarily works by removing nitrogen from the lungs, which would otherwise take up a significant portion of the lung capacity. This nitrogen is replaced with oxygen, leading to improved oxygenation of the tissues and an increased oxygen reserve. As a result, the patient can safely hold their breath for a longer period of time. It is recommended to preoxygenate the patient for at least 3 minutes.

      Further Reading:

      Rapid sequence induction (RSI) is a method used to place an endotracheal tube (ETT) in the trachea while minimizing the risk of aspiration. It involves inducing loss of consciousness while applying cricoid pressure, followed by intubation without face mask ventilation. The steps of RSI can be remembered using the 7 P’s: preparation, pre-oxygenation, pre-treatment, paralysis and induction, protection and positioning, placement with proof, and post-intubation management.

      Preparation involves preparing the patient, equipment, team, and anticipating any difficulties that may arise during the procedure. Pre-oxygenation is important to ensure the patient has an adequate oxygen reserve and prolongs the time before desaturation. This is typically done by breathing 100% oxygen for 3 minutes. Pre-treatment involves administering drugs to counter expected side effects of the procedure and anesthesia agents used.

      Paralysis and induction involve administering a rapid-acting induction agent followed by a neuromuscular blocking agent. Commonly used induction agents include propofol, ketamine, thiopentone, and etomidate. The neuromuscular blocking agents can be depolarizing (such as suxamethonium) or non-depolarizing (such as rocuronium). Depolarizing agents bind to acetylcholine receptors and generate an action potential, while non-depolarizing agents act as competitive antagonists.

      Protection and positioning involve applying cricoid pressure to prevent regurgitation of gastric contents and positioning the patient’s neck appropriately. Tube placement is confirmed by visualizing the tube passing between the vocal cords, auscultation of the chest and stomach, end-tidal CO2 measurement, and visualizing misting of the tube. Post-intubation management includes standard care such as monitoring ECG, SpO2, NIBP, capnography, and maintaining sedation and neuromuscular blockade.

      Overall, RSI is a technique used to quickly and safely secure the airway in patients who may be at risk of aspiration. It involves a series of steps to ensure proper preparation, oxygenation, drug administration, and tube placement. Monitoring and post-intubation care are also important aspects of RSI.

    • This question is part of the following fields:

      • Basic Anaesthetics
      3.3
      Seconds
  • Question 21 - A 35 year old male is brought to the emergency department with severe...

    Correct

    • A 35 year old male is brought to the emergency department with severe head and chest injuries. As his GCS continues to decline, it is determined that intubation is necessary. You begin preparing for rapid sequence induction (RSI). What is the appropriate dosage of sodium thiopentone for an adult undergoing RSI?

      Your Answer: 3-5 mg/kg

      Explanation:

      To perform rapid sequence induction in adults, it is recommended to administer a dose of sodium thiopentone ranging from 3 to 5 mg per kilogram of body weight.

      Further Reading:

      There are four commonly used induction agents in the UK: propofol, ketamine, thiopentone, and etomidate.

      Propofol is a 1% solution that produces significant venodilation and myocardial depression. It can also reduce cerebral perfusion pressure. The typical dose for propofol is 1.5-2.5 mg/kg. However, it can cause side effects such as hypotension, respiratory depression, and pain at the site of injection.

      Ketamine is another induction agent that produces a dissociative state. It does not display a dose-response continuum, meaning that the effects do not necessarily increase with higher doses. Ketamine can cause bronchodilation, which is useful in patients with asthma. The initial dose for ketamine is 0.5-2 mg/kg, with a typical IV dose of 1.5 mg/kg. Side effects of ketamine include tachycardia, hypertension, laryngospasm, unpleasant hallucinations, nausea and vomiting, hypersalivation, increased intracranial and intraocular pressure, nystagmus and diplopia, abnormal movements, and skin reactions.

      Thiopentone is an ultra-short acting barbiturate that acts on the GABA receptor complex. It decreases cerebral metabolic oxygen and reduces cerebral blood flow and intracranial pressure. The adult dose for thiopentone is 3-5 mg/kg, while the child dose is 5-8 mg/kg. However, these doses should be halved in patients with hypovolemia. Side effects of thiopentone include venodilation, myocardial depression, and hypotension. It is contraindicated in patients with acute porphyrias and myotonic dystrophy.

      Etomidate is the most haemodynamically stable induction agent and is useful in patients with hypovolemia, anaphylaxis, and asthma. It has similar cerebral effects to thiopentone. The dose for etomidate is 0.15-0.3 mg/kg. Side effects of etomidate include injection site pain, movement disorders, adrenal insufficiency, and apnoea. It is contraindicated in patients with sepsis due to adrenal suppression.

    • This question is part of the following fields:

      • Basic Anaesthetics
      5.6
      Seconds
  • Question 22 - You are getting ready to administer Propofol to a patient for cardioversion and...

    Correct

    • You are getting ready to administer Propofol to a patient for cardioversion and anticipate a potential side effect. What is a common adverse reaction associated with Propofol?

      Your Answer: Hypotension

      Explanation:

      Propofol often leads to hypotension as a common side effect. Other common side effects of Propofol include apnoea, arrhythmias, headache, and nausea with vomiting.

      Further Reading:

      Procedural sedation is commonly used by emergency department (ED) doctors to minimize pain and discomfort during procedures that may be painful or distressing for patients. Effective procedural sedation requires the administration of analgesia, anxiolysis, sedation, and amnesia. This is typically achieved through the use of a combination of short-acting analgesics and sedatives.

      There are different levels of sedation, ranging from minimal sedation (anxiolysis) to general anesthesia. It is important for clinicians to understand the level of sedation being used and to be able to manage any unintended deeper levels of sedation that may occur. Deeper levels of sedation are similar to general anesthesia and require the same level of care and monitoring.

      Various drugs can be used for procedural sedation, including propofol, midazolam, ketamine, and fentanyl. Each of these drugs has its own mechanism of action and side effects. Propofol is commonly used for sedation, amnesia, and induction and maintenance of general anesthesia. Midazolam is a benzodiazepine that enhances the effect of GABA on the GABA A receptors. Ketamine is an NMDA receptor antagonist and is used for dissociative sedation. Fentanyl is a highly potent opioid used for analgesia and sedation.

      The doses of these drugs for procedural sedation in the ED vary depending on the drug and the route of administration. It is important for clinicians to be familiar with the appropriate doses and onset and peak effect times for each drug.

      Safe sedation requires certain requirements, including appropriate staffing levels, competencies of the sedating practitioner, location and facilities, and monitoring. The level of sedation being used determines the specific requirements for safe sedation.

      After the procedure, patients should be monitored until they meet the criteria for safe discharge. This includes returning to their baseline level of consciousness, having vital signs within normal limits, and not experiencing compromised respiratory status. Pain and discomfort should also be addressed before discharge.

    • This question is part of the following fields:

      • Basic Anaesthetics
      5.5
      Seconds
  • Question 23 - A 25-year-old individual who was attacked with a baseball bat returns from the...

    Correct

    • A 25-year-old individual who was attacked with a baseball bat returns from the radiology department after undergoing a CT head scan. The CT images show the presence of intracranial bleeding, and after consulting with the on-call neurosurgical registrar, it is decided that the patient will be transferred to the nearby neurosurgical unit after intubation. How can you determine the amount of oxygen that will be required during the transfer?

      Your Answer: 2 x Minute Volume (MV) x FiO2 x transfer time in minutes

      Explanation:

      To determine the amount of oxygen needed for a transfer, you can use the formula: 2 x Minute Volume (MV) x FiO2 x transfer time in minutes. This formula calculates the volume of oxygen that should be taken on the transfer. The Minute Volume (MV) represents the expected oxygen consumption. It is recommended to double the expected consumption to account for any unforeseen delays or increased oxygen demand during the transfer. Therefore, the second equation is used to calculate the volume of oxygen that will be taken on the transfer.

      Further Reading:

      Transfer of critically ill patients in the emergency department is a common occurrence and can involve intra-hospital transfers or transfers to another hospital. However, there are several risks associated with these transfers that doctors need to be aware of and manage effectively.

      Technical risks include equipment failure or inadequate equipment, unreliable power or oxygen supply, incompatible equipment, restricted positioning, and restricted monitoring equipment. These technical issues can hinder the ability to detect and treat problems with ventilation, blood pressure control, and arrhythmias during the transfer.

      Non-technical risks involve limited personal and medical team during the transfer, isolation and lack of resources in the receiving hospital, and problems with communication and liaison between the origin and destination sites.

      Organizational risks can be mitigated by having a dedicated consultant lead for transfers who is responsible for producing guidelines, training staff, standardizing protocols, equipment, and documentation, as well as capturing data and conducting audits.

      To optimize the patient’s clinical condition before transfer, several key steps should be taken. These include ensuring a low threshold for intubation and anticipating airway and ventilation problems, securing the endotracheal tube (ETT) and verifying its position, calculating oxygen requirements and ensuring an adequate supply, monitoring for circulatory issues and inserting at least two IV accesses, providing ongoing analgesia and sedation, controlling seizures, and addressing any fractures or temperature changes.

      It is also important to have the necessary equipment and personnel for the transfer. Standard monitoring equipment should include ECG, oxygen saturation, blood pressure, temperature, and capnographic monitoring for ventilated patients. Additional monitoring may be required depending on the level of care needed by the patient.

      In terms of oxygen supply, it is standard practice to calculate the expected oxygen consumption during transfer and multiply it by two to ensure an additional supply in case of delays. The suggested oxygen supply for transfer can be calculated using the minute volume, fraction of inspired oxygen, and estimated transfer time.

      Overall, managing the risks associated with patient transfers requires careful planning, communication, and coordination to ensure the safety and well-being of critically ill patients.

    • This question is part of the following fields:

      • Basic Anaesthetics
      5.1
      Seconds
  • Question 24 - A 25 year old male presents to the emergency department with a significant...

    Correct

    • A 25 year old male presents to the emergency department with a significant laceration on his right forearm. You suggest that the wound can be stitched under local anesthesia. You opt to use 1% lidocaine for the procedure. The patient has a weight of 70kg. Determine the maximum amount of lidocaine 1% that can be administered.

      Your Answer: 18 ml

      Explanation:

      Lidocaine is a medication that is available in a concentration of 10 mg per milliliter. The maximum recommended dose of lidocaine is 18 milliliters.

      Further Reading:

      Local anaesthetics, such as lidocaine, bupivacaine, and prilocaine, are commonly used in the emergency department for topical or local infiltration to establish a field block. Lidocaine is often the first choice for field block prior to central line insertion. These anaesthetics work by blocking sodium channels, preventing the propagation of action potentials.

      However, local anaesthetics can enter the systemic circulation and cause toxic side effects if administered in high doses. Clinicians must be aware of the signs and symptoms of local anaesthetic systemic toxicity (LAST) and know how to respond. Early signs of LAST include numbness around the mouth or tongue, metallic taste, dizziness, visual and auditory disturbances, disorientation, and drowsiness. If not addressed, LAST can progress to more severe symptoms such as seizures, coma, respiratory depression, and cardiovascular dysfunction.

      The management of LAST is largely supportive. Immediate steps include stopping the administration of local anaesthetic, calling for help, providing 100% oxygen and securing the airway, establishing IV access, and controlling seizures with benzodiazepines or other medications. Cardiovascular status should be continuously assessed, and conventional therapies may be used to treat hypotension or arrhythmias. Intravenous lipid emulsion (intralipid) may also be considered as a treatment option.

      If the patient goes into cardiac arrest, CPR should be initiated following ALS arrest algorithms, but lidocaine should not be used as an anti-arrhythmic therapy. Prolonged resuscitation may be necessary, and intravenous lipid emulsion should be administered. After the acute episode, the patient should be transferred to a clinical area with appropriate equipment and staff for further monitoring and care.

      It is important to report cases of local anaesthetic toxicity to the appropriate authorities, such as the National Patient Safety Agency in the UK or the Irish Medicines Board in the Republic of Ireland. Additionally, regular clinical review should be conducted to exclude pancreatitis, as intravenous lipid emulsion can interfere with amylase or lipase assays.

    • This question is part of the following fields:

      • Basic Anaesthetics
      26.7
      Seconds
  • Question 25 - A 30-year-old woman is brought in by ambulance following a car accident where...

    Correct

    • A 30-year-old woman is brought in by ambulance following a car accident where her car was struck by a truck. She has suffered severe facial injuries and shows signs of airway obstruction. Her C-spine is triple immobilized. You perform a LEMON assessment for difficult intubation.
      Which of the following factors indicates a difficult intubation?

      Your Answer: Mallampati score of 4

      Explanation:

      Trauma patients who require a definitively secured airway include those who are apnoeic, have a Glasgow Coma Scale score of less than 9, experience sustained seizure activity, have unstable midface trauma or airway injuries, have a large flail segment or respiratory failure, have a high risk of aspiration, or are unable to maintain an airway or oxygenation through other means.

      To predict difficult intubations, the LEMON assessment can be utilized. The LEMON mnemonic provides a systematic approach to assess potential challenges in intubation. It stands for the following:

      – Look externally: Examine for any characteristics that are known to cause difficult intubation or ventilation.
      – Evaluate the 3-3-2 rule: Measure the incisor distance, hyoid/mental distance, and thyroid-to-mouth distance. If any of these measurements are less than the specified number of fingerbreadths, it may indicate a difficult intubation.
      – Mallampati: Assess the Mallampati score, which is a classification system based on the visibility of certain structures in the mouth and throat. A score of 3 or higher suggests a difficult intubation.
      – Obstruction: Check for the presence of any conditions that could potentially obstruct the airway.
      – Neck mobility: Evaluate the mobility of the patient’s neck, as limited mobility may make intubation more challenging.

      By utilizing the LEMON assessment, healthcare providers can identify potential difficulties in securing the airway and make appropriate interventions to ensure patient safety.

    • This question is part of the following fields:

      • Basic Anaesthetics
      12.5
      Seconds
  • Question 26 - A 15-year-old presents to the emergency department with facial swelling and respiratory distress....

    Correct

    • A 15-year-old presents to the emergency department with facial swelling and respiratory distress. Despite attempts at ventilation, it is determined that a cricothyroidotomy procedure is necessary. Which of the following statements about cricothyroidotomy is correct?

      Your Answer: Involves creating an airway via the space between thyroid and cricoid cartilages

      Explanation:

      Jet ventilation through a needle cricothyroidotomy typically involves using a 1 bar (100 Kpa) oxygen source.

      Further Reading:

      Cricothyroidotomy, also known as cricothyrotomy, is a procedure used to create an airway by making an incision between the thyroid and cricoid cartilages. This can be done surgically with a scalpel or using a needle method. It is typically used as a short-term solution for establishing an airway in emergency situations where traditional intubation is not possible.

      The surgical technique involves dividing the cricothyroid membrane transversely, while some recommend making a longitudinal skin incision first to identify the structures below. Complications of this procedure can include bleeding, infection, incorrect placement resulting in a false passage, fistula formation, cartilage fracture, subcutaneous emphysema, scarring leading to stenosis, and injury to the vocal cords or larynx. There is also a risk of damage to the recurrent laryngeal nerve, and failure to perform the procedure successfully can lead to hypoxia and death.

      There are certain contraindications to surgical cricothyroidotomy, such as the availability of less invasive airway securing methods, patients under 12 years old (although a needle technique may be used), laryngeal fracture, pre-existing or acute laryngeal pathology, tracheal transection with retraction into the mediastinum, and obscured anatomical landmarks.

      The needle (cannula) cricothyroidotomy involves inserting a cannula through the cricothyroid membrane to access the trachea. This method is mainly used in children in scenarios where ENT assistance is not available. However, there are drawbacks to this approach, including the need for high-pressure oxygen delivery, which can risk barotrauma and may not always be readily available. The cannula is also prone to kinking and displacement, and there is limited evacuation of expiratory gases, making it suitable for only a short period of time before CO2 retention becomes problematic.

      In children, the cannula cricothyroidotomy and ventilation procedure involves extending the neck and stabilizing the larynx, inserting a 14g or 16g cannula at a 45-degree angle aiming caudally, confirming the position by aspirating air through a saline-filled syringe, and connecting it to an insufflation device or following specific oxygen pressure and flow settings for jet ventilation.

      If a longer-term airway is needed, a cricothyroidotomy may be converted to

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      • Basic Anaesthetics
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  • Question 27 - A 65-year-old male patient is brought into the emergency department with suspected sepsis....

    Correct

    • A 65-year-old male patient is brought into the emergency department with suspected sepsis. It is decided to intubate the patient pending transfer to the intensive care unit (ICU). Your consultant requests you to prepare propofol and suxamethonium for rapid sequence intubation. What is the mechanism of action of suxamethonium?

      Your Answer: Non-competitive agonist of acetylcholine receptors at the neuromuscular junction

      Explanation:

      Suxamethonium, also called succinylcholine, is a type of drug used to block neuromuscular transmission. It acts as an agonist by binding to acetylcholine receptors at the neuromuscular junction. Unlike acetylcholine, suxamethonium is not broken down by acetylcholinesterase, which means it stays bound to the receptors for a longer time, leading to prolonged inhibition of neuromuscular transmission. Eventually, suxamethonium is metabolized by plasma cholinesterase.

      Further Reading:

      Rapid sequence induction (RSI) is a method used to place an endotracheal tube (ETT) in the trachea while minimizing the risk of aspiration. It involves inducing loss of consciousness while applying cricoid pressure, followed by intubation without face mask ventilation. The steps of RSI can be remembered using the 7 P’s: preparation, pre-oxygenation, pre-treatment, paralysis and induction, protection and positioning, placement with proof, and post-intubation management.

      Preparation involves preparing the patient, equipment, team, and anticipating any difficulties that may arise during the procedure. Pre-oxygenation is important to ensure the patient has an adequate oxygen reserve and prolongs the time before desaturation. This is typically done by breathing 100% oxygen for 3 minutes. Pre-treatment involves administering drugs to counter expected side effects of the procedure and anesthesia agents used.

      Paralysis and induction involve administering a rapid-acting induction agent followed by a neuromuscular blocking agent. Commonly used induction agents include propofol, ketamine, thiopentone, and etomidate. The neuromuscular blocking agents can be depolarizing (such as suxamethonium) or non-depolarizing (such as rocuronium). Depolarizing agents bind to acetylcholine receptors and generate an action potential, while non-depolarizing agents act as competitive antagonists.

      Protection and positioning involve applying cricoid pressure to prevent regurgitation of gastric contents and positioning the patient’s neck appropriately. Tube placement is confirmed by visualizing the tube passing between the vocal cords, auscultation of the chest and stomach, end-tidal CO2 measurement, and visualizing misting of the tube. Post-intubation management includes standard care such as monitoring ECG, SpO2, NIBP, capnography, and maintaining sedation and neuromuscular blockade.

      Overall, RSI is a technique used to quickly and safely secure the airway in patients who may be at risk of aspiration. It involves a series of steps to ensure proper preparation, oxygenation, drug administration, and tube placement. Monitoring and post-intubation care are also important aspects of RSI.

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      • Basic Anaesthetics
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  • Question 28 - You are part of the team managing a conscious patient in the emergency...

    Correct

    • You are part of the team managing a conscious patient in the emergency room. You decide to insert a nasopharyngeal airway adjunct. How should you determine the appropriate size of the nasopharyngeal airway?

      Your Answer: Sized according to the distance between the nostril and the tragus of the ear

      Explanation:

      Nasopharyngeal airway adjuncts (NPAs) are selected based on their length, which should match the distance between the nostril and the tragus of the ear.

      Further Reading:

      Techniques to keep the airway open:

      1. Suction: Used to remove obstructing material such as blood, vomit, secretions, and food debris from the oral cavity.

      2. Chin lift manoeuvres: Involves lifting the head off the floor and lifting the chin to extend the head in relation to the neck. Improves alignment of the pharyngeal, laryngeal, and oral axes.

      3. Jaw thrust: Used in trauma patients with cervical spine injury concerns. Fingers are placed under the mandible and gently pushed upward.

      Airway adjuncts:

      1. Oropharyngeal airway (OPA): Prevents the tongue from occluding the airway. Sized according to the patient by measuring from the incisor teeth to the angle of the mandible. Inserted with the tip facing backwards and rotated 180 degrees once it touches the back of the palate or oropharynx.

      2. Nasopharyngeal airway (NPA): Useful when it is difficult to open the mouth or in semi-conscious patients. Sized by length (distance between nostril and tragus of the ear) and diameter (roughly that of the patient’s little finger). Contraindicated in basal skull and midface fractures.

      Laryngeal mask airway (LMA):

      – Supraglottic airway device used as a first line or rescue airway.
      – Easy to insert, sized according to patient’s bodyweight.
      – Advantages: Easy insertion, effective ventilation, some protection from aspiration.
      – Disadvantages: Risk of hypoventilation, greater gastric inflation than endotracheal tube (ETT), risk of aspiration and laryngospasm.

      Note: Proper training and assessment of the patient’s condition are essential for airway management.

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      • Basic Anaesthetics
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  • Question 29 - A 68-year-old individual reports feeling unwell after having their dislocated shoulder reduced while...

    Correct

    • A 68-year-old individual reports feeling unwell after having their dislocated shoulder reduced while under sedation. You decide to prescribe ondansetron. What is the mechanism of action of ondansetron?

      Your Answer: 5-HT3 receptor antagonist

      Explanation:

      Ondansetron is a medication that works by blocking serotonin receptors in the body. It is commonly used as a first-line treatment for postoperative nausea and vomiting (PONV), which can occur after procedures done under sedation or anesthesia.

      Further Reading:

      postoperative nausea and vomiting (PONV) is a common occurrence following procedures performed under sedation or anesthesia. It can be highly distressing for patients. Several risk factors have been identified for PONV, including female gender, a history of PONV or motion sickness, non-smoking status, patient age, use of volatile anesthetics, longer duration of anesthesia, perioperative opioid use, use of nitrous oxide, and certain types of surgery such as abdominal and gynecological procedures.

      To manage PONV, antiemetics are commonly used. These medications work by targeting different receptors in the body. Cyclizine and promethazine are histamine H1-receptor antagonists, which block the action of histamine and help reduce nausea and vomiting. Ondansetron is a serotonin 5-HT3 receptor antagonist, which blocks the action of serotonin and is effective in preventing and treating PONV. Prochlorperazine is a dopamine D2 receptor antagonist, which blocks the action of dopamine and helps alleviate symptoms of nausea and vomiting. Metoclopramide is also a dopamine D2 receptor antagonist and a 5-HT3 receptor antagonist, providing dual action against PONV. It is also a 5-HT4 receptor agonist, which helps improve gastric emptying and reduces the risk of PONV.

      Assessment and management of PONV involves a comprehensive approach. Healthcare professionals need to assess the patient’s risk factors for PONV and take appropriate measures to prevent its occurrence. This may include selecting the appropriate anesthesia technique, using antiemetics prophylactically, and providing adequate pain control. In cases where PONV does occur, prompt treatment with antiemetics should be initiated to alleviate symptoms and provide relief to the patient. Close monitoring of the patient’s condition and response to treatment is essential to ensure effective management of PONV.

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      • Basic Anaesthetics
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  • Question 30 - You are overseeing a patient who has been administered ketamine. You have concerns...

    Correct

    • You are overseeing a patient who has been administered ketamine. You have concerns about restlessness and emergence phenomena during the recovery process. Which class of medication is commonly employed to manage emergence phenomena?

      Your Answer: Benzodiazepines

      Explanation:

      Benzodiazepines are medications that are utilized to address emergence phenomena, which are characterized by restlessness and distressing hallucinations experienced upon awakening from ketamine sedation or induction. These phenomena are more frequently observed in older children and adults, affecting approximately one out of every three adults. To manage emergence phenomena, benzodiazepines may be administered. It is important to note that the RCEM does not recommend preventive treatment and suggests addressing emergence phenomena as they arise.

      Further Reading:

      There are four commonly used induction agents in the UK: propofol, ketamine, thiopentone, and etomidate.

      Propofol is a 1% solution that produces significant venodilation and myocardial depression. It can also reduce cerebral perfusion pressure. The typical dose for propofol is 1.5-2.5 mg/kg. However, it can cause side effects such as hypotension, respiratory depression, and pain at the site of injection.

      Ketamine is another induction agent that produces a dissociative state. It does not display a dose-response continuum, meaning that the effects do not necessarily increase with higher doses. Ketamine can cause bronchodilation, which is useful in patients with asthma. The initial dose for ketamine is 0.5-2 mg/kg, with a typical IV dose of 1.5 mg/kg. Side effects of ketamine include tachycardia, hypertension, laryngospasm, unpleasant hallucinations, nausea and vomiting, hypersalivation, increased intracranial and intraocular pressure, nystagmus and diplopia, abnormal movements, and skin reactions.

      Thiopentone is an ultra-short acting barbiturate that acts on the GABA receptor complex. It decreases cerebral metabolic oxygen and reduces cerebral blood flow and intracranial pressure. The adult dose for thiopentone is 3-5 mg/kg, while the child dose is 5-8 mg/kg. However, these doses should be halved in patients with hypovolemia. Side effects of thiopentone include venodilation, myocardial depression, and hypotension. It is contraindicated in patients with acute porphyrias and myotonic dystrophy.

      Etomidate is the most haemodynamically stable induction agent and is useful in patients with hypovolemia, anaphylaxis, and asthma. It has similar cerebral effects to thiopentone. The dose for etomidate is 0.15-0.3 mg/kg. Side effects of etomidate include injection site pain, movement disorders, adrenal insufficiency, and apnoea. It is contraindicated in patients with sepsis due to adrenal suppression.

    • This question is part of the following fields:

      • Basic Anaesthetics
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