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Question 1
Correct
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An 80-year-old woman is suffering from gastroenteritis and requires iv replacement due to her inability to tolerate oral fluids. What is the maximum flow rate achievable through a 16G cannula?
Your Answer: 180 ml/min
Explanation:Different Flow Rates of Cannulas for Infusions
Cannulas are small tubes inserted into a vein to administer medication or fluids. Different sizes and colors of cannulas are available, each with varying flow rates. The grey 16G cannula has the highest flow rate of 180 ml/min, while the blue 22G cannula has the lowest flow rate of 33 ml/min. The pink 20G cannula is the most commonly used in adults for standard infusions, with a flow rate of 54 ml/min. The green 18G cannula has a flow rate of 80 ml/min, and the orange 14G cannula has the largest size and highest flow rate of 270 ml/min. It is important to choose the appropriate cannula size and flow rate for each patient’s needs.
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This question is part of the following fields:
- Anaesthetics & ITU
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Question 2
Incorrect
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Which of the following characteristics is not associated with cannabinoids?
Your Answer: Lowers intraocular pressure
Correct Answer: Bioavailability after oral administration is about 80%
Explanation:Cannabinoids and Their Effects
Cannabinoids are compounds found in the resin of cannabis sativa, with 9-tetrahydrocannabinol (9-THC) being the most important active component. However, the oral bioavailability of THC, whether in pure form or as part of marijuana, is low and highly variable, with effects taking anywhere from 0.5 to 3 hours to occur. Smoking marijuana also does not significantly increase bioavailability, with rates rarely exceeding 10-20%.
Interestingly, the analgesic effects of cannabinoids can be blocked by naloxone and other opioid receptor antagonists. Additionally, synthetic cannabinoids have been found to reduce inflammation caused by arachidonic acid by inhibiting eicosanoid production. Overall, the effects and limitations of cannabinoids is important for both medical and recreational use.
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This question is part of the following fields:
- Anaesthetics & ITU
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Question 3
Incorrect
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A 60-year-old man has been resuscitated after a cardiac arrest and is now being treated for hypoxic brain injury in the Neuro-Intensive Care Unit. His family is concerned about his prognosis. What is the most reliable source of information regarding his potential outcome?
Your Answer: Absent pupillary or corneal reflexes at three days after cardiac arrest
Correct Answer: Bilaterally absent somatosensory evoked responses (SSEPs) at 24–72 hours
Explanation:Prognostic Indicators for Hypoxic Brain Injury Patients
Hypoxic brain injury patients require ancillary tests to aid in determining their prognosis. Bilaterally absent somatosensory evoked responses (SSEPs) at 24–72 hours and complete generalised suppression of electroencephalographic (EEG) waves on day three are reliable indicators of poor prognosis. Absent pupillary or corneal reflexes at three days after cardiac arrest, along with the absence of motor response, is also a better prognostic marker. However, in the absence of either one of these factors, the prognosis should be evaluated using results from ancillary tests (SSEP/EEG). Extensor motor response on day three, despite the absence of motor response, is a reliable indicator for poor prognosis. Myoclonic status epilepticus (MSE) – bilateral and synchronous myoclonus of the face, limbs and axial skeleton – has been studied as a reliable marker for poor prognosis in these patients, even in the presence of brainstem and motor responses. However, it should not be considered in isolation as a prognostic indicator. It is important to note that the reliability of these indicators may be affected by factors such as noise interferences, hypothermia, and drugs given during resuscitation.
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This question is part of the following fields:
- Anaesthetics & ITU
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Question 4
Correct
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You are requested to evaluate a 50-year-old individual who underwent a left total knee replacement two days ago. The patient reports experiencing weakness in the movement of their right foot since the surgery. They are curious if the spinal anesthesia administered during the procedure could be the cause, despite no complications being reported at the time. Apart from this issue, the patient is in good health. Upon clinical examination, you observe a suspected foot drop as there is a weakened dorsiflexion of the right foot. What is the probable reason for this?
Your Answer: Poor intra-operative positioning and padding
Explanation:Post-Operative Foot Drop Caused by Prolonged Pressure on Common Peroneal Nerve
Prolonged pressure on the common peroneal nerve during anaesthesia is a well-known cause of post-operative foot drop. It is important to ensure that patients are adequately padded on the fibula head when positioning them under general or regional anaesthesia for extended periods of time. While a central neurological cause is unlikely to cause such well-defined peripheral nerve lesions, it is essential to take precautions to prevent nerve damage during surgery.
Treatment for post-operative foot drop is typically conservative, and the transient neuropraxia can often pass. However, in some cases, this may result in permanent injury. It is crucial to monitor patients closely after surgery and provide appropriate care to prevent further complications. By taking preventative measures and providing proper post-operative care, healthcare professionals can help reduce the risk of post-operative foot drop and other nerve injuries.
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This question is part of the following fields:
- Anaesthetics & ITU
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Question 5
Incorrect
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A 98-year-old gentleman is admitted for an incarcerated hernia. He has a past medical history of chronic kidney disease stage 3, secondary to hypertension, and a background of transient ischaemic attacks (TIAs) and osteoarthritis of both knees.
He has four good twitches on train of four testing (normal response), following which reversal of his muscle relaxant was given. Intraoperatively, he received a total of 100 micrograms of fentanyl, 20 mg of morphine and 1 g of paracetamol for pain. He has an arterial line in situ. Blood gas prior to finishing the procedure showed a pH of 7.35, PaCO2 of 5.4 kPa, HCO3− of 21 mmol/l, with a blood sugar of 7.2.
You attempt to wean him off ventilation, but 20 minutes later he still does not want to breathe unsupported or wake up.
What should your next course of action be?Your Answer: Re-sedate and take for a computed tomography (CT) head
Correct Answer: Give naloxone 100 micrograms iv
Explanation:Medical Interventions for a Post-Operative Patient with Reduced Consciousness
When dealing with a post-operative patient with reduced consciousness, it is important to rule out any reversible causes before administering any medical interventions. In the case of opiate toxicity, administering naloxone, an opiate antidote, can reverse the effects of the opiates. However, if the patient’s reduced Glasgow Coma Scale score and lack of respiratory effort are not caused by hypoglycemia, giving intravenous glucose is not necessary. It is also important to consider the patient’s age and wait a little longer to rule out any reversible causes. Administering a second dose of muscle relaxant reversal is unlikely to help if the patient has adequate contraction on train of four testing. Lastly, before re-sedating the patient for a CT head, it is necessary to rule out any reversible causes such as opiate toxicity.
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This question is part of the following fields:
- Anaesthetics & ITU
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Question 6
Correct
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A 60-year-old man comes to the clinic complaining of worsening shortness of breath over the past six months. Upon examination, he is diagnosed with aortic stenosis. What physical sign is the most reliable indicator of the severity of the valvular disease?
Your Answer: Length of the murmur
Explanation:Characteristics of Aortic Stenosis
Aortic stenosis is a condition where the aortic valve becomes narrowed, causing the heart to work harder to pump blood out to the body. Despite this increased workload, the apex beat in aortic stenosis is not displaced but has a heaving character. Additionally, the pulse is typically of small volume and slow rising. The second heart sound may be inaudible or paradoxically split.
It is important to note that the intensity of the murmur is not a reliable indicator of the severity of the disease. As the cardiac output is reduced with more severe disease, the murmur may become less intense. However, the murmur tends to become longer as the disease progresses, due to the longer ejection time needed. These characteristics can help healthcare professionals diagnose and monitor aortic stenosis in patients.
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This question is part of the following fields:
- Anaesthetics & ITU
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Question 7
Incorrect
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Which volatile agent was linked to the development of fulminant hepatitis after secondary exposure?
Your Answer: Enflurane
Correct Answer: Halothane
Explanation:Halothane Hepatitis and Precautions
Halothane hepatitis is a condition that can range from minor liver function issues to severe liver failure. It occurs when liver damage appears within 28 days of exposure to halothane, after excluding other known causes of liver disease. About 75% of patients with halothane hepatitis have antibodies that react to halothane-altered antigens. Therefore, it is important to take precautions when using halothane.
Halothane should be avoided if there has been a previous exposure within three months, if there is a known adverse reaction to halothane, if there is a family history of adverse reactions, or if there is pre-existing liver disease. These precautions can help prevent the occurrence of halothane hepatitis and ensure the safety of patients. It is important to carefully consider the use of halothane and take necessary measures to avoid any potential harm.
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This question is part of the following fields:
- Anaesthetics & ITU
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Question 8
Correct
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What is the commonly used curved-blade laryngoscope in adult practice?
Your Answer: Macintosh
Explanation:Types of Laryngoscopes
Laryngoscopes are medical instruments used to visualize the larynx and facilitate intubation. There are several types of laryngoscopes, each with its own unique features. The Miller, Oxford, and Wisconsin laryngoscopes have straight blades, while the Macintosh and McCoy laryngoscopes have curved blades. The McCoy laryngoscope is typically used for difficult intubations, as its blade tip is hinged and can be operated by a lever mechanism on the handle. Overall, the choice of laryngoscope depends on the individual patient and the specific needs of the intubation procedure.
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This question is part of the following fields:
- Anaesthetics & ITU
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Question 9
Correct
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A 50-year-old man with a history of hypertension, asthma and porphyria requires emergency surgery. His blood pressure and asthma are under control. What is the most suitable anaesthetic induction agent for the rapid sequence induction (RSI) procedure?
Your Answer: Propofol
Explanation:An Overview of Common Anaesthetic Induction Agents and Their Advantages and Adverse Effects
Propofol, ketamine, fentanyl, methohexital, and thiopental are commonly used anaesthetic induction agents. Propofol is the preferred choice for most people due to its rapid onset and offset of action, antiemetic and anticonvulsive effects, bronchodilation, and decreased cerebral metabolic oxygen demand and cerebral blood pressure. Ketamine is ideal for hypotensive patients due to its rapid onset, analgesic effects, bronchodilation, and maintenance of airway reflexes and respiratory drive. Fentanyl is an opiate analgesic used for pain relief, while methohexital is used for electroconvulsive therapy. Thiopental is a barbiturate used in general and regional anaesthesia. However, each agent has its own set of advantages and adverse effects that must be considered before use. For example, ketamine can increase intracranial pressure, cardiac output, and blood pressure, while thiopental can cause bronchoconstriction and is contraindicated in asthmatics and patients with a history of porphyria. It is important to carefully evaluate each patient’s medical history and condition before selecting an appropriate anaesthetic induction agent.
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This question is part of the following fields:
- Anaesthetics & ITU
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Question 10
Correct
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A patient is brought into the Resuscitation Room. Paramedics were called after he was found face down, unconscious on the road. He smells strongly of alcohol. He has a nasopharyngeal airway in situ (inserted by the ambulance service). There are no visible injuries, except for a small abrasion on his left knee and another on his left shoulder. He is currently on 15 l of high-flow oxygen via a non-rebreather mask.
In which of the following scenarios is a nasopharyngeal airway indicated for an elderly patient?Your Answer: Seizures
Explanation:The Use of Nasopharyngeal Airways in Seizure Management
Nasopharyngeal airways are a valuable tool in managing patients with seizures. During a seizure, jaw rigidity can make it difficult to position an oropharyngeal airway, making a nasopharyngeal airway a better option. These airways are used to secure an open airway in patients with a decreased Glasgow Coma Scale (GCS) score and those who cannot tolerate an oropharyngeal airway due to an intact gag reflex. The correct size of the airway is chosen by sizing the width of the patient’s nostril to the circumference of the tube, and insertion is facilitated by using a water-based lubricant. However, nasopharyngeal airways should not be used in patients with a patent airway or those with basal skull fractures and coagulopathy.
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This question is part of the following fields:
- Anaesthetics & ITU
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Question 11
Correct
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What is the correct information about Entonox?
Your Answer: Is an effective short term analgesic
Explanation:Entonox: A Mixture of Nitrous Oxide and Oxygen
Entonox is a gas mixture of 50% nitrous oxide and 50% oxygen that is stored in cylinders. The cylinders have a French blue body with blue and white quarters at the top. It is important to note that if the gas mixture cools below its pseudocritical temperature of −6°C, the nitrous oxide and oxygen may separate out through a process called lamination. This can result in a potentially dangerous and hypoxic gas being administered.
Despite being a flammable mixture, Entonox is not considered explosive. It is effective in providing short-term analgesia and is safe for both infants and mothers. The onset of action occurs approximately 30 seconds after inhalation, and the duration of action after analgesia is approximately one minute.
It is important to distinguish nitrous oxide (N2O) from nitric oxide (NO) as they are not the same. Overall, Entonox is a useful gas mixture for providing short-term pain relief, but it must be stored and administered properly to avoid any potential risks.
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This question is part of the following fields:
- Anaesthetics & ITU
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Question 12
Incorrect
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How should neuropathic pain be managed?
Your Answer: The analgesic response to amitriptyline occurs after three to four weeks
Correct Answer: Anticonvulsants are prescribed in similar doses to the treatment of epilepsy
Explanation:Neuropathic Pain and Treatment Options
Neuropathic pain is a chronic condition that affects neuronal membrane excitability and often results in allodynia, hyperalgesia, and hyperpathia. Unlike nociceptive pain, neuropathic pain is less responsive to opioids and can be more difficult to treat. To manage this type of pain, coanalgesics such as antidepressants, anticonvulsants, and antiarrhythmics are commonly prescribed. Anticonvulsants are typically administered at similar doses and schedules as in the treatment of epilepsy. The analgesic response to mexiletine can be predicted by evaluating the improvement in pain after an intravenous lidocaine infusion. Amitriptyline, on the other hand, has a faster analgesic response than its antidepressant effect, with pain relief occurring within a week of treatment. Overall, managing neuropathic pain requires a multifaceted approach that may involve a combination of medications and other therapies.
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This question is part of the following fields:
- Anaesthetics & ITU
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Question 13
Incorrect
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A 60kg woman with a functional residual capacity (FRC) of 2.5 l is pre-oxygenated adequately for 3 minutes. Oxygen extraction per minute is 250 ml.
How long will the patient have in theory before they begin to desaturate?Your Answer:
Correct Answer: 10 minutes
Explanation:Understanding Pre-Oxygenation and Desaturation Time
Pre-oxygenation is a crucial step in ensuring adequate oxygenation during medical procedures. In a 70-kg man, the functional residual capacity (FRC) is approximately 2.5 liters. If pre-oxygenated adequately, all of the FRC will be 100% oxygen, and oxygen extraction per minute is 250 ml. This means that the patient will have 10 minutes of adequate oxygenation in the absence of ventilation before desaturation occurs.
However, if only 21% (room air) was in the FRC, the patient would only have 2 minutes before they started to desaturate. It is important to note that the oxygen extraction rate is 250 ml per minute in a 70-kg male. A person who has been adequately preoxygenated will not start to desaturate until double this time period, which is 10 minutes.
Therefore, if the patient is oxygenated on room air only, the correct answer for desaturation time would be 2.5 minutes. However, if the patient has been adequately preoxygenated, they will desaturate well before 25 minutes is reached. Understanding pre-oxygenation and desaturation time is crucial in ensuring patient safety during medical procedures.
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This question is part of the following fields:
- Anaesthetics & ITU
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Question 14
Incorrect
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A 7-year-old girl is scheduled for an elective tonsillectomy. Your consultant has requested that you prepare all the airway equipment. What size of endotracheal tube (ETT) do you anticipate she will require?
Your Answer:
Correct Answer: 5.5 cuffed ETT
Explanation:Choosing the Correct Endotracheal Tube Size for an 8-Year-Old Child
When it comes to intubating an 8-year-old child, choosing the correct endotracheal tube (ETT) size is crucial. Cuffed ETTs are now considered safe for use in children, but not in neonates. To calculate the appropriate size of a cuffed ETT, use the formula (Child’s age/4) + 3.5. For an 8-year-old child, the correct size of a cuffed ETT would be 5.5 mm. If an uncuffed tube is preferred, use the formula (Child’s age/4) + 4 to calculate the tube size, which would be 6.0 mm for an 8-year-old child. It is important to note that using a cuffed tube offers more protection from aspiration. Avoid using a 4.5 mm cuffed ETT, as it is too small for an 8-year-old child.
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This question is part of the following fields:
- Anaesthetics & ITU
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Question 15
Incorrect
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To visualize the vocal cords, where should the tip of a Macintosh laryngoscope be inserted?
Your Answer:
Correct Answer: Into the vallecula
Explanation:Macintosh Laryngoscope: A Tool for Visualizing the Vocal Cords
The Macintosh laryngoscope is a medical instrument designed to aid in the visualization of the vocal cords. Its curved blade is specifically shaped to fit into the oral and oropharyngeal cavity. To use it, the blade is inserted through the right side of the mouth and gradually advanced, pushing the tongue to the left and out of view. The blade has a small bulbous tip that is intended to sit in the vallecula, a small depression between the base of the tongue and the epiglottis.
By lifting the laryngoscope up and forwards, the larynx is elevated, allowing for a clear view of the vocal cords. This tool is commonly used in medical settings, such as during intubation procedures or when examining the airway. Its design allows for a safe and effective way to visualize the vocal cords, aiding in the diagnosis and treatment of various medical conditions.
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This question is part of the following fields:
- Anaesthetics & ITU
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Question 16
Incorrect
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You are asked to take over a patient halfway through a case to relieve the consultant anaesthetist for a comfort break. The patient, who is 65 years old, has an endotracheal tube (ETT) in situ and is maintained on sevoflurane and ventilated at a rate of 14 breaths per minute, with a tidal volume of 600. You notice that the carbon dioxide (CO2) trace is high (ET 6.9) and increasing quite rapidly. The maxillofacial surgeon remarks that the patient’s jaw is quite tight and asks for more muscle relaxant. You check the patient’s temperature and find that it is high at 39.6 °C.
Which one of the following is your priority?Your Answer:
Correct Answer: Actively cool the patient, stop sevoflurane and give dantrolene
Explanation:Managing Malignant Hyperpyrexia: An Anaesthetic Emergency
Malignant hyperpyrexia is a life-threatening anaesthetic emergency triggered by inhalational anaesthetics and muscle relaxants in genetically susceptible individuals. It causes a hypermetabolic state, leading to increased CO2 production, oxygen consumption, heat production, metabolic and respiratory acidosis, hyperkalaemia, activation of the sympathetic nervous system, and disseminated intravascular coagulation.
Early signs include a rise in end-tidal CO2, rigid muscles, tachycardia, and tachypnoea. Treatment involves discontinuation of the triggering agent, rapid administration of dantrolene, active cooling, and treatment of hyperkalaemia. Dantrolene inhibits calcium release from the sarcoplasmic reticulum and reverses the hypermetabolic state.
It is important to inform the surgeon and stop the operation. Once the initial reaction is controlled, the patient will require transfer to the ICU and monitoring for 24-48 hours.
In contrast, giving more muscle relaxant or antibiotics is not recommended. Active management and stabilisation of the patient should precede discussion with the ICU. Malignant hyperpyrexia requires prompt recognition and management to prevent serious complications and death.
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This question is part of the following fields:
- Anaesthetics & ITU
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Question 17
Incorrect
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A 26-year-old man on the Medical Ward develops status epilepticus. He is immediately attended by the Foundation Year One Doctor who notices that his airway has been compromised. The patient is immediately examined and found to be haemodynamically stable, with a history of hypertension and asthma. The anaesthetist immediately performs a rapid sequence induction and intubation (RSII) to clear the patient’s airway.
Which of the following inducing agents used in RSII is most likely to be used in this patient?Your Answer:
Correct Answer: Propofol
Explanation:Common Inducing Anaesthetic Agents and Their Uses
Propofol, etomidate, ketamine, midazolam, and thiopental are all commonly used inducing anaesthetic agents with varying properties and uses.
Propofol is the drug of choice for RSII procedures in normotensive individuals without obvious cardiovascular pathology. It has amnesic, anxiolytic, anticonvulsant, and muscle relaxant properties, but no analgesic effects.
Etomidate provides haemodynamic stability without histamine activity and minimal analgesic effects. It is used in RSI procedures in patients with raised intracranial pressure and cardiovascular conditions, often in combination with fentanyl.
Ketamine is a non-competitive glutamate N-methyl-D-aspartate (NMDA) receptor blocker that produces dissociative anaesthesia. It can be used for induction of anaesthesia in patients with hypotension, status asthmaticus, and shock, but is avoided in hypertensive patients due to relative contraindications.
Midazolam is a benzodiazepine with anticonvulsive, muscle relaxant, and anaesthetic actions. At higher doses or in combination with other opioids, it induces significant cardiovascular and respiratory depression.
Thiopental is administered intravenously as an inducing anaesthetic agent or as a short-acting anaesthetic. It is also used as an anticonvulsant agent and to decrease intracranial pressure in neurosurgical procedures.
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This question is part of the following fields:
- Anaesthetics & ITU
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Question 18
Incorrect
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A 68-year-old man was recently admitted to hospital with small bowel obstruction. A nasogastric (NG) tube was inserted, and he has been prescribed intravenous (IV) fluids. Three days later, he reports feeling short of breath, and on examination, he has widespread fine crackles and pitting sacral oedema. His notes show that he has been receiving 2 litres of fluid a day and that he weighs 50 kg. You treat him, and once his symptoms have resolved, you're-calculate his daily maintenance fluid requirements.
Which of the following options is the most suitable amount of daily fluid to give to the patient?Your Answer:
Correct Answer: 1000–1500 ml
Explanation:Calculating Fluid Requirements for a Patient with Fluid Overload
When determining a patient’s fluid requirements, it is important to consider their weight and any underlying medical conditions. For this particular patient, who weighs 48 kg, her maintenance fluid requirement is between 1200-1440 ml per day, calculated using 25-30 ml/kg/day.
However, this patient has developed fluid overload and pulmonary edema, likely due to receiving 2 liters of fluid per day. While this may have been necessary initially due to fluid loss from bowel obstruction, it is now important to step down to normal maintenance levels.
Giving the patient 1500-2000 ml of fluid per day would still be too much, as evidenced by examination findings of pitting sacral edema and widespread fine crackles. The maximum amount of fluid needed for maintenance therapy is 1440 ml per day.
It is crucial to monitor fluid intake and adjust as necessary to prevent further complications from fluid overload. Giving too much fluid, such as 2500-3500 ml per day, can be harmful for a patient with fluid overload and should be avoided.
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This question is part of the following fields:
- Anaesthetics & ITU
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Question 19
Incorrect
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You have watched the anaesthetist anaesthetise a 70-year-old patient for a laparoscopic appendicectomy using thiopentone and suxamethonium. She has never had an anaesthetic before. The patient is transferred from the anaesthetic room into theatre and you notice that she becomes difficult to ventilate with high airway pressures. She has an endotracheal tube (ETT) in situ, with equal chest rise and sats of 95% on 15 l of oxygen. On examining her cardiovascular system, she has a heart rate of 110 bpm with a blood pressure of 68/45 mmHg. She has an erythematosus rash across her chest and face.
What is your first line of action?Your Answer:
Correct Answer: 0.5 ml of 1 : 1000 adrenaline intramuscularly (im)
Explanation:Management of Anaphylaxis: Medications and Dosages
Anaphylaxis is a severe and potentially life-threatening allergic reaction that requires immediate treatment. The first-line management for anaphylaxis is the administration of adrenaline, also known as epinephrine. The dosage of adrenaline varies depending on the age of the patient. For adults, 0.5 ml of 1 : 1000 adrenaline should be given intramuscularly (im), and the dose can be repeated after 5 minutes if there is no response. In children, the dosage ranges from 150 to 500 micrograms depending on age.
Intravenous (iv) administration of adrenaline is not recommended at a concentration of 1 : 1000. However, iv adrenaline can be administered at a concentration of 1 : 10 000 by an anaesthetist, titrated according to effect. An adrenaline infusion may be necessary for cardiovascular support of the patient.
Chlorpheniramine and hydrocortisone are also part of the treatment for anaphylaxis, but adrenaline takes priority. The dosages of these drugs vary depending on the age of the patient and can be given either im or through a slow iv injection.
It is important to note that anaphylaxis is a medical emergency, and prompt treatment with the appropriate medications is crucial for a positive outcome.
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This question is part of the following fields:
- Anaesthetics & ITU
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Question 20
Incorrect
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You are requested to evaluate a 22-year-old man who had undergone an incision and drainage procedure for pilonidal abscess. The nursing staff is worried about his unusual behavior. He has admitted to social cannabis use in the past.
Upon arrival, you observe that he is forcefully sticking out his tongue and bending his neck to the left and right. His eyes are looking upwards, and his pupils are dilated. His blood glucose level is 5 mmol/L, and all routine observations are normal. He was given paracetamol and an anti-emetic ten minutes ago.
What is the most suitable course of treatment?Your Answer:
Correct Answer: Intravenous procyclidine
Explanation:Oculogyric Crisis
Oculogyric crisis is a type of acute dystonic reaction that is commonly associated with the use of neuroleptics and anti-emetic medications like metoclopramide. Unfortunately, the clinical spectrum of this condition is not well understood, which often leads to misdiagnosis as a psychogenic disorder. Symptoms of oculogyric crisis can occur suddenly or over several hours and may include restlessness, agitation, malaise, and a fixed stare. The most characteristic symptom is the upward deviation of the eyes, which may be sustained or accompanied by other eye movements like convergence or lateral deviation. Other associated symptoms may include neck flexion, mouth opening, tongue protrusion, and ocular pain. Fortunately, the symptoms of oculogyric crisis can be rapidly resolved with the use of medications like procyclidine.
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This question is part of the following fields:
- Anaesthetics & ITU
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Question 21
Incorrect
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You are requested to attend to a 65-year-old male patient who has just returned from surgery in the high dependency unit. He underwent a left hemicolectomy to remove colon cancer. Your task is to prescribe the appropriate intravenous fluids for him.
What is the most effective way to determine the infusion rate for the fluids?Your Answer:
Correct Answer: Measure his urine output and adjust accordingly
Explanation:Importance of Adequate Hydration in Monitoring Organ Perfusion
Hourly urine output is a reliable indicator of organ perfusion, which is directly linked to hydration levels. However, if there is a urological obstruction, this measure may not be accurate. While a trend in central venous pressure (CVP) can be helpful, a single reading is not a reliable indicator of hydration status. Late signs of hypovolemia include dry mucous membranes and hypotension. Therefore, it is crucial to maintain adequate hydration levels to ensure proper organ perfusion and prevent hypovolemia.
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This question is part of the following fields:
- Anaesthetics & ITU
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Question 22
Incorrect
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You are asked to see a patient on the high dependency unit following an elective repair of her abdominal aortic aneurysm. Her last haemoglobin was 75 g/L (130-180) and your consultant has told you to give her four units of blood urgently.
The nurse informs you that the patient's date of birth is incorrect on the blood she is about to give, although all other details are correct. The patient mentions that this has happened before. She has previously received six units of blood in theatre without any issues.
What course of action should you take?Your Answer:
Correct Answer: Stop the blood transfusion
Explanation:Importance of Correct Patient Identification in Transfusions
Transfusions are a crucial aspect of medical treatment, but incorrect patient identification of samples and blood products can lead to fatal consequences. In fact, it is the most common cause of death following transfusion. Therefore, it is essential to ensure that patient identification is accurate and consistent throughout the process.
If there are any inconsistencies or doubts about the patient’s identity, it is crucial to stop the transfusion immediately and inform the laboratory. This step can prevent serious harm or even death. It is better to err on the side of caution and take the necessary steps to ensure that the patient receives the correct blood product.
In emergency situations where blood is needed immediately, and there is uncertainty about the patient’s identity, group O negative blood may be used. However, this should only be a temporary solution until the patient’s identity is confirmed, and the appropriate blood product can be administered.
In conclusion, patient identification is a critical aspect of transfusions, and any errors or inconsistencies should be addressed immediately to prevent harm to the patient. It is better to take the necessary precautions and ensure that the patient receives the correct blood product, even if it means delaying the transfusion.
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This question is part of the following fields:
- Anaesthetics & ITU
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Question 23
Incorrect
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A 32-year-old cyclist, who was in a car accident, needs to have a central venous line (CVL) inserted. Which of the following statements is the most precise?
Your Answer:
Correct Answer: CVL placement is required for the administration of adrenaline infusion
Explanation:Central Venous Lines: Placement, Uses, and Complications
Central venous lines (CVLs) are commonly used in medical settings for various purposes, including the administration of inotropes such as adrenaline, parenteral nutrition, blood products, fluids, and measurement of central venous pressures. However, the use of CVLs is not without risks and complications, which include local site and systemic infection, arterial puncture, haematomas, catheter-related thrombosis, air embolus, dysrhythmias, atrial wall puncture, lost guidewire, anaphylaxis, and chylothorax.
When it comes to the placement of CVLs, the site of choice is the subclavian vein, although the complication risk is higher. Femoral lines are more susceptible to infection due to the flora within the groin area. Consideration of the age of all lines should be made on daily review within the Intensive Care Unit/High Dependency Unit environment, as routine replacement of a CVL every fortnight is uncommon.
Lastly, a check radiograph for placement is recommended on insertion of both subclavian and internal jugular lines to confirm correct placement within the superior vena cava and to exclude a procedural pneumothorax. However, this does not need to be repeated on removal, as there are no needles or incisions involved in the removal of the line.
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This question is part of the following fields:
- Anaesthetics & ITU
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Question 24
Incorrect
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You are faced with a 60-year-old male patient who has a history of ischaemic heart disease (taking aspirin and clopidogrel) and reflux, and requires an emergency DHS for his neck of femur fracture. Despite administering a thiopentone and suxamethonium rapid sequence induction, you are unable to intubate the patient. You have attempted to reposition him, insert a bougie, and switch to a McCoy blade, but all efforts have been unsuccessful. The patient's oxygen saturation has dropped to 88%, and you are unable to ventilate him via a face mask due to his large face and thick beard. You are losing your seal and cannot achieve any tidal volume.
What would be your next step in managing this patient?Your Answer:
Correct Answer: Insert a laryngeal mask airway (LMA) and attempt to ventilate the patient
Explanation:Managing a ‘Can’t Intubate’ Scenario in a Patient with Neck of Femur Fracture
In a ‘can’t intubate’ scenario with a patient who has a neck of femur fracture, the priority is delivering oxygen. If attempts at intubation have been difficult and the patient is desaturating, the Difficult Airway Society recommends attempting ventilation with a laryngeal mask airway (LMA) as a temporary measure. If this fails and the patient continues to desaturate, an emergency cricothyrotomy is advised for urgent oxygen delivery. Using a videolaryngoscope to secure a definitive airway is not recommended if oxygenation is a priority. Similarly, attempting a fibreoptic intubation or using a long blade for further attempts at intubation can cause damage and swelling in the airway, leading to laryngospasm. Waking the patient up is also not advisable in this emergency situation, as neck of femur fractures have a high mortality rate if left untreated.
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This question is part of the following fields:
- Anaesthetics & ITU
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Question 25
Incorrect
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Before undergoing general anaesthesia, which regular medications need to be stopped?
Your Answer:
Correct Answer: Phenelzine
Explanation:Medication Management in Perioperative Period
Phenelzine and tranylcypromine are monoamine oxidase inhibitors that need to be discontinued at least two weeks before elective surgery due to their potential life-threatening interactions with pethidine and indirect sympathomimetics. Additionally, they can prolong the action of suxamethonium by decreasing the concentration of plasma cholinesterase. Carbamazepine, an anticonvulsant, should be continued throughout the perioperative period. Gliclazide, a short-acting oral hypoglycemic, can be taken if the surgery’s anticipated duration is short.
Lisinopril, an angiotensin-converting enzyme inhibitor (ACEi), and digoxin, a cardiac glycoside, should be continued pre-operatively. Morphine sulfate tablets should also be continued pre-operatively, and a morphine infusion (PCA) should be considered for postoperative analgesia. Pyridostigmine is used in the management of myasthenia gravis and should be continued before minor surgery. However, if perioperative muscle relaxation is required, omitting one or more doses of pyridostigmine would allow a reduction in the dose of the muscle relaxant. Proper medication management in the perioperative period is crucial to ensure patient safety and optimal surgical outcomes.
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This question is part of the following fields:
- Anaesthetics & ITU
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Question 26
Incorrect
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You are on an anaesthetic attachment in Day Surgery and are reviewing patients preoperatively. You review a 25-year-old man who is having an elective knee arthroscopy. He has not had a general anaesthetic before, but he tells you that his father had problems following suxamethonium anaesthetic, and he had to have a muscle sample sent off to find out the cause, which came back positive. His father is still alive.
Which of these is his father’s most likely diagnosis?Your Answer:
Correct Answer: Malignant hyperthermia
Explanation:Common Complications of Suxamethonium Administration
Suxamethonium is a commonly used muscle relaxant during anesthesia. However, it can lead to several complications, including malignant hyperthermia, raised intraocular pressure, anaphylaxis, prolonged paralysis, and hyperkalemia.
Malignant hyperthermia is a genetic myopathy that causes a hypermetabolic state, leading to circulatory collapse and death. Treatment involves recognition, removal of stimuli, continuation of anesthesia with intravenous agents, cooling, and administration of dantrolene.
Raised intraocular pressure and intracranial pressure can occur after suxamethonium administration, but this is only relevant to patients with ocular and intracranial diseases.
Anaphylaxis is a severe allergic reaction that can occur after suxamethonium administration. Diagnosis is based on signs and symptoms.
Prolonged paralysis can occur in patients with abnormal pseudocholinesterase level or function, which is generally due to inherited genetic alleles. Diagnosis is by blood test.
Hyperkalemia can occur after suxamethonium administration, especially in patients with severe muscle damage or recent burns. Diagnosis does not require a muscle biopsy.
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This question is part of the following fields:
- Anaesthetics & ITU
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Question 27
Incorrect
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A 42-year-old man was undergoing a routine appendectomy and was given general anaesthesia with succinylcholine and halothane. The patient was sedated and intubated during the procedure. After one hour, the anaesthetist observed that the patient had a temperature of 41 °C, blood pressure of 160/90 mmHg, and a pulse rate of 110 bpm. An arterial blood gas (ABG) test revealed a pH of 7.2 (normal value 7.35–7.45) and a PaCO2 of 6.6 kPa (normal value <4.5 kPa). What is the most likely diagnosis?
Your Answer:
Correct Answer: Malignant hyperthermia
Explanation:Common Adverse Reactions to Medications: Symptoms and Treatments
Malignant Hyperthermia, Neuroleptic Malignant Syndrome, Serotonin Syndrome, Acute Dystonia, and Meningitis are all potential adverse reactions to medications.
Malignant Hyperthermia is a rare condition that can occur after exposure to general anaesthetics or muscle relaxants. Symptoms include a sudden increase in temperature, acidosis, hypercapnia, and widespread skeletal muscle rigidity. Treatment involves dantrolene and supportive care such as cooling and correction of acidosis.
Neuroleptic Malignant Syndrome is a rare idiosyncratic reaction that can occur as a response to taking high-potency anti-psychotic medication. Symptoms include hyperthermia, fluctuating consciousness, rigidity, tachycardia, labile blood pressure, and autonomic dysfunction. Treatment involves discontinuing the medication and supportive management such as fluids and cooling. Dantrolene or bromocriptine may also be used.
Serotonin Syndrome occurs when a patient takes multiple doses, an overdose, or a combination of certain medications. Symptoms include confusion, agitation, hyperreflexia, shivering, sweating, tremor, fever, and ataxia. Treatment involves stopping the drugs and providing supportive care.
Acute Dystonia presents with spasm of various muscle groups and is a side-effect of anti-psychotic medication. It can occur in the first few hours of administration of anti-psychotic medication. It is also seen with the antiemetic metoclopramide where it can cause an oculogyric crisis. It is not usually associated with anaesthesia.
Meningitis is not a complication of anaesthesia or muscle relaxants.
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This question is part of the following fields:
- Anaesthetics & ITU
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Question 28
Incorrect
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A patient in their 70s is anaesthetised for an exploratory laparotomy. They were found to have perforated from a septic appendix. This has resulted in part of their bowel being removed and a stoma formation. The patient has been on the table for two and a half hours. Their core temperature at the end of the operation is 35.1 °C.
Which mechanism accounts for most heat lost?Your Answer:
Correct Answer: Radiation
Explanation:Understanding Heat Loss During Surgery: The Role of Radiation, Convection, Conduction, Evaporation, and Respiration
During surgery, the body can lose heat through various mechanisms. Radiation, which accounts for 40% of heat loss, depends on factors such as body temperature and the environment. To combat this, patients are covered with warming methods like the Bair Hugger™. Convection, or air movement, contributes to 30% of heat loss, while conduction (5%) occurs through contact with the operating table and surrounding air. Evaporation (15%) is higher if the abdomen is open, and humidity is kept at 50% in the theatre to reduce it. Finally, respiration accounts for 10% of heat loss. Understanding these mechanisms can help healthcare professionals better manage patient temperature during surgery.
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This question is part of the following fields:
- Anaesthetics & ITU
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Question 29
Incorrect
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You are due to transfer a critically unwell patient from theatre to intensive care. The oxygen cylinder is size D (contains 340 l of oxygen when full) and has been running for 12 minutes. The oxygen is running at 10 l/min. How long do you have to transfer the patient before the oxygen cylinder is empty?
Your Answer:
Correct Answer: 22 minutes
Explanation:Calculating Oxygen Remaining in a Cylinder
When using an oxygen cylinder, it’s important to know how much oxygen is left to avoid running out. To calculate the remaining oxygen, you need to know the cylinder size and the flow rate. For example, if a cylinder has 340 litres of oxygen and is flowing at 10 litres per minute, how much oxygen is left after 6 minutes?
In 12 minutes, 120 litres of oxygen would have already been used (12 min × 10 l/min = 120 l). To find out how much oxygen is left, subtract the amount used from the total amount: 340 – 120 = 220 litres. Then, divide the remaining gas by the flow rate (10 l/min) to get the remaining time: 220/10 = 22 minutes.
It’s important to note that if the flow rate is higher or the cylinder size is smaller, the remaining time will be shorter. Therefore, it’s crucial to monitor the oxygen levels and have a backup cylinder on hand in case of emergency.
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This question is part of the following fields:
- Anaesthetics & ITU
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Question 30
Incorrect
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An 80-year-old man who lives alone in a cabin is brought to the Emergency Department by his son. He was found lying on the floor unconscious but later regained consciousness. He now reports experiencing a headache, nausea, difficulty breathing, and feeling faint. He does not smoke, drink alcohol, or use any recreational drugs.
Which of the following tests is most likely to result in a likely diagnosis of carbon monoxide (CO) poisoning?Your Answer:
Correct Answer: Multi-wavelength oximetry analysis
Explanation:Multi-Wavelength Oximetry Analysis for Diagnosis of CO Poisoning
Carbon monoxide (CO) poisoning can be diagnosed through a thorough history and physical examination, but measuring the presence of dissolved CO in blood is necessary. Multi-wavelength oximeters can detect carboxyhaemoglobin and methaemoglobin in addition to oxyhaemoglobin and deoxyhaemoglobin. Normal CO levels are 1-3%, and any higher levels confirm CO poisoning. Arterial p(O2) levels remain unchanged in CO poisoning, so they cannot be used for diagnosis. CT scans can rule out other causes of neurological complications, and ECGs and cardiac enzyme measurements are necessary for patients with higher exposures or pre-existing cardiac conditions. Standard pulse oximetry cannot distinguish between carboxyhaemoglobin and oxyhaemoglobin and is not useful for diagnosing CO poisoning.
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This question is part of the following fields:
- Anaesthetics & ITU
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