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Question 1
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: Actively cool the patient, increase the respiratory rate and give antibiotics
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 2
Correct
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How can suxamethonium be described accurately?
Your Answer: May cause bradycardia
Explanation:Suxamethonium: A Depolarising Muscle Relaxant
Suxamethonium is a type of muscle relaxant that causes muscular fasciculations after being injected intravenously. It quickly induces neuromuscular paralysis, but recovery is spontaneous once it is metabolized by the enzyme pseudo or plasma cholinesterase, which is produced in the liver. However, certain pesticides and drugs, such as ecothiopate iodide, can inhibit cholinesterase activity and prolong the effects of suxamethonium. Additionally, reduced levels of plasma cholinesterase can be caused by liver disease, malnutrition, and pregnancy, while genetically determined abnormal enzymes can also lead to a prolonged action of suxamethonium. It’s important to note that neostigmine and other anticholinesterase drugs do not serve as reversal agents and can actually potentiate the neuromuscular block caused by suxamethonium.
When administering suxamethonium, it’s important to be aware that bradycardia (a slow heart rate) may occur in children after the first dose and in adults after repeated doses. Premedication with atropine should be considered to prevent this. It’s also crucial to note that suxamethonium is a potent trigger of both anaphylaxis and malignant hyperpyrexia, with the incidence of anaphylaxis being highest with rocuronium, atracurium, and suxamethonium.
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This question is part of the following fields:
- Anaesthetics & ITU
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Question 3
Correct
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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: 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 4
Correct
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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: 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 5
Correct
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What ASA grade (American Society of Anesthesiologists) is assigned to a patient with a severe systemic disease that poses a constant threat to their life?
Your Answer: IV
Explanation:Anesthesia Grading Score for Patient Risk
The American Society of Anesthesiologists developed a grading score in 1963 to assess patient risk during surgery. The score ranges from one to five and uses Roman numerals to indicate the severity of a patient’s systemic disease. Patients without systemic disease are classified as grade I, while those with mild to moderate systemic disease that does not limit their activities are classified as grade II. Patients with severe systemic disease that causes functional limitations are classified as grade III, and those with severe systemic disease that poses a constant threat to life are classified as grade IV. Additionally, the letter E is added to indicate emergency surgery. Finally, patients who are moribund and unlikely to survive more than 24 hours with or without surgery are classified as grade V. This grading system helps anesthesiologists determine the appropriate level of care and monitoring needed during surgery.
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This question is part of the following fields:
- Anaesthetics & ITU
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Question 6
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: Measure a single central venous pressure (CVP) from his central line
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 7
Incorrect
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Before undergoing general anaesthesia, which regular medications need to be stopped?
Your Answer: Lisinopril
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 8
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: Measurement of arterial PO2 levels
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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Question 9
Correct
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You are on call for the pediatric ward at night and are urgently called to a child who is choking on a piece of hot dog visible in their oropharynx. The child is in extremis with saturations of 87% and there is no effective cough.
What is the most appropriate immediate management for this pediatric patient?Your Answer: Back blows
Explanation:Resuscitation Council (UK) Recommendations for Choking Emergencies
When faced with a choking emergency, the Resuscitation Council (UK) recommends a specific course of action. If the patient is able to cough effectively, encourage them to do so. If not, but they are conscious, try five back blows followed by five abdominal thrusts (Heimlich manoeuvre) and repeat if necessary. However, if the patient becomes unconscious, begin CPR immediately. It is important to note that a finger sweep is no longer recommended as it can push the obstruction further into the airway. Additionally, high flow oxygen is necessary for breathing, but nasopharyngeal airways will not help in this situation. Removal with forceps is also not recommended as it can be hazardous. If the Heimlich manoeuvre fails, a cricothyroidotomy should be considered. While this procedure is recommended in the US and UK, it is not encouraged in some countries like Australia due to the risk of internal injury from over-vigorous use.
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This question is part of the following fields:
- Anaesthetics & ITU
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Question 10
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: Convection
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 11
Correct
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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: 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 12
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 13
Incorrect
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A 55-year-old male in the postoperative ICU with a central line catheter is experiencing intermittent fevers. What is the probable microorganism responsible for this condition?
Your Answer:
Correct Answer: Coagulase-negative Staphylococci
Explanation:Coagulase-Negative Staphylococci: Commonly Isolated Bacteria in Clinical Microbiology Laboratories
Coagulase-negative Staphylococci are frequently encountered in clinical microbiology laboratories. These bacteria, including Staphylococcus epidermidis, are susceptible to novobiocin and have become a significant cause of infection, especially in patients who are hospitalized and have foreign bodies implanted or those who have weakened immune systems.
The prevalence of coagulase-negative Staphylococci in clinical settings highlights the importance of identifying and treating these bacteria promptly. With the rise of antibiotic resistance, it is crucial to monitor the susceptibility patterns of these organisms to ensure effective treatment. By the characteristics and potential risks associated with coagulase-negative Staphylococci, healthcare providers can take appropriate measures to prevent and manage infections caused by these bacteria.
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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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You are conducting a pre-assessment for a 28-year-old man who is scheduled to undergo a colectomy for treatment resistant ulcerative colitis. This will be his first surgery. Your intended anaesthetic plan involves using propofol and sevoflurane as induction agents and suxamethonium as a muscle relaxant. What aspects of the patient's medical history and condition would cause you to modify your anaesthetic plan?
Your Answer:
Correct Answer: The patient’s mother was ‘unable to move’ for 5 h after having an abdominal hysterectomy
Explanation:Considerations for Anesthesia in a Patient with Medical History
When administering anesthesia to a patient, it is important to take into account their medical history and any potential risk factors. Here are some considerations for a patient with specific medical history:
Anesthesia Considerations for a Patient with Medical History
– Prolonged Paralysis: If a patient has a family or personal history of prolonged paralysis after receiving suxamethonium, it may be necessary to consider using a different muscle relaxant during surgery.
– Asthma: Patients with asthma are at a higher risk of airway irritation during endotracheal intubation. However, in some surgeries, intubation is necessary and careful monitoring is required.
– Blood Pressure: While a blood pressure of 110/75 may be normal for a 26-year-old male, it is important to review the patient’s past blood pressure measurements to ensure that this is the case. Induction agents with profound cardiovascular effects should be avoided if the patient is in shock.
– Family History of Cardiac Arrest: If a patient has a family history of cardiac arrest, it is important to review the facts of the case and consider any independent risk factors that may have contributed to the event.
– Penicillin Allergy: While anesthesia agents do not contain penicillin, it is important to document any allergies in case the patient requires antibiotics after surgery. -
This question is part of the following fields:
- Anaesthetics & ITU
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Question 15
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 16
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 17
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 18
Incorrect
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In case there is no intravenous access available, what is the next most favored way to administer adrenaline during a cardiac arrest?
Your Answer:
Correct Answer: Intraosseous
Explanation:Intraosseous Access as an Alternative to Intravenous Access in Emergency Situations
In emergency situations where intravenous access cannot be obtained quickly, intraosseous access should be attempted as it is preferred over endotracheal access. According to the Resuscitation Council (UK) guidelines, if intravenous access cannot be established within the first 2 minutes of resuscitation, gaining intraosseous access should be considered. This is particularly important during a cardiac arrest when epinephrine is an essential resuscitation drug. The recommended dose for intraosseous access is the same as intravenous access, which is 1 mg of 1:10,000 adrenaline each 3-5 minutes. Therefore, it is crucial for healthcare professionals to be trained in intraosseous access as it can be a life-saving alternative when intravenous access is not possible.
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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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A 57-year-old woman has undergone a mitral valve repair and is experiencing a prolonged recovery in the cardiac intensive care unit. To aid in her management, a pulmonary artery catheter is inserted.
What is one of the calculated measurements provided by the pulmonary artery catheter?Your Answer:
Correct Answer: Cardiac output
Explanation:Measuring Cardiac Output and Pressures with a Pulmonary Artery Catheter
A pulmonary artery catheter can provide direct and derived measurements for assessing cardiac function. Direct measurements include right atrial pressure, right ventricular pressure, pulmonary artery pressure, pulmonary artery wedge pressure, core temperature, and mixed venous saturation. The catheter can also be used to calculate cardiac output using the method of thermodilution. This involves a proximal port with a heater and a distal thermistor that senses changes in temperature.
Pulmonary artery wedge pressure is a direct measurement that can be obtained with the catheter, reflecting left atrial filling. However, it may not always accurately reflect the pressure in the left atrium due to various factors. Right ventricular pressure is another direct measurement that can be obtained.
Central venous saturation is a direct measure in some machines with a built-in saturation measurement probe, while in others, samples can be taken via the distal port and measured using a gas machine. Overall, a pulmonary artery catheter can provide valuable information for monitoring cardiac output and pressures in critically ill patients.
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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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What is the preferred intravenous induction agent for anesthesia in day case procedures?
Your Answer:
Correct Answer: Propofol
Explanation:Comparison of Different Anesthetic Agents
Propofol is a short-acting anesthetic agent with an elimination half-life of four hours. It is commonly used for day case procedures and sedation in intensive care units. On the other hand, etomidate is no longer preferred due to its side effects such as postoperative nausea and vomiting, venous thrombosis, and interference with glucocorticoid production. Ketamine, a phencyclidine derivative, can cause hallucinations and nightmares. Methohexitone may lead to involuntary muscular movement and epileptiform activity on an EEG. Lastly, thiopentone has the longest elimination half-life of 12 hours, which can cause a prolonged hangover effect.
In summary, different anesthetic agents have their own advantages and disadvantages. It is important to choose the appropriate agent based on the patient’s condition and the type of procedure being performed.
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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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The following blood gas values were obtained on a different ventilated patient.
pH 7.4 (7.35-7.45)
pO2 95 mmHg (90-120)
Bicarbonate 22 mmol/L (23-26)
pCO2 30 mmHg (35-45)
What is the most appropriate explanation for these results?Your Answer:
Correct Answer: Respiratory alkalosis
Explanation:Respiratory Alkalosis: Causes and Effects
Respiratory alkalosis is a condition that occurs when a person hyperventilates, leading to a decrease in the partial pressure of carbon dioxide (PaCO2) in the alveoli. This decrease in PaCO2 causes an increase in the ratio of bicarbonate concentration (HCO3) to PaCO2, which in turn increases the pH of the blood. As a result, the patient may appear to have an alkalosis with a high pH of 7.5, low pCO2, and normal PO2. However, the body tries to compensate for this by lowering the bicarbonate concentration. This condition can be caused by a variety of factors, including anxiety, fever, hypoxia, and pulmonary disease. It can also be a side effect of certain medications or a result of high altitude. Treatment for respiratory alkalosis depends on the underlying cause and may include addressing the underlying condition, breathing techniques, or medication.
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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 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 23
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 24
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 25
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 26
Incorrect
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You are requested to evaluate a 75-year-old woman who underwent a left mastectomy yesterday to treat breast cancer. Her potassium level is low at 3.1 mmol/L (normal range is 3.5-4.9), but she is asymptomatic and currently having her lunch. She has a history of hypertension and takes a thiazide diuretic regularly. What would be the appropriate course of action?
Your Answer:
Correct Answer: Prescribe an oral potassium supplement
Explanation:Treatment for Mild Hypokalaemia
Mild hypokalaemia can be treated with oral supplementation. If a patient is able to eat, intravenous fluids are unnecessary. It is best to advise the patient to take oral supplements for a few days. Foods such as tomatoes and bananas contain high levels of potassium and could be offered as well. However, it is important to note that the maximum concentration of potassium that can be given via a peripheral line is 40 mmol/L. It is also important to avoid loop diuretics as they can make the patient’s potassium levels even lower. As long as the patient is asymptomatic and able to eat, mild hypokalaemia can be easily treated with oral supplementation.
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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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What is the combination of ingredients in Hartmann's solution?
Your Answer:
Correct Answer: Sodium, chloride, potassium, calcium and lactate
Explanation:Hartmann’s Solution Composition and Metabolism
Hartmann’s solution, also known as lactated Ringer’s solution, is an intravenous fluid that is isotonic in nature. It contains various compounds, including sodium, chloride, potassium, calcium, and lactate. A litre of this solution contains 131 mmol of sodium, 111 mmol of chloride, 5 mmol of potassium, 2 mmol of calcium, and 29 mmol of lactate.
One of the unique features of Hartmann’s solution is the presence of lactate, which is metabolized by the liver to release bicarbonate. This process is important because bicarbonate would otherwise combine with calcium to form calcium carbonate, which can cause complications. Therefore, the metabolism of lactate helps to maintain the stability of the solution and prevent any adverse effects.
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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 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 29
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 30
Incorrect
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A 25-year-old woman presents with a sudden and severe headache. Upon examination, she is spontaneously opening her eyes and localising to painful stimuli, but is disoriented. What would be the most appropriate initial investigation?
Your Answer:
Correct Answer: Computed tomography (CT)
Explanation:Diagnosis of Subarachnoid Haemorrhage
Subarachnoid haemorrhage can be diagnosed with a high degree of accuracy through an urgent CT scan, which can confirm the condition in 95% of patients. In most cases, a lumbar puncture is not necessary unless the patient’s medical history suggests the need for one and the CT scan results are normal. If a bloody tap is suspected, the number of red blood cells should decrease with each successive sample. If an LP is performed six hours after the onset of symptoms, the supernatant fluid should be examined for xanthochromia after centrifugation.
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This question is part of the following fields:
- Anaesthetics & ITU
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