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A 65-year-old man presents with a six

month history of deteriorating


breathlessness. He is found to have aortic
stenosis. Which one of the following
physical signs provides the best clinical
marker of the severity of the valvular
disease?
(Please select 1 option)

Character of the apex beat


Character of the carotid pulse
Character of the second heart sound
Intensity of the murmur
Length of the murmur Correct
The apex beat in aortic stenosis is not
displaced but has a heaving character, the
pulse is characteristically of small
volume and slow rising, the second heart
sound maybe inaudible or paradoxically
split. The murmur tends to become
longer as the disease is more severe
because of the longer ejection time
needed. The intensity of the murmur is
not a good guide to severity as this will
become less as the cardiac output is
reduced with more severe disease.

A 24-year-old female is admitted with


palpitations. Her pulse is 160 beats/min,
blood pressure 70/50 mmHg and she has
a respiratory rate 32/min. She is awake,
alert and oriented but dyspnoeic. Her
electrocardiogram shows a regular
rhythm with QRS complex width of
0.11s.
What is the most appropriate therapy for
this patient?
(Please select 1 option)

Adenosine 6mg/6mg/12mg
Amiodarone 300mg
Atenolol 50mg

DC cardioversion Correct
Verapamil 10mg
Strictly speaking as this patient is
showing signs of decompromise (i.e.
systolic blood pressure <90) she should
be immediately DC cardioverted under
sedation/anaesthesia. In practice, most
people would try adenosine first whilst
organising a cardioversion.

A 67-year-old female is admitted with


blackouts. Her electrocardiogram shows
ventricular escape with complete heart
block. As you are standing there she
blacks out once more. Her rhythm strip
shows p wave asystole.
Which of the following would be the
initial immediate treatment here after
airway and breathing?
(Please select 1 option)

Adenosine 6mg
Atropine 0.6mg Incorrect answer selected
Percussion pacing This is the correct answer
Transcutaneous pacing
Transvenous pacing
Adenosine and atropine are not front line
agents in this scenario, particularly
adenosine which blocks AV conduction
-1 marks if you elected this. Transvenous
pacing is not a fast enough intervention
here. Transcutaneous pacing is the
immediate management but percussion
pacing may be effective as a holding
measure whilst this is instituted.
(Percussion pacing involves gentle
thumping of the lower left sternal edge
with the fist.)
A 62-year-old male with a history of
ischaemic heart disease is admitted with
chest pain of 13 hours duration and some

ST depression inferolaterally.:
Which of the following would be the
most appropriate treatment option for
this patient?
(Please select 1 option)

IV Diamorphine 10mg
Oral aspirin 600mg
Oral Isosobide mononitrate 30mg
Oxygen 100%
Subcutaneous low molecular weight heparin Correct
The treatment approach in this patient
with acute coronary syndrome would be
aspirin 300mg, try some GTN, if this
fails then ISDN IV, diamorphine (or
Morphine) 2.5 mg, 4L oxygen, and
subcutaneous low molecular weight
heparin

Which of the following is correct


concerning Entonox.
(Please select 1 option)

Has a duration of action of 1 minute after cessation of inhalation


This is the correct answer
Is a mixture of 50% nitric oxide and 50% oxygen
Is an explosive mixture
May produce respiratory depression in the new born Incorrect
answer selected
Takes approximately 30 minutes before producing effective
analgesia
Entonox is a mixture of 50% nitrous
oxide and 50% oxygen that is stored in
cylinders as a gas. The cylinders have a
French blue body and blue and white
quarters at the top. If the gaseous mixture
were to cool below its
pseudocritical temperature of minus 6

degrees celsius the oxygen and nitrous


oxide might separate out by a process
called lamination. Thus a potentially
hypoxic and dangerous gas may be
administered. Although entonox
represents a flammable mixture and both
nitrous oxide and oxygen support
combustion the mixture is not considered
explosive. It is effective in short term
analgesia, is safe to infant and mother
with an onset after inhalation of 30s and
a duration of action after analgesia of
approximately 1 minute.

A 3-year-old girl is brought in by


ambulance from a house fire. He has
extensive areas of peeling skin over the
trunk and face, with blackening around
the mouth and nostrils. Full term normal
delivery, no neonatal problems.
Immunisations up to date. No family or
social history of note.
On examination the temperature is
36.7C, respiratory rate 25/min, pulse
130/min. Capillary refill time of 3
seconds. 40% of 2nd and 3rd burns over
the trunk and face.
What is the most important part of
management?
(Please select 1 option)

Analgesia
Bag and mask ventilation
Face mask oxygen
Intubation Correct
IV fluid bolus
The picture is one of severe burns and
smoke inhalation. Shock can occur in the
first few hours from loss of large

amounts of plasma from denuded skin.


The airway should be secured by
immediate intubation before it becomes
too oedematous and occludes
completely. 100% O2 should be given, as
pulmonary oedema can be anticipated.
Two large-bore cannulae should be
inserted and 20 ml/kg of N. saline given.
Maintenance and continuing losses
should be calculated from the time of the
fire.

Which of the following regular


medications should be discontinued prior
to general anaesthesia?
(Please select 1 option)

Carbamazepine
Lisinopril
Morphine sulphate Incorrect answer selected
Phenelzine This is the correct answer
Pyridostigmine
Phenelzine and Tranylcypromine are
monoamine oxidase inhibitors, which
should be stopped at least 2 weeks prior
to elective surgery. It can cause lifethreatening interactions with pethidine
and indirect sympathomimetics. It also
prolongs the action of suxamethonium
by decreasing the concentration of
plasma cholinesterase. Carbamazepine is
an anticonvulsant and should be
continued throughout the perioperative
period. Gliclazide, a short acting oral
hypoglycaemic can be taken if the
anticipated duration of surgery is short.
Lisinopril, an ACEi and digoxin, a
cardiac glycoside, should be continued
pre-operatively. Morphine sulphate
tablets should be continued
preoperatively and a morphine Infusion
(PCA) considered for postoperative
analgesia. Pyridostigmine is used in the
management of myasthenia gravis and

should be continued prior to minor


surgery. However, if perioperative
muscle relaxation were required then
omitting one or more doses of
pyridostigmine would allow a reduction
in the dose of the muscle relaxant.

An 11 day old baby presents with poor


feeding and breathlessness. She had been
born at 37/40 weighing 2.7 kg by
elective caesarian section. She had never
fed well, but had deteriorated markedly
on the day of admission.
On examination she is responding to
pain, mottled and had a tympanic
temperature of 34.6C. Her heart rate is
130/min with impalpable pulses and
gallop rhythm. Her respiratory rate is
40/min with marked recession. She has a
4 cm liver. Her saturations and blood
pressure are unrecordable, but she has
obvious central cyanosis.
What is the most likely mechanism of
shock?
(Please select 1 option)

Anaemic
Cardiogenic Correct
Distributive
Hypovolaemic
Septic
The picture suggests duct-dependent
congenital heart disease, with
progressive worsening of symptoms as
the duct closed. Typical conditions
include: aortic coarctation, critical aortic
stenosis, truncus arteriosus and
hypoplastic left heart syndrome.

You are on call for hospital at night and


are urgently called to a patient on the
ward who is choking on a piece of steak
visible in his oropharynx. He is in
extremis with saturations of 87%.
Which of the following is the most
appropriate immediate management for
this patient?
(Please select 1 option)

Finger sweep
Heimlich manoeuvre Correct
High flow oxygen
Cricothyroidotomy
Removal with forceps
A finger sweep is more likely to push the
obstruction further into the airway and is
no longer advocated. High flow oxygen
is the Breathing part of A,B,C. and the
Airway is not clear. Nasopharyngeal
airways will not help in this situation.
Removal with forceps is potentially
hazardous. A Heimlich manoeuvre
should be performed with the possibility
of cricothyroidotomy in mind
immediately thereafter if this procedure
fails.

Theme:Post operative complications


ACT scan
BElevation of bed to 30 degrees
CFasciotomy
DInitiate Iow molecular weight heparin
treatment
EThrombolysis
FVenogram
GVenous duplex scan
Select the most appropriate intervention
from the list above for the following
cases who have undergone surgery.

At 3am you are called to see a man who


complains of a painful swollen calf 3
days post AP resection. On examination
his leg is hot, the calf is swollen and
tender but there are good palpable
pulses. Active movement is still present.

Correct
Heparinisation. Clinically this man has a
which does occur after surgery in the
lithotomy position, but usually occurs
earlier and active movement is lost. At
3am you will be very unlikely to get
confirmation of your diagnosis and so
treatment should be initiated whilst
waiting for a duplex scan to avoid
potential for clot propagation and
pulmonary emboli.

48 hours post femoral distal graft for


critical limb ischaemia the nurses note
the leg is swollen and blistered. A
palpable pulse is still present in the graft
and the leg is warm.

Correct
Elevate the bed to 30 degrees. This limb
is swelling due to a reperfusion
phenomena; DVT rarely occurs post
vascular surgery and compartment
syndrome usually occurs acutely. The
limb requires elevation to allow
increased venous/lymphatic drainage. If
left dependant swelling will increase and
the risk is that suture lines will give way
resulting in graft exposure.
Post-operative complications for different, specific operations...

Theme:Monitoring
AAirway pressures
BCardiac Output
CCentral venous pressure
DDisconnect alarm
EEnd tidal Carbon Dioxide
FHourly urine output
GInspired Oxygen concentration
HInvasive arterial pressure
IPeripheral nerve stimulator
JPulmonary artery flotation catheter
KTemperature
In the following scenarios all of the
patients are monitored using continuous
ECG, non-invasive blood pressure and
pulse oximetry. From the list of above
choose one additional yet essential
anaesthetic monitor for each case.
A 34-year-old male with 20% partial
thickness burns to the legs is having his
burns debrided under general
anaesthesia. Preoperative fluid
resuscitation was less than adequate.

Correct

A 24-year-old female presents for


elective tonsillectomy. Anaesthesia is
induced and the patient intubated with
some difficulty. No breath sounds are
detected during auscultation of the chest.
Shortly afterwards the patient starts to
desaturate.

Correct

During a general anaesthetic for a knee


arthroscopy the surgeon notices that the
knee feels stiff and that the muscle tone
in the thigh has increased. The patient
has been breathing isoflurane, nitrous
oxide and oxygen spontaneously through
an LMA for 30 mins. A nasopharyngeal
temperature probe is inserted which
reads 37.8 Celcius.

Correct

A patient undergoing laparoscopic


nephrectomy has been on the operating
table for over 3 hours during which 4
litres of intravenous normal saline has
been given. Saturation, pulse and blood
pressure have all been normal, however
only 30 ml of urine has been collected.

Correct

An obese middle aged male is in the


prone position having a 4 hour lumbar
fusion under general anaesthesia. He has
aortic stenosis, angina pectoris and long
standing controlled hypertension.

Correct

Monitoring urine output is a simple and


frequently reliable guide to intravascular
fluid status. Various burns formulae exist
for calculating the volume of
resuscitative fluid required and use
different types of fluid. Maintaining a
urine output between 0.5 and 1 ml per

Kg per hour would indicate adequate


hydration. If urine production were low
despite an adequate fluid challenge then
a central line would provide valuable
information. A pulmonary artery
floatation catheter is often reserved for
more serious cases.
The availability of end tidal CO2
monitoring is essential in every
environment where anaesthesia is
administered. The detection of CO2
clearly indicates that the tube is in the
trachea just as the absence of CO2
indicates an oesophageal intubation.
All of the volatile anaesthetic agents and
suxamethonium are potent triggers of
malignant hyperpyrexia. An uncommon
disease that needs prompt treatment once
suspected. Increased muscle rigidity,
pyrexia, cardiovascular instability and
desaturation have been observed.
However, the first indication that a
reaction may be in progress is a
sustained elevation of the end tidal CO2.
In the laparoscopic nephrectomy
scenario, 30 ml of urine in 3 hours is
clearly inadequate. Whether a suitable
fluid challenge has already been given to
the patient is dependent on the
preoperative fluid state of the patient.
Inserting a central line and measuring the
CVP would identify if further fluid or a
small dose of diuretic were required.
Urine production can be reduced by the
use of excessive pressures to create the
pneumoperitoneum.
Measurement of blood pressure at
regular intervals using a cuff is
appropriate for most cases. However an
obese male with significant co-morbidity
undergoing a long lumbar fusion needs
an invasive arterial cannula to directly
measure blood pressure. This will
provide a beat-by-beat measurement of
blood pressure and allow tight control to
be maintained. The combination of

coexisting disease requires the


maintenance of his diastolic pressure
within narrow limits of the preinduction
value. Failure to maintain this and
cardiovascular stability during the
perioperative period could lead to organ
ischaemia and infarction

Theme:Post operative complications


AChest infection
BMyocardial infarction
CPneumothorax
DPost op anaemia
EPulmonary embolism
FSystemic inflammatory response
syndrome (SIRS)
Select the most likely diagnosis in the
following cases who have undergone
surgery.
5 days post abdominal aortic aneurysm
repair a 72-year-old man complains of
shortness of breath. On examination he
has decreased breath sounds at both
bases. He has a white count of
13.6x106/l, a temperature of 38.2oC, a
pO2 10.1 kPa and pCO2 4.5 kPa and pH
of 7.4.

Correct
Chest infection. Aortic surgery often
leads to diaphragmatic splintage, basal
atelectasis and subsequent infection.
Aggressive physio, sitting out and early
mobilisation are methods of avoiding
this but once established treatment
should be with antibiotics, physio,
humidified oxygen and urgent culture of
both blood and sputum to ensure that the
organism is treated before it can infect
the graft.

72 hours post left hemi colectomy a


69-year-old male smoker complains of
chest pain associated with shortness of
breath. On examination he has full air
entry in his chest. His observations
reveal a pulse of 110 bpm, regular, a
Blood Pressure of 100/75 mmHg,
respiratory rate of 32 and a temperature
of 36.5oC. Full blood count, U&E and
troponin have been sent. His gases on air
are: pO2 8.1 kPa, pCO2 3.2 kPa and pH
7.5.

Correct
and infection; with the information
currently available you have to treat as a
PE because he is hypoxic despite his
tachypnoea with low pCO2 and is
apyrexial. Treatment with supplemental
oxygen and heparin should begin whilst
waiting for FBC, U&E and troponin to
become available. A chest X ray and
ECG should be performed and if PE
remains the most likely diagnosis a CT
pulmonary angiogram/VQ scan should
be performed.
Post-operative pneumonia is a common chest infection...

Advanced Life Support


AAdenosine
BAmiodarone
CBasic life support with adrenaline
DCall for the cardiac arrest team
ECheck for a central pulse
FChest tube with an under water seal
GDefibrillation at 200J
HGive a praecordial thump
ILidocaine
JSome other specific treatment if the

cause of the arrest is known


KSynchronised DC cardioversion
Select the most appropriate answer from
the list above that describes the most
appropriate treatment priority or action
in the following scenarios:
A 26-year-old known asthmatic has a
narrow complex tachycardia with a heart
rate of 220 / min. His BP is 85/50
mmHg. Intravenous access is established
and high flow oxygen is being given by
mask. Vagal manoeuvres are
unsuccessful.

Correct
The first patient is in cardiac arrest and
in order to activate the chain of survival,
calling the cardiac arrest team is
essential. When limited assistance is
available, performing effective basic life
support takes second priority over
alerting the arrest team.

A 64-year-old female who 10 days ago


had a total hip replacement is found
unconscious in the ward toilet. She is
unresponsive, apnoeic and pulseless.

Correct

A 51-year-old male is in refractory fine


VF. He has received defibrillatory shocks
and 1mg of adrenaline intravenously.
One minute of CPR is ongoing.

Incorrect - The correct answer is


Amiodarone
Amiodarone should be considered in
shock refractory eMedicine Refractory
VF or pulseless VT. It can be given as
early as the before the fourth
defibrillatory shock. Lidocaine can be
used as an alternative when amiodarone
is unavailable.
The third case has a peri-arrest rhythm,
which is compromising his cardiac
output. He needs to be sedated or
anaesthetised prior to being given a
synchronized DC shock starting at 100J.
Adenosine can induce bronchospasm and
should be avoided.

An elderly female has arrested during the


insertion of a right subclavian central
line. The ECG rhythm shows sinus
tachycardia. Adrenaline has been given
and 3 minutes of basic life support is
ongoing. As the cardiac arrest team
leader you notice that the trachea is
deviated to the left.

Incorrect - The correct answer is


Some other specific treatment if the
cause of the arrest is known
The fourth case is also in cardiac arrest
but has sinus tachycardia as a rhythm,
thus it is called PEA (pulseless electrical
activity). Previously known as EMD
(electromechanichal dissociation). The
deviated trachea suggests a right tension
pneumothorax, which requires
immediate needle thoracocentesis to
relieve the pressure. A chest tube with an
under water seal can be inserted later.

A praecordial thump has just been given


to a patient who had a witnessed and
monitored VF cardiac arrest on the
Coronary Care Unit. A change in rhythm
to a ventricular tachycardia is observed.

Incorrect - The correct answer is


Check for a central pulse
In the fifth case a pulse check is
indicated because of the rhythm change,
but also because the new rhythm could
also be pulseless VT, which should then
be shocked at 200J.

Day case anaesthesia


AAtracurium
BDiamorphine
CDiazepam
DDiclofenac
EEtomidate
FFentanyl
GPancuronium
HPropofol
ISuxamethonium
JThiopentone
Select the most appropriate answer from
the list above that describes the most
appropriate choice of drug or action in
the following scenarios:
A healthy female is scheduled for a
laparoscopic sterilization. Suitable
muscle relaxation will be provided by?

Incorrect - The correct answer is


Atracurium

Muscle relaxation is required during the


creation of a pneumoperitoneum, which
provides a clear view and access to the
fallopian tubes. The anticipated duration
of surgery is 20 to 30 mins, thus
atracurium is the best choice.
Suxamethonium is too short acting and
pancuronium lasts too long.

A young male is due to have a large


lipoma excised from his forearm. Which
agent would be a suitable intravenous
induction agent to allow placement of an
LMA?

Incorrect - The correct answer is


Propofol
Propofol is the best induction agent when
planning to use an LMA. It inhibits the
pharyngeal and laryngeal reflexes faster
than thiopentone or etomidate, providing
optimal conditions for inserting the
device.

A well controlled asthmatic patient


presents for a knee arthroscopy. Which
agent would provide appropriate
intraoperative analgesia?

Incorrect - The correct answer is


Fentanyl
Drugs that cause bronchoconstriction or
that have the potential to release
histamine are best avoided in asthmatics.
Therefore diamorphine and diclofenac
are not the best choice. Fentanyl does not
release histamine and small doses will
provide suitable intraoperative analgesia.

A 64-year-old male presents for a


cystoscopy. A hiatus hernia was
diagnosed 6 months ago. His current
medication is gaviscon and he has been
nil by mouth since midnight. Select a
suitable muscle relaxant to allow
placement of the endotracheal tube.

Incorrect - The correct answer is


Suxamethonium
Patients with a hiatus hernia must have
their airway protected as quickly as
possible following induction of
anaesthesia. Failure to protect the airway
with a cuffed endotracheal tube may lead
to soiling of the trachea from
regurgitation of residual gastric fluid.
Thus a rapid sequence induction should
be considered. Suxamethonium is the
correct choice as it provides optimum
intubating conditions in 30 to 45
seconds.

A 21-year-old male presents for dental


extractions under general anaesthesia. He
has epilepsy but has been seizure free for
9 months on his current medication.
Select an appropriate intravenous
induction agent.

Incorrect - The correct answer is


Thiopentone
Thiopentone is a barbiturate and has
anticonvulsant properties thus it the
correct answer. Diazepam is an
anticonvulsant but it is not used to
induce anaesthesia. Propofol and
etomidate have both been known to

cause movement resembling convulsions


thus are best avoided.

Theme:Antibiotic prophylaxis
AAngiography
BBronchoscopy
CDental procedure for patient with atrial
septal defect
DEmergency Appendicectomy
EGut surgery
FSigmoidectomy
GSplenectomy
HThyroidectomy
Choose the most appropriate procedure
that would require the following
antibiotic prophylaxis and preparation

3 days of intravenous broad spectrum


antibiotics commencing in the operating
theatre with the induction of anaesthesia

Correct

A 3 gram sachet of oral Amoxicillin, 1


hour before the surgical procedure

Correct

Long acting Benzathine Penicillin G,


with pnuemovax II immunisation

Correct

Intravenous metronidazole during the


induction of anaesthesia

Correct

Stop solids but can take fluids orally.


Two tablets of Sodium Picosulfate and
intra venous broad spectrum antibiotics
during anaesthesia

Correct

Antibiotic prophylaxis is used to prevent


infection and is based on the degree of
contamination involved in the surgical
procedure. Surgeries like breast, thyroid,
and hernia repairs where there is no risk
of wound contamination are classed as
CLEAN surgery. Antibiotic prophylaxis
is controversial in this group with most
people choosing no antibiotics at all or
one single shot of broad spectrum
antibiotic at induction. Surgeries like
Cholecystectomy, elective/ interval
appendicetomy or bowel surgeries where
the contamination of the wound can be
contained / controlled are classed as
CLEAN CONTAMINATED wounds &
require broad spectrum antibiotics given
at induction & every six hours intra
operatively if the surgery lasts more than
six hours. Use of post operative
antibiotics is debatable in these
situations. Emergency surgeries or
surgeries where the amount of

contamination is difficult to contain or


estimate (including traumatic wounds)
are classed as CONTAMINATED and
are shown to benefit from 72 hrs of intra
venous broad spectrum antibiotics.
Grossly contaminated wounds before the
start of surgery are classed as DIRTY
wounds & need therapeutic antibiotics as
opposed to prophylaxis the choice of
antibiotic being empirical as determined
by the source of contamination.
Certain special conditions need antibiotic
prophylaxis as otherwise they could
result in severe infections anywhere in
the body. These include immune
compromised states (including
Splenectomy & steroid therapy) and
congenital or acquired heart diseases.

Theme:Anaesthetic choice
AA spinal (subarachnoid block)
BAn epidural
CBiers block
DFibreoptic intubation
EInhalational induction and blind nasal
intubation
FIntravenous sedation
GRapid sequence induction with cricoid
pressure
HSpontaneous ventilation through a
facemask
ISpontaneous ventilation through a
laryngeal mask airway (LMA)
JStandard intravenous induction and
intubation
KSubclavian perivascular block
Please select the most appropriate choice
of anaesthetic from the above list for the
following scenarios:
A 24-year-old previously well male gives
a history of right iliac fossa pain

associated with anorexia and vomiting.


Acute appendicitis is suspected and he is
booked for an appendicectomy.

Incorrect - The correct answer is


Rapid sequence induction with cricoid
pressure
The appendicitis patient has an acute
abdomen and he needs an urgent
operation. We do not know when he last
had food but gastric emptying will be
delayed even if there is no ileus.
Therefore, the risk of regurgitation and
subsequent aspiration is high. To protect
his airway a cuffed endotracheal tube
must be secured following a rapid
sequence induction. Cricoid pressure is
applied in attempt to occlude the
oesophagus and thus reduce the risk of
gastric contents being aspirated. A
regional technique is contraindicated in
the presence of a raised white cell count.

A 59-year-old female has fallen and


presents with a displaced fracture to the
distal radius. Her past medical history
includes an inferior myocardial infarct 4
months ago and anticoagulation for atrial
fibrillation. She has been nil by mouth
for 6 hours and is booked for a
manipulation under anaesthesia (MUA).

Incorrect - The correct answer is


Biers block
The female who recently had an inferior
myocardial infarct is a high-risk patient
and alternatives to general anaesthesia
should be considered. A Biers block
(intravenous regional anaesthesia) can
provide anaesthesia for minor surgery to
the distal ends of both upper and lower

limbs. A tourniquet is applied and a


suitable local anaesthetic injected
intravenously. Using a double cuff can
reduce discomfort. A subclavian
perivascular block is contraindicated in
day case surgery due to the risk of
pneumothorax and in anticoagulated
patients

A 28-year-old female is scheduled to


have a knee arthroscopy and possible
anterior cruciate ligament (ACL)
reconstruction. She smokes 20 cigarettes
per day and has asthma. She admits to
never using the prescribed inhalers.

Incorrect - The correct answer is


Spontaneous ventilation through a
laryngeal mask airway (LMA)
The main patient issues for the female
scheduled for an arthroscopy is that she
is a heavy smoker, has asthma and is non
compliant with her medication. A
spontaneously ventilating technique
using an LMA is the method of choice.
As an LMA does not enter the trachea,
the risk of coughing and bronchospasm
is reduced. Unless an LMA is
contraindicated, avoiding intubation
would be the sensible choice. A knee
arthroscopy is a short procedure but if an
ACL reconstruction is required it can
increase the duration of surgery by
several hours. A regional technique
avoids any stimulation of the airway but
the anticipated duration of surgery
cannot be clearly defined. A spinal would
be acceptable, but should the procedure
be prolonged then conversion to a
general anaesthetic may be necessary.
The block provided by an epidural takes
time to become established but would be
preferable to a spinal as the block can be
supplemented if the surgery is extended.

A 21-year-old male sustained a fracture


of his mandible 36 hours ago that
requires an open reduction and internal
fixation. His mouth opening is severely
restricted due to spasm and pain. He has
been nil by mouth for the last 8 hours.

Correct
A fractured mandible with restricted
mouth opening presents a patient with a
difficult airway. The safest approach
would be to perform an awake fibreoptic
intubation via the nose. The oral aperture
may not significantly increase following
induction of anaesthesia, adequate
analgesia and neuromuscular paralysis.
The patient needs to be intubated for the
operation but the mouth may not
accommodate the blade of a
laryngoscope and the subsequent view of
the vocal cords may be less than optimal.
Inhalational induction of anaesthesia and
blind nasal intubation has been used in
the past but it cannot be justified when
fibreoptic equipment is available.

A 54-year-old male presents with an


acute abdomen and needs an emergency
laparotomy. He is known to have a
duodenal ulcer, which may have
perforated. His past medical history
includes angina and chronic bronchitis.
He is known to smoke and drink alcohol
to excess.

Incorrect - The correct answer is


Rapid sequence induction with cricoid
pressure

The male with a suspected perforated


duodenal ulcer presents several
significant risk factors for anaesthesia.
Following fluid resuscitation a rapid
sequence induction with cricoid pressure
is again indicated. However, due to his
angina major changes in both heart rate
and blood pressure should be avoided.
Thus, our choice of drugs, doses and
technique used all require modification.
In view of his respiratory disease an
epidural would certainly provide superior
postoperative analgesia over intravenous
opioid. However, performing the
operation under a regional block is
contraindicated. Post operatively he
should be considered for admission to a
critical care ward.

Examples of some anaesthetic agents...


Fluid and electrolyte disturbances
AFluid overload
BHypokalemia
CMetabolic acidosis
DMetabolic alkalosis
ERespiratory acidosis
FRespiratory alkalosis
Choose the most likely fluid/ electrolyte
abnormality in the following case
scenarios:

A 45-year-old male with pyloric stenosis


presents with profuse vomiting and
abdominal pain. What else besides a
hypokalaemia may be expected.

Correct

A 65-year-old man has a two day history


of anuria and back pain. He is tired,
complains of hiccups and has a pruritus.

Correct

A 60-year-old man with villous adenoma


presents with profuse diarrhoea.

Correct

A 68-year-old female presents 24 hours


after hysterectomy with breathlessness.
On examination, she has a raised jugular
venous pressure and bi-basal chest
crepitations.

Correct
Patients with pyloric stenosis develop hypochloremic hypokalaemic alkalosis as the
lose chloride ions with hydrogen ions when the vomit. The 65-year-old man has renal
failure as suggested by the anuria, hiccups and pruritus and will have a metabolic
acidosis (low pH, low bicarbonate and with compensation should have a high p02 and
low pC02). Villous adenoma is associated with profuse watery diarrhoea which is
typically associated with hypokalaemia. The post op female clearly has cardiac failure
with fluid overload as indicated by the raised JVP and bibasal crepitations.

Theme:Complications of anaesthesia and


analgesia
AEpidural anaesthetic
BGeneral anaesthetic
CIntramuscular pethidine
DNitrous Oxide

EPudendal block
FSpinal anaesthetic
For each complication below select the
SINGLE most likely anaesthetic or
analgesic from the list of options above.
Malignant hyperpyrexia syndrome

Correct

Reduced variability cardiotocograph

Incorrect - The correct answer is


Intramuscular pethidine

Sudden maternal hypotension

Correct

Severe headache

Correct

Aspiration syndrome

Correct

Pethidine, other opiates and some anti-hypertensives (alpha methyldopa and labetalol)
reduce CTG variability. Maternal hypotension is more likely to be secondary to
spinal, rather than epidural anaesthetic. In a spinal anaesthetic, a very fine needle is
used to puncture the dura and this is not often associated with a headache. Postdural
puncture headache appears to be highr in association with spinal (3%) than epidural
(1%). Malignant hyperpyrexia is most likely to be secondary to the use of volatile
anaesthetic agents
Theme:Pre-operative investigations
AArterial blood gases
BChest X-ray
CECG (12 lead)
DEchocardiograph
EFull blood count
FGlucose concentration
GHaemoglobin electrophoresis
HHaemoglobin A1c concentration
ILung function test
JProthrombin time and Activated Partial
Thromboblastin Time
KUrea and electrolytes
Select the most appropriate investigation
from the list above for the following
scenarios:

A 12-year-old African male presents with


a 2 day old penetrating wound to his calf.
His main complaint is pain. Pulse and
blood pressure are normal and a full
blood count reveals a haemoglobin of 8.5
g /dl. He is booked for exploration and
debridement of the wound.

Correct
Need to investigation for as a sickling
crisis can be precipitated by surgery.

A 63-year-old female is scheduled for a


sigmoid colectomy. 12 months ago she

had an anterior myocardial infarct but


has made a good recovery. She can climb
a flight of stairs slowly but gets short of
breath. Medication includes an ACE
inhibitor. Your examination reveals a
loud systolic murmur, breath sound are
vesicular.

Incorrect - The correct answer is


Echocardiograph
She is undergoing a sizeable procedure
and needs appropriate assessment of her
left ventricular function.

A 59-year-old previously healthy male,


presented 12 hours ago with bowel
obstruction, has become increasingly
confused. He is receiving oxygen by
mask. The pulse oximeter reads 100%,
pulse is 110 / min and blood pressure
135 / 85. Intravenous fluid resuscitation
is with 5% dextrose, infusing at a rate of
150 ml / hour.

Correct
This patient's confusion in the context of
his obstruction suggests marked
dehydration with sepsis and probable
renal impairment.

A 33-year-old female has been on


warfarin for 3 months following a
pulmonary embolism. She is scheduled
for open reduction and internal fixation
of an ankle fracture, sustained whilst
jogging. Her ankle is painful but
otherwise she is symptom free and takes
no other medication.

Correct
Obviously she requires appropriate
assessment of her INR before any
operative procedure.

A 19-year-old insulin dependent diabetic


has a penetrating injury to her left eye.
She is on twice daily insulin and had
lunch 4 hours ago. Her operation is
expected to begin within the hour.

Correct
Glucose always needs to be checked in a
diabetic patient and this yound woman
will require a sliding scale insulin regime
for her operation.

Surgery on anticoagulated patients can


result in excessive intraoperative blood
loss and complicate recovery due to
haematoma formation. For elective
surgery warfarin can be stopped and
surgery postponed until the INR is less
than 1.5. Intravenous heparin should be
substituted for the warfarin if
anticoagulation is essential. Fresh frozen
plasma will allow rapid correction of the
effect of warfarin and may be preferable
to vitamin K. Her jogging activity
suggests that the pulmonary embolism
has not significantly compromised her
gas exchange and so blood gas analysis
would not have a high priority.

Finish