facts learned from mcqs Flashcards

Question

*What are the points for Child-Pugh classification?

Answer 1

each of INR, Bilirubin, Ascites, Albumin & encephalopathy gets 1-3 points. 5-6= Child-Pugh A, 7-9= C-P B, 10+= C-P C

Answer 2

A= 10%, 15-30yrs B= 30%, eval for transplant C= 82%, life expectancy 1-3yrs

Answer 3

8.1, only 17% unionised @ physiological pH, lower degree of transfer across lipophilic membranes so slower onset cf other LAs eg. lignocaine pKa 7.9, 25% unionised @ physiology pH. (Adding bicarb speeds onset) Also, bupivacaine has large MW which slows onset but there's little difference in MW btwn LAs.

Answer 4

duration of action; highly PB (eg. bupiv 95%) = longer duration cf lower PB (lignocaine 70%)

Answer 5

potency. Bupivacaine more lipid soluble cf lignocaine so more potent.

Answer 6

decrease SpO2, increase SctO2 (a strong near-infrared absorber)

Answer 7

Reduces risk of death in bleeding trauma patients if given in the first 3hrs (all cause mortality @ 28d, death due to bleeding) without increase in vaso-occlusive events Did not reduce blood product use

Answer 8

3mg/kg (eg. for a 30kg child, 18mL of 0.5% lignocaine)

Answer 9

65mL/hr 0.9% saline with 5% dextrose

Answer 10

Effective lifestyle modifications= weight loss dietary salt restriction (limit to 65mmol/day) potassium supplementation (preferably by diet) unless contraindicated by CKD DASH diet (high vegetables, fruit, low-fat dairy, nuts & low in red meat & sweets- rich in K+, Mg++, Ca++, protein & fibre, low in fat saturated fat & cholesterol) smoking cessation exercise (aerobic, dynamic resistance & isometric- 3-4 sessions/week of moderate-intensity aerobic exercise) reduced ETOH

Answer 11

Nasociliary (from the ophthalmic (V1) branch of trigeminal nerve), meets ciliary ganglion & gives off long & short ciliary nerves supplying cornea ie: Trigeminal--> nasociliary (of the ophthalmic)--> long & short ciliary nerves (which are the terminal supply)

Answer 12

prol APTT, normal platelets/bleeding time/PT

Answer 13

A is XLR, f8 def, 1/5000 male births B is XLR, f9 def, 1/25000 male births C is AD/AR, f11 def

Answer 14

AD>AR normal/reduced plt, normal or prolonged bleeding time, normal/prol APTT, normal PT can do VWF:Ag & VWF:RCx, F8 VWF:RCx & F8 should both be 100IU/dl periop & >50IUl/dl immediately postop vWf qual/quant defect clinically significant in 1/10,000 for haemophilia may have prol APTT

Answer 15

Increased risk MH: known MH, FHx MH, congenital myopathy, exertional rhabdomyolysis, exertional heat illness, idiopathic hyperCKaemia, carrier of RYR1 variant of unknown significance

Answer 16

Serum ferritin <30ug/l In the presence of inflammation (CRP>5mg/l) and/or transferrin saturation <20%, serum ferritin <100ug/l Target Hb>=130g/l in both sexes PO iron 6-8/52 preop IV iron <6/52 preop or non-responder/not tolerating PO iron (International Consensus Statement Ass of Anaesthetists 2017)

Answer 17

Staphylomas (sclera outpouches) are more common in myopes (increased axial length >26mm) Other risk factors for globe perforation: thinner eye, deep set eyes, previous scleral buckle, posterior staphyloma (staphyloma more common in myopes), retrobulbar (intraconal) or peribulbar > subtenon's

Answer 18

enhance Brady effect

Answer 19

bradycardia may develop, esp if >6/12 post-transplant

Answer 20

effective (but caution as heart reliant on circulating catecholamines to increase CO)

Answer 21

normal response

Answer 22

exaggerated effect as increased adrenoceptor density

Answer 23

effective but no reflex bradycardia

Answer 24

decreased effect- indirect mechanism

Answer 25

exaggerated effect

Answer 26

inotropic effect intact, conduction effects on AVN likely absent

Answer 27

Normal A-a gradient <15mmHg

Answer 28

Low urine osmolality (<100mOsmol/kg) High serum osmolality Low urine sodium Hypovolaemia Abnormal thyroid, adrenal function

Answer 29

myopathies with RYR1 abnormalities (or STAC3)- central core myopathy, multiminicore disease, King-Denborough syndrome, periodic paralysis, idiopathic hyperCKemia, carrier of RYR1 variant of unknown significance conditions associated with rhabdo: exertion rhabdoymolysis severe statin-induced myopathy some muscle disorders don't confer higher risk of MH but are associated with significant rhabdo & hyperkalemia following sux or volatile eg. Duchenne or Becker muscular dystrophy (both X-linked, recessive leading to abnormal formation of dystrophin)- treat with non-triggering agents Immediate action if peaked T waves, raised eTCO2 in pt w suspected Duchennes: -stop volatile & give calcium Duchenne= most common childhood musc dystrophy. X-linked recessive. 1:3500 live births. lack dystrophin (anchor muscle cells to ECM), sarcolemma becomes incr permeable, incr intracellular Ca++ progressive wasting/weakness prox muscles, fatal late adolescence from resp/cardiac failure. waddling gait, calf pseudohypertrophy by age 3-5, inh anaes rhabdo sec incr Ca++ not MH but avoid triggers

Answer 30

intimal flap SEVERE PROXIMAL AORTIC DILATATION regurg pericardial effusion Type A associated features and complications: aortic regurgitation (acute dilatation of the aortic root, aortic leaflet prolapse, dissection flap prolapse, pre-existing disease, e.g. bicuspid valve) pericardial effusion and/or CARDIAC TAMPONADE REGIONAL WALL MOTION ABNORMALITIES or SEVERELY IMPAIRED LVEF intramural haematoma, aortic ulcer. colour flow Doppler: identifies true and false lumen detect aortic branch occlusion/ dissection (absent flow) TTE is considered limited inthe Dx of aortic dissection BUT recent contrast-TTE thought to have similar accuracy to TOE for Dx type A (sens 93%, spec 97%) but more limited in type B (sens 84%, spec 94%). Still useful as availability, rapidity, additional info on cardiac status. useful for emergency room but has low negative predictive value so can't rule out dissection (further tests if the TTE is -ve). limited if abnormal chest wall, obesity, emphysema, mech vent.

Answer 31

button batteries & magnets, a metal object & magnet or >1 magnet, lead objects (may lead to systemic absorption)

Answer 32

honey at regular intervals

Answer 33

>2cm wide & >6cm long

Answer 34

Those aged <12 months (rare risk of botulism with honey) Battery ingested >12hrs ago (higher risk oesophageal perforation)

Answer 35

Honey 10mL q10min if >12 months old & ingestion was within the last 12hrs Sucralfate suspension (10mLs q10mins) Battery removal by endoscopy shouldn't be delayed- ideally within 2hrs of battery ingestion, anaesthesia can proceed regardless of PO honey intake irrigate. ifno perf (sterile acetic acid) if in stomach, minimal risk complications (consider removing if remains for 4 days)

Answer 36

unable to consent local infection or neospasm anatomical or vascular anomalies recent MI anti-coagulated pts or those with coagulopathy glaucoma severe emphysema cardiac conduction block pre-existing contralateral phrenic nerve palsy (may precipitate resp distress) Indications: head/neck pain (sympathetically mediated) eg. CRPS, facial herpes zoster, phantom UL/ischaemic pain, vascular disease (Reynaud's, vasospasm), scleroderma, arrhythmia (eg. VF, VT) refractory to other therapy. stellate ganglion is fusion inf Cx with 1st-2nd SNS ganglion AEs= Horner's, tracheal/oes injury, haemorrhage, brachial plexus/RLN/phrenic palsy, PHx, intrathecal ant paratracheal approach, head extended, needle 2-3cm above & 2cm lat to suprasternal notch, 2-3cm above & 2cm lat to suprasternal notch

Answer 37

little conclusive evidence for or against epidural considered safer than spinal as demyelinated fibres more susceptible to toxic effects from LA- inform pt of risk of new/worsening neurologic Sx Regional is OK as long as pt understands potential for relapse, have follow-up in place PRISMS study 2004- slight reduction in relapse during pregnancy, significantly increase in relapse @ 3/12 postpartum regardless of anaesthetic technique or mode of delivery, no difference in relapse rates epidural vs no epidural

Answer 38

S1= closure of MV/TV S2= closure AV/PV S3= tightening of papillary muscles (rapid diastolic filling) S4= atria contracting against stiffened ventricle eg. with AS, PS, PHTN, HOCM

Answer 39

-30 to +90 deg LAD= -30 to -90 RAD= +90 to 180 extreme is 180 to -90

Answer 40

sedation score. APMSE book: "best early clinical indicator is increasing sedation" continuous CO2 monitoring is the most reliable way to detect OIVI at an early stage BUT this is limited to OT/PACU/ICU/some HDU Pts may have reasons other than OIVI to have low SpO2 & use of supplemental O2 makes SpO2 unreliable for early detection of OIVI

Answer 41

contralateral arm weakness, sensory loss, HEMI-NEGLECT, homonymous hemianopia, apraxia, spatial disorientation dominant: global receptive & expressive aphasia, agraphia, acalculia, finger agnosia, R)/L) disorientation,

Answer 42

protect against the consequences of suction failure/blockage- protecting the pt from pneumothorax.

Answer 43

codeine aspirin (analgesic doses- can use low dose for anti-platelet action if strongly indicated) parecoxib use caution with: tramadol (observe child for unusual drowsiness) oxycodone (greater risk drowsiness in doses >40mg/day)

Answer 44

change in volume/final change in pressure @ points of no gas flow (total compliance when all alveoli @ equilibrium w external environment) = (VT) / (Pplat -PEEP) in mL/cmH2O dynamic is pulmonary compliance during periods of gas flow. always less than or equal to static compliance as peak insp pressure is always greater than Pplat. Cdyn = (VT) / (PIP - PEEP)

Answer 45

epicondylar line= superior border. brachioradialis= lateral border. pronator teres= medial border. Median cubital vein connects the cephalic (lateral) & basilic (medial) veins median nerve (giving off antebrachial cutaneous nerve of the forearm) lies underneath & to the medial edge of it. Radial nerve (giving off superficial & deep radial nerve) lies underneath & to the lateral edge of it. MCNF is a branch from median nerve, LCNF from medradial, both may be damaged w cannulation separated from brachial artery (which bifurcates into radial & ulnar arteries) by bicipital aponeurosis biceps tendon lies deep to the median cubital vein & lateral to brachial artery. ulnar nerve lies outside of it

Answer 46

small incremental doses of benzodiazepine, thiopental or propofol

Answer 47

check if the means of or 2 more groups are significantly different from each other- normally distributed interval data (it CAN be used for 2 groups but more commonly use t-test). can use it for categorical independent variable w normally distributed interval dependent variable

Answer 48

15mg ( x 0.3)

Answer 49

graded drug provocation test (DPT) using the index penicillin. First skin test using SPTs and IDTs- skin tests for penicillin have a NPV approaching 100% & pts who don't react to SPT or IDT are unlikely to have severe immediate reaction on the DPT. PPV is <50%. In a pt who's had a clinical reaction, a +ve skin test, with immediate readings, can identify presence of IgE sensitisation so then avoid DPTs. Delayed readings required for Dx of non-immediate type IV hypersensitivity reactions but predictive value of these readings isn't well established.

Answer 50

reduced sensitivity over time in Dx of immediate reactions low S&S in pts with non-severe, non-immediate & vague reactions

Answer 51

serum-specific IgE assay low sens & spec but some pts can have -ve skin test, +ve serum-specific IgE & have anaphylaxis when exposed to the drug

Answer 52

Probably mainly the R1 side chain, however cefazolin has different R1 side chain to other penicillins and cephalosporins (except ceftezole). Cross-reactivity may also occur through IgE antibodies that recognise neodeterminants of the B-lactam ring structure. After a diagnosis of cefazolin anaphylaxis, SPT to the culprit (only small numbers of pts with cefazolin anaphylaxis have a PST), then penicillin DPT. If negative DPT, penicillins can be prescribed. Low ++ risk cross reactivity penecillin & 3rd gen cephalosporin

Answer 53

Early hypodynamic phase (1st 24-48hrs): increased SVR & PVR (ADH, catecholamines, haemoconcentration) reduced intravascular volume, fluid loss from circulation & hypoperfusion responds to fluid challenge, may need stress dose steroids IV hydrocortisone q6h reduced CO, even before reduction in plasma volume decreased SvO2 later hyper dynamic hyper metabolic phase (from 48-72hrs): reduced SVR (impaired vasoconstriction) limited response to fluid resus (may need inotropes) increased ++ CO (2-3x) tachycardia massive energy expenditure increased SvO2 (peripheral AV shunting) can last days to weeks if left untreated, multi-organ failure= the inevitable result

Answer 54

imbalance in production, absorption or flow of CSF leads to low ICP & sagging of the brain within the skull, . Usually postural headaches worse upright, eased by recumbency (or agg by coughing/strain, jugular venous compression) but they may be nonpostural & other neurologic symptoms can occur (or N&V, neck pain/stiffness, tinnitus, dizziness). May get more severe symptoms due to brainstem compression. Most commonly due to persistent CSF leak after lumbar puncture, may be spontaneous (eg. due to dural weakness).

Answer 55

Brain MRI shows diffuse meningeal enhancement & "brain sagging" (SEEPS: subdural fluid, enhancement of pachymeninges, engorgement of venous structures, pituitary enlargment, sagging of brain). Next step is MRI brain with & without gadolinium & MRI spine without gadolinium, looking for CSF leak. If no evidence CSF leak but still strong clinical suspicion, could do heavily T2-weighted MR myelography without dural puncture or gadolinium (benefit as doesn't risk gadolinium exposure, radiation or risks of intrathecal injection) or CT myelography (if noninvasive studies nondiagnostic- this involves contrast infusion via dural puncture also uses ionising radiation) or MR myelography with gadolinium injection or, if nondiagnostic or suspect CSF-venous fistula, digital subtraction myelography (useful for rapid leaks) & if still no evidence, proceed to radioisotope cisternography (intrathecal injection). If still no evidence of CSF leak, consider other causes.

Answer 56

<60cmH2O, it may be normal even if active CSF leak.

Answer 57

no- it's often normal.

Answer 58

no- it's often normal.

Answer 59

6-20cmH2O in adults or children, may be up to 25cmH2O in obesity

Answer 60

migraine, cervicogenic headache, Chiari I malformation (low-lying cerebellar tonsils), postural tachycardia syndrome (orthostatic intolerance), PDPH

Answer 61

lumbar epidural blood patch effective in 64%- do with 10-20mL autologous blood, at "blind" lumbar level vs attempting the site of leak if the leak is above to SC terminus or site unknown, but if mild/moderate symptoms <2/52 (and NO Hx precipitating injury or connective tissue disease), consider conservative therapy (bedrest/minimise upright posture, oral hydration, caffeine PO 200-300mg 2-3x/day, abdo binder, analgesia). Approx 50% will require >1 EBP. If sysmptoms persist, could try location of leak & EBP there.

Answer 62

pt refusal, localised infection at the site, increased ICP, coagulopathy, taking anticoagulants, active systemic infection (pt must be afebrile). Adverse effects: back pain, radiculopathy, leg paraesthesia, fever. Rarely transient bilat paraplegia & cauda equina syndrome from arachnoiditis if high-volume EBP, may develop headache/other symptoms from intracranial HTN.

Answer 63

For T2, the grey-white matter will be switched (ie. grey lighter than white). Usual (grey darker than white)= T1-weighted. Fat bright on T1, fluid brighter on T2.

Answer 64

tamponade of the leak (immediate symptom improvement may occur) then fibrin deposition & scar formation (within 3/52)

Answer 65

tamponade of the leak (immediate symptom improvement may occur) then fibrin deposition & scar formation (within 3/52)

Answer 66

spontaneous intracranial hypotension, up to 57% may require repeat blood patch

Answer 67

diagnostic evaluation to lacate site of CSF lead & guide targeted treatement of EBP at the spinal level of the leak or surgical/endovascular repair.

Answer 68

liver failure ETOH consumption

Answer 69

evaluating the interaction of (typically 2) drugs for a given endpoint

Answer 70

up to 40%, due to incr renal vascular resistance of up to 75%

Answer 71

kidney has intrinsic autoregulation, liver has dual supply of blood flow (hepatic arterial buffer response), GI region may lack these mechanisms

Answer 72

significant decrease, likely due to increased afterload & myocardial dysfunction

Answer 73

associated with delayed postop recovery of GI function, prolonged GI intramucosal acidosis is ass'd with periop M&M

Answer 74

may be wrapped in laser resistant metal foil, cuff may be filled with saline, which may be coloured with methylene blue dye, may have 2 cuffs

Answer 75

allows pt to speak. Breathing around the cuff & through fenestration as well as stoma reduces airway resistance & assists weaning when spont breathing

Answer 76

Montandon tube, offers better surgical access as breathing system connected well away from surgical field

Answer 77

G6PD deficiency (lack of NADPH prevents methylene blue from working & leads to haemolysis) renal impairment methaemoglobin reductase deficiency nitrite-induced methaemoglobinemia due to cyanide poising hypersensitivity Also methylene blue may precipitate serotonergic crisis in pts taking serotonergic meds (MAO inhibition)

Answer 78

methemoglobinaemia catecholamine-refractory vasoplegia septic shock hepatopulmonary syndrome antimalarial antineoplastic dye/stain (eg. enhance surgical visualisation of parathyroid glands, place in ETT cuff of laser tubes) neutralises heparin priapism treating ifosfamide neurotoxicitysympt or asympt w >>20% metHb (>10% if risk factors eg. anaemia or IHD)

Answer 79

1.5-2mg/kg IV over 20-60mins

Answer 80

monoamine oxidase with high selectivity for MAO-A, the isoform responsible for serotonin metabolism. Doses as low as 1mg/kg may --> severe serotonin toxicity.

Answer 81

ptosis (& may have "reverse ptosis" elevation of lower lid) miosis (pupillary near & light responses preserved but may be lag at dilating in dim conditions) anhydrosis flushing face warm arm

Answer 82

Horner's syndrome, since it causes sympathetic blockade of the ipsilateral face & arm.

Answer 83

pulmonary arterial HTN severe systemic ventricular dysfunction (EF <30%) severe MS severe symptomatic AS severe aortic dilatation (>50mm) in aortic disease associated with bicuspid aortic valve vascular ehlers-danlos Marfan with aorta dilated >45mm native severe coarctation complicated Fontan

Answer 84

rate control with B blocker or IV digoxin. Consider amiodarone if onset <48hrs (300mg IV over 20-60mins then 900mg over 24hrs (consider reduced dose if pt on digoxin))

Answer 85

rate control with B blocker or IV digoxin. Consider amiodarone if onset <48hrs (300mg IV over 20-60mins then 900mg over 24hrs (consider reduced dose if pt on digoxin))

Answer 86

reduced consciousness SBP <90mmHg chest pain heart failure rate-related symptoms uncommon @ <150bpm

Answer 87

B blocker (metoprolol 5mg IV) BUT contraindications= bronchospasm or evidence decompensated heart failure OR digoxin 250-500microg IV or PO(which is the drug of choice fro rate control in heart failure however has slower rate of onset- IV 5-30mins, PO >30 mins, vs B blocker 3-7mins))

Answer 88

70-120J biphasic but in AF an initial larger shock (120-150J biphasic) recommended

Answer 89

risk dig toxicity due to reduced digoxin clearance (risk severe bradycardia, conduction disturbances, idioventricular rhythm risks torsades

Answer 90

myocardial injury during the first 30 days after non cardiac surgery, of ischaemic etiology. There is evidence of elevated cTn with at least one value above the 99th percentile upper reference limit. Independently associated with mortality. includes MI (symptomatic & non symptomatic) or post-op troponin elevation with no evidence of non ischaemic etiology.

Answer 91

control BP, HR consider aspirin & statin consider, for risk stratification/management: cardiac enzyme trends until falling, lipid panel, HbA1c, echo, functional stress test

Answer 92

control BP, HR (goal 50-70bpm if able to tolerate this BP & no concern for depressed LVEF), pain consider aspirin consider P2Y12 inhibitor (only if ischaemic benefit outweighs bleeding risk) heparin drip B-blocker atorvastatin 80mg

Answer 93

encephalitis

Answer 94

tension (simple analgesia, massage, physiological) & migraine (usually recurring, unilateral, may be pulsating & with nausea/photophobia/visual disturbances, may have "aura"- NSAIDs, 5-HT agonists (sumatriptan)) headache pre-eclampsia (headache a serious premonitory sign & is present in 50% who go on to develop eclampsia) or eclampsia (hypertensive encephalopathy w headache, visual disturbance, N&V, seizures, stupor which may --> coma). analgesia & control underlying condition PDPH cortical vein thrombosis (headache often ass'd w focal neurology & seizures. may have a postural component- may be ass'd w PDPH (?secondary to cerebral vasodilation after CSF leak & prolonged dehydration). Dx with MRI & MR venography. Mx with anticoagulation, symptom control with focus on seizure prevention) SAH (more common if an arteriovenous malformation, cerebral aneurysms or hypertensive encephalopathy. Acute onset intense, incapacitating unilateral headache accompanied by nausea, neck stiffness & altered consciousness). diagnose with CT, seek urgent neurosurgeon opinion. posterior reversible leucoencephalopathy syndrome: severe, diffuse headache, may have focal neurological deficit, may be an association with pre-eclampsia (loss of cerebral autoregulation compromises BBB)- imaging shows symmetrical cerebral oedema. space-occupying lesions (tumour, subdural haematoma): dull headache ass'd with symptoms of raised ICP (N&V). may have focal neurology & altered consciousness. Neurosurg if bleed or tumour. cerebral infarction/ischaemia sinusitis meningitis (neck stiffness, photophobia, fever, +ve Kernig & Brudzinski & may have petechial rash, do CT to exclude other Dx & confirm with CSF culture, early ABx)

Answer 95

1:100-1:200, 50% of these will get PDPH.

Answer 96

CSF leak--> intracranial hypotension & pain is from traction on intracranial structures or compensatory cerebral vasodilation. with standing, increased hydrostatic pressure gradient augments CSF leakage.

Answer 97

postural headache (worse upright, strain, cough & improves with lying down) associated: neck stiffness, nausea, visual disturbance, photophobia, auditory symptoms in severe cases, cranial nerve palsy of abducens (susceptible to traction when CSF volumes are low)

Answer 98

postural headache (worse upright, strain, cough & improves with lying down) associated: neck stiffness, nausea, visual disturbance, photophobia, auditory symptoms in severe cases, cranial nerve palsy of abducens (susceptible to traction when CSF volumes are low) may occur. CN VII may also be affected. only do EBP if other causes of cranial n palsy (haemorrhage & thrombosis) excluded. cortical vein thrombosis or cerebral venous sinus thrombosis may be associated with PDPH (cerebral vasodilation after CSF leak, damage to cerebral venous endothelium & prolonged dehydration) cranial-subdural haematoma: caudal shift of brain may--> rupture of the fragile subdural bridging veins seizures

Answer 99

vasoconstriction

Answer 100

48-72hrs, higher failure rate if within 24hrs of dural puncture.

Answer 101

up to 20mL; inject until the pt feels back or buttock or leg pain/pressure (nerve root irritation)

Answer 102

lie flat for…, have stool softeners, admit overnight for observation, avoid strain or too much physical exertion

Answer 103

backache (which may be severe) during injection, neck or backache may persist for 24hrs even if get instantaneous relief of headache, fever, bradycardia, seizures. Late= meningitis, spinal-subdural haematoma or intrathecal haematoma, arachnoidits, cerebral venous sinus thrombosis, radicular pain, seizures, infection (either localised to the lower back or meningitis)

Answer 104

pituitary adenoma on brain MRI or CT visual field defects prominent supraorbital ridge large nose & jaw teeth separated or lacking abnormal glucose tolerance test, glycosuria, polyuria hypertrophy of sebaceous & sweat glands galactorrhea (prolactin) cardiomegaly HTN spade-shaped hands & feet arthrosis peripheral neuropathy sexual dysfunction

Answer 105

They'd have elevated growth hormone (>0/4microg/L) and/or elevated IGF-1 during the OGTT, growth hormone will NOT be suppressed to <0.4microg/L

Answer 106

150microg (0.15mL of 1mg/mL) if <6yo 300microg (0.3mL) if 6-12yo every 5 mins prn

Answer 107

predicted body weight based on gender & height; not ideal body weight. 5mL/kg predicted body weight.

Answer 108

males: PBW= 50 + 0.91 x (height in centimetres - 152.4) kg females: = 45.5+ 0.91 x (height in cm - 152.4) kg

Answer 109

6mL/kg predicted body weight in absence of severe acidosis

Answer 110

PaO2/FiO2 <=300mmHg with PEEP >=5cmH2O within 1 wk of known clinical insult billet opacities on chest imaging not fully explained by cardiac failure or fluid overload

Answer 111

PaO2/FiO2 <=300mmHg with PEEP >=5cmH2O within 1 wk of known clinical insult billet opacities on chest imaging not fully explained by cardiac failure or fluid overload

Answer 112

systematic recruitment maneouvers

Answer 113

PEEP >12cmH2O if it improves oxygenation without haemodynamic compromise or significant decrease in lung compliance; must maintain Pplat <30cmH2O

Answer 114

continuous NMB infusion (within first 48hrs of ARDS Dx ideally) & prone positioning >16hrs/day for several consecutive days

Answer 115

discussion of V-V ECMO (refractory hypoxaemia or where protective ventilation can't be applied)

Answer 116

diaphragm- contains a high proportion of type II fibres (diaphragm= 45% type I) with relatively high density of nAChR (conferring some resistance to NMBDs), relatively large muscle fibres attenuate rapidity of onset, yet high perfusion along with the higher density of glycolytic type II fibres helps speed offset

Answer 117

BART blue= flow away from transducer red= flow towards transducer

Answer 118

yes (as they may contain donor anti-A or anti-B) however plasma components of any RhD type can be given regardless of the RhD type of the recipient & RhD immunoglobulin isn't required in these situations

Answer 119

ideally- since incompatible plasma may cause haemolysis (eg. a group A pt given group O platelets- the ABO is compatible but plasma not compatible). Apheresis platelets have low-titre anti-A/B. If the RhD is incompatible (RhD +ve platelets given to a RhD negative pt), there may be sensitisation to residual red cell antigens so prophylactic RhD Ig may be needed if RhD +ve puts given to a RhD -ve pt, esp female children or women of childbearing age.

Answer 120

A (-ve or +ve) then AB

Answer 121

incidence in control - incidence in treatment group

Answer 122

onset of diastole. it gives rise to a start "V" on the art waveform (then diastolic augmentation). aims to increase coronary perfusion.

Answer 123

end of diastole, reduces aortic EDP & systolic pressures which decreases afterload, cardiac work, myocardial consumption & increases CO. it'll reduce aortic end-diastolic pressure cf unassisted.

Answer 124

diastolic augmentation encroaches on systole & may cause premature closure of AV, increase LVEDV/P, incr LV wall stress or afterload.

Answer 125

trace shows lack of sharp V. suboptimal coronary perfusion.

Answer 126

sharp decrease after diastolic augmentation, making the diastolic augmentation suboptimal which reduces coronary perfusion & there may even be retrograde carotid blood flow, plus the afterload reduction may be suboptimal

Answer 127

incr afterload (the assisted aortic EDP may be equal to unassisted) may impede LV ejection, there may be a prolonged rate of rise & reduced assisted systole & the augmented diastole may appear prolonged.

Answer 128

While electrical triggers are better, if arrhytthmias use art pressure waveform instead of ecg. R wave, mechanical event is just prior to AV opening, just before upstroke on systolic pressure waveform (inflation is just at dicrotic notch if ecg reliable, T wave ecg (TIN))

Answer 129

subset of adverse patient safety event that is: wholly preventable resulted in serious harm to or death of a patient the most serious incidents surgery at wrong site, wrong pt or wrong surgery that led to serious harm or death. retention of foreign object--> serious harm or death haemolytic blood transfusion reaction from ABO incompatibility--> serious harm or death suspected suicide of pt on acute psych unit/ward med error--> serious harm or death physical/mech restraint--> SHOD d/c or release of an infant to an unauthorised person use of incorrectly positioned oral or NGT--> serious harm or death

Answer 130

wilful & intentional act injuring a party

Answer 131

incident leading to pt harm

Answer 132

Behavior that is professionally unethical and/or illegal, e.g., negligence, incompetence, impairment from drugs or alcohol, egregious substandard care.

Answer 133

thromboembolic event

Answer 134

dabigatran

Answer 135

L) central maxillary incisor

Answer 136

superior gram-positive antimicrobial activity compared with cephalosporins of later generations

Answer 137

drug reaction with eosinophilia & systemic symptoms (DRESS), Stevens-Johnson syndrome, toxic epidermal necrolysis & other severe cutaneous reactions, severe IHD, pregnancy

Answer 138

"hypodynamic" phase hypoperfusion (fluid loss) decreased intravascular volume incr SVR & PVR (ADH, catecholamines, haemoconcentration) reduced CO decreased SvO2 responsive to fluid challenges

Answer 139

facial flushing (36%) dyspnoea (35%) chest pain (35%) GI discomfort headache AV block ST-T changes arrhythmias bronchospasm rare (0.1%) also likely have: impending sense of doom coronary steal

Answer 140

TAVI: HIGHER rates of short-term re-intervention, AV conduction disturbances & need for a PPM, major vasc complications, paravalvular leak (AR), mod-severe HF symptoms. Does have lower rates of major bleeding & AF. SAVR: higher gradient across valve & smaller valve area, new AF, major bleeding, AKI, 30-day transfusion requirement. All-cause mortality & disabling stroke similar across groups (nominally but not significantly higher in the TAVI group).

Answer 141

the probability of correctly finding a given, existing difference as significant. Is 1-B (type II error) & represents the sensitivity. Arbitrarily set @ 80% (ie. if a difference or effect exists, there's 20% probability of type II error).

Answer 142

the null hypothesis incorrectly accepted

Answer 143

increase the sample size, have a larger minimum effect size or difference representing clinical importance, having a smaller standard deviation in the population (hence smaller sample size needed), p value, (?higher incidence of outcome of interest in the population)

Answer 144

p value standard deviation (variance) in population difference to be detected sample size

Answer 145

What's the type 1 error rate usually set at?

Answer 146

higher. Can reduce risk by lowering the significance level. Bonferroni correction lowers the threshold for significance by dividing the overall type 1 error rate by the number of comparisons or hypotheses tested.

Answer 147

0.2 micrometers (200 nanometers)

Answer 148

reduce it to 80bpm, usually with rate slowing therapy eg. oral B blocker or CCB as outpt if no or mild symptoms. If pt is haemodynamically unstable after rate control, could use rhythm control.

Answer 149

if bleeding risk exceeds benefits or CHA2DS2-Vasc score of 0 in men or 1 in women & short paroxysms of AF that self-terminate.

Answer 150

fluid replacement followed by insulin administration- use crystalloid with sodium 130-154mmol/L

Answer 151

rocuronium

Answer 152

shunt, eg. atelectasis, ARDs

Answer 153

PAO2 = FiO2 x (Pb-PsvpH2O) - (PaCO2/RQ)

Answer 154

pt supine/semi-recumbent, probe anterior chest wall @ 2nd ICS MCL, sagittal orientation, marker cephalad

Answer 155

seashore sign (motion of lung) for normal bardode/stratosphere sign if no lung motion (PTx)

Answer 156

horizontal, reverberation artefact of the pleural line, indicate dry interlobular septa, if they are predominant, it suggests PCWP <=13mmHg (90% sens, 67% spec) & suggests IVT may safely be given without concern for pulm oedema

Answer 157

indicate alveolar/interstitial fluid or fibrosis at the lung surface (if >-3 B lines). B lines are sensitive for pulm oedema & are ABSENT IN PTx.

Answer 158

lung point- on M mode, transition btwn where there is & isn't lung sliding

Answer 159

aka ventricular partitioning device, percutaneously inserted cardiac device aimed at improving cardiac output and reducing cardiac remodeling in patients following MI. Improves compliance, reduces LVEDP & improves ventricular filling, reduces wall stress, helps maintain SV & CO

Answer 160

anterior rami of the C5-T1 spinal nerves

Answer 161

anterior & middle scalene muscles

Answer 162

skin & musculature of intrinsic back mm

Answer 163

superior (C5&6) middle (C7) inferior (C8, T1)

Answer 164

SCM, middle 1/3 of clavicle, trapezius contains divisions of brachial plexus (ant & post)

Answer 165

axillary artery lateral (ant divisions of sup & middle trunk) posterior (posterior division of sup, middle & inf trunk) medial (ant division of inferior trunk)

Answer 166

axillary (C5,6): teres minor (stabilise GHJ, ER shoulder) & deltoid (stabilise HOH & abduct GHJO, superior lat cutaneous nerve of arm (regimental badge area) musculocutaneous (C5-7): brachialis (pure flex), biceps brachii (flexion & supination), coracobrachialis (flex & adduct shoulder & stabilise humeral head (w deltoid & triceps)), sensory lateral forearm median (C5-T1): forearm flexors, thenar mm, 2 lateral lumbricals (index & middle fingers), sensory to lateral palm & lateral 3.5 fingers of palmar surface of hand radial (C5-T1): triceps, wrist & finger extensors, sensory to posterior arm & forearm, posterolateral hand Ulna (C8-T1): hand muscles aside from thenar mm & 2 lateral lumbricals, FCU & medial FDP. medial 1.5 fingers & associated palm area.

Answer 167

anterior rami of C1-4 spinal nerves

Answer 168

the "nerve point" of the neck, where the cutaneous branches of the cervical plexus exit the middle of the posterior border of SCM, utilised for cervical plexus blocks

Answer 169

greater auricular from C2-3, sensation to external ear & skin over parotid gland transverse cervical nerve from C2-3, curves around SCM & supplies anterior neck, anterolateral skin & upper sternum lesser occipital nerve C2-3, posterosuperior scalp supraclavicular: C3-4, supplies skin of supraclavicular fossa

Answer 170

anterior rami of T12-L4

Answer 171

iliohypogastric- T12-L1, IO & TA, posterolateral gluteal skin Ilioinguinal- L1, IO & TA, supplies antero-medial thigh, genital branch: scrotal & root of penis, labia/mons genitofemoral- L1-2, cremasteric, skin of scrotum, mons & labia, femoral branch: upper anterior thigh lateral cutaneous nerve of thigh: L2,3, no motor, anterolateral thigh down to knee obutrator: L2-4, medial thigh muscles (OE, AL, AB, AM & gracilis), sensory to medial thigh, branches to hip & knee Femoral: L2-4, anterior thigh muscles (iliacus, pectineus, sartorius, quads femoris), sensory anterior thigh--> medial leg

Answer 172

anterior rami of L4-S4 spinal nerves (the sacral plexus S1-4 join L4-5 to form the lumbosacral trunk)

Answer 173

superior gluteal- L4-S1, glute min, med & TFL, no sensory inf gluteal- L5-S1, glute max post fem cutaneous: S1-3, skin posterior thigh, leg & perineum pudendal: S2-4, perineal skeletalmuscles incl sphincters, penis & clitoris & most perineal skin (S2,3&4 keeps poo off the floor) sciatic: L4-S2, tibial innervates muscles of posterior compartment of thigh (aside from SH BF), hamstring component of add magnus & all muscles of post compartment of leg & sole of foot. common fibular (L4-S2) for SHB, muscles of ant/lat leg & EDB. tibial (L4-S3) supplies skin of posterolat leg, lateral foot & sole of foot. common fibular supplies lateral leg, dorsum of foot (sup fibular) & btwn 1st & 2nd webspace (deep fibular)

Answer 174

AHI or RDI 1-4.9= mild 5-9.9= mod >10= severe adults mild 5-14, mod 15-30, severe >30

Answer 175

S1= closing of atrioventricular valves (mitral & tricuspid) S2= closure of semilunar (aortic & pulmonic) valves

Answer 176

A2 is heard before P2, increased split with inspiration

Answer 177

Anything delaying R) heart emptying: -delayed closure of the pulmonary valve -may occur with delayed conduction down the R) bundle (R) BBB, pre-excitation LV, pacing LV, LV prem beats) -pulmonary stenosis -PAH

Answer 178

pulmonary HTN ASD first rule out causes of a lower intensity A2, eg. MR, AR, low diastolic arterial pressure, severe immobile aortic valve

Answer 179

ASD, R) heart failure, pulm HTN

Answer 180

delayed conduction down L) bundle branch (L) BBB, pre-excitation RV, RV pacing, prem RV beats) aortic stenosis

Answer 181

loss of either A2 or P2, eg: severe AS or AR congen absence of pulm valve may be difficult to hear P2 w obesity, emphysema, pericardial fluid

Answer 182

radial- less bleeding complications often use the antecubital vein for R) heart cath when using radio for arteriography & LV haemodynamics

Answer 183

accurate decision making in MS, where PCWP is unreliable as surrogate for LA pressure

Answer 184

Brockenbrough

Answer 185

delayed & higher systolic pressure, overshoot (by <20mmHg) due to summation effect of reflected waves within arterial system

Answer 186

young pts, aortic insufficiency or evidence of PVD (which would markedly reduce the overshoot)- should measure central aortic pressure above the AV (simultaneous with LV pressure)

Answer 187

1-8 & 15-30mmHg

Answer 188

pulmonic valve closure

Answer 189

15-30/4-12mmHg

Answer 190

nearly identical but the PCW is lower & slightly delayed due to transmission of pressure backward through pulm capillaries

Answer 191

R wave, "z point", situated @ the downslope of LV "a" wave

Answer 192

abnormal- continuing pressure decline over mid-diastole (rather than the rapid, then slow phases of diastolic filling followed by the "a" wave generated by atrial contraction)

Answer 193

volume overload (AR, MR, high-volume shunts) reduced LV contractility concentric hypertrophy (eg. HTN, valvular stenosis, restrictive or infiltrative cardiomyopathy)

Answer 194

elevated & abnormal LVEDP waveform, may also have elevated LVEDP in MR

Answer 195

Nasal passages (if nasal route) or oral gag and cough reflexes need to be suppressed effectively and laryngospasm prevented

Answer 196

Upper airway supplied by: TRIGEMINAL GLOSSOPHARYNGEAL VAGUS nerves Sensation to the nasal cavity ALL from trigeminal nerve: anterior ethmoidal (from ophthalmic (V1)--> nasociliary--> ant ethmoidal) provides anterior 1/3 of septum & ant nasal cavity (eg. nares) the greater & lesser palatine & nasopalatine nerves, branches of maxillary (V2) which travel through pterygopalatine ganglion (in sphenopalatine fossa posterior to middle turbinate) supply remainder of nasal cavity (turbinates, post 2/3 nasal septum) Glossopharyngeal (CNIX) provides sensory to most of pharynx (pharyngeal branch), post 1/3 tongue/anterior surface epiglottis/vallecula (lingual branch), fauces, tonsils (tonsilar branch), & most of the pharynx branches of vagus (CNX) -posterior & lateral walls of the pharynx are from pharyngeal nerve (branch of vagus- joins with pharyngeal branch of glossopharyngeal to form pharyngeal plexus) -sup laryngeal nerve has ext branch (cricothyroid) & internal branch (sensory to skin above VCs incl base of tongue, laryngeal surface of epiglottis, aryepiglottic folds & arytenoids) -RLN: motor to other VC muscles aside from cricothyroid & sensory below glottis ant 2/3 tongue is from lingual nerve (from V3, mandibular, not nec for nasal approach to fibreoptic)

Answer 197

100mA (current is from surface contact) microshock current (direct contact with myocardium): 100microamps (0.1mA)

Answer 198

Posterior MI is suggested by the following changes in V1-3: Horizontal ST depression Tall, broad R waves (>30ms) Upright T waves Dominant R wave (R/S ratio > 1) in V2 In patients presenting with ischaemic symptoms, horizontal ST depression in the anteroseptal leads (V1-3) should raise the suspicion of posterior MI.

Answer 199

1-3 days (following the initial flaccid paralysis & areflexia/neurogenic shock)

Answer 200

loss of reflexes below level of SCI, results in flaccid areflexia, usually along with hypotension of neurogenic shock gradual return of reflex activity when reflex arcs below redevelop, often--> spasticity & autonomic hyperreflexia areflexia days 0-1 initial reflex return days 1-3 early hyperreflexia days 4-28 late hyperreflexia 1-12/12

Answer 201

1mmol/kg, initially given over 2-3 minutes then as guided by arterial blood gases 1mmol/mL therefore 60mL for a 60kg adult

Answer 202

lack of fat-soluble vitamin (K) absorption (due to impaired bile acid excretion), required for manufacture of coag factors II, VII, IX & X; water-soluble vit K prescribed for obstetric cholestasis.

Answer 203

coagulopathy incr risk surgical wound infection incr stay in PACU & hospital LoS incr ventricular arrhythmias prol DoA vecuronium & rocuronium, increases plasma [] propofol (mainly due to reduced hepatic blood flow), decreases MAC postop shivering (which augments metabolic rate) increased myocardial O2 consumption (HTN, incr metabolic rate) incr pain

Answer 204

2 vertebral bodies below the carina

Answer 205

stimulation of obturator nerve

Answer 206

5mg/kg/hr for >48hrs (product recomends no >4mg/kg/hr)

Answer 207

pH, lactate, CK after 48hrs (CK [] takes 12-24hrs to peak after onset rhabdo so earlier measurement not of benefit), limit infusion rate to lowest possible, use multimodal sedation.

Answer 208

SLUDGE, Bradycardia/bronchorrhoea/bronchospasm. Confusion, CNS depression, weakness, miosis, GI cramping, vomiting, sweating, brady or tachy

Answer 209

100% O2, atropine 0.02mg/kg boluses (for brady, hypoT, secretions). BZD for seizures/agitation, may use bicarb for acidosis, for organophosohates use pralidoxime choride for muscle weakness. Activated charcoal NOT recommended. Avoid sux since the organophosphates inhibit acetylcholinesterase so prol NMB. can use NDNMBDs but they may be less effective due to competitive inhibition @ NMJ (likely need incr doses).

Answer 210

pros: higher mean airway pressures & duration of alveolar recruitment- may be better for oxygenation & gas exchange less risk barotrauma better @ compensating for leak (higher initial flow) WOB & pt comfort may be improved cons: harder to get consistent TV (depends on compliance) so minute ventilation variable, disadvantageous if need tight PaCo2 (eg. TBI) may get volutrauma

Answer 211

more stable MV, useful for tight control of PaCo2 (eg. TBI) cons: lower mean airway pressure, may not be as good for hypoxia (insp pause doesn't really help) poorer recruitment of lung units with poor compliance, greater risk atelectasis constant flows may not compensate for leak

Answer 212

decelerating flow main difference takes 3 breaths (VCV) to calculate dynamic compliance & then works out the pressure required to delivery desired volume pros= fuses benefits without magnifying cons of the other modes, ie: square pressure waveform, favours alveolar recruitment same relatively high mean airway pressures as with PCV- good for oxygenation low risk of barotrauma as pressure minimised for prescribed volume guaranteed MV, preserves PaCo2 control cons: may get variable TV with variable pt effort as each breath depends on the pressure characteristics of the preceding breath

Answer 213

<30cmH2O (higher RR, lower TV)

Answer 214

clear fluids (no more than 3mL/kg) up to 1hr prior to anaesthesia, breastmilk up until 3 hours, formula 4 hours, all else 6 hrs prior to procedure

Answer 215

clear fluids (no >3mL/kg) up to 1 hr b4 anaesthesia, limited solids, formula, breastmilk up to 6hrs pre- anaesthesia

Answer 216

aspiration

Answer 217

NSAIDs (eg. indomethacin COX-1 selective & diclofenac COX-2 selective- increase SS lithium [], risks lithium toxicity) should discontinue lithium 24hrs before surgery also, metronidazole may incr ss lithium [] & risk lithium toxicity ACE inhibitors AII RBs Diuretics (thiazides, potassium-sparing, loop) all --> lithium accumulation w supratherapeutic concentrations risks for lithium tox= change dosing regimen, acute renal failure, hyponatremia purely excreted by kidneys, narrow therapeutic index, interferes w ADH, cardiac dysrhy, GI disturbance, tremor. Prolong NMB & reduce Anaes requirement. Stop lithium >=24hrs prep.

Answer 218

D2 receptor D2 receptor blocking drugs may cause acute dystonic reactions (involuntary contraction of extremities, face, neck, larynx- intermittent or sustained. Thought to be due to imbalance of dopaminergic & cholinergic transmission

Answer 219

hydromorphone (but hydrocodone metabolism IS by CYP2D6, as is tramadol, codeine, oxycodone, amitryptilline, methadone, beta blockers

Answer 220

Femoral CVC, then IJ then subclavian

Answer 221

tunnelled lower risk placement emergent vs non-emergent lack of asepsis skill of operator catheter care, surveillance, infection control with use (eg. disinfect hub) prolonged duration in situ

Answer 222

laboratory-confirmed bloodstream infection not related to an infection at another site that develops within 48 hours of a central line placement

Answer 223

GP (eg. coagulase negative staph, enterococci, s. aureus) then GN (klebsiella, enterobacter, pseudomonas (more common if neutropenic or severe illness)) candida (more likely with femoral catheterisation, TPN, haematologic malignancy)

Answer 224

superior cavo-atrial junction (2 vertebral bodies below carina)

Answer 225

hypotension, lethargy, fatigue, altered mental state

Answer 226

vancomycin cefazolin beta-lactam & aminoglycoside (eg. cefepime or carbapenem)

Answer 227

3% NaCl 100mL

Answer 228

fluid overload complications from operative hysteroscopies

Answer 229

altered consciousness acute pulmonary oedema (CPAP, frusemide, ?GTN): desaturation, creps on lung auscultation metabolic acidosis (sodium bicarb), hyponatremia

Answer 230

isotonic electrolyte-containing distension media bipolar electrosurgical instruments closely monitor fluid status every 30 mins (net & total irrigation fluid amounts should be <3L & <8L, respectively (in these cases, the probability of OHIA is >10%); monitor fluid deficit (fluid overload considered when the fluid deficit is >1L with hypotonic solutions or >2.5L with isotonic solutions in healthy pts, based on expert opinion) Minimise intrauterine pressure to reduce intravascular & intraperitoneal absorption

Answer 231

increase in weak acids (eg. serum proteins, albumin, inorganic phosphate) or decrease in the strong ion difference

Answer 232

presence of an excess strong cations (Na+, K+, Ca++, Mg++) over strong anions (Cl-) (the normal value in plasma is 42mEq/L, strong anions or cations are those that exist in a fully ionised state in body fluids)

Answer 233

base excess is equivalent to Stewart's SID approach

Answer 234

B-hydroxybutyrate & acetoacetate, strong anions produced from the hepatic metabolism of fatty acids

Answer 235

lactate is more than 99% ionised lactic acidosis may be observed in cardiogenic or hypovolaemic shock, severe HF, severe trauma, sepsis

Answer 236

administration of fluids which reduce the strong ion difference (eg. NaCl which has no SID, cf plasma-lyte which has SID of 47.5

Answer 237

CO / BSA 2.5-4 L/min/m2

Answer 238

treat the underlying cause of the acidosis may give sodium bicarbonate if concern for suppressed cardiac function due to the metabolic acidosis

Answer 239

administering a solution with high SID may increase the pH, improving cardiac function

Answer 240

prominently increased opacity in both lung fields, increased hilar markings, figure 2 in useful tables/figures

Answer 241

communicate w surgeons ABG prophylactic diuretics

Answer 242

100mL bolus 3% saline, repeat twice more as needed if symptoms persist. monitor the serum sodium hourly until it's increased by 4-6mmol/L after which frequency of monitoring can reduce General measures= identify & Rx underlyinc cause, identify drugs that may contribute, reduce intake of electrolyte-free water (impose FR, eliminate hypotonic IVT, incr dietary salt) if SIADH or chronic hyponatremia consider loop diuretics, oral salt tabs & urea.

Answer 243

BOS# caustic ingestion or oesophageal stricture (risk perforation) coagulopathy (epistaxis risk) severe mid-face trauma (risk cribriform plate destruction) recent nasal surgery oesophageal varices suspected epiglottis emergency intubation/significant hypoxia orogastric if coagulopathy or facial truama

Answer 244

separation of hard palate from upper maxilla transverse # through maxilla & pterygoid plates @ level just above floor of nose

Answer 245

transects nasal bones, anterior/medial orbital walls/floor/inferior orbital rings, posterior maxilla & pterygoid plates

Answer 246

separates maxilla from skull base (craniofacial dysjunction), traverses the nasofrontal suture, medial orbital wall, lateral orbital wall (zygomaticofrontal suture), zygomatic arch & pterygoid plates

Answer 247

suxamethonium

Answer 248

LBW for induction, TBW for maintenance

Answer 249

lean body weight

Answer 250

ideal body weight

Answer 251

males ht - 100 females ht -110 the BW associated with maximum life expectancy for a given height

Answer 252

males: 50 + 0.9 per cm above 150cm females: 45 + 0.9 per cm above 150cm

Answer 253

assumes that everyone of a certain height should receive the same dose & doesn't take body composition into account; in morbidly obese may lead to under-dosing, ideal BW will be < lean BW for a given height

Answer 254

more useful in morbidly obese as LBW increases as TBW increases, albeit not proportional (as TBW ultimately incr out of proportion to LBW) correlates to CO (important in early distribution kinetics) & drug clearance

Answer 255

comparable analgesia, less motor weakness

Answer 256

Increased resting HR AF incr LV contractility incr CO (incr peripheral O2 needs & incr cardiac contractility) incr blood volume (reduced MAP incr RASS activation & renal Na+ resorption), preload decreased SVR & diastolic BP/afterload may have systolic HTN may develop high- or normal-output CCF LVEF doesn't appropriately increase during exercise, suggesting cardiomyopathy Incr red cell mass (EPO synthesis promoted by T3)

Answer 257

endothelial dysfunction & impaired VSM relaxation--> incr SVR diastolic HTN & incr afterload reduced CO slower resting HR

Answer 258

"rule of 3's", so the 95% CI is zero + 3/n

Answer 259

low serum thyroid levels in a pt who is clinically euthyroid but sick from another cause; Rx is for the underlying illness vs thyroid replacement Typically low or low-normal T3, T4, may have rel high rT3 (ie. low T3:rT3). Normal or low-normal TSH.

Answer 260

high TSH, normal T3 &T4

Answer 261

ID >=7.0mm

Answer 262

Those that inhibit CYP3A4 incr risk bleeding with apixaban, eg. fluconazole, a moderate CYP3A4 inhibitor, has a 3.5x incr risk of bleeding on apixaban cf when having apixaban sans fluconazole (esp GI bleeding)- systemic fluconazole only. Strong dual CYP3A4 & P-gp inhibitors can increase apixaban & rivaroxaban effect. P-gp inhibitors can increase dabigatran effect. Examples of strong CYP3A4 inhibitors: clarithromycin, ketoconazole, voriconazole) Moderate CYP3A4 inhibitors: amiodarone, diltiazem, verapamil, cyclosporine, cimetidine, erythromycin, grapefruit juice Pgp inhibitors: amiodarone, carvedilol, larrythromycin, itraconazole, ivacaftor, ketoconazole, quinidine

Answer 263

low CrCl (avoid if CrCl <15mL/min), body wt & higher age Those taking strong dual inhibitors of CYP3A4 & P-glycoprotein

Answer 264

autosomal dominant

Answer 265

well-demarcated angioedema without urticaria or pruritis (cutaneous) may cause debilitating abdominal pain (GI), nausea or vomiting due to intestinal oedema, or life-threatening laryngeal oedema (upper airway) symptoms usually take several hours to develop, resolve in 2-4 days sans Rx

Answer 266

rare autosomal dominant condition deficiency or dysfunction of the C1 esterase inhibitor which leads to excessive bradykinin, episodic increase in vascular permeability & angioedema

Answer 267

not mediated by histamine or other mast cell mediators, not responsive to epinephrine, antihistamines or glucocorticoids, must be managed by replacing C1 inhibitor (C1 inhibitor concentrate infusion) or blocking production or functioning of bradykinin

Answer 268

Dental & medical procedures, intubation/oral surgery/major dental work are particularly high risk, emotional stress, hormonal changes, infections, medications (incl oral contraceptives & ACE-inhibitors)

Answer 269

Intravenous C1-INH concentrate (Berinert), 1-6hr before procedure, aiming for functional C1-INH level of >=50% of normal at the time of procedure (usually get this with 20IU/kg body wt) 2nd line if C1 inh n/a: attenuated androgens, danazol (androgenic hormone) in incr doses for 5 days pre & 3 days post procedure is an alternative if berinert n/a 3rd line= FFP if C1 inhibitor n/a, or solvent/detergent-treated plasma The pt should have access to on-demand therapies as swelling often occurs 1 day or so AFTER procedure alt icabitant is a bradykinin receptor antagonist, has short half life so not ideal prophylactic agent

Answer 270

Headache, nausea, fever, anaphylaxis

Answer 271

Early in the day as swelling often happens a day or so AFTER procedure, airway symptoms can be slower to recognise if begin @ night

Answer 272

SBP >140 <180mmHg, DBP <105mmHg

Answer 273

60mins (from SBP <50mmHg)

Answer 274

30 mins (if greater for liver, risks biliary stricture), (from SBP <90mmHg)

Answer 275

90mins (from SBP <50mmHg)

Answer 276

heart 4hrs lung 6-8hrs liver/pancreas 12hrs (DBD), 6hrs (DCD) kidneys 18hrs (DBD), 12hrs (DCD)

Answer 277

the time from treatment withdrawal to the start of cold perfusion of the donated organs

Answer 278

washed with detergent & water but if contaminated, wash & disinfect (semi-critical devices)

Answer 279

critical (penetrate skin or mucous membrane) so require sterilisation

Answer 280

prevention of microbial contamination of living tissues or sterile materials

Answer 281

inactivation of non-sporing organisms using thermal or chemical means

Answer 282

complete destruction of all micro-organisms including spores

Answer 283

one that penetrates skin or mucous membranes, enter vascular system or a sterile space these devices require sterilisation

Answer 284

semi-critical device will be in contact with intact mucous membranes or may become contaminated with readily transmissible organisms. they require high level of disinfection or sterilisation.

Answer 285

semi-critical device will be in contact with intact mucous membranes or may become contaminated with readily transmissible organisms. they require high level of disinfection or sterilisation.

Answer 286

one that comes in contact with intact skin or doesn't contact the pt directly, these devices require low level disinfection or cleaning

Answer 287

lose ipsilateral motor power (CST), vibration/proprioception, light touch & contralateral pain/temp (beginning 1-2 segments below the lesion) retain contralateral vibration/proprioception, ipsilateral pain/temp hyperreflexia & spastic paralysis BELOW level of lesion ipsilateral (UMN lesion) flaccid paralysis of muscles supplied by the nerve of the level of lesion (LMN affected) if lesion above T1 will get ipsilateral Horner's with involvement of oculosympathetic pathway

Answer 288

subclavian artery

Answer 289

1mV (2 big squares)

Answer 290

PEA (this was in 50%, followed by asystole in 25%. Only 12% had shockable rhythm)

Answer 291

positively-charged quaternary & tertiary ammonium ions

Answer 292

4-6wks (possible immune refractory period & may get false -ve & only +ve results are considered valid during that time)

Answer 293

no may therefore be useful if urgent surgery is required within this period following an anaphylactic reaction

Answer 294

yes- at physiologic pH they have substituted ammonium groups similar to those present on NMBAs; morphine contains one while pholcodine contains two amine groups of which one is more protonated @ physiologic pH

Answer 295

Yes, but it's unclear whether these assays have equal diagnostic value for investigating allergic reactions to different classes of NMBAs (thought to be more reliable in detecting sensitisation to benzylisoquinoline NMBAs)

Answer 296

MANAGEMENT DEPENDS ON WHETHER OR NOT THE ANEURYSM IS EXPOSED. If exposed, goals are: -create a bloodless field to facilitate clipping & protect the brain -->induce hypoT- esmolol 10-20mg IV as needed to achieve MAP 50-60mmHg to reduce bleeding & facilitate clip placement -->induce temporary flow arrest with adenosine 0.5mg/kg -->reduce CMR with propofol 20-60mg IV (if using prop for maintenance, incr rate to 125-200cmg/kg/min- aim to achieve burst suppression on BIS) -volume resuscitation may be necessary once the clip placed; IVT & blood aiming for euvolaemia & Hb >=80g/L -once clip in place, lighten anaesthesia if ruptures prior to exposure, may be difficult to detect (may be heralded but unexplained incr BP & ICP. rapid decision necessary re: Surg, imaging or angio. Support pt with: -optimising CPP by allowing permissive HTN, aim CPP 50-70mmHg if ICP monitor, if not, MAP >90mmHg. vasopressors as needed to incr BP (NAdr pref) -manage intracranial HTN --> optimise O2 (aim PaO2 >80mmHg, PaCO2 32-38mmHg) & ventilation --> osmotheray, mannitol 0.25-1g/kg or HTS 100mL 3% NaCl, aim serum Na <=155mmol/L or osmolality <320mmol/L --> improve venous drainage with head elevation 15 degrees head-up, neutral position, tape vs tie of the ETT beware that opening of ventriculostomy abruptly may worsen bleeding (acutely elevates transmural pressure gradient) --> neuroprotection with propofol 20-60mg IV or incr rate to >125mcg/kg/min, titrate EEG to burst suppression IAR occurs with an endovascular procedure for an aneurysm (uncommon, if so it's most likely with coil deployment), reverse heparinisation with protamine.

Answer 297

no, not until bleeding controlled

Answer 298

sudden rise ICP sudden incr BP or decr HR extravasation of contrast

Answer 299

reduce coagulability (protamine to reverse heparin, IF REQUESTED BY RADIOLOGIST; 1mg protamine per 100 units heparin given) reduce BP to level before HTN due to bleeding reduce ICP (gentle hyperventilation, reverse trendelenburg, would've taped not tied ETT, consider mannitol or HTS) control seizures reduce CMR (prop) only continue coiling once BP controlled

Answer 300

retention may cause hyperosmolality & osmotic movement of water & K out of cells. May get vol expansion, hyponatremia, metabolic acidosis & hyperK.

Answer 301

1mg protamine per 100 units heparin

Answer 302

the quince or atraucan require orientation of bevel along with the dural fibres so less likely trauma, while it doesn't matter with Whitacre or sprotte

Answer 303

1. neurocognitive (childhood OSA may impair learning skills), psychiatric (eg. depression), endocrine (impaired glucose tolerance, dyslipidaemia, incr cortisol [], testicular/ovarian dysfunction), cardiovascular morbidity (HTN & Brady- and tachyarrhythmias are more common, pulm HTN, CHF & biventricular dysfunction incr risk of haemodynamic instability perioperatively- OSA IS AN INDEPENDENT RISK FACTOR FOR MI- dyslipidaemia, increase pro-inflammatory cytokines, endothelial dysfunction, incr platelet aggregation) & mortality in all age groups. they are @ incr risk of CVA with poorer outcome. difficult intubation, obstructed breathing, OPIOID SENSITIVITY Pulmonary complications postop delirium ****POSTOP CARDIAC EVENTS ((Composite outcome of myocardial injury, cardiac death, heart failure, thromboembolism, AF & stroke) within 30/7 of surgery) = sig incr HR IN SEVERE BUT NOT MILD/MOD OSA When are pts with obesity @ highest post risk? Sleep architecture disturbances greatest on PN1 but breathing disturbances during sleep greatest PN3 Death & anoxic brain damage/other critical evnents within 24hrs. More likely if on ward vs ICU. More likely if not use CPAP. Highest risk= SEVERE UNTREATED. Minimise risk by: Routine post O2 Minimise opioids Extubatne awake Incr intensity post-op monitoring (routine pulse ox or capnography) Referral for sleep studies: STOP-BANG 6-8 OR stop-bang 3-5 & MP 3-4 or neck >50cm2 or SpO2 <94% or bicarb >20 or NYNA III—> sleep studies Non-supine positioning where possible Continue CPAP if already on CPAP; those with severe OSA but not compliant w CPAP—> HDU invasive monitor. If not on CPAP or on CPAP + compliant OR mod risk based on screening or diff airway—> low-opioid & overnight SpO2

Answer 304

increasing age ASAIII-IV male poor physical reserve cardiopulmonary dysfunction pre-existing pulmonary HTN PFO OP bony mets hip fractures (esp pathological or intertrochanteric), warfarin use & diuretic use surg factors: long-stem arthroplasty, prev uninstrumented femoral canal NOT revision surgery, ?femoral canal diameter >21mm

Answer 305

1: hypoxia SpO2 <94% & hypotension with SBP decrease >20% 2: SpO2 <88% or SAP drop >40% or LOC 3. cardiovascular collapse requiring CPR Features BCIS: hypoxia, hypoT, arrhythnias, cardiac arrest Reversible, time-limited Limit risk by identifying high-risk pts (CEMENTED HIP ARTHROPLASTY), modify surg technique to reduce CV compromise (prep & dry canal, venting hole, bone-vacuum cement, avoid pressurisation, consider cementless) Anaes: vigilance (prepare for cement with 100% O2, normal BP, open IVDT) to haem changes, R) heart protection, normovol, adequate MAP, art line, incr FiO2 during @ risk times (reaming, insertion cement, insertion prosthesis, reduction joint, release tourniquet), appropriate depth (not excess @ risk times), avoid N2O (air embolism). Mx: early identification, 100% O2, aggressive resus, manage PAH & RV failure, pulm VD (prostacyclin) & inotropes (dob & milrinone, ephedrine), consider higher-level monitoring (TOE) & CVC ICU postop. Early post-op Ax (possible delirium w cerebral emboli)

Answer 306

VIE (vacuum insulated evaporator)

Answer 307

Boyle's Law: P1V1 = P2V2 P1= 150bar V1= 2L P2= 1bar (atmospheric) so, V2= (2 x 150) / 1 = 300L 300L at 10 L/min = 30mins

Answer 308

2.9L water capacity 440L oxygen at 13700kPa

Answer 309

1 month per 12 months

Answer 310

demyelinated axons are more sensitive to heat & symptoms can deteriorate with increase in temperature

Answer 311

no no yes (incr (50%) risk of major nonfatal extracranial bleeding likely may reduce nonfatal MI over 10 yrs possible reduction colon Ca incidence over 20yrs

Answer 312

consider it for adults aged 40-70 with high risk of ASCVD but NOT at incr bleeding risk do not give it on routine basis for primary prevention of ASCVD in adults >70yo don't give it to adults at any age @ incr risk bleeding

Answer 313

FEV1/FVC <70% & FEV1 30-49% predicted

Answer 314

60% 36% 85%

Answer 315

?desflurane, since GWP is the product of radiative efficiency & atmospheric lifetime & N2O has much longer atmospheric lifetime than des yet lower GWP

Answer 316

within first 5 postop hours

Answer 317

-external cardiac compressions aren't immediately initiated (concern for disruption of the surgical repair) -avoid administration of full 1mg epinephrine; may --> extremely high BP which may disrupt arterial suture lines; rather, if indicated at all, give 50mcg increments of epinephrine as needed with continuous reassessment -avoid atropine for asystole or severe brady, instead, initiate pacing (rate of 90, DDD, if pacing wires available) -if they are paced & in PEA, turn off pacing to "unmask" VF if VF or pulseless VT, give 3 successive defibrillator shocks & 300mg amiodarone IV initiate pacing for asystole or severe bradycardia- set pacemaker for dual chamber pacing (DDD mode) at 80-100bpm, max output voltage 20mA atrial & 25mA ventricle (deranged phys says max output) if PEA, external cardiac compressions while opening chest (within 5 mins); do manual cardiac massage 100-120bpm. internal defibrillator at 20J/s during attempts to treat VF.

Answer 318

characterised by medullary thyroid cancer, pheochromocytoma/paraganglioma, primary parathyroid hyperplasia MEN2B no hyperparathyroidism

Answer 319

cafe au lait spots peripheral neurofibromas neurocognitive abnormalities CNS tumors soft tissue sarcomas other tumors incl pheochromocytomas/paragangliomas

Answer 320

Bernoulli equation: 4v2 + RAP (using the continuous wave doppler trace through tricuspid valve), where v is the TR jet VTI

Answer 321

Na+ & Cl- 154, osmolarity 308mOsmol/L (considered isotonic), SG 1.0046 (plasma 1.02)

Answer 322

air-filled bronchi (dark) made visible by opacification of the surrounding alveoli, suggest a pathologic process going on filling alveoli w something other than air. they won't be visible if the bronchi themselves are opacified (eg. filled w fluid). Ddx: pulmonary consolidation pulmonary oedema pulmonary haemorrhage non-obstructive atelectasis severe interstitial lung disease neoplastic process pulm infarct

Answer 323

position of trachea. pulled toward opacified side: pneumonectomy, total lung collapse (eg. endobronchial intubation), pulmonary genesis or hypoplasia remains central: consolidation, pulm oedema/ARDS, pleural mass, chest wall mass, being on ECMO pushed away: pleural effusion, diaphragmaticc hernia, large pulm mass, diaphragmatic rupture

Answer 324

send for help up to 5 back blows (Heel of hand middle of back btwn sh blades, aim is to relieve obstruction, check between each to see if dislodged the FB) Infant head downwards across rescuers lap if not successful up to 5 chest thrusts, same hand position as CPR but thrusts slower rate & sharper. infant head down on back across rescuers thigh, adult sitting or standing. therafter, alternate 5 back blows & 5 chest thrusts.

Answer 325

24 (2) & 22 (1)

Answer 326

56cm long 19Fr ID 4.7mm contains 15mm adapter & luerlock can be used with an ETT ID >=7mm (as it has 6.5cm OD) can be loaded onto fiberoptic scope with OD 4.2mm or smaller LMA 2 or larger

Answer 327

83cm, 11-19Fr

Answer 328

100cm, 11-14Fr

Answer 329

posterior cerebral artery, supplying the R) occipital lobe

Answer 330

contralateral hemisensory loss (UL, LL, lower 2/3 of face) contralateral motor weakness, spasticity, hypertonicity/hyperreflexia ipsilateral eye deviation & contralateral homonymous hemianopia if dominant (usually L)-sided), Broca's aphasia (difficulty forming words) if superior part of MCA, wernicke's (difficulty understanding words & they may speak in fluent but unintelligible sentences & be unaware of this) if inferior part & if non-dominant, hemineglect/agosognosia/apraxia

Answer 331

contralateral hemisensory loss, due to thalamic infarct, may also have memory impairment & decr consciousness ACA: CL LL weak, executive dysfunction brainstem: crossed sensory or motor findings, nystagmus, diplopia, vertigo, horner's cerebellar: ataxia, nystagmus, vertigo, nausea, headache, rapid deterioration consciousness

Answer 332

PCA territory infarct

Answer 333

elevated IOP due to retrobulbar haematoma visual loss lateral canthotomy- decompressing the orbit, relieving pressure to prevent compartment syndrome & permanent vision loss other Mx: acetazolamide, mannitol, emerg orbital decompression don't see chemosis with retrobulbar haemorrhage

Answer 334

2hrs, possibly less

Answer 335

possibility of allergic reaction

Answer 336

those with known severe systemic allergic reaction to gelatin or neomycin

Answer 337

Substance P (NK1 is the receptor, substance P is the ligand, aprepitant antagonises the receptor)

Answer 338

retropharyngeal OEDEMA

Answer 339

multilevel surgery blood loss >300mL duration >5hrs combined ant & posterior operation previous Cx surgery

Answer 340

external loss of gastric secretions (vomiting, NG suction) or diuretics management approach= to treat the underlying cause- eg. treat cause of vomiting, stop or slow removal of gastric secretions, stop loop or thiazide diuretics then correct the factors maintaining the disorder (eg. Cl- administration, repletion of Cl-, K+ & ECF volume will promote renal bicarb secretion & return plasma bicarb to normal). if the metabolic alkalosis is due to persistent vomiting or gastric suction, drugs that reduce gastric HCl secretion may help (H2 blockers, PPIs) if the ethology unclear from Hx/exam, measurement of urine chloride & Na may help as may looking at the potassium- - low urine Cl occurs with vomiting or NG suction (unless the pt also on diuretics), spot urine Na also often low in these pts due to volume contraction - if the pt is hypokalaemia, this is usually due to urinary potassium losses, even if the pt has concurrent vomiting, since there is little K+ in gastric secretions

Answer 341

carbonic anhydrase inhibitor, promotes renal loss of bicarb along with sodium, water & potassium

Answer 342

3 days; 2 days & day of OT

Answer 343

3 days; 2 days & day of OT can withhold just for the day of the procedure but fasting before & after the procedure should be minimised

Answer 344

pts taking SGLT2i who have one or more of: • symptoms of abdo pain, nausea, vomiting, fatigue or metabolic acidosis – a normal or only modestly elevated plasma glucose level does not exclude the diagnosis. • finger prick capillary blood ketone (or blood beta-hydroxybutyrate) levels >1.0 mmol/L with or without hyperglycaemia • low (negative) base Excess (BE) < -5mmol/l indicating metabolic acidosis on arterial or venous blood gasses.

Answer 345

course of action depends on urgency of procedure, pt factors eg. HbA1c (>9% indicates higher risk of insulin insufficiency & risk of eDKA in this setting)... if: ketones <1 & BE > -5, there's no ketosis or metabolic acidosis so consider proceeding w day surgery with hourly monitoring of ketones intra-op & 2-hourly postop until E&D normally. provide written post-D/C info. more extensive surgery requires considering goals of care, collaboration with endocrine & critical care. if ketones >1 & BE > -5, ketosis without metabolic acidosis. get endocrine advice. it may be due to starvation (esp if the pt has HbA1c of <9%). could consider proceeding with periop insulin & dextrose infusions to mitigate risk of DKA. if ketones >1 & BE < -5, ketosis with metabolic acidosis. strongly consider postponing non-urgent surgery, escalate w endocrine & critical care.

Answer 346

in collaboration with endocrine & critical care: rehydration IV insulin infusion (with added dextrose once BGL <15mmol/L) hourly BGL, ketones & blood gas

Answer 347

high-frequency linear 10-14MHz

Answer 348

better resolution but less penetration (ie. better for superficial)

Answer 349

better tissue penetration but poorer resolution; allows visualisation at greater depth

Answer 350

uniform amplification of the returning US waves; higher gain= higher signal of reflected sound waves & image whiter.

Answer 351

as shallow as possible to still see all the structures of interest, since the image quality varies inversely w penetration depth

Answer 352

mode depth focus (at or 0.5cm below target nerve) gain frequency doppler

Answer 353

5 days, however if there is NORMAL renal function (CrCl >=80mL/min) & no additional risk factors for bleeding (age >65, HTN, antiplts), may consider 3 days or if CrCl 50-79mL/min consider 4 days. if CrCl <30mL/min, avoid neuraxial block if pt has been on dabigatran.

Answer 354

6hrs for all, immediately for clopidogrel provided no loading dose (in which case 6hrs)

Answer 355

ipsilateral tongue deviation (LMN) or contralateral (UMN)

Answer 356

II, IV, VII & XII

Answer 357

20mg parenteral morphine

Answer 358

preload (? this may be achieved w decr volatile?) & pulmonary resistance Keep Fontan pressure <20mmHg Transpulmonary gradient <5mmHg PVR <2WU/m2 for optimal circulation

Answer 359

ischaemic optic neuropathy (higher freq than pressure causing occlusion of retinal vessels). ischaemic optic neuropathy causes are uncertain but may relate to low arterial pressure, low hct, long surgery, large IV fluid volume.

Answer 360

multimodal perioperative care pathway aiming for early recovery for pts undergoing major surgery, includes pt optimisation, anaes, surg & OPD support. limit fasting, carb loading, education, normothermia, limit intraop IVT, multimodal analgesia, PONV & antibiotic prophylaxis, in/out IVC, d/c instructions & f/up plan.

Answer 361

is a complication specific to the use of V-A ECMO for severe cardiorespiratory failure, where the upper half of the body is perfused by blood of relatively low oxygen saturation from the heart, cf the lower body, where well-oxygenated blood is supplied via the peripheral femoro-femoral VA ECMO system.

Answer 362

BLEEDING & COAGULOPATHY; 5-79% of ECMO patients Answer= HAEMORRHAGE- particularly since most pts are on continuous anticoagulation. half of these haemorrhages relate to the cannulation site, arterial cannulation= highest bleeding risk. Risk intracranial haemorrhage (so avoid HTN) Thrombosis then infection

Answer 363

reduced FEV1 & FVC, normal DLCO, ratio normal or high

Answer 364

prevent rebreeding by securing the aneurysm, ideally within 24hrs

Answer 365

FRC, 20% by term (both RV & ERV decrease)

Answer 366

aim to maintain oxygen & ventilation, identify site of haemorrhage, position pt with suspected bleeding side down (R)-side down decubitus) to limit soiling of "good lung", isolate the non-bleeding lung to protect it from soiling & optimise oxygenation, most practically & rapidly with large-bore (at least size 8) single-lumen ETT & L) mainstem endobronchial intubation or DLT (less likely time for this) with bronchial cuff inflated, tracheal lumen clamped- also DLTs are difficult to insert w brisk bleeding & aren't large enough for passage of a flexible bronchoscope w suction capability. ?+/- tamponade the bleeding lung with bronchial blocker such as Arndt endobronchial blocker (theoretical risk mucosal ischaemia) ?suction with bronchoscope- flexible is less efficient cf rigid, flexible can be used to instil topical vasoconstrictors or haemostat agents, ?cooled saline volume resuscitate, manage hypoxaemia-related arrhythmia (primarily by treating cause- optimising gas exchange) manage any coagulopathy/bleeding diathesis/replace blood products apply PEEP to the bleeding lung if possible transport pt to medical imaging for diagnosis & embolisation if feasible

Answer 367

5mm distal to carina without herniation across it

Answer 368

any volume of blood that could obstruct the airway or cause significant haemodynamic compromise ("magnitude of effect" definition preferred over blood volume- ie. could be described as "haemoptysis that impairs gas exchange, causes haemodynamic instability or is >100mL/24hrs (the minimum volume reported to be life-threatening due to asphyxia))

Answer 369

bronchial circulation (supplies bronchial tree @ systemic pressure)

Answer 370

only gets to the level of main bronchi (may not get distal bleeding)

Answer 371

reduces the half life of carboxyHb (from 90mins at normobaric, down to 30mins) so HBO can prevent neurocognitive deficits associated with severe CO poisoning

Answer 372

<1.5%, may be up to 9% in smokers

Answer 373

CO>25% CO >20% if pregnant LOC severe metabolic acidosis (pH <7.1) evidence of end-organ ischaemia (ECG changes, chest pain, altered mental status)

Answer 374

if Rx initiated within 6hrs (benefit >12hrs after exposure is unproven)

Answer 375

intra-hepatic cholestasis of pregnancy PET with hepatic impairment (highest proportion of deranged LFTs in pregnancy are due to this) HELLP syndrome acute fatty liver pregnancy

Answer 376

assess for encephalopathy manage coagulopathy (plt function tends to remain stable, unlike HELLP, however use of regional may be precluded by coagulopathy) manage hypoglycaemia expedite delivery once pt stabilised as high maternal & foetal mortality Pt must be in HDU, particularly postop as symptoms can deteriorate post partum with worsening liver, renal function & coagulopathy for 48hrs

Answer 377

lactate >2.8mg/dL & presence of encephalopathy

Answer 378

mild, stable disease, balancing risks & benefits to mum & Bub

Answer 379

ULN transaminases is reduced by 25% in all trimesters ALP increases in the 3rd trimester due to placental production

Answer 380

elevated ALT (>1.5x normal), elevated bile acids (>1.5x normal), bilirubin is usually NORMAL

Answer 381

raised ALT (>2x normal), BA & bilirubin usually normal

Answer 382

raised ALT (>2x normal), BA usually normal, Bilirubin elevated (>1.5x normal)

Answer 383

elevated ALT (>3x normal), elevated bilirubin (>4x normal), bile acids usually normal

Answer 384

haemolysis, elevated liver function (ALT >2x ULN, elevated bilirubin >1.5x ULN, bile acids usually normal) & low platelets can present in late 3rd trimester, can also present post-partum occurs in 4-20% of pts with PET The BP elevation may be mild, as may be the proteinuria Pt may c/o upper quadrant pain/epigastric pain (in which case the pt should have abdo imaging as hepatic haematoma or rupture are rare but significant complications ass'd w high (up to 60%) mortality) LFT derangement may lag behind abdo pain so the LFTs should be repeated if not elevated N&V is common may c/o dyspnoea/chest pain & have tachypnoea due to concomitant metabolic acidosis The haemolysis is not usually severe enough to cause anaemia DIC occurs in about 20% of cases The trend in platelets should be monitored, replace if active bleeding or for operative delivery/placement of invasive lines acute renal failure is more common in HELLP than in other forms of PET & morbidity is often ass'd with AKI Pts should be managed in HDU given the course can be unpredictable complications= placental abruption, APH/PPH, pneumonia, liver haematoma, pulmonary oedema, ICH TREATMENT = Stabilisation & deliver foetus, timing of which balances risks to mother & foetus

Answer 385

liver function

Answer 386

late in 3rd trimester (30-38wks & up to 4.7 postpartum)

Answer 387

more common in women with multiple pregnancies, lower BMI & children with disorders of B-fatty acid oxidation

Answer 388

maternal mortality is high, ranges from 20-50% foetal mortality also high 20% have concurrent HELLP

Answer 389

Swansea criteria, there must be @ least six of the listed clinical features in the absence of another explanation: Vomiting Abdo pain Polydypsia/polyuria Encephalopathy Hypoglycaemia Elevated bilirubin Ascites/bright liver on US Leukocytosis Coagulopathy Renal impairment (develops in about 90% of pts) Elevated urate Elevated transaminases Elevated ammonia Microvesicular steatosis on liver biopsy Imaging (CT or MRI), liver biopsy or fat stain may support the Dx Other complications include: pancreatitis, ARDS, metabolic acidosis & elevated lactate Urgent delivery then Mx of liver failure

Answer 390

tends to be stable, unlike with HELLP it's often precluded by the presence of coagulopathy but it has been described & may improve hepatic blood flow ALT/AST all raised, bili, ammonia & WBCs can also be raised

Answer 391

pregnancy-related impairment of bile acid excretion causes pruritus, typically affecting hands & feet (palms & soles, worse @ night)- may be severe but rarely requires HDU LFTs typically show raised ALT & bile acids (both >1.5x ULN), normal bilirubin vitamin K malabsorption may occur (steatorrhoea) so the pt should have coagulation (raised PT, INR) assessed before proceeding with regional anaesthesia (<1.4 within 24hrs acceptable, changes slowly) neuraxial opioid may worsen pruritus but this must be balanced against need for effective pain control obstetric cholestasis may be a marker of other liver disease (eg. AFLP, hepatitis) so the collection of symptoms should be considered mum treated with ursodeoxycholic acid (a synthetic bile acid)- 300mg BD or TDS until delivery- timing of delivery depends on total bile acid level, hepatic function, severity of the pruritus balanced against foetal risks

Answer 392

gestational-related conditions (more common) or liver disorders incidental to pregnancy

Answer 393

hep A, B, C, D, E & G, along with HSV, CMV & EBV

Answer 394

hep E & HSV hepatic encephalopathy & hepatorenal syndrome caused by viral hepatitis have higher incidence during pregnancy viral hepatitis ass'd with obstetric complications eg. PROM, IUGR, prem delivery

Answer 395

fever, nausea, jaundice

Answer 396

usually improves during pregnancy (as with many other autoimmune conditions) management= immunosuppressive therapy which should be continued in pregnancy; AZA, cyclosporine & tacrolimus considered safe but not mycophenalate (contraindicated, teratogenic)

Answer 397

-hepatocellular damage: raised transaminases & sometimes bilirubin -cholestatic picture (raised ALP & GGT) -mixed picture (hepatocellular & cholestatic)

Answer 398

10% mortality rate portal HTN worsens so oesophageal varicies= major bleeding risk (lower if Rx before pregnancy)- potential for strain makes LSCS preferred mode for delivery use Bilirubin, INR & Cr for prognosis

Answer 399

generally favourable outcomes but higher risk pre-term delivery, LBW, PET & GDM. must continue immunosuppression (low risk teratogenicity with commonly-used agents) consider side-effects of immunosuppressants (neuropathy, electrolyte imbalance)

Answer 400

obstruction to hepatic venous outflow causing ascites & hepatomegaly +/- R) UQ pain. most cases are due to thrombosis.

Answer 401

individualised care plan liaise with liver unit, ICU (requires MDT planning & management) monitor carefully for complications & identify those @ risk of fulminant hepatic failure (for which liver transplantation may be considered- best predictors for deterioration necessitating liver transplant or resulting in death= lactate >2.8mg/dL with encephalopathy)

Answer 402

prolonged INR hypoglycaemia hypoalbuminaemia lactic acidosis

Answer 403

It doesn't. And it doesn't reduce hepatic blood flow so it's a suitable induction agent.

Answer 404

actrac & cistatrac; duration of roc unpredictable but can be reversed with sugammadex.

Answer 405

severe disease coagulopathy & need for resus will make regional unsuitable mild disease: balance risks based on plt count & +INR. only do epidural in very mild, stable disease (issues w placement, catheter removal & that all LA undergoes hepatic metabolism)

Answer 406

100mg IV hydrocortisone with 200mgIV/24hrs OR 6-8mg dexamethasone

Answer 407

an acute phase reactant. binds to ferroportin, stopping release of ferritin from enterocytes & macrophages.

Answer 408

Anaemia. EPO & other erythrocyte stimulation agents, decr body Fe stores, hypoxaemia, incr erythropoietic demand in contrast, infection, inflammation & malignancy may increase serum hepcidin levels, as does increase in body iron stores

Answer 409

a few hrs exposure= megaloblastic changes to bone marrow more prolonged exposure= agranulocytosis neurological symptoms from chronic B12 inactivation (resembles subacute combined degeneration of spinal cord, from damage to the posterior (fine touch/vibration/proprioception loss) & lateral (motor from lateral corticospinal tract) columns: general weakness, tingling and numbness in the hands and feet, and stiff limbs and may become irritable, drowsy, and confused.. may also get visual changes)

Answer 410

22mmHg (as they recommend treating >=22mmHg) IIa: Treating ICP above 22 mm Hg is recommended because values above this level are associated with increased mortality

Answer 411

posterior tibial (to block lateral plantar nerve) also need superficial peroneal nerve (L4-S1) to block dorsal surface

Answer 412

IV BZD, donepezil or propofol at the end of a seizure, dexmed may be useful if refractory, pre-med olanzapine helps remifentanil is NOT useful for agitation after ECT

Answer 413

small, flat & collapsed (2-3cm diameter), either round or ovoid in XC & often appears as "bull's eye" target and the muscular propriae (hypo echoic) appears thick.

Answer 414

Doxycycline 400mg PO 60mins before procedure (has been administered 10-12hrs b4 procedure so can have w food to limit risk nausea) or 100mg PO 60mins b4 then 200mg PO, 90 mins postop -NO evidence for adding metronidazole prophylaxis

Answer 415

lower pH promotes bicarb loss kidneys hypokalaemia, hyponatraemia

Answer 416

surgical factors= surgical approach with risk nerve damage): amputation (30-85%) sternotomy (30-50%) thoracotomy (5-67%) mastectomy (11-57%, breast surgery 13-35%) inguinal herniotomy (5-63%) LSCS (6-56%) knee replacement 19-43% pt factors: psychological vulnerability (eg. catastrophising), pre-op anxiety female younger age (adults) pre-op pain, mod-severe, lasting >1/12 repeat surgery prev opioid use (esp if inefficient) worker's comp genetic predisposition others: poorly controlled postop acute pain radiation therapy to the area neurotoxic chemotherapy For breast Ca surgery, PVB, local infiltration, IV lignocaine reduce incidence CPSP. sparing of intercostobrachial nerve doesn't decrease chest wall hypersensitivity.

Answer 417

CPSP is pain developing or increasing in intensity after a surgical procedure, in the area of the surgery, persisting beyond that time for expected wound healing (ie. 3 months) but not better explained by another cause (eg. infection, malignancy, pre-existing pain)

Answer 418

albumin (other unmeasured anion is phosphate under normal conditions, critically ill= lactic & keto acids)

Answer 419

prevention or control of bleeding in pts with factor IX deficiency (haemophilia B) ** but due to risk of thrombosis, better to use specific factor concentrate eg. monofix-VF or life-threatening haemorrhage associated with warfarin is off-label) could also use for pts with deficiencies of factor II or X

Answer 420

at the cavoatrial junction thrombus arrhythmia

Answer 421

MAO-A inhibitor, reversible avoid indirect-acting sympathomimetics & pro-serotonergic drugs Can withold (normal return to MAO activity in 24hrs) Interacts with: pethidine (norpethidine serotonergic), tramadol, dextromethorphan, Fentanyl causes efflux of serotonin & binds to serotonin receptors. methadone, oxycodone, fentanyl & tapentadol are intermediate risk opioids. Tramadol & pethidine high risk. ABx: linezolid MDMA (releases serotonin) indirect sympathomimetics can precipitate fatal hypertensive crisis. slowly titrate direct (Adr/norad/phenyl) due to incr receptor sensitivity. M relaxants: phenelzine decr plasma cholinesterase & prolongs sux. Panc releases stored NAdr. LAs: avoid cocaine, care w Adr mix. bzd, volatiles, antichol/nsaids all OK.

Answer 422

VF, cardiac tamponade & major bleeding

Answer 423

10 days. thereafter, pericardium is more difficult to access due to adhesions so open resus more challenging

Answer 424

50% 10% so no point in continuing after 3 stacked shocks- then amiodarone (VF or VT), ext cpr w opening chest within 5mins

Answer 425

pacing is the treatment. atropine delays that.

Answer 426

take pt off ventilator, manually ventilate increase FiO2 to 100% drop PEEP to zero to optimise preload exclude tension PTx stop sedating infusions & other infusions switch IABP to trigger mode (which assists CPR)

Answer 427

MAO is bound to the outer mitochondrial membrane. It breaks down NAdr, serotonin & dopaimine. Monoamine oxidase A is found in GI mocosa, liver, noradrenergic & serotonergic nerves- moclobemide is reversible & specific to MAO-A MAO-B is found in platelets, liver & dopaminergic nerves, selegiline is specific to MAO-B Phenelzine is a traditional MAO inhibitor inhibiting MAO nonselectively & irreversibly (worse reaction), duration weeks reversible moclobemide

Answer 428

indirect-acting sympathomimetics (direct still has incr effect but preferred since also metabilised by COMT so less dependent on MAO, ie. phenylephrine good, ephedrine & metaraminol avoid), due to an exaggerated response to increased NAdr release from nerve endings SSRI or tricyclics and tramadol & pethidine (latter cause serotonin & norepinephrine reuptake inhibition)- excessive amount of serotonin (MAO inhibition results in reduced breakdown & increased activity of serotonin) they also interact with foods high in biogenic ingested amines such as tyramine (hypertensive crisis may occur due to loss of protective effect of MAO-A in the gut) orthostatic hypotension can occur may get excitatory (inhibition of serotonin reuptake by pethidine) or depressive (decreased breakdown of pethidine)

Answer 429

phenylephrine- more rapid onset & short DO, ideal for continuous infusion, no adverse effect on foetal acid:base cf ephedrine

Answer 430

decrease in urinary concentrating ability resulting from resistance to the action of ADH, either due to resistance at the ADH site of action or interference with the countercurrent mechanism causes include hereditary such as V2 gene mutations, aquaporin-2 gene mutations, lithium toxicity, hypercalcemia, hypokalaemia

Answer 431

characterised by decreased release of ADH--> polyuria due to deficiency in ability to concentrate urine idiopathic, primary or secondary tumours, infiltrative diseases, neurosurgery, trauma polyuria, nocturia, polydipsia, may have neurologic symptoms related to the underlying neurologic disease, may develop decreased BMD (even those treated with desmopressin) elevated serum Na (high normal except if pt can't express or access (eg. postop) the hypernatremia may become severe) elevated serum osmolality dilute urine (osmolality <600msomol/kg) low in Na

Answer 432

correct free water deficit (if the pt has chronic >48hrs) hypernatremia, only want to lower the serum sodium by 10mmol/L in 24hrs (3mL/kg electrolyte-free water lowers serum Na by 1mmol/L), while acute hypernatremia want to replace entire water deficit within 24hrs (5% dextrose in water 3-6mL/kg/hr up to 666mL/hr, monitoring serum Na & glucose 1-2 hourly until serum Na <145mmol/L then reduce rate to 1mL/kg/hr until normal Na+) *as per RCH, use 0.9% NaCl w 5% dextrose to prevent hyponatremia! increase activity of ADH, with desmopressin (ADH analogue); oral 100mcg (start with 0.5microg & titrated, intranasal 10mcg (equivalent to 0.5microg PO is 5mircog intranasal), subcut 1microg low-solute diet (low-sodium, reduced protein) which may be combined with a thiazide

Answer 433

hyponatremia--> symptoms such as nausea, vomiting, headache, lethargy, seizures

Answer 434

less maternal bradycardia; similar agars, hypotension & use of rescue vasopressors

Answer 435

Hx: glass etching, electronic industries, cleaning solutions- highly corrosive acid Local injury + potentially fatal systemic reaction Fluoride complexes with Ca++ & Mg++ --> hypoCa & hypoMg. hypocalcaemia may cause K+ efflux--> hyperKalaemia. May get prolonged QTc. fluoride directly cardiotoxic (arrhythmias, primary cause of death with HF burns) inhalation can--> severe pulmonary injury

Answer 436

1.5x (bicarb) +8 21 + 8 = 29

Answer 437

PEA (50%), asystole 25%

Answer 438

Claustrophobia Hypoglycaemia Middle ear barotrauma Sinus squeeze Oxygen toxicity seizure Progressive myopia – typically reverses completely in days to weeks. Cumulative pulmonary oxygen toxicity Pulmonary barotrauma +/- air embolism Exacerbation of congestive heart failure in patients with severe disease, due to: a. Sinus bradycardia from stimulation of vagal activity and stimulation of a further measurable, nonoxygen dependent bradycardia that is associated with hyperbaric pressures. b. Systemic vasoconstriction causing increased afterload. Increased rate of maturation of cataracts with very long courses of HBOT.

Answer 439

if taking the pill, follow "missed pill advice" on packaging leaflet if using hormonal implant/innjection, use barrier contraception for next 7/7

Answer 440

Meta-analysis 2020 Anaesthesiology (RCTs 8200 participants): pts receiving volatile had lower incidences of one-year mortality & MI along with less need for inotropic medications & cardiac troponin release, higher cardiac output or index measurements & shorter extubation times NEJM RCT 2019: 5400pts randomly assigned to VA vs TIVA, no difference in mortality at 1 year or other outcomes incl MI. histological evidence preconditioning (no mortality benefit in vivo)

Answer 441

difficulty controlling the volatile uptake with different oxygenators & difficulty maintaining steady state plasma [] with variable FGFrates during different phases of CPB, poor correlation between oxygenator exhaust volatile [] & BIS inefficient scavenging & risk of OT environment pollution TIVA problem with changes in PPB capacity & variations in the free fraction of plasma propofol due to haemodilution, effects of hypothermia on hepatic clearance of propofol, absorption of propofol into the CPB circuit

Answer 442

hypothermia reduces anaesthetic requirement & if using volatile, there's greater uptake & plasma solubility during hypothermia. to avoid inadequate anaesthesia during rewarming, dose of IV or volatile should increase (blood propofol [] rapidly decreases during rewarming.

Answer 443

INR, tests extrinsic & common pathways & if prolonged, suggests impaired clotting factor synthesis or deficiency of vit K; it's non-specific (eg. prol in warfarin use, DIC). The clotting factors have relatively short half-lives (eg. VII 4-6 days).

Answer 444

marker of chronic liver impairment due to relatively long half life (20/7)

Answer 445

liver produces TPO & 10% of EPO so low Hb & plt may occur w hepatocellular damage

Answer 446

liver converts toxic NH3 to the less toxic urea (for excretion via the urea cycle)

Answer 447

low glucose

Answer 448

pre-hepatic cause (eg. haemolysis, Gilbert's) may have high unconjugated bilirubin given there'd be exhaustion of the liver's conjugating capacity (most common causes unconj hyperbili are Gilberts, haemolysis, resolution of haematoma or portal HTN) high direct bilirubin suggests biliary obstruction mixed (both high) suggests hepatic disease & impaired hepatic uptake & conjugation of bilirubin

Answer 449

both are found in hepatocyte mitochondria so elevation suggests hepatocellular damage AST is also found in heart, rbc, skeletal muscle ALT therefore more specific to hepatocytes so elevated ALT:AST more suggestive of hepatocellular damage

Answer 450

LDH (found in hepatocytes, also in heart, pancreas, rbc, lungs, placenta so can be elevated if MI, Ca, haemolysis etc.

Answer 451

enzymes found in hepatocytes AND ductal cells along bile duct/canaliculus; high ALP & GGT suggest hepatobiliary disease (intra- and extra-hepatic cholestasis) in isolation, GGT is non-specific (raised with ETOH) Also, ALP is non-specific (bone, placenta)

Answer 452

elevated conjugated bilirubin, GGT, ALP

Answer 453

position 1: chamber paced (A, V or D (dual)) position 2: chamber sensed (A, V, D or O if sensing is turned off) postion 3= response to sensing; inhibited, triggered (no clinical purpose), D (response can be I or T), O if no response to sensed events position 4= rate modulation (eg. with accelerometer, responds to perceived increased physiological demand eg bicycling) position 5= multi-site pacing

Answer 454

heart's intrinsic conduction system & artificial pacemaker are firing independently of what the other is doing; the paced beat only generates a contraction if it occurs outside of the absolute refractory period. only used as a temporary mode during surgery (only use on pacing-dependent pt. risk of R on T (pacing spike occurring on a T wave))

Answer 455

has both ventricular sensing & pacing; if it senses ventricular conduction it will inhibit pacing, which avoids the risk of R on T. if a prolonged period has passed without ventricular activity, it will pace. no synchrony between the atria & ventricles, so risk having an atrial contraction during a paced ventricular beat ("pacemaker syndrome"), inadequate cardiac output, not useful for pts in sinus rhythm, more useful for a pt with AV block & chronic AF.

Answer 456

theoretically a single lead in RA (but this is VERY RARE, since most pts with sinus node disease have some degree of AV block- it'd be more common to have dual chamber pacing wires & set it to AAI mode with the potential to have some ventricular pacing were AV block to occur), rather than sensing & pacing QRS complexes it senses & paces P waves. used for pts with isolated sinus node disease without AV block. even if it paces during the T wave doesn't risk v fib as it's pacing the A not V.

Answer 457

AV block without sinus node dysfunction- this mode will pace the ventricle but senses both A & V, response can be inhibit or trigger. eg. if senses a p wave but there's AV block, it'll trigger a ventricular depolarisation (appears as wide, abnormal QRS). if senses ventricular premature contraction it will inhibit ventricular pacing.

Answer 458

pt with AV block & sinus node dysfunction, in sinus rhythm. this is also the mode used for pacing in bradycardia arrest after cardiac surgery Can be: presence of a & v activity are both sensed so pacing inhibited to both a activity is sensed hence activity inhibited & lack of v activity sensed hence it's ventricular triggered (paced) lack of a activity sensed hence it's is paced & v activity is sensed hence inhibited neither a or v activity sensed hence both triggered

Answer 459

lowest rate at which the device will allow the heart to beat

Answer 460

fastest rate at which the device will track the heart- it'll track with the atrial rate up until the max limit set (typically 120-130bpm, may be higher in young/middle aged)

Answer 461

fastest rate at which the device will track the heart- it'll track with the atrial rate up until the max limit set (typically 120-130bpm, may be higher in young/middle aged)

Answer 462

used in VDD or DDD modes- it's the maximum time that it'll allow for delay between either sensing or paced atrial depolarisation before it'll trigger ventricular activity (if intrinsic activity isn't sensed beforehand), usually 150-200ms but this can be modulated ie. if a paced atrial activity the AV delay will be longer, or the it can be rate adaptive with the AV delay shorter during perceived exertion, as in the case of a natural pacemaker

Answer 463

a safety feature- minimum time after ventricular depolarisation paced or sensed, during which the pacemaker will ignore sensed atrial depolarisation- this prevents the pacemaker tracking excessive atrial impulses (eg. retrograde impulses) & causing dangerously high ventricular rates; typically 250-300ms & can be rate adaptive

Answer 464

posterolateral thoracotomy (traverses 6 dermatomal levels, starting at T3 posteriorly & going to approx T8 anteriorly) provides good access to lung, oesophagus, mediastinal structures, descending aorta, diaphragm anterolateral & axillary thoracotomies are used for specific lung resections (typically 5th ICS= lung resection), thoraco-abdominal for oesophageal (often @ 7th ICS for oesophageal), aortic or upper abdo, clamshell for bilateral (eg. lung transplant) chest drains are usually inserted around T8-9 ICS post thoracotomy. require coverage of the impulses from: -skin & intercostal muscles -parietal pleura (highly sensitive, from intercostal & phrenic nerves); visceral pleura insensate -lung & mediastinum (carried via vagus nerve) -also the lat dorsi (thoracodorsal, C6-8) & serratus anterior (long thoracic, C5-7)

Answer 465

mid-point of dermatomal distribution

Answer 466

mid-point of dermatomal distribution

Answer 467

mid-point of dermatomal distribution

Answer 468

30 mins/ 60 mins / 90 mins

Answer 469

heart 4hrs / lungs 6-8hrs /liver or pancreas 6hrs DCD or 12 hrs DBD / kidneys 12hrs DCD or 18hrs DBD

Answer 470

CONTROL SEIZURES with a BZD (midazolam 2-5mg (0.05-0.1mg/kg) or diazepam 2-5mg) or this (1mg/kg) or careful boluses of propofol (NOT if CV instability) then intralipid (20% lipid emulsion), 1.5mL/kg over 1 min (this is 100mL in a 70kg adult), then an infusion of 15mL/kg/hr (1000mL/hr in adults) if refractory, can do a max 2 further boluses, 5 mins apart, or can double the rate (30mL/kg/hr) after 3 mins BUT the max cumulative dose is 12mL/kg (ie. for a 70kg, don't give > 840mL)

Answer 471

recovery from LA-induced cardiac arrest may take >1hr lidocaine should not be used as anti-arrhythmic therapy

Answer 472

pancreatitis; daily lipase & amylase

Answer 473

Aust/NZ tripatriate Anaesthetic Data Committee, representing 3 organisations (ANZCA, ASA, NZ Society of Anaes), developed the WebAirs online reporting database for adverse anaesthetic incidents, can link into hospital system assisting Anaesthetists to report, evaluate & receive info re: adverse incidents- the info can be fed back to the system for closing the QI loop.

Answer 474

significant cardiovascular depression with propofol

Answer 475

lean body weight

Answer 476

brief, artefactual reduction (typically to low 90s)

Answer 477

660 & 940nm 805nm (indocyanine green increases the absorption of light, interpreted as increased oxyHb & falsely elevating NIRS readings)

Answer 478

pathologic effects of the herniated viscera on lung development- with lung compression there are decreases in bronchial & pulmonary artery branching & pulmonary hypoplasia ensues, then there's muscular hyperplasia of the pulmonary arterial tree & risk of pulmonary HTN. postnatally the infant often presents with resp distress

Answer 479

adrenal insufficiency

Answer 480

lung-protective ventilation, they avoid further injury to damaged lung tissue & decrease mortality limit peak Pinsp to 25cmH2O, keep PEEP 3-5cmH2O & allow permissive hypercapnia

Answer 481

reserved as a rescue when hypoxia & severe hypercapnia persist despite maximal conventional ventilation; as the initial mode of ventilation in CDH, HFOV has no difference in mortality but conventional ventilation has shorter time of ventilation, lower NO requirements, sildafenil & ECMO & less inotropic requirement.

Answer 482

because the main risk/prognostic factor is the degree of pulmonary hypoplasia so emergency surgery confers little benefit there's much debate & little consensus re: optimal timing of surgery, prior to surgery the pt should have: -normal MAP for gestation -pre-ductal SpO2 consistently 85-95% on FiO2 <0.5 -lactate <3mmol/L -UO >1mL/kg/hr

Answer 483

abdo phase: upper midline (T6-10) laparotomy or rooftop abdo incision (T8-9 bilaterally) Tx phase: R) posterolateral thoracotomy at the 4th-5th ICS

Answer 484

1 - neonate/infant up to 5kg - 4mL 1.5 - 5-10kg - 7mL 2 - 10-20kg - 10mL 2.5 - 20-30kg - 14mL 3 - 30-50kg - 20mL- max tube size 6 4 - 50-70kg - 30mL 5 - 70-100kg - 40mL 6 - adults >100kg - 50mL

Answer 485

1 - 3.5 1.5 - 4 2 - 5 2.5 - 5.5 3- 6.5 4- 7.5 5 & 6 - 8

Answer 486

trans-glottic ventilation all infra-glottic ventilation options have the advantages of: -minimising glottic movement -ensuring debris is blown away from vs into the tracheobronchial tree with exp flow -minimal entrainment of air (allows consistently delivered FiO2) -can measure airway pressures & EtCO2 -hunsacker mon-jet has a basket to help secure it's position within trachea during jet ventilation & limit risk of mucosal trauma however risk of shearing a laryngeal lesion on insertion which may seed tumour or virus (use of videolaryngoscope may limit this risk) -laserket is also a double-lumen, laser-resistant tube for trans-glottic ventilation (and EtCO2 can be measured), has a rounded tip & no basket so may be less traumatic with insertion/removal but not stabilised in trachea.

Answer 487

trans-glottic ventilation all infra-glottic ventilation options have the advantages of: -minimising glottic movement -ensuring debris is blown away from vs into the tracheobronchial tree with exp flow -minimal entrainment of air (allows consistently delivered FiO2) -can measure airway pressures & EtCO2 -hunsacker mon-jet has a basket to help secure it's position within trachea during jet ventilation & limit risk of mucosal trauma however risk of shearing a laryngeal lesion on insertion which may seed tumour or virus (use of videolaryngoscope may limit this risk) -laserjet is also a double-lumen, laser-resistant tube for trans-glottic ventilation (and EtCO2 can be measured), has a rounded tip & no basket so may be easier to traverse the glottis but potentially more traumatic in the trachea. -laserjet is smaller (3.4 vs 4.3mm ED) but either could interfere w access to posterior glottic lesion

Answer 488

<100microg/L

Answer 489

info re: the overall contractility of the heart or regional abnormalities (since it images all 3 territories), volume status (eg. collapsibility of the ventricle), may see evidence of large pericardial effusion or intracardiac mass, deviation of the inter ventricular septum. place L) of sternum, 3-4th ICS, marker to R) hip & US marker will be to L) of screen

Answer 490

apical subcostal parasternal

Answer 491

comparing ventricle sizes- evidence of RHF or RV dilation (eg. if PE)

Answer 492

medial & lateral plantar, calcanea

Answer 493

sural, lateral plantar & superficial peroneal

Answer 494

the ulnar nerve does all intrinsic hand movements EXCEPT: thumb ABduction (APB), thumb flexion (flexor pollicis brevis), thumb opposition (opponens pollicis), lateral 2 lumbricals; these are innervated by C8-T1 via the median nerve

Answer 495

infraspinatus & teres minor internal is subscapularis abduction initiated by supraspinatus

Answer 496

suprascapular nerve, C5-6

Answer 497

axillary nerve, C5-6

Answer 498

supra scapular nerve, C5-6

Answer 499

eyebrow movements, eg. frown close eyelids

Answer 500

central with high perfusion, small fibre size (larynx moree so), despite the fact that these muscles have high proportion of type II fibres & relatively high density of nAChR, conferring some resistance to NDMBs. adductor policis has predominantly type 1 slow twitch hence lower density nAChR, is more sensitive to NDNMBDs. The APM is more sensitive to nondepolarizing NMBAs, so recovery is delayed in comparison to central muscles (diaphragm, laryngeal muscles. offset sequence: diaphragm > larynx > corrugated supercilii (correlates well w larynx) > abdo mm > orbiculares oculists > geniohyoid (upper airway, very sensitive to NDNMBs) > AP (very sensitive)

Answer 501

synchronised DC shock, up to 3 attempts; 70-120J biphasic is the most common initial energy (except for AF, where 120-150J biphasic is recommended)

Answer 502

initial energy 70-120J biphasic (up to 3 attempts) do under sedation or GA if AF, 120-150J biphasic give amiodarone 300mg IV over 10-20mins (dose reduction may be reasonable if also on digoxin), then 900mg over 24hrs (*or if the rhythm was torsades, give Mg++ 2g over 10 mins)

Answer 503

with continuous ecg monitoring: vagal maneouvers (valsalva +/- leg lift or knees to chest, carotid sinus massage, diving reflex (cold ice on face)) adenosine 6mg rapid IV bolus; repeat 12 up to 2x more once sinus rhythm restored, consider it's probably re-entry PSVT, 12-lead ecg to be recorded, if recurs, repeat adenosine Rx, consider anti-arrhythmic prophylaxis if sinus not restored, seek expert help

Answer 504

most likely AF IV B blocker or digoxin or if <48hrs onset, cardiovert with amiodarone 300mg IV over 20-60mins then 900mg over 24hrs (dose reduce if on digoxin)

Answer 505

VT or SVT with BBB, former is Rx with amiodarone, latter with adenosine

Answer 506

AF with BBB (if so, Rx as for narrow complex) pre-excited AF (consider amiodarone) polymorphic VT (eg. torsades, Mg++ 2g over 10 mins) would seek expert help for this

Answer 507

Reduced MI (which overwhelmingly contributed to a sig reduction in their composite outcome of CV death/nonfatal MI/non-fatal cardiac arrest), new clinically significant AF & cardiac revascularisation BUT increased: total mortality nonfatal stroke clinically important hypotension (showing a significant link with death & stroke) & bradycardia

Answer 508

education to pt & staff re: the sterile field, thorough handwashing with surgical scrub solution, barrier precautions (cap/mask/gown/gloves/drape & eye protection, sterile drape), chlorhexidine in alcohol (0.5% chlorhexidine in alcohol, given that there's no evidence of superiority of 2% vs 0.5% for antimicrobial superiority & clear evidence of the neurotoxicity of chlorhexidine. For chn <2yo, volume should be absolute minimum necessary while still ensuring antisepsis) applied moving in to out. Prior to skin asepsis which is allowed to dry completely before skin palpated or punctured. Meticulous measures must be in place to ensure the chlorhexidine does not reach CSF (eg. use of swabsticks, dyed solution, equipment covered or protected while the antiseptic is applied).

Answer 509

2% chlorhex in ETOH

Answer 510

ETOH at least 6hrs, chlorhexidine more effective @ 24hrs.

Answer 511

ETOH at least 6hrs, chlorhexidine more effective @ 24hrs.

Answer 512

10% povidone iodine

Answer 513

non-specific plasma esterase's

Answer 514

4-12mmHg PAP 20-30/8-15mmHg *PCWP>15mmHg ass'd w LV dysfunction

Answer 515

PE, since PCWP normal it's not related to L) heart & acute more likely PE vs empysema

Answer 516

no but it must be immediately available & may be used if clinically indicated PS18: -breathing system MUST have O2 analyser -GA/sedation MUST have pulse ox -whenever auto ventilator, disconnection/vent failure alarm MUST be on & continuous & auto activated, -CO2 monitor foall GA, avail for sedation -ECG must be avail for all anaes; use if GA/major RA as indicated -NIBP avail for all pts; when used, @ least 10 minutely. IABP avail -BIS when clinically indicated -for all pts undergoing GA or if using inhalational; must have inhaled anaes agent monitor -temp monitor avail for all pts having GA, use it if using warmer -quant NMT avail for all pts w NMB, use whenever extubating pts after NDNMBAs -other equip (eg. oximetry) avail as indicated

Answer 517

measures the final step in coagulation, conversion of fibrinogen to fibrin. usually 14-19secs. prolonged if fibrinogen levels are low or if an agent inhibiting thrombin is present (eg. dabigatran, heparin/LMWH/bivalirudin) warfarin & direct Xa inhibitors don't influence thrombin time.

Answer 518

lab test measuring the extrinsic & common coagulation pathways. used to monitor LT use of anticoagulant through INR, evaluate liver function & evaluate coagulation disorders; may be prolonged by vit K antagonists, direct Xa inhibitors, vit K insufficiency, liver disease (esp obstructive jaundice), DIC normal range 11-13 seconds. INR = (PTtest/PTnormal)^ISI

Answer 519

lab test of intrinsic & common pathways best test for coagulation disorder, if performed properly it's abnormal in 90% of pts with a coagulation disorder used to monitor heparin, screen for haemophilia A (def VIII), B (lack of IX) & to screen for clotting inhibitors. Also prol in liver disease, deficiency of any coagulation factor other than VII, massive transfusion with plasma-depleted red cells, DIC. N range 25-38 secs

Answer 520

lesion must restrict trachea to <1cm

Answer 521

seizure cortical vein thrombus subdural haematoma stroke NOT encephalitis

Answer 522

medial & lateral superior & inferior

Answer 523

used to diagnose myocardial infarction in pts with L) BBB or ventricular paced rhythms in such pts, its common to see "appropriate discordance" where abnormal ventricular depolarisation is followed by abnormal depolarisation (eg. ST depression/TWI with +ve complexes, STE & T waves normal hight in -ve complexes) the 3 criteria to raises suspicion of infarction in pts with L) BBB: 1. concordant STE >1mm in leads with +ve QRS (score 5) 2. concordant ST depression >1mm in V1-3 (score 3) 3. excessively discordant STE >5mm in leads with a -ve QRS (score 2) a total score >= 3 has high specificity for diagnosing MI

Answer 524

rapid development proptosis reduced visual acuity deficiency in extra ocular movements tense eye or other signs of raised IOP

Answer 525

if electrical/inhalational burn, dehydrated or trauma

Answer 526

proteins in the white, not the yolk (propofol has egg lecithin, from the yolk)

Answer 527

adults- yes, but be prepared for anaphylaxis children, prob not (but would give if mild egg allergy)

Answer 528

dabigatran

Answer 529

opioids don't really, ketamine may increase SSEPs (but neither ketamine nor opioids impact MEPs)

Answer 530

evidence is conflicting, MEPs may be lost @ higher doses, impact on SSEPs is minimal

Answer 531

QT / square root of the cardiac cycle in secs. therefore, if the HR is 60, R-R interval is 5 squares so the QTc is the same as QT (RR = 60/HR)

Answer 532

junctional rhythm (atrial contraction occurs @ same time as ventricular so there's a fusion of a & c waves; atria contracting against closed TCV so cannon a wave) VT ventricular pacing *any conditions where there may be retrograde conduction of ventricular action potentials complete heart block these situations create a mechanical disadvantage for the cardiac output- expect a SBP drop- as the ventricle robbed of preload

Answer 533

fused C & V waves; backflow of blood obliterates the X descent

Answer 534

tricuspid stenosis (the Y wave is slow & lazy due to attenuated ventricular filling) also seen w pericardial disease (eg. tamponade)- anything restricting myocardial compliance & restricting filling of the chambers RV failure, pulmonary stenosis or pulm HTN may also cause this (anything that causes a loss of compliance beyond the TCV) canon a waves in junctional rhythm, V-tach, 3rd degree block from RA contraction against closed TCV in pericardial constriction the CVP would be raised & there'd be abrupt X & Y descent, while in cardiac tamponade the Y descent is prolonged

Answer 535

-surgical stress response -use of volatile anaesthetic -opioids for analgesia

Answer 536

no sig difference in cancer recurrence (median follow-up 36 months) no sig difference in incisional pain at 6 months no difference in incisional pain @ 12 months neuropathic breast pain didn't differ with regional at 6 or 12 months

Answer 537

graphically the studies included in a meta-analysis (statistical combo of numerical results from individual studies), demonstrate differences btwn studies & provide an estimate of overall result central vertical line= line of equity. indicates no difference btwn intervention/control (risk ratio 1). To the L) indicates benefit, to the R) indicates no benefit (some the other way around) horizontal scale @ bottom n/N= number of events / total number of pts %, weight of each trial in additional column to the R) each study a blob, size proportional to study's weight. CI extends horizontal from blob, if crosses line of equity, no difference. diamond pooled analysis of all studies.

Answer 538

auriculo-temporal from V3 (of trigeminal nerve)= tragus, anterior lobe & skin anterior to ear (to temporal area) auricular nerve of vagus= inside ear greater auricular= C2-3 = most of the helix, all of the ante helix, antetragus & earlobe lesser occipital= C2-3 = tiny bit of upper/posterior helix, area posterior to ear

Answer 539

emergency situation, requires rapid management stop trigger (a stimulus below the level of the lesion, eg. bladder or bowel distension or constipation/pressure sores)-eg. relieve distension of hollow viscus deepen anaesthesia head up- taking advantage of orthostatic BP drop administer 100% O2 rapid-onset, short-acting vasodilators (eg. GTN infusion 5mcg/min)- caution with longer-acting as risk hypoT when AD resolves. hypotensive effects of nitrates may be exaggerated in pts on sildefanil for erectile dysfunction. treat arrhythmias with B-blockers, anticholinergics treat myocardial ischaemia (eg. with GTN infusion) invasive monitoring if doesn't resolve quickly the disordered SNS response can --> severe HTN, raised ICP & risk of seizures & ICH cardiac complications= ischaemia, arrhythmias, pulm oedema incr BP at least 20% Brady- or tachycardia or heart block; may gen myocardial ischaemia/infarction/acute heart failure headache, nasal congestion flushing, sweating above the lesion (VD) pallor/blanching/vasoconstriction below the lesion chills piloerection may get ICH & seizures risk of ADR is higher with higher level sessions (above T6) incr frequency with more complete lesions generally observed 1yr after injury but can occur within wks of injury *due to risk of ADR, pts with high SCI may require deep GA or RA, even if they don't have sensory function @ the surgical site *ALWAYS ask pts with SCI Hx re: AD episodes- inciting events, regimens, prev surg & anaes Hx

Answer 540

9 Overall health status (eg. number of hospitalisations in past year) social support functional dependence continence functional performance (TUG) cognition mood nutritional status (weight loss) medication use 17

Answer 541

CO2 (liquid & electrical fires)

Answer 542

alert room & stop surgery, simultaneously briefly attempt to douse it (usually only effective in the first few seconds of the fire) then execute plan, incl appropriate fire extinguisher, cease oxidising gases/fuel removal which can be instantly done, plan for evacuation, activate fire alarm (which activates visual & audible alarms, closes fire doors, notifies local fire dept)

Answer 543

dry powder (but only up to 1000V for electrical)

Answer 544

backup battery & generator (ie. they are UPS-the battery should be constantly engaged & be in immediate action, seeing supply through until the generator powers on which can take mins to half an hour)

Answer 545

they activate an alarm indicating loss of ground power

Answer 546

number of pts that need to be treated to achieve @ least 50% pain relief in 1 pt cf placebo over 4-6hrs Etiologies may be peripheral or central Characterised by burning, p&n, tingling, numbness, electric shocks/shooting, crawling, itching, temp intolerance. allodynia or hyperalgesia. DN4 questionnaire 7 pain discriminators & 3 exam findings; score of 4+ indicates neuropathic pain likely. S&S 83 & 90%. Multi-D nonpharmacologic care & nonopioids (TCAs, SNRIs, gabapentanoids, topicals, transdermals)= first line. Trial 3-8 wks, change if no effect or side effects. first line + tramadol (1st line acute neuropathic) & tapentadol= 2nd line serotonin-specific reuptake inhibitors/anticonvulsants/NMDA antagonists & interventional therapies 3rd line neurostimulation 4th line low-dose opioids (no >90mg morphine equivalent units)= 5th line TCAs NNT 3.6 for moderate pain relief, NNH 28 (9 for minor adverse effects). Risk falls, arrhythmias, orthostasis, urinary retention in elderly. duloxetine/venlafaxine (SNRIs): NNT 6.4, NNH 11.8 gabapentin better evidence post-herpetic neuralgia & diabetic peripheral neuropathy, weak evidence other neuropathic pain conditions. NNT 6.3, NNH 25.6 pregabalin NNT 7.7, NNH 13.9 tramadol- NNT 4.4 (other ref combined NNT of 4.7) Gabapentin (specifically postherpetic neuralgia)- NNT 5.9 membrane stabilisers eg. systemic lidocaine reasonable for acute neuropathic pain (based on evidence for use chrnoic neuropathic) tramadol effective for neuropathicpaketamine useful for neuropathic pain after SCI reasonable to use alpha-2 delta ligands in Mx of acute neuropathic pain; they have evidence for efficacy w chronic neuropathic pain. bain

Answer 547

more blood fills the R) heart, delays systolic ejection, greater time until the pressure above the valve > the pressure in ventricle below.

Answer 548

more blood fills the R) heart, delays systolic ejection, greater time until the pressure above the valve > the pressure in ventricle below.

Answer 549

ischaemic symptoms suggestive of ACS but no elevation of troponin, with or without ECG changes of ischaemia (NSTEMI is the same but with trop rise)

Answer 550

unreasonable behaviour directed towards an individual or group that creates a risk to health & safety it's repeated & occurs as part of a pattern of behaviour

Answer 551

unwanted behaviour that offends, humiliates or intimidates a person & targets them on the basis of a characteristic set out in anti-discrimination law (eg. gender)

Answer 552

treating a person with an attribute set out in legislation less fairly than a person who does not have that attribute.

Answer 553

warm, non-glucose-containing, isotonic crystalloid to maintain euvolaemia

Answer 554

colloids may increase ICP in pts with altered BBBs as per the SAFE study (saline vs Alb fluid evaluation)- incr mortality among pts with TBI who got albumin, particularly among pts with severe TBI. Among TBI pts who received ICP monitoring, resus w alb ass'd w incr ICP.

Answer 555

1:19,000 1:8000 NMBD 1:136,000 without NMBDs

Answer 556

L) LL collapse- it's a triangular opacity @ the posteromedial aspect of L) lung (retrocardiac sail sign) edge of the collapsed lung may create a double cardiac contour L) hemidiaphragm & desc aorta may be obscured but can clearly see L) heart border

Answer 557

AP: obscures R) heart border lateral: triangular opacity in anterior aspect of chest overlying cardiac shadow, apex @ R) hilum

Answer 558

AP: obscures R) heart border lateral: triangular opacity in anterior aspect of chest overlying cardiac shadow, apex @ R) hilum

Answer 559

in normal subjects, serum GH suppressed to <=1ng/mL within 2hrs of glucose load. the post-glucose values in acromegaly are generally >2ng/mL.

Answer 560

premature closure cranial sutures--> limited growth skull (*raised ICP) mid-face hypoplasia, choanal atresia, cleft palate, OSA (difficult BMV) increased secretions low-Cx fusion (reduced neck ROM) may have fused tracheal rings (reduced ETT size) beaked nose/small nasal passages cardiac defects PCKD syndactyly (webbed/conjoined fingers/toes)

Answer 561

teicoplanin (16 per 100,000) patent blue (14.6 per 100,000) sux is 11 per 100,000 (*NDNMBDs have similar incidences of anaphylaxis so concern for anaphylaxis shouldn't be a major reason for choice) co-amoxiclav 8.8 roc 6 per 100,000 vanc 6 atrac 3 (miv also 3) chlorhex 0.78 per 100,000

Answer 562

SBP >=100mmHg for pts 50-69yo, >=110 for everyone else CPP should be 60-70mmHg

Answer 563

<22mmHg (22mmHg= threshold for Rx)

Answer 564

suitability for discharge from stage 1 recovery 5 domains (ROCCA: respiration, O2 sats, circulation, consciousness, activity): activity level respiration circulation (BP) consciousness O2 saturation by pulse oximetry need score >9 further modified incl 5 additional elements useful during phase II prior to discharge home (FUPAD): dressing pain ambulation feeding UO Minimum PACU: sedation 15min, GA 30min, LA could go immediately to stage 2

Answer 565

middle-aged women worsened by immobilisation, blood loss, sleep deprivation, pregnancy, Fe deficiency, renal failure, withdrawal of their dopaminergic medications such as pramipexole (it's dopa-responsive), neuroleptics (eg. droperidol, haloperidol, prochlorperazine, metoclopramide) & antihistamines (cyclizine, phenothiazines) & atypical antipsychotics (cloz, olanz, risp), antidepressants (TCAs, SSRIs) & tramadol, naloxone, naltrexone For PONV in RLS, ondans periop, schedule RLS pts am OT lists, encourage usual RLS meds, consider premed w BZD & opioids. ketamine & ondansetron are fine. may still get involunt LL movements after spinal or epidural but opioids added help. GCS & calf compressors. mobilise early, adequate opioids. If sig blood loss, Fe supplements.

Answer 566

if not significantly impacting QoL, non-pharm (sleep hygiene, exercise, massage) If sig QoL impact, gabapentin/pregabalin initial Rx. effective, low risk augmentation (aka symptom worsening). Non-ergoline dopamine agonists pramipexole or rotigotine given @ lowest possible dose (lower risk augmentation) are first line meds; lower incidence of augmentation than ergoline agonists (cabergoline, levodopa) which aren't used due to risk of valve, retroperitoneal pericardial & pleuropulmonary fibrosis Fe supplementation (target >300microg/L in adults), opioid

Answer 567

apomorphine (subcut, can give hourly) or rotigotine patch (can give every 24hrs) should give with anti-emetic (eg. ondansetron)

Answer 568

BZD or opioid (or pregabalin), mobilise asap if safe RLS disorder of dopamine; some inherited AD

Answer 569

urine osmolality <100

Answer 570

labetalol, methyldopa

Answer 571

hydralazine, nifedipine, prazosin

Answer 572

ACE-Is & ARBs- ass'd w foetal death & neonatal renal failure

Answer 573

suction failure

Answer 574

vit K deficiency (malabsorption)--> deficiency of vit K dependent coag factors II, VII, IX, X

Answer 575

mechanical heart valve moderate-severe mitral stenosis

Answer 576

rivaroxaban dabigatran

Answer 577

@ least 3/52 before cardioversion, 4/52 after

Answer 578

>=2 for men >=3 for women Can use HAS-BLED scoring (9 factor)s: HTN renal disease liver disease age >65 ETOH >=8x/week prev stroke prev major bleed/bleeding predisposition uses other meds incr bleeding risk (NSAIDs, aspirin) labile INR >=3 is high risk >5% risk mjor bleeding

Answer 579

Presence of AWAKE alveolar hypoventilation in an obese individual which can't be attributed to other conditions associated with alveolar hypoventilation. ie. pt presents with: -obesity (BMI >30kg/m2) -awake alveolar hypoventilation (PaCO2 >45mmHg) -other causes of hypercapnia & hypoventilation have been excluded

Answer 580

obesity (BMI >30kg/m2), particularly severe obesity (BMI >50kg/m2) where prevalence may be as high as 50%. central obesity reduced lung function due to obesity reduced insp m strength severe OSA (AHI >30/hr) Male gender (unlike OSA) is NOT a risk factor for OHS most present in 50s-60s

Answer 581

obese, hyper somnolent most have severe hypoxaemic hypercapnic respiratory failure R) heart failure from pulmonary HTN is common may have facial plethora from polycthaemia may have the Sx of OSA (STOPBANG)- in 90% of pts with OHS -all have PaCO2 >45mmHg when awake on RA -may have elevated bicarb (>27)- nonspecific (eg. dehydration, meds) & not 100% sensitive since other conditions (lactic acidosis, chronic hyperventilation) may lower the bicarb. A raised serum bicarb (>27) or base excess (>3mmol/L) in absence of another cause for metabolic alkalosis in an obese pt w PaCO2 <45mmHg may be an early indicator of OHS, should Ix. -hypoxaemia (PaO2 <70mmHg) with normal A-a gradient (may be sl widened due to V/Q mismatch or parenchymal/vascular lung disease), severe nocturnal desaturation is common -polycythaemia -may have restrictive PFTs but these are nonspecific (may be useful for ruling out underlying causes of hypoventilation) -ecg may show evidence of RVH from pulm HTN -get an echo if evidence pulm HTN CXR may show elevation of hemidiaphragms & heart enlargement (RVH or pericardial fat) but not gen nec preop

Answer 582

validated scoring system specific to obese pts undergoing bariatric surgery BMI >=50kg/m2 male systemic HTN risk factors for PE age >45 low risk (0-1) intermediate 2-3 high 4-5

Answer 583

monitoring equip drugs analgesia other

Answer 584

T5 transverse process in the plane under erector spinae

Answer 585

structures of porta hepatis: hepato-duodenal ligament with the 3 structures that run within it: HA, PV, CBD PV, R&L HA & R&L HDs NOT the hepatic vein

Answer 586

cerebral injury (cerebral oedema)- still uncommon but has a 25% of mortality rate, is more common among chn than adults with DKA, chn with severe acidosis +/- severe dehydration, higher BUN (represents hypovolaemia), lower PaCO2, younger age & new onset are @ greatest risk **50-80% of diabetes-related deaths in children are caused by cerebral injury

Answer 587

fatigue cold intolerance dysphagia resp dysfunction pain muscle weakness

Answer 588

50% of the dose of NDMRs poliovirus thought to damage the reticular activating system. the initial virus attacks anterior horn cells- surviving neurone sprout collaterals to reinnervate motor units but these are larger & fewer (ageing may --> overuse or decrease in the # of polio-affected motor neurone during ageing) very sensitive to anaesthetic medications (sedative/hypnotics, NMBDs, opioids) avoid sux (risk hyperkalaemia, prolonged doa, severe myalgia) 1/2 induction dose of NDNMBDs & preference short-acting agents, monitor quantitative TOFR potential delayed awakening consider bulbar dysfunction (laryngeal weakness or VC paralysis- FNE useful), sleep apnoea, restrictive ventilatory defect--> consider preop FNE, postop HDU no risk worsening post polio syndrome symptoms with neuraxial (retrospective data) however it's unknown if these pts more vulnerable to LA & if dose adjustment needed careful considering of positioning (chronic pain risk) care w analgesia- pts may have chronic pain but may be opioid sensitive (eg. risk OIVI if virus impacts RAS, if bulbar dysfunction) cold intolerance- premwarm pt & OT, monitor temp, warm IVT, postop warming plan for pre-ads, tertiary centre, post-op HDU or at least overnight monitoring

Answer 589

0.25mg/kg, give 2x ED95 & get max blockade @ 2.5mins, DOA 40mins atrac onset & duration of effect are predictable (hoffman elim spont deg @ physiological pH & temp), useful in critically ill pt (but hypothermia & cidosis slow metabolism of atracurium)

Answer 590

0.05mg/kg, more potent than actrac, need to give 4x ed95 (0.2mg/kg) for induction to get onset 2mins

Answer 591

half usual, so 0.25mg/kg induction

Answer 592

somatotropin (GH-secreting) adenoma from ant pituitary- these also account for about 1/3 of hormone-secreting pituitary adenomas

Answer 593

Primary GH excess: somatotroph-secreting pituitary adenoma GH-cell carcinoma familial syndromes (eg. MEN1 which is ass'd with GH-cell adenoma) ectopic or iatrogenic GH excess: pancreatic islet cell tumor lymphoma iatrogenic GHRH excess: central (eg. hypothalamic hamartoma) peripheral (eg. pancreatic islet cell tumor, bronchial carcinoid, SCLC, adrenal adenoma, medullary thyroid carcinoma, pheochromocytoma)

Answer 594

MEN1: pituitary adenoma, parathyroid hyperplasia, pancreatic tumors MEN2A: parathyroid hyperplasia, medullary thyroid carcinoma, pheochromocytoma MEN2B: mucosal neuromas, marfanoid body habits, medullary thyroid Ca, pheochromocytoma

Answer 595

packed red cells suspended in normal saline with haematocrit approx 60%

Answer 596

eye opening conjugate gaze facial grimace spontaneous tidal volume >5mL/kg purposeful movement greater success the more factors present but minimal yield going from 2-3 vs a higher # of predictors (waiting for 5 predictors a good strategy for high-risk pts)

Answer 597

no, surprisingly!

Answer 598

extubation in a plane where the pts pharyngeal reflexes have been ablated (ie. surgical anaesthesia- stage III 2

Answer 599

URI premed w midaz in all kids, ETCo2 >55 also ass'd w post-extubation intervention

Answer 600

comatose pts (not following commands) who've achieved ROSC following OOHCA & initial shockable rhythm (strong rec, low q evidence), for @ least 24hrs also SUGGESTED (wk rec, very low quality evidence)for non-shockable rhythms & in-hospital cardiac arrest, pregnant or haemodynamically unstable pts, pts undergoing coronary catheterisation or thrombolysis; only absolute CI is an AHD preventing aggressive care

Answer 601

pain out of proportion (early & common finding)- pain is the most important finding pain with passive stretch of muscles of affected compartment (early finding) persistent deep ache or burning tense compartment with "wood-like" feeling paraesthesias (within 30-120mins of ACS, suggests ischaemic nerve dysfunction) muscle weakness (2-4hrs) paralysis (later finding) pallor uncommon

Answer 602

thigh: anterior= quads, sartorius with the femoral & saphenous posterior= hamstrings with sciatic medial= adductors & gracilis w obturator ant leg= tib ant/EHL/EDL/fibularis tertius with DPN lat leg= fib long & brev with SPN deep posterior leg= popliteus, FHL, FDL, tib post with tibial nerve superficial post= gastrocs, soleus, plantaris (just mm) anterior arm: bb/br/cb with ulnar & median nn post arm: triceps & radial n deep & superficial volar forearm (superficial FCR, PL, FCU, PT, FDS) with deep (FDP, FPL, PQ) median & ulnar nerve dorsal forearm= BR, ECRL, ECRB, ECU, ED, EDM, APL, EPB, EPL, supinator & radial n

Answer 603

thigh: anterior= quads, sartorius with the femoral & saphenous posterior= hamstrings with sciatic medial= adductors & gracilis w obturator ant leg= tib ant/EHL/EDL/PT with DPN lat leg= fib long & brev with SPN deep posterior leg= popliteus, FHL, FDL, tib post with tibial nerve superficial post= gastrocs, solens, plantaris (just mm) anterior arm: bb/br/cb with ulnar & median nn post arm: triceps & radial n deep & superficial volar forearm (superficial FCR, PL, FCU, PT, FDS) with deep (FDP, FPL, PQ) median & ulnar nerve dorsal forearm= BR, ECRL, ECRB, ECU, ED, EDM, APL, EPB, EPL, supinator & radial n

Answer 604

deep posterior compartment

Answer 605

prolonged PT

Answer 606

R) lat decubitus (R)-side down, better for smaller volumes)

Answer 607

<120g/L <130g/L

Answer 608

could consider Fe therapy if the estimated Hb drop with surgery is >=30g/L important to determine the cause & need for GI Ix if ferritin suggests Fe deficiency (<30microg/L)

Answer 609

Fe therapy Ix cause (d/w gastroenterologist GI Ix & their timing in relation to surgery)

Answer 610

look @ CRP. If it's raised, commence Fe consider the clinical context- eg. haematology advice, renal advice if CKD, consider Ix in liaison with gastroenterologist (*some Dx Fe deficiency if ferritin 30-100, Tsat<20% & CRP>5) If CRP normal (or if the pt is anaemic with ferritin >100microg/L), it may be anaemia of chronic disease, inflammation or other cause of anaemia: consider clinical context, renal function, MCV/MCH & blood film, B12/folate, retics, liver & thyroid function, haematology advice or renal (if CKD)

Answer 611

2-3% particularly first-get cephalosporins, negligible with 2nd Cephalosporins most likely to cross-react w penicillins incl: -cephalexin (1st gen, high risk) -cefalcor (2nd gen) (both cefalexin & cefaclor have similar side chains to amoxicillin or ampicillin have similar side chains to amox/amp) -ceftriaxone (3rd gen) (Ceftriaxone has similar side chains to cefotaxime, cefepime, cefuroxime) safer (lack B lactam chain): cefazolin (1st gen), cefuroxime (2nd gen, but sim side chains to ceftriaxone), cefixime*(cefixime 3rd gen, least likely) ceftazadime is a 3rd gen with same side chain as azotrenan & similar to cefuroxime <1% Cefazolin has NO common side-chains w other beta lactams so often can be tolerated if peniciallin allergy or cephalosporin NO cross-reactivity with aztreonam (monobactam)

Answer 612

R) has horizontal & oblique L) just oblique

Answer 613

1:193,000 (for all GA sans NMB, 1:136,000)

Answer 614

1:193,000 (for all GA sans NMB, 1:136,000)

Answer 615

yes- highly selective for MAO-A, may be ass'd w severe serotonin toxicity

Answer 616

5mg/kg >7mg/kg- may cause haemolysis even if don't have G6PD, may get potentially fatal serotonin tox >5mg/kg

Answer 617

ferric Fe (3+), which has stronger affinity for O2, L) shift of OHDC & decreases O2 delivery to tissues- functional anaemia

Answer 618

ferric Fe (3+), which has stronger affinity for O2, L) shift of OHDC & decreases O2 delivery to tissues- functional anaemia

Answer 619

Less nausea in PACU and day 1 but similar btwn groups day 2 a meta-analysis from 2018 suggests that PVB reduces the risk of CPSP at 12 months, a subsequent RCT has confirmed these findings of reduced chronic postmastectomy pain with PVB use at 3 mth (OR 0.51; 95%CI 0.28 to 0.94) and at 6 mth (OR 0.48; 95%CI 0.25 to 0.94) (Qian 2019 Level II, n=184, JS 5).Pain Book 2020 BUT this question about Sessler study- no sig difference in cancer recurrence (median follow-up 36 months) no sig difference in incisional pain at 6 months no difference in incisional pain @ 12 months neuropathic breast pain didn't differ with regional at 6 or 12 months

Answer 620

70mL/kg ideal body weight (60mL/kg if >65yo) 80mL/kg 90mL/kg 100mL/kg

Answer 621

if definitely identified as AV=node independent (eg. sinus tachycardia), treat cause (anaemia, hyperthyroidism, anxiety, pain, hypovolaemia,, depth of anaesthesia, infection, PE, coronary ischaemia) if it's atrial tachycardia, synchronised cardioversion if unstable (50-100J). Consider Mg++, K+, amiodarone if it's AF & unstable, synchronised cardioversion (120-200J). if it's stable, treat the cause (eg. electrolytes, infection, anaemia), rate control (B blockers, dig (if HF)), cardiovert if <48hrs (amiodarone), consider anti-coagulation A flutter: synch CV (25-50J), drugs= digoxin, B blockers, flecainide, amiodarone If AV-node dependent- regular tacchycardia- vagal manoeuvres (CS massage, valsalva, diving reflex) NO verapamil or adenosine if WPW (could use flecainide for them) junctional tachy= amiodarone or flecainide persistent= B blockers, diltiazem, verapamil

Answer 622

narrow complex regular 50-100J narrow irregular 120-200J wide regular: 100J wide irregular: defibrillator (200J)

Answer 623

9 months MACE risk post ischaemic stroke? <3 months: 15% 3-6/12: 6% 6-12/12: 3% >12/12: 2.5% risk levels off after 9 months

Answer 624

body weight (kg)- use ideal BW if obese Hb concentration of elemental Fe in the product

Answer 625

can give as a single dose over 15mins (start slowly)

Answer 626

0.9% Nsaline with glucose 5% could consider addition of potassium if normal baseline electrolytes & renal function but has to be in premixed bags

Answer 627

[premorbid wt (kg) - current wt (kg)] x 1000

Answer 628

10-20mL/kg 0.9% NaCl as fast as possible

Answer 629

if moderate, enteral (oral or NG) preferred may require IV if severe or if can't tolerate enteral first estimate degree of dehydration & calculate fluid deficit: mL= (premorbid-current wt kg) x 1000 if wt unknown, % dehydration x wt (kg) x 10 if the fluid deficit is <=5%, replace in the first 24hrs if it's >5%, replace more slowly- 5% in first 24hrs & remainder over next 24hrs if still needed. replace ongoing losses as measured based on previous 1-4hours; generally replace GI losses with NaCl 0.9% + KCl 20mmol/L total fluid= rehydration + maintenance + ongoing losses

Answer 630

bupivacaine higher LA [] prolonged exposure to LA

Answer 631

50-100 microamps (0.05-0.1 amps), so max leakage current in equipment to avoid micro shock is 10microamps

Answer 632

**sulfonylureas (-azides) pioglitazone= thiazolinedione, improves glycaemic control but uncertain mort & complications (hence is a 3rd line agent). Ass'd. w wt gain & Na/fluid retention; unsuitable in mod/severe CCF. Improves insulin sensitivity. reduce circulating fatty acid concentrations. Sitagliptin= DDP-4 inhibitor, DDP-4 metabolises incretins (which stimulate insulin;l GLP-1 & GIP) so you get more endogenous insulin. can cause hypoglycaemia but not common & incr risk if combine w sulphonuylurea Metformin: acts by inhibition of mitochondrial 1 complex, decr hepatic glucose production, intestinal glucose absn & incr peripheral glucose uptake & utilisation. Doesn't impact insulin secretion so no hyop. Acarbose limits the breakdown of intestinal oligosaccharides (inhibits intestinal alpha glucosidase); therefore slows glucose uptake & lowers post -prandial glucose [], may promote weight loss (promotes GLP-1). Flatulence, diarrhoea, abode pain but not hypos Sulfonylrea cause insulin secretion (stimulate pancreatic beta cells), can cause hypoglycaemia meglitinides similar mechanism but weaker binding & more rapid dissociation GLP-1 agonists incretin mimetics, promote endogenous insulin release but in a glucose-dependent manner so don't tend to cause fasting hypoglycaemia. weight loss. improves LV function.

Answer 633

ceftazidime-avibactam It's a GN bacteria- with carbapenemases Place them on contact precautions, single room, own toilet, for the duration of hospital stay & maintained indefinitely for future hospitalisations, given prolonged colonisation & limited Rx options. also standard measures (hand hygiene, minimise use of invasive devices, antimicrobial stewardship). screening high-risk pts to detect rectal colonisation. don't need droplet precautions.

Answer 634

medial calf/arch of foot knee jerk quadriceps

Answer 635

standards for quality improvement reporting excellence; FOR REPORTING COMPLETED WORK, they are used as guideline for authors reporting on systematic, data-driven efforts to improve the quality, safety & value of healthcare. aim to improve completeness & transparency of reporting quality improvement work.

Answer 636

be encouraged to breastfeed as normal when feeling alert & well, exercise caution (observe infant for signs of abnormal drowsiness or resp depression) if sedative drugs were used & baby up to 6 wks old, esp if the mother showing signs of sedation. codeine should NOT be used in breastfeeding women.

Answer 637

highly individual- pts with T1DM or insulin-treated T2DM are at higher risk of ketoacidosis if basal insulin not supplied yet risk hypoglycaemia if insulin excess. endocrine advice Basal only: generally, if once-daily & safe morning glucose levels don't need to adjust If the pt's insulin has been adjusted to be in normal or low-normal or if BGL runs low, reduce dose by 20%. If the once-daily insulin is in the evening, typically reduce it by 20% if it's twice-daily, may be able to continue as long as basal dose correctly calculated. reduce both doses by 10-25% if concern about hypoglycaemia. basal and prandial: generally omit prandial insulin from commencement of fasting if basal insulin in the morning, pt to take 1/5-2/3 their TOTAL morning insulin as basal to prevent ketosis during the procedure if basal in evening, reduce basal the night before by 20% (unless mane BGLs high) if basal 2x/day, reduce evening before by 20% (unless mane BGLs high in which case give full dose) & give 1/2-2/3 TOTAL morning dose as basal insulin on the morning of surgery premixed, generally reduce dose night before by 20% & mane by 50% but if BGL generally <12 mane, omit morning if continuous pump & it's OK for the procedure, can continue their basal insulin rate. If pump has to be discontinued, administer basal (according to programmed insulin settings) 2-3hrs prior to pump discontinuation.

Answer 638

prostaglandins infusion (start low dose at 5ng/kg/min if think the duct still open, in neonatal collapse if think the duct has closed, start higher 20ng/kg/min to a max 100ng/kg/min), target SpO2 75-85%- must maintain the PDA with prostaglandin infusion, to provide systemic perfusion (adverse effects incl apnoea, hyperthermia, hypotension)

Answer 639

can present as shock with salt loss crisis (requires IV saline, hydrocortisone, correction of electrolytes)

Answer 640

non-accidental injury- low threshold for referral to child protection professionals

Answer 641

congenital heart disease sepsis metabolic disorders

Answer 642

cyanosis hypoxia despite O2 therapy tachypnoea without lung pathology pulmonary oedema (late) hepatomegaly cardiomegaly absent femoral pulses pathological murmur lactic acidosis unresponsive to initial resuscitation

Answer 643

temp (>38.5 or <36) HR >180 or <100bpm RR >50 leucs >34 x10^9/L hypotension NOT included (it's a late finding) preterm birth VLBW chorioamnionitis PROM >24hrs before delivery

Answer 644

metabolic acidosis, lactic acidosis, hyperammonaemia, hypoglycaemia

Answer 645

ICH (most commonly subdural), retinal haemorrhage, encephalopathy

Answer 646

bradycardia- prepare w atropine 20microg/kg

Answer 647

FiO2 30-40%, as higher may cause excessive flow through lungs which incr PVR

Answer 648

**impending resp arrest if running high-dose prostaglandin infusion for duct-dependent circulation, @ risk apnoea neuroprotection- ICH or cerebral oedema loss of airway reflexes due to depressed consciousness anticipate difficult airway anticipate bradycardia- atropine 20microg/kg prepared pre-O2 with FiO2 1.0 unless PDA-dependent lesion- in which case FiO2 30-40% (high []--> excessive flow through lungs which may incr PVR) pre-induction resuscitation with IVT boluses (10mL/kg) & consider inotropes, prepare adrenaline 1microg/kg as bolus, consider Adr infusion if pt required >40mL/kg fluid. if shock unresponsive to fluids & inotropes, 6-hourly hydrocortisone 2.5mg/kg. IV access asap- IO if difficult IV. if pt <1 wk old, umbilical vein may be patent for venous access'= if need central access, avoid IJ if suspect single ventricle circn (pt may get a Fontan), avoid femoral if suspect transposition great vessels (atrial septostomy is usually via femoral vein. MAP goal for term neonate is 40mmHg. in premature, MAP in mmHg is to the corrected GA. circulation time may be prolonged. induce with ketamine, fentanyl, NMBDs desaturation likely so consider gentle vent prior to intubation generally robertshaw (for neonatal/infant, gentle shallow blade curve to lift epiglottis indirectly) or miller (straight blade with shallow curved tip to lift epiglottis directly) tube size <28 wks is 2.5 28-34wks is 3 >34 wks is 3.5 term is 3.5-4 depth- not accurate to do diam x3 for size ETT<3 (only if size >=3) depth size 2.5 is 5.5cm 6cm from 25 wks size 3 is 6.5cm 7.5cm if size 3.5 9cm if size 4 target SpO2 >95% if sepsis or raised ICP, target pre-ductal (R) hand) & post-ductal (either foot) 75-85% in PDA-dependent CHD (post-ductal lower due to mixing of pulm blood through PDA) NGT may be required Hb 100 until 7 days of age, 75 after 8 days of age. broad-spectrum ABx keep warm manage seizures correct electrolytes & glucose COMMUNICATION WITH PARENTS- THEY MAY FIND WRITTEN RESULTS HELPFUL

Answer 649

1. keep PDA open for systemic perfusion 2. balance the flow btwn systemic & portal circulations, incr PVR or decr SVR so to avoiding a large proportion of CO going to the pulmonary circulation- important for circulations in parallel (incr prom flow means decr systemic flow which compromises myocardial perfusion & --> tissue hypoxia); can maintain "balanced circulation" by avoiding high FiO2, aiming SpO2 80%, PaCO2 37-45mmHg.applying modest (4-6cmH2O) PEEP

Answer 650

necrotising enterocolitis, incr incidence late-onset sepsis, incr mortality

Answer 651

abg ammonia glucose lactate if abnormal, support normal physiology, consult an expert in paediatric metabolic medicine

Answer 652

one of the more common metabolic causes of SUPC can result in insufficient mineralocorticoid & corticosteroid (important for maintaining salt/water balance & circulating volume) ass'd with: hypoglycaemia hyponatremia hyperkalaemia poor cardiac function with decreased responsiveness to catecholamines--> shock fluid boluses of saline 20mL/kg reAx after each bolus correct hypoglycaemia with dextrose early administration of hydrocortisone aids correction of electrolyte abnormalities aggressively treat hyperkalaemia (incl Ca gluconate) consult paediatric endocrinologist

Answer 653

urea cycle defect with resp acidosis, more likely secondary & suggestive of organic acid disorder presents with lethargy, poor feeding, tachypnoea, hepatomegaly, seizures, coma- Rx within 24hrs essential to limit neurological damage stop all protein intake, administer fluids with dextrose & intralipid, use ammonia scavenger meds (sodium benzoate or arginine) consider haemodialysis esp if ammonia [] excessive

Answer 654

reduced tone & alertness, convulsions, sweating, arrhythmias risk neurological damage absolute level for treatment depends on post-conceptional age, wt & clinical condition- generally <2.0mmol/L in term neonate needs Rx 10% dextrose 2-3mL/kg initial bolus. if require high amounts of dextrose, may need CVC (peripheral vascular irritation, fluid overload)

Answer 655

preterm birth, VLBW, chorioamnionitis, PROM >24hrs before delivery

Answer 656

Ask about tobacco use- even if known- emphasises that tobacco a significant issue Advise quitting- outline specific periop risks Refer

Answer 657

nicotine (1.55 all types, inhaler 1.9, patch 1.64)- 1st line, combo better, patch start high then wean varenicline (2.24)- champix, also 1st line; start 2/52 before smoking cessation to occupy receptors, gradual up-titration buproprion (1.64)- zyban- atypical antidepressant, start 1-2wks before smoking cessation clonidine & nortriptyline also help individual (1.57) group (1.88) Pharmacotherapy + counselling incr quit rates 50-70% periop

Answer 658

4-7% success tends to be grater in pts having surgery

Answer 659

smoking induces liver CYP450 enzymes.

Answer 660

smokers have higher opioid requirements & experience more postop pain.

Answer 661

infrapatellar branch of saphenous- poorly localised ant knee pain sl more medially, possibly referred to medial calf peroneal nerve palsy

Answer 662

foot drop, weakness DF & eversion paraesthesia/numbness over dorm of foot & lateral shin TKR esp if significant valves deformity or flexion contracture damage to lumbosacral trunk (btwn L4&5) w descent of foetal head. May occur during forceps delivery. esp short stature & large baby. less commonly CPN damage.

Answer 663

incr risk of staphyloma (15% if axial length 27-29mm, 60% if axial length >31mm) 30x higher risk of needle damage to globe if inferotemporal peribulbar MEDIAL CANTHUS approach or sub-Tenon's are safe

Answer 664

serotonergic medications such as SSRIs, since methylene blue is a potent MAO inhibitor

Answer 665

measurability, reversibility, low cost, familiarity ideally delay surgery until anti-PF4/heparin antibodies aren't present OR can treat with pre-op plasma exchange & then use intraop heparin just for the procedure. could give IVIG prior to heparin to reduce activity of heparin/P4 antibodies use an alternative- eg. bivalirudin, as it has relatively short life. drawback= unable to reverse so bleeding risk (although short 25min half life if normal renal function. can be used in hepatic insufficiency. expensive. Protocols using bivalirudin during cardiac surgery with & without CPB have been established.

Answer 666

must remain above carina don't insert beyond 25cm in adult (DAS= not beyond 26cm @ lips) Mean lip-carina distance 25cm males, 21cm females

Answer 667

also 45cm one, 8fr for ETT size 3 or larger

Answer 668

12 hrs 3 days (for a 7-day patch, 24hrs for a 3 day patch)

Answer 669

inhibition of hepatic gluconeogenesis (metformin inhibits mitochondrial transport chain complex 1, decreasing hepatic gluconeogenesis from lactate, pyruvate & alanine so there's excess lactate & substrate for lactate production) it tends to occur if metformin overdose or if pts have kidney or hepatic insufficiency or other disease causing AKI & impaired metformin elimination.

Answer 670

decreases insulin resistance decreases hepatic glucose output (inhibits gluconeogenesis & glycogenolysis), enhances peripheral glucose uptake

Answer 671

absolute: pt refusal, LA allergy, infection/marked orbital inflammation relative: myopic, unable to lie flat, children, communication difficulties, bleeding diathesis, previous scleral buckling or space-occupying lesions within the orbit

Answer 672

Femoral L2-4 (from saphenous & muscular branches) Common peroneal (L4-S2) & tibial (L4-S3) obturator L2-4 (posterior knee)

Answer 673

50microg range 50-100microg, 200microg if no response. if >3 boluses given, start Adr infusion, peripherally 3microg/min=3mL/hr

Answer 674

excreted renally, unchanged; not recommended if CrCl <30mL/min sugammadex CAN be removed via high-flux haemodialysis

Answer 675

Intervene if desat >20% optimise venous drainage increase DO2: -Augment MAP w vasopressor (MAP 110% normal to enhance collateral flow through CoW) -FiO2 100% -optimise CO (HR x SV) Surgical placement of carotid shunt Strategies to limit carotid vasospasm, selective perfusion coronaries -Optimise Hb reduce O2 consumption: manage any temp/seizures, adequate depth

Answer 676

small bowel <3cm large bowel <6cm appendix <6mm caecum <9cm For ileus: -exclude mechanical obstruction or other secondary causes (CT abdo w oral contrast S&S 90-100% for distinguishing ileus from complete SBO & may identify secondary causes of ileus). -correct reversible causes (prevention better than cure, ie. ERAS measures incl mid-Tx epidural or TAP block, minimally invasive vs open OT, opioid antagonist, multimodal analgesia, minimal length incisions, minimal bowel handling, limiting fluids. Routine NGT placement & use of COX2s are HARMFUL (incr risk anastamotic leak)- can use nonselective) -check electrolytes (incl K+ & Mg++) -multimodal analgesia (minimises opioid, non-selective NSAIDs & paracetamol) -IVT- normovolaemia -dietary restriction- bowel rest (sips of clear fluids, liquid diet if BS) -selective NGT if N&V -serial monitoring. &abdo exams (additional imaging if doesn't improve. in48-72hrs) discontinue meds that ay decrease colonic motility, avoid laxitives could have rectal tube encourage mobility, prone w hips elevated, alternate L) & R) each hour could use colonoscopic decompression can use parasympathomimetic drugs to enhance gut motility (eg. neostigmine, erythromycin)

Answer 677

BRADYCARDIA anaphylaxis (dose-dependent) delay reestablishment of neuromuscular block w steroidal NMBAs other adverse effects: cardiac arrhythmias (marked brady)

Answer 678

irrigating the brain with ice-cold saline occasionally: BZD, anti-epileptics or re-sedation w airway control are required

Answer 679

LEVEL OF INSERTION Is influenced by: height of drainage bag height of bed changing patient position supine to sitting larger bore catheter rate of CSF production length of the catheter

Answer 680

Supplementation required if >10mg/m2 hydrocort equivalent FOR >=1 MONTH Major procedures: 2mg/kg IV hydrocortisone @ induction followed by infusion: 0-10kg: 25mg/24hrs 11-20: 50mg/24hrs >20kg: prepubertal 100mg/24hrs pubertal 150mg/24hrs postop: 2mg/kg IV or IM 6-hourly or wt-based infusion (0-10kg 25mg/24hrs, 11-20 50mg/24hrs, >20kg prepubertal 100mg/24hrs, pubertal 150mg/24hrs. Once oral intake, double usual dose 48hrs postop then reduce to normal over 1 week. Minor: 2mg/kg @ induction, once enteral feeding, postop double oral dose for 24hrs. So this kid, major or minor surgery 48mg @ induction

Answer 681

22-26hrs (say 24hrs) for elderly, riva half life 11-13hrs young 5-9hrs DOACS half lives Dab 12-14 Riva 5-9 young, 11-13 elderly Api 8-15

Answer 682

PPmax-PPmin/PPmean over a respiratory cycle or other period of time (often averaged over 3+ breaths) It reflects where the heart is on the frank-starling curve, denoting fluid responsiveness. PPV 13-15% ass'd w volume responsiveness. Limited to mech vent pts w >=8mL/kg TV, sinus rhythm, no spont trigger. Stroke volume variation is (SVmax/SVmin)/SVmean. SVV >10% correlates with fluid responsiveness.

Answer 683

76% (higher in females & older age groups) "CMV safe"= leucodepletion or antibody testing. of donor blood, provides risk reduction for transfusion-transmitted infection. leucodepletion residual risk CMV 1 in 13,575,000. Should offer to all pregnant women, regardless of CMV status. CMV= a human herpes virus that can. be transmitted horizontally (bodily fluids) or vertically (postnatal infection through breastfeeding or congenital infection. if primary maternal infection in pregnancy). In most, a mild non-specific or asymptomatic illness & develop an immune response, seropositive 6-8wks after contracting virus. remain potentially infectious for life (dormant infection) esp in mononuclear white cells & their precursors.

Answer 684

no difference in 90 day all cause mortality incr vomiting (NNT for vomit=31) required more prokinetics & more insulin it provides higher residual gastric volumes TARGET trial: energy-dense vs routine enteral nutrition in critically ill, mechanically ventilated pts Multi-centre, double-blind RCT Aust/NZ 1mL/kg/hr of 1.5kcal/mL based on ideal body weight- approx 1900kcal/day 1mL/kg/hr 1kcal/mL approx 1300kcal/day energy dense= higher fat & carbo, similar protein Enteral nutrition is preferable. to parenteral (reduced gastric erosion, bacterial translocation & infectious complications

Answer 685

Hypertrophic cardiomyopathy: syncope in up to 25% of pts w HCM, may be due to dynamic LVOTO or arrhythmias, exertion ischaemia. Autosomal, most common form. of inherited cardiac malformation (1:500 adults) Syncope: transient loss of consciousness due to a period of inadequate cerebral nutrient flow (usually due to drop SBP & inadequate cerebral perfusion). Spontaneous & self-limited. AS: a presenting symptom in 10% of pts w symptomatic severe AS; rare presentation unless valve critically stenotic. Exertion. High mortality if untreated so AVR generally indicated. Myocardial ischaemia (—> bradycardia & arrhythmias)= rare cause of syncope (1%)

Answer 686

-30mL/kg IV crystalloid within the first 3hrs of resus Other recommendations: -Rx & resus immediately -use crystalloids as first-line fluid, balanced vs N saline -if large vols, use alb -dynamic measures to guide fluid resus -guide resus to decrease lactate -cap refill to guide resus as an adjunct -Target MAP >=65mmHg -Use norepinephrine as first-line vasopressor -If on Norepinephrine but inadequate MAP, add vasopressin rather than escalating norepinephrine. -If inadequate MAP despite those 2, add epinephrine. (*NE >=1microg/kg/min avoided- "decatecholaminisation", high doses NE can compromise host immune system, promote bacterial growth, may induce myocardial injury & oxidative stress, incr mortality, peripheral ischaemia. Commence vasopressin when NAdr requirement 20microg/min. Vasopressin 20units/mL vial. 20units in 20mL glucose 5% (vaso is compatible with NaCl 0.9%), final concentration 1unit/mL. Start at 0.6u/hr. wean no >0.6u/hr every 15 mins. usual range 0.6-2.4U/hr, high doses risk ischaemic side effects (peripheral, mesenteric). dedicated central line). Adr 1000mcg/50mL, 5mL/hr if urgent, if extra hands: Epi risks tachy, incr myocardial O2 consumption, hyperglycaemia, lactic acidosis, peripheral & splanchnic ischaemia. 0.5-2mcg/kg/min (3mg/50mL is 60mcg/mL) -If septic shock & cardiac dysfunction w hypoperfusion despite adequate volume & MAP, add dob to Nepi or use Epi alone. -Dobutamine 250mg (20mL) made up to a volume of 42ml with 5% glucose (can also use hartmann's or NaCl). final [] 6mg/mL, start @ 2.5mcg/kg/min. -Use art line over NIBP asap -start vasopressors peripherally @ first, to avoid delay in CVC -IVABx within 1hr for sepsis. w septic shock, seek sources & refine from empiric -If possible sepsis but no shock, time-limited Ix, ABx within 3hrs -if high risk MRSA, use ABx w MRSA cover empirically -if high risk MDR organisms, 2 ABx w GN cover empirically (until susceptibilities known) -daily assessment & de-escalation as indicated -If septic shock & ongoing vasopressor requirement, give IV corticosteroids -restrictive over liberal transfusion -use stress ulcer prophylaxis if risk factors for GI bleeding, use pharmacologic VTE prophylaxis (LMWH), only use mech if no pharmacological -If septic shock & AKI, use RRT if definitive indication -target BGL <10mmol/L w insulin infusion -use early enteral nutrition. if poss (within 72hrs) -don't use: sodibic for hypoperfusion-induced lactic acidaemia but DO use it for severe metabolic acidemia with AKI, IV vit C, IVIG, polymixin B hemoperfusion -If sepsis-induced hypox resp failure, HFNO over NIV -ARDS: low tidal vol (6mL/kg) over high TV (>10mL/kg), severe ARDS upper limit goal of plateau pressure 30cmH2O, mod-severe ARDS high PEEP over low PEEP If sepsis-induced severe ARDS, do use traditional recruitment maneuvers prone ventilation >12hrs/day if mod-severe ARDS sepsis-induced, intermittent vs continuous invusion NMBAs -VV ecmo if mech vent fails if infrastructure & experience in place -Discuss goals of care -Institutional performance improvement program for sepsis incl screening high risk pts.

Answer 687

Inflation middle T wave (onset of diastole, closure of the AV, ideally @ dicrotic notch), electrical activity precedes mechanical by a few ms. Deflation peak of R wave (onset of systole, just before AV closes, just before upstroke on art pressure waveform) If using pressure waveform (eg. arrhythmias), inflation w dicrotic notch, deflation just before upstroke arterial pressure waveform. IABP provides aortic counterpulsation, augments diastolic flow during diastole (increases DPTI (as increasees ADP),, incr Cor blood flow), reduces afterload during systole, improves LV performance (reduces LV tension time, reduces LV O2 consumption). contraindications: ABSOLUTE: significant AR, aortic dissection, clinically significant aortic aneurysm repair/stent, uncontrolled sepsis helium: less resistance to inflation/deflation (low density laminar flow), easily absorbed if balloon rupture relative: Uncontrolled bleeding Known atheroma or severe atherosclerosis Severe PAD that can’t be pretreated w tenting LVOTO Inability to achieve adequate timing Complications: Vascular: Limb ischaemia, visceral ischaemia Vascular laceration Major haemorrhage Non-vascular: Haemolytic, insertion site (usually groin) infection, peripheral neuropathy, balloon rupture (helium embolisation, thrombus formation), cholesterol embolisation, CVA Sepsis insertion 2-3cm distal to L) SC artery, @ carina When inflated shouldn’t be >80-90% diam Desc aorta

Answer 688

valsalva won't work, can use adenosine reduced dose (1.5mg >=60kg or as per AHA, 3mg analgesia, correct other reversible causes (eg. correct electrolytes) If irregular, B blocker cautious of bradycardia risk (digoxin not likely to be effective, could use amiodarone if evidence HF) diltiazem & verapamil are contraindicated tacrolimus & cyclosporine (can impair metabolism of CYP3A & incr drug levels renal tox. cardioversion (if adverse features: shock, syncope, myocardial ischaemia, heart failure); DCCV 120J

Answer 689

SOBA: This guy's ideal BW 55.4kg, lean BW 65.2kg, Adj40BW (IBW + 0.4(TBW-IBW)) 81.2kg propofol induction lean BW 2-3mg/kg 130-200mg maintenance TBW or Adj40BW suxamethonium 120-180mg (1-1.5mg/kg actual BW)if RSI rocuronium 40-79mg (0.6-1.2mg/kg LBW) opioids LBW & adjust doses down (more sensitive to OIVI), ie. fent 30-130microg 0.5-2microg/kg

Answer 690

myaesthenia gravis (relative resistance, dose increased; 2mg/kg for RSI) AVOID in: Hereditary: Pre-junctional disorders, eg. charcot-marie-tooth, Fredrich's ataxia Postjunctional disorders, eg. duchenne & becker muscular dystrophy, myotonic dystrophies, hyperkalemic & hypokalemic periodic paralysis Acquired: Pre-junctional eg. motor neurone, in multiple sclerosis IF the pt is mobility-limited, guillian barre due to muscle weakness (even after recovery. of neurological deficit) NMJ: Eaton-lambert post-junctional: -critical illness polyneuropathy -postpolio Friedrich’s ataxia: Autosomal recessive Due to altered mitochondrial proteins—> iron accumulation. Ataxia, sens neuropathy, cardiomyopathy (arrhythmias, HF), DM Degeneration of DRG, post columns, spin-cerebella & corticospinal tracts. BULBAR KYPHOSCOLIOSIS SUX AVOIDED (hyperK risk) INCR SENS TO NDMRS GBS: Acute inflammatory demyelinating peripheral polyneuropathy- viral or back infection Asc progressive m weakness, ANS dysfunction, areflexia 25% require mach vent. Asp risk BULBAR Resp insufficiency (may need post vent) ANS dysfunction- harm instability, ANS hyperreflexia type reactions SUX CI (hyperK) Sens to NDMR Incr risk VTE Neuropathic pain common IVIG, PEx NOT steroids Neuraxial controversial; document deficits DMD: XLR Becker= milder form Duchenne Asp risk bulbar, GI motility Poss macroglossia Sux/VA contraindicated (rhabdo/hyerK) Poss osa, sensitiviety to sed/hyp Pulmonary HTN/RV failure Rest lung disease from scoliosis, Resp m weakness Risk Perioperative Resp failure, impaired cough, recurrent aspirations DCM (tall R waves precordial, incr R:S, deep Q in I, aVL, V5-6) MR common (due to LV dilation_ Conduction/arrhhyhtmias May have mild cog impairment May be on ACE-I, B block, steroids

Answer 691

higher during initial hypodynamic ("ebb") phase DECREASED during later (>48hrs) hyperdynamic ("flow") phase, so higher doses are needed (bolus & infusion) to maintain therapeutic [] from 3-4 days post burn. Hepatic & renal Cl increase since reduction in alb increases free propofol fraction & plasma prop []s are then lower for a given dose regimen.

Answer 692

4 1=15 2=13-14 no motor def 3=13-14 w motor def 4= 7-12 +/- motor deficit 5= 3-6 +/- motor deficit

Answer 693

High risk factors: -prev preg w hypertensive disease -T1 or 2 DM -chronic HTN -kidney disease -autoimmune disease w potential vascular complications (antiphospholipid, SLE) Mod risk factors (require 2 of these to justify aspirin) -first preg -multifoetal gestation age >40 -interpreg interval >=10yrs -FHx (mother or sister) PET

Answer 694

incr SVR & CO also inc SV, incr inotropy, reduced diastolic function

Answer 695

IV Magnesium Correct metabolic/electrolyte derangement remove inciting medications consider overtrive atrial pacing or IV isoprenolol

Answer 696

IV Magnesium 25-50mg/kg (likely 2g at 15yo) Correct metabolic/electrolyte derangement ensure not taking QT prolonging drugs ?consider overdrive transvenous atrial pacing 100-140bpm or IV isoprenolol (which would worsen the pt if VT misdiagnosed as TdP) start 2microg/min & titrate to HR 100bpm if the pt doesn't respond pts w TdP typically B block, consider L) heart symp denervation, pacing to shorten QTC, ICD. avoid sotalol, amiodarone, droperidole, fluox, proca, flucon, flecainide, METHADONE. If give Mg++ for torsades, ensure potassium above 4.5 trans-venous pacing if resistant to Mg++. props safe. midaz fine. avoid ketamine as sypathomimetic. SUX prolongs QTc! all volatiles prolong QTc. Unstable: promptsynch CV with 2g IV Mg++ if pulseless (TdP degen to VF), CPR, defib, give 2g IV Mg++, NO amiodarone. instead, give IV lignocaine Lignocaine 1mg/kg IV/IO (adults & paeds)

Answer 697

Discuss w haematology, but guidelines= top-up transfusion, aiming for Hb >100g/L, pt-specific blood (ABO, Rh, Kell, HbS -ve without any other relevant antibodies), doesn't have to be done pre-op (could be intra), depending on haematologist advice

Answer 698

opioids ketamine nitrous (mildly depress) cf: incr w etomidate mild depr w props/barbiturates volatiles depress ++

Answer 699

5mg/kg (after 3rd shock)

Answer 700

if it'll take >1hr for the sample to get to the lab, needs to be refrigerated so get it to the lab ASAP Serum (serum separator) or plain tube (serum gel or lithium heparin gel)

Answer 701

cohort study

Answer 702

NOT abdominal aneurysm Primary GH excess: functioning pituitary macro adenoma MEN1 (pancreas islet, pituitary, parathyroid) ectopic: lymphoma, pancreatic islet-cell tumour GHrH excess: from hypothalamus bronchial carcinoid SCLC adrenal adenoma phaeochromocytoma Difficult airway (macrognathia, prognathism, macroglossia, frontal & nose enlargement, prominent upper incisors) Excess upper airway soft tissue—> prone to OSA (in up to 70%!), laryngoscopy challenge HTN LV hypertrophy IHD, arrhythmias, heart block, biventricular dysfunction, cardiomyopathy, myocarditis, myocardial fibrosis Elevated pulmonary pressures Difficult vascular access peripheral nerve entrapment (eg. carpal tunnel) Visual field defects & mass effects kyphoscoliosis proximal myopathy arthropathy osteoporosis hyperhydrosis colonic polyps/bowel Ca T2DM/glucose intolerance

Answer 703

Do NOT immediately commence CPR (can delay for shockable rhythms 1 min) Do NOT give full 1mg adrenaline Initially DO do 3x stacked shocks 150J (re-Ax between each one) 300mg amiodarone IV If no improvement, open chest (resternotomy within 5 mins); closed cardiac massage, internal defib 20J Manually vent w ambu bag FiO2 100%, 30:2, discontinue sedation If IABP, switch triggering mode to arterial tracing 50microg boluses of Adr

Answer 704

Monitors movement of the VCs on endotracheal tube--> EMG activity vocal cords (internal laryngeal muscles)

Answer 705

prothrombin complex concentrates (4-factor, 3-factor inactivated but NOT the activated PCC (with FAIBA; no heparin) UFH, LMWHs (enoxaparin, danaparoid), heparin flushes, heparin-bonded catheters, some hematopoietic stem cell products, some TPN, some forms of IV medications

Answer 706

7% GWP 365 over 100yrs (CO2 1, des 2540, iso 510, nitrous 365, sevo 130. iso does have some (0.01) ozone depletion potential but short life so minimal impact, sevo & des no ODP as nil chlorine) atmospheric life 114yrs

Answer 707

VO2/Hr (oxygen consumption/HR, mL/beat) represents product of SV & arterial-venous oxygen difference, surrogate for stroke volume should increase at the start of exercise & plateau@ highest predicted value

Answer 708

aprepitant Metabolism accelerated by drugs incr liver microsomal enzyme activity (phenytoin, rifampin, carbamazepine) Griseofulvin St John's wort

Answer 709

suprascapular nerve suprascapular nerve= majority of supply to shoulder joint blockade is more effective than shoulder LIA, less effective than interscalene block Supply to should joint (terminal branches)= primarily from suprascapular & axillary, with minor contributions from subscapular, musculocutaneous & lateral pectoral

Answer 710

*recruitment maneuver sans PEEP -Low TVs (6-8mL/kg predicted BW) -low PEEP (start at 5cmH2O, individualise to avoid incr in driving pressure (Pplat-PEEP) while maintaining low VT -low pplat (max 30cmH2O) -low driving pressure (max 15cmH2O; Pplat-PEEP) -recruitment manoeuvres if needed, lowest effective pressure (Pplat 30-40cmH2O non-obese, 40-50cmH2O obese, shortest effective time, fewest # of breaths; they have limited benefit without sufficient PEEP). -Ramp pt before induction (HOB >=30 degrees) & if no contraindication, before loss of spont vent use NIPPV or CPAP to limit atelectasis). Aggressively avoid obstruction during induction (eg. NPA). -After intubation, FiO2 <-0.4, use lowest possible FiO2 to achieve SpO2 >=94%. -No specific controlled vent mode is recommended. -target PaO2 55-80mmHg, SpO2 88-95%. -position to avoid ZPEEP during emergence, don't suction tracheal tube just before extubation. If high FiO2 for extubation (>0.8), consider CPAP with low FiO2 immediately after to reduce risk resorption atelectasis. Aim= improve mechanics of breathing & resp function, prevent PPCs. -Dedicated score should be used for risk evaluation of PPCs (main risks age >50yr, BMI >40, ASA >2, OSA, preop anaemia, preop hypoxaemia, emergency or urgent surgery, ventilation duration >2hrs, intraop haemodynamic impairment & low SaO2) -To evaluate the effect of interventions, assess the impact on respiratory system compliance with constant tidal volume.

Answer 711

Perforated viscus oesophageal stricture oesophageal tumour oesophageal perf/lac oesophageal diverticulum active GI bleed recent oes or gastric surgery relative: Hx radiation neck/mediastinum Hx GI surgery recent GI bleed dysphagia neck mobility restriction hiatal nernia (symptomatic) oesophageal varices coagulopathy active oesophagitis or PUD

Answer 712

Benzodiazepine, prop

Answer 713

Curvilinear probe, lower frequency increase depth setting. a focal zone adjust gain; excessive or inadequate blurs tissue boundaries. Increasing gain below the focus can help Doppler

Answer 714

fib conc 1g/25kg or cryo 1u/5kg

Answer 715

6 months ANZCA PS12 1. 5.1 Quitting smoking for one day will lower carboxyhaemoglobin and nicotine levels and could be expected to improve tissue oxygen delivery. 2. 5.2 Quitting smoking for as little as three weeks has been shown to improve wound healing. 3. 5.3 Quitting smoking for six to eight weeks results in sputum volumes that are not increased compared to non-smokers, and improved pulmonary function. 4. 5.4 Immune function is significantly recovered by 6 months after quitting smoking.

Answer 716

Age >=3yo surgery >=30mins personal or FHx PONV/personal Hx motion sickness strabismus & tonsillectomy

Answer 717

VV ECMO reinfused oxygenated blood withdraawn through rainage cannula, doesn't pass through systemic circulation, reduced systemic oxygenation & reduced efficiency. Improve by ncr distance btwn cannulae, echo & fluoroscopic guidance so reinfusion jet towards TCMdrainage cannula less -ve pressure

Answer 718

packed red cells suspended in saline, hct approx 60% (50-70%) trace amounts of plt/CFs/anticoagulant/microaggregates/other cells/contaminants aspirated

Answer 719

GLP1 agonists have slowing gE as part of their therapeutic effect DULAGLUTIDE does slow gastric emptying but effects are attenuated over time. sitagliptin does. GLP-1 agonists (exenatide, semaglutide): slow gastric emptying (--> nausea & vomiting), reduce postprandial glucagon & food uptake, enhance glucose-dependent insulin secretion. Don't usually cause hypoglycaemia. DDP-4 inhibitors (sitagliptin & other gliptins) inhibit DDP-4 from inhibiting GLP-1, effect is more modest than GLP-1 antagonists but they do slow gastric emptying & don't generally cause hypoglycaemia unless combined. w other therapies that do. Amylin analogues also slow gastric emptying (pramlintide). alpha glucosidase inhibitors (eg. acarbose) prolong the breakdown of polysaccharides to monosaccharides, reducing postprandial glucose levels. main side effect= flatulence.

Answer 720

hypotension

Answer 721

Peak of the QRS (highest point of the R wave or just after)

Answer 722

DOES include: -UTI (incl urosepsis, pyelonepritis), vulvovaginal candidiasis -euglycaemic ketoacidosis -bone fractures (osteoporotic mechanism) -incr falls risk (BP lowering from osmotic diuresis, intravascular volume contraction) -lower limb amputations (peripheral ischaemia) -AKI controversial; may be related. toother factors, dose adjust if GFR <60

Answer 723

hypocalcaemia

Answer 724

serotonin syndrome

Answer 725

Smaller initial bolus, smaller cumulative dose

Answer 726

60g (3g mannitol per 20mg vial dantrolene)

Answer 727

Turn bleeding side down, advance tube down the side of the non-bleeding lung

Answer 728

paracetamol, codeine, dihydrocodeine

Answer 729

PECS 1 block (doesn't cover anterior ramus intercostal nerves 2-6) PVB & TEA ARE effective, as is parasternal (btwn pec maj & int intercostal mm & transversus thoracis plane block (btwn transversus thoracic & intercostal m, level T4-5 intercostal space).

Answer 730

continue, despite , the large randomized POISE-2 trial found that perioperative aspirin increases bleeding risk but does not improve cardiovascular or mortality outcomes for non-card surg

Answer 731

inferior infarct RCA lesion proximal to the origin of major RV branches Acute LV failure & APO Echo: -incr RAP >10mmHg incr RAP:PCWP ratio >0.8 reduced CI REDUCED PAPI <=0.9 decreased TAPSE <17mm but may be inaccurate w RWMA Pulmonary artery pulsatility index (PAPi): calculated from ratio of pulmonary artery pressure to RA pressure (it's (PASP-PADP/RAP)). predicts RV failure after inf MI & LVAD implantation. lower PAPi ass'd w mortality, MACE, HF & hospitalisations.

Answer 732

First-line for postop delirium= Ax & Mx underlying cause (infection, pain, dehydration, metabolic derangement, constipation, urinary retention) & NON-PHARMACOLOGICAL INTERVENTIONS If severely agitated, after Rx of reversible causes & redirection/reorientation, small dose haloperidol (0.5-2mg), since it doesn't worsen the overall course of delirium (preferred over a benzo) DEXMEDETOMIDINE INFUSION: NNT=10 for postop delirium Melatonin (takes 30-45mins to start working, low 3-33% POBA, t1/2 1hr, anxiolysis, sleep disturbance, delirium, anxiety, pain, emergence agitation, myocardial protection; regulating circadian rhythm, anti-inflammatory & anti-oxidative) Postop delirium: common & serious. Incr LoS 2-3 days, 30-day mort 7-10%, incr risk significant functional decline & need for care facilities on discharge A cognitive disturbance characterised by acute & fluctuating impairment in attention & awareness Risk identification & peri-op risk reduction= the most vital part of post-op delirium management (multi-d, organisation-wide), since limited Rx options once delirium established Risk assessment, risk reduction & rescue Rx= cornerstone Risks: -Pt: poor baseline functional status, sensory impairment (visual, hearing), neurological/cardiac/respiratory/metabolic diseases -Higher ASA -Surgical: #NOF up to 70% risk postop delirium! -Emergency/complex procedures requiring postop ICU admission -Metabolic derangement -Pain (both pre-op & postop; preop pain is 1.5-2x higher risk postop delirium) Risk scores exist (eg. combo of MMSE & APACHEII) however validated for specific populations weakens translatability. Effective peri-op interventions: Non-pharmacological (family member re-orient, early mobilising, avoiding excessive bed rest/fasting/malnutrition) -Reorientation measures (non-pharmacological); minimising staff change/pt transfer, introduction of staff, natural light, time-keeping devices, reminding pts about previous events, future planning; Reorientation alone can reduce the incidence of overt delirium by 40%! Cognitive exercises, vision & hearing optimisation, sleep optimisation, mobilisation, hydration & nutrition. Implement as part of multicomponent interventions (reduce incidence of delirium with OR 0.4 (NNT=14.3) -Avoiding periop polypharmacy -Avoid prolonged fluid fasting (>6hrs= 10.6x OR postop delirium) -Pre-op complex geriatric assessment (CGA & OPTIMISATION- eg. orthogeriatric teams; multi-D approach to systematically evaluate & address often complex care needs in older pts, CGA-based periop care improves postop outcomes) -AVOID intraop BZD (2.4x higher risk postop delirium) & gabapentinoids (independent risk factors for postop delirium). TCAs & scopolamine also incr risk. -DoA monitoring (needs further evidence) -multimodal opioid-sparing analgesia, regional & NEURAXIAL important (neuraxial= independent predictor of delirium risk reduction) -paracetamol reduces delirium risk in cardiac surgery pts (NNT=5.6) -Parecoxib reduces delirium risk in ortho pts (NNT= 20) -DEXMEDETOMIDINE: neuroprotective. Intra-op dexmedetomidine infusion, postop dexmed. Reduces risk postop delirium w OR 0.35. Postop: non-pharmacological melatonin or ramelteon (melatonin agonist) dexmed, olanzapine & risperidone. but not haloperidol (overall value of antipsychotics unclear due to risk of complications) high-dose dexamethasone (in card surg) multimodal analgesia Those which may help (need further studies): TIVA vs VA- no diff, low quality evidence subhypnotic doses intraop ketamine show no difference, low quality evidence BIS guided anaes minimally invasive surgery avoidance of hypothermia strict BP control goal-directed fluid therapy restrictive transfusion Postop delirium usually postop days 2-5 previously BZD & antipsychotics were used for hyperactive/agitated delirium but BZD may worsen symptoms & antipsychotics don't reduce length of symptoms, don't reduce adverse outcomes ass'd w delirium & there are some concerns regarding safety of antipsychotics- incr M&M! rapid assessment: confusion assessment method For a diagnosis of delirium by CAM, the patient must display: 1. Presence of acute onset and fluctuating discourse AND 2. Inattention AND EITHER 3. Disorganized thinking OR 4. Altered level of consciousness IF give antipsychotics (best avoided as high anti-cholinergic affinity, effective @ sedation but may prolong delirium & POCD): haloperidol or risperidone 0.5mg po single, olanz 1.25mg single dose

Answer 733

volatile (esp des, sevo & iso no diff, halothane better than sevo) opioids poorly controlled pain Factors ass’d with LOWER incidence of emergence delirium: -propofol cf sevoflurane (propofol effective to reduce emergence agitation either as TIVA, as an infusion throughout or 3mg/kg over 3 mins @ the end (transition), or as a bolus 1mg/kg @ the end (TIVA greater magnitude of benefit for EA reduction). Obv the 3mg/kg over 3 mins prolongs emergence (8mins vs 4mins if 1mg/kg) -administration of fentanyl (intranasal 2mcg/kg, useful both for prevention or Rx of EA if IVC dislodged; or 1mcg/kg IV @ end of sevo anaes; fent higher PONV rate than alpha agonists or props) -alpha-2 agonists (clonidine or ESPECIALLY dexmed; dexmed results more impressive & consistent wrt reducing EA, reding rescue analgesia, reducing PONV & non clinically sig (minimal) incr emergence time; doses in Costi blue book for deemed: 0.15, 0.3, 0.5, 1mcg/kg early or late in anaes or as infusion +/- loading dose; 95% effective dose for reducing EA for tonsillectomy or adenoidectomy is 0.38mcg/kg. Dexmed premed performs better or equal to midaz for induction outcomes (parental separation, mask acceptance) & reduces incidence of EA. 1.5mcg/kg 45mins pre-induction. -Dexmed superior to propofol bolus 1mg/kg @ end of case. -ketamine either as a premed or bolus 0.25mcg/kg @ end of Anaes may reduce EA. -midaz premed doesn’t impact EA but IV midday @ the end may reduce EA. -propofol during or @ the end of anaesthesia *An intra-op DEXMED dose reduces incidence of emergence delirium in chn (OR 0.22). Clonidine also effective, OR 0.5 (but delayed emergence/hypotension limit usefulness w higher doses eg. 2mcg/kg). Doses ranged dexmed 0.15-4(!)mcg/kg, clonidine 1.5-2mcg/kg, IV post-induction. No differences in time spent in recovery or time to discharge. Less need for rescue analgesia. For reducing risk sevo EA, prop/fent/dexmed/clonidine/halothane/ketamine/IV midaz @ the end/analgesia/N2O washout may all be effective- ?reduce time for sevo emergence effective? Dexamethasone 0.2 mg kg−1 before operation has also been found effective in reducing ED A technique known as ADVANCE (Anxiety-reduction, Distraction, Video modelling and education, Adding parents, No excessive reassurance, Coaching, and Exposure/shaping) performed in the waiting room and at induction has shown to reduce the incidence of ED. Techniques to reduce parental & child anxiety. Parental presence @ emergence doesn’t improve EA (but does improve post-hospitalisation behavioural change). For a smooth calm emergence: -adequate IV analgesia -emergence on props (also reduces airway reactivity & PONV) -consider dexmed if cost allows (premed in anxious child, IV intra-op) Preschool age children & pre-op anxiety incr risk of both emergence delirium & post hospitalisation behavioural change. Other risk factors emergence agitation: preschool, pre-op anxiety, temperaments (eg. Poorly adaptable), ophthal/ENT procedures, sevo or desflurane, inadequate analgesia. Post-hospital behavioural change occurs in >50% of children undergoing a GA, usually short-lived, 5-10% may last up to 12 months. Risk factors= underlying anxiety in child or parent, prev bad hospital experience, emergence delirium, pre-school age. Parent presence upon eye opening in recovery reduces incidence of post hospital behaviour change. Emergence delirium= disassociated conscious state where child is unaware of his or her surroundings PAED (paediatric anesthesia emergence delirium) scale= the most widely used (& is “validated”). 5 items, 0-4. Research supports threshold PAED >12. PAED scale score eye contact/purposeful actions/awareness of surroundings/restlessness/inconsolability Hypoactive delirium: child unaware of surroundings, quiet & withdrawn; most screening tools may not identify it (Cornell Assessment of Paediatric Delirium, CAP-D, is used in ICU & RCH investigating it in PACU Hyper-active: motor agitation/restlessness, movements not purposeful, can’t be consoled, no eye contact, don’t recognise ppl/things.

Answer 734

conjunctival chemosis (superficial haemorrhange) Superficial haemorrhage may produce unsightly periorbital haematoma but is not vision-threatening. Not uncommon postop. May be delayed hyalase reaction. retrobulbar haemorrhage, if arterially based, may cause sudden bleeding, palpable dramatic increase IOP, globe proptosis, upper lid entrapment, may compromise optic nerve's vascular supply & impair vision. Urgent ophthal consult, consider lat canthotomy or paracentesis. continuous ecg as oculocardiac reflex may occur.

Answer 735

12 puffs (>6yo), ie 1200mcg (6 puffs <6yo) adjuncts: salbutamol IV infusion 1mcg/kg/min Mg 50% (500mg/mL): 50mg/kg, max 2g, over 20 mins, aka 0.1mL/kg) aminophylline 10mg/kg over 1 hr (max 500mg) hydrocort 2-4mg/kg (max 200mg)

Answer 736

median, paired with interquartile range or other %-based ranges Normal distribution, use mean with standard deviation; 68% of the data falls within 1STD, 95% within 2 & 99.7% within 3STDs

Answer 737

C2-4 skin btwn anterior scalene & SCM lesser occipital greater auricular transverse cervical supraclavicular

Answer 738

Substances that DO: epinephrine sulfonylureas (gliclazide) biguanides (metformin)- rare inhaled B agonists linezolid nucleoside reverse transcriptase inhibitors (NRTIs, used for HIV) propofol infusion syndrome

Answer 739

Drugs with potential for mast cell degranulation morphine codeine pethidine buprenorphine atracurium mivacurium LMWHs NSAIDs & aspirin MAY trigger mast cell degranulation (depends on the pts) sux is UNLIKELY to cause non-allergic mast cel degranulation but is the commonest cause of allergic anaphylaxis during anaesthesia so avoid it. avoid amethocaine (an ester LA) Rare disorder w pathologic accumulation of mast cells in tissues Other factors: pre-ads assess previous anaes records; avoid any known trigger factors (eg. for the pt). as well as drugs known to trigger mast cells pt should have a medic alert ACE inhibitors should be stopped several wks before planned surgery (on advice. of GP/allergy specialist). While B blockers may blunt BP supporting effect of epinephrine, generally OK in usual clinical doses; could change to another class a few wks before surgery if taken for BP but generally continue if for Cor artery disease or HF. ARBs generally continued. multi-D preop preparation & assessment (dermatology, immunology (pt should be assessed re: potential triggers preop & discussion btwn immunologist & anaes re: planning. skin prick testing may be unreliable), surgical & anaes; *bowel manipulation may trigger mast cell degranulation) Team brief to ensure other OT staff aware. of potential triggers (eg. contact pressure, antiseptic solutions (pt should have allergy testing if there's concern re: prev reactions to chlorhex or iodine), latex-containing equipment) limb tourniquets relatively contraindicated temperature control: avoid hyper/hypothermia avoid excessive SNS activation: -anxiety (preop anxiolysis) -pain (consider regional) -ensure adequate depth -give all drugs slowly & in the minimum dose required. stabilise mast cells w inh salbutamol & 100mg hydrocort immediately preop consider sodium cromoglycate in asthmatic pt (ie. for pts already taking it, but no evidence it should be commenced. it may improve diarrhoea & abdo pain in mastocytosis but doesn't have high systemic bioavailability so may not prevent hypotension etc. -art line, 2x large IVCs under light sedation -BIS, temp probe, 5-lead -warm the OT, warm the IVT, upper & lower FAWDs, pressure points -discuss w radiologist before any contrast -postop HDU. Day case not appropriate. proliferation of mast cells (cutaneous eg. urticaria pigmentosa, esp in chn), most adults have systemic involvement (esp bone marrow) symptoms relate to mast cell degranulation; release. of vasoactive mediators--> anaphylactic-like reactions can have severe adverse events, a previous uneventful anaesthetic doesn't guarantee future uneventful Do not need. to repeat tryptase pre-op but can do for baseline premed w antihistamine not evidence-based but could use in principle CAN use: fent remi midaz props volatile roc/vec & cis paracetamol dexamethasone neo/glyco regional (no evidence, neuraxial or nerve blocks should be avoided) cophenylcaine is fine (an alternative to amethocaine)

Answer 740

1% (PPV) (TP=1, TN 900, FP 99)

Answer 741

loss of vibratory sense or proprioception below level of lesion It DOES result in: Loss of motor function below level of lesion (initially flaccidity, later spasticity) initial loss of deep tendon reflexes, later hyperreflexia clonus loss of pain/temp sensation bladder & bowel dysfunction May get hypotension from ANS dysfunction sexual dysfunction

Answer 742

200mmoL. administering 10 mEq of potassium for every 0.1 mEq/L desired increase in serum potassium. *if the serum potassium level is >3, 100-200mmol are required. if the K+ is <3, need 200-400mmol

Answer 743

altitude asthma polycythemia Severe obesity pulm haemorrhage L)-R) intra-cardiac shunt mild L) heart failure (incr capillary blood volume) exercise just prior to the test- incr CO mueller manoeuver supine bronchodilator

Answer 744

CO= HR x SV SV= LVOT CSA x VTI 3000mL/min=3L/min *VTI units are velocity/time, so in cm (cm/second per second)

Answer 745

Conditions that ARE ass’d: Apert Down syndrome Pierre robin Treacher Collins Crouzon mucopolysaccharoidosis Neuromuscular syndromes Prader-willi Arnold-chiari syndrome Achondroplasia Spina bifida

Answer 746

Abdo phase via laparotomy (upper midline T6-10 or “rooftop” T8-9) (first stage) Then thoracic phase: posterolateral R) thoracotomy, 4th-5th interspace or thoracoscopy. Ivor Lewis better for Ca of lower 3rd oesophagus. Limited by high risk reflux, if leak @ intrathoracic anastamosis, high M&M risk. 3 stage involves thoracotomy or thoracoscopy first, laparotomy then neck incision (L) preferred since reduces risk of injury to RLN). Neck anastamosis easier to manage if anastomotic leak, lower risk GORD, more extensive proximal resection margin. Transhiatal: upper midline laparotomy & L) neck incision

Answer 747

amputation thoracic wall (thoracotomy) inguinal herniotomy

Answer 748

first line= benzodiazepines (lorazepam preferred intravenous; may have duration as long as 4-12 hrs as less redistribution to adipose). time to maximum effect up to 2mins. midazolam (rapid- often terminates seizures in <1min) pref for IM, nintranasal or buccal; 0.15mg/kg IM/IV (max 10mg paeds), 0.3mg/kg buccal/IN (max 10mg) diazepam pref for PR (effect as early as 10 seconds, duration <20mins, but stable @ room temp). 2nd line= non-BZD antiseizure meds (even if convulsions have ceased) levetiracetam fosphenytoin (prodrug, more rapid IV admin, no need for IV filter, lower potential for tissue or cardiotoxicity) & phenytoin (20mg/kg IV/IO loading, over 20mins max rate 50mg/min, monitored, NOT for age <1 mth), keppra 40mg/kg IV/IO max 3g, dilute to 50mg/mL & infusion over 5mins. valproate 3rd line phenobarbital can also give propofol insion; 2.5mg/kg IV/IO then 1-3mg/kg/hr midaz infusion 1mcg/kg/min Can use: ketamine isoflurane thiopentone not calcium

Answer 749

restrictive (5mL/kg on induction, 5mL/kg/hr intraop, 0.8mL/kg/hr @ least 24hr postop) vs liberal (10mL/kg induction, 8mL/kg/hr intraop, 1.5mL/kg/hr @ least 24hr postop) not ass'd w higher disability-free survival @ 1 yr but was ass'd w higher AKI.

Answer 750

ECMO= use of modified heart-lung machine to provide resp, circulatory (or both) support, for days to weeks. For reversible but severe causes of resp faiure or cardiogenic shock refractory to conventional treatment. Contraindicated if advanced malignancy, severe chronic organ failure, severe brain injury, non-recoverable pathology Cannulae can be placed under direct vision or percutaneous (eg. Guided by US or fluoroscopy). Centrifugal pumps (reliable, easy to care for). Gas exchanger (more efficient CO2 removal than O2 addition), newer devices less resistance to blood flow, less traumatic to blood, less thrombotic. Blood passed through membrane for gas exchange, warmer, return to blood. V-VA, provides support for both pulmonary & cardiac function, has a second venous cannula V-V (central or peripheral) for non-pulmonary gas exchange (support for resp failure). Indicated for hypoxic resp failure ANY cause w expected mort >50%, eg. PF<80. Eg. ARDS (primary eg. infection, aspiration), secondary (eg burns), pulm haemorrhage V-A ECMO (central or peripheral) for both gas exchange & haemodynamic support (provides organ perfusion despite cardiac failure. unloads RV failure (cannulae drain from RA & arterial returns to aorta to aorta) but not LV. eg. for ACS, cardiac arrest w CPR from reversible cause, toxidromes, acute cardiomyopathy, cardiogenic shock due to PE complication= harlequin/differential hypox where LV pumps poorly O2 blood to upper body & coronary, cannula supplies well oxygenated to lower half body, put pulse ox on R) hand (comp of peripheral VA ecmo) V-PA ECMO provides support for RV failure AND non-pulmonary oxygenation; blood bypasses the RV, often used to support RV failure following LVAD insertion. Complications: bleeding thromobsis infection neurological catastrophe differential hypoxia access insufficiency, recirculation, vascular injury, circuit breach (air embolism, blood loss), thrombus, pump failure

Answer 751

400mg (378mg)/day

Answer 752

posterior cord (passes from ceph to caud, under axillary artery, close to posterior cord)

Answer 753

2,5 nitrous 3,5 CO2 1,6 air 1,5 4 entonox single pin (7) in the centre

Answer 754

Norepinephrine

Answer 755

PVR: nitrous, PROSTAGLANDIN ANALOGUES & ERTOG ALKALOIDSValsalva Dramatic drops preload: rapid onset neuraxial, cautious oxytocin (infusion best) Should labour L) lateral Avoid PPH :)

Answer 756

Prostaglandin analogues & ergot alkaloids incr PVR drops in preload myocardial depression misoprostil OK

Answer 757

lower anaesthetic requirement & prolonged anaesthetic drug effects. Higher risk coagulopathy/bleeding/transfusion requirements, reduced CMRO2, impaired wound healing & incr infection risk reduced sens/gain of resp system to hypox/hypercapnia reduced chest wall compliance/ventilation shivering incr CO2 production & O2 consumption vasoconstriction followed by VD tachy followed by brady incr O2 demand & reduced supply (ischaemia) arrhythmia incr PVR (RV failure)

Answer 758

101-200mmHg (severe is <=100mmHg, mild >200 but <300mmHg). Ventilator settings that include PEEP >=5cmH2O

Answer 759

Osmolarity of 308mOsmol/L pH 5.5 Sodium 154mmol/L Chloride 154mmol/L No antimicrobial agents

Answer 760

ACE inhibitor (due to bradykinin excess)

Answer 761

SHOULD do: -TARGETED TEMPERATURE MANAGEMENT (33-36degC for @ least 24hrs) FOR ADULT CARDIAC ARREST (in-hospital any rhythm, out of hospital either shockable or non-shockable) PTS WHO REMAIN UNRESPONSIVE AFTER ROSC -Avoid & treat fever post TTM. Should have temp measured (bladder). keep sedated at least 40hrs while undertaking TTM (but aim to extubate early as possible if neurologically appropriate). Regular paracetamol. Actively cool if temp 37.7. Avoid shivering (regular paracetamol, target Mg >0.8mmol/L, consider buspirone (serotonin agonist). if shivering starts, dexmed or props or remi, Mg++ 1.2-1.6mmol/L target. tier 3= fentanyl boluses, muscle relaxant. -they recommend haemodynamic goals should be made but that must be pot-specific & inadequate data to suggest a threshold; the pts normal SBKP, at least 100mmHg -12-lead ecg; immediate angio & PCI if STEMI or NEW LBBB -Avoid hypoxia & hyperoxia (aim SpO2 94-98%) -kee[ PaCO2 physiologic; extrapolated from TBI they say 35-40mmHg -Treat BGL >10mol/L w insulin but avoid hypoglycaemia -Continue an infusion of any antiarrhythmic that restored a stable rhythm during resus (eg. lignocaine 2-4mg/min or amiodarone 0.6mg/kg/hr for 12-24hrs), may be reasonable to commence an antiarrhythmic drug if one wasn't used to get ROSC from a shockable rhythm. -Treat seizures but DO NOT GIVE ROUTINE SEIZURE PROPHYLAXIS, start seizure maintenance therapy after the first event, exclude potential precipitating causes -emergency cardiac catheterisation in comatose pts with ROSC after OHCA of suspected cardiac origin -evaluate pts for resus-related injuries NOT seizure prophylaxis

Answer 762

dose-dependent incr latency, increase conduction time & reduce amplitude

Answer 763

greater regularity, higher amplitude, lower frequency alpha waves (spindles) of surgical anaesthesia disappear, dominated by delta & theta waves burst suppression--> flat

Answer 764

severity of airflow limitation, categorises based on (in pts w FEV1/FVC <0.7), FEV1 >=80 >=50-80 >=30-50 <30 2x2 table: exacerbations 0 or 1 (not leading to admission) A or B >=1 leading to admission or >=2 exac C or D> -mMRC dyspnoea score 0-1 & COPD assessment tool score <10 A or C, mMRC >=2 or CAT >=10 B or D

Answer 765

Specifically wrt agitation etc, DOES include: anxiety chronic psychotropic use (NOT ETOH abuse or chronic opiate/BDZ use) Surgical: prolonged procedure >1hr, difficult cannulation, pancreatic duct dilation/contrast, biliary sphincterotomy, haemorrhage or duodenal perf Pt: obesity, COPD, OSA, severe acute illness, ileus, ascites, ETOH excess, CVD, elderly, pancreatitis, higher ASA Anaesthetic: bolus vs TCI (from UTD general risks converstion MAC to GA: Hypoxia/airway obstruction, aspiration, unplanned surgical extension Pt factors: inability to tolerate MAC, BMI >35, male, ASA IV other: non-anaes) thorough pre-op Ax crucial

Answer 766

Rectal NSAID (indomethacin, diclofenac and valdecoxib all worked – Meta analysis) prophylactic stent (only experienced endoscopists) Pharmacologic prophylaxis: rectally administered NSAID (indomethacin suppository 100mg or diclofenac 100mg immediately before ERCP) minimising trauma to biliary orific (limit cannulation, guidewire-assisted cannulation, only manipulate pancreatic duct if essential)

Answer 767

Urine osmolality low (urine SG therefore low; they don't quite correlate as SG considers the weight of the solute (therefore number & size), while osmolality just the number of particles. SG generally increases with osmolality. It can be falsely elevated (eg. Glucose) but there are no causes of falsely low urine SG, SG <=1.003 indicates maximally dilute urine (<=100mOsmol/kg) serum sodium would be high (as would serum osmolality), in contrast. toC SW where hyponatraemia & low plasma osmolality Impractical: can measure the urine osmolality before&after desmopressin (with central DI it'll rise, urine osmolality staying low= nephrogenic DI) Plasma vasopressin (low) is infrequently available

Answer 768

>30mL/kg (so risk volume overload, TRALI & MOF) cf fib conc which gives 1g/50mL

Answer 769

supine vs upright (diaphragm positioning more optimal) abdominal binders worn when sitting (no benefit when supine) loss. ofintercostals, lacf abdo tone. tocreate fulcrum for chest expansion w inspn, diaphragm flattened (lost mechanical advantage), w inspiration & dipahragm contraction chest wall sucked in (paradoxical chest wall movement). supine FVC & FEV1 are larger supine cf seated, down to injury level of T1. w time, spasticity develops so chest wall more rigid, less likely to collapse. above C3: ventilator dependent C3-5 depends on effect on diaphragm & accessory mm C6-8: may require intermittent NIV. accessory neck mm. &intact diaphragm help. exhale passive, cough impaired. thoracic: inefficient cough otherwise little resp compromise. Cx spine lesions develop restrictive vent deficit.

Answer 770

DIGOXIN Loop diuretic (for symptoms but not mortality benefit) Drugs that DO reduce M&M in HFrEF: ARNi (degrades neprolysin, which breaks down ANP & BNP, both agents which reduce blood volume. neprolysin also degrades bradykinin). ACE-I ARB Cardiospecific B blockers: bisoprolol, carvedilol, SR metoprolol MRA (spironolactone or eplerenone), provided eGFR>30 & K<5 hydralazine + nitrate combo SGLT2i reduce hospitalisation for HF & reduce cardiovascular mortality, irrespective of T2DM presence omega 3 polyunsaturated fatty acid supplement mortality benefit Initial pharmacologic therapy for HFrEF= combo diuretics, RAS inhibitor (ARNI, ACE-I or ARB) AND B-blocker Secondary= MRA & SGLT2-I in preg, hydralazine + nitrate= vasodilator therapy of choice, since ACE-I & ARB & sacubitril-valsartan contraindicated. Thiazolinediones & DDP-4 inhibitors & NSAIDs worsen HF symptoms

Answer 771

REDUCES TIME TO FIRST ORAL INTAKE. Single dose IV intra-op dexamethasone: -Decreases N&V in first 24hrs post -Decr time to first oral intake -decr post pain may incr risk postop bleeding but degree of risk unknown, likely low, reduces PONV (single intraop dose in chn half as likely to vomit), reduces swelling in oropharynx or soft palate

Answer 772

30cmH2O (20-30cmH2O) cuff pressure for mucosal ischaemia is lower. in shocked patients)

Answer 773

doxycycline 400mg w food 10-12hrs before OR doxycycline 100mg orally 60mins prior to procedure then 200mg 90mins after.

Answer 774

5mmol bolus KCl IV

Answer 775

up to 400mL clear fluids 2 hrs prior to OT, limited solid food up to 6hrs prescribed meds with a sip of H2O within 2hrs prior to anaesthesia

Answer 776

Adr neb over 5-10mins (OR 0.5mL/kg 1:1000, max 5mL) analgesia cool humidified mist (postextubation stridor; mild cases where stridor only) prophylaxis IV dex 0.15mg/kg (if croup stridor, 0.6mg/kg)

Answer 777

tightly fitting ETT, leak pressure >25cmH2O chn <4yo (smaller airway lumen) multiple intubation attempts longer intubation head & neck srugery (frequent position changes) URTI, recent croup coughing. onextubation subglottic stenosis prophylaxis: IV dex prior to extubation (0.15mg/kg) sedation. &pain control to prevent crying/agitation cool humidified mist if stridor mild only racemic epinephrine moderate

Answer 778

intrathecal; high spinal (total spinal=LOC)

Answer 779

Glossopharyngeal nerve IX

Answer 780

just left with red cells suspended in saline, FOETAL RED CELLS are left Removes: free Hb, plts, plasma, microaggregates, anticoagulants thrombogenic products (FDPs), complement proteins, leucocyte enzymes, SOME inflammatory mediators

Answer 781

risks RPE lack of oscillation suggests lung re-expanded usual initial suction -10- -20cmH2O, adults & paeds spont air leaks, use the minimum suction for re-expansion; initially water seal only (no suction); add suction -10cmH2O if incomplete PTx resolution, incr only as needed, increase if persistent air leak. if the tube is for fluid drainage, -20cmH2O good starting point, incr as indicated to aim for full lung expansion. LARGE PDIFFERENTIAL PRESSURE GRADIENT SHOULD BE AVOIDED DURING LUNG EXPANSION TO PREVENT RE_EXPANSION PULMONARY OEDEMA.. If large effusion, initially no suction, this may decr risk RPOEDEMA.. Traumatic PTx: immediate 20mL/kg (or 1500mL or >3mL/kg/hr indicates thoracotomy. rapid fluid removal w large effusions ass'd w RPE. if no air leak, clamp tube if pt gets cough/chest pain/dyspnoea or O2 desat (limit risk RPE). wait for symptom resolution before resuming drainage. Risk of RPO only when the lung starts to inflate, so can drain larger amounts if mediastinal shift CL to the effusion. excessive suction risks "air steal" & hypoxaemia, perpetuates leaks, damage lung if trapped in catheter

Answer 782

>=7Fr OR vessel dilated w sheath: leave in place, safe removal urgently discussed w vascular surgeon. Delay non-urgent surgery unless risk cancelling > risk proceeding. If proceed, leave needle/sheath in situ until end of operation (consider heparinisation if poss). Urgent vascular & radiological consult w immediate imaging to Ax injured site. Leaving arterial catheter in place w prompt repair carries less M&M than catheter removal w pressure (ass'd w major stroke, death). Carotid generally direct exploration/catheter removal/arterial repair, while sites not easily accessible surgically (subclavian) require endovascular (stent, vascular closure device, tract embolisation). Should NOT permit prolonged arterial cannulation; if immediate Rx not possible, consider heparinisation. Zone III (from 1cm above clavicle & below), require sternotomy or endovascular repair. Zone II (from 1cm above clavicle to angle of mandible) can be repaired w direct pressure/open cutdown/endovascular. Zone III angle of mandible to BoS. Remove small (22-25g) needles from carotid artery, apply pressure 5-10mins to prevent haemorrhagic complications, clinical Ax of bleeding/haematoma. Image to exclude sig complicaitons. Neuromonitor 24hrs postop (embolic stroke a risk if significant carotid atherosclerotic disease). For pts w Hx carotid atherosclerotic disease, >1 puncture or significant haematoma, could postpone elective surgery w 24hr neurol follow-up. Our quad lumen is 8.5Fr, 20cm.

Answer 783

postpone ELECTIVE surgery until cause established (discuss w Haematology) & corrected, w PO vit K 1-2mg PO. other options (day of surgery) PTx (15-30IU/kg (30 in this case (INR 1.5-2.5, target <1.4) 50 if life-threatening bleed)- prothrombotic risk, 4F contains heparin) or FFP (150-300mL if given w PCC for life-threatening bleed, 15mL/kg if PCC n/a) or (if day before surg, vit K 1-2mg PO only generally sufficient).

Answer 784

Turn off the last piece of equipment to be plugged in- that's usually the culprit of the fault in the system

Answer 785

Death due to bleeding give within 3hrs of birth

Answer 786

haemodynamically unstable pelvic fracture. Place pads in retroperitoneal space. Leave. insitu 24-48hrs. Controls VENOUS & bony source of bleeding (unlikely to control arterial haemorrhage) can use concurrent. w ex fix.

Answer 787

Nitrous oxide Sits below it's critical temp (36degC) existing as vapour in equilibrium w liquid phase

Answer 788

Reduced venous return, reduced cardiac output The initial incr IAP from 5mmHg first causes incr VR & CO As IAP rises (10-20mmHg), VR & CO decrease. Incr SVR means that @ IAP 10-20mmHg, BP ISQ or incr. From >20mmHg, VR, CO & BP all decr

Answer 789

2kg Size selection for I-Gel * Size 1.0 = 2 - 5 kg * Size 1.5 = 5 - 12 kg * Size 2.0 = 10 - 25 kg * Size 2.5 = 25 - 35 kg * Size 3.0 = 30 - 60 kg * Size 4.0 = 50 - 90 kg * Size 5.0 = > 90 kg

Answer 790

2kg Size selection for I-Gel * Size 1.0 = 2 - 5 kg * Size 1.5 = 5 - 12 kg * Size 2.0 = 10 - 25 kg * Size 2.5 = 25 - 35 kg * Size 3.0 = 30 - 60 kg * Size 4.0 = 50 - 90 kg * Size 5.0 = > 90 kg

Answer 791

Antiphospholipid syndrome (lupus anticoagulant) Pts have venous/arterial thrombosis +/- adverse pregnancy outcome, persistent aPL antibodies. Can be primary or with other condition eg. SLE, RA, systemic sclerosis, Bechet’s. Pt often presents w livedo reticular, digital ischaemia/gangrene, sequelae of DVT, heart murmur, neurological abnorms suggesting prev stroke Other DDx= heparin exposure, haemophilia A & B, factor XII or XI def, artefact

Answer 792

L1 vertebral body

Answer 793

Hypomagnesemia, hypokalaemia, hypocalcaemia, Brady Meds prolonging QT: methadone, droperidol, amiodarone + dig, TCA overdose Pt factors: congenital long QT syndrome, female, renal or liver failure

Answer 794

EXTEM A5 <=35, platelets EXTEM CT >=90, factors (FFP) Test tube shape: thrombocytopenia, give platelets Inverted martini: fibrinolysis (TxA) Wine glass: factor deficiency (give FFP) Champagne flute: fibrinogen deficiency (give cryo/fibrinogen) Brandy snifter= normal Extem= TF + CaCL2 + polybrene, extrinsic pathway Fibtem= Extem + cytochalasin D, inhibits plt activity, analysis of fibrinogen activity Aptem= Extem + aprotinin, excludes hyperfibrinolysis Intem= CaCl2 + ellagic acid, intrinsic pathway, APTT equivalent

Answer 795

6hrs (UTD: maximal risk in first 2-12hrs), 5-10% rebleed within the first 72hrs

Answer 796

Internal branch superior laryngeal nerve

Answer 797

1 (fibrinogen; approx 15mg/mL in cry vs 3mg/mL in FFP) & VIII 1 unit of cryo (20-30mL) has 150->300mg fibrinogen >80IU factor VIII 50-75 units factor XIII 100-150U vWF fibronectin 1 unit FFP (200-300mL) Has 1.14IU/mL factor VIIIc (ie < cry) 600mg fibrinogen

Answer 798

5mg/kg (80mg using (age+4)x2)

Answer 799

150microg (0.15mL of 1:1000) * Age > 12 years = 500 microgs (0.5 mL of 1:1000 Adrenaline) * Age 6-12 years = 300 microgs (0.30 mL of 1:1000 Adrenaline) * Age < 6 years = 150 microgs (0.15 mL of 1:1000 Adrenaline) * Age < 6 months = 0.01 mg/kg or 10 microgs/kg (0.01 mL/kg of 1:1000 Adrenaline)

Answer 800

Pathological Q waves ARE a feature in hypertrophic > dilated cardiomyopathy STEMI (they are a sign of myocardial necrosis, may take minimum 2hrs (sometimes up to 24hrs) to appear. LV aneurysm Pathological Q waves are >1mm wide, >2mm deep, >25% depth QRS, seen in V1-3 They are NOT a feature of dig tox (freq VEBs, high degree AV block, atrial tachycardia); cf digoxin effect (“sagging” st depression & TWI (reverse tick), PR pool, U waves, J point depression)

Answer 801

presence of rate modulation (O=none, R= rate modulation present)

Answer 802

200mg IVI over 24hrs

Answer 803

R wave, to avoid R on T phenomenon

Answer 804

3 2 for males For females scoring 2 & males scoring 1, decision for OAC depends on non-gender risk factor; if it is age 65-74, use chronic OAC.

Answer 805

Cranial nerve (abducens) palsy Cortical vein thrombosis Cerebral venous sinus thrombosis Cranial-subdural haematoma Seizures Stroke persistent headaches, chronic LBP, depression, bacterial meningitis NOT encephalitis or Sheehan syndrome

Answer 806

vasopressin

Answer 807

1-5% (intraperitoneal, intrathoracic, CEA, head & neck, ortho, prostate) High risk is >5% (aortic & major vascular, peripheral vascular) Low risk <1% (endoscopy, superficial, cataract, breast, ambulatory)

Answer 808

middle of T wave peak of the R wave

Answer 809

80 (GA x2)

Answer 810

DOES include: Eye opening Conjugate gaze Purposeful movement Vt >5mL/kg Facial grimace Movement other than cough/purposeful movement RR 16/min FiO2 0.35, SpO2 >97% Etsevo <0.2, des <1% Positive laryngeal stimulation test (return of sport vent <5s after gentle stimulation of glottis by cephalic, caudal movement of ETT in pt spont venting @ emergence)

Answer 811

AVN blocking drugs (esp adenosine, verapamil) sympathomimetics (direct-acting; Adr, dobutaime, increased adrenoceptor density)

Answer 812

opioid induced hyperalgesia

Answer 813

Splenomegaly or metabolic alkalosis Is characterised by: Cardiac: heart failure, pulmonary oedema, widened QRS, bradycardia, VT, VF, systole, brugada-like ecg changes (coved STE V1-3) Vascular: hypotension MSK: rhabdo (elev CK) Metabolic: acidosis (lactic, due to impairment normal oxidative phosphorylation), hyperkalemia, lipidaemia hepatomegaly & elevated liver enzymes Renal failure Risk >4mg/kg/hr for >-48hrs

Answer 814

calcium chloride Drugs that DO impact: insulin salbutamol bicarb (only in setting of acidaemia) spironolactone suxamethonium magnesium frusemide

Answer 815

tissue injury & hypoperfusion--> protein C pathway

Answer 816

Peripheral V-A ECMO. pts receiving peripheral VA-ECMO are dependent on retrograde flow to delivery oxygenated blood to the upper body. If they've got concomitant resp failure, risk poorly oxygenated blood preferentially being delivered to the myocardium & brain, risking hypoxic injury. *should avoid peripheral V-A ecmo in pts receiving ECMO for resp failure. Should measure SO2 in both hands of pts receiving peripheral V-A ECMO (the phenomenon is developing if lower SO2 readings in R) hand cf L).

Answer 817

NEXUS: for pts <60yrs if satisfy all of the 5: -Ax for absence of intoxication -Ax that the pt is alert & oriented -Ax no painful distracting injury -Absence of midline tenderness -Absence of focal neurology

Answer 818

recurrent laryngeal nerve

Answer 819

Compliance = 600 / (32 - 12) = 30

Answer 820

Less ulnar sparing less phrenic nerve block

Answer 821

APLS states if no vascular access, IM midaz 0.15mg/kg OR buccal/intranasal 0.3mg/kg (max 10mg). Then IV or IO 0.15mg/kg while preparing levetiracetam 40mg/kg or phenytoin 20mg/kg 5mins: midaz 0.15mg/kg IM or buccal/IN 0.3mg/kg (both max 10mg) at 10 mins, IV/IO midaz 0.15mg/kg prepare keppra or phenytoin 15mins keppra 40mg/kg max 3g over 5mins or phenytoin 20mg/kg over 20 mins 20 mins give the other or phenobarbitone (20mg/kg max 2g paeds) 25mins RSI

Answer 822

aspirin prevents, naproxen low risk NSAID's and haematological complications COX-1 (anti-platelet function) Constitutional Homeostatic Inhibition of platelet function COX-2 Inducible Pain, Inflammation, Fever, Vascular Permeability, inhibit prostacyclin (which inhibit plt activation) & stimulate thromboxane which promotes plt aggregation. Descending order from COX-1 > COX-2 selectivity Ketorolac = COX-1 selective Aspirin = COX-1 selective Naproxen = COX-1 selective Ibuprofen = COX-1 selective Diclofenac = COX-2 selective Celecoxib = COX-2 selective Meloxicam = COX-2 selective Valdecoxib = COX-2 selective

Answer 823

Administration of low-dose clonidine (or aspirin) in patients undergoing noncardiac surgery did not reduce the rate of the composite outcome of death or nonfatal myocardial infarction; it did, however, **increase the risk of clinically important hypotension and nonfatal cardiac arres**t, aspirin incr risk bleeding

Answer 824

Administration of aspirin before surgery and throughout the early postsurgical period had no significant effect on the rate of a composite of death or nonfatal myocardial infarction but increased the risk of major bleeding.

Answer 825

Gilbert's (inborn error of bili conjugation) Autosomal recessive decr activity of uridine diphsophate glucuronosyltransferase Bilirubin levels incr w stress/dehydr/fasting/infection

Answer 826

ICH OR eclamptic seizures (which may --> haemorrhage & cardiac arrest)

Answer 827

6 major subtypes, range from minor to life-threatening, mutations related to collagen proteins, AD or AR, features incl: chronic pain Ophthalmic: risk retinal detachment, globe rupture Fragile skin Hypermobile/unstable joints (C-spine, TMJ) risk premature spondylosis tissue fragility subtypes risk dural rupture & headache similar to PDPH. Some have Tarlov cysts (CSF-filled perineural cysts). some may have muscle weakness Atrophic scars, easy bruising PTx risk (vascular EDS) scoliosis Cardiac involvement (MR, MVP, AR) Possible POTS (esp w hypermobile variant) Vascular EDS may have arterial rupture--> X-match for vascular EDS or those w positive bleeding Hx or for surg factors most have some abnormality of plt aggregation (lab tests often normal) risk organ rupture. LA resistance, resistance to opioids has been reported. NOT intellectual disability Little evidence-based knowledge to guide Mx. check for bleeding Hx screen multisystem complications check airway difficulties (spondylosis, A-O instability, TMJ subluxation, mucosal fragility, scoliosis) facility consider discussion of open vs laparoscopy in vascular EDS Potential difficult airway if C spine instability, spondylosis or kyphosis, TMJ laxity consider pre-load w IVT & early vasopressors if POTS gentle +++ airway instrumentation, consider smaller ETT & regular cuff pressure checks (risk mucosal damage) Minimise airway pressure (risk PTx) ideally AVOID tourniquets- risk massive compartment bleeding & haemorrhagic shock Use non-invasive monitoring where possible (care w repeated NIBP). in vascular EDS avoid invasive wherever possible; use US. If need CVC, IJ pref over subclavian, limit use dilators, US mandatory. care w taping (shear forces, fragile skin) positioning/padding pressure points, protect eyes, avoid brachial plexus traction. blood strategy CONSIDER DDAVP (incr vWF & VIII levels) Consider TxA Cell salvage for pt/surg risk factors consider difficult/failed neuraxial risk (scoliosis, prev spine surgery, ineffectiveness of LAs. SOME CONSIDER NEURAXIAL CONTRAINDICATED IN VASCULAR EDS (risk haematoma/nerve injury if tissue fragility); individualise. If considering, pre-intervential MRI to help rule out spine pathology (eg. Tarlov cysts). Peripheral blocks; US mandatory (risk vascular puncture) ?consider avoiding if vascular EDS. Tissue scarring may impact the spread of LA. May impart LA resistance (eg. EMLA). Risk uterine rupture, delayed wound healing any mode delivery. anticipate severe bleeding. X-match, cell saver, DDAVP prophylaxis. Consider elective LSCS in high risk EDS subtypes. vascular subtype if in labour (?), consider PCA vs neuraxial. care w nitrous as spon PTx risk in some pts. If neuraxial, discuss extra PDPH (expert opinion), haematomoa risk. Postop early mobilisation limit risk of immobility, thorough monitoring bleeding site haematoma risk. monitor pts w POTs for CV instability. PONV prophylaxis (risks spont oes rupture). Staff looking after the pt to be aware of potential complications relevant to the pts subtype (compartment syndromes, vascular rupture, PTx, organ rupture; most common vascular EDS). Low threshold for Ix.

Answer 828

decr CMRO2 21degrees slow cardiac conduction, risk brady, arrhythmias, reduced CO, decr SVR, circulatory collapse pulm oedema, L)-shift OHDC, slow/shallow/irrecgular breathing hyperkalaemia, acidosis coagulopathy, thrombocytopaenia MILD hypothermia: hypERglycaemia Incr SVR & sig reduction cardiac index so MAP only decreased slightly Incr platelet adhesion

Answer 829

A life-threatening organ dysfunction caused by a dysregulated host response to infection

Answer 830

Regional wall motion abnormalities (endocardial hypokinesia, akinesia or diskinesia)on echo (flow heterogeneity--> metabolic changes--> altered mechanical function--> then ecg & pain. ie. regional malperfusion is the most sensitive clinical marker of ischaemia, chest pain the least).

Answer 831

are ass'd w incr harm. to foetus which may be reversible, no evidence congen malformations Category A= taken by large number of preg & women of child-bearing age, no evidence direct or indirect harm to foetus B1= limited number. no evidence harm. animal studies not demonstrated incr risk harm. B2= limited number. no evidence harm. animal studies inadequate/lacking. B3= limited number. no evidence harm. animal studies incr occurrence foetal harm. C= ass'd w incr harm which may be reversible. no evidence congen. D= incr risk foetal malformations or irreversible damage, may also have adverse pharmacological effects. X= contraindicated. High risk permanent damage.

Answer 832

accelerated haematopoiesis (with active bone marrow), eg. from: -HAEMOLYSIS (destruction, also see decr haptoglobin, incr LDH, incr bilirubin, incr RDW) which may be: -immune (transfusion reaction, RhO) -toxins (clostridial) -thrombotic microangiopathy (haemolytic anaemia) -traumatic (direct, shear stress, heat damage) -G6PD (XLR, where haemolytic anaemia occurs in response to infections, stressors, hypothermia, acidosis, fava beans, aspirin (exposure to oxidative drugs (avoid drugs causing oxidative stress & those that can induce metHb)) can--> haemolytic crisis)--> fever, dark urine, abdo/back pain, pallor). Avoid hypothermia, manage infection, limit surgical stress, avoid acidosis, avoid methylene blue. Prepare for blood loss (haemolysis risk). first on list, limit stress of fasting, aggressive glycaemic & temperature control. Generous analgesia. The pts may take vit E or folic acid -other haemolytic anaemias (sickle cell, thalassaemia) -DIC DDx for raised retics= blood loss normal retics 0.5-2% Other DDx of reticolocytosis (if no haemolysis) recovery from episode of bleeding (or ongoing bleeding), repletion of Fe, B12, folate, EPO, recovery from bone marrow insult (eg. infection, parvovirus), medicaiton or ETOH Unsafe drugs. forG6PD: acetazolamide co-trimoxazole dapsone diclofenac diazepam genatmicin lignocaine methylene blue maxalon nitrofurantoin nitroprusside penicillin prilocaine quinolones (eg. cipro) rasburicaise sulfonamides toludine blue phenazopyridine

Answer 833

Straight useful for: -macroglossia -large front incisors/irregular teeth -large floppy epiglottis -useful for pathologies where don't want to use much force or neck extension (mac blade requires maximum neck extension) -larynx fixed from scar/trauma/mass effect -short thick neck or morbid obesity NOT post column Macintosh 90 deg Kessel 110deg (often used w short handle) McCoy moveable distal tip Magill straight blade U cross section Miller straight w curved tip

Answer 834

Time Can give FFP however risk > ben when administering blood product

Answer 835

inhibits plasminogen--> plasmin hence fibrinogen--> fibrin

Answer 836

multiple sclerosis (denervation)

Answer 837

1IU, 2.5-7.5IU/hr infusion (if required after 2 mins, further 3IU bolus over >30s) Intrapartum caeser: 3IU oxytocin over >=30s, infusion 7.5-15IU/hr alt is carbetocin 100microg over >=30s

Answer 838

Creatinine MELD Na also uses sodium. If the pt ahs been dialysed twice within preceding 7 days, value for Cr becomes 400.

Answer 839

completely dissimilar side chains: ceftazidime (3rd gen) `cefazolin cefuroxime cefixime cefmetazole LOWEST risk 3rd gen cephalosporins (cephalexin, ceftriaxone, ceflacor possible)

Answer 840

thoracodorsal (supplies lat dorsi actions on GHJ vs scapula) serratus anterior IS long thoracic nerve trapezius (XI- spinal accessory nerve). rhomboids (dorsal scapular nerve) levator scap (C3-4 & dorsal scapular nerve (C5))

Answer 841

CRPS= debilitating condition, most often in limb followlin injury/trauma/surgery, 0.5-2% post-traum incidence. Dx criteria= regional pain, disproportionalte to initial trauma, skin colour & temp changes, oedema, vasomotor & sudomotor changes, motor dysfunction & trophic changes. CRPS1 (prev RSD)= sans obvious nerve injury CRPSII (prev "causalgia") with confirmed nerve lesion. acute phase: inflammatory dominance. OR cold phenotype. pain restricted to the affected limb hyperalgesia. May transition to chronic phase. inflammation diminishes, centrally-driven symptoms prevail (eg. sensory, motor symptoms & fear avoidance. paediatric more readily treated with physical/rehab therapy changes to areas distal to injury IS characterised by: pain: burning/stinging/tearing generally deep hypoaesthesia/hyperalgesia/allodynia arious types of sensory abnormalities are common in CRPS. Some patients have evidence of hyperalgesia, allodynia, or hypesthesia on examination . Sensory disturbances are usually distal in the limb, sometimes in a stocking/glove pattern oedema changes to areas distal to injury skin changes (incl colour, sweating, trophic changes (hair growth, skin atrophy)) temp changes functional motor impairment related to pain preceding OT/injury No clear unified pathological explanation, may involve cortical reorganisation. Latest thought= an immunoneurological disorder, with 4 components proposed: local tissue damage, pain processing, ANS/endocrine & immune (time course of homeostatic disturbance in that sequence). painful condition, continuing (spont/evoked) regional pain (not in dermatome, may be stocking/glove-like distribution), seemingly disproportionate in time or degree to usual course of any known trauma or other lesion. regional (not nerve territory or dermatome), usually distal predominance. variable progression. Type 1- no evidence peripheral nerve injury Type II has peripheral nerve injury present. Mx: Limb desensitisation techniques have not had efficacy validated. Opioids & NSAIDs no proven benefit, concern opioids worsening NO biers (no evidence) Calcitonin no evidence benefit Early diagnosis & intervention improve prognosis, those progressing to chronic phase poorer prognosis. Psych symptoms in first uyea ass’d w worse outcomes if untreated. Individualised. Best evidence= early oral corticosteroids 6 wk course, single IV bisphosphonate infusion. Absence of specific CRPS validated treatments so standard neuropathic pain Rx often used eg. Gabapentin, pregab, duloxetine (sari), tca, IV lignocaine & ketamine. Multimodal: CBT. Limited evidence but reasonable. MOTOR IMAGERY: documented benefit. Sympathetic nerve blocks Radio frequency lesioning of symptoms chain limited evidence efficacy in early CRPS. inflammatory: CS Regional osteopenia (acute CRPS1): bisphosphonates psych: CBT Pain/hyperalgesia/allodynia: alpha2delta ligands, TCAs SNS-mediated pain: SNS blocks, ketamine Chronic refractory: spinal cord or DRG stimulation Central motor symptoms: botox, intrathecal baclofen

Answer 842

Anaes: ABx not routinely administered LA/regional or GA.NSAIDs 1 hr preop to limit uterine contractions Generally regional better tolerated

Answer 843

6.5mm ID 4.7 size 7=smallest ETT 56cm long use over flexi bronch 4mm ID or less, eg. ambu slim 3.8mm which can fit ETT size 5, DLT size 37, ambu regular is 5 so too big, that scope fits 5.5 ETT or 39 DLT ultrathin bronch 2.2mm (no suction channel) storz 2.3mm fits 2.5ETT, 35Fr DLT 2.8mm fits ETT size 3, DLT 37Fr 3.there's an adult olympus 4.1mm ED

Answer 844

mast cell degranulation (histamine release from mast cells & basophils; non immune-mediated) influenced by dose of vancomycin infused & rate of infusion

Answer 845

Pull back ETT 1-3cm (endobronch intubation following capnoperitoneum). lung pulse= rhythmic movement of pleura in synchrony w cardiac rhythm, indicates opposition of parietal & visceral pleura.

Answer 846

facilitates intraop colonoscopy

Answer 847

R) UL middle lobe has lat & medial

Answer 848

LAD= apex, RCA= RV; all else is shared

Answer 849

Central retinal artery occlusion: retinal whitening, cherry red spot, oedema, segmental flow of retinal blood vessels (boxcarring). Post ION= initially normal optidc disc & fundus, later pallor. RAPD.

Answer 850

proceed to lobectomy (fine if FEV1 > 1.5L) or pneumonectomy (fine. ifFEV1 >2L (if it was < these thresholds, can have surgery if % ppo FEV1 or TLC was >40% If not, proceed to exercise testing; crack on if VO2max >15mL/kg/min If not, consider other options

Answer 851

Beck's triad: hypotension, raised JVP, muffled HS tacchycardia Pulsus paradoxus (10mmHg incr in SBP. w inspiration) Kussmaul sign: elevated JVP during inspiration Signs/symptoms obstructive shock Ecg: low voltage, electrical alternans CXR: enlarged globular heart echo: pericardial effusion (large is >20mm), R) heart affected before L), collapse of cardiac chambers, IVC dilation, incr resp variation in intracardiac blood flow, excessive shift of IVS w spont ins, functional effects dyspnoea, orthopnoea, chest discomfort, cool peripheries, low UO, diaphoresis, anx

Answer 852

Hydroxycobalamin 5mg over 15 minutes, repeat up to max dose 15mg Cyanide is not a common form of poisoning, however, should be considered in closed house fires or industrial fires Cyanide reversibly binds to ferric ions within the mitochondria causing anaerobic metabolism (inhibition of oxidative phosphorylation) Rapid development of tissue hypoxia and profound mydriasis, ALOC, seizures, coma and death HAGMA with serum lactate > 8.0 mol/L Early treatment with hydroxycobalamin 5 mg over 15-minutes can be life-saving Activated charcoal 50g Carbon monoxide inhalation improves with time and 100% oxygen administration

Answer 853

Hypercalcaemia Does include: Hypoglycaemia hypokalaemia Immunodeficiency (WCC, neutrophils or leukocytes) metabolic alkalosis Cardiac complications: sinus brady (decr BMR), orthostatic hypotension, arrhythmias (AV block, prolonged QTc, sinus arrest, wandering pacemakers, nodal escape beats, SVT, VT)ST depression, TWI, MV prolapse, pericardial effusion, congestive cardiac failure, cardiomyopathy, impaired myocardial contractility hypotension hypOcalcaemia, hypokalaemia, hypoMg++, hypoCl, ypocalc, hypophlsphataemia (impairs myocardium, reduces threshold for arrhythmias) renal calculi enlarged salivary glands, dental caries, oesophagitis/gastritis risk refeeding thrombocytopenia may have cognitive impairment seizures stress fractures poor wound healing Osteopaenia leading to fractures cold intolerance, vulnerable to pressure injuries often co-existing psychiatric conditions.

Answer 854

Highest deflection of the P wave= cavo-atrial junction

Answer 855

saphenous purely sensory obturator out of the way

Answer 856

Drugs that decrease DFT (K+ channel blockade): sotalol Those that incr (sodium channel blockade): amiodarone (in chronic stage, decreases in acute stage!) lignocaine verapamil venlafaxine atropine diltiazem flecainide no change = procainamide

Answer 857

LA if double density sign

Answer 858

photosensitivity (avoid direct light incl bright OT light/sunlight for 24hrs)/burn risk there's also risk lactic acidosis. These pts also get hepatic dysfunction (bili, AST, ALT, GGT all. go up) anaemia, thrombocytopaenia, leukocytosis, thromboembolism elevated amylase N&V hypotension, reduced PVR Gliolan is C/I in porphyria, pregnancy, if hypersensitive to ALA (haem precursor)

Answer 859

Characterised by rigidity Responsive to dantrolene

Answer 860

25mm23.5mm (22-25mm)

Answer 861

Down syndrome (mask vent might be difficult, laryngoscopy gen fine as MO normal, laryngoscope displaces large but soft tongue) -Apert -Hurler (mucopolysaccharoidosis type 1)- frequent URTI, chronic OM & OSA, dysmorphic features, limited reck ROM, macrocephaly, coarse facial features, depressed nasal bridge, short stature, , flexion/joint deformities, pectus hepatomegaly, fatty infiltration mitral valve prolapse, MR -treacher collins -pierre robin all difficult intubation

Answer 862

incr PVR hypodynamic phase initially: incr SVR, PVR, reduced CO, decr SvO2 subsequent incr vasc permeability, hyperdynamic & hypermetabolic flow phase

Answer 863

opioids (NMBDs augment them)

Answer 864

cerebral palsy

Answer 865

Defer surgery @ least 4wks, Fe infusion (or oral Fe & OT 12wks later)

Answer 866

ve witheld 96hrs if purely surgery, (normal renal fn 48hrs, 50-80 72hrs, 30-50 96hrs, <30 120hrs)

Answer 867

octreotide; 20-50microg IV boluses to effect (or as per UTD, 500microg followed by 50-200microg/hr infusion

Answer 868

SpO2 low (close to 100%), PaO2 generally normal since it reflects O2 dissolved in blood & this process isn't affected by CO.

Answer 869

Superior sagittal (where the incision for frontal crani is) Occurs when pressure gradient across vein; relatively -ve in vein cf atmospheric, particularly in noncollapsible venous structures. spont vent incr risk.most often during incision or dissection around vascular structures.

Answer 870

It induces CYP3A4 so, reduces effects of amiodarone, warfarin (2C9), MTx, cyclosporine, HIV protease inhibitors, alfentanil, midaz, lignocaine, some NSAIDs. Digoxin minor CYP3A4 metabolism. Theophylline some CYP3A4 metabolism. It works by inhibiting serotonin, NAdr, dopamine re-uptake, risks serotonin syndrome.

Answer 871

main goals: maintain preload, limit PVR, maintain contractility -ve pressure is ideal (spont vent) to limit drops in preload however if procedure requires paralysis, aiming to avoiding excessively high Paw, avoid atelectasis; LOW RR WITH SHORT Tinsp, low PEEP, relatively low TVs but ensure low-normocapnia need to preserve myocardial contractility

Answer 872

with 1 or more risk factors 1-2: 2 agents >2 3-4 paeds: No risk factors: 0 or ordans or Dex 1-2 dex & ondans 2+: dex, ondanks, consider TIVA

Answer 873

hyperfibrinolysis

Answer 874

Clonidine PROSPECT: include paracetamol, NSAIDs, dexamentasone w opioids as rescue.

Answer 875

spont vent vasopressor to defend RV perfusion (eg. vasopressin, NAdr) BUT don't want to overload dilated ventricle so initrope (dob) PAH mild 20-40, mod 41-55, seere >55

Answer 876

L4/5 peripheral disc bulge w impingement

Answer 877

100mL (desired increment Hb x body wt x 0.5) but if >20kg, just give 1 paeds unit (60mL) *4mL/kg incr Hb by 10 10mL/kg incr it by 30

Answer 878

if haem stable, throught to be antidromic VT, vaslalva. no adenosine or CCB. can give procainamide.

Answer 879

incr supply (high FiO2, hyperbaric) reduced demand (hypothermia, NMB) high flow states (hyperthyroidism, severe liver disease) severe sepsis may see high SvO2 as high CO &low O2 extraction; aim SvO2 >70% cyanide toxicity

Answer 880

HCM, HTN, AS, MR; reduced myocardial compliance; forced atrial contraction & raised LVED

Answer 881

HTN from splanchnic (T5-9) VC (below level of lesion; if injury T6 or higher, get splanchnic)

Answer 882

seated crani (100%) LSCS (40%) hip arthroplasty (30%) ant Cx discectomy 10%

Answer 883

pheochromocytoma pt refusal HIT if heparin-containing anticoagulnat discontinue it where temporary contamination of surgical field w solutions that may cause red cell lysis or drugs/subsances that shouldn't be given intravenously eg. cement, iodine, topical clotting agents. Wash the area w 0.9% NaCl before resuming ICS. Discuss sickle cell w haematologist on case by case basis. Chance salvaged blood returned to pt may sickle. avoid from grossly contaminated fields & manufacturers contraindicate it if bowel contaminationunless catastrophic haemorrhage, , should be able to use for part of procedure w LDF & broad-spectrum ABx.

Answer 884

physical dependence, predictable & physiological. increased dose. stop/reverse/reduce= withdrawal Tolerance: increasing dose required for same effect Dependence: withdrawal symptoms on reducing/abrupt cessation Addiction: aberrant drug seeking behaviours (departing from accepted standard) despite risk of psychological/physical/social harm

Answer 885

Fused C& V waves= tricuspid regurg

Answer 886

Suxamethonium, since the organophosphate inhibit acetylcholinesterase so prol NMB. Can use NDNMBs but may be less effective due to competitive inhibition @ NMJ (likely to need incr doses). The Rx for cholinergic toxicity includes pralidoximine; cleaves bond btw organophosphate & acetylcholinesterase, reactivating it

Answer 887

remove inner cannula- re-assess. Pass suction catheter if established trache, re-assess. Deflate/reinflate cuff (in case herniated over end of trache, re-assess

Answer 888

factors affecting membrane SA eg. emphysema (standing lower DLCO vs supine) factors affecting membrane diffusion barrier eg. CCF, pulmonary oedema, interstitial fibrosis, sarcoidosis factors causing lack of pulm blood volume eg. pulmonary HTN or PE, valsalva DLCO generally incr during exercise, may not incr adequately if pulm vascular bed reduced by emphysema Factors affecting uptake by Hb: anaemia CarboxyHb supplemental O2

Answer 889

less transfusion, more thrombosis (hence benefits offset by risks incl mortality & thrombotic complications so NICE recommend that EPO shouldn't be used in surgical pts to reduce blood transfusion. It stimulates rbc proliferation

Answer 890

GENTAMICIN- aminoglycosides CCBs Mg++ all contribute to muscle weakness, potentiation of actions of NMBDs VC<2.9L, pyridostigmine >750mg/day, Dx >6yrs ago, coexisting pulmonary disease

Answer 891

GENTAMICIN- aminoglycosides CCBs Mg++ all contribute to muscle weakness, potentiation of actions of NMBDs VC<2.9L, pyridostigmine >750mg/day, Dx >6yrs ago, coexisting pulmonary disease

Answer 892

strained broth (pulp-free juice, black coffee, cordial, carbo rich fluids (clear) specifically developed for periop use, all clear fluids) NOT soluble fibre, milk-based drinks & jelly.

Answer 893

cerebral oedema

Answer 894

bradycardia prol QTc (from hypocalc, hypoMg++, drugs, starvation) ST depression TWI AV blocks sinus arrest nodal escape beats wandering atrial pacemakers supraventricular tachycardia ventricular tachycardia

Answer 895

1 hr (can remove after 204hrs & normal aPTT) Aim CSF pressure <=10mmHg MAP aim >85mmHg Aim SCPP pressure >75mmHg COPS protocol for reduced MPEs or SSEPs: -CSF drain status -O2 delivery (ensure Hb >120, CI >2.5L/min/BSA) Patient status: mean BP >90mmHg SCPP>80mmHg (MAP-CSFP) cognitive status

Answer 896

Posterior cerebral ischaemia or CORTICAL BLINDNESS ION: most common cause POVL, painless but pupillary light reflexes absent, pupil dilated CRAO: RAPD, pupil reflexes sluggish/absent, painless corneal abrasion: painful, altered visual acuity generally not visual loss acute angle closure glaucoma: painful, fixed mid-dilated pupils retinal detachment painless, PLR maintained unless significant retinal death

Answer 897

does not increase risk SSI

Answer 898

does not increase risk SSI

Answer 899

does not increase risk SSI

Answer 900

lung point (distinction where normallung to absent (may or may not be present) absent lung pulse incr clarity A lines lack of B lines lack of sliding pleura other conditions: B lines fluid or fibrosis (interstitial syndrome) hepatisation (consolidation or atelectasis) Z lines= short, broad comet tails arise from pleural line but don’t reach distal edge of screen. Normal or in pts w PTx, don’t erase A lines & don’t move w lung sliding.

Answer 901

ADDUCTOR CANAL infusionsHigher []s of LA (but >0.375%, ropi >0.75%) Bupivacaine Longer duration of exposure to LA Eg. Continuous adductor canal infusion proximity to muscle plane

Answer 902

COPD. generally, it's mild pulm HTN (mean PAP <=40mmHg

Answer 903

haemodynamically defined as mPAP >20 mmHg and PAWP >15 mmHg

Answer 904

hypoxia & acidosis hypercapnia pre-existing heart disease, extremes of age, frailty, conditions causing mitochondrial dysfunction (eg. cartinine deficiency), liver or kidney disease (delayed LAST by depressing LA metabolism or distribution); reduce dose 10-20% in renal impairment. Liver impairment single dose blocks unaffected, repeated bolus or continuous infusion doses should be reduced. cardiac failure esp susceptible to LA-induced myocardial depression & arrhythmias + lower liver & renal perfusion slows metabolism & elimination. Smaller pt size, paeds (neonates & infants reduced AAG levels, chn have incr elemination half life; risk accumulation w continuous infusions), pregnancy (lower AAG, accelerated perfusion), lower AAG bupiv (racemic higher risk than levo), low CC:CNS (bup 2 vs 7.1 lidocation), higher dose, intrinsic VD (bupiv, ?clin sig?) subcut continuous vs single administration site: some (interscalene, stellate ganglion) risk intravasc injection. highly vascular (increased perfusion @ site of injection). toxicity highest to lowest= IV, subcut, mucosal, tracheal, intercostal, caudal, Lx epidural, brachial plexus, sciatic, topical. LOWER risk LAST with US guidance (less risk vascular injury, lower volumes used), frequent aspiration, incremental injection, ?epinephrine, and higher alpha1 acid glycoprotein levels (which have high affinity for amide LAs, reducing risk toxicity), ?intrinsic vasoconstricor (levo, ropiv)

Answer 905

CO2; 10.6microm long wavelength (this is long), shortest penetration. used for cutting & coagulation of sort tissue. Photo-thermal effect. lasers in visible & near IR range have greatest potential for retinal injury (400-550nm wavelength). Holmium:YAG: photo-mechanical effect. for tissue abloation or lithotripsy. Very intense but brief- explosive expansion of tissue. Argon: photo-dissociation, non-thernmal, corneal reshaping.

Answer 906

less maternal bradycardia also improve CO ?concerns re: foetal acidosis not borne out in evidence no diff in N, V & apgar scores

Answer 907

4 R) UL 3 R) ML 2 R) LL 5 L) UL 4 *incl sup & inf lingular L) LL 4 *the R) lung has 2 lobes & 10 segments, the L) has 2 lobes & 8 segments however for calculating PPO, 5 in L) LL

Answer 908

Lowest FiO2 possible (titrate SpO2 88-92%); these pts often took bleomycin which may--> pulm damage progressing to fibrosis & lifelong risk O2 tox. Sx nonspecific, incl dry cough, breathlessness, pleuritic cp, fever. O2 therapy can induce & exacerbate bleomycin lung injury. High []O2 incr risk. Pre-Ax Hx & exam, CXr, ABG, lung CT, PFTs or bronchoscopy (depending on findings). O2 titrated for SpO2 88-92%. may have intersitial shadowing, airwpace shadowing, risk PTx/pneumomediastinum.

Answer 909

diaphragm the central muscles with good supply have fast onset (larynx, diaphragm). however while diaphragm & orbicularis oculi (reflects diaphragm well) have fast offset, larynx has slow recovery as sensitive to NDMRs. Add pol poor blood supply, slow onset & offset.

Answer 910

70% alcohol (which is suitable for only 24hrs) Use 2% chlorhex in 70+% EtOH ethyl or isopropyl, or povidone iodine 10% in 70% ethyl EtOH remaining on skin at least 2min tincture of iodine, iodophor or chlorhex).

Answer 911

70% *may overDx COPD in elderly, perhaps should only be seen as clinically important if < LLN (z score <-1.64)

Answer 912

LBW Adj40 for maintenance

Answer 913

antidromie wide complex

Answer 914

ETOH liver disease ALT>AST: substance abuse, HIV, HBV, HCV ALP>2x normal: cholestatic (and conj bili high, uncong bili normal) low alb: systemic illness, malnutrition

Answer 915

use 4 lifelines; 3x lifelines max 3 attempts @ each unless game-changer, @ least 1 attempt by most experienced clinician for each lifeline consider: manipulations, adjuncts, different size/type, suction/O2 flow, muscle tone CICO status escalates w unsuccessful best effort @ each lifeline

Answer 916

10 mins it incr IOP avg 4-8mmHg, peaks 1-2 mins, lasts duration of nm blockade

Answer 917

COPD (mild pulm HTN, ?prob not elev PCWP)

Answer 918

Amiodarone 150mg over 10mins then infusion (onset <48hrs, lower dose as on digoxin) Unstable would be if reduced LOC, CP, SBP<90, HF

Answer 919

2 in males 3 in females

Answer 920

low resistance (valveless, no resistance to airflow, no points of possible mechanical failure) minimal dead space (if flow rate high enough!) valveless, low R- used in paeds up to 30kg The FGF is near pt need high FGF 2-3xMV to prevent rebreathing is needed (need to ensure that after the exp pause the next time they take a breath they won't be re-breathing expired gas or inhaling atmospheric air) no reservoir, can't manually ventilate w +ve pressure or feel compliance no valves means no PEEP can't scavenge waste

Answer 921

Pulmonary hypertension In patients with PAH, the primary cause of a low DLCO is a reduction in the pulmonary capillary blood volume, whereas in patients with IPF- PH FEV1/FVC>70 restrictive, <70 obstructive, look at post-bronchodilator result Reversibility (12% change is the cutoff) FEV1 - gold 1 (>80%), 2 (50-80%), 3 (30-50%), 4 (<30%) TLC for restrictive dz (80/50/30), mild/mod/sev/critical DLCO (adj Hb, VA)

Answer 922

face legs activity cry consolability

Answer 923

Knee extension

Answer 924

methaemoglobin reductase deficiency

Answer 925

reduced RR provides humidification & warming (assists secretion clearance, decr atelectasis, limits airway surface dehydration) improved pt comfort if hypoxaemic resp failure. reduce subjective feelings. of dyspnoea. Can deliver FiO2 of up to 1 in moderate resp distress (since can match higher insp flow). measured nasopharyngeal FiO2 close to that set on the device unless pt grossly tachypnoeic. REDUCES deadspace; washes out CO2, provides anatomical O2 reservoir in nasopharynx & oropharynx. Reduces WoB (reduces airflow resistance in nasopharynx as splints upper airway). CPAP effect; UA distending pressure 3.2-7.4cmH2O w mouth closed; +ve Paw, incr end-exp lung vol, improves alveolar recruitment. distending pressure transmitted to the lower airways to generate PEEP (depends on mouth being closed so PEEP variable)..

Answer 926

90kg, max ETT=8 4: 50-90kg, max ETT=7 3: 30-60kg, max ETT 6 2.5: 25-35kg, ett F 2: 10-25kg, max ETT 5 1.5: 5-12kg, ETT 4 1: 2-5kg , max ETT 3 (On iGel) sizes 2-4 can take a 12Fr suction or NGT, size 5 can accomodate 14Fr

Answer 927

DOES include: cricothyroid posterior & lateral cricoarytenoids transverse arytenoids oblique arytenoid thyroarytenoid NOT suprahyoid

Answer 928

knee extension CPN is L4-S2 damage DOES cause impaired: knee flexion (short head piceps) eversion, dorsiflexion, great toe E, sensory anterolat leg, dorsum foot provides genicular branches to knee joint, lat cut nerve to calf, sural communicating branch, then SPN (L5-S2) & DPN (L4-S2)

Answer 929

aBductor pollicis brevis which is from recurrent branch of median nerve C8-T1 ulnar nerve C8-T1 does: FCU medial half FDP hypothenar mm medial 2 lumbricals adductor pollicis interossei of hand palmaris brevis

Answer 930

Ferritin inflamm markers TIBC & transferrin rise in Fe deplete states, fall if inflammation or Fe overload

Answer 931

larynx Sequence of recovery (fastest to slowest): diaphragm>laryngeal muscles>corrugator supercili>abs>orbicularis oculi>geniohyoid>add pollicis

Answer 932

50% of dose

Answer 933

deep posterior compartment of leg

Answer 934

Initial PSNS 10-15secs; brady/hypoT or even asystole Sustained SNS response (peak 3-5mins, rise SBP 30-40%, rise HR >20%, incr myocardial O2 consumption; ventricular dysfunction for up to 6hrs after Rx) Also: incr IOP incr intragastric pressure nausea myalgia, general ill-ease dental damage oral cavity damage (tongue, gums)

Answer 935

Initial PSNS 10-15secs; brady/hypoT or even asystole Sustained SNS response (peak 3-5mins, rise SBP 30-40%, rise HR >20%, incr myocardial O2 consumption; ventricular dysfunciton for up to 6hrs after Rx Also: incr IOP incr intragastric pressure nausea myalgia, general ill-ease dental damage oral cavity damage (tongue, gums)

Answer 936

For 1 month +: 0.9% NaCl w glucose 5% (consideration of 20mmol/L KCl in pre-mixed bags, once normal baseline electrolytes & renal function have been confirmed) neonates 10% glucose +/- additional NaCl

Answer 937

Iliohypogastric (T12-L1) Ilioinguinal (T12-L1) Genitofemoral (L1-2) Lat fem cut (L2-3) Obturator (L2-4) femoral (L2-4)

Answer 938

100 (it's 114), des is 9-21

Answer 939

Coughing Bucking Breath Holding Laryngospasm Bronchospasm Stridor (Post-Extubation) Obstruction Aspiration Desaturation LRTI Atelectasis

Answer 940

Pt: age <1 preterm atopy or FHx atopy, wheezy child Tobacco exposure URTI within 2/52 obesity/OSA/sleep disordered breathing craniofacial abnormalities/airway abnormalities Anaes: non-paediatric specialist volatiles (inhalational induction incr risk) inadequate depth oxy, midaz, airway topicalisation ETT>SGA>FMV Surgical: airway (esp adenotonsillectomy), emergency, stimulating

Answer 941

obturator nerve, L2-4, which travels alongside posterolateral bladder wall before exiting pelvis] innervates add long & brevis, adductor magnus gets dual innervation from obturator & sciatic. NDNMBAs & obturator nerve blocks help prevent or minimise adductors spasm

Answer 942

reduced synthesis methionine & tetrahydrofolate Vit B12 deficiency & peripheral neuropathy neuro resembling subacute combined degeneration of the cord; myelopathy & peripheral neuropathy; limb weakness, ascending or I/M distal numbness & tingling with imbalance/ataxia, impaired proprioception, reduced grip strength skin hyperpigmentation vascular disease from hyperhomocysteinaemia teratogenic megaloglastic changes in bone marrow- agranulocytosis bone marrow failure after days risks increased in B12 deficiency (ETOH, vegan, elderly, malabsorption)

Answer 943

bridging dabigatran is 150 mg twice daily (after an initial 5 to 10 days of parenteral anticoagulation) rivaroxaban 15mg BD for the first 3 wks then 20mg daily apixaban 10mg BD for first 7 days then 5mg BD, down. to 2.5mg BD after >=6/12 Rx

Answer 944

Appearance: 0=blue/pale, 1=acrocyanotic, 2=all pink Pulse: 0=absent, 1=<100, 2=>100 grimace: 0=no response, 1=minimal response to stimulation, 2=cough/cry (prompt response to stimulation) activity: 0=absent, 1=weak (flexed UL/LL), 2=strong respiration: 0=absent, 1=irregular/slow, 2=good/crying

Answer 945

B lines between rib spaces Lung ultrasound: A lines= horizontal lines below pleura; present both in normal lungs & PTx M mode lung sliding shows “seashore sign” “Barcode sign” indicates lack of lung sliding Interstitial syndrome: characterised by B LINES. These artefacts are generated by juxtaposition of alveolar air & septal thickening (fluid or fibrosis). Normal lungs have occasional B lines but up to 2 between 2 adjacent ribs is normal. 3 OR MORE BETWEEN RIB SPACES are pathological. Present in any disease affecting interstitial (eg. Pulmonary oedema). Very severe oedema causes hyper echoic confluent pattern (white lung)

Answer 946

Calcium gluconate 2.5% gel to contaminated skin, 15-minutely Remove clothing & jewellery, bag & remove from care areas Wash, incl scrubbing under nails. Staff to wear PPE (incl chemical resistant gloves) Flush eyes w 0.9% saline Pts @ risk fluorosis (which manifests as hypocalcaemia, w prol QT) need continuous cardiac monitoring Mx arrhythmias or arrest w 10% calcium gluconate 0.5mL/kg up to 60mL, IV sodibic 1mmol/kg, IV mg sulfate 50% Continue to correct hypocalcaemia Discuss w toxicologist Inhalation, neb 1mL Ca gluconate in NaCl

Answer 947

Abdo (gen laparoscopy) & L) neck incision. don't need OLV, if need a CVC, place on R). don't need to turn the pt.

Answer 948

1. Avoid routinely performing preoperative blood investigations, chest X-ray or spirometry prior to surgery, but instead order in response to patient factors, symptoms and signs, disease, or planned surgery. 2. Avoid ordering cardiac stress testing for asymptomatic patients prior to undergoing low to intermediate risk non-cardiac surgery. 3. Avoid administering packed red blood cells (blood transfusion) to a young healthy patient with a haemoglobin of ≥70g/L who does not have on-going blood loss, unless the patient is symptomatic or haemodynamically unstable. 4. Avoid initiating anaesthesia for patients with limited life expectancy, at high risk of death or severely impaired functional recovery, without discussing expected outcomes and goals of care. 5. Avoid initiating anaesthesia for patients with significant co-morbidities without adequate, timely preoperative assessment and postoperative facilities to meet their needs.

Answer 949

54 wks term infants only if reached PMA 46 wks (*pt must be medically fit, risks discussed w carers & parents on individual basis)

Answer 950

-improve M&M in hip fracture -be cost-effective, reduce LoS & delays secondary to cancellations -for vascular, reduced LoS & complications incl delirium, cardiac/bladder/bowel Overall: likely. to have positive impact on postop outcomes eg. medical complications & LoS, in older pts undergoing elective & emergency surgery. mortality, LoS, financial cost.

Answer 951

-be superior to traditional scoring systems (eg. ASA & POSSUM) in identifying pts @ highest risk of adverse outcomes -elective ortho: improved LoS, reduced pressure sores, better pain scores, higher rates early mobilisation. -identifies issues affecting periop course that wouldn't likely have been detected w standard preop Ax. -improve M&M in hip fracture -be cost-effective, reduce LoS & delays secondary to cancellations -for vascular, reduced LoS & complications incl delirium, cardiac/bladder/bowel -improve communication w pts & their families -overall literature inconclusive; CGA periop is predominately assessment in absence of interventions. Overall: likely. tohave positive impact on postop outcomes eg. medical complications & LoS, in older pts undergoing elective & emergency surgery. mortality, LoS, financial cost. Blue book: CGA very strong evidence of reduced LoS.

Answer 952

Advanced health directive Guardian appointed by civil & administrative tribunal Power of attorney from AHD Statutory attorney in following order: spouse (close & continuing relationship), unpaid carer, close adult friend or relative Public guardian May only carry out care without consent if reasonably consider the pt has impaired capacity, it must be carried out urgently (imminent risk to life or health or must occur to prevent significant pain or distress) & it’s not reasonably practical to get consent from someone who may give it under guardianship & administration act or powers of attorney act. This includes providing life-sustaining measures eg. CPR. “Blood transfusion is not a life-sustaining measure”.

Answer 953

40 >35 if associated obesity illness pts also must have made reasonable attempts @ other WL techniques, age 18-65, capacity to understand risks & commitment ass'd w the surgery, no psych. or drug probs

Answer 954

tamponade= loss of Y descent TR= huge V wave, C&V fuse w blunted X descent

Answer 955

8.5Fr RIC 1L in 46 seconds. 6.5cm. 600mL/min in other ref. One study max flow rate 1.2L/min sheaths from 4Fr up to 11fR, lengths from 5.5 to 23cm. 8.5Fr sheath 1.17L/min max flow rate (more variable than RICC) MAC has 9 Fr distal lumen (& 12-gague prox lumen for incompatible fluid admin. has chlorhex. no catheter it is 500mL/min. Variable reports- absolute max 1.2L/min Vascath 13.5Fr, 400mL/min 14g IVC 250/400 16g 150/300 18g 100/150 20 70/100 22 35/70 24 20mL/min

Answer 956

initial manifestation may be cardiovascular collapse/cardiac arrest. CNS: initial excitatory (perioral tingling, tinnitus, slurred speech, light-headedness, tremor, confusion/agitation, excitation culminates in generalised convulsions). depressive phase= coma & resp depression. cardio: 3 phases: HTN & tacchy initially, then myocardial depression & hypotension, terminal phase= peripheral vasodilation, severe hypoT & arrhythmias incl sinus brady, conduction blocks, ventricular tachyarrhythmias, asystole. other LA toxicities: anaphylaxis: more common w esters. methyl-paraben or metabisulphite preservatives may be the cause. metHb may occur w prilocaine (its metabolite o-toludine)- avoid eutectic mixture of LA in those <1yo receiving MetHb-inducing drugs (phenytoin, sulphonamides, benzocaine)

Answer 957

Chlorhexadine 0.5% in ethanol

Answer 958

Likely anything but: SSRIs antiplatelets amiodarone fluconzole rifampin phenytoin a couple of studies suggest that atorvastatin & digoxin diltiazem NOT ass'd with incr risk major bleeding Pharmacokinetic interaction not considered as important as pharmacodynamic: Concurrent use of drugs that incr plasma levels of DOACs by inhibiting P-glycoprotein (eg. verapamil, amiodarone, quinidine) or CYP3A4 (for riva or apix) don't incr risk of major bleeding, however should avoid drugs which are strong inhibitors (eg. antifungal azoles, cyclosporine). From a study looking at bleeding risk: amiodarone, simvastatin, atorvastatin, verapamil, digoxin, diltiazem (this is the only one which significantly lowered) Presumed based on Pk: ezetimibe & lipid-lowering drugs except simvastatin w dabi metronidazole & ciprofloxin antacids gabapentin, pregabalin, lamotrigine Probably COX-2 selective NSAIDs; they have little to no inhibitory effect upon platelet function (eg. COXIB) Paracetamol Should use PPIs for pts on anticoagulation & high bleeding risk (eg. NSAIDs, aspirin, high bleeding risk scores). Concurrent use of antiplatelet drugs or SSRIs (which inhibit plt aggregation) WAS associated with increased risk of major bleeding (100% incr w antiplatelets, 70% w SSRIs) Antiplatelets inhibit plt aggregation (primary haemostasis), DOACs inhibit fibrin formation (secondary haemostasis)

Answer 959

atropine full-dose epinephrine external cardiac compressions

Answer 960

children pregnant well-trained athletes systolic heart failure (overly compliant myocardium--> dilated LV), eg. CCF most common cause, DCM, mitral prolapse, TR, L)--> R) shunts.

Answer 961

no diff death from any cause @ 1 yr or 30/7, no sig diffs btwn groups in secondary outcomes incl MI. Volatile may facilitate earlier extubation.

Answer 962

mutations in sodium channel precipitated by hyperKal, rest after exercise, stressful situations, possibly hypoglycaemia avoid cholinesterase inhibitors, SCh, K+. Maintain normothermia & normoglycaemia. Rx: glucose, insulin, epinephrine, B-agonists, Ca++

Answer 963

C4: shoulder shrugs C5: shoulder abduction and external rotation; elbow flexion C6: wrist extension C7: elbow extension and wrist flexion C8: thumb extension and finger flexion T1: finger abduction L2: hip flexion S1: hip extension L3: knee extension L5: knee F L4: ankle dorsiflexion L5: big toe extension S1: ankle plantarflexion S4: bladder and rectum motor supply

Answer 964

brachiocephalic artery

Answer 965

not indicated. never useful. Rx persistent mucosal bleeding w TxA. some type 1 & some type 2 (d/w haem), DDAVP 0.3mcg/kg. biostate (vWF & F8 concentrate 2:1 dosed on F8 u/kg) is indicated in type 3 w bleeding or pre-op in type 1 not responsive to DDAVP or if bleeding not controlled w DDAVP & to Rx bleeding in type 2 & 3. Each vial has 50IU/mL FVIII & 100IU/mL vWF.. DDAVP generally not for chn <3yo as risk hyponatremia & seizures (relatively CI if prev seizure disorders). restrict fluid to approx 80% maintenance in first 24hrs of DDAVP.

Answer 966

not indicated. never useful. Rx persistent mucosal bleeding w TxA. some type 1 & some type 2 (d/w haem), DDAVP 0.3mcg/kg. biostate (vWF & F8 concentrate 2:1 dosed on F8 u/kg) is indicated in type 3 w bleeding or pre-op in type 1 not responsive to DDAVP or if bleeding not controlled w DDAVP & to Rx bleeding in type 2 & 3. Each vial has 50IU/mL FVIII & 100IU/mL vWF.. DDAVP generally not for chn <3yo as risk hyponatremia & seizures (relatively CI if prev seizure disorders). restrict fluid to approx 80% maintenance in first 24hrs of DDAVP.

Answer 967

42mg IV x3 to get OME (126mg)), then x 3.33 to get approx 400mg IR tapentadol QID therefore 100mg; FPM calculator advises 25-50% dose reduction (not all opioids equal effect) so probably 50mg QID best approach.

Answer 968

29 (Winter's formula 1.5x bicarb +8 (+/-2)

Answer 969

quaternary ammonium component of NMBDs

Answer 970

(0.7 x HCO3-) + 20

Answer 971

1mmol/L for every 10mmHg elev CO2 acute, 4 chronic

Answer 972

2mmol/L for every 10mmHg drop CO2 acute, 5 chronic

Answer 973

PEA 50% asystole 25%

Answer 974

3/n (ie. if 100pts, 3/100=0.03)

Answer 975

20 seconds, less if brady/hypoxic risks: young, prematurity, Hx apnoea, lung disease, NEC postop monitoring HR 100, SpO2 94%, attend, confirm apnoea, stimulate, delay discharge if apnoea

Answer 976

4mL/kg packed red cells raises Hb by 10

Answer 977

amiodarone atracurium ketamine phenytoin thio rocuronium

Answer 978

overnight oximetry; contiuous, mod-severe if @ least 3 clusters of desat events SpO2 <90%

Answer 979

overnight oximetry; contiuous, mod-severe if @ least 3 clusters of desat events SpO2 <90%

Answer 980

non-specific tissue & plasma esterases

Answer 981

12 hrs 3 days SS fentanyl patch 17 hrs time to analgesic effect 12-24hrs after patch on

Answer 982

hypoK, hyperNa, NORMAL BSL (doesn't impact glucose), alkalosis, HTN

Answer 983

tetany (trosseau, chovstek), muscle spasms/cramps, muscle weak ("lemonade legs"), involunt movements reversible blindness, vertigal nystagmus rarely resp m weakness confusion/delirium, seizure, comas prol PR, QT, prone to atr/vent ectopy, torsades more prone. to dig tox often concurrent hypoCa & hypoK

Answer 984

1200mL/min 750mL/min or 50mL/100g/min 3.5mL/100g/min 200mL per litre oxyHb, 3mL dissolved so the blood O2 content is 2mL as oxyHb per 10mL blood

Answer 985

1200mL/min 750mL/min or 50mL/100g/min 3.5mL/100g/min 200mL per litre oxyHb, 3mL dissolved so the blood O2 content is 2mL as oxyHb per 10mL blood

Answer 986

ischaemia; DO2 @15mL/100g/min would be 3mL/100g/min

Answer 987

raised ICP

Answer 988

dabigatran (but not suitable for monitoring; very low plasma levels--> long or unmeasurable TT) rivaroxaban; normal PT suggests unlikely a sig rivaroxaban effect

Answer 989

may arise following r/a axillary LN generalised abN collection protein-rich IF, ass'd w oedema & altered tissue structure 4 stages subclinical (may be subjective but minimal tissue change, stage 0) to overt (stages I-III) discomfort, compression bandages, poor healing PGA 18 appendix 1: no lymph: no CI to NIBP or pIVC on affected arm & art line if clinically indicated WITH lymphoedema: alt site where practical but no absolute CI to using affected limb for monitoring & IV access, monitoring the PIVC in accordance w clinical standards

Answer 990

when best efforts produce inadequate or low EtCO2 (grade C or D) A= plateau B= no plateau but >10mmHg C= no planeau, EtCO2 <10mm Hg D=no Et CO2 Describe how achieved (1, 2 hands, guedel, NP)

Answer 991

amount of water vapour per volume of air. relative= amount of water vapour in air relative to max that could be contained in the air @ a particular temp, a proportion, relative vs absolute important when discussing thermal comfort. Temp 21-24deg C, relative humidity 50-60%

Answer 992

faithful or loyal- to patients & to professional standards, ie. follow guidelines

Answer 993

either in distal third of SVC or @ cavo-atrial junction. From lower limb terminate in IVC. UL may move 2.2 rib spaces w arm movement. tracheal bifurcation.

Answer 994

>4mm between atlas & odontoid peg inflexion widening of prevertebral soft tissue; <1/2 with ie at C2 should be <=7mm wide, C6 should be <1 width ie <=14mm chn, <22mm adults. If swelling ant to C3 exceeds 3mm, suspect C2 fracture. # ant tip of vertebral body >10deg

Answer 995

intrathecal or epidural yellow regional is white + yellow/black margin subcut beige IV blue IA red enteral green inh white misc pink central venous line white w blue border

Answer 996

% or rate without Rx (A)- % with Rx (B) A-B= X% NNT = 1/0.0X

Answer 997

CO2 air= black & white helium brown (heliox brown & white) oxygen= white argon=green nitrous= blue

Answer 998

limit intrathoracic pressure; low RR with short insp time (ie limit time that PiT is raised), low PEEP, limit TVs to 5-6L/kg, avoid incr PVR, important to avoid hypercarbia; simple procedures spont vent best as long as avoid hypercarbia.

Answer 999

hyperkalaemia, hyperphosphatemia, hyperuricaemia, hypOcalcaemia renal failure from myoglobinuria, metabolic acidosis

Answer 1000

200 165 275

Answer 1001

Infrared absorption spectroscoscopy -molecules with dissimilar atoms absorb IR & convert the energy into molecular vibration. Vibration frequency depends on molecular mass & atomic bonding. Can determine gas by the [] of a wavelength absorbed (molecules absorb IR @ specific wavelengths); Beer-Lambert law (Beer: amount. of light absorbed directly proportional to [] of the solute. Lambert path length. Refractometer: Raleigh: prisms split light. difficult for breath-breath analysis but for calibration & envt gas exposure. Piezoelectric eg. quartz, can't differentiate btwn vapours (but fast resposne) Raman: expensive but fast. almost as accurate as mass spectrometry. Mass spectrometry: long response & delay times, costly but very accurate- research.

Answer 1002

II, IX, X, ATIII, heparin, sodium/phosphate/citrate/chloride (small amounts 7 & 5)

Answer 1003

lateral position, injecting saline

Answer 1004

56cm 19Fr semi-pliable accommodates fibreoptic scope (it has an ID of 4.7mm_ 2x rapifit connectors; one for standard 15mm ID bag, one for jet ventilation so can oxygenate @ any time, or swivel connector 7.0mm ETT is the smallest that can accommodate AIC =

Answer 1005

begins in 10-20mins, peaks 30-60, lasts 4-6hrs. benefits for hypokalaemia aren't sustained long however the insulin levels can remain high enough to cause hypoglycaemia. Therefore, give ongoing glucose following the initial bolus & monitor every hour.

Answer 1006

30x higher risk of needle damage to globe if inferotemporal peribulbar MEDIAL CANTHUS approach or sub-Tenon's are safe

Answer 1007

30x higher risk of needle damage to globe if inferotemporal peribulbar MEDIAL CANTHUS approach or sub-Tenon's are safe

Answer 1008

Not CoaA as this has weak femoral pulses Most likely VSD L)-->R) shunt, since PDA usually continuous (apex is more likely MR though), VSD may develop diastolic if large

Answer 1009

1 faint, not all posn 2 faint, all posn 3 mod loud, no thrill IV load & palpable thrill V very loud, thrill, hear w steth slightly off chest VI loudest, heard with steth off chest

Answer 1010

small (Qp:Qs <1.5) may be asymp, continuous flow murmur mod (Qp:Qs 1.5-2.2, exercise intolerance, mod L)-->R) hsunt incr LA & vent fvolume load large Qp:Qs >2.2: LV volume overload, eventual rise PAP & may reverse shunt & eisenmenger syndrome. FTT, poor feeding, resp distress. adult: systolic ejection murmur, eisenmenger incl cyanosis & clubbing.

Answer 1011

small (Qp:Qs <1.5) may be asymp, continuous flow murmur mod (Qp:Qs 1.5-2.2, exercise intolerance, mod L)-->R) hsunt incr LA & vent fvolume load large Qp:Qs >2.2: LV volume overload, eventual rise PAP & may reverse shunt & eisenmenger syndrome. FTT, poor feeding, resp distress. adult: systolic ejection murmur, eisenmenger incl cyanosis & clubbing.

Answer 1012

to measure impedance of the neutral pad & make sure it's safe (ie. that it's not coming off & risking burning skin)

Answer 1013

loses 5% potency per month @ 25 degrees. so once remove from fridge, use within 21 days.approx 99% efficacy

Answer 1014

60 days (some say 12 weeks!) atrac? discard. @end of day panc 3 months sux 30 days

Answer 1015

type 2b: they bind too well to plts so DDAVP promotes the clumping & thrombocytopaemnia 2a can't bind properly to plts to form clot type 3 complete lack vWF type 1 get low levels of vWF & low FVIII, can give DDAVP if responder

Answer 1016

wrong type of pacemaker; they have AV conduction issue (AAI inhibits impulse if senses native atrial activity, if none then atrial pacing is initiated. used in sinus dysfunction with intact AV conduction)

Answer 1017

tracheostomy-related problems (tracheostomy dislodgement led to half of all cases of death & brain damage) tracheal tube displacement/misplacement & failed intubation were equal

Answer 1018

1.7-3.5mmolL

Answer 1019

improves analgesia & is opioid-sparing for up to 24hrs after major surgery incl abdo, ortho, spinal, cardiothoracic adding ITM to IT bup/fent prolongs pain relief after labour addint IT fent & morph to spinal prolongs time first analgesic request after CXS ITM vs periopheral regional for LL arthroplasty offers similar analgesic benefits but incr adverse effeics ITM has higher incidence of OIVI, pruritis & PONV cf PCA opioid pruritis w IT opioids. isdose-dependent, can effectively treat & prevent w 5HT3 antagonists in non-obstetric but only for Rx (not prevent) in obs naloxone reduces pruritis & nausea but not vomiting. adding IT magnesium prolongs analgesia in non-obs! IT clonidine + morph sl prolongs analgesia & opioid sparing should use lowest effective dose of ITM (no consistent dose-responsiveness for analgesia but incr adverse effects dose-related) monitor for OIVI 18-24hrs after ITM. adverse: OIVI, pruritis, N&V, urinary retention (minor OT), reactivation oral herpes simplex labialis

Answer 1020

3.5-7.5hrs (late resp depression can occur 3.5-12hrs, peak 6 hrs)

Answer 1021

mast cell degranulation (NOT IgE mediated)

Answer 1022

1= IgE mediated (anaphylaxis) 2= Ab mediated (IgM or IgG bind to cells--> destruction) 3= complex formation 4= delayed response, T-cell mediated

Answer 1023

anaphylaxis to blood products

Answer 1024

23 months when store @ -25 it has VIII, fibrinogen, XIII & vWF & fibronectin

Answer 1025

within 6 hrs of thawing or 4hrs of pooling.

Answer 1026

170 & 490L approx 14000kPa (about 2000psi)

Answer 1027

3; proceduralist, sedationist, assistant to both (the assistant to the practitioner administering sedation must be exclusively available to that person @ induction & emergence & during procedure as required; if GA is intended, person specifically to assist the anaesthetist required throughout

Answer 1028

10mL of 10% (13.6mEq in CaCl cf 4.6 in Ca gluconate) over 2-3 mins, cardiac monitoring can repeat after 5 mins acts within mins, 30-60mins duration insulin 10U w 50mL 50% glucose drops it by 1mEq/L, onset 10-20mins, peak 30-60, DOA 4-6hrs salbutamol lowers it by 0.5-1.5mEq/L, peak effect within 30 mins infusion, 90 mins neb.

Answer 1029

SVC syndrome. severe tracheal deviation, Cerebrovasc disease, severe C spine disease w limited neck ext, prev chest RTx, aneurysm.

Answer 1030

usually 1-2 hrs (it's sudden onset hypoxaemic resp insufficiency); symptoms may be delayed as long as 6hrs. fever, chills, dyspnoea, tachy, tachypnoea, hypoT, hypoxaemia, noncardiogenic bilat pulm oedema w resp failure.

Answer 1031

most can only detect if TOFR <=0.4

Answer 1032

brow bulge deep nasolabial fold eyes squeezed shut open mouth taut tongue chin quiver purse lips NOT mouth closed cry requires O2 for SpO2>95% incr vital signs expression sleeplessness

Answer 1033

high; at least 8x fundamental frequency (pulse rate); if lies close to nat frequency, resonates & excess amplification incr nat frequ by having smaller length, less 3 way taps/attachments, lower compliance of cannula, lower density fluid, incr diam cannula, limit bubbles/cots. Damping= delay in response time due to anything reducing the energy in an oscillating system & reduces the amplitude of oscillations. Most damping due to frictional resistance in the fluid. some damping necessary but excess or inadequate impairs output. optimal DC is 0.7. Over-damped (max amp under-est & min amp over-estimated, MAP unaffected, damping reduces nat frequ) damping with clots/bubbles, vasospasm, taps. Under-damped overshoots, SBP overestimated. lower natural frequency of the system, lower MEASURED SYSTOLIC PRESSURE

Answer 1034

dorsal scapular nerve (for lev scap/rhomboids)

Answer 1035

patent blue injection

Answer 1036

inferonasal; away from site of surgery & away from insertion of sup & inf obliques

Answer 1037

S4, to S2 L5-S1 it gets up to L3/4 in adults (hence it's L5 in young chn)

Answer 1038

it decreases it, postpartum ass'd w increase MS activity. postpartum relapses more likely if incr relapse rate in the year before preg or incr relapse during pregnancy. exclusive breastfeeding ass'd w reduction postpartum MS relapse.

Answer 1039

stable narrow-complex SVT.

Answer 1040

potentiate effect of clopidogrel, sedatives, antidepressants reduces effect of digoxin, warfarin, anticonvulsants

Answer 1041

limit catabolism (limit insulin resistance, lipolysis & protein catabolism which --> hyperglycaemia or ketosis.

Answer 1042

limit catabolism (limit insulin resistance, lipolysis & protein catabolism which --> hyperglycaemia or ketosis.

Answer 1043

hypotension They DO include: acute neurovisceral attacks: -abdo pain, back pain, leg pain -nausea, vomit, constipation -psychosis, confusion, seizures, hallucinations, insomnia, dep/anxiety/agitation -tachycardia/palpitations, HTN, rarely arrhythmias -peripheral neuropathy: generally motor, distal, mild sens symptoms, may progress to motor paralysis involving resp & pharyngeal, bladder dysfinction hyponatraemia photosensitive skin chnages

Answer 1044

similar. no stat sig difference @ 30 days for CVA, MI, death or LoS GALA & cochrane.

Answer 1045

100microamps

Answer 1046

every 4 mins (every 2nd 2-minute CPR round, during which about 5 rounds of 30:2)

Answer 1047

neuronal atrophy limited neuro reserve incr risk POCD or POD reduced CBF (atherosclerosis0

Answer 1048

old notes 20mg/kg & 40mg/kg but latest RCH website: paracetamol just 15mg/kg & PR 15-20mg/kg (max 24hr dosing 90mg/kg/day >1 month but 60mg/kg/day if birth-1 month) Dose on IDEAL body weight

Answer 1049

ipsilateral motor, vibration, light touch (dorsal columns) & proprioception/position contralateral pain& temp & crude touch segmental loss pain & temp, weakness often greater in ULs than LLs bladder & rectal dysfunction, saddle anaesthesia asymmetric multiradicular pain, LL weakness & sensory loss, bladder dysfunction

Answer 1050

anterior wedge clay shovelers transverse process UNILATERAL facet burst # vertebral body isolated #s articular pillar & vertebral body

Answer 1051

anterior wedge clay shovelers transverse process UNILATERAL facet burst # vertebral body isolated #s articular pillar & vertebral body

Answer 1052

larger occiput relative to bodies cervical spine fulcrum higher weaker Cx muscles & incr ligament laxity (incr mobility of upper Cx spine) immature vertebral joints & horizontal articulating facets, facilitate sliding of upper Cx spine vulnerable growth plates spinal cord more elastic so may get SCIWORA

Answer 1053

-GCS 15 -no neuro deficit -no neck pain, diff neck ROM, midline tendernes, palpable step-off, substantial chest/abdo/pelvis injury -mechanism not high-risk (MVA>89kph, axial load) -no anatomical predisposition (DS, spondylitis, prior C-spine injury)

Answer 1054

-GCS 15 -no neuro deficit -no neck pain, diff neck ROM, midline tendernes, palpable step-off, substantial chest/abdo/pelvis injury -mechanism not high-risk (MVA>89kph, axial load) -no anatomical predisposition (DS, spondylitis, prior C-spine injury)

Answer 1055

30-70L/min with 45-60PSIG

Answer 1056

1atm=1bar=760mmHg=100kPa=14psi

Answer 1057

call for help remove triggers (eg. synthetic colloid) invasive monitoring (art, CVC, TOE) resistant hypoT: -additional IV fluid 50mL/kg NAdr 3-4mcg/min Vasopressin 1-2U then 2U/hr if neither avail, phenyl. ormetaraminol Glucagon 1-2mg 5-minutely (counteract. Bblock) ECMO resistant bronchospasm: consider where's the tube? circuit? device malfunction? tension PTx continue Adr infusion (which starts once done 3 boluses Adr), add: salbutamol 12 puffs (1200mcg) bolus 100-200microg then infusion 5-25mcg/min Mg++ 2g (8mmol) over 20 mins consider inhalational or ketamine

Answer 1058

PVD sickle cell AVF care ++ Hx VTE

Answer 1059

Abrupt decrease in kidney function—> retention of urea & other nitrogenous waste products & dysregulation of extracellular volume & electrolytes. Criteria: -decr UO to <0.5mL/kg/hr for 6hrs -incr serum Cr >=1.5x baseline presumed to have occurred within 7 days -incr Cr 26.5micromol/L within 48hrs KDIGO criteria: Stage 1: 1.5-1.9x Cr baseline within 7 days OR incr Cr >=26.5mmol/L in 48hrs OR UO <0.5mL/kg/hr for 6-12hrs Stage 2: 2-2.9x baseline Cr OR UO <0.5mL/kg/hr for >=12hrs Stage 3: 3x baseline Cr OR incr Cr 353 OR UO <0.3mL/kg/hr for >=24hrs or anuria >=12 hrs OR initiation of RRT OR in can <18, eGFR <35

Answer 1060

TOE (high sens 0.02mL/kg air) Precordial doppler 2nd best (0.05mL/kg air) then PA cath 0.24mL/kg TCD also high then ETH2 or ETCO2 both mod ecg 1.25mL/kg oes steth 1.5mL/kg

Answer 1061

C3-C4 spec 100%

Answer 1062

yes but avoid indirect sympathomimetics eg. ephedrine/metaraminol

Answer 1063

naloxone atropine vasopressin (adults) Adr Lignocaine Incr doses 3-10x for ETT route

Answer 1064

45mm (humerus, excessive tissue) 25mm (>40kg) 15mm (3-39kg) 15g (Ezi-IO) should use if unable to gain IV access in life-threatening situation within short period of time (max 90 seconds 2 attempts paed cannulation in APLS) Avoid: over infection over site of previous attempts (risk etravasation through old hole, compartment syndrome) local indwelling metalwork over limbs w possible prox #s over fracture (compartment syndrome risk) osteogenesis imperfecta sites: proximal humerus, 1cm above surgical neck (@ greater tubercle, which is poorly developed in small children)--> pts hand on abdo & elbow adducted, most prominent aspect of greater tubercle, 1cm superior to surgical neck.preferred in resus as infusion enter circulation fastest rate (except sternum bhut that requires specialised device). prox humerus straight to SVC, bypass pelvic & abdo vessels, important in trauma w abdo/pelvic injuries. child humeral shaft may be easier to identify. 2 fingers below patella & 1-2cm medial to tibial tuberosity in adults prox tibia: 2-3cm below tib tub, <2yo tib tub might not be developed, in which case go 3cm distal & 1cm medial to lower aspect patella. distal femur: 2-3cm above lat condyle. distal tib: 3cm prox to med mall. @ least 1 black line (5mm from hub) should be visible following insertion to ensure needle is sufficient length infusion more painful than insertion; infuse lignocaine 2% prior to flushing the cannula w 10mL n/saline. drap bloods before flushed. need pressure bag. any med/fluid that can be infused through central line can be infused IO. same dose & onset. prox humerus about 80mL/min, tibia 15mL/min, sternum (specific cannula, >12yo only), up to 120mL/min *UTD: max flow rates under pressure 265mL/min at tbial, 150mL/min @ humerus (while nunmbers not under pressure have tibia as lower rate) remove within 24 hrs (earlier if alt access gained), earlier if erythema, swelling, evidence extravasation. rarely osteomyelitis, fracture, necrosis epiphyseal plate, compartment syndrome, extravasation. IO good correlation for Hb, Cl, glucose, Cr, alb, urea poor correlaton for plt, CO2, Na, K, Ca++ (potassium correlation worse than sodium)

Answer 1065

bone marrow, blood

Answer 1066

FV resistent to aPC (activated protein C), a natural anticoagulant that degrades Va; therefore more prone to clotting. (factor V procoagulnat CF amplifies thrombin production). Autosomal dominant. most pts (99%) heterozygous only 5-10% of heterozygotes get VTE in their lifetime VTE recurrence in heterozygotes cf those lacking the variant 1.4x OR.

Answer 1067

head upmay reduce time. todesat by 50 secs CPAP non-significant incr in time to desat (fRC goes back to pre-CPAP levels once anaesthetised & CAPAP removed)

Answer 1068

immature BBB, immature renal function (doesn't reach adult value of 25%u ntil 1 year, slows elim of renally cleared drugs & prol DOA active metabolites)

Answer 1069

RA below manubrium, LA v5, LL ground (R) hip/lower costal margin. monitors lead 1, observe flutter waves & detecting P waves in wide complex tacchys Useful for anterior wall ischaemia

Answer 1070

fibreoptic

Answer 1071

36 at least 24 for anaes location where triggering anaes performed, larger hospitals or remote 36 20mg per vial, Reconstitute in 60mL sterile water dose 2.5mg/kg, can repeat 10-15minutely until crisis over

Answer 1072

orthopnoea, chest pain, sudden onset breathlessness diastolic murmur (soft systolic murmur normal) S4 (S3 normal) JVP >2cm (up to 2cm normal) persistent tachy (HR rise by 10-20bpm normal) pleural effusion marked peripheral oedema or breathlessness (mild normal)

Answer 1073

pericardial pelvic R) flank (periphepatic) L) flank (perisplenic)

Answer 1074

dental damage

Answer 1075

EFFICACY: large RCT, 300-3000 pts, usually required before public access. Phase 0= exploratory (animal, pilot) Phase 1= safety & tolerability (20-80 volunteers) Phase 2= dose finding (20-200, observational) Phase 4= effectiveness 5= comparative effectiveness

Answer 1076

Apply dose reduction 25-50% to allow for incomplete cross-tolerance (closer to 50% if frail/elderly)

Answer 1077

1/12th to 1/6th of total daily opioid dose

Answer 1078

witnessed, monitored, pulseless VT if defib not immediately avail. ineffective & not recommended for VF

Answer 1079

PE + pulmonary infarction COPD (often vent defect more pronounced than perfusion Pneumonia hiatus hernia tumors pleural effusions

Answer 1080

nasopalatine (anterior), greater palatine (posterior)

Answer 1081

procedure >5hrs lithotomy trendelenburg external compression lower legs compression iliac vessels systemic hypotension/blood loss/hypovolaemia PVD obesity

Answer 1082

weakness proximal/axial/girdle muscles. ass'd. wSCLC. sensitive to NDMRs.

Answer 1083

Beginning of each list. Ultimately the responsibility of anaesthetist but may be delegated to a suitably trained person. -Service label device & sub-assemblies. -high-pressure: O2 cylinder pressure, content sufficient, no leak, can turn on/off gas supply lines pressure turn reserve cylinder off -low pressure: turn on each gas, observe appropriate operation of flow indicator verify function of O2 supply failure warning -vaporisers: liquid levels filling ports sealed correct seating, locking & interlocking circuit leaks w each vaporiser on & off leaks upstream of CGO (low pressure system bulb) -breathing systems: manually check assembly CO2 colour & change if needed ensure maintains a pressure >30cmH2O w flow 300mL/min manually ventilate breathing bag, watching unidirectional valves as handbag ventilated, then check for easy spill (simultaneously squeeze both) ceheck auto ventilation with the breathing bag, confirm disconnection & high pressure alarms -scavenging system properly connected, not blocked -emergency ventilation : bag & oxygen -IV & other apparatus to use (suction, TIVA) Document level c2 check

Answer 1084

half bolus of PCA, cease background infusion, hourly SS until <2 for @ least 2hrs

Answer 1085

3.4mmHg/min During THRIVE, eTCO2 incr 0.15kPA (1.1mmHg as 1kPa=7.5mmHg) per min, so eTCO2 incr 11mmHg over 10 mins, however PaCO2 incr 0.24kPA (or 1.8mmHg) /min, so incr 18mmHg/10 mins

Answer 1086

don't cut through them; 6 vs 2 layers so hard to access space, vascular so may get haemorrhage. push it out of the way. must avoid (rel CI) if Hx scleral disease w possible scarring & friability of sclera. scleral buckles/adhesions hinder dissection or spread of anaes, risk globe perf avoid if infection or trauma, prev extensive vitreo-retinal surgery, sub tenon's in same quadrant, Surgery requiring complete akinesia, surgery where conj haemorrhage -vely compromises outcome, severe ocular pemphigoid

Answer 1087

20mmHg (no threshold to predict depends on person perfusion etc to get IAH-induced new organ dysfunction) intra abdo HTN sustained pressure >12mmHg

Answer 1088

CI <2L/min/m2 & hypoT <90 despite adequate IV volume, high dose inotropes & IABP, eg. ACS, sepsis w profound cardiac depression, pulm embolism w cardiogenic shock/cardiac failure pulmonary: severe ARDS eg. P/F <80

Answer 1089

defib off, no change pacing

Answer 1090

<60mins resection, exp operator, height <60cm & <1-1.5L, aovoid glycine, anticipate if prostate >50g

Answer 1091

sore throat neuropraxia lingual nerve: taste/sensation hypoglossal & RLN (cuff) RLN complete= VC paramedian. if partial. &only abductors damaged, VC midline position (more dangerois). dyspnoea, voice change, dysphagia, aspiration

Answer 1092

Most important predictive factors for acute prognosis after SAH: -LoC & neuro grade on admission -Age (inverse correlation) -Amount of blood on initial CT head (inverse correlation) -hypoxaemia -hyperglycaemia -renal insufficiency -fever -anaemia -cardiac complications, while often reversible, ass'd w poor outcomes -neurogenic pulmonary oedema may --> hypoxaemia, contributing to cerebral hypoxia & poor outcomes. It does have high early mortality (approx 20% die prior to hospital) Early mortality: rebleeding vasospasm delayed ischaemia hydrocephalus cerebral oedema electrolyte abnormalities incr ICP seizures cardiac complications Later: cerebrovascular events MI

Answer 1093

compression of lumbosacral trunk; L4&5 w descending fetal head. May also occur w forceps delivery. most common mother short stature large baby. may also occur w stirrups.

Answer 1094

degree of RVOTO

Answer 1095

transgastric mid-papillary short-axis view (gives idea about portion of the territories of all 3 main coronary arteries perfusing the LV)

Answer 1096

I >90 II 60-89 IIIa 45-59 IIIb 30-44 IV 15-29 V <15

Answer 1097

5 yrs, MICROVASCULAR DECOMPRESSION (w crani) 10 yrs

Answer 1098

0.2% 99.8%- ie. typing reduces risk of transfusion reaction to 0.2% 99.94% 99.95% To screen, add "standard" blood cells (with known, significant non-ABO-Rh antibodies) to receipient's serum. To cross, add donor blood to recipient's serum.

Answer 1099

Hep B 1:250,000 Hep C 1:1mil HIV 1:2mil

Answer 1100

2%/month at room temp 8%/month at 37deg in the fridge it's 0.3%/month

Answer 1101

sux (44%) vecuronium (40%) atrac (20%) panc (19%) cisatrac (5%)

Answer 1102

Guillian-Barre Pre-junctional, acute, progressive, paralytic neuropathy due to autoimmunity in response to infection hyporeflexia, symmetrical ascending weakness

Answer 1103

elevated ferritin low Fe, transferrin/TIBC, tsat Hb decr, MCV normal to decr elevated ferritin (or normal) low Fe, transferrin/TIBC, tsat CRP is elevated Hb decr, MCV decr elevated (or normal) ferritin Serum Fe is normal or increased transferrin normal transferrin saturation normal

Answer 1104

10 L/min for 90 mins After 90 mins, can reduce FGF to 3 L/min Before filters on, remove vaporisers, flush machine with O2 or air, 10L/min, 90 seconds, with 2L test lung change full breathing circuit & soda lime while maintaining flushing @ 10L/min insert activated charcoal filters on insp & exp ports, keep FGF going 10L/min for 90 mins from commencement of anaes, then can reduce FGF to 3L/min can use ACFs @ 3L/min until 12 hrs have elapsed from commencement of anaes. single-use.

Answer 1105

workstation add "susceptible to MH" to surgical safety checklist & make awll aware of precautions required move all VAs *& sux from room & trolley Same PACU

Answer 1106

slip= action not taken out as intended/planned lapse= missed actions or omission violation= deliberate illegal mistakes= error due to faulty plan/intention (but doing what thought was right @ the time) sentinel event= adverse event resulting in death or serious harm

Answer 1107

AML, ALL, NHL, CNS tumours

Answer 1108

atrac, since it has lower risk anaphylaxiscf sux or vec

Answer 1109

staph aureus

Answer 1110

440mg (4mg/kg actual BW) also give 4mg/kg if TOFC 1, 2mg/kg if TOFC 2-4

Answer 1111

infraorbital

Answer 1112

ECG; potential to reduce inappropriate interventions based on falsely low HR estimates based on pulse ox or auscultation but unclear if outcomes improved by early ecg *as per ANZCOR, HR monitored by oximeter should be intermittently checked by ecg or ausc auscultate precordium with stethoscope (more reliable than cord palpation) base of umbi cord preferable to other palpation locations (hard to palpate in newborns, absence of pulses= unreliable sign Pulse oximetry reliable display within 30 seconds of application, ecg even more quickly pulse ox great as also gives info about oxygenation Newborn HR soon after birth should be 130 (varies 110-160)

Answer 1113

no change; incr high freq & decr low freq components

Answer 1114

N2O>des>halo>iso>sevo GWP100 Des>iso>N2O>sevo>CO2

Answer 1115

medial rectus

Answer 1116

FLACC 2 months-8yrs & up to 18 if cognitive impairment Self-report of pain is preferred when feasible & is possible to an EXTENT from 4yo (depend on cognitive & emotional maturity) Revised faces pain scale/Wong baker faces 3-12 yrs (Wong Baker preferred, valid & reliable, but the smiling & crying anchor faces may lead to confounding w affect) VAS 8 & up Coloured anchor scale validated & reliable for acute pain Ax, recommended >=8yo, slider from white graduations to deep red NRS-11 has been validated & is reliable; chn <8yo may need screening tasks >=12, can use multidimensional eg. McGill pain questionnaire Neonates: -modified pain assessment tool (mPAT)= observational, involves behavioural (eg. sleep pattern) & physiological responses to painful stimuli (eg. RR, HR, SpO2, BP) & includes nurse's perception -Premature infant pain profile (acute procedural pain, post-op pain) -CRIES: crying, requires O2 for SaO2 >95%, incr vital signs, expression, sleeplessness APMSE: 4-5yo use simplified-FPS or pieces of hurt (four chips) some 5 & >=6yo: NRS-11 or FPS-revised >=8yo: CAS & VAS

Answer 1117

Resus, fluid IV glucagon 50mcg/kg (up to 10mg) then 2-10mg/hr Ca++ gluconate vasopressor high-dose insulin euglycaemic therapy (w dextrose to avoid hypos) intralipid if refractory to standard measures

Answer 1118

Anaes: -R) lung collapsed (it's 10% larger, shunt is smaller if L) lung collapsed) -poor sat on 2 lung vent, esp when lateral -supine during OLV Pt: -normal PFTs pre-op (pts w severe airflow limitation on pre-op spirometry tend to have better PaO2 during OLV than pts w normal spirometry) -restrictive lung disease -V or Q % higher in the operative lung pre-op

Answer 1119

hepatic failure complications DO include: -hypovolaemia -hypokalaemia: partly due to incr GI loss of secreted K+ w hyperosmotic & stimulant preparations, incr urinary loss due to hyperphosphaturia w use of sodium phosphate -phosphate nephropathy -hypocalcaemia -hypermagnesaemia (picolax, citrafleet), esp if CKD iso-osmotic polyethylene glycol (PEG): iso-osmotic (eg. GoLytely- 4L), don't cause fluid/electrolyte shifts mut may incr plasma volume & exac HF. Doesn't damage colonic mucosa. avoid solutions with ascorbic acid if G-6 P defic Use them in older adults or those w renal insufficiency, end-stage liver disease or electrolyte imbalances or taking diuretics low [] Na so risk hyponatraemia hyperosmotic: sodium sulfate-based: poorly absorbed anion, doesn't produce significant fluid & electrolyte shifts, s3L sodium phosphate tablet (osmoprep) is the only tablet form. however, black box warning: fluid shifts, hyperphosphate, hypoCa,K,hypERN, renal damage incl phosphate nephropathy so avoid if NYHA II/IV, renal insuffic, severe liver disease, incr risk for electrolyte abnorm, pts w IBD or diarrhoea of unknown etiology shouldn't get these preparations- mucosal damage. avoid sodium picosulfate in pts w HF, renal insufficiency, ESLD or electrolyte issues as it's a stimulant laxative, potential for electrolyte shifts, higher risk hyponatremia cf PEG solutions.

Answer 1120

3-7mmHg 1.5-6mmHg

Answer 1121

40mmHg 40-50mmHg 0-5yo, 50-60mmHg for 6-17yo, 60-70mmHg adults BTF: III.1. Treatment to maintain a CPP at a minimum of 40 mm Hg is suggested. III.2. A CPP target between 40 and 50 mm Hg is suggested to ensure that the minimum value of 40 mm Hg is not breached. There may be age-specific thresholds with infants at the lower end and adolescents at or above the upper end of this range.

Answer 1122

reduces days of mechanical ventilation & days in ICU but not days in hospital & ass'd w more unfavourable outcomes @ 6/12.

Answer 1123

deflate tracheostomy cuff, insert fenestrated piece, insert one0way valve

Answer 1124

1. Hx IE 2. Prosthetic heart valve or prosthetic material used for cardiac valve repair (eg. annuloplasty rings & cords) 3. cardiac transplant w valvulopathy (consult cardiologist) 4. RHD 5. Congenital heart disease, a) if un-repaired cyanotic defects incl palliative shunts & conduits or b) repaired defects but residual defects @ or adj to a prosthetic patch or device (which inhibit endothelialisation) or c) repaired but within 6 months (still endothelialising)

Answer 1125

5 days, 20-24deg

Answer 1126

SS= acute, hyperreflexia/myoclonus, dilated pupils, may have diarrhoea cf NMS which is slower onset, muscle rigidity/hyporeflexia, pupils no change, may have paralytic ileus

Answer 1127

the satisfaction or economic advantage gained from the outcome that results from a particular decision

Answer 1128

-QRS >0.14s -Concordance of the QRS complexes in the chest leads -Fusion beats (presence confirms VT, absence doesn’t exclude it) -Capture beats (result in a narrow QRS, their presence confirms a Dx of VT but their absence doesn’t exclude it) -extreme axis, or mean frontal plane axis changing during the tachycardia (esp >40 deg L) or R) -evidence of atrioventricular dissociation is diagnostic of VT (absence of evidence AV diss’n doesn’t exclude) -evidence of a prev MI incr likelihood of VT

Answer 1129

thyroid & hyoid fractures

Answer 1130

CT angiogram (97-100% sensitivity) CXR 98% NPV if normal

Answer 1131

SVC to R) PA SVC + IVC to R) PA +/- fenestration to RA incidations: tricuspid atresia, pulm atresia, hypoplastic R) or L) heart

Answer 1132

males (women of child bearing age risk developing ABs through exposure to foetal blood- the Abs canthen react w the recipients neutrophils in pulm vasculature to produce an immune response)

Answer 1133

ABCDE; monitor SpO2, BP, pulse, 12-lead ecg apply O2, IV access correct reversible causes (eg. electrolytes) If any adverse features (syncope, shock, heart failure, myocardial ischaemia): atropine 500microg. If satisfactory response (or no adverse features) consider if the pt is @ risk of asystole (recent asystole, mobitz II, CHB w broad QRS, ventricular pause >3s)--> if no, observe If yes, interim measures= atropine 500microg IV isoprenaline 5microg/min IV adrenaline 2-10microg/min IV alternative drugs (aminophylline, dopamine, glucagon (if B blocker or CCB overdose) or glycopyrrolate can be used instead of atropine) arrange transvenous pacing

Answer 1134

vaporiser incorrectly seated on backbar leaks around agent filling device fracture in gas piping cracked rotameter flow tubes leaks in high & intermediate pressure systems usually from defective valves, connectors, hanger yokes

Answer 1135

autoimmune disease of persistent aPL antibodies, recurrent venous & arterial thrombosis or adverse pregnancy outcomes May be primary or secondary (ass'd with connective tissue diseases (RA, SLE, systemic sclerosis, Behcet's)) Manifests: obs -recurrent miscarriage -stillbirth/IUFD -severe PET <34/40 -severe IUGR -chorea gravidarum (involunt movements, altered speech/affect) non-obs -recurrent venous/arterial thrombosis -livedo reticularis -cardiac murmurs -neurol features transient amaurosis fugax, TIA, CVA -digital ischaemia -thrombocytaemia, haemolytic anaemia persistent aPL antibodies (lupus anticoagulant), prol aPTT, false +ve syphillis test, thrombocytopenia haemolytic anaemia

Answer 1136

several days Can restart P2Y12 inhibitors 12-24hrs after neuraxial block (no loading dose) Stop clopi os ticag 5-7 days before neuraxial (prasugrel 7-10). need to do plt function tests if hold for only 5 days. P2Y12 assay similar when clopi stopped 5 days vs 7 (indicates <10% inhibition)

Answer 1137

4 mins (baby out @ 5)

Answer 1138

4 mins (baby out @ 5)

Answer 1139

cord compression (late decels indicate contractions in presence of hypoxia eg. cord compression) - early decels normal physiologic response to minor head compression (raised ICP) CTG big square= 1 minute DR: define risk (gestation, are they in labour, events until now) C: are theire contractious, regularity BR: baseline rate Normal FHR 110-160bpm Baseline FHR: mean FHR when stable, excl acc & dec, define over 5-10 mins incr by maternal fever, hypovolaemia, foetal arrhythmia, infection, distress. reduced rate if slep (low normal), drugs, congenital heart block. Variability: sign of intact foetal neural circuitry. Baseline variability: minor fluctuation in baseline FHR, determined as diff btwn highest peak & lowest trough in FHR over 1 min segments, normal variability 6-25bpm, reduced 3-4, absent <3, increased (salutatory) >25bpm Accels: transient incr FHR >=15bpm above baseline, lasting 15 secs Decels: transient episodes of dec FHR 15bpm & lasting @ least 15 secs *late decels may be <15bpm from baseline -early decels: benign. Ass’d w sleep cycle, often @ 4-8cm Cx dilation. caused by mild head compression, normal physiological response to mild incr ICP. Uniform shape, mirror contraction. -variable decels: intermittent, significance depends on overall clinical picture. -complicated variable decels: have non-reassuring additional features indicating likelihood of hypoxia eg. Rising baseline HR or fatal tacchy, reduced or absent variability, onset of nadir after peak contraction, large amp/longer duration decel -prolonged decels: dec >15bpm 90secs to <5mins -late decels: uniform, repetitive dec FHR, slow onset med to late contraction, nadir >20secs after peak contraction, end after contraction (don't recover from contraction). Caused by contractions in presence of hypoxia. Or suggests some degree of placental insufficiency -sinusoidal: smooth & regular, 2-5 cycles w amplitude 5-15bpm around baseline rate. lack baseline variability, no accels. Typically reflects severe anaemia (Hb <50) or peri-arrest Preterm: higher baseline HR, access are less amplitude & shorter duration

Answer 1140

no HR >130 w exercise no change QT interval w valsalva

Answer 1141

CHF HTN Age >=75 DM Stroke/TIA 2

Answer 1142

60mg daily; -50-90kg 40mg daily -91-130kg 60mg daily -131-170kg 80mg daily >171kg 0.5mg/kg

Answer 1143

40mg BD (if that not an option, 60mg daily) <50kg 20mg daily -50-100kg 40mg daily -100-150kg 40mg BD (or if BMI 41-60 as per latest QH) >150kg 60mg BD QH: if BMI >60, specialist advice If eGFR 15-29, enoxaparin 20mg s/c daily <15 don't use LMWH

Answer 1144

Z score preferred, if N/A, DLCO >140% pred is abnormally high 76-140% pred is normal 61-75% mild impairment 41-60% mod impairment <40% severe impairment

Answer 1145

suggests: insufficient neuromuscular reserve abnormal resp mechanics inadequate effort

Answer 1146

suggests: insufficient neuromuscular reserve abnormal resp mechanics inadequate effort eg. myaesthenia gravis. may also be heralded by decr FVC, normal or high residual volume, resuded max insp/esp pressures. MVV good as a dynamic test of ehnduratce.

Answer 1147

Genitofemoral neuralgia haematoma intravascular injection intrathecal or epidural injection perforation viscera

Answer 1148

17-28% CKMB in 37% LV dysfunction in 8-30% Most severe form cardiac injury ass'd w SAH: stunned myocardium (reversible LV systolic dysfunction, cardiogenic shock, pulm oedema)

Answer 1149

2% (1.8) HBV 30% HIV 0.3%

Answer 1150

adenontonsilectomy otorhinolaryngological strabismus tonsillectomy

Answer 1151

ABCDE, card monitoring, IV access life threatening (muscle weakness/paralysis, cardiac conduction abnormalities or arrhythmias)= hyperkalaemic emergency. Stop K, Rx with rapidly-acting therapies. IV Ca++ if ecg changes or serum K >6.5, insulin (50% glucose 50mL with 10U actrapid over 10-15mins), & aremove K+ from body (eg. haemodialysis) If not life threatening but serum K >6.5, do the same as per emerg. >5.5, consider if significant renal impairment, ongoing tissue breakdown (eg. rhabod) or ongoing K absorption (eg. GI bleeding); if so manage as per emergency If just renal impairment or pt needs K+ optimised for surgery, lower K promptly (eg haemodialysis if ESKD, discontinue meds causing hyper K, sodibic if metabolic acidosis, diuretics if hypervolaemic, or cation exchanger) Otherwise, lower slowly: dietary modification, diuretics, bicarb if metabolic acidosis, reversal of triggers/contributors, resonium.

Answer 1152

potassium (varies 25%, as does Cr, CO2) also not good for Na (varies by 5%), Ca++ (varies by 10%)

Answer 1153

monitored pulseless VT, no immediately avail defib

Answer 1154

primarily intorsion also depression, abduction

Answer 1155

0=0.2 1=0.6 2=2.2 3=3.2 4=4.8 5=7.2 6=9.7 7=11.2 8=10.8 9=12.2

Answer 1156

1= no symptoms w normal phys activity, normal functional status 2= mild symptoms normal physical activity, slight functional limitation, comfort @ rest 3= moderate symptoms normal phys activity, marked limitation functional status, comfortable only @ rest. 4= severe symptoms, features of HF w minimal physical activity (even @ rest), severe limitation functional status

Answer 1157

mental nerve (branch of inferior alveolar from mandibular)

Answer 1158

afferent via long/short ciliary of ophthalmic branch trigeminal nerve then vagus efferent

Answer 1159

spoont vent facemask

Answer 1160

spoont vent facemask

Answer 1161

Atm bar psi kPA mmHg cmH2O 10atm= 1000kPA 10atm= 147psi 10atm=7600mmHg 10atm= 10000cmH2O

Answer 1162

prothrombinex 50IU/kg

Answer 1163

decrease- 2 stage, initial small decr then several mins later, sharper decr to lower values.

Answer 1164

intubate from mouth

Answer 1165

place L) lateral

Answer 1166

>110mL w cuff deflated has 98% NPV for post-extubation stridor

Answer 1167

thoracic outlet syndrome

Answer 1168

0.21 only up to 100% if HR <60 & commencing compressions once compressions finished, titrate SpO2 to target oals

Answer 1169

2.5mSv/annum 15mSv 0.1

Answer 1170

Given just before removal of vessel clamps, reduces requirement for post-transplant dialysis but doesn't improve long-term graft funciton in absence of adequate hydration

Answer 1171

neither incr risk of bleeding nor risk thrombotic complications nor death

Answer 1172

reduces blood product usage, lower bleeding risk, no difference thrombotic complications or death (30 day), possibly seizure link

Answer 1173

4-10 days (or 3-14)

Answer 1174

60mg daily

Answer 1175

410 ((130x2) + 150)

Answer 1176

mental nerve, from inf alveolar)

Answer 1177

sup oblique

Answer 1178

inability to apply -ve pressure to pleural cavity

Answer 1179

thyroxine non-compliance, subclinical hypothyroidism (autoimmune shows elevated TSH but low T3/T4)

Answer 1180

Most common congenital cause UA obstruction Usually within 2/52 of birth, insp stridor, worse feeding or lying supine. Generally conservative Mx better 6-9months later; if severe Ax rigid branch, secondary lesion in 20%. 5-10% surgical Rx.

Answer 1181

Most common congenital cause UA obstruction Usually within 2/52 of birth, insp stridor, worse feeding or lying supine. Generally conservative Mx better 6-9months later; if severe Ax rigid branch, secondary lesion in 20%. 5-10% surgical Rx.

Answer 1182

8Fr 2.5=5Fr 3-3.5=7

Answer 1183

3.5-7.5hrs (peak is 6, late can be up to 12hrs)

Answer 1184

50mcg//kg inc by 50mcg/kg q2m max 250mcg/kg

Answer 1185

T test (non-par= Wilcoxin rank sum (aka Mann-whitney U test)) Paired T-test (non-parametric wilcoxin signed rank) Wilcoxin rank sum (aka Mann-whitney U test) ANOVA (non-par=Kruskal Wallis) Bland Altman Fisher's exact Chi squared (can use for the other categorical but less exact than Fisher's)

Answer 1186

1. Define research question: -hypothesis, study type 2. Protocol: 1. Background- lit review. Review what's been done, set scene. 2. Hypotheses: formed as a statement (to disprove) 3. Methods: P: inclusion/excl I C O (specific & measurable)- primary= sample size etc based on this allocation, data recording Analyse & store data How address safety issues/protocol breatches, analysis (having statistician useful from the beginning 3. Funding 4. Ethics & governance (legal regulations & quality assurance) Once ethics approved or waived, collect data. Ethics: chairperson, lay person, someone involved in professional care/counselling, lawyer, 1-2 ppl with current experinence w the proposals Analyse Submit to journal Pilot: test out the methods/procedures, identify issues, to establish effect & sample size Confounder= a variable independently associated with intervention & outcome Bias= systematic error in the study resulting in incorrect estimates of the association. Usually methodological issue. Selection bias: some groups over-represented Recall bias Observation bias (Hawthorne effect: when pts being watched, consciously or subsonsciously impacts their behaviour Confirmation bias Publication bias: not report -ve trails

Answer 1187

summarise findings of a meta-analysis Small box= point estimate (eg. the mean, size represents # of participants). horizontal line= confidence interval (95%) Vertical line= line of no difference. Diamond= cumulative result of all studies (cumulative point estimate)

Answer 1188

Eclampsia prophylaxis MgSO4 for foetal neuroprotection if <30/40

Answer 1189

compresss the interesting part, btwn 20-80% response, where relationship usually linear

Answer 1190

tramadol & codeine: risk serotonin syndrome metoprolol: CYP2D6 substrate so plasma levels incr (escitalopram CYP2D6 inhibitor)- codeine, tramadol also CYP2D6 omeprazole CYP2C19 inhibitor so will incr plasma concentrations of escitalopram

Answer 1191

ibuprofen, naproxen, indomethacin

Answer 1192

Naproxen Diclofenac & the COX-2 selectives highest risk

Answer 1193

YOUNGER AGE severe head injury/acute neurological injury sepsis high catechol & GC levels low CHO:high lipid intake inborn errors FA oxidation

Answer 1194

promethazine can worsen hypoT

Answer 1195

/3, altered mentation, SBP <100, RR>22

Answer 1196

Serotonin syndrome CYP inhibition (may reduce efficacy of codeine, tramadol CYP2D6 substrates) bleeding risk (unclear if ass'd w transfusion) atrial arrhythmias (5-HT receptors in atria) VT (QT prol) Delirium

Answer 1197

thiazide diuretics, gliclazide, frusemide, sulfasalazine, amiodarone, diazoxide, indapamide, celecoxib BUT none contain arylamine group SO unlikely that cross-reactivity exists btwn sulfonamide ABx & other sulfonamide drugs If pts have an allergic reaction to one cdrug there's a stronger chance of allergic reaction to other drugs, even if unrelated. SO, pts with a Hx of allergy to a non-arylamine sulfonamide drug need not be considered contraindicated to have arylamine sulfonamide drugs. Benzoaine & procainamide DO have arylamine group, theoretical ana[hylaxis risk.

Answer 1198

-ve pressure generated when suction applied to the system

Answer 1199

Depends on pt initial & target INR & if bleeding; INR 1.5-2.5 & target 1.4-2, 15units/kg. If INR >3.6 & want it <=1.3, 50IU/kg

Answer 1200

0.24, 0.28, 0.32, 0.36 The FiO2 w hudson 6L/min 0.6, 8L/min 60%

Answer 1201

120mins (90-120mins- pt-dependent, corresponds to depletion of ATP stores), every 30 mins incr risk nerve injury 3-fold)

Answer 1202

Nysora: 30 mins 20-30 mins; should inflate @ least 20 mins to avlid LA toxicity w deflation (not evidence-based). If had to inflate before 30 ins, gradual deflation/reinflation to proloong LA washout. Double cuff, on then elevate UL, inflate to 100mmHg above SBP, pulse goes, keep intralipid nearby.

Answer 1203

no difference 4% alb cf 0.9% NaCl, avoid 4% alb in head injuries (incr 28 day mort)

Answer 1204

Identification of the device & location of extension cable, liaison with the clinician managing the device, establish the conseequences of having the device off, if deactivating device= severe symptoms, oral meds started before turning the device off. If turned off during procedure, turn on after surgery & interrogate postop. Potential interactions: -electrocautery may burn neural tissue around electrodes or reprogram it- turn it off for electrocautery procedures, bipolar safer (similar to considerations w ICD & SC stimulators). If momnopolar, ground pads as far as poss from generator, lowest possible energy. NO short-wave diathermy modalities (radio frequency currents that head electrodes) -Artefacts/interference on ECG -safety of cardiac defies not established in DBS; if required, paddles as par as poss from generator, lowest energy, check generator after ECT, RF nkeuroablation & peripheral nerve stimulation likely safe if pulse generator off & stimulator probes as far as poss from generator. -MRI may cause incr temperature of electrodes & brain injury, device reprogramming; follow manufacture instructions.

Answer 1205

No- while it binds antithrombin III, doesnt have the extra chain like heparins do, doesn't cause HITs

Answer 1206

bactericidal (@ high doses) vs bacteriostatic, faster onset &longer duration of action, efficacy in presence of blood, lower incidence skin reaction, less colonisation epidural catheter it has MORE neurotox vs iodine

Answer 1207

5-7hrs 24hrs

Answer 1208

Difference in the concentrations between strong cations (Na+, K+, Ca++, Mg++) & strong anions (Cl- & SO4-); strong ions are those that dissociate completely in a particular solution (this case, @ blood pH 7.4). SID normal human plasma is 42.

Answer 1209

Nominal: each category has no impact on the other Ordinal: natural progression in the data

Answer 1210

Average. is the measure of central tendency for reporting normal data (where it's also the median & the mode) median is middle point (50% data above, 50% below), most useful measure of centraltendency for skewed data. mode= most frequently appearing.

Answer 1211

68% 95% 99.7%

Answer 1212

The sampling distribution of any statistic will be normal or near-normal if the sample size is large enough; this allows normal-based tests to be used for analysis of means.

Answer 1213

sample mean +/- 1.96x SE

Answer 1214

Parametric tests: correlation, linear regression Non-para: spearman's rank correlation

Answer 1215

First consider: what’s the effect we are looking for? How much type 1 error willing to accept? How much type 2 error (B) willing to effect What sample size is needed to achieve this.. Calculation has degrees of freedom; control 3 things (alpha, B, effect size), 4th (sample size) determined by these; determine PROSPECTIVELY Often work out for power (1-B) of 90% to account for attrition Power will increase if incr sample size & incr If incr effect size

Answer 1216

Using best available research to guide clinical care Identify clinical question gather, appraise & analyse the evidence & relevance to practice Mofify practice as a result

Answer 1217

Using best available research to guide clinical care Identify clinical question gather, appraise & analyse the evidence & relevance to practice Mofify practice as a result

Answer 1218

Group A Rx then washout w no Rx, then group B no Rx & then washout Rx

Answer 1219

1. Are the results valid (eg. were the groups treated equally apart from experimental therapy?) lack of blinding or lack allocation concealment generally overestimates Rx effects, ITT analysis preserves benefit of randomisation, loss to follow-up impacts study's validity 2. What are the results Will the results help me care for my pts?

Answer 1220

A weighted RR over entire duration of a study, derived from time-to-event or Kaplan-Meier curve. Takes into account timing of events which might not be evenly distributed throughout study period (cf overall RR)

Answer 1221

A weighted RR over entire duration of a study, derived from time-to-event or Kaplan-Meier curve. Takes into account timing of events which might not be evenly distributed throughout study period (cf overall RR)

Answer 1222

Increase increase

Answer 1223

RR 2=2 2x more likely RR 0.5=0.5 half as likely

Answer 1224

Case control, where no way of knowing how many ppl had the exposure (ie. Don't know the denominator); it's the probability of the event occurring vs probability of the event not occurring, cf risk which is the chance of the outcome vs the chance of the outcome in whole population (hence better for prospective & cohort) OR & RR are closer for rare outcomes, incr event rate, the diff more extreme (OR will overestimate RR if OR>1 & underestimate the true RR if OR <1 if common outcome.

Answer 1225

propofol, NMDA antag (ketamine, Mg++), pregabalin, N2O, gradual taper opioid dose, rotation NOT clonidine

Answer 1226

Before surgery, 40mg PO onset of action 1hr peak 4hrs

Answer 1227

FVC TV IRV ERV NOT RV so not TLC

Answer 1228

Triceps twitch Medial cord= wrist twitch (FCU) Lateral cord elbow flexion (corocobrachialis)

Answer 1229

2% if source known +ve, seroconversion rates are 0-10%

Answer 1230

Alcoholic (liver disease) B12 def Compensatory reticulocytosis Drugs (cytotoxic, Azothioprine)/Dysplasia bone marrow Endocrine (hypothyroidism) Folate Thalassaemia Anaemia chronic disease Iron def Lead poisoning Sideroblastic (body unable to utilise Fe, rbcs aneucleated, high ferritin but low transferrin & TIBC) ACD, renal, marrow haemoglobinopathies

Answer 1231

Alcoholic (liver disease) B12 def Compensatory reticulocytosis Drugs (cytotoxic, Azothioprine)/Dysplasia bone marrow Endocrine (hypothyroidism) Folate Thalassaemia Anaemia chronic disease Iron def Lead poisoning Sideroblastic ACD, renal, marrow haemoglobinopathies

Answer 1232

Hereditary fructose intolerance (it contains sorbitol which can cause adverse reaction w parenteral admin). Idarucizumab is 5g, lasts 24hrs, no dose adj for renal impairment.

Answer 1233

Warm ischaemia (inevitable with DCD): donor is from asystole—> cold perfusion. Recipient warm ischaemia= from removal from ice—> reperfusion. Cold ischaemia= from end donor warm ischaemia to onset recipient warm ischaemia.

Answer 1234

1. Active invasive Ca in the last 3 yrs excl non-melanoma skin Ca & primary brain tumour 2. Haematological malignancy 3. Untreated systemic infection 4. Variant CJD 5. HIV disease (not infection)

Answer 1235

ICP duration MV ICU LoS BUT worse functional outcome @ 6 mths, no change hospital LoS & more meical/surg complicaitons RESCUE ICP decomp crani pts w TBI had lower mort but higher rates poor functional outcome vs medical care

Answer 1236

High frequency current (1MHz), ass’d with higher threshold for adverse physiological effects

Answer 1237

vWD, haemophilia A, haemophilia B *haemophilia A X-linked recessive so can be passed from mother to son

Answer 1238

Hypoglycaemia (hyperglyc, hyper/hypovol, trauma, hyper Na, surgery, HES, thrombin & TNF alfa do)

Answer 1239

SV incr by >=10% after a fluid challenge

Answer 1240

Avoid BZD, if need premed use clonidine Consider IV lignocaine to suppress laryngospasm but avoid topical lignocaine to VCs Pre-op salbutamol neb 2.5mg for chi w current & recent (<2wks) URTI Least invasive device (FM vs LMA vs ETT) Deep removal of airway device is ass’d w incr airway obstruction despite reducing laryngospasm & PRAE Experienced anaesthetist Propofol blunts airway reflexes but limited BD VA good bronchodilator BUT does’t suppress airway reflexes; use for intra-op bronchospasm but not induction/emergence (avoid des) Don’t use VA for laryngospasm! Better to do IV vs inhalation induction

Answer 1241

Avoid BZD, if need premed use clonidine Consider IV lignocaine to suppress laryngospasm but avoid topical lignocaine to VCs Pre-op salbutamol neb 2.5mg for chi w current & recent (<2wks) URTI Least invasive device (FM vs LMA vs ETT) Deep removal of airway device is ass’d w incr airway obstruction despite reducing laryngospasm & PRAE Experienced anaesthetist Propofol blunts airway reflexes but limited BD VA good bronchodilator BUT does’t suppress airway reflexes; use for intra-op bronchospasm but not induction/emergence (avoid des) Don’t use VA for laryngospasm! Better to do IV vs inhalation induction

Answer 1242

42 days 35 days 28 days 5 days (agitator) 12 months if <-25deg (FFP can be used for up to 24hrs if kept 1-6degc). either can usewithin 4 hrs afer thawing if at room temp. don't put cryo in fridge (may re-precipitate).Blood products through 170-200micron filter. 5 days

Answer 1243

After 2-4% of minor & up to 50% major obs trauma Clinical findings: PV bleed, abdomen cramp, uterine tenderness, leakage amniotic fluid, maternal hypovolaemia, larger than normal uterus for GA, change FHR After trauma, PV bleed ominous sign Trans abode US < 50% accurate for placental abruption, CTG more sensitive (foetal distress) Minimum 4hrs CTG, 24 if frequent uterine activity, abdominal tenderness, PV bleed, ROM, hypotension

Answer 1244

After 2-4% of minor & up to 50% major obs trauma Clinical findings: PV bleed, abdomen cramp, uterine tenderness, leakage amniotic fluid, maternal hypovolaemia, larger than normal uterus for GA, change FHR After trauma, PV bleed ominous sign Trans abode US < 50% accurate for placental abruption, CTG more sensitive (foetal distress) Minimum 4hrs CTG, 24 if frequent uterine activity, abdominal tenderness, PV bleed, ROM, hypotension

Answer 1245

alcohol (immediate antimicrobial stronger & quicker but no residual effect)

Answer 1246

4-6mmol/24hrs

Answer 1247

60-70mmHg (& also, jugular venous sats <50% may be threshold to avoid to reduce mort & improve outcomes)

Answer 1248

mixed obstructive/restrictive

Answer 1249

Head 18% (adult 9%) Each leg 14% (adult each leg 18%)

Answer 1250

TxA cf placebo reduced death due to bleeding but not death from all causes or hysterectomy if gave witin 3hrs, reduced death no diff thromboembolic events, complications (incl seizures), surgical interventions issues: low fragility index, change power calc & hypothesis after commencement

Answer 1251

2.6-4.2, <2.2mL/min2 suggests cariogenic shock

Answer 1252

Unconsciousness Less CV changes; sudden apnoea, LOC & dilated pupils Factors for total spinal: Drug: incr dose Baricity Prior drugs (eg. Epidural) Pt: Higher BMI or abdominal girth or pregnancy, compressed thecae sack (eg. Spinal canal anomaly), dwarfism Technical: higher insertion, lying vs sit, cephalic direction

Answer 1253

Square root of the variance Sum of the squared deviation from the mean

Answer 1254

Withold 2 wks preop Reversible discontinue day of OT

Answer 1255

Anti cholinesterase inhibitor for mod-severe AZD (as is rivastigmine, galantamine) Antagonise ND-NMBDs (may get ACh receptor down regulation) Require higher dose of ND-NMB, ND-NMB have decr duration of action. Donepezil, galantamine & rivastigmine enhance effect of sux, risk phase=II interaction. Neostigmine may be relatively ineffective, incr doses may be required. Should cease pre-op: galantamine & rivastigimne have short half lives (7-8 & 3-4hrs, respectively), can discontinue the day before surgery. Donepezil has long half-life 70hrs, washout period 2-3wks. BUT risk decline cognitive function so multi-D consideration. If continue, could use attach or cis (spontaneously inactivated but still need higher doses of these) OR could use sugammadex reversal if use lg doses roc or vec.

Answer 1256

Anti cholinesterase inhibitor for mod-severe AZD (as is rivastigmine, galantamine) Antagonise ND-NMBDs (may get ACh receptor down regulation) Require higher dose of ND-NMB, ND-NMB have decr duration of action. Donepezil, galantamine & rivastigmine enhance effect of sux, risk phase=II interaction. Neostigmine may be relatively ineffective, incr doses may be required. Should cease pre-op: galantamine & rivastigimne have short half lives (7-8 & 3-4hrs, respectively), can discontinue the day before surgery. Donepezil has long half-life 70hrs, washout period 2-3wks. BUT risk decline cognitive function so multi-D consideration. If continue, could use attach or cis (spontaneously inactivated but still need higher doses of these) OR could use sugammadex reversal if use lg doses roc or vec.

Answer 1257

until end-tidal carbon dioxide is < 45 mmHg and core temperature is <38.5oC (cool until 38 deg C, prevent a fall to < 36deg C)'maximum 10mg/kg has been quoted but sometimes need to exceed this for crisis (latest guidelines no ceiling) actual body weight, max 300mg initial dose.

Answer 1258

until end-tidal carbon dioxide is < 45 mmHg and core temperature is <38.5oC (cool until 38 deg C, prevent a fall to < 36deg C)

Answer 1259

<5ppm Before place the activated charcoal filters, flush machine w high-flow O2 or air (any mix) >10L/min for 90s. Place charcoal filters on insp & exp limbs, reduce FGF 1-3L/min w filters, change them after 12hrs.

Answer 1260

Static field: movement of pulse generator’s internal components Modulated RF field: induces voltage across pacemaker electrodes, heating cardiac tissue Gradient magnetic field: over- and under-sensing Risk/benefit decisions, reprogramming in liaison w cardiologist, ALS equip & personnel, continual monitoring, consent, interrogation post examination Lithotripsy at least 15cm from pacemaker, use low shock waves.

Answer 1261

Ondansetron (5HT3 antagonists) SC reduces pain & improves mobilisation after osteoporosis-related vertebral compression fractures. Reduces acute NOT chronic PLP. Causes sedation, nausea, skin flushing, serotonertic activity.

Answer 1262

acute pericarditis

Answer 1263

For limb lead reversal, normal R wave progression in precordial leads BOTH limb lead reversal (LA/RA reversal), lead 1 complex totally inverted, aVR positive complexes, RAD

Answer 1264

1 unit per 5-10kg body weight, so for 70kg pt, 7-14 units

Answer 1265

Sensitivity/ (1-spec) how much more likely is it that a patient who tests positive has the disease compared with one who tests negative. -ve likelihood ratio= 1-sens/spec

Answer 1266

2 mcg/kg (0.1mL.kg) life-threatening 0.2-0.5mL/kg (4-10mcg/kg) Draw up 1mg in 50mL= 20mcg/m infusion 0.3-6mL/kg/hr (0.1-2mcg/kg/min)

Answer 1267

Amitryptilline (low doses for 90 days from onset HZ rash). (?NNT 2), gabapentin NNT 3.2) PHN= chronic pain 3/12 after HZ. Incr risk older age, female, worse acute pain, severe rash, dermatomal pain before the rash. Immunisations >60yo reduces both HZ & post-herp neuralgia Start antivirals within 72hrs to accelerate acute pain but that doesn’t reduce incidence/severity/durn of neuralgia. CONTINUOUS OR REPEAT PVB in acute phase HZ reduce incience of PHN at 3,6,12 months! Continuous epidural in acute phaze of HZ reduces incidence of PHN at 312 Mx w gabapentanoids (pregabalin & 5% lignocaine plaster more effective than TCAs (APMSE), Gabapentin, TCAs (amitriptyline, nortriptyline may have better SE profile), consider lignocaitn (multimodal). Capsaicin cream or patch. Opioids if not responding. UTD: start with low dose gabapentin or pregabalin, up-titrate to limit SEs amitriptylline 2nd line (may not tolerate SEs, nortriptylline may be better (anticholinergic; sedation & dry mouth, care ++ in elderly Early appropriate analgesia vital in management of HZ, may assist reduction incidence PHG. Nerve blocks in acute phase reduce duration of HZ-associated pain. Topical aspirin, lignocaine, CR oxycodone help acute pain.

Answer 1268

hypocalcaeima

Answer 1269

inhibit COX-2 mediated PG synthesis Onset analgesia 7-14mins, peak within 2 hrs DOA 6 to >24hrs (great for day stay)

Answer 1270

Improvement ketones

Answer 1271

Aim: simultaneous Ax & management, goal effective spont or assisted respns within 1 minute. Equipment: resuscitaire on, warmer 27 deg, towels to warm bub & for btwn scapulae, flowmeter 10L/min, blender 21% (term), Neopuff PEEP 5cmH2O, PIP 20-25cmH20 preterm, 30cmH2O term, PPV rates will be 40-60/min 10Fr suction, size 0.1 laryngoscope, size 3,3.5 tracheal tubes, T-piece, self- or flow-infl 240mL bag, have Adr, fluids (slaline 10mL/kg, blood 10mL/kg), 5Fr umbi catheter ready in case prolonged resus Monitoring: pulse ox for R) side, pre-ductal, stethoscope Senior anaes as TL, airway, CPR 2nd clinician for Ax Hr, ventilation Post-resus care: handover to peds/neonatal team, debrief

Answer 1272

Those with vesicant properties (blister potential & tissue injury eg. calcium, amphotericin B), hypertonic solutions (max osmolarity peripheral 500mOsmol/L, >10% DEXTROSE OR >5% PROTEIN), those with pH <5 or >9, vasopressors & inotropes 3Fr basilic vein above elbow= preferred PICC insertion site(cephalic vein acute angle @ SC junction) PICC should be in distal third SVCvc or cavo-atrial junction, if LL to IVC. confirm tip position, UL PICCs move avg 2.2 rib spaces w UL movement soinsert w line fixed so tip optimally placed when arm comfortable). If a CVC or for high flows (eg. HD), RA better. consider if duration therapy 10 days-2 months. can be inserted & revoved without GA in SOME chn. Generally tunnelled if instionn >6wks Generally use 10mL or larger syringes to flush as smaller higher pressures risk damaging lines. Care with volumes! MIDLINES ARE 8-12 CM, FOR PERIPHERAL SOLUTIONS ONLY, STILL STERILE GOWN/MASK/1 MIN HAND SCRUB & STERILE GLOBES DUE TO DWELL TIME (usually 6-10 days, may be longer). FAR AWAY ENOUGHT FROM ELBOW THAT CAN FLEX, ENSURE THE 8-12CM DOESN'T CROSS THE AXILA.

Answer 1273

First 7-10 days of life. 2.5-8Fr (5Fr for newborn Resus). Ideally terminates in IVC above diaphragm but for Resus, can use once free flow of blood on aspiration achieved. Generally 4cm depth insertion (first mark 5cm). Not if abdominal wall defects, peritonitis, nec enterocolitis.]

Answer 1274

generally 5cm lines for chn <15kg, 8cm 16-40kg & 13cm if >40kg. 4-5Fr if <6/12, 5Fr if 6/12-5yrs, 7Fr if >5yrs. Confirm tip position. Confirm tip position by radiography.

Answer 1275

24-22g, 22-20g for neonates if <22g, need 0.012 diameter wire. paeds, art line fluid continuously infused is 1-2mL/hr vs 3mL/hr w pressurised fluid bag. Paeds use syringe drive. Also have special needle-free access port (limit deadspace & conamination). Syringe driver rather than pressure bag (limits volume infused, prevent clotting of line). low volume tubing.

Answer 1276

Block NAdr & serotonin reuptake. block fast Na channels--> QRS prolongation, inhibit K channels, direct myocardial depression. also block muscuarinic histamine & alpha 1 adrenergic receptors. So, sedation/coma, seizures, hypoT, tachy, broad complex dysrhythmias & anticholinergic syndroem in OD. Rx w IV, high flow O2 (ABC) sodibic 1mmol/kg until BP improves & QRS narrows. hyperventilate to pH 7.5-7.55. once airway secure, NGT & 1g/kg activated charcoal. Rx seizures q IV benzo. treat hypotension w crystalloid. consider vasopressors. ongoing arrhythmias, more sodibic, lignocaine is a 3rd line agent after bicarb & hyperventilation. avoid 1a (procainamide) & 1c (flecainide) antiarrhythmics, B blockers & amiodoarone (may worsen hypoT & conduction abnormalities). ICU

Answer 1277

Block NAdr & serotonin reuptake. block fast Na channels--> QRS prolongation, inhibit K channels, direct myocardial depression. also block muscuarinic histamine & alpha 1 adrenergic receptors. So, sedation/coma, seizures, hypoT, tachy, broad complex dysrhythmias & anticholinergic syndroem in OD. Rx w IV, high flow O2 (ABC) sodibic 1mmol/kg until BP improves & QRS narrows. hyperventilate to pH 7.5-7.55. once airway secure, NGT & 1g/kg activated charcoal. Rx seizures q IV benzo. treat hypotension w crystalloid. consider vasopressors. ongoing arrhythmias, more sodibic, lignocaine is a 3rd line agent after bicarb & hyperventilation. avoid 1a (procainamide) & 1c (flecainide) antiarrhythmics, B blockers & amiodoarone (may worsen hypoT & conduction abnormalities). ICU

Answer 1278

Block NAdr & serotonin reuptake. block fast Na channels--> QRS prolongation, inhibit K channels, direct myocardial depression. also block muscuarinic histamine & alpha 1 adrenergic receptors. So, sedation/coma, seizures, hypoT, tachy, broad complex dysrhythmias & anticholinergic syndroem in OD. Rx w IV, high flow O2 (ABC) sodibic 1mmol/kg until BP improves & QRS narrows. hyperventilate to pH 7.5-7.55. once airway secure, NGT & 1g/kg activated charcoal. Rx seizures q IV benzo. treat hypotension w crystalloid. consider vasopressors. ongoing arrhythmias, more sodibic, lignocaine is a 3rd line agent after bicarb & hyperventilation. avoid 1a (procainamide) & 1c (flecainide) antiarrhythmics, B blockers & amiodoarone (may worsen hypoT & conduction abnormalities). ICU

Answer 1279

Free T4, sometimes T3, improvements may take 6-8 wks. TSH interpret with caution as may lag.

Answer 1280

Free T4, sometimes T3, improvements may take 6-8 wks. TSH interpret with caution as may lag.

Answer 1281

Vasopressin receptor antagonists, used for euvolaemic or hypoevolaemic hyponatremia, SEs thirst, incr urination, dry mouth. Also fluid restrict <1.5L/day if the urine Na + K divided by serum Na is <1, if the ratio is >1, <1L/day incr solute (sodium, proetin, urea) Inc solute intake with frusemide incr UO but risk hypokalemia Incr daily protein (urea therapy) Tolvaptam causes thirst Glucocorticoid deficiency or hypothyroidism: manage underlying cause (thyroxine or hydrocort) No urea or vaptans if awaiting transplant

Answer 1282

PCV: Delivers constant square pressure waveform with Pins being the control variable, initial higher flow early in insp phase to achieve this, volume variable depending on lung compliance Adv= good for hypoxia & poor lung compliance. Overall incr mean airway pressures, may improve oxygenation & be beneficial if hypoxaemia (in practice since PEEP is the dominant influence on mean airway pressure, need relatively high I:E ratios for this benefit), square waveform improves alveolar recruitment, early higher flow may reduce WoB, improve pt comfort & promote less ventilatory dys-synchrony, limited peak pressure helps limit barotrauma risk, pressure control variable allows for leak.Suggested teaching in ARDS is for PCV but this has weak evidence. PCF for OLV. Laparoscopy PCV. -ves: variable volume so may be hard to control hypercapnia. Uncontrolled volume risk volutrauma. High early insp flow may breach pressure limit early if the pt has high airway resistance & may end up not having good volumes. VCV: delivers set volume, fairly constant flow, pressure waveform parabolic slope as lungs distend. Useful if wanting strict control PaCO2 (eg. Neurosurgery) & situations where stable MV important. potentially disadvantageous wrt ventilatory dyssynchrony (lower initial flow). Useful to have stable MV over range of changing pulmonary characteristics eg. Resistance fluctuations. Lower initial flow rate advantage if airway resistance high. Disadvantage: lower Pawmean, theoretical disadvantage if severe hypoxia. Insp pause doesn’t significantly help & may incr WoB. May get poorer recruitment in lung areas w poorer compliance (long time constant). Volumes may be stable if there’s a leak. Insufficient flow may—> pt-vent dyssynchrony. Pre-op: To determine the severity & stability (deterioration/exacerbations) of relevant comorbidities & modifiable/optimisable risk factors Hx/exam/Ix: In addition to my standard anaesthetic assessment (incl thorough airway assessment), I’d specifically look for: Functional assessment: ADLs Multi-D planning/optimisation: consultations: who want & what questions Targets aiming for with optimisation

Answer 1283

1: symptoms only strenuous/prolonged exertion 2: ordinary activity slightly limited (eg. Walk/stairs rapid, after meals, cold/wind, emotional stress, >2 blocks on level ground or >1 flight stairs) 3: marked limitation ordinary activity (1 flight stairs, 1-2 blocks flat) 4: unable to undertake ordinary physical activity without discomfort, may have symptoms @ rest

Answer 1284

45-60 secs (3-4mins to full paralysis). if use intralingual, 2mgkg & full relaxation in 75 secs, so faster onset than IM

Answer 1285

19 or 30mm

Answer 1286

19 or 30mm

Answer 1287

Warfarin (& lmwh, fondaparinux or direct Xa inhibitors)- predominantly or exclusively inhibit Xa. dabigatran, argatroban, bivalirudin & DO impact TT.

Answer 1288

120secs, half induction dose of propofol or BZD

Answer 1289

diff btwn the 2 groups not stat sig

Answer 1290

ATIII deficiency (10-30% annual risk first VTE), also very high risk in preg Anitphospholipid syndrome also very high RR initial VTE & the highest absolute risk fo VTE in preg Compound FVL & Prothrombin 20210A gene mutation heterozygotes have elevated risk in pregnancy (as do either here or homo). APC resistance is common in pro, worsening risk of pts w FVL having thrombotic diathesis in pregnancy

Answer 1291

No difference. VL may reduce number of failed intubations (esp if diff airway), may improve glottic view & reduce laryngeal/airway trauma but no evidence suggests they reduce the number of intubation attempts, hypoxia or resp complications or impacts time for intubation. Intraosseous access: Medullary cavity. Direct, non-collapsible access to central venous circulation. Venous sinusoids, emissary veins, systemic. Recommended if don’t get IV access within 90s in critically ill children.

Answer 1292

POBA 60%, t1/2B 9 hrs, CYP3A4, take daily 1hr prior to chemo or pre=op, for highly emoetogenic, interfere w OCP. Causes GORD, tacky, abdominal discomfort, hiccups, tachypnoea.

Answer 1293

or acute radicular pain, lumbar epidural corticosteroid administration is effective for short-term relief (not long-term)

Answer 1294

or acute radicular pain, lumbar epidural corticosteroid administration is effective for short-term relief (not long-term)

Answer 1295

he gastric antrum is of particular interest as it is easily identifiable on ultrasound in the epigastric region. It is also the more dependent area of the stomach, meaning any gastric content will gravitate towards this region. Th

Answer 1296

Vagus & sympathetic nerves, pulmonary & bronchial vessels & lymphatics are interrupted. Pulmonary art & vv are reanastamosed but not bronchial arteries. Cough reflex is interrupted. Vent response to CO2 initially may be impaired but resolves.

Answer 1297

pH (good correlation, pooled mean difference 0.035pH units; vbg usually 0.03-0.04 pH units), pCO2 (if normal & pt not shocked however correlation poor with PaCO2 >45mmHg)), bicarb & BE from a VBG usually adequate for clinical decision making however lactate above 2, CO2 above 45 lack of correlation & PO2 values compare poorly VBG used to guide DKA ABG necessary for PaCO2 in severe shock, to accurately determine PaCO2 if hypercapnia, to accurately determine arterial lactate >2mM 7.32

Answer 1298

pH (good correlation, pooled mean difference 0.035pH units; vbg usually 0.03-0.04 pH units), pCO2 (if normal & pt not shocked however correlation poor with PaCO2 >45mmHg)), bicarb & BE from a VBG usually adequate for clinical decision making however lactate above 2, CO2 above 45 lack of correlation & PO2 values compare poorly VBG used to guide DKA ABG necessary for PaCO2 in severe shock, to accurately determine PaCO2 if hypercapnia, to accurately determine arterial lactate >2mM 7.32

Answer 1299

Ass’d w acute leukaemia & high-grade lymphomas. May be sopnt, usually after chemo & occ w single-therapy dexamethasone. hyperK, renal failure, acidosis. Hyperphosphataemia, incr uric acid (serum & urine), hypocalcaemia. Mx w aggressive fluid, hyperK Rx, consider RRT, consider rasburicase (urate oxidase).

Answer 1300

Alkalosis ACE-I Endothelia receptor antagonists Prostacyclin analogues Phosphodiesterase inhibitors Vasopressin Acetazolamide high doses NO Hypothermia Volatiles Factors promoting incr pulmonary pressures via VC (hence promote HPV): Acidaemia Hypercapnia Hyperaemia Catecholamines Hyperthermia Newborn/infants (HPV response reduces w time) Fe deficiency

Answer 1301

Nausea Hypophosphataemia Injection site reactions (incl skin discolouration) Headache HTN dizziness

Answer 1302

Incr Ca++ excretion (N/S IVF promotes renal elimination) Loop diuretics: dear resorption of Ca++ in LoH steroids: inhibit effects of vi D (which promotes GI & renal Ca++ reabsorption) Reduce Ca++ release: Calcitonin (inhibit osteoclasts) Bisphosphonates (inhibit osteoclast) Inorganic phosphate Stop drugs that may incr Ca++: Ca, via D, thiazides)

Answer 1303

CYP2D6 metabolism so less O-desmethyl tramadol production; O-desmethyl tramadol is 200x more potent @ MOP (tramadol is racemic, S=SSRI & mu, R=SNRI)

Answer 1304

Palpable systolic carotid thrill or precordial esp leaning forward on expiration Paradoxical splitting S2 Signs LV failure

Answer 1305

Na & Cl 154mmol/L. osm 300 Na+ 131, Cl- 111, Ca++ 2, K+ 5, lactate 28 (bicarb), 276mosmoL/L (248 effective, the lactate doesn't count- otherwise 276) Na+ 140, Cl- 98, K+ 5, Mg++ 1.5, acetate 27, gluconate 23, osm 294mOsmol/L (271 product info)

Answer 1306

Indications: foot & ankle surgery, BKA, post compartment knee Amenable to catheters Consent IV Monitoring: as per PG03, BP, GCS, RR + have SpO2 (if sedation, on) & ecg avail Assistant: trained/skilled/briefed Position: prone, lat or supine knee flexed, ergonomically for clinicians & comfy ofr pt Prep: chlorhex allow to completely dry Local ready: 15-20mL 0.75% & 1% for skin, syringe 20mL for block & 5mL for skin US, sterile sheath Linear transducer, 100mm sonoplex or 8cm epidural needle if catheter SB4UB: Pt verify too, use consent form to cross check with nurse, pt ID, side, check site marking, allergies. Before needle, re-verify site (marking visible) & re-verify if change sides or pt position. DOCUMENT block, side, dose LA (% & volume), any catheter instructions (these should be designated marked specific to regional eg. Yellow, protocol for their management), post monitoring instructions, any adverse events, f/up plan & contact if queries.

Answer 1307

Indications: foot & ankle surgery, BKA, post compartment knee Amenable to catheters Consent IV Monitoring: as per PG03, BP, GCS, RR + have SpO2 (if sedation, on) & ecg avail Assistant: trained/skilled/briefed Position: prone, lat or supine knee flexed, ergonomically for clinicians & comfy ofr pt Prep: chlorhex allow to completely dry Local ready: 15-20mL 0.75% & 1% for skin, syringe 20mL for block & 5mL for skin US, sterile sheath Linear transducer, 100mm sonoplex or 8cm epidural needle if catheter SB4UB: Pt verify too, use consent form to cross check with nurse, pt ID, side, check site marking, allergies. Before needle, re-verify site (marking visible) & re-verify if change sides or pt position. DOCUMENT block, side, dose LA (% & volume), any catheter instructions (these should be designated marked specific to regional eg. Yellow, protocol for their management), post monitoring instructions, any adverse events, f/up plan & contact if queries.

Answer 1308

Volume status corrected UO >1mL/kg/hr K+ >3.5 Bicarb <26 Cl- >100

Answer 1309

ts low density facilitates rapid transfer of gas from console to the balloon. It is also easily absorbed into the blood stream in case of rupture of the balloon.

Answer 1310

Low RR, prolong exp time, reduce minute ventilation, rase insp flow rate (which shortens insp time & prolongs exp time), permissive hypercapnia gen ok depending on pt factors, pH >7.2, haemodynamics.

Answer 1311

postop, D2

Answer 1312

Go back on bypass if catheters still in bleeding lung side down, DLT for lung protection, PEEP bleeding lung, draw PAC back deflated (DON'T WEDGE), reverse coagulation, bronchoscopy to locate site bleeding& consider BB, PEEP bleeding lung Confer with friends, consider surgical pulmonary artery repair, lung resection, or angiographic embolization

Answer 1313

PICCS (virchow’s: trauma endothelial injury, hypercoaguable pts) pt: prev Hx DVT, obesity, malign, critical illness, DM, COPD Device: incr number of lumens, L)-sided, exchanging over guidewire, catheter relatively large cf vein into which inserted (C: vein ratio optimal <45%), Cephalic higher rate than basilic, more proximal (eg. Axillary)—> lower rates DVT. Provider: pt selection, proper placement & positioning, US-guidance, minimal eattempts, appropriate catheter selection, PICC tip @ CAJ or RA (greater blood flow, lower risk VTE; higher rate VTE if tip terminates in mid to pro third of SVC. Electrocardiographic guidance may be ass’d w lower rates DVT than radiographic.

Answer 1314

Maximum height of P wave, suggests tip at SA node at cavo/RA junction; biphasic when in RA, inverted suggests approaching RV

Answer 1315

Maximum height of P wave, suggests tip at SA node at cavo/RA junction; biphasic when in RA, inverted suggests approaching RV

Answer 1316

Anaphylaxis (8 cases), aspiration 7

Answer 1317

Tumour @ lung apex NSCLC, may spread to ribs & vertebrae, may compress brachiocephalic vein, subclass artery, phrenic n, RLN, vagus, stellate ganglion— Horner’s syndrome Brachial plexus involvement—> pan coast syndrome Rx may involve radiation/chemo neoadjuvant, surgery may= r/o upper lobe & ass’d structures & mediastinal LN.

Answer 1318

Absolute contraindications to systemic thrombolytic therapy in acute PE include an intracranial neoplasm, aortic dissection, recent (ie, <2 months) intracranial or spinal surgery or trauma, history of a hemorrhagic stroke, active bleeding or bleeding diathesis (eg, severe thrombocytopenia), or nonhemorrhagic stroke within the previous three months. Relative contraindications include severe uncontrolled hypertension (ie, systolic blood pressure >200 mmHg or diastolic blood pressure >110 mmHg), non-hemorrhagic stroke more than three months prior, surgery within the previous 10 days, pregnancy

Answer 1319

Absolute contraindications to systemic thrombolytic therapy in acute PE include an intracranial neoplasm, aortic dissection, recent (ie, <2 months) intracranial or spinal surgery or trauma, history of a hemorrhagic stroke, active bleeding or bleeding diathesis (eg, severe thrombocytopenia), or nonhemorrhagic stroke within the previous three months. Relative contraindications include severe uncontrolled hypertension (ie, systolic blood pressure >200 mmHg or diastolic blood pressure >110 mmHg), non-hemorrhagic stroke more than three months prior, surgery within the previous 10 days, pregnancy

Answer 1320

Lung point, 100% specific, 100% PPV when seen but may not be seen in large PTx presence of lung sliding 100% NPV for PTx but absence of lung sliding not specific enough to r/o PTx in criticallhy ill (DDx inflammatory adherences) Blines help rule out PTx

Answer 1321

4g over 20 mins (preprepped 4g/100mL 0, 1g/hr, 2g bolus over 5 mins if further seizure (can repeat 5 mins later)

Answer 1322

Reasonable for pts known s aureus carriers with high risk SSI (cardiothoracic, ortho, hardware implantation, immunocompromised) Mupirocin 2% to nares BD for 5 days Chlorhex 2% or 1% triclosan washday 5 days vancomycin 1g (1.5g if >80kg actual body weight), commence 120mins prior to incision (should be given at a rate of 1g over at least 60 minutes and 1.5g over at least 90 minutes (in adult patients). Vancomycin should be timed to begin 15 to 120 minutes before skin incision. teicoplanin 15mg/kg up to 800mg (400mg if <=80kg), 5mins before procedure (?15-120mins prior to skin incision)

Answer 1323

60-80 but lower values (eg. 55-60) may not be abnormal in some cardiac pts. Act if desaturated >20% Depends on adequate CBF & O2 content; reduction in CBF (decreased CO, in/outflow obstruction (eg. Head position/ties, vasoconstriction eg. If hypocapnia) may reduce values, as may decrease O2 content: inadequate ventilation, low HCt or incr cerebral metabolism. Course of actions: Optimise DO2 (incr CO, incr MAP, FiO2, PaCO2 (optimise ventilation), consider transfusion (r/o anaemia) optimise venous drainage (neutral, ET ties Optimise O2 consumption: adequate depth & analgesia, temp, r/o seizures.

Answer 1324

>40mL/kg in 24h or >20mL/kg in 2hrs & anticipated ongoing loss Key signs: narrow pulse pressure/lactic acidosis/reduced UL est blood volumes preterm 90-100mL/kg, term-3mths 90mL/kg, >3 mths 80mL/kg NO permissive hypoT cryo , plt, FFP rbc 10mL/kg fib conc 70mL/kg TxA 15mg/kg Ca 0.3mL/kg gluconate

Answer 1325

Gabapentin or pregab, both B3 Other meds carbamazepine, lamotrigine, phenytoin, valproate are cat D

Answer 1326

Withdraw needle, insert 15deg post & lateral

Answer 1327

Under euglycemic conditions, most insulin-mediated glucose uptake occurs in muscle

Answer 1328

hypothalamic-pituitary abnormalities & severe hypotonia in infancy, hyperphagia w risk morbid obesity, learning difficulties & behavioural problems or psychiatric problems.hypotonia at birth partially improves with age. characteristic narrow forehead, almond-shaped eyes, thin upper lip, down-turned mouth, very small hands & feet. GH deficiency--> short stature. decreased bond mineral density without altered Ca, phosphate, vit D or parathyroid hormone. cognitive dysfunction- food-seeking & obsessive behaviours. clinically & genetically heterogenous. involves chromosome 15. mostly sporadic. early Dx, multi-D care & GH treatment. Complications linked to obesity. Anaes considerations: -aggression/violence -convulsions -morbid obesity -sleep apnoea -sensitivity to sedative/hypnotic agents. Incr risk post hyoxia & hypercapnia independent of obesity; altered CO2 & O2 responses -potentially difficult airway; obesity, dentition, neck circumference, may have micrognathia/palatal abnormalities/limited neck mobility. Have difficult airway equipment. Aspiration risk (GI motility, obesity).Rumination, stealing Bx so risk of aspiration is extreme, treat as unfasted can get regard even >10 hrs after last ate Abnormally thick & viscous saliva (glycol premed) -risk periop Resp failure; kyphoscoliosis, obesity, hypotonia may predispose to restrictive lung disease. OSA risk obstruction. consider polysomnography. -primary myocardial involvement (*predisposition to cardiovascular complications is independent of obesity); consider 12-lead & echo. Cor pulmonate. Arrhythmia. -HTN -Hypotonia (improves beyond 2yo); can still use NMBDs but monitor closely. Sux has been used safely. -difficult IV access; US -thermoregulation disturbance -Glucose intolerance & DM -prone to hypoglycaemia after long periods of fasting, disturbed thermoregulation (tendency towards poikilothermia), may get hyper or hypothermia, occ pemetabolic acidosis; 50% insulin dependent, tend to use circuling glucose for lipogeneiss vs basal metabolic need

Answer 1329

Turner: Short stature DIFFICULT AIRWAY: May have micrognathia, short webbed neck Ovarian dysgenesis XO karyotype CARDIAC: 30% bicuspid AV, 10% coarctation 50% renal abnormalities Noonan: Phenotypically similar Turner: short, webbed neck, may have micrognathia CARDIAC: PV stenosis, HCM, ASD, ToF, aortic coarctation, MV anomalies, AV canal defects Hydronephrosis Put dysfunction

Answer 1330

Ocular Coloboma Heart defects eg. R)-sided aortic arch, VSD, ASD, PDA, ToF, double outlet RV Atresia choanal (diff airway), growth Retardation of development Genital anomalies Ear anomalies/deafness Vertebral anomalies Anal atresia Cardiac defects eg. VSD Tracheo-oesophageal fistulae Renal abnormalities Limb (radial) dysplasia

Answer 1331

15mg/kg then 1mg/kg/hr infusion Novoseven IV bolus 50micro/kg if critical, ongoing bleeding (d/w haem).

Answer 1332

1:4500, 5x incr risk if pre-existing pathology, incr if age 50-70yo, 3.4x incr risk if dental restorations, 20x incr risk difficult to intubate, NOT incr if emergency or inexperienced laryngoscopists. 20% w emergence.

Answer 1333

4-6mEq/L in first 2hrs 1-2hrs, achieve with 100mL boluses over 10 mins; recheck Na+ after each. Overall, if low risk no >10mEq/L in first 24 hrs & no >18mEq first 48hrs High risk if <105Na+, hypoK, malnutrition, ETOH, liver disease If Na+ overcorrected, may need to give desmopressin Seek cause once pt stabilised

Answer 1334

B= 170 C=490 CD=630L

Answer 1335

May be diagnosed in-utero Presents with Resp distress, scaphoid abdomen; abdo organs protruding through breach in diaphragm—> pulmonary hypoplasia, pulmonary HTN, persistent R)—>L) shunting through DA. Most common on L) side. I&V, avoid BMV as risk gastric insufflation. Goals= avoid pulmonary HTN (blunt SNS, avoid hypercapnia) but gentle ventilation (risk barotrauma to hypo plastic lung, consider HFOV (controversial), NO, echo. Surgery within a few days when pulmonary hypoplasia stabilised. Abdo/subcostal incision or thoracoscopic, patch to close diaphragm, don’t need OLV (lung gradually expands). Avoid pulmonary HTN, avoid barotrauma. Sig mortality risk. Thoracoscopic “minimally invasive” but longer duration, higher PaCO2, risk acidosis. Also require higher ventilator pressure, high r recurrence rates after thoracoscopic & little evidence to suggest mortality benefit.

Answer 1336

May be diagnosed in-utero Presents with Resp distress, scaphoid abdomen; abdo organs protruding through breach in diaphragm—> pulmonary hypoplasia, pulmonary HTN, persistent R)—>L) shunting through DA. Most common on L) side. I&V, avoid BMV as risk gastric insufflation. Goals= avoid pulmonary HTN (blunt SNS, avoid hypercapnia) but gentle ventilation (risk barotrauma to hypo plastic lung, consider HFOV (controversial), NO, echo. Surgery within a few days when pulmonary hypoplasia stabilised. Abdo/subcostal incision or thoracoscopic, patch to close diaphragm, don’t need OLV (lung gradually expands). Avoid pulmonary HTN, avoid barotrauma. Sig mortality risk. Thoracoscopic “minimally invasive” but longer duration, higher PaCO2, risk acidosis. Also require higher ventilator pressure, high r recurrence rates after thoracoscopic & little evidence to suggest mortality benefit.

Answer 1337

4yo w age-appropriate tool; 7-10yo skills of measurement, classification, seriation (asc/desc order)

Answer 1338

Unstable: sync CV, pads trajectory away from uterus, foetal monitoring during & after Vagal Adenosine won’t enter foetal circle & maternal side effects short-lived Metoprolol if adenosine ineffective, slow infusion less hypotension Verapamil if adenosine & B blockers contraindicated (higher risk hypoT) Amiodarone only if life-threatening & can’t use other therapies; preg class B, hypothyroidism, short-term only

Answer 1339

red= water, for paper/wood/cloth & plastic Foam (blue) can use for liquids, oil, carbonaceous White (powder) can use on carbonaceous, liquids/oil, can use for electrical CO2 (black) for oil/liquids & electrical

Answer 1340

Don't need airborne precautions if extrapulmonary & latent TB airborne transmissible: P2 or N95 filter on exp circuit pt in -ve pressure room or surgical mask can use PAPRs, N95, Fit is the most important N95 gets @! least 95% airborne particles & not oal resistant R 95,99,100 oil resistant P95,99,100 are oil proof

Answer 1341

Don't need airborne precautions if extrapulmonary & latent TB airborne transmissible: P2 or N95 filter on exp circuit pt in -ve pressure room or surgical mask can use PAPRs, N95, Fit is the most important N95 gets @! least 95% airborne particles & not oal resistant R 95,99,100 oil resistant P95,99,100 are oil proof

Answer 1342

Substance P (NK-1 receptors)

Answer 1343

R) axis or 90 deg axis Reduced voltage QRS esp precordial P waves prom II, III, aVF, flat 1, aVL Clockwise rotation heart; delayed R/S transition precordial & may have no R wave V1-2, persistent S in V6 Sagging PR & ST segments

Answer 1344

ION PION>AION 1/60,000-1/120,000GAs, 3/10,000 spine & 8/10000 cardiac

Answer 1345

Topical spray, mucosal contact w LA-soaked pledgets or direct LA injection at posterior tonsillar pillar or peristyloid Sensory post 1/3 tongue, vallecula, anterior epiglottis, pharyngeal walls, tonsils

Answer 1346

100% O2 via non-rebreather, cardiac monitoring, intubate if induicated (eg. GCS) The half-life of carboxyhemoglobin (COHb) in a patient breathing room air is approximately 250 to 320 minutes; this decreases to 90 minutes with high-flow oxygen provided via a nonrebreathing mask. Thus, the most important interventions in the management of a CO-poisoned patient are prompt removal from the source of CO and institution of high-flow oxygen by face mask.” Hyperbaric Oxygen only indicated if: · CO level >25 percent · CO level >20 percent in pregnant patient (see 'HBO during pregnancy' below) · Loss of consciousness · Severe metabolic acidosis (pH <7.1) · Evidence of end-organ ischemia (eg, ECG changes, chest pain, or altered mental status) Note – SpO2 is useless in CO poisoning

Answer 1347

100% O2 via non-rebreather, cardiac monitoring, intubate if induicated (eg. GCS) The half-life of carboxyhemoglobin (COHb) in a patient breathing room air is approximately 250 to 320 minutes; this decreases to 90 minutes with high-flow oxygen provided via a nonrebreathing mask. Thus, the most important interventions in the management of a CO-poisoned patient are prompt removal from the source of CO and institution of high-flow oxygen by face mask.” Hyperbaric Oxygen only indicated if: · CO level >25 percent · CO level >20 percent in pregnant patient (see 'HBO during pregnancy' below) · Loss of consciousness · Severe metabolic acidosis (pH <7.1) · Evidence of end-organ ischemia (eg, ECG changes, chest pain, or altered mental status) Note – SpO2 is useless in CO poisoning

Answer 1348

incr ACh receptors; require 2-3fold incr dose if 30% TBSA burns

Answer 1349

Varenicline (RR 2.3) Behavioural therapy 2.0 nortryptiline NRT (1.9) Bupropion 1.7, same as clonidine RCT & meta-analyses have shown that more intensive intervention= greater abstinence rate so follow-up beyond the lone pre-anaesthesia consultation is vital Combination of pharmacological therapy with multisession face-to-face counselling significantly improves changes of quitting (RR 10.8, cochrane review Thomsen 2014)

Answer 1350

Absolute contraindications: acute myocardial infarction (MI) (within 2 days) high-risk unstable angina uncontrolled cardiac arrhythmias causing symptoms of hemodynamic compromise active endocarditis symptomatic severe aortic stenosis decompensated symptomatic heart failure acute pulmonary embolus pulmonary infarction acute noncardiac disorder that may affect exercise performance or be aggravated by exercise (eg, infection, renal failure, thyrotoxicosis) acute myocarditis or pericarditis physical disability that would preclude safe and adequate test performance inability to obtain consent acute aortic dissection Relative Contraindications: left main coronary stenosis or its equivalent moderate stenotic valvular heart disease electrolyte abnormalities tachyarrhythmias or bradyarrhythmias atrial fibrillation with uncontrolled ventricular rate hypertrophic cardiomyopathy mental impairment leading to inability to cooperate high-degree AV block severe arterial hypertension

Answer 1351

3 milivolts ULN

Answer 1352

Mu agonist & Norad reuptake inhibitor 18-fold lower affinity for mu than morphine but only 3x less potent as analgesic due to dual mechanism & synergy. No active metabolites, no relevant functional serotonin re-uptake inhibition Includes actions on descending pathways of pain inhibition. Similar efficacy to conventional opioids w reduced GI adverse effects (N, V, constipation) Lower rates abuse & doctor shopping vs oxycodone No adverse HR or BP effects in clinically recommended (max 500mg/day) ranges, even in pts w hTN Glucoronidation; may require dose adj in severe hepatic dysfunction. No dose adj required for mild-mod renal impairment, lack of studies on severe so not recommended.

Answer 1353

our atm has 0.0875ppm environmentally safe no MH $10/L expensive, most cost related to priming/flushing of the anaes circuit Low BGPC 0.115 (rapid onset/offset) minimal CV depression even in cardiac disease neuroprotection profound analgesia doew have unreliagle bis like other non-GABA-ergic agents MAC about 70%, extrapolated from studies using other agents since impractical/unsafe to run higher [] xenon in a closed circuit (risk hypoxia)

Answer 1354

our atm has 0.0875ppm environmentally safe no MH $10/L expensive, most cost related to priming/flushing of the anaes circuit Low BGPC 0.115 (rapid onset/offset) minimal CV depression even in cardiac disease neuroprotection profound analgesia doew have unreliagle bis like other non-GABA-ergic agents MAC about 70%, extrapolated from studies using other agents since impractical/unsafe to run higher [] xenon in a closed circuit (risk hypoxia)

Answer 1355

Laparotomy LSCS Repair open fractures

Answer 1356

Neuropathic pain= pain caused by lesion or disorder of the somatosensory nervous system Nociplastic pain= pain that arises from altered nociception despite no clear evidence of actual or threatened tissue damage causing activation of peripheral nociceptors or evidence of disease or lesion of the somatosensory system causing pain.

Answer 1357

* Cellular components, so FFP, cry & other plasma-derived components don’t require CMV screening All cellular products in Oz are leucodepleted but neither leudodepletion nor CMV seronegativity completely eliminates CMV transmission risk. CMV seronegative products should be used for pregnant women during pregnancy (but not delivery) Intrauterine tennsfusions Neonates Granulocyte transfusions for CMV neg pts. Depending on policy, solid organ transplants, haematology/onc/i9mmunodeficient pts 0.9% risk seroconversion for CMV negative blood products (ie 9 per 1000) Another study suggested (from a modelling approach), residual risk of leucodepleted-only products is 1 in 13million; neglibible).

Answer 1358

No sig reduction in 28d in-hospital mortality if gave <3hrs of injury. Was a sig reduction in mortality in pts w mild-mod (GCS 9-15), better result if gave early. No diff modified rankin scale.

Answer 1359

Calcium chloride

Answer 1360

Calcium chloride

Answer 1361

Cryo (8U/L vs 1.5U/L in FFP) Also, cry has 15g fibrinogen/L (fs 20g/L in fib conc or 2g/L in FFP)

Answer 1362

Useful for circumcision hypospadius repair Paraphimosis reduction Repair of penile lac Release of trapped penile skin From S2-4 via pudendal nerve, which runs in pudendal canal w pudendal artery. Pudendal nerve divides in pudendal canal—> terminal branches to the dorsal penile nerves & the perineal nerve branch. The subpubic space is roofed by scarpa's fascia, deep membranous continuation of superficial abdo fascia. Dorsal penile nerve on each side runs under inf pubic ramus, deep to suspensory ligament, each lying in its own space. They continue directly within Buck’s fascia on the penis next to dorsal vessels. Aim w penile block= inject LA into the bilateral spaces deep to scarpa's & buck's fascia on either side of suspensory ligament (which is continuous w Buck/s fascia) 0.1mL/kg/side (max 5mL) CIMPLE La WITHOUT epinephrine, avoid ropiv (intrinsic vasoconstrictor) Bleb to skin @ dorsal of penis base. Gently retract penis down to make scarpa's fascia taut. Advance until touch pubic symphysis, withdraw slightly then redirect to pass below pubic symphysis, 5-10mm lat to midline, advance sl caudally & until "pop" as needle enters compartment just under scarpa's fascia. Aspirate, infiltrate. Repeat the other side (can do in 1 from the midline, my preference is 2 separate injections to avoid risk of midline structures. Dorsal nerve block doesn’t achieve total anaesthesia; innervation of the frenulum is via perineal branch. Achieve this with further Anaes @ base of ventral penis or partial ventral ring block.

Answer 1363

5mg/kg (chn 4mg/kg), max block @ 3-4 mins, lasts 15-20mins

Answer 1364

Fr unit is equal to 0.33mm outer diameter. So, a size 9ETT which has OD of 12.2mm, equivalent to 37Fr (12.2/0.33)=36.9 aka 37Fr external diameters: size 4=5.4 size 5=6.8 size 6=8.2 size 7=9.6 size 8=11 size 9=12.2

Answer 1365

1 nurse for each patient that has not regained airway reflexes, 1 nurse for 3 awake patients who have regained airway reflexes

Answer 1366

Norad 3-40microg/min vasopressin 1-2 units bolus then 2 units/hr Glucagon 1-2mg IV every 5 mins until response

Answer 1367

Supplies deltoid (abduction of shoulder beyond 90 degrees), tires minor (ER) Sensation skin over shoulder "regimental badge" area

Answer 1368

Euglycaemic DKA, hyperglycaemic DKA Glycosuria UTIs Hypotension They have LOW risk of hypoglycaemia as their efficacy to incr urinary glucose excretion attenuates @ lower plasma glucose levels may cause hyperglycaemic DKA

Answer 1369

INCREASE LV AFTERLOAD due to impedance to aortic flow: —> may get increased contractility & cardiac output (anrep effect, incr inotropy) —>increases myocardial wall stress (=(delta p x radius)/ 2w) DEPENDING on myocardial supply:demand matching & cardiac function, result may be increase or decrease CO; if pre-existing incr LV pressure & poor coronary perfusion (inadequate supply to meet demand; CorPP = ADP - LVEDP), risk poor perfusion & ischaemia & reduced CO —> risk hypertensive crisis & end-organ damage (particularly renal failure) —> MAP increase much higher for supracoeliac (approx 50%) vs suprarenal (20-30%) or infrarenal (10-20%) —> myocardial ischaemia, functional AR, incr CSF pressure & ICP CATECHOLAMINES: promote active vasoconstriction (SVR)proximal & distal to clamp, further increase arterial resistance INCREASE PRELOAD due to passive recoil of circulation distal to XC: —> increase preload (higher degree for supracoeliac>suprarenal as higher volume of blood distal to XC, splanchnic circulation a significant reservoir volume has 25-30% of CO; supracoeliac much higher increase in PCWP, EDA, ESA & higher reduction in ejection fraction; higher rate of regional wall motion abnormalities supracoeliac>suprarenal>infrarenal) —> increased contractility of LV DEPENDING on where it exists on the frank-starling curve (pre-existing LV failure or poor compliance more likely to precipitate acute LV failure & reduced CO, particularly for supra coeliac XC) REDUCED TISSUE PERFUSION DISTAL TO XC: —> all reduce perfusion distal to X-clamp, producing anaerobic metabolism, production of vasoactive metabolites (CO2, K+) in the tissues, including lower limbs for all levels. The amount of tissue/organ impacted increases with more proximal clamp level. —> infrarenal does increase renovascular resistance, reduce GFR & reduce renal blood flow by 40% (RAAS alterations)—> risk Perioperative renal failure —> suprarenal—> direct reduction in renal blood flow due to interruption perfusion to kidneys —> supracoeliac—> splanchnic hypoperfusion, risk of ischaemia, large volume of blood passively recoils to increase preload —> risk anterior spinal artery syndrome if interruption to artery of adamkiewicz & inadequate MAP to support collaterals (ScPP = MAP - CSFpressure) Stasis distal to XC may increase risk atheroembolism on XC release Management: -aim to have SBP approx 80-100mmHg @ time of XC (pt-specific target); avoid excess fluid (restrictive pre-XC, aim to preserve vital organ perfusion) -anticipating the haemodynamic response to XC (particularly HTN), medications prepared: -adequate depth of anaesthesia -adequate analgesia (rapid-acting agent eg fentanyl boluses) -consider bolus epidural 5mL 0.2% ropivacaine depending on pts haemodynamics -vasopressors off -vasodilators prepared (rapid-acting, titratable best): GTN 50mcg/mL (50mg in 1L N/saline, useful as reduces LV preload & dilates coronaries but reduces perfusion pressure collateral circulation), hand bolus 25mcg in emergencies, could also use propofol 20-60mg IV boluses -if adequate myocardial function, consider rapid-acting B blocker esmolol 10-20mg boluses +/- infusion -could consider frusemide if not hypovolaemic -while on XC, avoid warming LLs (reduce risk tissue burns) *mesenteric artery aneurysms have supracoeliac XC but it’s not on for long (3-5mins) vs on for 1 hr w AAA Un-clamping: Magnitude of response depends on level of the clamp Reduction in after load—> reduces ventricular wall stress & O2 demand However risk reduced myocardial O2 supply as: -reduced preload (blood redistribution back to limbs—> central hypovolaemia) -distal vasodilation with release of vasoactive mediators from ischaemic tissues distal to clamp(reduce peripheral vascular resistance) & increased vessel permeability —> risk reduced coronary perfusion pressure, supply < demand & myocardial ischaemia —> reduce renal perfusion & risk renal injury -potassium: risk cardiac arrhythmias/arrest -CO2 incr SNS activation, increase PVR & risk R) heart failure -acidosis risks myocardial depression & reduced CO -risk pulmonary oedema (combination of vascular permeability, LV systolic dysfunction) Manage by: -anticipation of “decamping hypotension” by: -load with fluid/blood products pre-XC removal (adequate “fill”), albumin (care w Cl load), guided by CVP (aim 5mmHg above baseline just prior to unclamping), ensure the fluids warm -AIM= normotension w XC on, CVP 5mmHg > baseline by time of unclamping -clear communication w surgeons; attenuate w gradual release of XC (eg. One leg at a time, can always re-clamp if haemodynamics unmanageable) -discontinuation/reduction of vasodilators -vasopressors (NAdr), positive inotropes -CHECK CALCIUM & replace as needed -correct acid base disturbance prior to unclamp -increase minute ventilation to attenuate myocardial depression with lactic acidosis -consider sodibic -Anticipate & manage arrhythmias -anticipate risk thromboembolism, incr RVSP & RHF -if epidural, limit boluses until aorta closed (care w SNS blunting)

Answer 1370

9Fr 65cm Min ETT 7

Answer 1371

5Fr (paeds) 4.5mm ETT 7Fr 7mm ETT 9Fr 8mm ID but size 9 tube best Fuji/ambu min size 8.5 EzBlocker: min size 9 BB cuff 6-9mL

Answer 1372

Improves mortality in mod-severe ARDS Physiology of prone positioning: Alters gas exchange to consistently improve oxygenation -ameliorates ventral-dorsal transpulmonary pressure difference; Ptp = (Paw - Ppl). When supine, higher dorsal Ppl & greater expansion of ventral vs dorsal alveoli. Effect exaggerated in ARDS (excess lung weight). Tends to overinflated ventral alveoli, collapse dorsal. Ventilation more homogenous in prone, less over distension of ventral alveoli (& cyclic atelectasis), improved distribution of ventilation, improves oxygenation -reduces dorsal lung compression (by heart & diaphragm), there’s a smaller volume of “dependent lung” since heart is dependent -improved cardiac output (may be due to increased lung recruitment & reduced HPV, incr RV preload & decr RV after load & decr PVR) -improves lung perfusion -may increase FRC & reduce shunt (*assuming abdomen unsupported) -may alter distribution of extravascular lung water & secretions (secretion mobilisation, improved bronchial drainage & ventilation) -improved delivery of aerosolised meds -more homogenous perfusion CONTRAINDICATIONS: Facial or pelvic fractures Burns or open wounds on ventral body surface Conditions (RA, trauma) ass’d w spinal instability Conditions ass’d w incr ICP (ICP >30 or CPP <60mmHg) life-threatening arrhythmias Acute bleeding eg. Shock Trach surgery or sternotomy within 2 wks *pts w ant chest tube & air leaks, severe burns or recent lung transplant or critical conditions limiting life expectancy excluded from prone positioning in severe ARDS trial Consider implications of prone on chest tube drainage, consider tube position (2-4cm above carina), ensure all central & lg-bore access firmly secured Consider how pt’s head/neck shs will be supported Feeds need to be stopped, stomach empty Consider process if copious secretions (suction ready) Care re: pressure areas, brachial plexus injury Reassess lines/tube position etc after turn. Rev tren & periodic tilt, document skin checks. Risks: Pressure injuries (nerve, crush, retinal damage) Venous stasis Dislodge ett or other lines Impaired volumes if diaphragm limitation Vomit Arrhythmias desats

Answer 1373

Voice is produced by temporarily blocking the stoma so that exhaled air from the lungs can be directed from the trachea through the prosthesis into the esophagus and then out through the mouth

Answer 1374

Can’t fit adult bougie, paeds bougie too short Adult bougie 14Fr, 70cm length, ID3mm paeds 8Fr, 35cm, ID 1.6mm

Answer 1375

AB Rh+ (Universal Donor, Absence of Anti-A and Anti-B antibodies, Rhesus matching not required)

Answer 1376

Deliberate hypotension is defined as the reduction of systolic blood pressure (BP) to 80–90 mmHg, and that of MAP to 50–65 mmHg or 30% lower than the baseline level

Answer 1377

Low PB (eg. Dabigatran 30% vs other DOACs 90%) better dialysis potential Large MW better trapping in dialysis membrane Large VD poorly dialysable Barbiturates Lithium Isoniazid Salycilates Theophylline Metformin/methanol Ethyene glycol Dabigatran Carbamazepine, uraemia:)

Answer 1378

Increased blood loss, no effect on INR or APTT

Answer 1379

Recommendations in the literature include the avoidance of infusion rates of more than 5 mg kg−1 h−1 for more than 48 h5, 51 to always use propofol in combination with other sedative agents (such as opioids), and to monitor pH, lactate, and creatine kinase when infusions are prolonged, especially if high doses cannot be avoided.52 The AstraZeneca Summary of Product Characteristics for Diprivan 1% and the German Medical Association recommend a lower maximum infusion rate of 4 mg kg−1 h−1.53 Monitor daily pH, CK, lactate, Cr, K+ Use the minimum dose & use other sedative adjuncts No established management, change to alternaive sedation & treatment should focus on the clinical features shown to be associated with mortality: ECG changes, hyperkalaemia, hypotension, and fever could use hamofiltration (doesn't eliminate props but does for it's water-soluble metabolites) but care re: citrate levels (hypocalcaemia) in pt w PRIS as citrate metabolised in mitochondria, citrate tox --> hypocalcaemia Risk factors: critical illness, higher mort in TBI, higher dose & duration (eg. >5mg/kg/hr doubles risk PRIS cf lower doses, >48hrs incr risk.

Answer 1380

Femoral > IJ > subclavian

Answer 1381

difficult intubation, obstructed breathing, OPIOID SENSITIVITY Pulmonary complications postop delirium

Answer 1382

4 weeks per year off

Answer 1383

1.1 >0.6 suggests at risk of DKA ketosis. BE <-5 also suggests metabolic acidosis

Answer 1384

MOST IMPORTANT GOAL= PREVENT REBLEEDING. clip or coil as early as faesible (pref within 24hrs) the only effective treatent to prevent rebleeding. Short-term outcomes improved w endovascular coil vs surgical clip.

Answer 1385

Linear Transducer 8-14MHz.

Answer 1386

20mg IV morphine

Answer 1387

patients with LAST who exhibit seizures or impending seizures, or signs of cardiovascular toxicity (ie, arrhythmias, severe hypotension, or cardiac arrest) along with ACL

Answer 1388

consrictive pericarditis (also incr y descent)

Answer 1389

Mississippi divides into 3 classes based on plt (class 1 <50, 2 50-100, 3 100-150, AST, ALT & LDH (>600), relates to bleeding incidence, M&M Tennessee complete/incomplete, depending on whether has all of: AST+/- ALD >40IU/L, put <100, LDH >600, AST >70

Answer 1390

Reduction in airflow >=90% lasting >=90% of the duration of 2 normal breaths Hypo is reduction in airflow >=30% lasting >=90% of 2 normal breaths + desaturated 3% or arousal

Answer 1391

R) side down, encourages drainage of gastric content to dependent antrum, incr send to detect smaller volumes

Answer 1392

R) side down, encourages drainage of gastric content to dependent antrum, incr send to detect smaller volumes

Answer 1393

LL elevation w supine @ end of strain

Answer 1394

In V1-3: Horizon ST dep, tall, broad R waves, upright T waves, dominant R wave (R/S >1) in V2 Posterior MI either RCA or L)Cx

Answer 1395

Fluoxetine (an SSRI)

Answer 1396

It may underestimate it; Alb decr by 1g/L—> anion gap decr by 0.25mmol. use corrected AG (AG + (0.25 x (40-alb))

Answer 1397

Brain abscess Congenital spherocytosis is a relative contraindication, asthma, Tx surgery, emphysema w CO2 retention, URTI, seizures, middle ear surgery/isusues, fevers, optic neuritis ABSOLUTE= bleo, cisplatin, premature infants, untreated PTx, disulfiram

Answer 1398

Adrenaline Atropine Lignocaine naloxone May need to give 3-10x dose

Answer 1399

Small tracheostomy tube/6 cuffed tracheal tube; consider aintree catheter & fibreoptoc scope/bougie/aec

Answer 1400

plt should be >100, INR <1.3, normal APTT, anticoag & antiplt witheld.CSF drain status; normal or malfunction? replace if malfunctioning, lie flat & ICP <10mmHg, drain 10mL increments. O2 delivery: Sats>95%, Hb >120, CI >2.5mL/kg/min Pt status: MAP >90mmHg, SCPP >80mmHg Neurological Ax & correct factors altering DO2 (sepsis, bleeding, compartment syndrome, tamponade, visceral ischaemia, AF) (Goals spinal drain MAP>85, ICP<15, if ICP >15 incr MAP until ScPP >70, keep SpO2 >95%) prior: consent, document plt >100, INR <1.3, normal APTTm, anticoag & antiplt witheld, avoid placement if evidence raised ICP best done 24hrs preop, if traumatic/bloody tap delay heparin @ least 60mins. If 2x bloody taps, d/w surgeons consider potponing insurgery. sterile setup, L4/5, 16g. ScPP >60, avoid hypoT or large incr CVP (ScPP=MAP-CSFp) zero@ phlebostatic axis (4th ICS, mid A-P point chest wall; corresponds to RA) CSF pressure <10mmhg (goal ScPP >60mmHg); intermittent (5-10mL if CSFP >10mmHg) vs continuous preferred to avoid large vol drainage. Too much drain risks SAH (10-20mL/hr intermittent best, aim CSF pressure <10) <=15mL/hr if no SC ischaemia, <=20mL/hr if SC ischaemia. Consider <72hrs. Avoid hypo. If bloody CSF drain may indicate ICH—> imaging If new-onset LL neurological deficit (ONGOING MONITORING!), SC ischaemia vs neuraxial haematoma; incr ScPP, imaging. Hold heparin 4-6 hrs (ASRA) before remove drain (& ensure plt >100 & INR <1.3 & APT N), hold heparin 1hr after removal ASRA: restart Heparin 1hr after procedure, restart heparin 1hr after catheter removal

Answer 1401

Remains below CT (38deg) so exists as vapour in equilibrium w liquid phase. Has BP of -88

Answer 1402

Hydrocortisone 2mg/kg @ induction then wt-based infusion: 25mg/24hrs if up to 10kg, 50mg/24hrs if up to 20, over 20 100 for prepubertal, 150mg/24hr if pubertal (or post could be 2mg/kg 4hrly IV or IM

Answer 1403

Hydrocortisone 2mg/kg @ induction then wt-based infusion: 25mg/24hrs if up to 10kg, 50mg/24hrs if up to 20, over 20 100 for prepubertal, 150mg/24hr if pubertal (or post could be 2mg/kg 4hrly IV or IM

Answer 1404

0.01mg/kg=0.01kmL/kg 1:1000

Answer 1405

female hypoMg++ hypoK hypoCa brady long QT TCA OD

Answer 1406

female hypoMg++ hypoK hypoCa brady long QT TCA OD

Answer 1407

female hypoMg++ hypoK hypoCa brady long QT TCA OD

Answer 1408

1. Analgesia & amnesia (initiation—> LOC): normal m tone, voluntary eye movement 2. Delirium & unconsciousness (from LOC to onset automatic breathing): Excitement: tone normal to incr, irreg shallow Br, mod eye movement, risk swallow/retch/vomit; corneal reflex disappears, secretion tears increases. 3. Surgical anesthesia: br becomes regular, less volumes through the 4 planes, eye movt sl—> nil 4. Resp paralysis: flaccid, no eye movement

Answer 1409

Risk for chronic pain post Incr post pain, opioid consumption, nociceptive threshold changes Keep Remi TCI <0.1mcg/kg/min, <2.7ng/mL Remi sparing: ketamine, prop, NO, COX2, alpha2, gabapentin Dexmed or MR instead of Remi

Answer 1410

low aortic pressure

Answer 1411

Rocuronium 1.2mg/kg (min impact w renal impairment)

Answer 1412

Rocuronium 1.2mg/kg (min impact w renal impairment)

Answer 1413

Ketamine: increase MEPs (opioids small dose-dep MEP depression)

Answer 1414

Ketamine: increase MEPs (opioids small dose-dep MEP depression)

Answer 1415

5mg/lg, so if 16kg, 80mg

Answer 1416

5mg/lg, so if 16kg, 80mg

Answer 1417

5mg/lg, so if 16kg, 80mg

Answer 1418

cumulative doses of up to 800mg for surgery & post analgesia administered over 24hrs well tolerated, then post continuous infusions at rates of UP TO 28mg/hr for 72hrs

Answer 1419

Spike before p wave= atrial paced Before qrs= ventricular paced FTC= pacemaker stimulations don’t —> myocardial activation (see a pacing spike, no activity, genuine or during refractory period.  Failure to sense (under sensing) doesn’t sense true p or r waves, may —> overpacing eg. Pacing after intrinsic activity Oversensing= senses signals that aren’t true p or r waves (which normally inhibit pacemaker), DDD pacemaker would lead to overpacing if over senses atrial activity, DDI would lead to underpacing. Failure to pace= doesn’t pace as expected Failure to rate adjust (only elevate to rate responsive PM)

Answer 1420

-risk Ax (Hx substance abuse, Fix substance abuse, psych disorder, aberrant drug taking Bx). -Multimodal: Self-management & non-opioid -opioid trial- set goals based on function. Agreement, consent (incl no replacement of lost scripts). Dispensing according to risk Ax. -trial 6-8 wks (long-acting oral or transdermal) -regular re-Ax & documentation: 5A’s: Analgesia Activity Adverse effects Affect Aberrent behaviour Initially weekly. Limited dose 100mg/day OME. Involve other colleagues. Wean within 3/12 after acute pain. Slow: 10-25% of starting dose @ monthly intervals, fast 10-25% at weekly intervals. Alert to dependence/addiction.

Answer 1421

calculate 24hr OME, decrease dose new opioid by 25-50% due to incomplete cross-tolerance.

Answer 1422

Combine fiberoptic scope & intubation stylets. Can use independently, w laryngoscopes, or with SGA devices.

Answer 1423

minimal: drug-induced state where respond purposefully to verbal commands or light tactile stimulation, resp & CV unaffected. moderate: drug-induced state of depressed consciousness during which pts retain the ability to respond purposefully to verbal commands & tactile stimulation deep: depressed cons, not easily roused, may respond only to noxious. may need to have airway support, CV function generally maintained

Answer 1424

CS>instrumental Induction/augmentation labour (esp if hyper-stimulation) Instrumental CS And age >35, male foetus, multiple pregnancy, eclampsia, uterine rupture, placenta praevia, placental abruption. Overall rare so unpredictable.

Answer 1425

CS>instrumental Induction/augmentation labour (esp if hyper-stimulation) Instrumental CS And age >35, male foetus, multiple pregnancy, eclampsia, uterine rupture, placenta praevia, placental abruption. Overall rare so unpredictable.

Answer 1426

CS>instrumental Induction/augmentation labour (esp if hyper-stimulation) Instrumental CS And age >35, male foetus, multiple pregnancy, eclampsia, uterine rupture, placenta praevia, placental abruption. Overall rare so unpredictable.

Answer 1427

CS>instrumental Induction/augmentation labour (esp if hyper-stimulation) Instrumental CS And age >35, male foetus, multiple pregnancy, eclampsia, uterine rupture, placenta praevia, placental abruption. Overall rare so unpredictable.

Answer 1428

MI tachycardia 5-fold incr MI risk in hr following cannabis, 24-fold incr risk MI in the hour following cocaine Peripheral vasodilation (—> compensatory orthostatic hypoT & incr CO, DO2, cardiac work). MI risk rapidly decreases after 1hr. Physiologic effects blunted in chronic cannabis users.

Answer 1429

Rapid onset (rapid distribution to VRG, effects within seconds to mins inhaled, may be 1-2hrs w oral). highly lipid soluble so redistrubtue ++ , can accumulate once ingested, plasma half-life 20hrs but tissue half life may be days (up to 30) depending on frequency/chronicity of use. can't predict particularly as THC concentration, route of delivery varies. Most commonly smoked, ingestible products more risk of psychosis/violent behaviour. Effects: CV: acute: tachycardia, vasodilation, orthoasasis. Chronic: atheromatous disease *incr risk angina & MI esp 1hr after injestion. Marijuana may incr stimulatory effects of amphetamines & cocaine & the depressive effects of ETOH & BZD. Low doses THC--> SNS stimulation, tachy, HTN. High doses may inhibit SNS activity--> brady & hypoT. Pulmonary: bronchodilator, Airway effects of smoking marijuana mild cf tobacco; short-term bronchodilation but chronic cough & mild airflow obstruction over the long term. May get upper airway oedema, rarely PTx with valsalva-like maneouvers. airway hyperreactivity (may be more significant than tobacco as burns at higher temperature., airway oedema. chronic= bronchitis, emphysema *hyperreactivity risks PRAEs, Observe for stridor if UA oedema. chronic cough & wound dehiscence CNS: acute: anxiety or anxiolysis, paranoia, psychosis, dizzinesss, headache, analgesia. Chronic effects are similar but tolerance develops GI: dry mouth, anti nausea & incr appetite, abdominal pain. Chronic: hyperemesis. *may have electrolyte abnorms/dehydration with cannabinoid hyperemesis syndrome. endocrine: long term gynaecomastia, anovulation, galactorrhea. withdrawal: can develop within a day of cessation, may take weeks to resolve. anxiety, irritability, restlessness, anorexia, abdominal cramp, tremors, sweat, fever, chills, headache-> depressed mood & lack appetite. Could use BZD, synthetic THC (used for chemo-induced nausea, off-label for cannabis withdrawal.) Pre-op: Hx: last use (look for signs intoxication, most concerning Anaes implications are w acute intox) Ask re: freq, duration, route, mode. Exercise tolerance, CVS/angina symptoms. Other substance use. *if evidence acute intox, consider delay for 1hr after use due to high risk of MI within 1 hr of use. Await resolution of tachy/postural hypotension. CNS signs of intoxication: concern re: violent emergence. Resp exam. High-potency formulations may get HTN, tachy, fever (Ddx MH, thyrotoxicosis) Informed consent unlikely possible with acute cannabis intoxication. Intra-op: Anticipated higher doses needed Depth of Anaes monitoring but BIS may not be reliable. Maintenance requirements not clear in literature, cross-tolerance w other anaesthetic agents unknown.. Cannabis users report higher pain scores & require more rescue analgesics. Multimodal incl regional. Post-op: consider withdrawal. Analgesia ongoing multimodal Complication surveillance

Answer 1430

Encephalopathy (uraemia) Myopathies Neuropathies (esp ANS) Osteodystrophy (calcium homeostasis) May get cardiac failure, myocarditis pleural effusions Impaired gastric emptying Immunocompromised Access sites, volume & electrolyte status related to dialysis & timing (know baseline wt & bloods, volume status up & down, know usual UO & fl restriction); HD improves water balance, acid-base, electrolytes, HTN, decr pericarditis, neuropathy & renal osteodystrophy. improves plt function but usually not coagulopathy. Haem: Chronic compensated normocytic normochromic anaemia common (intake, EPO, hepcidin (ACD), microangiopathy) High vWF/VIII (coagulopathy), low factors II, V, VII, IX, X Impaired plt dysfunction w uraemia Water imbalance: RAAS/protein & chronic haemodialysis Renal impairment: hyperK, hyperMg++, low Ca++ (related to lack of renal vit D activation), acidosis (which may incr Ca++ liberation from bone) Pk implications (renal active metabolites, incr VD so may need higher props dosing, CNS sensitivity, atrac/cis organ independent) Comorbid: HTN DM common AV fistula: usually block, GA for revision (may be longer pro edure), consider pt comorbidities

Answer 1431

Encephalopathy (uraemia),. sensitivity to GA agents Myopathies Neuropathies (esp ANS- postural BP, sensorimotor peripheral) Osteodystrophy (calcium homeostasis), osteoporosis May get cardiac failure, haemorrhagic pericarditis (coagulopathy), pericarditis (?circulatory toxins), arrhythmias pleural effusions, pulmonary oedema Impaired gastric emptying Immunocompromised Access sites, volume & electrolyte status related to dialysis & timing (know baseline wt & bloods, volume status up & down, know usual UO & fl restriction); HD improves water balance, acid-base, electrolytes, HTN, decr pericarditis, neuropathy & renal osteodystrophy. improves plt function but usually not coagulopathy. Haem: Chronic compensated normocytic normochromic anaemia common (intake, EPO, hepcidin (ACD), microangiopathy); often they tolerate low Hb/Hct well, aim Hb at least 60, Hct0.3, use EXERCISE TOLERANCE or CV SYMPTOMS or CNS symptoms as indicator of pts ability to tolerate anaemia. if must use blood, LDF to reduce induction of HLA alloimunisation. High but defective vWF, high VIII (coagulopathy), low factors II, V, VII, IX, X, incr bleeding time Impaired plt dysfunction w uraemia Water imbalance: RAAS/protein & chronic haemodialysis; "dialysis disequilibrium syndrome" Renal impairment: hyperK (aim <5.5 preop, HD or resonium A, delay if pathology unknown), hyperMg++, low Ca++ (related to lack of renal vit D activation), acidosis (which may incr Ca++ liberation from bone), high phosphate, low albumin Pk implications (renal active metabolites, incr VD so may need higher props dosing, CNS sensitivity, atrac/cis organ independent) Comorbid: HTN (aim <160/<90 preop DM common AV fistula: usually block, GA for revision (may be longer pro edure), consider pt comorbidities

Answer 1432

T11-L2 & S2-4 for prostatectomy Kidney T10-L1 Bladder needs T11-L2 for dome Penis/scrotum S2-4 spinal level

Answer 1433

Sengstaken-Blakemore tube:For life threatening upper GI bleed from ruptured oesophageal/gastric varices 3 lumens (aspiration gastric contents, inflate yes balloon, gastric balloon. Intubate pt before insert, generally inserted at time of endoscopy if vatceal bleeding not controlled Confirm in stoach (aspiration gastric contents) 200mL n/saline slowly into gastric balloon Proximal end of tube secure to pts face Oesophageal balloon: air approx 40mL, 25-30cmH2O (manometer) Usually deflate balloons regular 8-10hr intervals, max time tube in 24-48hrs

Answer 1434

FiO2 100%, bronchial cufff down prior to transfers, re-confirm position

Answer 1435

Thyroid Thymoma Teratoma Terrible lymphoma “Safe” positioning Symptoms or 50% tracheal compromise Ax CT scan: trachea & great vessels Airway strategy Bleeding risk w mass manipulation Discuss with surgeon Mediastinoscopy: SVC obstruction a contraindication Why not EBUS? Stent before? Continuous BP measurement on R) UL (risk nominate), BP cuff on L) IV access LL if concern SVC compression Vagal response w any procedures near aortic arch RLN, Tx duct injury * Side: 1-2cm R) main bronchus (?1/20 it's <1cm to R) UL bronchus), bronchus intermedius is 1.5-2cm 1/250 R) UL bronchus off the trachea * Side: Main bronchus 4-6cm 1-3mL in bronchial cuff (max 4mL)- don't need much air if size cuff properly

Answer 1436

Diuretics not recommended as prophylaxis for renal failure No evidence frusemide or dopamine improve mortality Low-dose dopamine may reduce renal blood flow in early ATN, may cause pre-capillary vasoconstriction & increase risk post-op AKI Mannitol (0.25-0.5g/kg may incr UO & SCAVENGE FREE RADICALS (attenuate repercussion injury), may reverse cortical ischaemia but not conclusively shown to improve outcome Fenoldopam dopamine agonist may incr RBF, natriuresis, dear splanchnic & SVR- some evidence re: reducing risk of IV contrast but less evidence for open surgery, studies underpowered.

Answer 1437

Mg++ infusion. barbiturates, Mg++ or phenytoin for seizures w TURP syndrome (seizures may be BZD resistant)

Answer 1438

Regular: VT unstable shock (or any unstable for that matter), amiodarone Svt w BBB: adenosine irreg: AF w BBB manage as for narrow complex (B blocker or diltiaz consider amiodarone or dig if HF) Polymorphic: Mg++

Answer 1439

TURP syndrome; iso-osmolar (or sl hypo) hyponatremia CV risk pt factors, large resections & blood loss, fluid absorption Hypothermia w irrigant Transient bacteremia- treat pre-op UTIs DVT 5-10% Significant bleeding (more if procedure >60mins & prostates >50g; difficult to estimate blood loss due to constant irrigation; 15mL/g resected tissue roughly. Blood transfusions in approx 10%. Tissue plasminogen activator released from prostate. Optimise volume via PPV (fluid responsiveness) If minimal UO & risk ARF, 500mL fluid challenge If volume responsive & more fluid not detrimental, give more, otherwise PAC; insert CVP; raised? Consider mannitol/frusemide. If urea rise, fluid o/load, met acidosis, hyperK consider haemodialysis (diuretics only used for limited time (40-80mg IV frusemide; loop better natriuretic effect vs thiazides)

Answer 1440

TURP syndrome; iso-osmolar (or sl hypo) hyponatremia CV risk pt factors, large resections & blood loss, fluid absorption Hypothermia w irrigant Transient bacteremia- treat pre-op UTIs DVT 5-10% Significant bleeding (more if procedure >60mins & prostates >50g; difficult to estimate blood loss due to constant irrigation; 15mL/g resected tissue roughly. Blood transfusions in approx 10%. Tissue plasminogen activator released from prostate. Optimise volume via PPV (fluid responsiveness) If minimal UO & risk ARF, 500mL fluid challenge If volume responsive & more fluid not detrimental, give more, otherwise PAC; insert CVP; raised? Consider mannitol/frusemide. If urea rise, fluid o/load, met acidosis, hyperK consider haemodialysis (diuretics only used for limited time (40-80mg IV frusemide; loop better natriuretic effect vs thiazides)

Answer 1441

Almost no chance TURP syndrome (minimal fluid absorption) Pt can be on anticoagulation, better haemostats, minimal blood loss, easier estimate than with standard TURP (irrigant ++) Shorter IDC use & shorter LoS despite longer OT (less familiarity w technique?) Lower risk LT issues (bl neck damage/incontinence, lower rates retrograde ejaculation) MUST be under GA, pt can’t cough (so not spinal) Complex equipment/laser safety issues Vapourisation: KTP (green light)= a modified Nd:YAG laser beam, incr the frequency of the Nd:YAG, absorbed by Hb not water, massive heating & instant vaporisation virtually no bleeding & not the “sloughing” risks of standard Nd:YAG (eg. Risk BOO or missed prostatic Ca) BUT the vaporisation means can’t get histology. Can use NaCl irrigation. Thullium laser= another type of photovapourisation Other types laser: HoloLap (holmium); weaker wavelength than green light, cuts vs vaporise, still good heamostatic control but slower/longer OT times. Able to preserve histology.

Answer 1442

5 T’s mnemonic: ToF Total anomalous PV drainage Transposition of the great vessels Trunks arteriosus TCV abnormalities & hypo plastic R) heart syndrome

Answer 1443

Cyclosporine & tacrolimus both nephrotic, HTN, high K, low Mg++, cyclosporin neurological (paraesthesia), macro hyperglyc Myocphenolate BM suppression, malignancy risk, viral reactivation Azathioprine risk hepatoxocicity & BM suppression, N&V/diarrhoea Steroids Methotrexate: hepatotoxicicity, ILD sulfasalazine: neutropenia, thrombocytopenia, pulmonary fibrosis azathioprine: BM suppression, hepatitis

Answer 1444

Cardiac arrhythmias: 40% get AF Pulmonary oedema: 2-5%, mort >50%, more common after R) pneumonia Bronchopleural fistula: more common w R) pneumonectomy, early= cough, air leak, falling fluid level. Later may be empyema. Cardiac herniation: R)-sided if there was stripping of pericardial sac