Resus, Trauma, Crisis Flashcards

Question

An awake patient in the post-anaesthesia care unit complains of breathlessness. The FiO2 through the patient’s rebreather mask is 40%. An arterial blood gas taken at the time shows (ABG shown). The alveolar-arterial gradient (in mmHg) is approximately Blood gas shows: PaO2 135 PaCO2 48 SpO2 100% The A-a gradient is: A. 5 B. 30 C. 60 D. 90 E. 110

Answer 1

D 90 A-a = PAO2 - PaO2 Alveolar air equation gives PAO2 PAO2 = PiO2 - PaCO2 / R PAO2 = 0.4 x (760 - 47) - 48 / 0.8 so, as PaO2 given as 135 A-a = 228 - 135 = 93

Answer 2

c) Alprostadil (PGE1) From Paediatric BASIC on CHD: - Resuscitation of an infant or newborn in shock should follow a standard approach regardless of the aetiology. - Any patient with a duct dependent lesion either for pulmonary blood flow, or systemic output, will require PGE1. The problem is that whether or not a duct dependent lesion is present is unclear in most cases. If CHD has been diagnosed antenatally, PGE1 should be started. - The cyanosed neonate presenting with severe cyanosis (O2 <75) and/or in extremis should be started on PGE1; the assumption being that the duct has closed and needs to be reopened.

Answer 3

d) Respiratory Acidosis with incomplete compensation Uncertain of this answer, not enough info to calculate anion gap pH 7.2 = acidaemia pCO2 84 = respiratory acidosis HCO3 43 = metabolic alkalosis as compensation BE 16 = metabolic alkalosis Boston rules: Chronic fully compensated Respiratory acidosis Expected compensation is 3-4 mmol/L rise for every 10mmHg rise in PCO2. Expected metabolic compensation therefore is HCO3 = 24 + 4 x ((84-40)/10) = 24 + 4x (44/10) = 24 + 4 x (4.4) = 24 + 17.6 = 41.6 Metabolic acidosis PaCO2 should be 1.5 x HCO3 + 8 = 72.5 Rules (from K.Brandis Acid-base rules anaesthesia mcq): - 1 for 10 (acute resp acidosis), 4 for 10 (chronic resp acidosis) - 2 for 10 (acute resp alkalosis), 5 for 10 (chronic resp alkalosis) - 1.5xHCO + 8 = expected pCO2 in a metabolic acidosis - 0.7xHCO3 + 22 = expected pCO2 in a metabolic alkalosis https://www.anaesthesiamcq.com/AcidBaseBook/ab9_3.php

Answer 4

b. adrenaline 1mg boluses The risk of administering adrenaline in conventional doses is with profound hypertension, bleeding, or tearing of vessel anastomoses on return of spontaneous circulation (ROSC), which can precipitate catastrophic harm or further cardiac arrest. Adrenaline remains a useful drug in peri-arrest situations in smaller doses.

Answer 5

High C-Spine injury

Answer 6

b. 100ml Paediatric weight estimation: Luscombe: Weight (kg) = (age x 3) + 7 RCH: Weight (kg) = (age + 4) x 2 Formula for calculating transfusion volume (mL) Children <20 kg: PRBC (mL) = wt (kg) x Hb (g/L) rise (desired Hb – actual Hb) x 0.5 (transfusion factor) Children >20 kg: 1 unit PRBC Example: 6 + 4 x 2 = 20kg 20kg x 10g/l x 0.5 = 100ml

Answer 7

a) Cold Saline Irrigation

Answer 8

30ml/kg https://journals.lww.com/ccmjournal/Fulltext/2021/11000/Executive_Summary__Surviving_Sepsis_Campaign_.14.aspx

Answer 9

d. XIII But Fibrinogen (I) is the most significant factor that

Answer 10

e Na 140 Mg 1.5 K 5.0 acetate 27 lactate 0

Answer 11

b. Cold saline irrigation of brain Seizures, either focal or generalized, are most likely to occur during cortical mapping. They are treated by irrigating the brain tissue with ice-cold saline. They usually cease with this treatment alone, but occasionally benzodiazepines, anti-epileptic drugs, or re-sedation with airway control are required. An emergency plan for airway control has to be in place at all times and this can be challenging as the patient's head is fixed in head pins and often away from the ventilator. The options include the insertion of an LMA which may be easier than oro-tracheal intubation. Awake craniotomy is generally a well-tolerated procedure with a low rate of conversion to general anaesthesia and a low rate of complications. One of the most frequent complications is patient intolerance of the procedure, often because of the urinary catheter or prolonged positioning and intra-operative seizures.

Answer 12

c. 5 min Circulatory determination of death in the context of organ donation 12 Circulatory determination of death in the context of organ donation requires the absence of spontaneous movement, breathing and circulation. Absence of circulation is evidenced by absent arterial pulsatility for 5 minutes, using intra-arterial pressure monitoring and confirmed by clinical examination (absent heart sounds and/or absent central pulse). In cases without an arterial line, electrical asystole should be observed for 5 minutes on the electrocardiogram and confirmed by clinical examination. 13 For the purposes of organ donation, circulatory determination of death should be documented using a specific form (see Appendix E) to demonstrate explicitly that all criteria set out in this Statement are met. The same criteria should be listed in local hospital forms

Answer 13

a. HR increases

Answer 14

a) 3% saline 100ml 100ml bolus of 3% saline (should raise serum Na by 2-3 meq/L). If no improvement in neurological symptoms, can repeat bolus 1-2 more times at 10 minute intervals. Frusemide only recommended if APO

Answer 15

f. perindopril Hypotensive transfusion reactions, which account for almost 3% of all transfusion reactions, are associated with patients treated with angiotensin-converting enzyme inhibitors. The current hypothesis suggests that they are caused by bradykinin-induced vasodilation in the absence of allergic, hemolytic, or septic mechanisms. The hypotension observed frequently is unresponsive to conventional therapy with catecholamines. The suggested intraoperative management includes cessation of transfusion and washing red blood cells before blood replacement. Hypotensive reactions to transfusion may not always be recognized. To prevent these reactions, clinicians have several options: they may discontinue the ACE inhibitor (elective transfusion), not use a leukoreduction filter (if the patient has no absolute requirement for leukoreduced blood components), use washed cellular components, or use components that have undergone leukoreduction at the collection facility or the hospital blood bank before transfusion (since bradykinin is degraded during storage).

Answer 16

B. 7.32 https://emj.bmj.com/content/18/5/340 The values of pH on arterial and venous samples were highly correlated (r=0.92) with an average difference between the samples of −0.4 units. There was also a high level of agreement between the methods with the 95% limits of agreement being −0.11 to +0.04 units. https://litfl.com/vbg-versus-abg/ pH - Good correlation - pooled mean difference: +0.035 pH units

Answer 17

e. Sotalol Drugs that INCREASE defibrillation threshold: + Amiodarone (Chronic) + Atropine + lignocaine + Diltiazem + Flecainide + Verapamil + Venlafaxine + Anaesthetic agents. Drugs that DECREASE defibrillation threshold: - Sotalol - Amiodarone (acute) - Nifekalant Drugs with No Change in DFT = B- blocker = Disopyramide = Procainamide = Propafenone https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6304797/

Answer 18

a) PEA I couldn't find a great article on this anywhere. BJAED hasn't got much either

Answer 19

a) electrical alternans Physical findings in Tamponade: - A number of findings may be present on physical examination, depending upon the type and severity of cardiac tamponade - None of the findings alone are highly sensitive or specific for the diagnosis. Beck's triad 1. Low arterial blood pressure 2. Dilated neck veins 3. Muffled heart sounds - Are present in only a minority of cases of acute cardiac tamponade. Diagnosis: Clinical diagnosis is usually suspected based on the history and physical examination findings, which may include: ●Chest pain ●Syncope or presyncope ●Dyspnea and tachypnea ●Hypotension ●Tachycardia ●Peripheral edema ●Elevated jugular venous pressure ●Pulsus paradoxus

Answer 20

c) Early repair Coil within 24 hours Early repair - the outcome in terms of survival free of disability at 1 year is significantly better with endovascular coiling. Preferably within 24 hours

Answer 21

c) 0, 1, 4, 24 Serum tryptase levels are recommended to be collected as soon as possible after the onset of symptoms and then at 1 hour, 4 hours and after 24 hours. https://www.anzca.edu.au/resources/professional-documents/endorsed-guidelines/anaphylaxis-guideline-2022.pdf

Answer 22

Control seizures first a) Midazolam if an option or c) propofol or treat seizures 1st followedLAST - ABCD - Intralipid 1.5mL/kg

Answer 23

a) Pulmonary embolism A bit about the RV in PE: The right ventricle drapes around the LV. In response to an acute Pulmonary Embolus (PE) it first dilates. The RV can’t generate much force without training, so when the Pulmonary Vascular Resistance (PVR) first rises with a PE, the pulmonary artery pressures don’t actually rise substantially because the RV can’t generate large pressures. Looking at the ventricle in short axis, the septum may bow towards the LV which will form a D shape in diastole, producing a “volume overloaded right ventricle” appearance. Only later when the RV has been trained will it be able to generate higher pressures. If the LV is D shaped in systole, this is a “pressure overloaded right ventricle”. Acute cor pulmonale with both pressure AND volume overload (D shape in systole AND diastole) is often absent.

Answer 24

D. Withdraw PAC 2 cm and insert DLT LITFL: Pulmonary haemorrhage after PAOP measurement a life threatening time-critical emergency pulmonary artery rupture caused by inflation of the pulmonary artery catheter (PAC) balloon during ‘wedging’ (measurement of the pulmonary artery occlusion pressure) some experts advise against measuring PAWP because of the risk of pulmonary artery rupture 0.2% risk, 30% mortality RISK FACTORS pulmonary hypertension mitral valve disease anticoagulants age >60 years MANAGEMENT Goals prevent further pulmonary haemorrhage stop bleeding resuscitate Call for help ICU consultant anaesthetist/ OT cardiothoracic surgeon interventional radiology Resuscitation A may have to be emergently intubated if not already B FiO2 1.0 controlled ventilation if able to recognize which lung is haemorrhaging may be able to perform lung isolation (insert single lumen tube into unaffected side, exchange for a double lumen tube or use bronchial blocker with bronchoscopic assistance) apply PEEP to tamponade wound C large bore IV cannulae, fluids, blood products, inotropes Specific therapy Lay the patient ruptured side down withdraw pulmonary catheter 2-3 cm with balloon down then refloat PAC with balloon inflated to occlude pulmonary artery (to try to tamponade bleeding) stop antiplatelet agents and anticoagulants give reversal agents: — protamine for heparin — platelets for anti-platelet agents give blood products as indicated by FBC, coags and clinical state interventions — angiogram or bronchoscopy to isolate pulmonary vessel involved — if bleeding doesn’t settle will require lobectomy

Answer 25

1,500 mL immediately OR 200 mL/hr in the first 2-4 hours

Answer 26

Honey (or sucralfate) - 10 mL every 10 minutes (maximum 6 times) while awaiting surgical retrieval Source QCH guidelines

Answer 27

d) diltiazem Nondihydropyridine calcium channel blockers should be used cautiously in patients with HFrEF because of their negative inotropic effects, and the role of these agents in LVAD recipients remains unclear https://www.ahajournals.org/doi/10.1161/CIR.0000000000000673 Should also avoid sotolol

Answer 28

c) 20mmHg Intra-abdominal hypertension is defined as a sustained intra-abdominal pressure of >12 mm Hg, and abdominal compartment syndrome occurs at a pressure >20 mm Hg in association with new organ dysfunction. Intra-abdominal hypertension is graded as follows: Grade 1=12–15 mm Hg; Grade 2=16–20 mm Hg; Grade 3=21–25 mm Hg; and Grade 4 >25 mm Hg. ## Footnote https://academic.oup.com/bjaed/article/12/3/110/258792

Answer 29

Muscle relaxation or Recruitment maneuvers A, D and E are all appropriate for ARDS. Muscle relaxation and lung recruitment are controversial. Best answer is probably A muscle relaxation (not recommended unless there is dyssynchrony). Recruitment and higher PEEP are conditional. UP TO DATE: RE: Muscule relaxation: " Until a clear benefit is demonstrated, we suggest not routinely administering NMBs to patients with moderate to severe ARDS, unless other indications are present (eg, severe ventilator dyssynchrony, particularly if it leads to double triggering, or unwanted motor movement refractory to ventilator adjustment and sedation). " Recruitment manoeuvres – no positive influence on survival. https://derangedphysiology.com/main/required-reading/respiratory-medicine-and-ventilation/Chapter%20512/ventilation-strategies-ards Does this strategy improve survival? Probably not, according to this Cochrane review. In fact, in the ART trial (Cavalcanti et al, 2017) they probably caused harm. But, they can improve oxygenation temporarily. One can see the benefit of recruitment manoeuvres in patients who have accidentally become disconnected from the ventilator. The 2017 ATS guidelines were published in May of 20117, whereas the ART trial came out in September that year, and so the ATS guidelines still recommend recruitment manoeuvres whereas the rest of the world probably does not. In fact, in their answer to Question 8 from the first paper of 2018 the college remarked that if any trainee who confesses to the routine use of recruitment manouvres, "they were should be marked down" by the examiners.

Answer 30

a. Normal SpO2, Normal PaO2 ABG HbCO (elevated levels are significant, but low levels do not rule out exposure) lactate (tissue hypoxia) PaO2 should be normal, SpO2 only accurate if measured (not calculated from PaO2) MetHb (exclude) https://litfl.com/carbon-monoxide-poisoning/

Answer 31

hydroxycobalamin

Answer 32

a) Increase PVR UTD: Low cardiac output "ebb," phase (resuscitative phase) – In the first 48 hours after a major burn, cardiac output (CO) is reduced up to 60 percent from baseline due to: 1. hypovolemia from permeability-induced plasma loss 2. reduced myocardial response to catecholamines 3. increased systemic vascular resistance due to elevated vasopressin levels 4. depressed myocardial contractility 5. possible myocardial ischemia due to decreased coronary blood flow The large volumes that these patients require can sometimes result in over-resuscitation, leading to pulmonary edema and right heart failure. High cardiac output "flow," phase (recovery phase) During the recovery phase 72 to 96 hours postburn, hyperdynamic and hypermetabolic responses result in: 1. increased CO 2. Tachycardia 3. increased myocardial oxygen consumption 4. decreased systemic vascular resistance Elevation of catecholamines in major burns produces: 1. hyperdynamic circulation 2. augments energy expenditure 3. romotes protein catabolism in skeletal muscle. Nonselective beta blocker therapy is sometimes used to block catecholamine receptors, treat cardiac dysfunction, and modulate the hyperdynamic response during this phase

Answer 33

c. 1000 ml/hr 30% x 100kg x 4ml= 12000ml 50% in first 8hrs = 6000ml pt presents 2hrs late = 6000ml/6hrs = 1000ml/hr or 30% x 100kg x 3ml= 9000ml 50% in 1st 8 hrs= 4500ml pt presents 2hrs late= 4500ml/6hrs= 750ml/hr 750mls/hr EMSB recommends 3ml/kg, BJA recommends 4ml/kg -> go with 4ml/kg because electrical burn and more likely to require increased fluids anyway

Answer 34

Haemodynamically unstable pelvic fracture

Answer 35

More bleeding with normal INR and APPT https://academic.oup.com/bja/article/117/suppl_3/iii18/2664400 Bleeding observed at reduced temperatures (33 – 37 °C) often occurs because of defects in platelet adhesion, while at temperatures below 33 °C, both reduced platelet function and coagulation enzyme activity contribute Also lab INR and APTT are not temperature corrected

Answer 36

a) Phosphate hypophosphate: Clinical symptoms range from muscle weakness and paraesthesia to severe cardiac failure, seizures and diaphragmatic paralysis Refeeding malnourished patients with anorexia nervosa can be associated with hypophosphatemia, cardiac arrhythmia and delirium. Phosphorus repletion should be started early with and serum levels maintained above 3 mg/dL weakness and fatigue, in the context of a recent history of starting a regular diet while in a state of chronic malnutrition, are concerning for refeeding syndrome, which typically occurs 2 to 5 days after beginning nutritional repletion. Depleted phosphate stores due to prolonged starvation, hypocalcemia, and hypokalemia can lead to impaired muscle contractility and subsequently weakness, myalgia, and tetany. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4168120/

Answer 37

1st a) Atorvastatin 2nd c) Digoxin source of Atorvastatin > Digoxin https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5818856/ All of the DOACs are avid substrates for the excretory P-gp system of the gastrointestinal epithelial cells, and drugs that inhibit or induce the P-gp system may affect plasma DOAC levels Dabigatran and edoxaban are substrates for P-glycoprotein (P-gp) Apixaban and rivaroxaban are metabolised by cytochrome P450 enzyme CYP3A4 and are substrates for P-gp There is study evidence that among patients taking DOACs for non-valvular atrial fibrillation, concurrent use of amiodarone, fluconazole, rifampicin, and phenytoin compared with the use of DOACs alone, was associated with increased risk of major bleeding It is unlikely that clinically significant interactions occur between dabigatran and other drugs that are merely substrates for P-gp-mediated excretion. When dabigatran was coadministered with digoxin neither digoxin nor dabigatran plasma levels were significantly altered Rivaroxaban and apixaban are metabolised to an extent of 40–50 % in the liver to variable degrees by CYP3A4 and may interact with drugs that inhibit this enzyme. The metabolism of Apixaban and rivaroxaban can be decreased when combined with Atorvastatin which is also metabolised by CYP3A4

Answer 38

a) PE D-shaped left ventricle

Answer 39

b. PECS I (PECS II Covers SA and will extend to the sternum)

Answer 40

B. 29 PaCO2= 1.5 x 14 + 8 PaCO2= 21 + 8 PaCO2= 29 Winter’s formula: expected PaCO2 = [1.5 x (serum HCO3)] + [8±2] if PaCO2 lower, there is a concomitant primary respiratory alkalosis if PaCO2 higher, there is a concomitant primary respiratory acidosis

Answer 41

c) 20mcg Adr IV ANZAAG use Ring and Mesmer scale for anaphylactic reactions as a base for classifying anaphylaxis grade (see image) From sunny coast QH document With PAGS ‘Life Threatening Anaphylaxis’ can be distinguished from ‘Moderate Anaphylaxis’ in an adult by the presence of any one of these signs: * systolic blood pressure of <60 mmHg * life-threatening tachy- or bradyarrhythmia * oxygen saturation <90% * inspiratory pressures of >40 cmH2 | Life-threatening anaphylaxis

Answer 42

c) 93% ANZCOR suggests against the routine administration of oxygen in persons with chest pain.13 [2015 COSTR, weak recommendation, very-low certainty evidence] For persons with heart attack, routine use of oxygen is not recommended if the oxygen saturation is >93% [National Heart Foundation of Australia & Cardiac Society of Australia and New Zealand: practice advice].9

Answer 43

b) Factor VII Redcross: Cryoprecipitate contains most of the following found in fresh frozen plasma: 1. factor VIII 2. fibrinogen 3. factor XIII 4. von Willebrand factor 5. fibronectin Prothrombinex-VF® is a lyophilised concentrate of human coagulation factors it contains: Factors: II IX X small amount of factor VII. Also contains: plasma proteins (human) Antithrombin III (human) Heparin sodium (porcine) Sodium Phosphate Citrate Chloride

Answer 44

a) hypoxaemia After LA administration, any abnormal cardiovascular or neurological symptoms and signs, including isolated cardiac arrest, should raise suspicion of LAST Presenting features of LAST vary widely. Cardiovascular collapse may occur without preceding neurological changes. Clinical features of LAST: CNS - 2 stage process of excitatory phase followed by a depressive phase - early signs: 1. perioral tingling 2. tinnitus 3. slurred speech 4. lightheadedness 5. tremor 6. change in mental state: confusion and agitation - excitatory phase culminates in generalised convulsions -Depressive phase: 1. Coma 2. Respiratory depression CVS - 3 phases: - initial phase: Htn and tachycardia - intermediate phase: myocardial depression and hypotension - terminal phase: peripheral vasodialtion severe hypotension arrhythmias: 1. sinus bradycardia 2. conduction blocks 3. VT 4. Asystole

Answer 45

C. Cryoprecipitate contains Factor VIII, XIII, fibrinogen (factor I), fibronectin, vWF ## Footnote https://www.lifeblood.com.au/health-professionals/products/blood-components/cryoprecipitate

Answer 46

hypoCALCEMIA Hydrofluoric acid: highly corrosive inorganic aacid of element fluorine - used in glass etching, electronics industry and cleaning solutions for metals, stone and marble - dilute solutions can rapidly penetrate the skin and exposure of even a small area can be fatal (2%TBSA) Fluoride ions bind with calcium and magnesium ions in the tissues -> significant hypocalcaemia and hypomagnesaemia -> Hyperkalaemia may also be seen Direct cardiotoxic effects of fluoride ions can lead to cardiac arrhythmias that are difficult to treat

Answer 47

D. 30 ml/kg Identification and Management of Obstetric Hemorrhage Anesthesiology Clinics - Obstetric Anesthesia (2017) https://www.anesthesiology.theclinics.com/article/S1932-2275(16)30074-X/fulltext Although FFP, cryoprecipitate, and fibrinogen concentrates can all be used to increase fibrinogen levels, the optimal strategy for managing hypofibrinogenemia in obstetric hemorrhage is unclear. The relatively low concentration of fibrinogen in FFP limits its usefulness in the treatment of significant hypofibrinogenemia. To increase fibrinogen plasma level by 1 g/L, 30 mL/kg of FFP is necessary, increasing the risk of pulmonary edema and other hypervolemic complications. Cryoprecipitate, which is a concentrated source of fibrinogen, factor VIII, fibronectin, von Willebrand factor (vWF), and factor XIII, will increase fibrinogen levels by ~0.7 to 1 g/L for every 100 mL given. Although cryoprecipitate is associated with a lower transfusion volume, the standard “dose” (10 U) is typically prepared by pooling concentrates from multiple donors. Given the risk of infectious disease transmission and/or an immunologic reaction from exposure to multiple donors, several countries preferentially use purified, pasteurized fibrinogen concentrate for the treatment of congenital and/ or acquired hypofibrinogenemia. Fibrinogen concentrates are also prepared from large donor pools, but subsequent processing removes or inactivates potentially contaminating viruses, antibodies, and antigens. Studies comparing cryoprecipitate and fibrinogen concentrates utilization in hemorrhage resuscitation suggest fibrinogen concentrates are associated with lower blood loss, decreased RBC transfusion, and greater increases in plasma fibrinogen levels. Although the most appropriate method of fibrinogen replacement is somewhat controversial, the critical role of fibrinogen in reversing the coagulopathy accompanying obstetric hemorrhage is clear. As such, close monitoring and replacement of fibrinogen are crucial in the management of the bleeding parturient.

Answer 48

b. 60 BJA Article - Management of cardiac arrest following cardiac surgery - BJA Education In the CICU, the effectiveness of ECC is confirmed by monitoring the arterial pressure trace with a target compression rate and depth to achieve a systolic impulse of > 60 mm Hg to maintain a mean perfusion pressure, preventing ventricular distension, LV wall stress, and ischaemia.

Answer 49

D Na 154, 308 mOsm/L

Answer 50

c. Pneumonia Complete white-out of left lung with air bronchogram sign consistent with total consolidation. Patchy areas of ground glass opacities in right lung. There is silhouetting of the left heart border and left hemi-diaphragm. There is no rib crowding to suggest atelectasis. Complete white-out of the hemithorax with air bronchograms and trachea in a central position is consistent with consolidation secondary to pneumonia. The patient is on linezolid, micafungin, and piperacillin-tazobactam pending culture and susceptibility studies. Differential diagnosis of hemithorax white-out with a midline trachea include: - consolidation - pulmonary edema/ARDS - pleural mass - chest wall mass

Answer 51

B. Normal 2,3 DPG higher Hct-60% No immunimodulation require reinfusion within 6hrs pause with sement, caution metal fragments

Answer 52

c. 5mg/kg Methylene blue due to its monoamine oxidase(MAO) inhibiting property may precipitate potentially fatal serotonin toxicity at doses >5mg/kg. Source: STAT PEARLS - Methylene blue https://www.ncbi.nlm.nih.gov/books/NBK557593/

Answer 53

d) Warfarin Warfarin – no effect on thrombin time Heparin - causes considerable prolongation of TT. LMWH, fondaparinux or direct factor Xa inhibitors have no effect on TT as the predominantly inhibit factor Xa. -> However LMWH in very high concentration can affect TT. Dabigatran, Bivalirudin and other direct thrombin inhibitors prolong TT considerably. The thrombin time (TT), also known as the thrombin clotting time (TCT) is a blood test that measures the time it takes for a clot to form in the plasma of a blood sample containing anticoagulant, after an excess of thrombin has been added. Warfarin prevents thrombin synthesis but does not inhibit it, therefore no effect on TT.

Answer 54

d. Noradrenaline Supportive Management of Massive PE Coexisting left ventricular systolic dysfunction and diastolic dysfunction complicate the management of heart failure patients with massive PE. Although a common strategy in response to systemic arterial hypotension is to prescribe a fluid bolus, volume loading may worsen biventricular failure, pulmonary edema, and hypoxemia. An initial trial of volume expansion, limited to 250 to 500 mL, may be attempted in those heart failure patients without evidence of increased right-sided filling pressures or pulmonary edema.6 Although non–heart failure patients generally respond well to pure vasopressors for hemodynamic support in massive PE, many heart failure patients will not tolerate the isolated increase in systemic vascular resistance. PE patients with heart failure may require an agent with mixed vasopressor and inotropic properties such as norepinephrine, epinephrine, or dopamine. Whereas LV function often becomes hyperdynamic to compensate for RV failure, the presence of underlying LV systolic dysfunction in heart failure patients may limit the patient’s ability to maintain normal systemic cardiac output and may necessitate the addition of inotropes. https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.108.803965

Answer 55

c) Normothermia - TTM to 32-36 degrees is recommended for those that remain unresponsive

Answer 56

b. Rocuronium 1.2mg/kg Cis not appropriate for intubation Sux with K 6.3 is risky. (I've never heard of reduced dose)

Answer 57

e) Protamine The interpretation of this graph is not especially laborious. The cardinal abnormality is the massively prolonged CT and CF of the INTEM graph, which suggests that something has killed the intrinsic pathway of the clotting cascade. The CT returns to normal in the HEPTEM graph, which is essentially just an INTEM test with adde heparinase. The presence of heparinase seems to have reversed all of the coagulopathy - the CFT, alpha-angle and MCF have all returned to normal. Therefore, this patient has no coagulation problems other than the heparin. https://derangedphysiology.com/main/required-reading/haematology-and-oncology/Chapter 1.2.0.1/intepretation-abnormal-rotem-data

Answer 58

d. Stop volatile, calcium ?Duchenne muscular dystrophy? This patient most likely has Anaesthesia Induced Rhabdomyolysis (AIR) given the peaked Twaves and slow rise in ETCO2 Immediate MH Management: Stop administering Sevo, flush machine (or new), charcoal filters. Dantrolene.

Answer 59

R-wave peak

Answer 60

increased SVR EMSB handbook CO is reduced after Burn injury 2ry to: - myocardial depressant mediators - decreased blood volume - reduced venous return - increased pulmonary and systemic vascular resistance due to increased levels of catecholamines In the first 24hrs reduced cardiac output persists even after restoration of blood volume Between 24-48hrs post burn a hyperdynamic state develops with reduced peripheral resistance, increased oxygen consumption and increased cardiac output

Answer 61

a. Calcium (unless hyppocalcaemia is causing your seizures) Deranged Physiology: First line agents - Benzodiazepines: boluses every 2-5 minutes - Phenytoin: 20mg/kg loading dose Phenytoin on its own is useless. Or rather, it is inferior to benzodiazepines as a solitary agent. Always, both must be used simultaneously. Second line agents - Midazolam infusion - Phenytoin (well, rather, the American study recommends fosphenytoin) - Phenobarbital and levetiracetam are also in this second line of attack Third line agents: for refractory status epilepticus - Propofol infusion, or midazolam infusion, or thiopentone infusion. - At this stage, continuous EEG monitoring becomes mandatory - The role of traditional antiepileptic drugs is also exhausted at this stage, as there will probably be no benefit from adding them into a situation where a constantly observed burst suppression is already achieved by high dose anaesthetic infusion. Fourth line agents: for these, there is little evidence. - Volatile anaesthetic agents - Desflurane and Isoflurane - Ketamine - Lignocaine - Magnesium - Pyridoxine Fifth line therapies: - Hypothermia - Ketogenic diet - Deep brain stimulation - Surgical management

Answer 62

A. Magnesium TdP UTD - BB specifically propanolol or nadolol if Hx of syncope / seizures or resus SCA ## Footnote https://www.uptodate.com/contents/congenital-long-qt-syndrome-treatment

Answer 63

Endothelial damage due to ischaemia

Answer 64

Cardiac Arrest Source: LITFL

Answer 65

Nebulised Adrenaline 1mg 0.5ml/kg of 1:1000 Adrenaline nebulised once adrenaline given consider dose of Steroid dexamethasone or hydrocortisone

Answer 66

c) 5 back, 5 chest 4.1 Assess Severity The simplest way to assess severity of a FBAO is to assess for effective cough. 4.2 Effective Cough (Mild Airway Obstruction) The person with an effective cough should be given reassurance and encouragement to keep coughing to expel the foreign material. If the obstruction is not relieved the rescuer should call an ambulance. 4.3 Ineffective Cough (Severe Airway Obstruction) Conscious person If the person is conscious send for an ambulance and perform up to five sharp, back blows with the heel of one hand in the middle of the back between the shoulder blades. Check to see if each back blow has relieved the airway obstruction. The aim is to relieve the obstruction with each blow rather than to give all five blows. An infant may be placed in a head downwards position prior to delivering back blows, i.e. across the rescuer’s lap [Class B; LOE IV].1,2 If back blows are unsuccessful the rescuer should perform up to five chest thrusts. To perform chest thrusts, identify the same compression point as for CPR and give up to five chest thrusts. These are similar to chest compressions but sharper and delivered at a slower rate. The infant should be placed in a head downwards and on their back across the rescuer’s thigh, while children and adults may be treated in the sitting or standing position [Class B; LOE IV].1,2 With each chest thrust, check to see whether the airway obstruction has been relieved. The aim is to relieve the obstruction rather than deliver all five chest thrusts. If the obstruction is still not relieved and the person remains responsive, continue alternating five back blows with five chest thrusts. Unconscious person If the person becomes unresponsive a finger sweep can be used if solid material is visible in the airway.1,2 [Class A; LOE IV] Call an ambulance and start CPR.

Answer 67

d) Maintaining MAP >70 Recommends maintaining equal or greater than pts usual, or at least a SBP> 100mmHg https://www.resus.org.nz/assets/Uploads/ANZCOR-Guideline-11.7-Jan16.pdf

Answer 68

C. Between lowest renal artery to bifurcation of aorta https://litfl.com/reboa-in-resuscitation/ Anatomy: The aorta is divided into three separate zones for the purposes of REBOA (aortic length varies between individuals) Zone I of the aorta extends from the origin of the left subclavian artery to the coeliac artery (approx 20cm long in a young adult male) Zone II extends from the coeliac artery to the most caudal renal artery (approx 3cm long) Zone III extends distally from the most caudal renal artery to the aortic bifurcation (approx 10cm long) REBOA location based on injury: >suspected or diagnosed intra-abdominal haemorrhage due to blunt trauma or penetrating torso injuries (Zone I REBOA), or >blunt trauma patients with suspected pelvic fracture and isolated pelvic haemorrhage (Zone III REBOA), or >patients with penetrating injury to the pelvic or groin area with uncontrolled haemorrhage from a junctional vascular injury (iliac or common femoral vessels) (Zone III REBOA) Simplistic rendering of aorta. Zone 1 (from left subclavian artery to the upper border of the celiac trunk), Zone 2 (the upper border of the celiac trunk to the lower border of the distal take-off of the renal arteries), and Zone 3 (from the lower border of the lower renal artery to the aortic bifurcation). Zone 1 is occluded in the case of cardiac arrest or life-threatening intra-abdominal hemorrhage; Zone 2 has no current indication; and Zone 3 is occluded in the case of life-threatening pelvic or lower limb haemorrhage7. REBOA Resuscitative Endovascular Balloon Occlusion of the Aorta.

Answer 69

Warm ischaemia time: - Time from treatment withdrawal to the start of cold perfusion of the donated organs - Significance is the impact on graft function - Most important phase of WIT begins when the systolic BP is < 60mmHg - This includes the waiting period from the absence of circulation to the declaration of death and the time before initiating the flow of cold perfusate through the cannula Maximum WARM Ischaemia time - Heart 30 mins - Liver 30 mins - Pancreas 30 mins - Kidney 60 mins - Lungs 90 mins Maximum COLD Ischaemia time: - Heart = 4 hrs - Lungs = 6-8hrs - Liver/Pancreas = 12hrs (DBD)/6 hrs (DCD) - Kidneys = 18hrs (DBD)/ 12 hrs (DCD)

Answer 70

b. Octreotide 50mcg bolus Vasoactive hormone release intra-operatively is best treated with intravenous boluses of 20–50 µg of octreotide, titrated to haemodynamic response. Vasopressin as an alternative vasoconstrictor that may be useful if prolonged vasoconstriction is required; however, the evidence base is small. It must be borne in mind that concomitant fluid losses, especially bleeding, may be responsible for intra-operative instability rather than hormone excess and that fluid resuscitation may be the answer rather than further octreotide therapy https://academic.oup.com/bjaed/article/11/1/9/285683

Answer 71

E. Upper GI bleed Incompressible sites, large volume blood loss and mortality risk are a few of the things that made GI bleeds seem like a natural fit for TXA administration. Early research seemed promising, but trials were small. The HALT-IT trial examined over 15,000 patients to see if TXA reduced death [14]. Not only did TXA have no effect on mortality, it increased the risk of seizure and thromboembolic events. Take home: No demonstrated benefit with TXA in GI bleeding ## Footnote https://www.ems1.com/research-reviews/articles/understanding-txa-AFkqRLajUv46X7xV/

Answer 72

c. dobutamine ## Footnote UTD

Answer 73

albumin ALBUMIN AND PHOSPHATE the normal anion gap depends on serum phosphate and serum albumin the normal AG = 0.2 x [albumin] (g/L) + 1.5 x [phosphate] (mmol/L) albumin is the major unmeasured anion and contributes almost the whole of the value of the anion gap. every 1g/L decrease in albumin will decrease anion gap by 0.25 mmoles a normally high anion gap acidosis in a patient with hypoalbuminaemia may appear as a normal anion gap acidosis. this is particularly relevant in ICU patients where lower albumin levels are common Effects of albumin: Anion gap may be underesitmated in hypoalbuminaemia, because if albumin decreased by 1g/L then the anion gap decreases by 0.25 mmol To overcome the effects of the hypoalbuminaemia on the AG, the corrected AG can be used which is AG + (0.25 X (40-albumin) expressed in g/L

Answer 74

c) Normal 23 DPG https://www.bjaed.org/article/S2058-5349(20)30157-8/fulltext Advantages of Cell salvage: 1. reduction in need for donor blood transfusion 2. no restrictive transfusion triggers 3. superior oxygen delivery compared to donor blood -> red cells retain elliptical profiles and retain deformability -> increased concentrations of 2,3 DPG and ATP -> evidence supports early transfusion as oxygen carriage and deformability degrade over time 4. lack of adverse immunolgical effects -> no sensitisation to antigens; Kell, duffy or Lutheran -> donor blood transfusion causes dose-dependant transfusion related immunosupression (TRIM) this can lead to increased risk of post-op infection and posible increased risk of tumour growth in patients undergoing cancer surgery 5. Fulfills criteria for certain cultural groups to receive blood transfusion (JW) 6. Financial benefits despite equipment and staffing costs Disadvantages: 1. The salvaged blood contains clinically insignificant concentrations of clotting factors and platelets, and when large volumes of blood are processed, the use of clotting factors, platelets, and calcium may be necessary. 2. High initial cost of equipment and training 3. Processing of blood requires a few minutes, blood may not be immediately available in time critical scenariois 4. REinfusion hypotension can occur and can be very marked requiring vasopressors 5. More labor intensive than donor blood, increased diligence required when collecting blood 6. May not be appropriate for all situations of operative blood loss ->Malignancy: use is controversial but supported in some instances (cystectomy radical prostatectomy, nephrectomy) ->Sepsis: not absolute contraindication but colume of contaminated material and pus must be limited ->Haemaglobonpathy: relative contraindication in sickle cell trait/disease and thalassaemia due to red cell fragility and potential for haemolysis

Answer 75

b. COHb level 10%

Answer 76

100 < PaO2/FiO2 ≤ 200 with PEEP ≥5 cmH2O https://link.springer.com/article/10.1007/s00134-012-2682-1/tables/3

Answer 77

e) hypoglycaemia

Answer 78

b) Adrenaline -You do not use full dose adrenaline (rather, give smaller doses) -You do three "stacked shocks" -You try pacing (rate of 90, DDD) in asystole if pacing wires are available -If they are already paced and in PEA, you turn off the pacing to "unmask" VF. -These shocks and attempted pacing are all measures you take before starting CPR, which is a departure from the ACLS norms. -If you can't control a shockable rhythm with three stacked shocks, you give amiodarone immediately rather than after three cycles. -Amiodarone is the only drug in the protocol, which makes it easy to remember. - -After five minutes of unsuccessful resuscitation the chest should be re-opened. ---External CPR is pointless in all of the common causes of arrest in this scenario. Therefore, CPR is something you do while waiting to re-open the chest. -Non-surgical staff are encouraged to re-open the chest in an emergency ## Footnote https://derangedphysiology.com/main/required-reading/cardiac-arrest-and-resuscitation/Chapter%20221/cardiac-arrest-following-cardiac-surgery

Answer 79

c) 1.0 Clinicians should consider DKA/euDKA in patients taking SGLT2i who have one or more of: - symptoms of abdo pain, nausea, vomiting, fatigue or metabolic acidosis (a normal or only modestedly elevated plasma glucose level does not exclude diagnosis) - finger prick capillary blood ketone ( or blood beta-hydroxybutyrate) level >1/0mmol/l with or without hyperglycaemia - Low (negative) Base Excess <-5mmol/l indicating metabolic acidosis on arterial or venous blood gasses If the blood ketone leve is >1.0mmol/l in an unwell patient on SGLT2i, take arterial or venous blood gases to measure the BE. If ketones >1.0mmol/l and BE <-5mmol/l the patient has presumed DKA If the BSL is <14mmol/l it is presumed euDKA > for a ward patient a MET team should be activated or ICU contacted for review in collaboration with endocrinology services > management priorities include: 1. Rehydration 2. IV insulin with added dextrose if BSL <15mmol/l 3. hourly monitoring of blood glucose, ketones and blood gases 4. All should be reviewed by an endocrinologist or on-call physician and critical care specialist

Answer 80

4 hours Redcross: "Transfusion of each pack should be completed prior to the labelled expiry or within four hours, whichever is sooner. " Shelf life of platelets: 5 days (Stored at 20-24 degrees, must be agitated gently and continuously) FFP: Once FFP is thawed, must use within 24 hours. Albumin administration: At RCH we allow the product to be administered within 6 hours of piercing the bottle. (from RCH.org) Cryoprecipitate Thawed cryoprecipitate should be maintained at 20°C to 24°C until transfused. Once thawed, should be used within six hours if it is a closed single unit, or within four hours if it is an open system or units have been pooled.

Answer 81

Hypotension Citrate is the anticoagulant used in blood products. It is usually rapidly metabolised by the liver. Rapid administration of large quantities of stored blood may cause hypocalcaemia and hypomagnesaemia when citrate binds calcium and magnesium. This can result in myocardial depression or coagulopathy. Patients most at risk are those with liver dysfunction or neonates with immature liver function having rapid large volume transfusion https://litfl.com/citrate-toxicity/ Hypocalcaemia resulting in long QT, reduced inotropy, hypotension systemic hypocoag Metabolic Met alk with HCO3 formation HAGMA with citrate accumulation Hypernatraemia from Na citrate Hypomag due to citrate chelation Hypokalaemia due to low mag and met alk

Answer 82

c) Foetal RBC All others removed with leukodepletion filter

Answer 83

b. Procainamide BJA: Perioperative cardiac arrhythmias https://academic.oup.com/bja/article/93/1/86/265716 - Paroxysmal SVT (PSVT) due to re‐entrant circuits that involve accessory pathways (congenital electrical connections between the atrium and ventricle that bypass the AV node, such as Wolff–Parkinson–White Syndrome) pose caveats in the management of SVT. - It should be noted that patients with accessory pathways, in addition to PSVT, may also develop atrial fibrillation, and in the latter situation are at increased risk for developing ventricular fibrillation (VF) upon exposure to classic AV‐nodal blocking agents (digoxin, calcium channel blockers, beta blockers, adenosine) because these agents reduce the accessory bundle refractory period. - In such cases, i.v. procainamide, which slows conduction over the accessory bundle, is an acceptable option. Flecainide and amiodarone should also be considered, and cardiology consultation may be helpful.2

Answer 84

c) propofol https://anaesthetists.org/Portals/0/PDFs/Guidelines%20PDFs/Guideline_management_severe_local_anaesthetic_toxicity_v2_2010_final.pdf?ver=2018-07-11-163755-240&ver=2018-07-11-163755-240

Answer 85

a) reintubate from the mouth ? couldn't find other recalled answers ? Will depend on the remembered answers ? The key principles of the algorithm are: 1.Waveform capnography has a prominent role at an early stage in emergency management. 2.Oxygenation of the patient is prioritised. 3.Trials of ventilation via a potentially displaced tracheostomy tube to assess patency are avoided. 4.Suction is only attempted after removing a potentially blocked inner tube. 5.Oxygen is applied to both potential airways. 6.Simple methods to oxygenate and ventilate via the stoma are described. 7.A blocked or displaced tracheostomy tube is removed as soon as this is established and not as a ‘last resort’ BJA: Update on management of tracheostomy https://www.bjaed.org/article/S2058-5349(19)30125-8/fulltext https://www.tracheostomy.org.uk/storage/files/Patent%20Airway%20Algorithm.pdf

Answer 86

d. Able to turn head 45 deg NEXUS criteria: One easy mnemonic for these criteria is NSAID: Neuro Deficit Spinal Tenderness (Midline) Altered Mental Status/Level of Consciousness Intoxication Distracting Injury

Answer 87

c. transfuse for Hb >100 Emergency fixation means there is no time for an exchange transfusion perioperative goals: - planning and optimisation - ensuring adequate O2 delivery - hydration - analgesia - performed at a centre with a multidisciplinary sickle cell team Children presenting for high-risk surgery (for example neurosurgical, cardiothoracic, or complex orthopaedic surgery) or high-risk children (previous stroke, acute CS, or end-organ damage), who were not included in this study, commonly receive an exchange transfusion or top-up transfusion, aiming for a preoperative haemoglobin concentration of 10 g dl−1 and Hb SS <30%. There is less evidence available for the role of transfusion in children with other forms of SCD. Exchange transfusion vs. top-up transfusion Exchange Transfusion: - slowly removing the person’s blood and replacing with fresh donor blood or plasma - Performed in cycles lasting a few minutes with slow removal of 5-20ml of blood and an equal amount of fresh pre-warmed blood or plasma flows into the person’s body - in sickle cell disease blood is removed and replaced with donor blood to achieve a specific concentration of HbSS blood with a usual target of <30% - Exchange transfusion removes HbS and increases HBA Top-up transfusion: - standard transfusion process of giving donor blood - advantages of simple top-up include: 1. Increase oxygen carrying capacity 2. Decrease proportion of sickle haemoglobin HbS relative to Haemoglobin A (HBA) 3. Prevent or reverse complications of vast-occlusion 4. Can be given acutely - disadvantages include: 1. Hyperviscosity if the Hb is increased to significantly over the patients baseline (target Hb should be 100g/l) 2. HbS is not removed, only diluted

Answer 88

150mcg IM Then commence adrenaline infusion 0.1mcg/kg/min to 2mcg/kg/min Refractory management: Additional IV fluid 20-40ml/kg, Noradrenaline infusion 0.1- 2mcg/kg/min Vasopressin infusion 0.02-0.06 units/kg/hr, glucagon 40mcg/kg IV

Answer 89

c) 110 Brain trauma foundation Level III recommendation. To decrease mortality and improve outcomes: Maintain SBP at >100mmHg for patients 50 - 69 Maintain SBP at >110 for patients 15 - 49 Maintain SBP at >110 for patients 70 or older

Answer 90

pancreatic fistula -> should cause NAGMA HAGMA: Lactate Toxins Ketones Renal failure NAGMA Chloride Addison's, adrenal insuffiency, acetazolamide GI loss (pancreatic fistula) Extra: RTA Anion gap: - Anion Gap = Na+ – (Cl- + HCO3-) - The Anion Gap (AG) is a derived variable primarily used for the evaluation of metabolic acidosis to determine the presence of unmeasured anions - The normal anion gap is assumed to be 12, and the normal HCO3 is assumed to be 24 Delta ratio: - can check delta ratio in the presence of a high anion gap metabolic acidosis (HAGMA) to determine if it is a ‘pure’ HAGMA or if there is coexistant normal anion gap metabolic acidosis (NAGMA) or metabolic alkalosis.

Answer 91

d) TXA VWD Types: 1 - quantitative - minor effect on bleeding - DDAVP useful 2 - qualitative - spectrum of effects on bleeding - (2a,2b,2m,2n) - DDAVP may be useful in consult with haem 3 - absence - major bleeding - no effect of DDAVP factors not recommended in Type 1 TXA and DDAVP are recommended but DDAVP not in list TXA 10mg/kg IV q8h DDAVP 300mcg intranasal 90-120 mins preop (DDAVP increases factor VIII levels 2-5x via release of VWF which binds VIII and prevents its clearance) Treatment of bleeding in an individual with von Willebrand disease (VWD) depends on: 1. Severity of bleeding 2, Site of bleeding 3. the type of VWD 4. the previous responses to therapy. The two main approaches: 1. Increasing the level of normal von Willebrand factor (VWF) activity via DDAVP 2. Replacing the defective VWF with VWF concentrates VWF concentrates have been demonstrated to provide excellent to good hemostasis in a number of patient populations and a number of bleeding types. DDAVP is only effective in some individuals, produces a smaller increase in VWF activity, and has a later onset and shorter duration of action.

Answer 92

12 puffs 6puffs< 6yrs 12 puffs> 6 yrs

Answer 93

Deep Posterior Compartment Source: UpToDate

Answer 94

a) LUSCS Rates of VAE by surgical procedure: LUSCS: 10%-97% Neurosurgery: Posterior Fossa: 76% Cervical Laminectomy: 7-25% Lateral/Prone Neurosurgery: 15-25 % Total Hip Replacement: 30% Lap Cholecystectomy: 69%

Answer 95

c. Decreased platelet function

Answer 96

a) 15 mins 50UI/kg, Prothrombinex-VF is able to completely reverse a supratherapeutic INR within 15 minutes however, vitamin K is also required to sustain the reversal effect as the half-lives of the infused clotting factors are similar to endogenous factors. ## Footnote https://www.mja.com.au/journal/2013/198/4/update-consensus-guidelines-warfarin-reversal#:~:text=Prothrombinex%2DVF%20is%20able%20to,similar%20to%20endogenous%20clotting%20factors.

Answer 97

a) turn left lateral UTD: Cardiac herniation is usually seen within three days of surgery, presenting as sudden onset of hypotension and shock, cyanosis, chest pain, and superior vena cava syndrome. The acute event is usually preceded immediately by coughing, moving the patient, vomiting, or extubation. Treatment involves emergent surgery to reposition the heart and close the pericardial defect to prevent recurrence. ?bleeding Rapid filling of the PPS with blood can occur within 24 hours of surgery. This complication is more common after pleuropneumonectomy or pneumonectomy for suppurative lung disease. The clinical presentation may be with hypotension and shock due to the loss of intravascular blood volume. The mainstay of treatment is surgical reexploration and control of bleeding sources.

Answer 98

c) 1000 ml/hr 4ml/kg/hr x 30%TBSA x 100kg = 12,000mL 1/2 within the first 8hrs, remainder over the next 16 hours (starting at 6 hour mark in this stem so beware) 6,000mL/6hrs = 1000 mL/hr which is the rate you would run it over the next 6 hours.

Answer 99

c Haemophilia b

Answer 100

R hand probe should be attached to a preductal location (ie, the right upper extremity, usually the wrist or medial surface of the palm) N.B right foot - post ductal ## Footnote https://www.ahajournals.org/doi/pdf/10.1161/CIRCULATIONAHA.110.971119

Answer 101

B. Diazepam UTD Discontinuation of all serotonergic agents ●Supportive care aimed at normalization of vital signs ●Sedation with benzodiazepines ●Administration of serotonin antagonists ●Assessment of the need to resume use of causative serotonergic agents after resolution of symptoms

Answer 102

60 mmol 1mmol/kg The 8.4% bottles of sodium bicarbonate provide 1 mmol/mL of sodium and bicarbonate

Answer 103

a. Teicoplanin

Answer 104

E) High C-spine fracture Contraindications 1. Oesophageal stricture because of the risk for esophageal perforation 2. Basilar skull fracture or facial fracture due to the potential for intracranial misplacement 3. Avoided in patients with oesophageal varices because tube placement may trigger variceal bleeding 4. Patients with a bleeding diathesis, minimal trauma to the pharynx, esophagus, or stomach from nasogastric tubes can also lead to severe bleeding, and, thus, tubes are avoided whenever possible.

Answer 105

a) 10 Dose of Dantrolene = 2.5mg/kg Repeat every 10 minutes to a Maximum dose of 10mg/kg (Total Vials = 35) Each Vial Dantrolene = 20mg 80 x 2.5mg = 200mg Therefore 10 Vials of 20mg Dantrolene Or, TBW(kg)/8 = number of vials required for initial dose

Answer 106

C https://ranzcog.edu.au/wp-content/uploads/2022/05/Prevention-and-Management-of-Postpartum-Haemorrhage.pdf

Answer 107

D - AB Group AB plasma or group A plasma that is high-titre negative can be given in an emergency when the blood group is unknown. Group AB plasma is universal but in short supply.

Answer 108

b) 20mcg Grade (ANZAAG) 1 - mucocutaneous only (mild) 2 - mucocutaneous and hypotension and/or bronchospasm (moderate) 3 - life threatening hypotension and/or high airway pressure (severe) 4 - arrest For adults, put 3mg into a 50ml syringe (or 6mg into 100mls saline; and running in mls/hr = mcg/min) Doses: - 20mcg = Grade 2 - 100-200mcg = Grade 3 - 1mg = Grade 4 For Paediatrics: - put 1mg into 50ml syringe, (20mcg/ml; run @ 0.3ml/kg/hr = 0.1mcg/kg/min) - 2mcg/kg = Grade 2 (0.1ml/kg of this dilution) - 4-10 mcg/kg = Grade 3 - 10 mcg/kg = Grade 4 (0.1ml/kg of 1:10 000 (i.e. 100mcg/ml concentration)) - IM doses are: > 150mcg if <6 yrs > 300mcg if 6-12yrs;

Answer 109

a) Less transfusion, same thrombosis ●A 2019 meta-analysis of randomized trials comparing preoperative administration of EPO versus placebo (32 trials; 4750 patients, mostly orthopedic and cardiac surgery) found reduced blood transfusions in the EPO groups. Decreased blood transfusions were seen in the entire population (RR 0.59, 95% CI 0.47-0.73; 28 trials), as well as the subgroups undergoing cardiac surgery (RR 0.55, 95% CI 0.47-0.73; nine trials) and major orthopedic surgery (RR 0.36, 95% CI 0.28-0.46; five trials). In addition, the EPO group had increased hemoglobin levels. There was no increase in the incidence of thromboembolic events with EPO.

Answer 110

B. 50J ? In internal defibrillation, an initial dose of 20 joules is recommended to avoid burn-like injury to the myocardium. Care should be taken to avoid coronary vessels to prevent vessel damage. Subsequent doses can be increased to a maximum of 40 joules. Sterile internal pads must be used for internal defibrillation and should be readily available during any thoracotomy procedures Manufacturing manual for internal definition paddles say 50J maximum as higher has been shown to be damaging ## Footnote https://www.ncbi.nlm.nih.gov/books/NBK499899/

Answer 111

Fibrinolysis In APTEM, coagulation is also activated as in EXTEM. By the addition of aprotinin or tranexamic acid in the reagent, fibrinolytic processes are inhibited in vitro. The comparison of EXTEM and APTEM allows for a rapid detection of fibrinolysis. Furthermore, APTEM enables the estimation if an antifibrinolytic therapy alone normalises the coagulation or if additional measures have to be taken (e.g. administration of fibrinogen).

Answer 112

5 mmol bolus KCl 3.6 Potassium Potassium is an electrolyte essential for membrane stability. Low serum potassium, especially in conjunction with digoxin therapy and hypomagnesaemia, may lead to life threatening ventricular arrhythmias. Consider administration for: * Persistent VF due to documented or suspected hypokalaemia. [Class A; Expert consensus opinion] ANZCOR Guideline 11.5 August 2016 Page 9 of 13 Adverse effects: * Inappropriate or excessive use will produce hyperkalaemia with bradycardia, hypotension and possible asystole * Extravasation may lead to tissue necrosis. Dosage: A bolus of 5 mmol of potassium chloride is given intravenously

Answer 113

e) Prothrombinex may potentiate DIC due to increasing thrombotic tendancy Australian redcross

Answer 114

D. perindopril Acute hypotensive transfusion reaction (AHTR) is characterized by the abrupt onset of hypotension immediately after the start of transfusion and usually resolves when transfusion ceases. Recent studies have shown an association with pre-operative treatment with an angiotensin-converting enzyme (ACE) inhibitor https://www.lifeblood.com.au/health-professionals/clinical-practice/adverse-events/hypotension

Answer 115

e. 60g Each 20mg dantrolene contains 3g mannitol

Answer 116

b) 100 Brain trauma foundation Level III recommendation. To decrease mortality and improve outcomes: Maintain SBP at >100mmHg for patients 50 - 69 Maintain SBP at >110 for patients 15 - 49 Maintain SBP at >110 for patients 70 or older

Answer 117

b) 4% albumin - SAFE study (2004) showed increased mortality at 24 months when albumin used as resuscitation fluid cf normal saline. - Also caused higher ICP at 1 week post injury. - 4% albumin (274 mOsm/L & 266 mOsm/kg) is hypotonic and hypoosmolar.

Answer 118

5 days Previous MCQ2015A – cryoprecipitate once thawed must use within 4 hours. Previous MCQ2015B – FFP must be transfused within 4 hours once thawed, or stored at 2-6 degrees for 5 days.

Answer 119

a) Midazolam 0.15mg/kg 1st line: Midazolam IV/IO/IM --> 0.15mg/kg 2nd line: Midazolam IV/IO/IM --> 0.15mg/kg 3rd line: Keppra 40mg/kg (max 3g) 4th line: Phenytoin 20mg/kg or phenobarbitone 5th line: Intubation and deep sedation with midazolam, propofol +/- phenobarbitone

Answer 120

E. Urine output For adults with sepsis or septic shock, we suggest using dynamic measures to guide fluid resuscitation over physical examination or static parameters alone. Weak recommendation, very low-quality evidence. Remarks: Dynamic parameters include response to a passive leg raise or a fluid bolus, using stroke volume (SV), stroke volume variation (SVV), pulse pressure variation (PPV), or echocardiography, where available. https://journals.lww.com/ccmjournal/Fulltext/2021/11000/Surviving_Sepsis_Campaign__International.21.aspx

Answer 121

b) fibrinogen concentrate bleeding and low fib = concentrate not bleding and low = cryo

Answer 122

d) Peak of R wave The appropriate energy level is then selected, and the discharge/shock button is pressed and held. The defibrillator does not release the shock immediately. Instead, it waits for the next R-wave to appear and delivers the shock at the time of the R-wave. This allows the shock to be provided safely away from the T wave, avoiding the R-on-T phenomenon.

Answer 123

c) 30ml/kg After a dose of 10 to 15 mL/kg of FFP, plasma clotting factors rise about 15%, and the fibrinogen level rises by 40 mg/dL (0.4g/l) https://www.sciencedirect.com/topics/medicine-and-dentistry/fresh-frozen-plasma 1g/0.4g= 2.5 2.5 x 10ml/kg= 25ml/kg 2.5 x 15ml/kg= 37.5ml/kg 30ml/kg best answer For cryoprecipitate: One unit of Cryo is 15-20 mL in volume and contains 150-250 mg of fibrinogen. Cryo is generally transfused in pools of 10 units, which should increase an adult recipient's fibrinogen level by 50-100 mg/dL. (0.5-1g/l) 10 units of cryo= 200-300ml 200ml/70kg= 2.8ml/kg 300ml/70kg= 4.2ml/kg

Answer 124

Leave in situ and contact vascular surgeons

Answer 125

a) Open repair Flow chart from Blue book https://jamanetwork.com/journals/jamasurgery/fullarticle/1741862

Answer 126

suxamethonium Organophosphate nerve agent poisoning: https://www.bjanaesthesia.org.uk/article/S0007-0912(19)30401-5/fulltext The depolarising neuromuscular blocking agent suxamethonium: - may have a longer onset (i.e. 2 min) and - duration of action (up to 12 h) secondary to the OP inhibition of BuChE. Caution should be exercised with non-depolarising neuromuscular blocking agents for up to 2 yr and lower doses used to avoid prolonged paralysis. Caution should also be exercised when using other BuChE metabolised drugs such as ester local anaesthetics and mivacurium Mainstay of treatment Pralidoxime and Atropine (5-10mg IV every 5-10mins until reversal of 3 B's) Benzodiazepines used for seizure termination Glycopyrolate not mentioned in treatment but could be useful

Answer 127

a) Amiodarone 150mg over 30minutes, then 1mg/min for 6 hours UP TO DATE: Arrhythmias in COPD For patients with atrial fibrillation and COPD, we suggest using verapamil or diltiazem rather than metoprolol in patients who require ventricular rate control (Grade 2C). Metoprolol is reserved for patients who do not respond to the calcium channel blockers and do not have uncontrolled bronchoconstriction. For those with an accessory pathway or heart failure, amiodarone or digoxin may be preferred as outlined in the table (table 3). Addition of Digoxin in this answer stem could be prefered over Amiodarone

Answer 128

c. Two sets of pads, <1 second apart For DSED, to avoid possible defibrillator damage caused by shocks applied at the same instant, a short delay (<1 second) between shocks was created by having a single paramedic depress the “shock button” on each defibrillator in rapid sequence (anterior–lateral followed by anterior–posterior) Among patients with refractory ventricular fibrillation, survival to hospital discharge occurred more frequently among those who received DSED or VC defibrillation than among those who received standard defibrillation. https://www.nejm.org/doi/full/10.1056/NEJMoa2207304

Answer 129

?? XR Reviews

Answer 130

phaeochromatoma

Answer 131

d) Fetal cells Does not remove foetal red cells or vasoactive molecules (eg don’t use in pheochromocytoma surgery).

Answer 132

B 6 hours 20 x 25 x 4 = 2000 L (Parklands) In first 8 hours 50% 1 L in 8 hours FROM TIME OF BURN So in 6 hours.

Answer 133

a. Reduced Myoglobinaemia Repeat but its not myoglobinuria it was myoglobinaemia - There is NOT reduced myoglobinuria with AIR compared to MH (both have myoglobinuria) - There IS less increase in ETCO2 - There IS less muscle rigidity

Answer 134

Death in bleeding trauma patients Early administration of TXA safely reduced the risk of death in bleeding trauma patients and is highly cost-effective. Treatment beyond 3 hours of injury is unlikely to be effective. - Reduced death due to bleeding x 0.85 - Equivocal blood transfusion - Equivocal thromboembolism

Answer 135

Answer: c. Urgent transfer to theatre BJA Anaesthesia for interventional neuroradiology https://academic.oup.com/bjaed/article/8/3/86/293346 Clinical signs of a rise in ICP or a sudden rise in blood pressure with or without a fall in heart rate should alert the anaesthetist to this possibility. Extravasation of contrast may also be seen. The goals are to increase coagulability by reversing heparin, decrease bleeding by lowering blood pressure (to the level before the bleed), control ICP with hyperventilation, head elevation, steroids and osmotic agents, control seizures, and initiate cerebral protection. Once the bleeding is controlled, the pressure may be raised to check for leaks. Usually, the coiling continues; rarely, a ventriculostomy may be required. If the coiling is unsuccessful, a rescue craniotomy and clipping will be required. Management may also involve performance of CT scans and subsequent transfer to ICU.

Answer 136

b) no limitation in neck movement

Answer 137

C: 120ml/min An observational, prospective study comparing tibial and humeral intraosseous access using the EZ-IO. - humeral flow rates were significantly faster using a pressure bag (153 mL/min) compared with humeral those achieved without pressure bag (84 mL/min) - tibial flow rates to be significantly faster using a pressure bag (165 mL/min) compared with those achieved without a pressure bag (73 mL/min)

Answer 138

c. sinus tachy with prolonged QRS

Answer 139

C. Shockable: Adrenaline 1mg after 2nd shock Then every second cycle Amioderone 300mg after 3 shocks Non-shockable Adrenaline 1mg immediately (then every second cycle)

Answer 140

c) Cryo Cryo or TXA, TXA first line treatment however patient has low fibrinogen and requires fibrinogen replacement.

Answer 141

E3 V3 M4 = GCS 10

Answer 142

Idarucizumab (Praxbind) is a monoclonal antibody to dabigatran Dabigatran bleeding may be treated with: - idarucizumab - haemodialysis -PCC 25-50IU/kg - TXA will decrease fibrinolysis and has some effect - FFP also has some effect Humanized monoclonal antibody fragment (Fab) indicated in patients treated with dabigatran (Pradaxa) when reversal of the anticoagulant effects are needed for emergency surgery or urgent procedures, or in the event of life-threatening or uncontrolled bleeding - very high affinity for dabigatran (300x vs affinity for thrombin) - 5 g IV, provided as 2 separate vials each containing 2.5 g/50 mL (see Administration) - RE-VERSE-AD trial: undetectable levels <20ng/ml within minutes and for 24 hours - Limited data support administration of an additional 5 g depending on clinical situation Dosage Modifications Renal impairment: Renal impairment did not impact the reversal effect of idarucizumab; no dosage adjustment required Hepatic impairment: Dosing Considerations This indication is approved under accelerated approval based on a reduction in unbound dabigatran and normalization of coagulation parameters in healthy volunteers; continued approval for this indication may be contingent upon the results of an ongoing cohort case series study

Answer 143

C- Multifocal Atrial Tachycardia Cardioversion is contraindicated in MAT. Due to the multiple atrial foci, direct current (DC) cardioversion is not effective in restoring normal sinus rhythm and can precipitate more dangerous arrhythmias. - https://emedicine.medscape.com/article/155825-overview#a10 DCCV is indicated for 1. Any haemodynamically unstable narrow or wide QRS complex tachycardia 2. AF <48hrs 3. AF >48hrs with adequate anticoag/TOE to exclude thrombus 4. SVTs and monomorphic TVs not responding to trial of IV medical therapy DCCV is CONTRAindicated in: a. Digitalis toxicity and associated tachycardia b. AF >48hrs without adequate anticoagulation/TOE -BJAEducation 2017 https://academic.oup.com/bjaed/article/17/5/166/2669966

Answer 144

c) 2 minutes

Answer 145

You are inducing anaesthesia in a 20-year-old female through a cannula which was inserted in the right antecubital fossa while she was in the emergency department. After 10 ml of propofol has been injected, she complains of severe pain and it becomes clear that the cannula is intra-arterial. The most appropriate management is https://www.anztadc.net/Publications/Images/ANZCA/Unintended%20Intraarterial%20injection%20WebAIRS%20news%20ANZCA%20Bulletin%20September%202019.pdf

Answer 146

b) 30mcg Moderate = 2mcg/kg Life threatening = 4-10mcg/kg file:///Users/jbjon/Downloads/Australian_and_New_Zealand_Anaesthetic_Allergy_Gro.pdf

Answer 147

b) Stop/stop antibiotics For adults with suspected sepsis or septic shock, we suggest AGAINST using procalcitonin plus clinical evaluation to decide when to start antimicrobials, as compared to clinical evaluation alone. Weak, very low quality of evidence For adults with an initial diagnosis of sepsis or septic shock and adequate source control where optimal duration of therapy is unclear, we suggest using procalcitonin AND clinical evaluation to decide when to discontinue antimicrobials over clinical evaluation alone. Weak, low quality of evidence

Answer 148

a) C1-esterase inhibitor Treatment options: Plasma derived C1-esterase inhibitor = Berinert/Cinryze, Androgens = Danazol B2 Bradykinin Receptor antagonist = Icatibant FFP. Danazol (an androgen) is recommended as first line PROPHYLAXIS for planned procedures (need to give for 5-10 days prior and 2-5 days post) For emergency or high risk procedures C1 esterase inhibitor concentrate (Berinert or Cinryze) is recommended - give 1 hour before procedure - more effective than danazol but more expensive Berinert: - 20units/kg IV over 10 min - Symptoms usually stabilise in 30 mins - 2nd dose uncommon, but may be given 30mins to 2hrs after 1st dose Icatibant: - 30mg slow subcut infusion in abdominal area Due to the risk of precipitating laryngeal oedema, oropharyngeal procedures should usually involve general anaesthesia with endotracheal intubation Short answer: - if you have days before surgery increase danazole, if complex surgery increase danazole and give C1Inh - If you have acute emergency surgery give C1Inh Concentrate (Berinert/Cinryze) before and after - if you have an acute attack use C1Inh or Bradykinin antagonist (Icatibant) - If C1 Inh and Bradykinin antagonoist are not available then use FFP but this may worsen the attack due to the presence of C4 in the FFP - Has Cetirizine been misremembered instead of Cinryze as an option in this question? No it wasn't -> adrenaline, steroids, antihistamines have no role in treatment of HAE acute attack

Answer 149

Most likely answer will be related to hypophosphataemia Refeeding syndrome is a constellation of biochemical abnormalities which occurs when normal intake is resumed after a period of starvation. Its characteristic features are **low levels of phosphate, potassium, magnesium and sodium**. Its major complications include **cardiac arrhythmias, heart failure (due to hypophosphataemia), muscle weakness, rhabdomyolysis, seizures and an altered sensorium.** The major risk factors are calorie malnutrition of any cause, alcohol or drug use, low BMI (18-16) and starvation for 5-10 days. Pathophysiology With the restoration of glucose as a substrate, insulin levels rise and cause cellular uptake of these ions. **Depletion of adenosine triphosphate (ATP) and 2,3-diphosphoglyceric acid (2,3-DPG)** results in **tissue hypoxia** and **failure of cellular energy metabolism.** This may manifest as **cardiac and respiratory failure**, with **paraesthesiae** and **seizures** also reported. Thiamine deficiency may also play a part. - Exogenous sources of phosphate are inadequate to supplement the daily phosphate requirements - Intracellular phosphate stores are used to synthesise ATP (using protein and fat as fuel) - Homeostatic mechanisms maintain serum concentrations of these ions at the expense of intracellular stores Reference: https://derangedphysiology.com/main/required-reading/endocrinology-metabolism-and-nutrition/Chapter%20315/refeeding-syndrome "

Answer 150

****D. 20 mins **The time taken to reduce K+ with insulin/dextrose ranges from ~15-30 mins depending on source ** https://www.uptodate.com/contents/treatment-and-prevention-of-hyperkalemia-in-adults Treatment approach to hyperkalemic emergencies — Patients with a hyperkalemic emergency should receive (table 1): Intravenous calcium and insulin are rapidly acting treatments that provide time for the initiation of therapies that remove the excess potassium from the body. ●Intravenous calcium to antagonize the membrane actions of hyperkalemia ●Intravenous insulin (typically given with intravenous glucose) to drive extracellular potassium into cells ●Therapy to rapidly remove excess potassium from the body (ie, loop or thiazide diuretics if renal function is not severely impaired, a gastrointestinal cation exchanger, and/or dialysis [preferably hemodialysis] if renal function is severely impaired) ●Treatment of reversible causes of hyperkalemia, such as correcting hypovolemia and discontinuing drugs that increase the serum potassium (eg, nonsteroidal anti-inflammatory drugs, inhibitors of the renin-angiotensin-aldosterone system) RCH: http://www.rch.org.au/clinicalguide/guideline_index/Hyperkalaemia/ Insulin/glucose to be given at the same time If severe hyperkalaemia: - Dextrose 10% : 5ml/kg IV bolus (if no hyponatremia) - Insulin short action: 0.1 U/kg IV bolus (Max 10 units) Then followed by infusion insulin/glucose (see below) -If moderate hyperkalaemia: - Dextrose 10% IV at maintenance with 0.9% sodium chloride (normal saline) - Insulin short action infusion : 0.1 U/kg/h IV Note: Close monitoring of glucose every 30-60 minutes Onset of Action: 15 minutes, should reduce intravascular K+, reduction of 0.5-1.5mmol/L Duration: peak 60 minutes, 2-3hours American College of Emergency Physicians: Nebulized albuterol by face mask begins to take measurable effect after 15 to 20 minutes and lowers the serum potassium level by up to 1 mEq/L, depending on the dose. β-Agonists are safe despite the side effect of tachycardia. **Insulin, given intravenously in combination with glucose, also results in a similar fall in the potassium level after 20 to 30 minutes **and also lowers levels by up to 1 mEq/L. The combination of nebulized albuterol and intravenous insulin with glucose appears to be additive, lowering serum potassium by a mean of 1.21 mEq/L or more.11 Adult hyperkalemic patients who have ECG changes should receive continuous nebulized albuterol and 50 grams of intravenous dextrose plus 10 units of intravenous regular insulin. Emergency Medicine Journal J Accid Emerg Med. 2000 May; 17(3): 188–191. The management of hyperkalaemia in the emergency department INSULIN WITH GLUCOSE Insulin binds to specific membrane receptors and via an unknown second messenger, stimulates the sodium-potassium (Na-K) adenosine triphosphatase (ATP) pump resulting in intracellular uptake of K.5 This effect is independent of its hypoglycaemic action. Uraemia attenuates the hypoglycaemic response to insulin but does not affect its hypokalaemic action. Insulin has been the traditional temporising treatment against which newer treatments are compared. It is indicated in every case of hyperkalaemia that needs emergency treatment. Ten units (in adults) soluble insulin is given with 40–60 g glucose intravenously as a bolus. In children, a glucose load of 0.5 g/kg/h (2.5 ml/kg/h) should be given. This is because many of these patients increase their endogenous insulin production with the administration of a glucose load. If the blood glucose rises above 10 mml/l, insulin should be added at 0.05 u/kg/h.24 These studies show that the onset of hypokalaemic action is within 15 minutes and lasts for at least 60 minutes. The reduction in K observed is 0.65–1.0 mmol/l.5, 10 Delayed (30–60 minutes post insulin) hypoglycaemia is common (up to 75% of patients10) if less than 30 g glucose is given. LITFL: Treatment of hyperkalaemia involves stabilizing the myocardium to prevent arrhythmias, shifting potassium back into the intracellular space and removing excess potassium from the body. Drive Potassium into the Cell: Insulin & Glucose - Dose: IV fast acting insulin (actrapid) 10-20 units and glucose/dextrose 50g 25-50ml - Insulin drives potassium into cells and administering glucose prevents hypoglycaemia. - Begins to work in 20-30mins reduces potassium by 1mmol/L and ECG changes within the first hour Ca gluconate - should be part of initial treatment but it does not lower either total body or serum potassium, it acts as a membrane stabiliser LITFL: Correct Serious Conduction Abnormalities (Calcium) - Calcium is a very useful agent. It does not lower the serum potassium level, but instead is used to stabilise the myocardium, as a temporising measure. Calcium is indicated if there is widening of QRS, sine wave pattern (when S and T waves merge together), or in hyperkalaemic cardiac arrest. - The ‘cardiac membrane stabilising effects’ take about 15-30mins. Calcium Chloride - Dose: Calcium Chloride 10% 5-10mL = 6.8 mmol - 3 x more potent than Calcium Gluconate - Complication: severe thrombophlebitis - Calcium Gluconate: - Dose: Calcium Gluconate 10% 5-10mL = 2.2 mmol - Less potent, less irritating to veins - Potential Complications of Calcium administration - Bradycardia, hypotension and peripheral vasodilation - Generally these occur if administered too quickly - Avoid in digoxin toxicity (use magnesium as alternative) - salbutamol Drive Potassium into the Cell: Salbutamol - Dose: 10-20mg via nebulizer - Beta 2 agonist therapy lower K via either IV or nebulizer route. - Salbutamol can lower potassium level 1mmol/L in about 30 minutes, and maintain it for up to 2 hours. - Very effective in renal patients that are fluid overloaded - Drive Potassium into the Cell: Sodium Bicarbonate - Dose: 50- 200mmol of 8.4% Sodium Bicarbonate - Bicarbonate is only effective at driving Potassium intracellullarly if the patient is acidotic - Begins working in 30-60 minutes and continues to work for several hours. Eliminate Potassium From the Body: Calcium Resonium - Dose: 15-45g orally or rectally, mixed with sorbitol or lactulose - Calcium polystyrene sulfonate is a large insoluble molecule that binds potassium in the large intestine, where it is excreted in faeces - Effects take 2-3 hours M&M 2016: An intravenous infusion of glucose and insulin (30–50 g of glucose with 10 units of insulin) is also effective in promoting cellular uptake of potassium and lowering plasma [K+], but may take up to 1 h for peak effect

Answer 151

700ml 50% of blood volume in 3 hours S Blaine. BLAE Paediatric massive transfusion

Answer 152

serum free metanephrines and nor-metanephrines https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3230088/ ## Footnote https://www1.racgp.org.au/ajgp/2021/january-february/adrenal-disease-an-update

Resus, Trauma, Crisis Flashcards

(187 cards)