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The following are sample questions from my Written Board Review
PREP I believe it is the best course in the USA for Written Boards.
The idea of my program is to relentlessly focus upon and "tweak" the
test. This is best done through critical focus upon key words, key
concepts, old Board questions, and remembered Board questions. The
Big Blue book covers the essential information and the course
provides a way to identify strengths and weaknesses through questions
and answers.
The Board is many things but it is not stupid! The questions
themselves are usually not repeated and so it makes little sense to
memorize them. However, the concepts are repeated and therefore
questions are a very useful jumping-off point for answers which
provide the information to answer similiar questions. At the course,
topics are covered systematically, not randomly, as is the case
below. Tests (self-graded) are given and then the answers are
discussed. Obviously, this is a very useful way to identify
weaknesses in one's approach before the exam itself. In addition, it
is a very efficient way to cover a vast amount of territory relevant
to the Written exam. Trust me, it beats a lecture course by miles.
See you at the Course! --Niels F. Jensen, MD, Director
Sample Web Written PREP Test
Choices will be single best or K type
K type review:
A: 1, 2, 3 only
B: 1, 3 only
C: 2, 4 only
D: 4 only
E: All are correct
Index
Question 1
Question 2
Question 3
Question 4
Question 5
Question 6
Question 7
Question 8
Question 9
Question 10
Question 11
Question 12
Question 13
Question 14
Question 15
Question 16
Question 17
Question 18
Question 19
Question 20
1. Single best answer (1992 Remembered)
A 62-year-old male is brought to the ICU s/p CP bypass. Upon entry
to the ICU HR 90, BP 125/75, PADP 12, PAOP 10, and CVP 6.
After 30 minutes, HR is 120, BP 80/30, PADP 25, PAOP 25, and
CVP 8. The most likely reason for the hemodynamic changes is:
(A) Anaphylactic Reaction
(B) Ventricular Ischemia
(C) Pneumothorax
(D) Pulmonary Edema
(E) Septic Shock
B.
1. Ventricular ischemia is apparently leading to decreased
cardiac output and congestive heart failure, as evidenced by
the hypotension, elevated wedge, and elevated pulmonary
artery pressures.
2. Pulmonary edema itself would result from such ischemia but
would not explain (by itself) the hemodynamic changes and
specifically the elevated pulmonary capillary wedge pressure.
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2. K type (1994 Remembered)
A 2500 gm infant, 12 hours old, undergoing repair of an
omphalocele develops tachycardia to 160, decreased blood
pressure to 60/15, difficulty ventilating, and decreased urine
output. Appropriate therapy at this time
(1) increase depth of anesthesia
(2) additional dose of muscle relaxant
(3) give bolus D5 1/2 NS
(4) tell surgeon to forego primary closure
D.
1. Increased abdominal pressure is apparently causing
decreased compliance, decreased venous return, and even
decreased renal perfusion. Primary closure will not be possible
at this time.
2. Let's review this important topic from the Big Blue Book.
3. Omphalocele and gastroschisis (These considerations also
apply to NEC)
a. An omphalocele, herniation of the abdominal viscera into
the base of the umbilical cord, has a sac. It is caused when
the gut fails to return to the abdominal cavity at about the
tenth week of life.
1) The frequency of associated defects with omphalocele is
twice as great as with gastroschisis. We must always
consider the presence of congenital heart defects with both
groups of patients.
b. Gastroschisis is when the abdominal wall eviscerates
through a defect beside (lateral to) the umbilical cord.
There is no membrane covering of intestinal contents. It is
simply an evisceration through the abdominal wall. It is
due to intrauterine disruption of the omphalo-mesenteric
artery. Hypovolemia secondary to large intestinal fluid loss
is generally more severe with gastroschisis than with
omphalocele.
c. Important problems in both of these conditions are:
HAD --hypothermia, acidosis, and dehydration, depression
of respiration and consciousness.
d. What about a CVP in these patients?
1) It is somewhat controversial.
a) Adequate assessment of intravascular volume status
can be made on the basis of intraoperative urine output
and the character of the art line tracing and the
development of hypotension. In addition, the risks of
placement of this monitor are greater in the pediatric
population.
b) Dr. Berry does recommend the placement of a central
line to monitor fluid status in these often critically ill
patients.
e. Induction: These are cases which call for awake intubation
or for rapid sequence intubation with ketamine and sux.
f. Post-op extubation is hazardous because of the increased
intraabdominal pressure after reduction of the hernia.
g. Treat acidosis when pH is less than 7.0.
1) Treat peripheral perfusion. Warm the patient and
make sure perfusion is adequate.
2) dose of bicarbonate: base deficit X body weight in kg
X 0.4 (extracellular fluid as percentage of total body weight)
Pediatrics
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3. single best answer (1995 Remembered)
Hyperkalemia after succinylcholine in acute spinal cord injury is
(A) not clinically significant by EKG changes
(B) unlikely in the first 24 hours
(C) unlikely after 60 days
(D) reliably prevented by pretreatment with a non-depolarizer
(E) unlikely six months post-injury
B.
1. Sux is contraindicated in spinal cord injury patients for about
1 day to 1 year after injury. Sux causes the release of potassium
from the motor end plate membrane and the muscle membrane
in the spinal cord injury patient but not in the normal patient.
Normally the muscle membrane is only electrically sensitive.
In spinal cord injury patients it changes to one which is
chemically sensitive (like the motor end plate) as well. If Sux
causes ventricular fibrillation, treatment should be directed
at ABC's, then DC shock, followed by treatment of the
hyperkalemia.
2. The hyperkalemia caused by succinylcholine administration
is not reliably treated by pretreatment with a nondepolarizer.
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4. single best answer (1993 Remembered)
The treatment for SVT with blood pressure stable at 120/75 is:
(A) adenosine
(B) verapamil
(C) digoxin
(D) lidocaine
(E) synchronized cardioversion
A.
1. Supraventricular arrhythmias
a. Adenosine (6 mg initial, then 12 mg, and another 12 mg) by
rapid IV push followed by a 20 cc IV fluid bolus to ensure
central uptake. The drug can can cause transient standstill.
b. Verapamil is a second line of defense but it can be lethal
in VT.
2. Patients hemodynamically unstable with SVT should, as
you know, be cardioverted.
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5. single best answer (1992 Remembered)
Side effects of magnesium sulfate include all except:
(A) pulmonary edema
(B) neonatal hypotonia
(C) hypokalemia
(D) sensitivity to nondepolarizers
(E) maternal hypotension
C.
1. Hyperkalemia is a known side effect. Hypokalemia is not.
2. Let's review the side effects of magnesium in the context of
the treatment of severe pre-eclampsia. As you know, major
therapy revolves around bedrest and magnesium. If the patient
is seizing, the initial goal is support of oxygenation, ventilation,
and circulation. Control the seizure with thiopental or diazepam.
a. Bedrest
b. MgSO4 (therapeutic range is 4-6 meq/l)
1) Use 20% solution with recommended 4 gram loading dose
over 15 minutes and 1 gm/hr IV
thereafter.)
2) Effects: They are VAST!
a) V: vasodilator (probably on the basis of smooth m. relax.)
b) A: anticonvulsant
c) S: sedative, skeletal muscle relaxant: it decreases the
release of acetylcholine and decreases the sensitivity of
the motor end plate to acetylcholine.
d) T: tocolytic (decreases uterine activity) which
increases uterine blood flow.
3) Side effects
a) prolonged PR interval and wide QRS, muscle weakness
and loss of DTR's, respiratory insufficiency, and cardiac
failure are the classic signs and symptoms. Therapeutic
level is 5 meq/l. First sign is a prolonged PR interval and
widened QRS (5-10 meq/l), muscle weakness and loss of
DTR's (10 meq/l), respiratory paralysis (15 meq/l), and
cardiac \arrest (20 meq/l). The neonate can have decreased
muscle tone after birth and this is manifested by
respiratory depression and apnea. Treatment is CaCl2 by
IV route.
b) Increased sensitivity to depolarizing and
nondepolarizing muscle relaxants certainly occurs. No
fasciculation after sux. If mag has been used do not use
a defasiculating dose of nondepolarizer and decrease
the dose of sux by about one-half.
c) Side effects in the newborn include flaccidity,
respiratory depression, and apnea. The treatment is
calcium.
d) Other side effects include the following:
(U of I Drug Info)
Vasodilatation-Hypotension
Hyperthermia
Hyperkalemia
Hypocalcemia-Hypophosphatemia
Diarrhea
CNS depression
Pulmonary edema: rare; 2 cases reported
c. Hydralazine: Does not decrease uterine blood flow as
SNP does. In fact, it increases both uterine and renal blood
flow. There is an effect in 15-20 minutes which lasts for
2 hours. This should be given if MgSO4 does not work in
controlling the blood pressure. SNP has two potential
serious effects: it decreases uterine blood flow and it crosses
the placenta and increases the risk of fetal toxicity from cyanide.
1) Captopril has been associated with fetal death
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6. single best answer (1993 Remembered)
Meralgia paraesthetica involves:
(A) pain in lateral aspect of thigh
(B) inability to abduct thigh
(C) weakness below the knee
(D) inability to dorsiflex the foot
(E) burning pain in the hip
A.
Lower extremity nerve block
1. The nerve supply to the lower extremity consists of the lumbar
and sacral plexus.
a. The Lumbar Plexus: T12, L1,L2, L3,L4---Femoral, Obturator,
and Lateral Femoral Cutaneous Nerves
b. The Sacral Plexus: L4, L5, S1, S2---Sciatic Nerve
2. Sciatic nerve block
a. This is really a block of the sacral plexus
b. The sciatic nerve leaves the pelvis through the greater
sciatic notch and descends into the popliteal region. In the
popliteal fossa it divides into the tibial and the common
peroneal nerves.
c. The sciatic nerve innervates the hamstrings and all muscles
of the leg and foot.
d. It is sensory to the front (superficial and deep peroneal
nerves), back (posterior tibial nerve) and lateral (sural nerve)
aspect of the ankle. Sensation to the medial aspect of the
ankle is by the saphenous nerve, a branch of the femoral nerve.
3. Femoral nerve block
a. It enters the pelvis and passes under the inguinal ligament.
b. It divides under the inguinal ligament into anterior and
posterior divisions.
c. It is sensory to the anterior and medial thigh and leg.
d. It is sensory to the medial aspect of the ankle as the
saphenous nerve.
4. Lateral Femoral Cutaneous Nerve
a. It is sensory to the anteriolateral aspect of the thigh down
to the knee.
b. Meralgia Paresthetica: Compression of the lateral femoral
cutaneous nerve by the inguinal ligament to produce pain,
numbness, and paresthesias over the anteriolateral aspect
of the thigh.
5. Obturator Nerve
a. It supplies the adductors of the thigh.
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7. K type (1995 Remembered)
Landmarks for a superior laryngeal nerve block include:
(1) angle of the mandble
(2) cricothyroid membrane
(3) sternal notch
(4) greater cornu of the hyoid bone
D.
One could answer E. but then we get into the business of the
whole body being a landmark. I believe they want you to be
more restrictive.
Anatomy of the airway
1. Pharynx (glossopharyngeal (9th) nerve)
a. Hypopharynx: glossopharyngeal (9) and hypoglossal
(12) nerves
2. Larynx (vagus (10th) nerve)
a. Major cartilages of the larynx: There are five.
1) Hyoid
2) Thyroid
3) Cricoid
4) Arytenoid: attached to the cricoid and have attached
to them the VC's.
5) Epiglottic
b. Sensory and motor supply of the larynx and trachea are
branches of the vagus, namely the superior laryngeal nerve
and the recurrent laryngeal nerve.
c. Superior laryngeal nerve: blocked as it passes below the
greater cornu of the hyoid bone. Two main branches:
1) Internal laryngeal branch: It pierces the thyrohyoid
membrane and provides sensation to the area above the
vocal cords (epiglottis to the vocal cords).
2) External laryngeal branch: It provides innervation to
the cricothyroid muscle, a major tensor of the vocal cords.
d. Recurrent laryngeal nerve: It enters the larynx just posterior
to the cricothyroid articulation.
1) It is blocked by a transtracheal approach through the
cricothyroid membrane.
2) It runs in a groove between the trachea and the
esophagus. It can be easily blocked while performing a
stellate ganglion block.
3) The recurrent laryngeal nerve provides sensation
to the area below the vocal cords as well as control over all
of the laryngeal muscles except the cricothyroid.
4) Bilateral bruising is the only injury which can cause
rapid, severe respiratory obstruction.
3. Trachea (vagus (10th) nerve)
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8. K type (1995 Remembered)
A patient presents for transphenoidal resection of a pituitary
tumor for acromegaly. Important anesthetic considerations
include:
(1) narrowed subglottic space
(2) postoperative diabetes insipidus
(3) TMJ involvement
(4) large tongue
E.
A. Hypophysectomy
1. Performed for acromegaly, Cushing's disease, or metastatic
cancer.
2. Most common problem postoperatively is DI, which is a
lack of ADH.
a. Hallmark of DI is a low urine osmolality and a low urine
specific gravity. The osmolality is usually less than
150 mOsm/kg and the S.G. is usually less than 1.005.
b. The urine osmolality is never greater than the serum
osmolality.
3. Treatment is D51/4NS and ADH infusion.
B. Acromegaly:
1. The anterior pituitary secretes several hormones:
luteinizing hormone, follicle stimulating hormone, growth
hormone, thyroid stimulating hormone, ACTH, prolactin, and
melanocyte stimulating hormone.
2. Growth hormone is especially important. Excess growth
hormone before the epiphyses are closed leads to gigantism and
to acromegaly after they have closed. In both, there is
overgrowth of skeletal, soft, and connective tissues.
3. Effects upon the airway are important: the mandible increases
in thickness and length and this can lead to sketal problems,
especially involving the TMJ. The tongue and epiglottis enlarge,
pharyngeal tissue overgrowth leads to soft tissue upper
airway obstruction, and tracheal subglottic diameter is reduced.
4. There are several other considerations of anesthetic
mportance:
a. hypertension
b. increased risk of coronary artery disease
c. increased V/Q mismatching
5. Acromegaly has no effect upon our selection of drugs for the
maintenance of anesthesia but it does influence our approach to
the induction. While there can be ample distance between the
submentum and the hyoid, good mouth opening, good neck range
of motion (an apparently manageable airway). Often our hands
aren't big enough and our grip not strong enough to overcome the
forces leading to airway obstruction. The huge mandible, large
tongue, floppy epiglottis, small glottic opening place
acromegalics at high risk to obstruct with apnea and awake
fiberoptic intubation is most frequently the best approach.
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9. single best answer (1994 Remembered)
A 16 year old female is anesthetized with thiopental and
succinylcholine. Maintenance of anesthesia is with
halothane-oxygen. The patient is spontaneously ventilating.
Which is the most reliable sign of malignant hyperthermia?
(A) tachycardia
(B) hypertension
(C) tachypnea
(D) metabolic alkalosis (severe)
(E) increased ETCO2
E.
1. The classic initial signs of malignant hyperthermia are
tachycardia and tachypnea. These are secondary to sympathetic
stimulation from hypermetabolism and underlying hypercarbia.
2. These signs are, however, rather nonspecific. The
differentials covering each is long. Light anesthesia and pain
are difficult to rule out.
3. The ABG, on the other hand, is more reliable. It
consistently reveals hypercarbia, hypoxia, and both a
respiratory and metabolic acidosis. Hypercarbia is
therefore more specific and reliable.
4. The differential for hypercarbia includes reduced minute
ventilation, increased dead space, and increased production
of carbon dioxide--as in MH.
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10. single best answer (1993 Remembered)
A 55 year old patient undergoes a total hip arthroplasty under
epidural anesthesia. She receives post-operative epidural
analgesia with Duramorph. On post-op day one she develops
weakness of her lower extremities. There are also associated
sensory changes. Appropriate action at this time includes:
(A) reassure the patient and re-evaluate the next morning
(B) pull the catheter
(C) add local anesthetic
(D) obtain magnetic resonance imaging
(E) add fentanyl
D.
1. Neurologic problems of this type must be taken seriously. For
example, the epidural catheter could have migrated and now
be wrapped around a nerve root. Pulling it could worsen the
situation. The best approach would be to obtain an MRI and
diagnose the problem. A neurologist and/or a neurosurgeon would
then guide treatment.
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11. K type (1994 Remembered)
66 year old with aortic regurgitation presents for frontal
craniotomy. Drugs which would best reach hemodynamic
goals include:
(1) pancuronium
(2) sufentanyl
(3) isoflurane
(4) halothane
B.
Aortic Insufficiency: Volume overload of the LV leading to
Angina, CHF, and Ischemia because of decreased aortic
diastolic pressure.
1. The murmur is a decrescendo diastolic murmur.
2. The goals are to achieve small increases in heart rate and
decreases in SVR.
a. A slow heart rate leads to an increased diastolic time and
therefore worsened regurgitation (leading to decreased
diastolic blood pressure and lower coronary perfusion pressure.)
b. An increased SVR also increases the regurgitant fraction.
c. Maintain contractility and volume.
3. The problem here is volume overload of the left ventricle.
4. Sufentanyl and halothane could lead to bradycardia.
Pancuronium would be beneficial from the standpoint of the
moderate tachycardia it causes. Isoflurane would lead to a
small reduction in SVR and increase in HR--both desirable in
aortic regurgitation.
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12. single best answer (1994 Remembered)
What is the maximum amount of leakage current from equiptment:
(A) 10 milli amps
(B) 100 milli amps
(C) 1 amp
(D) 10 amp
(E) 10 micro amps
E.
1.
MACROSHOCK MICROSHOCK
1 mA perception 10 uA rec. max leakage current
10 mA "let go";
>10 sustained
contractions
100 mA V Fib 100 uA V fib
( milliamps ) ( microamps )
2. Recall definitions:
a. Macroshock: The amount of current applied to the outside
of the body.
b. Microshock: The amount of current applied to the inside
of the body.
3. They want you to know some basic numbers. Memorize them!
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13. K type (1994 Remembered)
Cardiovascular effects of pipecuronium include:
(1) small increase in heart rate, minimal change in SVR
(2) minimal change in heart rate, slight increase in SVR
(3) heart rate unchanged, slight decrease in SVR
(4) minimal change in either heart rate or SVR
D.
1. Second generation long-acting nondepolarizers: Doxacurium
and Pipecuronium (These were asked about first on the written
exam in 1993)
a. Doxacurium
1) long-acting bisquaternary ammonium compound
2) does not release histamine, no cardiovascular side-effects
3) similar to pancuronium in elim. half-life and dep. upon
renal clearance
4) may not trigger MH
b. Pipecuronium
1) long-acting steroidal non-depolarizing agent
2) does not release histamine, no cardiovascular side-effects
3) similar to pancuronium in elim. half-life and dep. upon
renal clearance
4) compared to children and adults, potency is increased
and duration is shortened in infants.
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14. single best (1994 Remembered)
Which of the following statements about ketorolac
tromethamine (toradol) is not true?
(A) 10 mg of ketorolac has the analgesic equivalent of 50 mg
meperidine
(B) 10 mg of ketorolac has the analgesic equivalent of 6 mg of
morphine
(C) Ketorolac is a cyclooxygenase inhibitor which has a
half-life of about 3 hours
(D) Bronchospasm is a contraindication to the use of ketorolac
(E) Ketorolac may inhibit platelet aggregation and prolong
bleeding time
C.
We know that ketorolac was on the written in 1993. Here is the
information you need to know.
I. Ketorolac Tromethamine (Toradol) [Information from the
package insert]
1. Ketorolac is a NSAID which has very effective analgesic,
anti-inflammatory, and antipyretic actions.
2. It inhibits the synthesis of prostaglandins (cyclo-oxygenase
inhibition) and is a peripherally acting analgesic. The IM doses
available are 15, 30, and 60 mg. Ten milligrams of Ketorolac is
comparable to 50 mg of meperidine or 6 mg of morphine.
a. Ketorolac causes less drowsiness, nausea, and vomiting than morphine.
b. The half-life of Ketorolac is about 6 hours.
3. Ketorolac is not recommended as a preoperative medication
because it inhibits platelet aggregation and may prolong
bleeding time. Its role in obstetrical anesthesia has not been
adequately studied.
4. Contraindications:
a. Bronchospasm
b. Angioedema
c. Nasal polyps
5. Complications:
a. Gastrointestinal: ulceration, bleeding, perforation
b. Renal: acute renal failure, nephritis
c. Hemorrhage:
d. Hypersensitivity: anaphylaxis, bronchospasm,
angioedema
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15. K type (1995 Remembered)
Landmarks for the sciatic nerve block include:
(1) Posterior superior iliac spine
(2) Iliac crest
(3) Greater trochanter
(4) Ischial tuberosity
B.
(Review anatomy chapter of Big Blue)
Sciatic nerve block
a. The sciatic nerve arises from the sacral plexus
b. The sciatic nerve leaves the pelvis through the greater
sciatic notch and descends into the popliteal region. In the
popliteal fossa it divides into the tibial and the common
peroneal nerves.
c. The sciatic nerve innervates the hamstrings and all muscles
of the leg and foot.
d. It is sensory to the front (superficial and deep peroneal
nerves), back (posterior tibial nerve) and lateral (sural nerve)
aspect of the ankle. Sensation to the medial aspect of the
ankle is by the saphenous nerve, a branch of the femoral nerve.
e. The classic approach is with the patient lying in a lateral
position with the hip and knee flexed. A line should be drawn
between the posterior superior iliac spine and the greater
trochanter. At the midpoint of this line a perpendicular
(bisecting line) line should be drawn 3 cm downward. This is
the target for the block.
f. No significant complications resulting from this block have
been documented.
g. The only surgical procedure which may possibly be done
using the sciatic nerve block as the sole anesthetic would
involve the sole of the foot. If surgery involves the lower
extremity blocking the sciatic nerve is usually combined with
femoral, obturator, or lateral femoral cutaneous nerve blocks.
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16. single best answer (1993 Remembered)
Eight cc's of 2.5% thiopental are injected inadvertantly into an
arterial line. The patient complains of pain but the hand
remains pink. Appropriate steps include:
(A) administer sodium nitroprusside IV
(B) papaverine intra-arterial
(C) administer nitroglycerine IV
(D) perform a stellate ganglion block
(E) reassure the patient and take no action at present
B.
1. Steps in the management of intra-arterial injection of
thiopental: (1993 exam) (Information from package insert
from Abbott)
a. Leave needle in place if possible
b. Inject the artery with dilute papaverine (40-80 mg) or
10 cc of 1% procaine. These steps inhibit smooth muscle
spasm. According to the AMA Drug Evaluation, lidocaine is
also acceptable in place of procaine. (p. 172, 1993)
c. If necessary perform sympathetic block of the brachial
plexus and/or stellate ganglion.
d. Heparinize to prevent thrombus formation.
e. Consider a-adrenergic blockade (phentolamine).
2. At present, with the hand pink, a stellate ganglion block
does not seem indicated.
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17. single best answer (1995 Remembered)
The following are signs of a venous air embolus:
(A) rise in both end tidal carbon dioxide and end tidal nitrogen
(B) fall in end tidal nitrogen and rise in end tidal carbon dioxide
(C) fall in end tidal carbon dioxide with a rise in end tidal
nitrogen
(D) no change in end tidal nitrogen but a fall in end tidal
carbon dioxide
(E) no change in either end tidal nitrogen or end tidal carbon
dioxide
17. C.
A significant venous air embolus is detected by the the mass
spectrometer. End tidal nitrogen rises and end tidal carbon
dioxide falls.
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18. K type (1995 Remembered)
True of the celiac plexus and celiac plexus block:
1. The celiac plexus is formed by the greater and lesser
splanchnic nerves at L3
2. The celiac plexus is located at L1
3. One of the side effects is hypertension
4. When performed with alcohol is one of the most definitive
pain treatments for pancreatic cancer pain
18. C.
Celiac Plexus Block:
1. The plexus is formed from the greater and lesser splanchnic
nerves at L1 vertebral level.
2. Used when malignant tumors are present in the pancreas,
liver, gall bladder, and/or stomach leading to intractable pain.
3. The plexus lies clustered around the celiac artery, lateral
to the aorta.
4. Problems and complications:
a. Hypotension
b. Diarrhea (relative vagal over-activity leads to increased
peristalsis and gut constriction)
5. An alcohol celiac plexus block is the most effective of all
therapeutic endeavors in the treatment of pancreatic cancer pain.
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19. K type (1995 Remembered)
True of trigeminal neuralgia and its treatment
(1) Is actually a neuralgia in the distribution of the occipital
nerve
(2) Is characterized by a dull, aching pain
(3) Injection of steroids is most effective
(4) Treatment is a block of the gasserian ganglion, located in
the middle cranial fossa
19. D.
Trigeminal Neuralgia (tic douloureux) ,
1. Characterized by a sharp pain in the face--roughly in the
distribution of the maxillary branch of trigeminal nerve.
2. The treatment is a Gasserian ganglion block if all branches
of the nerve are involved.
3. The definitive treatment is a neurolytic nerve block, usually
with glycerol.
4. The gasserian ganglion is located in the middle cranial
fossa. It is adjacent to Meckel's Cave, which contains CSF.
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20. K type (1995 Remembered)
A patient with known type 1 von Willebrand's disease presents
for emergency appendectomy. Which of the following could be
used in management:
(1) cryoprecipitate
(2) DDAVP
(3) FFP
(4) factor VIII concentrate-Humate-P (virus deactivated)
20. E.
1. Type 1 von Willebrand's is the mildest of the three forms of
the disease. von Willebrand's disease is characterized by lack
of von Willebrand's factor which leads to a relative lack of
factor VIII as well as a platelet abnormality in that
von Willebrand's factor is necessary to activate platelets.
von Willebrand's factor is a "big brother", protecting factor VIII.
In von Willebrand's disease there is less factor VIII in the
plasma. Factor VIII does not circulate as a free molecule. It is
accompanied by von Willebrand's factor.
2. I spoke to a hematologist about this confusing question.
Basically, the answer is that all "could" be used--depending
upon the circumstances. Cryoprecipitate, DDAVP, and FFP
could all be used in this situation but currently the most favored
product would likely be a purified factor VIII concentrate which
is virus deactivated, e.g. Humate P. The problem is that many
hospitals do not have it. If that is the case, since most type 1
von Willebrand's patients are DDAVP responsive one would
administer DDAVP. Cryo and FFP take time to thaw anyway.
If the patient has a history of poor responsiveness to DDAVP,
however, and virus deactivated, purified concentrate is not
available, cryoprecipitate or FFP (in this order) should be
administered.
3. See Big Blue (Blood and Coag)
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