| September
2000
Anaesthetics / Medical Vivas – (from
Steve Tavakol)
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| Scenario
1: A 7 year old falls from a bicycle at 7.00 pm and sustains a
compound fracture of the skull near the hairline anteriorly
with a 3cm stone embedded in the wound. After transportation
to your hospital by air, she requires surgery at 5.00 am to
repair the wound. Her history is remarkable only for asthma,
for which she takes occasional medication. She appears
tired, wanting to sleep, but is co-operative. The CT scan
shows about half the stone lodged in the fracture and
pushing against the dura.
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Pre op assessment of Asthma
How would you anaesthetise this patient?
Why would you not use STP?
Why would you not use sux?
Post extubation noisy breathing in recovery, nurse calls
you. What would you do?
Differential diagnosis?
How to manage?
You noticed a tooth is missing, How would you manage?
ENT surgeon on his way, transfer the child to OR, she goes
blue, what would you do?
Would you use Heimlech Manoeuvre?
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| Scenario
2: An 85 year old woman is added to the emergency list for a
laparotomy for suspected perforated diverticulum and
peritonitis. She is taking unknown medication for
"heart problems". On examination she is in
considerable pain and is peripherally shut down. Her heart
rate is 90 per minute, in atrial fibrillation with a blood
pressure 105/80 mmHg and she has a 2.6 ejection systolic
murmur over her percordium radiating to both her carotids.
There are no beds available in your intensive care unit.
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How would you resuscitate?
No ICU beds available, would you transfer to another
hospital?
She says to you
she has heart problems
How would you obtain consent in a mentally incompetent
elderly?
What are the CVS changes in elderly?
She is in rapid AF preop (shown ECG), digitalised, slows
down
How do you anaesthetise her? What monitoring?
She goes to rapid AF, hypotensive in recovery
Cardiovert? - Why it may not work?
Tell me about risks of thromboemboli with AF
Causes of unconscious patient postop?
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| Scenario
3: You are called to assist the on-call registrar in intubating
a patient with a neck haematoma following a cervical fusion
earlier in the day. The patient is a 66 year old male, Type
II Diabetic on Metformin and diet, with cervical myelopathy
(Right C5,6) and has had an anterior cervical fusion with
iliac bone graft. He was noted as Grade II on earlier
intubation, however, after preoxygenation, Thiopentone and
Rocuronium, the registrar is now unable to intubate.
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How would you proceed?
You cannot ventilate what would you do next?
Can ventilate with oropharyngeal airway
What are you going to do now?
Bougie keeps slipping back
Saturation dropping, what do you do now?
Cannot ventilate, cannot intubate drill
Describe how do you do cricothyroidotomy?
What partial pressure oxygen do we get brain injury?
PO2 50 corresponds to what saturation?
You have been successful in orally intubating this Patient.
Patient is sent to ICU. Cuff leak in ICU, what do you do?
How do you change the tube?
Shown a blood gas with high anion gap metabolic acidosis,
with high glucose, what are your differential diagnoses?
What is type II diabetes?
How does metformin work?
What does increase BSL, decrease BSL mean?
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| Scenario
4: A 24 year old 80 kg male motor accident victim has been
admitted to the intensive care unit following surgery for
abdominal trauma. His condition is stable, but due to closed
chest injuries he remains intubated and ventilated. You are
asked to review him in 36 hours postoperatively because he
has developed tachycardia and a temperature of 39.0 degrees.
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What are the most likely causes and what is its
significance?
What is SIRS?
How do you manage this?
What antibiotics would you use and why?
Low CVP, tachycardia, decrease urine out put, management.
When would you start inotropes?
Which inotrope? And Why?
Do you know any experimental therapy for SIRS?
Antibiotics? Cultures? Change of CVLs, What type of CVL?
What type of dressing?
Ways to decrease sepsis in ICU.
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| Scenario
5: You are the consultant on call. The registrar phones you on
Saturday at 3.00 pm to say that the recipient for the renal
transplant has arrived. The operation is scheduled to start
at 5.00 pm.
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What information would you like from the registrar?
Any common coexisting problems?
Last dialysed 2 hours ago, how would you optimise the
patient prior to surgery?
Would you transfuse Hb 6.5? What is optimal HT?
How would you give anaesthetics for renal transplant?
What monitoring would you use?
How to optimise prior to graft?
Urine out put is nil after grafting, what would you do?
Would you use inotropes?
How would you manage this patient post op?
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| Scenario
6: You are the Anaesthetist on a retrieval term sent to a
remote farm where a building accident has occurred 8 hours
ago. A 40 year old labourer is trapped under a collapsed
wall. He is prone and is pinned by masonry lying on his
legs. You are unable to access his head. On your arrival the
initial observations are mild confusion, PR 120, BP 100/80
and a respiratory rate of 32/min.
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(Given signs of class III shock) What class of shock is
this?
How would you assess this patient?
What would your management be?
Some one comes with machinery to remove the block, would you
let them to do this?
Surgeon wants to amputate the leg would you let him?
Hyperkalaemia?
What would your role as an anaesthetist be for this
amputation on the field?
How would you provide anaesthesia/analgesia? (no access to
the patient’s airway, but able to communicate and patient
is maintaining his own airway)
Ketamine? Sciatic nerve block? Infiltration with
lignocaine?
Would sciatic nerve block be enough? What approach in prone
patient? (Raj approach), Cannot do femoral nerve block
Patient is transferred to hospital after successful
amputation, two days later comes to OR for amputation of the
other leg, how would you give anaesthesia for this?
O2 sats decrease to 91%, How to differentiate fat embolism
from thromboembolism?
Would you anticoagulate with fat embolism?
You see this patient two months later with painful leg.
CRPII/Phantom limb pain what can you offer this patient?
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| Scenario
7: You are asked to assess a 60 year old man for a possible
laparotomy for a small bowel obstruction. He also has
symptoms of double vision, dysphagia, dysarthria and
generalised muscle weakness. He has a 30 pack year history
of smoking but has not smoked for 2 years.
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What are your differential diagnoses?
What drugs help?
What are important anaesthetic considerations in this
patient?
How would you differentiate Myasthenia Gravis from
Myasthenic Syndrome?
Do EMG, muscle biopsy, how does the neuromuscular junction
look like under the microscope?
What other information would you require prior to the
surgery?
What is the response to sux in Myasthenia Gravis and Eaton
Lambert Syndrome?
What is phase II block?
What type of muscle relaxant would you use? Would you use
Mivacurium?
What monitoring would you use?
What are the Leventhal criteria?
What are the features of Cholinergic and Myasthenic Crises?
And how would you differentiate between the two?
How do you manage post operatively?
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| Scenario
8: A 45 year old patient presents for endometrial resection of
a submucous fibroid. She has had a heavy menstrual blood
loss for several months and complains of increasing
tiredness, exertional dyspnoea, cough and palpitations. She
has a past history of rheumatic fever and has been told she
has a mitral heart murmur. Her only treatment is iron
replacement.
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Blood loss
Anaemia
Mitral stenosis, peripheral signs,
Rheumatic fever
Hypo-osmolar Hyponatraemia
ECG changes with LAH
CXR changes with LAH
AF
synchronised
cardioversion
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| Scenario
9: A healthy 25 year old multiparous woman had an
uncomplicated vaginal delivery three hours ago, but since
then has had vaginal bleeding for which the surgeon now
plans to perform an examination under anaesthesia and
uterine curettage. The student nurse reports the patient has
lost about 500ml of blood since delivery.
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How would you manage?
How would you anaesthetise this patient
Patient refuses spinal, and you give GA, Thio, Sux, RSI.
Hypotensive, tachycardia after intubation, what would you
do?
What are likely causes?
Patient had anaphylaxis, how would you resuscitate?
Patient resuscitated successfully, extubated, post op had
more bleeding, now surgeon wants to do hysterectomy, How
would you anaesthetise this patient now?
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