SINGLE BEST ANSWERS
1. You are an FY1 and are called to see a collapsed 28 yr old man,
previously fit and well (ASA1) with a documented penicillin allergy. He
took Co-amoxiclav orally 30 minutes ago. He has a marked rash, facial
swelling, audible wheeze and stridor. Initial observations: HR 150/min,
RR 40/min and BP 70/35 mm Hg. Oxygen has been administered and
help summoned.
The most appropriate immediate treatment is:
A.
B.
C.
D.
E.
Chlorphenamine 10 mg IM
Hydrocortisone 200 mg IM
Epinephrine (Adrenaline) 50 mcg IV titrated to effect
Epinephrine (Adrenaline) 500 mcg IM
Salbutamol 5 mg nebulised.
Correct Answer: D.
This is life threatening Anaphylaxis in a patient who has a known penicillin
allergy and has been given a penicillin containing drug.
A. and B. These are treatments to be given after initial resuscitation.
C. IM administration of adrenaline is the route of choice for most healthcare
professionals. (IV adrenaline would generally only be used by anaesthetists
that have used it before.)
D. Bronchodilators may be considered as part of management, but not first
line treatment and this patient is not a known asthmatic (ASA1). It is worth
knowing that Adrenaline will also cause bronchodilation.
Ref: “Emergency Treatment of Anaphylactic Reactions”: Resuscitation Council
2008.
ASA grades: American Society of Anesthesiologists’ physical status
classification system.
2. At the end of a laparoscopic cholecystectomy on a 50kg patient (ASA 1)
the general surgeon asks to use a local anaesthetic for wound infiltration
to provide postoperative analgesia. The patient has no known drug
allergies.
An appropriate dose of local anaesthetic would be:
A.
B.
C.
D.
E.
Bupivacaine 0.25% 30mls
Levobupivacaine 0.5% 30mls
Lidocaine 0.5% 40mls
Lidocaine 1% with adrenaline (1 in 200,000) 40mls
Lidocaine 2% 10mls
Correct Answer: A.
All of these dilutions are available, however this patient’s weight is a limiting
factor for local anaesthetic toxicity.
Derivation of this answer relies on the correct use of maths and the knowledge
of maximum recommended doses of commonly used local anaesthetics.
Maximum recommended doses of local anaesthetics are to be found in BNF and
any standard anaesthetic text:





Lidocaine 3mg/kg (plain) and 7mg/kg with adrenaline.
Bupivacaine/Levobupivacaine 2mg/kg.
Adrenaline 4mcg/kg, maximum concentration 1 in 200,000
1ml of a 1% solution contains 10mg/ml
1 in 1000 solution contains 1mg/ml
Further reading: A nomogram for calculating the maximum dose of Local
Anaesthetic. D J Williams, J D Walker. Anaesthesia 2014, 69, 847-853.
3. A patient presents to the emergency department with sudden onset
tachycardia 160/min and a blood pressure of 100/50 mm Hg. There are
no other symptoms. An ECG shows no ischaemic changes, a QRS
complex duration less than 0.12s and a regular R-R interval.
Appropriate pharmacological treatment is:
A. Adenosine 6mg
B. Amiodarone 300mg
D. Digoxin 0.5mg
E. Esmolol 100 mg
F. Verapamil 2.5 mg
Answer: A
Resuscitation council guidelines (2010) for the management of Narrow
Complex Tachycardia in a stable patient recommends Adenosine, if vagal
manoeuvres fail.
Digoxin tries to rhythm control atrial fibrillation. Esmolol is for rate control of
atrial fibrillation. Verapamil or diltiazem can be used for chronic tachycardia
treatment if adenosine works initially.
People often get confused with atropine, adenosine and amiodarone.
 Amiodarone stabilises the myocardium, and therefore it is used in VT or
VF. Remember: M for Myocardium. (Check the shockable arm of the
resuscitation guidelines.)
 Adenosine is used in narrow complex tachycardia, if it doesn’t work, or
if the patient is unstable they need shocking back into a normal rhythm
with DC synchronised cardioversion. Remember: DS for DC
synchronised. (Check the ALS tachycardia algorithm.)
 Atropine is used in bradycardias if the patient is unstable, if there is no
satisfactory response, transcutaneous pacing can be used (other drugs can
be tried too, see the ALS bradycardia algorithm). Remember: TP for
transcutaneous pacing.
4. You are asked to see a previously fit and well 60 year old ASA1 patient
(70kg) on the ward who underwent a laparotomy for small bowel
obstruction 12hrs ago. He has an epidural in situ for postoperative pain,
containing 0.1% levobupivacaine with Fentanyl 2mcg/ml, running at
4ml/hr. His observations are BP 70/40 mmHg, HR 90/min and his urine
output for the previous hour is 10mls. He tells you that he is feeling
unwell.
Initial management should be:
A.
B.
C.
D.
E.
Administer a broad spectrum antibiotic
Administer high flow oxygen
Give 500mls 0.9% NaCl
Perform a 12 lead ECG
Stop the epidural infusion
Answer: B
This patient is hypotensive and his urine output is low. He is in shock, which
could be hypovolaemic, cardiac, septic or distributive (vasodilatation from
epidural). However, the assessment and management should always follow the
ABC approach – ensure an adequate airway, then give high flow oxygen and
assess breathing.
Ref: BTS Emergency Oxygen Guideline Group, Guidelines for emergency
oxygen use in adult patients (2008). British Thoracic Guidelines. Thorax
63(sVI). https://www.brit-thoracic.org.uk/document-library/clinicalinformation/oxygen/emergency-oxygen-use-in-adult-patientsguideline/emergency-oxygen-use-in-adult-patients-guideline/ (This has a flow
chart for use of emergency oxygen.)