Anaesthesia, Autumn Term 2013
Question 1.
1A. You are a physician at an emergency unit. You meet an overweight man who
seems to breathe badly. Which clinical signs would indicate an obstructed airway?
Name three findings on examination which point in this direction. Only your first
three answers will be considered. (1.5p)
Correct answers: wheezing, rattling breathing sounds, gasping for air (agitated
patient), cyanosis, retraction of chest or jugulum, visible foreign body (e.g. teeth),
abdominal breathing, auxiliary breathing movements, freeing the airway results in
improvement.
1B. How do you rapidly get a free airway? Give examples for two adequate measures.
Only your first two answers will be considered. (1p)
Correct answers: chin lift, jaw thrust, insertion of an oropharyngeal airway, nasal
trumpet, recovery position, sniffing position.
Not correct answer: intubation.
Question 2.
A 34-year-old man with known and normally well-controlled diabetes arrives at the
emergency department with a few days’ deterioration of his general condition.
Abdominal pain and vomiting. The patient looks dehydrated. You take a blood gas
which shows pH 7.05, pCO2 3.4, pO2 8.2, BE -17, sodium 128, potassium 2.4,
chloride 82.
Which type of acid-base imbalance prevails? (2p)
Correct answers: Metabolic acidosis (1 p) partly compensated by a compensatory
respiratory alkalosis (1 p). (The low chloride level may be explained by vomiting but
this is not obligatory for full score).
Question 3.
An otherwise healthy 35-year-old woman with a BMI of 33 will undergo an acute
appendectomy. Which type of anaesthesia should you choose? She reports being
afraid of anaesthesia. When you look into her mouth you find a Mallampati score of 3.
How do you secure her airway? For full score, not only the method of anaesthesia is
necessary but also the mentioning of at least three important preparations. (2p)
Correct answer: General anaesthesia with intubation. Rapid Sequence Induction (RSI)
must be mentioned for full score. Preoxygenisation. Suction available. Experienced
person performing intubation. ”Airway trolley” (with a bougie available).
GlideScope®. Fiberscope.
Not correct: Spinal, EDA. Cricoid pressure gives points but may be omitted.
Question 4.
A 54-year-old woman undergoes an explorative laparotomy due to an ileus. You plan
to give her a PCEA (patient-controlled epidural analgesia) for postoperative pain
control. It contains a mixture of bupivacaine (local anaesthetic) and sufentanil
(opioid).
4A. What is the mechanism of action for local anaesthetics? (1p)
Correct: (Reversible) inhibition of nerve impulses through blocking of sodium
channels.
4B. You intend to perform a nerve block by infiltration. Name three symptoms that
may occur in case of accidental (unintentional) intravasal injection of local
anaesthetics. Only your first three answers will be considered. (1.5p)
Correct answer: e.g. periorbital pins and needles, metal taste in the mouth, dizziness,
cramps, loss of consciousness, hypertension, arrhythmia, cardiac arrest, loss of blood
pressure, tinnitus.
Question 5.
A 78-year-old man arrives for hip replacement surgery. He is on medication for
hypertension and has atrial fibrillation and COLD. His medication contains a betablocker (Seloken®), an anticoagulant (Waran®) and drugs for his COLD (Symbicort®
and Spiriva®). You plan for a spinal anaesthesia.
5A. Name three contraindications to consider before puncturing the spinal canal. Only
your first three answers will be considered (1.5p).
Correct answers: coagulation disorders, the patient refuses, skin infection at the
puncture site, sepsis, tight valve stenoses, intracranial hypertension, peripheral nerve
disease.
5B. The patient enquires about the risks of spinal anaesthesia. Name three
complications that may occur in spinal anaesthesia. Only your first three answers will
be considered (1.5p).
Correct answers: post-spinal headache, spinal haemorrhage, epidural haemorrhage,
epidural haematoma, total spinal block, loss of blood pressure, nerve root injury,
meningitis, inadequate analgesia.
5C. When the patient arrives in theatre, his blood pressure is 160/95, his pulse rate is
72 and his saturation is 92 % on air. You perform the spinal anaesthesia as planned.
About a minute later, the patient starts to show symptoms of dizziness, develops cold
sweats and feels nauseous. The blood pressure now is 70/50, his pulse rate 100.
What is the best treatment for this condition and what is the physiological explanatory
mechanism for it? (2p)
Correct answer part 1: administer antihypotensive drugs. Suggestions for
vasoconstrictors: ephedrine, phenylephrine, noradrenaline. Fluids give only 0.5 p
Correct answer part 2: the loss of blood pressure is caused by vasodilatation
False: hypovolaemia (only gives points if specified as relative hypovolaemia),
vasovagal response, toxic reaction.