Multiple Choice Questions

Traumatic brain injury: an evidence-based 4. In a patient with a severe traumatic brain injury:
review of management
(a) Intracranial pressure is reduced by hyperventilation to a
1. Immediately after traumatic brain injury: PaCO2 ,4.0 kPa.
(b) Intracranial pressure is reduced by saline 5%.

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(a) A single episode of hypotension (systolic pressure
(c) Intracranial pressure is necessary to calculate cerebral
,90 mm Hg) is associated with a doubling of mortality.
perfusion pressure.
(b) Patients with a deteriorating conscious level, such as a
(d) Monitoring of intracranial pressure is necessary in patients with
reduction in motor score of .2 points, should be intubated
severe traumatic brain injury undergoing non-neurosurgical
before transfer to a neurosurgical unit.
procedures such as fixation of a long bone fracture.
(c) An immediate computed tomography (CT) scan is indicated
(e) Intracranial pressure should be treated if it is persistently in
if the patient’s Glasgow Coma Scale (GCS) score is ,13 on
the range 20 –25 mm Hg.
arrival in the emergency room.
(d) The initial resuscitation process should focus on establishing
a clear airway before treating the brain injury. Preinduction techniques to relieve anxiety in
(e) The GCS is used to assess severity of brain injury before children undergoing general anaesthesia
resuscitation.
5. Increased preoperative anxiety in children is associated with the
2. Appropriate statements regarding anaesthesia for trauma craniot- following postoperative sequelae:
omy include: (a) Emergence delirium.
(a) A modified rapid sequence induction is rarely performed (b) Reduced analgesic requirements.
since it is likely to lead to an increase in intracranial pressure. (c) Altered sleep pattern.
(b) To avoid displacement of the tracheal tube, a tie should be (d) Enuresis.
applied firmly around the patient’s neck. (e) Separation anxiety.
(c) To optimize intraoperative cerebral perfusion, partial pressure 6. To reduce perioperative anxiety, effective pre-induction techni-
of arterial carbon dioxide (PaCO2) should be maintained
ques are likely to include:
between 4.0 and 4.5 kPa.
(d) In patients undergoing trauma craniotomy, total intravenous (a) Preoperative midazolam.
anaesthesia with propofol is associated with lower mortality (b) Routine presence of the parents at induction of anaesthesia.
than either isoflurane or sevoflurane anaesthesia. (c) Inhalational induction rather than intravenous induction of
(e) Neurosurgical intervention is necessary in one-third of general anaesthesia.
patients with moderate or severe traumatic brain injury. (d) Use of video games.
(e) Use of clowns.
3. Appropriate statements concerning patients with traumatic brain
injury in the critical care unit include: 7. Appropriate statements regarding sedative premedication include:

(a) A cerebral perfusion pressure of 70 –90 mm Hg is (a) Midazolam is typically administered orally at a dose of
recommended. 2 mg kg21.
(b) Management algorithms have reduced mortality rates both in (b) The use of midazolam or clonidine results in decreased
intensive care and in hospital. anxiety, increased cooperation and decreased negative behav-
(c) Pharmacological thromboprophylaxis is often avoided within ioural changes.
24 h of injury. (c) Clonidine is an a2 agonist with analgesic as well as sedative
(d) Seizure activity increases the risk of secondary brain injury. properties.
(e) Tight glycaemic control (blood glucose 4.5–6.0 mmol litre21) (d) Antihistamines remain a popular form of pre-medication.
is associated with reduced mortality. (e) The usual dose of intramuscular ketamine is 4–8 mg kg21.

232 doi:10.1093/bjaceaccp/mkt054
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 Multiple Choice Questions

8. Appropriate statements regarding the presence of parents at induc- (c) Mitochondrial failure leads to lactic acidosis and myocyte
tion of general anaesthesia include: necrosis.
(d) Hyperlipidaemia is attributable to mitochondrial failure and
(a) The presence of the parents is superior to preoperative sed-
increased levels of catecholamines.
ation in reducing anxiety and increasing compliance with
(e) Parenteral nutrition may lead to the exacerbation of the
mask induction.
syndrome.
(b) Parents are likely to be satisfied when they are involved
during the induction of anaesthesia.
(c) Children benefit more from their mother’s presence than their Ethico-legal considerations of teaching
father’s presence at induction. 13. In the year 2013, challenges for anaesthetic training of middle-

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(d) Children of calm parents are most likely to benefit from their grade doctors resident in the UK include:
presence.
(e) There is universal consensus that the presence of parents at (a) The 48 h working week compared with a 60 h working week.
induction of anaesthesia is of little benefit. (b) The rising number of elderly patients.
(c) Use of ultrasound during regional anaesthetic block.
(d) Anaesthetic educational goals which remain undefined.
Propofol infusion syndrome
(e) Fibre optic intubation in patients who are awake.
9. The original definition of propofol infusion syndrome coined by
14. Despite potential complications, novice anaesthetists are
Bray in 1998 includes the presence of the following clinical conditions:
allowed to intubate patients under supervision. Appropriate state-
(a) Bradycardia of ,40 beats min21. ments concerning the ethical justification for learning in this situ-
(b) Metabolic acidosis with base excess more negative ation include:
than 210 mmol litre21.
(a) Future generations of patients are likely to benefit from this
(c) Rhabdomyolysis.
training.
(d) C-reactive protein levels .100 mg litre21.
(b) There are likely to be unequivocal benefits to current patients.
(e) White cell count .12  109 litre21.
(c) Doctors are enabling patients to act altruistically.
10. Factors that predispose to propofol infusion syndrome include: (d) With enhanced attention, there is a reduction in immediate
risk of sore throat.
(a) Age ,12 years.
(e) Patients are obliged to participate in reciprocal justice.
(b) Renal failure.
(c) Sepsis.
15. During an all-day theatre session of healthy patients requiring
(d) A propofol infusion rate of .4 mg kg21 h21.
dental extraction, a supervisor teaches fibre optic intubation to a
(e) Lipid infusions, such as total parenteral nutrition.
trainee doctor. Statements referring to appropriate patient consent
11. A 50-year-old patient sedated for head injuries suddenly devel- for this process include:
ops severe metabolic acidosis 2 days after propofol infusion was
(a) The patient considers the risks of this process but agrees
commenced. The management of suspected propofol infusion syn-
voluntarily that training should proceed.
drome ( propofol infusion syndrome) should include:
(b) As an example of heteronomy, the patient gives consent for
(a) Continuing the propofol infusion at a lower dose of training to go ahead.
2 mg kg21 h21. (c) The supervisor informs the patients about what the trainee
(b) Stopping propofol and administering an alternative agent, may be doing and the degree of supervision.
such as midazolam. (d) Patients who give consent are aware that they are placed early
(c) Commencing renal replacement therapy if creatine kinase on the list.
levels are .30 000 units litre21 and the creatinine level is (e) After consent was obtained initially, training proceeds in a
.500 mmol litre21. patient who becomes anxious after further reflection about
(d) Treating bradycardias (heart rate ,40 beats min21) with oral damage.
external pacing.
16. Appropriate statements regarding a theatre session on teaching
(e) Commencing a glucose infusion.
and learning fibre optic intubation in patients having routine dental
12. Appropriate statements regarding the pathophysiology of propo- extraction include:
fol infusion syndrome include:
(a) Supervisors should allow the trainee to decide what he or she
(a) The function of the endoplasmic reticulum is reduced. wishes to learn.
(b) Cardiogenic shock occurs as a result of the b-blocking like (b) Supervisors should inform patients that a doctor-in-training
actions of propofol. will be undertaking part of the procedure.

Continuing Education in Anaesthesia, Critical Care & Pain j Volume 13 Number 6 2013 233
Multiple Choice Questions

(c) Because a trainee doctor is performing the procedure, a court (b) The main myocardial protective property of glyceryl trinitrate
of law is likely to expect that the standard of care will be less is mediated by coronary vasodilatation.
than that provided by an established consultant. (c) Organ-protective strategies focus on maintaining organ blood
(d) Although supervisors take precautions, they are unlikely to flow and perfusion pressure.
prevent the occurrence of harm, such as trauma to the airway. (d) Compared with infrarenal application, cross-clamping of the
(e) As the prime consideration, the anaesthetic should be such aorta in the suprarenal position is associated with a higher
that there is maximization of benefit to future patients. postoperative dialysis rate.
(e) Vasoconstrictors are expected to increase blood pressure without
necessarily improving cardiac output and organ perfusion.
Anaesthesia for elective open abdominal

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aortic aneurysm repair
Unintended awareness and monitoring
17. The risk of abdominal aortic aneurysm rupture is:
of depth of anaesthesia
(a) Directly and linearly related to the aneurysmal diameter.
21. Appropriate statements concerning unintended awareness
(b) Similar in male and female patients with aneurysms of com-
include:
parable diameter.
(c) Similar in smokers and non-smokers in patients with similar (a) Awareness is defined as explicit recall after general anaesthe-
sized aortic aneurysms. sia with pain.
(d) Likely to be lower in diabetic patients than in non-diabetic (b) Up to 50% of patients who experience awareness may not ini-
patients. tially have explicit recall.
(e) Is about 5% annually for aneurysms between 3.0 and 4.5 cm (c) Cases of awareness involve the use of neuromuscular blockers
in diameter. approximately one-third of the time.
(d) Most cases are preventable.
18. Appropriate statements regarding preoperative management in
(e) Long-term psychological harm occurs in up to one-third of
patients with abdominal aortic aneurysm include:
cases.
(a) If tolerated, statins should be administered to all high-risk
22. Patients who report awareness during surgery:
patients.
(b) b-Blockers should be started for patients of both low and high (a) Should be assumed to be fabricating because of the unreliabil-
cardiovascular risk. ity of reporting.
(c) Patients with stable cardiovascular risk factors are likely to (b) Are likely to suffer short-term adverse psychological symptoms.
require coronary arterial catheterization and stress echocardi- (c) Should be offered counselling to reduce the potential for
ography. long-term psychological symptoms.
(d) Patients with stable heart failure should be referred for a car- (d) Are unlikely to experience prolonged psychological harm
diology opinion. provided there is an absence of intraoperative pain.
(e) In the presence of coronary stents placed 12 months previous- (e) May be looking primarily for an apology.
ly, asymptomatic patients may stop taking clopidogrel to
23. Appropriate statements regarding prevention of awareness
reduce the risk of intraoperative bleeding.
include:
19. Appropriate statements regarding the anaesthetic management of
(a) During unexpected light anaesthesia, midazolam should be
open repair for infrarenal abdominal aortic aneurysm include:
administered to prevent retrospective recall.
(a) To reduce metabolic requirements, the patient’s temperature (b) Bispectral index (BIS) values of 40 –60 are unlikely to be
is allowed to decrease to 34.08C. associated with awareness.
(b) A period of postoperative ventilation is likely to be required. (c) A depth-of-anaesthesia monitor is necessary for all total intra-
(c) Invasive pressure monitoring is essential. venous anaesthesia.
(d) Renal protection strategies are likely to prevent acute kidney (d) Educational programmes and audit are expected to reduce the
injury. incidence of awareness by approximately 50%.
(e) Minor haemodynamic changes are likely to occur with aortic (e) Persistent hypertension and tachycardia are likely to signify
cross-clamping and unclamping. inadequate depth of anaesthesia.
20. Appropriate statements regarding organ protection strategies in 24. Appropriate statements regarding depth of anaesthesia monitor-
open abdominal aortic aneurysm repair include: ing include:
(a) Intraoperative urine output is a good indicator of post- (a) Auditory evoked potentials have low signal-to-noise ratio and
operative renal impairment. are detected at amplitudes of 10– 100 mV.

234 Continuing Education in Anaesthesia, Critical Care & Pain j Volume 13 Number 6 2013
 Multiple Choice Questions

(b) The Narcotrend index is a measure of the spontaneous cor- (b) In non-diabetic patients, prevention of hyperglycaemia of
tical EEG. blood sugar below 10 mmol litre21 is of benefit in reducing
(c) BIS monitors are sensitive to the hypnotic effects of xenon the incidence of post-operative cognitive dysfunction.
and ketamine anaesthesia. (c) A 70-yr-old man with a pyrexia of 38.58C, white cell count
(d) In the context of reducing awareness during volatile anaesthe- of 22  109 litre21 and increased greenish sputum production
sia with muscle relaxation, a BIS protocol (40 –60) is superior 1 week post cardiac surgery has a high risk of cognitive
to an end-tidal agent (ETAG) protocol (MAC .0.7). dysfunction.
(e) BIS values can be affected by surgical diathermy and tem- (d) A patient presenting for coronary bypass grafting with a
perature. blood pressure of 200/95 mm Hg is at a higher risk of post-
operative cognitive dysfunction compared with a patient with

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a blood pressure of 125/75.
Postoperative cognitive dysfunction after
(e) Cognitive dysfunction may be attributable to progression of
cardiac surgery
disease in patients with vascular disease.
25. Appropriate statements regarding neuropsychological tests for
postoperative cognitive dysfunction include:
Initial management of acute spinal cord
(a) The letter digit coding test analyses speed of processing of in- injury
formation.
29. Appropriate statements regarding the spinal column, spinal canal
(b) When there is a reduction of .20% from the baseline meas-
and the spinal cord include:
urement in one neuropsychological test, postoperative cogni-
tive dysfunction is diagnosed. (a) Cauda equina syndrome is associated with injuries above
(c) Trail-making tests assess memory. lumbar vertebrae L1–L2.
(d) There is common agreement on what battery of tests should (b) Compared with mid-thoracic fractures, cervical fractures are
be used for diagnosis of postoperative cognitive dysfunction. likely to be associated with cord injury.
(e) The variable incidence of postoperative cognitive dysfunction (c) Spinothalamic tracts carry sensory fibres for pain and tem-
is attributable to the timing of measurements of neuropsycho- perature to the thalamus from the contralateral side of the
logical tests. body.
(d) The anterior complex provides the most support to the
26. Factors associated with postoperative cognitive dysfunction are
system.
likely to include:
(e) The most common site of injury to the vertebral column is at
(a) Age. the mid-thoracic level.
(b) Systemic inflammation and neuroinflammation.
30. Appropriate statements regarding spinal cord injury include:
(c) Macroemboli.
(d) Absence of pre-existing cognitive impairment. (a) Hyperextension is a common mode of injury in children and
(e) A high level of education. young adults.
(b) In the elderly, falls from a height account for a large propor-
27. Methods used to minimize cognitive dysfunction after coronary
tion of injuries.
surgery are likely to include:
(c) In the UK, the second most frequent cause of traumatic spinal
(a) Identification of patients who are at high risk of developing cord injury is violence.
this condition before surgery. (d) Spinal cord injury is four times more likely to occur in males
(b) Avoiding cardiopulmonary bypass during coronary revascu- than in females.
larization. (e) In the UK, there are around 6000 new cord injuries each year.
(c) Ensuring that cerebral oxygen saturation is maintained within
31. Appropriate statements regarding spinal cord damage include:
20% of the preinduction baseline reading.
(d) Long duration of cumulative deep hypnotic time. (a) Injuries above thoracic vertebra T5 may be associated with a
(e) Using the pH-stat method of acid – base balance in adults. decrease in systemic vascular resistance and a secondary in-
crease in inotropy.
28. Appropriate statements regarding cognitive dysfunction after
(b) As neurogenic shock is associated with a compensatory de-
cardiac surgery include:
crease in vagal activity, there is no change in heart rate.
(a) Sevoflurane may offer some protection against cognitive dys- (c) Neurogenic shock manifests itself as the loss of muscle
function. reflexes caudal to the level of injury.

Continuing Education in Anaesthesia, Critical Care & Pain j Volume 13 Number 6 2013 235
Multiple Choice Questions

(d) Paralysis with loss of vibration is attributable to anterior (b) Spinal immobilization is unlikely to be required after a road
spinal artery syndrome. traffic accident involving a fully conscious patient whose only
(e) The neurological level is the most caudal level of normal sen- complaint is abdominal pain.
sation and motor function on either the left side or right side (c) In patients with an acute high spinal cord injury, the
of the body. diaphragm is expected to have a greater inspiratory
excursion in the upright position than in the supine
32. Appropriate statements regarding the management of high spinal
position.
cord injury include:
(d) The incidence of pulmonary embolism is 90%.
(a) Application of cricoid pressure is likely to be avoided during (e) Therapeutic cooling is recommended as it has been shown to
intubation. be beneficial in patients with spinal cord injury.

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236 Continuing Education in Anaesthesia, Critical Care & Pain j Volume 13 Number 6 2013