Download Update 11 - Update in Anaesthesia - WFSA

Update in Anaesthesia 89ANSWERS TO ASSESSMENT SECTION ON PAGE 831. FTTTF2. FTTFFThe murmur is systolic. Blood pressure depends on cardiacoutput and systemic vascular resistance (SVR). In aorticstenosis there is often a reduced cardiac output but highcompensatory vasoconstriction. Depending on the balancebetween the two, there may be normotension, hypotension(as is classically described) or even hypertension.Vasodilation can cause potentially fatal downward spiralof blood pressure, so vasodilating drugs (such ashydralazine) are dangerous. A fixed stroke volume meanscardiac output cannot be maintained at very slow heartrates. By increasing heart rate and systemic vascularresistance, ketamine may prove useful. Voltage criteria forleft ventricular hypertrophy is often seen on the ECGbecause the heart has been pumping against an increasedresistance (or “afterload”).3. TTTTTKussmauls sign is the rise in JVP (jugular venous pulsation)on inspiration, and is associated with impaired heart fillingas occurs in constrictive pericarditis or cardiac tamponade.Normally the neck veins collapse and JVP falls oninsiration.4. TTFTTFluid in the pericardium should be drained beforeanaesthesia as severe hypotension can occur at induction.A fast heart-rate and adequate preload maximize cardiacoutput in cardiac tamponade.5. TTTTFConstrictive pericarditis can be caused by a number ofconditions including TB. The clinical features are essentiallythose of right sided heart failure, including elevated JVP,massive liver enlargement and ascites. Dependent oedemais also usually a feature of right sided heart failure but isoften absent, minimal or much less pronounced than thehepatomegaly and ascites in this particular condition.6. FTTFTRheumatic fever causes a pan-carditis and can causepericarditis which may be heard as a rub or seen on theECG as concave elevated ST segments7. TTTFFBlood urea level reflects three things: i) production (it isproduced by the liver as proteins are broken down). Thuslevels are low in liver failure and high after a gastro-intestinalbleed (effectively a large protein load). ii) clearance fromthe body, which is done by the kidneys. iii) body waterlevels - so simplistically the urea will be raised in dehydrationand diluted or lowered in over-hydration.8. TTTFTPost-primary TB may cause cavitation but the primarycomplex does not.9. FFTTFThe Apgar score includes assessment of 5 parameters witha maximum score of 1010. FFFTTMinimum GCS score is 3. Noting pupil size is crucialin the assessment of head injury, but is not part of theGCS score. A reduced GCS in association with a skullfracture means that there is a significant possibility (about1 in 4) of an intracranial haematoma.11. TFFTTWhen dealing with a head injured patient, you need toconsider the whole patient. If they are at risk of bleedingto death from another injury, then this should be treatedfirst. “Secondary insults” such as hypovolaemia,hypotension and hypoxaemia should be correctedaggressively.12. TTTTTWith fractured base of skull the fracture may be difficultor impossible to see on X-ray but can be diagnosedclinically in the presence of bruising over the mastoid(Battle’s sign), blood behind the tympanic membrane (orat the external auditory meatus)or periorbital bruising(Raccoon/Panda eyes). The fracture of bone alerts us tothe possibility of damage to the underlying brain whichneeds to be assessed clinically by GCS measurement andneurological examination.13. FTTFTIntracranial pressure (ICP) can be reduced with a dose of100ml of 20% mannitol but 1000ml in one dose is toomuch. Frusemide augments the effects of mannitol in