Short answer questions in anaesthesia : an approach to written (and oral) answers

Cover 1 Half-title 3 Title 5 Copyright 6 Contents 7 Preface 15 Preface to the 1st Edition 17 Abbreviations 19 1. Advice on answering short answer questions 21 The composition of the paper 21 The marking system 22 How the questions are marked 22 Presentation, layout and legibility 23 Some general points 24 At the examination 25 What the words in examination questions mean 27 The outline answers 28 Pharmacology topics 29 Introduction 29 Chemistry 29 Mechanism of action 29 Uses 29 Dose and routes of administration 30 Onset and duration of action 30 Main effects and side effects 30 Pharmacokinetics 30 Miscellaneous 30 Oral questions 31 2. General anaesthesia 33 An adult Jehovah’s witness requires surgery during which significant blood loss is probable. Describe your management. 33 Introduction 33 Religious beliefs 33 Preoperative assessment 33 Operative management 33 Postoperative care 34 Marking points 34 For what reasons should general anaesthesia for elective cases be postponed? 35 Introduction 35 Cardiovascular 35 Respiratory 35 Gastrointestinal 35 Systemic and metabolic 35 Investigations 35 Preoperative preparation 35 Marking points 35 What are the causes and management of hypoventilation immediately following anaesthesia? 36 Introduction 36 Management 36 Marking points 36 What are the problems of anaesthetising patients in the magnetic resonance imaging unit? 37 Introduction 37 Marking points 37 What are the problems of monitoring patients in the magnetic resonance imaging unit? 38 Introduction 38 Marking points 38 How may coagulation be assessed in the perioperative period? 39 Introduction 39 Marking points 39 What causes bradycardia during general anaesthesia? What is its management? 40 Introduction 40 Causes 40 Management 40 Marking points 40 An adult patient develops tachycardia during general anaesthesia. Outline the causes and briefly note your management. 41 Introduction 41 Causes and management 41 Marking points 41 How would you determine the causes of arterial hypotension (80/60 mmHg) during a transurethral prostatectomy (TURP)? 42 Introduction 42 Generic causes 42 Specific causes 42 Marking points 42 What methods are available for the prevention of venous thromboembolism in routine surgical practice? Which patients are at particular risk? 43 Introduction 43 Risk factors 43 Marking points 43 What factors are associated with perioperative myocardial infarction? 44 Introduction 44 Marking points 45 What is the role of the laryngeal mask in difficult intubation? 46 Introduction 46 Unexpected difficult intubation. 46 Anticipated difficult intubation 46 Marking points 46 What problems does morbid obesity present to the anaesthetist? 47 Introduction 47 Marking points 47 Outline the methods for detecting awareness during general anaesthesia and give a brief account of their effectiveness 48 Introduction 48 Marking points 48 What are the causes of awareness under general anaesthesia? 49 Introduction 49 Marking points 49 What do you understand by the ‘stress response’ to surgery? Outline briefly the effects of anaesthesia on this response 50 Introduction 50 Endocrine response 50 Modification of the response by anaesthesia 50 Marking points 51 Describe the diagnosis and management of local anaesthetic toxicity 52 Introduction 52 Causes 52 Clinical features 52 Management 52 Marking points 52 Describe the complications associated with abdominal laparoscopy. 53 Introduction 53 Trauma associated with the instruments 53 Problems associated with gas insufflation 53 Problems associated with position 53 Marking points 53 What signs would lead you to suspect that a patient under general anaesthesia was developing malignant hyperthermia? Describe your immediate management. 54 Introduction 54 Recognition 54 Management 54 Marking points 55 What is the pathophysiology of malignant hyperthermia? How does dantrolene affect the process? How would you investigate a patient in whom the diagnosis is suspected and who presents for non-urgent surgery? 56 Introduction 56 Pathophysiology 56 Dantrolene 56 Investigation preoperatively 56 Marking points 57 What features would lead you to suspect that a patient undergoing surgery had suffered venous air embolism? With what procedures may this complication be associated? 58 Introduction 58 Clinical features 58 Procedures implicated 58 Marking points 58 Outline the diagnosis and management of massive venous air embolism. 59 Introduction 59 Diagnosis is assisted by awareness of high risk procedures 59 Diagnosis 59 Management 59 Marking points 60 Describe the anaesthetic arrangements involved in a gynaecology day-case list of 15 patients. 61 Introduction 61 Preoperative selection 61 On the day of surgery 61 Marking points 61 A patient requiring surgery claims to be allergic to latex. How would you confirm the diagnosis? Outline your perioperative management. 62 Introduction 62 Individuals at risk 62 Perioperative management 62 Marking points 62 What are the causes of heat loss during general anaesthesia? What are the effects of hypothermia in the perioperative period? 63 Introduction 63 Mechanisms of heat loss 63 Effects of hypothermia 63 Marking points 64 What hazards does a patient encounter when they are positioned in the lithotomy position for surgery? What additional hazards are introduced when the operating table is tilted head-down? Describe briefly how these hazards may be minimised. 65 Introduction 65 Lithotomy hazards 65 Hazards associated with head-down (Trendelenburg) position 66 Marking points 66 What factors predispose a patient to aspirate gastric contents into the lungs during general anaesthesia? How can the risk be minimised? How should pulmonary aspiration be treated? 67 Introduction 67 Predisposing factors 67 Prevention 67 Treatment 68 Marking points 68 What factors contribute to postoperative cognitive deficits in elderly surgical patients? How may these risks be minimised? 69 Introduction 69 Preoperative factors 69 Perioperative factors 69 Specific procedures may be associated with increased POCD 69 Marking points 70 What immunological consequences may follow homologous blood transfusion? 71 Introduction 71 Marking points 71 Outline the effects of old age upon morbidity and mortality in anaesthesia 72 Introduction 72 Marking points 73 What are the risks associated with carotid endarterectomy? How may anaesthetic technique reduce these risks? 74 Introduction 74 Risks of the procedure 74 Anaesthetic options: general anaesthesia 74 Anaesthetic options: regional anaesthesia 74 Marking points 75 What is the glucocorticoid response to surgery? Describe your approach to steroid replacement both in patients who are currently receiving corticosteroids and in those who have discontinued treatment. 76 Introduction 76 Steroid response to surgery 76 Rationale underlying perioperative steroid replacement 76 Replacement regimens 77 Marking points 77 What are the implications of anaesthetising a patient in the prone position? 78 Introduction 78 Respiratory effects 78 Airway 78 Circulation 78 Musculoskeletal 78 Pressure effects 78 Marking points 79 A patient presenting for total hip replacement tells you that he has a pacemaker. What further information do you require and how will this influence your anaesthetic management? 80 Introduction 80 Reasons for a permanent pacemaker 80 Pacemaker details 80 Implications for anaesthesia 80 Marking points 81 What factors would alert you to the fact that a patient might be difficult to intubate? 82 Introduction 82 History 82 Mouth opening and oral cavity (oral and pharyngeal plane) 82 Extension of the head at the atlanto-occipital joint (pharyngeal and laryngeal plane) 82 Viewing of the larynx (laryngeal plane) 82 Problems at the laryngeal inlet 82 Predictive tests 82 Radiology 83 Marking points 83 A patient proves impossible to intubate. What factors determine the rate of haemoglobin desaturation? What can be done to maintain oxygenation in this situation? 84 Introduction 84 Basic principles 84 Oxygen reserves 84 Desaturation rate also depends on oxygen consumption 84 Maintenance of oxygenation 84 Marking points 84 What safety features should be incorporated into a patient controlled anaesthesia (PCA) system for adults and what is the purpose of each? Having sent a patient to the ward with PCA what instructions would you give to the nursing staff? 85 Introduction 85 Administration of excessive dose 85 Safety instructions 85 Other monitoring and instructions 86 Marking points 86 You plan to anaesthetise a patient for total hip replacement under subarachnoid block with sedation. What do you understand by the term ‘sedation’ in this context, and what drugs and techniques are available? 87 Introduction 87 Sedation techniques 87 Marking points 88 Outline the causes and the physiological effects of hypercapnia. A patient has a PaCO2 of 12 kPa. How does this affect oxygenation? 89 Introduction 89 Hypoventilation 89 Increased ventilation of dead space 89 Inspired CO2 89 Increase in CO2 89 Physiological consequences: mediated via the sympathetic nervous system 89 Marking points 90 What are appropriate criteria for the selection of adult patients for day-case surgery under general anaesthesia? 91 Introduction 91 General well-being and previous history 91 Surgery 91 Cardiovascular exclusions 91 Respiratory exclusions 91 Central nervous system exclusions 91 Metabolic and endocrine 91 Other systems 91 Medication which should usually preclude day-case surgery 92 Social criteria 92 Marking points 92 An 8-year-old child presents for extraction of four deciduous molar teeth in the dental chair. Describe the anaesthetic management and identify the problems that may be encountered. 93 Introduction 93 Preoperative assessment 93 Anaesthetic technique 93 Potential problems 94 Marking points 94 What are the physiological changes that occur when a patient undergoes electroconvulsive therapy (ECT)? What are the potential complications and in which patients is ECT contraindicated? 95 Introduction 95 Complications: associated with anaesthesia 95 Complications: associated with the (modified) convulsion 95 Contraindications: also predictable in light of the effects described 95 Marking points 96 List the factors which may cause atrial fibrillation. How would you recognise the onset of this rhythm during anaesthesia and how would you treat it? 97 Introduction 97 Causes of atrial fibrillation 97 Recognition intraoperatively 97 Treatment 97 Marking points 98 What are the indications for induced hypotension? What drugs may be used to achieve it? What are the problems with the technique and how can they be minimised? 99 Introduction 99 Indications 99 Drugs used to induce hypotension: singly or in combination 99 Potential problems 100 Marking points 101 What criteria are appropriate for the discharge of patients who have undergone day-case surgery? Why might overnight admission be necessary? 102 Introduction 102 Discharge criteria 102 Social criteria 102 Reasons for overnight admission 102 Marking points 103 What place does preoperative medication (premedication) have in current adult anaesthetic practice? 104 Introduction 104 None 104 Continuation of preoperative therapy 104 Anxiolysis 104 Sedation 104 Analgesia and neuroleptanalgesia 104 Control of secretions 105 Control of gastric pH and volumes 105 Modification of the sympathetic response 105 Marking points 105 An adult patient is known to be very difficult to intubate. Describe a technique of awake fibreoptic intubation. What supplemental nerve blocks may be needed? 106 Introduction 106 Equipment requirements 106 Preparation 106 Intubation 106 ‘Spray as you go’ technique 106 Supplemental nerve blocks 107 Technique 107 Marking points 107 What factors may lead to inadvertent intra-arterial injection of a drug? How would you recognise it? Describe your management of such an event. 108 Introduction 108 Anaesthesia 108 Intensive care 108 Accident and emergency 108 Recognition of intra-arterial injection 108 Management 108 Marking points 109 Describe the complications of tracheal intubation. 110 Introduction 110 Complications associated with the tube 110 Complications associated with the mechanics of insertion (laryngoscopy and adjuncts) 111 Drugs 111 Marking points 111 Describe the anaesthetic management of a patient undergoing elective thyroid surgery. 112 Introduction 112 Preoperative assessment 112 Is there evidence of airway compromise? 112 Intraoperative considerations 112 Postoperative considerations 113 Marking points 113 A 45-year-old woman with type 1 diabetes mellitus which is controlled by insulin requires total abdominal hysterectomy. Describe the anaesthetic management. 114 Introduction 114 Associated complications 114 Anaesthetic management 114 Glycaemic control 114 Marking points 115 What is the anaesthetist’s contribution to safe intraocular surgery under general anaesthesia? 116 Introduction 116 Operative conditions 116 Implications for anaesthetic technique (summary) 117 Marking points 117 3. Anaesthesia and medical disease 119 A patient who has undergone heart transplantation requires non-cardiac surgery. What problems may this present for the anaesthetist? 119 Introduction 119 Natural history of the transplanted heart 119 Physiological changes 119 Drug regimens 120 Marking points 120 What are the anaesthetic implications of dystrophia myotonica? 121 Introduction 121 Anaesthetic implications 121 Marking points 121 What are the anaesthetic considerations in a patient with autonomic neuropathy? 122 Introduction 122 Predisposing causes 122 Diagnosis 122 Anaesthetic considerations 122 Marking points 122 Describe your management of a patient who requires surgical removal of a phaeochromocytoma. 123 Introduction 123 Preoperative management 123 Anaesthetic management 123 Postoperative management 123 Marking points 124 A patient who is HIV seropositive is scheduled for laparotomy. What factors determine the risks of transmission to anaesthetic staff? How may this risk be minimised? 125 Introduction 125 Marking points 125 A 20-year-old patient requires open reduction and fixation of a forearm fracture sustained 12 hours previously. He has sickle cell disease. Describe the anaesthetic management. 126 Introduction 126 Preoperative management 126 Perioperative management 126 Anaesthetic options 126 Marking points 127 A 38-year-old woman requires total abdominal hysterectomy. She has multiple sclerosis. How does this influence your anaesthetic management? 128 Introduction 128 Preoperative assessment 128 Perioperative management 128 Marking points 128 A 75-year-old man with chronic obstructive airways disease requires a transurethral resection of the prostate. Outline the advantages and disadvantages of subarachnoid anaesthesia for this patient. 129 Introduction 129 Marking points 129 A 25-year-old intravenous drug abuser requires surgery for a compound tibial fracture. What problems may this present for the anaesthetist? 130 Introduction 130 Substances used 130 Patient’s affect 130 General health 130 Marking points 131 What features are important in the anaesthetic management of a patient with myasthenia gravis? 132 Introduction 132 Associated disorders 132 Anaesthetic considerations 132 Perioperative management 132 Marking points 133 A patient with hepatic porphyria requires general anaesthesia. Why may this be significant? 134 Introduction 134 Metabolic disorder 134 Symptoms 134 Anaesthetic implications 134 Marking points 135 A patient presenting for elective surgery is found to be anaemic. What are the implications for anaesthetic management? 136 Introduction 136 Causes 136 Management 136 Operative management of the anaemic patient 137 Marking points 137 How would you assess a patient with chronic obstructive pulmonary disease (COPD) who presents for laparotomy? What are the major perioperative risks and how may they be reduced? 138 Introduction 138 Preoperative assessment: history 138 Preoperative assessment: signs 138 Preoperative assessment: investigations 138 Perioperative risks: anaesthesia and surgery 139 Risk reduction 139 Marking points 139 A surgical patient smokes 20–30 cigarettes a day and requires a general anaesthetic. Does this have any significance? 140 Introduction 140 Chronic effects 140 Acute effects 140 Should smokers be encouraged to stop preoperatively? 141 Marking points 141 A patient in chronic renal failure requires a laparotomy. What are the anaesthetic implications? 142 Introduction 142 Implications of chronic renal failure for anaesthesia 142 Influence of anaesthesia on renal function 142 Marking points 143 Outline the anaesthetic implications of managing patients with thyroid disease who require non-thyroid surgery. 144 Introduction 144 Myxoedema 144 Hyperthyroidism 145 Marking points 145 Describe the assessment of a patient with arterial hypertension. Why is it important that it should be treated preoperatively? 146 Introduction 146 Preoperative assessment 146 Importance of preoperative control 146 Marking points 147 A patient has a history of chronic alcohol abuse. What are the anaesthetic implications? 148 Introduction 148 Cardiovascular 148 Central nervous system 148 Gastrointestinal 148 Haematological 148 Hepatic 148 Effects of anaesthetic agents 148 Immune system 148 Respiratory system 149 Metabolic 149 Withdrawal syndrome 149 Marking points 149 4. Medicine and intensive care 151 Describe the diagnosis and management of Guillain–Barré syndrome. 151 Introduction 151 History 151 Examination 151 Investigations 151 Management 151 Prognosis 152 Marking points 152 Outline your management of a patient with status asthmaticus whom you are asked to see in the A&E department. 153 Introduction 153 Assessment 153 Management 153 Marking points 154 What are the indications for tracheostomy in adults? 155 Introduction 155 Indications 155 Marking points 155 Classify each type of heart block and describe the appropriate treatment in the perioperative period. 156 Introduction 156 Sick sinus syndrome (variety of disorders including sinoatrial block) 156 1st degree AV block 156 2nd degree (or partial) AV block 156 3rd degree (or complete) AV block 156 Bundle branch and fascicular blocks 156 Pacemakers 157 Postoperatively 157 Marking points 157 What are the causes of muscle weakness in the intensive care patient? 158 Introduction 158 Potentially treatable causes 158 Non-treatable causes 158 Marking points 158 List the indications for renal support in intensive care patients. What are the principles of haemofiltration? What complications may be associated with the technique? 159 Introduction 159 Indications 159 Principles of haemofiltration (HF) 159 Complications 160 Marking points 160 What factors influence your decision to wean an intensive care patient from mechanical ventilation? 161 Introduction 161 What is required for comfortable spontaneous ventilation? 161 Circulatory adequacy 161 Pre-morbid condition 161 Additional factors 161 Predictive factors 162 Marking points 162 What are the indications for nutritional support in the critically ill? Outline the advantages and disadvantages both of parenteral and of enteral nutrition. 163 Introduction 163 Indications 163 Parenteral nutrition 163 Enteral nutrition 163 Marking points 164 What can be measured directly and what can be derived from pulmonary artery catheters? What is the clinical value of these measurements? 165 Introduction 165 Direct measurements and derived values 165 Clinical situations in which these values are useful 165 Marking points 166 What is the aetiology and pathogenesis of acute lung injury (adult respiratory distress syndrome)? How is it diagnosed? Outline its management. 167 Introduction 167 Aetiology and pathogenesis 167 Diagnosis 167 Management 167 Marking points 168 What factors determine oxygen delivery? How might you optimise this prior to major surgery? 169 Introduction 169 Oxygen delivery 169 Cardiac output 169 Oxygen saturation 169 Haemoglobin concentration 169 Dissolved oxygen 169 Optimisation 170 Marking points 170 Under what circumstances does oxygen have adverse effects? What are the symptoms of toxicity? Outline the underlying mechanisms. 171 Introduction 171 Adverse effects at atmospheric pressure 171 Toxic effects under hyperbaric conditions 171 Symptoms 171 Mechanism of toxicity 172 Marking points 172 What are the indications for cricothyroidotomy and for percutaneous tracheostomy? Describe a technique for performing these procedures with reference to the anatomy involved. List the main complications. 173 Introduction 173 Cricothyroidotomy 173 Percutaneous tracheostomy 173 Complications 174 Marking points 174 5. Obstetric anaesthesia and analgesia 175 A woman complains of persistent headache following a regional anaesthetic for obstetric delivery. What are the distinguishing clinical features of the likely causes? 175 Introduction 175 Marking points 176 What are the anaesthetic options for manual removal of retained placenta? 177 Introduction 177 Risks of the procedure 177 Surgical requirements 177 Anaesthetic options 177 Marking points 177 A fit primigravida suffers inadvertent dural puncture with a 16G Tuohy needle during attempted epidural insertion for analgesia in the first stage of labour (cervix 4 cm dilated). What is your management? 178 Introduction 178 Marking points 178 A fit multigravida complains of a typical postdural puncture headache 24 hours after inadvertent dural puncture with a 16G Tuohy needle during attempted epidural insertion for analgesia. What is your management? 179 Introduction 179 Marking points 179 What are the advantages of retaining motor power in a woman having an epidural for normal labour? How can this be achieved? What checks should be made before allowing the woman to get out of bed? 180 Introduction 180 Advantages 180 Methods of retaining motor power 180 Checks prior to ambulation 180 Marking points 180 A fit primigravida is undergoing elective caesarean section for breech presentation under subarachnoid anaesthesia and suffers amniotic fluid embolism. What is the pathophysiology? How may it present and what is the differential diagnosis? 181 Introduction 181 Predisposing factors 181 Pathophysiology 181 Clinical presentation 181 Differential diagnosis 182 Marking points 182 What is the aetiology of pre-eclampsia? List the clinical features of severe pre-eclampsia and outline the relevance of the condition for anaesthesia. 183 Introduction 183 Clinical features of severe pre-eclampsia 183 Anaesthetic implications 183 Marking points 184 You have sited a lumbar epidural catheter for pain relief in the first stage of labour but the midwife tells you that it is ineffective. Why might it have failed and what is your management? 185 Introduction 185 Marking points 186 What clinical features would alert you to the fact that a woman undergoing caesarean section under subarachnoid anaesthesia was developing a high block? Describe your management. 187 Introduction 187 Clinical features 187 Management: depends on rapidity of onset and height of spread 187 Marking points 188 A woman undergoing caesarean section under subarachnoid anaesthesia complains of pain. Describe your management. How may this situation be prevented? 189 Introduction 189 Assessment 189 Timing 189 Prevention 190 Marking points 190 What are the pathophysiological and clinical features of HELLP syndrome? What are the diagnostic laboratory findings and the priorities in management? 191 Introduction 191 Pathophysiology 191 Clinical features 191 Diagnostic laboratory findings: consistent with the acronym 191 Management priorities 191 Marking points 192 Describe the anaesthetic management of major intrapartum haemorrhage requiring emergency operation. 193 Introduction 193 Assessment 193 Resuscitation phase 193 Anaesthetic phase 193 Marking points 194 Describe the management of emergency caesarean section for cord prolapse in a fit 21-year-old primagravida. 195 Introduction 195 Marking points 196 6. Paediatric Anaesthesia 197 How does the physiology of an infant aged 6 months differ from that of an adult? 197 Introduction 197 Surface area to mass ratio 197 Cardiovascular 197 Respiratory 197 Renal 198 Marking points 198 What are the anatomical differences of relevance to the anaesthetist between an infant aged 6 months and an adult? 199 Introduction 199 Surface area to mass ratio 199 Airway 199 Cardiovascular system 199 Nervous system 199 Marking points 199 Describe the anaesthetic management for a 5-year-old patient who requires re-operation for haemorrhage an hour after tonsillectomy. 200 Introduction 200 Main problems 200 Management 200 Marking points 201 A 6-week-old child presents for pyloromyotomy (for pyloric stenosis). Describe the management of this case. 202 Introduction 202 Preoperative management 202 Anaesthetic management 202 Marking points 202 What are the problems associated with anaesthetising patients with Down syndrome? 203 Introduction 203 Central nervous system 203 Cardiovascular system 203 Drugs 203 Respiratory system and airway 203 Immune system 203 Marking points 203 Describe your procedure for cardiac life support of a child aged 5 years. 204 Introduction 204 Weight and endotracheal tube (ETT) size 204 Marking points 205 You are called to A&E to see a 3-year-old child with stridor: what are the principal differential diagnoses? 206 Introduction 206 Marking points 206 A 3-year-old child presents to A&E with a presumptive diagnosis of acute epiglottitis. List the differential diagnoses. How would you manage this condition? 207 Introduction 207 Differential diagnosis 207 Management 207 Marking points 208 A 10-year-old boy is brought into A&E unconscious, having been found at the bottom of an outdoor swimming pool. His rectal temperature is 30°C and his heart rate is 25 bpm. Describe your management. 209 Introduction 209 Primary survey 209 Airway 209 Breathing 209 Circulation 209 Treatment of hypothermia 209 Poor prognostic features 209 Marking points 210 A 5-year-old girl is brought into A&E, having been rescued from a house fire. An estimated 20% of her body surface area has been affected and she has burns to face, neck and torso. Describe your management. 211 Introduction 211 Primary survey 211 Airway 211 Breathing 211 Circulation 211 Assessment of burn 211 Other management 212 Marking points 212 A 2-year-old child is believed to have inhaled a foreign body 2 days ago, although there are no signs of upper airway obstruction. The child requires bronchoscopy: outline your anaesthetic management. 213 Introduction 213 Preoperative assessment 213 Premedication 213 Anaesthetic technique 213 Postoperative care 214 Marking points 214 What are the choices for postoperative analgesia for a child aged 4 years presenting for repair of inguinal hernia as a day case? State briefly the advantages and disadvantages of each method. 215 Introduction 215 Options for pain control 215 Marking points 215 Outline the circulatory changes that take place at birth. What problems may congenital heart disease present to the anaesthetist? 216 Introduction 216 Circulatory changes at birth 216 Cyanotic congenital heart disease 216 Acyanotic congenital heart disease 216 Marking points 217 An 8-week-old male infant weighing 3.0 kg is scheduled for inguinal hernia repair. He was delivered prematurely at 34 weeks. List the risk factors and state how these can be minimised. 218 Introduction 218 Potential problems 218 Marking points 219 How does the common cold influence fitness for anaesthesia in children? 220 Introduction 220 Pathophysiology of coryza 220 Risks of anaesthesia and surgery 220 Practical considerations 220 Marking points 221 7. Neuroanaesthesia 223 What are the causes of raised intracranial pressure? Describe the clinical features and explain the underlying pathophysiological mechanisms. 223 Introduction 223 Causes 223 Clinical features 223 Pathophysiology 224 Specific clinical signs 224 Marking points 224 A young adult requires intramedullary nailing of a femoral fracture 18 hours after an accident in which he was knocked unconscious. What are the anaesthetic options in this case? 225 Introduction 225 Anaesthetic options 225 Marking points 225 A young adult is admitted with an acute head injury. What are the indications for tracheal intubation, ventilation and transfer to a neurosurgical unit? 226 Introduction 226 Assessment 226 Criteria for intubation and ventilation 226 Marking points 227 How would you manage the transfer of a patient to a regional neurosurgical unit for evacuation of an extradural haematoma? 228 Introduction 228 Marking points 229 A patient is admitted to ITU with a severe closed head injury. There is no focal lesion requiring neurosurgical intervention. What principles govern your management during the first 24 hours? 230 Introduction 230 Management 230 Marking points 230 What are the pathophysiological insults which exacerbate the primary brain injury following head trauma? How can these effects be minimised? 231 Introduction 231 Marking points 231 What particular problems may occur during lower abdominal surgery in a patient who suffered a traumatic transection of the spinal cord at the level of C6 four weeks previously? How would you prevent them? 232 Introduction 232 Airway 232 Breathing 232 Circulation 232 Autonomic hyperreflexia 232 Marking points 233 Describe how cerebral blood flow is regulated. How may it be influenced by general anaesthesia? 234 Introduction 234 Regulation 234 Anaesthetic factors 234 Marking points 234 8. Acute and Chronic Pain 235 What methods of pain relief are available following abdominal hysterectomy? 235 Introduction 235 Analgesia options 235 Marking points 236 What is meant by ‘neuropathic’ pain? What symptoms does it produce? Outline with brief exam