APEX MOCK EXAM 1/90 Complete Q’s and
A’s
Match each West zone of the lung with its corresponding pressures:
Zone 1
Zone 2
Zone 3
Zone 4 - -Zone 1: P alveolar> P arterial> P venous> P interstitial (dead
space)
Zone 2: P arterial> P alveolar> P venous> P interstitial (matched V/Q)
Zone 3: P arterial> P venous> P Alveolar> P interstitial (shunt)
Zone 4: P arterial> P interstitial> P venous> P alveolar (increase pressure in
the interstitium-pulm edema)
- Which interventions are MOST appropriate in the "cant ventilate can't
intubate" scenario? Select 2
Percutaneous transtracheal jet ventilation
Tracheostomy
Surgical cricothyrotomy
Retrograde intubation - -Percutaneous transtracheal jet ventilation
Surgical cricothyrotomy
Surgical cricothyrotomy and transtracheal jet ventilation can reestablish
ventilation very quickly, and are appropriate options in the cant Ventilate
can't intubate scenario.
Retrograde intubation is best used one ventilation as possible. It takes 5 to 7
minutes to complete in the hands of an experience practitioner. This is often
performed for the patient with a suspected or known difficult airway in a
controlled setting before the induction of Anesthesia. It is also useful in the
patient with an unstable cervical spine.
- At what point during laparoscopic cholecystectomy is a gas embolism most
likely to occur?
A. Initial abdominal insufflation.
B. During the cholangiogram
C. The risk is the same throughout the procedure.
D. Dissection of gallbladder from the liver bed. - -A. Initial abdominal
insufflation.
There is a risk of air embolism if a trocar is inadvertently placed into a blood
vessel, or any time when intravascular pressure falls below intraabdominal
pressure.
Gas embolism creates an airlock in the right heart, and thus obstructs
forward flow.
,Signs and symptoms include : decreased EtCO2, increased EtN, increased
PAP, pulmonary edema, decreased blood pressure, hypoxia, dysrhythmias,
cyanosis, and a mill wheel murmur.
TEE is the most sensitive indicator of gas embolism.
The risk of gas embolism is greatest during initial insufflation of the
abdomen, especially those with previous abdominal surgery .
- Which finding places a child at the GREATEST risk for laryngospasm?
A. Upper respiratory infection.
B. Upper airway surgery.
C. Exposure to secondhand tobacco smoke.
D. Gastro esophageal reflux. - -A. Upper respiratory infection.
Noxious stimulation of the internal branch of the superior, laryngeal, nerve
and precipitate laryngospasm. This complication can lead to complete airway
obstruction negative pressure pulmonary edema, aspiration of gastric
contents, cardiac arrest, and death.
The risk of laryngospasm is greatest in the child with an upper respiratory
infection 9.6/100
The Distractors were the other risk factors for laryngospasm:
-Preoperative risk factors include exposure to secondhand smoke and GERD.
-Intra-operative risk factors include upper airway surgery, mechanical irritant
(secretions), airway manipulation during light planes of anesthesia, and the
excitement phase during an inhalation induction.
- Which lung volume increases as a function of aging? - -Aging is associated
with the loss of lung elastic recoil. Said another way, There is an increased
lung compliance. Lung elastic recoil is integral to the maintenance of airway
diameter. Loss of this property causes a small airways to collapse
prematurely. This causes gas trapping, and gas trapping increases RESIDUAL
VOLUME.
- A Morbidly obese patient is undergoing removal of an infected hip
hardware under general anesthesia. Midway through the procedure you
observe the following vital signs. What is the MOST likely diagnosis?
Increased HR
hypotension
Increased CVP
Drop in ETCO2
Drop in O2 sats
PIP increased
A. PE
B. Exsanguination.
C. Myocardial infarction
D. Congestive heart failure. - -A. PE
,pulmonary embolism creates a mechanical obstruction in the pulmonary
circulation. If the embolism is of sufficient size, it significantly increases dead
space ventilation and pulmonary vascular resistance. A Precipitous fall in
EtCO2 and tachycardia are usually the first signs of PE. Dead space
ventilation, contributes to arterial hypoxemia. Cardiac filling pressures may
increase as a result of increased PVR. Hypotension may occur &
bronchospasm may increase peak inspiratory pressure.
Immediate treatment consists of 100% FiO2 and hemodynamic support with
fluids and inotropes. If symptoms do not resolve, pulmonary embolectomy or
thrombolysis in the non-surgical patient should be considered.
MI, CHF and exsanguination can cause some, but not all, of the physiological
changes in the question so these weren't the best options.
- All of the following are contraindications to retrograde tracheal intubation,
EXCEPT:
A. Neck flexion deformity.
B. Cervical spine injury.
C. Goiter.
D. Coagulopathy. - -B. Cervical spine injury
Retrograde intubation involves puncturing the cricothyroid membrane in
passing a wire through the vocal cords and out of the mouth. Next, an
endotracheal tube is loaded over the wire and advanced into the trachea.
Most of the reported cases of retrograde intubation described its use in
patients with cervical spine injuries.
Neck flexion deformity can make this procedure challenging, if not
impossible.
a goiter may prevent you from accurately identifying the cricothyroid
membrane. Coagulopathy increases the risk of bleeding into the airway
following needle puncture.
- In the patient with chronic bronchitis which preoperative interventions
MOST reliably reduce the incidence of post operative, pulmonary
complications?
A. Smoking cessation for 8 weeks.
B. Prophylactic doxycycline.
C. Instruction in postop pulmonary toilet techniques.
D. Adequate hydration. - -A. Smoking cessation for 8 weeks
Smoking cessation is the most reliable method to reduce postoperative
Pulmonary complications. A patient who has not had a cigarette for at 8
eight weeks has the same level of baseline perioperative pulmonary risk as a
patient who does not smoke.
Prophylactic antibiotics to sterilize the sputum are not indicated and may
actually encourage secondary infection. Antibiotics are reserved for patients
with purulent sputum, and or pulmonary infiltrates.
, Instruction in postop pulmonary toileting, techniques, and adequate
hydration are additional therapies to decrease the risk of postop pulmonary
complications .
- When providing Anesthesia to a patient undergoing video assisted
thoracoscopic surgery for removal of bullae:
A. Jet ventilation should be avoided.
B. A bronchial blocker is preferred to a double lumen endotracheal tube.
C. 50% nitrous oxide is an acceptable technique.
D. A small tidal volume with high respiratory rate is preferred. - -D. A small
tidal volume with high respiratory rate is preferred.
Bullae are large air-filled spaces in the lungs that result from damage to
normal alveolar tissue. Rupture can lead to pneumothorax tension,
pneumothorax and/or cardiovascular collapse. To reduce the risk of rupture
the patient should be allowed to spontaneously gonna lay until the chest is
opened. positive pressure, increases tension and may result in rupture. To
minimize into alveolar pressures (ideally below 20cmH2O) a small tidal
volume with high respiratory rate is recommended. High frequency
generation is an acceptable alternative to positive pressure ventilation.
Nitrous oxide will expand the bullae and may rupture it.
A double lumen endotracheal tube is the airway of choice as the ability to
ventilate each lung separately is vital.
- A unilateral vagus nerve injury during a radical neck dissection will MOST
likely present with:
A. Aphonia
B. Stridor
C. Hoarseness.
D. No clinically relevant sign of injury. - -C. Hoarseness
What happens if the vagus nerve is injured?
Vagus
Unilateral: hoarseness
Bilateral: aphonia
External branch of the SLN :
Unilateral : minimal effects
Bilateral : hoarseness, easily fatigued voice
Internal branch of the SLN :
No effect since this nerve is sensory only
Recurrent laryngeal nerve :
Unilateral : hoarseness
Bilateral : stridor, dyspnea (acute injury), aphonia (chronic injury)
- Which size LMA classic is the most appropriate for a patient that weighs
12kg? - -2
A’s
Match each West zone of the lung with its corresponding pressures:
Zone 1
Zone 2
Zone 3
Zone 4 - -Zone 1: P alveolar> P arterial> P venous> P interstitial (dead
space)
Zone 2: P arterial> P alveolar> P venous> P interstitial (matched V/Q)
Zone 3: P arterial> P venous> P Alveolar> P interstitial (shunt)
Zone 4: P arterial> P interstitial> P venous> P alveolar (increase pressure in
the interstitium-pulm edema)
- Which interventions are MOST appropriate in the "cant ventilate can't
intubate" scenario? Select 2
Percutaneous transtracheal jet ventilation
Tracheostomy
Surgical cricothyrotomy
Retrograde intubation - -Percutaneous transtracheal jet ventilation
Surgical cricothyrotomy
Surgical cricothyrotomy and transtracheal jet ventilation can reestablish
ventilation very quickly, and are appropriate options in the cant Ventilate
can't intubate scenario.
Retrograde intubation is best used one ventilation as possible. It takes 5 to 7
minutes to complete in the hands of an experience practitioner. This is often
performed for the patient with a suspected or known difficult airway in a
controlled setting before the induction of Anesthesia. It is also useful in the
patient with an unstable cervical spine.
- At what point during laparoscopic cholecystectomy is a gas embolism most
likely to occur?
A. Initial abdominal insufflation.
B. During the cholangiogram
C. The risk is the same throughout the procedure.
D. Dissection of gallbladder from the liver bed. - -A. Initial abdominal
insufflation.
There is a risk of air embolism if a trocar is inadvertently placed into a blood
vessel, or any time when intravascular pressure falls below intraabdominal
pressure.
Gas embolism creates an airlock in the right heart, and thus obstructs
forward flow.
,Signs and symptoms include : decreased EtCO2, increased EtN, increased
PAP, pulmonary edema, decreased blood pressure, hypoxia, dysrhythmias,
cyanosis, and a mill wheel murmur.
TEE is the most sensitive indicator of gas embolism.
The risk of gas embolism is greatest during initial insufflation of the
abdomen, especially those with previous abdominal surgery .
- Which finding places a child at the GREATEST risk for laryngospasm?
A. Upper respiratory infection.
B. Upper airway surgery.
C. Exposure to secondhand tobacco smoke.
D. Gastro esophageal reflux. - -A. Upper respiratory infection.
Noxious stimulation of the internal branch of the superior, laryngeal, nerve
and precipitate laryngospasm. This complication can lead to complete airway
obstruction negative pressure pulmonary edema, aspiration of gastric
contents, cardiac arrest, and death.
The risk of laryngospasm is greatest in the child with an upper respiratory
infection 9.6/100
The Distractors were the other risk factors for laryngospasm:
-Preoperative risk factors include exposure to secondhand smoke and GERD.
-Intra-operative risk factors include upper airway surgery, mechanical irritant
(secretions), airway manipulation during light planes of anesthesia, and the
excitement phase during an inhalation induction.
- Which lung volume increases as a function of aging? - -Aging is associated
with the loss of lung elastic recoil. Said another way, There is an increased
lung compliance. Lung elastic recoil is integral to the maintenance of airway
diameter. Loss of this property causes a small airways to collapse
prematurely. This causes gas trapping, and gas trapping increases RESIDUAL
VOLUME.
- A Morbidly obese patient is undergoing removal of an infected hip
hardware under general anesthesia. Midway through the procedure you
observe the following vital signs. What is the MOST likely diagnosis?
Increased HR
hypotension
Increased CVP
Drop in ETCO2
Drop in O2 sats
PIP increased
A. PE
B. Exsanguination.
C. Myocardial infarction
D. Congestive heart failure. - -A. PE
,pulmonary embolism creates a mechanical obstruction in the pulmonary
circulation. If the embolism is of sufficient size, it significantly increases dead
space ventilation and pulmonary vascular resistance. A Precipitous fall in
EtCO2 and tachycardia are usually the first signs of PE. Dead space
ventilation, contributes to arterial hypoxemia. Cardiac filling pressures may
increase as a result of increased PVR. Hypotension may occur &
bronchospasm may increase peak inspiratory pressure.
Immediate treatment consists of 100% FiO2 and hemodynamic support with
fluids and inotropes. If symptoms do not resolve, pulmonary embolectomy or
thrombolysis in the non-surgical patient should be considered.
MI, CHF and exsanguination can cause some, but not all, of the physiological
changes in the question so these weren't the best options.
- All of the following are contraindications to retrograde tracheal intubation,
EXCEPT:
A. Neck flexion deformity.
B. Cervical spine injury.
C. Goiter.
D. Coagulopathy. - -B. Cervical spine injury
Retrograde intubation involves puncturing the cricothyroid membrane in
passing a wire through the vocal cords and out of the mouth. Next, an
endotracheal tube is loaded over the wire and advanced into the trachea.
Most of the reported cases of retrograde intubation described its use in
patients with cervical spine injuries.
Neck flexion deformity can make this procedure challenging, if not
impossible.
a goiter may prevent you from accurately identifying the cricothyroid
membrane. Coagulopathy increases the risk of bleeding into the airway
following needle puncture.
- In the patient with chronic bronchitis which preoperative interventions
MOST reliably reduce the incidence of post operative, pulmonary
complications?
A. Smoking cessation for 8 weeks.
B. Prophylactic doxycycline.
C. Instruction in postop pulmonary toilet techniques.
D. Adequate hydration. - -A. Smoking cessation for 8 weeks
Smoking cessation is the most reliable method to reduce postoperative
Pulmonary complications. A patient who has not had a cigarette for at 8
eight weeks has the same level of baseline perioperative pulmonary risk as a
patient who does not smoke.
Prophylactic antibiotics to sterilize the sputum are not indicated and may
actually encourage secondary infection. Antibiotics are reserved for patients
with purulent sputum, and or pulmonary infiltrates.
, Instruction in postop pulmonary toileting, techniques, and adequate
hydration are additional therapies to decrease the risk of postop pulmonary
complications .
- When providing Anesthesia to a patient undergoing video assisted
thoracoscopic surgery for removal of bullae:
A. Jet ventilation should be avoided.
B. A bronchial blocker is preferred to a double lumen endotracheal tube.
C. 50% nitrous oxide is an acceptable technique.
D. A small tidal volume with high respiratory rate is preferred. - -D. A small
tidal volume with high respiratory rate is preferred.
Bullae are large air-filled spaces in the lungs that result from damage to
normal alveolar tissue. Rupture can lead to pneumothorax tension,
pneumothorax and/or cardiovascular collapse. To reduce the risk of rupture
the patient should be allowed to spontaneously gonna lay until the chest is
opened. positive pressure, increases tension and may result in rupture. To
minimize into alveolar pressures (ideally below 20cmH2O) a small tidal
volume with high respiratory rate is recommended. High frequency
generation is an acceptable alternative to positive pressure ventilation.
Nitrous oxide will expand the bullae and may rupture it.
A double lumen endotracheal tube is the airway of choice as the ability to
ventilate each lung separately is vital.
- A unilateral vagus nerve injury during a radical neck dissection will MOST
likely present with:
A. Aphonia
B. Stridor
C. Hoarseness.
D. No clinically relevant sign of injury. - -C. Hoarseness
What happens if the vagus nerve is injured?
Vagus
Unilateral: hoarseness
Bilateral: aphonia
External branch of the SLN :
Unilateral : minimal effects
Bilateral : hoarseness, easily fatigued voice
Internal branch of the SLN :
No effect since this nerve is sensory only
Recurrent laryngeal nerve :
Unilateral : hoarseness
Bilateral : stridor, dyspnea (acute injury), aphonia (chronic injury)
- Which size LMA classic is the most appropriate for a patient that weighs
12kg? - -2
