Complete Revised Copy.
, CONTENTS
LIST OF ABBREVIATIONS v
PASSING THE FINAL SAQ ix
ACKNOWLEDGEMENTS xiii
1. Neurosurgery, neuroradiology and neurocritical care 1
2. Cardiothoracic surgery 23
3. Airway management 47
4. Critical incidents 53
5. Day surgery 73
6. General, urological and gynaecological surgery 77
7. Head, neck, maxillo-facial and dental surgery 99
8. Management of respiratory and cardiac arrest 109
9. Non-theatre 111
10. Orthopaedic surgery 117
11. Perioperative medicine 121
12. Regional anaesthesia 141
13. Sedation 153
14. Trauma and stabilisation 155
15. Intensive care medicine 165
16. Obstetrics 197
17. Paediatrics 223
18. Pain medicine 245
19. Ophthalmic 267
20. Plastics and burns 269
21. Vascular surgery 273
22. Anatomy 281
23. Applied clinical pharmacology 283
24. Applied physiology and biochemistry 293
25. Physics and clinical measurement 309
26. Statistical basis of trial management 325
Index 327
Complete Revised Copy. iii
, NEUROSURGERY, NEURORADIOLOGY AND NEUROCRITICAL CARE
1. NEUROSURGERY,
NEURORADIOLOGY AND
NEUROCRITICAL CARE
a) What characteristic neurological changes occur immediately and in the first three months following
transection of the spinal cord at the fourth thoracic vertebra? (25%)
b) What other clinical problems may develop following this type of injury? (40%)
c) List the advantages of a regional anaesthetic technique for a cystoscopy in this patient. (20%)
d) Why and when may suxamethonium be contraindicated in a patient with spinal injury? (15%)
September 2011
Underline the key words in a question; make sure you are always answering
the question asked and that you don’t miss out a section, as would be easy
to do here.
a) What characteristic neurological Immediate Changes at three months
changes occur immediately and Sensory Complete sensory loss below the Ongoing anaesthesia.
in the first three months following level of injury (and, to a variable
transection of the spinal cord extent, above the level of Development of chronic neuropathic and
at the fourth thoracic vertebra? transection due to secondary injury; nociceptive pain.
(25%) haemorrhage, oedema, ischaemia).
Motor Spinal shock: flaccid paralysis. Hyper-reflexia with spasticity. Initially,
Even reflexes are obliterated as upregulation of receptors facilitates reflexes,
these depend on tonic then new interneurones develop.
descending facilitation.
Autonomic Neurogenic shock: loss of Autonomic dysreflexia (or sympathetic
sympathetic function (in injuries hyper-reflexia): abnormal synapse development
at T4 or above, but also at lower in spinal cord distal to lesion results in
levels if significant secondary non-noxious stimuli causing reflex sympathetic
neurological damage occurs) output below level of lesion, resulting in lower
with unopposed parasympathetic body and splanchnic vasoconstriction. The
activity. Results in hypotension, resulting rise in blood pressure activates
bradycardia and sometimes baroreceptors, thus causing vasodilatation
other arrhythmias. above the level of the lesion and bradycardia,
which is insufficient to reduce blood pressure
Loss of other autonomic reflexes to normal. Onset is variable, may take up to a
(voiding, bowel emptying, coital). year to develop.
Bowel emptying, voiding and coital reflexes
return, but may not be efficient and so many
patients require catheterisation.
Complete Revised Copy. 1
, the Final FRCA Short Answer Questions
b) What other clinical problems Follow the alphabet to categorise your answer and ensure you are able to
may develop following this type extract as many facts from your brain as possible.
of injury? (40%)
Respiratory:
>> Loss of innervation of intercostal muscles results in failure of expansion of
ribcage and, therefore, reduced tidal volumes.
>> Inefficient seesaw breathing: the diaphragm contracts, pushes abdominal
contents down and out due to loss of abdominal wall tone and the chest
wall is sucked in.
>> Breathing worse in the sitting position. Abdominal contents pull down
on the diaphragm, thus expanding expiratory intrathoracic volume, so
reducing volume for expansion in inspiration. A high proportion of minute
ventilation therefore spent on ventilating dead space, resulting in V/Q
mismatch and atelectasis.
>> Difficulty clearing secretions: inefficient coughing due to loss of abdominal
wall tone.
Cardiovascular:
>> Neurogenic shock (may last 24 hours to several weeks): vasodilatation
and bradycardia resulting in hypotension. Sensitive to position with
postural hypotension. Sensitive to fluid depletion, especially with positive
pressure ventilation.
>> Later, autonomic dysreflexia predisposes to periods of uncontrolled
hypertension, risking headache, flushing, nasal congestion, seizures,
retinal haemorrhages, stroke, coma, death.
>> Long-term, patients are at risk of ischaemic heart disease due to physical
inactivity and development of diabetes.
>> Difficulty with intravenous access due to fragile skin, reduced surface
blood flow.
Endocrine:
>> Initial stress response may result in hyperglycaemia which may
exacerbate secondary neurological injury.
>> Increased risk of developing diabetes in the longer term.
Gastrointestinal:
>> Reduced gastrointestinal motility: delayed gastric emptying (aspiration
risk), paralytic ileus, constipation, pseudo-obstruction.
>> Increased risk of gall stones and their complications.
>> Prone to stress ulceration due to unopposed vagal activity.
Haematological:
>> Immobility and thrombogenicity of trauma predispose to thromboembolic
disease. Risk falls after three months (possibly due to muscle spasm
facilitating the muscle pump of venous return, decreased venous
distensibility and femoral artery atrophy).
>> Anaemia is common.
Immune, infection:
>> Risk of nosocomial colonisation with multi-resistant organisms.
Cutaneomusculoskeletal:
>> Contractures resulting from spasticity cause pain and further reduction in
function.
>> Osteoporosis results from loss of limb use.
>> Risk of pressure sores including in unusual places such as occiput.
Renal and genitourinary:
>> Nephrogenic bladder. Impaired sensory and motor function may lead to
incomplete voiding (predisposing to infection) and uncoordinated voiding
(predisposing to vesico-ureteral reflux and, thus, chronic kidney disease).
Intermittent or long-term catheterisation is usually required.
2 Complete Revised Copy.
, CONTENTS
LIST OF ABBREVIATIONS v
PASSING THE FINAL SAQ ix
ACKNOWLEDGEMENTS xiii
1. Neurosurgery, neuroradiology and neurocritical care 1
2. Cardiothoracic surgery 23
3. Airway management 47
4. Critical incidents 53
5. Day surgery 73
6. General, urological and gynaecological surgery 77
7. Head, neck, maxillo-facial and dental surgery 99
8. Management of respiratory and cardiac arrest 109
9. Non-theatre 111
10. Orthopaedic surgery 117
11. Perioperative medicine 121
12. Regional anaesthesia 141
13. Sedation 153
14. Trauma and stabilisation 155
15. Intensive care medicine 165
16. Obstetrics 197
17. Paediatrics 223
18. Pain medicine 245
19. Ophthalmic 267
20. Plastics and burns 269
21. Vascular surgery 273
22. Anatomy 281
23. Applied clinical pharmacology 283
24. Applied physiology and biochemistry 293
25. Physics and clinical measurement 309
26. Statistical basis of trial management 325
Index 327
Complete Revised Copy. iii
, NEUROSURGERY, NEURORADIOLOGY AND NEUROCRITICAL CARE
1. NEUROSURGERY,
NEURORADIOLOGY AND
NEUROCRITICAL CARE
a) What characteristic neurological changes occur immediately and in the first three months following
transection of the spinal cord at the fourth thoracic vertebra? (25%)
b) What other clinical problems may develop following this type of injury? (40%)
c) List the advantages of a regional anaesthetic technique for a cystoscopy in this patient. (20%)
d) Why and when may suxamethonium be contraindicated in a patient with spinal injury? (15%)
September 2011
Underline the key words in a question; make sure you are always answering
the question asked and that you don’t miss out a section, as would be easy
to do here.
a) What characteristic neurological Immediate Changes at three months
changes occur immediately and Sensory Complete sensory loss below the Ongoing anaesthesia.
in the first three months following level of injury (and, to a variable
transection of the spinal cord extent, above the level of Development of chronic neuropathic and
at the fourth thoracic vertebra? transection due to secondary injury; nociceptive pain.
(25%) haemorrhage, oedema, ischaemia).
Motor Spinal shock: flaccid paralysis. Hyper-reflexia with spasticity. Initially,
Even reflexes are obliterated as upregulation of receptors facilitates reflexes,
these depend on tonic then new interneurones develop.
descending facilitation.
Autonomic Neurogenic shock: loss of Autonomic dysreflexia (or sympathetic
sympathetic function (in injuries hyper-reflexia): abnormal synapse development
at T4 or above, but also at lower in spinal cord distal to lesion results in
levels if significant secondary non-noxious stimuli causing reflex sympathetic
neurological damage occurs) output below level of lesion, resulting in lower
with unopposed parasympathetic body and splanchnic vasoconstriction. The
activity. Results in hypotension, resulting rise in blood pressure activates
bradycardia and sometimes baroreceptors, thus causing vasodilatation
other arrhythmias. above the level of the lesion and bradycardia,
which is insufficient to reduce blood pressure
Loss of other autonomic reflexes to normal. Onset is variable, may take up to a
(voiding, bowel emptying, coital). year to develop.
Bowel emptying, voiding and coital reflexes
return, but may not be efficient and so many
patients require catheterisation.
Complete Revised Copy. 1
, the Final FRCA Short Answer Questions
b) What other clinical problems Follow the alphabet to categorise your answer and ensure you are able to
may develop following this type extract as many facts from your brain as possible.
of injury? (40%)
Respiratory:
>> Loss of innervation of intercostal muscles results in failure of expansion of
ribcage and, therefore, reduced tidal volumes.
>> Inefficient seesaw breathing: the diaphragm contracts, pushes abdominal
contents down and out due to loss of abdominal wall tone and the chest
wall is sucked in.
>> Breathing worse in the sitting position. Abdominal contents pull down
on the diaphragm, thus expanding expiratory intrathoracic volume, so
reducing volume for expansion in inspiration. A high proportion of minute
ventilation therefore spent on ventilating dead space, resulting in V/Q
mismatch and atelectasis.
>> Difficulty clearing secretions: inefficient coughing due to loss of abdominal
wall tone.
Cardiovascular:
>> Neurogenic shock (may last 24 hours to several weeks): vasodilatation
and bradycardia resulting in hypotension. Sensitive to position with
postural hypotension. Sensitive to fluid depletion, especially with positive
pressure ventilation.
>> Later, autonomic dysreflexia predisposes to periods of uncontrolled
hypertension, risking headache, flushing, nasal congestion, seizures,
retinal haemorrhages, stroke, coma, death.
>> Long-term, patients are at risk of ischaemic heart disease due to physical
inactivity and development of diabetes.
>> Difficulty with intravenous access due to fragile skin, reduced surface
blood flow.
Endocrine:
>> Initial stress response may result in hyperglycaemia which may
exacerbate secondary neurological injury.
>> Increased risk of developing diabetes in the longer term.
Gastrointestinal:
>> Reduced gastrointestinal motility: delayed gastric emptying (aspiration
risk), paralytic ileus, constipation, pseudo-obstruction.
>> Increased risk of gall stones and their complications.
>> Prone to stress ulceration due to unopposed vagal activity.
Haematological:
>> Immobility and thrombogenicity of trauma predispose to thromboembolic
disease. Risk falls after three months (possibly due to muscle spasm
facilitating the muscle pump of venous return, decreased venous
distensibility and femoral artery atrophy).
>> Anaemia is common.
Immune, infection:
>> Risk of nosocomial colonisation with multi-resistant organisms.
Cutaneomusculoskeletal:
>> Contractures resulting from spasticity cause pain and further reduction in
function.
>> Osteoporosis results from loss of limb use.
>> Risk of pressure sores including in unusual places such as occiput.
Renal and genitourinary:
>> Nephrogenic bladder. Impaired sensory and motor function may lead to
incomplete voiding (predisposing to infection) and uncoordinated voiding
(predisposing to vesico-ureteral reflux and, thus, chronic kidney disease).
Intermittent or long-term catheterisation is usually required.
2 Complete Revised Copy.
