500

1. 0

2. 0 Diagnosis Management Miscellaneous Anticoagulation Drugs 100 100 100 100 100 200 200 200 200 200 300 300 300 300 300 400 400 400 400 400 500 500 500 500 500

3. Diagnosis100 Points 0 Following epidural insertion and test dose, a patient experiences tinnitus, circumoral numbness, a metallic taste, disorientation, seizures, hypotension, dysrhythmias, and later cardiac arrest.

4. Diagnosis100 Points 0 What is systemic toxicity of local anesthetics?

5. Diagnosis 200 Points 0 Following insertion of an epidural and test dose, the patient complains of feeling very short of breath, followed shortly by dysphonia, upper extremity weakness, respiratory depression, pupillary dilatation, bradycardia, hypotension and loss of consciousness.

6. Diagnosis 200 Points 0 What is inadvertent intrathecal injection of local anesthetic with high spinal?

7. Diagnosis 300 Points 0 28-year-old woman after spinal for C-section experiences a headache that worsens with sitting or standing, improves with lying down.

8. Diagnosis 300 Points 0 What is post-dural puncture headache?

9. Diagnosis 400 Points 0 19 yo healthy M POD 3 from ACL rupture repair, had received an epidural for post-op anelgesia, and tinzaparin q 24 hours starting 6 hours post surgery. Epidural removed POD 2 at 12 hours after tinzaparin dose. POD 3 having progressive loss of sensation in perianal area, L1 to S5, muscle weakness in lower extremities, loss of bladder and bowel sphincter function. What is the diagnosis?

10. Diagnosis 400 Points 0 What is spinal epidural hematoma? http://www.casesjournal.com/content/pdf/1757-1626-0002-0000006732.pdf

11. Diagnosis 500 Points 0 28-year-old woman who presented with a severe headache, numbness in the upper extremities, photophobia and vomiting 3 days post partum from a vaginal delivery and an epidural anaesthesia. What is the diagnosis and way to minimize such a complication?

12. Diagnosis 500 Points 0 What is pneumocephalus and loss of resistance using saline rather than air? The mechanism involves inadvertent puncture of the dural layer during epidural injections for treatment of radiculopathy or induction of epidural anaesthesia with the introduction of air in the dural space. The headache of pneumocephalus is usually immediate in onset, aggravated by any motion, and is not relieved by lying down. As little as 2 ml of air can cause symptoms. The air is usually reabsorbed after 2 days and the headache usually resolves within 5 days of the dural puncture. The development of pneumocephalus following blood patches and epidural anaesthesia involving the placement of catheters has also been reported. No randomised trials have studied the treatment of pneumocephalus, but administration of 40–100% oxygen has been suggested. Patients should be admitted for observation if symptoms are severe. BMJ Case Reports Pneumocephalus after epidural injections R B Nolan, D A Masneri, D Pesce

13. Management100 Points Cause and treatment of shivering after neuraxial anesthesia

14. Management 100 Points Shivering after neuraxial anesthesia is caused by sympathetic block induced vasodilation with redistribution of heat from core to the periphery Treatment is IV meperidine 25 mg Q5 min PRN Other options include IV Clonidine 150 mcg, IV tramadol 3 mg/kg and IV nefopam 10 mg

15. Management 200 Points This procedure is the treatment of choice for severe debilitating post-dural puncture headaches. Describe it.

16. Management 200 Points What is an epidural blood patch? 10 – 20 mL of the patient’s blood is injected into the epidural space to form a clot over the dural defect.

17. Management 300 Points If left untreated, how many days does it usually take for a postdural puncture headache to resolve?

18. Management 300 Points What is 7-10 days?

19. Management 400 Points 0 Dosing of 20% intralipid emulsion for treatment of systemic bupivacaine toxicity

20. Management 400 Points 0 IV bolus of 20% lipid emulsion 1.5 mL/kg of lean body mass given over 1 minute, followed by infusion of 0.25 mL/kg until at least 10 mins following achievement of circulatory stability If ciruculatory stability is not obtained within 5 minutes, administer a second 1.5 mL/kg bolus, followed by infusion of 0.5 mL/kg/min Maximum total cumulative dose of lipid is 10 mL/kg over 30 minutes (Side note: even though propofol is formulated as a 10% lipid emulsion, don’t use it for lipid rescue because the dose needed to treat LA toxicity would result in massive hypotension)

21. Management 500 Points 0 What are conservative and non-invasive treatments of post-dural puncture headaches?

22. Management 500 Points 0 Conservative treatment with oral analgesics and caffeine. Alternative to epidural blood patch is a transnasalsphenopalatine ganglion block

23. Miscellaneous100 Points The anatomic structures that are crossed when performing a spinal block

24. Miscellaneous 100 Points What is: Skin Subcutaneous tissue Supraspinous ligament Interspinous ligament Ligamentumflavum Dura mater Arachnoid membrane

25. Miscellaneous 200 Points Four risk factors for increased risk of post-dural puncture headache

26. Miscellaneous 200 Points What is: • Women • Obese • Parturients • Younger patients

27. Miscellaneous 300 Points Give five advantages of spinal anesthesia over general anesthesia

28. Miscellaneous 300 Points What is: • Endotracheal intubation avoided • Mental status can be followed • Pulmonary compromise is decreased • Decreased incidence of venous thromboembolic complications • In elective hip surgery, there is 20-30% reduction in blood loss

29. Miscellaneous 400 Points Imaging modality of choice to diagnose spinal epidural hematoma

30. Miscellaneous 400 Points What is MRI?

31. Miscellaneous 500 Points Treatment of spinal epidural hematoma

32. Miscellaneous 500 Points What is laminectomy and neurosurgical evacuation of hematoma?

33. Anticoagulation 100 Points Latest gestational age at which pregnant women taking vitamin K antagonists should be transitioned to heparin (UFH or LMWH)

34. Anticoagulation100 Points What is GA = 36 weeks?

35. Miscellaneous 200 Points Minimum number of hours before induction of labour or C-section at which pregnant women taking LMWH should be transitioned to IV or subcutaneous UFH

36. Anticoagulation 200 Points What is 36 hours before induction of labour or C-section?

37. Anticoagulation 300 Points Number of hours before scheduled delivery at which IV heparin should be discontinued

38. Anticoagulation300 Points What is 4-6 hours before scheduled delivery?

39. Anticoagulation 400 Points How long should postpartum prophylactic anticoagulation with heparin (UFH or LMWH) be delayed after 1) vaginal delivery and 2) C-section?

40. Anticoagulation 400 Points What is: 1) 12 hours post vaginal delivery and 2) 24 hours after C-section?

41. Anticoagulation 500 Points Patients receiving UFH for more than 4 days should have this test prior to neuraxial block and catheter removal. What’s the test and why?

42. Anticoagulation500 Points What is platelet count and heparin-induced thrombocytopenia?

43. Drugs100 Points In systemic LA toxicity, CNS toxicity symptoms typically precede CVS toxicity so a patient may experience cerebral symptoms without hemodynamic compromise. Which local anesthetic drug is an exception to this pattern: i.e. where cardiac toxicity may occur in the absence of CNS toxicity?

44. Drugs100 Points What is bupivacaine toxicity?

45. Drugs200 Points Which opioid has local anesthetic effects?

46. Drugs200 Points What is meperidine?

47. Drugs300 Points 3 drugs that can treat neuraxial opioid induced pruritis and doses

48. Drugs 300 Points What is • Naloxone (opioid antagonist) 40 to 160 mcg IV sometimes up to 400 mcg total? • Naltrexone (opioid antagonist) 6 mg orally • Nalbuphine (mixed opioid agonist-antagonist) 2.5 – 5 mg IV ? • FYI: Ondansetronprohylaxis does not decrease incidence of pruritis but reduces severity of pruritis and the need for treatment of the pruritis Mechanism of opioid-induced pruritiis is unclear but it is NOT caused by histamine release so treatment with antihistamine e.g. diphenhydramine is NOT indicated, but often used for its soporific effect

49. Drugs 400 Points Drug and dose to treat uterine hypertonus

50. Drugs 400 Points What is IV nitroglycerin 60 – 90 mcg x 1 or 2 doses?