answer booklet for saq paper one - apagbi · 2018. 3. 22. · left-to-right: asd, vsd, avsd, patent...

Disclaimer:ThisanswerpaperwaswrittenbyanaesthetictraineesandeditedbyDrDavidNewbyandDrElinHughes(APAGBITraineeRepresentative).Itisintendedasalearningresource,tostimulatediscussion,andtoencouragefurtherlearning.Itinnowayintendstorepresenttheviewsofanyprofessionalbody,includingtheRoyalCollegeofAnaesthetists,ortheAssociationofPaediatricAnaesthetistsofGreatBritainandIreland.

Question1.A3-year-oldwithsuspectedmeningococcalsepticaemiarequiresurgenttransfertotheregionalspecialistPaediatricIntensiveCareUnit(PICU)foron-goingmanagement.a) Outlinethecriticalstepsrequiredtoarrangesafeandtimelyinterhospitaltransferforthis

childbyroad(9marks)• Refertolocalguidelinesregardingemergencypaediatrictransport• Initiateinitialstabilisationatthebasehospital FollowanABCapproach:

Secureairway.Intubationbysenioranaesthetist. VentilationwithPEEP,establishventilationontransferventilatorpriorto

departure.Appropriatefluidresuscitation,cardiovascularsupport,2xivaccess,considerinvasivemonitoringdependingonexpertise.Administerantibiotics,obtainbaselinebloodresults,gases,imagingetc.

• ContactregionalretrievalteamSpecialisttransportteamshavededicatedconsultantintensivistsandareavaluablesourceofadviceandguidanceforcliniciansinvolvedininitialstabilisation.

• Confirmtherequirementforinter-hospitaltransfertoaspecialistcentreDirectedadviceandtreatmentgoalsmaybegivenbytheretrievalteamregardingthechild’sspecificmanagement.Ifthechildshowssignificantimprovement,transfermaynotultimatelybenecessary.

• DeterminemodeandtimeframeforretrievalAscertainwhetherthechildwillberetrievedbyadedicatedtransferteamfromthereceivinginstitution,orwhetherthebasehospitalwillbeassemblingtheirowntransportteam.Thiswilldependontheurgencyofthetransfer,theneedsofthechildandtheskillsetofthepersonnelavailable.Timecriticaltransfersmayneedtobeperformedbythebasehospital.

• Assemblebasehospitaltransferteampersonnel

MockPaediatricAnaestheticAnswerBookletforPaper1April2016


Inthecaseofabasehospitalbasedtransportteam,skillsofthetransportteamshouldmatchtherequirementsofthepatient.A2-persontransportteamistheacceptedminimumforventilatedpatients.AtransportteamwilltypicallycompriseaTeamLeader,AssistantandaDriver/Technician.

• Continueon-goingstabilisationandtreatmentasnecessarywithsupportfromretrievalteamwhereavailable.

• Assembleequipment,drugsandmonitoringnecessaryfortransferThiswillincludeairwayequipment,transferventilator,calculationsofoxygenrequirements,sparebatteriesformonitors,syringedriversfordrugsetc.Ideallythemajorityofthiswouldbereadilyavailableonadedicatedtransfertrolley.Intermsofdrugcalculations,localretrievalservicewebsitesoftenincorporateaneasilyaccessiblecalculatorbasedontheweightofthechild.

• Ensureameansofcommunicationduringthetransfer Useamobilephonewithessentialcontactnumbersinstalled.

• ConsiderparentsItmaybeappropriatetoallowoneparenttotravelinthetransportambulance.Unnecessaryseparationcanleadtosignificantdistressandparentsareanessentialsourceofinformation.Wherethisisnotpossibleorpractical,ensureparentsknowwheretogoonceatthereceivinginstitution.

• Useofapre-departuretransferchecklist Thesehavebeenshowtoreducetheincidenceofadverseevents.

b) Whatparticularinformationshouldbeexchangedwiththereceivinghospitalpriortodeparturefromthebasehospital?(6marks)• Nameofreceivinginstitution• NameofacceptingConsultant• Patientdetails• Reasonforreferral• Allergies• Medications• Immunisations• Childprotectionissues• Currentconditionofthechild(ABCD,Everythingelse–bloodresultsandgases,

imaging,cultures)• Immediateneedsofthepatientonarrival• Exactlyhowtogetfromtheambulanceentrancetothereceivingward/PICU/theatre


c)Listthespecificcomplicationsyoumightanticipateoccurringinaventilatedchildrequiringinter-hospitaltransferbyroad?(5marks)• Oxygenfailureorinsufficientoxygen

Theself-inflatingbagcanbeusedintheeventofoxygenfailurebuttheambulanceshouldthenbedivertedtothenearesthospitaltoreplenishthesupply.

• PowerfailureSometransportventilatorsutiliseanelectricalpowersourcebutwillhavealimitedbatterylife.Plugtheventilatorintoasuitablepowersourcewheneveroneisavailableandensurethatyouknowthebatterylifeoftheventilator.Inthischild,powerfailureisalsolikelytoaffectinotropeandfluidpumps.

• VentilatoryproblemsHighpeakpressures,poorcapnographtrace,highFiO2requirements,inabilitytoventilate.Significantdeteriorationcanoccurduringtransfer,especiallyincaseswherethechildisunstablepriortotransport.Ifventilatoryproblemsoccurfollowingintubationthemnemonic“DOPES”canbeusedtodeterminethecaseofthedeterioration:

DDisplaced CheckpositionofETT–thesecaneasilymigrateOObstructed ChecktheETTispatent,suctionsecretionsPPneumothorax EnsureequalairentrybilaterallyEEquipment Ventilatorfunctioningcorrectly?SStomach NGtodecompress,excludeoesophagealintubation

• MigrationoftubesandlinesEnsurealltubesandlinesareadequatelysecuredpriortodeparture.

• MonitoringissuesMonitoringmaybeproblematicduetomovementartefact,powerfailureetc.

• Injuryfrominadequatelysecuredoxygencylindersand/orventilatorOxygencylindersinparticulararelarge,heavyitemswhichmaycausesignificantinjuryiftheyarenotadequatelysecuredinthebackofamovingambulance.


Question2.a)Listthecommoncausesofstatusepilepticsinchildren.(6marks)

-Metabolicabnormalities(hypoglycaemia,hyponatraemia,hypocalcaemia)-Febrileillness-CNSinfections(e.g.meningitis)-Epilepsy-Anticonvulsantwithdrawal-Trauma-Poisoning

b)Whatisyourmanagementplanforachildinstatusepilepticus(8marks)

- ABCDo Emphasisonestablishingapatentairway/provisionofhighflow

oxygen/checkingbloodglucoseo IVorIOaccess

- Cessationofconvulsionso Lorazepam0.1mg/kgIV/IOorMidazolam0.5mgPOorDiazepam0.5mg/kg

PRo After10minutes,onefurtherdoseoflorazepam0.1mg/kgo Earlyseniorinputo 10minutesaftersecondbenzodiazepinedose,phenytoin20mg/kgIVI+/-

paraldehyde0.4ml/kgPR,orphenobarbitone20mg/kgifpatientalreadyonphenytoin

o Thiopentoneinducedanaesthesiaifallabovefailsc)Listthepotentialcomplicationsofprolongedconvulsions.(4marks)-Respiratory -airwayobstruction -aspiration -LRTI -pulmonaryoedema-Cardiac -hypo/hypertension -brady/tachyarrhythmias-Cerebral -hypoxicbraininjury -raisedICP(e.g.cerebraloedema) -cerebralhaemorrhage


-Other -electrolyteabnormalities(e.g.hypoglycaemia) -rhabdomyolysis -acutetubularnecrosis -acutepancreatitis -disseminatedintravascularcoagulopathy


Question3.NearInfra-RedSpectroscopy(NIRS)canbeusedtomonitorthepre-termneonateduringanaesthesia.(a)HowdoesNIRSwork(4marks)andwherespecificallycanitbeplaced?(2marks)Near-infraredlight(700to1000nm)Penetratesthroughthesuperficiallayersofthehead,includingthescalpandtheskullrScO2isthepercentageofoxyhaemoglobinoverthesumofoxy-anddeoxyhaemoglobininpooledarterial,capillaryandvenousblood.rScO2isessentiallydeterminedbycerebraloxygendemandandsupplyCerebral-headSplanchnic-abdomenRenal-abdomen(b)Listintra-operativefactorsknowntocauseareductioninNIRS(7marks)Lowhaematocrit/anaemiaIncreasedcerebraloxygenconsumption-seizuresHypotension/HypovolaemiaHypoxiaMisplacementofNIRSprobeDeephypothermiccardiacarrestCardiacshunt–largeVSD,largePDAHypocapnia(c)Whatarethepotentialpost-operativecomplicationsofasevereandprolongedreductioninNIRS.(7marks)Majororganhypoperfusion-Myocardiacischaemia-Cerebralhypoxia/Stroke-Acutekidneyinjury-NecrotisingenterocolitisPost-operativecognitivedysfunctionIncreasedmorbidityandmortalityProlongedlengthofhospitalstay


Question4.Congenitalheartdefectscanbecyanoticoracynotic.a)Whatdothesetermsreferto?(4marks)ThosewithaLtoRshuntandthosewithaRtoLshuntb)Give4examplesofeach(8marks)Left-to-right:ASD,VSD,AVSD,PatentDuctusArteriosus;Right-to-left:TetralogyofFallot,TranspositionoftheGreatArteries,TruncusArteriosus,TricuspidAtresia,Ebstein’sAnomalyc)WhatisEisenmenger’ssyndrome?Describethecardiacabnormality(8marks)ChronicLtoRShuntcausedbyacongenitalheartdefecte.g.VSDCausespulmonaryhypertensionChronicRtoLshuntresultinginRVoverloadandRVHChronicPulmonaryovercirculationEventualreversaloftheshuntwhichbecomespredominantlyRighttoLeftPresentswithcyanosis,heartfailure,polycythaemia


Question5.a)Describetheanatomicalfeaturesofthenormalpaediatricairway(7marks)Therearemarkedanatomicalandphysiologicalvariantsbetweenthepaediatricpopulationandadults.Thesetendtobemorepronouncedintheneonatalpopulation(<4weeksofage)andbecomelesssignificantasthechildages.Children’sheadsareproportionatelylargercomparedtotheirbodies,andhaveamoreprominentocciput.This,combinedwithshorternecks,meansthattheidealpositiontomaintaintheairwayinisintheneutralpositionratherthan“sniffingthemorningair”asintheadultpatient.Alargetonguecancrowdthemouth;micrognathiaandlimitedmouthopeningcompoundpotentiallydifficultlaryngoscopy.Thelarynxismoreanterior,morecephalad,andfunnelshapedintthepaediatricpatient.ThecricothyroidcartilageisatthehigherlevelofC3/4ininfancy,changingtoC5by6years.Ananteriorlarynxcanmakelaryngoscopymorechallenging.TheepiglottisislongerandUshapedandcanbecomeanobstacletointubation.Thecricothyroidmembraneissmallerinwidththeninadults.Endotrachealtubesshouldbesizedaccordingtothecricoidcartilagediameter,whichisthenarrowestpartofthepaediatricairway(contrastwithadults,whereitisthelaryngealinlet).TheTracheaisshorter(4cmneonates)makingaccidentalendobronchialintubationmorecommon.b)Whataretheadvantages(5marks)anddisadvantages(3marks)ofusingcuffedendotrachealtubesinthepaediatricpopulation?Advantages‘Tighter’fitleadstolessleak:reducedneedfortubechanges;abletoproduceandmaintainPEEP;reducesanaestheticgaspollution;moreaccuratemonitoringofcapnographyandgasanalysis;lowflowanaesthesiacanbeemployedwithcostandenvironmentalimplicationsDisadvantagesHighcuffpressurescancauselaryngealoedema/uppertrachealnecrosis;cuffedtubeshaveareducedinternaldiametertoallowforthecuffsoworkofbreathingishigherinthesettingofspontaneousventilationc)ComparethecharacteristicairwaycomplicationsofDownsSyndromewithPiereRobinsyndrome(5marks)Down’ssyndromeisoneofthemostcommoncongenitalsyndromes.AirwayDifficultiesincludepotentialoractualatlanto-occipitalinstability,macroglossia,smalloralcavityandpoorpharyngealtonemakingupperairwayobstructionmorelikely.PierreRobinSequencehasanumberoffeaturesthatcanmakeintubationmorechallenging.Micrognathia,relativemacroglossiawithorwithoutcleftpalateallcomplicateairwaymanagement.Thesepatientstendtobecomelesspronetoairwayobstructionanddifficultintubationastheygetolder.


Question6.Youarepre-assessinga3-yearoldchildwithDown’ssyndromefordentalextractionsundergeneralanaesthesiaonthedayofsurgery.Onexamination,youfindasystolicmurmurwhichhasnotpreviouslybeendescribed.a)Howwouldyouevaluatethesignificanceofthemurmur?(8marks)Thesignificanceofamurmurdiscoveredinanychildshouldbeevaluatedviaathoroughhistory,physicalexaminationandinvestigationsasappropriate.DuetotheincreasedincidenceofpathologicalcardiacabnormalitiesassociatedwithDown’ssyndrome,particularlyendocardialcushiondefects(AVSDs,ASDs,VSDs)ahigherdegreeofsuspicionforanon-innocentmurmurshouldbeassumed.Featuresfromthehistoryofthechildwhichwouldbeacauseforconcernsandfurtherinvestigationincludecyanoticepisodes,evidenceofheartfailuresuchasdyspnoea,orthopnoeaorparoxysmalnocturnaldyspnoea,andsyncope.Poorgrowthandfeedingmayalsobeassociatedwithapathologicalmurmur,anddetailsofgeneralpoorhealthorrecurrenthospitaladmissionsshouldbeinvestigated.Also,ifthechildhasahistoryofaknowncardiaccondition,thedetailsofthisshouldbeavailablebeforeproceedingwithelectivesurgery.Onexamination,innocentmurmurstendtooccurinearlysystole,aresoftandvarywithposture.Incontrasttothis,anyharshorhighgrademurmur,oroneoccurringinlatesystole,pansystoleordiastoleshouldbeinvestigated.Forexample,aVSDwouldcauseaharsh,pan-systolicmurmur.Also,ifthereareanyotherpositivefeaturesoncardiacexaminationsuchasapalpableheaveorthrillorabnormalheartsounds,thechild’selectiveprocedureshouldbedelayeduntilthemurmurcanbemoreformallyinvestigatedwithECGforarrhythmias,chestradiographforevidenceofcardiomegalyorfailure,echocardiographyandreferraltoapaediatriccardiologistifappropriate.b)What,ifany,areyourspecificanaestheticconsiderationswhencaringforachildwithDown’ssyndrome?(10marks)Therearemultipleperi-operativeconcernsrequiringcarefulconsiderationspriortoanaesthetisingachildwithtrisomy21,themainbeingcommunicationdifficultiesduetointellectualimpairment,underlyingcardiacdiseaseandincreasedincidenceofdifficultairwaymanagementduetoanatomicalanomalies.

Pre-operative:a. Carefulairwayassessmentlookinginparticularforrelativelylargetongue,

crowdingofmidfacialstructures,higharchedpalate,micrognathiaandshortbroadneckmayallindicateadifficultairwayandifIwasconcerned,thecasewouldrequireaskilledpaediatricanaesthetistwithappropriatedifficultintubationequipmentavailableaswellasasecondanaesthetistforassistance.


Asmallerendotrachealtubeshouldalsobeavailableforthepossibilityofsubglotticstenosis.

b. Carefulairwaymanipulationisalsowarrantedbecauseoftheincidenceofatlanto-axialinstabilityalthoughscreeningxraysarenotadvisedifthechildisasymptomatic.

c. Intravenousaccessmaybedifficultandsospecificequipmentsuchasanultrasoundandtwoskilledanaesthetistsshouldbeavailable.

d. Acalmenvironmentandtheuseofalightsedativepremedicationmaybehelpfulinananxiouschildwithtrisomy21wherecommunicationisdifficultaslongasitisnotprecludedbytheriskofhypoxiaduetounderlyingcardiorespiratorydisease.

Intra-operative:

a. Strictasepsisforallproceduresduetorelativecellularimmunodeficiencyputtingthechildatagreaterriskofinfection.

b. Increasedvigilanceforaspirationduetotheincreasedincidenceofgastro-oesophagealrefluxdiseaseanduseranitidinepre-opertivelytominimisetherisk.

c. Attempttooptimisecardiorespiratoryfunctionduetopossibilityofunderlyingpathologyandifthereisaknowncardiaccondition,theanaestheticshouldbeperformedinacentrewiththeappropriateskillbaseandservicestomanagecongenitalheartdiseaseperi-operatively.

Post-operative:a. Judicioususeofopiatesduetoincreasedsensitivityandincidenceof

obstructivesleepapnoea.b. Attempttooptimiserapidrecoverythroughtheuseofshorteracting

anaestheticagentsandensurethechildisnursedinamonitoredenvironmentovernight,suchasHDUastheyaremorepronetohypotoniawhichmaycauseairwaycompromise,atelectasisandincreasedriskofchestinfection.Supplementalhumidifiedoxygenandphysiotherapyshouldbeimplementedearlyifrequired.

c. Carefulmulti-modalanalgesicplanningandinvolvementoftheparentsandthepainteamifpossibleduetothechallengesofassessingpainduetocommunicationdifficultybalancedwiththeriskofairwayobstructionandopioidsensitivity.


c)Wouldyouprovideantibioticprophylaxisforthischildwhenyouproceedtosurgery?Ifso,what?(2marks)ThecurrentAHAandNICEguidelinesrecommendthatroutinedentalprocedureswithoutgingivalmanipulation(eg.fillings)donotrequireantibioticprophylaxisunlessthechildhasanunrepairedcyanoticcardiaclesion,iswithin6monthsofarepair,orhaspreviouslyhadbacterialendocarditis.Theemphasisisinsteadonmaintaininggoodoralhealthanddentalhygiene.Planningforthisprocedurewouldrequireadiscussionwiththeoperatingdentistastotheextentofthetreatmentrequiredandadiscussionwiththeparentstomanagetheirexpectationforprophylacticantibioticsastheymayhavesomeconcerns.


Question7.A3-year-oldboyhasahistoryofintermittentepisodesofstridor.HeisbookedforamicrolaryngoscopyandbronchoscopyonyourENTlist.a)Listpotentialcausesofintermittentstridorinthisboy.(5marks)Laryngomalacia(orpharyngo/trachea/bronchomalacia)LaryngealwebLaryngealstenosis(subglotticstenosis)LaryngealpapillomatosisForeignbodyVascularringTumoureghaemanigiomab)DescribedifferentmethodsofmaintainingoxygenationforENTairwaysurgeryandtheirrelativemerits(15marks)Independentofbronchoscope:IntermittentBMV;Nasopharyngealtube;THRIVE;MLTThroughbronchoscope:Ventilating(Storz);Venturi•Intermittentbag-maskventilationandapnoeapro’s:familiartechnique,canuseinhalationagenttomaintainanaesthesiacons:noairwayprotection;riskofgastricinsufflation,mayprovedifficulttoensureadequatemask-sealeverytime;interruptssurgery;riskofdesaturation•Nasopharyngealairway(orendotrachealtubeinnasopharynx)pro’s:simpletechnique;inhalationalagentscanbeusedcons:reliesonpatentairwayandpatientspontaneousbreathing;riskofepistaxis;significantleakofanaestheticgas;inaccuracy/inabilitytoadequatelymonitorairwaygases•High-flownasalcannula(THRIVE)pro’s:reliablyprolongsapnoeicwindowwithminimalrisesinCO2cons:reliesonpatentairway;gastricinsufflation;pneumothorax;relativelyexpensiveequipment(andunfamiliartomanystaff);maintenanceofanaesthesiabyIVdrugs•MLTandIPPVpro’s:familiarequipmentandintubatingtechnique;maintaininhalationalanaesthesia;monitorairwaygases;‘secures’airwaycons:canobstructsurgicalview;accidentalextubation;operativefieldrelativelymobile


•Ventilatingbronchoscope(Storz):pro’s:canbeusedwithspontaneousventilationorIPPVviaaJackson-ReesT-pieceattachedattheoperatorend;inhalationagentscanbeusedtomaintainanaesthesiacons:greatlyincreasestheworkofspontaneousbreathingbyreducingthecross-sectionalareaofthetrachea;invariablycauseshypercarbia;environmentalleakofanaestheticgases•Venturibronchoscopeusingintermittentjetventilation(Sanders):pro’s:facilitatesamotionlessoperatingfield;minimalequipmentrequirements;cons:maintenanceofanaesthesiabyIVdrugs;entrainedair‘dilutes’FiO2;unabletoadequatelymonitorgasdelivery;hypercarbiaisproblematic;riskofbarotrauma;riskofgastrapping;gastricinsufflationwhenusedsupra-glottically


Question8.A6-year-oldboy,normallyfitandwell,presentsforemergencyappendicectomy.Hehasbeenvomitingandunabletotolerateoralfluidsforthelastday.Hehasatemperatureof38.5oC.a)Whataretheclinicalfeaturesofdehydrationinchildren?(6marks)RESP–tachypnoeaCVS–tachycardia;hypotension;prolongedCRT;weakperipheralpulses;coolperipheriesCNS–alteredconsciousnessRENAL–oliguria/anuriaOTHER–sunkeneyes;drymucusmembranes;reducedskinturgorb)Calculateaninitialresuscitativeintravenousfluidbolusandongoingmaintenancefluidsforthischild,showingyourworking.(6marks)Weightestimation=(agex3)+7=(6x3)+7=25kg

Fluidbolus:20mls/kgofanon-glucosecontainingisotoniccrystalloidwithasodiumconcentrationof131-154mmol/litre.20x25=500mls0.9%sodiumchlorideorHartman’ssolutionacceptable

Maintenancefluids:4mls/kgforfirst10kg 4x10=402mls/kgfornext10kg 2x10=201ml/kgforeachextrakg 1X5= 5

Total=65mls/hourofanon-glucosecontainingisotoniccrystalloidwithasodiumconcentrationof131-154mmol/litre.

Or,thesameformulausedtocalculatethetotaldailyrequirement:100mls/kg/dayforfirst10kg50mls/kg/dayfornext10kg20mls/kg/dayforeachextrakgwhichgives1600mls/dayc)Statewhatmonitoringandclinicalassessmentsarerequiredifthischildremainsonintravenousfluids.(4marks)Serumureaandelectrolytesatleastevery24hoursBloodglucoseatleastevery24hoursDailyweightFluidsinput,outputandbalanceAssessmentoffluidstatusAssessmentofongoinglosses(eg.gastrointestinallosses)


d)Listthesymptomsofhyponatraemia.(4marks)-Headache-Nauseaandvomiting-Confusion-Reducedconsciousness/irritability-Lethargy-Seziures-Apnoea-Coma


Question9.a)Define‘sedation’andoutlinethedifferentstages(3marks)Threelevelsofsedation(AmericanSocietyofAnesthesiologists):

- Minimal- Moderate- Deep

Minimal:patientrespondsnormallytovoicethoughmaybecognitivelyimpaired;noeffectonA,B,CModerate:patientissleepybutrousable,respondspurposefullytovoiceorlighttactilestimuli(approximatesto‘conscioussedation’,definedspecificasastateofCNSdepressionthatenablestreatmenttobecarriedout,butduringwhichverbalcontactismaintained)A:maintained,B:adequatebreathingspontaneously,C:usuallymaintainedDeep:patientisasleep,noteasilyroused,canrespondpurposefullytorepeatedpainfulstimuliA:mayneedassistancetomaintainpatentairwayB:spontaneousventilationmaybeinadequateC:usuallymaintainedb)Name3diagnosticand3therapeuticproceduresthatwouldbesuitableforconscioussedationinanotherwisehealthychild.(6marks)Diagnosticincludes:-ECHO-CT-MRI-gastroscopy-colonoscopy

Therapeuticincludes:-Dentalprocedures-Woundcareieburnsdressings,suturinglacerations-Radiotherapy-Fracturemanipulation


c)Whatissuesmaycontradictsedationinchildren?(6marks)AbnormalairwayanatomyKnowndifficultairway(congenitaldefects–micrognathiaetc)ordocumentedfrompreviousanaestheticsPathology:adenotonsillarhypertrophy;OSA;cardiorespiratorydisease;bowelobstructionPatient:allergiestosedative;refusal;significantbehaviouralproblemsd)Whataretheminimumstandardsofmonitoringrequiredforconscioussedation?(5marks)-Pulseoximetry-ECG-NIBPGoodpracticetousecapnography.Othermonitoringdependentonspecificneedsofchild.


Question10.a)Describethebloodsupplyandvenousdrainageofthetonsils.(5marks)Thepalatinetonsilhasarichbloodsupplyfromtheexternalcarotidartery(1/2mark)branches.Thelowerpoleofthetonsilreceivesbranchesfrom:

• Dorsallingualartery(1/2mark).• Ascendingpalatinearteryfromthefacialartery(1/2mark).• Tonsillarbranchofthefacialartery(1/2mark).

Theupperpoleofthetonsilreceivesbranchesfrom:• Ascendingpharyngealartery(1/2mark).• Lesserpalatineartery(1/2mark).

(Note that the internal carotidartery liesapproximately2cm fromthepalatine tonsils,butcontributesnobranches).Venous drainage is more diffuse with a venous peritonsillar plexus (1/2 mark) about thecapsule.Thevenousbloodflowsinto:

• Lingual(1/2mark)andpharyngealveins(1/2mark).• Whichfeedintotheinternaljugularvein(1/2mark).

b)Whataretheanaestheticconsiderationsinbleedingtonsil?(5marks)Theanaestheticconsiderationsinbleedingtonsilinclude:

• Hypovolaemia• Riskofpulmonaryaspiration(swallowedbloodwithorwithoutoralintake)• Potentialforadifficultintubationbecauseof:

o Excessivebleedingobscuringtheviewo Oedemaafterearlierairwayinstrumentation

• Asecondgeneralanaesthetic(residualeffectsoffirst;issuesofdosing)• Stresstobothchildandparents.• Fullstomach• Cardiovascularcollapseoninductionofanaesthesia1markforeachoftheabove,uptoamaximumof5marks

c)Beforeinduction,inadditiontothestandardequipment,whatotherequipmentshouldbeimmediatelyavailable?(3marks)-Aselectionoflaryngoscopeblades(1mark).-Smallerthanexpectedtrachealtubes,twoofeachsize(1mark).-Twosuctioncathetersshouldbeimmediatelyavailable(1mark).


d)Describetwotechniquesforinductionofanaesthesiaforposttonsillectomyhaemorrhage(4marks),andbrieflyoutlinestepstobetakenpriortoextubation?(3marks)There is little agreement on the safest technique of anaesthesia for a bleeding tonsil; theanaesthetist should adopt an approachwithwhich they are comfortable, cognizant of thepotentialhazards.Twooptionsinclude:

• A rapid sequence induction (1 mark) with pre-oxygenation (1/2 mark) and cricoidpressure(1/2mark).

• Inhalational inductionwith sevoflurane in oxygen (1mark) starting in a headdownlateralposition(1mark).

Ifusinginhalationalinduction,alaryngoscopebladecanbegentlyintroducedafterthechildshouldbetomovedtothesupineposition,suxamethoniummaybegivenandcricoidpressureapplied until the trachea is intubated. Facemask ventilation should be avoided as it mayprecipitateregurgitationofbloodfromthestomach.

• Furtherfluidandbloodshouldbegivenasrequired(1mark).• Beforeterminationofanaesthesiaawideboreorogastrictubeshouldbepassedinan

efforttoemptythestomach(1mark).• Extubationshouldbeinalateral,headdownposition(1mark).


Question11.A4yearoldchildwhohadablowfromacricketbatarrivesattheemergencydepartment.Hebrieflylostconsciousnessatthetime.HisGCSwas15onarrivaltohospitalandduringtriage.YouareaskedtoreviewhimpriortoaheadCTscan.Hehassincebecomesleepyandagitated.a)Describeyourimmediatemanagement(6marks)Primarysurvey:Cspineimmobilisation,ABCDapproachinaccordancewithATLS/APLSIVaccessAVPUConsolidatehistory,sequenceofevents,drugsgiven,medicalandanaesthetichistory.b)Whatsignsmightindicateabasalskullfracture?(4marks)CSFleakfromears,noseBattlessign:bruisingbehindtheearsPanda/racooneyesHaemotympanumc)YoudecidethatgeneralanaesthesiaiswarrantedfortransfertoCT.Howwouldyouconductanaesthetictotryandminimisesecondarybraininjury?Whatphysiologicalparameterswouldaimforwhilstunderanaesthetic?(10marks)RSIifindicatedwithinlineCspinestabilisation–considerusingopiatetoobtundpressorresponsetolaryngoscopyVentilationtomaintainadequateoxygenation.AimfornormalrangePaCO2topromoteadequatecerebralperfusion.Capnography.ControlledventilationwithneuromuscularblockadetoallowtightcontrolofgasexchangeandpreventsurgesinICPsecondarytocoughing.ArteriallinetomonitorBPandextrapolateCPPcarefullyandcontinually.Analgesia.Anticonvulsantsasrequired.Maintainnormothermiaandnormoglycaemia


Question12.A15-yearoldgirlisinagreementwithhermedicalteamforlife-savingcorrectiveheartsurgery,whowishtoperformtheprocedureimminently.(a)Whocangiveconsentforthisprocedure?(8marks)Consenttotreatanindividualundertheageof18yearscanbeobtainedfromoneoffoursources:1.Thosewithparentalresponsibility2.Aminorovertheageof16years3.Aminorundertheageof16yearswhoisdeemedtobeGillickcompetent4.FromthecourtsParentshavelegalobligationstowardstheirchild,enshrinedinthe‘ChildrensAct1989’.Thisstatesthat“alltherights,duties,powers,responsibilitiesandauthoritywhichbylawaparentofachildhasinrelationtothechildandhisproperty”,andincludes:

- Theprovisionofahomeforthechild- Theprovisionofprotectionandmaintenanceofthechild- Discipliningthechild- Providingforeducation- Agreeingtomedicaltreatment

(http://www.legislation.gov.uk/ukpga/1989/41/section/3)Parentalresponsibilityisreiteratedtosomeextentbyarticle8oftheEuropeanCourtofHumanRights.Thisqualifiedrightprotectstheprivatelivesofindividualsagainstarbitraryinterferencebyapublicauthorityandprivateorganisations.However,theprinciplethathealthserviceprovisionconstitutesaninterferencewiththeparentalrightsandresponsibilitiessetoutin‘TheChildrensAct1989’hasbeentestedbythecourtsanddismissed(SilberJ.)Section8(1)ofthe‘FamilyLawReformAct1969’statesthataminorof16yearsofagemaygiveconsentforamedicalorsurgicalprocedure,andthatindoingsoitisunnecessarytoobtainparentalorguardianconsent.Thisisastatutorypresumptionofcapacity;rebuttal(ina16-or17-yearold)ispossibleifthepatientisunabletobelieve,retain,weighinformation,orcommunicateachoice.ThebasisofGillickcompetence(GillickvsWestNorfolkandWisbeachAHA,1986)isthatminorsundertheageof16-yearshavesufficientmaturityandunderstandingtomakethedecisioninquestionifthey:


- havetheabilitytounderstandthechoicesandtheconsequences- areabletoweighupinformationinordertoarriveatananswer- understandthenatureoftheproposedintervention,includingtherisksandside

effects,andanunderstandingofthealternativeoptions- communicatetheirdecision

Itisadevelopmentalconcept,neithergainednorlostonaday-to-daybasis.(b)ListtheFraser-competencecriteria(5marks)Althoughoriginallyappliedspecificallywithreferencetocontraceptiveadvice,theprinciplessetoutbyLordFraserhavebeenappliedtootherhealthcarerelatedprocedures.Itsuggeststhatatreatingdoctorshouldbesatisfiedthat:1.Thepatientwillunderstandtheadvicegiven2.Everyreasonableefforthasbeenmadetopersuadethepatienttoinformtheirparents,ortoallowthedoctortodoso3.Thatthepatientislikelytocontinuetobeexposedtotheriskforwhichtheyhavepresentedtothedoctorforadvice4.Thatthepatientwilllikelysufferphysicalormentalharmunlessthedoctorprovidesforthemwhattheyhavepresentedfor5.ThatitisinthebestinterestsofthepatientthatthedoctortreatsthemwithoutparentalconsentPartofthe‘understandingprocess’includesthepatientdemonstratinginsightintothewidercontextualissuesoftheirrequest,withtheonusremaininguponthedoctorthatthisbesatisfactorilymet.TheGeneralMedicalCouncilhavealsoprovideddirectionforitsmembersofissuesofconsent,statinginsimilarfashionthat:“(adoctor)mustdecidewhetherayoungpersonisabletounderstandthenature,purposeandpossibleconsequencesofinvestigationsortreatments…proposed,aswellastheconsequencesofnothavingtreatment.Onlyiftheyareabletounderstand,retain,useandweighthisinformation,andcommunicatetheirdecisiontootherscantheyconsenttothatinvestigationortreatment”(http://www.gmc-uk.org/guidance/ethical_guidance/children_guidance_24_26_assessing_capacity.asp)(c)Thepatientchangeshermind.Cansherefusetreatment?(8marks)Apersonagedover18-yearsofagemayrefusetoprovideconsentforamedicalintervention,eveniftheirreasonsappearillogicaltoothers.Wherea16-to18-yearoldispresumed(rebuttable)competenttoconsentbystatute,thisisnotthesameforrefusaloftreatment.


Thisisprincipallybecauseachild’scapacityisdeterminedwithinthecontextofthedecisionbeingmade.WhereaGillickcompetentchild,oroneaged16-or17yearsold,refusesaninterventioninthefullknowledgethatsuchadecisionwillresultinharmortheirdeath,thecourtshaveoverruledonthebasisthatthechilddoesnotfullyunderstandthewiderimplicationsoftheirdecision,whichmayincludetheeffectonfamilymembers,themannerofdeathitself,andanypainandsufferingthatmaybeincurred.Theyarethen,bydefinition,lackingcompetence.Thecourtshavegonefurther:a14-yearoldwhorefusedalife-savingbloodtransfusionbecauseofherprofoundreligiousbeliefswasoverruledonthegroundsthatherupbringinghadanunavoidableandprofoundinfluenceonherdecision;shethereforelackedtheconstructiveformulationofbeliefsthatcomewithadultexperience.ShecouldnotbedeemedGillickcompetentasshelackedsufficientinformation,and,onthefacts,treatmentwasinherbestinterests.Thismayseemlikethecourtswieldingtoomuchpower;however,itmustberememberedthattheguidingprinciplesforthecourtsasoutlinedinthe‘ChildrensAct1989’isthatthewelfareorbestinterestsofthechildistheparamountconcern.Thegravertherisksofrefusal,thegreaterthelikelihoodthatrefusalwillbeoverruled.

answer booklet for saq paper one - apagbi · 2018. 3. 22. · left-to-right: asd, vsd, avsd, patent...

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