August 2015 CA-1 Basic Exam Prep

Stem:

A 58 year old male ICU patient is scheduled for diagnostic laparoscopy.

PMHx: The patient has a history of MI 2 months ago, chronic HTN, and DM.

Meds: Calcium and Magnesium replacement given in ICU, clopidogrel, metoprolol,

HCTZ, famotidine

Allergies: Procaine

PE: Vital Signs: HR = 78, BP = 138/79 mmHg, RR = 17, T = 37 C Weight: 70kg

CV: RRR
Airway: MP 2, FROM, normal mouth opening

Lab: Hgb 11.6, Ca = 13.4 mg/dL, Mg = 5.1 mg/dL

Intraoperative Management

1. How would you induce this patient?

2. Would you use paralytic for this case?

3. How would you monitor your neuromuscular blockade?

4. What is concerning about the patients preoperative lab values?

5. At the end of the case, you give reversal and after 10 minutes, the
patient has 3 twitches. How adequately reversed is the patient?

6. After the surgeon has closed skin, he asks if he can infiltrate local
anesthetic. What do you respond?

7. What is the maximum volume of 0.25% plain bupivacaine the surgeon

can use?

Postoperative Management
1. After extubation in the PACU, pt appears agitated and keeps asking
about a strange noise. What could be the cause?

2. The patient is also experiencing PONV. Could etomidate be a cause of

this?
3. In the ICU, patient continues to be hypotensive, has nausea and
vomiting, weakness, and disorientation. What could have caused this?
Extra Topic #1
A 10 year old male with PMHx of muscular dystrophy of an unknown type presents
for a distal radius ORIF. Prior to arriving in the holding area, the preop nurse has
applied EMLA cream to 4 sites to prepare for IV placement.
1. What is EMLA cream?

2. After IV induction and intubation, O2Sat is 85%. What would you do?
What do you think is the cause?

3. You suspect methemoglobinemia secondary to the EMLA cream. How

would you confirm? How would you treat?

4. Would you paralyze this patient? What concerns do you have?

Extra Topic #2
A 24 year old male presents from the ED for a dislocated shoulder reduction after a
fight in a bar. The patient is extremely agitated and angry, attempting to tear out IVs
and flip over the stretcher.
1. What would you do?

2. IV access is obtained. You decide to maintain anesthesia with a

ketamine infusion. How would you monitor depth of anesthesia?
Would you use a BIS monitor?

3. The Lab calls with a drug screen positive for PCP. How does this impact
your management?

4. The patient becomes acutely hypotensive and tachycardic. You note

that the abdomen is becoming increasingly distended. The decision is
made to perform exploratory laparotomy. How would you proceed?

5. After rapid sequence induction and intubation with succinylcholine,

you note increased tachycardia and flushing. Why?

6. You notice new peaked T waves on the EKG. What is the mechanism?
What further EKG changes would you expect?

7. After the surgery, the decision is made to leave the patient intubated
and sedated with a propofol drip. The surgeons ask how long the drip
will have to be off before the patient will be awake for neuro checks.
What will you respond?
Extra Topic #3
You are paged to the ED to intubate a 5 month old female. The ER physician states
that the patient presented with a history of nausea and vomiting at home, which
then progressed to weakness and now the baby had little muscle tone at all, and had
now stopped breathing. When the ER doc asked the parents about any new foods or
medicines, the parents stated that they began sweetening the babys oatmeal with
honey over the weekend to encourage her to eat more.

1. What are the possible causes?

2. How does the botulism toxin cause weakness?