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A Guide for study
2nd Edition
1955
By
ARTHUR B. TARROW
LT. COLONEL, UNITED STATES AR FORCE (MEDICAL CORPS)
33 Published By
THE LYDETTE PUBLISHING COMPANY
P. O. BOX 2566
SAN ANTONIO, TEXAS
UNIVERSITY OF MICHIGAN
MEDICAL LIBRARY
B A S I C S C I E N C E S I N A N E S T H E S I O L O G Y
(A Guide for Study)
By
A rthur B. Tarrow
Lt. Colonel, United States Air Force (Medical Corps)
B. A., M. D. - Syracuse University College of Medicine
M. S. (Anesthesiology) - Graduate School – Baylor University
Diplomate, American Board of Anesthesiology
Fellow, American College of Anesthesiologists
Assistant Professor of Anesthesiology, Graduate School,
University of Texas
Chief of Anesthesiology Section, Lackland Air Force Base,
San Antonio, Texas
Second Edition
Second Printing
ſ | dical
Kº D
r)
Á.
by
Arthur B Tarrow
Lt Colonel, USAF (MC)
All Rights Reserved
Published by
THE LY DETTE PUBLISHING COMPANY
P. O. Box 2566
San Antonio, Texas
Litho in U.S. A. by
The Fotolith Corporation
San Antonio, Texas
D E D I C A T I O N
To My Wife Anne
For Her Constant Support and Guidance
ii
F O R. E. W. O. R. D
"DEATH treads on the heels of pain -allaying substance, and if the
doctor wants to relieve pain he must come to terms with death. A
narcotic works only by throwing the patient into an artificial sleep
which is death's own brother; only by carefully devised means can the
doctor save from death those whom he has rendered in sensitive to pain.
Every doctor who relieves pain must measure his strength and skill
with DEATH. ''
– Fülop Müller
Anesthesiology is in a state at present similar to that of obstetric s in the latter half
of the 19th Century. At that time, relatively few cases were delivered by physicians and
even more rarely, did the se deliveries take place in hospitals. Queen Victoria's de –
livery of Prince Leopold in 1853 gave the specialty of obstetrics (and incidentally anes -
the siology) an incalcuable inpetus. Obstetrics became a more interesting specialty to
the medical profession from a scientific as well as financial viewpoint.
With their knowledge of Basic Sciences and their interest in scientific research,
the medical profession and fellow scientists soon brought about a remarkable advance
in the techniques of obstetrics and a steady decline in the morbidity statistics. Today
most people demand the services of a physician for deliveries and it is rare for this de –
livery to take place in the home.
It took the impetus of World War II to make the specialty of Anesthesiology interest-
ing to the medical profession as a whole. Surgical teams functioned smoothly. The
young, enthusiastic surgeons returning from the services, have welcomed the as sistance
of the large number of anesthesiology residents. A nesthesiology has become a budding
specialty with training centers scattered through the country.
It is in the se centers that Basic Sciences and scientific investigation are stressed.
Each physician is taught to be a teacher of others . There is no substitute for a know -
ledge of Basic Sciences when new frontiers are to be opened. It is from the se centers
that advances in techniques and the steady reduction of morbidity statistics will come.
iii
PREFA CE TO SECOND EDITION
The purpose of this manual is to help members of the medical profession prepare
for the examinations of the American Board of Anesthesiology. It cannot be used as a
substitute for comprehensive reading in the fields associated with an esthesiology. As
the title states, it is a guide for study. It should acquaint the student with the type of
questions asked so that he can slant his study methods in the proper direction.
The original organization of this manual, presented in the first edition has been
retained. The manual is divided into the five major divisions of the American Board of
Anesthesiology examinations in the Basic Sciences. Each of the five divisions has been
further sub-divided into the following:
1. Main Sub-Section - Questions available prior to 1949
2. Supplement l Sub-Section - Examinations given July, 1949
3. Supplement 2 Sub-Section - Examinations given July, 1952
A rearrangement has been made from the first edition in the bibliographies and out-
lines. In the first edition, each of the sub-sections had its own bibliography and only the
main section had an outline. In this edition, the bibliographies in the three sub-sections
have been combined and all three sub-sections are included in one outline.
The references for each question have been listed by name rather than by number.
Little credit can be taken by the author for Originality in the articles or techniques
mentioned. Credit is given in all instance s to the authors.
The author feels that the following books are useful not only for use with this manual,
but also as a basic list in starting a library:
ADRIANI, J. : The Chemistry of Anesthesia. Ed. 1, Spring field, Ill., Charles C.
Thomas, 1946.
A DRIA NI, J. : The Pharmacology of Anesthetic Drugs. Ed. 3, Springfield, Ill.,
Charles C. Thomas, 1952.
ADRIANI, J. : Techniques and Procedures of Anesthesia. Ed. 1, Springfield, Ill
Charles C. Thomas, 1947.
• 3
BARA CH, A. L. : Physiologic Therapy in Re spiratory Diseases. Ed. 2, Philadelphia,
Penn., J. B. Lippincott Co. , 1948.
BEST, C. H. and TAY. OR, N. B. : The Physiologic Basis of Medical Practice. Ed. 5,
Baltimore, Maryland, The Williams & Wilkins Co., 1950.
BOYD, W. : Textbook of Pathology. Ed. 5, Philadelphia, Penn., Lea & Febiger, 1947.
BURSTEIN, C. L. : Fundamental Consideration in Anesthesia. Ed. 1, New York, N. Y. p
Macmillan Co. , 1949.
COLLINS, V. J. : Anesthesiology, Ed. 1, Philadelphia, Penn., Lea & Febiger, 1952.
CULL EN, S. C. : Anesthesia in General Practice. Ed. 3, Chicago, Ilk
. , The Year Book
Publishers, 1951.
GILL ESPIE, N. A. : Endotracheal Anesthesia. Ed. 2, Madison, Wisc. , The University
of Wisconsin Press, 1948.
iv 5
GOODMAN, L. and GILLMAN, A. : The Pharmacological Basis of Therapeutics. Ed. 1,
New York, N. Y. , The Macmillan Co. , 1941.
GRAY, H. : Anatomy of the Human Body. Ed. 25, Philadelphia, Penn., Lea and
Febiger, 1948.
GUEDEL, A. E. : Inhalation Anesthesia. Ed. 2, New York, N. Y. , The Macmillan Co.
1951.
y
LUNDY, J. S. : Clinical Anesthesia. Ed. 1, Philadelphia, Penn. , W. B. Saunders Co.,
1942.
MACINTOSH, R. R. and MUSHIN, W. W. : Physics for the Anesthetist. Ed. 1, Spring-
field, Ill., Charles C. Thomas, 1946.
MCDONALD, J. J. , CHUSID, J. G. and LANGE, J. : Correlative Neuroanatomy. Ed. 5,
Palo Alto, California, University Medical Publishers, 1952.
PIT KIN, G. P. : Conduction Anesthesia. Edited by Southworth, J. L. and Hing son, R. A. ,
Ed. 2, Philadelphia, Penn., J. B. Lippincott Co. , 1953.
The following books are excellent additional reference texts:
BASIC SCIENCES FOR OR THOPEDICS: Veterans Administration, Ed. 1, Washington,
D. C. , U. S. Government Printing Office, 1948.
BEECHER, H. K. : Re suscitation and Anesthesia for Wounded Men. Ed. 1, Springfield,
Ill., Charles C. Thomas, 1949.
BEECHER, H. K. : Principles, Problems, and Practices of Anesthesia for Thoracic
Surgery. Ed. 1, Springfield, Illinois, Charles C. Thomas, 1952.
BONICA, J. J. : The Management of Pain. Ed. 1, Philadelphia, Penn., Lea and
Febiger, 1953.
CECIL., R. L. and LOEB, R. F. : A Textbook of Medicine. Ed. 8, Philadelphia, Penn.,
W. B. Saunders Co. , 1947.
CLEMENT, F. W. : Nitrous Oxide Oxygen Anesthesia. Ed. 2, Philadelphia, Penn.,
Lea and Febiger, 1945.
COURVILLE, C. B. : Untoward Effects of Nitrous Oxide Anesthesia. Ed. 1, Mountain
View, Calf. , Pacific Press Publishing Association, 1939.
GRINKER, R. R. : Neurology. Ed. 2, Springfield, Ill., Charles C. Thomas, 1937.
JUDOVICH, B. and BATES, W. : Pain Syndromes. Ed. 3, Philadelphia, Penn., F. A.
Davis, 1949.
KEYS, T. E. : The History of Surgical Anesthesia. Ed. 1, New York, N. Y., Schuman's,
1945.
KOLMER, J. A. : Clinical Diagnosis by Laboratory Examination. Ed. 2, New York, N. Y.,
Appleton Century Croft Corp., 1949.
LEIGH, M. C. and BELTON, M. K. : Pediatric Anesthesia. Ed. 1, New York, N. Y. ,
The Macmillan Co., 1948.
MOORE, D. C. : Regional Block: A Handbook for Use in the Clinical Practice of Medicine
and Surgery. Ed. 1, Springfield, Ill., Charles C. Thomas, 1953.
SAKLAD, M. : Inhalation Thera and Resuscitation. Ed. 1 * -
C. Thomas, 1951. py 1 OIl . 1, Springfield, Ill., Charles
I N A P P R E C I A T I O N
To: Dr. Ralph T. Knight, Professor Emeritus in Anesthesiology, the University
of Minnesota Medical School. This physician and gentlemen has always had great
respect for the Armed Forces because of his close contact with the services in both
World Wars. As one of the early pioneers in the teaching and practice of Anesthesiology,
he has always stressed the thought that Anesthesiologists are physicians and must
consider the patient as a whole. His gentlemanly bearing has been an inspiration to
many, not only in the practice of medicine, but also in the conduct of living.
To: The following members of the University of Minnesota Anesthesiology Division,
past and present, who as sisted in the preparation of questions in the Main Sub-Section:
Dr William E. Anders on
Dr Joe W Baird
Dr Ellis N Cohen
Dr Ernest F C rider
Dr Darrell B Faubien
Dr Christine Furman
Dr Ward R Johns On
Dr Charles F Keifer
Dr Wood row E Lomas
Dr Fred N Nolan
Dr Delbert F. Small
Dr Fredrick Van Bergen
Dr Stanley We solow ski
Dr David Wilsey
To: The following Residents in Anesthesiology, Lackland Air Force Base, who
did much of the original research on the questions in Supplement 2 Sub-Section:
Major John T Martin, USAF(MC)
Captain Robert J McCann, USAF(MC)
ARTHUR B T AR ROW
Lt.Col. USAF(MC)
vi
T A B L E O F C O N T E N T S
C H A P T E R I . . . Page 9 . . . . . . . . . . . . . . A N A T O M Y
C H A P T E R II . . Page 59 . . . . . . . . . . . . . P H Y S I O L O G Y
C H A P T E R III . . Page 444 . . . . . . . . . . . . . rathology
C H A P T E R IV . . Page 467 . . . . . . . PHY S I C S and C H E MIS T R Y
C H A P T E R V . . Pdge 217 . . . . . . . . . . . . P H A R M A C O L O G Y
A N A T O M Y
Chapter I
OUT LINE – A NATO MY
SYSTEM QUESTION NUMBER
RESPIRATORY Main Sect. Suppl. 1 Suppl. 2
1. Nasal and Oral Pharynx. . . . . . . . . . . . . . . 1, 7 13 sº - sº-
2. Larynx and Endotra cheal Intubation. . . . . 2, 3, 4, 5 15, 16 50, 5 1, 5.3
3. Bronchi. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6, 8, 9, 10, 1 1, 10, 1 1, 12, 47, 48, 49,
12, 1 3, 15 14 52
4. Lungs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 - - - 54, 59
CIRCULATORY, INCLUDING MEDIASTINUM 83, 84, 85, 89 55, 56, 57, 35, 37, 43,
42 45, 57, 60
MUSCULO-SKELETA L. . . . . . . . . . . . . . . . . . . 82, 86, 87, 88 58 55, 56
NERV OUS.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - - - 1 – 9 * - sº
1. Cranial Nerves. . . . . . . . . . . . . . . . . . . . . . 16, 17, 18 37, 38, 39, 12, 1 3, 23,
60, 6 1, 78 5 1, 52 24, 25, 26,
27, 28, 29,
44
2. Cervical Plexus. . . . . . . . . . . . . . . . . . . . . . 22, 23, 24, 23, 53, 54, 14, 16, 19
60
3. Brachial Plexus. . . . . . . . . . . . . . . . . . . . . . 25, 26, 27, 24, 25, 26, 15, 17, 18,
28, 29, 30, 27, 28, 29, 20, 21, 22
31, 32, 33, 47, 48, 49,
34, 35 50, 59
4. Thoracic & Abdominal Wall Nerves. . . . 36, 37, 38, 31, 43, 44 58
39, 40, 74, 45, 46
5. Lumbar Plexus. . . . . . . . . . . . . . . . . . . . . . *- * * 30, 32 30, 33, 34,
36
6. Sacral Plexus . . . . . . . . . . . . . . . . . . . . . . . 4 1, 42, 43, - - - 3 1, 32, 38,
44, 45 39, 40, 4 I
7. Sympathetic Nerves. . . . . . . . . . . . . . . . . 46, 47, 48, 33, 34, 35, 8, 9
49, 50, 5 1, 40, 4 l
52, 53, 54,
55, 56, 93,
94
8. Parasympathetic Nerves. . . . . . . . . . . . . . 62, 63 64 36 10
9. Mis cellaneous - Including Definitions,
Positioning. . . . . . . . . . . . . . . . . . . . . . . 90, 91, 92 - - - 42
10. Spinal Cord, Vertebrae, Cerebra. . . . . . 66, 67, 68, 17, 18, 19 1, 2, 3, 4,
Spinal Fluid, & Meninges. . . . . . . . . . . . . 69, 7 U, 71, 20, 21, 22 6, 7, 46
72, 73, 74,
79, 80, 81
11. Spinal Anesthesia. . . . . . . . . . . . . . . . . . . . * - sº * - sº- 5, 11
12, Paravertebral Blocks. . . . . . . . . . . . . . . . 75, 76, 77 wº- - - - - -
BIBLIOGRAPHY – AN: . A "TO. , Y
ADRIANI, J. : The Pºlai macology of An “sthetic Drugs. Ed. 3, Springfield, Ill.,
Charles C. T in ºn a s, 1952.
ADR] ANI, J. : Techniques and Procedures of Anesthesia. Ed. 1, Springfield, Ill.,
Charles C. 1 in ornas, 1947.
BASIC SCIENCES FOR OR THOPEDICS: Veterans Administration, Ed. 1, Washington,
D. C., U. S. Government Printing Office, 1948.
B EST, C. H. and TAYLOR, N. B. : The Physiologic Basis of Medical Practice. Ed. 5,
Baltimore, Md. , The Williams and Wilkins Co., 1950.
BONIC A, J. J. : The Management of Pain. Ed. 1, Philadelphia, Pa., Lea and Febiger,
1953.
CIBA PHARMAC E U TICAL PRODUCTS, Inc. Summit, N. J. : Control of Pain with
Saddle Block and Higher Spinal Anesthesia, 1948.
COLE, F. : C or respondence. Anesthesiology, 14:507 (Sept) 1953.
COLLINS, V. J. : Anesthesiology. Ed. 1, Philadelphia, Pa., Lea and Febiger, 1952.
CULLEN, S. C. : Anesthesia in General Practice. Ed. 3, Chicago, Ill., The Year Book
Publishers, 1951.
DOR LAND, W. A. N. : The American Illustrated Medical Dictionary. Ed. 22, Philadel-
phia, Pa., W. B. Saunders Co., 1951.
GILLE SPIE, N. A. : Endotra cheal Anesthesia. Ed. 2, Madison, Wisc. , The Univer –
sity of Wisconsin Press, 1948.
GRAY, H. : Anatomy of the Human Body, Edited by Lewis. W. H. , Ed. 25, Philadelphia,
Pa., Lea and Febiger, 1948.
GRINKER, R. R. : Neurology. Ed. 2, Springfield, Ill., Charles C. Thomas, 1937.
HOLT, L. E., Jr. and McINTOSH, R. : Holt's Pediatric. Ed. 12, New York City, N. Y.,
Appleton, Century, Croft, Inc., 1953.
JACKSON, C. and JACKSON, C. L. : Diseases of the Nose, Throat and Ear. Ed. 1.
Philadelphia, Pa., W. B. Saunders Co., 1947.
KESSLER, H. E. : Pentothal Sodium Anesthesia by Way of the Sternum: The J. of Oral
Surg. , 5: 106 (April) 1947. Abstract Anest. and Analg. 26: 128-129 (Nov-Dec) 1947.
KNIGHT, R. T. : Personal Corn munication.
LEIGH, M. D. and BE L T ON, M. K. : Pediatric An esthesia. Ed. 1, New York, N. Y. ,
The Macmillan Co. , 1948.
LUNDY, J. S. : Clinical Anesthesia. Ed. 1, Philadelphia, Pa., W. B. Saunders Co. ,
1942
1:ii
12
MACINTOSH, R. R. and MUSHIN, W. W. : Local Anesthesi, Brachial Plexus. Ed. 1,
Springfield, Ill., Charles C. Thomas.
MC DONALD, J. J. , CHUSID, J. G. and LANGE, J. : C or relative Neuroanatomy. Ed. 6,
Palo Alto, Calif., University Medical Publishers, 1952.
PIT KIN, G. P. : Conduction Anesthesia, Edited by Southworth, J. L. and Hing son, R. A. ,
Ed. 2, Philadelphia, Pa. , J. B. , Lippincott Co., 1953.
TAR ROW, A. B., TUR KEL, H. , and THOMPSON, M. S. : Infusions Via the Bone
Marrow and Biopsy of the Bone and Bone Marrow: Anesthesiology, 13:50 1 -509
(Sept) 1952.
1:iii
13
14
MAIN SUB - SEC TION
A NATOMY
Describe the anatomy or make a drawing to illustrate the upper respiratory tract
involved in placing a catheter for the or apharyngeal insufflation of oxygen for the
purpose of theraphy.
A. – See diagrams (A dr. Techs. , p. 344).
Describe the anatomy of, or make an anatomical drawing of, the parts involved
in passing tubes into the pharynx and trachea.
A. - See diagrams (Lundy, p. 458).
Explain the essential differences in the technique of laryngoscopy as advocated
recently by MacIntosh and the one commonly used.
A. - (Gille spie, p. 92, 93, - Lundy, p. 460 - 462).
In the MacIntosh technique the tip of the blade is inserted in the vallecula
anterior to the epiglottis (with patient in Supine position). When the laryngo scope
is lifted anteriorly, the epiglottis is lifted and the cords come into view. In the
technique using the Flagg, Lundy or Wisconsin blades, the tip of the laryngo scope
blade is inserted be neath the epiglottis (patient in supine position) and it is lifted
directly, exposing the cords.
Describe the larynx.
A. (Gray, p. 1108).
The larynx is the organ of voice, situated between the tra chea and the base of the
tongue. It is broad above presenting a triangular shape with base posteriorly. In –
feriorly, it is narrow and cylindrical. The following cartilages are found in the
larynx: Thyroid, cricoid, epiglottis, two arytenoids, two corniculates, and two
cuneiforms. These are connected by ligaments and are moved by intrinsic and
extrinsic muscles. The interior is lined with the same mucosa as that found in the
pharynx. The larynx extends from the superior aperture to the lower border of
the cricoid, and is divided into two parts by the true vocal cords, which are attach-
ed anteriorly to the thyroid cartilage and posteriorly to the arytenoids. The blood
supply is from superior and inferior thyroid arteries. The nerve supp' v is from
the vagus. The superior laryngeal nerve supplies sensory fibers for the entire
larynx and motor fibers to the crioid -thyroid muscle. The inferior laryngeal
nerve supplies the rest of the laryngeal muscles.
Which nerve is sensory to the larynx 2
(1) Superior laryngeal
(2) Inferior laryngeal
(3) Nerve of Wrisberg
(4) Glossopharyngeal
(5) Recurrent laryngeal
A. No. 1 (Gray, p. 940).
Sketch roughly the larynx, trachea, and main bronchi going to each pulmonary lobe
on each side, showing approximate levels against vertebrae, ribs. (Note: Be sure
to show the difference in the angles which the right and left main bronchi make with
the trachea).
A. - See diagrams (Gray, p. 112 l; Jackson & Jackson, p. 597).
} : 1
10.
1 1.
12.
The average distance from incisors to vocal cords in a normal adult male is:
(1) 5 cm
(2) 10 cm
(3) 13 cm
(4) 18 cm
(5) 22 cm
A. No. 3 (Gille spie, p. 62).
Every patient varies and it is advisable to measure endotra cheal tubes to fit each
individual. The tube is placed next to the patient's head in the natural curve and
cut off at that length which places the tip in the suprasternal notch. This allows
3 – 5 cm to the carina which is located at the level of the junction of the 2nd rib
with the sternun.
The average distance from incisors to the carina in a normal adult male is:
(1) 13 cm
(2) 17 cm
(3) 22 cm
(4) 26 crºn
(5) 29 cm
A. No. 4 (Gille spie, p. 130).
The trachea extends from:
(1) C4-C6
(2) C4-T6
(3) C6 - T5
(4) C2-C7
(5) T1 - T2
A. No. 3 (Gray, p. 1121).
The length of the trachea in a full term newborn is:
(1)
(2)
(3)
(4)
(5)
A. No. 3 (Collins, p. 390; Cole) See question 10, p. 1:22.
C II).
C rºl
C In
Crn
CIO.
:
:
Why use a shorter length tube in females 2
A. (Gray, p. 1121).
Shorter and smaller endotracheal tubes are needed for women be cause they usually
have a smaller larynx, trachea (both in length and diameter).
Describe briefly the size and relationships (to each other) of the two main bronchi.
A. (Gray, p. 1122).
The trachea is from 9.5 to 12.2 cm in length with a diameter of 1.6 cm and ex-
tends from C6 to T4 or T5.
l: 2 15
13.
14.
15.
16.
17.
Of the bronchi, the right bronchus is wider, shorter, and more vertical making
an angle of about 24 degrees with a median plane. It is 2.5 cm long, has a
diameter of 1.8 cm and enters the lung Opposite the fifth thoracic vertebra. The
left bronchus is smaller but longer and makes an angle of about 60 to 75 degrees
with the median plane. It is 5 cm. long and 1.6 cm. in diameter and enters the
lung opposite the sixth thoracic vertebra.
The right main bronchus leaves the trachea at about what angle:
(1) 5 degree s
(2) 25 degrees
(3) 45 degrees
(4) 65 degree s
(5) 90 degree s
A. No. 2 (Jackson and Jack son, p. 597).
The alveolar area in an adult lung is approximately:
(1) 10 square meters
(2) 20 square meters
(3) 40 square meters
(4) 50 square meters
(5) 100 square meters
A. No. 4 ( Best, p. 346).
Which one of the following statements is incorrect:
(1) The smallest bronchi contain cartilage.
(2) The cilia terminate in the re spiratory bronchioles.
(3) Smooth muscle terminates in the alveolar sacs.
(4) An alveolus is 1 cell thick.
(5) Terminal bronchioles contain secreting glands.
A. No. 3 (Gray, p. 1 136).
The alveolae do not contain smooth muscle but consist merely of a single
layer of mucosa and a small armount of adjacent connective tissue, which
contains the blood vessels and nerves.
Which is not a branch of the 5th nerve 2
(1) Ophthalmic
(2) Ciliary ganglion
3) Maxillary nerve
(
(4) Mandibular nerve
(5) Digastric nerve
A. No. 5 (Gray, p. 934).
The diga stric nerve is a branch of the 7th and supplies the posterior belly of the
diga stric muscle.
The Ophthalrnic is a division of what nerve 2
A. (McDonald, p. 65).
Trigeminal nerve.
16
1 : 3
18.
19.
20.
2 1.
22.
23.
What area of anesthesia is produced by blocking the maxillary division of the tri-
geminal nerve 2
A. (Gray, p. 928; Lundy, p. 184).
Blocking of either the left or right maxillary nerve in the pterygopalatine fossa
includes all of its branches distal to the block. For this reason, it is usually re-
served for operations on the maxillary sinuses and more extensive Operations
involving the maxillary bone or septectomies in the nose.
Anesthesia is produced in the upper jaw, antrum, the ethnoid sinuses, the nasal
mucosa (except for the distribution of the internal nasal and the anterior and pos –
terior ethnoids of the na sociliary nerve) the hard palate, the exterior of the face
(except for the areas of the mandibular and Ophthalmic divisions.)
(a) What is the location of the gas serian ganglion ? (b) How is it blocked ?
A. (A dr. Techs. , p. 27 l; Pitkin, p. 360).
The gas serian ganglion is usually blocked by injecting by the lateral route through
the foramen ovale. A few have blocked this ganglion by the orbital route through
the foramen rotundum and even fewer have tried by the supraorbital route through
the superior orbital fissure. It lies at the posterior extremity of the for armen
ovale, which is a canal, approximately 1 cm. long.
Which is not a division of the facial nerve 2
(1) Zygomatic
(2) Temporal
(3) Buccal
(4) Post auricular
(5) Sphenopalatine
A. No. 5 (Gray, p. 933)
The 7th nerve does not supply muscles of:
(1) Face
(2) Scalp
(3) Platysma
(4) Diga stric
(5) Sternorna stoid
A. No. 5 (Gray, p. 904).
The sternoma stoid muscles are supplied by the 11th nerve and the anterior
branches of Cervical 2 and 3.
Which divisions form the cervical plexus 2
A. (McDonald, p. 81). C 1 - C4
What landmarks are used in completing a left phrenic nerve block 2
A. (Lundy, p. 567; Pitkin, p. 443).
The needle is placed one finger breadth above the clavicle and between the sternal
head of the sternocleidomastoid muscle. The needle is advanced 2 cm. until fas-
cia is encountered. The fascia is pierced and the drug instilled. Lundy makes a
subcutaneous wheal one fingerbreadth above the clavicle and 1/4 - 1/2 inches deep.
It extends between the two heads of the sternocleidomastoid muscle.
1:4 17
24.
25.
26.
27.
The levator scapulae is innervated by:
(l)
(2)
(3)
(4)
(5)
A.
C 1 - 2 – 3
C2-3-4
C3-4-5
C4-5-6
C5-6 – 7
No. 2 (Gray, p. 426).
The brachial plexus is formed by:
(1)
(2)
(3)
(4)
(5)
A.
Ant. prim. divisions of C5, 6, 7, 8 and T 1.
Post. prim. divisions of C5, 6, 7, 8 and T 1.
Ant. prim. divisions of C5 6, 7, 8.
Ant, and prim. divisions of C5, 6, 7, 8 and T 1, 2.
Ant. prim, divisions of C2, 3, 4, 5.
No. 1 (Gray, p. 960; MacIntosh, p. 15).
The lateral, medial, and posterior cords of the brachial plexus get their name s
because of their relationship to :
(1)
(2)
(3)
(4)
(5)
A.
Subclavian artery
Scaleni muscle s
Axillary artery
Internal car otid artery
Cervical plexus
No. 3 (Gray, p. 960).
The axillary artery is a continuation of the subclavian after it reaches the lateral
border of the first rib.
What landmarks would be used and where would needle S be placed for blocking
the brachial plexus with a local anesthetic 2
A. (Adr. Techs. , p. 290; Lundy, p. 102; MacIntosh, p. 35).
LANDMARKS
(1) A point midway and I finger breadth above the superior border of the clavicle.
The midpoint of the Clavicle is obtained by bisecting the distance between
the acromio clavicular and ster no clavicular joints.
(2) The lateral border of the subclavian artery above the clavicle.
(3) The external jugular vein, rendered prominent by having the patient puff
out his cheeks.
PROCED URE
(1)
(2)
(3)
(4)
An intradermal wheal is raised one finger breadth above the midpoint of the
Clavicle, using procaine without adr enalin.
The subclavian arter y is pressed aside by the left index finger.
A needle (not attached to a syringe) is introduced through the wheal and ad-
vanced posteriorly, caudad and medially until the first rib is encountered.
In this area paresthesias occur in the distribution of the brachial plexus.
After four quadrant a spiration to insure that no vessel has been entered, 40–
50 cc. of 2% mety caine or procaine with 1 – 260,000 adrenalin is injected (or
20–25 cc. of 2% Xylocaine and 1 - 260,000 adr enalin).
18
28.
29.
30.
3 1.
(5) If no nerve paresthesias can be obtained, the three-needle technique of
Knight may be employed. 10-15 cc. of 2% solution is injected in the area
of the first rib where the original needle touches it. Two other needles are
placed 1 cm. on either side of this marker along the first rib. 10-15 cc. of
2% solution is injected in each of these two needles and the area massaged.
(6) A circlet of 1% procaine without adrenalin around the upper arm insures an es-
thesia for a tourniquet cuff. This is necessary because of the inter costobra-
chial and medial brachial cutaneous nerves which overlap on the upper arm.
Concerning brachial plexus block:
(a) What structures near the brachial plexus should the an esthetist avoid injuring
or piercing with the needle 2
(b) What area of anesthesia can be expected 2
A. (Adr. Techs. , p. 290; MacIntosh, p. 54).
(a) The following structures should be avoided:
(1) Subclavian artery and external jugular vein.
(2) The dome of the lung, which is located medial to and extends superiorly
above the first rib.
(b) Sensory anesthesia of the hands, for earm and upper arm to the deltoid, ex-
cept the medial aspect of the upper arm which is innervated by branches of
T 1 and T2.
What are the relation of the brachial plexus and :
(a) The scaleni muscles 2
(b) The first rib 2
(c) The long thoracic nerves 2
A. (MacIntosh, p. 15 - 19).
(a) In the neck the brachial plexus lies in the posterior triangle. It emerges be -
tween the anterior and medial scaleni muscles.
(b) As the upper, middle and lower trunks divide to form the medial, lateral and
posterior cords, they cross the anterior a spect of the first rib. The first rib
is an important landmark for the brachial plexus block.
(c) The long thoracic nerves arise from the 5th, 6th and 7th cer vical nerves at
their roots. The roots of the 5th and 6th pierce the medial scalene muscle
while that of the 7th passes anterior to that muscle. The long thoracic nerve
descends into the thorax behind the brachial plexus, resting on the surface of
the ser ratus anterior.
What are the anatomical relationships of the clavicle, the subclavian artery and
the subclavian vein 2
A. (Lundy, p. 103).
The vein is superficial and inferior to the artery. Both arch 1 to 1-1/2 cm. above
the superior border of the clavicle in its inner medial one-third. At the junction of
the middle and inner third of the clavicle the artery and vein pass beneath it. Thus
a needle placed 1 to 1-1/2 cm. above the superior border of the clavicle may pene -
trate the artery, particularly if it is not palpated and retracted by the index
finger of the hand not placing the needle.
In performing a brachial plexus block, a paresthesia of the radial nerve is elicited
(ant. approach). To get the rest of the plexus, the needle must be moved:
(1) Cephalad
(2) Posteriorly
(3) Laterally
(4) Medially
(5) Superior
1:6
19
32.
33.
34.
35.
36.
37.
A. No. 4 (Lundy, p. 103).
Using the three-needle technique of Knight the superior needles come nearest
the upper or lateral cord. The middle needle contacts the posterior cord and
the inferior needle contacts the middle cord.
The bice s receives its segmental innervation from :
(1) C2-C3
(2) C3-C4
(3) C4-C5
(4) C5-C6
(5) C6-C7
A. No. 4 (Gray, p. 432).
Draw a cross section near the elbow, showing and labeling the nerves that
innervate the hand and the landmarks helpful in locating these nerves.
A. See diagrams (Pitkin, p. 628–632)
Describe the sensory innervation of the hand. At what points are the sensory
nerves of the hand accessible for blocking with a local anesthetic 2
A. See diagrams - (Gray, p. 964, 965).
The ulnar nerve supplies the ulnar half of the hand (both dorsal and palmar),
including the small finger and half of the ring finger. The radial nerve supplie 3
the remainder of the dorsum of the hand. The medial nerve supplies the radial
half of the palmar surface and finger tips of the dor sum of the first, second, Jnd
third and one-half of the fourth fingers. The median nerve is available at the
brachial plexus, in the ante Cubital fossa, and at the wrist (at the level of the sty-
loid process of the ulna between tend ons of the palmaris longus and flexor carpi
radialis). The radial nerve is lateral to the biceps tend on in the ante Cubital fossa.
The ulnar : « ve may be blocked at the elbow or wrist by injecting to the radial
side of the xor carpi ulnaris at the level of the styloid of the ulna.
Numbness of the 5th finger and lateral part of the 4th finger may be due to pres–
sure injury of:
Radial Nerve
Ulnar nerve
Medial nerve
Musculo spiral nerve
Sural nerve
:
A.
N 2 (Gray, p. 964).
What nerves supply the anterior abdominal wall 2 Draw a diagram showing their
respective distribution.
A. See diagrams - (Gray, p. 976).
State the spinal root segments involved in the sensory cutaneous innervation at
(a) The nipple (b) The ensiform cartilage (c) The umbilicus (d) The pubis.
A. (Pitkin, p. 533).
(a) T4 (b) T6 (c) T 1 O (d) T 12 - Ll.
1 : 7
20
38.
39.
40.
4 l.
What inter costal nerves must be blocked, and at what points, in Order to produce
anesthesia of the abdominal wall 7
A. (Pitkin, p. 533–536).
By inter costal block of the lower six inter Costal nerves on a line drawn from the
third rib in the mid-axillary line to the posterior superior spine. The ilio in-
guinal, ilio hypogastric and genito-femoral nerves must also be blocked to insure
complete abdominal wall anesthesia.
From what nerve roots do the (a) ilio inguinal and (b) genitofemoral nerves arise,
and what is their sensory distribution ?
A. See diagrams - (Gray, p. 978).
Sensory Distribution:
(a) Ilio-inguinal nerve - This nerve passes with the spermatic cord through the
inguinal canal, and supplies the skin of upper and medial thigh, the root of
penis and scrotum and skin of the mons vener is and labia majora in the
female.
(b) Genito-femoral nerve - This nerve divided into (1) External spermatic nerve
which innervates the skin of the scrotum. (2) The lumbo -inguinal nerve -
which innervates the skin of the anterior upper thigh.
What nerve pathways must be interrupted to provide adequate regional anes the sia
for inguinal hernior rhaphy Ž
A. (Pitkin, p. 546).
The local her nior rhaphy block may be accomplished fol. Jw 3: (1) 1% procaine
with 1 – 260,000 adrenalin is used except for the skin heals when procaine without
adrenalin is used. (2) A superficial skin wheal is rºle le from the unbilicus to the
anterior superior spine. A second skin wheal is 1... e from the anterior superior
spine to the pubic tuber cle. (3) The distance betwee., the unbilicus and the an -
terior spine is trise cted and three needles are pushed through the wheal and just
through the deep fascia. 10 ccs. are injected through each of the three needles.
(4) The ilio-inguinal and ilio-hypogastric nerves are blocked just medially and
2-4 cm. deep to the anterior superior spine along the ilia C wing. (5) 10cc S. 1s
injected in a needle which is thrust through the deep fascia 3 cms. superior and
2 cms. laterally to the pubic ber cle. (6) With a finger in the external ring, a
needle is passed along the spermatic cord for 1 to 2 cms. in scie the ring and 10 cc s.
of the solution injected. If this is a good injection, there will be no need for later
injection along the neck of the sac. Thus the nerve pathways interrupted are
branches of T 10, 1 1, 12 and Ll.
What are the landmarks fo blocking the tibial nerve at its highest point (where it
leaves the sciatic nerve) 2
A. (Adr. Techs. , p. 306).
Bend of the knee. The angle formed by the semi-membranosus muscle and the
biceps tendon of the superior border of the popliteal space.
Technique: The bend of the knee is located and the angle between the above men-
tioned muscles evaluated. The angle is bisected by a line drawn vertically through
the popliteal space. A wheal is raised on this line 7 cm. above the fold of the knee.
A needle is pushed through the deep fascia and advanced from 1 to 1 1/2 cm. fur-
ther until the nerve is touched. 5 to 10 ccs. of 2% procaine with adrenalin are
injected if paresthesia is obtained or 20 ccs. in this area if none can be obtained.
1 :8 21
42.
43.
44.
45.
46.
47.
Describe a method for producing block anesthesia for a surgical procedure
involving a bunion.
A. (Adr. Techs. , p. 310).
(1) Procaine with 1-260,000 adrenalin may be used (or Xylocaine 1% with
1 – 260,000 adrenalin).
(2) A metatarsal block is begun by making a skin wheal 2 to 2-1/2 inches
proximal to the web of the second and great toe.
(3) 10 ccs. of 1% metycaine or procaine is infiltrated down into the sole of
the foot. 10 to 20 ccs. of metycaine or procaine are injected in a fan shape
into the web between the great toe and the second to e.
(4) A superficial skin circlet is made around the metatar sal bone from the
original wheal to the sole of the foot where the needle was originally felt.
This insures anesthesia of any cutaneous nerves which Overlap.
Following a successful caudal and trans – sacral block, what structures are
an esthetized 2
A. (Pitkin, p. 732; Lundy, p. 136).
Perineum, anus, lower rectum, vagina, cervix, prostate, and trigone of the
bladder.
Trans sacral block will not give regional anesthesia to:
(1) Upper scrotum
(2) Internal sphincter anus
(3) Trigone
(4) Prepuce
(5) Cervix
A. No. 1 (Ciba, p. 30).
Segmental innervation of the medial aspect of the heel is from :
(1) L3
(2) L4
(3) L5
(4) S 1
(5) S2
A. No. 4 (Bonica, p. 53).
(a) Name the divisions of the autonomic nervous system.
(b) With which nerves is each division as sociated ?
A. (Gray, p. 997 - 1000).
(a) Parasympathetic and sympathetic.
(b) The preganglionic fibers of the parasympathetic system leave the brain
with the 3rd, 7th, 9th and 10th nerves and the spinal cord with the 2nd, 3rd,
and 4th sacral nerves. The preganglionic fibers of the sympathetic system
leave the spinal cord in the anterior nerve roots of all the thoracic and the
lst, 2nd and 3rd lumbar nerves.
Pre-ganglionic sympathetic fibers have their origin in :
A. (Gray, p. 1004).
Cell bodies located in the inter mediolateral column of the thoracic and upper
3-4 lumbar segments of the spinal cord.
1:9
22
48.
49.
5 0.
5 1.
52.
53.
54.
Post-ganglionic sympathetic fibers have their origin in :
A. (Gray, p. 1004).
From the spinal cord, sympathetic fibers pass through the white rani communi-
cantes to the prevertebral sympathetic ganglia, where they may synapse or pass
up or down the chain and synapse several segments higher or lower. The se fiber s
may pass through the ganglia entirely to the large ganglia located close to the
organs innervated. (Celiac, pulmonary and cardiac plexuses). In either of the se
conditions, wherever they synapse, the post-ganglionics continue from the point
of synapse.
Gray rami carry what type of fiber 2
A. (Gray, p. 949; Best, p. 1075).
Sympathetic post-ganglionic efferents. See question 8, p. 1:34.
Why are preganglionic fibers called white 2
A (Best, p. 1074).
Because they have a myelin sheath, which is in contrast to the post-ganglionics
which are called gray and have no sheath.
Which do not carry sympathetic fibers ?
(1) Olfactory
(2) Oculomotor
(3) Facial
(4) Glossopharyngeal
(5) Pelvic
A. No. 1 (Gray, p. 1000) See question 36, p. 1:28
The pelvic nerve is the sacral portion of the parasympathetic nervous systern.
Which is incorrect about the stellate ganglion ?
(1) It occupies the lowest portion in the cervical sympathetic chain.
(2) It is made up of inferior cervical and first thoracic ganglia.
(3) The inferior cervical and first thoracic ganglia may be completely fused.
(4) It lies behind the first portion of the vertebral artery.
(5) It is anterior to the subclavian artery.
A. No. 5 (Adr. Techs. , p. 260).
In a stellate ganglion block the sympathetic ganglion blocked is :
(1) Middle and inferior cervical
(2) Inferior cer vical and D 1.
(3) Inter mediate and inferior cer vical
(4) D 1, 2
A. No. 2 (Adr. Techs. , p. 260).
What is Horner's Syndrome, and how is it produced 2
A. (Lundy, p. 158).
55.
56.
5 7.
Due to paralysis or section of cer vical sympathetics or central lesion causing
interruption in the cord of these sympathetic fibers. The results are unilateral
with "ptosis, miosis, enophthalmos, congestion or conjunctiva, increased
temperature and no sweating.
Finsterer is associated with:
(1) Anterior approach for splan chnic block.
(2) Posterior approach for splanchnic block.
(3) Transfusion of blood
(4) Transfusion of plasma
(5) Caudal block.
A. No. 1 (Lundy, p. 162).
Briefly describe the technique involved in performing an injection for relief
of disturbed circulation of blood in a case of "immersion foot''.
A. (Lundy, p. 159; Pitkin, p. 904).
The para vertebral approach is most generally taught: (1) The patient is placed
with affected side up with a pillow beneath him to insure opening the space between
rib margin and ilium. (2) The patient is prepared and draped. (3) A 5 inch needle
is inserted 2-1/2 finger breadths (4 cms. from the median) through a skin wheal
between transverse process of Tl2 and Ll. (4) Contact with body of vertebra is
made by directing the needle medially and anteriorly. The needle is withdrawn
and directed more vertically until it slip S off the anterior lateral aspect of the
vertebra. 10 to 15 ccs. of 1% procaine or metycaine with 1 - 260,000 adrenalin is
injected at this point. (5) A needle between Li and L2 is placed in similar rela-
tion to the anterior lateral surface of the vertebra and the same armount of solution
is injected.
The wide iateral approach with one needle is used in some clinics. (1) The
patient is prepared and draped as before. (2) The tip of the twelfth rib is found.
One fingerbreadth posteriorly and one finger breadth inferior to the tip of the 12th
rib an intradermal wheal is made (6 to 8 cm. from the midline of the back).
(3) A 5-6 inch gague 22 needle is inserted until the body of the vertebra is found.
(4) The needle is withdrawn and reins er ted in a more vertical direction until it is
felt to slip over the anterior edge of the vertebra. 20 ccs. of 1% metycaine with
1 – 260, 000 ad renalin is injected after careful aspiration has insured the lack of blood
or cerebral spinal fluid. (5) The tip of the needle is at the level of L2 and directly
on the sympathetic chain. The needle has passed posteriorly to the kidneys.
Discuss briefly, from the viewpoint of the anesthetist, the anatomical relationship
branches.
A (Gray, p. 938 . .
The right Vå gº & 11e rve after passing through the jugular for amen is joined by the
internai portion of the spinal accessory nerve and continues down in the car otid
sheath between internal caroticſ and internal jugular vein. In the lower part of the
neck it occupies a common sheath with the common car otid artery and the internal
jugular vein and is deep to them. It then passes in front of the first part of the
subclavian artery and descends in the thorax on the right of the tra chea to the back
of the root of the right ing. It then breaks up into a number of branches forming
the pulrnonary piexus. At the lower part of the thorax the fibers become associ-
ated in a cºrrºr on tº ºr k passing through the diaphragm supplying the stomach and
celiac plexus. The important branches of the vagus nerve to the anesthetist are:
(1) The superior laryngeal nerve which arises from the ganglion no do surn
(2) The recurrent nerve which arises from the vagus at the root of the neck
Passing around the subclavian artery and a scending to the lower border of the
cricoid cartilage forming the inferior laryngeal nerve (3) The vagus as it lies in
the thorax and abdorneº, and becomes subject to irritation.
1 : 1 1
24
58.
59.
60.
6 1.
62.
63.
64.
which nerve is in the same dural sheath as the vagus nerve, as it emerges
through the jugular foramina 7
A. (Gray, p. 939).
The 11th cranial nerve.
Which muscle does the superior laryngeal nerve innervate 7
A. (McDonald, p. 73).
Crico-thyroid.
Following major intrathoracic surgery laryngeal obstruction occurs. What nerve
or nerves has been injured 2
A. (Gray, p. 941).
The left recurrent laryngeal.
The inferior laryngeal nerve originates from:
(1) Vagus
(2) Hypoglos sai
(3) 7th Cervical
(4) Spinal accessory
(5) Gloss opharyngeal
A. No. 1 (Gray, p. 941 j.
Peristalsis of smal! 3:1te stine is augmented and inhibited by what nerves 2
A. (McDonald, p. 72).
Augmented by parasympathetics and inhibited by the sympathetics.
Distal colon and recturn receive motor innervation from :
A. (McDonald, p. 134}.
From the parasympathetics thrºugh the pelvic nerve.
What is the structure of the "pelvic nerve" 2
A. (Best, p. 1078).
It may be a single trunk or a plexifor nº structure derived from sacr 2, 3 and 4,
and carrying parasympathetic fibers to pelvic viscera.
Identify the following and indicate their significance in regional aris sthesia:
(a) Ligam enturn flavum
(b) Internal malleolus
(c) Pubic tuber cle
(d) Hyoid bone
(e) Anterior superior iliac spine
A. (Adr. Techs. J. 288, 309; Lundy, p. 1 i 6, 118).
(a) Thick plates or closely woven yellow elastic tissue interposed between two
adjacent vertebrae. The first connects the axis with the third cervical, and
66.
67.
68.
the last the fifth lumbar with the sacrum. Significance in regional anes thesia
is that in spinal punctures one receives a definite sensation as the needle
passes through the lingamentum flavum.
(b) The tibial nerve runs posteriorly in the leg until it reaches the interval be -
tween the medial malleolus and the heel where it divides beneath the la ciniate
ligament into the medial and lateral plantar nerves. It may be blocked at this
point easily.
(c) Used as a landmark when doing field blocks for an inguinal her nior rhaphy. So-
lution is injected in the space above the pubic tubercle and in the preve sical
Spa Ce.
(d) Used as a landmark for blocking the superior laryngeal nerves. The thumb and
index finger of the left hand search the groove between the hyoid bone and the
thyroid cartilages, the hand is moved to and fro until the groove is definitely
palpated. Then the hand is brought to rest so that the tip of the left thumb and
of the left index finger fall short of the cornua of the hyoid bone.
(e) This is used as a landmark for producing regional an esthesia and field block
for repair of inguinal hernia – a wheal two finger breadths from the anterior
superior ilia C spine along an imaginary line to the unbilicus. Some infiltra-
tion may be required from the anterior superior iliac spline to a point over -
lying the external ring. For bilateral hernias injection is carried out from the
anterior superior spine on One side to the corresponding spine on the other
side in an arch passing just under the unbilicus. This is also a landmark for
blocking the lateral femoral cutaneous nerve.
With an individual in the Supine position, what typical curves are as sumed by the
normal spinal column 2 Locate each.
A. (Pitkin, p. 788).
There are two curves with concavity anteriorly – the thoracic and the sacral, and
two curves with convexity anteriorly - the cer vical and lumbar. The cer vical
curve extends from C1 to T2; the thoracic from T2 to T 12; the lumbar from T 12 to
L5, and sacral, from S1 to coccyx. There is also a slight lateral curve with con –
vexity to the right. The sacral and thoracic curves occur primarily, the lumbar
and cervical, later as the erect posture is a s sunned.
Describe the coverings and relations of the spinal cord.
A. (Gray, p. 901 – 907).
The Coverings from without-in are: (1) Dura mater is a tough fibrous membrane
which terminates at the 2nd sacral vertebra. (2) Between ligaments of the vertebrae
and the dura is epidural space filled with areolar and fatty tissue, lymph and bloou
vessels. (3) Between the dura and arachnoid is the subdural space which contains
a small amount of fluid. (4) The arachnoid is a thin, transparent membrane separat-
ed from the pia mater by a wide subarachnoid cavity which contains the spinal fluid.
(5) The pia mater closely invests the spinal cord and sends septa into its substance.
The human spinal cord has certain fiber tracts which carry sensation. Pain and
temperature are carried by:
(1) The column of Bell
(2) The direct cerebellar tract
(3) The spin othalamic tract
(4) The dorsal spino cerebellar tract
(5) The direct pyramidal tract
A. No. 3 (Gray, p. 780).
26
69.
70.
7 l.
72.
73.
The total volume of cerebro spinal fluid in an adult is about:
(1) 25 cc.
(2) 75 cc.
(3) 130 cc.
(4) 200 cc.
(5) 250 cc.
A. No. 3 (Best, p. 1070).
Draw and label a typical spinal nerve, showing roots, ganglion, branches and
connections to the sympathetic or autonomic gangliated cord.
A. See diagrams - (Gray, p. 949).
Spinal ganglia are found on the posterior roots except:
(1) Cl
(2) C3
(3) C5
(4) C 8
(5) T 1
A. No. 1 (Gray, p. 948).
The posterior root of C-1 may be wanting or much smaller than the anterior root.
Describe the epidural ("peridural") space. What is its significan Ce in regional
anes the sia 2
A. (Pitkin, p. 731 - 739).
The epidural space is that area between the dura and the bony layer of the vertebra.
It is filled with adipose tissue with a rich Venous network and is easily stripped
from the dura by fluid. The space is small in the cervical area but is larger in the
center of the thoracic region where there is reduced size of the spinal cord. In the
lumbar area it is triangular shaped and large. In the sacral area, the dura is
closely adher ent anteriorly. It may be used for segmental anesthesia. The anes –
thetic agent does not spread rapidly and there is no fear of central paralysis or
dural headaches as in spinal anesthesia because the space terminates at the foramen
magnum. There is little fall in blood pressure. There is no direct contact with the
spinal cord. In 20 minutes with the average dose, anesthesia spreads over a zone
of 2 to 4 pairs of spinal nerves. Finally, 8 to 10 pairs of spinal nerves will be af-
fected with some hyper esthesia at the edge S. Voluntary movement is somewhat
affected but the greatest loss is sensory. This type of an esthesia has the disadvan-
tage of unequal spread; thus one may have anes the sia from T6 to T 10 with a small
area at T8 unanesthetized. The caudal block is one form of epidural anes thesia.
Concerning Continuous Caudal anes thesia :
(a) To what sensory level (in terms of spinal segments) must anesthesia be pro-
duced to give relief from pain in labor and delivery.
(b) To what level (in terms of spinal segments) does sensory an esthesia usually
rise when uterine contractions are stopped by the anesthesia 2
(c) What are the landmarks used in introducing the caudal needle 2
(d) what anatomic structures must the anesthetist avoid injuring or piercing, when
using the caudal needle to effect caudal anesthesia 2
A. (Pitkin, p. 758).
74.
76.
Caudal anesthesia - The birth canal is supplied by somatic nerves of the lumbo-
sacral plexus with a few fibers from T-1 1 and T-12. Pain impulses of labor are
transmitted through the 11th and 12th thoracic nerves. Motor impulses to the upper
uterine segment a rise from the upper sympathetic ganglia (thoracic) and run in the
fibers of the celiac, aertic, renal, and hypogastric plexus, and then along the blood
vessels to the uterus. The lower uterine segment and cervix receive their nerve
supply through the parasympathetic fibers of the 2, 3 and 4 sacral nerves.
(a) To give relief from pain in labor and delivery anes thesia must extend to the
1 I th thoracic spinal segment.
(b) Uterine contractions are stopped when an esthesia reaches the 6th thoracic
spinal segment.
(c) Landmarks used in introducing the caudal needle are (1) tip of coccyx
(2) sacral cornua (3) triangular hiatus.
(d) The following anatomical structures must be avoided when performing a
caudal puncture (1) dural and arachnoidal sac (2) venous plexus lining wall
of caudal Canal.
The root of the spine of the s capula is at:
(1) T2
(2) T3
(3) T4
(4) T5
(5) T6
A. No. 2 (Gray, p. 1367).
(a) Describe the sensory innervation of the neck.
(b) What landmarks would be used and where would needles be placed to produce
an esthesia of the neck by paravertebral injection by the lateral route 7
A. (Lundy, p. 91).
(a) The anterior division of the first 4 cer vical nerves emerge from the inter-
vertebral for a men, passes behind the vertebral artery to the tip of the trans –
verse process of the vertebra. At the tip of the transverse process it
divides into as cending and descending branches which inter connect to form
the cer vical plexus. The superficial cer vical plexus emerges at the posterior
edge of the stern ona stoid muscle and supplies the skin and superficial stru C –
tures. The innervation is in the form of a ''Monk's Hood'' – the area from
behind the ear over the head and a cross the shoulders.
(b) The transverse process of the 2nd cer vical vertebra lies one finger breadth
inferior to the tip of the nastoid process. The transverse process of the
4th cer vical vertebra lies midway between the mastoid process and the Clavi –
cular head of the sterno cleidoma stoid muscle. It may frequently be palpated.
Midway between these two transver se processes lies that of the 3rd cer vical
vertebra.
In the lateral approach, the needles are placed at the tips of the transverse pro-
cesses. Injection is also made along the posterior border of the sternonastoid
nus cle to insure block of the superficial cervical plexus.
Using segrinental block in visceral surgery:
(a) Which thor a co-lumbar sympathetic ganglion or ganglia
(b) Which cord segments must be blocked for surgery on the
(1) Appendix
(2) Spleen
28
77.
78 .
(3) Fundus of the uterus
(4) Cervix
(5) Sigmoid
(6) Bladder
(7) Hernia
A. (Pitkin, p. 594- 6 14).
(l) a. Superior mesenteric ganglia
b. Right Thoracic 1 1, 12 and L 1
(2) a. Coeliac ganglion
b. Left 6, 7, 8, 9, 10, 11, 12 (as sisted by inter costal block if
the organ is large).
(3) a. Hypogastric and pelvic ganglia
b. Bilaterally - T 10, 1 1, 12 and L (Caudal)
(4) a. Hypogastric and pelvic plexus - if done
b. Bilaterally - T 11, 12 and 1 st 4 sacrals (caudal)
(5) a. Inferior me senteric plexus
b. Bilaterally - T 10, 1 1, 12, L 1, plus sacral (Caudal)
(6) a. Inferior me senteric plexus - if done
b. Bilaterally – T | 1 , 12, L 1, plus sacrals (Caudal)
(7) a. Not done
b. Unilateral – T 12, L 1, L 2.
What landmarks are used and how are they used in placing a needle for :
(a) Paravertebral block of the sixth right thoracic nerve 2
(b) In the second lumbar inter space 2
(c) In the caudal canal 2
(d) In the second sacral for an en 2
A. (Gray, p. 1367; Lundy, p. 142, 147).
(a) A line connecting the two inferior angles of the scapulae passes through the 7th
thoracic vertebra, when a per son is erect with hands at sides. The root of the
spine of the scapula passes through the spine of the third thoracic. Count up
two spinous processes to locate the fifth. Check by counting down from C1 and
T3. Draw a line 4 crh. from and parallel to the midline. Raise a wheal 4 cm.
and at the level of the 5 in Spinous process. Insert needle perpendicular to skin
until the transverse process is encountered. Then direct needle 45 degrees
caudal to glance off the lower edge of this process until the one adjacent to the
6th intervertebrae space is found.
(b) Line between iliac crests passes through 4th inter space. Count up two inter-
spaces. Check by 12th rib and vertebra.
(c) The coccyx is palpated in gluteal cleft. De pression at sacro-coccygeal joint
corresponds to sacral hiatus. The sacral cornua can be felt on either side of
the hiatus. The needle is introduced through the hiatus passing through the lig-
annent into the canal.
(d) One centimeter caudad and one centimeter medial to the posterior superior
iliac spine.
Branches of Trigeminal pass through certain for armen. Which does not apply:
(1) Infraorbital
(2) F. Spinosum
(3) F. rotundum
(4) Mental for armen
(5) F. ovale
A. No. 2 (McDonald, p. 65).
1 : 16 - 29
79.
80.
8 1.
82.
83.
84.
In the roof of the 4th ventricle of the brain is located:
(1)
(2)
(3)
(4)
(5)
A.
For annina of Luschka
For annina of Monroe
Aqueduct of Sylvius
For annen of Magendie
Cisterna magna
No. 4 (Gray p. 815).
A cervical vertebra can be easily distinguished by:
(1)
(2)
(3)
(4)
(5)
A.
(a)
(b)
(c)
(d)
(a)
(b)
(c)
(d)
The
(l)
(2)
(3)
(4)
(5)
A
Costal pit on the transverse process
Bifid spinal process
Large size of the body
Horizontally projecting spine
Triangular shaped vertebral foramen
No. 2 (Gray, p. 92).
Give the relationship of the Cervical nerves to their corresponding
vertebrae.
Give the level of the cricoid cartilage in relation to the vertebra.
Give the relationship of the vertebral artery to the cervical transverse pro-
C 62 S S e S .
Give the level of the upper border of the thyroid cartilage in relation to the
cer vical vertebrae.
(Gray, p. 95 1, 1109).
The first cervical nerve emerges from the vertebral canal between the
occipital bone and the atlas and is called the suboccipital nerve. Therefore
the 2nd issues from below the 1st cervical and so on.
At the 6th cervical vertebra
Passes through foramina of the transverse process.
At the 4th cervical vertebrae.
mylohyoid muscle:
Draws the pharynx upward
Prevents food from entering the larynx
Approximates the facial pillars
Presses the tongue against the hard palate
Closes the Opening to the na sopharynx
No. 4 (Gray, p. 373; Best, p. 560) See question 56, 1:46.
What is the origin of the vertebral artery 2
A.
The
(Gray, p. 580).
first part of the subclavian artery.
Locate the most accessible veins in the upper and lower extremities available
for intravenous therapy. (Illustrate with drawings if you wish).
A.
See diagrams - (Lundy, p. 592).
30
1 : 1 7
85.
86.
87.
88.
89.
90.
Make a diagrammatic drawing of a sagittal section of the adult sternum to indicate
the ess ential anatomy for properly placing a needle for marrow cavity injections.
Show the position of the properly placed needle.
A. (Tarrow; Kessler).
The needle should point cephalad and should be inserted in the midline opposite the
third rib, below the manubrio-sternal junction. It may also be placed in the man-
ubrium just above this junction.
Give the innervation of the diaphragm and name the important structures passing
through its orifices.
A. (Gray, p. 389).
The diaphragm is supplied with motor fibers by the phrenic nerve and with sensory
fibers by the phrenic and lower five or six inter costal nerves. The important
structures passing through its openings are - a Orta, esophagus, vena Cava, greater
and lesser splan chnic nerves, anu the hermia zygous vein.
In forced inspiration what muscles are brought into action ?
A. (Gray, p. 391).
The trapezius, ser ratus anterior, pectoralis and latis simus dorsi as sist the usual
mus cles when the shoulder and vertebral borders are fixed. The scaleni and the
sternocleidomastoid come into play when the head becomes stationary. The an-
terior abdominal muscles by tightening allow the diaphragm to pull harder on the
lower ribs.
The midule madia stinum contains all but one of the following:
(1) Heart
(2) Right vagus
(3) Right phrenic
(4) Pericardium
(5) Left phrenic
A. No. 2. (Gray, p. 1128).
This is contained in the superior mediastium.
What is the correct relationship of structures in the femoral canal 2
A. (Gray, p. 601).
The relationship of the structures in the femoral canal is important when doing a
fermoral nerve block. From medial to lateral, the relationship is vein, artery,
nerve (VAN). A finger is placed on the femoral artery and the solution placed
lateral to it.
In considering the contents of the inguinal canal, which is not included ?
(1) Cremasteric artery (branch of deep epigastric)
(2) Deep epiga stric artery
(3) Genital branch of the genito crural nerve.
(4) Inguinal branch of the ilio-inguinal nerve.
(5) Hypogastric branch of ilio -hypogastric nerve.
A. No. 5. (Gray, p. 406).
1 : 18 3 |
91.
92.
93.
The clue to the answer to this question is the word "contents'." The C remasteric
artery (or external spermatic artery) accompanies the spermatic cord in the canal.
The deep epigastric artery (or inferior epigastric artery) curves along the lower
and medial margins of the internal inguinal ring and behind the commencement of
the spermatic cord. It is one of the landmarks for the hernioplasty operation. The
genitocrural nerve (or genitofemoral nerve) gives off a branch called either the
genital branch or the external spermatic nerve, which passes through the abdominal
inguinal ring and is part of the contents. The inguinal branch of the ilioinguinal
nerve accompanies the spermatic cord through the subcutaneous inguinal ring and
is distributed to the medial aspect of the thigh near the scrotum. This leaves
answer 5. This nerve never actually is in the Canal but lies between the internal
oblique and the tras versus muscles. It perforates the external oblique about 2.5
cm. above the subcutaneous inguinal ring and is distributed to the skin ther e.
Which is the safest position p Os top eratively for a patient in deep an e s the sia :
(1) Prone
(2) Prone with foot elevated
(3) Supine
(4) { lateral with foot of bed elevated
(5) Supine with head elevated
A. No. 4 (Adr. Techs. , p. 169).
In this position vomitus is most easily disposed of by the patient and the tongue
has less tendency to obstruct the air way. Besides this, there is little interference
with chest expansion which may occur with p r one positions.
State:
(a) Distance from teeth to vocal cords in average adult male.
(b) The nerve supply (sensory and notor) of the an us.
(c) The position of the conus medullaris (inferior end of spinal cord) in relation
to the vertebral column in the adult.
(d) The position of the conus medullaris in relation to the vertebral column in the
infant.
(e) The segments of the spinal cord from which the phrenic nerve takes its origin.
A. (Gille spie, p. 130; Gray, p. 767, 958, 1232).
(a) I 3 crºn.
(b) The levator ani muscle and sphincter ani externus are supplied by the fourth
sacral nerve and the inferior in err, or rhoidal branch of the puclencial - Ser, sory
nerve is the inferior hernor rhoidal nerve which arises from the puC endal
which a rises from 2nd, 3rd , and 4th sacral nerves.
(c) Conus medulla ris begins at the upper level of the 2nd lumbar vertebrae and
extends to the first segment of the coccyx as the filum terminale.
(d) At birth the conus medullaris is located at about the 3rd lumbar vertebrae.
(e) Phrenic nerve arises mainly from 4th cervical nerve but receives branches
from the 3rd and 5th also.
When postganglionic sympathetic fibers are cut, what happens to the adr enalin
sensitivity ?
A. (Basic Science of Orthopedics, p. 5-6).
This sensitivity is increased. Following preganglionic sympath ectormy however
the post ganglionics do not degenerate and the sensitivity of the effector organ to
adrenalin is only moderate. Thus in sympathectomy for the lower limb, only the
2-4 L ganglia are removed. The 5th L and all sacral ganglia are preserved and
the refore the greater number of postganglionics which supply the more peripheral
parts of the limbs survive. Marked sensitivity to adrenalin does not develop in
this peripheral area.
32
94.
What are tests for successful sympathetic denervation ?
A. (Basic Sciences for Orthop edics, p. 7).
Absence of sweating on exposure to heat, absence of goose-flesh on application of
ice, marked vas constriction (visible) following intrarnuscular injection of very
dilute adr enalin.
1 :20
33
SUPPLE MENT I SU B SECTION
ANA TOMY
l. The motor nerve to the face is the .
(1) Infraorbital
(2) Trigeminal
(3) Glossopharyngeal
(4) Facial
(5) Maxillary
A. No. 4 (Gray, p. 931).
2. The facial nerve does not supply motor fibers to which one of the following
muscles:
(1) Muscles of the face
(2) Muscles of the scalp
(3) The platysma
(4) The digastric
(5) The ster nonna stoid
A. No. 5 (Gray, p. 93 1).
The sternoma stoid receives its innervation from Cranial l l and Cervical 2 and 3.
3. The motor nerve supply of the tongue is from the :
(1) Lingual nerve
(2) Hypoglossal nerve
(3) Glossopharyngeal nerve
(4) Vagus nerve
(5) Mandibular nerve
A. No. 2 (Gray, p. 943).
4. The mandibular branch of the fifth cranial nerve passes through the :
(1) for annen ovale
(2) optic for an en
(3) foramen spinosum
(4) for annen vesalii
(5) foramen rotundum
A. No. 1 (Gray, p. 923).
5. The mandibular nerve is a branch of the :
(l) Olfactory
(2) Optic
(3) Oculornotor
(4) Trigeminal
(5) Facial
A. No. 4 (Gray, p. 923).
34 1:21
10.
l 1 .
The lacrimal nerve is a branch of which of the following cranial nerves 2
(1) Olfactory
(2) Optic
(3) Oculomotor
(4) Trochlear
(5) Trigeminal
A. No. 5 (Gray, p. 914).
The lacrimal nerve is the smallest of the three branches of the ophthalmic. It
supplies the la crimal gland, the conjunctiva, and skin of the upper eye lid.
Which of the following is not a branch of the first division of the trigeminal nerve 2
(1) La Crimal
(2) Middle meningeal
(3) Infratrochlear
(4) Long ciliary
(5) Rami of the external nasal
A. No. 2 (Gray, p. 920).
The middle meningeal is a branch of the maxillary nerve just after its origin from
the gas serian ganglion. It follows the middle meningeal artery.
The sphenopalatine ganglion is located:
(1) In front of the for annen ovale
(2) Near the infraorbital for annen
(3) At the pterygopalatine fossa
(4) At the base of the tongue
(5) In the anterior cranial fossa
A. No. 3 (Gray, p. 921).
Indicate the one incorrect relationship in the following statements:
(1) Foramen rotundum – maxillary nerve
(2) Stylomastoid for annen - facial nerve
(3) Jugular for annen – glossopharyngeal nerve
(4) Inferior orbital fissure – optic nerve
(5) Foramen ovale – mandibular nerve
A. No. 4 (Gray, p. 1 13).
The optic nerve enters the orbit through the optic for amen. The maxillary nerve
is the main nerve entering the orbit through the inferior orbital fissure.
The distance from the cords to the carina in a newborn baby is:
(1) 1-1/2 crim.
(2) 7 CII l.
(3) 5 CII] .
(4) 9 CIYl.
(5) 11 CIY) .
A. No. 3 (Collins, p. 390; Cole) See question 10, p. 1:2.
The distance from the lips to the birucation of the tra chea in an average adult is:
(1) 12 cm.
(2) 18 cm.
12.
13.
14.
(3) 22 cm.
(4) 28 cm.
(5) 33 cm.
A. No. 4 (Gillespie, p. 130).
The usual figure given is 26 cm. from the incis or teeth. In any event there is
enough variation so that answer 4 is most nearly correct. The Corina is located
at the level of the Angle of Louis and each patient can be measured for an endo –
tracheal tube length by insuring that the tip of the bevel goes no further than the
suprasternal notch.
In the normal adult male, the bifurcation of the tra chea is at the level of the
7th cer vical vertebra
2nd thoracic vertebra
5th thoracic vertebra
7th thoracic vertebra
9th thoracic vertebra
:
A. No. 3 (Gray, p. 1 121).
Under which set of conditions will oxygen therapy by catheter be most likely to
a chieve its purpose in the average adult 2
(1) When the tip of the Catheter is on a level with the tip of the uvula, with several
holes in the distal inch of the Catheter.
(2) When the tip of the catheter is just short of the depth at which swallowing
occurs, with holes in the distal 1/4 in. Of the catheter.
(3) When the catheter is inserted to a distance equivalent to that from the tip of
nose to the external auricular Orifice.
(4) When the tip of the catheter is in the nasopharynx, with holes in the distal
1 / 4 in. of the catheter.
(5) When the tip of the catheter lies 3 inches beyond the nares.
A. No. 2 (Adr. Techs. , p. 34.2).
This will place the tip of the catheter in the nasopharynx above the level of irrita-
tion of the swallowing or gagging reflex and below the level of leakage of air
through the nostrils. Holes should be perforated in the last inch to insure against
blockage. This is a poor question.
Which of these statements is correct 2
(1) If an endotra cheal tube is inserted too deeply, it is more likely to enter the
left bronchus than the right.
(2) If an endotra cheal tube is placed in the right bronchus, it may occlude the
eparterial bronchus.
(3) If an endotra cheal tube is placed in the left bronchus, it will often occlude the
branch to the lowe r lobe.
(4) The left bronchus is more directly in line with the tra chea than is the right.
(5) The left bronchus has three main branches.
A. No. 2 (Gille spie, p. 132; Gray, p. 1 122; Jackson, p. 597).
The right bronchus is almost a direct continuation of the trachea, branching at an
angle of 25 degrees. The eparterial bronchus to the right upper lobe commences
about 2 cm. from the cornia. An endotra cheal tube is most likely to enter the
right bronchus and because of the close approximation of the eparterial bronchus,
to occlude it.
36
1 23
15.
16.
17.
18.
1 9.
The sensory innervation of the interior of the larynx is derived from:
(1)
(2)
(3)
(4)
(5)
A.
The
The
(1)
(2)
(3)
(4)
(5)
A.
Anterior cer vical nerves
Vagus nerves
Phrenic nerves
Ansa hypoglossi
First inter costal nerves.
No. 2 (Gray, p. 940).
superior laryngeal branches.
vocal cords are attached anteriorly to:
Thyroid cartilage
Cricoid cartilage
Epiglottis
Arytenoids
Corniculate cuneiform Cartilages.
No. 1 (Gray, p. 1 1 16).
Posteriorly, the vocal cords are attached to the ary tenoids.
In the newborn, the spinal cord usually extends :
(1)
(2)
(3)
(4)
(5)
A.
To the first lumbar vertebra
To the 12th thoracic vertebra
Through the entire length of the vertebral canal
To the third lumbar vertebra
To the first sacral vertebra
No. 4 (Pitkin, P. 83 l ).
Up to the third month of uterine life the spinal Cord O C Cupies the entire length of
the vertebral canal, but by parturition the inferior end of the cord is at the level
of the body of the 3rd lumbar vertebra.
border of the 1st lumbar vertebra.
In the adult, the cords end at the lower
Indicate the incorrect statement regarding spinal fluid.
(1)
(2)
(3)
(4)
(5)
A.
The
(1)
(2)
(3)
(5)
Spinal fluid is considered as a chor oid plexus filtrate.
Specific gravity of spinal fluid is approximately 1.006.
Protein content of spinal fluid is lower in the ventricles than in the lumbar
region of the cord.
The foramen of Magendie allows passage of spinal fluid from the fourth ven-
tricle to the subarachnoid space.
Spinal fluid is normally slightly xanthochromatic.
No. 5 (Grinker, p. 152).
majority of fibres conveying pain sensation ascend the spinal cord in the .
Cortico – spinal tract
Lateral spin othalamic tract
Ventral spin othalamic tract
Rubro spinal tract
Vestibulospinal tract
No. 2 (Gray p. 781).
20.
21.
22.
23.
24.
The highest point of the spinal curve with the patient in the supine position is
which one of the following 2
(l) L-4 (4) 3rd lumbar inter space
(2) L-3 (5) 4th lumbar inter space
(3) L-2
A. No. 2 (Gray, p. 93; Grinker, p. 55; Pitkin, p. 788).
According to Gray, the lower three lumbar vertebrae have a greater convexity
than the upper two. Grinker states that the supine position straightens out the
lumbar curve somewhat. Pitkin states that L3 is at the greatest convexity in the
supine position.
A normal adult, in a supine, horizontal position has the lowest point of the thoracic
spinal curvature at:
(1) T-2
(2) T-5
(3) T-7
(4) T-9
(5) T – 1
A. No. 3 (Gray, p. 93)
l
The normal adult spinal Column contains about:
(1) 5 to 10 cc. spinal fluid
(2) 20 to 30 c.c. spinal fluid
(3) 50 to 60 cc. spinal fluid
(4) 100 to 1 15 cc. spinal fluid
(5) 150 to 175 cc. spinal fluid
A. No. 2 (Best, p. 1070; A dr. Chen. , p. 51).
The total armount of fluid is from 130 – 150 cc. but the amount in the spinal column
is only 20–30 cc. Therefore the addition of large volumes of an esthetic mixtures
when 10 – 15 cc. are used (as with light nuper Caine) will for ce the level of anes -
thesia quite high.
Select the incorrect statement. The phrenic nerves:
(1) A rise from cervical 3, 4 and 5.
(2) Give branches to the adrenal glands and liver.
(3) Lie in the mediastinum posterior to the root of the lung
(4) The left phrenic nerve is longer than the right
(5) Most branches supply the diaphragm after pier cing it to the peritoneal side.
A. N.C. 3 (Gray, p. 958; 1128).
The phrenic nerves lie in the middle neqiastinum.
Which is correct 2 The usual innervation to the arm is from the following nerve
r OOt S :
(1) C3 – C4–C5 - C6-C7-C8
(2) C4 - C5-C8 - C7-C8 – Tl
(3) C5 - C6-C7-C8-T1
(4) C5-C6-C7-C8-T1 - T2
(5) C6-C7-C8-T1 - T2.- T3
A. No. 4 (Gray, p. 964).
In the upper medial aspect near the axilla there is an overlap of T-2.
38
| :25
26.
27.
28.
29.
30.
Choose the one nerve that is given off before the anterior primary divisions unite
to form the brachial plexus.
(1) Lateral anterior thoracic nerve
(2) Long thor a Cic nerve
(3) Subs capular - subscapular is
(4) Medial antibrachial
(5) Ulnar nerve
A. No. 2 (Gray p. 962).
Select the correct statement. The median nerve is:
(1) A branch of the medial cord of the brachial plexus
(2) Derived from nerves C5 - C6-C7-C8 and T1 .
(3) Derived from nerves C8 and T 1.
(4) Derived from nerves C6-C7-C8.
(5) Derived from nerves C4-C5 - C6.
A. No. 2 (Gray, p. 967).
Gray states that this nerve is derived from C6, C7, C8 and T 1 roots.
In the ante cubital fossa, the median nerve lies in relation to the bra Chial artery.
Which is the correct statement 2
(1) The nerve is superior to the artery.
(2) The artery is lateral to the nerve.
(3) The artery is superior to the nerve.
(4) The artery is anterior to the nerve.
(5) The nerve is lateral to the artery.
A. No. 2 (Gray, p. 967).
The artery is lateral to the nerve. The nerve is medial to the artery.
The median nerve at the wrist lies most frequently in which of the following
locations 2
(1) On ulnar side and superficial to the tendon of the palmar is longus.
(2) Radial side of the flexor carpi radialis tendon.
(3) Deep to and on the radial side of the tend on of the palmar is longus.
(4) On the ulnar side and deep to the tend on of the palmaris longus.
(5) At the junction of the ulnar one-third anu the radial two-thirds of the anterior
a spect of the wrist at distal crease.
A. No. 3 (Gray, p. 967).
The ulnar nerve derives its principal fibers from which group of the following
spinal nerves 2
(1) C5 and C6
(2) C6 and C7
(3) C7 and C8
(4) C8 and T )
(5) T 1 and T2
A. No. 4 (Gray, p. 968).
The ilio -inguinal and ilio -hypogastric nerves usually a rise from which of the
following nerves 2
1:26 39
31.
32.
33.
34.
(l) T9 to T 10
(2) T 10 to T11
(3) T 11 to Tl2
(4) T 12 to Ll
(5) L1 to L2
A. No. 4 (Gray, p. 979).
The motor fibers to the fundus and body of the uterus are derived from the spinal
cord segments:
(1) T1 to T4
(2) T4 to T12
(3) L1 to L3
(4) T1 l to Tl2
(5) T4 to T10
A. No. 2 (Ciba, p. 9)
The technique of saddle block for obstetrical delivery is based on the fact that the
motor nerves arise this high and the sens Ory nerves a rise from spinal cord seg-
ments from T 11 down.
What nerves must be blocked to give complete an esthesia for the entire lower
linnb 2
(1) Sciatic nerve
(2) Sciatic and femoral nerves
(3) Sciatic, femoral, and external cutaneous
(4) Sciatic, femoral, external Cutane sou, and obturator
(5) Sciatic, femoral, external Cutaneous, obturator, and ilio -inguinal nerves.
A. No. 5 (Gray, p. 980; Pitkin, p. 648).
Pitkin states that complete an esthesia of the lower limbs requires blocking of all
the nerves. The upper thigh is supplied by the ilio-inguinal nerve (skin near the
femoral triangle); the ilio -hypogastric nerve (the gluteal area); the genito-femoral
nerve (skin adjacent to the scrotum); the lateral femoral cutaneous nerve (anterior –
lateral aspect to the thigh). The sciatic, femoral and obturator nerves supply deep
sensation in the lower extremities. The Obturator and femoral nerves also supply
skin and fascia on the anterior and medial a spect of the thigh.
The preganglionic cells of the sympathetic nerves have their irigin in :
(1) Anterior horn
(2) Posterior horn
(3) Lateral horn
(4) Posterior sensory ganglion
(5) Sympathetic ganglion
A. No. 3 (Gray, p. 950).
Which one of the following statements is correct 2
(1) Pre ganglionic fibers are carried by the white and gray rami communicantes.
(2) Postganglionic fibers are carried by the white and gray rami communicantes.
(3) Preganglionic fibers are carried by the gray and postganglionic fibers by the
white ranni communicantes .
(4) Pre ganglionic fibers are carried by the white and postganglionic fibers by the
gray rani communicantes.
(5) Proganglionic and postganglionic fibers may be carried on either gray or
white rani communicantes.
A. No. 4 (Gray, p. 949).
40
1 : 27
35.
36.
37.
38.
39.
The lower limb receives its vas oc on strictor impulses from which of the following
spinal Cord segments:
(1) 3rd to 5th dorsal
(2) 6th to 9th dorsal
(3) 10th thoracic to 2nd lumbar
(4) 3rd to 5th lumbar
(5) list to 5th sacral
A. No. 3 (Best, p. 1075).
Not all the sumpathetic ganglia have white rami communicantes. Only those at
the levels of T 1 to L.2 have white but all the ganglia have gray rami communicantes
to the corresponding spinal nerves. Thus vasoconstrictor fibres which will pass
out through S2, arise in the cord higher up, pass through the white ramus communi-
cantes at a high level to the sympathetic ganglion. Here they may synapse or go
directly down the chain to S2 ganglion (where they may synapse) and then pass out
through the S2 nerve.
Which of the following nerves do not carry parasympathetic impulses 2
(1) Olfactory
(2) Oculomotor
(3) Facial
(4) Gloss opharyngeal
(5) Pelvic
A. No. 1 (Gray, p. 1000)
The carotid sinus nerve is a branch of the :
(1) Oculomotor
(2) Facial
(3) Gloss Opharyngeal
(4) Vagus
(5) Hypoglossal
A. No. 3 (Gray, p. 938).
Which one of the following is not a branch of the vagus 2
(1) Pharyngeal
(2) Superior laryngeal
(3) Recurrent laryngeal
(4) Superior cardiac
(5) Parotid nerve.
A. No. 5 (Gray, p. 938).
This is a branch of the 9th.
Efferent fibers of the vagus are:
(1) Pre ganglionic in character
(2) Postganglionic in character
(3) Unmyelinated
(4) Distributed to the ventricles
(5) Motor to the entire gastrointestinal tract
A. No. 1 (McDonald, p. 72).
The postganglionics are close to or within the Organ innervated.
1 :28 41
40.
41.
4 2.
43.
44.
45.
The head receives its vas Oconstrictor inpulses from which of the
following spinal cord segments 2
(1) 1st to 3rd cervical (4) 3rd to 4th thoracic
(2) 4th to 6th cer vical (5) 6th to 8th thoracic
(3) 1st and 2nd thoracic
A. No. 3 (Best, p. 1075).
Which of the following is not related to Horner's Syndrome 2
(1) Anhidros is
(2) Mydriasis
(3) Visual disturbance
(4) Lagophthalmus
(5) Enophthalmus
A. No. 2 (Dorland).
Lagophthalmos is the inability to close the eyelid – as occurs in exophthalm, c
goiter.
The obliteration of certain foetal structures occurs by certain approximate times.
Which is in correct 2
Anterior fontanelle – 18th month
Posterior fontanelle - 2nu nnon th
Ductus arterios us – at birth
For annen ovale - 10th day
) Umbilical circulation – at birth
5432l
A. No. 4 (Holt, p. 570).
The foramen ovale gradually closes during the first month but a small opening
per sists until the latter part of the first year or even a little later. This is a
difficult question be cause the patent ductus is completely oblite rated only after
eight weeks.
The umbilicus receives its sensory cutaneous innervation from :
(l) T4 (4) T 10
(2) T5 (5) T12
(3) TT
A. No. 4 (McDonald, p. 130).
The nipple derives its sensory cutaneous innervation from :
(l) Tl (4) T6
(2) T2 (5) T.9
(3) T4
A. No. 3 (McDonald, p. 130
The ensiform receives its sensory cutaneous innervation from:
(l) T3 (4) T7
(2) T4 (5) T.9
(3) T5
A. No. 4 (McDonald, p. 130)
42
1 :29
46.
47.
48.
49.
50.
5 1.
The skin over the pubis receives its sensory cutaneous inner vation from :
(l) T5 (4) T12
(2) T7 (5) L2
(3) T 10
A. No. 4 (McDonald, p. 130).
Which is an unlikely complication following brachial plexus block 2
(1) Prieurnothorax
(2) Hemiparalysis of the diaphragm
(3) Horner's syndrome
(4) Neuritis
(5) Temporary diminution of hearing on the same side.
A. No. 5 (Adr. Techs. , p. 292).
The accepted deep bony landmark to the brachlal plexus is the
(1) Clavicle
(2) First rib
(3) Chas saignac's tubercle
(4) Sixth cervical vertebrae
(5) Seventh cervical vertebrae
A. No. 2 (Adr. Techs. , p. 291).
Select the investigator credited with perfecting the supra clavicular approach of the
brachial plexus block.
(l) Louis Bazy
(2) Halsted
(3) Kulenkampff
(4) Kapp is
(5) Hirschel
A. No. 3 (Pitkin, p. 480. ).
Which is correct 2 If, during the performance of a brachial plexus block, a
pares thesia is experienced by the patient in his fifth finger on the arm being blocked
the needle has come in proximity to the .
(1) Middle trunk
(2) Lower trunk
(3) Upper trunk
(4) Ulnar nerve
(5) Posterior cord
A. No. 2 (Gray, p. 959; Pitkin, p. 438).
The needles in the supra clavicular approach are in contact with the trunks just
before they be come cords.
Which is correct 2 A useful bony landmark in performing a block of second division
of the trigeminal nerve from the lateral approach is the :
(1) Lateral plate of the pterygoid
(2) Vertical plate of the palatine
(3) Tip of mastoid process
(4) Greater wing of the sphenoid
(5) Styloid process
1:30 43
52.
54.
55.
56.
A. No. 1 (Lundy, p. 89; Pitkin, p. 374).
Lundy states in his technique that the needle is slipped off the pterygoid
plate into the pterygomaxillary fissure. Pitkin, quoting Schloes ser, states that
the needle should slip off the posterior part of the orbit and is then directed up-
ward, medialward and posterior until it comes to rest against the great wing of
the sphenoid. The needles are in about the same position in either technique.
For operative procedures on the maxillary antrum, one should block:
(1) Ciliary ganglion
(2) Cervical nerves 2, 3, 4.
(3) Sphenopalatine ganglion and second division of the fifth cranial nerve.
(4) Glossopharyngeal nerve
(5) Third division of the fifth cranial nerve.
A. No. 3 (Pitkin, p. 388).
In performing a posterior paravertebral block in the cervical region of an adult,
wheals are raised the following distance from the spines of the cer vical vertebrae:
(1) 1 cm.
(2) 2 cm.
(3) 3.5 cm.
(4) 4 cm.
(5) 4.5 cm.
A. No. 4 (Pitkin, p. 438; Lundy, p. 101).
One to two finger breadths is the usually accepted distance. This would be about
2 cm – 4 cm.
When a deep cervical block is done for a thyroidectomy, the following nerves
must be blocked.
(1) C1, C2, C3
(2) C2, C3, C4
(3) C3, C4, C5
(4) C4, C5, C6
(5) C5 C6, C7
A. No. 2 (Lundy, p. 93).
The vertebral artery arises from the :
(1) Sub clavian
(2) Internal mammary
(3) Common carotid
(4) External carotid
(5) Internal carotid
A. No. 1 (Gray, p. 582)
The middle men ingeal artery is a branch of the :
(1) External car otid
(2) Internal car otid
(3) Internal maxillary
(4) Inferior alveolar
(5) Superior alveolar
A. No. 3 (Gray, p. 559).
44
1 : 31
57.
58.
59.
60.
Which of the following is not supplied by the hypogastric artery 2
(1) Walls and viscera of the pelvis
(2) Buttocks
(3) Medial side of the thigh
(4) Lower leg
(5) Generative organs
A. No. 4 (Gray, p. 620).
Which one of the following muscles is not in contraction during a forced expiration ?
(1) Rectus abdominis
(2) Diaphragm
(3) Transversus thoracis
(4) Obliquus externus abdominis
(5) Transversus abdominis
A. No. 2 (Gray, p. 39 )
When the diaphragm is contracted it drops down and the thoracic cavity is enlarged.
In a forced expiration, the diaphragm is relaxed and the other muscles mentioned
a ct on the rib cage to contract the thoracic cavity for cefully.
The deltoid receives its segmental innervation from :
(1) C2, C3
(2) C3, C4
(3) C4, C5
(4) C5, C6
(5) C6, C7
A. No. 4 (Gray, p. 402).
The sternocleidoma stoid muscle receives its segmental innervation from which of
the following:
(1) C1, C2, C3, C4
(2) C2, C3, C4, C5
(3) C3, C4, C5, C6
(4) C4, C5, C6, C7
(5) C5, C6, C7, C8
A. No. 1 (Gray, p. 371).
This muscle is usually innervated by Cranial l l and by anterior branch of C2, and
perhaps C3. No reference could be found which could give such innervation to the
sternorna stoid muscle. However, all the other answers contain branches from the
brachial plexus, which does not innervate this muscle.
SUPPLE MENT 2 SUB – SEC TION
A NATO MY
The average total volume of cerebro spinal fluid is considered to be :
No. 4 (Best, p. 1070; Collins, p. 130).
The dural sac of the spinal Cord extends to :
(1)
(2)
(3)
(4)
(b)
A.
2nd Lumbar vertebra
5th lumbar vertebra
2nd sacral segment
4th sacral segment
Coccyx
No. 3 (Pitkin, p. 21).
The spinal cord usually enus in the adult at:
No. 3 (Pitkin, p. 21).
The spinal cord occupies the entire spinal canal until the third month of fetal life.
By parturition the spinal C or Ci has receded to the level of L3 because of the une 1ual
growth of the cord and the vertebrae. By aciult life the final level of Ll is attaine C.
The dural sac occupies a position to the level of S2 in the adult.
The ordinary position at birth of the conus medullaries is opposite:
.
Ll body
L2
L3 body
L4 - L5 inter space
T 12 - Ll inter space
No. 3 (Collins, p. 125).
er for rning a spinal an esthetic the agent should be deposited in the space
between :
'1'he pia mater and the arachnoid membrane
The arachnoid Inernbrane and the dura
The dura and the bonymargins of the spinal canal
Directly into the intrannedullary space of the cord
The pia mater and the cord
No. 1 (Pitkins, p. 21; Collins, p. 125).
46
1 : 33
10.
The vertebral column usually contains vertebrae and segments:
(1) 29
(2) 31
(3) 33
(4) 35
(5) 36
A. No. 3 (Pitkins, p. 13).
In the spinal cord the anterior or ventral is the efferent (motor) root. The efferent
root carries all but which one of the following:
(1) Motor fibers to the voluntary muscles giving them tone and causing contraction
(2) Vaso constrictor impulses to blood vessels, ducts and bronchi
(3) Inhibitory impulses to intestinal muscles, ducts and bronchi
(4) Vasodilator inpulses to blood vessels
(5) A white ranus to the sympathetic system
A. No. 2 (Gray, p. 949, 1004, l l 24; Best, p. 275).
There is no question about the validity of answer s 1, 3, and 5. However, either of
answer S 2 and 4 may be in correct. Best and Toylor states the evidence for the
existence of a vasodilator Center and Vasolidator fibres. After Ergotoxine, which
abolishes secretory as well as vas O Constrictor and sympathetic effects, stimulation
of the splan chnic or abdominal sympathetics cause dilation of the vessels of the
intestines or of the legs. The answer to this question is 2. There are vaso con–
strictor impulses to the blood vessels, but there are only inhibitory actions on the
ducts and bronchi of the lungs. Gray's Anatomy states that the sympathetic fibres
pass to the musculature of the bronchi There is no vaso constrictor effect on the
bronchi themselves.
The gray rani communicans carry:
(1) Somatic fibres
(2) visceral afferent alone
(3) visceral efferent alone
(4) visceral afferent and postganglionic efferent
(5) postganglionic efferent alone
A. No. 5 (Gray, p. 949; Best, p. 1079).
Older edition of Gray's Anatomy (23rd) show visceral afferents in the gray ramus
communicans. However, the latest edition (25th) shows only efferent postgangli-
onics in the gray ramus communicans. Best and Taylor also states that
sympathetic efferent fibres appear in the gray ramus communicans.
The lower limb receives its vas constrictor impulses from which of the following
spinal Cord segments:
(1) 3rd to 5th dorsal
(2) 6th to 9th dorsal
(3) 19th thoracic to 2nd lumbar
(4) 3rd to 5th lumbar
(5) list to 5th sacral
A. No. 3 (Pitkin, p. 220; Best, p. 274).
The parasympathetic innervation to the gastrointestinal tract via the Vagus extends
to :
(l) The small bowel to the duodenal junction
(2) The jejunum
1 1.
12.
13.
14.
15.
(3) The signoid
(4) The as cending colon as far as the junction of the pelvic Colon
(5) Pylorus
A. No. 3 (Gray, p. 6 15, 1017).
This is a poorly worded question because of the use of the words, "The Junction of
the pelvic colon". Gray's Anatomy states that the superior me senteric plexus
which contains the branches of the vagus supplies the same a reas as the middle
colic artery. The mid-colic artery anastomoses with the left colic artery and the
right colic artery. The right Colic artery, a branch of the inferior hemorroidal
artery, supplies the signoids and anastomoses with the middle coll c artery.
Thus, the vagus nerve which passes through the superior me senteris plexus sup-
plies the as Cending and transverse colon as far as the signoid colon.
The sympathetic paralysis which accompanies spinal anesthesia for upper abdomi-
nal surgery not infrequently produces :
Warm moist lower extremities
Dilatation of small intestine s
Suppression of renal function, despite a well maintained blood pressure
Slowing of the heart rate, if blood pressure is well maintained
Tachycardia with rise in blood pressure
l
2
5
4
5
A. No. 4 (Adr. Pharm. , p. 93).
Which one of the following may be expected if both vagi are blocked at their exit
from the skull:
Bilateral vocal cord paralysis
Loss of salivary secretion
Dilation of the pupil
Decrease in pulse rate
l
2
3
4
5) Decrease in insulin production
A. No. 1 (Collins, p. 224).
Efferent fibers of the vagus are:
(1) Preganglionic in character
(2) Postganglionic in character
(3) Unmyelinated
(4) Distributed to the ventricles
(5) Motor to the entire G. I. tract
A. No. 1 (Gray, p. 939).
Pain caused by diaphragmatic irritation may be referred to the dermatone
segment of:
A. No. 2 (Pitkin, p. 102).
The scalenus anticus muscle at the level of the first rib is separated from the
brachial plexus by:
48
1 : 35
16.
| 7.
18.
19.
(1) Subclavian vein
(2) Scalenus medius muscle
(3) Vertebral artery
(4) Subclavian artery
(5) Tubercle of chas saignac
A. No. 4 (Gray, p. 376, 581).
The anterior scalene muscle arises from the anterior tubercles of the transverse
processes of the 3rd, 4th, 5th and 6th cervical vertebrae, and is inserted into the
superior surface of the first rib. Therefore, the answer to this question is, that
at the level of the first rib where the scalene anticus is inserted it has beneath it
the second portion of the subclavian artery. The brachial plexus is superior to
the artery at that point.
When a deep cervical block is done for a thyroidectomy the following nerves must
be blocked :
(1) C1, C2, C3
(2) C2, C3, C4
(3) C3, C4, C5
(4) C4, C5, C6
(5) C5, C6, C7
A. No. 2 (Pitkin, p. 434).
The sensory innervation of the volar surface of the middle finger is:
(1) The radial nerve
(2) The radial and the median nerve
(3) The median nerve
(4) The median and ulnar nerve
(5) The ulnar nerve
A. No. 3 (Pitkin, p. 173).
Weakness on abduction and adduction of the interos sei signifies involvement of:
(1) Median nerve
(2) Posterior cord of brachial plexus
(3) Ulnar nerve
(4) Median antibra chial cutaneous nerve
(5) Radial nerve
A. No. 3 (Mc Donald et. all, p. 114).
Which of these nerves does not have a sensory distribution to the skin:
(1) Cl
(2) T1
(3) Ll
(4) Sl
(5) X-cranial
A. No. 1 (Gray, p. 950).
There is actually no correct answer in this group of five. However, what is ex-
Pected is answer no. 1. CI rarely has sensory innervation to the skin. However
Gray's Anatomy states that the nerve occasionally has a cutaneous branch which
communicates with the greater and lesser occipital nerves.
1:36 49
20.
21.
24.
23.
Inability to flex the distal phalanges of the thumb and index finger in 1 cates injury
to :
1) Median nerve
2) Musculo spiral nerve
3) Ulnar nerve
4) Posterior cord of brachial plexus
(5) Radial nerve
(
(
(
(
A. No. 1 (McDonald, p. 115).
The brachial plexus is formed by:
(1) Anterior divisions of cer vical spinal nerves 5 - 6 - 7-8- and thoracic nerve 1
(2) Posterior divisions of cer vical spinal nerves 5-6 - 7-8 and thoracic nerve 1
(3) Anterior divisions of cervical spinal nerves 7-8 and thor a cl C nerves 1 - 2 - 5
(4) Posterior division of cervical spinal nerves 7-8 and thor a cic nerves 1 - 2 – 3
(5) Anterior divisions of cervical spinal nerves 5-6-7 and posterior division of
cer vical nerve 8 and thoracic nerve i
A. No. 1 (Gray, p. 959).
In the wrist, the median nerve lies lateral to the .
(i) Palmar is longus
(2) Transver se carpal ligament
(3) Flexor carpi radialis
(4) Pisiform bone
(5) Flexor digit or unn sublini's
A. No. 1 (Adr. Techs. , p. 295).
Which of these nerves supplying the skin of the anterolateral surface of the head is
not a branch of the V cranial:
1) Auriculo-temporal-mandibular
2) Zygomatico-temporal
3) Supraorbital
4) Supratrochlear
5) Posterior auricular motor branch
A. No. 5 (Gray, p. 934).
This question and the following question concern the nerves a rounci the ear and
temporal area of the head. The auriculo-temporal nerve, a branch of the mandibu-
lar nerve, supplies the Superior auricula and the skin C overing anterior to the helix
and tragus. The Zygomatico – ternporal nerve, a branch of the maxillary division
of the 5th nerve, is distributed to the skin of the lateral position of the fore head,
anterior to the auricula. The supraorbital nerve is one of the terminal branches
of the frontal nerve, a division of the ophthalmic nerve. It supplies the skin over
the medial aspect of the Orbit. The supratrochlear nerve is another terminal
branch of the frontal nerve and supplies the skin at the inner canthus and mid for e-
head. The posterior auricular nerve is a branch of the 7th cranial nerve and sup-
plies the musculature around the auricula. It is not a sensory nerve. Thus, the
anterior portion of the skin in front of the auricula is supplied by the auriculo-
temporal branch of the mandibular nerve and anastomoses with the zygomatico-
temporal branch of the maxillary division of the 5th nerve. The skin behind the
ear is supplied by the greater auricular nerve, a branch of the 2nd and 3rd cer vical
nerves and ana stomoses with the greater occipital nerve, another branch of the 2nd
cervical nerve. The most superior portion of the auricular is innervated by a corn-
bination of auriculo temporal nerve and the greater auricular nerve.
50
1 : 37
24.
26.
27,
28,
29.
A patient complains of marked hyper esthesia and, neuralgia in a sm. . . . a r cº where
the upper margin of the ear blends with the skin of the face, aggravate by the
pressure of the bow of his glasses. What nerve would you block to relieve his
pain 2
(1) First cer vical
(2) Mandibular
(3) Ophthalmic
(4) 2nd and 3rd cervical
(5) Facial
A. No. 2 (Gray, p 925, 954).
The sensory innervation of the posterior third of the tongue is supplied by :
(1) The lingual nerve
(2) The chorda tympani
(3) The glossopharyngeal nerve
(4) The mandibular nerve
(5) The palatine nerve
A. No. 3 (Gray, p. 1172).
Which one of the following is noted when the gas serian ganglion is cut:
(1) Facial paralysis
(2) Loss of salivary secretion on the affected side
(3) Ptosis of lid
(4) Vasodilatation and dryness of skin on the face
(5) Corneal anesthesia
A. No. 5 (Gray, p. 1039).
Answer S 1 and 2 result from 7th nerve paralysis. Answers 3 and 4 occur with
sympathetic paralysis on that sie, e.
The trigeminal nerve is primarily a sensory nerve except for the following branch
which carries motor fibers in addition:
(1) Ophthalmic branch
(2) Ma sillary branch
(3) Mandibular branch
(4) Nas O – ciliary branch
(5) Mental branch
A. No. 3 (Gray, p. 923).
Which is correct 2 A useful bony landmark in performing a block of the second
division of the trigeminal nerve from the lateral approach is :
(1) Lateral plate of the pterygoid
(2) Vertical plate of the palatine
(3) Tip of mastoid process
(4) Greater wing of the sphenoid
(5) Styloid process
A. No. 1 (Pitkin, p. 374; Gray, p. 154).
The sensory innervation of the anterior two-thirds of the tongue is supplied by:
(1) Lingual nerve
(2) Glossopharyngeal nerve
(3) Hypoglossal nerve
1 : 38 51
30.
31.
32.
33.
34.
(4) Chorda tympani nerve
(5) Gloss opalative nerve
A. No. 1 (Gray, p. 1172).
The ilio -inguinal and iliohypogastric nerves a rise from which of the following:
(l) T 10 and T 11
(2) T 11 and T 12
(3) T 12 and Ll
(4) L1 and L2
(5) L2 and L3
A. No. 3 (Gray, p. 980).
The pudendal nerves arise from the anterior division of which are the following:
(1) T 12, Ll and L2
(2) L1, L2, L3
(3) L3, L4, L5
(4) L4, L5, Sl
(5) S2, S3, S4
A. No. 5 (Gray, p. 996).
The nerve supply to the scrotum is :
(1) The ilio – inguinal nerve
(2) The posterior scrotal nerves
(3) The ilio -inguinal and posterior femoral cutaneous nerves
(4) The ilio -inguinal, posterior S Crotal and posterior femoral cutaneous nerves
(5) Posterior scrotal and posterior femoral cutaneous nerves
A. No. 4 (Pitkin, p. 140, 157, 169, 171).
Four nerves supply the scrotum. The first nerve is the cutaneous branch of the
ilio-inguinal nerve which supplies the skin of the anterior abdominal wall just
over the symphysis pubis, the skin of the upper part of the thigh and the skin of
the upper part of the scrotum and dor sum of the penis. The second nerve is the
external spermatic nerve, a branch of the genito-femoral nerve. This nerve
exits through the inguinal ring and supplies the skin of the lateral part of the scro-
tum and adjacent part of the thigh. The third nerves are the posterior femoral cut-
aneous nerve branches which supply the under side of the scrotum communicating
with the branches of the pudendal nerve. The fourth group of nerves are branches
of the pudendal nerve divided into medial and lateral portions and called the pos –
terior scrotal nerves. These supply the under side of the scrotum, anas tomosing
with the posterior femoral cutaneous nerves.
The sensory innervation to the hip joint is chiefly from :
(1) The obturator nerve
(2) The ilio -inguinal nerve
(3) The femoral nerve
(4) The fourth lumbar somatic nerve
(5) The fifth lumbar somatic nerve
A. No. 1 (Gray, p. 982; Pitkin, p. 886).
The lateral femoral cutaneous nerve is more accessible for block:
(1) In the mid thigh
(2) Two inches above inguinal ligament
(3) Lateral to the upper portion of inguinal ligament
52
1:39
35.
37.
38.
39.
(4) Mid portion of inguinal ligan) ent
(5) Two cm. above pubic tuber cle
A. No. 3 (Pitkin, P. 660).
The vertebral artery arises from the:
(1) Subclavian
(2) Internal mannary
(3) Common carotid
(4) External carotid
(5) Internal carotid
A. No. 1 (Gray, p. 584).
The femoral nerve a rises from the Dorsal division of:
(1) The 1st, 2nd, and 3rd lumbar nerves
(2) The 2nd, 3rd, and 4th lumbar nerve S
(3) The 2nd, 3rd, and 4th and 5th lunbar nerves
(4) The 3rd, 4th, and 5th lumba r nerves
(5) The 2nd and 3rd lumbar nerve s
A. No. 2 (Gray, p. 978).
The correct relationship of the structures in the femoral canal from within out is :
(1) Opening, vein, nerve, a r tery
(2) Opening, vein, arter y, nerve
(3) Vein, artery, nerve, opening
(4) Artery, nerve, Opening, vein
(5) Nerve, opening, vein, artery
A. No. 2 (Pitkin, p. 660).
Loss of planter flexion of the ankle and toes signifies palsy of :
(1) Median plantar nerve
(2) Deep per oneal nerve
(3) Sural nerve
(4) Tibial nerve
(5) Lateral plantar nerve
A. No. 4 (McDonald, p. 116).
Indicate the correct statement regarding the perineal nerve:
(1) It is the smallest of the two terminal branches of the pudendal nerve.
(2) It passes along the lateral wall of the is chio-rectal fossa.
(3) It is located by use of Bryant's triangle.
(4) The nerve has no motor components.
(5) Nerve block is best done in the Sims position
A. No. 2 (Pitkin, p. 170).
There is no real answer to question 39, although answer 2 comes the closest to it.
The perineal nerve which is the largest of the terminal branches of the pudendal
nerve may lie in the lateral wall of the is chial recal fossa. It is the pudencial
nerve itself which usually lies in this position and is so designated. The perineal
nerve is the largest of the terminal branches, has muscular components, is best
blocked in the lithotomy position. Bryant's triangle is the skin over the hip joint.
1:40 53
40.
41.
42.
43.
44.
Indicate the incorrect statement concerning the sciatic nerve:
(1) Most frequently arises from S2, S3 and S4
(2) Supplies the skin about the anus primarily through its perineal branch
(3) Leaves the pelvis through the greater sciatic foramen
(4) Divides into three main branches usually in Alcock's canal
(5) Supplies part of the scrotum through its terminal branches
A. No. 3 (Pitkin, p. 158).
Indicate the correct statement Concerning the sciatic nerve :
(1) It is formed by I. 3 Sl
(2) It passes out of the pelvic by way of the lesser sciatic for a men
(3) It turns downward between the greater tuber O sity of the femur and the tuber –
osity of the is chium
(4) It first be comes superficial at the popliteal space
(5) No branches are given off to the thigh muscles
A. No. 3 (Pitkin, p. 158).
The sciatic nerve turns downward between the greater tubero sity of the femur and
the tuberosity of the is chium. However it also becomes superficial in the pop-
liteal space. Prior to that it lies beneath the gluteus maximus and the hamstring
muscles.
In considering the anatomical contents of the inguinal canal, which one of the fol-
lowing is not included:
(1) The cremasteric artery, a branch Of the Cie ep epiga stric artery
(2) The deep epiga stric artery
(3) The genital branch of the genito crural nerve
(4) The inguinal branch of the ilio -inguinal nerve
(5) The hypogastric branch of the iliohypogastric nerve
A. No. 5 (Gray, p. 629, 979).
Either answer 2 or 5 is correct. The deep epiga stric artery curves forward along
the medial margin of the abdominal inguinal ring. It gives off a branch called the
cremaster lc artery which accompanies the spermatic cord. The hypogastric
branch (or the anterior cutaneous branch) of the llio-hypogastric nerve becomes
cutaneous by perforating the ap Oneur Osis of the external oblique just above the
inguinal ring and is distributed to the skin of the hypogastric region. Answer 5
was chosen because answer 2 is more nearly correct in Cie scribing the anatomical
contents of the inguinal canal.
The relation of the blood vessels and the nerve along the inter costal grooves is
from above - downward :
(1) Nerve, artery, vein
(2) Artery, vein, nerve
(3) Vein, artery, nerve
(4) The three run parallel to each other
(5) The artery and vein run parallel to each other with the nerve below
A. No. 3 (Gray, p. 606).
The styloid process of the temporal bone is the bony landmark in performing
which one of the following blocks:
(l) Lingual
(2) Mandibular
(3) Gloss Opharyngeal
54
1:41
46.
47.
48.
5 0.
(4) Vagus
(5) Phrenic
A. No. 3 (Collins, p. 225).
The posterior media Stinum Contains:
(1) Hennia zygos vein, vagus, pulmonary artery, thor a cic duct
(2) Descending a Orta vagus, es Ophagus, splan Chnic nerve
(3) Vagus, a scending a Orta, a zygos vein, bronchi
(4) A scending aorta, a zygos vein, splan chnic nerve
(5) Phrenic nerve, descending a Orta e sophagus, bifurcation of tra chea
A. No. 2 (Gray p. 1128).
What is Chas saignac's tuber cle :
(1) A prominence of the hamate bone on the palmar surface of the hanu
(2) The tip of the C or a Coid process Of the S Capula
(3) The tip of the spinous process of the 7th dorsal vertebra
(4) The subcutaneous part of the head of the fibula
(5) The tip of the transver se process of the 6th cer vical vertebra
A. No. 5 (Dorland, p. 1571).
The distance from the in C is or teeth to the Carlna in the average adult male is about:
(l) l 5 c nh.
(2) 19 crºn.
(3) 2 1 c rin.
(4) 26 cm.
(5) 29 cm.
A. No. 4 (Gillespie, p. 130).
The right main bronchus leaves the tra chea at an approximate angle of:
...} : . .
2
}
2 ) . . . . . . . . . . . . . .
) 4 º' de: gree S-
) 65 degree. 5
3
4
5) 90 degree s
A Isis). 2 (Gille spie, p. 132; Gray, p. 1122).
The left tºpper lobe bronchus usually arises from the left main bronchus about
1 r orn the tra cheal bifurcation:
(1) 2 cm.
(2) 5 cro.
(3) 8 cm.
(4) 10 cm.
(5) 5 inches
A. No. 2 (Gray, p. 1122).
The diameter of the tra chea in a newborn infant is:
(1) 2–3 m, m
(2) 6–7 mm
(3) 8 - 10 mm.
(4) 10 - 12 mm.
(5) 16 - 18 nann.
A. No. 2 (Collins, p. 390; Cole) Collins states the outside diameter of tubes for
newborn use is 4.6 mm.
1:42 55
52.
5 3.
54.
5
5
The vocal cords are attached anteriorly to the :
(1) Thyroid cartilage
(2) Cricoid cartilage
(3) Epiglottis
(4) Arytenoids
(5) Corniculate Cuneiform cartilages
A. No. 1 (Gray, p. 1 119).
The left bronchus :
(1) Lies anterior to the aortic arch
(2) Is smaller in diameter than the right bronchus
(3) Is almost a direct continuation of the tra chea
(4) Gives off an eparterial branch above the right pulmonary artery
(5) Is shorter than the right bronchus
A. No. 2 (Gray, p. 1122).
Which of these statements if false, concerning tra cheal intubation ?
(1) A long tra cheal tube enters the right bronchus more readily than the left.
(2) The eparterial branch bronchus is easily occluded by a tra cheal tube in the
left bronchus.
(3) If a cuff is inflated during light an esthesia, it may not remain air tight when
the tra chea relaxes in deeper planes.
(4) The distance from the cords to the carina is about 12 cm. in the average
adult male
(5) A tube of 4 mm. Outside diameter is usually suitable for a newborn baby.
A. No. 2 (Gray, p. 1 ſ 22).
Which of the following is in C or rect Concerning the anatomy of the lung 2
(1) The smallest bronchi contain Cartilage
(2) Cilia terminate in the respiratory bronchiole
(3) Smooth muscle terminates in the alveolar sa c's
(4) The alveolus is one cell thick
(5) Terminal bronchioles contain secreting glands
A. No. 3 (Gray, p. 1 136).
Cart, lage is lost in the terminal bronchioles when they be come 1 millimeter in
size. Cllia and secreting glanus are found in the respiratory bronchioles. There
is no smooth muscle in the alve Olar sa C S.
In a for ced in spiration, the access or y muscles which are brought into action
in clusi e
(1) Intel mal inte I Costal muscles
(2) The lat is simus Cior Si muscle
(3) The sterno cleidonna stoid muscle
(4) External inter costal muscles
(5) External obli Gu e muscle s
A. No. 3 (Gray, p. 37 l).
The nylohyoid nºus cle :
) Draws pharynx upward
) Prevents food from entering larynx
3) Presses tongue against hard palate
1) Approximates fauciel pillars
) Ciosely opening to nasopharynx
56
| :43
57.
58.
60.
A. No. 3 (Best, p. 560; Gray, p. 373).
The middle meningeal artery is a branch of:
(1) External car Otid
(2) Internal car Oticſ
(3) Internal maxillary
(4) Inferior alveolar
(5) Superior alveolar
A. No. 3 (Gray, p. 568).
The optimum level of analgesia during a continuous caudal anes the tic for labor
and delivery in the average patient is :
(l) T4
(2) T6
(3) T8
(4) T 10
(5) T 12
A. No. 4 (Collins, p. 456).
What is the main anatornical reas on for newborn infants to brea the abdominally 7
Lack of bony substance in the ribs
Undeveloped thoracic musculature
Inmaturity of the peripheral nerves
Ribs leave the vertebral Column in a right angle plane
The lung par enchyma is collapse Ci -
I
2
3
4
5
A. No. 5 (Leigh, p. 15).
The most common reas on for any patient, including a newborn, to breathe abdomi-
nally is obstruction at the glottic level. However, in the newborn, when the lung
parenchyma is collapsed, there is an attempt to breathe more rapidly and for c e –
fully. Leigh explains this but does not exactly answer this question. The usual
cause of abdominal breathing may be lung collapse. However, other causes may
be the under developed thoracic musculature.
In the fetus, blood enters the carotid arteries by means of:
) The acrta
(2) The ductus arteriosus
) The the besian vein
(4) The pulmonary vein
(5) The pulmonary artery
A. No. 1 (Gray, p. 512).
P H Y S I O L O G Y
C h a p t e r II
59
O UT LINE – PHYSIC, LOGY
tº e º e º E tº e º s º $ tº $ tº $ 4 & 9 º' tº
Lungs, Positive
* 9 g g g º e º ſº º s = e s is a g º is tº a
tº e s m s tº a tº a tº 4 s tº 8 tº º is 8 tº º ºs
tº e º 'º e º ſº e s tº # * * is # 3 & 4 & # 9
* * * * * * s
is s e s ſº tº ſº e º e º is a s
a s is e º a s e s s a “ s is e º s e e s e
• * * * * * * * * s e e º e s a s
* * e s e º 'º e º 'º e º e s a s a e e
s e s tº e º a s is e º e
SYSTEM
RES PIRA TOR Y
1. General Questions Including Vital Capacity,
Gas Laws, Dead Space
2. Anoxia. . . . . . . . . . .
3. Re spiratory Carbon Dioxide . . . . . . . . . . . . .
4. Cyanos is . . . . . . . . .
5. Ernphy serma . . . . . . . . . . . . . . . . .
6. Pulmonary Edena
7. Laryngo spasm . . . .
8. Cessation of Re spiration
9. Respiration without Re spiratory Movement,
Paradoxical Re spiration
10. Mobilization of the
Pressure . . . . . . . .
11. Collapse of the Lungs, Atelecta sis
Pneum othorax . . .
12. Positioning of the Patient . . . . . . . . . . . . . . .
CIRCULATORY
1. General Questions including Blood Con-
stituents, Blood Functions, and Blood
Volume . . . . . . . . . .
2. Blood Pressure, Circulation Time
3. Heart and Cardiac Arrest
4. Venous Pressure .
5. Hemorrhage and Treatment Including
Transfusion Reactions
6. Oxygen in the Blood
7. Carbon Dioxide in the Blood
8. Pernicious Anemia
* * * * * * * * * * * * * * * * * * * * *
g 3 º' s p & b & a s a tº t e º $ tº a
QUESTION NUMBER
Main Sect.
19, 20
64, 65
22
2 3
24
25, 26
27 – 29
30, 31, 32
34 – 36
37-46
47-49
15, 50, 5 1,
52, 53
54
Suppl. l
1, 2, 4, 6,
42
15, 19, 46,
59
7 – 1 O
20
2 1
12 – 14
27
39, 48
6, 44, 45,
46, 47, 48,
58
22, 23, 25,
28, 3.5
30, 3 1, 32,
34
26
5, 40
Suppl. 2
4, 32
l, 38, 52
16 – 18
3
5 1
19, 50
39
3 1, 35
45, 47
10, 12, 13,
14, 59
37, 41, 57,
60
8, 9
5, 7, 20
55, 56
61
OUT LINE – PHYSIC) LOGY Cont'd
SYSTEM QUESTION NUMBER
Main Sect.
9. Non-Protein Nitrogen . . . . . . . . . . . . . . . . . . 55
10. Reflexes Including Carotid, Hering – Breur,
Bainbridge . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33, 55
C. NERVO US
1. Shock . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56, 57, 58
2
Convulsions . . . . . . . . . . . . . . . . . . . . . . . . . . 59
3. Parasympathetic Nervous System and
Cholinergic Fibres . . . . . . . . . . . . . . . . . . . . 6 Q
4. Sympathetic Nervous System and
A drenergic Fibres . . . . . . . . . . . . . . . . . . . . . * *
5 Pain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
6. Spinal Anesthesia . . . . . . . . . . . . . . . . . . . . . . * *s
7. Nerve Fibres . . . . . . . . . . . . . . . . . . . . . . . . . - -
8 Brain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - -
D. MISC E L L A NEOUS
1. Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
2. Voniting and Intestinal Tract . . . . . . . . . . . 66 – 68
3. Urinary Tract . . . . . . . . . . . . . . . . . . . . . . . . 69 – 74
4. Liver . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
5. Metabolism and Fluid Balance . . . . . . . . . . 7 5–79
6. Operations in the Neck Area . . . . . . . . . . . . 8 1
7. Oxygen Therapy . . . . . . . . . . . . . . . . . . . . . . . - -
8. Cry moane sthesia . . . . . . . . . . . . . . . . . . . . . * *
Suppl. 1
16, 17, 18,
29, 33, 56,
60
49, 50, 55,
57
53
54
52
5 |
Suppl. 2
2 1, 22, 23,
33, 34
36
15, 24, 27,
28
56
25
29, 30, 44
40
42
49, 53, 54,
58
1 1
43
62 2:ii
BIBLIOGRAPHY – PHYSIOLOGY
ADRIANI, J. : The Chemistry of Anesthesia. Ed. 1, Springfield, Ill., Charles C.
Thomas, 1946.
ADRIANI, J. : The Pharmacology of Anesthetic Drugs. Ed. 3, Springfield, Ill.,
Charles C. Thomas, 1952.
ADRIANI, J. : Techniques and Procedures of Anesthesia. Ed. 1, Springfield, Ill.,
Charles C. Thomas, 1947.
BARA CH, A. L. : Physiologic Therapy in Re spiratory Diseases. Ed. 2, Philadelphia,
Pa., J. B. Lippincott Co. , 1948.
BASIC SCIENCES FOR ORTHOPEDICS: Veterans Administration. Ed. 1, Washington,
D. C. , U. S. Government Printing Office, 1948.
BEST, C. H. and TAYLOR, N. B. : The Physiologic Basis of Medical Practice, Ed. 5,
Baltimore, Md. , The Williams And Wilkins Co. , 1950.
BURST EIN, C. L. : Fundamental Considerations in Anesthesia. Ed. 1, New York, N. Y. ,
The Macmillan Co. , 1949.
CECIL., R. L. and LOEB, R. F. : Textbook of Medicine. Ed. 8, Philadelphia, Pa., W. B.
Saunders Co. , 1947.
CHRIST OPHER, F. : A Textbook of Surgery. Ed. 4, Philadelphia, Pa. , W. B. Saunder s
Co., 1946.
CLEMENT, F. W. : Nitrous Oxide – Oxygen Anesthesia. Ed. 2, Philadelphia, Pa., Lea
and Febiger, 1945.
COLLINS, V. J. : Principles and Practice of Anesthesiology, Ed. 1, Philadelphia, Pa.
Lea and Febiger, 1952.
y
CULLEN, S. C. : Anesthesia in General Practice. Ed. 3, Chicago, Ill., The Year
Book Publishers, 1951.
DORLAND, W. A. N. : The American Illustrated Medical Dictionary. Ed. 22, Philadel-
phia, Pa., W. B. Saunders Co., 1951.
DRA PER, W. B. and WHIT EHEAD, R. W. : Diffusion Re spiration in the Dog A nesthetized
by Pentothal Sodium Anesthesiology; 5:262-273 (May) 1944.
GAMBLE, J. L. : Chemical Anatomy, Physiology and Pathology of Extracellular Fluid.
Ed. 5, Cambridge, Mass. , Harvard University Press, 1950
GILLESPIE, N. A. : Endotracheal Anesthesia. Ed. 2, Madison, Wisc. , The Univer sity
of Wisconsin Press, 1948.
GOODMAN, L. and GILMAN, A. : The Pharmacological Basis of Therapeutics, Ed. 1,
New York, N. Y. , The Macmillan Co. , 1941.
GUEDEL, A. E. : Inhalation Anesthesia. Ed. 2, New York, N. Y. , The Macmillan Co. 3.
1951.
HEUPER, W. C. : Experimental Statistics in Cardio Vascular Pathology: The Effects of
Intravenous Injections of Solutions of Gum Arabic, Egg Albumin and Gelatin Upon
the Blood and Organs of Dogs and Rabbits, American Journal of Pathology, 18; 895,
1942.
2:iii 63
HIM WICH, H. E. : The Brain and the Symptomatology of the Anoxias: Anesthesiology,
10:663-672 (Nov.) 1949.
JUDOVICH, B. and BATES, W. : Pain Syndrome s, Ed. 3, Philadelphia, Pa., F. A.
Davis, 1949.
KEYS, T. E. : The History of Surgical Anesthesia. Ed. 1, New York, N. Y.
1945.
, Schuman's
LUNDY, J. A. : Clinical Anesthesia. Ed. 1, Philadelphia, Pa., W. B. Saunders Co.,
1942.
NICHOLSON, M. J. : Hemolytic Transfusion Reactions; Anesthesiology, 9:345-357
(July) 1948.
PIT KIN, G. P. : Conduction Anesthesia, Edited by Southworth, J. L. and Hing son, R. A.,
Ed. 2, Philadelphia, Pa., J. B. Lippincott Co. , 1953.
ROLLASON, W. N. : Anesthesia and the "Bloodless" Field: Current Researches in
Anesthesia and Analgesia, 32:289- 304 (Sept-Oct) 1953.
SEIFRIZ, W. : The Effects of Various Anesthetic Agents on Protoplasm. Anesthe si-
ology, 11:24-30 (Jan) 1950.
SLOCUM, H. C. , HOEFLICH, E. A. , and ALLEN, C. R. : Circulation and Re spiratory
Distress from Extreme Positions on the Operating Table. Surgery, Gynecology
and Obstetric s, 84: 1051 – 1058 (June) 1947 .
WHIT EHEAD, R. W. , SPENCER, J. N. , PARRY, T. M. and DRA PER, W. B. : Studies
on Diffusion Re spiration. No. IV. The Oxygen and Carbon Dioxide Content of the
Hydrogen Ion Concentration of Arterial and Venous Abdominal Blood of Dogs During
Diffusion Re spiration. A nesthesiology, 10:54-60 (Jan) 1949.
WILSON, S. J. : Blood Transfusion Reactions: Their Etiology, Prevention and Treat-
ment. Anesthesiology, 10:188 (Mar) 1949.
WILLIAMS, J. T. : Obstetrics. Ed. 10, Edited by Eastman, N. J. New York, N. Y. ,
1950.
2: iv
64
MAIN SUB – SEC TION
PHYSIOLOGY
1. (a) Define: (1) Tidal air. (2) Complemental air. (3) Reserve air. (4) Residual
air. (5) Vital capacity.
A. (Best p. 361-363)
(l) The normal flow of air into the lungs announting to 30 cu in or 500 cc.
(2) The amount of air which may be inspired after an ordinary expiration;
it is equal to 3000 cc.
(3) The amount of air which may be expired after an ordinary expiration; it is
equal to 90 to 120 cu in or 1250 to 1800 cc.
(4) The air which remains in the lungs after a forced expiration and which can-
not be forced out; it announts to 90 to 100 cu in or 1200 to 1500 cc.
(5) It is the maximum annount of air which can be inspired after a powerful ex-
piration and is equal to about 2.6 liters per square meter of body surface
in males and 2.07 liters in females. The average figure is about 3500 cc.
(b) What factors in health and disease influence vital capacity ?
Health - varies with height and weight and type of work (sedentary lower than
vigorous)
Disease – reduced in lung and vascular diseases particularly.
(1) Pheunnonia, TB, emphysema.
(2) Intrathoracic – pericardial effusions, pleural effusions, tunnors.
(3) Heart disease - engorgement pulmonary vessels encroaching on alveolar
spaces.
(4) Pressure on outside - fractures rib cage, or deformities plus abdominal
pressures from over distension, tumors, etc.
2. Define the following:
A. (Best p. 250, 36 1, 4 13, 421)
a. Anoxe mia - low O2 content of capillary blood.
b. Anoxia - failure of tissues to receive O2 from any cause.
C. Hyperpnea - increase in the minute volume due to either depth or rate
of respiration or both.
d. Hypopnea – reverse of hyperpnea.
e. A pnea - suspension of breathing.
f. A capnea - low CO2 tension in blood.
g. Tidal respiration - normal breath for that particular individual (about
500 cc).
h. Minute volume respirations - Tidal respirations times the rate per
minute.
3. What are the approximate normal values for oxygen and for carbon dioxide, expressed
in either millinn eters, or tension, or percentage in:
(a) Inspired air (d) Tissue Spaces
(b) Pulmonary alveoli (e) Venous blood
(c) Arterial blood
A. (Best p. 368 and 369)
Vol. Percent Mm. Hg.
(a) O2 20. 9 158
CO2 . 04 . 2
Vol. Per cent Mnn. Hg.
(b) O2 13. 5 | O 5
CO2 5. 1 - 5. 5 40
(c) O2 19. 2 | () ()
CO2 48 40
(d) O2 less than 50 mm. Hg. favoring release of O2 from the blood.
CO2 40–60 mm. favoring passage of CO2 to the blood.
(e) O2 12 – 15 4 ()
CO2 52 46
(a) What factors determine the concentration of inhaled gases in the blood 2
(b) What factors determine the concentration of inhaled gases in the tissues 2
A. (A dr. Pharm. , p. 19)
(a) Partial pressure of the agent in the alveoli and this in turn is proportional to
the concentration in the inspired air; the air - blood ratio of the gas, that is the
distribution between the two; an ount of pulmonary ventilation and the blood
flow through the lung; the above control the physical a mount; chemical unions,
to /
if any, are in addition.
(b) Solubility of the gas in the tissues; the blood flow which is in turn dependent
primarily on the cardiac output; the blºod supply or the degree of vascularity
of the tissue; the pressure of the gas in the arterial blood as compared with
that in the tissues.
Discuss the transportation of oxygen from the atmosphere to the tissues, and of
carbon dioxide from the tissues to the atmosphere. (Include in your discussion a
statement of why each gas flows in the direction it does rather than in the opposite
direction.
A. (Best, p. 131, 398)
Oxygen is supplied from the atmosphere to the alveola e and thence to the arterial
blood from which the tissues obtain their oxygen supply.
Carbon dioxide from tissue metabolis nn is taken up by the venous blood and carried
to the lungs, where it is released to the alveolae, and exhaled into the atmosphere.
The exchange of all gases is dependent upon the gradients of partial pressure of those
gases. Venous blood is lower - oxygen 40 mm - and higher in CO2 - 46 mm. ; the re-
fore, CO2 flows from the tissues to the veins to the alveolae. Arterial blood leaving
the lungs has an oxygen pressure of 100 mm. The partial pressure of oxygen in the
alveolae is 105 mm. and the refore the flow of blood is into the blood stream and into
the tissues.
The Chloride Shift compensates for the changes in pH by the addition of CO2 in the
tissues and the loss of CO2 in the lungs.
(l) Tissues:
(a) Oxyhemoglobin is reduced as O2 goes to the tissues.
(b) Reduced hemoglobin is a weaker acid than oxyhemoglobin - gives up alkali
to carbonic acid which has been formed by means of carbonic anhydrase.
(c) Concentration of bicarbonate is increased in the cells over the plasma – bi-
carbonate passes into the plasma for equalization of concentration and is
combined with sodium.
(d) Since potassium is left in the cells ionized - chloride of the plasma diffuses
in to be combined with it.
66
2:2
(2) Lungs:
(a) The reverse takes place - bicarbonate passes into the cells and chloride,
out.
What is the partial pressure in mm. Hg. of water vapor in the lung:
A. (Best, p. 368)
The partial pressure of water vapor remains the same at all altitudes – 47 mm.
of mercury. It becomes important as altitude increases and partial pressure
of oxygen de creases. At altitudes over 34, 000 feet, the total partial pressure
of oxygen is so low that oxygen must be delive red under pressure to keep pilots
well oxygenated. At 40,000 feet, the following calculation may be made when the
pilot is breathing pure oxygen. Atmospheric pressure equals 14 l n m. mercury.
Subtracted from this is the total of 47 mm (water) and 36 mm. (CO2) and oxygena –
tion without some pressure becomes in possible.
When is the physiological dead space greater than the anatomical dead space:
A. (Best, p. 364)
In deep breathing the physiologic dead space occupies more area than the ana –
tomic. Physiologic dead space is defined as that portion of the air in the lung
which remains undiluted with the alveolar contents. This may vary greatly
according to the depth of respiration. In a shallow breath only a hundred cc.
of air may be inspired and this may remain in the large bronchi. The ana-
tomic dead space, however, is clearly defined and does not vary – i. e. that
space extending from the nostrils to and including the terminal bronchioles.
What are the signs in the order of their usual appearance of
(a) acute and of (b) chronic oxygen want 7
A. (Best, p. 421, 432; Goodman, p. 678; A dr. Pharm. , p. 123)
(a) A cute: In about this sequence - rapid pulse and respiration; cyanosis;
decreased mental concentration; loss of fine muscular movements; faulty
judgment labile emotions; at this stage, many faint. Others proceed with
analgesia; in pairment of all muscular movements; staggering gait; quick
fatigue; unconsciousness.
It is stated that many of the signs and symptoms are very similar to those
of acute alcoholic intoxication.
(b) Chronic: In discussion of chronic oxygen want in emphysema there may be
cyanosis but the associated dyspnea may not be as severe as might be an-
ticipated. The respiratory center has long since become insensitive to
stimulation by carbon dioxide, which is increased both in the alveolar air
and in the blood. There is an increase in the red cell count, the hemoglo-
bin, and in the oxygen capacity of the blood to compensate. The pulse and
blood pressure have usually compensated and are in normal ranges.
Describe the respiratory changes in the order of their occurrence in a normal indi-
vidual which accompany a gradual reduction in oxygen tension in the inspired atmo-
sphere from 20% to 4%.
A. (Best, p. 421; A dr. Pharm. , p. 123)
According to Best and Taylor, in the anoxic type of anoxia, the intensity of the
effects is influenced by the abruptness of the onset, its degree, duration and the
general physical condition of the body. If the arterial oxygen fall to 15 vol. /
percent, the patient becomes dyspneic. Further decrease, if abrupt, leads to
2: 3 67
10.
1 1.
12.
unconsciousness. If the fall is accomplished n : , re slowly, the r C is first 1 –
creased breathing both in depth and rate, and then periodic or ea thin witi, In, or e
and more prolonged periods between the gas ping breaths. An oxygen tº ºn to it of e º 6
than 5% in the tissues is not compatible with life.
In Adriani's Pharma cology, the re is a brief statement that resp; ration incre à ses
when the inspired air decreases from 16-12% oxygen. Further de crease results
in irregularity because the breathing is then maintained by the Carotid Body.
Symptoms of bewilderment, dis orientation may be a C C C inpa tied in y innus lo
twitching and unconsciousness. Cessation of respiratiºn super venes at 4%.
In the anoxia test for cardiac function, 10% oxygen is given for 10 rilinutes with
E KG and B P readings constantly being rinade. If the an sina of which the patient
complained is re-duplicated, he is presumed to have cardiac deficiency.
(a) How does a noxernia occur in an aviator flying at 42 thousand feet and breath –
ing 100 per cent oxygen 2
(b) What is meant by the tension of a gas in the blood and how is it measured 2
(Best, p. 72, 371; Barach, p 26, 27)
(a) At an altitude of 42,000 feet when the avia to r is ºr ea thing 100% oxygen, the
alveolar oxygen tension is reduced to that of an aviator breathing air with-
out oxygen at 14, 500 feet. The pressure of water vapor and CO2 totaling about
about 83 mm. Hg. Constitute a large proportion of the total bar one tric pres–
sure of 128 mm. Hg. Thus the re is not enough oxygen tension remaining
when it is at 45 mm. Hg. to a de quately saturate the alveolar blood.
(b) The tension of gas in the blood is usually expressed in mm. Hg, and means
the number of mm. Hg. which would be required to maintain that gas in
solution in the blood.
The Haldane or Van Slyke method measures the total O2 in the blood by
measuring it after it has been freed iny the addition of potassium ferricya -
nide. CO2 is measured after liberation by the addition of lactic acid.
Another method of Peters and Van Slyke is to measure the oxygen content
and then the capacity (by completely saturating it with O2). The percentage
of actual capacity can then easily be determined.
Discuss : (a) Mountain sickness. (b) Ca is son disease.
A .
(Best, p. 42.3, 426)
(a) Mountain sickness - At high altitude, low bar one tric pressure and consequent
reduction of oxygen partial pressure are found. This results in anoxenia
and signs and symptoms of oxygen want. First, the mount, in climber ex-
periences excitement and exhilaration; later dullness, weakness, headache,
vomitting, dyspnea and cyanosis. If severe enough, pro stration can occur.
(b) Cais son disease - Under additional pressure increased a mounts of air are
dissolved in the blood plasma. When the pressure is reduced too rapidly
this air is released as bubbles in the blood. Oxygen, is absorbed, but the
nitrogen bubbles may form emboli in the small vessels. Symptoms depend
upon the site where such emboli lodge – brain, lungs, heart, spinal roots,
etc.
What is the most reliable sign of oxygen want:
1.
2.
3.
Hypertension
Pulse rate
Deepened respiration
68
2:4
13.
14.
15,
16.
Hypotension
Increased
No. 2 (Cullen, p. 244)
When oxygen want occurs, the pulse rate rises and when it is relieved, the
. . . . - º - s * f \, ! 3. **
pulse rate returns to the original rate. If oxygen is administered and the
- l . . .
pulse rate does not change, other causes must be sought for the change in
pulse.
Which of the following does not cause anoxic anoxia :
:
A
high altitudes
CO poisoning
Pulmonary edema
emphysema
tetrology of Fallot
No. 2 ( Best, p. 437). CO causes anemic a noxia.
Carbon monoxide has an affinity for hemo slot. 300 times greater than oxygen.
The result is that the hemo loi, in is unable tº transport oxygen and an anemia
is present despite adequate quantities of re. cells and hemoglobin.
Outline the symptoms and signs of mild, mode rate and severe carbon dixoide excess.
A. (Lundy, p. 450)
Mi LD NMO DE RATE S E V E RE
Psychic disc onfort (ii 2, Ziness unconsciousness
Respiration increased dept: de pressed a r rested
little increase
in rate
Blood pressure increased markedly increased falls
Pulse rate no de r a tely i i , , , , , , s e : mod, increased mod, increase C
Musculature twitch in spasm of groups convulsions
(a) What is the meaning of CC2 cºlºbining power of the blood 2
(b) Of what significance is it in a n e s the sia 2
(c) What is its normal value 2
A. (Best, p. 133, 401)
(a) It is the ability of blood plasma to combine with CC 2 to form bicarbonates. In
acidosis the bicarbonates are neutralized by the excess a cids, the reby depleting
them. The refore determining the CO2 combining power gives an index as to
how much acid is being produced and the reserve of Jicar ponate left to neutra -
lize more acids. A severe reduction in CO2 combining power means that a ci-
dosis is present and the blood pH is out or about to go out of balance.
(b) It is significant in anesthesia in that certain anesthetics such as ether, chloro-
form, nitrous oxide, (and anoxia), CC2 excess tends to increase acidosis. They,
the refore should not be employed in conditions which already have produced
acidosis such as diabetes, nephritis, excessive diarrhea and fistulae of the sn't all
bowel. Alkalosis occurs in vonniting and high intestinal obstruction. These
Conditions must be corrected by fluid and electrolyte balance by the a nesthetist.
(c) 55 - 80 volumes per cent.
The respiratory center sensitivity to CO2 is indicated by what increase from what
% rise in inspired carbon dioxide:
2 : 5 69
18.
A. (A dr. Pharm. , p. 116)
An increase of 6-10% in inspired air increases ventilation about 200-300%. As
concentrations above 10% increase, the ventilation decreases until unconscious –
ness results with about 25-30%. An increase in alveolar content of . 1% doubles
ventilation and a decrease in . 1% causes apnea.
(a) Discuss cyanosis briefly for the senior medical student.
(b) Discuss the important points to be thought of in connection with cyanosis in the
anesthetized patient. (Cover all ordinary methods of a nesthetizing patients. )
A. (Best, p. 438-440)
(a) Cyanosis means blueness of the skin. The cause is the absolute amount of
reduced hermoglobin in the circulation. To see a blue tinge, one must have
about 5 grams of Red Hemoglobin but this varies.
Modifying factors are:
1. Pigment of the skin.
Jaundice
3. State of capillaries (Thus in dilated a reas such as ears, face, and hands,
there may be deeper cyanosis than in other a reas.
(b) The following conditions may cause cyanosis:
1. Low oxygen inhaled in atmosphere - a gent may dilute oxygen.
Obstruction - secretions, relaxed tongue, adductor spasm, tra cheal
collapse.
3. Limited tidal exchange - depressed center, inter Costal paralysis, com -
pression of chest, pneum othorax, trendelenburg and other inhibiting
positions.
4. Decreased vital capacity – break of compensation due to tuberculosis.
5. Barrier to diffusion – bronchio's pasm from allergy to a gent, and pul-
monary edema.
6. Failure of transport system – my ocar dial insufficiency, decreased blood
volume due to shock or he morrhage, alterations of hemoglobin if carbon
monoxide or nitric oxide contanninate, transfusion reactions.
7. Disturbances of tissue respiration - a nesthetics may inhibit re spiratory
enzymes.
Discuss emphysema for the senior medical student. Limit the discussion to 200
words and emphasize the anesthetist's interest.
A. (Best, p. 432, 434)
There is extreme distention due to the coales cing of alveoli, air sacs, and even
adjacent lobules, which by their joining form the characteristic blebs seen on the
surface of the lungs. Thus the total active respiratory surface is greatly decreased.
The alveolar and capillary walls thicken and many capillaries are occluded, thus
decreasing, both actually and potentially the blood supply available for gaseous ex-
change through the thickened membrane. There is a great loss of the elastic tissue
of the lung and expiration becomes an active, rather than the normal passive process.
As the diaphragm is often pushed down by distention, the resp ration is chiefly costal
in type and the chest becomes barrel shaped, with the ribs more horizontal and the
A P diameter is often greater than the transverse.
The residual air is increased 2 to 3 times normal and the comple mental air is de –
creased while the tidal air remains almost normal or slightly decreased. The vital
capacity is de creased 20 to 60%. There is chronic anoxenia and carbon dioxide
retention; the oxygen saturation of the blood is around 85%.
70
2 : 6
19.
20.
21.
Chief problem of the anesthetist: maintaining adequate a nesthetic concentration
and at the same time providing sufficient oxygenation.
Enumerate agents, and their dosage, useful in control of pulmonary edema.
A. (Barach, p. 100)
1. Oxygen (or 50% He and 20% O2) under pressure (4-6 mm. ) on expiration by
anesthetic machine or by the positive pressure helmet of Barach.
2. High spinal anesthetic to produce pooling of blood in the peripheral vessels -
procaine 150 mgs.
3. Sucrose 50% 100 cc. IV. to produce dehydration.
4. Digitalis until digitalized (1 gr. per 10 lbs body weight) and maintenance of
1 1/2 gr per day.
What is the rationale for the statement ''Intubate during conna to prevent pulmonary
e de ma''.
A. (Barach, p. 440)
When the diffusion coefficient of oxygen through the alveolar membrane is reduced
as a result of pulmonary edema, oxygen administration by raising the pressure of
this gas in the alveolar air will increase the rate of duffusion a cross the pulmonary
epithelium. The oxygen saturation of the blood flowing through the damaged pulmon-
ary eqithelium is increased.
A noxenia increases the permeability of the pulmonary epithelium to fluids and
consequently encourages e dema formation. In other words, a vicious circle is
established: edema inducing anoxe mia and the latter increasing the edema. This
circle is broken by oxygen administration.
Intubation establishes an adequate air way and prevents a spiration. A tube may act
as a foreign body in stimulating respiration. This helps to Counteract the effects
of coma in producing more normal respiration and reduces the edema. The need
to maintain an air way in a comatose per son is obvious and the tube makes it pos-
sible to administer pure oxygen. By de creasing the negativity in the chest on in-
spiration less fluid may be sucked into the pulmonary alveoli.
(a) Why is shallow breathing said to be disadvantageous when anesthesia is being
induced with diethyl ether given by the semi-open drop method.
(b) What is the usual cause of laryngospasm when nitrous - oxide, oxygen and ether
are being administered by the closed system 2
(c) If an endotra cheal tube is used during inhalation anesthesia, what are some of
its advantages 2
(d) If an endotra cheal tube is used as in (c) what are some of its disadvantages 2
A. (A dr. Tech. , p. 64, 73)
(a) Shallow breathing is disadvantage ous because it causes an insufficient amount
of a nesthetic agent to reach the tissues and insufficient oxygenation. There is
also danger that the patient may suddenly take a deep gasp, if CO2 is accumu-
lating, resulting in a sudden excess of ether and laryngeal spasm.
(b) Too rapid introduction of ether in light anesthesia, and is due to excess ether.
(c) It eliminates complicated motor driven apparatus, manometers and devices for
warming the ether vapor. The operating field is free of escaping gas.
Normal respiratory rhythm and amplitude is possible. CO2 is controlled.
Foreign matters such as blood and vomitus are excluded from the tra chea. One
may maintain the lightest of anesthesia. There is complete, easy control of
2 : 7 71
22.
23.
artificial respiration. Inhalation a nesthesia becomes possible for nose and
throat operations. It protects the tra chea from external pressure.
(d) Special training is required to pass the tube. The pharynx and larynx may be
traumatized. Laryngeal edema may result from trauma of tube in place for
long periods.
Give five distinctly different causes for the cessation of active respirations during
ether anesthesia.
A. (A dr. Techs. , p. 141)
(1)
i
Hypocapnia from hyperventilation and raising the threshhold of the res –
piratory center to carbon dioxide.
Reflex stimulation, such as traction on intestines with breath holding.
A nesthesia 4th stage.
Laryngeal spasm or bronchial spasm.
Neurological disturbances, particularly increased intra cranial pressure.
Circulatory failure - shock or cardiac arrest and anoxia of respiratory
Center.
What is meant by "re spiration without respiratory movement"? What application
may it have in clinical anesthesia 2
A. (Gille spie, p. 336; Whitehead)
(a)
Definition of controlled re spiration: ''The continuance of pulmonary ven-
tilation by artificial methods during a deliberately induced a pnea produced
by inhibiting the stimulus to respiration. Adriani states that the technique
of apneic respiration:
(1) Provides intermittently motionless field in thoracic and abdominal
surgery.
(2) Provides adequate saturation of tissues with gaseous and Volatile
anesthetic drugs in the face of respiratory depression. The apnea in
this technique is due to any one or the combinations of the following:
a. Removal of the carbon dioxide stimulus by hyperventilation.
b. Decrease of sensitivity of re spiratory Center or carbon dioxide by
depressant drugs.
c. Stimulation of the Hering – Breuer reflex by over distention of the
alveoli.
In the insufflation technique, which was employed by Meltzer and Auer, the
following conditions were needed:
(l) That the lungs be kept in a continuous inspiratory state of distension
by large volumes of gas under pressure.
(2) That the fresh air reach the lowest part of the tra chea.
(3) That the air escapes by another path than the one by which it enters.
Under these conditions, in certain cases, Meltzer and Auer postulated that
the tissues could be supplied without anoxia and without the usual respira -
tory movements. It was the large volume of agent, blown into the lungs
under some positive pressure which supplied the necessary oxygen and
removed the waste products. That this technique did not give satisfactory
results may have been due to several factors:
(1) Cyanosis occurred occasionally despite the large volume of oxygen in-
sufflated.
(2) If pharyngoal obstruction or laryngoal spasm occurred, the pressure in
the alveolae would be built up to dangerous proportions.
72
2 : 8
24.
25.
26.
27.
(3) The stomach might become distended with excess gases pushed in
when pharyngeal obstruction occurred.
(4) An increase in possible pressures in the lungs inhibited circulatory re-
turn to the right auricle.
(c) A third technique recently described by the Denver group known as Diffusion
Respiration, requires:
(1) Replacement of nitrogen within this respiratory tract and in the atmo-
phere at the glottis by oxygen.
(2) Adequate circulation.
The animals used were placed in respiratory arrest (after denitrogenation
with O2) by pentothal or pentothal and curare. Oxygen was supplied at 6 -
8 litters per minute. The head or body of the animal was enclosed in a
leakproof chamber and a non-resistant expiratory valve for the overflow
was provided. A small endotra cheal tube was placed in the tra chea but
stoppered so that respiration took place around the tube. The experimen-
tors comment that adequate oxygenation of the blood and tissues took place
for at least 30 minutes. In the next 15 minutes oxygen content fell but re-
covered after artificial respiration through the catheter was instituted.
During the 45 minutes the CO2 of the blood rose and the pH fell to levels
of 6. 7 – 6.8. The pH also resumed normal levels after artificial respira -
tion. The method by which oxygenation of the blood and tissues takes place
was designated the "hemoglobin-oxygen pump."
(a) Upon what principle is the immobilizing lung therapy proposed ?
(b) How is it performed ?
A. (Best, p. 359)
(a) Resting of lung to facilitate healing.
(b) Usual method is pneumothorax or thora Coplasty.
When massive collapse of a lung has occurred, what explanations are advanced for
the sudden dyspnea and cyanosis which follow, other than the collapsed lung is poorly
ventilated ?
A. (Collins, p. 288)
When massive collapse of the lung occurs dyspnea and cyanosis may result from
pain impulses transmitted by the way of the sympathetic or parasympathetic nervous
systems. Reflex vasospasm of the pulmonary vessels of both lungs results in pain,
dyspnea, chest splinting and shock. There also may be spasm of the coronary ves-
sels with further pain and shock and a reflex slowing of the heart rate.
What are the effects of various conditions on vital capacity – as pneumothorax,
bilateral.
A. (Best, p. 362)
The effects depend on the vital capacity of the patient before the penumothorax and the
size of the openings causing the penum othorax. If the vital capacity approximates the
tidal volume before the bilateral pneumothorax occurs, the patient may die immedi-
ately. If the cause of the bilateral pneumothorax are small openings or wounds and
the vital capacity is high, the patient may survive. If one wishes to anesthetize such
patients who have survived, an endotra cheal tube and high oxygen under some posi-
tive pressure should be used.
List six functions of the blood.
A. (Best, p. 1)
2 :
9 73
28.
29.
30.
Respiratory
Nutritive
Excretory
Maintains water content of the tissues
Regulates body temperature
Protective and regulatory (antibodies, circulates hormone. )
(a) What is the total volume of whole blood by weight 2
(b) What is the total volume of plasma by weight 2
(c) What is the blood volume of a normal sized man 70 kgro. in C c. 2
A. (Best, p. 18)
(a) 1 / 12th of total body weight.
(b) 1/25th of total body weight.
(c) 80 cc / K = 5600 cc.
Significant increases in blood volume is frequently found in all but one of the follow –
ing:
(1) congenital heart failure
(2) polycythemia
(3) splenic anemia
(4) hypertension
(5) pregnancy
A. No. 4 (Best, p. 24 – 26)
Reduction in blood volume occurs in hemorrhage with loss of whole blood; dehydra -
tion when water is lost; pernicious anemia when red cells are reduced and plasma
is increased ; chronic anemias where the red cells are reduced; obesity where
there is a relative decrease in relation to body surface; in myxedema where both
red cells and plasma are reduced.
Increase in blood volume occurs in:
Polycythemia vera – mainly red cells but also plasma.
Cirrhosis of the liver with an increase in plasma.
Leukemia with increase in white cells and plasma.
Congenital defects such as tetrology of Fallot etc. where both red cells and
plasma increase.
Banti's disease with splenomegaly with increase in plasma.
Hyperthyroidism with increase in both red cells and plasma.
The answer to this question is the refore hypertension in which blood volume plays
no significant part.
(a) Define blood pressure.
(b) Enumerate the principal factors controlling blood pressure in a normal indivi-
dual.
A. (Best, p. 146, 147)
(a) Blood pressure is the pressure of the blood on the walls of the arteries.
(b) It is dependent on the energy of the heart action, the elasticity of the walls of
the arteries, the resistance in the capillaries, the venous back pressure, the
volume of the blood and its visco sity.
State some accepted the ories of the cause of decrease in blood pressure during
Spinal anes the sia.
A. (Pitkin, p. 847; Adr. Pharm. p. 93)
74
32.
33.
Spinal anesthesia causes a paralysis of vasoconstrictor fibers to the arteries, with
resulting vasodilatation, loss of tone, and decreased peripheral resistance. The
sympathetic fibers involved are from the thora co-lumbar area. The fall in blood
pressure depends on the height of anesthesia and the number of these fibers involved.
The fall of blood pressure does not take place in sympathe ctenized animals, which
indicates the influence of the vasoconstrictors. Low spinal blocks are as sociated
with little fall in blood pressure, since all vasoconstrictor fibers a rise from the cord
above the second or third vertebrea, Pitkin advanced the theory that the fall of
blood pressure was due to blocking of the fibers supplying the adrenal gland,
with resultant deficiency of circulating adrenalin.
Spinal anesthesia likewise affects the venous circulation in several ways. The
paralysis of the voluntary muscles in the area involved decreases the muscle pump
action and decreases and slows the return of blood to the right side of the heart.
The inspiratory thoracic suction pump action which brings the blood into the great
veins of the thorax is decreased in proportion to the number of inter costal nerves
involved.
What factors may (a) increase or (b) de crease blood pressure during a nesthesia 2
A. (A dr. Techs. p. 53)
(a) Factors which may increase blood pressure during a nesthesia:
Excitement during induction
Pain stimuli during light a nesthesia
Carbon dioxide excess due to poor ventilation with depleted soda line.
A noxia
Toxic reaction to local anesthetic drugs
Thyrotoxicosis §
Increased intracranial pressure
Use of vasopress or drugs such as ephe drine or epinephrine.
Trendelenburg position
(b) Factors which may decrease blood pressure during a nesthesia:
(1) Overdose of a nesthetic drug - including excessively deep anesthesia
(2) Hemorrhage
(3) Reflex stimulation
a. Shock from trauma
b. Traction on viscera, me sentery, or other structures.
Terminal phase of severe anoxia
Terminal phase of carbon dioxide excess
Vasodilatation with spinal anesthesia
Toxic reaction to local anesthetic drugs
Poor position of patient with pressure on the inferior vena cava
Cardiac failure
4
5
6
7
8
9
List effects resulting from stimulation or receptors in
(a) the carotid sinus
(b) the carotid body
A. (Best, p. 282, 408)
(a) Raising pressure within the carotid sinus produces slowing of heart and decrease
in blood pressure. Reducing pressure in the carotid sinus produces cardiac
acceleration and increase in blood pressure, and liberation of adr enalin.
34.
35.
36.
(b) Stimulation of carotid body by lowered oxygen tension increases the respira -
tions, causes vaso constriction and rise in blood pressure.
a) Discuss briefly the possible etiology of ventricular fibrillation during anes thesia.
(b) What a nesthetics are most prone to cause this phenomenon.
(c) Diagnosis by the anesthesiologist.
A. (Best, p. 238; A dr. Techs. p. 154)
(a) Ventricular fibrillation occurs chiefly during the induction and recovery periods
due to release of epinephrine and its action on the heart. The heart has already
been made irritable by the high concentration of some a nesthetics. Administra -
tion of epinephrine is contra-indicated. Thyrotoxicosis with cardiac damage is
another factor which may predispose to fibrillation.
(b) Cyclopropane, chloroform and ethyl chloride are prone to cause fibrillation.
(c) EKG at time of fibrillation or if chest is open, the heart will be visibly fibril-
lating.
Why is it unwise to use a sympathomimetic (such as epinephrine or ephe drine) in the
presence of chloroform or cyclopropane 2
A. (A dr. Techs. , p. 91)
These two anesthetic agents increase irritability of the conduction system and of
the heart muscle, predisposing to cardiac fibrillation. Ephe drine and epinephrine
also act on the pacemakers of the heart and tend to cause irritability. A drenalin
given to a patient sensitized by cyclopropane may produce cardiac irregularity lead-
ing ultimately to ventricular fibrillation. Neosynephrine does not seem to cause
such marked effects and may be used as a vasopressor, if necessary.
By what mechanisms may cardiac arrest take place during anesthesia 2
A. (Best, p. 238; A dr. Techs. p. 154)
(1) Ventricular fibrillation:
a. Occurs usually during the induction or recovery period due to the release of
epinephrine and its action on a heart whose irritability has been increased
by anesthetics, particularly cyclopropane, chloroform, and ethyl chloride.
b. Thyrotoxicosis, particularly when cardiac changes are present and drugs
which increase cardiac irritability are employed. (Both cyclopropane and
adrenalin).
(2) Reflex stimulation:
a. Stimulation of the vagi at the hilum of the lungs, along the esophagus, in
the bronchi, tra chea, during intubations.
b. Stimulation of a hyperactive carotid sinus.
c. Emboli:
1. Pulmonary: This type is uncommon but may occur in syndromes in
which intravascular clotting is a possibility.
2. Fat: This type occurs in manipulations of large bones which have
been recently fractured.
3. Air: This type occurs in thoracic surgery or when large veins are
accidentally opened.
(3) Cardiac failure:
a. Myocardial is chemia due to occlusion of a coronary vessel.
b. Sudden myocardial depression from toxic anesthetic drugs.
c. Cardiac arrest following respiratory failure and prolonged acute anoxia.
76
2: 12
37.
38.
39.
40.
What protective physiological mecha is rºls are called into action when he morrhage
occurs ?
A .
(Best, p. 26)
(a) Immediate - (1) Fall in blood press u : « limiting further bleeding (2) Clotting
of blood (3) Increased heart rate through Carotid sinus and a Ortic reflexes
which are stimulated by fall in blood pressure; increased blood pressure
also due to adrenalin liberation and an oxernia cardiac center (4) Contrac-
tion spleen for RBC (5) Increase in respiration due to a nozia of che more –
ceptors in the carotid body. (6) Reduction of the capacity of the vascular
bed and redistribution of blood - (skin, intestines, mucosa not essential).
(b) Delayed - (1) Replacement lost fluids from tissue fluids and proteins (2)
Replacement RBC and WBC by the bone marrow (3) Replacement of clotting
factors by the liver.
What are the factors and how do they operate in the clotting of blood 2
A .
(Best, p. 1 12- 115; Basic Sc in Orth p. 13)
(a) Prothrombin plus thromboplastin in the presence of ionized calcium yields
thronbin.
(b) Thrombin plus fibrinogen equals fibrin or clot. Prothrombin is formed by
the liver and is governed by the levels of Vit K.
Assuming that they are available, under what circumstances during anesthesia
would you recommend the intravenous use of whole Citrated blood, plasma, so-
lutions of glucose, physiologia saline solution, or solutions of a cacia, gelatin,
pectin or isinglass (agar agar) 2
Under what circumstances would you use vasopress or substances and in what
dose 2
(Best, p. 40, 50, 5 l; A dr. Pharm. p. 104)
1. Whole blood – treating he morrhage and shock, and replacing blood loss
during surgery.
2. Plasma – treating shock due to severe burns, treating shock if no blood is
available.
3. Glucose solutions in water – as replacement and nutritive therapy in pro-
longed surgery not requiring blood; preferred to saline; useful in diabetes
if covered with insulin.
4. Physiologic saline - in limited a mounts in prolonged surgery for replace -
ment therapy in cases of dehydration, e.g. following obstruction, excessive
voniting etc.
5. Solutions of acacia, etc. - to combat shock in absence of whole blood or
plasma. At present, these agents have been used less and less because of
the toxic effects on the liver.
To produce vasoconstriction, in blood pressure falls due to spinal or caudal
a nesthesia or with any of the above mentioned agents (Ephe drine 10-15 mg. in-
travenously, repeated, or 25–50 mg. intra muscularly; Neosynephrine 25-.5 mg.
intravenously, repeated or 3 mg. intramuscularly; Vas oxyl 5 – 10 mg. intraven-
ously, repeated, or 15 mg. intramuscularly. ) One large dose should not be
given. Small repeated doses will maintain pressure.
A bottle of Rh neg O blood contains:
1) A and B and Anti-Rh agglutinins
2) a and b in serum and anti Rh agglutinins
3 a and b in serum and no anti Rh agglutinins
:
4 l.
46.
(4) A and B and no anti Rh agglutinins
(5) No a or b and no anti Rh agglutinins
A. No. 3 (Best, p. 43, 45, 46).
The blood is designated by those agglutinogens in the cells. (A or B). The
agglutinins in the blood stream are anti A or anti B. In an Rh negative, there
are no anti Rh agglutinins in the serum.
How long does it take for the following blood elements to be come lost in stored
citrated blood 2
A : (Basic Sc in Orth, p. 39)
(a) RBC – 30 days for depletion to 1 1/2 million per cc of whole blood.
(b) WBC – 10 days no leuke cytes remain – In 24 hour s 50% are lost
Name three types of blood transfusion reactions. Give the symptoms or findings
by which you would identify each type.
A. (Collins, p. 477; Wilson; Nicholson)
(a) Hermolytic (b) A naphylactic (C) Hyrogenic
In an an esthetized per son, there may be no signs of transfusion reaction unless a
sample of urine is examined. A concious patient may exhibit signs innediately or
they may develop in 2–3 hours after transfusion. The complaints after even a few
cc. of incompatible blood may be :
Tingling sensations.
Disconnfort
Anxiety
Fullness of the head
Pre c or dial pressure and the sense of fullness in the chest.
Dyspnea.
Pain in the lumbar and chest regions
Chill followed by high fever.
Q. Signs of shock such as rapid pulse, cyanosis, nausa and vomiting.
10. He moglobinuria
What is the objection to a cacia for transfusion ?
A (Basic Sc in Orth, p. 39, 40; Heuper)
A cacia possesses antigenic properties. It is fixed and stored in the liver. Plasma
proteins may be depressed to low levels (particularly fibrinogen which causes pro-
longation of bleeding time. )
How much osmostic pressure does 25 grams of human albumin exert 2
A (Basic Sc in Orth, p. 40)
A s much as 1 000 cc. of whole blood or 500 cc. of plasma.
What is the difference between serum and plasma 2
A , (Basic Sc in Orth, p. 42)
Serum is obtained from coagulated blood and does not contain fibri ogen.
What are advantages and disadvantages of plasma over whole blºº
A. (Basic Sc in Orth, p. 43, 44)
78
47.
48.
49.
50.
51.
Advantages:
1. It may be quickly and simply administered from dried stocks with out cross –
matching. g
2. There are no antigenic properties to cause reactions.
3. There is no neces sity for special storage.
4. It does not increase the hennoc oncentration in burns or in severe shock which
is not due to hemorrhage.
Disadvantages:
1. For those conditions, which require replacement of red cells, plasma is
not so useful, although it may be used until whole blood is available.
2. The dangers of the transmission of hepatitis from the use of pooled plasma
are being studied and have caused a marked decrease in its use.
The drop in oxygen tension of arterial blood during its passage from the heart to
the capillaries is:
1)
2)
3)
4)
5)
A.
0 mm. Hg.
20 mm. Hg.
30 mm. Hg.
40 mm. Hg.
50 mm . Hg.
No. 1 (Best, p. 375) It is only after passage through the capallaries that O2 is
lost.
What is the degree of oxygen saturation of the blood 2
A.
(Basic Sc in Orth, p. 1 })
Content 18, 6 Q 5%
Capacity 20.
Oxygen in simple solution in normal arterial blood at sea level is about:
. 24 vol. Wo
2. 4 vol. 96
5. 0 vol. 9/6
24. vol. 9%
40. vol. "%
No. 1 (Best, p. 37 l)
What is the quantity of carbon dioxide in simple solution in the blood 2
What is the role of carbamino compound 2
(A dr. Chem. p. 360; A dr. Pharm. p. 122; Best, p. 40 l)
about 5% of the CO2 of the blood is in simple solution.
about 2-10% of the CO2 is combined directly with hemoglobin and is known
either as carb he moglobin or carbarnino compound. It is attached to the hermo –
globin radical in the amino portion. It is an unstable substance and releases
CO2 readily in the lungs. (Adriani states that 20% of the CO2 is thus combined,
whereas, Best and Taylor gives the figure as 2-10%).
What is the role of carbon dioxide in oxygen dissociation curve 2
A.
(Best, p. 375)
The Bohr effect describes the changes in the oxygen dissociation curve when carbon
dioxide is added to the blood. This occurs in the tissues with resultant lowering of
2 : 15 79
52.
53.
54.
55.
56.
the pH. of the blood and a flattening of the curve to the right. In other words, car -
bon dioxide when added to the blood helps to release oxygen to the tissues from
hemoglobin. The reverse is true in the lungs when the pH of the blood is raised
when CO2 is released.
What is the "bicarbonate buffer systern ?'"
A. (Basic Sc in Orth, p. 26)
Carbonic acid and Bicarbonate combined with basic ions of Na and K govern a large
part of the pH of the blood. Because CO2 and H2CO3 are being constantly formed
in the body any excess of alkali may be quickly neutralized or removed by the kid-
neys. When any acid in excess is formed in the body CO2 can be easily blown off
from the lungs.
What are the peripheral effects of CO2 as compared to the central effects:
A. (A dr. Pharm. p. 116)
Peripheral effects are vasodilitation; central effects are vasoconstriction. The
splanchnic vessels constrict. The effect on the pial vessels is like that of the
peripheral vessels – dilatation. (See question 24 in Supplement 1).
State ways in which pernicious anemia is significant in a nesthesiology.
A. (Lundy, p. 30, 31)
Pernicious anemia is significant in that it greatly reduces the oxygen carrying capa –
city of the blood. It also predisposes to capillary permeability in the face of anoxia
and hence predisposes to shock under general anesthesia. In cases of severe and
long standing pernicious anemia with combined de generation of the cord, spinal
anesthesia is contraindicated. Further damage to the cord may result and the
patient may claim damages.
(a) What is the significance of non-protein nitrogen in the blood 2
(b) What is its normal value 2
A. (Best, p. 8)
(a) Non-protein nitrogen in the blood is made up of urea, uric acid, creatinine,
creatine, a minº, a cids. At any given time, it is the balance between nitrogne ous
wastes entering the blood stream and leaving in the urine. Thus in fevers with
excess catabolism, adrena l insufficiency, dehydration, hemorrhage, intestinal
obstruction, peritonitis and renal insufficiency, there is a rise. In the latter
part of pregnancy, there may be a normal decrease in NPN, because of the use
of Nitrogen by the fetus.
In those patients who have a high NPN, it is wise to use Cyclopropane or Ni-
trous Oxide with sufficient oxygen, and not to use those agents such as ether or
chloroform, which irritate the kidneys.
(b) 28–40 mg.
(a) Define surgical shock.
(b) What are some of the the ories of the mechanism of the production of shock 2
(c) Describe several in detail.
A. (Best, p. 301)
(a) Surgical shock may be either primary to secondary. Primary shock may be de-
fined by three qualities. It is of a nervous origin, its site located in the arter-
ioles, and it is characterized by vasodilatation. Typically, a severe wound,
Concussion, or other violent nerve stimulus causes vasornoter paralysis with a
20
2: 16
57.
58.
59.
quick fall of blood pressure and symptoms of profound weakness; unconscious –
ness or apathy; thready pulse; (usually fast, sometimes slow) pale, moist skin;
often subnormal temperature; faint tic-toc heart sounds and poorly filled veins.
Secondary shock can be defined as capillary failure resulting from local injury
and attended by passage of the fluid into the injured tissues; reduced volume and
flow of blood; peripheral vasoconstriction; and anoxia.
(b) It is debated whether shock is a fluid shift or an intoxication. It is now claimed
that it is both, with intoxication the more fundamental factor.
(c) Fluid Shift Theory: The essential feature of a wheal or contusion is accumula -
tion of fluid in the injured tissues. This process may be conceived as an abnor-
mal permeability of injured capillaries or an increased attraction of water by
chemical products of the injured tissues, or both. This abnormal fluid leakage
is confined to the injured area.
Toxic Theory: The products of injured tissue which cause the s welling and other
local phenomena in a wheal may cause systemic intoxication if they are absorbed
in sufficient quantity. Cannon and Bayliss proved that:
1. Shock can be fatal when fluid migration is not large enough for an explana –
tion, or when a deficit of circulating fluid has been prevented by suitable
injection.
2. Cross transfusions from an injured part of one animal can be fatal to a
normal recipient or contrary wise the injured animal may be cured.
3. A demonstration of circulating substances of vaso exiter or depress or
action.
However, further experiments have not be e in a ble to duplicate the se find –
ings. Phemister found that the fluid from an injured area failed to affect
the blood pressure.
What information about shock would be useful for an enlisted lay man serving as a
stretcher-bearer during war-time:
A. (Cullen, p. 230)
The stretcher – bearer should be taught to observe and record the type and rate
of the pulse and respiration and, if equipment is available to record the blood pres–
sure at regular intervals. He should be instructed in the control of hemorrhage
and the use of blood plasma for shock; maintenance of body temperature without
excessive overheating; to give morphine for the relief of pain; to apply available
sterile dressings to wounds; not to give opiates to head injuries; and nothing by
mouth to injuries of the abdominal cavity.
One of the following is not a characteristic of shock:
Fall in blood pressure
Increase in pulse rate
Increase in capillary permeability
A rteriolar dilatation
Hemoc oncentration
i
A
(Best, p. 301) No. 4
Arteriolar constriction of the splanchnic and cutaneous areas takes place as a
compensatory mechanism in response to the decrease in circulating blood vol-
ume. This decreased volume presumably comes from either pooling of blood
in the capillary bed or leakage of plasma from the vascular system.
Discuss convulsions under anesthesia listing the most commonly accepted causes
and give treatment you would use.
60.
6 1.
62.
A .
(A dr. Techs. p. 155) Convulsions under anesthesia may be due to several causes:
A sphyxia from any cause.
Carbon dioxide excess.
Overdosage of local anesthetic drugs.
Stimulation of motor centers.
Idiopathic in type.
:
Treatment Consists of:
Maintaining high oxygen.
Supplying carbon dioxide if necessary.
Administration of a short acting barbiturate.
Discontinuing the anesthetic agent.
:
Where are autonomic cholinergic fibers found 2
A .
(Best, p. 1083)
1. All pre ganglionic fibers at their junction with the post ganglionics.
2. Parasympathetic post ganglionic fibers.
3. Postganglionic sympathetic fibres to the sweat glands and uterus.
What is Head's Law of Referred Pain 2
A.
(Basic Sc in Orth, p. 9)
Inpulses from the viscera are transmitted to the spinal cord, where they make con-
tact with segmental secondary and tertiary pain neurons until the brain is reached.
There being only one system of pain nerves - some innervating the skin and others
the viscera, the brain misinterprets and localizes the visceral pain in the somatic
segment of the skin.
Define the following terms as they are used in relation to a nesthesiology:
al
b
C
d
e
f
)
Traction reflexes
Mechanical dead space
Relative humidity
Controlled respiration
Carotid body apnea
Secondary saturation
(A dr. Chem. p. 38; A dr. Techs. p. 38, 104, 141, 336; Clement, p. 104)
Traction reflexes are cardiovascular changes which occur when traction is made
on the gall bladder, stormach, pericar diurn and heart and are due to stimulation
of visceral afferents in the vagus - the so-called vago — vagal reflex. The blood
pressure drops and the pulse slow s.
Mechanical dead space is that space containing gases which are rebreathed with-
out coming in contact with the absorbent and therefore are not freed of CO2.
This is to be differentiated from the physiologic and anatomic dead spaces which
pertain to the lungs.
Relative humidity is the percentage of moisture in the air as compared to the
a mount necessary to cause saturation.
Controlled respiration is the continuation of rhythmic breathing by the anes the s-
iologist by pressure on the breathing bag, during a period when the patient is
in a pnea from any cause.
Carotid body apnea results from giving the patient large quantities of oxygen,
after the Carotid body has taken over respiration in the face of oxygen lack. The
stimulation to respiration is temporarily removed and the patient be comes a pneic.
Secondary saturation is part of the McKess on technique of inducing deepened
anesthesia with nitrous oxide and oxygen. The patient is given pure nitrous
oxide until signs of oxygen lack appear, after which a flush of pure oxygen is
82
2 : 18
63.
64.
65.
66.
given, followed by a mixture containing maintenance doses of nitrous oxide and
Oxygen.
What is the range of normal value for each of the following:
) Blood he moglobin
) Blood NPN
) Blood chloride expressed as sodium chloride
) Blood urea
) Erythrocyte count
) Pulse pressure
g) PSP output of the kidneys.
a.
b
C
d
e
f
A. (Best, p. 56, 7, 36, 34, 10, 54,453)
14 – 16 grams / 100 cc.
25–35 grams / 100 cc.
450–500 mg. / 100 cc. "
10 – 15 mg. / 100 cc.
e) 4.5-5. 0 million.
f) 40 mm. Hg.
g) . 1 gram is injected I. V. 40- 60% appears the first hour and 20-25% in the
second. By the end of two hours a total of 60- 85% should have appeared.
(Normal kidneys will pass the dye in 15 min. )
:
Discuss laryngospasm included the causes and treatment:
A. (A dr. Techs. p. 149)
Laryngospasm is due to reflex or direct stimulation of the vocal cords. It may be
due to:
1. Sudden high concentrations of a nesthetic agent
2. Soda lime dust
3. Foreign bodies and mucus.
4. Oral air way in light anesthesia.
The treatment is mainly prophylactic. This includes avoiding the above and :
1. Preventing stimulation before adequate surgical planes are reached.
2. Premedicating drugs to keep the reflex level low.
In the event that laryngospasm occurs the following treatment should be instituted:
1. Removal of all stimulating agents (anesthetic, mucus, foreign bodies, oral
air way).
2. Oxygen under pressure by mask.
3. Insertion of an endotra cheal tube if necessary.
4. A tropine sulphate in doses of 1/75 grain intravenously.
What is the Brewer – Luckhardt reflex 2
A. (A dr. Techs. p. 114)
The patient begins to crow or develops laryngospasm when upper abdominal surgery
is in progress and the surge on tugs on the viscera.
What errors in the conduct of anesthesia tend to increase vomiting 2
A. (Best, p. 574, 575; Lundy, p. 433)
1. Not emptying the stomach before operation and/or having a Miller Abbott
tube in place. This tube acts as a wick and keeps the cardia open. When
2: 19 83
67.
68.
69.
70.
71.
tissues relax as anesthesia progresses or the patient is put in Trendelenburg
position, reflux of stomach contents may occur.
Irritating the pharynx with an airway before reflexes are eliminated.
Pumping air into the stomach and distending it.
Sensitivity to morphine.
A noxia.
Irritation of the respiratory mucosa (ether especially).
Central reflex vonniting from irritating agents such as ether.
In spinal anesthesia, drop of blood pressure with resultant nausea.
Describe the methods employed by the anesthesiologist during inhalation a nesthesia
to aid in the control of distended intestines. Why is each effective 2
A. (Christopher, p. 897; Lundy, p. 385-386)
1. A Miller-Abbott tube. This may be attached to a Wangensteen suction be -
fore, during and after operation. It progresses down the intestine and
continuously draws off any gas formed.
2. Morphine sulphate will often prevent or correct atony and dilatation of the
bowel because of its specific effect on the gut.
3. Parasympathetic drugs such as Mecholyl Chloride - 10–20 mg. by hypo;
prostigmine . 5 – 1 mg. by hypo or physostigmine 2 mg. by hypo.
Use of an endotra cheal tube so that air cannot be pumped into the stonnach.
Breathing pure oxygen is supposed to has ten the absorption of nitrogen but
this is not practical during most a nesthetic procedures.
.
If a patient has been overdosed with an oil- ether mixture given by rectum (a) how
would you proceed to support the patient 2 (b) How could you remove some of the
ether and how has ten elimination of some of the remainder ?
A. (A dr. Techs. p. 19.8, 199)
(a) The anes the Siologist must insure the patient's oxygenation for however
long it may be necessary. Intravenous fluids and vasopress or can be
used as needed. Flush with Soap Suds enema S.
(b) Open the clamp on the rectal catheter. Increasing, respiration arti-
ficially helps to eliminate the ether.
What is the reabsorption rate of the kidney tubules 2
A. (Best, p. 456)
In a normal person about 125 cc. of urine are filtered through the glome ruli per
minute. Since only 1–2 cc. per minute reaches the bladder, about 99% of the water
must be reabsorbed in the tubules.
What substances do the renal tubule absorb 2
A. (Best, p. 451)
The reabsorption of sugar, phosphate, chloride, sodium and 90% of the water takes
place in the proximal convoluted tubule; acidification takes place in the distal tubule
due to the reabsorption of bicarbonate. There is a constant ratio between chlorides
and bicarbonates – one falling as the other rises.
A cute urinary retention from chronic nephritis with NPN of 120 will show one of the
following:
(1) total base reduced
(2) Uncompensated carbon dioxide excess
(3) compensated carbon dioxide excess
(4) total ammonium (urinary) is increased
(5) elevated CO2 combining power.
84
2:20
72.
73.
74.
75.
76.
77.
A. (Best, p. 460-463) No. 1. No. 4 may also be correct from base loss.
At post mortem a lower nephron syndrome is present. What was probably the
anesthetic agent used ?
A. (A dr. Pharnh. p. 40)
With chloroform there is fatty degeneration of the tubules but the glorne ruli rerna in
intact.
Which of the inhalation drugs is least apt to cause albuminuria 2
A. (A dr. Pharm. p. 22)
Nitrous oxide when used without superimposed a noxia Causes no known change S in
the kidney.
What are the laboratory findings in uremia 2
A. (Best, p. 481)
Urea clearance less than 5%.
PSP O – 10 in 2 hour s.
NPN over 100 mg. per 100 cc.
Urea nitrogen over 70 rmg.
Creatinine above 5 mg.
Whatever urine volume the re is has a low SG 1 007 - 1 0 1 2.
:
(a) Why is less a nesthetic agent needed in old patients 2
(b) In what age group is the metabolic rate highest ?
A. (Cullen p. 33; Lundy, p. 2 1 0 1 ; Adr. Chenn. , p. 422).
(a) The amount of a nesthetic agent used depends largely on the basic metabolic
rate of the patient. Thus in children and during puberty when the rate is the
highest and when anxiety and irritability are greatest, the patients require
more anesthetic agent relatively. As these factors decrease, all the agents
are required in lesser quantities. It is a well known fact that much smaller
doses of spinal anesthetics will give prolonged a nesthesia in old patients.
(b) According to Guedel, the peaks of metabolism occur at about the age of six,
followed by a slow decrease at the age of ten, with a secondary peak during
puberty.
What is the mode of action of propyl thioura cil 7
A. (Best, p. 787)
Despite thyroid hyperplasia, a de crease in the formation of thyroxin takes place.
No interference with the action of the thyroxin has been found. A decrease in hyper-
thyroid symptoms is noted quite rapidly. At operation, the enlargement of the gland
with increase in vascularity becomes apparent.
(a) Why limit salt post operatively 2
(b) What are the water compartments of the body ?
A. (Basic Sc in Orth. p. 21)
(a) Ordinarily satt is excreted by the kidneys so that replacement of about 10 grams
per day is necessary. Postoperatively either because of increased adrenocor-
tical action or tº tº a nesthetic agents, salt is not excreted for 24–48 hours. The re-
fore salt added ºf intravenous fluids is retained and may cause edema of trau-
matized wounds or the body tissues in general. However if continuous gastric
2:2 1 85
78.
79.
80.
81.
suction is being maintained, a recalculation must be made to compensate for
this loss (gastric secretions contain . 5-. 9 percent sodium chloride and the
volume must be measured. )
(b) The intracellular and extracellular compartments, using the cell membrane as
the dividing line. The extracellular compartment is divided into the blood
plasma and interstitial fluid by the wall of the blood vessels.
What are normal daily water and salt requirements 2
A. (Basic Sc in Orth, p. 23)
The total fluid ordinarily taken in is 3 liters. An output of 1 liter a day is consid -
ered average with normal intake. For a patient who is on no food by mouth, 1 liter
of normal saline will normally replace the loss of sodium chloride in the urine. (If
no gastric suction is being used. )
What are the advantages of 1/6 molar lactate over saline 2
A , (Basic Sc in Orth, p. 31)
When injected intravenously, lactate breaks down into bicarbonate and glucose which
are readily available for neutralization and metabolism. Saline may cause saline
edema post operatively, when salt is retained by the kidney. However, the fact that
sodium is being given may be a detrimental feature of the use of m / 6 molar sodium
lactate.
What physiologic functions of the liver are of particular interest to the anesthesiologist
and why 2
A. (Best, p. 550)
(1) Detoxifying functions – most all a nesthetic agents are detoxified to some extent
in the liver.
(2) Formation of glycogen - important in giving an esthesia to diabetics, etc.
(3) Formation urea, uric acid – chloroform, vine thene, etc. cause increased of
uric acid in urine.
(4) Formation of fibrinogen and serum albumin and globulin.
(5) De composition R. B. C. and hemoglobin.
(6) Formation of bile.
(7) Deanninization of a mino acids.
(8) Regulates specific dynamic reaction of proteins.
(a) What is your choice of a nesthetic agent and method for operations performed
for acute septic conditions of the throat or neck, or both 2
(b) Why do you choose this agent and method 2
(c) Why do you avoid some of the ouhe agents and methods 2
(d) Would pre-operative trache otomy alter your choice of a nesthetic agent and meth-
od, and why &
A. (Lundy, p. 470)
Septic Conditions in the neck such as cellulitis, abscess, infected carcinoma,
are best treated by avoiding any local anesthesia and concentrating on rectal,
intravenous or inhalation anesthesia.
When the condition is confined to the pharynx, it may be best to use regional
blocks, avoiding the infected area, or intravenous and rectal anesthesia. Masks
and endotra cheal tubes may spread the sepsis and irritative agents such as ether,
vine thene and ethyl chloride may be injurious. Pre operative tracheotomy would
definitely change the plan of anesthesia. With a cuffed or uncuffed endotrache o-
tomy tube, inhalation, intravenous, or rectal anesthesia becomes feasible. Oxy-
gen with the anesthesia agent may be given without fear of sepsis spread.
86
2: 22
SUPPLE MENT I SUB - SEC TION
PHYSIOLOGY
The percentage of oxygen in alveolar air is:
(1) 18%
(2) 16.5%
(3) 15.8%
(4) 14.2%
(5) 10.5%
A. No. 4 (Best, p. 368)
Vital capacity is:
(1) the total amount of air which can be exhaled after a maximal inspiration.
(2) the air which passes in and out during ordinary respiration.
(3) the air which is inhaled during a maximal inspiration.
(4) the air which can be forcibly expelled after an ordinary expiration.
(5) the amount of air remaining in the lungs after the most strenuous expiratory
effort.
A. No. 1 (Best, p. 36 l)
Increased rate of breathing is defined as :
(1) eupnea.
(2) dyspnea.
(3) hyperpnea.
(4) tachypnea.
(5) apneusis.
A No. 4 (Dorland)
The physiological dead space is a term applied to:
(1) the space from the nares, including the mouth, pharynx, tra chea and bronchi,
to the respiratory bronchioles.
(2) the space in the mask and tubing in the gas machine.
(3) the space in the soda lime canister.
(4) the space occupied by the alveoli and air sacs.
(5) the space within the lung which just prior to expiration contains prefectly
fresh air.
A. No. 5 (Best, p. 364) This must be contrasted with the anatomical dead space
which extends from the nostrils to and including the terminal bronchioles. The
anatomical dead space does not vary, but the physiological can vary according
to the depth of respirations.
How many cubic centimeters of oxygen does l gm. of hemoglobin carry when
saturated ?
. 52
. 34
l
2
3
4
5
:
.
A. No. 2 (Best, p. 371)
The output of carbon dioxide from the average-sized adult male at rest is approxi-
mately:
2 : 2 3 87
1 1.
88
(1) 100 cc. per minute.
(2) 250 cc. per minute.
(3) 350 cc. per minute.
(4) 400 cc. per minute.
(5) 500 cc. per minute.
A. No. 2 (Best, p. 364; A dr. Pharm. p. 116; A dr. Chenn. p. 68) A driani's
Chemistry states that 18 liters of carbon dioxide are breathed out per hour.
This amounts to 300 cc. per minute. Best and Taylor states that 4% of the
expired air is CO2. This a mounts to 400 cc. per minute if 500 cc. is the tidal
exchange. Adriani's Pharmacology gives 800 cc. per minute as the average
output.
The initial effect of carbon dioxide excess on the character of respiration in an
otherwise normal individual is :
(1) an increase in re spiratory rate.
(2) an increase in respiratory depth.
(3) a combination of (1) and (2).
(4) an increase in rate but decrease in depth.
(5) a decrease in rate and depth.
A. No. 2 (Best, p. 116; Goodman, p. 685; Collins, p. 92) Goodman
states that both are increased. Adriani's Pharmacology states
1% - 2% increases volume; 3% - 4% increases rate as well.
Increase in alveolar carbon dioxide concentration by 0.2% increases the respiratory
volume by:
(l) 5%
(2) 10%
(3) 25%
(4) 50%
(5) 100%
A. No. 5 (A dr. Pharm. p. 116)
The highest carbon dioxide tension is found in :
(l) inspired air.
(2) expired air.
(3) venous blood.
(4) arterial blood.
(5) alveolar air.
A. No. 3 (Best, p. 369)
Indicate the incorrect figure for carbon dioxide tension stated below:
Atmospheric air – 0.2 mm. / Hg.
Alveolar air – 30 mm. / Hg.
Arterial blood - 40 mm. /Hg.
Tissues – 60 mm. / Hg. *
Venous blood – 46 mm. / Hg.
i
A
No. 2 (Best, p. 368). In answer 1, the figure should be 3 mm. The alveolar
air may or may not be 30 mm. mercury depending on the amount of carbon
dioxide which is blown off but it averages 40 mm. of mercury. No reference
could be found for tissue carbon dioxide tension, but it undoubtedly is about 60
mm. mercury to insure passage of CO2 into the blood stream.
The basal metabolic rate as used in clinical medicine is calculated:
2: 24
12.
13.
14.
from the amount of carbon dioxide liberated for an interval of eight to ten
minutes.
from the amount of oxygen taken up per hour per sq. meter of body surface.
from the rate and depth of respirations at rest recorded on a drum.
from the relation of oxygen taken up to carbon dioxide given off per unit of
time.
from the amount of oxygen consumed as corrected for temperature.
No. 2 (Best, p. 6 14, 619). Of two men of equal age but varying in weight, the
larger will put out more total heat than the smaller. However, the heat pro-
duction per unit of body surface may be practically the same. Heat production
is measured by oxygen consumption. -
Collateral respiration is :
A.
the ability to maintain adequate oxygenation of the blood by oxygen injected
intravenously through a hypo needle.
the ability to maintain adequate oxygenation of the blood in the presence of
high oxygen concentrations in the alveoli, but without respiratory movement.
the ability to maintain adequate oxygenation of the blood by artificial respiration
by the Eve method.
the ability to maintain adequate oxygenation of the blood by intermittent posi-
tive pressure through a gas machine.
the ability of the peripheral alveoli within a lobe to have an interchange of gases
between the lobules through the pores of Kohn, and thereby prevent collapse of
a lobule even though its bronchiole may be plugged.
No. 5 (Best, p. 355)
Which of the following most closely defines diffusion re spiration ?
Gas exchange between the atmosphere and lung alveoli in the absence of rhy-
thmically recurring differences in the barometric pressure.
Exchange of gases between the lungs and outside air caused by pumping of the
heart and movement of the diaphragm.
Movement of gases caused by changes in nitrogen concentration of atmosphere
and in the pulmonary tree.
Gas exchange as a result of differences recurring rhythmically between the
baronnetric pressure of the intra pulmonary gas and the outside a trnosphere.
Exchange of gases caused by the forcing of oxygen under high pressure into a
pulmonary tree.
No. 1 (Gille spie, p. 40; Draper; Whitehead) Three conditions were laid down
by the Denver group for successful diffusion re spiration. The first is replace -
ment of nitrogen within the respiratory tract and in the atmosphere at the
glottis by oxygen; second, and adequate circulation; third, a patent airway. The
interval between respiratory and circulatory arrest can be prolonged by what
this group calls the "hemoglobin-oxygen pump", which sucks oxygen into the
arterial blood stream and replaces that lost in the alveolae. This question is
worded poorly.
Paradoxical breathing is most commonly observed during:
:
A
pneumothorax.
a telectasis.
pneumonia.
laryngospasm.
controlled respiration.
No. 1 (Gillespie, p. 196) When the pleural cavity is opened, inspiration is
associated with a sinking of the chest on that side instead of a rising. This
may occur when laryngeal obstruction occurs - the so-called rocking horse
type of inspiration. The abdominal muscles contract and bulge out, but the
chest falls in.
2:25 89
15.
16.
17.
19.
20.
With an open he mith orax the usual cause of profound reduction of he noglobin is one
of the following:
l
2
3
4
5
A
The
i
The
i
A
The
i
Position of the patient
Reduction of oxygen per centage in inhaled at: he re
Effects of anesthetic agent
Reflexes due to operation
Circulation of blood through the collapsed lung
No. 5 (Cecil, p. 990). This answer would be correct if the question were "pro-
found reduction of oxyhemoglobin". There is some doubt that hemoglobin de-
creases when an open hemithorax occurs. In fact, the he innoglobin is ºr ore a lºt
to be increased by the release of re d cells from the spleen a red the re cºuction of
stored blood in the liver, as soon a s the effects of a noxia a r < felt. Flo & ever,
oxyhemoglobin is reduced because blood which pass c s through the collapsed
lung is not aerated.
Hering – Breuer reflex is activated by:
drop in blood pressure.
expansion and relaxation of the lung.
increase in blood pressure.
increase in depth of respiration.
increase in minute volunne of respiration.
No. 2 (Best, p. 407)
chemore ceptors are stinnulated by which one of the follo & ing:
Oxygen tension of arterial blood of 9 & minn. Fig.
A level of 24 per cent oxygen in the # 1 r.
By a scending to an altitude of 1, 50 ... e. t.
By breathing an air mixture contain irg i 8 per cent of y gº r.
A 97.4 per cent oxygen saturation of a rterial blood.
No. 4 (Best, p. 409). This c or responds to about 92 ºne r cent saturation of the
arterial blood or about 70 minn. mercury arterial oxyger, tension.
strongest chemical stimulus to the carotid body in its re spiratory role is :
oxygen lack.
oxygen excess.
carbon dioxide excess.
carbon dioxide lack.
lactic acid.
No. 1 (Best, p. 40.9)
What per cent of normal effort in moving air through a constricted portion of res-
piratory tract is necessary to move a mixture of helium 80% and oxygen 20% 2
l
2
3
4
5
A.
15%
25%
45%
65%
85%
No. 2 (A dr. Chem. p. 69). The figures usually given are about 33% of normal
effort.
Cyanosis is not always a good method for deter mining oxygenation of tissues because:
(l)
five grams per 100 cc. of reduced hemoglobin must be present to give cyanosis.
90
2 : 26
21.
22.
23.
24.
25.
anesthetic agents may diminish saturation of he moglobin.
the oxygen in physical solution is not considered.
transfused blood has reduced oxygen carrying capacity.
cyanosis does not parallel oxyhemoglobin-reduced hemoglobin dissociation.
.
A. No. 1 (Best, p. 438)
Which one of the following is not characteristic of chronic emphys enna º
Lung distended, alveoli enlarged.
Total respiratory surface reduced.
Residual air decreased.
Diaphragmatic excursions restricted.
l
2
3
4
5) Vital capacity reduced.
A. No. 3 (Best, p. 432). Residual air is 2 or 3 times normal, in many ca 3 c 3.
Diastolic pressure is predominantly due to:
the pumping action of the heart.
the quantity of blood in the arterial system.
the peripheral resistance plus the elasticity of the art ºrial v i s sels.
the viscosity of the blood.
the pulse rate.
i
A. No. 3 (Best, p. 149)
The main factor determining the filling of the corona ry vessels is:
systolic pressure.
pulse pressure.
dia stolic pressure.
mean aortic pressure.
pulse rate.
:
A
No. 4 (Best, p. 327). In a or tic regurgita tion, C or on a ry flow, is increased on
systole but reduced on dias, tole, because of the Sudden drop to low levels of
the diastolic pressures. Thus a compensation is set up. The same thing
applies to aortic stenosis, when the systolic pressure is reduced and prolonged,
dia stolic pressures are not affected, and the coronary flow is compensated in ,
part.
In the absence of the central effect of carbon dioxide, a rise in carbon dioxide
concentration in the circulating blood will cause:
(l) vasodilation due to a local effect on the peripheral blood vessels.
(2) decreased cardiac output.
(3) vasoconstriction due to an increase in epinephrine in the Circulating blood.
(4) vas oc on striction due to local effect.
(5) no change of Calibre in the peripheral blood vessels.
A. No. 1 (Best, p. 290). Carbon dioxide excess causes vasoconstrictor center to
be corne active. This is the main action o' carbon dioxide. The local effect ºn
the peripheral vessels is to dilate the m. Thus the se actions are opposite.
Which one of the following is considered a secondary factor in the maintenance of
the blood pressure ?
The pumping action of the heart
The peripheral resistance
The elasticity of the arterial walls
The viscosity of the blood
l
2
3
4
5) The age of the patient
2 : 27 91
26.
27.
28.
29.
30.
A .
No. 5 (Best, p. 146).
Venous return to the right heart is greatest during:
normal inspiration.
normal expiration.
the absence of respiratory movements.
deep inspiration.
forced expiration.
No. 4 (Best, p. 167)
When positive pressure on expiration alone is used as an adjunct to inhalation the rapy,
a complication which must be carefully watched for is:
an increase in re spiratory rate.
a fall in systolic blood pressure.
irregularity of the pulse.
a decrease in the pulse rate.
irregularity of the respiratory movements.
No. 2 (Gillespie, p. 143). The fall in systolic pressure is due in part to the
interference with venous return of the blood. When too nuch positive pressure
is applied, flows in the vena cava are innpaired and cardiac output is decreased.
In an adult patient in the erect position, the blood pressure is greatest in:
l
2
3
4
5
A.
bronchial artery.
carotid artery.
renal artery.
femoral artery.
radial artery.
No. 4 (Best, p. 170)
Stimulation of the press or eceptors by a rise in systemic pressure results in:
i
A.
The
i
slowing of pulse but no respiratory change.
inhibition of respiration and increase in pulse rate.
an increase in pulse rate and resulting a pnea.
an inhibition of respiration and a slowing of pulse rate.
no change.
No. 4 (Best, p. 282, 409) Slowing of respirations are minimal.
origin of the cardiac rhythm in the normal heart is in the
Sino-auricular node.
Purkinje fibers.
auricular – ventricular node.
bundle of His .
vagus center.
No. 1 (Best, p. 197)
The sole path by which the Cardiac impulse can be conveyed from auricles to
ventricles is :
3 1.
I
2
3
4
5
the sino – auricular node.
the auricular - ventricular node.
the bundle of His .
Purkinje fibers.
the interventricular septum.
92
2 - 28
32.
33.
34.
35.
36.
37.
The
:
A
The
i
The
i
A
The
i
The
i
A
No. 3 (Best, p. 200)
E-R interval in the electrocardiogram is an index of:
the period of maximal ejection of ventricular systole. -
the conduction time between the auricular - ventricular Connection.
the period of isometric relaxation.
the length of auricular contraction.
the length of auricular filling.
No. 2 (Best, p. 217)
Bainbridge reflex is activated by:
distention of the right auricle.
distention of the left auricle.
distention of the aorta.
increase in systemic blood pressure.
decrease in systemic blood pressure.
No. 1 (Best, p. 247). This results in increased heart rate with increased
filling of right auricle. It is me deated thru the Vagus nerve from the right
auricle,
Fick principle is useful in calculating or interpreting which of the following
Respiratory quotient
Vital capacity
B allis to cardiogram
Gardiac output
Bohr effect
No. 4 (Best, p. 267)
Total oxygen consumed per minute
a TV difference in vol/percent X 100 equals output in liters/min.
normal circulation time from elbow to tongue is :
0. 5 seconds
2. 4 seconds
8.6 seconds
13. 7 seconds
20. 5 seconds
No. 5 (Best, p. 179). Best and Taylor lists sacchar in arrn-tongue as 10. 7 sec.
(8–16). However, total circulating time with de cholin averages 20 seconds.
function of sodium in the contraction of cardiac muscle is to :
carry carbon dioxide.
insure rhythmicity.
carry out the Bohr effect.
insure the chloride shift.
buffer the blood.
No. 2 (Best, p. 192). The action of sodium is to insure excitability and con-
tractility of the heart muscle. The other answers given do not apply.
effect of the calcium ion upon the heart is to:
lengthen systole.
shorten systole.
38.
39.
40.
4 1.
lengthen diastole.
shorten diastole.
reduce contractility.
No. 1 (Best, p. 192)
Main line of biological oxidation is known as the:
i
The
:
Golgi Cycle.
Krebs cycle.
Ross cycle.
Shiff's cycle.
Cori cycle.
No. 2 (Best, p. 389, 390)
widely open pneumothorax, which of the following is not correct
There is a reduction in the intrapleural negative pressure only on the affected
side.
There is a bilateral reduction in the intrapleural negative pressure.
There is a tendency to impede filling of the right heart.
There is a tendency to produce stasis in the venous system.
The mediastinum and its contents moves to the sound side.
No. 1 (Best, p. 358). Both lungs tend to collapse, although the negative pres–
sure is more reduced on the open side than on the closed side.
supply of oxygen to tissue is ultimately and directly dependent upon
the saturation of the he moglobin.
the oxygen content of the blood.
the oxygen tension in the plasma.
the oxygen capacity of the blood.
the flow rate of the blood.
No. 3 (Best, p. 375)
In what way can ether cause histotoxic hypoxia 2
i
A
Blocking dehydrogenase
Paralyzing indolphenol oxydase
Oxidizing reduced cytochrome
Reducing oxidized cytochrome
It cannot cause histotoxic hypoxia.
No. 1 (Seifriz; Himwich). Hinnwich states "one type of acute anoxia cannot be
avoided, although fortunately it might not be excessive, namely histotoxic
anoxia, the interference with the cellular c idation in the brain which is part
of the ne chanism of anesthesia. ''
Somewhere in the chain, "glucose + dehydrogenase + coenzyme + cytochrone
reductase + cytochrome B + cytochrome C + cytochrome A + cytochrome oxidase
+ O2 yields H2O + CO2 + energy, ether interferes with the glucose oxidation.
Splitting off the H-atoms of the glucose molecule gives water and energy with
the concomitant formation of CO2. Cyanide gives a similar picture because it
is a histotoxic agent. It interferes with the chain of events by combining with
Cytochrome oxidase.
Seifriz postulates ''gelation" of narcotized tissues with any type of anes the sia.
The tissues are in a state of suspended animation until the anesthetic agents are
removed.
2 : 3 ()
42.
43.
44.
45.
46.
4 7.
Blood and air are separated in the lungs by:
alveolar epithelium, connective tissue and Capillary end othelium.
capillary endothelium and alveolar epithelium.
capillary endothelium alone.
alveolar epithelium alone.
alveolar sacs and lymph channels.
.
s
A. No. 2 (Best, p. 346)
The inhalation of 100 per cent oxygen de creases cardiac output in normal indivic ut ls.
This is due to :
(1) decreased heart rate.
(2) decreased stroke volume.
(3) pulmonary vasodilation.
(4) decreased heart rate and stroke Volune.
(5) cerebral vas oc on striction.
A. No. 1 (Best, p. 251)
What is the function of the chlorid C shift 2
(1) Pre serve chloride
(2) Increase alkali
(3) Neutralized alkali
(4) Increase the carbon dioxide carrying capacity of the blood
(5) Control acid – base balance
A. No. 4 (Best, p. 131, 399). However, this does control the acid base balance to
a great extent, because the addition of CC2 in the tissues tends to make the
blood more a cid.
What is normal albumin concentration in plasnia 2
(l) 6 gm. Wo
(2) 4 gn. W6
(3) 2 gm. Wo
(4) 1 gn. W6
(5) 0.25 gm."
A. No. 2 (Best, p. 5)
One of the following clinical pictures suggests that of marked oxygen deficiency, but
with adequate elimination of carbon dioxide. Identify this syndrome.
(1) Slow, bounding pulse; elevated blood pressure; tendency to opisthotonus; irregu-
lar respiration.
(2) Fast pulse; elevated blood pressure; twitching of facial muscles; increased
respiratory rate.
(3) Soft, slow pulse; lowered blood pressure; depressed re spiration; clonic convul-
S 1 OIn S .
(4) Fast, thready pulse; unchanged blood pressure; unchanged respiration; opistho-
to nu S.
(5) Fast pulse; lowered blood pressure; hyper pnea; clonic convulsions
A. No. 1 (Adr. Pharm. p. 123; Collins, p. 487).
Which one of the following is primarily responsible for the osmotic pressure pro-
duced by the blood plasma 2
(1) Fibrinogen
(2) Albumin
48.
49.
50.
51.
52.
96
Globulin
Histannine
Glucose
No. 2 (Best, p. 5)
Death following a single pulmonary embolus which occludes only one vessel in one
lung is due to:
(1)
2
3
4
5
A
the decrease in the amount of aerated lung, due to collapse of the part of one
lung.
the mediastinal shift due to collapse of part of one lung.
the reflex effect on both lungs and the heart.
a decrease of oxygenated blood going back to the heart.
the hemorrhage which the embolus may produce in the alveoli.
No. 3 (Cecil, p. 939, 940). Pulmonary emboli may throw patients into shock
with depression of the cardiac system because of reflexes through the vagus
nerve. Much depends on the size of the vessel occluded. A large vessel causes
loss of an entire section of lung, whereas a small vessel may be occluded with
no effects at all.
A cetylcholine is not liberated at which one of the following nerve endings 2
Sympathetic preganglionic
Somatic motor
Para sympathetic postganglionic
Sympathetic postganglionic
Parasympathetic pre ganglionic
No. 4 (Best, p. 1083)
Vagotomy in the treatment of recalcitrant peptic ulcer results in:
i
A
The
i
rapid emptying time of the stomach because of decreased pyloric spasm.
marked increase of gastric tonus with decrease of acid secretion.
no changes in gastric motility or secretory activity.
increased mucin and pepsin formation but decreased acid secretion.
marked decrease in motility and secretion of stomach.
No. 5 (Goodman, p. 322)
center of heat regulation in man is in:
cerebral cortex.
spinal Cord.
hypothalamus.
pons.
medulla.
No. 3 (Best, p. 726)
What is the function of the internuncial neur one 2
i
A
Facilitate occlusion
Antagonize central summation
Produce reflex delay
Play a role in reciprocal innervation
Give vegetative effect to a single impulse
No. 5 (Best, p. 92 1). Single inpulses are thus multiplied by as sociation with
one or more internuncial neur ones.
2:32
53.
54.
55.
56.
57.
58.
Which one of the following nerve groups is considered "adr energic" 2
:
A .
Postganglionic parasympathetic fibers
Postganglionic sympathetic fibers
Preganglionic fibers to the adrenal glands
Somatic motor nerves to skeletal muscles
Postganglionic fibers to sweat glands
No. 2 (Best, p. 1080)
A patient who is to have a spinal anesthesia has a pulse of 82. Within five minutes
after administering the anesthetic the pulse is 50.
bradycardia is which one of the following 2
(1)
(2)
(3)
(4)
(5)
A .
Stimulation of reflexly of the vagus nerve
Depression of cardio-accelerator nerves
Excessive pre medication
Muscular paralysis in the legs
Increase in circulation time by 100%
No. 2 (Burstein, p. 1 18)
Pre ganglionic fibers are:
l
2
3
4
5
A .
adr energic.
sympathetic.
para sympathetic.
somatic.
cholinergic.
No. 5 (Best, p. 1083)
Which one of the following reflex mediations is incorrect 2
l
2
3
4
5
A .
Plantar – Cortico – spinal tract
Hering – Breuer - Vagus
Pupillary constriction – Cervical sympathetics
Bainbridge - Vagus
Carotid sinus – 9th and 10th cranial nerve s
No. 3 (Best, p. 1089; Goodman, p. 322). Dilatation is controlled by the
sympathetics.
Prostigmine acts on the cholinergic nerves by:
1)
2)
3)
4)
5)
One
i
inhibiting the activity of choline ste rase.
increasing the production of acetylcholine.
decreasing the amount of acetylcholine formed.
increasing the rate of de struction of acetylcholine.
inhibiting the action of acetylcholine on the end-organ.
No. 1 (Goodman, p. 339; Best, p. 1082)
of the early investigators responsible for the classification of blood groups i ,
Wiener.
Landsteiner.
Lattes.
Mir sky.
Bar croft.
No. 2 (Keys, p. 12)
The most correct reas on for this
2 : 33 G7
59.
60.
The first scientific study of oxygen want was made by:
(1) Priestly.
(2) Gay-Lussac.
(3) Paul Bert.
(4) Lavoisier.
(5) Mosso.
A. No. 3 (Barach, p. 4)
Much of the original work regarding the carotid sinus mechanism was done by:
(1) Lundy.
(2) Heymanns.
(3) de Takats.
(4) Waters.
(5) Smithwick.
A. No. 2 (Best, p. 408)
98
2:34
SUP, PLE MENT II SUB – SEC TIC) N
PHYSIOLOGY
The most reliable sign of early oxygen want is the
hypertension
pulse rate
depth of respiration
hypotension
rate of respiration
l
2
3
4
5
A. No. 2 (Cullen, p. 244)
A ssuming that the only things that are keeping an individual's respiratory activity
functioning are the carotid bodies, and 100 per cent oxygen is administered, which
one of the following will probably occur:
(1) Hyper pnea
(2) A pnea
(3) A pneusis
(4) Eupnea
(5) Polypnea
A. No. 2 (Burstein, p. 17)
Cyanosis is not always evidence of severe hypoxia. At which level of hemoglobin
concentration would the above statement be true for a normal white individual:
(1) 7 gn.
(2) 10 gm.
(3) 12.5 grin.
(4) 14 gn.
(5) 17 gm.
A. No. 5 (Best, p. 438). In a patient with 17 grams of he nº oglobin it takes little
hypoxia to cause cyanosis. Cyanosis will result when 5 grams of reduced he nº o –
globin are present in the peripheral circulation. Thus, it is possible to have 12
grams of hemoglobin present in the circulation which is adequate for good oxygena -
tion although the patient appears cyanotic.
In an adult with a tidal exchange of 500 cc. how many cubic centimeters mix with
alveolar air :
(1) 75 cc.
(2) 150 cc.
(3) 250 cc.
(4) 350 cc.
(5) 450 cc.
A. No. 4 (Best, p. 364). During an inspiration with a tidal exchange of 500 cc. a
portion of the fresh air fills the dead space (150 cc). The remaining 350 cc.
mixes with the residual and supplemental airs (2000 cc. ) which rennains in the
lung after the previous expiration.
The alveolar oxygen percentage in a normal woman breathing 50% oxygen and 50%
nitrogen would be approximately:
(1) 10%
(2) 15%
(3) 30%
(4) 45%
(5) 55%
2 : 35 99
10.
A. No. 3 (Best, p. 364). A proportion is made as follows. (The alveolar oxygen
X
14. 2. = H . The end result is 33.9%. The closest
content is normally 14.2%) 20. 9 O
answer in this question is 30%.
The supply of oxygen to tissue is ultimately and directly dependent upon:
the saturation of the hemoglobin
the oxygen content of the blood
the oxygen tension in the plasma
the oxygen capacity of the blood
the flow rate of the blood
:
A. No. 3 (Best, p. 375)
The drop in oxygen tension in arterial blood from the time it leaves the heart until
it reaches the capillaries is on the order of:
(1) 0 mm. Hg.
(2) 5 mm. Hg
(3) 8 mm. Hg
(4) 10 mm. Hg.
(5) 20 mm. Hg
A. No. 1 (Best, p. 375). Best and Taylor states that practically no oxygen is lost
from the arterial blood until the capillaries have been reached.
Which one of the following normally contributes least to the maintenance of venous
pressure ?
(1) Capillary pressure and flow.
(2) Gravity
(3) Intrapleural pressure
(4) Propulsive action of heart and arteries
(5) Tone of skeletal muscle
A. No. 1 (Best, p. 167). Answer 1 was chosen although it is obvious that the venous
return will depend somewhat on the capillary pressure and flow. However, capil-
lary pressure and flow depends ultimately on the propulsion action of the heart and
arteries.
A rise in venous pressure results in:
(1) an increase in pulse rate
(2) a decrease in pulse rate
(3) a decrease in systemic pressure
(4) a drop in pulse pressure
(5) increased left ventricular work
A. No. 1 (Best, p. 247)
The pulmonary systolic arterial pressure is approximately:
(1) 1/6 of systolic systemic arterial pressure
(2) 1/4 of systolic systemic arterial pressure
(3) 1/3 of systolic systemic arterial pressure
(4) 1/2 of systolic systemic arterial pressure
(5) same as systolic systemic arterial pressure
A. No. 1 (Best, p. 332; Collins, p. 208)
When positive pressure on expiration alone is used as an adjunct to inhalation therapy,
| ()()
2: 36
12.
13.
14.
15.
16.
a complication which must be carefully watched for is:
An increase in respiratory rate
A fall in systolic blood pressure
Irregularity of the pulse
A decrease in the pulse rate
Irregularity of the respiratory movements
i
A.
No. 2 (Barach, p. 68)
The main factor determining the filling of the coronary vessels is:
systolic pressure
pulse pressure
diastolic pressure
mean aortic pressure
pulse rate
:
A.
No. 4 (Best, p. 327; Collins, p. 207). Best and Taylor explains this best.
Although it is true that the coronary arteries are filled during diastole, it is
more innportant to calculate the mean aortic pressure. As an example, in
aortic regurgitation, where there is a sharp drop in diastolic pressure there is
however, a compensatory rise in systolic pressure. Thus, the mean aortic
pressure is compensated for by the high systolic pressure and the coronary
arteries can be filled despite the fact that there is a low diastolic pressure.
Collins explains that the coronary vessels are filled by the diastolic aortic
pressure which is the effective pressure. This is incorrect.
The mean arterial pressure is the pulmonary circuit of a normal individual is
approximately:
(1) 20 mm. Hg.
(2) 40 mm. Hg.
(3) 60 mm. Hg.
(4) 80 mm. Hg.
(5) 120 mm. Hg.
A. No. 1 (Best, p. 332; Collins, p. 208)
Which of the following factors is not directly involved in control of coronary cir-
culation:
(1) A ortic Blood Pressure
(2) Oxygen lack
(3) Carbon dioxide excess
(4) Heart rate
(5) Venous distention
A. No. 5 (Best, p. 327; Collins, p. 208)
One of the following is caused by vagal depression:
Increased pulse rate
Bronchial constriction
Excess secretion of respiratory tree
Bradycardia
Irregular pulse
i
A. No. 1 (Best, p. 243)
The initial effect of carbon dioxide excess on the character of respiration in an
otherwise normal individual is:
2 : 37
101
17.
18.
19.
20.
2. l.
an increase in respiratory rate
an increase in respiratory depth
a combination of one and two
an increase in rate but decrease in depth
a decrease in rate and depth
i
A. No. 2 (Collins, p. 92)
of the total CO2 in the blood, the amount combined directly with hemoglobin is on
the or der of:
(1) 1 - 2%
(2) 2 - 10%
(3) 10 - 25%
(4) 25 - 50%
(5) 50 - 75%
A. No. 2 (Collins, p. 192)
In whole blood the quantity of carbon dioxide in simple solution, in volumes %, is:
:
.
l
A. No. 3 (Best, p. 371) This is 5% of total volume.
The Meltzer – Auer Technique of insufflation is unsatisfactory be cause it:
(1) increases the alveolar CO2 slightly
(2) increases the alveolar CO2 markedly
(3) does not alter the alveolar CO2
(4) decreases the alveolar C C2 markedly
(5) decreases the alveolar C C2 slightly
A. No. 3 (Gille spie, p. 42; Draper, p. 207). This is a mbigiously worded. All
author's writing about the insufflation technique state that the difficulty with this
technique is the marked increase in carbon dioxide in the alveoli which even-
tually causes the patient to convulse or die. The answer chosen here is as good
as answer 2. The CO2 is not removed adequately with this technique.
Concerning the oxygen and carbon dioxide content of the blood of a normal foetus,
select the incorrect state nent:
Oxygenated or arterial blood is carried by the umbilical vein.
Oxygen in the unbilical artery is about 4 volumes per cent.
Carbon dioxide content of unbilical artery is about 40 volumes per cent.
Foetal blood oxygen capacity is 22 volumes per cent.
I
2
3
4
5) Oxygenated foetal blood is about 60 per cent saturated.
A
No. 3 (Williams; Collins, p. 368)
The receptor endings for the Bainbridge reflex are in the :
Lung alveoli
Carotid body
Conus arteriosis
Right auricle
A Ortic arch
i
A .
No. 4 (Best, p. 247)
102
2 : 38
22.
23.
24.
25.
26.
27.
28.
A reflex originating in the celiac plexus is characterized by:
fall in systolic blood pressure associated with tachycardia
decrease in pulse pressure associated with tachycardia
decrease in pulse pressure associated with bradycardia
decrease in diastolic pressure associated with bradycardia
l
2
3
4
5 rise in diastolic pressure with tachycardia
:
A. No. 3 (Burstein, p. 63; Collins, p. 302)
Distention of the lung will elicit a reflex response known as :
Bainbridge reflex
Hering – Breuer reflex
Carotid sinus reflex
Carotid body reflex
1
2
3
4
5) Celiac plexus reflex
A. No. 2 (Best, p. 407)
Section of both vagus nerves in the neck of a rabbit cause s :
(1) rapid, shallow re spiration
(2) apnea
(3) slow, deep re spiration
(4) irregular, jerky respiration
(5) no change in respiration
A. No. 3 (Collins, p. 186)
Which statement is incorrect:
Local pain is pain without radiation.
Transmitted pain implies root or trunk involvement.
Visceral pain is controllable by severing spinal nerves.
l
2
3
4
5) Referred pain signifies derma tonne involve nº ent,
. No. 4 (Judovich, p. 8)
Local temperature changes over a painful area occur frequently.
A
Concerning the autonomic nervous systern, select the incorrect statement:
The cranial outflow is located in nerves III, VII, I X and X.
All spinal nerves have gray rami communicantes.
All grey rami communicantes are postganglionic sympathetic.
All white rami communicantes are cholinergic.
All spinal nerves have white ranni communicantes.
:
A
No. 5 (Best, p. 1075)
All pre ganglionic autonomic fibers are:
unmyelinated and adrenergic
myelinated and adrenergic
shorter than postganglionic fibers
myelinated and cholinergic
unmyelinated and cholinergic
:
A. No. 4 (Best, p. 1075, 1082)
Cholinergic fibers are found in all but one of the following groups.
cholinergic:
Which is not
103
29.
30.
3 1.
32.
33.
:
Parasympathetic postganglionic fibers
Postganglionic sympathetic fibers to sweat glands
Sympathetic pre ganglionic fibers
Postganglionic sympathetic fibers to heart and intestine
Postganglionic sympathetic fibers causing vasodilatation
No. 4 (Best, p. 1083)
During uncomplicated spinal anesthesia in a normal male, which one of the following
is the most likely finding:
l
2
3
4
5
A.
Unaltered oxygen capacity and carbon dioxide Content
Unaltered oxygen capacity, arterial oxygen content and carbon dioxide content
Reduced carbon dioxide combining power
Increased carbon dioxide tension
Lowered arterial oxygen content
No. 2 (Ref. - none)
A patient who is th have a spinal anes the sia has a pulse of 82. Within 5 minutes
after administering the anesthetic the pulse is 50. The most correct reason for this
bradycardia is which one of the following:
l
2
3
4
5
A
The
i
A
Stimulation reflexly of the vagus nerve
Depression of cardio-accelerator nerves
Excessive premedication
Muscular paralysis in the legs
Increase in circulation time by 100%
No. 2 (Burstein, p. 118)
optimum posture for pulmonary ventilation is:
Supine
Sitting
Prone
Standing
Trendelenburg
No. 4 (Collins, p. 51; Slocum, p. 105 l). In the unanesthetized patient, the
standing position is the optimum posture. This is due to the fact that the weight
of the intestinal viscera is removed from the diaphragm as much as possible.
However, in the anesthetized patient, the supine or sitting position favors ven-
tilation. The compensatory mechanisms which influence circulation are depressed,
including the press or receptors in the car otid sinus and the muscle tone.
Physiological dead space is greater than anatomical dead space when:
:
i
the tidal air is greater than normal
the tidal air is less than normal
the residual air is less than normal
the person is less than 2 years old
full expansion of the lungs has failed to occur at birth
No. 1 (Best, p. 364)
A
A ortic and carotid chemore ceptors (bodies) have their effect on:
Circulation
Respiration
Cerebration
Detoxification
De Carboxylation
104
2:40
34 .
35.
36.
37.
38.
39.
A. No. 2 (Best, p. 283; Burstein, p. 17)
A ortic and carotid press or eceptors (sinuses) have their effect on:
(1) Circulation
(2) Re spiration
(3) Cerebration
(4) Detoxification
(5) De carboxylation
A. No. 1 (Best, p. 283; Burstein, p. 17)
A disastrous fall in blood pressure is often initiated when the position of a patient
under anesthesia is changed. This is because the anes the sia has altered the nor rnal
compensatory mechanism which regulates:
the venous return to the heart
the respiratory center in the medulla
the cardiovascular center in the medulla
the carotid sinus
l
2
3
4
5 the Bainbridge reflex
A. No. 4 (Burstein, p. 76; Collins, p. 51). As mentioned in question 31 the fall
in blood pressure when the position of a patient is changed suddenly under
anes thesia is due to the lack of compensatory mechanisms which have been
depressed by a nesthesia.
An early clinical sign of impending shock is:
Hypotension
Cutaneous vasoconstriction
Increased amplitude of respiration
Increased rate of respiration
l
2
3
4
5) Bradycardia
A. No. 2 (Cullen, p. 200)
Ventricular fibrillation can be suspected in a patient under cyclopropane a nesthesia
by:
Arrhythmia
Sudden cessation of pulse
Tachycardia
A pnea
l
2
3
4
5) Bradycardia
A. No. 2 (A dr. Tech. , p. 91)
When prolonged drop in blood pressure to below 70 mm. Hg. occurs during a spinal
anesthetic for vaginal delivery for pregnancy, fetal death is likely because:
there is insufficient oxygenation of maternal blood
intra-uterine pressure is greater than blood pressure
of failure of the maternal kidney to excrete toxic products
there is increased tendency for premature placental Separation
l
2
3
4
5) fetal blood may cross the placental barrier to the maternal side
A. No. 2 (Rollas on)
With an open he mithorax the usual cause of
rofound reducti $ 2
of the following: p eduction of hemoglobin is one
(1) Position of the patient
2 : 4 l 105
40.
4 1.
42.
43.
44.
45.
2) Reduction of oxygen percentage in inhaled atmosphere
3) Effects of a nesthetic agent
4) Reflexes due to operation
5) Circulation of Blood through the collapsed lung
A. No. 5 (Collins, p. 410) This question should read "oxyhemoglobin".
The largest myelinated nerve fibers in the body measure 20 microns in diameter
and conduct nerve impulses at approximately:
(l) 10 meters /sec
(2) 50 meters /sec
(3) 100 meters / sec
(4) 200 meters /sec
(5) 500 meters/sec
A. No. 3 (Best, p. 908)
The sole path by which the cardiac impulse can be conveyed fro in auricles to ven-
tricles is :
the S - A node
the A - V node
the Bundle of His
Purkinje fibers
l
2
3
4
5) the interventricular septum
A. No. 3 (Best, p. 200)
Which one of the following regulatory mechanisms is not primarily associated with
the hypothalmus:
Water metabolism
Temperature regulation
Respiratory cycle regulation
Sleep regulation
l
2
3
4
5) Carbohydrate metabolism
A. No. 3 (Best, p. 10 1 2)
Cry moanalgesia is :
experimental pain relief on criminals
loss of pain due to C old
pain relief due to diather my
electrical anes the sia
pain relief due to synthetic drugs
i
A. No. 2 (Dorland, p. 370)
Which of the se is not a likely cause of nausea during spinal anes the sia:
(1) Cerebral hypoxia from hypotension
(2) Excessively rapid absorption of the drug
(3) The opiate given for pre -anesthetic medication
(4) Traction on visc era
(5) Psychic upset
A. No. 2 (A dr. Tech. , p. 216)
The potassium ion in the blood of normal patients is:
(1) free in the plasma
106
, 2:42
46.
47.
48.
49.
50.
:
A
only in the red blood cell
in plasma as KCI
in plasma as potassium phosphate
in plasma as potassium carbonate
No. 5 (Best, p. 19; Garnble, chart 2). There is no carbonate radical in the
blood. The ion existing is the bicarbonate ion. (There are also chlorides,
acid phosphates, sulfates and proteins. )
Choose the incorrect statement. The known materials in the circulating blood
which influence heart action the least are:
(1)
(2)
(3)
(4)
(5)
A.
Ca, K and Na ions
adr enalin
carbon dioxide and lactic acid
oxygen
hemoglobin
No. 3 (Collins, p. 196). This is a diffic ºf qi te 5 rion to answer because all the
answers seem to be correct. One must C in oose a 11 answer which has the least
action. Calcium causes increased muscula. contraction strength. The reverse
is true of potassium. Sodium ions are necessary to the heart. The three ions
are needed for normal contraction. A dr & Hall n Cause s an increased cardiac
rate and increased cardiac output. The heart cannot contract an oxygen debt.
Oxygen is delivered to the heart through the he moglobin mechanisms. A de-
creased pH caused by an increased carbon dioxide causes a state of relaxation.
Minimal traces of lactic acid rnay cause sensation of contractility. Thus,
answer 3 was chosen as the least effective rine chanism for change.
Sodium is present in more than traces in all but one of the following:
(1)
(2)
(3)
(4)
(5)
A.
The
(1)
(2)
(3)
(4)
(5)
A.
The
(l)
(2)
(3)
(4)
(5)
A.
Red blood cells
Inter stitial fluids
Edena fluid
Blood plasma
Spinal fluid
No. 1 (Best, p. 19)
effect of the calcium ion upon the heart is to :
lengthen systole
shorten systole
lengthen diastole
shorten diastole
reduce contractility
No. 1 (Best, p. 192)
only site of urea formation in the body is:
Pancreas
Kidneys
Liver
Intestines
Urinary Bladder
No. 3 (Best, p. 635)
Diffusion respiration is:
(1)
(2)
exchange of gases betwº en bloc, d g : fi : * : * ~ *
s - *-
* * = ... --> ' ' ... *-> -->
exchange of gases between alveoli a 1. d
21 & . . vi
2 - 3 3 107
5 1.
52.
53.
54.
55.
56.
(3) Equalization of gases throughout respiratory spaces
(4) as sisting gaseous exchange by controlled respiration
(5) maintenance of gaseous exchange without respiratory movements
A. No. 5 (Whitehead)
In pulmonary emphysema which of the following is caused:
(1) the alveolar content of O2 and CO2 is increased
(2) the alveolar content of O2 and CO2 is decreased
(3) the alveolar content of O2 is decreased and CO2 increased
(4) the alveolar content of O2 is increased and CO2 decreased
(5) the alveolar content of O2 and CO2 is unchanged
A. No. 3 (Best, p. 432)
The respiratory center is rendered less sensitive to CO2 by:
increase of oxygen content of blood
a small reduction in oxygen content of blood
a marked reduction in oxygen content of blood
a reduction of nitrogen in the blood
a decrease in the water content of alveolar air
:
A. No. 3 (Guedel, p. 19)
At what ages in the normal child is the metabolic rate the highest:
(1) 6 months to 1 year
(2) l year to 5 years
(3) 6 years to 12 years
(4) 10 years to 15 years
(5) 15 years to 20 years
A. No. 2 (Cullen, p. 33)
Indicate the volume of fluids lost per day by normal adults through evaporation from
the skin and lungs during rest or light activity:
(1) 200 - 400 cc.
(2) 400 – 800 cc.
(3) 800 - 1500 cc.
(4) 1500 - 2000 cc.
(5) 2000 – 3000 cc.
A. No. 3 (Best, p. 21). 500 cc. is lost through the skin. 350 cc. through the expired
air. Therefore, answer 3 is chosen.
You are measuring the CO2 concentration at the lips, at the end of expiration, in an
efficient closed circle or to -and-fro absorption system, with only basal oxygen flow –
ing. Which of the following should the concentration of CO2 approximate:
1%
. 5%
. 0%
. O96
l
2
3
4
5 . 5%
:
A. No. 4 (Best, p. 364)
The conscious patient exposed to an atmosphere containing . 03% carbon dioxide for
as long as 30 minute 5 will exhibi the following:
108
2:44
57.
58.
59.
60.
The
Hyper pnea
Periodic apnea
Signs of alkalos is
Signs of a cidosis
Nothing
No. 5 (Best, p. 364)
condition essential to the termination of the circus movement of the ventricular
fibrillation is :
prolongation of the refractory period
the existence of local blocks
the slowing of rate of conduction of the wave
increase of the diameter of the anular course
a de crease in the wave of conduction
No. 1 (Burstein, p. 102)
co-efficient of oxygen utilization is:
the ratio between tidal exchange and oxygen consumption
the A V difference
the ratio between oxygen consumed by nervous tissue and the entire oxygen
uptake
the proportion of the total oxygen content of the blood which is given off to the
tissue
the ratio between oxyhemoglobin and reduced hemoglobin in venous blood
No. 4 (Best, p. 376)
In an adult patient in the erect position, the blood pressure is greatest in:
l
2
3
4
5
A.
Bronchial artery
Carotid artery
Renal artery
Femoral artery
Radial artery
No. 4 (Best, p. 169)
Concerning the normal electrocardiogram, which of the following statements is
inc or rect:
P wave is caused by excitation of the auricles.
P – R interval varies between 0. 13 and 0. 16 second.
QRS complex should not exceed O. 1 second.
T wave is caused by contraction of the ventricles.
The P - R interval is the conduction time of the bundle of His .
No. 5 (Best, p. 217). Answers 1, 2 and 3 are correct. The T waves however,
are caused by the retreat of the excitation wave. The ventricle is still contract-
ing. The P-R interval measures the time taken for the impulse to pass over
the auricle and the AV connections as far as the upper part of the interventri-
cular septum.
2 : 45 109
P A T H O L O G Y
C h a p t e r III
111
OUT LINE – P A THOLOGY
SYSTEM
RESPIRATORY
1. Anoxia including Re spiratory
Obstruction. . . . . . . . . . . . . . . . . . . . . . . º
2. A sphyxia. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3. Cyanosis. . . . . . . . . . . . . . . . . . . . . . . . . . . .
4. Asthma. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5. Bronchiolar C on striction . . . . . . . . . . . .
6. Atelectasis . . . . . . . . . . . . . . . . . . . . . . . . . .
7. Pneumonia. . . . . . . . . . . . . . . . . . . . . . . . . .
8. Emphysema and Fibrosis. . . . . . . . . . . * * *
9. Endotra cheal Anesthesia Effects. . . . . .
10. Larynx. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
I 1. Miscellaneous including Positioning,
Tracheotomy, Pulmonary Pressures,
Pulmonary Edena, Vital Capacity. . .
CIRCULATORY
l, Blood Pressure Factors Including
Vagal Effects, Hypertension. . . . . . . .
2. Embolism. . . . . . . . . . . . . . . . . . . . . . . . . . .
3. Arrhythmias including Ventricular
Fibrillation, Coronary Artery
Disease. . . . . . . . . . . . . . . . . . . . . . . . . º
4. Tetralogy of Fallot. . . . . . . . . . . . . . . . . . .
5. Blood Sugar Under Anesthesia. . . . . . . . .
6. Transfusions and Reactions. . . . . . . . . . .
7. lons Circulating and Influencing Heart
Action. . . . . . . . . . . . . . . . . . . . . . . . . . . -
8. Miscellaneous including White Count
Main Sect.
16, 17,
18, 19, 2 1
23 – 25
28 – 33
34, 36
22, 37, 38,
39, 40
4 1, 42, 43
45, 46
48
QUESTION NUMBER
Suppl. I
-
19, 2 I , 22
23, 25, 26, 56
15, 31
3 3, 40, 4 l
1, 3, 4, 5,
49
35
5 ()
Suppl. 2
39
8
5, 34
4 3, 44
46
42, 45
1, 2, 3
49
35
18, 19, 21
22
31, 32, 33,
50
after Anesthesia, Arterial Pentothal
Injection, Oxygen The rapy, Hemato-
crit, A-V Difference, Blood Volume
Venous Pressure, Thronbosis,
Aortitis
• * * * * * * * * * * - C - e º 'º e º e º e s e º e e
27, 28, 29
13, 24, 52
23
4, 6, 7,
26, 37, 53
113
OU TLINE – PA THOLOGY
SYSTEM
NERV OUS
1.
Spinal Fluid and Spinal Anesthesia. . . . .
Peridural Anesthesia . . . . . .
Blocks with Alcohol. . . . . . . .
Sympathetic Blocks. . . . . . . .
tº e º 'o tº º ºs e - e -
Brain Pathology including Convulsions,
Coma, Cerebral Hemorrhage. .
Shock and Hypotension. . . . . .
Mis cellaneous including Trilene, Nerve
Reflex Distrophy. . . . . . . . . -
Palsie s
MISCELLANEOUS
1.
2.
10.
1 1.
12.
l 3.
Chronic Alcoholism. . . . . . . .
Heat Retention. . . . . . . . . . . .
Refrigeration. . . . . . . . . . . . .
© & © tº tº ºr 4 tº º ſº &
º
tº e º 'º e tº s e 6
tº g g tº g o o e
tº tº Q 6 to º ºs o ºn tº 9
Heart, Liver and Kidney Dannage with
Chloroform, Aver tin, Cyclopropane. .
Diabetes. . . . . . . . . . . . . . . . . .
Hyp erthyroidism © tº 0 º tº º ſº tº a 0.
Eclampsia and Problems of
o, a * * * * * * *
tº º 0 tº º tº º 4 & º 0.
the
o & 6 tº 6 tº o e º 'º o
o tº 6 c e º s 6 c a o
Clinical Picture with Barbiturate
Poisoning. . . . . . . . . . . . . . .
A Cid Base Balance. . . . . . . . .
• 6 tº e o a cº e t c ºx
Authors, Books, & Techniques . . . . . . . -
Urinary Tract
Miscellaneous including Morphine Over-
dose, Curare Effects, Reflexes, Burns
with Anesthetic Agents, Tachyphylaxis
Autopsy
* * * * * * * * * a o a
0 w tº g o ºs g c tº
(Cont'd)
QUESTION NUMBER
Main Sect. Suppl. 1 Suppl. 2
57, 58, 6.1, 30 13, 14, 5 1
6.2, 64, 65 52
66 * - sºme 56
67, 68, 6.9 - - - - = -
60, 70, 71 34 10, 48
54 20, 38, 39 20, 41, 47,
54
35, 73, 74, 75, 48, 5.3 25
76
- sº - 36, 37 * * -
59 17, 32 9, 1 1, 12,
36, 55
77 - *** - - -
78 * - * 27, 38
79 * - sº * *- -
80, 8 1 , 8.2 12, 14, 16 24
83, 84
47, 85 - - - * - -
86 46 * * *
87, 88 * - as 30
89, 90 44, 45 16, 1 7
20, 72, 93 - - - * - -
15, 94, 95, 42, 43 | 5
96, 97, 98
8; 26 57, 58, 59,60 57, 58, 59,
60
* * * * * * * c e o e o a • * * *
tº e s tº tº e º & © tº 6
- - - 54, 55 28, 29
91, 92 1 1, 18, 47 40
114
BIE LIOG R A PHY - P A THOLOGY
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ADRIANI, J. : The Pharmacology of Anesthetic Drugs. Ed. 3, Springfield, Ill.,
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3 :iii | 15
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3 : V 117
MAIN SUB-SECTION
P A THOLOGY
A pilot at an altitude where the pressure is 150 mm. Hg. is still anoxic because:
A. (Barach, p. 26)
The relative increase in the partial pressures of water and carbon dioxide
causes a decrease in the partial pressure of oxygen in the alveoli. In this ex-
anple, the partial pressure of oxygen may be calculated: (150–47) times 20. 9%
or 21 mm. of mercury. The 47 mm. of water vapor tension in the alveoli is
constant from the ground up. The carbon dioxide level remains about 40 mm.
of mercury tension until a level of 19-15000 feet is attained when increased
respirations due to anoxia of any degree causes some hyperventilation. The
carbon dioxide tension is therefore lowered to from 30–35 mm. of mercury.
The figure of . 209 is merely a transposition of 20/100. The end result is
alveolar oxygen tension far below the minimum necessary to force oxygen into
the arterial blood stream (where the venous blood has a tension of 30–40 mm.
of mercury).
Inhalation therapy is not as effective in anemic anoxia as in anoxic anoxia. In
anemic an Oxia :
(1) Oxygen tension of blood is normal
(2) Tissue cells are not able to utilize additional Oxygen
(3) Arterio-venous difference is normal
(4) Oxygen in simple solution is greater than normal
(5) Circulation time is abnormal
A. No. 1 (Best, p. 440)
The blood is already nearly as fully saturated as possible, in anemic or stagnant
anoxia.
(a) What is the relative affinity for hemoglobin of carbon monoxide and of oxygen 2
(b) What is the appearance of a patient with severe carbon monoxide poisoning 2
(c) What irrever sible pathological changes of the central nervous system may fol-
low C O poisoning 2
A. (Best, p. 437).
(a) CO combines with hemoglobin volume for volume with an affinity of 300 times
that of oxygen.
(b) He has a cherry red appearance.
(c) Bilateral necrosis of the lenticular and corp or a striata nuclei of the brain.
Which is incorrect in stagnant anoxia 2
(1) Arterial oxygen content is normal
(2) Arterial oxygen "% saturation is normal
(3) Arterial oxygen tension is normal
(4) A-V difference is decreased
(5) Venous oxygen tension is decreased
A. No. 4 (Best, p. 422).
The A-V difference is increased.
How may the conduct of anesthesia cause cerebral damage to the patient 2
A. (Best, p. 936; Barach, p. 43).
118
3 : 1
The cells of the cerebral cortex when deprived of oxygen supply for 5 or more
minutes may be irreparably damaged. Some damage may result in the se delicate
cells for even 1/2 minute deprivation. The brain stem centers may survive
after a longer period of complete anoxia, 25 to 35 minutes, and the spinal centers
- 40 to 60 minutes. The autonomic Centers are relatively resistant to oxygen lack.
Thus the order of degeneration is: (1) pyramidal cells in the cortex (2) Purkinje
cells (3) medulla (4) spinal ganglia.
Chronic anoxia from the following causes may do as much damage over a long
period of time: (1) poor position (2) anoxic concentration of oxygen (3) Hemor-
rhage and loss of hemoglobin (4) hypotension from cardiac failure or spinal anes -
thesia (5) depressant agents such as pentothal (6) too high concentration of
agents and histotoxic anoxia.
Hemorrhage may result from sudden hypertensions in arterios clerotic or suscep-
tible patients. Hypertension may be caused by sudden adrenalin release, stormy
induction, CO2 accumulation and sensitivity to the particular anesthetic agent.
Describe the clinical course and pathologic changes associated with cerebral anoxia.
A. (Cour ville, p. 96; Adr. Pharm, p. 124).
The clinical course of a patient depends on how long and how severely he has been
anoxic. Those with severe prolonged anoxia may become de cerebrate. The milder
cases may not have any evidence of the episode.
The immediate post-operative course of a patient who had a bout of severe anoxia
may reveal: slow pulse, coma, twitching of small muscles, convulsions, prolonged
cyanosis, hyper themia within 6 to 48 hours.
Delayed reactions include stupor, mental Cloudiness, blindness, and Parkins onism.
Pathological changes in nerve tissue following administration of nitrous oxide in
anoxic concentration are similar to changes in:
(1) Alcohol poisoning
(2) Chloroform
(3) Potassium poisoning
(4) Carbon monoxide poisoning
(5) Oxygen lack
A. No. 5 (Adr. Pharm. , p. 124; Cour ville, p. 17).
There are no specific changes in the body directly attributable to nitrous oxide.
The pathologic changes in patients as defined by Cour ville, are all due to the anoxia
associated with the use of nitrous oxide.
The author of "Untoward Effects of N2O Anesthesia'' is :
(1) Clement
(2) Van Liere
(3) Hender son
(4) McKess on
(5) Cour ville
A. No. 5 (Cour ville).
Choose statement which does not apply. Pathological changes in Central Nervous
System as a result of anoxia.
3:2 119
12.
14 .
(1) Un Syrn One trical de gene rative changes
(2) Widened peri-vascular and peri-cellular spaces
(3) Decrease of Pyramidal and purkinje cells
(4) Located principally in medulla
A. f. c. 4 (C our ville, p. 127) The nain effects are on the cerebral cortex.
What change 8, take place in the brain when the patient dies in asphyxia 2
A {{... our v . . . . p. 135; Adr. Pharm. , p. 124).
Large and s 111a | 1 peri vascular, pete chial hemorrhages, scattered throughout the
brain are the Inna in picture. Because the changes are so rapid, only the acute
hermorrhagic picture can be founci. The vessel walls be corne permeable to the blood
ele run ent S.
Describe the gross pathologic findings of the lungs (a) of an individual drowned in
resh water; (b) of an individual killed by a spiration of v Ornitus.
G2
|
A. (Moore, p. 6 19; Adr. Techs. , p. 161).
(a) iſ the p 3 lic nt has had laryngo spasm and a sphyxia the lungs may not be filled
with water. Where water has been a spirated the lungs are filled with water.
There is no evidence of pneumonia.
(b) There is patchy consolidation of both lungs or lobular pneumonia. There may
be collapsed areas dark purple in Color and depressed below surface. A thin
fibrinous material may cover the surface of the lung.
(c) if death were due to massive a telectasis, the lungs may be so collapsed that
they no longer fill the Chest Cavity. Vonitous may be present in the bronchial
tra Ct.
In death from acute asphyxia an immediate characteristic pathological finding is :
(1) Pete chial hernorrhages of the meninges
(2) Liver necrosis
A. INo. 1 ( : Cir. Pharn). , p. 1 24; Cour ville p. 135).
There is cya in O S is in a patient 12 hours postoperatively, patient's respirations,
pulse and blood pressure are normal. Which of the following conditions may have
caused this .
(i) Sulla - he a oglobin following the use of Sulfa
(2) Shallow breathing
(3) Morphine idiosyncrasy
(4) Pulmonary atelectasis
(5) Shock
A. No. 1 (Goodman, p. 1031). See question 34, p. 3:44. This is a poor question.
, 3, & 4 are eliminated be cause the statement 1s made that respirations are normal
noi 3 & 5 are eliminated be cause pulse and blood press a re normal, Only 1 is left.
O Odrina in and Gilman state that Cyanosis does O C Cur with stilfa drugs but that sulf-
end oglobin is usually present in neglible announts. Mºthermoglobin is more common.
One of the following is wrong: During I. V. Pentotha i N2O O2 anesthesia:
) Respiratory exchange may be inadequate
) Posture of the patient is more important than with ether
) Cyanosis is an accurate indicator whether oxygen is adequate
Hyper capnea will not always be manifested by increased respiratory effort.
Fentothal and N2O act synergistically.
:
3 : 3
15.
16.
| 7.
A. No. 3 (Best, p. 438; Clement, p. 131).
Cyanosis is never an accurate indication of the anoxia of the body tissues. Patients
with low hemoglobin may not show cyanosis even with severe hypoxia. Five grams
of reduced hemoglobin are necessary for cyanosis to become apparent, and the
patient may not have much more than this annount of hemoglobin in toto. There are
so many other modifying factors such as pigmentation and thickness of the skin,
that cyanosis should never be the one outstanding criterion of oxygenation of the
body.
There is a decrease of available oxygen to the tissues in alkalosis because:
(1) O2 cannot diffuse readily through the alveolar membrane.
(2) of stagnation of the blood.
(3) of a lack of hemoglobin.
(4) of a shift of the O2 dissociation curve to the left.
(5) of a shift of the O2 dissociation curve to the right.
A. No. 4 (Best, p. 373).
In alkalosis, there is a shift of the oxygen dissociation curve to the left. The hemo-
globin tends to hold on to the oxygen more tenaciously and therefore less is released
to the tissues. The rever se becomes true when the pH becomes more acid up to
certain linits.
What are the signs and symptoms of a pulmonary at electasis of the left lower lobe 2
A. (Best, p. 434; Lundy, p. 371).
Main physical signs are those of shifting of thoracic contents toward the affected
side: (1) In spection - chest wall moving poorly on that side - cyanosis - dyspnea
(2) Palpation - poor voice sounds - tactile fremitus absent (3) Percussion - dull-
ness – heart moved toward affected side (4) A us cultation - poor breath sounds in
area – course rales above this area.
Symptoms - the patient may be cyanotic, have pain in chest, be dyspneic.
Temperature - 100-104 F.
Leukocytosis of 10–2000.
Discuss post-anesthetic atelectasis. (Include in your answer various theories of
the mechanism of its production).
A. (Best, p. 434; Lundy, p. 371).
The prevention and treatment of post Operative anesthetic atelect as is concerns all
anesthetists. Proper management of the patient during and innediately after
anesthesia in many instances prevents its occurrence.
Theories: a. Edena of mucous membranes similar to angion eurotic edema, might
produce enough obstruction to cause pulmonary Collapse.
b. Bronchial spasm has been suggested as a possible cause.
C. Vas Omoter the Ory - dilatation and stasis of the blood vessels might
produce obstruction in bronchioles by an outpouring of secretion.
d. Mechanical obstruction - actual plugging of a bronchus or several
bronchi by tenacious secretions which have collected in the tracheo-
bronchial tree during anes the sia or by vomitus which has been aspirat-
ed either during or immediately after anesthesia.
3:4 121
18.
19.
20.
The onset may be gradual or sudden. The bronchus be cornes plugged and if this plug
is not removed by a spiration or if the patient is unable to remove the plug by cough-
ing or change of position, the air in the involved region be comes absorbed with
resulting atelectasis. More rapid atelectasis may develop if the patient has been
breathing highly absorbable gases (O2).
Symptoms and Signs - (a) dyspnea - out of proportion to the degree of pulmonary
involvement present (b) discomfort over lung involved (c) rapid pulse, in-
crease in temperature (d) cyanosis depends on degree of lung tissue involved.
Preventive neasures - (a) Preoperative atropine; (b) empty stomach; (c) no for e1gn
bodies in the mouth; (d) aspiration of secretions postoperatively from pharynx
and tra chea; (e) insure teeth are undamaged (f) use of Helium and O2 at end of
operation to prevent absorption of gases; (g) insure frequent turning of patient
and stimulate him to breath well.
Treatment - (a) attempt to remove plug by (1) having patient cough (2) striking him
on back over area (3) Bronchoscopy (b) support with O2 or Helium and O2.
At necropsy, what are the pathological findings when death follows bronchial
pneumonia as contrasted to the pathological changes when massive at electasis is the
cause of death 7 -
A. (Boyd, p. 420, 460).
Massive a telectasis usually results from occlusion of a large bronchus. This may
be from a for eign body, mucous, Carcinoma, etc. Grossly, the lung tissue is of
firm, fleshy consistency. Microscopically, the alveolar walls are in close contact
or collapsed. The distinctive microscopic feature of bronchial pneumonia is the
presence of nodular consolidation. On section, areas of Consolidation are seen
separated by lung tissues that contains air. Microscopically the alveoli are filled
with p. m. n. 's, fibrin serum, or erythrocytes. The bronchioles are usually filled
with pus cells.
Outline the pathology and prevention of a spirational pneumonia.
A. (Gille spie, p. 212-2 14; Adr. Tech S. , p. 159).
(a) Pathology
l. There may be primary a tele C tasis of a segment of the lung from occlu-
Sion of a bronchus due to mucous, pus, or for eign body.
2. May be secondarily invaded by Organisms causing infection.
(b) Prev ention
1. Use of an endotra cheal tube with a cuff to prevent a spiration in cases
where intestinal obstruction or threatened regurgitation are present.
2. Careful aspiration of mucous through endotra cheal tube.
3. Bronchos copy and a spiration if necessary.
4. Hyperventilation and inflation of lung in chest cases.
In death from Barbital poisoning (short acting) of 5 days, the cause is usually:
(1) Renal shutdown
(2) Acute hepatitis
(3) Pulmonary edema
(4) Bilateral lobar pneumonia
(5) Edenna of glottis
A. No. 4 (Goodman, p. 142).
122
3:5
21.
22.
23.
24.
25.
Pneumonia of the hypostatic or bronchopneumonic type is the usual cause of demise
in patients who survive immediate death due to respiratory center paralysis.
On the basis of the pathological conditions that are present, discuss the difficulties
that may be encountered during induction of inhalation anesthesia in a patient suf-
fering from war gas poisoning.
A. (Goodman, p. 71 l).
Most of the gases have multiple effects, but the chief offenders are the Lung Irri-
tant Class of gases, such as chlorine and phos gene. The aftermath of a cute poison-
ing include chronic bronchitis, asthma, and pos sibly pulmonary TB from activation
of pre-existing but quiescent lesions. -
The chief difficulty is in maintaining adequate concentrations of the anesthetic drug
while at the same time trying to provide enough oxygen. Other factors : excessive
secretions; lowered permeability and diffusion of gases due to thickened pulmonary
membranes and decreased blood supply in lungs; pulmonary edema
What are the usual pathological findings in the cases of death from massive air
embolism 2
A. (Boyd, p. 83).
To demonstrate air embolism at post-morten the large Vessels should be tied off
and the heart opened under water. The right heart contains frothy blood.
(a) Describe the lungs grossly and microscopically in pulmonary emphysema.
(b) What effect does pulmonary emphysema have on the administration of anesthetics.
A. (Boyd, p. 462).
(a) The lungs are voluminous, pale and dry. Large blebs or bullae project on the
surface, especially at the apex, margins and base. The lung is particularly
soft and has a feathery feel, with pitting on pressure due to destruction of
elastic tissue. Microscopically the alveoli are few in number and large in
size. The septa between the aveoli are disrupted. Vessels are narrowed and
obliterated causing vascular obstruction.
(b) It may be difficult to use an inhalation anesthetic because the concentration in
the blood may not rise to a level sufficient to produce adequate anesthesia due
to a level sufficient to produce adequate anesthesia due to the avascularity and
poor absorption in the lungs. The patient may be come an oxic very readily due
to the loss of alveolar respiratory area and the poor pulmonary circulation.
What difficulties are usually encountered during inhalation anes the sia for a patient
suffering from pulmonary fibrosis.
A. (Adr. Techs. , p. 141).
The chief difficulty is one of reduced lung volume and a consequent decrease in
vital capacity. Enough oxygen must be supplied to take care of the metabolic re-
quirements. At the same time the required amount of anesthetic agent must be
absorbed to produce anesthesia.
Cyanosis in emphysema may be pronounced and the dyspnea less than expected
because:
A. (Best, p. 432).
In chronic emphysemas, the respiratory center becomes relatively in sensitive to
volumes of CO2 which in a normal person would cause severe dyspnea.
3:6 123
26.
27.
28.
29.
"Ascending respiratory paralysis" described by Albert H. Miller is in reference
to :
(1)
Intraspinal anesthesia
(2) Epidural anesthesia
(3) Inhalation anesthesia
(4) Barbiturate poisoning
(5) CO poisoning
A. No. 3 (Lundy, p. 715).
Which of the following elevates the respiratory threshhold:
(1)
(2)
(3)
(4)
(5)
Hypoxia
CO., excess
Pain
Fear
Hyper ventilation with O2
A. No. 2 (Adr. Pharm., p. 116).
Concerning endotra cheal anes thesia:
(a)
(b)
(c)
(d)
(a)
(b)
(c)
(d)
What lesion or lesions of the vocal cords, causing hoarseness, may be seen or
should be looked for before an endotra cheal tube is inserted 2
What has usually happened to a patient if bilateral paralysis of the vocal cords
is present 2
What is the approximately normal distance between the resting vocal cords and
what is the distance between them if bilaterally paralyzed ?
Should an endotracheal tube be used for general an esthesia by inhalation if bi-
lateral paralysis of the vocal cords exists before anesthesia is begun ? Why?
(Gille spie, p. 151 - 162; Jackson, p. 526.
Lesions of the vocal cords causing hoarseness: (1) laryngitis, a cute or chor nic
(2) diphtheritic laryngitis (3) Tb C laryngitis (4) syphilitic laryngitis (5) Pa –
pilloma (6) Nodular fibroma (7) Car cinoma
Bilateral paralysis is usually due to cutting of the recurrent laryngeal nerves,
perhaps in thyroidectomy or chest operations. Car cinoma may also cause
this by local infiltration.
The rapidity of paralysis determines the position of the cords. When both
nerves are severed from injury or operation, the cords come together and
patient may be completely obstructed. In more slowly developing lesions in-
volving both laryngeal nerves, the cords go through stages (abductor pare sis
or paralysis) and the patient may go into laryngeal spasm easily. When only
abductor pares is is present, the cords may open on inspiration; on abductor
paralysis the cords come together on inspiration and open slightly on expira–
tion and open slightly on expiration. After complete recurrent paralysis, the
cords remain fixed in cadaveric position midway between phonetic and quiet
inspiration.
In a patient with bilateral paralysis of the vocal cords an endotra cheal tube
should be used with general anes thesia in order to maintain a patent air way.
Tracheotomy may have to be performed.
If damage is done to a vocal cord by an endotra cheal tube, how is the damage
usually caused.
124
3 : 7
30.
3 1.
32.
33.
(b)
If an endotra cheal tube is left in place for a long period (two days) what type of
lesion may it produce 2 What is the mechanism of production of the lesion ?
(Gille spie, p. 151 - 162; Lorhan; Jackson).
Trauma by the endotra cheal tube is usally the cause of damage to the vocal
cords. This may be due to inexpert intubation or too large a tube.
An endotra cheal tube left in place too long a period may cause edema or ul-
ceration of the cords. This is caused by pressure and irritation of the tube.
However, there are numerous cases on record where end otra cheal tubes have
been left in the patient for days without serious sequelae.
Contact granuloma of the vocal cords may only be seen after intubation. (True or
False).
A.
(Lundy, p. 482). False
It is a condition seen when no an esthetics have been given.
Which of the following is the least likely complication resulting from trauma to the
vocal cords with an endotra cheal tube:
(l)
(2)
(3)
(4)
(5)
A.
Ederma of the glottis
A telectasis of the lungs
Obstruction of the air way
Hindrance to removal of CO2
Anoxenia
No. 2 (Adr. Techs. , p. 145).
How could media stinal emphysema result from direct vision end otra cheal intubation ?
A.
(a)
(b)
(a)
(b)
(a)
(Gillespie, p. 4 3, 14.1).
Emphysema has been caused by trauma and performation of the posterior
pharynx or perforation of the larynx, (more probable with a metal endotra cheal
tube) or perforation of pharynx or larynx during intubation when the patient
strains or coughs. Gille spie advances another possibility: bronchilar
pressures of 24 mm. Hg. usually produced mediastinal emphyserna in Ciogs
and sometimes this occurred at 10 mm. Hg. In cats, 16 to 20 mm. Hg, was
sufficient to produce emphysema. In the one human case cited, a pressure of
only 12 mm. Hg. was used during the closure of a chest case with subsequent
mediastinal emphysema.
Mechanism: Air breaks through in small bubles from over distended alveoli to
the peri-vascular connective tissue and tracks along the course of the arterioles
to the great vessels to the media stinum, thereby producing emphysema. This
process takes place much more readily with the chest open.
What pathological changes are often as sociated with tracheal collapse during
thyroidectomy 2
How may an esthesia and surgery be conducted to prevent this complication:
(Gille spie, p. 179).
Some pathological conditions often found with tracheal collapse or pre-disposing
to collapse are (1) Substernal thyroid (2) large cervical thyroid tumor Causing
displacement (3) Possible invasion of or weakening of the structures of the
tra chea by thyroid malignancy (4) Previous surgery of the neck with resultant
tight constrictive bands of scar tissue (5) Rough handling of tissues during
surgical procedure.
3:8 125
34.
35.
36.
37.
38.
(b) Prevention: (1) In any cases where respiratory obstruction is anticipated,
intubation is indicated. (2) Viewing the V O Cal C ord s p O stope ratively for
nerve injury and possible obstruction is helpful. (3) Tracheotomy prophy -
lactically and anesthesia through the tracheotomy opening may be indicated
in malignancy.
The principal factor to maintain blood pressure is:
A. The heart. (Best, p. 147).
Discuss the possible sequelae of too long- continued hypotension during spinal
anesthesia.
A. (Cullen, p. 152).
a. In already susceptible patients, Cerebral thrombos is due to slow blood flow
in the brain may occur. Diffuse pete chial and nerve cell damage due to lack
of oxygen may result beca use the nerve cells are very susceptible.
b. Coronary thrombosis and heart muscle damage uue to an Oxia blood flow may
occur, particularly in an already da Imaged heart.
c. Anuria and kidney damage from anoxia and decreased blood flow may occur.
d. Respiratory failure may result as a consequence of cerebral anemia. Nausea
and vomiting of the gastric Contents is also a possibility from this cause.
Which is not a sign of organic heart disease ?
(1) History of congestive heart failure
(2) Dia stolic murmur
(3) Hyper tension
(4) Systolic murmur
(5) Cardiac enlargement
A. No. 3 (Best, p. 156).
All the conditions are signs of organic heart disease except hypertension, which is
caused by an increase in peripheral resistance, usually caused by arteriolar con-
striction.
Explain the relatively high incidence of fat embolism following fructure of the long
bones.
A. (Boyd, p. 82).
In the adult, the marrow cavity of the long bones is occupied chiefly by the
hemopoietic materials with a large blood supply - fine connective and fatty tissues.
Fracture through One of these long bones may allow small fat globules to enter the
ruptured veins.
(a) Define embelus.
(b) Mention frequent sources of emboli
(c) State the sequelae of embolism
A. (Boyd, p. 74).
(a) An embolus is a solid body transported from one part of the circulatory system
to another where it may become impacted.
126
3:9
39.
40.
41.
42.
43.
(b)
(c)
The
:
A.
The
The usual form of embolus is a fragment of a thrombus which has ſo ºn ea either
in the heart or blood vessels. Other forms of emboli are fat globules, air
bubbles, tumor cells, clumps of bacteria, and amniotic fluid. The sequela e of
embolus will depend upon two main factors: (1) The nature of emboli (2) The
circulatory arrangement in the organ where the embolus lies.
If the embolus is septic, it will result in pus formation and abscesses. If it is
non-infectious, its effects will be due to is chemia alone. The seriousness of
the infection produced depends upon the size of embolus and size of the vessel
it occludes. The efficiency of the collateral circulation of the aflected part
plays a great role, particularly in the brain and the heart.
most common cause of emboli is :
Failing heart
Arterios cler O S is
Trauma
Chronic auricular fibrillation
Aneurysm
No. 4 (Boyd, p. 75).
commonest site of thrombi are on the walls of the auricles. During perious of
fibrillation, these thrombi are apt to be ui º lodged.
Myoglobin emia is found in one of the following conciitions :
(1)
(2)
(3)
(4)
(5)
A.
Fat
Deep ether anesthesia
Thyroid storm
Nephrosis
Diabetes
Crush injuries
No. 5 (Boyd, p. 82).
embolism is usually due to some injury to the bone narrow, particularly
fractures. It has been reported in severe convulsive disorders and delirium
tremens, where the exertions of the individual introduces the bone marrow
fat into the blood stream.
Describe the appearance of the heart after death from Ventricular fibrillation.
(No
Reference). In the gross, it is dilated due to terminal effects. Microscopic-
ally, no changes are found which are pathognomoniC.
(a)
If a major coronary occlusion took place while you were a cliministering general
anesthesia what physical signs would you expect to observe.
What occurrences other than coronary O C clusion might cause similar signs 2
(Adr. Techs. , p. 152, 153).
(1) Hypotension (2) Decreased pulse pressure (3) Tachy Car Clia or irregularity
(4) Pallor and/or cyanosis (5) Heart sounds poor quality (6) EKG abnormality.
Other causes of similar findings: (1) Shock from trauma or hemorrhage
(2) Too great a depth of an esthesla Or too high a concentration of anesthetic
agent (3) Atelectasis with cardiac shift.
Which is not a significant arrhythmia in an esthesia:
(l)
(2)
(3)
V entricular fibrillation
Auricular fibrillation
Heart block
3 : 10 127
44.
45.
46.
47.
48.
(4) Pulsus alternans
(5) Sinus arrhythmia
A. No. 5 (Best, p. 240).
Sinus arrhythmia is a normal occur ence due to vagal stimulation. The heart rate
increases toward the end of inspiration and showing toward the end of expiration.
A rise in venous pressure causes in creased heart rate. What is this reflex called ?
A. (Best, p. 247). Bainbridge reflex.
A patient four years of age -- Tetrology of Fallot will most often show one of the
following:
(1) Reduced blood volume
(2) Normal blood oxygen Content
(3) Increased oxygen capacity
(4) Red blood cell volume per centage below normal
(5) Hemoglobin below normal
A. No. 3 (Best, p. 436).
The Tetrology of Fallot has the following features:
(1) Dextraposition of the aorta (2) Pulmonary Stenosis (3) Interventricular
septal defect and (4) enlargement of the right ventricle. To compensate for
the poor oxygenation of the blood be cause of the inter ventricular septal defect
and pulmonic stenosis, the circulating hemoglobin is increased to 18 – 20
grams per 100 cc. The Oxygen capacity of the blood is ther efore increased
but the actual oxygen content is not increased or is de creased.
Cyanosis is a regular feature of:
) Coarctation of the aorta
) Simple I. V. septal defect
) Tetralogy of Fallot
) Patent ductus arteriosus
) Bis cuspid aortic valve
A. No. 3 (Best, p. 436; Cecil, p. 1209).
Both cyanosis and clubbing of the finger s are common features in this condition.
A known diabetic with a pre op-blood sugar of 200 mb. "% is given ether for 35 minutes
at the end of which his blood sugar is :
(1) 50 mg. "%
(2) 100 mg. "%
(3) 400 mg%
(4) 600 mg%
(5) Unchanged
A. No. 3 (Adr. Pharm., p. 35).
Doubling of the blood sugar may take place in 15 minutes A slow increase occurs
after that up to 200%.
Which one of the following has little effect on the blood sugar 2
(1) A vertin
(2) Ether
128
3 : 1 1
49.
50.
5 1 .
52.
53.
(3) Cyclopropane
(4) Chloroform
(5) Vinethene
A. No. 5 (Adr. Pharm. , p. 38).
There is only a slight increase with vine thene.
The leukocyte count increase following inhalation anesthesia returns to normal in :
(1) 200 hrs.
(2) 175 hrs.
(3) 72 hrs.
(4) 24 hrs
(5) 6 hrs.
A. No. 3 (Adr. Pharm. ).
This depends on the type of anesthetic agent used. Nitrous oxide causes some vari-
ation in leukocytes but normal counts are usually found after 24 hours, with cyclo,
ethylene and ether, the counts usually return to normal within 48 hours. Thus in
72 hours, all counts should usually have returned to normal.
Which is correct: Blood preserved with the A CD mixture at 37°F should not be
used after :
(l) 10 days
(2) 16 days
(3) 21 days
(4) 28 days
(5) 36 days
A. No. 3 (Lundy, p. 602, 603; Turner; Barton).
Who should receive high titered O blood 2
A. (Wilson).
"O" only. The high titer of anti "A" agglutinins in the donor's serum can cause con-
siderable reaction. Usually the donor's agglutinins are so diluted by mixing with
the recipient's serum that little effect is noted. The usual transfusion reaction is
between the donor's cells and patient's serum. However, when there is a high anti
"A" titer in the donor's serum, a reaction may take place in the donors serum and
receip ent's cells. ''O' blood with an agglutinin titer of less than 1 – 2000 can be
used as a universal donor.
The administration of anti-histanninic drugs to patients receiving blood transfusions
inhibits or prevents what type of reactions 2
A. Allergic. (Wilson).
A young adult female belonging to the Rh negative classification needs repeated
blood transfusions. Give an explanation as to why it would be advisable to give Rh
negative blood to this patient.
A. (Seldon; Wallenstein; Wiener).
If given repeated Rh positive transfusion, the patient builds up anti Rh positive anti-
bodies. This may occur to a small degree with one transfusion but is more apt to
do so with repeated transfusions, with resultant severe reaction between the anti Rh
and the Rh antibodies.
3: 12 129
54.
55.
56.
5 / .
If this fernaie patient were to be married to a Rh positive husband and were to be -
come pregns tº t, the fetus would be Rh positive. The anti Rh antibodies which the
patient has developed, pass through the placenta to the fetus and may cause either
early abortion, erythroblastosis fetalis, or hemolytic jaundice of the newborn.
Again this does not occur too frequently with the first fetus but more frequently
with subsequent births unless a heavy anti-Rh concentration has already been
built up by repeated transfusions.
Ir, travenous barbiturates are not indicated in :
[.. the Y cºnvulsions
E clan: ptic convulsions
Cortical stirnulation from pro Caine
Excited States
Cardiova 5 cºllar collapse due to cocaine
i
A
tºo. § {{` ºr man, p. 297).
There is no effective therapy for the sudden Cardio-vascular collapse from cocaine
pol & Cº., 1* g. Jºe tº inly, no depressing a gent such as a barbiturate should be given to
an alread ºf tieſ essed patient. However despite the poor prognosis, measures such
as artificial respiration with an endotra cheal tube and walling off the site of the in-
jection by a cºrriquet as sist to some degree.
Choose the in correct; Which of the following substances has the least influence on
heari, a cii ºr ;
~3.
*
{ }
sº
i
:
.
**t
i.ºs
2
n
...]
}
n
a
º
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i
r
3.
C
i
d
N
ſº
§
(
B
Sº
!
.../
2
G
()
)
This is a difficul: question. Hermoglobin itself does not affect the heart but the
oxygen whic. . . . . a ri’ies does affect i he heart action predominately.
‘I he is ; G n iſ bio Ox} is :
Free in plasma
Only in tº yº ſº ſº, 's
...”
in p1 ≤ c : : - ; K:
111 p 13 s tº 3 a 3 ſº. HPC
:
** * ... … -- - - - - * - 2-, -,
! Ii P ić.31% º ż, , ... ... O 3
A. N. C. , 2. 1, p. 594, 6 : 4; #3 est, p. 3)
f : " ... ... . . -- ... ...
* 8. § - U 8.s. i... : :" |
This is a diffi....' ... ºvie 3 tion to an 8 wer the way it is put. There is some potassium
iO3) iſ e º 1,1 , i. 3 ºtha as ar, ion , although it is nº Ostly present in the RBC's. It
nia y De cºnjº gº tº it the iCrºic state vºltſ, chloride or with either of the two phosphate
buffer ions ſº J4 or H2PO4.
|
-
If a patient aas received a diagnosis of hypertrophic lumbar arthritis (a) what
difficulty ºf i , º, anticipate in doing a lurribar puncture ? (b) what would cause
the difficult ºr 2 Describe the pathologic condition and its location with reference to
&
the path of the eedle.
13()
a-
!
3
58.
59.
60.
(a) Optimum position to inject would be hard to obtain be cause of inability to bend
the spine, with difficulty in finding an adequate inter space. There may be
difficulty in introducing the needle through the calcified inter spinous ligaments
and calcified ligament flavum.
(b) The difficulties are produced by the pathological changes which include:
(1) ossification of the spinal ligaments (2) bony ankylosis (3) diminution of
the size of the inter space.
(a) Can injury to the ulnar nerve occur in the course of spinal anesthesia as well
as in the course of inhalation anesthesia 2
(b) What are the signs of paralysis in the distribution of the ulnar nerve 2
(c) How long may ulnar paralysis last 7
(d) How long does ulnar paralysis usually last 7
A, (Lundy, p. 222; Grinker, p. 194).
(a) Injury to the ulnar nerve can occur in the course of spinal anesthesia as well
as in the course of general anesthesia due to pressure on the nerve as the arm
lies in contact with the table, particularly if the level of an esthesia is high
enough to prevent sensation in the ulnar nerve distribution. The brachial
plexus may also be injured when the patient is removed from the table or due
to poor position of the shoulder braces.
(b) Signs of paralysis of the ulnar nerve are (1) sensory loss of the 5th finger and
ulnar half of the ring finger, inner volar and dorsal surface of the hand to just
above the wrist (2) claw hand (resulting from impair ment of adductors of
fingers, loss of flexion of 1st phalanx and extension of terminal phalanges,
atrophy of hypothenar eminence, hollowing of inter Osseous inter spaces)
(3) Radial deviation of hand may be present.
(c) Ulnar paralysis may be permanent but usually is not severe.
(d) Recovery depends up on degree of damage and place of damage when complete
destruction of nerve fibers occurs. The nerve returns at rate of 1 – 4 mm. per
day.
The most common cranial nerve paralysis following spinal anes thesia is:
(1) Abdu cens
(2) Optic
(3) Vagus
(4) Trigeminal
(5) Glossopharyngeal
A. No. 1 (Collins, p. 345).
The abduc en's nerve (with the resultant diplopia) is involved in 90% of the cranial
nerve palsies. No good explanation has been advanced why this nerve should be so
commonly involved.
Explain how and why a lumbar sympathetic block with procaine may aid in the dif-
ferential diagnosis of arterios clerotic and vasospastic disease of the lower extremity
and of pain in the lower extremity.
A. (Lundy, p. 561, 569; Collins, p. 244).
Arteriosclerotic disease of the extremity involves organic changes in the tissue
forming the wall of the blood vessels. The vessels ususally become rigid and
stenosed. In vasospastic disease a sympathetic imbalance produces vasoconstric-
tion in the otherwise normal blood vessel. By blocking the sympathetic nerves this
spasm is released, the vessels dilate, and the extremity warms. In arterios –
clerotic disease there is no change in blood vessel lumen when the sympathetic
chain is blocked.
3: 14 131
6 1.
62.
63.
64.
65.
It is unwise to administer spinal anesthesia to a patient with advanced pernicious
anemia because:
A. (Lundy, p. 31). Because of the possibility of permanent injury of spinal cord.
Symptoms from spinal cord involvement after a spinal anesthetic in cases with per –
nicious anemia have been reported. Whether the anesthetic agents aggravated the
cord lesion or made the patient aware of symptoms already present, is debateable.
However, because of mediocolegal problems, it is not advised to use spinal anes –
thesia in any such case.
Spinal fluid which has previously been withdrawn is found to be coagulated. Which
of the following would you suspect 2
{1) Drain abscess
(2) Traumatic tap
(3) Poliomyelitis
(4) Cord tumor
(5) Arterios clerotic hypertension
A. No. 4 (Grinker, p. 246).
The syndrome of Froin, due to clotting of the spinal fluid shows an increase in cells
and protein. In brain abscess there is definite in crease in white cells, associated
with a clinical picture of septic nature. After a traumatic tap red cells may be
found, but no coagulation occurs. The picture of early polio may show an increase
in white cells but no increase in protein.
What is the dose and concentration of procaine in spinal fluid of a dog to consistently
produce permanent pathology, according to Lundy ?
(1) 5 cc of 20%
(2) 5 cc of 10%
(3) 2 cc of 10%
(4) 10 cc of 4%
(5) 20 cc of 1 %
A. No. 1 (Lundy, p. 207).
One week after an uncomplicated spinal anesthetic with procaine, the spinal fluid:
(1) Is normal
(2) Has an increased leukocyte count
(3) Has an increased protein content
(4) Is under increased pressure
(5) Has an increased chloride content
A. No. 1 (Adr. Pharm. , p. 95).
There are variations in the length of time that cells appear in the spinal fluid but
by the end of a week, in the uncomplicated case, the cells and the fluid have return-
ed to a normal state.
If spinal anesthesia is given when the spinal fluid pressure is 200 mm. H
O, which
of the following would you do? 2
(1) No alteration in technique
(2) Increase both the dose and the speed of injection
(3) Increase the dose
(4) Increase the dilution
A. No. 1 (Pitkin, p. 37, 794).
132
3: 15
66.
67.
68.
69.
70.
Variations in spinal fluid pressure in individuals places 200 mm. as about the
upper limit of normal.
Following continuous caudal an esthesia which complication is most likely to occur:
(l) Leukocytes in the spinal fluid
(2) Arachnoiditis
(3) Headache
(4) Cauda equina syndrome
(5) Peridural abscess
A. No. 5 (Pitkin, p. 729).
Because the peridural space is the site of the caudal injection a nu because it is
continuously in proximity to the anal area, abscesses are more likely to occur than
the other conditions mentioned. The other conditions occur from arachnoid
injections.
What is the effect of alcohol used for therapeutic nerve blocking on sensory nerves 2
A. (Adr. Techs. , p. 264).
Protoplasmic coagulation at the site and Wallerian de generation of the nerve distal
to the block occur. Unsheathed nerves are attacked first and with less concentra-
tions. With higher concentration, the sheathed nerves are also affected.
What are the advantages and disadvantages of alcohol used for therapeutic nerve
blocking 2
A. (Adr. Techs. , p. 264; Judovich, p. 295).
(a) Advantages: (1) Destroys by S Clerosing - resulting in true Wallerian degen -
eration, thus giving relief from intractable pain (2) Long acting 6 - 12 months.
(b) Disadvantages: (1) Small unsheathed nerves permanently destroyed, large
nerves temporarily impaired. (2) Fibrosis results which pre-disposes to
neuritis. (3) If not properly done, hyperesthesia develops. (4) In mixed
nerves – an amount great enough to give anesthesia will produce motor
paralysis.
When a peripheral nerve is cut, the degeneration of the proximal end extends to
where:
A. (Best, p. 901).
Nerve fibres as far centrally from the line of incision as the first Node of Ranvier
show Wallerian degeneration. This degeneration is a decomposition of the myelin
and a fragmentation and disinter gration of the neurofibrils. The end result is an
absorption of all this degenerated material by the body. All that remains is an
empty neurolemna sheath. Regeneration takes place by proliferation of the neuro -
fibrils from the proximal segment of the cut nerve and their extension along the
neurolemna sheath. If this sheath is ruptured at any point there is a tendency to -
ward neurona formation.
Sympathetic block is not indicated in:
(1) Raynaud's disease
(2) Thrombophlebitis
(3) Phlebothrombosis
(4) Adynamic ileus
(5) Dynamic ileus
A. No. 5 (Best, p. 594).
3:16 133
71.
72.
73.
74.
75.
In a dynamic ilius there is already an overactivity of the parasympathetic
system. Increasing this activity by blocking the antagnostic sympathetics would
only aggravate the situation. In the other conditions, sympathetic blocks have
been known to as sist in the alleviation of the symptoms.
The following are the components of a Horner's syndrome:
A. (Best, p. 1089).
The components of the Horner's syndrome are ptosis, miosis, enophthalmos, vaso-
dilatation, and anhydrosis on that side. The ptosis is due to the loss of the sympa –
thetics action to the levator palpebra Superior iris; the miosis occurs from
de nervation of the pupillary dilator; enophthalmos Occurs because of the loss of
action of Mueller's muscle.
Which pathologic process occurs in barbiturate poisoning:
(1) Necrosis of the hypothalamus
(2) Zonal necrosis of the liver
(3) Generalized venous congestion
(4) Coronary infarct
(5) Generalized ana sarca
A. (Goodman, p. 132; A dr. Pharm. , p. 7 l).
Necrosis of the basal nuclei, particularly the hypothalamus have been reported
after death from barbiturates. However, Adriani states that no specific site of
pathology in the central nervous system has been attributed to the barbiturates.
In peripheral vascular failure, which is most common:
(1) Hemoc oncentration
(2) Low CO2 combining power
(3) Dyspnea
(4) He modilution
(5) Anemia
A. No. 1 (Best, p. 30 l).
He moconcentration is one of the techniques in the diagnosis of early subclinical
shock using the falling drop technique s of Scudder. Due to peripheral vascular
failure, fluid passes into the tissues, concentrating the blood. The body soon
the reafter attempts to dilute this concentrated blood by dehydrating the intracellu-
lar compartments.
How does the body compensate for primary shock 2
A. (Best, p. 30 l; Collins, p. 378).
By the release of epinephrine in the body which cause s was constriction, stimulate s
Cardiac action and stimulates the spleen to release its store of RBC. The distri-
bution of the blood tends to keep the vital centers well oxygenated. When finally
the compensatory reactions fail, the blood pressure declines and the true picture
of shock occurs.
When does shock become irrever sible 2
A. (Best, p. 305; Collins, p. 376).
When the circulation and oxygenation remains insufficient for such lengths of time
that there is damage to the vital centers of respiration and circulation, irrever si-
ble shock will ensue.
134
76.
77.
78.
Morphine sulfate when given in shock is not absorbed from a subcutane Ous dose
because:
A. (Collins, p. 376),
Slowing of the peripheral blood flow accounts for the poor absorption of the mor-
phine.
Discuss chronic alcoholism (Let your discussion include the relation between
alcoholism and a nesthesia).
A. (Goodman, p. 109).
Symptoms of the alcoholism are like those of anesthesia - first and second stages
loss of inhibitions – third and fourth stages - depression after great inge stions of
alcohol. Both alcohol and some anesthetics obey the Oil-water solubility principle.
In severe, chronic alcoholism there is damage to the cerebrum, liver, kidneys
and fatty degeneration of the heart. The se are the same areas which are affected
by anesthetics. It seems to take a great deal of a nesthetic agent to a nesthetize
alcoholic patients, but once induced, they take very little. There seems to be a
lack of detoxification in the liver and the refore the re is an accumulation of the
drugs. They also sleep for prolonged periods after the operations because of this
same effect.
Pathology includes fatty degeneration of the heart, liver and kidneys. There is
evidence of chronic nephritis, due to the alcohol as well as the irritants in the al-
cohol. There may be albumin and casts in the urine.
Discuss briefly the pathological physiology of heat retention, heat exhaustion and
heat stroke.
A. (Best, p. 728).
(a) Heat Retention: Heat loss is regulated by:
Radiation, convection, and conduction.
Evaporation of water from lungs and skin.
Raising temperature of inspired air to body temperature.
Liberation of carbon dioxide from blood in the lungs.
Urine and feces
i
Approximately 90% of the heat loss is due to 1 and 2. The factors involved in
increased he at production are (1) re distribution of the blood from the internal
organs to the skin (2) Increase in blood volume (3) Increased circulatory rate.
In the operating room conditions of high humidity, heavy draping, poor
ventilation and use of drugs such as atropine are added to the lack of heat reg-
ulation from the anesthetic agents.
(b) Heat Exhaustion: This is due to excessive loss of sodium chloride and fluids
plus a disturbance of the heat regulating mechanism. Often high humidity and
poor ventilation are factors which cause decreased heat loss from the body
by diminishing radiation and convection. The treatment is replacement of the
lost saline by intravenous or oral saline.
(c) Heat stroke: It is due to exhaustion of the heat dissipating mechanisms and
complete loss of heat regulation as a result of exposure to a hot, humid atmo-
sphere. The hyperthermia may damage the nervous tissue and prove fatal.
In heat stroke the body temperature ºnay be very high, 107 - 1 10°F and the
skin is dry and hot. The Chief factors involved are loss of radiation, convec –
tion, and conduction; abscence of per spiration ; re distribution of blood.
3: 18 135
79.
80.
8 1.
82.
83.
The treatment must be viliant and inne diate. Temperature must be reduced
by every means - ice packs, ice enema S and iced drinks, and measure s to
support the patient in shock must be instituted.
Discuss briefly the rationale of refrigeration for anputation.
A. A dr. Techs. , p. 321).
(a) Advantages: 1. No inhalation or other type of anesthesia by drugs is neces –
sary. It can thus be used in very poor risk patients. 2. Shock during
surgery is minimal. 3. Lowered temperature reduces oxygen and other
metabolic requirements of extremity. 4. Sepsis is reduced. 5. May be used
post operatively to reduce pain.
(b) Disadvantages: 1. Period of insensitivity to pain may not Outlast operation.
2 TCumbersonne in its execution. 3. Reduced temperature interfere s with
healing.
(c) Contra-indications: None.
What tissue damage may be produced by chloroform and how may it be minimized 2
A. (A dr. Pharm. , p. 43).
The following may be caused: hepatitis with central necro sis; fatty de generation
of the tubules of the kidney; cloudy swelling of the heart. All the se are minimized
by having the patient in an excellent state of nutrition; by administering adequate
glucose and fluids prior to surgery; and insuring adequate oxygen supply.
Necrosis of the liver has been demon Strated at postmor term examination after
death following clinical anesthesia. Outline briefly the course of the different
anesthetic procedures that might have been used.
A. (A dr. Pharm. , p. 43).
The two most common anesthetic agents said to produce liver damage are chloro-
form and ethyl-chloride. If administered properly, such damage need rarely
occur. An abundance of oxygen must be used. A nesthesia should not be pushed,
but administered carefully and slowly. Since liver glycogen becomes depleted,
adequate supplies of glucose pre operatively and during surgery are of considerable
benefit.
What are the histologic findings in the liver after death from an over dose of
(a) chloroform (b) cyclopropane 2
A. (A dr. Pharm. , p. 28, 4.3).
(a) Chloroform: Chloroform produce s marked central necrosis. Acute yellow
atrophy may develop with the microscopic picture of complete necrosis. The
liver cells are either disinter grating or have disappeared, replaced by granu-
lar debris.
Microscopic changes in simple central necrosis are changes in the cell body
and nucleus. Swelling of the cytoplasm and loss of its normal reticulated
appearance may occur. The nuclear changes are (1) chromatolysis
(2) caryorrhexis (3) and pycnosis.
(b) None.
Which causes the least alteration of hepatic function:
(1) Chlorofor rn
(2) Ether
136
3 : 19
84.
85.
86.
(3) Tribromenthanol
(4) Cyclopropane
(5) Vinyl ether
A. (Adr. Pharm. , p. 28).
Cyclopropane cause s no demonstrable damage to the liver. The Other agents do.
What would the immediate pathologic changes be found in the liver in a patient
dying from cyclopropane 2
(1) Passive congestion
(2) Cloudy swelling
(3) Fat degeneration
(4) Autolysis
(5) None
A. No. 5 (A dr. Pharm. , p. 28).
Discuss diabetes mellitus. (Let your discussion concern chiefly those a spects
which have a bearing on a nesthesia. ).
A. (A dr. Techs. , p. 12, 81).
(a) Certain agents cause increased blood sugar and depleted liver glycogen.
The se include ethyl ether and chloroform. Cyclopropane or pentothal do not
cause this.
(b) Preme dication should be reduced somewhat (2/3 - 1/2) because of the tendency
toward acidosis from morphine. Acidosis from any cause must be avoided
because of the already reduced CO2 combining power.
(c) Ethylene and N, O are effective only with low oxygen. Anoxia from any cause
results in acid 5 sis. Therefore these agents must be used only as supplemental
agents when diabetes is present.
(d) Paraldehyde and avertin enhance acidosis.
(c) Supplemental fluids, such as glucose, must be covered with 12 units of regular
insulin per 50 grams of glucose in average uncomplicated case.
Discuss hyperthyroidism. (Let your discussion concern chiefly those a spects
which have a bearing on ane sthesia. )
A. (Lundy, p. 92; Munsel).
(a) There are two forms of clinical hyperthyroidism (1) Adenomatous goiter
with hyperthyroidism (2) Exophthalmic goiter.
The following symptoms may be present : (1) loss of weight and gain in appe-
tite (2) increase in heart rate (3) nervous irritability (4) muscle weakness
and trem or of hands and legs (5) increased systolic blood pressure (6) in-
tolerance to heat (7) marked elevation of BMR (8) increased heart size
(9) Exophthalmos (in type 2).
(b) It is important that patients with hyperthyroidism be adequately prepared be -
fore surgery by adequate doses of iodine or thiouracil until BMR and pulse
rate approach normal value.
3:20 137
87.
88.
89.
(c) Adequate premedication is vital. It may be best to "sneak the patient" because
he may be excitable. This is done by the administration of a small dose of
pentothal in the room and transporting the patient to the Operating room, un-
conscious.
(d) In the actual administration of the anesthetic procedure (1) it is necessary to
guard against respiratory obstruction due to tracheal collapse following removal
of enlarged gland. (An endotracheal tube is advised where any question of ob-
struction is present. ) (2) It is well to avoid agents having toxic cardio-vascu-
lar effects, such as chloroform and cyclopropane. (3) It is well to in spect the
cords post-operatively to see that the recurrent laryngeal nerves have not been
severed.
Discuss eclampsia. (Let your discussion concern Chiefly those a spects which have
a bearing on anesthesia).
A. (Best, p. 166).
(a) Eclampsia is an acute toxemia which occurs during pregnancy and is charac –
terized by tonic and clonic convulsions. Its incidence is 1 in every 400 cases
of pregnancy.
(b) In the pathology of eclampsia, the following are present (1) The liver is most
frequently affected and the refore the anesthetic agent which is least damaging
to the liver should be employed. (2) The heart often shows early areas of myo-
car dial de generation so any anesthetic which is irritating to the cardiac mus-
cles should not be employed. Hypertension is one of the earliest and most con -
stant findings in toxemia.
(c) The kidneys show marked tubular degeneration with swelling of the epithelium.
The re is pronounced fatty degene ration and albuminous changes in the cells.
The use of ether is contraindicated because of the se changes.
(d) Convulsions are common.
(e) The choice of anesthetic technique is caudal or spinal with barbiturate sedation.
The reduction in pressure is beneficial and the kidney functions are improved.
(f) For control of convulsions, IV barbiturates are most frequently used.
List the causes of cyanosis in the newborn, including mechanical and pathological
conditions.
A. (Barach, p. 242; Gille spie, p. 21 l; Lundy, p. 6 30, 63.1).
(a) Mechanical: (1) Obstruction of airway by mucous or anniotic fluid. (2) A telec –
tasis or unexpanded lung areas, (3) Depressed re spiration due to over sedation
of mother and fetus.
(b) Pathological: (1) Congenital heart deformity (2) Congenital deformity of res-
piration system (3) A spiration into lungs (4) Erythroblastosis fetalis
(5) Brain damage due to trauma or hemorrhage during delivery.
Discuss the chief considerations from the ane sthetist's viewpoint in dealing with
cases of acute intestinal obstruction.
A. (A dr. Techs. , p. 159; Collins, p. 3 17, 318).
(a) If possible, have a continuous suction attached prior to the operation to a spirate
the materials from the distended loops of gut. Reconnect this to a mechanical
suction in the Operating room prior to induction.
138
3:2 1
90.
9 1.
92.
(b) Guard against a spiration of the materials which have been explosively expelled
from the gut when sphincters are relaxed during induction. A motor suction
apparatus should be available and the patient should be placed in Trendelenburg
position.
(c) An endotracheal tube with a cuff is best used to prevent a spiration during the
procedure.
(d) Pre operatively and during the operation insure electrolyte control. The patient
has lost much chloride in the vomitus and may be in alkalosis.
(e) Relaxation must be adequate because of mechanical difficulties encountered by
the surgeon with distended inte stine s.
(f) Insure adequate oxygen supply. The distended bowel may be hampering res-
piration and oxygenation. High oxygen is supposed to as sist in reabsorption of
nitrogen with a reduction in the distension.
In acute inte stinal obstruction one of the following may occur:
(1) Elevated serum calcium
(2) Elevated NPN
(3) Increased blood volun (e
(4) Hypocalcemia
(5) Increased serum biliru Jin
A. (Best, p. 8
Bilirubin and calcium have nothing to do with intestinal obstruction. There is a
de crease in blood volume in dehydration and inte stinal obstruction. There is a
definite rise in NPN in this condition.
What is tachyphylaxis 2
A. (Goodman, p. 424).
The diminishing effects of repeated successive doses of ephe drine illustrates the
action of tachyphylaxis. This phenomenon does not apply to all drugs.
A patient in excellent condition, but unconscious, was left alone in his room after
his return from the Operating room. Fifteen minutes later he was found dead. At
postmorten examination, what regions would you wish the pathologist to examine
most carefully and what findings are the most likely 2
A. (A dr. Techs. , p. 160, 16 1).
(a) Heart:
1. Thronbosis of wall
2. Coronary occlusion
3. Air embolus and right heart filled with frothy air.
1. Atelectasis due to plugging bronchus
2. Embolus - of fat, air in blood.
1. He morrhage .
2. Embolus and occlusion.
3. Anoxia and pete chial type of hemorrhages.
1. Obstruction due to foreign body - blood, mucus, actual foreign
body. *~
2. Edenatous larynx.
3. Trauma of larynx – due to tube.
3:22 139
Q 3.
94.
95.
96.
97.
What are the clinical and pathological evidences of gross overdose of
pentobarbital sodium (Nembutal) 2
A. (Adr. Pharm. , p. 70).
The clinical evidence that is seen is that of deep central nervous system depression
with loss of reflexes; dilated pupils; diminished blood pressure.
The pathological evidence includes recovery of drug in urine and various parenchy –
matous Organ S.
Which of the following is correct: Large volumes of Na are not lost to the body:
High intestinal obstruction
Intestinal obstruction with voniting
Continuous gastric suction
Excess sweating
l
2
3
4
5) Heat retention
A. No. 5 (Best, p. 596).
In vomiting, or continuous suction, it is the chloride ion which is lost, not sodium.
In heat retention, however, the re is an absence of Sweating and the body retains
all its ions and excess heat to the detriment of the body.
Sodium bicarbonate serves for the storage and transportation of:
(1) Oxygen
(2) Chloride
(3) Carbon dioxide
(4) Proteins
(5) Potassium
No. 3 (Best, p. 132 Gamble Chart No. 8).
verage adult daily requirement of sodium is:
(1) . 29 gms.
(2) . 75 g ms.
(3) 1.50 grins.
(4) 3.00 grins.
(5) 4.50 gms.
A. (Wangensteen; Gamble Charts 33, 45).
None of the se answers are correct. The average post operative salt require ment is
4-9 gras. , as suggested by Wange steen. Post Operatively, there is the danger of
salt retention if too much saline is administered. The kidneys do not excrete salt
as well as in normal states. Thus the re nay be only 4 grins. lost in in sensible pers –
piration. If a gastric continuous suction is being used, 5 gms. per liter is also
lost. Therefore, replacement of salt should depend on the calculated loss of fluid
and edema of the wound and other tissues of the body. The average healthy adult
usually takes from 10- 12 grams a day in his food.
What is the difference between types of dehydration ?
A. (Gamble Chart 36A).
The usual difference is due to the loss or failure to lose salt with the water. If the
basic great loss is salt, the extracellular volume is decreased. This occurs in pro-
fuse sweating, vomiting, diarrhea, drainage from a fistula or continuous gastric or
inte stinal drainage. Water alone will not correct the difficulty and in fact will ag-
gravate the situation. Isotonic saline corrects the inbalance. If water alone has
140
3 : 2 3
98.
been lost, as occurs in severe starvation, water with no salt will correct the
difficulty. If salt is given, salt edema may result.
What is a simple test for response to therapy of dehydration ?
A. (Gamble Chart 50).
The silver nitrate test for urine chlorides reveals whether the kidney is again
secreting chloride, (if the kidney is normal). During dehydration, chlorides are
not excreted by the kidney. When this test becomes positive again, it can be as -
sumed that an adequate replacement is being accomplished.
3:24
141
SUPPLEMENT I SU B – SECTION
P A THOLOGY
The vital capacity of a patient is lowest in which of the following positions 2
(1) Sitting
(2) Supine – horizontal
(3) Prone, with kidney bar up
(4) 45° head down – supine
(5) 45° head up - supine
A. No. 3, (Slocum; Sokalchuk; Stephen).
Slocum, Hoeflick, and Allen state that any Trendoleni, urg positions which are steep
cause a great strain on the patient. The weight of the abdominal organs must be
lifted. The result may be serious post-operatively, when at electasis may result.
However, Stephen states that it was in the prone position with the kidney rest tip
without benefit of chest supports that the most marked decrease in vital capacity
O C C Ul r S .
Of the following which is the least likely complication daic to endot rac heal intubation ?
(1) Laryngeal granulomata
(2) Subcutaneous emphysema
(3) Bronchopneumonia
(4) Acute edema of the glottis
(5) Ulceration of the glottis
A. No. 3. (Gille sple, p. 142, 14 3, 152, 153,
3
l
5
5
5).
Laryngeal granulomata occur as a result of traunna and organization of the blood
clots but they may occur in intubation. Gille spie states that the incidence of post-
operative respiratory complications was less when patients were intubated, pro-
bably because of more adequate ventilation, Sºli, cutaneous emphysema has been
noted when too great intrap, ll, nonary ºr e s sure s were produced either by bag pres –
sure, coughing, or breathing with the glottis closed,
A trache otomy would be of no value in which of the following 2
(1) Bilateral recurrent laryngeal nerve injury
(2) Ludwig's Angina with respiratory obstruction
(3) Fracture of the cer vical spine wit . . espirat, tºy paralysis
(4) A fractured lar ynx
(5) Bulbar poliomyelitis
No. 3 (Gille spie, A. 82).
In bulbar polio with paralysis, a trache Otomy would be of little use. A re spirator
is needed, If the re is no re spiratory paralysis, there may be little need for a res –
pirator. If secretions accumulate or there is laryngeal paralysis, a trache O torny
may be needed. In answer 3, a re spirator is mandatory. There is no laryngeal
paralysis because the muscle s of the lar ynx are controlled by the vagus, which
remains unaffected.
What is the least intrapulmonary pressure that is said to be sufficient to rupture
the alveoli in a healthy adult male 2
142
(4) 50 mm. Hg
(5) 60 mm. Hg
A. No. 3 (Gille spie, p. 142; Adr. Techs., p. 337).
5. Pulmorary edema develops during inhalation of the ane Sthe sia in a patient who was
in normal condition pre operatively. Which of the se is a likely precipitating factor 2
Per sistent expiratory obstruction to breathing
Per sistent inspiratory obstruction to breathing
Traumatic shock
Anemic hypoxia
l
2
3
4
5) Excitement during induction of a nesthesia
A. No. 2 (Adr. Techs. , p. 143).
The per sistent negative pulmonary pressure s in a patient obstructed on inspiration,
acts like a suction pump to draw fluids into the alve Oli.
6. Bronchiolar constriction during general ane Sthe Sia is manifested by:
(1) prolonged, forceful expirations.
(2) prolonged in spirations,
(3) prolonged inspirations and prolonged, forceful expirations.
(4) short inspirations and prolonged, forceful expirations.
(5) diminished in spirations and diminished expirations.
A. No. 4 (Cullen, p. 58, 59).
The inspirations are relatively short because the effort is directed toward getting
the entrapped air out. The chest is in continuously expanded condition. The anes –
the sidlogist notices that he has a great deal of difficulty making his breathing bag
move even with an endotracheal tube in place and after he has checked for the other
usual cause s of obstruction.
7. The pneumonias following operations have been classified as follows: Which one is
most likely to occur after spinal a de 5the 3ia ?
(1) A spiration
(2) Hypostatic
(3) Infective
(4) Embolic
(5) A telectatic
A. No. 5 (Faulconer)
8. In obstructive or chronic hypertrophic emphysema of the lungs, as seen in the fluo-
r OSC Opic examination:
(1) the diaphragm is low but moves well during in spiration.
(2) the diaphragm is low and moves poorly during in spiration.
(3) the diaphragm is in normal position and moves normally during re spiration.
(4) breathing in Predominantly diaphragmatic.
(5) the diaphragm is high and moves poorly during respiration.
A. No. 2 (Best, p. 432).
9. Histological examination of the lungs of a patient with virus pneumonia reveals:
(l) an exudate of fibrin and polymorphs in the alveoli.
(2) an interstitial inflammatory process with little exudate in the alveoli.
(3) scattered areas of fibrosis around the bronchi.
(4) hemorrhage into the alveoli with marked infiltration of mononuclear cells.
3:26 143
10.
1 1.
12.
13.
(5) he crotic areas surrounded by giant cells scattered throughout the lungs.
A No. 2 (Boyd, p. 435).
There is a scattered inter stitial inflammation. X-Ray reveals many more findings
than would be assumed from the seriousness of the clinical picture.
A patient is to be operated on for relief of a compressive lesion of the cervical
cord and is unable to cough effectively. Secretions in the bronchi are profuse.
Which of the se procedures would you recommend as being the most practical and
effective in preventing recurring atelectasis during the postoperative period 2
(1) Daily bronchoscopic aspiration
(2) Twice daily trache obronchial toilet by catheter a spiration through an endotrac –
heal tube
(3) Trache obronchial toilet four time s daily with endotrac heal tube and catheter
(4) Temporary trache otolny so that the ward personnel can a spirate mucus with a
catheter when ever any accumulate s
(5) Postural drainage (head of bed low)
A. No. 4 (Gille spie, p. 217; Lundy, p. 356, 357).
This is the most practical method be cause of the expected prolongation of the con -
dition post operatively. The se patients can be expected to cause difficulty at any
time and an anesthesiologist may not be available quickly. It is best not to leave
an endotracheal tube in place for prolonged periods.
In comatose patients the rate of re spiration is slowest in :
morphine overdose.
barbiturate intoxication.
carbon monoxide poisoning.
cerebral malaria.
l
l
3
4
5) diabetic ketosis.
A. No. 1 (Goodman, p. 14 1, 2 10).
Re spirations may be slowed to 2-4 time s a minºute in this condition, Cerebral ma -
laria cause s slow re spirations but this may be a sociated with other clinical nan-
ife stations. In diabetic ketosis, the re spirations are usually rap id and deep. In
all of the se conditions the anesthesiologist administers oxygen by whatever means
is most effective. Analeptic agents are used only after and with adequate oxyge -
nation.
Under circumstances of adequate oxygenation central necrosis of the liver lobule
is not caused by one of the following drugs.
(1) Chloroform
(2) Tribrome thanol
(3) Trichlore thanol
(4) Ethyl cholride
(5) Ethylene
A. No. 5 (A dr. Pharm. , p. 24)
The halogen radical may cause liver damage. Ethylene causes no damage without
a noxia.
What early result may occur from an injection of 5 cc. of a 2 1/2% sodium pen-
tothal solution into the ante brachial artery 2
(1) Apnoea
144
3:27
14.
15.
16.
17.
18.
(2) Pulmonary edema
(3) A nesthesia of the fore arm and hand
(4) Pain and burning of hand
(5) Clubbing of the fingers
A. No. 4 (Lundy, p. 542)
A vertin is most contraindicated in which one of the following in stance s 2
(1) Intracranial injury
(2) Hypertension
(3) Diabetes
(4) Chronic glomerular nephritis
(5) Appendicitis
A. No. 4 (Adr. Pharm., p. 58).
A vertin is eliminated through the kidneys after detoxification in the liver. Pro -
longation of anesthetic effects is noted with kidney damage.
In poisoning from nitric oxide the most probable finding will be :
pulmonary irritation and edema.
asphyxia a s result of combination of nitric Oxide with he in Oglobin.
asphyxia from inhibition of tissue re spiration.
asphyxia from laryngeal spasm.
l
2
3
4
5) circulatory failure due to toxic action on myocardium during a nesthesia.
A. No. 2 (Adr. Pharm., p. 21).
This occurs but so does pulmonary irritation because of the formation of HNO3.
This is a poor question for this reason.
Sudden early death with chloroform anesthesia following adequate premedication
is most likely due to:
direct myocardial depression because it is a protoplasmic poison.
sensitization of the myocar dium.
acute liver damage.
central nervous system effects.
l
2
3
4
5) medullary depression.
A. No. 2 (A dr. Pharm., p. 43).
Although it is a direct myocardial depressant, early deaths are usually caused by
severe arrhythmias from sensitization of the myocardium.
After the use of trichlorethylene the most likely connplication one encounter s is:
liver de generation.
transient cardiac damage.
anesthesia of the trigeminal nerve.
pulmonary edema.
nephritis.
(l
(2
(3
(4
(5
A. No. 3 \- undy, p. 41.8; Goodman, p. 77; Firth).
Trichlor ethylene was used for relief of trigemenal neuralgia after it was acciden-
tally discovered that such relief occurred as a complication of its employment for
Other purposes.
A patient with myasthenia gravis requires emergency operation on the left leg.
Which one of the following is contraindicated 2
3:28 145
19.
20.
2 1.
22.
(1 Cyclopropane -oxygen
tº Nitrous oxide -ether - oxygen
3) Sodium pentothal-curare -oxygen
(4) Divinyl ether-oxygen
(5) Spinal
A. No. 3 (Cole)
Curare in very small doses cause s prolonged and severe reactions in mye sthenia
gravis.
If pathological changes follow the administration of nitrous oxide they are because:
(1) of the effects of the nitrous oxide itself.
(2) of the effects of anoxia.
(3) of the effects of impurities in the gas.
(4) the drug causes he molysis of red blood cells.
(5) it is an in Organic gas.
A. No. 2 (Cour ville, p. 17; Lundy, p. 433)
Members of the McKe s son school agree that tissue anoxia must not be permitted to
occur but disagree with many other anesthesiologists as to percent mixtures which
will cause the anoxia.
A twenty-five year old man dies by drowning. His body was recovered after a
thirty minute search and was promptly autopsied. Which of the following would
you least expect to find 2
(1) Multiple sub-pial hemorrhage s
(2) Small areas of cerebral softening and necrosis
(3) Subendocardial pete chiae
(4) Pheripheral cyanosis
(5) Acute cardiac dilatation
A. No. 2 (Cour ville, p. 33; Adr. Pharm. , p. 142).
Cerebral softening and necrosis will not have had time to develop. The other con-
ditions mentioned are results of acute a sphyxia.
In which of the following episodes occurring in connection with an anesthetic would
the brain show the least pathologic change which would point to anoxia as the causa-
tive factor 2
(1) Death during anesthesia
(2) Death after five days of coma and convulsions
(3) Death after 25 days of coma and convulsions
(4) Death after 46 days of coma and convulsions
(5) Survival with residuals of blindness and speech difficulties 5 months after
ane sthesia,
A. No. 1 (Cour ville, p. 33; Goodman, p. 55; Adr. Pharm. , p. 124).
In all the conditions mentioned except 1, the brain would show definite microscopic
and macroscopic changes. Many patients who have died during or after operations
because of anoxia, show no changes at all.
Which is the correct order of the following in their decreasing susceptibility to
oxygen lack 7
(1) Cortex, cerebellium, medulla, spinal cord
(2) Cortex, medulla, cerebellum, spinal cord
(3) Cortex, medulla, spinal cord, cerebellum
146
3:29
23.
24.
25.
26.
27.
(4) Medulla, cortex, cerebellum, spinal C ord
(5) Cortex, cerebellum, spinal cord, medulla
A. No. 1 (Adr. Pharm., p. 123).
"Anoxia not only stops the machine, it wrecks the machinery'' primarily by :
(l) interference with cerebral blood supply.
(2) interference with cardiac conduction.
(3) destruction of deeper cerebral cortical layers.
(4) renal damage.
(5) hemorrhage from mucous membranes.
A. No. 3 (A dr. Pharm., p. 123; Courville, p. 13).
He morrhages from all serous surfaces may be severe. Not only the brain but
other organs can be affected. However, de struction of deeper cortical layers
results in serious damage. This quotation is from the work of Haldane.
When a patient is undergoing Oxygen the rapy the best guide to its use is to:
(1) increase the flow of oxygen until respirations resume normal.
(2) increase the rate and rhythm of oxygen flow until the patient is no longer cya-
notic,
(3) increase the oxygen flow until the patient is able to breat he .
(4) increase the oxygen flow until the lowest pulse rate is obtained.
(5) increase the oxygen flow until the pulse deficit has been corrected.
A. No. 4 (Cullen, p. 244).
Which one of the following statements is not correct. In anemic anoxia:
(1) there is a lowered arterial oxygen content,
(2) there is a normal arterial oxygen tension.
(3) there is a lowered venous oxygen tension.
(4) the A-V difference is increased.
(5) the amount of Oxygen in physical solution in the arterial blood is decreased.
A. No. 5 (Best, p. 421).
The arterial tension is normal but the capacity is reduced because of the reduced
quantity of he moglobin. The physical solution is unchanged.
In states of anoxia the greate st A-V difference occurs in:
(l) anoxic anoxia.
(2) anemic anoxia.
(3) stagnant anoxia.
(4) histotoxic anoxia.
(5) demand hypoxia.
A. No. 3 (Best, p. 422)
When the blood stream is slowed, more oxygen is released to the tissues.
A bottle of type "o" Rh negative blood contains:
(1) A & B agglutinogens in cells and anti Rh substance in the serum.
(2) anti a and anti b agglutinins and anti Rh substance in the serum.
(3) no agglutinogens (A & B), agglutinins (a & b) or anti Rh substance.
(4) A & B agglutinogens and no anti Rh substance.
3 : 30 147
28.
29.
30.
3 1.
32.
(5) a & b agglutinins in the serum and no anti Rh substance.
A. No. 5 (Lundy, p. 6 18).
The incidence of serum homologous jaundice is more likely to be produced by:
(l) whole blood transfusions.
(2) plasma from one donor.
(3) plasma from a pool of ten donors.
(4) plasma from a pool of fifty donors.
(5) plasma from a pool of one hundred donors.
A. No. 5 (De Gowen, p. 355; Rappaport)
Plasma made from lots with less than 100 donor S had less incidence than that made
from 100 - 1000 donor groups. It takes only as small an annount as . 1 cc. of in-
fected serum to cause a batch of plasma to be contaminated.
Urticaria appearing at the termination of a blood transfusion in a conscious patient
is best treated by which of the following, if the re are no other untoward symptoms ?
1) Immune globulin intranuscularly
2) Glucose intrave nously
3) An anti-histanninic drug orally or intravenously
4) Sodium lactate intravenously
5) Repeated small compatible transfusions
(
(
(
(
(
A. No. 3 (Wilson).
The least likely cause of nausea and vomiting during spinal anesthesia is which one
of the following :
systolic blood pressure below 70 resulting in cerebral anemia
unblocked sympathetic afferent fibers
relaxation of the sphincters of the pylorus and gallbladder
idiosyncrasy to morphine
l
2
3
4
5) high blood level of adrenalin
A. No. 5 (Lundy, p. 218).
Which one of the following portions of the nervous system is least affected by
complete anoxia 2
Pyramidal cells
Purkinje cells
Spinal cord
Sympathetic ganglia
l
2
3
4
5) Basal nuclei
A. No. 4 (A dr. Pharm., p. 123)
All the others are definitely affected but the sympathetics have not been so men-
tioned.
Indicate the nerve and as sociate pathology which is incorrect.
Abduce n's nerve - divergent strabismus
Median nerve - ape hand
Ulnar nerve - claw hand
Phrenic nerve - diaphragmatic paralysis
l
2
3
4
5) Radial nerve - wrist drop
A. No. 1 (Gray, p. 929).
148
3 : 31
33.
34.
35.
36.
37.
Convergent strabismus results from 6th nerve paralysis.
Which of the following is of least value in the treatment of bilateral recurrent lar -
yngeal nerve paralysis 2
(l) Trache otomy
(2) Endotracheal intubation
(3) Oral airway
(4) Procaine injection of the superior laryngeal nerves
(5) Helium-oxygen under pressure
A. No . 3 (Jackson, p. 526, 529; Pitkin, p. 462).
If the bilateral recurrent paralysis were of some time standing, the vocal cords
might be partially separated. Many patients are ambulatory with such paralysis
and are only uncomfortable during episodes of upper re spiratory infections. If the
paralysis is acute, the other measures would be effective. One can produce good
aeration without an oral airway by holding the jaw properly.
Sympathectomy produces the most beneficial effect upon the peripheral circulation
in:
(1) Raynaud's disease.
(2) arteriosclerotic geng rene.
(3) thrombo-ange itis obliterans.
(4) saddle embolus in the aorta.
(5) erythromelalgia.
A. No. 1 (Pitkin, p. 910).
Erythromelalgia is not of vascular origin. Until the embolus is removed from the
aorta, sympathetic blocks will cause little continued relief. In established arterial
wall disease or thromboangiitis obliterans, blocks are not effective, although they
may relieve acute spasm and pain.
A vagal stimulating reflex is manifested mainly by:
(1) bradycardia and rise in arterial blood pressure.
(2) bradycardia and arterial hypotension.
(3) tachycardia and arterial hypotension.
(4) tachycardia and arterial hypertension.
(5) bradycardia and rise in dia stolic pressure.
A. No. 2 ( Best, p. 243)
The reas on for "fast" and "slow" pain is due to:
(1) a difference in speed of conduction along different nerve fibers.
(2) the beginning of tissue reaction in the damaged area.
(3) a delayed vascular response in the damaged area.
(4) local vas oc on striction.
(5) local vasodilation.
A. No. 1 (Best, p. 936).
Indicate the incorrect statement.
(1) Neuralgic and Bympathetic pain may coexist in the same body area.
(2) Causalgic pain typically is "burning".
(3) Prefrontal lobotomy stop 8 tabetic pain.
(4) Visceral malignancy raely give H begmental tenderness without spinal cord in-
Va. 8 1 On.
3 : 32 149
38.
39.
40.
4 1.
(5) Extensive pulmonary metastases frequently is painless.
A. No. 3 (Judovich, p. 6, 17, 130; Grinker, p. 759).
Grinker states that tabet ic pains may be of all types, including sharp and lanci .
nating pains in the lower extremities, girdle sensations encircling the abdomen,
neuralgic pains associated with the cranial nerves, especially the 5th.
The se patients have frequently had abdominal explorations because of symptons
similar to perforated ulcers or appendicitis. Chor dotomy relieves the lancinat -
ing pains but does not stop the nausea and vomiting.
Prefrontal lobotomy does not stop pain but is useful for the relief of uncontrollable
patients. If the patient has pain, it irritates him less. His sense of awareness
change S.
In a toxic reaction to cocaine, the convulsions are presumed to originate in:
(1) the spinal cord.
(2) the hypothalamus.
(3) the medulla.
(4) the onotor cortex.
(5) the motor end plate s.
A. No. 4 (Goodman, p. 290).
It is the motor cortex which irritated in cocaine toxicity. The bar biturates are
effective in controlling the se cortical convulsions.
One of the most danger ous uses of local anesthetic s is as sociated with:
dilute solutions used as an intrave nous drip.
intra-urethral injection.
injection of muscular are as where vascularity is great.
direct contact with nerve trunks where permanent injury may result.
l
2
3
4
5) topical conjunctival in stillation.
A. No. 2 (Lundy, p. 62, 196).
This is particularly true if there are lesions already present or mucosal trauma
is caused by instrumentation.
The most common type of tumor occuring in the larynx is:
fibroma.
Car C in orna.
papilloma.
Sal r COIIla. ,
l
2
3
4
5) lipoma.
A. No. 1 (Jackson, p. 585, 599).
Jacks on and Jackson state that true fibromas of the larynx are very rare. However
they state that the term fibroma is applied throughout the country to turnors of in-
flammatory or traumatic origin (as for example Organizing he matomas or fibrous
polyps or cysts. ) Common usage of the term makes the fibroma a frequent tumor
of the larynx. Squamous cell carcinoma is the most frequently occuring malig-
nant turn Or. -
In a patient with carcinoma of the bronchus (upper lobe left) the anesthetist most
frequently finds:
(l) increased intracranial pressure from cerebral metastasis.
150
3 : 33
42.
43.
44.
45.
(2) paralysis of the left diaphragm.
(3) paralysis of left vocal cord.
(4) marked decrease of vital capacity.
(5) metastasis to larynx.
A. No. 3 (Boyd, p. 471). See question 2, p. 3:38.
A severely dehydrated diabetic was treated successfully for coma with insulin,
glucose, saline, and sodium lactate. She later became apathetic and listless, deve -
loped gasping respirations and died of respiratory paralysis. The most probable
explanation was:
(1) washing out of carbon dioxide while in acidosis.
(2) too rapid an increase in blood pH.
(3) marked potassium deficit.
(4) insulin overdosage.
(5) cerebral edema from over hydration.
A. No. 3 (Bland, p. 76).
While alkalosis may develop, it is the sudden loss of potassium in the formation of
hexose which causes the main difficulty. The administration of excesses of sodium
in a patient who has had acidosis must be guarded. It is difficult to control the pH
of blood when both insulin and alkalis are being administered simultaneously.
Edena of body tissue is not caused by which one of the following:
(l) inflamation.
(2) inadequate blood flow.
(3) low plasma protein.
(4) too little sodium.
(5) anoxia of tissue s
A. No. 4 (Best, p. 478).
When sodium chloride is given, edema is frequently caused in a patient on the verge
of this condition. The edema disappears on a salt free diet. Sodium bicarbonate
cause s a similar effect whereas chlorides other than with sodium exert little or
no effect. The other conditions mentioned all cause e dema.
What gas is found in the distended bowel of inte stinal obstruction in the greate st
concentration ?
(1) Nitrogen
(2) Hydrogen
(3) Methane
(4) Methane and sulfur dioxide
(5) Carbon dioxide
A. No. 1 (Adr. Chem. , p. 62).
An uncommon characteristic found in advanced intestinal obstruction is:
(1) acidosis.
(2) elevated blood urea.
(3) decreased kidney output.
(4) he moc oncentration
(5) fecal vomiting.
A. No. 1 (Best, p. 594).
Alkalosis usually occurs because of loss of chlorides in the vomitus.
3 : 34 151
46.
47.
48.
49.
50.
What is the most serious circulatory complication in thyr Ocardiac disease fronn
the a nesthetist's viewpoint ?
(1) Arteriosclerosis
(2) Tachycardia
(3) Auricular fibrillation
(4) Hypertension
(5) Congestive failure
A. No. 5 (Cecil, p. 120 l).
Until this condition can be cleared, any ane sthetist would he sitate to give a general
a nesthetic. One difficulty is that digitalis is not too effective. The most effective
treatment pre operatively is rest and iodine (or thiouracil) to relieve the thyrotoxi-
C Osis,
A reflex originating in the celiac plexus is characterized by:
fall in systolic pressure as sociated with tachycardia.
de crease in pulse pressure as sociated with tachycar dia.
decrease in pulse pressure as sociated with bradycar dia.
decrease in diastolic pressure as sociated with bradycardia.
1
2
3
4
5 rise in diastolic pressure as sociated with tachycardia.
:
A. No. 2 or 3 (Burstein; Burstein, p. 63, 116).
Burstein makes the specific statement that celiac plexus stimulation cause s a
marked decrease in pulse pressure but no change in the pulse rate. However, as
quickly as the pulse pressure is reduced, the a Crtic and carotid sinus mechanisms
come into action to cause a compensatory tachycardia.
The pulse pressure in marked peripheral vascular collapse is:
(1) increased.
(2) decreased.
(3) unchanged.
(4) variable.
(5) decreased then increased.
A. No. 2 (Best, p. 167).
There is decreased circulating blood volume and decreased cardiac output, which
results in decreased pulse pressures (ie decreased systolic pressure s.) In a
marked collapse the compensatory mechanisms cannot conne into play. The se night
cause a return of the pressures in milder shock states. -
In chronic cardiac decompensation the vital capacity is:
(l) increased due to hypoxia.
(2) increased due to carbon dioxide accumulation.
(3) decreased due to vascular engorge ment of lung s and decreased elasticity.
(4) decreased because of hypoxia of the re spiratory center.
) unchanged due to compensatory mechanisms.
A. No. 3 (Best, p. 263).
Which of the following is the most outstanding and sonnet in e s the only symptom in
a small embolus producing a small pulmonary infarct 2
(1) Increased temperature
(2) Increased re spiratory rate
(3) Pleural pain
(4) Hemoptysis
152
3 : 35
5 1.
52.
53.
54.
55.
(5) Dyspnea
A. No. 3 (Boyd, p. 79).
Hemoptysis may also occur but is not as frequent a sign as sudden ). in in the ch. . . . t.
A prolongation of the P-R interval beyond 0.2 second is known as:
(l) auricular fibrillation.
(2) first degree heart block.
(3) sinus bradycardia.
(4) bigenminal rhythm.
(5) pulsus alternans.
A. No. 2 (Best, p. 226).
The most common earliest symptom in sudden arterial OC clusion is:
(1) numbness.
(2) coldness.
(3) tingling.
(4) pain.
(5) e dema.
A. No. 4 (Cecil, p. 1283).
What is the role of the liver in advanced shock 2
(1) Insignificant
(2) Serves as a reservoir to pool blood
(3) Mobilizes the blood proteins
(4) Produces vas o-depress or material (VDM)
(5) Produces va so-excitor substance (VEM)
A. No. 4 (Best, p. 305).
In advance d shock, VDM is liberated from the liver and depresses arterioles.
In
this late state, therapy prove s to be ineffective, . . VEM is a product of the kidney
which is liberated in early shock. It constricts the arterioles in an attempt to
keep up circulation. The liver also serves as a reservoir for blood and in early
shock delivers from 25-50 percent of its own weight in blood.
Following ether ane Sthe sia by inhalation with no operation, the urine most fre-
quently show 8 or contains:
(1) a small amount of hemoglobin.
(2) albumin.
(3) increased sodium bicarbonate content.
(4) reduced annonia content.
(5) tyrosine, leucine and methionine crystals,
A. No. 2 (Adr. Pharm. , p. 35).
One of the earlie st signs of renal failure is:
l
2
) the presence of white cells in the urine.
) the presence of red cells in the urine,
) the presence of casts in the urine.
) an abnormal ure a nitrogen or NPN.
) inability to concentrate urine adequately.
(
(
(3
(4
(5
A. No. 5 (Be st, p. 466).
y A * *
3:36
153
When a low specific gravity is found consistently, kidney damage must be sus-
pected. An increased NPN indicates either an increased catabolism or poor kidney
function. However, in many conditions unas sociated with kidney disease the NPN
rises (ie fevers, he morrhage into the GI tract, etc.)
56. One of the following men is well known to a nesthesiologists for his publications on
a noxia :
(1) Max's on
(2) Hing son
(3) Adams
(4) Living ston
(5) Cour ville
A. No. 5 (Cour ville).
57. A book entitled, "Adventures in Re spiration'' was written by:
Haldane.
Hender son, Yandell.
Van Lie re.
Cour ville.
l
2
3
4
5) Hender son, V. E.
A. No. 2 (Barach, p. 20).
58. Who propounded the the or y of anoci-association ?
(l) Gwathmey
(2) Flagg
(3) Lundy
(4) Crile
(5) Water s
A. No. 4 (Lundy, p. 713).
59. The "acapnia the or y of shock" is as sociated with:
(1) Crile.
(2) Freeman.
(3) Cannon.
(4) Hender son.
(5) Moon.
A. No. 4 (Best, p. 302).
60. Which of the following is the author of "Segmental Neuralgia in Painful Syndron & 3" 2
(1) Robinson
(2) Lull and Hings on
(3) Livingston
(4) Judovich and Bates
(5) Rape c
A . No. 4 (Judovich).
The new edition of this book is known as "Pain Syndromes".
154 3 : 37
SUPPLEMENT 2. SUB SECTION_
PATHOLOGY
In exposing the larynx by direct vision, a malignant mass is noted on the vocal
cord. The most probable choice is:
(l) basal cell carcinoma.
(2) squamous cell carcinoma.
(3) fibro-adenoma.
(4) columnar epithelioma.
(5) rhabdomyosarcoma.
A. No. 2 (Jackson, p. 559; Boyd, p. 421).
In a patient with carcinoma of the bronchus (upper lobe left) the anesthetist most
frequently finds:
(1) increased intracranial pressure from cerebral metastasis.
(2) paralysis of the left diaphragm.
(3) paralysis of left vocal cord.
(4) marked decrease of vital capacity.
(5) metastasis to larynx.
A. No. 3 (Boyd, p. 47).
Which of the following is of least value in the treatment of bilateral recurrent
laryngeal nerve paralysis 2
(l) Trache otomy
(2) Endotracheal intubation
(3) Oral airway
(4) Procaine injection of the superior laryngeal nerves
(5) Helium-oxygen under pressure
A. No. 3 (Jackson, p. 528).
The average hematocrit reading in the healthy male is:
(1) 20
(2) 30
(3) 45
(4) 60
(5) 75
A. No. 3 (Best, p. 15).
What is the least number of grams of reduced hemoglobin in venous blood which
will result in cyanosis 2
(1) 2. 3
(2) 3.2
(3) 5
(4) 8.6
(5) 14
A. No. 3 (Best, p. 438).
Arteriovenous difference is decreased in which one of the following 2
Spinal anesthesia
Cardiac failure
Cyclopropane anesthesia
Ether a nesthesia
i
3:38 155
10.
1 1.
(5) Traumatic shock
A. No. 3 (A dr. Chem. , p. 437).
Significant increase in blood volume is frequently found in all but one of the con-
ditions below. Indicate that condition.
Congestive failure
Polycythamia vera
Splenic anemia (congestive splenomegaly)
Benign e s sential hypertension
l
2
3
4
5) Pregnancy
A. No. 4 (Best, p. 24).
Which one of the following portions of the nervous system is least affected by
c cmplete anoxia 7
(1) Pyramidal cells
(2) Purkinje cells
(3) Spinal cord
(4) Sympathetic ganglia
(5) Basal nuclei
A. No. 4 (Van Liere, p. 208).
Of the following which is not characteristic of reflex dystrophy 2
(1) Burning pain
(2) Temperature changes
(3) Hyperesthesia
(4) Muscle Contracture
(5) Trophic changes
A. No. 1 (Grinker, p. 82 l; Boyd, p. 927).
The dystrophes are characterized by atrophy of the muscles and a decrease in all
forms of sensation in the dystrophic limbs. There is usually no pain or hyper-
esthesia.
Horner's syndrome is most often observed in the presence of:
(1) mixed tumor of the parotid gland.
(2) carcinoma of the larynx.
(3) advanced mitral stenosis.
(4) carcinoma of the thyroid.
(5) Riedel's struma.
A. No. 4 (Ref. , none).
There was no reference which could be found but Horner's syndrome occurs
after deliberate blocking or from degeneration of the sympathetic nerves on that
side The thyroid is the gland closest to the sympathetic nerves and should
cause de generation of the sympathetic nerves if it were to occur. Riedel's Struma
is due to chronic thyroiditis causing a small atrophic type of thyroid gland.
Indicate the nerve and as sociated pathology which is incorrect.
(1) Abducens nerve - divergent strabismus
(2) Median nerve - ape hand
(3) Ulnar nerve - claw hand
(4) Phrenic nerve - diaphragmatic paralysis
(5) Radial nerve - wrist drop
156
3: 39
12.
13.
14.
15.
16.
A. No. 1 (Mc Donald, p. 10).
Select the incorrect statement concerning paralysis of the abducens nerve
following spinal anesthesia.
(1) The sixth nerve is involved in about 10% of all cases of paralysis of the cranial
nerve S.
(2) The onset of symptoms varies from 3 to 21 days.
(3) The incidence is equal in both eyes.
(4) Women are more prone to develop this complication than men.
(5) The syndrome seems to follow a definite pattern.
A. No. 1 (Bryce, p. 275-276; Collins, p. 345).
The 6th nerve is involved in 90% of cases of cranial nerve palsy. However, there
is the fact that men are more prone to develop this complication than women.
While this is a unilateral disease, usually, the incidence may or may not be
equal in both eyes.
Spinal analgesia is induced to the level of D 10. The blood pressure drops from
140/90 to 1 10/60. The blood flow through the small finger of the left hand would
then be :
1) four time s as great as before spinal.
2) twice as great as before spinal.
3) less than before spinal.
(4) same as before spinal.
(5) unrelated to spinal at all.
A. No. 4 (Pitkin, p. 847).
This is a question in which the D - 10 level is the important point. A fall in blood
pressure is related to the quantity of arteriolar surface available for compensation
as compared with the quantity of area de nervated by the spinal anesthetic. It
takes a spinal to T6 or T8 to cause sufficient area to be de nervated so that com-
pensatory vas OC on striction in the upper areas cannot compensate (splanchnic
dilatation).
If previously withdrawn sample of clear spinal fluid coagulate S, which of the
following conditions would you suspect 2
(1) Cord tumor
(2) Traumatic tap
(3) Arteriosclerotic hypertension
(4) Poliomyelitis
(5) Brain abce s s
A. No. 1 (Kolmer, p. 323).
Loss of excess HCL in severe vomiting from pyloric obstruction results in:
(1) uncompensated alkali excess in which the Na HCO3 is increased without a
proportionate rise in H2CO3.
(2) a lowering of the pH.
(3) compensated alkali excess in which there is a parallel rise in NaHCO3 and
H2CO3.
(4) normal acid-base balance.
(5) compensated CO., excess in which H2CO3 is increased accompanied by a pro-
portional rise in Nafico.
A. No. 1 (Gamble, chart 42).
The least common manife station of complete obstruction of the jejunum of 10 hours
3:40 157
17.
18.
19.
2 1.
duration is:
anhydrernia
alkalo sis.
acidosis.
azotemia.
l
2
3
4
5) fecal v Orniting.
A. No. 3 (Best, p. 595; Collins, p. 404).
In acute intestinal obstruction one may expect:
(1) an elevated serum chloride.
(2) an elevated NPN
(3) increased blood volume.
(4) hypocalcemia.
(5) increased derum bilirubin.
A. No. 2 (He st, p. 594).
Death from a small pulmonary embolism is due to which one of the following 2
1) Lack of aerating surface in the lung
2) Plugging of pulmonary artery
3) Reflex effects on bronchioles and heart
4) Massive collapse
5) Pulmonary edema
(
(
(
(
(
A. No. 3 (Collins, p. 288).
Sudden death under anesthesia is not infrequently attributed to cerebral embolism
Which one of the following sources is most likely to cause such embolism 2
º
(1) Systemic veins
(2) Intertrabecular space s of the right ventricle
(3) Vegetations from the tricuspid valve
(4) Pulmonary veins
(5) Inferior and superior me senteric veins
A. No 4 (Gray, p. 650).
From an anatomical viewpoint the only answer could be number 4. Other emboli
mentioned would cause pulmonary embolism. The lungs would filter out the
emboli before reaching the cerebral circulation.
The cornmon site of cerebral hermor rhage is the .
(1) middle cerebral artery.
(2) pontine artery.
(3) anterior cerebellar artery.
(4) lenticulos triate artery.
(5) temporal artery.
A. No. 4 (Mc Donald, p. 192).
When death occurs and a fat e in bolus is suggested which one of the following rules
it Out 2
Negative section of lung and brain stained with Scharlach red
Operation was on femur recently fractured
1)
2)
3) History of sudden circulatory collapse followed by respiratory failure
4) Operation in which onenturn is manipulated
| 58
3:41
22.
23.
24.
25.
26.
27.
(5) Operation was on skull
A. No. 1 (Collins, p. 288; Warren).
A negative section with Sharlach red of the lungs and brain usually rules out fat
emboli. These are the areas where emboli lodge and cause death.
The hyperglycemia following administration of ether is due to:
(1) stimulation of a glycogenolytic center.
(2) increased output of epinephrine.
(3) direct effect of ether on liver cells.
(4) suppression of insulin production.
(5) increased glycogenolysis in muscle.
A. No. 2 (Adr. Pharm. , P. 33; Adr. Chem. , p. 376).
Choose the predominant method of identification of potassium deficiency.
(1) EKG
(2) Hypotension
(3) Convulsions
(4) Paralysis
(5) Hyperthermia
A. No. 1 (Best, p. 192).
In chronic deficiency states one of the following is untrue:
(1) fat content of liver is increased.
(2) glycogen content of liver is increased.
(3) decrease in rate of sythe sis of plasma proteins.
(4) decreased formation of prothronbin.
(5) drop in hepatic functional capacity.
A. No. 2 (A dr. Chem. , p. 385).
Controlled hypotension as described by Hale means:
(1) keeping the blood pressure low by means of vasodilating drugs.
(2) withdrawing blood through an arterial cannula and replacing the blood as nec –
essary.
(3) withdrawing blood from a vein and giving it back to the patient intravenously
when needed.
(4) using high spinal anesthesia without using any vasopress or drugs.
(5) not replacing blood lost during an Operation until the operation is over.
A. No. 2 (Hale).
An increase in venous pressure is characteristic of:
(1) shock.
(2) high spinal anesthesia.
(3) 3rd plane ether anesthesia.
(4) respiratory obstruction.
(5) e s sential hypertension.
A. No. 4 (Best, p. 174).
Which of the following is incorrect in regard to heat retention ?
(1) Skin hot, dry, flushed
3:42 | 59
28.
29.
30.
3 1.
32.
(2) Tachycardia, B. P. increased.
(3) Tachypnea
(4) Hemoc oncentration
(5) Hyperthermia
A. No. 4 (Collins, p. 327)
From the anesthetist's standpoint the most significant pathological physiological
change in uremia is:
(1) elevated NPH
(2) reduced combining power for carbon dioxide.
(3) the he moc oncentration.
(4) the convulsive manife stations.
(5) the odor of ammonia on the breath.
A. No. 2 (Best, p. 481).
In acute renal insufficiency from chronic nephritis with an NPH of 120 is most
apt to find:
(1) the total base of blood is reduced.
(2) a compensated carbon dioxide excess is present.
(3) an uncompensated carbon dioxide excess is present.
(4) total urinary annonia is increased.
(5) an elevated carbon dioxide combining power.
A. No. 1 (Best, p. 136)
In eclampsia gravidar un:
(1) the blood pressure is lower ed.
(2) the blood pressure is raised without change in diastolic pressure.
(3) the blood pressure is raised with a pronounced rise in diastolic pressure.
(4) the blood pressure is raised with a pronounced rise in systolic and a small
rise in dia stolic pressure.
(5) there is no change in blood pressure.
A. No. 3 (Best, p. 166).
Which one of the following statements is incorrect 2
(1) The Rh factor has the characteristic s of an antigen.
(2) Approximately 85% of Caucasians are Rh positive.
(3) Transfusion reactions do not occur if recipient and donor have the same type
blood if donor's blood is free of bacteria and excess protein.
(4) Rh positive blood given to an Rh negative 12 year old girl jeopardizes her
chance s bearing normal children.
(5) Transfusion reaction in an Rh negative receiving Rh positive blood primarily is
due to hemolysis.
A. No. 3 (Kolmer, p. 474).
The important lesion following an incompatible blood transfusion, in which the pa -
tient dies after two days to a week, is thought to be:
(l) a lesion of the renal tubules,
(2) multiple embolism of the flocculated cells.
(3) inpermeability of the filtration apparatus of the glomeruli.
(4) pulmonary edema.
(5) hemolytic anemia.
A. No. 1 (Best, p. 43; Collins, p. 480).
160
3:43
33.
34.
35.
36.
37.
38.
Frequently the only sign of an incompatible transfusion reaction during a nesthesia
is :
(1) Elevated Temperature
(2) Tachycardia
(3) Hypotension
(4) Increased bleeding tendency
(5) Chill
A. No. 4 (Collins, p. 479; Wintrobe, p. 313).
Cyanosis is observed in a patient twelve hours postanesthesia. The patient's res-
pirations, pulse and blood pressure are normal. The cyanosis is probably due to:
(1) Sulfhemoglobinemia following the use of sulfanilamide
(2) Shallow breathing
(3) Morphine idiosyncrasy
(4) Pulmonary atelectasis
(5) Shock
A. No. 1 (Goodman, p. 1031) This is a poor question. See question 13, p. 3:3.
Because the conditions mentioned are that the patient's respiration, pulse and
blood pressure are normal, answers 2, 3, 4, and 5 can be eliminated. It is known
that sulpha drugs can cause sulhemoglobinemia.
Irritation of auricular branch of vagus causes:
(1) Tinnitis
(2) Coughing
- (3) Cyanosis
(4) Verrigo
(5) Broncho spasm
A. No. 2 (Best, p. 355).
Claw hand is due to injury of the :
(1) Median nerve
(2) Ulnar nerve
(3) Radial nerve
(4) Circumflex nerve
(5) Nerve of Wrisberg
A. No. 2 (McDonald, p. 95).
A positive Homan's sign is one of the diagnostic criteria of:
(1) Varicose veins which are suitable for treatment
(2) Varicose veins which are not suitable for treatment
(3) Thr onbosis of the deep veins of the calf
(4) Incompetence of the deep vein
(5) Thrombosis of the femoral artery
A. No. 3 (Dorland, p. 1367).
º * * * - O
A patient may exhibit a hyperthermia of 102 F. during anesthesia . Which of the
following circumstances would not contribute intrins incally to this:
(1) Thyrotoxico sis
(2) Dehydration
(3) Endotracheal insufflation of ether-oxygen
3:44 ! ()
39.
40.
4 1.
42.
43.
(4) Closed carbon dioxide absorption technique
(5) High environmental humidity
A. No. 3 (Adri. Chem. , p. 424).
Which is the commonest complication of general a nesthesia:
(1) Respiratory depression
(2) Respiratory obstruction
(3) Cardiac arrhythmias
(4) Tachycardia
(5) Cyanosis
A. No. 2 (A dri. Tech. , p. 139).
Following a closed circuit ether anesthetic, a patient was noted to have
burns of the face conforming to the area of contact of the mask. These
burns were probably due to:
(1) Excessive ether vapor tension
(2) Previous sterilization of mask in lysol and rinsing in alcohol
(3) Excessive pressure
(4) Allergy to rubber
(5) Excessive pressure
A. No. 2 (Adr. Tech. , p. 26).
If convulsions develop in a thyrotoxic patient 8 hours after subtotal thy-
roidectomy the most likely cause is:
(1) Cerebral damage
(2) Removal of too much thyroid tissue
(3) Acidosis and hyperglycemia
(4) Tetany
(5) Thyroid crisis
A. No. 4 (Best, p. 781, 813; Yater, p. 478).
Yater states that crises can occur postoperatively in those patients who have been
insufficiently prepared with lugol's solution. However, Best & Taylor states that
tetany occurs most frequently due to the inadvertent removal of parathyroid glands
and occurs post operatively in many instances. The fibrillary twitchings of the
muscles are followed by tonic or chronic muscular contraction.
In chronic emphysema which of the following is not true:
(1) Lungs are in a state of collapse
(2) Enlargement of the air sac s
(3) Air sacs show fewer alveoli
(4) Contiguous air sacs fuse to form large air spaces
(5) Inter stitial pulmonary tissue is increased
A. No. 1 (Best, p. 433).
Helium 80% and oxygen 20% are used in therapy of asthma because:
(1) Helium is non-inflammable
(2) This mixture is more comfortable for the patient because of the atomic
weight of helium
(3) This mixture is cheaper than 100% oxygen
(4) Helium loosens the bronchial secretions
(5) Helium de saturates rapidly from tissues
A. No. 2 (Collins, p. 492).
162
3:45
44.
45.
46.
47.
48.
49.
The chief lesion found in true asthmatic S is:
(1) Dilation of the bronchi
(2) Lumina of bronchi are filled with mucus and pus
(3) Thickening of wall of smaller bronchi
(4) A telectatic are as
(5) Acute inflammation of the bronchioles
A. No. 3 (Best, p. 430; Yater, p. 548).
While it is true the lumina of the bronchi may be filled with mucous and pus, this is
more frequently found in the smaller bronchioles. The patients are able to remove
secretions from the larger bronchi. After chronic asthmatic attacks, the smaller
bronchi and the larger bronchi become thickened and no longer elastic.
One of the following is not usually present in emphysema:
(1) Hyperennia of the septa between alveoli
(2) Few but large ve scicles
(3) Diminished amount of elastic tissue
(4) Barrel - shaped chest
(5) Hyper-resonance of the lungs
A. No. 1 (Best, p. 432)
What is the most likely cause of death in phenobarbital poisoning on the 6th day:
(1) Primary respiratory failure
(2) Yellow liver atrophy
(3) Pneumonia
(4) Adrenal in sufficiency
(5) Cerebral cortical necro sis
A - No. 3 (Goodman, p. 142).
Intravenous barbiturates are not indicated in the treatment of:
(1) So-called ether convulsions
(2) Convulsions from eclampsia
(3) Excessive cortical stimulation from procaine
(4) Cardiovascular collapse due to cocaine
(5) Excited states
A. No. 4 (Adr. Tech. , p. 206).
Which of these signs is not a part of a Horner's syndrome:
(1) Forehead sweating
(2) Miosis
(3) Enopthalmos
(4) Ptosis
(5) Conjuctival injection
A. No. 1 (Collins, p. 242).
Which of these signs or symptoms is not usually seen in acute pulmonary edema:
(1) Tachycardia
(2) Engorged veins
(3) Tachypnea
(4) Frothy sputum
(5) Scleral pete chia
A. No. 5 (Barach, p. 100).
3:46 163
50.
5 1.
52.
53.
54.
55.
A 27-year old man, blood type A, Rh negative, who has never been transfused,
is bleeding from an injury and needs blood. Which of the following blood should
not be used in this emergency, under any circumstances:
(l) Type A, Rh negative
(2) Type A, Rh positive
(3) Type O, Rh positive
(4) Type A B, Rh negative
A. No. 4 (Best, p. 43).
The incidence of postoperative spinal headaches is greatest in :
(1) children
(2) young adult males
(3) young adult females
(4) pregnant women
(5) middle-aged males and females
A. No. 4 (Greene).
Spinal anesthesia produced the following effect on the small bowel:
(1) A tony
(2) Sustained contraction
(3) Increased peristals is
(4) Dilatation
(5) Rever se peristalsis
A. No. 2 (Pitkin, p. 848).
When aortic in sufficiency due to syphilitic heart disease is present the most in -
portant factor to be considered in selecting anesthesia is:
(1) The increased cardiac output
(2) Myocar dial changes which affect the output of the heart
(3) The elevation in systolic pressure
(4) The level of the diastolic pressure
(5) The presence of an aneurysm of the aorta
A. No. 5 (Collins, p. 444).
Which of the following is the most significant in convulsions under ether anes the sia:
(1) Jactitation of the extremities
(2) Shallow rapid breathing
(3) Low blood p 1 essure
(4) Twitching of the facial muscles
(5) High blood pressure
A. No. 3 (Collins, p. 290).
Collins states that initially the pulse is rapid and blood pressure elevated. When
a crisis occurs a shocked state develops with decreased blood pressure.
When a peripheral nerve is severed the filaments of the proximal end:
(1) Do not degenerate
(2) Degenerate up to the first node of Ranvier
(3) Degenerate only if non-myelinated all the way back to the cord
(4) Degenerate whether myelinated or not all the way back to the cord
(5) Degenerate if not myelinated to the first node of Ranvier
A. No. 2 (Best, p. 90 l).
164
3:47
56.
57.
58.
59.
60.
Incision and drainage of an abscess of a pilonidal cyst is to be performed. Which
one of the following technic s is contraindicated:
(1) Spinal
(2) Epidural (lumbar)
(3) Caudal
(4) Ether
(5) Cyclopropane
A. No. 3 (Pitkin, p. 765).
Who first described the anesthetic properties of cyclopropane :
(1) Gelfan & Bell
(2) Hender son & Lucas
(3) Chauncey Leake
(4) Romberger
(5) Schmidt
A. No. 2 (A dr. Pharm. , p. 27).
The name Pitkin is associated with a technic using which of the following drugs:
(1) Procaine - dextrose
(2) Procaine alcohol gliadin
(3) Procaine –pontocaine
(4) Metycaine
(5) Stovaine
A. No. 2 (Pitkin, p. 809).
Pontocaine -glucose solution for spinal anesthesia was first used extensively by:
(1) Sise
(2) Tovell
(3) Maxson
(4) Barker
(5) Howard - Jones
A. No. 1 (Collins, p. 139).
"The Untoward Effects of Nitrous Oxide Anesthesia" was written by:
(1) Drinker
(2) Courville
(3) Goodman
(4) Barach
(5) Clement
A. No. 2 (Courville).
3:48 165
P H Y S I C S and C H E M I S T R Y
C h a pter IV
167
OUT LINE – PHYSICS & CHEMISTRY
Physics
SUBJECT
Main Sect.
Gas Laws & Definitions . . . . . . . . . . . . . 1, 2, 3, 4, 5,
6, 7, 69
Cylinders & Gases in Cylinders . . . . . 8, 9, 10, 1 1,
12
Flow meters. . . . . . . . . . . . . . . . . . . . . . . . 13, 14
Gases in the Body including Vapor &
Dead Space . . . . . . . . . . . . . . . . . . . . . . . . 18, 19, 20,
2 1
CO2 Absorption (Circle and To and
Fro) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22, 23, 24,
25, 26, 27,
28, 50, 51
Explosions . . . . . . . . . . . . . . . . . . . . . . . . 29 - 37
Physics of Cerebrospinal Fluid . . . . . . 38–41
Calculation of Problems . . . . . . . . . . . . 42-46
Miscellaneous Physics including
Boiling Points, Partial Pressure of
Gases, The ories of Narcosis, pH,
Oxygen . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16, 17, 47,
48, 4.9, 52,
15, 70, 72
Men Associated with the Physics and
Chemistry of Anesthesiology . . . . . . . . 53 – 57
Chemistry
Chemical Formulae. . . . . . . . . . . . . . . . . 58-61, 67,
71, 82, 87,
88, 89, 90
Analyses of Gases . . . . . . . . . . . . . . . . . . 62-66
Anesthetic Agents
1. Nitrous Oxide . . . . . . . . . . . . . . . . . 73, 74, 86
2. Ethylene . . . . . . . . . . . . . . . . . . . . . . 75, 76
3. Di-Ethyl Ether . . . . . . . . . . . . . . . . 68
4. Chloroform . . . . . . . . . . . . . . . . . . . . 77-79
QUESTION NUMBER
Suppl. 1
7, 14, 18,
36, 40, 46
3, 4, 5, 10,
31, 32
8, 9, 28, 29,
30
50, 51, 52
26
2, 20–25,
39, 41
43, 44, 45,
47, 53
48, 54–56
57-59
1 1, 34
35, 38, 42
60
16, 49
Suppl. 2
14, 15, 26,
32, 33, 40,
47,
31, 36, 37,
38, 4.3, 44,
45
4 1
1, 2, 3, 4, 6,
30, 35
50, 51, 52,
53
22
21, 34, 39
9, 16, 42,
46, 56, 59
27 – 29, 54,
55, 57, 58,
60
23 — 25
48
13, 49
12
4:i
169
OUT LINE – PHYSICS & C HE MISTRY
Chemistry Cont'd
SUBJECT
A vertin . . . . . . . . . . . . . . . . . . . . . . .
Pentothal & Other Barbiturates . .
Procaine, Pontocaine, Nuper-
caine, Cocaine . . . . . . . . . . . . . . . .
Nitrogen, Helium . . . . . . . . . . . . . .
Main Sect.
QUESTION NUMBER
Suppl 1
27, 33
12, 15, 17,
13, 19, 37
Suppl 2
170
P, IT, LIOGRAPHY – PHYSICS & CHEMISTRY
ADRIANI, J. : The Chemistry of Anesthesia. Ed. 1, Springfield, Ill., Charles C.
Thomas, 1946.
A DRIA NI, J. : The Pharmacology of Anesthetic Drugs. Ed. 3, Springfield, Ill.
Charles C. Thomas, 1952.
ADRIA NI, J. : Techniques and Procedures of Anes the Sia. Ed. 1, Spring field, Ill
Charles C. Thomas, 1947.
• 3
BARA CH, A. L. : Physiologic Therapy in Re spiratory Disease S. Ed. 2, Philadelp in 1: .
Pa., J. B. Lippincott Co., 1948.
BEST, C. H. and TAYLOR, N. B. : The Physiologic Basis of Medical Practice. Ed. * ,
Baltimore, Md. , The Williams and Wilkins Co. , 1950. -
BOURNE, W. : Pure Ether and Impurities. A Review. A nesthesiology, 7:500 – 6 ſ. 5
(Nov.) 1946,
COLLINS, V., J. : Anesthesiology, Ed. 1, Philadelphia, Pa., Lea and Febiger, 1952.
COMROE, J. H. and DRIPPS, R. D. : Oxygen Therapy, Ed. 1, Springfield, I11. ,
Charles C. Thomas, 1950.
CULLEN, S. C. : Anesthesia in General Practice. Ed. 3, Chicago, Ill., The Year
Book Publishers, 1951.
DORLAND, W. A. N. : The American Illustrated Medical Dictionary. Ed. 22, Phila -
delphia, Pa., W. B. Saunders Co., 1951.
FAULC ONER, A., Jr. and LATTERELL, K. E. : Tensions of Oxygen and Ether Vapor
During Use of Semi-Open, Air-Ether Method of Anesthesia. Anesthesiology,
10:247-259 (May) 1949.
FUNDAMENTALS OF ANESTHESIA: An Outline by the Subcommittee on Anesthesia of
the Division of Medical Science, National Research Council. Ed. 1, Chicago,
Ill. , American Medical Association Press, 1942.
GISVOLD, Dr. (Dept. of Pharmacology, U. Minnesota): Minneapolis, Minnesota,
Personal Communication.
GOODMAN, L. and GILMAN, A. : The Pharmacological Basis of The rapeutics. Ed. 1,
New York, N. Y. , The Macmillan Co., 1941.
HADFIELD, C. F. : The Use of Anesthetics in S-Ray Departments. Radiography,
10:17–23 (Mar) 1944, Abstracted in Anesthesiology, 6:9 l (Jan) 1945.
KEYS, T. E. : The History of Surgical Anesthesia. Ed. 1, New York City, N. Y.,
Schuman's, 1945.
KNIGHT, R. T. : (Director Emeritus, Division of Anesthesiology, U. Minnesota,
Minneapolis, Minnesota) Personal Communication.
LUNDY, J. S. : Clinical Anesthesia. Ed. 1, Philadelphia, Pa., W. B. Saunders Co.,
1942.
MACINTOSH, R. R. and MUSHIN, W. W. : Physics for the Anesthetist. Ed. 1,
Springfield, Ill., Charles C. Thomas, 1946.
4:iii i.7 i
J. H. : A n In strºnent for Deter mir, –
PAULING, L, , WOOD, R. E. , and STURD EVANT,
Science, 1 03:33.8 (Mar. 15) la: 6.
ing the Partial Pressure of Oxygen in a Gas;
Conduction Anesthesia, Edited by So thworth, J. L. , and Hing son, R, A,
PIT KIN, G. P. :
1 () 53.
Ed. 2, Philadelphia, Pa. , J. B. Lippincott Co. ,
T he
THORNT ON, M. D. , MART IN, R. C. , LIVINGSTONE, H. M. , and ADAMS, W. E. :
Effect of Variations of Intratrac heal Pre S sure and A nesthetic Mixtures on the
Arterial Blood Oxygen. A nesthesiology, 6:498–504 (Sept) 1945.
WHITE HEAD, R. W. , SPENCER, J. N. , PARRY, T. M. , and D R A PER, W. E. : Studies,
on Diffusion Re spiration. No. IV. The Oxygen and Carbon Dioxide Confert and
The Hydrogen Ion Concentration of Arterial and Venous Abdominal Flood c.f Dogs
During Diffusion Re spiration. A nesthesiology, 10:54 – 60 (Jan) 1949.
172
MAIN SUB-SECTION
PHYSICS AND CHE MISTRY
Charles Law states that:
A. (Macintosh, p. 108).
Charles and Gay-Lussac are essentially the same laws. Charles originated the
theorem and Gay-Lussac confirmed it with experiments. Gases kept at constant
pressure will expand 1/273 of their volume at O degree C. with each rise in centi-
grade temperature.
Process of equalization of molecular concentration of gases is known as:
Diffusion
Joule – Thompson effect
Brownian m overn ent
Avogadros number
l
2
3
4
5 Newton's third law of motion.
A. No. 1 (Macintosh, p. 62; A dr. Chem. p. 36).
Define (a) Volume per cent, (b) vapor pressure, (c) absolute humidity, (d) heat of
vaporization, (e) partial pressure of a gas.
A. (A dr. Pharm. p. 113, 133, 134; Dorland).
(a) Volume per cent: C c. of gas liberated from 100 cc. of liquid.
(b) Vapor pressure: The pressure of a saturated vapor. The pressure exerted
by a vapor when in contact, under equilibrium conditions, with the solid or
liquid phase of the same substance, so that neither condensation nor evapora -
tion occur S.
(c) Absolute humidity: The number of grams of water vapor possible per unit vo-
lume of air.
Relative humidity: The amount of water vapor actually present compared to the
annount necessary for saturation of a given annount of air at a given temperature.
(d) Heat of Vaporization: The heat required to change a unit weight of liquid to the
vapor state at a given temperature.
(e) Partial Pressure of a gas: The pressure exerted by each of the constituents
of a mixture of gases.
(a) Define heat of vaporization. (b) When gas at a constant temperature is bubbled
through (or blown over the surface of) ether in a jar at a constant rate, why is it
that the rate of vaporization of the ether is fast at the beginning and slow later 2
A. (A dr. Pharm. p, 133; Macintosh, p. 229).
(a) The heat required to convert one gram of water to vapor - equals 537 cal.
(b) Rate of evaporation is rapid at first, but since heat is absorbed, the tempera -
ture of the liquid is lowered. This lowers the vapor pressure and decreases the
rate of evaporation.
What is meant by the oil/water solubility ratio of a gas 2 Give the ratio for one
a nesthetic gas.
A. (A dr. Pharm. p. 9).
This is the ratio of the amount of gas that will go into solution in oil as compared
with water. This ratio determines its potency according to the Meyer – Overton law.
The higher the ratio, the greater the potency. Ether has a ratio of 3. 2; chloroform's
ratio is 100.
4 : 1 173
10,
Define the following: (a) Absolute zero (b) atomic weight (c) flash point.
A. (A dr. Pharm. p. 133).
(a) Absolute zero is the lowest possible temperature – 273 degrees below Ze r O.
centigrade.
(b) Atomic weight is the weight of an atom of a chemical element as compared with
that of an atom of oxygen taken at 16.
(c) Flash point is the lowest temperature at which the vapor of a volatile liquid
will ignite.
(a) What are the atomic weights of carbon, hydrogen, nitrogen, oxygen 2
(b) What is the molecular weight of carbon dioxide, cyclopropane, ethylene, helium,
nitrogen, nitrous oxide, oxygen 2
(c) Are these data used in calibrating flow meters on an a nesthetic machine 2 Why?
(d) Can you use a flow meter calibrated for carbon dioxide to measure the flow of
nitrous oxide 2 Why 2
A. (A dr. Chem. p. 26; A dr. Pharm. p. 134).
(a) C - 12. 01; H – 1.008; N – 14. 08; O – 16.
(b) CO2 - 44; Cyclo - 42; Ethylene - 28: Helium - 4.008; N2 - 28.0% of N2O - 44. 016.
(c) Molecular weight is employed in calibrating the hydraulic type of flow meter.
A small sphere or cylinder is suspended in the path of a jet of the gas and rises
with the increased pressure of the jet. The height is proportional to the volume
flow per minute and to the molecular weight.
(d) The meter may be used only for a gas for which it is designed or for one of
approximately the same molecular weight. The weights of CO2 and N2O are
sufficiently similar for their use with the same flow meter.
As a conservative measure, it is suggested that oxygen cylinders be filled with gas
under 3000 pounds pressure per square inch instead of 2000 pounds, Discuss the
significance of such change. What modifications, if any, would you consider that
such change made necessary in the technical aspects of a nesthesia and inhalation
therapy:
A. (Macintosh, p. 89).
Although the cylinder walls of the storage tanks can withstand pressures up to 3 or
4 thousand pounds per square inch, as a safety measure it would be necessary to
increase the width of the wall if pressure were increased to 3000 pounds per square
inch. It is required that the walls be able to resist five-thirds of the currently used
service pressure. As sunning that the reducing valve was adjusted to take care of
this increased pressure, gas would still flow from the machine at a pressure just
slightly above atmospheric pressure, and no change would be necessary in a nesthesia
technique.
Which of the following gases may be liquified ºy pressure at room temperature so
that it may be safely marketed as a liquid in cylinders:
A. (Lundy, p. 290; Adr. Chem. p. 62; Adr. Pharm. p. 21, 24). See question 42, p. 4:40.
Oxygen - No Cyclopropane - Yes (atmospheric pressure)
Nitrogen - No Ethylene - No (liquified at 10°C)
Heliurn - No Nitrous oxide – Yes (Nitrous oxide may be compressed
Helium and Oxygen - No at 28°C with 50 atm. pressure).
Carbon dioxide - Yes (liquified at 30. 9°C or 87.6°F)
The usual pressure in a tank of cyclopropane is:
(1) 40 lbs. per sq. inch
(2) 45 to 50
(3) 60
174
4:2
1 1.
12.
13.
14.
15.
(4) 75 to 80
(5) None
A. No. 4 (Fundamentals of Anesthesia, p. 197)
When does pressure drop in a N2O cylinder 3
A. (Macintosh, p. 95)
Pressure in the nitrous oxide guage will only begin to drop when all the liquid
nitrous oxide has been vaporized and the gas begins to lose pressure. Tanks must
be watched carefully after that for emptying.
What gas would be contained in a brown colored tank:
(1) Carbon dioxide
(2) Oxygen
(3) Helium
(4) Ethylene
(5) Cyclopropane
A. No. 3 (Lundy, p. 290).
Describe the working principle of: (a) The dry flow meter (Heidbrink); (b) the
water flow meter (For egger); (c) the intermittent flow machine (McKesson).
A. (A dr. Tech. p. 33).
(a) Dry flow meter - The flow of gases suspends a spherical or cylindrical float
in a transparent tube the sides of which are calibrated in gallons per minute
or liters per minute.
(b) Water flow meter – A constriction in the inlet tube causes an increased pres–
sure of the flowing gases; this increase in pressure is transmitted to a column
of water which is depressed in a calibrated tube in proportion to the flow of gas.
(c) 1. Intermitten flow of gases with single control.
2. Gas mixing chamber with check valve; as the patient inhales the check
valve lifts and admits N2O and O2 from two reservoir bags. The propor-
tion of the two gases entering the chamber is regulated by mixture control
dial graduated in percentage of O2.
3. Two reservoir bags one for N2O and one for O2 enclosed in metal drums.
- The mechanism is such that the flow of gases to these bags from the cylin-
ders takes place only during inspiration. Reducing valves or regulators
on the cylinders reduce the pressure of the gases to 60 lbs. per square
inch.
Which type of flowneter is most sensitive to calibration and reading:
(!) Open water manometer
(2) Closed water manorneter
(3) Closed Hg. manometer
(4) Open Hg. manometer
(5) Open manometer with mineral oil
A. No. 1 (Adr. Techs. p. 35).
The partial pressure of N2 at sea level is:
(1) 120
(2) 150
(3) 250
(4) 550
(5) 600
16.
17.
18.
19.
20.
2 1.
22.
A. No. 5 (Best, p. 369).
At forty thousand feet the volume per cent of oxygen is:
1)
2)
3) 20
4)
5)
A. No. 3 (Macintosh, p. 80).
A i
ir contains what per cent of CO2:
(1) : 003
(2) . 03
(3) . 3
(4) 1.0
(5) 3. O
A. No. 2 (Best, p. 369).
What is partial pressure of water vapor in the alveoli at sea level, 10000 feet
and 50 000 feet 2
A. (Barach, p. 28; Macintosh, p. 80).
It remains constant at 47 mm. mercury. A S one ascends to the 34000 foot level,
the relative increase in volume and tension of the combined vapor and carbon dioxide
(which are nearly constant) causes the flier to demand 100 per cent oxygen for an
oxygen tension corresponding to sea level. Above this level to 42000 feet, oxygen
must be taken under pressure for the aviator to remain efficient.
What principle in physics is involved that makes respiration more satisfactory
during an attack of bronchial asthma if a mixture of helium 80 per cent and oxygen
20 per cent is inhaled by the patient than if air is inhaled 2
A. (Barach, p. 122).
The fact that a density of 80% helium - 20% oxygen mixture is about 1/3 that of air,
is put to use in an effort to make breathing easier.
Why use Helium in an obstructed tracheobronchial tree ?
(1) Less readily absorbed
(2) Lighter and easier to move
(3) Non-explosive
A. No. 2 (A dr. Chem. p. 69).
Which is least quickly absorbed from the alveoli when the bronchus is occluded ?
(1) Helium
(2) Nitrogen
(3) Vine thene
(4) Ethylene
A. No. 1 (A dr. Chem. p. 67).
Helium takes 26 hours; nitrogen 16 hours; the rest of the anesthetic gases are
absorbed within a matter of hours at the most, and a telectasis may quickly occur.
Use diagrams to illustrate the general principles of a "circle type" and "to and fro
176
4:4
23.
24.
25.
26.
27.
type" carbon dioxide absorbing unit for anesthesia. Discuss briefly the following
factors: temperature, resistance and dead space for each appliance.
A. (Adr. Chem. p. 94; Adr. Pharm. p. 29; Adr Techs. p. 41-43).
Circle type: The inspired air is warmed but not excessively (3 l to 33 C ). There
is more resistance due to the tube surface, the large cannister, and the valves.
Only the space beneath the mask is dead space, if the valves function properly.
To and Fro Type: The inspired gases are warmed above body temperature, (from
37 to 42 degrees C). The resistance is low, - from 2.5 to 3. mm. water. The space
at the mask end of the cannister acts as dead space when the soda line is exhausted.
With a large cannister and low tidal volume, dead space increases.
(a) What is the chemical composition of "Soda Line" 2
(b) What chemical reactions take place when it comes in contact with exhaled air 2
(c) What is the source of water formed in the breathing bag when the "to and fro"
absorption method is being used ?
A. (Adr. Chem. p. 85). See question 88, p. 5:22.
(a) NaOH (5%)
CaOH 90%
Silicates of Sodium and Calcium for cohesion.
H2O 2–4% in low moisture type.
H2O 14 – 19% in high moisture type.
.
(b) 2 Coz + 2H2O — H2cos — 4H' (Hydrogen ion) + 2 cos
2 Na OH) — 4CH- (Hydroxyl ion) + 2 Na' + → Nazco, ca cos
Ca(OH) \
4H2O + 1300 Cal per grrn. molecule
(c) Water in the breathing bag is the result of the chemical reaction of CO2 + soda
line and the condensation of water vapor from the patients lungs.
\
Why is soda lime 4–8 mesh used ?
A. (A dr, Chem. p. 81).
4–8 mesh is used be cause it is the optimum for good absorption. The smaller the
size of the granule, the greater the surface for absorption. However, this must be
balanced with the resistance encountered with too finely granulated soda lime.
What is inter granular and intragranular space in a 8 x 13 cm. (500 gram) cannister.
A. 425 cc. (A dr. Chern. p. 92).
Why is high moisture soda lime used ?
A. (A dr. Chem. p. 81).
Weak acidic substances require moisture to be effectively absorbed by alkalis. Mois.
ture is also needed for the formation of carbonic acid from carbon dioxide. Conse -
quently, 14-20% moisture is added to soda lime to make it more efficient.
The average resistance in a circle type absorption machine is:
1 mm. H2O
8 mm. H2O
8 mm. Hg.
2 CIO . H2O
0 cro. H2O
4 : 5 177
28.
29.
30.
3 1.
A. No. 2 (A dr. Chem. p. 98)
In the total machine – 8mm of water; in the cannister itself about 2 – 3 mm. water
When is the optimum efficiency of soda lime expected ?
A. (Adr. Chem. p. 93).
The efficiency is best when the patient's tidal volume equals the inter granular and
intragramular space.
Discuss briefly the flammability of vapors and gases used in a nesthesia, and of
their combinations.
A. (A dr. Pharm. p. 131).
All gases used in anesthesia will either explode or support combustion. N2 O sup-
ports combustion although non-inflammable. Ether, cyclopropane, ethylene, ethyl chloride
are highly inflammable. Explosions usually occur from static sparks which may be
caused by the following:
) Brushing drapes
) Rubbing parts of the anesthetic machines
) Silk rubbing on silk or wool on wool.
) Sparking-type machines.
Suction
Coagulation & cutting currents
X-Ray machines
Fans
Defective wires or plugs
The prevention of explosions:
A void the above
Do not pour ether in the presence of No. 4 above.
Use an inter coupler with ether, cycle or ethylene.
l
2
3
4) High humidity in the operation room between 55-65%.
Give the range of explosability of the following agents when mixed with (a) air;
(b) oxygen;
A. (Cullen, p. 276).
Ethylene (a) 2. 75% - 28.6%
(b) 2.9% - 79.9%
Ethyl ether (a) 1.85% - 36.5%
(b) 2. 10% - 82 %
Divinyl oxide (a) 1.7% - 27 %
(b) 1.83% - 83.5%
Ethyl chloride (a) 4.7% - 14.8%
(b) not used with oxygen
Cyclopropane (a) 2.4% – l O. 3%
(b) 2.45% - 63. 1%
Which of the following mixtures has the widest explosive range 2
A. (A dr. Chern. p. 1 25; Cullen, p. 276).
1.5–85% at ordinary room temperature and atmospheric pressure is given by
178
4:6
32.
33.
34.
35.
36.
37.
38.
39.
40.
4 1.
Adriani for Ethylene. Cullen's widest range is for vine thene and oxygen.
1. 83 - 83.5%.
What is explosive range of oxygen ether mixture ?
A. 2. 10-82. 5% (A dr. Pharm. p. 32).
What is the resistance of the Horton intercoupler ?
A. 1 megohm or 1 million ohms. (A dr. Techs. p. 165).
Under which of the following conditions would electrical charges accumulate 2
Dry gas passing through dry metal tubes.
Moist gas passing through wet metal tubes.
Dry gas passing through dry rubber tubes.
Moist gas passing through wet rubber tubes.
:
A. No. 1 and No. 3 (Adr. Pharm. p. 131).
Covers should not be put over gas machine because:
(1) Dust accumulates under the cover.
(2) Sets up static charges when removed.
A. No. 2 (Adr. Techs. p. 164).
Why rinse the tubes with water before use with gases 2
A. (Cullen, p. 280).
With moisture, static charges do not develop; the dry gases are wetted.
What is the most difficult to eliminate of the fire hazards 2
A. Static charges. (Cullen, p. 278).
What is the pH of spinal fluid 2
A. 7.35 or approximately the same as blood. (A dr. Chern. p. 380).
The specific gravity of 1: 1500 nupercaine in 0.5% saline is:
(1) 1. 001
(2) 1. 003
(3) 0, 005
(4) 1, 007
(5) 1. 0.09
A. No. 2 (A dr. Chem. p. 382).
The specific gravity of 1% pontocaine in normal saline is:
(1) 1. 001
(2) 1. 003
(3) 1. 007
(4) 1. 0 1 0
(5) 1... O 14
A. No. 3 (Pitkin, p. 795).
What is the specific gravity of 2 1/2% procaine; 5-10% procaine.
4 : 7 179
42.
43.
44.
45.
46.
A (A dr. Chenn. p. 382).
2 1/2% procaine is is obaric l 005; 5 - 10% procaine is hyperbaric.
(a) Give the quantity in grams of a drug that would be needed to prepare one ounce
of 1% solution. (b) How many grains would be used to prepare 100 cc. 2 (c) Write
the practical metric equivalent for: (1) 5 grains (2) l / 150 gr (3) 10 minirºs (4)
99 degrees F (5) 6 inches.
A. (Adr. Pharm. p. 138).
(a) . 32 grams
(b) 15 grains (60 mg per grain and 15 grains per gram. )
(c) (1) 33.3 mg.
(2) .. 4 mg.
(3) . 66 cc s.
(4) 37, 2 C
(5) 15, 24 cm.
Give the metric equivalent of each of the following: (a) 5 grains (b) 1 ounce (c) 1
drachm (d) 1 gallon (e) l pound.
A. (Macintosh, p. 226).
(a) 3 grann - 300 mgms.
(b) 30 cc. – 30 grams
(c) 4 cc. - 4 grams
(d) 4 liters
(e) 1 lb = . 4.5 K ; K = 2.2 lbs.
How many milligrams of procaine are contained in 50 cc. of a 1.5% solution:
(1) 150 mg.
(2) 300 mg.
(3) 450 mg.
(4) 600 mg.
(5) 750 mg.
A. No. 5 (Macintosh, p. 226).
1.5% solution contains 1.5 grams per 100 cc. In 50 cc. 75 grams.
One gram of procaine in how many cc. of saline makes a 2.0% solution:
(1) 5
(2) 25
(3) 50
(4) 75
(5) 100
A. No. 3 (Macintosh, p. 206).
How many milligrams of pontocaine are contained in 2 cc. of a C. 5% solution:
(1) 10
(2) 15
(3) 20
(4) 30
(5) 40
A. No. 1 (Macintosh, p. 206).
5 gram or 500 mg per 100 cc.; in 1 C C – 5 mg; in 2 cc. 10 mg.
180
4 : 8
47.
48.
49.
50.
51.
Are the following statements true or false ?
(a) If the pressure does not change, the volume of a gas varies directly as the cen-
tigrade temperature.
(b) If the temperature does not change, the volume of a gas varies inversely as
the pressure exerted. .
(c) The upper limit of inflammability of cyclopropane when mixed with oxygen is 40%.
(d) Chloroform is inflammable.
(e) Chloroform can be safely used in the presence of an open flame.
A. (Best, p. 367; Macintosh, p. 108).
True – Charles' Law.
True – Henry's Law.
False (6.3% is upper limits)
False
True. Phosgene may be formed if the actual flame is applied.
Describe the mechanism and principle of a Drinker Respirator.
A. (Barach, p. 377).
The Drinker Respirator is an airtight steel chamber enclosing all of the patients
body except the head. An intermittent negative pressure is produced by the alter-
nate compression and relaxation of a large diaphragm. Atmospheric air is drawn
into the lungs during the phase of negative pressure. Inspiration is produced by
creating a negative pressure in the pleural space by creating a sub-atmospheric
tension about the thorax. Expiration is produced by elastic recoil of the lung
tissue, although it is possible to produce a positive pressure on expiration, if
desired.
(a) How do you check an aneroid blood pressure dial for accuracy 2
(b) Describe the construction and principle of action of one type of flow meter.
(c) List other types of flow meters.
A. (Macintosh, p. 142).
(a) It should first be as certained that the needle fluctuates properly and at rest falls
to zero. If this is satisfactory, the only real test of accuracy would be to check
with another instrument preferably a mercury sphygmomanometer.
(b) The dry flow meter depends upon suspension of a spherical or cylindrical float
in a transparent tube by the pressure of the flow of gases. The sides of the
guage are calibrated in liters or gallons per minute.
(c) Water depression wet flow meters - rotameteres – inclined plane meters.
CO2 accumulation is least during:
(1) Circle absorption
(2) To & Fro absorption
(3) Semi-closed
(4) Semi-open
(5) Open-drop
A. No. 5 (A dr. Techs. p. 62).
In the semi-closed system, if there is at least 10 liters of air blowing through,
the CO2 will be washed out.
Which of the following is not a disadvantage to endotracheal anesthesia.
(1) Operator must be skilled with a laryngoscope
(2) Deeper anesthesia is needed
(3) Endotracheal tube may be blocked
4:9 181
52.
53.
54.
55.
56.
57.
(4) Increase in dead space
(5) Tube decreases lumen of larynx
A. No. 4 (A dr. Techs. p. 114).
There is a de crease in dead space because of the elimination of the area in the mouth
and tra chea, particularly if connectors are used, attached directly to the machine.
A little more dead space is left if the mask is used over the open end of the endo-
tra cheal tube.
(a) What is Hygrometry 2 (b) What is a hydrometer 2 (c) What is a hygrometer ?
A. (A dr. Chenn. p. 33).
(a) Measurement of water vapor in gas.
(b) Measures the specific gravity of liquids.
(c) Measures humidity or water vapor pressure in gases.
What contributions have the following chemists made to a nesthesia 2
A. (Barach, p. 3; Keys, p. 33, 38, 4.2: Lundy, p. 675).
(a) Lavoisier – gave the name "oxygen" to that element.
(b) Serturner – is olated morphine from opiun, in 1805.
(c) Davy – discovered the anesthetic properties of nitrous oxide.
(d) Einhorn - discovered procaine.
(e) Waldie – suggested the use of chloroform to Simpson for obstetrics.
(f) Wils tatter - synthesized tribronnethanol in 1923 – used as an a nesthetic by
Duisberg.
Priestly first identified ?
(1) H2
(2) N2
(3) Ethyl chloride
(4) N2O
(5) Ethyl ether
A. No. 4 (Lundy, p. 707).
The name of Page is as sociated with:
(1) Caudal Anesthesia
(2) Spinal Anesthesia
(3) Blood Transfusion
(4) Plasma Transfusion
A. No. 1 (Lundy, p. 714).
"Physics for the Anesthetist" was written by:
(1) Macintosh & Mushin
(2) Macintosh & Bannister
(3) A driani
(4) Henders on
(5) Barach
A. No. 1 (Macintosh).
Howard Jones is identified with:
(1) 1: 1500 Nupercaine
(2) 1:2000 Nupercaine
182
58.
A . No.
(3) Procaine 1: 1000
(4) Intracaine 1:25
5) Stovaine 1:25
1 (A dr. Chem. p. 262).
C HE MISTRY
For each of the following, give the chemical formula and state whether the gas is
lighter or heavier than air.
A. (Adr. Pharm. – various pages).
Air has a molecular weight of 29. 23.
cular weight of any particular gas and compare it with that of air.
than 29. 23, the gas will be lighter than air; and vice versa.
HEC A VIER
H H
(a) Ethylene ! I
H - C - C - H
H H
(b) Cyclopropane ! ſ X
H – C ~TC – H
T-Sc.-H
H
(c) Carbon Dioxide O = C = O X
(d) Carbon Monoxide C = O
(e) Helium He
(f) Hydrogen H2
H H H
! ! H l
(g) Ether vapor H–C - C - O - C - C – H X
H H H H
(h) Oxygen O2 X
H H
! |
(i) Ethyl chloride vapor H - C - C – C 1 X
! l
H H
H H H H
(j) Divinyl oxide vapor | 1 I X
H – C = C - O - C = C – H
H
!
(k) Chloroform vapor C 1 - C – C 1 X
!
C 1
(1) Nitrous oxide N - O - N X
The refore it is easy to calculate the mole-
If it is less
LIGHTER
X
183
59. Name and give the chemical formula for a representative a nesthetic agent in each of
the following groups of drugs:
(a) Alcohols (d) Halogenated compounds
(b) Aldehydes (e) Ur eides
(c) Ethers (f) Sulphonated compounds
A. (A dr. Chem. p. 176, 145, 158, 177, 223, 26 1).
(a) Alcohols - Ethyl alcohol A mylene hydrate
H H CH3
| I |
H-g-g-OH CH3-g-C2H5
H H OH
(b) Aldehydes - Chloral hydrate
C 1 H
! t
C - C - OH
| f
C 1 OH
(c) Ethers - Ethyl ether
H H H H
! I ! t
H-º-º-o-º-º-H
H H H H
(d) Halogenated Compounds - Chloroform
C 1
ci-º-H
C 1
(e) Ureides - Pentothal sodium
Na O
(f) Sulphonate Compounds - Sulphonal

CH3 O2C2H5
CH3 SO2C2 H5
184 4 : 12
60.
6 1.
62.
For each of the following, give the chemical formula and molecular weight.
(a) Cyclopropane (b) Divinyl ether (c) Chloroform (d) Tribromethanol.
A. (A dr. Pharm).
H2
C
(a) Cyclopropane º Mo1. Weight 42.08
(b) Divinyl ether (Vine thene) Mol. Weight 70. 0
H H H. H.
º ! | I
H- C - C - O - C = CH
(c) Chloroform Mol. Weight 1 19.5
C C 13H
(d) Tribromethanol Mol. Weight 282. 7
B r H
; l
E r - C - C – CH
| l
Br H
r)
What is a hydrocarbon 2 an alcohol 2 an ether ? a halogen 2 a base ? an a cid 2
Give an example of each (Name and Formula).
A. (A dr. Chem. p. 495).
Hydrocarbon is a compound containing H and C - (Methane - CH4).
Alcohol is a compound in which one or more H are replaced by an OH in a
hydrocarbon - (methyl alcohol CH3OH).
Ethers are organic oxides derived from alcohol . (diethyl ether - (C2H5)2O).
Halogens are compounds containing bromide or chlorine - (chloroform - CHC 13).
A cids are compounds which have carboxyl (COOH) replacing an H in a hydrocarbon –
(acetic acid - CH3COOH).
Outline a method for the quantitive deter mination of each gas in an anesthetic
atmosphere containing nitrogen, oxygen, carbon dioxide and Cyclopropane.
A. (Best, p. 370-371; A dr. Chern. p. 37).
For such a determination, one must know the ternperature, volume, and the pres–
sure of the gas or mixture. There are two chief methods of accomplishing such a
determination: – by physical methods and by chemical methods. The latter is much
more complicated.
PHYSICAL: More complex. Principles involved are conduction of electricity, heat
and sound.
CHE MIC A. L. : These break down into three methods:
1. Changes in volume with the termperature and pressure constant. This is
a widely employed inethod.
2. Changes in pressure with the temperature and volume constant.
4 : 13 185
3. By the end products formed by a gas with a reagent at a known volume a no.
with the temperature and volume constant.
a. volumetrically
b. gravimetrically
c. color inne trically
(1) Volume principle :
Or sat method: uses a precision instrument. Hg. is the best displacing fluic as
it does not react in any way with the gases.
Sannple of the gas is placed in the 100 cc. burette at room temperature and at
atmospheric pressure. When absorption is complete, the remaining unabsorbe &
gas is redrawn into the burette and measured after adjustment to atmospheric
pressure and equalization of the fluid levels in the bulb and the buretto .
Several pipettes may be used so several gases may be analyzed in succession
from a single specimen of a nixture of gases.
Haldane method: similar to Cr sat; - can be used with small samples of gas, -
TO co Tand is accurate to . 0.1%.
Van Slyke method: the usual type used in hospita is for determination of the
combining power of carbon dioxide. It is volume tric.
(2) Changes in pressure - nanometric.
The changes in pressure are produced by the chemical absorption of gases at
a fixed temperature and fixe (; volume.
Van Slyke - Neill; this manometric apparatus differs fron, the volumetric
method of Van Slyke in that greater accuracy is allowed. The sample may be
as small as . 1 cc and is accurate to . 0 1 to 1. Wo. It measures both:
a . gases in liquids )
b. mixed sample of gases)
Quantitatively
The apparatus is essentially a manorneter, a leveling bulb, and a burette. A
table of constant values for certain gases at given temperatures by quick pres–
sure changes in mm. of Hg may be multiplied to determine the volume of the gas
in a given volume of fluid without tedious calculations.
Blood may be analyzed for total carbon dioxide; oxygen, nitrogen, cyclopro-
pane, ethylene and nitrous oxide are deter mined as residual gases since they
are not absorbed by any particular reagent. Ether in blood is not satisfactorily
analyzed by this technique as ether has a high vapor pressure and dissolves in
the reagents.
End Products Methods:
(
3
)
This is a widely employed technique. Each technique with this principle is
individualized for the particular gas.
Carbon dioxide is passed into alkali e s and precipitated as carbonates and then
determined gravimetrically.
For hydrocarbons - ethylene, cyclopropane, and the others – di ethyl and di-
vinyl - by the iodine pentoxide train: A measured sample containing the gas
or vapor of a drug at a known temperature and pressure is passed through a
tube 2.5 cm in diameter and 25 cms. in length filled with as bestos impregnated
with iodine pentoxide heated to 200 to 300 degree S centigrade. Organic substances
are oxidized to carbon dioxide and water and liberate free iodine, hydrogen
iodide, or both. The iodine and hydrogen iodine are Collected in potassium
186 4 : 14
63.
64.
65.
66.
67.
iodido solution and are determined quantitatively with standard sodium bisul-
phate or thiosulphate solutions.
Other gases important in anesthesia are measured by conversion to nonvol-
a tile substances. Carbon monoxide reacts with hemoglobin to form carbon-
monoxide hemoglobin which is bright red and is estimated in a color meter.
Nitrous oxide may be determined colorimetrically in a similar manner by
use of the diazo reaction.
In the analysis of cyclopropane one of the following is used:
Pyrogallic acid
Copper ammonium solution
Sodium hydrogen sulphite
KI
Sulphuric acid
i
A
No. 4 (A dr. Chenn. p. 43)
One of the following is not used in oxygen analysis:
) Pyrogallic acid
) Copper armmonium solution
) Sodium hydrogen sulphite
) KI
A. No. 4 (A dr. Chenn. p. 43).
One of the following is used for carbon dioxide analysis:
(1) Copper ammonium solution
(2) Pyrogallic acid
(3) Sodium hydrogen sulphite
(4) KOH
(5) H2SO4
A. No. 4 (A dr. Chem. p. 67).
Describe a simple method for determining the oxygen and carbon dioxide concentra-
tion in any oxygen therapy tent. What reagents are needed ?
A. (Lundy, p. 729).
Boothby Method: A known amount of air (10 cc) is taken from the tent. The sample
is passed back and forth in a tube containing potash which absorbs the CO2 and a
reading is made. The burette is calibrated in per centage of original volume, so
no calculation is required. After the CO2 is absorbed, the oxygen is absorbed in
a tube containing copper wire and a solution of a mmonium chloride, water, and
ammonia. The final reading on the burette after a portion of both gases and a
return of the fluid in both absorption tubes to the original levels marked on the
tubes or board is the contraction in volume of the sample, due to absorption of both
gases, and the percentage of oxygen in the tent air will be the reading on the burette
minus the reading obtained for CO2. By having the lower end of the burette smaller
than the upper part the CO2 per cent can be determined to within one-half percent
and the oxygen to within 1.96.
Reagents needed: Potash for the carbon dioxide. For the Oxygen: Ammonium
chloride, water, and ammonia, and copper wire.
What is an ether ? Name three that have been used in clinical a nesthesia. How do
they differ chemically 2
A. (A dr. Pharm. p. 5).
4 : 15 187
68.
69.
70.
Ethers are organic oxides derived from alcohols. R-O-R
Di-ethyl ether C2 H5O C2H5
Di- methyl ether CH3-O-CH3
Di-Vinyl ether C2H4-O-C2H4 (vine thene)
Di- methyl ether might be used more if it were not so difficult to obtain.
Discuss the deterioration of ether; the process, predisposing factors, and pre-
vention.
A. (A dr. Chem. p. 163; Bourne; Lundy, p. 306).
Ether is prepared commercially:
Below 130 C.
H2SO4
C2H5SO4 + C2H5OH —x H2SO4 + C2H5 - O2- C2H5
(Above 130 C. ethylene is formed).
Even under ideal conditions, ethylene and some degradation and oxidative products
are formed. By-products also include sulphur dioxide and trioxide, sulphur acids,
mercaptains and thioethers. Sulphuric acid acts as an oxidizing agent and may form
aldehydes and acids. Esters of sulphuric acid may also be present.
The purity of ether is of concern to the anesthetist. However, with present day
manufacturing methods, the above mentioned products rarely occur.
Bourne, experimenting with old and supposedly impure ethers, concluded that any
degre dation products, totaling less than 1% caused little or no effects on the respira–
tion, blood pressure and recovery of the patients. -
Lundy states that ether is cheapest in drums and that containers have little to do
with the production of impurities.
Knight has arranged an apparatus for dispensing ether from drums. This apparatus
was suggested by Dr. Hirchfelder of the Department of Pharmacology, University
of Minnesota.
The prevention of deterioration of ether in large or small drums or cans should
include:
1. Storage in copper-lined cans. Glass containers should not be used because
light and air has ten the formation of aldehydes and per oxides.
2. The tests for purity are so simple that the ether purity should be checked,
particularly near the end of a large drum. Tests include:
a. Neutrality to litmus.
b. Aldehydes
c. Per oxides.
Why does moisture form on the outside of an ether vaporizing jar 2
A. (A dr. Chenn. p. 30).
Chilled by the loss of heat by ether vaporization, moisture of the air precipitates.
(80 cal/cc . )
What is the approximate boiling point of ethyl ether ?
A. 36.5 degrees C. (A dr. Pharm. P. 32).
188
4:16
71.
72.
73.
74.
75.
76.
77.
An example of an unsaturated ether is :
(1) Diethyl ether
(2) Metopryl
(3) Propethylene
(4) Cypronne
(5) Cypreth
A No. 3 (A dr. Chern. p. 174).
Cyprome is cyclopropyl methyl ether; cypreth is cyclopropyl ethyl ether; metopryl
is methyl normal propyl ether; diethyl ether is saturated. Another clue is that the
ethylene radical in propethylene has a double bond.
What is the partial pressure of 5% ether in air 2
(760 x 5)
100 (Ref No. 15 - p. 66).
A. 38 mm . of mercury.
What impurities are most likely to be found in nitrous oxide 2 If nitric oxide is
an impurity how may it complicate anesthesia 2
A. (A dr. Pharm. p. 21).
Nitrogen, oxygen, carbon dioxide, nitric oxide. Nitric oxide combines with hemo-
globin and produces asphyxia. It also forms nitric acid in the tissues, producing
pulmonary edema.
The great hazard in nitrous oxide is:
(1) S with a valence of 4
(2) C with a valence of 2
(3) N with a valence of 2
(4) C with a valence of 4
(5) N with a valence of 5
A. No. 3 (Adr. Pharm. p. 21).
Dehydration of alcohol by sulphuric acid above 140 C. yields:
(1) Chloroform
(2) Vine thene
(3) Ethylene
(4) Ethyl Chloride
(5) Cyclopropane
A. No. 3 (A dr. Pharm. p. 24).
The most important impurity in Ethylene is:
Phosgene
Phosphoric acid
Carbon monoxide
Ethylene glycol
A cetylene
:
A. No. 3 (Adr. Pharm. p. 24).
State dangers in the use of chloroform in the presence of (a) an open flame
(b) eclampsia.
y
A. (A dr. Chem. p. 184; A dr. Pharm. p. 40).
(a) COC 12 - Phosgene is formed.
4 : 1 7 189
78.
79.
80 .
8 1.
82.
83.
(b) Liver damage already present - central necrosis and a Cute yellow a trophy may
occur; direct action on heart already laboring may cause difficulty; increases
intracranial pressure; depresses renal functions already depressed.
Which one of the following requires the lowest concentration in the inspired a trºos –
phere to obtain 2nd plane anesthesia:
(1) Chloroform
(2) Ethyl chloride
(3) Ether
(4) Vinyl ether
(5) Cyclopropane
A. No. 1 (A dr. Pharm. p. 40).
Chloroform is used more frequently than ether in tropical countries because :
Chloroform has a higher molecular concentration
Chloroform has a higher boiling point
Chloroform has a greater de n sity
Chloroform is more potent
l
2
3
4
A No. 2 (Goodman, p. 4 1 3 - 4 14).
What is the chemical formula of trib r one thanol 2 What is the no aximun, solubility
of tribromethanol in water 2 In a mylene hydrºte ' What is ''', vertin'" .
A. (A dr. Pharm. p. 57).
Chemical for rnula of tribrome thanol: F3 R Fº, r H
f | |
= C + H2 — Fºr C - C - CH
º
E R - C –
f
B r FS r H
Maximum solubility in H2O - 3. 7 grin, per 100 cc. at 370 C. Maximurn solubility
in annylene hydrate – 1 g m + 0. 5 C C — , C C avertin fluid. A vertin is tribrorne -
thanol with amylene hydrate.
What is annylene hydrate 2 Describe its physical properties and probable fate in the
body.
A. (Goodman, p. 100; A dr. Pharm. p. 57).
It is an inflammable, volatile tertiary annyl alcohol, being a colorless fluid, soluble
in 8 parts of water and readily soluble in glycerin. It is fairly non-toxic and is a
hypnotic, between chloral hydrate and paraldehyde in potency.
Fate: eliminated unchanged through the lungs and kidneys.
Why are drugs of the barbituric acid family commonly administered in the form of
their sodiurn salts 2
A. (Adr. Chem. p. 232).
To insure greater solubility for intravenous administration, the more soluble sodium
salts are used.
Which of the barbiturates is excreted most rapidly:
) anytal
) trianal
) barbital
)
(l
(2
(3
(4) phenobarbital
190
84.
85.
86.
87.
88.
A. No. 1 (A dr. Chenn. p. 240).
Procaine breaks down in the body to:
Diethylaminoethanol and para-aminobenzoic acid
Dimethylamine-propanol and para-aminobenzoic acid
Benzoic acid and ec gonine
Para-amino-benzoic acid and diethylamine - propanol
Benzoic acid and diethylaminoethanol.
(
(
(
(
(
i
A. No. 1 (A dr. Chem. p. 263).
The great portion is broken down in the liver. A cetylation of the aminobenzoic
acid may take place during this breakdown.
Which one of the following is not a para anino benzoic acid derivative:
(1) Procaine
(2) Bute sin
(3) Mety caine
(4) Monocaine
(5) Tutocaine
A No. 3 (A dr. Pharm. p. 82). An ester of methyl pipe ridinopropanol.
In which one of the following three ways does nitrous oxide act 2
(a) 1. As an oxidizing agent (supporting connbustion).
2. A s a reducing agent (furnishing fuel for combustion).
3. Inert in the presence of a flame (the reby smothering combustion).
(b) Ditto cyclopropane.
(c) Ditto helium.
(d) Ditto carbon dioxide.
A . (A dr. Pharm. p. 21, 27, 1 17, 115).
a) As an oxidizing agent
b) As a reducing agent
c) Inert in the presence of flame
d) As a quenching agent
What are some of the dangerous impurities or de generation products (if any) which
might be found in cyclopropane, chloroform, paraldehyde, ethylene, ethyl chloride 2
What might be their effects if administered to a patient:
A. (A dr. Pharm. p. 27, 40, 55, 24, 46).
Cyclopropane forms organic halides, cyclohexane, in organic gases such as nitrogen, car -
bon dioxide and oxygen. All of the se are e s sentially harmless. In addition Propylene
may be for med. This is a potent narcotic, explosive and toxic to the cardiovascular
system.
Chloroform forms ketones, ethyl alcohol, esters and for mates and phos gene. Phos-
gene is very irritating but its formation is prevented by preservatives.
Paraldehyde forms alcohols, organic acids and acetic aldehyde.
Ethylene forms methane, propane, acetylene, H2S, CO2, N2 and CO. The latter
causes me the moglobin.
Ethyl chloride forms acetic acid, ethyl alcohol, HCL and aldehydes.
Which of the following solutions may be sterilized (1) by boiling; (2) by autoclaving.
4 : 19 191
89.
90.
91.
A
.
.
)
procaine f) tribronnethanol
(
cocaine (g) paralda hyde
ephe drine (h) alcohol
epinephrine (i) butyn
pentothal (j) atropine
(Gisvold).
either - better by autoclave; if boiled, for 3 minutes only.
cannot be sterilized; de composes rapidly with heat.
both methods.
cannot be sterilized by either.
sodium salt cannot be sterilized without de gradation.
de composes rapidly above 70 degrees C.
both methods.
both methods.
both methods.
(and scopolamine) neither method. There is loss of effect and possible degrada –
tion with sterilization.
What effect on narcotic potency occurs when halogens are added to a narcotic drug 2
What effect on narcotic potency occurs when more hydroxyl radicals are added to
hydrocarbons 2
A .
(A dr. Chem. p. 138, 180). Halogens enhance narcotic action. Hydroxyls de –
crease narcotic action.
Alkaloids are:
i
Easily soluble in cold water
Easily soluble in hot water
Soluble in normal saline
Soluble in ether
Soluble only as salts
No. 4 (Goodman, p. 16). The alkaloid is soluble in organic solvents and the
salt of the alkaloid is soluble in water.
gas content of a distended small bowel is primarily:
O2
N2
A ir
Indole
H2O
No. 2 (Best, p. 590; A dr. Chem. p. 62). The odor of the feces is due to indole
and skatole.
192
4 : 20
SUPPLE MENT I SUB-SECTION
PHYSICS AND CHE MISTRY
Which gas can be placed on the flow meter calibrated for carbon dioxide so that
approximate volumes will be obtained 2
(1) Cyclopropane
(2) Hydrogen
(3) Helium
(4) Nitrogen
(5) Chlorine
A. No. 1 (A dr. Chem. p. 24).
Meters must be calibrated for particular gases or gases with the same or nearly
the same molecular weight. (Cyclopropane -42. CC2-44).
13 cm. of water pressure equals:
O. 3 mm Hg pressure.
O. 9 mm. Hg pressure.
13.0 mm. Hg pressure.
l
2
.
cm. Hg pressure.
|
2
3
4 O
5 6 cm. Hg pressure.
A. No. 4 (A dr. Chem. p. 506).
1 cm. water equals 73 mm. mercury. 1 mm. mercury equals 1.3 cm. Water.
At sea level the partial pressure of water vapor in the alveoli of a normal subject is:
(1) 5 mm
(2) 20 mm
(3) 23 mm
(4) 47 nrn
(5) 156 mm
A. No. 4 (Barach, p. 26).
At a barometric pressure of 380 mm. the partial pressure of water vapor in the
alveoli of a normal subject is :
(1) 5 mrn.
(2) 20 mm.
(3) 23 mm.
(4) 47 nrn.
(5) 156 mm.
A. No. 4 (Barach, p. 26).
Water vapor pressure remains constant at all altitudes. As as cent is made to high
altitudes, water vapor and carbon dioxide occupy more and hore of the lung volume,
leaving less and 1ess for oxygen.
What is the approximate combined partial pressures of nitrogen and oxygen in the
alveoli of an individual breathing room air at sea level ?
(l) 380 mm. Hg
(2) 420 mm. Hg
(3) 540 mm. Hg
4:21 193
(4) 6.70 mm. Hg
(5) 760 mm. Hg
A. No. 4 (Best, p. 369; Macintosh, p. 80).
A queous vapor equals 47 mm. Hg, and carbon dioxide 40 mm. mercury; the rest
is the total of oxygen and nitrogen.
The reas on for the formation of frost or dew on the reducing valve of a nitrous
Oxide tank is that:
(1) the mechanism of the regulator needs repair.
(2) heat is necessary to vaporize a liquid and to expand a gas.
(3) the connecting tube from the valve is a good insulator and a poor heat conductor.
(4) the nitrous oxide in the tank has a low specific heat.
(5) the gas is compressed at a low temperature.
A. No. 2 (Macintosh, p. 27).
When the nitrous oxide liquid expands to vapor, heat is absorbed. For this reas on,
nitrous oxide must have almost all its water vapor removed before sealing in a tank
or it may freeze in the connections.
In determining rate of flow through an orifice which of the following properties of a
gas is most significant 2
(1) Density
(2) Viscosity
(3) Critical temperature
(4) Conductivity
(5) Radioactivity
A. No. 1 (A dr. Chem. , p. 24; Macintosh, p. 120, 138).
The flow rate of gases through an orifice depends on density rather than viscosity.
The less dense gases such as helium flow nuch more quickly. This effect is used
in partial laryngeal obstruction. However, the flow of gases through a length of
tube depends on its viscosity, Thus helium and oxygen have similar viscosities.
The average volume of air space in a charged to and fro (For egger) cannister,
8 x 13 cms. in diameter, is:
(1) 125 cc.
(2) 400 cc.
(3) 500 cc.
(4) 700 cc.
(5) 1000 cc.
A. No. 2 (A dr. Chenn., p. 92).
The tube 30" long on the expiratory side of a circle filter, if the valves are perfect,
represents:
no dead space.
entirely dead space.
dead space up to the valve.
dead space halfway to the valve.
l
2
3
4
5) dead Space through the valve up to the soda lime.
A. No. 1 (A dr. Chenn., p. 100).
Dead space is defined as that area which contains gases which are inhaled, not
194
4:22
10.
1 1 .
12.
13.
14.
15.
having been freed of carbon dioxide by the absorbent. The dead space in a circle
filter where the valves are working properly is confined to the mask.
The dead space in the currently used gas machine mask, for an adult, is approximately:
(1) 10 cc.
(2) 30 cc.
(3) 100 cc.
(4) 500 cc.
(5) 1000 cc.
A. No. 3 (A dr. Chem. , p. 101).
The most dangerous likely contaminant of nitrous oxide is:
(1) nitrogen
(2) Nitrogen hydroxide
(3) nitric oxide
(4) hydrogen chloride
(5) propylene
A. No. 3 (A dr. Pharm p. 21).
Diffusion from the lung to the blood stream is slowest for :
(1) nitrogen
(2) nitrous oxide
(3) helium
(4) carbon dioxide
(5) air
A. No. 3 (A dr. Chem. , p. 69).
This factor is used to prevent postoperative a telectasis. The patient's lungs are
inflated with helium at the end of an operation. Helium remains in the lungs
during the difficult postoperative period when the patient may be unable to rid him –
self of bronchial secretions.
Nitrogen is carried in the blood:
in simple solution
in combination with hemoglobin
in combination with some metal as a salt
in loose combination with the proteins
combined with oxygen in blood to form some nitrous oxide
:
A
No. 1 (Best, p. 369).
The rate of diffusion of one gas compared to another is:
(1) directly proportional to the pressures of each gas.
(2) inversely proportional to their molecular sizes.
(3) inversely proportional to the square roots of their atomic weights.
(4) inversely proportional to the square roots of their molecular weights.
(5) inversely proportional to the square of their molecular weights.
A. No. 4 (A dr. Chem. , p. 46).
Helium is used for inhalation therapy because:
(1) it is inert and soothes the mucous membranes.
(2) it is light and reduces the effort of respiration.
(3) it has a low co-efficient of viscosity.
4 :23 195
16.
18.
19.
20.
(4) it is in soluble in tissue fluids.
(5) it is soluble in lipoids.
A. No. 2 (A dr. Chem. , p. 69).
Which is the heaviest of these gases or vapors 2
(1) Ether
(2) Cyclopropane
(3) Chloroform
(4) Nitrous oxide
(5) Ethylene
A. No. 3 (A dr. Chem. , p. 505).
Chloroform has a molecular weight of 1 18 as Compared with ether, 74.
Which of the following gaseous mixtures would deliver oxygen to the alveoli of an
asthmatic patient with a minimum expenditure of energy on the part of the patient 2
(1)
(2) Oxygen 30% - Helium 70%
(3) Oxygen 50% - Nitrogen 50%
(4) Oxygen 60% - Nitrogen 40%
(5) Oxygen 30% - Nitrogen 70%
A. No. 2 (A dr. Chem . , p. 69).
The process of equalization of a molecular concentration of a gas is known as:
(1) dispersion.
(2) diffusion.
(3) osmosis.
(4) doppler effect
(5) Arthus phenomenon.
A. No. 2 (A dr. Chem. , p. 36; Whitehead).
The mixing of gases through the phenomenon of diffusion is essential to passage of
gases through the alveoli and into the tissues. It has particular interest in the
light of articles by the Denver group on diffusion respiration. They state the
conditions for such respiration to be (a) replacement of nitrogen within the respira–
tory tract and in the atmosphere at the glottis by oxygen (b) an adequate circulation
(c) a patent airway. They advance the theory that oxygen is sucked into the blood
stream and oxygen replaced in the alveoli by the "hemoglobin - oxygen pump''. The
difficulty has been the increase in carbon dioxide in the alveolae and blood stream,
resulting in a decrease in the available oxygen tension.
In the fractional distillation of liquid air:
nitrogen boils off first.
oxygen boils off first.
both oxygen and nitrogen boil off at the same time.
the nitrogen boils off causing the oxygen to solidify and remain behind
1
2
3
4
5) the oxygen boils off causing the nitrogen to solidify and remain behind.
A. No. 1 (A dr. Chem. , p 55).
After adding 4 cc. of 1% pontocaine to 6 cc. of 10% dextrose, the concentration of
pontocaine is:
196
4:24
2 1.
22.
23.
24.
25.
(4) 0.2%
(5) O. 04%
A. No. 3 (A dr. Pharm , p. 138).
1% equals 10 mg. per cc. ; 4 cc contains 40 mg; the 10 cc. of this solution the re-
fore contains 40 mg. or . 04 grams; . 04 grams in 10 cc. equals . 4 grams in 100 cc.
In a mixture of 4 cc. of 1% pontocaine and 6cc. of 10% dextrose, the concentration
of dextrose is :
(l) 0.06%
(2) 0.4%
(3) O. 6%
(4) 4.0%
(5) 6.0%
A No. 5 (A dr. Pharm. , p. 138).
10% equals 100 mg. per cc.; 6 cc. equals 600 mg; the 10 cc. contains 600 mg or
6 grams; 6 grams in 10 cc. equals 6 grams in 100 cc.
A 10% solution contains:
(1) 10 mg. per CC.
(2) 20 mg. per cc.
(3) 60 mg. per C C.
(4) 80 mg. per C C.
(5) 100 mg. per C C.
A. No. 5 (A dr. Pharm. , p. 138).
How many milligrams of nupercaine are there in 9 cc. of 1: 1500 nupercaine
solution:
A. No. 3 (A dr. Pharm , p. 138).
1 grams in 1500 cc. equals . 66 grams in 1000 cc. or 66 mg. in 100 cc. or .66 mg.
in 1 cc ; 9 cc. contains 9 times . 66 or 6 mg.
A 2 cc. anpule contains procaine 1% and ephe drine 5%. Give total amount of
ephe drine in anpule.
(l) 300 mgm.
(2) 120 mgm.
(3) 100 mgm.
(4) 3 grrl.
(5) 6 gm.
A. No. 3 (A dr. Pharm. , p. 138).
5% ephe drine equals 5 grams per 100 cc. or . 05 grans in 1 cc ; 2 cc equals . 05
times 2 or . 1 grams, or 100 mg.
100 cc. of 1% procaine (w/v) in physiological saline contains how much procaine:
(1) 1 mgm.
4:25 197
26.
27.
28.
29.
(2) 10 mgm.
(3) 100 mgm.
(4) l gram.
(5) 10 grams.
A. No. 4 (A dr. Pharm. , p. 138).
1% procaine equals l gram per 100 cc.
Which one of the following solutions used in spinal anesthesia is not closely is obaric 2
(1) 1: 100 pontocaine in saline
(2) 1:200 nuper caine in water
(3) 1: 1500 nupercaine in 0.5% saline
(4) 1:1000 pontocaine in spinal fluid
(5) 5% procaine in water
A. No. 3 (A dr. Chem. , p. 262; Lundy, p. 230).
1 – 1500 nupercaine in 5% saline has a specific gravity of 1.0025. 1% pontocaine
in saline is practically isotonic; pontocaine in spinal fluid is almost isotonic. 5%
procaine in water has a specific gravity of 1.006 which is slightly hyperbaric for
some patients but within the limits of 1.008, which is usually given as the upper
limit of spinal fluid specific gravity; 1 - 200 nupercaine in water is almost is obaric
and is therefore usually mixed with glucose when used.
The optimal pH of procaine hydrochloride is:
:
i
. 1
A. No. 3 (Adr. Chem. , p. 263; Pitkin, p. 284).
The usual pH of procaine is 6, as given in Adriani's Chemistry and Pitkin's Con-
duction A nesthesia. Because the anesthetic effect of local anesthetic agents depends
on the concentration of the free base, it would seem theoretically logical to combine
procaine with a weak acid, such as boric acid, for optimal effects (Procaine Borate
pH 8.0). This does not work out practically because of the rapid buffering in tissues.
The reas on for using soda lime of "high moisture" content is that it:
allows clumping of granules of soda lime.
provides greater activity.
increases the neutralization reaction.
facilitates reaction in drier atmosphere s.
l
2
3
4
5) makes the soda lime less dusty.
A. No. 3 (A dr. Chem. , p. 81).
This is a poor question because answers 2, 3, or 4 are correct. However, answer
4 is meant for filters as used on gas masks, which filter atmospheric air. In
answer 2, the shade of meaning must be that the activity is the same once the patient
rebreathes and provides the moisture.
Heat produced when carbon dioxide is passed through soda lime is due to:
(1) formation of Calcium carbonate.
(2) friction of carbon dioxide molecules and soda line.
(3) union of hydroxyl and hydrogen ions to form water.
(4) formation of Carbonic acid.
(5) union of carbonic acid and silica.
198
4:26
30.
3 1.
32.
33.
34.
35.
A No. 1 (A dr. Chem. , p. 94).
This is another poor question because heat arises from both the heat of neutraliza-
tion and the heat of solution, although the heat of solution is supposed to be minimal
in present day absorbents. Therefore, answer 1 seems most appropriate.
Soda line contains:
(1) sodium hydroxide 5% or less.
(2) sodium hydroxide 50%.
(3) sodium hydroxide 20%.
(4) sodium per oxide 5%.
(5) sodium oxide 5%.
A. No. 1 (A dr. Chem. , p. 80).
The total percentage increase of oxygen above normal carried in the arterial blood
of a normal individual by breathing pure oxygen is:
(1) 0.2–0. 5%
(2) 0.7–1. 0%
(3) 4-6%
(4) 10-15%
(5) 20-30%
A. No. 4 (Comroe, p. 8).
Normal blood is 94-95% saturated breathing atmospheric air. Therefore, 4-6%
could be added to the total blood by breathing pure oxygen. This figure is further
increased by small amount of oxygen added in simple solution.
What percentage of carbon dioxide in blood is lost as it passes through the lungs 2
(1) l per cent
(2) 5 per cent
(3) 10 per cent
(4) 15 per cent
(5) 20 per cent
A. No. 3 (Best, p. 401).
Nuper caine is:
a quinoline derivative.
a cinnamic acid ester.
an ester of methyl piperidino propanol.
an ester of beta diethylamino ethanol.
(1)
(2)
(3) a carbarmic acid ester.
(4)
(5)
A. No. 1 (Adr. Pharm., p. 83)
Which one of the following is an inorganic chemical compound 2
(1) Vinethene
(2) Nitrous oxide
(3) Pentothal
(4) Metopryl
(5) Ethylene
A. No. 2 (A dr. Pharm., p. 21).
The alcohol which is present in diethyl ether:
4:27 199
36.
37.
38.
39.
40.
4 l.
is added to preserve it.
is a contaminant from manufacture.
forms when (diethyl oxide) ether stands for a while.
forms when the aldehydes which form when ether stands.
is added to de crease it volatility.
t
:
A. No. 2 (A dr. Chern. , p. 166).
Gram molecular weight is the .
(1) weight of a gram of molecules.
(2) atomic weight of an element X 2.
(3) molecular weight of a substance expressed in grams.
(4) valence of an element multiplied by its atomic weight.
(5) weight of 22.5 liters of a substance in its vapor state.
A. No. 3 (A dr. Pharm. , p. 134).
The molecular weight of helium is:
l
2
3
4
5
:
->ºe
6.
4
A. No. 3 (A dr. Chem. , p. 69).
This is a monatomic element with both a to mic and molecular weight the same.
The molecular weight of ethyl ether is approximately:
55.
65.
75.
85.
l
2
3
4
5) 95.
A. No. 3 (A dr. Chem. , p. 505).
1 / 12 gr. of morphine sulfate equals approximately:
(1) gm. 0.0005
(2) gro. 0.005
(3) gm. 0.05
(4) gn. 0.5
(5) gm. 5.0
A. No. 2 (A dr. Chem. , p. 506).
F-
1 grain equals 60 mg. 1/12th part is 5 mg.
A hygrometer is an instrument for measuring:
specific gravity of gas.
dew point.
boiling point.
freezing point of highly volatile liquid.
electrical instrument for measuring oxygen in tents.
l
2
3
4
5
A. No. 2 (A dr. Chem. , p. 34).
One kilogram equals:
200
4:28
42.
43.
44.
45.
46.
(1) . 4.5 lbs.
(2) 2. 2 lbs.
(3) 500 grams.
(4) 39 oz.
(5) the weight of 1 liter of water at 20 degrees C.
A. No. 2 (Macintosh, p. 226).
In a hot, humid climate, which of these procedures would most simply and
efficiently make it possible to conduct open drop ether anesthesia 2
(1) Cover the mask with extra layers of gauze.
(2) Build a chimney of towels around the mask.
(3) Connect a motor blower to an ether bottle, and vaporize ether under the mask
from the very beginning.
(4) Mix alcohol with the ether.
(5) Change to a fresh mask whenever water accumulates on the gauze.
A. No. 4 (A dr. Chern. , p. 162).
The volatility of ether is decreased in the tropics by adding alcohol to it. One of
the advantages of chloroform in tropical climates is its low volatility. Covering the
mask or adding towels only reduces the amount of oxygen rather than de creasing
the volatility. A motor blower would only increase the volatility. Changing the
mask would merely decrease the concentration of ether inhaled during the period
of Changing.
Which one of the following has the highest boiling point 2
(1) Chloroform
(2) Ethyl chloride
(3) Trichlorethylene
(4) Diethyl ether
(5) Divinyl ether
A. No. 3 (Macintosh, p. 68).
Ether boils at:
(1) 0 degrees C.
(2) 25 degrees C.
(3) 35 degrees C.
(4) 55 degrees C.
(5) 100 degrees C.
A. No. 3 (A dr. Chern. , p. 162).
Absolute zero is :
(1) -273 degrees F.
(2) - 273 degrees C.
(3) 0 degrees C.
(4) 0 degrees F.
(5)
32 degrees F.
A. No. 2 (A dr. Pharm. , p. 133).
Critical temperature is defined as:
temperature to store gas without deterioration.
temperature to which a gas must be cooled to be liquified by pressure.
temperature at which freezing takes place.
temperature necessary to maintain oxygen tent.
temperature to maintain air conditioning in hot weather.
:
4:29 201
4 7.
48.
49.
50.
5 1 .
52.
A. No. 2 (Macintosh, p. 89).
The oil water ratio is determined by:
(1) dividing the solubility of a drug in oil, by its solubility in water.
(2) overlaying water with oil, adding the anesthetic drug and measuring the amount
in each layer.
(3) determining the solubility in each substance as standard conditions and dividing
that of water into that of oil.
(4) measuring the partial pressure of the drug in each solvent and dissolving the
water tension value into the oil tension value.
(5) comparing the solubility in oil with that of normal saline at 37 degrees C.
A. No. 2 (A dr. Chenn., p. 316).
The ratio of solubility in moles per given quantity of lipoids to that in an equal volume
of water is the oil/water ratio. The wording in this question is difficult to interpret.
Designate the tertiary alcohol which is useful in a nesthesiology.
(1) Trichlorethanol
(2) Trional
(3) A mylene hydrate
(4) Chloral hydrate
(5) d – A midone
A. No. 3 (A dr. Chem. , p. 143).
A vertin fluid contains this alcohol.
Which one of the following may produce phos gene when broken down 2
(1) Chloroform
(2) Nitrous oxide
(3) Cyclopropane
(4) Diethyl oxide
(5)
Helium
A. No. 1 (A dr. Pharm. p. 40).
The explosive range of ethylene in air is:
(1) 1, 0- 10.5%
(2) 2. 0-35%
(3) 3.5 - 15%
(4) 4. 0–25%
(5) 5. 0-75%
A. No. 3 (A dr. Chem. , p. 125).
The explosive range of ether in air is:
(1) O. 5 – 15%
(2) 1.83 - 36.5%
(3) 4.5-38. 0%
(4) 10.5-28.5%
(5) 15.5-80.5%
A. No. 2 (A dr. Pharm. , p. 32).
During electrosurgical resection of the prostate transurethrally, under nitrous oxide-
oxygen- pontothal anesthesia, the bladder ruptures suddenly. Which of these is the
likeliest cause 2
202
4:30
53.
54.
55.
56.
57.
Over distension of the bladder.
Explosion of hydrogen and oxygen in the "air bubble".
Explosion of nitrous oxide and oxygen which accumulated in the "air bubble".
Cutting dome of bladder with instrument.
l
2
3
4
5) Spontaneous rupture.
A. No. 4 (Hadfield).
The hydrogen found may be formed by electrolysis or by the breakdown of glucose.
Hydrogen most commonly occurs where patient is a diabetic with sugar in the urine
and the urine is obstructed. A relatively common accident is the performation of
the dome of the bladder or in the prostatic area by the cutting in strument.
Which of the following has an acid pH 2
(1) Pentothal solution (4%)
(2) Citrated "bank'' blood
(3) Re constituted pooled plasma
(4) Procaine solution (1%)
(5) Ringer - Locke's solution
A. No. 4 (A dr. Chem. , p. 263).
Citrated bank blood usually has a pH close to is otonic.
An example of an unsaturated triple -bonded hydrocarbon is:
(1) propane.
(2) ethylene.
(3) cyclopropane.
(4) acetylene.
(5) a mylene.
A. No. 4 (A dr. Chem. , p. 127).
An example of an unsaturated double-bonded hydrocarbon is:
(1) propane.
(2) ethylene.
(3) cyclopropane.
(4) is obutane.
(5) annylene.
A. No. 2 (A dr. Pharm. p. 24).
The chemical formula of ethyl ether is:
(1) C2H5O - CH3
(2) (C2H5)2O
(3) (C. H2)2 COH.
(4) CH, CH3-OH
(5)
A. No. 2 (A dr. Pharm., p. 32).
Cyclopropane content of blood may be determined by:
(1) Gravimetric analysis.
(2) Iodide pentoxide method.
(3) Potassium per manganate method.
(4)
(5)
Use of pyrogallic acid procedure.
Mercuric cyanide solution test.
4:3 1
58.
59.
60.
A. No. 2 (A dr. Chem. , p. 43).
The principle of the Pauling analyzer for oxygen involves one of the following:
(1) Reduction of copper sulfate
(2) Alteration of a paramagnetic field
(3) Increase in temperature of a platinum filament
(4) Oxidation of sulfurous acid
(5) Rotaneter
A. No. 2 (Faulconer; Pauling).
Which of the following agents is used to absorb cyclopropane in the Or sat apparatus 2
(1) Furning nitric acid
(2) Furning sulphuric acid
(3) Concentrated hydrochloric acid
(4) Mineral oil
(5) Potassium permanganate solution
A. No. 2 (A dr. Chem. , p. 132).
A nesthetic ether is prepared commercially by one of the following reactions:
(1) Ethyl alcohol and sulphuric acid
(2) Ethyl alcóhol and hydrochloric acid
(3) Ethylene and hydrochloric acid
(4) Ethylene and sulphuric acid
(5) Methyl alcohol and water.
A. No. 1 (A dr. Chem. , p. 162).
204
4:32
SU P P L E MENT 2 SUB – S EC TIC N
H. H. YSICS AND CHE MIS T R Y
The resistance in the average circle type of Carbon dioxide absorption na chine under
or dinary use is :
(1) ( – ). 5 nann, water
(2) ( – 1 . 0 in m , water
(3) l ; U – 2 . ( mm . water
(4) 2 . () – 5.0 m m. water
(5) 5 , () – 8. Q mm . water
A. No. 5 (A dr. Chen , p 68).
The resistance in the "to and fro" type of carbon dioxide absor otion nº achine under
or dinary use is:
0.4 m m. water
— 1. 0 nm water
— 1. 5 mm . water
– 3.0 mm . water
– 7. 0 m rin. water
:
.
i
A. No. 4 (A dr. Chenn., p. 98).
When regeneration occurs in soda line:
(1) Calcium hydroxide reforms
(2) Calcium carbonate reforms
(3) Sodium hydroxide reforms
(4) Sodium per oxide reforms
(5) Quicklime reforms
A. No. 3 (Adr. Chem. , p. 85).
The rate of heat loss from the body is least during a nesthesia by the technique of :
(1) Endotra cheal insufflation
(2) Semiclosed inhalation
(3) Carbon dioxide absorption, to and fro
(4) Carbon dioxide absorption, circle filter
(5) Open drop
No. 3 (Macintosh, p. 51).
º
redit for the clinical application of the circle filter technique of carbon dioxide:
1) Brian Sword
2) Ralph Waters
3) A rthur Guedel
4) Chevalier Jackson
5) Thomas Edison
A No. 1 (A dr. Chem. , p. 74).
Accumulation of carbon dioxide is least likely to occur during:
(1) Circuit absorption anesthesia
(2) To and fro absorption anesthesia
(3) Semi-closed anesthesia
(4) Semi-open anesthesia
(5) Open drop anesthesia
4 : 33 205
10.
1 1.
12.
A No. 5 (A dr. Techs. , p. 63).
Who discovered the analgesic and exhila rating effects of nitrous oxide:
(1) Priestley
(2) Dumas
(3) Wells
(4) Davy
(5) Brothers
A. No. 4 (A dr. Pharm. , p. 21).
Priestley first identified:
(1) Hydrogen
(2) Nitrogen
(3) Ethyl chloride
(4) Nitrous oxide
(5) Ethyl ether
A. No. 4 (A dr. Pharm. , p. 21).
Main energy transfer within the cell is accomplished through:
(1) Lactic acid
(2) A denosine triphosphate (A. T. P. )
(3) Glycogen
(4) Flavo protein (yellow enzyme of W, rburg).
(5) Creatinine
A. No. 2 (Best, p. 705, 71 l).
Lactic acid is a material derived from the oxidation of glycogen. When it accumu-
lates, the skeletal muscles fatigue. It is likely that the high acidity, which occurs
as a result of the production of lactic acid, is the cause of fatigue rather than the
exhaustion of the glycogen stores. A. T. P. is believed to be the immediate source
of the energy for contraction.
Vinyl ether or divinyl oxide is a hybrid of:
(1) Ethyl ether and ethyl chloride
(2) Ethyl ether ethylene
(3) Ethyl chloride and ethylene
(4) Ethyl ether and propethylene
(5) Ethylene and propethylene
A. No. 2 (A dr. Chem. , p. 170; Goodman, p. 72).
Vinyl ether is derived from vinyl alcohol. Vinyl alcohol and vinyl ether are related
to ethylene.
Which of the following is one of the de composition products of vine thene:
Carbon monoxide
Propylene
Formaldehyde
Nitric oxide
l
2
3
4
5) Carbon dioxide &
A. No. 3 (A dr. Chem. , p. 172).
Dehydration of alcohol by sulphuric acid below 140 degrees C. yields:
206
4:34
13.
14.
15.
16.
17.
(1) Chloroform
(2) Vine thene
(3) Ethylene
(4) Ethyl ether
(5) Cyclopropane
A. No. 4 (A dr. Pharm. , p. 32).
One of the most dangerous impurities likely to occur in ethylene is:
(1) Phos gene
(2) Phosphoric acid
(3) Carbon monoxide
(4) Ethylene glycol
(5) A cetylene
A No. 3 (A dr. Pharm. , p. 24).
A vapor differs from a gas in that:
it exists as such far above the boiling point of the liquid
it exists as such at about the boiling point of the liquid
it exists as such far below the boiling point of the liquid
it cannot be liquified by cooling only but requires pressure
1
2
3
4
5) it is always heavier than air.
A. No. 3 (A dr. Chem. , p. 28; Macintosh, p. 91).
This is a confusing question. A liquid will boil when the vapor pressure of the
liquid equals the atmospheric pressure. Therefore, at reduced atmospheric pres–
sure liquids boil at lower temperatures. A mixture of liquids with different boiling
points has a boiling point between the se two boiling points. This is the reas on for
the addition of alcohol to vinyl ether. It decreases its volatility. Macintosh states
that a vapor is a gaseous substance below its critical temperature. Liquifaction
of gases at room temperature are impossible because temperature of the room is
above the critical temperature of the gas.
Addition of a halogen radical to an anesthetic agent:
Decreases the toxicity to the cardiac conducting mechanism
Increases the toxicity to the cardiac conducting mechanism
Does not affect the cardiac conducting mechanism
Increases the toxicity to the myocardium
l
2
3
4
5) Decreases the toxicity to the myocardium
A. No. 4 (A dr. Chem. , p. 181; Goodman, p. 59).
Where will the boiling point of a solution be the highest:
(1) In Denver
(2) In New York City
(3) On top of Mt. McKinley
(4) In Death Valley
(5) On top of Mt. Ever st
A. No. 4 (A dr. Chem. , p. 28; Macintosh, p. 91).
The drug first used to produce spinal anesthesia was:
(1) Procaine
(2) Cocaine
(3) Stovaine
(4) Pontocaine
(5) Nupercaine
4:35 207
18.
1 9.
20.
2 1.
22.
23.
\ , No. 2 (Collins, p. 125).
Nuper caine is :
(1) a quinoline derivative
(2) a cinnamic acid ester
(3) a car bannic acid ester
(4) an ester of methyl pipe ridino propanol
(5) an ester of beta diethylamino ethanol
A. No. 1 (Collins, p. 260).
The specific gravity of 1: 1500 nupercaine in 0.5% saline is on the order of:
(1) 1, 001
(2) 1. 003
(3) 1, 005
(4) 1. 007
(5) 1. O09
A. No. 2 (Collins, p. 26 1).
The specific gravity of 1% pontocaine in normal saline is :
1. () () |
1. 003
1. O 07
1. () 10
l
l
2
3
4
5 , 0.14
A. No. 3 (A dr. Chen. , p. 38.2
A 2 cc. arnpule contains procaine 1% and ephe drine 5%; Give total amount of pro-
caine in annpule :
(1) 120 mgm.
(2) 20 mgm.
(3) 60 mgm.
(4) 300 mgm.
(5) 30 mgm.
A . No. 2 (Ref. - none).
All but one of the following solutions are isotonic for intravenous use:
Whole fresh blood
5% glucose in water
0.85% sodium chloride in water
5% glucose in 0.85% NaCI
l
2
3
4
5) N/6 sodium lactate solution
A. No. 4 (Goodman, p. 585).
Of the following, which one is used in analyzing for cyclopropane in a gas mixture:
Pyrogallic acid
Copper annonium solutions
Sodium hydrosulfite
Potassium hydroxide
Sulfuric acid
:
A. No. 5 (A dr. Chem. , p. 132).
208
4:36
24.
25.
26.
27.
28.
29.
30.
Of the following, which one is used in analyzing for carbon dioxide in a gas mixture 2
Pyrogallic acid
Copper annonium solutions
Sodium hydrosulfite
Potassium hydroxide
l
2
3
4
5) Sulfuric acid
A. No. 4 (A dr. Chem. , p. 67).
The testing of tribromethanol with Congo red normally results in a pink color of the
indicator. However, in the presence of products of de Composition the indica to r will
turn :
Brown
Red
Pink
Purple
1
2
3
4
5) Green
A. No. 4 (A dr. Pharm. , p. 57).
Valence is the :
affinity of one element for combining with hydrogen
number of electrons in the nucleus
number of atoms in a molecule
number of protons in a nucleus
atomic number of an element
:
A. No. 1 (A dr. Chem. , p. 502).
Alkaloids are:
(1) easily dissolved in cold water
(2) easily dissolved in hot water
(3) soluble in normal saline
(4) soluble in ether
(5) soluble only as salts
A. No. 4 (A dr. Chern. , p. 210).
Inorganic salts usually contain:
(1) an acid residue and an anion
(2) a metal and an OH ion
(3) an acid residue and a metallic ion
(4) an acid residue and H
(5) two different anions
A. No. 3 (Dorland, p. 1321).
Esters are:
(1) Organic oxides
(2) The reaction products of alcohols and Organic acids
(3) An unsaturated heterocyclic compound
(4) A Chlorinated alcohol
(5) Organic bases
A. No. 2 (A dr. Chem. , p. 115).
The main component by weight of soda lime is:
4 : 37 209
3 1.
32.
33.
34.
35.
(1) Na2CO3
(2) Na2SO4
(3) Ca (OH)2
(4) NaOH
A. No. 3 (A dr. Pharm. , p. 129).
The reason for the formation of frost or dew on the reducing valve of the nitrous
oxide tank is that:
(1) the mechanism of the regulator needs repair
(2) heat is necessary to vaporize a liquid and to expand a gas
(3) the connecting tube from the valve is a good insulator and a poor heat conductor
(4) the nitrous oxide in the tank has a low specific heat
(5) the gas is compressed at a low temperature
A. No. 2 (Macintosh, p. 25, 27).
Indicate the statement which does not apply. Vaporization of a liquid may be accelerated
(l) raising the temperature
(2) increasing the evaporating surface a rea
(3) removing evaporated molecules by air currents
(4) subjecting the liquid to vacuum
(5) increasing its latent heat of vaporization
A. No. 5 (Macintosh, p. 27, 31).
The lowest temperature at which the vapor of a liquid may be ignited by a flame is
known as :
Sparking distance
Flash point
Critical temperature
Ignition potential
l
2
3
4
5) Heat of vaporization
A. No. 2 (A dr. Pharm. , p. 135).
What is the partial pressure at sea level of ether vapor in a mixture of 5% ether
vapor in air:
(1) 18 mms. of mercury
(2) 38 m ms. of mercury
(3) 76 mm s. of mercury
(4) 125 mm s. of mercury
(5) 250 mm s. of mercury
A. No. 2 (Macintosh, p. 74).
The partial pressure of any substance in mm. of mercury in the air may be deter-
mined by multiplying 760 mm. of mercury (total atmospheric pressure) by volume
percent of that substance.
At a barometric pressure of 380 mm. the partial pressure of water vapor in the
alveoli of a normal subject is :
(1) 5 mm .
(2) 20 mm.
(3) 2.3 mm.
(4) 47 mm.
(5) 156 mm.
210
4 : 38
36.
37.
38.
39.
40.
A. No. 4 (Macintosh, p. 80).
Carbon dioxide exerts a pressure of 40 mm. of mercury. The vapor pressure in
the alveoli exerts 47 mm. of mercury. These materials remain quite constant and
the combined pressure is approximately 90 mm. under all conditions whether it be
at sea level or at 30, 000 - 50, 000 feet.
A "G" cylinder of oxygen at 2000 lbs. pressure contains about:
(1) 20 cubic feet of gas
(2) 120 cubic feet of gas
(3) 220 cubic feet of gas
(4) 2000 cubic feet of gas
(5) 10 liters of liquid oxygen overlaid by 20 liters of gas
A. No. 3 (A dr. Chem. , p. 18).
What is the usual pressure in a full cylinder of cyclopropane:
(1) 40 lbs. per sq. in.
(2) 45 to 50 lbs. per sq. in.
(3) 60 lbs. per sq. in.
(4) 75 to 90 lbs. per sq. in.
(5) none of the above.
A. No. 4 (Collins, p. 278).
Which of the following gases may be safely marketed as a liquid in cylinders:
(1) Oxygen
(2) Nitrogen
(3) Nitrous oxide
(4) Helium
(5) Helium and oxygen
A. No. 3 (Collins, p. 270).
Under standard conditions of temperature and pressure the partial pressures of
the following mixture of gases cyclopropane 25% - oxygen 25% - nitrogen 50% will
be respectively:
190, 190, 380 mm. Hg.
100, 150, 410 mm. Hg.
95, 25, 260 mm. Hg.
200, 200, 360 mm. Hg.
l
2
3
4
5) 1 1 0, 2 1 0, 350 mm. Hg.
A. No. 1 (Macintosh, p. 75).
In a liter of two dis similar gases of varying molecular weights at the same tem-
perature and pressure:
the density is the same
the number of molecules is the same
the speed of the molecules is the same
the number of atoms is the same
l
2
3
4
5) the specific gravity is the same
A. No. 2 (Collins, p. 31).
In a liter of such gases the densities will be different. Thus, nitrous oxide has a
density of 2 grams per liter while ether has 3.3 grams per liter, obtained by divid-
ing the molecular weight by 22.4 liters. The specific gravities will be different.
4:39 211
4 1.
42.
43.
44.
45.
46.
Thus, nitrous oxide has 1.5 and ether vapors 2.6. The speed of the molecules will
vary. The number of molecules will be the same according to Avagodro's law.
In the measurement of gas pressures for a nesthesia, which of the following is most
sensitive and easiest to calibrate and read:
(1) open water manometer
(2) closed water manometer
(3) closed mercury manometer
(4) open mercury manometer
(5) open manometer containing mineral oil
A. No. 1 (A dr. Chem. , p. 15).
Which of the following cannot be compressed to liquid at room temperature :
(1) oxygen
(2) nitrous oxide
(3) ethylene
(4) carbon dioxide
(5) cyclopropane
A. No. 1 (Macintosh, p. 89).
This cannot be answered correctly but No. 1 is the answer sought. See question
number 10 in main section.
The Federal Government agency conce ºne d with the handling of gas cylinders employed
in a nesthesia is :
(1) the Treasury Department
(2) the Department of Agriculture
(3) the Inter state Commerce Commission
(4) the Federal Trade Commission
(5) the Pure Food and Drug Administration
A. No. 3 (A dr. Chern. , p. 16).
Which of the following compounds is lighter than air :
(1) Carbon monoxide
(2) Cyclopropane
(3) Ether vapor
(4) Carbon dioxide
(5) Nitrous oxide
A. No. 1 (Collins p. 176; Macintosh, p. 5).
The molecular weight of CO2 is most nearly the same as that of:
(1) N2O
(2) He
(3) O2
(4) Nitrogen
(5) Ether vapor
A. No. 1 (Ref. - none).
Ether boils at:
(l) OO C .
(2) 259 C.
(3) 350 C.
212
4:40
47.
48.
49.
50.
5 1.
52.
(4) 550 C.
(5) 100 O C.
A. No. 3 (A dr. Pharm. , p. 32).
The passage of ether vapor from a Yankauer mask to the brain tissue is due
principally to its :
(1) Diffusion coefficient
(2) Replacing inert nitrogen
(3) Affinity for cell lipids
(4) Pressure gradient
(5) CO2 increase under mask
A. No. 4 (Macintosh, p. 62).
Which of the following is an oxidizing agent:
(1) Nitrous oxide
(2) Cyclopropane
(3) Helium
(4) Ether
(5) Carbon dioxide
A. No. 1 (A dr. Chem. , p. 65).
Which one of the following gases may de compose when compressed in one stage:
(1) Helium
(2) Nitrous oxide
(3) Carbon dioxide
(4) Ethylene
(5) Cyclopropane
A. No. 4 (A dr. Chem. , p. 123).
Which of the following mixtures of cyclopropane and oxygen is not explosive:
(1) 3% cyclopropane in 97% oxygen
(2) 4 liters of cyclopropane and 1 liter of oxygen
(3) 1/8 cyclopropane and 7/8 oxygen
(4) equal parts of cyclopropane and oxygen
(5)
cyclopropane flowing at 1 liter per minute and oxygen flowing at 30 gallons
per hour
A. No. 2 (A dr. Pharm. , p. 27; Collins, p. 176).
The explosive range of ether in air is:
(1) (). 5 – 15 . 0%
(2) 1. 83 – 36 . 5%
(3) 4.5 - 38.0%
(4) 10.5 - 28.5%
(5) 15. 5 – 80.5%
A. No. 2 (A dr. Pharm. , p. 32).
The explosive range for ether in oxygen is:
(1) 1. 0 – 90%
(2) 1. 83 - 36.5%
(3) 2. 1 – 82. 5%
(4) 5. 5 - 75. 3%
(5) 10. 3 – 83.2%
4:41
213
53.
54.
55.
56.
57.
58.
A. No. 3 (A dr. Pharm. , p. 32).
The Horton inter coupler has a resistance between any two terminals of:
(1) 100 Chris
(2) 1000 Ohm's
(3) 1 (), () () (; C)hns
(4) 1 000, 000 Chms
(5) l Mcgohm
A. No. 5 (A dr. Techs. , p. 165).
The basic chemical structure of the barbiturate s c or sists of ur ea and :
(1) Malonic acid
(2) Succinic acid
(3) Nic Otinic acid
(4) Butyric acid
(5) Ste a ric acid
A. No. 1 (A dr. Techs. , p. 1 b S).
The barbiturate s used in Inc clicine dissolve in W. a to r be cause:
(1) they are salts of strong a cids and weak iya Ses
(2) they are salts of weak a cids and strong b: s 6 s.
(3) they are easily soluble whether in soluble form or not
(4) they form a cid solutions
(5) they form alkali solutions
A. No. 2 (A dr. Fº harn: , , p. 65).
The sodium salts of a barbiturate have a pH of a pproximately :
(1) 3.5
(2) 5. 5
(3) 7, 3
(4) 9. 5
(5) 12. 0
A. No. 4 (A dr. Pharm. , p. 65).
Indicate which one of the following organic compounds is of value in a nesthesia:
(1) (C2H5)2O
(2) (CH3)2C)
(3) C2H5OCH3
(4) (C2H5)2CO
(5) CH3CHO
A. No. 1 (A dr. Pharm. , p. 51).
Chloroform is :
Trichlor ethanol
Trichlor methane
Tetra chlor methane
Trichlor ethylene
Dichlor methane
:
A
No. 2 (A dr. Pharm. p. 40).
214
4:42
59.
60.
The boiling point of vine thene is about:
4
4
A. No. 1 (Adr. Pharm. , p. 36).
One of the following agents is not related to a nesthesia:
(1) C2H5C1
(2) C2H4
(3) C2H4C OCH2 Br
(4) CB r 3CH2CH
(5) C2H3CC2H3
A No. 3 (Ref. - none).
4:43
. Y
4
P H A R M A C O L C G Y
C h a pter V
217
OUT LINE – PHARMA COLOGY
SUBJECT QUESTION NUMBER
Main Sect. Suppl. 1 Suppl. 2
THE ORIES OF NARCOSIS. . . . . . . . . . . . . . . 1, 2, 93 9, 10 18, 55
PREMEDICATING A GENTS
1. Morphine & Substitute S. . . . . . . . . . . • ‘º 6 - 9 3–7, 26 52 – 5 3
2. Belladonna Group. . . . . . . . . . . . . . . . . º 10 - 15 18, 22 40, 4 |
3. Combination of Premedicating Agents
& Choice of Agents. . . . . . . . . . . . . . . . . 3, 4, 5 2 * - *se
A NEST HETIC AC ENTS
1. Inhalation Agents
a. Ether. . . . . . . . . . . . . . . . . . . . . . . . . 17, 18, 20, l | 1, 58
2 l
b. Ethylene. . . . . . . . . . . . e e º gº x * > e o 6 - - - 58 * = *
c. Cyclopropane. . . . . . . . . . . . . . . . . . 23, 24 42 l, 57
d. Ethyl Chloride. . . . . . . . . . . . . . . . o * tº - 34 - º ºs
e. Vine thene. . . . . . . . . . . . . . . . . . . . . 25, 26 35 4
f. Nitrous Oxide. . . . . . . . . . . . . . . . o 27 * -º º 5, 21
g. Chloroform. . . . . . . . . . . . . . . . . . . . 28 46 - - -º
h. Trichlorethylene. . . . . . . . . . . . . . . * gºs - * * * 3
i. Inhalation Therapy with Carbon
Dioxide - Oxygen, & Helium. . . . . . 86, 89, 90 - amºe sºme 6
2. Rectal Agents
a . A vertin. . . . . . . . . . . . . . . . . . . . . . o 29, 30, 31 30 - 3 3 15 - 1 7
b. Ether in oil. . . . . . . . . . . . . . e 3 e º e *E* - - - * * 12
3. Intravenous Agents
a. Barbiturates. . . . . . . . . . . . . . . . . o 32 – 35 l 1 – 13 56
b. Curare. . . . . . . . . . . . . . . . . . . . . . gº 37–45, 48, 5 1 - -- -
50
c. Paraldehyde. . . . . . . . . . . . . . . . . . . 5 1 28, 29 - * *
4. Regional Agents
a . Procaine, Pontocaine, Cocaine . . . . 53-58 37-40 27, 30
b. Epinephrine and other Sympatho-
ninetic A mine S. . . . . . . . . . . . . . e 60–64 24, 25 35, 43–47, 60
5. Miscellaneous Agents including
Erg Otrate, Pitres sin, Ammonium
salts, Prostigmine, Pilocarpine,
Bromides, Sodium Nitrate, Digitalis. . 73, 91 17, 23, 27 37, 38, 4.2
A NA LEPTICS INCLUDING D F P . . . . . . . . 65, 66 14, 15, 16, - - -
50
5: i 219
MISCELLANEOUS PROBLEMS
1.
2.
10.
1 1.
12,
13.
14.
15.
16.
17.
18.
19.
20.
2 1.
22.
23.
24.
25.
26.
Definitions. . . . . . . . . . . . . . . . . . . . . . . .
Site of Action or Site of
Detoxification. . . . . . . . . . . . . . . . . . . .
Dosage s of Drugs or Choice of
Agents. . . . . . . . . . . . . . . . . . . . . . . . . . .
Toxicities of Agents. . . . . . . . . . . . . . . .
Treatment of Toxic Reaction. . . . . . . g
Incompatibilities. . . . . . . . . . . . . . . . . . .
Transfusicns, Transfusion Reactions,
Isotonic Solutions, Blood Pre serva –
tives. . . . . . . . . . . . . . . . . . . . . . . . . . . . e
Effect on the Ute rus. . . . . . . . . . . . . . . .
Effect on the GI Tract. . . . . . . . . . . . . d
Effect on the Kidneys. . . . . . . . . . . . . .
Effect on Spleen. . . . . . . . . . . . . . . . . . o
Effect on Intracranial Pressure. . . . . .
Effect on Re spiratory Tract, Bron-
chioles, Anoxia, Asthma, Pressure
for Anesthesia. . . . . . . . . .
Effects on White Blood Count Post-
operatively. . . . . . . . . . . . . . . . . . . . . . .
Diabetes. . . . . . . . . . . . . . . . . . . . . . . . .
Hyperthyroidism. tº tº e g is a 6 dº o cº o e > º
Blood Sugar. . . . . . . . . . . . . . . . . . . . . . º
Calculations. . . . . . . . . . . . . . . . . . . . . . .
Spinal Anesthesia. . . . . . . . . . . . . . . . . e
General Statements of Many Agents &
Men Associated with Pharmacology. .
Pharmacological Action at Myoneural
Junction and Autonomic Nervous
Height of Activity of Metabolism. . . . .
67, 68
6 9-71
75, 76
77 – 8 1
36, 46, 47,
49, 59, 82, 83
84
85, 103
l Q
Q 8
Q 7
94-96
52, 74
Q Q
1 0 1
100
87, 102
60
44
4 3
48
47, 54, 59
19, 20, 21,
55
25, 26
13
2 1, 5 l
10
20, 22, 2 3
54
8, 9, 32
19
28, 29, 33
34
24
31
39
220
BIBLIOGRAPHY – PHAR MA COLOGY
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ADAMS, R. C. : Intravenous Anesthesia. Ed. 1, New York, N. Y. , Paul B. Hoeber
Inc. , 1944.
ADRIA NI, J. : The Chemistry of Anesthesia. Ed. 1, Springfield, Ill., Charles C.
Thomas, 1946.
ADRIANI, J. : The Pharmacology of Anesthetic Drugs. Ed. 3, Springfield, Ill.,
Charles C. Thomas, 1952.
ADRIANI, J. : Techniques and Procedures of Anesthesia. Ed. 1, Springfield, Ill.,
Charles C. Thornas, 1947.
BAILEY, H. A. , GOTH, A. and LA C KEY, R. W. : Re - Evaluation of Metrazol in
Experimental Barbiturate Poisoning. Current Researches in Anesthesia and
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BAIRD, J. W. Pentothal - Curare Solution; Observation on Its Use in 500 Cases.
Current Researches in Anesthesia and Analgesia, 27:336-342 (Nov-Dec) 1948.
BARA C H., A. L. : Physiologic Therapy in Re spiratory Diseases. Ed. 2, Philadelphia,
Pa, , J. B. Lippin cott Co. , 1948.
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(May - June) 1947.
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(Mar 22) 1941.
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BUR KE, J. C. , LINEGAR, C. R. , FRANK M. N. , and MCINTYRE, A. R. : E serine and
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CIBA PHARMACE JTICAL PRODUCTS, Inc., SUMMIT, N. J. : Control of Pain with
Saddle Block and Higher Spinal Anesthesia., 1948.
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and Febiger, 1945.
COLLINS, V. J. : Anesthesiology. Ed. 1, Philadelphia, Pa., Lea and Febiger, 1952.
CULLEN, S. C. : Anesthesia in General Practice. Ed. 3, Chicago, Ill., The Year
Book Publishers, 1951.
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222 5 : iv
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224 5 : vi
MAIN SUB-SECTION
PHARMA COLOGY
(a) List four the ories concerning the mechanism of the action of anesthetic drugs.
(b) Explain one theory.
A. (A dr. Pharm. , p. 9)
Lipoid the Ory
Protein coagulation the Ory
Surface tension theory
1
2
3
4) Electrical polarity theory
(b) The Lipoid Theory - Solubility of narcotics is high and the water solubility is
low. Oil/water ratio is an index of potency. The higher the ratio the higher
the potency. The drugs diffuse into nerves and produce selective narcosis.
Experimental drugs with narcotic properties such as ether and nembutal exert
action as follow s:
Disrupt hydrogen ion concentration within cell membrane
Unknown
Inhibit carbohydrate metabolism of brain
Prolong the conduction time of nervous tissue
l
2
3
4
5) Decrease cranial blood supply.
A. No. 3 (McCowan; Seifriz).
The mode of action of a nesthetic s is unknown. However, Quastel, at the Car diff
City Mental Hospital, as reported by McCowan, demonstrated that the barbiturates
inhibit the oxygenation of glucose and lactic acid of the brain, and thus deprive
the brain of one of its chief sources of energy.
Discuss the prea nesthetic medication in children and state what you would use on
an average child of (1) 3 years (2) 6 years (3) 9 years (4) 14 years for ton sil-
lectormy.
State the authority for the preane sthetic technique in children as you have given
it above.
A. (Cullen, p. 36; Knight; Leigh, p. 10).
CULL EN
Morphine A tropine Scropolannine
Age Grains mg. Grains ng. Grains ng.
3 1/12 5. 4 1/200 . 33 - ºn - -
6 1/8 7. 5 1/200 . 33 1/200 . 33
9 1/8 7. 5 1/200 . 33 1/200 . 33
4 1/6 10. 1 / 150 . 43 1 / 150 . 4 3
3 1/48 1/4 1/300 . 22 1/450 . 14
6 1 / 36 1. 8 1/200 . 33 1/30 . 22
9 1/24 2. 7 1/200 . 33 1 / 300 . 22
4 1 / 12 5. 4 1/75 . 87 1 / 150 . 4 3
5 : 1 225
KNIGHT
Morphine A tropine Sc Opolannine
A ge Grains Eng: Grains lºng. Grains Ing.
3 1 / 3.2 2. - gEs – - - - 1/800 . 07
6 1/24 2. 7 - * *- - * * 1/600 . 1
9 1 / 16 4. 1 - * - - - - 1 / 400 . 15
4 1 / 12 5. 4 - - - - * - 1 / 300 . 22
Write an order for pre operative morphine for each of the following cases: (give
dose, and time interval before administering the anesthetic)
(a) A healthy man, aged 30, for inguinal her nior rhaphy under local anesthesia.
(b) Same man and same type of Operation under open drop ether.
(c) A child of 3 years, weighing 70 pounds having bronchitis, for appendectomy,
under spinal anesthesia.
(d) A man, aged 30, with choked Optic disks, for craniotomy and removal of brain
tunn or under ether ane Sthe sia.
A. (Cullen, p. 36: Knight)
Knight
a) grains 1/4 - 15. mg 1 hr. pre -ane sthetic induction
b) grains 1/4 - 15. mg. 1 hr. pre -ane sthetic induction
c) grains 1/20 - 3. mg. 1 hr. pre -ane sthetic induction
d) none
Cullen
) grains 1/4 - 15. mg. 1 hr. pre -ane sthetic induction
) grains 1/4 - 15. mg. 1 hr. pre -ane sthetic induction
) not indicated
) none
Discuss choice of drugs for preane sthetic medication for the average adult surgical
patient when cyclopropane is to be administered. Let your answer include experi-
mental and clinical data.
A. (A dr. Techs. , p. 10, 1 l; Water s).
Water s, in his experimental work, found that the ratio of morphine-25 and scopola -
mine – l gave Optimum results for premedication. He found that this ratio was
even better for this purpose than morphine and atropine. The beneficial effects of
morphine and scopolarmine were prominent and the undesirable effects minimized.
Analgesia, reduction of reflex irritability and metabolism (morphine), plus drying
of secretions, mental sedation and amnesia (SC Opolamine), overbalanced the res-
piratory depression and nausea (morphine), plus excessive secretions and toxic
reactions (scopolannine).
Describe the action of morphine when given in (a) the rapeutic dose (b) toxic dose.
A. (Adr. Pharm. , p. 78).
(a) The rapeutic doses:
(1) Brain – pain paths to consciousness interrupted.
(2) Pupils-constricted.
(3) Depression, temperature regulating, respiratory, cough centers.
(4) Intracranial pressure increased.
(5) Stimulation, vomiting center.
226
5: 2
10.
(6) Spasm of urethra and sphincter of the bladder.
(7) Decreased motility and secretions of gastrointestinal tract; liver function
decreased and glyocogen depleted.
(8) Uter us - decreased motility; passes placenta barrier and affects baby.
b. Toxic effects:
(1) Coma and skeletal musculature flaccidity.
(2) Depresses me dullary centers - with depressed re spiration, temperature,
cough, and circulatory regulating centers.
(3) Collapse and death.
Analgesic drugs such as morphine produce their relief of pain by:
) Inhibiting transmission of afferent impulses
) Interfering with perception of pain
) Interfering with response to pain
) Inhibiting initiation or transmission of inpulses and disrupting perception of
such inpulse s.
) Eliminating cause of pain impulse.
(
5
A. No. 2 (Goodman, p. 194).
Methyl morphine is:
(1) Dilau did
(2) Codeine
(3) Dionine
(4) A pomorphine
(5) Demer ol
A. No. 2 (A dr. Chem. , p. 214).
Met had on is how many times more portent than morphine:
.
l
2
3
4
5
l
A. No. 1 (Batter man; Christenson; Beecher; Kirchof).
Recent investigations have shown that analgesia and pain relief require dose s
e qual to that of morphine in effect. There are articles which state that as many
toxic effects occur as with morphine, and that addiction may take place.
De scribe the pharmacological effects of a member of the atropine series.
A. (A dr. Pharm. , p. 102).
A tropine :
(1) Stirnulate s cortex (depresses in large doses -- scopolarmine depresses in all
doses); resenbles alcoholic inebriation.
(2) Stirnulate s re spiratory center -- rate and minute volume increased.
(depresses re spiratory center in toxic doses.
(3) Dilate s the bronchi.
(4) Depresses secretions of upper and lower respiratory tract and depresses
the sweat glands.
(5) Therapeutic dose s have little effect on the heart rate. Increased heart
rate with larger doses, due to paralyzing of vagus endings; toxic doses
depress the center in the medulla, resulting in fall of blood pressure.
5 : 3 227
1 1.
12.
13.
14.
15.
(6) Dilation of cutaneous vessels ; also increased body temperature due to in-
creased metabolism; large doses also aid this by depression of the sweat
glands.
(7) Mydriasis and cyclople gia; increased intre ocular tension.
(8) Gastrointe stinal peristals is decreased; increased tone of the sphincters;
paralyzes the vagus.
(9) Paralysis of the smooth muscles of the bile and renal tracts.
Atropine acts by the following mechanism:
(1) Central depression of brain
(2) Paralysis of autonomic parasympathetic nerves
(3) Block ganglionic nerve impulse
(4) Produces annesia
(5) Reduces rate of metabolism
A. No. 2 (Goodman, p. 462).
Atropine and scopolamine exert their pharmacologic action by ?
A. (Adr. Chem. , p. 266).
Inhibition of the action of acetyl choline at the myoneural junction.
What e s sential difference s may be expected when using atropine or scopolamine in
comparable doses for preane sthetic medication ?
A. (A dr. Pharm. , p. 102, 103).
(1) A tropine. Diminishes secretion by paralyzing parasympathetic nerve endings.
Stimulates cortex and medullary centers. Paralyzes vagus nerve endings.
This peripheral action of atropine on the vagus is greater than scopolannine.
(2) Scopolannine. Diminishes secretions by paralyzing parasympathetic nerve
endings. Depresses cortex and produce S annesia. Enhances cortical de –
pression of morphine, when used with morphine. Possesses a more marked
effect on secretions than atropine.
A s compared with atropine, scopolannine has:
Identical peripheral and central effects.
Weaker vagus effect but more sedation.
Weaker vagus effect, but more excitatory central nervous system effect.
Similar vagus effect, but more excitatory central nervous system effect.
l
2
3
4
5) More chemical stability.
A. No. 2 (Goodman, p. 464).
(a) What are the signs and symptoms of atropine poisoning 2 (b) How should it
be treate d ?
A. (Goodman, p. 469).
(a) The patient looks "wild as a hare, red as a beet, and dry as a bone". A tro-
pine has a wide margin of safety, but toxic reactions occur, especially with
children. Fatalities are rare. The chief diagnostic features are:
Bizarre mental and neurological effects, including delirium.
Anaphylaxis or shock. Death due to me dullary exhaustion.
(1) Dry mucus membranes
(2) Circumoral pallor
(3) Widely dilated, unresponsive pupils
(4) Tachycardia
(5) Cutaneous flush
(6) Fever
(7)
(8)
228
5:4
16.
17.
18.
19.
20.
(b) Treatment consists of:
(1) If taken orally, gastric lavage.
(2) Oxygen must be supplied for dangerous re spiratory depression. CNS
stimulants are best used only as an adjunct to oxygen therapy.
(3) Pentothal in small doses to curb excitement.
(4) Pilocarpine (5 mg. ) may be given and repeated until the mouth is moist.
(5) The remainder of the treatment is symptomatic -- reduction of fever
with alcohol rubs and ice caps.
Give four results of parasympathetic stimulation.
A. (Best, p. 1080).
(1) Slowing of the heart.
(2) Constriction of the pupil.
(3) Excessive salivation.
(4) Increased motility of the intestinal tract.
Blood concentration in the 2nd plane, 3rd stage is 120 mg. "%; the agent is:
Cyclopropane
Nitrous oxide
Ethylene
Chloroform
Di-ethyl ether
(l
(2
(3
(4
(5
A. No. 5 (Adr. Pharm. , p. 32).
What is the fate of ether in the body ?
A. (Adr. Chem. , p. 172; Adr. Pharm, p. 32).
85% to 90% of ethyl ether is eliminated unchanged through the lungs. The re-
mainder passes through the skin, urine, and other body fluids.
What is the effect of ethyl ether given for inhalation anesthesia on the gastro-intes -
tinal tract 2
A. (Adr. Pharm. , p. 33)
(1) Nausea and vomiting during induction and postoperatively; due to central stimu-
lation, but also from local irritation.
(2) The movements of the stomach are decreased. There mav be dilatation of the stonnach
(acute gastric dilatation). The ennptying time of the stomach may be decreased
50%. Gastric secretions and acidity are decreased. The mucous membranes
are irritated. It, the inte stine s there is decreased peristals is and secretion
due to sympathetic stimulation. The vessels are dilated, with loss of all muscle
tone. Peristals is is exaggerated on recovery.
(a) What are the deleterious effects from the administration of ethyl ether.
(b) Discuss methods which have been suggested for their mitigation.
A. (Lundy, p. 401, 409).
(a) The deleterious effects are:
(1) Nausea and vomiting, pre and postoperatively.
(2) Dilatation of the stonnach .
(3) Laryngeal spasm .
(4) Convulsions .
(5) Acidosis .
(6) Respiratory tract irritation.
(7) Renal irritation.
5: 5 229
2 1.
22.
(b)
Methods of mitigation are:
(1) Nausea and vomiting is usually not severe enough to warrant mitigation.
In severe cases, the potency of the patient's airway should be in sured and
the patient placed in a position for drainage.
(2) If handling of abdominal viscera has been necessary during the operation,
a stomach tube should be inserted as a precautiong against dilatation.
(3) A slow induction is indicated to avoid laryngeal spa sm. Induction with
vine thene may decrease this tendency. It is the sudden increased concen -
tration of ether which cause s laryngeal spasm as a protective measure.
(4) Convulsions may be treated with intravenous barbiturate (sodium pentothol)
and inhalations of Oxygen. Carbon dioxide is not recommended.
(5) Ether is best not used in renal failure or acidosis, without giving 15–30
grains of bicarbonate in the 6 hours pre operatively.
(6) Ether is best not used in acute respiratory disease, but may be used in
some chronic respiratory disease S, such as emphysema or fibrosis, with
Cautlon.
(a) What are some of the reasons why ether has not been very satisfactory as
an agent for intravenous anesthesia 2
(b) What are some of the difficulties encountered when ether in Oil is used for
rectal ane sthesia 2
A. (A dams, p. 6 l; A dr. Techs. , p. 198).
The following disadvantages have be ºn noted for intravenous use:
1) Ether intravenously may be painful.
2) Intravenous ether increased blood pressure.
3) Bleeding may be increased and fluid accumulate in the abdomen.
4) There is a tendency to pulmonary edema.
5) There is a tendency to purpura.
6) There is a danger of septic thrombosis.
7) Ether is relatively in soluble in water or saline, and large amounts
of fluids are necessary for anesthesia.
A driani discus sing the difficulties with rectal anesthesia states:
(1) The depths of an esthesia is not controllable.
(2) The drug is difficult to retrieve.
(3) Dosage is not accurate.
(4) It may have to be supplemented.
(5) The duration is unpredictable.
(6) It causes much excite ment and salivation.
(7) A normal respiratory tract is e s sential.
Who first described the anesthetic properties of cyclopropane:
(1) Geffan & Bell (4) Ronnberger
(2) Hender son & Lucas (5) Schmidt
(3) Leake
No. 2 (A dr. Pharm. , p. 27).
In a case in which cyclopropane is the main anesthetic agent used, why may it
be well to use ether also 2
In a case in which cyclopropane is the main anesthetic agent used, why may it
be well to avoid the use of ether ?
If ether is avoided as in (b), what other agents, given by injection or by mouth,
may be used in place of ether ?
What is the value of "controlled respiration" (Guie del's apneic technic) when
administering cyclopropane and oxygen 2
230
24.
25.
26.
27.
A. (Adr. Pharm., p. 28; Adr. Techs. , p. 88, 336; Lundy, p. 529).
(a) Adriani states that ether should be added to prevent or correct car-
diac irregularities as it has a protective action or the heart. It can
be given to increase relaxation and thus reduce the concentration of cyclorpro-
pane. Ether stimulates repiration if depressed by cyclopropane.
(b) Adriani states that both agents are respiratory depressants and with the com -
bination the re is increased danger of respiratory arre St. Premedication for
the combination is a problem since cyclopropane requires less dosage than
ether. Epinephrine cannot be used with cyclopropane, and is an emergency
drug for ether.
(c) Lundy suggests supplementing cyclopropane with pentothal and/or ethylene to
reduce the amount Of the agent used. Increased relaxation may be obtained
with cura re.
(d) Controlled respiration provides a de quate saturation of the tissues with little
re spiratory movement. It provides an intermittantly motionless field in thor -
acic and abdominal surgery.
Does cyclopropane alter bleeding and clotting time 2
A. (A dr. Pharm. , p. 29).
It does not alter bleeding Or Clo ting time, although surgeons claim that the exces –
sive Capillary Oozing is due to this agent. The Oozing is due to the peripheral ar-
teriolar and capillary dilatation.
What is the main toxic effect of divinyl ether ?
A. (A dr. Techs . , p. 37).
Central necros is and decreased liver function have been noted, particularly when
the patient has been an oxic for short periods.
What percent alcohol is added to venthene 2
A. (Adr. Pharm. , p. 36).
4% absolute alcohol to decrease its volatility.
(a) Describe the administration of nitrous oxide by the carbon dioxide absorption
technique.
(b) What is secondary saturation and give importance in N2O anes the sia.
a . Clement's states:
(1) Fill the apparatus with pure oxygen and place the mask on the face.
(2) Turn on CO2 absorber and set the rate of flow of N, O at 8 liters
per minute and oxygen at 2 liters per minute. Opén the exhaling
valve for escape of the excess gas.
(3) As soon as the patient is in stage 3, fasten the mask to the face, de-
crease the N2O to 1 liter per minute or less, according to the needs
of the patient.
b. Secondary saturation is used because the nitrogen in the tissues remaining
after primary saturation may prevent complete nitrous oxide saturation.
Therfore, pure nitrous oxide is given until signs of hypoxia appear, when
Oxygen is given in one quick flush. Maintenance doses of N2O are then
used. This secondary saturation may be repeated until the desired anes-
thetic levels are reached.
5: 7 231
28.
29.
30.
3 1.
32.
In the opinion of Clement, secondary saturation is useful to attain complete
anesthesia with nitrous oxide alone. The se views of the McKesson school have
not been accepted completely by most of the other teaching centers.
The chief danger during chloroform anes the sia is:
(l) Re spiratory arrest
(2) Cardiac damage and arrest
(3) Liver damage
(4) Kidney damage
(5) Pulmonary irritation.
A. No. 2 (Adr. Chem. , p. 32).
(a) What is the fate of tribromethanol in the body ?
(b) In what form is it ordinarily marketed ?
(c) What precautions should the anesthetist take in preparing it for administration,
and why 2
A. (A dr. P'harm. , p. 57).
(a) A vertin is quickly destroyed in the liver by combination with glycuronic acid
(70% to 80% in 2–4 hours). The fat tissues in the body take it up quickly, the
brain and kidneys to the greate St extent. The muscle S contain it in lower con-
centrations than the blood. Precautions for its use include:
(1) Do not use in colitis, tumors of the C Olon, paralytic ileus, general anemia
or sepsis, bowel obstruction, C , C hexia, liver, kidney or heart diseases.
(2) Use in minimal doses for basal anesthesia Only.
(3) Have oxygen handy because the re spirations may be depressed.
(4) Test the mixture before use with Congo red, to insure that irritating acids
have not been formed.
A vertin is not more widely used because of the deleterious effects commonly seen
O () :
(l) The blood pressure.
(2) The respiration.
(3) The liver.
(4) The kidney.
(5) The heart.
A. No. 2 (A dr. Pharm. , p. 57).
A vertin is widely used, but not as extensively as it might be because of the depres –
sion of respiration, the liver damage, and the difficulty in preparation. It was
used more frequently when a non-explosive agent was needed in brain surgery be –
fore pentothal-curare or pentothal-curare-N, ) C On binations were discovered to be
effective.
A change in the indicator commonly used in preparation for administration of
A vertin is evidence that:
(1) The alcohol has separated from Amylene Hydrate
(2) A mylene Hydrate has de composed
(3) Halogenated breakdown products are present
(4) Concentration is not optimal for administration
(5) Too much Amylene Hydrate.
A. No. 3 (A dr. Pharm. , p. 57).
In the manufacture of barbiturates the following sub stance s are utilized:
232
5 : 8
33.
34.
35.
.
A.
Urea and malonic acid.
Urea and uric acid.
Urea and barbituric acid.
Urea and succinic acid.
No. 1 (Adr. Pharm. , p. 67).
An ampoule of pentothal has added to it:
Claciunn carbonate.
Nothing,
Sodium carbonate.
Chlorbutanol.
Sodium bicarbonate.
No. 3 (Abbott).
Name some barbituric acid derivative s representative of each of the following
classification s :
(1) Long acting.
(2) Medium acting.
(3) Short acting.
(4) Ultra – short acting.
What factor's other than their duration of action logically place the se drugs in
the designated classifications 2
(A dr. Pharm. , p. 67, 78).
a. (1) Barbital, phenobarbital
(2) Ipiral, dial, alurate
(3) Armytal, Nembutal, Phanoderm, Perno ston
(4) Evipal, Pentothal
b. These may be ciassified according to their fate in the body. The long acting
drugs are eliminated mostly unchanged in the urine over a long period. The
medium acting barbiturates are partly destroyed and partly eliminated un-
changed in the urine. The short and ultra short acting agents are complete -
ly destroyed, and only the products of de struction are found in the urine.
Other classifications might be based on molecular weight and the structural
arrangement. Two short aliphatic group's produce long acting drugs. One
short and one long aliphatic group produce short acting drugs. Branching
of aliphatic chains increase the potency. A romatic structures on aliphatic
groups increase toxicity. The potency increases with molecular weight
up to 250.
A short-acting barbiturate loses its advantage s if given in large doses. What
measure S are commonly employed to keep the do ses of barbiturate s to a
minimum ?
What are the important considerations before and during intravenous adminis –
tration of pentothal sodium to a patient who is in shock 2 How do the se consid -
erations differ from those which apply when the patient is in average good
condition and from those which apply when the patient is in poor condition.
(Lundy, p. 531).
The following may be used to reduce the dose of barbiturate:
1. Personal contact in advance to reduce apprehension.
2. Slow induction.
3. Premedication adequate
5: 9 233
36.
37.
3 Q.
40.
4. Supplementation by spinal, local, regional or rectal anesthesia.
5. Use of N2O and cura re.
(b) In shock, minimal amounts of pentothal should be used with an overabundance
of oxygen. Intravenous blood or plasma, plus pressor substances, should be
supplied. Minimal amounts of pre medicating drugs are needed, and these
should be restricted to a belladonna derivative. The use of pentothal in shock
is debatable, especially if the patient is in poor condition, because it tends to
decrease blood pressure and re spirations further.
Enumerate, in the order of their importance, the rapeutic measures you would
employ in the early treatment of a patient poisoned severly by barbituric acid
derivative :
A. (Adr. Techs. , p. 229, 340).
(1) Provide satisfactory airway.
(2) Augment respiratory movement with a respirator or anesthetic machine.
(3) A spirate stomach contents, and lavage stomach with sodium bicarbonate
solution. *** *-ºs . .
) Support circulation with intravenous fluids.
) Administer analeptic S - picrotoxin or met razal.
) Good nursing care, with frequent turning and clean sing.
) Antibiotic s to prevent pneumonia.
A. No. 1 (Adr. Pharm. , p. 96; Cullin, p. 117).
Each co. of d-tubocurarine contains how many equivalent squibb units:
(l) 3
(2) 0. 5
(3) 20
(4) 100
(5) 40
A. No. 3 (Adr. Pharm. , p. 96).
What is the basic action of curare 2
A. (A dr. Pharm. , p. 96).
Elevate s threshold to acetyl chlorine at my on eural junction.
(a) How long does it take curare to act 2
(b) How long does it take pentothal to act 2
A. (Adri. Pharm. , p. 96).
(a) Curare effects begin after intravenous injection within 3 minutes. The effects
may last from 20–60 minutes.
(b) Pentothal takes effect almost immediately, although there is a cumulative
effect after large doses have been given over a period of time.
234
4 1.
4 3.
44.
45.
46.
How long does curare action last 2
A. (Adr. Pharm. , p. 96).
Curare action lasts approximately 20–30 minutes in a non-narcotized patient.
Under a nesthesia effects may last 40–60 minutes. There is evidence that there
is some cumulative effect because smaller doses are needed in the latter stage s
of long Operations.
How is curare eliminated from the body when given I. V. or I. M. 2
) Eliminated unchanged by the kidney.
) Detoxified by the liver and excreted through the kidney.
) Detoxified by liver conjugation and excreted through the kidney.
) Destroyed in liver, muscles, and reticuloendothelial system and eliminated
through the kidney.
(5) Metabolized in the body and eliminated through the kidney.
A. No. 2 (A dr. Pharm. , p. 97).
It is partly detoxified by the liver and the rest is excreted unchanged by the kidneys.
Which one of the following is said not to pass the placental barrier 2
(1) Nitrous oxide
(2) Cur are
(3) Cyclopropane
(4) Ether
(5) Pentothal
A. No. 2 (Harroun; Whitacre; Adr. Pharm. , p. 97).
Whether curare passes the placental barrier is still debatable. Whitacre states that
it does not affect the child in Caesarian section. Adriani states it is believed to pass
into the fetal circulation.
Does curare have a CNS action ?
A. (Smith; Adr. Pharm. , p. 97).
It does not except in large, repeate Cl dose S. Smith allowed himself to be curarized
and intubated and retained his sensorium throughout the experiment. The EEG
remains unchanged.
Does cura re have action on the heart 2
A. (A dr. Pharm. , p. 97).
No evidence has as yet been presented of direct action of curare on the heart.
The EEG remains normal.
(a) Discuss briefly the signs and symptoms of an over dose of cu rare.
(b) What treatment would be useful.
A. (Cullen, p. 122; Hoffman - La Roche).
(a) An overdose of curare results in generalized muscular weakness and paralysis.
Re spiratory movements are depressed or absent, due to inter costal and dia-
phramatic paralysis. Consequently hypoxia occurs and CO2 accumulates in
the body, resulting in cyanosis, tachycardia, elevation of blood pressure and
cardiac irregularities.
5 : 1 1 235
47.
48.
49.
50.
5 1.
(b) Treatment consists of:
1. Artificial or as sisted respiration with Oxygen until the effects of curare
have disappeared.
2. Prostigmine 1–2 mg. with atropine (.4 mg. per mg. prostigmine) or
Tensilon 10 mg. , repeated as necessary.
The prime treatment for over dosage of curare is:
(1) Artificial ventilation with oxygen
(2) Intravenous prostigmine methyl sulphate
(3) Intravenous prostigmine bromide
A. No. 1 (Cullen, p. 22; Hoffman–La Roche).
Although prostigmine or tensilon antagonizes the action of curare, the fundamental
is sue involved is to keep the patient oxygenated. The curare will be detoxified and
the effects will wear off in due time.
What is the correct dose of curare when used with ether ?
A. (Cullen, p. 120).
Ether also has a curariform action. Therefore when it is used, the doses of curare
should be reduced to 1/3 - 1/2 (Cullen).
The effects of curare may be counteracted by use of prostigmine. It is of advan-
tage to add:
(l) Choline sterase to further potentiate the prostigmine.
(2) Atropine to block the "muscarine effect" of prostigmine.
(3) A sympathomimetic amine to present indirect blocking of the sympathetic system.
(4) A tropine to block the "nicotinic effect" of prostigmine.
(5) A sympathomimetic amine to prevent a fall in blood pressure.
A. No. 2 (Burke).
What are two techniques in use for giving pentothal and curare ?
A. (Baird).
The technique of using separate syringes for pentothal or curare in contrast to the
use of mixtures of pentothal and curare is as follows:
Curare is first given (with a little pentothal or the patient feels suffocated at the
end of 4 - 5 minutes, 10 - 15 ccs. of pentothal is injected. By this
time the curare effect is at its height and the patient can be intubated easily. The
technique of using combined pentothal and cui are in one solution is based on this
same slow effect of curare over a period of 5 - 10 minutes. 15-20 cc s. of mixture
(pentothal 2 1/2% curare 5 units per cc.) are given as the intercostals are watched
for dirminishing activity. Oxygen or 50-50 nitrous oxygen mixture is administered
by mask. When the inter costals are depressed so that the diaphragm alone func -
tions, the patient can be intubated.
(a) What is the fate of paraldehyde in the body ?
(b) What is the average adult dose of paraldehyde administered rectally for hypnosis ?
(c) What is the average adult dose of paraldehyde administered orally for hypnosis 2
A. (Adr. Pharm. , p. 55).
(a) The metabolic fate of paraldehyde is not corapletely known. A certain amount is
eliminated unchanged by the lungs and some paraldehyde is found unchanged in
the urine. The liver oxidizes up to 80% of the paraldehyde.
236
5: 12
52.
53.
54.
55.
56.
(b) 15–30 cc.'s.
(c) 5 cc.'s. - This may be repeated several times.
Which drug has least effect on re spiration:
(1) Demerol
(2) Paraldehyde
(3) Pantapon
(4) Dilaudid
(5) Nembutal
A. No. 2 (Goodman, p. 179).
It is best given iced.
Paraldehyde in large doses (30-60 cc 's.) does not depress the re spiration.
Using procaine as a standard of comparison, give the relative intravenous toxicity
of the following drugs: cocaine, intracaine, lar ocaine, diothane, nupercaine,
pontocaine, metycaine.
A. (Adr. Pharm. , p. 87-89; Collins, p. 214).
) Cocaine — 4
) Intracaine - 1.5
) Larocaine - 2 1/2
) Diothane – 2
) Nupercaine - 20
) Pontocaine - 10
) Metycaine – 3
Absolute toxicity of cocaine to nupercaine is:
1) I
(
(2) 3
(3) 5
(4) 10
(5) 20
A. No. 3 (Collins, p. 214).
The absolute toxicity is 5. However, the relative toxicity, which is the absolute
toxicity as compared with the dose s producing comparable the rapeutic results,
is even less than procaine.
Which is not an ester of para armino benzoic acid:
(1) Procaine
(2) Pontocaine
(3) Nupercaine
(4) Butyn
(5) Larocaine
A. No. 3 (Adr. Pharm. , p. 87).
This is a quinoline derivative.
Which is a quinine derivative 2
(1) Monocaine
(2) A mylocaine
(3) Tutocaine
(4) Butyn
(5) Eucipin
237
5
7
58.
59.
(
A. No. 5 (A dr. Pharm. , p. 91).
(a) State the indication for the use of procaine intravenously.
(b) Give the strength of solution and the rate of administration.
(c) What restorative procedures would you use in the case of an untoward reaction
due to the intravenous administration of procaine 2
A. (Brown; Burstein; Fraser; Gordon; Knight; Pedigo; State; Tovell; Zeluff).
(a) and (b) - Once the fear that procaine would be fatal if given intra venously had
been dispelled, it quickly came into use as an adjunct to an e s the sia and as a the ra –
peutic agent. When used in chest surgery, it has been injected continously in 1%
solutions to eliminate cardiac and vago-vagal reflexes (Burstein). It has been
used in more routine cases to reduce the quantity of the primary agent (Brown).
It has been used to correct car diac irregularities in doses of 40 – 100 mg. (1%
solution used, repeated if necessary - – Burstein).
The rapeutically, it has been used:
To chº, nge burn dressings - (Gordon).
For superficial debridennents - (Tovell) .
For postope rative pain - (Fraser).
For relief of muscle spasm - (Zeluff).
For urticaria - (Zeluff).
For hiccups - (Knight).
For postoperative anuria - (Pedigo; .
For thronbophlebitis, acute - (Pedigo).
For allergies and serum sickness - State).
For rheumatoid arthritis – (Pedigo).
(c) Untoward reactions are treated by:
) Intravenous pentothal until convulsions are controlled.
) Effective oxygenation by the rmost effective means.
) Trendelenburg position.
) Support with drugs and fluids for shock.
List (a) local anesthetic agent (b) strength of solution, and (c) technic you would
use for the following with procaine or cocaine:
) Removal of a wart.
) Spinal anesthesia to last one hour .
) Spinal anesthesia to last four hours.
) A nesthesia of pharyngeal in C Q is nie mb ranes.
) Block of median nerve.
) Block of sciatic nerve.
A. (A dr. Pharm. , p. 87).
(1) 1/2 to 1% procaine -- local infiltration.
(2) 5% procaine -- 100 mgs. -- single injection technic.
(3) 3% procaine -- continuous spinal technic, or 3% procaine with epinephrine and
dextrose (single injection).
(4) 1–4% cocaine -- topical.
(5) 2% procaine -- regional block at elbow or wrist.
(6) 2% procaine -- regional block.
In what ways can the an esthetist protect the patient against the toxic effects of
procaine 2
A. (Adr. Pharm. , p. 86).
238
F. : 14
6 1.
62,
63.
Epinephrine delays a D G orption.
Insure that the needle is not in a vein by frequent a spiration.
Administration of barbiturates pre operatively.
Pentothal ready for in stant use during procedures.
Oxygen available.
Endotrac heal equipment available for use,
Dosage reduced to rhiniinuins.
The optiºn air, Concertiation of cpinephrine in local an esthetics is :
(1) 1 - 2.5, 000
(2) 1-50, 000
(3) 1 - 150, 00 U
(4) 1–500, 000
(5) 1 - 750, 000
A , 1 Jo 3 (P. iki. p. 11).
It is w c 11 to R C C D the epile phrine within 1 - 150, 000 to 300, 000. Dentists prefer to
use i - 25 000 to 1-50, 000 and the post-extraction ache is undoubtedly due to the
hype 1 & 1.11a which results as a secondary reaction after the local anesthetic wears
off,
is for in c 1 years when strong epinephrine conce nt rations were used it was thought
wise to 1 e Strict procaine to 5 - 10 CC' S. for local infiltration. Reactions with the use
of procaine and strong epinephrine solutions were not due to the procaine but to
the absorption of epinephrine. There is little pain following a local nerve block
when a more dilute epinephrine concentration is used.
Discuss the use S of epinephrine in local anesthetic solutions.
A. (Lundy, p. 64).
(1) is ocal anesthetic has longer duration because of slower absorption.
(2) Contraindicated in hypertensive s, exophthalmic goiter patients, Severe cardiac Or
in extreriely nervous patients, or those with a history of reactions to previous
1ocal agents.
(3) Untoward reactions include dyspnea, trernor, pallor, apprehension, increased
pulse iſ ate, nausea and vomiting, and convulsions. The ultimate outcome may
be re gpiratory and circulatory failure.
(4) Solutions may be mixed as follows: 1 cc of 1 - 2600 per 100 cc 's of 1% solution
is the optimum solution,
What are 3 orne different vas oppressor substance s C Onn only used ?
A. (A di’. Pharm, , p. 104).
(1) Ephe drine
(2) Arte renol
(3) Neo Gynephrine
(4) Epinephrine
(5) Cobefrine
(6) Methe drine
(7) Was oxyl
Can ephe drine be boiled ?
A. (A dr. Chic ſa, , p. 280),
EPic drific can be boiled. It is also so stable that it can be given by mouth.
5 : 15 239
64.
65.
66.
67.
68.
Why is neo synephrine used when cyclo is the anesthetic agent 2
A. (Goodman, p. 44; Winthrop).
It has been found that neosynephrine causes less cardiac irregularities than ephe –
drine, and is the refore preferable when a vasopress or must be used.
Define analeptic. Enumerate three specific physiological disturbance s where an
analeptic is useful. In each instance name an indicated analeptic.
A. (A dr. Techs. , p. 357).
Analeptic is defined as a drug which is strengthening, invigorating, or stimulating.
(1) Spinal anesthesia hypotension – – ephedrine or ne O synephrine intravenously.
(2) Barbiturate poisoning -- pic rotoxin .
(3) Uterine dilatation, third stage -- pitocin.
(4) Respiratory arrest -- oxygen and artifical re spiration.
(5) Circulatory collapse -- arte renol.
The usual dose of picrotoxin is:
(1) . 0005 g ms.
(2) . 001 grins.
(3) . 0 15 grins.
(4) . 0 1 grrls.
(5) . 1 grrl S.
A. No. 2 (Adr. Pharm. , p. 264).
In barbiturate poisoning, 1 mg. is injected intravenously once per minute until re-
flexes return. The patient may require a total of 50 - 150 mgs. However, it is the
axiom of the anesthesiologist that this drug should only be used as an adjunct to
oxygen therapy.
Define the following:
Pharmacognosy
Pharmacy
Pharmacodynamic s
Pharmacotherapeutic s
al
b
C
d
e) Toxicology
A. (Dorland )
(a) That branch of pharmacology that treats of crude drugs.
(b) The art of preparing and compounding medicine s.
(c) The study of actions with medicine.
(d) The treatment of disease with medicine.
(e) The study of poisons, their action, detection and treatment of conditions
produced by them.
Define the following:
(a) Boyle's Law
(b) Charles' Law
(c) Henry's Law
A. (Best, p. 367).
(a) Boyle's Law - The pressure of a gas varies inversely as the volume, providing
the temperature remains constant.
240
5: 16
6 9.
70.
71.
(b) Charles' Law – With pressure constant, volume varies in proport on to abso-
Iute temperature; volume increased 1/273 of its volume at zero degrees centi-
grade for each degree rise.
(c) Henry's Law - Solubility of a non-reacting gas in a liquid is proportional to the
partial pressure of the gas if temperature is constant.
What is the site and mechanism of action of (a) curare (b) physostigmine (c) epine -
phrine (d) ergotoxin (e) ephe drine 2
A. (Adr. Pharm. , p. 96, 100, 106).
(a) Curare acts at myoneural junction.
(b) Physostigmine acts at chole nergic synapse by inhibiting the cholinies terase,
thereby allowing the acetylcholine action to be sustained.
(c) Epinephrine acts at myoneural junction by direct stimulation.
(d) Erogotoxin is sympatholytic in action, depressing the excitatory and sensory
effects of adrenalin by not affecting the inhibitory effects (vaso-dilatation and
hyperglycemia).
(e) Ephedrine acts at myoneural junction of sympathetic system.
Are the se agents modified or detoxified in the body ? If so, how and where 2
(a) Ether (b) Cyclopropane (c) Chloroform (d) Nitrous oxide (e) Pentothal
sodium (f) Procaine (g) Veronal.
A. (Adr. Chem. , p. 267; Adr. Pharm. , p. 22, 28, 3.3, 41 68, 7.4, 87).
(a) Ether is not altered.
(b) Cyclopropane is not altered.
(c) Chloroform is not altered.
(d) Nitrous oxide is not altered.
(e) Pentothal is rapidly destroyed in all tissues in the body, particularly in the
liver. The end products are eliminated in the urine.
(f) Procaine is 95% hydrolyzed in the liver, forming para-aminobenzoic acid and
diethyl-aminoethanol. The aminobenzoic acid may be acetylated.
(g) Veronal (Sodium barbital) is eliminated through the kidneys unchanged.
Discuss briefly the pharmacologic action of the following:
A tropine
Scopolarmine
Pilocarpine
Nic Otine
Caffeine
Acetylcholine
Prostigmine
Epinephrine
Morphine
Ergotamine
Metrazol
|
j
k
A. (Adr. Pharm. , p. 78, 100, 102, 103, 104, 106, 109, l 12).
(a) Atropine - Depresses the vagus nerve; produces pupillary dilatation; diminishes
secretions; depresses laryngeal reflexes; increases heart rate; decreases ga, S -
trointe stinal motility.
(b) Scopolamine - Effect similar to atropine; in addition produces psychic sedation
and annesia.
(c) Pilocarpine - Produces secretion of sweat, tears, salivary glands, digestive
glands. It produces miosis.
(d) Nicotine - Stimulates the CNS. In large doses produces convulsions. It pro-
duce s a curare -like action on skeletal muscles.
5: 17 241
72.
73.
74.
7 5.
(e) Caffeine - Causes CNS stimulation; bronchodilatation; diure sis; dilate s the
coronaries; produces a slight rise in blood pressure.
(f) Acetylcholine - Increase S gastrointe stinal peristals is; stimulates salivary,
lacrimal and sweat glands; produces broncho spasm, vasodilitation and cardiac
irregularity.
(g) Prostigmine - Produces miosis; increases gastrointestinal motility; acts on
myo-neural junction producing fibrillary twitchings; increases secretions.
(h) Epinephrine - Produces mydriasis; bronchodilatation; was on of or stimalation
including increase in blood pressure and pulse rate and coronary dilatation;
stimulates metabolism.
(i) Morphine - Depresses the CNS including the re spiratory center; decreases
gastrointestinal motility; produce 3 C on stipation, produces toiliary spasm; con -
tracts bronchi; decreases metabolism.
(j) Ergotamine - Increases uterine contractions; increased blood or e s sº re cause s
bradycardia decreases response to adr energic drugs.
(k) Metrazol - Stimulates CNS: increase s reflex activity of the cord.
What is the chemical mediator at the ganglion synapse of the syn. Øathetic system 2
A. (A dr. Pharm, , p. 106).
Acetyl choline.
How does pilocarpine act 2
A. (Goodman, p. 339).
Pilocarpine stimulates the effector cells directly. Prostigmine inactivates choline
esterase and allows acetyl choline to act for prolonged periods.
What percentage s or partial pressures of the following agents are required in the
inspired atmosphere to maintain surgical anes the sia:
Nitrous oxide
Ethylene
Cyclopropane
Di-ethyl ether
Divinyl ether (Vineth ene)
A. (Adr. Pharm. , p. 21, 24, 27, 32, 36).
(a) 85–90%
(b) 30 - 90%
(c) 7–2.3%
(d) 3.5–4.5%
(e) 4%
Give the therapeutic dose of the following drugs when they are given separately to
an average adult male, aged thirty:
(a) Chloral hydrate, rectally.
(b) Paraldehyde, orally.
(c) Dilaudid, subcutaneously.
(d) Pentobarbital sodium Orally.
A. (A dr. Pharm. , p. 139).
(a) 15-30 grains
(b) 3 cc 's.
(c) 1/32 grains
(d) 1 1/2 - 3 grains
242
5 : 1 &
76. State the advantages and disadvantages of:
77.
78.
(a)
(b)
A.
(a)
(b)
Ether by inhalation.
Tribromethanol, rectally.
(Adr. Techs. , p. 58, 190).
Advantages -- cheap: simple equipment; safest in inexpert hands.
Disadvantages -- unpleasant to patient for induction and recovery; long re-
Cove Fy period, nausea and vomiting; active excitement state; inflammable;
irritating to face and eyes; stimulates bronchial secretion; wastes a large
annount by open methods.
Advantages -- non-inflammable; quiet induction, safe for children; safe in
aTſergic states; safe in high altitudes; basal anesthetic; safety between re spira -
tory and circulatory failure.
Disadvantages -- requires special equipment and enemas; difficult to regulate
doses; irregular absorption; limits length of operating time; cannot be used in
colonic diseases; post operative sedation long; re spiratory depression.
What are the chief toxic effects of each of the following:
(d)
Cocaine hydrochloride.
Ethyl ether.
Nitrous oxide.
Carbon dioxide.
(Adr. Techs. , p. 48, 75; Lundy, p. 450).
Cocaine hydrochloride - CNS stimulation followed by depression and paralysis;
euphoria, elation, progressing to excitement convulsions, nausea and vomiting;
blood pressure depression; respiratory collapse; cyano sis.
Ethyl ether -- Re spiratory failure due to me dullary depression; fatty necro sis
of the Tiver and kidneys; re spiratory tract irritation; pulmonary complications.
Nitrous oxide – – The toxic effects are those sinnilar to anoxia of the brain, due
to the high nitrous oxide and low oxygen concentrations; vomiting, respiratory
failure; circulatory failure.
Carbon dioxide -- Gasping, depressed re spirations; pallor; blood pressure
depression; slow pulse; twitching and convulsions. (In mild doses blood pres –
sure, pulse and re spiratory depth are increased. )
List the toxic effects of each of the following:
(a)
(b)
(c)
(d)
Procaine hydrochloride.
Metrazol.
Epinephrine.
A noxia.
(Adr. Pharm. , p. 86, 109, 104, 124).
Procaine hydrochloride -- early tremor, dizziness, apprehension; later nause a
and vomiting, unconsciousness, convulsions.
Metrazol -- Tremors, convulsions, respiratory stimulation.
Epinephrine -- Early - blanching, rapid pulse, elevated blood pressure, re-
actions of fear, anxiety and dizziness; later – increase in early reactions, plus
cardiac irregularities and ventricular fibrillation.
Anoxia -- Produce s gasping, rapid respiration; elevation of blood pressure;
slow, bounding pulse; cardiac irritability and irregularity; cyanosis of skin;
muscle twitching.
5: 19 243
79. What are the chief toxic effects of each of the following:
:
(b)
(d)
Chloroform.
Cyclopropane.
Trib Fornethanol.
Pic rotoxin.
(Adr. Pharm. , p. 29, 43, 59, 119).
Chloroform: Liver function is extremely impaired and necrosis appears around
the center vein of the liver lobule. Acute yellow atrophy may be a sequela of
chloroform anesthesia. It decreases the cardiac output 30% and slow s the rate
of peripheral circulation. It increases the irritability of the heart and predis -
poses to arrhythmia and ventricular fibrillation. It causes direct myocar dial
darnage.
Cyclopropane: It has a definite tendency to cause cardiac arrhythmias which
arº due to ectopic pacermaking mechanisms. Occassionally ectopic control of
tº . . . . , t beat is so aberrant as to result in ventricular fibrillation. Elimina –
' ' . . . . . . yo lop C. p.3, nº results in rapid restoration of normal rhythm. No term –
ºf a Tºy or pe ſº, a tº sºrt damage to cardiac muscle can be demonstrated.
‘ī‘r bromethanol: (A vertin) Re spiratory depression is enhanced by premedica –
tation with morphine, and direct depression of the vasomotor centers occurs.
Large and repeated doses cause toxic effects on the liver.
Picrotoxin: Confusion, trembling and convulsions; asphyxia (CNS medullary
effects).
80. Give the signs and synoptoms when an Overdose of (a) helium; of (b) carbon dioxide,
is given to man.
A.
(a)
(b)
(Lundy, p. 446; Best, p. 421).
Helium: Overdose of helium can be expressed in terms of oxygen want. The
signs include: rising blood pressure, increase in pulse rate and hypernia,
anxiety, restles sness, muscle twitching and angina. If anoxia continues, res-
pirations become depressed and then cease; blood pressure falls and disappears;
pulse become irregular and then ceases.
Carbon dioxide: Carbon dioxide excess is first emphasized by increase in depth
of respirºton with little increase in rate. Later the respirations become de –
pressed and arrested. The blood pressure first rises and later falls. If con-
tinued, convulsions occur, and death results.
81. Administration of trichlorethylene ane Sthe sia with absorption system sometime s
produces a toxic de struction of the trigeminal nerve because:
i
A.
It selectively destroy fibers of the trigerminal.
It forms a toxic connpound with soda lime.
|Excessive dust is produced.
It produces anoxic anoxia.
It produces histotoxic anoxia.
Jc. 2 (Adr. Pharm. , 44, 45).
This agent is no longer used for the purpose of relieving trigeminal neuralgia, but has
become a useful agent for obstetrical analgesia and as an adjunctive agent for general
anesthesia. It forms toxic compounds with scº - i.ime.
5:20
82.
83.
84.
85.
How would you treat a patient:
(a) Who had a convulsion while you were performing a brachial plexus block with
procaine 2
(b) Who had severe delirium when recovering from Cyclopropane anesthesia 2
(c) Who has severe re spiratory depression after avertin has been given 2
A. (Adr. Pharm. , p. 86; Adr. Techs. , p. 155; Goodman, p. 101).
(a) Give short acting barbiturate intravenously; stop infiltration; observe for 24
hour S.
(b) If blood pressure is low, administer neosynephrine and/or blood and fluids if
there has been much blood loss during the Operative procedure; A porn Orphine –
1/32 gr. , may be used intravenously.
(c) Artificial respiration to maintain oxygenation of the blood; stimulation of the
respiratory and circulatorv systems with picrotoxin; wash out the colon with
e Ile II la S >
Over dosage of prostigmine is treated with:
(1) Physostigmine.
(2) A tropine.
(3) Morphine.
(4) Curare.
(5) Metrazol.
A. No. 2 (Adr. Chem. , p. 266).
What are the common incarnpatibilities that must be guarded against in the Operating
roorn when handling:
(a) Procaine solutions 2
(b) Sodium antal solutions ºf
A. (Goodman, p. 1323).
(a) Procaine hydrochloride has an acid pH. Therefore, solutions which are alka-
line may cause it to precipitate.
(b) Sodium armytal has an alkaline pH, and should not be mixed with solutions having
an acid pH. Syringes which have been used with acid must be thoroughly
cieansed before use with sodium anytal.
The administration of an antihistanninic to a person receiving a blood transfusion:
(i Alids in the prevention of allergic reactions.
{2} A s a tio od preservative.
{3} ºr events coagulation.
{4} ESuffers the blood,
{5} Prevents A and B agglutination.
.*
A. , No. 1 (Wilson).
Give arguments for or against:
{3. The use of carbon dioxide-oxygen mixtures for carbon monoxide poisoning.
{b} Helium-oxygen mixtures for asthma.
(c) Oxygen for aviators.
{d} Heliurn for divers.
(e)
©
**
Carbon dioxide for aviators,
-
d
(Barach, p. 26; Goodman, p. 678, 686, 690, 69.1, 698).
5: 2 i 245
87.
88.
89.
(a) 5-10% carbon dioxide is more effective than oxygen alone. The carbon dioxide
lowers the affinity of hemoglobin for carbon monoxide, allowing the oxygen and
hemoglobin to form oxy-hemoglobin more readily. It stimulates re spiration
and thus has tens the removal of the monoxide, which can be expelled from the
body in about 30 minutes.
(b) Helium is indicated in obstruction of the re spiratory tract. The patient is
often refractory to drugs and in need of oxygen. After the patient has been
made comfortable and less anoxic, the sensitivity to epinephrine may return.
80% helium and 20% oxygen is only 1/3 as heavy as air.
(c) Aviators must have oxygen for high altitudes. At 42,000 feet the he moglobin
will be 95% saturated only with the use of 100% oxygen at 10 - 12 millimeters
of mercury positive pressure.
(d) On breathing compressed air the diver has large quantities of nitrogen dis -
solved in the body fluids. When pressure is quickly released to normal, the
nitrogen is released from the fluids as gas emboli because nitrogen has high
solubility, and slow rate of diffusion. If decompression is accomplished
with helium and oxygen, the time is only 1/23 of that required for de compres–
sion with air because helium displaces the nitrogen.
(e) In normal individuals, the hyper nea and discomfort occasioned by inhalation of
10% carbon dioxide for more than a few minutes is unbearable. Hypernea is
already present from the anoxic stimuli.
How are the blood sugar and carbon dioxide combining power of the plasma affected
by surgical anesthesia with each of the following:
(a) Ether
(b) Morphine
(c) Cyclopropane
(d) Pentothal
(e) Chloroform.
A. (Adr. Pharm. , p. 35, 78, 29, 75, 42).
Carbon dioxide Blood
Combining power ugar
(a) Ether decreased increased
(b) Morphine decreased increased
(c) Cyclopropane decreased increased slightly
(d) Pentothal increased unchanged
(e) Chloroform decreased increased
Write the formula for the reaction of soda lime.
A. (Adr. Chem. , p. 78, 85).
44 grams (22.2 liters) of CO2 unite with the soda lime yielding Na Carbonate, Ca
Carbonate, and 18 grams of 2O.
2 NAOH + H2CO3 — Na2 CO3 + 2 HOH
+ CA (OH)2
Z
2NAOH + CACO 3
Anesthesia, although accompanied by convulsive phenomena, may be obtained with
what percent of CO2:
246
5:22
Q ().
Q 1.
92.
93.
(l) 5% (4) 25–30%
(2) 10% (5) 40%
(3) 10–20%
A. No. 5 (Adr. Pharm. , p. 116; Goodman, p. 686). See question 6, p. 5:40.
Under which of the following in stance S is a CO2-O2 mixture good therapy:
(1) Morphine poisoning.
(2) Barbiturate poisoning.
(3) C O poisoning.
(4) Cyanide poisoning.
(5) Fracture of skull.
A. No. 3 (Goodman, p. 372).
The principal cardiac action of digitalis is:
) It strengthens cardiac systole.
) It directly stimulates the conduction system of the heart.
) It lengthens the time of systole.
) It decreases the filling time of the heart.
) It shortens the P-R interval.
i
A. No. 1 (Gold; Goodman, p. 512).
Digitalis increases the force of the ventricular contraction. If the heart is
dilated, digitalis makes it contract and become efficient. Whether this results
from better systolic contraction or increase of heart tone is debatable. Other
effects are (a) decreased ventricular rate; (b) decreased venous pressure because
of more efficient propulsion of the blood; (c) relief of dyspnea because of decrease
in the encroachment of the engorge d veins on the alveoli; (d) decrease of edema,
due to better circulation; (e) decrease of cyanosis.
Of the following drugs, which decreases coronary blood flow:
(1) Neo synephrine
(2) Epinephrine
(3) Papaverine
(4) Pitres sin
(5) Ephe drine
A. No. 4. (Goodman, p. 405, 663).
Pitres sin causes coronary constriction.
Which vitamin is involved in the intermediate metabolism of carbohydrates:
1)
2)
3)
4)
5)
:
2
A. No. 5 (Best, p. 388).
This is a difficult question to answer. Either 3 or 5 would be correct. Nicotinic
acid and riboflavin act in the transport of hydrogen from cellular metabolites.
Thiamine also functions as a co-enzyme in decarboxylation, oxidation and other
sinnilar processes.
5 :23 247
94. Discuss briefly the advisability of using each of the following drugs in the presence
of marked increase of intracranial pressure :
95.
96.
97.
(a
(b
(c
(d
A.
(a)
Morphine
Tribromethanol (avertin)
Nitrous oxide
Glucose
(Adr. Techs. , p. 370; Lundy, p. 32).
Morphine tends to increase intracranial pressure and to depress re spiration.
The se conditions are already present with increased inter cranial pressure and
therefore morphine may aggravate them.
A vertin reduces intracranial pressure and may be used (although it depresses
re spiration).
Nitrous oxide alone is not feasible, but with high oxygen and used as a supple -
mental agent it is satisfactory.
Glucose in 50% solution produces a primary decrease in intracranial pressure
by dehydration; however, a secondary rise may result. Therefore its use is
questionable.
In neuro surgical operations you would not use one of the following because it
would increase the intracranial pressure:
l
2
3
4
5
A.
Barbiturates
A tropine
Morphine
A vertin
Nitrous oxide
No. 3 (Adr. Pharm. , p. 78).
If anoxia is not allowed to supervene, avertin and pentothal decrease intracranial
pressure. Nitrous Oxide Or atropine without anoxia have no deleterious effects.
A drop in intracranial pressure would be most likely to occur during an operation
when the anesthetic is :
Ether
Ethyl chloride
Nitrous oxide
Morphine
Pentothal
No. 5 (A dr. Pharm. , p. 74).
What effects do the following drugs and agents have on the size of a spleen of
nor mal structure :
(a)
(b)
(c)
(d)
(e)
A.
(a)
(b)
(c)
(d)
(e)
Ethe r (f) Flpinephrine
Barbitu rate (4) Ephe drine
A noxia (h) Pit tº c s sin
Chloroform (i) He morrhage
Spinal anes the Bia (j) Cyclopropane
(Adr. Pharm. , p. 33, 72, 15, 41, 93, 104, 105, 28).
Decreased (f) De C reased
Dilated (g) Dec reased
Decreased (h) Decreased
Decreased (i) Decreased
Increased 2-3 times (j) Dilated or no change
248
5: 24
98.
99.
| 00,
1 0 1.
The urinary output is not reduced by ane sthesia when it is well administered with:
(1) Ether
(2) Chloroform
(3) Local procaine infilitration
(4) Vine thene
(5) Cyclopropane
A. No. 3 (Adr. Pharm. , p. 85).
How does anesthesia with each of the following affect the white blood count post-
operatively:
(a) Ether
(b) Cyclopropane
(c) Sub dural procaine
A. (A dr. Pharm. , p. 35, 29).
(a) Ether increases WBC with maximum of 48 hours.
(b) Increases 2 or 5 times with maximum of 8 hours. Returns to normal in 48 hrs.
(c) None found.
Discuss briefly the advisability of using each of the following drugs in the presence
of hyperthyroidism:
(a) Nitrous oxide
(b) Ether
(c) Cyclopropane
(d) Epinephrine
(e) Tribromethanol (avertin)
A. (Adr. Techs. , p. 370; Lundy, p. 8, 92, 551).
(a) Nitrous oxide as the primary agent would not be satisfactory in hyperthyroid-
is m. The oxygen requirement is increased and therefore the nitrous oxide
would have to be used in an oxic concentrations. However, nitrous oxide
would be a satisfactory supplemental agent.
(b) Ether would be safe.
(c) Cyclopropane would not be the safe st to use because of the tendency already
present to cardiac irregularities and ventricular fibrillation.
(d) Epinephrine should be prohibited due to possibility of increasing the irritability
of the heart and producing ventricular fibrillation.
(e) Tribromethanol (A vertin) is very satisfactory for basal anesthesia if a high
concentration of oxygen is used.
Discuss briefly the advisability of using each of the following drugs in the presence
of diabetes:
(a) Ethyl chloride
(b) Procaine hydrochloride (Novacaine)
(c) Morphine
(d) Ether
(e) Ethylene
A. (Adr. Techs. , p. 59, 8.1, 370; Lundy, p. 25, 35).
(a) This is not a safe anesthetic for diabetics. With it the respiratory center is
depressed; the threshold to CO2 is raised; liver function is depleted; blood
lipase is increased; CO2 combining power is decreased; blood glucose is in-
creased up to 200%; ketone bodies may appear.
5:25 249
102.
103.
104.
(b) This may be used as local or spinal a nesthetic agent.
(c) It is not advisable to use morphine in large doses in the presence of uncon -
trolled diabetes. With morphine the re spiratory center is depressed; the
re spiratory rate is increased; the exchange of CO2 is decreased; and the thres -
hold to CO2 is increased. There is a tendency toward acidosis and hypergly-
cernia when morphine is used.
(d) This is not the choice of anesthetics in diabetes. Ether reduces the insulin
production and blood amylase is increased 100% blood glucose is increased
100 - 200% in 15 minutes; ketones are increased late in a nesthetic ; CO2 corn –
bining power decreases promptly on induction of anes the sia.
(e) This is a relatively safe anesthetic in diabetes if a high oxygen content is used.
Two anesthetics which commonly elevate the blood sugar are:
Ether and chloroform
Nitrous oxide and cyclopropane
Ethyl chloride and ethylene
A vertin and Procaine
l
2
3
4
5) Trichlorethylene and Cocaine.
A. No. 1 (A dr. Pharm. , p. 29, 35).
The addition of glucose as a blood preservative was begun:
(1) Ancient time s
(2) 1914
(3) 1925
(4) 1934
(5) 1944
A. No. 2 (Barton; Turner).
Discuss briefly the advisability of using:
(a) Spinal anesthesia in the presence of pernicious anemia.
(b) Pentothal sodium intravenously in the presence of dyspnoea.
A. (Adr. Techs. , p. 175, 2 17).
(a) Spinal anesthesia is contraindicated because of the possibility of causing or
hastening degenerative cord changes. From a medico-legal point of view the
patient may claim that damage was caused by the drug rather than from the
disease.
(b) Pentothal depresses the re spiratory center and the refore further decreases
the respiratory exchange. As a general rule it should not be used in such
case S except with high oxygen concentrations.
250
5:26
SUPPLEMENT I SUB - SECTION
PHARMA COLOGY
Which one of the following is not a pharmacological feature of a well-conducted
e the r anes the sia 2 -
(1) Vasodilatation
(2) Change in character of respiration
(3) Reduction of plasma volume
(4) Increase in coagulation time
(5) Depression of liver and kidney function
A. No. 4 (A dr. Pharm. , p. 35).
Coagulation time is decreased 25% .
The most efficient combination of morphine – scopolamine, as stated by Waters,
is in the following ratio:
Morphine gr. 1/x to scopolamine 1/10x
Morphine gr. 1/x to scopolamine 1 / 15x
Morphine gr. 1/x to scopolarmine 1/25x
Morphine gr. 1/x to scopolamine 1/35x
l
2
3
4
5) Morphine gr. 1/x to scopolarmine 1/40x
A. No. 3 (Waters; A dr. Pharm. , p , 120).
In the rapeutic dose S (premedicant dose s ) morphine usually produces an effect on
the re spiration in which:
(l) rate, depth, minute volume and response to carbon dioxide are diminished.
(2) rate, minute volume and response to carbon dioxide are decreased, while depth
is increased.
(3) spasmodic irregularities are increased.
(4) there is a less favorable air exchange resulting in re spiratory inefficiency.
(5) decreased pulmonary epithelial permeability exists.
A , No. 2 (A dr. Pharm. , p. 78).
If the dose of morphine sulfate to a given patient is raised from 1/2 grain to 1
grain, the pain threshold elevation may be expected to be:
(1) none.
(2) less than 20%
(3) 50%
(4) 100%
(5) 150%
A. No. 1 or 2. (Beecher; Beecher, p. 89).
Beecher states that the optimum morphine dose is 10 mg. Greater pain relief is
obtained with larger doses, but this relief is very little more, and not proportional.
Perhaps in such large doses, Answer l is correct.
Morphine sulfate when administered intravenously usually produces its maximal de -
pressant effect within:
(1) 1 - 2 minutes.
(2) 3 - 7 minutes.
(3) 15–30 minutes.
5: 27 251
7
10.
(4) 30–45 minutes.
(5) 60-90 minutes.
A. No. 2 (Goodman, p. 195).
Analgesic effects are maximal in 20 minutes but depressant effects are maximal
in 5 minutes. This depression precedes analgesic maximums.
Which one of the following is not true in regard to demerol in therapeutic doses 2
It possesses atropine – like action.
It is spasmolytic.
It is an analgesic.
It is a hypnotic.
(l
(2
(3
(4
(5) It depresses re spiration as much as morphine.
A. No. 5 (Gottschalk: A dr. Pharm. , p. 80).
Adriani states that demerol in large doses will cause the respirations to be de -
pressed. This has been noted in clinical experience. However, the effects were
not as marked as with morphine in sedating and premedicating dosages.
The accepted non-proprietary name of the drug 6 - dimethylamine-4, 4-diphenyl-3
heptanone, also called Amidone and Dolophine is :
(1) Methadon.
(2) Metapon.
(3) Meperidine.
(4) Mecholyl.
(5) Mer cre sin.
A. No. 1 (Adr. Pharm. , p. 81; Kirchof).
The concentration of glucose in water which is isotonic with the body fluids is:
(1) . 85 per cent
(2) 3.0 per cent
(3) 4.2 per cent
5.5 per cent
(5) 7. O
per cent
A. No. 4 (Goodman, p. 585).
The Lipoid theory of narcosis was advanced by:
(1) Bernard.
(2) Meyer – Overton.
(3) Burge.
(4) Traube.
(5) Warburg.
A. N.J. 2 (Adr. Pharm. , p. 9).
Narcotic drugs cause inhibition of tissue respiration by exerting their effects upon
the .
(1) Dehydrogenases.
(2) Oxidases.
(3) Peroxidases.
(4) Catalases.
(5) Anhydrases.
A. No. 1 (Best, p. 380).
252
5:28
1 1.
12.
13.
14.
15,
The theories of Krile and Warburg on dehydrogenases and oxidases and their re-
lationship to tissue re spiration are still the Oretical. No One knows how tissue
respiration takes place or how narcotics exert their effects.
The essential organic nucleus of the barbituric acid compounds is:
(1) Carbamic derivative.
(2) Ure ide.
(3) Para-aminobenzoic acid ester.
(4) Malonyl urea.
(5) A pipe ridine ring.
A. No. 4 (Adr. Pharm. , p. 65).
Which one of the following statements concerning barbiturates is incorrect 2
(1) Little change in BMR with hypnotic doses.
(2) Large doses cause myocardial depression.
(3) Cause oliguria followed by polyuria.
(4) Depress carotid sinus reflex.
(5) Minute volume exchange increased.
A. No. 5 (A dr. Pharm. , p. 70).
Hypnotic doses frequently are given before BMR's in excitable patients to insure
a basal rate.
Which one of the barbiturates listed below, in therapeutic dose, is the longest
acting 2
(1) Pentothal sodium.
(2) Nernbutal
(3) Phenobarbital
(4) Amytal
(5) Evipal
A. No. 3 (Ad r. Pharm. , p. 68).
The length of action is related to the type of product found in the urine. Those
which are eliminated unchanged act the longest. Those which are eliminated
after complete breakdown act the shorte st.
The most effective drug for the treatment of respiratory depression due to bar -
biturate s is :
(1) Coramine .
(2) Metrazol.
(3) Picrotoxin.
(4) Oxygen.
(5) Caffeine.
A. No. 4 (Adr. Techs. , p. 338).
It must be emphasized that analeptics do not help the body eliminate the barbiturates.
Giving Picrotoxin to a patient without first providing oxygen causes initial stimula -
tion to the re spiratory center and then depression.
What is the primary site of action of pic rotoxin:
(1) Heart
(2) Carotid body
(3) Sympathetic myoneural junction
5:29 253
16.
17.
18.
19.
20.
(4) Spinal cord
(5) Me dullary respiratory center.
A. No. 5 (Goodman, p. 263).
On a theoretical basis of narcosis which would seem to be the drug of choice in
treatment of severe barbiturate poisoning 2
(1) Metra zol
(2) Benze drine sulfate
(3) Picrotoxin
(4) Sodium succinate
(5) Mecholyl
A. No. 4 (Tucci).
The action of the annonium sulfate salts or the Pitcher plant distillate when used
in the subarachnoid space is :
(1) On all the spinal nerves bathed by the solution.
(2) On only the sensory nerves.
(3) On all the unmyelinated nerves.
(4) On only the sympathetic nerves.
(5) On only the unmyelinated somatic nerves (i. e. C fibers).
A. No. 5 (Judovich, p. 242).
Which one of the following is not a property of scopolanine 2
(1) Depresses the frontal lobe.
(2) Interrupts the synapse at the thalamus.
(3) Dilates the pupil.
(4) Dries the saliva.
(5) Lowers the body temperature.
A. No. 5 (Adr. Pharm. , p. 103).
Although scoplannine and all the belladonna group drugs exert an anti-sweating
effect and thus raise the body temperature, such effects usually occur with large
doses or in children, whose temperature regulating centers are unstable. Nowhere
could any effects of Scopolamine on the thalamus be found, although it is used in
Parkinsonian disease to alleviate tremors.
Which one of the following drugs does not have a direct effect on the autonomic
nervous system:
(1) DFP (di-isopropyl-fluorophosphate)
(2) BAL (British anti-Lewisite)
(3) Dibe namine
(4) Tetraethyl ammonium salts
(5) d – Tubocurarine
A. No. 2 (Adr. Pharm. , p. 97, 100; Grimson; Veterans).
BAL is used in arsenical poisoning. DFP is an anti-choline sterase. Dibenamine
is a sympathetic depressant. Tetraethyl ammonium salts (etanon) is a lytic agent
at the ganglia for both parasympathetics and sympathetics. Curare in high doses
can block sympathetic ganglia.
Which of the following agents blocks the muscarinic effect of acetylcholine 2
(1) Eserine
(2) Prostigmine
254
5 : 30
2 1.
22.
23.
24.
25.
26.
(3) A tropine
(4) Curare
(5) Ergotamine
A. No. 3 (Goodman, p. 339, 340; A dr. Pharm. , p. 102).
The nicotinic action of acetylcholine is blocked by:
(1) Atropine
(2) Curare
(3) Physostigmine
(4) Scopolamine
(5) Ergotoxine.
A. No. 2 (Adr. Pharm. , p. 97).
The parasympathetic action of atropine is accomplished by:
(1) Depressing formation of acetylcholine.
(2) Enhancing formation of choline ster as e.
(3) Depressing myoneural junction directly.
(4) Inhibiting action of acetylcholine.
(5) Stimulating adre nergic activity.
A. No. 4 (Adr. Pharm. , p. 100).
Atropine raises the threshold to action of acetylcholine but does not cause depres–
sion of the formation of acetyl choline.
Tetraethyl ammonium chloride in the rapeutic dosage acts on:
(1) The sympathetic components of the autonomic nervous system.
(2) The cranio - sacral components of the automatic nervous system.
(3) The entire autonomic nervous system.
(4) The somatic efferent components of the nervous system.
(5) The somatic afferent components of the nervous system.
A. No. 3 (Veterans).
Epinephrine is contraindicated in local anesthetic mixtures for digital blocks
because:
(1) Absorption of the drug is enhanced.
(2) Very small amounts of local anesthetic are required.
(3) Gang rene may result.
(4) The toxicity of the drug is enhanced.
(5) It produces cardiac effects.
A. No. 3 (Ad r. Chem. , p. 300).
Of the following drugs, which one cannot be sterilized by any method involving
heat, without changing the chemical structure ?
Morphine
Procaine
Neosynephrine
Epinephrine
l
2
3
4
5) Ephe drine
A. No. 4 (Adr. Chem. , p. 280; Adr. Pharm., p. 104).
Which one of the following drugs does not have a sympathetico-mimetic action:
5 : 31 255
27.
28.
29.
30.
3 1.
(1) Neosynephrine
(2) Corba sil
(3) Me peridine
(4) Ethyl ether
(5) Ephe drine
A. No. 3 (Adr. Pharm. , p. 195; A dr. Chem. , p. 275).
Dennerol has an atropine – like effect.
Physostigmine does not cause which one of the following:
(1) Dilatation of the pupils.
(2) Increased gastrointestinal tone
(3) Increased output of epinephrine
(4) Fibrillary twitchings of skeletal muscles with Over dosage.
(5) Increased secretions of mucous, salivary and sweat glands.
A. No. 1 (Goodman, p. 340, 379).
ºys ostigmine causes the effects of (2), (3), (4) and (5) and contraction of the pupil.
The dose of intravenous paraldehyde is about:
(1) 5 cc.
(2) 19 cc.
(3) 15 cc.
(4) 20 cc.
(5) 30 cc.
A. No. 1 (Ad r. Pharm. , p. 56).
Paraldehyde depresses all the following functions or organs except one:
(l) Urine formation
(2) Carotid sinus
(3) Hering – Breuer reflex
(4) Cough center
(5) Small bowel movements
A. No. 3 (Adr. Pharm. , p. 55). The cough reflex is inhibited in deep hypnosis.
A vertin is normally administered in what strength 2
(1) 1%
(2) 2.5%
(3) 5%
(4) 10%
(5) 15%
A. No. 2 (Adr. Pharm. , p. 57).
A mylene hydrate is used primarily with tribrorne thanol as which one of the
following:
(1) Pre servative
(2) Catalyst
(3) Synergist
(4) Antagonist
(5) Solvent
A. No. 5 (Adr. Chem. , p. 143).
256
5 : 32
32.
33,
34.
35,
36.
37.
Which of the following correctly indicates the respective armounts of components
of avertin fluid 2
TRIBROM ET HANOL A MYLENE HYDRATE
(1) 0. 10 grin. 0. 50 gm.
(2) 1. 00 grrl. 0. 50 gm.
(3) 0. 10 grin. 0.05 gro.
(4) 1. 50 gn. 0.01 grrl.
(5) 1. 00 gm. 0. 10 gm.
A. No. 2 (Adr. Techs. , p. 186).
A vertin fluid is not contraindicated in an individual with:
(1) Hepatic disease.
(2) Renal disease.
(3) Intra-cranial turnor.
(4) Enteritis.
(5) Shock.
A. No. 3 (Adr. Techs. , p. 191).
It is used in neurosurgery because it decreases intracranial pressure. It is also
useful in neurosurgery when the surgeons desire to use electro-cautery.
Which one of the following statements about ethyl chloride is incorrect 2
(1) Muscular relaxation is incomplete at safe depths.
(2) Ventricular fibrillation and sudden car diac arrest may occur during its use.
(3) It has a potentiality for damaging parenchymatous organs.
(4) It is more toxic than chloroform.
(5) Ethyl chloride is the same as monochlorethane.
A. No. 4 (Adr. Pharm. , p. 47).
Commercially dispensed vinyl ether has added to it 4 per cent absolute alcohol:
(1) To help keep it sterilized.
(2) To prevent formation of poisonous by-products.
(3) To decrease its volatility.
(4) To decrease its irritability.
(5) To increase its volatility.
A. No. 3 (A dr. Chern, , p. 17 1).
Procaine was first synthe sized by in 1905.
(1) Einhorn
(2) Bier
(3) Corning
(4) Hickman
(5) Priestly
A. No. 1 (Adr. Pharm. , p. 87).
Cocaine belongs to which of the following groups.
(1) Benzoic acid enters
(2) Quinoline derivatives
(3) Quinine derivative s
(4) Alcohol group
(5) Para-aminobenzoic acid ester
5 : 33 257
38.
39.
4 (9.
4 l.
42.
A. No. 1 (A dr. Pharm. , p. 89).
Which one of the following has the greate St va Soc on strictive effect when used for
topical anesthesia 2
(1) Cocaine
(2) Butyn
(3) Pontocaine
(4) Nupercaine
(5) Procaine
A. No. 1 (Goodman, p. 295, 300).
This is one of the dangerous actions of cocaine. In concentrations used for local
anesthesia, cocaine has a deleterious effect on the C or nea, resulting in cloudiness,
pitting or ulceration.
Pontocaine belongs to the .
(1) A lo Oho! group.
(2) Penzoic acid ester group.
} Para-aminobenzoic acid ester group.
) Para-ethoxybenzoic acid ester group.
) Quinoline group.
ſ
:
A No. 3 (Adr. Pharm. , p. 87).
The primary breakdown products of procaine are:
Para-aminobenzoic acid and di-ethylene glycol.
Para-arminobenzoic acid and di-ethyl annino ethanol.
Para -aminobenzoic acid and diso – quinoline.
Piperidine and di-ethyl annino ethanol.
Para -aminobenzoic acid and urea.
l
2
3
4
5
A. No. 2 (Adr. Chem. , p. 263).
You are administering cyclopropane to an Obstetrical patient; the obstetrician asks
you to suggest an oxytoxic drug for intravenous administration after the third stage,
while he is repairing his episiotomy. Which one of the following drugs would you
sugge St:
(1) Synkamin
(2) Surgical pituitrin
(3) Obstetrical pituitrin
(4) Pitocin
(5) Quinine methyl sulfate
A. No. 4 (Goodman, º º ż, , 668; Parsloe).
All posterior pituitary ºx acts have some press or effects. Coronary arteries are
& on stricted. However, ºitocin has only one-half unit of press or effect as compared
with 10 units of oxytoxic action per cc. Quinine has been used traditionally to cause
abortion, but has little practical value in the third stage.
Cyclopropane does not have which one of the following properties 2
(1) Dilatation of the spleen
(2) Bronchiolar dilatation
(3) Enhance s laryngeal reflexes
(4) It is a parasympathomimetic drug
(5) Slight elevation of the blood Sugar.
A. No. 2 (Adr. Pharm. , p. 28).
258
5 : 34
43.
Of the following anesthetic agents, which one depresses the salivary glands 2
1) Ether
2) Pentothal
3) Cyclopropane
4) Chloroform
5) Nitrous oxide
(
(
(
(
(
A. No. 2 or 5 (Adr. Pharm. , pp. 22, 41, 74).
Chloroform is supposed to stimulate the salivary glands on induction and recovery
but to depress during anesthesia. Nitrous oxide depresses during anes thesia, but
effects are present at other times. Pentothal causes production of mucus.
44. The chief danger in the use of pituitary extract in anesthesia lies in:
45.
46.
47.
1) The direct toxicity to heart muscle.
2) The marked vasoconstriction of the coronary arteries.
3) Vasodilatation which always follows the desired vasoconstriction effect.
4) Constriction of cerebral vessels.
5) Renal shutdown.
A No. 2 (Goodman, p. 663).
Under which one of the following types of anes the sia does the spleen dilate 2
(1) Ether
(2) Chloroform
(3) Nitrous oxide
(4) Ethylene
(5) Spinal
A. No. 5 (A dr. Pharm. , p. 93).
The concentration of chloroform in inhaled air necessary for light anesthesia is:
vols. per cent.
vols. per cent.
vols. per cent.
vols. per cent.
vols. per cent.
:
.
1
2
3
4
5
&
A. No. 2 (Adr. Pharm. , p. 40).
This is very variable -- one volume percent results in light anesthesia -- one and
one-half volume s percent, deep anesthesia -- two volumes percent may result in
respiratory arrest. One can see, therefore, that there is little room for poor tech-
nique with chloroform, particularly in a closed system.
Which of the following is the most irritant to the mucosa of the upper respiratory
tract, as measured by stimulation of salivary secretion ?
(1) Cyclopropane
(2) Ethylene
(3) Nitrous oxide
(4) Oxygen 20% and helium 80%
(5) Oxygen 50% and nitrogen 50%
A. No. 1 (A dr. Pharm. , p. 28).
5:35 259
48.
49.
50.
5 1.
52.
53.
After oral inge stion in the postabsorptive state, the site of maximum absorption of
ethyl alcohol is the :
(l) Stomach
(2) Jejunum
(3) A scending colon
(4) Cecum
(5) Ilium
A. No. 2 (Goodman, p. 1 120).
Oxygen demand and reflex irritability parallel the normal metabolic rate throughout
life. They reach their peak:
(1) Between 17 and 31 years
(2) In the fourth decade
(3) Between 1/2 year and 13 year s
(4) At the time of birth
(5) In patients past 50 years
A. No. 3 (Cullen, p. 33).
D F P (di-iso-flour yl-phosphate) is an effective antidote for curare because it:
(1) Destroys choline sterase.
(2) Increases the output of acetylcholine,
(3) Detoxifies curare.
(4) Makes the receptor more responsive to aſ et vlcholine.
(5) Makes the muscle more irritable.
A. No. 1 (Adr. Pharm. , p. 199; Veter ans).
Curare, in major proportion, is destroyed or liminated by the :
(l) Lungs
(2) Liver
(3) Kidney
(4) Muscle
(5) Gastrointe stinal tract
A. No. 3 (A dr. Pharm. , p. 97; Cullen, p. 1 7).
The most effective treatment clinically for an overdose of d-tubocurarine is by:
(1) Intravenous prostigmine
(2) Schaefer's method of artificial respiration
(3) Intravenous atropine
(4) Oxygen with carbon dioxide absorption ar, controlled respiration
(5) Intramuscular metrazol.
A. No. 4 (Baird).
Sodium nitrite may be used intravenously:
(1) To increase blood pressure
(2) To produce coronary vasoconstriction
(3) To lower blood pressure
(4) To decrease basal metabolic rate
(5) To treat allergic transfusion reaction.
A. No. 3 (Lundy, p. 228).
260
55,
5
6
9
57.
58.
During inhalation anesthesia, the transition from activity to inactivity of the inter –
costal muscles occurs :
(1) In all stages of anesthesia.
(2) During the third and fourth planes of the third stage.
(3) During the first and second stages. -
(4) After the patient ceases to breathe.
(5) In the recovery phase of anesthesia.
A. No. 2 (Lundy, p. 347).
P
Preganglionic nerves of the cardio-accelerator pathways are:
(1) Adrenergic.
(2) Derived from the intermediolateral celll column of the lower cervical segments.
(3) Choline rgic.
(4) Synapsed at the middle Cardiac plexus.
(5) Derived from the lower thoracic (5 – 10) segments.
A. No. 3 (Best, p. 1083).
Some fibers may be synapsed at the middle car diac plexus (also designated the
cardiac plexus).
Which of the following agents has an action on the peripheral vessels which is
opposite to that of the other four 2
(1) Papaverine hydrochloride
(2) Nicotinic acid
(3) Nitroglycerine
(4) Ergotamine tart rate
(5) His tarnine
A. No. 4 (Goodman, p. 658, 1285).
Ergotrate causes peripheral vas oc on striction. Papaverine and nitroglycerine are
given as vasodilators. Histannine cause S peripheral vasodilation, as noted in a
skin wheal. Nicotinic acid may cause flushing, itching and burning of the skin and
an increase in cutaneous temperature of 1 degree to 2 degrees C.
Which of the following statements about bromides is incorrect 2
(1) Reduces gastrointe stinal motility
(2) Excreted unchanged in urine
(3) No effect on blood pressure with ordinary doses
(4) Cause S cortical and medullary depression
(5) In ordinary doses has no effect on ventilation
A. No. 1 (Goodman, p. 157).
Goodman and Gilman state that bromides cause nausea and vomiting. That is the
reason of failure of suicides who have taken large doses of bromides. However,
the Dios Chemical Company claims that their bromide product "Neurosine" gives
relief from gastralgia. Gastralgia is defined by them to mean the central aware -
ness of gastric irritation. It is thus being used for its sedative effects.
A patient dies on the operating table. Post mortem shows death was due to carbon
monoxide poisoning. What anesthetic agent was probably used on this patient.
(1) Ethyl chloride
(2) Nitrous oxide
(3) Cyclopropane
(4) Ethylene
(5)
Divinyl oxide
5 : 37 261
59.
f) ().
A. No. 4 (A dr. Pharm. , p. 24).
Which one of the following is of little value in relieving broncho spasm 2
(1) Oxygen
(2) Aminophyllin
(3) A tropine
(4) Curare
(5) Intravenous procaine
A. No. 4 (Cullen, p. 100; Adr. Pharm. , p. 97).
Curare through its production of histannine in sensitive individuals is supposed to
cause broncho spa sm.
Which of the following statements is correct 2 By flash point is meant:
(1) The lowest temperature at which a combustible mixture ignites and continues
to burn.
) The lowest temperature at which a vapor of a liquid may be ignited.
) The temperature at which the maximum explosiveness of a gas occurs.
) The amount of heat required to change a gram of water through 19 C.
) The heat required to change a unit weight of liquid to vapor state at a given
termperature.
A. No. 2 (A dr. Pharm. , p. 135).
262
5.
SUPPL EMENT II SU B – SECTION
PHAR MA COLOGY
What proportion of cyclopropane is necessary for moderately deep (2nd plane)
surgical anes the sia:
(l) 5 to 10%
(2) 10 to l 5%
(3) 20 to 25%
(4) 30 to 35%
(5) 40 to 45%
A. No. 2 (Collins, p. 275; Adr. Pharm. , p. 27).
The most serious prognostic change in Cardiac rate or rhythmn during cyclopropane
anes the sia is :
(1) Premature ventricular extra systole s
(2) Bradycardia
(3) Bigeminal rhythm
(4) Ventricular tachycardia
(5) Trigeminal Rhythm
A. No. 4 (Best, p. 232 – 238; Goodman, p. 93).
Premature extra systole s and bradycardia are common occurrences during cyclopro-
pane anesthesia. Bigeminal or Trigeminal rhythm occurs when extra systole s are
forceful enough to open the seminular valves and are coupled with the normal beat.
If they occur every second beat it is called big eminal rhythm. If every third beat,
it is calle trigeminal rhythm. There is a compensatory pause following the extra-
systoles. This is frequently seen with overdose of digitalis. When ventricular
tachycardia occurs, it is usually a premonia or y sign of vent ricular irritability and
One of the following drugs when used with soda line may react with the sodium hy-
droxide and form dichloracetylene which is a toxic and dange tº ous connpo ind:
Chloroform
Ehylene
Ethyl chloride
Tetrachlorethylene
Trichlorethylene
i
A. No. 5 (Adr. Pharm. , p. 44).
V
ine thene is marketed in dark bottles and contain s % of , lo ohol:
(1) None
(2) .. 5%
(3) 1.5%
(4) 3.5%
(5) 10%
A. No. 4 (Adr. Pharm. , p. 36).
Nitrous oxide was first used with positive pressure by;
(1) Priestly (3) Bert
(2) Davy (2) Andrew s
(5) Hickman
A. No. 3 (Adr. Pharm. , p. 21).
5: 39 263
10.
1 1.
Anesthesia, although accompanied by convulsive phenomena, may be obtained with
what concentration of Carbon dioxide: .
(1) 5 per cent
(2) 10 per cent
(3) 10 to 20 per cent
(4) 25 to 30 per cent
(5) 40 per cent
A No. 5 (Adr. Pharm. , p. 116).
Arrhythmias occur least frequently with which of the listed an esthetic agents:
(1) Chloroform
(2) Ethylene
(3) Ethyl chloride
(4) Cyclopropane
(5) Ether -
A. No. 2 (Adr. Pharm. , p. 25).
Which of the following anesthetic agents will produce the most marked hyperglycemia:
(1) Cyclopropane
(2) Ethylene
(3) Chloroform
(4) Ethyl chloride
(5) Ethyl ether
A. No. 3 (Adr. Pharm. , p. 35 & 42; Goodman, p. 64).
Hyperglycemia of ether narcosis is due primarily to:
(1) Decrease in body metabolism
(2) Increase in metabolism during stage II
(3) Direct ether effect upon the liver
(4) Glycogenolysis due to hormonal activity
(5) Inability of liver to transform blood glucose to glycogen
A. No. 4 (Adr. Chem. , p. 378).
During ether anesthesia the human spleen:
(l) Dilates
(2) Constricts
(3) Is affected only passively by such changes as those which concern positioning
of patient on the operating table - .
(4) Is unaffected
(5) Behaves in no characteristic manner.
A. No. 2 (Adr. Pharm. , P . 34).
A patient with a blood ether level of 120 mg. per 100 cc. would show clinically:
(1) Inerbriation
(2) Death
(3) Surgical anesthesia
(4) Delerium | | `
(5) No subjective or objective symptoms
A. No. 3 (Collins, p. 84).
264
5:40
12.
13.
14,
16.
17.
In what percent solution is rectal ether in oil usually employed in an adult:
15%
25%
45%
6.5%
l
2
3
4
5) 8.5%
A. No. 4 (Collins, p. 164; Adr. Techs. , p. 197).
Cullen states that approximately a 50% mixture should be used. Collins states
that a 65% solution of ether in olive oil is usually employed.
The effect of stage l l l plane 3 of ether anesthesia intestinal activity is characterized
(1) Decrease of inte stinal contractions and maintenance of tonus
(2) Decrease in inte stinal contractions and decrease of tonus
(3) Decrease in inte stinal contractions and increase in tonus
(4) Increase in inte stinal contractions and increase in tonus
(5) Increase in intestinal contractions and decrease in tonus
A. No. 2 (Adr. Pharm. , p. 34).
The average adult dose of paraldehyde administered intravenously is:
(1)
(2) 5 to 10 cc.
(3) 15 to 20 cc.
(4) 25 to 30 c.c.
(5) 30 to 50 cc.
A. No. 2 (Adr. Pharm. , p. 56).
What is the major method of detoxification of avertin in the body:
(1) Conjugation
(2) Hydrolysis
(3) Oxidation
(4) Reduction
(5) Dearmination
A. No. 1 (Adr. Pharm. , p. 57).
A mylene hydrate is used primarily with Tribromethanol as which one of the
following:
Pre servative
Catalyst
Synergist
Antagonist
l
2
3
4
5) Solvent
A. No. 5 (Adr. Chem. , p. 191).
The preparation of avertin to be adminstered rectally in a dose of 80 mgm/kgm to
a patient weighing 1 1 0 pounds would be:
cC. avertin in 100 cc. water
C C. avertin in 90 c.c. water
C C. avertin in 150 cc. water
C C. avertin in 132 cc. water
cc. avertin in 165 cc. water
i
.
.
5:41 265
18.
1 9.
20.
2. l.
22.
A. No. 4 (A dr. Techs. , p. 187).
The Meyer-Overton theory of anesthesia is also known as the
(1) Surface tension theory
(2) Cell permeability theory
(3) Colloid the or y
(4) Oxidation inhibition the Ory
(5) Lipoid the ory
A. No. 5 (Collins, p. 249).
One of the following is incorrect:
(1) One Kilogram = 2.2 pounds
(2) One fluid ounce – 29. 57 cubic centimeters
(3) One cubic centimeter - 16. 23 minims
(4) One grain = 0.005 gms.
(5) One fluid dram = 2.652 cubic centimeter s
A. No. 4 (Adr. Chem. , p. 506; Dorland).
This is confusing. In answer 5 which states that one fluid dram equals 2.652 cc.
the dictionary states that in avoirdupois weight it equals 1/16 of an ounce so that
this is correct. However, the usual fluid dram used (a teaspoon) equals 4 cc.
The incorrect answer is 4. One grain equals 64.8 milligrams.
Which one of the following anesthetic agents is more apt to cause respiratory
arrest by oxygen want than by depth of anesthesia:
Ethylene
Ethyl chloride
Vine the ne
Chlorofor n
l
2
3
4
5) Cyclopropane
A. No. 1 (A dr. Pharm. , p. 25).
A supression of urine formation does not occur under which of the following well-
administered an esthetics:
(1) Nitrous oxide - oxygen
(2) Cyclopropane
(3) Chloroform
(4) Ether
(5) A vertin
A. No. 1 (A dr. Pharm. , p. 22).
Of the following drugs, which one has the least depressant effect on re spiration in
the therapeutic dose:
1) Denner ol
2) Paraldehyde
3) Pantopon
4) Dilaudid
5) Nembutal
A. No. 2 (Adr. Pharm. , p. 55).
Paraldehyde stimulates respiration in light hypnosis but does cause depression
with larger doses. The barbiturates cause medullary center depression with large
hypnotic doses but relatively little effects with light hypnotic doses.
266
5:42
23.
24.
25.
26.
27.
28.
Which one of the following a nesthetic agents has the least stimulating effect on
re spiration:
(1) Cyclopropane
(2) Divinyl ether
(3) Ethylene
(4) Diethyl ether
(5) Ethyl Chloride
A. No. 1 (Adr. Pharm. , p. 22).
The fourth stage of anesthesia by inhalation is characterized by:
(1) Presence of Cheyne – Stokes respirations
(2) Existence of tracheal tug
(3) Barely audible heart sounds
(4) Existence of apnea
(5) Rolling downward (inferiorly) of the eyeballs
A. No. 4 (Guedel, p. 10)
The minimal lethal dose of drug represents:
(1) That annount which cause S untoward symptoms in the average individual.
(2) The amount of drug which is fatal to 50% of animals under controlled experi-
mental conditions.
(3) The amount which is the smallest dose to have the the rapeutic effects.
(4) The largest amount which can be tolerated without producing toxic symptoms.
(5) That amount of drug which is recommended by the pharmaceutical company for
the rapeutic effects.
A. No. 2 (Goodman, p. 11).
Tachyphylaxis is that property of a drug which:
(1) Exhibits a decreasing effect from succeeding doses of the same amount of drug
(2) Prevents the production of tachycardia under anesthesia
(3) Cause s a slough after repeated injections in the same area
(4) Produces a rapid anaphylactic reaction
(5) Abolishes tactile sense
A. No. 1 (Goodman, p. 424).
This information can be found under ephe drine which has a typical tachyphylactic
action.
Which of the following is not an ester of paraminobenzoic acid:
(1) Procaine
(2) Pontocaine
(3) Butyn
(4) Nupercaine
(5) Larocaine
A. No. 4 (Adr. Pharm. , p. 83).
What concentration of procaine is isobaric with spinal fluid in the average normal
patient:
e r C ent
(1) 0.5 per cent (4) 3. 0 p
5) 3.5 per cent
(2) 2.0 per cent (
(3) 2.5 per cent
A. No. 2 (Adr. Chem. , p. 382)
5:43 267
29.
30.
3 1.
32.
33.
34.
What percentage Procaine solution is suggested by Sarnoff for differential spinal
anes the sia:
(1) (). 0.2%
(2) 0.2%
(3) 2.0%
(4) 2.8%
(5) 5.2%
A. No. 2 (Pitkin, p. 827).
Chief signs and symptoms of severe procaine poisoning are:
(1) Chills and fever, apllor, dizzine s s
(2) Convulsions, high blood pressure, fast pulse
(3) Hypotension, convulsions, re spiratory failure
(4) Dyspnea, hypotension, flushing of skin
(5) Hypertension, headache, nausea and vomiting
A. No. 3 (Adr. Pharm. , p. 85; Collins, p. 158).
Indicate the discoverer of local ane sthesia with cocaine:
(1) Nieman
(2) Wohler
(3) Corning
(4) Koller
(5) Halstead
A. No. 4 (A dr. Chem. , p. 256; Keys, p. 40).
High spinal anesthesia precludes hyperglycernia by:
Decreasing demands of metabolism
Obtunding adrenal gland stimulation
Depressing liver function directly
Enhancing glucose excretion by kidneys
(l
(2
(3
(4
(5) Compensatory activity of para sympathetic 3
A. No. 2 (A dr. Chem. , p. 378).
Involuntary defecation during spinal anesthesia occurs rarely be cause of:
(1) Inhibition of splanchnic and lumbar sympathetic s
(2) Compensatory stimulation of the vagus
(3) Paralysis of the sacral para sympathetic nerves
(4) Paralysis of defecating center
(5) Hypotension
A. No. 3 (Best, p. 585).
Best & Taylor states that inhibitory impulses of the colon are located within the
lumbar cord. There are intrinsic plexuses which control the tone of the sphincter
valve when spinal anest he sia is employed.
One of the following statements is incorrect:
(1) General ane sthetics reduce the urinary output.
(2) Cyclopropane, ethylene, spinal, do not seriously alter the blood glucose level.
(3) Cyclopropane alters the coagulation time.
(4) Ether produces an increase of the red cell volume in the peripheral blood.
(5) Pentothal produce s a decrease of the red cell volume in the peripheral blood.
268
5:44
36.
38.
39.
A. No. 3 (Adr. Pharm. , p. 29).
Cyclopropane does not alter the coagulation time. Surgeons sometimes state that
there appears to be more bleeding peripherally, but this is better attributed to the
vasodilation which cyclopropane produces rather than the increased coagulation
time. There is a slight increase in blood sugar with several of the agents mentioned
in answer 2.
Of the following drugs which one cannot be sterilized by any method involving heat
without changing the chemical structure:
(1) Morphine
(2) Procaine
(3) Neosynephrine
(4) Epinephrine
(5) Ephe drine
A. No. 4 (Adr. Pharm. , p. 104; Goodman, p. 41 l).
Which of the se recommended drugs is of least value in the treatment of acute
barbiturate poisoning:
(1) Coramine
(2) Picrotoxin
(3) Metrazol
(4) Sodium succinate
(5) Benze drine
A. No. 4 (A dr. Pharm. , p. 1 12; Barrett; Schack; Bailey).
Which of the following agents has an action on the peripheral vessels which is
opposite to that of the other four :
(1) Papaverine hydrochloride
(2) Nicotinic acid
(3) Nitroclycerine
(4) Ergotamine tartrate
(5) Histannine
A. No. 4 (Goodman, p. 483).
Tetraethyl ammonium chloride in the rapeutic dosage acts on:
(1) The sympathetic components of the autonomic nervous system
(2) The cranio-sacral components of the autonomic nervous system
(3) The entire autonomic nervous system
(4) The somatic efferent components of the nervous system
(5) The somatic afferent components of the nervous system
A. No. 3 (A dr. Pharm. , p. 100 - 106).
The nicotinic action of acetylcholine is blocked by:
(1) A tropine
(2) Curare
(3) Physostigmine
(4) Scopolamine
(5) Er gotoxine
A. No. 2 (Goodman, p. 339).
5:45 269
40.
4 1.
42.
43.
44.
The parasympathetic action of atropine is accomplished by:
Depressing formation of acetylcholine
Enhancing formation of cholinesterase
Depressing myoneural junction directly
Inhibiting action of acetylcholine
l
2
3
4
5) Stimulating adr energic activity
A. No. 4 (A dr. Chem. , p. 266).
This question should read "The action on the parasympathetic nervous system is
accomplished by". Acetylcholine formation is not interfered with, but the action of
acetylcholine on the end plate is interfered with. Acetylcholine is rapidly destroyed
by choline sterase. Other drugs such as prostigmine and physoshgm inhibiting
the action of choline sterase allow acetylcholine to act longer, giving the appearance
that the se drugs are parasympathetic stimulants. Pilocarpine increases acetylcho-
line rather than interfering with the enzymes.
A s compared with atropine, scopolamine has :
(1) Peripheral and central actions which are identical for practical purposes
(2) A weaker vagus effect but a more sedative effect
(3) A weaker vagus effect but a more excitatory central effect
(4) A similar vagus effect but a more excitatory central effect
(5) More chemical stability
A. No. 2 (Adr. Pharm. , p. 10 l).
Pitressin in addition to its vasopress or effects does one of the following:
Has diuretic activity
Has marked uterine stimulating properties
Dilates capillaries
C on stricts coronary vessels
l
2
3
4
5) Depresses peristalsis
A. No. 4 (A dr. Pharm. , p. 105; Goodman, p. 667).
There is sometimes confusion concerning the various pituitary extract products.
Pituitary extract itself contains both pitres sin and pitocin. Pitres sin causes pressor
activity and very little oxytoxic activity. Pitocin has great oxytoxic activity and
very little pressor activity, making it a good drug for use in childbirth. Pitres sin
should not be used in childbirth (or in anes the sia at all) because of its action con-
stricting all the vessels of the body including the coronary vessels.
An Outstanding pharmacological property of ephe drine is that it directly stimulates:
(1) The re spiratory center
(2) The coronary vessels
(3) The myocar dium
(4) The pylorus of the stomach
(5) The kidney pelvis
A. No. 3 (Goodman, p. 426)."
Which one of the following possesses no immediate press or effect when administered
intravenously:
(1) Arte renol
(2) Ephe drine
(3) Pituitrin
(4) Pitres sin
(5) A drenal cortical extract
270
5:46
45.
46.
47.
48.
A. No. 5 (Lundy; Smith).
One of the problems which has been brought to the attention of a nesthesiologists by
Lundy is the administration of anesthetic agents to patients who have had cortisone.
There is danger of sudden shock which does not respond to the usual resuscitative
measure s. Lundy state s that cortis one administration prior to surgery has depress –
ed adrenal cortical function. The increased stress of surgery and anesthesia on a
patient who already has depressed adrenal cortical function need not be elaborated
upon. The shock which occurs is sudden and extreme and the re is little time to
combat it once it has begun. Because of the fact that adrenal cortical extract in
doses of 50-100 mg. can be used in an emergency does not mean that it has an
innnne diate action.
How does an overdose of epinephrine usually kill:
(1) Cerebral hemorrhage
(2) Heart block
(3) Dilation of the heart
(4) Vagal stimulation
(5) Sinus tachycardia
A. No. 1 (Goodman, p. 412).
10 mgms. of ephedrine sulfate injected intravenously into man will ordinarily produce:
(1) Ventricular fibrilation
(2) No change in pulse rate
(3) Cardiac arrhythmia
(4) Increase in pulse rate
(5) Decrease in pulse rate
A. No. 4 (Adr. Pharm. , p. 104; Goodman, p. 428).
Neosynephrine in therapeutic doses in an unatropinized individual results in one of
the following:
(1) Tachycardia due to direct cardiac stimulation
(2) Bradycardia due to vagal stimulation and lengthening of diastole
(3) Diminution in cardiac size
(4) Sufficient vasocon striction to produce demonstrable tissue necrosis
(5) Ventricular fibrillation under cyclopropane anesthesia
A. No. 2 (Collins, p. 3 17; Thomas).
Collins states that neosynephrine causes bradycardia, either by compensatory
action (after its peripheral vasoconstrictor effect has occurred) or by direct depres–
sion of the SA node. By increasing the tone of the peripheral arterioles the blood
pressure is raised. This causes an increased pressure in the carotid sinus which
results in a slowing of the pulse. Thomas, in his discussion states that neo syne –
phrine causes a slowing of the pulse by its action in stimulating the vagus nerve.
An asthmatic attack is often relieved by certain drugs as epinephrine because they:
) Inhibit laryngospasm
) Lessen spasm of alveolar ducts
) Inmprove circulation of the bronchial tree
)
)
Stimulate ciliary action of the mucosa, facilitating rapid removal of secretions
Directly relax bronchiolar muscles
i
A.
No. 5 (Adr. Pharm. , p. 104).
5:47 271
49.
5 0.
5 1.
52.
A nervous and excited patient was admitted in a severe attack of typical bronchial
asthma. Of the following Orders written by an interne which would you consider
the most ill advised:
(1) Epinephrine 0.5 cc. of a 1:1000 solution sc.
(2) Aminophylline 0.5 gms. in 250 cc. of 10% dextrose solution
(3) Pentobarbital 0. gms. by mouth
(4) Dilau did 4 mg rh.. sc.
(5) Potassium Iodide, saturated solution 0.3 cc. in milk q. 4 hrs.
A. No. 4 (Adr. Pharm. , p. 79; Goodman, p. 200).
This patient in a severe type of bronchial asthma might have been given epinephrine
or anninophylline to alleviate his attack despite the fact that he was nervous. Pento-
barbital and potassium iodide may help after the acute episode has been treated.
However, dilaudid should never be given because it stimulate s the bronchial muscu-
lature to contract just as does norphine.
The anesthesia in progress has been cyclopropane curare; at its termination pros –
tigmine is given and broncho spasm develops. The broncho spasm is due to exaggera-
ted vagovagal reflexes because the prostigmine :
(1) Antagonized the parasympathetic depression of curare
(2) Exaggerated the parasympathetic stimulation of cyclopropane
(3) Released an increased amount of acetylcholine
(4) Decreased the amount of choline ster a se
(5) Decreased the amount of acetylcholin -
A. No. 2 (Adr. Pharm. , p. 100; Adr. Chem. , p. 266).
Curare and cyclopropane have been used for this patient, both of which are parasym -
pathomimetic agents. Prostigmine inhibits the action of cholinesterase. Hydrolysis
of acetylcholine is decreased and therefore acetylcholine can act over a longer period
of time. With loss of choline ster as e by the prostigmine the cyclopropane parasym –
pathomimetic effects may also have come into play. Answer 4 is the answer chosen
as the most important cause.
Concerning the fate and excretion of the following drugs, one of the following state -
ments is incorrect:
(1) Curare is partly destroyed by the liver, and the remainder is eliminated un-
changed by the kidney.
(2) Tribromethanol is detoxified by the liver and excreted by the kidneys.
(3) Thiobarbiturates are almost completely excreted unchanged by the kidneys.
(4) Nitrous oxide, ethylene, cyclopropane, ether are excreted unchanged, chiefly
through the lungs.
(5) Local anesthetic drugs are chiefly destroyed by the liver
A. No. 3 (Adriani's Pharm. , p. 74).
Generalized pruritis and/or itchy nose in the premedicated patient is most likely
due to:
(1) Atropine
( ) Morphine
(3) Nembutal
(4) Hyoscine
(5) Demer ol
A. No. 2 (Adr. Pharm. , p. 78).
272
5:48
53.
54.
55.
56.
57.
58.
Which one of the se lºcaloids is not a natural component of opium ?
(1) Morphine
(2) Papaverine
(3) Codeine
(4) Narcotine
(5) Dilaudid
A. No. 5 (Collins, p. 68).
The leucocytes following cyclopropane anes the sia are:
(1) Decreased 2 or 3 time s
(2) Unchanged
(3) Increased 2 or 3 time s
(4) Decreased slightly
(5) Increased slightly
A. No. 3 (Adr. Pharm. , p. 29),
Narcotic drugs cause inhibition of tissue re spiration by exerting their effects
upon the :
l) Dehydrogenases
2) Oxidase s
3) Per oxidase s
4) Catalases
5) Anhydrases
A. No. 1 (Adr. Pharm. , p. 8).
The essential organic nucleus of the Barbituric acid compounds is:
(1) Carbamic derivative
(2) Ure ide
(3) Paramino – -benzoic acid ester
(4) Malonyl urea
(5) A piperidine ring
A. No. 4 (Adr. Pharm. , p. 7; Goodman, p. 126).
Which is not correct 2 Cyclopropane is:
(1) Stored as a liquid
(2) Induce s an esthesia when used in concentrations of 20–25%
(3) An agent which causes a decrease in spleen volume
(4) Prepared form K, 3 di-chlor propane
(5) An isomer of propylene
A. No. 3 (Adr. Pharm., p. 28),
If you discovered the boiling point at sea level of an anesthetic agent to be 36 o C.,
the agent in question would be:
Cyclopropane
Ethylene
Ethyl ether
Vine the ne
Chloroform
i
A. No. 3 (Adr. Pharm. , p. 32).
5:49 273
52 The principal cardiac action of digitalis:
60.
(1) Strengthens cardiac systole
(2) Directly stimulates conduction system of the heart
(3) Lengthens the time of systole
(4) Decreases filling time of the heart
(5) Shortens the P – R inter val
A. No. 1 (Goodman, p. 505).
Which of the se drugs is not a sympathomimetic annine:
(1) Epinephrine
(2) Priscoline
(3) Neosynephrine
(4) Ephe drine
(5) Pare drinol
A. No. 2 (Grimson).
274
5:50
- & - - -
HNMF;|TYQEMICHIGAN *,
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i–ºr-º-
DATE DUE
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ſ UUL J. & 1964