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Ebook PDF Basic Essentials A Comprehensive Review For The Anesthesiology Basic Exam 1St Edition Ebook PDF Full Chapter
Ebook PDF Basic Essentials A Comprehensive Review For The Anesthesiology Basic Exam 1St Edition Ebook PDF Full Chapter
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DOI: 10.1017/9781108235778
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To my supportive family, loving husband and the
inspirational mentors who have paved the way …
Alopi
vii
Contents
viii
Contributors
x
List of Contributors
xi
Preface
The ABA Staged examinations consist of the BASIC, Advanced • Basic Sciences (24%): 44–52 questions
and Applied Exams. The BASIC Exam was first introduced in • Clinical Sciences (36%): 65–79 questions
2014 in a series of exams that eventually allows resident anes- • Organ-based Basic and Clinical Sciences (37%): 66–82
thesiologists to become American Board of Anesthesiology questions
(ABA) certified. Candidates can take the BASIC exam after • Special Problems or Issues in Anesthesiology (3%): 4–8
completing their Clinical Anesthesia (CA) for one year. This questions
exam focuses on the scientific basics of clinical anesthetic
practice with a focus on pharmacology, physiology, anatomy, Test Preparation
anesthesia equipment and monitoring.
This comprehensive review for the BASIC examination is based
As with most examinations, the BASIC examination may
on the ABA content outline. Each chapter contains a thorough
induce a great deal of stress for resident anesthesiologists; how-
summary of each of the required content categories and sub-
ever, with the appropriate resources, the candidates can pass
categories. We recommend you to use this book to annotate
the exam on their first attempt. Per the ABA, a diplomate of the
into as you learn more high-yield information from various
Board must possess “knowledge, judgment, adaptability, clini-
resources. This book is meant to be an ultimate source of high-
cal skills, technical facility, and personal characteristics suf-
yield information as you take notes into it over three years of
ficient to carry out an entire scope of anesthesiology practice
anesthesiology residency. The BASIC exam will focus on many
without accommodation or with reasonable accommodation.”
facets of anesthetic management from basic pharmacology and
The examination provides a means for the ABA to evaluate if a
physiology to the application of these details to clinical man-
candidate has attained a certain level of proficiency to proceed
agement. This book is a good foundation to obtain high-yield
with advanced training. The BASIC Essentials book is meant
information; however, use of multiple resources including text-
to provide a comprehensive review of the content for the ABA
books, articles, and question banks is recommended.
BASIC exam. Detailed information is also available on the
The key to being prepared for the BASIC exam is to start
ABA website (www.theaba.org) and the booklet of information
studying early. Start reading textbooks, doing questions, and
published on the website.
annotating into this review book early on in residency, so when
time comes to really start studying you will be well equipped
Exam Structure with a great source of information – all in one place!
The BASIC examination is a computer-based test that is admin-
istered in numerous test centers across the country. The exam Test Day Tips
consists of 200 questions and examinees are given four hours Just like most exams you’ve taken thus far, this exam can be
to complete the examination. The questions consist of only A anxiety provoking. The key is to stay calm and have faith in
type. A-type questions are multiple choice questions with a sin- your preparation. As with any exam, start your day by eating
gle best answer out of four choices that require the application a well-balanced and nutritious breakfast. Wear something
of knowledge as well as recall of factual information. The ques- comfortable. Go through the tutorial the day of the exam. It
tions can be simply stated or include a brief clinical scenario. may seem like a waste of time but can help ease you into the
Some questions will require interpretation of an image. exam by preparing you for how to use the tools on the screen
rather than trying to find them later. Pace yourself during the
Exam Content exam even if it means leaving a question “marked” so you can
The BASIC exam covers four content categories: basic sciences, return to it later. There will be questions where you don’t know
clinical sciences, organ-based basic and clinical sciences, and the answers, and it is perfectly reasonable to return to those
special problems or issues in anesthesiology. The examination questions so you can move on to questions that you may know
outline can be found on the ABA website. Per the ABA, the the answers. There is no penalty for guessing, so do NOT leave
breakdown of the questions is as follows: an answer blank. There is a 25 percent chance that you pick
xiii
Preface
the correct answer even if you cannot eliminate any answer don’t feel like you need to because that mental break will help
choices. Read each question carefully and look for key words. you stay focused for the second half. If you have time left at the
When time comes for the break, use it. There is no reason to end of the exam, use it to review your marked questions or even
power through the entire exam without taking a break. Use this the entire exam if you have time. Be hesitant to change your
time to hydrate, eat a snack, or use the restroom even if you answers and second guess yourself.
xiv
Chapter
Anatomy
1
Chapter 1: Anatomy
Chassaignac’s tubercle
• Another name for the anterior tubercle of the transverse Chest
process of C6
• Lies just posterior to the carotid artery, which can be
compressed upon this structure to increase vagal tone via
Surface Landmarks
Trachea
carotid massage
• Begins at C6 and continues inferiorly until it bifurcates at
• Marks the approximate location of the vertebral artery,
the primary carina
which enters deep to this structure into the spinal column
• This bifurcation occurs at the level of the sternal angle, or
after rising from the subclavian artery
Angle of Louis, which is the joint between the sternum and
• Clinically used to identify the appropriate location to per-
manubrium and the connection of the T2 costal cartilages.
form nerve blocks of the brachial plexus, cervical plexus,
This structure also marks the approximate level of the
and stellate ganglion
T4–T5 intervertebral disk.
Vertebrae prominens
Lungs
• Another name for the spinous process of the C7 vertebral
body • Are divided into their lobes by the structures called fissures
• This spinous process is the most prominent in the • Three lobes on the right and two lobes on the left plus the
majority of patients (can be C6 or T1 in small subset of lingual
patients). • Fissures
• Bilaterally, the oblique fissure divides the superior and
Stellate ganglion inferior lobes on the left and superior and middle lobes
• Named for its “star-like” appearance on the right.
• Is the fusion of the inferior cervical and first thoracic • The fissures begin posteriorly at the level of T4,
sympathetic ganglia traveling caudally and laterally, and then around the
• Located lateral to the vertebral body of C7 torso to terminate anteriorly approximately at the level
• Blockade of this structure is clinically useful for the of the seventh rib on the midclavicular line.
treatment of sympathetically mediated pain syndromes, • The right lung is divided a second time by the hori-
such as complex regional pain syndrome (CRPS) or zontal fissure, which begins anteriorly approximately
Raynaud’s phenomenon. at the fourth costal cartilage and traverses laterally to
• Side effect associated with stellate ganglion blockade the anterior axillary line, where it intersects with the
is Horner’s syndrome (e.g., ptosis, anhidrosis, miosis), oblique fissure at the level of the fifth rib. This fissure
and may frequently occur following many of the demarcates the border between the inferior and mid-
cervical and brachial plexus nerve blocks. dle lobes.
Brachial plexus Heart
• Provides cutaneous and motor innervation to the upper • Point of maximal impulse (PMI)
extremity • Landmark for the apex of the heart located at level of the
• Lies between the anterior and middle scalene muscles in fifth intercostal space (ICS) 6–10 cm lateral to midline
the neck before running alongside the subclavian and • Auscultation zones
axillary arteries • Aortic: Second ICS right upper sternal border
• Pulmonary valve: Second ICS left upper sternal border
Radiological Anatomy • Tricuspid valve: Fourth left ICS on the sternal border
See Figure 1.2. • Mitral valve: Fifth left ICS midclavicular line
2
Chapter 1: Anatomy
Figure 1.3 Normal radiograph of the chest. Superimposed on this image are outlines of some of the major topographical landmarks of the chest.
Figure 1.4 Transesophageal echo (TEE) image depicting normal anatomy of the heart
Axillary artery
• Direct continuation of the subclavian artery, it begins at the Upper Extremity Innervation
border of the first rib, coursing laterally until the border of Brachial plexus
the teres muscle where it becomes the brachial artery.
• Originates from a complex network of nerves formed by
Brachial artery ventral rami of C5–T1
• The pulsation that is typically felt just medial to the biceps • Provides sensory and motor innervation of the upper
brachii tendon at the cubital fossa extremities. Clinically, the anesthesiologist can provide
• Subsequently bifurcates into the radial and ulnar arteries surgical anesthesia to the upper extremity via blockade of
(Figure 1.5) the brachial plexus (see Box 1.1)
4
Chapter 1: Anatomy
Figure 1.6 Normal anatomical relationships of the major vessels, nerves, bones, and muscles of the popliteal fossa
• ROOTS: After exiting the spinal column, the C5–T1 roots Intercostobrachial nerve
split and recombine to form the superior (C5–C6), middle • Skin over axilla and medial arm is the only part of the arm
(C7), and inferior (C8–T1) trunks, which lie between the not innervated by the brachial plexus.
anterior and middle scalene muscles. • Intercostobrachial nerve which is derived from T2–T3
• TRUNKS: Further split into anterior and posterior • If not blocked separately, can contribute to tourniquet
divisions pain (Figure 1.7)
• Superior trunk gives rise to the suprascapular nerve
which innervates 70 percent of the shoulder joint. Of Lower Extremity Vasculature
the brachial plexus blocks, the interscalene block (ISB) Small saphenous vein
is the only one that blocks this nerve. It is also the only • Begins posterior to the lateral malleolus and extends
block that can be used for shoulder surgery without proximally on the posterior lower leg until the popliteal
supplementation. fossa, where it drains into the popliteal vein
• Roots/trunks are blocked for the ISB. Popliteal vein
• Due to proximity, the phrenic nerve, stellate ganglion, • Lies between the popliteal artery and the tibial nerve at the
superficial cervical plexus, recurrent laryngeal nerve, popliteal fossa (Figure 1.6)
and CN XI are frequently blocked with ISB. • Continues proximally through the adductor magnus
• DIVISIONS: Recombine into the lateral, medial, and pos- muscle, where it becomes the femoral vein
terior cords, which are named for their relationship with
the subclavian artery Great saphenous vein
• Level of blockade for supraclavicular block • Longest vein in the body. Typically found superficially at
• CORDS: Split further and recombine to form the terminal the dorsum of the foot medial to the medial malleolus
branches • Commonly cannulated in pediatrics for peripheral venous
• Level of blockade for infraclavicular block access
• BRANCHES: • Used as a landmark to block the saphenous nerve at the
• There are five major terminal branches of the brachial ankle. It innervates the medial aspect of the foot
plexus, including: • Courses proximally on the medial surface of the leg before
■■ Axillary nerve (C5–C6) entering the fossa ovalis to empty into the femoral vein on
■■ Musculocutaneous nerve (C5–C7) the anterior thigh near the inguinal crease
■■ Radial nerve (C5–T1) Femoral artery
■■ Median nerve (C5–T1) • Arises as the direct continuation of the external iliac artery
■■ Ulnar nerve (C8–T1) • Lies just lateral to the femoral vein at the inguinal ligament
5
Chapter 1: Anatomy
• Divides into superficial femoral artery and profunda ■■ Common peroneal nerve
femoris ■■ Supplies the muscles of anterior compartment of leg
• The profunda femoris (deep artery of the thigh) pro- • Blockade or damage results in foot drop
vides vascular supply to the structures of the thigh.
Cutaneous innervation of the distal lower extremity, ankle,
• The superficial femoral artery courses posteriorly and
and foot is supplied by a combination of five nerves – four derived
distally until resurfacing at the popliteal fossa as the
from the sciatic nerve and one derived from the femoral nerve
popliteal artery.
(Figure 1.8).
Popliteal artery • Sciatic branches (all of these can be blocked at once with a
• Divides into two major branches: anterior and posterior popliteal block)
tibial arteries • Tibial nerve: Provides sensory innervation to the heel
• Anterior tibial artery and plantar surface of the foot
• Terminates as the dorsalis pedis (DP) artery ■■ Blocked by injection next to PT pulsation posterior
• DP pulse can be palpated on the dorsal surface of the to medial malleolus
foot between the extensor hallicus longus and extensor • Superficial peroneal nerve: Sensory to the dorsum of
digitorum longus tendons. the foot
• DP pulse is a landmark for deep peroneal nerve block- ■■ Blocked by superficial infiltration of local anes-
ade which innervates the space between the first and thetic between medial and lateral malleoli
second toes. • Deep peroneal nerve: Sensory to the web space
• Posterior tibial artery (PT) between the first and second toes
• Pulsation can be felt posterior to the medial malleolus ■■ Blocked at the intermalleolar axis by injection
at the ankle. posterior to the extensor hallicus longus tendon
• PT pulse is a landmark for blockade of the posterior ■■ Blocked at the dorsum of the foot by injecting next
tibial nerve which innervates the plantar aspect of the to DP pulsation
foot (Figure 1.7). • Sural nerve: Derived from both the tibial and common
peroneal nerves. Provides sensory innervation to the
Lower Extremity Innervation posterior lower leg and lateral ankle
■■ Blocked by injection of local anesthetic between
Lumbar plexus
lateral malleolus and Achilles tendon
• Originates from a complex network of nerves formed by
ventral rami of T12–L4 • Femoral branch
• Gives rise to femoral, obturator, lateral femoral cutaneous, • Saphenous nerve provides sensory innervation at the
ilioinguinal, genitofemoral, and iliohypogastric nerves medial lower leg and medial ankle and foot.
• Femoral nerve (L2–L4): ■■ Blocked by injection medial to medial malleolus
next to great saphenous vein
• Found deep into the inguinal ligament lateral to the
femoral artery Box 1.2 lists some of the normal anatomical relationships
and topographic landmarks associated with nerve blocks of the
• Provides motor innervation to the muscles for knee
lower extremities.
extension. Blockade of the femoral nerve results in
80 percent reduction in quadriceps strength
• Sensory innervation anterior and medial thigh via two
Radiological Anatomy
anterior cutaneous branches See Figures 1.9–1.11.
• Lateral femoral cutaneous nerve (LFCN) (L2–L3):
• Provides only cutaneous innervation of the lateral thigh
Spinal Anatomy, Landmarks,
• Obturator nerve (L2–L4): and Dermatomes
• Innervates the adductor muscles Surface Landmarks
• Sensory innervation varies within the population:
Box 1.3 describes some of the clinically relevant surface land-
■■ One-third posterior knee, one-third medial thigh, marks, and important key sensory and motor areas of innervation.
one-third no innervation
Sacral plexus (L4–S4) Spinal Anatomy
• Sciatic nerve (L4–S3) Vascular supply
• Front of the piriformis muscle, traveling distally • Anterior two-third of spinal cord receives its blood supply
toward the popliteal fossa from a single anterior spinal artery, which arises from the
• Two major branches vertebral arteries.
■■ Tibial nerve • Receives branches from 6–8 radicular arteries, most
• Motor function of all the muscles of the poste- important of which is the artery of Adamkiewicz,
rior compartment of the leg arising most commonly from T9–T12
6
Chapter 1: Anatomy
Figure 1.7 Distribution of the major cutaneous nerve branches of the upper and lower extremities
7
Chapter 1: Anatomy
Figure 1.8 Normal anatomical relationship of the major vessels, nerves, bones, and the ankle
I see increasing reason to believe that the view formed some time
back as to the origin of the Makonde bush is the correct one. I have
no doubt that it is not a natural product, but the result of human
occupation. Those parts of the high country where man—as a very
slight amount of practice enables the eye to perceive at once—has not
yet penetrated with axe and hoe, are still occupied by a splendid
timber forest quite able to sustain a comparison with our mixed
forests in Germany. But wherever man has once built his hut or tilled
his field, this horrible bush springs up. Every phase of this process
may be seen in the course of a couple of hours’ walk along the main
road. From the bush to right or left, one hears the sound of the axe—
not from one spot only, but from several directions at once. A few
steps further on, we can see what is taking place. The brush has been
cut down and piled up in heaps to the height of a yard or more,
between which the trunks of the large trees stand up like the last
pillars of a magnificent ruined building. These, too, present a
melancholy spectacle: the destructive Makonde have ringed them—
cut a broad strip of bark all round to ensure their dying off—and also
piled up pyramids of brush round them. Father and son, mother and
son-in-law, are chopping away perseveringly in the background—too
busy, almost, to look round at the white stranger, who usually excites
so much interest. If you pass by the same place a week later, the piles
of brushwood have disappeared and a thick layer of ashes has taken
the place of the green forest. The large trees stretch their
smouldering trunks and branches in dumb accusation to heaven—if
they have not already fallen and been more or less reduced to ashes,
perhaps only showing as a white stripe on the dark ground.
This work of destruction is carried out by the Makonde alike on the
virgin forest and on the bush which has sprung up on sites already
cultivated and deserted. In the second case they are saved the trouble
of burning the large trees, these being entirely absent in the
secondary bush.
After burning this piece of forest ground and loosening it with the
hoe, the native sows his corn and plants his vegetables. All over the
country, he goes in for bed-culture, which requires, and, in fact,
receives, the most careful attention. Weeds are nowhere tolerated in
the south of German East Africa. The crops may fail on the plains,
where droughts are frequent, but never on the plateau with its
abundant rains and heavy dews. Its fortunate inhabitants even have
the satisfaction of seeing the proud Wayao and Wamakua working
for them as labourers, driven by hunger to serve where they were
accustomed to rule.
But the light, sandy soil is soon exhausted, and would yield no
harvest the second year if cultivated twice running. This fact has
been familiar to the native for ages; consequently he provides in
time, and, while his crop is growing, prepares the next plot with axe
and firebrand. Next year he plants this with his various crops and
lets the first piece lie fallow. For a short time it remains waste and
desolate; then nature steps in to repair the destruction wrought by
man; a thousand new growths spring out of the exhausted soil, and
even the old stumps put forth fresh shoots. Next year the new growth
is up to one’s knees, and in a few years more it is that terrible,
impenetrable bush, which maintains its position till the black
occupier of the land has made the round of all the available sites and
come back to his starting point.
The Makonde are, body and soul, so to speak, one with this bush.
According to my Yao informants, indeed, their name means nothing
else but “bush people.” Their own tradition says that they have been
settled up here for a very long time, but to my surprise they laid great
stress on an original immigration. Their old homes were in the
south-east, near Mikindani and the mouth of the Rovuma, whence
their peaceful forefathers were driven by the continual raids of the
Sakalavas from Madagascar and the warlike Shirazis[47] of the coast,
to take refuge on the almost inaccessible plateau. I have studied
African ethnology for twenty years, but the fact that changes of
population in this apparently quiet and peaceable corner of the earth
could have been occasioned by outside enterprises taking place on
the high seas, was completely new to me. It is, no doubt, however,
correct.
The charming tribal legend of the Makonde—besides informing us
of other interesting matters—explains why they have to live in the
thickest of the bush and a long way from the edge of the plateau,
instead of making their permanent homes beside the purling brooks
and springs of the low country.
“The place where the tribe originated is Mahuta, on the southern
side of the plateau towards the Rovuma, where of old time there was
nothing but thick bush. Out of this bush came a man who never
washed himself or shaved his head, and who ate and drank but little.
He went out and made a human figure from the wood of a tree
growing in the open country, which he took home to his abode in the
bush and there set it upright. In the night this image came to life and
was a woman. The man and woman went down together to the
Rovuma to wash themselves. Here the woman gave birth to a still-
born child. They left that place and passed over the high land into the
valley of the Mbemkuru, where the woman had another child, which
was also born dead. Then they returned to the high bush country of
Mahuta, where the third child was born, which lived and grew up. In
course of time, the couple had many more children, and called
themselves Wamatanda. These were the ancestral stock of the
Makonde, also called Wamakonde,[48] i.e., aborigines. Their
forefather, the man from the bush, gave his children the command to
bury their dead upright, in memory of the mother of their race who
was cut out of wood and awoke to life when standing upright. He also
warned them against settling in the valleys and near large streams,
for sickness and death dwelt there. They were to make it a rule to
have their huts at least an hour’s walk from the nearest watering-
place; then their children would thrive and escape illness.”
The explanation of the name Makonde given by my informants is
somewhat different from that contained in the above legend, which I
extract from a little book (small, but packed with information), by
Pater Adams, entitled Lindi und sein Hinterland. Otherwise, my
results agree exactly with the statements of the legend. Washing?
Hapana—there is no such thing. Why should they do so? As it is, the
supply of water scarcely suffices for cooking and drinking; other
people do not wash, so why should the Makonde distinguish himself
by such needless eccentricity? As for shaving the head, the short,
woolly crop scarcely needs it,[49] so the second ancestral precept is
likewise easy enough to follow. Beyond this, however, there is
nothing ridiculous in the ancestor’s advice. I have obtained from
various local artists a fairly large number of figures carved in wood,
ranging from fifteen to twenty-three inches in height, and
representing women belonging to the great group of the Mavia,
Makonde, and Matambwe tribes. The carving is remarkably well
done and renders the female type with great accuracy, especially the
keloid ornamentation, to be described later on. As to the object and
meaning of their works the sculptors either could or (more probably)
would tell me nothing, and I was forced to content myself with the
scanty information vouchsafed by one man, who said that the figures
were merely intended to represent the nembo—the artificial
deformations of pelele, ear-discs, and keloids. The legend recorded
by Pater Adams places these figures in a new light. They must surely
be more than mere dolls; and we may even venture to assume that
they are—though the majority of present-day Makonde are probably
unaware of the fact—representations of the tribal ancestress.
The references in the legend to the descent from Mahuta to the
Rovuma, and to a journey across the highlands into the Mbekuru
valley, undoubtedly indicate the previous history of the tribe, the
travels of the ancestral pair typifying the migrations of their
descendants. The descent to the neighbouring Rovuma valley, with
its extraordinary fertility and great abundance of game, is intelligible
at a glance—but the crossing of the Lukuledi depression, the ascent
to the Rondo Plateau and the descent to the Mbemkuru, also lie
within the bounds of probability, for all these districts have exactly
the same character as the extreme south. Now, however, comes a
point of especial interest for our bacteriological age. The primitive
Makonde did not enjoy their lives in the marshy river-valleys.
Disease raged among them, and many died. It was only after they
had returned to their original home near Mahuta, that the health
conditions of these people improved. We are very apt to think of the
African as a stupid person whose ignorance of nature is only equalled
by his fear of it, and who looks on all mishaps as caused by evil
spirits and malignant natural powers. It is much more correct to
assume in this case that the people very early learnt to distinguish
districts infested with malaria from those where it is absent.
This knowledge is crystallized in the
ancestral warning against settling in the
valleys and near the great waters, the
dwelling-places of disease and death. At the
same time, for security against the hostile
Mavia south of the Rovuma, it was enacted
that every settlement must be not less than a
certain distance from the southern edge of the
plateau. Such in fact is their mode of life at the
present day. It is not such a bad one, and
certainly they are both safer and more
comfortable than the Makua, the recent
intruders from the south, who have made USUAL METHOD OF
good their footing on the western edge of the CLOSING HUT-DOOR
plateau, extending over a fairly wide belt of
country. Neither Makua nor Makonde show in their dwellings
anything of the size and comeliness of the Yao houses in the plain,
especially at Masasi, Chingulungulu and Zuza’s. Jumbe Chauro, a
Makonde hamlet not far from Newala, on the road to Mahuta, is the
most important settlement of the tribe I have yet seen, and has fairly
spacious huts. But how slovenly is their construction compared with
the palatial residences of the elephant-hunters living in the plain.
The roofs are still more untidy than in the general run of huts during
the dry season, the walls show here and there the scanty beginnings
or the lamentable remains of the mud plastering, and the interior is a
veritable dog-kennel; dirt, dust and disorder everywhere. A few huts
only show any attempt at division into rooms, and this consists
merely of very roughly-made bamboo partitions. In one point alone
have I noticed any indication of progress—in the method of fastening
the door. Houses all over the south are secured in a simple but
ingenious manner. The door consists of a set of stout pieces of wood
or bamboo, tied with bark-string to two cross-pieces, and moving in
two grooves round one of the door-posts, so as to open inwards. If
the owner wishes to leave home, he takes two logs as thick as a man’s
upper arm and about a yard long. One of these is placed obliquely
against the middle of the door from the inside, so as to form an angle
of from 60° to 75° with the ground. He then places the second piece
horizontally across the first, pressing it downward with all his might.
It is kept in place by two strong posts planted in the ground a few
inches inside the door. This fastening is absolutely safe, but of course
cannot be applied to both doors at once, otherwise how could the
owner leave or enter his house? I have not yet succeeded in finding
out how the back door is fastened.