WorksheetsBGHMC CV Module 2025 Quiz D
Total questions: 50
Worksheet time: 38mins
An 82-year-old with symptomatic severe aortic stenosis (AVA 0.6 cm²), GI bleeding stabilized, now requires urgent right hemicolectomy. In the OR after minimal doses of etomidate and fentanyl, MAP falls to 52 mmHg, HR 86, sinus rhythm. Best immediate step?
Titrate phenylephrine to restore diastolic pressure and coronary perfusion.
Titrate ephedrine to improve heart rate and contractility.
Titrate nitroglycerin to reduce wall stress and preload.
Titrate esmolol to reduce myocardial oxygen demand.
Titrate norepinephrine only after a 1 L crystalloid bolus.
A 68-year-old with ischemic cardiomyopathy (EF 25%), ARNI continued morning-of, becomes profoundly vasoplegic after induction. Best vasopressor plan?
Titrate norepinephrine as first-line and add vasopressin if refractory.
Titrate phenylephrine as first-line and add ephedrine if refractory.
Titrate epinephrine as first-line and add milrinone if refractory.
Titrate dopamine as first-line and add nitroprusside if refractory.
Titrate vasopressin as sole agent throughout the case.
During thoracotomy with one-lung ventilation (FiO₂ 1.0), after recruitment and proper lateral decubitus, SpO₂ falls from 95%→86%. Best next maneuver?
Apply CPAP 2–5 cmH₂O with oxygen to the non-dependent lung.
Increase desflurane to deepen anesthesia and reduce oxygen consumption.
Increase PEEP to 14 cmH₂O on the dependent lung immediately.
Add nitroprusside to improve perfusion homogeneity.
Add nitrous oxide to augment alveolar ventilation.
A 75-year-old with severe pulmonary hypertension (mPAP 48 mmHg), chronic sildenafil and inhaled prostacyclin, becomes hypotensive during pneumoperitoneum; PAP rises to 70/38, ETCO₂ increases from 33→45. Best integrated first step?
Increase minute ventilation and titrate norepinephrine to maintain MAP.
Increase PEEP to 15 cmH₂O and titrate phenylephrine to maintain MAP.
Reduce minute ventilation and titrate vasopressin to maintain MAP.
Increase volatile depth and titrate nitroglycerin to reduce PVR.
Start epinephrine and tolerate permissive hypercapnia.
A pacer-dependent CRT-P patient needs major head-and-neck surgery with frequent monopolar cautery above the clavicle. Preop programming is available. Best device plan?
A 72-year-old with concentric LVH (HFpEF), CKD stage 4, develops hypotension after induction: PPV 6%, TEE shows small hyperdynamic LV, no RWMAs. Best hemodynamic move?
Titrate phenylephrine to restore afterload before cautious fluid.
Titrate dobutamine to increase inotropy and stroke volume.
Titrate nitroprusside to reduce afterload and LV wall stress.
Titrate esmolol to slow heart rate and prolong diastole.
Titrate large crystalloid bolus to reduce PPV to <3%.
In awake carotid endarterectomy under regional anesthesia, contralateral weakness appears after cross-clamp; MAP is 140 mmHg (baseline 130 mmHg). Best action?
Request immediate shunt placement to restore regional flow.
Hyperventilate to reduce cerebral metabolic demand.
Start nicardipine to maintain MAP 110 mmHg.
Administer mannitol to reduce cerebral edema.
Increase anesthetic depth to suppress agitation.
A patient with symptomatic severe mitral stenosis (mean gradient 15 mmHg) and chronic AF (rate 78) develops hypotension (MAP 58) and rising ETCO2 during pneumoperitoneum. Best initial step?
Increase minute ventilation and titrate phenylephrine to maintain SVR.
Increase PEEP and titrate nitroglycerin to reduce pulmonary pressures.
Reduce minute ventilation and titrate ephedrine to increase heart rate.
Increase volatile anesthetic and titrate esmolol to control demand.
Liberalize IV fluids to raise CVP by >5 mmHg.
A 64-year-old with continuous-flow LVAD shows Doppler MAP 48 mmHg, low pulsatility index, rising lactate after positioning; ventilation is controlled with PEEP 8 cmH2O. Best correction?
Reduce PEEP and give a fluid bolus while titrating norepinephrine.
Increase PEEP and give nitroprusside while lowering LVAD speed.
Maintain PEEP and give esmolol while increasing LVAD speed.
Reduce PEEP and give furosemide while maintaining current LVAD speed.
Maintain PEEP and give phenylephrine while lowering LVAD speed.
Beach-chair shoulder arthroscopy: arm-cuff MAP 70 mmHg; external auditory meatus is 30 cm above the transducer. Best interpretation and action?
Cerebral perfusion is ~47 mmHg; increase systemic pressure promptly.
Cerebral perfusion is ~70 mmHg; maintain current settings.
Cerebral perfusion is ~60 mmHg; begin vasodilator therapy.
A 67-year-old with severe chronic aortic regurgitation becomes brady-hypotensive after remifentanil bolus: MAP 55, HR 42. Best pressor/inotrope choice now?
Titrate ephedrine to raise heart rate and forward flow.
Titrate phenylephrine to raise diastolic pressure and reduce regurgitation.
Titrate vasopressin to increase SVR without cardiac stimulation.
Titrate esmolol to reduce diastolic time and regurgitation.
Titrate nitroglycerin to reduce afterload and preload.
A 58-year-old on apixaban (CrCl 32 mL/min) took last dose 24 h ago; femoral neck fracture needs repair today. Neuraxial anesthesia is requested. Best plan?
Choose general anesthesia and avoid neuraxial until adequate washout.
Proceed with single-shot spinal using a small-gauge needle.
Administer vitamin K and proceed with epidural.
Give four-factor PCC and proceed with combined spinal-epidural.
Administer protamine and proceed with spinal.
Laparoscopic colectomy, insufflation pressure 15 mmHg, in a patient with ischemic functional MR; acute pulmonary edema appears with SVR rise. Best integrated move?
Lower insufflation pressure and add nitroglycerin while supporting MAP with phenylephrine.
Raise insufflation pressure and add phenylephrine to improve coronary perfusion.
Maintain insufflation and add esmolol to reduce oxygen consumption.
Lower insufflation pressure and add high PEEP to reduce preload.
Maintain insufflation and add vasopressin to increase SVR.
After supraceliac cross-clamping for open AAA, MAP climbs from 85 → 140, ST depression appears, PCWP rises. Best pair of actions?
Deepen anesthesia and add short-acting vasodilator (e.g., NTG/clevidipine).
Give phenylephrine and large crystalloid bolus.
Start esmolol and reduce FiO2 to limit coronary steal.
Increase PEEP and give mannitol.
Start dopamine and expand volume aggressively.
A patient with suspected intraop PE: sudden hypotension, ETCO2 drop, hypoxemia. TEE obtained immediately. Most supportive pattern?
Dilated RV with septal flattening (D-shaped LV) and apical sparing.
Hyperdynamic LV with small, underfilled RV and no septal motion.
Large pericardial effusion with diastolic RV collapse.
Global LV hypokinesis with normal RV size.
Normal ventricular size with severe MR jet.
Carotid endarterectomy under GA: loss of SSEPs after cross-clamp with stump pressure borderline. MAP is 100% of baseline. Best next step?
Lower MAP.
Raise MAP.
Increase FiO2.
Administer mannitol.
Administer thiopental.
A 60-year-old with HOCM (resting LVOT gradient 40 mmHg) has hypotension during emergence with coughing. Best immediate correction?
Give phenylephrine and volume while deepening anesthesia.
Give dobutamine and reduce volatile anesthetic.
Give nitroglycerin and increase PEEP.
Give ephedrine and start esmolol.
Give milrinone and lower afterload aggressively.
A 76-year-old with mechanical mitral valve (INR goal 3.0) and prior embolic stroke is scheduled for open hysterectomy with epidural. Best perioperative anticoagulation approach?
Hold warfarin and bridge with therapeutic heparin per neuraxial timing.
Hold warfarin without bridging and proceed with neuraxial.
Continue warfarin and check INR day of surgery.
Switch to apixaban 48 h before surgery.
Switch to enoxaparin prophylaxis only.
Intraop orthodromic AVRT (narrow complex) occurs in a patient with WPW; BP 92/58, perfusing. Best therapy?
Administer adenosine and reassess rhythm and pressure.
Administer diltiazem and reassess rhythm and pressure.
Administer amiodarone and reassess rhythm and pressure.
Administer esmolol and reassess rhythm and pressure.
Administer procainamide and reassess rhythm and pressure.
A 72-year-old with long-standing HTN and LVH undergoes major spine surgery. What blood-pressure strategy best minimizes myocardial events?
Maintain within ~10–20% of the patient’s baseline pressures.
Maintain MAP 55–60 mmHg to limit bleeding.
Maintain SBP <100 mmHg throughout the case.
Allow wide swings if the average MAP is adequate.
Lower diastolic pressure to improve LV filling.
Intraop torsades de pointes occurs after QT-prolonging antiemetic; the patient is hypotensive but perfusing. Best first treatment?
Administer magnesium sulfate and reassess rhythm.
Administer amiodarone and reassess rhythm.
Administer lidocaine and reassess rhythm.
Administer adenosine and reassess rhythm.
Administer esmolol and reassess rhythm.
A 69-year-old with restrictive amyloid cardiomyopathy becomes hypotensive after modest blood loss; TEE shows small LV, normal EF, collapsible IVC. Best intervention?
Give cautious crystalloid to restore preload and avoid tachycardia.
Give nitroprusside to reduce LV afterload and wall stress.
Give esmolol to slow heart rate and prolong diastole.
Give milrinone to increase inotropy and lusitropy.
Give phenylephrine to raise SVR without fluids.
A 65-year-old with moderate AS and CAD is a chronic β-blocker user. Best periop β-blocker plan?
Continue β-blocker perioperatively with careful titration.
Hold β-blocker to avoid bradycardia intraoperatively.
Switch to short-acting β-blocker and stop after induction.
Load with high-dose β-blocker on the morning of surgery.
Replace β-blocker with calcium-channel blocker.
A 58-year-old with bioprosthetic aortic valve placed 3 months ago on aspirin needs urgent noncardiac surgery. Best antiplatelet decision?
Continue aspirin and proceed to surgery.
Stop aspirin 7 days prior to surgery.
Stop aspirin morning-of surgery.
Add clopidogrel for enhanced protection.
Bridge with therapeutic heparin.
A 71-year-old with long-QT develops polymorphic VT after ondansetron; MAP 60, pulses present. Best immediate action?
Give magnesium sulfate and correct electrolytes.
Give amiodarone and deepen anesthesia.
Give procainamide and hyperventilate.
Give lidocaine and start β-blocker.
Give adenosine and prepare for pacing.
26. Vascular case: during iliac limb deployment on EVAR, sudden bradycardia and hypotension with ST depression occurs; no bleeding. Most consistent mechanism and response?
Vagal/ischemic reflex—treat with atropine and optimize MAP.
Atheroembolism—treat with heparin bolus and vasodilator.
Protamine reaction—treat with epinephrine and fluids.
Tension pneumothorax—treat with immediate chest decompression.
Septic physiology—treat with antibiotics and fluids.
Intraop hypotension and new LBBB develop during bowel resection. ST analysis is unreliable. Best diagnostic step that also guides therapy?
Obtain intraoperative TEE to assess regional function and preload.
Place a PA catheter to trend wedge pressure and cardiac output.
Obtain a troponin and continue without changes.
A 74-year-old with severe TR from pulmonary hypertension becomes hypotensive after PEEP is increased from 5→10 cmH2O. Best correction?
Reduce PEEP, optimize preload, and support MAP with norepinephrine.
Increase PEEP further to reduce venous return and edema.
Add nitroglycerin to reduce RV preload further.
Add phenylephrine to raise SVR without changing PEEP.
Add esmolol to slow heart rate and improve filling.
Hip fracture repair is planned; 84-year-old on apixaban took last dose 36 h ago, CrCl 34 mL/min. Best anesthesia choice today?
Select general anesthesia and avoid neuraxial block.
Proceed with spinal anesthesia after negative anti-Xa assay.
Proceed with epidural anesthesia after vitamin K.
Proceed with combined spinal-epidural after PCC.
Proceed with spinal anesthesia using a pencil-point needle.
A 70-year-old with stable CAD, Hb 7.8 g/dL, HR 92, MAP 74, TEE without new RWMAs, is otherwise stable. Best transfusion stance now?
Optimize hemodynamics and oxygenation; no automatic transfusion solely for CAD.
Transfuse to Hb ≥10 g/dL to prevent myocardial ischemia.
Transfuse to Hb ≥9 g/dL to prevent stroke.
Avoid transfusion unless Hb <6 g/dL regardless of status.
Transfuse for any ST-T abnormality on ECG.
During thoracotomy, hypoxemia persists despite CPAP to the non-dependent lung and recruitment of the dependent lung. Best next strategy?
Provide intermittent reinflation of the non-dependent lung.
Increase volatile concentration to reduce O2 demand.
Add nitrous oxide to improve alveolar ventilation.
Increase PEEP blindly to 15 cmH2O.
Start nitroprusside to redistribute perfusion.
A 62-year-old with paced rhythm and poor METs needs open aortobifemoral bypass. Resting ECG is uninterpretable. A single noninvasive test is needed that will change management. Best choice?
Vasodilator nuclear perfusion imaging for ischemia risk.
Exercise treadmill ECG without imaging.
Coronary calcium scoring CT.
Coronary CT angiography with contrast.
Six-minute walk test only.
A patient with severe AS under neuraxial anesthesia becomes hypotensive with tachycardia. Best immediate hemodynamic correction?
Phenylephrine
Norepinephrine
Dopamine
Atropine
A CRT-D patient (not pacer-dependent) needs open abdominal surgery with monopolar cautery above the umbilicus. Best device strategy?
Deactivate tachy therapies preop, place external pads, and keep magnet available.
Place a magnet continuously to disable pacing and shocks.
Leave device unchanged because CRT prevents oversensing.
Turn off all device functions and rely on external defibrillation.
Convert to bipolar cautery and ignore device management.
A 66-year-old with Brugada pattern on ECG requires emergent laparotomy. Best anesthetic maintenance approach?
Avoid prolonged high-dose propofol infusion and maintain normothermia/electrolytes.
Use high-dose bupivacaine epidural for sympathetic suppression.
Use isoflurane at 2 MAC to prevent arrhythmia.
Use ketamine infusion to preserve blood pressure.
Use nitrous oxide to reduce anesthetic requirement.
A 70-year-old with recent DES for stable angina (9 months ago) on aspirin + clopidogrel must undergo cancer resection now. Best antiplatelet plan?
Continue aspirin and stop clopidogrel ~5 days preoperatively.
Stop both aspirin and clopidogrel 7 days preoperatively.
Continue dual antiplatelet therapy through surgery.
Stop aspirin but continue clopidogrel.
Bridge with IV heparin for platelet inhibition.
After declamping the aorta, MAP falls to 55 mmHg, acidosis appears, and ETCO₂ rises. Best pre-emptive strategy you should have instituted?
Volume loading with vasopressors ready and gradual declamping.
High PEEP and hyperventilation throughout the clamp.
Diuretics pre-declamp to prevent overload.
Nitroprusside infusion pre-declamp to prevent hypertension.
Immediate cross-clamp removal without staging.
A patient with severe MS and pulmonary hypertension develops AF with RVR and hypotension during bowel manipulation. Best initial therapy?
Rate control with β-blocker or diltiazem (if LV function adequate) and vasoconstrictor support.
Amiodarone as first step for pharmacologic conversion.
Procainamide as first step for pharmacologic conversion.
Adenosine as first step for AV-nodal blockade.
Immediate synchronized cardioversion despite stability.
Severe AS: which rhythm change most endangers hemodynamics and requires prevention/treatment?
New-onset atrial fibrillation with loss of atrial contribution.
Sinus bradycardia to 55 bpm.
First-degree AV block.
Junctional rhythm at 60 bpm.
Sinus tachycardia to 100 bpm.
A 63-year-old with resistant HTN and CKD develops severe emergence hypertension (MAP 125) without pain. Best titratable agent?
Nicardipine infusion with careful titration.
Nitroprusside infusion as first choice.
Hydralazine boluses for longer control.
Labetalol large boluses for rapid control.
Esmolol infusion as sole agent.
An ICD patient presents for laparotomy. Team places a magnet during cautery. What function is reliably suspended by magnet application across most ICDs?
Tachyarrhythmia therapies while pacing mode may be unchanged.
Brady pacing while tachy therapies continue as normal.
All device functions including pacing and sensing.
Asynchronous pacing and tachy therapies together.
Neither pacing nor tachy therapies are affected.
A 60-year-old on long-term statin and β-blocker has postoperative troponin elevation without symptoms (MINS). Best early management bundle?
Optimize oxygen supply-demand, continue guideline therapies, and involve cardiology.
Start routine thrombolysis for suspected silent MI.
Schedule immediate cath for all MINS cases.
Discontinue β-blocker to avoid bradycardia.
Stop statin to reduce rhabdomyolysis risk.
A patient with tamponade physiology requires urgent subxiphoid window. Best induction/ventilation strategy?
Ketamine with maintenance of spontaneous ventilation and avoidance of PEEP.
Propofol with high PEEP to increase venous return.
Etomidate with deep volatile and immediate paralysis.
Sevoflurane mask with nitrous oxide and moderate PEEP.
Spinal anesthesia to avoid general anesthesia.
During OLV, anesthetic depth is increased from 1.0 → 1.8 MAC volatile. Which physiologic effect most likely worsens oxygenation?
A. Blunting of hypoxic pulmonary vasoconstriction with increased shunt.
B. Reduction of mean airway pressure with improved V/Q.
C. Augmentation of HPV with decreased shunt.
A 66-year-old with NSTEMI two weeks ago (no PCI) requires urgent hemicolectomy for bleeding cancer. On low-dose aspirin. Best antiplatelet decision?
Continue aspirin and proceed with surgery.
Stop aspirin 7 days prior to surgery.
Stop aspirin morning of surgery.
Add clopidogrel for 7 days preoperatively.
Replace aspirin with LMWH.
A patient with pheochromocytoma after tumor vein ligation becomes profoundly hypotensive. Best first-line pressor?
Norepinephrine infusion to restore SVR and coronary perfusion.
Phenylephrine infusion to restore SVR without β-effect.
Vasopressin infusion as the sole agent.
Epinephrine infusion as the sole agent.
Dopamine infusion at 10 μg/kg/min.
You suspect dynamic LVOT obstruction after diuresis: TEE shows small LV cavity, SAM, peak gradient 60 mmHg. Best immediate therapy?
Phenylephrine with volume and reduction of inotropy.
Dobutamine to increase contractility and stroke volume.
Milrinone to improve lusitropy and reduce afterload.
Nitroglycerin to reduce preload and afterload.
Esmolol bolus followed by nitroprusside.
A patient with ICD and good intrinsic rhythm needs laparotomy below the umbilicus with bipolar cautery only. Best device plan?
No routine reprogramming; have magnet and external pads available.
Continuous magnet to force asynchronous pacing.
Turn all device functions off preoperatively.
Convert to monopolar cautery and reprogram to asynchronous pacing.
Deactivate brady pacing while keeping tachy therapies active.
A 67-year-old with HFrEF on norepinephrine 0.1 μg/kg/min remains hypotensive with rising lactate; TEE shows global LV depression, full IVC, no dynamic obstruction. Best pharmacologic pairing?
Add low-dose dobutamine or milrinone while maintaining MAP with norepinephrine.
Add phenylephrine and lower volatile depth.
Add esmolol to reduce demand.
Add nitroprusside to lower afterload.
Add vasopressin as sole escalation.
50. The best acute drug therapy for a 59-year-old with WPW under GA who develops AF with rapid conduction and a BP of 102/60 (perfusing) is:
Amiodarone
Adenosine
Metoprolol
Verapamil
