WorksheetsBGHMC CV Module 2025 Quiz E
Total questions: 50
Worksheet time: 38mins
Elderly patient with critical aortic stenosis develops hypotension (MAP 50) after gentle induction; sinus rhythm, HR 82, no bleeding. Which immediate action best restores coronary perfusion and stroke volume?
Titrate phenylephrine to raise diastolic pressure while maintaining sinus rhythm.
Titrate ephedrine to increase heart rate and contractility promptly.
Titrate nitroglycerin to reduce left-ventricular wall stress emergently.
Titrate esmolol to lower myocardial oxygen demand immediately.
Titrate norepinephrine only after a large crystalloid bolus first.
HFrEF (EF 20%) on sacubitril/valsartan becomes vasoplegic post-induction with wide pulse pressure and low SVR. Which vasopressor plan best counters ARNI-associated vasodilation?
Titrate norepinephrine as first-line and add vasopressin if refractory.
Titrate phenylephrine as first-line and add ephedrine if refractory.
Titrate epinephrine as sole agent for combined α/β support.
Titrate dopamine at 10 μg/kg/min for renal and cardiac effects.
Titrate vasopressin alone without catecholamines.
One-lung ventilation (right lung dependent) with FiO₂ 1.0: after recruitment and correct positioning, SpO₂ falls from 96% → 86%. Which maneuver most reliably improves PaO₂?
Apply continuous positive airway pressure 2–5 cmH₂O with oxygen to the nondependent lung.
Increase volatile anesthetic to deepen anesthesia and reduce metabolic rate.
Increase PEEP on the dependent lung abruptly to 14 cmH₂O.
Add nitroprusside to homogenize perfusion distribution.
Add nitrous oxide to augment alveolar ventilation of the dependent lung.
Severe pulmonary hypertension on sildenafil + inhaled prostacyclin becomes hypotensive during pneumoperitoneum; EtCO₂ rises and PAP spikes. What integrated first step best supports RV perfusion and lowers PVR triggers?
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.
Pacer-dependent CRT-P for head-and-neck surgery with frequent monopolar cautery above clavicle. What device plan best prevents pacing inhibition?
Program asynchronous pacing, apply cautery precautions, and arrange post-op interrogation.
Place a magnet continuously and allow intrinsic sensing to govern mode.
Leave factory settings and rely on external pads for rescue pacing.
Disable the device entirely and use transcutaneous pacing only.
Convert to bipolar cautery without any device changes.
Severe concentric LVH (HFpEF), CKD4: post-induction hypotension with PPV 6% and small hyperdynamic LV on TEE. What hemodynamic move best restores perfusion without pulmonary congestion?
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 a large crystalloid bolus to normalize PPV.
Awake carotid endarterectomy: contralateral weakness appears after cross-clamp; MAP is already ~10% above baseline. What action most directly restores cerebral perfusion?
Request immediate intraluminal shunt placement to reestablish flow.
Hyperventilate to lower cerebral metabolic demand rapidly.
Start nicardipine to maintain strict normotension throughout.
Administer mannitol to reduce intracranial volume promptly.
Increase anesthetic depth to blunt agitation and movement.
Severe mitral stenosis with chronic AF (rate 80): during pneumoperitoneum, PaCO₂ rises to 55 mmHg and MAP falls to 58 mmHg. What initial step best prevents acute decompensation?
Increase minute ventilation and titrate phenylephrine to maintain SVR.
Increase PEEP and titrate nitroglycerin to reduce LA pressure.
Reduce minute ventilation and titrate ephedrine to increase heart rate.
Increase volatile anesthetic and titrate esmolol to slow rate further.
Liberalize fluids to raise CVP by >5 mmHg rapidly.
Continuous-flow LVAD shows Doppler MAP 48 mmHg, low pulsatility index, rising lactate; PEEP 8 cmH₂O. Which combined adjustment best treats suspected suction/underfilling?
Reduce PEEP, give fluid bolus, and titrate norepinephrine for MAP.
Increase PEEP, start nitroprusside, and lower LVAD speed.
Maintain PEEP, give esmolol, and increase LVAD speed.
Reduce PEEP, give furosemide, and hold LVAD speed.
Maintain PEEP, give phenylephrine, and lower LVAD speed.
Beach-chair arthroscopy: arm-cuff MAP 72 mmHg; external auditory meatus is 28 cm above transducer. What interpretation and action best protect cerebral perfusion?
Cerebral MAP ≈ ~50 mmHg; increase systemic pressure promptly.
Cerebral MAP ≈ ~72 mmHg; maintain current settings.
Cerebral MAP ≈ ~60 mmHg; begin vasodilator therapy.
Cerebral MAP ≈ ~55 mmHg; lower FiO₂ to augment HPV.
Cerebral MAP ≈ ~45 mmHg; deepen anesthesia only.
Severe chronic aortic regurgitation becomes brady-hypotensive after a remifentanil bolus (MAP 55, HR 42). Which agent best improves forward flow immediately?
Titrate ephedrine to raise heart rate and cardiac output.
Titrate phenylephrine to raise diastolic pressure alone.
Titrate vasopressin to increase SVR selectively.
Titrate esmolol to shorten diastole paradoxically.
Titrate nitroglycerin to reduce afterload primarily.
Femoral neck fracture; apixaban taken 24 h ago with CrCl 30 mL/min; surgery today. Which anesthetic plan best balances urgency and neuraxial safety?
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 catheter placement.
Give four-factor PCC and proceed with combined spinal-epidural.
Administer protamine and proceed with spinal anesthetic.
Laparoscopic colectomy with functional ischemic MR: insufflation raises SVR and causes pulmonary edema. What integrated step best improves forward stroke volume?
Lower insufflation pressure and add nitroglycerin while supporting MAP with norepinephrine.
Raise insufflation pressure and add phenylephrine to improve CPP.
Maintain insufflation and add esmolol to reduce demand.
Lower insufflation pressure and add high PEEP to reduce preload.
Maintain insufflation and add vasopressin to augment SVR.
Supraceliac cross-clamp raises MAP from 85 → 140 with ST depression and rising LVEDP. Which paired intervention best limits ischemia?
Deepen anesthesia and add short-acting vasodilator (NTG/clevidipine).
Give phenylephrine and a large crystalloid bolus immediately.
Start esmolol and reduce FiO₂ to reduce coronary steal.
Increase PEEP and give mannitol for LV unloading.
Start dopamine and expand volume aggressively.
Sudden hypotension, EtCO₂ drop, and hypoxemia suggest PE; intraop TEE is obtained. Which pattern most supports acute RV pressure overload?
Dilated RV with septal flattening (D-shaped LV) and apical sparing.
Hyperdynamic LV with small RV and normal septal contour.
Large pericardial effusion with diastolic RV collapse.
Global LV hypokinesis with normal RV dimensions.
Normal ventricular size with severe central MR jet.
CEA under GA: SSEPs drop after clamp; stump pressure is borderline; MAP equals baseline. What step best augments collateral perfusion?
Raise MAP to ~>120% of baseline and reassess monitoring.
Reduce MAP slightly to prevent reperfusion injury.
Start nitroprusside to normalize ST segments.
Hyperventilate to PaCO₂ 25 mmHg for cerebral protection.
Administer mannitol to improve relaxation.
HOCM with resting gradient 35 mmHg: during emergence and coughing, MAP drops and a new harsh systolic murmur appears. Which immediate maneuver best reduces dynamic obstruction?
Give phenylephrine with small fluid bolus and deepen anesthesia.
Give dobutamine with reduced volatile to increase contractility.
Give nitroglycerin with higher PEEP to reduce preload.
Give ephedrine and start esmolol for rate control.
Give milrinone and lower afterload aggressively.
Mechanical mitral valve with prior embolic stroke scheduled for open hysterectomy with epidural. Which anticoagulation approach best balances thrombosis and neuraxial safety?
Hold warfarin and bridge with therapeutic heparin per neuraxial timing.
Hold warfarin without bridging and proceed to epidural placement.
Continue warfarin and check INR day of surgery only.
Switch to apixaban 48 h prior and proceed with neuraxial.
Switch to prophylactic LMWH without bridging.
Orthodromic AVRT occurs intraoperatively in WPW; BP 90/55 but perfusing. What first therapy most safely terminates the rhythm?
Administer adenosine and reassess rhythm promptly.
Administer diltiazem and reassess rhythm promptly.
Administer amiodarone and reassess rhythm promptly.
Administer esmolol and reassess rhythm promptly.
Administer procainamide and reassess rhythm promptly.
Long-standing HTN with LVH undergoing major spine surgery: what intraoperative pressure strategy best limits ischemic injury?
Maintain within ~10–20% of patient’s baseline pressures.
Maintain MAP 55–60 mmHg to reduce bleeding risk.
Maintain SBP <100 mmHg during exposure phases.
Allow wide swings if time-weighted MAP is adequate.
Lower diastolic pressure deliberately to improve filling.
21. Torsades de pointes appears after a QT-prolonging antiemetic; pulses present, MAP 60. What first treatment best addresses the mechanism?
Administer magnesium sulfate and correct electrolytes.
Administer amiodarone and deepen anesthesia promptly.
Administer lidocaine and initiate β-blocker therapy.
Administer adenosine and prepare for pacing.
Administer procainamide and hyperventilate.
Restrictive amyloid cardiomyopathy with modest blood loss becomes hypotensive; TEE shows small LV cavity, normal EF, collapsible IVC. What intervention best restores output?
Give cautious crystalloid to restore preload and avoid tachycardia.
Give nitroprusside to reduce afterload and wall stress.
Give esmolol to prolong diastole at the expense of rate.
Give milrinone to increase inotropy and lusitropy primarily.
Give phenylephrine to raise SVR without fluids.
Moderate AS and CAD on chronic β-blocker therapy presenting for laparotomy. What β-blocker plan best balances ischemia risk?
Continue β-blocker perioperatively with careful titration.
Hold β-blocker to avoid intraoperative bradycardia entirely.
Switch to short-acting β-blocker and stop after induction.
Load with high-dose β-blocker morning of surgery.
Replace β-blocker with a calcium-channel blocker.
24. Bioprosthetic AVR 3 months ago on aspirin requires urgent noncardiac surgery. What antiplatelet decision best balances thrombosis and bleeding?
Continue aspirin and proceed to surgery.
Stop aspirin 7 days prior to surgery.
Stop aspirin morning of surgery.
Add clopidogrel preoperatively for extra protection.
Bridge with therapeutic heparin preoperatively.
Congenital long-QT develops polymorphic VT after ondansetron; pulses present. What immediate action best shortens QT and terminates arrhythmia?
Give magnesium sulfate and correct potassium and calcium.
Give amiodarone and accept transient QT prolongation.
Give procainamide and hyperventilate to alkalosis.
Give lidocaine and start β-blocker therapy.
Give adenosine and attempt overdrive pacing.
EVAR iliac manipulation produces abrupt bradycardia, hypotension, and ST depression without bleeding. What mechanism/response pairing is most appropriate?
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 needle decompression.
Sepsis—treat with antibiotics and fluid resuscitation.
New left bundle branch block with hypotension occurs intraoperatively; ST analysis is unreliable. What diagnostic step best guides immediate hemodynamic therapy?
Obtain intraoperative TEE to assess regional function and filling.
Place a PA catheter for wedge and thermodilution trending.
Obtain a troponin and continue; reassess later.
Apply magnet over the ICD to force asynchronous pacing.
Trend EtCO₂ as a substitute for cardiac output.
Severe tricuspid regurgitation from pulmonary hypertension decompensates when PEEP is increased from 5–10 cmH₂O. Which correction best supports RV output?
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 rate and increase diastolic filling.
Hip fracture repair today; apixaban taken 36 h ago; CrCl 34 mL/min. What anesthetic approach is most appropriate now?
Select general anesthesia and avoid neuraxial block.
Proceed with spinal after a negative anti-Xa assay.
Proceed with epidural after vitamin K administration.
Proceed with combined spinal-epidural after PCC.
Proceed with spinal using a pencil-point needle cautiously.
Stable CAD intraoperatively with Hb 7.8 g/dL, HR 90, MAP 75, TEE without new wall-motion changes. What transfusion stance best reflects myocardial oxygen supply–demand?
Optimize hemodynamics and oxygenation; no automatic transfusion solely for CAD.
Transfuse to Hb ≥10 g/dL to prevent ischemia universally.
Transfuse to Hb ≥9 g/dL to prevent neurologic events.
Avoid transfusion unless Hb <6 g/dL regardless of status.
Transfuse for any nonspecific ST-T change on ECG.
Thoracotomy hypoxemia persists despite CPAP to nondependent lung and dependent recruitment. What next step best restores oxygenation?
Provide intermittent reinflation of the nondependent lung.
Increase volatile anesthetic to lower metabolism.
Add nitrous oxide to improve ventilation efficiency.
Increase PEEP blindly to 15 cmH2O.
Start nitroprusside to redistribute perfusion.
Paced rhythm and poor METs for open aortobifemoral bypass; one preop test must change management. What test best evaluates ischemia when ECG is uninterpretable?
Vasodilator nuclear perfusion imaging for ischemic risk.
Exercise treadmill ECG without imaging.
Coronary calcium scoring CT only.
Coronary CT angiography with contrast.
Six-minute walk test only.
Severe AS under neuraxial anesthesia becomes hypotensive with tachycardia. Which correction best restores coronary perfusion and output?
Titrate phenylephrine and control heart rate to restore SVR and diastolic time.
Titrate ephedrine and allow higher heart rate to maintain output.
Titrate nitroglycerin and increase volatile depth.
Titrate vasopressin and increase PEEP.
Titrate esmolol alone without vasoconstriction.
34. CRT-D, not pacer-dependent, undergoing upper abdominal surgery with monopolar cautery. What plan best mitigates inappropriate shocks?
Deactivate tachy therapies preoperatively; place external pads; keep magnet available.
Place a magnet continuously to disable pacing and shocks.
Leave device unchanged; CRT eliminates oversensing risk.
Turn off all device functions and rely on external defibrillation.
Convert to bipolar cautery and ignore device management.
Brugada pattern on ECG requires emergent laparotomy. Which maintenance approach best limits malignant arrhythmia risk?
Avoid prolonged high-dose propofol infusion; maintain normothermia/electrolytes.
Use high-dose bupivacaine epidural for sympathetic suppression.
Use isoflurane at 2 MAC to prevent arrhythmias reliably.
Use ketamine infusion to preserve blood pressure primarily.
Use nitrous oxide to reduce anesthetic requirement.
Drug-eluting stent for stable angina placed 9 months ago; on aspirin + clopidogrel; cancer resection now. What antiplatelet plan best balances thrombosis/bleeding?
Continue aspirin and stop clopidogrel ~5 days preop.
Stop both aspirin and clopidogrel 7 days preop.
Continue dual antiplatelet therapy through surgery.
Stop aspirin but continue clopidogrel.
Bridge platelet inhibition with IV heparin.
Anticipating aortic declamping: which pre-emptive strategy best attenuates hypotension and acidosis at release?
Volume loading with vasopressors ready and gradual declamping sequence.
High PEEP and hyperventilation maintained during clamp.
Pre-declamp diuretics to prevent overload.
Pre-declamp nitroprusside to avoid hypertension.
Rapid unclamp to minimize ischemia time.
Severe MS with pulmonary hypertension develops AF with RVR and hypotension. What initial therapy best stabilizes filling and pulmonary pressures?
Rate control with β-blocker or diltiazem (if LV function adequate) plus vasoconstrictor support.
Amiodarone as first-line conversion strategy immediately.
Procainamide as first-line conversion strategy immediately.
Adenosine as first-line AV-nodal blockade strategy.
Immediate synchronized cardioversion despite relative stability.
Severe AS intraoperatively: which rhythm change most compromises hemodynamics and demands rapid correction?
New-onset atrial fibrillation with loss of atrial contribution.
Sinus bradycardia to 55 bpm with preserved PR.
First-degree AV block with PR 240 ms.
Junctional rhythm at 60 bpm without hypotension.
Sinus tachycardia to 100 bpm with stable pressure.
Resistant hypertension with CKD causes severe emergence hypertension (MAP 125) without pain. Which agent best provides smooth, titratable control with favorable organ perfusion?
Nicardipine infusion with careful titration.
Nitroprusside infusion as first choice routinely.
Hydralazine boluses for sustained control.
Large labetalol boluses for rapid control.
Esmolol infusion as sole therapy.
ICD patient: magnet applied during cautery. Which function is reliably suspended in most ICDs by magnet placement?
Tachyarrhythmia therapies while pacing mode may be unchanged.
Brady pacing while tachy therapies continue normally.
All device functions including pacing and sensing.
Asynchronous pacing and tachy therapies together.
Neither pacing nor tachy therapies are affected.
Postoperative troponin elevation (MINS) without symptoms in a high-risk patient. What early management bundle best improves outcomes?
Optimize oxygen supply–demand, continue guideline therapies, and involve cardiology.
Start routine thrombolysis for suspected silent MI in all cases.
Schedule immediate catheterization for all MINS patients.
Discontinue β-blocker to avoid bradycardia risk.
Stop statin to reduce rhabdomyolysis risk postoperatively.
Tamponade physiology requires urgent subxiphoid window. What induction/ventilation approach best preserves venous return and cardiac output?
Ketamine with maintained spontaneous ventilation and avoidance of PEEP.
Propofol with high PEEP to improve LV filling via afterload.
Etomidate with deep volatile and immediate muscle paralysis.
Sevoflurane mask with nitrous oxide and moderate PEEP.
Spinal anesthesia to sidestep general anesthetics.
OLV oxygenation worsens as volatile anesthetic is increased from 1.0 → 1.8 MAC. What mechanism most likely explains the decline in PaO₂?
Blunting of hypoxic pulmonary vasoconstriction with increased shunt fraction.
Reduction of mean airway pressure with improved V/Q matching.
Augmentation of HPV with decreased shunt fraction.
Increase in mixed venous oxygen content improving shunt.
Increase in cardiac output improving oxygen delivery.
NSTEMI two weeks ago (no PCI), urgent colectomy for bleeding cancer; on low-dose aspirin. What antiplatelet stance best balances reinfarction vs bleeding?
Continue aspirin and proceed with surgery.
Stop aspirin 7 days before surgery.
Stop aspirin morning of surgery.
Add clopidogrel for one week preoperatively.
Replace aspirin with LMWH temporarily.
Pheochromocytoma after tumor vein ligation becomes profoundly hypotensive. What first-line vasopressor best addresses sudden catecholamine withdrawal and vasodilation?
Norepinephrine infusion to restore SVR and coronary perfusion.
Phenylephrine infusion to raise SVR without β-effects.
Vasopressin infusion as sole pressor therapy.
Epinephrine infusion as sole pressor therapy.
Dopamine infusion at 10 μg/kg/min.
Suspected dynamic LVOT obstruction after diuresis: TEE shows small LV, SAM, gradient 60 mmHg. What immediate management best improves hemodynamics?
Phenylephrine with small volume and reduction of inotropy.
Dobutamine to increase contractility and stroke volume.
Milrinone to enhance lusitropy and lower afterload.
Nitroglycerin to reduce preload and afterload simultaneously.
Esmolol bolus followed by nitroprusside infusion.
ICD patient with good intrinsic rhythm undergoing lower abdominal surgery using bipolar cautery only. What device plan is most appropriate?
No routine reprogramming; keep magnet and external pads available.
Continuous magnet to force asynchronous pacing throughout.
Turn off all device functions preoperatively.
Convert to monopolar cautery and reprogram to asynchronous pacing.
Deactivate brady pacing while leaving tachy therapies active.
HFrEF on norepinephrine 0.1 μg/kg/min remains hypotensive with rising lactate; TEE shows global LV depression, no obstruction, full IVC. What drug pairing best increases forward flow while maintaining MAP?
Add low-dose dobutamine or milrinone while maintaining MAP with norepinephrine.
Add phenylephrine and reduce volatile depth only.
Add esmolol to reduce myocardial demand mainly.
Add nitroprusside to lower afterload primarily.
Add vasopressin as sole escalation strategy.
50. WPW under GA develops atrial fibrillation with rapid pre-excited conduction; BP stable at 105/65. What acute pharmacologic strategy best limits pathway conduction?
Procainamide to slow accessory pathway conduction and stabilize rate.
Adenosine to block AV node and terminate AF immediately.
Diltiazem to block AV node and slow the ventricular response.
Esmolol to block AV node and slow the ventricular response.
Amiodarone as universal first-line agent for AF.
