EmergencyPedia



Past Paper MCQ

PHARMACOLGY MCQ

(Autonomic Pharmacology)

MCQ Questions

1) You are an Emergency Department Registrar. At 2am a patient presents with a

systolic BP of less than 100. The left ventricular filling pressure of more than 20mmHG and a cardiac output of less than 2.5L/min. In this patient what is your first line of treatment?

a. normal saline

b. diuretics

c. inotropes

d. vasodilators

e. vasodilators and inotropes ANSWER - ?

• Cardiac Output (Q) = Heart Rate x Stroke Volume = 5 L/min

• Cardiac Output can normally Increase 700% during Exercise

• Q is Increased by: Anxiety and excitement (50-100%), Eating (30%), Exercise, High environmental temperatures, Pregnancy, Adrenaline

• Q is Decreased by: Standing from lying, Rapid arrhythmias, Heart disease

• NB - Heart receives 15% of the Cardiac Output at Rest

2) Which does not cause vasoconstriction

a. lactate

b. serotonin

c. adrenaline

d. ADH

3) Regarding neurotransmitters in the brain

a. strychnine stimulates glycine receptors – antagonizes glycine receptors

b. atropine antagonises GABA receptors – antagonize muscarinic receptors

c. butyrophenones stimulate dopamine receptors – antagonize DA receptors

d. ondansotron antagonises seretonin receptors – YES

e. atenolol stimulates noradrenaline receptors – erm….no

Summary of Neurotransmitters

• Acetylcholine

• Noradrenaline

• Seretonin

• Glycine

• Dopamine

4) Beta-Blockers

i) Regarding adrenoceptor antagonists, which of the following is ‘selective’?

a. labetolol

b. pindolol

c. propranolol ANSWER – B

d. phenoxybenzamine

ii) Beta-blockers

a. cannot be used with calcium channel blockers

b. can be used in variant angina

c. works in angina by vasodilatation

d. increases myocardial oxygen consumption All options are FALSE

iii) Propanolol

a. Is a sodium channel blocker

b. Is lipid soluble

c. Is excreted unchanged ANSWER – ?B

iv) Regarding the Beta Blocker Propranolol:

Which statement is CORRECT?

a. has Na+ blocking activity

b. is beta 1 selective

c. has intrinsic sympathomimetic activity

d. is poorly lipid soluble ANSWER – A

v) Metoprolol

a. Is an Unselective Beta-blocker

b. Is only renally excreted

c. Half life is 3-4 hours

d. Has a very high first pass metabolism

e. IV dose is the same as oral dose ANSWER – C

vi) Regarding the Beta Blocker Propranolol

a. Is a highly selective B receptor antagonist

b. Is poorly lipid soluble

c. Has sodium channel blocking activity ANSWER – C

• Labetalol – has effects on alpha and beta receptors. T ½ 4.9 hours

• Sotalol – also has effects on potassium channels (class III)

• Pinodol – Beta 1 Selective

• Nadolol – very long acting

• Propranolol – Relatively UN-selective Beta Blocker (makes asthma worse)

- Notably the Exception in most cases when it comes to Beta Blockers

- Poorly absorbed orally (unlike most other Beta Blockers)

- t ½ 3-6 hours

- Crosses the Blood Brain Barrier – Seizures in Overdose

• NB Phenoxybenzamine - an unselective Beta Blocker

5) Beta-Blockers 2

i) The most lipid soluble beta blocker is

a. Propranolol

b. Atenolol

c. Metoprolol

d. Pindolol

e. Sotalol ANSWER – A

ii) Propranolol

a. is a highly selective beta receptor antagonist

b. is poorly lipid soluble

c. has sodium channel blocking action

d. has intrinsic sympathomimetic activity

e. has an oral bioavailability of > 50 % ANSWER – C

iii) Characteristics of the drug propranolol include all of the following EXCEPT

a. lipid solubility

b. local anaesthetic action

c. half life of 3-6 hours

d. bioavaliability of 30 %

e. beta sympathetic selectivity ANSWER – E

6) Inhaled Anticholinergic Drugs

i) The Drug Ipratropium (Atrovent®)

a. can cause significant side effects that can last up to 4 hours

b. has a significant effect on the central nervous system

c. has a marginally less systemic action than atropine

d. equally effective in bronchodilation as a β2 receptor agonist

ANSWER - A

ii) Regarding ipratropium

a. It readily enters the CNS

b. It causes miosis

c. It is well absorbed orally

d. It inhibits mast cells ANSWER - E

e. It can cause severe effects which last for 4 hours

iii) Ipratropium bromide

a. does not usually cause acute angle glaucoma

b. does not cause the development of tolerance

c. inhibits mucociliary clearance

d. does not work synergistically with salbutamol

• Ipratropium is an Isopropryl Quaternary Atropine Derivative

• Anticholinergic with T ½ of 3 hours and onset over 20 minutes

• Generally minimally absorbed and the drug is not metabolised

7) Cholinergic Drugs

i) Regarding the acetylcholinesterase inhibitors (e.g. physiostigmine, neostigmine) which of the following is TRUE?

a. These drugs reverse the effects of suxamethonium

b. These drugs cause tachycardia

c. They cause decreased secretions

d. They reverse the effects of tubocurarine ANSWER – D

ii) Anticholinesterases

a. antagonise tuburocarine

b. antagonise sux

c. are never used in myasthenia gravis

d. regenerate Ach ANSWER – A

iii) Anticholinesterases (various stems in past pharmacology exams)

a. Are not useful in myasthenia gravis

b. Antagonise sux

c. Antagonise tubocurarine

d. Decrease BP ANSWER – C

iv) The cholinesterase inhibitor with the shortest duration of action is

a. physostigmine

b. edrophonium

c. neostigmine

d. parathion

e. malathion ANSWER – B

vii) Praloxidime

a. regenerates acetylcholine

b. regenerates acetylcholine receptor

c. regenerates acetylcholinesterase

d. regenerates succinylcholine

ANSWER – C

• These drugs are used in reversal of anaesthesia and a small dose of Glycopyrolate or Atropine are often required to counteract the cholinergic effects of the drug

• These drugs have a number of useful applications including the following:

Edrophorium (Tensilon®) Testing (Myasthaenia Gravis)

Bethanachol - Atonic Bladder

Pilocarpine – Glaucoma

‘Stigmine’ treatment of Anticholinergic Syndrome

Reversal of paralysis at the end of operation

Donezepil in Alzheimer's

Length of Action – ‘Phonium (short) – ‘Thion (long).

Pralidoxime reactivates cholinesterase after organophosphate binding / inhibition

8) Anticholinergic Drugs 2

i) Benztropine causes

a. Miosis – mydriasis

b. Diarrhoea – constipation

c. Confusion – this one

d. Bronchorroea – dries up secretions

e. GIT haemorrhage – don’t think so

ANSWER – B

ii)) The major side effect of benztropine is (NB centrally acting)

a. miosis

b. confusion

c. diarrohea

d. GIT haemorrhage

e. Bronchorrhea

ANSWER – B

iii) Side effects of atropine are all EXCEPT

a. Bronchodilation

b. Increased GI motility

c. Bradycardia with low doses

d. Cutaneous vasodilatation at high doses ANSWER – B

• Anticholinergic effects:

- Hot as Hare (hyperthermic)

- Blind as Bat (blurred vision)

- Dry as a Bone (dry mouth and reduced secretions and GIT motility)

(urinary retention)

- Red as a Beet (flushed)

- Mad as a Hatter (agitation, confusion)

9) Drugs and the Eye

i) Regarding the treatments for glaucoma, which INCREASES aqueous outflow?

a. timolol

b. lantanoprost

c. carbechol

d. adrenaline

e. acetazolamide ANSWER - B

ii) Match these eye drugs with their mechanism of action

a. pilocarpine and ciliary contraction

b. prostaglandins and decreased aqueous production

c. b-blockers and increased outflow ANSWER – A

iii) Regarding the treatment of glaucoma, which DECREASES aqueous outflow?

a. Timolol

b. Lantanoprost

c. Carbechol

d. Adrenaline

e. Acetazolamide

iv) Treatment of glaucoma does not include

a. alpha blocker – alpha stimulation

b. beta blocker – timolol

c. carbonic anhydrase inhibitor – acetazolamide

d. cholino-mimetic agents – pilocarpine

v) Effects of occular medications:

a. pilocarpine – ciliary muscle contraction

b. prostaglandin = reduced secretion

c. timolol = pupil ilatation

vi) Regarding the eye, which of the following causes decreased outflow?

a. timolol

b. adrenaline

c. carbechol

d. prostaglandins ANSWER – All False

vii) Drugs used to treat glaucoma; which is CORRECT pairing

a. pilocarpine – ciliary muscle contraction

b. timolol – ciliary muscle contraction

c. acetazolamide – increased aqueous production

d. latanoprost – increased aqueous production

e. dipivefrine – decreased outflow ANSWER – A

• They Seem to like this ‘eye’ autonomic question:

• Pilocarpine – ciliary muscle contraction (cholinoceptor agonist)

• Muscarinic Blocker like Atropine would decrease outflow

• Timolol – β-blocker →↓ secretion

• Acetazolamide – CA inhib →↓ HCO3 prodn

• Latanoprost – prostaglandin →↑ outflow

9) Depolarsiing Muscle Relaxants

i) Concerning the IV drug Suxamethonium, which is TRUE?

a. acts via non-competitive blockade of receptors

b. has no significant CVS side effects

c. is broken down by ‘pseudocholinesterase’ at the Neuromuscular Junction

d. cannot be used for Rapid Sequence Intubation

ANSWER – A

ii) Suxamethonium

a. Is a non-depolarising neuromuscular blocking agent

b. Is contraindicated in all eye operations

c. Stimulates cardiac muscarinic receptors and autonomic ganglia

d. Its action is directly terminated by the action of plasma cholinesterase

e. Should not be administered to patients with burns > 24 hours old because of its hypercalcaemic effect

ANSWER – ?C

• Suxemethonium is an acetylcholine dimer

• 80% or more is metabolized before it reaches target site (NMJ)

• Side effects (basically increased everything except HR) - ↑IOP ↑?ICP ↑Saliva ↑Gastric Secretions ↑ BP ↑ Muscle Pains ↑

• Trismus and Malignant Hyperthermia

• Avoid in Hyperkalaemia and Burns more than 24-48 hours old

11) Toxicology Presentations

i) You are an Emergency Department Registrar. At 2am a patient presents who

ingested a ‘substance’. They are confused and agitated. They have mydriasis and a temperature of 39 degrees Celsius. This is LEAST likely caused by:

a. adrenaline

b. amphetamines

c. aspirin

d. chlordiazepoxide ANSWER – D

ii) A young male punter comes in with a high blood pressure, mydriasis and a high temperature. Which drug has he most likely taken?

a. Atropine

b. Adrenaline

c. Aspirin

d. Naloxone

e. Cocaine ANSWER – E

iii) A man presents with dilated pupils, confusion, hyperpyrexia.

Which of the following drugs would not account for this

a. atropine OD – could well be this one

b. morphine – this one

c. datura – ???

iv) A healthy young man recieves a normal dose of a drug which induces midriasis and increased systolic blood pressure . The drug could be:

a. adrenaline – this one

b. acetylcholine

v) A young man presents with dilated pupils, confusion and hyperpyrexia. Which of the following could not account for these effects.

a. Atropine

b. Datura

c. Morphine – this one

vi) A 51 year old presents to hospital with classic cardiac chest pain. Further investigation includes and angiogram, which is normal. The cardiologist makes a diagnosis of "vasospasm". Which is most likely to cause this?

a) Adrenaline

b) Propranolol

c) Prazocin

d) Atropine ANSWER – A

vii) A patient presents with difficulty walking, agitated, a temperature of 39 degrees and dilated pupils. Which is least likely to produce this effect?

a. atropine OD – cause all the above

b. amphetamine OD – cause agitation, staggering

c. aspirin OD – causes hyperpyrexia, agitation

d. tricyclic OD – doesn’t cause these – seizures + arrythmias

e. angels trumpet – aka datura – contains atropine

viii) A young man is injected with an iv drug. He shows a resultant tachycardia, midriasis, normal blood pressure and reduced sweating. The most likely drug is

a. nicotinic antagonist – no – would have muscular symptoms

b. muscarinic antagonist – this one – eg atropine

c. cholinomimitic – would be miosis, decreased HR, increased sweating

d. adrenergic agonist – would raise BP, and increase sweating

e. adrenergic antagonist – would be bradycardic

ix) An overdose patient has tachycardia, hypertension and urinary retention; what did they overdose on?

a. Aspirin

b. Amphotericin

c. Tricyclics

• Chlordiazepoxide is a long acting benzodiazepine

• The other drugs could cause a similar clinical picture

• Atropine may have an effect when applied directly to the eye

12) Autonomic effects of Psychiatric Medications

i) Regarding Amitryptiline (Tricyclic Antidepressant) which are NOT effects

a. Diarrhoea and Increased Bowel Sounds

b. Sedation

c. Urinary retention

d. Postural hypotension

e. Impotence ANSWER – A

ii) Regarding SSRI’s

a. haemodialysis is useful in OD

b. inhibit cytochrome P450

c. have minimal drug interactions

d. have anti-muscarinic effects

e. ?protein binding

ANSWER – B

The most dangerous drug in overdose is

a. imipramine

b. moclobenide

c. sertraline

d. trazodone

e. paroxeteine

ANSWER – A

Antidepressant with the highest antimuscarinic effect is

a. amitryptiline

b. imipramine

ANSWER – B

• SSRI - highly protein bound

• SSRI – unlikely to be ‘dangerous’ in OD (citalopram has significant cardiac effects including QT prolongation in OD)

• Tricyclics (TCAs) may have Anticholinergic effects:

- Hot as Hare (hyperthermic)

- Blind as Bat (blurred vision)

- Dry as a Bone (dry mouth and reduced secretions and GIT motility)

(urinary retention)

- Red as a Beet (flushed)

- Mad as a Hatter (agitation, confusion)

10) Muscle Relaxants

i) Regarding non-depolarising muscle relaxants

a. Pancuronium is eliminated via the kidney

b. Rocuronium is an isoquinolone derivative

c. Rocuronium undergoes Hoffman elimination

d. Vecuronium is eliminated predominantly via the kidney

e. Atracurium is eliminated via plasma pseudocholinesterase ANSWER – A

ii) Neuromuscular junction blockers; which is INCORRECT

a. vecuronium is predominantly kidney excreted

b. atracurium is inactivated by Hofmann elimination

c. pancuronium has a longer duration of action than vecuronium

d. pancuronium and vecuronium have the same structure

ANSWER – A

iii) The muscle relaxant commonly associated with tachycardia is low dose

a. Suxamethonium

b. Atracurium

c. Vecuronium

d. Pancuronium

e. Tubocurare ANSWER – D

iv) Which of the following statements are FALSE regarding vecuronium

a. it has minimal cardiovascular effects

b. its duration of action is less than ten minutes

c. it is predominantly renally excreted

d. it has a significantly longer duration of action than pancuronium ANSWER – B

v) Which is true of neuromuscular blockers

a. atracurium causes hypotension in volume depleted patients

b. pancuronium causes histamine release

c. vecuronium is an isoquinolone derivative

d. ‘gallium’ is eliminated by the liver

e. gentamicin increases their efficacy ANSWER – E

vi) Which drug decreases the effect of neuromuscular blockade?

a. Atropine

b. Tubocurarine

c. gentamicin

d. neostigmine ANSWER – D

vii) Which statement is true regarding recovery from irreversible neuromuscular blockade?

a. it relies on receptor turnover – yes

viii) The muscle relaxant with the longest duration of action is

a. atracurium

b. mivacurium

c. pancuronium

d. vecuronium ANSWER – C

ix) Vecuronium, all of the following are true except

a. Has minimal CVS effects

b. Is predominantly renally excreted – no, liver excretion

c. Has a significantly longer duration of action than pancuronium – no, panc longer

x) Atracurium

a. Has a longer duration of action than vecuronium

b. Is associated with histamine release

c. Is a steroid derivative

d. Is eliminated by non renal/liver dependant mechanisms ANSWER – B

xi) Regarding pancuronium - which is incorrect?

a. It is a steroid

b. It does not release histamine

c. It is renally excreted

d. It has a shorter duration of action than vecuronium ANSWER – D

xii) Termination of irreversible neuromuscular block involves

a. regeneration of receptors –this one

b. increase in end plate Ach

• Atracurium is usually used in renal failure patients as it undergoes Hoffman Degradation

• Panc and vec are same structure – steroid derivative – no histamine release. Panc causes tachy

• Atrac tubo – isoquinoline derivatives – histamine release as well as sux

•

21) Prazosin; which is correct

a. it is non-selective - alpha-1 selective

b. reduces afterload and preload – alpha-1 cause vasoconstriction

(therefore inhibiting lowers systemic BP)

c. half life is 18 hours - 2-3hours

d. alters lipid levels - ??

e. causes lupus like syndrome - don’t think so

28) Prazosin

a. is non-selective

b. worsens lipid levels

c. causes SLE like syndrome

d. reduces BP by affecting both resistance + capacitance vessels this one – alpha

29) Prazosin

a. Has a half life of 18 hours

b. Adversely affects lipid profiles

c. Produces a reflex bradycardia

d. Has a first dose hypotensive effect ? this one

e. Can increase CO by decreasing preload and leaving afterload unchanged

• Alpha Blockers

• .

• .

• .

•

12)

i) L-dopa; which is correct

a. abrupt stop can increase tremor – causes rebound hypertension

b. precursor to dopamine – yes, by L amino acid decarboxylase

c. ? 25% reaches the brain – 1-3% only

ii) What is true of L-Dopa?

a. 33% reaches the CNS – 1-3%

b. it is the precursor of dopamine – true

c. suddenly stopping it will cause tremor – rigidity

d. it’s half life is about 5 hours – 1 hour

e. 40% less is required if it is given with a peripheral carboxylase inhibitor – up to 75%

iii) Regarding the treatment of Parkinsons, which is INCORRECT

a. L-dopa is contraindicated in acute psychoses – true

b. Bromocriptine has less CNS effects than L-dopa – FALSE more CNS effects

Administration of L-dopa with a dopa decarboxylase inhibitor decreases side effects

iv) In the treatment of parkinsons disease

a) Antimuscarinics are better for the treatment of (?) tremor than dopamine agonists – less effective

b) Administration of L-dopa with a dopa decarboxylase inhibitor decreases side effects – true

v) L-Dopa

a. 1-3% reaches the brain – true

b. Precursor to tyrosine – no, both precursor to dopamine

c. abrupt stop can increase tremor – no rigidity

d. rarely needs increase in dose once effective – needs to keep increasing hence dose holidays

• Parkinson’s Drugs

• .

• .

• .

Which of the following drugs has a pure beta agonist effect in the circulation?

a. Adrenaline

b. Levosimendin

c. Noradrenaline

d. Isoprenaline

ANSWER – D

Which adrenergic agent has a pure beta agonist effect in the circulation?

a. Adrenaline

b. Noradrenaline

c. Isoprenaline

d. Levosimendin

ANSWER – C

What is the correct order of catecholamine synthesis?

a. Tryptophan – dopa – dopamine – adrenaline – noradrenaline – no

b. Tysosine - dopa- dopamine – adrenaline – noradrenaine

c. Tyrosine – dopa – dopamine – noradrenaline – adrenaline – yes

d. Tyrosine – dopamine – dopa – noradrenaline – adrenaline

e. Tyrosine – dopamine – dopa – adrenaline – noradrenaline

Isoprenaline’s effects include all EXCEPT

a. hyperglycaemia

b. increased glycerol

c. bronchodilation

d. increased diastolic pressure

ANSWER – D

The drug Dobutamine

a. Results in ATP -> AMP – activates adenylyl cyclase ATP -> cAMP

b. Can decrease systemic vascular resistance / afterload –

c. .

d.

ANSWER – C

Salbutamol

Initially causes a drop in PaO2

Cause hyperkalemia

Cause hypercarbia

Alpha receptor activation causes

uterine relaxation

cutaneous vessel dilaation

VIVA

Pharmacology

Notes

Most Common Topics are listed first

List of Topics for the PHARMACOLGY VIVA

(BRACKET DENOTES THE APPROX NUMBER OF OCCURENCES AS OF 2009)

Topics for VIVA – PHARMACOLOGY ACEM

• Section 1 Basic Pharmacology (always one question from this area)

Pharmacokinetics (Half Life, Clearance, Elimination Kinetics, Biotransformation, First Pass Metabolism) Other Basic Topics, (New agents Agonists and Antagonists, Receptors, 2nd Messengers, Drug Responsiveness, Potency and Efficacy, Volume of Distribution, Steady state, Loading Does (20+)

Age, Pregnancy, Drugs in Children (7)

• Section 2 – Antibiotics and Antivirals

Antibiotics (Beta Lactams Macrolides) (27)

Acyclovir and Antiretrovirals (3)

• Section 3 – Cardiac Drugs

Anti Anginals, CCF and Beta-Blockers (sotalol) (11)

Antihypertensives (Emergency, ACE inhibitor) (6)

Sodium Channel Blockers and LA (6)

Calcium channel Blockers (6)

Atropine (3)

Adenosine (3)

Frusemide / Diuretics (3)

Amiodarone (3)

Digoxin (2)

Adrenaline (Vasopressors and Resus Drugs) (5)

• Section 4 – CNS Drugs

Suxemethonmium ( and DPMR) (7)

Tri-cyclic Antidepressants, SSRI (5)

Benzodiazepines (4)

Phenytoin (4)

Barbiturates (4)

Carbamazepine (3)

Propafol (3)

Ketamine (3)

Nitrous Oxide, Halothane and Sevoflurane (2)

Haloperidol and Antipsychotics (2)

MOA Inhibitors (2)

Anti-emetics (2)

Alcohol and Methanol (2)

Sodium valproate (1)

• Section 5 – Endocrine Drugs

Glucagon and Insulin (4)

Steroids (4)

Oral Hypoglycaemics (3)

• Section 6 – Opioids and Analgesics

Aspirin and NSAIDS and COX (7)

Opiates and Receptors (6)

Paracetamol (2)

Colchicine (1)

• Section 7 – Anticoagulants and Thrombolysis

Heparin (4)

Thrombolysis (3)

Warfarin (2)

Clopidogrel (2)

• Section 8 – Respiratory Drugs

Salbutamol (2)

Cromoglycate (1)

Benztropine (1)

Ipratropium (1)

Methylxanthines (1)

• Section 9 – Immunisation, GI Drugs and Toxicology

PPIs and H2 Antagonists (3)

Immunisation (Active, Passive, Specific) (2)

Methods of Decontamination (1)

• Section 10 – New Topics

RCT and other methods of analysis of new drugs

Drugs in Pregnancy

Drugs in the Elderly

Toxicology

The Pharmacology Template

PHARMACOKINETICS

- Introduction (Drug, class, prototype drug, history etc)

- Absorption and Routes of Administration and Bioavailability

- Distribution

- Metabolism of Drug

- Clearance

- Half Life

- Dosing

- Monitoring

PHARMACODYNAMICS

- Introduction (as above)

- Mechanism of Action of the Drug

- Organ Effects (E.g. CV, Resp, GI, CNS)

- Side Effects

- Indications (Primary Secondary)

- Contraindications

- Toxidromes

- Major Drug Interactions

- Other Specific Idiosyncratic Issues with the Drug

Memorise this template and use it as a framework for answering questions in the Viva. I found it a very useful way of forming my answers.

At this stage I would recommend tutorial/pharmak.htm and page 36-38 of ‘Basic and Clinical Pharmacology’ for rapid reference.

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