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Clinical Cases for
the FRCA
 MasterPass Series

100 Medical Emergencies for Finals

Prasanna Sooriakumaran, Channa Jayasena, and Anjla Sharman
300 Essential SBAs in Surgery: With Explanatory Answers
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Cases for Surgical Finals: SAQs, EMQs and MCQs
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Clinical Cases for the FRCA: Key Topics Mapped to the
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Alisha Allana

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com/MasterPass/book-series/CRCMASPASS
 Clinical Cases for
the FRCA
Key Topics Mapped to the
RCoA Curriculum

Alisha Allana, MBBS BSc FRCA

Anaesthetic Registrar, Wessex Deanery, UK
First edition published 2022
by CRC Press
6000 Broken Sound Parkway NW, Suite 300, Boca Raton, FL 33487-2742

and by CRC Press

2 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN

© 2022 Taylor & Francis Group, LLC

CRC Press is an imprint of Taylor & Francis Group, LLC

Tis book contains information obtained from authentic and highly regarded sources. While all reasonable eforts
have been made to publish reliable data and information, neither the author[s] nor the publisher can accept any
legal responsibility or liability for any errors or omissions that may be made. Te publishers wish to make clear
that any views or opinions expressed in this book by individual editors, authors or contributors are personal to
them and do not necessarily refect the views/opinions of the publishers. Te information or guidance contained
in this book is intended for use by medical, scientifc or health-care professionals and is provided strictly as a
supplement to the medical or other professional’s own judgement, their knowledge of the patient’s medical history,
relevant manufacturer’s instructions and the appropriate best practice guidelines. Because of the rapid advances in
medical science, any information or advice on dosages, procedures or diagnoses should be independently verifed.
Te reader is strongly urged to consult the relevant national drug formulary and the drug companies’ and device
or material manufacturers’ printed instructions, and their websites, before administering or utilizing any of the
drugs, devices or materials mentioned in this book. Tis book does not indicate whether a particular treatment is
appropriate or suitable for a particular individual. Ultimately it is the sole responsibility of the medical professional
to make his or her own professional judgements, so as to advise and treat patients appropriately. Te authors and
publishers have also attempted to trace the copyright holders of all material reproduced in this publication and
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rial has not been acknowledged please write and let us know so we may rectify in any future reprint.

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Library of Congress Cataloging-in-Publication Data

Names: Allana, Alisha, author.
Title: Clinical cases for the FRCA : key topics mapped to the RCoA curriculum / by Alisha Allana.
Other titles: Master pass
Description: First edition. | Boca Raton, FL : CRC Press, 2021. | Series: MasterPass series |
Includes bibliographical references and index.
Identifers: LCCN 2021037279 (print) | LCCN 2021037280 (ebook) |
ISBN 9780367742119 (hardback) | ISBN 9780367698034 (paperback) | ISBN 9781003156604 (ebook)
Subjects: MESH: Royal College of Anaesthetists (Great Britain) | Anesthesia—methods |
Perioperative Care—methods | Anesthesiology—education | Clinical Decision-Making. |
United Kingdom | Case Reports | Study Guide
Classifcation: LCC RD81 (print) | LCC RD81 (ebook) | NLM WO 218.2 | DDC 617.9/6—dc23
LC record available at https://lccn.loc.gov/2021037279
LC ebook record available at https://lccn.loc.gov/2021037280

ISBN: 978-0-367-74211-9 (hbk)

ISBN: 978-0-367-69803-4 (pbk)
ISBN: 978-1-003-15660-4 (ebk)

DOI: 10.1201/9781003156604

Typeset in Minion Pro

by codeMantra
Khalil – this book is written for you, and because of you.
Always believe that you can do anything.
CONTENTS
Foreword ix
Preface xi
Acknowledgments xiii
Abbreviations xv
Author xix

1 Neurosurgery, Neuroradiology and Neurocritical Care 1

2 Cardiothoracic Surgery 21
3 Airway Management 47
4 Critical Incidents 57
5 Day Surgery 63
6 General, Urological and Gynaecological Surgery 69
7 Head, Neck, Maxillo-Facial and Dental Surgery 77
8 Management of Respiratory and Cardiac Arrest 83
9 Non-theatre 87
10 Orthopaedic Surgery 91
11 Perioperative Medicine 101
12 Regional Anaesthesia 117
13 Sedation 127
14 Trauma and Stabilisation 131
15 Intensive Care Medicine 135
16 Obstetrics 153
17 Paediatrics 175
18 Pain Medicine 193
19 Ophthalmic 205
20 Plastics and Burns 209
21 Vascular Surgery 215

Index 221

vii
FOREWORD
It has been nearly 30 years since I passed the FRCA, and since I passed, I have
been running exam preparation courses for almost all of those 30 years. I know
frst-hand that exam preparation is hard work, and that much of that work is
made more difcult by the number of resources that have to be consulted to
try and fnd the exact piece of knowledge required to answer an exam ques-
tion. Invariably, bits of information can be readily found, but these ofen pro-
vide subtly difering or conficting statements, requiring further research to
clarify in one’s own mind the truth of the topic in question. Tis can lead to a
curiosity-driven quest across innumerable resources, which, while interesting,
can also be very time-consuming during a period when time is a very precious
resource indeed.
What Dr Allana has managed to produce here is, in my opinion, remarkable.
It is a concise summary of the current opinion and evidence to allow FRCA
exam questions to be answered correctly and confdently. While it is aimed
primarily at the Final FRCA, I can also see it being useful for primary FRCA,
FFICM and EDIC, as well as for those running teaching courses and simulation
programmes, and also as a clinical resource for departments of anaesthesia and
critical care medicine. Te management of each case scenario is laid out clearly
with an intuitive structure and with relevant references to allow the interested
reader to further research into the topics if they wish.
Te decision to ofer this material as a book, rather than an online resource,
is, I believe, very sensible. A book is a resource that can be utilised without
adding to “screen time”, it can be annotated and marked and it can be shared
and passed between candidates in the throes of exam preparation. Part of the
key to exam success is developing a structure to hang your knowledge onto –
having these structured summaries readily to hand and adding your own bits
of “detail” will help all candidates to not only remember the answers in an
exam but also to recall this knowledge better at a future time when it is needed
clinically.
I commend this book to all anaesthetists and intensivists at any stage in their
career, not just those sitting an exam. It is an excellent resource and “aide mem-
oire” for teaching and for clinical work. I wish Dr Allana every success with its
publication.
Dr Jonathan Harrison BM, FRCA
Chairman of SCIP (South Coast Intensive Primary) course
Clinical Director & Consultant Anaesthetist
Portsmouth Hospitals University Trust

ix
PREFACE
Te clinical cases in this book are mapped directly to the Royal College of
Anaesthetists’ curriculum, and can be used to revise for both the written
and viva, Primary and Final sittings. With the addition of critical incidents
throughout, the questions can also be used as the basis for simulation train-
ing and teaching for individual modules. Te answers are based on the most
up-to-date guidelines and protocols, and can be used as a guide to manage
complex theatre cases by all anaesthetists, from the eager novice to the skilled
consultant.
Revision for the FRCA examinations is a long, sometimes challenging, and
hopefully rewarding journey. Nothing compares to the clinical experience and
management of patients frsthand, but the aim of this book is to fll in any gaps,
highlight important cases and support revision of difcult topics.
Alisha Allana

xi
ACKNOWLEDGMENTS
Tanks to my husband, for always having faith in me and being there every step
of the way; and to my parents and siblings, for their unwavering support and
endless supply of food.
Tanks to everyone who facilitated viva preparation for me while I was revising
for the exams, and to all the trainees who allowed me to practice the questions
for this book on them. I hope it helped you as much as it did me!
Particular thanks and a huge amount of appreciation go to the following indi-
viduals who contributed in so many ways to ensure that the text of this book is
as complete and up to date as possible. Your insight, knowledge and experience
have been invaluable in the production of Clinical Cases for the FRCA.

Dr Alice Aarvold
Consultant Anaesthetist
University Hospital Southampton NHS
Foundation Trust
(Airway & Head & Neck)

Dr James Eldridge
Consultant Anaesthetist
Portsmouth Hospitals University NHS
Trust (Obstetrics)

Dr Daniel Growcott
Consultant Anaesthetist
Portsmouth Hospitals University NHS
Trust (Orthopaedics & Regional)

Dr Joanna Harding
Consultant Anaesthetist
University Hospital Southampton NHS
Foundation Trust (Pain Medicine)

Dr Jonathan Huber
Consultant Cardiac Anaesthetist
University Hospital Southampton NHS
Foundation Trust (Cardiac surgery)

Dr Nicholas Jenkins
Consultant Anaesthetist
Portsmouth Hospitals University NHS
Trust (Perioperative Medicine, General & Day Case Surgery)

xiii
 Acknowledgments

Dr Leonid Krivskiy
Consultant Anaesthetist
University Hospital Southampton NHS
Foundation Trust (Toracics)

Dr Jessica Lees
Consultant Anaesthetist
University Hospital Southampton NHS
Foundation Trust (Paediatrics)

Dr Benjamin Tomas
Consultant Neuro-anaesthetist and Intensivist
University Hospital Southampton NHS
Foundation Trust (Neurosurgery)

Dr Hania Ward
Consultant Anaesthetist
University Hospital Southampton NHS
Foundation Trust (Trauma, Ophthalmic & Vascular)

Dr Matthew Williams
Consultant Anaesthetist and Intensivist
Portsmouth Hospitals University NHS
Trust (Intensive Care Medicine & Arrest)

Dr Robin Wilson
Consultant Anaesthetist
University Hospital Southampton NHS
Foundation Trust (Paediatrics)

xiv
 Abbreviations

ABBREVIATIONS
2,3-DPG 2,3-diphosphoglyceric acid
AAGBI Association of Anaesthetists of Great Britain and Ireland
ABG arterial blood gas
ACE angiotensin converting enzyme
ADH anti-diuretic hormone.
ALS advanced life support
ARDS acute respiratory distress syndrome
BMI body mass index
CF cystic fbrosis
COPD chronic obstructive pulmonary disease
CP cerebral palsy
CPAP continuous positive airway pressure
CPB cardiopulmonary bypass
CPET cardiopulmonary exercise testing
CPR cardiopulmonary resuscitation
CSF cerebrospinal fuid
CT computed tomography
CTG cardiotocography
CVP central venous pressure
DIC disseminated intravascular coagulation
DKA diabetic ketoacidosis
ECG electrocardiogram
ECT electroconvulsive therapy
EEG electroencephalogram
ENT ear, nose and throat
FBC full blood count
FEV1 forced expiratory volume in 1 second
FFP fresh frozen plasma

xv
 Abbreviations

FVC forced vital capacity

GCS Glasgow Coma Score
GDD global developmental delay
IASP International Association for the Study of Pain
ICP intra-cranial pressure
INR international normalised ratio
ITU intensive care unit
IV intravenous
IVIg intravenous immunoglobulin
LV lef ventricle
MAC minimum alveolar concentration
MCV mean cell volume
MRI magnetic resonance imaging
NAP National Audit Project
NICE National Institute for Health and Care Excellence
NMDA N-methyl-D-aspartate
NSAIDs non-steroidal anti-infammatory drugs
ODP operating department practitioner
OSA obstructive sleep apnoea
PCA patient controlled analgesia
PEEP positive end expiratory pressure
PO oral
P-POSSUM Portsmouth-Physiological and Operative Severity Score for the
enumeration of Mortality and Morbidity
PRES posterior reversible leucoencephalopathy syndrome
ROSC return of spontaneous circulation
RV right ventricle
SIADH syndrome of inappropriate ADH secretion
SIRS systemic infammatory response syndrome
SVR systemic vascular resistance
TCI target controlled infusion

xvi
 Abbreviations

TEG thromboelastogram
TENS transcutaneous electrical nerve stimulation
THRIVE transnasal humidifed rapid-insufation ventilatory exchange
TIA transient ischaemic attack
TIVA total intravenous anaesthesia
TRAM transversus rectus abdominis myocutaneous
U+E urea and electrolytes
UKOSS UK Obstetric Surveillance System
VF ventricular fbrillation
VO2 oxygen uptake
VTE venous thromboembolism

xvii
AUTHOR
Alisha is an anaesthetic registrar in the Wessex deanery, with an interest in
medical education, simulation and patient safety.

xix
1
NEUROSURGERY,
NEURORADIOLOGY AND
NEUROCRITICAL CARE

CASE: SUBARACHNOID HAEMORRHAGE

A 36-year-old female patient is listed for emergency embolisation of a
cerebral aneurysm following a grade IV subarachnoid haemorrhage. She
is intubated and ventilated following a drop in her GCS in the emergency
department. She takes sertraline for depression but has no other known
medical conditions.

What are the treatment options for this patient?

Conservative
• Supportive therapy on the neuro-intensive care unit to maintain a
dequate cerebral perfusion pressure and optimal gas exchange.
• Avoidance of extremes of blood pressure to minimise the risk of
re-bleeding and ischaemia.
• Excellent blood glucose and core temperature control (primarily
treatment of pyrexia).
• Consideration of seizure prophylaxis.
Pharmacological
• 60 mg oral nimodipine (via a nasogastric tube) every 4 hours for
21 days to minimise the risk of vasospasm.
Interventional
• Surgical clipping.
• Endovascular coiling.

What are the benefts of coiling over clipping for this patient?
• Te International Subarachnoid Aneurysm Trial (ISAT) evaluated
the diference between clipping and coiling for subarachnoid
haemorrhage secondary to aneurysm rupture.
• Coiling demonstrated a reduced risk of mortality at 1 year, but with a
slightly higher incidence of re-bleeding.

What are the complications associated with a subarachnoid haemorrhage?

• Re-bleeding (minimal if the aneurysm is secured).

DOI: 10.1201/9781003156604-1 1
 Clinical Cases for the FRCA

• Hydrocephalus.
• Cerebral vasospasm (most common at days 3–21).
• Arrhythmias and ischaemic cardiac events. A troponin rise is
commonly seen following a subarachnoid haemorrhage, likely
due to endocardial ischaemia secondary to an increase in aferload
and endogenous vasopressor release at the ictus. Patients with
poorer-grade bleeds may also develop Takotsubo’s cardiomyopathy.
• Aspiration, pneumonia and pulmonary oedema (particularly if
co-existing heart disease is present).
• Endocrine pathology e.g. cerebral salt wasting syndrome, diabetes
insipidus, SIADH.

What are the concerns associated with anaesthetising this patient?

Remote site anaesthesia
• Appropriate stafng required e.g. ODP, senior anaesthetist or
emergency help.
• Lack of familiar or appropriate monitoring and equipment, and
potentially out of hours.
• Lack of an appropriate recovery area.
• Poor lighting and limited access to the patient during the
procedure.
Specifc concerns associated with the pathology
• Tis is a critically unwell patient undergoing an emergency high-risk
procedure that requires an experienced senior anaesthetist for
optimal management.
• High risk of perioperative complications.
• Tere may be poor compliance from the patient if they are not sedated,
but have an altered GCS.
• Risks associated with induction of anaesthesia in a potentially
unstarved patient at a remote site.
• Te patient may need an external ventricular drain before or afer the
procedure if hydrocephalus is evolving.

How would you manage this patient during her procedure?

• Take a thorough preoperative history and conduct the relevant
examination and appropriate investigations. Te patient is intubated
so a history can be taken from a family member and from her GP/
hospital notes.
• Ensure a completed consent form and WHO checklist and discuss
the patient with the multidisciplinary team and a consultant
neuroanaesthetist.
• Consider the best location for the initial management of the patient
prior to the procedure e.g. in neurocritical care if unstable.

2
 Neurosurgery and Neurocritical Care

• Apply AAGBI standard monitoring and insert an arterial cannula

for invasive blood pressure monitoring with large bore intravenous
access present.
• Prepare the appropriate emergency drugs and equipment including
the resuscitation and difcult airway trolleys. Check the position of
the endotracheal tube following the transfer.
• Insert a temperature probe, catheter and nasogastric tube (if required)
prior to the procedure to facilitate adequate monitoring, drug
administration and passage of high contrast volumes.
• Depending on the clinical situation before the procedure and any
procedural concerns or complications, the patient may be extubated,
but they may also require ongoing care in the high dependency or
intensive care unit.

BIBLIOGRAPHY
Luoma A. Acute management of aneurismal subarachnoid haemorrhage.
Continuing Education in Anaesthesia, Critical Care & Pain. 2013; 13 (2):
52–58.
Patel S & Reddy U. Anaesthesia for interventional neuroradiology. BJA
Education. 2016; 16 (5): 147–152.

CASE: ANEURYSM CLIPPING

A 59-year-old female patient is undergoing an elective craniotomy for
clipping of an aneurysm. She has severe COPD and a permanent pacemaker
in situ. Her current medication includes captopril, tiotropium, salbutamol
and simvastatin.

What added information would you like prior to this case?

Patient factors
• A full and thorough anaesthetic history focusing on the patient’s
known cardiovascular and respiratory comorbidities, any previous
anaesthetics and an airway assessment.
• A focused pacemaker history, to include the reason for and date of
insertion, the date of the most recent check and any malfunction, the
pacemaker mode and how dependent the patient is on the pacemaker.
• A baseline neurological examination checking for signs of raised
intracranial pressure (fuctuating GCS, headache, vomiting and
visual changes), gross focal neurological signs and any symptoms of
hydrocephalus.

3
 Clinical Cases for the FRCA

• Relevant investigations following the history and examination. Tis

is likely to include an ECG to assess pacemaker function, bedside
observations, blood tests including a full blood count and clotting,
and CT/MRI brain imaging.
Surgical factors
• Te patient’s position during the procedure.
• Te likelihood of diathermy use perioperatively, taking into account
the permanent pacemaker.
• Te urgency and likely duration of the procedure.
• Consideration of alternative procedures given the comorbid state
of the patient. Radiological coiling is minimally invasive; hence,
there would be a decreased requirement for opioid analgesia and its
associated side efects.
Anaesthetic factors
• Tis is a patient with numerous comorbidities undergoing a
major operation. Te case should be supervised by a consultant
neuroanaesthetist.
• Discuss the patient with the neurocritical care unit for the availability
of postoperative level 2/3 care.

Which of her medication, if any, would you stop prior to surgery?

• Continue nimodipine, inhalers and simvastatin.
• Omit captopril on the morning of surgery; administration of ACE
inhibitors can cause signifcant uncontrollable intraoperative
hypotension.

What are the anaesthetic goals in this case?

• Maintenance of cerebral perfusion and gas exchange.
• Maintenance of haemodynamic stability, in particular avoiding the
pressor response to laryngoscopy.
• Rapid postoperative emergence with good analgesia and prevention
of coughing/vomiting.
• Reducing the risk of complications specifc to neurosurgery e.g. air
embolism.

Which anaesthetic agent(s) would you use to anaesthetise this patient?

Tere is no right answer to this question – discuss the agent(s) that you feel most
comfortable with. Te best anaesthetic for this patient is a safe anaesthetic that
fulfls the above goals!
TIVA anaesthetic
• Use the Marsh or Schneider model with propofol and the Minto
model with remifentanil.
• Ensure appropriate efect site concentrations of the drugs in use.

4
 Neurosurgery and Neurocritical Care

• Te concentrations should be titrated to overcome the hypertensive

response to stimuli e.g. during the application of Mayfeld pins.
Volatile agents
• Induction with appropriate doses of propofol and fentanyl.
• Maintenance of anaesthesia with sevofurane (note that sevofurane
uncouples the cerebral blood fow and cerebral metabolic rate of oxygen).
• Avoid nitrous oxide (can worsen pneumocephalus postoperatively).
• Control the hypertensive response to stimuli using an opioid
(alfentanil bolus, remifentanil infusion) and/or a short-acting beta
blocker (esmolol infusion).

If using a TIVA method, what features are important for safety?

• Ensure adequate training and competence of the anaesthetist.
• Use a TCI-specifc infusion pump that has been checked and serviced.
• Ensure that the pump alarms are enabled to alert the anaesthetist to
high pressures and an empty syringe.
• Consider two person checking of the drugs.
• Use Luer-lock connectors and anti-syphon valves.
• Ensure that there is a visible cannula during the procedure.
A crystalloid solution can be used to maintain patency perioperatively
(0.9% saline).

Te surgeon states that the brain appears tight and swollen intraopera-
tively. What is your immediate management?
• Raise the patient to a head-up position if possible.
• Optimise the cerebral blood fow by adjusting the PaCO2 to a
low-normal range and ensuring normoxia.
• Judicious use of mannitol 0.5–1 g/kg (or hypertonic saline, as long
as serum sodium adjustment occurs at a safe rate) afer a discussion
with the surgeon.
• Re-assess the patient using an ABCDE approach and facilitate further
procedures or treatment as directed by the surgical team.

What analgesia regimen would you prescribe for this patient

postoperatively?
• IV morphine and paracetamol intraoperatively and in recovery as
necessary.
• Regular oral morphine and paracetamol postoperatively, which can
be escalated to a morphine or fentanyl PCA if required.
• Avoid NSAIDs in the immediate postoperative period due to the
bleeding risk.
• Prescribe adequate laxatives and consider regular anti-emetics.
• A scalp block can also be performed perioperatively by the surgeon
or anaesthetist.

5
 Clinical Cases for the FRCA

BIBLIOGRAPHY
Nimmo AF et al. Guidelines for the Safe Practice of Total Intravenous Anaesthesia
(TIVA). London: Association of Anaesthetists. 2018.

CASE: TETANUS
A 36-year-old Turkish builder is admitted to the emergency department
with difculty breathing, spasms and neck stifness. You are asked to review
him urgently due to concerns regarding his airway.

What are the potential causes of this patient’s symptoms?

Infective
• Meningitis/encephalitis.
• Oral or dental infection/abscess.
• Generalised sepsis.
• Tetanus.
Non-infective
• Electrolyte disturbances e.g. hypocalcaemia.
• Epileptic seizure.
• Drug reactions/withdrawal.
• Strychnine poisoning (pesticide).
• Psychological cause.

How is tetanus diagnosed?

Tetanus is caused by toxins released by Clostridium tetani, but it is primarily a
clinical (rather than microbiological) diagnosis based on the patient’s history and
symptoms.
History
• Known or observed injury or trauma with an open wound.
• Sudden onset of symptoms.
• Lack of up-to-date tetanus vaccination.
• Work or home environment associated with metal, soil or manure.
Examination
• Muscle rigidity and spasms, including neck stifness, masseter spasm
and truncal rigidity.
• Autonomic dysfunction and severe haemodynamic instability.
• Respiratory failure.

What are the treatment options for patients with suspected tetanus?
• Treatment is largely supportive. Patients should be managed in the
intensive care unit in a darkened, quiet room and observed closely.

6
 Neurosurgery and Neurocritical Care

• Ensure appropriate airway management with early intubation and

lung protective ventilation if there are any concerns.
• Ensure close monitoring and treatment of haemodynamic instability
with vasopressors and inotropes if required.
• Antimicrobial therapy should be commenced as soon as possible
(intravenous metronidazole is the frst line) and the patient should be
discussed with a microbiology consultant.
• Tetanus human IVIg should be given to neutralise the unbound toxin.
• Consider wound debridement if there is an obvious source of infection.
However, maintenance of cardiovascular and respiratory stability is the
priority.
• Benzodiazepines and sedative agents can be used for spasm and
rigidity control.

What is an autonomic storm?

• Tetanus is associated with rapid and signifcant changes in cardiovas-
cular status.
• An autonomic storm arises due to the sudden release of adrenaline
and noradrenaline into the bloodstream, causing severe hypertension
and tachycardia.
• Tis may be followed by episodes of hypotension, bradyarrhythmias
and cardiac arrest.
• Te patient may also demonstrate other signs of sympathetic nervous
system instability including sweating, ileus and increased secretions.

When you assess the patient, the oxygen saturations are 91% on 15 L
oxygen, the GCS is 10 and there is a marked stridor. What is your
management?
Tis is an anaesthetic and medical emergency that needs immediate management
by the multidisciplinary team. Help should be sought immediately.
• Declare an airway emergency and call for urgent senior help given
the likely risk of a difcult airway/intubation and the obvious need
for the patient to go to intensive care. Whilst awaiting specialist help,
maintain the patient’s airway using a Mapleson C circuit with airway
adjuncts if necessary.
• Ask the anaesthetic assistant to prepare emergency equipment and drugs
for intubation and ventilation and formulate a plan, including the plan
for airway management in the event of failed oxygenation or intubation.
• Te equipment should include an intubation checklist, suction
switched on and readily accessible, a videolaryngoscope, the difcult
airway trolley, an appropriately sized endotracheal tube (with one size
smaller immediately available) and the resuscitation trolley.
• Apply AAGBI standard monitoring and invasive blood pressure
monitoring if possible, but insertion of an arterial cannula should not
delay further management.

7
 Clinical Cases for the FRCA

• Given the risk of haemodynamic instability on induction, draw

up vasopressor and vagolytic agents prior to induction. Perform a
rapid sequence induction, maintaining a stable cardiovascular state using
appropriate doses of the induction agent, opioid and muscle relaxant.
• Te airway should be secured with an appropriately sized
endotracheal tube and lung protective ventilation initiated. Te
patient should be managed on the intensive care unit.
• Ongoing sedation with benzodiazepines may improve hypertonia. If
not, muscle relaxant infusions may be required, with monitoring of
creatine kinase levels and further treatment.

BIBLIOGRAPHY
Taylor AM. Tetanus. Continuing Education in Anaesthesia, Critical Care &
Pain. 2006; 6 (3): 101–104.

CASE: PARKINSON’S DISEASE

A 68-year-old male patient is listed for an elective anterior resection. He was
diagnosed with Parkinson’s disease 2 years ago and is an ex-smoker. You are
asked to review him in the preoperative assessment clinic.

What is Parkinsonism?
• Triad of symptoms: resting tremor, rigidity and bradykinesia.
• Tere are numerous causes of Parkinsonism that lead to an imbalance
between dopamine and acetylcholine levels in the basal ganglia,
including:
• Parkinson’s disease.
• Infective causes.
• Trauma.
• Drugs.

What are the perioperative risks in patients with Parkinson’s disease?

• Patients with Parkinson’s disease have:
• An overall increase in morbidity and mortality.
• A higher likelihood of falls.
• An increased incidence of a difcult airway and aspiration
pneumonitis.
• A higher risk of developing postoperative pulmonary complications.
• An increased likelihood of venous thromboembolism due to
perioperative immobility.

8
 Neurosurgery and Neurocritical Care

• An increased length of stay in intensive care and hospital, with its

associated complications.
• More chance of developing postoperative delirium and cognitive
decline.
• Potential for adverse efects of missed doses of anti-Parkinson’s
medications.

What are the key concerns when assessing this patient preoperatively?
General
• Tis is a high-risk patient undergoing major abdominal surgery.
Te patient should be discussed with the multidisciplinary team
including the surgical team, a consultant anaesthetist and a
neurologist, as well as the intensive care team for consideration of
postoperative level 2/3 care.
• Given that the patient is being assessed in the preoperative clinic,
there is adequate time available for optimisation of the patient prior
to the procedure.
• Carry out a thorough anaesthetic assessment including the
patient’s comorbidities, regular medication, a social history and the
airway.
Systemic symptoms of Parkinson’s disease
• Te patient may demonstrate signs of a difcult airway due to a
fxed fexion neck deformity, rigidity and poor upper airway muscle
function causing increased secretions and a higher risk of aspiration.
In addition, the patient may have delayed gastric emptying secondary
to the side efects of anti-Parkinsonian agents and dysphagia.
• A restrictive pulmonary deficit and obstructive sleep apnoea
are common in patients with Parkinson’s disease, making
ventilation challenging. Lung function tests and a chest x-ray may
be indicated.
• Postural hypotension and arrhythmias are common in patients
with severe Parkinson’s disease and may lead to intraoperative
haemodynamic instability, particularly on induction of
anaesthesia.
Medication
• Te dosage and timing of Parkinson’s medication should be noted
and discussed with a disease specialist.
• Te medication may interact with anaesthetic and analgesic agents
with potential for worsening of symptoms.
• Ensure a return to oral intake as soon as possible through adequate
hydration, analgesia and enhanced recovery where possible.
• Consider a nasogastric tube for medication postoperatively afer
discussing with the surgeon and neurologist.

9
 Clinical Cases for the FRCA

What is your plan for analgesia and anti-emesis in this patient?

Analgesia
• Continue medication that the patient may be on for chronic pain,
or convert to an intravenous dose if the patient is unable to take
medication orally.
• Use regional nerve blockade or local anaesthetic infltration where
possible to minimise the use of opioid-based drugs.
• Assess the patient’s dexterity (and therefore their ability to use a PCA)
prior to prescribing analgesic regimens.
• Avoid pethidine and high-dose fentanyl, which may lead to increased
rigidity during the perioperative period.
Anti-emesis
• Anti-emetic medications that act as dopamine receptor antagonists
should be avoided as they may lead to extra-pyramidal side efects or
intensify pre-existing Parkinsonian symptoms.
• Drugs that can be used safely include domperidone (a dopamine
receptor antagonist that does not cross the blood brain barrier),
ondansetron and cyclizine.
• However, other methods of minimising nausea and vomiting should
be favoured including hydration, reassurance, avoidance of opiates
where possible and efective analgesia.

BIBLIOGRAPHY
Chambers DJ, Sebastian J & Ahearn DJ. Parkinson’s disease. BJA Education.
2017; 17 (4): 145–149.

CASE: EPILEPSY
A 26-year-old male patient is listed for shoulder surgery following an injury
while playing cricket last year. He has a history of epilepsy. You are asked to
review him prior to his procedure.

What is epilepsy?
• A neurological condition caused by excessive or abnormal electrical
activity in the brain.
• Tis leads to a spectrum of symptoms including a predisposition to
behavioural changes and seizures.
• Epilepsy is diagnosed following two separate episodes of seizure
activity.
• It is classifed according to the cause and type of seizures:
• Focal (simple or complex).
10
 Neurosurgery and Neurocritical Care

• Generalised (absence, tonic-clonic, myoclonic or atonic).

• Mixed.

How would you assess this patient?

History
• Take a full history including any cardiovascular and respiratory
comorbidities, regular medication and allergies and a social history.
• Ask the patient about any previous anaesthetics.
• Take a focused history regarding the diagnosis of epilepsy, to include:
• Te date of diagnosis.
• Te cause of epilepsy, if known.
• Any previous and current treatment (including the timing of doses).
• Seizure frequency and type.
• Known seizure triggers.
• Comorbidities secondary to the diagnosis or treatment.

Examination
• Routine examinations including an airway assessment. Specifc
examinations would not usually be indicated unless there was an
obvious reason noted from the history.
Investigations
• Baseline observations.
• Anti-epileptic medication levels only if poor compliance with treat-
ment is suspected or a prolonged procedure/inpatient stay is expected.
• Further blood tests or investigations should be guided by the history
and examination and would not usually be necessary for routine
day-case surgery.

What are the key concerns when anaesthetising this patient?

Adequate anti-epileptic medication levels
• Continue regular anti-epileptic medication during the perioperative
period, factoring in timings for each dose.
• Avoid prolonged fasting.
• Minimise perioperative nausea and vomiting.
Minimising risk of seizures
• Avoid drugs that decrease the seizure threshold.
• Ensure optimal oxygenation and avoid hypocapnia, which may
provoke seizures.
• Plan perioperative analgesia, discussing with the surgical team.
Awareness of drug interactions
• Some anti-epileptic drugs act as enzyme inducers or inhibitors,
which needs to be taken into account when choosing anaesthetic and
analgesic agents.
11
 Clinical Cases for the FRCA

Which commonly used agents should be avoided in patients with epilepsy?

• Enfurane has been associated with abnormal EEG activity, but is not
commonly used in the UK.
• Methohexitone may provoke seizures, but is not used in the UK.
• Dopamine receptor antagonists e.g. metoclopramide can cause
dystonia and may mimic seizures, thus introducing diagnostic
challenges postoperatively and should be avoided.
• Alfentantil, tramadol and pethidine increase EEG brain activity and
lower the seizure threshold.

During the procedure, the surgeon notes a sudden increase in muscle

tone, which is associated with a heart rate of 145 and a blood pressure of
189/101. How do you proceed?
• Tis may be seizure activity under general anaesthetic. Alert the
theatre team, call for urgent help and conduct a rapid ABCDE
assessment to determine the cause of the patient’s symptoms and rule
out other potential causes.
• Apply 100% oxygen and manually ventilate the patient to assess
compliance. Ensure that the patient has a normal-high end tidal
carbon dioxide level.
• Check and correct electrolyte levels, acid–base balance,
temperature and glucose (an arterial blood gas would be prudent
when possible).
• Ensure adequate anaesthesia, muscle relaxation and analgesia.
• If the suspected seizure activity does not terminate, consider
benzodiazepines, phenytoin or other anti-convulsants, noting what
the patient has already taken preoperatively. Escalate to specialist care
for further advice.
• Once the patient is stable, have a discussion with the surgeons
regarding the expected duration of the procedure and the plan for
postoperative care.

BIBLIOGRAPHY
Carter E & Adapa R. Adult epilepsy and anaesthesia. BJA Education. 2015;
15 (3): 111–117.

CASE: POSTERIOR FOSSA SURGERY

A 48-year-old male patient is undergoing posterior fossa surgery for excision
of a metastatic lesion secondary to lung cancer. He has a body mass index
(BMI) of 41 and initially presented with seizures. You are asked to review
him prior to his procedure.
12
 Neurosurgery and Neurocritical Care

What added information would you like before proceeding with this case?
Patient factors
• Take an anaesthetic history focusing on pre-existing comorbidities;
particularly complications associated with obesity e.g. obstructive
sleep apnoea, hypertension and ischaemic heart disease.
• Explore the diagnosis of lung cancer, including investigations and
treatment so far.
• Discuss any interventions for the metastatic brain lesion and in
particular, symptoms he has developed including the seizures
mentioned in the history.
• Ask the patient about previous anaesthetics and conduct an
airway assessment (the he may have a difcult airway due to his
raised BMI).
• Take a medication and social history.
Surgical factors
• Preferred patient positioning. Te options for posterior fossa surgery
include sitting, prone, lateral and park-bench.
• Discuss any potential complications or challenges that may arise
perioperatively with the suggested management in an emergency.

What specifc signs and symptoms may the patient have due to the
tumour?
• Signs suggestive of cerebellar involvement e.g. tremor, ataxic gait and
dysarthria.
• Bulbar cranial nerve palsies. Te patient may have had episodes of
choking or aspiration due to a poor gag refex. Coughing may also be
impaired.
• Te patient presented with seizures, which suggests raised intracranial
pressure. Other symptoms include a headache, nausea, vomiting and
fuctuating conscious levels. Te patient should be assessed for these
on the day of surgery as he may require preoperative medical or
surgical management.
• Fluid and electrolyte imbalance and signs suggestive of
hypovolaemia secondary to vomiting, diabetes insipidus, SIADH or
poor oral intake.
• Side efects of high-dose steroids and other treatment that may have
been initiated following the initial diagnosis.

Te surgeons would like to proceed in the sitting position. What are the
contraindications to surgery in this way?
Absolute
• Presence of a ventriculo-atrial shunt.
• Presence of a patent foramen ovale.
13
 Clinical Cases for the FRCA

Tis is due to the potential risk of a venous air embolus entering the arterial
circulation.
Relative
• Poorly controlled hypertension (due to the risk associated with
hypotension when sitting).
• Very young/old patients.
• Chronic obstructive pulmonary disease.
• Autonomic neuropathy.

What specifc complications are associated with surgery in the sitting

position?
• Perioperative haemodynamic instability.
• Venous air embolism.
• Pneumocephalus.
• Tongue swelling.
• Permanent nerve damage (cervical spine fexion injury).

What forms of monitoring would you use when anaesthetising this

patient?
• Full AAGBI standard monitoring including ECG, capnography, pulse
oximetry and core temperature.
• “Train of four” monitoring if using neuromuscular blocking
agents.
• Invasive blood pressure monitoring.
• Central venous pressure monitoring.
• Consider monitoring for venous air embolus:
• Precordial Doppler.
• Transoesophageal echocardiography.
• Somatosensory-evoked potentials if there is a surgical indication.

What are the anaesthetic goals for this patient?

• Maintenance of a stable blood pressure and cerebral perfusion
pressure.
• Quick ofset of anaesthetic to allow for rapid postoperative
neurological monitoring.
• Careful patient positioning and padding to minimise the risk of
complications secondary to the procedure and sitting position.

BIBLIOGRAPHY
Jagannathan S & Krovvidi H. Anaesthetic considerations for posterior fossa
surgery. Continuing Education in Anaesthesia, Critical Care & Pain. 2014;
14 (5): 202–206.
14
 Neurosurgery and Neurocritical Care

CASE: CHRONIC SPINAL CORD INJURY

A 32 year-old female patient is listed for an elective Caesarean section. She
has a history of mild asthma, for which she takes salbutamol, and had a
spinal cord injury following a road trafc accident 5 years ago. You are asked
to review her prior to her procedure.

How would you assess this patient?

History
• Take a detailed history of the symptoms, complications and treatment
following the spinal cord injury. Knowledge of the level of the spinal
cord injury will be essential to form an appropriate management
plan. Te history should include:
• Any previous episodes of autonomic dysrefexia.
• Te presence of symptoms suggestive of central sleep apnoea.
• Any prolonged ventilation or tracheostomy.
• Current pressure sores.
• Current treatment of chronic pain and/or spasticity.
• Take a medical history including the severity of asthma and any past
hospital admissions.
• Ask the patient about previous anaesthetics, in particular those
following the road trafc accident and review the anaesthetic charts
if they are available.
Examination
• Conduct cardiovascular, respiratory and neurological examinations
including palpation of the spinous processes to determine the ease of
neuraxial blockade if necessary.
• Carry out an airway assessment. Te patient may present with a
potential difcult airway depending on the level of the spinal cord
injury and/or spinal fxation that may have occurred.
Investigations
• Bedside observations including blood pressure and heart rate at rest.
• Baseline blood tests to include clotting and a cross-match if indicated.
• Further investigations should be guided by the patient’s
comorbidities and symptoms, but may include an ECG, echo and
lung function tests.

What are the key concerns in patients presenting with a chronic spinal
cord injury?
Airway and respiratory system
• Te level of the spinal cord lesion will determine its efect on
ventilation. Lesions above C5 will require ventilatory support.
15
 Clinical Cases for the FRCA

• Decreased lung volumes and poor muscle function secondary to the

neurological injury may predispose the patient to atypical respiratory
tract infections and aspiration.
• Surgical fxation of the cervical spine may cause difculty with
intubation and ventilation.
Cardiovascular system
• Autonomic dysrefexia may occur during perioperative period,
causing massive haemodynamic instability and end-organ damage
e.g. myocardial infarction.
• Tere is an increased risk of undiagnosed ischaemic heart disease in
this patient due to reduced movement and exercise levels.
• Te patient presents with a high risk of venous thromboembolism
secondary to immobility.
• Te patient will have an overall reduction in plasma volume and
haemoglobin concentration, which may be signifcant if there is
signifcant blood loss perioperatively.
Neurological system
• Spasticity and contractures can make patient positioning and the
surgical procedure challenging, and may require extra time.
• Previous spinal surgery can lead to unreliable neuraxial blockade.
• Patients with chronic spinal cord injuries have a high incidence of
chronic pain.
Other
• Impaired haemostasis and temperature control.
• Delayed gastric emptying.
• Chronic urinary retention and a high incidence of urinary tract infections.

What are the options for anaesthesia in this patient?

Te anaesthetic technique should be chosen based on the level of the lesion, the
procedure (in this case, a Caesarean section) and the symptoms and preference
of the patient. It should be decided following a multidisciplinary team discussion
involving the patient, obstetrician, anaesthetist and neurosurgical team.
Te options for anaesthesia are detailed below.
• General anaesthetic.
• Neuraxial blockade (it would be prudent to discuss this with the
neurosurgical team prior to the procedure).
• No anaesthetic (if the patient does not have autonomic dysrefexia and
has no sensation in the neurological distribution of the surgical site).

Te Caesarean section is carried out under a spinal anaesthetic. During

the procedure, the patient suddenly complains of a headache and blurred
vision, with difculty in breathing. On examination her chest is fushed
and her blood pressure is 178/93. How do you manage this?

16
 Neurosurgery and Neurocritical Care

• Call for help, alert the theatre team and conduct a rapid ABCDE
assessment of patient.
• Tis is possible autonomic dysrefexia, which is a medical emergency
and should be treated immediately.
• Pause the surgery as soon as possible.
• Position the patient in a reverse Trendelenburg position.
• Check the level of neuraxial blockade and consider a general
anaesthetic if inadequate.
• Administer a short-acting antihypertensive agent e.g. sublingual
nifedipine.
• Check the urinary catheter to ensure adequate drainage.
• Consider other causes in the diferential diagnosis e.g. pain,
pre-eclampsia.
• Consider level 2/3 care postoperatively if haemodynamic instability
continues and discuss with a specialist.

BIBLIOGRAPHY
Petsas A & Drake J. Perioperative management for patients with a chronic
spinal cord injury. BJA Education. 2015; 15 (3): 123–130.

CASE: AWAKE CRANIOTOMY

A 25 year-old male patient is listed for an awake craniotomy for excision of
a brain tumour. He has no other medical comorbidities.

What are the indications for an awake craniotomy?

• Excision of tumours or arterio-venous malformations from specifc
areas of the brain e.g. close to eloquent speech sensory and motor
areas. Awake surgery allows for continuous monitoring of function
to minimise postoperative neurological impairment.
• Functional neurosurgery including some surgery for epilepsy.
• Insertion of deep brain stimulators.

What added information would you like prior to proceeding with this case?
Patient factors
• Take an anaesthetic history focusing on any medical conditions,
previous anaesthetics and the airway. Te following factors may
preclude an awake craniotomy:
• Any condition that causes involuntary movements.
• Poor compliance with healthcare professionals e.g. due to acute
confusion and learning difculties.

17
 Clinical Cases for the FRCA

• Uncontrollable cough.
• Difculty lying fat e.g. due to a raised BMI and obstructive sleep
apnoea.
• High anxiety levels.
• Language barrier.
• Take a history of the brain tumour to include the diagnosis, any
previous or current symptoms and treatment. Te preoperative
assessment should include a detailed neurological history and
examination to determine the patient’s preoperative status.
Surgical factors
• Discuss the expected duration of surgery including the likely period
of being awake.
• Conduct a multidisciplinary discussion to include the patient
suitability for awake neurosurgery and any challenges that may arise.

What are the key aspects to prepare for this procedure?

Patient preparation
• Psychological assessment for an awake procedure.
• Ensure adequate information describing the perioperative events and
theatre complex.
Anaesthetic preparation
• Preoperative assessment by an experienced neuroanaesthetist.
• Conduct a multidisciplinary team meeting to discuss specifc factors
such as the anaesthetic plan, positioning, temperature and noise
levels.

What are the options for anaesthesia in this patient?

Awake for the duration of the procedure
• Use conscious sedation, allowing the patient to maintain spontaneous
ventilation and a response to stimuli.
• Agents of choice include propofol, remifentanil, clonidine,
dexmedetomidine and benzodiazepines.
Asleep – awake – asleep
• Induction of general anaesthetic with a target-controlled infusion
using propofol and remifentanil. Securing of airway with endotracheal
tube or laryngeal mask airway.
• Reduction of anaesthetic agent concentrations during the “awake”
period, followed by reintroduction of general anaesthesia for closure.
Asleep/sedated – awake
• As above, but the patient is kept awake for closure.
• In some centres, a general anaesthetic is not required initially.

18
 Neurosurgery and Neurocritical Care

How is a scalp block performed?

• Ensure consent, apply AAGBI monitoring, prepare emergency drugs
and equipment and calculate the maximal dose of permitted local
anaesthetic to avoid the risk of toxicity.
• A scalp block is performed under sedation or general anaesthetic.
• Use a sterile technique, and conduct a “stop before you block”
moment.
• Infltrate local anaesthetic to block specifc nerves:
• Supraorbital nerve (at the supraorbital notch).
• Supratrochlear nerve (medial to the supraorbital notch).
• Zygomaticotemporal nerve (at the temporalis muscle).
• Auriculotemporal nerve (anterior to the auricle).
• Lesser occipital nerve (posterior to the auricle).
• Greater occipital nerve (medial to the occipital artery).
• Greater auricular nerve (posterior to the auricle).

While the surgeon is carrying out cortical mapping, the patient has a
seizure. How do you proceed?
• Alert the theatre team and call for urgent help.
• Ask the surgeons to irrigate the surgical site with ice-cold saline.
• Administer pre-prepared agents for seizure control following a
discussion with the surgeon.
• Consider deepening sedation or general anaesthetic (with appropriate
airway management) if seizure control is not achieved with the above
measures.

What are the known complications associated with an awake craniotomy?

• Loss of the airway/airway obstruction.
• Respiratory depression.
• Aspiration.
• Air embolus.
• Haemodynamic instability.
• Anxiety/lack of compliance perioperatively.
• Local anaesthetic toxicity.

BIBLIOGRAPHY
Burnand C & Sebastian J. Anaesthesia for awake craniotomy. Continuing
Education in Anaesthesia, Critical Care & Pain. 2014; 14 (1): 6–11.

19
Other documents randomly have
different content
 Fußnoten
[1] Schulzen.
[2] Rittermäßiger
[3] König.
[4] Alp.
[5] Juro ist der wendische Name für Georg.
[6] Großes weißes Tuch.
[7] Ohrfeige.
[8] Vorsängerin.
[9] Totenschmaus.
[10] ist viel herablassender, freundlicher.
[11] Spree.
[12] Slawischer Name für Bautzen.
[13] Jetzt versaufen wir das Fell! (der Verstorbenen).
[14] Böhmischen Krone.
[15] Aus der russischen Zeitung »Golos«.
[16] Gott führt die Seinen wunderlich zusammen.
[17] Ohrfeige.
[18]

»Jana stawa baba, »Ein altes Weib,

Jaden stary kón Ein altes Pferd
Nejstej togo carta wert.« Sind beide nicht den Teufel
wert.«

[19] Nach dem böhmischen Volksgesang. »Stoji hruška w širem

poli«.
[20] Der Branntwein ist ein Umwerfer.
[21] Wasser macht hungrig (schwach).
[22] Wendische Formel beim Zutrinken.
[23] Kämmerchen.
[24] Andere Hand – anderes Glück.
[25] Elbe.
[26] Kälbchen.
[27] Sau.
[28] Du Plunderliese.
[29] Wer mit der Katze gepflügt hat, weiß, wie sie zieht.
[30] »Gedächtnistag des Meisters Johann Hus.« Der 6. Juli. Hus
wurde bekanntlich am 6. Juli 1369 geboren und am 6. Juli 1415
zu Konstanz verbrannt.
[31] Er lebe!
[32] Slawische Bezeichnung der Deutschen während der Zeit des
Frankfurter Parlamentes.
[33] Fürst! Fürst!
[34] Pán Krystus, neýmocnegssj pán, racz techto klenotuw
ostrzjhati sam, až do neyposlednegssho dne.
[35] Spinngesellschaft.
[36] Kirmes.
[37] Maske.
[38] Branntwein.
[39]

Meine Mutter ist eine Witwe,

Ich bin eine liederliche Kröte!

[40] Sohn des Hauses.

[41] Vater!
[42] Wendischer Nationaltanz.
[43] Gemeindeversammlung.
[44] Gemeindeschöffen.
[45] Schlafgöttin.
 Beachten Sie
bitte die folgenden
Seiten!

Von

PAUL KELLER
erschien in gleicher Ausstattung

Heimat
»Ein Roman aus den schlesischen Bergen, ein sehr
starkes Werk des Dichters, der seine Menschen aus
dem Innern, aus dem Herzen zeichnet.«
Frankfurter Nachrichten

DIE GELBEN ULLSTEIN-BÜCHER

RUDOLF HANS BARTSCH

Hannerl und ihre Liebhaber

Das Schicksal einer lustigen, kleinen Wienerin, die im
Glauben, über der Liebe zu stehen, an ihr zugrunde
geht.

ELISABETH RUSSELL

Urlaub von der Ehe

Ein sonniger, humorvoller Ferienroman aus einer
oberitalienischen Villa, in der einige Frauen und
Mädchen glauben, den Männern entfliehen zu können.

P. O. HÖCKER

Die Sonne von St. Moritz

»Saison in St. Moritz, das mondäne Treiben des
Luxushotels, der sport- und klatschlüsternen ›Welt‹
geben den Rahmen dieser neuen Erzählung Höckers.
In dieser strahlenden Umgebung erfüllt sich das
Schicksal zweier Menschen, um endlich, nach
mancherlei Verwicklung, zu einem versöhnlichen Ende
zu führen.«
Nürnberger Zeitung

CARL ROESSLER

Wellen des Eros

»Roeßler hat hier mit der Gabe außerordentlich
scharfer Charakterisierung ein Buch geschaffen, wie es
nur einer kann, der all' die Figuren bis ins Innerste
kennt.«
Neue Freie Presse

PAUL FRANK

Das Liebesschiff
Das Liebeserlebnis einer schönen, vielumworbenen
Frau, die sich bis zum geheimnisvollen Verschwinden
eines Mannes für keinen ihrer zahlreichen Verehrer
entscheiden kann.

HERMANN LINT

Horizont der Liebe

»Am Horizont der Liebe geistert eine schöne Frau,
rätselhaft verschwunden, rätselhaft auftauchend in
neuer, verhängnisvoller Erscheinung.«
Hannoverscher Kurier

LUDWIG THOMA

Krawall
Eine Reihe köstlicher Burlesken von der kochenden
bayrischen Volksseele, von Richtern, Bauern und
Städtern, von Krach und Krawall vor Gericht.

P. G. WODEHOUSE

Der schüchterne Junggeselle

Eine der amüsantesten Schöpfungen des großen
englischen Humoristen. Die Handlung spielt auf dem
Dachgarten eines New-Yorker Wolkenkratzers und
schildert »schreckliche Abenteuer«, die ein sehr
sympathischer, sehr blonder, sehr junger, sehr
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EDMUND SABOTT
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Gedruckt
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 Weitere Anmerkungen zur Transkription
Offensichtlich fehlerhafte Zeichensetzung wurde stillschweigend korrigiert.
Die Darstellung der Ellipsen und der Gedankensprünge wurde vereinheitlicht.
Sofern hier nicht aufgeführt, wurden unterschiedliche Schreibweisen beibehalten.
Korrekturen:
S. 28: daß → daß du
Ich verbitte mir, daß du mich hier
S. 38: zuckte → zückte
das Messer nach ihm zückte
S. 44: Haaresbre te → Haaresbreite
nicht um Haaresbreite dem einen näher
S. 57: ber → aber
alle Weise zu hindern, was ihm aber mißlang
S. 67: gib → gibt
Es gibt heuer recht viele
S. 67: Geberde → Gebärde
Sie machte eine Gebärde mit der Hand
S. 74: übscher → hübscher
Aber er ist ein hübscher Mann
S. 76: us → aus
der Buchdrucker aus Bautzen
S. 79: bewunderswert → bewundernswert
ein Reich ist nur in einer Einheit bewundernswert
S. 79: Baudissin → Budissin
ich bin im sächsischen Budissin geblieben
S. 82: chlesien → Schlesien
ebenso wie Schlesien geschichtlich und rechtlich
S. 96: Wicaz → Wičaz
Sie war als die Sprichwörter-Wičaz bekannt
S. 123: sie → Sie
ich danke, daß Sie mich
S. 124: sie → Sie
Vergönnen Sie nun auch meinem lettischen Bruder
S. 147: Strin → Stirn
machte er die Stirn runzelig und sagte
S. 149 druzba → družba
Oberlande heißt man's družba
S. 179: hat → Er hat
Er hat es mir geschrieben
S. 180: der → oder
ob ich ein Glas Wein oder ein Glas Milch bringen darf
S. 181: ber → aber
fremde Meinung bekämpfen, aber man dürfe
S. 200: n → an
Denkt an jeden Kaufmann, jeden Gewerbetreibenden
S. 201: wischen → zwischen
Wortgefecht zwischen Juro und Samo ausgewachsen
S. 218: hiner → hinter
einen Steckbrief hinter mir erlassen
S. 229: war → wär
Hättest du das getan, wär alles gut
S. 243: nd → und
er bezwang sich und sprach
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