2010

Question 1

Obstructive renal failure with hyperkalemia (no level given).

a) give 4 EKG changes
b) list 4 management principles

Answer 1

a) i. Peaked T waves
ii. Widened QRS
iii. Bradycardia
iv. Sinus wave pattern
- prolonged PR
- decreased or disappearing P wave

b)

i. Stabilization of cardiac membrane with calcium
ii. Shift of K into cells – alkalinization (bicarb), beta agonism (ventolin), insulin & glucose
iii. Excretion via binder? – kayexalate
iv. Hemodialysis

Question 2

What mode of ventilation is shown in the illustration?

a) Give three contraindications to its use.
b) proposed advantages

Answer 2

Contraindication:

i. COPD b/c of risk of hyperinflation
ii. Upper airway obstruction
iii. Problems with increased ICP
iv. Neuromuscular disease

Proposed advantages:

i. Lower peak airway pressures
ii. Lower minute ventilation
iii. Decreased adverse effects upon circulatory function
iv. Spontaneous ventilation throughout entire I/E cycle
v. Decreased need for sedation??
vi. Near elimination of NMB

Proposed disadvantages

i. Barotrauma
ii. Volutrauma, atelectrauma

Question 3

Compare CSW & SIADH based on:

CVP, IV volume, urine osm, urine Na, serum Na

Answer 3

see image

Question 4

9. Post-op bowel resection starting TPN – what nutrient do you not give?

Answer 4

PARENTERAL nutrition recommendations on supplements:

• glutamine should not be used
• parenteral dipeptides should not be used
• insufficient data for zinc
• IV lipids that reduce amount of omega 6 fatty acids
• insufficient data RE: IV branched chain amino acids

2015 Recommendation: Based on 31 studies (10 level 1 studies and 21 level 2 studies), when parenteral nutrition is prescribed to critically ill patients, we recommend parenteral supplementation with glutamine NOT be used. There are insufficient data on the use of intravenous glutamine in critically ill patients receiving enteral nutrition but given the safety concerns we also recommend intravenous glutamine not be used in enterally fed critically ill patients.

2015 Recommendation: There are insufficient data to make a recommendation on the use of enteral glutamine vs. parenteral dipeptide supplementation. However given concerns of glutamine supplementation in general as per sections 4.1c EN glutamine, 9.4a PN glutamine and 9.4b EN+PN glutamine, we strongly recommend that glutamine supplementation NOT be used in critically ill patients, hence we do not recommend the use of enteral glutamine or parenteral dipeptides.

Recommendation: There are insufficient data to make a recommendation regarding IV/PN zinc supplementation in critically ill patients.

2015 Recommendation: When parenteral nutrition with intravenous lipids is indicated, IV lipids that reduce the load of omega-6 fatty acids/soybean oil emulsions should be considered. However, there are insufficient data to make a recommendation on the type of lipids to be used that reduce the omega-6 fatty acid/soybean oil load in critically ill patients receiving parenteral nutrition.

2013 Recommendation: In patients receiving parenteral nutrition or enteral nutrition, there are insufficient data to make a recommendation regarding the use of intravenous supplementation with higher amounts of branched chain amino acids in critically ill patients.

Question 5

HFOV:

contraindications (2)

complications (2)

how to improve oxygenation (other than O2)

give two causes of chest wiggling?

Answer 5

2 contraindications

i. Known severe airflow obstruction
ii. Severe intracranial hypertension

2 complications

i. Pneumothorax
ii. Hypotension

How to improve oxygenation

i. Increase mPaw by 2 cm water increments
ii. Recruitment maneuver
iii. Increase bias gas flow

2 possible causes for the left chest to stop wiggling

i. Right mainstem intubation
ii. Pneumothorax
iii. Mucous plugging and atelectasis

Question 6

Pressure time curve

a. Label where pressure overcomes airway resistance.
b. Label where pressure overcomes respiratory system elastance.

Answer 6

I’m not sure…

a. ? when flow starts during inspiration the ventilator must have overcome the resistance
b. ?no idea what this means…

Question 7

Regarding transpulmonary pressue. How do you calculate it?

Answer 7

a) i. Transpulmonary pressure = plateau pressure (alveolar P) – pleural pressure
ii. plateau pressure (alveolar pressure) measured by inspiratory hold
iii. Intrapleural pressure measured by esophageal balloon

Question 8

how did ARDSnet calculate weight for tidal volume?

what blood gas value did ARDSnet target to be normal?

Answer 8

b) i. Predicted body weight based on height
ii. PBW Male = 50 + 2.3 (height in inches -60)
iii. PBW Female = 45.5 + 2.3 (height inches - 60)

i. PaO2 of 55-80 mm Hg or Sat 88-95%

Question 9

What are two risk factors for development of non-traumatic pneumothorax in a
ventilated patient?

Answer 9

Alveolar overdistention: (Bagging, RM intubation, excess MAP/PEEP)

Primary disease:

• Obstructive lung disease, asthma
• ARDS/ALI
• necrotizing lung infection
• lung malignancy

Question 10

16. 4 steps for assessing a qualitative cuff leak.

Answer 10

1. supraglottic suction
2. ?preoxygenate
3. deflate cuff
4. feel and listen for air movement using stethoscope on pts trachea

Auscultation – deflate the cuff & occlude the ETT, put your hand at mouth to feel exhaled air

Record the difference between the inspiratory tidal volume & the expiratory tidal volume while the cuff around the ETT is deflated (average of any 3 values on 6 consecutive breaths).

• Cuff leak < 110 ml is more associated with post-extubation stridor.
  c. Record the difference in exhaled tidal volume from before to after ETT cuff deflation. Divide this number by the exhaled tidal volume before cuff deflation. This is “percent cuff leak”.
• Patients with a cuff leak of < 10% are at risk for stridor or reintubation.

e. Qualitative
i. Deflate cuff
ii. Occlude ETT
iii. Feel for air
iv. Listen for air

Question 11

Name the two most important abnormalities on the flow volume loop (patient is obese & has a history of pneumonia, prolonged wean & trach).

Name 2 abnormalties. What is the most likely diagnosis?

I guessed at the loops based on the previously provided description…

Answer 11

see image with associated captions

Question 12

Myotonic dystrophy with influenza CAP, now going to the ward. Intubated & extubated a few times. Trouble swallowing. Symptoms of cor pulmonale for 6 months prior to admission. What 4 long-term interventions will reduce readmissions to the ICU?

Answer 12

a. Physio
b. Secretion management
c. Trach for pulmonary toilet
d. Code discussion
e. Feeding tube & nutrition
f. Assessment for need for nocturnal biPAP
g. Vaccination with Pneumovax

I couldn’t confirm above…but found one paper suggesting:

?avoiding discharges between 6pm and 6am?

Question 13

When should antibitotics be administered in the setting of severe septic shock? What is one indication for dual antibiotic coverage?

Answer 13

a. Within one hour of diagnosis (and preferably after blood cultures drawn)
b. Dual antibiotic coverage for neutropenic patients or those with documented or high suspicion of pseudomonas infection.

From Surviving Sepsis Campaign guidelines:

Multidrug therapy is often required to ensure a sufficiently broad spectrum of empiric coverage initially. Clinicians should be cognizant of the risk of resistance to broad-spectrum β-lactams and carbapenems among gram-negative bacilli in some communities and healthcare settings. The addition of a supplemental gram-negative agent to the empiric regimen is recommended for critically ill septic patients at high risk of infection with such multidrug-resistant pathogens (e.g., Pseudomonas, Acinetobacter, etc.) to increase the probability of at least one active agent being administered (110). Similarly, in situations of a more-than-trivial risk for other resistant or atypical pathogens, the addition of a pathogen-specific agent to broaden coverage is warranted. Vancomycin, teicoplanin, or another anti-MRSA agent can be used when risk factors for MRSA exist. A significant risk of infection with Legionella species mandates the addition of a macrolide or fluoroquinolone.

Question 14

24. Meningococcal meningitis on antibiotics. 3 days out with no sedation but GCS of 5.
    a. What are 2 potential causes for a reduced LOC?

b. Most appropriate test?

Answer 14

1. Cerebral edema or raised ICP
2. Seizures
3. thrombosis, vasculitis, acute cerebral hemorrhage, mycotic aneurysms
4. ischemic infarct
5. Hydrocephalus – but CT head normal
6. Cerebral venous thrombosis (usually sagittal sinus thrombosis)

b) MRA/MRV vs EEG???

Question 15

Forest plot.
a. Is there statistical hererogeneity?

b. What are 2 potential causes for statistical heterogeneity?

Answer 15

1. Visually assess the Forest plot
   a. If confidence intervals of two studies do not overlap you can
   assume they have a high degree of heterogeneity
   b. First graph = heterogeneity
   c. Second = lack of statistical heterogeneity

do statistical test (chi square)???

i. Small sample size
ii. Publication bias

The heterogeneity is indicated by the I². A heterogeneity of less than 50% is termed low, and indicates a greater degree of similarity between study data than an I² value above 50%, which indicates more dissimilarity.

Question 16

Severe hypothyroidism with bradycardia, hypotension & pneumonia. What 3 treatments would you give aside from ventilation & fluids?

Answer 16

1. T4 IV in loading dose of 200 to 400 mcg following by 50-100mcg daily
2. T3 may be given simultaneously 5 to 20 mcg IV then 2.5-10mcg q8H
3. Hydrocortisone 100 mg IV q8H because of possible coexisting adrenal insufficiency
4. Antibiotics & supportive care
5. Passive NOT active rewarming

Question 17

According to the NICE-SUGAR trial, what is the recommended target glucose range in the critically ill?

Answer 17

NICE-SUGAR trial was largest multicenter Normoglycemia in Intensive Care Evaluation Survival Using Glucose Algorithm Regulation (6100 patients – medical & surgical – randomized to either IIT intensive insulin therapy (4.5-6 mmol/L) or conventional glucose control (< 10)

i. Conventional – defined only by a max target, the insulin infusion was reduced then discontinued if the blood glucose level dropped below 8
1. Results: a. The IIT group had significantly lower time weighted blood glucose
6. 2 vs. 7.9 but also significantly higher 90 d mortality (27.5 vs. 24.9 OR 1.14)
b. The IIT had significantly higher incidence of severe hypoglycemia (6.8 vs. 0.5%)
c. In the subgroup of operative patients, those who received IIT had a sig higher mortality than those who received conventional glycemic control OR 1.31
ii. While most clinicians agree that such glycemic control is a desirable intervention, the optimal blood glucose range is controversial.

iii. Therefore, for hyperglycemic critically ill patients uptodate recommends target of 7.7 to 10 rather than a more stringent target of 4.4 to 6.1. (grade 1C)
iv. They also suggest a target of 7.7 to 10 rather than a more liberal target of 10-11.1
(grade 2C)

Question 18

b. An intracranial bleed in which location MOST OFTEN requires surgical management?

Answer 18

posterior fossa

Question 19

33. List 4 drugs considered STANDARD therapy to give to a patient with STEMI going for PCI?

Answer 19

my answers:

ASA

Clopidogrel

heparin/LMWH

nitrates

pain control

beta-blockers (if not in heart failure or bradycardic)

old answers:

a. Heparin or LMWH (fonda, enox)
b. ASA 160 mg po chewed
c. Plavix 600 mg po
d. GPIIb/IIIa inhibitor

Question 20

34. 4 absolute contraindications to thrombolytics in STEMI?

Answer 20

absolute contraindications:

history of intracranial hemorrhage

history of ischemic stroke within last 3months (unless stroke was within 3hrs)

cerebral vascular malformationor a primary or metastatic intracranial malignancy

symptoms/signs suggestive of aortic dissection

bleeding diathesis (except menses)

significant blosed head or facial trauma within last 3months

Question 21

Cold calorics. What happens in a normal patient?

What happens in a coma patient with a normal brainstem?

Answer 21

a. Cold saline irrigated into ear canal
b. Appropriate response in awake non comatose patient is eyes deviated toward the ear with nystagmus (fast away from irrigated ear)
c. Comatose – loss of nystagmus but if brainstem still intact will have eye deviation to affected ear

A cold caloric response is also present in conscious people, producing not only deviation of the eyes toward the stimulated ear, but also nystagmus (with the fast phase away from the irrigated side), severe vertigo, nausea, and vomiting. If nystagmus occurs, the patient is awake and not truly in coma; this can be a useful confirmatory test for psychogenic unresponsiveness.

Question 22

What external landmark is used to level the arterial line when trying to calculate CPP?
According to AHA guidelines, what is the target for CPP in SAH? (I think these guidelnies were updated…no longer there)

what is the target SBP to reduce risk of rebleeding in pts post SAH (according to AHA 2012 guidelines)?

Answer 22

External landmark = ear tragus

The magnitude of blood pressure control to reduce the risk of rebleeding has not been established, but a decrease in systolic blood pressure to <160 mm Hg is reasonable.

Question 23

Nutrition question. Bad pneumonia and no bowel sounds but not in shock. not tolerating po nutrition. when to start TPN?

Answer 23

from Osama’s talk:

BOTTOM LINE – Early TPN should only be considered for someone who cannot be fed adequately enterally who is at high nutritional risk

• No clear definition of “early” or “nutritionally high risk”
• In malnourished patients not tolerating EN, starting TPN earlier than day 8 is probably advisable

Question 24

Non-variceal GIB
a. 3 clinical predictors of increased mortality in a non-variceal bleed?

b. 1 intervention to reduce bleeding in PUD?

Answer 24

i. Age > 60
ii. Active bleeding
iii. Comorbid illness
iv. Hypotension
v. Hematemesis
vi. Severe coagulopathy

i. Endoscopy

could not confirm above…seem to be multiple scoring systems for risks with UGIB but couldn’t find any that were strictly nonvariceal

Question 25

42. 3 evidence based ways to decrease rebleeding in a patient with UGIB secondary to varices?

Answer 25

a. Banding
b. TIPS
c. Nadolol
d. Sclerotherapy

Question 26

Question about procedures surrounding care of central line once in place.
a. What do you use to clean the hubs before access?

b. How often are gauze dressings changed?
c. How often are transparent dressings changed?
d. How often is IV tubing for fluids changed?
e. How often is IV tubing for blood changed?
f. How often is IV tubing for lipids changed?

Answer 26

a) 2% chlorhexidine or 70% alcohol & MUST be allowed to air dry
b) Every 2-3 days or when soiled or damped

c. How often are transparent dressings changed?
Every 7 days unless soiled

d. How often is IV tubing for fluids changed?
Every 72h

e. How often is IV tubing for blood changed?
Every 24h

f. How often is IV tubing for lipids changed?
Every 24h

Propofol needs to be changed every 6h or when vial is changed

Question 27

Healthy young lifeguard jumps feet first into recreational pool and doesn’t surface for 2 mins. Pulled out and found to be in VF. Shocked once and regained pulse in VT.

What are the 3 most likely underlying causes?

They show a strip below. What is the rhythm?

What is the underlying cause in this patient?

What is the treatment of choice for this condition?

Answer 27

3 most likely underlying causes:

i. Hypothermia induced dysrrythmia
ii. Prolonged QT syndrome
iii. Seizure
iv. HOCM

b. Rhythm – torsades de pointes
c. Most likely underlying cause in this patient – prolonged QT syndrome & cold water submersion further prolonging QT interval
d. Treatment of choice for this condition? ICD
e. Immersion syndrome refers specifically to syncope resulting from cardiac dysrhythmias on sudden contact with water that is at least 5d C less than body temperature. Proposed as mechanisms for the syndrome are vagal stimulation leading to asystole and ventricular fibrillation secondary to Q-T prolongation with a massive release of catecholamines on contact with cold water.

…couldn’t confirm any of this on UTD

Question 28

Patient with WCT and can’t use EKG. ! Look at other exams
a. 2 clinical findings that help you differentiate between VT and SVT with aberrancy and their pathophysiology?

b. One pharmacologic way to differentiate.
c. One non-pharmacologic way to differentiate.

Answer 28

cannon a waves

variable intensity of the first heart sound

…both of these suggestive of VT

b) adenosine

• If there is no change in the ventricular rate and rhythm, the WCT is likely VT. One exception would be if the adenosine was not properly administered (ie, rapid intravenous push followed by saline flush) and, because of its short half-life and metabolism by red blood cells, did not reach the heart.
• If the ventricular activity temporarily slows or ceases (for 5 to 10 seconds), the remaining atrial activity is typically easily seen on the ECG and can be analyzed to determine the etiology of WCT. A second dose of 12 mg of adenosine, although appropriate for the treatment of known SVT, is probably not appropriate for WCT that is not known to be SVT.
• Adenosine is administered via rapid intravenous push, followed immediately by 10 mL saline flush. Common side effects include facial flushing, shortness of breath, palpitations, chest pain, and lightheadedness.

c) Vagal maneuvers – We recommend Valsalva maneuver or carotid sinus pressure (if no carotid bruits are present) as the initial intervention, given the ease with which this can be rapidly performed at the bedside.

Question 29

49. List of toxins and you have to list the most specific antidote (can only use each treatment once).
    a. ASA
    b. TCA
    c. Theophylline
    d. Valproate
    e. Nitrites – Methemoglobinemia?
    f. Cyanide
    g. Isoniazid

Answer 29

a. ASA – Na bicarb or dialysis
b. TCA – Na bicarb
c. Theophylline – MDAC, dialysis
d. Valproate - carnitine or hemodialyais
e. Nitrites – Methemoglobinemia? – Methylene blue
f. Cyanide – hydroxycobalamin
g. Isoniazid – Pyridoxine

did not confirm answers

Question 30

List of symptoms, list the toxin:

a. Bradycardia, miosis, bronchospasm, diarrhea
b. Fever, tachycardia, dry skin, urinary retention, mydriasis
c. Abdominal pain, hypocalcemia, AGMA
d. Ketones, fruity breath, no anion gap
e. Urinary retention, mydriasis, refractory hypotension
f. Fever, rigidity, autonomic instability, decreased LOC

Answer 30

List of symptoms, list the toxin:

a. Bradycardia, miosis, bronchospasm, diarrhea >>> Cholinergic (organophosphate)
b. Fever, tachycardia, dry skin, urinary retention, mydriasis >>> Anticholinergic
c. Abdominal pain, hypocalcemia, AGMA >>> ethylene glycol
d. Ketones, fruity breath, no anion gap >>> Isopropyl alcohol
e. Urinary retention, mydriasis, refractory hypotension >>> TCAs
f. Fever, rigidity, autonomic instability, decreased LOC >>> NMS (or SS)

Question 31

Other than mallampatti, list 4 predictors for difficult intubation.

Answer 31

LEMON

b. Look
c. Evaluate 3-3-2
d. Mallampati
e. Obstruction/obesity
f. Neck mobility

upper lip bite test

3-3-2 from UTD:

• 3: This assessment indicates the ease of access to the airway. A normal patient can open his mouth sufficiently to permit three of his own fingers to be placed between the incisors. Adequate mouth opening facilitates both insertion of the laryngoscope and obtaining a direct view of the glottis.
• 3: This assessment provides an estimate of the volume of the submandibular space. A normal patient is able to place three of his fingers along the floor of the mandible between the mentum and the neck/mandible junction (near the hyoid bone).
• 2: This assessment identifies the location of the larynx relative to the base of the tongue. A normal patient is able to place two fingers in the superior laryngeal notch (ie, the space between the superior notch of the thyroid cartilage and the neck/mandible junction, near the hyoid bone). If the larynx is too high in the neck, direct laryngoscopy is difficult or impossible because of the angles that have to be negotiated to permit visualization.

Question 32

Patient with some disease on 350 mg/hr of propofol and some versed is doing okay when after 3 days, develops hypotension, rhabdo and metabolic acidosis.

What are risk factors for propofol infusion syndrome?

What are clinical manifestations of it?

Answer 32

• high doses (> 4 mg/kg/hr or > 67 mcg/kg/min or >280 mg/24h in 70 kg adult)
• prolonged use (> 48h)
• Young age
• critical illness
• high fat & low CHO intake
• inborn errors of mitochondrial FA oxidation
• concomitant catecholamine infusion or steroid therapy

Characteristics:

• Acute refractory bradycardia
• severe MA
• cardiovascular collapse
• rhabdo
• hyperlipidemia
• renal failure
• hepatomegaly

Question 33

What are 2 risk factors for PA rupture in pts with PA catheter?

c. What is the main complication of a self limited PA rupture?
d. What 2 ways can you diagnose it?

Answer 33

1. PAH
2. Mitral valve disease
3. Advanced age
4. Hypothermia
5. anticoagulant therapy
6. Women

Self-limiting pulmonary hemorrhage following perforation can result in the formation of a pulmonary artery pseudoaneurysm, which is at risk of subsequent hemorrhage that can be fatal.

Contrast enhanced CT, to confirm: Pulmonary angiogram

Question 34

According to the 2008 SCCM guidelines on end of life care, what are 2 ethical distinctions that must be taken into account when discussing end of life issues?

Answer 34

1. Withholding and withdrawing life support are equivalent
2. There is an important distinction between killing and allowing to die
3. The doctrine of “double effect” provides an ethical rationale for providing relief of pain and other symptoms with sedatives even when this may have the foreseen (but not intended) consequence of hastening death

ref: Truog. SCCM Guidelines 2008 36:3.

Question 35

63. You have an old guy diagnosed with an unresectable tumour. He is given one year to live. Wife doesn’t think he can cope with the diagnosis and asks you not to tell him.
    a. What are 3 reasons for telling him the truth?

Answer 35

i. Patient autonomy
ii. Without knowing the patient cannot make informed decisions or give consent
iii. Not given time or opportunity to arrange affairs
iv. May feel isolated because people are talking around them

Question 36

23 yo smoking 37 weeks G3P2 with normal pregnancy until this point. Comes in with dyspnea, hypoxemia, tachy, normal BP and pink frothy sputum with bilateral crackles. Shown CXR with bilateral airspace disease. WBC 13.8, Hb 118, normal platelets.

a. What are the 2 most likely causes?
b. She then has a cardiac arrest, how many minutes should it be before a perimortem C/S is performed?

Answer 36

i. Peripartum cardiomyopathy
ii. Amniotic fluid embolus
iii. ARDS – CAP, aspiration
iv. PE

The American Heart Association and others recommend cesarean delivery if spontaneous circulation has not returned within four minutes of maternal cardiorespiratory collapse. Ideally, perimortem cesarean should be initiated within four minutes, and delivery of the newborn should be completed within five minutes (known as the “four-minute rule” or “the five-minute rule”).

Question 37

66. What are 3 complications of IVIG?

Answer 37

aseptic meningitis

fever

Rate related reactions

Concurrent infections/phlogistic reactions — Phlogistic reactions are generalized inflammatory symptoms that may accompany the use of IVIG, especially in patients with an acute infection. This may be more likely in patients with an underlying immunodeficiency that puts them at risk of bacterial infections. Often, the reaction occurs in the setting of a chronic sinus or lung infection.

Symptoms may resemble those that accompany the onset of infection in individuals with intact immune function. Examples include chills (and even rigors), fever, flushing, flu-like myalgias, arthralgias, malaise, nausea, vomiting, and/or headache. Symptoms may be especially pronounced if the infection has not been treated with antibiotics and the patient is receiving IVIG for the first time.

Reactions resembling anaphylaxis — Reactions resembling anaphylaxis are usually rate-related and often occur midway through an IVIG infusion. Patients may develop urticaria, flushing; tachycardia; chest tightness, wheezing, or dyspnea; pain in the chest or lower back; nausea and/or vomiting; and/or a sense of impending doom or sudden anxiety.

Other transfusion reactions

TRALI

TACO

Anaphylaxis in IgA-deficient patients — Anaphylaxis during IVIG administration is extremely rare, but it may be life-threatening. Anaphylaxis with hypotension and/or respiratory compromise is a medical emergency and should be rapidly treated with epinephrine and other therapies. In the rare cases when anaphylaxis is seen, it generally occurs in patients with IgA deficiency, due to patient antibodies to IgA (ie, anti-IgA) that react with the IgA present in IVIG products

Delayed Reactions

Thromboembolic events

CNS effects - headache, aseptic meningitis

Renal complications - Boxed Warning about the risks of acute renal failure, osmotic nephrosis, and death from renal dysfunction. Additional complications such as hyponatremia can also occur.

Hematologic complications - hemolysis, neutropenia; usually transient

Late Reactions

dermatologic reactions - eczematous dermatitis

can impair response to live virus vaccines

theoretical risk of infections - ?prions, ?viruses

Question 38

Patient with cardiac arrest.
a. How many breaths per minute do you provide and how do you synchronize them with chest compressions at 100 bpm?
…In an intubated patient?

…In a non-intubated patient?

Answer 38

b. In an intubated patient? Unsynchronized breaths 10 per minute (about 1 every 6 s) with CPR at rate of 100bpm
c. In a non-intubated patient? 30:2 compression to ventilation rate with experienced provider.

Question 39

What are 4 clinical indicators that an asthmatic should be intubated?

Answer 39

decision to intubate pt with asthma is a clinical one…

a. Confusion or depressed level of consciousness
b. Normal or elevated CO2 (PCO2 > 42-45)
c. Signs of respiratory fatigue or inability to maintain respiratory drive
d. Unable to lie supine
e. Desaturation/hemodynamic collapse
f. No improvement with maximal medical therapy

Ask yourself:

●Is there failure of airway maintenance or protection?

●Is there failure of oxygenation or ventilation?

●Is deterioration, particularly of the airway, anticipated? (ie, What is the expected clinical course?)

Question 40

73. What are the 4 components of a HIT scoring system (the 4 T score)?
    a. What is the exact pathophysiology of HIT?

b. What are 2 classes of drugs & an example from each class that can be used to treat HIT?

How is it diagnosed?

Answer 40

4 Ts – each is scored 0, 1, 2 with a total score possible of 8, low risk (0-3) don’t do
test, high risk (6-8) stop heparin & initiate treatment

1. Thrombocytopenia (2= plt count decrease > 50% with nadir > 20, 1 =
   decrease 30-50% with nadir 10-19, 0 = decrease < 30% or nadir < 10)
2. Timing (2= onset between day 5-10 or < 1 day if heparin exposure within
   30 days, 1 = onset > 10 days, 0 = decrease < 4 days without recent
   exposure)
3. Thrombosis or other complications (2 = new thrombosis, skin necrosis,
   systemic reaction after initial IV bolus, 1 = progressive or recurrent
   thrombosis, 0 = -)
4. Other causes for thrombocytopenia (2 = none apparent, 1 = possible, 0 =
   definite)

Formation of autoantibodies against platelet factor 4:heparin complexes resulting in activation & aggregation of platelets causing thrombocytopenia as well as arterial & venous thrombosis

i. Direct thrombin inhibitor (argatroban, bivalirudin, lepirudin)
ii. anticoagulant, Xa and IIa inhibitor: Danaparoid
iii. Xa inhibitor: Fondaparinux
iv. Vit K antagonist: Warfarin

immunoassay (eg, enzyme-linked immunosorbent assay [ELISA], rapid immunoassay) more commonly available but serotonin release assay is felt to be gold standard

Question 41

80. According to IDSA guidelines, what are the two most accurate ways to measure temperature?

Answer 41

a. O’Grady et al. Crit Care Med. 2008 36:1330-49
b. Most accurate:
i. PA thermistor
ii. Urinary bladder thermistor
iii. Esophageal probe
iv. Rectal probe

2008 IDSA guidelines:

Choose the most accurate and reliable method to measure temperature based on the clinical circumstances of the patient. Temperature is most accurately measured by an intravascular, esophageal, or bladder thermistor, followed by rectal, oral, and tympanic membrane measurements, in that order (Table 2). Axillary measurements, temporal artery estimates, and chemical dot thermometers should not be used in the ICU (level 2). Rectal thermometers should be avoided in neutropenic patients (level 2).

• A new onset of temperature of 38.3°C is a reasonable trigger for a clinicalassessmentbutnotnecessarily a laboratory or radiologic evaluation for infection (level 3).
• A new onset of temperature of 36.0°C in the absence of a known cause of hypothermia (e.g., hypothyroidism, cooling blanket, etc.) is a reasonable trigger for a clinical assessment but not necessarily a laboratory or radiologic evaluation for infection (level 3).

Question 42

81. Patient with acalculous cholecystitis.
    a. List 4 conditions associated with acalculous cholecystitis.

c. List 2 finding on ultrasound diagnostic of acalculous cholecystitis.

Answer 42

1. Burns
2. Major trauma
3. TPN
4. Pregnancy/childbirth
5. Infections
6. Mechanical ventilation
7. DM
8. ESRD
9. Immunosuppression

Laboratory tests in patients with acalculous cholecystitis are nonspecific. Leukocytosis is present in 70 to 85 percent of patients [22]. Abnormal liver tests include conjugated hyperbilirubinemia and a mild increase in serum alkaline phosphatase and serum aminotransferases

Ultrasound findings:

• 3.5- to 4-mm (or more) thick wall (if the gallbladder is distended to at least 5-cm longitudinally, and the patient has no ascites or hypoalbuminemia)
• Sonographic Murphy’s sign is defined as inspiratory arrest during deep breath while gallbladder is being insonated)
• Pericholecystic fluid (halo)/subserosal edema

Other imaging findings in patients with acalculous cholecystitis include:

• Intramural gas
• Sloughed mucosal membrane
• Echogenic bile (sludge)
• Hydrops (distension greater than 8-cm longitudinally or 5-cm transversely, with clear fluid)