2013

Question 1

1. Oscillate trial
   a. 3 reasons (that the authors listed in their paper) explaining why the mortality in the treatment arm was higher than the control

Answer 1

• HFOV protocol mean airway pressure was set too high leading to hemodynamic effects (venous return, RV function)
• HFOV had higher rates of sedatives potentially leading to hemodynamic effects
• HFOV with ?increased rates of barotrauma

Question 2

2. 2 papers
   a. Crash-2 trial
   i. List the intervention that was used
   b. Hypolyte Trial
   i. List the intervention and the primary outcome

Answer 2

Crash-2 trial:
-bolus of tranexemic acid 1 g then 1g over 8 hours

Hypolyte Trial:

• Continuous IV infusion of either hydrocortisone or placebo within 36 hour of trauma onset immediately after the completion of a short corticotropin test
• hydrocortisone 200 mg/d for 5 days, followed by 100 mg on day 6 and 50 mg on day 7

-Primary outcome: Hospital acquired pneumonia within 28 days

Question 3

3. End stage liver disease now with new renal failure (question describes hepatorenal syndrome)
   a. 2 treatments to consider

Answer 3

UTD:
In patients with hepatorenal syndrome who are critically ill, we suggest initial treatment with norepinephrine in combination with albumin. Norepinephrine is given intravenously as a continuous infusion (0.5 to 3 mg/hr) with the goal of raising the mean arterial pressure by 10 mmHg, and albumin is given for at least two days as an intravenous bolus (1 g/kg per day [100 g maximum]). Intravenous vasopressin may also be effective, starting at 0.01 units/min and titrating upward as needed to raise the mean arterial pressure as noted below.

In patients with hepatorenal syndrome who are not critically ill, our suggestions depend upon the availability of certain drugs:
•terlipressin in combination with albumin
•Where terlipressin therapy is not available…midodrine, octreotide, and albumin.

In highly selected patients who fail to respond to medical therapy with the above regimens and who are considered well enough to undergo the procedure, transjugular intrahepatic portosystemic shunt (TIPS) is sometimes successful. However, this procedure is associated with numerous complications and, because of the need for intravenous contrast, it may cause acute kidney injury. For this reason, some experts prefer dialysis as a first option (continuous renal replacement therapy) in most cases, particularly for patients whose serum creatinine remains above 1.5 mg/dL despite medical therapy.

In patients who fail to respond to the above therapies, develop severely impaired renal function, and either are candidates for liver transplantation or have a reversible form of liver injury and are expected to survive, we recommend dialysis as a bridge to liver transplantation or liver recovery.

Question 4

4. Graph of antibiotic level vs time with points described – peak:MIC, area under curve:MIC, Time:MIC.
   a. Describe the principle of each strategy
   b. how you would dose your drug to achieve this
   c. List 1 antibiotic class that demonstrates each strategy

Answer 4

http://www.rxkinetics.com/antibiotic_pk_pd.html

The primary measure of antibiotic activity is the minimum inhibitory concentration (MIC). The MIC is the lowest concentration of an antibiotic that completely inhibits the growth of a microorganism in vitro. While the MIC is a good indicator of the potency of an antibiotic, it indicates nothing about the time course of antimicrobial activity.

PK parameters quantify the serum level time course of an antibiotic. The three pharmacokinetic parameters that are most important for evaluating antibiotic efficacy are the peak serum level (Cmax), the trough level (Cmin), and the Area Under the serum concentration time Curve (AUC). While these parameters quantify the serum level time course, they do not describe the killing activity of an antibiotic.

Integrating the PK parameters with the MIC gives us three PK/PD parameters which quantify the activity of an antibiotic: the Peak/MIC ratio, the T>MIC, and the 24h-AUC/MIC ratio. The Peak/MIC ratio is simply the Cpmax divided by the MIC. The T>MIC (time above MIC) is the percentage of a dosage interval in which the serum level exceeds the MIC. The 24h-AUC/MIC ratio is determined by dividing the 24-hour-AUC by the MIC.

Concentration-dep killing and prolonged persistent effects
-These antibiotics (AG’s, fluoroquinolones, daptomycin and the ketolides), the ideal dosing regimen would maximize concentration, because the higher the concentration, the more extensive and the faster is the degree of killing. Therefore, the Peak/MIC ratio is the important predictors of antibiotic efficacy. For aminoglycosides, it is best to have a Peak/MIC ratio of at least 8-10 to prevent resistence.

Time-dep killing and minimal persistent effects
-These antibiotics (beta-lactams, clindamycin, erythromcyin, and linezolid) demonstrate the complete opposite properties. The ideal dosing regimen for these antibiotics maximizes the duration of exposure. The T>MIC is the parameter that best correlates with efficacy. For beta-lactams and erythromycin, maximum killing is seen when the time above MIC is at least 70% of the dosing interval.

Time-dep killing and moderate to prolonged persistent effects
-These antibiotics (vancomycin, tetracyclines, azithromycin, and the dalfopristin-quinupristin combination) have mixed properties, they have time-dependent killing and moderate persistent effects. The ideal dosing regimen for these antibiotics maximizes the amount of drug received. Therefore, the 24h-AUC/MIC ratio is the parameter that correlates with efficacy. For vancomycin, a 24h-AUC/MIC ratio of at least 400 is necessary for MRSA.

old answer
Peak:MIC; or Cmax:MIC Peak MIC
One time dose drug administrations
Aminoglyocsides

T:MIC Drug concentration that remain above MIC
Bacterial eradication is time dependent  concentration dependent
Increase frequency of dosage due to short half-life Beta-lactams

AUC:MIC Hybrid of time and concentration
The true dose is more important than the amount of time Fluoroquinolones
Vancomycine
Azithromycine

Question 5

5. Pheochromocytoma
   a. List 4 classic symptoms of Pheo
   b. Which drug class should not be given as initial treatment

Answer 5

classic symptoms:

• episodic headache
• sweating
• tachycardia
• Other symptoms include:
  
  • forceful palpitations
  • tremor
  • pallor
  • dyspnea
  • generalized weakness
  • panic attack-type symptoms

All patients with pheochromocytoma need to undergo preoperative alpha-adrenergic blockade; we suggest phenoxybenzamine as the first-line drug (Grade 2C).
After adequate alpha-adrenergic blockade has been achieved, beta-adrenergic blockade is begun. For beta-adrenergic blockade, we suggest cautious, low-dose administration. As an example, a patient is usually given 10 mg of propranolol every six hours to start.
Because of the reduction in postoperative morbidity, hospital stay, and expense compared with open laparotomy, we suggest laparoscopic adrenalectomy by an experienced endocrine surgeon for adrenal pheochromocytomas (Grade 2C).

Question 6

6. Long stem, suspicious for hereditary angioedema
   a. List 4 features that support a diagnosis of hereditary angiodedema.
   b. What is the pathophysiology of hereditary angioedema?
   c. What are 2 treatment options other than epi, steroids, Benadryl, ranitidine?

Answer 6

a) HAE should be considered in patients who demonstrate one or more of the following:
●Recurrent episodes of angioedema without urticaria or pruritus, lasting two to five days (without treatment).
●Unexplained recurrent episodes of self-limited, colicky, abdominal pain (typically lasting one to three days), especially in patients who also have had cutaneous angioedema.
●Unexplained laryngeal edema (even a single episode).
●Angioedema episodes in the absence of angiotensin-converting enzyme (ACE) inhibitors, nonsteroidal anti-inflammatory drugs (NSAIDs), or history to suggest an allergic cause.
●A family history of angioedema.
●A low complement component 4 (C4) level in a patient with angioedema.

b) The swelling (ie, angioedema, sometimes called “giant” swelling) that occurs in HAE results from excessive production of bradykinin, a potent vasodilatory mediator. Bradykinin also has important vascular permeability-enhancing effects. The best characterized forms of HAE arise from deficiency or dysfunction of C1 inhibitor (C1INH).

c) …Of note – none of those would be helpful (this treatment is mostly for mast-cell stimulated histamine release
-human plasma-derived C1 inhibitor concentrate
Hereditary angioedema (HAE) is a condition characterized by recurrent episodes of angioedema affecting the upper airway, bowel wall, or skin, which typically last two to four days. The angioedema of HAE is mediated by bradykinin and does not respond to epinephrine, antihistamines, or glucocorticoids. Instead, first-line therapies for HAE act by replacing the C1 inhibitor (C1INH) that is deficient or dysfunctional in this disease or by inhibiting the production or function of bradykinin.

Question 7

7. One intervention for brain dead donors that has been shown to improve success of lung transplant

Answer 7

high-dose steroids, recommended dose of methylprednisolone is 15mg/kg IV daily (to a maximum of 1000mg IV daily)
according to:
file:///C:/Users/mr683636/AppData/Local/Temp/TGL_eBook_English_Android_v25.pdf

but UTD also seems to suggest thyroxine and vasopressin

Question 8

8. Post cardiopulmonary bypass for MVR, initially ok, valve is perfect on initial ECHO, on volume A/C, FiO2 0.4, Peep 5. Then 6 hours later, on Pressure support, peep 12, FiO2 0.4, now hypoxemic, PCO2 36 PaO2 50 sats 90%. Chest xray is exactly the same as 6 hours earlier.
   a. What is the most likely cause of his hypoxemia?
   b. Which one test would you perform?

Answer 8

a) -Iatrogenic ASD from a transeptal approach with R to L shunt (due to pulmonary HTN)
b) -TEE with bubble study

Question 9

9. Research Ethics
10. Industry sponsored research trial, you are considering running this trial at your centre.
    a. Which 4 criteria must be met for you to participate
    b. What 4 things need to be completed before enrolling patients
    c. What 4 things need to be told to the patient when consenting in this setting

Answer 9

test
sfg
?????

Question 10

11. An important ethical component or research is respect for persons.
    a. What are 4 key features
    b. Another question we don’t remember…

Answer 10

a) autonomy
?from Belmont report: protecting the autonomy of all people and treating them with courtesy and respect and allowing for informed consent. Researchers must be truthful and conduct no deception.

so would you say:

• autonomy
• courtesy/respect
• informed consent
• truthful, no deception

Question 11

12. A recent paper (unsure when) which employed the “VALUE” mnemonic and used a family handout
    a. List the 4 ways this intervention improved psychologic outcomes in family members
    b. Another question we can’t remember about this paper

Answer 11

VALUE
Value family statements
Acknowledge family emotions
Listen to family
Understand patient as a person
Elicit family questions

?decreased rates of depression, anxiety and PTSD in family members?

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2628462/

Question 12

13. IABP normal tracing showing
    a. What is the timing?
    b. Mark the point of inflation and deflation
    c. What is the most important indicator of balloon deflation (or maybe it was inflation….can’t remember)

Answer 12

c) ?lowering of pts supported DBP 10-15mm Hg lower than their unsupported DBP?

Caption for the image: The timing of balloon inflation and deflation is adjusted in the 1:2 mode. The inflation point is moved rightward (later) until it occurs in late diastole, and the dicrotic notch is uncovered. The inflation timing is moved progressively earlier in the cardiac cycle until the dicrotic notch on the central aortic tracing just disappears. Examples of early, late, and correct inflation are shown in the top two tracings. Similarly, the deflation knob is moved leftward (earlier) and then slowly advanced toward the right (later in the cardiac cycle) until the end-diastolic pressure dips 10 to 15 mmHg below the patient’s unassisted diastolic pressure. This will produce a maximal lowering of the patient’s unassisted systolic pressure. Examples of early, late, and correct deflation timing are shown in the bottom two traces.

diastolic augmentation (increases DBP)

increases coronary perfusion pressure
increases coronary blood flow
increases myocardial oxygen supply
systolic unloading (decreases SBP, decreases HR, decreases mean pulm wedge pressure, increases CO)

decreases LV wall tension
decreases LVEDP
increases cardiac output
decreases myocardial oxygen demand

Question 13

14. Patient with inferior STEMI, giving fibrinolytics, doing well, ST’s normal, pain free, intermittently has a rhythm that is abnormal. Showed a wide complex rhythm at a rate of 60 (just the rhythm strip)
    a. What is the rhythm?
    b. What are 2 management options

Answer 13

Accelerated idioventricular rhythm:
Slow ventricular tachycardia is also known as an “accelerated idioventricular rhythm” or “AIVR” and is a common rhythm after an MI. An idioventricular rhythm — not accelerated — has a heart rate of < 60 beats per minute.

AIVR is hemodynamically stable, and thus no specific treatment is needed. This rhythm meets all of the ACC/AHA and Brugada Criteria for ventricular tachycardia except the heart rate is < 100 beats per minute, hence the term “slow ventricular tachycardia” is commonly used. AV dissociation may be seen similar to ventricular tachycardia.

Clinically, AIVR has been best studied in patients with acute ST-elevation myocardial infarction (STEMI). In the thrombolysis era, AIVR was noted to be a marker of reperfusion. [11] However, not all patients with reopened coronary artery have AIVR. In patients with acute myocardial infarction treated with primary percutaneous coronary intervention, the reported incidence of AIVR varied significantly, raging from 15-50%, depending on methods of monitoring.

no specific treatment needed…

old answers:
Management options:
	Atropine
	Manage electrolyte abnormalities
	TVP

Question 14

15. Sudden drop in ETCO2 in an intubated patient. The vent, circuit, and ETT are all in good position with no problems.
    a. List 4 causes of the drop in ETCO2

Answer 14

• Pulmonary embolism
• Cardiac arrest
• Pneumothorax
• Decreased production – hypothermia or intoxication

Question 15

16. What are 2 causes of a false positive ETCO2 when the ETT is actually in the esophagus?

Answer 15

Causes of a false positive EtCO2 when ETT is in esophagous

• Production of CO2 in stomach due to previous ingestion of CO2
• Gastric pH can cause change in the indicator
• CO2 being “blown” down to stomach

Question 16

17. List 4 ways to manage bleeding from a pelvic fracture

Answer 16

• massive transfusion protocol
• pelvic binder
• unstable + FAST pos —> emergency laparotomy with preperitoneal packing
• pelvic angiography and embolization/coiling
• resuscitative endovascular balloon occlusion of the aorta (REBOA)
• internal/external fixation

old answers:

• Apply binder to close pelvic ring
• Manage hypothermia and acidosis
• Give tranexemic acid bolus and infusion
• Go for embolization
• External or internal fixation

Question 17

18. 3 medications to give to a brain dead donor

Answer 17

• Vasopressin 1U IV bolus then 0.04 U/min
• T4 20 mcg bolus followed by infusion of 10 mcg/hr
• Methylprednisolone 15 mg/kg q24h

Question 18

19. list the 4 types of tissue hypoxia and briefly describe the mechanism of each

Answer 18

hypoxemia - low oxygen content in arterial blood
anemia - amount of functional Hgb is too small and hence capacity to carry oxygen is too low
stagnant type - blood flow is reduced or unevenly distributed
histotoxic type - cells are unable to use the oxygen, characteristically produced by cyanide but can be done by any agent that decreases cellular respiration including narcotics, alcohol, formaldehyde, acetone, and certain anesthetic agents

Question 19

20. define the following
    a. inotropy
    b. chronotropy
    c. lusitropy
    d. dromotropy
    e. List 3 medications that increase lusitropy

Answer 19

f. Inotropy - A reflection of contractility
g. Chronotropy - Heart rate
h. Lusitropy - rate of myocardial relaxation
i. Dromotropy - AV velocity conduction

o List 3 medications that increase lusitropy
 Milrinone (phosphodiesterase inhibitor)
 Dobutamine
 Epinephrine
-isoproterenol
 ?Digoxin
—I also found that ACEi and angiotensin subtype type I blockers increase myocardial relaxation in experimental studies

Question 20

21. Long stem, diabetic patient, multiple meds, recently started on enalapril, glyburide, metformin, nifedipine. Now presents with nausea, vomiting, abdom pain, resp rate of 40, blood pressure stable, labs showed elevated Cr (140), pH = 6.96, HCO3 = 7, PCO2 = 12
    a. What is the most likely diagnosis?
    b. What one treatment will you do?

Answer 20

 Metformin overdose

 IHD – multiple rounds required
*use of bicarb is controversial and UTD suggests only in severe acidosis

UTD:
dialysis recommended if
-severely elevated serum lactate concentration (>20 mmol/L)
-severe metabolic acidosis (pH ≤7.0)
-failure to improve (as determined by pH, lactate concentration, or clinical status) with supportive care and bicarbonate therapy within two to four hours.

dialysis suggested if:
-Elevated serum lactate concentration between 15 to 20 mmol/L
-Metabolic acidosis (pH of 7.0 to 7.1)
-Comorbidities:
•Shock or persistent hemodynamic instability requiring vasopressor therapy despite acute administration of IV boluses of isotonic crystalloid totalling 30 mL/kg
•Kidney injury – Creatine >2 mg/dL (adults), or >1.5 mg/dL (elderly), or 2 times upper limit of normal (children), or chronic kidney disease (stage 3b or higher with eGFR <45 mL/min/1.73 m2, oliguria, or anuria)
•Liver failure – liver injury with coagulopathy (INR >1.5) and any degree of encephalopathy

•Decreased level of consciousness

Question 21

22. Using data from the “Trauma coma databank”
    a. What are 4 predictors of poor outcome clinically on exam?
    b. What are CT findings that predict a poor outcome (list 2).

Answer 21

???couldn’t find answer

old ones
o	What are 4 predictors of poor outcome clinically on exam?
	Hypoxia
	Hypotension
	Low GCS
	Absence of brainstem reflexes
o	What are CT findings that predict a poor outcome (list 2)
	Herniation
	Midline shift
	Hydrocephalus
	ICH
	Depressed skull fracture

Question 22

23. Patient presents post head injury with a decreased LOC
    a. Calculate the GCS and show each component
    b. Other than brainstem reflexes, list 4 clinical exam findings of elevated ICP
    c. What are 4 types of cerebral edema
    d. List 4 interventions to manage elevated ICP

Answer 22

Eyes
4 - spontaneously open
3 - opens to voice
2 - opens to pain
1 - closed

Motor
6 - follows commands
5 - localizes to pain
4 - withdraws from pain
3 - decorticate posturing (abnormal flexion)
2 - decerebrate posturing (extension to painful stimuli)
1 - no response

Verbal
5 - oriented
4 - disoriented
3 - words
2 - incomprehensible sounds
1 - no response

o	Other than brainstem reflexes, list 4 clinical exam findings of elevated ICP
	Decreased LOC
-spontaneous periorbital bruising
	Hypertension
	Bradycardia
	respiratory depression

 Vasogenic
 Cytotoxic
 Osmotic
 Interstitial

• normocapneia
• head of bed elevation
• hyperosmolar therapy (hypertonic saline, mannitol)
• sedation
• paralysis
• cooling
• EVD for CSF drainage
• barbiturates
• ensure no neck ties or trach ties
• don’t over PEEP pt

-Decompressive craniectomy
Level IIA
Bifrontal DC is not recommended to improve outcomes as measured by the GOS-E score at 6 mo post-injury in severeTBIpatients with diffuseinjury(without mass lesions),andwith ICP elevationtovalues.20 mmHg for more than 15 min within a 1-h period that are refractory to first-tier therapies. However, this procedure has been demonstrated to reduce ICP and to minimize days in the ICU.
A large frontotemporoparietal DC (not less than 12 x 15 cm or 15 cm diameter) is recommended over a small frontotemporoparietal DC for reduced mortality and improved neurologic outcomes in patients with severe TBI.
*The committee is aware that the results of the RESCUEicp trial2 were released soon after the completion of these Guidelines. The results of this trial may affect these recommendations and may need to be considered by treating physicians and other users of these Guidelines. We intend to update these recommendations if needed. Updates will be available at https://braintrauma.org/coma/guidelines.

Prophylactic hypothermia
Level IIB
Early (within 2.5 h), short-term (48 h post-injury), prophylactic hypothermia is not recommended to improve outcomes in patients with diffuse injury.

Hyperosmolar therapy
Recommendations from the prior (Third) Edition not supported by evidence meeting current standards. Mannitol is effective for control of raised ICP at doses of 0.25 to 1 g/kg body weight. Arterial hypotension (systolic blood pressure ,90 mm Hg) should be avoided. Restrict mannitol use prior to ICP monitoring to patients with signs of transtentorial herniation or progressive neurologic deterioration not attributable to extracranial causes.

Cerebrospinal fluid drainage
Level III
An EVD system zeroed at the midbrain with continuous drainage of CSF may be considered to lower ICP burden more effectively than intermittent use.
Use of CSF drainage to lower ICP in patients with an initial GCS ,6 during the first 12 h after injury may be considered.

Ventilation therapies
Level IIB
Prolonged prophylactic hyperventilation with PaCO2 of #25 mm Hg is not recommended. Recommendations from the prior (Third) Edition not supported by evidence meeting current standards. Hyperventilation is recommended as a temporizing measure for the reduction of elevated ICP. Hyperventilation should be avoided during the first 24 h after injury when CBF often is reduced critically. If hyperventilation is used, SjO2 or BtpO2 measurements are recommended to monitor oxygen delivery.

Anesthetics, analgesics, and sedatives
Level IIB
Administration of barbiturates to induce burst suppression measured by EEG as prophylaxis against the development of intracranial hypertension is not recommended.
High-dose barbiturate administration is recommended to control elevated ICP refractory to maximum standard medical and surgical treatment. Hemodynamic stability is essential before and during barbiturate therapy.
Although propofol is recommended for the control of ICP, it is not recommended for improvement in mortality or 6-month outcomes. Caution is required as high-dose propofol can produce significant morbidity.

Steroids
Level I
The use of steroids is not recommended for improving outcome or reducing ICP. In patients with severe TBI, highdose methylprednisolone was associated with increased mortality and is contraindicated.

Nutrition
Level IIA
Feeding patientsto attain basal caloric replacement at least by the fifth day and at most by the seventh day post-injury is recommended to decrease mortality.
Level IIB
Transgastric jejunal feeding is recommended to reduce the incidence of ventilator-associated pneumonia.

Infection prophylaxis
Level IIA
Early tracheostomy is recommended to reduce mechanical ventilation days when the overall benefit is thought to outweigh the complications associated with such a procedure. However, there is no evidence that early tracheostomy reduces mortality or the rate of nosocomial pneumonia.
The use of PI oral care is not recommended to reduce ventilator-associated pneumonia and may cause an increased risk of acute respiratory distress syndrome.
Level III
Antimicrobial-impregnated catheters may be considered to prevent catheter-related infections during external ventricular drainage.

Deep vein thrombosis Prophylaxis
Level III
LMWH or low-dose unfractioned heparin may be used in combination with mechanical prophylaxis. However, there is an increased risk for expansion of intracranial hemorrhage.
In addition to compression stockings, pharmacologic prophylaxis may be considered if the brain injury is stable and the benefit is considered to outweigh the risk of increased intracranial hemorrhage.
There is insufficient evidence to support recommendations regarding the preferred agent, dose, or timing of pharmacologic prophylaxis for deep vein thrombosis.

Seizure prophylaxis
Level IIA
Prophylactic use of phenytoin or valproate is not recommended for preventing late PTS.
Phenytoin is recommended to decrease the incidence of early PTS (within 7 d of injury), when the overall benefit is thought to outweigh the complications associated with such treatment. However, early PTS have not been associated with worse outcomes.
At the present time there is insufficient evidence to recommend levetiracetam compared with phenytoin regarding efficacy in preventing early post-traumatic seizures and toxicity.

Question 23

24. Patient of CVVHDF (blood flow = 125, dialysate = 1l/hour), unhappy with metabolic picture
    a. List 2 strategies to improve clearance

Answer 23

• increase dialysate flow rate
• ensure fluid replacement is post filter
• can also increase blood flow rate?

Question 24

25. CXR and CT scan of a trauma patient
    a. List 4 findings on either CT or CXR (basically subQ emphysema, bilat pneumos, rib fractures, left hemo, pneumomediatinum)
    b. What is the most likely pulmonary cause for this

Answer 24

?traumatic injury to lung parenchyma…?BPF with PPV

Question 25

26. CXR shown with 2 devices – PPM and ICD (maybe cardiac resynch), huge heart
    a. What is the underlying disease process in this patient
    b. Now post cardiac surgery CXR of same patient – basically frankenstein’s CXR – more devices than I have ever seen!!!
    i. What is the anatomical course that the impella takes
    ii. What is the device labeled (pointed to 2 large tubes, one at the apex, the other about 6 inches beside the first one, to the patient’s right and at the same level)
    iii. What is the marker pointing at – maybe something in the tricuspid or mitral valve region?

Answer 25

 Dilated cardiomyopathy

• Sits across the aortic valve in – drawing blood from the LV into the aorta
• LVAD device?

Question 26

27. Patient with ARDS, bunch of info about vent, (with suboptimal vent settings – Vt = 6mL/kg, Pplat = 26, Peep = 5, Fio2 = 0.60, sats 85-88%, and a PCO2 of 36)
    a. What 4 changes can you make to the vent to improve this patient’s condition while maintaining a lung protective strategy

Answer 26

 Increase PEEP to 10
 Allow for permissive hypercapnea
 Increase Vt by 1 to 2 mL/kg to 8 mL/kg
 Target oxygenation goal to SpO2 88-95%

ARDSnet ventilator setup
1. calculate PBW
men = 50+2.3[ht inches-60]
women = 45.5+2.3[ht inches-60]
2. select any ventilator mode
3. set ventilator settings to 4. achieve initial Vt 8mL/kg PBW
4. reduce Vt by 1mL/kg until 6mL/kg
5. set initial rate to approximate baseline MV (not >35bpm)
6. adjust Vt and RR to achieve pH and plateau pressure goals

oxygenation goal PaO2 55-80 or SpO2 88-95%

plateau pressure goal =30cm H2O

1. check plateau pressure
   - if Pplat >30 decrease Vt by 1mL/kg
   - if Pplat<25 and Vt <6 increase Vt by 1ml/kg until Pplat 25 of Vt 6
   - if Pplat <30 and breath stacking or dys-synchrony occurs may increase Vt in 1mL/kg increments to 7-8 if Pplat remains <30

Question 27

28. Severe asthmatic, presents with resp failure, intubated, has cardiac arrest post intubation
    a. List 3 etiologies for the cardiac arrest in this patient
    b. Now, patient has ROSC and is doing well, what are 2 risk factors (specific to the treatment of her condition) for critical illness weakness

Answer 27

• dynamic hyperinflation
• breath-stacking
• hypovolemia from presentation
• ?tension pneumothorax
• tube migration and mainstem vs esophageal intubation

old answers
	High RVSP
	Hypoxia
	Hypercarbia
	Life threatening bronchospasm
	Auto PEEP
	High risk pneumothorax

 ?steroids
 paralysis

Question 28

29. List 2 mechanisms for auto peep

Answer 28

mechanistically I think the answers should be:

• breath stacking (which can occur in someone with normal lungs)
• obstructive lung disease (asthma, COPD)

old answers:
o Breath stacking
o High RR
o High Ti (i.e. high I:E ratio)

Question 29

30. Central line infections
    a. List 4 methods to decrease rates during insertion process
    b. List 4 things that prevent infection in a central line that is already in position (maintenance things)

Answer 29

-perform hand hygiene before insertion
-adhere to aseptic technique
-use maximal sterile barrier precautions (mask, cap, gown, gloves, full body drape)
-choose the best insertion site to minimize infections and noninfectious complications based on individual patient characteristics (avoid femorals in obese pts)
->0.5% chlorhexidine with alcohol
-sterile gauze dressing or sterile transparent semipermeable dressing over site
-For patients 18 years of age or older, use a chlorhexidine impregnated dressing with an FDA cleared label that specifies a clinical indication for reducing CLABSI for short term non-tunneled catheters unless the facility is demonstrating success at preventing CLABSI with baseline prevention practices
b)

• Comply with hand hygiene requirements
• Bathe ICU patients over 2 months of age with a chlorhexidine preparation on a daily basis
• Scrub the access port or hub with friction immediately prior to each use with an appropriate antiseptic (chlorhexidine, povidone iodine, an iodophor, or 70% alcohol)
• Use only sterile devices to access catheters
• Immediately replace dressings that are wet, soiled, or dislodged
• Perform routine dressing changes using aseptic technique with clean or sterile gloves.
• Change gauze dressings at least every two days or semipermeable dressings at least every seven days.
• For patients 18 years of age or older, use a chlorhexidine impregnated dressing with an FDA cleared label that specifies a clinical indication for reducing CLABSI for short-term non-tunneled catheters unless the facility is demonstrating success at preventing CLABSI with baseline prevention practices.
• Change administrations sets for continuous infusions no more frequently than every 4 days, but at least every 7 days.
• If blood or blood products or fat emulsions are administered change tubing every 24 hours.
• If propofol is administered, change tubing every 6-12 hours or when the vial is changed

Question 30

31. VAP prevention

a. List 6 evidence based strategies that have been proven to prevent VAP

Answer 30

VAP prevention (specific guideline, see table 2 pg 920):
http://www.inicc.org/media/docs/StrategiestoPreventVAPinAcuteCareHospitals-2014Update.pdf

use NIPPV (minimize invasive MV)
manage pts without sedation whenever possible
interrupt sedation daily
assess readiness to extubate daily
perform SBTs with sedatives turned off
facilitate early mobility
utilize ETT with supraglottic suction for pts expected to require >48-72hrs of MV
change vent circuit ONLY if visibly soiled or malfunctioning
elevate head of bed 30-45degrees

evidence that intervention improves outcomes but insufficient data on possible risks:
selective oral/digestive decontamination
???regular oral care with chlorhexidine

no impact on VAP rates/average duration of MV/LoS/mortality:
stress ulcer prophylaxis
early tracheostomy
monitoring gastric residuals
early parenteral nutrition

Question 31

32. Guy riding bike, wearing helmet, falls onto head, presents with spinal cord injury, awake, no resp distress, Has some strength to deltoids and biceps, hypersentivity to touch in feet.
    a. What is the level of injury
    b. 2 immediate mechanisms of injury
    c. 2 molecular mechanisms of injury (may have said slightly delayed)
    d. 4 management steps you would take in the care of this patient

Answer 31

 Incomplete C6

 Rotational
 Flexion
 Blunt

 Apoptosis
 Necrosis
 Cytotoxic release of TNF-alpha, NO

	C/Spine collar
	Target MAP 85-90 mmHg
	Order imaging CT Head and Spine followed by MRI once stable for ligamentous injury
	Glycemic control
-?DVT prophylaxis

Question 32

33. myxedema coma (they tell you this)
    a. which is the most important medication to give and how would you administer this (be specific)
    b. what adjunctive medication is extrememly important in this setting

Answer 32

 levothyroxine (T4): Load 5-8 mcg/kg IV; then 50-100 mcg IV qd
 triiodothyronine (T3): give if patient is bradycardic 5 – 10 mcg IV q8h

 Hydrocortisone 100mg IV q8H until exclusion of possible adrenal insufficiency

Question 33

34. patient with previous splenectomy, now septic with diffuse petechial rash
    a. what are 3 specific organisms
    b. what 2 treatments, other than supportive care.

Answer 33

• Streptococcus pneumoniae
• Haemophilius influenzae
• Neisseria meningitidis

Meningitic doses of Abx:

• Vancomycin 15 to 20 mg IV q 12h
• Ceftriaxone 2 g IV q12h
• +/-Dexamethasone

Question 34

35. Propofol infusion syndrome suspected
    a. What are 4 risk factors?
    b. What are 4 abnormalities on bloodwork other than elevated CK?

Answer 34

• high dose (>4mg/kg/hr)
• prolonged infusion (>48h)
• young age
• critical illness
• high fat and carbohydrate intake
• inborn errors of mitochondiral fatty acid oxidation
• concominant catecholamine infusion
• concominant steroid therapy
• traumatic brain injury

b)

• metabolic acidosis (combination of lactate and renal failure)
• rhabdomyolosis (increased CK and myoglobin) from direct muscle necrosis of both skeletal and cardiac muscle
• renal failure
• hypertriglyceridemia
• hyperkalemia
• lipemia

Question 35

36. Patient with a stroke (1 hour ago, dysarthria, hemiparesis), 65 year old guy, previously healthy
    a. 4 contraindications to lytics on History
    b. 4 labwork contraindications to lytics
    c. 2 contraindications on CT scan
    d. your patient is a candidate for lytics, list 3 reasons justifying administration of lytics (a little vague)

Answer 35

4 contraindications to lytics on History

• ischemic stroke or severe head trauma in last 3months
• previous intracranial hemorrhage
• intra-axial intracranial neoplasm
• GI malignancy or hemorrhage in last 21d
• intracranial or intraspinal surgery last 3m

Clinical
symptoms suggestive of SAH
persistent HTN SBP>185, DBP<110
active internal bleeding
presentation consistent with IE
stroke known or suspected to be associated with aortic arch dissection
active bleeding diathesis

4 labwork contraindications to lytics
 plts <100
 current anticoagulant use with INR>1.7 or PTT>40s
 therapeutic doses of LMWH within last 24h (does not apply to prophylaxis)
—current use of NOAC with evidence of anticoagulation effect by lab tests

2 contraindications on CT scan
 hemorrhage
 extensive regions of obvious hypodensity consistent with irreversible injury

your patient is a candidate for lytics, list 3 reasons justifying administration of lytics (a little vague)
 Decrease odds of death
 Increase odds of being discharged home vs. institution
 Increase odds of walking at discharge

Benefits to IV thrombolysis, especially if given early: (meta-analysis of 58,000 patient registry)

• Improved odds of walking independently at discharge
• Improved odds of being discharged home rather than an institution
• Decreased odds of death at discharge and symptomatic hemorrhagic transformation

https://www.strokebestpractices.ca/recommendations/acute-stroke-management/acute-ischemic-stroke-treatment

Question 36

37. 2 indications for stress ulcer prophylaxis

Answer 36

UTD Recommends:
o	Patient predicted to be mechanically ventilated for more than 48 hrs
o	Hx of previous UGIB within last yr
o	Coagulopathy (plts <50, INR>1.5, PTT>2xULN)
-TBI
-traumatic SCI
-severe burns >35% BSA
-NSAIDs
-antiplatelet agents

o	Two of the following:
	Sepsis
	ICU stay for more than 1 wk
	Occult GI bleeding
	High dose corticosteroids

Question 37

38. PPI question
    b. from a specific paper on PPIs, what are the benefits of giving these medications?
    ..changed to SUP ICU trial
    -what was the population?
    -what was the primary outcome?
    -what was the result?

Answer 37

• adults admitted to ICU with acute illness (not electively) and one or more risk factors for clinically important GI bleeding (shock, use of anticoagulant agents, RRT, MV expected to be >24h, or coagulopathy [plts <50, INR >1.5, PT>20s])
  
  • excluded pts with contraindication for PPI, receiving PPI/H2b prior to enrollment, PUD during that hospitalization, pregnant, organ transplant, palliative

-intervention pantoprazole 40mg IV daily vs placebo

• primary outcome: mortality at 90d, not significantly different
• sec outcomes:
  
  • any clinically important events (GIB, pneumonia, Cdiff, MI) not different

-study did not meet target enrollment

Question 38

39. Delirium
    a. 4 outcomes associated with delirium
    b. list 2 validated delirium assessment tools
    c. from the guidelines what is the best way to prevent delirium

Answer 38

cognitive impairment at 3 months
cognitive impairment at 12 months
longer hospital LoS
mortality (not in PADIS though)
\+/-costs although not really pt centered (uptodate)
\+/- longer time on MV

b) CAM ICU
ICDSC: intensive care delirium screening checklist

c) We suggest using a multicomponent, nonpharm intervention that is focused on, reducing modifiable risk factors for delirium, improving cognition, and optimizing sleep, mobility, hearing and vision
- reorientation, cognitive stimulation
- minimize light/noise at night
- reduce sedation (awake during day)
- reduce immobility
- reduce visual or hearing impairment (eyeglasses and hearing aids)

PADIS suggests AGAINST use of pharmacologic agents to prevent delirium. Also suggest NOT using haloperidol and atypical antipsychotics to treat delirium. We suggest using dexmedetomidine for delirium in MV adults where agitation is precluding weaning/extubation. We suggest NOT using bright light therapy to reduce delirium in critically ill adults.

Woah, interesting statement from the PADIS guidelines:
Questions: What are the short- and long-term outcomes of delirium in critically ill adults and are these causally related?
Ungraded Statements: Positive delirium screening in critically ill adults is strongly associated with cognitive impairment at 3 and 12 months after ICU discharge and may be associated with a longer hospital stay.

Delirium in critically ill adults has consistently been shown NOT to be associated with PTSD or post-ICU distress.

Delirium in critically ill adults has NOT been consistently shown to be associated with ICU LOS, discharge disposition to a place other than home, depression, functionality/dependence, or mortality.

uptodate, not specifically on ICU pts, but pts with delirium in general:

Delirium has an enormous impact upon the health of older persons. Patients with delirium experience prolonged hospitalizations, functional and cognitive decline, higher mortality, and higher risk for institutionalization, even after adjusting for baseline differences in age, comorbid illness, or dementia.

Delirium can be disturbing for affected patients and relatives and is associated with worse outcome, and much higher ICU and hospital LOS and costs.

old answers
o	4 outcomes associated with delirium
	Increased mortality
	Increased ICU LOS
	Increased risk for pneumonia
	Increased risk of neurocognitive decline

o from the guidelines what is the best way to prevent delirium
 Early mobilization
 Sleep promotion

Question 39

40. 25 year old guy, previously well, presents with horse voice, dysphonia, drooling, fever, trismus, woody induration
    a. what are the 2 most likely infectious etiologies
    b. what are the 2 most important immediate treatments
    c. what is the most important diagnostic test (be specific)
    d. 2 potential complications

Answer 39

Ludwig’s angina:
Streptococcus (viridans, like anginosus), Peptostreptococcus, Fusobacterium, bacteroides, actinomyces…
-Viridans group streptococcus
-Haemophilus influenzae

 Airway management
 Antibiotics: PipTazo/Vanco, Cipro/Flagyl

• airway compromise
• mediastinitis

Ludwig’s angina
clinical presentation: Patients typically present with fever, chills, and malaise, as well as mouth pain, stiff neck, drooling, and dysphagia, and may lean forward to maximize the airway diameter [7]. They may have a muffled voice or be unable to speak at all. Trismus is usually absent unless there is spread into the parapharyngeal space. As the illness progresses, breathing may become difficult; stridor and cyanosis are considered ominous signs.
On physical examination, patients have tender, symmetric, and “woody” induration, sometimes with palpable crepitus, in the submandibular area [7]. The mouth is held open by lingual swelling. There is typically no lymphadenopathy. The floor of the oropharynx is usually elevated and erythematous, and is tender to palpation. Occasionally, the inflammation extends to the epiglottis.
Requires antibiotics: Streptococcus (viridans, like anginosus), Peptostreptococcus, Fusobacterium, bacteroides, actinomyces

Abx: Ceftriaxone + Metronidazole
Clindamycin + levofloxacin if pen allergic
Meropenem if penicillin allergic

REMEMBER to secure the airway if necessary

Retropharyngeal Abscess
Retropharyngeal abscesses are among the most serious of deep space infections, since infection can extend directly into the anterior or posterior regions of the superior mediastinum, or into the entire length of the posterior mediastinum via the danger space.

The cardinal clinical features of parapharyngeal space infections are similar to the general findings of deep neck space infection (see ‘General clinical features’ above) and consist of:
•Trismus (ie, the inability to open the jaw)
•Induration and swelling below the angle of the mandible
•Medial bulging of the pharyngeal wall
•Systemic toxicity with fever and rigors

Complications – Parapharyngeal space infections are potentially life-threatening because of the possibility of involving the carotid sheath and its vital contents (eg, common carotid artery, internal jugular vein, vagus nerve), propensity for airway impingement, and bacteremic dissemination. Suppuration may also advance quickly to other spaces, particularly to the retropharyngeal and “danger” spaces, possibly reaching the mediastinum inferiorly or the base of the skull superiorly.

Treatment
Indications and methods for drainage — For patients who have a dental source of infection, we recommend early removal of that source [36]. Additional initial decisions on drainage for parapharyngeal or retropharyngeal space infections depend upon whether local suppuration has developed or whether only the initial phase of diffuse cellulitis is present. Abscess formation is often difficult to determine clinically but can be identified on imaging studies. This differentiation is important because drainage should be delayed in the cellulitis stage, whereas loculated abscesses should be drained.

Open surgical drainage has been the traditional approach to abscess management. For patients with well-defined deep neck space infections without airway compromise, ultrasound-guided needle aspiration is an effective alternative and is associated with decreased hospital stay and improved cost savings [37,38]. In retropharyngeal space infection complicated by acute necrotizing mediastinitis, surgical drainage of the mediastinum is required and may be performed by either the cervico-mediastinal or the transthoracic approach.

Abx: Ceftriaxone + Metronidazole OR Clindamycin + Levofloxacin
if concern RE ear/mastoid infection: PipTazo
*these Abx choices would be different in immunocompromised pts

Question 40

42. E Ecoli bacteremia treated for 2 days with meropenem, not improving
    a. Why is this occurring?
    b. What antibiotic will you change to?

Answer 40

 Carbapenemase acquired E. Coli
Carbapenem-resistant Enterobacteriaceae, are a family of germs that are difficult to treat because they have high levels of resistance to antibiotics. Klebsiella species and Escherichia coli (E. coli) are examples of Enterobacteriaceae, a normal part of the human gut bacteria, that can become carbapenem-resistant. Types of CRE are sometimes known as KPC (Klebsiella pneumoniae carbapenemase) and NDM (New Delhi Metallo-beta-lactamase).

UTD:
For infections caused by Klebsiella pneumoniae carbapenemase (KPC)-producing organisms, we favor ceftazidime-avibactam if the organism is susceptible.

When a polymyxin (colistin or polymyxin B) is used for either KPC- or metallo-beta-lactamase-producing Enterobacteriaceae, we typically use it with a second active agent [118,137]. A potential second agent is meropenem, especially if the isolate has an MIC to meropenem ≤8 mcg/mL. Tigecycline could be considered as a second agent, especially for infections involving the gastrointestinal tract and lungs, given its penetration into these tissues.

old answer
o What antibiotic will you change to?
 Aminoglycoside
 Polymixin - Colistin

Question 41

43. Pressure volume curve shown, patient is on Pressure control ventilation
    a. Label the axes
    b. Show how it will change with a decrease in compliance

Answer 41

https://derangedphysiology.com/main/cicm-primary-exam/required-reading/respiratory-system/Chapter%20555/pressure-volume-loops-presence

Question 42

44. Pressure volume curve, near the end of the loop it does not come back to baseline.
    a. Assuming the patient is not air trapping, what is the cause of this abnormality?
    b. Assuming the vent circuit is functioning normally, what are 2 causes of this abnormality

Answer 42

Vt-insp is more than the Vt –exp. Therefore there is a volume that is leaked

 BPF
 cuff leak

Question 43

45. Compliance

a. given pressures and volumes, calculate static compliance

Answer 43

Cstat: VT / (Pplat – PEEPtot)

Question 44

46. you have a patient that you want to use an esophageal balloon in.
    a. Write the equation (or define) the transpulmonary pressure with respect to the esophageal balloon.
    b. What transpulmonary pressure will you target?
    c. Which vent variable you adjust to meet this target?

Answer 44

 Pressure difference between transalveolar pressure and alveolar distending pressure
TPP is the difference between the alveolar pressure (Palv) and pleural pressure (Ppl).
TPP is the net distending pressure applied to the lung.
 Ptranspulm = Palv - Ppleural
= Pplat - Pesoph
*TPP can be calculated both at end-inspiration and end-expiration

• Targetting pressures of 0-10 at end expiration and less than 25 cmH2O at end inspiration

• PEEP
  https: //derangedphysiology.com/main/required-reading/respiratory-medicine-and-ventilation/Chapter%205.1.2.3/transpulmonary-pressure-guide-therapy

Question 45

47. Patient with Inferior-Right sided MI, goes into RV failure
    a. 4 principles of management
    b. becomes bradycardic and unstable, what is the best way to pace this patient? Why?

Answer 45

o	4 principles of management
	Maintain preload – with fluid bolus
	Decrease afterload
	Consider inotropic support
	Increase coronary perfusion
•	Mechanical assist device

o becomes bradycardic and unstable, what is the best way to pace this patient? Why?
 AV pacing

from UTD regarding heart failure
…Single-chamber pacing (eg, right ventricular [RV] demand pacing [VVI] or right atrial demand pacing [AAI]) or dual chamber pacing (eg, DDD) is not indicated to treat heart failure (HF). Patients with HF should receive such pacemaker therapy only if there is a standard bradycardic indication for pacing.

Question 46

48. Young, G3P2 at 37 weeks, now presents with acute SOB, CXR = bilat infiltrates, hemodynamically borderline, no fever
    a. What are 2 pregnancy related causes of this picture?

Answer 46

o Aspiration
o Tocolytics - The use of tocolytic beta-2 agonists (eg, terbutaline) to inhibit preterm labor is associated with pulmonary edema.
o Cardiogenic pulmonary edema due to peripartum cardiomyopathy
-Eclampsia/Pre-eclampsia - Pulmonary edema is an uncommon complication of severe preeclampsia and eclampsia.
-ARDS - Acute respiratory distress syndrome (ARDS) may occur in pregnant women due to conditions associated with pregnancy (eg, amniotic fluid embolism) or not associated with pregnancy (eg, trauma).
???o Alloimmunization from baby  ARDS type picture

Question 47

49. Young female, long labour, oxytocin induction, immediately postpartum, develops coagulopathy, shock, DIC picture, hypotension, resp failure
    a. In this patient, what are 2 pregnancy related causes of pulmonary deterioration in this patient?

Answer 47

 Amniotic fluid embolism
-eclampsia/pre-eclampsia (can get DIC, pulm edema with it)

 ARDS
 Pulmonary embolism

Question 48

50. Patient with variceal bleeding

a. List 4 non-pharm treatments other than transfusion and supportive care

Answer 48

	Blakemore
	Endoscopy with banding
	Endoscopy with sclerotherapy
	TIPS or surgical shunting
	Liver transplantation
-esophageal stent
-BRTO (balloon retrograde total occlusion) for gastric or ectopic varices and also needs presence of a spontaneous shunt

Question 49

51. Patient post op cardiopulmonary bypass

a. List 5 non-surgical, causes of immediate bleeding post op!

Answer 49

o	Hypothermia
o	Metabolic acidosis from poor CO
o	Thrombocytopenia
o	Improper reversal of heparin
o	Hypocalcemia
-heparin rebound
-HIT?

Question 50

52. Myasthenia gravis
    a. What are 2 treatments that decrease the need for mechanical ventilation (other than noninvasive ventilation)
    b. What are the threshold values for the Vital capacity and Negative Inspiratory Force that will make you consider intubation in this patient

Answer 50

 PLEX
 IVIG
-Pyridostigmine
-Steroids/azathioprine/mycophenolate mofetil/cyclosporine

• VC less than 1.5 L, less than 20 mL/kg
• MIP of less than negative 30
• MEP of less than positive 40

Question 51

53. Crohns, on home TPN
    a. 2 ways to determine daily calorie needs?
    b. what would the patient’s daily carb requirement be?
    c. what is the daily protein requirement for this patient?

Answer 51

• predictive equations
• weight based estimations
• indirect calorimetry (can’t really do at home)
• Carbs 3g/kg/d
• Protein 1.5g/kg/d

Question 52

54. Malnourished patient
    a. What are 2 features on the history
    b. What are 2 physical exam findings
    c. 2 adjustments to TPN

Answer 52

o	What are 2 features on the history
	Daily description of diet
	Syncope
	Fall
	Failure to meet ADLs
	History of weight loss
o	What are 2 physical exam findings
	Temporal lobe wasting
	Weakness of quadriceps
	Sacral edema
	Ankle
o	2 adjustments to TPN
	Decrease carbohydrate
	Decrease calories
	Supplement electrolytes

Question 53

55. patient has stable VT
    a. what are 2 alternative rhythms (other than VT) that give a wide complex
    b. list 2 features that would confirm this is VT

Answer 53

SVT w aberrhancy
SVT with pre-excitation
paced rhythm
artifact
VT

A-V dyssynchrony:

• capture beats –> diagnostic for VT
• fusion beats –> diagnostic for VT
• dissociated P waves with atrial rate slower than ventricular rate, varying PR intervals, different PP and RR intervals

Question 54

56. 5 drugs you can remove with dialysis

Answer 54

o	salicylates
o	Lithium
o	Methanol
o	Ethylene glycol
o	Metformin
o	Procainamide
o	Theophylline

• barbiturates
• isoniazid
• theophylline/caffeine

Question 55

57. Shown CXR, with PA cath, crosses midline, seems too far in, and there is an infiltrate? On the same side. Patient coughs up blood after insertion.
    a. What is the most likely cause of the hemoptysis
    b. 3 risk factors for this to occur

Answer 55

 PA rupture

	Pulmonary hypertension
-advanced age
	Female gender
	Hypothermia
	Coagulopathic
	Multiple attempts
	Forced insertion
-mitral valve disease

Question 56

58. dude getting a contrast CT, air gets injected with the contrast, sudden onset chest pain and difficulty breathing.
    a. What is the diagnosis
    b. What are 2 immediate interventions

Answer 56

 Venous air embolism

• trendelenburg positioning, left lateral
• FiO2 1.0
• aspirate through R IJ CVC
• hyperbaric oxygen (if hemodynamic unstable and with evidence of cardiopulmonary compromise and/or end-organ damage due to air embolism)
• life support care: mechanical ventilation, vasopressors etc
• closed cardiac massage (i.e. compressions) can be a last resort therapy
• of note positioning for arterial air embolism is different - supine to minimize any cerebral edema and are bubbles are propelled forward in the arterial system

Question 57

59. Transport questions
    a. What altitude is the cabin pressure of a normal commercial airliner set at? (how many feet is it pressurized too)
    b. 2 vital sign changes that would occur at this altitude?
    c. At this altitude, what percentage of sea level pressure is present (give a range)

Answer 57

 8000 ft

 Increase in HR
 Increase in RR
 Hypoxia

-barometric pressure at sea level ~760mm Hg
-barometric pressure at 8000 feet ~560mm Hg
-corresponds to ~75%
 Decrease in PaO2 from 90 to 60

Question 58

60. Patient, on multiple meds, including clomipramine, opioids, recently started on another agent (seemed serotonergic). Now patient presents with clonus everywhere, fever (temp 41.5 deg), tachy, altered LOC.
    a. Likely etiology
    b. Which 2 immediate treatments would you institute
    c) list 5 drugs that can cause serotonin syndrome

Answer 58

 Serotonin syndrome

 Cyproheptidine
-benzodiazepines

• amphetamines (dextroamphetamine, methamphetamine)
• cocaine
• MDMA (ecstasy)
• levodopa, carbi-levodopa
• tramadol
• SSRI (citalopram, escitalopram, fluoxetine, paroxetine, sertraline)
• SNRI (duloxetine, venlafaxine)
• trazadone
• TCAs (amitriptyline, clomipramine, nortriptyline)
• St John’s wort
• 5HT3 receptor antagonists (ondansetron)
• metochlopramide
• valproate
• carbamazepime
• cyclobenzaprine
• fentanyl
• lithium
• ergot derivatives
• LSD
• tryptophan

Question 59

61. List 5 physiologic consequences of abdominal compartment syndrome

Answer 59

	Mesenteric ischemia
	Acute renal failure
	Hypotension
	Hypoxia
	Hypercarbia
-increased ICP

Question 60

62. How to position an obese patient for intubation (single line answer)

Answer 60

 Having them in the recumbent position either with troop pillow or head up of the bed up.

Question 61

64. Rapid sequence intubation (with neuromuscular blockers)
    a. 2 benefits
    b. 2 potential negative consequences
    c. 5 steps/things to do other than preparing equipment and starting IV access

Answer 61

o 2 benefits
 Short time from induction with unsecured airway to secured airway
 Precalculated doses of induction
-optimal intubating conditions with use of NMB

o 2 potential negative consequences
 Inadequate induction
 Hypotension due to BP meds

o 5 steps/things to do other than preparing equipment and starting IV access
 Airway examination
 Preoxygenate
 Mobilizing assistant
 Cricoid pressure
 Back-up technique
 Precalculation of drugs to be given as bolus

STOP MAIN
Suction
Tools for intubation (DL, VL, bougie)
Oxygen source
Positioning

Monitors
Assistant, AMBU bag
IV access
Drugs

Question 62

66. 2 cardiovascular effects of lightning strike (mechanisms of injury to the CV system)

Answer 62

 Myocardial stunning/ventricular failure/Takotsubo
 Arrhythmia
 Elevated ST segment
-myocardial contusion
-pericardial disease
-aortic injury
-inappropriate therapies from cardiac implantable devices

Question 63

67. you have a patient with ARDS (acute onset), all infections have been ruled out.
    a. List 5 pulmonary causes of ARDS in this patient (not systemic!!!)

Answer 63

	Aspiration
	Neurogenic pulmonary edema
	Pulmonary contusion
	Venous air embolism
	Fat embolism
	Near drowning
	Smoke inhalation

• lung and hematopoietic stem cell transplant
• drugs: aspirin, cocaine, opioids, TCAs

Question 64

describe complications of iron ingestion and management.

Answer 64

The clinical features of iron toxicity are typically described in five (often overlapping) phases that are manifestations of the toxic effects of iron. These phases include:

1) gastrointestinal (GI) features
2) a latent phase
3) shock and elevated anion gap metabolic acidosis
4) hepatotoxicity/hepatic necrosis
5) bowel obstruction

We recommend that patients with any of the following indications receive intravenous deferoxamine (chelating agent) (Grade 1B):

• Severe symptoms (altered mental status, hemodynamic instability, persistent vomiting and/or diarrhea)
• Elevated anion gap metabolic acidosis
• Peak serum iron concentration (SIC) greater than 500 mcg/dL (90 micromol/L)
• Significant number of pills on abdominal radiograph

We suggest that patients with a significant number of radiopaque pills in the stomach on abdominal radiograph receive orogastric lavage and/or whole bowel irrigation (WBI)

Question 65

69. Hypothermic cardiac arrest

a. 2 changes to ACLS in this setting

Answer 65

 Active core rewarming techniques
 Prolonged CPR
 Patient must be warmed to 34*C
-move pt carefully (can trigger arrhythmias)
-repeat defibrillation should be attempted once pt partially warmed to ~32degrees C

Active external rewarming is used to treat patients with moderate hypothermia, refractory mild hypothermia, and as an adjunct in severe hypothermia. It consists of some combination of warm blankets, radiant heat, or forced warm air applied directly to the patient’s skin. Rewarming of the trunk should be undertaken BEFORE the extremities to minimize the risk of core temperature afterdrop, hypotension, and acidemia.

For severe and recalcitrant moderate hypothermia, we suggest initiating treatment with less invasive rewarming techniques (eg, warmed IV isotonic crystalloid), and progressively adding more invasive ones (eg, warmed pleural lavage) as needed. Extracorporeal blood rewarming techniques are used to treat perfusing patients who fail to rewarm, have completely frozen extremities, or have severe rhabdomyolysis and hyperkalemia. For salvageable, non-perfusing patients with severe hypothermia, we suggest treatment with extracorporeal membrane oxygenation (ECMO) or cardiopulmonary bypass when that option is readily available (Grade 2C).

Rough handling of the moderate or severe hypothermic patient can precipitate arrhythmias, including ventricular fibrillation, that are often unresponsive to defibrillation and medications. Cardiopulmonary resuscitation (CPR) should continue until the patient is rewarmed to 30 to 32°C (86 to 90°F), at which point renewed attempts at defibrillation and resuscitation with ACLS medications are undertaken. The neuroprotective effects of low temperature may allow recovery following prolonged arrest.

For patients who fail to rewarm appropriately despite aggressive rewarming measures, we suggest treatment with empiric broad spectrum antibiotics and a single dose of glucocorticoid (Grade 2C). Such patients may also need treatment for hypoglycemia, myxedema coma, or other contributing causes.

After resuscitation, pay careful attention to potential complications, including hypotension during active rewarming, arrhythmia, hyperkalemia, hypoglycemia, rhabdomyolysis, bladder atony, and bleeding diathesis.

Question 66

70. amiodarone is commonly used in the ICU
    a. list 2 indications for use?
    b. List 1 thing to monitor?
    c. List criteria to consider stopping or decreasing dose of amiodarone

Answer 66

• restoration and maintenance of sinus rhythm in critically ill pts with HD unstable Afib
• ventricular rate control in critically ill pts with atrial fibrillation and RVR
• treatment of ventricular arrhythmias/ventricular storm
• VF/pVT cardiac arrest after second attempt at defibrillation in anticipation of third defibrillation attempt

 Prolongs refractory period in myocardial cells by blocking sodium, potassium and calcium channels
 Antiarrhythmic
 Rate control as it has significant beta blocking properties in the critically ill

 QTc

	Prolonged QT
	Thyroid issues
	Pulmonary alveolitis
	Peripheral neuropathy
	Tremors
	Sleep disturbance
	Headache

Question 67

71. You are a new intensivist, have a patient with MDR infection on isolation, surgeon refusing to wear gown/gloves despite yourself and the nurse talking with him
    a. List 3 ways that you will approach this conflict and your strategy for resolution

Answer 67

http://www.royalcollege.ca/rcsite/bioethics/primers/conflict-resolution-e#approaches

competing style
avoiding style
compromising style
accommodating style
collaborating style

Collaborating style is preferred:

• These are the “let’s work it out together” people.
• This approach is highly assertive and highly cooperative.
• It satisfies all parties equally.

When to use

• As often as possible.
• This is the preferred method of conflict resolution.
• It leads to creative, durable outcomes.
• It supports open discussion of issues and equal distribution of work.
• It creates learning positive environments.

Disadvantages

• It can take time to develop mutually agreeable outcomes.
• This approach can be overused and lead to frustration for those who need a decision.

Question 68

73. HES (colloids) – they partially repeated the question
    a. List 4 possible negative consequences of colloid administration
    b. An anesthetist want to give HES as a volume expander to a post op bowel perf with septic shock.
    i. List 3 ways you would approach this with the goal of conflict resolution and keeping patient safety in mind

Answer 68

 Acute renal failure in sepsis and septic shock
 Coagulopathy due to impact on vWF and FVIII
-impaired platelet activity
 +/- Anaphylaxis
 Increased risk of mortality

Question 69

74. List whether FRC increases or decreases in the following patients when moving from upright to supine
    a. C6 quad
    b. Bilateral phrenic nerve paralysis

Answer 69

o C6 quad
-Normal (phrenic nerve innervated by C3-5)

o	Bilateral phrenic nerve paralysis
	???
	All the active parameters (i.e. requiring muscle of inspiration) are decreased:
•	VC
•	FEV1
•	PEF
•	IC
	All passive parameters are increased
•	RV
•	FRC

Question 70

what are risk factors for delirium in critically ill patients?

Answer 70

modifiable: benzodiazepine use, blood transfusions
nonmodifiable: greater age, dementia, prior coma, pre-ICU emergency surgery/trauma, increasing APACHE scores