Critical Care

Question 1

Pulmonary artery catheterization can help to diagnose and guide treatment of shock, but has not been shown to improve survival or any other patient-related outcomes.

Question 2

What is the VASST study?

Answer 2

The VASST Study comparing norepinephrine with norepinephrine + vasopressin in septic shock showed no overall difference in survival between the treatment groups. The norepinephrine + vasopressin group had decreased norepinephrine requirement. Mortality benefit was seen in the subgroup of patients with less severe septic shock receiving both norepinephrine+ vasopressin when the norepinephrine dose was < 15 μg/min.

Question 3

In a 2012 meta-analysis, norepinephrine was compared with dopamine for septic shock. The results suggested an increased risk of death for dopamine compared with norepinephrine.

Question 4

Phenylephrine can reduce CO and induce reflex bradycardia.

Question 5

Intra-aortic balloon counterpulsation has not shown a mortality benefit in patients with cardiogenic shock.

Question 6

Norepinephrine is the first- line vasoconstrictor for most forms of shock.

Question 7

SVO2 is typically decreased in low flow states (cardiogenic shock) or anemia, but is normal or high in distributive shock.

Question 8

Causes of distributive shock?

Answer 8

SLAM D ANT
Systemic inflammatory response syndrome (pancreatitis, burns, trauma)
Liver failure Anaphylaxis Myxedema coma
Drugs or toxins (insect bites, transfusion reactions, heavy metal poisoning)
Adrenal insufficiency Neurogenic shock (central nervous system or spinal
cord injury)
Toxic shock syndrome

Question 9

Left ventricular failure is the most common cause of post-myocardial infarction shock.

Question 10

Hypotension and inferior myocardial infarction should raise suspicion for right ventricular infarct with associated cardiogenic shock, especially if hypotension occurs after nitroglycerin or vasodilators. Obtain right- sided ECG. ST elevation > 1 mm in lead V4R or V5R is specific for right ventricular infarct.

Question 11

Common secondary causes of hypertension emergencies?

Answer 11

(1) renal crisis from collagen vascular disease,
(2) severe hypertension after renal transplantation,
(3) pheochromocytoma,
(4) cocaine,
(5) rebound hypertension,
(6) preeclampsia/eclampsia.

Question 12

Early decompression with transjugular intrahepatic portosystemic shunt within 24–48 hours in high-risk patients results in reduction of treatment failure and mortality rate in severe variceal bleeds

Question 13

Indications for stress ulcer prophylaxis in critically ill patients?

Answer 13

mechanical ventilation > 48 hours
coagulopathy
& two or more of the following: sepsis, ICU admission > 1 week,
occult gastrointestinal bleed > 6 days, steroid therapy.

Question 14

Scoring system for mortality in upper gastrointestinal bleed: AIMS 65

Answer 14

Albumin < 3.0 g/dL
INR > 1.5
Altered Mental status
Systolic blood pressure < 90 mm Hg
Age > 65 years

Question 15

Hyperventilation for increased ICP is only useful if there is a planned intervention within 6–24 hours because it may eventually result in rebound elevation of ICP.

Question 16

most common cause of death in acute liver failure?

Answer 16

Cerebral edema

Question 17

Etiology of acute pancreatitis:

Answer 17

I GET SMASHED

Idiopathic
Gallstones Ethanol Trauma
Steroids
Mumps Autoimmune (PAN) Scorpion stings Hyperlipidemia.
Hypercalcemia
ERCP
Drugs (including azathioprine
and diuretics)

Question 18

Enteral feeds are often held in ICU patients with a large gastric residual volume. However, two recent trials showed that gastric residual volume up to 500 mL could be safely tolerated and not measuring gastric residual volume improved caloric intake without increasing the incidence of pneumonia.

Question 19

How do you initially treat myxedema coma?

Answer 19

Initial treatment of myxedema coma requires an IV bolus of T4 and T3. IV hydrocortisone is also given for potential concurrent adrenal insufficiency.

Question 20

Initial management of thyroid storm includes administration of propranolol, thionamide (propylthiouracil or methimazole), and hydrocortisone.

Question 21

How long is AC recommended for HIT w/o thrombosis and HIT w/thrombosis?

Answer 21

Anticoagulation is recommended for 4–6 weeks for patients with heparin-induced thrombocytopenia without thrombosis and for at least 3 months for patients with thrombosis.
Vitamin K antagonists (warfarin) are avoided because they can exacerbate the prothrombotic state.

Question 22

Most cases of TTP-HUS are idiopathic, but known associations include bloody diarrhea caused by Shiga toxin-producing bacteria (e.g., Escherichia coli 0157:H7), pregnancy in patients with congenital or acquired ADAMTS13 deficiency, and drugs (chemotherapy, immunosuppression).

Question 23

A 47-year-old woman who worked in a textile mill with wool had malaise, fever, and myalgia 5 days ago is now presenting with severe hypoxia and delirium. Chest radiography shows widened mediastinum. What type of exposure is suggested?

Answer 23

Bacillus anthracis
inhalation

Question 24

In suspected bacterial meningitis, to be beneficial, dexamethasone is given before or simultaneously with the first dose of antibiotic.

Question 25

Clindamycin is included in the empiric antibiotic treatment of severe soft tissue infection because of its antitoxin effects against streptococci and staphylococci species.

Question 26

What is the Single most important predictor of hemorrhagic stroke in patients with preeclampsia?

Answer 26

systolic blood pressure > 160 mm Hg.

Question 27

What is the most common etiology of postpartum hemorrhage?

Answer 27

Uterine atony

Question 28

What is the biggest risk factor for tocolytic- associated pulmonary edema?

Answer 28

Prolonged tocolytic therapy > 24–48 hours

Question 29

How do you treat Venous thromboembolism related to pregnancy?

Answer 29

with low-molecular- weight heparin for a minimum of 3–6 months, including the duration of the pregnancy and at least 6 weeks postpartum.

Question 30

Delirium is a risk factor for death in the ICU.

Question 31

Use of glucocorticoids in moderate to severe head injury was associated with worsened outcomes in a large randomized clinical trial.

Question 32

Neurleptic Malignant Syndrome is associated with all classes of neuroleptic agents, including the newer atypical antipsychotic meds such as risperidone and olanzapine.

Question 33

Dantrolene, acetaminophen, and aspirin are ineffective and are not indicated in the treatment of heat stroke.

Question 34

Concomitant use of which antibiotic with serotonergic agents can cause serotonin syndrome?

Answer 34

Linezolid

Question 35

With the new Berlin definition of ARDS in 2012, the pulmonary capillary wedge pressure criterion was removed. If there is no known etiologic risk factor for ARDS, cardiac function should be assessed objectively with echocardiography.

Question 36

What condition is associated with the pathologic finding of diffuse alveolar damage with no known cause?

Answer 36

Acute interstitial pneumonia (Hamman-Rich syndrome)

Question 37

The key in mechanical ventilator management of ARDS is to prevent volutrauma, atelectrauma, and oxygen toxicity.

Question 38

A low tidal volume strategy improves outcomes in ARDS. However, increases in respiratory rate may be insufficient to compensate for low tidal volumes. Permissive hypercapnia is allowed if there are no contraindications

Question 39

A patient presents with ARDS. You want to follow evidence-based ventilatory management strategies. What are the goals?

Answer 39

Tidal volume 6 mL/kg predicted body weight and plateau pressure < 30 cm H2O

Question 40

Assess the airway:
LEMON

Look externally: Abnormal facie, abnormal anatomy, trauma

Evaluate 3-3-2 rule (3 fingers mouth opening, 3 fingers along floor of mandible, 2 fingers superior to laryngeal notch): Predicts difficult visualization for direct laryngoscopy

Mallampati score (Figure 2-8): Score of I or II predicts easy laryngoscopy, and score of III or
IV predicts difficultly

Obstruction/obesity

Neck mobility: Ideally,
patient should be in the sniff position for intubation.

Question 41

Predictors of difficult bag mask ventilation:
MOANS

Mask seal: Abnormal anatomy and facial hair

Obstruction/obesity

Age > 55 years, loss of elasticity, increased incidence of restrictive and obstructive lung disease

No teeth

Stiffness: Lung conditions that decrease lung compliance

Question 42

In pressure-targeted breaths, tidal volume may vary depending on lung compliance (and patient assistance) and therefore will be affected by changes in clinical state. For example, with resolution of pulmonary edema or ARDS, lung compliance improves and results in larger tidal volume for the same set inspiratory pressure and time.

Question 43

A patient requires intubation. He is obese and has a Mallampati class IV airway. Current saturation is 90% on a high-flow mask. What is the best next step?

Answer 43

Perform awake intubation with fiberoptic guidance.

Question 44

A patient with a severe exacerbation of COPD is having ineffective triggering because of auto-PEEP. You increase the applied PEEP. What parameter would you follow to determine whether excessive PEEP is being applied?

Answer 44

A rise in peak pressure. As long as applied PEEP is less than auto-PEEP, peak pressures will not change. However, once applied PEEP is greater than auto- PEEP, peak and plateau pressures will increase, placing the patient at risk for ventilator-induced lung injury.

Question 45

A patient who is receiving mechanical ventilation because of ARDS has increased work of breathing and a concave deflection on the pressure– time graphic. Increasing the flow rate improves the inspiratory flow asynchrony and relieves the work of breathing.

Answer 46

Auto-PEEP is apparent on the flow–time graphic when expiratory flow does not return to baseline before the next inspiratory cycle.

Question 47

Airway pressure release ventilation is an option for patients with refractory hypoxemia as a result of ARDS. It is best used in patients who are breathing spontaneously and are without bronchospasms or copious amounts of secretions that would put them at high risk for auto- PEEP.

Question 48

Question 49

Question 50

Question 51

Question 52

Question 53

Question 54

Question 55

What do you see here?

Answer 55

Ineffective triggering. Patient inspiratory effort does not trigger a breath (arrows)

Question 56

What do you see here?

Answer 56

Cycling asynchrony with delayed termination. Flow-time graphic (top) and pressure time graphic (bottom). Variation in expiratory flow on the flow time graphic (green arrows). Pressure spike caused by the pt’s expiratory effort during inspiratory time.

Cycling asynchrony caused by duration of breath longer than the patient desires is seen on the flow–time graphic with variation in expiratory flow and is seen as pressure spikes on the pressure– time graphic. Increasing the flow should improve cycling asynchrony.

Question 57

Answer 57

Auto-PEEP is apparent on the flow–time graphic when expiratory flow does not return to baseline before the next inspiratory cycle.

Question 58

What are the specific ventilator strategies in a patient with severe airflow obstruction?

Answer 58

Smaller tidal volume and lower respiratory rate to decrease administered minute ventilation to reduce the risk of auto- PEEP. If there are no contraindications, permissive hypercapnia is tolerated in this subset of patients.

Question 59

A 78-year-old woman is evaluated in your clinic for exertional dyspnea that started 1 week ago. She was recently intubated for 10 days for ARDS and was extubated successfully 4 weeks ago. Spirometry is performed and shows flattening of both the inspiratory and expiratory flow loops. What is the most appropriate next step in evaluation of this patient’s dyspnea?

Answer 59

Fiberoptic laryngoscopy to evaluate for tracheal stenosis

Question 60

Depending on the clinical situation, it is common to see hypotension in a patient who is given positive pressure ventilation because of the effects of a decrease in venous return. This phenomenon is further exacerbated with PEEP administration and hypovolemia.

Question 61

A 67-year-old man who is being treated for pneumonia is receiving mechanical ventilation with a current setting of pressure support of 18 cm H2O with PEEP of 5 cm H2O and FiO2 40%. He is placed on a spontaneous breathing trial but becomes anxious, tachycardic, and hypertensive, with oxygen saturation dropping to 89%. He is returned to his baseline ventilator settings and stabilizes. What is the strategy to successfully liberate him from the ventilator?

Answer 61

Repeat spontaneous breathing trials daily.

Question 62

Good candidates for NPPV include those with exacerbation of COPD, cardiogenic pulmonary edema, or immunocompromised state with minimal secretions, mild to moderate acidosis, nonsomnolence, and hemodynamic stability.

Question 63

During CPR, the Advanced Cardiac Life Support
provider can use EtCO2:

To evaluate the
effectiveness of CPR, denoted by an increase in EtCO2 (EtCO2 increases with increased cardiac output)

To determine resumption of spontaneous circulation, which is accompanied by a dramatic increase in EtCO2 (first indicator because of increased cardiac output)

EtCO2 < 10 mm Hg indicates poor quality of CPR.

Question 64

What is the optimal position for a patient who is bleeding from the right lung?

Answer 64

The patient should be placed in the right-side- down (bleeding side down) decubitus position.