Critical Care

Question 1

TCA (Tricyclic Antidepressant) Overdose
(e.g. Amitriptyline)
Features

Answer 1

◙ Excessive sedation, Dry mouth and skin.

◙ Sympathomimetic effect: tachycardia, Sweating, Dilated Pupils.

◙ ECG: Sinus tachycardia (Common),

Prolongation of QRS, QT, PR

Dilated pupils –
Dry mouth –
Dry flushed skin –

Drowsiness –
Hypotension –

Urine retention –
Tachycardia –
Severe Sedation

Question 2

RX of TCA OVERDOSE

Answer 2

◙ ECG monitoring is essential: Widened QRS, PR, QT and Broad
complex tachycardia.

◙ As the patient is in severe metabolic Acidosis

→ give an IV bolus of 250 ml Normal Saline (0.9%).

+ Sodium Bicarbonate (50 mmol IV slowly) of 8.4% NaHCO3.

♠ N.B. aim for pH of 7.5-7.55!

♠ Sodium bicarbonate will correct ECG changes and cardiac rhythm.

♠ Do not forget that in a patient with amitriptyline (TCA) overdose, if he is
acidotic, 2 steps to be done:

1) ECG monitoring.
2) IV fluids including Sodium Bicarbonate (HCO3).

In a previous exam, the candidates were asked about the dose of the Sodium
Bicarbonate,

the answer was:
→ IV fluids + Sodium Bicarbonate 50 ml of 8.4% IV.

Question 3

Refeeding syndrome features
Tissue hypoxia
Myocardial dysfunction

Inability of diamphragm to contract

decrease p
Decrease k
VIT def
Pulm oedema
Congestive heart failure

Answer 3

High glucose
High insulin

Increased cellular uptake of phosphate
Increase in phosphate demand
Hypophosphatamia

Question 4

Refeeding syndrome is a syndrome consistin

of metabolic disturbances that
occur as a result of reinstitution of nutrition to patients who are starved,
severely malnourished or metabolically stressed.

Answer 4

◙ When too much food and/or liquid nutrition supplement is consumed during
the initial 4 to 7 days of refeeding,

this triggers synthesis of glycogen, fat and
protein in cells, to the detriment of serum concentrations of potassium,
magnesium and phosphorus (Consumed → ↓ K+, Mg++, Phosphate

).
◙ Cardiac, pulmonary and neurological symptoms can be signs of refeeding
syndrome. The low serum minerals, if severe enough, can be fatal!

◙ To avoid refeeding syndrome →
Slow feeds + Give Supplements of Potassium, Magnesium and Phosphate.

Question 5

A 36 YO man presents to the ED with a Severe headache with vomiting for 1
day.

The headache started when he was lifting weights in a gym.

He has
photophobia and neck stiffness and GCS of 12/15. A CT head is ordered and it
shows

His BP is normal with mild tachycardia. Which drug is useful in this case?

[Aspirin ▐ or: Clopidogrel ▐ or: Sumatriptan ▐ or: Nimodipine]

Answer 5

√ Firstly, this is a case of Subarachnoid hemorrhage (SAH).

√ The hyperintense areas on the CT → blood in the subarachnoid basal
cisterns.

√ In SAH, cerebral vasospasm can occur 4-12 days later and it is serious.

◙ To diminish this anticipated cerebral vasospasm,

→ we give Calcium Antagonist (e.g. Nimodipine) for 5-14 days.

Question 6

SAH features

Answer 6

Common hints:
√ The worst headache in life.

√ Thunderclap headache.

√ Feeling of “kicked in the head” (SEVERE headache worse at back of head).

√ Severe “Occipital”.

√ Meningeal irritation (Neck stiffness, Photophobia),
Vomiting, Collapse,
Seizures.

Question 7

SAH diagnosis and mng

Answer 7

♦ Dx:

√ CT brain (without contrast)

√ If inconclusive → LP “Lumber Puncture” after 12 hours of the onset of the
headache:

(CSF is Bloody, then → Xanthochromic “Yellow” due to bilirubin). “Imp √”

N.B. Calcium Antagonists (e.g. Nimodipine) is beneficial as it can help reduce
the cerebral vasospasm that may result due to Subarachnoid hemorrhage.

Question 11

4
A 36 YO presents to the ED with a Severe headache with vomiting for 1 day.

The headache started when he was lifting weights in a gym.

He has
photophobia and neck stiffness and GCS of 12/15.

A CT head was done and it
did not show evidence of intracranial bleeding. What should be done next

Answer 11

?
As the CT is inconclusive, we need to confirm SAH via:

→ LP “Lumber Puncture” after 12 hours of the onset of the headache

Question 12

A man was sitting on the passenger seat when the car went into a road
traffic accident. He was hit in the left side.

The most commonly injured organ is → Spleen.

Answer 12

The most commonly injured organ is → Spleen.

• Common after trauma to the left side especially after RTA.

• Manifestations:
Left side Chest and Abdomen Bruises,

Abdominal
Distension,

rapid fall in BP and rise in HR.

• Abdominal X-ray → Absent left psoas shadow.

• FAST (U/S for trauma) → free peritoneal fluids.

• CT Abdomen → Diagnostic

• If confirmed → Urgent surgery.

Question 13

DD of splenic rupture

Answer 13

• Note: Subsplenic hematoma is different from Splenic rupture.

The
former might be treated conservatively “if stable” by being observed by
the surgical team

whereas the latter (Splenic rupture) if confirmed,
urgent surgery is required.

Question 14

A stem with long history of a patient after RTA being managed in a critical care
unit with an X-ray showing an Nasogastric tube being curled above the
hemidiaphragm.

Answer 14

Coiled NGT after Road Traffic Accident → Diaphragmatic Rupture.

Question 15

A stroke patient in the critical care unit has been unable to feed orally.
Therefore, an NGT is inserted for enteral feeding.

The most accurate way to assess the right placement of NGT is:

Answer 15

The most accurate way to assess the right placement of NGT is:

→ Assess the position using Chest X-Ray.

Question 16

An old patient with triple vessel disease presents with

sudden onset chest
pain of 4 hours,
shortness of breath,
dizziness and sweating.

His ECG shows
ST depression “ischemia” in several leads.

His blood pressure is 140/80. The
patient is anaemic with haemoglobin level of 62 g/L.

What is the most
appropriate management?

Answer 16

→ Dual antiplatelets (Aspirin + Clopidogrel)
+ SC Fondaparinux
+ Blood transfusion.

Notes:
√ Triple vessel disease means that 3 big vessels (the left anterior descending,
right coronary and circumflex arteries: LAD, RCA, Cx artery) have blockages
from atherosclerotic plaques.

√ This patient has ACS “acute coronary syndrome” secondary to anemia and
the pre-existing triple vessel disease.

√ Aspirin (oral) and fondaparinux (SC LMWH) are given whenever there is heart
ischemia.

Question 17

√ Blood Transfusion is indicated if

Answer 17

f:
♠ Hb < 80 g/L + Symptoms of Anemia. Or:

♠ HB < 70 g/L + With or Without Symptoms of Anemia.

Question 18

An immunocompromised elderly patient with previous history of PE and MI
taking medications for COPD for 10 years

. He presented complaining of
breathlessness and Coughing.

Pneumonia was diagnosed and he died after a
few hours. X-ray showed Multiple patchy opacities. What will be filled in the
1a part of the death certificate

?
Pneumonia
A. COPD
B. C. Lung Failure
D. Chest Infections.
Regarding death certificate

Answer 18

• In the 1a part of the death certificate, write the “Disease or condition
directly leading to death” clearly and specifically.

• In 1b part, we will write the condition that has led to 1a.
In this scenario,
immunosuppression is to be written in 1b.

Question 19

AVOID vague terms and modes of dying such as (Respiratory distress/
Cardiac arrest/ Cardiovascular event/ Chest infections)

Answer 19

1. ◙ Write → [Small cell carcinoma of the main right bronchus]

instead of just
“Lung cancer”.

2. Inferior Myocardial Infarction
   ◙ Write →

Instead of “coronary thrombus/ Cardiac arrest/ Cardiovascular event/ Acute
coronary syndrome…etc”

3. Pneumonia of the left lower lobe

◙ Write → Instead of “lung infection/ respiratory failure”

Question 20

known asthmatic child has been breathless for over 12hours.
He has
oxygen saturation of 86% on high flow oxygen. He has not taken his
nebulisers for a day.

His chest is silent. What is the most appropriate initial
management?

A. IV aminophylline
B. IV magnesium sulphate
C. Intubate and ventilate

Answer 20

Desaturating (Despite High Flow O2) + Silent Chest
→ Going into Resp. Failure
→ Intubate

Question 21

Metabolic acidosis
Respiratory acidosis and alkalosis

Answer 21

Regarding Acid-Base Imbalance (Important):

√ Excessive intake of
Paracetamol,
Aspirin,
Alcohol,
SSRI (e.g. Citalopram)
→ Metabolic Acidosis.

√ In Asthma and COPD
→ Respiratory Acidosis.

√ In Pulmonary Contusion (e.g. after a fall on the chest → Pulmonary
contusion/ edema → hypoxemia and accumulation of CO2)
→ Respiratory Acidosis.

√ Panic attacks AND Pulmonary embolism can cause
→ Respiratory Alkalosis.

However, PaO2 is Normal in Panic attacks and Low in Pulmonary
embolism.

Question 22

The steps (approach) to determine the type of the blood gas
abnormality.

Answer 22

1. Is the patient acidaemic (pH <7.35) or alkalaemic (pH >7.45)?
2. Respiratory component: What has happened to the PaCO2?

• PaCO2 > 6.0 kPa suggests a respiratory acidosis (or respiratory
compensation for a metabolic alkalosis)

• PaCO2 < 4.7 kPa suggests a respiratory alkalosis (or respiratory
compensation for a metabolic acidosis)

3. Metabolic component: What is the bicarbonate level/base excess?

• bicarbonate < 22 mmol/l (or a base excess < - 2mmol/l) suggests a
metabolic acidosis (or renal compensation for a respiratory alkalosis)

• bicarbonate > 26 mmol/l (or a base excess > + 2mmol/l) suggests a
metabolic alkalosis (or renal compensation for a respiratory acidosis)

Simply, know that CO2 is an Acid, and Bicarbonate (HCO3) is an Alkali.

Question 23

Glasgow Coma Scale (GCS)
Important, you may encounter a question that asks you to calculate the
patient’s GCS score

Answer 23

Total score: 15
√ Remember: below 8 → intubate.
13-15: mild
▐ 9-12: moderate
▐ 3-8: severe

Example:
Calculate the GCS for the following patient:
√ Unintelligible sounds.
√ Opens his eyes on verbal request.
√ Withdraw his hand on pain stimulation.

Answer:
√ Unintelligible sounds = 2
√ Opens his eyes on verbal request = 3
√ Withdraw his hand on pain stimulation = 4

Question 24

Acute Chest Syndrome (A complication of Sickle Cell Disease)

√ Acute chest syndrome in a patient with sickling disorder is defined by a new
pulmonary infiltration on chest x-ray +

at least one of the following:

chest pain,
cough, sputum,
fever, hypoxia, (
low oxygen level) and
lung infiltrates.

Answer 24

chest syndrome may be the result of sickling in the small blood vessels

in the
lungs causing a

pulmonary infarction/embolus or viral or bacterial pneumonia.

√ It may develop as a single event, or during a painful vaso-occlusive crisis.

The
clinical course is usually self-limited when small areas of the lung tissue are
involved,

but without proper care, acute chest syndrome can rapidly progress
and result in death.

√ Chest pain when breathing is the most common presenting complaint in
adults.

Fever, cough, tachypnea (abnormally rapid breathing), hypoxemia (

an
unusually low concentration of oxygen in the blood), or

abdominal pain are
common presentations for infants and children.

Question 25

Acute chest syndrome management

Answer 25

Rx → • Adequate analgesia (the patient may need to be given morphine sulphate • O2, • Empiric antibiotics, • Blood transfusion (not always; based on clinical picture and investigations), • (IV fluid may worsen the pulmonary edema and thus is used with cautio

Question 26

Asthma exacerbation that leads to low pH, high PaCO2 (i.e. Respiratory Acidosis) and fails to be managed needs to be admitted to \_____as the patient may require intubation

Answer 26

ICU

Question 27

Ioc for aortic dissection is ct angiography

Answer 27

• Hypertension • Severe chest pain radiating to the back • A big difference in the blood pressure between right and left arm → Suspect Aortic dissection ◙ The investigation of choice (important): √ If the patient is stable → CT Angiography. (= CT of the Aorta). √ If the patient is unstable → Trans-oesophageal echo (TOE) in theatre. ◙ Important risk factors → Marfan’s syndrome ▐ Ehlers-Danlos Syndrome. ◙ Chest X-ray → Wide mediastinum.

Question 30

Massive Blood Transfusion ◘ Massive transfusion is when a patient receives ≥ 10 units of blood (or ½ of the blood volume) within 24 hours.

Answer 30

◘ Important complications: “recent exam” √ Hypocalcemia (↓ Ca++). √ Hypomagnesemia (↓ Mg++). √ Hypo or Hyperkalemia (↑ or ↓ K+). Metabolic Alkalosis. (Citrate is metabolised to bicarbonate → ↑ pH). • Hypocalcemia and Hypomagnesemia can result due to citrate toxicity. • Each unit of blood contains around 3 g of citrate. • When citrate is high, the Ca++ and Mg++ bind to it and thus become reduced in serum.

Question 31

Do not mix things up: Refeeding syndrome- hypo P Massive transfusion- hypo Ca,hypo mg

Answer 31

√ Refeeding syndrome “starvation, low BMI, then sudden massive nutrition” → Hypophosphatemia, hypomagnesemia, hypokalemia (↓ Phosphate, Mg++, K+). √ Massive transfusion can cause → Hypocalcemia, hypomagnesemia, hypo or hyperkalemia (↓ Ca++, ↓ Mg++ , ↓or↑ K+).

Question 32

Q) A few hours after surgery, a patient develops fever (40 degrees), hypotension (85/50), tachycardia (130 bpm), and tachypnea (25 breaths per minute). What is the likely diagnosis?

Answer 32

• This is likely a case of post-op sepsis. This patient is going into septic shock. • IV fluids should be given immediately. If they fail to raise the blood pressure, then it is septic shock, not just sepsis! • Note that the high fever makes the diagnosis of sepsis/ septic shock more likely than hypovolemic or cardiogenic shock.

Question 33

Red flag criteria for sepsis management

Answer 33

• Responds only to voice or pain/ or unresponsive. • Acute confusional state. • Systolic B.P ≤ 90 mmHg (or drop >40 from normal). • Heart rate > 130 per minute. • Respiratory rate ≥ 25 per minute. • The patient requires oxygen to keep SpO2 ≥ 92%. • Non-blanching rash, mottled/ ashen/ cyanotic. • Not passed urine in last 18 h/ UO < 0.5 ml/kg/hr. • Lactate ≥ 2 mmol/l. • Recent chemotherapy.

Question 34

If any of the red flags are present → the ‘Sepsis Six’ should be started straight away:

Answer 34

Give 3 → O2, IV fluids, IV Antibiotics 1) High flow O2. 2) IV Fluids Resuscitation: NICE recommend a bolus of 500ml crystalloid over less than 15 minutes. 3) IV broad spectrum Antibiotics. Take 3: 1) Blood Cultures. 2) Full blood count, U&E, Clotting factors, Lactate. 3) Start monitoring UOP (Urine Output) hourly.

Question 35

The patient is to be ADMITTED with in-patient management. Notes: - Sepsis may lead to → acute kidney injury → ( oliguria, high serum urea and creatinine). - If the patient’s BP failed to respond to IV fluid (i.e. persistent HYPOTENSION despite appropriate IV fluid)

Answer 35

→ This is called → Septic Shock. Otherwise, it is sepsis.

Question 36

A 35 YO man had road traffic accident and was sent to the emergency department. He has multiple injuries to his abdomen, pelvis and thighs. X-ray reveals a fracture of his left shaft of femur. He was intubated and sent to the ICU. A few hours later, while on mechanical ventilation, he developed hypotension (85/45 mmHg) and desaturation (90%). On chest auscultation, he has decreased air entry on the left chest. The ventilator machine shows that a higher pressure is needed in order to achieve the required tidal volume. What is the likely diagnosis?

Answer 36

The likely diagnosis → Tension pneumothorax. • One of the most common causes of tension pneumothorax is mechanical ventilation in patients with pleural injury. One should suspect it if a patient on mechanical ventilation suddenly deteriorates and develops low O2 saturation and hypotension. “This patient has deteriorated suddenly after being put on mechanical ventilation”. Fat embolism is an important differential diagnosis here as well “long bone fracture, desaturation, hypotension • However, 2 important features mentioned in this stem makes the diagnosis of tension pneumothorax more likely, which are: √ Decreased air entry on one side of the chest. √ A higher pressure is required to achieve the target tidal volume.

Question 38

Always if O2 sat < 92, the INITIAL step is to

Answer 38

→ give high flow O2 (ABC).

Question 39

Vomiting, diarrhea → Dehydration The appropriate IV fluid is

Answer 39

→ normal saline (0.9% NaCl).

Question 40

Hypovolemic shock

Answer 40

Preload reduced Afterload increased Cardiac output increased RX iv fluids

Question 42

In a recent exam, a scenario was given that a patient has undergone an aortic valve replacement operation . After the surgery, his blood pressure has dropped and his pulmonary capillary wedge pressure (PCWP) has raised . The only type of shock where PCWP increases is

Answer 42

→ Cardiogenic Shock.

Question 43

Cardiogenic shock

Answer 43

Preload increased After load increased Cardiac output reduced Ionotropics Revascularisation

Question 44

Distributive shock Neurogenic Septic shock

Answer 44

Afterload reduced Preload reduced Cardiac output increased Pressure Iv fluids

Question 45

√ Hypertension (+) √ Sudden chest/ substernal pain “tearing” that radiates to the back (+) √ Big difference of blood pressure between right and left arm (>20 mmHg

Answer 45

Aortic dissection. IV labetalol. ◙ Suspect → ◙ Give → BB, e.g., → ◙ Investigations? Imp. √ • If the patient is hemodynamically stable → → CT angiography of the aorta. If unstable then ➡️. TOE (Transoesophageal echocardiography).

Question 46

young man was found unconscious on the floor with MDMA (Ecstacy) pilles in his pocket. Now in the ER, he is agitated, sweaty, and has HR of 110 and RR of 22. His limbs are rigid and his pupils are dilated. His temperature is 40.5. He is mechanically ventilated. What medication is useful in this case

Answer 46

? This is a case of MDMA (ecstacy) toxicity. Dantrolene can be used to manage drug-induced hyperthermia.

Question 47

Ecstacy (MDMA) Overdose:

Answer 47

• Agitation, confusion, anxiety, ataxia. • Tachycardia, hypertension • Tachypnea. • Thirst. • Metabolic acidosis (e.g., ↑ venous lactic acid). • Hyperthermia (↑ body temperature) • Spots of colours (flashing/ flouring colours). • Uncontrolled body movements, muscle rigidity, trismus. Dilated pupil

Question 49

Mng of ecstasy overdose

Answer 49

• Supportive: ABC + treat metabolic acidosis. • IV diazepam or lorazepam: for agitation. • Dantrolene may be used for hyperthermia if simple measures fail.

Question 50

Trauma to head + Any of the following signs: → Basilar skull fracture. Temporal bone The most commonly affected bone The answer can also be → (imp.)middle cranial fossa fracture As the middle cranial fossa represents the depressed part of the skull base

Answer 50

√ Hemotympanum = (Blood in the middle ear cavity and ecchymosis of the tympanic membrane). Panda or raccoon eyes (Periorbital ecchymosis). √ Cerebrospinal fluid (CSF) leakage from ear or nose (CSF otorrhea ± rhinorrhea) √ Battle’s sign (Mastoid ecchymosis = bruise behind ear)

Question 51

• Full thickness circumferential burns affecting a limb can cause compartment syndrome (severe pain + absent or reduced pulse + paraesthesia)

Answer 51

→ Urgent Escharotomy is needed to relieve the pressure.

Question 52

Crushing injury causing compartment syndrome (e.g., a heavy concrete fell on a limb for a long time that has led to loss of circulation and a resultant compartment syndrome)

Answer 52

→ Urgent Fasciotomy is needed to relieve the pressure and restore the circulation.

Question 53

So: √ Full thickness circumferential burns that led to compartment syndrome √ Crushing injury that has led to compartment syndrome

Answer 53

→ Urgent escharotomy. → Urgent fasciotomy.

Question 55

Severe hypertension during intracerebral hemorrhage can be managed with

Answer 55

→ Labetalol. (Recently asked). • Labetalol and Nicardipine are recommended for rapidly treating hypertension during cerebrovascular emergencies. • Cerebral blood flow is not compromised with labetalol, making it a desirable agent in the treatment of uncontrolled hypertension during cerebrovascular emergencies. • Bradycardia may occur and labetalol is generally not given if the heart rate is <60 beats per minute. Labetalol blocks α-, β1-, and β2-adrenergic receptors. Due to this combined blockade of both α- and β-receptors, cardiac output is maintained while the systemic BP is lowered).

Question 56

Management of COVID-19 Pneumonitis (In summary: For the Purpose of the Exam) For patients on mechanical ventilations → opt for lung protective ventilation and alveoli recruitment strategies, which are as follows: Start by → optimising PEEP (Positive end-expiratory pressure). If no response → Prone position (also called ventral decubitus).

Answer 56

If no hypoxia (mild covid-19) → Supportive symptomatic Rx. • If O2 is required → Simple O2 delivery methods ( eg, nasal cannula, non- rebreathing mask) + Dexamethasone; was proven to reduce mortality (trials). • If still hypoxemic → High flow oxygen through high flow nasal cannula. • If still, and ARDS (Adult respiratory distress syndrome) has developed → Mechanical ventilation might be needed.

Question 57

A patient is in the intensive care unit for the third day for COVID-19 pneumonitis. He is intubated and ventilated and his FiO2 was set to 0.1. His arterial blood gases show: pH 7.23 (7.35-7.45), low PaO2, high PaCO2, Normal bicarbonate. His chest X-ray is as follows: What is the most appropriate next step in management? → Prone positioning.

Answer 57

• The patient has adult respiratory distress syndrome (Bilateral diffuse infiltrates; bilateral white-out appearance) due to COVID-19. • He is on maximal PEEP. • He is still hypoxemic (low PO2 and high PCO2) → respiratory acidosis. • As he is on mechanical ventilation, lung protective ventilation and alveoli recruitment strategies → Prone positioning.

Question 58

Aortic Dissection (in short) √ Chest pain: typically, sudden severe, radiates to the back/ shoulders (eg, interscapular sudden severe pain) and ‘tearing’ in nature. √ Other Presenting Features: Tachycardia, Tachypnea, Hypotension. √ If unstable (eg, SBP < 90) → Trans-oesophageal echocardiogram (in theatre) √ Note: in aortic dissection, around 30% of patient would have normal ECG features. The rest may have features of ischemia.

Answer 58

Widening of the mediastinum. Imp √. √ X-ray may show → √ Aortic regurgitation. √ Sometimes: a big difference of blood pressure between right and left arms. √ Hx of hypertension or trauma (as risk factors). Note that hypertension is a risk factor, while hypotension is a presenting sign. Investigations: √ If hemodynamically stable → CT angiography (definitive). Imp √.

Question 60

Points on the Management of COPD Exacerbation “imp”

Answer 60

• 24% - 28% Oxygen (not 100%) using “venturi face mask”. • Maintain O2 saturation between 88-92%. • Nebulised salbutamol (with ipratropium bromide). • Corticosteroids: 100 mg IV hydrocortisone or 30 mg prednisolone stat. (prednisolone should be continued as 30 mg OD for 7-14 days). • Still no response? → IV aminophylline. • If purulent sputum, fever, high CRP → give Antibiotics.

Question 61

Copd management • One important indication for intubation to remember: GCS ≤ 8.

Answer 61

→ Non-Invasive Ventilation • After giving all these medical options, if he is still dyspnoeic, with impaired blood gas showing respiratory acidosis (low Ph, high PaCO2): (NIV). NICE recommends non-invasive ventilation (NIV) in patients with COPD exacerbation especially if Ph is 7.25-7.35 (respiratory acidosis). Intubate and ventilate • If NIV failed or if there is impaired mental status (confusion), respiratory arrest, high aspiration risk → (invasive ventilation). • One alternative valid answer is → Shift patient to ICU (intensive care unit).

Answer 63

Normal PCWP is (6-12 mmHg). If elevated (>18), think → Cardiogenic Shock.

Question 64

Cerebral Oedema as a Complication of DKA • Cerebral oedema is a rare but serious complication of diabetic ketoacidosis (DKA). • Its symptoms can include: √ Headache. √ Altered mental status. √ Fundoscopy → Papilloedema.

Answer 64

• Rx → Give Mannitol (Other possible → Dexamethasone).

Question 65

A 60-year-old woman is brought to the Emergency Department after slipping and hitting her head on a concrete floor. At the scene, she was conscious but complained of severe headache and nausea. On arrival, she is alert but disoriented . Her initial assessment reveals a Glasgow Coma Scale (GCS) score of 14. Her vital signs are as follows: heart rate of 95 beats per minute, blood pressure of 120/75 mmHg, respiratory rate of 20 breaths per minute, and oxygen saturation of 94% on room air. Over the next hour, her condition worsens; she becomes increasingly lethargic, her GCS score drops to 9, and her oxygen saturation decreases to 92% despite receiving supplemental oxygen via a nasal cannula. No other significant injuries are noted, and there is no evidence of external bleeding. What is the most appropriate immediate management for this patient? A. Administer high-flow oxygen through a non-rebreather mask and reassess oxygen saturation within 10 minute B. Perform an immediate CT scan of the head C. Initiate immediate intubation to secure the airway D. Administer intravenous fluids and reassess GCS after fluid resuscitation E. Perform an immediate bedside glucose test to exclude hypoglycaemia

Answer 65

In trauma patients with a rapidly declining GCS, the priority is to secure the airway to prevent hypoxia and ensure adequate ventilation. The most appropriate and immediate management step in this scenario is to initiate intubation.

Question 66

Detailed Explanation: 1. Patient Presentation: - The patient is a 60-year-old woman who has sustained a significant head injury after a fall. - Initially, she is conscious but disoriented with a GCS score of 14, indicating a mild level of brain injury but no immediate concerns about severe brain injury. - Her vital signs are relatively stable, with a heart rate of 95 beats per minute, a blood pressure of 120/75 mmHg, a respiratory rate of 20 breaths per minute, and an oxygen saturation of 94%. 2. Clinical Deterioration: - Within an hour, the patient’s condition deteriorates significantly: - Her GCS score drops from 14 to 9, indicating a severe decline in her level of consciousness. - Her oxygen saturation falls to 92% despite supplemental oxygen via nasal cannula, showing inadequate oxygenation. 3. Assessment of Options: A. Administer high-flow oxygen through a non-rebreather mask and reassess oxygen saturation within 10 minutes: (Invalid) - While this might temporarily improve oxygenation, it does not address the severe decline in the patient's level of consciousness and the potential airway compromise. B. Perform an immediate CT scan of the head: (Invalid)

Answer 66

- A CT scan is important to assess the extent of the head injury, but the immediate priority is to manage the patient’s airway due to the drop in GCS and oxygen saturation. C. Initiate immediate intubation to secure the airway: (Valid) - With a GCS score of 9, the patient is at significant risk of losing her airway protection. Intubation is necessary to ensure a secure airway, adequate ventilation, and oxygenation. D. Administer intravenous fluids and reassess GCS after fluid resuscitation: (Invalid) - There is no indication of hypovolemia or shock in this scenario, and fluid resuscitation will not address the primary issue of airway compromise. E. Perform an immediate bedside glucose test to exclude hypoglycaemia: (Invalid) - Although hypoglycemia can cause altered mental status, there is no indication in this scenario that it is the primary issue. The critical concern here is airway management.

Question 67

Distributive shock

Answer 67

Vasodilatory Septic Anaphylaxis Neurogenic Drug/toxin Addisonian crisis

Question 68

Cardiogenic shock

Answer 68

Pericarditis/ PE Cardiomyopathy Valve failure AML Arrhythmia

Question 69

Obstructive shock

Answer 69

Tension pneumothorax Cardiac tamponade PE

Question 70

Hypovolemic shock

Answer 70

Hemorhagic Fluid loss Intravascular volume loss