Critical Care

Question 0

Diagnosis of ARDS?

Answer 0

• bilateral pulmonary infiltrates on CXR

- PaO2/FiO2 ratio <18 Hg (low filling pressure excludes pulmonary edema)

Question 1

Predictors to assess readiness for extubation?

Answer 1

• Rapid shallow breathing index, ratio of RR to tidal volume: 60-105 predicts successful extubation.
• Negative inspiratory force greater than -20 cm H2O
• Weaned to 5 cm H2O PEEP before extubation.
• Minute ventilation < 10 L/min
• Spontaneous RR <20 breathes/min

Question 2

Physiological changes in ARDS?

Answer 2

• hypoxemia unresponsive to increased FiO2
• Decreased pulmonary compliance
• Decreased FRC

leakage of protein rich fluid into interstitium and alveolar spaces

Question 3

TRALI

Answer 3

Tranfusion related acute lung injury
-Tx respiratory support, mechanical ventilation if needed
Risk factor is transfusion of plasma-containing blood products from multiparous women.

Question 4

Agent of choice for cardiogenic shock?

Answer 4

Dobutamine - synthetic catecholamine, beta 1 adrenergic agonist.

Question 5

Thoracic epidural narcotic is given for postoperative pain relief in thoracic and upper abdominal surgery. When side effects of respiratory depression or generalized itching occur. What is next step?

Answer 5

Give IV opiate antagonist such as naloxone.

Question 6

What is the cardiac index?

Answer 6

CI = CO/BSA (body surface area)
CI = SVxHR/BSA

Question 7

Next step after diagnosis of acalculous cholecystitis is made?

Answer 7

Percutaneous drainage of the gallbladder (percutaneous cholecystostomy tube)

Question 8

PE suggesting cardiac tamponade?

Answer 8

Beck triad:
-systemic hypotension
-JVD
-Distant heart sounds
Pulsus paradoxus - decrease in systolic BP by more than 10 mm Hg at the end of inspiratory phase of respiration

Question 9

What finding on echocardiogram would suggest cardiac tamponade?

Answer 9

Pericardial fluid

Right atrial collapse

Question 10

What finding on swan-ganz monitoring would suggest cardiac tamponade?

Answer 10

equalization of pressures across the four chambers
Right atrial pressures and CVP increase
CO decrease

Question 11

Safe total dose of lidocaine?

Answer 11

4.5 mg/kg or about 30-35 mL of 1% solution.

If epinephrine is added, safe dose is 7mg/kg by decreasing rate of absorption into bloodstream.
Don’t inject epinephrine into tissues supplied by end arteries - fingers, toes, ears, nose, penis.

Question 12

Patient with history of prolonged paralysis during general anesthesia.

Answer 12

Pseudocholinesterase deficiency - prolongs effects of succinylcholine, a depolarizing neuromuscular blocking agent, and mivacurium, a non-depolarizing agent.

Question 13

Most accurate measure of nutritional status?

Answer 13

Serum albumin - half life of 3 weeks
Pre-albumin half life of 2 days
Ferritin - half life of hours only

Question 14

Rare but deadly complication of a tracheostomy?Treatment?

Answer 14

tracheoinnominate artery fistula (TIAF)
-occur 2 days to 2 months after tracheostomy

Tx: Transport immediately to the OR for bronchoscopic evaluation

Immediate steps: over-inflate cuff or reintubation from above and removal of tracheostomy and finger compression of the innominate artery against the sternum through the tracheostomy wound.

Question 15

Patient with von Willebrand disease. What do you give pre-operatively?

Answer 15

Cryoprecipitate - provides factor VIII R: WF (the von Willebrand factor)

Question 16

Patient with hemophilia. What do you give pre-operatively?

Answer 16

High-purity factor VIII:C concentrates.

C - procoagulant activity

Question 17

In what situations can ECMO be used?

Answer 17

Potentially reversible pulmonary or cardiac disease
Meconium aspiration syndrome, sepsis, pneumonia, congenital diaphragmatic hernia

Bridge to cardiac or lung transplantation

Question 18

How do you diagnose ventilator associated pneumonia?

Answer 18

Samples obtained using bronchoscopy with bronchoalveolar lavage show greater than or equal to 10,000 colony forming units per milliliter of single organism

Question 19

How do you differentiate between hypovolemic shock and cardiac shock?

Answer 19

Central venous pressure will be decreased in hypovolemic shock
Central venous pressure will be increased in cardiogenic shock

Question 20

Known complication of angiography or aortic manipulation during surgery

Answer 20

Cholesterol atheroembolism can result in lower extremity ischemia, acute myocardial infarction, ischemic bowel, acute or chronic renal failure

Question 21

Lab findings that suggest atheroembolization?

Answer 21

eosinophilia, Microscopic hematuria for proteinuria and elevated inflammatory mediators

Question 22

Side effect of rapid injection of morphine?

Answer 22

Hypotension

Question 23

What does bleeding time test?

Answer 23

assesses the interaction of platelets in the formation of the platelet plug. Will pick up the efficiencies of both qualitative and quantitative platelet function

Question 24

What does the partial thromboplastin time test?

Answer 24

Defects in the contact and intrinsic phases of coagulation and used to monitor the status of patients on heparin

Question 25

What does the prothrombin time measure?

Answer 25

The speed of coagulation in the extrinsic pathway. Used to monitor patients receiving Coumadin derivatives. Will detect deficiencies in factors two, five, seven, 10 and fibrinogen