Critical Care Boards Cardiovascular Questions

Question 1

What are the two potential causes of this are poor functioning of the oxygenator?

Answer 1

clot formation on the oxygenator surface
inadequate oxygen supply to the oxygenator

Question 2

What is the relatively normal difference between the P1 and P2 pressures in the ECMO circuit and at what pressure gradient has been cited as the threshold for a prompt oxygenator change?

Answer 2

Normal pressure difference is 20mmHg
A pressure gradient of 70mmHg has been cited as threshold to prompt an oxygenator exchange

Question 3

What is recirculation in the ECMO circuit?

Answer 3

Recirculation is when a large proportion of the oxygenated blood from the return cannula being drawn again into the ECMO circuit (via the drainage cannula) without being circulated throughout the body. This can occur when the return cannulas are too close together in femorojular vv configurations. When recirculation occurs the blood in the P1 limb of the ECMO circuit has high PO2 levels which are only slightly below those in the p2 limb of the Ecmo circuit.

Question 4

What are the indications for surgery in tricuspid endocarditis?

Answer 4

Most experts agree that patients with failure of medical therapy (persistent bacteremia or enlarging vegetation), large vegetations (>1 cm), fungal endocarditis, and heart failure due to tricuspid regurgitation should be considered for valve surgery

Question 5

What are the primary criteria for Pulse Pressure Variation (PPV) accuracy?

Answer 5

Primary criteria for PPV accuracy: sinus rhythm, ventilation with sufficiently large tidal volumes (at least 8 mL/kg of ideal body weight), passive breathing (patient is pharmacologically paralyzed), and high-quality arterial waveform.

Question 6

How do you calculate the PPV?

Answer 6

PPV is calculated as follows: (maximum PP − minimum PP)/average of maximum and minimum PP, with values >10% to 15% correlating well with significant increase in cardiac output with fluid administration.

Question 7

Answer 7

Dampened arterial pressure waveform with characteristic delayed recovery from fast flush test (top, A) and arterial pressure waveform with crisp waveform and several beats of oscillation after fast flush test (bottom, B).

Question 8

What are the three main mechanisms that arrhythmias are initiated and maintained with:

Answer 8

automaticity, afterdepolarizations, and reentry

Question 9

What is the definition of automaticity?

Answer 9

Automaticity, such as that seen with sinus tachycardia, atrial premature complexes, and some atrial tachycardias, is due to an increase in the slope of phase 4 (slow spontaneous depolarization) of the action potential of pacemaker cells, in this case those in the sinus node. The depolarization threshold is reached more quickly and repeatedly

Question 10

What are afterdepolarizaations?

Answer 10

Afterdepolarizations are associated with an increase in cellular calcium accumulation, leading to repeated myocardial depolarization during phase 3 (early) and phase 4 (delayed) of the action potential.

Early afterdepolarizations may be related to the initiation of torsades de pointes.

Delayed afterdepolarizations are responsible for arrhythmias related to digoxin toxicity and for catecholamine-induced ventricular tachycardia

Question 11

What are re-entry arrhythmias?

Answer 11

reentry is due to inhomogeneities in myocardial conduction and refractory periods. With reentry, conduction is blocked in one pathway, allowing slow conduction in the other. When the timing is just right, this allows for sufficient delay so that the blocked site has time for reentry and propagation of the tachycardia within the two pathways. Reentry appears to be the mechanism for most supraventricular and ventricular tachycardia

Question 12

Which of the following hemodynamic findings is most useful to distinguish constrictive pericarditis from restrictive cardiomyopathy?

Answer 12

Ratio of RV end-diastolic to RV end-systolic pressure

Question 13

What should you be concerned of is a patient develops fever, altered mental status, rapid atrial fibrillation and heart failure after coronary angiography?

Answer 13

Thyroid storm

Question 14

What therapy for thyroid storm includes inhibition of new thyroid hormone synthesis?

Answer 14

Propylthiouracil (PTU) and glucocorticoids decreases conversion of T4 to T3 which may modulate autoimmunity and correct relative adrenal insufficiency.

Exogenous iodine is often given after a drug to inhibit hormone synthesis is on board because this inhibits release of preformed hormone from the thyroid gland

Definitive therapy is radioactive iodine or thyroidectomy

Question 15

What is label A?

Answer 15

Letter A is an enlarged coronary sinus which should always raise suspicion for a left-sided superior vena cava (SVC), seen in roughly 0.5% of the population.

The CS also enlarges due to elevated right atrial pressures, partial anomalous pulmonary venous return to the CS, and coronary arteriovenous fistula or when it abnormally receives a hepatic vein. An enlarged CS is usually asymptomatic and discovered incidentally during echocardiographic imaging, device implantation, or surgery.

Question 16

The diagnosis of sepsis (S2 criteria) requires the presence of infection and at least two of the four SIRS criteria.

Answer 16

Question 17

In the S2 criteria what separates severe sepsis from septic shock?

Answer 17

manifestations of organ dysfunction is severe sepsis
definition of shock is pressors

Question 18

What are the criteria of the Q Sofa score?

Answer 18

. There are three components, each of which is readily identified at the bedside: (1) respiratory rate ≥22/min, (2) altered mentation, and (3) SBP ≤100 mm Hg
if you have 2 of 3 then the score is positive.

Question 19

Hypotension in a patient with an acute inferior wall myocardial infarction (MI) should raise the suspicion for what?

Answer 19

concomitant right ventricular (RV) infarction

Question 20

What feature is most indicative of the difference between constrictive and restrictive pericarditis?

Answer 20

Respiratory changes in RV and LV pressures
A characteristic feature of constrictive pericarditis is ventricular interaction with respiration (increased volume of one ventricle at the expense of the other) for the reasons described. Because of this interaction, there is disjunction between RV and LV pressures with respiration, such that one goes up as the other goes down

Question 21

What are the main ways long QT syndrome is divided into?

Answer 21

Question 22

What is the constellation of symptoms that suggest thyroid storm after coronary angiography and what is the name of the syndrom and what causes it ?

Answer 22

Fever, altered mental status, rapid atrial fibrillation, and heart failure after coronary angiography

Thyroid storm in a patient with subclinical hyperthyroidism can be precipitated by administration of iodinated contrast material (Jod-Basedow syndrome)

Question 23

What are the clinical features of restrictive cardiomypathy?

Answer 23

Clinical features that raise the suspicion for the diagnosis include manifestations of restrictive cardiomyopathy with signs of right heart failure, such as jugular venous distension, hepatomegaly, and lower extremity edema, and signs and symptoms of left heart failure. eg. Amylodosis.

Question 24

What is noninvasive test to diagnose amylodosis?

Answer 24

Bone scintigraphy

Question 25

A very loud holosystolic murmur in a patient with a ventricular septal defect most likely reflects what?

Answer 25

Normal RV pressures

Question 26

What is on the ddx for hypotension and low cardiac output after cardiac surgery?

Answer 26

left ventricular dysfunction, which can result from perioperative myocardial infarction or myocardial stunning after cardioplegia; reduced preload, which can be due to blood loss or decreased venous tone; and mechanical complications

Question 27

The presence of enlarged coronary sinus should raise suspicion for what?

D

Answer 27

Left sided SVC

Question 28

What test is used to differentiate between pseduo vs true aortic stenosis?

Answer 28

Dobutamine stress echo

Question 29

What medication’s slow conduction through the accessory pathway and convert the atrial fibrillation or flutter back to sinus rhythm.

Answer 29

Ibutilide is a Class III antiarrhythmic drug that prolongs refractoriness of both the AV node and accessory pathway and acutely terminates atrial fibrillation or flutter. Procainamide is a Class Ia antiarrhythmic that increases refractoriness of atrial and ventricular myocardium without any AV nodal-blocking effect.

Question 30

Prospective randomized controlled trials have established which of the following outcomes from the use of epinephrine administered during resuscitation of patients with out-of-hospital cardiac arrest?

Answer 30

Higher incidence of return of spontaneous circulation

Question 31

What does this image show and how would you position this patient?

Answer 31

Left lateral decubitus, Trendelenburg positioning

The CT pulmonary angiogram demonstrates a large volume of air in the right atrium, ventricle, and pulmonary outflow tract, with leftward bowing of the interventricular septum, suggestive of acute right heart strain

Question 32

How do your treat Vtach in post cardiac surgery patient?

Answer 32

Shock ×3, check for rhythm and pulse, CPR, call cardiac surgeon for sternotomy, 300-mg IV amiodarone, prepare chest for resternotomy, repeat shock every 2 min, and perform resternotomy within 5 min by any trained personne

Question 33

Initial treatment for patients with Duchenne muscular dystrophy and cardiomyopathy?

Answer 33

Glucocorticoids should be given to treat the patient’s cardiomyopathy and muscle disease.
42.34%

Question 34

Answer 34

Pericardial tamponade

The respiratory variation of mitral and tricuspid flow velocities is greatly increased in cardiac tamponade, (defined by published criteria as >30% variation in mitral and >60% variation in tricuspid velocity), reflecting ventricular interdependence.

Question 35

What are measurement is een on the M-mode image?

Answer 35

The measurement shown on the M-mode image is the distance between the point of maximal opening of the anterior leaflet of the mitral valve (the E point) and the interventricular septum, the so-called E-point septal separation (EPSS). This value is normally <6 mm. EPSS is abnormally large when the left ventricle (LV) is enlarged and valve opening is limited by low flow

Question 37

According to both American Epilepsy Society and Neurocritical Care Society guidelines for treatment of status epilepticus, what is the recommended agent for benzodiazepine-refractory seizure?

Answer 37

levetiracetam

Question 39

What effect does CPAP have on cardiac?

Answer 39

Positive airway pressure from CPAP raises the mean intrathoracic pressure, and this can have multiple effects on cardiac function. One is to reduce left ventricular afterload, especially in patients such as this one who have underlying left ventricular dysfunction. This occurs because the increased intrathoracic pressure surrounds the heart (epicardial pressure decreases transmural pressure) and is not present outside the thorax. Removal of the intrathoracic pressure will eliminate this effect, and the resulting increase in left ventricular afterload, in conjunction with other mechanisms described below, can precipitate left ventricular failure

Question 40

Name the glass type and teg shape and product to be given

Question 41

How do you treat refeeding syndrome?

Answer 41

Decrease the enteral feeding rate to 20 mL/h until serum phosphorous levels do not require repletion for 3 consecutive days.

Question 42

What is the definition and treatment of Intra-abdmoinal Hypertension?

Answer 42

Question 43

What are abg targets for a patient with acute brain injury?

Answer 43

PaO2 >110 mm Hg; PaCO2 >35 mm Hg to <45 mm Hg

Question 44

In patients with TBI who do you lower the CPP?

Answer 44

CPP<70 and MAP <90

Question 45

What is the relevance of diaphramatic changes in the ICU?

Answer 45

Patients with either thickening or thinning of the diaphragm over the first week of ventilatory support have longer weaning periods and ICU length of stay as compared with patients with no change in diaphragm thickness.

Question 46

What is first line treatment for afib in patients with group 1 PH?

Answer 46

In patients with group 1 PH, rhythm control is the first-line therapy for managing atrial arrhythmias. Atrial flutter occurs through a reentrant circuit, usually in the right atrium, which is relatively easy to map and ablate safely in the electrophysiology laboratory

Question 47

How do you treat for vaccine-induced immune thrombotic thrombocytopenia (VITT),?

Answer 47

Testing for antiplatelet factor 4 antibodies

Question 48

What do you do with a nonvaccinated employee exposed to varicella?

Answer 48

Temporarily reassign to a location remote from patient-care areas from the 8th day after the first exposure through the 21st day after the last exposure.

Question 49

How do you treat a sulfonylurea overdose?

Answer 49

octreotide 50 μg subcutaneousl

Question 50

What do you do with refractory Alcoholic Hepatitis?

Answer 50

stop the mehtylpred

Question 51

What is the demonstrated effect of beta lactams on bacteria?

Answer 51

Beta-lactam antibiotics demonstrate a time-dependent effect on killing bacteria and subsequent microbiologic eradication. Prolonged infusions attain the pharmacodynamic efficacy target for beta-lactam antibiotics more effectively than do short infusions; thus, a prolonged infusion administration strategy can improve microbiologic and clinical cure

Question 52

An ionized calcium level <4 mg/dL (<1.0 mmol/L) has been associated with what?

Answer 52

a 50% increase in mortality from trauma

Question 53

What are risk factors of developing hyperk from Depolarizing neuromuscular blockers, like succinylcholine?

Answer 53

existing hyperkalemia, renal failure, burns covering significant total body surface area, spinal cord injury, chronic limb paralysis, prolonged bed rest, and rhabdomyolysis.

Question 54

Effective CPR is indicated by ETCO2 measurements at what level?

Answer 54

between 10 and 20 mm Hg. W

Question 55

Which of the following is the most likely critical laboratory test abnormality during rewarming?

Answer 55

Hypothermia is known to increase insulin resistance and decrease endogenous insulin secretion, leading to hyperglycemia during the cooling phase of targeted temperature management (TTM). Patients often require high doses of insulin to maintain serum glucose levels between 100 and 140 mg/dL (5.55-7.77 mmol/L). As patients go through the rewarming phase of TTM, insulin resistance resolves. To avoid clinically significant hypoglycemia, the physician often decreases insulin infusions at time of rewarming, and blood glucose levels must be followed closely

Question 56

What is the equation of Pulmonary Vascular Resistance?

Answer 56

PVR = (mPAP - PAWP) / CO

Question 56

Answer 56

Question 57

When doing a passive leg raise your look a cardiac output and what else?

Answer 57

When the end-tidal CO2 value rises >5% (2 mm Hg when the end-tidal CO2 is 40 mm Hg), a fluid bolus will augment cardiac output by >15% (specificity 100

Question 58

Which fungal orgainsim is resistant to esistant to fluconazole, echinocandins, and amphotericin B?

Answer 58

Candida Auris

Question 59

What is the most reliable O2 measurement in hyperleukocytosis?

Answer 59

SpO2 may be more reliable than PaO2 measured with arterial blood gas.