Definitions

Question 1

ARDS

Answer 1

Berlin 2012 definition: “ARDS is an acute diffuse, inflammatory lung injury, leading to increased pulmonary vascular permeability, increased lung weight, and loss of aerated lung tissue…[with] hypoxemia and bilateral radiographic opacities, associated with increased venous admixture, increased physiological dead space and decreased lung compliance.” Key components - acute, meaning onset over 1 week or less - bilateral opacities consistent with pulmonary edema must be present and may be detected on CT or chest radiograph - PF ratio <300mmHg with a minimum of 5 cmH20 PEEP (or CPAP) - “must not be fully explained by cardiac failure or fluid overload,” in the physician’s best estimation using available information — an “objective assessment“ (e.g. echocardiogram) should be performed in most cases if there is no clear cause such as trauma or sepsis. The only evidence exists in cis-atracurium therapy and proning the patient. There is no survival benefit to prostacyclin, nitric oxide, or surfactant therapy and steroid therapy remains controversial.

Question 2

Volume of Distribution

Answer 2

VOD = dose/plasma concentration of free drug at time zero For opiates: Diamorphine: 5l/kg Fentanyl: 4l/kg Morphine: 3.5l/kg Alfentanil: 0.6l/kg Remifentanil: 0.3l/kg

Question 3

Cholinergic Toxidrome

Answer 3

Features: confusion, decreased conscious state, salivation, bronchorrhoea, bronchospasm, Bradycardia, emesis, incontinence, abdominal cramps, sweating, hypotension Causative agents: Organophosphates, some fungi Management Principles: Anti-cholinergic-atropine Anti-cholinesterase re-activator - Pralidoxime, benzodiazepines

Question 4

Anti-Cholinergic Toxidrome

Answer 4

Features: Tachycardia, hypertension, confusion, coma, dry skin, fever, flushing, ileus, urinary retention Causative agents: Antihistamines Antidepressants Antiparkinsonian drugs Antipsychotic agents Atropine Treatment: Supportive

Question 5

Serotonin Syndrome

Answer 5

Features: Altered mental status, autonomic dysfunction, neuromuscular hyperactivity Causative agents: Antidepressants Amphetamines Ecstasy Management principles: Benzodiazepines Seratonin antagonist – Cyproheptadine

Question 6

Sympathomimetic Toxidrome

Answer 6

Features: Delusions, paranoia, tachycardia, hypertension, hyperreflexia, diuresis, piloerection Causative agents Amphetamines, cocaine, sympathetic agents Management principles: Benzodiazepines

Question 7

Severe CAP (SCAP)

Answer 7

Infectious Disease Society of America/American Thoracic Society (ATS/IDSA) consensus guidelines on the management of CAP in adults Any major criteria or >3 minor criteria Major criteria - Invasive mechanical ventilation - Septic shock with the need for vasopressors Minor criteria - Respiratory rate ≥30 breaths/min - PaO2/FiO2 ratio ≤250 - Multilobar infiltrates - Confusion/disorientation - Uremia (blood urea nitrogen level ≥20 mg/dL) - Leukopenia (white blood cell count <4 ×109/L) - Thrombocytopenia (platelet count <100 ×109/L ) - Hypothermia (core temperature <36°C) - Hypotension requiring aggressive fluid resuscitation