Management

Question 1

SAH (diagnosed)

Answer 1

• Blood Pressure Management: Maintain systolic BP below a target (e.g., <160 mmHg) to reduce rebleeding risk. Use IV antihypertensives like nicardipine, labetalol.
• Pain Control: Analgesics for headache, avoiding medications that might mask neurological changes.
• Neurological Monitoring: Frequent neurological exams. Intracranial pressure monitoring if indicated.
• Imaging and Diagnosis: CT scan for initial diagnosis. Cerebral angiography to identify aneurysms.
• Aneurysm Management: Surgical clipping or endovascular coiling based on aneurysm characteristics.
• Vasospasm Surveillance and Treatment: Nimodipine to prevent vasospasm. Daily transcranial Dopplers, with aggressive management of detected vasospasms.
• Fluid and Electrolyte Management: Maintaine euvolemia. Monitor and manage electrolyte imbalances, especially sodium.
• Temperature Management: Keeping core body temperature below 37.2°C, using acetaminophen and cooling devices if required.
• Prevention of Secondary Complications: DVT prophylaxis (intermittent pneumatic pressure). Stress ulcer prophylaxis. Regular bowel and bladder care.
• Multidisciplinary Care: Involvement of neurosurgery, neurology, rehabilitation, and others.
• Family and Patient Support: Informing and supporting patient and family about condition, prognosis, and care plan.

Question 2

Vasospasm (initial)

Answer 2

• Nimodipine: Start an oral calcium channel blocker to reduce the risk of ischemic complications.
• Blood Pressure Control: Maintain systolic blood pressure (SBP) between 140-160 mmHg for optimal cerebral perfusion without increasing the risk of rebleeding.
• Fluid and Electrolyte Balance: Administer intravenous fluids to maintain euvolemia and ensure a stable fluid balance.
• Monitor and correct electrolyte imbalances, particularly sodium and magnesium.
• Oxygenation and Ventilation: Avoid hypoxia by providing supplemental oxygen if necessary.
• Temperature and Glucose Control: Maintain normothermia using antipyretics or cooling blankets if fever develops. Regular monitoring and control of blood glucose levels.
• Intracranial Pressure (ICP) Management: Elevate the head of the bed to 30 degrees to facilitate venous drainage. Aim to keep ICP below 20 mmHg.
• Pain and Stress Management: Provide analgesia for headache and discomfort. Consider sedation to minimize agitation and stress.
• Prevention of Secondary Complications: Avoid straining, constipation, and vigorous coughing to prevent spikes in ICP.
• Nutritional Support: Initiate early enteral nutrition to support recovery and rehabilitation.

Question 3

Intestinal obstruction (medical)

Answer 3

• NPO.
• Nasogastric tube
• IV fluid resuscitation and electrolyte management.
• Pain control
• Antiemetic medication for nausea and vomiting.
• Broad-spectrum antibiotics if signs of infection or sepsis are present.

Question 4

Intestinal obstruction (surgical)

Answer 4

• Exploratory laparotomy.
• Identify and relieve the site of obstruction.
• Address any identifiable cause of obstruction (e.g., adhesiolysis, hernia, tumor).
• Resect any non-viable bowel.
• Perform bowel anastomosis if resection is necessary.
• Ostomy if needed
• Ensure adequate hemostasis.
• Consider placing a drain if indicated.
• Close the abdomen in layers.
• Postoperative orders for ICU care and monitoring.
• Plan for postoperative imaging if needed for reassessment.

Question 5

Abdominal Compartment Syndrome (conservative)

Answer 5

• Sedation and Analgesia
• Neuromuscular Blockade: Consider if sedation alone is inadequate to control IAP.
• Avoidance of Constrictive Dressings
• Prokinetics, enemas
• Decompression: Nasogastric or orogastric tube, rectal tube, paracentesis.
• Optimize fluid balance
• Optimize enteral feeding
• Body Positioning: Elevate head of bed to 30 degrees.
• Diuretics and Renal Replacement Therapy
• Optimal Ventilatory Setting with alveolar recruitment.
• Maintain APP > 60 mmhg (use vasopressors)

Question 6

Abdominal Compartment Syndrome (surgical)

Answer 6

• Decompressive Laparotomy
• Temporary Abdominal Closure: Use of negative pressure wound therapy.

Question 7

BB CCB overdose (suspected)

Answer 7

Link

Initial Assessment and Stabilization:
- Check vital signs.
- ABCDEF approach; secure the airway.
- Administer oxygen, consider non-invasive ventilation (BiPAP).
- Insert two large peripheral IV cannulas.
- Insert Foley’s catheter.
- Start cardiac monitoring, obtain ECG.

Investigations:
- CBC, electrolytes, renal function tests (RFT), random blood sugar (RBS), TSH, liver function tests (LFT), cardiac enzymes, BNP, coagulation profile.
- Arterial blood gas (ABG).
- Chest X-ray (CXR).
- Toxicology screen.

Medication and Hemodynamic Support:
- Administer atropine 0.3-0.5 mg IV every 5 minutes up to 3 mg for bradycardia.
- Start dopamine (2-10 μg/kg/min) or epinephrine (2-10 μg/min) for hypotension.
- Consult cardiology for transcutaneous pacing if needed.
- Initiate IV diuresis after stabilizing hemodynamics.

Toxicology Management:
- Administer activated charcoal within the first 4 hours of ingestion.
- Calcium gluconate 3-6 gm IV, or calcium chloride 1-3 gm IV.
- Glucagon 50-150 μg/kg stat, followed by an infusion of 50-100 μg/kg/hr.

Continuous Monitoring and Reassessment:
- Monitor vital signs, ECG, and response to treatments continuously.
- Adjust management based on clinical status and investigation results.
- Ensure multidisciplinary approach involving cardiology, toxicology, and critical care.

Further management:
- ICU admission for monitoring of the VS
- Frequent monitoring of serum K and RBS
- Psychiatry consultation

Question 8

Thyroid storm

Answer 8

• Propranolol or other beta-blockers
• Propylthiouracil (PTU) or methimazole
• Iodine 1 hour after antithyroid medications
• Hydrocortisone
• Management of precipitating factors: treat infections, control other exacerbating conditions

Question 9

Pulmonary hypertension

Answer 9

• HFNC > NIV
• Avoid mechanical ventilation, high PEEP
• Be cautious with fluid

Vasopressors:

• Norepinephrine > vasopressin
• Avoid phenylephrine

Inotropes:

• Milrinone > dobutamine
• Epinephrine?

Question 10

Variceal bleeding

Answer 10

• Octreotide
• PPI
• Ceftriaxone
• Massive transfusion protocol
• Endoscopy

Question 11

Acute pancreatitis and concurrent acute cholangitis

Answer 11

endoscopic retrograde cholangiopancreatography (ERCP) within 24 h of admission.

Question 12

Feeding in acute pancreatitis

Answer 12

In mild AP, oral feedings can be started immediately if there is no nausea and vomiting. In severe AP, enteral nutrition is recommended to prevent infectious complications, whereas parenteral nutrition should be avoided.

Question 13

Acute pancreatitis (surgery)

Answer 13

• In patients with mild AP, found to have gallstones in the gallbladder, a cholecystectomy should be performed before discharge to prevent a recurrence of AP
• In a patient with necrotizing biliary AP, in order to prevent infection, cholecystectomy is to be deferred until active inflammation subsides and fluid collections resolve or stabilize
• The presence of asymptomatic pseudocysts and pancreatic and/or extrapancreatic necrosis do not warrant intervention, regardless of size, location, and/or extension
• In stable patients with infected necrosis, surgical, radiologic, and/or endoscopic drainage should be delayed preferably for more than 4 weeks to allow liquefication of the contents and the development of a fibrous wall around the necrosis
• In symptomatic patients with infected necrosis, minimally invasive methods of necrosectomy are preferred to open necrosectomy

Question 14

Trauma

Answer 14

• Airway (A): Assess for airway compromise due to low GCS (8), indicating potential head injury. Prepare for possible intubation.
• Breathing (B): Evaluate for breathing issues from chest trauma. Consider differential diagnoses like hemopneumothorax, lung contusion, or flail chest.
• Circulation (C): Address possible circulatory compromise. Explore causes like hemothorax, intraperitoneal bleeding, pelvic fractures, or retroperitoneal bleeding indicative of hemorrhagic shock.
• Disability (D): Examine for neurological deficits attributable to head injury. Differential diagnoses include basal skull fracture, hemorrhagic brain contusion, subdural hematoma (SDH), subarachnoid hemorrhage (SAH), epidural hematoma (EDH), or brain edema.
• Exposure/Environmental Control (E): Fully expose the patient for assessment while ensuring protection against hypothermia. Maintain cervical spine protection throughout.

Question 15

Lower GI bleeding

Answer 15

• Airway: Assess GCS, prepare for possible Rapid Sequence Intubation (RSI).
• Breathing: Administer oxygen, evaluate respiratory status.
• Circulation: Establish two IV lines, administer crystalloids, consider massive transfusion protocol if hemodynamically unstable.
• Local Examination: Check for bleeding per rectum.
• Investigations:
  
  • CBC (Complete Blood Count)
  • U&E (Urea and Electrolytes)
  • Coagulation profile
  • Blood group typing
  • LFT (Liver Function Tests)
  • Cardiac enzymes
  • ABG (Arterial Blood Gas)
• Lactate levels
• Imaging:
  
  • ECG (Electrocardiogram)
  • Echocardiogram
  • Chest X-Ray
  • Abdominal Ultrasound
  • CT Abdomen (if patient stabilizes)
• Consult General Surgery: For further evaluation of abdominal pain and rectal bleeding.
• Anticoagulation Reversal: Assess and reverse anticoagulant medication as necessary.

Question 16

Headache

Answer 16

• Detailed History:
  
  • Characterize the headache (onset, duration, intensity, location).
  • Assess for associated symptoms (nausea, vomiting, photophobia, neurological deficits).
  • History of similar episodes, family history of headaches or cerebrovascular diseases.
  • Risk factors: Smoking, hypertension, drug use (cocaine, amphetamines), family history of aneurysms.
• Physical Examination:
  
  • Vital signs: Confirm tachycardia and hypertension.
  • Neurological exam: Assess for focal deficits, mental status, cranial nerve function.
  • Neck stiffness, photophobia (suggestive of meningismus).
  • Fundoscopic exam: Look for papilledema.
• Evaluation for Subarachnoid Hemorrhage (SAH) Complications:
  
  • Rebleeding: Sudden worsening of headache, altered mental status.
  • Hydrocephalus: Headache, nausea, vomiting, altered consciousness.
  • Vasospasm: Delayed neurological deficit, typically 3-14 days post-hemorrhage.
  • Seizures: Inquire about any witnessed convulsive activity.
• Laboratory Investigations:
  
  • Complete blood count, electrolytes, renal function tests.
  • Coagulation profile (especially if anticoagulant use is suspected).
  • Cardiac enzymes (if cardiac cause for symptoms is suspected).
• Imaging:
  
  • CT Brain without contrast: Initial test of choice for suspected SAH.
  • If CT is negative and suspicion remains high, consider lumbar puncture.
• Specialist Involvement:
• Neurology consultation for further assessment and management.
• Interventional radiology: For possible angiography to identify aneurysm or vascular malformation.
• Management of Hypertension:
• Initiate antihypertensive medication to maintain systolic BP between 140-160 mmHg.
• Medications such as labetalol, nicardipine, or other IV agents for acute management.
• Monitoring and Follow-up:
• Close monitoring of neurological status and blood pressure.
• Consider admission to a stroke unit or ICU for close observation and management

Question 17

Asthma

Answer 17

Initial Assessment:

• Assess airway, breathing, circulation (ABCs).
• Measure vital signs: respiratory rate, heart rate, blood pressure, oxygen saturation.
• Perform a focused respiratory examination.

Diagnostic Investigations:

• Chest X-ray to rule out pneumonia or complications of asthma.
• Complete blood count (CBC) to evaluate for infection or anemia.
• Arterial blood gases (ABGs) for assessing gas exchange.
• Sputum culture and sensitivity if productive cough is present.
• Influenza and COVID-19 testing, given current epidemiology.

Immediate Management:

• Administer supplemental oxygen to maintain SpO2 > 94%.
• Nebulized short-acting beta-agonists (e.g., salbutamol) for bronchodilation.
• Systemic corticosteroids for anti-inflammatory effect if exacerbation of asthma is suspected.
• Empirical antibiotics if bacterial infection is suspected.

Question 18

Cardiogenic shock

Answer 18

• Airway: Ensure patency. Anticipate need for intubation if respiratory distress worsens.
• Breathing: High-flow oxygen, monitor oxygen saturation. Consider CPAP or NIPPV if respiratory failure.
• Circulation: IV access, fluid resuscitation for hypotension. Monitor BP and heart rate.
• Disability: Assess consciousness level (GCS). Check blood glucose.
• Exposure: Full examination, noting skin lesions or signs of infection.
• History and Examination:
  
  • Symptom Onset and Duration: Timeline of fever, SOB, edema.
  • Recent Illnesses: Details of viral infection.
  • Cardiac Symptoms: Chest pain, palpitations, orthopnea.
  • Heart Exam: Murmurs, JVP, heart sounds.
  • Respiratory Exam: Lung auscultation.
  • Abdominal Exam: Liver size, ascites.
  • Extremities: Pitting edema.
• Investigations:
  
  • Labs: CBC, CMP, coagulation profile, ABG, lactate, troponin, BNP.
  • Imaging: Chest X-ray, ultrasound abdomen & IVC, ECHO.
  • Microbiology: Blood cultures, urine analysis.
• Differential Diagnosis: Heart failure, pneumonia, sepsis, liver disease, pulmonary embolism.
• Management:
  
  • Sepsis: Broad-spectrum antibiotics after cultures.
  • Cardiac: Diuretics for fluid overload, consult cardiology.
  • Respiratory: Mechanical ventilation if indicated.
  • Hemodynamic: Vasopressors for hypotension.
• Monitoring: ICU monitoring, vital signs, repeat labs.
• Consultations: Cardiology, Infectious Disease, Pulmonology.
• Patient Education: Inform about condition, treatment, outcomes.

Question 19

Seizure in HIV-Positive Patient

Answer 19

Stabilization:
- Airway management (assess for patency, protection)
- Breathing and circulation support
- Seizure control (benzodiazepines like lorazepam)

Diagnostic Evaluation:
- Blood tests: CBC, electrolytes, renal function, liver enzymes, glucose
- Lumbar puncture (if no contraindication) for CSF analysis
- Imaging: MRI brain (preferred) or CT scan
- EEG if recurrent seizures

Management of Seizure:

Consultations:
- Consult Infectious Disease for antiretroviral therapy
- Neurology Consultation

Follow-up and Monitoring:
- ICU

Question 20

Status Epilepticus

Answer 20

Link

Initial Seizure Control:
- Benzodiazepines first-line: Lorazepam IV, followed by Diazepam or Midazolam if needed.

Second-Line Antiepileptics:
- Phenytoin/Fosphenytoin: Adjust dose for therapeutic levels.
- Levetiracetam (Keppra): Advantageous due to minimal drug interactions, renal dose adjustment.
- Valproate: Monitor for hepatic metabolism and drug interactions.

Management of Refractory Status Epilepticus:
- Continuous EEG monitoring.
- Phenobarbital: If seizures persist after initial treatments.
- Propofol or Midazolam infusion: Considered for ongoing seizures, requires ICU.

Airway Management (if needed):
- Rapid Sequence Intubation (RSI) for airway protection, especially if patient is in status epilepticus and unable to protect airway.

Use of Anesthetic Agents:
- General anesthetics like Thiopental or Pentobarbital for intractable seizures.

Question 21

TB menegitis

Answer 21

Antituberculous Therapy:
- Rifampicin
- Isoniazid (with Pyridoxine to prevent neuropathy)
- Pyrazinamide
- Ethambutol or Streptomycin (especially if drug resistance is suspected)

Duration: Intensive phase for 2 months, followed by continuation phase for at least 4-7 months.

Corticosteroids:
- Dexamethasone or Prednisolone
- Reduces inflammation and improves outcomes.

Monitoring and Adjustments:
- Monitor liver function tests (antituberculous drugs can be hepatotoxic).
- Adjust dosages based on renal and liver function.

Supportive Care:
- Manage raised intracranial pressure.
- Symptomatic treatment for headache, fever.
- Nutritional support and hydration.

HIV Management:
- Antiretroviral therapy (ART) initiation or adjustment.
- Monitor for drug-drug interactions between ART and TB medications.

Follow-up:
- Regular CSF analysis to monitor response.
- Neurological assessment to evaluate for any complications.

Infection Control:
- Isolation until non-infectious (if pulmonary TB is also present).
- Contact tracing and screening.

Question 22

COVID ARDS (initial)

Answer 22

• Initial Assessment: Evaluate airway, breathing, circulation; assess respiratory rate, oxygen saturation, work of breathing.
• Respiratory Support: Oxygen therapy (nasal cannula, face mask), non-invasive ventilation or high-flow nasal cannula if indicated, early intubation for respiratory failure.
• Infection Control: Isolation precautions, Personal Protective Equipment for healthcare workers.
• Diagnostic Testing: RT-PCR for SARS-CoV-2, chest imaging, blood tests including CBC, CRP, D-dimer, ferritin, LDH, liver and renal function.

Question 23

ARDS (diagnosed)

Answer 23

• Lung Protective Ventilation: Use low tidal volume ventilation (4-6 mL/kg predicted body weight), maintain plateau pressures <30 cm H2O.
• Positive End-Expiratory Pressure (PEEP): Adjust PEEP to optimize oxygenation while minimizing lung injury.
• Oxygenation Target: Maintain SpO2 88-95% or PaO2 55-80 mmHg.
• Prone Positioning: For patients with severe ARDS (PaO2/FiO2 < 150 mmHg).
• Fluid Management: Conservative strategy to avoid fluid overload.
• Sedation and Analgesia: To facilitate mechanical ventilation and patient comfort.
• Neuromuscular Blocking Agents: Consider in early severe ARDS for ventilator synchrony.
• Monitoring: Regular assessment of respiratory parameters, hemodynamics, and organ function.
• Nutritional Support: Enteral nutrition, maintain adequate caloric intake.
• Venous Thromboembolism Prophylaxis: Given increased risk in critically ill patients.
• Gastric Ulcer Prophylaxis: To prevent stress ulcers.
• Management of Underlying Cause: Treat the primary illness or trigger for ARDS.
• Consideration of Advanced Therapies: ECMO (Extracorporeal Membrane Oxygenation) for refractory hypoxemia.

Question 24

Post CABG handover

Answer 24

• Anesthesia report: type and duration of anesthesia.
• Inotropes: specific agents and dosages used.
• Heparin and Protamine: doses and response.
• CPB time: duration of cardiopulmonary bypass.
• Aortic cross clamp time: duration.
• Fluid balance: intraoperative fluids, blood products transfusions, intravenous fluids.
• Intraoperative events: arrhythmias, bleeding issues.
• Surgical details: type of surgery, complications, bypass time.

Question 25

Post CABG (initial assessment)

Answer 25

• Hemodynamics: heart rate, blood pressure, central venous pressure, pulmonary artery catheter readings.
• Peripheral pulses: presence and quality.
• Urine output: volume and frequency.
• Respiratory status: endotracheal tube position, chest tube status, SpO2, assessment of other drains.
• Neurological status: consciousness level, pupil reactions.
• Investigations:
  
  • CBC, Coagulation Profile, ACT: to assess hematologic status and anticoagulation (post-CPB, bleeding risk).
  • Serum electrolytes, RBS, ABG: for metabolic status and gas exchange.
  • ECG, CXR: to evaluate cardiac and pulmonary status post-surgery.
• Temperature: to monitor for hypothermia or fever.

Question 26

Hemorrhagic shock after CABG (diagnosed)

Answer 26

• Hold Heparin
• Notify the Surgical Team: immediately inform the cardiothoracic surgery team.
• Hemodynamic Monitoring: assess vital signs, ensure hemodynamic stability.
• Blood Product Administration: prepare for potential transfusion (packed red blood cells, fresh frozen plasma, platelets).
• Coagulation Assessment: check coagulation parameters (PT, aPTT, INR, fibrinogen, platelet count).
• Increase Monitoring: closely monitor other drains, urine output, and hemodynamic parameters.
• Bedside Ultrasound: to assess for cardiac tamponade or significant intrathoracic bleeding.

Question 27

Post CABG hypotension

Answer 27

ABCD:
- Airway and Breathing: Check patency, ventilator settings, SpO2, ABG.
- Circulation: Manual BP, ECG, CVP, POCUS, drain outputs, check for myocardial infarction (cardiac enzymes, ECHO), evaluate inotropes, pacemaker, IABP, VAD.
- Disability: Quick neurological assessment.

Investigations:
- Hypovolemia: Assess fluids, capillary refill.
- Cardiac Tamponade: Beck’s triad, ECHO, pericardial drain output.
- Surgical Issues: Consider surgical exploration if indicated.
- Chest X-ray, hemoglobin, electrolytes, lactate.

Management:
- Adjust medications (inotropes, vasopressors).
- Fluid therapy, blood products if needed.
- Continuous monitoring and reassessment.
- Notify surgical team, consider cardiology consult.

Question 28

Post CABG arrest (modified ACLS)

Answer 28

• External Pacing: In asystole or severe bradycardia, consider external pacing prior to external cardiopulmonary resuscitation (CPR).
• Defibrillations: In case of ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT), consider three consecutive defibrillations before starting external CPR.
• Emergency Resternotomy: If electrical therapies (defibrillation, pacing) fail, consider emergency resternotomy within 5 minutes.
• Restrict Epinephrine Use: To avoid rebound hypertension, use epinephrine cautiously.
• Pulseless Electrical Activity (PEA): If PEA is present, turn off any pacing to rule out fine VF.
• Emergency Echocardiography: Utilize emergency echocardiography to assess cardiac function and identify reversible causes.

Question 29

Suspected PE

Answer 29

• Assess patient’s stability: Monitor vital signs, check for hemodynamic stability.
• Obtain history: Focus on risk factors for PE (recent surgery, immobility, malignancy, previous VTE).
• Perform physical examination: Look for signs of DVT, respiratory distress, and hemodynamic compromise.
• Conduct diagnostic tests:
  
  • ECG: Look for signs of right heart strain.
  • Chest X-ray: Rule out other causes of symptoms.
  • Blood tests: D-dimer, troponin, BNP, arterial blood gases.
• Assess clinical probability: Use tools like the Wells score or Geneva score.
• Imaging studies:
  
  • CT Pulmonary Angiography (CTPA) is the gold standard if patient is stable and has adequate renal function.
  • V/Q scan as an alternative in patients with contraindications to CTPA.
• Consider bedside echocardiography: Assess for right ventricular strain.
• Doppler lower limbs
• Initiate anticoagulation: Start empiric treatment if high clinical suspicion, unless contraindicated.
• Consult with multidisciplinary team as needed: Include pulmonology, cardiology, and hematology.
• Monitor and support: Ensure adequate oxygenation, hemodynamic support, and follow-up imaging/tests as needed.

Question 30

Suspected hepatic encephalopathy

Answer 30

• Assess airway, breathing, and circulation (ABCs) immediately. Ensure airway patency and provide supplemental oxygen as needed.
• Initiate intravenous access; consider central line if peripheral access challenging.
• Administer fluid resuscitation cautiously, using crystalloids; monitor for response and potential pulmonary edema.
• Obtain vital signs including pulse, blood pressure, respiratory rate, temperature, and oxygen saturation.
• Perform focused physical examination: check for signs of chronic liver disease, evaluate abdominal distension, and note neurologic status.
• Check blood glucose and correct hypoglycemia if present.
• Order urgent labs: CBC, liver function tests, renal function tests, coagulation profile, ammonia levels, arterial blood gas, lactate, and blood cultures.
• Perform bedside ultrasound to assess ascites and cardiac function.
• Initiate empirical broad-spectrum antibiotics, considering spontaneous bacterial peritonitis (SBP) as a potential precipitant.
• Consider paracentesis to diagnose and relieve tense ascites; send ascitic fluid for analysis including cell count, culture, and SAAG.
• Assess for hepatic encephalopathy: check GCS, look for asterixis, and consider EEG if needed.
• Administer lactulose for suspected hepatic encephalopathy; consider rifaximin if advanced.
• Arrange for urgent gastroenterology/hepatology consultation.
• Prepare for potential ICU transfer given hemodynamic instability and risk of further decompensation.

Question 31

HE with seizure

Answer 31

• Secure the patient’s safety by preventing injury during the seizure.
• Administer oxygen and ensure airway patency; prepare for intubation if necessary.
• Administer a benzodiazepine such as lorazepam or diazepam for seizure control.
• Obtain intravenous access for fluid and medication administration.
• Check blood glucose and correct hypoglycemia if present.
• Check electrolytes including sodium, potassium, calcium, magnesium, and phosphate to identify and correct imbalances.
• Order urgent neuroimaging (CT or MRI) to rule out structural causes of seizure.
• Consider lumbar puncture if infectious etiology is suspected, following neuroimaging.
• Administer an appropriate antiepileptic drug, considering liver function.
• Evaluate for hepatic encephalopathy and treat accordingly.
• Continuous monitoring of vital signs and neurological status.
• Consult neurology for further management and guidance.

Question 32

VV ECMO with hypoxia

Answer 32

• Optimize ECMO settings: Adjust flow rates and FiO2 for maximum oxygen delivery and effective CO2 removal.
• Ventilator adjustments: Use lung-protective strategies, like low tidal volumes and plateau pressures, to reduce lung injury.
• Prone positioning: Improves ventilation-perfusion matching in ARDS, potentially beneficial for patients on ECMO.
• Recruitment maneuvers: Use cautiously to open collapsed alveoli; monitor for hemodynamic stability and lung overdistension.
• Adjust sweep gas flow: Increase ECMO sweep gas flow rate to enhance CO2 removal, indirectly improving oxygenation.
• Hemodynamic optimization: Ensure adequate cardiac output and perfusion for optimal tissue oxygen delivery.
• Fluid management: Balance fluid resuscitation with diuresis to maintain lung function and avoid fluid overload.
• Blood transfusions: Keep hemoglobin at appropriate levels for sufficient oxygen-carrying capacity.
• Address underlying cause: Treat primary pathology causing respiratory failure (e.g., infection, embolism).
• Sedation and paralysis: Consider sedatives and neuromuscular blockers to reduce oxygen consumption and improve ventilator synchrony.
• Consider adjunct therapies: Inhaled nitric oxide or prostacyclin for pulmonary vasodilation, corticosteroids for inflammation, surfactant in specific cases.
• Continuous reassessment: Regularly monitor arterial blood gases, ECMO parameters, and patient status to adapt interventions.

Question 33

Suspected Preclampsia

Answer 33

• Stabilize airway, breathing, and circulation; focus on maternal safety.
• Measure vital signs, especially blood pressure; assess for preeclampsia symptoms.
• Perform neurological check; decreased LOC may suggest eclampsia.
• Monitor fetal heart rate and uterine contractions.
• Administer magnesium sulfate for seizure prevention, suspecting eclampsia.
• Contact obstetrics for ultrasound and cardiotocography (CTG) assessment.
• Consider delivery if severe or refractory hypertension poses risks to mother or fetus.
• Begin antihypertensive treatment (options include labetalol, hydralazine).
• Order labs: CBC, LFTs, coagulation profile, urinalysis for protein.
• Ensure ongoing monitoring of both mother and fetus; prepare for ICU admission if needed.
• Rule out other causes of hypertension and altered LOC in pregnancy, like intracranial events.

Question 34

Pregnant cardiac arrest

Answer 34

• Initiate Advanced Cardiac Life Support (ACLS) protocol immediately.
• Begin cardiopulmonary resuscitation (CPR) with modifications for pregnancy (displace uterus to the left).
• Call for additional help and announce “pregnant patient in cardiac arrest”.
• Perform CPR with deeper sternal compressions than usual, considering pregnancy adaptations.
• Apply defibrillator pads; prepare for defibrillation if indicated.
• Administer epinephrine and other ACLS medications as per protocol.
• Consider reversible causes: Hypovolemia, Hypoxia, Hydrogen ion (acidosis), Hypo-/Hyperkalemia, Hypothermia, Tension pneumothorax, Tamponade (cardiac), Toxins, Thrombosis (pulmonary), Thrombosis (coronary).
• Prepare for emergency perimortem cesarean delivery if resuscitation is unsuccessful after 4 minutes.
• Ensure advanced airway management while minimizing interruptions in chest compressions.
• Consider targeted temperature management (TTM) to reduce neurological injury post-cardiac arrest.

Question 35

Inceased ICP

Answer 35

• Good sedation, analgesia
• Hypertonic saline and mannitol to reduce ICP (target Na 155, serum osmolality 320)
• Maintain lower normal PCO2 35-38 mmHg
• EVD drain and ICP monitor
• Anti-Seizure prophylaxis
• Avoid hypovolemia with good volume resuscitation to Maintain CPP 60 -70

Question 36

Suspected methanol toxicity (initial)

Answer 36

• ABC
• Airway RSI
• IVF boluses
• Vasopressors
• Checking blood sugar

Question 37

Methanol toxicity (diagnosed)

Answer 37

Immediate Management:
- Stabilize airway, breathing, and circulation.
- Administer high-flow oxygen.
- Establish intravenous access for fluid resuscitation.

Specific Antidote:
- Administer intravenous fomepizole, the preferred antidote for methanol poisoning. If unavailable, use ethanol as an alternative.

Correction of Acidosis:
- Administer intravenous sodium bicarbonate to correct severe metabolic acidosis.

Hemodialysis:
- Initiate urgent hemodialysis for severe acidosis, high methanol levels, or renal failure.

Supportive Care:
- Monitor vitals, electrolytes, and renal function.
- Thiamine and folate supplementation.
- Dextrose

Prevent Further Absorption:
- If ingestion was recent, consider gastric lavage or activated charcoal.

Intensive Care Monitoring:
- Close monitoring in ICU for complications like visual disturbances, CNS depression, or respiratory failure.

Consultations:
- Involve toxicology and nephrology specialists for multidisciplinary management.