Pretest_2_CriticalCare

Question 1

Bleeding from a tracheostomy could indicate a ______________ fistula, which has a 50% mortality rate.

Answer 1

Tracheoinnominate artery (trachea to right brachiocephalic artery). Inflate the tracheostomy, reintubate the patient, remove tracheostomy and place finger into site to anteriorl compress before median sternotomy

Question 2

What is the “rapid shallow breathing index”?

Answer 2

respiratory rate to tidal volume (in L; normal tidal volume is 0.5 L)

Question 3

What are the indications to attempt extubation?

• rapid shallow breathing index
• negative inspiratory force
• respiratory rate
• minute ventilation
• PEEP

Answer 3

• rapid shallow breathing index (RR:TV) of 60-105
• negative inspiratory force greater than -20cm H2O
• respiratory rate less than 20/min
• minute ventilation (RR times tidal volume) < 10L/min
• PEEP <5

Question 4

Which inhalational anesthetic can cause progressive distension of air-filled spaces?

Answer 4

Nitrous oxide, which has a low solubility compared with other inhalation anesthetics. It can lead to worsened distention (which is bad for intestinal obstruction!!)

Question 5

How is ARDS diagnosed?

Answer 5

1) bilateral pulmonary infiltrates on Xray
2) PaO2/FiO2 ratio less than 200
3) pulmonary wedge pressure less than 18 (to exclude pulmonary edema)

Question 6

ARDS is marked by which 3 major physiologic alterations?

Answer 6

1) hypoxemia (unresponsive to increased FiO2)
2) decreased pulmonary compliance
3) decreased functional residual capacity (air in lungs following expiration)

Question 7

Banked blood shifts the hemoglobin-oxygen dissociation curve to the (left/right). Why?

Answer 7

Left (decreasing oxygen uptake by tissues). This is because banked blood is low in 2,3-DPG (an RBC organic phosphate)

Question 8

Chronic lung disease shifts the hemoglobin-oxygen dissociation curve to the (left/right). Why?

Answer 8

Right, enhancing oxygen uptake by the tissues. Chronic lung disease leads to chronic hypoxia, which leads to an increase in 2,3-DPG

Question 9

What is the progression of dopamine’s effects by dose?

1) low
2) higher
3) highest

Answer 9

low ( mainly dopaminergic receptor mediated effects: increase of blood flow to kidneys
higher (2-10) –> B1 agonist effects = inotropic effect on myocardium = increased CO and BP
highest (>10) –> a receptors cause peripheral vasoconstriction, decreased kidney function, hypertension

** at all doses, DBP rises = increase in coronary blood flow

Question 10

T/F: An opioid antagonist (like naloxone) will inhibit the central effects of morphine (respiratory depression,generalized pruritus), but will not affect the local pain-relieving effects.

Answer 10

True!

Question 11

In the case of acalculous cholecystitis, what procedure should be undertaken?

Answer 11

percutaneous drainage of the gallbladder

Question 12

In septic shock there is a(n) (increase/decrease) in CO and a(n) (increase/decrease) in peripheral resistance.

Answer 12

increase in CO, and decrease in peripheral resistance

Question 13

How does PEEP lead to increased dead space ventilation? What are other potential negative impacts?

Answer 13

increased PEEP leads to decreased capillary perfusion = increased dead space ventilation

can also result in barotrauma and decreased venous return

Question 14

What is the Beck traid of cardiac tamponade?

Answer 14

1) systemic hypotension
2) jugular venous distension
3) distant heart sounds

Question 15

Define pulsus paradoxus:

Answer 15

decrease in SBP by more than 10 mm Hg at the end of the inspiratory phase of respiration

Question 16

How does epinephrine affect the anesthetic effect of anesthesia?

Answer 16

It doubles the duration of infiltration anesthesia and increases the maximal safe total dose by decreasing the rate of the drug’s absorption. But DO NOT inject into areas supplied by end arteries (finger tips, penis, toes, ears).

Question 17

Indirect hyperbilirubinemia and anemia are seen in (immediate/delayed) hemolytic transfusion reactions.

Answer 17

Delayed

Question 18

Why is the urine acidotic in contraction alkalosis (by vomiting, gastric outlet obstruction, etc)?

Answer 18

Because there is exchange of sodium for hydrogen ions in the distal tubule to maintain volume status

Question 19

A tracheoinnominante artery fistula (TIAF) is due to low placement of the tracheostomy tube (distal to the __ and __ tracheal rings). How should it be confirmed?

Answer 19

2nd and 3rd tracheal rings. Confirmed in the OR with bronchoscopy

Question 20

A tracheostomy is placed (above/below) the cricoid cartilage, the strap muscles are (spared/divided), the thyroid isthmus is divided if necessary, and the trachea is entered at the ___ tracheal ring.

Answer 20

BELOW the cricoid cartilage
strap muscles are spared (retracted laterally)
second tracheal ring

Question 21

Treatment of malignant hyperthermia includes cessation of the offending agent, (hyper/hypo) ventilation, administration of ______, and (acidification/alkalinization) of the urine.

Answer 21

HYPERventilation
administration of dantrolene
alkalinization of the urine

Question 22

Acute PE causes CVP to (elevate/decrease)

Answer 22

Elevate – stress on RV –> stress on RA

Question 23

_________ is strongly suggestive of cholesterol atheroembolization.

Answer 23

Eosinophilia

Question 24

Addison’s disease/adrenocortical insufficiency is characterized by (hypo/hyper)natremia and (hypo/hyper)kalemia.

Answer 24

Hyponatremia

Hyperkalemia

Question 25

Which incisions contribute to V/P mismatch?

Answer 25

Thoracic and upper abdominal

Question 26

Patient with burns is made hyperkalemic after induction with this anesthetic agent:

Answer 26

succinylcholine
(this agent causes a rise in potassium in everyone due to its efflux from the skeletal muscle at the NMJ; patients with burns, trauma, severe infections, or neuromuscular disorders have a greater than normal potassium efflux)

Question 27

To assess volume status and need for ongoing inotropic support, use what to monitor?

Answer 27

pulmonary artery catheter (post AAA repair, etc)

Question 28

Which coagulation factors does prothromin time measure?

Answer 28

Factors II, V, VII, X, fibrinogen

Question 29

The thrombin time measures which coagulation factors?

Answer 29

Fibrinogen

Question 30

Cardiac risk is elevated when there are >__ PVCs/min, when there is dyspnea on exertion, and in _______ regurgitation (in addition to CHF, MI within 6 months, etc).

Answer 30

> 5 PVC’s min
dyspnea on exertion
mitral regurgitation

Question 31

Why is it that massive overdose in local anesthetics might only be reflected as depressive symptoms?

Answer 31

Usually toxicity results in stimulation of neurons, followed by depression. In a massive overdose, all the neurons may be depressed at the same time.

Question 32

What is paradoxical acidic urine?

Answer 32

In the contraction alkalosis accompanying gastric outlet obstruction (loss of gastric acid), potassium depletion and volume deficits provoke exchange of sodium for hydrogen ion in distal tubule with exacerabtion of metabolic alkalosis. The urine is acidic despite the alkalosis.

Question 33

When is awake intubation contraindicated?

Answer 33

if elevated ICP is suspected or if a penetrating eye injury exists

Question 34

What does the partial thromboplastin time measure?

Answer 34

Factors II, V, VIII, IX, X, XI, XII, fibrinogen

Question 35

What is the normal PaO2/FiO2 ratio?

Answer 35

500

<200 = ARDS

Question 36

CT imaging show multiple small intraparenchymal hemorrhages at the gray-white matter interface of the cerebral cortex, corpus callosum, or brainstem suggests

Answer 36

diffuse axonal injury
(most common = deceleration injury, child abuse, falls, assaults).
MRI may initially be normal

Question 37

Name every point that can be awarded for the GCS

Answer 37

Eyes (4 possible points)
open eyes spontaneously = 4
to voice = 3
to painful stimuli = 2
does not open eyes = 1

Verbal response (5 possible)
normal, oriented = 5
confused/disoriented = 4
utters inappropriate words = 3
incomprehensible = 2
no sounds = 1

Motor response (6 possible)
obeys commands = 6
localizes pain = 5
withdraws from pain = 4
decorticate (flexion) = 3
decerebrate (extension) = 2
no movement = 1

Question 38

Which of the following is atypical for an acute abdomen: n/v following onset, writing in pain, focalized pain, sudden-onset abdominal pain, voluntary guarding?

Answer 38

writhing in pain (more classic of colicky pain); most acute abdomens = motionless

Question 39

What is the name given to the phenomenon describing shoulder pain secondary to peritoneal fluid or air?

Answer 39

The Kehr sign (based on anatomic overlap of C3, C4 dermatomes in shoulder and phrenic nerve roots)

Question 40

Shoulder pain following a lap cholecystectomy is more likely due to

Answer 40

subdiaphragmatic air (from insufflation)

Question 41

Name whether the following structures are innervated by the greater, lesser, or least splanchnic nerves. Which dermatomes do they correspond to?

Esophagus through proximal duodenum (foregut)
Distal duodenum to transverse colon (midgut)
Descending colon to anus (hindgut)

Answer 41

foregut = greater = T5-T9
midgut = lesser = T9-T11
hindgut = least = T11-L3

Question 42

What are risk factors for atypical angina (unusual presentations of MI)?

Answer 42

female gender, diabetes mellitus, advanced age

Question 43

If you suspect a perforated duodenal ulcer, what is the next step in management?

Answer 43

upright AXR looking for free air

Question 44

What are the stages of shock?

Answer 44

Stage 1: 100

Stage 3: 30-40% blood loss (1500-2000); UOP 20; tachy>120; hypovolemic shock, SBP 100 or less

Stage 4: >40% blood loss (>2000); UOP negligible, tachy>140, SBP<70, SHOCK

Blood is given with crystalloids for stage 3 and 4 shock