SCCM BOARD REVIEW QUESTIONS

Question 1

In the management of healthcare-associated ventriculitis and meningitis recommend that empiric therapy includes what?

Answer 1

vancomycin plus an antipseudomonal beta-lactam (eg, cefepime, ceftazidime, or meropenem)

Question 2

What is a major complication of frostbite?

Answer 2

Microvascular thormbosis

Question 3

How do you treat microvascular thrombosis?

Answer 3

Treatment includes ibuprofen, low-molecular-weight heparin, and consideration of intra-arterial tissue plasminogen activator.

Question 4

According to the guidelines, relative adrenal insufficiency is diagnosed based on what?

Answer 4

a change in baseline cortisol at 60 minutes of less than 9 µg/dL after cosyntropin administration or a random plasma cortisol level of less than 10 µg/d

Question 5

What is the calculation for FENA?

Answer 5

Fractional Excretion of Sodium (FENa), % = 100 × (SCr × UNa ) / (SNa × UCr)

FACTS & FIGURES
Pre-Renal Intrinsic Post-Renal
FENa <1% >1% >4%
UNa (mmol/L) <20 >40 >40
Pre-Renal: Anything causing decreased effective renal perfusion: hypovolemia, heart failure, renal artery stenosis, sepsis, etc. Remember, contrast-induced nephropathy will often look pre-renal.

Intrinsic: ATN, AIN, glomerulonephritides, etc.

Post-Renal: Obstruction (e.g. BPH, bladder stone, bilateral ureteral obstructi

Question 6

What is the calculation for FE urea?

Answer 6

Can be used with patients on diuretics?

Fractional Excretion of Urea (FEUrea) = (SerumCr * UUrea) / (SerumUrea x UCr) %

 Prerenal  Intrinsic renal	Postrenal
 ≤ 35%	   >50%	            N/A

Question 7

What is a rapid way to diagnose systolic dysfunction on echo?

Answer 7

Fractional shortening of the left ventricle and the E-point septal separation (EPSS) of the mitral valve and septum.

Fractional shortening of the left ventricle is measured on parasternal long axis view. On M-mode view, the cursor is placed across the distal tip of the mitral leaflets, and the diameter is measured at that level at the end of systole and the end of diastole. The formula is (EDD – ESD/EDD) × 100 of the ventricular walls, where EDD is end-diastolic dimension and ESD is end-systolic dimension.

** A normal shortening is above 35% to 45%. Anything lower implies poor systolic function of the left ventricle.**

THe EPSS is measured with M-mode cursor over the tip of the anterior mitral leaflet. As the mitral valve moves during diastole there are 2 repeating waves; the first is the E wave, which reflects the initial and maximal opening of the valve to allow passive filling of the left ventricle, followed by the A wave, which reflects the atrial contraction.

** EPSS is the minimal distance between the E wave and the septum and should be less than 7 mm. If it is more than 1 cm it reliably reflects poor ejection fraction.**

Question 8

According to both the American Epilepsy Society and Neruocritical Care guidelines for treatment of status epilepticus refractory to seizures what is the recommended agent>

Answer 8

levetiracetam (Keppra)

Question 9

Which of the following is a characteristic of a drug that is likely to be effectively removed by continuous renal replacement therapy?

Answer 9

minimal protein binding

Question 10

What type of drugs are not likely to be removed by CRRT?

Answer 10

Drugs or toxins that are extensively large (monoclonal antibodies), extensively protein bound, with an extensive charge, or with a large volume of distribution are least likely to be effectively removed by continuous renal replacement therapy.

Question 11

What are possible causes for PRES posterior reversible encephalopathy syndrome?

Answer 11

Pre-eclampisia
Immunosupression like tacro
Cerebral sinus venous thrombosis
Posterior circulation ischemic or hemorrhagic stroke
Vasculitis of the central nervous system
Herpes simplex encephalitis
Autoimmune encephalitis
Uremic encephalopathy

Question 12

When a patient presents with leukostasis what is the preferred approach?

Answer 12

Induction Chemotherapy
leukapheresis is reserved when chemo is not possible and has not been associated with improved survival

Question 13

What are the risks of antiemetics?

Answer 13

Antiemetics can notoriously prolong QTc interval on ECG, especially when administered together and intravenously. This can lead to fatal ventricular arrhythmias.

Question 14

In patient with lactate elevation and high pressor requirement post cardiac arrest cooling what is the next step.

Answer 14

initiate warming to 36 degrees C

Question 15

Which drug can interfere with the analgesic effect of Tramadol?

Answer 15

Fluoxetine

Tramadol is a prodrug that is metabolized by cytochrome P450 enzymes CYP2D6 and CYP3A4 to its more potent opioid analgesic metabolites. Because of this, the analgesic potency of a given dose of tramadol is influenced by a patient’s cytochrome P450 activity, with poor metabolizers experiencing little conversion to the active metabolite and patients with a high metabolic profile experiencing the greatest analgesic effects.

Fluoxetine is a strong inhibitor of CYP2D6 and thus significantly reduces the metabolism of tramadol to its active metabolite.

Question 16

What lab value is an indicator of a metabolic alkalosis due to mineralocorticoid excess?

Answer 16

urine chloride concentration greater than 20 mEq/L suggest mineralocorticoid excess as the cause of metabolic alkalosis.

Vomiting, nasogastric suction, postdiuretic use, and posthypercapnic states are associated with chloride-responsive metabolic alkalosis, with urine chloride concentrations less than 15 mEq/L

Question 17

Dopamine primarily causes stimulation of alpha-1 receptors at which of the following doses?

Answer 17

Vasoconstriction, mediated through alpha-1 stimulation, occurs primarily at doses of 10 to 20 µg/kg/min

Question 18

Dopamina at does of Doses of 5 to 10 µg/kg/min primarily cause stimulation of what?

Answer 18

Doses of 5 to 10 µg/kg/min primarily cause stimulation of beta-1 receptors.

Question 19

What to happnes with dopamine with doses above 20 µg/kg/min?

Answer 19

no additional beneficial effect of vasoconstriction in a patient with shock but do cause substantial tachycardia and arrhythmias via beta-1 stimulation.

Question 20

What is the three drug regimen recommended for anthrax exposure?

Answer 20

Ciprofloxacin, linezolid, and meropenem

Question 21

What is optimal dosing appoach for Zosyn?

Answer 21

Beta-lactam antimicrobials exhibit time-dependent bacterial killing, which means the pharmacokinetic/pharmacodynamic (PK/PD) target of interest is the fraction of time during the dosing interval that the drug concentration exceeds the organism’s minimum inhibitory concentration (MIC). For this reason, shorter dosing intervals or prolonged infusions for this medication class are preferred relative to higher doses delivered less frequently.

Question 22

After TAVR when is an pacemaker placement recommended?

Answer 22

The European Society of Cardiology recommends a period of careful observation and EEG monitoring up to 7 days before considering pacemaker implant; however, in cases of complete atrioventricular block with slow escape rhythm, the guidelines recommend earlier intervention.

Question 23

What are the three types of common adverse event with checkpoint inhbitors and state them in order of timing?

Answer 23

Dermatologic toxicity is the earliest adverse event, with onset an average of 3.6 weeks after treatment initiation.

The onset of hepatotoxicity most commonly occurs 8 to 12 weeks into treatment.

Diarrhea/colitis most commonly occurs approximately 6 weeks into treatment.

Question 24

What is a risk factor for the development of postoperative acute kidney insufficiency?

Answer 24

Previous cardiac surgery

Question 25

What type of fracture is surgical stabilization of rib fractures recommend on?

Answer 25

Flail segement

The term “early” is considered to be within 72 hours of injury.

Question 26

Which test best distinguishes between acute fatty liver and hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome in pregnancy?

Answer 26

serum ammonia level

Question 27

What is the anti-hypertensive agent of choice in a patient with underlying liver and renal disease?

Answer 27

Clevidipine is a short-acting dihydropyridine calcium channel blocker that undergoes rapid hydrolysis by blood and extravascular tissues to inactive metabolites. Its pharmacokinetics are least likely to be affected by aging, renal dysfunction, or hepatic dysfunction

Question 28

What best describes a drug that is most likely to be highly eliminated by continuous venovenous hemodiafiltration therapy?

Answer 28

Small molecule, low protein binding, small volume of distribution

Question 29

What is the treatment for a patient with LVOT obstruction and tachycardia?

Answer 29

The cardiomyopathy is nonischemic as evidenced by the cardiac catheterization data. The most appropriate therapy is beta blockade to relieve the LVOT obstruction by slowing the heart rate and allowing the left ventricle to fill in.

Question 30

What is the American College of Obstetricians and Gynecologists’ (ACOG) criteria for hypertensive emergency?

Answer 30

Systolic blood pressure and diastolic blood pressure are above 160 and 110 mm Hg, respectively, and she has evidence of end-organ damage (creatinine 2.1 mg/dL).

Question 31

What does ACOG recommend for the treatment of hypertensive emergency?

Answer 31

ACOG recommends admitting patients with hypertensive emergency to the ICU for continuous monitoring of both mother and fetus. It is recommended to reduce blood pressure slowly to normal range within 24 to 48 hours, not within the first hour. It is also recommended to reduce diastolic blood pressure by 20% or to 100 to 110 mm Hg within 30 to 60 minutes.

Question 32

If regular insulin, 5 units IV, is administered rather than regular insulin, 10 units IV, which of the following effects on serum potassium and risk of severe hypoglycemia will most likely result?

Answer 32

Similar decrease in serum potassium and decreased risk of severe hypoglycemia

Question 33

A 72-year-old woman presents with chest pain, shortness of breath, and a loud systolic murmur. Echocardiography shows left ventricular outflow track 2.4 cm, left ventricular outflow track peak velocity 100 cm/s, and aortic jet peak velocity 5.0 m/s. What is the aortic valve area?

Answer 33

Aortic valve area (AVA) can be determined by measuring left ventricular outflow tract (LVOT) diameter, then converting to cross-sectional area (CSALVOT); LVOT peak velocity (VTILVOT where VTI is velocity-time integral); and aortic valve (AV) jet peak velocity (VTIAV), using the continuity equation AVA = (CSALVOT × VTILVOT)/VTIAV.

0.9 cm2

Question 34

What is the treatment for neurogenic pulmonary edema?

Answer 34

No specific therapy, including steroids or phentolamine, has proven effective for this condition

Question 35

What is neurogenic pulmonary edema?

Answer 35

Neurogenic pulmonary edema (NPE) is a clinical condition arises as acute respiratory distress taking place in conjunction with severe neurological damage/injury. By definition, this condition incorporates a clinical picture of a large accumulation of extra-vascular pulmonary fluid, of acute onset, always in the immediate outcome of serious central nervous system (CNS) lesions, mostly the brainste

Question 36

A 73-year-old man with a history of diastolic dysfunction has a myocardial infarction and undergoes emergent percutaneous angioplasty. Immediately afterward, his blood pressure falls to 93/70 mm Hg. Right heart catheterization reveals pulmonary capillary wedge pressure 17 mm Hg and low cardiac output. Which of the following is the most appropriate initial treatment?

Answer 36

Fluid bolus

It is important to preserve adequate preload in patients who have had an acute myocardial infarction, even in those with a history of heart failure. A volume challenge should be initiated. Although inotropes such as dobutamine may be required, they can, in the case of inadequate preload, worsen the hypotension. Vasopressors increase myocardial oxygen demand and are not first-line therapies. Furosemide may also worsen the hypotension, even in the face of relatively normal pulmonary capillary wedge pressure.

Question 37

What are the indications for a provoked VTE and when is a IVC filter indicated?

Answer 37

The guideline for treatment duration for provoked VTE is 3 months. It should be treated with anticoagulation when there are no contraindications to anticoagulant therapy, regardless of whether it is proximal or distal.

Inferior vena cava filters do not prevent or treat venous thromboses and their sequelae (such as chronic venous insufficiency). Their only purpose is to prevent life-threatening pulmonary emboli. Thus, their utility is strictly limited to patients for whom anticoagulation is contraindicated

Question 38

Which of the following is the most appropriate management approach to patient with Boerhaave syndrome?

Answer 38

Swallow study and broad-spectrum antibiotics including fluconazole

Question 39

A 26-year-old man with no significant past medical history develops shortness of breath with PaO2 59 mm Hg on room air, confusion, and a petechial rash over the upper torso and conjunctiva 2 days after sustaining an isolated right femoral fracture. Which of the following is the most likely expected finding on chest CT?

Answer 39

Diffuse, patchy ground-glass opacities with intralobular septal thickening and small, centrilobular nodules in a peripheral and upper lobe distribution

Fat embolism syndrome is characterized by respiratory distress, confusion, and a petechial rash over the anterior upper torso, axillary regions, and conjunctiva. Typical findings on chest CT are diffuse, patchy ground-glass opacities with intralobular septal thickening (crazy-paving pattern) and small (< 10 mm) ill-defined centrilobular nodules in a predominately peripheral and upper lobe distribution often located in the subpleural regions and along the interlobular septa (thought to represent the vasculogenic origin of mechanical obstruction by fat globules).

Question 40

Which of the following is a consequence of low serum potassium?

Answer 40

Increase in serum pH

Lower serum potassium levels result in increased reuptake of potassium in the distal nephron via the H-K exchanger, resulting in loss of hydrogen ions and a resultant rise in serum pH. Low potassium levels are associated with lower magnesium levels. High potassium levels increase the likelihood ventricular arrhythmias while low levels are more often associated with atrial arrhythmias. Low potassium can result in decreased gut motility, constipation, and nausea, but not diarrhea. Potassium has no significant effect on the proportion of bound calcium.

Question 41

A 65-year-old man is evaluated in the emergency department for altered mentation and difficulty speaking. He was last seen normal before he went to sleep at 10:00 p.m. last night. This morning when he awoke at 6:00 a.m., he had difficulty speaking, right-sided weakness, and confusion. Noncontrast head CT shows no bleeding or acute pathology. Blood pressure is 170/85 mm Hg and heart rate is 110 beats/min and irregular. Telemetry strip shows atrial fibrillation. He takes no anticoagulant medications and his INR is normal. Diffusion-weighted MRI shows a lesion consistent with a middle cerebral artery ischemic stroke but this lesion is not seen on fluid-attenuated inversion recovery MRI. The most appropriate next step is

Answer 41

IV thrombolytic therapy with recombinant human tissue plasminogen activator

Wake up trial and extend trial

Question 42

A 68-year-old man underwent endovascular repair of a ruptured infrarenal abdominal aortic aneurysm. He received 8 units packed RBCs, 6 units fresh frozen plasma, 2 apheresis units platelets, and 1 L crystalloid solution before the repair was completed. He was admitted to the ICU intubated for respiratory distress. Initially, his hemodynamic status normalized after resuscitation. 24-hours after ICU admission, his vital signs are: blood pressure, 100/40 mm Hg; heart rate, 120 beats/min; and urine output, 20 mL/hr. His abdomen is distended but soft, with guarding on deep palpation to the left lower quadrant. Laboratory results show WBC count, 18,000/mcL; hematocrit, 24% (which is unchanged); and platelet count, 170,000/mcL. Arterial blood gas analysis shows: pH, 7.23, PCO2, 35 mm Hg; PO2, 119 mm Hg; bicarbonate, 17 mEq/L; and base deficit, 10 mEq/L. Which of the following is the most appropriate next step in management?

Answer 42

Perform flexible sigmoidoscopy.

infrarenal abdominal aortic aneurysm

Question 43

What is the recommended treatment for a mycotic aneurysm?

Answer 43

Open surgical repair remains the standard treatment, along with antibiotics for at least 6 weeks

Question 44

How do you treat hyperammonemia in patient with a discontinuous colon due to surgery?

Answer 44

IV levocarnitine

Question 45

How do you treat increased intracranial pressure in a patient with TBI?

Answer 45

Administration and IV bolus of 3% saline

Question 46

How do you differentiate NMS and MH from Serotonin Syndrome?

Answer 46

Hyperreflexia

Question 47

A 51-year-old man with bilateral internal carotid stenosis of 90% on the left and 80% on the right is admitted to the ICU after a left carotid endarterectomy. Which of the following is the most appropriate treatment strategy for optimal cerebral blood flow?

Answer 47

Nicardipine infusion to reduce SBP to less than 120 mm Hg

Question 48

What is the differenital diagnosis for black pleural fluid?

Answer 48

metastatic melanoma. Other causes of black pleural effusion include fungal infections (Aspergillus niger and Rhizopus oryzae) and charcoal-containing empyema.

Question 49

What is the test you order for hereditary angioedeama?

Answer 49

Measure serum complement C4 level. C1 if c4 is low

Question 50

Mineralocorticoid excess, current diuretic administration, milk-alkali syndrome, Bartter syndrome, and severe hypokalemia are associated with what urine chloride concentrations.

Answer 50

over 20 mEq/L

Question 51

Vomiting, nasogastric suction, postdiuretic use, and posthypercapnic states are associated with chloride-responsive metabolic alkalosis, with what urine chloride concentrations

Answer 51

less than 15 mEq/L.

Question 52

Dopamine primarily causes stimulation of alpha-1 receptors at which of the following doses?

Answer 52

11-20 µg/kg/min

Question 53

In patients with inhalational anthrax what 3-drug regimen should be used until meningitis can be excluded by cerebrospinal fluid testing

Answer 53

Ciprofloxacin, linezolid, and meropenem

Question 54

Beta-lactam antimicrobials exhibit time-dependent bacterial killing, which means what?

Answer 54

pharmacokinetic/pharmacodynamic (PK/PD) target of interest is the fraction of time during the dosing interval that the drug concentration exceeds the organism’s minimum inhibitory concentration (MIC). For this reason, shorter dosing intervals or prolonged infusions for this medication class are preferred relative to higher doses delivered less frequently.

Question 55

Vancomycin is a time-dependent antimicrobial with the trough concentration or area under the inhibitory curve (AUIC) as the preferred PK/PD targets which means what?

Answer 55

High peaks are associated with greater toxicity, so relatively lower doses delivered more frequently are preferred in patients with robust kidney function

Question 56

Gentamicin is a concentration-dependent antibiotic with a prolonged post-antibiotic effect meaning what

Answer 56

The degree to which the maximum concentration exceeds the organism’s MIC better predicts the outcome than the trough levels. Persistently elevated trough levels are associated with increased risk of nephrotoxicity. Thus, traditional aminoglycoside dosing several times daily is generally less preferred than pulse dosing, which delivers a higher dose at a less frequent interval to maximize PK/PD.

Question 57

In cases post TAVR with complete atrioventricular block with slow escape rhythm what is reccommended?

Answer 57

Pacemeake implant otherwise watch for seven days

Question 58

What risk factors for AKI after cardiac surgery?

Answer 58

female gender, congestive heart failure, left ventricular ejection fraction below 35%, preoperative intra-aortic balloon pump, chronic obstructive pulmonary disease, insulin-dependent diabetes mellitus, previous cardiac surgery, emergency surgery, elevated preoperative creatinine, and coronary bypass with valvular intervention.

Question 59

Which of the following tests best distinguishes between acute fatty liver and hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome in pregnancy?

Answer 59

Serum ammonia level