Figure 43.1. Rhythm strip of patient in Question 1.

QUESTION 2. A 50-year-old woman with a history of hypertension is brought to the emergency room after an extensive house fire. On presentation she is afebrile, her heart rate is 120 beats per minute, blood pressure is 105/45 mm Hg, respiratory rate is 23 breaths per minute and unlabored. Her Sao₂ is 98% (pulse oximetry). The best next step in her evaluation would be:

    A. Immediate intubation and bronchoscopy to exclude lower airways thermal injury

    B. Arterial blood gas for Pao₂ determination

    C. Administration of methylene blue and check cyanomethemoglobin level

    D. Arterial blood gas with co-oximetry

QUESTION 3. Which of the following statements is true regarding central venous catheters?

    A. The frequency vof mechanical complications of central line placement (arterial puncture, hematoma, and pneumothorax) is twice as high for internal jugular catheterizations as for subclavian vein catheterizations.

    B. Femoral vein cannulation carries a higher risk of arterial puncture than internal jugular or subclavian site.

    C. Subclavian vein catheterization is associated with a higher infection rate than internal jugular vein catheterization.

    D. Routine exchanges of catheters every 7 days is associated with a decreased rate of catheter infection.

QUESTION 4. A 35-year-old woman is admitted to the intensive care unit with crush injury after a motor vehicle accident. After 48 hours of admission, she develops an increased oxygen requirement. She is intubated, and mechanical ventilation is initiated. Which of the following interventions is not universally recommended to reduce incidence of ventilator-associated pneumonia?

    A. Continuous aspiration of subglottic secretions

    B. Selective decontamination of the digestive tract

    C. Elevation of the head of the bed to >30°

    D. Changes of ventilator circuit only when visibly soiled

QUESTION 5. A 23-year-old college student is brought to the emergency room after ingestion of 60 mL of wintergreen oil in a suicidal gesture. She is lethargic and unable to answer questions. On presentation she has a respiratory rate = 28 breaths per min with deep respirations. Oral temperature = 100.5°F, heart rate = 128 beats per minute, blood pressure = 124/60 mm Hg. Skin has no rashes. There is no evidence of external trauma. Lungs are clear. Cardiovascular examination shows a regular rate and rhythm with a normal S1 and S2. Abdomen is soft with mild diffuse tenderness. Neuro examination is nonfocal. Her laboratory data reveal a Sodium = 136 mEq/L, Potassium = 3.8 mEq/L, Chloride ion = 100 mEq/L, Bicarbonate = 18 mEq/L, Creatinine = 0.6 mg/dL, Glucose = 90 mg/dL, WBC = 12,000/μL, Hct = 42%, Platelet = 300,000/μL. Arterial blood gas (ABG) on 2 L via NC reveals pH = 7.44, Paco₂ = 22 mm Hg, Pao₂ = 100 mm Hg. Chest x-ray is normal. Electrocardiogram (EKG) reveals normal sinus rhythm (NSR) without ischemia. The remainder of her laboratory studies are pending. In the emergency room she was begun on intravenous normal saline (NS). Activated charcoal was given. Your next step should be to:

    A. Administer acetazolamide

    B. Begin mechanical ventilation

    C. Change intravenous fluid (IVF) to bicarbonate- containing solution

    D. Begin beta blocker

    E. Administer N-acetylcysteine

QUESTION 6. A decision is made to intubate an asthmatic patient for impending respiratory failure. During intubation, the patient receives sedation and a short-acting paralytic agent. Initial ventilator settings are assist control, respiratory rate = 16 breaths per minute, tidal volume = 500 mL, positive end-expiratory pressure (PEEP) = 5 cm H₂O, inspiratory flow rate = 60 L/minute, Fio₂ = 1.0. An end-inspiratory pause is administered, and the peak inspiratory pressure (PIP) and plateau pressure (P_plat) are measured. Compliance (C_stat) and airway resistance (R_aw) are calculated. In this patient with status asthmaticus the most likely findings would be:

    A. PIP = 35 cm H₂O, P_plat =15 cm H₂O, C_stat = 50 mL/cm H₂O, R_aw = 20 cm H₂O/L/sec

    B. PIP = 17 cm H₂O, P_plat = 15 cm H₂O, C_stat = 50 mL/cm H₂O, R_aw = 2 cm H₂O/L/sec

    C. PIP = 32 cm H₂O, P_plat = 30 cm H₂O, C_stat = 20 mL/cm H₂O, R_aw = 2 cm H₂O/L/sec

    D. PIP = 35 cm H₂O, P_plat = 15 cm H₂O, C_stat = 40 mL/cm H₂O, R_aw = 2 cm H₂O/L/sec

QUESTION 7. After 4 hours on these ventilator settings, the peak inspiratory pressure (PIP) is noted to now be 50 cm H₂O. Review of the ventilator waveforms indicates the flow-time curve graphic shown in Figure 43.2.

    Which ventilator change should be considered next?

    A. Increase the set respiratory rate

    B. Decrease the Fio₂

    C. Decrease the set inspiratory time

    D. Increase the inspiratory flow rate

    E. Decrease the tidal volume

QUESTION 8. Which of the following statements is false regarding the fat embolism syndrome (FES)?

    A. FES refers to the triad of respiratory dysfunction, neurological changes, and renal failure caused by entry of fat particles into the microcirculation.

    B. FES occurs in 5–10% of patients with multiple long bone fractures or concomitant pelvic fractures.

    C. There is commonly a latent period after the injury before clinical manifestation is noted.

    D. FES without pulmonary involvement is uncommon.

QUESTION 9. A 50-year-old male smoker with chronic obstructive pulmonary disease and diabetes mellitus type 2 is admitted to the ICU with pneumonia and respiratory failure. He is intubated, and mechanical ventilation is initiated. Laboratory studies on presentation reveal Sodium = 140 mEq/L, WBC =19,000/μL (89% polys, 4% bands), Potassium = 4.6 mEq/L, Hct = 38%, Chloride = 110 mEq/L, Platelet = 190,000/μL, Bicarbonate = 26 mEq/L, Glucose = 230 mg/dL.

    Intravenous vancomycin, levofloxacin, Solu-Medrol, and bronchodilator therapy are ordered. A ventilator bundle is implemented including elevation of head of bed, daily assessment of readiness to extubate, daily sedation holiday, GI prophylaxis with intravenous Pepcid, and deep vein thrombosis (DVT) prophylaxis with heparin subcutaneously. An intravenous insulin infusion is begun with goal glucose of ≤180 mg/dL. On hospital day 7 patient remains intubated. He has new right lower extremity pain. Right dorsalis pedis and posterior tibialis pulses are newly absent. Laboratory values reveal Sodium = 136 mEq/L, WBC = 12,000/μL (93% polys, 0% bands), Potassium = 3.6 mEq/L, Hct = 36%, Chloride = 106 mEq/L, Platelet = 40,000/μL, Bicarbonate = 22 mEq/L, Glucose = 114 mg/dL. Platelet factor-4 (PF4) antibodies and vascular imaging studies are ordered. In addition to surgical consultation, appropriate treatment includes:

    A. Stop unfractionated heparin and begin platelet infusion

    B. Stop unfractionated heparin and monitor platelets daily

    C. Stop unfractionated heparin and begin low- molecular-weight heparin

    D. Stop unfractionated heparin and begin argatroban

    E. Stop unfractionated heparin and begin warfarin

QUESTION 10. 60-year-old man is admitted with severe midepigastric abdominal pain radiating to the back. Oral temperature is 103°F. Heart rate is 100 beats per minute, and current blood pressure is 110/60 mm Hg. Lipase is elevated. Abdominal CT scan reveals pancreatic inflammation with areas of necrosis. Biliary ducts are not dilated. The best next step in management would be:

    A. Begin enteral nasojejunal feeds

    B. Normal saline (NS)

    C. Empirical antibiotic treatment with aminoglycoside

    D. Empirical antifungal therapy

QUESTION 11. Decisions regarding end-of-life care are guided by all the ethical principles outlined below except one.

    A. Autonomy

    B. Nonmaleficence

    C. Beneficence

    D. Social justice

QUESTION 12. A 75-year-old man is admitted to the intensive care unit with increased respiratory distress. He is a current smoker (75-pack-year history). Most recent outpatient spirometry revealed an FEV₁ of 50% of predicted. At home he is on inhaled tiotropium and an albuterol inhaler as needed. Treatment was initiated with supplemental oxygen, 4 L/minute via nasal cannula, intravenous steroids, inhaled bronchodilators, and broad-spectrum antibiotics. He notes progressive dyspnea. On evaluation he appears fatigued but follows all commands. He is currently afebrile, heart rate is 96 beats per minute, blood pressure is 104/62 mm Hg, and his respiratory rate is 32 breaths per minute with use of accessory muscles. Oxygen saturation is 92%. Auscultation of lungs reveals bilateral expiratory wheezes. Arterial blood gas reveals pH = 7.29, Pco₂ = 60 mm Hg and Po₂ = 66 mm Hg.

    What would be the best next treatment?

    A. Increase FIO₂ to 6 L via nasal cannula

    B. Diuresis

    C. Initiation of noninvasive ventilation

    D. Intubation and initiation of mechanical ventilation

QUESTION 13. 67-year-old woman with a history of hypertension and coronary artery disease presents with 72 hours of progressive lethargy, fever, and dysuria. On evaluation in the emergency department she is lethargic but arousable. Her heart rate is 126 beats per minute and regular, blood pressure = 70/46 mm Hg, respiratory rate = 24 breaths per minute unlabored. Jugular venous pressures do not appear to be elevated. Lungs are clear to percussion and auscultation. Cardiac examination reveals a tachycardia but regular rate and rhythm. There are no murmurs noted. Abdomen is soft and nontender. WBC = 13,000/μL with a left shift. Hct is 42%. Urinalysis reveals too numerous to count WBCs. EKG is unremarkable. Urine and blood cultures are obtained. Antibiotics are initiated. What is the most appropriate next step in treatment?

    A. Initiation of vasopressin drip

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