5. A 70-year-old woman is hypotensive and drowsy 4 days following abdominal surgery. Which one of the above conditions is most consistent with the following measurements on pulmonary artery catheterisation?
| Value | Reference range | |
|---|---|---|
| Cardiac output (L/min) | 9 | 5.2–7.4 |
| Central venous pressure (mmHg) | 4 | 2–6 |
| Pulmonary artery wedge pressure (mmHg) | 14 | 5–12 |
| Mixed venous saturation (%)* | 80 | 65–75 |
*Assuming normal arterial oxygen saturation.
Clinical
6. Which one of the following has been associated with the best chance of survival with a good neurological outcome after an out-of-hospital cardiac arrest?
A. Early defibrillation of ventricular fibrillation
B. Early administration of epinephrine (adrenaline)
C. Chest compression at a rate of 70/min
D. Atropine to treat asystolic cardiac arrest
E. Intravenous calcium chloride during cardiopulmonary resuscitation
7. Which one of the following therapeutic strategies can improve the survival of patients with adult respiratory distress syndrome and acute lung injury?
A. Early high-dose corticosteroids
B. Low frequency oscillatory ventilation
C. Low positive end-expiratory pressure
D. Low tidal volume ventilation
E. Supine positioning
8. A 69-year-old woman with stage 3 chronic kidney disease due to perinuclear anti-nuclear cytoplasmic antibody (p-ANCA) associated vasculitis presented with a 24-h history of acute dyspnoea, chest discomfort and watery diarrhoea. She was commenced on azathioprine (75 mg daily) 7 days prior to presentation to replace cyclophosphamide as part of her maintenance immunosuppressive therapy. On examination, she was drowsy, temperature was 35.2 o C. She was found to be hypotensive (blood pressure of 70/40 mmHg), tachycardic (pulse rate 120 beats/min) and the extremities were cold. First and second heart sounds were present without any murmur. She received intensive intravenous fluid therapy but remained hypotensive. A pulmonary artery catheter is placed and the readings are shown below. Which of the following is the most likely diagnosis?
| Value | Reference range | |
|---|---|---|
| Central venous pressure (mmHg) | 13 | 0–5 |
| Pulmonary artery pressure (mmHg) | 40/14 | 20–25/5–10 |
| Pulmonary capillary wedge pressure (mmHg) | 22 | 6–12 |
| Cardiac output (L/min) | 2.2 | 4–8 |
A. Cardiogenic shock
B. Hypovolaemic shock
C. Pericardial effusion
D. Septic shock
E. Toxic shock syndrome
9. Following acute smoke inhalation, which one of the following treatments is appropriate in the treatment of cyanide intoxication?
A. Hyperbaric oxygen
B. Beta-2 agonists
C. Methylene blue
D. Glucagon
E. Hydroxycobalamin
10. Which one of the following treatments can improve gastric motility in critically ill patients in the intensive care unit?
A. Diltiazem
B. Fentanyl
C. Rantidine
D. Erythromycin
E. Pantoprazole
11. A 35-year-old man, a victim of a motor vehicle accident, was found to have massive intracranial haemorrhage on computed tomography of his brain. He has been in a coma for the last 3 days in the intensive care unit and is currently on ventilator support. After talking to the family members, a decision was made to determine whether this patient fulfils the brain death criteria. Which one of the following regarding brain death testing is correct?
A. Sedative drugs should be administered
B. During apnoea testing, breathing is absent despite an arterial PCO2 of greater than 60 mmHg (8 kPa) and an arterial pH of less than 7.30
C. Four-vessel angiography is required to establish intracranial blood flow
D. Upgoing plantar responses excludes a diagnosis of brain death
E. There should be a minimum 2-h observation and mechanical ventilation during which the patient has unresponsive coma
12. Which one of the following should be included in the parenteral nutrition for critically ill patients?
A. Carbohydrate as glucose of 0.5 g/kg ideal body weight/day
B. Amino acid mixture 0.3–0.5 g/kg ideal body weight/day
C. Lipid emulsions 1–2 g/kg ideal body weight/day
D. Weekly multivitamins and trace elements
E. Separate infusions of lipid from amino acid-containing mixtures
13. Which one of the following is correct concerning patient management after successful resuscitation for ventricular fibrillation cardiac arrest?
A. Early post-resuscitation electrocardiography accurately identifies acute coronary occlusion
B. Oxygen supplementation should be administered to achieve oxygen saturation of 85–90%
C. Mechanical ventilation should be adjusted to achieve normocarbia
D. Myocardial dysfunction after arrest is usually irreversible
E. Pyrexia after cardiac arrest is self-limiting and does not require treatment
14. Which one of the following statements is true concerning pulmonary artery catheters?
A. The pulmonary artery wedge pressure is a measure of left atrial pressure
B. The use of pulmonary artery catheters is associated with improved intensive care unit survival
C. There is an increased incidence of ventricular arrhythmias
D. Left bundle branch block is a common complication
E. The normal pulmonary artery wedge pressure is 20–25 mmHg
15. In adult comatose patients after cardiac arrest, which one of the following parameters predicts a poor outcome?
A. Absence of pupillary light and corneal reflexes at 72 h
B. Absence of vestibulo-ocular reflexes at 12 h
C. Glasgow coma scale (GCS) of less than 5 at 12 h
D. Presence of myoclonus
E. A computed tomography (CT) scan showing cerebral infarction
16. A 65-year-old man presented with a 3-day history of fever and dysuria. His other medical problems included type 2 diabetes, chronic kidney disease (CKD) with serum creatinine of 178 μmol/L due to diabetic nephropathy, hypertension and anaemia with a haemoglobin of 85 g/L. He was transferred to the intensive care unit 2 h after admission because of severe urosepsis (APACHE II score 30) and persistent hypotension (blood pressure 85/50 mmHg) despite intravenous fluid resuscitation. Which one of the following statements concerning treatment options is correct?
A. Blood should be transfused to maintain a haemoglobin level above 100 g/L
B. High-dose steroids should be administered
C. Patients should be placed in the supine position
D. Blood glucose level should be strictly controlled between 4.5 and 6.0 mmol/L
E. There is no clear benefit of colloid over crystalloid fluid resuscitation
17. A 60-year-old man presents with sudden onset of palpitations. He is alert and orientated. His blood pressure is 100/70 mmHg. His cardiac rhythm is shown below. Which one of the following medications is contraindicated in this patient to correct the rhythm disturbance?
A. Amiodarone
B. Lignocaine
C. Verapamil
D. Magnesium
E. Procainamide
18. Which one of the following factors is associated with increased chances of a successful spontaneous-breathing trial after prolonged mechanical ventilation?
A. Pneumonia as cause of respiratory failure
B. Chronic heart failure
C. Upper airway stridor at extubation
D. Partial pressure of arterial carbon dioxide of greater than 45 mmHg after extubation
E. Daily interruption of sedative infusion
19. A 50-year-old man with cirrhosis due to hepatitis C (from past intravenous drug use) and refractory ascites is being evaluated for liver transplantation. His clinical condition is also complicated by porto-pulmonary hypertension. Which one of the following is an absolute contraindication to orthotopic liver transplantation?
A. A single hepatocellular carcinoma lesion of 3 cm in diameter
B. Acute kidney injury due to hepatorenal syndrome
C. Not responsive to interferon–ribavirin treatment
D. Pulmonary artery pressure of 55 mmHg
E. Refractory ascites
Theme: Management of cardiac arrest and arrhythmias (for Questions 20–23)
A. Adenosine
B. Epinephrine (adrenaline)
C. Amiodarone
D. Atropine
E. Calcium chloride (10%)
F. Flecainide
G. Lignocaine
H. Magnesium sulphate
For each of the following scenarios, select the most appropriate treatment to be administered.
20. Which one of the above is administered in the management of pulseless ventricular tachycardia that persists after three shocks?
21. Which one of the above is used in the management of torsades de pointes?
22. Which one of the above should be administered to a patient experiencing palpitations caused by rapid atrial fibrillation (AF) with an accessory pathway?
23. Which one of the above should be administered to a patient who develops ventricular tachycardia at the onset of his regular haemodialysis with pre-dialysis biochemistry showing a potassium level of 7.0 mmol/L (3.4–4.5 mmol/L)?
Answers
Basic Science
1. Answer B
Acute metabolic acidosis is common in seriously ill patients and when severe, can be associated with a poor clinical outcome (Kraut and Madias, 2012). Therefore, rapid recognition and provision of effective therapy are essential. The majority of cases of severe metabolic acidosis are caused by lactic acidosis and ketoacidosis. This disorder is associated with the following deleterious effects:
Acute metabolic acidosis is common in seriously ill patients and when severe, can be associated with a poor clinical outcome (Kraut and Madias, 2012). Therefore, rapid recognition and provision of effective therapy are essential. The majority of cases of severe metabolic acidosis are caused by lactic acidosis and ketoacidosis. This disorder is associated with the following deleterious effects:
- Decreased cardiac contractility and cardiac output
- Decreased tissue oxygen delivery
- Predisposition to cardiac arrhythmias
- Peripheral vasodilatation
- Resistance to catecholamines
- Pulmonary arterial vasoconstriction; may worsen pulmonary hypertension and induce/worsen right heart failure
- Venoconstriction
- Hypotension
- Decreased adenosine triphosphate (ATP) generation
- Impairment in glucose regulation
- Stimulation of inflammatory mediators
- Impairment of the immune response
- Impaired phagocytosis
- Increased apoptosis.
The beneficial effects include:
- Decreased affinity of haemoglobin for oxygen. leading to favourable haemoglobin–oxygen dissociation for tissue extraction of oxygen. The reduction in 2, 3-diphosphoglycerate (2, 3-DPG) counteracts this rightward shift. Note that a severe rightward shift also may result in poor haemoglobin saturation when passing through pulmonary capillaries
- Vasodilatation of vessels with increased blood flow to tissues
- Increased ionised calcium with augmented myocardial contractility.
Kraut, J.A. and Madias, N.E. (2012). Treatment of acute metabolic acidosis: a pathophysiologic approach. Nat Rev Nephrol 8, 589–601.
2. Answer B
The aims of managing respiratory failure in acute exacerbation of chronic obstructive pulmonary disease (COPD) are to prevent tissue hypoxia and control acidosis and hypercapnia while medical therapy works to improve lung function and reverse the precipitating cause of the exacerbation. pH is the best marker of severity and reflects acute deterioration in alveolar hypoventilation compared with the chronic stable state.
Non-invasive ventilation (NIV) can involve continuous positive airway pressure (CPAP), whereby the patient breathes spontaneously with positive end-expiratory pressure (PEEP), or biphasic positive airway pressure (BiPAP), whereby the patient breathes spontaneously with pressure support ventilation (PSV) and PEEP. In NIV, the patient receives air or a mixture of air and oxygen from a flow generator through a full facial or nasal mask. NIV augments alveolar ventilation (reverses respiratory acidosis and hypercarbia), leads to alveolar recruitment (reverses hypoxia), decreases the work of breathing (reduces respiratory muscle insufficiency) and reduces left ventricular afterload (improves cardiac output) (Nava and Hill, 2009).
NIV as an adjunct to usual medical care significantly reduces mortality, need for endotracheal intubation, risk of treatment failure and length of hospital stay. There is good evidence for benefit of NIV in patients with moderate respiratory acidosis with a pH of 7.35 or lower and raised partial pressure of arterial carbon dioxide. NIV is contraindicated with respiratory arrest, an unprotected airway, upper airway obstruction, untreated pneumothorax, inability to clear secretions and marked haemodynamic instability.
The aims of managing respiratory failure in acute exacerbation of chronic obstructive pulmonary disease (COPD) are to prevent tissue hypoxia and control acidosis and hypercapnia while medical therapy works to improve lung function and reverse the precipitating cause of the exacerbation. pH is the best marker of severity and reflects acute deterioration in alveolar hypoventilation compared with the chronic stable state.
Non-invasive ventilation (NIV) can involve continuous positive airway pressure (CPAP), whereby the patient breathes spontaneously with positive end-expiratory pressure (PEEP), or biphasic positive airway pressure (BiPAP), whereby the patient breathes spontaneously with pressure support ventilation (PSV) and PEEP. In NIV, the patient receives air or a mixture of air and oxygen from a flow generator through a full facial or nasal mask. NIV augments alveolar ventilation (reverses respiratory acidosis and hypercarbia), leads to alveolar recruitment (reverses hypoxia), decreases the work of breathing (reduces respiratory muscle insufficiency) and reduces left ventricular afterload (improves cardiac output) (Nava and Hill, 2009).
NIV as an adjunct to usual medical care significantly reduces mortality, need for endotracheal intubation, risk of treatment failure and length of hospital stay. There is good evidence for benefit of NIV in patients with moderate respiratory acidosis with a pH of 7.35 or lower and raised partial pressure of arterial carbon dioxide. NIV is contraindicated with respiratory arrest, an unprotected airway, upper airway obstruction, untreated pneumothorax, inability to clear secretions and marked haemodynamic instability.
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