Transcript Board Review

Critical care Board Review
2008
Antoinette Spevetz, MD, FCCP, FCCM
CPR
• Outcome is improved in patients with
witnessed arrest, those who present in VF
or VT
• Asystole or PEA has poor survival
• On first analysis 40% of victims are in VF
• Push hard, push fast, allow full chest recoil
and minimize interruptions
CPR
• Four links
– Early
– Early
– Early
– Early
recognition and activation of 911
bystander CPR
delivery of shock
ACLS v
ACLS
• Vasopressin may substitute for one dose
of epinephrine
According to ACLS guidelines, which of the following
recommendations for vasopressin administration (single
40-U intravenous bolus) us correct?
(A) It is not recommended
(B) It is an alternative to epinephrine for ventricular
fibrillation or pulseless ventricular tachycardia
(C) It is an alternative to epinephrine for pulseless
electrical activity
(D) It is a second-line intervention, following 3
doses of epinephrine for cardiac arrest
• Which of the following statements is correct
regarding in hospital cardiac arrest and CPR
– A. pts who have VF have better outcomes that
patients who have asystole
– B. asystole is more common than VF in pts with
cardiac arrest
– C. early use of Ca channel blockers improves
neurologic recovery
– D. sodium bicarb should be given every 5 min during
CPR
– E. well performed external cardiac compression
usually provides 40-50% of normal circulatory flow
PEA
•
•
•
•
•
•
•
•
•
•
Hypovolemia
Hydrogen ion
Hypo/hyperkalemia
Hypoglycemia
Hypothermia
Toxins
Tamponade
Tension pneumothorax
Thrombosis
Trauma
A 55 year old man arrives in the ED in
complete cardiopulmonary arrest.
Cardiopulmonary resuscitation, started by
the paramedic team who transported him,
is still in progress. Electrocardiographic
monitoring reveals a heart rate of 72 per
minute but no pulse can be palpated.
Which of the following is the most appropriate
next step?
(A) Dobutamine infusion
(B) Amiodarone infusion
(C) Normal saline by rapid infusion
(D) Electrical cardioversion
(E) Insertion of a transvenous
pacemaker
Hypothermia
• Unconscious patients with spontaneous
circulation after out of hospital arrest
should be cooled to 32-34C for 12-24
hours
• Cooling may be beneficial for other
rhythms
In which of the following circumstances is
induced hypothermia (to 33.0 C [91.4 F]) most
likely to result in improved outcome?
(A) Traumatic head injury
(B) Comatose survivors of cardiac arrest
(C) Stroke
(D) Bacterial meningitis
(E) Encephalitis
• In a patient with out of hospital VF which of the
following is most likely to improve the likelihood
of survival with intact neurologic function?
–
–
–
–
–
A. amiodarone
B. dilantin
C vasopressin
D. induced hypothermia to 33C
F. automated external defibrillation
Pain, Anxiety and Delirium
• Must be regularly assessed
• Evoke a stress response
• Complicate management of life saving
devices
• Assess pain first using a numeric scale
• Assess anxiety and sedation using
validated scales (RASS )
Pain, Anxiety and Delirium
• Assess delirium with CAM-ICU
• Use non pharmacologic means when
possible
• Use intermittent bolus when possible and
daily sedation vacations
• When other factors are ruled out use
haldol as the drug of choice
• Can see persistent neuropsychological
dysfunction in ICU survivors
Inhalation Injuries
• Injury can occur as a result of three
mechanisms
– Direct thermal injury
– Low oxygen concentration
– Toxic products of combustion
Inhalation Injuries
• Initial assessment
– Evaluate upper airway – are there burns,
soot, singed eyebrows, carbonaceous sputum
– Intubate if airway compromise or with
significant second or third degree burns
– Hot gases (steam) can rapidly cause upper
airway injury
– Upper airway takes the brunt of the damage –
usually do not see lower airway damage
Inhalation Injuries
•
•
•
•
•
•
•
•
Tissue edema will worsen over 24-48 hours
Keep intubated at least 72 hours
Err on the side of intubation
hypoxia or diffuse infiltrates at admission are a poor
prognostic sign
Normal CXR does not exclude inhalational injury
Aggressive respiratory therapy (heliox, racemic epi,
elevate HOB)
Bronchoscopy
No steroids
Inhalation Injuries
• Toxic gases
– Act as asphyxiants
– Cause airway irritation
– Function as systemic toxins
• CO and cyanide are two most common
inhaled systemic toxins
• CO is cause of death in 75% of fire
fatalities
Inhalational Injuries
• CO competes directly with O2 for Hgb
binding, fixes to cytochrome oxidase and
displaces the oxyhgb dissociation curve to
the left
• Breathing 100% O2 decreases t1/2 to 3090 minutes
• No real benefit to hyperbaric
Inhalational Injury
• Closed space fires generate cyanide
through combustion of wood, silk, nylon,
and polyurethane
• May see nml PaO2, O2 sat, and O2
content
• Mixed venous will be high due to
undelivered O2
• Treatment : amyl nitrate, sodium nitrite,
sodium thiosulfate (Lilly kit)
Agents of warfare
• Decontamination
• Agents
– Nerve gas – vaporized liquid (miosis,
salivation, resp failure from diaphragm
paralysis) Rx with 2-PAM and atropine
– Chlorine- bronchospasm, pulm edema
– Mustard gas – rhinorrhea, airway injury,
vesicant causing burns
– Phosgene- tracheobronchitis, airway injury,
pulm edema, vesicant
Which of the following best describes the earliest
radiological findings of inhalation anthrax?
(A) Mediastinal widening and pleural effusions
(B) Lobar consolidation
(C) Interstitial infiltrates
(D) Multiple pulmonary nodules
(E) Multiple thin-walled cavities
Anaphylaxis
Release of mediators from mast cells and
basophils triggered by IgE allergen
interaction or by a nonantibody antigen
mechanism
(foods like peanuts & shellfish, insect stings,
latex)
Signs &symptoms include urticaria,
conjunctival puritis, bronchospasm,
nausea, vomiting.
Anaphylaxis
• Shock is caused by severe hypovolemia and
•
•
•
vasodilitation
Death from refractory bronchospasm, upper
airway obstruction and cardiovascular collapse
Treatment – fluids, epi, intubation,
antihistamines, H2 antagonist, steroids,
glucagon if pt is on B blocker (ABCD approach)
Monitor for biphasic anaphylaxis
•l
Hypertensive Crisis
• Hypertensive emergencies – HTN and end
organ damage (encephalopathy, cardiac,
renal)
• Hypertensive urgency – no end organ
damage
Hypertensive Crisis
• Search for secondary cause
– Cerebral infarct, ICH
– MI, LV failure, angina
– Dissecting aneurysm
– Severe preeclampsia
– Renovascular HTN
– Abrupt withdrawal from antihypertensives
– Drug use
Hypertensive Crisis
• Hypertensive urgencies can be discharged from
•
•
•
•
the ED. Those who are elderly, have h/o stroke,
ischemia should be watched
HTN emergencies should be admitted to ICU
and treated with parenteral agents
Goal of therapy is to reduce end organ damage
not normalize the BP
Decrease the MAP 20-25 % or diastolic <120
With ischemic stroke cerebral autoregulation is
disturbed and BP therapy may worsen situation
Hypertensive Crisis
• Oral drugs
– Captopril – reflex tachycardia, contraindicate
in pregnancy, RAS, potentiated with lasix
– Clonidine – sedation, abrupt cessation causes
rebound
– Labetalol – bronchospasm, careful with
diuretic
– Prazosin – pheo, can cause syncope, palp,
tachy, hypotension
Hypertensive Crisis
• Parenteral drugs
– Diazoxide – potent arterial vasodilator, lg doses can
cause hypotension and reflex tachy, increases LV
contractility, causes increased myocardial O2
consumption
– Enalapril – useful in CHF, contraindicated in
pregnancy
– Esmolol – usual B blocker stuff
– Fenoldopam – selective peripheral dopamine receptor
agonist, causes vasodilation of renal bed, decreases
preload and afterload (good for LV failure)
Hypertensive Crisis
• Hydralazine – arteriolar vasodilator, used in
•
•
•
•
•
•
preeclampsia, caution with hypovolemia, CAD, aortic
dissection, causes reflex tachy
Labetalol – iv or infusion
NTG – venodilator and coronary vasodilator, tolerance
develops
Nicardipine – decreases cerebral and cardiac ischemia,
easy to use
Phentolamine – pheo, can cause arrhythmias and tachy
Nipride – arterial and venodilator, rapid onset, easy
titration, concern over toxicity (thiocyanate)
Trimethaphan – ganglionic blocker, aortic dissection
A 70-year-old man is evaluated in the
emergency department because of headache
and mild nausea. Blood pressure is
210/125 mm Hg. He has a long history of
hypertension but is not adherent to his
antihypertensive regimen. He has not taken any
medications for three weeks. He does not use
illicit drugs. The patient is admitted to the
intensive care unit.
S1 and S2 are regular, with a summation gallop.
No pulmonary wheezes or crackles are heard.
Funduscopic examination is negative for
papilledema. Neurologic findings are nonfocal.
Electrocardiogram shows sinus tachycardia with
evidence of left ventricular hypertrophy and a
strain pattern; no new changes are noted
compared with a tracing obtained six months
ago.
Laboratory studies
Hematocrit
Leukocyte count
Peripheral blood film
Blood urea nitrogen
Serum creatinine
Serum electrolytes:
Sodium
Potassium
33%
10,500/μL
Microangiopathic hemolysis
60 mg/dL
5.2 mg/dL
135 mEq/L
5.4 mEq/L
Chest radiograph shows slight cardiac enlargement, clear
lung fields, and no evidence of pleural effusion.
Computed tomogram of the head (without contrast) is
normal.
Which of the following is most likely to decrease blood
pressure and increase blood flow to the kidneys?
(A) Clonidine
(B) Fenoldopam
(C) Nifedipine
(D) Nitroprusside
A 73-year-old woman is admitted to the
intensive care unit following an acute
ischemic stroke in the left parietal cortex.
She has a long history of hypertension,
peripheral vascular disease, chronic kidney
disease, and cigarette smoking. Blood
pressure is 225/135 mm Hg. Serum
creatinine is 2.2 mg/dL at admission
(baseline of 2.0 mg/dL).
Which of the following is most appropriate
for blood pressure control in this patient?
(A) Hydralazine
(B) Labetalol
(C) Nifedipine
(D) Nitroprusside
(E) No antihypertensive treatment
Hyperthermic emergencies
• Nonexertional heat stroke – fever above
•
•
105, hot dry skin, and CNS dysfunc (children left
in cars)
Body has huge capacity for heat dissipation (2
ml of sweat results in a kilocal of heat loss.
Humans can produce 2 l per hour)
Heatstroke shares pathophys of sepsis –
activation of clotting, inhibition of endogenous
fibrinolysis, generation of proinflammatory
cytokines like TNF and IL - 1
Hyperthermic emergencies
• Exertional heat stroke – high
fever,(105), hot dry skin, cns dysfunction
in setting of physical exertion
• vigorous physical activity in a hot humid
environment
• Rhabdo more likely, dehydration
Hyperthermic emergencies
• Temps above 104 (40C) are life
threatening.
• Brain death begins at 106 (41C)
• First sign is absence of sweating, warm
dry skin
• Above 105 LOC, muscle rigidity, seizure,
rhabdo, DIC
• Death above 113
Hyperthermic emergencies
malignant hyperthermia - excessive heat generation
-
resulting from dysfunctional Ca channels in skeletal m
Genetic predisposition
Precipitated by exposure to halogenated inhalational
anesthetics and/or depolarizing NM blockers (halothane
and suc)
More common in younger people
Dx: muscular rigidity, fever (41-45C) rapid rise, acidosis,
tachy, tachypnea, arrhythmias, mottling, rhabdo,
massive increase in metabolic rate, tissue hypoxia
RX: stop exposure, dantrolene (inhibits Ca release from
sarcoplasmic reticulum
A 15 year old boy sustained pulmonary
contusions and multiple fractures of the
ribs and lower extremities in a car
accident approximately 12 hours ago.
Open reduction and internal fixation of the
femoral and tibial fractures were required
and general anesthesia was administered
without complications.
On physical examination in the ICU, the
patient is confused and tachypneic. His
temperature is 40.0 C (104.0 F), pulse
rate is 130 per minute, respirations are 38
per minute and blood pressure is 100/70
mm Hg. His skin is mottled. His arms are
diffult to flex or extend.
Laboratory Studies
Serum creatine kinase
Serum calcium
Serum potassium
Arterial blood studies
1500 U/L
10.2 mg/dL
5.7 mEq/L
(with pt. breathing 50% oxygen by face mask)
PO2
PCO2
pH
150 mm Hg
50 mm Hg
7.21
Which of the following should you administer
now?
(A) Glucose and insulin
(B) Dantrolene
(C) Propranolol
(D) Nitroglycerin
(E) Sodium bicarbonate
Hyperthermic emergencies
• Neuroleptic malignant syndrome – drug associated
•
•
•
•
•
hyperthermic syndrome characterized by fever, muscle rigidity,
altered mentation, pulm dynfunction and autonomic instability
Differential includes thyroid storm, heatstroke, tetanus, pheo, Li
toxicity, MAO crisis, serotonin syndrome
Etiology involves some combination of drug induced changes in
dopamine levels in brain and skeletal m.
Usually caused by antipsychotics, not a clear dose-risk relationship,
can be seen in antipsychotic withdrawal or withdrawal of
antiParkinson meds
No rigid criteria for diagnosis – fever, rigidity, extrapyramidal
symptoms, rhabdo
Rx: stop drug, fluids, dantrolene, bromocriptine
Hyperthermic emergencies
• COOL…………fans, cooling blankets, cold
IV fluids, cold lavage, control shivering
• Combine convection and evaporation
• Spray with water and use fan
Hypothermia
• Core temp of less than 95F or 35C
• Caused by medications that alter
perception of cold, increase heat loss
through vasodilation, inhibit heat
generation
• Seen in adrenal insuf, hypoglycemia,
myxedema, hypopit, sepsis, DKA,
malnutrition, burns and spinal cord injuries
Hypothermia
• Cardiac – Osborn wave, increased HR and BP initially
•
•
•
•
•
and then as temp falls they decrease, myocardial
instability
Neuro – decrease resp drive, lethargy, confusion, coma,
deep tendon reflexes disappear, pupils become fixed
Renal – cold diuresis, volm depletion
Resp – drive decreases, resp acidosis, curve shifts to left
Heme – hemoconcentration, increased WBC, low plts,
impaired clotting
Rhabdo, hyperglycemia, pancreatitis, ileus, dvt
Hypothermia
• Overly aggressive RX kills people
• Gentle handling, rewarming, close
observation, search for underling ds
• Stay away from the heart with lines
• Warm fluids, gastric lavage, cover head
and neck, blankets, warm air
• Temp greater than 85 (29C) before death
is declared
Nutrition
• Pts in ICU require 25-30 kcal/kg/day and 1-1.5
•
•
•
•
protein. Calories should not come from protein
Monitor prealbumin
Oral feeding always preferred
TPN usually 70% dextrose and 30% lipid
calories. Associated with increased infection,
gut mucosal atrophy and translocation of gut
bacteria
Immunonutrition MAY be beneficial
A 51-year-old man is in the intensive care unit
because of sepsis and multiple organ system
failure following colonic resection for a ruptured
diverticulum five days ago. Infected peritoneal
fluid was drained from the abdominal cavity
during surgery. The patient weighs 80 kg
(176 lb). He is tolerating enteral nutrition with a
standard commercial preparation (1 kcal/mL),
10 mL/hr.
Which of the following should you order next?
(A) Advance the current nutritional preparation, as
tolerated
(B) Change to an enhanced preparation of glutamine,
arginine, antioxidant, and omega-3 fatty acids
(C) Begin supplemental total parenteral nutrition
(D) Add daily parenteral administration of lipid
suspension
Poisonings and Overdoses
• Acetominophen
– Usually fatal does exceeds 140mg/kg
– P450 system converts less than 5% to
reactive metabolites which are then detoxified
by glutathione
– Massive OD overwhelms the glutathione
supply
– Ethanol, BCP, phenobarb predisposes to
toxicity
Poisonings and Overdoses
• Acetaminophen -symptoms are initially minimal
– n/v – then RUQ pain and oliguria in a few
days. Transaminases peak and hepatic necrosis
follows in 3-5 days. Poor prognostic factors
include late presentation, coagulopathy,
metabolic acidosis, renal failure, cerebral edema
– N-acetylcysteine is drug of choice – load of 140
mg/kg then 17 doses of 70 mg/kg q 4
– Charcoal OK
– Use nomogram
– Watch for hypoglycemia
Poisonings and Overdoses
• Salicylates – rare but 1/3 die before
leaving the ED, lethal dose 10-30 gms
– Altered MS, tinnitus, hypoxia, hyperosmolarity,
hyperthermia, seizures
– Direct cns stim and resp alk with
compensatory renal wasting of sodium
– Metabolic acidosis (increased AG)
– Pulm edema
– May also see metabolic alk secondary to n/v
Poisonings and Overdoses
• Salicylates
– risk of bleed secondary to inhibition of prothrombin,
plt function impairment and gastric mucosa irritation
– Give vit k, plts and FFP
– Oil of wintergreen has very high amt of salicylate (1
tsp =20 tabs)
– Rapidly absorbed so gastric evacuation does not
usually help
– Bicarb may lower toxicity and promote excretion
– Development of worsening acidosis (sedation and
MV)
– Can lead to a quick decline
– Dialysis
Poisonings and Overdoses
• Stimulants
– Direct cns toxicity or catecholamine release
– Present with aggitation, HTN, tachycardia,
mydriasis, warm moist skin
– PCP – nystagmus
– Ecstacy – hyperthermia, jaw clinching
– Cocaine – cardiac ischemia
– Nonspecific care, fluids. Haldol, benzos for
HTN, careful is using B blocker alone
(unopposed alpha)
Poisonings and Overdoses
• Ethanol
– Coma with levels higher than 300 mg/dl
– Death about 600 mg/dl
– Supportive therapy, thiamine, lytes, dialysis
rarely needed
Poisonings and Overdoses
• Alcohol withdrawal
– Symptoms within 36 hours of last drink but
may be delayed
– DTs should be managed in ICU
– Fever (r/o infection), tachycardia, HTN
– Npo, benzos
Poisonings and Overdoses
• Methanol
– Formic acid and formaldehyde
– Found in windshield de icing fluid, solid fuel
– 30 ml is toxic
– Optic neuritis and blindness
– Acidosis with anion and osmolar gaps
– Any CNS finding can be seen
Poisonings and Overdoses
• Ethylene glycol
– Toxic metabolites – oxalic, glycolic, and
glycolic acid
– Found in antifreeze
– 100 ml toxic
– Cns symptoms
– More CV features (tachycardia, HTN, pulm
edema), renal failure
– Acidosis, with gaps
Poisonings and Overdoses
• Treatment
– Remove remaining drug from stomach
– Prevent formation of toxic metabolites
– Remove parent drug from circulation
– Treat acidosis
– Use ethanol fomepizole or 4 methylpyrazole
– dialysis
Poisonings and Overdoses
• Isopropyl alcohol
– Intoxication and ketotic breath
– Gastritis
– Osmolar gap but no anion gap
– dialysis
Poisonings and Overdoses
• CO Poisoning
– Vehicle exhaust, natural gas heating, inhaled
smoke, propane
– Shifts curve to the left
– Headache, n/v, progresses to chest pain,
difficulty thinking, disorientation, weakness,
delayed neurophychiatric syndrome occurs 340 days after recovery
– Pulse ox overestimates arterial oxygenation
Poisonings and Overdoses
• Benzos
– Potentiated by ethanol and opiates
– Depressed consciousness and respiration
– Supportive treatment
– Flumazinil is a competitive receptor antagonist
that reverses resp depression
– Duration of action is shorter than that of the
benzo
– May ppt withdrawal symptoms
Poisonings and Overdoses
• Barbiturates
– Potent vasodilators, cause sedation, and
depressed respiration, negative inotrope,
profound cns depression
– Supportive therapy
– Evacuation of stomach, protect airway
– Those with underlying liver disease most
prone to toxicity
Poisonings and Overdoses
• Opioids
– Depressed consciousness
– Resp failure, aspiration is a common
complication
– Hypothermia, decreased gut motility,
noncardiogenic pulm edema, seizures
– Supportive therapy, intubation, gastric lavage
– naloxone
Poisonings and Overdoses
• Digitalis – hyperkalemia and arrhythmia
– Treat with charcoal, fix lytes, atropine and
pacing for severe bradycardia, lidocaine and
dilantin for ventricular arrthymias
– Digibind – cannot follow assay any longer
• B blocker and Ca channel
– Bradycardia and hypotension
– Ca, glucagon, atropine,insulin infusion
Poisonings and Overdoses
A 45 year old college professor is brought to the
ED after he took an overdose of propranolol.
After endotracheal intubation and orogastric
lavage, he receives activated charcoal, 2 liters of
normal saline, atropine, and an isoproterenol
drip.
On arrival in the ICU, his temperature is 37.6 C
(99.7 F), pulse rate is 48 per minute,
respirations are 14 per minute (on the
ventilator) and blood pressure is 70/40 mm Hg.
Poisonings and Overdoses
Which of the following should you do next?
(A) Increase isoproterenol
(B) Start dopamine
(C) Arrange for hemodialysis
(D) Infuse sodium bicarbonate
(E) Infuse glucagon
Poisonings and Overdoses
• TCA
– Anticholinergic signs
– Hot as a hare, blind as a bat, dry as a bone,
red as a beet and mad as a hatter
– Ileus
– EKG shows QRS complex beyond 0.12 sec,
QTc and PR lengthened
– Observe 12 hrs after EKG nml
– Bicarb, lidocaine, NE for low BP
Poisonings and Overdoses
• Serotonin reuptake inhibitors
– Fever, confusion, restlessness, shivering,
nausea
– May see cns effects, rhabdo
– Supportive therapy, cooling, benzos for
seizure
A 29-year-old woman is brought to the emergency department after
she was evacuated from the smoke-filled second floor of her house.
The fire was started by a kerosene heater on the first floor.
The patient is unconscious, but the pupils are responsive, and she
spontaneously moves her arms and legs. Temperature is 37.3 C
(99.2 F), pulse rate is 135 per minute, respirations are 26 per
minute, and blood pressure is 130/75 mm Hg. While the patient
breathes 100% oxygen by face mask, arterial blood pH is 7.18,
PCO2 is 28 mm Hg, and PO2 is 595 mm Hg. Arterial oxygen
saturation by co-oximetry is 57%; carboxyhemoglobin is 43%. No
trauma or burns are noted. No soot is present in the mouth or
nostrils. A soft systolic murmur is heard. The lungs are clear, and
the abdomen is soft.
Hemoglobin is 12.9 g/dL, leukocyte count is
7200/μL (80% segmented neutrophils, 8% band
forms, 9% lymphocytes, 3% monocytes), and
platelet count is 195,000/μL. Serum electrolytes
show an anion gap metabolic acidosis. Chest
radiograph is normal.
The patient is admitted to the intensive care unit
and is intubated; FIO2 is 1.0. Your institution
does not have a hyperbaric chamber, but a
hospital 15 minutes away has such a facility.
Which of the following should you do?
(A) Continue current care
(B) Administer 100% oxygen by endotracheal tube for
two to four hours; if the patient’s condition does not
improve, transfer for hyperbaric oxygen therapy.
(C) Administer methylene blue; if the patient’s
condition does not improve, transfer for hyperbaric
oxygen therapy.
(D) Transfer immediately for hyperbaric oxygen
therapy.
Poisonings and Overdoses
A 34-year-old woman is brought to the
emergency department following a suicide
attempt. Three hours ago, she ingested
12 tablets (2100 mg) of glyburide. Plasma
glucose is 15 mg/dL. She is intubated and
treated with multiple 50-mL doses of 50%
dextrose in 50 mL of water (D50W), 50 g of
activated charcoal by nasogastric tube, and
three intravenous bolus doses of diazoxide.
Poisonings and Overdoses
Plasma glucose has decreased from 140 mg/dL on admission to the
ICU to 52 mg/dL. You order administration of additional D50W.
Which of the following medications is most appropriate to inhibit
further insulin release in this patient?
(A) Epinephrine
(B) Glucagon
(C) Hydrocortisone
(D) Metoprolol
(E) Octreotide
Poisonings and Overdoses
A 30-year-old healthy worker was rescued from
a fire in a plastics factory. Emergency medical
teams quickly arrived and found the patient
comatose; his pulse rate was 60 per minute with
frequent ventricular premature complexes,
respirations were 22 per minute, and blood
pressure was 80/40 mm Hg. Administration of
100% oxygen, intravenous fluids, and dopamine
did not change his vital signs. The patient was
transported to the hospital within 15 minutes of
rescue.
Poisonings and Overdoses
On admission to the intensive care unit (ICU),
the patient is comatose. Temperature is 36.0 C
(96.8 F), pulse rate is 105 per minute, and blood
pressure is 100/60 mm Hg. She is receiving
mechanical ventilation in the assist-control mode
with a set rate of 16 breaths/min and FIO2
of 0.30; arterial oxygen saturation is 98%
measured by pulse oximetry.
Poisonings and Overdoses
Initial laboratory tests reveal arterial blood PO2 is 360 mm Hg,
PCO2 is 32 mm Hg, and pH is 7.30; carboxyhemoglobin is 15%.
While preparations are being made to administer hyperbaric oxygen
therapy, which of the following should you now administer?
(A) Methylene blue
(B) Sodium thiosulfate
(C) Glucagon
(D) N-acetylcysteine
(E) Nitric oxide
Poisonings and Overdoses
Which of the following is characteristic of
nitroprusside toxicity?
(A) Metabolic alkalosis
(B) Elevated plasma glucose level
(C) Elevated serum creatinine
level
(D) Elevated arterial oxygen saturation
(E) Elevated mixed venous oxygen
saturation
Poisonings and Overdoses
A 20 year old man is brought into the ED
because of unresponsiveness. His family gives
you a half empty bottle of amitriptyline; the
prescription has been filled this morning. On
physical examination, his pulse rate is 65 per
minute and blood pressure is 90/50 mm Hg. His
skin is hot and dry. Arterial blood studies show
PO2 is 80 mm Hg, PCO2 is 35 mm Hg and pH is
7.20. Electrocardiogram discloses a QRS interval
of 0.14 second.
Poisonings and Overdoses
Which of the following should you
administer first?
(A) Diazepam
(B) Sodium bicarbonate
(C) Atropine
(D) Flumazenil
(E) Physostigmine
Vent Bundle
• PUD prophylaxis
• HOB 30 degrees
• DVT prophylaxis
• Daily sedation vacation
• Weaning trial
Central line bundle
• Chlorhexidine
• Full body drape
• Masks, hats gown
The Society of Critical Care Medicine, American Thoracic Society, American College of
Clinical Pharmacy, and Centers for Disease Control and Prevention guidelines
regarding intravascular catheter-related infections define category IA
recommendations as "strongly supported by well-designed experimental, clinical, or
epidemiologic studies."
Based on these guidelines, which of the following is a category IA recommendation?
(A) Catheter tips should not be cultured routinely
(B) Strict use of gloves and sterile technique decreases the need for hand
washing
(C) Guidewires can be used to exchange catheters suspected, but not proven,
to be infected
(D) Topical antibiotic ointment or cream should be used at insertion sites
(E) Skin should be disinfected with acetone before catheter insertion
Which of the following central venous
catheter sites has the lowest combined
risk for infection and thrombosis?
(A) Femoral vein
(B) Internal jugular vein
(C) Subclavian vein
Rhabdomyolysis
• Caused by skeletal muscle damage
• Most common risk factor is ETOH abuse
• Crush injury, drugs, toxins, infection
• Muscle pain, weakness and dark urine
• Myoglobin is rapidly cleared so may not
see it in urine
• Hypovolemia, renal failure
• Fluids, diuretics, bicarb
A 65-year-old man who has diabetes mellitus, hypercholesterolemia,
and hypertension is admitted to the cardiac care unit following
coronary artery revascularization surgery. He has a 40-pack-year
history of cigarette smoking.
Which of the following interventions has been reported to improve
this patient's overall in-hospital mortality?
(A) Maintaining plasma glucose level of 80–110 mg/dL
(B) Administration of a nebulized beta agonist
(C) Administration of a beta blocking agent
(D) Administration of an angiotensin-converting enzyme
inhibitor
(E) Administration of clopidogrel
A 30-year-old man comes to the emergency department
because of hemoptysis and severe shortness of breath;
he has a large left-sided pneumothorax consistent with a
stab wound. He undergoes emergent tube thoracostomy
and is admitted to the intensive care unit. The admitting
physician subsequently sees a television news broadcast
about a stabbing and recognizes the patient's
photograph as the suspect who fatally wounded another
man. The incident was witnessed by several onlookers
who positively identified the killer. Shortly after the
broadcast, police officers arrive at the hospital; they do
not have a court order or a search warrant.
The Health Insurance Portability and Accountability Act
permits release of which of the following information
about the patient to the police?
(A) HIV status
(B) Results of DNA analysis
(C) Blood specimens for evidentiary
purposes
(D) Name, type of injury, date and time of
treatment, and description of physical
characteristics
A 48-year-old man is evaluated in the
emergency department because of hypotension,
dehydration, and obtundation. He has a history
of alcoholism. Aggressive volume resuscitation is
started with 0.9% saline (2500 mL rapidly
infused during the first hour). He is transferred
to the intensive care unit (ICU) because of acute
pancreatitis.
In the ICU, the patient is intubated, and mechanical ventilation is
started in the assist-control mode with a set rate of 18 breaths/min,
tidal volume of 0.5 L, FIO2 of 0.40, and PEEP of 7 cm H2O. Peak
pressure is 25 cm H2O, and plateau pressure is 20 cm H2O. The
patient is lethargic but arousable. Temperature is 38.1 C (100.5 F),
pulse rate is 115 per minute, respirations are 28 per minute and
labored, and blood pressure is 100/60 mm Hg. Chest examination
reveals symmetrically elevated diaphragms and bronchial breath
sounds posteriorly at the bases. A grade 1/6 systolic ejection
murmur is audible at the left sternal border and aortic areas without
radiation. The abdomen is firm with epigastric tenderness. The urine
appears dark and concentrated. Electrocardiogram is normal, and
chest radiograph shows plate-like atelectasis in the
supradiaphragmatic regions.
The patient's condition initially improves.
However, during the next 16 hours, pulse
rate increases to 125 per minute, and
blood pressure gradually decreases to
80/50 mm Hg. Central venous pressure is
19 mm Hg. Arterial blood pH is 7.26,
PCO2 is 38 mm Hg, and PO2 is 60 mm Hg.
Intake has exceeded output by 7500 mL
since admission.
Laboratory studies
Plasma glucose
Serum electrolytes:
Sodium
Potassium
Chloride
Bicarbonate
Urinalysis
180 mg/dL
144 mEq/L
5.0 mEq/L
100 mEq/L
12 mEq/L
Dark urine; 1–2 RBCs,
2–4 WBCs/hpf
The patient remains deeply obtunded
although no sedative medications have
been given. Dopamine is started; blood
pressure increases to 100/50 mm Hg, but
urine output decreases to less than
15 mL/hr. Peak pressure is now
40 cm H2O, and plateau pressure is
35 cm H2O.
Which of the following is the most
appropriate next step?
(A) Insert a pulmonary artery catheter
(B) Measure bladder pressure
(C) Discontinue saline and start sodium
bicarbonate
(D) Start furosemide
(E) Start an insulin infusion
(F) Start total parenteral nutrition
An 18-year-old man sustains a closed head injury and is admitted to the intensive
care unit. He is receiving mechanical ventilation and has a Glasgow coma scale score
of 6.
According to the Brain Trauma Foundation guidelines, which of the following
treatments during the first 24 hours is most likely to improve morbidity and mortality?
(A) Fluid and sodium restriction to reduce cerebral edema and control
intracranial pressure
(B) Corticosteroids to reduce cerebral edema and control intracranial
pressure
(C) Prophylactic mannitol to reduce cerebral edema and control
intracranial pressure
(D) Hyperventilation to reduce intracranial pressure
(E) Isotonic or hypertonic crystalloid to maintain mean arterial
pressure greater than 90 mm Hg
The fiduciary relationship between physician and
patient is based on the ethical principles of
autonomy, beneficence, and which of the
following?
(A) Altruism
(B) Entitlement
(C) Distributive justice
(D) Non-malfeasance
(E) Risk management
A 20-year-old black man who has sickle
cell disease is admitted to the intensive
care unit after intubation for severe
respiratory distress. Three days ago, he
developed a mild upper respiratory tract
infection. Two days ago, he began to have
pain in his back and limbs and had
pleuritic chest pain that was followed by
progressive shortness of breath.
On admission, he is conscious and
receiving mechanical ventilation in the
assist-control mode. Temperature is 38.5 C
(101.3 F), pulse rate is 100 per minute,
and blood pressure is 110/60 mm Hg.
Examination of the chest reveals diffuse
rhonchi. Examination of the heart is
normal except for tachycardia.
Laboratory studies
Hemoglobin
8.1 g/dL
Leukocyte count
18,000/μL
Arterial blood studies (FIO2 = 0.80):
PO
255 mm Hg
PCO
226 mm Hg
pH
7.45
Chest radiograph shows extensive bilateral pulmonary infiltrates.
Electrocardiogram reveals sinus tachycardia. Bronchoalveolar lavage
is performed; Gram stain of lavage fluid shows a few neutrophils
and no organisms.
In addition to treatment with intravenous hydration, narcotic
analgesics, and broad-spectrum antibiotics, which of the following
should be done now?
(A) Begin methylprednisolone
(B) Begin heparin and order ventilation–perfusion lung scan
(C) Order exchange transfusion
(D) Place a pulmonary artery catheter
(E) Request open lung biopsy
Which of the following interventions is most likely to
result in an immediate decrease in the elevated
intracranial pressure of a patient who has an acute
closed head injury?
(A) Administration of dexamethasone, intravenously
(B) Administration of acetaminophen through a
nasogastric tube
(C) Increase in mean systemic arterial pressure after
volume administration
(D) Decrease in minute ventilation
(E) Elevation of the head from supine to 30 degrees
A 32-year-old man was admitted to the intensive
care unit four days ago after sustaining a blunt
head injury in a motor vehicle collision. He has
been comatose since admission, and his current
Glasgow coma score is 6T (intubation and
mechanical ventilation). He is being treated for
ventilator-associated pneumonia and acute
kidney failure secondary to rhabdomyolysis.
With the patient breathing 50% oxygen by
mechanical ventilation, arterial blood pH is 7.34,
PCO2 is 38 mm Hg, and PO2 is 62 mm Hg. An
intraparenchymal fiberoptic (Camino) catheter is
in place; intracranial pressure has increased to
28 cm H2O from 15 cm H2O. Neurologic
examination is unchanged except for unilateral
pupillary dilatation. Blood urea nitrogen is
80 mg/dL, and serum creatinine is 2.2 mg/dL.
In addition to hyperventilation as a temporizing
measure, which of the following should you do
next?
(A) Induce hypothermia to 33.0 C (91.4 F)
(B) Administer mannitol
(C) Administer methylprednisolone
(D) Begin hemodialysis
(E) Refer for emergency craniectomy
A 45-year-old man who was recently treated for small
cell lung cancer is admitted to the intensive care unit
because of acute shortness of breath and severe chest
pain. Chest radiograph shows remarkable shrinkage of
the previously large mass in his left hemithorax. Arterial
blood studies (with the patient breathing 60% oxygen by
face mask) reveals PO2 is 48 mm Hg, PCO2 is 25 mm Hg,
and pH is 7.50. Pulmonary arteriogram shows large clots
bilaterally in the pulmonary circulation. Morphine is
administered to control the patient's pain. He soon
begins to tire, and he requires intubation and mechanical
ventilation.
The patient has a living will that states
that he does not want "heroic measures,"
including mechanical ventilation, but he
does wish to receive the continued
support of his physicians. You explain the
potential reversibility of his acute problem,
but he still refuses intubation. You believe
that he is mentally competent. He is still in
pain.
Which of the following should you do now?
(A) Administer additional morphine and
oxygen
(B) Discontinue morphine
(C) Discontinue oxygen and other support
(D) Restrain the patient and proceed with
intubation
(E) Obtain a psychiatric consultation
An 82 year old woman who has
emphysema is brought to the ED from a
nursing home because of an apneic
episode. An attendant observed that she
was aspirating her gastrostomy feeding.
She has been bedridden and unable to
communicate since she had a stroke 2
years ago.
On physical examination, decubitus ulcers are present on
the buttocks and contractures of the extremities are
noted. Electrocardiogram demonstrates complete heart
block with a ventricular rate of 45 beats/min. The
patient’s son, who is her spokesman, is contacted. He
says that everything should be done for her. A
temporary pacemaker is implanted and she is admitted
to the ICU. With the patient breathing 2L of oxygen by
nasal cannula, arterial blood PO2 is 58 mm Hg, PCO2 is
50 mm Hg, and pH is 7.32. Serum creatinine is 6.5
mg/dL.
During the next 5 days, urine output
averages only 200 mL daily despite a
normally paced heart rate and the
administration of diuretics. Serum
creatinine rises to 8.1 mg/dL. Arterial
oxygen saturation during apneic episodes
falls between 73% and 76%. The
patient’s son continues to insist that
everything be done for his mother.
Which of the following should you do next?
(A) Transfer the patient to another hospital
(B) Ask the patient’s son for permission to implant a
pacemaker, intubate and perform hemodialysis
permanent
(C) Tell the son that more aggressive interventions are unlikely
to be of medical benefit and are not advisable for his mother
(D) Do not offer to implant a permanent pacemaker, intubate or
perform hemodialysis and tell the son that everything is being done
(E) Obtain a court order to not attempt resuscitation for this patient