Deck 13: Medical Critical Care Issues

Question 1

Based on the 2011 Berlin Definition, severe ARDS describes a patient with acute onset of worsening pulmonary symptoms, signs of noncardiogenic pulmonary edema, and a:

A) P/F ratio ≤ 100 mm Hg.
B) P/F ratio 100 to ≤ 200 mm Hg.
C) P/F ratio 200 to ≤ 300 mm Hg.
D) P/F ratio > 300 mm Hg.

Answer 1

A

Question 2

ARDS may be caused by conditions related to certain:

A) lung diseases.
B) lung diseases and medical conditions.
C) medical conditions and trauma.
D) infections, medical conditions, and trauma.

Answer 2

D

Question 3

_______ is a lung injury caused by the repeated shear forces exerted by the cycle of collapse (at end expiration) and re-expansion (at beginning of inspiration) during mechanical ventilation.

A) Barotrauma
B) Volutrauma
C) Acute respiratory distress syndrome
D) Acute lung injury

Answer 3

B

Question 4

When bilateral infiltrates or opacities on chest radiograph are caused by ARDS, the pulmonary capillary wedge pressure (PCWP) is typically:

A) above the normal range.
B) below the normal range.
C) near the normal range.
D) above or below the normal range, depending on the baseline pulmonary artery pressure.

Question 5

The mechanical ventilation strategy outlined below is the recommended initial settings for what condition?
Volume- or pressure-controlled ventilation with an initial V_T of 8 mL/kg PBW while keeping the plateau (static) pressure (P_plat) ≤ 30 cm H₂O.

A) Barotrauma
B) Hypoxic ischemic encephalopathy
C) Ventilator-associated events
D) Acute respiratory distress syndrome

Question 6

Ventilator-associated pneumonia is a complication associated with use of:

A) interface for noninvasive positive pressure ventilation.
B) mechanical ventilation.
C) artificial airway and mechanical ventilation.
D) noninvasive positive pressure ventilation.

Question 7

"An abnormal WBC (≤ 4,000 or ≥ 12,000 cells/mm³) or an abnormal temperature (< 36ºC or > 38ºC) and the use of a new antimicrobial agent for infection treatment continued for at least 4 days" is a statement that describes:

A) infection-related ventilator-associated complications (IVAC).
B) ventilator-associated conditions (VAC).
C) ventilator-associated pneumonia (VAP).
D) ventilator-associated events (VAE).

Question 8

"Sputum/BAL with ≥ 25 neutrophils and ≤ 10 epithelial cells per field (low power field, ×100) and/or positive sputum culture" is a statement that describes:

A) ventilator-associated events (VAE).
B) infection-related ventilator-associated complications (IVAC).
C) ventilator-associated conditions (VAC).
D) ventilator-associated pneumonia (VAP).

Question 9

Sedative vacation (spontaneous awakening trial), spontaneous breathing trial, head of bed elevation, handwashing, less frequent ventilator circuit change, and use of subglottic secretion drainage are some methods for reducing the incidence of:

A) acute respiratory distress syndrome.
B) ventilator-associated pneumonia.
C) hypoxic ischemic encephalopathy.
D) volutrauma.

Question 10

Hypoxic-ischemic encephalopathy (HIE), or hypoxic brain, is an acute brain injury caused by conditions leading to a severe or prolonged lack of:

A) ventilation.
B) nutrition.
C) oxygen.
D) blood flow.

Question 11

A 77-year-old man presented to the emergency department with abdominal pain with a medical history of heavy alcohol abuse and hypertension. Upon physical exam he appeared drowsy and confused, and his distal extremities were cool and cyanotic. His SBP was 75/50 mm Hg, HR 125 beats per minute, and lactic acid 6.0. His abdomen was tense and distended. A CT scan of the abdomen showed extraluminal gas and suspected extraluminal feces consistent with a perforated sigmoid colon. He was treated with IV antibiotics, and crystalloids (Normal Saline or Lactated Ringers) were started. What is the initial fluid challenge for a patient with sepsis?

A) 10 mL/kg
B) 20 mL/kg
C) 30 mL/kg
D) 40 mL/kg

Question 12

A 77-year-old man presented to the emergency department with abdominal pain with a medical history of heavy alcohol abuse and hypertension. Upon physical exam he appeared drowsy and confused, and his distal extremities were cool and cyanotic. His SBP was 75/50 mm Hg, HR 125 beats per minute, and lactic acid 6.0. His abdomen was tense and distended. A CT scan of the abdomen showed extraluminal gas and suspected extraluminal feces consistent with a perforated sigmoid colon. He was treated with IV antibiotics, and crystalloids (Normal Saline or Lactated Ringers) were started. What is the goal of a CVP with a patient with sepsis?

A) CVP of ≥ 5 mm Hg
B) CVP of ≥ 6 mm Hg
C) CVP of ≥ 7 mm Hg
D) CVP of ≥ 8 mm Hg

Question 13

A 43-year-old female presents to the emergency department with encephalopathy. She has been undergoing chemotherapy for the past 3 months for treatment of ovarian cancer. ALT 170 units/L and AST 120 units/L. Ammonia level is 250, and her mental status is obtunded. Her husband reports that she drinks a glass of wine every night. What is the culprit of her acute liver failure?

A) Ovarian cancer
B) Nightly wine
C) Chemotherapy
D) Lethargy

Question 14

A 57-year-old male was admitted to the hospital with lethargy, generalized weakness, volume depletion, and poor urinary output. He is a resident of a nursing home, has a peg tube with tube feedings, and water flushes. He was recently treated with metronidazole for diarrhea caused by Clostridium difficile. On physically examination, he had a HR of 100 beats per minute, dry mucous membranes, and reduced skin turgor. Vital signs showed a temperature of 37.8°C, BP 105/55 mm Hg lying, and 90/50 mm Hg sitting. Jugular venous pule not visible. Labs were drawn and revealed a BUN of 79 mg/dL, creatinine of 2.4 mg/dL, potassium of 7.5 mEq/L, bicarbonate level of 20 mEq/L, and sodium of 125 mEq/L. What is the most likely culprit of this patient's acute renal failure?

A) Lethargy
B) Tube feeding
C) Being a nursing home resident
D) Having Clostridium difficile

Question 15

A 57-year-old male was admitted to the hospital with lethargy, generalized weakness, volume depletion, and poor urinary output. He is a resident of a nursing home, has a peg tube with tube feedings, and water flushes. He was recently treated with metronidazole for diarrhea caused by Clostridium difficile. On physically examination, he had a HR of 100 beats per minute, dry mucous membranes, and reduced skin turgor. Vital signs showed a temperature of 37.8°C, BP 105/55 mm Hg lying, and 90/50 mm Hg sitting. Jugular venous pule not visible. Labs were drawn and revealed a BUN of 79 mg/dL, creatinine of 2.4 mg/dL, potassium of 7.5 mEq/L, bicarbonate level of 20 mEq/L, and sodium of 125 mEq/L. What is the life-threatening issue that must be corrected for this patient?

A) Sodium of 125 mEq/L
B) Potassium of 7.5 mEq/L
C) Bicarbonate of 20 mEq/L
D) Lethargy

Question 16

A 42-year-old female presents to the emergency department with mild lethargy and reports abdominal pain with nausea and vomiting. While obtaining a history, she advises that she intentionally ingested 50 tabs of 325 mg Tylenol 7 hours ago and all it has done is made her sick. Laboratory findings show an aspartate aminotransferase (AST) of 4001 and an alanine aminotransferase (ALT) of 5021. What is the appropriate initial treatment for this patient?

A) N-Acetylcysteine (Mucomyst)
B) Zofran
C) Arterial blood gas
D) Chest x-ray

Question 17

A 36-year-old woman presented to the emergency department by emergency medical services (EMS) after she was found unresponsive by her family. EMS reports that she takes methadone due to heroin addiction. EMS intubated her on scene to secure her airway. Naloxone 2 mg was given IV with no response. What is your next step?

A) Naloxone 2 mg IV
B) Check her lactate level
C) Arterial blood gas
D) Obtain a chest x-ray

Question 18

A 36-year-old woman presented to the emergency department by emergency medical services (EMS) after she was found unresponsive by her family. EMS reports that she takes methadone due to heroin addiction. EMS intubated her on scene to secure her airway. Why will this patient require repeated doses of Naloxone?

A) She requires mechanical ventilation.
B) Methadone has a duration of 48 to 72 hours.
C) She has hypoxia.
D) A nasogastric tube could not be placed.

Question 19

A 71-year-old man presents to the emergency department at the instruction of his primary care physician. The patient felt well when he went to bed at midnight but awoke at 8:00 a.m. with left upper extremity weakness and numbness. He called his physician, who told him to go to the emergency department. He arrives at the emergency department at 9:00 a.m. The patient's medical history includes hypertension and hyperlipidemia for which he takes a thiazide diuretic and a statin. His blood pressure is 178/92 mm Hg; physical examination reveals mild left-sided neglect, a mild left central facial palsy, mild left upper and lower extremity weakness, and a mild left hemi-sensory deficit. Complete blood count and serum electrolytes and plasma glucose levels are normal. CT scan of the head is normal. Which of the following is the most appropriate next step in this patient's management?

A) Start aspirin.
B) Start intravenous heparin.
C) Start clopidogrel.
D) Start intravenous tissue plasminogen activator.

Question 20

A 45-year-old man is evaluated in the emergency department for acute shortness of breath with right-sided chest pain. He also has a dry cough with scanty blood streaking of his phlegm. He is a nonsmoker and has no other past medical illnesses; he has just returned by airplane from Japan.
On physical examination, his temperature is 37.4°C (99.4°F), blood pressure is 102/76 mm Hg, pulse rate is 98 beats per minute, and respiration is 32 breaths per minute. D-dimer is elevated. Creatinine is 0.5. Breath sounds are clear bilaterally. There are no rhonchi auscultated. He feels soreness in the left calf and has trace left ankle edema. All peripheral pulses are intact. What is your first step in treatment for this patient?

A) CT angiogram of the chest
B) Sputum culture
C) X-ray of the left lower leg
D) None of these is correct.

Question 21

A 45-year-old man is evaluated in the emergency department for acute shortness of breath with right-sided chest pain. He also has a dry cough with scanty blood streaking of his phlegm. He is a nonsmoker and has no other past medical illnesses; he has just returned by airplane from Japan.
On physical examination, his temperature is 37.4°C (99.4°F), blood pressure is 102/76 mm Hg, pulse rate is 98 beats per minute, and respiration is 32 breaths per minute. D-dimer is elevated. Creatinine is 0.5. Breath sounds are clear bilaterally. There are no rhonchi auscultated. He feels soreness in the left calf and has trace left ankle edema. All peripheral pulses are intact. Anticoagulation has been started and lower extremity venous Doppler studies are positive for bilateral deep vein thromboses. What is the next step?

A) 12-lead EKG
B) Placement of an inferior vena cava filter
C) Consult to an orthopedic surgeon
D) None of these is correct.