critical care

Question 1

What effect does amiodarone have on serum levels of T3 and T4 in euthyroid patients?

Answer 1

Amiodarone inhibits type 1 and type 2 deiodinase enzymes leading to decreased serum levels of T3 and increased T4, on the lowe and higher end of normal respectively

Question 2

What is the best test to diagnose a patient with multiple enlarged lymph nodes and several weeks of fevers, night sweats, and weight loss?

Answer 2

The best test is excisional lymph node biopsy.

Question 3

What are the 4 criteria used to transition to subQ insulin from an insulin drip when treating DKA?

Answer 3

1. Anion Gap has closed
2. Bicarb > 17
3. Appropriate mentation
4. Tolerating PO

Question 4

What are the endocrine complications of immune checkpoint inhibitors?

Answer 4

Endocrine complications include adrenal insufficiency, thyroid disease, and hypophysitis.

Question 5

What defines sepsis in terms of organ dysfunction?

Answer 5

Sepsis is defined by an increase of ≥2 points in total SOFA score from baseline.

Question 6

What should be done for a DKA patient when the pH falls below 6.9?

Answer 6

A bicarb drip should be started.

Question 7

What does a Wells score of <2 indicate?

Answer 7

<2 is low risk for PE.

Question 8

What does a Wells score of 2-6 indicate?

Answer 8

2-6 is intermediate risk for PE.

Question 9

What does a Wells score of >6 indicate?

Answer 9

> 6 is high risk for PE.

Question 10

What is a widely noted cardiac side effect of phenylephrine?

Answer 10

Reflex bradycardia.

Question 11

What is the initial fluid challenge for patients with sepsis-induced hypoperfusion?

Answer 11

The initial fluid challenge should be at ≥30 mL/kg (~2L in a 70-kg adult).

Question 12

What is the most appropriate initial anticoagulation therapy for a patient with high risk for bleeding submassive PE?

Answer 12

LMWH

Question 13

What do the 2021 Surviving Sepsis Campaign guidelines recommend regarding IV antibiotics?

Answer 13

Administration of effective IV antibiotics within 1 hour of recognizing sepsis or septic shock.

Question 14

What should be done if a DKA patient displays hypokalemia?

Answer 14

Potassium must be replaced before starting insulin.

Question 15

What is the next step if a patient has an intermediate Wells score?

Answer 15

Obtain D-dimer; if less than 0.05, no further imaging is obtained.

Question 16

What are signs of acute tubular necrosis (ATN)?

Answer 16

Granular casts or muddy brown casts.

Question 17

What is the safest way to deliver vasopressors?

Answer 17

Through central venous access (internal jugular, subclavian, femoral catheter, or peripherally inserted central catheter).

Question 18

What is the likely diagnosis for a neutropenic patient with septic necrotic purpuric plaques?

Answer 18

Likely diagnosis is ecthyma gangrenosum.

Question 19

What is a widely noted adverse effect of norepinephrine?

Answer 19

Peripheral digital ischemia.

Question 20

What is the mechanism of action of benzodiazepines?

Answer 20

Benzodiazepines stimulate the GABA A receptor.

Question 21

What is the half-life of diazepam?

Answer 21

The half-life of diazepam is 20 to 120 hours.

Question 22

What is the most likely etiology for an 81-year-old former smoker with acute on chronic cough and leg edema not responsive to furosemide?

Answer 22

Most likely etiology is COPD exacerbation.

Question 23

What is the typical adult bolus dose and infusion rate for midazolam?

Answer 23

Typical adult bolus dose is 1 to 5 mg, and an infusion rate of 1 to 5 mg/hr.

Question 24

What is the most useful diagnostic test to guide antibiotic treatment in a patient with pneumonia?

Answer 24

Lower respiratory tract culture.

Question 25

What is the most appropriate treatment for asthma exacerbation?

Answer 25

Nebulized duoneb and IV steroids.

Question 26

What do the 2021 Surviving Sepsis guidelines recommend regarding crystalloid solutions?

Answer 26

Choosing a balanced crystalloid solution, such as lactated Ringer's, instead of saline.

Question 27

What is the goal SAS score for mechanically ventilated patients?

Answer 27

The goal SAS score is 3 to 4.

Question 28

What is the bicarb level threshold?

Answer 28

Bicarb > 17

Question 29

What indicates appropriate mentation?

Answer 29

Appropriate mentation

Question 30

What is the most appropriate treatment for asthma exacerbation?

Answer 30

Nebulized duoneb and IV steroids

Question 31

What do the 2021 Surviving Sepsis guidelines recommend for fluid resuscitation?

Answer 31

Choose a balanced crystalloid solution, such as lactated Ringers, instead of saline.

Question 32

What is the typical RAS scale goal for mechanically ventilated patients?

Answer 32

Typical goals for mechanically ventilated patients for the RAS scale is -2 to 0.

Question 33

What is the range of the Richmond Agitation–Sedation Scale (RASS)?

Answer 33

Range of scale is -5 (cannot be aroused) to 4 (combative).

Question 34

How is sepsis defined in terms of SOFA score?

Answer 34

Organ dysfunction as defined by an increase of ≥2 points in total SOFA score from baseline.

Question 35

What are the SIRS criteria?

Answer 35

Diagnosed if ≥ 2 of the following 4 criteria are fulfilled: 1. Temperature: > 38°C or < 36°C 2. Heart rate: > 90/min 3. Respiratory rate: > 20/min or PaCO2 < 32 mm Hg 4. White blood cell count: > 12,000/mm3, < 4000/mm3, and/or > 10% band cells.

Question 36

What is the typical bolus dose of lorazepam?

Answer 36

Typical bolus dose is 1 to 4 mg, with an infusion rate of 1 to 5 mg/hr.

Question 37

Why is it relevant that lorazepam does not have an active metabolite?

Answer 37

Its offset may be more predictable than midazolam or diazepam.

Question 38

What is the diagnosis for a patient with acute hypoxemic respiratory failure and multifocal pulmonary opacities?

Answer 38

Dx: Pneumonia

Question 39

What is the first line treatment in hypotonic hypovolemic hyponatremia?

Answer 39

Isotonic fluids

Question 40

What are the qSOFA criteria?

Answer 40

1. Alteration in mental status (Glasgow Coma Score ≤13) 2. Systolic blood pressure ≤100 mm Hg 3. Respiratory rate ≥22/min.

Question 41

What is the initial fluid of choice for DKA?

Answer 41

Isotonic saline until the patient's intravascular volume has been restored.

Question 42

What should be added to IV fluids in DKA if K is normal?

Answer 42

Potassium to prevent hypokalemia.

Question 43

What is the recommended blood pressure for patients with diabetes mellitus?

Answer 43

The American Diabetes Association recommends BP < 140/90.

Question 44

What is the half-life of midazolam?

Answer 44

Midazolam has a half-life of 3 to 11 hrs.

Question 45

What receptors does norepinephrine act on?

Answer 45

Norepinephrine acts on α1 >> β1 > β2 receptors.

Question 46

What is the next step if the Wells score is low?

Answer 46

Stratify using PERC Criteria.

Question 47

What is the treatment for severe hypercalcemia?

Answer 47

IV bisphosphonates and isotonic saline.

Question 48

What predisposes a patient taking TNF inhibitors to disseminated histoplasmosis?

Answer 48

Living in the midwestern United States.

Question 49

What should be done for DKA when blood glucose decreases to approximately 300 mg/dL?

Answer 49

Add dextrose to intravenous (IV) fluid to prevent hypoglycemia.

Question 50

What is the effect of amiodarone in euthyroid patients?

Answer 50

Can inhibit type 1 and type 2 deiodinase enzymes leading to decreased serum levels of T3 and increased T4.

Question 51

What is the acceptable increase in serum creatinine after initiation of an ACE-I or ARB?

Answer 51

An increase in serum creatinine up to 30% is acceptable.

Question 52

What is the first-choice vasopressor in septic shock according to the 2021 Surviving Sepsis Campaign guideline?

Answer 52

Norepinephrine.

Question 53

What is the treatment for acute decompensated heart failure?

Answer 53

Should be started on IV diuretics, particularly loop, regardless of the renal function.

Question 54

What should be withheld in treating ATN?

Answer 54

ACE-I or ARBs drugs should be withheld as they interfere with glomerular autoregulation and can lead to hyperkalemia.

Question 55

What is the typical bolus dose of diazepam?

Answer 55

Typical bolus dose is 1 to 5 mg.

Question 56

What factors make lymphoma more likely in suspected cases?

Answer 56

Age >40, lymphadenopathy in more than 3 body sites, constitutional symptoms.

Question 57

What is the Glasgow Coma Scale score indicating severe impairment?

Answer 57

A score of ≤13 indicates severe impairment.

Question 58

What is the systolic blood pressure threshold for concern?

Answer 58

Systolic blood pressure ≤100 mm Hg.

Question 59

What respiratory rate is considered a concern?

Answer 59

Respiratory rate ≥22/min.

Question 60

What is the onset of action for Lorazepam?

Answer 60

Lorazepam has an onset of action of 5 to 20 minutes.

Question 61

Which patients should ideally avoid bisphosphonates?

Answer 61

Patients with GERD should ideally avoid bisphosphonates.

Question 62

Which electrolytes should be monitored and replaced if low?

Answer 62

Phosphate and magnesium.

Question 63

What class of drug is Milrinone?

Answer 63

Milrinone is a phosphodiesterase inhibitor.

Question 64

What condition is Milrinone typically used for?

Answer 64

Milrinone is typically used in cardiogenic shock.

Question 65

What does Dopamine act on?

Answer 65

Dopamine acts on D1>B1>A1>A2.

Question 66

What type of inhibitor is Ipilimumab?

Answer 66

Ipilimumab is a CTLA-4 inhibitor.

Question 67

What type of inhibitor is Pembrolizumab?

Answer 67

Pembrolizumab is a PD-1 inhibitor.

Question 68

What type of inhibitor is Avelumab?

Answer 68

Avelumab is a PD-L1 inhibitor.

Question 69

What class do Pembrolizumab, Avelumab, and Ipilimumab belong to?

Answer 69

All are in the immune checkpoint inhibitor class of drugs.

Question 70

What is SIRS?

Answer 70

SIRS is diagnosed if ≥ 2 of the following 4 criteria are fulfilled.

Question 71

What is the temperature criterion for SIRS?

Answer 71

Temperature: > 38°C or < 36°C.

Question 72

What is the heart rate criterion for SIRS?

Answer 72

Heart rate > 90/min.

Question 73

What is the respiratory rate criterion for SIRS?

Answer 73

Respiratory rate > 20/min or PaCO2 < 32 mm Hg.

Question 74

What is the white blood cell count criterion for SIRS?

Answer 74

White blood cell count > 12,000/mm3, < 4000/mm3, and/or > 10% band cells.

Question 75

What are the criteria for transitioning to subQ insulin from an insulin drip in DKA?

Answer 75

1. Anion Gap has closed 2. Bicarb > 17 3. Appropriate mentation 4. Tolerating PO.

Question 76

What is sepsis?

Answer 76

Sepsis is a severe, life-threatening condition resulting from a dysregulation of the patient's response to an infection.

Question 77

What is the GFR threshold for avoiding bisphosphonates?

Answer 77

Bisphosphonates are usually avoided in patients with GFR of less than 35.