Critical care: anaesthesiology, blood gases & respiratory care

Question 1

75yo thin cachectic woman undergoes a trachoestomy for failure to wean from the ventilator. 1w later, she develops significant bleeding from the tracheostomy. which of the following would be an appropriate initial step in the management of this problem?

a. remove the tracheostomy and place pressure over the wound
b. deflate the balloon cuff on tracheostomy
c. attempt to reintubate the pt with an endotracheal tube
d. upsize the tracheostomy
e. perform fiberoptic evaluation immediately

Answer 1

C

= sentinel bleed from trachoinominate artery fistula = >50% mortality

bleeding has stopped = immediate fiberoptic exploration

bleeding continuing = (stopgap measures)

1) inflate tracheostomy balloon to compress innominate artery
2) reintubate pt with endotracheal tube
3) remove tracheostomy & place figer through site with anterior compression of innominate artery
- -> 4) median sternotomy in OR

Question 2

53 yo woman has been intubated for several days after sustaining a R pulmonary contusion after a motor vehicle collision as well as multiple rib fractures. which of the following is a reasonable indication to attempt extubation?

a. negative inspiratory force (NIF) of -15cm HxO
b. PO2 of 60mmHg while breathing 30% inspired FiO2 with a positive end-expiratory pressure (PEERP) of 10cm H2O
c. spontaneous respiratory rate of 35 breaths per minute
d. rapid shallow breathing index of 80
e. minute ventilation of 18L/min

Answer 2

D

b - too low of PO2
c. - will fatigue
e - 18L/min too high of O2 requirement

Predictors of successful extubation

• rapid shallow breathing index = ratio of RR / tidal volume = 60-105
• negative expiratory force > -20
• PEEP = 5cm H2O
• Minute ventilation < 10L/min
• Spontaneous RR < 20.

Question 3

19yo man receives an un cross-matched blood during resuscitation after a gunshot wound to the abdomen. he develops fever, tachycardia, and oliguria during teh transfusion and is diagnosed as having a hemolytic rxn. which of the following is the most appropriate next step in management of this pt?

a. administration of a loop diuretic such as furosemide
b. treating anuria with fluid and pottassium replacement.
c. acidifying the urine to prevent Hgb precipitation in the renal tubules
d. removing foreign bodies, such as Foley catheters, which may cause hemorrhagic complication
e. stopping the transfusion immediately.

Answer 3

E

1) stop transfusion
2) Foley = d/t precipitation of hemoglobin in renal tubules
3) Na-bicarbonate = alkalinize urine to prevent Hgb precipitation
4) mannitol = stimulate diuresis
5) Restrict fluid, K

Question 4

74yo woman with a hx of a previous total abdominal hysterectomy presents with abdominal pain and distension for 3d. she is noted on her plain films to have dilated small bowel and air fluid levels. she is taken to the operating room for SBO. which of the following inhalational anaesthetics should be avoided b/c of accumulation in air-filled cavities during general anaesthesia.

a. biethyl ether
b. nitrous oxide
c. halothane
d. methoxyflurane
e. tricholoroethylene

Answer 4

B

Nitrous oxide = lower solubility v. other anaesthetics (more soluble v. nitrogen - the form that diffuses out of gass filled compartments) –> can cause progressive distension of air-fluid spaces during prolonged anaesthesia by diffusing into gas-filled compartment
–> worsened distension (ex. SBO)

Question 5

61yo alcoholic man presents with severe epigastric pain radiating to his back. his amylase and lipase are elevated, and his diagnosed with acute pancreatitis. over the first 48h, he is determined to have 6 Rnason’s criteria, including a PAO2 < 60. his chest xray reveals b/l pulmonary infiltrates, and his wedge pressure is low. which of the following criteria must be met to make a diagnosis of ARDS.

a. hypoxemia defined as PaO2/FiO2 ratio of <200
b. hypoxemia defined as a PaO2 of <60
c. pulmonary capillary wedge pressure >18
d. lack of improvement in oxygenation with administration of a test dose of furosemide
e. presence of a focal infiltrate on CXR

Answer 5

A

if C - cardiac problem. so CAN’T be elevated
if d - crue but not a criteria

criteria for ARDS

1) hypoxemia unresponsive to elevation of inspired O2 conc.
2) decreased pulmonary compliance = lungs stiffer & harder to ventilate
3) decreased functional residual capacity

= leakage of protein-rich fluid into interstitium & alveoli from non-cardiogenic cause = “diffuse fluffy infiltrates b/l”
===> shunt formation, decreased resting lung volume, increased dead-space ventilation

Question 6

50yo man has respiratory failure due to pneumonia and sepsis after undergoing splenectomy for a traumatic injury. which of the following management strategies will improve tissue O2 uptake (i.e. shifting the O2 dissociation curve).
a. transfusion of banked blood to correct acute anemia.
b. correction of acute anemia with erythropoetic stimulating agent
c. administration of bicarbonate to promote metabolic alkalosis
d hypoventilation to increase the PaCO2
e. administration of an antipyretic to lower the pt’s temp.

Answer 6

D

SHIFT TO THE RIGHT = O2 dropped off to tissues = tissue O2 uptake
PaCO2
H+
Temp

SHIFT TO THE LEFT = O2 retained by Hgb (like myoglobin)
Myoglobin

Question 7

64yo man with hx of severe emphysema is admitted for hematemesis. the bleeding ceases soon after admission, but the pt becomes confused and agitated. arterial blood gases are as follows. pH 7.23, PO2 42; PCo2 75. which of the following is the best initial therapy for this pt?

a. correct hypoxemia with high flow nasal O2
b. correct acidosis with sodium bicarbonate
c. administer 10mg IV dexamethasone
d. administer 2mg IV ativan
e. intubate the pt

Answer 7

E

respiratory acidosis - low RR.

speed up RR

• endotracheal intubation
• ventilatory support

signs of hypoxemia

• agitation
• confusion

Question 8

62yo woman with a hx of coronary artery disease presents with a pancreatic head tumor & undergoes a pancreaticoduodenectomy. postop, she develops a leak from the pancreaticojejunostomy anastamosis and becomes septic. a swan-ganz catheter is placed, which demonstrates an increased cardiac output and decreased systemic vascular resistance. she also develops acute renal failure and oliguria. which of the following is an indication to start dopamine?

a. to increase splanchnic flow
b. to increase coronary flow
c. to decrease heart rate
d. to lower peripheral vascular resistance
e. to inhibit catecholamine relese.

Answer 8

B

septic shock

Dopamine
- increased diastolic BP
- coronary blood flow
(low dose) - directed blood flow to kidneys & bowel (vasodilation of renal & mesenteric BV, mild vasoconstriction of peripheral bed
(high dose) - B1 receptor activity - increased CO & BP
(highest dose) - alpha activity = peripheral vasoconstriction, shifting of blood from extremities to organs, decreased kidney fx, HTN

Question 9

29yo woman on oral contraceptives presents with abd pain. a CT scan of the abdomen demonstrates a large hematoma of the R liver with the suggestion of an underlying liver lesion. her Hgb is 6, and she is transfused 2units of pRBCs and 2U of fresh frozen plasma. 2h after starting the transfusion, she develops respiratory distress and requires intubation. she is not volume overloaded clinically, but her CXR shows b/l pulmonary infiltrates. which oft the following is the management strategy of choice?

a. continue the transfusion and administer an antihistamine
b. stop the transfusion and administer a diureticc. stop the transfusion, perform bronchoscopy, and start broad-spectrum empiric antibiotics
d. stop the transfusion and continue supportive respiratory care
e. stop the transfusion and send a coomb’s test

Answer 9

D

TRALI = transfuion related acute lung injury
- sxs = respiratory distress, hypoxemia, b/l pulmonary infiltrates (non-cardiogenic)

Tx (overall) = mechanical ventilation

Complications

1) allergic rxn –> antihistamine
2) transfusion-associated circulation overload (pts with heart failure) –> diuretics
3) hemolytic rxn = dx: positive coombs test –> stop transfusion; identify responsible antigen

Question 10

68yo hypertensive man undergoes successsful repair of a ruptured abdominal aortic aneurysm. he receives 9L ringer lactate solution a nd 4U of whole blood during the operation. 2h after transfer to the surgical ICU, the following hemodynamic parameters are obtained: systemic BP 90/60, pulse 110, CV 7mmHg, pulmonary artery wedge pressure (PCWP) 8, cardiac output 1.9, SVR 1400 (nml = 900-1300), PaO2 140, urine output 15 (specific gravity: 1.029), and Hct 35% . given this data, which of the following is the most appropriate next step in management?

a. administration of a diuretic to increase Urine output
b. administration of a vasopressor agent to increase systemic BP
c. administration of a fluid challenge to increase urine output
d. administration of a vasodilating agent to decrease elevated SVR
e. a period of observation to obtain more data.

Answer 10

C. rapid fluid infusion; expansion of IV volume (lactated ringers, blood).

b/c very hypotensive, likely from blood loss

NOT vasopressor - increases PVR & BP, decreased tissue perfusion
NOT vasodilation = decreased PVR –> HYPOTENSION; vascular collapse
NOT diuretic –> increased volume depletion

Question 11

59yo man with a hx of MI 2y ago undergoes an uneventful aortofemoral bypass graft for aortoiliac occlusive disease. 6h later, he develops ST segment depression, and a 12-lead EKG shows anterolateral ischemia. his hemodynamic parameters: systemic BP70/40, pulse 100, CVP 18, PCWP 25, cardiac output 1.5L/min, and SVR 1000. which of the following is the single best pharmacologic intervention for this pt?

a. sublingual nitroglycerin
b. IV nitroglycerin
c. a short-acting B-blocker
d. sodium nitroprusside
e. dobutamine

Answer 11

E

increased LA pressure
low cardiac output

–> cardiogenic shock - MI from bypass

NOT

options:
1) Dobutamine (B1) = inotropic; mildly increased peripheral vasodilation (chronotropy)
- increased CO + stable myocardial O2 demand on an already failing heart.
2) Nitroglycerin/nitroprusside + ionotrope = relax heart, and maintain BP

B blocker = decreased cardiac contractility & HR

Question 12

56yo an undergoes a L upper lobectomy. an epidural catheter is inserted for postoperative pain relief. 90 min after the first dose of epidural morphine, the pt complains of itching and becomes increasingly somnolent . blood gas measurement reveals the following pH 7.24, PaCO2 58, PaO2 100, and HCO3- 28. which of the following is the most appropriate initial therapy for this pt?

a. endotracheal intubation
b. intramuscular diphenhydramine (Benadryl)
c. epidural naloxone
d. IV naloxone
e. alternative analgesia.

Answer 12

D

likely liver lobectomy - being given an epidural with dilaudid

allergic to morphine

respiratory acidosis = due to depressed respiratory drive.
reverse the opiate

Question 13

71yo man returns from the OR after undergoing a triple coronary bypass. his initial cardiac index is 2.8L/min-m2. HR is then noted to be 55 BPM, BP is 110/80, wedge pressure is 15, and his cardiac index has dropped to 1.6L/min-m2. he has a normal LV. which of the following maneuvers will increase his cardiac output.?

a. increase his PVR
b. increase his CVP
c. increase his HR to 90 by electrical pacing
d. increase his blood viscosity
e. increase his inspired O2 concentration

Answer 13

C

poor cardiac output (due to low preload)- not necessarily cardiogenic shock.

a - only for BP

cardiac index = cardiac output / body surface area

CI = CO/BSA
= (SV*HR)/BSA

Question 14

73yo woman with a long hx of heavy smoking undergoes femoral artery-popliteal bypass for rest pain in her L leg. b/c of serious underlying respiratory insufficiency, she continues to require ventilatory support for 4d after her operation. as soon as her endotracheal tube is removed, she begins complaining of vague upper abd pain. she has daily fever spikes of 39C (102.2 F) and a leukocyte count of 18,000. an upper abd ultrasonogram reveals a dilated gallbladder, but no stones are seen. a presumptive diagnosis of acalculous cholecystitis is made. which of the following is the next best step in her treatmt?

a. nasogastric suction and broad-spectrum abx
b. immediate cholecystectomy with operative cholangiogram
c. percutaneous drainage of the gallbladder
d. endoscopic retrograde cholangiopancreatography (ERCP) to visualize and drain the CBD.
e. provocation of cholecystokinin release by cautious feeding of the pt

Answer 14

C. Acute postoperative cholecystitis
= thickened gallbladder, pericholecystic fluid; nonvisualization of gallbladder on HIDA (=no taking up fluid b/c blocked).
==> potential fatal complication

no stone to take out.

tx = percutaneous drainage + Abx

ascending cholangitis -> charcot’s triad = fever, abd pain, jaundice.

reynold’s pentad = charcot’s + MS changes + hypotension.

Question 15

32 yo man undergoes a distal panreatectomy, splenectomy, and partial colectomy for a gunshot wound to the L upper quadrant of the abdomen. 1wk later, he develops a shaking chill in conjunction with a temp spike of 39.4C (103F). his BP is 70/40, pulse 140, and RR 45. he is transferred to the ICU, where he is intubated and a swan-ganz catheter is placed. which of the following is consistent with the expected initial swan-gantz catheter readings.

a. increase in CO
b. increase in PVR
c. increase in pulmonary artery pressure
d. increase in PCWP
e. increase in CVP

Answer 15

A- to compensate for decreased peripheral vascular resistance

sepsis = SIRS + bacterial source

• decreased PVR
• normal central pressure
• increased CO

Tx

• resuscitation = fluid replacement, vasopressor
• stabilization = Abx for GNR, anaerobes (intra-abdominal)
• laparotomy, drainage of colleciton

likely sub-diaphragmatic abscess - common complication post-splenectomy

Question 16

43yo trauma pt develops ARDS and has difficulty oxygenating despite increased concentrations of inspired O2. after the PEEP is increased, the pt’s oxygenation improved. what is the mechanism by which this occurs?

a. decreasing dead-space ventilation
b. decreasing the minute ventilation requirement
c. increasing tidal volume.
d. increasing functional residual capacity
e. redistribution of lung water from the interstitial to the alveolar space

Answer 16

D

PEEP= keeps alveoli openat end of expiration

• INCREASED FUNCTIONAL RESIDUAL CAPACITY
• increase surface area for diffusive exchnage of gases

complications

• overdistension = barotrauma; pneumothorax
• decreased VR, CO
• increased dead space ventilation = increased ventilation requirements

Question 17

27yo man was assaulted and stabbed on the L side of the chest between the areola and sternum. he is hemodynamically unstable with jugular venous distension, distant heart sounds, and hypotension. which of the following findings would be consistent with a diagnosis of hemodynamically significant cardiac tamponade

a. more than a 10mmHg decrease in systolic BP at the end of the expiratory phase of respiration
b. decrease RA pressures on swan-ganz monitoring
c. equalization of pressures across the 4 chambers on the swan-ganz monitoring
d. compression of the LV on echocardiography
e. overfilling of the RA

Answer 17

C

increased pressures, soft heart sounds

• Beck triad = systemic hypotension, jugular venous distension, distant heart sounds
• pulses paradoxus = decrease in SBP by >10mmHg at end of inspiratory phase of respiration
• ECHO = pericardial fluid & RA collapse
• Swan Ganz = Equalization of pressures across the 4 chambers
• decreased RA pressure; decreased CO; increased CVP

Question 18

55yo woman requires an abdominoperineal operation for rectal cancer. she has a hx of stable angina. which of the following clinical markers is most likely to predict a cardiac event during her noncardiac surgery and should prompt further cardiac workup prior to her operation?

a. abnormal EKG
b. prior stroke
c. unstable angina
d. uncontrolled HTN
e. her age.

Answer 18

C

–> because can lead to MI

MAJOR predictors of cardiac event during noncardiac surgery

• unstable angina
• recent MI
• decompensated CHF
• significant arrhythmia
• severe valvular disease

MED predictors

• mild angina
• prior MI
• compensated / prior CHF
• DM
• renal insufficiency

MINOR predictors

• older age, abn EKG, irregular rhythm,
• poor functional capacity
• prior stroke
• uncontrolled HTN

Question 19

a 22yo man sustains severe blunt trauma to the back. he notes that he cannot move his LE. he is hypotensive and bradycardic. which of the following is the best inital management of the pt?

a. digital block with 1% lidocaine without epinephrine up to 4.5mg/kg
b. digital block with 1% lidocaine with epinephrine up to 4.5mg/kg
c. digital block with 1% lidocaine with epinephrine up to 7mg/kg
d. local injection around the nail bed with 1% lidocaine without epinephrine up to 4.5mg/kg
e. local injection around the nail bed with 1% lidocaine without epinephrine up to 7mg/kg

Answer 19

A

digital block = at side of the nail bed of the specific digit.
inject with lidocaine for local anaesthesia & epinephrine to decrease bleeding.

For a normal sized person (70kg) = 4.5mg/kg of lidocaine.

where NOT to use epinephrine

• tissues supposed by end arteries
• ex. fingers, toes, ears, nose, penis

Question 20

22yo man sustains severe blunt trauma to the back. he notes that he cannot move his LE. he is hypotensive and bradycardic. which of the following is the best initial management of the pt?

a. administration of phenylephrine
b. administration of dopamine
c. administration of epinephrine
d. IV fluid bolus
e. placement of a transcutaneous pacer

Answer 20

D

Neurogenic shock due to spinal cord injury –> loss of sympathetic tone; bradycardia; loss of reflexive increase in HR

Tx = fluids + vasoconstrictors (dopamine, phenylephrine)

If bleeding –> hypovolemic shock

Question 21

58 yo woman with multiple comobidities and previous cardiac surgery is in a high speed motor vehicle collision. she is intubated for airway protection. b/c of hemodynamic instability. a central venous catheter is placed in the R subclavian vein. while the surgeon is securing the catheter, the cap becomes displaced and air enters the catheter. suddenly, the pt becomes tachycardic and hypotensive. which of the following is the best next maneuver.

a. decompression of the R chest with a needle int he 2nd intercostal space.
b. placement of a R chest tube.
c. withdrawal of the central venous catheter several cm.
d. placement of a pt is a L lateral decubitus trendelenburg position
e. b/l “clamshell” thoracotomy with aortic cross-clamping

Answer 21

D
= air embolism into heart.
don’t clamp the aorta.

Tx

1) place into L lateral decubitus trendelenburg
2) aspirate central venosu catheter
3) LATER - thoracotomy

Tension pneumo = decompression of R chest with needle / chest tbe
Arrhythmia = withdrawal of central venous catheter

Question 22

30yo man is scheduled for a laparoscopic cholecystectomy for biliary colic. he reports a family hx of prolonged paralysis during general anaesthesia. which of the following meds should be avoided during his procedure?

a. succinylcholine
b. vecuronium
c. pancuronium
d. halothane
e. etomidate

Answer 22

A
succinylcholine = depolarizing agent
Mivacurium; vecuronim, pancuronium, cis-attracurium = non-depolarizing

–> family hx of pseudocholinesterase deficiency ==> do not use cholinesterase anaesthetics

Question 23

18yo woman develops urticaria and wheezing after an injection of IV contrast for an abd CT scan. her BP is 120/60, HR is 155, and RR is 30. which of the following is the most appropriate immediate therapy?

a. intubation
b. epinephrine
c. B-blockers
d. iodine
e. fluid challenge

Answer 23

B

allergy to contrast fluid

LETHAL rxns
- bronchospasm, laryngospasm, hypotension, dysrhythmia

NONLETHAL rxns
- pruritis, urticaria, sycope, weakness seizure.

Tx

1) epinephrine –> for larygeal obstruction & respiratory
2) histamine antagonists
3) aminophylline
4) rydroscortisone

Question 24

a pt develops a fever and tachycardia during a blood transfusion after a redo coronary artery bypass procedure. the nurse subsequently discovers that there was a mix-up in the cross-match b/c of a labeling error. which of the following is diagnotic in a pt with an immediate hemolytic rxn secondary to a blood transfusion?

a. serum haptoglobin >50
b. indirect bili > 5
c. direct bili > 5
d. positive coombs test
e. myoglobinuria

Answer 24

E. delayed hemolytic rxn = antibodies to Rh antigens; extravascular hemolysis

1) decreased haptoglabin 50
2) hemoglobinuria with free Hgb > 5
3) positive coombs test
4) (delayed:2-10d) haotoglobin, in/direct BIl

Question 25

72yo man w/ DM, renal insufficiency, and coronary artery disease presents in septic shock from emphysematous cholecystitis. his O2 sat is 100% on 6L NC and his Hgb is 7.2. his mixed venous O2 sat is 58%. which of the following treatment options will improve his O2 delivery the most?

a. increase his inspired O2 conc.
b. transfer him to a hyperbaric chamber
c. administer ferrous sulfate
d. administer an erythropoetic agent
e. transfuse 2U of pRBCs

Answer 25

E. Treat his anemia.

nml mixed venous O2 sat = 40%
He’s already on O2 - increasing probs won’t help
low Hgb
? high mixed venous O2 sat = not extracting enough O2

Can’t use hyperbaric b/c PaO2 is too low

Question 26

an obese 50yo woman undergoes a lap cholecystectomy. in the recovery room, she is found to be hypotensive and tachycardic. her arterial blood gases reveal a pH of 7.29, PaO2 of 60, and PaCO2 of 54. which of the following is the most likely cause of his
pt’s problem.
a. acute PE
b. CO2 absorption from induced pneumoperitoneum
c. alveolar hypoventilation
d. pulmonary edema
e. atelectasis from a high diaphragm

Answer 26

C

respiratory acidosis - PaCO2 = alveolar ventilation

from decreased respiration

acute hypoxemia
- pulmonary embolism, pulmonary edema, significant atelectasis

Question 27

65yo man who had a 25lb weight loss over the previous 6 mo is diagnosed with adenocarcinoma of the distal esophagus. he undergoes a transhiatal esophagectomy complicated by a cervical leak. he is receiving enteral feeds through a jejunostomy tube. after a week, his physicians wish to assess his nutritional resuscitation. which of the following is the most accurate measure of adequacy of his nutritional support?

a. urinary nitrogen excretion level
b. total serum protein level
c. serum albumin level
d. serum transferrin level
e. respiratory quotient

Answer 27

C

measure of protein nutritional adequacy.

short-term nutritional status

• pre-albumin
• acute phase serum proteins = CRP, haptoglobin, fibrinogen, ferritin

Question 28

63yo man with multiple rib fractures & pulmonary contusion requires prolonged intubation. he is unable to be weaned from the ventilator and is on a volume control mode. he has a tracheostomy and a percutaneous gastrotomy in place through which he is being fed. the surgeon orders a respiratory quotient, which is the ratio of the rate of CO2 production over the rate of O2 uptake. the RQ is 1. based on this information, which of the following is the next step in his management.

a. decreased the inspired concentration of oxygen
b. decrease the rate on the ventilator
c. increase the rate on the ventilator
d. decrease the carbohydrates in his enteral feeds
e. increase the total number of calories in his enteral feeds.

Answer 28

D

RQ should be 4/5 based on what we consume & produce (nutrition)

RQ < 0.8 = lipid-filled diet
RQ >0.8 = carb-heavy diet

Question 29

22yo woman is involved in a major motor vehicle accident and receives a tracheostomy during her hospitalization. 5d after placement of the tracheostomy she has some minor bleeding around the tracheostomy site. which of the following is the most appropriate immediate therapy?

a. removal of the tracheostomy at bedside
b. exchange the tracheostomy at bedside
c. exchange the tracheostomy in the OR
d. bronchoscopic evaluation of the trachea at bedside
e. bronchoscopic evaluation of the trachea in the OR

Answer 29

E

if it’s bleeding a lot - try to stop the bleeding and place an endotracheal tube . OR is probably better

no / minimal bleeding - bronchoscopic eval

tracheoinnominate artery fistula = deadly comoplication of a tracheostomy.

Question 30

72yo man undergoes resection of an abd aneurysm. he arrives in the ICU with a core temp of 33C (91.4F) and shivering. which of the following is a physiologic consequence of the shivering?

a. rising mixed venous O2 sat
b. increased production of CO2
c. decreased consumption of O2
d. rising base excess
e. decreased minute ventilation

Answer 30

B

hypothermia - vasoconstriction of of the peripheral blood vessels.
shivering –> thermogenin –> increased ATP & energy use –> increased H2O and CO2 produced

= leads to O2 debt in muscles,m lactic acidemia

Question 31

39yo woman with a known hx of von Willebrand disease has a ventral hernia after a previous C/S and desires to undergo elective repair. which of the following should be administered preop?

a. high purity factor 8: C concentrates
b. low molecular weight dextran
c. fresh-frozen plasma
d. cryoprecipitate
e. whole blood

Answer 31

D
von Willebrand = makes factor 8 more stable

dx = decreased factor 8: C activity

tx

• Factor 8 R: WF
• cryoprecipitate

Question 32

you are the physician on call for the extracorporeal membrane oxygenation (ECMO) service. there are 5 calls today, but only 1 machine and one technologist available? which of the following pts is the most appropriate recipient of this service?

a. a 1d old, full-tern, anencephalic 4kg boy suffering from meconium aspiration syndrome and hypoxia.
b. a 75yo man with alzheimer disease, severe pneumonia, and elevated pulmonary arterial pressure
c. a neonate with a diagnosis of severe pulmonary hypoplasia who is in respiratory failure
d. a 5yo girl with rhabdomyosarcoma metastatic to the lungs
e. a 3d old boy preoperative for a congenital diaphragmatic hernia

Answer 32

E

need an exit plan

Indications (= potentially reversible pulmonary / cardiac dz)

• meconium aspiration syndrome
• sepsis
• pneumonia
• congenital diaphragmatic hernia
• bridge to cardiac / lung transplantation

C/I - conditions doomed to fail
- hypoplastic lungs

Question 33

72yo man has multiple injuries and an altered sensorium after a high speed motor vehicle collision. he is intubated for his decreased mental status. during intubation, a large amount of gastric contents are noted in the posterior pharynx and he aspirates. which of the following is the appropriate initial treatment?

a. bronchoscopy for aspiration of particulate matter
b. steroids
c. prophylactic antibiotics
d. inhaled nitric oxide
e. high PEEP.

Answer 33

A

he’ll likely get aspiration pneumonitis – with gross aspiration (not aspiraiton pneumonia)
- already being intubated for airway

Management

• bronchoscopy for particulate matter in bronchial tree
• only start abx if pneumonia actually develops

Question 34

a pt with severe neurological devastation after head trauma has a prolonged course in the ICU. he has been mechanically ventilated for his entire hospital stay. which of the following clinical findings is diagnostic of a ventilator-associated pneumonia?

a. WBC > 12,000
b. <10,000 colony-forming U/mL of an organism on bronchoalveolar lavage
c. >10,000 colony-forming U/mL of an organism on bronchoalveolar lavage
d. purulent tracheal secretions
e. RLL infiltrate on CXR

Answer 34

C

CXR is diagnostic of pneumonia, but not VAP.

VAP: >/= 10,000 colony-forming U/mL of a single organism

empiric abx initiated after cultures are obtained

Question 35

shortly after the administration of an inhalational anaesthetic and succinylcholine for intubation prior to an elective inguinal hernia repair in a 10yo boy, he becomes markedly febrile, displays a tachycardia of 160, and his urine changes color to a dark red. which of the following is the most appropriate treatment at this time?

a. complete the procedure but pretreat with dantrolene prior to future elective surgery
b. administer inhalational anaesthetic agents
c. administer succinylcholine
d. hyperventilate with 100% O2
e. acidify the urine to prevent myoglobin precipitation in the renal tubules.

Answer 35

D

malignant hyperthermia = inhalational ahaesthesia + succinylcholine

• unexplained fever during anaesthesia
• tachycardia, increased O2 consumption, increased CO2 production, increased serum K
• myoglobinuria, acidosis
• Rigidity after succinlcholine injection

tx

• stop procedure & anaesthesia
• hyperventilation with 100% O2
• IV dantrolene.

Question 36

42yo man has had a rocky course for the 3d following a bowel resection for intestinal perforation due to IBD. his CVP has been 12-14 but is now 6, in the face of diminished blood pressure and oliguria. which of the following is the most likely etiology of his hypotension?

a. pulmonary embolism
b. hypervolemia
c. positive pressure ventilation
d. pneumothorax
e. gram negative sepsis

Answer 36

E

septic shock - decreased CVP
(phase 1) - hypodynamic = hypovolemia, myocardial depression
(phase 2) - hyperdynamic = fluid resuscitation; normal to increased CO.

Question 37

acute renal failure occurs following aortic angiography in a 72yo man. his weight has been rising, his lungs show rales at both bases, and he is dyspneic. his fractional excretion of sodium is >1. he has eosinophilia on his peripheral smear, an elevated ESR, and proteinuria with microscopic hematuria. which of the following is the likely cause of his renal failure.

a. hypovolemia
b. renal artery cholesterol embolism
c. acute tubular necrosis
d. cardiogenic shock
e. aortic dissection

Answer 37

B. cholesterol atheroembolism = eosinophilia

• CHF and fluid overload from acute MI
• LE ischemia
• ischemic bowel
• acute / chronic renal failure
• eosinophilia
• microscopic hematuria / proteinuria
• elevated ESR
• high FENa = intrarenal cause

Question 38

55yo woman has been hospitalized b/c of recurrent pancreatitis, ARDS, prolonged ileus and need for parenteral nutrition. she demonstrates weakness, lassitude, orthostatic hypotension, nausea & fever. which of the following abnormalities is most likely to explain these sxs?

a. hypothermia
b. hypokalemia
c. hyperglycemia
d. hyponatremia
e. hypervolemia

Answer 38

D

adrenocortical insufficiency (semiacute) seen during stress/surgery

• high K
• low Na, glucose, volume
• fever, weight loss
• nausea, lassitude, vomiting, fever,

Dx = high urinary Na; lack of response to ACTH

Question 39

19yo man sustains severe LE trauma, including a femur fracture and a crush injury to the foot. he requires vascular reconstruction of the popliteal artery. one day after surgery, he becomes dyspneic and hypoxemic and requires intubation and mechanical ventilation. which of the following is the most likely etiology of his decompensation?

a. aspiration
b. atelectasis
c. fat embolism syndrome
d. fluid overload
e. pneumonia

Answer 39

C

from fracture of a long bone
- acute respiratory failure, altered MS, petechiae

Question 40

33yo woman is brought to the ED from the scene of a severe MVA. she is combative, confused, and uncooperative and appears dusky and dyspneic. which of the following is the most appropriate management of her airway?

a. awake endotracheal intubation is indication in pts with penetrating ocular injury
b. steroids have been shown to be of value in the treatment of aspiration of acidic gastric secretions
c. the stomach may be assumed to be empty only if a hx is obtained indicating no ingestion of food or liquid during the prior of 8h
d. intubation should be performed as soon as possible (in the ED) if the pt is unstable.
e. cricothyroidectomy is containdicated in the presence of maxillofacial injuries.

Answer 40

D = most important management = endotracheal or tracheotomy (if needed d/t maxillofacial injuries)

make no assumptions about stomach

Question 41

following a boating injury in an industrial use river, a pt begins to display fever, tachycardia, and rapidly expanding area of erythema, blistering, and drainage from a flank wound. an xray shows gas in the soft tissues. which of the following measures is most appropriate?
a. administration of an antifungal agent
b. administration of an antitoxin
c. wide debridement
d administration of hyperbaric O2
e. early closure of tissue defects

Answer 41

C

concerns for necrotizing fasciitis = likely strep anaerobes

tx

• wide debridement
• delayed wound reconstruction until stable, viable wound surface has been established

controversial management
- hyperbaric O2

Question 42

following pelvic gynecologic surgery, a 34yo woman becomes dyspneic, her peripheral arterial O2 sat falls from 94% to 81% and her measured PaO2 is 52 on a 100% non-rebreather mask. she is hemodynamically stable. a CT angiogram is consistent with a RLL pulmonary embolus. which of the following is the nxt step in her mangement?

a. systemic anticoagulation with heparin infusion
b. systemic anticoaglation with warfarin
c. placement of an IVC filter
d. thrombolytic therapy
e. open pulmonary embolectomy.

Answer 42

A. usually use warfarin in PE - but bridge with heparin first b/c Proteins C&S inhibited first usually (anticoagulants) ==> leading to procoagulant state.

only 1 PE - don’t need IVC filter

Question 43

72yo woman who is planning to undergo ventral hernia repair is on warfarin for A-fib. she is advised to cease her warfarin several days before her surgery and is hospitalized perop for herparinization. during her hospital stay, she complains of severe abdomianl and flank pain. her PT is normal, but her aPTT is elevated. an abd CT scan demonstrates a large retroperitoneal hematoma. which of the folllowing should be administered to reverse the effects of the heparin?

a. thrombin
b. VitK
c. protamine sulfate
d. aprotinin
e. platelet transfusion

Answer 43

C. protamine sulfate

PTT - elevated due to heparin

vitK, FFP = for warfarin

Question 44

42yo man who was in a who was in a house fire is transferred to your burn unit. he has singed nose hairs and facial burns. direct laryngoscopy in the ED demonstrates pharyngeal edema and mucosal sloughin. he has 60% total body surface area burns. which of the following is the next step in the management of this pt?

a. hyperbaric O2
b. IV steroids
c. iinhaled steroids
d. bronchoscopy
e. intubation

Answer 44

E

definitely first –> esp. if see singed nose hairs & facial burns.

Question 45

24o man presents in septic shock from an empyema. he is febrile to 103F, tachycardic in the 120s, and hypotensive to the 90s. his O2 sat is 98% on 2L O2. his WBC is 25,0000 and creatinine is 0.8. his BP does not respond to fluid administration despite a CVP of 15. which of the following therapies is indicated in the managing of this pt?

a. intubation
b. recombinant human activated protein C
e. epinephrine
d. NorE
e. dobutamine

Answer 45

D. NorE or dopamine

1) intubation - if hypoxic
2) fluid resuscitation - to CVP of 8-12
3) vasopressors - to MAP of 65

breathing is fine
Dobutamine (B1) = inotropic; mildly increased peripheral vasodilation (chronotropy)

Question 46

match side effects with appropriate agent:
a. Nitrous oxide (N2O)
b. succinylcholine
c. midazolam
d. pancuronium
e. morphine
65yo man with a 35% body surface area burn develops hyperkalemia after induction

Answer 46

Ba

hyperkalemia - from breakdown of muscle
pts with burns, severe infections or neuromuscular d/o

a. Nitrous oxide (N2O) - laughing gas
b. succinylcholine - depolarizing agent
c. midazolam - anaesthetic
d. pancuronium - nondepolarizing agent
e. morphine - pain

Question 47

match side effects with appropriate agent:
a. Nitrous oxide (N2O)
b. succinylcholine
c. midazolam
d. pancuronium
e. morphine
an acutely injured pt becomes hypotensive shortly after induction

Answer 47

E

increasing opiates can drop BP.

a. Nitrous oxide (N2O) - laughing gas
b. succinylcholine - depolarizing agent
c. midazolam - anaesthetic
d. pancuronium - nondepolarizing agent
e. morphine - pain

Question 48

match side effects with appropriate agent:
a. Nitrous oxide (N2O)
b. succinylcholine
c. midazolam
d. pancuronium
e. morphine
a pt with a bowel obstruction develops increasingly distended loops of bowel after induction

Answer 48

A. N2O stays in the alveoli and inflates, worsening any distension (SBO).

a. Nitrous oxide (N2O) - laughing gas
b. succinylcholine - depolarizing agent
c. midazolam - anaesthetic
d. pancuronium - nondepolarizing agent
e. morphine - pain

Question 49

for each clinical problem, select the best method of physiologic monitoring necessary for the pt. 
a. central venous catheterization
b. pulmonary artery catheterization
c blood gas monitoring 
d. intracranial pressure monitoring
e. arterial catheterization
f. continuous ECG monitoring
74yo an has a 5h elective operation for repair of an abd aortic aneurysm. he had a small MI 3y earlier. in the ICU on the first postoperative day, he is hypotensive and is receiving dobutamine by continuous infusion.

Answer 49

B

likely from anaesthesia

pulmonary artery catheter readings - to assess volume status & need for ongoing ionotropic support

Question 50

for each clinical problem, select the best method of physiologic monitoring necessary for the pt. 
a. central venous catheterization
b. pulmonary artery catheterization
c blood gas monitoring 
d. intracranial pressure monitoring
e. arterial catheterization
f. continuous ECG monitoring
62yo woman underwent a R carotid endarterectomy for symptomatic high grade carotid artery stenosis. postop, her BP is 202/105, and she is started on a nitroprusside infusion

Answer 50

E

concern about cyanide poisoning & need beat-to-beat monitoring of BP (direct measure of BP and CO).

Question 51

for each clinical problem, select the best method of physiologic monitoring necessary for the pt. 
a. central venous catheterization
b. pulmonary artery catheterization
c blood gas monitoring 
d. intracranial pressure monitoring
e. arterial catheterization
f. continuous ECG monitoring
a comatose 28yo woman sustained a depressed skull fracture in an automobile collision. she has been unconscious for 6w. her vital signs are stable and she breathes RA. following her initial decompressive craniotomy, she has returned to the OR twice due to intracranial bleeding.

Answer 51

D

indications for ICP

• repeated surgeries for intracranial bleeding
• subarachnoid hemorrhage
• hydrocephalus
• postcraniotomy status
• Reye syndrome

Question 52

for each test, select the coagulation factor whose functions are measured.
a. Factor 2
b. Factor 5
c. Factor 8
d. Platelets
e. fibrinogen
a pt is receiving oral warfarin to effect anticoagulation b/c of an artificial heart valve. prothrombin time is 21 (INR 2.3)

Answer 52

A.

warfarin = PT - factor 7.
& common pathway - 5a, 10a, 2a, 1a

Fibrinogen = factor 1

Question 53

for each test, select the coagulation factor whose functions are measured.
a. Factor 2
b. Factor 5
c. Factor 8
d. Platelets
e. fibrinogen
a pt with heparin induced thrombocytopenia is placed in hirudin and undergoes assessment of his cloting function. thrombin time is 30sec

Answer 53

E

thrombin time = qualitative abnormalities in fibrinogen & presence of inhibitors to fibrin polymeriation ==> fibrin + fixed plasma volume –> measure clotting time

Question 54

for each test, select the coagulation factor whose functions are measured.
a. Factor 2
b. Factor 5
c. Factor 8
d. Platelets
e. fibrinogen
a pt is to undergo a coronary bypass. bleeding time is 6sec.

Answer 54

D

bleeding time = platelets & formation of platelet plug.