Intensive Care - Study Points

Question 1

Recite the normal range for vital signs in a healthy adult.

Answer 1

Question 2

Identify how each of the vital signs may vary physiologically with age.

Answer 2

Question 3

Identify how each of the vital signs may vary physiologically with pregnancy.

Answer 3

Question 4

Differentiate between type I and type II respiratory failure.
- Definition?
- Primary abnormality?
- 5 Causes?
- Blood Gas Analysis?

Answer 4

Type 1 respiratory failure occurs when the respiratory system cannot adequately provide oxygen to the body, leading to hypoxemia. Type 2 respiratory failure occurs when the respiratory system cannot sufficiently remove carbon dioxide from the body, leading to hypercapnia.

Question 5

Compare clinical conditions that may cause type I or type II respiratory failure.
- 4 Examples of each and their mechnanism, ABG and Clinical features?

Answer 5

Question 6

Define acute respiratory distress syndrome (ARDS) and list the common causes.
- 8 Systemic causes?
- 9 Lung specific?

Answer 6

ARDS is a clinical syndrome of acute respiratory failure characterized by hypoxemia and bilateral pulmonary infiltrates that cannot be fully accounted for by heart failure or fluid overload.

Question 7

Describe the clinical features of cardiac failure focusing on differentiating between left, right and biventricular failure.
- 6 General features?

Answer 7

Heart failure (HF): a complex clinical syndrome in which there is structural or functional impairment of ventricular filling and/or ejection of blood.
Left heart failure (LHF): HF caused by structural or functional impairment of the left heart circulatory system that results in tissue hypoperfusion and/or increased pulmonary capillary pressure
Right heart failure (RHF): HF caused by structural or functional impairment of the right heart circulatory system that results in impaired blood flow to the pulmonary circulation and/or elevated venous pressures.
General features of heart failure
1. Nocturia
2. Fatigue
3. Tachycardia, various arrhythmias
4. S3/S4 gallop on auscultation
5. Pulsus alternans - alternating strong and weak pulses (with a regular pulse rhythm) caused by alterations in cardiac output. Associated with left ventricular failure and cardiac tamponade.
6. Cachexia

Question 8

• List 6 Clinical Features of Left-Sided Heart Failure?
• List 6 Clinical Features of Right-Sided Heart Failure?
• 2 Clinical Features of Biventricular Heart Failure?
• 3 Additional Features in Advanced Heart Failure?
• How to differentiate Left, Right, and Biventricular Failure?

Answer 8

Question 9

List the major causes of cardiac failure.

Answer 9

The three major causes of HF are CAD, hypertension, and diabetes mellitus. Patients typically have multiple risk factors that contribute to the development of HF.

Question 10

List 11 Causes of Heart Failure and explain the mechanism and consequences of each.

Answer 10

Question 11

Outline a protocol/flowchart for the investigation & diagnosis of AKI?

Answer 11

Question 12

List 5 causes of acute liver failure (ALF) & 4 Miscellaneous?

Answer 12

Question 13

List 14 Causes of Acute Liver Failure?

Answer 13

Question 14

List 8 Drugs that can cause Acute Livery Injury/Failure.

Answer 14

Question 15

Describe 10 clinical features seen in a person with Acute Liver Failure.

Answer 15

Question 16

Recite the normal range for vital signs in a healthy adult and identify how each may vary physiologically with age and pregnancy. (Essential)

Answer 16

Question 17

Describe the ways vital signs change with illness and identify values that indicate critical illness and require urgent medical review (eg. RRT). (Essential).

Answer 17

Question 18

• Differentiate between type I and type II respiratory failure. (Essential)
• Compare clinical conditions that may cause type I or type II respiratory failure. (Essential)

Answer 18

Type 1 Respiratory Failure
- Type 1 respiratory failure involves hypoxaemia (PaO2 <8 kPa / 60mmHg) with normocapnia (PaCO2 <6.0 kPa / 45mmHg).
- It usually occurs due to ventilation/perfusion (V/Q) mismatch – the volume of air flowing in and out of the lungs is not matched with the flow of blood to the lung tissue.
- As a result of the ventilation/perfusion mismatch, PaO2 falls, and PaCO2 rises. The rise in PaCO2 rapidly triggers an increase in a patient’s overall alveolar ventilation, which corrects the PaCO2 but not the PaO2 due to the different shapes of the CO2 and O2 dissociation curves.
- The final result is hypoxaemia (PaO2 < 8 kPa / 60mmHg) with normocapnia (PaCO2 < 6.0 kPa / 45mmHg).
- Causes of type 1 respiratory failure -
- Examples of VQ mismatch include:
1. Reduced ventilation and normal perfusion (e.g. pneumonia, pulmonary oedema, bronchoconstriction)
2. Reduced perfusion with normal ventilation (e.g. pulmonary embolism)

Question 19

Define acute respiratory distress syndrome (ARDS).

Answer 19

Question 20

ARDS Severity
- PaO2/FiO2 & Mortality for Mild, Moderate & Severe?

Answer 20

Question 21

List the 9 most common causes of ARDS in Australia.

Answer 21

Question 22

Describe the clinical features of cardiac failure focusing on differentiating between left, right and biventricular failure. (Desirable)

Answer 22

General features of heart failure
1. Nocturia
2. Fatigue
3. Tachycardia, various arrhythmias
4. S3/S4 gallop on auscultation
5. Pulsus alternans
6. Cachexia

Question 23

List the major causes of cardiac failure.
- 7 Cardiovascular?
- 4 Endocrine/metabolic?
- 2 Pulmonary?
- 3 Toxic?
- 2 Other?

Answer 23

The 3 major causes of HF are CAD, hypertension and diabetes mellitus. Patients typically have multiple risk factors that contribute to the development of HF.

Question 24

List the causes of acute liver failure (ALF).

Answer 24

CAUSES (DAVES)
* Drugs – paracetamol, idiosyncratic, illicit, herbal/alternative (amanita mushroom), halothane
* Alcohol
* Viruses – HAV, HBV +/-D, HCV, HEV, CMV, EBV, HSV
* Extras – acute fatty liver of pregnancy, HELLP, toxins, ischaemic necrosis, vascular, metabolic, autoimmune, Wilson’s disease, Budd-Chiari, post hepatic surgery, idiopathic
* Sepsis

Question 25

Describe the clinical features (10) seen in a person with ALF and the biochemical abnormalities (7) you would expect in these patients.

Answer 25

Question 26

Compare and contrast the clinical features and radiological findings of the following neurological insults: ischemic stroke, haemorrhagic stroke, meningitis, encephalitis, subarachnoid haemorrhage, subdural haemorrhage and extra-dural haemorrhage.

Answer 26

Question 27

**Ischaemic Stroke** - Clinical Features? (4) - Radiological Findings?

Answer 27

1. Sudden onset of focal neurological deficits – eg. Weakness/paralysis, paraesthesias, aphasia, dysarthria 2. Nonspecific symptoms – eg. Impaired consciousness, N&V, headache, seizures 3. Symptoms depende on location of stroke/vessel involved. 4. Symptoms suggesting a specific aetiology: - Aortic dissection: chest pain, hypotension, dyspnea - Endocarditis: fever, heart murmur

Question 28

**Ischaemic Stroke** - Clinical Features? (4) - Radiological Findings?

Answer 28

** Radiological findings - Characteristic neuroimaging findings in ICH** * Hematoma within the cerebral parenchyma (i.e., intraaxial lesion) - Typical locations: - Supratentorial: lobar, or within the thalamus or basal ganglia - Infratentorial: in the cerebellum or brainstem - The density of the hematoma varies depending on the imaging modality used and age of the hematoma.

Question 29

Answer 29

Question 30

**Meningitis - Clinical Features** - Classic triad? - Pathogen-specific symptoms? - Physical examination?

Answer 30

**Meningitis Clinical Features** * Classic triad of meningitis - Fever - Meningismus: Headache, Neck stiffness, Photophobia - Altered mental state * Nausea, vomiting * Malaise * Seizures

Question 31

**Radiological findings in Meningitis** - Indications for imaging? - 2 Modalities? - 3 Supportive findings?

Answer 31

Question 32

**Encephalitis** - Clinical features? - Neuroimaging: MRI? CT? Electroencephalography?

Answer 32

Question 33

Clinical Features of a Subarachnoid Haemorrhage?

Answer 33

Question 34

Radiological Finding of SAH?

Answer 34

Question 35

**Subdural Haematoma - Clinical Features** - Acute SDH? - Subacute SDH? - Chronic SDH?

Answer 35

**Subacute SDH** **Symptom Onset** - 4-20 days after the inciting event - Can be acute or insidious **Progression**: A rebleed can cause rapid neurological decline **Clinical features**: a combination of features of acute SDH & chronic SDH

Question 36

**Subdural Haematoma - Radiological Findings** - CT Head without IV contrast? - MRI Head: 2 Indications?

Answer 36

**MRI head** **Indications** 1. Neurological features unexplained by CT findings 2. Suspected subacute SDH or chronic SDH **Characteristic findings** = Similar to those on CT scan. Intensity of the lesion on T2-weighting depends on the length of time since the inciting event. - Acute SDH: hypointense - Subacute SDH: hyperintense - Chronic SDH: hyperintense core with a hypointense rim

Question 37

Extra-dural haematoma - Clinical Features?

Answer 37

Question 38

**Extra-dural haematoma - Radiological Findings** - CT Head non-contrast: indications? characteristic findings? (6)

Answer 38

Question 39

Assign a Glasgow Coma Score to patients based on their clinical condition.

Answer 39

Question 40

Draw an algorithm for advanced life support in the setting of cardiorespiratory arrest.

Answer 40

Question 41

Outline the management of Out of Hospital Cardiac Arrest once ALS treatment has been successful. - Post-resuscitation care? - Prevention of recurent MI?

Answer 41

Question 42

Identify the relationship between Mean Arterial Pressure, Intracranial Pressure ICP and Cerebral Perfusion Pressure CPP and provide normal values for each.

Answer 42

* CPP is the difference between the mean arterial pressure (MAP) and the ICP (CPP = MAP – ICP). * MAP and ICP must be measured simultaneously.

Question 43

**Define**: - Seizure? - Acute symptomatic seizure? - Reflex seizure? - Unprovoked seizure? - Epilepsy? - Reflex epilepsy? - Drug-resistant epilepsy? - Resolved epilepsy?

Answer 43

Question 44

List 8 Seizure triggers.

Answer 44

**Seizure triggers** - Seizure triggers are stimuli that can precipitate seizures both in people with and without epilepsy. 1. Excessive physical exertion 2. Alcohol consumption 3. Fever (febrile seizures) 4. Sleep deprivation 5. Flashing lights (e.g., strobe lights, video games) 6. Music 7. Hormonal changes (e.g., at different phases of the menstrual cycle, after menopause) 8. Medication-related issues in patients with known epilepsy: e.g., poor adherence, recent changes in drug doses or formulation, new medication interactions

Question 45

**List 11 Causes of acute symptomatic seizures **

Answer 45

**Causes of acute symptomatic seizures ** 1. TBI 2. Stroke 3. Anoxic encephalopathy 4. Intracranial surgery 5. Acute CNS infections (e.g., meningitis, encephalitis) 6. Electrolyte imbalance (e.g., hypoglycemia, hypocalcemia) 7. Acute metabolic disturbances (e.g., uremia) 8. Alcohol withdrawal 9. Recreational drug use 10. Prescription drug toxicity 11. Exacerbations of autoimmune disorders (e.g., SLE)

Question 46

**Common causes of epilepsy** - 4 Genetic? - 8 Structural? - 2 Metabolic? - 2 Immune? - 2 Infective?

Answer 46

Question 47

**Causes of epilepsy according to the age group** - 6 Neonates and infants (< 6 months)? - 7 Older infants (> 6 months) and children (< 10 years)? - 4 Adolescents (10–18 years)? - 7 Adults (18–60 years)? - 6 Older adults (> 60 years)?

Answer 47

Question 48

Answer 48

Question 49

Investigative approach of a patient with seizures?

Answer 49

Question 50

**Treatment of a patient with acute seizures** - Approach? - Initial stabilisation?

Answer 50

Initial stabilization for acute seizures 1. Call for help and remove or control hazards (e.g., remove sharp objects in the patient's vicinity). 1. Perform an ABCDE assessment; if needed, perform cardiopulmonary resuscitation. 1. Initiate basic airway maneuvers, start oxygen therapy, and place the patient in the recovery position. 1. Check POC glucose and vital signs.

Question 51

**Treatment of a patient with acute seizures** - Overview of pharmacotherapy for acute seizures? - Algorithm?

Answer 51

Question 52

Management of rapidly reversible causes of seizures?

Answer 52

Question 53

What is an Anion Gap? How do you calculate it? What is the normal range? - Affect of Albumin and Phosphate?

Answer 53

**ALBUMIN AND PHOSPHATE** - The normal anion gap depends on serum phosphate and serum albumin - The normal AG = 0.2 x [albumin] (g/L) + 1.5 x [phosphate] (mmol/L) - Albumin is the major unmeasured anion and contributes almost the whole of the value of the anion gap. - Every 1g/L decrease in albumin will decrease anion gap by 0.25 mmoles. - A normally high anion gap acidosis in a patient with hypoalbuminaemia may appear as a normal anion gap acidosis. - This is particularly relevant in ICU patients where lower albumin levels are common

Question 54

Causes of HIGH ANION GAP METABOLIC ACIDOSIS? - LTKR? - CATMUDPILES?

Answer 54

**Causes (LTKR)** - Lactate - Toxins - Ketones - Renal

Question 55

Calculate the anion gap and differentiate between causes of a normal and high anion gap metabolic acidosis. **NORMAL ANION GAP METABOLIC ACIDOSIS - Causes** - CAGE? - ABCD? - How do you calculate the urinary anion gap and why?

Answer 55

NAGMA results from loss of HCO3- from ECF **Causes (CAGE)** - Chloride excess - Acetazolamide/Addisons - GI causes – diarrhea/vomiting, fistulae (pancreatic, ureters, billary, small bowel, ileostomy) - Extra – RTA **Causes (ABCD)** - Addisons (adrenal insufficiency) - Bicarbonate loss (GI or Renal) - Chloride excess - Diuretics (Acetazolamide)

Question 56

Compare the pathophysiology, clinical features, metabolic abnormalities and management of diabetic ketoacidosis (DKA) and hyperosmolar hyperglycaemic state (HHS).

Answer 56

- **DKA** is characterized by a rapid onset of hyperglycemia and ketone production leading to metabolic acidosis. Clinical features include abdominal pain, Kussmaul respirations, and a fruity breath odor. Management involves fluid resuscitation, insulin therapy, and correcting electrolyte imbalances. - **HHS** features a more gradual onset with severe hyperglycemia and significant dehydration but without significant ketoacid formation. Clinical symptoms include profound dehydration and altered mental status. Management focuses on fluid replacement, insulin therapy, and careful correction of electrolytes while addressing the underlying cause.

Question 57

Compare and contrast enteral and parenteral methods of nutrition, including the indications, advantages, and complications of each in critically ill patients.

Answer 57

- **Enteral Nutrition** is often preferred when the GI tract is functional as it helps maintain gut integrity and is associated with fewer complications related to infection. It can be administered through various routes depending on the patient's condition and ability to tolerate feeding. Complications primarily involve GI symptoms and potential issues related to tube placement and maintenance. - **Parenteral Nutrition** is indicated when the GI tract is non-functional or severely compromised. It allows for complete nutritional support directly into the bloodstream, but it comes with higher risks, including infection and metabolic disturbances. Proper management involves close monitoring of metabolic parameters and catheter care to avoid complications.

Question 58

Describe the general principles of managing patients with drug overdose in the ICU (10 Steps).

Answer 58