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100
A 64-year-old woman weighing approximately 60 kg (132 lbs), is admitted to the ICU from the emergency department following intubation and initiation of mechanical ventilation. No past medical history is available. Chest radiograph reveals a right lower lobe infiltrate consistent with pneumonia. Ventilator settings are Fio2 of 0.5, assist-control volume ventilation, rate of 16/min (total assisted rate of 20/min), tidal volume of 600 mL, square inspiratory waveform, peak inspiratory flow rate of 80 L/min, and positive end-expiratory pressure of 5 cm H2O. The patient exhibits dyssychronous breathing. Pulse oximetry oxyhemoglobin saturation is 98%. Flow-over-time waveform is shown (see Figure below). Which of the following is most likely to be effective in improving the dyssynchronous breathing? A. Decreasing peak inspiratory flow rate B. Switching to decelerating inspiratory flow waveform C. Increasing set ventilator rate to ≥20/min D. Positioning patient with left side down E. Increasing set positive end-expiratory pressure
What is E. Increasing set positive end-expiratory pressure
100
A 22-year-old woman presents with acute liver failure due to acetaminophen toxicity. Her vital signs are stable. On examination, grade 2 encephalopathy is found, and the INR is 7.0. No signs of active bleeding are noted, and serum hemoglobin level is 13 g/dL. The most appropriate next step in the management of her severe coagulopathy is: A. Administration of fresh frozen plasma B. Administration of recombinant factor VIIa C. Plasmapheresis D. Monitoring without intervention E. Administration of factor IX complex
What is D. Monitoring without intervention
100
A 74 yo in ER temp 102, WBC 39K, procalcitonin 13, lactate 11, glu 600 Na 134 K 7.2 Cl 100 HCO3 5 BUN 58, Cr 3.8. ABG=6.95/20/162 on O2. What are the acid base problems and causes? a) AG met acidosis, met alkalosis, and resp alkalosis from DKA b) AG met acidosis from DKA, AKI, and lactic acidosis with sepsis and respiratory acidosis (likely from fatigue) c) AG met acidosis from lactic acidosis and appropriate respiratory compensation d) AG met acidosis from lactic acidosis, DKA, Renal failure and toxic alcohol ingestion e) AG met acidosis from lactic acidosis, DKA, AKI, NAG met acidosis (could be due to diarrhea), and appropriate respiratory compensation
What is B
100
Which of the following is not an indication for emergent hemodialysis? a) refractory hyperkalemia b) severe lithium overdose/toxicity c) refractory hypervolemia d) uremic encephalopathy e) BUN over 100 with Cr over 15 f) refractory metabolic acidosis g) uremic pericarditis
What is e)
200
Which of the following patient data are utilized in the calculation of the appropriate tidal volume for a patient with acute respiratory distress syndrome (ARDS) in accordance with ARDSNet recommendations? A. Body mass index B. Weight C. Height D. Age
What is C. Height
200
A 45-year-old, otherwise healthy man is brought by ambulance to the emergency department because of a massive upper gastrointestinal tract bleed. Initial laboratory results show hemoglobin level of 3 g/dL, hematocrit of 9%, platelet count of 200,000/µL, total bilirubin level of 1.4 mg/dL, and international normalized ratio (INR) of 1.2. He is resuscitated and admitted to the ICU. An esophagogastroduodenoscopy (EGD) reveals a large duodenal ulcer with active bleeding. He undergoes endoscopic therapy and is placed on a proton pump inhibitor drip. Over the course of the first 48 hours, the patient requires 12 units of packed red blood cells. On hospital day 3, the patient’s laboratory results reveal a platelet count of 90,000/µL, total bilirubin level of 2.4 mg/dL (indirect bilirubin level of 1.8 mg/dL) and an INR of 2.2. His complete blood count is stable, and testing for immunoglobulin G antibodies to Helicobacter pylori returns positive results. Which of the following is the most likely cause of the patient’s thrombocytopenia? A. Idiopathic thrombocytopenic purpura B. Disseminated intravascular coagulation C. Heparin-induced thrombocytopenia D. Dilutional effect from massive transfusion of red blood cells E. Hepatic failure from proton pump inhibitor therapy
What is D. Dilutional effect from massive transfusion of red blood cells
200
Which of the following best predicts effective resuscitation from injury related to blood loss? a) improving mental status b) BP of 130/90 c) Normalizing lactate level d) urine output of 80ml/hr
What is c)
200
Which of the following is unlikely to lower K+ at least temporarily? a) kayexalate b) albuterol neb c) NaHCO3 d) Insulin (with D50 to prevent hypoglycemia) e) Furosemide f) Calcium gluconate
What is f)
300
A 28-year-old man weighing 80 kg (176 lbs) is admitted to the ICU following intubation and initiation of mechanical ventilation for community-acquired pneumonia associated with severe hypoxemia. His breathing pattern is dyssynchronous. Ventilation settings on assist- control, volume-cycled ventilation are Fio2 of 0.6, rate of 14/min (total rate assisted is 25/min), tidal volume of 700 mL, positive end-expiratory pressure (PEEP) of 10 cm H2O, and peak inspiratory flow rate of 60 L/min, with a square inspiratory flow waveform. Pulse oximetry reveals an oxyhemoglobin saturation of 96%. Pressure-over-time waveform is shown in the Figure. Which of the following is most likely to relieve the patient’s dyssynchronous breathing? A. Increasing peak inspiratory flow rate B. Switching to a decelerating inspiratory flow waveform C. Increasing ventilator rate D. Increasing PEEP E. Decreasing PEEP
What is A. Increasing peak inspiratory flow rate
300
A 50-year-old patient with chronic kidney disease is admitted to the ICU at 11 PM with altered mental status for 2 days, fever, tachycardia, and hypoxemia. A chest radiograph reveals a right lower lobe infiltrate. Prolonged bleeding from venipuncture sites and bleeding from the nasal mucosa after passage of a nasogastric tube is also noted. Platelet count is 100,000/µL, prothrombin time is 11.5 seconds, partial thromboplastin time is 35 seconds, blood urea nitrogen level is 150 mg/dL, and creatinine level is 10 mg/dL. Which of the following treatments is most likely to result in rapid improvement in the bleeding diathesis? A. Platelet transfusion B. Hemodialysis for uremia C. Conjugated estrogens D. Cryoprecipitate E. Desmopressin acetate
What is E. Desmopressin acetate
300
Which of the following findings is most likely to be present in a patient with severely low Magnesium? a) respiratory depression b) bradycardia c) Tetany d) hypotension e) Loss of patellar tendon reflexes
What is c)
300
A patient presents with ventilator associated pneumonia. Which of the following abx would not be appropriate? a) Vancomycin b) Cefepime c) Merropenem d) Ertapenem e) Zyvox
What is d)
400
A 25-year-old, asthmatic woman undergoes emergent laparotomy for a perforated appendix. Postoperatively, she develops profound dyspnea and acute respiratory failure. She is intubated with a rapid-sequence induction. Mechanical ventilation is initiated in an assist- control mode at 16/min, tidal volume of 550 mL, positive end-expiratory pressure of 0 cm H2O, and Fio2 of 1.0. In the postanesthesia recovery room, the patient is deeply sedated, with RR of 16/min on a set rate of 16/min with the ventilator. The flow graphic waveform shown in the Figure is displayed on the ventilator. Which of the following would be most effective in correcting this problem? A. Decrease the inspiratory flow rate. B. Increase tidal volume. C. Decrease respiratory rate. D. Increase positive end-expiratory pressure.
What is C. Decrease respiratory rate.
400
A 65-year-old woman is admitted to the ICU after coronary bypass surgery for acute myocardial infarction with cardiogenic shock. The postoperative course is complicated by acute renal insufficiency, and on postoperative day 5 the patient develops acute dyspnea with hypoxemia. A diagnosis of left lower extremity deep venous thrombosis is made by lower extremity ultrasonography, with probable pulmonary embolism. The patient is started on IV unfractionated heparin (weight-based nomogram) to achieve a partial thromboplastin time (PTT) 1.5 to 2 times the normal value. Laboratory studies at this time reveal normal electrolyte levels, a blood urea nitrogen level of 45 mg/dL, creatinine level of 2.8 mg/dL, WBC count of 9,000/µL, hemoglobin level of 10.1 g/dL, platelet count of 250,000/µL, and normal prothrombin time, international normalized ratio, and partial thromboplastin time. After 2 days of therapeutic anticoagulation with unfractionated heparin, the patient reports right lower extremity pain. Examination of the right lower extremity reveals a cold, painful extremity with loss of distal pulses. Laboratory studies reveal a blood urea nitrogen level of 50 mg/dL, creatinine level of 2.8 mg/dL, platelet count of 90,000/µL, international normalized ratio of 1.2, and PTT of 50 seconds. Which of the following therapeutic options is most appropriate at this time? A. Increase unfractionated heparin to achieve a higher PTT. B. Discontinue unfractionated heparin and start enoxaparin. C. Discontinue unfractionated heparin and start warfarin. D. Discontinue unfractionated heparin and start argatroban. E. Discontinue anticoagulation.
What is D. Discontinue unfractionated heparin and start argatroban.
400
Which of the following is the best combination of analgesic/sedation and paralytic for a patient with ESRD? a) morphine and vecuronium b) morphine and cisatracurium c) hydromorphone and cisatracurium d) hydromorphone and vecuronium e) Hydromorphone and pancuronium
What is C
400
Which of the following is not a relative or absolute contraindication for therapeutic hypothermia after cardiac arrest? a) Active internal bleeding b) Poor baseline prognosis and condition c) Immediate aroused state and following commands post-resuscition d) Age over 85 yo e) Over 24 hours since ROSC
What is d)
500
A 44-year-old woman is admitted to the ICU from the emergency department, where she presented with severe acute pancreatitis. She required intubation and seems to have developed acute respiratory distress syndrome (ARDS). On physical examination, she is intubated and sedated. Examination of the lungs reveals diffuse crackles and rhonchi, cardiac examination reveals regular tachycardia with normal heart sounds, and her abdomen is very tender and has decreased bowel sounds. Chest radiograph shows diffuse bilateral infiltrates. Initially, the patient had a good oxygen saturation on a Fio2 of 50% and positive end-expiratory pressure of 8 cm H2O. Now on arrival to the ICU her oxygen saturation has dropped and her Fio2 has been increased to 100%. A pressure-volume curve is shown in the Figure. Please select the point on this pressure-volume curve that would be most appropriate as the initial target to set PEEP in this patient. A. Point A B. Point B C. Point C D. Point D
What is A. Point A
500
A patient with septic shock secondary to pneumonia is admitted and treated in the ICU. On hospital day 3, his blood pressure is stable, and he is being weaned from norepinephrine. Hemoglobin is 8.5 g/dL, platelets are 35,000/µL, prothrombin time is 18 seconds, and partial thromboplastin time is 40 seconds. Which of the following best characterizes the blood products that should be transfused at this time? A. Red blood cells, platelets, and fresh-frozen plasma B. Red blood cells and platelets only C. Red blood cells only D. Platelets only E. No blood products
What is E. No blood products
500
A 55 yo with a h/o COPD and past sarcoidosis presents with massive hemoptysis. His CT of the chest shows B/L upper lobe cavities with mycetomas and some surrounding ground glass opacities. Bronchoscopy shows significant blood emanating from the RUL take off. Recent office spirometry shows FEV1 of 0.7 liters. He continues to cough up copious blood and is intubated and Hgb is dropping. What is the best next step? a) ask thoracic surgery to perform a RUL resection b) Repeat bronchoscopy and instill fibrin glue to the RUL entrance c) Transfuse PRBCs and FFPs and correct any underlying coagulopathy and observe d) Ask IR to perform bronchial artery embolization e) Ask IR to instill itraconozole to the mycetoma/cavity
What is d
500
A 64 yo female with severe COPD on home O2 presents to the ER with 3 days of dyspnea and wheezing. Her admission O2sat=88% on her normal 2 lpm O2. She is increased to 50% Venti mask. She is given IV solumedrol and duonebs. She is lethargic, but responds to loud voice. ABG=7.20/80/90. What is the next best step? a) intubate and place on mechanical ventilation and repeat ABG b) NIPPV using BiLevel and reduce FiO2 and then repeat ABG c) reduce to 3 lpm O2 and repeat ABG d) No change
What is b