Self-Evaluation Process 2012 Update in Critical Care
MedicineModule A2-M Version 2012-1
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ConfidentialOnly for use at the Scott & White Learning Sessions held July 16th 2012.
Stephen Sibbitt, MD, FACPCMO Scott & White Memorial Hospital
Curtis Mirkes, DO, FACPProgram Director
IM Residency
31st Annual Internal Medicine Review
July 16th 2011
Question 1
Utilized Heart muscle is
damaged and needs to rest in order to heal
Bridge in patients awaiting heart transplantation or in patients who have rejected a transplanted heart.
HeartMate ® Implantable
Left ventricle (LVAD)Right ventricle (RVAD)Both ventricles (BIVAD)
Question 1
1Hunt SA et al. J Am Coll Cardiol. 2001;38:2101–2113.
2New York Heart Association/Little Brown and Company, 1964. Adapted from: Farrell MH et al. JAMA. 2002;287:890–897.
ACC/AHA HF Stage1 NYHA Functional Class2
A At high risk for heart failure but withoutstructural heart disease or symptomsof heart failure (eg, patients withhypertension or coronary artery disease)
B Structural heart disease but withoutsymptoms of heart failure
C Structural heart disease with prior orcurrent symptoms of heart failure
D Refractory heart failure requiringspecialized interventions
I Asymptomatic
II Symptomatic with moderate exertion
IV Symptomatic at rest
III Symptomatic with minimal exertion
None
Classification of HF: Comparison Between ACC/AHA HF Stage & NYHA Functional Class
Question 1
Question 1
Question 1
A. Continuation of current management
B. Placement of a left ventricular assist device
C. Plasma exchangeD. Proceeding to ABO non-matched
heart transplantation
Question 1
Question 2
Beta-lactam antibiotics Penicillins
AmpicillinAmoxicillinPiperacillin
Cephalosporins (generations)1st gen: cephalothin2nd gen (cephamycins): cefoxitin,
cefotetan3rd gen: ceftazidime, cefotaxime,
ceftriaxone4th gen: cefepime
Question 2
Beta-lactam antibiotics Monobactam: aztreonam Carbapenems:
ImipenemMeropenemErtapenem
InhibitorsSulbactam (ampicillin/sulbactam:
Unasyn)Tazobactam (piperacillin/tazobactam:
Zosyn)Clavulanate (amoxicillin/clavulanate:
Augmentin)
Question 2
A. If renal function worsens, the dose should be decreased, rather than increasing the interval
B. The volume of distribution is decreased, necessitating a lower loading dose
C. The patient may benefit from shorter infusion times
D. The Cockcroft-Gault equation will accurately estimate the patient's glomerular filtration rate
Question 2
During severe bacterial infections and sepsis, blood levels rise rapidly (up to x100K) – no elevation from viral infections
Is the Standard of Care for much of Europe in the management of infection and sepsis
Question 3
Morgenthaler N. et al., Clin Lab 2002, 48: 263-270
Question 3
Question 3
A. An elevated procalcitonin level mitigates against myocardial infarction
B. A procalcitonin-guided strategy will decrease the patient's mortality risk
C. A low procalcitonin level makes septic shock less likely
D. A low procalcitonin level excludes bacteremia
Question 3
Use ideal body weight for underweight patient
Use adjusted body weight for overweight patient
Ideal body weight = ((Body height cm)-100) – (10% x (Body
height-100))
Adjusted body weight = Actual body weight (ABW) – (25% x (Actual
Body Weight- Ideal Body Weight))
Question 4
Question 4
Question 4
A. Total parenteral nutrition providing 35 kcal/kg (based on actual body weight)
B. Enteral nutrition providing 35 kcal/kg (based on actual body weight)
C. Enteral nutrition providing 22 kcal/kg (based on adjusted body weight)
D. Combined parenteral and enteral nutrition providing a total of 35 kcal/kg (based on ideal body weight)
Question 4
Question 5
Question 5
Extended-spectrum beta-lactamases (ESBL) confer resistance to beta-lactam agents and ESBL-containing organisms are multi-drug resistant.
Question 5
Question 5
A. CeftriaxoneB. CiprofloxacinC. Imipenem-cilastatinD. Piperacillin-tazobactam
Question 5
Question 6
Central Venous Pressure (CVP):CVP = right atrial pressure (RAP) =
right-ventricular end-diastolic pressure (RVEDP) (Right Ventricular Preload)
Pulmonary Capillary Wedge Pressure (PCWP)
PCWP = left atrial pressure (LAP) = left-ventricular end-diastolic pressure (LVEDP) (Left Ventricular Preload)
Question 6
Cardiac Output (CO) = HR x SV (L/min)
Normal CO = 4 to 8 L/min
Cardiac Index (CI) = CO/BSA (L/min/m2)
Normal CI = 2.5-4.2 L/min/m2
Question 6
Etiology of shock
Example CVP CO SVR VO2 sat
Preload Hypovolemic
Low Low High Low
Contractility
Cardiogenic High Low High Low
Afterload DistributiveHyperdynamic Septic
Low/High
High Low High
Hypodynamic Septic
Low/High
Low High Low/High
Neurogenic Low Low Low Low
Anaphylactic
Low Low Low Low
Etiology & Hemodynamic Changes in Shock
Question 6 Intraaortic Balloon Pump (IABP)
Counterpulsation is synchronized to the EKG or arterial waveforms
Increase coronary perfusion
Decrease left ventricular stroke work and myocardial oxygen requirements
Indications for its use include
Failure to wean from cardiopulmonary bypass
Cardiogenic shock after MI
Heart failure
Refractory ventricular arrhythmias with ongoing ischemia
Question 6
Question 6
A. Less anticoagulation is neededB. A higher level of underlying cardiac
function is requiredC. Mortality from cardiogenic shock is
reducedD. Ventricular loading is reduced, and
cardiac performance is improvedE. Percutaneous left ventricular assist
devices can be used in severe aortic regurgitation
Question 6
Question 7
Question 7
A. Arterial blood gas studiesB. Depth of chest wall compressionC. Quantitative waveform
capnographyD. Good air entry on auscultation of
the lungs
Question 7
Question 8
Question 8
Question 8
A. Rebound hypercoagulability and subsequent thromboembolism
B. Depletion of thrombin due to the surgical acute-phase response
C. Thrombogenesis due to postoperative hypovolemia
D. Decreased fibrin turnover
Question 8
Question 9
Medication Onset (min)
Duration (min)
Side Effects
Ultra short ActingSuccinylcholine 1 – 1.5 5 - 10 ↑ K, ICP
Intermediate ActingAtracurium
Rocuronium Cisatracurium
21
3 - 6
3030 – 60
30
Rash, Histamine Release Expensive
Long ActingPancuronium 1.5 – 2 60
Question 9
Question 9
A. Succinylcholine is contraindicated following thermal injury
B. Atracurium is indicated, as it has minimal cardiovascular effects in hypotensive patients
C. Cisatracurium is indicated because of its favorable onset of action
D. Rocuronium is contraindicated, as it may propagate hypotension
Question 9
Question 10
Question 10
A. Decreased incidence of infectionsB. Increased incidence of burnout C. Decreased job satisfactionD. Increased incidence of cross-
contamination
Question 10
Question 11
Anion Gap 140 – 100 – 15 = 25
Calculated Osmolality 2 X Na + BUN/2.8 + Glucose/18 2(140) + 18/2.8 + 130/18 294
Osmolal Gap = Measured Osm – Cal Osm -4 (normal ≤ 10)
Question 11Degree of Compensation For metabolic acidosis,Expected PCO2 = 1.5(HCO3) + 8 ± 2
= 1.5(15) + 8 ± 2= 22.5 + 8 ± 2= 30.5 ± 2= 28.5, 32.5
Actual PCO2 is 30 appropriate compensation
7.3 / 30 / 94 / RA
Question 11
Question 11
Classic clinical triad: Mental status changes Autonomic hyperactivity Neuromuscular abnormalities
Wide ranging symptoms
Question 11
Question 11
Lactic acid can exist in two forms: L-lactate and D-Lactate. In mammals, only the levorotary form is a product of metabolism.
D-Lactate can accumulate in humans as a byproduct of metabolism by bacteria, which accumulate and overgrow in the GI tract with jejunal bypass or short bowel syndrome.
The lab measures only L-lactate.
Question 11
Medical conditions (w/o tissue hypoxia) Hepatic failure Thiamine deficiency
(co-factor for pyruvate dehyrogenase)
Malignancy Bowel ischemia Seizures Heat stroke Tumor lysis Drugs/Toxins
Metformin (particulary associated with hypovolemia and dye)
Tissue underperfusion Shock, shock,
shock Hypoxia Asthma CO poisoning Severe anemia
L-Lactic Acidosis
Question 11
A. Serotonin syndromeB. Salicylate poisoningC. D-Lactic acidosisD. Vitamin B1 deficiencyE. Vitamin B6 deficiency
Question 11
Question 12
A. The use of real-time ultrasonography for central line placement has been found to decrease the complication rate in all sites of insertion
B. Ultrasonography and chest radiography have the same accuracy for detection of pleural effusion and parenchymal consolidation in critically ill patients
C. The Focused Assessment with Sonography for Trauma (FAST) technique of point-of-care ultrasonography has been shown to decrease the need for computed tomography and to reduce the time to intervention
D. The finding of B lines on pleural ultrasonography predicts the presence of pneumothorax
Question 12
Question 13
Acute Lung Injury Bilateral pulmonary infiltrates on chest x-ray Pulmonary Capillary Wedge Pressure <
18 mmHg (2.4 kPa) PaO2/FiO2* <300 mmHg (40 kPa) = ALI PaO2/FiO2 <200 mmHg (26.7 kPa)= ARDS
Question 13Direct Insult Indirect Insult
CommonAspiration Pneumonia
Pneumonia
CommonSepsis
Severe TraumaShock
Less CommonInhalation Injury
Pulmonary contusionsFat Emboli
Near DrowningReperfusion Injury
Less CommonAcute Pancreatitis
Transfusion Related TRALIDIC
Head InjuryBurns
Drug Overdose
Question 13
Question 13
Question 13
Potential beneficial prevention strategies Mechanical ventilation, tidal volume limited to 6 to 8
mL/kg; maintenance of airway pressure at less than 30 cm H2O; use of moderate PEEP level;
Blood products: limitation of the use of packed red blood cells to evidence-based guidelines; limitation of the use of fresh frozen plasma and platelets to the setting of actual bleeding;
Intravenous fluids, maintenance of neutral to negative fluid balance except in the setting of shock or during resuscitation;
Resuscitation timeline: adequate repletion of circulating volume as quickly as possible after development of shock; and
Drug toxicity: avoidance of drugs that have direct pulmonary toxicity, such as amiodarone, when possible; another anti-arrhythmic medication should be used.
A. Administration of inhaled corticosteroids to patients who have a PO2/FIO2 ratio less than 350 or use of positive end-expiratory pressure (PEEP) greater than 8 cm H2O, or both
B. Limiting transfusion of fresh frozen plasma and platelets to those patients who are actually bleeding
C. De-escalation of antibiotics if sputum cultures show no growth at 48 hours
D. Early bronchoscopy with bronchoalveolar lavage in patients at high risk for ventilator-associated pneumonia
Question 13
Question 14
Question 14
Question 14
A. The mortality in critically ill medical and surgical patients does not differ between hyperglycemic and normoglycemic patients
B. Mortality rates are proportional to blood glucose levels in critically ill patients who have hyperglycemia
C. In patients who have had myocardial infarction, glucose levels below the usual target of 140 to 180 mg/dL for critically ill patients are recommended for optimal outcome
D. After adjustment for severity of illness, hypoglycemia was not found to be an independent risk factor for death
Question 14
Question 15
Question 15
A. Increased time for return of spontaneous circulation
B. No difference in survival at 30 daysC. Reduced survival if the airway is
occludedD. Reduced survival to hospital
admission
Question 15
Question 16
Question 16
A. Associated with long-term cognitive impairment
B. Not associated with increased mortality
C. Associated with increased length of stay in the ICU, but not length of stay in hospital
D. Occurs independent of the age of the patient
Question 16
Question 17
Question 17
A. A-B-C, referring to opening the airway (A), giving 2 breaths (B), and 30 chest compressions (C)
B. C-A-B, referring to 30 chest compressions (C), opening the airway (A), and giving 2 breaths (B)
C. C-B-D, referring to 30 chest compressions (C), 2 breaths (B), and defibrillation (D)
D. D-A-B, referring to defibrillation (D), opening the airway (A), and 2 breaths (B)
Question 17
Question 18
IAP should be expressed in mmHg and measured at end-expiration in the
complete supine position after ensuring that abdominal muscle contractions are
absent and with the transducer zeroed at the level of the midaxillary line.
Question 18
IAH is graded as follows: Grade I IAP 12 - 15 mmHg Grade II IAP 16 - 20 mmHg Grade III IAP 21 - 25 mmHg Grade IV IAP > 25mmHg.
The IAH grades have been revised downward as the detrimental impact of elevated IAP on end-organ function has
been recognized
ACS = IAH + organ dysfunctionThe most common organ dysfunction /
failure(s) are: Metabolic acidosis despite resuscitation Oliguria despite volume repletion Elevated peak airway pressures Hypoxemia refractory to oxygen and PEEP
Abdominal Compartment Syndrome (ACS) is defined as a sustained IAP > 20mmHg (with or without an APP < 60mmHg) that is associated with new organ dysfunction/ failure.”
Question 18
A. mm Hg, zeroed to the bladder with the patient semirecumbent (head of bed elevated to a 45-degree angle)
B. cm H2O, zeroed to ear level with the patient in the supine position
C. mm Hg, zeroed to the mid-axillary line with the patient in the supine position
D. cm H2O, zeroed to the mid-axillary line with the patient in any position
Question 18
Question 19
Question 19
A. Both teams should be called when the patient has hypotension, tachycardia, respiratory distress, or altered consciousness
B. Both teams should contain an anesthesiology practitioner
C. Rapid-response teams typically have a call rate of 5 to 10 in 1000 admissions, and code teams have a call rate of 20 to 40 in 1000 admissions
D. Delays in the activation of rapid-response teams and code teams have been associated with increased mortality
Question 19
Question 20
Question 20
A. Emergent magnetic resonance imaging of the thoracic spine
B. Intravenous corticosteroidsC. NorepinephrineD. Emergent placement of an epidural
drain
Question 20
Question 21
A. DopamineB. DobutamineC. NorepinephrineD. Vasopressin
Question 21
Question 22
IAH is graded as follows: Grade I IAP 12 - 15 mmHg Grade II IAP 16 - 20 mmHg Grade III IAP 21 - 25 mmHg Grade IV IAP > 25mmHg.
The IAH grades have been revised downward as the detrimental impact of elevated IAP on end-organ function has
been recognized
A. Grade I, less than 5 mm Hg; Grade IV, greater than 40 mm Hg
B. Grade I, greater than 25 mm Hg; Grade IV, less than 50 mm Hg
C. Grade I, 5-10 mm Hg; Grade IV, greater than 50 mm Hg
D. Grade I, 12-15 mm Hg; Grade IV, greater than 25 mm Hg
Question 22
Question 23
A. In all infections regardless of the risk of death
B. In patients with witnessed aspiration
C. Only in immunosuppressed patientsD. Only in serious infections when the
risk of death with monotherapy is greater than 25%
Question 23
Question 24
Tidal Volume (mL) Plateau Pressure/PEEP (cm H2O) FIO2PO2 (mmHg)
A. 700 20/10 1.0 100B. 320 35/18 1.0 60C. 540 30/14 0.7 105D. 500 25/5 0.5 120
Question 24
Question 25
Routes of administration Insufflated
(snorted) IV (mainlined) Inhaled
(freebased) Oral
Cocaine Pharmacokinetics: Absorption
Question 25
Cocaethylene
Alcohol inhibits metabolism of cocaine Alcohol + cocaine chemically react to form
cocaethylene• Cocaethylene Effects
– Similar effects to cocaine
– Greater cardiac toxicity than cocaine
– 3-5x the half-life of cocaine
– Associated with seizures, liver damage, compromised immune system
Question 25
A. Acute respiratory distress syndrome
B. Propylene glycol intoxicationC. Mesenteric ischemiaD. Cocaethylene formation
Question 25
Question 26
Question 26
Question 26
A. His prognosis for return of renal function to baseline is better than those of patients who have impaired left ventricular function
B. In patients who have type 1 cardiorenal syndrome, the use of beta-adrenergic blockers worsens mortality
C. This patient's acute on chronic renal dysfunction probably caused his acute heart failure (type 3 acute renocardiac syndrome)
D. Addition of an angiotensin-converting enzyme inhibitor drug to this patient's chronic regimen will improve his 12-month mortality
Question 26
Question 27
Question 27
A. Continue current managementB. Discontinue albuterol nebulizationC. Change intravenous fluid to 5%
dextrose in water with 2 ampules of bicarbonate (100 mEq/L)
D. Administer tromethamine (TRIS) buffer
Question 27
Pressure ventilation vs. volume ventilationPressure-cycled modes deliver a fixed pressure at variable volumeVolume-cycled modes deliver a fixed volume at variable pressure
• Pressure-cycled modes• Pressure Support Ventilation
(PSV)• Pressure Control Ventilation
(PCV)• CPAP• BiPAP
• Volume-cycled modes• Control• Assist• Assist/Control• Intermittent Mandatory
Ventilation (IMV)• Synchronous Intermittent
Mandatory Ventilation (SIMV)
Volume-cycled modes have the inherent risk of volutrauma.
Question 28
Question 28
A. The modality allows the patient to define their inspiratory flow rate and tidal volume
B. The incidence of barotrauma is lessC. The need for tracheostomy to
facilitate weaning is lessD. Closed loop technology
automatically adjusts the FIO2
Question 28
Question 29
Posterior reversible encephalopathy syndrome (PRES)
Question 29
AJR 2008;29:1036-42
Conditions at Risk for PRES
Question 29
A. Contrast-enhanced magnetic resonance imaging of the brain
B. Lumbar puncture and cerebrospinal fluid examination
C. Intravenous contrast-enhanced computed tomography of the head
D. Cerebral angiography
Question 29
Question 30
A. Discontinuation of lorazepamB. Initiation of zolpidemC. Discontinuation of
methylprednisoloneD. Discontinuation of inhaled beta-
adrenergic agonists
Question 30
Questions?
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