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Which of the following parameters may be a late sign of cardiovascular disturbance signaling failure of the compensatory mechanisms? A. Tachycardia B. Bradycardia C. Hypotension D. Hypertension - ✔✔C Investigative tests should be based on the patient's history and physical examination as well as on previous tests. Which of the following is one of the most important indicators of critical illness? A. Respiratory acidosis B. Metabolic acidosis C. Elevated creatinine D. Hyponatremia - ✔✔B A 22-year-old man is brought to the emergency room after falling from a horse. He is awaiting transfer to another facility. He has a chest contusion and a non-displaced femur fracture. He is in spinal motion restriction with a cervical collar and long backboard. He has worsening respiratory distress and hypoxemia requiring endotracheal intubation. Which of the following modifications of the manual assisted ventilation technique is appropriate? A. Place an oral airway one size larger than usual. B. Add additional downward pressure on the face mask once it is sealed. C. Use a jaw thrust technique in place of neck extension. D. Increase the tidal volume with each manual assisted breath. - ✔✔C
Which of the following anatomic features is most likely to contribute to difficulty in maintaining a patent airway in a supine patient? A. Edentulous mandible B. Posteriorly displaced tongue C. Deviated nasal septum D. Anteriorly displaced thyroid cartilage - ✔✔B An elderly patient is on the medical ward for respiratory distress. Which of the following is correct regarding airway assessment? A. Laryngeal displacement toward the chest during inspiration occurs only with upper airway obstruction B. Chest rise with inspiration indicates an adequate tidal volume C. Unilateral absent breath sounds on auscultation is a tension pneumothorax D. Complete airway obstruction is likely when chest retraction and movement is present, but there are no breath sounds - ✔✔D An 82-year-old man who awoke with chest pain in the morning is being evaluated in the emergency department. He is alert and oriented. Shortly after being placed on a cardiac monitor in normal sinus rhythm with ST segment elevations, he becomes unresponsive and develops ventricular fibrillation. Which of the following initial interventions is most appropriate for this patient? A. Do not initiate treatment because, due to his age, he probably has a do-not-resuscitate order on file. B. Attempt to contact the family before treating to discuss the level of intervention. C. Start cardiopulmonary resuscitation while preparing to defibrillate. D. Start bag-mask-valve ventilation while preparing to intubate. - ✔✔C Which of the following is the purpose of cardiopulmonary resuscitation? A. To reverse symptomatic bradycardia in an ICU patient who is on multiple vasoactive infusions B. To reverse sudden cardiac death in a patient who is in the palliative care unit
C. Assist control volume ventilation D. Assist control pressure ventilation - ✔✔C A 56-year-old man presents to the emergency department with a three-day history of fever, shaking chills, cough, and sputum production. He was previously in good health and takes only amlodipine for a history of hypertension. In the emergency department, his heart rate is 130 beats/min, respiratory rate 32breaths/min, blood pressure 80/40 mm Hg, temperature 38.8°C (102°F), and oxygen saturation 92% on 6 liters of oxygen by nasal cannula. Pulmonary examination demonstrates crackles and bronchial breath sounds in both lower lobes. A chest radiograph shows multilobar consolidations. Although awake and alert, he appears visibly distressed and has marked accessory muscle use. Apart from antibiotics and resuscitation for sepsis, which of the following is the next best step for management of his respiratory failure? A. Trial of noninvasive mechanical ventilation by face mask B. Intubation and initiation of invasive mecha - ✔✔B A 56-year-old man is admitted to the ICU for pneumonia. He is intubated, with the following settings: assist control, tidal volume 550 mL, respiratory rate 12 breaths/min, positive end-expiratory pressure 5 cm H2O, FIO2 1.0. Vital signs are: temperature 38.7°C (101.6°F), heart rate 122 beats/min, respiratory rate 20 breaths/min, blood pressure (BP) 88/46 mmHg, SpO2 97%. A central venous line and arterial line have been placed. He has been started on broad-spectrum antibiotics. Which of the following is a clinical indicator that he would benefit from further fluid resuscitation? A. Heart rate persistently greater than 90 beats/min B. Passive leg raise resulting in at least 20% increase in systolic BP C. Urine output of less than 0.5 mL/kg/hour D. Systolic BP less than 90 mm Hg - ✔✔B A 75-year-old man with a history of hypertension is evaluated in the emergency department for nausea, vomiting, and abdominal pain. He is lethargic but can answer questions appropriately. His pulse is 130 beats/min, blood pressure 70/30 mm Hg, and respiratory rate 28 breaths/min. On physical examination, he is noted to have dry mucous membranes, poor capillary refill, and a distended abdomen with rebound tenderness. Arterial blood gas analysis reveals: pH 7.32, PCO2 28 mmHg, PO2 74 mm Hg, bicarbonate 13 mmol/L. Serum
lactate is 8.0 mEq/L. Which of the following findings has been shown to correlate with a worse prognosis in a patient with this clinical picture? A. Hypotension B. Acidemia on blood gas analysis C. Elevated serum lactic acid D. Tachypnea - ✔✔C A 65-year-old man is septic, with perforated diverticulitis. He undergoes emergent colectomy with creation of a colostomy. Multiple areas of purulence are identified in the peritoneal cavity. Postoperatively, he continues to be febrile and hypotensive. Chest radiograph is clear. Central venous pressure is 18 mm Hg, and hemoglobin is 13g/dL. Which of the following vasoactive drugs is most appropriate to administer next? A. Epinephrine B. Phenylephrine C. Norepinephrine D. Dobutamine - ✔✔C A 76-year-old woman with a history of congestive heart failure and hypertension is admitted with altered mental status and mild upper respiratory symptoms. According to family, her mental status has been gradually declining over the past three to four days. Because of generalized weakness and upper respiratory symptoms, she has had a limited amount of food and drink for the past 72 hours. Her home medications include metoprolol, lisinopril, and furosemide. Her family states that she has been compliant with these medications. On physical examination, vital signs are: heart rate 118 beats/min, blood pressure 96/53 mm Hg, respiratory rate 14 breaths/min, and oxygen saturation 98% on room air. Other findings included dry mucous membranes, poor skin turgor, and the absence of jugular venous distention. Pulmonary examination is clear on auscultation. She opens her eyes to voice, but mumbles incomprehensible sounds and has - ✔✔B While fighting a house fire, a 38-year-old man fell 10 feet through a burning roof into an actively burning bedroom. On arrival at the emergency department two hours later, he has abdominal pain. His focused assessment with sonography in trauma (FAST) examination shows fluid between his spleen and left kidney. His voice is hoarse, and he has carbonaceous sputum. He has blistering burns on his face and
A. Protamine sulfate B. Aminocaproic acid C. Somatostatin D. Tranexamic acid - ✔✔C Which of the following would not be an expected laboratory finding associated with preeclampsia? A. Alanine aminotransferase level of 60 U/L B. Normal glucose level C. Decreased fibrinogen level D. Normal bilirubin level - ✔✔C Hyponatremia - indications for 3% NS? - ✔✔Seizures or AMS What speed/rate can Na be correct in hyponatremia? - ✔✔8 mEq/24 hours 43 yo m with hx of CAD comes with left hemiparesis x 1 hour. CT shows no bleed. What do we do? - ✔✔Administer TPA/TNK 22 yo m after MVA; incomprehensible sounds, no eye opening to painful stimuli, CT scan shows increased ICP and subdural bleed; what is the first thing we do? - ✔✔Elevate head of bed to 30- 45 degrees Male presents with no breath sounds and tracheal deviation to the left side, what do we do? - ✔✔ 16 gauge needle cdecompression BP 86/52, HR 126, RR 29; what class of shock is this? - ✔✔Three/ Progressive Stage Male after MVA; FAST shows bleeding, on way to OR his BP tanks, what do we do to resuscitate? - ✔✔1:1:1 RBCS, platelets, FFP
male presents after MVA in cervical spine collar; while waiting for xray the SpO2 drops to 85%, left pupil is larger than right, he does not respond, only grunts, moves limbs to pain; what do we do? - ✔✔intubate with inline intubation NSTEMI or STEMI what do we want our SpO2 to stay above? - ✔✔> 94% Who should go to cath lab IMMEDIATELY with NSTEMI? - ✔✔If they have shock with NSTEMI =immediate cath lab/CABG After STEMI, what drug has been shown to decrease risk of mortality? - ✔✔ACE inhibitors Loose stools after treatment for UTI with antibiotics; MRI shows pancolitis, what is the tx? - ✔✔IVF, metronidazole, PO Vanco (It's CDIFF) Hospital day 14, pt with tachycardia; culture from central line = gram + cocci what do we do? - ✔✔Remove with line and treat with vanco Fever and headache with period of confusion in 20 year old patient; what is the likely cause? How do we treat? - ✔✔Cause: Neisseria meningitidis (meningococcal) Tx: Vanco, ceftriaxone 45 year old male with AMS, redness on upper thigh and scrotal area x 4 days (gangrenous); hx of poor controlled DM What is it? How to treat? - ✔✔Fournier's cellulitis
15 month child choked; CXR shows hyperinflated right lung, what is the diagnosis? - ✔✔Right mainstream bronchus obstruction d/t foreign body aspiration How to confirm intubation? - ✔✔-Wave form capnography
- End tidal CO2 monitoring What is the most critical indicator of distress? - ✔✔Tachypnea Causes of pulsus paradoxus - ✔✔Cardiac tamponade (becks triad), increased intrathoracic pressure, pericarditis, pericardial effusion 60 yo with JVD, missed dialysis 2 days ago; in respiratory distress; BP 80/40, rr 35, pulsus paradoxes 20mm, lungs clear, muffled hear sounds; what is the likely cause/dx? - ✔✔Cardiac tamponade Pt is receiving bag mask ventilation over 1 second with 100% O2 15 LPM, 10 compressions per minute; but the chest is NOT rising with ventilations; what do you do? - ✔✔Check seal, listen for leaks A patient has hyperkalemia, which med is contraindicated in intubation? - ✔✔Succinylcholine (neuromuscular blockade med) - it can cause hyperkalemia in itself Vtach/vfib arrest; CPR and shocks administered, now we have achieved ROSC; what is the best treatment? Why? - ✔✔Code Ice/ Targeted temperature management (32-36 degrees) because it preserves brain function Shunt physiology most common examples - ✔✔Pneumonia Atelectasis OD in suicide is what type of respiratory failure? - ✔✔Acute hypercapnic 55 yo with COPD exacerbation; pH 7.2, CO2 92, PO2 108; pt on vent at tidal volume 375, AC mode, FiO of 35%, PEEP 5, rate 20, peak airway pressure 55, plateau 18, autopeep 15
BP is now 70/40, why is it low? Treatment? - ✔✔Why low: High auto PEEP, should not have pressure in the lung at the end of exhalation Tx: Increase expiration time so they can empty lung completely with exhalation 45 yo male, vent for ARDs d/t aspiration pneumonia; his vent settings are AC mode, tidal volume 5 mL/kg, RR 20, PEEP 22, peak airway pressure 40, plateau 35, FiO2 100% PH 7. PaO2 88 What do we do? - ✔✔Lower PEEP to 18 to Lower pressure inside lung 72 year old male with CHF with accessory muscle use is awake and alert RR 34 BP 120/ HR 120 SpO2 90% on 8L CXR shows bialteral infiltrate consistent with CHF ABG 7.34 pH, 64 paO2, 50 paCO Treamtent? - ✔✔He needs pressure to get air in, so Bi-pap because he is alert and responsive with stable BP (other options are CPAP, vent) What decreases SVO2 - ✔✔Decreased o2 delivery
If too high it is forcing too much air, so lower the tidal volume or respiratory rate What is the normal inspiratory to expiratory ratio - ✔✔1 : 2- 3 Candidates for NPPV must be - ✔✔Alert, cooperative Hemodynamically stable Able to control airway secretion Able to coordinate with machine What settings should NPPV be initiated at? - ✔✔CPAP has to start at 8 BiPAP has to start at 8 inspiratory/4 expiratory What does a high inspiratory plateau pressure indicate? - ✔✔Alveolar distension, which can cause a pneumothorax How to manage high autopeep - ✔✔Disconnect pt from vent and push on chest to get air out, then reconnect and either decrease tidal volume or RR so they have time to exhale What should PEEP start at on vent setting? - ✔✔ 5 - 8 How is body weight predicted? - ✔✔45.5 + 2.3 (ht in inches - 60) If a patient is on a ventilator at FiO2 100% at PEEP of 24 and they are still hypoxic, what is our next step? Then what? Then what? - ✔✔Increase the inspiratory time, to make the ratio 3:1 inspiratory:expiratory If still hypoxic do prone position for 18 hours, 6 off
If still hypoxic do ECMO At FiO2 of 30% what is the highest the PEEP can be? At 40% At 50% At 60% At 70% At 80 % At 90% At 100% - ✔✔30%- 5 - 8 40%- 8 50%- 10 60%- 12 70%- 14 80%- 16 - 18 90%- 18 - 22 100% 22- 24
