1. Self-Evaluation Process
2012 Update in Critical Care Medicine
Module A2-M Version 2012-1
Confidential
Only for use at the Scott & White Learning Sessions held July 16th 2012.
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2. 31st Annual Internal Medicine Review
July 16th 2011
Stephen Sibbitt, MD, FACP Curtis Mirkes, DO, FACP
CMO Scott & White Program Director
Memorial Hospital IM Residency
3. Question 1
Left ventricle (LVAD)
Right ventricle (RVAD)
Both ventricles (BIVAD)
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
4. Question 1
Classification of HF: Comparison Between ACC/AHA HF Stage &
NYHA Functional Class
ACC/AHA HF Stage1 NYHA Functional Class2
None
A At high risk for heart failure but without
structural heart disease or symptoms
of heart failure (eg, patients with
hypertension or coronary artery disease)
I Asymptomatic
B Structural heart disease but without
symptoms of heart failure
II Symptomatic with moderate exertion
CStructural heart disease with prior or
current symptoms of heart failure
III Symptomatic with minimal exertion
D Refractory heart failure requiring IV Symptomatic at rest
specialized interventions
1HuntSA 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.
8. Question 1
A. Continuation of current management
B. Placement of a left ventricular assist device
C. Plasma exchange
D. Proceeding to ABO non-matched heart
transplantation
13. 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
14. Question 3
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
Morgenthaler N. et al., Clin Lab 2002, 48: 263-270
17. 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
18. Question 4
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))
21. 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)
28. 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
29. Question 6
Etiology & Hemodynamic Changes in Shock
Etiology of Example CVP CO SVR VO2 sat
shock
Preload Hypovolemic Low Low High Low
Contractility Cardiogenic High Low High Low
Afterload Distributive
Hyperdynamic Low/High High Low High
Septic
Hypodynamic Low/High Low High Low/High
Septic
Neurogenic Low Low Low Low
Anaphylactic Low Low Low Low
30. 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
33. Question 6
A. Less anticoagulation is needed
B. A higher level of underlying cardiac function is
required
C. Mortality from cardiogenic shock is reduced
D. Ventricular loading is reduced, and cardiac
performance is improved
E. Percutaneous left ventricular assist devices can
be used in severe aortic regurgitation
37. Question 7
A. Arterial blood gas studies
B. Depth of chest wall compression
C. Quantitative waveform capnography
D. Good air entry on auscultation of the lungs
42. 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
46. 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
49. Question 10
A. Decreased incidence of infections
B. Increased incidence of burnout
C. Decreased job satisfaction
D. Increased incidence of cross-contamination
50. 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)
51. Question 11
Degree of Compensation
For metabolic acidosis,
Expected PCO = 1.5(HCO3) + 8
2 2
= 1.5(15) + 8 2
= 22.5 + 8 2
= 30.5 2
= 28.5, 32.5
7.3 / 30 / 94 / RA
Actual PCO is 30 appropriate compensation
2
55. 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.
60. 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
62. Question 13
Direct Insult Indirect Insult
Common Common
Aspiration Pneumonia Sepsis
Pneumonia Severe Trauma
Shock
Less Common Less Common
Inhalation Injury Acute Pancreatitis
Pulmonary contusions Transfusion Related TRALI
Fat Emboli DIC
Near Drowning Head Injury
Reperfusion Injury Burns
Drug Overdose
65. 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.
66. Question 13
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
70. 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
73. Question 15
A. Increased time for return of spontaneous
circulation
B. No difference in survival at 30 days
C. Reduced survival if the airway is occluded
D. Reduced survival to hospital admission
76. 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
79. 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)
80. 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.
81. 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
82. Question 18
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.”
ACS = IAH + organ dysfunction
The 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
83. 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
86. 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
89. Question 20
A. Emergent magnetic resonance imaging of the
thoracic spine
B. Intravenous corticosteroids
C. Norepinephrine
D. Emergent placement of an epidural drain
91. Question 21
A. Dopamine
B. Dobutamine
C. Norepinephrine
D. Vasopressin
92. 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
93. Question 22
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
95. Question 23
A. In all infections regardless of the risk of death
B. In patients with witnessed aspiration
C. Only in immunosuppressed patients
D. Only in serious infections when the risk of
death with monotherapy is greater than 25%
99. 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
105. 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
108. Question 27
A. Continue current management
B. Discontinue albuterol nebulization
C. Change intravenous fluid to 5% dextrose in
water with 2 ampules of bicarbonate
(100 mEq/L)
D. Administer tromethamine (TRIS) buffer
109. Pressure ventilation vs. volume ventilation
Pressure-cycled modes deliver a fixed pressure at variable volume
Volume-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 Volume-cycled modes have the inherent
• Assist risk of volutrauma.
• Assist/Control
• Intermittent Mandatory Ventilation
(IMV)
• Synchronous Intermittent
Mandatory Ventilation (SIMV)
112. Question 28
A. The modality allows the patient to define their
inspiratory flow rate and tidal volume
B. The incidence of barotrauma is less
C. The need for tracheostomy to facilitate
weaning is less
D. Closed loop technology automatically adjusts
the FIO2
116. 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
119. Question 30
A. Discontinuation of lorazepam
B. Initiation of zolpidem
C. Discontinuation of methylprednisolone
D. Discontinuation of inhaled beta-adrenergic
agonists
