Intensive Care Medicine Module 1

Which of the following is the strongest risk factor for developing critical illness myopathy (CIM) in ICU patients?

Use of intravenous glucocorticoid

Correct Incorrect Correct answer

Hyperglycemia

Correct Incorrect Correct answer

Hyperthyroidism

Correct Incorrect Correct answer

Higher illness severity index

Correct Incorrect Correct answer

Systemic inflammatory response syndrome

Correct Incorrect Correct answer

A patient with respiratory failure and chronic obstructive pulmonary disease has been started on noninvasive ventilation.

Which one of the following physiological changes is likely to occur?

Alveolar recruitment improving oxygenation

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Reduced airway resistance

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Increased work of breathing

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Reduced left ventricular preload

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Reduced bronchial secretions

Correct Incorrect Correct answer

A 21-year-old man with a history of injecting drug use is admitted to the Intensive Care Unit with a severe bilateral pneumonia. He has a recent history of recurrent skin boils which have been difficult to treat. He has received a number of courses of oral antibiotics for these lesions with little effect. He is intubated and gram stain of the endotracheal aspirate shows Gram positive cocci. Sputum cultures show a heavy growth of Staphylococcus aureus with sensitivities to follow. He is treated with intravenous ceftriaxone and a macrolide.

What is the most appropriate additional treatment?

Vancomycin

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Flucloxacillin

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Rifampicin

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Meropenem

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Gentamicin

Correct Incorrect Correct answer

A 25-year-old man with advanced cystic fibrosis is admitted to hospital because of fever and increasing cough and sputum expectoration. A chest X-ray on admission shows changes consistent with extensive bilateral bronchiectasis with upper zone predominance. Physiotherapy and intravenous anti-pseudomonas therapy are commenced.

Two days later he coughs up approximately 500 ml of bright red blood. Because of marked breathlessness he is transferred to the intensive care unit (ICU) and requires endo-tracheal intubation and ventilation because of continuing, large volume haemoptysis.

Fibreoptic bronchoscopy in the ICU showed blood staining of all major airways and clots of blood in the orifice of the right upper lobe bronchus. A definite bleeding source could not be identified.

Which one of the following should be the next procedure for this patient?

Bronchial arteriography and possible embolisation

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Selective intubation of the left main bronchus.

Correct Incorrect Correct answer

Explorative thoracotomy and possible lobectomy

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Pulmonary arteriography

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Computed tomography (CT) scan of the chest with contrast

Correct Incorrect Correct answer

A 65-year-old man collapses at a shopping centre. Cardiopulmonary resuscitation is commenced immediately and continued until an ambulance arrives 12 minutes later. He is intubated, ventilated and defibrillated, administered sedation and muscle relaxant by a doctor present at the scene, prior to urgent transfer to the nearest hospital.

Neurological review 24 hours after admission to the intensive care unit reveals intermittent jerking movements and partial eye opening, often in response to tactile stimulation, which family members interpret as awareness of their presence.

Examination after cessation of sedation and neuromuscular blockade reveals fixed dilated mid-range pupils, flaccid limbs and areflexia. His cranial computed tomography (CT) scan is shown.

The most likely diagnosis is:

hypoxic-ischaemic brain injury

Correct Incorrect Correct answer

status epilepticus

Correct Incorrect Correct answer

ventilation related air embolism

Correct Incorrect Correct answer

massive middle cerebral artery stroke.

Correct Incorrect Correct answer

basilar artery thrombosis

Correct Incorrect Correct answer

A 32-year-old woman with gram-negative septicaemia was admitted to an intensive care unit with a high fever, hypoxia and hypotension. During her convalescence she complained of unsteady gait and blurred vision during head movement. Her visual acuity was found to degrade by three lines on the Snellen chart when the examiner moved her head from side to side while she read the chart.

The most likely diagnosis is:

bilateral vestibular failure

Correct Incorrect Correct answer

bilateral ischaemic optic neuropathy

Correct Incorrect Correct answer

acute disseminated encephalomyelitis.

Correct Incorrect Correct answer

an exacerbation of multiple sclerosis with bilateral internuclear ophthalmoplegia

Correct Incorrect Correct answer

hypoxic damage to the Purkinje cells of the cerebellum

Correct Incorrect Correct answer

Which one of the following has the greatest positive impact on outcome in patients with acutely bleeding peptic ulcers?

Endoscopic injection therapy

Correct Incorrect Correct answer

Nil by mouth for 24 hours.

Correct Incorrect Correct answer

Admission to an intensive care unit

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Intravenous ranitidine

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Intravenous octreotide

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An unconscious 50-year-old man is brought to the emergency department four hours after an intentional overdose of approximately fifty 50 mg amitriptyline tablets. He has had a brief convulsion in the ambulance on the way to hospital.

An ECG shows a sinus tachycardia with widened QRS complexes of 0.13 seconds. Monitoring shows runs (lasting up to five seconds) of a broad complex tachycardia.

He is intubated and transferred to intensive care.

The most important initial management is:

bicarbonate therapy

Correct Incorrect Correct answer

amiodarone therapy

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phenytoin therapy

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lignocaine therapy

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haemodialysis

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A 42-year-old man in the intensive care unit following a motor vehicle accident develops Staphylococcus aureus bacteraemia. He is commenced on vancomycin.

Following the first infusion, he develops a rash involving the face and upper trunk. His blood pressure falls to 100/70 mmHg.

What is the most appropriate next step?

Continue vancomycin but slow the rate of infusion

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Stop vancomycin, commence linezolid

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Stop vancomycin, commence dalfopristin/quinupristin

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Commence rapid desensitisation for vancomycin

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Continue vancomycin but premedicate with hydrocortisone

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A 72-year-old male has been in intensive care for ten days following an episode of urinary tract sepsis. He has a persistent low grade fever.

He has a white cell count of 14.1 x 109/L [4.0-10.0], serum sodium is 128 mmol/L [134-145], and potassium is 5.0 mmol/L [3.5-5.0].

He has been weaned from mechanical ventilation, his renal function is normal and his delirium has cleared.

His urine is sterile. His ECG demonstrates a left bundle branch block. A synthetic adrenocorticotrophic hormone (ACTH) stimulation test demonstrates baseline cortisol of 350 nmol/L which rises to 400 nmol/L at 30 minutes.

He has been on noradrenaline at doses of 0.08 μg/kg/minute to 0.16 μg/kg/minute. Each attempt to cease the noradrenaline has led to hypotension associated with oliguria and obtundation.

Which of the following is the most likely cause of the persistent hypotension?

Adrenal suppression due to critical illness.

Correct Incorrect Correct answer

Persistent focus of infection.

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Hypovolemia.

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Sepsis related myocardial dysfunction

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Accumulation of opiate and sedative drugs

Correct Incorrect Correct answer

A 30 year old man admitted to intensive care develops systemic sepsis on day seven. Klebsiella pneumoniae is grown from the blood cultures with the following sensitivities:

ampicillin- resistant
cefotaxime- resistant
imipenem- sensitive
gentamicin- resistant
amikacin- sensitive

The most likely mode of resistance of this organism is:

extended spectrum beta lactamase production

Correct Incorrect Correct answer

altered binding proteins.

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chromosomally-mediated resistance

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inducible beta lactamase production

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intrinsic resistance.

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An 18-year-old woman is admitted following an episode of loss of consciousness at college. She has a two-day history of fever. The day after admission she requires fluid resuscitation and admission to the intensive care unit after an episode of cardiovascular collapse on the ward. Her electrocardiogram (ECG) is shown above.

What is the most likely diagnosis?

Pericarditis

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Acute anterior myocardial infarction

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Cardiomyopathy

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Hyperkalaemia

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Hypokalaemia

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A 45-year-old man with a long history of asthma presents to hospital with acute shortness of breath, requiring intubation and ventilation for respiratory support. A chest X-ray reveals right upper lobe consolidation. He is treated with intravenous methylprednis(ol)one, metronidazole, and ceftriaxone with his clinical course complicated by renal and cardiac failure requiring inotropic support and a short period of dialysis. Attempts to wean ventilation support are unsuccessful. Nerve conduction studies reveal the following:

Needle examination reveals fibrillation potentials with small motor unit potentials in all muscles examined.

The most likely diagnosis is:

critical illness myopathy

Correct Incorrect Correct answer

critical illness neuropathy

Correct Incorrect Correct answer

acute polymyositis

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acute inflammatory demyelinating polyneuropathy

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steroid myopathy

Correct Incorrect Correct answer

A 45-year-old female is recovering from septic shock due to faecal peritonitis. Repeated attempts to wean her from mechanical ventilation have failed due to hypercapnic respiratory failure. Neurological examination reveals diffuse weakness with decreased reflexes and distal sensory loss. Creatine kinase levels have been normal. Nerve conduction studies show a diffuse, symmetric, distal axonal sensorimotor neuropathy.

Which of the following is the most likely explanation for the inability to wean from mechanical ventilation?

Critical illness polyneuropathy

Correct Incorrect Correct answer

Acute inflammatory demyelinating polyneuropathy

Correct Incorrect Correct answer

Prolonged action of neuromuscular blocking agents.

Correct Incorrect Correct answer

Epidural abscess

Correct Incorrect Correct answer

Critical illness myopathy

Correct Incorrect Correct answer

Which of the following ECG changes is most prominent in TCA (eg: Amitriptyline) overdose?

Widening of QRS complex

Correct Incorrect Correct answer

Peaked p waves

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Inverted T waves

Correct Incorrect Correct answer

Left bundle branch block

Correct Incorrect Correct answer

Shortened PR interval

Correct Incorrect Correct answer

A 62-year-old man is admitted to the intensive care unit with community-acquired pneumonia and severe respiratory failure for which he is intubated and given mechanical ventilation. He becomes progressively hypoxaemic, hypotensive and oliguric.

Assessment at this stage shows: arterial blood pressure 93/55 mmHg

Arterial blood gases on 60% inspired oxygen:

PaO2 53 mmHg
PaCO2 34 mmHg
pH 7.31

Oxygen saturation 83%

Hemoglobin concentration 105 g/L [125-180]

Pulmonary capillary wedge pressure 5 mmHg [3-12]

Cardiac output 3.0 L/min [predicted cardiac output 4.5]

The most appropriate intervention to achieve an increase in oxygen delivery to his tissues is:

a volume infusion

Correct Incorrect Correct answer

the addition of positive end-expiratory pressure (PEEP).

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an increase in the inspired O2 (FiO2).

Correct Incorrect Correct answer

a transfusion of packed red cells.

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an increase in minute ventilation

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In patients with acute metabolic acidosis, which one of the following effect is most likely observed?

Decreased tissue oxygen delivery

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Increased adenosine triphosphate (ATP) generation

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Increased affinity of haemoglobin for oxygen

Correct Incorrect Correct answer

Peripheral vasoconstriction

Correct Incorrect Correct answer

Which one of the following correctly describes the effects of Norepinephrine?

Norepinephrine improves blood pressure in the setting of low peripheral vascular tone

Correct Incorrect Correct answer

Norepinephrine exerts an agonist effect on beta2-adrenoreceptors

Correct Incorrect Correct answer

Norepinephrine exerts an antagonist effect on alpha1-adenoreceptors

Correct Incorrect Correct answer

Adverse effects of norepinephrine are mostly related to alpha2- adrenoreceptor antagonism

Correct Incorrect Correct answer

Dysrhythmias are common with norepinephrine use

Correct Incorrect Correct answer

In a community cardiac arrest, which one of the following has been associated with the best chance of survival with a good neurological outcome?

Early defibrillation of ventricular fibrillation

Correct Incorrect Correct answer

Early administration of epinephrine (adrenaline)

Correct Incorrect Correct answer

Chest compression at a rate of 70/min

Correct Incorrect Correct answer

Atropine to treat asystolic cardiac arrest

Correct Incorrect Correct answer

Intravenous calcium chloride during cardiopulmonary resuscitation

Correct Incorrect Correct answer

Which one of the following therapeutic strategies can improve the survival of patients with adult respiratory distress syndrome and acute lung injury?

Low tidal volume ventilation

Correct Incorrect Correct answer

Early high-dose corticosteroids

Correct Incorrect Correct answer

Low frequency oscillatory ventilation

Correct Incorrect Correct answer

Low positive end-expiratory pressure

Correct Incorrect Correct answer

Supine positioning

Correct Incorrect Correct answer

Following acute smoke inhalation, which one of the following treatments is appropriate in the treatment of cyanide intoxication?

Hydroxycobalamin

Correct Incorrect Correct answer

Hyperbaric oxygen

Correct Incorrect Correct answer

Beta-2 agonists

Correct Incorrect Correct answer

Methylene blue

Correct Incorrect Correct answer

Glucagon

Correct Incorrect Correct answer

Gastric emptying in the critically ill is delayed because of impaired function of the proximal and distal stomach and the pylorus. However, it can be improved by the use of the following medication:

Erythromycin

Correct Incorrect Correct answer

Diltiazem

Correct Incorrect Correct answer

Fentanyl

Correct Incorrect Correct answer

Rantidine

Correct Incorrect Correct answer

Pantoprazole

Correct Incorrect Correct answer

In Australia and New Zealand, whole brain death is required for the legal determination of death. However, prior to brain death testing, certain preconditions must be met.

Which of the following is NOT a precondition prior brain death testing?

Low blood pressure

Correct Incorrect Correct answer

Absence of hypothermia

Correct Incorrect Correct answer

Exclusion of sedative drug effects

Correct Incorrect Correct answer

Intact neuromuscular function

Correct Incorrect Correct answer

Absence of severe electrolyte disturbance

Correct Incorrect Correct answer

All of the following drug undergoes non-organ metabolism, except?

Propofol

Correct Incorrect Correct answer

Esmolol

Correct Incorrect Correct answer

Atracurium

Correct Incorrect Correct answer

Inhaled nitric oxide

Correct Incorrect Correct answer

Adrenaline

Correct Incorrect Correct answer

Which of the following feature is most consistent with life-threatening asthma?

Silent chest

Correct Incorrect Correct answer

Inability to complete sentences in one breath

Correct Incorrect Correct answer

PaO2 of >8kPa.

Correct Incorrect Correct answer

PaCO2 of >6kPa

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Peak expiratory flow rate of less than 50 percent predicted

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The following statements are all true regarding Hepatorenal Syndrome, except?

Terlipressin must be given by infusion

Correct Incorrect Correct answer

It is commonly over-diagnosed in patients with cirrhotic liver disease.

Correct Incorrect Correct answer

HRS Type 1 carries the poorest outcome

Correct Incorrect Correct answer

HRS patients may be suitable donors for kidney transplant.

Correct Incorrect Correct answer

The condition is associated with splanchnic vasodilatation

Correct Incorrect Correct answer

A 69-year-old male has a diagnosis of myasthenia gravis (MG). Which of the following medications should be avoided to reduce the risk of exacerbation?

Gentamicin

Correct Incorrect Correct answer

Paracetamol

Correct Incorrect Correct answer

Trimethoprim

Correct Incorrect Correct answer

Aspirin

Correct Incorrect Correct answer

Losartan

Correct Incorrect Correct answer

A 60-year-old male is admitted with a gradual onset of peripheral oedema and frothy urine. He is subsequently diagnosed with nephrotic syndrome.

Which of the following feature is NOT consistent with this diagnosis?

Hypercalcemia

Correct Incorrect Correct answer

Hypercoagulability

Correct Incorrect Correct answer

Hyperlipidemia

Correct Incorrect Correct answer

Hypovolemia

Correct Incorrect Correct answer

High risk of myocardial infarction

Correct Incorrect Correct answer

When assessing a patient with moderate to severe traumatic brain injury, which of the following assessment is least likely to be useful in predicting the patient’s prognosis?

Sensory neurological deficit.

Correct Incorrect Correct answer

Age

Correct Incorrect Correct answer

Pupillary reaction

Correct Incorrect Correct answer

Glasgow coma score

Correct Incorrect Correct answer

Serum glucose

Correct Incorrect Correct answer

In regards to lumbar puncture, which of the following statement is true?

Meningitis is a relatively rare complication of LP.

Correct Incorrect Correct answer

LP should not be performed in patients with suspected bacteraemia

Correct Incorrect Correct answer

Aspirin should be stopped for at least 24 hours prior to LP.

Correct Incorrect Correct answer

LP is safe to be performed in patients with a suspected spinal epidural abscess

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LP should not be performed in patients with platelet counts less than 100,000/μL

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A 58-year-old man presents with acute pulmonary embolism and cardiogenic shock. Echocardiography demonstrates severe right ventricular dysfunction. The intensivist plans to commence vasopressor therapy.

Which single statement best explains why norepinephrine is generally considered the vasopressor of choice in this setting?

It increases systemic vascular resistance with modest inotropic effect.

Correct Incorrect Correct answer

It selectively reduces pulmonary vascular resistance at all doses

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It has a pure chronotropic effect that improves right ventricular filling

Correct Incorrect Correct answer

It preferentially dilates the coronary arteries without affecting afterload

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It reliably reduces right ventricular afterload independent of dose

Correct Incorrect Correct answer

Intensive Care Medicine Module 1

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