Intensive Care Medicine

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

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?

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?

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?

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:

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:

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

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:

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?

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?

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:

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?

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:

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?

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

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:

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

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

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

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

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

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:

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?

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

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

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

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?

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?

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?

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