ATS Critical Care Board Review Question Book [1 ed.] 9780977644223

Table of contents :
Table of Contents
Foreword
Senior Editors
Faculty Contributors
Questions
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Answers

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American Thoracic Society

BOARD REVIEW

Question Book

ATS REVIEW FOR THE CRITICAL CARE BOARDS First Edition Senior Editorial Team Alison Clay, MD | Margaret M. Hayes, MD | Susan Pasnick, MD | Tisha Wang, MD

Copyright © 2018 by American Thoracic Society All rights reserved. This book or any portion thereof may not be reproduced or used in any manner whatsoever without the express written permission of the publisher except for the use of brief quotations in a book review. Printed in the United States of America First Printing, 2018 ISBN 978-0-9776442-2-3 American Thoracic Society 25 Broadway, 18th Floor New York, NY 10004 store.thoracic.org

Table of Contents Foreword………………….............................................................................. ii Senior Editors………………………................................................................ iii Faculty Contributors………………….............................................……......... iv Questions……………………………….....................…….................................... 1 Answers……………………………………………................................................ 79 Please note each question number matches the answer number starting on page 79.

i

Foreword As we began to embark on the first edition of the ATS Critical Care Board Review Book, we ambitiously suggested creating an accompanying board review question book. For years, the ATS Core Curriculum generated a number of critical care questions on core topics within critical care and these questions were revised and optimized with the addition of dozens of new critical care questions inspired by the book itself. Similar to the book, this was a truly collaborative effort with a number of contributions made by medical educators from all across the country brought together by the ATS educational mission. We owe an immense amount of gratitude to the wonderful ATS staff who helped us get this to the finish line – Odalys Jimenez, Eileen Larsson, Lauren Krampen, Dorcas Gelabert, Lauren Lynch, and especially Jennifer Siegel-Gasiewski who kept us on track and provided an immense amount of both administrative and moral support. We also have Brian Kell to thank for his rapid and amazing editing skills and Bosede Cajuste to thank for the meticulous final medical copy edit. We also owe a big thank you to all the faculty and trainees who wrote questions for the ATS Critical Care Core Curriculum between 2013 and 2016. Without your valuable contributions, we would not have known where to start. To Susan, Molly, Alison – you all are the ultimate dream team of amazing women medical educators. Thank you for the countless hours of time you put into this amidst the busy clinical schedules and amazing work that you all do as physicians, medical educators, and human beings. It was such a true pleasure and privilege to work alongside you on this project. On behalf of the entire team, we now present to you the first edition of the ATS Critical Care Board Review Question Book. We hope you find these questions helpful and we wish you the very best of luck on the critical care boards. Warmest Regards, Tisha Wang MD on behalf of the editorial team

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Senior Editors Alison Clay, MD Assistant Professor of Surgery, Duke University School of Medicine Assistant Professor in Medicine, Duke University School of Medicine Department of Surgery, Duke University School of Medicine Margaret M. Hayes, MD Assistant Professor of Medicine, Harvard Medical School Associate Program Director, Beth Israel Internal Medicine Residency Division of Pulmonary, Critical Care, and Sleep Medicine Beth Israel Deaconess Medical Center Susan Pasnick, MD Director of Critical Care CHRISTUS St. Vincent Regional Medical Center, Santa Fe, NM Tisha Wang, MD Associate Professor of Clinical Medicine Fellowship Program Director Clinical Division Chief Division of Pulmonary, Critical Care, and Sleep Medicine UCLA Medical Center

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Faculty Contributors Shozab Ahmed, M.B.B.S, F.C.C.P

Assistant Professor Associate Program Director Internal Medicine Residency Program Associate Program Director Critical Care Fellowship Program Department of Internal Medicine Division of Pulmonary, Critical Care and Sleep Medicine University of New Mexico

Colleen L. Channick, MD

Assistant Professor of Medicine, Harvard Medical School Division of Pulmonary and Critical Care Medicine Massachusetts General Hospital

W. Graham Carlos, MD, MSCR

Associate Professor of Clinical Medicine Division of Pulmonary, Critical Care, Sleep and Occupational Medicine Indiana University School of Medicine

Daniel Crouch, MD

Assistant Professor of Medicine Division of Pulmonary and Critical Care Medicine University of California, San Diego

Shazia M. Jamil, MD, FCCP, FAASM

Clinical Associate Professor of Medicine University of California, San Diego School of Medicine Division of Pulmonary, Critical Care and Sleep Medicine Department of Medicine, Scripps Clinic

Ryan C. Maves, MD, FCCP, FIDSA

Commander, Medical Corps, U.S Navy Program Director, Infectious Diseases Fellowship Faculty Physician, Critical Care Medicine Service Naval Medical Center, San Diego, California Associate Professor of Medicine Uniformed Services University, Bethesda, Maryland

Jason T. Poston, MD

Assistant Professor of Medicine University of Chicago Medicine

Samaan Rafeq, MD

Senior Associate Director, Interventional Pulmonology Section Director, Interventional Pulmonary Fellowship NYU School of Medicine

Jeremy B. Richards, MD, MA

Assistant Professor of Medicine Beth Israel Deaconess Medical Center and Harvard Medical School

Carey C. Thomson, MD, MPH

Associate Chair, Department of Medicine Chief, Pulmonary and Critical Care Division Mount Auburn Hospital Associate Professor, Harvard Medical School

Carolyn H. Welsh, MD

Professor of Medicine Division of Pulmonary Sciences and Critical Care Medicine Staff physician and Sleep Program Director at The Eastern Colorado VA Health Care System University of Colorado Denver

Bishoy Zakhary, MD

Assistant Professor of Medicine Department of Pulmonary and Critical Care Medicine Oregon Health and Sciences University

Anna L. Zisman, MD

Assistant Professor of Medicine Department of Medicine and Section of Nephrology The University of Chicago

Jakob I. McSparron, MD

Assistant Professor of Medicine Division of Pulmonary and Critical Care Medicine University of Michigan

Gaetane Michaud, MS, MD, FRCPC

Associate Professor of Medicine, Pulmonary, Critical Care and Cardiothoracic Surgery Chief, Interventional Pulmonology NYU School of Medicine

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Medical Copy Editors Bosede Cajuste and Brian Kell

ATS ATS Review review forofthe theCritical pulmonary Care Boards boards

questions

1.

A 43-year-old woman with a history of heavy alcohol use is admitted to the ICU after being found unresponsive in her garage. She is afebrile with a HR of 110 bpm and a BP of 97/54 mm Hg. Her chemistry panel reveals: Na 137 mEq/L, K 5.1 mEq/L, Cl 97 mEq/L, HCO3 7 mEq/L, BUN 28 mg/dL, Cr 0.9 mg/dL, and glucose 108 mg/dL. Lactate is 3.1 mmol/L. Plasma osmolality is 332 mOsm/kg. Which of the following therapies is most appropriate for this patient? A. Intermittent hemodialysis B. Ultrafiltration C. Continuous veno-venous hemodialysis D. Hyperbaric oxygen therapy E. Observation pending results of comprehensive toxicology labs

2.

A 58-year-old man with diabetes mellitus, hypertension, coronary artery disease, and heavy alcohol abuse is admitted to the ICU for community-acquired pneumonia. He is intubated on hospital day 1 and started on piperacillin/tazobactam and moxifloxacin. His hospital course is complicated by alcohol withdrawal requiring sedation. On hospital day 5, he develops a fever and is pan-cultured. It is now hospital day 8. His exam is as follows: Vitals: Temp 37.6°C, HR 85 bpm, BP 115/65 mm Hg, RR 14/min on pressure support 14 cm H2O, PEEP 8 cm H2O, FiO2 50% General: Sedated, arouses only to deep sternal rub Cardiovascular: Regular rate and rhythm with no murmurs, rubs, or gallops

1

ATS Review for the Critical Care Boards | QUESTIONS

Pulmonary: Crackles in the right axilla Extremities: 1+ edema bilaterally Skin: Right subclavian line is clean, dry, and intact GU: Foley catheter in place Labs: WBC WBC 12,000 cells/µL (down from 14,000 the day prior) with 78% segmented neutrophils, 2% bands, 10% lymphs, 5% monocytes, and 3% eosinophils Blood cultures x 2 are no growth to date (one peripheral and one from the subclavian line). Urine culture and endotracheal aspirate are growing yeast. What is the most appropriate treatment strategy for this patient? A. Continue antibiotics for a 14-day course B. Continue antibiotics for a 14-day course, add fluconazole C. Discontinue antibiotics, start an echinocandin D. Discontinue antibiotics, replace the Foley catheter, start fluconazole E. Discontinue antibiotics, replace the Foley catheter

3.

A 44-year-old man with alcoholic cirrhosis develops rapidly progressive oliguric renal failure and is transferred from the floor to your ICU. You suspect hepatorenal syndrome as his work-up to date reveals no alternative explanation for his renal failure. Which of the following findings is most consistent with this syndrome? A. Urine Na of 15 mEq/L B. Urine protein of 1.4 g/dL C. Central venous oxygen saturation (ScvO2) of 60% with a pulmonary capillary wedge pressure (PCWP) of 8 mm Hg D. Cr of 1.5 mg/dL compared to 1.1 mg/dL one week prior E. Lack of improvement in renal function after discontinuation of diuretics and administration of albumin

2

ATS Review for the Critical Care Boards | QUESTIONS

4.

A 55-year-old man presents to the ED with chest pain. EKG demonstrates ST elevation in leads II, III and aVF. Vital signs show a HR of 56 bpm, BP of 75/55 mm Hg, and room air saturation of 96%. A bedside echocardiogram reveals right ventricular dilation and dysfunction. The patient is intubated and started on mechanical ventilation. In spite of increasing dobutamine and epinephrine doses, the patient has ongoing cardiogenic shock with rising lactate levels and decreasing urine output. What is the next best step in the management of this patient? A. B. C. D. E.

Place an intra-aortic balloon pump (IABP) Place an Impella device Place the patient on veno-venous extracorporeal membrane oxygenation (VV ECMO) Place the patient on veno-arterial extracorporeal membrane oxygenation (VA ECMO) Insert a durable right ventricular assist device

5.

A 55-year-old man with a history of coronary artery disease is mechanically ventilated for acute hypoxic respiratory failure. He is receiving fentanyl and propofol infusions to manage pain and agitation while intubated. On exam, he is not moving his extremities or overbreathing the ventilator. He grimaces and withdraws to nailbed pressure but does not open his eyes to voice. Which of the following is the most appropriate step in managing this patient? A. B. C. D. E.

Reduce the propofol and fentanyl infusions by 50% Interrupt the propofol infusion and administer an antipsychotic Change the propofol infusion to a benzodiazepine infusion Interrupt both the propofol and fentanyl infusions Continue the current pain and agitation regimen until the patient is ready for extubation

6.

A group of investigators is trying to determine if life stressors predispose patients to ARDS. They have access to a database of all ICU patients admitted to their hospital over the previous ten years. They identify all ARDS survivors and mail them a survey asking them about life stressors preceding their illnesses. Using the same database, they identify an equal number of ICU survivors without ARDS and send them the same survey.

3

ATS Review for the Critical Care Boards | QUESTIONS

Which of the following is the best description of this type of study? A. Randomized controlled trial B. Case-control study C. Cohort study D. Cross sectional analysis E. Meta-analysis

7.

A 55-year-old woman weighs 70 kg and has a history of bipolar disorder for which she takes lithium. She is brought to the hospital by her husband for an elective upper endoscopy for the evaluation of GERD. She has been NPO overnight. Nursing staff note that she is somnolent and only oriented to person and place. She is afebrile with a HR of 110 bpm and BP of 106/61 mm Hg. Her pre-procedure chemistry panel is as follows: Na 160 mEq/L, K 4.0 mEq/L, Cl 120 mEq/L, HCO3 24 mEq/L, BUN 40 mg/dL, Cr 0.9 mg/dL, and glucose 108 mg/dL. Which of the following is the next best step in the management of this patient? A. Start 5% dextrose in water (D5W) drip based on calculated free water deficit and volume of distribution to decrease serum sodium by 1–2 mEq/hr until back in the 140–145 mEq/L range B. Bolus 2L of normal saline over 2 hours C. Start D5W drip based on calculated free water deficit and volume of distribution to decrease serum sodium by 0.3–0.5 mEq/hr until serum sodium is back in the 140–145 mEq/L range D. Administer desmopressin 10 µg BID intranasally E. Place an NG tube and give free water at 250 mL q4 hrs until serum sodium is back in the 140–145 mEq/L range

8.

A 32-year-old man weighing 70 kg is burned while lighting fireworks for the 4th of July. He has second- and third-degree burns over his anterior chest and abdomen, as well as the anterior portions of both legs. The ambulance crew initiates IV fluids and pain medications during transport. By the time the patient arrives to the ED (30 minutes after his injury) he has received 2L of Lactated Ringer’s and 8 mg of morphine sulfate IV.

4

ATS Review for the Critical Care Boards | QUESTIONS

What is the most appropriate fluid strategy for this patient? A. B. C. D. E.

5L of additional fluid in the first 16 hours 3L of additional fluid in the first 8 hours 10L of additional fluid in the first 24 hours 7.5L of total fluid in the first 8 hours 15L of total fluid in the first 24 hours

9.

A 24-year-old man is admitted to the ICU with ARDS secondary to influenza. For the first 72 hours, he was heavily sedated (RASS -5) with propofol and fentanyl because of refractory hypoxemia. Today, his oxygenation has improved and his sedation is lightened to a RASS -2. His blood pressure is unchanged. He is requiring three vasopressors (phenylephrine, norepinephrine, and vasopressin) to keep his mean arterial pressure >65 mm Hg, but he is newly bradycardic. He remains on oseltamivir, vancomycin, and cefepime. His labs are significant for WBC count 17,000 cells/µL, Hgb 9.2 g/dL, platelets 389,000/µL, Na 134 mEq/L, K 5.2 mEq/L, HCO3 8 mEq/L, Cr 2.4 mg/dL. What is the next best step in the management of this patient? A. B. C. D. E.

Bolus sedation to keep his RASS -5 Discontinue oseltamivir Add micafungin Discontinue propofol Start renal replacement therapy

10.

A 74-year-old man with a history of atrial fibrillation and hypertension presents to the ED with severe chest pain that started abruptly while he was on his morning walk. Physical exam: Vitals signs: HR 128 bpm, BP 90/54 mmHg, RR 20/min General: Diaphoretic, ill-appearing, moderate distress Pulmonary: Lungs clear to auscultation bilaterally Cardiovascular: Distant heart sounds, tachycardic, soft diastolic murmur Neuro: Alert and oriented, mild dysarthria with flattening of the L nasolabial fold Extremities: Warm, no edema

5

ATS Review for the Critical Care Boards | QUESTIONS

EKG shows an irregularly irregular rhythm with no acute ST or T-wave changes, and CXR shows an enlarged cardiac silhouette. A bedside echocardiogram reveals a moderate to large pericardial effusion. Labs are sent and pending. Following a 1L bolus of normal saline, his BP is 88/52 mmHg. What is the next best step in the management of this patient? A. CT angiogram of the chest B. Pericardiocentesis C. Electrical cardioversion D. Administer tPA E. Surgical exploration

11.

A 39-year-old man was admitted 6 days ago with alcohol withdrawal seizures and aspiration pneumonia. He was intubated for acute hypoxic respiratory failure on the day of admission. He has been meeting criteria for moderate ARDS with PaO2/FiO2 ratio of 170–190 and has been on lung protective ventilation since intubation. His FiO2 is 50% with a PEEP of 12 cm of H2O. He is being treated with antibiotics and his DVT prophylaxis was stopped 2 days ago, secondary to worsening thrombocytopenia. The nurses are now reporting increased oxygen requirements for the last 30 minutes and the patient is requiring 100% FiO2 to keep his oxygen saturations between 88–90%. His BP has dropped to 82/49 mm Hg. A stat CXR and arterial blood gas have been ordered. While waiting for the CXR you perform a bedside ultrasound of the lung and the following images are obtained.

Ultrasound of the right lung (M-mode)

6

Ultrasound of the left lung (M-mode)

ATS Review for the Critical Care Boards | QUESTIONS

At this time which of the following interventions should be performed? A. Paralysis B. Thrombolytic therapy C. Diuresis D. Needle thoracostomy E. Increase PEEP

12.

A 66-year old man is admitted to the ICU for acute onset palpitations, chest pain, and dyspnea. He has no significant past medical history and takes only multivitamins. Examination reveals a man who is diaphoretic. He is afebrile and vital signs reveal: HR 142 bpm, BP 80/48 mm Hg, RR 24/ min, and room air saturation 87%. Cardiac exam reveals an irregularly irregular tachycardia. Jugular venous pressure (JVP) is elevated at 10 cm H2O and rales are heard over both lung fields. His EKG is shown below:

What is the most appropriate next step in the management of this patient? A. B. C. D. E.

Adenosine 6mg IV push Digoxin loading dose Direct current cardioversion Diltiazem 15mg IV push Metoprolol 10mg IV push

7

ATS Review for the Critical Care Boards | QUESTIONS

13.

A 22-year-old man with acute alcoholic pancreatitis diagnosed based on abdominal pain and elevated amylase/lipase is admitted to the ICU. He has just arrived with a HR of 123 bpm, BP of 80/40 mm Hg, and he has made no urine since arrival to the hospital 80 minutes prior. Which of the following is most likely to improve this patient’s outcome? A. B. C. D. E.

A CT of the abdomen with contrast Aggressive fluid resuscitation for at least 72 hours Early enteral nutrition Initiation of IV imipenem Early endoscopic retrograde cholangiopancreatography (ERCP) within 24 hours

14.

A 45-year-old woman presents to the ED with confusion and fever. She is accompanied by her fiancée. He reports that the patient developed headache, fevers, chills, and myalgias 6 days prior to presentation. She thought it was a viral illness and tried to take it easy. Three days prior to admission, the patient developed significant nausea and a rash. Yesterday, she noted abdominal pain and began vomiting, and today she became confused. Further history reveals that the patient was recently backpacking on the Appalachian Trail. Her exam is as follows: Vitals: Temp 39.7°C, HR 132 bpm, BP 95/46 mm Hg, RR 16/min General: Lethargic, oriented only to person, not place or date HEENT: No Kernig’s or Brudzinsky’s signs, no sinus tenderness, no oral lesions Cardiovascular: Regular, no murmurs Pulmonary: Clear to auscultation bilaterally Abdomen: Diffuse tenderness to palpation, no rebound tenderness, no splenomegaly Skin: Petechial rash on hands and soles Labs: WBC 3,100 cells/µL, Hgb 15.5 g/dL, platelets 116,000/µL, Na 127 mEq/L, K 4.1 mEq/L, Cl 94 mEq/L, HCO3 22 mEq/L, BUN 56 mg/dL, Cr 2.1mg/dL, AST 556 U/L, ALT 650 U/L, total bilirubin 4.6 mg/dL Urine and blood toxicology screens are negative. A lumbar puncture (LP) is performed. LP studies: WBC 85 cells/µL with 90% polymorphonuclear cells, RBC 0 cells/µL, glucose 75 mg/dL, protein 110 mg/dL What is the most appropriate antibiotic treatment for this patient?

8

A. Vancomycin, ceftriaxone, and acyclovir B. Amphotericin B C. Vancomycin, ceftriaxone, and doxycycline D. Methylprednisone, vancomycin, and ceftriaxone E. Fluconazole

ATS Review for the Critical Care Boards | QUESTIONS

15.

A 66-year-old woman presents with acute onset right hemiparesis and aphasia of 2 hours duration. In the ED, vital signs reveal HR 70 bpm, BP 195/115 mm Hg, and oxygen saturation 97% on room air. A stat CT head reveals no evidence of intracranial hemorrhage. After careful review of history, she is determined to be a candidate for thrombolytic therapy. What is the best strategy for managing this patient’s BP? A. Administer tPA and allow permissive hypertension as long as the BP remains 10% within first hour post-injury

39.

A 74-year-old man with metastatic prostate cancer presents to the hospital with back pain at the level of the mid-thoracic spine. He also reports lower extremity weakness and recent falls which he attributes to “not feeling his feet beneath him.” Which of the following therapeutic strategies is likely to have the greatest effect on this patient’s condition? A. Corticosteroids B. Narcotics as needed for back pain C. Chemotherapy D. Physical therapy E. Placement of a urinary catheter

40.

A 67-year-old man with COPD and diabetes mellitus is admitted to the ICU with septic shock from an infected leg wound. He is postoperative day 1 from a right below-knee amputation. He is mechanically ventilated and is requiring 0.2 m g/kg/min of norepinephrine to maintain a mean arterial pressure of 65 mm Hg.

20

ATS Review for the Critical Care Boards | QUESTIONS

Which of the following is the most appropriate nutritional strategy at this point? A. B. C. D. E.

Initiate parenteral nutrition immediately Initiate enteral feeding immediately Start enteral feeding once the patient is weaned off vasopressors Begin IV fluids with dextrose Hold nutrition until return of bowel sounds

41.

A 78-year-old man is admitted to the ICU with a COPD exacerbation. Initial ABG demonstrates pH 7.25, PaCO2 60 mm Hg, and PaO2 50 mm Hg on room air. The patient is awake and interactive and has expressed that he does not want to be intubated or resuscitated. Noninvasive ventilation is initiated with an inspiratory positive airway pressure (IPAP) of 10 cm H2O and expiratory positive airway pressure (EPAP) of 5 cm H2O. His respiratory rate is 30/ min and tidal volume is approximately 250 mL. Repeat ABG shows a pH of 7.22 and PaCO2 of 62 mm Hg. What is the most appropriate next step in the management of this patient? A. Endotracheal intubation B. Trial of Heliox at a concentration of 70% helium and 30% oxygen C. Increase IPAP to 15 cm H2O and continue EPAP of 5 cm H2O D. Continue IPAP of 10 cm H2O and increase EPAP to 10 cm H2O E. Increase IPAP to 12 cm H2O and increase EPAP to 7 cm H2O

42.

A 57-year-old man with diabetes mellitus presents to the ED of a community hospital with severe chest pain of 2 hours duration. No cardiac catheterization services are available. In the ED, an EKG is performed:

21

ATS Review for the Critical Care Boards | QUESTIONS

Vital signs include a HR of 95 bpm, BP of 105/65 mm Hg, and a room air oxygen saturation of 96%. The patient has good mental status and his extremities are warm. He is treated with aspirin, clopidogrel, and high-dose statin. Nitroglycerin eases the chest pain. The nearest hospital with cardiac catheterization services is approximately 65 minutes away. Which of the following is the appropriate next step? A. Perform a cardiac CT angiogram B. Place an intra-aortic balloon pump C. Transfer the patient to the catheterization-capable hospital D. Administer thrombolytic therapy and monitor the patient E. Administer thrombolytic therapy and then transfer the patient to the catheterizationcapable hospital

43.

A 62-year-old woman with chronic kidney disease and diabetes is admitted to the ICU for septic shock secondary to a urinary tract infection. She is treated with vasopressors and empiric cefepime. Her hemodynamics improve over the next 48 hours. However, she develops multiple generalized tonic-clonic seizures that are self-limited or promptly resolve with IV lorazepam. She has no history of seizures and is on no antiepileptic medications. What is the next best step in the management of this patient? A. B. C. D. E.

Change cefepime to levofloxacin Order an MRI of the brain Check an electrolyte panel and liver function tests Start propofol via continuous infusion Send serum lactate and prolactin levels

44.

A 56-year-old woman is brought to the ED after being found confused by her family. On arrival, her temp is 39.2°C with a WBC count of 15,000 cells/µL. She is confused, oriented to name only, and intermittently following commands. An infectious workup is pursued, and cultures are pending. An MRI is performed and shows numerous, diffuse, small, embolic-appearing infarcts in the bilateral hemispheres.

22

ATS Review for the Critical Care Boards | QUESTIONS

What is the most appropriate next step in the management of this patient after starting empiric antibiotics? A. Initiate a heparin drip for a presumed cardioembolic source of strokes B. Treat altered mental status with IV haloperidol C. Request a transthoracic or transesophageal echocardiogram to evaluate for intracardiac thrombus and valve abnormalities D. Administer intravenous tPA E. Consult neurosurgery

45.

A 32-year-old man is in shock after a traumatic amputation of his right leg following a snow mobile injury. He is taken emergently to the operating room. Which of the following interventions will improve his outcomes in the first 24 hours of his hospitalization? A. Activated Factor VII B. Giving 1 liter of normal saline for every 1 unit of PRBCs he receives C. Transfusing 1 unit of FFP and 1 unit of platelets for every 1 unit of PRBCs he receives D. Transfusing 1 unit of platelets for every 4 units of PRBCs he receives E. Transfusing to a goal hemoglobin of 10 g/dL

46.

A 55-year-old man with a history of hypertension and poorly controlled diabetes is admitted to the ICU with worsening abdominal pain and altered mental status. Vital signs reveal temp 38.7°C, HR 115 bpm, and BP 86/40 mm Hg. He has scleral icterus, jaundice, and his abdomen is diffusely tender, especially in the right upper quadrant (RUQ). Labs show WBC count of 26,000 cells/µL, total bilirubin 8.5 mg/dL, and lipase 550 U/L. Abdominal CT is shown below:

23

ATS Review for the Critical Care Boards | QUESTIONS

IV fluids, piperacillin-tazobactam, and vasopressors are initiated. What is the next best step in the management of this patient? A. B. C. D. E.

Hepatobiliary (HIDA) scan RUQ ultrasound Stat surgical consultation Abdominal plain films Stat interventional radiology consultation

47.

A 49-year-old man with a history of depression and hypertension is brought to the ED with confusion. His current medications include paroxetine, losartan, and verapamil. Upon arrival, he has a HR of 52 bpm and a BP of 77/48 mm Hg. His fingerstick glucose is elevated at 300 mg/dL, while other labs are unremarkable. Urine toxicology screen is negative for opiates, benzodiazepines, and tricyclic anti-depressants. An EKG is performed and shown below:

He is administered IV glucagon with little therapeutic benefit. In addition to starting a vasoactive agent, which of the following interventions should be considered at this time? A. Dantrolene B. Hemodialysis C. High-dose insulin D. Sodium bicarbonate E. Whole bowel irrigation

24

ATS Review for the Critical Care Boards | QUESTIONS

48.

A 27-year-old woman was skiing when she hit a tree and crashed. Her left ski boot came off during the fall, and her left leg was pinned under debris. After 25 minutes, members of her group located her and freed her leg. She complained of being very cold and noted severe burning pain in her left foot. She was transported to the ED, where her exam was as follows: Vitals: Temp 33°C, HR 36 bpm, BP 100/65 mm Hg, RR 8/min General: Alert and oriented x 2, shivering Cardiovascular: Regular rate and rhythm, no murmurs Pulmonary: Clear to auscultation bilaterally Abdomen: Nontender, nondistended Left lower extremity: As pictured

Which of the following is most accurate regarding this patient’s presentation? A. B. C. D. E.

Prehospital warming using hot water is indicated The patient’s bradycardia should be managed with atropine The presence of shivering is a poor prognostic sign Tissue plasminogen activator (tPA) may be indicated to help preserve her digits External rewarming with dry heat is indicated

49.

A 72-year-old man presents with chronic dyspnea. While symptoms have been present for several years, they now occur with minimal exertion. Past medical history includes a myocardial infarction (MI) with placement of drug-eluting stents in the left anterior descending (LAD) artery and left circumflex arteries. He also has a remote history of limited-stage, small cell lung cancer treated with radiation therapy. CXR is unrevealing and an echocardiogram demonstrates elevated pulmonary pressures and no significant pericardial effusion. The patient undergoes a left- and right-heart catheterization and the ventricular waveforms are shown in the figure below.

25

ATS Review for the Critical Care Boards | QUESTIONS

What is the appropriate next step in the management of this patient? A. B. C. D. E.

Start sildenafil for pulmonary hypertension Start high-dose IV diuretics Schedule the patient for pericardiectomy Schedule the patient for aortic valve repair Perform emergent pericardiocentesis

50.

A 21-year-old man presents with unresolving upper respiratory tract symptoms, including fevers and drenching sweats. Imaging reveals bulky lymphadenopathy of the head, neck, and the mediastinum. He is noted to have facial swelling and plethora as well as dilated vessels in his upper extremities and across his chest wall. A chest CT with contrast reveals significant compromise of his superior vena cava (SVC). What is your next step in the management of this patient? A. B. C. D. E.

26

Excisional biopsy of a neck lymph node Consult interventional radiology for consideration of SVC stent Urgent consultation for chemotherapy Urgent consultation for radiation Bronchoscopy with transbronchial needle aspiration

ATS Review for the Critical Care Boards | QUESTIONS

51.

A 38-year-old man with no significant past medical history was brought to the ED after sustaining a sudden cardiac arrest at home. According to the patient’s family, he was not feeling well for the past three days and was complaining of fever, chest pain, and cough with green colored phlegm. He was then found unresponsive in bed this morning. CPR was initiated by the family, and EMS arrived at the scene to find the patient in a polymorphic ventricular tachycardia. The patient was intubated with return of spontaneous circulation obtained after 12 minutes of CPR. In the ED, the patient’s vital signs are as follows: Temp 38.6°C, HR 100 bpm, BP 120/70 mm Hg, oxygen saturation 95% on FiO2 of 50%. The patient is able to follow simple commands. Lab data is significant for leukocytosis. Electrolytes are all within normal limits. Urine drug screen is negative. CXR shows right middle lobe opacities. EKG:

A quick bedside echocardiogram shows no wall motion abnormalities and a grossly normal ejection fraction. The patient is taken to the cardiac catheterization lab, and angiography shows clean coronaries. Which of the following is the most likely diagnosis? A. Pericarditis B. Brugada syndrome C. Takotsubo cardiomyopathy D. Myocardial infarction E. Wolff-Parkinson-White syndrome (WPW) 27

ATS Review for the Critical Care Boards | QUESTIONS

52.

A 36-year-old woman with type 1 diabetes mellitus presents to the ED with altered mental status and diabetic ketoacidosis. She is intubated for airway protection. Her family reports that she is often non-compliant with her insulin. Per family members, she developed nasal congestion and foul-smelling nasal discharge 2 days prior to presentation. She then developed fevers, chills, and confusion, and was brought to the ED. On physical exam, the patient has significant proptosis and periorbital swelling. No neck stiffness is appreciated. Endoscopic examination of the sinuses is performed and the resultant specimen is shown below.

Which of the following antimicrobial regimens should be initiated? A. Vancomycin and piperacillin-tazobactam B. Vancomycin and ceftriaxone (meningitis dosing) C. Liposomal amphotericin B D. Voriconazole E. Fluconazole

53.

A 61-year-old man with a history of hypertension, hypercholesterolemia, and myotonic dystrophy type 2 presents with acute shortness of breath. His vital signs are as follows: Temp 37.8°C, HR 118 bpm, BP 82/48 mm Hg, RR 30/min, oxygen saturation 95% on 6 L/min nasal cannula. A CT angiogram of the chest reveals extensive acute pulmonary emboli in the main left and right pulmonary arteries extending into the segmental and subsegmental arteries. The patient denies any history of recent bleeding or surgery.

28

ATS Review for the Critical Care Boards | QUESTIONS

What is the next best step in the management of this patient? A. B. C. D. E.

Unfractionated heparin (UFH) UFH and inferior vena cava filter Systemic thrombolytic therapy followed by UFH Catheter-directed thrombolysis followed by UFH Surgical embolectomy followed by UFH

54.

A 59-year-old man with ischemic cardiomyopathy is admitted to the ICU for dyspnea. His HR is 102 bpm, BP is 74/44 mm Hg, and oxygen saturation is 95% on room air. Cardiovascular exam reveals a regular tachycardia with an S3, bilateral edema to the thighs, and cool extremities. He is somnolent with bilateral crackles over the lower lung fields. His abdomen is soft with diminished bowel sounds. His EKG is unchanged from baseline. Given his complex cardiac history, a pulmonary artery catheter is placed and reveals a CVP of 10 mm Hg, pulmonary artery pressure of 45/24 mm Hg, pulmonary capillary wedge pressure of 22 mm Hg, and cardiac output of 2.8 L/minute. Cardiac enzymes reveal a troponin of 0.6 ng/mL and basic metabolic panel reveals Na 132 mEq/L, K 3.7 mEq/L, Cl 100 mEq/L, HCO3 23 mEq/L, BUN 10 mg/dL, Cr 1.4 mg/dL. What is the most appropriate medical therapy for this patient? A. Tissue plasminogen activator B. Enoxaparin C. Clopidogrel + eptifibatide D. Milrinone E. Nesiritide

55.

A 65-year-old man underwent prolonged resuscitation after a ventricular fibrillation cardiac arrest. Return of spontaneous circulation occurred 25 minutes into the resuscitation. On hospital day 3, the patient has a temp of 37°C with a BP of 112/72 mm Hg on dobutamine and epinephrine infusions. The patient has not responded to verbal or tactile stimuli since admission, with the exception of intermittent decorticate posturing. There is no corneal reflex, no cough with suctioning, and no pupillary response to light. There are no ocular movements using oculovestibular reflex testing.

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Which of the following is true regarding this patient’s presentation? A. Apnea testing should be performed to evaluate for brain death B. The presence of vasopressor support precludes a diagnosis of brain death C. The administration of neuromuscular blocking agents on day 2 of hospitalization precludes a determination of brain death D. Decorticate posturing precludes a diagnosis of brain death E. A physician from the organ procurement agency must be present to declare brain death

56.

A 68-year-old man who is 3 days post allogenic stem cell transplant for acute myelogenous leukemia is admitted to the ICU with septic shock and acute kidney injury. The patient is intubated on ventilator settings of 70% FiO2 with PEEP of 10 cm H2O. His pH is 7.15 and his other labs reveal: K 5.8 mEq/L, HCO3 11 mEq/L, BUN 85 mg/dL, and Cr 4.9 mg/dL. The decision is made to initiate continuous renal replacement therapy. What is the minimum dose of continuous renal replacement therapy (CRRT) that should be delivered to this patient? A. 5–10 mL/kg/hr B. 10–15 mL/kg/hr C. 20–25 mL/kg/hr D. 30–35 mL/kg/hr E. 40–45 mL/kg/hr

57.

A 68-year-old woman is admitted to the hospital for lower extremity cellulitis. She is treated with IV antibiotics and discharged on oral clindamycin to complete a 10-day course. Three weeks later, she re-presents to the hospital with 4 days of worsening abdominal pain and diarrhea with some associated dizziness. Her temp is 38.7°C and her BP is 100/52 mm Hg. Labs reveal: Cr 1.8 mg/dL (Cr was 0.9 mg/dL at the time of recent discharge), WBC count 16,000 cells/μL, lactate 2.8 mmol/L, and stool testing is positive for Clostridium difficile. Abdominal imaging does not show any evidence of ileus, toxic megacolon, or perforation. Given her clinical status, she is admitted to the ICU. She has never had a C. difficile infection in the past.

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What is the most appropriate antibiotic therapy for this patient? A. Oral vancomycin 500mg q6 hours B. Oral vancomycin 125mg q6 hours C. Oral fidaxomicin 200mg q24 hours D. IV metronidazole 500mg q8 hours E. Oral vancomycin 125mg q6 hours plus IV metronidazole 500 mg q8 hours

58.

You are managing a patient with severe systolic heart failure and septic shock in your ICU. While attempting to obtain a wedge pressure, you see the following tracing after inflating 1 mL of air into the balloon.

What is the next best step in management? A. Continue to advance the catheter until a wedge tracing is obtained B. Inflate an additional 1 mL of air into the balloon C. Deflate the balloon and remove the catheter completely D. Leave the balloon inflated in the current position E. Deflate the balloon and pull back to obtain a pulmonary artery (PA) tracing

59.

A 57-year-old woman presents to a community hospital ED with acute onset right-sided arm and leg weakness with dysarthria. Her symptoms began 3 hours and 10 minutes ago, when she was washing dishes. Her past medical history is significant for migraine headaches, poorly controlled diabetes, hypertension, and hyperlipidemia. Her surgical history is significant only for a total abdominal hysterectomy and oophorectomy for uterine fibroids when she was 45. She is a former smoker with a 40-pack-year smoking history. Vitals: Temp 36.7°C, HR 86 bpm, BP 170/97 mm Hg, RR 12/min, saturation 97% on room air The patient has right-sided facial droop and can barely overcome gravity with her right arm and leg. There is sensory loss as well in the same distribution. 31

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Labs reveal an INR of 1.2 and platelet count of 150,000/μL. On presentation to the ED, the patient’s NIH Stroke Score is 15. CT imaging performed within 20 minutes of arrival shows no evidence of intracranial hemorrhage, but hypoattenuation throughout more than half the distribution of the left middle cerebral artery. The patient is 30 minutes away from a facility that is capable of performing intraarterial thrombectomy. Which of the following best describes the most appropriate therapy for this patient? A. The patient is not a candidate for intravenous tPA because she is presenting >3 hours after the onset of symptoms B. The patient is a candidate for intravenous tPA, and she should receive this medication as soon as possible C. The patient is a candidate for intravenous tPA, but her uncontrolled hypertension precludes its use D. The patient is not a candidate for intravenous tPA because of her history of poorly controlled diabetes E. The patient should not receive tPA and instead should be transferred immediately for mechanical thrombectomy

60.

A 35-year-old man with interstitial lung disease is intubated for respiratory failure. His ventilator waveform is shown below.

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What is the main problem illustrated by this waveform? A. Auto-PEEP B. Water in the circuit C. Flow dyssynchrony D. Cycle dyssynchrony E. Triggering dyssynchrony

61.

A 35-year-old construction worker presents to the ED after sustaining a traumatic wound to the distal right leg several days earlier. He reports significant pain. Physical exam reveals: Temp 37.9°C, HR 100 bpm, BP 140/80 mm Hg, and RR 18/min. Scleral icterus is present. A 3x4 cm area of skin over the distal posterior right leg is purple with tenderness to palpation. The wound is open at the center without drainage. There are no bullae, but crepitus is present. Neurovascular examination is unremarkable. Labs: WBC count 22,000 cells/μL, Hgb 8 g/dL, Cr 1.8 mg/dL, AST 90 U/L, ALT 100 U/L, haptoglobin 1. His troponin is 0.15 (normal 7 g/dL In studies to date, transfusion of PRBCs for acute upper gastrointestinal bleed is associated with the best outcomes when restricted to individuals with a Hgb 40 mEq/L), all point to the diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). The initial step in management of asymptomatic SIADH with a serum Na >120 mEq/L is fluid restriction (choice B is correct). Initiation of isotonic fluid repletion in the setting of euvolemia and an ADH setpoint of urine osm >400 will lead to worsening of hyponatremia (choice A is incorrect). While hypertonic saline would be effective in bringing the sodium level up, this is not indicated at this juncture because the patient is not symptomatic (choice C is incorrect). In SIADH, loop diuretics may be given but should always be administered with salt tabs and are not first-line therapy (choice D is incorrect). Despite the lack of symptoms, therapy is indicated because chronic hyponatremia is associated with adverse outcomes, including falls, osteoporosis, and cognitive disturbances. In addition, any significant acute worsening of his hyponatremia could lead to altered mental status, seizures, and death. Therefore, withholding therapy unless the sodium falls further is not the correct approach (choice E is incorrect). SIADH can be associated with lung pathology, particularly pneumonia and small cell carcinoma, the latter of which may be present in this patient, given the finding of a lung mass.

1. Drogué HJ, Madias NE. Hyponatremia. N Engl J Med 2000;342:1581–9. 2. Renneboog B, Musch W, Vandemergel X, Manto MU, Decaux G. Mild chronic hyponatremia is associated with falls, unsteadiness, and attention deficits. Am J Med 2006;119 (1):71. e1–8. 104

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36. Correct Answer E. No change in therapy

The empiric regimen selected is appropriate for treatment of ventilator-associated pneumonia (VAP) with a known risk factor for antimicrobial drug resistance (≥5 days hospitalization before onset of VAP) and an appropriate knowledge of the local antibiogram (i.e., presumably a prevalence of methicillin-resistant Staphylococcus aureus (MRSA) >10–20%). Regimens recommended in this scenario are empiric MRSA coverage and two anti-pseudomonal agents (one beta lactam and one non-beta lactam). The patient has not demonstrated a clear response to therapy, but it may be too early to expect improvement, so continuing the current regimen is appropriate (choice E is correct). The other choices do not represent a substantive improvement in empiric coverage. Vancomycin and linezolid both have adequate coverage against MRSA (choice A is incorrect). Changing ciprofloxacin to ceftazidime would not improve the antibacterial spectrum of the current regimen (choice B is incorrect). Aerosolized colistin may have certain pharmacokinetic advantages over IV therapy, such as improved drug delivery to the site of infection and decreased systemic toxicity. Adjunctive inhaled colistin could be considered for multidrug resistant (MDR) gram-negative bacilli in combination with a systemic agent, but at this point there is no evidence for MDR organisms as culture results are still pending (choice C is incorrect). In patients with suspected VAP, there is no evidence that invasive microbiologic sampling (e.g., bronchoalveolar lavage or protected specimen brushing) with quantitative cultures improves clinical outcomes compared to noninvasive sampling with either quantitative or semiquantitative cultures (choice D is incorrect).

1. Kalil AC, Metersky ML, Klompas M, et al. Management of adults with hospital-acquired and ventilator-associated pneumonia: 2016 clinical practice guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis 2016;63(5):e61–e111. 2. Kalil AC, Klompas M, Haynatzki G, Rupp ME. Treatment of hospital-acquired pneumonia with linezolid or vancomycin: a systematic review and meta-analysis. BMJ Open 2013;3 (10):e003912. 3. Walkey AJ, O'Donnell MR, Wiener RS. Linezolid vs glycopeptide antibiotics for the treatment of suspected methicillin-resistant Staphylococcus aureus nosocomial pneumonia: a meta-analysis of randomized controlled trials. Chest 2011;139(5):1148–55.

37. Correct Answer

C. Decrease the respiratory rate This patient has acute on chronic respiratory acidosis that worsened after mechanical ventilation was initiated. He also developed hypotension. The most likely cause is breathstacking or auto-PEEP due to inappropriate ventilator settings and obstructive airways disease. When patients with acute exacerbations of COPD require mechanical ventilation, it is

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imperative to ensure adequate time for exhalation to avoid dynamic hyperinflation and subsequent hemodynamic compromise. The only offered choice that will increase exhalation time is to decrease the respiratory rate (choice C is correct). Increasing the tidal volume may worsen the hemodynamic impact of hyperinflation (choice E is incorrect). Increased PEEP will not improve air-trapping, though it can be used to overcome ineffective triggering in the setting of auto-PEEP (choice B is incorrect). While norepinephrine may help the patient’s blood pressure, it will not improve his ABG or treat the underlying problem (choice A is incorrect). IVF with bicarbonate also does not address the underlying problem (choice D is incorrect).

1. Parrilla FJ, Moran I, Roche-Campo F, Mancebo J. Ventilatory strategies in obstructive lung disease. Semin Respir Crit Care Med 2014;35(4):431–40. 2. Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management and prevention of COPD, 2016 [Internet]. GOLD. 2016 [cited 2018 May 31];Available from: http://goldcopd.org/global-strategy-diagnosis-managementprevention-copd-2016

38. Correct Answer

E. Carboxyhemoglobin >10% within first hour post-injury. Carboxyhemoglobin >10% within first hour post-injury strongly indicates smoke inhalation and is a risk factor for early intubation in patients with burns (choice E is correct). An upper extremity burn is not a risk factor for early intubation unless there is an associated facial burn (choice A is incorrect). Presence of expiratory wheezing alone on chest exam without stridor and/or respiratory distress is not a risk factor for early intubation (choice B is incorrect). Recent treatment for pneumonia and prior history of asthma are also not risk factors for early intubation in this scenario (choices C and D are incorrect).

1. Endorf FW, Gamelli RL. Inhalation injury, pulmonary perturbations, and fluid resuscitation. J Burn Care Res 2007;28(1):80–3.

39. Correct Answer A. Corticosteroids

Spinal cord compression by metastatic lesions is an oncologic emergency and should be dealt with in an urgent fashion. There is often edema surrounding the lesions and corticosteroids are a useful therapy for treating edema as well as pain (choice A is correct). Narcotics can be used to manage pain but would not impact the underlying cord compression (choice B is incorrect). In this scenario, a small subset of primary tumors is highly responsive to chemotherapy, but 106

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prostate cancer is not one of them (choice C is incorrect). Physical therapy would not have any meaningful impact in a situation of cord compression (choice D is incorrect). Although a bladder catheter can be considered given the frequent development of bladder dysfunction in the late stages of spinal cord compression, the catheter would not treat the underlying condition (choice E is incorrect).

1. Guddati AK, Kumar G, Shapira I. Early intervention results in lower mortality in patients with cancer hospitalized for metastatic spinal cord compression. J Investig Med 2017;65 (4):787–93.

40. Correct Answer

B. Initiate enteral feeding immediately Critically ill patients should receive early oral feeding as soon as it is tolerated clinically. Evidence suggests that early initiation of enteral feeding results in a reduction of nosocomial infections (choice B is correct; choice E is incorrect). Enteral feeding is generally tolerated in the post-operative period, even following primary GI surgery and in the absence of bowel sounds or flatus. There is no evidence that the immediate provision of parenteral nutrition would improve the patient’s clinical outcome, and early total parenteral nutrition may lead to increased risk of hospital-acquired infections (choice A is incorrect). Vasopressors, especially at a stable low dose, are not a contraindication to starting enteral feeds, although fiber supplementation should be avoided in these patients (choice C is incorrect). IV fluids with dextrose are insufficient from a nutritional standpoint, and in the absence of feeding contraindications or intolerance, they should not be given instead of feeds (choice D is incorrect).

1. Casaer MP, Mesotten D, Hermans G, et al. Early versus late parenteral nutrition in critically ill adults. N Engl J Med 2011;365:506–17. 2. Caesar MP, Berghe GV. Nutrition in the acute phase of critical illness. N Engl J Med 2014;370(13):1227–36. 3. Reintam Blaser A, Starkopf J, Alhazzani W, et al; ESCIM Working Group on Gastrointestinal Function. Early enteral nutrition in critically ill patients: ESICM clinical practice guidelines. Intensive Care Med 2017;43(3):380–98.

41. Correct Answer

C. Increase IPAP to 15 cmH20 and continue EPAP of 5 cm H20 This patient has a worsening respiratory acidosis as evidenced by his decreasing pH and increasing PaCO2. Appropriate management involves increasing his minute ventilation to improve his acidosis. Noninvasive positive pressure ventilation delivers a set pressure during inspiration (IPAP) and a lower pressure during expiration (EPAP). The difference between

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IPAP and EPAP, termed the driving pressure, influences tidal volume and therefore minute ventilation. Increasing the difference between IPAP and EPAP augments the tidal volume and increases minute ventilation (choice C is correct). Keeping the IPAP at 10 cm H2O and increasing the EPAP to 10 cm H2O will not augment the tidal volume and thus will not improve minute ventilation (choice D is incorrect). An IPAP of 12 cm H2O and an EPAP of 7 cm H2O still gives a driving pressure of 5, which is the same as the current settings (choice E is incorrect). Heliox is occasionally utilized in asthma exacerbations, but there is little data supporting its use in COPD (choice B is incorrect). Intubation is not in line with this patient’s goals of care and should not be pursued (choice A is incorrect).

1. Hess DR. Noninvasive ventilation for Acute Respiratory Failure. Respir Care 2013;58(6):950 –69. 2. Barreiro TJ, Gemmel DJ. Noninvasive ventilation. Crit Care Clin 2007;23(2):201–22.

42. Correct Answer

C. Transfer the patient to the catheterization-capable hospital

EKG courtesy of: Smith, S. Dr. Smith’s ECG Blog website. Available from: http://3. bp.blogspot.com/-MZVDX3NJ7Oo/UoEk0f3NNbI/AAAAAAAAC0c/EIFyPV43Nw0/ s1600/4.3+hours.png. Accessed 2018.

The patient is presenting with chest pain and an EKG concerning for acute myocardial infarction (MI) with ST-segment elevation in the anterior precordial leads (V1–3). Emergent revascularization is indicated. For hospitals without percutaneous intervention (PCI) capability, treatment depends on proximity to hospitals with PCI capability. If PCI can occur within 90 minutes of first medical contact, the patient should be transferred immediately (choice C is correct). Administration of thrombolytics prior to planned PCI is not appropriate if the patient can be transferred in time (choice E is incorrect).

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Thrombolytic therapy in lieu of PCI is indicated if the door-to-balloon time is longer than 90 mins (choice D is incorrect). A cardiac CT angiogram would not provide clinically relevant data and would delay transfer (choice A is incorrect). An intra-aortic balloon pump can be considered for cardiogenic shock or refractory angina, neither of which are present in this patient (choice B is incorrect).

ATS Review for the Critical Care Boards | ANSWERS

1. O’Gara PT, Kushner FG, Ascheim D, et al; American College of Cardiology Foundation/ American Heart Association Task Force on Practice Guidelines. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2013;82(1):E1–27.

43. Correct Answer

C. Check an electrolyte panel and liver function tests Seizures are not uncommon in critically ill patients, occurring in 1–3% of patients admitted to the ICU. Precipitants include central nervous system (CNS) pathology, medications, metabolic derangements, alcohol/drug withdrawal, cerebrovascular accidents, acidemia, and CNS infections. A broad evaluation for potential causes of, or contributors to, seizures is appropriate. In a patient with underlying renal dysfunction, the risk of developing electrolyte abnormalities is increased, such that identifying and treating any metabolic disturbances is clinically warranted. In this case, sending an electrolyte and liver function panel is an appropriate first step to assess for electrolyte or metabolic abnormalities that may be decreasing the patient’s seizure threshold (choice C is correct). While cephalosporins (particularly cefepime) decrease the seizure threshold, fluoroquinolones do so as well (choice A is incorrect). Changing to an alternative antibiotic with less epileptogenic properties, however, would be reasonable. Neuroimaging may be indicated; however, it is not the most reasonable next step in her care (choice B is incorrect). More basic assessments of her metabolic and acid/base status are indicated first. Initiating a continuous propofol infusion is overly aggressive in the setting of multiple selflimited and benzodiazepine-responsive seizure episodes (choice D is incorrect). Initiation of longer-acting antiepileptic medications may be warranted and choosing medications without significant sedating and respiratory depressive effects (such as levetiracetam) is more clinically appropriate. Lactate and prolactin measurements may be helpful in cases where there is uncertainty as to whether the tonic-clonic episodes represent true seizures. However, there is little clinical uncertainty in this case (choice E is incorrect).

1. Tesoro EP, Brophy GM. Pharmacological management of seizures and status epilepticus in critically ill patients. J Pharm Pract 2010;23(5):441–54. 2. Rubinos C, Ruland S. Neurologic Complications in the Intensive Care Unit. Curr Neurol Neurosci Rep 2016;16(6):57. 3. Foreman B, Hirsch LJ. Epilepsy emergencies: diagnosis and management. Neurol Clin 2012;30(1):11–41.

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44. Correct Answer

C. Request a transthoracic or transesophageal echocardiogram to evaluate for intracardiac thrombus and valve abnormalities Multifocal strokes in multiple vascular territories are highly suspicious for a cardioembolic source. This patient’s presentation should raise suspicion for infective endocarditis and other cardiac sources of emboli (e.g., intracardiac thrombus related to atrial fibrillation). Therefore, an echocardiogram is indicated (choice C is correct). Although the patient’s mental status should be monitored closely, there is no report that the patient is agitated, and thus there is no clear indication for antipsychotics such as haloperidol (choice B is incorrect). Because of the increased risk of hemorrhage in patients with septic embolic strokes, anticoagulation is generally not recommended, though with other cardiac sources of emboli, anticoagulation may be considered (choice A is incorrect). Intravenous tPA is not indicated in this patient who has an unclear time of onset of stroke (choice D is incorrect). There is also no clear indication for neurosurgical involvement in this patient’s case (choice E is incorrect).

1. Habib G, Hoen B, Tornos P, et al; ESC Committee for Practice Guidelines. Guidelines on the prevention, diagnosis, and treatment of infective endocarditis: the Task Force on the Prevention, Diagnosis, and Treatment of Infective Endocarditis of the European Society of Cardiology (ESD). Endorsed by the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and the International Society of Chemotherapy (ISC) for Infection and Cancer. Eur Heart J 2009;30(19):2369–413.

45. Correct Answer

C. Transfusing 1 unit of FFP and 1 unit of platelets for every 1 unit of packed red cells he receives Massive transfusion is defined as >10 or more units of PRBCs within 24 hours. Patients receiving massive transfusions are at risk for developing coagulopathy of trauma, which in turn increases their risk of death by three- to four-fold, especially in those with coagulopathy on admission. Activated factor VII has been used extensively in trauma but has not clearly been shown to improve outcomes and may add to overall prothrombotic risk (choice A is incorrect). Chloride-rich crystalloids are associated with worsened coagulopathy during trauma resuscitation and are not recommended (choice B is incorrect). The recent PROPRR trial found no significant difference in mortality for patients with severe traumatic injury randomized to resuscitation in a 1:1:1 (plasma, platelet, PRBC) ratio vs. a 1:1:2 ratio. However, significantly more patients achieved hemostasis and fewer died from exsanguination within the first 24 hours in the 1:1:1 group (choice C is correct; choice D is incorrect). In general, hemoglobin thresholds should not be used in the setting of active hemorrhage as the system is not in a steady state and one should not wait for lab values to proceed with aggressive transfusional support. There is also no data to support a goal hemoglobin level of 10 g/dL (choice E is incorrect).

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1. Niles SE, McLaughlin DF, Perkins JG, et al. Increased mortality associated with the early coagulopathy of trauma in combat casualties. J Trauma 2008;64(6):1459–63. 2. Pham HP, Shaz BH. Update on massive transfusion. Br J Anaesth 2013;111(S1):71–82. 3. Kasotakis G, Sideris A, Yang Y, et al; Inflammation and Host Response to Injury Investigators. Aggressive early crystalloid resuscitation adversely affects outcomes in adult blunt trauma patients: an analysis of the Glue Grant database. J Trauma Acute Care Surg 2013;74 (5):1215–21.

46. Correct Answer

E. Stat interventional radiology consultation

Reproduced, courtesy of James Heilman, MD (Own work) [CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0)], via Wikimedia Commons)

This patient is presenting with Reynold’s pentad (Charcot’s triad of fever, abdominal pain, and jaundice, plus hypotension and altered mental status) consistent with severe acute cholangitis. He was appropriately treated for septic shock with early antibiotics, IVF, and vasopressors. The abdominal CT shows acute cholecystitis with a large gallbladder, gallbladder wall thickening, and a large gallstone. The image does not show evidence of gangrenous cholecystitis (gas in the wall or lumen, intraluminal membranes, irregular or absent wall, abscess), which would be an indication for emergent surgical intervention as gangrenous cholecystitis is associated with a much higher mortality than non-gangrenous cholecystitis (12% vs. 1%). In the absence of gangrenous cholecystitis, patients who are critically ill or categorized as ASA class III, IV, or V are not typically taken to the operating room immediately as the risks of surgery outweigh the benefits (choice C is incorrect). Rather, percutaneous or endoscopic biliary drainage is recommended in order to decompress the gallbladder. Given the presence of septic shock, the best available option in this case is to consult interventional radiology for percutaneous biliary drainage (choice E is correct). Endoscopic intervention with drainage via ERCP would also be an appropriate option. Once the acute infection is treated and the patient becomes more stable, surgical intervention can be addressed. Although RUQ ultrasound, abdominal plain films, and HIDA scan may be used to evaluate abdominal pain, they will not impact the patient’s overall outcome or change management, as the diagnosis has been made based on the above data (choices A, B, and D are incorrect). 111

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1. Strasberg SM. Clinical practice. Acute calculous cholecystitis. N Engl J Med 2008;358:2804 –11. 2. Baron TH, Grimm IS, Swanstrom LL. Interventional approaches to gallbladder disease. N Engl J Med 2015;373(4):357–65.

47. Correct Answer C. High-dose insulin

Calcium channel blockers, such as verapamil, selectively antagonize the L-type calcium channels in the myocardium, which are responsible for myocardial contractility, vascular smooth muscle contractility, and conduction. Overdose is associated with peripheral vasodilation, bradycardia, and decreased inotropic activity. Because most calcium channel blockers are highly protein-bound with a large volume of distribution, systemic absorption is unpredictable. Toxicity can be both delayed and prolonged, and hemodialysis is an ineffective treatment modality (choice B is incorrect). Initial treatment of calcium channel blocker overdose includes administration of glucagon, calcium, and atropine, although the latter two options are often ineffective. Glucagon, though useful, is not FDA-approved for this purpose. Vasoactive agents with both inotropic and vasoconstrictor effects, such as epinephrine and norepinephrine, can be used. In refractory cases, high-dose insulin therapy can be used to improve inotropic activity, although the mechanism of action remains unclear (choice C is correct). The beneficial effects can also be delayed for up to 60 minutes, necessitating use of vasoactive agents in the interim. Lipid emulsion can also be considered in refractory cases, but data supporting its benefit are limited. Whole bowel irrigation is not indicated for calcium channel blocker toxicity and can lead to aspiration in patients with altered mental status (choice E is incorrect). Dantrolene is indicated for the treatment of malignant hyperthermia, which is not suggested by this patient’s presentation with bradycardia and hypotension (choice A is incorrect). Sodium bicarbonate is used to manage tricyclic antidepressant overdoses, not calcium channel blocker overdoses (choice D is incorrect). 1. Proano L, Chiang WK, Wang RY. Calcium channel blocker overdose. Am J Emerg Med 1995;13(4):444–50. 2. Greene SL, Gawarammans I, Wood DM, Jones AL, Dargan PI. Relative safety of hyperinsulinemia/euglycemia therapy in the management of calcium channel blocker overdose: a prospective observational study. Intensive Care Med 2007;33(11):2019–24. 3. Jamaty C, Bailey B, Larocque A, Notebaert E, Sanogo K, Chauny JM. Lipid emulsions in the treatment of acute poisoning: a systematic review of human and animal studies. ClinToxicol (Phila) 2010;48(1):1–27.

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48. Correct Answer

D. Tissue plasminogen activator (tPA) may be indicated to help preserve her digits

Reproduced, courtesy of Dr. S. Falz [CC BY-SA 3.0 (https:// creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons

This patient has severe frostbite with mild hypothermia. Heparin and tPA are indicated for severe frostbite in the first 24 hours when there is high risk of limb or digit amputation and no contraindication (choice D is correct). Warm water (not hot water) and body heat should be instituted for prehospital warming (choice A is incorrect). Bradycardia can be monitored as it tends to resolve with rewarming. Atropine should be used only in situations of associated hemodynamic instability (choice B is incorrect). The absence of shivering reflects a drop in core body temperature 15,000/µL, Cr >1.5 x baseline, serum albumin 38.3°C, ICU admission, and presence of pseudomembranous colitis. This is her first episode of CDI, and there is no evidence of ileus or toxic megacolon, which would affect the initial treatment plan. Oral vancomycin 125 mg q6 hours is first line therapy in severe CDI (choice B is correct). There is no indication to use an increased dose of oral vancomycin for initial therapy unless the CDI is fulminant with ileus, toxic megacolon, or shock (choice A is incorrect). Fidaxomicin is now considered an option for severe CDI; however the correct dosing is 200 mg q12 hours (choice C is incorrect). The addition of IV metronidazole to high dose oral vancomycin (500 mg q6 hours) is indicated in fulminant cases of CDI, especially with an ileus. The abdominal imaging in our patient does not reveal an ileus (choice E is incorrect). Intravenous metronidazole alone is not considered sufficient therapy for severe CDI if the patient is able to tolerate oral medications (choice D is incorrect). More recent 2017 guidelines discourage the use of metronidazole at all in first occurrences of CDI. If unable to take oral medications, intracolonic vancomycin can be considered, but this does place the patient at increased risk of bowel perforation. 1. Zar FA, Bakkanagari SR, Moorthi KM, Davis MB. A comparison of vancomycin and metronidazole for the treatment of Clostridium difficile-associated diarrhea, stratified by disease severity. Clin Infect Dis 2007;45(3):302–7. 2. Cohen SH, Gerding DN, Johnson S, et al. Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the society for healthcare epidemiology of America (SHEA) and the infectious diseases society of America (IDSA). Infect Control Hosp Epidemiol 2010;31(5):431–55. 3. Surawicz CM, Brandt LJ, Binion DG, et al. Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections. Am J Gastroenterol 2013;108(4):478–98.

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58. Correct Answer

E. Deflate the balloon and pull back to obtain a pulmonary artery (PA) tracing

Courtesy of: Bruen, Charles, http://resusreview.com/wp-content/ uploads/2013/11/Case54-Overwedge.jpg. Published 2013, Accessed 2018.

The tracing demonstrates a continuous increase in pressure with the balloon inflated, consistent with an “overwedged” position. This can be due to eccentric inflation or the balloon being trapped against the vessel wall. In this position, the pressure increases due to the continuous flow of flush fluid through the catheter tip. This “overwedged” position creates an increased risk for vessel rupture. The balloon should be deflated immediately followed by withdrawal of the catheter to the PA position prior to another attempt to wedge (choice E is correct). Since the catheter is advanced too far distally, any attempt to further inflate the balloon, advance the catheter, or leave it in place increases the risk of PA rupture (choices A, B, and D are incorrect). The catheter does need to be partially withdrawn, but not removed completely (choice C is incorrect). 1. Summerhill EM, Baram M. Principles of pulmonary artery catheterization in the critically ill. Overwedge.jpg. Published 2013, Accessed 2018.

59. Correct Answer

B. The patient is a candidate for intravenous tPA, and she should receive this medication as soon as possible The patient is presenting between 3 and 4.5 hours of symptom onset. New evidence suggests that tPA is effective for strokes in this time period (choice A is incorrect; choice B is correct). Use of tPA is contraindicated in patients presenting outside the 4.5-hour window and in those with a history of stroke or head trauma within 3 months, but it is not contraindicated in the setting of diabetes (choice D is incorrect). Uncontrolled hypertension should be treated prior to giving tPA, but tPA can be safely given with a systolic BP