Self-Evaluation Process 2012 Update in Critical Care

MedicineModule A2-M Version 2012-1

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ConfidentialOnly for use at the Scott & White Learning Sessions held July 16th 2012.

Stephen Sibbitt, MD, FACPCMO Scott & White Memorial Hospital

Curtis Mirkes, DO, FACPProgram Director

IM Residency

31st Annual Internal Medicine Review

July 16th 2011

Question 1

Utilized Heart muscle is

damaged and needs to rest in order to heal

Bridge in patients awaiting heart transplantation or in patients who have rejected a transplanted heart.

HeartMate ® Implantable

Left ventricle (LVAD)Right ventricle (RVAD)Both ventricles (BIVAD)

Question 1

1Hunt SA et al. J Am Coll Cardiol. 2001;38:2101–2113.

2New York Heart Association/Little Brown and Company, 1964. Adapted from: Farrell MH et al. JAMA. 2002;287:890–897.

ACC/AHA HF Stage1 NYHA Functional Class2

A At high risk for heart failure but withoutstructural heart disease or symptomsof heart failure (eg, patients withhypertension or coronary artery disease)

B Structural heart disease but withoutsymptoms of heart failure

C Structural heart disease with prior orcurrent symptoms of heart failure

D Refractory heart failure requiringspecialized interventions

I Asymptomatic

II Symptomatic with moderate exertion

IV Symptomatic at rest

III Symptomatic with minimal exertion

None

Classification of HF: Comparison Between ACC/AHA HF Stage & NYHA Functional Class

Question 1

Question 1

Question 1

A. Continuation of current management

B. Placement of a left ventricular assist device

C. Plasma exchangeD. Proceeding to ABO non-matched

heart transplantation

Question 1

Question 2

Beta-lactam antibiotics Penicillins

AmpicillinAmoxicillinPiperacillin

Cephalosporins (generations)1st gen: cephalothin2nd gen (cephamycins): cefoxitin,

cefotetan3rd gen: ceftazidime, cefotaxime,

ceftriaxone4th gen: cefepime

Question 2

Beta-lactam antibiotics Monobactam: aztreonam Carbapenems:

ImipenemMeropenemErtapenem

InhibitorsSulbactam (ampicillin/sulbactam:

Unasyn)Tazobactam (piperacillin/tazobactam:

Zosyn)Clavulanate (amoxicillin/clavulanate:

Augmentin)

Question 2

A. If renal function worsens, the dose should be decreased, rather than increasing the interval

B. The volume of distribution is decreased, necessitating a lower loading dose

C. The patient may benefit from shorter infusion times

D. The Cockcroft-Gault equation will accurately estimate the patient's glomerular filtration rate

Question 2

During severe bacterial infections and sepsis, blood levels rise rapidly (up to x100K) – no elevation from viral infections

Is the Standard of Care for much of Europe in the management of infection and sepsis

Question 3

Morgenthaler N. et al., Clin Lab 2002, 48: 263-270

Question 3

Question 3

A. An elevated procalcitonin level mitigates against myocardial infarction

B. A procalcitonin-guided strategy will decrease the patient's mortality risk

C. A low procalcitonin level makes septic shock less likely

D. A low procalcitonin level excludes bacteremia

Question 3

Use ideal body weight for underweight patient

Use adjusted body weight for overweight patient

Ideal body weight = ((Body height cm)-100) – (10% x (Body

height-100))

Adjusted body weight = Actual body weight (ABW) – (25% x (Actual

Body Weight- Ideal Body Weight))

Question 4

Question 4

Question 4

A. Total parenteral nutrition providing 35 kcal/kg (based on actual body weight)

B. Enteral nutrition providing 35 kcal/kg (based on actual body weight)

C. Enteral nutrition providing 22 kcal/kg (based on adjusted body weight)

D. Combined parenteral and enteral nutrition providing a total of 35 kcal/kg (based on ideal body weight)

Question 4

Question 5

Question 5

Extended-spectrum beta-lactamases (ESBL) confer resistance to beta-lactam agents and ESBL-containing organisms are multi-drug resistant.

Question 5

Question 5

A. CeftriaxoneB. CiprofloxacinC. Imipenem-cilastatinD. Piperacillin-tazobactam

Question 5

Question 6

Central Venous Pressure (CVP):CVP = right atrial pressure (RAP) =

right-ventricular end-diastolic pressure (RVEDP) (Right Ventricular Preload)

Pulmonary Capillary Wedge Pressure (PCWP)

PCWP = left atrial pressure (LAP) = left-ventricular end-diastolic pressure (LVEDP) (Left Ventricular Preload)

Question 6

Cardiac Output (CO) = HR x SV (L/min)

Normal CO = 4 to 8 L/min

Cardiac Index (CI) = CO/BSA (L/min/m2)

Normal CI = 2.5-4.2 L/min/m2

Question 6

Etiology of shock

Example CVP CO SVR VO2 sat

Preload Hypovolemic

Low Low High Low

Contractility

Cardiogenic High Low High Low

Afterload DistributiveHyperdynamic Septic

Low/High

High Low High

Hypodynamic Septic

Low/High

Low High Low/High

Neurogenic Low Low Low Low

Anaphylactic

Low Low Low Low

Etiology & Hemodynamic Changes in Shock

Question 6 Intraaortic Balloon Pump (IABP)

Counterpulsation is synchronized to the EKG or arterial waveforms

Increase coronary perfusion

Decrease left ventricular stroke work and myocardial oxygen requirements

Indications for its use include

Failure to wean from cardiopulmonary bypass

Cardiogenic shock after MI

Heart failure

Refractory ventricular arrhythmias with ongoing ischemia

Question 6

Question 6

A. Less anticoagulation is neededB. A higher level of underlying cardiac

function is requiredC. Mortality from cardiogenic shock is

reducedD. Ventricular loading is reduced, and

cardiac performance is improvedE. Percutaneous left ventricular assist

devices can be used in severe aortic regurgitation

Question 6

Question 7

Question 7

A. Arterial blood gas studiesB. Depth of chest wall compressionC. Quantitative waveform

capnographyD. Good air entry on auscultation of

the lungs

Question 7

Question 8

Question 8

Question 8

A. Rebound hypercoagulability and subsequent thromboembolism

B. Depletion of thrombin due to the surgical acute-phase response

C. Thrombogenesis due to postoperative hypovolemia

D. Decreased fibrin turnover

Question 8

Question 9

Medication Onset (min)

Duration (min)

Side Effects

Ultra short ActingSuccinylcholine 1 – 1.5 5 - 10 ↑ K, ICP

Intermediate ActingAtracurium

Rocuronium Cisatracurium

21

3 - 6

3030 – 60

30

Rash, Histamine Release Expensive

Long ActingPancuronium 1.5 – 2 60

Question 9

Question 9

A. Succinylcholine is contraindicated following thermal injury

B. Atracurium is indicated, as it has minimal cardiovascular effects in hypotensive patients

C. Cisatracurium is indicated because of its favorable onset of action

D. Rocuronium is contraindicated, as it may propagate hypotension

Question 9

Question 10

Question 10

A. Decreased incidence of infectionsB. Increased incidence of burnout C. Decreased job satisfactionD. Increased incidence of cross-

contamination

Question 10

Question 11

Anion Gap 140 – 100 – 15 = 25

Calculated Osmolality 2 X Na + BUN/2.8 + Glucose/18 2(140) + 18/2.8 + 130/18 294

Osmolal Gap = Measured Osm – Cal Osm -4 (normal ≤ 10)

Question 11Degree of Compensation For metabolic acidosis,Expected PCO2 = 1.5(HCO3) + 8 ± 2

= 1.5(15) + 8 ± 2= 22.5 + 8 ± 2= 30.5 ± 2= 28.5, 32.5

Actual PCO2 is 30 appropriate compensation

7.3 / 30 / 94 / RA

Question 11

Question 11

Classic clinical triad: Mental status changes Autonomic hyperactivity Neuromuscular abnormalities

Wide ranging symptoms

Question 11

Question 11

Lactic acid can exist in two forms: L-lactate and D-Lactate. In mammals, only the levorotary form is a product of metabolism.

D-Lactate can accumulate in humans as a byproduct of metabolism by bacteria, which accumulate and overgrow in the GI tract with jejunal bypass or short bowel syndrome.

The lab measures only L-lactate.

Question 11

Medical conditions (w/o tissue hypoxia) Hepatic failure Thiamine deficiency

(co-factor for pyruvate dehyrogenase)

Malignancy Bowel ischemia Seizures Heat stroke Tumor lysis Drugs/Toxins

Metformin (particulary associated with hypovolemia and dye)

Tissue underperfusion Shock, shock,

shock Hypoxia Asthma CO poisoning Severe anemia

L-Lactic Acidosis

Question 11

A. Serotonin syndromeB. Salicylate poisoningC. D-Lactic acidosisD. Vitamin B1 deficiencyE. Vitamin B6 deficiency

Question 11

Question 12

A. The use of real-time ultrasonography for central line placement has been found to decrease the complication rate in all sites of insertion

B. Ultrasonography and chest radiography have the same accuracy for detection of pleural effusion and parenchymal consolidation in critically ill patients

C. The Focused Assessment with Sonography for Trauma (FAST) technique of point-of-care ultrasonography has been shown to decrease the need for computed tomography and to reduce the time to intervention

D. The finding of B lines on pleural ultrasonography predicts the presence of pneumothorax

Question 12

Question 13

Acute Lung Injury Bilateral pulmonary infiltrates on chest x-ray Pulmonary Capillary Wedge Pressure <

18 mmHg (2.4 kPa) PaO2/FiO2* <300 mmHg (40 kPa) = ALI PaO2/FiO2 <200 mmHg (26.7 kPa)= ARDS

Question 13Direct Insult Indirect Insult

CommonAspiration Pneumonia

Pneumonia

CommonSepsis

Severe TraumaShock

Less CommonInhalation Injury

Pulmonary contusionsFat Emboli

Near DrowningReperfusion Injury

Less CommonAcute Pancreatitis

Transfusion Related TRALIDIC

Head InjuryBurns

Drug Overdose

Question 13

Question 13

Question 13

Potential beneficial prevention strategies Mechanical ventilation, tidal volume limited to 6 to 8

mL/kg; maintenance of airway pressure at less than 30 cm H2O; use of moderate PEEP level;

Blood products: limitation of the use of packed red blood cells to evidence-based guidelines; limitation of the use of fresh frozen plasma and platelets to the setting of actual bleeding;

Intravenous fluids, maintenance of neutral to negative fluid balance except in the setting of shock or during resuscitation;

Resuscitation timeline: adequate repletion of circulating volume as quickly as possible after development of shock; and

Drug toxicity: avoidance of drugs that have direct pulmonary toxicity, such as amiodarone, when possible; another anti-arrhythmic medication should be used.

A. Administration of inhaled corticosteroids to patients who have a PO2/FIO2 ratio less than 350 or use of positive end-expiratory pressure (PEEP) greater than 8 cm H2O, or both

B. Limiting transfusion of fresh frozen plasma and platelets to those patients who are actually bleeding

C. De-escalation of antibiotics if sputum cultures show no growth at 48 hours

D. Early bronchoscopy with bronchoalveolar lavage in patients at high risk for ventilator-associated pneumonia

Question 13

Question 14

Question 14

Question 14

A. The mortality in critically ill medical and surgical patients does not differ between hyperglycemic and normoglycemic patients

B. Mortality rates are proportional to blood glucose levels in critically ill patients who have hyperglycemia

C. In patients who have had myocardial infarction, glucose levels below the usual target of 140 to 180 mg/dL for critically ill patients are recommended for optimal outcome

D. After adjustment for severity of illness, hypoglycemia was not found to be an independent risk factor for death

Question 14

Question 15

Question 15

A. Increased time for return of spontaneous circulation

B. No difference in survival at 30 daysC. Reduced survival if the airway is

occludedD. Reduced survival to hospital

admission

Question 15

Question 16

Question 16

A. Associated with long-term cognitive impairment

B. Not associated with increased mortality

C. Associated with increased length of stay in the ICU, but not length of stay in hospital

D. Occurs independent of the age of the patient

Question 16

Question 17

Question 17

A. A-B-C, referring to opening the airway (A), giving 2 breaths (B), and 30 chest compressions (C)

B. C-A-B, referring to 30 chest compressions (C), opening the airway (A), and giving 2 breaths (B)

C. C-B-D, referring to 30 chest compressions (C), 2 breaths (B), and defibrillation (D)

D. D-A-B, referring to defibrillation (D), opening the airway (A), and 2 breaths (B)

Question 17

Question 18

IAP should be expressed in mmHg and measured at end-expiration in the

complete supine position after ensuring that abdominal muscle contractions are

absent and with the transducer zeroed at the level of the midaxillary line.

Question 18

IAH is graded as follows: Grade I IAP 12 - 15 mmHg Grade II IAP 16 - 20 mmHg Grade III IAP 21 - 25 mmHg Grade IV IAP > 25mmHg.

The IAH grades have been revised downward as the detrimental impact of elevated IAP on end-organ function has

been recognized

ACS = IAH + organ dysfunctionThe most common organ dysfunction /

failure(s) are: Metabolic acidosis despite resuscitation Oliguria despite volume repletion Elevated peak airway pressures Hypoxemia refractory to oxygen and PEEP

Abdominal Compartment Syndrome (ACS) is defined as a sustained IAP > 20mmHg (with or without an APP < 60mmHg) that is associated with new organ dysfunction/ failure.”

Question 18

A. mm Hg, zeroed to the bladder with the patient semirecumbent (head of bed elevated to a 45-degree angle)

B. cm H2O, zeroed to ear level with the patient in the supine position

C. mm Hg, zeroed to the mid-axillary line with the patient in the supine position

D. cm H2O, zeroed to the mid-axillary line with the patient in any position

Question 18

Question 19

Question 19

A. Both teams should be called when the patient has hypotension, tachycardia, respiratory distress, or altered consciousness

B. Both teams should contain an anesthesiology practitioner

C. Rapid-response teams typically have a call rate of 5 to 10 in 1000 admissions, and code teams have a call rate of 20 to 40 in 1000 admissions

D. Delays in the activation of rapid-response teams and code teams have been associated with increased mortality

Question 19

Question 20

Question 20

A. Emergent magnetic resonance imaging of the thoracic spine

B. Intravenous corticosteroidsC. NorepinephrineD. Emergent placement of an epidural

drain

Question 20

Question 21

A. DopamineB. DobutamineC. NorepinephrineD. Vasopressin

Question 21

Question 22

IAH is graded as follows: Grade I IAP 12 - 15 mmHg Grade II IAP 16 - 20 mmHg Grade III IAP 21 - 25 mmHg Grade IV IAP > 25mmHg.

The IAH grades have been revised downward as the detrimental impact of elevated IAP on end-organ function has

been recognized

A. Grade I, less than 5 mm Hg; Grade IV, greater than 40 mm Hg

B. Grade I, greater than 25 mm Hg; Grade IV, less than 50 mm Hg

C. Grade I, 5-10 mm Hg; Grade IV, greater than 50 mm Hg

D. Grade I, 12-15 mm Hg; Grade IV, greater than 25 mm Hg

Question 22

Question 23

A. In all infections regardless of the risk of death

B. In patients with witnessed aspiration

C. Only in immunosuppressed patientsD. Only in serious infections when the

risk of death with monotherapy is greater than 25%

Question 23

Question 24

Tidal Volume (mL) Plateau Pressure/PEEP (cm H2O) FIO2PO2 (mmHg)

A. 700 20/10 1.0 100B. 320 35/18 1.0 60C. 540 30/14 0.7 105D. 500 25/5 0.5 120

Question 24

Question 25

Routes of administration Insufflated

(snorted) IV (mainlined) Inhaled

(freebased) Oral

Cocaine Pharmacokinetics: Absorption

Question 25

Cocaethylene

Alcohol inhibits metabolism of cocaine Alcohol + cocaine chemically react to form

cocaethylene• Cocaethylene Effects

– Similar effects to cocaine

– Greater cardiac toxicity than cocaine

– 3-5x the half-life of cocaine

– Associated with seizures, liver damage, compromised immune system

Question 25

A. Acute respiratory distress syndrome

B. Propylene glycol intoxicationC. Mesenteric ischemiaD. Cocaethylene formation

Question 25

Question 26

Question 26

Question 26

A. His prognosis for return of renal function to baseline is better than those of patients who have impaired left ventricular function

B. In patients who have type 1 cardiorenal syndrome, the use of beta-adrenergic blockers worsens mortality

C. This patient's acute on chronic renal dysfunction probably caused his acute heart failure (type 3 acute renocardiac syndrome)

D. Addition of an angiotensin-converting enzyme inhibitor drug to this patient's chronic regimen will improve his 12-month mortality

Question 26

Question 27

Question 27

A. Continue current managementB. Discontinue albuterol nebulizationC. Change intravenous fluid to 5%

dextrose in water with 2 ampules of bicarbonate (100 mEq/L)

D. Administer tromethamine (TRIS) buffer

Question 27

Pressure ventilation vs. volume ventilationPressure-cycled modes deliver a fixed pressure at variable volumeVolume-cycled modes deliver a fixed volume at variable pressure

• Pressure-cycled modes• Pressure Support Ventilation

(PSV)• Pressure Control Ventilation

(PCV)• CPAP• BiPAP

• Volume-cycled modes• Control• Assist• Assist/Control• Intermittent Mandatory

Ventilation (IMV)• Synchronous Intermittent

Mandatory Ventilation (SIMV)

Volume-cycled modes have the inherent risk of volutrauma.

Question 28

Question 28

A. The modality allows the patient to define their inspiratory flow rate and tidal volume

B. The incidence of barotrauma is lessC. The need for tracheostomy to

facilitate weaning is lessD. Closed loop technology

automatically adjusts the FIO2

Question 28

Question 29

Posterior reversible encephalopathy syndrome (PRES)

Question 29

AJR 2008;29:1036-42

Conditions at Risk for PRES

Question 29

A. Contrast-enhanced magnetic resonance imaging of the brain

B. Lumbar puncture and cerebrospinal fluid examination

C. Intravenous contrast-enhanced computed tomography of the head

D. Cerebral angiography

Question 29

Question 30

A. Discontinuation of lorazepamB. Initiation of zolpidemC. Discontinuation of

methylprednisoloneD. Discontinuation of inhaled beta-

adrenergic agonists

Question 30

Questions?