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(BQ) This book contains 270 multiple-choice questions allowing self-assessment of the breadth of knowledge required of the modern intensivist. The MTF questions test factual knowledge and understanding of the evidence base underpinning intensive care medicine, while the SBA questions test the ability of the candidate to prioritise, compete options and make the best decision for the patient.
Intensive Care Medicine prelims Intensive Care Medicine MCQs_prelims Intensive Care Medicine MCQs.qxd 12/04/15 12:54 PM Page i Intensive Care Medicine MCQs Multiple Choice Questions with Explanatory Answers Editor: Steve Benington MBChB MRCP FRCA EDIC FFICM Authors: Shoneen Abbas MBChB MRCP FFICM Ruth Herod MBChB FRCA FFICM Daniel Horner BA MBBS MD MRCP(UK) FCEM FFICM prelims Intensive Care Medicine MCQs_prelims Intensive Care Medicine MCQs.qxd 12/04/15 12:54 PM Page ii Intensive Care Medicine MCQs — Multiple Choice Questions with Explanatory Answers tfm Publishing Limited, Castle Hill Barns, Harley, Shrewsbury, SY5 6LX, UK Tel: +44 (0)1952 510061; Fax: +44 (0)1952 510192 E-mail: info@tfmpublishing.com Web site: www.tfmpublishing.com Editing, design & typesetting: Nikki Bramhill BSc Hons Dip Law First edition: © 2015 Front cover image: © 2015 Sudok1/Dreamstime.com LLC Paperback ISBN: 978-1-910079-07-2 E-book editions: 2015 ePub ISBN: 978-1-910079-08-9 Mobi ISBN: 978-1-910079-09-6 Web pdf ISBN: 978-1-910079-10-2 The entire contents of Intensive Care Medicine MCQs — Multiple Choice Questions with Explanatory Answers is copyright tfm Publishing Ltd Apart from any fair dealing for the purposes of research or private study, or criticism or review, as permitted under the Copyright, Designs and Patents Act 1988, this publication may not be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, digital, mechanical, photocopying, recording or otherwise, without the prior written permission of the publisher Neither the authors nor the publisher can accept responsibility for any injury or damage to persons or property occasioned through the implementation of any ideas or use of any product described herein Neither can they accept any responsibility for errors, omissions or misrepresentations, howsoever caused Whilst every care is taken by the authors and the publisher to ensure that all information and data in this book are as accurate as possible at the time of going to press, it is recommended that readers seek independent verification of advice on drug or other product usage, surgical techniques and clinical processes prior to their use The authors and publisher gratefully acknowledge the permission granted to reproduce the copyright material where applicable in this book Every effort has been made to trace copyright holders and to obtain their permission for the use of copyright material The publisher apologizes for any errors or omissions and would be grateful if notified of any corrections that should be incorporated in future reprints or editions of this book ii Printed by Gutenberg Press Ltd., Gudja Road, Tarxien, PLA 19, Malta prelims Intensive Care Medicine MCQs_prelims Intensive Care Medicine MCQs.qxd 12/04/15 12:54 PM Page iii Contents Page Preface iv Acknowledgements vi Abbreviations vii Converting units of measurement xii Topic index xiii Paper 1: Questions Paper 1: Answers 39 Paper 2: Questions 105 Paper 2: Answers 143 Paper 3: Questions 219 Paper 3: Answers 259 iii prelims Intensive Care Medicine MCQs_prelims Intensive Care Medicine MCQs.qxd 12/04/15 12:54 PM Page iv Preface This book contains three 90-question multiple choice papers designed to test the candidate’s knowledge of intensive care medicine (ICM) and their ability to apply it Each paper begins with 60 multiple true false (MTF) questions consisting of a stem and five statements, each requiring a true or false answer These are followed by 30 single best answer (SBA) questions where a clinical vignette is presented with five possible solutions The candidate should select the one that best addresses the problem, mirroring clinical practice where a case usually has several possible approaches Topics have been chosen to cover the breadth of knowledge required of the modern intensivist, including resuscitation, diagnosis, disease management, organ support, applied anatomy, end-of-life care and applied basic sciences There is a strong focus on the evidence base underpinning the specialty, making this book particularly useful for physicians and others approaching professional examinations in ICM and related acute medical and surgical specialties There is no ‘pass mark’, although a score of less than four out of five in an MTF question or an incorrect response to an SBA question should help the candidate identify areas where they would benefit from further reading Each question is accompanied by a detailed and fully referenced answer; the majority of references are freely accessible online or through institutional subscriptions The authors are all senior trainees or consultants practising intensive care medicine in the UK with firsthand experience of passing professional examinations In addition, they have extensive training and experience in iv prelims Intensive Care Medicine MCQs_prelims Intensive Care Medicine MCQs.qxd 12/04/15 12:54 PM Page v Preface acute medicine, anaesthesia and emergency medicine, respectively, and have drawn on their experience to devise questions that reflect these specialties and their interface with intensive care medicine The authors hope that this book will be a useful resource not only for those approaching examinations but for anyone wishing to keep up-to-date in this fast-changing specialty Steve Benington MBChB MRCP FRCA EDIC FFICM Shoneen Abbas MBChB MRCP FFICM Ruth Herod MBChB FRCA FFICM Daniel Horner BA MBBS MD MRCP(UK) FCEM FFICM v prelims Intensive Care Medicine MCQs_prelims Intensive Care Medicine MCQs.qxd 12/04/15 12:54 PM Page vi Acknowledgements The Editor would like to thank Dr Ola Abbas and Dr Fiona Wallace for their invaluable help proofreading the manuscript Also, thanks to Dr John Macdonald, Dr Hakeem Yousuff, Dr Richard Ramsaran and Dr Andrew Martin for their comments while testing the questions vi prelims Intensive Care Medicine MCQs_prelims Intensive Care Medicine MCQs.qxd 12/04/15 12:54 PM Page vii Abbreviations The following are the most commonly used abbreviations throughout the book: AAGBI ABG ACS ACTH AF AFE AFLP AIS AKI ALF ALI ALS AP APACHE APLS APRV aPTT ARDS ARR ASIA AT ATLS ATN BE BMI BNP BP BTS CAM-ICU cAMP Association of Anaesthetists of Great Britain and Ireland Arterial blood gas Abdominal compartment syndrome Adrenocorticotropic hormone Atrial fibrillation Amniotic fluid embolism Acute fatty liver of pregnancy Abbreviated Injury Scale Acute kidney injury Acute liver failure Acute lung injury Advanced Life Support Acute pancreatitis Acute Physiology and Chronic Health Evaluation Advanced Paediatric Life Support Airway pressure release ventilation Activated partial thromboplastin time Acute respiratory distress syndrome Absolute risk reduction American Spinal Injury Association Anaerobic threshold Advanced Trauma Life Support Acute tubular necrosis Base excess Body mass index B-natriuretic peptide Blood pressure British Thoracic Society Confusion Assessment Method for the Intensive Care Unit Cyclic adenosine monophosphate vii prelims Intensive Care Medicine MCQs_prelims Intensive Care Medicine MCQs.qxd 12/04/15 12:54 PM Page viii Intensive Care Medicine MCQs — Multiple Choice Questions with Explanatory Answers viii CAP CDI cGMP CIN CK CKD ClCMAP CMV COPD CPAP CPET CPIS CPK CPP CPR CRP CRRT CSF CT CTPA CVC CVP CXR DBD DCD DDAVP DI DIC DKA DVT ECG ECMO EEG EMG ESR ETCO2 EVD FFP FRC HR Community-acquired pneumonia Clostridium difficile infection Cyclic guanosine monophosphate Contrast-induced nephropathy Creatine kinase Chronic kidney disease Chloride Compound muscle action potential Cytomegalovirus Chronic obstructive pulmonary disease Continuous positive airway pressure Cardiopulmonary exercise testing Clinical Pulmonary Infection Score Creatinine phosphokinase Cerebral perfusion pressure Cardiopulmonary resuscitation C-reactive protein Continuous renal replacement therapy Cerebrospinal fluid Computed tomography Computed tomography pulmonary angiogram Central venous catheter Central venous pressure Chest X-ray Donation after brainstem death Donation after cardiac death Desmopressin Diabetes insipidus Disseminated intravascular coagulation Diabetic ketoacidosis Deep vein thrombosis Electrocardiogram Extracorporeal membrane oxygenation Electroencephalography Electromyography Erythrocyte sedimentation rate End-tidal carbon dioxide External ventricular drain Fresh frozen plasma Functional residual capacity Heart rate prelims Intensive Care Medicine MCQs_prelims Intensive Care Medicine MCQs.qxd 12/04/15 12:54 PM Page ix Abbreviations GBS GCS GFR GMC GTN HAS HCM HFOV HME HRS IABP IAH IAP ICP ICU ICUAW ILCOR INR ISS K+ KDIGO LDH LMA LMWH LP LQTS LVOT MAP MDR MELD MEN MEOWS MET MG Mg2+ MH MHRA MI MODS MPAP MPM Guillain-Barré syndrome Glasgow Coma Scale Glomerular filtration rate General Medical Council Glyceryl trinitrate Human albumin solution Hypertrophic cardiomyopathy High-frequency oscillatory ventilation Heat and moisture exchangers Hepatorenal syndrome Intra-aortic balloon pump Intra-abdominal hypertension Intra-abdominal pressure Intracranial pressure Intensive care unit Intensive care unit-acquired weakness International Liaison Committee on Resuscitation International Normalised Ratio Injury Severity Score Potassium The Kidney Disease: Improving Global Outcomes Lactate dehydrogenase Laryngeal mask airway Low-molecular-weight heparin Lumbar puncture Long QT syndrome Left ventricular outflow tract Mean arterial pressure Multidrug resistance Modified End-stage Liver Disease Multiple endocrine neoplasia Modified Early Obstetric Warning Score Metabolic equivalent Myasthenia gravis Magnesium Malignant hyperthermia Medicines and Healthcare Products Regulatory Agency Myocardial infarction Multiple Organ Dysfunction Score Mean pulmonary artery pressure Mortality Prediction Model ix Paper questions_Paper questions.qxd 12/04/15 11:18 AM Page 128 Intensive Care Medicine MCQs — Multiple Choice Questions with Explanatory Answers 64 A 75-year-old man is admitted to the emergency department with confusion and photophobia His family report that he has been generally unwell and lethargic for a week and has had diarrhoea He is pyrexial at 38.9°C His white cell count is 18.0 x 103/ml Lumbar puncture is performed Cerebrospinal fluid (CSF) analysis reveals a pleocytosis, and CSF protein levels are moderately elevated at 0.80g/L CSF glucose is 1.3mmol/L The Gram stain is negative The most likely diagnosis is: a b c d e Neisseria meningitis Subdural haematoma Listeria meningitis Viral meningitis Cryptococcal meningitis 65 You are asked to review a 45-year-old man on the ICU with refractory hypoxia He was admitted several days ago with acute pancreatitis and has subsequently developed severe acute respiratory distress syndrome His PEEP and FiO2 have been escalated over the course of the day He is now saturating at 85% on FiO2 0.65 with PEEP at 15cm H2O and plateau pressures of 29cm H2O There is little to remove on tracheal suction He is sedated and paralysed and the I:E ratio is currently 1:1 Which of the following options would be the most effective next step? a b Commencing inhaled nitric oxide Adjusting the PEEP to 20cm H2O in line with the ARDSnet high PEEP ladder Placing the patient in the prone position Inverting the I:E ratio Commencing high-frequency oscillatory ventilation c d e 128 Paper questions_Paper questions.qxd 12/04/15 11:18 AM Page 129 Paper 2 a b c d e Noradrenaline infusion Further crystalloid administration Transfusion of packed red cells Administration of a starch for fluid resuscitation Transfer to theatre for immediate wound debridement 67 A 79-year-old man is on the coronary care unit at a peripheral hospital after an inferior ST elevation myocardial infarction (STEMI) which was too late a presentation to consider transfer for primary coronary intervention He deteriorates in the early hours one morning with chest pain and a drop in blood pressure BP is 90/52mmHg He has had slow intravenous fluid running His jugular venous pressure is elevated and chest is clear Which of the following is the most appropriate course of action? a b c d e Re-referral to the local cardiac centre Intravenous nitrates Stop intravenous fluids Intravenous furosemide Thrombolysis Questions A 24-year-old 75kg man is brought in by ambulance to the emergency room having been found in a local park On examination he is found to have a large leftsided groin abscess Observations include a temperature of 35°C, heart rate (HR) 139bpm and a mean arterial pressure (MAP) of 47mmHg His serum lactate is 4.3mmol/L Bloods show a haemoglobin concentration of 94g/L and a white cell count of 21 x 109/L He is given an initial bolus of 2L of Hartmann’s solution, his MAP improves to 52mmHg and his HR decreases to 124bpm The most appropriate next step from the list below is: Paper 66 129 Paper questions_Paper questions.qxd 12/04/15 11:18 AM Page 130 Intensive Care Medicine MCQs — Multiple Choice Questions with Explanatory Answers 130 68 Which of the following qualities is most essential when designing a scoring system to assess risk of mortality in critically ill patients? a b c d e Validity Generalisabilty Complexity of statistical modelling Discrimination Simplicity of variables 69 A 54-year-old woman is admitted to hospital following ingestion of an unknown substance 14 hours previously She is acting strangely and complaining of visual disturbances, nausea and abdominal pain On examination her observations are as follows: GCS 14, HR 118bpm, BP 89/54mmHg, respiratory rate 30/min Urine toxicology is negative for amphetamines, barbiturates, benzodiazepines and opiates Blood results: serum Na+ 139mmol/L, serum K+ 4.3mmol/L, serum urea 6.5mmol/L, serum creatinine 105μmol/L, Cl- 106mmol/L, blood glucose 5.8mmol/L, serum osmolarity 312mOsm/L Paracetamol and salicylate levels are awaited Arterial blood gas (on air): pH 7.15, pO2 13.1kPa, pCO2 2.1kPa, HCO3- 7mmol/L No abnormalities are seen on chest X-ray ECG shows sinus tachycardia, QRS duration 100ms What is the most likely intoxicant? a b c d e Ethylene glycol Salicylates Tricyclic antidepressants Cyanide Paraquat Paper questions_Paper questions.qxd 12/04/15 11:18 AM Page 131 Paper 2 a b c d e Acute fatty liver of pregnancy Liver haematoma Veno-occlusive disease Cholestasis of pregnancy Viral hepatitis 71 A 25-year-old male is admitted to the intensive care unit with meningococcal sepsis On arrival he has a lactate of 5mmol/L, a pulse of 160bpm and a blood pressure of 76/25mmHg Capillary refill time is seconds He has been intubated in the emergency department and has central access He has been resuscitated with 4L of crystalloid fluid His estimated weight is 72kg He has warm peripheries and bounding pulses From the following options, what would be the next recommended measure? a b c d e Hydrocortisone infusion Further fluid bolus with 20ml/kg 4.5% human albumin solution Intravenous vasopressin infusion Intravenous noradrenaline infusion Further crystalloid boluses until lactate 20% Repeat chest X-ray shows no abnormalities Given these results, what is the most likely diagnosis? a b c d e Pulmonary embolism Haemorrhage Cardiogenic shock Tamponade Tension pneumothorax Questions Which of the following interventions has shown the most potential benefit in reducing the rate of contrastinduced nephropathy (CIN) in critically ill patients with acute kidney injury undergoing CT imaging with contrast? Paper 82 137 Paper questions_Paper questions.qxd 12/04/15 11:19 AM Page 138 Intensive Care Medicine MCQs — Multiple Choice Questions with Explanatory Answers 138 84 A 46-year-old woman’s house is set alight by her chip pan She is trapped in her bedroom for up to 2 hours The ICU physician is asked to assess her in the emergency department resuscitation room She has singed nasal hairs and a hoarse voice She has 40% burns to her torso and extremities and is agitated and in pain Which of the following is the best option in terms of airway management? a b c d e Rapid sequence induction and tracheal intubation Awake fibreoptic intubation Observe on a high dependency unit Perform an elective tracheostomy Trial of continuous positive airway pressure ventilation 85 A 91-year-old man falls in the garden and sustains fractures to ribs 4-6 on the right side and a small pneumothorax which is managed conservatively He has no other associated injuries and there is no evidence of myocardial or pulmonary contusions His past medical history includes ischaemic heart disease, previous myocardial infarction and chronic obstructive pulmonary disease (COPD) His medication includes aspirin and clopidogrel He is managed on the surgical ward for 24 hours, and then a request is made for assistance with analgesia In addition to the regular paracetamol and NSAID analgesia he is already receiving which of the following options would be the best choice for pain management in this patient? a b c d e Paravertebral block Intercostal nerve blocks Thoracic epidural Entonox® Change from oral to intravenous paracetamol Paper questions_Paper questions.qxd 12/04/15 11:19 AM Page 139 Paper 2 a b c d Electrolyte replacement and continue enteral feeding Electrolyte replacement and stop enteral feeding Electrolyte replacement and reduce enteral feeding Electrolyte replacement and convert enteral feed to parenteral nutrition Potassium replacement, continue enteral feeding and allow shift of other electrolytes from total body stores to render equilibrium e 87 A 76-year-old nursing home resident is admitted to hospital in a confused state On examination the patient is found to be hyperreflexic with a GCS of She is tachycardic and hypotensive with dry mucous membranes but maintains a good urine output Bloods show serum Na+ 171mmol/L, K+ 2.8mmol/L, serum glucose 12mmol/L and serum osmolality 310mOsm/kg Urinalysis shows osmolality 272mOsm/kg Once the patient is stabilised and her serum sodium returned to normal a water deprivation test is performed Prior to the test her urine osmolality is 275mOsm/kg, after water deprivation urine osmolality is 274mOsm/kg and after the administration of desmopressin, urine osmolality is 270mOsm/kg The most likely diagnosis is: a b c d e Primary hyperaldosteronism Cushing’s syndrome Nephrogenic diabetes insipidus Central diabetes insipidus Hypodipsia Questions A long-stay patient develops hypophosphataemia, hypomagnesaemia and hypokalaemia following the introduction of enteral nutrition What is the most appropriate next management step? Paper 86 139 Paper questions_Paper questions.qxd 12/04/15 11:19 AM Page 140 Intensive Care Medicine MCQs — Multiple Choice Questions with Explanatory Answers 88 A 27-year-old man is bought into the emergency department by ambulance complaining of shortness of breath He has a history of asthma and takes salbutamol and beclometasone inhalers regularly Which of the following examination findings would be the most worrying clinical sign? a b c d e Heart rate of 125/minute Speaking in short sentences due to breathlessness Respiratory rate of 28/minute Peak expiratory flow rate of 40% predicted Blood pressure of 80/60mmHg 89 You are managing a patient with a World Federation of Neurosurgeons (WFNS) grade subarachnoid haemorrhage post-coiling, who is now at day 7 Today they have developed a dense left-sided weakness The neurosurgical team suspects vasospasm Which of the following options is most likely to be of benefit? a b Intravenous high-dose nifedipine Aggressive fluid loading aiming for hypervolaemia and a supranormal CVP Induced hypertension aiming to increase MAP by 10-20% Haemodilution to a haematocrit of 0.23 Prescription of high-dose atorvastatin c d e 90 140 You are asked to review a 58-year-old 90kg man on the medical ward He was admitted 24 hours previously with a 3-week history of fatigue, anorexia, weight loss, pyrexia and abdominal pain His past medical history includes a history of hypertension, kidney stones and a recent course of antibiotics for a Paper questions_Paper questions.qxd 12/04/15 11:19 AM Page 141 Paper 2 Hypovolaemia Acute tubular necrosis Acute glomerulonephritis Urinary tract obstruction Acute interstitial nephritis Questions a b c d e Paper urinary tract infection Bloods show an acute rise in serum creatinine to 2.5 times his baseline and he has passed 80ml urine over the last 4 hours His fractional excretion of sodium is 4% and coarse granular casts and renal tubular epithelial cell casts are seen on urine microscopy There are no red cell or white cell casts or eosinophils The most likely pathophysiology is: 141 Paper questions_Paper questions.qxd 12/04/15 11:19 AM Page 142 Intensive Care Medicine MCQs — Multiple Choice Questions with Explanatory Answers 142 ... image: © 2 015 Sudok1/Dreamstime.com LLC Paperback ISBN: 97 8 -1 - 910 07 9-0 7-2 E-book editions: 2 015 ePub ISBN: 97 8 -1 - 910 07 9-0 8-9 Mobi ISBN: 97 8 -1 - 910 07 9-0 9-6 Web pdf ISBN: 97 8 -1 - 910 07 9 -1 0-2 The entire... 2. 81, 3.2, 3 .15 , 3 .16 , 3.24, 3.34, 3.66, 3.83, 3.88 Miscellaneous 1. 49, 1. 56, 1. 89, 2.42, 2.79, 3. 41, 3. 71, 3.82 Neurology & neurosurgery 1. 1, 1. 8, 1. 10, 1. 16, 1. 17, 1. 29, 1. 53, 1. 55, 1. 58, 1. 61, ... Topic index Renal 1. 13, 1. 21, 1. 22, 2.25, 2.50, 2.82, 2.90 Respiratory & ventilation 1. 4, 1. 11, 1. 18, 1. 50, 1. 51, 1. 59, 1. 69, 1. 70, 1. 76, 1. 77, 1. 87, 2.23, 2.26, 2.65, 2.88, 3 .1, 3.7, 3.8, 3 .13 , 3.44,