2015 intensive care medicine MCQsSteve benington

v acute medicine, anaesthesia and emergency medicine, respectively, andhave drawn on their experience to devise questions that reflect thesespecialties and their interface with intensive

Multiple Choice Questions with Explanatory Answers

Intensive Care Medicine

MCQs

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

Web site: www.tfmpublishing.com

Editing, design & typesetting: Nikki Bramhill BSc Hons Dip Law

The entire contents of Intensive Care Medicine MCQs — Multiple Choice

Questions with Explanatory Answers is copyright tfm Publishing Ltd Apart

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Printed by Gutenberg Press Ltd., Gudja Road, Tarxien, PLA 19, Malta

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

Preface

v

acute medicine, anaesthesia and emergency medicine, respectively, andhave drawn on their experience to devise questions that reflect thesespecialties and their interface with intensive care medicine The authorshope that this book will be a useful resource not only for thoseapproaching examinations but for anyone wishing to keep up-to-date inthis 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

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

Acknowledgements

The following are the most commonly used abbreviations throughout the book:

AAGBI Association of Anaesthetists of Great Britain and Ireland

ABG Arterial blood gas

ACS Abdominal compartment syndrome

ACTH Adrenocorticotropic hormone

AF Atrial fibrillation

AFE Amniotic fluid embolism

AFLP Acute fatty liver of pregnancy

AIS Abbreviated Injury Scale

AKI Acute kidney injury

ALF Acute liver failure

ALI Acute lung injury

ALS Advanced Life Support

AP Acute pancreatitis

APACHE Acute Physiology and Chronic Health Evaluation

APLS Advanced Paediatric Life Support

APRV Airway pressure release ventilation

aPTT Activated partial thromboplastin time

ARDS Acute respiratory distress syndrome

ARR Absolute risk reduction

ASIA American Spinal Injury Association

AT Anaerobic threshold

ATLS Advanced Trauma Life Support

ATN Acute tubular necrosis

BE Base excess

BMI Body mass index

BNP B-natriuretic peptide

BP Blood pressure

BTS British Thoracic Society

CAM-ICU Confusion Assessment Method for the Intensive Care Unit

cAMP Cyclic adenosine monophosphate

Abbreviations

viii

CAP Community-acquired pneumonia

CDI Clostridium difficile infection

cGMP Cyclic guanosine monophosphate

CIN Contrast-induced nephropathy

COPD Chronic obstructive pulmonary disease

CPAP Continuous positive airway pressure

CPET Cardiopulmonary exercise testing

CPIS Clinical Pulmonary Infection Score

CTPA Computed tomography pulmonary angiogram

CVC Central venous catheter

CVP Central venous pressure

CXR Chest X-ray

DBD Donation after brainstem death

DCD Donation after cardiac death

DDAVP Desmopressin

DI Diabetes insipidus

DIC Disseminated intravascular coagulation

DKA Diabetic ketoacidosis

DVT Deep vein thrombosis

ECG Electrocardiogram

ECMO Extracorporeal membrane oxygenation

EEG Electroencephalography

EMG Electromyography

ESR Erythrocyte sedimentation rate

ETCO2 End-tidal carbon dioxide

EVD External ventricular drain

FFP Fresh frozen plasma

FRC Functional residual capacity

HR Heart rate

ix

GBS Guillain-Barré syndrome

GCS Glasgow Coma Scale

GFR Glomerular filtration rate

GMC General Medical Council

GTN Glyceryl trinitrate

HAS Human albumin solution

HCM Hypertrophic cardiomyopathy

HFOV High-frequency oscillatory ventilation

HME Heat and moisture exchangers

HRS Hepatorenal syndrome

IABP Intra-aortic balloon pump

IAH Intra-abdominal hypertension

IAP Intra-abdominal pressure

ICP Intracranial pressure

ICU Intensive care unit

ICUAW Intensive care unit-acquired weakness

ILCOR International Liaison Committee on Resuscitation

INR International Normalised Ratio

ISS Injury Severity Score

LVOT Left ventricular outflow tract

MAP Mean arterial pressure

MDR Multidrug resistance

MELD Modified End-stage Liver Disease

MEN Multiple endocrine neoplasia

MEOWS Modified Early Obstetric Warning Score

MET Metabolic equivalent

MODS Multiple Organ Dysfunction Score

MPAP Mean pulmonary artery pressure

MPM Mortality Prediction Model

MRC Medical Research Council

MRI Magnetic resonance imaging

MRSA Methicillin-resistant Staphylococcus aureus

NICE The National Institute for Health and Care Excellence

NIV Non-invasive ventilation

Na+ Sodium

NAC N-acetyl cysteine

NF Necrotizing fasciitis

NHSBT National Health Service Blood and Transplant

NICE National Institute for Health and Care Excellence

NMS Neuroleptic malignant syndrome

NNT Number needed to treat

NPV Negative predictive value

NSAID Non-steroidal anti-inflammatory drug

PAC Pulmonary artery catheter

PAOP Pulmonary artery occlusion pressure

PCI Primary coronary intervention

PCR Polymerase chain reaction

PCV Pressure-controlled ventilation

PCWP Pulmonary capillary wedge pressure

PE Pulmonary embolism

PEEP Positive end-expiratory pressure

PEFR Peak expiratory flow rate

P:F ratio Ratio of partial pressure of arterial oxygen to fraction of

inspired oxygenPLR Passive leg raising

PN Parenteral nutrition

POSSUM Physiological and Operative Severity Score for the

enUmeration of Mortality and MorbidityPPI Proton pump inhibitor

Pplat Plateau pressure

PPV Positive predictive value

PRIS Propofol infusion syndrome

PT Prothrombin time

PTHrP Parathyroid hormone-related protein

QALY Quality-adjusted life-year

RASS Richmond Agitation Severity Scale

RCT Randomised controlled trial

rFVIIa Recombinant Factor VIIa

RIFLE Risk, Injury, Failure, Loss, End-stage renal disease

ROC Receiver operator characteristic

Intensive Care Medicine MCQs — Multiple Choice Questions with Explanatory Answers

ROSC Return of spontaneous circulation

ROSIER Recognition of Stroke in the Emergency Room

RR Respiratory rate

RSBI Rapid Shallow Breathing Index

RTS Revised Trauma Score

SAH Subarachnoid haemorrhage

SAPS Simplified Acute Physiology Score

ScvO2 Central venous oxygen saturation

SDD Selective digestive tract decontamination

SIADH Syndrome of inappropriate antidiuretic hormone secretion

SID Strong ion difference

SLE Systemic lupus erythematosus

SNAP Sensory (or mixed) nerve action potential

SOFA Sequential Organ Failure Assessment

STEMI ST elevation myocardial infarction

SVC Superior vena cava

SVRI Systemic vascular resistance index

TBI Traumatic brain injury

TBSA Total body surface area

TEG Thromboelastography

TIA Transient ischaemic attack

TIPSS Transjugular intrahepatic portosystemic shunting

TISS Therapeutic Intervention Scoring System

TLS Tumour lysis syndrome

TRISS Trauma Injury Severity Score

TSS Toxic shock syndrome

TTP Thrombotic thrombocytopaenia purpura

VAD Ventricular assist device

VAP Ventilator-associated pneumonia

VATS Video-assisted thoracoscopic surgery

VCV Volume-controlled ventilation

VF Ventricular fibrillation

VT Ventricular tachycardia

Vt Tidal volume

VTE Venous thromboembolism

vWF von Willebrand Factor

WCC White cell count

WFNS World Federation of Neurosurgeons

WPW Wolff-Parkinson-White

WSACS World Society of the Abdominal Compartment Syndrome

Abbreviations

Laboratory results presented in the questions are given in standard UK

units The following conversion factors may be useful to readers from

other areas:

1μmol/L = 0.0113mg/dL (e.g serum bilirubin, creatinine)

1kPa = 7.5mmHg (e.g PaO2)

Converting units of

measurement

Cardiovascular 1.15, 1.25, 1.31, 1.33, 1.41, 1.47,

1.75, 1.85, 1.90, 2.10, 2.28, 2.43,2.46, 2.55, 2.60, 2.67, 2.73, 2.74,2.76, 2.77, 2.83, 3.19, 3.21, 3.36,3.40, 3.45, 3.50, 3.53, 3.64, 3.76,3.81

Diagnostic tests 2.12, 3.30

Ethics & legal 1.57, 1.60, 2.36

Evidence and biostatistics 1.20, 2.3, 2.68, 3.11, 3.18

Gastroenterology & hepatology 1.7, 1.52, 1.65, 1.88, 2.24, 2.35, 2.75,

3.25, 3.49, 3.51, 3.86

Haematology & clotting 1.2, 1.5, 1.26, 1.44, 1.84, 3.10, 3.38,

3.39, 3.48

Topic index

Metabolic & nutritional 1.9, 1.24, 1.37, 1.40, 1.62, 1.64, 1.82,

2.7, 2.8, 2.21, 2.41, 2.44, 2.52, 2.59,2.63, 2.80, 2.86, 2.87, 3.4, 3.5, 3.29,3.31, 3.42, 3.58, 3.68, 3.69, 3.70

Microbiology & infection control 1.28, 1.36, 1.74, 2.34, 2.40, 2.45,

2.47, 2.48, 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, 1.42,

1.53, 1.55, 1.58, 1.61, 1.66, 1.73,1.79, 1.80, 2.19, 2.22 2.27, 2.30,2.38, 2.64, 2.89, 3.22, 3.35, 3.46,3.72, 3.77

Obstetrics 2.70, 2.72, 3.67, 3.75

Organ donation 1.45, 2.39, 3.32, 3.62

Organ support & sedation 1.12, 1.72, 1.78, 1.81, 1.86, 2.1, 2.5,

2.16, 2.20, 2.62, 3.43, 3.47, 3.59,3.85, 3.87, 3.89

Paediatrics 1.46, 3.14, 3.55

Pharmacology 1.3, 1.6, 2.15, 2.18, 2.54

Physics & clinical measurement 1.30, 1.43, 2.13, 2.14, 2.17, 2.21,

2.51, 2.57, 2.78, 3.27, 3.33, 3.54,3.56

Intensive Care Medicine MCQs — Multiple Choice Questions with Explanatory Answers

Resuscitation & sepsis 1.34, 1.35, 2.4, 2.11, 2.37, 2.61, 2.66,

xvi

a Affects more females than males.

b Is a disease of the middle-aged

c When secondary to a respiratory illness, the majority of casespresent within a month

d The presence of cranial nerve signs effectively rules out thediagnosis

e The most common associated pathogen is Clostridium perfringens

2 In the trauma patient with massive haemorrhage, the following statements are correct:

a An initial target systolic blood pressure of 80-90mmHg isrecommended for the patient without brain injury

b Desmopressin at a dose of 0.3μg/kg is recommended in thebleeding patient taking platelet-inhibiting drugs

c Recombinant factor VIIa (rFVIIa) can be considered as a rescuemeasure provided the platelet count is greater than 30 x 109/L

d Pre-injury warfarin use doubles the odds of death for traumapatients with blunt head injury

e Antifibrinolytic drugs recommended for use in the bleeding majortrauma patient include tranexamic acid, aprotinin and aminocaproicacid

Paper 1

Questions

a Inability to complete sentences in one breath.

b PaO2of >8kPa

c Silent chest

d PaCO2>6kPa

e Peak expiratory flow rate (PEFR) <50% of predicted

5 With regard to bleeding and coagulopathy in the critically ill patient:

a If a platelet transfusion is indicated, 1 unit will raise the count byapproximately 20 x 109/L

b The principal constituents of cryoprecipitate include Factors VIII,XIII, vWF, fibronectin and fibrinogen

c A suggested dose of fresh frozen plasma in the bleeding traumapatient with coagulopathy is 30ml/kg

d Desmopressin at a dose of 0.3μg/kg is a useful treatment inpatients with coagulopathy related to uraemia, cirrhosis and aspirinuse

e At temperatures of 33-35°C, altered enzyme kinetics equate to a33% reduction in normal clotting factors

a An antagonist has receptor affinity and intrinsic activity.

b Increasing the dose of a partial agonist can elicit a maximal effect

c β-receptor blockers are reversible antagonists

d Flumazenil is an inverse agonist

e Phenoxybenzamine is an irreversible antagonist at α-adrenoceptors

7 Regarding the hepatorenal syndrome (HRS):

a It is commonly over-diagnosed in patients with cirrhotic liverdisease

b HRS Type 1 has the poorest outcome

c Kidneys from patients with HRS are suitable for transplantation

d The condition is associated with splanchnic vasodilatation

e Terlipressin must be given by infusion

8 With regard to a patient with a neuromuscular disorder on the critical care unit:

a Potassium-sparing diuretics should be avoided in patients withhypokalaemic periodic paralysis

b Suxamethonium use should be avoided in patients with myastheniagravis

c Patients with motor neurone disease typically require double thestandard dose of suxamethonium to provide optimum intubatingconditions

d Local anaesthesia can exacerbate symptoms of multiple sclerosis

e In Guillain-Barré syndrome, non-depolarising neuromuscularblocking drugs may be used, but should be significantly dose-reduced

c Parenteral nutrition can be administered peripherally.

d Approximately 1g/kg/day of nitrogen is required

e Copper, zinc and selenium (trace elements) are present incommercially produced parenteral nutrition solutions

10 A 67-year-old male has a diagnosis of myasthenia gravis (MG) Which of the following medications should be avoided to reduce the risk of exacerbation?

a PEFR <33% is a criterion diagnosis

b Aminophylline should be given as a first-line intravenousbronchodilator

c The use of IV magnesium sulphate to reduce mortality is supported

b SDD is ‘selective’ because it is anaerobe-sparing.

c Primary endogenous pathogens are targeted by intravenousantibiotics for the first 4 days

d After 10 days potentially pathogenic micro-organisms have beeneradicated and all antibiotics are stopped

e There is level I evidence that SDD increases the prevalence ofantibiotic resistance

13 A 59-year-old male is admitted with a gradual onset of peripheral oedema and frothy urine He is subsequently diagnosed with nephrotic syndrome The condition is associated with:

a Age

b Pupillary reaction

c Sensory neurological deficit

d The presence of non-evacuated haematoma on CT brain scan

e Serum glucose

6

15 Regarding the use of ventricular assist devices (VADs) for the management of acute and chronic heart failure:

a Ventricular assist devices can be used for a maximum of 3-4 weeks

b A short-term left ventricular assist device takes blood from the rightatrium and injects it into the main pulmonary artery

c Most modern ventricular assist devices produce a pulsatile flow

d The insertion of an LVAD worsens aortic regurgitation

e All patients with VADs must be anticoagulated

16 Regarding diagnostic lumbar puncture (LP):

a Meningitis is a relatively rare complication of LP

b Suspected bacteraemia is a contraindication to LP

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

d LP is contraindicated in patients with a suspected spinal epiduralabscess

e It is recommended that LP is not performed in patients with plateletcounts of <100 x 109

b One risk of applying PEEP is a reduction in oxygen delivery (DO2).

c A decelerating flow pattern is seen in volume-controlled ventilation

d The difference between peak and plateau pressures is greaterwith volume-controlled ventilation than pressure-controlledventilation

e Dynamic compliance equals the tidal volume divided by (peakpressure minus total positive end-expiratory pressure)

19 The following are examples of severity scoring systems

in the intensive care unit:

a Acute Physiology and Chronic Health Evaluation III (APACHE III)

b CT Calcium Score

c Sequential Organ Failure Assessment (SOFA)

d Mortality Prediction Model (MPM)

e Glasgow-Blatchford Score

20 The following are examples of superiority randomised controlled trials (RCTs) relevant to critical care, whose results support the proposed null hypothesis:

c Therapeutic plasma exchange requires central venous access.

d Paraesthesia is a common complication

e Thrombosis is a common complication

22 In patients with, or at risk of, acute kidney injury (AKI), international consensus guidelines suggest the following:

a In critically ill patients, insulin therapy should target a plasmaglucose of about 6-8mmol/L

b Administration of colloid boluses to expand intravascular volume

c Parenteral nutrition should be used in preference to the enteralroute in patients with AKI

d N-acetyl cysteine (NAC) should not be used for the prevention ofpost-surgical AKI

e Low-dose dopamine has a role in the treatment of established AKI

23 With regard to the Medical Research Council-funded CRASH trials:

a The CRASH 1 trial examined the role of steroids in traumatic braininjury (TBI)

b The CRASH 2 trial assessed the role of tranexamic acid intraumatic brain injury (TBI) within a pilot sample

c The CRASH 3 trial is designed to assess the effectiveness oftranexamic acid in TBI within a multicentre cohort

b A high serum ketone level indicates more severe disease.

c DKA should be treated with a fixed rate insulin infusion

d When managing a patient with DKA, their usual insulin regimeshould be stopped but oral antidiabetic medication should becontinued

e DKA is deemed to have resolved when urinary ketones are nolonger detectable

25 The following apply to levosimendan:

a It impairs diastolic relaxation

b It is a sodium channel sensitiser

c It increases myocardial oxygen consumption

d It can be used with β-blockers

e No loading dose is required due to the very short half-life

26 With regard to thrombotic thrombocytopaenia purpura (TTP):

a Platelet transfusion is recommended to maintain a platelet count of

>10 x 109/L

in the mid-axillary line.

b A chest drain should be inserted in the 5th intercostal space, justanterior to the mid-axillary line

c Abdominal paracentesis can safely be performed 1cm below theumbilicus

d A central venous catheter inserted into the femoral vein will liemedial to the femoral nerve and lateral to the femoral artery

e Needle insertion for landmark-guided pericardiocentesis isimmediately below and to the right of the xiphisternum, between thexiphisternum and the right costal margin

28 A 67-year-old male has been mechanically ventilated for 2 weeks on the ICU He has had multiple courses of antibiotics for chest sepsis He develops profuse

diarrhoea over 2 days A diagnosis of Clostridium difficile infection is considered Regarding this

organism:

a Around 20% of all cases of antibiotic-associated diarrhoea are due

to Clostridium difficile

d Stool culture has a high specificity but low sensitivity for diagnosis.

e Asymptomatic carriage of C difficile among hospitalised patients islow

29 Regarding the acute management of a subarachnoid haemorrhage:

a The peak incidence of vasospasm occurs at day 4

b Use of intravenous magnesium to reduce the incidence ofvasospasm is supported by the MASH (Magnesium for AneurysmalSubarachnoid Haemorrhage) trials

c Hypervolaemia, hypertension and haemodilution therapy reducesthe incidence of vasospasm

d Mean arterial pressure (MAP) targets should be set to >90mmHgfollowing protection of the aneurysm

e Clipping and coiling are equally effective treatment options in terms

a An IABP is contraindicated in aortic stenosis.

b The IABP can be inserted via the femoral route

c The balloon inflates during systole

d Heliox is used to inflate the balloon

e An IABP improves cerebral and coronary perfusion

32 In a patient with acute severe tricyclic antidepressant poisoning:

a A dominant R-wave >3mm is often seen in lead aVR

b QRS prolongation is a useful prognostic feature and should beroutinely measured

c First-line treatment for acute dysrhythmia should include a 2-4gbolus of magnesium sulphate

d Intralipid®can be used as a rescue measure

e The pH should be normalised by intubation and hyperventilation

33 Regarding the physiology of the donor heart following cardiac transplantation:

a β-adrenergic blockers will have no effect on the heart rate

b The Valsalva manoeurvre will have no effect on heart rate

c Glyceryl trinitrate (GTN) will cause coronary vasodilatation

d The post-cardiac transplant patient can suffer anginal pain

e The heart rate will not increase during exercise unless apacemaker is fitted

a A precordial thump.

b Administration of emergency drugs via the endotracheal tube

c Intraosseous access as a route of drug delivery

d Administration of 1mg adrenaline after the third DC shock

e Amiodarone after the fourth DC shock

35 The following are recognised complications of therapeutic hypothermia:

a Mortality is directly proportional to time to intervention

b The most common type of necrotising fasciitis is caused by Group

A Streptococcus (Streptococcus pyogenes)

c Skin changes are a common early presentation of necrotisingfasciitis

d Surgical debridement must be performed as antibiotics are unable

to penetrate the infected necrotic tissue

e Clindamycin is first-line monotherapy

14

37 In a patient with suspected rhabdomyolysis:

a The absence of myoglobinuria excludes the diagnosis

b Administration of sodium bicarbonate and mannitol are themainstays of treatment

c Alkalinisation of the urine aims to increase the solubility of theTamm-Horsfall protein-myoglobin complex

d Bicarbonate should be titrated to a urinary pH >9

e Hypercalcaemia is frequently seen in the early stages

38 Regarding the prevention and grading of pressure ulcers in the critically ill:

a Pressure, shear and friction are all required for a pressure ulcer todevelop

b The Waterlow score is used to grade pressure ulcers

c All grade I pressure ulcers have intact skin

d The APACHE II score correlates well with the occurrence ofpressure ulcers

e Critically ill patients should be turned every 2-3 hours to prevent thedevelopment of pressure ulcers, if their clinical condition allows

39 A patient presents with a paracetamol overdose The following factors would increase the chances of severe hepatotoxicity:

a High body mass index

b Regular consumption of ethanol in excess of recommendedamounts

c Use of hepatic enzyme inhibitors

d Malnourishment

e St John’s Wort

a Dilated right ventricle on echocardiography.

b Systolic blood pressure <90mmHg

c Elevated troponin

d B-natriuretic peptide (BNP) level of <10pg/ml

e SpO2<94% on room air

42 Regarding the diagnosis of brainstem death:

a Fixed and dilated pupils must be present

b The absence of corneal reflex indicates no function in the midbrainregion

c The visual evoked responses must be demonstrated to be absent

d Motor response to a sternal rub excludes the diagnosis

e A cough reflex response to bronchial stimulation by a suctioncatheter placed down the trachea to the carina excludes thediagnosis

a Intravenous immunoglobulin.

b Steroid therapy

c Platelet transfusion

d Monoclonal antibody infusion

e Fresh frozen plasma

45 Regarding the ethical and legal aspects of organ donation after cardiac death and after brainstem death in the UK:

a Once the decision for organ donation in a brainstem dead patienthas been made, management should move from a ‘patient-focusedapproach’ to an ‘organ management approach’

b Regarding donation after cardiac death, it is ethically acceptable todelay the process of withdrawal in the donor until the donor process

is in place

c Verbal expression of a wish to donate organs expressed beforedeath is a valid form of consent for organ retrieval after death

a Size 5 uncuffed endotracheal tube.

b In the case of witnessed ventricular fibrillation, synchroniseddefibrillation at 64 Joules

c In a cardiac arrest, 160μg adrenaline, IO or IV

d Lorazepam 1.6mg/kg IV for the emergency treatment ofconvulsions

e Atropine 640μg for the emergency treatment of bradycardiasuspected to be due to vagal overactivity

47 In the diagnosis and management of venous thromboembolic disease:

a A ventilation-perfusion (V/Q) scan is a useful investigation ifpulmonary embolism (PE) is suspected

b A negative D-dimer in the context of low clinical probability reliablyexcludes PE

c The incidence of venous thromboembolism in critically ill patients isaround 65%

d Patients with a confirmed pulmonary embolism secondary to cancershould be anticoagulated with low-molecular-weight heparininjections for at least 6 months

e The Wells score can be used to guide further management andinvestigation

18

48 In a patient with suspected iron overdose:

a Abdominal X-ray is a useful investigation

b Activated charcoal should be offered if the patient presents within 1hour of overdose

c Endoscopic retrieval is recommended as a therapeutic option in theevent of a large overdose and early presentation

d Chelation therapy with desferrioxamine should be commencedimmediately for patients with systemic features of toxicity

e Early administration of intravenous proton pump inhibitors reducesthe incidence of gastric scarring

a Legionella should be routinely tested by sputum analysis

b This patient should be reviewed for critical care admission

19

c Oral antibiotics should be commenced immediately

d Steroids are not recommended

e If a pleural effusion has a pH of >7.2 on a diagnostic tap then formalchest drainage is indicated

51 The 2012 Berlin definition of ARDS includes the following components:

a Continuous positive airway pressure (CPAP) or positive expiratory pressure (PEEP) >5cm H2O

a Platelet transfusion is not routinely indicated for patients who arenot actively bleeding and are haemodynamically stable

b Platelet transfusion is indicated in patients who are actively bleedingand have a platelet count of less than 80 x 109/L

c Prothrombin complex concentrate should be given to patients whoare taking warfarin and are actively bleeding

d Fresh frozen plasma (FFP) should not be given unless the patient’sprothrombin time (international normalised ratio [INR]) or activatedpartial thromboplastin time is greater than 2.5 times normal

e Recombinant factor Vlla should be given early if available

20

53 With regard to traumatic brain injury (TBI), the following interventions are supported by the Brain Trauma Foundation guidelines:

a Urgent prehospital triage direct to neuroscience centres

b Therapeutic hypothermia for raised intracranial pressure refractory

to first-line treatments

c Hyperventilation to achieve hypocarbia

d Osmotherapy in the presence of progressive neurologicaldeterioration not attributable to extracranial causes

e ICP monitoring in all patients with a Glasgow Coma Scale (GCS)

c The Simplified Acute Physiology Score 2 (SAPS 2) score can becustomised to a geographical region

d An increase in the Sequential Organ Failure Assessment (SOFA)score during the first 48 hours in the ICU predicts a mortality rate

of at least 50%

e The Therapeutic Intervention Scoring System (TISS) assessesnursing workload

55 Regarding viral encephalitis:

a It is commonly caused by the mumps virus

b The disease usually affects the parietal lobes

c CT of the brain is a useful investigation in suspected cases

d Herpes simplex encephalitis has a mortality rate of up to 70% ifuntreated

e Stress ulcer prophylaxis.

57 The following are principles regarding patient confidentiality and the management of confidential information in the UK:

a Once an adult has died, their next of kin has the right to full access

of the patient’s medical records

b When a patient suffering from a genetically heritable disease hasrefused consent to disclosure, it is illegal to inform their next of kin

c Permission from the next of kin authorises disclosure of a patient’sconfidential medical records after their death

d Caldicott Guardians can authorise a treatment when the patient hasrefused to consent

e All NHS institutions must appoint a Caldicott Guardian

58 The following are considered risk factors for aneurysmal subarachnoid haemorrhage:

22

59 When considering the diagnosis of associated pneumonia (VAP) in a mechanically ventilated patient:

ventilator-a A CPIS score >6 has poor specificity for the diagnosis of VAP

b A VAP is defined as a hospital-acquired pneumonia occurring at anytime point in a mechanically ventilated patient

c Ventilator care bundles may include the use of a volume pressure tapered cuff

low-d Use of endotracheal tubes with subglottic suction have level Ievidence showing a reduced incidence of VAP

e Late VAP (>5 days) is most commonly caused by streptococcal orstaphylococcal organisms

60 Regarding the principles of medical ethics and consent:

a Respect for a patient’s autonomy means that an operation cannot

be performed if a patient who has capacity refuses, even if it isdeemed in the patient’s best interest by the medical team

b Oral consent is explicit consent

c Non-maleficence retains primacy over autonomy as shown by bloodand marrow donation

d In order to obtain informed consent the patient must be informed ofall conceivable risks and benefits of the treatment

e Consent is needed from the next of kin to perform a procedure on

an adult patient who lacks capacity

in his lower limbs He is ataxic, tachypnoeic and has double vision He has a normal computed tomography (CT) of the brain The next most appropriate test from the list below would be:

a High gastric residual volumes should prompt prescription of a 7-dayprokinetic regimen, following exclusion of obstructive causes

b Intravenous propofol infusion provides a significant proportion ofdaily calorie intake

c The Malnutrition Universal Screening Tool (MUST) is the goldstandard for identifying malnourished patients

d Early parenteral nutrition should be commenced in patients whocannot meet calorific targets by enteral nutrition alone

e Early provision of glutamine antioxidant supplements for critically illpatients improves outcome