SBAq for final FFICM

Cambridge University Press978-1-107-54930-2 — Single Best Answer Questions for the Final FFICM Keith Davies , Christopher Gough , Emma King , Benjamin Plumb , Benjamin Walton Frontmatte

Cambridge University Press

978-1-107-54930-2 — Single Best Answer Questions for the Final FFICM

Keith Davies , Christopher Gough , Emma King , Benjamin Plumb , Benjamin Walton

Frontmatter

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Single Best Answer Questions

for the Final FFICM

Cambridge University Press

978-1-107-54930-2 — Single Best Answer Questions for the Final FFICM

Keith Davies , Christopher Gough , Emma King , Benjamin Plumb , Benjamin Walton

Frontmatter

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Cambridge University Press

978-1-107-54930-2 — Single Best Answer Questions for the Final FFICM

Keith Davies , Christopher Gough , Emma King , Benjamin Plumb , Benjamin Walton

Frontmatter

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Single Best Answer Questions

for the Final FFICM

Cambridge University Press

978-1-107-54930-2 — Single Best Answer Questions for the Final FFICM

Keith Davies , Christopher Gough , Emma King , Benjamin Plumb , Benjamin Walton

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Davies, Keith (Specialist in intensive care medicine), author

Gough, Christopher, author King, Emma, 1980–, author

Plumb, Benjamin, author Walton, Benjamin, author

Single best answer questions for the final FFICM / Keith Davies, Christopher Gough,

Emma King, Benjamin Plumb, Benjamin Walton

Cambridge, United Kingdom ; New York : Cambridge University Press, 2016

Includes bibliographical references and index

LCCN 2015048884 ISBN 9781107549302 (hardback : alk paper)

MESH: Critical Care Great Britain Examination Questions

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Cambridge University Press

978-1-107-54930-2 — Single Best Answer Questions for the Final FFICM

Keith Davies , Christopher Gough , Emma King , Benjamin Plumb , Benjamin Walton

Cambridge University Press

978-1-107-54930-2 — Single Best Answer Questions for the Final FFICM

Keith Davies , Christopher Gough , Emma King , Benjamin Plumb , Benjamin Walton

Frontmatter

More Information

Cambridge University Press

978-1-107-54930-2 — Single Best Answer Questions for the Final FFICM

Keith Davies , Christopher Gough , Emma King , Benjamin Plumb , Benjamin Walton

prac-The Faculty of Intensive Care Medicine (FICM) oversees the training and tration of intensive care doctors in the United Kingdom To attain a Certificate ofCompleted Training (CCT) in Intensive Care Medicine (ICM), doctors must achievefellowship of the FICM by passing the final examination (FFICM)

regis-The final FFICM has three sections: a multiple-choice written examination (MCQ),

a structured oral examination (SOE) and an objective structured oral examination(OSCE) To be eligible to sit the oral sections of the examination, candidates must firstpass the MCQ

The MCQ is now made up of two types of question: 60 multiple true/false (MTF)

questions and 30 SBA questions The companion publication to this volume (Multiple

True False Questions for the Final FFICM, Cambridge University Press, 2015) has 270

example MTF questions with fully referenced explanations for practice and revision.This volume complements the original by providing practice and revision for the SBAquestions

This volume contains eight practice SBA examinations with 30 questions each, lowed by an expanded answer SBAs comprise a brief clinical case history followed

fol-by a question, often concerning the most likely diagnosis or best treatment The tion is followed by five answer stems, each of which could plausibly be correct Thecandidate must then select the single best answer for the question The answer sec-tions contain the correct answer, a short explanation of why the answer is the best ofthe five on offer and a long explanation which covers the topic of the original ques-tion and includes references for further reading This structure allows candidates tochoose whether to use this book as quick practice or fuller revision

ques-vii

Single best answer (SBA) questions can be notoriously difficult to answer, and tice is essential SBAs contain more grey areas than true/false questions, which givesthem greater discrimination power, but makes them more demanding With 240 prac-tice questions, this book will help with both SBA examination practice and revisionacross the whole range of topics demanded by the FFICM

prac-The Faculty of Intensive Care Medicine (FICM) oversees the training and tration of intensive care doctors in the United Kingdom To attain a Certificate ofCompleted Training (CCT) in Intensive Care Medicine (ICM), doctors must achievefellowship of the FICM by passing the final examination (FFICM)

regis-The final FFICM has three sections: a multiple-choice written examination (MCQ),

a structured oral examination (SOE) and an objective structured oral examination(OSCE) To be eligible to sit the oral sections of the examination, candidates must firstpass the MCQ

The MCQ is now made up of two types of question: 60 multiple true/false (MTF)

questions and 30 SBA questions The companion publication to this volume (Multiple

True False Questions for the Final FFICM, Cambridge University Press, 2015) has 270

example MTF questions with fully referenced explanations for practice and revision.This volume complements the original by providing practice and revision for the SBAquestions

This volume contains eight practice SBA examinations with 30 questions each, lowed by an expanded answer SBAs comprise a brief clinical case history followed

fol-by a question, often concerning the most likely diagnosis or best treatment The tion is followed by five answer stems, each of which could plausibly be correct Thecandidate must then select the single best answer for the question The answer sec-tions contain the correct answer, a short explanation of why the answer is the best ofthe five on offer and a long explanation which covers the topic of the original ques-tion and includes references for further reading This structure allows candidates tochoose whether to use this book as quick practice or fuller revision

ques-vii

Exam A: Questions

A1. A trauma patient is brought into the resuscitation room with an obviouslyunstable pelvis Despite ongoing fluid resuscitation with blood products the patientremains haemodynamically unstable, has a profound metabolic acidosis and contin-ues to deteriorate Focused assessment with sonography in trauma (FAST) scan ispositive

Which of the following is MOST important in the management of this patient’sbleeding?

A Administration of tranexamic acid

B 1:1:1 rather than 1:1:2 transfusion ratio for plasma:platelets:blood

C Treatment with interventional radiology

D Urgent damage control surgery

E Maintaining normothermia and ionized calcium levels>0.9 mmol/l

A2. A patient has been admitted to the intensive care unit (ICU) with severe sepsisand urgently requires a central venous catheter (CVC) You decide to insert the CVCinto the right internal jugular vein (IJV)

Which of the following approaches to central line insertion is the best?

A Landmark approach; lateral to the carotid artery pulsation

B Audio-guided Doppler ultrasound guidance in the head-up position

C Landmark approach; medial to the carotid artery pulsation

D Audio-guided Doppler ultrasound guidance in the head-down position

E Two-dimensional (2D) ultrasound guidance

A3. Of the following pathologies, which is the commonest cause for end-stage renalfailure in the United Kingdom?

A Hypertension

B Polycystic kidney disease

C Vasculitis

D Renal artery stenosis

E Immunoglobulin A (IgA) nephropathy

1

A Large gas bubble in the stomach

B Gas in the small bowel

C Gas in the small bowel and fluid levels at the same height within loops

D Gas in the large bowel

E Gas in the small bowel and rectum only

A6. You are about to intubate a patient with a life-threatening exacerbation ofasthma

Which of the following agents is MOST likely to improve lung mechanics andbronchospasm?

A Inferior mesenteric artery, superior rectal artery, rectal veins

B Coeliac trunk, left gastro-omental artery, splenic vein

C Right gastric artery, short gastric vein, splenic vein

D Superior mesenteric artery, right colic vein, inferior mesenteric vein

E Coeliac trunk, gastroduodenal artery, epigastric vein

A8. A patient is undergoing chemotherapy for acute leukaemia, is neutropenicand has a persistent temperature and cough despite treatment with broad-spectrumantibiotics A computed tomography scan of the thorax reveals pulmonary noduleswith surrounding halos of ground-glass opacity (‘halo sign’) Antigen testing on bron-

choalveolar lavage samples suggests a diagnosis of Aspergillus.

Which of the following would be the BEST treatment for this patient?

A9. A male patient with jaundice has the following blood results:

Aspartate transaminase (AST) 450 IU (<35 IU)

P wave then 220 ms pause before a narrow QRS complex

Which of the following is most likely to describe this situation?

A VVI pacing

B AOO pacing with first-degree heart block

C DDD pacing with the AV delay set at 200 ms

D VOO pacing with retrograde atrial contraction

E AAI pacing with underlying fast atrial fibrillation

A11. Which of the following is the LEAST invasive method of calculating cardiacoutput?

A Lithium dilution, e.g LiDCO

B Thermodilution, e.g PiCCO

C Indirect Fick method

D Oesophageal Doppler

E Volume clamp (Penaz method), e.g Finapress

A12. A 54-year-old man with no previous medical history is admitted with ness of breath and pleuritic chest pain 4 days after a 16-hour flight A computedtomography (CT) scan has demonstrated bilateral pulmonary emboli, and echocar-diography has revealed right heart dysfunction His heart rate is 112 bpm, bloodpressure is 104/52 and oxygen saturations are 94% on 50% inspired O2

short-Which would be the MOST appropriate treatment?

A Anticoagulate with low molecular weight heparin (LMWH)

B Anticoagulate with vitamin K antagonists

C Thrombolyze using alteplase

D Anticoagulate with unfractionated heparin infusion (UFH)

E Anticoagulate with dabigatran

3

right-Which of the following is the most likely diagnosis?

A Transient ischaemic attack (TIA)

B Partial anterior circulation syndrome (PACS)

C Carotid artery dissection

D Total anterior circulation syndrome (TACS)

E Malignant middle cerebral artery infarct

A14. A 54-year-old patient is ventilated with pneumonia He has plateau and peakend expiratory pressures of 28 and 12 cmH2O respectively His O2saturation are 92%with an FiO2of 0.4 and arterial blood gas findings are as follows: pH 7.26, PaO28.2kPa, PaCO2 7.6 kPa An echocardiography reveals an ejection fraction of 44% andpulmonary arterial pressure of 55 mmHg

What is the MOST likely cause of this patient’s pulmonary hypertension (PH)?

A Hypoxia and hypercapnia

B Chronic pulmonary hypertension

C Acute left ventricular dysfunction

D An acute pulmonary embolism

B A shocked trauma patient with massive blood loss unresponsive to crystalloids

C Hb<70 g/l in a stable patient admitted with an acute upper gastrointestinal

bleed

D Hb<70 g/l in a patient with septic shock on vasopressin and noradrenaline

E Hb<100 g/l in a patient in the intensive care unit with a history of

cardiovascular disease

4

Which of the following is LEAST true regarding this condition?

A Complete correction of electrolyte derangements with fluids, filtration and

electrolyte replacement should occur

B It occurs with increased frequency in those patients with bulky, rapidly

A17. A 74-year-old patient with Clostridium difficile diarrhoea, has a white cell count

(WCC) of 18× 109/l, a temperature of 39°C and evidence of ileus

Which of the following is the BEST treatment regimen?

fol-Which of the following criteria contribute most to his Murray score for ECMOreferral?

A PaO2/FiO2ratio of 25 kPa

B PEEP of 8 cmH2O

C Compliance of 38 ml/cmH2O

D Half of the chest X-ray showing infiltrates

E Uncompensated hypercapnia with a pH<7.2

5

Which of the following is most appropriate statement?

A Intubation is likely to be difficult; therefore, non-invasive ventilation should betrialled first

B Senior help should be called if there is difficulty in intubating after four

E Cricoid pressure may be reduced if there is difficulty intubating

A20. A 73-year-old man is admitted to hospital with shortness of breath and cough

He has a medical history of hypertension and asthma, for which he takes ramipril and

a salbutamol inhaler, respectively He has smoked 20 cigarettes per day since cence and drinks 15 to 20 units of alcohol per week He has moderate respiratorydistress with a respiratory rate of 28, oxygen saturations of 91% in air, a heart rate

adoles-of 105 bpm and blood pressure adoles-of 155/95 An arterial blood gas (ABG) is performedwith the following results:

D Chronic obstructive pulmonary disease

E Side effect of ramipril

A21. Which of the following complications is most frequently seen after pulmonaryartery catheter (PAC) insertion via the internal jugular vein?

A Carotid artery puncture

B An arrhythmia requiring treatment

C Bacterial colonization

D Pulmonary infarction

E Pulmonary artery rupture

A22. You have a patient requiring an urgent fresh frozen plasma (FFP) transfusion.Which of the following combinations is MOST appropriate?

A A patient with blood group AB receiving FFP grouped A

B A patient with blood group A receiving FFP grouped B

C A patient with blood group B receiving FFP grouped O

D A patient with blood group A receiving FFP grouped AB

E A patient with blood group AB receiving FFP grouped O

6

A Hypoxaemia 3 days after a large myocardial infarction Transthoracic

echocardiogram shows moderate left ventricular impairment with akinesis of

the apex PaO2/FiO2ratio is 35 kPa

B Hypoxaemia 5 days after a severe bronchopneumonia Chest X-ray shows

collapse of the left lower lobe PaO2/FiO2ratio is 30 kPa

C Hypoxaemia 2 days after a gastrointestinal (GI) bleed requiring transfusion of

one circulating volume Chest X-ray shows diffuse patchy infiltrates PaO2/FiO2

ratio is 45 kPa

D Hypoxaemia 4 days after an episode of pancreatitis with a Glasgow score of 4

Chest X-Ray shows diffuse patchy infiltrates PaO2/FiO2ratio is 30 kPa

E Hypoxaemia 5 days after coronary artery bypass graft surgery A pulmonary

artery catheter shows a pulmonary capillary wedge pressure of 25 mmHg

Computed tomography scan shows pulmonary infiltrates PaO2/FiO2ratio is

25 kPa

A26. You are asked to review a patient with known pancreatic cancer in the gency department He has hypotension and dehydration as a result of prolongedvomiting You are concerned that he has gastric outflow obstruction

emer-Which of the following sets of biochemical results would best fit with gastric flow obstruction?

B 7.37 12.0 kPa 4.1 kPa 22 mmol/l 166 mmol/l 3.7 mmol/l 131 mmol/l

C 7.29 12.8 kPa 3.3 kPa 16 mmol/l 134 mmol/l 2.1 mmol/l 113 mmol/l

E 7.54 10.4 kPa 6.1 kPa 46 mmol/l 127 mmol/l 2.7 mmol/l 128 mmol/l

7

What antibiotic regimen is the most appropriate?

A Tazobactam/piperacillin

B Ceftriaxone

C Tazobactam/piperacillin and gentamicin

D Ceftriaxone and gentamicin

E Ceftriaxone, vancomycin and gentamicin

A29. A 64-year-old man was admitted 6 hours ago to hospital with severe chestpain and shortness of breath You are called to see him as his blood pressure hasfallen over the past hour He is drowsy, diaphoretic, cold to the touch and haswidespread crackles on auscultation of his lung fields His 12-lead electrocardiogram(ECG) shows a large ST-elevation myocardial infarction (STEMI) His vital signs are

as follows: heart rate 95/min; blood pressure 80/48; respiratory rate 32/min; SpO2

92% on 10 l oxygen He has a venous lactate level of 6.3 mmol/l

You diagnose cardiogenic shock Which intervention has the strongest evidence ofbenefit?

A Intra-aortic balloon pump (IABP)

B Dobutamine

C Left ventricular assist device (LVAD)

D Revascularization therapy

E Levosimendan

A30. You are asked to review a patient suffering an acute exacerbation of asthma

in the emergency department, with all of the following signs present Which of thesigns gives the greatest cause for concern?

A Respiratory rate: 32

B PaCO2: 4.9 kPa

C Peak expiratory flow (PEF): 38% of predicted

D Inability to complete sentences in one breath

E Chest X-ray showing bibasal consolidation

8

Exam A: Answers

A1. A trauma patient is brought into the resuscitation room with an obviouslyunstable pelvis Despite ongoing fluid resuscitation with blood products the patientremains haemodynamically unstable, has profound metabolic acidosis and continues

to deteriorate Focused assessment with sonography in trauma (FAST) scan is tive

posi-Which of the following is MOST important in the management of this patient’sbleeding?

A Administration of tranexamic acid

B 1:1:1 rather than 1:1:2 transfusion ratio for plasma:platelets:blood

C Treatment with interventional radiology

D Urgent damage control surgery

E Maintaining normothermia and ionized calcium levels>0.9 mmol/l

Answer: D

Short explanation

Tranexamic acid administration, maintaining normothermia and ionized calcium els are important; however, they will not stop this patient’s massive ongoing bleed-ing The patient is deteriorating despite ongoing resuscitation with blood products,

lev-so control of bleeding is imperative This patient is haemodynamically unstable andacidotic, and his or her FAST scan is positive; immediate damage control surgery isrecommended in preference to interventional radiology

Long explanation

Patients presenting with haemorrhagic shock should be treated with rapid tion of the cause and source control in conjunction with fluid resuscitation with bloodproducts Initial fluid resuscitation should be commenced with crystalloids and earlyuse of blood products to target a systolic blood pressure of 80 to 90 mmHg until thebleeding has been controlled The blood pressure should be higher in the context of atraumatic brain injury

identifica-The Pragmatic, Randomized Optimal Platelet and Plasma Ratios (PROPPR) trialdemonstrated a significant decrease in the rate of exsanguination for those whoreceived blood products in a 1:1:1 rather than a 1:1:2 plasma:platelet:red blood cellratio Despite a trend to lower mortality seen in the 1:1:1 treatment arm, there was nosignificant decrease in mortality at 24 hours or 30 days Fibrinogen replacement with 9

Measures to maintain normothermia and ionized calcium levels>0.9 mmol/l are

required to minimize the coagulopathy that can occur with massive blood sions and the coagulopathy of trauma Trauma patients who are bleeding or who are

transfu-at risk of significant haemorrhage should receive tranexamic acid as soon as possible,either in the pre-hospital environment or starting in the emergency department.Rapid control of the source of the haemorrhage is crucial Tourniquets can be usedpreoperatively as an interim measure to stop arterial bleeding in life-threateningextremity injuries Interventional radiology or surgical intervention can be used tomanage patients with pelvic or intra-abdominal bleeding Patients with suspectedpelvic fractures should have a pelvic binder applied immediately to reduce anyongoing bleeding Treatment for pelvic fractures in patients who are haemodynam-ically unstable includes external fixation, preperitoneal pelvic packing and inter-ventional radiology Patients should have an initial FAST scan in the resuscitationroom If this is positive, surgical treatment with laparotomy and packing is recom-mended in preference to angiography Resuscitative endovascular balloon occlusion

of the aorta (REBOA) has been used as an emergency interim measure for unstablepatients

Damage control in preference to definitive surgery is recommended for thosepatients with severe haemorrhage shock and ongoing bleeding This is particularlythe case in those who are hypothermic (34˚C), acidotic (pH 7.2) or coagulopathic

or patients who have inaccessible major venous injury or require time-consumingprocedures

References

Holcomb JB, Tilley BC, Baraniuk S, et al Transfusion of plasma, platelets, and redblood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma:

the PROPPR randomized clinical trial JAMA 2015;313(5):471–482.

Magnone S, Coccolini F, Manfredi R, et al Management of hemodynamically

unsta-ble pelvic trauma: results of the first Italian consensus conference World J Emerg

Surg 2014;9(1):18.

Spahn DR, Bouillon B, Cerny V, et al Management of bleeding and coagulopathy

fol-lowing major trauma: an updated European guideline Crit Care 2013;17(2):R76.

A2. A patient has been admitted to the intensive care unit (ICU) with severe sepsisand urgently requires a central venous catheter (CVC) You decide to insert the CVCinto the right internal jugular vein (IJV)

Which of the following approaches to central line insertion is the best?

A Landmark approach; lateral to the carotid artery pulsation

B Audio-guided Doppler ultrasound guidance in the head-up position

C Landmark approach; medial to the carotid artery pulsation

D Audio-guided Doppler ultrasound guidance in the head-down position

E Two-dimensional (2D) ultrasound guidance

Answer: E

Short explanation

The National Institute for Health and Care Excellence (NICE) guidance recommendsthe use of 2D ultrasound imaging for CVC insertion into the IJV in all elective situ-ations, and it should be considered in all clinical scenarios including emergency situ-ations Audio-guided Doppler ultrasound is not recommended for CVC insertion

10

The 2D ultrasound findings that assist differentiation of the vein from the arteryinclude:

1 Wall thickness – thicker in the artery

2 Compressibility – vein is more compressible because of the lower pressure in thevein However, in extremely hypotensive states, the difference is less pronounced,and extra care should be taken

3 Pulsatility – arterial flow is more pulsatile

4 Colour-wave Doppler – arterial flow is more pulsatile

Venous flow can also be pulsatile, and arteries can also be compressed, so the ceding findings are to assist differentiation rather than being absolute

pre-The landmark technique can still be used in an emergency situation and involvespassing the needle along the expected path of the vein, with reference to surface land-marks This technique is associated with a higher incidence of complications, such asarterial puncture and pneumothorax The use of ultrasound guidance is preferred inall clinical situations, so long as there is no inappropriate delay to line placement

References

The American Institute for Ultrasound in Medicine (AIUM) AIUM Practice Guidelines

for the Use of Ultrasound to Guide Vascular Access Procedures Laurel, MD: AIUM,

April 2012

National Institute for Health and Care Excellence (NICE) Guidance on the use of

ultrasound locating devices for placing central venous catheters (Technology

Appraisal Guidance 49) London: NICE, 2002

A3. Of the following pathologies, which is the commonest cause for end-stage renalfailure in the United Kingdom?

A Hypertension

B Polycystic kidney disease

C Vasculitis

D Renal artery stenosis

E Immunoglobulin A (IgA) nephropathy

Answer: A

Short explanation

The commonest causes of chronic kidney disease that lead to end-stage renal failure

in the United Kingdom are the following:

r Diabetes (20–40%)

r Hypertension (5–25%)

r Glomerular disease which includes IgA nephropathy (10–20%), idiopathic

(5–20%), interstitial disease (5–15%)

r Rarer causes such as polycystic kidney disease, renal artery stenosis and

CKD is almost always a progressive condition, although only 1% of patients withCKD will reach end-stage renal failure However, the cost and morbidity burden ofthose who do places a huge requirement on resources It is important to detect andrefer CKD patients early because delays lead to poorer outcomes Patients with CKDwho present to hospital are at an increased risk of developing AKI, which will likelylead to a long-term decline in renal function and worse outcomes than those patientswithout CKD.

Filtration is not the sole function of the kidney However, estimated glomerularfiltration rate (eGFR) is the best measure of overall kidney function and thereforepresence of CKD An eGFR<60 mL/min/1.73 m2 is associated with a poorer out-come than that in patients with CKD and a higher eGFR It is important to considerother markers of kidney function when managing a patient with AKI or CKD, includ-ing albuminuria levels, proteinuria, structural abnormalities on imaging, electrolytebalance, blood pressure and histological changes seen on biopsy

CKD prognosis and risk can be estimated on the basis of staging using eGFR andalbuminuria eGFR stages (mL/min/1.73 m2) include the following: Grade 1 (>90),

Grade 2 (60–89), Grade 3a (45–59), Grade 3b (30–44), Grade 4 (15–29) and Grade 5(<15) Staging based on albuminuria (mg/g) ranges from: A1 (<30), A2 (30–300) and

A3 (>300).

The causes of CKD are increasing in incidence in the United Kingdom and areassociated with other co-morbidities such as heart disease and stroke, which makeCKD patients more likely to present to health services Similarly, the presence of CKDcomplicates the treatment of other co-morbidities and of ICU care, often limiting drugchoices or doses and requiring increased monitoring and care with electrolytes, nutri-tion and fluid balance

References

Goddard J, Turner AN, Cumming AD, Stewart LH Kidney and urinary tract

dis-ease In Boon NA, Colledge NR, Walker BR, Hunter JAA Davidson’s Principles

and Practice of Medicine 20th edition Edinburgh: Churchill Livingstone Elsevier,

2006: p 486

Kidney Disease: Improving Global Outcomes KDIGO 2012 clinical practice guideline

for the evaluation and management of chronic kidney disease Kidney Int Suppl.

effi-Long explanation

Failure to humidify gases delivered to a patient via a ventilator will lead to drying ofthe patient’s airways and the build-up of thick secretions, inflammation and potentialinfection Delivery of humidified gas is also an important method of reducing heatloss from the patient

Absolute humidity is measured in g/m3and is the mass of water vapour in a unit

of gas, which will vary with temperature Relative humidity is the amount of watervapour present, as a percentage of the maximum achievable at the temperature andpressure in question

HMEs use a hygroscopic material to capture exhaled water vapour as expiredgas cools and passes through the filter As cold inspired gas then passes back to thepatient, it is warmed and also picks up water from the filter material This methodbecomes inefficient with time but also provides a bacterial barrier between the patientand ventilator

Hot-water baths and the cascade humidifier are commonly used in ICUs becausethey provide a good level of humidification in a relatively efficient way There arerisks of thermal injury to the patient if the water is heated to too high a temperature;therefore, these systems often have thermostats and alarms in place

Nebulizers are not commonly used for humidification because they can lead tofluid overload and produce such small droplet sizes that water vapour deposits in thealveoli but not the upper airways For this reason, they are better used for medicationdelivery

A Large gas bubble in the stomach

B Gas in the small bowel

C Gas in the small bowel and fluid levels at the same height within loops

D Gas in the large bowel

E Gas in the small bowel and rectum only

Answer: E

Short explanation

A large gastric bubble is rarely concerning, often originating from nasogastric feeding

or air swallowing Gas in the small or large bowel is a normal finding, so long as thebowel is of a normal calibre Gas with fluid levels can also be normal, suggesting anileus but not necessarily obstruction An absence of gas throughout the large bowelwith gas only seen in the rectum is abnormal and highly suggestive of a mechanicallarge bowel obstruction

13

Large bowel obstruction may be worsened by a competent ileocaecal valve, as gasand fluid pressures build up and are not able to release back into the small bowel Thepresence of dilated loops leads to large fluid shifts, ischaemia, bowel oedema, venousobstruction, electrolyte disturbances, perforation, sepsis and, if not treated, death.Imaging may include an erect chest X-ray to look for free gas under the diaphragm.Classically, a contrast abdominal X-ray was performed, although computed tomog-raphy (CT) scans have largely replaced the need for this CT should be performedwith oral and intravenous contrast to demonstrate complete from partial obstruction.Water-soluble contrast is preferred because of the risks of peritoneal contaminationdue to bowel perforation.

Treatment is usually surgical Pseudo-obstruction may be managed conservativelyprovided there is a low threshold of suspicion for perforation Initial resuscitationmeasures should include a nasogastric tube on free drainage, fluid and electrolytereplacement and broad-spectrum antibiotics Volvulus and strictures may be decom-pressed or stented and further investigated with colonoscopy Those with divertic-ulitis or a malignant obstruction require surgery Intussusception is a more commoncause of obstruction in children than in adults The bowel ‘telescopes’ in on itself,often with a polyp or lesion at the centre This may be amenable to gas insufflation toreduce the intussusception or may require surgical intervention

References

Kahi CJ, Rex DK Bowel obstruction and pseudo-obstruction Gastroenterol Clin North

Am 2003;32(4):1229–1247.

Marini JJ, Wheeler AP Critical Care Medicine: The essentials 4th edition Philadelphia:

Lippincott, Williams & Wilkins, 2009, p 226

A6. You are about to intubate a patient with a life-threatening exacerbation ofasthma

Which of the following agents is MOST likely to improve lung mechanics andbronchospasm?

Long explanation

The classical rapid sequence induction (RSI) uses just two drugs: thiopentone andsuxamethonium There are often clinical scenarios in which this combination should

14

be altered, due to either detrimental effects of these agents (e.g suxamethonium in

a patient with a high potassium) or the presence of alternative agents that may havemore benefit (e.g propofol for laryngeal relaxation)

Muscle relaxants do not terminate bronchoconstriction The majority of them cancause significant histamine release, particularly suxamethonium and the benzyliso-quinoliniums such as atracurium, which in turn can cause hypotension and bron-chospasm The muscle relaxant that has the least histamine release associated with itsuse is vecuronium

With regard to the intravenous induction agents, propofol, thiopentone andketamine are in widest use in day-to-day practice Propofol, which is presented as alipid-water emulsion, causes rapid induction of anaesthesia and suppression of laryn-geal reflexes to a greater extent than thiopentone It has no effect on bronchospasm.Thiopentone, which is a thiobarbiturate induction agent, also causes rapid induction

of anaesthesia It causes less suppression of the laryngeal reflexes and can cause bothlaryngospasm and bronchospasm Ketamine, a phencyclidine derivative, has littleeffect on the laryngeal reflexes, and a patent airway can potentially be maintained.There is an increase in the production of secretions, and these can trigger the pre-served reflexes and cause laryngospasm Conversely, it reliably causes bronchodila-tion, and is therefore of benefit patients with asthma

Opioids are often given as part of a modified RSI, to suppress the laryngealresponse to intubation All opioids cause respiratory depression Brain-stem sensi-tivity to carbon dioxide is reduced, but its response to hypoxia is largely retained Ifopioids are given inappropriately early as part of a modified RSI and preoxygenation

is initiated, the hypoxic stimulus will fail to be triggered, and carbon dioxide els can rise dangerously Similarly to the muscle relaxants, histamine release is wellrecognized, especially from rapid administration For both classes of drug, slower ormore dilute injection will reduce the histamine-related side effects

lev-References

Smith T Chapter 6: Hypnotics and intravenous anaesthetic agents In Smith T,

Pin-nock C, Lin T Fundamentals of Anaesthesia 3rd edition Cambridge: Cambridge

University Press, 2009, pp 569–584

Chapter 8: General anaesthetic agents, Chapter 9: Analgesics, and Chapter 11: Musclerelaxants and anticholinesterases, in Section 2: Core drugs in anaesthetic practice

In Peck T, Hill S, Williams M Pharmacology for Anaesthesia and Intensive Care 3rd

edition Cambridge: Cambridge University Press, 2008

A7. In a normal adult patient, a red blood cell travelling from the aorta to the portalvein is most likely to pass through which structures?

A Inferior mesenteric artery, superior rectal artery, rectal veins

B Coeliac trunk, left gastro-omental artery, splenic vein

C Right gastric artery, short gastric vein, splenic vein

D Superior mesenteric artery, right colic vein, inferior mesenteric vein

E Coeliac trunk, gastroduodenal artery, epigastric vein

Answer: B

Short explanation

The rectal and epigastric veins drain into the inferior vena cava and are two of thecollateral connections between the portal and systemic circulations The right gastricartery supplies the right and inferior portions of the stomach, whereas the short gas-tric vein drains the superior and left-sided portions The right colic together with the

15

as ischaemic gut followed by perforation and peritonitis Ischaemic colitis carrieshigh morbidity and mortality and requires urgent intervention to restore the bloodsupply.

r The celiac trunk arises at approximately T12, immediately after the aorta emerges

from the diaphragm It divides into the left gastric, common hepatic and splenicarteries, which in turn supply the lesser curvature of the stomach, the liver, thegallbladder and the duodenum and spleen, pancreas and greater curvature of thestomach

r The superior mesenteric artery supplies the portion of the gut derived from the

embryological mid-gut including the distal duodenum, jejunum, ileum,

ascending colon and proximal portions of the transverse colon The blood supplyruns through the mesentry in connected loops forming ‘arcades’, which in turngive rise to the vasa recta

r The inferior mesenteric artery supplies the distal portions of the gut derived from

the hind-gut It branches into the left colic, sigmoid and rectal arteries Theterritory of the left colic crosses with that of the marginal artery supplied by thesuperior mesenteric artery as it supplies the portion of the colon at the splenicflexure

The venous drainage of the gut is predominantly into the portal vein, taking ent rich blood to the liver This system forms key collaterals with the systemic venousnetwork at four points: the oesophageal veins, the rectal veins, the paraumbilical (por-tal) veins and a few small twigs connecting the colic and retroperitoneal veins Thesesites become important in cases of raised portal venous pressure either due to throm-bus or hepatic fibrosis, most commonly due to alcoholic cirrhosis

nutri-In health, the main portal vein forms from the mesenteric plexus analogous to theterritory of the superior mesenteric artery (i.e the ileal, jejunal and right and middlecolic veins) The territory of the inferior mesenteric artery is drained via the superiorrectal, sigmoidal and left colic veins into the inferior mesenteric vein This drains viathe splenic vein into the portal vein The left and right gastric veins drain directlyinto the portal vein, along with the cystic, pancreatoduodenal and gastro-omental(gastro-epiploic) veins

Reference

Moore KL, Agur AMR, Dalley AF Essential Clinical Anatomy 5th edition Baltimore,

MD: Lippincott Williams & Wilkins, 2014

16

choalveolar lavage samples suggest a diagnosis of Aspergillus.

Which of the following would be the BEST treatment for this patient?

This patient has invasive aspergillosis All of the medications listed are antifungals,

but fluconazole and flucytosine are not used to treat invasive Aspergillus disease.

Although amphotericin B has activity against aspergillosis, liposomal amphotericin

B is used in preference to deoxycholate preparations because of its improved ity and side effect profile Voriconazole is recommended as first-line treatment, andposaconazole has been recommended as salvage treatment or is appropriate to beused as prophylaxis for at-risk patients

activ-Long explanation

Invasive aspergillosis occurs commonly in immunocompromised patients, such

as those with neutropenia, post-transplant immunosuppression or active acquiredimmune deficiency syndrome Pre-existing lung disease and medical co-morbidities,including critical illness, are also risk factors The commonest feature is persistentfever Cough, dyspnoea and haemoptysis can occur with pulmonary involvement(the commonest site of infection), and neurological signs and seizures may occur withneurological involvement The classical ‘halo sign’ seen on chest computed tomogra-phy is a nodule surrounded by ground-glass opacification

There are a number of different classes of antifungals with differing mechanisms

of action and activity against different fungi:

r Drugs that attack the cell membrane:

r Aspergillosis

b First-line treatment should be voriconazole; if contraindicated, liposomal

amphotericin should be used

b Alternative treatments such as Caspofungin, itraconazole and posaconazole

can be used as salvage treatments

r Invasive candidiasis:

b An echinocandin is the first choice; however, in uncomplicated Candida

albicans infections and in patients with no recent azole exposure, fluconazole

can be used as an alternative first line treatment

b Alternative treatments include voriconazole or amphotericin± flucytosine.

r Cryptococcosis

b Cryptococcal meningitis requires 2 weeks of treatment with both amphotericin

and flucytosine, followed by a course of fluconazole for at least 8 weeks

b Fluconazole alone can be used to treat milder cryptococcosis infections or as

prophylaxis

r Histoplasmosis

b Severe disease should be treated with amphotericin.

b Itraconazole is an option in the treatment of milder histoplasmosis infections

or as prophylaxis

References

Joint Formulary Committee British National Formulary (online) London: BMJ Group

and Pharmaceutical Press http://www.evidence.nhs.uk/formulary/bnf/current/5-infections/52-antifungal-drugs/treatment-of-fungal-infections (ac-cessed July 2015)

Lewis RE Current concepts in antifungal pharmacology Mayo Clin Proc 2011;

86(8):805–817

Sherif R, Segal BH Pulmonary aspergillosis: clinical presentation, diagnostic tests,

management and complications Curr Opin Pulm Med 2010;16(3):242–250.

Taccone FS, Van den Abeele, Bulpa P, et al Epidemiology of invasive aspergillosis incritically ill patients: clinical presentation, underlying conditions, and outcomes

Crit Care 2015;19:7.

18

A9. A male patient with jaundice has the following blood results:

Aspartate transaminase (AST) 450 IU (<35 IU)

of these diagnoses

Long explanation

Bilirubin is produced from breakdown of red blood cells It combines with albuminand is transferred to the liver in its unconjugated state Here it separates from albu-min and is conjugated with glucuronic acid by the action of glucuronyl transferase.Conjugated bilirubin travels within bile to the intestine, where bacterial proteases act

to convert it to urobilinogen in the terminal ileum Some urobilinogen (unconjugated)

is reabsorbed via the portal vein and is lost in the urine but the majority (90%) islost in the faeces as stercobilin

There are many causes of jaundice It can be classified as:

r Prehepatic:

b Increased bilirubin production – haemolysis (hereditary and acquired

haemolytic anaemias), haematoma resorption,

b Impaired conjugation – Crigler-Najjar syndrome

b Impaired hepatic uptake of bilirubin – Gilbert syndrome

b Physiological neonatal jaundice occurs due to a mixture of increased bilirubin

production and immature glucuronyl transferase enzymes

r Hepatic:

b Cirrhosis

b Metabolic: primary and secondary non-alcoholic steatohepatitis

b Genetic: hereditary haemochromatosis, alpha-1 antitrypsin deficiency, Wilson

disease, Dubin-Johnson syndrome

b Neoplastic: hepatic metastasis

b Autoimmune: primary biliary cirrhosis, autoimmune hepatitis

b Infection: hepatitis (A, C, or E), liver abscess, leptospirosis

b Vascular: heart failure (liver congestion), hepatic ischaemia

19

b Toxin: alcoholic hepatitis

b Pregnancy: cholestasis of pregnancy (intrahepatic cholestasis), HELLP

syndrome

b Drug toxicity

 Hepatocellular: amiodarone, highly active antiretroviral therapy (HAART),halothane, non-steroidal anti-inflammatory drugs (NSAIDs), omeprazole,rifampicin, selective serotonin reuptake inhibitors (SSRIs), paracetamol,total parenteral nutrition (TPN)

 Mixed: amitriptyline, enalapril, phenytoin

 Cholestatic: tricyclic antidepressants (TCAs), steroids, erythromycin

r Extra hepatic (patients often have pale stools and dark urine – a sign of

obstructive jaundice)

b Neoplastic: pancreatic cancer, cholangiocarcinoma

b Autoimmune: primary sclerosing cholangitis

b Other: common bile duct stone, portal lymphadenopathy

∗ Unconjugated hyperbilirubinaemia<20% conjugated bilirubin.

∗∗ Conjugated hyperbilirubinaemia>50% conjugated bilirubin.

References

BMJ Best Practice – Assessment of Jaundice Available at http://bestpractice.bmj.com/best-practice/monograph/511.html (accessed August 2015)

Roche SP, Kobos R Jaundice in the adult patient Am Fam Physician 2004;69(2):99–304.

A10. A patient returns from an aortic valve replacement (AVR) operation to the diac intensive care unit (CICU) He has atrial and ventricular epicardial pacing wires

car-in situ, connected to a temporary paccar-ing box The post-operative electrocardiogram(ECG) demonstrates a rate of 80 bpm with a pacing spike immediately followed by a

p wave then 220 ms pause before a narrow QRS complex

Which of the following is most likely to describe this situation?

A VVI pacing

B AOO pacing with first-degree heart block

C DDD pacing with the AV delay set at 200 ms

D VOO pacing with retrograde atrial contraction

E AAI pacing with underlying fast atrial fibrillation

Answer: B

Short explanation

The atrium is paced with a narrow QRS, suggesting an intrinsic rather than pacedventricular rhythm The prolonged AV nodal delay is consistent with first-degreeheart block (normal is 120 to 200 ms) This pacemaker could be set to DDD pacing, but

20

in an AAI mode would cause the pacemaker to inhibit and not pace.

Long explanation

Pacemakers can be temporary or permanent, and they can be connected to the heartvia transcutaneous pads, a temporary pacing wire, epicardial or endocardial wires(after open heart surgery) or through an implanted transvenous pacing system Theycan sense or pace and may be connected to any of the four chambers of the heart.Pacing systems are named according to a series of letters as follows:

and Trigger

C – Communicating

R – Rate modulation

D – Shock and Pacing

Intrinsic beats are almost always better co-ordinated and more effective at ating a cardiac impulse than paced beats, and therefore it is almost always preferable

gener-to allow a native rhythm gener-to exist if possible Because the focus of the depolarization in

a paced ventricular beat depends on the lead placement, the QRS complex is broad,rather than the rapid organized QRS complex generated through the AV node andconducting system Pacing spikes are visible on an ECG or monitor, and if capture

is obtained, each spike will be immediately followed by a depolarization If the atriaare paced, and the AV node and conduction pathways are intact, then the depolar-ization will propagate along the conduction system and lead to a normal ventriculardepolarization and QRS complex

First-degree heart block is a prolonged delay at the AV node (more than 200 ms).Second-degree heart blocks are partial dyssynchrony between the atria and ventri-cles with some beats conducted and some dropped and can be divided between type

1 (e.g Mobitz 2:1) and type 2 (Wenkebach phenomenon) Third-degree heart block

is complete AV node dissociation Disruption to the AV node is common after tic valve surgery because of the surgical proximity to the conducting system Manydisturbances will resolve after a few days, but some patients will require permanentpacing systems

aor-References

Diprose P, Pierce JMT Anaesthesia for patients with pacemakers and similar devices

Brit J Anaesthes CEPD Rev, 2001;1(6):166–170.

Hampton JR The ECG Made Easy 6th edition Edinburgh: Churchill Livingstone,

2003

21

A Lithium dilution, e.g LiDCO

B Thermodilution, e.g PiCCO

C Indirect Fick method

cen-Oesophageal Doppler measures blood flow velocity in the descending aorta usingthe Doppler principle, whereby the wavelength of reflected sound waves changedepending on the velocity of the blood flow A probe is positioned in the oesoph-agus adjacent to the descending aorta The aortic cross-sectional area must be known

to calculate the cardiac output, and this can either be measured (using ultrasound) orestimated from nomograms The technique relies on a number of assumptions (e.g.the proportion of cardiac output in the descending aorta) that can reduce its accuracy.Any Fick method relies on the Fick principle: blood flow to an organ may be calcu-lated by dividing the amount of a substance taken up by an organ per unit time by thearteriovenous concentration difference Oxygen uptake by the lungs divided by thedifference between mixed venous and arterial oxygen content (as measured by a PAcatheter) is an accurate estimate of cardiac output The indirect Fick method uses CO2

instead of oxygen, and the CO2difference between arterial and mixed venous blood.The Penaz technique involves a continuous measurement of finger blood pressurewith a cuff attached to a pressure transducer and negative-feedback controlled pump

An LED and detector allow measurement of the volume of arterial blood in the ger To keep constant the amount of light hitting the photocell, the cuff is inflated ordeflated to ensure a constant volume of blood in the finger These changes in cuffpressure correlate with the pressure waveform of the arterial supply to the finger,from which cardiac output values can be derived

fin-References

Davis P, Kenny G Basic Physics and Measurement in Anaesthesia 5th edition London:

Butterworth Heinemann Elsevier, 2005, Chapter 17, pp 187–198

22

Sturgess D, Morgan T Haemodynamic monitoring In Bersten AD, Soni N Oh’s

Inten-sive Care Manual 6th edition Oxford: Butterworth Heinemann Elsevier, 2009,

Chapter 12, pp 105–122

A12. A 54-year-old gentleman with no previous medical history is admitted withshortness of breath and pleuritic chest pain 4 days after a 16-hour flight A computedtomography (CT) scan has demonstrated bilateral pulmonary emboli, and echocar-diography has revealed right heart dysfunction His heart rate is 112 bpm, bloodpressure is 104/52 and oxygen saturations are 94% on 50% inspired O2

Which would be the MOST appropriate treatment?

A Anticoagulate with low molecular weight heparin (LMWH)

B Anticoagulate with vitamin K antagonists

C Thrombolyse using alteplase

D Anticoagulate with unfractionated heparin infusion (UFH)

E Anticoagulate with dabigatran

Answer: A

Short explanation

This patient has a sub-massive pulmonary embolism (PE) Thrombolysis is only cated in patients who have cardiovascular instability associated with a massive PE.Dabigatran should not be used as first-line treatment but can be used after initialanticoagulation Initiation with warfarin needs to be covered with other anticoagula-tion with UFH or LMWH LMWH is recommended in preference to UFH unless thepatient has a high bleeding risk or renal failure

indi-Long explanation

PEs have traditionally been classified as:

r Massive: present with cardiovascular compromise with a systolic blood pressure

(SBP)<90 mmHg or a drop in systolic pressure of 40 mmHg.

r Sub-massive: evidence of right ventricular (RV) dysfunction; however, the

cardiovascular features of a massive PE are absent

r Mild/non-massive: may present asymptomatically or with mild symptoms, and

there is no evidence of RV dysfunction or cardiovascular compromise

The recent guidelines from the European Society of Cardiology (ESC) risk stratifyPEs as high risk when there is the presence of sustained (>15 min) cardiovascular

compromise as described in the foregoing criteria and as not high risk in the absence

of these criteria

Both the National Institute for Clinical Excellence (NICE) and the ESC have duced guidelines for the treatment of PEs They recommend thrombolysis for patientswho have a massive or high-risk PE only Thrombolysis is associated with faster reso-lution of haemodynamic instability but no overall survival advantage compared withother anticoagulants

pro-For patients without signs of cardiovascular compromise, anticoagulation ment should be initiated with UFH, LMWH or fondaparinux Both NICE and theESC recommend routinely using LMWH or fondaparinux as first-line anticoagula-tion However, in the presence of renal failure (creatinine clearance<30 mL/min) the

treat-ESC guidelines recommend using UFH titrated to the activated partial tin time (aPTT) rather than LMWH This differs slightly from the NICE guidelines,which also recommend UFH for patients with renal failure (estimated glomerularfiltration rate<30 ml/min/1.73 m2) but also state that LMWH may be used withdose adjustments and along with monitoring of anti-Xa levels Both guidelines also 23

Konstantinides SV, Torbicki A, Agnelli G, et al 2014 ESC Guidelines on the diagnosisand management of acute pulmonary embolism: the Task Force for the Diagnosisand Management of Acute Pulmonary Embolism of the European Society of Car-

diology (ESC) Endorsed by the European Respiratory Society (ERS) Eur Heart J.

2014;35(43):3033–3073

National Institute for Health and Care Excellence (NICE) CG144: Venous

throm-boembolic diseases: the management of venous thromthrom-boembolic diseases and the role of thrombophilia testing London: NICE, 2012 http://www.nice.org.uk/guidance/

cg144 (accessed November 2014)

National Institute for Health and Care Excellence (NICE) TA287: Rivaroxaban for

treating pulmonary embolism and preventing recurrent venous thromboembolism

Lon-don: NICE, 2013 http://www.nice.org.uk/guidance/ta287/ (accessed ber 2014)

Novem-A13. A 74-year-old female patient presents with sudden onset, spontaneous, sided weakness There is no history of trauma, and she reports no history of pain.Two days later, she remains alert and oriented Neurological examination still revealsdecreased tone and power in the right arm and leg with diminished reflexes andright-sided neglect due to homonymous hemianopia

right-Which of the following is the most likely diagnosis?

A Transient ischaemic attack (TIA)

B Partial anterior circulation syndrome (PACS)

C Carotid artery dissection

D Total anterior circulation syndrome (TACS)

E Malignant middle cerebral artery infarct

Answer: B

Short explanation

This patient has suffered a stroke, not a TIA, because her symptoms have persistedfor more than 24 hours Patients with malignant middle cerebral artery infarcts expe-rience complications from cerebral oedema and raised intracranial pressure Whilstcarotid artery dissections can cause symptoms of a stroke, this is not the classical pre-sentation The symptoms described in this case are present in TACS, but there wouldalso be evidence of higher cerebral dysfunction, so this patient’s stroke is classified as

a PACS

Long explanation

Stroke is a clinical syndrome that presents with acute focal disturbance of cerebralfunction due to cerebrovascular disease The majority (80%) are ischaemic in originresulting from either an embolus or thrombus Symptoms are present for more than

24 hours; if they completely resolve within 24 hours, then a diagnosis of a TIA ismade The remaining 20% of strokes occur because of haemorrhage

24

r Total and partial anterior circulation syndromes (TACS/PACS)

b Affects the middle and anterior cerebral artery territories

b Patients have all of the following in TACS and 2 of 3 in PACS:

 Unilateral weakness (± sensory deficit)

 Higher cerebral dysfunction (dysphasia, visuospatial disorders)

r Posterior circulation syndrome (POCS)

b Affects the posterior cerebral circulation

b Patients have one of the following:

 Loss of consciousness

 Isolated homonymous hemianopia

 Cerebellar symptoms (cerebellar ataxia, dysphagia, dysphonia, nystagmus,coordination problems) or brain-stem symptoms (reduced Glasgow Coma

Score, cardiorespiratory disturbance)

r Lacuna syndrome (LACS)

b A subcortical stroke due to small vessel disease

b Patients have an absence of higher cerebral dysfunction and one of the

following:

 Unilateral weakness (± sensory deficit)

 Pure sensory stroke

 Ataxic hemiparesis

r For all of these, if an infarct is confirmed on imaging, then the term ‘infarct’ is

substituted for syndrome

With malignant middle cerebral artery infarction, patients present with signs of

a severe hemispheric stroke Cerebral oedema occurs within 24 to 48 hours, causingsymptoms of raised intracranial pressure, such as headaches, vomiting, papilloedemaand reduced Glasgow Coma Score

Carotid artery dissection is a rarer cause of ischaemic stroke It occurs more monly in younger patients and after trauma Patients tend to experience symptomsand signs of headache, neck pain, Horner syndrome or cranial nerve palsies in addi-tion to those associated with ischaemic stroke or a TIA

com-References

Bamford J, Sandercock P, Dennis M, et al Classification and natural history of

clin-ically identifiable subtypes of cerebral infarction Lancet 1991; 337(8756):1521–

1526

Thanvi B, Munshi SK, Dawson S, Robinson T Carotid and vertebral artery dissection

syndromes Postgrad Med J 2005;81(956):383–388.

Treadwell SD, Thanvi B Malignant middle cerebral artery (MCA) infarction:

patho-physiology, diagnosis and management Postgrad Med J 2010;86(1014):235–242.

25

8.2 kPa, PaCO27.6 kPa An echocardiography reveals an ejection fraction of 44% andpulmonary arterial pressure of 55 mmHg.

What is the MOST likely cause of this patient’s pulmonary hypertension (PH)?

A Hypoxia and hypercapnia

B Chronic pulmonary hypertension

C Acute left ventricular dysfunction

D An acute pulmonary embolism

The revised 2008 Dana Point classification categorizes pulmonary hypertensionaccording to its aetiology:

r Group 1: Pulmonary arterial hypertension (e.g idiopathic, congenital,

disease-related etc.)

r Group 1: Secondary to pulmonary venous hypertension (e.g occlusive disease)

r Group 2: Secondary to left heart disease

r Group 3: Secondary to chronic hypoxia or chronic lung disease (e.g chronic

obstructive pulmonary disorder, fibrosis, hypoventilation disorders etc.)

r Group 4: Secondary to chronic pulmonary thromboembolic disease

r Group 5: Unknown origin or secondary to multiple mechanisms (e.g.

haematological, vasculitic, metabolic disease etc.)

Acidosis, hypercapnia, hypoxia and extremes of lung volumes all result inincreased pulmonary vascular resistance and will increase pulmonary pressures.Pulmonary hypertension results in increased right ventricular afterload Whenthis develops acutely, the normally low pressure right ventricle cannot cope anddilates This can result in functional tricuspid insufficiency and a shift in the inter-ventricular septum, impairing left ventricular function and resulting in a reduction

in cardiac output If the rise in pulmonary pressures occurs gradually, the right tricle can adapt, and right ventricular hypertrophy develops As a result of this hyper-trophy, the right ventricle can tolerate higher pulmonary pressures before failing Amean pulmonary pressure>40 mmHg cannot be generated by the right ventricle in

ven-pulmonary hypertension of acute origin

References

Gali`e N, Hoeper MM, Humbert M, et al Guidelines for the diagnosis and treatment

of pulmonary hypertension: the Task Force for the Diagnosis and Treatment ofPulmonary Hypertension of the European Society of Cardiology (ESC) and the

26

European Respiratory Society (ERS), endorsed by the International Society of

Heart and Lung Transplantation (ISHLT) Eur Heart J 2009:30(20);2493–2537.

Matthews JC, McLaughlin V Acute right ventricular failure in the setting of acutepulmonary embolism or chronic pulmonary hypertension: a detailed review of

the pathophysiology, diagnosis, and management Curr Cardiol Rev 2008;4(1):49–

B A shocked trauma patient with massive blood loss unresponsive to crystalloids

C Hb<70 g/l in a stable patient admitted with an acute upper gastrointestinal

bleed

D Hb<70 g/l in a patient with septic shock on vasopressin and noradrenaline

E Hb<100 g/l in a patient in the intensive care unit with a history of

rec-Long explanation

The Canadian Transfusion Requirements In Critical Care (TRICC) study investigatedtransfusion requirements in critically ill patients with a Hb<90 g/l They found that

a restrictive transfusion strategy (transfusion trigger of<70 g/l aiming to keep the

Hb between 70 and 90 g/l), as opposed to a more liberal strategy (maintain the Hbconcentration between 100 and 120 g/l), resulted in a significantly decreased patienttransfusion requirement There was a non-significant trend to decreased all-cause30-day mortality in the patients in the restrictive treatment arm On subgroup anal-ysis, this was significant for two cohorts: patients younger than 55 years and thosewith an APACHE II score of20 There was no significant difference in mortal-ity for patients with pre-existing cardiac disease; however, there was a significantlyincreased rate of myocardial infarctions and pulmonary oedema in those on the lib-eral arm A recent pilot trial has suggested that patients with acute coronary syn-drome may benefit from a more liberal transfusion approach aiming to keep their

Hb100 g/l, but further trials are needed

The recent TRISS trial has compared transfusion triggers of<70 g/l and < 90 g/l

for the management of patients with septic shock and produced similar conclusions;

no significant difference in the 90-day mortality was identified between these twogroups

A restrictive transfusion protocol, with a transfusion trigger of 70 g/l and target

Hb range of 70 to 90 g/l, has been compared with a liberal transfusion protocol, with atransfusion trigger of 90 g/l and target Hb range of 90 to 110 g/l in patients with non-exsanguinating gastrointestinal bleeding The investigators identified a statistically

27

accor-Guidelines for the management of massive bleeding in trauma recommend diate O-negative blood transfusion for shocked patients with acute massive bloodloss unresponsive to fluids If there is a transient response to fluids, the patient islikely to require blood but type specific should be used.

imme-References

Carson JL, Brooks MM, Abbott JD, et al Liberal versus restrictive transfusion

thresh-olds for patients with symptomatic coronary artery disease Am Heart J 2013;

165(6):964–971

Herbert PC, Wells G, Blajchman MA, et al A multicentre, randomized

con-trolled clinical trial of transfusion requirements in critical care N Engl J Med.

1999;340(6):409–417

Holst LB, Haase N, Wetterslev J, et al Lower versus higher hemoglobin threshold for

transfusion in septic shock N Engl J Med 2014;371(15):1381–1391.

Spahn DR, Bouillon B, et al Management of bleeding and coagulopathy following

major trauma: an updated European guideline Crit Care 2013; 17(2):R76.

Villanueva C, Colomo A, Bosch A, et al Transfusion strategies for acute upper

gas-trointestinal bleeding N Engl J Med 2013; 368(1):11–21.

A16. A 54-year-old male patient is admitted to the intensive care unit with trolyte derangement and acute renal failure following initiation of treatment for hisBurkitt lymphoma Blood test results include the following:

Corrected Ca2+ 1.6 mmol/l 2.12–2.65

Which of the following is LEAST true regarding this condition?

A Complete correction of electrolyte derangements with fluids, filtration andelectrolyte replacement should occur

B It occurs with increased frequency in those patients with bulky, rapidly

elec-28

at risk.

The common metabolic derangements occur because of the rapid lysis of a largenumber of cells and the release of intracellular contents (ions and metabolites) intothe blood stream Common metabolic abnormalities include the following:

• Hyperphosphataemia Due to the release of intracellular phosphate

concentration of phosphate ions, resulting in thedeposition of calcium phosphate in the tissues

• High lactate dehydrogenase A sign of tissue breakdown and cancer cell death

• Hyperuricaemia Cell breakdown releases nucleic acids, which are

converted to uric acid

• Metabolic acidosis Can occur secondarily to acute kidney injury

Clinical complications of electrolyte disturbances:

but precipitation of uric acid and calciumphosphate crystals in the renal tubules isone major cause

• Tetany/neuromuscular irritability

• Seizures

• Cardiac arrhythmias

• Death

Management involves preventative treatment:

r Hyperhydration with intravenous (IV) fluids

r Reducing uric acid levels

b Xanthine oxidase inhibitor, allopurinol

b Recombinant urate oxidase, rasburicase, is most effective

Treatment for established tumour lysis syndrome:

r Aggressive IV hydration

r Rasburicase

r Correct electrolyte disturbances (hyperkalaemia: insulin/dextrose, bicarbonate)

(hyperphosphataemia: phosphate binders) There should be caution surrounding

the correction of hypocalcaemia however, because the administration of

additional calcium will further enhance calcium phosphate production and

deposition in the tissues in the presence of ongoing hyperphosphataemia

Calcium replacement should only be considered if the patient is symptomatic as

a result of hypocalcaemia

r Renal replacement therapy for acute kidney injury, refractory hyperkalaemia,

A17. A 74-year-old patient with Clostridium difficile diarrhoea, has a white cell count

(WCC) of 18× 109/l, a temperature of 39°C and evidence of ileus

Which of the following is the BEST treatment regimen?

All of the above are treatments for Clostridium difficile diarrhoea The presence of

ileus categorizes the patient as having life-threatening disease; therefore, the mend treatment regimen for this patient would be oral vancomycin and intravenousmetronidazole

recom-Long explanation

Public Health England has produced updated guidance in 2013 regarding the

man-agement of patients with Clostridium difficile diarrhoea It recommends the following:

r High index of suspicion in patients with diarrhoea if no alternative cause is clear

r Early isolation of the patient and the use of personal protective equipment

(gloves and aprons) and hand washing with soap and water (not alcohol gel)once the diagnosis is suspected

r Daily review of patients regarding the severity of the disease and documentation

of the severity of diarrhoea according to the Bristol Stool Chart

r Consideration to stopping unnecessary antibiotics or proton pump inhibitors

The guidance categorizes disease severity according to a number of clinical tures and recommends different treatments according to the severity

fea-30

r <3 stools/day r Oral metronidazole 400–500 mgTDS 10–14 days

r Consider fidaxomicin for patients at

high risk of recurrence (elderly,multiple co-morbidities, thosereceiving concomitant antibiotics)

r Alternative treatment in severe

disease not responding to oralvancomycin 125 mg QDS:

References

Public Health England Updated guidance on the management and treatment

of Clostridium difficile infection 2013

http://www.dhsspsni.gov.uk/updated-guidance.pdf (accessed February 2015)

A18. A 38-year-old patient has developed acute respiratory distress syndromeafter a viral pneumonia He is intubated and ventilated but showing little sign ofimprovement A decision is made to refer him to the local extracorporeal membraneoxygenation (ECMO) centre

Which of the following criteria contribute most to his Murray score for ECMOreferral?

A PaO2/FiO2ratio of 25 kPa

B PEEP of 8 cmH2O

C Compliance of 38 ml/cmH2O

D Half of the chest X-ray showing infiltrates

E Uncompensated hypercapnia with a pH<7.2