A 28-year-old soldier is brought back to a military treatment facility 45 minutes after sustaining injuries in a building fire from a mortar attack. He was trapped inside the building for around 20 minutes. On arrival, he is confused and appears uncomfortable. He has a Glasgow Coma Score of 13. His pulse is 113/min, respirations are 18/min, and blood pressure is 108/70 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 96%. Examination shows multiple second-degree burns over the chest and bilateral upper extremities and third-degree burns over the face. There are black sediments seen within the nose and mouth. The lungs are clear to auscultation. Cardiac examination shows no abnormalities. The abdomen is soft and nontender. Intravenous fluid resuscitation is begun. Which of the following is the most appropriate next step in management?

Intubation and mechanical ventilation

Insertion of nasogastric tube and enteral nutrition

Intravenous corticosteroid therapy

A 36-year-old male with fluctuating levels of consciousness is brought to the emergency department by ambulance due to a fire in his home. He currently opens his eyes to voice, localizes painful stimuli, responds when asked questions, but is disoriented and cannot obey commands. The patient’s temperature is 99°F (37.2°C), blood pressure is 86/52 mmHg, pulse is 88/min, and respirations are 14/min with an oxygen saturation of 97% O2 on room air. Physical exam shows evidence of soot around the patient’s nose and mouth, but no burns, airway obstruction, nor accessory muscle use. A blood lactate is 14 mmol/L. The patient is started on intravenous fluids. What is the next best step in management?

100% oxygen, hydroxycobalamin, and sodium thiosulfate

Sodium thiosulfate and sodium nitrite

A 27-year-old soldier is brought to the emergency department of a military hospital 20 minutes after being involved in a motor vehicle accident during a training exercise. He was an unrestrained passenger. On arrival, he has shortness of breath and chest pain. He appears pale and anxious. His temperature is 37°C (98.6°F), pulse is 110/min, respirations are 20/min, and blood pressure is 100/65 mm Hg. He is alert and oriented to person, place, and time. Examination shows pale conjunctivae and mucous membranes. There is bruising on the chest, extremities, and abdomen. The lungs are clear to auscultation. He has normal heart sounds and flat neck veins. The abdomen is flat, soft, and mildly tender. The remainder of the physical examination shows no abnormalities. High-flow oxygen is applied, and intravenous fluid resuscitation is begun. A chest x-ray is obtained. Which of the following is the most appropriate next step in management?

CT scan of the chest with contrast

Intubation with positive pressure ventilation

A 35-year-old man is brought to the emergency department from a kitchen fire. The patient was cooking when boiling oil splashed on his exposed skin. His temperature is 99.7°F (37.6°C), blood pressure is 127/82 mmHg, pulse is 120/min, respirations are 12/min, and oxygen saturation is 98% on room air. He has dry, nontender, and circumferential burns over his arms bilaterally, burns over the anterior portion of his chest and abdomen, and tender spot burns with blisters on his shins. A 1L bolus of normal saline is administered and the patient is given morphine and his pulse is subsequently 80/min. A Foley catheter is placed which drains 10 mL of urine. What is the best next step in management?

Additional fluids and escharotomy

Additional fluids and admission to the ICU

A 70-year-old man is brought to the emergency room with complaints of severe substernal chest pain for the last hour. The pain started suddenly, and the patient describes the pain as “going into the shoulder”. The patient took aspirin at home and has been given multiple doses of sublingual nitroglycerin, but the pain has not subsided. He has a blood pressure of 112/84 mm Hg, the pulse is 63/min, the respiratory rate is 18/min, and the temperature is 36.9°C (98.0°F). Cardiac auscultation reveals normal S1 and S2 sounds, however, an additional S4 sound is heard. The patient is sweating profusely, and the lungs are clear to auscultation. No jugular venous distension or pedal edema is observed. His initial ECG shows ST elevation in leads II, III, and aVF. Which of the following will likely have the most benefit in this patient?

Percutaneous coronary intervention

Critical care interventions for USMLE Step 1: High-Yield CCS Cases Lessons

Primary Survey - The ABCDE Drill

A sequential, systematic approach for managing critically ill patients. Treat life-threats at each step before proceeding to the next.

A - Airway with C-Spine Protection:
- Assess: Patency, stridor, foreign body.
- Intervene: Jaw thrust, suction, Oropharyngeal/Nasopharyngeal Airway (OPA/NPA), intubation. Maintain C-spine immobilisation.
B - Breathing & Ventilation:
- Assess: Respiratory Rate (RR), SpO₂, chest expansion, air entry.
- Intervene: High-flow O₂, bag-mask ventilation, needle decompression.
C - Circulation & Hemorrhage Control:
- Assess: Heart Rate (HR), Blood Pressure (BP), Capillary Refill Time (CRT), active bleeding.
- Intervene: Stop external bleeding, secure 2 large-bore IV lines, start crystalloid infusion.
D - Disability (Neurological Status):
- Assess: GCS/AVPU score, pupillary size & reaction, blood glucose.
E - Exposure & Environment:
- Assess: Fully expose patient to check for injuries.
- Intervene: Prevent hypothermia (warm blankets, warmed fluids).

⭐ In trauma, altered sensorium is due to head injury, hypoxia, or shock until proven otherwise. Always check blood glucose.

C-ABCDE approach to critical care interventions

Shock Management - Classify & Conquer

Goal: Restore perfusion; MAP > 65 mmHg, normalize lactate.
Initial Approach: ABCs, secure IV access (2 large-bore cannulas), start fluid resuscitation with crystalloids (e.g., 30 ml/kg in sepsis), and identify the cause.

Classification & Hemodynamics:

Hypovolemic: ↓ Preload (hemorrhage, dehydration). Tx: Fluids/blood.
Cardiogenic: ↓ Cardiac Output (MI, HF). Tx: Inotropes (Dobutamine), cautious fluids.
Distributive: ↓ SVR (sepsis, anaphylaxis). Tx: Vasopressors (Norepinephrine), fluids.
Obstructive: Extracardiac obstruction (tamponade, PE). Tx: Relieve obstruction (e.g., pericardiocentesis).

Hemodynamic Profiles of Four Types of Shock

⭐ Exam Favourite: In septic shock, Norepinephrine is the first-choice vasopressor to maintain MAP ≥ 65 mmHg. If MAP remains low despite Norepinephrine, consider adding Vasopressin.

ICU Interventions - Vents, Lines & Drugs

Mechanical Ventilation:
- Modes: Assist-Control (ACV), SIMV, Pressure Support (PSV).
- Key Settings:
  - Tidal Volume (Vt): 6-8 mL/kg IBW (lower in ARDS).
  - PEEP: Start 5-8 cm H₂O; titrate for oxygenation.
  - FiO₂: Titrate for SpO₂ >92%.
Central Venous Access:
- Sites: Internal Jugular (IJV) preferred > Subclavian > Femoral (↑ infection/DVT risk).
- Confirmation: CXR (tip at cavo-atrial junction).
Vasoactive Drugs:
- Vasopressors: Noradrenaline (1st line, septic shock), Adrenaline.
- Inotropes: Dobutamine (cardiogenic shock), Milrinone.

⭐ Propofol Infusion Syndrome (PRIS): A lethal complication of high-dose (>4 mg/kg/hr) or prolonged (>48 hrs) infusion. Features: metabolic acidosis, rhabdomyolysis, arrhythmias, and cardiac failure.

High‑Yield Points - ⚡ Biggest Takeaways

Airway first, always: Intubate for GCS < 8, impending airway compromise, or inability to clear secretions.

Breathing: Provide high-flow O₂. Perform needle thoracostomy for a tension pneumothorax before getting a chest X-ray.

Circulation: Secure 2 large-bore IV lines. Start crystalloid bolus for hypotension; add vasopressors (like norepinephrine) if refractory.

Disability: Check GCS and pupils. Always check a blood glucose level in any patient with altered mental status.

Sepsis: Administer broad-spectrum antibiotics within the first hour of recognition.

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