Critical Care Medicine — MCQs

Critical Care Medicine Indian Medical PG Practice Questions and MCQs

Question 51: The ideal parameters for cardiac massage in cardiopulmonary resuscitation are all EXCEPT:

A. Ratio of compression to ventilation should be 15:2 (Correct Answer)
B. Compressions to be given over lower third of sternum
C. Force should depress sternum approximately 1/3 of chest wall diameter
D. Force should depress sternum by 1½ inches

Explanation: ***Ratio of compression to ventilation should be 15:2*** - The currently recommended **ratio of chest compressions to ventilations** for adult cardiopulmonary resuscitation (CPR) by a single rescuer or two rescuers is **30:2**. - A 15:2 ratio was used in older guidelines but is **no longer ideal for adult CPR**; it is still used in pediatric CPR with two rescuers. *Compressions to be given over lower third of sternum* - Proper hand placement for chest compressions is on the **lower half of the sternum**, avoiding the xiphoid process. - This position ensures effective compression of the heart while minimizing the risk of injury to abdominal organs. *Force should depress sternum approximately 1/3 of chest wall diameter* - The recommended depth of chest compressions for adults is at least **2 inches (5 cm)**, but no more than 2.4 inches (6 cm). - This depth corresponds to approximately **one-third of the anterior-posterior diameter** of the adult chest, ensuring adequate blood flow. *Force should depress sternum by 1½ inches* - A compression depth of **1½ inches (approximately 3.8 cm)** is **insufficient** for effective adult CPR. - This depth would result in **inadequate blood circulation** to vital organs, reducing the chances of successful resuscitation.

Question 52: Which machine is used noninvasively to monitor external chest compressions during cardiopulmonary resuscitation?

A. Zoll pA02 monitor
B. Zoll strength sensor
C. Zoll R Series monitor
D. Zoll AED - plus automatic external defibrillator (Correct Answer)

Explanation: ***Zoll AED - plus automatic external defibrillator*** - This device is specifically designed with features like **Real CPR Help** that provide real-time audio and visual feedback on the depth and rate of chest compressions during CPR. - It uses an **electrode pad system** to sense compression depth and rate, guiding rescuers to provide high-quality compressions. *Zoll pA02 monitor* - This is a non-existent term or device; there is no standard Zoll product known as a "pAO2 monitor." - Monitors for pAO2 (partial pressure of arterial oxygen) are typically **blood gas analyzers** used in laboratory or critical care settings. *Zoll strength sensor* - While Zoll devices may incorporate sensors, "strength sensor" is too **generic** and does not specifically refer to a recognized, non-invasive CPR monitoring device. - This term does not accurately describe a specific Zoll product for monitoring external chest compressions. *Zoll R Series monitor* - The **Zoll R Series** is a hospital defibrillator/monitor that offers advanced monitoring capabilities, but its primary function is not non-invasive, real-time CPR compression feedback. - While it can display ECG and other vital signs, the dedicated, real-time compression feedback for basic CPR quality is more prominent in devices like the AED Plus.

Question 53: Intravenous anaesthetic agent of choice in status epilepticus

A. Thiopentone
B. Etomidate
C. Ketamine
D. Propofol (Correct Answer)

Explanation: ***Propofol*** - **Propofol** is favored due to its rapid onset and short duration of action, allowing for quick titration to seizure control and rapid assessment of neurological function post-seizure. - Its potent GABAergic effects effectively **suppress seizure activity** in refractory status epilepticus. *Thiopentone* - While effective in terminating seizures due to its potent GABAergic action, **thiopentone** has a much longer context-sensitive half-time, leading to prolonged sedation and delayed neurological assessment. - Its use often necessitates **intubation and mechanical ventilation** due to significant respiratory depression. *Etomidate* - **Etomidate** is a potent sedative that can terminate seizures but is strongly associated with **adrenal suppression** due to inhibition of 11-β-hydroxylase, which limits its use in status epilepticus, particularly with prolonged infusions. - It has a short duration of action but lacks the neuroprotective properties of other agents and can cause **myoclonus**, which might be confused with ongoing seizure activity. *Ketamine* - **Ketamine** primarily acts as an NMDA receptor antagonist and is often used in refractory status epilepticus that fails to respond to GABAergic drugs (benzodiazepines, propofol, barbiturates). - It is not considered the **first-line intravenous anesthetic agent of choice** and is typically reserved for later stages of management due to its different mechanism of action and potential side effects like hallucinations and cardiovascular stimulation.

Question 54: A Patient in medical intensive care unit who is intubated, suddenly removes the endotracheal tube. What should be done next?

A. Sedate and reintubate
B. Make him sit and do physiotherapy
C. Assess the patient and give bag and mask ventilation and look for spontaneous breathing (Correct Answer)
D. Give bag and mask ventilation and intubate

Explanation: ***Assess the patient and give bag and mask ventilation and look for spontaneous breathing*** - Upon accidental extubation, the immediate priority is to **assess the patient's airway, breathing, and circulation (ABCs)** and ensure oxygenation via **bag-mask ventilation** if needed, while observing for spontaneous breathing efforts. - This step allows for a controlled re-evaluation of the patient's respiratory status and provides time to plan for reintubation if indicated, without rushing into sedating or reintubating a potentially stable patient. *Sedate and reintubate* - While reintubation may ultimately be necessary, sedating and immediately attempting reintubation without prior assessment can be dangerous if the patient has **stable spontaneous breathing** or if there are other contributing factors like **airway swelling** that need to be addressed first. - Rushing to sedate and intubate could lead to complications if the patient's physiology is not fully understood post-extubation. *Make him sit and do physiotherapy* - This option is inappropriate for an intubated patient who has just accidentally self-extubated, as their airway and breathing status are of immediate concern. - Positioning for physiotherapy or performing chest physiotherapy is a secondary concern after ensuring **adequate oxygenation and ventilation** and confirming a stable airway. *Give bag and mask ventilation and intubate* - While bag-mask ventilation is an appropriate immediate step to maintain oxygenation, automatically proceeding to intubation without fully **assessing the patient's spontaneous breathing status** and overall stability is premature. - Some patients might tolerate extubation and breathe adequately on their own, negating the need for immediate reintubation.

Question 55: Best guide for the management of Resuscitation is:

A. Saturation of Oxygen
B. CVP
C. Blood pressure
D. Urine output (Correct Answer)

Explanation: ***Urine output*** - **Urine output** is considered the **gold standard** for assessing adequacy of resuscitation as it directly reflects **end-organ perfusion** and **tissue oxygenation**. A target of **0.5-1 mL/kg/hour** indicates adequate renal perfusion and overall circulatory status. - It serves as a reliable **endpoint of resuscitation** in trauma and critical care protocols, providing objective evidence that fluid resuscitation has achieved adequate **tissue perfusion** and **microcirculatory flow**. *Saturation of Oxygen* - While **oxygen saturation** is crucial for ensuring adequate **oxygen delivery** to tissues, it represents only one component of the oxygen delivery equation and doesn't reflect **tissue perfusion** adequacy. - Maintaining normal oxygen saturation does not guarantee adequate **end-organ perfusion** if cardiac output or tissue perfusion is compromised during resuscitation. *CVP* - **Central venous pressure** has poor correlation with actual **intravascular volume status** and **cardiac preload**, making it an unreliable guide for fluid resuscitation. - CVP measurements are influenced by multiple factors including **ventilator settings**, **tricuspid valve function**, and **chest wall compliance**, limiting its utility as a resuscitation endpoint. *Blood pressure* - While **blood pressure** provides immediate feedback on **circulatory status** and is emphasized in current **ACLS** and **ATLS** protocols as an immediate target, it may not accurately reflect **microcirculatory perfusion**. - Blood pressure can be maintained through **vasoconstriction** while **end-organ perfusion** remains inadequate, making it less reliable than urine output for assessing true resuscitation adequacy.

Question 56: A 70-year-old woman in the ICU develops acute respiratory distress syndrome (ARDS). What is the most appropriate ventilation strategy?

A. High tidal volume
B. Low tidal volume (Correct Answer)
C. High PEEP
D. Low respiratory rate

Explanation: ***Low tidal volume*** - **Low tidal volume ventilation** (LTVV) is the cornerstone of ARDS management, aiming to limit ventilator-induced lung injury (VILI) by reducing overdistension of viable lung tissue. - Recommended tidal volumes are typically **4-8 mL/kg of predicted body weight**, maintaining plateau pressures below 30 cmH2O. *High tidal volume* - **High tidal volumes** (e.g., >8 mL/kg PBW) are associated with increased **barotrauma** and **volutrauma**, exacerbating lung injury in ARDS. - This strategy risks **overdistension** of healthy lung regions, leading to worsened inflammation and mortality. *High PEEP* - While adequate **positive end-expiratory pressure (PEEP)** is crucial in ARDS to prevent atelectasis and improve oxygenation, excessively high PEEP can lead to hemodynamically significant **impaired venous return** and increased intrathoracic pressure. - The optimal PEEP level is individualized, often titrated to achieve optimal oxygenation and lung recruitment without significant adverse effects, but simply stating "high PEEP" without context is not the primary strategy. *Low respiratory rate* - A **low respiratory rate** may be used in conjunction with LTVV to manage **permissive hypercapnia**, allowing for lower driving pressures and reducing VILI. - However, it is not the primary ventilation strategy itself, and excessively low rates can lead to severe **acidosis** if CO2 clearance is insufficient.

Question 57: You are the first responder to a person who has collapsed. The person is unresponsive, not breathing, and has no pulse. After calling for help, what is the next immediate action?

A. Begin chest compressions (Correct Answer)
B. Open the airway
C. Give rescue breaths
D. Check for a pulse again

Explanation: **Begin chest compressions** - After confirming unresponsiveness, absence of breathing, and no pulse, the **immediate priority** is to start high-quality chest compressions to maintain vital organ perfusion. - Initiating compressions promptly is critical to improve outcomes for a person in **cardiac arrest**. *Open the airway* - While airway management is important in resuscitation, **opening the airway** is typically performed after initiating chest compressions, or in conjunction with rescue breaths, but not as the very first action when a person is pulseless. - For a pulseless patient, circulation (via compressions) takes precedence over ventilation initially, especially in adult out-of-hospital cardiac arrest. *Give rescue breaths* - **Rescue breaths** are part of cardiopulmonary resuscitation (CPR), but they follow the initiation of chest compressions in the C-A-B (Compressions, Airway, Breathing) sequence for adults. - Effective chest compressions must be started first to circulate any remaining oxygen in the blood. *Check for a pulse again* - **Repeated pulse checks** can delay the initiation of life-saving chest compressions. - Once a lack of pulse is identified, the focus should shift immediately to providing interventions rather than re-assessing.

Question 58: A 65-year-old male with a history of cardiovascular disease is admitted with severe bleeding following cardiac surgery. Thromboelastography (TEG) shows a prolonged R time, reduced MA, and increased LY30. Which therapy is the most appropriate?

A. Platelet transfusion
B. Cryoprecipitate
C. Tranexamic acid
D. Fresh frozen plasma (Correct Answer)

Explanation: ***Fresh frozen plasma*** - A **prolonged R time** on TEG indicates a **coagulation factor deficiency**, which is best corrected by administering **fresh frozen plasma (FFP)**. - FFP contains **all coagulation factors**, effectively addressing the initial clotting deficit identified by the prolonged R time. *Platelet transfusion* - A **reduced MA (Maximum Amplitude)** on TEG would suggest a **platelet dysfunction** or low platelet count, but the primary issue here is clotting factor deficiency. - While there is a reduced MA, the primary concern indicated by a prolonged R time is **coagulation factor deficiency**, making FFP more appropriate initially. *Cryoprecipitate* - **Cryoprecipitate** is primarily used to replace **fibrinogen**, Factor XIII, and von Willebrand factor, which would be indicated by a very low fibrinogen level or a TEG showing a specific deficit in clot strength not primarily addressed by a prolonged R time alone. - While fibrinogen is part of the clotting cascade, the **prolonged R time** suggests a more general deficiency of multiple factors, making FFP a broader and more comprehensive treatment. *Tranexamic acid* - **Tranexamic acid** is an **antifibrinolytic agent** used to prevent clot breakdown (fibrinolysis), as suggested by an **increased LY30** on TEG. - While it addresses the increased LY30, the primary concern of **prolonged R time** (coagulation factor deficiency) must be addressed first to form a clot, before preventing its breakdown.

Question 59: After ensuring the scene is safe, what is the next step in basic life support when a bystander witnesses a person suddenly collapse?

A. Check for responsiveness (Correct Answer)
B. Call for emergency services
C. Begin chest compressions
D. Open the airway

Explanation: ***Check for responsiveness*** - After ensuring scene safety, the immediate next step is to **check if the person is responsive** to determine if they are conscious and need help. - This typically involves tapping their shoulder and shouting, "Are you okay?" *Call for emergency services* - While calling for emergency services is crucial, it generally occurs **after determining unresponsiveness** and before or immediately after beginning chest compressions. - One should first confirm that the person is in need of emergency medical attention. *Begin chest compressions* - Chest compressions are initiated **after checking for responsiveness** and determining the person is unresponsive and not breathing normally. - Starting compressions prematurely on a conscious individual is inappropriate and potentially harmful. *Open the airway* - Opening the airway (e.g., head-tilt/chin-lift) is performed **after checking for responsiveness** and after calling for help, usually right before checking for breathing or delivering rescue breaths. - It’s part of the assessment for breathing, not the very first step after scene safety.

Question 60: A 60-year-old male collapses in a public place. Upon arrival, you find him unresponsive, with no pulse and not breathing. After starting CPR, what is the next immediate action to take?

A. Attach an AED and follow prompts (Correct Answer)
B. Check for pulse again
C. Administer IV epinephrine
D. Intubate and ventilate

Explanation: ***Attach an AED and follow prompts*** - After initiating CPR for an unresponsive, pulseless, and non-breathing patient, the **next immediate action** is to use an **automated external defibrillator (AED)** to assess for a shockable rhythm and deliver a shock if advised. - Early defibrillation significantly improves the chances of survival in cases of **sudden cardiac arrest**, particularly for rhythms like ventricular fibrillation. *Check for pulse again* - Rechecking the pulse after starting CPR is **not the next immediate step**; the initial assessment has already confirmed the absence of a pulse and CPR has begun. - Repeated pulse checks should be brief and performed only during rhythm analysis or after five cycles of CPR to minimize interruptions. *Administer IV epinephrine* - While epinephrine is a critical medication in advanced cardiac life support (ACLS), it is typically administered **after AED use and initial defibrillation attempts**, and specific rhythm analysis. - Epinephrine is not the first intervention after starting CPR; **defibrillation takes precedence** for shockable rhythms. *Intubate and ventilate* - Establishing an advanced airway through intubation is an important step in resuscitation, but it is **not the immediate next action** after starting CPR. - **Chest compressions and early defibrillation** are priorities, and ventilation can initially be provided with a bag-mask device.

Practice by Chapter

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Hemodynamic Monitoring in ICU

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Neurocritical Care

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