Critical Care Medicine Practice Questions

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

Zoll AED - plus automatic external defibrillator. ***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.

Q: Site for external cardiac massage is:

Lower third of sternum. ***Lower third of sternum*** - Compression in this area is optimal for effective **cardiac output** during resuscitation, as it directly overlies the heart. - This position minimizes the risk of injury to other organs while providing adequate force transmission to the heart. *Xiphoid process* - Compressing the **xiphoid process** can lead to serious complications such as **liver laceration** or other internal organ damage. - It does not provide effective compression of the heart due to its anatomical position. *Junction of body and manubrium sterni* - This area is too high to effectively compress the heart, resulting in **ineffective cardiac massage**. - Compression here is also less stable and can increase the risk of injuries to the **upper ribs** and **clavicle**. *2 fingers below xiphoid process* - Compressing too close to or below the **xiphoid process** risks damaging abdominal organs like the **liver** or **spleen**. - While it attempts to steer clear of the xiphoid itself, it places the compression point too inferiorly for optimal cardiac resuscitation.

Q: Intravenous anaesthetic agent of choice in status epilepticus

Propofol. ***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.

Q: During CPCR in ACLS the waveform of capnograph shows following change. This indicates:-

Return of spontaneous circulation. ***Return of spontaneous circulation*** - A **sudden, sustained increase** in **end-tidal carbon dioxide (ETCO2)** during CPCR often indicates the **return of spontaneous circulation (ROSC)**. - This rise reflects a sudden improvement in **pulmonary perfusion**, as the heart effectively pumps blood, delivering CO2 from the tissues to the lungs. *Check position of Endotracheal tube* - An improperly placed **endotracheal tube**, such as in the esophagus, would typically result in a **very low or absent capnograph waveform**, not a sustained increase. - While tube position should always be confirmed, a sudden increase in ETCO2 is not primarily indicative of a malpositioned tube. *Inadequate ventilation* - **Inadequate ventilation** would lead to a **decrease** in the **excretion of CO2** and potentially a lower or fluctuating ETCO2, not a clear, sustained rise. - Effective ventilation is crucial for accurate ETCO2 readings, but a change indicating ROSC suggests improved circulation rather than just ventilation. *Inadequate metabolism* - **Inadequate metabolism** or metabolic issues would typically affect CO2 production, but a **sharp, sustained increase** in ETCO2 during resuscitation primarily reflects improved **cardiovascular function** and blood flow to the lungs. - While metabolism is linked to CO2 production, the acute change observed during CPCR is more directly about systemic perfusion.

Q: What is the recommended chest compression rate (per minute) during CPR for adults?

100-120 compressions per minute. ***100-120 compressions per minute*** - This rate ensures adequate **blood flow** to vital organs, especially the brain and heart, during CPR [1]. - Delivering compressions within this range is a key component of high-quality CPR to maximize survival outcomes [1]. *60-80 compressions per minute* - This rate is too slow and would result in **insufficient blood flow** to the brain and other critical organs. - Inadequate compression rates can significantly reduce the effectiveness of CPR and patient survival chances. *40-60 compressions per minute* - This rate is critically low and would provide almost no effective **circulation** during cardiac arrest. - Such a slow rate would be highly detrimental and unlikely to sustain life or improve the patient's condition. *20-40 compressions per minute* - This rate is far below the recommended guidelines and would be entirely ineffective in maintaining **perfusion**. - Performing CPR at this rate would likely result in no meaningful benefit to the patient.

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

Low tidal volume. ***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.

Q: 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?

Begin chest compressions. **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.

Q: 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?

Fresh frozen plasma. ***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.

Q: 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?

Attach an AED and follow prompts. ***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.

Question 1

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

Accepted Answer

Zoll AED - plus automatic external defibrillator

Answer

Zoll pA02 monitor

Answer

Zoll strength sensor

Answer

Zoll R Series monitor

Question 2

Site for external cardiac massage is:

Accepted Answer

Lower third of sternum

Answer

Xiphoid process

Answer

Junction of body and manubrium sterni

Answer

2 fingers below xiphoid process

Question 3

Intravenous anaesthetic agent of choice in status epilepticus

Accepted Answer

Propofol

Answer

Thiopentone

Answer

Etomidate

Answer

Ketamine

Question 4

During CPCR in ACLS the waveform of capnograph shows following change. This indicates:-

Accepted Answer

Return of spontaneous circulation

Answer

Check position of Endotracheal tube

Answer

Inadequate ventilation

Answer

Inadequate metabolism

Question 5

What is the recommended chest compression rate (per minute) during CPR for adults?

Accepted Answer

100-120 compressions per minute

Answer

60-80 compressions per minute

Answer

40-60 compressions per minute

Answer

20-40 compressions per minute

Question 6

Which of the following is most associated with respiratory alkalosis?

Accepted Answer

Assisted control mode ventilation

Answer

SIMV

Answer

Non invasive ventilation

Answer

Pressure controlled

Question 7

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

Accepted Answer

Low tidal volume

Answer

High tidal volume

Answer

High PEEP

Answer

Low respiratory rate

Question 8

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?

Accepted Answer

Begin chest compressions

Answer

Open the airway

Answer

Give rescue breaths

Answer

Check for a pulse again

Question 9

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?

Accepted Answer

Fresh frozen plasma

Answer

Platelet transfusion

Answer

Cryoprecipitate

Answer

Tranexamic acid

Question 10

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?

Accepted Answer

Attach an AED and follow prompts

Answer

Check for pulse again

Answer

Administer IV epinephrine

Answer

Intubate and ventilate

Critical Care Medicine — MCQs

Critical Care Medicine — MCQs

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