Critical Care — MCQs
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The following are true of Mendelson's syndrome –
Which is the best initial fluid for resuscitation during the shock state:
What is the treatment for class I hypovolemic shock?
To prevent ventilator associated pneumonia, the most effective and evidence based results are seen with which of the following for critically ill patients:
Adverse effects of hypothermia are all except:
Which of the following is a feature of crush syndrome -
A patient presents with multiple fractures. He develops respiratory distress and dies after few days. CT brain shows petechial hemorrhage. Most likely diagnosis is:
Which of the following is not a component of APACHE score
Best indicator to determine fluid required in hypovolemic patient is
For shock patient, best guideline to check for adequacy of fluid replacement therapy:
Critical Care Indian Medical PG Practice Questions and MCQs
Question 111: The following are true of Mendelson's syndrome –
- A. Steroids have been shown to improve outcome
- B. Critical volume of aspirate is 50 mls
- C. Critical pH of gastric aspirate is 1.5
- D. Onset of symptoms generally occurs within 30 minutes (Correct Answer)
Explanation: ***Onset of symptoms generally occurs within 30 minutes*** - Mendelson's syndrome refers to **chemical pneumonitis** resulting from pulmonary aspiration of sterile gastric contents. - Symptoms like **bronchospasm**, **dyspnea**, and **tachycardia** typically manifest rapidly, often within minutes to 30 minutes post-aspiration. *Steroids have been shown to improve outcome* - **Corticosteroids** are generally **not recommended** for the treatment of Mendelson's syndrome or chemical pneumonitis caused by gastric aspiration. - Their use can potentially increase the risk of **secondary bacterial pneumonia** due to immunosuppression, without significant clinical benefit in improving lung injury. *Critical volume of aspirate is 50 mls* - The critical volume of aspirate associated with Mendelson's syndrome is generally considered to be **25 mL** or **0.3 mL/kg** of gastric contents. - Aspiration of volumes greater than this threshold significantly increases the risk of developing **severe pneumonitis**. *Critical pH of gastric aspirate is 1.5* - The critical pH of gastric aspirate associated with Mendelson's syndrome is generally considered to be **less than 2.5**. - A pH below this value indicates highly acidic gastric contents, which cause **severe chemical burns** to the tracheobronchial tree and lung parenchyma.
Question 112: Which is the best initial fluid for resuscitation during the shock state:
- A. Plasma substitutes
- B. Blood
- C. Crystalloids (Correct Answer)
- D. Colloids
Explanation: ***Crystalloids*** - **Isotonic crystalloids** (e.g., normal saline, lactated Ringer's) are the **first-line fluid of choice** for initial resuscitation in most shock states due to their availability, low cost, and effectiveness in expanding intravascular volume. - They freely distribute into the **interstitial space**, effectively restoring tissue perfusion throughout the body. *Plasma substitutes* - **Plasma substitutes** (e.g., albumin, dextran, gelatins) are **colloids** and are generally **not recommended as first-line** for initial resuscitation due to higher cost and potential side effects compared to crystalloids. - While they can expand intravascular volume effectively, evidence often shows **no significant mortality benefit** over crystalloids in the early phase of shock. *Blood* - **Blood products** (e.g., packed red blood cells) are indicated specifically for **hemorrhagic shock** with significant blood loss to improve oxygen-carrying capacity. - They are **not appropriate for initial resuscitation** in non-hemorrhagic shock states (e.g., septic shock unless anemia is severe) and require cross-matching, which can delay immediate fluid administration. *Colloids* - **Colloids** (including plasma substitutes and synthetic colloids) remain a subject of debate in initial shock resuscitation; while they expand intravascular volume more efficiently than crystalloids, they are **more expensive** and some (e.g., **hydroxyethyl starches**) have been associated with **adverse effects** like acute kidney injury. - They are generally **reserved for specific situations** or when large volumes of crystalloids fail to achieve hemodynamic stability.
Question 113: What is the treatment for class I hypovolemic shock?
- A. IV fluids alone
- B. Admission and IV fluids
- C. Blood transfusion
- D. Oral liquids (Correct Answer)
Explanation: ***Oral liquids*** - **Class I hemorrhagic shock** involves a **minimal blood loss** (up to 15%) with usually no significant changes in vital signs. - In most cases, patients are **hemodynamically stable** and can compensate for the fluid loss by drinking oral liquids. *IV fluids alone* - While IV fluids are suitable for **more severe classes of shock**, they are generally **not necessary for class I**, where oral rehydration is sufficient. - This option does not reflect the least invasive and appropriate treatment for the mildest form of hypovolemia. *Admission and IV fluids* - **Admission** to a hospital is usually reserved for patients with more severe symptoms or those requiring close monitoring for significant fluid loss [1]. - **IV fluids** are **not typically required** for class I shock as oral intake is preferred [1]. *Blood transfusion* - **Blood transfusions** are indicated in cases of **severe hemorrhage** (typically class III or IV) where there is a substantial loss of red blood cell mass. - It is **never the first-line treatment for class I shock** due to the minimal blood loss and associated risks.
Question 114: To prevent ventilator associated pneumonia, the most effective and evidence based results are seen with which of the following for critically ill patients:
- A. Powered brushing
- B. Manual brushing
- C. Betadine mouthwash
- D. Oral hygiene procedures plus chlorhexidine (Correct Answer)
Explanation: Oral hygiene procedures plus chlorhexidine - **Chlorhexidine** mouthwash, when combined with mechanical oral hygiene, significantly reduces the oral bacterial load, preventing aspiration of pathogenic bacteria into the lungs. - This comprehensive approach is a **gold standard** strategy for VAP prevention in critically ill patients, supported by strong evidence. *Betadine mouthwash* - While Betadine (povidone-iodine) has **antiseptic properties**, its efficacy in preventing VAP is not as well-established or consistently supported by evidence as chlorhexidine. - There are concerns about potential **mucosal irritation** and systemic absorption with prolonged use in critically ill patients. *Powered brushing* - Though powered brushing can provide effective plaque removal, it primarily focuses on **mechanical cleaning** without the added antimicrobial benefits of an antiseptic agent like chlorhexidine. - Its effectiveness alone in preventing VAP has **not been shown to be superior** to comprehensive oral care including antiseptics. *Manual brushing* - Manual brushing is a basic component of oral hygiene but, similar to powered brushing, lacks the **antimicrobial action** necessary to drastically reduce bacterial colonization in critically ill, intubated patients. - It is important for general oral cleanliness but **insufficient on its own** for preventing VAP effectively.
Question 115: Adverse effects of hypothermia are all except:
- A. Decreased peripheral resistance (Correct Answer)
- B. Cardiac arrhythmias
- C. Renal failure
- D. Reversible coagulopathy
Explanation: ***Decreased peripheral resistance*** - Hypothermia causes **vasoconstriction** in the periphery, which leads to **increased peripheral resistance**, not decreased. - This effect helps redirect blood flow to vital organs during cold exposure. *Cardiac arrhythmias* - Hypothermia significantly increases the risk of **cardiac arrhythmias**, especially **ventricular fibrillation**, as myocardial excitability changes [1]. - The most common ECG changes include a **prolonged PR interval**, **widened QRS complex**, and the presence of **J (Osborn) waves** [2]. *Renal failure* - Severe hypothermia can lead to **acute kidney injury** or **renal failure** due to reduced renal blood flow, direct cellular damage, and rhabdomyolysis [1], [3]. - Decreased kidney function can also impair the excretion of drugs and metabolic waste products. *Reversible coagulopathy* - Hypothermia causes a **reversible coagulopathy** due to impaired platelet function, decreased activity of coagulation factors, and increased fibrinolysis. - This can manifest as increased bleeding tendencies, particularly in trauma patients.
Question 116: Which of the following is a feature of crush syndrome -
- A. Hypophosphatemia
- B. Hypokalemia
- C. Hypercalcemia
- D. Myoglobinuria (Correct Answer)
Explanation: Myoglobinuria - **Myoglobinuria** is a hallmark of crush syndrome, resulting from the massive release of **myoglobin** from damaged muscle cells into the bloodstream [2]. - This excess myoglobin can precipitate in the renal tubules, leading to **acute kidney injury (AKI)** [1]. *Hypophosphatemia* - Crush syndrome typically results in **hyperphosphatemia**, not hypophosphatemia, due to the release of intracellular phosphate from damaged muscular cells. - The elevated phosphate levels contribute to reciprocal **hypocalcemia** through precipitation. *Hypokalemia* - Crush syndrome is characterized by **hyperkalemia**, caused by the release of intracellular potassium from damaged muscle cells. - **Hyperkalemia** is a significant and life-threatening complication due to its potential for cardiac arrhythmias. *Hypercalcemia* - Crush syndrome typically presents with **hypocalcemia** due to the precipitation of calcium with released phosphate and fatty acids. - Initial **hypocalcemia** may later be followed by **hypercalcemia** during the recovery phase, especially in those with renal failure, but hypocalcemia is more acute.
Question 117: A patient presents with multiple fractures. He develops respiratory distress and dies after few days. CT brain shows petechial hemorrhage. Most likely diagnosis is:
- A. Hypoxic ischemic encephalopathy
- B. Hemorrhage
- C. Fat embolism (Correct Answer)
- D. Stroke
Explanation: ***Fat embolism*** - The classic triad of **fat embolism syndrome** includes **respiratory distress**, neurological symptoms (such as **petechial hemorrhages** on CT brain), and petechial rash, often occurring after **multiple fractures** [1]. - The fat emboli, released from the bone marrow following trauma, travel to the lungs and systemic circulation, leading to organ dysfunction [1]. *Hypoxic ischemic encephalopathy* - While respiratory distress can lead to hypoxia, the presence of **petechial hemorrhages** in the brain following fractures is more characteristic of fat embolism [1]. - Hypoxic ischemic encephalopathy typically involves diffuse brain injury due to lack of oxygen and blood flow, without the specific pattern of petechial hemorrhages seen here. *Hemorrhage* - Although trauma can cause hemorrhage, the description of **multiple fractures** followed by **respiratory distress** and **petechial hemorrhage** in the brain points more specifically to fat embolism syndrome [1]. - A primary intracranial hemorrhage would present with acute neurological deficits, and systemic hemorrhage alone would not explain the respiratory distress and specific brain findings without other signs of massive blood loss. *Stroke* - A stroke is generally localized brain damage due to an interruption in blood supply, either ischemic or hemorrhagic. - The combination of **multiple fractures**, subsequent **respiratory distress**, and widespread **petechial hemorrhages** is not typical for a standard stroke but is highly indicative of fat embolism syndrome [1].
Question 118: Which of the following is not a component of APACHE score
- A. Serum calcium (Correct Answer)
- B. Serum sodium
- C. Serum potassium
- D. Creatinine
Explanation: ***Serum calcium*** - Serum calcium is **not included** as a variable in the Acute Physiology and Chronic Health Evaluation (APACHE) score. - The APACHE score focuses on parameters highly predictive of **mortality risk** in critically ill patients. *Serum sodium* - **Serum sodium** levels are an important component of the APACHE score, as significant abnormalities (both hyponatremia and hypernatremia) reflect severe physiological derangement. - Deviations from normal **sodium** ranges contribute to the overall severity score. *Serum potassium* - **Serum potassium** levels are also a crucial part of the APACHE score, as dyskalemia (hypokalemia or hyperkalemia) can have profound cardiac and neurological effects. - Abnormal **potassium** values are weighted in the scoring system to indicate increased illness severity. *Creatinine* - **Creatinine** levels are included in the APACHE score as a marker of **renal function**, which is a significant predictor of patient outcome. - Elevated **creatinine** indicates kidney dysfunction, contributing points to the overall severity assessment.
Question 119: Best indicator to determine fluid required in hypovolemic patient is
- A. 2D echo
- B. CVP
- C. PCWP (Correct Answer)
- D. Intra arterial BP
Explanation: ***PCWP*** - **Pulmonary capillary wedge pressure (PCWP)** indirectly measures left atrial pressure, which reflects left ventricular end-diastolic pressure, a key indicator of **cardiac preload** and fluid status [1]. - A low PCWP in a hypovolemic patient suggests the need for **fluid resuscitation** to optimize cardiac output. *2D echo* - While 2D echocardiography can assess **cardiac function** and some parameters related to fluid status (like IVC collapsibility), it is not the most direct or specific indicator for fluid requirement in an acutely hypovolemic patient. - Its use often requires a skilled operator and is primarily diagnostic for structural and functional abnormalities rather than real-time fluid responsiveness guidance. *CVP* - **Central venous pressure (CVP)** reflects right atrial pressure, which is a measure of **right ventricular preload** [1]. - CVP can be misleading in patients with **right ventricular dysfunction** or **pulmonary hypertension**, making it less reliable for assessing overall fluid status compared to PCWP [1]. *Intra arterial BP* - **Intra-arterial blood pressure (BP)** is a direct and accurate measure of systemic arterial pressure, indicating **perfusion**. - While hypotension (low BP) is common in hypovolemia, BP alone does not reliably indicate the *amount* of fluid required or the patient's **fluid responsiveness**, as compensatory mechanisms can maintain BP even with significant volume loss.
Question 120: For shock patient, best guideline to check for adequacy of fluid replacement therapy:
- A. Central Venous Pressure
- B. Urine output (Correct Answer)
- C. Hemoglobin
- D. Blood pressure and pulse
Explanation: Detailed assessment of a shock patient involves monitoring multiple parameters to guide fluid therapy. ***Urine output*** is a sensitive indicator of **renal perfusion** and overall tissue perfusion, reflecting the adequacy of fluid resuscitation [1]. A target urine output of **0.5-1 mL/kg/hour** is generally used in shock patients to ensure sufficient organ perfusion. *Central Venous Pressure* - **Central Venous Pressure (CVP)** can be a misleading indicator of fluid status, as it reflects right atrial pressure and not necessarily ventricular preload or cardiac output [1]. - While it provides some information, it has limitations as a sole measure for guiding fluid resuscitation due to its poor correlation with **volume responsiveness**, and certain conditions like pulmonary hypertension may raise CVP even in hypovolemia [1]. *Hemoglobin* - **Hemoglobin** levels primarily reflect the oxygen-carrying capacity of the blood and are crucial for diagnosing **anemia** or assessing **blood loss**. - It does not directly indicate the adequacy of fluid volume or tissue perfusion, especially in cases of distributive or cardiogenic shock without significant hemorrhage. *Blood pressure and pulse* - **Blood pressure** and **pulse rate** are important vital signs for assessing the initial response to fluid resuscitation and the presence of shock [1]. - However, they can be maintained within normal limits by compensatory mechanisms even in ongoing hypoperfusion (**compensated shock**), making them less reliable as a sole indicator of adequate fluid replacement [1].
Practice by Chapter
Shock Syndromes and Management
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Acute Respiratory Distress Syndrome
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Mechanical Ventilation Principles
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Hemodynamic Monitoring
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Nutrition in Critical Illness
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Sedation and Analgesia in ICU
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Multi-organ Dysfunction Syndrome
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Acid-Base and Electrolyte Disturbances
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Toxicologic Emergencies
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Neurological Emergencies in ICU
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Renal Replacement Therapy
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End-of-Life Care in ICU
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