Critical Care Practice Questions

Q: Which of the following is true regarding Acute Respiratory Distress Syndrome (ARDS)?

Lung compliance is decreased. Explanation: **Acute Respiratory Distress Syndrome (ARDS)** is characterized by diffuse alveolar damage leading to increased permeability of the alveolar-capillary membrane. 1. **Why Option B is Correct:** In ARDS, the alveoli are filled with protein-rich edema fluid and inflammatory debris, and there is a significant loss of functional surfactant [1]. This leads to alveolar collapse (atelectasis) and makes the lungs "stiff." Therefore, **lung compliance is markedly decreased**, requiring higher pressures to achieve the same tidal volume (often referred to as "Baby Lung" physiology) [1]. 2. **Why Other Options are Incorrect:** * **Option A:** ARDS typically causes **Type 1 Respiratory Failure** (Hypoxemic) [2]. While $CO_2$ retention can occur in late stages or due to protective lung ventilation strategies (permissive hypercapnia), the hallmark is profound hypoxemia due to right-to-left shunting [2]. * **Option C:** The **diffusion capacity (DLCO) is decreased**, not increased. The accumulation of fluid and the formation of hyaline membranes thicken the blood-gas barrier, severely impairing gas exchange. **High-Yield Clinical Pearls for NEET-PG:** * **Berlin Criteria:** Acute onset (within 1 week), bilateral opacities on imaging not fully explained by effusions/collapse, and respiratory failure not fully explained by heart failure (PCWP < 18 mmHg) [1]. * **Severity:** Based on $PaO_2/FiO_2$ ratio: Mild (201–300), Moderate (101–200), Severe (≤ 100). * **Management:** The mainstay is **Low Tidal Volume Ventilation** (6 mL/kg of predicted body weight) to prevent volutrauma and **Prone Positioning** (for at least 16 hours/day in severe cases) to improve V/Q matching.

Q: Which of the following is not a component of qSOFA score?

LDH-Lactate dehydrogenase. ***LDH-Lactate dehydrogenase*** - The **quick Sequential Organ Failure Assessment (qSOFA) score** is a rapid bedside tool used to identify adult patients with suspected infection who are at high risk for poor outcomes, but it does not include laboratory markers like LDH. - qSOFA only includes three simple, readily available clinical criteria (respiratory rate, mental status, and systolic BP), therefore **LDH** is not a component. *Respiratory rate >22* - A **respiratory rate of 22 breaths per minute (or higher)** is one of the three components of the qSOFA score (a score of 1 point is given if RR ≥ 22) [1]. - This parameter indicates a potential compensatory mechanism for **metabolic acidosis** or severe underlying respiratory compromise due to infection. *Altered mental status* - **Altered mental status** (Glasgow Coma Scale score < 15 or any change from baseline) is a key component of the qSOFA score (1 point) [1]. - This reflects neurological **end-organ dysfunction** secondary to systemic inflammation and hypoperfusion (sepsis-associated encephalopathy). *Systolic blood pressure < 100 mmHg* - A systolic blood pressure (SBP) **less than 100 mmHg** is the third component of the qSOFA score (1 point) [1]. - This criterion indicates **hemodynamic compromise** and potential **shock**, reflecting severe circulatory dysfunction associated with sepsis.

Q: Which of the following is seen in all kinds of shock?

Reduced tissue perfusion. ***Reduced tissue perfusion*** - **Shock** is fundamentally defined as a state of cellular and tissue hypoxia due to reduced oxygen delivery, which results from inadequate or ineffective **tissue perfusion** [1]. - In all forms (hypovolemic, cardiogenic, distributive, and obstructive), the core pathophysiological defect is the inability to meet the metabolic demands of the tissues, hence **reduced tissue perfusion** is a universal finding [1], [2]. *Increased peripheral resistance*- This finding is characteristic of **compensatory shock** (e.g., early hypovolemic or cardiogenic) as part of the sympathetic response to maintain mean arterial pressure. - It is *not* seen in **distributive shock** (like septic or anaphylactic shock), which is characterized by profound **vasodilation** and thus marked *decreased* peripheral resistance [2]. *Decreased respiratory rate*- A decreased respiratory rate is *not* characteristic of shock; rather, **metabolic acidosis** (due to anaerobic metabolism) typically stimulates the respiratory center, leading to **compensatory tachypnea** (increased rate). - A decreased respiratory rate might only be seen if shock is severe and complicated by **CNS depression** from drugs or profound decompensation. *Cold clammy skin*- **Cold, clammy skin** is the classic presentation of **hypoperfusion** combined with sympathetic-driven peripheral **vasoconstriction**, typically seen in *hypovolemic* and *cardiogenic* shock. - In contrast, **distributive shock** (especially **septic shock**) presents with **warm, flushed skin** due to widespread peripheral vasodilation and increased cardiac output (hyperdynamic state).

Q: A 20-year-old female diagnosed with septic shock presents with a blood pressure of 58/30 mmHg. After receiving 3 liters of crystalloid fluid, her mean arterial pressure (MAP) remains 58 mmHg. What is the next best step in management?

Start noradrenaline. ***Start noradrenaline*** - **Noradrenaline (Norepinephrine)** is the preferred first-line vasopressor in **septic shock** to achieve a target Mean Arterial Pressure (MAP) of $\ge 65$ mmHg, especially when fluid resuscitation (3L of crystalloids given) is inadequate [1]. - It primarily acts as an $\alpha$-agonist, causing significant **vasoconstriction** which increases systemic vascular resistance (SVR) and improves blood pressure. ***Start dopamine*** - Dopamine is considered a second-line agent due to its potential to cause more **tachyarrhythmias** compared to noradrenaline. - It is often reserved for patients with a low risk of tachyarrhythmias or relative **bradycardia** in addition to hypotension. ***Repeat crystalloid fluid*** - The current fluid challenge (3L) is substantial; administering more fluid without a pressor in refractory shock can lead to detrimental effects like **pulmonary edema** and fluid overload, which has diminishing returns on MAP [1]. - The patient's persistent hypotension (MAP 58 mmHg) despite significant fluid resuscitation indicates inadequate peripheral vascular tone (**vasoplegia**), requiring immediate vasopressor support [1]. ***Start vasopressin*** - **Vasopressin** is generally added as a second-line agent to noradrenaline (**vasopressor weaning**) to potentially reduce the dose of noradrenaline needed. - It is not recommended as the initial monotherapy for hypotension in septic shock because it lacks the potent $\alpha$-agonist effect of noradrenaline.

Question 1

All are true of septic shock, except?

Accepted Answer

Caused by gram-positive bacteria

Answer

Tachycardia

Answer

Warm skin

Answer

Decreased cardiac output

Question 2

In gram-negative septicemia, what are the early findings preceding shock?

Accepted Answer

Increased cardiac output, decreased total peripheral resistance

Answer

Increased cardiac output, increased total peripheral resistance

Answer

Increased cardiac output, transient total peripheral resistance

Question 3

A 40-year-old woman with a clinical suspicion of sepsis develops moderate hemoptysis one hour after a procedure. She has sinus tachycardia and clear lung fields. She has received IV fluids, blood cultures have been drawn, she is on antibiotics, and subcutaneous heparin for thromboembolic prophylaxis. A CXR has been performed. What is the next best step in management?

Accepted Answer

Withdraw the catheter

Answer

Perform an urgent echocardiogram

Answer

Administer protamine sulfate

Answer

Start inotropic agents

Question 4

When evaluating an arterial blood gas (ABG) from a client with a subdural hematoma, the nurse notes the PaCO2 is 30 mm Hg. Which of the following responses best describes this finding?

Accepted Answer

Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP).

Answer

Emergent; the client is poorly oxygenated.

Answer

Normal.

Answer

Significant; the client has alveolar hypoventilation.

Question 5

In which of the following conditions is a rapid reduction of blood pressure indicated?

Accepted Answer

Hypertensive encephalopathy

Answer

Cerebral infarct

Answer

Myocardial infarction

Answer

Any patient with hypertension

Question 6

Which of the following is true regarding Acute Respiratory Distress Syndrome (ARDS)?

Accepted Answer

Lung compliance is decreased

Answer

Type 2 respiratory failure

Answer

Increased diffusion capacity of the lungs

Answer

None of the above

Question 7

Which of the following describes the features of neurogenic shock?

Accepted Answer

Decreased peripheral resistance and decreased cardiac output

Answer

Increased peripheral resistance and decreased cardiac output

Answer

Increased venous return and increased cardiac output

Answer

Venoconstriction and decreased cardiac output

Question 8

Which of the following is not a component of qSOFA score?

Accepted Answer

LDH-Lactate dehydrogenase

Answer

Systolic blood pressure < 100 mmHg

Answer

Respiratory rate >22

Answer

Altered mental status

Question 9

Which of the following is seen in all kinds of shock?

Accepted Answer

Reduced tissue perfusion

Answer

Increased peripheral resistance

Answer

Cold clammy skin

Answer

Decreased respiratory rate

Question 10

A 20-year-old female diagnosed with septic shock presents with a blood pressure of 58/30 mmHg. After receiving 3 liters of crystalloid fluid, her mean arterial pressure (MAP) remains 58 mmHg. What is the next best step in management?

Accepted Answer

Start noradrenaline

Answer

Start vasopressin

Answer

Start dopamine

Answer

Repeat crystalloid fluid

Critical Care — MCQs

Critical Care — MCQs

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