FCCS Review 2023 Questions with correct Answers

What is the most important sign in a critically ill pt? Why? - ANSWER-Tachypnea Indicates metabolic acidosis w/ respiratory alkalosis compensation A pt misses dialysis for a few days and comes in with fluid overload. He's tachycardic and tachypneic. On physical exam, you find JVD, pulsus paradoxus (20 mmHg drop during inspiration), and HoTN (80/40) with distant, muffled heart sounds. Lungs are clear to auscultation. What is the dx? - ANSWER-Cardiac tamponade; obstructive shock If a pt has a thyromental distance of 2 cm, what can you expect about their airway? - ANSWER-Difficult airway w/ an anteriorly displaced larynx A COPD pt comes in with difficulty breathing. He then becomes apneic and unresponsive. How would you ventilate this pt? - ANSWER-BVM A pt arrives after falling from a ladder and has a frontal laceration. On examination, you find papilledema and labored breathing w/o being able to clear secretions. What is your biggest concern when intubating this pt? - ANSWER-Cerebral edema/increasing ICP Intubation tends to cause an increase in ICP. Administer lidocaine prior to intubation to inhibit vagal stimulation. An ESRD pt w/ hyperkalemia develops dyspnea and requires intubation. Which paralytic agent/NMB should you avoid and why? - ANSWER-Succinylcholine Worsens hyperkalemia A pt is admitted after an OD. He starts to have apneic episodes and his SpO2 is dropping. You place him on a non-rebreather mask w/ 100% O2, yet his SpO2 remains at 80%. Why is it not being corrected? Then, if you try a BVM and it also fails, and video laryngoscopy is unavailable, what is your next best choice for an airway? - ANSWER-The pt is having apneic episodes, which means that administering high-flow O2 will be ineffective. Choose an LMA if the BVM fails. What intervention improves outcomes with ROSC after cardiac arrest? - ANSWER-Targeted temperature management. 32-36 C A shunt means there is perfusion without ventilation. What disease process is an example of a shunt? - ANSWER-Pneumonia Which type of respiratory failure occurs with CNS depression after an OD? - ANSWER-Acute hypercapnic respiratory failure --> mixed A 50 y/o pt is having a COPD exacerbation. You have tried steroids, bronchodilators, etc. with no improvement. PCO2 is in the 90s, pH is 7.20. You decide to intubate. Vent settings are: VT 375, RR 20, FiO2 .35, PEEP 5. CXR is normal. A few minutes later, his BP drops to 70/40. Lungs are clear/equal. Vent shows peak airway pressure of 55 (high) and plateau pressure of 15. End expiratory hold gives auto-peep of 15. What is the cause of this pt's HoTN and why? - ANSWER-Auto-peep is the cause. COPD pts have difficulty exhaling --> pressure buildup in alveoli. We use PEEP for the pressure and to improve oxygenation. Auto-peep comes from breath-stacking --> intrinsic peep. Alveoli enlarge --> high peak airway pressure. All leads to low venous return --> low CO --> HoTN A COPD pt is admitted to the ICU for exacerbation. Pt is on a vent. Pt is tx w/ bronchodilators, steroids, and Abx. ABG was normal 1 hr ago, but now the peak airway pressure is up to 55 and plateau pressure is also high at 50. Pt becomes hypotensive at 70/40. You observe tracheal deviation to the R. Normal breath sounds on the right, diminished on the left. No wheezing. WBC is normal. What is the dx and treatment? - ANSWER-Tension pneumothorax Needle decompression/chest tube A pt in ARDS s/p pneumonia is on 100% FiO2 with PEEP of 22. PO2 is 88%. Peak airway pressure and plateau are both high. VT is 5 ml/kg. How can you decrease the airway pressures? - ANSWER-Decrease the PEEP, even though it will decrease PaO2. (Note: you can't decrease the VT because it is already on the low end). A young asthmatic pt is on the vent. His lungs are very tight. He is on the AC setting and there is a lot of auto-PEEP. You correct it by reducing the rate, giving him more time to exhale and making sure he has enough flow. FiO2 is at .50. He is sedated and seems comfortable. On ABG the pH is 7.24, CO2 is 65, O2 is 80, and bicarb is 29. What would you do with the vent settings in this case? - ANSWER-Keep the settings where they are. You can't hyperventilate the pt to blow off CO2 b/c the asthma will worsen. As long as the pH is > 7.2, the settings are okay as they are. CO2 will correct over time. Which two conditions are the most indicated for BiPAP? - ANSWER-COPD exacerbation Cardiogenic pulmonary edema A 70 y/o pt with CHF presents with SOB, accessory muscle use, RR 34, SpO2 90% on 8L O2. CXR reveals infiltrates in a bat wing pattern. She also has LE edema. She is dx with a CHF exacerbation w/ respiratory failure. Her ABG shows pH 7.3, PO2 64, CO2 50. What is the best tx for this pt? - ANSWER-Non-invasive BiPAP. A pt comes in w/ a femur fx and a rod is placed. Post-op he develops dyspnea and fever. HR 140, RR 30, SpO2 92% on non-rebreather. He is transferred to the ICU where you intubate, place a central line, and start resuscitating him. Hb 8.2, lactate 3.2, SVO2 is 52%. Why is his SVO2 low? How can we improve it? - ANSWER-Decreased O2 delivery and increased consumption. (normal is 65-70) Administer packed RBCs - 1U of blood will change his Hb from 8.2 to 9.2. O2, fluid, and VT would not work. A young pt after an MVA comes to the ER hypotensive and tachycardic. CXR is clear. He has a contusion on his chest wall and torso. He is unconscious. What will give you the best insight on what is causing his shock? Hb SCV Urine Output FAST exam - ANSWER-FAST exam 41 y/o pt in the SICU following debridement of b/l lower extremities for necrotizing fasciitis is intubated on AC. Temp 102, HR 116, RR 16, BP 92/46. ABG shows pH 7.23, PO2 133, PCO2 38, Na 139, K 3.7, Cl 102, Bicarb 16, lactate 4. Dx is metabolic acidosis w/ anion gap d/t infection. What is the most appropriate intervention? Increase VT Continue resuscitation Decrease RR Administer bicarb - ANSWER-Continue resuscitation. Don't need to increase VT bc the pt doesn't have respiratory acidosis. If you decrease the RR, the pt will go into respiratory acidosis. A pt has obstructive uropathy. A catheter is placed d/t the obstructive kidney injury. After the cath is placed, he has massive diuresis to the point where he is hypotensive, tachy, and lactate is 2x the ULN from decreased perfusion. How would you correct this? - ANSWER-Fluids - LR When treating hyponatremia, what is the first thing to assess? When do you give 3% NaCl? How do you correct it? - ANSWER-1. fluid status 2. seizures or changes in mental status 3. slowly, 8-12 meq over 24 hr What are the classifications of hemorrhagic shock? - ANSWER-I: <15%; HR <100, BP normal, RR normal II: 15-30%; HR >100, BP normal, RR 20-30 III: 30-40%; HR >120, BP low, RR 30-40 IV: >40%; HR >140, BP low, RR >40 An 84 y/o pt fell down the stairs. He is moaning and crying. He has a C-collar in place. His neck is painful and he has bruising on his face. He is tachy but BP is okay. You administer 2L O2 bc SpO2 was 92%. Shortly after he deteriorates, becoming altered and then comatose. His left pupil > the right. He is herniating from cerebral edema. How do you treat him? - ANSWER-Intubate and ventilate, maintaining c-spine precautions. Administer mannitol. A pt comes in with several cardiovascular RFs: elderly, DM, and HTN. He is having chest pain, SOB, and is diaphoretic. What diagnosis do you need to re-perfuse him immediately? - ANSWER-STEMI What is the most appropriate management for both STEMI and non-STEMI? nitro if bp >80 morphine q 30 min bb oxygen if sats are <94% - ANSWER-Oxygen Which NSTEMI needs to be sent to the cath lab immediately? - ANSWER-NSTEMI w/ shock Which medication improves outcomes for pts with STEMI? - ANSWER-ACE-I Give if BP is stable. It decreases LV remodeling and decreases afterload. A 70 y/o pt has been hospitalized for 15 days. He had a cholecystectomy and abscess formation which was tx appropriately. He has a central line in the right IJ. The site looks visibly infected, and he has a fever, is tachy, and hypotensive. WBCs are high. Blood culture and initial gram stain reveals G(+) cocci. What is the dx? What is the MC pathogen? What is the tx? - ANSWER-1. line-related infection 2. coag (-) staph epidermis 3. vanco + zosyn + ceftriaxone if MRSA: vanco + ceftriaxone if MSSA: zosyn + ceftriaxone What is the tx for meningitis? - ANSWER-young pt: ceftriaxone + vanco > 50 pt: add ampicillin A chemotherapy pt becomes septic. You suspect a neutropenic fever. What is the tx? - ANSWER-broad spectrum abx (vanco/zosyn) obtain blood, urine, and sputum culture CXR + CT What is the tx of hyperkalemia? - ANSWER-calcium gluconate + insulin + dextrose bicarb, kayexalate, albuterol definitive tx: dialysis How do you manage DKA? - ANSWER-Check potassium Multiple L bolus via at least 2 peripheral IVs Insulin infusion, 0.1U/kg/hr until sugar reaches 250 mg/dl Switch NS to D5W Once anion gap is closed, administer long-acting insulin 1 hr prior to d/c infusion A 70 y/o pt with COPD comes in with an exacerbation. He is rapidly becoming more hypoxic. To rule out PE, what test should you order? - ANSWER-CT A 22 y/o pt ingested drugs >4 hours ago. She came to the ICU obtunded w/ arousal to tactile stimulation. She is hemodynamically stable. RR 8 with an NG tube in place. What is the next step for tx of the ingestion? - ANSWER-Monitor / watchful waiting. The pt ingested the drugs more than 4 hours ago. Monitor RR and intubate if necessary. A pt presents with HTN, ripping/tearing pain to the back, and unequal pulses. What is the dx? What is the tx goal and what should you use? What medication is contraindicated? - ANSWER-1. aortic dissection 2. lower BP and HR 3. Labetalol, no reflex tachycardia 4. Nitro is contraindicated What decreases during pregnancy by ~25%? - ANSWER-Functional residual capacity A 24 y/o male comes in following a concussion. CT reveals a frontal lobe contusion. He does not require intubation and is kept on 3 L O2 NC. He then suddenly has a generalized seizure. What is the DOC? What do you give after the seizure? What med class is an absolute contraindication for seizures? - ANSWER-1. lorazepam IV 2. dilantin 3. NMB a 55 y/o male comes in with AMS and diffuse abdominal pain. He takes HCTZ and a multivitamin. HR 120 sinus tach. He is moaning in pain and unable to articulate what is happening. CT reveals lytic lesions in the vertebrae. You administer a 3L NS bolus which shows mild improvement. What is the dx and what is causing his symptoms? How do you tx? - ANSWER-Dx: multiple myeloma The hypercalcemia is what is causing the symptoms. Tx: Fluids, then diuretic or bisphosphonate if symptoms persist. How do you treat septic shock (4 things)? - ANSWER-2-3 L bolus NE Vasopressin Steroids