9Critical Care Dimercaprol, when used as a chelation agent, can increase the brain concentrations of which metal? A. Lead B. Arsenic C. Cadmium D. Chromium E. Mercury A patient was diagnosed with epilepsy over 30 years ago and has been on antiepileptic medications since diagnosis. The patient complains of a lupuslike syndrome and progressive ataxia and is found to have gingival hypertrophy on exam. What antiepileptic drug has the patient likely been taking? A. Levetiracetam B. Phenytoin C. Primidone D. Valproic acid E. Lamotrigine A 69-year-old man on aspirin and warfarin underwent a craniectomy for a traumatic subdural hematoma. Surgery was uneventful except for highvolume blood loss, and a blood transfusion was ordered postoperatively. Ten minutes after the transfusion was started, the patient started having tremors. His temperature was 102.8°F, blood pressure was 130/85 mm Hg, pulse was 100 bpm, and respiratory rate was 22 bpm. Per blood bank policies, the transfusion was stopped, and the patient was given acetaminophen. The blood products and a fresh type and screen sample were sent back to the blood bank. What was the patient’s most likely type of blood reaction? A. Acute hemolytic B. Delayed hemolytic C. Febrile nonhemolytic D. Allergic E. Transfusion-related acute lung injury (TRALI) What vitamin should be coadministered with isoniazid to prevent neuropathy? A. Vitamin A B. Vitamin B12 C. Vitamin C D. Vitamin B6 E. Vitamin E A 35-year-old patient admitted to the neurology ICU following polytrauma becomes hypotensive. What hemodynamic parameters are compatible with hypovolemic shock? A. Decreased right atrial pressure, decreased pulmonary capillary wedge pressure, decreased cardiac output, and increased systemic vascular resistance B. Normal or increased right atrial pressure, i ncreased pulmonary capillary wedge pressure, decreased cardiac output, and increased systemic vascular resistance C. Variable right atrial pressure, variable pulmonary capillary wedge pressure, increased cardiac output, and decreased systemic vascular resistance D. Increased right atrial pressure, normal or decreased pulmonary capillary wedge pressure, decreased cardiac output, and increased systemic vascular resistance E. Increased right atrial pressure, increased pulmonary capillary wedge pressure, decreased cardiac output, and increased systemic vascular resistance A 10-year-old boy with von Willebrand disease is scheduled to undergo a craniotomy for tumor resection. Besides having blood products readily available, what can be administered preoperatively to ready the patient for surgery? A. Desmopressin B. Von Willebrand factor C. Factor VII D. Intravenous crystalloids E. Factor IX In the conjunction with absence of brainstem reflexes, absent motor response, and the absence of complicating conditions (e.g., hypothermia, intoxication, etc.), what apnea test PaCO2 finding is consistent with brain death? A. PaCO2 of 40 mm Hg after 10 minutes of testing with no spontaneous respirations B. PaCO2 of 65 mm Hg with a 20 mm Hg rise over the patient’s baseline after 12 minutes of testing with no spontaneous respirations C. PaCO2 of 60 mm Hg with a 10 mm Hg rise over the patient’s baseline after 6 minutes of testing with no spontaneous respirations D. PaCO2 of 50 mm Hg after 10 minutes of testing with no spontaneous respirations Use the following answers for questions 8 and 9: A. Opening pressure 15, 2 WBC without an abnormal differential, protein 30, glucose 60 B. Opening pressure 22, 250 WBC with more than 80% being lymphocytes, protein 500, glucose 25 C. Opening pressure 30, 1,500 WBC with more than 80% PMN, protein 400, glucose 10 D. Opening pressure 21, 110 WBC with more than 50% lymphocytes, protein 80, glucose 50 Abbreviations: WBC, white blood cells; PMN, polymorphonuclear leukocytes What lumbar puncture cerebrospinal fluid study profile is consistent with bacterial meningitis? What lumbar puncture cerebrospinal study profile is consistent with viral meningitis? What aspect of propofol requires the use of an additional intravenous agent when propofol is used as a sedative in the acute trauma setting? A. Its lack of analgesia B. Its lack of hypnotic effects C. Its poor ability to lower intracranial pressure and offer cerebral protection D. Its poor induction properties in the setting of rapid intubation A woman with a family history of unknown but reportedly “significant” reactions to anesthesia is undergoing induction of anesthesia with a halogenated agent. She is noted to have a sudden increase in end-tidal PCO2 and tachycardia. The arterial blood gas reading indicates a metabolic acidosis. The patient had a previous surgery without any complications. What is the next step in the management of this patient? A. Stop the anesthetic agent. B. Administer dantrolene. C. Hyperventilate the patient to 100% FiO2. D. Administer calcium chloride. E. Administer glucose and insulin. What inhalational neuroanesthetic does not reduce cerebral metabolism? A. Halothane B. Enflurane C. Nitrous oxide D. Isoflurane E. Desflurane What is a major advantage of halogenated inhalational anesthetic agents? A. They suppress EEG activity. B. They decrease cerebral blood flow. C. They increase cerebral metabolism. D. They decrease intracranial pressure. E. They are relatively nonhepatotoxic at high doses. Propofol has what analgesic effect? A. Complete analgesia reversal B. No analgesic effect C. Strong analgesic effect D. Blunting of the effects of other analgesics What is the major side effect of nitroglycerin and nitroprusside when used for hypertension control in neurosurgical patients? A. Nitroglycerin and nitroprusside lower the seizure threshold. B. Nitroglycerin and nitroprusside can cause paralysis in acute use. C. Nitroglycerin and nitroprusside cause vasoconstriction. D. Nitroglycerin and nitroprusside raise intracranial pressure. E. Nitroglycerin and nitroprusside increase cerebral perfusion pressure. A patient with various intraparenchymal hemorrhages following trauma has been resuscitated fully except for a continued coagulopathy. As the coagulopathy is corrected, what fluids should be avoided for prolonged administration with regard to the coagulopathy? A. Nonhypertonic crystalloids (e.g., normal saline) B. Colloids (e.g., dextran, hetastarch) C. Hypertonic crystalloids (e.g., 3% normal saline) D. Osmotic agents (e.g., mannitol) E. Isotonic solutions (e.g., Isolyte) What is the definitive way to identify a patient at risk for malignant hyperthermia? A. Obtaining a muscle biopsy for in vitro testing B. Performing genetic testing C. Obtaining an adequate family history D. Assessing serum potassium levels E. Assessing serum creatine kinase levels What pressor agent should be avoided in spinal shock? A. Dopamine B. Phenylephrine C. Isoproterenol D. Levophed E. Dobutamine How do the steroid replacement requirements differ between primary and secondary adrenal insufficiency? A. In primary adrenal insufficiency, only glucocorticoids need to be replaced. B. In secondary adrenal insufficiency, only mineralocorticoids need to be replaced. C. In secondary adrenal insufficiency, both glucocorticoids and mineralocorticoids need to be replaced. D. In primary adrenal insufficiency, both glucocorticoids and mineralocorticoids need to be replaced. E. In primary adrenal insufficiency, only mineralocorticoids need to be replaced. What are the side effects associated with using a long-term, properly dosed, cortisone regimen for a patient with panhypopituitarism secondary to a pituitary adenoma? A. Hypertension and hypokalemia B. Hyperglycemia and salt wasting C. Hyperglycemia and volume depletion through dieresis D. Hypertension and hyperglycemia E. Salt wasting and volume depletion What anesthetic is ideal for a patient experiencing elevated intracranial pressure? A. Thiopental B. Enflurane C. Halothane D. Isoflurane A 45-year-old woman developed marked pallor and a petechial rash following a craniotomy for tumor resection. Her temperature is 101.2°F, blood pressure is 105/75 mm Hg, heart rate is 90 bpm, and respiratory rate is 18 bmp. Lab work reveals a serum creatinine of 2, hemoglobin of 8, platelet count of 36,000, prolonged bleeding time of 5 minutes, prothrombin time of 12.1 seconds, and partial thromboplastin time of 30 seconds. A peripheral blood smear shows fragmented red blood cells. There is no elevation in the serum d-dimer level. What is the most likely diagnosis? A. Idiopathic thrombocytopenic purpura B. Disseminated intravascular coagulation C. Thrombotic thrombocytopenic purpura D. Hemolytic uremic syndrome E. Sepsis What is the most reliable indicator that a patient is experiencing cerebral salt wasting and not the syndrome of inappropriate antidiuretic hormone secretion? A. The patient has a high plasma volume. B. The patient has a low serum sodium concentration. C. The patient has a low urine output. D. The patient is volume depleted. E. The patient has increasing cerebral edema. A man with chronic alcoholism is recovering after an alcohol-induced traumatic cerebral contusion. He is neurologically intact awaiting discharge after eating several full meals when he suddenly develops quadriplegia, confusion, difficulty speaking, and trouble swallowing. Serum sodium is 139 mEq/L. What is the most likely diagnosis? A. Beriberi B. Central pontine myelinolysis C. Pseudohyponatremia D. Cerebral edema E. Cervical spinal cord contusion When/how should hyperventilation be used in the setting of a severe head injury and with what goals? A. It should never be used. B. Prophylactic hyperventilation to achieve a PaCO2 of 30 mm Hg for 48 to 72 hours is safe and effective in reducing intracranial pressure (ICP). C. Hyperventilation to achieve a PaCO2 of 30 to 35 mm Hg is appropriate to use as a temporizing measure for patients with signs of progressive neurologic deterioration when ICP monitoring is not yet established. D. In the case of transtentorial herniation, hyperventilation to achieve a PaCO2 less than 25 mm Hg may be more effective in reducing ICP than achieving a PaCO2 less than 30 mm Hg. In the event of failed maximal medical management of increased intracranial pressure, what is the dosing regimen for pentobarbital for instituting a pentobarbital coma? A. 20 mg/kg intravenous bolus followed by 100 mg every 8 hours B. 100 mg intravenously every 4 hours C. 20 to 75 μg/kg/min intravenous continuous drip D. 10 mg/kg intravenous bolus over 30 minutes followed by a 1 mg/kg/h infusion What antipsychotic medication can lead to agranulocytosis? A. Clozapine B. Thioridazine C. Chlorpromazine D. Aripiprazole E. Quetiapine In patients with low albumin, what equation can be used to convert observed phenytoin levels to equivalent/corrected phenytoin levels? A. Equivalent level = Observed level/(0.1(Albumin level) + 0.1) B. Equivalent level = Observed level – 2(Albumin level) C. Equivalent level = Observed level/(2(Albumin level) + 3) D. Equivalent level = Observed level/Albumin level E. Equivalent level = Observed level – 3(Albumin level) What anesthetic agent can lead to the development of tension pneumocephalus following surgery in the supine position? A. Halothane B. Sevoflurane C. Nitrous oxide D. Propofol E. Remifentanil What are the two main factors that should be present for an air embolism to occur? A. Noncollapsible vein and negative pressure in the vein B. Collapsible vein and positive pressure in the vein C. Noncollapsible vein and positive pressure in the vein D. Collapsible vein and patent foramen ovale E. Patent foramen ovale and negative pressure in the vein Following traumatic skull base fractures, if patients are placed on empiric antibiotic coverage, what organism should be targeted with this coverage? A. Staphylococcus aureus B. Staphylococcus epidermidis C. Streptococcus pneumoniae D. Hemophilus influenza E. Neisseria meningitis A postoperative patient has a potassium level of 6.7, and an electrocardiogram shows peaked T waves. What should be administered next in this patient’s management? A. Calcium gluconate B. Kayexalate C. Insulin and glucose D. Lasix E. Albuterol Use the following answers for questions 33 to 36: A. Atropine B. Physostigmine C. Flumazenil D. Glucagon E. Phentolamine F. Naloxone G. Protamine H. Dimercaprol What is the reversal agent for benzodiazepines? What is the reversal agent for morphine? What is the antidote agent for anticholinergic poisoning? What is the reversal agent for dopamine overdose? What is the mechanism of action of isoproterenol? A. Selective β-adrenergic agonism B. Nonselective β-adrenergic agonism C. Selective β-adrenergic blockade D. Nonselective β-adrenergic blockade E. Trace amine-associated receptor 1 (TAAR1) antagonism How does assist control ventilation work? A. Breaths are patient- or time-triggered with a constant tidal volume for each breath. B. Breaths are patient- or time-triggered, flow limited, and volume cycled; breaths taken by patients are not assisted. C. Breaths are patient-triggered, and inspiratory pressure is added to patient-initiated breaths. D. Breaths are not triggered, and continuous pressure is applied to the ventilation circuit throughout the breathing cycle. Use the following answers for questions 39 and 40: A. Respiratory alkalosis B. Metabolic acidosis C. Combined respiratory and metabolic alkalosis D. Partially compensated respiratory acidosis What pathology is represented by the following arterial blood gas values? pH: 7.30 PCO2: 43 mm Hg HCO3–: 20 mEq/L What pathology is represented by the following arterial blood gas values? pH: 7.56 PCO2: 28 mm Hg HCO3–: 25 mEq/L In an adult patient with a normal head CT following a concussion, what risk factors increase the likelihood for intracranial hypertension? A. Age greater than 60 years, systolic blood pressure less than 100 mm Hg, and posturing on motor exam B. Age greater than 40 years, systolic blood pressure less than 90 mm Hg, and posturing on motor exam C. Age greater than 65 years, systolic blood pressure less than 110 mm Hg, and posturing on motor exam D. Age greater than 35 years, systolic blood pressure less than 80 mm Hg, and posturing on motor exam What is the conversion factor between mm Hg and cm H2O? A. 1 mm Hg = 1.36 cm H2O B. 1 mm Hg = 1.63 cm H2O C. 1 mm Hg = 0.735 cm H2O D. 1 mm Hg = 0.375 cm H2O A 22-year-old patient with a traumatic brain injury is admitted to the intensive care unit with a Glasgow Coma Scale score of 7. What is the recommended goal for the body temperature state for this patient? A. Induced hypothermia B. Permissive hypothermia C. Normothermia D. Permissive hyperthermia E. Induced hyperthermia What intravenous anesthetic may cause adrenal insufficiency? A. Propofol B. Dexmedetomidine C. Etomidate D. Ketamine A 55-year-old woman remains comatose for 4 days following resuscitation from a heart attack. She is off sedation and shows absence of brainstem reflexes. The patient is unable to complete the apnea test portion of the brain death examination. Median nerve somatosensory evoked potentials (SSEPs) are obtained. What finding would be predictive of a poor neurologic outcome? A. Bilateral absence of the N20 waveform B. Bilateral absence of the N9 waveform C. Bilateral absence of the N13 waveform D. Unilateral absence of the N13 waveform How does pressure support ventilation work? A. Breaths are patient- or time-triggered with a constant tidal volume for each breath. B. Breaths are patient or time triggered, flow limited, and volume cycled; breaths taken by patients are not assisted. C. Breaths are patient-triggered, and inspiratory pressure is added to patient-initiated breaths. D. Breaths are not triggered, and continuous pressure is applied to the ventilation circuit throughout the breathing cycle. Use the following answers for questions 47 to 49: A. Tenia solium B. Herpes simplex C. Cryptococcus D. Toxoplasmosis E. West Nile virus F. JC virus A 35-year-old man with HIV has a multiple ring-enhancing lesions on MRI. What is the most likely diagnosis? A 70-year-old woman with HIV and noncompliance with HAART has 3 weeks of progressively worsening mental status along with a left visual field deficit and right-sided weakness. MRI reveals nonenhancing white matter lesions without surrounding edema. The lesions appear hyperintense on T2 and hypointense on T1 sequences. What is the most likely diagnosis? A 73-year-old woman with neck stiffness, headache, left leg weakness, and fever rapidly progressed to having flaccid paralysis and areflexia. Cerebrospinal fluid studies show a white blood cell count over 200, a normal red blood cell count, protein of 87, and a normal glucose level. Cerebrospinal fluid Gram stain shows no organisms, and the culture is negative. What is the most likely diagnosis? A 65-year-old man with a history of chronic obstructive pulmonary disease is admitted for a lobar intracranial hemorrhage. The patient is intubated and sedated. He suddenly develops pulseless electrical activity. Auscultation of the lungs reveals absent breath sounds on the right. The trachea is deviated to the left. What is the best next step in the patient’s management? A. Chest tube placement B. Chest radiograph C. Needle thoracotomy D. Ultrasound of the lungs E. Decrease the tidal volume on the ventilator A 28-year-old man is admitted to the intensive care unit after being hit by a car. He has a 5-mm subdural hematoma on the right and a right femur fracture. Two days after admission, he develops tachypnea, tachycardia, and hypotension and becomes disoriented. On exam, he has new petechiae across his chest. An electrocardiogram is obtained and is unremarkable. A chest radiograph is normal except for two rib fractures. What is the patient’s most likely diagnosis? A. Subdural hematoma expansion B. Pulmonary embolism C. Fat embolism D. Cardiac contusion E. Pulmonary contusion Use the following answers for questions 52 to 54: A. Benign intracranial hypertension B. Aseptic meningitis C. Cerebellar ataxia D. Cochlear and vestibular damage E. Unpleasant taste What are the major potential side effects of penicillin and cephalosporins? What are the major potential side effects of amphotericin B? What are the major potential side effects of ethambutol? How will the urine osmolalities of a patient with central diabetes insipidus (DI) and of a normal individual respond to the injection of DDAVP? A. In a patient with central DI, DDAVP will cause a 50% increase in urine osmolality, whereas it will cause an increase of 5% in a normal individual. B. In a patient with central DI and in a normal individual, DDAVP will cause a 50% increase in urine osmolality. C. In a patient with central DI and in a normal individual, DDAVP will cause a 25% increase in urine osmolality. D. In a patient with central DI, DDAVP will cause a 50% increase in urine osmolality, whereas it will cause a decrease of 5% in a normal individual. E. In a patient with central DI, DDAVP will cause a 25% increase in urine osmolality, whereas it will cause a decrease of 5% in a normal individual. Use the following answers for questions 56 to 59: A. Hodgkin lymphoma B. Neuroblastoma C. Small cell lung cancer D. Thymoma E. Carcinoid tumor What clinical syndrome/condition is associated with opsoclonus-myoclonus in a child? What clinical syndrome/condition is associated with cerebellar dysfunction in an adolescent? What clinical syndrome/condition is associated with limbic encephalitis and myasthenia gravis? What clinical syndrome/condition is associated with Lambert-Eaton myasthenia syndrome? During hyperventilation therapy, a PCO2 below what level could worsen cerebral ischemia? A. 35 mm Hg B. 32 mm Hg C. 28 mm Hg D. 25 mm Hg E. 20 mm Hg What is the main anticipated outcome in proceeding with donation after cardiac death? A. Asystole or pulselessness will occur within 1 hour of withdrawal of care. B. The patient needs to undergo brain death examination after withdrawal of care. C. The transplant surgeon will have to declare the patient deceased. D. The heart will be removed for donation. What is the total blood volume of a 1-year-old boy weighting 10 kg? A. 200 mL B. 400 mL C. 800 mL D. 1.4 L E. 1.6 L A patient develops leukopenia after starting a new drug therapy regimen for trigeminal neuralgia. What medication likely is the cause of the leukopenia? A. Gabapentin B. Baclofen C. Carbamazepine D. Levetiracetam E. Lamotrigine A 45-year-old homeless man is admitted to the hospital after being hit by a car. Thirty-six hours after admission, he becomes agitated and starts complaining of hearing people cursing him and feeling people touching him. His vitals are stable. The patient has a history of alcohol intake and smokes one pack of cigarettes per day. He does not use any drugs and has no significant psychiatric history. What is his most likely diagnosis? A. Alcoholic hallucinosis B. Intensive care unit delirium C. Schizophrenia D. Brief psychotic episode E. Delirium tremens The lower limit of a normal systolic blood pressure for a given age in children may be estimated by what formula? A. 70 mm Hg + 2(Age in years) B. 70 mm Hg + 3(Age in years) C. 50 mm Hg + 2(Age in years) D. 40 mm Hg + 2(Age in years) E. 40 mm Hg + 3(Age in years) Pulmonary capillary wedge pressure is reflective of: A. Pulmonary artery pressure B. Central venous pressure C. Left atrial pressure D. Right atrial pressure E. Left ventricular pressure In the setting of liver failure, an ammonia level of greater than what value is associated with cerebral herniation due to cerebral edema? A. 100 μmol/L B. 150 μmol/L C. 200 μmol/L D. 250 μmol/L E. No ammonia level is predictive of cerebral herniation. Where does antidiuretic hormone (ADH) act in the kidneys? A. Glomerulus B. Proximal renal tubule C. Distal renal tubule D. Loop of Henle E. Collecting duct What is the mechanism of action of ketamine when used as an intravenous sedative? A. GABA-A agonist B. GABA-B agonist C. NMDA receptor antagonist D. Decreases the extent of gap junction cell coupling E. Unknown mechanism of action What is the crystalloid of choice to be administered along with a blood transfusion? A. Lactated Ringer’s solution B. 0.9% normal saline C. D5 water D. 0.225% normal saline A patient presents to the emergency room in status epilepticus. According to the standard treatment algorithm for status epilepticus, after securing the patient’s airway, breathing, and circulation, what medication should be given first? A. Lorazepam 0.1 mg/kg intravenously B. Phenytoin/fosphenytoin 20 mg/kg intravenous load C. Phenytoin/fosphenytoin 125 mg/kg intravenous load D. Dextrose 50 mL of D50 intravenous bolus E. Thiamine 100 mg intravenously Deficiency of what nutrient is associated with ophthalmoplegia, ataxia, and confusion? A. Cyanocobalamin B. Thiamine C. Pyridoxine D. Folate E. Niacin A patient is in coma with the respiratory pattern shown in this image. Where is the patient’s lesion?
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