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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2669_Библиотеки_им_академика_М_И_Перельмана
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MCQ 7 (2024)
45 year old patient is admitted to the general internal medicine ward with acute
respiratory failure secondary to influenza. Their medical history includes hypertension.
They were initially managed with conventional oxygen therapy, with nasal prongs
4L/min. On repeat assessment their hypoxemia is worsening with O2 sats 85% on nonrebreather mask at 12L/min and they have increased work of breathing. They are
following commands and speaking in short sentences. VBG shows pH 7.42, CO2 35,
Bicarb 24.
What is the best next step in management?
1. Non-Invasive Ventilation
2. High-Flow Nasal Cannula
3. Intubation
4. Proning
5. Hydrocortisone 100 mg IV
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MCQ 7 (2024)
1. Non-Invasive Ventilation
Non-invasive ventilation should be used for hypoxemia secondary to cardiogenic pulmonary edema, and can be considered for acute
respiratory failure in patients with chest trauma, immunocompromised state, post-operative, palliative with dyspnea. There is no
recommendation made for de novo respiratory failure without these conditions.
2. High-Flow Nasal Cannula
Strong indication for hypoxemic respiratory failure OVER conventional oxygen therapy
3. Intubation
There is no strong indication for intubation yet. Airway is protected (patient is talking, alert) and work of breathing/hypoxemia may
improve on HFNC.
4. Proning
Self proning can be considered for hypoxemia in setting of covid in non-intubated patients. However, HFNC would be used first.
5. Steroids
Steroids have a benefit in treating Severe COMMUNITY ACQUIRED PNEUMONIA (data covered in ID lecture) and with COVID 19
(Dexamethasone) – however can actually be harmful (more nosocomial infection, possibly more mortality) with influenza. Even if you
didn’t know this data, in this setting next best step (ABCs!) is to administer more oxygen if you were choosing best answer on MCQ.
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MCQ 8 (2024)
65 year old patient is admitted to the ICU after an unwitnessed out-of-hospital cardiac arrest
secondary to fentanyl overdose. It is now 60hrs since the arrest. CT head shows diffuse grey-
white matter loss in keeping with a hypoxemic-ischemic brain injury, with cerebral edema and
tonsillar herniation. Post-cardiac arrest management included therapeutic hypothermia
targeting 35-36 degrees C. Passive rewarming has started and the current core temperature is
35.6 degrees C. The patient was sedated with propofol and ketamine which were stopped
24hrs after the cardiac arrest. No neuromuscular blockers were used. MAP is currently 70 with
vasopressin, ABG showing pH 7.33, PaCO2 45, lactate 1.7. Bicarb 24. Further labs show Na
150, K 3.4, Cr 140, Urea 15, Calcium 2.1, Mg 0.8, Phosphate 0.7, Bilirubin 20, ALT 60, ALP 80.
Which of the following would prevent death by neurological criteria assessment?
1. Time since cardiac arrest
2. Core temperature
3. Metabolic derangement
4. Shock
5. Sedative medication
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MCQ 8 (2024)
1. Time since cardiac arrest
Updated canadian guidelines 2023 state to wait at least 48hrs since cardiac arrest before completing DNC assessment.
2. Core temperature
Core temperature must be ≥36 degrees C in latest guidelines (previously 34) before completing DNC assessment
3. Metabolic derangement
Metabolic derangements that are severe should be corrected before completing DNC assessment. However, none of the metabolic
derangements in this case would be considered severe enough.
4. Shock
Shock is resuscitated in this case with vasopressor support and a normal lactate. Only un-resuscitated shock prevents DNC assessment
(i.e. high lactate, end organ ischemia/dysfunction, MAP < 65 despite vasopressors).
5. Sedative medication
New guidelines suggest waiting 5 half lives of medications. 60hrs would be long enough for fentanyl (1/2 life approx 4-7hrs) and
ketamine/propofol (stopped approx 40hrs ago).
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MCQ 9 (2024)
80 year old patient presents to the emergency department with nausea and vomiting secondary to a small
bowel obstruction. Past medical history includes chronic pain, depression, cholecystectomy. Home
medications are citalopram, hydromorphone contin, senna. The patient undergoes an urgent laparotomy
with resection of adhesions for management of the small bowel obstruction. They are admitted to the ICU
for post-operative management. Issues during the ICU stay include post-operative ileus, delirium and pain.
ICU medications include hydromorphone CR, IV fentanyl, IV gravol, IV metoclopramide, lansoprazole,
citalopram, dalteparin 5000 u sc daily. On post-operative day 3 the patient develops a temperature of 39
degrees C. Vitals shows BP 130/80, HR 110, RR 20, Sats 96% 2L NP. Examination shows pupils 5mm and
equal, diaphoresis, agitation, lower limb rigidity with brisk reflexes, ankle clonus x 12 beats bilaterally.
Which syndrome most likely explains the findings?
1. Sympathomimetic toxidrome
2. Anti-cholinergic toxidrome
3. Serotonin syndrome
4. Neuroleptic malignant syndrome
5. Malignant hyperthermia
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MCQ 9 (2024)
1. Sympathomimetic toxidrome
No inciting cause. Rigidity not expected. Patient would have significant hypertension.
2. Anti-cholinergic toxidrome
Excessive levodopa could cause this, but would expect dilated pupils. Does not explain hypertonia.
3. Serotonin syndrome
Fentanyl and citalopram (SSR) could cause serotonin syndrome; addition of metoclopramide to the mix can worsen risk of
serotonin syndrome in patients on SSRIs!! He has fever, rigidity, hyperreflexia and clonus so this fits the bill.
4. Neuroleptic malignant syndrome
There are features of NMS (hyperthermia, rigidity,) and an inciting cause potentially (metoclopramide) – however the
hyperreflexia doesn’t fit with this syndrome and is better explained by serotonin syndrome.
5. Malignant hyperthermia
To o l on g si nc e vo la ti le anaesthetic. This would occur minutes/hrs after exposure.
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MCQ 10 (2024)
A patient has been admitted to the intensive care unit after a motor vehicle collision.
Their injuries include a severe traumatic brain injury (TBI), rib fractures, splenic
laceration, and facial fractures including an orbital fracture with disruption of the ocular
muscles resulting in fixed abduction of the right eye. The patient remains GCS 3 48hrs
into admission with CT evidence of severe cerebral edema, mass effect and herniation.
Examination reveals no brainstem reflexes. No further options are available for
management of the TBI. Review of the chart shows no confounders to death by
neurologic criteria (DNC) assessment.
What is the appropriate next step?
1. Wait a further 24hrs hours before completing DNC assessment
2. Order an MRI
3. Proceed with DNC assessment
4. Order a CTA head and neck as an ancillary test
5. Order SSEPs
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MCQ 10 (2024)
1. Wait a further 24hrs hours before completing DNC assessment
DNC assessment can occur ≥48 hrs after a cardiac arrest, or earlier if neuroimaging shows a
devastating injury. There has been no cardiac arrest and imaging shows a devastating injury so
there is no need to wait longer.
2. Order an MRI to characterise the cause of coma
MRI is useful in neuroprognostication, but is not an accepted ancillary test
3. Proceed with DNC assessment
Cannot proceed with DNC because the ocular injury and persistent lateral abduction prevents
assessment of brainstem reflexes. For example, vestibulo-ocular requires assessment of eye
movement (nystagmus).
4. Order a CTA head and neck as an ancillary test
An ancillary test is required. CTA is an accepted option.
5. Order SSEPs for neuroprognostication
SSEPs are useful in neuroprognostication, but is not an accepted ancillary test
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MCQ 11 (2024)
A patient presents 4 hours after an ingestion of an unknown quantity of pills and clear
liquid. They are initially confused and agitated, and subsequently become drowsy.
Bloodwork shows Na 140, K 4.5, Cl 105, bicarb 21, urea 10, glucose 5, VBG pH 7.30 pco2
40, lactate 2.4, serum etoh 30 mmol/l, plasma osmolality 395, serum/urine ketones
positive, acetaminophen 80 micromol/l (upper limit normal < 66, rumack-mathew
treatment threshold >800 micromol/l at 6hrs)
What is the next best step in management?
1. D10 infusion
2. NAC infusion
3. Dialysis
4. Fomepizole
5. Single Dose Activated Charcoal
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MCQ 11 (2024)
1. D10 infusion
This can be used for salicylate toxicity to prevent cerebral hypoglycemia despite normal serum blood glucose levels. There is no
respiratory alkalosis to suggest salicylate toxicity.
2. NAC infusion
The acetaminophen level given is below the treatment threshold at this time post ingestion so NAC is not the next best step. In scenarios
where the time of ingestion is uncertain or there are risk factors for hepatotoxicity then NAC can still be given.
3. Dialysis
Acetaminophen is dialyzable (See EXTRIP for indications), but this scenario is not in keeping with a massive overdose. Dialysis could be
indicated for a toxic alcohol ingestion in this scenario, but there is no evidence of a clear indication (severe acidosis, known high parent
alcohol level, renal failure).
4. Fomepizole
This scenario shows a mild anion gap metabolic acidosis (AG 14) with high osmolar gap (calculate osmolality = 2x Na (280) + glucose (5) +
urea (10) + 1.25xetoh (45) = 340, measured 395, osmolar gap 55). Although the this could be due to isopropyl alcohol, an early ethylene
glycol/methanol ingestion which has not yet had time to convert into toxic metabolites and cause a severe metabolic acidosis cannot be
ruled out. Therefore the best next step is to give fomepizole while awaiting volatile screen results.
5. Single Dose Activated Charcoal
The risk of aspiration is high (uncooperative, drowsy, not intubated) so this would not be of benefit. SDAC does not work for toxic
alcohols. It could be used for acetaminophen but the risk of aspiration does not outweigh the benefit in this case.
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