MD Medicine

Selection Exam April 2024

Mock MCQ Session – Intensive Care medicine
Ceylon College of Physicians

Pavithra Sathananthasarma
MBBS (Jaffna), MD (Med)
Consultant Intensivist (Acting)
National Hospital of Sri Lanka
[email protected]
1) Regarding acute respiratory distress syndrome (ARDS),

1. Severe skin burn can lead in to acute respiratory distress syndrome (ARDS)

2. Bacterial pneumonia is not an aetiological factor of ARDS.

3. Pleural effusion is a characteristic feature of ARDS.

4. Right heart catheterization is essential for the diagnosis of ARDS.

5. Intubation and ventilation is an essential part of management of ARDS.

TFFFF
2) Regarding vasoactive agents,

1. Dobutamine has no place in the management of septic shock.

2. Dopamine has higher risk of arrythmia compared with equivalent doses of

noradrenaline.

3. IV vasopressin should be titrated up or down depending on the severity of septic

shock

4. IV metaraminol causes systemic vasodilation.

5. IV phenylephrine causes significant mesenteric vasoconstriction.

FTTFT
3) In cardiopulmonary resuscitation (CPR)
1. In cardiopulmonary resuscitation (CPR), chest compression should precede
rescue breaths.
2. Energy level of initial shock in biphasic defibrillation is 360 J.
3. IV adrenaline should be given after the 3rd DC shock in shockable rhythm.
4. IV amiodarone should be given after the 3rd DC shock in shockable rhythm.
5. End-tidal CO2 level (EtCO2) is helpful to identify the effectiveness chest
compressions.

TFTTT
4) In acute kidney injury (AKI)
1. Acute kidney injury (AKI) is diagnosed when the urine output is less than 0.5
ml/kg body weight.
2. IV furosemide is known to deteriorate acute kidney injury.
3. Acidification of urine may help to improve rhabdomyolysis.
4. Preexisting hypovolemia precipitates contrast induced nephropathy.
5. Calcium gluconate reduces serum K levels in severe hyperkalemia.

FTFTF
5) In sepsis
1. Hyper-lactataemia indicates poor prognosis in sepsis.
2. CSF samples for bacterial culture should essentially be obtained prior to the
commencement of antibiotics in suspected bacterial meningitis.
3. IV adrenalin infusion increases blood lactate levels in septic shock.
4. IV hydrocortisone is indicated in refractory septic shock.
5. Macrophage activation syndrome is a known complication of severe sepsis.

TFTTT
6) Regarding acute liver failure,

1. Hypoglycemia is a characteristic feature of acute liver failure.

2. Prothrombin time is usually not altered in acute liver failure.
3. Blood lactate levels are characteristically low in acute liver failure.
4. Liver transplantation is not an option for patients with severe acute liver failure.
5. Pregnancy is known to cause acute liver failure.

TFFFT
7) Regarding intra-abdominal hypertension,

1. Acute pancreatitis is known to increase intra-abdominal pressure.

2. Intra-abdominal hypertension is known to cause acute kidney injury.
3. Bladder pressure is a surrogate marker of intra-abdominal pressure.
4. Insertion of nasogastric tube does not play a role in reducing intra-abdominal
hypertension.
5. Severe intra-abdominal hypertension is an indication for invasive ventilation.

TTTFT
8) True/false regarding neuro-critical care,

1. Cerebral perfusion pressure is dependent on intracranial pressure.

2. Hypocarbia (low blood CO2 levels) reduces cerebral blood flow.
3. Hypothermia does not affect the cerebral metabolism.
4. Guillain Barre syndrome increases CSF protein levels.
5. Lumber puncture is contraindicated in uncomplicated spontaneous
sub-arachnoid hemorrhages.
TTFTF
9) In status epilepticus,

1. Status epilepticus should be suspected if an episode of convulsion exceeds more

than 5 minutes.
2. IV lorazepam is a known first line drug in the management of status epilepticus.
3. Persistent seizure activity is known to damage central nervous system.
4. IV propofol is a known drug to be used in status epilepticus.
5. Continuous EEG monitoring is mandatory to paralyze and ventilate a patient with
status epilepticus.
TTTTF
10) Regarding metabolic abnormalities,

1. Sudden reduction of Na levels when treating severe hypernatremia could result

in central pontine myelinolysis.
2. Metabolic alkalosis could be treated with normal saline (0.9% NaCl).
3. Refeeding syndrome results in high levels of serum phosphate.
4. Low level of serum ionized calcium is a known feature in tumour lysis syndrome.
5. Head injury is known to cause increased urinary loss of Na.
TTFTT
11) Regarding catheter related blood stream infections,

1. There is no requirement of obtaining blood samples through central venous line

for blood cultures in the diagnostic process of central venous line associated
sepsis.
2. Culture of the tip of central venous line is not the gold standard test of central line
associated sepsis.
3. Total parenteral nutrition increases the risk of central line associated infection.
4. Risk of infection is less with subclavian central line compared with femoral central
line.
5. Antibiotic prophylaxis is essential to prevent central line associated infection
FTTTF
12) True/False regarding respiratory support,
1. CPAP (Continuous Positive Airway Pressure) improves the outcome of acute
pulmonary oedema.
2. BiPAP (Bilevel Positive Airway Pressure) is not indicated if the blood pH > 7.2 in
hypercarbic COPD patients.
3. Invasive ventilation enhances venous return of blood to the heart.
4. Acute pancreatitis is known to increase pulmonary capillary leakage.
5. Acute respiratory distress syndrome (ARDS) is excluded when pulmonary capillary
wedge pressure is more than 18 mmHg.
TFFTF
13) True/false regarding end-of-life care,
1. Percutaneous endoscopic gastrostomy (PEG) feeding is a therapeutic option
in patients with severe dementia.
2. Competent patients with mental capacity could lawfully refuse life sustaining
treatment.
3. Once the DNACPR (do not attempt cardiopulmonary resuscitation) status is
agreed upon, it cannot be revoked.
4. It is essential to have the permission of next-of-kin to terminate the ventilator
in a brain-dead patient.
5. All deteriorating inward patients should have cardiopulmonary resuscitation
(CPR) if they develop cardiac arrest.
TTFFF
14) When considering the diagnosis of ventilator - associated
pneumonia (VAP) in a mechanically ventilated patient,

1. A CPIS score >6 has poor specificity for the diagnosis of VAP.
2. A VAP is defined as a hospital-acquired pneumonia occurring at any time point in
mechanically ventilated patient.
3. Ventilator care bundles may include the use of a low-volume low-pressure tapered cuff.
4. Use of endotracheal tubes with subglottic suction have level I evidence showing a reduced
incidence of VAP.
5. Late VAP (>5 days) is most commonly caused by streptococcal or staphylococcal organisms

FFFTF
15) Regarding the logistics of organ donation,

1. Functional warm ischaemic time begins with the onset of asystole.

2. Cold ischaemic time is the time from initiation of cold preservation until the
restoration of warm circulation after transplant.
3. Age >80 years is a contraindication to organ donation.
4. A donation after cardiac death (DCD) patient is not suitable for heart donation.
5. Noradrenaline is the first-line agent for the management of fluid-resistant
hypotension in the brainstem-dead donor.
FTFTF
Best of Five Questions
16) A 23-year-old lady who is 32 weeks’ pregnant presents to the hospital
with severe vomiting. Her blood pressure is 168/110mmHg. She has no
headache and no visual disturbances. Liver function tests reveal bilirubin
of 165μmol/L, aspartate aminotransferase of 700 IU/L, fibrinogen 0.5g/L
and a prothrombin time of 29 seconds. Her plasma glucose is 2.3mmol/L.

Which of the following is the most likely diagnosis?

1. Acute fatty liver of pregnancy
2. Liver haematoma
3. Veno-occlusive disease
4. Cholestasis of pregnancy
5. Viral hepatitis
17) Which of the following patients would be most likely to benefit from
Veno- Venous Extracorporeal Membrane oxygenation (VV-ECMO)
1. A 65-year-old post-ST-elevation myocardial infarction (STEMI) with
cardiogenic shock and refractory hypoxaemia.
2. A 35-year-old with worsening idiopathic pulmonary fibrosis and acute
hospital-acquired pneumonia.
3. A 45-year-old male out-of-hospital cardiac arrest (suspected cardiac
aetiology) following 45 minutes of advanced life support and intermittent
return of spontaneous circulation.
4. A 60-year-old lung transplant patient with early graft failure and refractory
hypoxaemia.
5. A 30-year-old renal transplant patient with end-stage vascular access who
has now developed Cytomegalovirus (CMV) pneumonitis and refractory
hypercarbia on ventilation.
18) A 17-year-old woman is brought into the emergency department by
ambulance. She was found at home by her parents and admitted to taking 15g of
paracetamol 10 hours previously. Activated charcoal was administered, an N-
acetyl cysteine infusion commenced and 2L of crystalloid infused. Twenty-four
hours after admission, her GCS drops to 14 and bloods showed: Ph – 7.3, INR -
5.7, serum potassium - 4.4mmol/L, serum creatinine - 290μmol/L and a lactate of
2.8mmol/L. She is not actively bleeding.

The next step in the management should be:

1. Bicarbonate infusion.
2. Fresh frozen plasma.
3. Immediate placement on the super-urgent liver transplant scheme.
4. Renal replacement therapy.
5. Administration of vitamin K
19) A 57-year-old man with alcohol-related liver disease (Child-Pugh Class
B) is admitted in the early hours with an upper gastrointestinal bleed and
gross ascites. He is intubated and ventilated to facilitate an urgent
endoscopy which shows three oesophageal varices which are banded. The
next morning, he fails a spontaneous breathing trial and is re-sedated.
The most appropriate course of action would be:
1. Insertion of an ascitic drain with 100ml 20% albumin cover for every 3L of
ascites drained.
2. Intravenous terlipressin.
3. Trial of extubation onto non-invasive ventilation.
4. An ascitic drain with 100ml 4.5% albumin for every 3L ascites drained.
5. Start spironolactone and repeat spontaneous breathing trial after 24
hours.
20) A 70-year-old man is admitted to the unit following a laparotomy for faecal
peritonitis. The anaesthetist reports a stormy peri-operative episode, with prolonged
periods of hypotension following induction and eventual stabilisation on high-dose
adrenaline infusion. During the operation it was noted that his T-waves had become
inverted on the cardiac monitor and ECG confirmed this in leads V2-V6. A high
sensitivity troponin was sent on closure and has come back at 174ng/mL. Baseline
troponin measurements were normal. Focused echo on the unit notes global left
ventricular systolic dysfunction.
Which of the following is the likely diagnosis for his ECG and biochemical findings?
1. Type 1 myocardial infarction.
2. Type 2 myocardial infarction.
3. Type 3 myocardial infarction.
4. Type 4 myocardial infarction.
5. Type 5 myocardial infarction
Arrivé, François & Coudroy, Rémi & Thille, Arnaud. (2021). Early Identification and Diagnostic Approach in Acute Respiratory Distress Syndrome (ARDS). Diagnostics. 11. 2307.
Fanelli V, Vlachou A, Ghannadian S, Simonetti U, Slutsky AS, Zhang H. Acute respiratory distress syndrome: new definition, current and future therapeutic options. J Thorac
Dis. 2013;5(3):326-334.
Papazian et al. Ann. Intensive Care (2019) 9:69
Pelosi et al. Crit Care (2021) 25:250
 Recommendations 2021 Recommendation Strength and Changes From 2016
Quality of Evidence Recommendations
For adults with septic shock and cardiac Weak, low quality of evidence
dysfunction with persistent hypoperfusion
despite adequate volume status and arterial
blood pressure, we suggest either adding
dobutamine to norepinephrine or using
epinephrine alone.
 Dopamine
In a randomized trial comparing norepinephrine to dopamine, mortality outcomes were similar with
both drugs; however, dopamine was associated with a higher occurrence of arrhythmias, which
limits its utility if other agents are available

Dopamine was associated with a higher occurrence of arrhythmias, which limits its utility if other
agents are available.

De Backer D, Biston P, Devriendt J, et al; SOAP II Investigators: Comparison of dopamine and norepinephrine in
the treatment of shock. N Engl J Med 2010; 362:779–789
 Recommendations 2021 Recommendation Strength and Changes From 2016
Quality of Evidence Recommendations
For adults with septic shock on Weak, moderate quality
norepinephrine with inadequate mean evidence
arterial pressure levels, we suggest adding
vasopressin instead of escalating the dose of
norepinephrine.

Norepinephrine-sparing effect has been observed with vasopressin in doses of 0.01–

0.03 U/min, leading to its recommendation as an adjunctive therapy
 RIFLE, AKIN, and KDIGO systems for AKI classification.

Bethany C. Birkelo et al. CJASN 2022;17:717-735

©2022 by American Society of Nephrology

Joannidis, M., Klein, S.J. & Ostermann, M. 10 myths about frusemide. Intensive Care Med 45, 545–548 (2019).
Brian Michael I. Cabral, Sherida N. Edding, Juan P. Portocarrero, Edgar V. Lerma, Rhabdomyolysis, Disease-a-Month, Volume 66, Issue 8, 2020,
Fangfei Zhang, Zeyuan Lu, Feng Wang, Advances in the pathogenesis and prevention of contrast-induced nephropathy, Life Sciences, Volume 259, 2020
CPP = MAP – ICP
MAP = DP + (SP-DP)
3
An LP is performed to evaluate the cerebrospinal fluid for the presence of red blood
cells (RBCs) and xanthochromia. LP may be negative if performed less than 2 hours
after an SAH occurs; LP is most sensitive 12 hours after onset of symptoms.
 Management of MAlk
1) Aggressive electrolyte repletion
• Hypokalemia
• Hypomagnesemia
• 2) if hypovolemic, give normal saline
• Resuscitation with normal saline may be helpful among patients with hypovolemia (“saline-responsive
alkalosis”).
• Urine chloride <10-30 mM predicts improvement following normal saline.
• This is one situation where normal saline is superior to Lactated Ringers or Plasmalyte (because you're looking
for an acidotic fluid).
3) if hypervolemic, give diuretics which promote bicarbonate excretion
• Acetazolamide
• Spironolactone
• Amiloride
4) hold or decrease the dose of alkalosis-inducing diuretics (e.g., furosemide)
5) proton pump inhibitor in patients with ongoing vomiting or nasogastric suction
6) for intubated patients, adjust ventilator to target mildly alkalemic pH
7) reformulate total parenteral nutrition (TPN)
8) dialysis
9) intravenous hydrochloric acid
Mehta, Sangeeta, Abdullah Al-Hashim and Sean Keenan. “Noninvasive ventilation in patients with acute cardiogenic pulmonary edema.” Respiratory care 54 2 (2009):
186-95; discussion 195-7 .
Summary of the cardiovascular effects of positive pressure ventilation. All parts of the circulation are affected including the pulmonary vasculature (green), and
the right (blue) and left (red) sides of the heart. See text for details. RA, right atrium
https://www.nhs.uk/conditions/do-not-attempt-cardiopulmonary-resuscitation-dnacpr-decisions/
https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/treatment-and-care-towards-the-end-of-life/cardiopulmonary-resuscitation-cpr
IVAC
CDC-NHSN
CPIS
Modified CPIS
Mao Z, Gao L, Wang G, et al. Subglottic secretion suction for preventing ventilator-associated pneumonia: an updated meta-analysis and
trial sequential analysis. Crit Care. 2016;20(1):353. Published 2016 Oct 28. doi:10.1186/s13054-016-1527-7
https://resources.wfsahq.org/atotw/management-of-brain-dead-donor-for-organ-transplant/
https://litfl.com/contraindications-to-solid-organ-donation/
• AFLP
• relatively rare/high mortality (perinatal mortality 20-30% earlier)
• early recognition and management have improved.
• third trimester
• microvesicular fatty infiltration
• abnormal oxidation of mitochondrial fatty acids?
• It can coexist with pre-eclampsia
• It is characterised by
• insidious onset of jaundice
• clotting derangement (PT / Fibrinogen )
• transaminitis (usually not exceeding 1000IU/L).
• hypoglycaemia
• hepatic encephalopathy
• Liver haematoma
• No enough history (RUQ pain and more evidence of haemodynamic instability/history of trauma)

• Cholestasis of pregnancy
• Common
• bilirubin would be less than 100μmol/L
• associated with a normal clotting profile

• Viral hepatitis
• associated with much higher levels of transaminase levels
• more clues in the history to suggest veno- occlusive disease such as Budd-Chiari syndrome with the classic
triad of abdominal pain, ascites and hepatomegaly
• usually diagnosed by the use of Doppler of the portal vein on ultrasound scanning
• Budd-Chiari syndrome tends to occur more frequently in the post-partum state.
 • ECMO - management of refractory respiratory failure
• CESAR (Conventional ventilation or ECMO for Severe Adult Respiratory failure) trial
• increased use during the 2009 swine flu pandemic and during the 2020-2021 CoVID pandemic

• Several positively slanted review articles assessing critical care utilisation are available.
• Drawbacks – Limitations / cost/ risks
• CESAR - the mortality difference reported (p=0·03) reflects the transfer of patients to a specialist respiratory centre with the capacity for
ECMO, rather than a direct effect of the intervention itself

• ECMO
• via arteriovenous supply (with propulsion cardiovascular support)
• venovenous for assistance with gas exchange only

• Respiratory ECMO
• survival rates of >50% on average
• graft failure listed as a common indication

• Extracorporeal cardiopulmonary resuscitation - favour for refractory cardiac arrest in the young
• Vascular access issues and terminal diagnoses require careful consideration of both risk and cost prior to use.
• Significant amount of paracetamol with a delayed presentation to hospital
• Despite correct initial management she has developed liver failure

• There is no indication for renal replacement therapy or bicarbonate at this stage

• The INR should be monitored to assess progression of her liver failure

• FFP is not required unless there is active bleeding or surgical intervention is planned
• Vitamin K should, however, be administered to ensure that vitamin K deficiency is not the cause of her
coagulopathy

• She does not meet the criteria for the super-urgent liver transplant scheme post-paracetamol poisoning but as
she is clinically deteriorating her case should be discussed with a liver unit
• Criteria for placement on the super-urgent liver transplant scheme
• The gross ascites is a sign of decompensation of alcohol-related liver disease
• primarily related to sodium and water retention due to secondary hyperaldosteronism
• The abdominal distension may splint the diaphragm and impair ventilation
• Draining the ascites would facilitate extubation

• Consensus guidelines suggest that a large-volume paracentesis should be performed in a single

session with volume expansion being given once paracentesis is complete, ensuring that
albumin is given (8g albumin per litre of ascites removed, equivalent to roughly 100ml of 20%
albumin per 3L ascites)
(level of evidence Ib; recommendation: A)

• This prevents cardiovascular decompensation due to fluid shifts post-drainage

• Many patients with decompensated liver disease requiring intubation have a very poor prognosis,
but intubation to facilitate the management of variceal bleeding carries a good short-term survival,
and palliation in this situation with the information given would not be appropriate.
• Myocardial infarction (MI) = the death of myocardial cells
• The causes for this cell death are numerous and not all related to thrombotic pathology
• Definitions and subtypes of MI exist to characterize epidemiology, standardise reporting and focus on therapeutic
options
• Type 1 MI
• spontaneous myocardial infarction, usually a result of ruptured plaque following mural/wall thrombus
• acute coronary syndrome requiring antiplatelet therapy and definitive cardiological treatment
• An acute intra-operative event of this type would be extremely unfortunate and relatively rare
• Type 2 MI - cell death secondary to an ischaemic (supply/demand) imbalance to the myocardium
• can regularly occur in the critically ill patient
• Common causes include septic shock, hypoxia and hypovolaemia
• Antiplatelet therapy can be counterproductive here and lead to worsening coagulopathy with no direct benefit
• Type 3 MI
• represents sudden death attributable to likely spontaneous myocardial ischaemia, in the absence of biomarker corroboration
• Type 4 MI - associated with percutaneous coronary intervention
• Type 5 MI – associated with coronary artery bypass grafting

• This patient is most likely to have suffered a Type 2 MI due to intraoperative hypotension and septic shock