50. Answer: C
The ductus arteriosus usually closes shortly after birth. Failure of the ductus to close in the early weeks of life results in a PDA, which allows blood to flow between the aorta and the pulmonary artery, increasing blood flow in the pulmonary circulation. Patients with a large PDA can exhibit signs and symptoms of pulmonary hypertension and heart failure. Patients with a small PDA are often asymptomatic but may develop infective endocarditis. PDAs are most commonly closed using catheter‐based or surgical intervention. An enlarged left ventricle and calcification of the duct may be evidenced on CXR.
Stout K, Daniels C, Aboulhosn J, et al. 2018 AHA/ACC Guideline for the Management of Adults With Congenital Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2019;139(14).
https://ahajournals.org/doi/pdf/10.1161/CIR.0000000000000603
2 Critical Care Medicine
Questions
Answers can be found in the Critical Care Medicine Answers section at the end of this chapter.
1 1. Which of the following treatment options reduces the mortality of acute respiratory distress syndrome (ARDS)?Aggressive intravenous fluid administration for reversal of shock.Intravenous albumin administration.Intravenous hydrocortisone administration.Lung‐protective invasive mechanical ventilation with lower tidal volumes and airway pressures.
2 2. A 70‐year‐old man returns to the cardiology ward from the operating theatre after a pacemaker implantation for complete heart block. He complains of shortness of breath and chest pain. On examination, his HR is 120/min, BP is 90/70 mmHg and his respiratory rate is 30/min. His JVP is markedly elevated and his heart sounds are quiet. Air entry is symmetrical on lung auscultation. Oxygen saturation is 90% on room air. An ECG shows sinus tachycardia but is otherwise within normal limits.What is the next most appropriate investigation?CXR.CT of the chest.Echocardiogram.Serial troponin levels.
3 3. Which of the following clinical findings would be UNUSUAL in severe acute carbon monoxide poisoning?Chest pain.Headache.Loss of consciousness.Low oxygen saturation on pulse oximetry.
4 4. A 42‐year‐old man is admitted to the intensive care unit with severe sepsis. Regarding the diagnosis of disseminated intravascular coagulation (DIC), which of the following statements is most correct?Abnormal prothrombin time is required to diagnose DIC.A low fibrinogen level (<100 g/mL) is present in about 30% of septic patients with DIC.DIC affects less than 20% of patients with septic shock.The most frequent clinical manifestation of DIC in sepsis is haemorrhage.
5 5. Which type of circulatory shock is the most common in patients in the intensive care unit?Cardiogenic shock.Distributive shock.Hypovolaemic shock.Obstructive shock.
6 6. A 48‐year‐old man presents to the Acute Medical Unit because he experienced chest discomfort three hours ago and generalised weakness in the last two days. He is known to have IgA nephropathy and hypertension, but he does not have regular follow up. His BP is 90/60 mmHg. His rapid troponin level is 1320 ng/L [<29]. His previous ECG was normal 1 year ago when he was admitted for a kidney biopsy.Which one of the following ECGs would make you call the on‐call cardiology registrar immediately and prepare the patient to go to the cardiac catheter laboratory?
7 7. Which one of the following is NOT an indication for extracorporeal membrane oxygenation (ECMO) treatment?Acute myocardial infarction with cardiogenic shock.Cardiac failure due to intractable arrhythmias.Postcardiac arrest as part of advanced life support.Refractory septic shock in adults with preserved left ventricular function.
8 8. You are reviewing a 78‐year‐old woman who was admitted yesterday with an infective exacerbation of COPD, with a baseline FEV1 of 40% of the predicted value. She has become progressively drowsier throughout the day, as her GCS is now 12. She is confused and responds to voice on review, is moving all four limbs spontaneously and eyes open to voice. On examination, she is saturating 92% on 4 L of oxygen via nasal cannulae, her respiratory rate is 20/min, and other observations are normal. Her neurological examination shows normal power, tone reflexes and sensation, pupils are normal, but there is slowed thinking and lack of interest in the world, and she is not oriented to place or time. She takes 20 mg of slow release morphine for relief of breathlessness daily and is not on long‐term oxygen therapy at home. There is no obvious tremor or myoclonus at rest, but asterixis is present.Which of the following is likely the biggest contributor to her drowsiness?Hypercarbia.Hypoxia.Infection.Opiates.
9 9. A 65‐year‐old has an anterior myocardial infarction. He has cardiogenic shock despite successful revascularisation. An intra‐aortic balloon pump (IABP) is inserted, which will:Decrease diastolic blood pressure.Increase the afterload of left ventricle.Increase coronary blood flow.Increase systolic blood pressure.
10 10. Which of the following outcomes has the LEAST evidence for being improved by advance care planning?Comfort at the end of life.Decreased use of hospital resources.Enhanced surrogate decision making.Patient and family satisfaction.
11 11. A 62‐year‐old man is admitted to intensive care unit because of necrotising fasciitis of the left leg after sustaining an injury while changing a flat tyre. He is known to have type 2 diabetes and hypertension.Which one of the following complications is LEAST likely in this patient?Capillary leak syndrome.Intravascular haemolysis.Posterior reversible encephalopathy syndrome.Systolic heart failure.
12 12. A 25‐year‐old woman is brought in by ambulance to the emergency department. Her partner has found a few empty packets of immediate‐release paracetamol (~40 gm paracetamol ingestion) at home. Her family thinks she might have taken an overdose of paracetamol within the last 6 hours after she was last seen well. Past medical history includes depression, borderline personality disorder, and previous suicide attempts. On examination, her temperature is 37 °C, BP is 85/50 mmHg, HR is 110 bpm, and respiratory rate is 12/min. Her investigation results are shown below:TestsResultsNormal valuesUrea6 mmol/L2.7–8.0Creatinine170 umol/L45–90Haemoglobin129 g/L115–155Platelet count170 x 109/L150–450Glucose level4.0 mmol/L3.2–5.5Phosphate level0.80 mmol/L0.75–1.50Alanine aminotransferase (ALT)150 U/L0–55INR1.30.9–1.3pH on ABG7.347.35–7.45Arterial lactate3.5 mmol/L0.2–2.0Which one of the following is the appropriate next step of management?Commence activated charcoal.Commence ‘two‐bag’ N‐acetylcysteine infusion regimen.Commence ‘three‐bag’ N‐acetylcysteine infusion regimen.Urgent referral to the liver transplant unit.
13 13. You attend a Medical Emergency Teams (MET) call. The patient is a 64‐year‐old man who was admitted one hour ago because of an infective exacerbation of COPD and dehydration. His past medical history includes congestive heart failure and hypertension. ECG shows pulseless electrical activity (PEA) with no features of acute myocardial infarction. His troponin is normal on admission. PEA in this patient when compared with ventricular tachycardia (VT) or ventricular fibrillation (VF) cardiac arrest:Has a good prognosis as it is not likely caused by acute myocardial infarction.Is more common in patients with congestive heart failure.Is more common in patients with respiratory failure.Is not due to hypoxia or tension pneumothorax.
14 14. A 37‐year‐old woman has been admitted to intensive care unit (ICU) with pneumococcal pneumonia. She has a history of alcohol induced liver cirrhosis and has required intubation and ventilation.Which of the following is correct regarding prophylaxis with proton‐pump inhibitors (PPIs) or histamine H2–receptor antagonists against