15 15. In patients with AKI due to septic shock who are admitted to the intensive care unit, which of the following statements regarding dialysis treatment is correct?AKI is not associated with worsening mortality.Delayed dialysis compared to early dialysis has a lower mortality rate.Early dialysis compared to delayed dialysis has a lower mortality rate.There is no difference in mortality rate in early vs. delayed dialysis.
16 16. A 70‐year‐old woman presents to the emergency department following a 3‐day history of chills and dysuria. She reports dizziness and light‐headedness. She has a temperature of 38.6ºC, heart rate of 125 bpm and her BP is 85/55 mmHg. Physical examination reveals dry mucous membranes, undetectable JVP. She is tachycardic with no adventitious sounds and her chest is clear. There is suprapubic tenderness. Her investigations reveal the following:TestsResultsNormal valuesSerum creatinine159 μmol/L45–90Urea27 mmol/L2.7–8.0Lactate5.0 mmol/L0.2–2.0Anion gap25 mmol7–17WCC20 x 109/L4–11Haemoglobin90 g/L115–155Urine microscopy>100 WBC/HPF, abundant bacteriaWhich of the following is most appropriate regarding management of this patient?Placement of central venous catheter and administration of intravenous fluid guided by central venous pressure.Intravenous fluid administration of 60ml/kg body weight.Intravenous fluid administration of 30ml/kg body weight.Intravenous fluid administration to achieve mean arterial pressure 85 mmHg.
17 17. A 43‐year‐old woman is admitted to a high dependency unit because of exacerbation of asthma. This is her third admission within 12 months. She is diagnosed with severe asthma. Which one of the following considerations in this case is INCORRECT?Approximately 50% of patients with severe asthma have type 2 inflammation.Exhaled nitric oxide should be monitored in patients with severe asthma and used to guide therapy.Mepolizumab is indicated for use as an add‐on treatment for patients with an eosinophilic phenotype of severe asthma.Recurrent exacerbations of severe asthma are often associated with gastroesophageal reflux.
18 18. 18.A 72‐year‐old man is day 7 in ICU because of severe biliary sepsis. He has been on piperacillin/tazobactam for 7 days and develops severe diarrhoea. He is diagnosed with severe Clostridium difficile colitis. His repeat abdominal CT shows large intestine distension, colonic wall thickening, and fat stranding.What is your first line treatment of choice in this case?Faecal microbiota transplantation.Intravenous metronidazole.Oral fidaxomicin.Oral vancomycin.
19 19. Which one of the following measures is NOT in the Hour‐1 Bundle of care elements in the initial resuscitation for sepsis and septic shock?Administer broad‐spectrum antibiotics.Apply vasopressors if hypotensive during or after fluid resuscitation to maintain mean arterial pressure (MAP) ≥80 mmHg.Begin rapid administration of 30 mL/kg crystalloid for hypotension or lactate level ≥ 4 mmol/L.Measure lactate level.
20 20. A 76‐year‐old man has had an inferior myocardial infarction 4 days ago. Today he is feeling lightheaded. On examination his blood pressure is 85/65 mmHg. An ECG is done immediately. Which one of the following findings is an indication for temporary pacing?
21 21. A 25‐year‐old man is brought into the emergency department by ambulance after a motor bike injury 40 min ago. On examination, his GCS is 9, he is unable to move his right hand due to pain. Both pupils are reactive to light. He does not take regular medications. X‐ray shows a right‐sided distal radius fracture. CT brain shows intra‐cranial haemorrhage in the right hemisphere with no mass effect and no major extracranial bleeding.Which one of the following medications has been shown to reduce head injury related death compared to placebo when given within 3 hours of injury?Desmopressin.Fresh frozen plasma.Prothrombinex.Tranexamic acid.
22 22. Which of the following measurements in the VBG DOES NOT correlate with the readings in ABG in critically ill patients?Bicarbonate.Lactate.pH.The partial pressure of Oxygen (PaO2).
23 23. A 72‐year‐old man is admitted with pneumonia and treated with intravenous penicillin and azithromycin. He is known to have CCF, smoking related COPD and AF for which he is taking sotalol. He has a cardiac arrest in the medical ward. After 3 cycles of CPR, 3 boluses of 1mg epinephrine and 3 defibrillator shocks, he remains unconscious with the below ECG trace.What is the next most appropriate step?5 mg epinephrine intravenously.10 mls of 10% calcium gluconate intravenously.10 mls of magnesium sulphate intravenously.300 mg amiodarone intravenously.
24 24. An 80‐year‐old woman presents to emergency department following a 2‐day history of fever and dysuria. She reports dizziness and light‐headedness. She has a temperature of 39.6°C, HR of 120 bpm and her BP is 80/55 mmHg. Physical examination reveals dry mucous membranes and undetectable JVP. Her chest is clear on auscultation. There is renal angle tenderness. Her investigations reveal the following:TestsResultsNormal valuesSerum creatinine178 μmol/L45–90Urea28 mmol/L2.7–8.0Lactate3.0 mmol/L0.2–2.0Anion gap25 mmol7–17WCC26 x 109/L4–11Haemoglobin90 g/L115–155Urinalysis3+ leukocyte esterase, nitrate positiveAfter taking blood cultures and commencing fluid resuscitation and intravenous antibiotics, her BP improves to 100/60 mmHg and HR is 98/min.Which of the following strategies is most appropriate in further managing her haemodynamic state?Placement of central venous catheter with serial central venous pressure and central venous oxygen saturation (Scvo2) measurement.Whole blood transfusion and serial haemoglobin measurement.Administration of inotropic medication.Continued monitoring of blood pressure and urine output.
25 25. Which one of the following measures is NOT recommended in the treatment of severe sepsis or septic shock, according to the latest guidelines from the Surviving Sepsis Campaign?Use antimicrobial treatment for 7 to 10 days for most serious infections associated with sepsis and septic shock.Use combination antimicrobial therapy for the routine treatment of neutropenic sepsis.Use empiric broad‐spectrum antimicrobials for patients presenting with sepsis or septic shock to cover all likely pathogens.Use intravenous antimicrobials within one hour after recognition of sepsis or septic shock.
QUESTIONS (26–31) REFER TO THE FOLLOWING INFORMATION
Match each of the following inotropic/vasopressor agents with the best description of their mechanism of action:
1 Dobutamine.
2 Levosimendan.
3 Metaraminol.
4 Milrinone.
5 Noradrenaline.
6 Omecamtiv.
7 Phenylephrine.
8 Vasopressin.
1 26. A mixed alpha and beta agonist with greater alpha‐1 activity than beta activity.
2 27. Enhancement of troponin C sensitivity to intracellular calcium.
3 28. Inhibition of the enzyme responsible for breakdown of cyclic adenylate monophosphate (cAMP).
4 29. Direct stimulation of actin‐myosin cross‐bridging.
5 30. A mixed alpha and beta agonist with greater beta activity than alpha activity.
6 31. Pure alpha‐1 receptor agonist.
QUESTIONS (32–35) REFER TO THE FOLLOWING INFORMATION
You are the co‐leader for Medical Emergency Response Team. When you attend the following medical emergency, what is the most appropriate immediate management?
1 intravenous amiodarone.
2 intravenous appropriate antibiotics.
3 intravenous calcium chloride.
4 intravenous calcium gluconate.
5 intravenous epinephrine.
6 intravenous fluid.
7 intravenous dextrose.
8 intravenous hydrocortisone.
9 intravenous insulin.
10 intravenous magnesium.
11 intravenous naloxone.
32.