Critical care revision notes

CRITICAL CARE REVISION NOTES
DR.SHERIF BADRAWY

‫اﻟﺮﺣﻴﻢ‬ ‫اﻟﺮﺣﻤﻦ‬ ‫ﷲ‬ ‫ﺑﺴﻢ‬
◨ This is a summary of Benington's MCQ
book targeting EDIC exam
◨ This book is mainly for part 1 EDIC, with
MCQs type A & K.
◨ Hope U'll find it useful
1a

The maximum rate of potassium infusion
should not exceed
2a
Critical Care revision notes
Dr.Sherif Badrawy
Digitally signed
by Dr.Sherif
Badrawy
Date: 2015.12.18
22:58:29 +03'00'

【40mmol/h】 as this may cause
arrhythmias and asystole.
2b
Dr.Sherif Badrawy

Normal sodium requirement is
3a
Dr.Sherif Badrawy

1-2mmol/day.
3b
Dr.Sherif Badrawy

Extracellular calcium exists in three forms:
4a
Dr.Sherif Badrawy

40% protein bound (largely to albumin),
47% free ionised, and 13% complexed with
citrate, phosphate and sulphate.
4b
Dr.Sherif Badrawy

the physiologically important form of
calcium
5a
Dr.Sherif Badrawy

【The ionised form】
as it may be reduced by alkalosis through
greater protein binding
5b
Dr.Sherif Badrawy

1g of magnesium sulphate contains
6a
Dr.Sherif Badrawy

4mmol magnesium
6b
Dr.Sherif Badrawy

The normal range for phosphate in the
plasma is
7a
Dr.Sherif Badrawy

0.8-1.5mmol/L
7b
Dr.Sherif Badrawy

Normal QT interval is
8a
Dr.Sherif Badrawy

0.38-0.46s (9-11 small squares)
8b
Dr.Sherif Badrawy

corrected QT interval (QTc) Bazett's
formula,
9a
Dr.Sherif Badrawy

QTc = QT/√R-R, adjusting for heart rate.
9b
Dr.Sherif Badrawy

How Mains isolating transformer reduce
the risk of electrical injury in the ICU
10a
Dr.Sherif Badrawy

【isolates the power supply from earth】
If a patient comes into contact with faulty
equipment the current cannot flow
through the patient to earth.
10b
Dr.Sherif Badrawy

How An 【earth leakage circuit breaker】
reduce the risk of electrical injury in the
ICU
11a
Dr.Sherif Badrawy

【switches off the electrical supply】
if stray currents are detected flowing to
earth, reducing the potential for
microshock.
11b
Dr.Sherif Badrawy

Other methods to reduce the risk of
electrical injury in the ICU
12a
Dr.Sherif Badrawy

Use of a common earth & Use of Class II
equipment.(double insulation)
12b
Dr.Sherif Badrawy

inefficient methods of cooling
13a
Dr.Sherif Badrawy

cold air blankets, bladder irrigation and
gastric lavage all
13b
Dr.Sherif Badrawy

efficient methods of cooling
14a
Dr.Sherif Badrawy

♧ Ice water bodily immersion.
♧ Extracorporeal heat exchange.
♧ Rapid infusion of 30ml/kg bolus of
crystalloid at 4°C.
♧ Central venous cooling catheter
14b
Dr.Sherif Badrawy

presence of sternal fracture suspect ? + no
response to fluid resuscitation
15a
Dr.Sherif Badrawy

cardiac tamponade
15b
Dr.Sherif Badrawy

Beck's triad
16a
Dr.Sherif Badrawy

↑JVP, muffled heart sounds and
hypotension
16b
Dr.Sherif Badrawy

Why A widened cardiac shadow is not a
sensitive sign for acute traumatic
tamponade ?
17a
Dr.Sherif Badrawy

dt only small volumes of blood (<500ml) in
the pericardial space are required to cause
HD compromise.
17b
Dr.Sherif Badrawy

Human albumin 4% will be more effective
than crystalloid for fluid resuscitation ?
18a
Dr.Sherif Badrawy

NO
18b
Dr.Sherif Badrawy

adverse prognostic factors in severe TBI ?
According to CRASH (Corticosteroid
Randomisation After Significant Head
Injury) trial
19a
Dr.Sherif Badrawy

♧ risk of death also increases linearly with every
point decrease in GCS.
♧ Age > 40
♧ Dilated pupils
♧ CT pathology including petechial hges,
subarachnoid blood, midline shift and
obliteration of the basal cisterns
♧ Patient sex is not useful as a prognostic
indicator
19b
Dr.Sherif Badrawy

Tuberculous meningitis is common in
20a
Dr.Sherif Badrawy

immigrants, the homeless, alcoholics and,
increasingly, in HIV positive patients
20b
Dr.Sherif Badrawy

CSF in Tuberculous meningitis
21a
Dr.Sherif Badrawy

low glucose, moderately elevated protein,
and classically a lymphocytic pleocytosis
(although a CSF neutrophilia is common in
the early stages, and an acellular picture
may be found in HIV-related cases).
21b
Dr.Sherif Badrawy

A positive India ink stain of CSF suggests
22a
Dr.Sherif Badrawy

cryptococcus,
although a negative stain does not rule
this out.
22b
Dr.Sherif Badrawy

meningitis not associated with low glucose
?
23a
Dr.Sherif Badrawy

viral meningitis
23b
Dr.Sherif Badrawy

In RV infarction RA pressure is
24a
Dr.Sherif Badrawy

usually 【elevated & > 10mmHg】.R to L
shunting can occur at the atrial level
through a patent foramen ovale in the
presence of elevated right atrial pressure
24b
Dr.Sherif Badrawy

Right ventricular infarction rarely occurs in
isolation and is usually accompanied by
25a
Dr.Sherif Badrawy

inferior infarction
25b
Dr.Sherif Badrawy

The flow of crystalloid through a 16G
intravenous cannula is approximately
26a
Dr.Sherif Badrawy

150ml/min
26b
Dr.Sherif Badrawy

flow is proportional to
27a
Dr.Sherif Badrawy

♧ the fourth power of the radius [NOT to
the square of the radius]
♧ & inversely proportional to the viscosity
of the fluid and the length of the tube
27b
Dr.Sherif Badrawy

Intraosseous access is contraindicated in
adult patients ?
28a
Dr.Sherif Badrawy

NO, Used if intravenous access is not
possible, though the
tougher bony cortex makes this difficult
[tibia, sternum and iliac crest]
28b
Dr.Sherif Badrawy

Lund concept for the management of
traumatic brain injury
29a
Dr.Sherif Badrawy

focuses on the importance of【Starling's
forces in the development of brain
oedema】 in the presence of disordered
cerebral autoregulation following
traumatic brain injury
29b
Dr.Sherif Badrawy

Components of Lund concept for the
management of traumatic brain injury
30a
Dr.Sherif Badrawy

✾ BP limited to pre-injury normal levels (to prevent ↑pre-capillary
pressure in the presence of impaired arteriolar autoregulation)
using 【metoprolol and clonidine】.
✾ 【Albumin】 is transfused to maintain plasma colloid oncotic
pressure.
✾ 【Thiopentone】is used to promote arteriolar VC (2ry to flow-
metabolism coupling),
✾ 【dihydroergotamine】is used to ↑venoconstriction and
↓cerebral blood volume.
✾ A minimum【 CPP of 50mmHg】 is accepted to ↓inotropes and
vasopressors which might ↑cerebral oedema by ↑cerebral blood
volume (no mannitol is used).
30b
Dr.Sherif Badrawy

prerequisites for the use of recombinant
factor VIIa in bleeding trauma
31a
Dr.Sherif Badrawy

✾ 【Platelet count > 50】 ➜ generate the
'thrombin burst' which the rFVIIa provokes
✾ 【Fibrinogen >0.5 g/L 】➜ translate this
thrombin generation into clot formation
✾ 【temperature > 32°C】
✾【pH >7.20.】
✾ 【Ionised Ca2+ >0.8mmol/L】
31b
Dr.Sherif Badrawy

Mechanism of Tranexamic acid action ?
32a
Dr.Sherif Badrawy

a competitive inhibitor of plasminogen and
plasmin.
32b
Dr.Sherif Badrawy

significantly reduces blood loss and
transfusion requirements in cardiac
surgery ?
33a
Dr.Sherif Badrawy

✾ 【Aprotinin】 ➜ forms irreversible
complexes with a variety of proteases
including plasmin
✾ isolated from bovine lungs and has a
high incidence of anaphylaxis (0.5%)
✾ ±associated with an increased incidence
of myocardial infarction, stroke and renal
failure
33b
Dr.Sherif Badrawy

Inhalational injury, when Pharyngeal
oedema is likely
to increase ?
34a
Dr.Sherif Badrawy

✾ 【once fluid resuscitation is
commenced】, and early intubation is
advised.
✾ Lung function is likely to worsen over the
next 12 hours.
34b
Dr.Sherif Badrawy

Common sites of thermal injury in the
Airway during burn ?
35a
Dr.Sherif Badrawy

Most of the heat from hot gas inhalation is
dissipated in the 【upper airways】, so
thermal injury below the glottis is unusual.
35b
Dr.Sherif Badrawy

Lavage with sodium bicarbonate 1.4% to
the bronchial tree has a role in the
management of thermal injury patient ?
36a
Dr.Sherif Badrawy

may be performed 【following intubation
to neutralise acidic deposits】 and remove
soot contamination, although evidence for
the effectiveness of this therapy is lacking.
36b
Dr.Sherif Badrawy

A cherry red visage has several causes
other than carbon monoxide poisoning ?
37a
Dr.Sherif Badrawy

alcohol, emotion and heat
37b
Dr.Sherif Badrawy

Risk factors for antimicrobial-resistant
infection
38a
Dr.Sherif Badrawy

✾ Prolonged hospital admission,
Prolonged MV
✾ indwelling devices
✾ poor hand hygiene
✾ High nursing workload.
✾ Understaffing in the ICU.
38b
Dr.Sherif Badrawy

BP of 75/50mmHg and a HR of 125bpm,
PAP 15/7mmHg, CVP 3mmHg, PAOP
5mmHg, cardiac index 1.6L/min/m2, SVR
2750 dyne/sec/cm5. The MOST LIKELY
diagnosis
39a
Dr.Sherif Badrawy

Hypovolaemia.
39b
Dr.Sherif Badrawy

BEST guide to the need for further intravenous
fluid replacement?
✾ Response of oesophageal Doppler to passive
leg raising.
✾ PA catheter
✾ Titrate fluid resuscitation against repeated
blood lactate
✾ pulse pressure variation
✾ UOP
40a
Dr.Sherif Badrawy

✾ 【Response of oesophageal Doppler to
passive leg raising.】
❅ Passive leg raising autotransfuses about
300ml of blood into the central circulation.
If stroke volume ↑significantly 【>10% by
oesophageal Doppler】
, indicates preload-responsiveness. it is
reversible if no improvement is seen
40b
Dr.Sherif Badrawy

PAOP as a guide to the need for further
intravenous fluid replacement?
41a
Dr.Sherif Badrawy

✸ PAOP is a poor predictor of whether a
fluid bolus will ↑COP
41b
Dr.Sherif Badrawy

Blood lactate & UOP as a guide to the need
for further intravenous fluid replacement?
42a
Dr.Sherif Badrawy

✸ Blood lactate & UOP will not DD bw
cardiogenic shock and septic shock
42b
Dr.Sherif Badrawy

Pulse pressure variation as a guide to the
need for further intravenous fluid
replacement?
43a
Dr.Sherif Badrawy

✸ 【Pulse pressure variation of >13%】
accurately predict response to fluid, but
is【only reliable in MV patients without
spontaneous respiratory effort】.
43b
Dr.Sherif Badrawy

sources of error in pulse oximetry
44a
Dr.Sherif Badrawy

✸ Use of 【local anaesthetic may cause a fall in SpO2】
✸ Jaundice, foetal haemoglobin and dark skin do
not affect the signal
✸ 【Severe tricuspid regurgitation】 reduces the SpO2
reading
✸ Readings are 【unreliable below 70% SpO2】
✸ any reading below 90% indicates serious
hypoxaemia due to the steep fall in the oxygen
dissociation curve at this point.
44b
Dr.Sherif Badrawy

most useful indicator when considering a
diagnosis of massive pulmonary
embolism?
45a
Dr.Sherif Badrawy

✸ 【A fall in end-tidal CO2 to 1.3kPa】. dt
degree of V/Q mismatch
✸ S1Q3T3 us infrequently seen in and is
therefore insensitive
45b
Dr.Sherif Badrawy

Normal Capnograph VS Bronchospasm
Capnograph
46a
Dr.Sherif Badrawy

46b
Dr.Sherif Badrawy

daily interruption of sedation
47a
Dr.Sherif Badrawy

✸ 【↓Length of ICU stay】
✸【↓ period of MV】
✸ 【↓CT brain scans are required】
✸ In-hospital 【mortality is unaffected】
✸ drug-sparing effect was greater with
midazolam.
47b
Dr.Sherif Badrawy

serotonin syndrome CP ?
48a
Dr.Sherif Badrawy

✸ mental status
【hallucinations, restlessness, confusion,
coma】
✸ neuromuscular
【clonus, myoclonus, ataxia, hyper-reflexia】
✸ autonomic
【hyperthermia, tachycardia, swings in BP】
48b
Dr.Sherif Badrawy

serotonin syndrome precipitated by
49a
Dr.Sherif Badrawy

【MAOI, TCA】, lithium, valproate, fentanyl,
ondansetron and
sympathomimetic drugs of abuse
49b
Dr.Sherif Badrawy

Cyproheptadine MOA ?
50a
Dr.Sherif Badrawy

a 【serotonin antagonist】 which has been
used in the treatment of the serotonin
syndrome
50b
Dr.Sherif Badrawy

Etiology of serotonin syndrome
51a
Dr.Sherif Badrawy

a 【dose-related】 phenomenon, unlike
the neuroleptic malignant syndrome. The
latter is an idiosyncratic drug reaction to
dopamine antagonists
51b
Dr.Sherif Badrawy

DD in onset bw serotonin syndrome &
neuroleptic malignant syndrome
52a
Dr.Sherif Badrawy

✸ onset of the neuroleptic malignant
syndrome is usually gradual over a period
of several days. 【 ‫ﻧ‬‫ﻤ‬‫ﺲ‬ NMS = gradual】
✸ Onset of serotonin syndrome is rapid
over a period of hours
52b
Dr.Sherif Badrawy

neuroleptic malignant syndrome CP ?
53a
Dr.Sherif Badrawy

✸ extrapyramidal
【lead pipe rigidity, bradykinesia】
✸ autonomic
【hyperthermia, tachycardia, swings in
BP】
✸ fluctuating consciousness
53b
Dr.Sherif Badrawy

most strongly predictive of outcome in
acute pancreatitis?
54a
Dr.Sherif Badrawy

White cell count.
【NOT amylase or lipase or CRP】
54b
Dr.Sherif Badrawy

Non-invasive ventilation in pts with
idiopathic pulmonary
fibrosis (IPF) ?
55a
Dr.Sherif Badrawy

NIV is 【ineffective in preventing the need
for ETT & MV】 (in contrast to pts with
obstructive lung disease)
55b
Dr.Sherif Badrawy

commonest cause of worsening
respiratory failure
in patients with IPF ?
56a
Dr.Sherif Badrawy

progression of the disease process (47%),
followed
by pneumonia (31%)
56b
Dr.Sherif Badrawy

NOT an propriate treatment for acute
severe asthma ?
57a
Dr.Sherif Badrawy

Heliox.【NOT Intravenous aminophylline】
✸ Heliox did not alter outcome and could
not be
recommended in the emergency Rx of
acute severe asthma
✸ Heliox is not recommended in the latest
British Thoracic Society guidelines
57b
Dr.Sherif Badrawy

76-y F, Hx of AF, SOB, bibasal crackles,
80/50, SpO2 of 87% on 15L/min oxygen
NRBM, ECG AF ventricular rate of
170bpm.takes warfarin, her INR is 1.3 ,
Action ?
58a
Dr.Sherif Badrawy

✸【 synchronised DC shock】
Although there is a risk of embolisation
when cardioverting a patient with
longstanding (AF) who is not
anticoagulated (6.8%), this is outweighed
by the need for urgent heart rate control.
58b
Dr.Sherif Badrawy

FEV1 as a predictor of ICU survival in
patients with IPF ?
59a
Dr.Sherif Badrawy

FEV1 is not a useful predictor of ICU
survival in patients with IPF
59b
Dr.Sherif Badrawy

(IABP) for cardiac failure
60a
Dr.Sherif Badrawy

❤ inserted via the 【femoral artery or
subclavian artery】
❤ The balloon【inflates immediately following
the dicrotic notch】on the arterial waveform.
❤ The balloon 【deflates during isovolumetric
contraction】 of the LV.
❤ The augmentation pressure is the peak
pressure during IABP inflation in diastole.
❤ 【SBP usu ➜↓during IABP use】.
60b
Dr.Sherif Badrawy

IHD vs CRRT vs SLED1
61a
Dr.Sherif Badrawy

61b
Dr.Sherif Badrawy

IHD vs CRRT vs SLED2
62a
Dr.Sherif Badrawy

62b
Dr.Sherif Badrawy

Which is more efficient at removing urea
IHD vs CRRT
63a
Dr.Sherif Badrawy

【IHD is much more efficient at removing urea】
(clearance 198ml/min) than CVVHDF (30ml/min)
and, So, requires a much < time frame, and <
labour-intensive for the ICU staff.
Mortality is similar in ICU pts Rx with IHD or
CRRT.
IHD can be used successfully in HD unstable
pts.
CRRT is > labour-intensive for the ICU staff.
63b
Dr.Sherif Badrawy

Electrolyte disturbances in rhabdomyolysis
?
64a
Dr.Sherif Badrawy

✬ Hyperkalaemia.
✬ mild hypocalcaemia
✬ Hyperphosphataemia.
✬ Elevated serum creatinine.
✬ Hyperuricaemia.
64b
Dr.Sherif Badrawy

Etiology of mild hypocalcaemia in
rhabdomyolysis ?
65a
Dr.Sherif Badrawy

✬ seen early in the course of rhabdomyolysis
➜ 【Phosphate binds with calcium in the
extracellular fluid】 ➜ may precipitate in the
tissues
✬ in the recovery phase ➜ calcium is mobilised
from the tissues to the extracellular space ➜
avoided calcium supplementation unless
ionised levels are dangerously↓
65b
Dr.Sherif Badrawy

paracetamol toxicity N-acetylcysteine
66a
Dr.Sherif Badrawy

✬ Serious liver damage is unlikely if N-
acetylcysteine is given within 12hours of
ingestion
✬ NAC may be continued indefinitely at
150mg/kg/day in cases of acute liver failure
until improvement occurs or a transplant
is obtained
66b
Dr.Sherif Badrawy

the most sensitive prognostic marker in
paracetamol toxicity
67a
Dr.Sherif Badrawy

raised prothrombin time
67b
Dr.Sherif Badrawy

silhouette sign in CXR
68a
Dr.Sherif Badrawy

the absence of the normally well-defined
interface between lung and soft tissue
structures. If the air in the lung at the
interface is removed e.g.【consolidation】,
the radiographic boundary will disappear.
68b
Dr.Sherif Badrawy

Pleural capping sign in CXR
69a
Dr.Sherif Badrawy

obliteration of the medial aspect of the left
upper lobe seen in some cases of aortic
dissection
69b
Dr.Sherif Badrawy

Bat's wing sign in CXR
70a
Dr.Sherif Badrawy

shadowing is perihilar oedema of the lung
fields adjacent to the heart seen in
congestive cardiac failure.
70b
Dr.Sherif Badrawy

Air bronchograms sign in CXR
71a
Dr.Sherif Badrawy

(radiolucent) intrapulmonary airways
made visible by their passage through a
zone of (radio-opaque) consolidation.
71b
Dr.Sherif Badrawy

Wedge-shaped shadows sign in CXR
72a
Dr.Sherif Badrawy

may represent an area of infarcted lung in
pulmonary embolism
72b
Dr.Sherif Badrawy

Cocaine effects on anticoagulation ?
73a
Dr.Sherif Badrawy

a hypercoagulable state by decreasing
protein C and
antithrombin III levels, and increases
platelet activation.
73b
Dr.Sherif Badrawy

'crack lung' with Cocaine abuse ?
74a
Dr.Sherif Badrawy

Cocaine has immunogenic properties act
as a hapten triggers a 【hypersensitivity
pneumonitis】 when combined with
albumin or globulins characterised by
fever, dyspnoea, wheezing and diffuse
interstitial infiltrates
74b
Dr.Sherif Badrawy

commonest gastrointestinal complication
of cocaine
75a
Dr.Sherif Badrawy

✺ 【Bowel ischaemia】 dt vasospasm of
the mesenteric circulation
✺ Gastroduodenal perforation can also
occur
75b
Dr.Sherif Badrawy

Phencyclidine (PCP)
76a
Dr.Sherif Badrawy

✺ a recreational drug of abuse
✺ a weak base
✺ highly lipid-soluble and 78% protein-bound
➜ HD is ineffective.
✺ cholinergic, anticholinergic,
sympathomimetic, dopaminergic, narcotic and
serotonergic effects
✺ Hypertension agitation with pinpoint pupils
76b
Dr.Sherif Badrawy

physiology of pregnancy
77a
Dr.Sherif Badrawy

✺ SVR normally falls in early pregnancy.
✺ The RAS is up-regulated.
✺ SBP decreases to a lesser extent than
diastolic.
✺ Hypertension detected in the first
trimester is likely to be longstanding.
77b
Dr.Sherif Badrawy

Pre-eclampsia is a predictor of difficult
laryngoscopy
78a
Dr.Sherif Badrawy

【potentially difficult airway of pregnancy
is accentuated】, with facial and tongue
oedema making direct laryngoscopy
difficult.
78b
Dr.Sherif Badrawy

dobutamine effects
79a
Dr.Sherif Badrawy

✺ LVEDP is reduced.
✺ half-life of 2 minutes
✺ SVR is reduced.
✺ Cardiac index is increased
79b
Dr.Sherif Badrawy

Remifentanil is metabolised by
80a
Dr.Sherif Badrawy

【non-specific plasma esterases】and can
be used as normal if hepatic metabolism is
impaired
80b
Dr.Sherif Badrawy

DD bw Drugs with a low extraction ratio &
Drugs with a flow-limited in hepatic
metabolism in shock state
81a
Dr.Sherif Badrawy

Drugs with a low extraction ratio
are【metabolism-limited 】(they depend
on saturable enzyme systems for
metabolism) rather than flow-limited, and
will not be affected by reduced liver blood
flow, unless the reduction is so severe as
to cause hepatocellular injury and reduced
enzyme function.
81b
Dr.Sherif Badrawy

The Venturi effect (based on the Bernoulli
principle)
82a
Dr.Sherif Badrawy

【when a gas passes through a constriction the
pressure falls, allowing a second gas to be
entrained】. The Venturi mask has a
constriction through which oxygen flows,
entraining a fixed ratio of air dependent on the
size of the constriction and the flow of oxygen.
This allows a high volume of gas of a known
FiO2 to be available for inspiration (fixed
performance).
82b
Dr.Sherif Badrawy

oxygen administration
83a
Dr.Sherif Badrawy

✺ Maximum inspiratory flow may exceed
30L/min during spontaneous breathing.
✺ Nasal cannulae significantly improve
oxygenation even if the patient breathes
through the mouth.
✺ A Venturi mask uses the Bernoulli principle.
✺ An anaesthetic face mask increases dead
space.
83b
Dr.Sherif Badrawy

Clostridium difficile is a ?
84a
Dr.Sherif Badrawy

✺ a spore-forming gram-positive anaerobic
bacillus
✺ transmitted from patient to patient,
usually via the hands of hospital personnel
✺ 40% of hospitalized patients can harbor
C. difficile in their stool, most are
asymptomatic
84b
Dr.Sherif Badrawy

Oral vancomycin is the treatment of choice
for Clostridium difficile infection if ?
85a
Dr.Sherif Badrawy

High risk pts for serious complications such as
toxic megacolon, perforation and death in case
of recurrence.
✯ ↓GCS
✯ HD instability, dehydration
✯ age > 65
✯ WBCs >20
✯ creatinine >200
✯ Confluent pseudomembranes, megacolon
85b
Dr.Sherif Badrawy

Dx of Clostridium difficile infection ?
86a
Dr.Sherif Badrawy

✯ 【PCR】
✯ Enzyme immunoassay (EIA) for C. difficile
【glutamate dehydrogenase】(GDH)
✯ (EIA) for C. difficile【 toxins A and B】
✯ Cell culture cytotoxicity assay
✯ Selective anaerobic culture
✯ Colonoscopy or sigmoidoscopy
and【biopsy】
86b
Dr.Sherif Badrawy

Which form of vancomycin is used in Rx of
Clostridium difficile infection ?
87a
Dr.Sherif Badrawy

❏ Oral vancomycin as resistance is rare and it
reaches high concentrations in the colon.
❏ IV vancomycin is ineffective since it has poor
penetration of the colon
❏ IV metronidazole is effective, however, and
may be useful if an ileus preventing the enteral
administration of drugs is present
87b
Dr.Sherif Badrawy

first-line therapy for uncomplicated C.
difficile infection ?
88a
Dr.Sherif Badrawy

✺ oral metronidazole
✺ effective and cheap but associated with a
significant relapse rate of up to 25% in the
first 10 days following cessation of therapy.
88b
Dr.Sherif Badrawy

Rule of Nasojejunal faecal replacement in
Rx of Clostridium difficile infection ?
89a
Dr.Sherif Badrawy

Usen in Rx of chronic C. difficile infection,
【where it re-colonises the patient's colon
with normal flora】. It has【 no place in the
management of acute infection】.
89b
Dr.Sherif Badrawy

commonest adverse incident in the ICU?
90a
Dr.Sherif Badrawy

Line, drain and catheter dislodgement
then Medication errors then Equipment
failure.
90b
Dr.Sherif Badrawy

Flow-volume loop for Tracheomalacia
91a
Dr.Sherif Badrawy

✯ characteristic pattern of variable intrathoracic obstruction【normal inspiratory limb
and a flattened expiratory limb】.
✯ trachea to【collapse during expiration but remain patent during inspiration】.
✯ ischaemic injury to the trachea followed by chondritis necrosis of supporting tracheal
cartilage.
✯ dt tracheostomy or prolonged transtracheal intubation 91b
Dr.Sherif Badrawy

The following support a diagnosis of SIADH
?
92a
Dr.Sherif Badrawy

a. Urine sodium less than 20mmol/l.【✘】➜ > 20
b. Correction by water restriction.【✔】
c. Pitting oedema.【✘】➜ euvolaemic
d. Urine osmolality greater than plasma
osmolality.【✔】
【SIADH is characterised by a low plasma
sodium, high urinary sodium excretion and a
predisposing cause】
92b
Dr.Sherif Badrawy

The following may be signs of
【hypomagnesaemia】:
93a
Dr.Sherif Badrawy

a. Trousseau's and Chvostek's signs.【✔】
b. Hyperreflexia.【✔】
c. Flushing.【✘】➜ a sign of
hypermagnesaemia
d. Ataxia.【✔】
93b
Dr.Sherif Badrawy

Regarding microshock:
94a
Dr.Sherif Badrawy

a. Risk of ventricular fibrillation is
proportional to current density.【✔】
b. Microshock is unlikely with leakage
currents at mains frequency (50Hz).【✘】
c. Microshock is unlikely with a leakage
current of <50μA.【✔】
d. Type CF equipment is for cardiac use
and has a floating circuit.【✔】
94b
Dr.Sherif Badrawy

Regarding the use of therapeutic
hypothermia in cardiac
arrest survivors:
95a
Dr.Sherif Badrawy

a. Level 1 evidence exists in out-of-hospital cardiac
arrest patients with return of spontaneous circulation.
【✔】
b. Cooling should begin as soon as possible.【✔】
c. There is no significant difference in the incidence of
arrhythmia compared with normothermic controls.
【✔】
d. Therapeutic hypothermia should be continued for
at least 72 hours once instituted.【✘】
95b
Dr.Sherif Badrawy

RTA, fractures of right ribs 5-9 inclusive,
with clear lung fields, pH 7.23, PCO2 8.5kPa
(64mmHg), PO2 9.6kPa (73mmHg) (FiO2
0.8).
96a
Dr.Sherif Badrawy

a. A chest drain should be inserted
immediately.【✘】
b. A CT thorax may provide additional diagnostic
information.【✔】
c. Steroids are not indicated.【✔】(or
prophylactic
antibiotics)
d. Ventilation in the right lateral position is likely
to improve oxygenation【✘】
96b
Dr.Sherif Badrawy

pulmonary contusion in a trauma Pt ?
97a
Dr.Sherif Badrawy

✯ trauma + shear stress, bursting forces and【pulmonary
vascular damage with secondary alveolar haemorrhage】.
✯ Initial chest X-ray commonly ➜ clear lung fields, with
【opacities taking several hours to appear】.
✯ A CT scan has much > sensitivity ➜ evidence of
pulmonary contusion immediately post-injury.
✯ Haemorrhage into the affected lung may continue for
24-48 hours, and【contusions resolve after about 7 days】
.
97b
Dr.Sherif Badrawy

RTA, Abdominal Seatbelt injury, Hb
11.5g/dL, amylase
of 60IU/L & AST of 500IU/L.
98a
Dr.Sherif Badrawy

a. Mesenteric injury is a significant
concern.【✔】
b. Pancreatic injury is excluded by a
normal amylase.【✘】
c. The raised AST should increase
suspicion of hepatic injury.【✔】
d. Hypotensive resuscitation should be
employed.【✘】
98b
Dr.Sherif Badrawy

Compression from a seatbelt
99a
Dr.Sherif Badrawy

can cause subcapsular haematoma to
solid organs, and can cause increased
intraluminal pressure and rupture of
hollow viscera
99b
Dr.Sherif Badrawy

RTA,GCS of 5 with extensor posturing, and
dilated fixed pupils. A CT brain scan shows
a 6mm midline shift and diffuse petechial
haemorrhages.
100a
Dr.Sherif Badrawy

a. The GCS post-resuscitation has prognostic significance.
【✔】➜ the most important prognostic indicator.
b. Midline shift of > 5mm on the CT scan carries a poor
prognosis.【✔】
c. A 48-hour infusion of intravenous methylprednisolone is
indicated.【✘】
d. The verbal response is the most prognostically useful
component of the GCS.【✘】➜ motor component is the
most useful
100b
Dr.Sherif Badrawy

The following findings in cerebrospinal
fluid are characteristic of the Guillain-Barré
syndrome:
101a
Dr.Sherif Badrawy

a. Pleocytosis.【✘】
b. CSF glucose >2/3 of plasma glucose.【✔】
c. Protein >0.5g/L.【✔】
d. Oligoclonal bands.【✘】➜ multiple sclerosis
【Typical CSF in GBS are↑protein (normal
range is 0.2-0.4g/L), normal glucose and no
↑WBCs (↑WBCs should cast doubt on the
diagnosis)】.
101b
Dr.Sherif Badrawy

CSF characteristic of the Guillain-Barré
syndrome:
102a
Dr.Sherif Badrawy

elevated protein normal glucose and no
elevation of WBCs (an elevated WBCs
should doubt the diagnosis). Oligoclonal
bands are characteristic of (but not
specific to) demyelinating disease.
102b
Dr.Sherif Badrawy

A 78-y seizure 5 days postcarotid
endarterectomy. It spontaneously
terminates but on recovery he complains
of a severe left-sided 'pounding' headache
and a weak right arm. His BP is
205/110mmHg.
103a
Dr.Sherif Badrawy

a. A CT brain scan is not required.
【✘】➜to exclude stroke
b. His blood pressure should be reduced
by pharmacological means.【✔】
c. Glyceryl trinitrate is the agent of choice.
【✘】
d. A heparin infusion should be started
immediately.【✘】
103b
Dr.Sherif Badrawy

The history of seizure, headache and
neurological deficit post-endarterectomy
suggests
104a
Dr.Sherif Badrawy

✯ cerebral hyperperfusion syndrome
✯ blood flow is restored to part of the brain where
previously it was poor, and normal autoregulatory
mechanisms are ineffective
✯ peak ➜ day 5 post-op
✯ requires drug treatment (unlike ischaemic stroke where
BP is generally left untreated in the acute phase).
✯ labetalol or clonidine are preferred to nitrates
✯ If left unRx ➜ cerebral oedema and haemorrhagic
stroke
104b
Dr.Sherif Badrawy

Regarding sites of vascular access:
105a
Dr.Sherif Badrawy

a. The brachial artery lies between the biceps brachii
tendon and the ulnar nerve.【✘】
b. The femoral nerve travels in the femoral canal with the
femoral vein and artery.【✘】➜ outside the sheath
c. The carotid sheath contains the internal jugular vein,
carotid artery and vagus nerve.【✔】
d. The long saphenous vein can be cannulated 2cm
posterior and superior to the medial malleolus【✘】➜
anterior and superior
105b
Dr.Sherif Badrawy

Regarding the intensive care management
of patients with
blunt traumatic brain injury:
106a
Dr.Sherif Badrawy

a. Hyperglycaemia has no bearing on neurological
outcome.【✘】➜ glycaemic control improve survival and
neurological outcome
b. The incidence of deep vein thrombosis is less than 10%
in isolated head injury.【✔】
c. Prophylactic anticoagulation for thromboprophylaxis
should begin in the first 24h.【✘】➜ after 72h
d. Prophylactic hypothermia is a standard of care in the
management of these patients.【✘】➜ no statistically
significant reduction in mortality
106b
Dr.Sherif Badrawy

RTA, significant abdominal injuries, liver
lacerations and diffuse small vessel
bleeding, abdomen is packed and the
patient is transferred to the ICU,
continuous bleeding, regarding the use of
recombinant factor VIIa (rFVIIa)
107a
Dr.Sherif Badrawy

a. rFVIIa is not licensed for use in this situation.【✔】➜
licensed for haemophilia A and B
b. rFVIIa has been shown to reduce blood transfusion
requirements in【blunt trauma】.【✔】➜ This benefit
was not shown in patients with penetrating trauma
c. Use of rFVIIa is proven to reduce mortality in blunt
trauma.【✘】
d. The action of rFVIIa is independent of platelet
number and function.【✘】
107b
Dr.Sherif Badrawy

RTA, emergency splenectomy, external
fixation of a pelvic fracture and external
fixation of a femoral shaft fracture.ATLS
grade III shock, ABG lactate of 6.4mmol/L,
on arrival in the ICU this has reduced to
3.5mmol/L
108a
Dr.Sherif Badrawy

a. This man has a Type A lactic acidosis.【✔】➜
Type B is dt inability of the organs to metabolise
a lactate load
b. Lactate is of prognostic significance in trauma
patients.【✔】
c. Venous blood can be used for lactate analysis.
【✔】
d. Outlook will be poor if lactate remains above
2mmol/L after 48h.【✔】
108b
Dr.Sherif Badrawy

enclosed space with a burning coal fire.
GCS 13 saturation of 96% on high-flow
oxygen a brief tonic-clonic seizure which
self-terminates ABG pH 7.36, PO2 40.6kPa
(308mmHg), PCO2 4.4kPa
(33mmHg),calculated SaO2 99%.
109a
Dr.Sherif Badrawy

a. The history and findings are consistent with carbon
monoxide poisoning.【✔】
b. There is evidence of a saturation gap.【✘】
c. Oxygen therapy should be titrated down to a lower
PaO2.【✘】➜ A standard pulse oximeter measures only
two wavelengths of light and falsely interprets COHb as
oxyhaemoglobin, overestimating the true arterial oxygen
saturation
d. Hyperbaric oxygen therapy is contraindicated.【✘】
109b
Dr.Sherif Badrawy

the 'saturation gap'
110a
Dr.Sherif Badrawy

✯ In Co poisoning True SaO2 can be
measured using a co-oximeter which uses
multiple wavelengths of light. If measured
in this case, true SaO2 would be very low
when compared with the falsely elevated
SpO2
✯ SaO2 provided in this question is
calculated, however, this is not seen.
110b
Dr.Sherif Badrawy

The following assumptions are made when
determining
stroke volume using an oesophageal
Doppler probe:
111a
Dr.Sherif Badrawy

a. 70% of total cardiac output passes the probe.
【✔】
b. The ascending aorta runs parallel to the
oesophagus.【✘】➜ The descending aorta
c. The diameter of the aorta is constant
throughout systole.【✔】
d. Haematocrit is unchanged between
measurements.【✘】➜ haematocrit has no
bearing on SV determination.
111b
Dr.Sherif Badrawy

Concerning the measurement of cardiac
output by
thermodilution techniques:
112a
Dr.Sherif Badrawy

a. A pulmonary artery catheter is required.【✘】➜
only a central line and an arterial cannula
b. Cardiac output is inversely proportional to the area
under the temperature-time curve.【✔】
c. A small volume of injectate will underestimate
cardiac output.【✘】
d. 'Cold' injectate should be at 12-15°C.【✘】➜ ice-
cold, the closer the temperature is to blood
temperature, the less precise the measurement
112b
Dr.Sherif Badrawy

Regarding the management of carbon
monoxide
poisoning:
113a
Dr.Sherif Badrawy

a. The half-life of CoHb in air is about 4 hours.【✔】
b. A CoHb level of 60% is commonly lethal.【✔】
c. An otherwise fit and well patient with a CoHb level of
50% will have an arterial oxygen content of
approximately
5 mlO2/100ml when breathing 100% oxygen.【✘】
d. Untreated pneumothorax is an absolute CI to
hyperbaric oxygen therapy.【✔】
113b
Dr.Sherif Badrawy

The following information can be derived
from the arterial
pressure waveform:
114a
Dr.Sherif Badrawy

a. Stroke volume from the area under the entire
waveform.【✘】➜ from the area under the systolic portion
of the arterial waveform
b. Myocardial afterload from dP/dt.【✘】➜ The rate of rise
in pressure per unit time (dP/dt) is an index of contractility.
c. Hypovolaemia from a high dicrotic notch.【✘】➜ low
dicrotic notch and a narrow waveform
d. Vasodilatation from a steep diastolic rate of decay.
【✔】
114b
Dr.Sherif Badrawy

Regarding the physical principles behind
pulse oximetry:
115a
Dr.Sherif Badrawy

a. Light is transmitted through the
measurement site at 3Hz.【✘】➜ (30Hz)
b. Light is transmitted at wavelengths of
660nm (red) and 940nm (infrared).【✔】
c. The isobestic point indicates an SpO2 of
50%.【✘】
d. The Hagen-Poiseuille law underpins the
physics involved.【✘】
115b
Dr.Sherif Badrawy

The pulse oximeter measures ?
116a
Dr.Sherif Badrawy

✯ the absorbance of red and infrared light
transmitted through tissues
✯ Oxyhaemoglobin absorbs more infrared
light
(940nm) and allows more red light (660nm)
to pass through (and vice versa for
deoxyhaemoglobin).
116b
Dr.Sherif Badrawy

The isobestic point is
117a
Dr.Sherif Badrawy

the 【wavelength of light】at which
absorption is the same for oxy- and deoxy
Hb (805nm) regardless of the oxygen
saturation of the blood. a reference point
for some types of pulse oximeter.
117b
Dr.Sherif Badrawy

43-y SOB, pleuritic chest pain and
haemoptysis.Sat 87% on air, RR is 45, HR is
156, BP is 80/55 Echo moderate RV
dilatation, PAP 60mmHg.
118a
Dr.Sherif Badrawy

a. Pulmonary embolism is a likely diagnosis.【✔】
b. The mortality rate is around 1% with this clinical
picture.【✘】
c. 【Thrombolysis】 has been shown to reduce the risk
of death for such patients.【✘】➜ 【Improve RV
function but not to reduce the risk of death】
d. A left ventricular heave is a likely finding on
examination【✘】➜ RV affected not LV.
118b
Dr.Sherif Badrawy

The capnograph trace below could be
explained by:
119a
Dr.Sherif Badrawy

a. Oesophageal intubation.【✔】
b. Endobronchial intubation.【✘】
c. Massive haemorrhage.【✔】
d. Hyperventilation.【✘】
119b
Dr.Sherif Badrawy

Regarding the following intracranial
pressure trace:
120a
Dr.Sherif Badrawy

a. P1 represents transmitted arterial pulsation.【✔】
b. P2 exceeds P1 as intracranial compliance falls.【✔】
c. P3 represents the dicrotic notch.【✔】
d. P1, P2 and P3 are Lundberg waves.【✘】
120b
Dr.Sherif Badrawy

intracranial pressure trace
121a
Dr.Sherif Badrawy

✪ P1 ➜【transmitted arterial pulsation】 (the percussion wave);
✪ P2 related to ➜ 【brain compliance】 (the tidal wave) and ↑as brain compliance ↓
✪ P3 dt the 【closure of the aortic valve】 (the dicrotic wave).
✪ Lundberg waves ➜ longer, time-dependent patterns of pressure waves in patients with ↑ICP
121b
Dr.Sherif Badrawy

Regarding the aetiology of massive
haemoptysis:
122a
Dr.Sherif Badrawy

a. It more commonly originates from the bronchial than
the pulmonary circulation.【✔】In 【90% , bleeding from
the bronchial circulation】
b. Chest X-ray identifies the source of bleeding in a
minority of cases.【✘】identifies the source of bleeding in
64-80% of cases but CT is even more
c. The presence of a nasal septal perforation may suggest
Behcet's syndrome.【✘】Wegener's granulomatosis
d. Pulmonary-renal syndromes are the commonest cause.
【✘】【Bronchiectasis, tuberculosis and lung cancer】
122b
Dr.Sherif Badrawy

Massive haemoptysis is
123a
Dr.Sherif Badrawy

blood loss of 【100-1000ml in a 24-h】
period from the respiratory tract
123b
Dr.Sherif Badrawy

a patient just admitted to the ICU: sodium
145mmol/L, potassium 3.5mmol/L, urea
17mmol/L (BUN 48mg/dL), creatinine
170μmol/L (1.9mg/dL), bicarbonate
8mmol/L, chloride 105mmol/L, glucose
30mmol/L (550mg/dL). Regarding this
patient:
124a
Dr.Sherif Badrawy

a. The anion gap is raised.【✔】
b. The serum osmolality is raised.【✔】
c. The biochemical picture is consistent
with 【gastric outflow obstruction】.
【✘】causes a 【hypochloraemic
metabolic alkalosis due to loss of HCL】.
d. Excessive administration of 0.9% saline
can cause this biochemical picture.【✘】
124b
Dr.Sherif Badrawy

Concerning aortic dissection:
125a
Dr.Sherif Badrawy

a. Medical management is the preferred option in
uncomplicated Stanford Type B dissection.【✔】
b. Medical management includes noradrenaline
infusion to maintain renal perfusion pressure.【✘】
c. The commonest site of origin is the descending
aorta.【✘】【ascending aorta】
d.【A TEE is the Ix of choice in patients too unstable for
angiography】.【✔】
125b
Dr.Sherif Badrawy

Regarding the Injury Severity Score (ISS):
126a
Dr.Sherif Badrawy

a. It is comprised of anatomical and
physiological data.【✘】
b. The maximum score is 75.【✔】
c. Head injury carries the highest
weighting.【✘】
d. Six body regions are defined.【✔】
(head, face, chest, abdomen, extremities
[including pelvis], external).
126b
Dr.Sherif Badrawy

limitations of the Injury Severity Score (ISS)
127a
Dr.Sherif Badrawy

A patient with several wounds to the same
body region can only score once for that
region; in such a case the ISS may
underestimate the severity of their
injuries.
127b
Dr.Sherif Badrawy

The following are good predictors of
increased hospital
mortality in patients with COPD requiring
MV
128a
Dr.Sherif Badrawy

a. Mechanical ventilation lasting >72h.
【✔】
b. An FEV1 <30% predicted prior to ICU
admission.【✘】
c. One failed extubation attempt.【✔】
d. Presence of comorbidities.【✔】
128b
Dr.Sherif Badrawy

Facts about predictors of increased
hospital
mortality in patients with COPD requiring
MV
129a
Dr.Sherif Badrawy

✪ Interestingly, survival rates were also
much better in patients with a previous
episode of mechanical ventilation
✪ FEV1 is an important predictor of long-
term survival, but does not predict short-
term outcome in COPD patients requiring
MV
129b
Dr.Sherif Badrawy

Regarding therapeutic interventions for
massive
haemoptysis:
130a
Dr.Sherif Badrawy

a. Bronchial artery embolisation is successful in
the majority of cases.【✔】➜ 75-90% of patients
b. Emergency lung resection carries a 60%
mortality.【✘】
c. Bronchoscopic lavage with epinephrine
1:10000 may be useful.【✔】
d. Rigid bronchoscopy has no place in this
situation.【✘】➜ has a role but cannot visualise
the periphery of the tracheobronchial tree.
130b
Dr.Sherif Badrawy

(PEEP) in patients with (ARDS):
131a
Dr.Sherif Badrawy

a. High PEEP (>12cmH2O) reduces ICU mortality
compared with low PEEP (5-12cmH2O).【✘】
b. PEEP should be set below the lower inflection
point on the pressure-volume curve.【✘】
c. High PEEP improves the PaO2/FiO2 ratio
compared with low PEEP. 【✔】
d. PEEP causes atelectrauma.【✘】
131b
Dr.Sherif Badrawy

Regarding atrial fibrillation:
132a
Dr.Sherif Badrawy

a. Maximum cardiac output occurs with ventricular rate
controlled to 50bpm.【✘】➜ the optimum ventricular rate
is around 90bpm at rest
b. The atria are normally responsible for 40-50% of
ventricular filling.【✘】➜ 15-30%
c. Valvular heart disease is the commonest cause.【✘】➜
IHD
d. 'Atrial stunning' commonly occurs after successful
cardioversion.【✔】➜ Atrial mechanical function usually
improves over the first 24 hours.
132b
Dr.Sherif Badrawy

The following are absolute
contraindications to the use of an intra-
aortic balloon pump:
133a
Dr.Sherif Badrawy

a. Clinically significant aortic stenosis.
【✘】➜ clinically significant AR
b. Refractory angina.【✘】
c. Aortic dissection.【✔】
d. Severe peripheral vascular disease.
【✘】➜ a relative CI, Also Morbid obesity &
AAA.
133b
Dr.Sherif Badrawy

77-y M, in HDU, a new right-sided
homonymous hemianopia and dysphasia
HR of 85bpm, BP of 190/105 mmHg, SpO2
of 96% on room air. A CT brain scan is
unremarkable. Appropriate initial
management includes:
134a
Dr.Sherif Badrawy

a. Aspirin 300mg.【✔】➜ clinical evidence
of a stroke ➜ ↓recurrence of stroke
b. Clopidogrel 300mg.【✘】
c. Treatment dose of low-molecular-weight
heparin.【✘】
d. Labetalol.【✘】
134b
Dr.Sherif Badrawy

Anticoagulation in the acute phase of
ischaemic stroke
135a
Dr.Sherif Badrawy

Anticoagulation has no benefit in the acute
phase of ischaemic stroke (except in
special cases such as venous sinus
thrombosis) and should not be given
135b
Dr.Sherif Badrawy

Hypertension in acute stroke
136a
Dr.Sherif Badrawy

should not be actively lowered unless
pressures of 220mmHg (systolic) or
120mmHg (diastolic) are reached. If
thrombolysis is considered, lower
thresholds for treatment exist (185mmHg
systolic, 110mmHg diastolic)
136b
Dr.Sherif Badrawy

The following features favour a diagnosis
of encephalopathy over encephalitis in a
patient presenting
with an altered sensorium:
137a
Dr.Sherif Badrawy

a. Meningism.【✘】
b. Normal cerebrospinal fluid analysis.
【✔】
c. Gradual steady deterioration in mental
status.【✔】
d. Seizures.【✘】
137b
Dr.Sherif Badrawy

commonest cause of acute encephalitis
138a
Dr.Sherif Badrawy

Herpes simplex
138b
Dr.Sherif Badrawy

The following interventions are effective in
reducing the
incidence of acute renal failure in selected
populations:
139a
Dr.Sherif Badrawy

a. Low dose dopamine infusion
(2μg/kg/min).【✘】
b. Mannitol.【✘】
c. Normal saline infusion prior to
administration of radiocontrast media.
【✔】
d. N-acetylcysteine prior to administration
of radiocontrast media.【✔】
139b
Dr.Sherif Badrawy

IV drug abuser is admitted to the ICU.itchy,
and
feeling lethargic and unwell. She is sleepy
but arousable, and is incoherent and
extremely confused. Asterixis is present.
Serology confirms acute hepatitis B
infection; the
prothrombin time is 70 seconds.
140a
Dr.Sherif Badrawy

a. This patient has grade III hepatic encephalopathy.【✔】
b. The clotting deficit should be corrected with fresh frozen
plasma.【✘】➜ should not be corrected in the absence of
bleeding or invasive procedures
c. Survival rates for this condition without liver transplant
are around 60%.【✘】➜ Mortality without liver
transplantation is around 90% for fulminant hepatic failure
d. Cerebral oedema is a likely cause of the confusional
state 【✔】➜ best assessed with ICP monitoring (after CT
brain scan to exclude other causes)
140b
Dr.Sherif Badrawy

Regarding acalculous cholecystitis in the
ICU patient:
141a
Dr.Sherif Badrawy

a. It has a high mortality.【✔】➜ mortality
up to 40%
b. The incidence is around 0.2%.【✔】
c. Gram negative biliary tract sepsis is the
initiating cause.【✘】
d. U/S is highly sensitive and specific for
the condition.【✘】➜ only moderate, CT
has greater diagnostic accuracy
141b
Dr.Sherif Badrawy

45-y admitted to the ICU with signs of
sepsis. c/o of a painful, swollen knee for
the last 3 d no history of trauma no
previous history of joint problems or other
medical problems, apyrexial, ESR of
72mm/h. A diagnosis of septic arthritis is
considered.
142a
Dr.Sherif Badrawy

a. Septic arthritis is unlikely in the absence
of pyrexia.【✘】
b. An elevated ESR is a sensitive indicator
of septic arthritis.【✔】
c. Plain radiography is often diagnostic.
【✘】
d. A negative Gram stain of joint fluid
aspirate excludes the diagnosis.【✘】
142b
Dr.Sherif Badrawy

Regarding the RIFLE criteria classification
system for acute renal failure:
143a
Dr.Sherif Badrawy

a. The 'E' in 'RIFLE' represents end-stage
kidney disease.【✔】
b. Kidney failure can be diagnosed based
on urine output alone.【✔】
c. Criteria for risk of kidney injury are
specific but not sensitive.【✘】
d. Serum creatinine is accepted as an index
of glomerular function.【✔】
143b
Dr.Sherif Badrawy

RIFLE criteria
144a
Dr.Sherif Badrawy

144b
Dr.Sherif Badrawy

The following drugs require altered dosing
in patients with
advanced liver cirrhosis:
145a
Dr.Sherif Badrawy

a. Midazolam.【✔】
b. Remifentanil.【✘】
c. Atracurium.【✘】➜ Hofmann elimination (a
non-enzymatic process which occurs at
physiological pH and temperature)
d. Propofol.【✔】➜ conjugated in the liver with
glucuronides and sulphates before excretion in
urine
145b
Dr.Sherif Badrawy

When commencing renal replacement
therapy, the
following properties predict significantly
increased
clearance of a drug compared with the
anuric state:
146a
Dr.Sherif Badrawy

a. Low protein-binding.【✔】
b. Low volume of distribution.【✔】
c. High non-renal clearance.【✘】
d. High molecular weight.【✘】
146b
Dr.Sherif Badrawy

The following are common features of 3,4-
methylenedioxymethamphetamine
('ecstasy') poisoning:
147a
Dr.Sherif Badrawy

a. Rhabdomyolysis.【✔】
b. Hypernatraemia.【✘】➜ Hyponatraemia
dt excessive sodium loss in sweat,
excessive water intake and enhanced ADH
c. Hyperthermia.【✔】
d. Non-cardiogenic pulmonary oedema.
【✘】
147b
Dr.Sherif Badrawy

Other complications of ('ecstasy')
poisoning
148a
Dr.Sherif Badrawy

hypertension, tachyarrhythmias and,
rarely, stroke (haemorrhagic or
thrombotic) and hepatotoxicity.
148b
Dr.Sherif Badrawy

Regarding obstetric-related deaths in the
developed world:
149a
Dr.Sherif Badrawy

a. More mothers die from indirect causes (pre-existing
disease exacerbated by pregnancy) than direct causes
(bleeding, preeclampsia, etc.).【✔】
b. Haemorrhage is the leading direct cause of obstetric
death.【✘】
c. Inability to intubate the patient is the leading cause
of anaesthetic related deaths.【✘】
d. Psychiatric disease is the commonest indirect cause
of death.【✘】
149b
Dr.Sherif Badrawy

MCC of obstetric deaths ?
150a
Dr.Sherif Badrawy

MCC is cardiac disease exacerbated by
pregnancy (an indirect cause), MC direct cause
of death is thromboembolic disease, followed by
hypertensive
disease of pregnancy and then haemorrhage.
Psychiatric
disease is the second most common indirect
cause of death
150b
Dr.Sherif Badrawy

A patient with severe pre-eclampsia
becomes unwell in the
peripartum period with blurred vision,
clonus and a BP of
180/120mmHg. The following are
appropriate initial
antihypertensive treatments:
151a
Dr.Sherif Badrawy

a. Labetalol.【✔】
b. Hydralazine.【✔】
c. Nitroprusside.【✘】
d. Metolazone.【✘】
151b
Dr.Sherif Badrawy

previously fit pregnant woman, mildly
unwell in
the third trimester, palmar erythema, ALP
100IU/L, albumin 35g/L, ALT 35IU/L.
152a
Dr.Sherif Badrawy

a. Obstructive jaundice is likely to be present.
【✘】
b. There is evidence of pre-existing liver
disease.【✘】
c. Albumin is normally low in pregnancy
(compared with non-pregnant values).【✔】
d. Aminotransferases are normally elevated in
the third trimester.【✘】➜ ALP rise in normal
pregnancy
152b
Dr.Sherif Badrawy

Regarding noradrenaline (norepinephrine):
153a
Dr.Sherif Badrawy

a. A typical dose range would be 5-10μg/kg/min.
【✘】➜ 0.05- 0.5µg/kg/min
b. It is a metabolite of adrenaline (epinephrine).
【✘】➜ formed from dopamine & metabolised
to adrenaline
c. It causes coronary artery vasodilatation
increasing coronary blood flow.【✔】
d. It increases contractility of the pregnant
uterus.【✔】
153b
Dr.Sherif Badrawy

A postoperative patient, HDU, morphine
infusion 2mg/hour., still in pain following
surgery, and the nursing staff ask you to
adjust the morphine regime.
154a
Dr.Sherif Badrawy

a. Doubling the rate to 4mg/h will take about half an
hour to have significant effect.【✘】If a drug is infused
it takes about five half-lives to reach a steady state
b. The half-life of morphine is around 2-3 hours.【✔】
c. If the clearance of morphine is halved by renal
impairment, its half life will double.【✔】
d. The volume of distribution of morphine is around
0.5L/kg.【✘】
154b
Dr.Sherif Badrawy

The following data can be obtained from
transpulmonary
thermodilution:
155a
Dr.Sherif Badrawy

a. Cardiac output.【✔】
b. An estimate of preload.【✔】
c. An estimate of pulmonary oedema.
【✔】
d. An estimate of total circulating blood
volume.【✘】
155b
Dr.Sherif Badrawy

Transpulmonary thermodilution concept ?
156a
Dr.Sherif Badrawy

✪ the delivery of a bolus of 15-20ml of cold fluid (<8°C) through a CVC with
temperature-time measurement at an arterial site (usually femoral) with a
thermistor- tipped arterial cannula. The temperature-time curve produced
gives an estimate of COP according to a modified form of the Stewart-Hamilton
equation.
✪ global end-diastolic volume [GEDV] an estimate of preload which may be a
better predictor of fluid requirements than CVP
✪ extravascular lung water EVLW is a measure of pulmonary oedema guide
diuretic therapy a more sensitive marker of pulmonary oedema than chest X-
ray.
✪ Total intrathoracic blood volume can be estimated by transpulmonary
thermodilution, but not total circulating blood volume.
156b
Dr.Sherif Badrawy

Regarding pressure ulcers in the ICU:
157a
Dr.Sherif Badrawy

a. A high Waterlow score is associated with an
increased risk of pressure ulcer development.【✔】
b. Nursing workload increases by 50% if a pressure
ulcer is present.【✔】➜ since dressing changes and
positioning manoeuvres are time-consuming
c. Pressure ulcers bear little relation to in-hospital
mortality.【✘】
d. Patients with a pressure ulcer should be
repositioned every 8 hours.【✘】➜ every 2 hours
157b
Dr.Sherif Badrawy

Regarding the management of risk in the
ICU and the techniques available for
analysing risk factors:
158a
Dr.Sherif Badrawy

a. The vast majority of clinical adverse incidents are dt a
lack of technical skills in the medical staff.【✘】50% dt
non-technical skill deficit
b. Root cause analysis should be applied to all minor
incidents in order to prevent future major incidents.【✘】
c. Observational studies using simulated patients are
useful for assessing non-technical skills.【✔】
d. Attitudinal studies may not accurately reflect real life
performance.【✔】
158b
Dr.Sherif Badrawy

Root cause analysis ?
159a
Dr.Sherif Badrawy

✾ detailed examination of all the technical
and non-technical factors associated with
an adverse incident
✾ extremely time consuming and should
be reserved for serious critical incidents.
159b
Dr.Sherif Badrawy

Regarding tracheal stenosis as a
complication of
tracheostomy:
160a
Dr.Sherif Badrawy

a. MC occurs at the site of the tracheostomy tube cuff.
【✘】➜ at the level of the stoma or directly above it
b. It is a much more common complication than
tracheomalacia.【✔】➜ Tracheomalacia is a very rare
complication of tracheostomy.
c. Patients rarely show symptoms in the first 3 months
following decannulation.【✘】➜ present within 2 month
d. Stridor is an early sign.【✘】➜ Stridor is a late sign, and
signifies advanced stenosis (<5-10mm airway diameter).
160b
Dr.Sherif Badrawy

MC complication of tracheostomy
161a
Dr.Sherif Badrawy

✪ Tracheal stenosis
✪ symptoms may be non-specific
✪ Risk factors ➜ prolonged ETT, stomal
site infection, old age, sepsis, oversized
cannulae, excessive tube motion and
prolonged placement
✪ asymptomatic until 75% airway
narrowing has occurred
161b
Dr.Sherif Badrawy

tracheo-innominate artery fistula as a
complication of tracheostomy
162a
Dr.Sherif Badrawy

✪ rare but almost universally fatal complication
of tracheostomy.
✪ The innominate artery crosses the trachea at
the level of the ninth tracheal ring, and
therefore risk is increased with a low cannula
placement.
✪ bleeding, massive haemoptysis and near-
100% mortality.
162b
Dr.Sherif Badrawy

Tracheomalacia as a complication of
tracheostomy
163a
Dr.Sherif Badrawy

✪ ischaemic injury to the trachea followed
by chondritis and subsequent destruction
and necrosis of tracheal cartilage. As with
tracheal stenosis, symptoms may be non-
specific.
✪ Flow-volume loops may show a variable
intrathoracic obstruction (expiratory
collapse of the trachea).
163b
Dr.Sherif Badrawy

CP of refeeding syndrome ?
164a
Dr.Sherif Badrawy

✪ may occur with either enteral or parenteral nutrition.
✪ ↓serum phosphate ➜ arrhythmias, HF, Wernicke's
encephalopathy, leukocyte and platelet dysfunction
rhabdomyolysis, renal failure and myopathy. All
abnormalities are dt hypophosphataemia, which is a
consequence of ↑insulin [insulin causes cellular uptake of
phosphate ➜ hypophosphataemia].
✪ ↑insulin is dt switch from a starvation state to CHO
metabolism.
164b
Dr.Sherif Badrawy

Rx of refeeding syndrome ?
165a
Dr.Sherif Badrawy

prophylactic thiamine and intravenous
phosphate replacement if <0.5mmol/L or
symptomatic
165b
Dr.Sherif Badrawy

Third degree heart block , Asymptomatic,
the heart rate is <40bpm, Pacing ?
166a
Dr.Sherif Badrawy

CHB is an accepted indication for
transvenous pacing
even in the absence of symptoms if the HR
is <40bpm
166b
Dr.Sherif Badrawy

The lowest pH in the first 24h post-arrest
correlates with mortality when
167a
Dr.Sherif Badrawy

it is below 7.25, presumably reflecting the
duration of the arrest and the quality of
organ function in the post-resuscitation
phase.
167b
Dr.Sherif Badrawy

Regarding cardiac tamponade
168a
Dr.Sherif Badrawy

✪ It is more common in penetrating than blunt trauma.
✪ The jugular venous pressure may be normal.
✪ A fall of >10mmHg in systolic BP during inspiration
defines pulsus paradoxus.
✪ ECG findings of electrical alternans is pathognomonic of
cardiac tamponade.
✪ In chronic tamponade enlargement of the cardiac
silhouette but not in acute cases low compliance of the
pericardium leads to rapid tamponade
168b
Dr.Sherif Badrawy

Regarding the fluid resuscitation of the
trauma patient
169a
Dr.Sherif Badrawy

a. Resuscitation with large volumes of crystalloid increases
the incidence of abdominal compartment syndrome.
b. No evidence that Hypertonic saline increase survival
compared with crystalloid.
c. Arterial base deficit is a better indicator of adequacy of
fluid resuscitation than urine output.
d. Serum lactate is a better indicator of adequacy of fluid
resuscitation than urine output.
e. Rate of clearance of base deficit is correlated with
survival.
169b
Dr.Sherif Badrawy

J waves (with hypothermia) represents
170a
Dr.Sherif Badrawy

abnormality in the earliest phase of
ventricular repolarisation
170b
Dr.Sherif Badrawy

Classification of Post-traumatic seizure
(PTS)
171a
Dr.Sherif Badrawy

✪ early (within 7 days of injury) or late
(after 7 days).Prophylactic phenytoin is
effective in preventing early (<7 days) but
not late (>7 days) PTS.
✪ Routine seizure prophylaxis is
reasonable in high-risk cases but should
be stopped after 7 days unless a specific
indication for continued therapy exists
171b
Dr.Sherif Badrawy

Risk factors for Post-traumatic seizure
(PTS)
172a
Dr.Sherif Badrawy

GCS <10, SDH, EDH or ICH, depressed skull
fracture and penetrating head injury
172b
Dr.Sherif Badrawy

The incidence of thromboembolic
problems in patients treated with rFVIIa is
173a
Dr.Sherif Badrawy

✪ 1% in haemophiliacs, and 1.4% in cases
of non-haemophilia coagulopathy.
✪ given in large, supra-physiological doses
for major haemorrhage (an off-label
indication)
173b
Dr.Sherif Badrawy

patient with major burns
174a
Dr.Sherif Badrawy

a. Aggressive high calorie feeding (>200% of
resting requirement) increase mortality.
b. Enteral feeding is preferred to parenteral.
c. Protein requirement is 1.5-2g/kg/day.
d. Nutritional supplementation with glutamine
is of no proven benefit.
e. Hyperglycaemia should be treated
aggressively.
174b
Dr.Sherif Badrawy

Protein binding of thyroid hormones
175a
Dr.Sherif Badrawy

T4 is 99.97% protein-bound, T3 99.7%.
175b
Dr.Sherif Badrawy

Factors ↓peripheral conversion of T4 to T3
?
176a
Dr.Sherif Badrawy

critical illness, fasting, malnutrition and by
drugs including propylthiouracil,
corticosteroids, propranolol and
amiodarone.
176b
Dr.Sherif Badrawy

Effect of Dopamine and somatostatin on
TRH ?
177a
Dr.Sherif Badrawy

both inhibit TRH release
177b
Dr.Sherif Badrawy

treatment of choice for ESBL-producing
organisms ?
178a
Dr.Sherif Badrawy

carbapenems
178b
Dr.Sherif Badrawy

MCC of ESBL producing organisms ?
179a
Dr.Sherif Badrawy

gram-negative bacilli, of which Klebsiella
pneumoniae is the commonest.
179b
Dr.Sherif Badrawy

What's flow time corrected (FTc) in
oesophageal Doppler measurements ?
180a
Dr.Sherif Badrawy

FTc is a marker of afterload (a low FTc indicates
a high afterload). Since hypovolaemia causes an
increase in systemic vascular resistance, FTc is
also an indirect marker of preload and is often
used for this purpose.
However, other conditions such as hypothermia,
cardiac failure and vasopressor therapy may
similarly increase afterload (reducing FTc)
despite adequate or excessive preload.
180b
Dr.Sherif Badrawy

Normal value of flow time corrected (FTc)
in oesophageal Doppler measurements ?
181a
Dr.Sherif Badrawy

✪ an FTc of ~340ms is considered 'normal', this should
not be a target of fluid Rx. As with all forms of COP
monitoring, trends are > important than absolute
values. If a fluid bolus ➜ ↑FTc and a significant (>10%)
↑in SV, this suggests > volume is required.
✪ If there is little change, giving further fluid may be
harmful. FTc gives no information regarding cardiac
contractility (peak velocity is more useful in this
respect).
181b
Dr.Sherif Badrawy

markers of the adequacy of the
circulation?
182a
Dr.Sherif Badrawy

❁ Arterial lactate.
❁ Venous lactate.
❁ Base deficit.
❁ Central venous oxygen saturation.
❁ While a low PAOP may indicate hypovolaemia,
it is a poor predictor of the adequacy of
circulating volume,
and bears little relation to the adequacy of
tissue perfusion.
182b
Dr.Sherif Badrawy

When Hypotension is a problem with
opiates ?
183a
Dr.Sherif Badrawy

when patients have been inadequately
fluid-resuscitated, since the sympathetic
tone maintaining blood pressure is
damped by their administration.
183b
Dr.Sherif Badrawy

Fentanyl is useful in the ICU because of its
very short context sensitive half-life, True
or False ?
184a
Dr.Sherif Badrawy

Although fentanyl has a short offset
following a bolus dose, it has a much
longer context-sensitive half- life (around
300 minutes after an 8-hour infusion, and a
similar offset time to morphine after
infusion for 24 hours).
184b
Dr.Sherif Badrawy

best lead for monitoring rhythm
disturbances ?
185a
Dr.Sherif Badrawy

Lead II since its axis parallels the electrical
axis of the heart, giving the best
visualisation of the P wave.
185b
Dr.Sherif Badrawy

most sensitive detector of left ventricular
ischaemia ?
186a
Dr.Sherif Badrawy

Lead V5
186b
Dr.Sherif Badrawy

An oesophageal lead is used in the
detection of which ischaemia ?
187a
Dr.Sherif Badrawy

posterior ischaemia
187b
Dr.Sherif Badrawy

A low probability V/Q scan effectively rules
out a PE, True or False ?
188a
Dr.Sherif Badrawy

False, V/Q scans are reported as high,
intermediate, low probability or normal.
While a normal scan reliably
excludes a PE, a low probability scan does
not and requires further imaging unless
the clinical probability is also low.
188b
Dr.Sherif Badrawy

DD bw pulmonary angiography spiral CT in
Dx PE ?
189a
Dr.Sherif Badrawy

Although pulmonary angiography is the
gold standard, spiral CT is highly sensitive
for lobar or segmental PE; it may miss
subsegmental PE.
189b
Dr.Sherif Badrawy

Use of Echocardiography in PE ?
190a
Dr.Sherif Badrawy

❁ shocked ICU patient in whom PE is being
considered as the cause of the HD
compromise.
❁ the absence of RV dysfunction or
overload excludes Dx. Echo is not sensitive
for detecting subsegmental PE.
190b
Dr.Sherif Badrawy

Definition of Pseudohypoxaemia or
'leukocyte larceny' ?
191a
Dr.Sherif Badrawy

a spuriously low PaO2 in the ABG of
patients with a very high WBCs.
dt consumption of dissolved O2 in the
sample by the metabolically active
leukoblasts.
Immediate analysis of a sample placed on
ice will give a higher and more
representative PaO2.
191b
Dr.Sherif Badrawy

intracranial pressure monitoring devices
192a
Dr.Sherif Badrawy

❁ An intraventricular catheter is the gold standard.
❁ A Camino bolt cannot be re-zeroed once sited
❁ Infection rates are low with intraparenchymal strain
gauge monitors.
❁ Parenchymal ICP monitoring > accurate than
subdural, extradural and subarachnoid monitoring
❁ The pressure transducer for an intraventricular
catheter should be kept at the level of the foramen of
Munro
192b
Dr.Sherif Badrawy

critical care management of patients with
cystic fibrosis
193a
Dr.Sherif Badrawy

The outcome for respiratory failure
requiring MV is poor even in younger
patients.
193b
Dr.Sherif Badrawy

Drugs given via the ETT during CPR ?
194a
Dr.Sherif Badrawy

❁ Epinephrine.
❁ Atropine.
❁ Naloxone.
❁ Lidocaine.
194b
Dr.Sherif Badrawy

PaCO2 and pH are better predictors of the
need for mechanical ventilation than PaO2
in COPD Pts ?
195a
Dr.Sherif Badrawy

True
195b
Dr.Sherif Badrawy

flow-volume loop of a 40-year-old man best
described by a diagnosis of:
196a
Dr.Sherif Badrawy

Restrictive disease.
196b
Dr.Sherif Badrawy

volume/time graphic on a mechanical
ventilator suggests
197a
Dr.Sherif Badrawy

❁ Dynamichyperinflation isoccurring.
❁ waveform doesnot return to baseline on each occasion, and becomesprogressively higher
❁ Disconnect breathing circuit for a few secondsallowstrapped gasto escape returning the waveform to baseline
197b
Dr.Sherif Badrawy

management of atrial fibrillation
198a
Dr.Sherif Badrawy

❁ The risk of thromboembolic complications is similar with
electrical or chemical cardioversion.
❁ Digoxin is an ineffective rate control in the critically ill
patient.(ineffective in hyperadrenergic states)
❁ Successful cardioversion is more likely in atrial
fibrillation of short duration.
❁ Beta-blockers should not be used as first-line therapy in
patients with decompensated heart failure
❁ Rhythm control has no long-term mortality benefit
compared with rate control
198b
Dr.Sherif Badrawy

Which ONE of the following confers the greatest
mortality
benefit when used appropriately in the
management of STEMI ?
a. Aspirin.
b. Gylceryl trinitrate.
c. Atenolol.
d. Oxygen.
e. Thrombolysis.
199a
Dr.Sherif Badrawy

❁ Aspirin.
❁ a better answer than thrombolysis.
❁ aspirin in a dose of 162-325mg. This
should be given within 24 hours of STEMI,
but has not been shown to be as time-
critical as thrombolysis.
199b
Dr.Sherif Badrawy

What's this form ?
200a
Dr.Sherif Badrawy

Arterial pressure waveform intra-aortic balloon counterpulsation with a 1:2 ratio.
200b
Dr.Sherif Badrawy

Mechanism of intra-aortic balloon
counterpulsation
201a
Dr.Sherif Badrawy

The cylindrical balloon sits 【distal to the left subclavian
artery】 and 【inflates at the start of diastole】, 【gauged
by the dicrotic notch on the arterial trace】. It remains
inflated throughout diastole, the augmented pressure
wave ↑coronary perfusion pressure. 【It deflates during
isovolumetric contraction】, before ejection of blood from
the left ventricle begins.The fall in afterload produced by
this deflation reduces cardiac work and O2 consumption.a
modest ↑in COP is seen.
201b
Dr.Sherif Badrawy

An ischaemic stroke patient, If the patient
is a candidate for thrombolysis, should we
give aspirin ?
202a
Dr.Sherif Badrawy

NO, Aspirin should be given to all
ischaemic stroke patients who are not
candidates for thrombolysis
202b
Dr.Sherif Badrawy

Electromyelography showing an
incremental increase in compound muscle
action potential response with high rates
of repetitive stimulation is in keeping with
203a
Dr.Sherif Badrawy

Lambert-Eaton myasthenic syndrome
203b
Dr.Sherif Badrawy

Fasciculations are characteristic of
204a
Dr.Sherif Badrawy

lower motor neurone pathology and are
classically seen in patients with motor
neurone disease
204b
Dr.Sherif Badrawy

Pentoxyphylline in Rx of rhabdomyolysis
205a
Dr.Sherif Badrawy

Pentoxyphylline is a free radical scavenger
which have
theoretical but largely unproven benefits
in Rx of rhabdomyolysis
205b
Dr.Sherif Badrawy

risk factors for the development of
stress-related mucosal damage
206a
Dr.Sherif Badrawy

✲ Mechanical ventilation.
✲ Burns.
✲ Coagulopathy.
✲ Hypotension.
206b
Dr.Sherif Badrawy

85-year-old nursing home resident is
admitted to the
hospital with a painful, swollen right knee
joint, antibiotic therapy ?
207a
Dr.Sherif Badrawy

✲ Vancomycin + cefuroxime.
✲ Patient's at risk of MRSA ➜ nursing
home residents
and recent inpatients ➜ should be treated
with vancomycin and a 2nd or 3rd
generation cephalosporin
207b
Dr.Sherif Badrawy

regard to balloon tamponade with a
Sengstaken or
Minnesota tube
208a
Dr.Sherif Badrawy

✲ Acute bleeding is controlled in 90% of cases
✲ further bleeding is common following balloon
deflation 50% of cases).
✲ tube should be inserted to at least 【45cm
before inflation】 of the gastric balloon to
prevent inflation in the oesophagus.
✲ A volume of 【300-500ml fluid】 is required to
fully inflate the gastric balloon.
✲ Maximum traction should not exceed 1kg.
208b
Dr.Sherif Badrawy

Which drug will not have ↑clearance with
CRRT compared with the anuric state
a. Vancomycin.
b. Gentamicin.
c. Atenolol.
d. Amiodarone.
e. Lithium.
209a
Dr.Sherif Badrawy

d. Amiodarone.
Amiodarone has a very large Vd, is
eliminated in bile and is highly protein-
bound and is therefore not significantly
eliminated by RRT.
209b
Dr.Sherif Badrawy

For a drug to be significantly cleared by
renal replacement therapy, it must
210a
Dr.Sherif Badrawy

have low protein binding (only the free
fraction is filtered). It must have a low non-
renal clearance, It must have a low volume
of distribution
210b
Dr.Sherif Badrawy

Active cooling should be initiated if
211a
Dr.Sherif Badrawy

✲ the core temperature exceeds 40°C.
✲ Dantrolene has been used for the
treatment of hyperthermia in 'ecstasy'
Toxicity
211b
Dr.Sherif Badrawy

SIRS & Sepsis definition
212a
Dr.Sherif Badrawy

212b
Dr.Sherif Badrawy

Acute fatty liver of pregnancy
213a
Dr.Sherif Badrawy

✲ occurs in the third trimester
✲ dt enzymatic defect in fatty acid oxidation ➜
microvesicular fatty infiltration of hepatocytes in
the absence of significant inflammation or
necrosis.
✲ may co-exist with pre-eclampsia
✲ ↑↑jaundice, ↑transaminases (<1000IU/L),
derangement of coagulation, Hypoglycaemia,
hepatic encephalopathy
213b
Dr.Sherif Badrawy

DD bw Acute fatty liver of pregnancy &
HELLP
214a
Dr.Sherif Badrawy

marked elevations of bilirubin,
hypoglycaemia and severe coagulopathy in
AFLP
214b
Dr.Sherif Badrawy

DD bw Acute fatty liver of pregnancy &
Cholestasis of pregnancy
215a
Dr.Sherif Badrawy

Cholestasis of pregnancy rarely causes a
bilirubin level of >100µmol/L and does not
cause a coagulopathy.
215b
Dr.Sherif Badrawy

Morphine properties
216a
Dr.Sherif Badrawy

✲ undergoes extensive first pass metabolism ➜ only 25-
30% of an oral dose reaches the systemic circulation.
✲ metabolised in the liver to morphine 3-glucuronide and
morphine 6-glucuronide; the latter has a potency over ten-
fold greater than morphine.
✲ It inhibits neurotransmission in the CNS
✲ Peak effect takes 10-30 minutes from the time of IV
injection
✲ Respiratory depression manifests predominantly as a
fall in RR rather than tidal volume
216b
Dr.Sherif Badrawy

amiodarone properties
217a
Dr.Sherif Badrawy

✲ It is 98% protein-bound.
✲ It does not require dose adjustment in renal
failure.
✲ It has effect on heart rate even if the patient
is in sinus rhythm.[causes a 15% reduction in
heart rate of patients in sinus rhythm]
✲ It has a volume of distribution up to 70L/kg.
✲ It potentiates the effect of warfarin.
217b
Dr.Sherif Badrawy

The following ventilator graphic is best
described by
218a
Dr.Sherif Badrawy

Volume-controlled ventilation with pressure support
218b
Dr.Sherif Badrawy

Facts about CVVH
219a
Dr.Sherif Badrawy

✲ Replacement fluids usually contain lactate which is
metabolised by the liver to bicarbonate, replacing the
endogenous bicarbonate ion that is freely filtered during
CVVH.
✲ Excessive infusion of lactate-buffered solution may cause
metabolic alkalosis if liver is functioning normally
✲ Lactate-buffered solutions are usually avoided in liver failure
✲ Bicarbonate-buffered solutions have a short shelf-life
✲ Pre-dilution (adding replacement fluid prior to passage
through the filter) ↓HCT of the filtered blood and may ↓filter
clotting.
219b
Dr.Sherif Badrawy

CP of Persistent vegetative state.
220a
Dr.Sherif Badrawy

✲ for over 1 month a patient who is 'wakeful
without awareness'.
✲ eye opening and closing mirroring the sleep-
wake cycle, HD stable & non-purposeful
movements, no capacity to recognise or interact
with the world.
✲ dt severe disruption to the cerebral cortex,
but with intact brainstem and thalamic function
a diagnostic rather than a prognostic label
220b
Dr.Sherif Badrawy

'permanent vegetative state'
221a
Dr.Sherif Badrawy

Same CP after 12 months
221b
Dr.Sherif Badrawy

A minimally conscious state
222a
Dr.Sherif Badrawy

✲ retain some degree of awareness
✲ may be able to obey a simple command
and have
limited interaction with their environment
(e.g. social smiling, mood disturbance).
222b
Dr.Sherif Badrawy

Brainstem death
223a
Dr.Sherif Badrawy

✲ loss of all cranial nerve reflexes, and loss
of cardio-respiratory homeostasis.
✲ It is assumed that all higher mental
function has ceased also; such patients are
neither wakeful nor aware.
223b
Dr.Sherif Badrawy

locked-in syndrome
224a
Dr.Sherif Badrawy

✲ Awareness is preserved
✲ caused by an insult at the 【level of the midbrain】, such
as central pontine myelinosis or basilar artery thrombosis
✲ Quadriplegia and loss of function of the lower cranial
nerves may leave the patient almost totally void of means
of interaction with the world, despite full awareness.
✲ Vertical eye movements and blinking may be preserved
224b
Dr.Sherif Badrawy

The following drugs are recognised causes
of hypokalaemia:
225a
Dr.Sherif Badrawy

a. Gentamicin.【✔】➜ dt renal potassium
wasting
b. Triamterene.【✘】➜ potassium-sparing
diuretic
c. Piperacillin.【✔】➜ dt renal potassium
wasting
d. Metolazone.【✔】➜ inhibits Na+ and Cl-
absorption in the early DCT ➜ > K+ loss in the
urine
225b
Dr.Sherif Badrawy

Regarding electrical injury:
226a
Dr.Sherif Badrawy

a. Skin resistance is 100 times greater when dry than
when wet.【✔】➜ 100,000 Ohms when dry, but just 1000
Ohms when wet.
b. Ventricular fibrillation occurs at a lower current than
asystole.【✔】
c. A current of >50mA is required to cause microshock.
【✘】➜ can be caused by currents as small as 50mA if
directly applied to the heart (e.g. saline filled catheter or
pacing wire).
d. A current of 1A is sufficient to cause deep burns and
neurological injury.【✔】
226b
Dr.Sherif Badrawy

The following are accepted indications for
permanent
transvenous pacing:
227a
Dr.Sherif Badrawy

a. Symptomatic second degree heart block.
【✔】
b. Asymptomatic third degree heart block with
documented pauses of >3 seconds.【✔】
c. Sinus node dysfunction with documented
symptomatic bradycardia.【✔】
d. Asymptomatic third degree heart block with a
heart rate <40bpm.【✔】
227b
Dr.Sherif Badrawy

a Pt s/p PEA cardiac arrest admitted to ICU,
28 minutes of CPR, five doses of IV
epinephrine 1mg before ROSC, GCS of 3
and no pupillary reaction to light, but is
making spontaneous respiratory effort.
228a
Dr.Sherif Badrawy

a. Her prognosis would be better if her arrest rhythm were
ventricular fibrillation.【✔】➜ PEA/asystole, anoxic time >5
minutes and CPR time of >25 minutes all predict poor
neurological outcome but not suitable as prognostic markers
b. The length of her resuscitation time before return of
spontaneous circulation is not compatible with survival.【✘】
c. If she has absent pupillary reflexes at 72h further treatment
is futile.【✔】
d. Brain swelling on a CT scan accurately predicts poor
outcome.【✘】
228b
Dr.Sherif Badrawy

Critical care revision notes

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Viewers also liked

Viewers also liked (20)

Similar to Critical care revision notes

Similar to Critical care revision notes (20)

More from Sherif Elbadrawy

More from Sherif Elbadrawy (16)

Recently uploaded

Recently uploaded (20)

Critical care revision notes