Ebook Intensive care medicine MCQs - Multiple choice questions with explanatory answers: Part 1

Intensive Care Medicine


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IntensiveCareMedicine

MCQs
Multiple Choice Questions with Explanatory Answers

Editor:
Steve Benington MBChB MRCP FRCA EDIC FFICM

Authors:
Shoneen Abbas MBChB MRCP FFICM
Ruth Herod MBChB FRCA FFICM
Daniel Horner BA MBBS MD MRCP(UK) FCEM FFICM


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IntensiveCareMedicineMCQs—MultipleChoiceQuestionswithExplanatoryAnswers

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Contents
Page

Preface

iv

Acknowledgements

vi

Abbreviations

vii

Converting units of measurement

xii

Topic index

xiii

Paper 1: Questions
Paper 1: Answers

1
39

Paper 2: Questions

105

Paper 2: Answers

143

Paper 3: Questions

219

Paper 3: Answers

259

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Preface
This book contains three 90-question multiple choice papers designed to
test the candidate’s knowledge of intensive care medicine (ICM) and their
ability to apply it. Each paper begins with 60 multiple true false (MTF)
questions consisting of a stem and five statements, each requiring a true
or false answer. These are followed by 30 single best answer (SBA)
questions where a clinical vignette is presented with five possible
solutions. The candidate should select the one that best addresses the
problem, mirroring clinical practice where a case usually has several
possible approaches.
Topics have been chosen to cover the breadth of knowledge required
of the modern intensivist, including resuscitation, diagnosis, disease
management, organ support, applied anatomy, end-of-life care and applied
basic sciences. There is a strong focus on the evidence base
underpinning the specialty, making this book particularly useful for
physicians and others approaching professional examinations in ICM and
related acute medical and surgical specialties. There is no ‘pass mark’,
although a score of less than four out of five in an MTF question or an
incorrect response to an SBA question should help the candidate identify
areas where they would benefit from further reading. Each question is
accompanied by a detailed and fully referenced answer; the majority of
references are freely accessible online or through institutional
subscriptions.
The authors are all senior trainees or consultants practising intensive
care medicine in the UK with firsthand experience of passing professional
examinations. In addition, they have extensive training and experience in
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Preface

acute medicine, anaesthesia and emergency medicine, respectively, and
have drawn on their experience to devise questions that reflect these
specialties and their interface with intensive care medicine. The authors
hope that this book will be a useful resource not only for those
approaching examinations but for anyone wishing to keep up-to-date in
this fast-changing specialty.

Steve Benington MBChB MRCP FRCA EDIC FFICM
Shoneen Abbas MBChB MRCP FFICM
Ruth Herod MBChB FRCA FFICM
Daniel Horner BA MBBS MD MRCP(UK) FCEM FFICM

v


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Acknowledgements
The Editor would like to thank Dr Ola Abbas and Dr Fiona Wallace for their
invaluable help proofreading the manuscript. Also, thanks to Dr John
Macdonald, Dr Hakeem Yousuff, Dr Richard Ramsaran and Dr Andrew
Martin for their comments while testing the questions.

vi


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Abbreviations
The following are the most commonly used abbreviations throughout the book:
AAGBI
ABG
ACS
ACTH
AF
AFE
AFLP
AIS
AKI
ALF
ALI
ALS
AP
APACHE
APLS
APRV
aPTT
ARDS
ARR
ASIA
AT
ATLS
ATN
BE
BMI
BNP
BP

BTS
CAM-ICU
cAMP

Association of Anaesthetists of Great Britain and Ireland
Arterial blood gas
Abdominal compartment syndrome
Adrenocorticotropic hormone
Atrial fibrillation
Amniotic fluid embolism
Acute fatty liver of pregnancy
Abbreviated Injury Scale
Acute kidney injury
Acute liver failure
Acute lung injury
Advanced Life Support
Acute pancreatitis
Acute Physiology and Chronic Health Evaluation
Advanced Paediatric Life Support
Airway pressure release ventilation
Activated partial thromboplastin time
Acute respiratory distress syndrome
Absolute risk reduction
American Spinal Injury Association
Anaerobic threshold
Advanced Trauma Life Support
Acute tubular necrosis
Base excess
Body mass index
B-natriuretic peptide

Blood pressure
British Thoracic Society
Confusion Assessment Method for the Intensive Care Unit
Cyclic adenosine monophosphate

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viii

CAP
CDI
cGMP
CIN
CK
CKD
ClCMAP
CMV
COPD
CPAP
CPET
CPIS
CPK
CPP
CPR
CRP

CRRT
CSF
CT
CTPA
CVC
CVP
CXR
DBD
DCD
DDAVP
DI
DIC
DKA
DVT
ECG
ECMO
EEG
EMG
ESR
ETCO2
EVD
FFP
FRC
HR

Community-acquired pneumonia
Clostridium difficile infection
Cyclic guanosine monophosphate
Contrast-induced nephropathy
Creatine kinase

Chronic kidney disease
Chloride
Compound muscle action potential
Cytomegalovirus
Chronic obstructive pulmonary disease
Continuous positive airway pressure
Cardiopulmonary exercise testing
Clinical Pulmonary Infection Score
Creatinine phosphokinase
Cerebral perfusion pressure
Cardiopulmonary resuscitation
C-reactive protein
Continuous renal replacement therapy
Cerebrospinal fluid
Computed tomography
Computed tomography pulmonary angiogram
Central venous catheter
Central venous pressure
Chest X-ray
Donation after brainstem death
Donation after cardiac death
Desmopressin
Diabetes insipidus
Disseminated intravascular coagulation
Diabetic ketoacidosis
Deep vein thrombosis
Electrocardiogram
Extracorporeal membrane oxygenation
Electroencephalography
Electromyography

Erythrocyte sedimentation rate
End-tidal carbon dioxide
External ventricular drain
Fresh frozen plasma
Functional residual capacity
Heart rate


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Abbreviations

GBS
GCS
GFR
GMC
GTN
HAS
HCM
HFOV
HME
HRS
IABP
IAH
IAP
ICP
ICU
ICUAW
ILCOR
INR

ISS
K+
KDIGO
LDH
LMA
LMWH
LP
LQTS
LVOT
MAP
MDR
MELD
MEN
MEOWS
MET
MG
Mg2+
MH
MHRA
MI
MODS
MPAP
MPM

Guillain-Barré syndrome
Glasgow Coma Scale
Glomerular filtration rate
General Medical Council
Glyceryl trinitrate
Human albumin solution

Hypertrophic cardiomyopathy
High-frequency oscillatory ventilation
Heat and moisture exchangers
Hepatorenal syndrome
Intra-aortic balloon pump
Intra-abdominal hypertension
Intra-abdominal pressure
Intracranial pressure
Intensive care unit
Intensive care unit-acquired weakness
International Liaison Committee on Resuscitation
International Normalised Ratio
Injury Severity Score
Potassium
The Kidney Disease: Improving Global Outcomes
Lactate dehydrogenase
Laryngeal mask airway
Low-molecular-weight heparin
Lumbar puncture
Long QT syndrome
Left ventricular outflow tract
Mean arterial pressure
Multidrug resistance
Modified End-stage Liver Disease
Multiple endocrine neoplasia
Modified Early Obstetric Warning Score
Metabolic equivalent
Myasthenia gravis
Magnesium
Malignant hyperthermia

Medicines and Healthcare Products Regulatory Agency
Myocardial infarction
Multiple Organ Dysfunction Score
Mean pulmonary artery pressure
Mortality Prediction Model

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MRC
MRI
MRSA
NICE
NIV
Na+
NAC
NF
NHSBT
NICE
NMS
NNT
NPV
NSAID
PAC
PAOP
PCI

PCR
PCV
PCWP
PE
PEEP
PEFR
P:F ratio

x

Medical Research Council
Magnetic resonance imaging
Methicillin-resistant Staphylococcus aureus
The National Institute for Health and Care Excellence
Non-invasive ventilation
Sodium
N-acetyl cysteine
Necrotizing fasciitis
National Health Service Blood and Transplant
National Institute for Health and Care Excellence
Neuroleptic malignant syndrome
Number needed to treat
Negative predictive value
Non-steroidal anti-inflammatory drug
Pulmonary artery catheter
Pulmonary artery occlusion pressure
Primary coronary intervention
Polymerase chain reaction
Pressure-controlled ventilation
Pulmonary capillary wedge pressure

Pulmonary embolism
Positive end-expiratory pressure
Peak expiratory flow rate
Ratio of partial pressure of arterial oxygen to fraction of
inspired oxygen
PLR
Passive leg raising
PN
Parenteral nutrition
POSSUM Physiological and Operative Severity Score for the
enUmeration of Mortality and Morbidity
PPI
Proton pump inhibitor
Pplat
Plateau pressure
PPV
Positive predictive value
PRIS
Propofol infusion syndrome
PT
Prothrombin time
PTHrP
Parathyroid hormone-related protein
QALY
Quality-adjusted life-year
RASS
Richmond Agitation Severity Scale
RCT
Randomised controlled trial
rFVIIa

Recombinant Factor VIIa
RIFLE
Risk, Injury, Failure, Loss, End-stage renal disease
ROC
Receiver operator characteristic


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Abbreviations

ROSC
ROSIER
RR
RSBI
RTS
SAH
SAPS
ScvO2
SDD
SIADH
SID
SLE
SNAP
SOFA
STEMI
SVC
SVRI
TBI
TBSA

TEG
TIA
TIPSS
TISS
TLS
TRISS
TSS
TTP
VAD
VAP
VATS
VCV
VF
VT
Vt
VTE
vWF
WCC
WFNS
WPW
WSACS

Return of spontaneous circulation
Recognition of Stroke in the Emergency Room
Respiratory rate
Rapid Shallow Breathing Index
Revised Trauma Score
Subarachnoid haemorrhage
Simplified Acute Physiology Score
Central venous oxygen saturation

Selective digestive tract decontamination
Syndrome of inappropriate antidiuretic hormone secretion
Strong ion difference
Systemic lupus erythematosus
Sensory (or mixed) nerve action potential
Sequential Organ Failure Assessment
ST elevation myocardial infarction
Superior vena cava
Systemic vascular resistance index
Traumatic brain injury
Total body surface area
Thromboelastography
Transient ischaemic attack
Transjugular intrahepatic portosystemic shunting
Therapeutic Intervention Scoring System
Tumour lysis syndrome
Trauma Injury Severity Score
Toxic shock syndrome
Thrombotic thrombocytopaenia purpura
Ventricular assist device
Ventilator-associated pneumonia
Video-assisted thoracoscopic surgery
Volume-controlled ventilation
Ventricular fibrillation
Ventricular tachycardia
Tidal volume
Venous thromboembolism
von Willebrand Factor
White cell count
World Federation of Neurosurgeons

Wolff-Parkinson-White
World Society of the Abdominal Compartment Syndrome
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Convertingunitsof
measurement
Laboratory results presented in the questions are given in standard UK
units. The following conversion factors may be useful to readers from
other areas:
1μmol/L = 0.0113mg/dL (e.g. serum bilirubin, creatinine)
1kPa = 7.5mmHg (e.g. PaO2)

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Topicindex
Anaesthesia

2.84, 3.61, 3.90

Applied anatomy

1.27, 2.6, 2.9, 3.3, 3.52

Burns & trauma

1.14, 1.23, 1.71, 1.83, 2.29, 2.49,
2.58, 2.85, 3.9, 3.17, 3.20, 3.55, 3.65,
3.74

Cardiovascular

1.15,
1.75,
2.46,
2.76,
3.40,
3.81

Diagnostic tests

2.12, 3.30

Ethics & legal

1.57, 1.60, 2.36

Evidence and biostatistics

1.20, 2.3, 2.68, 3.11, 3.18

Gastroenterology & hepatology

1.7, 1.52, 1.65, 1.88, 2.24, 2.35, 2.75,
3.25, 3.49, 3.51, 3.86

Haematology & clotting

1.2, 1.5, 1.26, 1.44, 1.84, 3.10, 3.38,
3.39, 3.48

1.25,
1.85,
2.55,
2.77,
3.45,

1.31,
1.90,
2.60,
2.83,
3.50,

1.33,
2.10,
2.67,
3.19,
3.53,

1.41,
2.28,
2.73,
3.21,
3.64,

1.47,
2.43,
2.74,
3.36,
3.76,

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xiv

Metabolic & nutritional

1.9, 1.24, 1.37, 1.40, 1.62, 1.64, 1.82,
2.7, 2.8, 2.21, 2.41, 2.44, 2.52, 2.59,
2.63, 2.80, 2.86, 2.87, 3.4, 3.5, 3.29,
3.31, 3.42, 3.58, 3.68, 3.69, 3.70

Microbiology & infection control

1.28, 1.36, 1.74, 2.34, 2.40, 2.45,
2.47, 2.48, 2.81, 3.2, 3.15, 3.16, 3.24,
3.34, 3.66, 3.83, 3.88

Miscellaneous

1.49, 1.56, 1.89, 2.42, 2.79, 3.41,
3.71, 3.82

Neurology & neurosurgery

1.1, 1.8, 1.10, 1.16, 1.17, 1.29,
1.53, 1.55, 1.58, 1.61, 1.66,
1.79, 1.80, 2.19, 2.22 2.27,
2.38, 2.64, 2.89, 3.22, 3.35,
3.72, 3.77

Obstetrics

2.70, 2.72, 3.67, 3.75

Organ donation

1.45, 2.39, 3.32, 3.62

Organ support & sedation

1.12, 1.72, 1.78, 1.81, 1.86, 2.1, 2.5,
2.16, 2.20, 2.62, 3.43, 3.47, 3.59,
3.85, 3.87, 3.89

Paediatrics

1.46, 3.14, 3.55

Pharmacology

1.3, 1.6, 2.15, 2.18, 2.54

Physics & clinical measurement

1.30, 1.43, 2.13, 2.14, 2.17, 2.21,
2.51, 2.57, 2.78, 3.27, 3.33, 3.54,
3.56

1.42,
1.73,
2.30,
3.46,


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Topicindex

Renal

1.13, 1.21, 1.22, 2.25, 2.50, 2.82,
2.90

Respiratory & ventilation

1.4, 1.11, 1.18, 1.50, 1.51, 1.59, 1.69,
1.70, 1.76, 1.77, 1.87, 2.23, 2.26,
2.65, 2.88, 3.1, 3.7, 3.8, 3.13, 3.44,
3.60, 3.78

Resuscitation & sepsis

1.34, 1.35, 2.4, 2.11, 2.37, 2.61, 2.66,
2.71, 3.6, 3.23, 3.26, 3.63, 3.73, 3.80

Scoring systems

1.19, 1.38, 1.54, 1.68, 2.2, 2.33, 2.56,
3.12, 3.28

Surgery

2.53, 3.83, 3.84

Toxicology & poisoning

1.32, 1.39, 1.48, 1.63, 1.67, 2.31,
2.32, 2.69, 3.37, 3.57, 3.79, 3.89

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1

Guillain-Barrésyndrome(GBS):

a.
b.
c.

Affects more females than males.
Is a disease of the middle-aged.
When secondary to a respiratory illness, the majority of cases
present within a month.
The presence of cranial nerve signs effectively rules out the
diagnosis.
The most common associated pathogen is Clostridium perfringens.

d.
e.

2

Inthetraumapatientwithmassivehaemorrhage,the
followingstatementsarecorrect:

a.

An initial target systolic blood pressure of 80-90mmHg is
recommended for the patient without brain injury.

Desmopressin at a dose of 0.3μg/kg is recommended in the
bleeding patient taking platelet-inhibiting drugs.
Recombinant factor VIIa (rFVIIa) can be considered as a rescue
measure provided the platelet count is greater than 30 x 109/L.
Pre-injury warfarin use doubles the odds of death for trauma
patients with blunt head injury.
Antifibrinolytic drugs recommended for use in the bleeding major
trauma patient include tranexamic acid, aprotinin and aminocaproic
acid.

b.
c.
d.
e.

Questions

Multiple True False (MTF) questions — select true or false for each of
the five stems.

Paper 1

Paper1
Questions

1


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3

Thefollowingdrugsundergonon-organmetabolism:

a.
b.
c.
d.
e.

Esmolol.
Atracurium.
Inhaled nitric oxide.
Propofol.
Adrenaline.

4

Which of the following features of an asthma attack
are classified as ‘life-threatening’ in the 2011 BTS
asthmaguideline?

a.
b.
c.
d.
e.

Inability to complete sentences in one breath.
PaO2 of >8kPa.
Silent chest.
PaCO2 >6kPa.
Peak expiratory flow rate (PEFR) <50% of predicted.

5

With regard to bleeding and coagulopathy in the
criticallyillpatient:

a.

If a platelet transfusion is indicated, 1 unit will raise the count by
approximately 20 x 109/L.
The principal constituents of cryoprecipitate include Factors VIII,
XIII, vWF, fibronectin and fibrinogen.
A suggested dose of fresh frozen plasma in the bleeding trauma
patient with coagulopathy is 30ml/kg.
Desmopressin at a dose of 0.3μg/kg is a useful treatment in
patients with coagulopathy related to uraemia, cirrhosis and aspirin
use.
At temperatures of 33-35°C, altered enzyme kinetics equate to a
33% reduction in normal clotting factors.

b.
c.
d.

e.

2


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Paper1

a.
b.
c.
d.
e.

An antagonist has receptor affinity and intrinsic activity.
Increasing the dose of a partial agonist can elicit a maximal effect.
β-receptor blockers are reversible antagonists.
Flumazenil is an inverse agonist.
Phenoxybenzamine is an irreversible antagonist at α-adrenoceptors.

7

Regardingthehepatorenalsyndrome(HRS):

a.

It is commonly over-diagnosed in patients with cirrhotic liver
disease.
HRS Type 1 has the poorest outcome.
Kidneys from patients with HRS are suitable for transplantation.

The condition is associated with splanchnic vasodilatation.
Terlipressin must be given by infusion.

b.
c.
d.
e.

8

With regard to a patient with a neuromuscular
disorderonthecriticalcareunit:

a.

Potassium-sparing diuretics should be avoided in patients with
hypokalaemic periodic paralysis.
Suxamethonium use should be avoided in patients with myasthenia
gravis.
Patients with motor neurone disease typically require double the
standard dose of suxamethonium to provide optimum intubating
conditions.
Local anaesthesia can exacerbate symptoms of multiple sclerosis.
In Guillain-Barré syndrome, non-depolarising neuromuscular
blocking drugs may be used, but should be significantly dosereduced.

b.
c.

d.

e.

Questions

Regardingdrug-receptorinteractions:

Paper 1

6

3


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9

Regarding parenteral nutrition in the critically ill
patient:

a.

A patient with enteral feeds running at 40ml/hr with 4-hourly
aspirates of >200ml is deemed to be failing enteral nutrition.
Daily caloric intake should be 100-130% of the patient’s calculated
daily energy expenditure.
Parenteral nutrition can be administered peripherally.
Approximately 1g/kg/day of nitrogen is required.

Copper, zinc and selenium (trace elements) are present in
commercially produced parenteral nutrition solutions.

b.
c.
d.
e.

10

A 67-year-old male has a diagnosis of myasthenia
gravis (MG). Which of the following medications
shouldbeavoidedtoreducetheriskofexacerbation?

a.
b.
c.
d.
e.

Gentamicin.
Paracetamol.
Trimethoprim.
Ciprofloxacin.
Aspirin.

11

The following statements are true regarding the
managementofacutesevereasthma:

a.
b.

PEFR <33% is a criterion diagnosis.
Aminophylline should be given as a first-line intravenous
bronchodilator.
The use of IV magnesium sulphate to reduce mortality is supported
by level I evidence.
Ketamine 5mg/kg is the preferred induction agent if rapid sequence
intubation is required.
A restrictive fluid regime should be used in patients at risk of
intubation.

c.
d.
e.
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a.

Eight potentially pathogenic micro-organisms are responsible for
the majority of infections in critical care.
SDD is ‘selective’ because it is anaerobe-sparing.
Primary endogenous pathogens are targeted by intravenous

antibiotics for the first 4 days.
After 10 days potentially pathogenic micro-organisms have been
eradicated and all antibiotics are stopped.
There is level I evidence that SDD increases the prevalence of
antibiotic resistance.

b.
c.
d.
e.

13

A59-year-oldmaleisadmittedwithagradualonsetof
peripheral oedema and frothy urine. He is
subsequently diagnosed with nephrotic syndrome.
Theconditionisassociatedwith:

a.
b.
c.
d.
e.

Hypercalcaemia.
Venous thrombosis.
Hyperlipidaemia.
Risk of myocardial infarction.
Hypervolaemia.

14

The following have been demonstrated to be useful
prognosticvariablesinmoderatetoseveretraumatic
braininjury:

a.
b.
c.
d.
e.

Age.
Pupillary reaction.
Sensory neurological deficit.
The presence of non-evacuated haematoma on CT brain scan.
Serum glucose.

Questions

Regarding the role of selective digestive tract
decontamination(SDD)ontheICU:

Paper 1

12

5

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15

Regardingtheuseofventricularassistdevices(VADs)
for the management of acute and chronic heart
failure:

a.
b.
c.
d.
e.

Ventricular assist devices can be used for a maximum of 3-4 weeks.
A short-term left ventricular assist device takes blood from the right
atrium and injects it into the main pulmonary artery.
Most modern ventricular assist devices produce a pulsatile flow.
The insertion of an LVAD worsens aortic regurgitation.
All patients with VADs must be anticoagulated.

16

Regardingdiagnosticlumbarpuncture(LP):

a.
b.
c.

d.

Meningitis is a relatively rare complication of LP.
Suspected bacteraemia is a contraindication to LP.
Aspirin should be stopped for at least 24 hours prior to LP.
LP is contraindicated in patients with a suspected spinal epidural
abscess.
It is recommended that LP is not performed in patients with platelet
counts of <100 x 109.

e.

17

Withregardtointracranialpressure(ICP)monitoring:

a.

Ocular nerve sheath diameter >6mm measured with ultrasound
reliably predicts raised intracranial pressure of >20mmHg.
ICP monitoring through an external ventricular drain allows
therapeutic intervention.
On a standard intracranial pressure waveform, P3 represents
cerebral compliance.
Cerebral hypoxia results in hypoxic vasoconstriction and reduced
cerebral blood flow, thus causing a temporary reduction in ICP.
Lundberg Type A waves are always pathological.

b.
c.

d.
e.

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a.

Setting an extrinsic positive end-expiratory pressure (PEEP) less
than intrinsic PEEP will reduce elastic work of the respiratory
system.
One risk of applying PEEP is a reduction in oxygen delivery (DO2).
A decelerating flow pattern is seen in volume-controlled ventilation.
The difference between peak and plateau pressures is greater
with volume-controlled ventilation than pressure-controlled
ventilation.
Dynamic compliance equals the tidal volume divided by (peak
pressure minus total positive end-expiratory pressure).

b.
c.
d.

e.

19

Thefollowingareexamplesofseverityscoringsystems
intheintensivecareunit:

a.
b.
c.
d.
e.

Acute Physiology and Chronic Health Evaluation III (APACHE III).
CT Calcium Score.
Sequential Organ Failure Assessment (SOFA).
Mortality Prediction Model (MPM).
Glasgow-Blatchford Score.

20

Thefollowingareexamplesofsuperiorityrandomised
controlledtrials(RCTs)relevanttocriticalcare,whose
resultssupporttheproposednullhypothesis:

a.
b.
c.
d.
e.

ProCESS.
PROSEVA.

TTM.
VASST.
OSCAR.

Questions

Regarding the mechanics of positive pressure
ventilation:

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18

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IntensiveCareMedicineMCQs—MultipleChoiceQuestionswithExplanatoryAnswers

21

Regardingplasmaexchange:

a.

It is a highly effective treatment for thrombotic thrombocytopaenic
purpura.
The most commonly used replacement fluid is 4.5% albumin in
physiological saline.

Therapeutic plasma exchange requires central venous access.
Paraesthesia is a common complication.
Thrombosis is a common complication.

b.
c.
d.
e.

22

Inpatientswith,oratriskof,acutekidneyinjury(AKI),
international consensus guidelines suggest the
following:

a.

In critically ill patients, insulin therapy should target a plasma
glucose of about 6-8mmol/L.
Administration of colloid boluses to expand intravascular volume.
Parenteral nutrition should be used in preference to the enteral
route in patients with AKI.
N-acetyl cysteine (NAC) should not be used for the prevention of
post-surgical AKI.
Low-dose dopamine has a role in the treatment of established AKI.

b.
c.
d.
e.

23

WithregardtotheMedicalResearchCouncil-funded
CRASHtrials:

a.

The CRASH 1 trial examined the role of steroids in traumatic brain
injury (TBI).
The CRASH 2 trial assessed the role of tranexamic acid in
traumatic brain injury (TBI) within a pilot sample.
The CRASH 3 trial is designed to assess the effectiveness of
tranexamic acid in TBI within a multicentre cohort.

b.
c.

8