FCCS PRE TEST AND POST TEST EXAM 2024-2025, Exams of Nursing

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FCCS PRE TEST AND POST TEST EXAM

2024-2025 WITH ACTUAL CORRECT

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A 75-year-old man with a long history of smoking, chronic lung disease, and treatment noncompliance is brought to the emergency department by his daughter. He has had progressive dyspnea. He is awake, alert, and in moderate distress, with the use of accessory muscles during inspiration and expiration and a respiratory rate of 30 beats/min. There are audible expiratory wheezes. Which of the following pharmacologic treatments should be initiated?

A. Inhaled beta2-agonist B. Aerosolized racemic epinephrine C. Transtracheal lidocaine D. N-acetylcysteine A A 65-year-old woman is admitted with pulmonary edema due to acute diastolic left ventricular failure. She is alert and oriented but has a respiratory rate of 30 breaths/min and a room air SpO2 of 88%. On examination, she has 4 cm jugular venous distention and end-inspiratory crackles in her lung fields bilaterally. Room air arterial blood gas analysis shows: pH 7.28, PCO2 48 mm Hg, and PO2 58 mm Hg. Along with diuresis and antihypertensive therapy, she is placed on bilevel noninvasive ventilation with an inspiratory positive airway pressure (IPAP) of 12 cm H 2O and an expiratory positive airway pressure (EPAP) of 8 cm H2O delivered via full face mask with FIO2 0.5. Two hours after initiating noninvasive positive pressure ventilation (NPPV), the bedside nurse calls the physician to reassess the patient. The

patient is now agitated and fails to follow commands. SpO2 is now 85%. Repeat arterial blood gas analysis shows: C An 18-year-old, 55-kg (121-lb) woman has just been intubated for an acute asthma attack. She has been sedated and paralyzed in order to facilitate ventilation. Arterial blood gas analysis immediately before intubation revealed: pH 7.08, PCO2 75 mm Hg, and PO2 63 mm Hg on FIO2 0.4. On bagging, diffuse high- pitched wheezes are heard. Which of the following is the most appropriate initial ventilator mode for this patient?

A. Continuous positive airway pressure B. Pressure support ventilation C. Assist control volume ventilation D. Assist control pressure ventilation C A 56-year-old man presents to the emergency department with a three-day history of fever, shaking chills, cough, and sputum production. He was previously in good health and takes only amlodipine for a history of hypertension. In the emergency department, his heart rate is 130 beats/min, respiratory rate 32breaths/min, blood pressure 80/40 mm Hg, temperature 38.8°C (102°F), and oxygen saturation 92% on 6 liters of oxygen by nasal cannula. Pulmonary examination demonstrates crackles and bronchial breath sounds in both lower lobes. A chest radiograph shows multilobar consolidations. Although awake and alert, he appears visibly distressed and has marked accessory muscle use. Apart from antibiotics and resuscitation for sepsis, which of the following is the next best step for management of his respiratory failure?

A. Trial of noninvasive mechanical ventilation by face mask B. Intubation and initiation of invasive mechani B A 56-year-old man is admitted to the ICU for pneumonia. He is intubated, with the following settings: assist control, tidal volume 550 mL, respiratory rate 12 breaths/min, positive end-expiratory pressure 5 cm H2O, FIO2 1.0. Vital signs are: temperature 38.7°C (101.6°F), heart rate 122 beats/min, respiratory rate 20 breaths/min, blood pressure (BP) 88/46 mmHg, SpO2 97%. A central venous line and arterial line have been placed. He has been started on broad-spectrum antibiotics. Which of the following is a clinical indicator that he would benefit from further fluid resuscitation?

A. Heart rate persistently greater than 90 beats/min B. Passive leg raise resulting in at least 20% increase in systolic BP C. Urine output of less than 0.5 mL/kg/hour D. Systolic BP less than 90 mm Hg B

A 75-year-old man with a history of hypertension is evaluated in the emergency department for nausea, vomiting, and abdominal pain. He is lethargic but can answer questions appropriately. His pulse is 130 beats/min, blood pressure 70/30 mm Hg, and respiratory rate 28 breaths/min. On physical examination, he is noted to have dry mucous membranes, poor capillary refill, and a distended abdomen with rebound tenderness. Arterial blood gas analysis reveals: pH 7.32, PCO2 28 mmHg, PO2 74 mm Hg, bicarbonate 13 mmol/L. Serum lactate is 8.0 mEq/L. Which of the following findings has been shown to correlate with a worse prognosis in a patient with this clinical picture?

A. Hypotension B. Acidemia on blood gas analysis C. Elevated serum lactic acid D. Tachypnea C A 65-year-old man is septic, with perforated diverticulitis. He undergoes emergent colectomy with creation of a colostomy. Multiple areas of purulence are identified in the peritoneal cavity. Postoperatively, he continues to be febrile and hypotensive. Chest radiograph is clear. Central venous pressure is 18 mm Hg, and hemoglobin is 13g/dL. Which of the following vasoactive drugs is most appropriate to administer next?

A. Epinephrine B. Phenylephrine C. Norepinephrine D. Dobutamine C A 76-year-old woman with a history of congestive heart failure and hypertension is admitted with altered mental status and mild upper respiratory symptoms. According to family, her mental status has been gradually declining over the past three to four days. Because of generalized weakness and upper respiratory symptoms, she has had a limited amount of food and drink for the past 72 hours. Her home medications include metoprolol, lisinopril, and furosemide. Her family states that she has been compliant with these medications. On physical examination, vital signs are: heart rate 118 beats/min, blood pressure 96/53 mm Hg, respiratory rate 14 breaths/min, and oxygen saturation 98% on room air. Other findings included dry mucous membranes, poor skin turgor, and the absence of jugular venous distention. Pulmonary examination is clear on auscultation. She opens her eyes to voice, but mumbles incomprehensible sounds and has B While fighting a house fire, a 38-year-old man fell 10 feet through a burning roof into an actively burning bedroom. On arrival at the emergency department two hours later, he has abdominal pain. His focused assessment with sonography in trauma (FAST) examination shows fluid between his spleen and left kidney. His voice is hoarse, and he has carbonaceous sputum. He has blistering burns on his face and

insensate burns over his anterior chest, abdomen, and his entire left upper extremity circumferentially. His respiratory rate is 24-28 breaths/min, pulse 108 beats/min, blood pressure 131/73 mm Hg, and oxygen saturation as measured by pulse oximetry 98% on 2 liters nasal cannula. His estimated weight is 75 kg (165 lb). Which of the following is the most appropriate next intervention for this patient?

A. Endotracheal intubation with in-line stabilization for cervical spine protection and 100% oxygen for probable carbon A A 72-year-old woman with a history of hypertension, type 2 diabetes mellitus, and smoking develops sudden-onset severe chest pain associated with difficulty breathing and diaphoresis. Her vital signs on arrival in the emergency department are: blood pressure 165/92 mm Hg, heart rate 101 beats/min, respiratory rate 29 breaths/min, and oxygen saturation as measured by pulse oximetry 96% on room air. Which of the following ECG findings is the most significant indicator for immediate reperfusion in this patient?

A. ST segment depression B. ST segment elevation C. T wave inversions D. Peaked T waves B A 45-year-old man is admitted to the hospital with fever, altered mental status, and swelling and redness in the upper thigh and scrotal area of four days' duration. He has a history of poorly controlled diabetes and chronic renal insufficiency. On examination, he is lethargic. Vital signs are: heart rate 79 beats/min, blood pressure 90/40 mm Hg, respiratory rate 33 breaths/min, SpO2 88%, and temperature 39°C (102.2°F). The right thigh has erythema and cutaneous gangrene. Air is felt by palpation of the soft tissue. Laboratory test results include a white blood cell count of 31,000/μL with 15% bands, hemoglobin 11.5 g/dL, glucose 520 mg/dL, sodium 150 meq/L, potassium 4 meq/L, creatinine 2.5 mg/dL (baseline 2.2 mg/dL), and lactate 4.5 meq/L. IV fluids are started for aggressive resuscitation, and he is intubated. Blood cultures are obtained. Which of the following is the most appropriate strategy in this patient's ma B A 75-year-old man with alcoholic cirrhosis develops upper gastrointestinal bleeding on postoperative day two following total knee arthroplasty. He has been started on a proton pump inhibitor infusion. Four months ago, he underwent endoscopic banding of esophageal varices. Which of the following is the best medication to add to his regimen until more definitive endoscopy can be performed?

A. Protamine sulfate B. Aminocaproic acid C. Somatostatin D. Tranexamic acid

C

Which of the following would not be an expected laboratory finding associated with preeclampsia?

A. Alanine aminotransferase level of 60 U/L B. Normal glucose level C. Decreased fibrinogen level D. Normal bilirubin level C

Which of the following parameters may be a late sign of cardiovascular disturbance signaling failure of the compensatory mechanisms?

A. Tachycardia B. Bradycardia C. Hypotension D. Hypertension C Investigative tests should be based on the patient's history and physical examination as well as on previous tests. Which of the following is one of the most important indicators of critical illness?

A. Respiratory acidosis B. Metabolic acidosis C. Elevated creatinine D. Hyponatremia B A 22-year-old man is brought to the emergency room after falling from a horse. He is awaiting transfer to another facility. He has a chest contusion and a non-displaced femur fracture. He is in spinal motion restriction with a cervical collar and long backboard. He has worsening respiratory distress and hypoxemia requiring endotracheal intubation. Which of the following modifications of the manual assisted ventilation technique is appropriate?

A. Place an oral airway one size larger than usual. B. Add additional downward pressure on the face mask once it is sealed. C. Use a jaw thrust technique in place of neck extension. D. Increase the tidal volume with each manual assisted breath. C Which of the following anatomic features is most likely to contribute to difficulty in maintaining a patent airway in a supine patient?

A. Edentulous mandible B. Posteriorly displaced tongue C. Deviated nasal septum D. Anteriorly displaced thyroid cartilage B An elderly patient is on the medical ward for respiratory distress. Which of the following is correct regarding airway assessment?

A. Laryngeal displacement toward the chest during inspiration occurs only with upper airway obstruction B. Chest rise with inspiration indicates an adequate tidal volume C. Unilateral absent breath sounds on auscultation is a tension pneumothorax D. Complete airway obstruction is likely when chest retraction and movement is present, but there are no breath sounds D An 82-year-old man who awoke with chest pain in the morning is being evaluated in the emergency department. He is alert and oriented. Shortly after being placed on a cardiac monitor in normal sinus rhythm with ST segment elevations, he becomes unresponsive and develops ventricular fibrillation. Which of the following initial interventions is most appropriate for this patient?

A. Do not initiate treatment because, due to his age, he probably has a do-not-resuscitate order on file. B. Attempt to contact the family before treating to discuss the level of intervention. C. Start cardiopulmonary resuscitation while preparing to defibrillate. D. Start bag-mask-valve ventilation while preparing to intubate. C Which of the following is the purpose of cardiopulmonary resuscitation?

A. To reverse symptomatic bradycardia in an ICU patient who is on multiple vasoactive infusions B. To reverse sudden cardiac death in a patient who is in the palliative care unit C. To prolong the life of a patient who has a do-not-resuscitate order on file to allow time for family to arrive D. To reverse sudden, unexpected death from a reversible disease process or iatrogenic complications D

Hyponatremia - indications for 3% NS? Seizures or AMS

What speed/rate can Na be correct in hyponatremia? 8 mEq/24 hours 43 yo m with hx of CAD comes with left hemiparesis x 1 hour. CT shows no bleed. What do we do? Administer TPA/TNK 22 yo m after MVA; incomprehensible sounds, no eye opening to painful stimuli, CT scan shows increased ICP and subdural bleed; what is the first thing we do? Elevate head of bed to 30-45 degrees Male presents with no breath sounds and tracheal deviation to the left side, what do we do? 16 gauge needle cdecompression BP 86/52, HR 126, RR 29; what class of shock is this? Three/ Progressive Stage Male after MVA; FAST shows bleeding, on way to OR his BP tanks, what do we do to resuscitate? 1:1:1 RBCS, platelets, FFP male presents after MVA in cervical spine collar; while waiting for xray the SpO2 drops to 85%, left pupil is larger than right, he does not respond, only grunts, moves limbs to pain; what do we do? intubate with inline intubation NSTEMI or STEMI what do we want our SpO2 to stay above?

94% Who should go to cath lab IMMEDIATELY with NSTEMI? If they have shock with NSTEMI =immediate cath lab/CABG After STEMI, what drug has been shown to decrease risk of mortality? ACE inhibitors Loose stools after treatment for UTI with antibiotics; MRI shows pancolitis, what is the tx? IVF, metronidazole, PO Vanco

(It's CDIFF) Hospital day 14, pt with tachycardia; culture from central line = gram + cocci what do we do? Remove with line and treat with vanco Fever and headache with period of confusion in 20 year old patient; what is the likely cause? How do we treat?

Cause: Neisseria meningitidis (meningococcal)

Tx: Vanco, ceftriaxone 45 year old male with AMS, redness on upper thigh and scrotal area x 4 days (gangrenous); hx of poor controlled DM

What is it? How to treat? Fournier's cellulitis

Tx: Surgery immediately, then beta lactam, clindamycin (blocks toxin release), vanco Breast cancer patient with dry mucus membranes; BP 88/40. White blood cells 1.1 (neutropenia); diagnosed with neutropenia fever and sepsis, how to treat this patient?

1. get cultures
2. give broad spectrum ABs Ekg changes of hyperkalemia, treatment? Changes: Peaked T, sine wave, wide QRS

Tx: Calcium gluconate 10%; CANDIK Multiple myeloma treatment? Fluids (3L) Then lasix Shock patient; after NE,fluids and vasopressin have been given, what is our next choice if BP still low? Hydrocortisone DKA treatment? Once anion gap is closed, how does patient move toward discharge? Tx: Insulin and fluids

Long acting insulin (glargine) and then can go off drop BP 240/110, blood pressures are different in arm than leg and CXR shows a wide meadiastinum; what is the diagnosis? How to treat? Diagnosis: Aortic dissection

Tx: Beta blocker (labetalol) Pregnancy, what lung values are lowered? Why? Functional residual capacities, due to compression by uterus

15 month child choked; CXR shows hyperinflated right lung, what is the diagnosis? Right mainstream bronchus obstruction d/t foreign body aspiration How to confirm intubation? -Wave form capnography -End tidal CO2 monitoring What is the most critical indicator of distress? Tachypnea Causes of pulsus paradoxus Cardiac tamponade (becks triad), increased intrathoracic pressure, pericarditis, pericardial effusion 60 yo with JVD, missed dialysis 2 days ago; in respiratory distress; BP 80/40, rr 35, pulsus paradoxes 20mm, lungs clear, muffled hear sounds; what is the likely cause/dx? Cardiac tamponade Pt is receiving bag mask ventilation over 1 second with 100% O2 15 LPM, 10 compressions per minute; but the chest is NOT rising with ventilations; what do you do? Check seal, listen for leaks A patient has hyperkalemia, which med is contraindicated in intubation? Succinylcholine (neuromuscular blockade med) - it can cause hyperkalemia in itself Vtach/vfib arrest; CPR and shocks administered, now we have achieved ROSC; what is the best treatment? Why? Code Ice/ Targeted temperature management (32-36 degrees) because it preserves brain function Shunt physiology most common examples Pneumonia Atelectasis OD in suicide is what type of respiratory failure? Acute hypercapnic 55 yo with COPD exacerbation; pH 7.2, CO2 92, PO2 108; pt on vent at tidal volume 375, AC mode, FiO of 35%, PEEP 5, rate 20, peak airway pressure 55, plateau 18, autopeep 15

BP is now 70/40, why is it low? Treatment? Why low: High auto PEEP, should not have pressure in the lung at the end of exhalation

Tx: Increase expiration time so they can empty lung completely with exhalation

45 yo male, vent for ARDs d/t aspiration pneumonia; his vent settings are AC mode, tidal volume 5 mL/kg, RR 20, PEEP 22, peak airway pressure 40, plateau 35, FiO2 100%

PH 7. PaO2 88

What do we do? Lower PEEP to 18 to Lower pressure inside lung 72 year old male with CHF with accessory muscle use is awake and alert

RR 34 BP 120/ HR 120 SpO2 90% on 8L

CXR shows bialteral infiltrate consistent with CHF

ABG 7.34 pH, 64 paO2, 50 paCO

Treamtent? He needs pressure to get air in, so Bi-pap because he is alert and responsive with stable BP (other options are CPAP, vent) What decreases SVO Decreased o2 delivery Increased o2 consumption Male presents with SOB and femur fracture

Temp 100. HR 144 RR 30 BP 100/ SPO2 92% Hgb 8 SVO2 52%

How do we treat his hypotension? Fluid bolus How do we treat coughing during intubation? Lidocaine spray (because coughing increases ICP)

Management of unstable angina/NSTEMI MONA

1- analgesic/anti-ischemia: morphine, nitrates, oral beta blocker to slow HR and decrease its demand 2- ASA 3- heparin 4 -serial cardiac markers (CKMB/trops)

Consider reperfusion therapy What is the initial tidal volume a vent should be set at? 6 mL/kg What does the plateau pressure need to be below <

If too high it is forcing too much air, so lower the tidal volume or respiratory rate What is the normal inspiratory to expiratory ratio 1 : 2- Candidates for NPPV must be Alert, cooperative Hemodynamically stable Able to control airway secretion Able to coordinate with machine What settings should NPPV be initiated at? CPAP has to start at 8

BiPAP has to start at 8 inspiratory/4 expiratory What does a high inspiratory plateau pressure indicate? Alveolar distension, which can cause a pneumothorax How to manage high autopeep Disconnect pt from vent and push on chest to get air out, then reconnect and either decrease tidal volume or RR so they have time to exhale What should PEEP start at on vent setting? 5- How is body weight predicted?

45.5 + 2.3 (ht in inches -60) If a patient is on a ventilator at FiO2 100% at PEEP of 24 and they are still hypoxic, what is our next step? Then what? Then what? Increase the inspiratory time, to make the ratio 3:1 inspiratory:expiratory

If still hypoxic do prone position for 18 hours, 6 off

If still hypoxic do ECMO At FiO2 of 30% what is the highest the PEEP can be? At 40% At 50% At 60% At 70% At 80 % At 90% At 100% 30%- 5- 40%- 8 50%- 10 60%- 12 70%- 14 80%- 16- 90%- 18- 100% 22- What is the most important sign in a critically ill pt? Why? Tachypnea

Indicates metabolic acidosis (often w/ respiratory alkalosis compensation) A pt misses dialysis for a few days and comes in with fluid overload. He's tachycardic and tachypneic. On physical exam, you find JVD, pulsus paradoxus (20 mmHg drop during inspiration), and HoTN (80/40) with distant, muffled heart sounds. Lungs are clear to auscultation. What is the dx? Cardiac tamponade; obstructive shock If a pt has a thyromental distance of 2 cm, what can you expect about their airway? Difficult airway w/ an anteriorly displaced larynx A COPD pt comes in with difficulty breathing. He then becomes apneic and unresponsive. How would you ventilate this pt? BVM

A pt arrives after falling from a ladder and has a frontal laceration. On examination, you find papilledema and labored breathing w/o being able to clear secretions. What is your biggest concern when intubating this pt? Cerebral edema/increasing ICP

Intubation tends to cause an increase in ICP. Administer lidocaine prior to intubation to inhibit vagal stimulation. An ESRD pt w/ hyperkalemia develops dyspnea and requires intubation. Which paralytic agent/NMB should you avoid and why? Succinylcholine

Worsens hyperkalemia A pt is admitted after an OD. He starts to have apneic episodes and his SpO2 is dropping. You place him on a non-rebreather mask w/ 100% O2, yet his SpO2 remains at 80%. Why is it not being corrected?

Then, if you try a BVM and it also fails, and video laryngoscopy is unavailable, what is your next best choice for an airway? The pt is having apneic episodes, which means that administering high-flow O2 will be ineffective.

Choose an LMA if the BVM fails. What intervention improves outcomes with ROSC after cardiac arrest? Targeted temperature management.

32-36 C A shunt means there is perfusion without ventilation. What disease process is an example of a shunt? Pneumonia Which type of respiratory failure occurs with CNS depression after an OD? Acute hypercapnic respiratory failure --> mixed A 50 y/o pt is having a COPD exacerbation. You have tried steroids, bronchodilators, etc. with no improvement. PCO2 is in the 90s, pH is 7.20. You decide to intubate. Vent settings are: VT 375, RR 20, FiO2 .35, PEEP 5. CXR is normal. A few minutes later, his BP drops to 70/40. Lungs are clear/equal. Vent shows peak airway pressure of 55 (high) and plateau pressure of 15. End expiratory hold gives auto- peep of 15.

What is the cause of this pt's HoTN and why? Auto-peep is the cause.

COPD pts have difficulty exhaling --> pressure buildup in alveoli.

We use PEEP for the pressure and to improve oxygenation. Auto-peep comes from breath-stacking --> intrinsic peep. Alveoli enlarge --> high peak airway pressure. All leads to low venous return --> low CO --

HoTN A COPD pt is admitted to the ICU for exacerbation. Pt is on a vent. Pt is tx w/ bronchodilators, steroids, and Abx. ABG was normal 1 hr ago, but now the peak airway pressure is up to 55 and plateau pressure is also high at 50. Pt becomes hypotensive at 70/40. You observe tracheal deviation to the R. Normal breath sounds on the right, diminished on the left. No wheezing. WBC is normal.

What is the dx and treatment? Tension pneumothorax

Needle decompression/chest tube A pt in ARDS s/p pneumonia is on 100% FiO2 with PEEP of 22. PO2 is 88%. Peak airway pressure and plateau are both high. VT is 5 ml/kg.

How can you decrease the airway pressures? Decrease the PEEP, even though it will decrease PaO2.

(Note: you can't decrease the VT because it is already on the low end). A young asthmatic pt is on the vent. His lungs are very tight. He is on the AC setting and there is a lot of auto-PEEP. You correct it by reducing the rate, giving him more time to exhale and making sure he has enough flow. FiO2 is at .50. He is sedated and seems comfortable. On ABG the pH is 7.24, CO2 is 65, O is 80, and bicarb is 29.

What would you do with the vent settings in this case? Keep the settings where they are.

You can't hyperventilate the pt to blow off CO2 b/c the asthma will worsen. As long as the pH is > 7.2, the settings are okay as they are. CO2 will correct over time. Which two conditions are the most indicated for BiPAP? COPD exacerbation

Cardiogenic pulmonary edema A 70 y/o pt with CHF presents with SOB, accessory muscle use, RR 34, SpO2 90% on 8L O2. CXR reveals infiltrates in a bat wing pattern. She also has LE edema. She is dx with a CHF exacerbation w/ respiratory failure. Her ABG shows pH 7.3, PO2 64, CO2 50.

What is the best tx for this pt? Non-invasive BiPAP. A pt comes in w/ a femur fx and a rod is placed. Post-op he develops dyspnea and fever. HR 140, RR 30, SpO2 92% on non-rebreather. He is transferred to the ICU where you intubate, place a central line, and start resuscitating him. Hb 8.2, lactate 3.2, SVO2 is 52%.

Why is his SVO2 low? How can we improve it? Decreased O2 delivery and increased consumption.

(normal is 65-70)

Administer packed RBCs - 1U of blood will change his Hb from 8.2 to 9.2. O2, fluid, and VT would not work. A young pt after an MVA comes to the ER hypotensive and tachycardic. CXR is clear. He has a contusion on his chest wall and torso. He is unconscious. What will give you the best insight on what is causing his shock?

Hb SCV Urine Output FAST exam FAST exam 41 y/o pt in the SICU following debridement of b/l lower extremities for necrotizing fasciitis is intubated on AC. Temp 102, HR 116, RR 16, BP 92/46. ABG shows pH 7.23, PO2 133, PCO2 38, Na 139, K 3.7, Cl 102, Bicarb 16, lactate 4. Dx is metabolic acidosis w/ anion gap d/t infection.

What is the most appropriate intervention?

Increase VT Continue resuscitation Decrease RR Administer bicarb Continue resuscitation. Don't need to increase VT bc the pt doesn't have respiratory acidosis. If you decrease the RR, the pt will go into respiratory acidosis. A pt has obstructive uropathy. A catheter is placed d/t the obstructive kidney injury. After the cath is placed, he has massive diuresis to the point where he is hypotensive, tachy, and lactate is 2x the ULN from decreased perfusion.

How would you correct this?

Fluids - LR When treating hyponatremia, what is the first thing to assess?

When do you give 3% NaCl?

How do you correct it?

1. fluid status
2. seizures or changes in mental status
3. slowly, 8-12 meq over 24 hr What are the classifications of hemorrhagic shock? I: <15%; HR <100, BP normal, RR normal II: 15-30%; HR >100, BP normal, RR 20- III: 30-40%; HR >120, BP low, RR 30- IV: >40%; HR >140, BP low, RR > An 84 y/o pt fell down the stairs. He is moaning and crying. He has a C-collar in place. His neck is painful and he has bruising on his face. He is tachy but BP is okay. You administer 2L O2 bc SpO2 was 92%. Shortly after he deteriorates, becoming altered and then comatose. His left pupil > the right. He is herniating from cerebral edema.

How do you treat him? Intubate and ventilate, maintaining c-spine precautions. Administer mannitol. A pt comes in with several cardiovascular RFs: elderly, DM, and HTN. He is having chest pain, SOB, and is diaphoretic. What diagnosis do you need to re-perfuse him immediately? STEMI What is the most appropriate management for both STEMI and non-STEMI?

nitro if bp > morphine q 30 min bb oxygen if sats are <94% Oxygen Which NSTEMI needs to be sent to the cath lab immediately? NSTEMI w/ shock Which medication improves outcomes for pts with STEMI? ACE-I

Give if BP is stable. It decreases LV remodeling and decreases afterload.

A 70 y/o pt has been hospitalized for 15 days. He had a cholecystectomy and abscess formation which was tx appropriately. He has a central line in the right IJ. The site looks visibly infected, and he has a fever, is tachy, and hypotensive. WBCs are high. Blood culture and initial gram stain reveals G(+) cocci.

What is the dx? What is the MC pathogen? What is the tx?

1. line-related infection
2. coag (-) staph epidermis
3. vanco + zosyn + ceftriaxone

if MRSA: vanco + ceftriaxone if MSSA: zosyn + ceftriaxone What is the tx for meningitis? young pt: ceftriaxone + vanco

50 pt: add ampicillin A chemotherapy pt becomes septic. You suspect a neutropenic fever. What is the tx? broad spectrum abx (vanco/zosyn) obtain blood, urine, and sputum culture CXR + CT What is the tx of hyperkalemia? calcium gluconate + insulin + dextrose bicarb, kayexalate, albuterol

definitive tx: dialysis How do you manage DKA? Check potassium

Multiple L bolus via at least 2 peripheral IVs

Insulin infusion, 0.1U/kg/hr until sugar reaches 250 mg/dl

Switch NS to D5W

Once anion gap is closed, administer long-acting insulin 1 hr prior to d/c infusion A 70 y/o pt with COPD comes in with an exacerbation. He is rapidly becoming more hypoxic. To rule out PE, what test should you order? CT

A 22 y/o pt ingested drugs >4 hours ago. She came to the ICU obtunded w/ arousal to tactile stimulation. She is hemodynamically stable. RR 8 with an NG tube in place. What is the next step for tx of the ingestion? Monitor / watchful waiting.

The pt ingested the drugs more than 4 hours ago. Monitor RR and intubate if necessary. A pt presents with HTN, ripping/tearing pain to the back, and unequal pulses.

What is the dx?

What is the tx goal and what should you use?

What medication is contraindicated?

1. aortic dissection
2. lower BP and HR
3. Labetalol, no reflex tachycardia
4. Nitro is contraindicated What decreases during pregnancy by ~25%? Functional residual capacity A 24 y/o male comes in following a concussion. CT reveals a frontal lobe contusion. He does not require intubation and is kept on 3 L O2 NC. He then suddenly has a generalized seizure.

What is the DOC?

What do you give after the seizure?

What med class is an absolute contraindication for seizures?

1. lorazepam IV
2. dilantin
3. NMB a 55 y/o male comes in with AMS and diffuse abdominal pain. He takes HCTZ and a multivitamin. HR 120 sinus tach. He is moaning in pain and unable to articulate what is happening. CT reveals lytic lesions in the vertebrae. You administer a 3L NS bolus which shows mild improvement.

What is the dx and what is causing his symptoms?

How do you tx? Dx: multiple myeloma

The hypercalcemia is what is causing the symptoms.

Tx: Fluids, then diuretic or bisphosphonate if symptoms persist. How do you treat septic shock (4 things)? 2-3 L bolus NE Vasopressin Steroids what vital sign abn and BMP finding is the most important indicator of critical illness? tachypnea; metabolic acidosis what is the gas volume in an adult resus bag? 1-1.5 L waht is the mnemonic for airway prep? SOAP-ME Suction Oxygen Airways (OPA, NPA, Ett) Position: adjust bed Monitoring and Medications: EtCO2, RSI drugs Equipment: DL, VL, bougie what are indicators of a difficult mask? beard,no teeth, OSA, high BMI, age > 55 how should you evaluate a patient for intubatioN? *same order you go through to acutally intubate:

1. neck mobility
2. external face: small mandible, surg scarring
3. mouth (<3 finger breaths of opening is worrying)
4. tongue/pharynx
5. jaw: thyromental distance (from anterior prominence of thyroid cartilage to tip of mandible what are the 2 NM blockers to know for intubation? sux, roc

drugs: -lido p 28 a what periintubation drug has been shown to blunt response of increasing ICP in someone whith a head injury? lidocaine (1-1.5 mg/kg) what is goal temp ranges for targeted temperature management? what are the 2 potential big SEs? 32 to 36 C for at least 24 hours in comatose (GCS<8) patients following ROSC

SEs: coagulopathy, increased risk of infxn what percentage of normal CO does chest compressions produce? 1/ what is the goal CO2 following arrest? 38-42 (normocapnea) what are teh 3 broad types of respiratory failure? PNA is most often associated with which one? drug OD? CHF? COPD? dead space ventillation? hypoxemic (PaO2 <60), hypercapneic (PaCO2 >50), mixed

hypoxemic (although can be mixed) hypercapneic hypoxemic mixed hypercapneic define shunt physiology? waht is at the other end of the VQ spectrum? no V, still adequate Q

dead space what ratio is most useful in tracking hypoxia over time? P:F ratio, PaO2 and FiO

normal is 300- define minute ventilation (VA) VA = RR* (VT - VD) VD = dead space

define paradoxical breathing? why does it occur diaphragm is flaccid b/c of fatigue and moves upward during inspiration what FiO2 is given with 2 L NC? 8 L facemask? 28%, 60% what are BiPAP settings to start a patient on (EPAP, IPAP, Vt, backup rate), at what IPAP do you worry about gastric distention? 5, 10, 6-8 mL/kg, 6

IPAP > 20 what are the 4 indications for invasive ventillation? failure to oxygenate, failure to ventilate, failure to protect, projected clinical course what are teh ABCD of teh vent cycle? A: triggering (initiation of inspiration) B: end of inspiratory flow C: cycling (start of expiratory flow) what is assist-control ventilation? VT is guaranteed at present flow rate with a minimum RR however pt can initiate breaths and trigger teh vent, so Pt can breath at higher RR if he wants

can be either volume cycled or time cycled (pressure assist), volume is much more common what is PSV? SPV provides a preset level of inspiratory pressure with each vent detected pt effort

best for spontaneously breathign pt to offer increased comfort what is SIMV? synchronized intermittent manditory ventilation, breaths may be triggered by the pt or time delapsed, vent will synch to pt breaths, if no breath is detected vent will deliver preset VT at preset time PSV is usually paired with what other vent mode for pt comfort and decrease in pt's WOB? SIMV volume assist control waveforms?

pressure assist control ventilation waveforms?

review advantages/disadvantages to different vent modes on p 77 do it after you intubate what is the first mode used? AC, usally volume controlled what are best initial vent settings? (VT, FiO2, RR)? what is normal minute ventilation? VT = 4-8 mL/kg; closer to 8 for COPD, closer to 4 for ARDS

7-8 L/min

92-94% what is peak airway pressure? inspiratory plateau pressure? which one corresponds more to barotrauma? how can you decrease Pplat? Ppeak = a measure of airway resistance; < 40 is ideal

Pplateau = measure of compliance and alveolar distension, a static measurement; need an inspiratory hold of 1 sec; normal < 30 cm H2O

Pplat

decrease PEEP, decrease VT if you can't get FiO2 < 60 what should you do? increase PEEP waht is auto PEEP? how can tell its happening on tracing? badness, happens when expiratory time is too short to allow full exhalation. can decrease CO, need to adjust vent. To get rid of increase peak flow and decrease RR

can see on tracing by if a breath is initiated below baseline Most important indicator that a patient has a severe illness? Tachypnea 3 respiratory types, and their criteria Hypoxemic (PaO2 <50-60) Hypercapnic (PaCO2 >50, pH <7.36) Mixed Delta gap (formula, when and why it's used) Difference in AG from normal - Difference in HCO3 from normal

In AG metabolic acidosis it's used. It tells you if there's underlying metabolic alkalosis or respiratory acidosis with bicarb compensation IN ADDITION to the AG metabolic acidosis. Both of those would result in a high bicarb to begin with, and a smaller change in bicarb from normal. Winter's formula (equation, what it measures) 1.5[HCO3] + 8 +/- 2 If compensation is adequate in acid/base issues How AG changes with albumin changes Decreases 2.5-3 for every 1 decrease in albumin Hemodynamic changes after intubation Hypo/hypertension Arrhythmia Tachycardia Pressure support equation for BiPAP IPAP - EPAP 3 types of vent cycles Volume (preset tidal volume, relieves WOB the most) Time (constant pressure of time) Flow (constant pressure until inspiratory flow is below 25% of peak) Goal tidal volume 10 cc/kg Goal FiO2 on vent Start at 1.0, then decrease as SpO2 tolerates (goal of 92-94 saturation)

Ppeak Peak inspiratory pressure Pplat (try to keep it below ?) Inspiratory plateau pressure (shows alveolar distention) 30 AutoPEEP (what it is, what it causes, how to fix it) Breath stacking Decreases preload to the heart with positive pressure on the lungs --> hypotension Decrease RR, decrease inspiration time (goal is to have more time for the lungs to exhale) Danger of increased PEEP Increases autoPEEP, increases Pplat PaO2 we're usually happy with

60 When to consider NPPV vs invasive When it's a quickly solved problem in 1-2 days (e.g. COPD exacerbation) When the patient can be compliant with working with NPPV When to consider switching from NPPV to invasive ventilation support If things aren't really improving in a matter of hours If your therapeutic goals haven't been met in 4-6 hours Manual decompression (when you use it) If patient is air trapping like crazy on the vent, and you disconnect it and push up on the patients diaphragm to get everything out What a high A-a gradient means V/Q mismatch Volume assist-control breath (Volume cycled) Vent delivers preset tidal volume Pressure assist-control breath (time cycled) Vent delivers a constant pressure over a preset time Pressure support breath (flow cycled) Same as pressure assist-control breaths, but the vent cuts out when the flow rate decreases to 25% of initial peak flow rate

Assist-control ventilation Either volume or time cycled breaths given Usually the go to when you just started someone on the vent Gives the pt a set tidal volume and preset flow rate respiratory rate. Very rigid. However, if the patient wants to take extra breaths if they trigger them. Pressure support ventilation Waits for patient to start breath, and then helps out with a set amount of pressure Synchronized intermittent mandatory ventilation SIMV Delivers volume or time cycled breaths at a mandatory rate Patient can breathe spontaneously between mandatory breaths Spontaneous breaths count - this allows the patient to contribute to the mandatory tidal volume the machine requires them to breathe When do you give tPA in ACS? ONLY for a STEMI, and ONLY when PCI isn't readily available Tx of an inferior MI NO nitroglycerin Give fluids instead ABG findings in PE Decreased CO2 (hyperventilating) Decreased O2 (V/Q mismatch) When to give tPA in PE Only for huge ones and heparin's not working Lovenox class LMWH Airway in hematemesis pt Electively intubate it Tx of HTN urgency vs emergency No drip vs drip Intraabdominal HTN (criteria, effects)

12 mmHg End organ damage and decreased preload to heart causing hypotension