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

a stab wound to the upper abdomen.small
puncture wound under the left costal
margin. BP is 80/40mmHg, HR is 130bpm
and RR is 30 b/m.neck veins are distended.
Chest X-ray shows no evidence of
pneumothorax or haemothorax. ECG RBBB
and T wave inversion in lead V1. FAST scan
shows the presence of pericardial fluid.
229a
Dr.Sherif Badrawy

a. TTE is the diagnostic technique of choice when
considering traumatic cardiac tamponade as a Dx ?
【✔】➜ fast and sensitive in the right hands
b. A CT scan of the thorax should be performed
immediately to confirm the suspected diagnosis.【✘】
c. Rapid fluid infusion should be avoided to prevent RHF.
【✘】
d. Removal of at least 300ml fluid is required to materially
improve the clinical condition.【✘】➜ Removal of as little
as 30ml fluid may give dramatic improvement
229b
Dr.Sherif Badrawy

RTA, ? seatbelt injury, HD unstable, +ve
DPL, bilateral closed femoral fractures, OR
for emergency laparotomy
230a
Dr.Sherif Badrawy

a. Definitive surgery must be performed before transfer to the
intensive care unit.【✘】➜ coagulopathy, hypothermia and
metabolic acidosis are great risks to the pt ↑by prolonged
surgery. initial surgery should be damage control only
b. Surgical stabilisation of the femoral fractures should be
deferred until a later date.【✘】
c. Hollow viscus injury must be dealt with immediately.【✔】
d. The abdomen must be closed to prevent overwhelming
sepsis.【✘】➜ Abdominal closure may provoke abdominal
compartment syndrome which has ↑mortality
230b
Dr.Sherif Badrawy

What's damage control surgery ?
231a
Dr.Sherif Badrawy

packing a bleeding liver rather than formal
resection, debridement of a pancreatic injury
rather than pancreaticoduodenectomy, or
resecting non-viable bowel and stapling the
ends rather than attempting primary re-
anastomosis.
231b
Dr.Sherif Badrawy

Regarding the use of mannitol for the
treatment of raised
intracranial pressure:
232a
Dr.Sherif Badrawy

a. A typical dose is 250-500ml of 20%
mannitol as an IV bolus.【✔】
b. Intravascular volume depletion is a side
effect.【✔】
c. It increases calculated plasma
osmolality.【✘】
d. It has a rapid effect.【✔】
232b
Dr.Sherif Badrawy

Immediate management for a patient
suspected of having
anaphylaxis includes:
233a
Dr.Sherif Badrawy

a. High-flow oxygen.【✔】
b. Intravenous hydrocortisone 100-200mg.
【✘】➜ a 2ndry management but is not
time-critical
c. Epinephrine 0.5mg IV bolus.【✘】➜
Epinephrine should be given IM
d. Lie the patient flat and raise their legs.
【✔】
233b
Dr.Sherif Badrawy

crushing central chest pain.ECG shows
2mm ST elevation in leads II, III and aVf.
hypotensive, with a BP of 80/50mmHg and
↑JVP, lungs are clear to auscultation, ↑ST
in lead V4R.
234a
Dr.Sherif Badrawy

a. A nitrate infusion should be started to relieve the chest
pain.【✘】➜ may precipitate profound hypotension
b. A fluid challenge of 500-1000ml should be given.【✔】
c. A posterior myocardial infarction is the likely diagnosis.
【✘】➜ right ventricular infarction [↑ST in lead V4R is
highly sensitive and specific for RV infarction].
d. Thrombolysis is contraindicated.【✘】
234b
Dr.Sherif Badrawy

RTA, a liver laceration, During laparotomy
extensive bleeding + 15-unit blood transfusion,
MV, ICU, progressively worsening lung
compliance and hypoxaemia
(PaO2 9kPa [68mmHg] on 80% FIO2), over the
next few hours. Chest X-ray shows widespread
fluffy
infiltrates; the PAOP is 15mmHg.
235a
Dr.Sherif Badrawy

a. The chest X-ray may be consistent with
pulmonary oedema.【✔】
b. Diuretic therapy is indicated.【✘】
c. Corticosteroids are indicated.【✘】
d. Sufficient information is available to
diagnose TRALI.【✔】
235b
Dr.Sherif Badrawy

Regarding the cerebral monitoring of
patients with
traumatic brain injury:
236a
Dr.Sherif Badrawy

a. Intracranial pressure is a good surrogate measure of cerebral
metabolism.【✘】➜ a crude means of estimating
cerebral metabolism and blood flow
b. A jugular bulb SjvO2 of <50% has prognostic significance.
【✔】➜ > doubles mortality, A high mean SjvO2 (>75%) also
carries a poor prognosis since dead brain tissue does not
extract oxygen.
c. The greater the SjvO2 the better the neurological outcome.
【✘】
d. A low arterio-jugular oxygen content difference (AJDO2)
implies a poor outcome.【✔】
236b
Dr.Sherif Badrawy

ICP correlates with survival ?
237a
Dr.Sherif Badrawy

With severe head injury and ICP <20mmHg,
expected mortality is 18%; this rises to 45%
>20mmHg, 74% >40mmHg, and 100%
>60mmHg
237b
Dr.Sherif Badrawy

Recombinant factor VIIa is licensed for use
in the following scenarios:
238a
Dr.Sherif Badrawy

a. Second-line treatment of bleeding in major
blunt trauma.【✘】
b. Emergency reversal of the anticoagulant
effects of pentasaccarides (e.g. fondaparinux).
【✘】
c. Prophylaxis against bleeding for procedures
in patients with liver disease.【✘】
d. Treatment of major obstetric haemorrhage.
【✘】
238b
Dr.Sherif Badrawy

Recombinant factor VIIa is licensed for
treatment of ?
239a
Dr.Sherif Badrawy

✲ bleeding in haemophiliacs with
antibodies to
Factor XIII or IX, and also for patients with
acquired Factor VII deficiency
✲ surgical bleeding prophylaxis in these
patient groups.
✲ used off-label for many indications
including those listed in the question.
239b
Dr.Sherif Badrawy

Regarding the physiology of the patient
with major burns:
240a
Dr.Sherif Badrawy

a. Cardiac output is increased in the immediate post-burn
period.【✘】COP usu ↓immediately following injury dt
sympathetic activation ➜ ↑systemic and pulmonary vascular
resistance.
b. A hypermetabolic state begins in the first 6 hours post-burn.
【✘】➜ A hypometabolic ('ebb') phase is usual in the first few
days following a burn injury
c. Acidic drugs have an increased free fraction in the plasma.
【✔】dt ↓Albumin levels.
d. Sensitivity to non-depolarising muscle relaxants is
increased.【✘】➜ reduced from around 1 week post-burn.
240b
Dr.Sherif Badrawy

Definition of A hypometabolic ('ebb') phase
?
241a
Dr.Sherif Badrawy

It' is usual in the first few days following a
burn injury (or any major systemic insult),
with the hypermetabolic phase
supervening around 3 days post-burn.
241b
Dr.Sherif Badrawy

Regarding MRSA infection:
242a
Dr.Sherif Badrawy

a. Around half of all Staphylococcus aureus infections are
methicillin resistant.【✔】
b. MRSA infection rates are inversely related to nursing
staffing levels.【✔】
c. MRSA bacteraemia carries about a 15% mortality.【✔】
d. Active surveillance culture of patients is an effective
means of reducing MRSA infection rates.【✔】➜ as most
patients are colonised with rather than infected by MRSA
242b
Dr.Sherif Badrawy

PAOP overestimates LVEDP in the following
conditions:
243a
Dr.Sherif Badrawy

a. Mitral stenosis.【✔】➜ dt ↑Left atrial
pressure
b. Mitral regurgitation.【✔】➜ dt ↑Left
atrial pressure
c. Massive pulmonary embolism.【✔】
d. Catheter tip outside West zone III.【✔】
243b
Dr.Sherif Badrawy

The following are effective methods of
predicting an
increase in cardiac output in response to a
fluid challenge:
244a
Dr.Sherif Badrawy

a. Passive leg raising to 10° with oesophageal Doppler
monitoring.【✘】➜ elevated to >30° ➜ ↑COP after 30s
measured by oesophageal Doppler probe if the patient is
preload-responsive.
b. Pulmonary artery occlusion pressure.【✘】➜ a poor
predictor of LVEDP & preload-responsivness.
c. A large 'swing' on the arterial line trace in a mechanically
ventilated patient.【✔】
d. A fall of 3mmHg in central venous pressure during
unimpeded inspiration in a spontaneously breathing patient.
【✔】
244b
Dr.Sherif Badrawy

pulse pressure variation predicting an
increase in cardiac output in response to a
fluid challenge
245a
Dr.Sherif Badrawy

A pulse pressure variation of >13% ➜ a
sensitive and specific predictor of ↑COP in
response to a fluid bolus.
245b
Dr.Sherif Badrawy

65-y, M, trapped in a burning building for 1
hour before extrication, ataxic and listless
with a GCS of 12, RR of 30, HD stable, PaO2
44kPa (334mmHg), PaCO2 3.5kPa
(26.6mmHg), SaO2 99% and lactate
10.5mmol/L, CoHb on co-oximetry is 10.4%.
He has a brief seizure.
246a
Dr.Sherif Badrawy

a. This patient has severe carbon monoxide poisoning.【✘】➜
CoHb level of 10% is insufficient to explain a GCS of 12 and a
seizure (smokers may have CoHb levels of up to 10% with no
symptoms)
b. A normal lactate would rule out cyanide poisoning completely.
【✔】
c. Treatment for suspected cyanide toxicity should not be delayed
until laboratory blood cyanide levels are available.【✔】
d. Sodium nitroprusside may be appropriate treatment for this
man.【✘】➜ sodium thiosulphate, hydroxycobalamin and sodium
nitrite are used for Rx, Sodium nitroprusside is a cause of cyanide
toxicity.
246b
Dr.Sherif Badrawy

The following are accepted indications for
administering
sedative medication to a mechanically
ventilated intensive
care patient:
247a
Dr.Sherif Badrawy

a. To manage alcohol withdrawal.【✔】
b. To reduce oxygen consumption.【✔】
c. To reduce the long-term incidence of
psychological sequalae.【✘】
d. To provide amnesia covering periods of
neuromuscular blockade.【✔】
247b
Dr.Sherif Badrawy

A 67-year-old lady with chronic bronchitis
and emphysema is ventilated on the ICU
and has the following capnograph trace:
248a
Dr.Sherif Badrawy

a.The slope of phase IIissteeper than normal.【✘】➜ Phase IIIisthe plateau phase, which
in thiscase hasa steeper slope than normal
b.The abnormalwaveform isexplained by late emptying of alveoliwith higher V/Q ratios.【✘】➜ low V/Q ratio empty later in expiration than those that
are wellventilated.
c.The end-tidalCO2 reflectsalveoliwith the largest time constants.【✔】
d.Endobronchialintubation doesnot produce thispicture.【✔】
248b
Dr.Sherif Badrawy

The following are true of thrombolytic
therapy for pulmonary embolism:
249a
Dr.Sherif Badrawy

a. There is a 15% risk of clinically significant
bleeding.【✘】➜ 3% with TPA.
b. The S1Q3T3 pattern on the ECG is an
indication for thrombolysis.【✘】
c. Right ventricular function is often improved.
【✔】
d. Systemic hypotension is an absolute
contraindication to
thrombolysis.【✘】
249b
Dr.Sherif Badrawy

Regarding delirium in the intensive care
patient:
250a
Dr.Sherif Badrawy

a. It is an independent predictor of ↑mortality.【✔】
b. It is experienced by 30-40% of MV patients.【✘】➜
80% of MV patients.
c. The Confusion Assessment Method for ICU patients
(CAM-ICU) delirium assessment tool can be used in
patients unable to communicate verbally.【✔】
d. An acute change in mental state is sufficient to make
a Dx of ICU delirium using the CAM-ICU system.【✘】
250b
Dr.Sherif Badrawy

Types of Delirium in the ICU
251a
Dr.Sherif Badrawy

recognised in agitated, combative patients
or hypoactive Delirium ➜ > common,
under-recognised and possibly associated
with worse outcomes.
251b
Dr.Sherif Badrawy

Definition of Delirium in the ICU
252a
Dr.Sherif Badrawy

acute change or fluctuation in the course
of a patient's mental status, plus
inattention and either disorganised
thinking or an altered level of
consciousness
252b
Dr.Sherif Badrawy

Concerning Doppler ultrasound:
253a
Dr.Sherif Badrawy

a. The Doppler effect states that observed frequency ↑as
the source moves closer to the observer.【✔】
b. In colour flow Doppler, a red colour indicates arterial
blood flow.【✘】➜ represent direction of a given jet
c. For blood flow measurement the probe should ideally be
perpendicular to the direction of flow.【✘】➜ should be as
near parallel to the direction of blood flow as possible
d. Blood flow velocity is proportional to the cosine of q
(theta) according to the Doppler equation.【✔】
253b
Dr.Sherif Badrawy

44-y, F, acute pancreatitis, ALI, VAP after 8
days, antibiotics started.
254a
Dr.Sherif Badrawy

a. Dx should be confirmed microbiologically prior to
antibiotic treatment.【✘】
b. Tracheobronchial aspiration has a high negative
predictive value.【✔】➜ provided empirical antibiotics
have not been started
c. Quantitative cultures (e.g. protected specimen
brushings) have a high specificity for VAP.【✘】➜ not very
specific
d. Levofloxacin is a suitable antibiotic if empirical
treatment is warranted.【✘】
254b
Dr.Sherif Badrawy

Late onset VAP ?
255a
Dr.Sherif Badrawy

onset at least 5 days after hospital
admission.
255b
Dr.Sherif Badrawy

Regarding the measurement of lung
compliance in
MV patients:
256a
Dr.Sherif Badrawy

a. Static compliance calculation requires
knowledge of plateau pressure and PEEP.【✔】
b. Dynamic compliance calculation requires
knowledge of plateau pressure and PEEP.【✘】
c. Static compliance is greater than dynamic
compliance for the same patient.【✔】
d. Bronchospasm has more effect on dynamic
compliance than static.【✔】
256b
Dr.Sherif Badrawy

In a patient with known WPW syndrome,
who presents with fast AF, appropriate
pharmacotherapy includes:
257a
Dr.Sherif Badrawy

a. Procainamide.【✔】
b. Digoxin.【✘】
c. Verapamil.【✘】
d. Flecainide.【✔】
257b
Dr.Sherif Badrawy

72-y, F, recent onset fast AF, CCU
admission, severe abdominal pain and
looks generally unwell, abdomen is soft
and minimally tender, no guarding, ABG
profound
metabolic acidaemia. Appropriate initial
steps include :
258a
Dr.Sherif Badrawy

a. Obtaining a surgical opinion as this lady may need an
urgent laparotomy.【✔】➜ ?acute mesenteric ischaemia
b. Give intravenous morphine and observe overnight while
fluid resuscitating.【✘】
c. Urgent abdominal ultrasound.【✘】➜ Mesenteric
angiography is the investigation of choice,but should not
delay laparotomy if clinical suspicion is high, since
operative delay ↑mortality.
d. Thrombolysis.【✘】
258b
Dr.Sherif Badrawy

The following physiological observations
are commonly
seen in patients with an acute
exacerbation of COPD:
259a
Dr.Sherif Badrawy

a. Reduced respiratory compliance.【✔】
b. Increased pulmonary vascular
resistance.【✔】
c. Increased resistive load.【✔】
d. Increased mechanical efficiency of the
diaphragm.【✘】
259b
Dr.Sherif Badrawy

23-y, F, sudden SOB, Hx of asthma on
salbutamol
inhaler, unable to talk in sentences, HR
120bpm (sinus tachycardia).SaO2 100% on
NRBM 15L/min O2, flow-volume loop
260a
Dr.Sherif Badrawy

a. The inspiratory limb of the flow-volume loop is normal.【✘】
b. The flow-volume loop is consistent with bronchospasm.【✘】
c. Steroids and bronchodilators should be administered.【✘】
d. Awake fibreoptic intubation is indicated.【✘】
260b
Dr.Sherif Badrawy

Significance of this flow-volume loop
261a
Dr.Sherif Badrawy

✵ vocalcord dysfunction (VCD)
inspiratory limb isflattened but the expiratory limb isnormalwith no 'dip' suggestive of bronchospasm,
✵ commonly mistaken for acute severe asthma, leading to unnecessary
intubation and ventilation,
✵ MC in young adult femalesand hasan association with psychiatricdisease.
✵ Dx isconfirmed by indirect laryngoscopy ➜ complete adduction of the anterio 2/3 of
VCsduring inspiration with a 'glotticchink' posteriorly.
✵ Rx isSpeech therapy and/or psychotherapy
261b
Dr.Sherif Badrawy

Regarding the use of synchronised DC
cardioversion for
new onset atrial fibrillation in ICU surgical
patients:
262a
Dr.Sherif Badrawy

a. Sinus rhythm is initially restored in over 95% of
cases.【✘】➜ just 35%
b. Successful DC cardioversion of new onset AF is less
likely in medical than surgical patients.【✘】
c. Most successfully cardioverted patients maintain
sinus rhythm in the first 48 hours.【✘】
d. Successful cardioversion is unlikely if the first two
shocks are unsuccessful.【✔】
262b
Dr.Sherif Badrawy

The following favour a strategy of primary
angioplasty over thrombolysis in patients
with an acute STEMI:
263a
Dr.Sherif Badrawy

a. Cardiogenic shock.【✔】
b. Late presentation (onset of symptoms
>3h ago).【✔】
c. 'Door-to-balloon time' likely to exceed 90
minutes.【✘】
d. Diagnosis of STEMI in doubt.【✔】
263b
Dr.Sherif Badrawy

44-y,M, dilated cardiomyopathy,
cardiogenic shock while on the waiting list
for a heart transplant, refractory to
maximal medical Rx, left ventricular assist
device
(LVAD) is considered.
264a
Dr.Sherif Badrawy

a. Blood flow produced by an LVAD may be
pulsatile or non-pulsatile.【✔】
b. The LVAD takes blood from the RV or vena
cava and pumps it into the aorta.【✘】
c. An LVAD will increase COP much > IABCP.
【✔】
d. This patient could be maintained on a LVAD
for several months.【✔】typically used as a
bridge to transplantation in those with a HF
264b
Dr.Sherif Badrawy

58-y ,M, dense left hemiparesis, suddenly 2
hours
ago. BP is 175/105mmHg, CT brain no
evidence of haemorrhage. Thrombolysis is
considered.
265a
Dr.Sherif Badrawy

a. Thrombolysis reduces death and dependency
rates in carefully selected stroke patients.【✔】
b. Thrombolysis must be given within 12 hours
of presentation for the greatest benefit.【✘】
c. Haemorrhagic transformation is not
significantly greater with thrombolysis than
placebo.【✘】
d. There is no CI to thrombolytic therapy from
the information given.【✔】
265b
Dr.Sherif Badrawy

28-y, acute confusion, headache for the
past 2 days, low grade fever, disorientated
and has a mild left-sided hemiparesis, no
Hx of recent foreign travel, examination is
unremarkable except for the presence of a
cold sore
266a
Dr.Sherif Badrawy

a. Lumbar puncture is the initial investigation of
choice.【✘】Altered sensorium and focal neurological
deficit argue against Dx of viral meningitis.
b. Viral meningitis is the most likely diagnosis.【✘】
c. Empirical acyclovir is mandatory.【✔】
d. CT brain scan is not a useful investigation in this
case.【✘】➜ useful, rules out other pathologies
266b
Dr.Sherif Badrawy

mortality of Untreated Herpes simplex
encephalitis
267a
Dr.Sherif Badrawy

✵ 70%, mandating immediate intravenous
acyclovir on suspicion of the diagnosis.
✵ Even with treatment, mortality is 20-30%
267b
Dr.Sherif Badrawy

Regarding ARF on the ICU:
268a
Dr.Sherif Badrawy

a. Hypovolaemia is the commonest ppt factor in pts
with established ARF.【✘】➜ sepsis was the
commonest factor
b. Mortality is not significantly different between ICU
patients with and without ARF.【✘】
c. The prevalence of ARF requiring RRT in ICU pts is
about 45%.【✘】
d. The vast majority (86%) of ARF survivors are dialysis-
independent on hospital discharge.【✔】
268b
Dr.Sherif Badrawy

Regarding stress ulceration in ICU patients:
269a
Dr.Sherif Badrawy

a. Stress-related mucosal damage usually takes 3-5
days to develop.【✘】➜ evident after 24 hours.
b. The incidence of clinically important gastrointestinal
bleeding in ICU patients is 1.5%.【✔】
c. Bleeding from stress ulcers is associated with
significantly increased ICU mortality.【✔】
d. Acid suppression is an effective intervention.【✔】
269b
Dr.Sherif Badrawy

35-y, M, RTA, emergency laparotomy, on
MV in ICU, jaundiced with a bilirubin of
62mmol/L, The following would support a
diagnosis of 'ICU jaundice':
270a
Dr.Sherif Badrawy

a. Dilatation of the biliary tree on ultrasound.
【✘】
b. Grade III or IV encephalopathy.【✘】
c. An AST level of 1500U/L.【✘】➜ 'ICU jaundice'
= ↑bilirubin +normal liver enzymes, ↑AST level
would
raise the possibility of ischaemic hepatitis.
d. Intrahepatic cholestasis on liver histology.
【✔】
270b
Dr.Sherif Badrawy

The following are common findings in a
patient with
profound myxoedema:
271a
Dr.Sherif Badrawy

a. Coma.【✘】➜ few patients are comatose. Altered
mentation, depression and slowing of thought are
common
b. Hyponatraemia.【✔】➜
c. Elevated creatine kinase.【✔】➜ dt thyroid myopathy
d. Low/undetectable thyrotrophin.【✘】➜ Thyrotrophin
(TSH) is usually very high to drive thyroid hormone
production, except in rare cases of pituitary
hypothyroidism
271b
Dr.Sherif Badrawy

Regarding the detection of impaired renal
function in
critically ill patients:
272a
Dr.Sherif Badrawy

a. The Cockroft-Gault formula requires a urinary
creatinine value.【✘】
b. A normal serum creatinine measurement indicates
normal renal function in critically ill patients.【✘】➜
muscle mass is reduced in this population, even with poor
renal clearance, creatinine is not elevated above the
normal range
c. Measurement of the GFR requires a 24-hour urine
collection.【✘】
d. Calculated GFR correlates well with measured GFR.
【✘】
272b
Dr.Sherif Badrawy

Regarding tight glycaemic control in
critically ill patients:
273a
Dr.Sherif Badrawy

a. Maintenance of normoglycaemia is of no benefit in
medical ICU patients.【✘】➜ there's mortality benefit
b. Beneficial effects of tight glucose control in surgical
patients relate to the dose of insulin used rather than the
glucose levels per se.【✘】
c. Patients with a longer ICU stay (>5 days) benefit the
most.【✔】
d. Hypoglycaemic episodes are more likely with enteral
than with parenteral feeding.【✔】
273b
Dr.Sherif Badrawy

The following are elements of the 6-hour
sepsis resuscitation care bundle as
advocated by the Surviving Sepsis
Campaign group: [two 'sepsis care
bundles' to be implemented within 6 and
24 hours of the recognition of a septic
patient]
274a
Dr.Sherif Badrawy

a. Serum lactate measurement.【✔】
b. Administration of recombinant human
activated protein C.【✘】
c. Achievement of a central venous oxygen
saturation of >70%.【✔】
d. Administration of broad spectrum
antibiotics within the first 3 hours.【✘】➜
within 1 hour
274b
Dr.Sherif Badrawy

46-y, F, suspected CAP, temperature 38.3°C, BP
85/40, RR 24, HR 105, CXR consolidation in the
left lower zone, green sputum, Initial blood
cultures are negative, ABG (on 60% oxygen via
high-flow mask) pH 7.32, PaCO2 3.8kPa
(28.9mmHg), PaO2 8.9kPa (67.6mmHg), base
excess -7.3mmol/L and lactate 3.4mmol/L
(30mg/dL). A fluid challenge is given.
275a
Dr.Sherif Badrawy

a. The SIRS is present.【✔】
b. Sepsis cannot be diagnosed without a
positive blood culture.【✘】
c. Severe sepsis is present.【✔】
d. Septic shock is present.【✘】
275b
Dr.Sherif Badrawy

Regarding the use of HFOV in adult
patients with the ARDS compared with
conventional MV:
276a
Dr.Sherif Badrawy

a. Mean airway pressure is usually higher.【✔】➜ Peak
Aw P is reduced compared with conventional
ventilation, but end-expiratory lung volume is higher
and mean Aw P is usually higher.
b. Early improvement in oxygenation is typical.【✔】➜
not sustained beyond the first 24 h
c. Mortality is significantly reduced in surgical patients.
【✘】
d. Less arterial CO2 is eliminated.【✔】
276b
Dr.Sherif Badrawy

Regarding amniotic fluid embolism:
277a
Dr.Sherif Badrawy

a. Hypoxia is most commonly due to bronchospasm.
【✘】➜ dt V/Q mismatch, pulmonary oedema dt LV
dysfunction , or bronchospasm
b. The diagnosis should be questioned in the absence
of hypotension.【✔】
c. DIC occurs in 5-10% of patients.【✘】➜ occurs in
83% of patients
d. The majority of survivors have a permanent
neurological deficit.【✔】
277b
Dr.Sherif Badrawy

Regarding the pharmacology of NSAIDs :
278a
Dr.Sherif Badrawy

a. Bronchospasm may be ppt by ↑bradykinin
production.【✘】
b. ↓thromboxane A2 synthesis ↓platelet aggregation.
【✔】
c. NSAIDs are excreted unchanged in the urine.【✘】
d. NSAIDs have ↓protein binding and a ↑volume of
distribution.【✘】➜ highly protein bound and may
displace warfarin from its albumin binding
site,↓volume of distribution.
278b
Dr.Sherif Badrawy

Regarding amiodarone toxicity:
279a
Dr.Sherif Badrawy

a. Corneal microdeposits are rare.【✘】➜ MC
complication of amiodarone, occurring in over 90% of
patients
b. Pulmonary toxicity does not occur with short-term
therapy.【✘】➜ may occur acutely in the ICU patient,
immunologically-mediated hypersensitivity, > common in
pts with pre-existing lung disease & in Pts undergoing
cardiac surgery
c. Elevation of hepatic transaminases is common.【✔】
d. Neurotoxicity is a dose-related problem.【✔】
279b
Dr.Sherif Badrawy

Regarding the use of lithium dilution to
measure cardiac
output in the ICU:
280a
Dr.Sherif Badrawy

a. It cannot be used in patients taking lithium
carbonate.【✔】➜ alters the background
concentration in the
plasma and causes an overestimation of COP.
b. It cannot be used in patients who have
previously received atracurium.【✘】
c. Anaemia affects the measurement.【✔】
d. Central venous access is not required.
【✔】➜ central or peripheral line
280b
Dr.Sherif Badrawy

A patient on the ICU develops ARF ➜
haemofiltration. The following measures
will increase the efficiency of solute
clearance:
281a
Dr.Sherif Badrawy

a. Increasing blood flow rate.【✔】
b. Pre-dilution instead of post-dilution.
【✘】
c. Increasing the surface area of the filter.
【✔】
d. Using arteriovenous rather than
venovenous renal replacement.【✘】
281b
Dr.Sherif Badrawy

The following factors are associated with a
greater
likelihood of a critical incident occurring
during a patient's
care on the ICU:
282a
Dr.Sherif Badrawy

a. High severity of illness.【✔】
b. Long stay.【✔】
c. Higher level of care.【✔】
d. Renal replacement therapy.【✔】
282b
Dr.Sherif Badrawy

35-y, F, insulin overdose, ICU, MV, no
sedation for the last month but shows no
interaction or apparent awareness despite
periods of eye opening, A CT brain scan
and metabolic screening show no
reversible features. A diagnosis of
persistent vegetative state is
considered.rule out this diagnosis by:
283a
Dr.Sherif Badrawy

a. Intact sleep-wake cycle.【✘】
b. Bowel and bladder incontinence.【✘】
c. Spontaneous movements.【✘】
d. Social smiling.【✔】
283b
Dr.Sherif Badrawy

Indications of steroids in Rx
hypercalcaemia ?
284a
Dr.Sherif Badrawy

Steroids are ineffective in hypercalcaemia
of malignancy but are effective in
granulomatous causes such as
sarcoidosis.
284b
Dr.Sherif Badrawy

severe pre-eclampsia, In the ICU 1 day post
partum with confusion, weakness, flushing
and bradyarrhythmia , ECG shows
prolongation of the PR and QT intervals.
285a
Dr.Sherif Badrawy

Hypermagnesaemia
flaccid paralysis reflect a very high serum
magnesium level of >5mmol/L
285b
Dr.Sherif Badrawy

MCC of Hypermagnesaemia
286a
Dr.Sherif Badrawy

excessive iatrogenic administration
286b
Dr.Sherif Badrawy

consequences of therapeutic (32-34°C)
hypothermia
287a
Dr.Sherif Badrawy

✽ A 7% fall in cerebral metabolic rate for each
1°C fall in temperature, decreasing intracranial
blood volume and improving CPP.
✽ ↓reabsorption of solutes by the kidney. 'cold
diuresis'
✽ Hyperglycaemia dt ↓insulin secretion from
the pancreas
✽ ↑incidence of VAP.
✽ Prolonged PT.
287b
Dr.Sherif Badrawy

In trauma pt, The primary survey should
include the following points EXCEPT:
a. Use of airway adjuncts if indicated.
b. Control of external haemorrhage.
c. Cervical spine assessment.
d. Pupillary light reflex determination.
e. Percussion of the chest.
288a
Dr.Sherif Badrawy

c. Cervical spine assessment.
Although the cervical spine should be
maintained
in neutral alignment throughout the
primary survey, a cervical spine fracture is
not immediately life-threatening and
should be assessed radiographically and
clinically as part of the secondary survey.
288b
Dr.Sherif Badrawy

In penetrating abdominal injury, Peritonitis
in a HD stable patient is an indication for
laparotomy ?
289a
Dr.Sherif Badrawy

Yes, Peritonitis may reflect leakage of
digestive tract contents from a hollow
viscus and is an indication for laparotomy.
289b
Dr.Sherif Badrawy

The most commonly injured organ in
penetrating stab wounds is ?
290a
Dr.Sherif Badrawy

the liver (40%),
small bowel (30%), diaphragm (20%) and
colon (15%).
290b
Dr.Sherif Badrawy

A negative FAST scan has a high negative
predictive value for injury requiring
laparotomy ?
291a
Dr.Sherif Badrawy

No, negative FAST scan has a negative
predictive value for laparotomy of only
60%; it may miss free intraperitoneal
blood, and will not reliably identify injuries
to structures such as the diaphragm and
bowel.
291b
Dr.Sherif Badrawy

features of the abdominal compartment
syndrome?
[a combination of intra-abdominal
hypertension and end-organ dysfunction,
with reversal of this organ dysfunction on
relief of the pressure].
292a
Dr.Sherif Badrawy

✯ occurs with pressures > 20mmHg
✯ ↑pulmonary vascular resistance dt hypoxic VC
& ↑intrathoracic pressures
✯ ↓pulmonary artery occlusion pressure.
✯ ↓COP dt compression of venous return from
the IVC and hepatic portal vein.
✯ Oliguria.
✯ ↑intracranial pressure.
292b
Dr.Sherif Badrawy

The presence of mildly raised CSF protein,
normal CSF glucose and oligoclonal bands,
pseudobulbar palsy (including dysarthria)
and internuclear ophthalmoplegia
manifesting as occulomotor signs. is
strongly supportive of a diagnosis of ?
293a
Dr.Sherif Badrawy

multiple sclerosis (MS).
293b
Dr.Sherif Badrawy

Oligoclonal bands are ?
294a
Dr.Sherif Badrawy

distinct electrophoretic patterns dt ↑IgG
by plasma cells and are present in the CSF
of 85% of patients with multiple sclerosis.
Also present in SLE, neurosarcoidosis, CNS
lymphoma and subacute sclerosing
panencephalitis
294b
Dr.Sherif Badrawy

Srquence of drugs given in status
epilepticus ?
295a
Dr.Sherif Badrawy

✯ prehospital care➜ rectal diazepam or
buccal midazolam ➜ hospital care➜
lorazepam ➜ repeated after 10-20 minutes
➜ phenytoin or phosphenytoin ➜
Phenobarbitone ➜ refractory cases ➜
induction of general anaesthesia ➜
propofol, midazolam or thiopentone.
295b
Dr.Sherif Badrawy

management of status epilepticus in adults
?
296a
Dr.Sherif Badrawy

✯ Buccal midazolam 10mg is an alternative to rectal
diazepam.
✯ Phenytoin should be given at a rate < 50mg/minute can
ppt arrhythmias if given faster.(or phosphenytoin at a dose
of 15-20mg phenytoin equivalents/kg).
✯ Lorazepam is preferred to diazepam if intravenous
access is present.
✯ Ideally serum levels should be measured to guide
thiopentone infusion.
✯ 'Thiopentone coma' should be titrated to burst
suppression on the EEG.
296b
Dr.Sherif Badrawy

toxic megacolon CP ?
297a
Dr.Sherif Badrawy

✯ Enteral loss of potassium and fluid ➜
volume depletion hypokalaemia and a
metabolic alkalosis which carries a poor
prognosis
✯ Anaemia dt blood loss per rectum with a
lowered haematocrit
✯ Leukocytosis with left shift ➜ as a
component of the inflammatory response
297b
Dr.Sherif Badrawy

ICP monitoring in patients with traumatic
brain injury
298a
Dr.Sherif Badrawy

✯ Outcome is improved in patients who respond to ICP-
lowering therapies
✯ Haematoma requiring surgical
evacuation occurs in 0.5% of cases of ICP measurement,
most commonly with ventriculostomy catheter insertion
✯ A normal CT brain scan is associated with a reduced risk
of raised ICP in comatose TBI pts, but is not highly
sensitive; the incidence was 13% in one series (vs.~60%
with an abnormal CT).
298b
Dr.Sherif Badrawy

Regarding unstable fractures of the pelvis
299a
Dr.Sherif Badrawy

✯ The commonest cause of serious pelvic injury is MVC,
followed by falls from height.
✯ Mortality 30%-45%, bleeding being the major cause.
✯ Serious pelvic injury is correlated with intra-abdominal
injury which should be actively excluded.
✯ Arterial embolisation may be indicated in selected
cases; although most pelvic bleeding is venous, arterial
embolisation may stop arterial bleeding, while fixation of
the pelvic ring allows venous bleeding to tamponade itself
299b
Dr.Sherif Badrawy

minute volume in the anaesthetic
management of a patient with major burns
300a
Dr.Sherif Badrawy

✯ A high ventilator minute volume will be
required dt ↑CO2 production will be a
feature of the hypermetabolic phase, and
therefore minute volume will need to be
↑if normocapnia is to be maintained.
300b
Dr.Sherif Badrawy

Fick principle
in the calculation of cardiac output
formula
301a
Dr.Sherif Badrawy

✯ Cardiac output (Q) = VO2/Arterial O2
content - mixed venous O2 content
✯ CaO2 [Arterial O2 content] =
1.39 x [Hb] x (SaO2/100) + 0.023 x PaO2
(Hb in g/dL, PaO2 in kPa)
301b
Dr.Sherif Badrawy

42-y, F, admitted to the ICU generally
unwell 1 week following abdominal
surgery.oliguric, hypotensive (BP
80/35mmHg) and tachycardic (HR
130bpm).oesophageal Doppler probe, flow
time (corrected) 380ms, peak velocity
110cm/s, stroke volume 90ml, would you
give IV fluid ?
302a
Dr.Sherif Badrawy

✯ This patient is in shock, oesophageal Doppler shows a raised
flow time corrected (FTc), reflecting low SVR.
✯ Typical value for FTc is 330-360 ms
✯ A supra-normal FTc (>340ms) does not necessarily mean the
patient is adequately volume loaded
✯ A fluid challenge should be given and the stroke volume response
assessed
✯ Peak velocity (reflecting contractility) is at the upper end of
normal for this age (there is a linear decline from ≅120cm/s at 20
years old to ≅60cm/s at 90 years old
✯ In massive pulmonary embolism COP is↓dt impaired LV filling,
and FTc would be low dt compensatory systemic VC to maintain BP.
302b
Dr.Sherif Badrawy

Regarding electrical temperature
measurement
303a
Dr.Sherif Badrawy

✯ The resistance of a platinum
thermometer increases linearly with
increasing temperature.
✯ A thermocouple can measure
temperatures up to 1600°C.
✯ A radiation thermometer utilises
Planck's law.
✯ A thermistor is a type of semiconductor
303b
Dr.Sherif Badrawy

78-y,F, MV on the ICU with diffuse brain injury following a
fall, significant renal impairment, sick sinus syndrome for
which he is awaiting implantation of a permanent
pacemaker, proven allergy to egg protein. Which of the
following sedative agents would be most suitable
a. Midazolam.
b. Propofol.
c. Etomidate.
d. Clonidine.
e. Ketamine.
304a
Dr.Sherif Badrawy

✯ Midazolam ➜ Not suitable, active metabolite accumulates in renal
impairment, especially in the elderly.
✯ Etomidate ➜ Not suitable, cause adrenal suppression and should not be
used as maintenance sedation in the ICU.
✯ Clonidine ➜ Not suitable,α-2 agonist with sedative and analgesic-sparing
properties. an attractive agent dt lack of respiratory depression, it can cause
significant hypotension and bradycardia, a poor choice given this patient's
cardiac history.
✯ Ketamine ➜ Not suitable,↑ICP, CI in head injury Rx.
✯ Propofol ➜ suitable, Pts with anaphylactic egg allergy react to one of three
egg proteins (ovoalbumin, ovomucoid and conalbumin) whereas the propofol
lipid vehicle contains purified egg phosphatide (lecithin) which is not known to
be allergenic.
304b
Dr.Sherif Badrawy

28-y, F, elective femoral hernia repair is
anaesthetised with propofol, atracurium
and Sevoflurane, ETT, 30 minutes into the
procedure, progressively more difficult to
ventilate. Her BP falls to 60/40mmHg, her
HR is 150bpm and widespread
bronchospasm is heard on auscultation,
Dx ?
305a
Dr.Sherif Badrawy

✯ Latex allergy.
✯ an IgE mediated anaphylaxis, Symptoms, usually occur some
time (20-30 mins) following exposure, unlike drug anaphylaxis
which occurs immediately following intravenous injections. It
is more common in those routinely exposed to latex (e.g.
healthcare workers) and those with a variety of food allergies
including avocado, chestnut and kiwi.
✯ Patients with spina bifida and cerebral palsy probably dt
repeated urinary catheterisation.
✯ Rx same as that for drug anaphylaxis + all latex products
should be removed.
305b
Dr.Sherif Badrawy

Rx of ICU delirium
306a
Dr.Sherif Badrawy

✯ Pharmacological IV haloperidol 0.5-10mg.
✯ Benzodiazepines are not considered first-line therapy
unless to treat a benzodiazepine or alcohol withdrawal
delirium
✯ Non-pharmacological maintenance of a normal sleep-
wake cycle as far as possible (lights off at night),
orientation of the patient (clock on the wall), ensuring
spectacles and hearing aids are available if required, and
eliminating organic drivers of delirium such as pain and
hypoxia.
306b
Dr.Sherif Badrawy

Lundberg waves for ICP monitoring
307a
Dr.Sherif Badrawy

✯ three types of abnormal ICP waves
found in cases of ↑CP
✯ occur over a period of time and should
not be confused with the three peaks of
the normal intracranial pressure waveform
seen in normal individuals and related to
the arterial waveform.
307b
Dr.Sherif Badrawy

the three peaks of the normal intracranial
pressure waveform
308a
Dr.Sherif Badrawy

308b
Dr.Sherif Badrawy

P1 WAVE of the normal intracranial
pressure waveform
309a
Dr.Sherif Badrawy

309b
Dr.Sherif Badrawy

P2 & P3 WAVES of the normal intracranial
pressure waveform
310a
Dr.Sherif Badrawy

310b
Dr.Sherif Badrawy

Lundberg waves for ICP monitoring ➜ Type
A waves
311a
Dr.Sherif Badrawy

✯ Type A (plateau waves) are largest in
amplitude (50-100mmHg above baseline
ICP) and duration (5-20 minutes).
✯ cerebral vasodilatation in response to
critically low cerebral perfusion ➜ This
dilatation ➜ ↑ICP, compromising cerebral
perfusion.
311b
Dr.Sherif Badrawy

B waves
312a
Dr.Sherif Badrawy

✯ an amplitude of up to 50mmHg, and a
duration of <2 minutes.
✯ reflect reduced intracranial complianc
312b
Dr.Sherif Badrawy

C waves
313a
Dr.Sherif Badrawy

✯ a duration of approximately 5 minutes
and an amplitude of <20mmHg.
✯ can be pathological can also be seen in
normal individuals and are of less clinical
significance than type A and B waves
313b
Dr.Sherif Badrawy

The normal D-dimer excludes a diagnosis
of pulmonary embolism, True ?
314a
Dr.Sherif Badrawy

No, A positive D-dimer result is 96-98%
sensitive, meaning that false negatives are
possible though rare, and further
investigation should be pursued if clinical
suspicion is high.
314b
Dr.Sherif Badrawy

Etiology of Malignant hyperthermia
315a
Dr.Sherif Badrawy

✯ a rare disorder of calcium homeostasis
in skeletal muscle caused by a defect in the
ryanodine receptor.
✯ Suxamethonium and volatile anaesthetic
➜ trigger ↑↑ release of calcium from
sarcoplasmic reticulum ➜ generalised
excessive muscle contraction in
susceptible individuals.
315b
Dr.Sherif Badrawy

physiology of proning
316a
Dr.Sherif Badrawy

✯ Perfusion is thought to remain largely dorsal in the
prone position (i.e. not greatly affected by gravity).
✯ Ventilation is more homogenously distributed.
✯ A reduction in physiological shunt occurs dt
improvement in V/Q matching
✯ Compression of dorsal lung regions by the heart is
reduced.
✯ Anterior chest wall compliance is decreased.
316b
Dr.Sherif Badrawy

Precautions in Pts with severe aortic
stenosis
317a
Dr.Sherif Badrawy

✯ LV is hypertrophied and poorly compliant, and will
require a high preload and high filling pressures.
✯ Swift cardioversion of any atrial fibrillation that develops,as
The 'atrial kick' is of greater importance to help fill the stiff left
ventricle
✯ Intra-aortic balloon counterpulsation, inflates in diastole
improving coronary perfusion, it's CI in severe AR since it
increases the regurgitant fraction.
✯ Use of vasopressors to elevate systemic vascular resistance
✯ Dieuretics are used with caution since a drop in preload can
severely compromise
317b
Dr.Sherif Badrawy

CT brain in Cerebral venous sinus
thrombosis
318a
Dr.Sherif Badrawy

'empty delta sign' a triangular area of enhancement is seen on multiple
contiguous transverse CT images in the region of the superior sagittal sinus.
However, a CT scan is entirely normal in 10-20% of cases.
318b
Dr.Sherif Badrawy

CP of Cerebral venous sinus thrombosis
319a
Dr.Sherif Badrawy

✯ Nine in ten people with sinus thrombosis have a
headache; this tends to worsen over the period of several
days, but may also develop suddenly (thunderclap
headache), may be the only symptom of cerebral venous
sinus thrombosis
✯ symptoms of stroke: inability to move one or more
limbs, weakness on one side of the face or difficulty
speaking. This does not necessarily affect one side of the
body as in the more common "arterial" stroke.
✯ 40% have seizures, affecting only one part of the body
and unilateral, occasionally generalised
319b
Dr.Sherif Badrawy

Type of Pt of Cerebral venous sinus
thrombosis
320a
Dr.Sherif Badrawy

The condition is more likely in young
women, especially in the puerperium, and
is also associated with any
hypercoagulable state Systemic or
localised
infections may also precipitate the
condition.
320b
Dr.Sherif Badrawy

Rx of Cerebral venous sinus thrombosis
321a
Dr.Sherif Badrawy

Therapeutic anticoagulation is indicated
even in the presence of venous infarction
321b
Dr.Sherif Badrawy

CP of critical illness polyneuromyopathy ?
322a
Dr.Sherif Badrawy

✯ Ventilation for >7 days.
✯ A flaccid quadriparesis is a common
presentation
✯ Elevated serum creatinine kinase.
✯ Four twitches of equal height with train-of-
four nerve stimulation, If fade or a reduced
count is present this should raise suspicion of
residual neuromuscular blockade
322b
Dr.Sherif Badrawy

antimicrobial treatment in a catheterised
ICU patient suspected UTI
323a
Dr.Sherif Badrawy

✯ Candida in urine culture ➜ NO Rx unless isolated from multiple
sites,consider Rx if high levels are present (> (10)4cfu/ml), signs of infection are
present, and no other source of infection is apparent.
✯ Pyuria [>10 WBCs/ml urine]. alone not mandate antibiotic Rx, search for
urinary pathogens. Non-infectious causes of pyuria as recent antibiotic Rx,
systemic inflammatory conditions, nephrolithiasis and drugs [CST].
✯ Urine culture >(10)3 CFU/ml bacteria ➜ antibiotic Rx only in the presence of
clinical indicators of infection and may represent simple colonisation if such
indicators are absent.
✯ Positive urine dipstick for leukocyte esterase and/or nitrate ➜ further Ix, it is
not sufficiently specific to justify antibiotic Rx in the absence of supporting
evidence of UTI.
323b
Dr.Sherif Badrawy

How to r/o Budd chiari syndrome ?
324a
Dr.Sherif Badrawy

Doppler ultrasonography.
but the gold standard is hepatic
venography.
324b
Dr.Sherif Badrawy

SAAG
325a
Dr.Sherif Badrawy

325b
Dr.Sherif Badrawy

cocaine toxicity Rx
326a
Dr.Sherif Badrawy

✯ a benzodiazepine ameliorates both the
cerebral and CVS
manifestations
✯ alpha-blockade is preferable to beta-
blockade to avoid
unopposed alpha stimulation ➜ ↟BP.
326b
Dr.Sherif Badrawy

Gamma-hydroxybutyrate [derived from
GABA]
327a
Dr.Sherif Badrawy

✯ popular recreational drug
✯ also a muscle-bulking agent used by
bodybuilders
✯ Toxicity ➜ euphoria in small doses ➜
hypothermia, bradycardia, ↓GCS and
emesis.
✯ effects of overdose lasts only for several
hours
327b
Dr.Sherif Badrawy

Ecstasy poisoning
328a
Dr.Sherif Badrawy

✯ tachycardia and hyperpyrexia NOT
bradycardia & hypothermia.
328b
Dr.Sherif Badrawy

Ketamine poisoning as a recreational drug
329a
Dr.Sherif Badrawy

✯ loss of awareness with preservation of
airway and
cardiovascular reflexes
✯ hypertension, tachycardia in large
doses.
329b
Dr.Sherif Badrawy

parameters are directly set by the
operator of HFOV
330a
Dr.Sherif Badrawy

✯ Frequency.
✯ I:E ratio.
✯ Driving pressure.
✯ Mean airway pressure.
✯ Tidal volume is provided by oscillations
of pressure around the mean value (delta
P). directly related to the driving pressure,
and inversely related to the frequency
330b
Dr.Sherif Badrawy

HELLP Syndrome
331a
Dr.Sherif Badrawy

✯ Schistocytes are seen on the blood film.
✯ LDH is elevated
✯ Delivery of the foetus is the mainstay of treatment.
✯ Hypoglycaemia and acute liver failure are
uncommon.
✯ Not always in association with preeclampsia. 20% of
cases of HELLP have no antecedent history of HTN or
proteinuria.
331b
Dr.Sherif Badrawy

Aspirin effect on cyclo-oxygenase
332a
Dr.Sherif Badrawy

✯ Aspirin has greater effect on platelet cyclo-
oxygenase than endothelial cyclo-oxygenase in low
doses ➜ ↓thromboxane A2 production and platelet
aggregation.
✯ Aspirin irreversibly inhibits platelet cyclo-oxygenase.
✯ Even in high doses aspirin is a less effective analgesic
agent than most NSAIDS.
✯ All NSAIDs can displace warfarin from its albumin
binding site, promoting anticoagulation
332b
Dr.Sherif Badrawy

Regarding the hepatic clearance of drugs
333a
Dr.Sherif Badrawy

✯ Drugs with a high extraction ratio exhibit
flow-dependent metabolism.
✯ Enzyme induction significantly increases
clearance of drugs with a low extraction
ratio.
✯ Phenytoin has a low extraction ratio.
✯ A drug with a high extraction ratio will
have low bioavailability.
333b
Dr.Sherif Badrawy

sickle cell disease, How to prevent sickling
crises
334a
Dr.Sherif Badrawy

✯ Good hydration.
✯ correction of acidosis,
✯ excellent analgesia
✯ Exchange transfusion to maintain HbS
levels of <30%.
✯ Maintenance of normothermia
✯ Avoidance of hypoxaemia.
✯ Chest physiotherapy.
334b
Dr.Sherif Badrawy

Rx of Clostridium difficile diarrhoea
335a
Dr.Sherif Badrawy

✯ uncomplicated cases oral metronidazole DOCH, effective
and cheap
✯ Stop the antibiotic associated with the outbreak
[quinolones, clindamycin and cephalosporins]
✯ ileus is present ➜ oral metronidazole or vancomycin is
ineffective ➜ Use IV metronidazole [IV vancomycin is of no use
since it does not penetrate the large bowel in sufficient dose]
✯ Probiotics ➜ weak evidence
✯ IV immunoglobulin ➜ effective in small case series, for
refractory cases if antibiotic therapy is unsuccessful. It is not a
first-line treatment
335b
Dr.Sherif Badrawy

Notes on Antifungal Rx
336a
Dr.Sherif Badrawy

✯ Voriconazole ➜ QT prolongation in susceptible individuals
[patient on amiodarone]
✯ Amphotericin B ➜ wide spectrum of activity, effective
against most Candida ➜ renal impairment
✯ Fluconazole ➜ effective against C. albicans but less so
against other forms of Candida including C. glabrata which is
resistant in 60%
✯ Nystatin ➜ Rx of C. albicans of the skin and mm, but not for
systemic candidiasis
✯ Caspofungin ➜ a broad spectrum of activity suitable for
invasive Candida and Aspergillus
336b
Dr.Sherif Badrawy

Definition of Autonomy
337a
Dr.Sherif Badrawy

respect for the patient's wishes and
attitudes regarding
the treatment they wish to receive
337b
Dr.Sherif Badrawy

Definition of Non-maleficence
338a
Dr.Sherif Badrawy

the duty of the physician not to do harm to
the patient or members of the healthcare
team or wider community.
338b
Dr.Sherif Badrawy

Definition of Beneficence
339a
Dr.Sherif Badrawy

the duty of the healthcare team to 'do
good' to the patient by effecting a cure,
relieving suffering and generally acting in
their best interests.
339b
Dr.Sherif Badrawy

Definition of Utility
340a
Dr.Sherif Badrawy

the principle of doing the greatest good for
the greatest number of patients with the
resources available; [ the obligation to
provide a net balance of benefits over
harms with limited resources], a subset of
beneficence
340b
Dr.Sherif Badrawy

Definition of Justice
341a
Dr.Sherif Badrawy

the obligation to distribute benefits and
harms fairly.
341b
Dr.Sherif Badrawy

Definition of Paternalism
342a
Dr.Sherif Badrawy

implies that 'the doctor knows best' for the pt. While this
may be true in some contexts (e.g. which antibiotic is
appropriate for the pt's infection), in the wider sense it
contradicts the principle of pt autonomy. The physician has
a duty to act as the pt would wish him to act rather than
imposing his own beliefs. Giving a blood transfusion to a
devout Jehovah's Witness would be an extreme example of
paternalism.
342b
Dr.Sherif Badrawy

Regarding the refeeding syndrome:
343a
Dr.Sherif Badrawy

a. It occurs solely as a consequence of parenteral
nutrition.【✘】➜ both enteral and parenteral nutrition
b. It develops around day 4 following reinstatement of
nutrition.【✔】
c. Thiamine and B vitamins should be given prior to
commencing feeding after a prolonged period of poor
nutrition.【✔】➜ as patients are at risk of Wernicke's
encephalopathy
d. It is a consequence of low insulin levels.【✘】➜ High
insulin levels.
343b
Dr.Sherif Badrawy

46-y, M, electrocution, maintaining an
airway, has a palpable pulse but is
extending to pain and has fixed and
dilated pupils. His ECG is normal. A small
burn wound is found over the left forearm.
344a
Dr.Sherif Badrawy

a. The neurological prognosis is hopeless.【✘】
b. A normal ECG makes ongoing cardiac problems
unlikely.【✔】
c. The small entry wound makes significant tissue damage
unlikely.【✘】
d. Wet skin has 50% less impedance to current flow than
dry skin.【✘】➜ Wet skin has an impedance of around 100
times less than dry skin greater current to flow for a given
voltage with consequently greater tissue damage
344b
Dr.Sherif Badrawy

50-y, M, Out of the hospital Cardiac Arrest,
defibrillation on the arrival of the
paramedics, ROSC after 12 minutes, fixed
and dilated pupils and a GCS 5, with flexion
to pain, ICU & MV.
345a
Dr.Sherif Badrawy

a. His neurological prognosis is hopeless.【✘】➜ Initial
neurological presentation is a poor predictor of outcome
following ROSC neurological function are considered
unreliable in the first 72h post-ROSC.
b. He should be actively cooled to 32-34°C.【✔】
c. His age has a bearing on his survival chances.【✔】
d. Patients admitted to ICU following out-of-hospital
cardiac arrest have less than a 10% chance of survival to
hospital discharge.【✘】➜ around 30%
345b
Dr.Sherif Badrawy

FAST scanning in the emergency
assessment of
blunt abdominal trauma:
346a
Dr.Sherif Badrawy

a. Visualisation of the pericardium is a key view.
【✔】➜ subxiphoid view
b. Free intraperitoneal fluid volumes in excess of 500ml
are reliably detected.【✔】
c. It is moderately sensitive for detecting encapsulated
solid organ injury.【✔】
d. Hollow viscus injury is detected in 60-70% of cases.
【✘】➜ rarely detects injury to a hollow viscus even
in experienced hands.
346b
Dr.Sherif Badrawy

34-y, M, a stab wound to the abdomen, RR
of 30, HR of 130, BP of 65/40, A 3cm entry
wound in the epigastric area, firm
abdomen with guarding.
347a
Dr.Sherif Badrawy

a. Chest X-ray is mandatory.【✔】➜ A stab wound
could easily cause tension pneumothorax or cardiac
tamponade exclude clinically, then radiologically.
b. Complete head to toe exposure should be part of
the primary survey.【✔】
c. If a FAST scan is normal, laparotomy should be
deferred.【✘】
d. a fluid bolus should be given to this pt as soon as
vascular access is obtained.【✔】
347b
Dr.Sherif Badrawy

The following are causes of the abdominal
compartment
syndrome:
348a
Dr.Sherif Badrawy

a. High volume crystalloid resuscitation.
【✔】
b. Pancreatitis.【✔】
c. Blunt abdominal trauma.【✔】
d. Laparostomy.【✘】
348b
Dr.Sherif Badrawy

Etiology of Abdominal compartment
syndrome
349a
Dr.Sherif Badrawy

can be primary (due to an intra-abdominal
cause, e.g. pancreatitis, haemorrhage,
trauma, perforation), or secondary to high-
volume fluid resuscitation, extensive burns
or sepsis (any condition where capillary
leak can cause large volumes of fluid to be
sequestered in the abdominal
compartment).
349b
Dr.Sherif Badrawy

The following are causes of elevated
protein in
cerebrospinal fluid:
350a
Dr.Sherif Badrawy

a. Brain tumour.【✔】
b. Seizure.【✔】
c. Bacterial meningitis.【✔】
d. Neurosyphilis.【✔】
350b
Dr.Sherif Badrawy

Other causes of elevated CSF protein
351a
Dr.Sherif Badrawy

The previous + abscess, haemorrhage,
demyelinating disease and Guillain-Barré
syndrome.
351b
Dr.Sherif Badrawy

normal range of CSF protein
352a
Dr.Sherif Badrawy

is around 0.2-0.4g/L.
CSF protein is extremely non-specific
352b
Dr.Sherif Badrawy

causes of low CSF protein
353a
Dr.Sherif Badrawy

a chronic dural leak or repeated lumbar
punctures, and water intoxication.
Hypoproteinaemia is not a cause
353b
Dr.Sherif Badrawy

28-y ,M, mixed overdose, Rx with
antidepressant tablets, HR of 145bpm, BP
of 210/150, 39.7°C, extremely agitated and
has muscular rigidity and clonus; no
extrapyramidal features.
【history is highly suggestive of the
serotonin syndrome, SSRI, antidepressants
and ecstasy could cause this】
354a
Dr.Sherif Badrawy

a. MDMA ('ecstasy') should be considered as a
possible cause.【✔】
b. Benzodiazepine therapy is CI for this patient.
【✘】
c. ETT & MV may be indicated.【✔】
d. A 5-hydroxytryptamine agonist may have a
role in treatment of this patient.【✘】➜ A 5-
HT2A antagonist
cyproheptadine.
354b
Dr.Sherif Badrawy

58-y, F, recovering from CAP, received
ceftriaxone 2 wks ago, abdominal
distension, fever and profuse watery
diarrhoea, Tachycardia, dehydrated,
abdominal X-ray shows distended loops of
large bowel (10cm).
355a
Dr.Sherif Badrawy

a. This condition carries a mortality of 50%.【✘】➜
Mortality around 5%.
b. Colonoscopy is the investigation of choice.【✘】
c. Initial treatment should include oral clindamycin.
【✘】
d. An urgent surgical opinion should be obtained.
【✔】➜ a surgical emergency and may complicate any
form of colitis including IBD and ischaemia.
355b
Dr.Sherif Badrawy

The following interventions have been
shown to reduce
mortality in patients with septic shock:
356a
Dr.Sherif Badrawy

a. Antithrombin III.【✘】
b. Activated protein C.【✘】
c. Anti-TNF-a antibody.【✘】
d. High dose methylprednisolone.【✘】
356b
Dr.Sherif Badrawy

37-y, M, crushed against a wall by a truck,
significant abdominal injuries,
hypovolaemic shock, ATLS® class III,
laparotomy, splenectomy,retroperitoneal
bleeding, 18 units PRBCs, ICU ➜ 6 units
PRBCs, HCT 23%, platelets
30, fibrinogen 0.4g/L, INR 6.2.
357a
Dr.Sherif Badrawy

a. Recombinant factor VIIa should be given immediately.
【✘】➜ correction of platelets, fibrinogen, hypothermia,
acidosis and ionised calcium to minimum levels is a pre-
requisite for its use.
b. Class III shock implies blood loss of over 2L.【✘】➜ 1.5-
2L.
c. It is not mandatory to give vitamin K immediately.
【✔】➜ of little benefit as a dilutional coagulopathy dt
massive transfusion rather than a primary synthetic
problem.
d. His temperature should be checked【✔】
357b
Dr.Sherif Badrawy

41-y, M, RTA, shock, pelvis is unstable,
disrupted pelvic ring on X-ray, ETT, OR,
remains in shock despite 3L crystalloid and
1L gelofusine, HCT 28%, PT 28s.
358a
Dr.Sherif Badrawy

a. The presence of a coagulopathy worsens the prognosis.
【✔】
b. HCT is an insensitive indicator of the need for surgical
intervention.【✔】
c. A high level of PEEP should be used in theatre to prevent
lung derecruitment.【✘】➜ should be minimised until
bleeding controlled.
d. Immediate mechanical stabilization of the pelvic ring is
indicated.【✔】
358b
Dr.Sherif Badrawy

76-y, M, house fire, hospital 4 hours later,
ETT, Carbonaceous sputum from ETT, MV,
burns across his entire torso ant., face,
backs of both arms.
359a
Dr.Sherif Badrawy

a. He has burns to approximately 45% of his body surface area.
【✘】➜ ~ 36% BSA
b. A reasonable fluid regime would be 4ml/kg/% body surface
area burns over the next 24 h.【✘】
c. Use of suxamethonium would be dangerous in this
situation.【✘】➜ life-threatening hyperkalaemia about 10 days
post-burn, It is safe at the time of the injury
d. O2 Rx should be titrated initially to maintain PaO2 around
10kPa (76 mmHg).【✘】➜ CO poisoning. Arterial PaO2 may not
reflect blood oxygen carriage, and 100%
O2 is warranted.
359b
Dr.Sherif Badrawy

rule of 9 in burn
360a
Dr.Sherif Badrawy

360b
Dr.Sherif Badrawy

rule of 9 in children
361a
Dr.Sherif Badrawy

361b
Dr.Sherif Badrawy

44-y, M, HAP, Sputum and blood C&S ESBL
Klebsiella, empirical antibiotic
362a
Dr.Sherif Badrawy

a. Cefotaxime and gentamicin.【✘】
b. Piperacillin/tazobactam.【✘】
c. Imipenem.【✔】DOCH, good in vitro and
in vivo
effect against ESBL-producers.
d. Ciprofloxacin.【✘】
362b
Dr.Sherif Badrawy

66-y, M, SOB, X-ray pulmonary oedema, ETT,
MV, BP 185/120, HR 115, SpO2 92% on 80%
FIO2, oesophageal
Doppler probe ➜ flow time corrected (FTc)
270ms, peak velocity 35cm/s, stroke volume
40ml, fluid challenge of 250ml colloid over 10
minutes. Repeat readings : FTc 275ms, peak
velocity 33cm/s, stroke volume 39ml
363a
Dr.Sherif Badrawy

a. A further fluid bolus should be given.【✘】
b. A nitrate infusion is appropriate.【✔】
c. Frusemide is appropriate.【✔】
d. Cardiac contractility is normal for a man of this age.
【✘】
NB:FTc is low dt ↑SVR ➜ Hx suggesting HF (not all cases of
reduced FTc are due to hypovolaemia)lack of response to
a fluid challenge (no significant↑SV, ↓peak velocity)
suggesting that this patient is fluid-overloaded.
363b
Dr.Sherif Badrawy

Regarding the arterial pressure wave in the
hypovolaemic
mechanically ventilated patient:
364a
Dr.Sherif Badrawy

a. Changes in pulse pressure across the respiratory
cycle better reflect hypovolaemia than changes in
systolic pressure.【✔】
b. Pulse pressure is inversely proportional to stroke
volume.【✘】
c. The maximum fall in systolic pressure coincides
temporally with the peak inspiratory pressure.【✘】
d. The arterial pressure waveform is an unreliable
guide to fluid requirement in arrhythmias.【✔】
364b
Dr.Sherif Badrawy

Regarding the physics of direct arterial
blood pressure
measurement:
365a
Dr.Sherif Badrawy

a. The catheter connecting the arterial cannula
to the transducer should be short, stiff and
narrow to reduce resonance.【✘】
b. Bubbles and clots cause damping.【✔】
c. The resonant frequency of the system should
be greater than 30Hz.【✔】
d. The primary harmonic of the system is 100Hz.
【✘】
365b
Dr.Sherif Badrawy

Regarding the assessment of sedation on
the ICU:
366a
Dr.Sherif Badrawy

a. A score of 3-4 is desirable on the Richmond agitation
and sedation scale.【✘】
b. The commonest form of delirium in the ICU patient
is characterised by hyperarousal and agitation.【✘】➜
hypoactive form
c. The Ramsay scale does not assess patient agitation.
【✔】➜ It is primarily a test of rousability
d. The GCS is not useful for the assessment of
sedation.【✔】
366b
Dr.Sherif Badrawy

The Richmond agitation and sedation scale
367a
Dr.Sherif Badrawy

scored from +4 (combative and violent) to -
5 (unrousable). A score of 0 (alert and
calm) is desirable.
367b
Dr.Sherif Badrawy

The Ramsay sedation scale
368a
Dr.Sherif Badrawy

A score from 1 (anxious and restless) to 6
(unresponsive) is given, with 3-4 being
optimal.
368b
Dr.Sherif Badrawy

Effects of excessive heparinisation of an
ABG sample on the measured values may
include:
369a
Dr.Sherif Badrawy

a. Elevated PaCO2.【✘】
b. Reduced PaCO2.【✔】
c. Elevated PaO2.【✔】
d. Reduced bicarbonate.【✔】
369b
Dr.Sherif Badrawy

48-y, M, homeless, unresponsive on the
street, signs of malnutrition, temperature
of 28°C, HR of 42, GCS 5.
370a
Dr.Sherif Badrawy

a. Passive re-warming should be commenced limiting
temperature rise to 1°C per hour.【✘】
b. Intubation should be avoided as it may cause ventricular
fibrillation.【✘】
c. IV thiamine should be administered urgently.【✔】
d. If VF occurs, DC cardioversion should not be attempted
until the core temperature is above 30°C.【✘】➜
Cardioversion can be attempted < 30°C, but if a perfusing
rhythm is not restored after 3 shocks no further attempts
until core temperature > 30°C.
370b
Dr.Sherif Badrawy

Pt in HDU, acting strangely, normally a
nursing home resident and now appears
agitated and confused, features favour a
diagnosis of delirium as opposed to
dementia:
371a
Dr.Sherif Badrawy

a. Global cognitive impairment.【✘】➜ Focal
cognitive impairment is in keeping with
delirium, whereas global impairment suggests
dementia
b. An insidious onset of symptoms.【✘】➜ acute
with delirium (hours), insidious with dementia.
c. Inattention.【✔】
d. Psychotic symptoms.【✔】
371b
Dr.Sherif Badrawy

delirium vs dementia
372a
Dr.Sherif Badrawy

372b
Dr.Sherif Badrawy

Regarding acute epiglottitis in adults:
373a
Dr.Sherif Badrawy

a. It is more common than in children.【✔】
b. Haemophilus influenzae has been largely
eradicated as a cause.【✘】
c. Amoxycillin with clavulanic acid is appropriate
empirical therapy.【✔】
d. Patients usually appear systemically well.
【✘】➜ usually toxic and unwell with a high
fever.
373b
Dr.Sherif Badrawy

75-y, M, SDH 6 days ago, ETT, MV, massive
PE, confirmed by CTPA, IVC filter is
considered.
374a
Dr.Sherif Badrawy

a. Thrombolysis is absolutely CI.【✔】
b. Once placed the filter cannot safely be
removed.【✘】
c. IVC filters are effective in reducing the
incidence of further PE.【✔】
d. IVC filters do not improve survival.【✔】
374b
Dr.Sherif Badrawy

28-y, RTA, severe TBI, ICU, evacuated SDH,
ICP 40 mmHg.
Appropriate Rx to buy time while awaiting
a CT brain
375a
Dr.Sherif Badrawy

a. Dobutamine infusion.【✘】
b. Frusemide.【✔】➜ acceptable but mannitol is MC used
c. Hyperventilation to a PaCO2 of 3.5kPa (27mmHg).
【✔】➜ a PaCO2 < 4.0kPa (30mmHg) not recommended
for the routine Rx of head injury , dt cerebral artery VC and
may worsen brain ischaemia. However, as an acute Rx
➜↓ICP ➜ buy time until definitive Rx.
d. Thiopentone bolus.【✔】
375b
Dr.Sherif Badrawy

The following capnograph trace on a
ventilated patient is
consistent with:
376a
Dr.Sherif Badrawy

a.Endobronchialintubation following patient repositioning.【✘】➜ A rapid fallin the end-tidalCO2 over the course of a few breaths➜ a fallin COP ➜
↑physiologicaldead space (↑V/Q ratio).
b.Air embolism.【✔】
c.Incipient cardiacarrest.【✔】
d.Bronchospasm.【✘】➜ waveform'llbe rising to a peak rather than being 'flat-topped'
376b
Dr.Sherif Badrawy

75-y, F, 5 days after anterior MI, SOB, chest X-
ray ➜ pulmonary venous congestion. neck
veins distended. A systolic murmur on
auscultation. BP 80/65, PAC ➜ PAO2 Sat 88%,
PAP 50/23mmHg. The following are true:88%
is 【PAO2 Sat 88% is much higher than would
normally be expected (mixed venous oxygen
saturation should be around 70%)】
377a
Dr.Sherif Badrawy

a. This lady probably has papillary muscle rupture.
【✘】➜ VSD ➜ Lt to Rt shunt, usu within a week of MI
b. This lady is likely to need urgent surgery.【✔】➜ 30-
day survival is 24% with medical Rx and 47% when Rx
surgically.
c. ECG is the key investigation.【✘】➜ Ix of choice is
Doppler echo ➜ excludes papillary muscle rupture.
d. Urgent needle thoracocentesis is the treatment of
choice.【✘】➜ Rx of choice for cardiac tamponade
377b
Dr.Sherif Badrawy

55-y, M, massive haemoptysis [500ml blood
over a 3-h], several minor episodes of
haemoptysis over the last few months, BP
90/70, HR of 100, SpO2 of 85% on 15L/min
oxygen NRBM,
378a
Dr.Sherif Badrawy

a. IV access and rapid fluid challenge is the first priority.
【✘】➜ The 1st priority is to secure the airway and
improve O2.
b. A double-lumen tube is mandatory if tracheal intubation
is required.【✘】
c. Fibreoptic bronchoscopy may be useful in this case.
【✔】➜ may be difficult dt blood but should be attempted
by an experienced operator, Dx & Rx.
d. If a bleeding source is lateralised, the patient should be
ventilated with that side dependent.【✔】➜ to prevent
blood from contaminating the other lung.
378b
Dr.Sherif Badrawy

The following therapeutic manoeuvres
improve survival in
the ARDS:
379a
Dr.Sherif Badrawy

a. High levels of PEEP >15cm H2O.【✘】
b. Proning for >8 hours per day.【✘】
c. Low tidal volume ventilation (6ml/kg
predicted body weight).【✔】➜ and
limiting plateau pressure
d. Alveolar recruitment manoeuvres.【✘】
379b
Dr.Sherif Badrawy

Regarding atrial fibrillation in the
postoperative period:
380a
Dr.Sherif Badrawy

a. Overall incidence is low (<1%) in non-
cardiothoracic surgery.【✔】
b. It most commonly occurs in the first 3
postoperative days.【✔】
c. It resolves spontaneously in most patients.
【✔】
d. It occurs in 80-90% of patients following
coronary artery bypass grafting.【✘】
380b
Dr.Sherif Badrawy

67-y, M, CCU, central chest pain, like his
usual angina but
more severe, pain came on at rest and has
lasted for 3
h, ECG 1mm ST depression in the lateral
leads, CK normal on admission
381a
Dr.Sherif Badrawy

a. A diagnosis of ACS can be made.【✔】
b. Aspirin and clopidogrel should be
administered.【✔】
c. A glycoprotein IIb/IIIa inhibitor is not
indicated.【✘】
d. PCI is only beneficial in the presence of
STEMI.【✘】
381b
Dr.Sherif Badrawy

66-y, CCU, severe cardiogenic shock, ECG
significant ↓ST anterior leads, cold and
clammy, BP of 80/60, HR 120 (sinus tachy),
unrecordable Sao2, X-ray ➜ pulmonary
oedema, Despite appropriate inotropic
support his condition fails to improve over
the next few hours
382a
Dr.Sherif Badrawy

a. MI is the MCC of cardiogenic shock.
【✔】
b. MV is CI as it will further impair COP.
【✘】
c. CPAP ↓preload.【✔】
d. CPAP ↓afterload.【✔】
382b
Dr.Sherif Badrawy

49-y, M, painful left-sided ophthalmoplegia
following a recent sinusitis,chemosis, slight
proptosis, ↓visual acuity, Dx of cavernous
sinus thrombosis is considered.
383a
Dr.Sherif Badrawy

a. CT brain scan is likely to be a useful Ix in this case.
【✔】➜ MRI occasionally if CT fails to make Dx.
b. IV empirical antibiotics are indicated.【✔】 ➜ location of
the cavernous sinuses and their extensive venous
connections vulnerable to septic thrombi [MCC
Staphylococcus aureus]
c. Mortality is 80-100%.【✘】This is In the pre-antibiotic
era, now ~20% with appropriate antimicrobial Rx.
d. Cavernous sinus thrombosis is the MCC of cerebral
venous sinus thrombosis.【✘】
383b
Dr.Sherif Badrawy

The following are risk factors for the
development of critical illness
polyneuromyopathy:
384a
Dr.Sherif Badrawy

a. Sepsis.【✔】
b. Corticosteroids.【✔】
c. Neuromuscular blocking agents.【✔】
d. Poor glycaemic control.【✔】
NB : ✾ MV >4-7 days
✾ Nerve conduction ➜ show evidence of
denervation.
✾ muscle biopsy ➜ shows evidence of
myopathy.
384b
Dr.Sherif Badrawy

Regarding urinalysis:
385a
Dr.Sherif Badrawy

a. Red cell casts are always pathological.【✔】
b. A negative nitrite dipstick effectively excludes the
presence of bacteria in the urine.【✘】➜ Although 90% of
common urinary pathogens are nitrite-forming, [NOT
Pseudomonas, Staph albus, Staph saprophyticus,
Strept faecalis]
c. Hyaline casts are suggestive of bacterial endocarditis.
【✘】➜ Tamm-Horsfall glycoprotein, common in healthy
individuals.
d. White cell casts are a normal finding.【✘】➜
proliferative GN, AIN & acute PN.
385b
Dr.Sherif Badrawy

Regarding pharmacological prophylaxis of
stress ulceration in the ICU:
386a
Dr.Sherif Badrawy

a. Sucralfate neutralises gastric pH.【✘】
b. PPI are superior to H2-blockers in
preventing clinically significant bleeding.
【✘】
c. Tolerance occurs to ranitidine.【✔】
d. Antacids are effective with twice-daily
dosing.【✘】
386b
Dr.Sherif Badrawy

74-y, M, biliary tract sepsis, ICU, Over 3
days ➜ marked abdominal distension, X-
ray ➜ dilatation of the large bowel,
features favour Dx acute intestinal pseudo-
obstruction [Ogilvie's syndrome] over
mechanical obstruction:
387a
Dr.Sherif Badrawy

a. The presence of air in the rectosigmoid colon
on plain radiography.【✔】
b. A maximum colonic diameter of 10cm on
plain radiography.【✘】
c. Free passage of contrast during a contrast
enema study.【✔】
d. The presence of bowel sounds on
auscultation.【✘】
387b
Dr.Sherif Badrawy

Renal failure may cause alterations in the
following
pharmacokinetic properties of a drug:
388a
Dr.Sherif Badrawy

a. Absorption.【✔】
b. Distribution.【✔】
c. Metabolism.【✔】
d. Excretion.【✔】
388b
Dr.Sherif Badrawy

Pt has liver cirrhosis, major upper GI
bleeding dt oesophageal varices, ICU for
resuscitation, acute
pharmacological management
389a
Dr.Sherif Badrawy

a. Glypressin.【✔】➜ improve survival and
be as effective as balloon tamponade for
bleeding control
b. Propranolol.【✘】➜ prophylaxis rather
than treatment of an acute bleed.
c. Somatostatin.【✔】➜ selective
splanchnic VC & ↓portal pressure
d. Isosorbide mononitrate.【✘】
389b
Dr.Sherif Badrawy

65-y, F, exploratory laparotomy and right
hemicolectomy. With regard to her
nutrition:
390a
Dr.Sherif Badrawy

a. Parenteral feeding should be instituted only if
enteral feeding has been unsuccessful over a 72-hour
period.【✘】
b. Mortality is 20% higher in parenterally fed ICU
patients compared with enteral feeding.【✘】
c. Delayed feeding is associated with poorer ICU
outcome.【✔】
d. Parenteral feeding is associated with a higher risk of
infectious complications.【✔】
390b
Dr.Sherif Badrawy

The following are elements of the 24-h
sepsis mgmnt bundle as advocated by the
Surviving Sepsis
Campaign group:
391a
Dr.Sherif Badrawy

a. Administration of recombinant human activated
protein C for eligible patients.【✘】
b. Methylprednisolone 1g q.d.s. for patients requiring
vasopressors.【✘】➜ hydrocortisone 200-300mg/day
c. Maintain glucose <12.4mmol/L (225mg/dL).【✘】➜
between 3.8-8.3mmol/L
d. Maintain a plateau pressure of <30cmH2O for
mechanically ventilated patients.【✔】
391b
Dr.Sherif Badrawy

Regarding high frequency oscillatory
ventilation (HFOV):
392a
Dr.Sherif Badrawy

a. O2 can be improved by ↑mean airway pressure.【✔】➜
by greater splinting open of alveoli (with reduced shunt).
b. Expiration is passive.【✘】➜ Expiration is active (the
diaphragm moves both 'in' and 'out').
c. Frequency of ventilation is typically 50-100 breaths per
minute.【✘】➜ ~300 breaths/min
d. CO2 elimination can ↑ by reducing the frequency of
ventilation.【✔】➜ by either increasing DP or decreasing
the frequency
392b
Dr.Sherif Badrawy

The following forms of shock may be
present in amniotic
fluid embolism:
393a
Dr.Sherif Badrawy

a. Distributive.【✔】
b. Cardiogenic.【✔】
c. Obstructive.【✔】
d. Haemorrhagic.【✔】
393b
Dr.Sherif Badrawy

Types of shock in amniotic fluid embolism
394a
Dr.Sherif Badrawy

❂ Obstructive shock and cardiogenic shock ➜
predominate
early
❂ Obstructive ➜ dt PA VC dt exposure to
immunologically active substances
❂ Cardiogenic ➜ dt LV dysfunction.
❂ Distributive ➜ later dt SIRS ➜ capillary leak
❂ Haemorrhagic ➜ dt DIC ➜ life-threatening
Hge
394b
Dr.Sherif Badrawy

NSAIDs, selective for COX-2 isoenzyme:
395a
Dr.Sherif Badrawy

a. They significantly↓risk of GI bleeding compared with
non-selective NSAIDs.【✔】
b. They cause ↑thromboxane A2 production compared
with non-selective NSAIDs.【✔】
c. Rofecoxib > doubles the risk of MI compared with
placebo.【✔】➜ ↓prostacyclin in vascular endothelium
(which has VD and antiplatelet activity) & ↑thromboxane
A2 (pro-aggregatory platelet effects).
d. They are < effective analgesics than non-selective
NSAIDs.【✘】➜ efficacy of COX-2 agents is among the
highest of all NSAIDs.
395b
Dr.Sherif Badrawy

Regarding pharmacokinetics:
396a
Dr.Sherif Badrawy

a. A T1/2 is half the total time taken for the drug to be
completely cleared from the plasma.【✘】➜ time taken
for its conc to fall by 50%.
b. Vd is calculated from plasma conc x dose following an IV
bolus of a drug.【✔】
c. Clearance is usually expressed in ml/kg/min.【✘】➜
expressed as ml/min.
d. Zero order kinetics implies enzyme saturation.【✔】
396b
Dr.Sherif Badrawy

Which is more potent, Fentanyl or
alfentanil ?
397a
Dr.Sherif Badrawy

Fentanyl is more potent than alfentanil
(same efficacy with a lower dose)
397b
Dr.Sherif Badrawy

44-y, M, abdominal sepsis, ICU, renal
function deteriorates, requires RRT
398a
Dr.Sherif Badrawy

a. RRT is associated with excess in-hospital
mortality.【✔】
b. ARF requiring RRT is an independent risk
factor for ↑mortality.【✔】
c. Bleeding complications are MCC of death in
ICU pts with ARF.【✘】➜ infection is the MCC
here.
d. Hospital mortality is around 15% in ICU pts
requiring RRT.【✘】
398b
Dr.Sherif Badrawy

A patient on the ICU develops candidaemia
following a
prolonged period of MV dt abdominal
sepsis, C. albicans is isolated in blood and
urine cultures. The following are likely to
be effective antifungal agents:
399a
Dr.Sherif Badrawy

a. Voriconazole.【✔】
b. Fluconazole.【✔】
c. Caspofungin.【✔】
d. Amphotericin B.【✔】
✷ NB: continue Rx until 14 days after -ve
blood cultures
399b
Dr.Sherif Badrawy

The following are recognised
complications of prone
positioning in the anaesthetised patient:
400a
Dr.Sherif Badrawy

a. Stroke.【✔】head rotation ➜ vertebral or
carotid artery occlusion
b. Weakness of hand grip.【✔】➜ dt injury to
the brachial plexus (esp with arm extended)
c. Macroglossia.【✔】➜ dt ↑venous pressure
[excessive flexion of neck ➜ kinking of IJV]
d. Blindness.【✔】➜ dt retinal ischaemia dt
↑IOP ➜ ↓intra-orbital perfusion pressure
400b
Dr.Sherif Badrawy

Regarding the persistent vegetative state:
401a
Dr.Sherif Badrawy

a. Prognosis is worse if the cause is metabolic than if it is
traumatic.【✔】
b. The GCS is a useful assessment tool.【✘】
c. Neuroimaging is usually normal.【✘】 ➜ widespread
cortical and thalamic atrophy in PVS pts progresses with
time.
d. Life expectancy is normal if appropriate supportive care
is provided.【✘】 ➜ mortality of the PVS is 70% at 3 years
influenced by complications as pressure sores and
infections.
401b
Dr.Sherif Badrawy

Critical care revision notes

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Critical care revision notes