Critical Care Medicine Practice Questions

Q: Which of the following is NOT true regarding Cardiopulmonary Resuscitation (CPR)?

Chest compressions should be at least 6 inches deep.. The correct answer is **C**. According to the latest AHA (American Heart Association) guidelines, chest compressions should be performed at a depth of **2 to 2.4 inches (5 to 6 cm)** in adults. A depth of 6 inches is excessive and would likely cause severe internal injuries, such as rib fractures, lung contusions, or cardiac tamponade. ### Explanation of Options: * **Option A (Incorrect):** The recommended compression rate is **100–120 per minute**. While 100 is the minimum threshold, it is a correct statement in the context of standard CPR protocols. * **Option B (Incorrect):** For a single rescuer or two rescuers in an adult victim (without an advanced airway), the standard compression-to-ventilation ratio is **30:2**. * **Option D (Incorrect):** Once an advanced airway (like an ET tube) is in place, compressions are continuous, and ventilations are given at a rate of **1 breath every 6 seconds** (10 breaths/min). The range of 8–10 breaths per minute is clinically acceptable to avoid hyperventilation. ### High-Yield Clinical Pearls for NEET-PG: * **Push Hard, Push Fast:** Ensure full chest recoil after each compression to allow for ventricular filling. * **Minimize Interruptions:** Pauses in compressions should be kept to less than 10 seconds. * **EtCO₂ Monitoring:** A capnography reading of **<10 mmHg** during CPR indicates poor quality compressions or low ROSC (Return of Spontaneous Circulation) probability. * **Defibrillation:** For Shockable rhythms (VF/Pulseless VT), the initial energy for a Biphasic defibrillator is typically **120–200 J**.

Q: A 53-year-old woman has been intubated for several days after sustaining a right pulmonary contusion and multiple rib fractures following a motor vehicle collision. Which of the following is a reasonable indication to attempt extubation?

A rapid shallow breathing index of 80. **Explanation:** The decision to extubate a patient depends on their ability to maintain spontaneous ventilation and oxygenation. The **Rapid Shallow Breathing Index (RSBI)**, calculated as the ratio of respiratory rate (f) to tidal volume (Vt in liters), is one of the most reliable predictors of weaning success. **1. Why Option D is Correct:** An **RSBI < 105** is a strong predictor of successful weaning. An RSBI of 80 indicates that the patient is taking adequate tidal volumes without excessive tachypnea, suggesting that the respiratory muscles are not fatigued and can handle the work of breathing independently. **2. Why the Other Options are Incorrect:** * **Option A:** A **Negative Inspiratory Force (NIF)** (or MIP) should be more negative than **-20 to -30 cm H2O**. A value of -15 cm H2O indicates significant inspiratory muscle weakness, making extubation risky. * **Option B:** While a PO2 of 60 mmHg is acceptable, it is being achieved with a **PEEP of 10 cm H2O**. For extubation, a patient should generally be stable on a "minimal" PEEP of **5–8 cm H2O**. High PEEP requirements suggest the lung collapse or edema has not yet sufficiently resolved. * **Option C:** A spontaneous respiratory rate of **35 breaths per minute** indicates tachypnea and increased work of breathing. A rate ** 150–200. * Vital Capacity > 10 mL/kg. * Tidal Volume > 5 mL/kg. * **The "Gold Standard"** for assessing readiness is the **Spontaneous Breathing Trial (SBT)** for 30–120 minutes.

Q: Therapeutic hypothermia is of benefit in preventing neurological complications in which of the following conditions?

Cardiac arrest. **Explanation:** **Therapeutic Hypothermia (Targeted Temperature Management - TTM)** is a cornerstone in neuroprotection following **Cardiac Arrest**. The underlying medical concept is the reduction of cerebral metabolic rate for oxygen ($CMRO_2$). For every $1^\circ C$ drop in core temperature, the cerebral metabolic rate decreases by approximately 6-7%. This reduction helps mitigate secondary brain injury by decreasing excitatory neurotransmitter release (like glutamate), reducing free radical production, and stabilizing the blood-brain barrier. * **Cardiac Arrest (Correct):** Current guidelines (ILCOR/AHA) recommend TTM (32°C to 36°C) for adults who remain unresponsive after ROSC (Return of Spontaneous Circulation) from both shockable and non-shockable rhythms to improve neurological outcomes. * **Sepsis (Incorrect):** While fever management is important, induced hypothermia can impair immune function and worsen coagulopathy, potentially increasing mortality in septic patients. * **Poly-trauma (Incorrect):** Hypothermia is part of the "Lethal Triad" in trauma (along with acidosis and coagulopathy). It inhibits the coagulation cascade, leading to increased bleeding risk. * **Ischemic Stroke (Incorrect):** While theoretically beneficial, large clinical trials have not yet established TTM as a standard of care for acute ischemic stroke due to complications like pneumonia and lack of clear mortality benefit compared to cardiac arrest. **High-Yield Pearls for NEET-PG:** * **Target Temperature:** 32°C to 36°C for at least 24 hours. * **Adverse Effects of TTM:** Shivering (increases $O_2$ consumption), "Cold Diuresis" (hypokalemia, hypomagnesemia), bradycardia, and increased risk of wound infection. * **Rewarming:** Must be slow (0.25°C to 0.5°C per hour) to prevent rebound hyperkalemia and cerebral edema.

Q: Which of the following should be the ventilator settings for tidal volume in a patient with ARDS?

Tidal volume 5-7 ml/kg. **Explanation:** The primary goal in managing a patient with **Acute Respiratory Distress Syndrome (ARDS)** is to prevent **Ventilator-Induced Lung Injury (VILI)**. The correct answer is **C (5-7 ml/kg)** because it adheres to the principles of **Lung Protective Ventilation**. **1. Why 5-7 ml/kg is correct:** In ARDS, the functional lung volume is significantly reduced due to edema and alveolar collapse (often called the **"Baby Lung" concept**). Using traditional tidal volumes can lead to **volutrauma** (overdistension of alveoli) and **barotrauma**. The ARDSNet protocol recommends a low tidal volume strategy, typically starting at 6 ml/kg of **Predicted Body Weight (PBW)**, to minimize alveolar stretch and reduce mortality. The range of 5-7 ml/kg aligns with this evidence-based practice. **2. Why other options are incorrect:** * **Options A & B (8-12 ml/kg):** These represent traditional tidal volumes used in healthy lungs. In ARDS, these high volumes cause excessive plateau pressures, leading to alveolar rupture and systemic inflammatory release (biotrauma). * **Option D (4 ml/kg):** While ultra-low tidal volumes are sometimes used in research or with ECMO, 4 ml/kg is generally too low for standard management as it can lead to severe permissive hypercapnia and significant atelectasis unless specialized rescue therapies are in place. **High-Yield Clinical Pearls for NEET-PG:** * **Calculation Base:** Always use **Predicted Body Weight (PBW)** based on height and sex, NOT actual body weight, to calculate tidal volume. * **Plateau Pressure:** The goal is to keep Plateau Pressure (**Pplat**) **< 30 cm H₂O**. * **Permissive Hypercapnia:** It is often acceptable to allow PaCO₂ to rise (and pH to drop to ~7.25) to maintain low-volume ventilation. * **Driving Pressure:** (Pplat - PEEP) is a strong predictor of survival; the goal is usually **< 15 cm H₂O**.

Q: Which pulse is best palpated to check for the return of spontaneous circulation during cardiopulmonary cerebral resuscitation (CPCR)?

Carotid pulse. **Explanation:** The **carotid pulse** is the gold standard for assessing the Return of Spontaneous Circulation (ROSC) during CPCR in adults and children. This is because the carotid artery is a large, central artery located close to the heart. During low-flow states (like shock or early ROSC), peripheral pulses may disappear due to compensatory vasoconstriction, but central perfusion to the brain is prioritized. The carotid pulse is also easily accessible without interrupting chest compressions or interfering with airway management. **Analysis of Options:** * **Femoral Pulse (B):** While also a central pulse, it is often less accessible during active resuscitation due to the presence of multiple providers around the patient’s torso and legs. Additionally, in cases of severe abdominal trauma or obesity, it can be difficult to locate quickly. * **Brachial Pulse (C):** This is the preferred site for pulse checks in **infants (under 1 year)** because their short, thick necks make the carotid pulse difficult to palpate. In adults, it is a peripheral pulse and disappears early in hypotension. * **Any Palpable Pulse (D):** This is incorrect because peripheral pulses (like the radial pulse) require a systolic blood pressure of at least 80 mmHg to be palpable, whereas central pulses can often be felt at lower pressures (approx. 60 mmHg). **Clinical Pearls for NEET-PG:** * **Time Limit:** Pulse checks during CPR should take **no more than 10 seconds**. If a pulse is not definitely felt within 10 seconds, chest compressions must be resumed immediately. * **Site by Age:** * Adults/Children: Carotid. * Infants: Brachial or Femoral. * **ETCO2:** In advanced life support, a sudden, sustained increase in End-Tidal CO2 (typically >30-40 mmHg) is the most reliable physiological indicator of ROSC.

Q: A 34-year-old unresponsive female is brought to the emergency department with no proper history. What is the next step in management?

Check for carotid pulse. ### Explanation This question follows the **Basic Life Support (BLS) algorithm** updated by the American Heart Association (AHA). In an emergency scenario involving an unresponsive patient, the sequence of actions is critical for survival. **Why Option A is Correct:** According to the BLS protocol, once a patient is found to be **unresponsive**, the next immediate step is to simultaneously **activate the emergency response system** and **check for a pulse and breathing**. In an adult, the **carotid pulse** is the preferred site. This check should take at least 5 seconds but no more than 10 seconds. This step is vital to differentiate between respiratory arrest (pulse present, no breathing) and cardiac arrest (no pulse, no breathing). **Why Other Options are Incorrect:** * **Option B (Check for responsiveness):** This has already been established in the question stem ("unresponsive female"). Repeating this step would delay life-saving interventions. * **Option C (Chest compressions):** Compressions are only initiated *after* confirming the absence of a pulse. Starting compressions on a patient with a perfusing rhythm can cause unnecessary complications. * **Option D (Shock 300 Joules):** Defibrillation is only indicated for specific "shockable" rhythms (VF/Pulseless VT) identified via an AED or ECG monitor. Furthermore, 300J is not the standard starting dose for modern biphasic defibrillators (usually 120–200J). **High-Yield Clinical Pearls for NEET-PG:** * **Sequence:** Unresponsiveness → Activate EMS → Pulse/Breathing check → CPR (if no pulse). * **Pulse Check Site:** Carotid in adults/children; **Brachial** in infants. * **Compression Depth:** 2 to 2.4 inches (5–6 cm) in adults. * **Compression Rate:** 100–120 per minute. * **Ratio:** 30:2 (1 or 2 rescuers) for adults; 15:2 for children/infants if 2 rescuers are present.

Q: What is true regarding cardiopulmonary resuscitation?

Adrenaline is given if cardioversion fails.. In Cardiopulmonary Resuscitation (CPR), the management of cardiac arrest follows the Advanced Cardiovascular Life Support (ACLS) guidelines. **Explanation of the Correct Option:** **Option C** is correct because in cases of shockable rhythms (Ventricular Fibrillation or Pulseless Ventricular Tachycardia), the priority is defibrillation. If the initial shocks (cardioversion/defibrillation) fail to restore a perfusing rhythm, **Adrenaline (1 mg every 3–5 minutes)** is administered to improve coronary and cerebral perfusion pressure via its alpha-adrenergic vasoconstrictive effects. **Analysis of Incorrect Options:** * **Option A:** The most common initial rhythm in out-of-hospital cardiac arrest (OHCA) is **Ventricular Fibrillation (VF)**, not asystole. Asystole is often a late finding with a poorer prognosis. * **Option B:** According to current AHA guidelines, the universal compression-to-ventilation ratio for adults is **30:2**. A 5:1 ratio is obsolete and no longer recommended. * **Option D:** Calcium gluconate is **not** given routinely. It is only indicated in specific scenarios: hyperkalemia, hypocalcemia, or magnesium toxicity/calcium channel blocker overdose. Routine use can cause cerebral reperfusion injury. **High-Yield Clinical Pearls for NEET-PG:** * **Compression Depth:** 2–2.4 inches (5–6 cm) at a rate of 100–120 bpm. * **Shockable Rhythms:** VF and Pulseless VT. * **Non-Shockable Rhythms:** Asystole and PEA (Pulseless Electrical Activity). * **Amiodarone:** The first-line anti-arrhythmic (300mg bolus) given if VF/pVT persists after the 3rd shock. * **H's and T's:** Always look for reversible causes (Hypoxia, Hypovolemia, Hydrogen ion/Acidosis, Hypo/Hyperkalemia, Hypothermia; Tension pneumothorax, Tamponade, Toxins, Thrombosis).

Question 1

Brain death is indicated by the suppression of all reflexes except which of the following?

Accepted Answer

Patellar tendon reflex

Answer

Oculovestibular reflex

Answer

Corneal reflex

Answer

Pharyngeal reflex

Question 2

Which of the following is NOT true regarding Cardiopulmonary Resuscitation (CPR)?

Accepted Answer

Chest compressions should be at least 6 inches deep.

Answer

Chest compressions should be performed at a rate of 100 per minute.

Answer

The compression-to-ventilation ratio is 30:2.

Answer

Breathing rate should be 8-10 breaths per minute.

Question 3

A 53-year-old woman has been intubated for several days after sustaining a right pulmonary contusion and multiple rib fractures following a motor vehicle collision. Which of the following is a reasonable indication to attempt extubation?

Accepted Answer

A rapid shallow breathing index of 80

Answer

Negative inspiratory force (NIF) of -15 cm H2O

Answer

PO2 of 60 mm Hg while breathing 30% inspired FiO2 with a positive end-expiratory pressure (PEEP) of 10 cm H2O

Answer

Spontaneous respiratory rate of 35 breaths per minute

Question 4

Therapeutic hypothermia is of benefit in preventing neurological complications in which of the following conditions?

Accepted Answer

Cardiac arrest

Answer

Sepsis

Answer

Poly-trauma

Answer

Ischemic stroke

Question 5

Which of the following should be the ventilator settings for tidal volume in a patient with ARDS?

Accepted Answer

Tidal volume 5-7 ml/kg

Answer

Tidal volume 10-12 ml/kg

Answer

Tidal volume 8-10 ml/kg

Answer

Tidal volume 4 ml/kg

Question 6

Which pulse is best palpated to check for the return of spontaneous circulation during cardiopulmonary cerebral resuscitation (CPCR)?

Accepted Answer

Carotid pulse

Answer

Femoral pulse

Answer

Brachial pulse

Answer

Any palpable pulse

Question 7

After effective cardiopulmonary resuscitation, what physiological change is observed?

Accepted Answer

Constriction of pupil

Answer

Dilation of pupil

Answer

Elevation of blood pressure

Answer

None of the above

Question 8

A 34-year-old unresponsive female is brought to the emergency department with no proper history. What is the next step in management?

Accepted Answer

Check for carotid pulse

Answer

Check for responsiveness

Answer

Chest compressions

Answer

Shock 300 Joules

Question 9

What is true regarding cardiopulmonary resuscitation?

Accepted Answer

Adrenaline is given if cardioversion fails.

Answer

The most common presentation in ECG is asystole.

Answer

The compression to ventilation ratio is 5:1.

Answer

Calcium gluconate is given immediately.

Question 10

A patient weighing 80 kg is in shock. Calculate the infusion rate in drops per minute required for a vasopressor. The vial contains 200 mg in 5 ml. The drug is diluted in 250 ml Normal Saline. The recommended dose is microgram/kg/min. Assume 16 drops equal 1 ml.

Accepted Answer

8

Answer

16

Answer

24

Answer

32

Critical Care Medicine — MCQs

Critical Care Medicine — MCQs

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