MCQs in Critical Care Yatin Mehta, Prashant Kumar
INDEX
A
Abdominal cavity 196
Abdominal distension 123
Abdominal nodes 214
Abdominal pain 123, 134, 181, 326
severe 287
Abdominal tenderness 126
Abdominal trauma 323
Abdominal ultrasonography 334
Absolute neutrophil count 215
Acalculous cholecystitis, acute 125, 143, 322
Accidental kerosene ingestion 246
ACE inhibitor 6, 91
Acetaminophen overdose 248
Acetazolamide 210
Acid-base disorder 118
Acquired infections, prevent hospital 441
Acute kidney injury, staging of 165
Acute thrombotic stroke, suspicion of 79
Acute toxic cholangitis, therapy for 118
Adrenal insufficiency 209
Adriamycin 217, 244
Agitation 96
severe 248
Air filtration 444
Air fluid levels, multiple 123
Albuminuria 167
Alcohol
abuse, history of 294
abuser 293
intoxication, acute 249
Alcoholism, chronic 202
Alkaline phosphatase 121
Alkalosis 201
severe 208
Alkylating agents 243
Alleged medical negligence 418
Allergic bronchopulmonary aspergillosis 378
Alprazolam develops 291
Alternaria spp. 452
Aluminum phosphide 246, 256
Alveolar opacities 183
Alveolar-arterial oxygen gradient 53, 353
Amebic abscess 124
American College of Chest Physicians guidelines 196
American Heart Association guidelines 30, 319
American Society of Anesthesiologists 317
American Stroke Association guidelines 319
Amikacin 48
Amino acid 149, 154
Aminoglycoside 167, 179
nephrotoxicity 169
Amiodarone 6
side effect of 6
Amitryptilline 244
Amniotic fluid embolism 189
presentation of 185
syndrome 186
Amphotericin B 379
nephrotoxicity 169
Ampicillin 210, 272
Analgesia
implementation of 437
monitoring of 437
Analogon iloprost 368
Anemia, type of 167
Anesthetic drug 293
Aneurysmal subarachnoid hemorrhage 80, 87
Angiotensin converting enzyme inhibitors 2
Angiotensin II receptor blockers 191
Anion gap 204, 245
causes of normal 203
metabolic acidosis 248
Annual flu vaccine 449
Antecedent biliary-enteric fistula 140
Anthracycline 221
Antibody-mediated rejection 367
management of 360
Antidepressant medication, multiple 245
Antidiuretic hormone 204
Antifungal agent 273
Anti-lymphocyte antibodies 365
Antimicrobial therapy 310, 436
usage 424
Antiplatelet therapy 29
Anti-pneumocystis therapy 390
Antiretroviral therapy 270, 298
long-term 383
Anuria 171
Aortic injury 320
Aortic intramural hematoma 3
Apheresis platelet components 404
Apnea test 88
Arginine vasopressin, secretion of 226
Arterial blood
gas 41
partial pressure of oxygen in 53
pressure measurement, physics of direct 28
Arterial hyperenhancement 44
Arterial line 348
Arterial pressure
mean 81, 101
waveform 27, 30
Arteriovenous malformation 80
Arthralgias 380
Ascending colon, massive dilation of 123
Ascorbic acid 161
Aspergillosis 382
Aspergillus precipitin test 378
Aspirin 29, 91, 435
usage in ACS 423
Asthma
history of 45
in pregnancy 184
Atherosclerosis bioprosthetic valve 272
Atrial fibrillation 46, 27, 28, 202
postoperative 30
Atrium, dilated left 4
Autologous blood donation 400
Autonomic dysreflexia 90
Axillary line, anterior 294
Axonal injury, diffuse 86, 337
Azathioprine 122, 380, 388
Azithromycin 203, 290
B
Back pain, severe local 229
Bacterial infections 139
Barbiturates 111
Bariatric surgeries 156
Bartonella
bacteria 386
henselae 386
Bartter syndrome 210
Basal ganglia bleed 92
Basilar artery 336
Basilar tip aneurysm 104
Basophilic predominant inflammatory 42
Beauchamp childress system 347
Bedside echocardiography 293
Beta blocker overdose 246
Beta error 355
Bicarbonate-rich electrolyte solution 119
Bile duct cancers 117, 128
Biliary complications 134
Binary parenteral nutrition bags 150
Biostatistics and research methodology 392
Bipolar disorder 248
history of 291
Bishop Cairo classification 214, 226
Bispectral index, use of 247
Blast injury 247
Blast lung injury, management of 251
Bleeding patient 401
Bleomycin 217, 244
Blindness 245
Blood
bags, Gram stain of 410
coagulation studies 410
group 399
loss, signs of 335
pressure 45
stream infection, central line associated 218
tests 45
urea nitrogen 165, 316
Bloodstream infection, catheter-associated 447
Blunt abdominal trauma 320
Blunt aortic injuries 330
Blunt head injury 89
Blunt thoracic trauma 320
Blunt trauma patients 335
Body fluids 450
Boerhaave's syndrome 122, 138
Bolam test 418, 425
Bolus dose, single 28
Bone marrow
aspiration 411
biopsy 416
transplant 407, 444
Bony pelvis 189
Bouts of confusion 91
Bowel obstruction, small 123
Bowel rest 139
Bradyarrhythmia 364
Bradykinin 406
Brain
abscess 102
diagnosis of 96
risk factor for 96
surgical drainage of 96
dead donors, managements of 361
death 341
certification of 434
space occupying lesion 90
stem tests 79
tissue oxygen 85
Branched chained amino acids 151
Breast cancer 218
Breath, shortness of 378
Broad-spectrum antibiotic 288, 300
Bromocriptine 204
Bronchial asthma 44
Bronchial breath sounds 45
Bronchiectasis 50
Bronchoalveolar lavage 273, 325, 411
Bronchograms 45
Bronchopleural fistula 51
Bronchoscopy 411
area 449
infection control policies for 442
Bupivacaine
infusion 264
syringe 249
Burkholderia pseudomallei 307
Burkitt's lymphoma 222
Burn wound infections, invasive 452
Burns unit, infection control practices for 445
Burst suppression 89
ratio 89
C
Cachexia 367
Calcineurin inhibitor 191, 363
tacrolimus 280
Calcium
acetate 175
channel blocker 3, 249
Calculous cholecystitis, diagnosis of acute 125
Caloric assessment 150
Caloric source 149
Caloric test 99
Campylobacter 380
Cancer, chemotherapeutic agents for 239
Candida albicans 285, 378
Candida auris 275
Candida infective endocarditis, treatment of 273
Candidemia
empirical antifungal of 273
management of 273, 274, 306
Candidiasis 220
Capillary blood, end 53
Capillary perfusion 348
Capnogram 354
represents 347
Capnography 5, 333
Carbapenems 275
Carbohydrate 149
antigen, stool for 119
diet, low 155
Carbon dioxide, normal value of 53
Carbon monoxide 252
poisoning 202
Carboplatin 243
Carcinoma 214
breast 225
buccal mucosa 222
Cardiac allograft vasculopathy 362, 367
Cardiac arrhythmias 171
Cardiac care 420
Cardiac etiology 29
Cardiac filling pressures 368
Cardiac ischemia 409
Cardiac output 5
Fick formula for 1
Cardiac tamponade 5
Cardiac transplant 360
rejection 361, 367
Cardiogenic shock 3
Cardiology 1, 25
Cardiomegaly, moderate 45
Cardiopulmonary physiology 51
Cardiopulmonary resuscitation 182
Cardiorespiratory function, assessment of 360
Cardiovascular disease, risk of 174
Care for patients, quality of 435
Cat and dog bite wounds cause infections 251
Cat scratch disease 386
CAUTI
bundle implementation 444
prevention interventions 446
Cavernous venous sinus thrombosis 87
Cavitary pulmonary aspergillosis, chronic 382
Ceftriaxone 290
Cell lung carcinoma, small 231
Cellulitis 442
Center of disease control 440
Central diabetes incipidus
diagnosis of 229
management of 3
Central venous catheters 449
Cephalosporin 272
Cerbera odollam 246
Cerebral artery, middle 336
Cerebral blood flow 84
autoregulation of 88
Cerebral irritation, signs of 379
Cerebral microdialysis 85, 105
Cerebral palsy 328
Cerebral perfusion pressure 86
Cerebral salt wasting 200
syndrome 85, 105, 337
Cerebral saturation 7
Cerebral vasospasm 99
Cerebrospinal fluid 301
Cerebrovascular disease, severe 367
Cervical spine injury, low risk for 319
Charcoal 249
Charcot's triad 130
Chemical cardioversion 5
Chest pain 409
pleuritic 43, 44
Childhood asthma 54
Chlorhexidine-impregnated dressings 447
Cholangitis
acute 326
ascending 318
recurrent episodes of 125
Cholecystectomy 129
indications for 118
Cholecystokinin 119
Cholelithiasis 133
Cholescintigraphy 143
Choriocarcinoma 242
Christmas disease 416
Cisplatin 243
Citrate anticoagulation 166
CLABSI
for prevention of 441
problem of 449
Clavulanic acid 286
Clostridium difficile infection 300
diagnosis of severe 275
CMV disease 275, 285, 375, 383, 389
CNS
infection, postoperative 444
toxoplasmosis 274
Coagulase negative staphylococci 441
Coagulation factor deficiency 411
Cocaine abuser 248
Cold antibody hemolytic anemia 389
Cold water caloric reflex test 80
Colistin 222, 271
Collapsibility 2
Colloids 409
Colonic cancer, colectomy for 49
Colonoscopic decompression 140
Comatose patient, management of 88
Community acquired pneumonia 183, 204, 298
treated for 43
Complete blood count 401
Computerized tomographic pulmonary angiography 41
Congestive heart failure 409
Consent 425
Consumer Protection Acts 434
Contrast enhanced transthoracic echocardiogram 52
Contrast induced nephropathy 167, 205
chances of 29
incidence of 348
risk factor for 166
Corneal reflexes 356
Coronary angiogram 380
Coronary artery disease
accelerated form of 368
history of 201
Coronary vasospasm 219
Corticomedullary differentiation, loss of 165
Corticosteroids 46, 242, 364
Cough 182
history of increased 41
Crazy-paving 50
Creatine kinase 326
Criminal negligence
law pertaining to 426
qualifies for 419
Critical aortic stenosis 27
Critical care 346
infection control in 440
transfusions in 399
Critical illness polyneuropathy 423, 436
Critically ill
children 155
patients 52
Crohn's disease 122
Crush syndrome, management of 251
Cryoprecipitate 401, 402, 404, 408, 411, 414
indications of 410
poor plasma 404
transfusion 401
Cryptococcal infection 275
Cryptococcus neoformans 296, 311
Crystalloids 294
rapid infusion of 409
Cushing response, triad of 223
Cyanide toxicity, treatment of 245
Cyclophosphamide 226, 243, 244
Cystic lesions, multiple 378
Cytomegalovirus 401
D
Dacarbazine 217, 244
Damp sweeping 452
Dead-space ventilation 309
Death, diagnosis of 422
Deep vein thrombosis 86
in pregnancy 182
prophylaxis 43
Delirium 248, 356
Dementia 307
Dengue
hemorrhagic fever, diagnostic criteria 312
IgM for 381
infection, severe 297
shock syndrome 313
viral infection 313
Depression 271
Dermatomyositis 380
Diabetes
insipidus 89
mellitus 29, 79
history of 202
steroid induced 364
Diabetic foot infections, treatment of 318
Diabetic ketoacidosis 200, 210
management of 203
Dialysis
adequate dose of 171
indication for urgent 169
Diarrhea, history of 379
Diastolic pulmonary vascular pressure gradient 365
Dietary allowances 151
Diethylcarbamazine 273
adverse effects 282
single dose of 380
Digital subtraction angiography 82
Digoxin
sign of 254
therapeutic window of 26
toxicity 245
Dilated right ventricle, severely 44
Dilutional coagulopathy 402
Dispersion, measure of 393
Disseminated encephalomyelitis, acute 82
Disseminated intravascular coagulation 196, 415
Diuretics 169
D-lactic acidosis 349
DNA technology 408
Donor leukocytes 407
Donor platelet concentrate, single 404
Dopamine 210, 299
Doxycycline 271
Drug eluting stents 26
Drug fever 349
Drug, prescription of 419
Drugs and Cosmetics Act 427
Dyshemoglobinemia 356
Dyskaryotic cell lines 380
Dysphagia 289
Dyspnea 26, 182, 409
E
Echinocandin 274
Echinococcus granulosus 118
Eclampsia
cases 189
diagnostic feature of 181
Electrolyte disorders 183
Emergency room 41
Emphysematous cholecystitis 293
Empiric antibiotic therapy 218
Empiric therapy 278
End of life
care 343
decision 340
making 340
pathway, presence of 420
End stage renal disease, single predictor of 167
Endocarditis, treatment of 276
Endocrinology 199
Endogenous candidemia 378
Endophthalmitis 378
Endoscopic procedures 411
Endotracheal tube 354
position 290
Engraftment syndrome 234
Enhanced crossmatches 409
Enteral nutrition 429
delivery, quality of 424
Enteral tube feeding 160
Enterobacter cloacae 280
Environmental hazard 244
Enzyme secretion 131
Enzyme-linked immunosorbent assay 387
Epidemic diseases 434
Epidural anesthesia 186, 411
Epidural hematoma, acute 324
Epigastric pain 26, 45, 121
Episodic bradycardia 92
Epithelial cells, areas of necrosis in 378
Erythema 216
migrans 386
Erythropoietin, initial dose of 167
Escherichia coli 48
enterohemorrhagic 278
Esophageal Doppler 27, 288
ESPEN guidelines 151, 152
Estimated glomerular filtration rate 171
Ethanol 247
Ethylene glycol poisoning 250
Etomidate 308
Euthanasia 344, 431
implies 340
Exocrine tissue 119
Expiration, end of 53
Extensor posturing 356
Extracorporeal membrane oxygenation 2, 27, 42, 294, 309
complications of 6
signs of membrane failure in 4
Extradural hematomas 88
Extrapulmonary complications 389
F
Family satisfaction 341
Fast hugs bid 349
Fast-flush test 7
Fat embolism syndrome 325
diagnosis of 317
Fat soluble vitamins 151
Fatal cardiomyopathy
element causes 149
risk of 154
Fatty acids 164, 192
Fatty liver of pregnancy, acute 188, 191
Febrile illness 379
Febrile neutropenia 218, 221, 273
Fetal loss 189
Fetal movements, absence of 188
Fever 274
history of 90
Fibrinolytic agent 28
Fibronectin 157
Fiduciary obligation 421
Fluconazole 184, 218, 243
role of 274
Flumazenil 263
Fluoxetine 291
Flush device, continuous 348
Focal segmental glomerulosclerosis 184
Foodstuffs 157
Fosfomycin 222, 272
Free intraperitoneal fluid 331
Fresh frozen plasma 404
indications of 415
transfusions 47
Fusarium spp. 452
Fusobacterium necrophorum 302
G
Galactomannan 273
assay 378
Gallbladder gangrene incidence 334
Gamma hydroxybutyrate 249
Gamma irradiation inactivates lymphocytes 411
Gastric
antrum 120
bypass surgery 45
feeding 151
lavage 253
Gastrinoma patients 131
Gastrointestinal 117
bleeding, management of upper 147
endoscopy 381
Genitourinary injuries 323
Gentamicin 272
Gestation 189
Gestational trophoblastic neoplasms 219
Glasgow coma scale 324, 329, 338
Glasgow outcome scale 79, 86
Glasgow-Blatchford
bleeding score 125
score, modified 145
Glucose control in ICU 202
Glutamine 151, 158, 164
plasma levels of 158
Graft versus host disease, acute 216
Gram negative
bacilli 271
meningitis 81
Granulocyte transfusion 451
Granulomatous disease, chronic 386
Guillain-Barré syndrome 79, 87
H
H1N1
influenza 270
patient 440
pneumonia 50, 445
Haemophilia
earlier effective treatment for 408
history of 401
severe 401
Hagen-Poiseuille law flow 359
Halo sign 273
Hang hygiene compliance 420
Hartmaan's solution 205
HBV blood test, results of 445
Head injury 86, 321
neurological examination 324
Head trauma 310
Health care, medicolegal aspects of 434
Health evaluation
acute chronic 308
acute physiology 308
Healthcare-associated aspergillosis 445
Heart
and liver, transplantation 360
disease 182
left-sided 365
failure
acute 3
acute decompensated 28, 191
pathophysiology of acute 6
survival score 360
transplant 360, 365, 366
contraindication for 361, 367
Heat and moisture exchanger 54
Heat stroke, management of 251
Heavy metal poisoning 249
HELLP syndrome
diagnosis of 188
laboratory criteria for 185
management of 185
Hematologist plans 404
Hematopoietic growth factors, role of 224
Hemithorax, unilateral 318
Hemobilia 118
causes of 128
Hemodynamic 294
Hemoglobin 399
Hemolysis, rule out 410
Hemophagocytic lymphohistiocytosis 387
Hemophilia B, treatment of 416
Hemoptysis 290
Hemorrhagic infarct 322
Hemorrhagic shock 207
Heparin induced thrombocytopenia 26, 321, 348
Heparin prophylaxis 221
Hepatic blood flow 121
Hepatic enzyme abnormalities 118
Hepatic processes 135
Hepatic venous wedge pressure 124
Hepatitis
B 99
immune globulin 453
surface antigen 124
vaccine 453
viral infection 144
virus 124, 125
C 98
chronic 381
related cirrhosis 44
virus 124, 136
E infection 381
Hepatocellular carcinoma 145
Hepatopulmonary syndrome 52
Hepatorenal syndrome 166, 168, 205
diagnosis of 166
Hepatosplenomegaly 381
Herceptin receptors 219
Herpes simplex encephalitis 81
High flow nasal cannula 54
therapy 43
Hind brain, spectrum of 103
Hodgkin's lymphoma 223, 231, 244
Homans' sign 182
Hospital, direct liability of 423
Hounsfield units 322, 334
HSV encephalitis 101
Human disease 384
Human immunodeficiency virus 270
infected pregnant women 385
infection, acute 315
Human Resources Department 442
Human tissues 450
Hydatid cysts 144
Hydrocortisone
stress doses of 208
use of 201
Hyperbaric oxygen 55
Hypercalcaemia, severe 226
Hypercalcemia 210
management of 203, 214
mechanism for 224
symptoms of 223
Hypercapnia 41
Hypercapnic respiratory failure, extrapulmonary causes of 44
Hyperglycemia 264, 309
Hyperglycemic hyperosmolar state 212
Hyperkalemia 171
therapy for 170
Hyperlactatemia 201
Hyperlipidemia, pastmedical history of 293
Hyperosmolar hyperglycemic state 204
Hyperosmolar therapy 86, 106
Hypersensitivity pneumonitis 390
Hypertension, treatment for 182
Hypertensive response, acute 101
Hyperthermia 248, 249
Hyperthyroidism 203
Hypertonic saline 86
Hypertrophy 183
Hyperuricemia 174
Hyperventilation 207
Hyperviscosity syndrome 224, 240
Hypervolemia 351
complications of 346
Hypocalcemia 100
in septic shock 205, 213
Hypocapnia 198
Hypoglycemia 202
Hypokalemia 170, 203
Hypokinesia, severe global 27
Hyponatremia 249
Hypophosphatemia 205, 213, 354
causative factor for 200
causes of 347
Hypotension 27
episodes 171
Hypothesis tests, types of error in 395
Hypothyroid 201
Hypothyroidism 150, 292
Hypoxia, acute 293
I
Idiopathic pulmonary syndrome, diagnosis of 223
Idiopathic ventricular fibrillation 4
Ifosfamide 243
Imipenem 48
Immune modulating formula 152
Immune senescence 312
Immune thrombocytopenia, treatment of 403
Immunomodulating diet 159
formula 151
Immunosuppressant 360
Immunosuppression 360
Indian Association of Palliative Care 344
Infection
acquired, rates of 420
and sepsis, severe 287
prevention 440
surgical-site 444
Infectious diseases 378
Infectious mononucleosis 386
Infective endocarditis, diagnosis of 317
Influenza
developed 441
virus 276
Infratentorial extension 93
Inhalational injury cases, acute 51
Insect bite, treatment of 247
Insect related anaphylaxis, etiology for 247
Inspiratory oxygen fraction 48
Institute of healthcare improvement, component of 440
Insulin
administration 180
with glucose 170
Insulinoma 131
Intensive care unit 449
Intermediate syndrome 250
Intermittent fever 96
International subarachnoid treatment 89
Interstitial predominance 44
Intestinal ischemia, acute 334
Intra-abdominal hypertension 301
grades of 319
Intra-aortic balloon
counter pulsation 349
pump, hemodynamic effects of 28
Intracranial aneurysms 80
Intracranial brain hemorrhage 80
Intracranial haemorrhage, acute 81
Intracranial hypertension 166
Intracranial pressure 80, 329
Intrapulmonary vascular dilatation 52
Intravenous antibiotics 46
Intravenous aztreonam 46
Intravenous fluids 403
Intraventricular hemorrhage 93
Invasive aspergillosis, treatment of 378
Invasive candidemia, risk factor for 292
Invasive pulmonary aspergillosis 273
Invasive rhinocerebral mucormycosis 81
Investigations, record of 419
Ipsilateral hemiplegia, develops 79
Ischemic infarct, acute 167
Ischemic stroke, acute 351
Isolation facilities 444
Isotonic hyponatremia 175
J
Jaundice 326
presence of 142
Jugular vein
central vein cannulation, internal 7
distention 325
suppurative thrombophlebitis 302
K
Kayexalate 201
Ketamine 293
Ketosis 149
Kidney
disease 171
injury, acute 165, 251
Klebsiella pneumonia nosocomial infections 441
L
Lactatemia 123
Lactic acidosis 150, 155, 210
Laryngeal nerve, external branch of superior 327
Law binds physician 419
Law of confidentiality 419, 426
Left bronchial artery 42
Left ventricular
assist device 28, 366
dysfunction 369
failure, acute 166
Lemierre's syndrome 271, 302
Lethal drug, administration of 421
Leukocyte esterase, false negative test for 177
Leukoreduced blood products 401
Levine sign 3
Licorice ingestion 210
Liddle syndrome 210
Life
and personal liberty, right to 421
decision making, model for end of 339
support
forgoing of 340
treatments, forgoing of 343
Life-threatening
difficile colitis, treatment of 270
reaction 406
Lignocaine 245
Ligustrazine alleviates acute pancreatitis 132
Linezolid 210, 271, 278
Lithium 261
Liver
benign lesions of 117
disease 118, 415
chronic 166
function tests 148
malignant neoplasms of 117
segmental anatomy of 117
transplant 44
Lobe pneumonia, lower 293
Loiasis, treatment of 387
Loop diuretics 169
Lorazepam tablets 249
Lower lobe pneumonia, right 46
Lower segment cesarean section 123
Lumbar puncture 96, 348, 411
complications of 349
Lumbar spinal cord, trauma to 79
Lundberg A waves 100
Lundberg B waves 100
Lung
and bilateral mild pleural effusion 222
bilateral 218
consolidation 47
contusion 325
disease 29
hyper inflated 55
injury
acute 321, 325
ventilator induced 50
thoracic radiation for 55
transplant 50
ultrasound
addition of 55
deciphers 5
Lymphoblastic leukemia, acute 216, 402
Lymphocytic leukemia, acute 219
M
Magic mushrooms 251
Magnesium
deficiency 201
retention test 203
toxicity 187
Magnetic resonance angiography 82
Malaise, complains of 45
Malaria, severe 273
Mallory-Weiss syndrome 144
Mannitol 106
Massive blood
loss 317
transfusion, complications of 335
Massive hemoptysis 42
Massive transfusion 405
protocol 399
Maternal and child enquiries, centre for 198
Maxillofacial trauma 323
Mazzotti reaction 387
MDR-TB, management of 272
Mechanical ventilation 45, 53, 435
complication rate of 52
for respiratory failure, quality of 423
liberation from 51
Mediastinitis 332
acute 321
Medical Council Act 427
Medical jurisprudence 425
Medical law
and ethics 418
context of 426
Medical negligence
allegation of 426
claim of 418, 425
Medical practitioner 419
Medical professional 426
Medical records, maintenance of 427
Medical research 397
Medication errors 257
Melanoma 242
Melioidosis 277, 307
Meningococcal meningitis, diagnosis of 443
Mesenteric artery, origin of superior 126
Mesenteric ischemia 139
acute 126
Mesenteric vasospasm 327
Metabolic acidosis 123, 171, 184, 203, 245
severe 203
Metabolic alkalosis 128, 210, 354
causes of 204
treatment of 210
Metabolic cart 156
Metabolism 199
Metallic body implants 450
Metastatic malignancy 240
Metastatic spinal cord compression, evidence of 219
Metformin 91
causes type B lactic acidosis 254
intoxication causes 245
Methanol 253
intoxication 246
poisoning, treat 247
Methicillin resistant staphylococcus aureus 302, 442
modes of spread of 449
treatment of 271
Microcalorimetry 278
Microdialysis chart 90
Microscopic agglutination testing 386
Midazolam 111
Mid-ureteral calculi 173
Miller-Fischer syndrome 98
Milrinone 30
Minocycline 284
Minocycline over tigecycline, advantage of 274
Mite-borne infectious disease 315
Mitochondrial beta-oxidation 192
Mitral stenosis 202
Mitral valve, systolic anterior motion of 307
Moistens 54
Molecular weight, large 165
Monoclonal antithymocyte antibody-muromonab 364
Mononeuclosis 380
Motorcycle 91
Motorcyclist 91
Moxifloxacin 46, 275
Moyamoya 103
MRI brain 96
Mucinous carcinoma of ovary 220
Mucor spp. 452
Mucositis, evidence of 218
Multi-drug resistant 80
Multiorgan failure 28, 312
Murphy sign 334
Muscle contraction, smooth 50
Mushroom poisoning 209
Mycophenolate mofetil 365
Myeloblastic leukemia, acute 273
Myeloid leukemia, acute 273
Myeloma, multiple 400
Myelosuppression 388
Myocardial infarction, acute 3
Myocardial ischemia 126
Myoglobinuria 326
N
N-acetylcysteine 246
Nasal canulla 292
Nasogastric decompression 139
Nasogastric suction 327
Nasogastric tube placement 328
National Health Safety Network 309
National Healthcare Safety Network 52
National Nosocomial Infections Surveillance System 444
Natriuretic peptides 28
Necrotizing fasciitis, risk indicator for 270
Neonatal exchange transfusion 407
Neonatal intensive care unit 441
Nephrogenic fibrosing cholangitis 167
Neuraxial block 186
Neurocritical care 82, 85
unit 95
Neurogenic bladder 319
Neurointensive care 79, 92, 93
Neuroleptic malignant syndrome 228, 252
Neuromuscular disorders 307
Neuron specific enolase, level of 347
Neutropenic enterocolitis 224, 242
Neutrophil predominance 294
New York Heart Association 364
NIHSS score 90
Nimodipine 89
Nitroglycerin intravenous infusion 124
Non protein calorie sources 155
Non thyroidal illness syndrome 210
Non-convulsive status epilepticus 85
Non-Hodgkin's lymphoma 223, 231, 389
Noninvasive ventilation 2, 41
Nonocclusive mesenteric ischemia 318
Non-protein caloric sources 149
Non-rebreathing mask 222
Nonverbal communication, soler acronym for 421
NSTEMI management 435
Null hypothesis 394, 395
NUTRIC score 160
Nutrition 152
in acute pancreatitis 152
in burn victims 153
in critical care 149
in hepatic failure patients 152
in open abdomen 153
in traumatic brain injury 152
prescription, monitoring of 437
Nutritional assessment 149
Nutritional support, quality of 420
O
Obesity
hypoventilation syndrome 44
severe 367
Obstetric patient, resuscitation of 187
Obstetric sepsis 187, 198
Obstetrics and gynecology 181
Obstructive airway disease 53
Obstructive lung disease, chronic 46
Obstructive pulmonary disease, chronic 41
Obstructive sleep apnea 44
Octreotide 125, 126
Oliguria 27, 124
Oncology 214
Oncovin 244
Optic atrophy 245
Optical and colorimetric techniques 53
Oral anticoagulants, direct 322
Oral calcium acetate 167
Organ donation 423
consent for 422, 434
Organ failure assessment score 304
Organophosphate insecticides 257
Organophosphorus 248
Orientia tsutsugamushi 315
Oropharyngeal decontamination 441
Orthostatic hypotension 126
Oseltamivir 290
Osmolal gap 202, 250
Osteoporosis 364
severe 367
Over damped waveform, causes of 348
Overtraining syndrome 206
Oxazolidinone antibiotic 278
Oxygen
consumption, cerebral metabolic rate of 88
delivery 46, 346
dissociation curve 55
mask 287
saturation 47
gap 248
transport parameters 53
Oxygenation
defect 52
stable 309
P
Pain
and distress, freedom from 343
presence of 142
Palliation means 339
Palliative care 340, 439
Pancreas 119
adenocarcinoma of 119, 131
Pancreatic abscesses, causes of 132
Pancreatic ascites 123, 140
Pancreatic exocrine secretory 119
Pancreatic juice, bicarbonate concentrations of 119
Pancreatic pseudocysts, management of 133
Pancreaticoduodenectomy 121, 135
Pancreatitis 293
acute 120, 125, 137, 163
chronic 120
mild 117
Pancreato-duodenectomy 215
Pancytopenia 199, 401
Papillary carcinoma thyroid 217
Papillary thyroid cancer 242
Paracetamol 217
poisoning, transplant center in 244
Paralytic ileus 126, 147
postoperative 126
Paraquat poisoning 246, 264
Parasitic infection 128
Parenchymal changes 325
Parenteral anticoagulation 4
Parenteral intravenous fluids 43
Parenteral nutrition, quality markers for 424
Parkinson disease 328
Paroxysmal nocturnal dyspnea 409
Peak oxygen consumption 361
Peak serum creatine kinase levels 326
Peculiarities 51
Pediatric neurosurgical patients 90
Penicillin 272
resistance 301
Peptides, formulas containing 161
Percutaneous coronary intervention, primary 26
Periampullary carcinoma 215
Perilesional edema 271
Perioperative atelectasis 43
Periorbital cellulitis 224
Peripartum cardiomyopathy 182, 187, 196, 197
diagnosis of 187
incidence of 26
Peripheral blood
culture 274
stem cells 407
Peripheral enhancement 220
Peripheral vascular disease, severe 367
Peripheral vein suppurative thrombophlebitis 278
Peritoneal lavage 132
Peritoneovenous shunt 124
Persistent abdominal pain, causes of 246
Personal protective equipment 440
pH 41, 46
Pharmacology, acute 244
Phenytoin toxicity causes 104
Pheochromocytomas 204
Photopheresis 365
Physiologic scale, acute 308
Piperacillin 218
Pituitary
adenomas 90
apoplexy 204
gland 207
macroadenoma, transsphenoidal resection of 92
Plasma magnesium concentration 197
Plasmapheresis, contraindication of 80
Plateau pressure 49, 308
Plateau wave 80, 100
Platelet
concentrate 404
dose of 416
count 403
for prophylactic therapy, standard dose of 412
irradiation 403
products 404
transfusion 198, 402
Pleural effusion
bilateral mild 200
characteristics of 29
unilateral 231
Pleural sliding, presence of 326
Pneumococcal vaccine 215
Pneumocystis jirovecii 378
pneumonia 236, 297
treatment of 381
Pneumocystis pneumonia in malignancy 221
Pneumonia 296
bilateral 54
severity index 316
ventilator associated 49, 52, 436
Pneumothoraces 53
Pneumothorax 323
develops left-sided 45
diagnosis of 318
Poisoning 244
Poisonous snakes 250
Polyclonal antithymocyte globulin 364
Polymerase chain reaction 295
Polymorphisms, genotyping for 325
Polymyxin 278
B, advantage of 271
Polystyrene sulphonate 201
Portal hypertension, causes of 124
Portal venous pressure 124
Portosystemic venous shunt, indications for 118
Posaconazole 191
Positive serum galactomannan 218
Post-cardiac
arrest patients 356
surgery 2
transplant patient 362
Posterior reversible encephalopathy syndrome 88, 194
Postextubation laryngeal edema 55
Post-heart transplant complications 360
Postintensive care syndrome 293
Postpartum hemorrhage 199
Post-renal transplant 379
Postspinal headache 358
Post-transfusion hepatitis, causes of 124
Post-transplant lymphoproliferative disease 388
Post-transplant persistent pulmonary arterial hypertension, management of 368
Post-traumatic
epilepsy 86
seizure, risk factor for 86
Potential teratogenic 196
Preanesthetic check-up 45
Predeposit autologous donation 406
Prednisone 244
therapy, chronic 293
Preeclampsia 167
severe 187, 197
Pregnancy 166, 181
develops gradual progressive dyspnea 183
managing sepsis in 181
mechanical ventilation in 183
physiologic changes of 190
physiological adaptation of 185
trauma in 181, 187, 322
Premature newborns 407
Pressure support ventilation 288
Prilocaine 245
Prilox cream 245
Primary adjuvant therapy, pillars for 55
Procarbazine 244
Progesterone receptors 219
Promyelocytic leukemia, acute 219
Prone ventilation 42, 436
Propofol, use of 111
Prostacyclin 368
Protein content 157
Prothrombin complex concentrate 404
Proton pump inhibitor 126
Protozoal 390
Pseudocyst 120
recurrence, risk of 120
Pseudomembranous colitis 146
Psychiatric illness 307
Pulmonary arterial hypertension 332
characteristic of 321
Pulmonary arterial pressure 47
Pulmonary artery 1, 359
catheter 53, 350
hypertension 25, 44
causes of 25
massive embolism of common 46
occlusion pressure 30
Pulmonary aspergillosis, chronic 382
Pulmonary capillary wedge pressure 1
Pulmonary circulation 349
Pulmonary clearance medications 43
Pulmonary contusion 320
opacities 331
Pulmonary edema 413
bilateral perihilar 182
causes of 2
Pulmonary embolism 25, 30, 41
acute 367
diagnosis of 221
risk of 221
Pulmonary function, prevent deterioration of 244
Pulmonary hemorrhages 380
Pulmonary hypertension 365
evidence of 366
typical characteristics of 29
Pulmonary oxygen toxicity 52
Pulmonary toxicity 217
Pulmonary tuberculosis, history of treated 289
Pulmonary vascular disease, assessment of 361
Pulmonary vasculature 55
Pulse
oximeter 353
pressure
maximum 306
mean 306
minimum 306
variation 306
Pupillary responses, absence of 356
Purulent sputum 46
Pyoderma gangrenosum 270
Pyogenic abscess of liver 124
Pyogenic hepatic abscess, current therapy for 117
Pyogenic liver abscess 121, 135
treatment of 121
Pyogenic meningitis, management of suspected 272
Q
qSOFA 291, 295, 304, 311, 347, 352
Qualitative variables 393, 398
Quantitative futility 433
Quantitative serum hemoglobin 410
Quantitative variables 398
R
Radiation induced lung injury 55
Radiation pneumonitis 55, 224
Radiation syndrome, acute 245
Radiator coolant 248
Random donor platelet concentrate 404
Rankin scale, modified 87
Ranson's prognostic signs 123, 143
Recurrent variceal haemorrhage, prevention of 118
Red blood cell 399
Red cell eluate 409
Re-expansion pulmonary edema 50
predictive of 42
Refeeding syndrome 151, 159, 200, 207, 354
Refractory angina 366
Refractory asthma in ICU 43
Refractory hypoxemia 43
Renal cell carcinoma 242
Renal disease 154, 162
end stage 183
Renal dose, antibiotics need 169
Renal failure 152, 364
and hypotension 248
Renal impairment 169
Renal replacement therapy 166
continuous 151, 154, 166
Renal stone, unilateral 166
Renal tubular acidosis 205, 213
Renal tubulopathy 243
Replacement fluid, dose of 165
Residual bronchiectasis 289
Respiratory 41
alkalosis 207, 346, 354
causes of 50
care 435
compliance, sudden fall in 42
cycle 1
distress 312, 327
distress syndrome, acute 45, 325
management of 186
extracorporeal membrane oxygenation 6
failure 45, 52
acute 50, 52, 152
causes of 52
infections, prevalence of 447
muscle weakness 51
rate 46
Resuscitate order 340
Resuscitation, principles of 197
Retinoic acid 222
Retroviral disease 378
diagnosis of 379
Retroviral infection 380
acute 315
Retroviral syndrome, acute 298, 315
Rhabdomyolysis 204, 212, 317, 326
overdoses causing 249
Rhesus 196
Rheumatic heart disease 94
Rheumatoid arthritis 293
azathioprine for 380
Rhinocerebral mucormycosis 102
Rhizopus spp. 452
Riboflavin 154
Ribonucleic acids 164
Right ventricular infarction 25
Road traffic accident 79, 399
Rocuronium 293
Room air pressure, negative 451
Root canal treatment 289
Rotavirus 442
Routine liver chemistries 121
Roux-en-Y pancreaticojejunostomy 140
Ruptured mycotic aneurysm 94
S
Salbutamol, inhalation of 46
Salicylate intoxication 248
Salicylate overdose 260
Saliva 450
Salmonella bacteremia 379
Salmonella septicemia 385
Scedosporium prolificans 384
Schistosomiasis 386
Schizophrenia, treatment for 244
Sclerosis, multiple 328
Scorpion envenomation 247
Scrub typhus 315
Scrub typhus infection 298
Seizures, risk factor for 107
Selenium deficiency 154
Selenium supplementation 154
Sella turcica 207
Sent biopsies 289
Sentinel loop 122, 137
Sepsis 28, 312
prognostic factors of 290
severe 293
uncontrolled 130
Septic shock 204, 207, 295
Sequential compression devices 86
Serologic testing 121
Serotonin syndrome 204, 212, 305, 350, 359
Serotonin toxicity 254
Serum
alanine aminotransferase 188
amylase test 335
bilirubin 410
creatinine 171
digoxin level 26
ferritin 274
iron 29
lactic dehydrogenase 123
potassium concentration 180
procalcitonin 272
sodium 167
transaminases 121
voriconazole 273
Shigella 380
Sickle cell
anemia 403
disease 386
Sinus tachycardia 183
Six sigma DMAIC
format 442
methodology 448
Smoker, chronic 42
Social justice 339, 342
Sodium
bicarbonate 207, 261
nitroprusside 368
Soft tissue infection, necrotizing 300
Solid organ transplant 275
recipients 297
Somatosensory-evoked potentials 356
Sonography in trauma, focused assessment with 323
Sphincterotomy 287
Spina bifida, diagnoses of 328
Spinal cord
compression, malignant 223
injury 90, 328
acute 320
leads 100
sign of 81
Splenorenal shunt, distal 129
Spontaneous bleeding 402
Spontaneous breathing trial 51
Spontaneous intracerebral haemorrhage, management of 319
Spurious hypoxemia 236
Sputum production 46, 289
Staphylococcus aureus 452
Staphylococcus epidermidis 284
Statistical test 392
Status epilepticus 89
Stones obstructing ureteropelvic junction 173
Stones within ureter 173
Storing platelet 417
Streptococcus pneumoniae 388
infection 301
Streptokinase treatment 3
Stress ulcer prophylaxis 85
Stroke
index, normal value of 2
right sided 95
volume 300
variation 5
Subdural hematoma
acute 88
chronic 88
Subtotal thyroidectomy, postoperative case of 215
Sudden ventricular tachycardia, develops 4
Sulfamethoxazole 222, 224
Sulfite ion 149, 159
Supraventricular arrhythmia 364
Surgery and trauma 317
Surrogate 339, 342
Syndrome of inappropriate antidiuretic hormone secretion 85, 200, 324
diagnostic criteria of 214
Systemic complications, risk factor for 381
Systemic inflammatory response syndrome 304, 311
Systolic blood pressure 171
T
Tachycardia 27, 126, 248
Tachypnea 119, 182, 248
Tacrolimus 369
administration 184
Takotsubo cardiomyopathy 29
Targeted temperature management 348
Tazobectum 218
TB meningitis 274
T-cell
opsonization 364
response, suppression of 365
Teicoplanin 218
Telescopes 147
Temporary hemodialysis catheter 165
Temporary transvenous pacing
correct indication for 30
lead 25
Tenofovir nephrotoxicity, clinical presentations of 277
Terson syndrome 90
Thiamine 155
deficiency lack
signs associated with 161
symptoms associated with 161
Thiazide diuretics 3
Thoracic malignancies 55
Thrombocytopenia 188, 198, 289, 325, 332, 402
typical heparin induced 26
Thromboembolic events 219
Thromboembolic phenomenon 193
Thrombolytic therapy 30, 51
Thrombotic mesenteric ischemia, chronic 123
Thrombotic stroke
hyper acute 108
service, hyperacute 87
Thyroid storm 209
Tidal volume 49
Tigecycline 101
Tocolytic induced pulmonary edema, develops 51
Total abdominal hysterectomy 199
Total lymphoid irradiation 365
Toxoplasma gondii 286
Toxoplasmosis 379
Trachea, acute obstruction of 42
Tracheostomy 86
Transcellular shifts 354
Transesophageal echocardiography 4, 322
Transfusion reaction 399
Transient ischemic attach 3
Transpulmonary thermodilution method 30
Transthoracic echocardiography 4
Transurethral resection 184
Trauma
lethal triad of 324
management of 436
multiple 181
Traumatic acute subdural hematoma, management of 319
Traumatic brain injury 86, 323
essential diagnostic criteria for 324
management of 81
steroid in 87
Traumatic cardiac tamponade 320
Traumatic diffuse axonal injury 324
Tricyclic antidepressant 253
Trimethoprim 222, 224
Tubercular meningitis 80, 90
Tuberculosis, treatment for active 379
Tubular necrosis, acute 176
Tumor lysis syndrome 200, 207, 214, 221, 238
U
Ultrasound femoral vessels 190
Uncal herniation, sign of 79
Unstable angina 27
Upper airway 54
Upper esophagus, carcinoma of 223
Upper gastrointestinal bleeding 29, 123
Upper limb catheter, decreased risk of 49
Upper ureteral stones 173
Ureteral injury, cause of 319
Ureteral stones, distal 173
Urethral injury 320
Uric acid 174
excretion of 206
Urinary
angiotensinogen, measurement of 177
catheters 328
chloride 208
fat stains 325
pneumococcal antigen 316
tract infection 319
Urine
analysis 168
hemoglobin 410
ketones 202
legionella antigen 203
output 201
specimen, contamination of 167
Urology 181
Uterine rupture 196
V
Vaginal discharge 181
Vaginal fluid 450
Valve infective endocarditis 270
Vancomycin 47, 179, 271, 276
intermediate staphylococcus aureus 445
resistant enterococci 445
Variceal bleeding, acute 124
Vascular intestinal ischemia 322
Vascular nonocclusive 334
Vascular occlusive 334
Vascular resistance, metric unit for 1
Vasculitis 232
Vasodilatation 207
Vasodilators 7
Vasopressin 124, 312
acts 141
Vasopressor support 199
Vasospasm, management of 87
Vein of Galen 80
AVM 100
Vena cava, inferior 215
Venom immunotherapy 250
Veno-occlusive disease 219
Venous air embolism, detection of 90
Venous arterial blood management protection 354
Venous thromboembolic disease 183
Venous thromboembolism 346
in pregnancy 185
Veno-venous hemodiafiltration, continuous 165
Ventilation, volume control 288
Ventilation–perfusion 185
Ventilator alarms 49
Ventilator-associated
complication, infection-related 451
condition 451
event 309, 443
tracheobronchitis 445
Ventilatory support 48
Ventricular arrhythmias 249
Ventricular drain, external 82, 87, 295
Ventricular fibrillation 7
Ventricular waveform 1
Vertebral artery 80
Vicarious liability 419
Vinblastine 243, 244
Vinca alkaloids 243
Vincristine 217, 243
Viper bites 247
Viral
infection 389
pneumonias 310
Virus mask, aerosolization of 452
Visual disturbances 197
Vital parameters 199
Vital signs 45
Vitamin
A 154
C 161
in ESPEN guidelines 152
K 154
Voriconazole 382
prophylaxis 224
W
Wallace “rule of nine” 323
Water soluble occupational chemical 248
Waterhouse-Friderichsen syndrome 199, 206
Weakness, right sided 90
Weight loss 123
Weil disease 386
Wernicke's encephalopathy 89, 110
Western blot 379
Wheezing 378
Whipple's procedure 121, 227
White cell counts 96
World Society of abdominal compartment syndrome 319
Z
Zika virus 274
disease 285
Zollinger-Ellison syndrome 119
×
Chapter Notes

Save Clear


Cardiology (Part I)CHAPTER 1

Poonam Malhotra Kapoor
A Type Questions
(One best answer)
  1. What does ‘a’ wave in CVP mean and which wave of the ECG does it follow?
    1. Passive filling of the ventricle found on the T wave
    2. The atrial kick, found just after the P wave
    3. The atrial kick, found just after the T wave
    4. The atrial kick, found after the QRS complex
    5. Contraction of the ventricle, located at the ST segment
  1. Which portion of the ventricular waveform represents the preload state?
    1. Systolic peak
    2. Beginning diastole
    3. End diastolic pressure (EDP)
    4. End systolic pressure (ESP)
    5. The ventricular upstroke
  1. What is the normal pressure for the pulmonary artery?
    1. 45/10/40
    2. 30/30/24
    3. 25/10/15
    4. 50/15/33
    5. 45/10/15
  1. The normal pulmonary capillary wedge pressure (PCWP) is:
    1. 12–16 mm Hg mean
    2. 2–6 mm Hg mean
    3. 10–15 mm Hg mean
    4. 10–30 mm Hg mean
    5. 14–45 mm Hg
  1. What is the Fick formula for cardiac output?
    1. Wt. (kg) × 3/(Ao Sat - Pa Sat) × 1.36 × hemoglobin × 10
    2. Wt. (lbs.) × 3/Ao Sat × Pa Sat) × 1.36 × 10
    3. Height × weight/stroke volume × heart rate + hemoglobin
    4. Wt. (kg) × body surface area/(Ao Sat + Pa Sat) × 80
    5. Wt. (kg.) × 3/Ao Sat × Pa Sat) × 1.36 × 20
  1. What is the metric unit for vascular resistance?
    1. Dynes-5/cm
    2. Dynes-sec-cm−5
    3. mm Hg
    4. Cm2 × dynes × 5
    5. dyn·s/cm5
  1. Where, on the respiratory cycle, is the optimal measurement point for measuring atrial and wedge pressures?
    1. End inspiration
    2. You need inspiration and expiration, and average them
    3. End expiration
    4. Either one is OK, as long as you adjust the measurement scale
    5. None of the above
  1. In which case might a thermodilution cardiac output be superior to a Fick?
    1. Low cardiac output state
    2. Tricuspid valve regurgitation
    3. Mitral valve stenosis2
    4. High cardiac output state
    5. Pulmonary valve regurgitation
  1. The normal value of stroke index, postcardiac surgery is:
    1. 60–80 mL/m2
    2. 40–60 mL/m2
    3. 30–65 mL/m2
    4. 20–30 mL/m2
    5. 10–20 mL/m2
  1. The figure shows ultrasound guided IVC imaging showing collapsibility in the:
    zoom view
    1. Figure A only
    2. Figure B only
    3. Both Figures A and B
    4. Both are normal
    5. Both are abnormal
  1. The invasive method of diagnosing possible cause of pulmonary edema is:
    1. Cardiac biomarkers
    2. Right heart catheterization
    3. Hemoconcentration
    4. Transthoracic echocardiography
    5. Left heart catheterization
  1. The best therapeutic options for weaning associated pulmonary edema:
    1. Diuretics
    2. Vasodilators
    3. PEEP
    4. CPCP/BiPAP
    5. Nitroglycerin
  1. Which of the following is true regarding ECMO in adult patients with ARDS?
    1. VA—ECMO is associated with decreased mortality compared to VV—ECMO
    2. VA-ECMO is associated with increased mortality compared to VV-ECMO
    3. Anticoagulation is required but is not associated with increased complications
    4. Transfer to a specialized center with ECMO capability is associated with decreased mortality
    5. ECMO is contraindicated after ≥ 5 days of mechanical ventilation
  1. Noninvasive ventilation indicated in:
    1. Asthma
    2. Do-not-intubate (DNI) patients
    3. Hypoxemia
    4. All of the above
    5. None of the above
  1. Angiotensin converting enzyme inhibitors (ACEI) are indicated in:
    1. In a 40-year-old patient with idiopathic dilated cardiomyo-pathy
    2. In a patient after a myocardial infarction
    3. A hypertensive patient with proteinuria
    4. All of the above
    5. None of the above
  1. Cautions about the use of digitalis include:
    1. Hypokalemia
    2. Diabetes mellitus
    3. Low platelets
    4. High platelets
    5. Presence of atrial fibrillation
  1. Which of the following statements is true?
    1. Vitamin E is of proven value in the treatment of hypertension
    2. Prazosin has survival benefit in hypertension
    3. Folic acid supplementation may be beneficial in preventing ischemic heart disease
    4. Beta carotene has beneficial effects in ischemic heart disease through its antioxidant effects
    5. All statements are true3
  1. Regarding Calcium channel blockers:
    1. Reduce proteinuria
    2. Short acting nifedipine increases mortality in hypertension
    3. Can be used to delay surgery in patients with aortic regurgitation
    4. All of the above
    5. None of the above
  1. Side effects of thiazide diuretics include:
    1. Hypercalcemia
    2. Acute pancreatitis
    3. Hyperkalemia
    4. Hypocalcemia
    5. Hypoglycemia
  1. Streptokinase treatment in acute myocardial infarction (AMI):
    1. May be associated with an anaphylactic reaction
    2. Is as effective in improving prognosis in patients with inferior as well as anterior infarctions
    3. Should be started within 1 hour of AMI
    4. Both A and B
    5. Neither A nor B
  1. In the management of Central Diabetes insipidus in the cardiac patient in ICU, the dose of Desmopressin is:
    1. 2 µg/day
    2. 4 µg/day
    3. 6 µg/day
    4. 1 µg/day
    5. 5 µg/day
  1. One of the following antiplatelet drugs for myocardial infarction management should be avoided in case of history of transient ischemic attach (TIA) or stroke:
    1. Aspirin
    2. Clopidogrel
    3. Prasugrel
    4. Tocagrelor
  1. The most common presenting clinical symptom of acute heart failure is:
    1. Dyspnea
    2. Peripheral edema
    3. Palpitations
    4. Altered mentation
  1. Oxygen, noninvasive ventilation or invasive mechanical ventilation should be considered for the management of acute heart failure, when:
    1. SBP is less than 85 mm Hg
    2. Oxygen saturation is less than < 90%
    3. Dyspnea is severe
    4. Diastolic blood pressure is less than 60 mm Hg
    5. All of the above
  1. The Levine sign is typically seen in:
    1. Hypertensive crises
    2. Myocardial infarction
    3. Pulmonary hypertension
    4. Heart failure
  1. Cardiogenic shock is seen typically in Killip Classification:
    1. Class I
    2. Class II
    3. Class III
    4. Class IV
    5. Class V
  1. On low flow during weaning of ECMO:
    1. Heparin requirement increases
    2. High risk of clotting
    3. None of the above is correct
    4. Both (a) and (b) are correct
  1. During weaning of VV-ECMO FiO2 is reduced every hourly by:
    1. 10%
    2. 20%
    3. 5%
    4. 15%
    5. 25%
  1. Echocardiography in ECMO is useful in all of the following except:
    1. Excluding new reversible pathology
    2. LV dysfunction
    3. Undiagnosed cardiac valve pathology
    4. Limb ischemia
  1. Echocardiography can help to differentiate the need for VV or VA-ECMO in conditions such as:
    1. Pneumonia
    2. Pulmonary hypertension
    3. Medication overdose
    4. Bridge to lung transplant
    5. Severe septic cardiomyopathy
  1. By echocardiography, an aortic intramural hematoma may be difficult to distinguish from which of the following?
    1. A descending thoracic aortic aneurysm with mural thrombus
    2. An ascending thoracic aortic dissection4
    3. A descending thoracic aortic saccular aneurysm
    4. Protruding mobile atheroma in the aortic arch
    5. All of the above
  1. Signs of membrane failure in ECMO include:
    1. Decreasing PO2
    2. Increasing CO2
    3. Signs of consumptive coagulopathy
    4. All of the above
  1. Which of the following drugs is found to be useful in idiopathic ventricular fibrillation (IVF)?
    1. Quinidine
    2. Bisoprolol
    3. Verapamil
    4. Sotalol
  1. An 18-year-old patient develops sudden ventricular tachycardia characterized by QRS complexes of changing amplitude that appear to twist around the isoelectric line at a rate of 250/min and QT is 524 ms.
    zoom view
    What is the diagnosis?
    1. Torsades de pointes
    2. Ventricular fibrillation
    3. Polymorphic VT
    4. Atrial fibrillation
  1. Mr Ahmed, 56 year/M, BW-60 kg, postoperative presented in atrial fibrillation. While shifting from parenteral anticoagulation to new oral anticoagulation, it is wise to monitor his:
    1. Creatinine clearance as Dabigatran is eliminated renally
    2. Liver function test as Dabigatran is eliminated hepatically
    3. Creatinine clearance 24 hours after last dose of Rivaroxaban
    4. Creatinine clearance as Rivaroxaban is eliminated only renally
    5. PT and INR as clinical monitoring is insufficient
  1. All the following are potential hypercoagulable states in the ICU, except:
    1. Protein C deficiency
    2. Protein S deficiency
    3. Factor VII excess
    4. Factor VIII excess
    5. Splenomegaly
  1. The figure below shows dilated left atrium on a:
    zoom view
    1. 3D ECHO
    2. PET Scan
    3. CT Angio
    4. Cardiac MRI
    5. None of the above
  1. In trauma cases, transesophageal echocardiography (TEE) is a highly accurate tool for the evaluation of aortic injury and rupture. Which of the following findings is most consistent with a traumatic aortic injury of the thoracic aorta?
    1. A sessile irregularly bordered echo density in the mid descending thoracic aorta
    2. A markedly dilated ascending aorta and aortic arch
    3. A mobile linear flap located just distal to the aortic isthmus
    4. A mural echo density in a large descending thoracic aortic aneurysm
    5. All of the above
  1. In a patient with severe dyspnea, an apical four chamber view on transthoracic echocardiography (TTE) reveals significant ECHO free space over the RA. The possible diagnosis is:
    1. Right pleural effusion5
    2. Ascites
    3. RA infarction
    4. Tamponade
    5. All of the above
  1. To rule out a cardiac tamponade on a subcostal view on TTE:
    1. IVC is enlarged and collapses well
    2. IVC is not enlarged and collapsing well
    3. IVC is not enlarged and non-collapsing
    4. IVC is enlarged and non-collapsing
    5. All of the above
  1. The echocardiographic view in the intensive care frequently requested for discerning the LV systolic function is:
    1. Parasternal long axis
    2. Parasternal short axis
    3. 4 Chamber view
    4. All of the above
    5. None of the above
  1. In the setting of STEMI the ideally invasive arterial line, should be inserted in which artery:
    1. Radial
    2. Femoral
    3. Carotid
    4. Brachial
    5. Dorsalis pedis
  1. One of the modulators for structural alteration in AF is:
    1. Coronary blood flow reserve impairment
    2. Atrial fibroses
    3. Atrial dilatation
    4. Ectopic focal discharge from pulmonary vein
    5. All of the above
  1. The European guidelines for first line of antiarrhythmic drug selection in case of AF with symptomatic heart Failure is:
    1. Amiodarone
    2. Dofetilide
    3. Sotalol
    4. Flecainide
    5. All of the above
  1. The chemical cardioversion with drugs in hemodynamically unstable AF patients is less successful than direct cardioversion because there is a concern with drugs of:
    1. Tolerance
    2. Proarrhythmia
    3. Longer duration
    4. Electrolyte imbalance
    5. All of the above
K Type Questions
[Marked True (T)/False (F)]
  1. The lung ultrasound deciphers:
    1. Quantification of pleural effusion
    2. Quantification of pericardial effusion
    3. Sensitive in finding pneumothorax in obese patients
    4. Identification of pulmonary edema
    5. Identification of pulmonary over inflation
  1. Regarding transesophageal echocardiography (TEE) in patients with atrial fibrillation:
    1. Cardioversion can be safely performed off anticoagulation if TEE is negative for thrombus
    2. Spontaneous echo contrast is common and does not offer independent prognostic value
    3. Spontaneous echo contrast is highly associated with previous stroke or peripheral embolism in patients with atrial fibrillation
    4. Surgical ligation does not exclude flow into the left atrial appendage in majority of the cases
    5. Anticoagulation before proceeding with cardioversion should be started in few selected cases only
  1. Following is commonly used to measure cardiac output in the ICU:
    1. Pulse contour analysis
    2. Thermodilution
    3. Esophageal Doppler
    4. Bioimpedance
    5. Transcutaneous Doppler
  1. Capnography may be used in the ICU for:
    1. Indirect CO measurement
    2. Esophageal intubation alarm
    3. Return of spontaneous circulation (ROSC) after cardiac arrest
    4. Oxygen saturation monitoring
    5. Stroke volume monitoring
  1. Dynamic variables like stroke volume variation (SVV) can vary with:
    1. Lung dynamics
    2. Arrhythmias6
    3. Tidal volume
    4. Spontaneous breathing patient
    5. Mechanical ventilation
  1. Consider the following statements about digoxin:
    1. Is indicated in patients with mitral stenosis in sinus rhythm
    2. Currently the most accepted indication is heart failure
    3. Can cause tachyarrhythmias
    4. Can cause heart block
    5. Can cause hyperkalemia
  1. The side effects of ACE inhibitors are:
    1. Cough
    2. Headache
    3. Hypokalemia
    4. Worsening of renal function in patients with chronic renal failure
    5. Cause decrease in systemic vascular resistance (SVR)
  1. Amiodarone:
    1. Can cause hypothyroidism
    2. Has a half-life of 3 days
    3. Causes prolongation of the QT interval
    4. Is useful in the treatment of atrial fibrillation
    5. Safe in pregnancy
  1. Drugs which may be used in hypertensive crisis management in a post CABG patient:
    1. Nitroglycerin
    2. Sodium nitroprusside
    3. Sotalol
    4. Hydralazine
    5. Labetalol
  1. Side effect of Amiodarone is/are:
    1. Bradycardia
    2. Shortened QT interval
    3. Thrombophlebitis
    4. Corneal deposits
    5. Diarrhea
  1. The following may be used as alternatives to heparin:
    1. Low molecular weight heparin
    2. Dermatan sulfate
    3. Warfarin
    4. Hirudin
    5. Recombinant factor VIIa
  1. The pathophysiology of acute heart failure includes:
    1. Renal
    2. Cardio
    3. Vascular
    4. Endocrine
    5. Cerebral
  1. Laboratory changes associated with MI are:
    1. The CK-MB level is a fairly accurate method of diagnosing acute MI
    2. SGOT and LDH are not specific enzymes
    3. Skeletal muscle injury cannot increase the concentration of CK-MB
    4. The increase in CK-MB persists for 72 hours
    5. Plasma troponin concentration increases after 24 hours
  1. Signs of weaning failure during respiratory ECMO:
    1. Hypoxia
    2. Hypercapnia
    3. Fluid overload
    4. Limb ischemia
    5. Infection
  1. Common complications of ECMO include:
    1. Bleeding
    2. Thromboembolic events
    3. Sepsis
    4. Pulmonary embolism
    5. Cannula migration
  1. Following are potential hypercoagulable states in the ICU:
    1. Protein C deficiency
    2. Protein S excess
    3. Factor VII excess
    4. Factor VIII excess
    5. Low fibrinogen levels
  1. The CHA2 – DA2 – VASC score in atrial fibrillation is labeled ‘1’ in following cases of atrial fibrillation:
    1. Female sex
    2. Age > 75 years
    3. Hypertension
    4. Coronary heart failure with decreased ejection fraction
    5. Male sex
  1. Following statements about arrhythmias caused by accessory pathways (AP) are correct:
    1. Majority of APs conduct both antegradely and retrogradely7
    2. Around 50% of patients with pre-excitation have bypass tracts that conduct only antegradely
    3. Retrograde only conduction is more common than antegrade only conduction via APs
    4. In around 10% of patients spontaneous disappearance of pre-excitation may be seen
    5. Pre-excitation is seen in myelinated fibers
  1. Following statements about ventricular fibrillation (VF) are true:
    1. Ninety to ninety-five percent of individuals with VF reveal underlying structural heart disease
    2. No structural heart disease can be identified in 55% to 60% of patients
    3. According to the results of the Cardiac Arrest Survivors with Preserved Ejection Fraction Registry (CASPER) among patients with normal left ventricular function, idiopathic ventricular fibrillation (IVF) was diagnosed in 44% of patients with ventricular fibrillation without structural heart disease
    4. The diagnosis of idiopathic ventricular fibrillation (IVF) is based on the exclusion of currently known structural and primary electrical heart diseases following a complete noninvasive, invasive, and genetic workup
    5. All have atrial fibrillation first
  1. Consider the following statements related to vasodilators:
    1. The vasodilators that are feely available and commonly used in India are sodium nitroprusside and nitroglycerin
    2. Venodilators increase the preload
    3. They can lead to loss of hypoxic pulmonary vasoconstriction
    4. They may lead to metabolic acidosis
    5. The arterial vasodilators decrease SVR and increase cardiac output
  1. The following statements are correct about the Fast-Flush Test:
    1. It determines the dynamic response of the monitoring system to assess the distortion in the system
    2. It corresponds to a resonant frequency of 10-20 Hz
    3. Has dampening coefficient of 0.5–0.7 for arterial pressure monitoring
    4. Is excellent for filling pressure as well
    5. Corrects both under damping and over damping
  1. Regarding internal jugular vein central vein cannulation:
    1. Internal Jugular vein is directly anterior to the carotid artery
    2. Complications are less with internal jugular vein (IJV) puncture as compared to subclavian puncture
    3. Doppler ultrasound guided puncture could reduce the time and number of attempts
    4. Success rate is higher in infants than adults
    5. It is a rapid alternative to surgical cut down
  1. Methods to evaluate regional cerebral saturation, the correct statements are:
    1. Mixed venous saturation is most ideal
    2. BIS and NIRS correlate well in infants
    3. Lactate levels in superior vena cava are higher than inferior vena cava
    4. NIRS is 90% sensitive and specific for regional cerebral saturation monitoring
    5. BIS gives only depth of anesthesia/sedation
  1. For hypertensive emergencies in the ICU:
    1. Sodium nitroprusside is first choice for most cases of hypertensive crisis
    2. Labetalol can be used as it maintains the cardiac output
    3. Thiocyanate toxicity is seen with labetalol
    4. Nicardipine is useful in CAD as well
    5. Clevidipine cannot be used as it is a long-acting intravenous calcium channel blocker8
ANSWERS
A Type Answers
Q1. Answer b
The mechanical activity of the heart always follows the electrical activity of the heart. Since the P wave reflects atrial depolarization or contraction, look for the A wave to come directly after the P wave. In the case of a wedge pressure, there will be a delay, and the A wave may show up just after the QRS complex. The A wave is important, because it reflects the atrial kick, which drives 20–25% of the atrial blood into the left ventricle and helps establish the preload state (end diastolic pressure, EDP) of the ventricle. Line a piece of paper up to the P wave of the ECG and move the paper to the right. When you see an elevated portion of the waveform, you have found the A wave. In a case like atrial fibrillation where there is no P-wave on the ECG, there is no atrial kick, and therefore, no A wave on the atrial waveform. Sometimes in nodal rhythms A wave may be large due to atrium contracting against a closed tricuspid valve.
Q2. Answer c
EDP is an important measurement for the ventricle. The physicians routinely ask for pressures to be performed on a 40–50 mm Hg scale, and increase the paper speed to at least 50 mm/sec to assess the EDP. It reflects the preload state, and is a highly valuable measurement. It can be used to determine if patients are fluid overloaded, in heart failure, and if they can be aggressively hydrated for conditions like kidney disease. Along with isovolumetric contraction and after load, preload is a primary determinant of cardiac output.
Mielniczuk LM, Lamas GA, Flaker GC, et al. Left ventricular end-diastolic pressure and risk of subsequent heart failure in patients following an acute myocardial infarction. Congest Heart Fail. 2007;13(4):209-14.
Q3. Answer c
The normal pressure for the pulmonary artery is approximately 25 systolic, 10 diastolic, and a mean pressure of 15. If the pulmonary artery pressures are extremely elevated, it suggests either pulmonary artery hypertension or left heart failure that is elevating right-sided pressures. It is important to obtain a wedge pressure at this point, to see if the patient has pulmonary hypertension (PHTN) or a left-sided source that is causing the pressure elevation. By calculating effective mean pulmonary artery pressures and mean wedge pressures, a pulmonary vascular resistance can be calculated to determine if there is pulmonary artery hypertension, and the severity of PHTN, should it exist. Because this pressure is elevated, the catheter should be advanced into the pulmonary capillary beds for left heart analysis.
Rose-Jones LJ, Mclaughlin VV. Pulmonary hypertension: types and treatments. Curr Cardiol Rev. 2015;11(1):73-9.
Q4. Answer a
The normal PCWP pressure is around 12–16 mm Hg mean pressure. The PCWP is a left-sided pressure, and pathology associated with elevated wedge pressure is usually associated with left heart failure, or mitral valve stenosis. Because the wedge pressure is measured during the ‘right heart catheterization,’ it is more accurate to think of a ‘right heart cath’ as a hemodynamic study that looks at both left and right-sided pressures. Elevated wedge pressures are a classic finding for left heart failure. They may also indicate mitral valve stenosis. If the wedge pressure is associated with an elevated V wave, this is often associated with mitral valve regurgitation. When measuring the wedge pressure, there are a couple of points to remember for practice. The wedge pressure is delayed, in relationship to the right atrial pressure because it is an indirect measurement. Therefore, the A wave will usually arise shortly after the QRS complex, and the V wave will seem to be slightly before the A wave. This is important in making a diagnosis of mitral regurgitation, characterized by a classic, elevated V wave in the wedge pressure measurement. The first positive waveform after the P wave is the A wave, and the second positive waveform is the V wave.
 Muralidhar K. Central venous pressure and pulmonary capillary wedge pressure monitoring. Indian J Anaesth. 2002;46(4):298-303.
Q5. Answer a
The Fick formula has 2 variants, but both assess the same factors. They take the presumed oxygen content, i.e. the difference between arterial and venous O2 saturation. Either (BSA × 125) or (weight 9in kilograms × 3)/(Ao Sat-Pa Sat) × Hemoglobin × 1.36 × 10 can be used. These are presumed values and may not be completely accurate. Many variables can influence the output, including supplemental oxygen, sedation, and septal defects. Clinical assessment may facilitate the need to calculate a thermodilution (TD) or angiographic output.
 Kern M. Measurement of cardiac output in the cath lab: How accurate is it? Cath Lab Digest. 2014;22(7).
Q6. Answer b
Most computers record vascular resistance in metric units of dynes·sec·cm−5. To convert Wood units to metric units, simply multiply the Wood units by 80. To convert the metric numbers to Wood units, divide the metric units by 80. If the physician is performing tests on the patient to determine response to pulmonary hypertension, they might want to use Wood units, rather than metric units, to record real-time calculations.
 Kern M. measurement of cardiac output in the cath lab: How accurate is it? Cath Lab Digest 2014;22(7).
Q7. Answer c
The best area to assess hemodynamic pressures is at end expiration. This is described as the area where the measurement ‘falls off the cliff.’ The extremely low pressures are generated by the negative pressure created by the inspiratory effort. They can grossly distort accurate hemodynamics in patients who have significant respiratory variance. This includes patients who have sleep apnea, chronic obstructive pulmonary disease (COPD), and other lung diseases. In this patient, there is a sharp respiratory variance on the wedge pressure waveforms. It is important to make sure that the computer aligns with the expiratory measurements, and that the mean pressure is accurate, because it determines pulmonary vascular resistance. A tip to improve practice is to color in the ‘valleys’ that occur during the inspiratory effort and then discard them.
 Kern M. measurement of cardiac output in the cath lab: How accurate is it? Cath Lab Digest 2014;22(7).
Q8. Answer d
Cardiac output (CO) can also be measured by thermodilution technique. Thermodilution CO involves the use of a catheter with a proximal and distal port, as well as a thermistor, to measure temperature changes. Saline, which may be chilled, is injected into the proximal portion of the catheter, which lies in the right atrium. The injectate mixes with blood and warms up as it passes through the pulmonary arteries. This temperature change is captured by the thermistor and an output is generated. Typically, around 4–5 injections are performed, the outliers are discarded, and an average is taken. Thermodilution cardiac output is highly useful in patients with very high cardiac outputs, because very slight changes in Ao or Pa saturation can cause large changes in cardiac output via the Fick method. The TD technique is usually contraindicated in patients with tricuspid regurgitation, because the injectate is not able to cross the right atrium and reach the pulmonary artery before it becomes too diluted.
 Berthelsen PG, Eldrup N, Nilsson LB, Rasmussen JP. Thermodilution cardiac output. Cold vs room temperature injectate and the importance of measuring the injectate temperature in the right atrium. Acta Anaesthesiol Scand. 2002;46(9):1103-10.
Q9. Answer c
Variable
Formula
Normal range
Cardiac Index (CI)
Q/BSA
2.5–4.0 litre min−1 m−2
Stroke Volume
Q/HR
60–80 mL
Stroke Index
SV/BSA
30–65 m−2
Left ventricular stroke work index (LVSWI)
CI × (MAP – PAOP) × 0.0136
40–60 g m−1 m2
Q=Cardiac output, BSA=Body Surface Area, HR=Heart Rate, SV=Stroke Volume, MAP=Mean Arterial Pressure, PAOP=Pulmonary Artery Occlusion Pressure
 Kumar P. ICU Manual. New Delhi: Jaypee Brothers Medical Publishers; 2017.
Q10. Answer b
  1. Spontaneous breathing patients—fluid responsive, if (1) IVC measuring < 2 cm in diameter coupled with IVC collapse > 50% with each breath or (2) IVC collapsibility >12%10
  2. Mechanically ventilated patients—fluid responsive, if IVC distensibility >18%.
  3. IVC collapsibility = (Max diameter - min diameter)/(mean diameter) × 100
  4. IVC distensibility = (Max diameter - min diameter/min diameter) × 100
  5. Caval index (the fractional change in the IVC diameter during respiration).
  6. A greater than 50% decrease in IVC diameter is associated with a CVP <8 mm Hg in management of sepsis.
     Doppler ultrasound can be used to measure blood velocity in descending aorta and can be used for estimating cardiac output (Figs. A and B).
 Kumar P. ICU Manual. New Delhi: Jaypee Brothers Medical Publishers; 2017.
Q11. Answer b
zoom view
Q12. Answer a
Therapeutic options available to treat pulmonary edema: Rule out extra cardiac causes of weaning failure, Excessive preload: diuretics, Excessive afterload of myocardial ischemia: vasodilators. Use CPAP/BiPAP to prevent significant alteration in intrathoracic pressures.
 Jean-Louis T, Monnet X, Richard C. Weaning failure of cardiac origin: recent advances. Crit Care. 2010;14(2):211-5.
Q13. Answer d
Interest in ECMO support of severe ARDS has increased following reports of successful salvage of H1N1 patients and with advances in pump and oxygenator technology. The CESAR trial randomized 180 ARDS patients to best conventional expert treatment versus transfer to a specialized center with ECMO capabilities; significant reduction of six month mortality was seen in the specialized center. A European multicenter trial is underway to assess these findings in early severe ARDS. VV-ECMO is the preferred mode for support of acute respiratory failure. Bleeding events are responsible for the most serious complications on ECMO. ECMO support is most commonly considered within seven days of initiating mechanical ventilation, however, successful support is feasible after the initial time window.
 Brodie D, Bacchetta M. Extracorporeal membrane oxygenation for ARDS in adults. N Engl J Med. 2011;365:1905-14.
Q14. Answer d
There is strong evidence that non-invasive ventilation should be used for the initial management of acute respiratory failure in patients with exacerbated COPD, acute pulmonary edema, disorders with concomitant immunosuppression as well as to facilitate extubation in patients with COPD who have failed weaning attempts. In postoperative patients, noninvasive ventilation should be considered both 11as a prophylactic and as a therapeutic tool for improving gas exchange. Administration of noninvasive ventilation is also recommended in palliative care for hypercapnic and pulmonary edema patients.
 Ambrosino N, Vagheggini G. Non-invasive ventilation in exacerbations of COPD. Int J Chron Obstruct Pulmon Dis. 2007;2(4):471-6.
Q15. Answer d
ACEI have a variety of beneficial effects. They reduce symptoms and mortality in patients with heart failure due to any cause. ACEI also have effects on ventricular remodelling after a myocardial infarction, and can reduce the risk of development of myocardial dysfunction. ACEI reduce proteinuria in normotensive diabetics with proteinuria, and hypertensives with proteinuria. There is no indication for its use in a normotensive diabetic patient without proteinuria. ACEI cause systemic vasodilatation, and are contraindicated in patients with aortic stenosis, as they can result in hypotension.
 Izzo JL, Weir MR. Angiotensin-converting enzyme inhibitors. J Clin Hypertens (Greenwich). 2011;13(9):667-75.
Q16. Answer a
Hypokalemia worsens digitalis toxicity. However, in overdose, digoxin causes hyperkalemia. Elderly patients are at greater risk of digoxin toxicity because of reduced renal function. Digoxin has no effect on platelets. The presence of atrial fibrillation is an indication rather than a caution for the use of digoxin. Digoxin is used to control the ventricular rate in atrial fibrillation.
 Wofford JL, Ettinger WH. Risk factors and manifestations of digoxin toxicity in the elderly. Am J Emerg Med. 1991; 9(2 Suppl 1):11-5;33-4.
Q17. Answer c
Although antioxidants such as vitamin E and beta carotene have long been thought to be beneficial in the treatment of cardiovascular disease, there is no convincing trial evidence of such benefit. Elevated homocysteine levels increase cardiovascular risk by its procoagulant effects. Folate deficiency may result in elevated homocysteine levels, and it is thought that in patients who are folate deficient, folic acid supplementation may be of use. Again, there is no definite evidence. Nicotinic acid is an effective, but poorly tolerated, cholesterol lowering agent.
 Ganguly P, Alam SF. Role of homocysteine in the development of cardiovascular disease. Ganguly and Alam Nutrition Journal. 2015;14(6):2-10.
Q18. Answer d
Though calcium channel antagonists are effective anti-anginal agents, there is little evidence that they affect survival in patients with ischemic heart disease. There is some evidence that Diltiazem prevents reinfarction in patients with non Q MI. Calcium channel blockers reduce proteinuria in patients with diabetes. Short acting Nifedipine, although an effective antihypertensive agent, increases mortality in patient with hypertension and should not be used. Nifedipine is used in patients with aortic regurgitation to reduce symptoms and delay surgery.
 Sleight P. Calcium antagonists during and after myocardial infarction. Drugs. 1996;51(2):216-25.
Q19. Answer b
The most important side effects of thiazides are orthostatic hypotension, photosensitivity, hypokalemia, and anorexia and epigastric distress. Hepatic dysfunction, acute pancreatitis, and erythema multiform are known to occur. There are concerns that thiazides can cause hyperglycemia and worsen diabetes, but this effect is clinically not of importance.
 Dutta SK, Mobrahan S, Iber FL. Associated liver disease in alcoholic pancreatitis. Am J Dig Dis. 1978;23(7):618-22.
Q20. Answer d
Apart from the fact that streptokinase is effective only if given intravenously, it causes bleeding, and if given by the intramuscular route will result in the formation of a muscle hematoma. It is well known 12to cause anaphylactic reactions. Treatment with streptokinase is associated with a 25% reduction in mortality. There are long-term survival benefits. There is no benefit seen with streptokinase treatment in non ST elevation MI. Streptokinase is equally effective in all types of ST elevation MI. Percutaneous coronary intervention (PCI), also known as coronary angioplasty, is a nonsurgical technique for treating obstructive coronary artery disease, including unstable angina, acute myocardial infarction (MI), and should be performed within 90 minutes of first medical contact.
 Rubboli A, Capecchi A, Pasquale GD. Utilizing enoxaparin in the management of STEMI. Vasc Health Risk Manag. 2007;3(5): 691-700.
Q21. Answer b
Management of Diabetes Insipidus
Central Diabetes Insipidus (DI)
  • Desmopressin – intranasal or 4 µg/day IV or SC in divided doses
  • Low salt diet + low dose thiazides diuretics
Partial Central DI
  • Chlorpropamide, clofibrate, carbamazepine
    These drugs stimulate Arginine Vasopressin (AVP) secretion or its action on Kidney
    NSAIDs – They impair prostaglandin synthesis and potentiate AVP action.
 Mishra G, Chandrashekhar SR. Management of diabetes insipidus in children. Indian J Endocrinol Metab. 2011;15(Suppl3): S180-S187.
Q22. Answer c
Prasugrel: The loading dose of Prasugrel is 60 mg followed by 10 mg daily. Prasugrel should not be given in patients with history of TIA or stroke
Ticagrelor: The loading dose of Tricagrelor is 180 mg followed by 90 mg twice. When using Ticagrelor, the recommended maintenance dose of Aspirin is 81 mg daily.
 Alexander W. FDA Advisory Committee Meeting on Prasugrel For Acute Coronary Syndromes. P T. 2009;34(3):155-6.
Q23. Answer a
Dyspnea is the most common symptom and is present in 90% cases. Dyspnea typically is present at rest or with minimal exertion. Patients also may present with signs and symptoms related to systemic venous congestion such as peripheral edema. In elderly patients, atypical manifestations such as fatigue, depression, altered mental status or sleep disruptions can occur.
 Kamal AH, Maguire JM, Wheeler JL. Currow DC, Abernethy AP. Dyspnea Review for the Palliative Care Professional: Treatment Goals and Therapeutic Options. J Palliat Med. 2012;15(1):106-14.
Q24. Answer e
Oxygen therapy should be individualised based on clinical condition.
O2/NIV/Invasive mechanical ventilation
Oxygen saturation (Sao2) < 90%
Consider vasopressors/ nonvasodilating inotrope/right heart catheterization/ mechanical circulatory support (e.g. IABP, ventricular assist device)
SBP < 85 mm Hg
Diuretics right heart catheterization
Urine output < 20 mL/hr
Increasing dissolved oxygen in plasma by oxygen therapy may also be used to offset the effects of hypoperfusion to some extent (stagnant hypoxia) and may well be important in certain situations (cardiogenic shock), although the effect is only marginal. Increased inspired oxygen will only marginally 13mitigate the effects of anemic hypoxia but, because the CaO2 in patients with anemia is less than that in patients with normal haemoglobin, the effect of additional oxygen carried in solution may become more important in these situations.
 Kumar P. ICU Manual. New Delhi: Jaypee Brothers Medical Publishers; 2017.
 BTS guideline for oxygen use in adults in healthcare and emergency settings. June 2017 Volume 72 Supplement 1. Available from: https://www.brit-thoracic.org.uk/document-library/clinical-information/oxygen/2017-emergency-oxygen-guideline/bts-guideline-for-oxygen-use-in-adults-in-healthcare-and-emergency-settings/(Accessed 28 December 2017).
Q25. Answer b
Levine's sign is a clenched fist held over the chest to describe ischemic chest pain. Patients are anxious and restless and describe their pain with a clenched fist held against the sternum. Those presenting with failure may have cold and clammy extremities. As the referred pain associated with ischemia radiates to the area of the left proximal forelimb, the right, unaffected arm is used to produce the gesture. This clenched fist signal may be seen in patients with acute coronary syndrome (myocardial infarction and angina pectoris). A variant of this sign which uses the entire palm instead of the clinched fist over the chest is commonly known as the ‘Palm Sign’.
 Murday A. Optimal management of acute ventricular septal rupture. Heart. 2003;89(12):1462-6.
Q26. Answer d
The classification or index of heart failure severity in patients with acute myocardial infarction (AMI) was proposed by Killip and Kimball aiming at assessing the risk of in-hospital death and the potential benefit of specific management of care provided in Coronary Care Units (CCU).
Killip's class
  1. No congestive heart failure
  2. Mild congestive heart failure, rales, S3. congestion on Chest X-ray
  3. Pulmonary edema
  4. Cardiogenic shock
The Killip and Kimball classification performs relevant prognostic role in mortality at mean follow-up of 05 years post-AMI, with a similar pattern between NSTEMI and STEMI patients.
 de Mello BHG, Oliveira GBF, Ramos RF. Validation of the Killip-Kimball Classification and Late Mortality after Acute Myocardial Infarction. Arq Bras Cardiol. 2014;103(2):107-17.
Q27. Answer d
Weaning of VV-ECMO by reducing the pump flow was preferred technique in the past and is seldom practiced now. The reason for not using this technique is when one come on low flow there is high risk of clotting and usually heparin requirement increases. The weaning procedure is similar to VA-ECMO except the weaning can be done quickly. Flow can be reduced even by 20 mL/kg/min (as compared to 10 mL/kg/min of VA-ECMO) and even the time between the changes can be reduced. For VV-ECMO, idling may be reached at 40 to 50 mL/kg/min.
 Kapoor PM. Manual of extracorporeal membrane oxygenation in the ICU. New Delhi: Jaypee Brothers Medical Publishers; 2013.
Q28. Answer c
Usually the ECMO FiO2 is reduced by 5% per hour or even 30 minutes. Ventilator setting is upgraded to moderate level. Once the FiO2 requirement is 21% then the sweep gas flow is being reduced by 10% per hour or half hourly. Adjusting heparin dose is not required as there is no change in pump flow. Alternatively, few centers only decreases sweep gas flow by 10% per hour without changing FiO2 of ECMO. ECMO FiO2 is always kept 100%.
 Kapoor PM. Manual of extracorporeal membrane oxygenation in the ICU. New Delhi: Jaypee Brothers Medical Publishers; 2013.
14Q29. Answer d
Echocardiography helps exclude new reversible pathology, which may account for a patient's hemodynamic instability (such as cardiac tamponade, undiagnosed cardiac valve pathology, and LV dysfunction), avoiding the need for ECMO support.
 Kapoor PM. Manual of extracorporeal membrane oxygenation in the ICU. New Delhi: Jaypee Brothers Medical Publishers; 2013.
Q30. Answer d
Echocardiography plays a crucial role at every step of ECMO support. At the time of consideration, it can confirm the diagnosis and help in defining the choice between VV and VA-ECMO. By assessing cardiac function, echocardiography can help determine whether VV-ECMO is sufficient or whether VA-ECMO should be considered in conditions such as pneumonia with severe septic cardiomyopathy. Although, it is unlikely that utilization of echocardiography by itself will directly improve the outcome of patients supported on ECMO, echocardiography may help to reduce complications and guide clinicians in the daily management of these complex patients. It provides guidance at the time of cannulation. Once the patient is on ECMO support, it procures valuable information pertaining to recovery and possible complications. It is essential during the weaning phase for VA-ECMO.
 Douflé G, Roscoe A, Billia F, Fan E. Echocardiography for adult patients supported with extracorporeal membrane oxygenation. Crit Care. 2015;19:326.
Q31. Answer a
Aortic intramural hematoma is characterized by echocardiography as a circumferential or crescent-shaped smooth-margined thickening of the aortic wall without an intimal flap. The degree of aortic wall thickening should be >5–7 mm. Intimal calcium may be displaced by the accumulation of hematoma. Echolucent areas in the aortic wall may be seen suggestive of noncommunicating blood in the medial hematoma. An intramural hematoma is generally continuous over a relatively localized or extensive portion of the aorta. Aortic atheromatous disease and aortic aneurysms with mural thrombus can be commonly encountered diagnostic challenges. Important distinguishing features of intramural hematoma are its smooth aortic wall contour, continuous nature, and its echogenic border due to displaced intimal calcium. In contrast, aneurysms with mural thrombus have irregular borders, and the thrombus is located above the calcified intima. Aortic atheromatous disease often has irregular borders with protruding and/or mobile components, scattered areas of calcification, and is not continuous.
 Nishigami K. Echocardiographic characteristics of aortic intramural hematoma for the differentiation from atheromatous plaques and mural thrombi in the aorta. Journal of Echocardiography. 2011;9(4):167-8.
Q32. Answer d
Earliest sign of oxygenator failure will be rising delta pressure, i.e. the pressure difference between the inlet and outlet of the oxygenator. The preoxygenator increases as the resistance of the oxygenator increases while the postoxygenator pressure decreases leading to increased delta pressure. The other signs of membrane failure include deterioration in gas exchange (rising carbon dioxide and decreasing pO2 in postoxygenator blood gas), plasma leak, increased platelet consumption and picture of consumptive coagulopathy.
 Tamari Y, Tortolani AJ, Maquine M, et al. The effect of high pressure on microporous membrane oxygenator failure. Artif Organs. 1991 Feb;15(1):15-22.
Q33. Answer a
IVF has a high recurrence rate.
The recommended therapy is implantation of implantable cardioverter defibrillator (ICD). Currently, recommendations for a specific drug therapy are not available. Antiarrhythmic agents had no effect on the recurrence rate. In a study by Belhassen et al. patients with IVF have received oral quinidine guided by serial electrophysiological studies. In patients receiving continuous quinidine treatment, no recurrences of VF were reported during a mean follow-up period of 9.1 ± 5.6 years. In a subset of patients, these promising results were confirmed during long-term follow-up. Currently, pharmacologic therapy serves as an adjunct to ICD therapy in patients with multiple ICD discharges.15
 Belhassen B, Viskin S, Fish R, et al. Effects of electrophysiologic guided therapy with Class IA antiarrhythmic drugs on the long-term outcome of patients with idiopathic ventricular fibrillation with or without the Brugada syndrome. J Cardiovasc Electrophysiol. 1999; 10(10):1301-12.
Q34. Answer a
Torsades de pointes: VT characterized by QRS complexes of changing amplitude that appear to twist around the isoelectric line and occur at rates of 200 to 250/minute and QT intervals generally >500 ms. Polymorphic VT in the absence of QT prolongation is not considered as Torsades de pointes.
 Kumar P. ICU Manual. New Delhi: Jaypee Brothers Medical Publishers; 2017.
Q35. Answer a
Dabigatran is oral direct thrombin inhibitor anticoagulant. Absorption is rapid with peak plasma concentrations reached at 4–6 hours. Its oral bioavailability is low, but shows minimal interindividual variability. Dabigatran specifically and reversibly inhibits thrombin, the key enzyme in the coagulation cascade. The anticoagulant effect correlates adequately with the plasma concentrations of the drug, demonstrating effective anticoagulation combined with a low risk of bleeding. Dabigatran is mainly eliminated by renal excretion (a fact which affects the dosage in elderly and in moderate-severe renal failure patients), and no hepatic metabolism by cytochrome P450 isoenzymes has been observed, showing a good interaction profile. Rivaroxaban is also factor Xa (FXa) direct inhibitor anticoagulant drug. It produces a reversible and predictable inhibition of FXa activity with potential to inhibit clot-bound FXa. Its pharmacokinetic characteristics include rapid absorption, high oral availability, high plasma protein binding and a half-life of approximately 8 hours. Rivaroxaban elimination is mainly renal, but also through faecal matter and by hepatic metabolism.
 Baines OJP, Grana CE, Botella JA, García VI. Pharmacokinetics and pharmacodynamics of the new oral anticoagulants dabigatran and rivaroxaban. Farm Hosp. 2009;33(3):125-33.
Q36. Answer e
Hypercoagulable states in anesthesia and critical care
Acquired: Age, previous thrombosis, immobilization, major surgery, orthopaedic surgery, malignancy, oral contraceptives, pregnancy, hormonal replacement therapy, antiphospholipid syndrome, essential thrombocythemia, polycythemia vera, paroxysmal nocturnal hemoglobinuria, splenectomy
Inherited: FVL G1691A, protein C deficiency, protein S deficiency, antithrombin deficiency, dysfibrinogenemia, prothrombin mutation G20210A.
Mixed or unknown: Hyperhomocysteinemia, high levels of factor VIII, APC-resistance in the absence of FVL, High levels of factor IX, factor XI and TAFI.
 Bande BD, Bande SB, Mohite S. The hypercoagulable states in anesthesia and critical care. Indian J Anaesth. 2014;58(5):665-71.
Q37. Answer d
Cardiac magnetic resonance imaging (MRI) uses a powerful magnetic field, radiowaves and a computer to produce detailed pictures of the structures within the heart. It is used to detect or monitor cardiac disease and to evaluate the heart's anatomy and function in patients with congenital heart disease. Cardiac MRI (CMRI) does not use ionizing radiation, and it may provide images of the heart that are better than other imaging methods for certain conditions. Atrial dilatation can be both the cause and effect of atrial fibrillation (AF). Atrial enlargement is an important marker of left atrium (LA) structural remodeling and predictor of AF (re) occurrence and mortality. Hence, accurate assessment of LA dimensions is critical for AF assessment. CMRI with its high spatial and temporal resolution allows accurate delineation of the LA, LAA and pulmonary veins (PV) morphology. CMRI is today the gold standard for cardiac volumes and has shown excellent correlation with cadaveric casts. Despite the irregular rhythm, CMRI is able to measure accurate atrial and ventricular volumes.
 Prabh S, Voskoboinik A, Kaye DM. Atrial Fibrillation and Heart Failure Cause or Effect? Heart, Lung and Circulation. 2017;26(9):967-74.
16Q38. Answer c
TEE imaging of the aorta is a highly accurate method of aortic evaluation in patients with deceleration and blunt chest trauma. Characteristic echocardiographic findings suggestive of aortic injury include the presence of an intraluminal flap located near or just distal to the aortic isthmus, or near the gastroesophageal junction. The intraluminal flap is usually mobile, may be extensive or localized to a short segment of the aorta, and usually occurs at points of attachment such as the sinuses of Valsalva, the isthmus, and the diaphragm. Alternatively, intraluminal masses suggestive of discrete thrombus formation can be seen and typically occur at the arch, isthmus, or near the diaphragm; in these cases, development of aortic thrombus occurs in areas overlying intimal tears or injury. A sessile irregularly bordered echodensity located in the mid descending thoracic aorta is descriptive of aortic atheromatous disease. The presence of a dilated ascending aorta alone is not consistent with aortic injury. A mural echodensity in a large descending thoracic aortic aneurysm is most suggestive of mural thrombus.
 Patil TA, Nierich A. Transesophageal echocardiography evaluation of the thoracic aorta. Ann Card Anaesth. 2016; 19(Suppl 1):S44-S55.
Q39. Answer a
The right lung is very close to the RA. An echo-free space seen over the RA in an apical four-chamber view is consistent with right pleural effusion. Right pleural effusion may also present as an echo-free space next to the RA. Of course, pericardial effusion (PE) will present similar findings of echo-free spaces next to RA or RV and therefore, examination from the back with the patient sitting up becomes important for differentiation, as mentioned previously.
 Price S, Platz E, Cullen L, et al. Expert consensus document: Echocardiography and lung ultrasonography for the assessment and management of acute heart failure. Nature Reviews Cardiology. 2017;14:427-40.
Q40. Answer b
To make a rapid diagnosis of tamponade in a patient with pericardial effusion, it is important to perform a subcostal examination to image the inferior vena cava (IVC). If the IVC is not enlarged (< 20 mm) and collapses well (around 50% or more) during respiration, tamponade can be immediately excluded because these findings indicate there is no elevation of RA pressure which occurs in tamponade. An exception is a patient with hypovolemia due, e.g. to diuresis induced by a diuretic, hemorrhage, or inadequate fluid intake. In this situation, because of low blood volume status, the IVC is not enlarged and may also show some collapse, even though tamponade may have developed.
 Pérez-Casares A, Cesar S, Brunet-Garcia L, et al. Echocardiographic Evaluation of Pericardial Effusion and Cardiac Tamponade. Front Pediatr. 2017;5:79.
Q41. Answer d
Information
Echocardiographic view
LV systolic function
Parasternal long axis and short axis view, 2, 3 and 4-chamber view
Cardiac output
4-chamber view
Right heart assessment
Parasternal long axis and short axis view, 4-chamber view
Pericardial disease
Parasternal long axis and short axis view, 4-chamber view, subcostal view
Valvular disease
Parasternal long axis and short axis view, 4-chamber view
Volume status and responsiveness
4-chamber view, inferior vena cava
 Walley PE, Goodgame B, Punjabi V, et al. A practical approach to goal directed echocardiography in the critical care setting. Crit Care. 2014;18(6):681.
Q42. Answer a
In the setting of STEMI, radial access for primary PCI is the best option to avoid procedural bleeding depending on operator expertise and preference. In patients with STEMI and AF at low risk of bleeding (HAS-BLED 0-2), the initial use of triple therapy [oral anticoagulants (OAC), aspirin, and clopidogrel] should be considered for 6 months following PCI irrespective of stent type; this should be followed by 17long-term therapy (up to 12 months) with OAC and clopidogrel 75 mg/day (or alternatively, aspirin 75–100 mg/day).
 Alizadehasl A, Ziyaeifard M, Peighambari M, et al. Avoiding heparinization of arterial line and maintaining acceptable arterial waveform after cardiac surgery: A randomized clinical trial. Res Cardiovasc Med. 2015;4(3):e28086.
Q43. Answer a
Triggers, modulators and structural/functional alteration in Atrial Fibrillation
Triggers: Acute/chronic atrial stretch, Ectopic focal discharge from pulmonary vein.
Modulators: Autonomic nervous system
Structural/functional alterations: Atrial dilatation (macro-manifestation), atrial fibrosis (macro-manifestation), myocardial perfusion abnormalities (microvascular manifestation), coronary blood flow reverse impairment (Microvascular manifestation).
 Csepe TA, Kalyanasundaram A, Hansen BJ, et al. Fibrosis: a structural modulator of sinoatrial node physiology and dysfunction. Front Physiol. 2015;6:37.
Q44. Answer a
The European guidelines suggest that disopyramide be considered for patients with a vagal trigger associated with AF, whereas disopyramide and quinidine, procainamide, are completely omitted from the US guidelines. Dofetilide is not approved for use in Europe but is indicated in all clinical categories in the US guidelines. Both guidelines agree on the use of sotalol, amiodarone, and dronedarone for patients with coronary artery disease and amiodarone for patients with symptomatic congestive heart failure.
 Amin A, Houmsse A, Ishola A, et al. The current approach of atrial fibrillation management. Avicenna J Med. 2016;6(1):8-16.
Q45. Answer b
Chemical cardioversion: It can be accomplished with intravenous or oral antiarrhythmic drugs. In general, the conversion success of antiarrhythmic drug therapy is significantly higher for acute (< 7 days) compared with longer-duration AF. Drugs used for chemical cardioversion are: ibutilide, amiodarone, flecainide, propafenone and vernakalant. Chemical cardioversion is simple but less efficacious (50% success) as compared to electrical cardioversion (80–89% success). With drugs, pro-arrhythmic effect is a concern.
 Raghavan AV, Decker WW, Meloy TD. Management of Atrial Fibrillation in the Emergency Department. Emergency Medicine Clinics of North America. 2005;23(4):1127-39.
K Type Answers
Q1. Answer TTFTF
Utilities of thoracic ultrasound: Diagnosis of pleural effusion, Quantification of pleural effusion, Characterization of pleural effusion, Identification of pleural masses, Identification of parenchymal disease (infection or masses), Identification of pulmonary edema.
Limitations of lung ultrasound: The learning curve for acquiring skills for diagnosing pleural effusion, lung consolidation and alveolar-interstitial syndrome is short. But learning time for acquiring skills required for diagnosing pneumothorax is probably longer. Obese patients are frequently difficult to examine using lung ultrasound because of the thickness of their rib cage. The presence of subcutaneous emphysema or large thoracic dressings alters or precludes the propagation of ultrasound beams to the lung periphery. Lung ultrasound cannot detect lung over-inflation resulting from an increase in intrathoracic pressures.
 Saraogi A. Lung ultrasound: Present and future. Lung India. 2015;32(3):250-7.
Q2. Answer FFTTF
Patients undergoing cardioversion are treated conventionally with therapeutic anticoagulation for three weeks before and four weeks after cardioversion to decrease the risk of thromboembolism. TEE guided strategy has been proposed as an alternative that may lower stroke and bleeding events. Patients 18without atrial cavity thrombus or atrial appendage thrombus by TEE are cardioverted on achievement of therapeutic anticoagulation, whereas cardioversion is delayed in higher risk patients with thrombus. In patients with permanent atrial fibrillation, the presence of severe spontaneous contrast or smoke is a marker of increased risk of thromboembolic events. Electrical cardioversion causes left atrial appendage (LAA) stunning with increased severity of echo contrast immediately after the procedure. There have been published series of cases of embolic stroke after cardioversion in patients with negative TEE for LA thrombus who are not anticoagulated. For this reason, patients should have therapeutic levels of anticoagulation before proceeding with cardioversion. Patients with surgical LAA ligation show a high incidence of residual flow between the LA and LAA.
 Mathuria N. Role of TEE before atrial fibrillation ablation: Is less really more? Heart Rhythm. 2016;13(1):20.
Q3. Answer TTFFT
Pulse contour analysis monitors increase in SV reasonably accurately in addition to SVV which is a good preload indicator. Cardiac output noninvasive measurement is well known today. One such method is in which electrodes are placed in the neck and thorax region and the fluctuations in electrical impedance are measured. The change in aortic flow is measured by the change in the thoracic bioimpedance through the cardiac cycle. Esophageal Doppler measures blood flow velocity in the descending aorta by a Doppler probe kept in the esophagus 40 cm from the mouth. It is a useful monitor for measuring cardiac output. It has been used for high-risk surgical patients but its use in critical care is less common. Transcutaneous Doppler monitoring by an external probe can measure transpulmonary and transaortic cardiac output. Unfortunately, the bioimpedance (BoMed®) had problems with its reliability and was never accepted into clinical practice. Nexfin measure arterial blood pressure using a finger cuff. It is able to track blood pressure from the digital artery in real time.
 Critchley LAH. Minimally Invasive Cardiac Output Monitoring in the Year 2012. Available from: https://www.intechopen.com/books/artery-bypass/minimally-invasive-cardiac-output-monitoring-in-the-year-2012 (Accessed 28 December 2017).
Q4. Answer TTTFF
Uses of capnography in the ICU: Detection of ROSC after cardiac arrest, detection of esophageal intubation and accidental extubation, diagnosing air and pulmonary embolism, indirect indicator of cardiac output.
Noninvasive monitoring of cardiac output based on principle for capnography: Based on the well-known accepted Fick's Principle, Novametrix introduced NICO (Novametrix NICO®) cardiac output measurement device that uses partial CO2 breathing to determine cardiac output noninvasively. The NICO® Cardiopulmonary Management System provides continual cardiac output monitoring. These measurements are accomplished and measured by the proprietary NICO Sensor, which periodically adds a rebreathing volume into the breathing circuit. In addition, NICO provides non-invasive measurement of airway dead space. If arterial carbon dioxide tensions are known, physiological dead space can be calculated easily. Traditional capnography cannot be used to measure stroke volume or cardiac output.
 Kerslake I, Kelly F. Uses of capnography in the critical care unit. BJA Education. 2017;17(5):178-83.
Q5. Answer TTTTF
Limitations of SVV: (1) They can vary with tidal volume, peak inspiratory pressure and lung dynamics. (2) Can vary with cardiac arrhythmias. (3) Only validated in mechanically ventilated patients can be monitored. Spontaneously breathing patients may have irregular rate and tidal volumes interfering with the interpretation. The minimum tidal volume should be 8 mL/kg.
 Song Y, Kwak YL, Song JW, Kim YJ, Shim JK. Respirophasic carotid artery peak velocity variation as a predictor of fluid responsiveness in mechanically ventilated patients with coronary artery disease. BJA: British Journal of Anaesthesia. 2014;113(1):61-66.
Q6. Answer FFTTF
Digoxin has complex pharmacodynamics and pharmacokinetics. It has cardiac inotropic effects, can cause heart block, and in overdose can result in various types of tachyarrhythmias. There has been much controversy about the use of digoxin in heart failure. When digoxin was first discovered it was 19found to be effective in congestive heart failure. Subsequently there were concerns that although it improves symptoms it may increase mortality. The Digitalis Investigation Group or DIG trial showed that digoxin improved symptoms and reduced hospital admissions, but neither increased nor decreased mortality. It is used in resistant heart failure as an add-on drug to more beneficial drugs like angiotensin-converting-enzyme (ACE) inhibitors and spironolactone, and is no longer a first line drug in heart failure. However, in mitral stenosis with atrial fibrillation, it is useful in reducing the ventricular rate. There is no indication for its use in patients with mitral stenosis who are in sinus rhythm. The only still generally valid indication for a long-term digoxin treatment is chronic tachycardia atrial fibrillation (but not hyperthyroidism or Wolff-Parkinson-White syndrome). Digoxin therapy of left ventricular insufficiency in persons with normal sinus rhythm is controversial. Apparently, only a minority of the patients has drawn clinically relevant advantages from it.
 Currie GM, Wheat JM, Kiat H. Pharmacokinetic considerations for digoxin in older people. Open Cardiovasc Med J. 2011;5:130-5.
Q7. Answer TFFTT
Headache is not a recognized side effect of ACE inhibitors. Cough is common, and is an indication to switch over to an angiotensin receptor blocker. Hyperkalemia is a known side effect, especially in patients on spironolactone and those in renal failure. ACE inhibitors are useful even in late stages of renal failure; however worsening of renal function can occur, due to changes in intrarenal autoregulation. If renal function deteriorates, the ACE inhibitor may need to be discontinued. First dose hypotension is a well-known side effect, and patients are therefore advised to take the first dose while lying in bed.
 Francisco AM, García-Luque A, Fernández M, Puerro M. Side Effects of angiotensin converting enzyme inhibitors and angiotensin II receptor antagonists: are we facing a new syndrome. Am J Card 2012;110(10):1552-3.
Q8. Answer TFTTF
Amiodarone can cause both hypo-and hyperthyroidism. It has a very long half-life of nearly 100 days. It causes prolongation of the QT interval, and can be arrhythmogenic. It is used to convert atrial fibrillation to sinus rhythm, and therefore has a place in medical cardioversion of acute atrial fibrillation. Fetal thyroid abnormalities are known to occur, and the drug is contraindicated in pregnancy.
 Loh K. Amiodarone-induced thyroid disorders: a clinical review. Postgraduate Medical Journal. 2000;76:133-40.
Q9. Answer TTFFT
Drugs used in the management of hypertensive crisis: Sodium Nitroprusside, Labetalol, Nitroglycerin, Urapidil, Fenoldopam, Nicardipine, Clevidipine, Enalapril, Intravenous Hydralazine etc. Hydralazine reduces peripheral vascular resistance leading to a reflex tachycardia that can increase cardiac output. Therefore, hydralazine would not be a good choice in a patient with ischemic heart disease who may not tolerate the increased myocardial oxygen consumption. Because of the proarrhythmic effects of sotalol, ordinary beta-blockers are a safer alternative to sotalol after surgery.
 Powers DR, Papadakos PJ, Wallin JD. Parenteral hydralazine revisited. J Emerg Med. 1998;16:191-6.
 Varon J, Marik PE. Clinical review: The management of hypertensive crises. Crit Care. 2003;7(5):374-84.
Q10. Answer TFTTF
Amiodarone lowers the incidence of postoperative AF by about 40 to 50%. Adverse effects of amiodarone are hypotension, circulatory collapse, bradycardia, nausea, flushing, Torsades De Pointes, thyroid disease, pulmonary fibrosis, corneal deposits etc.
 Giardina EG, Zimetbaum PJ, Monitoring and management of amiodarone side effects. Available from: https://www.uptodate.com/contents/monitoring-and-management-of-amiodarone-side-effects (Accessed 29 November 2017).
 Mäntyjärvi M, Tuppurainen K, Ikäheimo K. Ocular side effects of amiodarone. Surv Ophthalmol. 1998;42(4):360-6.
Q11. Answer TTFTF
The ideal anticoagulation strategy for cardiac surgery with CPB does not exist. Heparin and protamine remain the gold standard for anticoagulation therapy. Bivalirudin is the most promising molecule despite its high cost and lack of a readily available antagonist.
 Bouraghda A, Gillois P, Albaladejo P. Alternatives to heparin and protamine anticoagulation for cardiopulmonary bypass in cardiac surgery. Can J Anaesth. 2015;62(5):518-28.20
Q12. Answer TTTFF
zoom view
 Arrigo M, Parissis JT, Akiyama E, Mebazaa A. Understanding acute heart failure: pathophysiology and diagnosis. European Heart Journal Supplements 2016;18(1):G11-G18.
Q13. Answer TTFTF
CK and CK-MB were the most commonly used serologic tests for the diagnosis of myocardial infarction prior to the widespread adoption of troponin. Their use has markedly diminished over time. They are discussed here predominantly for those areas of the world where cardiac troponin assays are not yet in use. Some clinicians prefer the use of CK-MB for the detection of early reinfarction. LDH was commonly used in the past in combination with aspartate aminotransferase (AST or SGOT) and CK-MB to diagnose MI. LD consists of M (muscle) and H (heart) subunits that give rise to five isoenzymes. The heart primarily contains LD1 and some LD2. Red cells, kidney, stomach, and pancreas are other important sources of LD1. In contrast, LD5 predominates in skeletal muscle and liver. LD activity rises to abnormal levels approximately 10 hours after the onset of MI, peaks at 24 to 48 hours, and remains elevated for six to eight days. However, since troponins are more specific than LD and remain elevated for 5 to 10 days, current recommendations suggest that LD no longer has a role in the diagnosis of MI. Skeletal muscle injury elevates CK-MB. The proportion of CK that is CK-MB can be as high as 50 percent with chronic skeletal muscle injury, such as dermatomyositis/polymyositis, due to increased production of B chain CK protein. So the proportion factor may mislead in such cases.
 Chan D. Leong LN. Biomarkers in acute myocardial infarction. BMC Med. 2010;8:34.
Q14. Answer TTTFF
Sometime weaning and trial off may not be successful and we need to go back on ECMO support. Signs of weaning failure during cardiac ECMO (VA-ECMO) are inappropriate tachycardia, hypotension drop in mixed venous saturation below 60% with or without worsening echocardiography. Signs of weaning failure during respiratory ECMO (VV-ECMO) are hypoxia or hypercapnia. The reason for weaning failure should be established and corrected if possible. The reason for weaning failure are that heart or lung have still not recovered completely to tolerate weaning, inadequate ventilator setting, presence of fluid overload and mucus plug. Persistent pulmonary hypertension, underlying other congenital heart disease can also be the cause for weaning failure. If the cause of weaning failure is identified then retry for weaning should be given after correction of the cause. If no factors are discovered then one should retry weaning after 24 to 36 hours.
 Aokage T, Palmér K, Ichiba S, Takeda S. Extracorporeal membrane oxygenation for acute respiratory distress syndrome. Journal of Intensive Care. 2015;3:17.
Q15. Answer TTTFF
ECMO is associated with significant complications related to the critically ill patient subset in which it is used and the therapy itself. Common complications include bleeding, thromboembolic events, and sepsis. Less common complications include limb ischemia, hemolysis, and mechanical failure (such as 21oxygenator or cannula or device thrombosis). Rarer but potentially catastrophic complications include intracerebral bleeding, circuit rupture, accidental decannulation, and air embolism.
 Cheng R, Hachamovitch R, Kittleson M, et al. Complications of extracorporeal membrane oxygenation for treatment of cardiogenic shock and cardiac arrest: a meta-analysis. Ann Thorac Surg. 2014;97:610-6.
Q16. Answer TFTTF
Established or potential hypercoagulable states are activated protein C resistance, Alpha-macroglobulin deficiency, Anticardiolipin antibodies, antithrombin deficiency, dysfibrinogenemia, factor V Leiden, Factor V deficiency, excess, Factor VII excess, Factor VIII excess, Factor IX excess, Heparin cofactor II deficiency, Hyperhomocysteinemia, Hyperfibrinogenemia, Lupus Anticoagulants, PAI – 1 excess, Plasminogen deficiency, Protein C deficiency, Protein S deficiency, Prothrombin G 20210A, tPA deficiency, TFPI deficiency, Thrombomodulin deficiency etc.
 Bande BD, Bande SB, Mohite S. The hypercoagulable states in anaesthesia and critical care. Indian J Anaesth. 2014;58(5): 665-71.
Q17. Answer TFTTF
Predictor
Score
CHF, decreased ejection fraction
1
Hypertension
1
Age > 75 years
2
Diabetes mellitus
1
Vascular disease
1
Stroke/TIA
2
Age 65–74 years
1
Sex, Female
1
Maximum potential score
9
 Wasmer K, Köbe J, Dechering D, et al. CHADS(2) and CHA(2)DS (2)-VASc score of patients with atrial fibrillation or flutter and newly detected left atrial thrombus. Clin Res Cardiol. 2013;102(2):139-44.
Q18. Answer TFTTT
The vast majority of A-V bypass tracts conduct both antegradely and retrogradely. Less than 5% of patients with preexcitation have bypass tracts that conduct only antegradely. This is much less common than the converse situation of retrogradely conducting bypass tracts in the absence of antegrade preexcitation (i.e. so-called concealed bypass tracts).
In patients who manifest only antegrade conduction over their bypass tract, spontaneous circus movement tachycardia, either antidromic or orthodromic, is not usually observed, but when it is, it is antidromic. The primary rhythm disturbance they manifest is atrial fibrillation. Over time antegrade conduction over an A-V bypass tract may disappear. Chen et al. noted a loss of pre-excitation in one fifth of symptomatic patients with WPW. Only 7.8% lost retrograde conduction. Spontaneous loss of pre-excitation has been observed in one fifth to one half of children with WPW.
 Skinner JR, Sharland G. Detection and management of life threatening arrhythmias in the perinatal period. Early Hum Dev. 2008;84(3):161-72.
Q19. Answer TFTTF
VF in patients without structural heart disease is rare. 90–95% of individuals with ventricular fibrillation reveal underlying structural heart disease.
  • No structural heart disease can be identified in only 5% to 10% of patients
  • According to the results of CASPER among patients with normal left ventricular function, a causal diagnosis for VF can be found in 56%. Most diagnoses were primary electrical diseases (catecholaminergic polymorphic VT [CPVT], long QT syndrome, early repolarization syndrome, 22and Brugada syndrome [69%]). In 31% of patients, a subtle structural heart disease (i.e. coronary spasm, subclinical arrhythmogenic right ventricular cardiomyopathy and myocarditis) was identified. In addition, IVF was diagnosed in 44% of patients with VF without structural heart disease.
  • The diagnosis of IVF is based on the exclusion of currently known structural and primary electrical heart diseases following a complete noninvasive, invasive, and genetic workup.
 Axel Sarrias, Roger Villuendas, Felipe Bisbal, et al. From Atrial Fibrillation to Ventricular Fibrillation and Back. Circulation. 2015;132:2035-36.
Q20. Answer TFTFT
Severe acute pulmonary hypertension may contribute to the development or worsening of right ventricular (RV) failure. Pulmonary hypertension and RV failure may reduce left ventricular (LV) filling, LV systolic and diastolic pressures, and cardiac output and lead to systemic hypotension. Decreased arterial blood pressure may compromise LV and RV coronary perfusion at a time when RV end-diastolic pressures and RV myocardial oxygen consumption are increased due to increased RV wall tension, thereby leading to RV ischemia. RV ischemia exacerbates RV failure, causing a further reduction in cardiac output and blood pressure. Concomitant LV dysfunction further impairs RV performance due to the loss of the interventricular septal contributions to RV function, which are largely determined by LV function. One of the key interventions to break this vicious cycle is to reduce the RV afterload, for example, by decreasing pulmonary vascular resistance (PVR), thereby enabling the RV to pump more blood forward. Although systemic vasodilators may reduce PVR, concomitant reduction of systemic blood pressure not only decreases the RV coronary perfusion pressure but also decreases LV contraction, which adversely affects RV function. Inhalation of nitric oxide (NO) produces selective pulmonary vasodilation without reducing the systemic arterial pressure in patients with pulmonary hypertension. Although the only current Food and Drug Administration-approved indication of inhaled NO is persistent pulmonary hypertension of newborns, off-label use of inhaled NO is widespread. However, inhaled NO is very expensive; despite the need to treat RV dysfunction in patients undergoing cardiac surgery, as well as patients undergoing heart and lung transplantation or requiring the placement of a ventricular assist device, there is no established consensus concerning the use of pulmonary vasodilators for these indications.
 Fumito I, Warren ZM. Inhaled Pulmonary Vasodilators in Cardiac Surgery Patients: Correct Answer Is ‘NO’. Anesthesia and Analgesia 2017;125(2):375-7.
Q21. Answer TTTFF
Fast-flush test is a method of determining the dynamic response of the monitoring system to assess the amount of distortion existing in the system. The fast-flush valve is opened for a short time and the resulting flush artifacts are examined (see Figure on page 23). An optimal fast-flush test results on one undershoot followed by small overshoot, and then followed by the waveform. An adequate fast-flush test usually corresponds to a resonant frequency of 10-20 Hz with a damping coefficient of 0.50.7 for peripheral arterial pressure monitoring. The arterial trace should normalize within three oscillations in an optimally dampened system.
Table   Causes of dampening
Overdamping
Underdamping
Air bubbles
Excessive tubing length
Clot
Patient on inotropes
Kink
Deflated pressure bag
Over complaint tubing
Poor connections of stopcock
23
zoom view
Fast-Flush test should be done in the following circumstances: every 8 hourly, when significant change appears in patient hemodynamic status, after zeroing and sampling, change in tubing, damped waveform seen on the monitor.
 Kumar P. Peripheral arterial catheterization. In: Kumar P (Ed.). ICU Manual. 1st Edition. India: Jaypee Brothers Medical Publishers (P) Ltd, 2017; p 18-23.
Q22. Answer TTTFF
The IJV provides a useful and reliable site with a low failure rate and its cannulation is traditionally performed with the aid of both palpation and anatomical landmarks. Various approaches may be used to reach the IJV. Variations between the carotid artery and the IJV, and the depth and size of the IJV may account for failure to locate the vein, and these factors were found to be independent of age and size. The IJV was found directly anterior to the carotid artery, at the level between the two heads of the sternocleidomastoid muscle, in about 50% of cases, and anterior or anterolateral at the level of the cricoid cartilage in about 30% of the cases. Doppler ultrasound guided puncture could reduce the time and the number of attempts for successful cannulation. Direct two-dimensional ultrasound identification proved to be more precise and efficient, especially in small children, and it is now recommended when difficulties are anticipated, complications have been encountered, or when repeated IJV cannulation is required.
Using ultrasound guided IJV cannulation in infants can be 100% successful with ultrasound, as compared with a 75% success rate using a traditional palpation method. Incidence of carotid artery punctures may be 0% versus 25% respectively. In 2002, these findings were repeated by Asheim and coworkers, who found a 100% success rate in 45 consecutive children and a median time to aspirate blood from the IJV of 12 s. Complications include arterial puncture, haematoma formation and catheter malposition, but thrombosis and pneumothorax are rarely reported.
 Haas NA. Clinical review: Vascular access for fluid infusion in children. Crit Care. 2004;8(6):478-84.
Q23. Answer FTTFT
In a study of 20 neonates and small infants, venous oxygen saturation was lower and lactate level higher from the superior vena cava compared with the inferior vena cava. Cerebral tissue oxygenation was analyzed by near-infrared spectroscopy. Based on these measurements, the authors concluded that mixed venous saturation alone is inadequate to evaluate regional cerebral saturation.24
 Redlin M, Koster A, Huebler M, et al. Regional differences in tissue oxygenation during cardiopulmonary bypass for correction of congenital heart disease in neonates and small infants: Relevance of near-infrared spectroscopy. J Thorac Cardiovasc Surg. 2008;136:962-7.
Q24. Answer TTFTF
A great number of medications are available for the treatment of hypertensive emergencies. Sodium nitroprusside is a first-choice for the majority of hypertensive emergencies, and it acts within seconds as a potent arterial and venous dilator. The most important disadvantage is thiocyanate toxicity. The toxicity is more likely to occur if patients have hepatic or renal failure and when the agent is administered for more than 48–72 h. Labetalol can be used to treat hypertensive emergencies through IV administration with a non-selective β-blocker and a1 adrenergic receptor blocker with 6.9:1 ratio of antagonism reducing the systemic vascular resistance but maintaining the cerebral, renal, and coronary blood flow. It is interesting that despite the β-blocking effect it maintains also the cardiac output. Nitroglycerine is a venodilator that mainly reduces the preload and decreases the cardiac oxygen demands, and it is often used in hypertensive crises. This agent is used primarily in acute myocardial infarction and acute pulmonary edema along with other antihypertensive regimens. Other agents that can be used in hypertensive emergencies include nicardipine (dihydropyridine calcium channel blocker), which is a useful agent for patients with coronary artery disease due to its beneficial effect on coronary blood flow or clevidipine, which is a new short-acting intravenous dihydropyridine calcium channel blocker. Enalapril is an angiotensin-converting enzyme inhibitor, but it is not recommended since it can aggravate renal blood flow, and the potential of renal failure in patients with hypertensive emergency is high. Fenoldopam is an important medication, and it acts through peripheral dopamine-1 receptors as a vasodilator and as a diuretic.
 Goswami S, Gupta MK, Mehta Y. Hypertensive urgencies and emergencies. In: Chawla R, Todi S (Eds). ICU protocol book 2nd Edition. Springer India (pub); 2018 (in press).
25Cardiology (Part II)
Prashant Kumar, Qurat Ul Ain Makhdoomi
A Type Questions
(One best answer)
  1. Common causes of pulmonary artery hypertension in the intensive care unit are the following except:
    1. Acute respiratory distress syndrome
    2. Pulmonary embolism
    3. Interstitial lung disease
    4. Lobar pneumonia
    5. Chronic obstructive pulmonary disease
  1. The most appropriate ventilation strategy in pulmonary artery hypertension (PAH) is:
    1. Low tidal volume, low PEEP, permissive hypercapnia
    2. High tidal volume, low PEEP, permissive hypercapnia
    3. Low tidal volume, low PEEP, without permissive hypercapnia
    4. Low tidal volume, high PEEP, permissive hypercapnia
    5. High tidal volume, high PEEP, permissive hypercapnia
  1. Pulmonary Embolism with shock can initially be best treated by:
    1. Large fluid bolus, norepinephrine, dobutamine, fibrinolytics
    2. Small fluid bolus, norepinephrine, dobutamine, fibrinolytics
    3. Small fluid bolus, norepinephrine, dobutamine, anticoagulation
    4. Large fluid bolus, norepinephrine, dobutamine, anticoagulation
    5. Large fluid bolus, norepinephrine, dobutamine, no fibrinolytics
  1. Right ventricular infarction is most commonly associated with myocardial infarction involving:
    1. Anterior wall
    2. Posterior wall
    3. Lateral wall
    4. Anteroseptal wall
    5. Inferior wall
  1. A 45-year-old man is found collapsed at home. There is no history available. His ECG is shown below:
    zoom view
    What is the diagnosis?
    1. Anterolateral ST elevation
    2. Atrial fibrillation with fast ventricular rate
    3. Polymorphic VT or torsades de pointes
    4. Wolff Parkinson-White syndrome
    5. S1Q3T3
  1. Temporary transvenous pacing lead was placed in a case of acute coronary syndrome with high grade AV block. Chest X-ray shows the right ventricular position as shown in the picture below:26
    zoom view
    The pattern on 12 lead ECG in this lead position is:
    1. Normal ECG
    2. ST elevation pattern in lateral leads
    3. Left bundle branch block (LBBB)
    4. Right bundle branch block (RBBB)
    5. Short PR interval with prominent R in V1
  1. A 79-year-old undergoes primary percutaneous coronary intervention (PCI) for anterior wall myocardial Infarction. He required Intubation and mechanical ventilation due to cardiogenic shock. Percutaneous tracheostomy is planned due to difficult weaning. The following is an appropriate strategy for dual antiplatelet in case of drug eluting stents (DES):
    1. Dual antiplatelet therapy (DAPT) are not required for DES placed in stable ischemic heart disease (SIHD)
    2. Aspirin may reasonably be continued while Clopidogrel is stopped for 3–5 days before planned procedure; there is no need to restart Clopidogrel if no stent thrombosis is detected in the interval
    3. Aspirin may reasonably be continued while Clopidogrel is stopped for 3–5 days before planned procedure; Clopidogrel to be restarted post procedure as before and completed for at least 6 months as scheduled
    4. In case of bare metal stent the minimum duration of DAPT is at least 12 months
    5. In case of bleeding in patients on DAPT, platelet transfusions have no role due to long half-life of antiplatelet drugs
  1. The maximum incidence of peripartum Cardiomyopathy occurs at the following stage of pregnancy:
    1. 32 weeks
    2. 37 to 40 weeks (term)
    3. During delivery
    4. Postpartum (up to 4 weeks of delivery)
    5. Late (4 weeks to 20 weeks of delivery)
  1. A 45-year-old patient who was hospitalized following the ingestion of 100 tablets of 0.25 mg digoxin. Serum digoxin level was found to be 12.6 ng/mL. The ECG recorded AF with PVC.
    zoom view
    What is the therapeutic window of digoxin?
    1. 0.10–0.5 ng/mL
    2. 0.5–2 ng/mL
    3. 2–6 ng/mL
    4. 6–12 ng/mL
    5. >12.0 ng/mL
  1. Typical heparin induced thrombocytopenia (HIT) occurs after the following days of starting heparin:
    1. 1–2
    2. 2–5
    3. 4–10
    4. 21–28
    5. ≥ 28
  1. A 74-year-old hypertensive woman was admitted through the emergency department for epigastric pain and dyspnea that had started two days ago. The blood pressure was 90/60 mm Hg and echocardiography shows as below:
    zoom view
    27One of the following is most appropriate initial strategy to manage shock in this condition:
    1. Inotropic support without intra-aortic balloon pump (IABP)
    2. Extracorporeal membrane oxygenation (ECMO)
    3. Early surgery
    4. Trans catheter closure using Amplatzer®
    5. Inotropic support with Intra-aortic balloon pump (IABP)
  1. A 65-year-old male is ventilated in the ICU following an emergency laparotomy for perforated sigmoid diverticulum. He has critical aortic stenosis (AS) and is being considered for an aortic valve replacement. Management strategy which is not appropriate:
    1. To reduce BP, calcium channel blockers (CCB) are preferred over ACE inhibitors
    2. Aggressive use of anti arrhythmics to maintain normal sinus rhythm
    3. Maintenance of a high left ventricular preload
    4. Avoidance of diuretics
    5. Beta-blockers should be avoided or used in low doses
  1. Regarding the arterial pressure waveform in the hypovolemic mechanically ventilated patients which is correct?
    1. Changes in systolic pressure better reflect hypovolemia as compared to changes in pulse pressure across the respiratory cycle
    2. PPV is an indicator of volume status
    3. Pulse pressure is directly proportional to stroke volume
    4. The maximum fall in systolic pressure coincides temporally with the peak inspiratory pressure
  1. A 45-year-old man is admitted into ICU following abdominal surgery. He has oliguria, hypotension and tachycardia 135 bpm, BP systolic 80/40 mm Hg. An esophageal Doppler probe is used showing corrected flow time (FTc) 256 ms (normal value 330 to 360 ms), Peak Velocity (PV) 55cm/s (normal value 90–120 cm/s). Stroke volume 39 mL (Normal value 60 to 100 mL). Which one of the following is most appropriate diagnosis?
    1. Intraoperative myocardial infarction
    2. Massive pulmonary embolism
    3. Hypovolemia
    4. Septic shock
    5. Abdominal compartment syndrome
  1. Which of the following best distinguishes a condition of non- ST segment elevation MI from unstable angina?
    1. Severe chest pain
    2. ST segment depression in two or more contiguous leads of ECG
    3. Raised troponin level
    4. Chest pain lasting more than 15 minutes
    5. NT pro BNP level
  1. A 28-year-old previously well woman is seen in the emergency room with sudden onset palpitation. The ECG shows atrial fibrillation (AF) with a ventricular rate of 140 bpm. On examination, she complains of a feeling of breathlessness but is able to talk in sentences. She also feels very mild pain in the chest. The most appropriate first line treatment of her arrhythmia would be:
    1. Oral digoxin 250–500 over 30 minutes
    2. Intravenous metoprolol 2.5–5 mg over 1 minute
    3. Intravenous flecainide 100–150 mg over 30 minutes
    4. Synchronized cardioversion under sedation
    5. Intravenous verapamil 5 m intravenous bolus
  1. The following assumptions regarding cardiac output is correct when determining from esophageal Doppler probe except:
    1. Changes in Stroke Distance (SD) is directly related to Stroke volume (SV)
    2. Estimate of cross sectional area may be an important source of error
    3. The device has errors in high and low cardiac output
    4. Corrected flow time (FTc) < 330 ms indicates good ventricular fillings
    5. Peak velocity is generally less in the old than in young individuals
  1. A 36-year-old previously healthy male who takes care of a horse presented to the medical casualty ward with a one-day history of fever, arthralgia and severe myalgia. He developed hypotension on the second day of illness. ECG showed sinus tachycardia with ST segment depression in lateral leads which evolved into rapid AF in the subsequent days. 2D echocardiogram showed dilated cardiac chambers with severe global hypokinesia and an ejection fraction of 20%. Leptospirosis was confirmed by positive leptospira IgM 28and negative IgG. He develops shock and multiorgan failure.
    One of the following is False in this condition:
    1. Milrinone is less proarrhythmic than Dobutamine
    2. Aldosterone antagonist spironolactone has have symptomatic and survival benefit
    3. Immunosuppressive therapy may be started in secreted patients who have connective tissue diseases also
    4. Beta-blockers are contraindicated
    5. Intra-aortic balloon counter pulsation (IABP) is an option for patient unresponsive to pharmacologic therapy
  1. A 44-year-old man with dilated cardiomyopathy is on the waiting list for heart transplantation. His condition is refractory to maximal medical therapy, and placement of a left ventricular assist device (LVAD) is considered. One of the following is false about LVAD:
    1. Third generation LVAD produce pulsatile flow to mimic normal physiology
    2. Echocardiography is an important imaging modality used to determine the indication of left ventricular assist device (LVAD)
    3. The LVAD takes blood from the left ventricle and delivers into the aorta
    4. Approximately one-fourth of VAD patients suffer from gastrointestinal bleeding
    5. LVADs may be used as a bridge to transplant for candidates awaiting heart transplantation
  1. Regarding the physics of direct arterial blood pressure measurement, which is correct?
    1. The natural frequency of system should be at least 4 times the fundamental frequency of arterial wave
    2. The catheter connect the arterial cannula to the transducer should be short, stiff and wide to increase natural frequency
    3. The fluid used within the tubing should be of high density
    4. Clot causes under damping
K Type Questions
[Marked True (T)/False (F)]
  1. Hemodynamic effects of the intra-aortic balloon pump (IABP) are the following:
    1. Increase of afterload
    2. Reduction of preload
    3. Improvement in cardiac output
    4. Increase in systolic blood pressure
    5. Improvement of coronary blood flow
  1. Fibrinolytic agent given as single bolus dose:
    1. Streptokinase
    2. Tenecteplase
    3. Reteplase
    4. Alteplase
    5. Fondaparinux
  1. Consider the following statements about natriuretic peptides:
    1. Natriuretic peptides are released in response to Atrial and ventricular wall stretch
    2. Marked elevation in natriuretic peptides are also a prognosticator
    3. NT-pro brain natriuretic peptide (BNP) level up to 350 normal for all age groups
    4. BNP and NT-proBNP can be collectively used to differentiate systolic heart failure from preserved ejection failure heart failure
    5. BNP level of less than 100 is reasonably able to rule out heart failure
  1. Hemodynamic profiles used to describe acutely decompensated heart failure (ADHF):
    1. Warm and wet
    2. Warm and red
    3. Cold and wet
    4. Cold and dry
    5. Warm and friable
  1. Regarding atrial fibrillation (AF) in sepsis:
    1. Vernakalant is a new oral antiarrhythmic which has been found effective in AF of more than 7 days of duration
    2. Amiodarone has less negative inotropic effects compared to B-blockers and calcium channel blockers
    3. The incidence of AF is higher in sepsis when compared to patients without sepsis
    4. Synchronized cardioversion is the treatment of choice for hemodynamically unstable patients
    5. Short-term anticoagulation therapy is considered for persistent AF to avoid risk of bleeding
  1. Mark the following statements as True or False:
    1. A normal electrocardiogram (ECG) can exclude acute myocardial Infarction
    2. ST elevation myocardial infarction (STEMI) in whom the time in whom expected time to primary PCI is greater than 120 minutes 29should be considered for fibrinolytic therapy within 30 minutes
    3. Cardiogenic shock is most often associated with anterior wall myocardial infarction (AWMI)
    4. Advanced atrioventricular block is not a contraindication to B-blockers in the first 24 hours.
    5. Nitrates are useful in RV infarction because of its propensity to increase RV preload and hence cardiac output
  1. Typical characteristics of pulmonary hypertension (PH) due to lung disease are:
    1. Echocardiography is gold standard for diagnosis of PH
    2. PAP of more than 35 mm Hg must be specifically addressed for its long-term adverse effects
    3. PH is poor prognostic factor in both chronic obstructive pulmonary disease (COPD) and interstitial lung disease (ILD)
    4. Bosentan is the therapy of choice with excellent long-term results for COPD with documented chronic hypoxemia
    5. PH is more prevalent in advanced COPD than ILD
  1. Features typical of Takotsubo cardiomyopathy:
    1. Involvement of left ventricular apex
    2. ECG changes undifferentiated from myocardial infarction
    3. Gradual onset
    4. Chest pain or discomfort similar to myocardial infarction
    5. Coronary insufficiency on angiography
  1. An 82-year-old lady, a known case of diabetes mellitus, CAD, and post CABG (15 years ago) brought to emergency with complaints of breathlessness, decreased urine output and weakness. She was diagnosed as carcinoma breast which was treated by surgery, chemotherapy and radiotherapy 10 years ago. She has a baseline ejection fraction of 20%. USG chest revealed large pleural effusion of the right side. Diagnostic/therapeutic thoracentesis reveled total protein 3.5 gm/dL (serum protein 5.0 gm/dL), LDH 300 U/L (Serum LDH 350U/L), NT pro BNP 1500 few pus cells, no micro-organism, no AFB, no fungal elements, no malignant cells. In the past 2 days 750 mL of pleural fluid was drained in the chest drain bag. Serum NT pro BNP was 18000 pg/ mL. She has received aggressive diuretic therapy in the last few days. The following characteristics of pleural effusion support cardiac etiology despite of exudative characteristics in these settings:
    1. Post CABG status
    2. Carcinoma breast in the past
    3. NT pro BNP in pleural fluid 1500 pg/mL
    4. Total protein in pleural fluid 2.5 gm/dL
    5. Serum NT pro BNP was 18000 pg/mL
  1. An 64-year-old male, CAD, TVD HTN, DM, post CABG patient presented with shortness of breath, bilateral leg swelling and severe weakness. He complains of passage of blood in stool. LV EF is 55%. He is taking Aspirin 150 mg once a day in the last 2 years. On arrival his Hb was 4.5 gm/dL and was transfused 2 units of Packed Red Blood Cells. Iron studies reveal- Serum Iron- 46 microgram/dL (49-181), Ferritin 20.70 (17-464), Vitamin B12 839 (261-462).
    There is splenomegaly. Upper GI endoscopy reveal grade I varices with no stigmata of recent bleeding. USG abdomen reveals liver parenchymal disease mild splenomegaly with ascites. Approach to manage upper gastrointestinal bleeding due to antiplatelet therapy includes:
    1. Packed red blood transfusion to correct blood loss
    2. Reversal of the effect of co-prescribed anticoagulants should also be considered
    3. Upper GI endoscopy is avoided in active bleeding
    4. Platelet transfusion is contraindicated due to risk of thrombosis in such cases
    5. Decisions to withhold anti-platelet drugs with due consideration
  1. Cardiologists may use one of the following strategies to reduce the chances of contrast induced nephropathy (CIN) following percutaneous coronary intervention:
    1. Judicious hydration possibly guided by patient's hemodynamic status
    2. No role of minimizing the volume of contrast agent
    3. Stopping nephrotoxic agents
    4. Allow intervals between two contrast exposures30
    5. N-Acetylcysteine 600 mg for two days including the day of the procedure
  1. Correct indication(s) for temporary transvenous pacing:
    1. Symptomatic bradycardia unresponsive to temporary transcutaneous pacing
    2. Symptomatic bradycardia not responding to drugs
    3. Atrial fibrillation waiting for cardioversion
    4. Hemodynamically unstable patient with hypokalemia where defibrillation is contraindicated
    5. Bradycardia with severe coagulopathy
  1. Regarding arterial pressure waveform:
    1. In severe sepsis there is a delayed dicrotic notch
    2. Hypovolemia is characterized by an increase in pulse pressure
    3. Stroke volume can be obtained from the area under the entire waveform
    4. Dicrotic notch is delayed in hypovolemia
  1. Regarding postoperative atrial fibrillation (AF):
    1. Overall incidence in the noncardiac surgery is low compared to cardiac surgery
    2. It most commonly occurs on the 7th postoperative day
    3. Generally it resolves spontaneously
    4. It increase the risk of stroke three fold
    5. Incidence has no relation with age
  1. The following can be assessed from transpulmonary thermodilution method (TPTD):
    1. Preload
    2. Cardiac Index
    3. Estimate of pulmonary edema
    4. An estimate of total circulating blood volume
  1. Mark True or False on drug class and the respective examples in the following pairs:
    1. Direct Thrombin Inhibitor—Ximelagatran
    2. Factor Xa Inhibitor—Tenecteplase
    3. P2Y12 Inhibitor—Prasugrel
    4. Glycoprotein IIb/III inhibitors—Tirofiban
    5. Recombinant tPA—Fondaparinux
  1. According to the American Heart Association (AHA) guidelines which of the followings are correct?
    1. Heart failure with reduced ejection failure (HFrEF) is when left ventricular ejection fraction is less than 40%
    2. Heart failure with preserved ejection fraction (HFpEF) is when left ventricular ejection fraction is more than 50%
    3. Heart failure with reduced ejection fraction (HFrEF) borderline is defined as ejection fraction 41% to 49%
    4. Heart failure with reduced ejection failure (HFrEF) was earlier called as systolic heart failure
    5. Heart failure with preserved ejection fraction (HFpEF) was earlier called as diastolic heart failure
  1. About Milrinone:
    1. Increases blood pressure by vasoconstriction
    2. Increases cardiac output by inotropy
    3. less tachycardia than b-agonists
    4. Thrombocytopenia and hepatic dysfunction are known adverse effects
    5. Commonly prescribed dose is 50 mg/kg loading followed by 0.375–0.75 mcg/kg/min IV
  1. About pulmonary artery occlusion pressure (PAOP):
    1. PAOP is a static parameter
    2. PAOP is generally considered not good predictor of volume responsiveness
    3. Pulmonary artery wedge pressure (PAWP), and pulmonary artery occlusion pressure (PAOP) are one and the same thing
    4. In normal hearts pulmonary artery wedge pressure (PAWP) is more than left ventricular end diastolic pressure (LVEDP)
    5. In mitral stenosis PAWP is more than LVEDP
  1. Mark True or False about thrombolytic therapy for pulmonary embolism (PE):
    1. There is a 10% risk of clinically significant bleeding
    2. Tenecteplase is US FDA approved drug for acute PE
    3. Significant RV dysfunction and myocardial necrosis is an indication of thrombolysis
    4. Systemic hypotension is an absolute contraindication to thrombolysis31
ANSWERS
A Type Answers
Q1. Answer d
Causes of pulmonary artery hypertension in the ICU:
  1. Pulmonary hypertension due to left heart disease: Systolic dysfunction, diastolic dysfunction, valvular disease: Mitral stenosis, mitral regurgitation
  2. Pulmonary hypertension due to lung diseases and/or hypoxia: Chronic obstructive pulmonary disease, interstitial lung disease, sleep-disordered breathing, alveolar hypoventilation disorders
  3. Unclear and/or multifactorial mechanisms: Hematological disorders: myeloproliferative disorders, systemic disorders: sarcoidosis, vasculitis, metabolic disorders: glycogen storage disease
  4. Others: Tumor obstruction, fibrosing mediastinitis, chronic renal failure on dialysis
    Triggers of right ventricle failure in the ICU: Sepsis, arrhythmias, pericardial effusion, anemia, hypoxemia, acidosis, metabolic abnormalities, withdrawal of pulmonary vasodilators, pulmonary embolism, and myocardial infarction. A French series of 46 patients with PAH admitted to the ICU for right ventricle failure found a causative factor in 41% of patients.
 Sztrymf B, Souza R, Bertoletti L, et al. Prognostic factors of acute heart failure in patients with pulmonary arterial hypertension. Eur Respir J. 2010;35(6):1286-93.
Q2. Answer c
Mechanical ventilation may have untoward hemodynamic effects in patients with PAH. Increases in lung volume and decreases in functional residual capacity can increase pulmonary vascular resistance (PVR) and right ventricular afterload. In patients with normal right ventricular function, transient increases in PVR are inconsequential. However, in patients with pre-existing or impending right ventricular failure, lung hyperinflation and either inadequate or excessive PEEP can fatally reduce cardiac output. The elevated pulmonary artery pressure (PAP) correlated directly with increased right atrial pressure and PVR. Right ventricular outflow impedance in mechanically ventilated patients increases as tidal volume is progressively increased and this is ameliorated with the application of low levels of PEEP between 3 cm H2O and 8 cm H2O. Optimal ventilator management of patients with PAH may be with low tidal volumes and relatively low PEEP. This strategy of low tidal volume ventilation is similar to the strategy used to ventilate patients with ARDS, but care should be taken to avoid permissive hypercapnia, which may have untoward hemodynamic effects, including increased PAP, arrhythmia and vasodilatation.
 Zamanian RT, Haddad F, Doyle RL, et al. Management strategies for patients with pulmonary hypertension in the intensive care unit. Crit Care Med. 2007;35(9):2037-50.
Q3. Answer b
Traditionally, volume expansion with 1 to 2 L of crystalloid is the initial treatment for hypotension in patients with undifferentiated shock. However, in hypotensive patients with moderate-to-severe RV dysfunction; the aggressive fluid administration may lead to further increased RVEDP as well as decreased RV coronary perfusion pressure, ultimately resulting in RV ischemia and further deterioration in RV function. Fluids should be used with caution, and early consideration should be given to vasopressor therapy. Norepinephrine, epinephrine, and high-dose dopamine have demonstrated favorable hemodynamic effects in the setting of acute PE and circulatory failure. Anticoagulation with heparin should be begun while pursuing the diagnostic workup. Thrombolytic therapy causes rapid lysis of clot and more rapid improvement in RV hemodynamics. Thrombolytic therapy is recommended as standard, first-line treatment in patients with massive PE, unless contraindicated. The role of thrombolytic therapy for submassive PE is controversial.
 Sekhri V, Mehta N, Rawat N, et al. Management of massive and nonmassive pulmonary embolism. Arch Med Sci. 2012;8(6):957-69.
Q4. Answer e
Right ventricle myocardial infarctions (RVMIs) accompany inferior wall ischemia in up to one-half of cases. Nearly 70% of all AMIs involve some or part of the left ventricle. Left ventricle can be involved in different proportions in all other MI due to its large share of heart muscle as a whole.32
 Ondrus T, Kanovsky J, Novotny T, et al. Right ventricular myocardial infarction: from pathophysiology to prognosis. Exp Clin Cardiol. 2013;18(1):27-30.
Q5. Answer a
12 lead ECG showing an anterolateral ST elevation myocardial infarction. ST segment is showing elevation in precordial leads V1 to V5.
Septal leads = V1-2
Anterior leads = V3-4
Lateral leads = V5-6
 Anterior Myocardial Infarction. Available from: https://lifeinthefastlane.com/ecg-library/anterior-stemi/ (Accessed 28 December 2017).
Q6. Answer c
The universally accepted rule that RV pacing will produce LBBB and left ventricle (LV) pacing of an RBBB pattern on a surface ECG. Paced RBBB morphology in patients with RV apical pacing is usually indicative of inadvertent LV pacing through intracardiac defects such as patent foramen ovale, a ventricular septal defect. Sometimes it may represent coronary sinus pacing.
 Jain R, Mohanan S, Haridasan V, et al. Change in QRS morphology in right ventricular apical pacing: is it a red flag sign? Heart Asia. 2014;6(1):152-4.
Q7. Answer c
Noncardiac surgery is often required in patients taking DAPT after PCI with stenting. Cessation of DAPT prior to the recommended duration of its use, as well as the prothrombotic and proinflammatory state associated with surgery; contribute to an increased risk of adverse cardiovascular events such as stent thrombosis, myocardial infarction, or even death. On the other hand, for some patients such as those undergoing neurosurgical procedures, the risk of bleeding attributable to DAPT may be greater than the risk of adverse cardiovascular events without such therapy. Best is to defer elective noncardiac surgery for at least 12 months, as opposed to operating sooner, irrespective of stent type. In patients who cannot wait at least 12 months for noncardiac surgery an attempt to defer surgery for at least 30 days after bare metal stent placement and at least six months after DES placement is preferred. For most patients undergoing noncardiac surgery who are taking DAPT after PCI with stenting because they have not reached the recommended duration of such therapy, continuing DAPT, as opposed to stopping it prior to surgery is recommended. In patients for whom the risk of bleeding is likely to exceed the risk of a perioperative event due to the premature cessation of DAPT; aspirin alone is continued. In patients for whom a bleeding complication could be catastrophic, such as patients undergoing neurosurgical, prostate or posterior chamber eye procedures, stopping both antiplatelet agents might be reasonable.
 Mahmoud KD, Sanon S, Habermann EB, et al. Perioperative cardiovascular risk of prior coronary stent implantation among patients undergoing noncardiac surgery. J Am Coll Cardiol. 2016;67:1038.
Q8. Answer d
Peripartum cardiomyopathy occurs in the first 4 months postpartum; fewer than 10% of cases occur prepartum. Common symptoms include dyspnea, cough, orthopnea, hemoptysis, and paroxysmal nocturnal dyspnea. Most affected patients have New York Heart Association (NYHA) class III or IV function. Additional symptoms include nonspecific fatigue, malaise, palpitations, chest and abdominal discomfort, and postural hypotension. Diagnosis requires a high degree of suspicion, because symptoms of peripartum cardiomyopathy can be confused with physiologic changes associated with advanced pregnancy. Common signs of peripartum cardiomyopathy include displacement of the apical impulse, presence of S3, and evidence of mitral or tricuspid regurgitation. Engorgement of the neck veins, pulmonary crepitations, hepatomegaly, and pedal edema may also be present.
 Sliwa K, Hilfiker-Kleiner D, Petrie MC, et al. Current state of knowledge on aetiology, diagnosis, management, and therapy of peripartum cardiomyopathy: a position statement from the Heart Failure Association of the European Society of Cardiology Working Group on peripartum cardiomyopathy. Eur J Heart Fail. 2010;12(8):767-78.
33Q9. Answer b
Serum digoxin level: Therapeutic levels are 0.6–1.3 to 2.6 ng/mL. Levels associated with toxicity overlap between therapeutic and toxic ranges. False-negative assay results may occur with acute ingestion of non-digoxin cardiac glycosides (e.g. herbal compounds, such as foxglove or oleander). Levels determined less than 6–8 hours after an acute ingestion do not necessarily predict toxicity. The best way to guide therapy is to follow the digoxin level and correlate it with serum potassium concentrations and the patient's clinical and ECG findings. Assuming that the digoxin level was drawn at the correct time, at steady state, and under conditions of stable renal function, there is a linear relationship between digoxin dose and serum concentration.
 Goldberger ZD, Goldberger AL. Therapeutic ranges of serum digoxin concentrations in patients with heart failure. Am J Cardiol. 2012;109(12):1818-21.
Q10. Answer c
Heparin induced thrombocytopenia is a complication of heparin therapy. There are two types of HIT. Type 1 HIT presents within the first 2 days after exposure to heparin and the platelet count normalizes despite continued heparin therapy. Type 1 HIT is a nonimmune disorder that results from the direct effect of heparin on platelet activation.
 Type 2 HIT is an immune-mediated disorder that typically occurs 4–10 days after exposure to heparin and has life- and limb-threatening thrombotic complications. In general medical practice, the term HIT refers to type 2 HIT.
 HIT must be suspected when a patient who is receiving heparin has a decrease in the platelet count, particularly if the fall is over 50% of the baseline count, even if the platelet count nadir remains above 150 × 109/L. Clinically, HIT may manifest as skin lesions at heparin injection sites or by acute systemic reactions (e.g. chills, fever, dyspnea, chest pain) after administration of an intravenous bolus of heparin.
 Warkentin TE, Greinacher A. Heparin-induced thrombocytopenia: recognition, treatment, and prevention: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004;126(3 Suppl):311S-337S.
Q11. Answer e
The treatment of patients with ventricular septal defect (VSD) depends on the type of defect, its size, shunt severity, PAP, vascular resistance and associated acquired complications including double chambered right ventricle, aortic regurgitation, and pulmonary hypertension (PH). Observational data suggest that surgical closure decreases the risk of endocarditis by at least half. Observational series also suggest that surgical closure in patients with significant shunts reduces PAP and improves long-term survival. Therefore, repair of VSD should be considered in all adult patients who are symptomatic or have signs of left ventricular volume overload without irreversible pulmonary vascular disease and for those with complications related to the VSD, such as progressive aortic valve regurgitation. Observation is reserved for (1) asymptomatic patients with no evidence of left ventricular volume overload and (2) medical management is suggested for patients with symptoms and/or left ventricular volume overload who are not candidates for repair such as those with large defects and severe irreversible PH (Eisenmenger complex). Application of IABP results in better clinical improvements.
 Ammash NM, Warnes CA. Ventricular septal defects in adults. Ann Intern Med. 2001;135:812.
Q12. Answer a
The patient with severe aortic stenosis is relatively ‘afterload fixed and preload dependent’. Thus all afterload reducing agents (ACE inhibitors, CCB) are contraindicated. Only in mild AS, CCB have been used but not suggested. However, in patients with mild-to-moderate AS vasodilators such as hydralazine can increase cardiac output. Nitrates and diuretics can be used to treat angina and congestion, but with great care, as they may provoke a decrease in cardiac output. To treat hypertension low dose ACE inhibitors are considered better than CCB.34
 Carabello BA, Paulus WJ. Aortic stenosis. Lancet. 2009;373(9667):956.
Q13. Answer c
Pulse pressure is the difference between the systolic and diastolic pressure. It is measured in millimeters of mercury (mm Hg). For example, if resting blood pressure is 120/80 mm Hg, pulse pressure is 40 mm Hg. Pulse pressure is proportional to stroke volume, or the amount of blood ejected from the left ventricle during systole and inversely proportional to the compliance of the aorta. A pulse pressure is considered abnormally low if it is less than 25% of the systolic value. The most common cause of a low (narrow) pulse pressure is a decrease in left ventricular stroke volume. If the pulse pressure is extremely low, i.e. 25 mm Hg or less, the cause may be low stroke volume, as in congestive heart failure and/or cardiogenic shock. A chronically increased stroke volume is also a technical possibility, but very rare in practice.
 Franklin SS, Gustin W, Wong ND, et al. Hemodynamic patterns of age-related changes in blood pressure. The Framingham Heart Study. Circulation. 1997;96(1):308.
Q14. Answer c
Esophageal Doppler hemodynamic parameters interpretation:
  • Stroke volume (SV) measured by stroke distance × aortic root diameter—indicates blood ejected per beat of heart
  • Peak velocity (PV)—indicates contractility
  • Corrected (systolic) flow time (FTc)—indicates preload
  • This patient is having low SV/SD and FTc was short indicating an increased afterload. The most common cause of this is hypovolemia.
 Morris C. Oesophageal Doppler monitoring, doubt and equipoise: evidence based medicine means change. Anaesthesia. 2013;68(7):684-8.
Q15. Answer c
Cardiac troponins are sensitive markers for minor degrees of myocardial damage and elevated values can diagnose MI with high degrees of sensitivity and specificity.
 Shyu KG, Kuan PL, Cheng JJ, et al. Cardiac troponin T, creatine kinase, and its isoform release after successful percutaneous transluminal coronary angioplasty with or without stenting. Am Heart J. 1998;135(5 Pt 1):862.
Q16. Answer d
Atrial fibrillation (AF) is the most frequent arrhythmia treated with electrical cardioversion. When monophasic waveforms are used, 100 to 200 joules (watt-seconds) is often adequate to restore sinus rhythm, although >200 joules may be required, particularly for AF of long duration. The overall success rate (at any level of energy) of electrical cardioversion for AF is 75 to 95% and is related inversely both to the duration of AF and to left atrial size.
 Gurevitz OT, Ammash NM, Malouf JF, et al. Comparative efficacy of monophasic and biphasic waveforms for transthoracic cardioversion of atrial fibrillation and atrial flutter. Am Heart J. 2005;149(2):316.
Q17. Answer d
Corrected flow time (FTc) indicates preload (normal = 0.33–0.36 s). Corrected flow time (FTc) by esophageal Doppler is considered to be a ‘static’ preload index. FTc predicts fluid responsiveness. However, FTc should be used in conjunction with other clinical information.
 Lee JH, Kim JT, Yoon SZ et al. Evaluation of corrected flow time in esophageal doppler as a predictor of fluid responsiveness. British Journal of Anaesthesia. 2007;99(3):343-8.
Q18. Answer d
There is definite cardiac involvement in leptospirosis, which even though not symptomatically evident, may add to the morbidity or be contributory to the mortality associated with the disease. There is a possibility of dilated cardiomyopathy as a delayed consequence of severe myocarditis. Medical therapy is recommended such as beta-blocker or ACE inhibitor administration. ICD may be needed for arrhythmias.
 Shah K, Amonkar GP, Kamat RN, et al. Cardiac findings in leptospirosis. J Clin Pathol. 2010;63(2):119-23.
35Q19. Answer a
Short-term circulatory assist devices improve cardiovascular hemodynamics. The LVAD can be used two ways: (1) Bridge-to-transplant, which means it can help a patient survive until a donor heart becomes available. This option may be appropriate for people whose medical therapy has failed and who are hospitalized with end-stage systolic heart failure. (2) Destination therapy, which is an alternative to heart transplant. Destination therapy provides long-term support in patients who are not candidates for transplant. Both continuous and non-pulsatile devices are available, each with different effects on a patient's physiology. In general, these effects are not clinically significant with the exception of bleeding events which are more common with continuous-flow devices in some series. Both devices increase survival beyond medical management. Continuous-flow devices are smaller and are associated with less overall morbidity than pulsatile devices. Reduced pulsatility in patients supported with the continuous-flow LVAD HeartMate II is associated with an increased risk of nonsurgical bleeding.
 Simon D, Fischer S, Grossman A, et al. Left ventricular assist device-related infection: treatment and outcome. Clin Infect Dis. 2005;40(8):1108.
Q20. Answer b
Every material has a frequency at which it oscillates freely. This is called its natural frequency. If a force with a similar frequency to the natural frequency is applied to a system, it will begin to oscillate at its maximum amplitude. This phenomenon is known as resonance. Resonance may occur when the frequency of the pressure waves in the incoming impulse matches the natural frequency of the transducer thereby causing superimposition of pressure waves. The natural frequency of the system may be increased by using a stiff diaphragm and short wide-bore tubing. If the natural frequency of measuring system lies close to the frequency of any of the sine wave components of the arterial waveform, then the system will resonate, causing excessive amplification, and distortion of the signal. In that case, an erroneously wide pulse pressure and elevated systolic blood pressure would result. Tubing system should have very high natural frequency—at least eight times the fundamental frequency of the arterial waveform (the pulse rate). Therefore, for a system to remain accurate at heart rates of up to 180 bpm, its natural frequency must be at least: (180 bpm × 8)/ 60 secs = 24 Hz. Damping reduces the high-frequency noise to allow a more accurate reproduction of the wave form. Too little damping allows oscillations which distort the results while too much damping delays the signal.
 Wilkinson MB, Outram M. Principles of pressure transducers, resonance, damping and frequency response. Anaesthesia & Intensive Care Medicine. 2009;10(2):102-5.
K Type Answers
Q1. Answer FTTFT
Hemodynamic effects of the intra-aortic balloon pump include: (1) Reduction in systolic blood pressure. (2) Fall in end-diastolic aortic pressure. (3) Shortening of the isometric phase of left ventricular contraction (4) Reduction in left ventricular wall stress. (5) Increase in left ventricular ejection fraction. (6) Reduction of preload/afterload.(7) Increase in DPTI/TTI ratio. (8) Improvement of coronary flow. (9) During hemorrhagic shock, an improvement in vasoregulatory control of splanchnic blood flow
 Prondzinsky R, Unverzagt S, Russ M, et al. Hemodynamic effects of intra-aortic balloon counter pulsation in patients with acute myocardial infarction complicated by cardiogenic shock: the prospective, randomized IABP shock trial. Shock. 2012;37(4):378-84.
Q2. Answer FTFFF
Streptokinase—20,000 IU by bolus followed by 2,000 IU/min for 60 minutes.
Tenecteplase—70 to less than 80 kg: 40 mg IV bolus administered over 5 seconds.
Reteplase—10 units IV bolus (over 2 minutes), then Second dose given 30 minutes after first (for total cumulative dose of 20 units).
Alteplase—0.9 mg/kg (not to exceed 90 mg total dose), with 10% of the total dose administered as an initial intravenous bolus over 1 minute and the remainder infused over 60 minutes.
Fondaparinux—It is a synthetic and specific inhibitor of activated Factor X (Xa) not a fibrinolytic drug.
 Ali MR, Hossain MS, Islam MA, et al. Aspect of Thrombolytic Therapy: A Review. Scientific World Journal. 2014:8.
36Q3. Answer TTFFT
The natriuretic peptide system impacts salt and water handling and pressure regulation and may influence myocardial structure and function. Both atrial natriuretic peptide (ANP) and BNP are increased in heart failure (HF), as ventricular cells are recruited to secrete both ANP and BNP in response to the high ventricular filling pressures. The plasma concentrations of both hormones are increased in patients with asymptomatic and symptomatic left ventricular dysfunction, permitting their use in diagnosis. In an analysis of more than 4,000 patients from the Val-HeFT trial, those with a baseline plasma BNP concentration in the highest quartile (≥238 pg/mL) had a significantly greater mortality at two years than those with a plasma BNP in the lowest quartile (<41 pg/mL) (32.4 versus 9.7%). Normal plasma BNP values increase with age and are higher in women than men. It cannot be collectively used to differentiate systolic heart failure from heart failure with preserved ejection. A normal value of BNP is used to exclude heart failure.
 Kinnunen P, Vuolteenaho O, Ruskoaho H. Mechanisms of atrial and brain natriuretic peptide release from rat ventricular myocardium: effect of stretching. Endocrinology. 1993;132(5):1961.
Q4. Answer TFTTF
Clinical assessment of hemodynamic profiles (ADHF): The assessment of patients with HF is based on whether clinical symptoms indicate that filling pressure is or is not elevated (wet or dry) and perfusion is or is not adequate (warm or cold), with combinations of these parameters yielding four possible hemodynamic profiles.
  • Dry-warm—PCWP normal, CI normal
  • Wet-warm—PCWP elevated CI normal
  • Dry-cold—PCWP low/normal, CI decreased
  • Wet-cold—PCWP elevated, CI decreased
 Fonarow GC, Weber JE. Rapid clinical assessment of hemodynamic profiles and targeted treatment of patients with acutely decompensated heart failure. Clin Cardiol. 2004;27(Suppl V):V1-V9.
Q5. Answer FTTTF
Vernakalant is indicated for the rapid conversion of recent onset of AF to sinus rhythm in adults for non-surgery patients that lasts for less than 7 days of duration and post-cardiac surgery patients with AF lasting less than 3 days of duration. Intravenous amiodarone may be an effective short-term agent for ventricular rate control in acutely ill or postoperative patients. Intravenous amiodarone is generally well tolerated in critically ill patients who develop rapid atrial tachyarrhythmias refractory to conventional treatment and may be less likely to cause systemic hypotension than intravenous calcium channel blockers or beta-blockers. Sepsis patients have higher incidence of AF which exhibited higher rates of mortality and stroke, and heart failure risk. Synchronized cardioversion is the treatment of choice for hemodynamically unstable patients which also acts faster than chemical cardioversion.
 Katritsis DG, Gersh BJ, Camm AJ. Anticoagulation in atrial fibrillation—current concepts. Arrhythm Electrophysiol Rev. 2015;4(2):100-7.
Q6. Answer FTTFF
Patients presenting to emergency departments with a complaint of chest pain and who ultimately have a myocardial infarction (MI) may have a normal initial ECG in the following circumstances: (1) If the MI is very small, the magnitude of ECG changes may be undetected. It has been suggested that, in some infarcts, at least 3% of the left ventricle must be involved for ECG changes to develop. (2) The traditional 12-lead ECG generously interrogates the anterior wall, apex, and inferior wall. Infarctions in the lateral and posterior segments of the left ventricle, however, are not directly interrogated by conventional ECGs. It has been estimated that up to 50% of infarctions in the left circumflex distribution may be electrocardiographically normal. (3) Patients may present so early in the course of their MI that ECG disturbances are not yet apparent. Such patients are destined, often within a short time, to develop recognizable ECG abnormalities. Reperfusion strategy, for ST elevation or LBBB on ECG presenting within 12 hours pain onset (Benchmark)- call-to-needle time of under 60 minutes, with door-to-needle time within 30 minutes of patient arrival (thrombolysis), or door- to-skin time within 90 min [percutaneous coronary intervention (PCI)]. Left ventricular dysfunction (LVD) is the most frequent cause of cardiogenic shock occurring in 74.5% of patients. This was followed by acute mitral regurgitation (8.3%), ventricular septal rupture (4.6%), isolated right ventricular shock (3.4%), tamponade 37or cardiac rupture (1.7%), and other causes (8%). Infarctions were located anteriorly in most of the patients (55%) in the SHOCK trial registry.
 Cweres L, Cooke D, Zalenski R, et al. Myocardial infarction with an initially normal electrocardiogram—angiographic findings. Clin Cardiol. 1995;18:563-8.
 Hochman JS, Boland J, Sleeper LA, et al. Current spectrum of cardiogenic shock and effect of early revascularisation on mortality. Results of an international registry. SHOCK registry investigators. Circulation. 1995;91:873-81.
Q7. Answer FTTFT
Patients with PH due to diffuse lung disease (e.g. COPD, ILD, or overlap syndromes) or conditions that cause hypoxemia (e.g. obstructive sleep apnea, alveolar hypoventilation disorders) are classified as having group 3 PH.
 Clinical classification of pulmonary hypertension (NICE, 2013):
  • Group 1: Pulmonary arterial hypertension (PAH)-idiopathic
  • Group 2: Pulmonary hypertension owing to left heart disease
  • Group 3: Pulmonary hypertension owing to lung diseases and/or hypoxia
  • Group 4: Chronic thromboembolic pulmonary hypertension (CTEPH)
  • Group 5: Pulmonary hypertension with unclear multifactorial mechanisms.
    In group 3 PH have mild-to-moderate elevations in mPAP (25 to 35 mm Hg) compared to group 1 where mean mPAP is 50 mm Hg. If echocardiogram is suggestive of mild pulmonary hypertension (e.g. PASP 20 to 39 mm Hg) in the absence of any other etiology for PH, then most clinicians do not proceed with right heart catheterization (RHC), but rather observe patients for progressive symptoms over time. RHC is the gold standard for evaluation. The dual endothelin receptor antagonist, bosentan, is an orally active therapy, which is effective in the treatment of PH in idiopathic and familial PH, in PH associated with connective tissue disease and in PH which may develop in association with other conditions. COPD with hypoxemia may better be treated by supplementary oxygen therapy first.
 Klings ES. Pulmonary hypertension due to lung disease and/or hypoxemia (group 3 pulmonary hypertension): Epidemiology, pathogenesis, and diagnostic evaluation in adults. Available from: https://www.uptodate.com/contents/pulmonary-hypertension-due-to-lung-disease-and-or-hypoxemia-group-3-pulmonary-hypertension-epidemiology-pathogenesis-and-diagnostic-evaluation-in adults (Accessed 28 December 2017).
Q8. Answer TTFTF
Stress cardiomyopathy (also called apical ballooning syndrome, Takotsubo cardiomyopathy, broken heart syndrome, and stress-induced cardiomyopathy) is a syndrome characterized by transient regional systolic dysfunction of the left ventricle (LV), mimicking myocardial infarction, but in the absence of angiographic evidence of obstructive coronary artery disease or acute plaque rupture. In most cases of stress cardiomyopathy, the regional wall motion abnormality extends beyond the territory perfused by a single epicardial coronary artery. The term ‘takotsubo’ is taken from the Japanese name for an octopus trap, which has a shape that is similar to the systolic apical ballooning appearance of the LV in the most common and typical form of this disorder; mid and apical segments of the LV are depressed, and there is hyperkinesis of the basal walls. A midventricular type and other variants have also been described.
 Kurowski V, Kaiser A, von Hof K, et al. Apical and midventricular transient left ventricular dysfunction syndrome (takotsubo cardiomyopathy): frequency, mechanisms, and prognosis. Chest. 2007;132(3):809.
Q9. Answer FFTFT
The pleural NT-proBNP levels are elevated in all patients who have transudate. Therefore if the NT-proBNP levels of pleural effusion are within the normal range, transudate resulting from congestive heart failure can be ruled out. Inclusion of pleural fluid NT-proBNP measurement in the routine diagnostic panel would enhance discrimination among the different causes of pleural effusions.
 Tomcsanyi J, Nagya E, Somloia M, et al. NT-brain natriuretic peptide levels in pleural fluid distinguish between pleural transudates and exudates. Eur J Heart Fail. 2004;6:753-6.
Q10. Answer TTFFT
Gastrointestinal bleeding is a relatively common complication in patients receiving antiplatelet therapy and is associated with an increased risk of recurrent ischemic events and mortality. Prophylaxis with antisecretory 38drugs such as PPIs reduces the risk of GIB. Early endoscopy is useful for both the diagnosis and the therapeutic management of GIB. Antiplatelet therapy should be resumed immediately after endoscopic hemostasis of GIB, unless the bleeding is life threatening. Aspirin inhibits platelet activation by inactivating platelet cyclooxygenase. Aspirin has a rapid onset of action after oral administration (<1 hour but 3–4 hours with enteric-coated preparations) and has a plasma half-life of 20 minutes. However, laboratory evidence of platelet inhibition may persist for 4 days because the effect of aspirin on individual platelets is irreversible.
 Yasuda H, Matsuo Y, Sato Y, et al. Treatment and prevention of gastrointestinal bleeding in patients receiving antiplatelet therapy. World J Crit Care Med. 2015;4(1):40-6.
Q11. Answer TFTTF
Prevention of CIN: (1) Identifying patients at risk: All patients with eGFR <60 mL/min/1.73 m2 and comorbidities including diabetes, heart failure, liver failure, or multiple myeloma. (2) Preventive measures: Avoid volume depletion and NSAIDs, low dose iso-osmolal agent. Fluid administration 3 mL/kg crystalloid over one hour preprocedure and 1 to 1.5 mL/kg/hour during and for four to six hours postprocedure, with administration of at least 6 mL/kg postprocedure. (3) Sodium bicarbonate, acetylcysteine, statins, diuretics and ascorbic acid are not recommended.
 KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney Int Suppl. 2012;2(Suppl 1):8.
Q12. Answer TTFTF
Transvenous cardiac pacing: (1) Indications: Bradycardias, symptomatic sinus node dysfunction, second- and third-degree heart block, atrial fibrillation with a slow ventricular response, new left bundle branch block, bifascicular block, alternating bundle branch block, malfunction of an implanted pacemaker, tachycardias, supraventricular dysrhythmias, ventricular dysrhythmias. (2) Contraindications: Prosthetic tricuspid valve, severe hypothermia. (3) Complications: Inadvertent arterial puncture, venous thrombosis/thrombophlebitis, pneumothorax/other anatomic injury, ventricular arrhythmia, misplacement of the pacing catheter, myocardial/pericardial, perforation, entanglement of the pacing catheter. Coagulopathy is relative contraindication.
 Aguilera PA, Durham BA, Riley DA. Emergency transvenous cardiac pacing placement using ultrasound guidance. Ann Emerg Med. 2000;36:224-7.
Q13. Answer TFFT
Arterial waveforms may provide a deeper insight into overall hemodynamic status. Vasodilatation usually causes lower systolic/diastolic pressures associated with a wide pulse pressure (PP) and delayed dicrotic notch. Vasoconstriction is usually associated with a narrow PP. Regular calibration is essential when pulse contour analysis is used to measure cardiac output.
 Midway through the downstroke, a notch, called the dicrotic notch, may be visible, indicating closure of the aortic valve. The dicrotic notch also represents the beginning of diastole. The remainder of the waveform's downstroke represents blood flow into the arterial tree, with the lowest point representing diastole. Arterial catheterization can also help to guide volume replacement and monitor patients with hypovolemic or septic shock during the administration of pressor or inotropic agents.
zoom view
39Stroke volume can be obtained by area under the systolic portion of the waveform:
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 Nirmalan M, Dark PM. Broader applications of arterial pressure wave form analysis. Anesthesia Critical Care & Pain. 2014;14(6):285-90.
Q14. Answer TFTTF
Atrial fibrillation (AF) and atrial flutter (AFl) occur frequently after cardiac surgery. Its reported incidence ranges from 0.4% to 26% in patients undergoing non-cardiac non-thoracic surgery. AF occurs in 15–40% of patients in the early postoperative period following coronary artery bypass graft surgery (CABG in 37–50% after valve surgery, and in as many as 60% undergoing valve replacement plus CABG. The incidence is less in beating heart surgery than CABG on cardiopulmonary bypass (CPB). The incidence increases with increasing age. Atrial arrhythmias occur most often within the first few days after surgery. In a prospective, multicenter study of 4,657 patients undergoing surgery, the majority of first episodes of AF occurred by day two, while the majority of recurrent episodes occurred by day three. Forty-three percent of patients with AF had more than one episode.
 Maisel WH, Rawn JD, Stevenson WG. Atrial fibrillation after cardiac surgery. Ann Intern Med. 2001;135(12):1061.
Q15. Answer TTTF
Transpulmonary thermodilution method (TPTD) is a safe, multiparametric advanced cardiopulmonary monitoring technique that provides important parameters required for making decisions in critically ill patients. The TPTD provides more reliable indicators of preload than filling pressures, the unique measurement of extravascular lung water (EVLW) and comparable accuracy in measuring cardiac output (CO). TPTD-guided algorithms have been shown to improve the management of high-risk surgical and critically ill patients.
 Intermittent measurement of the CO by TPTD when coupled with pulse contour analysis, offer automatic calibration of continuous CO, as well as accurate assessment of volumetric preload, fluid responsiveness and EVLW.
 Sakka SG, Reuter DA, Perel A. The transpulmonary thermodilution technique. J Clin Monit Comput. 2012;26(5):347-53.
Q16. Answer TFTTF
  • Direct Thrombin Inhibitor—Ximelagatran
  • Factor Xa Inhibitor—Fondaparinux
  • P2Y12 Inhibitor—Prasugrel
  • Glycoprotein IIb/III inhibitors—Tirofiban
  • Recombinant tPA—Tenecteplase
Q17. Answer TTTTF
Definitions of HFrEF and HFpEF40
Classification
EF (%)
Description
Heart failure with reduced ejection fraction (HFrEF)
≤40
Also referred to as systolic HF. Randomized controlled trials have mainly enrolled patients with HFrEF, and it is only in these patients that efficacious therapies have been demonstrated to date.
Heart failure with preserved ejection fraction (HFpEF)
≥50
Also referred to as diastolic HF. Several different criteria have been used to further define HFpEF. The diagnosis of HFpEF is challenging because it is largely one of excluding other potential noncardiac causes of symptoms suggestive of HF. To date, efficacious therapies have not been identified.
a. HFpEF, borderline
41 to 49
These patients fall into a borderline or intermediate group. Their characteristics, treatment patterns, and outcomes appear similar to those of patients with HFpEF.
b. HFpEF, improved
>40
It has been recognized that a subset of patients with HFpEF previously had HFrEF. These patients with improvement or recovery in EF may be clinically distinct from those with persistently preserved or reduced EF. Further research is needed to better characterize these patients.
 2013 ACCF/AHA Guideline for the Management of Heart Failure: Executive Summary. Journal of the American College of Cardiology. 2013;62(16):0735-1097.
Q18. Answer FTTTF
Milrinone is a phosphodiesterase 3 inhibitor which increases the heart's contractility and decrease pulmonary vascular resistance. Milrinone also causes vasodilatation which helps alleviate increased pressures (afterload) of the heart, thus improving its pumping action. Amrinone and milrinone can cause thrombocytopenia. Loading dose 50 mcg/kg administered over 10 minutes followed by a maintenance dose titrated according to hemodynamic and clinical response; Maintenance dose: IV infusion: 0.375 to 0.75 mcg/kg/minute; lower initial doses of 0.1 mcg/kg/minute (with final maintenance doses of 0.2 to 0.3 mcg/kg/minute) have also been recommended. It can lead to hypotension which can be alleviated by coadmistering norepinephrine.
 Abraham WT, Adams KF, Fonarow GC, et al. ADHERE Scientific Advisory Committee and Investigators, ADHERE Study Group. In-hospital mortality in patients with acute decompensated heart failure requiring intravenous vasoactive medications: an analysis from the Acute Decompensated Heart Failure National Registry (ADHERE). J Am Coll Cardiol. 2005;46(1):57.
Q19. Answer TTTFT
The pulmonary wedge pressure or PWP, or cross-sectional pressure (also called the pulmonary arterial wedge pressure or PAWP, pulmonary capillary wedge pressure or PCWP, or pulmonary artery occlusion pressure or PAOP), is the pressure measured by wedging a pulmonary catheter with an inflated balloon into a small pulmonary arterial branch. It estimates the left atrial pressure. PAOP is a static parameter generally considered not good predictor of volume responsiveness. PAWP and PAOP is one and the same thing. In normal hearts pulmonary artery wedge pressure (PAWP) is less than left ventricular end diastolic pressure (LVEDP) by 2–3 mm Hg. In mitral stenosis PAWP is more than LVEDP.
 Chaliki HP, Hurrell DG, Nishimura RA, et al. Pulmonary venous pressure: relationship to pulmonary artery, pulmonary wedge, and left atrial pressure in normal, lightly sedated dogs. Catheter Cardiovasc Interv. 2002;56(3):432-8.
Q20. Answer FTTF
Thrombolysis in PE: (1) used in massive or high risk PEs, (2) can be used up to 14 days after symptoms begin, (3) PE resolve more quickly than with heparin alone, (4) as successful as embolectomy in massive PE (earlier the better), (5) indicated in patients with RV compromise + hemodynamically unstable, (6) rTPA 1.5 mg/kg is maximum dose (as good through peripheral IV or CVL), (7) alteplase 100 mg (0.6 mg/kg) as a continuous infusion over 2 hours.
 Contraindications: Absolute (1) bleeding, (2) recent stroke, (3) HI, (4) current GI bleeding. Relative (1) PUD, (2) surgery within 7 day, (3) prolonged CPR.
 Major hemorrhage following thrombolytic therapy for acute PE is a common complication that warrants specific evaluation of patient risk factors prior to determining appropriate candidacy for thrombolytic therapy.
 The increased fibrin specificity and single bolus administration of TNK-tPA do not increase the risk of intracranial hemorrhage but are associated with less non-cerebral bleeding, especially amongst high-risk patients. A total of 4.66% of patients in the TNK-tPA group experienced major non-cerebral bleeding, in comparison with 5.94% in the rt-PA group.
 Wang TF, Squizzato A, Dentali F, et al. The role of thrombolytic therapy in pulmonary embolism. Blood. 2015;125(14):2191-9.