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Multiple Choice Questions with Explanatory Answers
Steve Benington MBChB MRCP FRCA EDIC FFICM
Shoneen Abbas MBChB MRCP FFICM
Ruth Herod MBChB FRCA FFICM
Daniel Horner BA MBBS MD MRCP(UK) FCEM FFICM
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tfm Publishing Limited, Castle Hill Barns, Harley, Shrewsbury, SY5 6LX, UK
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The entire contents of Intensive Care Medicine MCQs — Multiple Choice
Questions with Explanatory Answers is copyright tfm Publishing Ltd. Apart
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Converting units of measurement
Paper 1: Questions
Paper 1: Answers
Paper 2: Questions
Paper 2: Answers
Paper 3: Questions
Paper 3: Answers
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This book contains three 90-question multiple choice papers designed to
test the candidate’s knowledge of intensive care medicine (ICM) and their
ability to apply it. Each paper begins with 60 multiple true false (MTF)
questions consisting of a stem and five statements, each requiring a true
or false answer. These are followed by 30 single best answer (SBA)
questions where a clinical vignette is presented with five possible
solutions. The candidate should select the one that best addresses the
problem, mirroring clinical practice where a case usually has several
Topics have been chosen to cover the breadth of knowledge required
of the modern intensivist, including resuscitation, diagnosis, disease
management, organ support, applied anatomy, end-of-life care and applied
basic sciences. There is a strong focus on the evidence base
underpinning the specialty, making this book particularly useful for
physicians and others approaching professional examinations in ICM and
related acute medical and surgical specialties. There is no ‘pass mark’,
although a score of less than four out of five in an MTF question or an
incorrect response to an SBA question should help the candidate identify
areas where they would benefit from further reading. Each question is
accompanied by a detailed and fully referenced answer; the majority of
references are freely accessible online or through institutional
The authors are all senior trainees or consultants practising intensive
care medicine in the UK with firsthand experience of passing professional
examinations. In addition, they have extensive training and experience in
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acute medicine, anaesthesia and emergency medicine, respectively, and
have drawn on their experience to devise questions that reflect these
specialties and their interface with intensive care medicine. The authors
hope that this book will be a useful resource not only for those
approaching examinations but for anyone wishing to keep up-to-date in
this fast-changing specialty.
Steve Benington MBChB MRCP FRCA EDIC FFICM
Shoneen Abbas MBChB MRCP FFICM
Ruth Herod MBChB FRCA FFICM
Daniel Horner BA MBBS MD MRCP(UK) FCEM FFICM
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The Editor would like to thank Dr Ola Abbas and Dr Fiona Wallace for their
invaluable help proofreading the manuscript. Also, thanks to Dr John
Macdonald, Dr Hakeem Yousuff, Dr Richard Ramsaran and Dr Andrew
Martin for their comments while testing the questions.
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The following are the most commonly used abbreviations throughout the book:
Association of Anaesthetists of Great Britain and Ireland
Arterial blood gas
Abdominal compartment syndrome
Amniotic fluid embolism
Acute fatty liver of pregnancy
Abbreviated Injury Scale
Acute kidney injury
Acute liver failure
Acute lung injury
Advanced Life Support
Acute Physiology and Chronic Health Evaluation
Advanced Paediatric Life Support
Airway pressure release ventilation
Activated partial thromboplastin time
Acute respiratory distress syndrome
Absolute risk reduction
American Spinal Injury Association
Advanced Trauma Life Support
Acute tubular necrosis
Body mass index
British Thoracic Society
Confusion Assessment Method for the Intensive Care Unit
Cyclic adenosine monophosphate
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Clostridium difficile infection
Cyclic guanosine monophosphate
Chronic kidney disease
Compound muscle action potential
Chronic obstructive pulmonary disease
Continuous positive airway pressure
Cardiopulmonary exercise testing
Clinical Pulmonary Infection Score
Cerebral perfusion pressure
Continuous renal replacement therapy
Computed tomography pulmonary angiogram
Central venous catheter
Central venous pressure
Donation after brainstem death
Donation after cardiac death
Disseminated intravascular coagulation
Deep vein thrombosis
Extracorporeal membrane oxygenation
Erythrocyte sedimentation rate
End-tidal carbon dioxide
External ventricular drain
Fresh frozen plasma
Functional residual capacity
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Glasgow Coma Scale
Glomerular filtration rate
General Medical Council
Human albumin solution
High-frequency oscillatory ventilation
Heat and moisture exchangers
Intra-aortic balloon pump
Intensive care unit
Intensive care unit-acquired weakness
International Liaison Committee on Resuscitation
International Normalised Ratio
Injury Severity Score
The Kidney Disease: Improving Global Outcomes
Laryngeal mask airway
Long QT syndrome
Left ventricular outflow tract
Mean arterial pressure
Modified End-stage Liver Disease
Multiple endocrine neoplasia
Modified Early Obstetric Warning Score
Medicines and Healthcare Products Regulatory Agency
Multiple Organ Dysfunction Score
Mean pulmonary artery pressure
Mortality Prediction Model
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Medical Research Council
Magnetic resonance imaging
Methicillin-resistant Staphylococcus aureus
The National Institute for Health and Care Excellence
National Health Service Blood and Transplant
National Institute for Health and Care Excellence
Neuroleptic malignant syndrome
Number needed to treat
Negative predictive value
Non-steroidal anti-inflammatory drug
Pulmonary artery catheter
Pulmonary artery occlusion pressure
Primary coronary intervention
Polymerase chain reaction
Pulmonary capillary wedge pressure
Positive end-expiratory pressure
Peak expiratory flow rate
Ratio of partial pressure of arterial oxygen to fraction of
Passive leg raising
POSSUM Physiological and Operative Severity Score for the
enUmeration of Mortality and Morbidity
Proton pump inhibitor
Positive predictive value
Propofol infusion syndrome
Parathyroid hormone-related protein
Richmond Agitation Severity Scale
Randomised controlled trial
Recombinant Factor VIIa
Risk, Injury, Failure, Loss, End-stage renal disease
Receiver operator characteristic
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Return of spontaneous circulation
Recognition of Stroke in the Emergency Room
Rapid Shallow Breathing Index
Revised Trauma Score
Simplified Acute Physiology Score
Central venous oxygen saturation
Selective digestive tract decontamination
Syndrome of inappropriate antidiuretic hormone secretion
Strong ion difference
Systemic lupus erythematosus
Sensory (or mixed) nerve action potential
Sequential Organ Failure Assessment
ST elevation myocardial infarction
Superior vena cava
Systemic vascular resistance index
Traumatic brain injury
Total body surface area
Transient ischaemic attack
Transjugular intrahepatic portosystemic shunting
Therapeutic Intervention Scoring System
Tumour lysis syndrome
Trauma Injury Severity Score
Toxic shock syndrome
Thrombotic thrombocytopaenia purpura
Ventricular assist device
Video-assisted thoracoscopic surgery
von Willebrand Factor
White cell count
World Federation of Neurosurgeons
World Society of the Abdominal Compartment Syndrome
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Laboratory results presented in the questions are given in standard UK
units. The following conversion factors may be useful to readers from
1μmol/L = 0.0113mg/dL (e.g. serum bilirubin, creatinine)
1kPa = 7.5mmHg (e.g. PaO2)
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2.84, 3.61, 3.90
1.27, 2.6, 2.9, 3.3, 3.52
Burns & trauma
1.14, 1.23, 1.71, 1.83, 2.29, 2.49,
2.58, 2.85, 3.9, 3.17, 3.20, 3.55, 3.65,
Ethics & legal
1.57, 1.60, 2.36
Evidence and biostatistics
1.20, 2.3, 2.68, 3.11, 3.18
Gastroenterology & hepatology
1.7, 1.52, 1.65, 1.88, 2.24, 2.35, 2.75,
3.25, 3.49, 3.51, 3.86
Haematology & clotting
1.2, 1.5, 1.26, 1.44, 1.84, 3.10, 3.38,
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Metabolic & nutritional
1.9, 1.24, 1.37, 1.40, 1.62, 1.64, 1.82,
2.7, 2.8, 2.21, 2.41, 2.44, 2.52, 2.59,
2.63, 2.80, 2.86, 2.87, 3.4, 3.5, 3.29,
3.31, 3.42, 3.58, 3.68, 3.69, 3.70
Microbiology & infection control
1.28, 1.36, 1.74, 2.34, 2.40, 2.45,
2.47, 2.48, 2.81, 3.2, 3.15, 3.16, 3.24,
3.34, 3.66, 3.83, 3.88
1.49, 1.56, 1.89, 2.42, 2.79, 3.41,
Neurology & neurosurgery
1.1, 1.8, 1.10, 1.16, 1.17, 1.29,
1.53, 1.55, 1.58, 1.61, 1.66,
1.79, 1.80, 2.19, 2.22 2.27,
2.38, 2.64, 2.89, 3.22, 3.35,
2.70, 2.72, 3.67, 3.75
1.45, 2.39, 3.32, 3.62
Organ support & sedation
1.12, 1.72, 1.78, 1.81, 1.86, 2.1, 2.5,
2.16, 2.20, 2.62, 3.43, 3.47, 3.59,
3.85, 3.87, 3.89
1.46, 3.14, 3.55
1.3, 1.6, 2.15, 2.18, 2.54
Physics & clinical measurement
1.30, 1.43, 2.13, 2.14, 2.17, 2.21,
2.51, 2.57, 2.78, 3.27, 3.33, 3.54,
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1.13, 1.21, 1.22, 2.25, 2.50, 2.82,
Respiratory & ventilation
1.4, 1.11, 1.18, 1.50, 1.51, 1.59, 1.69,
1.70, 1.76, 1.77, 1.87, 2.23, 2.26,
2.65, 2.88, 3.1, 3.7, 3.8, 3.13, 3.44,
Resuscitation & sepsis
1.34, 1.35, 2.4, 2.11, 2.37, 2.61, 2.66,
2.71, 3.6, 3.23, 3.26, 3.63, 3.73, 3.80
1.19, 1.38, 1.54, 1.68, 2.2, 2.33, 2.56,
2.53, 3.83, 3.84
Toxicology & poisoning
1.32, 1.39, 1.48, 1.63, 1.67, 2.31,
2.32, 2.69, 3.37, 3.57, 3.79, 3.89
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Paper 1 questions_Paper 1 questions.qxd 12/04/15 10:35 AM Page 1
Affects more females than males.
Is a disease of the middle-aged.
When secondary to a respiratory illness, the majority of cases
present within a month.
The presence of cranial nerve signs effectively rules out the
The most common associated pathogen is Clostridium perfringens.
An initial target systolic blood pressure of 80-90mmHg is
recommended for the patient without brain injury.
Desmopressin at a dose of 0.3μg/kg is recommended in the
bleeding patient taking platelet-inhibiting drugs.
Recombinant factor VIIa (rFVIIa) can be considered as a rescue
measure provided the platelet count is greater than 30 x 109/L.
Pre-injury warfarin use doubles the odds of death for trauma
patients with blunt head injury.
Antifibrinolytic drugs recommended for use in the bleeding major
trauma patient include tranexamic acid, aprotinin and aminocaproic
Multiple True False (MTF) questions — select true or false for each of
the five stems.
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Inhaled nitric oxide.
Which of the following features of an asthma attack
are classified as ‘life-threatening’ in the 2011 BTS
Inability to complete sentences in one breath.
PaO2 of >8kPa.
Peak expiratory flow rate (PEFR) <50% of predicted.
With regard to bleeding and coagulopathy in the
If a platelet transfusion is indicated, 1 unit will raise the count by
approximately 20 x 109/L.
The principal constituents of cryoprecipitate include Factors VIII,
XIII, vWF, fibronectin and fibrinogen.
A suggested dose of fresh frozen plasma in the bleeding trauma
patient with coagulopathy is 30ml/kg.
Desmopressin at a dose of 0.3μg/kg is a useful treatment in
patients with coagulopathy related to uraemia, cirrhosis and aspirin
At temperatures of 33-35°C, altered enzyme kinetics equate to a
33% reduction in normal clotting factors.
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An antagonist has receptor affinity and intrinsic activity.
Increasing the dose of a partial agonist can elicit a maximal effect.
β-receptor blockers are reversible antagonists.
Flumazenil is an inverse agonist.
Phenoxybenzamine is an irreversible antagonist at α-adrenoceptors.
It is commonly over-diagnosed in patients with cirrhotic liver
HRS Type 1 has the poorest outcome.
Kidneys from patients with HRS are suitable for transplantation.
The condition is associated with splanchnic vasodilatation.
Terlipressin must be given by infusion.
With regard to a patient with a neuromuscular
Potassium-sparing diuretics should be avoided in patients with
hypokalaemic periodic paralysis.
Suxamethonium use should be avoided in patients with myasthenia
Patients with motor neurone disease typically require double the
standard dose of suxamethonium to provide optimum intubating
Local anaesthesia can exacerbate symptoms of multiple sclerosis.
In Guillain-Barré syndrome, non-depolarising neuromuscular
blocking drugs may be used, but should be significantly dosereduced.
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Regarding parenteral nutrition in the critically ill
A patient with enteral feeds running at 40ml/hr with 4-hourly
aspirates of >200ml is deemed to be failing enteral nutrition.
Daily caloric intake should be 100-130% of the patient’s calculated
daily energy expenditure.
Parenteral nutrition can be administered peripherally.
Approximately 1g/kg/day of nitrogen is required.
Copper, zinc and selenium (trace elements) are present in
commercially produced parenteral nutrition solutions.
A 67-year-old male has a diagnosis of myasthenia
gravis (MG). Which of the following medications
The following statements are true regarding the
PEFR <33% is a criterion diagnosis.
Aminophylline should be given as a first-line intravenous
The use of IV magnesium sulphate to reduce mortality is supported
by level I evidence.
Ketamine 5mg/kg is the preferred induction agent if rapid sequence
intubation is required.
A restrictive fluid regime should be used in patients at risk of
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Eight potentially pathogenic micro-organisms are responsible for
the majority of infections in critical care.
SDD is ‘selective’ because it is anaerobe-sparing.
Primary endogenous pathogens are targeted by intravenous
antibiotics for the first 4 days.
After 10 days potentially pathogenic micro-organisms have been
eradicated and all antibiotics are stopped.
There is level I evidence that SDD increases the prevalence of
peripheral oedema and frothy urine. He is
subsequently diagnosed with nephrotic syndrome.
Risk of myocardial infarction.
The following have been demonstrated to be useful
Sensory neurological deficit.
The presence of non-evacuated haematoma on CT brain scan.
Regarding the role of selective digestive tract
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for the management of acute and chronic heart
Ventricular assist devices can be used for a maximum of 3-4 weeks.
A short-term left ventricular assist device takes blood from the right
atrium and injects it into the main pulmonary artery.
Most modern ventricular assist devices produce a pulsatile flow.
The insertion of an LVAD worsens aortic regurgitation.
All patients with VADs must be anticoagulated.
Meningitis is a relatively rare complication of LP.
Suspected bacteraemia is a contraindication to LP.
Aspirin should be stopped for at least 24 hours prior to LP.
LP is contraindicated in patients with a suspected spinal epidural
It is recommended that LP is not performed in patients with platelet
counts of <100 x 109.
Ocular nerve sheath diameter >6mm measured with ultrasound
reliably predicts raised intracranial pressure of >20mmHg.
ICP monitoring through an external ventricular drain allows
On a standard intracranial pressure waveform, P3 represents
Cerebral hypoxia results in hypoxic vasoconstriction and reduced
cerebral blood flow, thus causing a temporary reduction in ICP.
Lundberg Type A waves are always pathological.
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Setting an extrinsic positive end-expiratory pressure (PEEP) less
than intrinsic PEEP will reduce elastic work of the respiratory
One risk of applying PEEP is a reduction in oxygen delivery (DO2).
A decelerating flow pattern is seen in volume-controlled ventilation.
The difference between peak and plateau pressures is greater
with volume-controlled ventilation than pressure-controlled
Dynamic compliance equals the tidal volume divided by (peak
pressure minus total positive end-expiratory pressure).
Acute Physiology and Chronic Health Evaluation III (APACHE III).
CT Calcium Score.
Sequential Organ Failure Assessment (SOFA).
Mortality Prediction Model (MPM).
Regarding the mechanics of positive pressure
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It is a highly effective treatment for thrombotic thrombocytopaenic
The most commonly used replacement fluid is 4.5% albumin in
Therapeutic plasma exchange requires central venous access.
Paraesthesia is a common complication.
Thrombosis is a common complication.
international consensus guidelines suggest the
In critically ill patients, insulin therapy should target a plasma
glucose of about 6-8mmol/L.
Administration of colloid boluses to expand intravascular volume.
Parenteral nutrition should be used in preference to the enteral
route in patients with AKI.
N-acetyl cysteine (NAC) should not be used for the prevention of
Low-dose dopamine has a role in the treatment of established AKI.
The CRASH 1 trial examined the role of steroids in traumatic brain
The CRASH 2 trial assessed the role of tranexamic acid in
traumatic brain injury (TBI) within a pilot sample.
The CRASH 3 trial is designed to assess the effectiveness of
tranexamic acid in TBI within a multicentre cohort.