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SBAq for final FFICM

Cambridge University Press
978-1-107-54930-2 — Single Best Answer Questions for the Final FFICM
Keith Davies , Christopher Gough , Emma King , Benjamin Plumb , Benjamin Walton
Frontmatter
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Single Best Answer Questions
for the Final FFICM

www.cambridge.org


Cambridge University Press
978-1-107-54930-2 — Single Best Answer Questions for the Final FFICM
Keith Davies , Christopher Gough , Emma King , Benjamin Plumb , Benjamin Walton
Frontmatter
More Information

www.cambridge.org



Cambridge University Press
978-1-107-54930-2 — Single Best Answer Questions for the Final FFICM
Keith Davies , Christopher Gough , Emma King , Benjamin Plumb , Benjamin Walton
Frontmatter
More Information

Single Best Answer Questions
for the Final FFICM

Keith Davies
Consultant in Anaesthesia and Intensive Care Medicine, North Bristol NHS Trust, Bristol,
United Kingdom

Christopher Gough
Specialty Trainee in Intensive Care Medicine and Anaesthesia (Dual CCT), Severn Deanery,
United Kingdom

Emma King
Specialty Trainee in Intensive Care Medicine and Anaesthesia (Joint CCT), Severn Deanery,
United Kingdom

Benjamin Plumb
Specialty Trainee in Intensive Care Medicine and Anaesthesia (Dual CCT), Severn Deanery,
United Kingdom

Benjamin Walton
Consultant in Critical Care and Anaesthesia, North Bristol NHS Trust, Bristol,
United Kingdom

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Cambridge University Press
978-1-107-54930-2 — Single Best Answer Questions for the Final FFICM
Keith Davies , Christopher Gough , Emma King , Benjamin Plumb , Benjamin Walton
Frontmatter
More Information

University Printing House, Cambridge CB2 8BS, United Kingdom
Cambridge University Press is part of the University of Cambridge.
It furthers the University’s mission by disseminating knowledge in the pursuit of
education, learning and research at the highest international levels of excellence.
www.cambridge.org
Information on this title: www.cambridge.org/9781107549302
C Keith Davies, Christopher Gough, Emma King, Benjamin Plumb,
Benjamin Walton 2017

This publication is in copyright. Subject to statutory exception
and to the provisions of relevant collective licensing agreements,
no reproduction of any part may take place without the written
permission of Cambridge University Press.
First published 2017
Printed in the United Kingdom by Clays, St Ives plc.
A catalogue record for this publication is available from the British Library
Library of Congress Cataloging-in-Publication Data
Davies, Keith (Specialist in intensive care medicine), author.
Gough, Christopher, author. King, Emma, 1980–, author.
Plumb, Benjamin, author. Walton, Benjamin, author.
Single best answer questions for the final FFICM / Keith Davies, Christopher Gough,
Emma King, Benjamin Plumb, Benjamin Walton.
Cambridge, United Kingdom ; New York : Cambridge University Press, 2016.
Includes bibliographical references and index.
LCCN 2015048884 ISBN 9781107549302 (hardback : alk. paper)
MESH: Critical Care Great Britain Examination Questions
Classification: LCC RC86.9 NLM WX 18.2 DDC 616.02/8076–dc23
LC record available at http://lccn.loc.gov/2015048884
ISBN 978-1-107-54930-2 Paperback
Cambridge University Press has no responsibility for the persistence or accuracy
of URLs for external or third-party internet websites referred to in this publication,
and does not guarantee that any content on such websites is, or will remain,
accurate or appropriate.
.........................................................................................
Every effort has been made in preparing this book to provide accurate and up-to-date
information which is in accord with accepted standards and practice at the time of
publication. Although case histories are drawn from actual cases, every effort has been
made to disguise the identities of the individuals involved. Nevertheless, the authors,
editors and publishers can make no warranties that the information contained herein is
totally free from error, not least because clinical standards are constantly changing
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Cambridge University Press
978-1-107-54930-2 — Single Best Answer Questions for the Final FFICM
Keith Davies , Christopher Gough , Emma King , Benjamin Plumb , Benjamin Walton
Frontmatter
More Information

Contents
Preface

page vii

Exam A: Questions

1

Exam A: Answers

9

Exam B: Questions

46

Exam B: Answers

54

Exam C: Questions

90

Exam C: Answers

98

Exam D: Questions

134

Exam D: Answers

142

Exam E: Questions

179

Exam E: Answers

187

Exam F: Questions

223

Exam F: Answers

231

Exam G: Questions

266

Exam G: Answers

274

Exam H: Questions

310

Exam H: Answers

318

Index

354

v

www.cambridge.org


Cambridge University Press
978-1-107-54930-2 — Single Best Answer Questions for the Final FFICM
Keith Davies , Christopher Gough , Emma King , Benjamin Plumb , Benjamin Walton
Frontmatter
More Information

www.cambridge.org


Cambridge University Press
978-1-107-54930-2 — Single Best Answer Questions for the Final FFICM
Keith Davies , Christopher Gough , Emma King , Benjamin Plumb , Benjamin Walton
Frontmatter
More Information

Preface
Single best answer (SBA) questions can be notoriously difficult to answer, and practice is essential. SBAs contain more grey areas than true/false questions, which gives
them greater discrimination power, but makes them more demanding. With 240 practice questions, this book will help with both SBA examination practice and revision
across the whole range of topics demanded by the FFICM.
The Faculty of Intensive Care Medicine (FICM) oversees the training and registration of intensive care doctors in the United Kingdom. To attain a Certificate of
Completed Training (CCT) in Intensive Care Medicine (ICM), doctors must achieve
fellowship of the FICM by passing the final examination (FFICM).
The final FFICM has three sections: a multiple-choice written examination (MCQ),
a structured oral examination (SOE) and an objective structured oral examination
(OSCE). To be eligible to sit the oral sections of the examination, candidates must first
pass the MCQ.
The MCQ is now made up of two types of question: 60 multiple true/false (MTF)
questions and 30 SBA questions. The companion publication to this volume (Multiple
True False Questions for the Final FFICM, Cambridge University Press, 2015) has 270
example MTF questions with fully referenced explanations for practice and revision.
This volume complements the original by providing practice and revision for the SBA
questions.
This volume contains eight practice SBA examinations with 30 questions each, followed by an expanded answer. SBAs comprise a brief clinical case history followed
by a question, often concerning the most likely diagnosis or best treatment. The question is followed by five answer stems, each of which could plausibly be correct. The
candidate must then select the single best answer for the question. The answer sections contain the correct answer, a short explanation of why the answer is the best of
the five on offer and a long explanation which covers the topic of the original question and includes references for further reading. This structure allows candidates to
choose whether to use this book as quick practice or fuller revision.

vii

www.cambridge.org


Preface
Single best answer (SBA) questions can be notoriously difficult to answer, and practice is essential. SBAs contain more grey areas than true/false questions, which gives
them greater discrimination power, but makes them more demanding. With 240 practice questions, this book will help with both SBA examination practice and revision
across the whole range of topics demanded by the FFICM.
The Faculty of Intensive Care Medicine (FICM) oversees the training and registration of intensive care doctors in the United Kingdom. To attain a Certificate of
Completed Training (CCT) in Intensive Care Medicine (ICM), doctors must achieve
fellowship of the FICM by passing the final examination (FFICM).
The final FFICM has three sections: a multiple-choice written examination (MCQ),
a structured oral examination (SOE) and an objective structured oral examination
(OSCE). To be eligible to sit the oral sections of the examination, candidates must first
pass the MCQ.
The MCQ is now made up of two types of question: 60 multiple true/false (MTF)
questions and 30 SBA questions. The companion publication to this volume (Multiple
True False Questions for the Final FFICM, Cambridge University Press, 2015) has 270
example MTF questions with fully referenced explanations for practice and revision.
This volume complements the original by providing practice and revision for the SBA
questions.
This volume contains eight practice SBA examinations with 30 questions each, followed by an expanded answer. SBAs comprise a brief clinical case history followed
by a question, often concerning the most likely diagnosis or best treatment. The question is followed by five answer stems, each of which could plausibly be correct. The
candidate must then select the single best answer for the question. The answer sections contain the correct answer, a short explanation of why the answer is the best of
the five on offer and a long explanation which covers the topic of the original question and includes references for further reading. This structure allows candidates to
choose whether to use this book as quick practice or fuller revision.

vii
03 Feb 2017 at 12:12:04
001


03 Feb 2017 at 12:12:04
001


Exam A: Questions
A1. A trauma patient is brought into the resuscitation room with an obviously
unstable pelvis. Despite ongoing fluid resuscitation with blood products the patient
remains haemodynamically unstable, has a profound metabolic acidosis and continues to deteriorate. Focused assessment with sonography in trauma (FAST) scan is
positive.
Which of the following is MOST important in the management of this patient’s
bleeding?
A.
B.
C.
D.
E.

Administration of tranexamic acid
1:1:1 rather than 1:1:2 transfusion ratio for plasma:platelets:blood
Treatment with interventional radiology
Urgent damage control surgery
Maintaining normothermia and ionized calcium levels >0.9 mmol/l

A2. A patient has been admitted to the intensive care unit (ICU) with severe sepsis
and urgently requires a central venous catheter (CVC). You decide to insert the CVC
into the right internal jugular vein (IJV).
Which of the following approaches to central line insertion is the best?
A.
B.
C.
D.
E.

Landmark approach; lateral to the carotid artery pulsation
Audio-guided Doppler ultrasound guidance in the head-up position
Landmark approach; medial to the carotid artery pulsation
Audio-guided Doppler ultrasound guidance in the head-down position
Two-dimensional (2D) ultrasound guidance

A3. Of the following pathologies, which is the commonest cause for end-stage renal
failure in the United Kingdom?
A.
B.
C.
D.
E.

Hypertension
Polycystic kidney disease
Vasculitis
Renal artery stenosis
Immunoglobulin A (IgA) nephropathy

1
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002


Exam A: Questions

A4. Which of the following methods of humidification is able to generate the highest relative humidity in an ICU ventilator circuit?
A.
B.
C.
D.
E.

Heat and moisture exchange filter (HME)
Cascade humidifier
Cold-water bath
Hot-water bath
Ultrasonic nebulizer

A5. Which of the following gas patterns seen on plain erect abdominal X-ray is most
suggestive of significant bowel pathology requiring surgery?
A.
B.
C.
D.
E.

Large gas bubble in the stomach
Gas in the small bowel
Gas in the small bowel and fluid levels at the same height within loops
Gas in the large bowel
Gas in the small bowel and rectum only

A6. You are about to intubate a patient with a life-threatening exacerbation of
asthma.
Which of the following agents is MOST likely to improve lung mechanics and
bronchospasm?
A.
B.
C.
D.
E.

Atracurium
Ketamine
Propofol
Thiopentone
Fentanyl

A7. In a normal adult patient, a red blood cell travelling from the aorta to the portal
vein is most likely to pass through which structures?
A.
B.
C.
D.
E.

Inferior mesenteric artery, superior rectal artery, rectal veins
Coeliac trunk, left gastro-omental artery, splenic vein
Right gastric artery, short gastric vein, splenic vein
Superior mesenteric artery, right colic vein, inferior mesenteric vein
Coeliac trunk, gastroduodenal artery, epigastric vein

A8. A patient is undergoing chemotherapy for acute leukaemia, is neutropenic
and has a persistent temperature and cough despite treatment with broad-spectrum
antibiotics. A computed tomography scan of the thorax reveals pulmonary nodules
with surrounding halos of ground-glass opacity (‘halo sign’). Antigen testing on bronchoalveolar lavage samples suggests a diagnosis of Aspergillus.
Which of the following would be the BEST treatment for this patient?
A.
B.
C.
D.
E.

Voriconazole
Amphotericin B deoxycholate
Fluconazole
Flucytosine
Posaconazole

2
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002


Bilirubin
Reticulocytes
Aspartate transaminase (AST)
Alkaline phosphatase (ALP)
International normalized ratio
Ceruloplasmin

200 µmol/l
<1%
450 IU
300 IU
1.4
33 mg/dl

(3–17 µmol/l)
(<1%)
(<35 IU)
(<250 IU)
(0.8–1.2)
(20–35 mg/dl)

Exam A: Questions

A9. A male patient with jaundice has the following blood results:
60% conjugated

Which of the following is the MOST likely cause of the patient’s jaundice?
A.
B.
C.
D.
E.

Alcoholic cirrhosis
Primary sclerosing cholangitis
Wilson disease
Pancreatic cancer
Haemolysis

A10. A patient returns from an aortic valve replacement (AVR) operation to the cardiac intensive care unit (CICU). He has atrial and ventricular epicardial pacing wires
in situ, connected to a temporary pacing box. The post-operative electrocardiogram
(ECG) demonstrates a rate of 80 bpm with a pacing spike immediately followed by a
P wave then 220 ms pause before a narrow QRS complex.
Which of the following is most likely to describe this situation?
A.
B.
C.
D.
E.

VVI pacing
AOO pacing with first-degree heart block
DDD pacing with the AV delay set at 200 ms
VOO pacing with retrograde atrial contraction
AAI pacing with underlying fast atrial fibrillation

A11. Which of the following is the LEAST invasive method of calculating cardiac
output?
A.
B.
C.
D.
E.

Lithium dilution, e.g. LiDCO
Thermodilution, e.g. PiCCO
Indirect Fick method
Oesophageal Doppler
Volume clamp (Penaz method), e.g. Finapress

A12. A 54-year-old man with no previous medical history is admitted with shortness of breath and pleuritic chest pain 4 days after a 16-hour flight. A computed
tomography (CT) scan has demonstrated bilateral pulmonary emboli, and echocardiography has revealed right heart dysfunction. His heart rate is 112 bpm, blood
pressure is 104/52 and oxygen saturations are 94% on 50% inspired O2 .
Which would be the MOST appropriate treatment?
A.
B.
C.
D.
E.

Anticoagulate with low molecular weight heparin (LMWH)
Anticoagulate with vitamin K antagonists
Thrombolyze using alteplase
Anticoagulate with unfractionated heparin infusion (UFH)
Anticoagulate with dabigatran

3
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002


Exam A: Questions

A13. A 74-year-old female patient presents with sudden onset, spontaneous, rightsided weakness. There is no history of trauma, and she reports no history of pain.
Two days later, she remains alert and oriented. Neurological examination still reveals
decreased tone and power in the right arm and leg with diminished reflexes and
right-sided neglect due to homonymous hemianopia.
Which of the following is the most likely diagnosis?
A.
B.
C.
D.
E.

Transient ischaemic attack (TIA)
Partial anterior circulation syndrome (PACS)
Carotid artery dissection
Total anterior circulation syndrome (TACS)
Malignant middle cerebral artery infarct

A14. A 54-year-old patient is ventilated with pneumonia. He has plateau and peak
end expiratory pressures of 28 and 12 cmH2 O respectively. His O2 saturation are 92%
with an FiO2 of 0.4 and arterial blood gas findings are as follows: pH 7.26, PaO2 8.2
kPa, PaCO2 7.6 kPa. An echocardiography reveals an ejection fraction of 44% and
pulmonary arterial pressure of 55 mmHg.
What is the MOST likely cause of this patient’s pulmonary hypertension (PH)?
A.
B.
C.
D.
E.

Hypoxia and hypercapnia
Chronic pulmonary hypertension
Acute left ventricular dysfunction
An acute pulmonary embolism
Pulmonary atelectasis

A15. Which of the following indications has the LEAST strong evidence base for
initiating a blood transfusion?
A. Haemoglobin (Hb) <70 g/l in a previously well patient admitted to the intensive
care unit
B. A shocked trauma patient with massive blood loss unresponsive to crystalloids
C. Hb <70 g/l in a stable patient admitted with an acute upper gastrointestinal
bleed
D. Hb <70 g/l in a patient with septic shock on vasopressin and noradrenaline
E. Hb <100 g/l in a patient in the intensive care unit with a history of
cardiovascular disease

4
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002


K+
PO4 3−
Corrected Ca2+
Uric acid

Result

Reference Range

7.2 mmol/l
1.8 mmol/l
1.6 mmol/l
598 µmol/l

3.5–5.0
0.8–1.2
2.12–2.65
210–480

Exam A: Questions

A16. A 54-year-old male patient is admitted to the intensive care unit with electrolyte derangement and acute renal failure following initiation of treatment for his
Burkitt lymphoma. Blood test results include the following:

Which of the following is LEAST true regarding this condition?
A. Complete correction of electrolyte derangements with fluids, filtration and
electrolyte replacement should occur
B. It occurs with increased frequency in those patients with bulky, rapidly
proliferating tumours
C. It occurs spontaneously but is often precipitated by initiation of chemotherapy
treatment
D. Electrolyte derangements result from release of intracellular contents as tumour
cells lyse
E. Treatment with rasburicase is more effective at reducing uric acid levels than
allopurinol
A17. A 74-year-old patient with Clostridium difficile diarrhoea, has a white cell count
(WCC) of 18 × 109/l, a temperature of 39°C and evidence of ileus.
Which of the following is the BEST treatment regimen?
A.
B.
C.
D.
E.

Intravenous metronidazole
Oral vancomycin and oral metronidazole
Oral fidaxomicin
Oral vancomycin and intravenous metronidazole
Oral vancomycin

A18. A 38-year-old patient has developed acute respiratory distress syndrome following a viral pneumonia. He is intubated and ventilated but showing little sign of
improvement. A decision is made to refer him to the local extracorporeal membrane
oxygenation (ECMO) centre.
Which of the following criteria contribute most to his Murray score for ECMO
referral?
A.
B.
C.
D.
E.

PaO2 /FiO2 ratio of 25 kPa
PEEP of 8 cmH2 O
Compliance of 38 ml/cmH2 O
Half of the chest X-ray showing infiltrates
Uncompensated hypercapnia with a pH <7.2

5
03 Feb 2017 at 12:15:34
002


Exam A: Questions

A19. A 60-year-old, 160-kg man with a history of obstructive sleep apnoea has been
referred to intensive care. He is in type 2 respiratory failure after an intentional overdose of benzodiazepines. He is haemodynamically stable but has a Glasgow Coma
Score (GCS) of 5 and is making snoring noises. You decide to intubate and transfer to
intensive care for supportive management.
Which of the following is most appropriate statement?
A. Intubation is likely to be difficult; therefore, non-invasive ventilation should be
trialled first
B. Senior help should be called if there is difficulty in intubating after four
attempts
C. The patient should be transferred to the operating theatre in anticipation of a
difficult airway
D. Given his background of obstructive sleep apnoea, he is likely to require
ventilation for some time; therefore you should proceed immediately to a
percutaneous tracheostomy
E. Cricoid pressure may be reduced if there is difficulty intubating
A20. A 73-year-old man is admitted to hospital with shortness of breath and cough.
He has a medical history of hypertension and asthma, for which he takes ramipril and
a salbutamol inhaler, respectively. He has smoked 20 cigarettes per day since adolescence and drinks 15 to 20 units of alcohol per week. He has moderate respiratory
distress with a respiratory rate of 28, oxygen saturations of 91% in air, a heart rate
of 105 bpm and blood pressure of 155/95. An arterial blood gas (ABG) is performed
with the following results:
pH 7.28
pO2 7.1 kPa
pCO2 8.9 kPa
HCO3 − 38.1 mmol/l
What is the most likely cause of his shortness of breath and cough?
A.
B.
C.
D.
E.

Pulmonary embolus
Asthma
Pneumonia
Chronic obstructive pulmonary disease
Side effect of ramipril

A21. Which of the following complications is most frequently seen after pulmonary
artery catheter (PAC) insertion via the internal jugular vein?
A.
B.
C.
D.
E.

Carotid artery puncture
An arrhythmia requiring treatment
Bacterial colonization
Pulmonary infarction
Pulmonary artery rupture

A22. You have a patient requiring an urgent fresh frozen plasma (FFP) transfusion.
Which of the following combinations is MOST appropriate?

6

A.
B.
C.
D.
E.

A patient with blood group AB receiving FFP grouped A
A patient with blood group A receiving FFP grouped B
A patient with blood group B receiving FFP grouped O
A patient with blood group A receiving FFP grouped AB
A patient with blood group AB receiving FFP grouped O

03 Feb 2017 at 12:15:34
002


A.
B.
C.
D.
E.

Exam A: Questions

A23. Which of the following anticoagulants is most likely to be affected by a sudden fall in a patient’s glomerular filtration rate (GFR)?
Warfarin
Dabigatran
Rivaroxaban
Apixaban
Heparin

A24. You are about to perform a rapid sequence induction (RSI) on a patient in
convulsive status epilepticus (CSE). Which of the following agents is most likely to
terminate the seizures?
A.
B.
C.
D.
E.

Atracurium
Ketamine
Propofol
Rocuronium
Thiopentone

A25. You are explaining to a medical student how to diagnose acute respiratory
distress syndrome (ARDS). In relation to the Berlin criteria, which of the following
descriptions would best fit with a diagnosis of ARDS?
A. Hypoxaemia 3 days after a large myocardial infarction. Transthoracic
echocardiogram shows moderate left ventricular impairment with akinesis of
the apex. PaO2 /FiO2 ratio is 35 kPa.
B. Hypoxaemia 5 days after a severe bronchopneumonia. Chest X-ray shows
collapse of the left lower lobe. PaO2 /FiO2 ratio is 30 kPa.
C. Hypoxaemia 2 days after a gastrointestinal (GI) bleed requiring transfusion of
one circulating volume. Chest X-ray shows diffuse patchy infiltrates. PaO2 /FiO2
ratio is 45 kPa.
D. Hypoxaemia 4 days after an episode of pancreatitis with a Glasgow score of 4.
Chest X-Ray shows diffuse patchy infiltrates. PaO2 /FiO2 ratio is 30 kPa.
E. Hypoxaemia 5 days after coronary artery bypass graft surgery. A pulmonary
artery catheter shows a pulmonary capillary wedge pressure of 25 mmHg.
Computed tomography scan shows pulmonary infiltrates. PaO2 /FiO2 ratio is
25 kPa.
A26. You are asked to review a patient with known pancreatic cancer in the emergency department. He has hypotension and dehydration as a result of prolonged
vomiting. You are concerned that he has gastric outflow obstruction.
Which of the following sets of biochemical results would best fit with gastric outflow obstruction?

A.
B.
C.
D.
E.

pH

PaO2

PaCO2

HCO3−

Na+

K+

Cl−

7.55
7.37
7.29
7.26
7.54

11.1 kPa
12.0 kPa
12.8 kPa
14.5 kPa
10.4 kPa

6.3 kPa
4.1 kPa
3.3 kPa
1.6 kPa
6.1 kPa

53 mmol/l
22 mmol/l
16 mmol/l
8 mmol/l
46 mmol/l

132 mmol/l
166 mmol/l
134 mmol/l
136 mmol/l
127 mmol/l

3.0 mmol/l
3.7 mmol/l
2.1 mmol/l
4.7 mmol/l
2.7 mmol/l

93 mmol/l
131 mmol/l
113 mmol/l
102 mmol/l
128 mmol/l

7
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002


Exam A: Questions

A27. A 47-year-old man with alcoholic liver cirrhosis and ascites is admitted to
hospital. He is febrile with abdominal pain and delirium. Routine blood tests show
increased white blood cells (WBC) and C-reactive protein (CRP) with normal electrolytes and renal function. An ascitic tap shows 500 WBCs/µl and organisms visible
on microscopy.
What is the most likely organism?
A.
B.
C.
D.
E.

Klebsiella pneumoniae
Escherichia coli
Enterobacteriaceae
Streptococcus pneumoniae
Staphylococcus aureus

A28. A 61-year-old man has been admitted to the emergency department. He
has a diagnosis of acute myeloid leukaemia and is receiving chemotherapy. He has
been unwell for 24 hours and has a temperature of 38.5°C. His neutrophil count is
0.4 × 109 /l.
What antibiotic regimen is the most appropriate?
A.
B.
C.
D.
E.

Tazobactam/piperacillin
Ceftriaxone
Tazobactam/piperacillin and gentamicin
Ceftriaxone and gentamicin
Ceftriaxone, vancomycin and gentamicin

A29. A 64-year-old man was admitted 6 hours ago to hospital with severe chest
pain and shortness of breath. You are called to see him as his blood pressure has
fallen over the past hour. He is drowsy, diaphoretic, cold to the touch and has
widespread crackles on auscultation of his lung fields. His 12-lead electrocardiogram
(ECG) shows a large ST-elevation myocardial infarction (STEMI). His vital signs are
as follows: heart rate 95/min; blood pressure 80/48; respiratory rate 32/min; SpO2
92% on 10 l oxygen. He has a venous lactate level of 6.3 mmol/l.
You diagnose cardiogenic shock. Which intervention has the strongest evidence of
benefit?
A.
B.
C.
D.
E.

Intra-aortic balloon pump (IABP)
Dobutamine
Left ventricular assist device (LVAD)
Revascularization therapy
Levosimendan

A30. You are asked to review a patient suffering an acute exacerbation of asthma
in the emergency department, with all of the following signs present. Which of the
signs gives the greatest cause for concern?
A.
B.
C.
D.
E.

Respiratory rate: 32
PaCO2 : 4.9 kPa
Peak expiratory flow (PEF): 38% of predicted
Inability to complete sentences in one breath
Chest X-ray showing bibasal consolidation

8
03 Feb 2017 at 12:15:34
002


Exam A: Answers
A1. A trauma patient is brought into the resuscitation room with an obviously
unstable pelvis. Despite ongoing fluid resuscitation with blood products the patient
remains haemodynamically unstable, has profound metabolic acidosis and continues
to deteriorate. Focused assessment with sonography in trauma (FAST) scan is positive.
Which of the following is MOST important in the management of this patient’s
bleeding?
A.
B.
C.
D.
E.

Administration of tranexamic acid
1:1:1 rather than 1:1:2 transfusion ratio for plasma:platelets:blood
Treatment with interventional radiology
Urgent damage control surgery
Maintaining normothermia and ionized calcium levels >0.9 mmol/l

Answer: D

Short explanation
Tranexamic acid administration, maintaining normothermia and ionized calcium levels are important; however, they will not stop this patient’s massive ongoing bleeding. The patient is deteriorating despite ongoing resuscitation with blood products,
so control of bleeding is imperative. This patient is haemodynamically unstable and
acidotic, and his or her FAST scan is positive; immediate damage control surgery is
recommended in preference to interventional radiology.

Long explanation
Patients presenting with haemorrhagic shock should be treated with rapid identification of the cause and source control in conjunction with fluid resuscitation with blood
products. Initial fluid resuscitation should be commenced with crystalloids and early
use of blood products to target a systolic blood pressure of 80 to 90 mmHg until the
bleeding has been controlled. The blood pressure should be higher in the context of a
traumatic brain injury.
The Pragmatic, Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial
demonstrated a significant decrease in the rate of exsanguination for those who
received blood products in a 1:1:1 rather than a 1:1:2 plasma:platelet:red blood cell
ratio. Despite a trend to lower mortality seen in the 1:1:1 treatment arm, there was no
significant decrease in mortality at 24 hours or 30 days. Fibrinogen replacement with
03 Feb 2017 at 12:15:41
003

9


Exam A: Answers

fibrinogen concentrate or cryoprecipitate should occur with fibrinogen levels below
1.5 to 2 g/l.
Measures to maintain normothermia and ionized calcium levels >0.9 mmol/l are
required to minimize the coagulopathy that can occur with massive blood transfusions and the coagulopathy of trauma. Trauma patients who are bleeding or who are
at risk of significant haemorrhage should receive tranexamic acid as soon as possible,
either in the pre-hospital environment or starting in the emergency department.
Rapid control of the source of the haemorrhage is crucial. Tourniquets can be used
preoperatively as an interim measure to stop arterial bleeding in life-threatening
extremity injuries. Interventional radiology or surgical intervention can be used to
manage patients with pelvic or intra-abdominal bleeding. Patients with suspected
pelvic fractures should have a pelvic binder applied immediately to reduce any
ongoing bleeding. Treatment for pelvic fractures in patients who are haemodynamically unstable includes external fixation, preperitoneal pelvic packing and interventional radiology. Patients should have an initial FAST scan in the resuscitation
room. If this is positive, surgical treatment with laparotomy and packing is recommended in preference to angiography. Resuscitative endovascular balloon occlusion
of the aorta (REBOA) has been used as an emergency interim measure for unstable
patients.
Damage control in preference to definitive surgery is recommended for those
patients with severe haemorrhage shock and ongoing bleeding. This is particularly
the case in those who are hypothermic (ࣘ34˚C), acidotic (pH ࣘ7.2) or coagulopathic
or patients who have inaccessible major venous injury or require time-consuming
procedures.
References
Holcomb JB, Tilley BC, Baraniuk S, et al. Transfusion of plasma, platelets, and red
blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma:
the PROPPR randomized clinical trial. JAMA. 2015;313(5):471–482.
Magnone S, Coccolini F, Manfredi R, et al. Management of hemodynamically unstable pelvic trauma: results of the first Italian consensus conference. World J Emerg
Surg. 2014;9(1):18.
Spahn DR, Bouillon B, Cerny V, et al. Management of bleeding and coagulopathy following major trauma: an updated European guideline. Crit Care. 2013;17(2):R76.

A2. A patient has been admitted to the intensive care unit (ICU) with severe sepsis
and urgently requires a central venous catheter (CVC). You decide to insert the CVC
into the right internal jugular vein (IJV).
Which of the following approaches to central line insertion is the best?
A.
B.
C.
D.
E.

Landmark approach; lateral to the carotid artery pulsation
Audio-guided Doppler ultrasound guidance in the head-up position
Landmark approach; medial to the carotid artery pulsation
Audio-guided Doppler ultrasound guidance in the head-down position
Two-dimensional (2D) ultrasound guidance

Answer: E

Short explanation

10

The National Institute for Health and Care Excellence (NICE) guidance recommends
the use of 2D ultrasound imaging for CVC insertion into the IJV in all elective situations, and it should be considered in all clinical scenarios including emergency situations. Audio-guided Doppler ultrasound is not recommended for CVC insertion.

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The NICE guidance on the use of ultrasound locating devices for placing CVCs (NICE
Guidance 49, published 2002) is clear in its recommendation for the use of 2D ultrasound in the insertion of all elective lines and its consideration for all emergency
lines. 2D ultrasound provides real-time imaging of the anatomy, allowing differentiation between the artery and vein, therefore lowering the risk of arterial puncture.
Audio-guided Doppler ultrasound, by comparison, does not generate any image but
does generate a sound from flowing blood to help locate the vessels. Audio-guided
Doppler ultrasound is not recommended in the NICE guidance.
The 2D ultrasound findings that assist differentiation of the vein from the artery
include:

Exam A: Answers

Long explanation

1. Wall thickness – thicker in the artery
2. Compressibility – vein is more compressible because of the lower pressure in the
vein. However, in extremely hypotensive states, the difference is less pronounced,
and extra care should be taken
3. Pulsatility – arterial flow is more pulsatile
4. Colour-wave Doppler – arterial flow is more pulsatile
Venous flow can also be pulsatile, and arteries can also be compressed, so the preceding findings are to assist differentiation rather than being absolute.
The landmark technique can still be used in an emergency situation and involves
passing the needle along the expected path of the vein, with reference to surface landmarks. This technique is associated with a higher incidence of complications, such as
arterial puncture and pneumothorax. The use of ultrasound guidance is preferred in
all clinical situations, so long as there is no inappropriate delay to line placement.
References
The American Institute for Ultrasound in Medicine (AIUM). AIUM Practice Guidelines
for the Use of Ultrasound to Guide Vascular Access Procedures. Laurel, MD: AIUM,
April 2012.
National Institute for Health and Care Excellence (NICE). Guidance on the use of
ultrasound locating devices for placing central venous catheters (Technology
Appraisal Guidance 49). London: NICE, 2002.
A3. Of the following pathologies, which is the commonest cause for end-stage renal
failure in the United Kingdom?
A.
B.
C.
D.
E.

Hypertension
Polycystic kidney disease
Vasculitis
Renal artery stenosis
Immunoglobulin A (IgA) nephropathy

Answer: A

Short explanation
The commonest causes of chronic kidney disease that lead to end-stage renal failure
in the United Kingdom are the following:

r Diabetes (20–40%)
r Hypertension (5–25%)
r Glomerular disease which includes IgA nephropathy (10–20%), idiopathic
(5–20%), interstitial disease (5–15%)

r Rarer causes such as polycystic kidney disease, renal artery stenosis and
vasculitis with each representing less than 5%.

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11


Exam A: Answers

Long explanation
Chronic kidney disease (CKD) is a general term for a disorder of renal structure or
function lasting more than 3 months. It is considered on a continuum between normal
kidney function and end-stage renal failure requiring long-term dialysis, transplantation or preceding death. Patients with CKD more commonly develop co-morbidities
and require intensive care than the general population. Equally, patients requiring
critical care are more at risk of developing an acute kidney injury (AKI) and subsequently chronic kidney disease.
CKD is almost always a progressive condition, although only 1% of patients with
CKD will reach end-stage renal failure. However, the cost and morbidity burden of
those who do places a huge requirement on resources. It is important to detect and
refer CKD patients early because delays lead to poorer outcomes. Patients with CKD
who present to hospital are at an increased risk of developing AKI, which will likely
lead to a long-term decline in renal function and worse outcomes than those patients
without CKD.
Filtration is not the sole function of the kidney. However, estimated glomerular
filtration rate (eGFR) is the best measure of overall kidney function and therefore
presence of CKD. An eGFR <60 mL/min/1.73 m2 is associated with a poorer outcome than that in patients with CKD and a higher eGFR. It is important to consider
other markers of kidney function when managing a patient with AKI or CKD, including albuminuria levels, proteinuria, structural abnormalities on imaging, electrolyte
balance, blood pressure and histological changes seen on biopsy.
CKD prognosis and risk can be estimated on the basis of staging using eGFR and
albuminuria. eGFR stages (mL/min/1.73 m2 ) include the following: Grade 1 (>90),
Grade 2 (60–89), Grade 3a (45–59), Grade 3b (30–44), Grade 4 (15–29) and Grade 5
(<15). Staging based on albuminuria (mg/g) ranges from: A1 (<30), A2 (30–300) and
A3 (>300).
The causes of CKD are increasing in incidence in the United Kingdom and are
associated with other co-morbidities such as heart disease and stroke, which make
CKD patients more likely to present to health services. Similarly, the presence of CKD
complicates the treatment of other co-morbidities and of ICU care, often limiting drug
choices or doses and requiring increased monitoring and care with electrolytes, nutrition and fluid balance.
References
Goddard J, Turner AN, Cumming AD, Stewart LH. Kidney and urinary tract disease. In Boon NA, Colledge NR, Walker BR, Hunter JAA. Davidson’s Principles
and Practice of Medicine. 20th edition. Edinburgh: Churchill Livingstone Elsevier,
2006: p. 486.
Kidney Disease: Improving Global Outcomes. KDIGO 2012 clinical practice guideline
for the evaluation and management of chronic kidney disease. Kidney Int Suppl.
2013;3(1).
The UK Renal Association website. http://www.renal.org/ (last accessed April
2015).
A4. Which of the following methods of humidification is able to generate the highest relative humidity in an ICU ventilator circuit?
A.
B.
C.
D.
E.

12

Heat and moisture exchange filter (HME)
Cascade humidifier
Cold-water bath
Hot-water bath
Ultrasonic nebulizer

Answer: E
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HMEs achieve approximately 70% efficiency, and cold-water baths achieve 30% efficiency, which can be improved to almost 90% if the water is heated. A cascade water
bath is similar to a hot water bath with the gas bubbled through the water. Nebulizers, especially active ones such as an ultrasonic device, achieve the highest humidity,
which can exceed 100%.

Exam A: Answers

Short explanation

Long explanation
Failure to humidify gases delivered to a patient via a ventilator will lead to drying of
the patient’s airways and the build-up of thick secretions, inflammation and potential
infection. Delivery of humidified gas is also an important method of reducing heat
loss from the patient.
Absolute humidity is measured in g/m3 and is the mass of water vapour in a unit
of gas, which will vary with temperature. Relative humidity is the amount of water
vapour present, as a percentage of the maximum achievable at the temperature and
pressure in question.
HMEs use a hygroscopic material to capture exhaled water vapour as expired
gas cools and passes through the filter. As cold inspired gas then passes back to the
patient, it is warmed and also picks up water from the filter material. This method
becomes inefficient with time but also provides a bacterial barrier between the patient
and ventilator.
Hot-water baths and the cascade humidifier are commonly used in ICUs because
they provide a good level of humidification in a relatively efficient way. There are
risks of thermal injury to the patient if the water is heated to too high a temperature;
therefore, these systems often have thermostats and alarms in place.
Nebulizers are not commonly used for humidification because they can lead to
fluid overload and produce such small droplet sizes that water vapour deposits in the
alveoli but not the upper airways. For this reason, they are better used for medication
delivery.
Reference
Davis PD, Kenny GNC. Basic Physics and Measurement in Anaesthesia. 5th edition. London: Elsevier, 2003.

A5. Which of the following gas patterns seen on plain erect abdominal X-ray is most
suggestive of significant bowel pathology requiring surgery?
A.
B.
C.
D.
E.

Large gas bubble in the stomach
Gas in the small bowel
Gas in the small bowel and fluid levels at the same height within loops
Gas in the large bowel
Gas in the small bowel and rectum only

Answer: E

Short explanation
A large gastric bubble is rarely concerning, often originating from nasogastric feeding
or air swallowing. Gas in the small or large bowel is a normal finding, so long as the
bowel is of a normal calibre. Gas with fluid levels can also be normal, suggesting an
ileus but not necessarily obstruction. An absence of gas throughout the large bowel
with gas only seen in the rectum is abnormal and highly suggestive of a mechanical
large bowel obstruction.

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Exam A: Answers

Long explanation
Large bowel obstruction is a surgical emergency. It is important to distinguish true
mechanical obstruction from pseudo-obstruction or ileus. The incidence of large
bowel obstruction increases with age. The commonest causes are cancers, strictures,
diverticulitis and volvulus. Faecal impaction may lead to dilated loops of large bowel
proximal to the blockage, and pseudo-obstruction can lead to dilated loops and perforation, the latter requiring emergency surgery.
Large bowel obstruction may be worsened by a competent ileocaecal valve, as gas
and fluid pressures build up and are not able to release back into the small bowel. The
presence of dilated loops leads to large fluid shifts, ischaemia, bowel oedema, venous
obstruction, electrolyte disturbances, perforation, sepsis and, if not treated, death.
Imaging may include an erect chest X-ray to look for free gas under the diaphragm.
Classically, a contrast abdominal X-ray was performed, although computed tomography (CT) scans have largely replaced the need for this. CT should be performed
with oral and intravenous contrast to demonstrate complete from partial obstruction.
Water-soluble contrast is preferred because of the risks of peritoneal contamination
due to bowel perforation.
Treatment is usually surgical. Pseudo-obstruction may be managed conservatively
provided there is a low threshold of suspicion for perforation. Initial resuscitation
measures should include a nasogastric tube on free drainage, fluid and electrolyte
replacement and broad-spectrum antibiotics. Volvulus and strictures may be decompressed or stented and further investigated with colonoscopy. Those with diverticulitis or a malignant obstruction require surgery. Intussusception is a more common
cause of obstruction in children than in adults. The bowel ‘telescopes’ in on itself,
often with a polyp or lesion at the centre. This may be amenable to gas insufflation to
reduce the intussusception or may require surgical intervention.
References
Kahi CJ, Rex DK. Bowel obstruction and pseudo-obstruction. Gastroenterol Clin North
Am. 2003;32(4):1229–1247.
Marini JJ, Wheeler AP. Critical Care Medicine: The essentials. 4th edition. Philadelphia:
Lippincott, Williams & Wilkins, 2009, p 226.
A6. You are about to intubate a patient with a life-threatening exacerbation of
asthma.
Which of the following agents is MOST likely to improve lung mechanics and
bronchospasm?
A.
B.
C.
D.
E.

Atracurium
Ketamine
Propofol
Thiopentone
Fentanyl

Answer: B

Short explanation
Thiopentone and atracurium can cause bronchospasm, propofol has little effect, and
opioids may precipitate bronchospasm and chest-wall rigidity. Ketamine is a bronchodilator.

Long explanation

14

The classical rapid sequence induction (RSI) uses just two drugs: thiopentone and
suxamethonium. There are often clinical scenarios in which this combination should

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Exam A: Answers

be altered, due to either detrimental effects of these agents (e.g. suxamethonium in
a patient with a high potassium) or the presence of alternative agents that may have
more benefit (e.g. propofol for laryngeal relaxation).
Muscle relaxants do not terminate bronchoconstriction. The majority of them can
cause significant histamine release, particularly suxamethonium and the benzylisoquinoliniums such as atracurium, which in turn can cause hypotension and bronchospasm. The muscle relaxant that has the least histamine release associated with its
use is vecuronium.
With regard to the intravenous induction agents, propofol, thiopentone and
ketamine are in widest use in day-to-day practice. Propofol, which is presented as a
lipid-water emulsion, causes rapid induction of anaesthesia and suppression of laryngeal reflexes to a greater extent than thiopentone. It has no effect on bronchospasm.
Thiopentone, which is a thiobarbiturate induction agent, also causes rapid induction
of anaesthesia. It causes less suppression of the laryngeal reflexes and can cause both
laryngospasm and bronchospasm. Ketamine, a phencyclidine derivative, has little
effect on the laryngeal reflexes, and a patent airway can potentially be maintained.
There is an increase in the production of secretions, and these can trigger the preserved reflexes and cause laryngospasm. Conversely, it reliably causes bronchodilation, and is therefore of benefit patients with asthma.
Opioids are often given as part of a modified RSI, to suppress the laryngeal
response to intubation. All opioids cause respiratory depression. Brain-stem sensitivity to carbon dioxide is reduced, but its response to hypoxia is largely retained. If
opioids are given inappropriately early as part of a modified RSI and preoxygenation
is initiated, the hypoxic stimulus will fail to be triggered, and carbon dioxide levels can rise dangerously. Similarly to the muscle relaxants, histamine release is well
recognized, especially from rapid administration. For both classes of drug, slower or
more dilute injection will reduce the histamine-related side effects.
References
Smith T. Chapter 6: Hypnotics and intravenous anaesthetic agents. In Smith T, Pinnock C, Lin T. Fundamentals of Anaesthesia. 3rd edition. Cambridge: Cambridge
University Press, 2009, pp 569–584.
Chapter 8: General anaesthetic agents, Chapter 9: Analgesics, and Chapter 11: Muscle
relaxants and anticholinesterases, in Section 2: Core drugs in anaesthetic practice.
In Peck T, Hill S, Williams M. Pharmacology for Anaesthesia and Intensive Care. 3rd
edition. Cambridge: Cambridge University Press, 2008.
A7. In a normal adult patient, a red blood cell travelling from the aorta to the portal
vein is most likely to pass through which structures?
A.
B.
C.
D.
E.

Inferior mesenteric artery, superior rectal artery, rectal veins
Coeliac trunk, left gastro-omental artery, splenic vein
Right gastric artery, short gastric vein, splenic vein
Superior mesenteric artery, right colic vein, inferior mesenteric vein
Coeliac trunk, gastroduodenal artery, epigastric vein

Answer: B

Short explanation
The rectal and epigastric veins drain into the inferior vena cava and are two of the
collateral connections between the portal and systemic circulations. The right gastric
artery supplies the right and inferior portions of the stomach, whereas the short gastric vein drains the superior and left-sided portions. The right colic together with the

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Exam A: Answers

middle colic veins drain directly into the portal vein, whereas the inferior mesenteric
vein drains the descending colon and rectum into the splenic vein.

Long explanation
The normal arterial supply of the gut is via three large anterior branches of the aorta:
the coeliac trunk, superior mesenteric artery and inferior mesenteric artery. These
vessels may be threatened by trauma or surgery to the descending aorta, including rupture of an abdominal aortic aneurysm. Infarction or ischemia will manifest
as ischaemic gut followed by perforation and peritonitis. Ischaemic colitis carries
high morbidity and mortality and requires urgent intervention to restore the blood
supply.

r The celiac trunk arises at approximately T12, immediately after the aorta emerges
from the diaphragm. It divides into the left gastric, common hepatic and splenic
arteries, which in turn supply the lesser curvature of the stomach, the liver, the
gallbladder and the duodenum and spleen, pancreas and greater curvature of the
stomach.
r The superior mesenteric artery supplies the portion of the gut derived from the
embryological mid-gut including the distal duodenum, jejunum, ileum,
ascending colon and proximal portions of the transverse colon. The blood supply
runs through the mesentry in connected loops forming ‘arcades’, which in turn
give rise to the vasa recta.
r The inferior mesenteric artery supplies the distal portions of the gut derived from
the hind-gut. It branches into the left colic, sigmoid and rectal arteries. The
territory of the left colic crosses with that of the marginal artery supplied by the
superior mesenteric artery as it supplies the portion of the colon at the splenic
flexure.
The venous drainage of the gut is predominantly into the portal vein, taking nutrient rich blood to the liver. This system forms key collaterals with the systemic venous
network at four points: the oesophageal veins, the rectal veins, the paraumbilical (portal) veins and a few small twigs connecting the colic and retroperitoneal veins. These
sites become important in cases of raised portal venous pressure either due to thrombus or hepatic fibrosis, most commonly due to alcoholic cirrhosis.
In health, the main portal vein forms from the mesenteric plexus analogous to the
territory of the superior mesenteric artery (i.e. the ileal, jejunal and right and middle
colic veins). The territory of the inferior mesenteric artery is drained via the superior
rectal, sigmoidal and left colic veins into the inferior mesenteric vein. This drains via
the splenic vein into the portal vein. The left and right gastric veins drain directly
into the portal vein, along with the cystic, pancreatoduodenal and gastro-omental
(gastro-epiploic) veins.
Reference
Moore KL, Agur AMR, Dalley AF. Essential Clinical Anatomy. 5th edition. Baltimore,
MD: Lippincott Williams & Wilkins, 2014.

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