ACCS Clinical Knowledge and Skills 3 — Questions and Answers
Question 1: A patient with septic shock remains hypotensive after 30 mL/kg IV crystalloid. MAP is 58 mmHg. What is the first-line vasopressor?
- Epinephrine
- Norepinephrine (Correct answer)
- Dopamine
- Vasopressin
Correct answer: Norepinephrine
Norepinephrine is the first-line vasopressor for septic shock per Surviving Sepsis Campaign guidelines due to its potent alpha-adrenergic effect with less tachycardia than dopamine.
Question 2: Which ventilator setting change is most appropriate when a patient on volume-controlled ventilation develops a sudden increase in peak airway pressure with unchanged plateau pressure?
- Increase tidal volume
- Suction the endotracheal tube for secretions (Correct answer)
- Decrease PEEP
- Increase respiratory rate
Correct answer: Suction the endotracheal tube for secretions
An isolated rise in peak pressure with stable plateau pressure indicates increased airway resistance, most commonly from secretions or bronchospasm, not reduced lung compliance.
Question 3: A critically ill patient has serum sodium of 118 mEq/L and is having seizures. What is the immediate treatment?
- Restrict free water to 1 L/day
- Administer 3% hypertonic saline IV (Correct answer)
- Give oral sodium chloride tablets
- Initiate slow continuous venovenous hemofiltration
Correct answer: Administer 3% hypertonic saline IV
Symptomatic severe hyponatremia with seizures requires immediate 3% hypertonic saline to raise sodium by 1-2 mEq/L/hr until symptoms resolve.
Question 4: Which parameter best reflects oxygen delivery adequacy at the tissue level in hemodynamically unstable patients?
- PaO2
- SaO2
- Mixed venous oxygen saturation (SvO2) (Correct answer)
- Hemoglobin concentration
Correct answer: Mixed venous oxygen saturation (SvO2)
SvO2 reflects the balance between oxygen delivery and consumption; values below 65% indicate inadequate oxygen delivery relative to tissue demand.
Question 5: A patient on heparin infusion develops a platelet count drop from 280,000 to 80,000 over 5 days with new thrombosis. What is the most appropriate action?
- Increase heparin dose to treat the thrombosis
- Discontinue heparin and start a direct thrombin inhibitor (Correct answer)
- Transfuse platelets immediately
- Switch to low-molecular-weight heparin
Correct answer: Discontinue heparin and start a direct thrombin inhibitor
This presentation is classic for heparin-induced thrombocytopenia (HIT) with thrombosis; all heparin products must be stopped and a non-heparin anticoagulant initiated.
Question 6: Which clinical finding distinguishes neurogenic pulmonary edema from cardiogenic pulmonary edema in a trauma patient?
- Bilateral infiltrates on chest X-ray
- Normal or hyperdynamic cardiac function with elevated ICP history (Correct answer)
- Elevated BNP level
- Response to diuretic therapy
Correct answer: Normal or hyperdynamic cardiac function with elevated ICP history
Neurogenic pulmonary edema occurs after central nervous system injury with intact or hyperdynamic cardiac function, distinguishing it from cardiogenic causes.
Question 7: A patient with acute liver failure develops asterixis, confusion, and EEG slowing. Which intervention directly targets the underlying mechanism of hepatic encephalopathy?
- IV thiamine replacement
- Lactulose administration to reduce ammonia absorption (Correct answer)
- Sodium bicarbonate for metabolic acidosis
- Plasmapheresis
Correct answer: Lactulose administration to reduce ammonia absorption
Lactulose acidifies colonic contents and traps ammonia as ammonium, reducing its absorption and lowering serum ammonia levels in hepatic encephalopathy.
ACCS Clinical Knowledge and Skills 3
A patient with septic shock remains hypotensive after 30 mL/kg IV crystalloid.
MAP is 58 mmHg.
What is the first-line vasopressor?