ACCS Patient Management and Care 2 — Questions and Answers
Question 1: A mechanically ventilated patient with ARDS has a PaO2/FiO2 ratio of 80 mmHg. Which ventilator strategy is most appropriate?
- Increase tidal volume to 10 mL/kg IBW
- Apply low tidal volume (6 mL/kg IBW) with PEEP titration (Correct answer)
- Decrease PEEP to reduce barotrauma
- Switch immediately to high-frequency oscillatory ventilation
Correct answer: Apply low tidal volume (6 mL/kg IBW) with PEEP titration
Lung-protective ventilation with low tidal volume (6 mL/kg IBW) and optimized PEEP is the evidence-based standard for ARDS management.
Question 2: A critically ill patient on vasopressors develops acute mesenteric ischemia. Which finding is the earliest indicator?
- Bloody diarrhea
- Metabolic acidosis with elevated lactate (Correct answer)
- Abdominal rigidity
- Rising creatinine
Correct answer: Metabolic acidosis with elevated lactate
Elevated lactate from anaerobic metabolism is often the earliest sign of mesenteric ischemia before overt peritoneal signs develop.
Question 3: Which medication is first-line for managing refractory status epilepticus in an ICU patient who has failed benzodiazepines and a second-line AED?
- Phenobarbital infusion
- Propofol infusion
- Midazolam continuous infusion (Correct answer)
- Levetiracetam IV bolus
Correct answer: Midazolam continuous infusion
Continuous midazolam infusion is a first-line anesthetic agent for refractory status epilepticus when second-line AEDs fail.
Question 4: An ICU patient has central DI following traumatic brain injury. Which lab pattern is expected?
- Low serum sodium, high urine osmolality
- High serum sodium, low urine osmolality (Correct answer)
- High serum sodium, high urine osmolality
- Low serum sodium, low urine osmolality
Correct answer: High serum sodium, low urine osmolality
Central DI causes hypernatremia (high serum Na) with dilute urine (low urine osmolality) due to ADH deficiency.
Question 5: A post-cardiac surgery patient develops cardiac tamponade. Which hemodynamic finding is characteristic?
- Widened pulse pressure
- Equalization of diastolic pressures across cardiac chambers (Correct answer)
- Elevated cardiac output with low CVP
- Isolated elevated PAOP
Correct answer: Equalization of diastolic pressures across cardiac chambers
Cardiac tamponade causes equalization of diastolic pressures (CVP ≈ PAOP ≈ PAD) due to external cardiac compression.
Question 6: A patient with septic shock has a ScvO2 of 58% despite adequate MAP. What is the most appropriate next step?
- Increase vasopressor dose
- Transfuse RBCs if Hgb < 10 g/dL or optimize cardiac output (Correct answer)
- Start empiric antibiotics
- Administer hydrocortisone
Correct answer: Transfuse RBCs if Hgb < 10 g/dL or optimize cardiac output
Low ScvO2 indicates inadequate oxygen delivery; optimizing cardiac output or correcting anemia improves oxygen delivery to tissues.
Question 7: Which intervention has the strongest evidence for reducing VAP (ventilator-associated pneumonia) incidence in the ICU?
- Prophylactic antibiotics
- Oral chlorhexidine decontamination (Correct answer)
- Supine positioning
- Routine ventilator circuit changes every 48 hours
Correct answer: Oral chlorhexidine decontamination
Oral chlorhexidine decontamination is part of VAP bundles and has strong evidence for reducing oropharyngeal colonization and VAP rates.
ACCS Patient Management and Care 2
A mechanically ventilated patient with ARDS has a PaO2/FiO2 ratio of 80 mmHg.
Which ventilator strategy is most appropriate?