ACCS Patient Management and Care 3 — Questions and Answers
Question 1: A patient with acute liver failure develops cerebral edema. Which intervention is the priority to reduce intracranial pressure?
- Administer furosemide 40 mg IV
- Elevate head of bed to 30° and give hypertonic saline or mannitol (Correct answer)
- Initiate therapeutic hypothermia to 32°C
- Start lactulose via NGT
Correct answer: Elevate head of bed to 30° and give hypertonic saline or mannitol
Head-of-bed elevation with osmotic therapy (mannitol or hypertonic saline) is the first-line approach to lower ICP in acute liver failure.
Question 2: A patient with pulmonary embolism is hemodynamically unstable. Systolic BP is 80 mmHg despite fluids. What is the most appropriate intervention?
- Anticoagulate with unfractionated heparin alone
- Perform systemic thrombolysis with alteplase (Correct answer)
- Place an IVC filter
- Start therapeutic anticoagulation and monitor
Correct answer: Perform systemic thrombolysis with alteplase
Massive PE with hemodynamic instability is an indication for systemic thrombolysis with alteplase unless contraindicated.
Question 3: Which parameter best guides fluid resuscitation in a mechanically ventilated patient with septic shock?
- Central venous pressure (CVP)
- Pulse pressure variation (PPV) (Correct answer)
- Mean arterial pressure (MAP)
- Heart rate trend
Correct answer: Pulse pressure variation (PPV)
Pulse pressure variation >13% in a fully ventilated patient reliably predicts fluid responsiveness, unlike static measures like CVP.
Question 4: A patient in the ICU develops Clostridioides difficile colitis not responding to oral vancomycin. What is the next best treatment?
- IV metronidazole
- Fecal microbiota transplant
- Oral fidaxomicin (Correct answer)
- Cholestyramine
Correct answer: Oral fidaxomicin
Fidaxomicin is preferred over vancomycin for non-severe CDI and has shown superiority in recurrence reduction; it is the appropriate escalation.
Question 5: A trauma patient receives massive transfusion. Which electrolyte abnormality is most commonly associated with rapid packed RBC transfusion?
- Hyperkalemia
- Hypocalcemia (Correct answer)
- Hypernatremia
- Hypomagnesemia
Correct answer: Hypocalcemia
Citrate in banked blood chelates ionized calcium, causing hypocalcemia during massive transfusion, which impairs cardiac contractility.
Question 6: Which approach is recommended when weaning vasopressors in a patient recovering from septic shock?
- Stop all vasopressors simultaneously once MAP >65 mmHg for 1 hour
- Wean norepinephrine first before removing adjunctive agents
- Wean adjunctive vasopressors before reducing norepinephrine (Correct answer)
- Transition directly to oral midodrine before stopping IV vasopressors
Correct answer: Wean adjunctive vasopressors before reducing norepinephrine
Adjunctive vasopressors (vasopressin, phenylephrine) should be weaned first while maintaining norepinephrine, reducing the risk of hemodynamic instability.
Question 7: A patient with severe TBI has an ICP of 28 mmHg and CPP of 55 mmHg despite head elevation and sedation. What is the next step?
- Administer prophylactic anticonvulsants
- Administer hyperosmolar therapy (mannitol or hypertonic saline) (Correct answer)
- Perform decompressive craniectomy immediately
- Increase FiO2 to 100%
Correct answer: Administer hyperosmolar therapy (mannitol or hypertonic saline)
Hyperosmolar therapy is the next step for ICP >20 mmHg unresponsive to first-tier measures before considering surgical decompression.
ACCS Patient Management and Care 3
A patient with acute liver failure develops cerebral edema.
Which intervention is the priority to reduce intracranial pressure?