FRCS Critical Care and Emergency 2 — Questions and Answers
Question 1: During a cardiac arrest, the Resuscitation Council UK algorithm recommends administering adrenaline at what dose and frequency for a shockable rhythm?
- 1 mg IV after the third shock, then every 3-5 minutes (Correct answer)
- 1 mg IV immediately, then every 3-5 minutes
- 0.5 mg IV after each shock
- 1 mg IV after the first shock only
Correct answer: 1 mg IV after the third shock, then every 3-5 minutes
In a shockable rhythm (VF/pulseless VT), the Resuscitation Council UK recommends adrenaline 1 mg IV after the third shock (along with amiodarone 300 mg), then 1 mg every 3-5 minutes (alternate cycles). In non-shockable rhythms (PEA/asystole), adrenaline 1 mg is given as soon as IV access is obtained, then every 3-5 minutes.
Question 2: A patient develops tension pneumothorax. What is the immediate emergency treatment before chest drain insertion?
- Needle decompression in the 2nd intercostal space, midclavicular line (Correct answer)
- Urgent CT thorax
- Emergency thoracotomy
- High-flow oxygen and observation
Correct answer: Needle decompression in the 2nd intercostal space, midclavicular line
Tension pneumothorax is a clinical diagnosis requiring immediate needle decompression — a large-bore cannula (14-16G) inserted in the 2nd intercostal space, midclavicular line (or 4th/5th intercostal space, anterior axillary line in ATLS). This converts the tension pneumothorax to a simple pneumothorax by releasing trapped air. A formal chest drain (intercostal tube) is then inserted as definitive management. CT should never delay treatment.
Question 3: What is the initial recommended dose of intravenous amiodarone for a patient in refractory ventricular fibrillation according to the ALS algorithm?
- 300 mg (Correct answer)
- 150 mg
- 600 mg
- 900 mg
Correct answer: 300 mg
Amiodarone 300 mg IV is given after the third shock in refractory VF/pulseless VT, along with adrenaline 1 mg. A further dose of 150 mg may be given after the fifth shock if VF persists. Amiodarone is a class III antiarrhythmic that prolongs the action potential duration and refractory period. It should be diluted in 5% dextrose for peripheral administration.
Question 4: A 60-year-old man is ventilated in ICU with the following settings: FiO2 0.6, PEEP 10 cmH2O, tidal volume 450 ml (6 ml/kg IBW). His plateau pressure is 35 cmH2O. What is the driving pressure?
- 25 cmH2O (Correct answer)
- 35 cmH2O
- 10 cmH2O
- 45 cmH2O
Correct answer: 25 cmH2O
Driving pressure = Plateau pressure - PEEP = 35 - 10 = 25 cmH2O. Driving pressure reflects the cyclical strain on the lung and is an independent predictor of mortality in ARDS. A driving pressure >15 cmH2O is associated with increased mortality. This patient's driving pressure of 25 cmH2O is concerning and may warrant reducing tidal volume or adjusting PEEP to improve lung compliance.
Question 5: Which vasopressor is recommended as first-line in the management of septic shock according to the Surviving Sepsis Campaign guidelines?
- Noradrenaline (norepinephrine) (Correct answer)
- Adrenaline (epinephrine)
- Dopamine
- Vasopressin
Correct answer: Noradrenaline (norepinephrine)
Noradrenaline is the first-line vasopressor for septic shock (SSC 2021 guidelines). It is a potent alpha-1 agonist causing vasoconstriction with mild beta-1 effects supporting cardiac output. Vasopressin (up to 0.03 units/min) can be added as a second agent to reduce noradrenaline requirements. Dopamine is associated with more arrhythmias. Adrenaline is second-line when additional inotropy is needed.
Question 6: A patient presents to the emergency department with a Glasgow Coma Scale (GCS) score of 8. According to ATLS principles, what airway intervention is indicated?
- Definitive airway (endotracheal intubation) (Correct answer)
- Oropharyngeal airway only
- Nasopharyngeal airway only
- Oxygen via non-rebreather mask only
Correct answer: Definitive airway (endotracheal intubation)
A GCS of 8 or below indicates the patient cannot reliably protect their own airway and is at risk of aspiration. ATLS and UK resuscitation guidelines recommend definitive airway protection with endotracheal intubation (or surgical airway if intubation fails). The rule is 'GCS 8 — intubate.' Simple adjuncts may be used temporarily but do not provide definitive protection.
FRCS Critical Care and Emergency 2
During a cardiac arrest, the Resuscitation Council UK algorithm recommends administering adrenaline at what dose and frequency for a shockable rhythm?