FRCS Critical Care and Emergency — Questions and Answers
Question 1: A patient with severe sepsis has a serum lactate of 6.2 mmol/L. According to the Surviving Sepsis Campaign (SSC) guidelines, what is the target for lactate clearance within the first 6 hours?
- Decrease by at least 20% within 6 hours (Correct answer)
- Normalise to below 1 mmol/L within 6 hours
- Decrease by 50% within 2 hours
- No specific lactate target is recommended
Correct answer: Decrease by at least 20% within 6 hours
The Surviving Sepsis Campaign recommends targeting at least a 20% reduction in serum lactate within the first 6 hours as a marker of adequate resuscitation. Lactate clearance serves as a surrogate for improved tissue perfusion and oxygen delivery. Serial lactate measurements guide the adequacy of fluid resuscitation, vasopressor therapy, and source control.
Question 2: In the primary survey of a trauma patient (ATLS), after addressing airway with cervical spine control, what is the next priority?
- Breathing and ventilation (Correct answer)
- Circulation with haemorrhage control
- Disability (neurological assessment)
- Exposure with environmental control
Correct answer: Breathing and ventilation
The ATLS primary survey follows the ABCDE sequence: Airway (with C-spine protection), Breathing (and ventilation), Circulation (with haemorrhage control), Disability (neurological status), and Exposure (with environmental control). After securing the airway, assessment of breathing is the next priority — look for tension pneumothorax, open pneumothorax, flail chest, and massive haemothorax, which are immediately life-threatening.
Question 3: A patient in the ICU develops acute respiratory distress syndrome (ARDS). According to the Berlin definition, what PaO2/FiO2 ratio defines moderate ARDS?
- 100-200 mmHg (Correct answer)
- 200-300 mmHg
- Less than 100 mmHg
- 300-400 mmHg
Correct answer: 100-200 mmHg
The Berlin definition classifies ARDS severity by PaO2/FiO2 ratio on PEEP >= 5 cmH2O: Mild = 200-300 mmHg, Moderate = 100-200 mmHg, Severe = <100 mmHg. Moderate ARDS has a mortality of approximately 32%. Management includes lung-protective ventilation (tidal volume 6 ml/kg ideal body weight), permissive hypercapnia, and prone positioning for severe cases.
Question 4: A 70 kg patient with 40% total body surface area full-thickness burns presents 1 hour post-injury. Using the Parkland formula, what volume of Hartmann's solution should be administered in the first 8 hours from the time of burn?
- 5600 ml (Correct answer)
- 11200 ml
- 2800 ml
- 8400 ml
Correct answer: 5600 ml
Parkland formula: 4 ml x body weight (kg) x %TBSA burned = 4 x 70 x 40 = 11,200 ml in the first 24 hours. Half of this (5,600 ml) is given in the first 8 hours from the time of burn injury, and the remaining half over the next 16 hours. The fluid is titrated to maintain urine output of 0.5-1 ml/kg/hour in adults.
Question 5: Which scoring system is used in UK emergency departments to assess the severity of community-acquired pneumonia and guide admission decisions?
- CURB-65 (Correct answer)
- APACHE II
- SOFA
- Glasgow-Blatchford
Correct answer: CURB-65
CURB-65 scores one point each for: Confusion (AMT <= 8), Urea >7 mmol/L, Respiratory rate >= 30, Blood pressure (systolic <90 or diastolic <= 60), and age >= 65 years. Score 0-1: home treatment; 2: consider hospital admission; 3-5: consider ICU. It is recommended by NICE and the British Thoracic Society for community-acquired pneumonia assessment.
Question 6: A post-operative patient develops a pulmonary embolism with haemodynamic instability (systolic BP 70 mmHg). What is the definitive pharmacological treatment?
- Systemic thrombolysis with alteplase (Correct answer)
- Therapeutic dose LMWH
- Intravenous unfractionated heparin bolus
- Oral rivaroxaban
Correct answer: Systemic thrombolysis with alteplase
Massive (high-risk) pulmonary embolism with haemodynamic compromise requires systemic thrombolysis. Alteplase (50-100 mg IV over 2 hours) is the standard agent. NICE and ESC guidelines recommend thrombolysis for PE with sustained hypotension (systolic <90 mmHg). While heparin is given adjunctively, it does not dissolve existing clot. Surgical embolectomy or catheter-directed therapy are alternatives if thrombolysis is contraindicated.
FRCS Critical Care and Emergency
A patient with severe sepsis has a serum lactate of 6.2 mmol/L.
According to the Surviving Sepsis Campaign (SSC) guidelines, what is the target for lactate clearance within the first 6 hours?