Respiratory MCQs

93. A 56-year-old woman is admitted to the ICU with a thunderclap headache and a rupture of an aneurysm of the anterior cerebral artery. She is treated with endovascular coiling. On admission to the ICU, she was originally intubated and sedated. Over the course of 4 days, she is extubated but continues to demonstrate right hemiparesis and aphasia. Seven days after her presentation, she abruptly declines with alert mental status and marked worsening of her hemiparesis. A head CT is performed urgently and does not show any progression of bleeding or widening of the ventricles. She has been on nimodipine 60 mg every 4 hours since presentation. What is the most likely diagnosis for her worsened condition?

=============================

💡

92. A 67-year-old man has been in the ICU for 3 weeks after admission for sepsis due to pneumococcal pneumonia. He is currently on minimal ventilatory support with inspiratory pressure support of 15 cmH 2 O and expiratory pressure of 5 cmH 2 O. The FiO 2 is 0.4. Spontaneous tidal volumes on these settings average 450 mL. He is no longer sedated, appears alert, and is following commands. He appears weak and debilitated. He is not able to lift his arms or legs off the bed. His chest radiograph shows marked improvement in the bilateral infiltrates. For the past week, he has failed spontaneous breathing trials. When the inspiratory pressure support is dropped to less than 10 cmH 2 O, the patient begins to breathe rapidly at 28 breaths/min, and the tidal volume drops to 220 mL. What is the most likely cause of the patient’s inability to be liberated from the ventilator?

=============================

💡

91. A 56-year-old man is admitted to the hospital following a witnessed cardiac arrest. Upon arrival of emergency medical personnel, the rhythm is ventricular fibrillation. The patient is cardioverted into sinus rhythm with return of spontaneous circulation. His estimated duration without circulation is 10 minutes. ECG demonstrated evidence of acute myocardial infarction in an anterior distribution. The patient is treated with primary angioplasty of a 100% occlusion of the proximal left anterior descending artery. He is brought to the ICU intubated and requires use of norepinephrine to maintain his mean arterial pressure greater than 60 mmHg. Initial neurologic examination shows absence of corneal and gag reflexes. When you move the head side to side, the eyes move in concert with the head movement and do not stay fixed. Intermittent myoclonus is present. You are considering use of hypothermia. Which of the following statements correctly characterizes the use of hypothermia in this patient? A. A head CT should be performed to determine the extent of cerebral edema before deciding upon whether to employ therapeutic hypothermia. B. Temperature management should be directed at prevention of fevers only with a target temperature of 36°C. C. Therapeutic hypothermia is recommended to target a temperature of 32–34°C for 24 hours. D. There is no role for therapeutic hypothermia because the patient’s prognosis is very poor. E. There is no role for therapeutic hypothermia because it does not change patient outcomes.

=============================

💡

90. A 55-year-old woman is admitted to the ICU following a subarachnoid hemorrhage caused by a rupture of the posterior communicating artery. The patient is treated with intravascular placement of a coil in the aneurysm, and a ventriculostomy is placed for intracranial pressure (ICP) monitoring. Upon arrival to the ICU after surgery, she is intubated and minimally responsive to painful stimuli. She does not respond to voice. The initial ICP is 45 mmHg, and the initial blood pressure is 138/85 mmHg (mean arterial pressure, 103 mmHg) with the head of the bed elevated at 30 degrees. The ICP remains at 45 mmHg over the next 5 minutes. What would you recommend next in the management of this patient?

=============================

💡

89. Intraparenchymal intracranial pressure monitoring is preferred over ventriculostomy in which of the following patients? A. A 24-year-old man admitted with traumatic brain injury following a motor vehicle accident and a Glasgow Coma Scale score of 6 B. A 35-year-old woman with autoimmune hepatitis admitted with fulminant hepatic failure and an international normalized ratio of 3.5 C. A 48-year-old man admitted to the ICU with subarachnoid hemorrhage following a rupture of an anterior cerebral artery aneurysm D. A 68-year-old woman admitted with a hemorrhagic stroke in the right temporal region with associated midline shift visualized on CT scan E. All of the above are appropriate candidates for ventriculostomy.

=============================

💡