Sample Written Exam – Critical Care Medicine (Adult)
Question 1
You are the intensivist on call at a community coronary care unit (CCU). You are called to see a 45-
year-old man with an acute inferior myocardial infarction. The ECG shows 2 mm of ST-segment
elevation in leads II, III and aVF, and 1.5 mm of ST-segment elevation in lead V4R. Tissue
plasminogen activator (TPA) is administered and the patient’s chest pain resolves after 25 minutes.
He is subsequently admitted to the CCU where he develops hemodynamic instability with sinus
tachycardia (110 bpm) and persistent hypotension (systolic blood pressure 80-85 mm Hg). Additional
findings on physical examination include normal breath sounds and distended neck veins with a
positive Kussmaul sign. The chest radiograph does not demonstrate overt congestive heart failure.
a. List FOUR MAJOR hemodynamic treatment principles that are required for the proper care of
this patient.
MODEL ANSWER (0.5 marks each, 2 marks total)
• maintenance of optimal right ventricular (RV) preload (volume infusion).
• reduction of RV afterload
• RV inotropic support (inotropes) (dobutamine, milrinone)
• early reperfusion - emergency percutaneous transluminal coronary angioplasty
(PTCA)
b. With appropriate therapy, the patient's condition improves and his hemodynamic status is
stabilized. Several hours later, he develops complete heart block and his condition
deteriorates. What is the BEST type of cardiac pacing for this patient?
MODEL ANSWER (0.5 marks)
• atrioventricular (AV) sequential pacing (and NOT VVI pacing)
c. Give ONE reason for your choice in part (b) above. Be specific.
MODEL ANSWER (0.5 marks)
• AV synchrony important for maintenance of adequate RV preload
• adverse effects of AV dissociation
• loss of AV synchrony
• loss of atrial contribution or atrial "kick" to ventricular filling
Question 2
a. List TWO methods of performing a spontaneous breathing trial (SBT) to assess a patient's ability
to wean from mechanical ventilation.
MODEL ANSWER (0.5 marks each, 1 mark total)
• continuous positive airway pressure (CPAP) with or without pressure support
• T-piece trial
b. List FIVE criteria that would indicate a failure of the SBT.
MODEL ANSWER (any 5 of the following, 0.5 marks each; 2.5 marks total)
• tachypnea or breathing rate > 35/min
• rapid shallow breathing index or ratio of respiratory frequency to tidal volume > 105
• hemodynamic instability
• cardiac arrhythmia
• hypoxia
• patient distress/dyspnea
• signs of myocardial ischemia
• worsening hypercapnia
Question 3
A 20-year-old woman is admitted to the ICU following 4 days of severe vomiting and diarrhea. Her
past medical history is unremarkable except for an episode of post-streptococcal glomerulonephritis
at age 8, from which her mother reports she has completely recovered. On admission, her serum
sodium level is 138 mmol/L, serum creatinine level is 140 μmol/L, urine sodium level is 5 mmol/d,
urine creatinine level is 600 mmol/d , and urine specific gravity is 1.030 (urine osmolality is 850
mmol/kg). She has had only 20 mL of urinary output during the 4 hours since her admission.
a. Write the formula for fractional excretion of sodium.
MODEL ANSWER (0.5 marks)
• [urine sodium/serum sodium] / [urine creatinine/serum creatinine] x 100% = 85%
b. In this patient, what TWO laboratory test results are consistent with the diagnosis of pre-
renal failure?
MODEL ANSWER (any 2 of the following, 0.5 marks each; 1 mark total)
• low urine sodium
• high specific gravity
• high urine creatinine
• high urine osmolality
2
Question 4
A 47-year-old man with alcohol use disorder climbs a high-voltage tower. After being persuaded to
climb down, he touches the high voltage line on his way down. He does not lose consciousness or
fall. He is assisted to the ground and taken to the local community hospital. He has contact injury
sites on his left hand and right foot.
Excluding death, list FOUR MAJOR complications of electrocution.
MODEL ANSWER (0.5 marks each, 2 marks total)
• Cardiac dysrhythmia
• Rhabdomyolysis
• Compartment syndrome
• Nerve and vessel injury
• Renal failure
Question 5
a. In anaphylactic shock, what is the MOST important pharmacologic treatment? Be specific.
MODEL ANSWER (0.5 marks)
• Epinephrine 1/1000, 0.3-0.5ml sc/IM/IV, stat and q 5 15 min
b. List THREE additional pharmacologic therapies recommended for the management of
anaphylactic shock.
MODEL ANSWER (0.5 marks each, 1.5 marks total)
(Doses not required but wrong dose, no mark)
• Anti H1 (diphenhydramine) (25-50mgIV q4 6h)
• Anti H2 (ranitidine) (50 mg IV or 150 mg po q 8 hrs)
• Corticosteroids (125 MP mg IV or 50 prednisone mg p.o.)
• Glucagon 5 15ug/min IV (if on beta blockers)
• Ventolin/inhaled beta agonist
