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CICM First Part study materials
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CICM First Part practice questions

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Question 1Intensive care medicine (general)

A 70 kg adult in septic shock is started on a noradrenaline infusion at 0.1 micrograms/kg/min. What dose in micrograms per minute is being delivered?

  1. 0.7 micrograms/min
  2. 1.4 micrograms/min
  3. 7 micrograms/min Correct answer.
  4. 70 micrograms/min

Explanation

Dose in micrograms per minute equals the weight-based rate multiplied by body weight, so 0.1 × 70 gives 7 micrograms per minute. Checking the arithmetic against the pump rate prevents tenfold dosing errors at the bedside.

Question 2Intensive care medicine (general)

Which finding best defines the systemic inflammatory response syndrome in an adult?

  1. A mean arterial pressure below 65 mmHg
  2. Two or more of abnormal temperature, tachycardia, tachypnoea and abnormal white cell count Correct answer.
  3. A single blood culture growing a gram-negative organism
  4. A lactate concentration above 4 mmol/L

Explanation

SIRS is defined by two or more nonspecific physiological criteria: temperature, heart rate, respiratory rate or carbon dioxide, and white cell count. It is a screening concept and does not require a positive culture or hypotension.

Question 3Intensive care medicine (general)

In an adult with suspected community-acquired pneumonia, which feature most strongly predicts severe disease requiring intensive care assessment?

  1. Temperature of 38.5 degrees Celsius
  2. Crackles at the right base
  3. Respiratory rate of 32 breaths per minute Correct answer.
  4. Productive cough with green sputum

Explanation

A markedly raised respiratory rate is a core severity marker in tools such as CURB-65 and reflects failing respiratory reserve. Fever, sputum colour and focal crackles are common but poorly discriminate severity.

Question 4Intensive care medicine (general)

What is the first-line vasopressor for a hypotensive adult in septic shock after adequate fluid resuscitation?

  1. Noradrenaline Correct answer.
  2. Dobutamine
  3. Adrenaline
  4. Vasopressin

Explanation

Noradrenaline is recommended as the initial vasopressor because it raises mean arterial pressure with less tachyarrhythmia than adrenaline. Dobutamine is an inotrope, and vasopressin is usually added later as a second agent.

Question 5Intensive care medicine (general)

Which parameter is used to calculate the oxygen content of arterial blood?

  1. Cardiac output and systemic vascular resistance
  2. Haemoglobin, oxygen saturation and arterial partial pressure of oxygen Correct answer.
  3. Arterial partial pressure of carbon dioxide and pH
  4. Haemoglobin and serum lactate

Explanation

Arterial oxygen content depends mainly on haemoglobin-bound oxygen plus a small dissolved fraction determined by the arterial partial pressure of oxygen. Carbon dioxide, cardiac output and lactate do not enter the content equation.

Question 6Intensive care medicine (general)

A patient has a serum sodium of 120 mmol/L with confusion. Which initial approach is most appropriate if the hyponatraemia is chronic and the patient is symptomatic?

  1. Free water restriction alone with no monitoring
  2. Immediate haemodialysis
  3. Rapid correction to 140 mmol/L within 6 hours
  4. Cautious hypertonic saline with frequent sodium checks targeting a limited rise over 24 hours Correct answer.

Explanation

Symptomatic chronic hyponatraemia warrants careful hypertonic saline, but the rise must be limited because over-rapid correction risks osmotic demyelination. Frequent monitoring allows the rate to be adjusted before harm occurs.

Question 7Intensive care medicine (general)

Which acid-base picture is most consistent with prolonged vomiting?

  1. Respiratory alkalosis with a normal anion gap
  2. Respiratory acidosis with a raised bicarbonate
  3. Metabolic alkalosis with hypochloraemia and hypokalaemia Correct answer.
  4. Metabolic acidosis with a raised anion gap

Explanation

Gastric fluid loss removes hydrogen and chloride, generating a chloride-responsive metabolic alkalosis, and potassium is lost in urine. The anion gap is typically normal or low.

Question 8Intensive care medicine (general)

Which statement about the anion gap is correct?

  1. It is unaffected by hypoalbuminaemia
  2. It is normally less than zero
  3. It is calculated as chloride plus bicarbonate minus sodium
  4. It is calculated as sodium minus the sum of chloride and bicarbonate Correct answer.

Explanation

The anion gap estimates unmeasured anions as sodium minus chloride minus bicarbonate. Albumin is the dominant unmeasured anion, so hypoalbuminaemia lowers the gap and can mask a raised gap acidosis.

Question 9Intensive care medicine (general)

A patient with severe acute pancreatitis develops tachypnoea and hypoxaemia on day two. What is the most likely explanation?

  1. Pulmonary embolism
  2. Pneumothorax
  3. Acute respiratory distress syndrome Correct answer.
  4. Cardiogenic pulmonary oedema

Explanation

Severe pancreatitis is a well-recognised cause of acute respiratory distress syndrome through systemic inflammation and pancreatic enzyme release. The timing and hypoxaemia fit this non-cardiogenic process.

Question 10Intensive care medicine (general)

Which ventilator strategy is standard for a patient with acute respiratory distress syndrome?

  1. Zero positive end-expiratory pressure
  2. Low tidal volume ventilation of about 6 mL/kg predicted body weight with plateau pressure limitation Correct answer.
  3. Routine prone positioning for all patients regardless of severity
  4. High tidal volume ventilation to normalise carbon dioxide

Explanation

Lung-protective ventilation using low tidal volumes based on predicted body weight and limiting plateau pressure reduces ventilator-induced lung injury and mortality. Permissive hypercapnia is accepted to achieve this.

Question 11Intensive care medicine (general)

Which finding suggests that a patient with a tracheostomy is developing a blocked tube?

  1. Increasing inspiratory pressure with difficulty passing a suction catheter Correct answer.
  2. Stable oxygen saturation on room air
  3. Bilateral equal breath sounds
  4. A dry cough after eating

Explanation

Rising airway pressures together with inability to pass a suction catheter indicate luminal obstruction from secretions or a mucus plug. Immediate assessment and tube change may be required.

Question 12Intensive care medicine (general)

A patient is intubated after a head injury. Which target best reflects current practice for carbon dioxide control?

  1. Prolonged hyperventilation to 25 mmHg
  2. Permissive hypercapnia above 60 mmHg
  3. Normocapnia with arterial carbon dioxide around 35 to 40 mmHg Correct answer.
  4. No monitoring of carbon dioxide

Explanation

Normocapnia is the standard target because both hypercapnia and hypocapnia can worsen cerebral perfusion through changes in cerebral blood volume. Brief hyperventilation is reserved for impending herniation.

Question 13Intensive care medicine (general)

Which electrolyte abnormality most commonly causes prolonged QT interval and torsades de pointes?

  1. Hypernatraemia
  2. Hypokalaemia Correct answer.
  3. Hypophosphataemia
  4. Hyperchloraemia

Explanation

Low potassium delays repolarisation and prolongs the QT interval, predisposing to torsades de pointes, especially with concurrent hypomagnesaemia. Sodium, chloride and phosphate disturbances do not typically cause this.

Question 14Intensive care medicine (general)

Which statement about acute kidney injury in critical illness is correct?

  1. Creatinine rises immediately with any fall in filtration
  2. Serum creatinine may rise only after substantial loss of glomerular filtration Correct answer.
  3. Oliguria always indicates established tubular necrosis
  4. Fluid resuscitation is contraindicated in all forms of acute kidney injury

Explanation

Creatinine is a delayed marker because a new steady state takes time to develop after filtration falls. Significant injury can therefore exist with a near-normal creatinine, so urine output and context must be considered.

Question 15Intensive care medicine (general)

A patient with a suspected tension pneumothorax becomes hypotensive with distended neck veins and absent breath sounds on one side. What is the immediate management?

  1. Observation with supplemental oxygen
  2. Urgent decompression without waiting for imaging Correct answer.
  3. CT scan of the chest
  4. Chest radiograph before any intervention

Explanation

Tension pneumothorax is a clinical diagnosis and a life-threatening emergency, so decompression must not be delayed for imaging. Waiting risks cardiovascular collapse.

Question 16Intensive care medicine (general)

Which agent is the first-line antidote for organophosphate poisoning with cholinergic features?

  1. Flumazenil
  2. N-acetylcysteine
  3. Atropine Correct answer.
  4. Naloxone

Explanation

Atropine antagonises muscarinic effects such as bradycardia, bronchorrhoea and bronchospasm, and is titrated to drying of secretions. Pralidoxime may be added for nicotinic effects but atropine is the immediate priority.

Question 17Intensive care medicine (general)

A patient with a suspected opioid overdose has pinpoint pupils and a respiratory rate of 6 breaths per minute. What is the most appropriate immediate action?

  1. Give adrenaline intramuscularly
  2. Give naloxone and support ventilation Correct answer.
  3. Give atropine
  4. Give flumazenil

Explanation

The triad of reduced consciousness, pinpoint pupils and hypoventilation indicates opioid toxicity, which responds to naloxone alongside airway and ventilatory support. Titrated dosing avoids abrupt withdrawal and agitation.

Question 18Intensive care medicine (general)

Which finding is characteristic of anaphylaxis rather than a simple vasovagal reaction?

  1. Isolated light-headedness on standing
  2. Rapid improvement on lying down
  3. Bradycardia with pallor and sweating
  4. Urticaria with hypotension that persists when lying flat Correct answer.

Explanation

Anaphylaxis is a multisystem IgE-mediated process with skin, respiratory and cardiovascular features, and hypotension does not resolve with recumbency alone. Vasovagal reactions typically feature bradycardia and rapid improvement when supine.

Question 19Intensive care medicine (general)

Which statement about enteral nutrition in a critically ill adult is correct?

  1. Parenteral nutrition is always superior in the first 48 hours
  2. Enteral feeding is preferred over parenteral nutrition when the gut is functional Correct answer.
  3. Gastric residual volumes should be checked hourly in all patients
  4. Enteral feeding should be withheld for a week after admission

Explanation

The enteral route maintains gut mucosal integrity, is cheaper and carries fewer infectious complications, so it is preferred when the gastrointestinal tract works. Parenteral nutrition is reserved for intolerance or contraindications.

Question 20Intensive care medicine (general)

A patient with severe diabetic ketoacidosis has a potassium of 3.1 mmol/L. What should happen before insulin is given?

  1. Bicarbonate should be given
  2. Fluids should be withheld
  3. Potassium replacement should begin promptly Correct answer.
  4. Insulin should be given immediately at a high dose

Explanation

Insulin drives potassium into cells and can precipitate dangerous hypokalaemia, so replacement must start before or alongside insulin when potassium is already low. Total body potassium is depleted even when serum values appear normal.

Question 21Intensive care medicine (general)

Which feature best distinguishes delirium from dementia in an older intensive care patient?

  1. Focal neurological deficit with preserved attention
  2. Stable cognitive function throughout admission
  3. Gradual progressive memory loss over years
  4. Acute onset with fluctuating attention and altered consciousness Correct answer.

Explanation

Delirium is an acute, fluctuating disturbance of attention and awareness, often triggered by illness or drugs. Dementia is chronic and progressive, although the two frequently coexist.

Question 22Intensive care medicine (general)

A patient is being assessed for brain death. Which prerequisite must be satisfied before testing?

  1. A documented family request
  2. Absence of any spinal reflexes
  3. Exclusion of confounding factors such as sedatives, hypothermia and metabolic derangement Correct answer.
  4. A confirmed flat electroencephalogram

Explanation

Brain death testing requires that reversible causes of coma, including drugs, hypothermia and severe metabolic disturbance, have been excluded. Ancillary tests are only needed in specific circumstances rather than universally.

Question 23Intensive care medicine (general)

Which statement about prone positioning in severe acute respiratory distress syndrome is correct?

  1. It reliably increases mortality
  2. It improves oxygenation and mortality when applied for prolonged periods in moderate to severe cases Correct answer.
  3. It should be avoided in all patients with abdominal surgery
  4. It is used only as a rescue therapy after several weeks of ventilation

Explanation

Prolonged prone positioning of around 12 to 16 hours daily improves oxygenation and reduces mortality in moderate to severe ARDS. It recruits dorsal lung regions and reduces ventral overdistension.

Question 24Intensive care medicine (general)

Which mechanism best explains the hypotension seen in a high cervical spinal cord injury?

  1. Loss of sympathetic vasomotor tone causing vasodilation and bradycardia Correct answer.
  2. Excess catecholamine release causing vasoconstriction
  3. Primary myocardial infarction
  4. Acute adrenal haemorrhage

Explanation

Interruption of sympathetic outflow above the mid-thoracic level removes vasoconstrictor tone, producing vasodilation, and unopposed vagal activity causes bradycardia. This is neurogenic shock and often responds to vasopressors as well as fluids.

Question 25Intensive care medicine (general)

A patient with a large pulmonary embolism is hypotensive with a raised central venous pressure and clear lungs. Which treatment is most appropriate?

  1. Systemic thrombolysis if there is no contraindication Correct answer.
  2. Large-volume fluid loading as the sole therapy
  3. Diuresis to lower central venous pressure
  4. Beta-blockade to reduce heart rate

Explanation

High-risk pulmonary embolism with haemodynamic instability warrants reperfusion, usually systemic thrombolysis, provided there is no major contraindication. Fluids alone may worsen right ventricular failure.

Question 26Intensive care medicine (general)

A patient in the intensive care unit has a central venous pressure of 18 mmHg, a mean arterial pressure of 55 mmHg, and warm peripheries with a normal lactate. Which shock state is most likely?

  1. Cardiogenic shock
  2. Distributive shock Correct answer.
  3. Hypovolaemic shock
  4. Obstructive shock

Explanation

Warm peripheries with a normal lactate and a high central venous pressure suggest vasodilatation rather than poor perfusion from a pump or volume problem. Distributive shock, such as septic or neurogenic shock, typically produces low systemic vascular resistance and a normal or high cardiac output. The mean arterial pressure is low despite adequate filling pressures, which fits this pattern.

Question 27Intensive care medicine (general)

Which intravenous fluid is recommended as the initial resuscitation fluid for most critically ill adults requiring volume expansion?

  1. Balanced crystalloid Correct answer.
  2. 0.9% sodium chloride
  3. 5% glucose
  4. Human albumin solution

Explanation

Balanced crystalloids such as Hartmann's solution or Plasma-Lyte are preferred for initial resuscitation because they contain buffers that reduce the risk of hyperchloraemic acidosis compared with 0.9% sodium chloride. Large volumes of 0.9% sodium chloride can cause hyperchloraemia and renal vasoconstriction. Glucose solutions are not resuscitation fluids because they distribute rapidly into total body water and provide little intravascular volume.

Question 28Intensive care medicine (general)

A patient with septic shock remains hypotensive despite adequate fluid resuscitation. Which vasopressor is recommended as the first-line agent?

  1. Noradrenaline Correct answer.
  2. Vasopressin
  3. Dobutamine
  4. Adrenaline

Explanation

Noradrenaline is the recommended first-line vasopressor in septic shock because it increases systemic vascular resistance with less tachycardia than adrenaline and a lower risk of arrhythmia. It is started when hypotension persists despite fluid resuscitation. Dobutamine is an inotrope used for low cardiac output, and vasopressin is usually added as a second agent.

Question 29Intensive care medicine (general)

A patient with severe community-acquired pneumonia has a CURB-65 score of 3. What does this score predict?

  1. Need for invasive ventilation
  2. Risk of acute kidney injury
  3. Likelihood of bacteraemia
  4. Risk of death within 30 days Correct answer.

Explanation

The CURB-65 score uses confusion, urea, respiratory rate, blood pressure, and age to estimate 30-day mortality in community-acquired pneumonia. A score of 3 indicates high mortality risk and usually prompts consideration of intensive care admission. It does not specifically predict need for ventilation, renal injury, or bacteraemia.

Question 30Intensive care medicine (general)

A patient with acute respiratory distress syndrome is ventilated with a tidal volume of 6 mL/kg predicted body weight. Which additional ventilator setting is most important to limit ventilator-induced lung injury?

  1. Plateau pressure below 30 cmH2O Correct answer.
  2. Positive end-expiratory pressure above 15 cmH2O
  3. Respiratory rate above 35 breaths per minute
  4. Peak inspiratory pressure below 20 cmH2O

Explanation

Lung-protective ventilation in acute respiratory distress syndrome aims to limit alveolar overdistension by keeping the plateau pressure at or below 30 cmH2O. Plateau pressure reflects alveolar pressure and is a better target than peak pressure, which is influenced by airway resistance. High positive end-expiratory pressure and high respiratory rates are not universally targeted and may cause harm if applied indiscriminately.

Question 31Intensive care medicine (general)

A patient with severe acute pancreatitis develops a heart rate of 120 beats per minute, a haematocrit that has fallen from 0.45 to 0.30, and a rising creatinine. Which complication is most likely?

  1. Pancreatic pseudocyst
  2. Splenic vein thrombosis
  3. Infected pancreatic necrosis
  4. Retroperitoneal haemorrhage Correct answer.

Explanation

A falling haematocrit with tachycardia and deteriorating renal function in severe acute pancreatitis suggests significant retroperitoneal bleeding, often from erosion of the gastroduodenal artery or splenic artery. This is a life-threatening complication that may require urgent imaging and angiography or surgery. Pseudocysts and infected necrosis typically present later with fever, pain, or a mass.

Question 32Intensive care medicine (general)

Which finding on arterial blood gas analysis is most consistent with a metabolic alkalosis?

  1. pH 7.50, bicarbonate 20 mmol/L
  2. pH 7.48, bicarbonate 32 mmol/L Correct answer.
  3. pH 7.30, bicarbonate 18 mmol/L
  4. pH 7.28, bicarbonate 30 mmol/L

Explanation

Metabolic alkalosis is characterised by a primary rise in bicarbonate and a compensatory rise in pH, so a pH above 7.45 with a bicarbonate above 26 mmol/L fits. The other options show either metabolic acidosis or a mixed picture with acidaemia. Compensation for metabolic alkalosis is hypoventilation, which raises carbon dioxide but does not usually fully correct the pH.

Question 33Intensive care medicine (general)

A patient with a tracheostomy has increasing respiratory distress, diminished air entry, and a rising carbon dioxide level. Which action is most appropriate first?

  1. Increase the oxygen flow
  2. Suction the tracheostomy tube Correct answer.
  3. Remove the tracheostomy tube
  4. Deflate the cuff

Explanation

A blocked tracheostomy tube should be suspected when there is increasing distress, reduced air entry, and hypercapnia. The first step is to suction the tube to relieve secretions or a mucous plug, and if this fails the tube should be removed and the patient managed with bag-mask ventilation while a replacement is prepared. Deflating the cuff or increasing oxygen does not address obstruction.

Question 34Intensive care medicine (general)

A patient with a severe traumatic brain injury is intubated and ventilated. Which carbon dioxide target is recommended to avoid worsening cerebral ischaemia?

  1. 45 to 50 mmHg
  2. 35 to 40 mmHg Correct answer.
  3. 30 to 35 mmHg
  4. 25 to 30 mmHg

Explanation

Normocapnia, with a carbon dioxide tension of approximately 35 to 40 mmHg, is recommended for most patients with severe traumatic brain injury. Hypocapnia below 30 mmHg can cause cerebral vasoconstriction and worsen ischaemia, while hypercapnia can raise intracranial pressure. Brief hyperventilation is reserved for impending herniation.

Question 35Intensive care medicine (general)

Which electrolyte disturbance is most strongly associated with cardiac arrest in a patient with chronic kidney disease?

  1. Hypophosphataemia
  2. Hyperkalaemia Correct answer.
  3. Hypochloraemia
  4. Hypernatraemia

Explanation

Hyperkalaemia is a common and dangerous complication of chronic kidney disease because reduced renal excretion leads to potassium accumulation. Severe hyperkalaemia can cause peaked T waves, widened QRS complexes, and ventricular arrhythmias including cardiac arrest. Sodium, chloride, and phosphate disturbances are less likely to cause sudden cardiac arrest in this context.

Question 36Intensive care medicine (general)

A patient with acute kidney injury in the intensive care unit has a serum potassium of 6.8 mmol/L and ECG changes. Which treatment is most appropriate to stabilise the myocardium?

  1. Intravenous calcium gluconate Correct answer.
  2. Intravenous furosemide
  3. Oral sodium polystyrene sulfonate
  4. Intravenous insulin with glucose

Explanation

Intravenous calcium gluconate or calcium chloride is given to stabilise the cardiac membrane in severe hyperkalaemia with ECG changes. It does not lower the serum potassium but protects against arrhythmia while other measures are arranged. Insulin with glucose and furosemide shift or remove potassium but do not immediately stabilise the myocardium.

Question 37Intensive care medicine (general)

Which statement about the use of neuromuscular blocking agents in acute respiratory distress syndrome is correct?

  1. They should be considered for severe cases with refractory hypoxaemia or high plateau pressures. Correct answer.
  2. They increase the risk of barotrauma by abolishing spontaneous effort.
  3. They should be used routinely in all patients with moderate to severe acute respiratory distress syndrome.
  4. They improve survival by reducing ventilator-induced lung injury.

Explanation

Neuromuscular blocking agents may be considered in severe acute respiratory distress syndrome when there is refractory hypoxaemia, high plateau pressures, or patient-ventilator dyssynchrony. They are not recommended for routine use in all patients because they cause prolonged paralysis and require deep sedation. Their benefit is thought to come from eliminating spontaneous effort and improving lung protection.

Question 38Intensive care medicine (general)

A patient with an acute upper gastrointestinal bleed has a haemoglobin of 70 g/L and is haemodynamically stable. What is the recommended transfusion threshold for most critically ill patients?

  1. 70 g/L Correct answer.
  2. 90 g/L
  3. 80 g/L
  4. 100 g/L

Explanation

A restrictive transfusion threshold of 70 g/L is recommended for most critically ill patients, including those with acute upper gastrointestinal bleeding, because it reduces exposure to blood products without increasing mortality. A threshold of 80 g/L or higher is generally reserved for specific situations such as active cardiovascular disease. Transfusing at 100 g/L is not supported by evidence and increases risks.

Question 39Intensive care medicine (general)

Which statement about stress ulcer prophylaxis in critically ill patients is correct?

  1. It is most clearly indicated in patients with coagulopathy or prolonged mechanical ventilation. Correct answer.
  2. It increases the risk of Clostridioides difficile infection without any benefit.
  3. Proton pump inhibitors are less effective than histamine-2 receptor antagonists.
  4. It should be given to all patients admitted to intensive care.

Explanation

Stress ulcer prophylaxis is indicated for patients at high risk of gastrointestinal bleeding, such as those with coagulopathy, prolonged mechanical ventilation, or shock. It is not recommended for all intensive care patients because it can increase the risk of pneumonia and Clostridioides difficile infection. Proton pump inhibitors are effective and commonly used.

Question 40Intensive care medicine (general)

A patient with severe acute respiratory distress syndrome is being considered for prone positioning. Which statement is correct?

  1. Prone positioning should be continued for at least 16 hours per day. Correct answer.
  2. Prone positioning is contraindicated in patients with a tracheostomy.
  3. Prone positioning improves oxygenation but has no effect on mortality.
  4. Prone positioning should be started within 12 hours of intubation for the best effect.

Explanation

Prone positioning for severe acute respiratory distress syndrome is most effective when sessions last at least 16 hours per day. It improves oxygenation and has been shown to reduce mortality in patients with moderate to severe disease. It is not contraindicated in patients with a tracheostomy, although care must be taken with the airway.

Question 41Intensive care medicine (general)

A patient with a high cervical spinal cord injury becomes hypotensive with bradycardia and warm peripheries. Which mechanism best explains this?

  1. Loss of sympathetic vasomotor tone Correct answer.
  2. Myocardial depression from contusion
  3. Hypovolaemia from blood loss
  4. Increased vagal tone from unopposed parasympathetic activity

Explanation

High cervical spinal cord injury interrupts descending sympathetic pathways, causing loss of vasomotor tone and resulting in vasodilatation, hypotension, and relative bradycardia. This is neurogenic shock. The bradycardia occurs because unopposed vagal tone remains, but the primary mechanism of hypotension is loss of sympathetic outflow.

Question 42Intensive care medicine (general)

Which statement about the diagnosis of brain death is correct?

  1. EEG is required in all patients to confirm brain death.
  2. A single set of brainstem tests is sufficient in all cases.
  3. Hypothermia and sedative drugs must be excluded before testing. Correct answer.
  4. Diabetes insipidus must be present to confirm brain death.

Explanation

Before brain death testing, reversible causes of coma such as hypothermia, sedative drugs, and metabolic disturbances must be excluded. Brainstem testing must be performed by competent clinicians and may need to be repeated or supplemented with ancillary tests in certain situations. Diabetes insipidus is common but not required, and EEG is not universally required.

Question 43Intensive care medicine (general)

A patient with severe diabetic ketoacidosis has a serum potassium of 3.1 mmol/L. What should be done before starting an insulin infusion?

  1. Start a phosphate infusion
  2. Give intravenous sodium bicarbonate
  3. Give intravenous calcium gluconate
  4. Give intravenous potassium chloride Correct answer.

Explanation

Insulin drives potassium into cells and can cause dangerous hypokalaemia in patients with diabetic ketoacidosis who already have low serum potassium. Potassium should be replaced intravenously before insulin is started when the serum potassium is below 3.3 mmol/L. Bicarbonate, phosphate, and calcium are not indicated for this purpose.

Question 44Intensive care medicine (general)

A patient with severe acute pancreatitis is tolerating enteral nutrition. Which statement about nutrition in this patient is correct?

  1. Enteral nutrition helps maintain gut barrier function and reduces infectious complications. Correct answer.
  2. Parenteral nutrition is preferred to rest the pancreas.
  3. Nasogastric feeding is contraindicated.
  4. Enteral nutrition should be delayed until pain resolves.

Explanation

Enteral nutrition is preferred in severe acute pancreatitis because it maintains gut mucosal integrity, reduces bacterial translocation, and lowers infectious complications compared with parenteral nutrition. Feeding can be started once the patient is haemodynamically stable and does not need to wait for pain resolution. Nasogastric feeding is acceptable if nasojejunal access is not available.

Question 45Intensive care medicine (general)

Which finding is most characteristic of anaphylaxis rather than a vasovagal reaction?

  1. Pallor and sweating
  2. Nausea and vomiting
  3. Bradycardia
  4. Urticaria and angioedema Correct answer.

Explanation

Anaphylaxis is an acute multisystem allergic reaction that typically includes skin features such as urticaria and angioedema, along with respiratory or cardiovascular compromise. Vasovagal reactions commonly cause bradycardia, pallor, sweating, and nausea without urticaria. The presence of skin and mucosal allergic features strongly favours anaphylaxis.

Question 46Intensive care medicine (general)

A patient with septic shock has a lactate of 4 mmol/L and a mean arterial pressure of 60 mmHg after 30 mL/kg of crystalloid. Which management step is most appropriate next?

  1. Give a further 30 mL/kg of crystalloid
  2. Transfuse packed red blood cells
  3. Start low-dose dopamine
  4. Start a noradrenaline infusion Correct answer.

Explanation

In septic shock, noradrenaline should be started when hypotension persists despite adequate fluid resuscitation, typically after about 30 mL/kg of crystalloid. Further large-volume fluid boluses may worsen outcomes through fluid overload. Red cell transfusion is guided by haemoglobin, and low-dose dopamine is not recommended.

Question 47Intensive care medicine (general)

A patient with severe acute respiratory distress syndrome is ventilated with a positive end-expiratory pressure of 15 cmH2O. Which finding suggests that the positive end-expiratory pressure is too high?

  1. Increased urine output
  2. Reduced tidal volume
  3. Increasing plateau pressure with haemodynamic compromise Correct answer.
  4. Improving oxygenation

Explanation

Excessive positive end-expiratory pressure can cause alveolar overdistension, raising plateau pressure and impairing venous return, which leads to hypotension and reduced cardiac output. Improving oxygenation is a desired effect, not a sign of excess. Reduced tidal volume and increased urine output are not typical signs of excessive positive end-expiratory pressure.

Question 48Intensive care medicine (general)

Which statement about the use of corticosteroids in septic shock is correct?

  1. They increase mortality by causing hyperglycaemia.
  2. They should be given to all patients with septic shock.
  3. They are recommended when blood pressure remains inadequate despite adequate fluid and vasopressor therapy. Correct answer.
  4. They should be given as a single high dose.

Explanation

Corticosteroids are considered in septic shock when hypotension persists despite adequate fluid resuscitation and vasopressor therapy, typically at a dose of hydrocortisone 200 mg per day. They are not recommended for all patients because the benefit is modest and adverse effects include hyperglycaemia and hypernatraemia. High-dose single administration is not recommended.

Question 49Intensive care medicine (general)

A patient with a severe head injury has a Glasgow Coma Scale score of 7. Which intervention is most appropriate to reduce secondary brain injury?

  1. Give intravenous mannitol routinely
  2. Keep the head flat and the neck flexed
  3. Hyperventilate to a carbon dioxide of 30 mmHg
  4. Maintain normocapnia and adequate cerebral perfusion pressure Correct answer.

Explanation

In severe traumatic brain injury, secondary injury is reduced by maintaining normocapnia, adequate oxygenation, and a cerebral perfusion pressure of about 60 to 70 mmHg. Hyperventilation is reserved for impending herniation because it can cause cerebral ischaemia. Routine mannitol is not recommended, and the head should be elevated with the neck in a neutral position.

Question 50Intensive care medicine (general)

A 55-year-old man is admitted to intensive care with septic shock. He has received 30 mL/kg of crystalloid and remains hypotensive, so a norepinephrine infusion is started. Which parameter is the most appropriate initial target to guide the adequacy of this vasopressor therapy?

  1. A systolic blood pressure of at least 90 mmHg
  2. A mean arterial pressure of at least 65 mmHg Correct answer.
  3. A urine output of at least 0.5 mL/kg/h alone
  4. A central venous pressure of 8 to 12 mmHg

Explanation

Guidelines recommend titrating vasopressors in septic shock to a mean arterial pressure target of at least 65 mmHg, because organ perfusion pressure depends on mean rather than systolic pressure. Central venous pressure is no longer used as a resuscitation endpoint because it poorly predicts fluid responsiveness, and urine output is an adjunct marker rather than the titration target for vasopressor dose.