Back in action 👋🏼

Dear all, 
Critical care has grown by leaps and bounds in the last few years. Also Critical Care Medicine is now recognised as a Superspeciality and will be a Superspeciality Degree course from the year 2019.

I wanna sincerely apologise for not posting regularly on the group. But now I have decided to post very much regularly and atleast one/ two MCQs per week, with explanations. 
I want to thank Dr Mayur S Shah , for recollecting all the MCQs that appeared in the 2018 FNB entrance exam, which I will post here with explanations. 

Also with the MCQs, I will be posting regular reading material  on my blog https://icucare.blogspot.com .... which will work as a good information platform. 

You can gain access to power points in critical care medicine, from this blog link https://medicalslides-ppt.blogspot.com . If you wish to have them in a PowerPoint format, pls post a comment on the ppt you want / shoot a mail to fnbcriticare@gmail.com. 

Also I will posting all the landmark trials - current as well the previous ones, on this blog https://criticalupdates.blogspot.com . 
So please log on regularly to be updated.
Cheers !!! 

2010 - AHA ECC Adult Chain of Survival

The links in the 2010 AHA ECC Adult Chain of Survival are as follows:
1.  Immediate recognition of cardiac arrest and activation of the emergency response system
2.  Early CPR with an emphasis on chest compressions
3. Rapid defibrillation
4. Effective advanced life support
5. Integrated post–cardiac arrest care

Vaughan Williams Classification of Anti-arrythmic Drugs

Class	Action	Drugs	Caution
Ia	Sodium channel inhibition: prolong repolarization	Quinidine, procainamide, disopyramide	myocardial infarction, congestive heart failure, renal disease
Ib	Sodium channel inhibition: shorten repolarization	Lidocaine	Proarrhythmias
Ic	Sodium channel inhibition: no effect on repolarization but reduce conductivity	Flecainide, propafenone	Structural heart disease, myocardial infarction, congestive heart failure
II	B-Adrenergic inhibition	Timolol, esmolol, atenolol, bisoprolol	Acute heart failure, bronchospasm
III	Potassium channel inhibition: prolong repolarization	Amiodarone, sotalol	Renal disease, pulmonary disease
IV	Calcium channel inhibition	Verapamil, diltiazem	Not in conjunction with B-blockers
Misc	Na-K ATPase inhibition: potentiate parasympathetic response	Digoxin	Renal disease, hypokalemia

Types of Antibiotics:

Concentration-dependent activity of antibiotics: Rate of kill is related to peak concentration above breakpoint,

eg: Aminoglycosides, fluoroquinolones, amphotericin B and metronidazole

Time-dependent activity: Kill rates related to the length of time concentrations are sustained above breakpoint MIC.

eg: Penicillins, cephalosporins, macrolides, carbapenems, clindamycin, linezolid and glycopeptides

Causes of ALI/ ARDS

Causes of Acute Lung Injury and Acute Respiratory Distress Symdrome are:

DIRECT Causes:

• Pneumonia
• Aspiration
• Inhalational injuries
• Blunt pulmonary trauma
• Near drowning

INDIRECT Causes:

• Sepsis
• Severe traumatic shock
• Large volume blood transfusion (>15 units)
• Pancreatitis
• Reperfusion after cardiopulmonary bypass

Although more than 60 conditions have been associated with ARDS, the most frequent cause is sepsis, followed by pneumonia and aspiration.

Knaus Criteria for Multiple System Organ Failure

Multiple systems organ failure is said present when more than one of the system dysfunctions is detected by test values exceeding the threshold values.

1. Respiratory failure (presence of one or more):

- Respiratory frequency <5, >49 (>two years of age)
- Alveolar-arterial difference in O2 >350 mmHg or PaO2/ Fi02 <200 (without congenital cardiac lesion)
- Requires mechanical ventilatory support >24 h
- PaCO2 >50 mmHg and pHa <7.25

2. Circulatory failure (presence of one or more):

- Heart rate <50/mm or episode of ventricular tachycardia/fibrillation
- Mean systemic arterial pressure <50 mmHg and (or) systolic systemic arterial pressure <60 mmHg
- Cardiac Index <2 L/min per sq. meter of body surface (acute onset) and (or) pHa <7.25, PaCO2, <35 without respiratory failure

3. Renal failure (presence of one or more):

- Urine volume 9.3 mL/kg body weight per hour for 8h
- Serum creatinine >266 umol/L
- Urea nitrogen >1.00 g/L or urea >0.60 g/L

4. Hepatic failure (presence of both):

- Bilirubin >60 mg/L or a twofold increase in alkaline phosphatase in serum and
- Prothrombin time >4 s over upper limit of normal range or a twofold increase in aspartate aminotransferase in serum

5. Hematologic failure (presence of one or more):

- Leukocytes <1500/mL or >40000/mL
- Platelets <20000/mL or evidence of ongoing disseminated intravascular coagulation

6. Neurologic failure

- Glasgow Coma Scale <6 (without sedation)

7. Uncontrolled sepsis (presence of one or more):

- Positive blood culture despite antibiotic therapy
- Fever >39.5 °C (rectal temp) for >24 h or spikes on three successive days

Toxicology:

Toxins removable by Hemodialysis:
- Salicylates
- Lithium
- Methanol
- Ethylene Glycol
- Isopropanol

Toxins removable by Hemoperfusion
- Barbiturates
- Carbamazepine
- Theophylline
- Valproic Acid

Indications of Plasmapheresis:

1. Hyperviscosity syndromes (treatment of choice)

2. Myasthenic crisis

3. Hemolytic Uremic Syndrome / Thrombotic Thrombocytopenic Purpura

4. Guillain Barre Syndrome / Acute Inflammatory Demyelinating Polyneuropathy

5. Wegener's granulomatosis, microscopic polyangiitis, and Churg-Strauss syndrome

6. Desensitization prior to transplantation by reducing the level of antidonor antibodies via plasmapheresis of blood has been useful in reducing the hazard of hyperacute rejection.

7. Post-transfusion Purpura

8. Pemphigus Vulgaris

9. Familial chylomicronemia syndrome (during pregnancy)

10. POEMS (polyneuropathy, organomegaly, endocrinopathy, M-proteins, and skin changes) syndrome

Diagnostic Criteria for ALI and ARDS

1. Acute Onset

2. Presence of a predisposing condition.

3. Bilateral infiltrates on frontal chest x-ray, consistent with pulmonary edema.

4. PaO2 / FiO2 < 200 mm Hg for ARDS, < 300 mm Hg for ALI, regardless of the level of positive end-expiratory pressure (PEEP).

5. Pulmonary artery occlusion pressure =18 mm Hg or no clinical evidence of left atrial hypertension.

Bernard GR, Artigas A, Brigham KL, et al. The American–European Consensus Conference on ARDS: definitions, mechanisms, relevant outcomes, and clinical trial coordination. Am Rev Respir Crit Care Med 1994;149:818–824.

Metabolic Acidosis: Causes

Elevated anion gap:

• Methanol intoxication
• Uremia
• Diabetic ketoacidosis, alcoholic ketoacidosis, starvation ketoacidosis
• Paraldehyde toxicity
• Isoniazid
• Lactic acidosis
  • Type A:  tissue ischemia
  • Type B:  Altered cellular metabolism
• Ethanol or ethylene glycol intoxication
• Salicylate intoxication

Normal anion gap: will have increase in [Cl-]

• GI loss of HCO₃-
  • Diarrhea, ileostomy, proximal colostomy, ureteral diversion
• Renal loss of HCO₃-
  • proximal RTA
  • carbonic anhydrase inhibitor (acetazolamide)
• Renal tubular disease
  • ATN
  • Chronic renal disease
  • Distal RTA
  • Aldosterone inhibitors or absence
  • NaCl infusion, TPN, NH₄+ administration

Recommended daily protein intake:

Normal / unstressed 0.75 g/kg/day

Critical illness/ injury 1.0 – 1.5 g/kg/day

Acute renal failure (undialyzed) 0.8 – 1.0 g/kg/day

Acute renal failure (dialyzed) 1.2 – 1.4 g/kg/day

Peritoneal dialysis 1.3 – 1.5 g/kg/day

Burns and Sepsis 1.5 – 2.0 g/kg/day

CVVHD 1.7 – 2.5 g/kg/day

Generally, the optimal protein intake in critically ill patients is given at twice the recommended daily amount (approximately 0.8 g per kg per day) of normal adults, at approximately 1.5 g per kg per day. With renal impairment, at least 1 g per kg should be provided and greater amounts given if tolerated or dialysis is initiated. In patients with liver failure at least 1 g per kg of standard protein should be provided and up to 1.5 g per kg if tolerated. This is done recognizing the overall impairments in protein utilization that accompanies metabolic stress, as well as the heightened needs during catabolism.

Ref: The Washington Manual of Critical Care; Irwin and Rippe’s Intensive Care Medicine

Well’s Criteria for Pulmonary Embolus

VARIABLES	POINTS
Symptoms/signs of DVT ( minimum of leg swelling and pain with palpation of the deep veins	3.0
Alternative diagnosis deemed less likely than PE	3.0
Heart rate >100 beats/min	1.5
Immobilization/surgery in previous 4 wk	1.5
Previous VTE	1.5
Hemoptysis	1.0
Recent or current malignancy	1.0

Clinical Probability:

Low Probability <2.0

Intermediate Probability 2.0 -6.0

High Probability >6.0

Well’s Criteria for Deep Venous Thrombosis

VARIABLES	POINTS
Cancer (receiving treatment, treated in the past six months, or palliative care	1
Paralysis, paresis, or recent plaster immobilization of the lower extremities	1
Recently bedridden for three days or more, or major surgery within the previous 12 weeks requiring general or regional anesthesia	1
Localized tenderness along the distribution of the deep venous system	1
Entire leg swollen	1
Calf swelling at least 3 cm larger than that on the asymptomatic side (measured 10 cm below tibial tuberosity)	1
Pitting edema confined to the symptomatic leg	1
Collateral superficial veins (non-varicose)	1
Previously documented DVT	1
Alternative diagnosis at least as likely as DVT	Minus 2

</= 1 points: Clinical probability of DVT unlikely
> 1 points: Clinical probability of DVT likely

Risk Factors for Venous Thrombo Embolism

Surgery                                                                                                Trauma (major or lower extremity)                         Immobility, paresis                                                  Malignancy                                                                                             Cancer therapy (hormonal, chemotherapy, or radiotherapy)
Previous VTE
Increasing age
Pregnancy and the postpartum period
Estrogen-containing oral contraception or hormone replacement therapy
Selective estrogen receptor modulators
Acute medical illness
Heart or respiratory failure
Inflammatory bowel disease
Nephrotic syndrome
Myeloproliferative disorders
Paroxysmal nocturnal hemoglobinuria
Obesity
Smoking
Varicose veins
Central venous catheterization
Inherited or acquired thrombophilia