CARDIOPULMONARY AND CEREBRAL RESUSCITATION (1)

1. Clinical death defines:

a. cessation of blood circulation and breathing

b. heart starts beating in a regular rhythm

c. might develop in cardiac arrest

d. absence of pulse at a large artery in a non-monitored patient, with altered state of conscious

e. all of the above.

2. CPR:

a. stands for cardiopulmonary resuscitation

b. is formed of maneuvers and techniques to reanimate the sick in clinical death

c. it can be commenced at any give time after heart and breathing stopped.

d. irreversible injuries at cell level appear immediately

e. "mouth to mouth" breath combined with chest compressions is a technique rediscovered in 1960 by P. Safar & Kouwenhoven.

3. Resuscitation time:

a. is a term with of no clinical importance

b. it contains 4 main components: a-lesion time, lesion time, phase of paralysis, time to die

c. is the time passed from cardiac arrest till the induction of irreversible injuries

d. RT is 20 to 30 minutes for the liver cell, retinal cell 120 minutes, 180 minutes for renal cell

e. phase of paralysis – from the first signs of functional deficit till the disappearance of organ function

4. The optimal time for reversible resuscitation:

a. 4-8 minutes

b. 5-10 minutes

c. under 4 minutes for subjects in a state of hypothermia

d. 4 minutes

e. in case of opiate poisoning, the RT is shortened to 5-7 minutes

5. Causes of cardiac arrest:

a. secondary cardiac arrest due to arrhythmia, atrioventricular block, IMA, electrocution, drug overdose

b. secondary cardiac arrest due to depression of the respiratory centers, airway obstruction, massive pulmonary embolism, anaphylactic shock, electrolyte disturbances

c. causes of cardiorespiratory arrest are: airway obstruction, breathing problems (acute or chronic), circulatory problems

d. laryngospasm, bronchospasm is considered to be a cause of cardiac arrest

e. pneumothorax, haemothorax, infection, exacerbation of COPD, asthma, pulmonary embolus is considered to be a cause of cardiac arrest

6. Recognition of cardiac arrest:

a. patient is unconscious without a pulse in large vessels

b. skin is pink, warm, patient is breathing

c. pupils are miotic, small

d. absence of carotid pulse and lack of consciousness present in the first 15 seconds of the heart stopping

e. apnea is an early sign

7. Measures in case of a cardiac arrest:

a. listening to the heart or BP measurement are necessary gestures

b. start resuscitation after having an ECG monitor

c. chain of survival means early recognition of cardiac arrest, early CPR, post resuscitation care

d. chain of survival means early recognition of cardiac arrest, early CPR, early defibrillation, post resuscitation care

e. initiate the chain of survival

8. Objectives of cardio-pulmonary resuscitation:

a. first, initiate advanced life support

b. first, initiate basic life support

c. second – advanced life support, resumption of spontaneous cardiac circulation and ventilation

d. in third stage, initiate prolonged life support with cerebral resuscitation & maintenance of vital functions (intensive therapy)

e. BLS includes artificial ventilation, external cardiac massage, defibrillation, recognition of MI and stroke, removal of foreign bodies in case of obstructive airways

9. BLS:

a. cardiac arrest must be suspected in any person found unconscious without any reasons

b. if the person doesn’t respond to any stimuli, you must follow the ABCDE of CPR

c. don’t call for help before starting ABCDE assessing

d. the general population learns the “phone fast/phone first” algorithm

e. all of the above

10. ABCDE approach:

a. stands for airway, breathing, circulation, defibrillation, environment

b. treat life-threatening problems before moving to the next part of assessment

c. call for appropriate help early

d. the aim of the initial treatment is to keep the patient alive

e. ABCDE can be skipped when talking about an in-hospital resuscitation

11. First steps in ABCDE:

a. ensure personal safety

b. if patient is awake, shake well and shout “How are you?”

c. if he responds normally he has a patent airway, is breathing and has brain perfusion

d. Look, Listen and Feel for no more than 1 minute

e. insert an IV cannula as soon as possible

12. ABCDE approach – airway:

a. signs of airway obstruction - paradoxical chest and abdominal movements, use of the accessory muscles of respiration

b. central cyanosis is a late sign of airway obstruction

c. airway obstruction causes hypothermia

d. simple methods of airway clearance are required (head tilt, chin lift, jaw thrust, guedel canulla)

e. provide high-concentration oxygen using a mask with an oxygen reservoir (15 l/min)

13. ABCDE approach – breathing

a. look, listen and feel for the general signs of respiratory distress

b. assess the depth of each breath, the pattern, chest expansion

c. count the respiratory rate (normal respiratory rate is 20-25 breaths/min)

d. percuss the chest, look for any deformity, auscultate the chest

e. use a pocket mask or a bag-mask ventilator to improve oxygenation and ventilation

14. ABCDE approach – circulation:

a. consider hypovolaemia to be the primary cause of shock, until proven otherwise

b. color of the skin, limb temperature, capillary refill time

c. count the pulse rate

d. don’t measure patient’s BP, unnecessary measure

e. insert one or more large IV cannulae and give a rapid fluid challenge if the patient is hypertensive

15. Immediate treatment for acute coronary syndromes include:

a. aspirin 75 mg orally

b. nitroglycerine as sublingual glyceryl trinitrate

c. oxygen to aim a SpO2 of 100%

d. Morphine or fentanyl to avoid sedation

e. aspirin 300 mg orally, nitroglycerine, oxygen to obtain an SpO2 of 94-98%, titrated morphine to avoid respiratory depression

16. ABCDE approach – disability:

a. exclude or treat hypoxia and hypertension

b. check the drug cart for reversible drug-induced causes of depressed consciousness

c. examine the pupils

d. assess using AVPU score or Glasgow Coma Scale

e. measure blood glucose to exclude hyperglycaemia

17. BLS:

a. the presence of pulse and normal breathing continues to be the main sign of cardiac arrest in a non-responsive victim

b. maintaining airway patency and supporting breathing and the circulation

c. the rescuer should only stop CPR if the victim shows signs of regaining consciousness

d. don’t ask for an automated external defibrillator

e. compress the chest to a depth of 5-6 cm and at a rate of 100-120 min

18. BLS:

a. keeping the airway open, look, listen, and feel for normal breathing

b. shout for help

c. open the airway using head tilt and chin lift

d. start chest compression before assessing breathing and circulation

e. all of the above

19. BLS:

a. after 30 compressions open the airway again using head tilt and chin lift

b. seal the airway and give a rescue breath

c. give five breaths and 30 compressions

d. check the victim's mouth and remove any visible obstruction

e. continue with chest compressions and rescue breaths in a ratio of 30:2

20. In-hospital resuscitation – select the incorrect answers:

a. personal safety is not something important, you are in a hospital, nothing dangerous

b. give oxygen, attach monitoring, record vital signs, obtain IV access

c. if the doesn’t respond, turn the patient on to his belly, open airway

d. in case of cervical spine injury, perform head tilt, chin lift to open the airway without manual in-line stabilization of head & neck

e. if no pulse or breathing, start CPR and call for help

21. In-hospital resuscitation:

a. ensure low quality chest compressions of 5-6 cm depth, rate 100-120 compressions/min

b. change about every 2 min or earlier the person that is doing the chest compressions

c. tracheal intubation should be attempted immediately as you discover the patient is not breathing

d. once the patient’s trachea has been intubated, continue chest compressions uninterrupted

e. wait until you have an ECG monitor to for a defibrillator

22. In-hospital resuscitation:

a. when the defibrillator arrives, apply self-adhesive defibrillation electrodes and analyse the rhythm

b. pause for 30 seconds briefly to assess the heart rhythm

c. if rhythm is VF or pulseless VT, charge the defibrillator, restart chest compressions, deliver shock

d. wait for 3-5 minutes between shocks to deliver the next one

e. all of the above

CARDIOPULMONARY AND CEREBRAL RESUSCITATION (2)

23. Advanced life support:

a. heart rhythms associated with cardiac arrest – shockable & non-shockable rhythms

b. shockable rhythms: VT & PEA

c. non-shockable rhythms: PEA & asystole

d. chest compressions, airway management, ventilation, IV access, adrenaline and identification and correction of reversible factors are common in both groups

e. non-shockable rhythms: VF & asystole

24. Shockable rhythms – choose the incorrect answers:

a. first monitored rhythm is VF/VT in 25% of cardiac arrest

b. uninterrupted chest compressions, apply self-adhesive defibrillation/monitoring pads

c. confirm VF/VT from ECG (after 3-5 min of CPR)

d. once the defibrillator is charged, give the shock without any warning

e. restart CPR using a ratio of 30:2, starting with rescue breaths

25. Shockable rhythms:

a. if VF/VT is seen on ECG, charge the defibrillator

b. tell everyone to stand clear, then deliver the shock

c. deliver the next shock within 2 minutes

d. if no signs of life, stop CPR within 5 minutes

e. If VF/VT persists, deliver up to third shocks and give 1 mg adrenaline iv and amiodarone 300 mg iv while performing a further 2 min CPR

26. Adrenaline in shockable rhythms:

a. the first dose of adrenaline is given immediately after delivery of the first shock

b. amiodarone 300 mg may be given after the third shock

c. subsequent doses of adrenaline are given after alternate 2 minute loops of CPR (every 3-5 min ~ 4 min) for as long as cardiac arrest persists

d. lidocaine 1 mg/kg may be used after amiodarone

e. non of the above

27. Precordial thump:

a. has a high success rate for cardioversion of a shockable rhythm

b. there is more success with pulseless VT than with VF

c. use the ulnar edge of a clenched fist, deliver a sharp impact to the lower half of the sternum

d. it can be given in the first 5 minutes after the onset of a shockable rhythm

e. can be used more than 10 times if unsuccessful

28. Non-shockable rhythms:

a. they are PEA and asystole

b. PEA is non-organized cardiac electrical activity in the absence of any palpable pulse

c. asystole is absence of electrical activity on the ECG trace

d. attempts to pace true asystole are successful

e. PEA = pulseless electrical anormality

29. Treatment of PEA/Asystole:

a. start CPR and wait for 2 minutes until delivering first shock

b. give amiodarone 300 mg immediately

c. give adrenaline 1 mg iv as soon as IV acces is achieved, continue CPR 30:2 ratio

d. recheck the rhythm after 2 minutes, organized electrical activity is seen, check for a pulse, if not, continue CPR

e. if VF/VT at rhythm check, administer adrenaline 1 mg IV

30. During CPR:

a. good quality chest compressions between defibrillation attempts, recognizing and treating reversible causes (4 H and 4 T), obtaining a secure airway, a vascular access

b. a bag mask or a supraglottic airway device (LMA) should be used in the absence of personnel skilled in tracheal intubation

c. obtain IV access immediately, flush the drugs with 20-30 ml of glucose 10%

d. if iv access can not be established, consider gaining intraosseous (IO) access

e. maintain low quality, uninterrupted chest compressions

31. Reversible causes of cardiac arrest – select the incorrect answers:

a. H stands for hypoxia, hypovolemia, hyperkalemia/hypokalemia, hyperthermia

b. T stands for tension pneumothorax, cardiac tamponade, toxins, thrombosis

c. toxins can be antagonized with appropriate antidotes (if they are available)

d. hypothermia can be suspected in any drowning incident, use a low reading thermometer

e. all of the above

32. Reversible causes of cardiac arrest:

a. hypoxia can be minimized by ventilating the patient lungs adequately

b. hypovolemia is the most common cause of cardiac arrest and appears due to severe haemorrhage (trauma, drains, occult)

c. hyperkalemia/hypokalemia can be seen by testing the arterial blood gases

d. tension pneumothoras – primary cause of PEA

e. cardiac tamponade is easy to diagnose

33. Airway management & ventilation:

a. airway obstruction is partial or complete

b. the commonest site of airway obstruction in a conscious patient is the pharynx

c. laryngeal obstruction may be caused by oedema from burns, inflammation or anaphylaxis

d. obstructions in the airway below the larynx are the most common

e. all of the above

34. Recognition of airway obstruction – select the incorrect answers:

a. inspiratory stridor - presence of liquid or semisolid foreign material in the upper airways

b. use the Look, Listen and Feel approach

c. expiratory wheeze - laryngeal spasm or obstruction

d. in partial airway obstruction, air entry is diminished and usually noisy

e. complete airway obstruction will be noisy

35. Chocking:

a. severe airway obstruction: patient unable to speak, breathing sounds wheezy, attempts at coughing are silent, patient becomes unconscious

b. conscious patient shows signs of mild airway obstruction - 5 back blows followed by 5 abdominal thrusts

c. unconscious patient with signs of severe airway obstruction – start CPR

d. severe airway obstruction and patient is conscious – 5 sharp back blows followed by 5 abdominal thrusts

e. conscious patient with severe airway obstruction – encourage to cough

36. Opening the airway:

a. head tilt, chin lift

b. jaw thrust

c. in case of cervical spine injury, undertake head tilt, chin lift with jaw thrust without any manual in-line stabilization of the head & neck

d. guedel airway

e. all of the above

37. Artificial ventilation:

a. is started as soon as possible in any patient in whom spontaneous ventilation is inadequate or absent

b. tidal volumes in the region of 6-7 ml/kg will provide adequate oxygenation and ventilation

c. the pocket resuscitation mask or bag-mask ventilation. have a unidirectional valve, which directs the patient’s expired air away from the rescuer.

d. some masks have a port for additional oxygen

e. gastric inflation can be prevented by delivering up to 10 ml/kg of oxygen

38. Laryngeal Mask Airway (LMA):

a. can provide high inflations pressures, avoiding this way the gastric inflation

b. difficult cu use, requires the use of laryngoscope

c. limitations - may cause coughing, laryngospasm, risk of Mendelsohn syndrome

d. maintain chest compressions while inserting the LMA

e. appropriate sizes are 4 for women and 5 for male

39. Tracheal intubation:

a. advantages - maintenance of a patent airway, protected from aspiration of gastric contents or blood

b. disadvantages of TI over bag-mask ventilation - risk of an unrecognized misplaced tube

c. facial burns and trauma to the head – can be easily intubated

d. can be introduced easily, without the need of any training

e. need to confirm the correct placement of tracheal tube during clinical assessment (observation of chest expansion, auscultation of both lungs at the axilary line) or with the use capnograph

PERI-ARREST ARRYTHMIAS

40. Rhythm abnormalities that occur in the peri-arrest period:

a. arrhythmias that lead to cardiac arrest - complications of acute MI, coronary diseases

b. arrhythmias that occur after initial resuscitation from cardiac arrest

c. assess the patient clinically

d. record a 12-lead ECG to identify the rhythm

e. calm the patient and the relatives

41. Adverse features of arrhythmias – choose the incorrect answers:

a. shock – hTA (systoloc BP < 90 mmHg), pallor, sweating, cold extremities, confusion or impared consciousness

b. heart failure - chest pain and/or evidence of myocardial ischaemia

c. extremes of heart rate – extreme tachycardia > 150 bpm, extreme bradycardia below 40 bpm

d. syncope –loss of consciousness because of global reduction in blood flow to the brain

e. pulmonary oedema

42. Tachyarrhythmia:

a. attempt to correct tachyarrythmia with synchronized pacing

b. if cardioversion fails, give amiodarone 300 mg iv over 10-20 min

c. loading dose of amiodarone can be followed by an infusion of 900 mg over 24 h iv

d. synchronized cardioversion can be done on a conscious patient, with no sedation needed

e. broad-complex tachycardia or atrial fibrillation, start with 120-150 J biphasic shock (200 J monophasic)

43. Tachyarrhythmia, patient with no adverse features:

a. if QRS duration is 0,12 sec or more, this is a broad complex tachycardia

b. if QRS duration is 0,12 sec or more, this is a narrow complex tachycardia

c. broad-complex tachycardia - attempt synchronized cardioversion

d. irregular broad-complex tachycardia – more likely to be atrial fibrillation

e. if the patient becomes pulseless, give 1 mg adrenaline immediately

44. Narrow-complex tachycardia

a. regular narrow-complex tachycardias - tachycardia, AVNRT, AVRT due to WPW syndrome and atrial flutter with regular AV conduction

b. sinus tachycardia is an arrhythmia

c. AVNRT – most uncommon type of paroxysmal supraventricular tachycardia, with a HR > 100 bpm

d. atrial flutter with 2:1 conduction produces a tachycardia of about 300 bpm

e. perform synchronized cardioversion for treating it

45. Treatment of regular narrow-complex tachyarrhythmia:

a. pacing

b. synchronized cardioversion

c. adenosine 20 mg as a very rapid iv bolus

d. Valsalva manoeuvre

e. if adenosine is contra-indicated, consider verapamil 2,5-5 mg iv over 2 min

46. Rapid narrow-complex tachycardia with no pulse:

a. the appropriate treatment is immediate synchronized cardioversion

b. irregular narrow-complex tachycardia - synchronized cardioversion, start anticoagulation

c. if the aim is to control the HR, the usual drog of choice is a calcium channel blocker

d. Digoxin may be used in patients with heart failure

e. the longer a patient remains in AF the greater is the likelihood of atrial thrombus developing

47. Brady-arrhythmias:

a. heart rate of < 60 bpm, physiological, cardiac in origin, non-cardiac in origin or drug induced

b. initial treatment is cardiac pacing

c. pharmacological treatment is reserved for those patients in which pacing didn’t work

d. give atropine 500 mcg iv, repeat every 3-5 min up to a total dose of 3 mg

e. pacing is not painful for the patient

CARDIAC ARREST IN SPECIAL CIRCUMSTANCES

48. Potasium disorders:

a. extracellular potassium concentration is between 3,5-5,0 mmol/l

b. when serum pH decreases (acidaemia), serum potassium concentration decreases

c. hyperkalaemia ia caused by increased potassium release from cells or impaired excretion by the kidneys

d. hyperkalaemia = serum potassium > 5,5 mmol/l

e. abnormal erythrocytes or thrombocytosis may cause a high potassium concentration

49. Causes of hyperkalaemia:

a. liver failure

b. renal failure

c. drug – NSAID, beta-blockers, potassium sparing diuretics

d. metabolic alcalosis

e. all of the above

50. ECG changes in hyperkalaemia:

a. first degree heart block (prolonged PR interval)

b. ST segment depression

c. narrow QRS

d. sinus bradycardia

e. cardiac arrest (PEA, VF/VT, asystole)

51. Patient not in cardiac arrest, treatment of hyperkalaemia:

a. if hypovolemic, give fluid to enhance urinary potassium excretion

b. if mild elevation of potassium, remove it with glucose/insuline 10 units short acting or 25 g glucose IV over 15-30 min

c. if moderate elevation, give calcium resonium (15-30 g)

d. severe elevation without ECG changes - shift potassium into cells with glucose/insulin, salbutamol 5 mg nebulised or sodium bicarbonate

e. severe elevation with ECG changes – seek expert help and do nothing else

52. Patient in cardiac arrest, treatment of hyperkalaemia:

a. calcium chloride: 10 ml 10% IV by rapid bolus injection

b. sodium bicarbonate: 100 mmol IV rapid injection

c. sodium bicarbonate: 50 mmol IV rapid injection

d. glucose/insulin: 10 IU short-acting and 25 g glucose IV by rapid injection

e. calcium chloride: 50 ml 10% IV by rapid bolus injection

53. Hypokalaemia:

a. defined as serum potassium below 3,5 mmol/l

b. cause – diarrhea, diuretics, laxatives, steroids, adrenaline, diabetes insipidus, magnesium depletion

c. ECG features are T wave flattening, arrhythmias, ST segment changes

d. can not induce cardiorespiratory arrest

e. in dialysis patients, hypokalaemia never occurs

54. Hypokalaemia – treatment:

a. IM potassium is required

b. the maximum recommended IV infusion rate of potassium is 20 mmol/h

c. ECG monitoring is not essential

d. patients with potassium deficient can also be deficient in magnesium

e. only a, b and d are correct

55. Hypercalcaemia:

a. clinical presentation – confusion, weakness, abdominal pain, hypotension, arrhythmia, cardiac arrest

b. treatment – fluid replacement IM, furosemide, hydrocortisone 300-400 mg iv

c. ECG changes – shortened QRS, AV block, cardiac arrest

d. defined as total serum calcium of > 2,6 mmol/l

e. all of the above

56. Hypocalcaemia:

a. defined as total serum calcium of < 2,1 mmol/l

b. cause – chronic renal failure, calcium channel blocker overdose, rhabdomyolisis

c. presentation – confusion, weakness, respiratory depression

d. treatment - calcium chloride 10% 10-40 ml iv, magnesium sulphate 50% 4-8 mmol iv

e. all of the above

57. Hypermagnesaemia:

a. causes – renal failure or iatrogenic causes

b. presentation – confusion, weakness, respiratory depression, AV block, cardiac arrest

c. treatment - Ca chloride 10% 5-10 ml iv, ventilatory support

d. can induce cardiac arrest

e. only a,b and c are correct

58. Hypomagnesaemia:

a. causes – drugs overdose, overfeeding

b. presentation – agitation, sweating, rapid heart rate, rapid breathing rate

c. treatment - 2 g 50% magnesium sulphate IV over 15 min

d. defined as serum magnesium < 0,6 mmol/l

e. all of the above

59. Poisoning:

a. frequent cause of cardiac arrest

b. a common cause of non-traumatic coma in young people

c. initial treatment - airway obstruction and respiratory arrest secondary to a decreased consciousness is common

d. pacing for life-threatening tachyarrhythmia or cardioversion for bradyarrhythmias

e. drug-induced hypotension is common after self-poisoning and responds to fluid therapy

60. Poisoning - specific treatments:

a. activated charcoal– give it only to intubated patients (in case of carbemazepine, dapsone, phenobarbital, quinine, theophyline overdose)

b. gastric lavage is useful only within five hours after ingesting the poison

c. whole-bowel irrigation can reduce drug absorption

d. IV sodium bicarbonate can be useful in moderate to severe salicylate poisoning

e. haemodialysis for poisoning with methanol, ethylene glycol, salicylates, lithium

61. Opioid poisoning

a. causes respiratory depression, pinpoint pupils and coma + respiratory arrest

b. the opioid antagonist is adrenaline

c. acute withdrawal from opioids causes pulmonary oedema, ventricular arrhythmia, agitation

d. the opioid antagonist is naloxone

e. respiratory arrest is usually secondary to a cardiac arrest

62. Benzodiazepines poisoning:

a. can cause euphoria, sweating, cardiac depression

b. there is no specific antagonist for benzodiazepines

c. flumazenil can be used even if there is a risk of seizures

d. flumazenil is not used in comatose patients

e. the antagonist for benzodiazepines is flumazenil (anexate)

63. Tricyclic antidepressants poisoning:

a. is translated into hypertension, seizures, coma, arrhythmias

b. can produce a broad complex tachycardia (VT)

c. include mydriasis, fever, dry skin, delirium, tachycardia, ileus, urinary retention

d. the treatment is sodium bicarbonate

e. all of the above

64. Local anaesthetic toxicity:

a. the patient is agitated, with altered consciousness, with/without tonico-clonic convulsions, sinus bradycardia, asystole, VT

b. can be potentiated in pregnancy, extremes of age or hypoxaemia

c. it can appear after general anesthesia

d. treatment IV 20% lipid emulsion in addition to ALS

e. only a, b are correct

65. Cocaine toxicity:

a. may cause haemoragic shock, obstructive shock, septic shock

b. it induces agitation, symptomatic tachycardia, HTA, hyperthermia and myocardial ischaemia with angina

c. there is no drug treatment for cocaine toxicity

d. nitrates can be used as a first-line therapy

e. all the answers are correct

66. Hypothermia:

a. the body core temperature is below 35°C

b. can be mild (32-35°C), moderate (28-32°C) and severe (below 28°C)

c. can develop during exposure to hot environments, et or windy, immobilized people or following immersion in hot water

d. the risk is increased in case of drug or alcohol ingestion, exhaustion, illness, injury or neglect

e. the core temperature measured in the lower third of the oesophagus correlates well with the temperature of the heart

67. Treatment of hypothermia:

a. ventilate the patient with high concentration O2, warmed and humidified

b. the victim is pulseless, declare the patient dead

c. give adrenaline even regardless of the patient’s temperature

d. rewarming with heated IV fluids and warm humidified gases

e. ECG is not important in a hypothermic patient

68. Hyperthermia:

a. it may be exogenous, caused by environment or secondary to endogenous heat production

b. malignant hyperthermia = rare disorder of skeletal muscle calcium homeostasis

c. start cooling the patient to get to a the core temperature aprox 39°C

d. electrolyte abnormalities are of no interest in hyperthermia

e. cooling techniques: cool drinks, fanning, spraying tepid water, iced packs, immersion in cold water, cold IV fluids, IV cooling catheters, extra corporeal circuits

69. Drowning:

a. common cause of accidental death

b. appears due to hypervolemia

c. for drowning to occur, usually at least the face and airway must be immersed

d. if you see a drowned person, jump immediately into the water and try to save him/her

e. treatment implies 4 phases: aquatic rescue, BLS, ALS, post-resuscitation care

70. Treatment of drowning:

a. if the victim is in deep water, open airway and start in-water rescue breathing

b. if the victim is in deep water, start chest compressions

c. CPR with a 30:2 ratio chest compressions and ventilations

d. if the victim’s temperature < 30 degrees, limit defibrillation attempts to 3 and withhold IV drugs until temperature increases above 30°

e. always perform tracheal intubation to drowned patients

71. Asthma:

a. causes of cardiac arrest from asthma: severe bronchospasm, hypoxia, stimulant drugs or electrolyte abnormalities

b. tension pneumothorax can cause cardiac arrest in an asthmatic patient

c. ABCD approach does not apply to cardiac arrest induced by asthma

d. give high concentrations of O2, salbutamol 5 mg nebulised, with repeted doses if necessary

e. treatment includes IM corticosteroids

72. Asthma treatment for preventing cardiac arrest:

a. ipratropium 0,5 mg every 4-6 h produces bronchodilatation

b. magnesium sulphate can not be given nebulised

c. first line treatment for acute severe status asthmaticus include nebulised bronchodilatators

d. aminophyline has a loading dose of 6 mg/kg over 20-30 minutes

e. don’t give iv fluids to asthmatic patients even if they are hypovolemic

73. Anaphylaxis inducing cardiac arrest:

a. patient who is exposed to a trigger (allergen) develops a sudden illness with rapidly developing life-threatening airway and/or breathing and/or circulation problems

b. airway problems – airway swelling, stridor, wheeze, shortness of breath, hypoxia

c. circulatory problems – bradycardia, hypertension, cardiac arrest

d. skin changes - often the first feature

e. all of the above

74. Cardiac arrest & treatment of anaphylaxis:

a. airway & ventilation interventions (tracheal intubation, bag-mask ventilation, O2)

b. adrenaline is not used for treating anaphylaxis

c. adrenaline should not be given IM, only IV

d. rapid IV fluid challenge (20 ml kg) in a child or 500–1000 ml in an adult) and monitor the response

e. antihistamines, steroids, bronchodilators & cardiac drugs are of no importance in this resuscitation scenario

75. Cardiac arrest associated with pregnancy:

a. causes – cardiac arrest, pulmonary oedema, hypotensive disorders of pregnancy, sepsis, haemorrhage

b. ectopic pregnancy and pulmonary embolism are some of the causes of cardiac arrest in pregnancy

c. place the patient in the left lateral position or manually and gently displace the uterus to the left

d. give high-flow oxygen guided by pulse oximetry

e. all of the above

76. In case of haemorrhage in pregnancy, consider the following:

a. fluid resuscitation

b. oxytocin and prostaglandin analogues to correct uterine atony

c. always perform hysterectomy

d. aortic cross-clamping in catastrophic haemorrhage

e. uterine compression sutures

77. In case of cardiovascular disease in pregnancy:

a. pregnant women may develop an acute coronary syndrome

b. pregnant patients can have atypical features such as epigastric pain and vomiting

c. percutaneous coronary intervention is the reperfusion strategy of choice for ST-elevation myocardial infarction in pregnancy

d. thrombolysis should never be considered

e. risk factors – malnutrition, young age, smoking, diabetes, hypotension

78. Electrocution:

a. electric shock injuries are caused by the direct effects on cell membranes and vascular smooth muscle

b. lightning strikes deliver as much as 500 kV over a few milliseconds

c. contact with AC may cause tetanic contraction of skeletal muscle

d. in lightning strike, the patient may develop hypertension, tachycardia, non-specific ECG changes, myocardial necrosis

e. all of the above

79. Resuscitation in lightning strike scenario:

a. airway management may be difficult, with the need of tracheal intubation

b. VF is the commonest initial arrhythmia after high-voltage AC shock – treat with adrenaline

c. vigorous fluid therapy is required if there is significant tissue destruction

d. dilated or non-reactive pupils can be used as a prognostic sign

e. there is no specific therapy for electrical injury

SHOCK

80. Shock:

a. most widely accepted classification of shock is made by Marks & Spencer

b. clinical syndrome characterized by acute global tissue hypoperfusion and inadequate needs of tissue perfusion

c. 4 major types: hypovolemic, cardiogenic, extracardiac obstructive shock and distribution shock

d. decreased flow of tissular oxygenated blood oxygen below the critical level needed to carry out normal cellular metabolic processes

e. only a, b & c are correct

81. Shock – tissue hypoxia:

a. is due to hypoperfusion, the essential pathophysiological element

b. during shock, oxygen consumption is increased for the tissue needs and it generates hypoxia and other cellular metabolic disorders

c. reducing O2 consumption can be determined by low oxygen supplies, reduced flow, flow maldistribution, low tissue oxygen extraction (septic shock)

d. shock can be reduced to an imbalance between systemic oxygen supply (DO2) and oxygen consumption at the tissue level (VO2)

e. all of the above

82. Shock pathophysiology:

a. septic shock is characterized by low indexed systemic vascular resistance, tendency to hypotension and inadequate blood flow to assure the tissue needs

b. inadequate tissue perfusion with decreased or increased flow leads to tissue hypoxia

c. hypervolemia occurs frequently in the presence of massive peripheral edema

d. cellular injury is given by the deficit supply in energy, inability to use supplied nutrients, or failure to produce energy from them

e. only a & b are correct

83. Hypovolemic shock:

a. most frequently encountered

b. characterized by tissue hypoperfusion, relative/absolute reduction of circulating volume, decreased venous return and preload, decreased cardiac output, increased HR and peripheral vascular resistance

c. forms: hemorrhagic, traumatic, by loss of water and electrolytes, in burns

d. it appears only in children patients

e. d is incorrect

84. Hypovolemic shock – etiopathogenesis:

a. the reduction of volume expansion with more than 30% is critical for survival

b. activation of the sympathetic nervous system causes peripheral arteriolar dilatation, decreased HR, stimulation of the medulosuprarenal, activation of the rennin-angiotensin system

c. metabolic changes triggered by the release of catecholamines will release glucose/products of glycolysis in the interstitial compartment

d. the release of endogenous opioids increases sympathetic response in the central nervous centers

e. the cause of acute renal failure is renal hyperperfusion

85. Hypovolemic shock – clinical presentation:

a. hypertension, tachycardia, polipnea, old and cyanotic extremities, with no capillary pulse, oliguria

b. central venous pressure is low, indicating reduced preload

c. hyperventilation occurs late

d. progressively altered consciousness (dizziness, confusion)

e. visceral pain occurs late and mainly interested in kidney function

86. Treatment of hypovolemic shock:

a. etiologic treatment

b. assessment of respiratory function and appropriate treatment

c. circulating blood volume recovery is not a priority of the hemodynamic treatment

d. treatment should always be started with bood

e. treatment begins with saline electrolyte solutions or macromolecular solutions

87. Treatment of hypovolemic shock – solutions used to restore blood volume:

a. isotonic saline solutions (normal saline , Ringer's solution, Hartman) or hypertonic

b. 5% glucose

c. macromolecular solutions - gelatin derivatives and hydroxyethyl starch (HES)

d. products derived from blood - albumin 5%

e. red cell packs to restore oxygen transport

88. Treatment of hypovolemic shock:

a. first colloidal solution to increase blood volume, followed by infusion of crystalloid solutions for volume restoration

b. insert one or more high-lumen cannulas

c. colloids – saline solution, Hartmann’s, Ringer lactate

d. colloids - blood , stable plasma protein solution, fresh frozen plasma, dextran, gelatine (Haemacel) and hydroxyethyl starch (HES)

e. whole blood can be used at any time

89. Treatment of hypovolemic shock:

a. fresh frozen plasma - useful when hypovolemia is associated with altered coagulation

b. Dextran 70 - exercise a colloid osmotic pressure higher than plasma

c. Haemacel - disavantage: cause of bleeding & complications

d. Hydroxyethyl starch (HES) - does not cause allergic reactions

e. crystalloid solutions – used for restoring the interstitial fluid

90. Treatment of hypovolemic shock – drugs:

a. administration of vasoactive substances is always necessary - noradrenaline

b. if volume deficiency is associated with reduced myocardial reserve – administer cardiotonics

c. in case of renal failure – furosemide or manitol

d. in case of disseminated intravascular coagulation, use whole blood

e. heparin can be used at any time

91. Cardiogenic shock – definition:

a. inadequate tissue perfusion results from cardiac dysfunction, most often systolic

b. the heart suddenly can't pump enough blood to meet the body's needs

c. decreased cardiac output and evidence of tissue hypoxia in the presence of adequate intravascular volume

d. clinically - sustained hypotension, reduced cardiac index, elevated pulmonary capillary wedge pressure

e. only a, c and d are correct

92. Cardiogenic shock – pathophysiology:

a. low cardiac output state secondary to extensive left ventricular infarction, development of a mechanical defect or right ventricular infarction

b. disorders that lead to cardiogenic shock - myocardial infarction, acute myocarditis, sustained arrhythmia, severe valvular dysfunction, decompensation of end-stage cardiomyopathy

c. tissue hyperperfusion, with consequent cellular hypoxia, causes accumulation of lactic acid and intracellular alkalosis

d. shift to the right for the left ventricular end-systolic pressure-volume curve

e. the stroke volume is decreased

93. Cardiogenic shock – systemic effects:

a. the pump failure increases ventricular diastolic pressures

b. decrease in myocardial oxygen requirements

c. increased cardiac output, with tissue hypoperfusion

d. renal fluid retention

e. pulmonary venous congestion and hypoxemia

94. Cardiogenic shock – etiology:

a. systolic & diastolic dysfunction

b. cardiac arrhythmias

c. coronary artery disease

d. valvular dysfunction

e. asthma

95. Cardiogenic shock – etiology:

a. complications of acute MI can result in cardiogenic shock

b. use of beta blockers and angiotensin-converting enzyme (ACE) inhibitors in acute coronary syndromes must be carefully timed and monitored

c. is more likely to be associated with posterior MI

d. subventricular tachyarrhythmias are often associated with cardiogenic shock

e. all of the above

96. Cardiogenic shock – clinical presentation:

a. systemic hypertension, defined as systolic blood pressure below 90 mmHg

b. low cardiac output, manifested by sinus tachycardia, low urine output and cool extremities

c. heavy substernal chest pain, may radiate to the left arm or the neck, atypical, burning, sharp

d. nausea, vomiting, and sweating

e. diaphoresis, dyspnea, presyncope /syncope, palpitations, anxiety

97. Cardiogenic shock – physical examination:

a. ashen or cyanotic and have cool skin and mottled extremities

b. patients show signs of hyperperfusion

c. systolic murmur is generally heard in patients with acute mitral regurgitation or ventricular septal rupture

d. the pulse pressure may be low, and patients are usually tachycardic

e. all of the above

98. Cardiogenic shock – laboratory studies:

a. FBC count to exclude anemia

b. troponin levels peak at 14 hours after acute MI, peak again several days later and remain abnormal for 10 days

c. arterial blood gases – not important in this case

d. Brain natriuretic peptide – indicator of sepsis

e. lactate - indicator of shock

99. Cardiogenic shock –drugs:

a. aspirin – reduces the pain that the patient is feeling

b. thrombolytics - help dissolve a blood clot that's blocking blood flow to the heart

c. clopidogrel - prevent new clots from forming

d. dopamine/epinephrine – of no use in this case

e. heparine for increasing INR

100. Septic shock – risk factors:

a. diabetes, genitourinary diseases, biliary diseases, intenstinal diseases

b. immunosuppressive diseases are of no interest in septic shock

c. leukemia, lymphoma

d. recent infection

e. use of antibiotics

101. Septic shock – symptoms:

a. cool, pale extremities, with high or very low body temperature

b. low BP, low or absent urine output

c. slow HR

d. agitation, lethargy, confusion

e. dyspnea

102. Septic shock – test and diagnosis:

a. blood and urine test are necessary to discover the evidence of infection

b. blood test are used to discover low blood oxygen levels, disturbances in body's acid-base balance

c. simple chest x-ray may show signs of chest infection (pneumonia, pulmonary edema)

d. CT is not important

e. MRI - helpful in identifying soft tissue infections

103. Septic shock – treatment:

a. oxygenotherapy

b. drugs – inotrops

c. antibiotics – given only after identification of infectious agent

d. vasopressors – to increase blood pressure

e. fluid therapy

104. Anaphylactic shock:

a. signs - rapid, weak pulse, a skin rash, and nausea and vomiting

b. common triggers include foods, medications, insect venom, latex, etc

c. broncho-constriction & dizziness

d. in case of anaphylactic shock, do mouth to mouth ventilation

e. for some people, aerobic may trigger anaphylactic shock

105. Anaphylactic shock – treatment:

a. adrenaline (epinephrine)

b. oxygen

c. packed red cells & fresh frozen plasma

d. antihistamines and cortisone to reduce inflammation

e. beta-agonists (albuterol, salbutamol)

106. Neurogenic shock:

a. main mechanism – acute disfunction of the sympathetic nervous system

b. hypertension

c. digoxine is used as a first line treatment

d. treatment includes epinephrine, norepinephrine

e. iv fluids

107. Extracardiac obstructive shock - produced by:

a. pulmonary embolism, gas embolism

b. tamponade secondary to trauma, myocardial rupture

c. during anticoagulant therapy

d. polycythemia vera

e. malignant hypertermia

108. Distributive shock – appears after:

a. sepsis, septic shock

b. neurogenic shock

c. hypovolemic shock

d. overdose with benzodiazepines

e. anaphylaxis

INTENSIVE CARE IN RESPIRATORY FAILURE

109. Respiratory failure refers to:

a. preserved pulmonary gas exchange

b. the patient is unable to maintain blood gases homeostasis

c. arterial hypoxemia

d. global alveolar hypoventilation, lung diffusion disorder, altered ventilation perfusion ratio, development of intrapulmonary right-left shunt

e. all of the above

110. Global alveolar hypoventilation – main causes:

a. poisoning with barbiturates, narcotics, overdose of anesthetics

b. foreign bodies, spasm, edema

c. multiple rib fractures, pneumothorax

d. pneumonia

e. only a, b and c are correct

111. Respiratory failure – classification:

a. there are 4 types of RF: hypoxic RF, hypercapnic RF, ventilator pump RF and mixed RF

b. hypoxemic RF - eliminating CO2 is normal or even increased

c. type II RF - hypoxemia associated with hypercapnia

d. mixed RF – low PaO2, high PaCO2

e. ventilator pump failure – result is hypocapnia

112. Hypoxemic acute respiratory failure (HARF):

a. defined as severe hypoxemia refractory to oxygen therapy

b. determining focal or diffuse alveolo-capillary membrane lesions, with effects on pulmonary gas exchange

c. decreased respiratory labor & increase in energy + O2 consumption

d. feeling of shortness of breath and muscle fatigue

e. emergence of intrapulmonary right-left shunt

113. Hypoxemic acute respiratory failure – diagnose:

a. dyspnea, tachypnea, excessive respiratory labor

b. favored by cardiac disease, diabetes, dysmenorrheal syndrome

c. X-ray shows “padded“ lung

d. ABG’s – characteristic is hypoxia

e. echocardiography – invasive method

114. Acute hypercapnic respiratory failure (AHRF):

a. is an acute, new RF

b. is evolving in the context of COPD, chronic interstitial lung pathology, extrinsic restrictive chronic pathology

c. COPD is one of the rarest conditions that will develop in AHRF

d. COPD – most common is chronic bronchitis, in male patients, usually past 45 years, heavy smokers

e. COPD result in decreased resistance to airflow in the airways

115. Chronic obstructive pulmonary disease:

a. pathological changes - inflammatory edema and glandular mucosal cell hypertrophy with mucus hypersecretion

b. CO2 elimination is affected late and is manifested by hypercapnia

c. with hypercapnia, is favored the occurrence of hypoxemia

d. chronic hypercapnia is translated in changes in respiratory management, with respiratory acidosis

e. can appear pulmonary hypertension

116. COPD:

a. changes in fluid and electrolyte homeostasis - edema fluid retention

b. pink puffer = patient with emphysema

c. emphysema – second major pathological entity within COPD

d. blue bloater = patient with asthma

e. asthma is not a chronic lung pathology

117. Asthma:

a. bronchiolar smooth muscle spasm

b. bronchoconstriction can be induced by histamine release

c. decreased flow resistance in the airways, especially in expiration

d. during asthma attack, tachypnea appers

e. asthma attack can be treated with bronhodilatators (salbutamol)

118. Diagnose of AHRF:

a. agitation, confusion, coma, sweating

b. dyspnea, tachypnea, see-saw breathing

c. respiratory arrest

d. respiratory alcalosis, metabolic alcalosis

e. arrhythmias, due to severe hypoxemia/hypercapnia

119. Respiratory failure – clinical presentation:

a. respiratory signs - patient experience irritability, euphoria, is agitated, aggressive

b. respiratory rate of 30 breaths per minute or less than 12

c. tachycardia, arrhythmia, hypertension and paradoxical pulse

d. cyanosis is a late sign, hard to see usually

e. inspiratory dyspnea, hypoxemia and hypercapnia

120. Treatment of respiratory failure:

a. desobstruct the gastric-way, control/assist the ventilation, oxygenotherapy

b. desobstructing the airway – supraglottic is very difficult to achieve

c. Heimlich maneuver – can be done on conscious and unconscious patients

d. desostructing the airway means only tracheal intubation

e. oro-nasopharyngeal desobstruction – head tilt, chin lift, jaw thrust, guedel pipes, Robertazzi tubes

121. Tracheal intubation indications:

a. usually done for general anesthesia, but can be used in intensive care for treating respiratory failure as well

b. for securing the airways in case of pulmonary aspiration risk

c. for feeding the comatose patient

d. TI is used only for mechanical ventilation

e. all of the above

122. Traheostomy – choose the incorrect answers:

a. easy to be done, without complications

b. done for obstruction of the lower upper airway when intubation is impossible

c. done in case of apnea in suspected cervical spine injury

d. compared to tracheal intubation has a better tolerance by the patient, suction of the secretions and can ease communication with the patient

e. percutaneus tracheostomy can be performed in the intensive care unit at the bedside

123. Treatment of acute respiratory failure in ICU:

a. main purpose – correct the hypertension

b. oxygen therapy produces an increase in the concentration of O2 in inspired air (FiO2)

c. indication of oxygenotherapy - patients with hypoxemia secondary to alveolar hypoxia

d. side effect of O2 administration – atelectasis, O2 toxicity, retrolentar fibrosis

e. O2 toxicity is related to the inspired anesthetic gases that the patient receive during oxygen therapy

124. Treatment of acute respiratory failure – drugs:

a. bronchodilators – methylprednisolone, ipratropium bromide

b. the usual antibiotics used are ampicillin group, tetracycline, sulphonamides

c. infection with Gram-positive cocci use a third-generation cephalosporins (cefotaxime, ceftriaxone)

d. the most effective and least toxic substances are the β2-agonists

e. theophylline and aminophylline (Miofilin) are second line therapy substances

125. Acute respiratory failure and chest trauma:

a. appears because of hyperventilation produced by abnormal mechanical alteration of the thoracic wall & pain

b. hypoventilation produced by rib fractures

c. inadequate expansion of the lungs due to pleural and mediastinal fluid

d. obstruction of the airway through foreign body

e. it appears rarely

126. Status asthmaticus:

a. bronchic asthma crisis, with an unusual severity, resistant to conventional treatment, with a duratio of 30-60 min

b. obstruction of the airway associated with hyperinflation of the lungs, produced by spasm, mucus, inflamatory edema

c. clinical presentation – dispneea, high breathing rate, tachycardia, hypotension, colaps, hypocapnia/normocapnia

d. oxygenotherapy is not indicated in status asthmaticus

e. the first therapeutical measure is to rise the SaO2

127. Status asthmaticus – drugs:

a. the preferred drug is adrenalin, 0,3 - 0,5 mg

b. salbutamol can be used IV or as an inhalator

c. aminofilin should not be used in status asthmaticus

d. ipratropium bromide has a rapid onset, therefore can be used in status asthmaticus

e. IV hemisuccinat hidrocortizone, metilprednisolon, dexametazon, betametazon

128. ARDS:

a. interstitial infiltrative changes and/or alveolar changes that interest the whole lung, which determines an acute respiratory failure with severe hypoxemia and hypocapnia

b. in the permeability of the capillary endotelium and in the integrity of the alveolar epitelium, allowing the creation of an edema rich in proteins in the interstitial and alveolar space of the lungs

c. most rare causes are sepsis, shock, trauma

d. late signs – dispnea, tahipnea, hypoxia, interstitial edema, vesicular murmur, hypoxia + hypocapnia and respiratory alkalosis

e. diagnosis – chronic debut, PaO2 and FiO2 ratio is < 200

129. ARDS – treatment:

a. there are drug treatments that can cure 100% ARDS

b. O2 suppliment using concentrations of 50-60% or mechanical ventilation

c. reduce oxygen comsumption and putting the respiratory muscles into rest

d. diuretics (furosemid, etacrinic acid) should be administered late

e. in normo-proteinic patients, it’s indicated to raise the oncotic pressure with human albumin

1. a, c, d 2. a, b 3. c, d 4. d 5. b, c, d, e 6. a, d 7. d, e 8. b, c, d, e 9. a, b, d 10. b, c, d 11. a, c, e 12. a, b, e 13. a, b, d, e 14. a, c, 15. b, e 16. a, b, c, d 17. b, c, e 18. a, b, c, 19. a, b, d, e 20. a, b, c, d 21. b, d 22. a, c 23. a, c, d 24. c, d, e 25. a, b, e 26. b, c 27. b, c 28. a, c, 29. c, d 30. a, b, d 31. b, c, d 32. a, c, d 33. a, c 34. a, c, e 35. a, d 36. a, b, d 37. a, b, c, d 38. d, e 39. a, b, e 40. a, b, c, d, e 41. b, e 42. b, c, e 43. a, c, d 44. a, c, e

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89. a, b, d, e 90. b, c, 91. a, b, c, d 92. a, b, d, e 93. a, d, e 94. a, b, c, d 95. a, b, c 96. b, c, d, e 97. a, c, d 98. a, b, e 99. b, c, e 100. a, c, d 101. a, b, d, e 102. a, b, c, e 103. a, d, e 104. a, b, c 105. a, b, d, e 106. a, d, e 107. a, b, c, d 108. a, b, d, e 109. b, c, d 110. a, b, c, d 111. b, d 112. a, b, d, e 113. a, c 114. b, d 115. a, c, d, e 116. a, b, c 117. a, b, d, e 118. a, b, c, e 119. b, c, d, e 120. c, e 121. a, b 122. a, b 123. b, c, d 124. b, d, e 125. b, c, d 126. a, b, c, e 127. a, b, e 128. a, b 129. b, c