Critical Care 🏥

A 40-year-old individual is brought into the Emergency Department after a tumble from a height. He confesses to consuming an unknown amount of paracetamol and citalopram. He shares that he landed on his thoracic region and is experiencing discomfort while breathing. On examination, multiple contusions are observed on his chest. His temperature reads 37.5°C, pulse rate stands at 93 beats/minute, blood pressure at 138/80 mmHg, and respiratory rate at 22 breaths/minute. His arterial blood gas results are as follows:

pH 7.29 (7.35-7.45)

Bicarbonate 24 mmol/L (22-26)

pCO2 6.7 kPa (4.7-6.0)

PaO2: 10 kPa (>10.6)

Which condition does these abnormalities indicate?

A 67-year-old man was taken to the hospital after experiencing a week’s worth of breathing difficulties and coughing. Upon admission, his temperature is 36.6°C, heart rate 92 beats/minute, respiratory rate 26 breaths/minute, and blood pressure is 82/61 mmHg. His medical history reveals chronic obstructive pulmonary disease (COPD). A chest X-ray was performed and shows left upper lobe opacity. His blood results are as follows:

Haemoglobin 133 g/L (130-180)

White cell count 18 x 109/L (4-11)

Platelets 451 x 10″/L (150-400)

Serum urea 12 mmol/L (20-7)

Serum creatinine 338 μmol/L (70-150)

eGFR 32 mL/min

He was put on intravenous fluids and antibiotics. However, he passes away a day after being admitted to the intensive care unit. The doctor completes only part 1(a) and part 2 of the death certificate. What likely fills in part 1(a) of the death certificate?

A 23-year-old individual arrives at the Emergency Department struggling with breathlessness. With halting sentences, he reveals that he’s been unsuccessfully managing his asthma with inhalers. He seems mildly agitated, with supraclavicular retractions evident. His lips and fingernails display a bluish hue. Senior medical assistance is enlisted, and he’s promptly administered the appropriate nebulizers, oxygen, and intravenous corticosteroids. After a local anaesthetic is applied, an arterial blood gas sample is collected an hour post active treatment. The test results are as follows:

pH 7.22 (7.35-7.45)

PaO2: 10 kPa (10-14 kPa)

PaCO2: 6.3 kPa (4.7-6.0)

Base excess: -4 mmol/L mmol/L (±2)

What should be the next course of action?

A 66-year-old gentleman underwent an elective transurethral resection of the prostate just a few hours prior. Post procedure, he exhibits signs of confusion and has a seizure. His medical history includes type 2 diabetes. His laboratory results are as follows:

Sodium 119 mmol/L (135-145)

Potassium 6.1 mmol/L (3.5-5)

Urea 5 mmol/L (2.0-7)

Creatinine 85 μmol/L (70-150)

eGFR >90 mL/min

Glucose 7.0 mmol/L

Afterward, he is administered intravenous 3% sodium chloride. A 12-lead ECG is performed which indicates sinus rhythm without hyperkalemic changes. Which among the following is the most suitable next step in managing this patient’s condition?

A 41-year-old woman is admitted to the emergency room, experiencing an abrupt headache and weakness in her left arm, her left leg, and the left side of her face. She doesn’t have any known medical conditions and isn’t on any medication at present. Her vital signs are as follows: blood pressure of 200/120 mmHg, pulse rate of 101 beats per minute, a respiratory rate of 14 breaths per minute, and a temperature of 36.8°C. Her airway has been secured and oxygen is being supplied to her. A head CT scan is conducted.

What is the best initial course of action?

A 36-year-old male is rushed to the Emergency Department due to a vehicular accident. His injuries are consistent with blunt force trauma to his chest, but no penetrating wounds are observed. Initially, his observations are normal with a Glasgow Coma Scale of 13. However, after an hour, his Glasgow Coma Scale decreases to 9. His latest observations include a respiratory rate of 4 breaths per minute, a heart rate of 120 beats per minute, oxygen saturation at 92%, and blood pressure of 100/60 mmHg. What should be the most appropriate INITIAL action?

A 37-year-old man presents to the Emergency Department complaining of a severe headache accompanied by vomiting that began yesterday. The headache was triggered while he was weightlifting at the gym. His symptoms include neck stiffness and photophobia, and he has a Glasgow Coma Scale of 12/15. He does not have a previous medical history. On examination, he exhibits right-sided hemiparesis, and his pupils are equal and responsive. A CT scan reveals the following:

His vitals are as follows: blood pressure of 120/80 and a heart rate of 100 beats per minute. What is the most appropriate course of treatment?

A 77-year-old woman presents to the Emergency Department experiencing intense interscapular pain that started 12 hours prior. The pain came on suddenly, and she has been struggling to breathe deeply. Since the onset of the pain, she has felt lightheaded. Her vitals are as follows: temperature 36.5°C, heart rate 100 beats/minute, blood pressure 90/62 mmHg, respiratory rate 26 breaths/minute, and oxygen saturation 98%. An ECG is immediately performed, which reveals normal sinus tachycardia. What is the SINGLE most suitable diagnostic test?

A 37 year old man undergoes a laparoscopic cholecystectomy under general anesthesia following an acute cholecystitis episode six days earlier. The surgery proceeds without issues. However, two hours post-surgery, the patient starts experiencing shortness of breath in the recovery room. His vitals are as follows: respiratory rate 25 breaths/minute, heart rate 122 beats/minute, oxygen saturation 96%, temperature 40°C, and blood pressure 87/50 mmHg. What is the SINGLE most likely diagnosis?

A 70 year old man suffering from an acute exacerbation of COPD is in the resuscitation room. His oxygen saturations are at 80%, and non-invasive ventilation (NIV) has been initiated. Despite these measures, his condition continues to worsen, and he’s unable to tolerate NIV. His Glasgow Coma Scale has dropped to 8/15. What is the SINGLE most suitable next step in managing this patient?

A 27 year old woman arrives at the Emergency Department following a residential fire incident. She displays significant bruising, swelling, and full-thickness circumferential burns on her left arm. Upon examination, her left radial pulse is undetectable and she reports numbness in her left fingers. Despite being administered intravenous morphine, she remains in severe pain. What is the SINGLE most appropriate immediate action?

A 34 year old man is involved in a motorbike accident where he is struck by a car traveling at 50 miles/hour. The collision results in a head injury. He is taken to the resuscitation area, where his Glasgow Coma Scale is recorded as 8. There is a clear fluid discharge coming from his left ear, and considerable bruising is seen on his left temporal region and behind the left ear. What could be the possible cause of the discharge?

A 33 year old man comes in with a sudden onset headache at the back of his head, which started 8 hours ago. He characterizes it as the most intense pain he’s ever experienced. He also complains of being sensitive to light, has a stiff neck, and has vomited three times since the onset of the headache. Upon examination, there are no neurological deficits. His vitals include a blood pressure of 130/80 mmHg, a heart rate of 90 beats/minute, and a respiratory rate of 16 breaths/minute. A CT scan of his head was performed, revealing no signs of intracranial bleeding. What should be the next step in managing this patient?

A 34 year old man shows up with a sudden and severe headache in the back of his head which initiated 9 hours back. He calls it the worst pain he’s ever endured. He is light-sensitive, his neck is stiff, and since the headache began, he has vomited three times. Upon examination, no neurological deficits are found. His blood pressure reads 130/80 mmHg, his heart rate is 90 beats/minute, and he’s breathing at a rate of 16 breaths/minute. A CT head scan was done, but no signs of an intracranial bleed were detected. What’s the next most suitable course of action?

A 30-year-old male is rushed into the Emergency Department by paramedics due to a decrease in consciousness level. He was discovered in his home by a friend, unconscious, with pills of 3,4-methylenedioxy-N-methylamphetamine (MDMA) on his person. His limbs are stiff, his pupils are wide, and he is both agitated and perspiring heavily. His vital signs are as follows: heart rate at 105 beats/minute, respiratory rate at 22 breaths/minute, blood pressure at 140/70 mmHg, and a temperature of 40.8°C. Blood tests reveal a venous lactate level of 4.1 mmol/L (normal range: 0.6-2.4). He has been placed on a mechanical ventilator. What is the SINGLE most suitable drug to administer?

A 79 year old gentleman is brought into the Emergency Department demonstrating an altered state of consciousness, fever, and general distress. His wife reports that he had a typical cold infection just a week ago. His temperature measures 38.5°C, his pulse is 95 bpm, BP is 120/80 mmHg, respiratory rate is 20 breaths/minute and oxygen saturation levels sit at 95% while breathing air. Upon examination, his speech is incoherent, he is capable of briefly opening his eyes upon verbal command and he retracts his hand in response to pain. He also presents with a non-blanching rash on his chest. Positive Kernig’s and Brudzinski’s signs are observed and the patient exhibits neck stiffness. What is this patient’s Glasgow Coma Scale score?

A 35 year old woman undergoes a significant haemorrhage during her caesarean section delivery. She receives 16 units of packed red blood cells, 4 units of platelets and 8 units of plasma during the procedure and also undergoes a hysterectomy. Which electrolyte imbalance can arise from the blood transfusion?

A 65 year old man has just undergone an open aortic valve replacement surgery. In the recovery room a few hours later, his blood pressure falls to 77/30 mmHg, a significant drop from his blood pressure of 120/70 mmHg recorded an hour post-operation. His current pulse rate is 120 beats/minute and he has a cardiac output of 3 L/min. His pulmonary capillary wedge pressure measures at 22 mmHg, significantly higher than the normal range of 6-12 mmHg. What is the SINGLE most probable cause?

A 79 year old man was brought to the hospital with a week-long history of breathlessness, cough, and fever. His past medical history includes a pulmonary embolism two years ago, a heart attack at age 71, and a diagnosis of COPD at age 62. He has been on immunosuppressive therapy following a kidney transplant 22 years ago. A chest X-ray conducted upon his hospitalization reveals multiple patchy opacities. He is subsequently initiated on intravenous antibiotics. However, his condition continues to worsen, becoming less responsive and hypotensive over the next day. He passes away two days after being admitted to the intensive care unit. What is the most suitable condition to be recorded in part 1(a) of the death certificate?

A 23 year old woman with a BMI of 10 kg/m^2 who persistently refuses to eat has been admitted to the medical ward for feeding via a nasogastric tube. Which electrolyte imbalance should be anticipated in this case?

A 35 year old patient has been in the Intensive Care Unit for the past three days due to COVID-19 pneumonitis. He has been intubated and ventilated, with his FiO2 set at 0.1. An arterial blood gas assessment and a chest X-ray have been performed, and the results are as follows:

pH 7.22 (7.35 -7.45)

PaO2 6.8 kPa (>10.6)

PCO2 7.9 kPa (4.7-6.0)

Bicarbonate 22 mmol/L (22 – 26)

Base excess -2 (-2 to +2)

The chest X-ray is displayed below:

What should be the next step in managing this patient?

A 28-year-old woman is admitted to the hospital after a suicide attempt involving amitriptyline. She is unconscious and shows dilated pupils. An ECG reveals a prolonged QT interval and a broad QRS complex. Her blood pressure is 85/60 mmHg. The results of her arterial blood gas (ABG) are as follows:

pH: 7.05 (normal range: 7.35 – 7.45)

BE: -13 (normal range: -2 to +2)

Lactate: 6.6 mmol/L (normal range: 0.6 – 2.4)

What is the most appropriate course of action?

A 66-year-old man is experiencing chest discomfort and dizziness that started a few hours ago. He has also been dealing with diarrhea for the past four days. He began taking perindopril two weeks ago. His temperature is 37.1°C, blood pressure is 101/68 mmHg, respiratory rate is 15 breaths/minute, and heart rate is 40 beats/minute. An ECG conducted in the Emergency Department reveals widening of the QRS complex. His blood test results indicate:

Sodium: 139 mmol/L (normal range: 135-145)

Potassium: 7.0 mmol/L (normal range: 3.5-5)

Urea: 6 mmol/L (normal range: 2.0-7)

Creatinine: 220 μmol/L (normal range: 70-150)

eGFR: 30 mL/min (normal range: >90)

What is the most appropriate course of action?

A 54-year-old man with pre-existing triple vessel disease experiences a sudden onset of chest pain that began four hours ago. He is also experiencing shortness of breath, sweating, and dizziness. His blood pressure is 140/80 mmHg, and his blood test results show a hemoglobin level of 63 g/L (normal range: 130-180 g/L). The ECG image is provided.

What is the most appropriate course of action?

A 24-year-old male of African descent with sickle cell disease and a history of admissions for painful crises presents to the Emergency Department with symptoms of fever, chest pain, shortness of breath, and cough. The symptoms started three days ago and have been progressively worsening. The patient describes the chest pain as severe and exacerbated by inhalation. His vital signs are as follows: temperature 38.5°C, pulse 111 beats/minute, blood pressure 130/85 mmHg, respiratory rate 20 breaths/minute, and oxygen saturation 88% on room air. Upon auscultation of the chest, bilateral fine crackles with diminished sounds are heard over both lung bases. The chest X-ray reveals bilateral basilar airspace opacities and bilateral pulmonary edema.

What is the most likely diagnosis?

A 39-year-old woman with a history of sickle cell anemia presents to the Emergency Department with severe, diffuse chest pain that started 6 hours ago. She has also developed a non-productive cough over the past 3 days and has been feeling unwell and experiencing shortness of breath. The patient receives frequent blood transfusions, with the most recent one being 3 weeks ago. Upon examination, her heart rate is 130 beats/minute, blood pressure is 96/64 mmHg, and body temperature is 39°C. She is currently receiving intravenous fluids and supplemental oxygen.

What is the next appropriate step in the management?

A 44-year-old woman was transferred to the Intensive Care Unit following admission from the medical ward due to hypertensive cardiomyopathy complicated by acute pulmonary edema. She has been experiencing worsening chest and back pain over the past few hours, accompanied by sweating and nausea. Upon examination, her mean arterial blood pressure is significantly higher in her right arm compared to her left arm. The patient is currently hemodynamically stable.

What is the most appropriate investigation in this case?

A 6-year-old child arrives at the pediatric A&E with acute breathlessness that has persisted for the past 12 hours. The child has a known history of asthma but has been unable to use his salbutamol and beclomethasone inhalers for the past two days due to misplacement. The child appears drowsy with poor respiratory effort, and his oxygen saturation is 86%. Immediate high-flow oxygen therapy is initiated, and the child has a silent chest.

What is the most appropriate management in this case?

A 54-year-old man is brought to the hospital by ambulance after a road traffic accident. He was driving at 70 mph when he crashed into a stationary car in front of him. He was wearing a 3-point seatbelt. Upon arrival at the hospital, he is experiencing shortness of breath, coughing, and severe abdominal and chest pain. His pulse rate is 145 beats/minute, respiratory rate is 30 breaths/minute, blood pressure is 105/80 mmHg, and oxygen saturation is 85%. Examination reveals bruises on his chest and abdomen, and tenderness is noted at the epigastrium. Diminished breath sounds are auscultated on the left chest. A chest X-ray shows a higher than normal position of the diaphragm with visible gas bubbles in the pleural cavity. The mediastinum appears shifted to the right side. Following the insertion of a nasogastric tube, a repeat chest X-ray shows the tip of the tube curled above the left hemidiaphragm.

What is the most likely diagnosis?

A 64-year-old woman is experiencing difficulty swallowing safely after a stroke. To ensure enteral feeding, a nasogastric tube is inserted. Which method is the most accurate for verifying the correct placement of a nasogastric tube?

A 14-year-old African boy is brought to the Emergency Department with a high temperature, cough, and chest discomfort. The boy reports experiencing the most severe pain he has ever felt, which worsens when he breathes in. During the examination, the boy is feverish and has low blood pressure. The X-ray reveals hazy areas in the lower parts of both lungs. The boy has a medical history of sickle cell disease, and there is a clinical suspicion of acute chest syndrome. A blood sample is collected for culture, matching blood types, complete blood count, and chemical analysis. The boy is given oxygen, empirical antibiotics, a medication to reduce fever, and intravenous fluids. The results of his blood tests are pending. What is the next most appropriate course of action?