All questions
Question 1
A 72-year-old man is in the ICU after subdural hematoma evacuation. Over 2 hours he develops worsening headache, vomiting, and decreased responsiveness. Exam: GCS drops from 14 to 10, left pupil 5 mm sluggish, right 3 mm reactive; new right arm weakness. Vitals: BP 178/92, HR 52, irregular respirations on ventilator triggering. Labs: INR 1.1, platelets 210k. CT head earlier today shows postoperative changes with small residual hematoma. Current regimen: fentanyl 50 mcg/hr, propofol 20 mcg/kg/min. What diagnostic test should be prioritized to assess the patient's neurologic status?
- Repeat noncontrast CT head immediately (correct answer)
- Routine EEG to evaluate subclinical seizures
- MRI brain with and without contrast
- Lumbar puncture for cerebrospinal fluid analysis
- Carotid duplex ultrasonography at bedside
Explanation: This question tests Step 2 CK competency in managing neurologic and sedation issues in critical care. Neurologic and sedation management in the ICU involves careful monitoring of sedation levels and addressing any neurologic changes promptly. In this scenario, specific findings such as worsening headache, GCS drop, dilated pupil, and new weakness suggest possible hematoma expansion, guiding the management plan. The correct answer, choice A, is appropriate because it addresses the immediate clinical need based on current guidelines. A common distractor, choice C, fails because it overlooks a critical aspect of the patient's condition, such as the urgency of ruling out acute changes before advanced imaging. To improve clinical decision-making skills, focus on current guidelines for sedation and neurologic assessments, and practice interpreting clinical data accurately.
Question 2
A 59-year-old woman is ventilated after complicated hysterectomy with massive transfusion. She is intermittently agitated and hypertensive during suctioning despite deep sedation. Exam: RASS -3 baseline but spikes to +2 with procedures; grimaces to pain. Labs: Hgb 8.1 g/dL, lactate 1.8, electrolytes normal; CT head normal. Current regimen: propofol 40 mcg/kg/min, no scheduled analgesic, midazolam PRN. What is the most appropriate next step in managing this patient's sedation?
- Prioritize analgesia by starting an opioid infusion (correct answer)
- Increase propofol and avoid all opioids
- Start haloperidol to treat procedure-related pain
- Discontinue propofol and use only benzodiazepines
- Add scopolamine patch for agitation control
Explanation: This question tests Step 2 CK competency in managing neurologic and sedation issues in critical care. Neurologic and sedation management in the ICU involves careful monitoring of sedation levels and addressing any neurologic changes promptly. In this scenario, specific findings such as agitation during procedures and high pain scores suggest inadequate analgesia, guiding the management plan. The correct answer, choice A, is appropriate because it addresses the immediate clinical need based on current guidelines. A common distractor, choice B, fails because it overlooks a critical aspect of the patient's condition, such as the need for balanced analgesia in addition to sedation. To improve clinical decision-making skills, focus on current guidelines for sedation and neurologic assessments, and practice interpreting clinical data accurately.
Question 3
A 71-year-old man with atrial fibrillation is intubated after aspiration. After stopping sedation, he awakens but has new right gaze preference and left hemiplegia. Exam: NIHSS high; pupils equal/reactive. Labs: glucose 140, platelets 180k; CT head without contrast shows no hemorrhage. Current regimen: propofol recently stopped, fentanyl 25 mcg/hr. What diagnostic test should be prioritized to assess the patient's neurologic status?
- CT angiography head and neck for large-vessel occlusion (correct answer)
- Lumbar puncture to evaluate for CNS infection
- Routine EEG to confirm focal motor seizures
- MRI brain in 48 hours for definitive diagnosis
- Carotid duplex only, then reassess tomorrow
Explanation: This question tests Step 2 CK competency in managing neurologic and sedation issues in critical care. Neurologic and sedation management in the ICU involves careful monitoring of sedation levels and addressing any neurologic changes promptly. In this scenario, specific findings such as gaze preference and hemiplegia suggest large-vessel occlusion, guiding the management plan. The correct answer, choice A, is appropriate because it addresses the immediate clinical need based on current guidelines. A common distractor, choice D, fails because it overlooks a critical aspect of the patient's condition, such as the urgency of acute stroke evaluation over delayed MRI. To improve clinical decision-making skills, focus on current guidelines for sedation and neurologic assessments, and practice interpreting clinical data accurately.
Question 4
A 68-year-old man is in the intensive care unit (ICU) for septic shock secondary to pneumonia. He is intubated and mechanically ventilated. Over the past hour, his nurse reports that he has become completely unresponsive, even to deep sternal rub. His vital signs are temperature 38.1°C (100.6°F), blood pressure 105/65 mmHg on norepinephrine, heart rate 95/min, and respirations 16/min (ventilator-controlled). His pupils are 3 mm and reactive to light. He is not on any continuous sedative infusions, having been weaned off this morning. A fingerstick glucose is 110 mg/dL.
Which of the following is the most appropriate next step in the management of this patient's altered mental status?
- Administer a bolus of naloxone
- Obtain a non-contrast CT scan of the head
- Initiate continuous electroencephalography (EEG) (correct answer)
- Check serum ammonia level
Explanation: This patient in the ICU has an acute, profound change in mental status without a clear metabolic or structural cause. In critically ill patients, nonconvulsive status epilepticus (NCSE) is a common and underdiagnosed cause of unexplained coma or altered mental status. The absence of motor convulsions does not rule out seizure activity. Continuous EEG is the gold standard for diagnosing NCSE and is the most appropriate next step to identify and treat this reversible cause of coma.
Question 5
A 54-year-old woman with acute respiratory distress syndrome (ARDS) requires deep sedation for ventilator synchrony and prone positioning. She is currently on infusions of propofol at 70 mcg/kg/min and fentanyl at 150 mcg/hr. Her blood pressure is 85/50 mmHg, requiring an increasing dose of norepinephrine. Laboratory studies show a new metabolic acidosis with an anion gap of 18, lactate of 4.5 mmol/L, and serum triglycerides of 550 mg/dL. An ECG shows diffuse T-wave inversions.
Which of the following is the most appropriate next step in management?
- Increase the propofol infusion rate for deeper sedation
- Discontinue the propofol infusion and switch to an alternative sedative (correct answer)
- Administer a sodium bicarbonate infusion to correct the acidosis
- Initiate broad-spectrum antibiotics for suspected sepsis
Explanation: This patient's presentation of metabolic acidosis, hypertriglyceridemia, hemodynamic instability, and ECG changes in the setting of a high-dose propofol infusion is highly suggestive of propofol-related infusion syndrome (PRIS). PRIS is a rare but life-threatening complication. The most critical step in management is to immediately discontinue the propofol infusion and switch to an alternative sedative agent, such as a benzodiazepine or dexmedetomidine.
Question 6
An 82-year-old man is admitted to the ICU after a colectomy for colon cancer. On postoperative day 2, he develops fluctuating consciousness, inattention, and disorganized thinking. He is agitated at night and calm during the day. He has no focal neurologic deficits. His medications include IV morphine via a patient-controlled analgesia pump. He has no history of dementia. The Confusion Assessment Method for the ICU (CAM-ICU) is positive.
Which of the following is the most appropriate initial step to manage this patient's condition?
- Administer a low dose of intravenous haloperidol
- Apply soft wrist restraints to prevent self-harm
- Initiate frequent reorientation and optimize the sleep-wake cycle (correct answer)
- Replace morphine with intravenous lorazepam for sedation
Explanation: The patient is experiencing ICU delirium, characterized by acute onset of fluctuating mental status, inattention, and disorganized thinking. The first-line management for delirium is non-pharmacologic. This includes strategies like frequent reorientation, maintaining a normal sleep-wake cycle (e.g., opening blinds during the day, minimizing nighttime interruptions), early mobilization, and addressing sensory impairments (e.g., providing glasses and hearing aids). Pharmacologic agents are reserved for cases of severe agitation that pose a safety risk.
Question 7
A 24-year-old man is admitted to the neurocritical care unit after a severe traumatic brain injury. An intracranial pressure (ICP) monitor is placed. His initial ICP is 15 mmHg. Three hours later, the nurse calls because the ICP has acutely risen to 28 mmHg. His blood pressure is 160/95 mmHg, and his heart rate is 58/min. He is intubated and sedated.
In addition to ensuring the head of the bed is elevated to 30 degrees and the patient's head is in a neutral position, which of the following is the most appropriate immediate intervention?
- Perform a lumbar puncture
- Administer a bolus of mannitol (correct answer)
- Increase PEEP on the ventilator to 15 cm H2O
- Administer high-dose dexamethasone
Explanation: This patient has a dangerously elevated ICP (>20-22 mmHg) and signs of Cushing's triad (hypertension, bradycardia), indicating impending brain herniation. The most appropriate immediate step, after basic measures like head positioning, is to administer hyperosmolar therapy to osmotically draw fluid out of the brain parenchyma. Mannitol or hypertonic saline are first-line agents for this purpose. Dexamethasone is used for vasogenic edema from tumors or abscesses, not TBI. Lumbar puncture is contraindicated due to the risk of herniation. High PEEP can increase intrathoracic pressure and impair cerebral venous outflow, potentially worsening ICP.
Question 8
A 45-year-old man is intubated and mechanically ventilated in the ICU for community-acquired pneumonia. He is agitated and appears to be in pain, frequently triggering ventilator alarms. His blood pressure is 130/80 mmHg and heart rate is 115/min. The team plans to initiate sedation.
According to current evidence-based guidelines, which of the following is the most appropriate initial approach to sedation for this patient?
- Start a continuous infusion of lorazepam
- Start a continuous infusion of propofol
- Administer intermittent boluses of midazolam
- Administer an intravenous opioid bolus and start an infusion (correct answer)
Explanation: Current guidelines for pain, agitation, and delirium in the ICU recommend an 'analgesia-first' or 'analgosedation' approach. This prioritizes treating pain, a common cause of agitation, before adding a hypnotic-sedative agent. An intravenous opioid like fentanyl or hydromorphone should be administered first to manage pain. If agitation persists after adequate analgesia is achieved, a sedative can be added. Benzodiazepines (lorazepam, midazolam) are associated with a higher risk of delirium and are no longer first-line agents for sedation in most ICU patients.
Question 9
A 33-year-old woman with fulminant hepatic failure is awaiting liver transplantation. She becomes progressively obtunded and develops decerebrate posturing. She is intubated for airway protection. An ICP monitor is not in place. There is high suspicion for cerebral edema and increased intracranial pressure.
Which of the following interventions is most appropriate to acutely lower suspected intracranial pressure while awaiting definitive treatment?
- Administer lactulose enemas until she has a bowel movement
- Initiate continuous renal replacement therapy
- Temporarily increase the ventilator respiratory rate to 30/min (correct answer)
- Place a nasogastric tube to decompress the stomach
Explanation: In a patient with signs of impending brain herniation (e.g., decerebrate posturing), immediate action is needed to lower ICP. Hyperventilation causes cerebral vasoconstriction by lowering PaCO2, which rapidly decreases cerebral blood volume and ICP. This is a temporizing measure used as a bridge to more definitive therapies (like hyperosmolar agents or surgery). The target PaCO2 is typically 30-35 mmHg. Lactulose treats hyperammonemia but does not act quickly enough for an acute herniation syndrome. CRRT and NG tube placement are not direct, immediate treatments for critically elevated ICP.
Question 10
A 58-year-old woman is admitted to the ICU with a large intracerebral hemorrhage. She is intubated and sedated. Her ICP is being managed with hyperosmolar therapy. Her serum sodium is 152 mEq/L. Her clinical team wants to select a sedative agent that will have minimal impact on cerebral hemodynamics and allow for frequent, rapid neurologic assessments.
Which of the following is the most appropriate choice for sedation in this patient?
- Propofol (correct answer)
- Lorazepam
- Dexmedetomidine
- Midazolam
Explanation: Propofol is an ideal sedative for patients with increased ICP requiring frequent neurologic checks. It has a very rapid onset and short half-life, allowing for quick awakening during sedation holidays. It also decreases cerebral metabolic rate of oxygen consumption (CMRO2), which can help lower ICP. Benzodiazepines like lorazepam and midazolam have longer, more unpredictable half-lives and active metabolites, which can accumulate and make neurologic assessment difficult. Dexmedetomidine does not reliably decrease CMRO2 and can cause hypotension, which can be detrimental in neurocritical care where maintaining cerebral perfusion pressure is key.
Question 11
A 50-year-old woman with a history of hypertension is found unresponsive and brought to the emergency department. A non-contrast head CT reveals a large subarachnoid hemorrhage. She is taken to the ICU, intubated, and an external ventricular drain (EVD) is placed. Her intracranial pressure is 18 mmHg. Her blood pressure is 170/100 mmHg.
Which of the following is the most appropriate management for this patient's increased intracranial pressure at this time?
- Drain 5 mL of cerebrospinal fluid via the EVD (correct answer)
- Administer a bolus of 3% saline
- Start a propofol infusion for sedation
- Administer intravenous labetalol to lower blood pressure
Explanation: In a patient with an external ventricular drain (EVD) in place, the most direct and effective first-line method to control intracranial pressure is to drain cerebrospinal fluid (CSF). This directly reduces intracranial volume and thus pressure. While hyperosmolar therapy (3% saline) and sedation (propofol) are also used to manage ICP, CSF drainage is the most immediate intervention available via the EVD. Blood pressure control is important in subarachnoid hemorrhage, but CSF drainage is the primary intervention for the elevated ICP itself.
Question 12
A 75-year-old man is delirious in the ICU. He is severely agitated, pulling at his central line and endotracheal tube, posing an immediate danger to himself. Non-pharmacologic interventions and verbal de-escalation have failed. The team decides to use a pharmacologic agent.
Which of the following is the most appropriate medication to manage this patient's severe agitation?
- A low dose of an atypical antipsychotic (correct answer)
- A continuous infusion of a benzodiazepine
- A single dose of intravenous diphenhydramine
- A loading dose of phenytoin
Explanation: For severe, dangerous agitation in ICU delirium where non-pharmacologic measures have failed, guidelines suggest the short-term use of antipsychotics. Low doses of agents like haloperidol, olanzapine, or quetiapine can be used to control agitation and ensure patient safety. Benzodiazepines are generally avoided as they can worsen or prolong delirium, except in cases of alcohol or benzodiazepine withdrawal. Diphenhydramine has anticholinergic properties that would worsen delirium. Phenytoin is an anti-epileptic and has no role in managing delirium.
Question 13
A 35-year-old woman is in the ICU for management of Guillain-Barré syndrome. She is intubated due to respiratory muscle weakness. She is alert and oriented but anxious. She requires light sedation to tolerate the endotracheal tube. It is important for her to remain interactive to participate in her care and for neurologic monitoring. Her blood pressure is 100/70 mmHg and heart rate is 75/min.
Which sedative agent would be most appropriate for this patient?
- Midazolam infusion
- Propofol infusion
- Dexmedetomidine infusion (correct answer)
- Ketamine infusion
Explanation: Dexmedetomidine is an alpha-2 adrenergic agonist that provides 'cooperative sedation,' meaning patients are sedated but remain arousable and able to interact, which is ideal for this patient. It does not cause respiratory depression, which is beneficial. Propofol would provide deeper sedation, making interaction difficult. Midazolam is associated with delirium and prolonged sedation. Ketamine can cause hallucinations and emergence reactions, which may not be ideal for an anxious but alert patient.
Question 14
An 80-year-old woman is admitted to the ICU with urosepsis and acute kidney injury. She develops altered mental status. Her temperature is 38.5°C, blood pressure is 95/60 mmHg on vasopressors, and heart rate is 110/min. Her sodium is 138 mEq/L, glucose is 150 mg/dL, and calcium is 8.9 mg/dL. Her BUN is 80 mg/dL and creatinine is 3.5 mg/dL. She is agitated and confused.
In addition to delirium, which of the following is the most likely contributor to her altered mental status?
- Hyponatremia
- Hypoglycemia
- Uremic encephalopathy (correct answer)
- Hypertensive encephalopathy
Explanation: The patient has severe acute kidney injury with a BUN of 80 mg/dL. Uremia, the accumulation of nitrogenous waste products due to kidney failure, is a common cause of metabolic encephalopathy in the ICU. Symptoms can range from confusion and lethargy to seizures and coma. While she also has delirium precipitated by sepsis, uremia is a very likely direct contributor to her altered mental status. Her sodium and glucose are normal, and she is hypotensive, not hypertensive.
Question 15
A 55-year-old man is being monitored in the ICU after a thrombectomy for a large vessel ischemic stroke. A daily sedation vacation is performed. The nurse assesses his level of consciousness and motor function. He is able to open his eyes to voice, localize to a painful stimulus with his right arm, and withdraws from pain with his left arm. He does not verbalize due to intubation.
Which of the following Glasgow Coma Scale (GCS) scores best represents this patient's neurologic status?
- GCS 6T
- GCS 8T (correct answer)
- GCS 10T
- GCS 12T
Explanation: The Glasgow Coma Scale is composed of three components: Eye Opening, Verbal Response, and Motor Response. This patient's score is calculated as follows: Eye Opening to voice = 3 points. Verbal Response is untestable due to intubation, scored as 'T'. Best Motor Response (taking the better of the two sides) is localizing to pain = 5 points. Therefore, his GCS is E3 M5 VT = 8T. The 'T' indicates the verbal component cannot be assessed due to intubation.
Question 16
A 46-year-old man with a history of seizures is admitted to the ICU for aspiration pneumonia and is intubated. He is sedated with propofol. After 24 hours, the propofol is stopped for a neurologic assessment. The patient remains comatose with no spontaneous movements. There are brief, rhythmic twitching movements of his right eyelid and thumb noted by the nurse.
Which of the following is the most likely cause of this patient's persistent unresponsiveness?
- Prolonged effect of propofol
- Uremic encephalopathy
- Nonconvulsive status epilepticus (correct answer)
- Anoxic brain injury from aspiration
Explanation: This patient has a history of seizures and is exhibiting subtle motor findings (eyelid and thumb twitching) in the context of a persistently depressed mental status after sedation has been weaned. This clinical picture is highly suspicious for nonconvulsive status epilepticus (NCSE). The subtle motor signs can be the only external manifestation of ongoing, generalized seizure activity in the brain. An EEG is required for diagnosis. While the other options are possible, the specific clinical findings point most strongly toward NCSE.
Question 17
A 70-year-old man is in the ICU for a COPD exacerbation and is difficult to wean from the ventilator. He has been on a continuous midazolam infusion for 5 days. He is now more awake but remains agitated, disoriented, and is unable to follow commands. He has visual hallucinations, reporting that there are 'bugs on the walls.' His vital signs are stable, and a metabolic panel is unremarkable.
Which of the following medications is most likely contributing to this patient's clinical picture?
- Albuterol
- Ipratropium
- Methylprednisolone
- Midazolam (correct answer)
Explanation: The patient is presenting with classic features of ICU delirium. Benzodiazepines, such as midazolam and lorazepam, are a major independent risk factor for the development of delirium in critically ill patients. Their use, especially via continuous infusion in older adults, is strongly associated with prolonged confusion, agitation, and hallucinations. While high-dose steroids can cause psychosis, benzodiazepines are a more common and potent cause of delirium in this setting.
Question 18
A 40-year-old man with no past medical history is admitted with a severe headache. A CT scan shows a large right-sided intraparenchymal hemorrhage with midline shift. He is intubated in the emergency department. In the ICU, his blood pressure is 180/100 mmHg, heart rate is 50/min, and he has irregular respirations. His right pupil becomes fixed and dilated.
This patient's clinical signs are most consistent with which of the following neurologic emergencies?
- Central cord syndrome
- Brainstem herniation (correct answer)
- Nonconvulsive status epilepticus
- Cerebral vasospasm
Explanation: The patient is exhibiting Cushing's triad: hypertension (180/100 mmHg), bradycardia (50/min), and irregular respirations. This triad, coupled with a unilateral fixed and dilated pupil ('blown pupil'), is a classic sign of uncal herniation, a type of brainstem herniation. The expanding hematoma is compressing the brainstem and the ipsilateral oculomotor nerve (cranial nerve III), leading to these life-threatening signs. This is a neurosurgical emergency.
Question 19
A 77-year-old woman is in the ICU following a coronary artery bypass graft surgery. She is extubated but remains confused and is inattentive. A CAM-ICU assessment is performed. The patient is awake and calm (Richmond Agitation-Sedation Scale score of 0). She is able to correctly squeeze the examiner's hand when she hears the letter 'A' in a sequence of letters only 3 out of 10 times. When asked simple yes/no questions, her answers are disorganized and illogical.
Based on this assessment, which of the following is the most likely diagnosis?
- Hypoactive delirium (correct answer)
- Postoperative cognitive dysfunction
- Sundowning phenomenon
- Wernicke encephalopathy
Explanation: The patient meets the criteria for delirium based on the CAM-ICU: (1) acute change in mental status, (2) inattention (failing the letter squeeze test), and (3) disorganized thinking. Because her psychomotor activity is reduced (RASS score of 0, calm), this is classified as hypoactive delirium. Hypoactive delirium is more common than the hyperactive form but is often missed. Postoperative cognitive dysfunction is a longer-term diagnosis, while sundowning is a pattern of confusion in the evening, not a specific diagnosis. There are no features of Wernicke encephalopathy (ataxia, ophthalmoplegia).
Question 20
A 28-year-old woman is in the ICU with bacterial meningitis. She is intubated and sedated. Her ICP is 24 mmHg. Her mean arterial pressure (MAP) is 75 mmHg. The team is calculating her cerebral perfusion pressure (CPP).
What is this patient's calculated cerebral perfusion pressure, and what is the appropriate goal for CPP in neurocritical care?
- CPP is 51 mmHg; goal is >80 mmHg
- CPP is 51 mmHg; goal is 60-70 mmHg (correct answer)
- CPP is 99 mmHg; goal is >80 mmHg
- CPP is 99 mmHg; goal is 60-70 mmHg
Explanation: Cerebral Perfusion Pressure (CPP) is calculated as Mean Arterial Pressure (MAP) minus Intracranial Pressure (ICP). In this case, CPP = 75 mmHg - 24 mmHg = 51 mmHg. Current guidelines for managing traumatic brain injury and other causes of elevated ICP recommend maintaining a CPP between 60 and 70 mmHg to ensure adequate cerebral blood flow without causing excessive edema. A CPP of 51 mmHg is too low and indicates cerebral hypoperfusion, necessitating interventions to either raise MAP (with vasopressors) or lower ICP.