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Category: Critical Care Medicine-Neurologic Disorders--->Management Strategies
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Question 1# Print Question

A 31-year-old man, with no past medical history, is admitted to the ICU with acute liver failure (ALF) following ingestion of an unknown herbal supplements. On initial examination, he is awake, oriented only to self, follows simple commands and has mild asterixis but no focal motor deficits. Notable laboratory test results include AST 1734, ALT 1567, T. Bilirubin 2.3, and Ammonia 110. On day 2 of ICU admission, he has a witnessed generalized tonic-clonic seizure. Two milligrams of lorazepam are administered intravenously and the convulsions are terminated. A Stat Head CT is performed, which shows diffuse cerebral edema and no ischemic or hemorrhagic changes.

What is the MOST appropriate medication to administer at this time?

A. Fosphenytoin
B. Valproate
C. Levetiracetam
D. Midazolam infusion

Question 2# Print Question

A 76-year-old woman, with past medical history of hypertension, coronary artery disease, atrial fibrillation, and Parkinson disease is admitted to the ICU with progressively worsening mental status. She suffered a ground level fall 2 days before her admission. Her home medications are amlodipine, lisinopril, levodopa, and apixaban. On physical examination, she is somnolent, only opens her eyes to painful stimuli, pupils are equal in size and briskly reactive to light, does not vocalize, and withdraws from noxious stimuli in all four extremities. The patient is emergently intubated for airway protection and admitted to the ICU. On arrival to the ICU, a head CT is obtained (see figure below).

What will be the MOST appropriate next step in treatment?

A. Administer stat IV levetiracetam
B. Administer stat IV mannitol
C. Administer stat IV NaCl 3%
D. Neurosurgical consultation for hematoma evacuation

Question 3# Print Question

A 45-year-old woman, who is an active smoker and has history of untreated hypertension, presented following a sudden “thunderclap” headache. Head CT revealed (see figure below) subarachnoid hemorrhage of an anterior communicating artery aneurysm. She underwent successful endovascular coiling of the aneurysm, and an external ventricular drain was placed for hydrocephalus. Five days after presentation, she acutely became somnolent.

Vital signs are

  • T 37.4
  • HR 94
  • R 24
  • BP 124/75 (MAP 91)
  • O2 saturation 95% on room air

On examination she is somnolent but easily arousable and follows simple commands with all four extremities, but there is a clear drift of the right hand and leg.

What is the most appropriate next step in management?

A. Administer stat IV Levetiracetam
B. Bolus 1 liter of fluid
C. Consult interventional radiology for stat angioplasty
D. Administer empiric IV Vancomycin and Ceftriaxone in meningitis doses

Question 4# Print Question

A 57-year-old man, with past medical history of hypertension and hyperlipidemia, presented with an acute onset of slurred speech and right-sided weakness. He was diagnosed with an acute left middle cerebral artery (LMCA) stroke and IV tPA was administered. He was then admitted to the ICU for close monitoring. On day 3 poststroke, his focal deficits persist, and it is noted that one of his pupils is larger than the other. He subsequently becomes unresponsive and is emergently intubated and hyperventilated. Stat head CT demonstrated increasing cerebral edema and midline shift of 9.6 mm and uncal herniation without signs of cerebral hemorrhage.

What is the most appropriate next step in treatment?

A. Transfuse to keep the hemoglobin>10 mg/dL
B. Administer IV dexamethasone
C. Administer hypertonic saline
D. Readminister IV tPA at half the original dose

Question 5# Print Question

A 76-year-old man with history of COPD and stage 3 chronic kidney disease underwent elective craniotomy for tumor resection. His postoperative course was complicated by the development of status epilepticus and respiratory failure. On postoperative day 5, he developed a fever of 38.7°C and his WBC increased from 12 000 to 19 500. Blood, urine, and respiratory cultures were obtained.

A CSF sample revealed:

  • Nucleated cells 230 cells/mL 3
  • RBC: 1500 cells/mL 3
  • Protein 220
  • Glucose 34 mg/dL (systemic glucose 110 mg/dL)

Which empiric antibiotic regimen is most appropriate to initiate at this time? 

A. Ceftazidime and vancomycin
B. Ampicillin, ceftriaxone, and vancomycin
C. Vancomycin, ceftriaxone, and metronidazole
D. Cefepime and vancomycin

Category: Critical Care Medicine-Neurologic Disorders--->Management Strategies
Page: 1 of 2