AS7.1-5 | Intensive Care Management — Practice Quiz

Correct. Level III (tertiary) ICUs provide 24-hour on-site intensivist cover, full multiorgan support (mechanical ventilation, renal replacement, vasopressors, invasive monitoring), and serve as regional referral centres. Level I units offer continuous monitoring and basic interventions but cannot sustain full organ support.

ICU level classification (I–III) reflects the intensity of organ-support capability and intensivist staffing model, not simply the size or specialty of the unit.

Incorrect. The defining distinction is the capability for multiorgan support and the model of physician cover, not patient age or nurse ratios. Level III = full organ support + 24-hour intensivist on site; Level I = monitoring + basic interventions.

Correct. ICU admission is indicated when a patient has multiorgan threat — here, both refractory haemodynamic instability (shock) and acute hypoxaemic hypercapnoeic respiratory failure that may require mechanical ventilation. Either criterion alone might justify high-dependency care; the combination mandates ICU.

ICU admission criteria centre on actual or threatened organ failure requiring active support — haemodynamic, respiratory, renal, neurological. Single abnormal vital signs generally do not meet the threshold.

Incorrect. Fever and tachycardia are common in infection and alone do not mandate ICU. The key driver is haemodynamic instability plus respiratory failure severe enough to anticipate need for organ support (vasopressors, mechanical ventilation).

Correct. In an intubated unconscious patient (GCS ≤8, absent gag), securing the endotracheal tube, verifying cuff pressure (20–30 cmH2O to prevent aspiration and mucosal ischaemia), and maintaining 30–45 degree head-of-bed elevation are the core daily airway management priorities.

GCS ≤8 = loss of airway protective reflexes. Endotracheal intubation is mandatory; daily management includes cuff pressure check, tube fixation, and head-of-bed elevation as part of the ventilator care bundle.

Incorrect. A patient with GCS 5 and no gag reflex cannot protect their airway; a nasal cannula or supraglottic airway is wholly inadequate. Oral suctioning frequency should be demand-driven (PRN secretions) not fixed 8-hourly. The answer is cuff check + 30–45 degree head elevation.

Correct. The ARDSNet lung-protective protocol specifies a tidal volume of 6 mL/kg ideal body weight (range 4–8 mL/kg) to minimise ventilator-induced lung injury (volutrauma and barotrauma). For a 70 kg man, 6 × 70 = 420 mL.

Lung-protective ventilation in ARDS: tidal volume 6 mL/kg IBW, plateau pressure <30 cmH2O, PEEP titrated to oxygenation. Using actual instead of ideal body weight is a common and dangerous error.

Incorrect. Higher tidal volumes (8–12 mL/kg) cause volutrauma and worsen ARDS outcomes. The ARDSNet protocol mandates 6 mL/kg IBW, keeping plateau pressure below 30 cmH2O. Always use ideal body weight, not actual body weight.

Correct. Oliguria (urine output <0.5 mL/kg/hour) combined with a persistently elevated serum lactate (>2 mmol/L) indicates inadequate tissue perfusion and possible renal compromise despite an acceptable MAP and SpO2. This finding demands reassessment of fluid status, vasopressor dose, and cardiac output.

In septic shock, monitor the full perfusion picture: MAP, lactate clearance, urine output, ScvO2. Urine output <0.5 mL/kg/hour + lactate >2 mmol/L = hypoperfusion requiring action, even if MAP appears adequate.

Incorrect. MAP 62 mmHg meets the Surviving Sepsis target (≥65 mmHg borderline but not the most urgent signal here), SpO2 96% is acceptable, and low-grade fever alone requires no immediate intervention. The combination of oliguria and high lactate signals global hypoperfusion.

Correct. ICU discharge requires not only clinical stability in the patient but also confirmation that the receiving environment can sustain the patient's remaining needs. A structured step-down assessment includes ward capacity, nurse-to-patient ratio, and monitoring capability. Bounce-back within 48 hours carries 2–3× higher mortality.

ICU discharge has two components: patient-side (stable physiology off organ support) and environment-side (the step-down unit or ward must have the capacity to safely manage ongoing needs). Failing the environment check causes preventable bounce-backs.

Incorrect. Complete radiological resolution of pneumonia is not required for ICU discharge — clinical and physiological stability is. Prolonged afebrility is also not a discharge prerequisite. The receiving ward's capability to manage the patient is a mandatory parallel assessment.

Correct. GCS ≤8 = inability to protect the airway. Noisy, gurgling respirations with blood and secretions indicate active airway compromise. The immediate priority is definitive airway securing: suction the oropharynx and perform rapid sequence intubation (RSI) with in-line cervical spine immobilisation given the trauma mechanism.

GCS ≤8 + airway compromise = immediate RSI. In trauma, maintain in-line cervical spine immobilisation during laryngoscopy. Suction before intubation if blood/secretions are present to improve visualisation.

Incorrect. A non-rebreather mask does not protect a compromised airway; a nasopharyngeal airway is only a temporising bridge, not definitive; bag-mask ventilation is a temporising measure before intubation, not an endpoint. GCS ≤8 with active aspiration risk = RSI.

Correct. Sudden unilateral absent breath sounds with high peak airway pressure and SpO2 drop in a ventilated patient should prompt immediate consideration of right mainstem intubation (ETT migration) or tension pneumothorax. The absent breath sounds on the LEFT (the shorter, more vertical right bronchus is the common migration site) with NO tracheal deviation or haemodynamic collapse most likely indicates right mainstem intubation. Withdraw the ETT gently and auscultate to confirm bilateral ventilation.

DOPE mnemonic for sudden ventilator deterioration: Displacement (ETT migration), Obstruction (secretion/kink), Pneumothorax, Equipment failure. Rule out ETT displacement first — it is the most common and easiest to fix.

Incorrect. Pulmonary embolism does not cause unilateral absent breath sounds or high peak pressure in a ventilated patient. Tension pneumothorax is possible but would also cause haemodynamic deterioration and tracheal deviation. The first step is to exclude ETT migration (commonest, most immediately reversible cause) by withdrawing and auscultating before committing to chest drain insertion.