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

Question 6#Print Question

A 24-year-old woman, with history of recent upper respiratory infection, was admitted to the ICU with a week of progressive ascending weakness. On initial examination she was awake, alert, oriented, and cooperative. She had quadriparesis and areflexia. She subsequently developed respiratory distress and was intubated. Head and cervical spine CT are read as normal. A lumber puncture is performed, which reveals the following CSF profile:

  • 0 WBCs
  • 0 RBCs
  • Protein 120 mg/dL
  • Glucose 80 mg/dL

What is the next best step in management?

a. Administer IV methylprednisolone
b. Administer intravenous immunoglobulin
c. Perform stat nerve conduction and electromyography studies
d. Administer IV Acyclovir


Question 7#Print Question

A 38-year-old man suffers multisystem trauma and hemorrhagic shock after a motor vehicle accident. Initial CT imaging revealed a left-sided depressed skull fracture with underlying subdural hematoma (SDH) with contrecoup intracerebral hemorrhage, multiple bilateral rib fractures, lung contusions, and a splenic laceration. After initial damage control surgery, he was admitted to the ICU, where an increased intracranial pressure (ICP) monitor was placed. The patient remained sedated and ventilated, with limited neurological examination. On ICU day 2, he developed acute kidney injury with oliguria, and by day 3 he became anuric unresponsive to diuretic therapy. On the same day he had a sustained elevation in ICP to 27 mm Hg. Basic metabolic panel on day 3:

  • Na 142
  • K 4.7
  • Cl 109
  • BUN 45
  • creatinine 3.5

What is the next most appropriate step to manage the ICP elevation?

a. Administer IV mannitol
b. Administer dexamethasone
c. Administer NaCl 23.4%
d. Neurosurgical consultation for an emergent decompressive hemicraniectomy


Question 8#Print Question

A 45-year-old man with a history poorly controlled hypertension is admitted to the ICU after elective endovascular repair of a descending thoracic aortic aneurysm. His intraoperative course was uneventful but on arrival in the ICU, he complains of lower limb weakness. His vital signs are within normal limits with blood pressure 110/65. On physical examination, he is awake, alert, and oriented. His cranial nerves and upper limb strength are intact. There is a clear nearly symmetric motor deficit in the bilateral lower limbs, with 3/5 weakness in the proximal muscles, and 2/5 in the distal ones. Tone is flaccid, and there is no Babinski sign or sensory deficit.

In addition to increasing the blood pressure what is the MOST appropriate next step in management?

a. Increase the blood pressure and insert a lumbar drain for CSF drainage
b. Obtain a stat MRI brain and spine
c. Initiate high-dose steroid treatment
d. Obtain a stat angiogram of the lumbar vessels


Question 9#Print Question

A 78-year-old woman with past medical history of hypertension, COPD, and coronary artery disease is admitted to the ICU with respiratory failure due to community-acquired pneumonia. She is intubated and mechanically ventilated. Empiric antibiotic therapy for pneumonia was initiated following obtaining cultures. On the morning of her third ICU day, she his noted to be less arousable when sedation is decreased. On examination she does not follow commands, has a gaze preference to the left, and only moves her left side spontaneously. A stat head CT does not show any acute findings. The last documented normal neurological examination was at the shift change the day prior. The patient’s home meds include a baby aspirin (81 mg) and a statin.

What is the MOST appropriate intervention at this time?

a. Administer stat IV tPA
b. No acute intervention
c. Administer stat fosphenytoin
d. Obtain a stat CT angiogram and CT perfusion study for possible thrombectomy


Question 10#Print Question

A 32-year-old woman is admitted to the hospital with a 2-week course of progressively worsening confusion. She has no past medical history except for a mild upper respiratory infection two weeks before admission. On examination, she is awake, not oriented to time, place, or person and is only able to follow simple commands. There are no obvious focal neurological deficits. During the assessment, she develops a generalized tonic-clonic seizure. The seizure does not break despite three 2 mg doses of IV lorazepam and is emergently intubated and a propofol infusion is initiated, which terminates the convulsions. She is treated empirically with antibiotics for bacterial meningitis and acyclovir for viral encephalitis. EEG monitoring is notable for left temporal focal nonconvulsive status epilepticus, and fosphenytoin is administered with resolution of the seizures is administered. A head CT is obtained but does not show any acute abnormality. An MRI of the brain shows bitemporal T2 hyperintensities and no sign of a space occupying lesion, hemorrhage, or stroke. A lumbar puncture is performed, and CSF content shows:

  • 8 WBCs
  • 0 RBCs
  • Glucose 80 mg/dL (systemic 120 mg/dL)
  • protein 95 mg/dL

PCR for HSV 1&2, CMV, EBV, and VZV are negative, and acyclovir is discontinued. Gram stain and cultures are negative.

What is the MOST appropriate therapeutic intervention at this time?

a. Administer methylprednisolone
b. Re-administer IV acyclovir
c. Administer valproic acid
d. Wean propofol to obtain a neurological examination




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