Neurology, Donation & Ethics – Full Test

Uma Montfort is a 88-year-old female admitted to a level two unit for non-invasive ventilation in the context of decompensated congestive heart failure and pulmonary edema. The bedside nurse is concerned the patient has developed delirium.

Based on the DSM, list four essential components to the diagnosis of delirium (4 marks)

History provided by the nurse includes significant alcohol consumption by the patient. The nurse wonders if alcohol withdrawal may be contributory.

Provide the usual time course for presentation of delirium tremens after cessation of drinking alcohol (1 mark)

List two contraindications to haloperidol use excluding allergy (2 marks)

You are admitting Jason Murphy, a patient post subarachnoid hemorrhage.  The admission note states Fisher Grade 3.

Describe the criteria for Fisher Grade 3 (1 mark)

Provide one pharmacologic agent indicated for vasospasm prophylaxis (1 mark)

Provide the time frame for vasospasm risk (1 mark)

The patient has developed vasospasm and the neurosurgery team has asked for a target SBP of > 180 mmHg.  The patient is currently on phenylephrine at 500 mcg/minute and norepinephrine at 18 mcg/min.  The CVP is 12, and the fluid balance is positive 4 liters over the previous 24 hours.  There is mild pulmonary edema beginning on the a.m. chest radiograph.  Despite the vasopressors the SBP is ~ 160 mmHg.

Describe your management plan with justification (3 marks)

Geraldine Emmanuel is a 72-year-old patient transferred from another hospital with a history of progressive weakness, and is now intubated for respiratory failure.  The patient was well until approximately 3 days prior, and developed nausea, vomiting and diarrhea, followed by progressive muscle weakness. On examination the patient is awake and alert but unable to eye open, and can respond by a barely perceptible nod/shake of head. Temperature is 38.6. Pupils are 6 – 7 mm and slightly reactive to light. Chest is clear to auscultation.  Heart rate is sinus, 126 with normal heart sounds. Mucous membranes are dry.  Abdomen is distended and tympanic.  Foley catheter is in place

Provide the most likely diagnosis (1 mark)

Describe the pathophysiology (2 marks)

Outline two elements in the management of this condition (2 marks)

Provide one respiratory monitoring parameter to risk stratify Ms. Emmanuel’s need for mechanical ventilation and describe the value of that parameter that would prompt consideration for intubation (1 mark)

Your patient, Hubert Milliken, has a left 6^th cranial nerve palsy.  They are obtunded with reactivity on EEG.

Describe expected response to instillation of 50mL of ice cold water to the right ear with the patients head at 30^o. (3 marks)

Mariano Rivera is a 27-year-old gentleman admitted to the intensive care unit after presenting with blunt trauma, positive fast, spleen injury post-operative hour 2 from a trauma laparotomy, four compartment packing and splenectomy.  Trans-cranial doppler is shown below.

Characterize the doppler pattern (1 mark)

Provide three pharmacologic management strategies to address the abnormality in doppler pattern (3 marks)

Propose the most reasonable investigation to be done emergently (1 mark)

Choose which TCD pattern below (A or B) is consistent with a more favourable result following your management (1 mark)

TCD A

TCD B

Robert Porteroy is a 60-year-old male admitted to the intensive care unit four days ago with aneurysmal subarachnoid hemorrhage. Robert had previously expressed wishes stipulating the quality of life projected by your medical team was inconsistent with his values, therefore withdrawal of life support was recommended. On assessment he has moderately increased work of breathing on morphine 5mg/h and midazolam 1mg/h. He received rocuronium 48 hours ago. eGFR is 50mL/min/1.73m³.

Name ONE standardized scoring systems recommended for assessing pain during withdrawal of life support (1 mark)

Provide TWO clinical signs or bedside investigations that would support rocuronium effect has sufficiently worn off (2 marks)

Nursing staff has controlled pain, however, Robert remains symptomatically dyspneic. Provide the MAXIMUM midazolam infusion dose limit (1 mark)

After extubation Robert remains profoundly dyspneic despite morphine 20mg/h and midazolam 5mg/h. Provide TWO alternative sedative agents aside from different opioids or benzodiazepines (2 marks)

Matt Vance is a 45 year old gentleman with asthma, chronic kidney disease (eGFR 40), depression and GERD admitted to the ICU post-operatively from a duodenal ulcer perforation with Graham patch two days ago. After extubation hydromorphone 1mg IV q2h was initiated for pain. Over the past three hours Matt has become progressively drowsier with reduced respiratory rate. General Surgery has recommended removal of an abdominal drain.

List TWO recommended pharmacologic adjuvants to opioids for pain management in critically ill adults (2 marks)

List THREE adverse effects of opioids (3 marks)

Provide TWO risk factors for peri-procedural pain present in Matt’s situation (2 marks)

Margaret van Horn is a 70 year old female with frontotemporal dementia admitted to the intensive care unit with septic shock from community acquired pneumonia. She is invasively ventilated and receiving vasopressors. Current settings are: PSV PS 15 PEEP 8 FiO2 0.5 rate 24. Arterial blood gas shows the following: pH 7.35 pCO2 45 pO2 65 HCO3 23 BE -1. She is receiving norepinephrine 0.1mcg/kg/m. With spontaneous awakening trials and discontinuation of sedatives she becomes tachypneic with coughing and bearing down on the endotracheal tube. You are asked to articulate a plan for sedation management while she is receiving invasive ventilation.

List THREE non-benzodiazepine intravenous sedation agents you would consider (3 marks)

List TWO benefits of light sedation over deep sedation (2 marks)

List TWO non-pharmacologic strategies to reduce delirium (2 marks)

Arash Bagheri is a 70-year-old man with COPD and type 2 diabetes is intubated in the ICU on day 10 following admission for septic shock secondary to urosepsis. He is currently ventilated on FiO₂ 0.35, PEEP 5, tidal volume 400 mL, and has a PaO₂ of 78 mmHg, PaCO₂ of 44 mmHg. His creatinine has improved to 98 µmol/L.

He is receiving dexmedetomidine at 0.7 mcg/kg/hr with intermittent haloperidol for agitation. RASS is fluctuating between +1 and –2. When performing CAM-ICU, he erroneously squeezes the nurses hand 3 times with SAVEAHAART, knows a stone will not float in water, but does not believe there are fish in the sea and does not believe a hammer can be used to pound a nail. He is drowsy during the day but agitated overnight. The bedside nurse reports increased confusion and verbal aggression since yesterday, despite stable hemodynamics (MAP 72 mmHg on no vasopressors).

No fevers are reported. There is no new focal neurological deficit. Latest labs show: Na⁺ 134 mmol/L, K⁺ 4.1 mmol/L, Glucose 7.0 mmol/L, Lactate 1.8 mmol/L, WBC 11.4 ×10⁹/L. CT head is normal.

List three likely contributors to this patient’s ICU delirium that should be addressed in the next 12 hours (3 marks)

Miyuki Tanaka is a 38-year-old female with no major past medical history is extubated after 12 days in the ICU for influenza-related ARDS. She experienced periods of deep sedation, short-term renal dysfunction, and required vasopressors for 3 days.

Now on day 14, she is weaned off oxygen, hemodynamically stable, and expected to be transferred to the ward tomorrow. She reports fragmented memories, anxiety, nightmares about being restrained, and is unsure what happened during her ICU stay. Her spouse notes she seems emotionally distant and struggles to concentrate. The ICU team has limited social work and chaplaincy coverage on weekends.

List FOUR evidence based interventions that support psychological recovery after ICU discharge (4 marks)

A 45-year-old woman, Ilinca Matej, with diabetes and ESRD was admitted to the ICU with urosepsis and ARDS. Over four weeks she received multiple antibiotic courses, analgosedative medications, parenteral glucocorticoids, and underwent tracheostomy on ICU day 9 for prolonged weaning. Multiple weaning attempts have failed with tachypnea and hypercapnia. Infectious causes and occult heart failure have been excluded. Cranial nerve exam is normal with no focal deficits, but she has generalized weakness, hyporeflexia, NIF of −15 cmH2O, and VC of 800 mL.

a) State the most likely diagnosis and describe its typical clinical pattern. (2 marks)

b) List TWO diagnostic tests to confirm the diagnosis. (1 mark)

c) List FIVE risk factors for ICU-acquired weakness. (5 marks)

d) List THREE diagnoses in the differential. (3 marks)

Vance Horton is a 25-year-old male presenting to your ICU after prolonged seizure in the emergency department treated with propofol infusion.

Define prolonged seizure or status epilepticus (2 marks)

Identify the most common etiology of status epilepticus (1 mark)

List TWO pharmacologic options from different medication classes with doses for management of status epilepticus (2 marks)

Abraham Paval is a 45-year-old man admitted to the ICU following a diarrheal illness with nausea, vomiting, altered sensorium, hypertension, and elevated creatinine. He begins seizing and continues despite 10 mg IV diazepam at the six-minute mark.

a) State the diagnosis and its formal definition. (3 marks)

b) List the first, second, and third-line medication classes with specific agents and dose ranges for treatment, in order. (6 marks)

c) List TWO common precipitants of status epilepticus that must be excluded. (2 marks)

A 51-year-old woman, Liljana Talib, was admitted 24 hours ago with decreased LOC (GCS E1V1M5) and left hemiparesis from a large right-sided subarachnoid hemorrhage with intraparenchymal and intraventricular extension. She underwent coiling of an anterior communicating artery aneurysm and has an intraventricular drain in situ. ICP has risen acutely from 16 to 30 mmHg and is sustained. Right pupil is 5 mm and unreactive; left pupil is 3 mm and reactive.

a) State the most likely diagnosis. (1 mark)

b) List SIX interventions to optimize CPP and reduce ICP. (6 marks)

c) State the single most important next step in care beyond ICP management. (1 mark)

Mirabella Orsino is a 66-year-old woman who was treated in the ICU for sepsis, pneumonia, and ARDS with antibiotics, corticosteroids, and a neuromuscular blocking agent. After the paralytic agent is discontinued she has persistent profound neuromuscular blockade.

a) List FOUR risk factors for the development of persistent neuromuscular blockade. (4 marks)

Clementina Cenric is a 72-year-old woman who has been mechanically ventilated for five days is noted by the nursing staff to have fluctuating behavior and difficulty following commands. The team initiates formal delirium screening using the CAM-ICU.

a) List the FOUR components assessed by the CAM-ICU. (4 marks)

Stephanos Oswoldo is a 53-year-old 70 kg man who has been in the ICU for four days with community-acquired pneumonia on norepinephrine and vasopressin. His creatinine is 400 μmol/L. Medications include midazolam 4 mg/hr, fentanyl 100 mcg/hr, ceftriaxone, and erythromycin. The bedside nurse reports a declining level of consciousness.

a) List TWO pharmacokinetic drug-related reasons for the decline in level of consciousness. (2 marks)

Joel Brown is a 65-year-old man who develops rapidly ascending bilateral limb weakness with diminished reflexes following a gastroenteritis episode. He is referred to ICU for increasing dyspnea and tachypnea. CSF analysis shows: colour clear, WBC 2 cells/mm³, RBC 8 cells/mm³, CSF:plasma glucose ratio 68%.

a) State where the sample was obtained, identify the missing CSF parameter, and state what result you would expect. (3 marks)

b) List THREE diagnoses in the differential. (3 marks)

c) List THREE indications for ICU admission. (3 marks)

d) List TWO treatment options for this condition. (2 marks)

Fatima Hassan is a 54-year-old woman admitted to the ICU with a spontaneous intracerebral hemorrhage and a GCS of 7. She is intubated and sedated. Serial neurological examination is unreliable due to sedation requirements. Her head CT shows a large thalamic hemorrhage with intraventricular extension and early hydrocephalus. The team is considering invasive ICP monitoring.

a) List THREE clinical indications for invasive ICP monitoring in this patient. (3 marks)

b) State the target cerebral perfusion pressure (CPP) range when using invasive ICP monitoring to guide management. (1 mark)

c) State ONE non-invasive modality that can be used as an alternative when invasive ICP monitoring is contraindicated or unavailable. (1 mark)

You are called by your outreach team nurse to respond to Felix Astoria, a patient on the ward with a seizure.  You arrive to find a 49-year-old female admitted to Neurology with TTP who is undergoing treatment with plasma pheresis and had been stable until just after finishing her first pheresis session whereupon she became confused and somnolent and suffered a seizure.  She is now post ictal, unresponsive but maintaining her airway and her O₂ saturation on simple face mask oxygen.  She has been placed in the recovery position.  The CCOT nurse hands you the blood gas plus they have just obtained by arterial stab.

pO₂ 145 pCO₂ 45 pH 7.63 Total CO₂ 46 Na 147 K 3.2 Cl 83 Glucose 7.4 Lactate 6 Ionized calcium 0.98 Hb 110

Provide the blood gas interpretation (4 marks)

The patient had normal blood gases yesterday.  Other lab abnormalities were BUN 15, Creat 323 umol/L and Plt 89.  Provide the most likely etiology and treatment for this etiology (2 marks) 

Xander Boler, a 29-year-old man with a hypoxic-ischemic brain injury following cardiac arrest has shown no clinical signs of brain function for 72 hours. The ICU team is preparing for a formal determination of death by neurological criteria.

a) List the FIVE minimum clinical criteria required for diagnosis of death by neurological criteria. (5 marks)

a) List FIVE confounding factors that must be excluded before brain death declaration can proceed. (5 marks)

Lonnie Beveridge is a 54-year-old man with alcohol withdrawal delirium who is agitated and requiring escalating doses of benzodiazepines in the ICU. The team is considering dexmedetomidine as an adjunct for sedation and delirium management.

a) Describe the pharmacologic mechanism of action of dexmedetomidine. (1 mark)

b) List THREE adverse effects requiring monitoring during dexmedetomidine use. (3 marks)

Sophie Dunk is a 68-year-old woman on day 4 of mechanical ventilation for pneumonia who is noted to have fluctuating levels of attention and disorganized thinking overnight. The bedside nurse asks about the CAM-ICU assessment tool.

a) Define CAM-ICU and state its purpose in the ICU. (2 marks)

Walter Daniels is admitted to your care with large intracranial hemorrhage.  The nurse calls to tell you that the patient’s left pupil has suddenly dilated and is fixed.

Identify the most likely hemisphere for this intracranial hemorrhage (1 mark)

Explain the pathophysiology of pupillary dilatation in this context (2 marks)

You order mannitol for the patient.  It is provided as a 20% solution in 500mL. Calculate the mass of mannitol in one litre (1 mark)

The junior resident at the bedside removes the patient from the ventilator and commences bagging via the endotracheal tube to improve the patient’s intracranial pressure.

Describe the expected impact on cerebral blood flow (1 mark)

Priya Sharma is a 47-year-old woman with a large spontaneous intracerebral hemorrhage and sustained ICP of 32 mmHg despite head of bed elevation to 30 degrees, fever management, isotonic fluids, and mild sedation. She is intubated with an intraventricular drain in situ. The team is escalating ICP management in a stepwise fashion.

a) State the TWO osmotic therapy agents available, their first-line doses for life-threatening ICP elevation, and their monitoring parameters. (6 marks)

b) State the PaCO2 target for hyperventilation used as a temporizing measure and explain why more aggressive hyperventilation is avoided. (2 marks)

c) Besides propofol list ONE third-tier pharmacologic option for refractory elevated ICP, specifying the drug class and a key adverse effect. (1 mark)

Erin Myers is a 19-year-old female with prolonged seizure admitted for titration of anti-epileptic drugs. She is maintained in burst-suppression with propofol infused at 40mL/hour.

List FOUR laboratory abnormalities consistent with propofol related infusion syndrome (4 marks)

Provide ONE example of a continuous intravenous sedation agent that would also suppress seizure (1 mark)

Provide ONE example of a continuous intravenous sedation agent that would not suppress seizure (1 mark)

Calculate the caloric contribution of propofol to your patient in 24 hours (1 mark)

Carl Mendelsen is a 55-year-old man with no prior psychiatric history, intubated for 6 days following severe pancreatitis with ARDS. He is on propofol 65 mcg/kg/min, has received haloperidol 5 mg IV twice in the past 8 hours, and has a fentanyl infusion at 12.5 mcg/hr. His nurse calls because he is combative (RASS +3), pulling at his ETT, and CAM-ICU is positive. Labs show triglycerides 6.8 mmol/L, pH 7.28, lactate 3.1 mmol/L, and CK 840 U/L.

a) State what the CAM-ICU assesses and identify the two core features required for a positive result. (2 marks)

b) Identify the most urgent concern raised by the combination of high-dose propofol and the laboratory values, name this syndrome, and state two management steps. (3 marks)

c) State your modification to the fentanyl dosing and pharmacokinetic benefit to fentanyl over morphine for prolonged infusion (2 marks)

Nkechi Osei-Bonsu is a 38-year-old woman with severe TBI (GCS 6) managed with an external ventricular drain for ICP monitoring and CSF drainage. She is on controlled ventilation, head of bed 30 degrees, PaCO2 38 mmHg, sodium 145 mmol/L. At hour 18 her ICP acutely reads 32 mmHg; the drain was clamped and the transducer line flushed 20 minutes prior, then the patient was repositioned flat for CT transport. CT head shows no new hemorrhage, no midline shift, and sulcal effacement unchanged from admission. On return, the patient is repositioned at 30 degrees but the transducer remains at the mid-axillary line rather than the external auditory meatus.

a) State the two most likely technical causes of the spurious ICP reading of 32 mmHg in this patient. (2 marks)

b) State the correct anatomical zeroing reference point for an EVD transducer, and calculate the ICP error introduced by a transducer positioned 10 cm below that reference. (3 marks)

c) State two complications specific to EVD insertion that must be excluded before attributing the elevated ICP to monitor error. (2 marks)

Tariq Al-Masri is a 41-year-old man with acetaminophen-induced acute liver failure, INR 6.8, bilirubin 380 µmol/L, and Grade IV hepatic encephalopathy. He is intubated and an EVD is placed for ICP monitoring given transplant candidacy assessment. ICP is 28 mmHg, CPP 58 mmHg, MAP 86 mmHg. Sodium is 148 mmol/L, creatinine 398 µmol/L with oliguria consistent with hepatorenal syndrome type 1, and he is anuric on norepinephrine. The team proposes mannitol 1 g/kg IV.

a) State two reasons mannitol is contraindicated in this patient, and name the serum osmolality threshold above which mannitol must be withheld. (3 marks)

b) State the preferred osmotherapy agent, name one limitation of its use in this patient, and state the target serum sodium range for ICP control. (3 marks)

c) State two non-osmotherapy ICP interventions applicable despite the hepatorenal constraints. (2 marks)

d) State the specific reason ICP monitoring determines management beyond routine neuromonitoring in this patient. (1 mark)

Ron Kaplan is a 52-year-old man with severe ARDS (P/F ratio 72 mmHg) intubated for 36 hours. He is about to undergo prone positioning. Current sedation: propofol 40 mcg/kg/min, RASS -1. His ventilator dyssynchrony is marked with frequent double-triggering and breath stacking. The ICU nurse asks whether the sedation protocol’s default target of RASS 0 to -1 should be maintained during proning.

a) State the appropriate RASS target during prone positioning and neuromuscular blockade, and identify two patient safety rationales specific to proning that justify this departure from light sedation targets. (3 marks)

b) State the class of agent used for neuromuscular blockade in ARDS, name the specific agent with the strongest evidence, and state the maximum recommended duration of continuous infusion. (2 marks)

Adam Okondo is a 47-year-old woman intubated and mechanically ventilated following damage control laparotomy for blunt abdominal trauma with small bowel injury. She has a temporary abdominal closure with a negative pressure wound dressing in situ. On postoperative day 2 she is on a protocolized sedation order targeting RASS 0 to -1. Her nurse documents agitation with RASS +2, pulling at lines, and grimacing. She is on propofol 20 mcg/kg/min and has received two doses of IV haloperidol 5 mg in the past 4 hours without effect. She has no fentanyl or analgesic infusion running.

a) Identify the most important omission in this patient’s current management and state why it is producing the observed agitation. (2 marks)

b) State two specific harms of light sedation targeting in this patient that are distinct from the standard risks of under-sedation in a typical intubated ICU patient. (2 marks)

Emeka Nwachukwu is a 45-year-old man with moderate-severe TBI, admission GCS 9, bifrontal contusions, extubated day 4, neurologically improving. Day 6: sodium 126 mmol/L (was 138 mmol/L day 4), urine sodium 88 mmol/L, urine osmolality 520 mOsm/kg, clinically hypovolemic with rising creatinine. During assessment he has a witnessed generalized tonic-clonic seizure lasting 90 seconds. He has been on levetiracetam since admission. The team asks whether to continue prophylaxis beyond day 7 and what prognosis to give the family.

a) Identify the hyponatremia syndrome, state the single clinical feature that distinguishes it from SIADH, and state the correct treatment direction. (3 marks)

b) State the evidence-based time window for prophylactic antiepileptic use in TBI and state whether levetiracetam should continue beyond day 7. (2 marks)

c) State two recognized pitfalls in early prognostication after TBI that must be communicated to the family. (2 marks)

Cormac Almeida is a 67-year-old man with hypertension and type 2 diabetes admitted with septic shock from pneumonia requiring 18 days of mechanical ventilation, deep sedation (RASS -3 to -4) throughout, and no physiotherapy due to staffing constraints. He received corticosteroids for vasopressor-refractory shock for 10 days. He is extubated on day 22. His wife reports he has not slept normally since extubation, seems confused at times, and cried unprovoked twice yesterday. On exam he cannot lift his arms against gravity.

a) State the syndrome this clinical picture represents. (1 mark)

b) State the three primary domains of this syndrome and classify each of this patient’s symptoms into the correct domain. (3 marks)

c) List four ICU risk factors for this syndrome present in this patient’s course. (2 marks)

d) State two ICU-based prevention strategies absent in this case supported by current evidence. (1 mark)

e) State two components of a structured post-ICU follow-up strategy for this patient and his wife. (1 mark)

Piotr Banda is a 58-year-old man with severe ARDS who received 14 days of controlled mechanical ventilation with cisatracurium infusion and high-dose methylprednisolone for 12 days. On day 18 he is awake but fails every SBT within 20 minutes. Neurological exam shows proximal limb weakness with preserved distal sensation, absent deep tendon reflexes in the lower limbs, and facial muscle sparing. He has a tracheostomy. His cough effort on suctioning is weak and insufficient to mobilize secretions into the tracheostomy tube, resulting in worsening atelectasis on CXR.

a) State the clinical weakness pattern and identify one finding that distinguishes this presentation from pure steroid myopathy. (2 marks)

b) List four bedside measurements used to quantify respiratory muscle strength in a tracheostomized patient. (2 marks)

c) State two modifiable risk factors for ICUAW present in this patient’s course. (1 mark)

d) List three interventions to address the inadequate cough and secretion clearance in this patient. (2 marks)

Zelda Goldie is a 45-year-old female you are called to assess on the neurology floor.  They were admitted with a closed head injury with observation in a level two unit for the past 12 hours.  The nurse tells you that the patient began to seize with generalized tonic/clonic movements five minutes before you arrived. On examination vitals are stable.  The patient is having a generalized seizure.

Define prolonged seizure or status epilepticus (2 marks)

Provide one FIRST-LINE medication for treatment of seizure exceeding five minutes (1 mark)

Identify the brain regions most vulnerable to damage from prolonged seizure (1 mark)

Michael Falk is a 35-year-old male admitted with decreased level of consciousness from traumatic brain injury ten days ago.  EEG is performed to prognosticate the injury severity.

Describe the EEG trace (1 mark)

During the recording, Mr. Falk’s EEG tracing changes.  There are no clinical observable differences in his examination or vitals.

Interpret the EEG (1 mark).

Rheanna Jamieson is a 38-year-old female intubated in your ICU following subarachnoid hemorrhage and coiling of an MCA aneurysm.  She is day 3 post coiling and is receiving triple H therapy for treatment of vasospasm.  Systolic blood pressure target is greater than 170 mm Hg.  Achieving this target has been challenging.  You are called to the bedside because of a decline in neurologic status.

Vitals show heart rate of 92bpm BP 168/80mm Hg.  Ventilator settings are controlled ventilation FiO₂ 0.5 PEEP 10.  She is on norepinephrine at 0.2mcg/kg/m, phenylephrine 200 mcg/minute and vasopressin 2.4u/h. She has extensor posturing bilaterally with reactive pupils.  She had been localizing when you examined her last night. Her bloodwork reveals the following:

CT head does not demonstrate new bleeding.

Identify the most likely etiology for decline in neurologic status (1 mark)

Explain the mechanism for this decompensation (3 marks)

Thom Marigold is a 42-year-old patient admitted with decreased level of consciousness in the context of decompensated cirrhosis.  The patient’s MELD-Na score is 12.

Interpret the EEG and identify the predominant rhythm (1 mark)

Provide the frequency of EEG activity (1 mark)

Corinne Gardner is a 24-year-old female admitted with prolonged seizure. Lumbar puncture is consistent with bacterial meningitis. You are interpreting the EEG.

List four waveform frequencies in a normal EEG. Provide the frequency range for each waveform (4 marks)

Define seizure (2 marks)

You are called to assess Lesley Smith, a 58-year-old previously healthy woman who was found collapsed at home. She was last seen 3 hours previously, when she was well.   She is intubated.  Her CT is shown below.

Provide the most likely diagnosis based on the CT imaging and clinical history (1 mark)

List the two most common etiologies for this presentation (2 marks)

Identify the most likely etiology (1 mark)

Neurosurgery assesses the patient and describes her as Hunt-Hess Grade 3.  Based on this grading, describe your anticipated neurological examination (2 marks)

Early the next morning the patient has a sudden deterioration with extensor posturing.  Provide the most likely reason for her deterioration (1 mark)

Gwendolyn Poirier is a 40-year-old woman admitted with decreased level of consciousness in the context of glioblastoma multiforme.  You are asked to help with the clinical diagnosis of brain death following massive intracranial hemorrhage.  With respect to the clinical examination of cranial nerves, outline the afferent and efferent nerve (name and number) pathways involved with the following reflexes (8 marks).

Corneal Reflex
Pupillary Reflex
Oculocephalic Reflex
Gag Reflex

Following the physical examination you proceed with apnea testing for Neurologic Determination of Death using apneic oxygenation.

Describe the blood gas (pH, PaCO2, PaO2) you will attempt to achieve prior to inducing apnea (3 marks)

Describe the MOST IMPORTANT bedside clinical monitoring after commencement of testing (1 mark)

Outline your investigation strategy during the apneic period (1 mark)

Explain the rate at which pCO₂ increases in mmHg/minute, assuming an in-line ETT catheter for oxygen and not carbon dioxide enrichment (1 mark)

Idris Manuel is a 63-year-old male day 3 post admission following cardiac arrest.  CT head on admission had showed loss of grey white differentiation.  Overnight he had an episode of hemodynamic instability that has since resolved.  His Glasgow coma scale score is 3 and his pupils are non-reactive.  You think it is likely that he has progressed to neurological death.

List three criteria for a positive apnea test (3 marks)

List three clinical situations where ancillary testing is indicated for NDD (3 marks)

List two ancillary tests for NDD (2 marks)

Fumiko Hashimoto is a 63-year-old woman with a devastating brainstem stroke involving the pons and midbrain. Her family has consented to withdrawal of life-sustaining therapy and donation after circulatory determination of death (DCC). Life-sustaining therapy is withdrawn in the operating room. Circulation ceases at time zero. At 4 minutes and 20 seconds of observation, the cardiac monitor shows a brief return of an organized rhythm lasting 8 seconds before irreversible asystole resumes.

a) Name the phenomenon observed at 4 minutes 20 seconds and state whether the DCC observation period restarts from this point or continues from time zero. (2 marks)

b) State the minimum observation period required before DCC can be declared in Canada (1 mark)

c) State why infratentorial brainstem injury without significant supratentorial involvement does not fulfill Donation by Neurologic Criteria and requires ancillary investigation. (1 mark)

d) Identify ONE bedside investigation capable of ruling OUT Death by Circulatory criteria (1 mark)

Adaeze Okonkwo is a 41-year-old woman with a massive spontaneous intracerebral hemorrhage and complete absence of brainstem reflexes. During the first neurological determination of death examination, the physician applies sternal pressure and observes bilateral arm flexion, shoulder adduction, and both hands rising above the level of the chest. There is no response to supraorbital pressure. All confounders have been excluded. The examining physician is uncertain whether this finding invalidates the Death by Neurologic Criteria (DNC).

a) Name this specific finding, classify it as a spinal or centrally mediated response, and state whether it invalidates DNC. (3 marks)

Ryszard Kowalczyk is a 58-year-old man with devastating anoxic brain injury on day 3 post-cardiac arrest who meets all preconditions for NDD. During the closed-circuit CPAP apnea test, the ventilator waveform shows a series of triggered breaths appearing at a rate of 8 per minute. The chest wall does not move. The physician at the bedside observes no respiratory effort with the patient’s gown drawn to the umbilicus. ABGs at 10 minutes: PaCO2 58 mmHg, baseline PaCO2 was 42 mmHg, pH 7.31.

a) Identify the most likely cause of the triggered breaths on the ventilator waveform and state whether this finding invalidates the apnea test. (2 marks)

b) List ONE respiratory monitor you could use to CONFIRM absence of spontaneous respiratory effort (1 mark)

c) Name THREE blood gas criteria for positive apna test and whether these criteria have been met here (Write Yes or No) (2 marks)

d) State ONE modification to the closed-circuit apnea test setup that reduces the risk of this artefact occurring. (1 mark)

e) This unit uses CPAP for apnea testing. List TWO other respiratory strategies during apnea testing (2 marks)

Hyeon-Ji Bae is a 29-year-old man with a devastating traumatic brain injury who meets clinical criteria for Death by Neurologic Criteria (DNC). His family has been at the bedside for 36 hours. The bedside nurse reports that the family does not understand that death has occurred and believes the ventilator is keeping him alive. The ICU team and the organ donation coordinator are planning a family meeting to discuss DNC and the possibility of organ donation

a) List THREE communication strategies recommended when delivering news of neurological death to families of potential donors. (2 marks)

b) State ONE factor identified as a ignificant barrier to family consent for organ donation. (1 mark)

Robert Edward Rutherford, date of birth October 19th 1955, is admitted to the hospital under the orthopedic service after a fall at home on April 14th, 2022.   His previous medical history includes type II diabetes mellitus treated with oral hypoglycemic, chronic obstructive lung disease with 2 L/min home oxygen, and a previous myocardial infarction.

Radiographs show a fracture of his right femur.  This is repaired with a plate on April 16th under spinal anesthesia. Mr. Rutherford makes a slow recovery however 5 weeks after admission plans are being made for transfer to rehabilitation hospital.  Unfortunately, despite prophylactic dalteparin, he has a PEA arrest due to massive pulmonary embolism.  A prolonged attempt at resuscitation is unsuccessful and he is declared dead at 14:30 hours on June 5th, 2012.  Family does not want autopsy or organ donation.

List four death circumstances necessitating coroner notification (4 marks)

Hayley Thom is an 82-year-old woman is admitted to medicine with an upper GI bleed.  In the course of the admission resuscitation goals were addressed and the woman stated that she did not want further investigations but was accepting of blood transfusion and medical therapy but if she were to deteriorate she would not want any heroics.  After exploring her wishes and preferences the resuscitation care set was completed as a DNR restricted.  Shortly after admission she has further bleeding and deteriorates to the point that she cannot consent.  Her family arrive and want her intubated, investigated and to receive maximal treatments.

Provide one ethical principle that would be violated if one follows the family request (1 mark)

List three essential elements for informed consent (3 marks)

Describe the principles informing decision making in Ontario for substitute decision makers (2 marks)

Anderson Meeks is a 58-year-old man with septic shock, acute kidney injury, thrombocytopenia, and encephalopathy admitted to the ICU following emergency bowel resection. The bedside team calculates his Sequential Organ Failure Assessment (SOFA) score on admission and again at 48 hours.

a) List the SIX organ systems variables e.g. for Respiratory, Coagulation, Hepatic, Cardiovascular, Neurologic and Renal. (6 marks)

b) State what a rising SOFA score over the first 48 hours of ICU admission predicts, and state ONE validated use of the delta-SOFA compared to the admission SOFA alone. (2 marks)

You are the director of your ICU.  Your charge nurse tells you that two physicians, Dr Ahmed and Dr. Bath, are having a heated argument in the unit.  Nurses are uncomfortable.  You ask the two docs to step into your office.  They refuse and walk away.

Describe four strategies to resolve this situation (4 marks)

You are on call and get to talking to a junior nurse, Dene Cristen.  They are troubled by a death in the ICU of a young man who was quadriplegic and ventilator dependent and decided that he no longer wished to continue with ventilation.  The nurse is upset that the ICU had participated in MAID (medical assistance in dying).  You were part of the circle of care of this young man and you know that he had withdrawal of life support.  Provide the differences between MAID and withdrawal of life support to draw the distinction between these two forms of dying according to the following categories: (6 marks)

• Intent
• Necessity for patient consent/capacity
• Medication Dosing

You are the intensivist navigating a challenging family situation for Leopold Bluth, a patient lacking capacity.

Describe two important elements that define “capacity” in the healthcare consent setting (2 marks)

Describe the person who is responsible for determining whether a patient is mentally capable to consent to treatment offered (1 mark)

List and order the top seven potential substitute decision makers according to their hierarchy.  Base your response on the Health Care Consent act (7 marks)

Outline three requirements of a substitute decision maker as it pertains to providing or refusing to provide consent (3 mark)

Your colleague, Dr. Richelle divulges struggling with coping during clinical work.

Define burnout (1 mark)

List TWO signs or symptoms of burnout (2 marks)

List TWO strategies or resources for physicians experiencing psychological distress (2 marks)

Due to resource scarcity, you are chairing the Mercy Hospital Drug and Therapeutics Committee and tasked with determining eligibility for certain medications. Your committee is considering the use of corticosteroids in the critical care unit.

Complete the following chart, indicating whether steroids are indicated for the listed condition and if so, the type of steroid and dose. If steroids are not indicated, write N/A for Medication Name and Dose (8 marks)

Describe one ethical principle employed during this process (1 mark)

Maurice Leblanc is a 67-year-old male under your care in the intensive care unit.  He was admitted ten days ago with aneurysmal subarachnoid hemorrhage.  There is evidence of ongoing vasospasm. Two days ago he became hypotensive requiring higher doses of norepinephrine, blood, urine and sputum cultures were drawn and empiric cefazolin was provided. Gentamicin was also ordered for Mr. Leblanc and not administered due to discontinuation by a pharmacy technician who noted an allergy in his medical record.

A CSF culture drawn two days ago was positive for pseudomonas, however, this is brought to your attention now.  Mr Leblanc becomes increasingly unstable.  Appropriate antimicrobials are ordered.  Based on the adverse events framework, describe the type of adverse event reflected by the gentamicin order (1 mark)

Based on the same framework, describe the type of adverse event reflected by the CSF culture result (1 mark)

It is felt Mr. Leblanc experienced harm in the form of organ dysfunction for multiple days as a result of his care.  Outline appropriate steps in disclosure to his substitute decision maker, if any (4 marks)

Provide two words or expression that should be avoided when making apologies to families (2 marks)

Aiyana Whitehorse is a 44-year-old woman with ARDS on mechanical ventilation in the ICU. Her resident team has recently transitioned to 16-hour duty shifts from 30-hour shifts. The ICU director notes an increase in near-miss events and suspects handover frequency may be a contributing factor. A quality improvement committee is reviewing barriers to effective handover and the impact of duty hour changes.

a) List FOUR factors identified in the Royal College Handover Toolkit that contribute to omission of crucial information during handover. (4 marks)

b) When considering duty-hour reduction, identify ONE mechanism by which errors may be REDUCED and ONE mechanism by which they may be INCREASED. (2 marks)

c) List ONE evidence-based outcome noted in studies evaluating implementation of standardized handover tools such as I-PASS. (1 mark)