Critical care, emergency medicine and nutrition support: a BCPS review from shock to feeding

Study cases written by our editors, not BPS items. The real BCPS exam is computer-based multiple choice, answered in order with no going back.

1. Case 01

   A 30-year-old man (80 kg) with a crush injury of both legs needs rapid sequence intubation for agitation and hypoxemia. Labs: K 6.7 mEq/L with peaked T waves, CK 48,000 units/L. Etomidate has been chosen for induction. Which neuromuscular blocker is most appropriate?

   1. AOption A: Rocuronium 1.2 mg/kg IV now
   2. BOption B: Cisatracurium 0.2 mg/kg IV
   3. COption C: Succinylcholine 1.5 mg/kg IV
   4. DOption D: Vecuronium 0.1 mg/kg IV

   Pick an option: the verdict and a note on every option open here.

   Best answer: A.

   Succinylcholine depolarizes muscle cells and raises serum potassium by about 0.5 mEq/L, and much more in crush injury and rhabdomyolysis, so it is contraindicated with K 6.7 mEq/L. Rocuronium at 1.2 mg/kg is non-depolarizing and gives intubating conditions within about 60 seconds, comparable to succinylcholine. Vecuronium and cisatracurium are also non-depolarizing, but their onset at these doses is too slow for rapid sequence intubation.

   A

   Correct: high-dose rocuronium is non-depolarizing and gives intubating conditions in about 60 seconds without raising potassium.

   B

   Cisatracurium is non-depolarizing, but its onset is too slow for rapid sequence intubation.

   C

   Succinylcholine raises potassium and is contraindicated with K 6.7 mEq/L and rhabdomyolysis.

   D

   Vecuronium at this dose has an onset too slow for rapid sequence intubation.

2. Case 02

   A 34-year-old woman with anorexia nervosa (BMI 14.8 kg/m², minimal intake for 12 days) started parenteral nutrition at 10 kcal/kg/day yesterday after thiamine. Today she is weak and short of breath. Labs: phosphorus 1.1 mg/dL (baseline 3.0), K 3.1 mEq/L, Mg 1.5 mg/dL, glucose 142 mg/dL. Which action is most appropriate?

   1. AOption A: Add calcium gluconate and continue the advance
   2. BOption B: Hold the calorie advance; replace phosphate IV
   3. COption C: Advance PN to goal calories and recheck tomorrow
   4. DOption D: Increase the PN amino acid content

   Pick an option: the verdict and a note on every option open here.

   Best answer: B.

   Severe hypophosphatemia with low K and Mg on day 1 of feeding is refeeding syndrome, caused by insulin-driven intracellular shift; calorie advancement should be held and phosphate (with K and Mg) replaced IV, with labs checked at least daily. Advancing to goal calories is the tempting plan but increases the insulin surge and can cause respiratory failure, arrhythmia and death. Calcium binds phosphate and does not correct the deficit, and adding amino acids does not treat the electrolyte shift.

   A

   Calcium binds phosphate and does not correct the deficit, and continuing the advance feeds the refeeding shift.

   B

   Correct: severe hypophosphatemia on day 1 of feeding is refeeding syndrome, so hold the advance and replace phosphate IV.

   C

   Advancing to goal is tempting but increases the insulin surge and can cause respiratory failure and arrhythmia.

   D

   More amino acids do not treat the electrolyte shift driving her weakness and dyspnea.

3. Case 03

   A 58-year-old woman with septic shock from pyelonephritis received cultures, piperacillin/tazobactam within 1 hour, and 30 mL/kg balanced crystalloid. She is on norepinephrine 0.12 mcg/kg/min with MAP 66 mm Hg. Her initial lactate was 4.4 mmol/L. Which monitoring strategy is most appropriate to guide further resuscitation?

   1. AOption A: Titrate fluids to a urine output of 2 mL/kg/hr
   2. BOption B: Repeat lactate within 2–4 hours and target its decline
   3. COption C: Titrate fluids to a central venous pressure of 8–12 mm Hg
   4. DOption D: Titrate therapy to a ScvO2 of 70% or higher

   Pick an option: the verdict and a note on every option open here.

   Best answer: B.

   Surviving Sepsis guidance suggests guiding resuscitation by serial lactate measurement (with capillary refill time as an adjunct) because falling lactate tracks restored perfusion and lower mortality. CVP and ScvO2 targets come from early goal-directed therapy protocols that ProCESS, ARISE, and ProMISe showed add no benefit. A urine output target of 2 mL/kg/hr is excessive (0.5 mL/kg/hr is the usual threshold) and invites fluid overload.

   A

   A urine output target of 2 mL/kg/hr is excessive and invites fluid overload; 0.5 mL/kg/hr is the usual threshold.

   B

   Correct: a repeat lactate within 2–4 hours tracks restored perfusion, and its fall guides further resuscitation.

   C

   CVP targets come from early goal-directed protocols that ProCESS, ARISE and ProMISe found added no benefit.

   D

   ScvO2 targets belong to the same early goal-directed protocols, which showed no added benefit in later trials.

4. Case 04

   A 66-year-old man is mechanically ventilated for septic shock and requires norepinephrine 0.2 mcg/kg/minute. He has oliguric AKI (SCr 3.0 mg/dL, baseline 1.0 mg/dL; urine output 15 mL/hour). CPOT pain score is 5 with a goal of analgesia-first sedation. Which continuous infusion is most appropriate?

   1. AOption A: Hydromorphone 0.5 mg/hour
   2. BOption B: Propofol 20 mcg/kg/minute alone
   3. COption C: Fentanyl 50 mcg/hour
   4. DOption D: Morphine 2 mg/hour

   Pick an option: the verdict and a note on every option open here.

   Best answer: C.

   Fentanyl causes no histamine release, has minimal hemodynamic effect and has no active metabolites that accumulate in kidney failure, so it is preferred for analgesia in hypotensive, oliguric patients. Morphine releases histamine (hypotension) and its active 6- and 3-glucuronide metabolites accumulate in AKI. Hydromorphone’s 3-glucuronide metabolite can also accumulate in renal failure, and propofol alone provides no analgesia and worsens hypotension.

   A

   Hydromorphone’s 3-glucuronide metabolite can accumulate in kidney failure, so it is less suited than fentanyl.

   B

   Propofol alone gives no analgesia, which an analgesia-first approach needs, and it worsens hypotension.

   C

   Correct: fentanyl has minimal hemodynamic effect and no active metabolites that build up in oliguric AKI.

   D

   Morphine releases histamine and its glucuronides accumulate in AKI, a poor fit in shock with oliguria.

5. Case 05

   A 45-year-old woman has an end-jejunostomy with about 100 cm of remaining small bowel after resection for mesenteric ischemia 10 days ago. She receives parenteral nutrition and is starting oral intake. Stoma output is 3.2 L/day, and she is thirsty and drinking large amounts of water and juice. Na 132 mEq/L, Mg 1.4 mg/dL. Which intervention is most appropriate?

   1. AOption A: Start loperamide and high-dose PPI therapy
   2. BOption B: Start teduglutide now to promote adaptation
   3. COption C: Encourage more water and fruit juice
   4. DOption D: Stop PN and advance to a full oral diet

   Pick an option: the verdict and a note on every option open here.

   Best answer: A.

   Early after massive resection, gastric acid hypersecretion and rapid transit drive high stoma output, so a high-dose PPI and an antimotility agent such as loperamide (given before meals) are first-line; hypotonic drinks should be replaced with an oral rehydration solution. Drinking more water and juice is the instinctive response but worsens output because hypotonic fluid draws sodium into the jejunal lumen. Teduglutide is for PN-dependent patients after the adaptation period, and stopping PN now would cause dehydration and malnutrition.

   A

   Correct: early after massive resection, acid hypersecretion and rapid transit respond to a high-dose PPI plus loperamide.

   B

   Teduglutide is for PN-dependent patients after the adaptation period, not 10 days after resection.

   C

   Hypotonic water and juice draw sodium into the jejunal lumen and raise stoma output further.

   D

   Stopping PN with 3.2 L/day of output would cause dehydration and malnutrition.

6. Case 06

   A 54-year-old woman (70 kg) has a confirmed pulmonary embolism with SBP 80 mm Hg for 20 minutes despite a 500-mL fluid bolus, RV dilation on echocardiography and troponin elevation. She has no history of stroke, recent surgery, bleeding or uncontrolled hypertension. A heparin bolus has been given. Which treatment is most appropriate?

   1. AOption A: Apixaban 10 mg orally twice daily
   2. BOption B: Continue heparin infusion alone
   3. COption C: Alteplase 0.9 mg/kg IV (max 90 mg)
   4. DOption D: Alteplase 100 mg IV over 2 hours

   Pick an option: the verdict and a note on every option open here.

   Best answer: D.

   Sustained hypotension makes this high-risk PE, for which systemic thrombolysis with alteplase 100 mg over 2 hours is recommended (CHEST; 2026 AHA/ACC acute PE guideline) when there is no contraindication; heparin is held during the infusion and then resumed. Continuing heparin alone is appropriate for normotensive PE but does not reverse RV failure in time. The 0.9 mg/kg (maximum 90 mg) regimen is the acute ischemic stroke dose, and an oral DOAC is not appropriate in hemodynamically unstable PE.

   A

   An oral DOAC is not appropriate in hemodynamically unstable PE.

   B

   Heparin alone suits normotensive PE but does not reverse RV failure in time when she is in shock.

   C

   The 0.9 mg/kg regimen capped at 90 mg is the acute ischemic stroke dose, not the PE dose.

   D

   Correct: sustained hypotension makes this high-risk PE, treated with alteplase 100 mg over 2 hours when nothing contraindicates it.

7. Case 07

   A 70-year-old woman with septic shock from pneumonia has received adequate fluids and antibiotics. For the past 6 hours she has needed norepinephrine 0.3 mcg/kg/minute plus vasopressin 0.03 units/minute to keep MAP at 65 mm Hg. She has no history of adrenal disease, and her glucose is 168 mg/dL. Which adjunct therapy is most appropriate?

   1. AOption A: Methylprednisolone 125 mg IV every 6 hours
   2. BOption B: Fludrocortisone 50 mcg orally daily alone
   3. COption C: Dexamethasone 6 mg IV daily
   4. DOption D: Hydrocortisone 50 mg IV every 6 hours

   Pick an option: the verdict and a note on every option open here.

   Best answer: D.

   The Surviving Sepsis Campaign suggests IV corticosteroids for septic shock with ongoing vasopressor requirement (norepinephrine of at least 0.25 mcg/kg/minute for at least 4 hours), using hydrocortisone 200 mg/day, usually as 50 mg every 6 hours, which shortens shock duration. Dexamethasone 6 mg is the COVID-19 dose and has no mineralocorticoid activity. Fludrocortisone alone gives no glucocorticoid effect, and high-dose methylprednisolone increases adverse effects without benefit in shock.

   A

   High-dose methylprednisolone adds adverse effects without benefit in septic shock.

   B

   Fludrocortisone alone gives no glucocorticoid effect for shock.

   C

   Dexamethasone 6 mg is a COVID-19 dose and has no mineralocorticoid activity.

   D

   Correct: an ongoing vasopressor need calls for hydrocortisone 200 mg/day, usually 50 mg every 6 hours, which shortens shock.

8. Case 08

   A 42-year-old man (85 kg) with a moderate traumatic brain injury and a small contusion with subarachnoid hemorrhage is in the trauma ICU. Repeat head CT at 24 and 48 hours shows no expansion, he needs no further neurosurgical intervention, and intermittent pneumatic compression devices are on. CrCl is 105 mL/min and platelets 240,000 cells/mm³. Which VTE prophylaxis plan is most appropriate now?

   1. AOption A: Continue compression devices only for 14 days
   2. BOption B: Start enoxaparin 30 mg SC every 12 hours
   3. COption C: Start apixaban 2.5 mg orally twice daily
   4. DOption D: Start a therapeutic heparin infusion

   Pick an option: the verdict and a note on every option open here.

   Best answer: B.

   Once repeat imaging shows a stable hemorrhage (usually 24–72 hours after injury), pharmacologic prophylaxis should be added to mechanical prophylaxis, and trauma guidance prefers LMWH such as enoxaparin 30 mg every 12 hours. Delaying for 2 weeks is the tempting cautious choice, but TBI patients have a very high VTE risk and delay increases DVT and PE without reducing hemorrhage expansion. Apixaban is not established for trauma prophylaxis and is hard to reverse, and a therapeutic heparin infusion is a treatment dose that would raise bleeding risk.

   A

   Delaying drug prophylaxis 2 weeks raises DVT and PE risk without reducing hemorrhage expansion.

   B

   Correct: once repeat CT shows a stable bleed, enoxaparin 30 mg every 12 hours is the preferred trauma prophylaxis.

   C

   Apixaban is not established for trauma prophylaxis and is harder to reverse.

   D

   A therapeutic heparin infusion is a treatment dose that would raise intracranial bleeding risk.

9. Case 09

   A 58-year-old woman is admitted to the ICU after an uncomplicated laparoscopic colectomy for monitoring of new atrial fibrillation. She is breathing spontaneously, eating, and has no shock, coagulopathy, GI bleeding history or chronic liver disease. She had C. difficile infection 1 year ago. She is on apixaban for AF. Which stress ulcer prophylaxis plan is most appropriate?

   1. AOption A: Sucralfate 1 g four times daily
   2. BOption B: Pantoprazole 40 mg IV daily
   3. COption C: No stress ulcer prophylaxis
   4. DOption D: Famotidine 20 mg IV twice daily

   Pick an option: the verdict and a note on every option open here.

   Best answer: C.

   Stress ulcer prophylaxis is indicated in critically ill patients with risk factors such as coagulopathy, shock, mechanical ventilation over 48 hours or chronic liver disease (SCCM 2024); she has none, so prophylaxis would add risk without benefit. Acid suppression increases C. difficile and pneumonia risk, which matters given her prior infection. Sucralfate is less effective than acid suppression and is no longer a recommended prophylaxis option, and a therapeutic anticoagulant alone, without other risk factors, does not mandate prophylaxis.

   A

   Sucralfate is less effective than acid suppression and is no longer a recommended prophylaxis option.

   B

   A PPI adds C. difficile and pneumonia risk without benefit when she has no prophylaxis indication.

   C

   Correct: she has no shock, coagulopathy, ventilation or liver disease, so prophylaxis would add risk without benefit.

   D

   Famotidine is acid suppression too, and her prior C. difficile makes unneeded acid suppression a real risk.

10. Case 10

    A 31-year-old man with a severe traumatic brain injury has ICP 28 mm Hg despite sedation, head-of-bed elevation and normocapnia. BP is 92/54 mm Hg on norepinephrine after hemorrhage from a femur fracture, CVP is 4 mm Hg, Na 138 mEq/L and serum osmolality 288 mOsm/kg. He has a central venous catheter. Which treatment is most appropriate to lower ICP?

    1. AOption A: 23.4% sodium chloride 30 mL IV (central line)
    2. BOption B: Pentobarbital load, then infusion to burst suppression
    3. COption C: Furosemide 40 mg IV push, repeated as needed
    4. DOption D: Mannitol 20% 1 g/kg IV over 15 minutes

    Pick an option: the verdict and a note on every option open here.

    Best answer: A.

    Hypertonic saline lowers ICP by drawing water out of brain tissue and also expands intravascular volume, which matters in a hypotensive, hypovolemic patient; 23.4% saline must be given through a central line. Mannitol lowers ICP too, but its osmotic diuresis can worsen hypovolemia and hypotension, reducing cerebral perfusion pressure. Furosemide alone does not reliably lower ICP and depletes volume, and pentobarbital coma is a last-tier therapy that causes marked hypotension.

    A

    Correct: hypertonic saline lowers ICP and expands intravascular volume, which suits a hypotensive patient; 23.4% needs central access.

    B

    Pentobarbital coma is a last-tier option and causes marked hypotension he cannot afford.

    C

    Furosemide does not reliably lower ICP and depletes volume in a patient who is already hypovolemic.

    D

    Mannitol lowers ICP, but its osmotic diuresis worsens hypovolemia and cerebral perfusion pressure.

11. Case 11

    A 45-year-old woman with a history of severe postoperative nausea and vomiting, who does not smoke, is scheduled for laparoscopic cholecystectomy under general anesthesia. Her preoperative ECG shows a QTc of 515 ms from congenital long QT syndrome. Which antiemetic prophylaxis is most appropriate?

    1. AOption A: Ondansetron 4 mg IV at end of surgery
    2. BOption B: Haloperidol 1 mg IV at end of surgery
    3. COption C: Dexamethasone 4 mg IV at induction
    4. DOption D: Droperidol 0.625 mg IV at end of surgery

    Pick an option: the verdict and a note on every option open here.

    Best answer: C.

    Dexamethasone 4–8 mg at induction prevents PONV through anti-inflammatory and central effects and does not prolong the QT interval, so it suits long QT syndrome. Ondansetron is the usual first choice, but 5-HT3 antagonists prolong QTc dose-dependently and should be avoided at a QTc of 515 ms. Droperidol carries a boxed warning for QT prolongation and torsades, and haloperidol also prolongs QTc.

    A

    Ondansetron prolongs QTc dose-dependently and should be avoided with a QTc of 515 ms.

    B

    Haloperidol also prolongs QTc, which rules it out in congenital long QT syndrome.

    C

    Correct: dexamethasone at induction prevents PONV without prolonging the QT interval.

    D

    Droperidol carries a boxed warning for QT prolongation and torsades.

12. Case 12

    A 40-year-old man with chronic heavy alcohol use reports taking acetaminophen 1,000 mg six to eight times daily for 4 days for a toothache. He is nauseated with right upper quadrant tenderness. Labs: acetaminophen 30 mcg/mL (time since last dose uncertain), AST 380 units/L, ALT 420 units/L, INR 1.3. Which action is most appropriate?

    1. AOption A: Repeat the level in 4 hours before deciding
    2. BOption B: Hold treatment; level is below the 150 line
    3. COption C: Start IV acetylcysteine now
    4. DOption D: Give activated charcoal only

    Pick an option: the verdict and a note on every option open here.

    Best answer: C.

    The Rumack-Matthew nomogram applies only to a single acute ingestion at a known time; after repeated supratherapeutic ingestion, any detectable acetaminophen or raised aminotransferases is an indication for acetylcysteine, and chronic alcohol use (glutathione depletion) increases the risk. Withholding treatment because the level is below the treatment line is the classic misapplication of the nomogram. Waiting for a repeat level delays an antidote that works best early, and activated charcoal has no role days after the last dose.

    A

    Waiting 4 hours for another level delays an antidote that works best when started early.

    B

    The nomogram applies only to a single acute ingestion at a known time, not to repeated ingestion like this.

    C

    Correct: repeated supratherapeutic ingestion with raised aminotransferases is an indication for acetylcysteine now.

    D

    Activated charcoal has no role days after the last dose, and it would not replace the antidote.

13. Case 13

    A pharmacist is compounding a 2-in-1 parenteral nutrition admixture for a 60-year-old patient on long-term home PN who needs calcium 15 mEq/day and phosphate 30 mmol/day. Which compounding practice best prevents calcium-phosphate precipitation?

    1. AOption A: Add calcium first, then phosphate, to the bag
    2. BOption B: Infuse through a 0.22-micron filter without checking solubility
    3. COption C: Use calcium gluconate and check the solubility curve
    4. DOption D: Use calcium chloride for its higher calcium content

    Pick an option: the verdict and a note on every option open here.

    Best answer: C.

    Calcium gluconate dissociates less than calcium chloride, so it is the preferred salt in PN, and the amounts should be checked against a calcium-phosphate solubility curve for the specific amino acid concentration, volume and temperature, with phosphate added early and calcium near the end. Adding calcium first, while the solution is most concentrated, promotes precipitation. Calcium chloride is highly dissociated and precipitates more readily, and a filter only traps precipitate; it does not make an unsafe formulation safe (precipitate emboli have caused deaths).

    A

    Adding calcium first, while the solution is most concentrated, promotes precipitation; phosphate goes in early.

    B

    A filter only traps precipitate; it does not make an unsafe formulation safe.

    C

    Correct: calcium gluconate dissociates less than the chloride salt, and the solubility curve confirms the amounts are compatible.

    D

    Calcium chloride is highly dissociated and precipitates with phosphate more readily.

14. Case 14

    A 29-year-old man with severe traumatic brain injury has received propofol at 80 mcg/kg/minute for 72 hours to control ICP. Today he has new metabolic acidosis (lactate 5.8 mmol/L), CK 9,400 units/L, triglycerides 640 mg/dL, rising norepinephrine requirement and a new Brugada-like ECG pattern. Which action is most appropriate?

    1. AOption A: Continue propofol and start a bicarbonate infusion
    2. BOption B: Reduce propofol to 50 mcg/kg/minute and recheck lactate
    3. COption C: Stop propofol and change to another sedative
    4. DOption D: Continue propofol and add fenofibrate

    Pick an option: the verdict and a note on every option open here.

    Best answer: C.

    Lactic acidosis, rhabdomyolysis, hypertriglyceridemia, worsening shock and ECG changes during high-dose prolonged propofol indicate propofol-infusion syndrome, which is often fatal unless propofol is stopped at once and another sedative (for example, midazolam) is used. Reducing the dose is the tempting compromise, but continued exposure keeps impairing mitochondrial fatty acid oxidation. Treating the acidosis or triglycerides while continuing propofol addresses consequences rather than the cause.

    A

    Bicarbonate treats the acidosis but not its cause, and continued propofol keeps the syndrome going.

    B

    Dose reduction is a tempting compromise, yet any continued exposure keeps impairing mitochondrial fatty acid oxidation.

    C

    Correct: acidosis, rhabdomyolysis, high triglycerides and ECG changes point to propofol infusion syndrome, so stop it now.

    D

    Fenofibrate addresses only the triglycerides and leaves the toxic infusion running.

15. Case 15

    A 61-year-old man has been mechanically ventilated for 4 days for ARDS. Two weeks ago he was hospitalized for a bleeding duodenal ulcer. Platelets are 92,000 cells/mm³ and INR 1.6. Enteral nutrition at goal rate started yesterday. Which stress ulcer prophylaxis plan is most appropriate?

    1. AOption A: Sucralfate 1 g per tube every 6 hours
    2. BOption B: No prophylaxis now that tube feeds are at goal
    3. COption C: Famotidine 20 mg IV twice daily
    4. DOption D: Pantoprazole 40 mg IV once daily

    Pick an option: the verdict and a note on every option open here.

    Best answer: D.

    Mechanical ventilation beyond 48 hours, coagulopathy and a recent GI bleed put him at high bleeding risk, and SCCM 2024 prefers a PPI over an H2RA in that situation because PPIs suppress acid more reliably. Famotidine is an acceptable agent for lower-risk patients but is less protective here. Enteral nutrition alone has not been shown to replace pharmacologic prophylaxis in high-risk patients, and sucralfate is less effective and can form bezoars with tube feeds.

    A

    Sucralfate is less effective and can form bezoars with tube feeds.

    B

    Enteral nutrition alone has not been shown to replace drug prophylaxis in a high-risk patient.

    C

    Famotidine is acceptable at lower risk but protects less reliably than a PPI here.

    D

    Correct: ventilation, coagulopathy and a recent ulcer bleed make him high risk, and a PPI is preferred over an H2RA.

16. Case 16

    A 48-year-old man with short bowel syndrome has received home parenteral nutrition for 3 years. Because of a product shortage, his PN has contained no trace elements for the past 5 months. He now has fatigue, proximal muscle weakness, white nail beds and new heart failure with an LVEF of 30%; coronary angiography and thiamine levels are normal. Which deficiency most likely explains his findings?

    1. AOption A: Copper
    2. BOption B: Zinc
    3. COption C: Chromium
    4. DOption D: Selenium

    Pick an option: the verdict and a note on every option open here.

    Best answer: D.

    Selenium deficiency during long-term PN without trace elements causes a dilated cardiomyopathy (as in Keshan disease), skeletal myopathy and whitening of the nail beds, which matches this picture. Copper deficiency is the tempting alternative, but it causes anemia, neutropenia and myeloneuropathy rather than cardiomyopathy. Zinc deficiency causes dermatitis, alopecia and poor wound healing, and chromium deficiency causes glucose intolerance and peripheral neuropathy.

    A

    Copper deficiency causes anemia, neutropenia and myeloneuropathy rather than cardiomyopathy.

    B

    Zinc deficiency causes dermatitis, alopecia and poor wound healing.

    C

    Chromium deficiency causes glucose intolerance and peripheral neuropathy.

    D

    Correct: selenium deficiency causes cardiomyopathy, skeletal myopathy and white nail beds, matching this picture.

17. Case 17

    A 58-year-old man on mechanical ventilation for 5 days now passes spontaneous breathing trials, but each sedation interruption brings severe agitation with CAM-ICU-positive delirium, so extubation has been deferred twice. Pain is controlled (CPOT 1) and there is no alcohol withdrawal. HR is 92 beats/minute and MAP 78 mm Hg. Which medication is most appropriate?

    1. AOption A: Quetiapine 50 mg BID
    2. BOption B: Lorazepam 2 mg IV every 4 hours
    3. COption C: Dexmedetomidine IV infusion
    4. DOption D: Haloperidol 5 mg IV every 6 hours

    Pick an option: the verdict and a note on every option open here.

    Best answer: C.

    PADIS suggests dexmedetomidine for ventilated adults whose agitated delirium prevents weaning or extubation, because it calms without respiratory depression and allowed earlier extubation in trials. Scheduled haloperidol is the tempting traditional choice, but trials showed no reduction in delirium duration, so it is not routinely recommended. Quetiapine and other scheduled antipsychotics have the same lack of benefit, and benzodiazepines such as lorazepam worsen delirium.

    A

    Scheduled quetiapine has not shortened delirium in ventilated patients and does not solve the weaning problem.

    B

    Lorazepam worsens delirium and adds respiratory depression.

    C

    Correct: dexmedetomidine calms agitated delirium without respiratory depression and allowed earlier extubation in trials.

    D

    Scheduled haloperidol did not reduce delirium duration in trials, so it is not routinely recommended.