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BOARD REVIEW
American Thoracic Society
ATS REVIEW FOR THE CRITICAL CARE BOARDS
First Edition
Senior Editorial Team 
Alison Clay, MD | Margaret M. Hayes, MD | 
Susan Pasnick, MD | Tisha Wang, MD
Question Book
Copyright © 2018 by American Thoracic Society
All rights reserved. This book or any portion thereof 
may not be reproduced or used in any manner 
whatsoever without the express written permission of 
the publisher except for the use of brief quotations in a 
book review.
Printed in the United States of America
First Printing, 2018
ISBN 978-0-9776442-2-3 
American Thoracic Society
25 Broadway, 18th Floor 
New York, NY 10004
store.thoracic.org
i
Table of Contents
Foreword………………….............................................................................. ii
Senior Editors………………………................................................................ iii 
Faculty Contributors………………….............................................……......... iv
Questions……………………………….....................…….................................... 1
Answers……………………………………………................................................ 79
Please note each question number matches the answer number starting on page 79.
ii
Foreword
As we began to embark on the first edition of the ATS Critical Care Board Review 
Book, we ambitiously suggested creating an accompanying board review question 
book. For years, the ATS Core Curriculum generated a number of critical care 
questions on core topics within critical care and these questions were revised and 
optimized with the addition of dozens of new critical care questions inspired by the 
book itself. Similar to the book, this was a truly collaborative effort with a number of 
contributions made by medical educators from all across the country brought together 
by the ATS educational mission.
We owe an immense amount of gratitude to the wonderful ATS staff who helped us 
get this to the finish line – Odalys Jimenez, Eileen Larsson, Lauren Krampen, Dorcas 
Gelabert, Lauren Lynch, and especially Jennifer Siegel-Gasiewski who kept us on track 
and provided an immense amount of both administrative and moral support. We also 
have Brian Kell to thank for his rapid and amazing editing skills and Bosede Cajuste 
to thank for the meticulous final medical copy edit.
We also owe a big thank you to all the faculty and trainees who wrote questions 
for the ATS Critical Care Core Curriculum between 2013 and 2016. Without your 
valuable contributions, we would not have known where to start. 
To Susan, Molly, Alison – you all are the ultimate dream team of amazing women 
medical educators. Thank you for the countless hours of time you put into this amidst 
the busy clinical schedules and amazing work that you all do as physicians, medical 
educators, and human beings. It was such a true pleasure and privilege to work 
alongside you on this project.
On behalf of the entire team, we now present to you the first edition of the ATS 
Critical Care Board Review Question Book. We hope you find these questions helpful 
and we wish you the very best of luck on the critical care boards.
Warmest Regards,
Tisha Wang MD on behalf of the editorial team
iii
Senior Editors
Alison Clay, MD
Assistant Professor of Surgery, Duke University School of Medicine
Assistant Professor in Medicine, Duke University School of Medicine
Department of Surgery, Duke University School of Medicine
Margaret M. Hayes, MD
Assistant Professor of Medicine, Harvard Medical School
Associate Program Director, Beth Israel Internal Medicine Residency
Division of Pulmonary, Critical Care, and Sleep Medicine
Beth Israel Deaconess Medical Center
Susan Pasnick, MD
Director of Critical Care 
CHRISTUS St. Vincent Regional Medical Center, Santa Fe, NM
Tisha Wang, MD
Associate Professor of Clinical Medicine
Fellowship Program Director 
Clinical Division Chief
Division of Pulmonary, Critical Care, and Sleep Medicine
UCLA Medical Center
iv
Faculty Contributors
Shozab Ahmed, M.B.B.S, F.C.C.P 
Assistant Professor 
Associate Program Director Internal Medicine Residency Program 
Associate Program Director Critical Care Fellowship Program 
Department of Internal Medicine 
Division of Pulmonary, Critical Care and Sleep Medicine 
University of New Mexico
 
Colleen L. Channick, MD 
Assistant Professor of Medicine, Harvard Medical School 
Division of Pulmonary and Critical Care Medicine 
Massachusetts General Hospital
 
W. Graham Carlos, MD, MSCR
Associate Professor of Clinical Medicine
Division of Pulmonary, Critical Care, Sleep and Occupational 
Medicine Indiana University School of Medicine
Daniel Crouch, MD 
Assistant Professor of Medicine 
Division of Pulmonary and Critical Care Medicine 
University of California, San Diego
 
Shazia M. Jamil, MD, FCCP, FAASM
Clinical Associate Professor of Medicine
University of California, San Diego School of Medicine 
Division of Pulmonary, Critical Care and Sleep Medicine
Department of Medicine, Scripps Clinic
Ryan C. Maves, MD, FCCP, FIDSA 
Commander, Medical Corps, U.S Navy 
Program Director, Infectious Diseases Fellowship 
Faculty Physician, Critical Care Medicine Service 
Naval Medical Center, San Diego, California 
Associate Professor of Medicine 
Uniformed Services University, Bethesda, Maryland
 
Jakob I. McSparron, MD 
Assistant Professor of Medicine 
Division of Pulmonary and Critical Care Medicine 
University of Michigan
 
Gaetane Michaud, MS, MD, FRCPC 
Associate Professor of Medicine, Pulmonary, Critical Care and 
Cardiothoracic Surgery 
Chief, Interventional Pulmonology 
NYU School of Medicine
 
Jason T. Poston, MD
Assistant Professor of Medicine University of Chicago 
Medicine
Samaan Rafeq, MD 
Senior Associate Director, Interventional Pulmonology Section 
Director, Interventional Pulmonary Fellowship 
NYU School of Medicine
 
Jeremy B. Richards, MD, MA 
Assistant Professor of Medicine 
Beth Israel Deaconess Medical Center and Harvard Medical 
School
Carey C. Thomson, MD, MPH 
Associate Chair, Department of Medicine 
Chief, Pulmonary and Critical Care Division 
Mount Auburn Hospital 
Associate Professor, Harvard Medical School 
Carolyn H. Welsh, MD 
Professor of Medicine 
Division of Pulmonary Sciences and Critical Care Medicine 
Staff physician and Sleep Program Director at The Eastern 
Colorado VA Health Care System 
University of Colorado Denver
 
Bishoy Zakhary, MD 
Assistant Professor of Medicine 
Department of Pulmonary and Critical Care Medicine 
Oregon Health and Sciences University
 
Anna L. Zisman, MD 
Assistant Professor of Medicine 
Department of Medicine and Section of Nephrology 
The University of Chicago
Medical Copy Editors
Bosede Cajuste and Brian Kell
ATS review of the pulmonary boards
questions
1. 
A 43-year-old woman with a history of heavy alcohol use is admitted to the ICU after being found 
unresponsive in her garage. She is afebrile with a HR of 110 bpm and a BP of 97/54 mm Hg. Her 
chemistry panel reveals: Na 137 mEq/L, K 5.1 mEq/L, Cl 97 mEq/L, HCO3 7 mEq/L, BUN 28 mg/dL, 
Cr 0.9 mg/dL, and glucose 108 mg/dL. Lactate is 3.1 mmol/L. Plasma osmolality is 332 mOsm/kg.
Which of the following therapies is most appropriate for this patient?
A. Intermittent hemodialysis
B. Ultrafiltration
C. Continuous veno-venous hemodialysis
D. Hyperbaric oxygen therapy 
E. Observation pending results of comprehensive toxicology labs
2. 
A 58-year-old man with diabetes mellitus, hypertension, coronary artery disease, and heavy alcohol 
abuse is admitted to the ICU for community-acquired pneumonia. He is intubated on hospital day 
1 and started on piperacillin/tazobactam and moxifloxacin. His hospital course is complicated by 
alcohol withdrawal requiring sedation. On hospital day 5, he develops a fever and is pan-cultured. 
It is now hospital day 8.
His exam is as follows:
Vitals: Temp 37.6°C, HR 85 bpm, BP 115/65 mm Hg, RR 14/min on pressure support 14 cm H2O, 
PEEP 8 cm H2O, FiO2 50% 
General: Sedated, arouses only to deep sternalrub 
Cardiovascular: Regular rate and rhythm with no murmurs, rubs, or gallops 
ATS Review for the Critical Care Boards
questions
1
ATS Review for the Critical Care Boards | QUESTIONS
2
Pulmonary: Crackles in the right axilla 
Extremities: 1+ edema bilaterally 
Skin: Right subclavian line is clean, dry, and intact 
GU: Foley catheter in place
Labs: WBC WBC 12,000 cells/µL (down from 14,000 the day prior) with 78% segmented 
neutrophils, 2% bands, 10% lymphs, 5% monocytes, and 3% eosinophils 
Blood cultures x 2 are no growth to date (one peripheral and one from the subclavian line). Urine 
culture and endotracheal aspirate are growing yeast.
 
What is the most appropriate treatment strategy for this patient?
 
A. Continue antibiotics for a 14-day course
B. Continue antibiotics for a 14-day course, add fluconazole
C. Discontinue antibiotics, start an echinocandin
D. Discontinue antibiotics, replace the Foley catheter, start fluconazole
E. Discontinue antibiotics, replace the Foley catheter
3. 
A 44-year-old man with alcoholic cirrhosis develops rapidly progressive oliguric renal failure and is 
transferred from the floor to your ICU. You suspect hepatorenal syndrome as his work-up to date 
reveals no alternative explanation for his renal failure. 
Which of the following findings is most consistent with this syndrome?
A. Urine Na of 15 mEq/L
B. Urine protein of 1.4 g/dL
C. Central venous oxygen saturation (ScvO2) of 60% with a pulmonary capillary wedge pressure 
(PCWP) of 8 mm Hg
D. Cr of 1.5 mg/dL compared to 1.1 mg/dL one week prior
E. Lack of improvement in renal function after discontinuation of diuretics and administration of 
albumin
ATS Review for the Critical Care Boards | QUESTIONS
3
4. 
A 55-year-old man presents to the ED with chest pain. EKG demonstrates ST elevation in leads 
II, III and aVF. Vital signs show a HR of 56 bpm, BP of 75/55 mm Hg, and room air saturation 
of 96%. A bedside echocardiogram reveals right ventricular dilation and dysfunction. The 
patient is intubated and started on mechanical ventilation. In spite of increasing dobutamine 
and epinephrine doses, the patient has ongoing cardiogenic shock with rising lactate levels and 
decreasing urine output.
What is the next best step in the management of this patient?
A. Place an intra-aortic balloon pump (IABP)
B. Place an Impella device
C. Place the patient on veno-venous extracorporeal membrane oxygenation (VV ECMO)
D. Place the patient on veno-arterial extracorporeal membrane oxygenation (VA ECMO)
E. Insert a durable right ventricular assist device
5. 
A 55-year-old man with a history of coronary artery disease is mechanically ventilated for acute 
hypoxic respiratory failure. He is receiving fentanyl and propofol infusions to manage pain 
and agitation while intubated. On exam, he is not moving his extremities or overbreathing the 
ventilator. He grimaces and withdraws to nailbed pressure but does not open his eyes to voice. 
Which of the following is the most appropriate step in managing this patient?
A. Reduce the propofol and fentanyl infusions by 50% 
B. Interrupt the propofol infusion and administer an antipsychotic 
C. Change the propofol infusion to a benzodiazepine infusion 
D. Interrupt both the propofol and fentanyl infusions 
E. Continue the current pain and agitation regimen until the patient is ready for extubation
6. 
A group of investigators is trying to determine if life stressors predispose patients to ARDS. They 
have access to a database of all ICU patients admitted to their hospital over the previous ten 
years. They identify all ARDS survivors and mail them a survey asking them about life stressors 
preceding their illnesses. Using the same database, they identify an equal number of ICU survivors 
without ARDS and send them the same survey. 
ATS Review for the Critical Care Boards | QUESTIONS
4
Which of the following is the best description of this type of study? 
A. Randomized controlled trial 
B. Case-control study 
C. Cohort study
D. Cross sectional analysis 
E. Meta-analysis
7. 
A 55-year-old woman weighs 70 kg and has a history of bipolar disorder for which she takes 
lithium. She is brought to the hospital by her husband for an elective upper endoscopy for the 
evaluation of GERD. She has been NPO overnight. Nursing staff note that she is somnolent 
and only oriented to person and place. She is afebrile with a HR of 110 bpm and BP of 106/61 
mm Hg. Her pre-procedure chemistry panel is as follows: Na 160 mEq/L, K 4.0 mEq/L, Cl 120 
mEq/L, HCO3 24 mEq/L, BUN 40 mg/dL, Cr 0.9 mg/dL, and glucose 108 mg/dL. 
Which of the following is the next best step in the management of this patient?
A. Start 5% dextrose in water (D5W) drip based on calculated free water deficit and volume of 
distribution to decrease serum sodium by 1–2 mEq/hr until back in the 140–145 mEq/L 
range
B. Bolus 2L of normal saline over 2 hours
C. Start D5W drip based on calculated free water deficit and volume of distribution to decrease 
serum sodium by 0.3–0.5 mEq/hr until serum sodium is back in the 140–145 mEq/L range
D. Administer desmopressin 10 µg BID intranasally
E. Place an NG tube and give free water at 250 mL q4 hrs until serum sodium is back in the 
140–145 mEq/L range
8. 
A 32-year-old man weighing 70 kg is burned while lighting fireworks for the 4th of July. He has 
second- and third-degree burns over his anterior chest and abdomen, as well as the anterior 
portions of both legs. The ambulance crew initiates IV fluids and pain medications during 
transport. 
By the time the patient arrives to the ED (30 minutes after his injury) he has received 2L of 
Lactated Ringer’s and 8 mg of morphine sulfate IV.
ATS Review for the Critical Care Boards | QUESTIONS
5
What is the most appropriate fluid strategy for this patient?
A. 5L of additional fluid in the first 16 hours
B. 3L of additional fluid in the first 8 hours
C. 10L of additional fluid in the first 24 hours
D. 7.5L of total fluid in the first 8 hours
E. 15L of total fluid in the first 24 hours
9. 
A 24-year-old man is admitted to the ICU with ARDS secondary to influenza. For the first 
72 hours, he was heavily sedated (RASS -5) with propofol and fentanyl because of refractory 
hypoxemia. Today, his oxygenation has improved and his sedation is lightened to a RASS 
-2. His blood pressure is unchanged. He is requiring three vasopressors (phenylephrine, 
norepinephrine, and vasopressin) to keep his mean arterial pressure >65 mm Hg, but he 
is newly bradycardic. He remains on oseltamivir, vancomycin, and cefepime. His labs are 
significant for WBC count 17,000 cells/µL, Hgb 9.2 g/dL, platelets 389,000/µL, Na 134 mEq/L, 
K 5.2 mEq/L, HCO3 8 mEq/L, Cr 2.4 mg/dL.
What is the next best step in the management of this patient?
 
A. Bolus sedation to keep his RASS -5
B. Discontinue oseltamivir
C. Add micafungin
D. Discontinue propofol
E. Start renal replacement therapy 
10. 
A 74-year-old man with a history of atrial fibrillation and hypertension presents to the ED with 
severe chest pain that started abruptly while he was on his morning walk.
Physical exam:
Vitals signs: HR 128 bpm, BP 90/54 mmHg, RR 20/min
General: Diaphoretic, ill-appearing, moderate distress
Pulmonary: Lungs clear to auscultation bilaterally
Cardiovascular: Distant heart sounds, tachycardic, soft diastolic murmur
Neuro: Alert and oriented, mild dysarthria with flattening of the L nasolabial fold
Extremities: Warm, no edema
ATS Review for the Critical Care Boards | QUESTIONS
6
EKG shows an irregularly irregular rhythm with no acute ST or T-wave changes, and CXR 
shows an enlarged cardiac silhouette. A bedside echocardiogram reveals a moderate to large 
pericardial effusion. Labs are sent and pending. Following a 1L bolus of normal saline, his BP is 
88/52 mmHg. 
What is the next best step in the management of this patient?
 A. CT angiogram of the chest
 B. Pericardiocentesis 
 C. Electrical cardioversion
 D. Administer tPA
 E. Surgicalexploration
11. 
A 39-year-old man was admitted 6 days ago with alcohol withdrawal seizures and aspiration 
pneumonia. He was intubated for acute hypoxic respiratory failure on the day of admission. He 
has been meeting criteria for moderate ARDS with PaO2/FiO2 ratio of 170–190 and has been on 
lung protective ventilation since intubation. His FiO2 is 50% with a PEEP of 12 cm of H2O. He 
is being treated with antibiotics and his DVT prophylaxis was stopped 2 days ago, secondary to 
worsening thrombocytopenia. 
 
The nurses are now reporting increased oxygen requirements for the last 30 minutes and 
the patient is requiring 100% FiO2 to keep his oxygen saturations between 88–90%. His BP 
has dropped to 82/49 mm Hg. A stat CXR and arterial blood gas have been ordered. While 
waiting for the CXR you perform a bedside ultrasound of the lung and the following images are 
obtained.
Ultrasound of the right lung (M-mode) Ultrasound of the left lung (M-mode)
ATS Review for the Critical Care Boards | QUESTIONS
7
At this time which of the following interventions should be performed?
A. Paralysis
B. Thrombolytic therapy
C. Diuresis
D. Needle thoracostomy
E. Increase PEEP
12. 
A 66-year old man is admitted to the ICU for acute onset palpitations, chest pain, and dyspnea. He 
has no significant past medical history and takes only multivitamins. Examination reveals a man 
who is diaphoretic. He is afebrile and vital signs reveal: HR 142 bpm, BP 80/48 mm Hg, RR 24/
min, and room air saturation 87%. Cardiac exam reveals an irregularly irregular tachycardia. Jugular 
venous pressure (JVP) is elevated at 10 cm H2O and rales are heard over both lung fields. His EKG is 
shown below:
What is the most appropriate next step in the management of this patient?
A. Adenosine 6mg IV push
B. Digoxin loading dose
C. Direct current cardioversion
D. Diltiazem 15mg IV push
E. Metoprolol 10mg IV push
ATS Review for the Critical Care Boards | QUESTIONS
8
13. 
A 22-year-old man with acute alcoholic pancreatitis diagnosed based on abdominal pain and 
elevated amylase/lipase is admitted to the ICU. He has just arrived with a HR of 123 bpm, BP of 
80/40 mm Hg, and he has made no urine since arrival to the hospital 80 minutes prior. 
Which of the following is most likely to improve this patient’s outcome?
A. A CT of the abdomen with contrast
B. Aggressive fluid resuscitation for at least 72 hours
C. Early enteral nutrition
D. Initiation of IV imipenem
E. Early endoscopic retrograde cholangiopancreatography (ERCP) within 24 hours
14. 
A 45-year-old woman presents to the ED with confusion and fever. She is accompanied by her 
fiancée. He reports that the patient developed headache, fevers, chills, and myalgias 6 days 
prior to presentation. She thought it was a viral illness and tried to take it easy. Three days 
prior to admission, the patient developed significant nausea and a rash. Yesterday, she noted 
abdominal pain and began vomiting, and today she became confused. Further history reveals 
that the patient was recently backpacking on the Appalachian Trail. Her exam is as follows: 
Vitals: Temp 39.7°C, HR 132 bpm, BP 95/46 mm Hg, RR 16/min 
General: Lethargic, oriented only to person, not place or date 
HEENT: No Kernig’s or Brudzinsky’s signs, no sinus tenderness, no oral lesions 
Cardiovascular: Regular, no murmurs 
Pulmonary: Clear to auscultation bilaterally 
Abdomen: Diffuse tenderness to palpation, no rebound tenderness, no splenomegaly 
Skin: Petechial rash on hands and soles 
Labs: WBC 3,100 cells/µL, Hgb 15.5 g/dL, platelets 116,000/µL, Na 127 mEq/L, K 4.1 
mEq/L, Cl 94 mEq/L, HCO3 22 mEq/L, BUN 56 mg/dL, Cr 2.1mg/dL, AST 556 U/L, ALT 
650 U/L, total bilirubin 4.6 mg/dL 
Urine and blood toxicology screens are negative. A lumbar puncture (LP) is performed. 
LP studies: WBC 85 cells/µL with 90% polymorphonuclear cells, RBC 0 cells/µL, glucose 75 
mg/dL, protein 110 mg/dL
What is the most appropriate antibiotic treatment for this patient?
A. Vancomycin, ceftriaxone, and acyclovir
B. Amphotericin B
C. Vancomycin, ceftriaxone, and doxycycline
D. Methylprednisone, vancomycin, and ceftriaxone
E. Fluconazole
ATS Review for the Critical Care Boards | QUESTIONS
9
15. 
A 66-year-old woman presents with acute onset right hemiparesis and aphasia of 2 hours 
duration. In the ED, vital signs reveal HR 70 bpm, BP 195/115 mm Hg, and oxygen saturation 
97% on room air. A stat CT head reveals no evidence of intracranial hemorrhage. After careful 
review of history, she is determined to be a candidate for thrombolytic therapy. 
What is the best strategy for managing this patient’s BP?
A. Administer tPA and allow permissive hypertension as long as the BP remains <220/120 mm 
Hg
B. Reduce the BP to <185/110 mm Hg before administering tPA
C. Rapidly lower the systolic BP to <140 mm Hg to avoid hemorrhagic conversion
D. Lower the mean arterial pressure by 20% over the first hour and an additional 5–15%over the 
next 23 hours
E. Target a cerebral perfusion pressure <120 mm Hg
16. 
A 55-year-old man is admitted to the hospital for initiation of chemotherapy for Stage III 
Burkitt lymphoma. In addition to chemotherapy, he is treated with IVF hydration at a rate 
of 150 ml/hr. On hospital day 2, he develops significant electrolyte abnormalities and is 
transferred to the ICU for further management. 
At the time of transfer, he is afebrile with HR 102 bpm, BP 110/65 mm Hg, RR 18/min, and 
oxygen saturation of 92% on room air. He has a Foley catheter in place and has urinated 
about 250 mL over the previous 3 hours. His labs are notable for a K of 6.1 mEq/L from 5.8 
mEq/L, phosphate of 9.0 mg/dL from 7.5 mg/dL, uric acid of 9.5 mg/dL from 8.0 mg/dL, and 
calcium of 6.5 mg/dL. The patient’s Cr is 1.3 mg/dL. His EKG shows sinus tachycardia with no 
additional findings. 
What is the next best step in the management of this patient?
A. Start hemodialysis 
B. Begin IV calcium gluconate
C. Begin allopurinol 
D. Begin rasburicase
E. Begin IVF with bicarbonate
ATS Review for the Critical Care Boards | QUESTIONS
10
17. 
You are caring for a 48-year-old man with ARDS. His ventilator waveforms are displayed below: 
 
 Courtesy of Dr. Neil MacIntyre
Which mode of mechanical ventilation is this patient receiving?
A. Synchronized intermittent mechanical ventilation (SIMV) with pressure support
B. Pressure assist control ventilation
C. Volume control ventilation
D. Airway pressure release ventilation
E. Pressure support ventilation
18. 
A 58-year-old man with a suprapubic catheter due to a spinal cord injury is admitted to the ICU 
for hypotension. The patient receives aggressive IVF resuscitation and is started on meropenem 
for a possible catheter-associated urinary tract infection. When the patient’s blood pressure 
does not improve with antibiotics and IVF, he is diagnosed with adrenal insufficiency. On 
hospital day 5, admission blood and urine cultures show no growth and meropenem is stopped. 
 
On hospital day 6, the resident sends a urinalysis because the urine appears cloudy with 
sediment. 
 
Urinalysis reveals: 45 WBC/high powered field (HPF), 2 RBC/HPF, negative leukocyte esterase, 
and negative nitrite.
 
ATS Review for the Critical Care Boards | QUESTIONS
11
What is the next best step in the management of this patient? 
A. Continue current management
B. Replace the suprapubic catheter
C. Begin rotating antibiotics, one week of each month (ciprofloxacin, trimethoprim/
sulfamethoxazole, cefuroxime)
D. Irrigate the catheter with gentamicin
E. Begin IV tigecycline
19. 
A 75-year-old woman with a history of osteoporosis, hypertension, and hypothyroidism is 
found minimally responsive in her apartment by her son. In the ED, her core temp is 94°F, 
and she has a HR of 52 bpm, BP of 90/60 mm Hg, and RR of 8/min. Her exam is notable for 
generalized nonpitting edema. She is intubated and transferred to the ICU. Her admission 
labs are notable for hyponatremia, hypoglycemia, anda normal WBC count. CXR reveals an 
enlarged heart and bilateral pleural effusions. 
In addition to IVF, broad spectrum antibiotics, and warming measures, what is 
the most appropriate next step in her management? 
A. IV hydrocortisone alone
B. IV levothyroxine alone
C. PO methimazole
D. IV hydrocortisone and IV levothyroxine
E. IV hydrocortisone and PO methimazole
20. 
A 54-year-old woman is intubated for sepsis complicated by ARDS. It is hospital day 3 and she 
is on pressure assist control ventilation with a PIP of 14 cm H2O, RR of 18/min, PEEP of 10 cm 
H2O, and FiO2 of 50%. The team is discussing physical therapy during daily multi-disciplinary 
rounds. 
What is the best plan for physical therapy in this patient? 
A. Physical therapy is not indicated as she has only been hospitalized for 3 days
B. Physical therapy is not indicated because her ventilator support is too high
C. Physical therapy is not indicated as it increases the risk of delirium
D. Physical therapy is indicated and has been shown to reduce patient morbidity
E. Physical therapy is indicated and has been shown to reduce patient mortality 
ATS Review for the Critical Care Boards | QUESTIONS
12
21. 
A 61-year-old man with diabetes mellitus presents with chest pain and hypotension. During 
cardiac catheterization, left main disease is found and the patient is scheduled for CABG. Prior 
to transfer to the CCU, an intra-aortic balloon pump is placed. The waveform is shown below. 
What changes should be made to the balloon pump settings to optimize coronary 
perfusion?
A. Inflation is occurring too late; adjust timing to ensure inflation just prior to the dicrotic notch
B. Inflation is occurring too early; adjust timing to ensure inflation after the dicrotic notch
C. Deflation is occurring too late; adjust timing to ensure deflation during end diastole
D. Deflation is occurring too early; adjust timing to ensure deflation during mid-systole
E. Timing of inflation and deflation is appropriate; but settings should be switched to 1:1
22. 
A 30-year-old woman presents to the ED with headache and confusion. Her only medication is 
an oral contraceptive. She denies abdominal pain, nausea, diarrhea, shortness of breath, upper 
respiratory symptoms, and chest pain. Neurologic exam is non-focal, and a CT scan of the brain 
demonstrates no acute abnormality. Laboratory evaluation reveals WBC count 6,500 cells/
µL, Hgb 8.0 g/dL, platelets 10,000/µL, Na 135 mEq/L, K 5.2 mEq/L, Cl 105 mEq/L, HCO3 22 
mEq/L, BUN 72 mg/dL, and Cr 1.7 mg/dL. Urine hCG is negative. The peripheral blood smear 
demonstrates thrombocytopenia and a large number of schistocytes. 
What is the next best step in the management of this patient? 
A. Platelet transfusion
B. Plasma exchange 
C. Rituximab
D. High-dose corticosteroids 
E. Intravenous immunoglobulin (IVIG)
ATS Review for the Critical Care Boards | QUESTIONS
13
23. 
A 64-year-old patient undergoes liver transplantation for cirrhosis from hepatitis C. The 
surgery is uneventful and the patient returns to the ICU. Liver function tests over the first three 
days are shown. 
12 hrs post-op 24 hrs post-op Day 2 Day 3
AST 4785 U/L 2130 U/L 750 U/L 3122 U/L 
ALT 4500 U/L 1976 U/L 500 U/L 3122 U/L 
Total 3.7 mg/dL 4.5 mg/dL 3.0 mg/dL 2.2 mg/dL
Total Bilirubin 3.7 4.5 3.0 2.2
INR 2.4 1.5 1.0 2.6
What is the next best test for evaluating this patient?
A. Liver biopsy
B. Doppler imaging of the hepatic vessels
C. Placement of a biliary drain
D. Quantitative measurement of factors II, IV, VI, IX
E. Hepatitis C viral load
24. 
A 34-year-old man is brought to the ED after he was found down at his parents’ house. Police 
suspect a suicide attempt by ingestion. It is unclear what he ingested, although his prescription 
bottle of lithium was empty, as were his parents’ metformin, digoxin, and aspirin prescription 
bottles. Poison control recommends initiation of renal replacement therapy. 
You are concerned that renal replacement therapy is an ineffective method of 
management for which potential ingestion? 
A. Ethylene glycol
B. Lithium
C. Aspirin
D. Metformin
E. Digoxin
ATS Review for the Critical Care Boards | QUESTIONS
14
25. 
A 32-year-old man has had a prolonged ICU course complicated by septic shock and ARDS. He 
has been intubated for 12 days and initially required vasopressors for the management of shock. 
He has now been weaned from vasopressors and his sedative and analgesic infusions have been 
titrated down. He is interactive and answering yes/no questions, but is profoundly weak in his 
upper and lower extremities, more proximally than distally. He has failed multiple spontaneous 
breathing trials over the past several days, and his intensivist is concerned that he may require 
tracheostomy tube placement. 
Which of the following is most often associated with this patient’s condition?
A. Hyperglycemia
 B. Fluoroquinolones
 C. Acidemia
 D. Hypoalbuminemia
 E. Partial complex seizures
26. 
A new biomarker is being assessed as a non-invasive method to diagnose lung cancer in 
patients with known lung nodules. It is found to have a sensitivity and specificity of 90% when 
evaluated in a population of elderly male veterans who are heavy and active smokers. It is then 
tested at an academic medical center in a population in which the mean age is 15 years younger, 
the gender ratio is 50% female, and 40% of participants are non-smokers. 
Compared to the VA population, what would you expect to be different with 
regard to sensitivity, specificity, positive predictive value, and negative predictive 
value in the academic medical center population? 
A. No change would be expected in the test characteristics between the two populations
B. The test would have a higher sensitivity and specificity
C. The test would have a lower sensitivity and specificity
D. The test would have a higher positive predictive value
E. The test would have a higher negative predictive value
27. 
A 42-year-old man is admitted to the ICU with multilobar pneumonia. His past medical history 
is significant only for hypertension. He is intubated with an FiO2 of 80% and a PEEP of 12 
cm H2O. His mean arterial pressure is 68 mm Hg on 0.2 µg/kg/min of norepinephrine. Blood 
glucose values drawn 2 hours apart are 325 mg/dL and 290 mg/dL. 
ATS Review for the Critical Care Boards | QUESTIONS
15
What is the next best step for management of his hyperglycemia?
A. Check hemoglobin A1c and initiate insulin therapy if result is >6.0%
B. Start sliding scale insulin per your ICU’s protocol in order to achieve a blood sugar of <150 
mg/dL
C. Initiate treatment with an insulin drip targeting a blood sugar of 80–110 mg/dL
D. Initiate treatment with an insulin drip targeting a blood sugar of 140–180 mg/dL
E. Start metformin 500 mg daily
28. 
A 67-year-old woman with a past medical history of significant anxiety is admitted to the ICU 
for a severe COPD exacerbation requiring intubation. Although improving, she still requires 
ventilator support 48 hours after admission. Her ventilator settings are pressure support 10 cm 
H2O, PEEP 10 cm H2O, and FiO2 50%. Her sedation regimen includes dexmetomidine at 0.9 
µg/kg/hr and fentanyl at 75 µg/hr. Her RASS varies between -1 and +1. She occasionally hits or 
shakes the bed rails. 
 
What is the next best step in managing this patient’s sedation?
A. Increase the fentanyl and dexmedetomidine
B. Interrupt her sedation daily
C. Add benzodiazepines to treat her anxiety
D. Continue current level of sedation
E. Apply restraints to reduce the risk of self-extubation
29.
A 45-year-old man is involved in an altercation at a nearby pub and is shot in the epigastrum. 
On arrival to the ED, the patient’s exam is as follows: 
 
Vitals: Temp 37.9°C, HR 145 bpm, BP 85/42 mm Hg, RR 20/min 
General: Patient appears in acute distress 
Pulmonary: Decreased breath sounds in the right base posteriorly, otherwise breath sounds are 
present and symmetric 
Abdomen: Entrance wound to the right ofmidline just below the right costal margin; abdomen 
distended and tender 
A bedside Focused Assessment with Sonography for Trauma (FAST) scan is positive.
ATS Review for the Critical Care Boards | QUESTIONS
16
While awaiting the OR for emergent laparotomy, which of the following strategies 
is most likely to improve this patient’s outcome? 
A. Aggressive resuscitation with normal saline
B. Initiation of the massive transfusion protocol
C. Initiation of vasopressors to keep the MAP >65 mm Hg
D. Administration of recombinant factor VII
E. Cooling the patient to 36°C 
30. 
A 72-year-old woman is admitted to the ICU with septic shock due to Streptococcus 
pneumoniae bacteremia complicated by acute renal failure and acute respiratory failure. 
After a complicated 10-day course, she is clinically improving with decreased vasopressor 
requirements. However, with spontaneous awakening she is profoundly weak in all extremities 
and only intermittently follows commands.
Which of the following is the best diagnostic test for identifying the likely cause of 
this patient’s weakness?
A. Check serum creatine kinase levels
B. Perform the Medical Research Council Neuromuscular Exam
C. Obtain an electromyogram
D. Get a muscle biopsy
E. Order a spinal MRI
31. 
A 45-year-old woman admitted with a COPD exacerbation is trialed on pressure support 
ventilation. Her current ventilator settings are pressure support 16, PEEP 0 cm H2O, FiO2 40%. 
Her spontaneous rate is 16. The following ventilator graphic is noted: 
ATS Review for the Critical Care Boards | QUESTIONS
17
Which of the following changes would the patient benefit from? 
A. Increase the inspiratory time
B. Decrease the inspiratory time
C. Increase the PEEP
D. No changes would be beneficial at this time
E. Decrease the inspiratory pressure
32. 
A 38-year-old man with a history of significant alcohol intake presents to the ED with 
hematemesis. The patient is afebrile, awake, and responsive. 
Vitals: HR 92 bpm, BP 100/55 mm Hg, RR 15/min 
Labs: Hgb 8.1 g/dL, INR 1.4, total bilirubin 2.2 mg/dL, albumin 3.0 g/dL 
GI is consulted and plans to scope the patient. 
Which of the following is true regarding transfusion thresholds for this patient? 
A. He should receive packed red blood cells (PRBCs) because his hemoglobin is <9 g/dL
B. He should not receive PRBCs because his hemoglobin is >7 g/dL
C. He should receive PRBCs despite a hemoglobin >7 g/dL because he likely has Child Pugh 
Class B liver disease
D. He should be transfused regardless of hemoglobin level because he is exsanguinating
E. He should receive a 1:1:1 ratio of PRBCs, platelets, and fresh frozen plasma using a massive 
transfusion protocol
33. 
A 32-year-old man is evaluated after reporting palpitations with a pulse rate of 150 bpm. He 
has a 4-year history of palpitations, which have increased in frequency over the last 6 months. 
He denies any other medical problems and takes no medications. Other vital signs show a BP 
of 127/72 mm Hg, RR of 16/min, and oxygen saturation of 98% on room air. His EKG is shown 
below: 
ATS Review for the Critical Care Boards | QUESTIONS
18
What is the most appropriate therapy for this patient’s condition?
A. Direct current cardioversion (DCCV)
B. Digoxin
C. Metoprolol
D. Radiofrequency catheter ablation
E. Verapamil
34. 
Which of the following is true regarding asthma in pregnancy?
A. Approximately two-thirds of patients with asthma will experience a worsening of their 
symptoms during pregnancy
B. Exacerbations occur most commonly in the second trimester
C. The fetus is at risk for patent ductus arteriosum
D. All asthma medications are pregnancy category “C”
E. The left lateral decubitus position should be avoided as much as possible
35. 
A 59-year-old man with a 50-pack-year smoking history presents to the ED for evaluation of 
hemoptysis. CXR demonstrates a 3-cm right hilar mass. He is hemodynamically stable with a 
HR of 72 bpm, and a BP of 142/88 mm Hg. He is alert and oriented x 3, skin turgor is normal, 
and there is no edema. His chemistry panel reveals: Na 122 mEq/L, K 3.7 mEq/L, Cl 92 mEq/L, 
HCO3 22 mEq/L, BUN 25 mg/dL, Cr 0.9 mg/dL, and glucose 98 mg/dL. Plasma osmolality is 
260 mOsm/kg, urine sodium is 77 mEq/L, and urine osmolality is 452 mOsm/kg.
ATS Review for the Critical Care Boards | QUESTIONS
19
What is the most appropriate step in the management of his hyponatremia?
A. Start normal saline at 100 mL/hr
B. Start fluid restriction of 800 mL per day
C. Start hypertonic saline at 20 mL/hr
D. Start furosemide at 20 mg daily
E. Withhold therapy unless Na falls below 115 mEq/L 
36. 
A 77-year-old woman is admitted for a right middle cerebral artery ischemic stroke for which 
she receives IV tPA. On hospital day 3, she develops somnolence attributed to cerebral edema 
and requires intubation for airway protection and ventilatory support. On hospital day 5, she 
develops a new fever with increased respiratory secretions and a new right lower lobe infiltrate 
on CXR. Endotracheal aspirates are sent for culture. Based on review of the local antibiogram 
she is placed on vancomycin, cefepime, and ciprofloxacin. Forty-eight hours after the initiation 
of antibiotics, she remains intermittently febrile. Culture results are still pending. 
What is the next best step in the management of this patient?
A. Change vancomycin to linezolid
B. Change ciprofloxacin to ceftazidime
C. Add inhaled colistin to the antibiotic regimen
D. Perform protected specimen brushing with quantitative cultures
E. No change in therapy
37. 
A 75-year-old man with COPD (FEV1 45% predicted) is intubated in the ED for hypercapnic 
respiratory failure due to an acute exacerbation of COPD. His ABG on presentation is pH 7.24, 
PCO2 78 mm Hg, PaO2 48 mm Hg with a HCO3 of 32 mEq/L. He is intubated and placed on 
volume assist control ventilation with a tidal volume of 400 ml, RR 26/min, FiO2 of 60%, and 
PEEP of 8 cm H2O. 
Upon transfer to the ICU his ABG is pH 7.18, PCO2 85, PaO2 95 mm Hg, and vitals are as 
follows: Temp 36.4°C, HR 125 bpm, BP 70/45 mm Hg, RR 26/min. 
Which of the following is the next best step in this patient’s management?
A. Start a norepinephrine drip and titrate to MAP >65 mm Hg
B. Increase the PEEP
C. Decrease the respiratory rate
D. Start IVF with bicarbonate
E. Increase the tidal volume
ATS Review for the Critical Care Boards | QUESTIONS
20
38. 
A 42-year-old man with a history of cough-variant asthma presents with difficulty breathing 
and a second-degree right upper extremity burn after helping to extinguish a brush fire while 
on a camping trip. His past medical history is significant for an episode of community-acquired 
pneumonia 3 months prior that was treated with outpatient antibiotics. 
In the ED, his vitals are as follows: Temp 37.1°C, HR 92 bpm, BP 148/83 mm Hg, RR 22/min, 
and oxygen saturation of 91% on nasal cannula oxygen.
Lung exam reveals diffuse wheezing, and despite supplemental oxygen he remains short of 
breath. An arterial blood gas with co-oximetry shows a carboxyhemoglobin of 12%.
Which of the following is a risk factor for requiring intubation in this patient?
A. Upper extremity burn
B. Presence of expiratory wheezing on chest exam
C. Recent treatment for pneumonia
D. Prior history of asthma
E. Carboxyhemoglobin >10% within first hour post-injury
39. 
A 74-year-old man with metastatic prostate cancer presents to the hospital with back pain at 
the level of the mid-thoracic spine. He also reports lower extremity weakness and recent falls 
which he attributes to “not feeling his feet beneath him.” 
Which of the following therapeutic strategies is likely to have the greatest effect 
on this patient’s condition? 
A. Corticosteroids
B. Narcotics as needed for back pain
C. Chemotherapy
D. Physical therapy
E. Placement of a urinary catheter
40. 
A 67-year-old man with COPD and diabetes mellitus is admitted to the ICU with septic shock 
from an infected leg wound.He is postoperative day 1 from a right below-knee amputation. 
He is mechanically ventilated and is requiring 0.2 m g/kg/min of norepinephrine to maintain a 
mean arterial pressure of 65 mm Hg. 
ATS Review for the Critical Care Boards | QUESTIONS
21
Which of the following is the most appropriate nutritional strategy at this point?
A. Initiate parenteral nutrition immediately
B. Initiate enteral feeding immediately
C. Start enteral feeding once the patient is weaned off vasopressors
D. Begin IV fluids with dextrose
E. Hold nutrition until return of bowel sounds
41. 
A 78-year-old man is admitted to the ICU with a COPD exacerbation. Initial ABG demonstrates 
pH 7.25, PaCO2 60 mm Hg, and PaO2 50 mm Hg on room air. The patient is awake and 
interactive and has expressed that he does not want to be intubated or resuscitated. 
Noninvasive ventilation is initiated with an inspiratory positive airway pressure (IPAP) of 10 
cm H2O and expiratory positive airway pressure (EPAP) of 5 cm H2O. His respiratory rate is 30/
min and tidal volume is approximately 250 mL. Repeat ABG shows a pH of 7.22 and PaCO2 of 
62 mm Hg. 
What is the most appropriate next step in the management of this patient? 
A. Endotracheal intubation
B. Trial of Heliox at a concentration of 70% helium and 30% oxygen
C. Increase IPAP to 15 cm H2O and continue EPAP of 5 cm H2O
D. Continue IPAP of 10 cm H2O and increase EPAP to 10 cm H2O
E. Increase IPAP to 12 cm H2O and increase EPAP to 7 cm H2O
42. 
A 57-year-old man with diabetes mellitus presents to the ED of a community hospital with 
severe chest pain of 2 hours duration. No cardiac catheterization services are available. In the 
ED, an EKG is performed:
ATS Review for the Critical Care Boards | QUESTIONS
22
Vital signs include a HR of 95 bpm, BP of 105/65 mm Hg, and a room air oxygen saturation 
of 96%. The patient has good mental status and his extremities are warm. He is treated with 
aspirin, clopidogrel, and high-dose statin. Nitroglycerin eases the chest pain. The nearest 
hospital with cardiac catheterization services is approximately 65 minutes away.
Which of the following is the appropriate next step?
A. Perform a cardiac CT angiogram
B. Place an intra-aortic balloon pump
C. Transfer the patient to the catheterization-capable hospital
D. Administer thrombolytic therapy and monitor the patient
E. Administer thrombolytic therapy and then transfer the patient to the catheterization-
capable hospital
43. 
A 62-year-old woman with chronic kidney disease and diabetes is admitted to the ICU for 
septic shock secondary to a urinary tract infection. She is treated with vasopressors and empiric 
cefepime. Her hemodynamics improve over the next 48 hours. However, she develops multiple 
generalized tonic-clonic seizures that are self-limited or promptly resolve with IV lorazepam. 
She has no history of seizures and is on no antiepileptic medications. 
What is the next best step in the management of this patient?
A. Change cefepime to levofloxacin
B. Order an MRI of the brain
C. Check an electrolyte panel and liver function tests
D. Start propofol via continuous infusion
E. Send serum lactate and prolactin levels
44. 
A 56-year-old woman is brought to the ED after being found confused by her family. On arrival, 
her temp is 39.2°C with a WBC count of 15,000 cells/µL. She is confused, oriented to name only, 
and intermittently following commands. An infectious workup is pursued, and cultures are 
pending. An MRI is performed and shows numerous, diffuse, small, embolic-appearing infarcts 
in the bilateral hemispheres.
ATS Review for the Critical Care Boards | QUESTIONS
23
What is the most appropriate next step in the management of this patient after 
starting empiric antibiotics?
A. Initiate a heparin drip for a presumed cardioembolic source of strokes
B. Treat altered mental status with IV haloperidol
C. Request a transthoracic or transesophageal echocardiogram to evaluate for intracardiac 
thrombus and valve abnormalities
D. Administer intravenous tPA
E. Consult neurosurgery
45. 
A 32-year-old man is in shock after a traumatic amputation of his right leg following a snow 
mobile injury. He is taken emergently to the operating room.
Which of the following interventions will improve his outcomes in the first 24 
hours of his hospitalization?
A. Activated Factor VII
B. Giving 1 liter of normal saline for every 1 unit of PRBCs he receives
C. Transfusing 1 unit of FFP and 1 unit of platelets for every 1 unit of PRBCs he receives
D. Transfusing 1 unit of platelets for every 4 units of PRBCs he receives
E. Transfusing to a goal hemoglobin of 10 g/dL
46. 
A 55-year-old man with a history of hypertension and poorly controlled diabetes is admitted to the 
ICU with worsening abdominal pain and altered mental status. 
Vital signs reveal temp 38.7°C, HR 115 bpm, and BP 86/40 mm Hg. He has scleral icterus, jaundice, 
and his abdomen is diffusely tender, especially in the right upper quadrant (RUQ). 
Labs show WBC count of 26,000 cells/µL, total bilirubin 8.5 mg/dL, and lipase 550 U/L. 
Abdominal CT is shown below:
ATS Review for the Critical Care Boards | QUESTIONS
24
IV fluids, piperacillin-tazobactam, and vasopressors are initiated. 
What is the next best step in the management of this patient?
A. Hepatobiliary (HIDA) scan
B. RUQ ultrasound
C. Stat surgical consultation
D. Abdominal plain films
E. Stat interventional radiology consultation
47. 
A 49-year-old man with a history of depression and hypertension is brought to the ED with 
confusion. His current medications include paroxetine, losartan, and verapamil. Upon arrival, 
he has a HR of 52 bpm and a BP of 77/48 mm Hg. His fingerstick glucose is elevated at 300 
mg/dL, while other labs are unremarkable. Urine toxicology screen is negative for opiates, 
benzodiazepines, and tricyclic anti-depressants. An EKG is performed and shown below: 
He is administered IV glucagon with little therapeutic benefit. 
In addition to starting a vasoactive agent, which of the following interventions 
should be considered at this time? 
A. Dantrolene
B. Hemodialysis
C. High-dose insulin
D. Sodium bicarbonate
E. Whole bowel irrigation
ATS Review for the Critical Care Boards | QUESTIONS
25
48.
A 27-year-old woman was skiing when she hit a tree and crashed. Her left ski boot came off 
during the fall, and her left leg was pinned under debris. After 25 minutes, members of her 
group located her and freed her leg. She complained of being very cold and noted severe 
burning pain in her left foot. She was transported to the ED, where her exam was as follows: 
Vitals: Temp 33°C, HR 36 bpm, BP 100/65 mm Hg, RR 8/min 
General: Alert and oriented x 2, shivering 
Cardiovascular: Regular rate and rhythm, no murmurs 
Pulmonary: Clear to auscultation bilaterally 
Abdomen: Nontender, nondistended 
Left lower extremity: As pictured
Which of the following is most accurate regarding this patient’s presentation?
A. Prehospital warming using hot water is indicated
B. The patient’s bradycardia should be managed with atropine
C. The presence of shivering is a poor prognostic sign
D. Tissue plasminogen activator (tPA) may be indicated to help preserve her digits
E. External rewarming with dry heat is indicated
49. 
A 72-year-old man presents with chronic dyspnea. While symptoms have been present 
for several years, they now occur with minimal exertion. Past medical history includes a 
myocardial infarction (MI) with placement of drug-eluting stents in the left anterior descending 
(LAD) artery and left circumflex arteries. He also has a remote history of limited-stage, small 
cell lung cancer treated with radiation therapy. CXR is unrevealing and an echocardiogram 
demonstrates elevated pulmonary pressures and no significant pericardial effusion. The patient 
undergoes a left- and right-heart catheterization and the ventricular waveforms are shown in 
the figure below. 
ATS Review for the Critical Care Boards | QUESTIONS26
What is the appropriate next step in the management of this patient?
A. Start sildenafil for pulmonary hypertension
B. Start high-dose IV diuretics
C. Schedule the patient for pericardiectomy
D. Schedule the patient for aortic valve repair
E. Perform emergent pericardiocentesis 
50. 
A 21-year-old man presents with unresolving upper respiratory tract symptoms, including 
fevers and drenching sweats. Imaging reveals bulky lymphadenopathy of the head, neck, and 
the mediastinum. He is noted to have facial swelling and plethora as well as dilated vessels in 
his upper extremities and across his chest wall. A chest CT with contrast reveals significant 
compromise of his superior vena cava (SVC).
What is your next step in the management of this patient?
A. Excisional biopsy of a neck lymph node
B. Consult interventional radiology for consideration of SVC stent
C. Urgent consultation for chemotherapy
D. Urgent consultation for radiation
E. Bronchoscopy with transbronchial needle aspiration
ATS Review for the Critical Care Boards | QUESTIONS
27
51.
A 38-year-old man with no significant past medical history was brought to the ED after 
sustaining a sudden cardiac arrest at home. According to the patient’s family, he was not 
feeling well for the past three days and was complaining of fever, chest pain, and cough with 
green colored phlegm. He was then found unresponsive in bed this morning. CPR was initiated 
by the family, and EMS arrived at the scene to find the patient in a polymorphic ventricular 
tachycardia. The patient was intubated with return of spontaneous circulation obtained after 12 
minutes of CPR. 
In the ED, the patient’s vital signs are as follows: Temp 38.6°C, HR 100 bpm, BP 120/70 mm 
Hg, oxygen saturation 95% on FiO2 of 50%. 
The patient is able to follow simple commands. 
Lab data is significant for leukocytosis. Electrolytes are all within normal limits. Urine drug 
screen is negative. 
CXR shows right middle lobe opacities. 
EKG: 
A quick bedside echocardiogram shows no wall motion abnormalities and a grossly normal 
ejection fraction. The patient is taken to the cardiac catheterization lab, and angiography shows 
clean coronaries.
Which of the following is the most likely diagnosis?
A. Pericarditis
B. Brugada syndrome
C. Takotsubo cardiomyopathy
D. Myocardial infarction
E. Wolff-Parkinson-White syndrome (WPW)
ATS Review for the Critical Care Boards | QUESTIONS
28
52. 
A 36-year-old woman with type 1 diabetes mellitus presents to the ED with altered mental 
status and diabetic ketoacidosis. She is intubated for airway protection. Her family reports 
that she is often non-compliant with her insulin. Per family members, she developed nasal 
congestion and foul-smelling nasal discharge 2 days prior to presentation. She then developed 
fevers, chills, and confusion, and was brought to the ED. 
On physical exam, the patient has significant proptosis and periorbital swelling. No neck 
stiffness is appreciated. Endoscopic examination of the sinuses is performed and the resultant 
specimen is shown below.
Which of the following antimicrobial regimens should be initiated?
A. Vancomycin and piperacillin-tazobactam
B. Vancomycin and ceftriaxone (meningitis dosing)
C. Liposomal amphotericin B
D. Voriconazole
E. Fluconazole 
53. 
A 61-year-old man with a history of hypertension, hypercholesterolemia, and myotonic 
dystrophy type 2 presents with acute shortness of breath. His vital signs are as follows: Temp 
37.8°C, HR 118 bpm, BP 82/48 mm Hg, RR 30/min, oxygen saturation 95% on 6 L/min nasal 
cannula. A CT angiogram of the chest reveals extensive acute pulmonary emboli in the main 
left and right pulmonary arteries extending into the segmental and subsegmental arteries. The 
patient denies any history of recent bleeding or surgery. 
ATS Review for the Critical Care Boards | QUESTIONS
29
What is the next best step in the management of this patient?
A. Unfractionated heparin (UFH)
B. UFH and inferior vena cava filter
C. Systemic thrombolytic therapy followed by UFH
D. Catheter-directed thrombolysis followed by UFH
E. Surgical embolectomy followed by UFH
54. 
A 59-year-old man with ischemic cardiomyopathy is admitted to the ICU for dyspnea. His HR is 
102 bpm, BP is 74/44 mm Hg, and oxygen saturation is 95% on room air. Cardiovascular exam 
reveals a regular tachycardia with an S3, bilateral edema to the thighs, and cool extremities. 
He is somnolent with bilateral crackles over the lower lung fields. His abdomen is soft with 
diminished bowel sounds. 
His EKG is unchanged from baseline. Given his complex cardiac history, a pulmonary artery 
catheter is placed and reveals a CVP of 10 mm Hg, pulmonary artery pressure of 45/24 mm Hg, 
pulmonary capillary wedge pressure of 22 mm Hg, and cardiac output of 2.8 L/minute. Cardiac 
enzymes reveal a troponin of 0.6 ng/mL and basic metabolic panel reveals Na 132 mEq/L, K 3.7 
mEq/L, Cl 100 mEq/L, HCO3 23 mEq/L, BUN 10 mg/dL, Cr 1.4 mg/dL. 
What is the most appropriate medical therapy for this patient? 
 
A. Tissue plasminogen activator
B. Enoxaparin
C. Clopidogrel + eptifibatide
D. Milrinone
E. Nesiritide
55. 
A 65-year-old man underwent prolonged resuscitation after a ventricular fibrillation cardiac 
arrest. Return of spontaneous circulation occurred 25 minutes into the resuscitation. On 
hospital day 3, the patient has a temp of 37°C with a BP of 112/72 mm Hg on dobutamine 
and epinephrine infusions. The patient has not responded to verbal or tactile stimuli since 
admission, with the exception of intermittent decorticate posturing. There is no corneal reflex, 
no cough with suctioning, and no pupillary response to light. There are no ocular movements 
using oculovestibular reflex testing. 
ATS Review for the Critical Care Boards | QUESTIONS
30
Which of the following is true regarding this patient’s presentation?
A. Apnea testing should be performed to evaluate for brain death
B. The presence of vasopressor support precludes a diagnosis of brain death
C. The administration of neuromuscular blocking agents on day 2 of hospitalization precludes a 
determination of brain death
D. Decorticate posturing precludes a diagnosis of brain death
E. A physician from the organ procurement agency must be present to declare brain death
56. 
A 68-year-old man who is 3 days post allogenic stem cell transplant for acute myelogenous
leukemia is admitted to the ICU with septic shock and acute kidney injury. The patient is
intubated on ventilator settings of 70% FiO2 with PEEP of 10 cm H2O. His pH is 7.15 and his
other labs reveal: K 5.8 mEq/L, HCO3 11 mEq/L, BUN 85 mg/dL, and Cr 4.9 mg/dL. The
decision is made to initiate continuous renal replacement therapy.
What is the minimum dose of continuous renal replacement therapy (CRRT) that 
should be delivered to this patient?
A. 5–10 mL/kg/hr
B. 10–15 mL/kg/hr
C. 20–25 mL/kg/hr
D. 30–35 mL/kg/hr
E. 40–45 mL/kg/hr
57. 
A 68-year-old woman is admitted to the hospital for lower extremity cellulitis. She is treated
with IV antibiotics and discharged on oral clindamycin to complete a 10-day course. Three
weeks later, she re-presents to the hospital with 4 days of worsening abdominal pain and 
diarrhea with some associated dizziness.
Her temp is 38.7°C and her BP is 100/52 mm Hg. Labs reveal: Cr 1.8 mg/dL (Cr was 0.9 mg/dL
at the time of recent discharge), WBC count 16,000 cells/µL, lactate 2.8 mmol/L, and stool
testing is positive for Clostridium difficile.
Abdominal imaging does not show any evidence of ileus, toxic megacolon, or perforation.
Given her clinical status, she is admitted to the ICU. She has never had a C. difficile infection in
the past.
ATS Review for the Critical Care Boards | QUESTIONS
31
What is the most appropriate antibiotic therapy for this patient?
A. Oral vancomycin 500mg q6 hours
B. Oral vancomycin 125mg q6 hours
C. Oral fidaxomicin 200mg q24 hours
D. IV metronidazole 500mg q8 hours
E. Oral vancomycin 125mg q6 hours plus IV metronidazole500 mg q8 hours
58. 
You are managing a patient with severe systolic heart failure and septic shock in your ICU.
While attempting to obtain a wedge pressure, you see the following tracing after inflating 1 mL
of air into the balloon.
What is the next best step in management?
A. Continue to advance the catheter until a wedge tracing is obtained
B. Inflate an additional 1 mL of air into the balloon
C. Deflate the balloon and remove the catheter completely
D. Leave the balloon inflated in the current position
E. Deflate the balloon and pull back to obtain a pulmonary artery (PA) tracing
59. 
A 57-year-old woman presents to a community hospital ED with acute onset right-sided arm 
and leg weakness with dysarthria. Her symptoms began 3 hours and 10 minutes ago, when 
she was washing dishes. Her past medical history is significant for migraine headaches, poorly 
controlled diabetes, hypertension, and hyperlipidemia. Her surgical history is significant only 
for a total abdominal hysterectomy and oophorectomy for uterine fibroids when she was 45. 
She is a former smoker with a 40-pack-year smoking history.
Vitals: Temp 36.7°C, HR 86 bpm, BP 170/97 mm Hg, RR 12/min, saturation 97% on room air
The patient has right-sided facial droop and can barely overcome gravity with her right arm and
leg. There is sensory loss as well in the same distribution.
ATS Review for the Critical Care Boards | QUESTIONS
32
Labs reveal an INR of 1.2 and platelet count of 150,000/µL.
On presentation to the ED, the patient’s NIH Stroke Score is 15. CT imaging performed within
20 minutes of arrival shows no evidence of intracranial hemorrhage, but hypoattenuation
throughout more than half the distribution of the left middle cerebral artery.
The patient is 30 minutes away from a facility that is capable of performing intraarterial
thrombectomy.
Which of the following best describes the most appropriate therapy for this 
patient?
 
A. The patient is not a candidate for intravenous tPA because she is presenting >3 hours
 after the onset of symptoms
B. The patient is a candidate for intravenous tPA, and she should receive this medication as
 soon as possible
C. The patient is a candidate for intravenous tPA, but her uncontrolled hypertension
 precludes its use
D. The patient is not a candidate for intravenous tPA because of her history of poorly
 controlled diabetes
E. The patient should not receive tPA and instead should be transferred immediately for
 mechanical thrombectomy
60. 
A 35-year-old man with interstitial lung disease is intubated for respiratory failure. His 
ventilator waveform is shown below. 
ATS Review for the Critical Care Boards | QUESTIONS
33
What is the main problem illustrated by this waveform?
A. Auto-PEEP
B. Water in the circuit
C. Flow dyssynchrony
D. Cycle dyssynchrony
E. Triggering dyssynchrony
61. 
A 35-year-old construction worker presents to the ED after sustaining a traumatic wound to the
distal right leg several days earlier. He reports significant pain. Physical exam reveals: Temp
37.9°C, HR 100 bpm, BP 140/80 mm Hg, and RR 18/min. Scleral icterus is present. A 3x4 cm
area of skin over the distal posterior right leg is purple with tenderness to palpation. The wound
is open at the center without drainage. There are no bullae, but crepitus is present.
Neurovascular examination is unremarkable.
Labs: WBC count 22,000 cells/µL, Hgb 8 g/dL, Cr 1.8 mg/dL, AST 90 U/L, ALT 100 U/L,
haptoglobin <10 mg/dL, creatinine kinase 400 U/L
Plain radiograph of the right leg is shown in figure below.
ATS Review for the Critical Care Boards | QUESTIONS
34
IV penicillin and clindamycin are administered.
Over the next 24 hours, the patient’s HR rises to 140 bpm, BP drops to 80/40 mm Hg, and the
patient develops labored breathing. The purple discoloration now includes the entire distal 
right leg. 
What is the most likely pathogen causing this patient’s condition?
A. Fusobacterium necrophorum
B. Clostridium perfringens
C. Methicillin-sensitive Staphylococcus aureus
D. Escherichia coli
E. Haemophilus influenzae
62. 
A 23-year-old man who recently immigrated from Pakistan presents with a diffuse vesicular
rash, fever, and respiratory distress. Chest x-ray reveals patchy, bilateral airspace opacities. He
requires high-flow oxygen and is started on IV vancomycin, ceftriaxone, azithromycin, and 
acyclovir. Polymerase chain reaction testing of vesicular fluid is positive for varicella-zoster
virus (VZV).
What infection prevention precautions are appropriate for this patient?
A. Standard precautions
B. Airborne precautions
C. Droplet precautions
D. Contact precautions
E. Airborne and contact precautions
63. 
A 64-year-old woman is intubated for an acute COPD exacerbation triggered by a respiratory
infection. She has developed an ileus and is not receiving enteral medications or nutrition. She
has a history of chronic pain and long-standing oxycodone use, and she has been without opiate
medications for the past 24 hours. Her nurse reports that she appears uncomfortable and her
Critical Care Pain Observation Tool (CPOT) score is elevated.
ATS Review for the Critical Care Boards | QUESTIONS
35
What is the most appropriate plan to treat this patient’s pain?
A. Fentanyl continuous infusion titrated to CPOT score
B. Hold opiates given the ileus
C. Restart the patient’s home oxycodone
D. Intermittent morphine boluses as needed
E. Midazolam continuous infusion titrated to comfort
64. 
A 35-year old woman presents to the ED after a motor vehicle collision with blunt trauma to the
chest, abdomen, and left lower extremity. She is noted to be hypotensive, and the massive
transfusion protocol is initiated. The patient is found to have a hemothorax, aortic dissection,
grade III splenic laceration, and a pelvic fracture. She undergoes endovascular repair of the 
aortic dissection and presents to the ICU. Thromboelastogram shows the following: 
What is the next appropriate step in the management of this patient?
A. Continue to monitor; there is no evidence of coagulopathy
B. Administer fresh frozen plasma
C. Administer platelets
D. Administer cryoprecipitate
E. Administer tranexamic acid
0
20
40
40
20
0
20
40
40
20
NORMAL
PATIENT
FIG 2 
(NOTE: questions OR answers?)
0
20
40
40
20
0
20
40
40
20
NORMAL
PATIENT
FIG 2 
(NOTE: questions OR answers?)
ATS Review for the Critical Care Boards | QUESTIONS
36
65. 
A 37-year-old man is admitted with pulmonary contusions and ARDS and requires intubation
and mechanical ventilation.
The respiratory therapist notes an unusual waveform in the pressure graphic and points it out 
to you. 
What is the main problem seen on the ventilator waveforms? 
A. Flow dyssynchrony
B. Ineffective triggering
C. Cycle dyssynchrony
D. Double triggering
E. Water in the circuit
66. 
A 45-year-old man with type 1 diabetes mellitus is brought to the ED with severe abdominal
pain. He reports non-compliance with insulin therapy for the past 3 days since running out of 
his medications. He is afebrile with a HR of 120 bpm, BP of 100/65 mm Hg, RR of 28/min, and
oxygen saturation of 98% on room air. His exam is notable for dry mucus membranes and
diffuse abdominal tenderness without rebound or guarding. His labs reveal glucose of 430 mg/ 
dL, K of 3.0 mEq/L, and HCO3 of 11 mEq/L. His EKG is normal. He is given 4 liters of IVF and
an insulin drip is started. Upon transfer to the ICU, he suffers a cardiac arrest.
ATS Review for the Critical Care Boards | QUESTIONS
37
What is the most likely etiology of his arrest?
A. Myocardial infarction
B. Anaphylaxis
C. Arrhythmia
D. Pulmonary embolism
E. Hypovolemia
67. 
A 47-year-old man is referred for evaluation of exertional dyspnea. His past medical history is
notable for ARDS due to H1N1 influenza that required prolonged mechanical ventilation and
tracheostomy approximately 1 year ago. He was decannulated 6 months ago and has not 
required supplemental oxygen. He didwell until several weeks ago when he noticed increasing 
dyspnea with physical activity. Office spirometry and flow-volume loop reveals:
Which of the following is the most likely explanation for his symptoms and PFTs?
A. Asthma
B. COPD
C. Tracheomalacia
D. Tracheal stenosis
E. Restrictive lung disease secondary to history of ARDS
Parameter Actual Predicted % Predicted
FEV1 (L) 3.07 4.12 75
FVC (L) 4.58 5.16 89
FEV1/FVC 0.67 0.8 N/A
ATS Review for the Critical Care Boards | QUESTIONS
38
68. 
A 34-year-old woman presents to the ED with acute dyspnea. Her medication list includes
levothyroxine, multivitamins, and oral contraceptives. On exam, HR is 115 bpm, BP is 108/72
mm Hg, and room air saturation is 82%. She is administered supplemental oxygen. A CXR
appears clear. While awaiting a CT scan, the patient becomes altered and hypotensive.
Which physical exam findings would you expect to find in this patient?
A. Elevated jugular venous pressure (JVP), pulmonary rales, cool extremities, delayed
 capillary refill
B. Elevated JVP, clear lungs, cool extremities, delayed capillary refill
C. Elevated JVP, pulmonary rales, cool extremities, normal capillary refill
D. Normal JVP, clear lungs, warm extremities, normal capillary refill
E. Normal JVP, clear lungs, warm extremities, delayed capillary refill
69. 
A 64-year-old woman is admitted to the ICU with hypoxemic respiratory failure and confusion.
Over the previous month, she has become more fatigued and has had intermittent low-grade
fevers. Her CXR shows bilateral opacities. Laboratory studies are notable for a total WBC count
of 114,000 cells/µL with 60% blasts, 20% young unidentified cells, and 2% metamyelocytes, a
Hgb of 6.9 g/dL, and a platelet count of 20,000/µL.
What is the next best step in the management of this patient?
 
 A Transfuse 1 unit of packed red blood cells
B. Administer furosemide 80 mg intravenously
C. Transfuse platelets
 D Administer 1 liter of isotonic crystalloid
E. Perform a lumbar puncture
70. 
A 67-year-old man is admitted to the ICU with severe alcohol withdrawal and agitation. He has
been on dexmedetomidine for 3 days and was started on a lorazepam drip 2 days ago. He 
seemed to be improving yesterday, but today he is more lethargic and sleepy. His labs are 
notable for a Cr of 1.8 mg/dL (up from 1.0 mg/dL yesterday). Other labs reveal Na 139 mEq/L, 
K 5.0 mEq/L, Cl 100 mEq/L, HCO3, 10 mEq/L, and BUN 52 mg/dL.
ATS Review for the Critical Care Boards | QUESTIONS
39
What is the next best step in the management of this patient?
A. Discontinue dexmedetomidine
B. Discontinue lorazepam
C. Administer naloxone
D. Start methylphenidate
E. No change in current management
71. 
A 56-year-old man with cirrhosis and heart failure is admitted for new onset seizures and acute 
kidney injury. He is given a loading dose of phenytoin (20 mg/kg actual body weight) after 
which the total phenytoin level is 30 µg/mL (goal 15–20 µg/mL) and the free phenytoin level is 
9 µg/mL (goal 1–2 µg/mL). 
Which of the following is the most likely reason for the elevated phenytoin level?
A. Decreased hepatic blood flow due to liver disease and heart failure
B. Drug-drug interaction with beta blocker
C. Hypoalbuminemia from chronic liver dysfunction
D. Inappropriately high loading dose
E. Laboratory error
72. 
Which of the following ventilator adjustments is a solution for premature cycling? 
A. Increase the inspiratory time
B. Decrease the inspiratory time
C. Increase the ramp
D. Decrease the respiratory rate
E. Increase the respiratory rate
ATS Review for the Critical Care Boards | QUESTIONS
40
73. 
An 18-year-old primagravid woman with a past medical history notable for lupus nephritis 
with a baseline creatinine of 1.6 mg/dL is admitted to labor and delivery with concerns for 
severe preeclampsia at 38 weeks. She is given a loading dose of 6 g of magnesium sulfate, and 
then started on a continuous magnesium sulfate infusion at 2 g/hr and undergoes a cesarean 
delivery. Later that evening, she is found to be somnolent and appears to have a flaccid 
paralysis. Patellar reflexes are absent. She is afebrile, HR is 52 bpm, BP is 90/61 mm Hg, RR 
is 8/minute, and oxygen saturation is 96% on room air. EKG shows sinus bradycardia with a 
prolonged QRS.
Which of the following therapies should be initiated immediately?
A. IV calcium gluconate 2 g over 5 min
B. D50 1 amp + 10 units of insulin IV
C. Endotracheal intubation
D. NaHCO3 1 amp IV push
E. Ultrafiltration
74. 
A 65-year-old man with a history of hypertension and tobacco abuse presents to the ED with 
cough and shortness of breath that have been worsening over the previous 3–4 weeks. Physical 
exam is as follows: 
 
Vitals: Temp 36.1°C, HR 95 bpm, BP 135/84 mm Hg, RR 24/min, oxygen saturation 78% on 
room air 
General: Alert and oriented, in moderate respiratory distress 
Cardiovascular: Regular rate and rhythm, no murmurs, rubs, or gallops
Pulmonary: Bilateral crackles, no egophony, no dullness 
Abdomen: Non-tender, non-distended, no organomegaly 
Extremities: No edema 
Skin: No rashes 
A CXR reveals bilateral diffuse pulmonary infiltrates. 
The patient is intubated in the ED and started on ceftriaxone and azithromycin for community-
acquired pneumonia. 
Over the next 7 days, the patient neither improves nor worsens and antibiotics are 
broadened despite cultures being negative. A bronchoscopy with bronchoalveolar lavage and 
transbronchial biopsies is performed and histopathology is shown below.
ATS Review for the Critical Care Boards | QUESTIONS
41
What is the next best step in the management of this patient? 
A. Start ganciclovir
B. Start rituximab
C. Start methylprednisolone
D. Transfer to a facility capable of performing whole lung lavage
E. Discuss withdrawal of life support
75. 
A 52-year-old woman is being evaluated for persistent dyspnea 6 months after an ICU 
admission for an acute saddle PE. Given the clot burden, catheter-directed thrombolysis was 
discussed as a therapeutic option, but the patient improved on anticoagulation alone and was 
discharged on rivaroxaban after a 5-day hospital stay. 
A V/Q scan demonstrates peripheral mismatched perfusion defects in several segments, and 
an echocardiogram shows a mildly dilated right ventricle with an estimated pulmonary artery 
systolic pressure (PASP) of 66 mm Hg. 
A CT angiogram of the chest reveals chronic pulmonary emboli in the proximal segmental and 
subsegmental arteries. Right heart catheterization shows PA pressures of 65/30 mm Hg with a 
mean of 42 mm Hg and a pulmonary capillary wedge pressure of 12 mm Hg.
ATS Review for the Critical Care Boards | QUESTIONS
42
Which of the following is the most appropriate therapeutic option to consider in 
this patient? 
A. Pulmonary thromboendarterectomy
B. Sildenafil
C. Balloon pulmonary angioplasty
D. IV remodulin
E. Escalation of anticoagulation with addition of clopidogrel and aspirin to rivaroxaban
76. 
A 54-year-old man is admitted to the ICU with worsening hypotension in the setting of 
aortic valve endocarditis. His HR is 118 bpm and his BP is 85/35 mm Hg. A transthoracic 
echocardiogram reveals severe aortic regurgitation with a 7-cm mobile vegetation. 
 
What is the next best step in the management of this patient?
A. Placement of a left ventricular assist device
B. Administration of metoprolol
C. Placement of an intra-aortic balloon pump
D. Emergent aortic valve surgery
E. Placement of a temporary pacemaker
77. 
A 62-year-old man is admitted to the ICU with altered mental status, nausea, and vomiting for 
the past week. His spouse reports frequent urination, a 3-month history of cough productive of 
intermittent blood-streaked sputum, and a 10-lb weight loss. A CXR reveals a 6-cm left upper 
lobe mass in the periphery of the lung, as well as mediastinal adenopathy consistent with a 
locally advanced lung cancer. 
 
What is the best test to explain the cause of the patient’s non-respiratory 
symptoms?
A.Serotonin
B. Adrenocorticotropic hormone (ACTH)
C. Parathyroid hormone-related peptide (PTHrP)
D. Bradykinin
E. Calcium channel antibodies
ATS Review for the Critical Care Boards | QUESTIONS
43
78. 
A 25-year-old man with status asthmaticus is intubated in the ICU. His initial blood gas 
shows pH 6.9, PaCO2 74 mm Hg, PaO2 200 mm Hg with a base excess of -8 and a calculated 
bicarbonate of 14 mEq/L. 
He is given pancuronium and started on volume-controlled ventilation with a RR of 30/min, 
tidal volume of 400 (6 ml/kg per predicted body weight), PEEP of 5 cm H2O, and FiO2 of 100%. 
The respiratory therapist is concerned about his flow graphic on the ventilator and the nurse is 
noting a drop in the patient’s BP.
Which of the following would be the best intervention to pursue at this time?
A. Increase sedation
B. Bolus additional neuromuscular blockade
C. Increase the respiratory rate
D. Decrease the respiratory rate
E. Change to pressure-controlled ventilation
79. 
A 57-year-old man with diabetes, hypertension, and coronary artery disease is admitted to the 
ICU with hypertensive urgency. BP on admission was 193/110 mmHg, and after treatment is 
down to 162/95 mmHg. On rounds, the patient reports that he had an overnight episode of 
numbness and weakness in his right arm that lasted about 10 minutes. In retrospect, he had a 
similar episode 2 days prior though it was somewhat shorter in duration. The patient now feels 
normal and has a normal neurologic exam. An hour later, he has another episode, lasting 20–
25 minutes with observed right facial droop and arm weakness. Again, the patient returns to 
normal. An urgent CT angiogram of the head and neck is obtained and shows severe left carotid 
stenosis. 
ATS Review for the Critical Care Boards | QUESTIONS
44
Which of the following should be included in the early management of this 
patient?
A. Intensive blood pressure lowering with goal BP <130/80 mm Hg
B. Vascular surgery consult
C. Interventional radiology consult for intra-arterial thrombolysis
D. IV tPA
E. Cardiology consult
80. 
A 35-year-old woman presents to the ED with progressive fatigue and new onset of confusion. 
She is 2 months status post a normal spontaneous vaginal delivery that was complicated by 
hemorrhage requiring multiple transfusions. She was discharged with a Hgb of 8.5 g/dL. 
On exam she is afebrile with a HR of 124 bpm, BP of 85/45 mm Hg, and oxygen saturation of 
97% on room air. Her labs are pending, but a fingerstick glucose is 40 mg/dL and a point-of-
care Hgb returns at 10 g/dL. 
After administration of dextrose and IVF as well as transfer to the ICU, which of 
the following is the most appropriate management for this patient?
A. Consult ob-gyn for emergent hysterectomy
B. Start empiric vancomycin and piperacillin/tazobactam
C. Start oxytocin
D. Start hydrocortisone, levothyroxine, and desmopressin
E. Start empiric anticoagulation
81. 
A 75-year-old man is admitted to the ICU with sepsis and ARDS and is now on day 6 of 
mechanical ventilation. His predicted body weight is 60 kg. He is on volume assist control 
ventilation with the following settings: tidal volume 420 ml, RR 14/min, PEEP 10 cm H2O, and 
FiO2 50%. 
What is the best strategy for weaning ventilator support?
A. Change the ventilator mode to pressure regulated volume control with a maximum peak 
pressure of 30 cm H2O and a tidal volume of 360 ml
B. Change the ventilator mode to synchronized intermittent mandatory ventilation (SIMV) with 
a tidal volume of 420 ml, RR 8/min and pressure support of 10 cm H2O
C. Place the patient on pressure support of 5–8 cm H2O for at least 30 minutes
D. Reduce the RR to zero
E. Initiate a T-piece trial
ATS Review for the Critical Care Boards | QUESTIONS
45
82. 
A 71-year-old woman presents after a fall with a resultant left femoral neck fracture. The patient 
has no prior medical history and lives independently. While awaiting surgical repair, the patient 
complains of chest pain. An EKG is non-revealing. However, an echocardiogram demonstrates 
a dilated left ventricle with an ejection fraction of ~25%. The patient undergoes a left heart 
catheterization with a left ventriculogram. 
Which statement regarding this condition is true? 
A. This disease is typically associated with left main coronary disease
B. This disease most commonly presents in male smokers
C. This disease requires treatment at a center with cardiothoracic surgery
D. This disease typically resolves within several weeks
E. This disease is steroid responsive
83. 
A 78-year-old woman weighing 60 kg is admitted to the ICU with severe pneumonia and septic 
shock. She is intubated and requires FiO2 60% and PEEP of 12 cm H2O to maintain adequate 
oxygenation. She is on broad spectrum antibiotics, as well as norepinephrine to keep her mean 
arterial pressure >65 mm Hg. You decide to start tube feeds via orogastric (OG) tube. 
 
What is the ideal number of kilocalories she should receive on this first day of 
feeding? 
 
A. 10 kcal
B. 100 kcal
C. 500 kcal
D. 1000 kcal
E. 2000 kcal
ATS Review for the Critical Care Boards | QUESTIONS
46
84. 
Which of the following statements is true regarding direct oral anticoagulants 
(DOACs)?
A. All DOACs except for rivaroxaban are associated with increased bleeding risk compared to 
vitamin K antagonists
B. Edoxaban is not FDA approved for the treatment of venous thromboembolism (VTE)
C. All DOACS exert their mechanisms by the inhibition of factor Xa
D. All DOACs have similar efficacy to vitamin K antagonists in the treatment of patients with 
VTE
E. All DOACs require IV anticoagulation prior to initiation
85. 
A 49-year-old, 80 kg, previously healthy man develops acute chest pain and dyspnea. On 
presentation, he is alert and oriented with the following vital signs: Temp 37.8°C, HR 118 bpm, 
BP 105/62 mm Hg, RR 28/min, and oxygen saturation 89% on room air. He undergoes CT 
angiogram which is positive for saddle pulmonary embolism extending into bilateral segmental 
and subsegmental arterial branches, with RV-to-LV diameter ratio >1. His troponin is 0.15 
(normal <0.1 ng/ml). The patient has no contraindications to thrombolytic therapy.
 
Which of the following is the most appropriate treatment for this patient? 
A. Discharge the patient on rivaroxaban 20 mg daily
B. Transfer the patient to an ECMO capable facility
C. Start low molecular weight heparin 40 mg daily
D. Start fondaparinux 7.5 mg daily
E. Begin tPA 100 mg IV over 2 hours, followed by a heparin drip
 
86. 
A 22-year-old woman is brought to the ED by ambulance after being found somnolent on a 
park bench. 
 
Vital signs: Temp 35°C, HR 52 bpm, BP 95/65 mm Hg, RR 8/min
 
Her Glasgow Coma Scale (GCS) is 7 and she has pinpoint pupils. Her lung exam is notable for 
decreased breath sounds at the right lung base and she has multiple skin lesions on her arms 
and legs. 
An ABG on room air shows: pH 7.17, PaCO2 68 mm Hg, PaO2 70 mm Hg 
ATS Review for the Critical Care Boards | QUESTIONS
47
What is the most appropriate next step in the management of this patient?
A. Administer flumazenil
B. Administer atropine
C. Initiate emergent hemodialysis
D. Administer naloxone
E. Administer activated charcoal
87. 
 
Which of the following is an expected physiologic change during pregnancy? 
 
 A. Decreased FEV1
B. Decreased FRC
C. Decreased cardiac output
D. Increased FEV1/FVC ratio
E. Decreased minute ventilation
88. 
A 40-year-old man with a history of drug abuse presents with a 2-day history of right leg 
swelling and pain. Exam reveals: Temp 38.3°C, HR 110 bpm, BP 100/50 mm Hg, and RR 18/
min. There is circumferential erythema over his proximal right leg extending to the knee, with 
pain out of proportion to palpation and areas of tense edema. There is no crepitus, blistering, or 
skin necrosis. 
Labs: WBC count 16,000 cells/µL, Na 132 mEq/L, Cr 1.5 mg/dL, glucose 200 mg/dL, and CRP 
30 mg/dL 
Plain films of the right leg show no evidence of subcutaneous gas.