Prometric Exam Questions for Critical Care Medicine Specialists 2026: 20 MCQs with Answers on Septic Shock, ARDS and Ventilation, Haemodynamics, Sedation and Delirium, Renal Replacement, Nutrition, Neurocritical Care and End-of-Life Decisions

The specialist critical care medicine paper (ICU5231 at DHA, and the equivalents at SCFHS, QCHP, NHRA and the other authorities) is 100 to 150 single-best-answer questions in up to three hours with a pass mark of about 60%. Candidates with an intensive care fellowship, EDIC, CICM, IDCCM or DM, or anaesthesia and internal medicine specialists with recognised ICU training, sit it after the authority confirms the title. The paper is protocol-driven: it wants the current guideline answer for the common ICU syndromes, the physiology behind it, and the judgement calls at the bedside. This set covers what recurs. The licensing route is in the intensivist guide.

Sepsis and shock

Question 1

A 60-year-old with pneumonia has a lactate of 4.5 mmol/L and a mean arterial pressure of 58 mmHg after 30 mL/kg of crystalloid. The next step is:

1. Another 30 mL/kg bolus before any vasopressor
2. Start noradrenaline as the first-line vasopressor, peripherally if central access is delayed, targeting a MAP of 65 mmHg, with vasopressin added when the noradrenaline dose rises (around 0.25 to 0.5 µg/kg/min) and hydrocortisone 200 mg/day for ongoing vasopressor requirement
3. Dopamine as first line
4. Dobutamine alone

Answer: B. Surviving Sepsis Campaign guidance favours early noradrenaline over repeated fluid boluses; dynamic measures of fluid responsiveness guide further fluid, not fixed volumes.

Question 2

Which bedside finding best predicts that a hypotensive ventilated patient will respond to a fluid bolus?

1. A central venous pressure of 6 mmHg
2. A pulse pressure variation above 12 to 13% in a patient in sinus rhythm receiving controlled ventilation with tidal volumes of at least 8 mL/kg, or a positive passive leg raise (a rise in cardiac output of about 10% or more)
3. Cool peripheries
4. A heart rate above 100

Answer: B. Static pressures such as CVP do not predict fluid responsiveness; passive leg raise works in spontaneously breathing patients and arrhythmia, where pulse pressure variation fails.

Question 3

A patient after a large anterior myocardial infarction has a MAP of 60 mmHg, cold extremities, pulmonary oedema, a cardiac index of 1.8 L/min/m² and a pulmonary capillary wedge pressure of 24 mmHg. The shock type and initial management are:

1. Hypovolaemic shock; fluid bolus
2. Cardiogenic shock; inotropic support (dobutamine, or noradrenaline for hypotension), urgent revascularisation, diuretics once perfusion improves, and consideration of mechanical circulatory support
3. Distributive shock; vasopressin
4. Obstructive shock; thrombolysis

Answer: B. Fluids worsen cardiogenic shock with raised filling pressures; the four shock types (hypovolaemic, cardiogenic, obstructive, distributive) are differentiated by filling pressures, cardiac output and vascular resistance, increasingly with echocardiography.

Question 4

A patient with septic shock from a urinary source has not had a clear source control plan. Which principle is tested?

1. Antibiotics alone are sufficient
2. Source control (drainage of an obstructed infected kidney, removal of an infected line, debridement of necrotic tissue) within 6 to 12 hours of recognition, alongside antibiotics within one hour and de-escalation once cultures return
3. Delay source control until the patient is stable
4. Repeat cultures daily

Answer: B. Delayed source control is an independent predictor of death in sepsis.

Respiratory failure and ventilation

Question 5

A 45-year-old with ARDS (PaO₂/FiO₂ 110 on PEEP 12) weighs 70 kg with a predicted body weight of 65 kg. The ventilator settings should target:

1. Tidal volume 10 mL/kg, plateau pressure under 40 cmH₂O
2. Tidal volume about 6 mL/kg predicted body weight (around 390 mL), plateau pressure 30 cmH₂O or less, driving pressure under 15 cmH₂O, moderate to high PEEP, permissive hypercapnia, and prone positioning for 12 to 16 hours a day while the ratio stays below 150
3. Zero PEEP to protect the heart
4. Pressure support ventilation only

Answer: B. Low tidal volume ventilation and prone positioning both reduce mortality; routine neuromuscular blockade is no longer recommended for all patients, and ECMO is considered for refractory hypoxaemia at experienced centres.

Question 6

A ventilated patient is on day 5 of mechanical ventilation. Which set of criteria indicates readiness for a spontaneous breathing trial?

1. Any patient awake
2. Resolution or improvement of the cause of respiratory failure, PaO₂/FiO₂ above 150 to 200 on PEEP of 8 or less and FiO₂ of 0.4 to 0.5 or less, haemodynamic stability on minimal or no vasopressors, able to initiate breaths, and adequate mental status; then a 30-minute to 2-hour trial on low pressure support or T-piece, with a paired daily sedation interruption
3. A rapid shallow breathing index of 150
4. Tidal volume of 3 mL/kg during the trial

Answer: B. A rapid shallow breathing index below about 105 breaths/min/L predicts success; cuff leak testing identifies patients at risk of post-extubation stridor, and prophylactic non-invasive ventilation after extubation benefits high-risk patients.

Question 7

A patient with a COPD exacerbation has pH 7.26, PaCO₂ 9.5 kPa and is alert and cooperative after one hour of controlled oxygen, bronchodilators and steroids. The next step is:

1. Immediate intubation
2. Non-invasive ventilation (bilevel positive airway pressure) with close monitoring and a low threshold for intubation if pH, consciousness or respiratory rate worsen within 1 to 2 hours
3. High-flow nasal oxygen alone
4. Increase oxygen to 15 L/min

Answer: B. NIV reduces intubation and mortality in acidotic COPD exacerbations and in cardiogenic pulmonary oedema; high-flow nasal oxygen is preferred in hypoxaemic (type 1) failure without hypercapnia.

Question 8

A ventilated patient suddenly desaturates with high airway pressures and absent breath sounds on the right, hypotension and tracheal deviation. The management is:

1. Increase PEEP
2. Disconnect from the ventilator and hand-ventilate while assessing, and perform immediate needle or finger thoracostomy followed by a chest drain for tension pneumothorax, a clinical diagnosis that does not wait for a radiograph
3. Chest radiograph then CT
4. Bronchoscopy

Answer: B. The DOPES mnemonic (displacement, obstruction, pneumothorax, equipment, stacked breaths) structures sudden deterioration on the ventilator.

Sedation, delirium and neurocritical care

Question 9

Which sedation strategy is associated with shorter ventilation and ICU stay?

1. Deep continuous benzodiazepine sedation
2. Analgesia-first (analgosedation) with light sedation targets (RASS 0 to −2), propofol or dexmedetomidine rather than benzodiazepines, daily sedation interruption or protocolised titration, and routine delirium screening with CAM-ICU
3. No analgesia to allow neurological assessment
4. Continuous neuromuscular blockade

Answer: B. Benzodiazepines increase delirium; the ABCDEF bundle (assess pain, both awakening and breathing trials, choice of sedation, delirium, early mobility, family) is the organising framework.

Question 10

A patient in status epilepticus has not responded to two adequate doses of intravenous lorazepam. The next agent is:

1. Another benzodiazepine dose and wait
2. A second-line antiseizure medication: levetiracetam, valproate or fosphenytoin (all similarly effective), followed by anaesthetic doses of propofol, midazolam or ketamine with continuous EEG if seizures continue beyond about 40 minutes (refractory status), while treating the cause (glucose, electrolytes, infection, toxins, non-adherence)
3. Oral carbamazepine
4. Immediate neurosurgical referral

Answer: B. Time is the tested variable: benzodiazepine by 5 minutes, second-line drug by 20 minutes, anaesthesia by 40 minutes.

Question 11

A patient with a severe traumatic brain injury has an ICP of 25 mmHg and a MAP of 90 mmHg. The cerebral perfusion pressure and target are:

1. 115 mmHg; too high, reduce blood pressure
2. 65 mmHg (MAP minus ICP), within the recommended 60 to 70 mmHg range; ICP above 22 mmHg is treated with tiered measures (sedation, CSF drainage, hyperosmolar therapy, brief hyperventilation, then decompressive craniectomy or barbiturates)
3. 25 mmHg; give fluids
4. 90 mmHg; no action

Answer: B. Steroids are harmful in TBI; hypotension and hypoxia are the secondary insults most strongly linked to death.

Question 12

After return of spontaneous circulation from an out-of-hospital cardiac arrest, a comatose patient is admitted to ICU. The post-resuscitation bundle includes:

1. Rapid rewarming to 38 °C and 100% oxygen for 24 hours
2. Temperature control to prevent fever (targeting 32 to 36 °C or normothermia below 37.5 °C per current guidance) for at least 72 hours, avoiding hyperoxia (saturations 92 to 98%) and hypotension (MAP above 65), normocapnia, glucose 7.8 to 10 mmol/L, early coronary angiography for ST elevation, and multimodal neuroprognostication no earlier than 72 hours after normothermia
3. Prognostication at 24 hours with pupillary reflexes alone
4. Immediate withdrawal if no response at 12 hours

Answer: B. Premature prognostication is the error tested; EEG, somatosensory evoked potentials, neuron-specific enolase and imaging are combined.

Renal, metabolic and nutrition

Question 13

A patient with septic AKI has a potassium of 5.6 mmol/L, pH 7.30, urea 25 mmol/L and urine output of 0.3 mL/kg/h for 10 hours, with no pulmonary oedema. The best approach to renal replacement therapy is:

1. Start continuous renal replacement therapy immediately in all stage 2 AKI
2. Watchful waiting with correction of hyperkalaemia and acidosis medically, starting RRT for refractory hyperkalaemia, severe acidosis, fluid overload, uraemic complications or persistent oliguria beyond about 72 hours, since early initiation does not improve survival (STARRT-AKI, AKIKI)
3. Furosemide infusion to convert to non-oliguric AKI and avoid dialysis
4. Peritoneal dialysis

Answer: B. Continuous modalities are preferred in haemodynamically unstable patients; regional citrate anticoagulation is standard where available.

Question 14

A ventilated patient on day 3 in ICU has a functioning gut and no shock. The nutrition plan should be:

1. Parenteral nutrition from day 1 at full calories
2. Early enteral nutrition within 24 to 48 hours, advancing towards about 70% of estimated energy needs by the end of the first week (or indirect calorimetry targets), protein 1.2 to 2.0 g/kg/day, with supplemental parenteral nutrition only if enteral intake remains inadequate after about a week, and glucose kept at 7.8 to 10 mmol/L
3. Nil by mouth until extubation
4. Full-calorie feeding from the first hour

Answer: B. Overfeeding in the acute phase is harmful; gastric residual volume thresholds have been relaxed and prokinetics are used before switching to post-pyloric feeding.

Question 15

A 25-year-old with DKA has pH 6.95, potassium 3.1 mmol/L, glucose 32 mmol/L and bicarbonate 5 mmol/L. Before starting the insulin infusion, the essential step is:

1. Give a bicarbonate infusion
2. Replace potassium first (hold insulin until potassium is above 3.3 to 3.5 mmol/L) because insulin will drive potassium into cells and precipitate arrhythmia; fluids are started immediately, insulin at 0.1 units/kg/h once potassium is safe, with glucose added to fluids when glucose falls below about 14 mmol/L while the insulin continues until ketones clear
3. Insulin bolus of 20 units
4. Restrict fluids to prevent cerebral oedema

Answer: B. Bicarbonate is rarely indicated (pH below 6.9 with cardiovascular compromise); the Gulf has a high incidence of type 1 diabetes and DKA admissions.

Haematology, infection and ethics

Question 16

A trauma patient is receiving a massive transfusion. The principles include:

1. Red cells only until the haemoglobin normalises
2. A balanced ratio of plasma, platelets and red cells approaching 1:1:1, early tranexamic acid within 3 hours, calcium replacement (citrate chelation), prevention of hypothermia and acidosis, viscoelastic or conventional coagulation testing to guide fibrinogen and platelet replacement, and permissive hypotension until haemorrhage control except in traumatic brain injury
3. Large volumes of crystalloid first
4. Wait for coagulation results before plasma

Answer: B. The lethal triad of hypothermia, acidosis and coagulopathy is the physiological frame; fibrinogen below 1.5 to 2 g/L is replaced.

Question 17

Which bundle element has the strongest evidence for reducing central line-associated bloodstream infection?

1. Routine replacement of catheters every 7 days
2. Hand hygiene, maximal sterile barrier precautions at insertion, chlorhexidine-alcohol skin antisepsis, avoiding the femoral site in adults where possible, daily review of necessity with prompt removal, and chlorhexidine bathing in high-risk units
3. Prophylactic systemic antibiotics at insertion
4. Topical antibiotic ointment at the site

Answer: B. Routine catheter replacement increases complications without reducing infection; multidrug-resistant Gram-negatives in Gulf ICUs make stewardship and infection prevention heavily tested.

Question 18

A patient on broad-spectrum antibiotics for 10 days develops profuse watery diarrhoea, fever, a white cell count of 25 × 10⁹/L and abdominal distension. Management is:

1. Loperamide and continue current antibiotics
2. Test for Clostridioides difficile, stop unnecessary antibiotics, isolate with contact precautions and soap-and-water hand hygiene, and treat severe or fulminant infection with oral vancomycin or fidaxomicin (plus intravenous metronidazole in fulminant disease), with surgical review for toxic megacolon
3. Oral metronidazole as first line for severe disease
4. Alcohol hand gel is sufficient

Answer: B. Alcohol gel does not kill spores; antimotility agents worsen toxic megacolon.

Question 19

A 78-year-old with metastatic cancer and multi-organ failure is not improving after a week of full support. The family asks that "everything be done." The appropriate approach is:

1. Continue all treatment indefinitely to avoid conflict
2. A structured family meeting with the treating team, exploring the patient's known wishes and values, explaining prognosis honestly, offering a time-limited trial with explicit goals, involving palliative care and religious or cultural support (including an imam where the family wishes), and following the hospital's and national policy on withholding and withdrawing treatment, with a second opinion or ethics consultation if disagreement persists
3. Withdraw treatment without discussion
4. Transfer to another hospital

Answer: B. Gulf states have legal frameworks for do-not-resuscitate decisions and withdrawal of futile treatment (for example UAE Federal Law and SCFHS policy); euthanasia is prohibited, but allowing natural death with comfort care is permitted within those frameworks.

Question 20

Which statement about the apnoea test during brain death determination is correct?

1. It can be performed with a core temperature of 34 °C
2. Prerequisites include a known irreversible cause, core temperature above 36 °C, systolic blood pressure of at least 100 mmHg, no sedatives or paralytics, and normal electrolytes; the patient is pre-oxygenated, disconnected from the ventilator with oxygen insufflation, and observed for respiratory effort while PaCO₂ rises to at least 60 mmHg (or 20 mmHg above baseline), with ancillary tests (cerebral blood flow studies) when the test cannot be completed
3. A single examiner at any time after injury is sufficient
4. Spinal reflexes exclude brain death

Answer: B. National laws specify the number of examiners and the interval between examinations; organ donation programmes operate in Saudi Arabia, the UAE, Qatar, Kuwait and Oman.

How to practise

• Learn the bundles: sepsis hour-one, ARDS lung protection, ABCDEF, post-cardiac arrest, CLABSI and VAP prevention, massive transfusion.
• Know the trial-based answers: when not to give fluid, when not to start RRT early, why benzodiazepines and steroids in TBI are wrong.
• Practise interpretation: blood gases, ventilator waveforms, haemodynamic profiles, electrolyte emergencies.
• Practise under time in the Critical Care Medicine bank with the error-log method.

Related sets: anaesthesiology, emergency medicine, pulmonology and nephrology. ICU nurses should see the critical care nursing questions.

Frequently asked questions

How many questions are in the Prometric critical care medicine exam?

Typically 100 to 150 single-best-answer MCQs in up to three hours, with a pass mark of about 60%, varying by authority.

Which critical care topics come up most?

Sepsis and vasopressors, ARDS ventilation, weaning, sedation and delirium, renal replacement timing, post-cardiac arrest care, status epilepticus and ICU infection prevention.

Which guidelines does the exam follow?

Surviving Sepsis Campaign, ARDS Network and ESICM guidance, the PADIS sedation guidelines, KDIGO, Brain Trauma Foundation and current resuscitation council post-arrest guidance.

Can anaesthetists or internists sit the critical care paper?

Only when the authority recognises their intensive care training for the critical care title; otherwise they sit their primary specialty paper.

Are these real exam questions?

No. They are original practice questions written to the published blueprint. Real exam content is confidential.