A 62-year-old man (70 kg) is admitted to the cardiac ICU for cardiogenic shock following an acute myocardial infarction. He is receiving norepinephrine at 0.05 mcg/kg/min via a central line and is supported on an Impella CP device set at performance level 8 (~3.5 L/min). Over the past 48 hours, his mean arterial pressure has remained >70 mmHg, lactate has normalized to 1.2 mmol/L, and urine output is >0.5 mL/kg/hr. Which of the following is the most appropriate strategy for weaning temporary mechanical circulatory support?

A 68-year-old man with severe chronic obstructive pulmonary disease is brought to the emergency department after being found unresponsive with bradypnea. He recently started a new opioid for chronic back pain. Paramedics noted transient improvement after administering naloxone en route. On arrival, he remains on low-dose norepinephrine via a central line; vital signs are blood pressure 95/60 mmHg, heart rate 110 bpm, respiratory rate 6 breaths/min, and SpO₂ 85% on room air. An arterial blood gas prior to intubation shows pH 7.18, PaCO₂ 78 mmHg, PaO₂ 55 mmHg, and HCO₃⁻ 28 mEq/L. Given his COPD, which of the following is the most critical consideration in managing his opioid toxidrome?

A 62-year-old, 75-kg man with acute‐on‐chronic heart failure presenting in cardiogenic shock is managed in the ICU. He is receiving norepinephrine at 0.08 mcg/kg/min and has an Impella CP device set at P-level 5 (2.5 L/min). Over the past 24 hours, his mean arterial pressure has remained 68–72 mmHg, lactate has decreased from 4.5 to 1.8 mmol/L, urine output is 0.8 mL/kg/hr, and echocardiography shows left ventricular ejection fraction improved from 15% to 25%. Given his clinical stability and principles of de-escalation in cardiogenic shock, what is the most appropriate next step in managing his temporary mechanical circulatory support?

A 45-year-old man presents to the ICU after ingesting a dapsone preparation. He is intubated, hypotensive on norepinephrine to maintain a mean arterial pressure >65 mmHg, and his blood appears chocolate brown. Laboratory studies show a methemoglobin level of 25%. Which route of administration is most appropriate for the initial dose of methylene blue?

A 45-year-old man in the intensive care unit for acute respiratory failure becomes acutely agitated and disoriented over one hour. His temperature is 39.5°C, heart rate 130 bpm, blood pressure 155/90 mmHg, and respiratory rate 28 breaths/min. On examination, he has dilated, poorly reactive pupils, warm dry skin, and absent bowel sounds. He was treated with high-dose diphenhydramine for severe pruritus earlier in the day. Based on this presentation, which toxidrome is the most consistent finding?

A 45-year-old man (weight 70 kg) is admitted to the ICU 2 hours after an accidental overdose of topical lidocaine. He is intubated on assist-control ventilation and requires a norepinephrine infusion at 0.1 mcg/kg/min to maintain a mean arterial pressure >65 mmHg. Initial arterial blood gas reveals pH 7.32, PaCO2 48 mmHg, PaO2 88 mmHg, and lactate 3.2 mmol/L. His pulse oximetry reads 85% despite 100% FiO2, and his blood appears dark chocolate-brown. Co-oximetry confirms a methemoglobin level of 28%. Which of the following is the most appropriate initial intervention?

A 45-year-old man (weight 75 kg) is admitted to the ICU for cardiogenic shock following a massive tricyclic antidepressant overdose. He is supported with an Impella CP device at performance level P-8 (8.0 L/min). A pulmonary artery catheter shows a cardiac index of 2.5 L/min/m², PCWP 16 mmHg, and CVP 10 mmHg. He is afebrile, heart rate 78 bpm, blood pressure 100/60 mmHg on no vasopressors. Lactate is 1.2 mmol/L and urine output is 0.8 mL/kg/hr. A structured, gradual weaning protocol is planned. Which of the following is the most appropriate initial step in weaning his Impella support?

A 45-year-old man presents with generalized cyanosis and persistent hypoxemia (SpO2 ~85%) despite 100% FiO2. His arterial blood gas shows PaO2 of 95 mmHg. Which additional laboratory finding would MOST strongly confirm the suspected diagnosis?

A 45-year-old man is admitted to the critical care unit following an intentional overdose. He is intubated on assist-control ventilation with a propofol infusion for sedation, and a central venous catheter is in place. During the morning assessment, his vital signs are noted as: temperature 39.5°C (103.1°F), heart rate 130 bpm, blood pressure 145/90 mm Hg, and respiratory rate 18 breaths/min (ventilator-controlled). Physical examination reveals widely dilated and unresponsive pupils, flushed and dry skin, absent bowel sounds, and a distended bladder despite recent Foley catheter insertion. The patient is agitated and picking at the bedsheets. Based on the patient’s clinical presentation, which of the following toxidromes is MOST consistent with these findings?

A 62-year-old man with a history of acute-on-chronic heart failure is admitted to the critical care unit. He is on assist-control ventilation with a continuous norepinephrine infusion via a central line. He was placed on temporary mechanical circulatory support (tMCS) with an Impella CP for cardiogenic shock. Over the past 48 hours, his hemodynamics have stabilized, with a mean arterial pressure (MAP) >70 mmHg, improving urine output, and decreasing lactate levels. During morning rounds, it is noted that while his immediate stability is good, his underlying chronic heart failure is severe, and he has previously expressed concerns about long-term quality of life with extensive medical interventions.

Given this clinical presentation, which of the following is the most appropriate next step in this patient’s management?