CICM Second Part Exam Practice SAQs 15022018

As prepared by Bevan Roodenburg, here are the practice written questions from a recent CICM Second Part exam practice session at The Alfred ICU, with recommended reading from Lifeinthefastlane.com’s Critical Care Compendium and other FOAM sources:

Q1.

A 35-year-old man presents 4 days after a penetrating wound to the thigh with fevers, trismus, and generalised myalgias.

  1. How is the diagnosis of tetanus made? (2marks)
  2. List 6 differential causes for presentation with features of tetanus. (2 marks)
  3. List the different modes of death from tetanus? (1mark)
  4. Describe specific therapies for the management of tetanus. (5 marks)

Learn more here:

Tetanus

  1. How is the diagnosis of tetanus made?
    A.
    Clinical. Hx-recent wound, incubation typically 2-24 days, can be 1d-6months!. Non immunised or immune-defficient. Generalised form: increased muscle tone and spasm, Masseter muscles often first, dysphagia, stiff neck, shoulder/back pain. Paroxysms of severe muscle spasms. Culture often negative.
  2. List 6 differential causes for presentation with features of tetanus.
    A.
    Strychnine poison, drug induced dystonia, local infection ,stiff person syndrome, hypocalcaemia, malignant hyperthermia, stimulant use, serotonin syndrome, seizure, psychiatric disorders, other sepsis. (from college question on same)
  3. List the different modes of death from tetanus?
    A.
    Vomiting/aspiration ,apnoea, laryngospasm, hypoventilation, sudden cardiac arrest and autonomic dysregulation.
  4. Describe specific therapies for the management of tetanus.
    A.
    Organism: Antitetanus Immunoglobulin, antibiotics (pen or metronidazole or macrolide), wound debridement
    Spasms: magnesium, intrathecal magnesium, diaz/benzo, paralysis and ventilation+/- tracheostomy
    Autonomic dysfunction: sedation, alpha/beta blockade, analgesia

Q2.

An 87-year-old man is referred by the Emergency department with sepsis from a urinary tract infection. He presents with fever, lethargy, dysuria and pre-syncope, and is referred to ICU with persisting oliguria, hypotension and elevated lactate despite 3.5L of IV crystalloid and appropriate broad spectrum antibiotics.

His vital signs are:

  • Temp 38.5C
  • HR 120/min
  • BP 80/40 mmHg
  • RR 28/min
  • SpO2 92% on 4L 02 via standard nasal prongs
  • He is orientated but exhausted.
  1. Describe your approach to determining his suitability for ICU admission (50%)
  2. Describe (broadly) your recommendations for the care of this patient (50%)

Learn more here:

CICM IC-14 Statement on Withholding and Withdrawing Treatment: http://cicm.org.au/CICM_Media/CICMSite/CICM-Website/Resources/Professional%20Documents/IC-14-Statement-on-Withholding-and-Withdrawing-Treatment.pdf

Urosepsis

Suitability

  • ICU admission requires complex and careful consideration for every pt. Involving multiple medical teams, patient and family. The wishes of the patient are fundamental. So patient and or family should always be consulted.

Assessment of patient:

Indication for admission involves considering the balance of:

  • Need
    • acute critical illness/injury requiring monitoring or therapeutic interventions not possible/safe outside of ICU. Depends on physiology/prognosis for the patient without ICU care. Actual or potential disability/life threat
  • Benefit
    • Reversibility considered. Preventability of death/disability considered. Reasonable expectation for response and acceptable quality of life likely.
  • Burden of ICU
    • Intensive care can be painful, stressful, undignified, drawn out, debilitating, long term convalescence and rehabilitation required. Loss of independence and functional capacity is expected in many and even more so where frailty exists

Recommendations

  • Category 1. Appropriately meets needs and burden outweighed by potential benefit, so admit to ICU with no limits to ICU management
  • Category 2. Provisionally appropriate but with explicit limits to types of management (such as RRT/ventilation).
  • Category 3. Inappropriate for ICU admission. Where burden disproportionately outweighs a small potential benefit ICU can be inappropriate. “ICU will be of no enduring benefit to this patient”.

Q3.

A 32 -year-old man presents with 2 days history of fever, productive cough and progressive dyspnea. He is diagnosed with community acquired pneumonia.

He has a history of incomplete quadriplegia after a traumatic spinal injury ten years earlier. He lives with supportive parents who are not contactable due to overseas travel. He is usually wheelchair bound, requires 24 hour nursing care which he receives 365 days/year. He is only just able to move his right arm enough to feed himself but requires support with all other personal care.

His vital signs are:

  • Temp 38.5C
  • RR 38/min
  • BP 130/70 mmHg
  • HR 110/min (regular)
  • SpO2 84% on estimated Fi02 0.9 via NIV after failure of non-rebreather mask to correct his hypoxia
  1. Describe your management of this patient’s immediate care. (50%)
  2. List potential complications that should be considered in the management of this patient during an ICU admission. (50%)

Learn more here:

Gall A, Turner-Stokes L. Chronic spinal cord injury: management of patients in acute hospital settings. Clinical medicine. 2008; 8(1):70-4. [pubmed] [pdf]

Community Acquired Pneumonia

ANSWER 1. expected to be focused on identifying need for intubation, with modified RSI and attendant risks of spinal patients with regards to difficult airway, regurgitation, hypoxia, autonomic instability and shock, etc..

ANSWER 2. See attached article with lists of complications and DON’T FORGET the increased risk of MISSED DIAGNOSIS due to lack of sensation of pathology such as pressure injuries, compartment syndrome, bowel obstruction, urinary retention etc etc .


You can access all the previous practice questions since 2014 here:
https://docs.google.com/document/d/1_Ta8IvVaVtc5Il7-kJwj6qKGu54OmifJGRUWCXud8dY/edit
See this link on INTENSIVE for exam resources:
http://intensiveblog.com/resources/#3

The post CICM Second Part Exam Practice SAQs 15022018 appeared first on INTENSIVE.

CICM Second Part Exam Practice SAQs 31012018

As prepared by Chris Nickson, here are the practice written questions from a recent CICM Second Part exam practice session at The Alfred ICU, with recommended reading from Lifeinthefastlane.com’s Critical Care Compendium and other FOAM sources:

Q1.

  1. What are the differences between viscoelastic haemostatic assays (such as TEG® and ROTEM®) and plasma clotting assays? (50%)
  2. Suggest a cause of the haemostatic abnormality, and appropriate therapy, for each of the thromboelastogram profiles a) to f) shown below:  (50%)

Learn more here:

Thromboelastogram (TEG)

Q2.

Critically evaluate the role of corticosteroids as a therapy in septic shock (100%)

Learn more here:

Corticosteroids in Refractory Shock

ADRENAL

Steroids in Sepsis

 

Q3.

Outline your approach to the management of a 20 year-old man with Down Syndrome who ingested a large volume of drain cleaner and presents with throat pain, drooling and respiratory distress.

Learn more here:

Corrosive Ingestion


You can access all the previous practice questions since 2014 here:
https://docs.google.com/document/d/1_Ta8IvVaVtc5Il7-kJwj6qKGu54OmifJGRUWCXud8dY/edit
See this link on INTENSIVE for exam resources:
http://intensiveblog.com/resources/#3

The post CICM Second Part Exam Practice SAQs 31012018 appeared first on INTENSIVE.

CICM Second Part Exam Practice SAQs 17012018

As prepared by Chris Nickson, here are the practice written questions from a recent CICM Second Part exam practice session at The Alfred ICU, with recommended reading from Lifeinthefastlane.com’s Critical Care Compendium and other FOAM sources:

Q1.

Discuss the role of apnoeic oxygenation in the management of critically ill patients (100%)

Learn more here:

Apnoeic oxygenation

Q2.

Compare and contrast toxic epidermal necrolysis (TEN) with acute graft versus host disease (aGVHD) (100%)

Learn more here:

Stevens Johnson Syndrome and Toxic Epidermal Necrolysis

Acute Graft Versus Host Disease

TEN and acute GVHD disease are both multi-system skin disorders that both have high mortality. Though they can usually be distinguished by clinical presentation, histopathology is confirmatory. They may be difficult to distinguish in severe cases occuring after allogenic haematopoietic stem cell transplant.

TEN Acute GVHD
Cause malignancy (carcinomas and lymphomas)
infection (Mycoplasma pneumoniae, herpes virus, hepatitis A)
drug induced (penicillins, sulfa drugs, quinolones, cephalosporins, anticonvulsants, COX-2, immunosuppressants, allopurinol, corticosteroids)post-SCT/ organ transplantpost-immunisation
idiopathic
Occurs after allogenic haematopoietic stem cell transplant (30-50%) due to graft immune response
Pathophysiology Immune-related cytotoxic reaction aimed at destroying keratinocytes that express a foreign antigen

Results in separation of the epidermis from the dermis

Antigens on the host cells are attacked by the donated T cells

Tissue damage results in cytokine storm

Organs/ sites primarily affected Skin (>30% BSA)

Mucosal membranes

Skin

Liver

GI tract

+/- other organs (e.g. lung)

Clinical features Occurs 1-8 weeks after cause

Flu-like prodrome (1d-3wks)

Mucositis then after 1-3d

skin rash – macular, with purpuric center, then vesicles, then sheet-like exfoliation

<100d after SCT

puriritic/ painful MP rash +/- vesicles

GI: mucositis, diarrhoea, ileus

Other mucosae and eyes

Complications Sepsis, scarring & strictures, vision impairment, bleeding, fluid loss (e.g. hypovolaemic shock and AKI), capillary leak (e.g. ARDS), death
Diagnosis Clinical presentation

Skin biopsy (early): Necrotic keratinocytes with full-thickness epithelial necrosis and detachment

Clinical presentation

Tissue biopsy: skin (eg, eosinophilic bodies, mononuclear infiltration), liver (eg, necrosis of the bile duct), and gut (eg, crypt-cell degeneration)

CT abdo findings

Hyperbilirubinaemia

Specific therapy None proven by high quality trials, but options are:

  • Plasmapheresis
  • Corticosteroids
  • Cyclophosphamide
  • CSA
  • TNF-alpha inhibitors
  • IVIg
First line

  • Corticosteroids
  • +/- other immunosuppressants

Second line options

  • MMF/ CSA/ tacrolimus
  • ATG
  • Ruxilitinib
  • PUVA
  • Etc, etc!
Supportive care and monitoring
  • MDT approach
  • Severe cases referred to burns center
  • Wound care (e.g. dressings)
  • Treat infection (antimicrobials)
  • Analgesia and sedation
  • Eye care
  • Fluid replacement
  • Control bleeding (e.g. blood products)
  • TPN for GI mucosal involvement
Prognosis Predicted by SCORTEN

10-70% mortality (varies with quality of Rx and rapidity of Rx)

Varies with Grade I to IV

20% if complete response to steroids

80% mortality if refractory to steroids

50% develop chronic GVHD

Q3.

Describe the Stewart (physico-chemical) approach to acid-base disturbances, and discuss the pros and cons of this method. (100%)

Learn more here:

Strong Ion Difference


You can access all the previous practice questions since 2014 here:
https://docs.google.com/document/d/1_Ta8IvVaVtc5Il7-kJwj6qKGu54OmifJGRUWCXud8dY/edit
See this link on INTENSIVE for exam resources:
http://intensiveblog.com/resources/#3

The post CICM Second Part Exam Practice SAQs 17012018 appeared first on INTENSIVE.