CICM SAQ 2015.1 Q1

Question

You are called to review a 29-year-old male with confirmed asthma in the Emergency Department. He has been unwell for 2 days with increasing cough, wheeze and shortness of breath. He has just been intubated.

  • a) Describe what ventilator settings you will initially set and give the reasons for your answer. (40% marks)

Two hours later he has become increasing difficult to ventilate. You quickly assess and exclude all other causes except severe bronchospasm.

  • b) Briefly outline your management of this situation. (60% marks)

Answer

Answer and interpretation

a) Describe what ventilator settings you will initially set and give the reasons for your answer. (40% marks)

b) Briefly outline your management of this situation. (60% marks)

Ensure adequate sedation:

  • Ketamine +/- propofol +/- analgesia
  • Preferentially use non histamine releasing analgesia – fentanyl

Muscle relaxation:

  • Non steroid/non histamine releasing agents – ideally cisatracurium

Bronchodilator therapy

  • Regular inhaled salbutamol – MDI, nebuliser
  • IV infusion salbutamol
  • IV adrenaline infusion
  • Anticholinergic therapy – Ipratropium bromide inhaled regularly
  • Magnesium infusion – aiming for Mg 1.5-2.5 mmol/L
  • Methylxanthine therapy – Aminophylline infusion

Steroid therapy

  • 100 mg 6 hrly hydrocortisone (or any reasonable steroid / dose)

Ventilation

  • Confirm ventilator settings
  • Tidal volume 6-8 mL/kg
  • Check plateau (rather than peak) inspiratory pressure with inspiratory pause in volume control mode and paralysed patient
  • Reduce respiratory rate if possible
  •   Minimise PEEP
  • Check for evidence of dynamic hyperinflation with expiratory hold in paralysed patient
  • Permissive hypercapnia

Other strategies

  • Answer and interpretationInhaled volatile anaesthetic agents
  • Heliox if available
  • Consider ECCO2 removal / ECMO
  • Pass rate: 71%
  • Highest mark: 8.8

Additional comments:

  • Common scenario and should be basic knowledge. Some candidates gave a poor explanation for their choice of ventilator settings in part a). Candidates who failed the question had knowledge gaps and inadequate detail in their answer.
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Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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