Hot Case Templates

GENERAL APPROACH

• Introduction
• Cubicle
• Infusions
• Ventilator
• Monitor
• Equipment
• Question specific examination

GENERAL QUESTIONS

Why does this patient have severe respiratory failure?

• Brain
• Cough
• Nerves
• NMJ
• Respiratory Muscles
• Pleura
• Airways (large and small)
• Parenchymal
• Chest wall
• Ventilator asynchrony
• Cardiac failure
• Abdominal distension/failure

“This patient has Respiratory Failure for multiple reasons. These include… “

List headings of causes -> clinical signs associated with list

Why is this patient failing to wean from ventilation?

• Brain
• Cough
• Nerves
• NMJ
• Respiratory Muscles
• Pleura
• Airways (large and small)
• Parenchymal
• Chest wall
• Ventilator asynchrony
• Cardiac failure
• Abdominal distension/failure

“There are multiple reasons why this patient is failing to wean from mechanical ventilation. These include…”

List headings of causes -> clinical signs associated with list

Why is this patient in Renal Failure?

• Acute, Chronic or Acute on Chronic
• Pre – volume status, shock + causes, temperature
• Intra – nephrotoxics, urine for casts + protein, sepsis, CK, nephritic/nephrotic syndromes
• Post – catheter flushed, intra-abdominal pressure, hydronephrosis

Can you extubate this patient?

• Original condition requiring intubation
• Airway
• Breathing (Respiratory function) – ventilation parameters including ABG and CXR
• Cardiovascular function
• Neurological function
  Assessment of environment – time of day, level of airway skill in unit, planned procedures

Why is this patient shocked? – must find the shock!

Is shock PROVED?

• Volume = Hypovolaemic – bleeding, dehydration, 3rd spacing (signs: cool peripherally, CR, pale, low CVP, low BP, narrow pulse pressure, high HR)
• Distributive – SIRS, septic, anaphylaxis, drugs (signs: WWP, dilated, bounding pulse, low diastolic pressure, wide pulse pressure, pressors, low CVP, high Q, low SVRI, active praecordium)
• Pump = Cardiogenic – myocardia, valves, rhythm, pericardium, left and right sided (signs: cool peripherally, shut down, bounding pulse, narrow pulse pressure, inotropes, high CVP, low SvO2, low Q, crackles in chest, oedema)
• Obstructive – TP, tamponade, abdominal compartment syndrome (signs: cool peripherally, narrow pulse pressure, inotropes, vasopressors, high CVP, muffled heart sounds, low Q)
• Endocrine — adrenal insufficiency, thyroid disorders
• ? = is it real? Technical – transducer height, quality of trace

Why is this patient jaundiced?

• Acute, Chronic or Acute on Chronic Liver Disease
• Pre-hepatic
• Hepatic
• Post-hepatic

Why is this patient not waking up? OR Why has this patient got a decreased LOC?

Structural – focal

• SOL (e.g. abscess, tumor)
• CVA
• Trauma
• Bleed

Non-structural – global

• Meningism – SAH, meningitis
• No meningism – metabolic, electrolytes, sepsis/seizures, organ failures, toxins (MESOT)

Why is this patient weak?

Unilateral or bilateral weakness?
Upper vs Lower motor neuron lesion?

• Brain
• Spinal cord
• Peripheral nerves
• NMJ
  Muscles

Is this patient brain dead?

• Diagnosis
• Exclusion of treatable causes
• Preconditions
• Responsiveness
• Brainstem reflexes
• Apnoea
• Imaging
• Other relevant information – second assessment by suitably trained doctor

Why is this patient febrile?

Infectious

• community acquired
• nosocomial (surgical site, lines, chest, urine, sinusitis)

Non-infectious

• head injury
• DVT -> PE
• drug/toxin
• SIRS (post surgery, trauma, aspiration, pancreatitis)
• Hypermetabolic syndromes

-> thyroid storm
-> NMS
-> MH
-> heat stroke
-> phaeochromocytoma
-> liver failure
-> burns
-> cocaine toxicity
-> serotonin syndrome

What injuries has this multiple-trauma patient sustained?

• Stage of illness
• Primary, secondary or tertiary survey (examine from head to toe)
• Rehabilitation phase
• Complications of stay

“My assessment follows a primary and secondary survey. Injuries from head to toe including relevant injuries are…”

How is this patient with multi-organ failure progressing?

• Initial illness and response to treatment
• Diagnosis correct
• Organ failures and support for each organ
• Complications of stay – nosocomial infection…

Why does this patient have polyuria?

• Cause
• Volume status
• Complications
• Treatment

SPECIFIC PATIENT APPROACHES

The COPD Patient

• Stable of illness – acute, respiratory weaning
• Ventilation strategy – NIV, invasive, weaning strategy
• Tracheostomy consideration
• Nutritional state
• Quality of life and prognosis

• Brain
• Cough
• Nerves
• NMJ
• Respiratory Muscles
• Pleura
• Airways (large and small)
• Parenchymal
• Chest wall
• Ventilator asynchrony

• Cardiac failure
• Abdominal distension/failure

The Post Cardiac Surgical Patient

• Type of surgery
• Emergency or Elective
• Post-operative complications (bleeding, bleeding, tamponade, graft occlusion, CVA)
• Shock assessment
• Causes and type of heart disease

The Post Cardiac Arrest Survivor

Prognositication

• Rhythm
• CPR (time to and quality)
• Time to ROSC
• Cause of arrest – ability to treat cause
• Therapeutic hypothermia
• Coma -> need to wait until 72 hrs
• Assessment @ 72 hours – pupils, corneal reflexes, motor response, SSEPs (N20 peak absence), iso-electric EEG, burst suppression, status myoclonus

Other issues

• Cause of cardiac arrest – IHD, arrhythmias, drowning, drug
• Complications (organ failures)

Why did this young patient have an out of hospital cardiac arrest?

• Cardiovascular – arrhythmia, electrolyte abnormality, long QT, Brugada syndrome, myocarditis (influenzae), ischaemia, congenital heart disease, shock, HOCM, ARVD
• Respiratory – TP, pneumonia with hypotension, PE
• Neurological – SAH, brain haemorrhage
• Renal – hyperkalaemia
• Drugs – overdose: TCA, opioids, stimulants, cocaine

The patient with an Intra-abdominal Catastrophe

• Cause
• Treatment (source control)
• Nutrition
• Complications – ACS, fungal sepsis
• How to move forward?

The patient who has had an Abdominal Aortic Aneurysm repair

• Emergency or Elective
• End-organ damage
• Complications
  — brain injury
  — spinal cord ischaemia
  — ileus
  — MI
  — lower limb ischaemia
  — compartment syndromes
  — renal injury

The patient who has had a Subarachnoid Haemorrhage

• Hemisphere
• Site
• Territory
• Complications
• Neurological – bleeding, seizure, hydrocephalus, vasospasm, increased ICP
• Respiratory – aspiration, neurogenic pulmonary oedema
• Cardiovascular – AMI
• Electrolytes – SIADH, CSW, DI
• Treatment done
• Management

The patient with a Head Injury

• Isolated TBI or not?
• Phase of illness: < 48 hours, day 2-7, late
• Complications:
  — refractory intracranial pressure
  — VAP
  — nosocomial infection
  — ventriculitis

The patient with a Spinal Injury

• Phase of injury
  — Acute: ileus, cardiovascular, ventilation
  — Sub-acute: recurrent atelectasis and segmental collapse
  — Chronic: pain, psychological issues, infection (uro, resp, pressure areas), autonomic dysreflexia, spasm.
• ASIA Classification (A-E)
• Cord syndrome presentation
• Other injuries/issues

The patient with Burns

• Burn
  — Site
  — Depth
  — Extent
• Phase of Burn
  — Resuscitation (Day 1)
  — Post-resuscitation (Day 2-6)
  — Inflammatory/infective (Day 7)
• Complications

The Transplant Patient

• Transplant – liver, heart, lung, heart-lung, bone marrow, renal, pancreatitic
• Phase of care – immediate post op, sepsis, rejection, respiratory failure, renal failure
• Surgery – graft function, anatomy, anastomoses
• Infection – bacterial (early), opportunistic: fungal, viral, mycobacterial (late)
• Immunosuppression – rejection, GVHD, drug side effects, malignancy

The Obstetric Patient

• Illness requiring ICU admission
• Pregnancy + Baby
• Delivery – when or already done

Long Stay ICU Patient

• Illness requiring ICU admission
• Reason for ongoing admission
• Things that need to happen to allow discharge

Can you decannulate this patient with a Tracheostomy?

• Reason for insertion – resolved/treated
• Airway – cuff down, size, speaking, absence of airway obstruction
• Respiratory assessment – FiO2, cough, sputum load, swallow, infection, WOB, CXR
• Cardiovascular – can patient deal with increase O2 demand
• Neurological – power, cough, awake, alert
• Environmental – time of day, level of staff, MDT involvement

Why has this patient got Liver Failure?

TYPE

• Hyperacute (Fulminant) – < 7 days
• Acute – 7 – 28 days
• Sub acute – 28 days to 6 months

CAUSES (DAVE)

• Drugs – paracetamol, halothane, idiosyncratic
• Alcohol
• Viral (A->G, CMV, HSV, EBV)
  Extras – fatty infiltration in pregnancy, HELLP, Wilsons, Reye’s

Neurological Exams for the CICM Examination

• Paralysed patient – pupils only
• Quick examination where neuro not the focus – GCS or responsiveness, pupils, movement of limbs, tone, reflexes.
• Unconscious examination – GCS or responsiveness, pupils, oculocephalic reflexes, corneals, cough, gag, limbs (posture, tone, reflexes, movement to pain)
• Conscious examination – everything! GCS, CNS, PNS.