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.
CCC 700 6

Critical Care

Compendium

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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