OSCEs for the Final FFICM OSCEs for the Final FFICM Raj Nichani is a Consultant in Anaesthesia and Intensive Care Medicine, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK Brendan McGrath is a Consultant in Anaesthesia and Intensive Care Medicine, University Hospital South Manchester, and Honorary Senior Lecturer at University of Manchester, UK University Printing House, Cambridge CB2 8BS, United Kingdom Cambridge University Press is part of the University of Cambridge It furthers the University’s mission by disseminating knowledge in the pursuit of education, learning and research at the highest international levels of excellence www.cambridge.org Information on this title: www.cambridge.org/9781107579453 © Raj Nichani and Brendan McGrath 2016 This publication is in copyright Subject to statutory exception and to the provisions of relevant collective licensing agreements, no reproduction of any part may take place without the written permission of Cambridge University Press First published 2016 Printed in the United Kingdom by TJ International Padstow, Cornwall A catalogue record for this publication is available from the British Library Library of Congress Cataloguing in Publication data Names: Nichani, Raj, author | McGrath, Brendan, 1974- , author Title: OSCEs for the final FFICM / Raj Nichani, Brendan McGrath Description: Cambridge ; New York : Cambridge University Press, 2016 | Includes bibliographical references and index Identifiers: LCCN 2016011814 | ISBN 9781107579453 (Paperback) Subjects: | MESH: Critical Care | Great Britain | Examination Questions Classification: LCC RC86.8 | NLM WX 18.2 | DDC 616.02/8–dc23 LC record available at http://lccn.loc.gov/2016011814 ISBN 978-1-107-57945-3 Paperback Cambridge University Press has no responsibility for the persistence or accuracy of URLs for external or third-party internet websites referred to in this publication, and does not guarantee that any content on such websites is, or will remain, accurate or appropriate Every effort has been made in preparing this book to provide accurate and up-to-date information which is in accord with accepted standards and practice at the time of publication Although case histories are drawn from actual cases, every effort has been made to disguise the identities of the individuals involved Nevertheless, the authors, editors and publishers can make no warranties that the information contained herein is totally free from error, not least because clinical standards are constantly changing through research and regulation The authors, editors and publishers therefore disclaim all liability for direct or consequential damages resulting from the use of material contained in this book Readers are strongly advised to pay careful attention to information provided by the manufacturer of any drugs or equipment that they plan to use For Emma, Cerys and Bethan – thanks for the constant understanding and support and all the cups of coffee you brought down to the cellar whilst working on this book! For Jaya, Neel and Taran – thank you for all your incredible encouragement, love and patience Mum and Dad – for your untiring affection and strength of belief in me Contents Foreword Preface The FFICM – the examiner’s view page x xi xii Section I: Data interpretation 21 Acute coronary syndrome and papillary muscle rupture 59 Acid base 22 TTP/HUS 62 Methaemoglobin 23 Subarachnoid haemorrhage 64 Infective diarrhoea and toxic megacolon 24 Post-oesophagectomy anastomotic leak 66 Major burn 13 25 Pulmonary embolism 68 Ruptured hemidiaphragm 16 Post cardiac arrest 19 26 Heparin-induced thrombocytopenia 71 Necrotizing fasciitis 22 27 Brainstem death 74 ARDS 24 Stridor 27 28 Tricyclic antidepressant overdose 76 29 Chest-pain assessment 79 10 Hyponatraemia 29 11 Chest drain complications 33 30 Intra-abdominal hypertension 82 12 Interpretation of pulmonary function tests 35 31 Selective decontamination of the digestive tract 86 13 Serotonin syndrome 38 32 Bone marrow transplant 89 14 Propofol infusion syndrome 41 33 Acute kidney injury 93 15 Guillain–Barré syndrome 44 34 Broncho-pleural fistula 97 16 Epidural management 46 35 Myasthenia gravis 100 17 Panton–Valentine leukocidin (PVL) MRSA pneumonia 49 36 RV infarct 102 18 Surviving (urological) sepsis 52 37 Rhabdomyolysis 104 38 Cerebrovascular accident 107 39 Acute leukaemia 110 19 Ventilator-associated pneumonia 55 20 Refeeding syndrome 57 vii Contents viii Catheter-related bloodstream infection and vancomycinresistant enterococcus 40 Diabetic ketoacidosis 113 41 Failure to wean 116 42 Pleural effusion 118 43 Intensive care unit follow-up clinic anaemia 10 Spinal needles 202 121 11 Capnography 204 44 Acute liver failure 123 12 Patient transfer 208 45 Cirrhosis with upper gastro-intestinal bleeding 127 13 Tracheostomies 210 46 Sedation and sedation scoring 131 14 Central lines 213 15 Haemofiltration 216 200 47 Encephalitis, epilepsy and MRI scans 134 16 Intra-aortic balloon pump 218 48 Acute renal failure in a HIVpositive man 137 49 Digoxin toxicity and cardiac pacing 141 Section III: Ethics and communication 221 50 Acute pancreatitis 144 51 Cortisol and thyroxine in the critically ill Anaphylaxis 223 Pulmonary embolism 224 148 Malignant hyperthermia 226 52 TEG and major haemorrhage 151 Organ donation 228 53 Poisoning 154 End-of-life care 230 54 Electrocardiogram interpretation 156 Muscular dystrophy 233 55 Chest X-ray interpretation 163 Delirium 235 Section II: Equipment 177 Deterioration post discharge 237 Arterial lines 177 Consent for tracheostomy 239 Tracheostomy weaning and communication 10 Blood transfusion 241 180 11 Alcoholic liver disease 245 Bronchoscopy 183 12 Long QT 248 Cooling devices 185 Pulmonary artery catheter 188 Nasogastric tubes 190 High-flow nasal cannula 194 Cardiac output technologies 196 Section IV: Resuscitation and simulation 251 Displaced airway 253 Child submersion 256 Section IV: Resuscitation and Simulation Resuscitation 10 Overview A 30-year-old woman suffers an anaphylactic reaction to an antibiotic on a surgical ward and the candidate is called to assess her Initial resuscitation does not help and she develops a cardiac arrest Key learning objectives/assessment criteria Rapid assessment of the patient Knowledge of initial treatment of anaphylaxis Management of cardiac arrest Background for candidates A 30-year-old lady has been admitted to a surgical ward with suspected cholecystitis Her past medical history is otherwise unremarkable The junior doctor has just given her a dose of antibiotic and she has become short of breath and feels faint within 10 minutes The doctor and a nurse have asked for your help as she looks awful and they are really worried that this might be a severe reaction to the antibiotic Information for simulation facilitators Initial set-up Manikin laid on bed Ward-based – oximeter, non-invasive BP, no ECG Wheeze, RR 34 bpm HR 140 bpm, BP 65/40 Capillary refill seconds Rash if possible under clothes You will need: Mock induction and vasopressor drugs (including adrenaline) Intravenous fluids Intravenous access Training defibrillator Airway management equipment One doctor and one nurse for the cardiopulmonary resuscitation (CPR) 284 Resuscitation 10 Initial vital signs: HR 140 bpm sinus Non-invasive BP 65/40 mmHg RR 34 bpm SpO2 90% Progress and mark scheme Action Simulation action/response Marking Check/assess airway Apply 100% FiO2 via nonrebreather mask Patient opens eyes to voice, groaning 1 Assess breathing: Inspection, palpation, percussion and auscultation Check O2 saturation AE symmetrical with widespread wheeze O2 saturation not recording Assess circulation – HR, BP, capillary refill BP 65/40 mmHg HR 140 bpm, regular, capillary refill seconds 1 (both) Large-bore intravenous access Blood for full blood count, urea and electrolytes, cross-match Fluid challenge as low BP Arterial blood gas (both) Assess disability: AVPU or GCS Check blood glucose Eye opens to voice BM is 4.2 Expose patient Widespread rash Recognize anaphylaxis Drugs: Adrenaline 0.5 mg (intramuscular) Chlorphenamine 10 mg (intravenous) Hydrocortisone 200 mg (intravenous) Salbutamol nebulizer 1 1 Patient has cardiac arrest Call for help Commence CPR 30:2 Attach defibrillation pads and recognize pulseless electrical activity arrest Airway management/ intubation 285 Section IV: Resuscitation and Simulation 286 (cont.) Action Simulation action/response Marking Recognize and treat reversible causes (4 ‘H’s and ‘T’s) Hypotension, hypoxia, hyper/hypo kalaemia/thermia Toxins, thrombo-embolism, tamponade, tension pneumothorax Intravenous adrenaline mg The cardiac arrest should continue until the candidate has had the chance to comment on the reversible causes of the cardiac arrest and give an adrenaline bolus In practice settings, the manikin may resume a circulation if time allows and discussion about post arrest care could include the role of adrenaline infusions, mast cell tryptase and airway management in the patient with anaphylaxis (difficult) Section I: Data interpretation Title of question Domain/syllabus map Data Acid base 2.5, 4.8 Data Methaemoglobin 2.5, 2.6, 3.10, 4.1 Data Infective diarrhoea and toxic megacolon 2.6, 4.1, 11.2, 11.3 Data Major burn 1.6 Data Ruptured hemidiaphragm 2.2, 2.6, 2.8, 5.7 Data Post cardiac arrest 1.3, 3.3, 3.6 Data Necrotizing fasciitis 3.1, 4.2 Data ARDS 2.6, 3.8 Data Stridor 2.6, 3.1 Data 10 Hyponatraemia 3.1, 3.2 Data 11 Chest drain in liver 2.6, 3.3, 11.4 Data 12 Interpretation of pulmonary function tests 2.8 Data 13 Serotonin syndrome 2.8, 3.10 Data 14 Propofol infusion syndrome 2.3, 2.8, 4.1 Data 15 Guillain–Barré Syndrome 2.8, 3.6 Data 16 Epidural management 5.16 Data 17 Panton–Valentine leukocidin (PVL) MRSA pneumonia 2.4, 2.6, 3.8 3.9, 4.2 Data 18 Surviving (urological) sepsis 2.5, 2.6, 2.7, 3.9 Data 19 Ventilator-associated pneumonia 2.6, 4.2, 11.4, 11.6 Data 20 Refeeding syndrome 4.9 Data 21 Acute coronary syndrome and papillary muscle rupture 2.6, 3.3, 4.5 Data 22 TTP/HUS 2.7, 2.8, 3.4 Data 23 Subarachnoid haemorrhage 2.6, 3.6 Data 24 Post oesophagectomy anastomotic leak 2.6, 5.1, 6.1, Data 25 Pulmonary embolism 2.3, 2.6, 3.3 Data 26 Heparin-induced thrombocytopenia 2.8, 11.4 Data 27 Brainstem death 2.6, 8.4 Data 28 Tricyclic overdose 2.3, 3.10 Appendix: Curriculum mapping Appendix: Curriculum mapping 287 Appendix: Curriculum mapping 288 (cont.) Title of question Domain/syllabus map Data 29 Chest-pain assessment 2.1, 2.6 Data 30 Intra-abdominal hypertension 2.6, 2.8, 3.7 Data 31 Selective decontamination of the digestive tract 4.2 Data 32 Bone marrow transplant 2.6, 2.8, 6.4 Data 33 Acute kidney injury 2.8, 3.2, 3.4 Data 34 Broncho-pleural fistula 1.5, 2.6 Data 35 Myasthenia gravis 3.6 Data 36 RV infarct 2.3, 3.3, 4.4 Data 37 Rhabdomyolysis 2.3, 4.7, 4.8 Data 38 Cerebrovascular accident 2.6, 3.6, 6.3 Data 39 Acute leukaemia 2.8, 3.1 Data 40 Diabetic ketoacidosis 2.8, 4.8 Data 41 Failure to wean 7.1 Data 42 Pleural effusion 2.6, 2.8 Data 43 Intensive care unit follow-up clinic anaemia 2.2, 2.8 Data 44 Acute liver failure 2.6, 2.8, 3.5 Data 45 Cirrhosis with upper gastro-intestinal bleeding 3.5, 5.18 Data 46 Sedation and sedation scoring 7.3 Data 47 Encephalitis, epilepsy and MRI scans 2.6, 3.6 Data 48 Acute renal failure in an HIV-positive man 1.4, 3.1, 3.4, 4.2, Data 49 Digoxin toxicity and cardiac pacing 2.3, 2.8, 3.10, 5.12 Data 50 Acute pancreatitis 2.6, 2.8, 3.7, 11.7 Data 51 Cortisol and thyroxine in the critically ill 2.8, 3.1 Data 52 TEG and major haemorrhage 2.8, 3.3 Data 53 Poisoning 3.10 Data 54 Electrocardiogram interpretation 2.3 Data 55 Chest X-ray interpretation 2.6 Title of question Domain/syllabus map Equipment Arterial lines 5.8 Equipment Tracheostomy weaning and communication 4.6, 5.6 Equipment Bronchoscopy 5.5 Equipment Cooling devices 1.3 Equipment Pulmonary artery catheter 5.14 Equipment Nasogastric tubes 5.19 Equipment High-flow nasal cannula 5.1 Equipment Cardiac output technologies 5.14 Equipment Catheter-related bloodstream infection and vancomycin-resistant enterococcus 4.2, 11.4, 11.6 Equipment 10 Spinal needles 5.15 Equipment 11 Capnography 2.7 Equipment 12 Patient transfer 10.1 Equipment 13 Tracheostomies 5.6 Equipment 14 Central lines 5.9, 5.10 Equipment 15 Haemofiltration 4.7 Equipment 16 Intra-aortic balloon pump 3.3, 4.5 Appendix: Curriculum mapping Section II: Equipment Section III: Ethics and communication Title of question Domain/syllabus map Ethics Anaphylaxis 12.1 Ethics Pulmonary embolism 12.1 Ethics Malignant hyperthermia 3.1, 12.1 Ethics Organ donation 8.2, 12.1, 12.4 Ethics End-of-life care 8.2, 12.1, 12.4, 12.12 Ethics Muscular dystrophy 3.2, 12.1, 12.4, 12.12 Ethics Delirium 7.2 Ethics Deterioration post discharge 12.1, 12.2, 12.7, 12.12 Ethics Consent for tracheostomy 12.1, 12.4, 12.12 Ethics 10 Blood transfusion 4.3 Ethics 11 Alcoholic liver disease 2.2, 2.4, 2.8, 12.12 Ethics 12 Long QT 2.3, 3.1, 12.1 289 Appendix: Curriculum mapping 290 Section IV: Resuscitation and simulation Title of question Domain/Syllabus map Resuscitation Displaced airway 5.1, 5.2, 5.3, 11.4 Resuscitation Child submersion 1.2, 9.1, 9.2 Resuscitation Child with seizures 3.6, 9.1 Resuscitation Bleeding trauma with head injury 1.5 Resuscitation Asthma 1.1, 2.5, 3.1, 5.1, 5.2 Resuscitation Pregnancy and VF arrest 1.2, 3.11, 5.11 Resuscitation Chest opening on the intensive care unit 3.3, 4.4, 6.2 Resuscitation Paediatric sepsis 3.3, 9.1 Resuscitation Tracheostomy emergency 5.1, 5.2, 5.3 Resuscitation 10 Anaphylaxis 1.2, 3.1, 3.3 Index A–a gradient, 6–7 See alveolar–arterial oxygen gradient abdominal compartment syndrome (ACS), 84 abdominal injuries, 264–266 abdominal pain acute abdomen, 103 acute pancreatitis, 144–147 ileal conduit, 3–5 necrotizing fasciitis, 23 post surgery, epidural management, 46–48 toxic megacolon, 9–12 abdominal X-ray, ileus, 164 acid base data, 3–5 ACS, 84 See abdominal compartment syndrome (ACS) activated partial thromboplastin time (APTT), 151 acute coronary syndrome, 59–61 acute kidney injury (AKI), 93–96 haemofiltration, 216–217 in TLS, 111–112 acute leukaemia, 110–112, 174 acute liver failure, 123–126 acute pancreatitis, 144–147 acute renal failure, 137–140 acute respiratory distress syndrome (ARDS), 24–26 Berlin definition, 24–25 chest X-ray, 175 ECMO cannulae, 175–176 refractory hypoxia, 175–176 definition, 24–25 patient transfer, 208–209 post HSCT, 89–92 Addison’s disease, 148–149 adjustable flange tracheostomy tube, 211–212 adrenal glands, function in critical care, 148–149 adrenaline, anaphylaxis, 284–286 advanced directive end-of-life care, 231 muscular dystrophy, 233 tracheostomy consent, 239–240 AG See anion gap (AG) agitation, 38–40 airway anaphylaxis, 284–286 difficult airway, 253–255 inhalational injury, 14–15 NAP-4 audit, 28 stridor, 27 tracheostomy blocked, 281–283 AKI See acute kidney injury (AKI) albumin levels, alcoholic liver disease, 245–247 alveolar–arterial oxygen gradient (A–a gradient), 6–7 anaemia, 121–122 anaesthetic drugs, reaction to, 226–227 analine dyes, side effects, anaphylaxis communication, 223 resuscitation simulation, 284–286 anion gap (AG) ethylene glycol poisoning, 155 ileal conduit, 3–5 anterolateral ischaemia ECG interpretation, 158 post cardiac arrest, 19–21 anticoagulation, haemofiltration and, 216–217 anti-diuretic hormone secretion, syndrome of inappropriate (SIADH), 30–32 antimicrobial therapy antibiotic side effects, dapsone, in VAP, 56 MRSA pneumonia, 56 aorta, dissecting descending, 80 aortic thoracic stent, 174 APTT, 151 See activated partial thromboplastin time (APTT) ARDS See acute respiratory distress syndrome (ARDS) arrhythmias, atrial fibrillation (AF), 157 atrial flutter, 158 arterial blood gas changes, in therapeutic hypothermia, 186 arterial lines, 177–179 resonance, 178–179 arterial waveforms, 196–199, 218 ascites, 245–246 asthma, 267–270 back pain radiating to chest, 79–81 severe sudden, 102–103 back problems, respiratory difficulties and, 175 BAL, 183–184 See bronchoalveolar lavage bicarbonate infusion, 114 bleeding See also coughing blood; haemorrhage abdominal trauma, 264–266 blood clotting/coagulation abormalities, 128–129 assessment, 151–153 coagulopathy, 245–246 blood pressure, sudden fall and rise, 161–162 blood transfusions massive, 152 reactions, 243–244 strategy, 122 body surface area (BSA), burns, 13–14 bone marrow transplant, 89–92 bradycardia digoxin toxicity, 142–143 junctional, 159 brain abscess, 165–166 291 Index 292 brain dysfunction, delirium, 235–236 brainstem death, 74–75 communication with relatives, 228–229 criteria, 74 breathing against ventilator, 207 breathing difficulties See respiratory difficulties bronchoalveolar lavage (BAL), 183–184 broncho-pleural fistula, 97–99 bronchoscopy, equipment and procedures, 183–184 bronchus, nasogastric tube in, 190 burns, major trauma, 13–15 CABG, 116–117, 274–277 See coronary artery bypass grafting (CABG) CAM, 235 See confusion assessment measure cancer, communication with relatives, 224–225 capnography, cardiopulmonary resuscitation (CPR), 207 collision broadening, in capnography, 204–205 hypercapnia, 207 hyperventilation, 207 interpretation, 204–207 oesophageal intubation, 207 rebreathing, 207 carbon dioxide measurement, 204–207 carboxyhaemoglobin, 14 cardiac output, measurement, 188–189 cardiac arrest anaphylaxis, 223, 284–286 pulmonary embolism due to medical omission, 224–225 post resuscitation, 19–21 therapeutic hypothermia, 185–187 ventricular fibrillation in pregnancy, 271–273 cardiac effusion, 174 cardiac output technologies, 196–199 cardiac pacemaker, 168–169 malfunction, 161–162 cardiac pacing, transcutaneous, 141–143 cardiac tamponade, 274–277 cardiac vibrations, 207 cardiogenic shock IABP use, 218–219 PAC in wrong place, 189 cardiomyopathy, 164–165 catheter-related bloodstream infection (CRBSI), 200–201 central-line associated bloodstream infection (CLABSI), 200–201 central lines, 213–215 complications, 213–214 infection, 200–201 waveform, 214–215 central venous catheter (CVC) See central lines cerebral aneurysm, rupture, 166 cerebral oedema acute liver failure, 125–126 brain CT, 125–126 cerebral salt wasting syndrome, 31–32 cerebral vasospasm, subarachnoid haemorrhage and, 65 cerebrospinal fluid (CSF) pressure, 202–203 protein levels, 44 cerebrovascular accident (CVA), 107 chemotherapy, complications, 110–112 chest drain bleeding, 33–34 indications for, 34 insertion, 18 residual pneumothorax, 168 site, 34 chest opening, on ICU, 274–277 chest pain acute coronary syndrome, 59–61 assessment, 79–81 broncho-pleural fistula, 97–99 chest X-ray ankylosing spondylitis, 175 aortic thoracic stent, 174 ARDS, 89–91, 175–176 cardiac effusion, 174 cardiac pacemaker, 168–169 cardiomyopathy, 164–165 central line location, 213 ECMO cannulae, 175–176 elevated hemidiaphragm, 16 endobronchial intubation, 172–173 equipment placement error, 189 IAH, 83 interpretation, 163–176 lung fibrosis, 170 mediastinal mass, 28 NG in bronchus, 190 normal, pleural effusion, 66–67, 118, 172 pneumonia, 49–50 pneumothorax, 97 loculated, 167–168 post laparotomy, 98–99 pulmonary oedema, 59 respiratory failure, 24 VAP, 55 Child C liver disease, 247 children paediatric life-support algorithm, 256–259 safeguarding processes, 256–259, 260–263 seizures, 260–263 sepsis, 278–279 submersion in water, 256–259 chronic obstructive pulmonary disease (COPD), 194–195 CINM, 116–117 See critical illness neuromyopathy (CINM) cirrhosis, liver, 127–130 CLABSI, 200–201 See centralline associated bloodstream infection clinical governance issues, 255 Clinical Pulmonary Infection Score (CPIS), 55–56 clopidogrel, overdose, 48 Clostridium difficile infection, 87–88 risk factors, 11 toxic megacolon, 9–12 clotting abormalities, upper GI bleeding, 128–129 coagulation, assessment, 151–153 coronary syndrome, acute, 59–61 cortisol, in the critically ill, 148–150 coughing blood ‘coffee ground’, 127–128 fresh, 96 CPIS, 55–56 See Clinical Pulmonary Infection Score (CPIS) CRBSI, 200–201 See catheterrelated bloodstream infection creatine kinase, raised, 42 critical care unit (CCU) delirium in, 235–236 deterioration post discharge, 237–238 critical care, never events, 191 critical illness neuromyopathy (CINM), 116–117 CSF See cerebrospinal fluid (CSF) CURB-65 score, 49–50 CVA, 107 See cerebrovascular accident (CVA) dapsone, side effects, dead space, in respiratory support, 195 defibrillation, resuscitation simulation, 272–273 delirium, assessment, 235–236 diabetes insipidus, 32 diabetic ketoacidosis, 113–115 diarrhoea classification, 11 gastroenteritis, 44–45 infective, 9–12, 87–88 difficult airway, resuscitation simulation, 253–255 digital subtraction angiogram (DSA), 179 digoxin toxicity bradycardia, 142–143 cardiac pacing, 141–143 displaced airway resuscitation simulation, 253–255 risk/prevention, 253–255 dissecting descending aorta, 80 drowning, resuscitation simulation, 256–259 drug overdose clopidogrel, 48 tricyclics, 76–77 drug side effects dapsone, digoxin, 141–143 serotonin syndrome, 38–40 drugs, choices in intubation, 267–270 DSA, 179 See digital subtraction angiogram (DSA) Duchenne’s muscular dystrophy, 233–234 early goal directed therapy (EGDT), 54 ECG See electrocardiogram (ECG) ECMO, 175–176, 219 See extracorporeal membrane oxygenation (ECMO) EEG See electroencephalogram (EEG) EGDT, 54 See early goaldirected therapy (EGDT) electrocardiogram (ECG), 156–162 anterolateral ischaemia, 19 digoxin toxicity, 142 failure to wean, 116 hyperkalaemia, 105 PE, 68–69 PRIS, 42–43 RV infarct, 102–103 torsades de pointes, 78 tricyclic overdose, 76–77 electroencephalogram (EEG), 134 anterolateral ischaemia, 20 seizure activity, 134 electrolyte changes, therapeutic hypothermia, 186 emphysema, surgical, 173, 198 encephalitis, 134–136 encephalopathy, 123–126 end-of-life care, ethics and communication, 230–232 endobronchial intubation CT, 173 chest X-ray, 172–173 endoscopic retrograde cholangiopancreatography (ERCP), 169–170 endotracheal tube, removed by patient, 253–255 Index coagulopathy, alcoholic liver disease, 245–246 collapsed patient alcoholic, 154–155 junctional bradycardia, 159 communication end-stage care brainstem death, 75 respiratory failure, 37 urological sepsis, 54 tracheostomy and, 181–182 community acquired pneumonia See pneumonia, community acquired compartment syndrome, rhabdomyolysis and, 104–106 computed tomography (CT) abdomen pancreatic pseudocyst, 146 pancreatitis with necrosis, 145 brain abscess, 165–166 cerebral oedema, 125–126 CVA, 107 ICH, 20–21, 166 SAH, 64–65, 171–172 chest endobronchial intubation, 173 pleural effusion, 17 surgical emphysema, 170–173 criteria with therapeutic hypothermia, 185 patient transfer, ARDS and, 208–209 thorax, dissecting descending aorta, 80 confusion assessment measure (CAM), 235 consciousness, discussion with relatives, 230–231 cooling of patient, 40 re-warming, 187 serotonin syndrome, 40 COPD, 194–195 See chronic obstructive pulmonary disease (COPD) coronary artery bypass grafting (CABG), 116–117, 274– 277 coronary stent, complication, 103 293 Index end-stage care brainstem death, 75 respiratory failure, 37 urological sepsis, 54 enteral feeding malnourished patient, 57–58 therapeutic hypothermia, 187 enterococcus, vancomycinresistant (VRE), 200–201 epidural, management, 46–48 epilepsy, encephalitis and, 134–136 ERCP, 169–170 See endoscopic retrograde cholangiopancreatography (ERCP) ethics disclosure to relatives, 224–225 HIV patient in intensive care, 137–140 organ donation, 75 ethylene glycol poisoning, 154–155 euthyroid syndrome, sick, 149–150 examiners, xiii code of conduct, xii extracorporeal membrane oxygenation (ECMO), 175–176, 219 fever definitions, 40 FFICM, xii MCQ, xiii–xiv OSCE, xiv–xv SOE, xiv standard setting, xiii Fick principle, 199 flow-volume loops, 36 fluid bolus, child resuscitation, 278–279 fluid resuscitation, head/ abdominal trauma, 264–266 flush solution, arterial line, 179 fungal infection, PCP pneumonia, 137 294 gall bladder, ERCP, 169–170 gastroenteritis See diarrhoea gastrointestinal bleeding, 127–130 Goodpasture’s syndrome, 96 Guillain–Barré syndrome, 44–45, 239–240 haematemesis, 127–130 haematological malignancy, 110–112, 174 haematoma, epidural, 48 haemodialysis, 213, 216 haemofiltration, 214, 216–217 haemolytic reactions, blood transfusions, 243–244 haemolytic uraemic syndrome (HUS), 62–63 haemopoetic stem cell transplant (HSCT), 89–92 haemorrhage internal, 264–266 TEG test, 151–153 head injury, abdominal injuries and, 264–266 headache, severe, 166 heart block bifascicular, 159 ECG, 157, 159–160 right bundle branch block (RBBB), 160 heart failure, acute, 59–61 hemidiaphragm, ruptured, 16–18 heparin-induced thrombocytopenia (HIT), 71–73 hepatic encephalopathy, 123–126 high-flow nasal cannula, 194–195 HIT, 71–73 See heparininduced thrombocytopenia (HIT) HIV-positive patient, 137–140 HSCT, 89–92 See haemopoetic stem cell transplant (HSCT) HUS (haemolytic uraemic syndrome), 62–63 hyperkalaemia, 104–106, 111– 112 hyperpyrexia, malignant, 226–227 hyperthermia, serotonin syndrome, 38–40 hypoalbuminaemia, hypocalcaemia, 111–112 hyponatraemia, 29–32 hypotension cardiac tamponade, 274–277 post surgery, 48 hypothermia child submersion, 256–259 therapeutic, 185–187 hypoxia during surgery, 6–8 endobronchial intubation CT, 173 chest X-ray, 172–173 refractory ECMO and, 175–176 surgical emphysema, 170–173 IABP, 218–219 See intra-aortic balloon pump (IAPB) IAH, 82–85 See intraabdominal hypertension (IAH) ICH, 20–21, 166 See intracerebral haemorrhage (ICH) intensive care follow-up clinic, 121–122 ileal conduit acid base data, 3–5 hypoalbuminaemia, ileus, abdominal X-ray, 164 immunocompromised patient pneumonia, 50 renal failure, 137–140 infective diarrhoea, 9–12, 87–88 inhalational injury, major burns, 13–15 inherited condition, unexpected event, 226–227 intensive care unit chest opening in, 274–277 HIV patient care, 137–140 infection reduction, 200–201 lumbar puncture in, 202–203 intermittent positive pressure ventilation (IPPV), 267–270 intra-abdominal hypertension (IAH), 82–85 intra-aortic balloon pump (IABP), 218–219 intracerebral haemorrhage (ICH), 20–21, 166 intravenous catheter, in CRBSI, 200–201 jaundice, 123–126 ketoacidosis, diabetic, 113–115 kidney injury, acute See acute kidney injury (AKI) lactate levels, ethylene glycol poisoning, 155 lactic acidosis, 41–43 lasting power of attorney end-of-life care, 231 muscular dystrophy, 233 tracheostomy consent, 239–240 left atrium, enlargement, 160 leg emboli, 157 legal issues end-of-life care plan, 231–232 end-stage muscular dystrophy, 233–234 tracheostomy consent, 239–240 leukaemia, acute, 110–112, 174 LFTs, 89–91 See liver function tests (LFTs) Light’s criteria, 119 limb weakness epidural and, 48 Guillain–Barré syndrome, 44–45 liver disease alcoholic, 245–247 Child C, 247 cirrhosis, 127–130 liver failure, acute, 123–126 liver function tests (LFTs), 89–90, 91 liver, injury, 33–34 local anaesthetics, side effects, long QT syndrome, 248–250 low-molecular-weight heparin (LMWH), omission, 224–225 lumbar puncture, 202–203 contraindications, 135 risks, 202–203 viral encephalitis, 134–135 lung disease fibrosis chest X-ray, 170 flow-volume loops, 36 major haemorrhage, TEG test, 151–153 malignant hyperpyrexia, 226–227 malnourished patient, refeeding syndrome, 57–58 mediastinal mass, 28 medical error equipment placement, 189 LMWH omission, 224–225 PAC placement, 189 penicillin reaction, 223 meningitis, paediatric, 278–279 mental capacity consent, 239–240 end-of-life care, 231–234 metabolic acidosis diabetic ketoacidosis, 113–115 ethylene glycol poisoning, 154–155 ileal conduit, 3–5 PRIS and, 41–43 methaemoglobin, 6–8 methicillin-resistant Staphylococcus aureus (MRSA), 49–51, 56 modified Glasgow score, 147 MRSA pneumonia, 49–51, 56 multiple sclerosis, 52–54 muscular dystrophy, 233–234 myasthenia gravis, 100–101 NAI, 256–263 See nonaccidental injury (NAI) NAP-4 audit, 28 nasal cannula, high flow, 194–195 nasogastric tubes, 66–67, 190– 193 nasojejunal tubes, 192–193 nausea, urea and electrolytes abnormal, 29–32 necrosis, in acute pancreatitis, 145 necrotizing fasciitis, 23 nephropathy, uric acid, 111–112 neurological outcome anterolateral ischaemia, 20–21 SAH, 65 scoring systems, 21 neuromuscular disease, respiratory failure, 35–37 non-accidental injury (NAI), in child, 256–263 non-invasive ventilation (NIV), 194–195 nosocomial infection, 87–88, See also pneumonia, hospital acquired Index intubation broncho-pleural fistula, 97–98 child resuscitation, 260–263, 279–280 drugs used, 64 endobronchial intubation CT, 173 chest X-ray, 172–173 severe asthma, 267–270 IPPV, 267–270 See intermittent positive pressure ventilation (IPPV) oesophagectomy, complication, 66–67 oral feeding, tracheostomy and, 182 organ donation, 75, 228–229 osmolar gap, poisoning, 155 oxygen delivery, haemoglobin in, 122 oxygen requirements, patient transfer, 208 pacemaker, 161–162, 168–169 pacing, transcutaneous, 141–143 paediatrics life-support algorithm, 256–259 safeguarding processes, 256–259, 260–263 seizures, 260–263 sepsis, 278–279 submersion/drowning, 256–259 pain caused by arterial line, 179 management post surgery, 46–48 palliative care, planning, 233–234 palpitations, 158 pancreatic pseudocyst, 146–147 pancreatitis, acute, 144–147 Panton–Valentine leukocidin (PVL), 49–51 papillary muscle rupture, 59–61 295 Index 296 patient transfer, 208–209 chest drain misplaced, 34 major burns, 15 PEEP, 25–26 See positive endexpiratory pressure (PEEP) pituitary failure, 148 plasma exchange, 63 pleural effusion, 17–18 causes, 118–119 CT, 17 chest X-ray, 172 post oesophagectomy, 66–67 Pneumocystis jiroveci (PCP) pneumonia, 137 pneumonia acute leukaemia, 174 chest X-ray, 49–50, 174 community-acquired, 49–51 diabetic ketoacidosis, 113–115 pleural effusion, 118–120 refeeding syndrome, 57–58 hospital acquired alcoholic liver disease, 247 MRSA, 49–51, 56 post discharge from critical care unit, 237–238 VAP, 55–56 PCP fungal infection, 137 recurrent, 35–37 scoring systems, 55–56 tracheostomies, 210–212 pneumothorax bleeding chest drain, 33–34 loculated, 167–168 patient on ventilator, 209 severe asthma, 267–270 surgical emphysema, 168, 173 tension, 267–270 poisoning, 154–155 positive end-expiratory pressure (PEEP), 25–26 potentially pathogenic microorganisms (PPMS), 86–88 pregnant patient TTP/HUS in, 62–63 ventricular fibrillation arrest, 271–273 PRIS, 41–43 See propofol infusion syndrome (PRIS) prone positioning, in ARDS, 25–26 propofol infusion syndrome (PRIS), 41–43 propofol, ‘safe’ dose, 132–133 pulmonary artery catheter (PAC), 188–189 pulmonary embolism, 68–70 medical omission, 224–225 scoring system, 68 pulmonary function test, 35–37 pulmonary oedema, 59–61, 167–168 pulmonary renal syndrome, 96 pulse contour analysis, 198 pulse power analysis, 198 pulse pressure variation, 197–198 PVL, 49–51 See Panton– Valentine leukocidin (PVL) radial artery aneurism, 179 Ranson’s criteria, 145 rasburicase, 111–112 refeeding syndrome, 57–58 relatives, communication with condition deterioration, 237–238 diagnosis disclosure, 224–225 end-of-life care, 230–234 post cardiac arrest, 248–250 renal abscess, 53–54 renal failure acute, 137–140 multi-organ failure, 247 resonance, arterial line, 178–179 respiratory difficulties See also ARDS; pneumonia; pneumothorax acute kidney injury, 93–96 acute pancreatitis, 145–147 acute renal failure, 137–140 anaemia, 121–122 back problems and, 175 cardiomyopathy, 164–165 chest pain, 49–50 Guillain–Barré syndrome, 44–45 myasthenia gravis, 100–101 post oesophagectomy, 66–67 pulmonary oedema, 167–168 RBBB, 160 ruptured hemidiaphragm, 16–18 stridor, 27–28 respiratory failure muscular dystrophy, 233–234 urological sepsis, 52–54 ventricular fibrillation arrest in pregnancy, 271–273 respiratory gases, measurement, 204–207 respiratory muscle weakness, 35–37 respiratory support, equipment, 194–195 resuscitation scenarios, presentation, 251 rhabdomyolysis, 104–106 right coronary artery infarcts, 103 right ventricular infarct, 102–103 safeguarding processes, for children, 256–263 SAH See subarachnoid haemorrhage (SAH) SIADH, 30–32 See anti-diuretic hormone secretion, syndrome of inappropriate SDD, 86–88 See selective decontamination of the digestive tract (SDD) SDH, 260–263 See subdural haemorrhage (SDH) sedation, 131–133 scoring, 132 seizures brain abscess, 165–166 child with, 260–263 encephalitis and, 134–136 Seldinger chest drain, 34 selective decontamination of the digestive tract (SDD), 86–88 Sengstaken–Blakemore (SB) tube, 129–130 sepsis HIT and, 71–73 paediatric, 278–279 septic shock, 113–115 serotonin syndrome, 38–40 serum chloride, ileal conduit and, 4–5 shivering, in therapeutic hypothermia, 186–187 tachycardias, ECG, 161 targeted temperature management (TTM) trial, 20 TEG, 151–153 See thromboelastography (TEG) temperature control, patient cooling, 40, 185–187 tension pneumothorax, 267–270 terlipressin, 129 therapeutic hypothermia, 186, See also cooling of patient thrombocytopenia, heparininduced (HIT), 71–73 thrombocytopenic purpura, thrombotic (TTP), 62–63 thromboelastography (TEG), 151–153 thrombolysis acute stroke, 108 pulmonary embolism, 69 thrombotic thrombocytopenic purpura (TTP), 62–63 TLCO, 36–37 See transfer factor of the lung for CO (TLCO) TLS, 110–112 See tumour lysis syndrome (TLS) toxic megacolon, 9–12 tracheostomies, 210–212 blocked, 281–283 consent for, 239–240 emergency (blocked), 281–283 fenestrated tracheostomy tube, 211–212 single vs double cannula, 281–283 weaning, 180–182 Trachman study, 210 transducer, arterial line, 177–178 transfer factor of the lung for CO (TLCO), 36–37 tricyclic overdose, 76–77 TTM, 20 See targeted temperature management (TTM) trial TTP, 62–63 See thrombotic thrombocytopenic purpura tumour lysis syndrome (TLS), 110–112 ultrafiltration, 216 upper gastrointestinal bleeding, 127–130 urea and electrolytes (U&Es), 29–32 uric acid nephropathy, 111–112 urinary catheter, 52–54 urological sepsis, 52–54 Index shock classification, 33 septic, 113–115 ventricular fibrillation arrest in pregnancy, 271–273 sick euthyroid syndrome, 149–150 simulation facilitators, information for, 251 simulation scenarios, presentation, 251 sinus tachycardia, 76–77 sodium bicarbonate, 77 sodium levels, 30 speaking valves, tracheostomy, 181–182 spinal needles, 202–203 spontaneous breathing trials (SBTs), 180–181 staphylococcus aureus infection See also MRSA PVL infection, 50 sternotomy, 274–277 streptococcal infection, 23 stridor, 27–28 stroke acute (See also subarachnoid haemorrhage (SAH)) classification, 107 CVA, 107 scoring system, 108 end-of-life care, 230–232 strong ion difference, 4–5 subarachnoid haemorrhage (SAH), 64–65 brain CT, 64–65, 171–172 classification, 65 hyponatraemia, 31–32 in child, 260–263 subglottic suction cuffed tracheostomy tube, 211–212 surgery, abdominal pain management, 46–48 synacthen test, 148–149 syncopal episodes, 159 syndrome of inappropriate anti-diuretic hormone secretion (SIADH), 30–32 vancomycin-resistant enterococcus (VRE), 200–201 VAP, 55–56 See ventilatorassociated pneumonia (VAP) vascular access catheter, 213, 214 ventilator displaced airway, 253–255 failed intubation, 253–255 patient transfer for CT, 208–209 settings in ARDS, 25–26 weaning from, 116–117, 210–212 ventilator-associated pneumonia (VAP), 55–56 ventricular fibrillation, 271–273 viral encephalitis, 135–136 vomiting, ‘coffee ground’, 127–128 VRE, 200–201 See vancomycinresistant enterococcus (VRE) waveforms, arterial line, 178–179 weakness, sudden unilateral, 107–109 weaning from tracheostomy, 180–182 from ventilator, 116–117, 210–212 weight assessment, drug dosage for child, 262–263 Wolff–Parkinson–White syndrome, 161 wound management, necrotizing fasciitis, 23 297 ... Identifiers: LCCN 201601 181 4 | ISBN 9 781 107579453 (Paperback) Subjects: | MESH: Critical Care | Great Britain | Examination Questions Classification: LCC RC86 .8 | NLM WX 18. 2 | DDC 616.02 /8 dc23 LC record... 177 Consent for tracheostomy 239 Tracheostomy weaning and communication 10 Blood transfusion 241 180 11 Alcoholic liver disease 245 Bronchoscopy 183 12 Long QT 2 48 Cooling devices 185 Pulmonary... sepsis Tracheostomy emergency 10 Anaphylaxis 2 78 Appendix: Curriculum mapping Index Colour plates appear between pp 176 and 177 281 284 Contents 287 291 ix Foreword Intensive care medicine has become