CICM Second Part Exam Practice SAQs 01092022

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 answers and FOAM references.

Question 1

A 60 year old man with chronic alcohol abuse and Child-Pugh B cirrhosis and chronic ascites presents by ambulance after being found on the floor, with hypotension and confusion.

1 a. Describe your approach to investigate the causes for his decompensation. (8 marks)

Note this asks for “approach to investigate”, and I’d suggest using an opening statement such as:

Aims of investigations/list of differentials

         -Likely drug and alcohol use, non-adherence, SBP (or other sepsis), GI bleed, hepatic vein or portal vein clot, poor nutrition

Answer should include summary of these the following, to address said aims:

History Exam and bedside (BSL), bloods (LFTs, coags, ammonia, FBE, ?MELD score, renal function..  and imaging- CT quad phase liver, USS liver/portal vein, ascetic tap MCS? 

https://derangedphysiology.com/main/required-reading/gastroenterology-and-hepatology/Chapter%20121/acute-decompensation-chronic-end-stage-liver-disease

1b. List treatment options specifically for severe acute alcoholic hepatitis? (2 marks)

Glucocorticoids

Pentoxifylline

Cease beta blockers (?reduces hepatorenal syndrome)

N-Acetylcysteine

Liver transplantation?

References https://www.ncbi.nlm.nih.gov/books/NBK470217/

https://derangedphysiology.com/main/required-reading/gastroenterology-and-hepatology/Chapter%201.1.3/management-acute-liver-failure

Question 2

Critically evaluate the use of bougie or stylet for optimising chances of successful intubation in critically unwell patients requiring emergency intubation.

Remember, there is a useful template for these critically evaluate questions :

<https://litfl.com/critically-evaluate-template>

Note recent published evidence for bougie and or stylet vs no adjuncts:

BEAM in JAMA 2018

STYLETO  in ICM 2021

The Bougie study JAMA 2021

Advice: as you go through the prep for this exam, the written exam syllabus is very broad, but the last few years of questions gives a good indication of likely topics. Recently published studies in ICU medicine are a must-know and websites/year books like CCR are wonderfully easy to access and use:

https://criticalcarereviews.com/

Question 3

You are called the emergency department of a small country hospital to take care of a 45year old man just arrived by ambulance, after choking on food at a restaurant.  At the scene, first aid attempts failed and he then had failed intubation attempts by paramedics who had poor laryngoscopic view and could not visualise food in his upper airway.  

He has an LMA in situ.  He never required CPR. He has oxygen saturations of 70% and is difficult to ventilate with suspicion of upper airway partial obstruction.  He has an interosseus needle in situ but no IV access. He is obese, estimated to be 180cm tall and 200kg. 

Describe your approach to his immediate management.

The point of this is to practice writing good answers to similar questions. Opening statements cover a lot of ground, and then allow more specific answers.  quickly describing resuscitation in a general way (team, equipment etc) then more specifics for the “special patient”.

“Special patients” are important as they don’t fit the usual resuscitation and are often thrown in to complicate an otherwise straightforward question on resuscitation with standard ALS..

eg.  obese, elderly, paediatric, pregnant women (late term even better-a foetus, too!), shocked, hypoxic, brain injured, severely metabolically deranged, difficult airway… etc etc..

Here we have a difficult airway and obese person with severe hypoxia.

opening statement should cover the issues expected in this case, and a suggested headings as below:

Likely food in airway and difficult intubation but need to do it: anticipate difficult IV access, difficult airway (Get best intubater and surgical airway available), 

Patient

Staff

Equipement

Drugs

Etc etc.

Contingency plans.  

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

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