CICM Second Part Exam Practice SAQs 13022025

This was a question in the 2024.2 exam – an answer rubric is provided in the exam report.

A suggested answer guide is provided below:

Seek and treat underlying reasons for aggression:

• Medical/Psychiatric assessment: Conduct a thorough assessment (history, examination, investigations) to identify any underlying medical or psychiatric conditions. This includes evaluating for delirium, withdrawal symptoms (e.g. ethanol, nicotine, cannabis, amphetamines, GHB, opioids), or psychiatric disorders such as psychosis or bipolar disorder.
• Toxidrome: Assess for signs of specific toxidromes that may be contributing to the patient’s aggression. Examples of common relevant toxidromes include:
  • Sympathomimetic: e.g. agitation, tachycardia, hypertension, and hyperthermia.
  • Anticholinergic: e.g. dry skin, mydriasis, urinary retention, and altered mental status.
  • Serotonin toxicity: CNS (confusion, agitation), Autonomic (e.g. HR, BP changes), neuromuscular (e.g. ocular clonus, limb rigidity and clonus (especially lower limbs), hyperthermia)
  • Extrapyramidal syndromes: e.g. akathisia
  • Withdrawal symptoms (vary with syndrome): e.g. tremor, tachycardia, restlessness, agitation, hallucinations
• Gather further information: Gather additional information such as previous admissions, forensic records, collateral history about the presentation, psychosocial stressors, and the circumstances of the aggression during the previous extubation attempt.

Staff Safety:

• Training: Ensure all staff are trained in de-escalation techniques.
• Protective measures: Use personal protective equipment (PPE) and have security personnel on standby.
• Safety of other patients: Implement measures to ensure the safety of other patients, such as isolating the aggressive patient in a secure area and minimizing their contact with other patients.
• Other safety measures: Implement additional safety measures such as having security present. consider physical restraints (e.g. shackles) at the time of extubation (eg if extreme impulsivity with high of harm to self or other if becomes aggressive), but this may exacerbate agitation

Logistics:

• Staff numbers and availability: Ensure adequate staffing, including additional personnel for support.
• Timing: Schedule extubation during daytime when more staff and resources are available.
• Unit activities: Minimize unit activities to reduce environmental stressors (e.g. noise, bystanders).

Patient Safety and Smooth Emergence:

• Monitoring: Continuous monitoring of vital signs (hr, rr, SpO2, BP)  and readiness for extubation
• Environment: Create a calm and quiet environment to reduce agitation
• Communication: Clearly communicate the plan to the patient to reduce anxiety
• Nonpharmacological Techniques:
  • Calming Techniques: Use techniques such as music therapy to reduce anxiety
  • Patient Engagement: Engage the patient in conversation to orient them and reduce confusion
• Pharmacological Techniques:
  • Medications: Use medications like dexmedetomidine or clonidine, and/or or low-dose antipsychotics to manage agitation (e.g. olanzapine or quetiapine) prior to, during, and after extubation

Team Plan:

• Consultation of specialty services: Consult psychiatry or toxicology services for additional support and guidance
• Communication: Ensure detailed communication among the team about the plan and potential backup strategies. E.g. MDT huddles for planning, immediately prior to extubation, and to assess progress prior to end of shift
• Backup Plan: Develop a clear backup plan for managing aggressive behavior during emergence.
  • Provide a duress alarm to staff
  • Recognise warning signs early and ensure safe exit route
  • Verbal de-escalation
  • Stepwise Approach to Chemical Restraint:
  • Physical Restraint (only when absolutely necessary to ensure the safety of the patient and others, and when less restrictive measures have failed)
  • Re-intubation plan (note previous airway grade and history, ensure equipment and checklist available, consider  pre/per/reoxygenation strategies and plan A/B/C/D for intubation.

De-escalation

Physical Restraint

Chemical Restraint