As prepared by Chris Nickson, here are the practice written questions from a recent CICM Second Part exam practice session at The Alfred ICU, with recommended reading from LITF.com’s Critical Care Compendium and other FOAM sources:
Q1.
Discuss the role of apnoeic oxygenation in the management of critically ill patients (100%)
Learn more here:
http://lifeinthefastlane.com/ccc/apnoeic-oxygenation/
Q2.
Compare and contrast toxic epidermal necrolysis (TEN) with acute graft versus host disease (aGVHD) (100%)
Learn more here:
https://lifeinthefastlane.com/ccc/stevens-johnson-syndrome-and-toxic-epidermal-necrolysis/
https://lifeinthefastlane.com/ccc/acute-graft-versus-host-disease/
TEN and acute GVHD disease are both multi-system skin disorders that both have high mortality. Though they can usually be distinguished by clinical presentation, histopathology is confirmatory. They may be difficult to distinguish in severe cases occuring after allogenic haematopoietic stem cell transplant.
| TEN | Acute GVHD | |
| Cause | malignancy (carcinomas and lymphomas) infection (Mycoplasma pneumoniae, herpes virus, hepatitis A) drug induced (penicillins, sulfa drugs, quinolones, cephalosporins, anticonvulsants, COX-2, immunosuppressants, allopurinol, corticosteroids)post-SCT/ organ transplantpost-immunisation idiopathic |
Occurs after allogenic haematopoietic stem cell transplant (30-50%) due to graft immune response |
| Pathophysiology | Immune-related cytotoxic reaction aimed at destroying keratinocytes that express a foreign antigen
Results in separation of the epidermis from the dermis |
Antigens on the host cells are attacked by the donated T cells
Tissue damage results in cytokine storm |
| Organs/ sites primarily affected | Skin (>30% BSA)
Mucosal membranes |
Skin
Liver GI tract +/- other organs (e.g. lung) |
| Clinical features | Occurs 1-8 weeks after cause
Flu-like prodrome (1d-3wks) Mucositis then after 1-3d skin rash – macular, with purpuric center, then vesicles, then sheet-like exfoliation |
<100d after SCT
puriritic/ painful MP rash +/- vesicles GI: mucositis, diarrhoea, ileus Other mucosae and eyes |
| Complications | Sepsis, scarring & strictures, vision impairment, bleeding, fluid loss (e.g. hypovolaemic shock and AKI), capillary leak (e.g. ARDS), death | |
| Diagnosis | Clinical presentation
Skin biopsy (early): Necrotic keratinocytes with full-thickness epithelial necrosis and detachment |
Clinical presentation
Tissue biopsy: skin (eg, eosinophilic bodies, mononuclear infiltration), liver (eg, necrosis of the bile duct), and gut (eg, crypt-cell degeneration) CT abdo findings Hyperbilirubinaemia |
| Specific therapy | None proven by high quality trials, but options are:
|
First line
Second line options
|
| Supportive care and monitoring |
|
|
| Prognosis | Predicted by SCORTEN
10-70% mortality (varies with quality of Rx and rapidity of Rx) |
Varies with Grade I to IV
20% if complete response to steroids 80% mortality if refractory to steroids 50% develop chronic GVHD |
Q3.
Describe the Stewart (physico-chemical) approach to acid-base disturbances, and discuss the pros and cons of this method. (100%)
Learn more here:
http://lifeinthefastlane.com/ccc/strong-ion-difference/
You can access all the previous practice questions since 2014 here:
https://docs.google.com/document/d/1_Ta8IvVaVtc5Il7-kJwj6qKGu54OmifJGRUWCXud8dY/edit
See this link on INTENSIVE for exam resources:
https://intensiveblog.com/resources/#3