CICM Second Part Exam Practice SAQs 20102022

As prepared by Yannick Planche, here are the practice written questions from a recent CICM Second Part exam practice session at The Alfred ICU, with recommended reading from LITFL.com Critical Care Compendium and other FOAM sources:

Q1. a) Discuss the investigations relevant to the diagnosis and classification of pulmonary hypertension (PH) (7 marks)

Investigations

  • PH defined as mean pulmonary artery pressure ³ 25mmHg
  • Tests should focus on 
    • confirming diagnosis (echocardiography, RH catheterisation)
    • classifying type PH (bloods, RFT, echocardiography)
    • and grading severity (echocardiography, RH catheterisation)
  • Bloods – BNP (?RHF), ANA/ENA (?CTD), ACE (?sarcoidosis), LFT (?PHTN), HIV serology
  • ECG – ?RH strain or RVH (RAD, RBBB, dom R V1, dom S V5,6), ?large RA (p-pulmonale)
  • Echocardiography – ?RH dysfunction, ?LH disease, ?valvular disease, ?PASP
  • Respiratory Function Tests – ?COPD ?RLD ?normal spirometry low DLCO
  • RH Catheterisation – confirm PH (mPASP > 25), ?PAH (PVR > 3 woods), ?RH Fx (CI)

Classification of Pulmonary Hypertension (PH)

  1. Pulmonary Arterial Hypertension (PAH)
    1. Idiopathic
    1. Heritable
    1. Drug/toxin induced (e.g. amphetamines)
    1. Associated (CTD, HIV, portal HTN)
    1. Responders to CCB
  • Left Heart Disease
    • HFrEF
    • HFpEF
    • Valvular disease
  • Lung disease / chronic hypoxia
    • Obstructive lung disease
    • Restrictive lung disease
    • Hypoxia (obesity-hypoventilation) 
  • Pulmonary artery obstructions
    • Chronic thromboembolic PH (CTEPH)
    • Other 
  • Multifactorial aetiology
    • Hematological disorders (e.g. sickle cell) 
    • Systemic disorders (e.g. sarcoidosis)
    • Complex congenital heart disease
    • Other

1 b) Explain the biological pathways targeted in the treatment of pulmonary arterial hypertension (3 marks)

*source unknown

REFERENCES:

JAMA. 2022;327(14):1379-1391. https://doi.org/10.1001/jama.2022.4402

MJA 2016; 205(6): 271-276. https://doi.org/10.5694/mja16.00468

Q2. Discuss the assessment and management of a potentially lethal drug overdose (10 marks)

Assessment

  • History
    • Agent(s)
    • Dose(s)
    • Time since ingestion
    • Clinical features and progress
    • Patient factors (weight and co-morbidities)
  • Investigations
    • [drug] – blood and urine
    • UEC – renal failure? hypoK+? hyperK+?
    • ABG – acidosis? hyperBSL? hypercapnia? hypoxia?
    • CK – rhabdomyolysis?
    • osmolar gap – toxic alcohol?
    • CXR – aspiration? NGT placement? 
    • ECG – rate, rhythm, PR, QRS, QTc, domR in AVR

Resuscitation 

  • Always secure ABC first
  • Consult early with toxicologist
  • Seek and treat complications of overdose
    • Hyperthermia
    • Hypoglycaemia
    • Seizures 

Decontamination

Activated Charcoal

  • within 1hr ingestion
  • 50g (adult); 1g/kg (kids)
  • indications
    • aspirin
    • paracetamol
    • digoxin
    • TCA
    • theophylline
    • phenobarbitone
    • paraquat

Multi-dose Activated Charcoal (MDAC)

  • initial 50g bolus
  • then 25g Q2H
  • rarely useful > 6hrs
  • indications
    • massive paracetamol OD
    • phenobarbitone coma
    • carbamazebine coma
    • theophylline OD

Enhanced Elimination

Urinary Alkalisation

  • NaHCO3 iv 1-2mM/kg bolus
  • then infusion 150mM over 4hrs
  • frequent FWT; aim pH > 7.5
  • regular K+ replacement
  • monitor HCO3 and K+ Q4H
  • continue until improving (clinical, lab)
  • indicated drugs
    • salicylates
    • phenobarbitone

Haemodialysis (indications)

  • toxic alcohols
  • lithium (severe chronic)
  • salicylate (severe)
  • phenobarbitone (coma)
  • carbamazepine (massive OD) 
  • valproate (massive OD)
  • theophylline OD
  • metformin (lactic acidosis)
  • paraquat (charcoal haemoperfusion)

Antidote Therapy

  • Commence as early as possible
  • In consultation with toxicologist
  • May be empirically indicated during CPR 
  • (e.g. NaHCO3, atropine, naloxone, digibind)

Q3. a) Discuss the basic management of any patient with a severe, acute traumatic brain injury (TBI) (4 marks)

*source unknown

3 b) Discuss the management of intracranial hypertension in patients with TBI (4 marks)

*source unknown

3 c) Discuss the role of hypothermia in the management of TBI. Cite any relevant evidence. (2 marks)

  • Supposed benefit in the prevention of secondary neurological injury 
  • There is no role for the use of hypothermia in the routine management of TBI
  • Two landmark trials 
  • EUROtherm3235
    • cooling in patients with sustained ICH in the setting of TBI
    • increased mortality in cooling group
    • and increased incidence of poor neurological outcomes
  • POLAR 2018
    • therapeutic cooling of patients with severe TBI due to blunt trauma
    • no benefit in neurological outcomes or mortality
    • increased risk of infection and prolonged MV duration

REFERENCES:

Intensive Care Med. 2019; 45(12): 1783–1794. https://doi.org/10.1007%2Fs00134-019-05805-9

JAMA 2018 Dec 4;320(21):2211-2220. https://doi.org/10.1001/jama.2018.17075N Engl J Med 2015; 373:2403-2412 https://doi.org/10.1056/NEJMoa1507581

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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