ICU Fellowship Exam Question Types and Useful Structures

Author: Novia Tan, Ruvini Vithanage, Jeff Kam, George Zhou

General Tips for Structure

• Read and react to the question as a consultant
  • Is that the right thing to do?
  • Is that the right place?
• Structure – 30-60 secs to first get structure out
• 5 min mark – stop and re-read question – make sure you are answering the question
• Practicing to time – different types of practice questions
  • Practice 2-3 minutes for Structure and Headings
  • Practice to 8-9 minutes 
  • Practice consecutive questions in increments – e.g. 3 questions, then 5 questions then 10 questions. 
  • Finally simulate Full Exam – 15 questions x 2 in one day with a one our meal break(only a few times to avoid fatigue). 

Answering the Question

• Tailor answers specifically for the question and context – information in question will need to be directly addressed in your question. 
• Extraneous or generic detail regarding a condition without the context of the question will be unlikely to be awarded marks. 

Types: 

• Assessment
• Management
• Critically evaluate
• Quality Improvement
• Procedure
• Compare and Contrast

Assessment

History	– Features/risk factors/complications – MAP: Medications, Allergies, Past Medical history – Concerning history for urgency – eg. trend
Examination	– Features/complications/ +/- risk factors – Look for features of … – General appearanceVital signsSpecific systems
Investigations	– Bedside Investigations (ECG, Urine Dip, VBG) – Lab – Imaging/Other – XR/CT/MRI/Echo (Be specific)  – Consider pre-test probability, sensitivity/specificity – Expected findings … – Microbiology – BIOPSY (with all organ failures)

 

Diagnostic Issues

• Differential diagnoses – VINDICATE
• Infection (Infections)
  • Bacterial: gram positive, negative, atypical, intracellular
  • Viral
  • Fungal
  • Parasitic/protozoan
  • Opportunistic
  • Specific to immunocompromised population
  • Nosocomial

Imaging Considerations – ConTRAST + SUICA

• Contrast
• Timing
• Radiation
• Anatomy
• Sedation
• Transport

SUICA

• Safety
• Unit wide approach
• Implementation
• Cost
• Availability

Management

• Opening statement (SICC)
  • Severity of problem
  • Issues in management eg. Obese/low resource setting
  • Competing interests
  • Confounders/Protocols/Guidelines

Substructures for Management Questions

• Crisis
• Immediate management
• General management questions with no clear diagnosis
• Specific Management for Specific Populations
  • ID
  • Transplant
  • Trauma
  • Toxicology
  • Difficult Airway
  • Pregnant
  • Paediatric
  • CVS

Crisis Management

• Declare emergency
  • Assemble team
  • Delegate roles
  • Send for additional help
  • Multiple coordinated simultaneous actions
• ABCD
• Definitive
• Supportive
• Additional considerations
  • Anticipate___
  • Stepwise escalation strategy

 

Immediate Management Required

Immediate Resuscitation	– Address immediate threats to life (first priority) – *Consider endpoint/timeframe/failure/pitfalls (ETFP)
PlacePersonMonitoringAccess
Confirm Dx(Investigations)
Definitive(Treatment, Surgery)Disposition
Monitor for and prevent specific complications
General supportive care (less emphasis for immediate management)	FASTHUGS IN BED Please
Systems	– Care of patient including open disclosure – Systems issue: incident reporting, case review, adherence to guidelines/lack of – Prevention of future events

 

SIP DDD CS

• Severity
• Immediate resuscitation
• Place, Person, Monitoring, Access
• Diagnosis/Investigations/Precipitant
• Definitive treatment (Transfer/Multidisciplinary team)
• Disposition
• Complications
• Supportive care
• Systems

General Management with no clear diagnosis

• Risk stratification
• Management priorities will depend on cause of ___
  • management according to hemodynamic tolerability
• Focus on stabilisation of ABC and correction of reversible causes
• Weigh benefits of ____ against ____
• Tiered strategy/staged sequence of therapies/intervention
• Conservative vs Surgical Management

Management in ID

Management in ID	Specific Terms
Immediate Management	Goal directed fluid administration Reassessment of resuscitation efficacy (lactate)
PlacePersonMonitoringAccess	Septic screen + specific site sampling Imaging: to localise infection/look for potential complications
Confirm Dx(Investigations)	Source control Empiric antibiotic therapy Antibiotics explanation CaRT DR – Choice, Rationale ,Timing, Duration, Route
Definitive(Treatment, Surgery)Disposition
Monitor for and prevent specific complications	Infection PreventionInfection control/isolation Department of health – notifiable disease Organisational level changes Organisation Education Data collection & audit
General supportive care

 

Management of Transplant Patients

• Principles
  • Protocolised care with multidisciplinary involvement
  • Early identification of bleeding and early graft function
  • Supportive care
• Specific care
  • Graft function
  • Immunosuppression choice, route and monitoring (drug levels/Toxicities)
  • Phase of care
  • Infection
    • Antimicrobial Prophylaxis 
    • Surveillance 

Management of Toxicology

RESUS RISK IS DEAD

• Resuscitation
• Risk assessment (PACE)
• Investigations
• Supportive Care
• Decontamination
• Enhanced elimination
• Antidotes
• Disposition

Risk Assessment – PACE

• Patient
• Agent – dose/timing/preparation (SR vs IR)
• Clinical Features
• Environment

Management Specific to Paediatrics

Management Considerations

TFG – NSFW (Thank Fking God – Not Safe For Work)

• Temperature control
• Fluid administration
• Glucose control
• Nutrition
• Sepsis
• Family
• Weight

Management Specific to Pregnant Patients

DDDDDD

• Dual
  • Support of fetus – corticosteroids/monitoring with CTG
  • Support of mother
• Drugs – teratogenicity of treatments/dose adjustment in pregnancy
• Delivery – safety/timing/practicality
• Diagnostic – radiation risk/modality
• multiDisciplinary
• Disposition
  • Retrieval/transfer to tertiary obstetric centre

 

Management of Difficult Airway/Airway Emergency

Immediate	Declare airway emergency Assemble team and delegate roles Seek assistance from most appropriate resources available senior anaesthetics/ENT Assess time pressure & resources Assess need for immediate intubation
Optimization	Optimise medical management Optimise pre-intubation conditions Preoxygenation with 100% O2 via NRB CPAP for stridor if toleratedAtropine to dry secretions
Preparation DEPPP	Drugs: Sedatives, muscle relaxants, resuscitation drugs Equipment – Standard equipment + Difficult airway trolley: – Airway Plan A + B + intubation LMA + cricothyroid Equipment + bronchoscopy – EtCO2 – Full monitoring – Secure IV access – Arrest trolley nearby People Patient: Preoxygenate, positioning – ramped Place Location for intubation depending on distance to be moved and patient stability
Assessment	Identify potential difficulties: Intubation, BVM Past history of intubation if time permits Airway assessment (beard, MO, MP, TMD, neck extension, jaw protrusion) Assess neck anatomy and mark cricothyroid membrane Consider feasibility of moving to theatre, awake tracheostomy or AFOI
Plan	Go through checklist Oxygenation plan Intubation plan: Verbalise Plan A-E
Induction	Opioid heavy induction1.5mg/kg rocuronium

 

Management of Trauma

Critical Care Priorities

Initial	Immediate assessment & resuscitation: Identify Life threats – appropriate prioritization Cspine, ABCDE Correct macrovascular instability Restore circulating volume Correct coagulopathy Reverse oxygen debt
Ongoing	Repeat assessment Optimise fluid status Ensure definitive haemostasis Correct microvascular status: endothelial injury and glycocalyx dysfunction likely Correct acid-base status Correct nutritional status Remain vigilant for sequalae Sepsis Electrolyte disorder TACO/TRALI

AAAA

• ATLS
• Anticoagulation
• Antibiotics
• ADT
• Analgesia

Management Structure for CVS Questions

• preload, contractility, afterload, rate, rhythm

 

Critically Evaluate

• Introductory Statement
• Rationale for therapy
• Advantages and disadvantages
• Evidence – mention more than 1 trial (2-3 trials)
• How to apply to clinical practice
  • cost
  • availability
  • risk
  • safety
  • logistical challenges
  • specific content related matter
• My practice – Give overall statement with evidence

 

Compare and Contrast

Comparison – when would you diagnose/treat over other?

• Aetiology
• Risk Factors
• Diagnosis
• Management
• Evidence
• Underline key differences

QI

Audit cycle

• Identify issue
• Form working party/engage stakeholders
• Implementation of change
• Audit and follow-up data collection
• Feedback
• Re-training
• Ongoing audit
• Legal: documentation, confidentiality, notification
• Follow up: check in, riskman, future steps 

Procedure

• Patient factors/preparation
• Environment factors
• Personnel
• Equipment
• Drugs
• Indications
• Contraindications
• Risk/Benefits
• Complications
• Steps of procedure

Treatment Failures

CaTCH uP

• Cause (underlying disease/wrong diagnosis)
• Treatment/dose
• Complications
• Host factors (immunocompromised)
• Bug/Pathogen