Hot Case Template
19/8/10
GENERAL APPROACH
Introduction
Cubicle
Infusions
Ventilator
Monitor
Equipment
Question specific examination
GENERAL QUESTIONS
Why does this patient have severe respiratory failure?
Brain
Cough
Nerves
NMJ
Respiratory Muscles
Pleura
Airways (large and small)
Parenchymal
Chest wall
Ventilator asynchrony
Cardiac failure
Abdominal distension/failure
“This patient has Respiratory Failure for multiple reasons. These include… “
List headings of causes -> clinical signs associated with list
Why is this patient failing to wean from ventilation?
Brain
Cough
Nerves
NMJ
Respiratory Muscles
Pleura
Airways (large and small)
Parenchymal
Chest wall
Ventilator asynchrony
Cardiac failure
Abdominal distension/failure
Jeremy Fernando (2011)
“There are multiple reasons why this patient is failing to wean from mechanical ventilation.
These include…”
List headings of causes -> clinical signs associated with list
Why is this patient in Renal Failure?
Acute, Chronic or Acute on Chronic
Pre – volume status, shock + causes, temperature
Intra – nephrotoxics, urine for casts + protein, sepsis, CK, nephritic/nephrotic
syndromes
Post – catheter flushed, intraabdominal pressure, hydronephrosis
Can you extubate this patient?
Original condition requiring intubation
Airway
Breathing (Respiratory function) – ventilation parameters including ABG and CXR
Cardiovascular function
Neurological function
Assessment of environment – time of day, level of airway skill in unit, planned
procedures
Why is this patient shocked? – must find the shock!
Hypovolaemic – bleeding, dehydration, 3rd spacing (signs: cool peripherally, CR,
pale, low CVP, low BP, narrow pulse pressure, high HR)
Distributive – SIRS, septic, anaphylaxis (signs: WWP, dilated, bounding pulse, low
diastolic pressure, wide pulse pressure, pressors, low CVP, high Q, low SVRI, active
praecordium)
Cardiogenic – myocardia, valves, rhythm, pericardium, left and right sided (signs:
cool peripherally, shut down, bounding pulse, narrow pulse pressure, inotropes, high
CVP, low SvO2, low Q, crackles in chest, oedema)
Obstructive – TP, tamponade, abdominal compartment syndrome (signs: cool
peripherally, narrow pulse pressure, inotropes, vasopressors, high CVP, muffled heart
sounds, low Q)
Technical – transducer height, quality of trace
Why is this patient jaundiced?
Acute, Chronic or Acute on Chronic Liver Disease
Pre-hepatic
Hepatic
Post-hepatic
Why is this patient not waking up? OR Why has this patient got a decreased LOC?
Jeremy Fernando (2011)
Structural – focal
Abscess
CVA
Trauma
Bleed
Non-structural - global
Meningism – SAH, meningitis
No meningism - metabolic, electrolytes, sepsis/seizures, organ failures, toxins
(MESOT)
Why is this patient weak?
Unilateral or bilateral weakness
Upper vs Lower motor neuron lesion
Brain
Spinal cord
Peripheral nerves
NMJ
Muscles
Is this patient brain dead?
Diagnosis
Exclusion of treatable causes
Preconditions
Responsiveness
Brainstem reflexes
Apnoea
Imaging
Other relevant information – second assessment by suitably trained doctor
Why is this patient febrile?
Infectious
- community acquired
- nosocomial (surgical site, lines, chest, urine, sinusitis)
Non-infectious
- head injury
- DVT -> PE
- drug/toxin
- SIRS (post surgery, trauma, aspiration, pancreatitis)
- Hypermetabolic syndromes
-> thyroid storm
-> NMS
-> MH
-> heat stroke
-> phaeo
-> liver failure
-> burns
Jeremy Fernando (2011)
-> cocaine toxicity
-> serotonin syndrome
What injuries has this multiple-trauma patient sustained?
Stage of illness
Primary, secondary or tertiary survey (examine from head to toe)
Rehabilitation phase
Complications of stay
“My assessment follows a primary and secondary survey. Injuries from head to toe
including relevant injuries are…”
How is this patient with multi-organ failure progressing?
Initial illness and response to treatment
Diagnosis correct
Organ failures and support for each organ
Complications of stay – nosocomial infection…
Why does this patient have Polyuria?
Cause
Volume status
Complications
Treatment
SPECIFIC PATIENT APPROACHES
The COPD Patient
Stable of illness – acute, respiratory weaning
Ventilation strategy – NIV, invasive, weaning strategy
Tracheostomy consideration
Nutritional state
Quality of life and prognosis
Brain
Cough
Nerves
NMJ
Respiratory Muscles
Pleura
Airways (large and small)
Parenchymal
Chest wall
Ventilator asynchrony
Cardiac failure
Abdominal distension/failure
Jeremy Fernando (2011)
The Post Cardiac Surgical Patient
Type of surgery
Emergency or Elective
Post-operative complications (bleeding, bleeding, tamponade, graft occlusion, CVA)
Shock assessment
Causes and type of heart disease
The Post Cardiac Arrest Survivor
Prognositication
Rhythm
CPR (time to and quality)
Time to ROSC
Cause of arrest – ability to treat cause
Therapeutic hypothermia
Coma -> need to wait until 72 hrs
Assessment @ 72 hours – pupils, corneal reflexes, motor response, SSEPs (N20 peak
absence), iso-electric EEG, burst suppression, status myoclonus
Other issues
Cause of cardiac arrest – IHD, arrhythmias, drowning, drug
Complications (organ failures)
Why did this young patient have an out of hospital cardiac arrest?
Cardiovascular - arrhythmia, electrolyte abnormality, long QT, Brugada syndrome,
myocarditis (influenzae), ischaemia, congenital heart disease, shock, HOCM, ARVD
Respiratory - TP, pneumonia with hypotension, PE
Neurological - SAH, brain haemorrhage
Renal - hyperkalaemia
Drugs - overdose: TCA, opioids, stimulants, cocaine
The patient with an Intra-abdominal Catastrophe
Cause
Treatment (source control)
Nutrition
Complications – ACS, fungal sepsis
How to move forward?
The patient who has had an Abdominal Aortic Aneurysm repair
Emergency or Elective
End-organ damage
Complications
- brain injury
- spinal cord ischaemia
Jeremy Fernando (2011)
-
ileus
MI
lower limb ischaemia
compartment syndromes
renal injury
The patient who has had a Subarachnoid Haemorrhage
Hemisphere
Site
Territory
Complications
Neurological – bleeding, seizure, hydrocephalus, vasospasm, increased ICP
Respiratory – aspiration, neurogenic pulmonary oedema
Cardiovascular – AMI
Electrolytes – SIADH, CSW, DI
Treatment done
Management
The patient with a Head Injury
Isolated TBI or not?
Phase of illness: < 48 hours, day 2-7, late
Complications:
- refractory intracranial pressure
- VAP
- nosocomial infection
- ventriculitis
The patient with a Spinal Injury
Phase of injury
Acute: ileus, cardiovascular, ventilation
Sub-acute: recurrent atelectasis and segmental collapse
Chronic: pain, psychological issues, infection (uro, resp, pressure areas),
autonomic dysreflexia, spasm.
ASIA Classification (A-E)
Cord syndrome presentation
Other injuries/issues
The patient with Burns
Burn
Site
Depth
Extent
Phase of Burn
Resuscitation (Day 1)
Post-resuscitation (Day 2-6)
Jeremy Fernando (2011)
Inflammatory/infective (Day 7)
Complications
The Transplant Patient
Transplant – liver, heart, lung, heart-lung, bone marrow, renal, pancreatitic
Phase of care – immediate post op, sepsis, rejection, respiratory failure, renal failure
Surgery – graft function, anatomy, anastomoses
Infection – bacterial (early), opportunistic: fungal, viral, mycobacterial (late)
Immunosuppression – rejection, GVHD, drug side effects, malignancy
The Obstetric Patient
Illness requiring ICU admission
Pregnancy + Baby
Delivery – when or already done
Long Stay ICU Patient
Illness requiring ICU admission
Reason for ongoing admission
Things that need to happen to allow discharge
Can you decannulate this patient with a Tracheostomy?
Reason for insertion – resolved/treated
Airway – cuff down, size, speaking, absence of airway obstruction
Respiratory assessment – FiO2, cough, sputum load, swallow, infection, WOB, CXR
Cardiovascular – can patient deal with increase O2 demand
Neurological – power, cough, awake, alert
Environmental – time of day, level of staff, MDT involvement
Why has this patient got Liver Failure?
TYPE
Hyperacute (Fulminant) - < 7 days
Acute - 7 – 28 days
Sub acute – 28 days to 6 months
CAUSES (DAVE)
Drugs – paracetamol, halothane, idiosyncratic
Alcohol
Viral (A->G, CMV, HSV, EBV)
Extras – fatty infiltration in pregnancy, HELLP, Wilsons, Reye’s
Jeremy Fernando (2011)
Neurological Exams for the CICM Examination
Paralysed patient – pupils only
Quick examination where neuro not the focus – GCS or responsiveness, pupils,
movement of limbs, tone, reflexes.
Unconscious examination – GCS or responsiveness, pupils, oculocephalic reflexes,
corneals, cough, gag, limbs (posture, tone, reflexes, movement to pain)
Conscious examination – everything! GCS, CNS, PNS.
Jeremy Fernando (2011)