2014, Hot Cases 1

Prince Charles Hospital
51-year-old male, day 7 post resuscitation from out-of-hospital VF arrest. Clinical signs included ongoing sedation requirements, high FiO2 requirements, central flail segment and decreased air entry at bases. Candidates were directed to assess his suitability for extubation.
70-year-old female, day 3 ICU following re-admission for shock three days post AVR and who underwent re-sternotomy two days earlier for cardiac tamponade. She had a background of end-stage kidney disease treated with peritoneal dialysis. Clinical signs included decreased air entry at bases, prosthetic aortic valve and pericardial rub, vascath and peritoneal dialysis catheter in situ. Candidates were directed to assess her suitability for extubation.
7-year-old female, day 3 ICU, with scleroderma, pulmonary fibrosis and pulmonary hypertension, presenting with haemoptysis and respiratory failure. Clinical findings included signs of scleroderma with CREST, blood-stained respiratory secretions, bronchial breathing at left base with diffuse crackles, aortic regurgitation and hepatomegaly. Candidates were directed to identify the key clinical findings and to provide a management plan.
59-year-old female, day 6 ICU, admitted with Klebsiella sepsis with cavitating pulmonary lesions and liver abscess, two weeks after returning from Malaysia. She was intubated for worsening hypoxaemia, tachypnoea and respiratory alkalosis. Clinical signs included a widespread rash, fever, right lower lobe changes, poor lung compliance and septic shock on high-dose vasopressors. Candidates were directed to examine her and identify possible causes for her fever.

Princess Alexandra Hospital
42-year-old male, day 2 ICU, admitted following unsuccessful clot retrieval for right MCA infarct, complicated by perforation of MCA. Clinical signs included puncture wound right groin and dense left hemiparesis but obeying commands right side. Candidates were directed to assess him and provide a plan for the day.
39-year-old female, day 5 ICU, intubated for MRI following presentation with a stroke. MRI showed multiple lesions and large left MCA territory stroke, inflammatory in origin. Clinical findings included right hemiparesis, eyes deviated to left, not obeying commands and left-sided neglect. Candidates were directed to examine her with focus on the neurological deficits and a cause for the stroke.
72-year-old male, day 14 ICU, post Ivor-Lewis oesophagectomy, complicated by anastamotic leak, multiple pneumothoraces, and atrial fibrillation. Clinical findings included bleeding from fresh tracheostomy with intermittent air leak, subcutaneous emphysema, left bronchopleural fistula, bile draining from right-sided chest drains and jejunostomy feeding tube. Candidates were directed to establish the nature of the post-operative complications.
42-year-old male, day 6 ICU, admitted following surgery for anastamotic leak and faecal peritonitis post anterior resection for metastatic colorectal carcinoma. Clinical signs included decreased breath sounds bilaterally, multiple abdominal drains and an ileostomy. Candidates were asked to examine him and identify the major clinical issues.
42-year-old male, day 6 ICU, following admission with shock, with type A thoracic aortic dissection, right CVA and severe aortic regurgitation, and now post Bentall's procedure. Clinical signs included on sedation and muscle relaxants, sternotomy scar, right groin wound, prosthetic aortic valve, bronchial breath sounds at left base and decreased air entry right base. o Candidates were directed to examine his cardiovascular system with a view to finding the cause for his initial collapse.
67-year-old male, day 2 ICU post elective low anterior resection.Clinical findings included obesity, haemodynamic instability with high dose inotropic support, atrial fibrillation, aortic stenosis and low urine output, bibasal collapse and a fresh midline incision with a viable stoma. Candidates were directed to examine him and determine the cause for his haemodynamic instability and failure to wean.

Royal Brisbane and Women’s Hospital
36-year-old male, day 26 ICU, was in a motor vehicle accident with chest and orthopaedic injuries. Clinical findings included obesity; fever with fluctuant mass on right thigh, decreased breath sounds bibasally, hepatomegaly and a sacral pressure sore. Candidates were directed to examine him and determine why he was still ventilator-dependent at day 26.
79-year-old female, day 22 ICU with strangulated hiatus hernia was treated by gastrectomy and primary anastomosis. Clinical findings included global weakness, right-sided ICC sites, bronchial breath sounds at right base, decreased air entry with crackles at left base, abdominal wound and jejunostomy tube. o Candidates were directed to examine her with a view to establishing why she was difficult to wean.
33-year-old female with a history of significant alcohol use, day 3 post coiling of PICA aneurysm and who had been re-intubated for confusion. CT scan the previous day had shown a left cerebellar infarct. Clinical findings included ongoing blood-stained CSF drainage, hypertonic saline infusion in progress, no obvious neurological defect, intact airway reflexes and a clear chest. Candidates were directed to examine her with a view to determining her suitability for extubation and to make a management plan.
75-year-old female 5 days following right hemi-hepatectomy for a mass lesion that initially had an uneventful recovery but was readmitted for a decrease in conscious level. Clinical findings included jaundice, lower body swelling and encephalopathy with lateralising signs L>R. Candidates were directed to examine her and discuss the possible causes of her decreased conscious state.
69-year-old female day 19 ICU post SAH secondary to left peri-callosal aneurysm treated with craniotomy, clipping and insertion of EVD and with slow neurological recovery and failed extubation for fluctuating conscious state and retained secretions. Clinical findings included drowsiness but able to obey commands and no focal neurological signs and high urine output. Candidates were directed to examine her and provide a differential diagnosis for her fluctuating neurological state.
53-year-old female, day 7 ICU, with pneumococcal pneumonia and bacteraemia, admitted following a Medical Emergency Team call for respiratory distress. Her ICU stay had been complicated by acute kidney injury and biventricular failure. She had not required invasive ventilatory support. Clinical findings included fever, widespread septic vasculitic rash, left sided bronchial breath sounds and signs of right heart failure. Candidates were directed to examine her to determine her cardio-respiratory status and the cause of her respiratory failure.
48-year-old man, day 7 ICU following repair of mycotic coronary artery aneurysms. Background of diabetes, and dialysis-dependent renal failure. Shocked, on adrenaline and noradrenaline infusions and VA ECMO. Clinical findings included fluid overload, AV fistula, poor circulation to the right leg, and oozing from the sternal wound. Candidates were asked to assess with regard to the cause of the renal failure.
41-year-old male, day 3 ICU, attempted self-hanging, asystolic at the scene and resuscitated with return of spontaneous circulation after 3 doses of adrenaline. Clinical findings were GCS 3 with absent brain stem reflex responses. Candidates were directed to assess him for brain death.

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