2014, Hot Cases 2

Unspecified hospital in Sydney
  • 60-year-old male, day 6 ICU admitted with GCS 3, query cause, and persisting coma and a background history of alcohol abuse. Clinical findings included GCS 5-7 off sedation, brain stem reflexes present (except oculo-vestibular), weak extension of upper limbs to pain, global hyporeflexia with up going plantar responses bilaterally, and presence of skin abrasions and sacral pressure sore.
  • Candidates were asked to examine him with a specific focus on his neurology with a view to establishing a differential diagnosis for his presentation and a management plan.
  • 17-year-old male, day 50 in the ICU. Initially admitted with a reduced level of consciousness secondary to a new onset of a seizure disorder. Current clinical findings include GCS 3, ongoing benzodiazepine infusion, BIS monitor in-situ, intermittent clinical and EEG seizures, bilateral leg swelling, gross global muscle wasting, and still requiring mechanical ventilation via a tracheostomy.
  • Candidates were asked to assess his current issues given his prolonged ICU stay.
  • 65-year-old man, Day 10 ICU. Post operative sterotactic biopsy lesion right temporal lobe. Subsequently slow neurological recovery. Clinical findings included a VP shunt, VI cranial nerve lesion on the right, monoparesis of the right arm, upward plantar on the right.
  • Candidates were informed the patient was slow to recover following a neurosurgical procedure. They were asked to assess his neurological state, provide a differential diagnosis, and outline a plan for his further management.
  • 65-year-old male, day 1 in the ICU, with acute hypoxic respiratory failure. His clinical findings included obesity, intubated ventilated, paralysed and sedated, low cardiac index on PiCCO, inotropic and vasopressor support, high FiO2 and PEEP. His bedside echo demonstrated globally reduced left ventricular function, his chest X-ray showed an endobronchial intubation with bilateral infiltrates.
  • Candidates were asked to assess the patient with regards to his initial management plan.
  • 45-year-old man, day 13 ICU. Admitted with SCC tongue, necrotising pneumonia, neutropenic sepsis and multi organ failure. Clinical findings included bilateral wheeze, crepitations at the right lung base, and portacath in situ.
  • Candidates were informed the patient had a background of intravenous drug use and hepatitis C, and had been admitted with respiratory failure. They were asked to examine and provide a differential diagnosis.
  • 56 year-old-man, day 4 ICU. Background of MI three weeks previously, followed by respiratory failure of uncertain aetiology with bilateral lung infiltrates, normal cardiac output and low filling pressures. Clinical findings included bilateral fine crepitations, evidence of airflow obstruction, and a vasodilated state.
  • Candidates were informed that the patient had respiratory failure and shock following a recent MI. They were asked to examine him to find a likely cause.
  • 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.
  • 75-year-old female, day 5 ICU post jejunal flap to the hard palate for SCC palate and background of cardiomyopathy with PPM/AICD, and chronic kidney disease requiring intermittent haemodialysis, now managed with CRRT. Clinical findings included gross oedema, swollen neck, abdominal incision, previous donor graft sites, AV fistula right upper limb, dusky oral jejunal flap, hypothermia, presence of CRRT circuit and TPN.
  • Candidates were told she was day 5 post-jejunal flap for oral cancer and asked to examine her with a view to a plan for ongoing management.
  • 62-year-old female, day 4 in the ICU, who presented with a collapse. She was off sedation but remained unresponsive. Clinical findings included treatment with nimodipine and noradrenaline, 2 external ventricular drains with blood stained CSF and normal ICP, reduced level of consciousness, some brainstem signs, present cough and gag, temperature of 38.2 degrees. A CT brain demonstrated subarachnoid and intraparenchymal haemorrhage.
  • Candidates were asked to assess the patient to assess a likely cause for collapse and provide the current priorities in management.
  • 27-year-old female, day 3 ICU with multi-trauma following motor vehicle crash. Her injuries included traumatic brain injury and raised ICP with bilateral SAH and basal ganglia and intra-parenchymal haemorrhage, blunt chest trauma with right-sided contusion, rib fractures and pneumothorax, liver laceration and multiple facial and limb abrasions. Findings on examination included Codman catheter, right ICC, sandbags supporting C-spine, large scalp abrasion with degloving and extensive skin abrasions.
  • Candidates were asked to perform a secondary survey, describe the findings and outline the likely clinical problems.
  • 78-year-old female, day 2 in the ICU, with a left haemothorax following a recent fall. Clinical findings included intubated and ventilated, left intercostal catheters with 700ml of blood, multiple previous AV fistulae, currently on CVVHDF, multiple bruises, left leg splinted. Chest x-ray demonstrated persistent left haemothorax.
  • Candidates were asked to assess the patient with regards to the contributors to her current clinical state and make a plan for ongoing management.
  • 67-year-old female, day 7 post elective left common carotid stent placement , heparinised for visual disturbance day 1 post stent, complicated by large subdural and intra-parenchymal bleeds and refractory intracranial hypertension despite bilateral craniectomies. Clinical findings included sedation to control ICP, the presence of a femoral arterial puncture site, bifrontotemporal craniectomies and bilateral subdural drains, dilated unreactive pupils with absent corneal and oculo-cephalic reflexes and generalised hyporeflexia.
  • Candidates were directed to assess her neurological status and discuss what they would say to the next-of-kin.
  • 39-year-old male, day 6 in the ICU, who presented following a head injury while intoxicated. He was slow to recover neurological function post-operatively. Clinical findings included invasive ventilatory suport, temperature of 38 degrees, right hemiplegia, brisk reflexes in left leg, bilateral upgoing plantars, normal brainstem reflexes, signs of left sided pneumonia. His CT showed an acute extradural haematoma.
  • Candidates were asked to assess the patient with regards to potentially reversible factors that may be contributing to his slow neurological recovery.
  • 27-year-old man, day 5 ICU. Post op evacuation of left parietal extradural haematoma. Clinical findings included a craniotomy scar, fever, decreased air entry at the left base and bronchial breath sounds at the right.
  • Candidates were informed the patient had been found wandering the streets in an agitated state, and on arrival at the hospital had dropped his GCS from 13 to 7. They were asked to begin by examining the patient’s neurology.
  • 84-year-old man, Day 2 ICU. Background of traumatic brain injury following a fall. Currently agitated, requiring restraints. Clinical signs included a GCS score of 6, left hemiparesis, left facial haematoma, left basal bronchial breathing and a soft systolic murmur.
  • Candidates were informed the patient had been admitted to ICU 2 days previously having been found at the bottom of his stairs with a GCS of 3. They were asked to examine his neurological system as well as any other systems they thought appropriate and give an overview of his present condition.
  • 52-year-old male, day 3 in the ICU following elective CABG x 3. He remained ventilated with hypoxic respiratory failure. On examination he was obese, febrile, had high ETCO2, moderate PEEP and FiO2, reduced breath sounds at both bases. There were no focal neurological issues but he was heavily sedated. His chest x-ray showed bilateral infiltrates.
  • Candidates were asked to assess him with regards to the barriers weaning sedation and attempting extubation.
  • 69-year-old lady Day 2 ICU. Post coronary artery grafts and mitral valve repair. Background history of connective tissue disease. Clinical findings included sclerodactyly reduced radial pulse and brisk carotids, absent JVP, pedal oedema, paced cardiac rhythm, pansystolic murmur audible at the left sternal edge.
  • Candidates were informed she was day 2 following emergency cardiac surgery. They were asked to examine her cardiovascular system and overall state, and outline plans for ongoing management and ICU discharge.
  • 65-year-old male day 11 post attempted anterior cervical spinal fixation complicated by arterial bleeding not controlled by attempted stenting and required sternotomy and thoracotomy and suturing of bleeding points. Course in ICU complicated by ventilator-associated pneumonia and failed extubation. Background history of ankylosing spondylitis and life-long low BMI. Clinical findings included severe generalised wasting.
  • Candidates were asked to examine him with a view to making a plan for weaning.
  • 63-year-old woman, three weeks in ICU with respiratory failure, secondary to pseudomonas pneumonia, complicated by a probable intracerebral event and slow wean, and a background of chronic lung disease. Clinical findings included presence of tracheostomy, hyperinflated chest, tachypnoea and poor lung compliance, severe cachexia and generalised weakness.
  • Candidates were asked to examine her and devise a weaning strategy
  • 76-year-old man, Day 6 ICU background of prosthetic aortic valve endocarditis. Findings included ankle oedema, implanted pacemaker and obesity.
  • Candidates were told he was recovering from recent cardiac surgery and to assess his suitability for extubation.
  • 60-year-old male, 2 months in hospital for H1N1 influenza requiring ECMO complicated by ischaemic bowel, acute kidney injury and critical illness weakness syndrome. Clinical findings included flaccid weakness, more so in the upper than lower limbs: spontaneous respiration via tracheostomy with small tidal volumes and poor cough with copious secretions; abdominal wound with ileostomy.
  • Candidates were asked to examine him with a view to assessing his suitability for ward transfer and decannulation of the tracheostomy.
  • 56-year-old man, one month in ICU with severe necrotising pancreatitis, septic shock and multi-organ failure and subsequent right femoral DVT. Clinical findings included GCS 15, cachexia and proximal muscle weakness, ongoing respiratory failure, AF/flutter and low dose vasopressor support and an abdominal drain.
  • Candidates were asked to examine him with a view to identifying the ongoing clinical issues and the management priorities