2015, Hot Cases 1

Unspecified hospital in Melbourne

70 - year - old female, day 10 in ICU, following an elective AAA repair, with on - going requirements for mechanical ventilation. Clinical signs included the presence of confusion but with no focal neurological deficits, normal cardiorespiratory exam ination, large NG aspirates and TPN, anuria and CRRT, ischaemic toe and new onset fever. Candi dates were asked to examine her and identify reasons for a difficult wean from ventilatory support.

56 - year - old female, day 2 in ICU, admitted following a sub-arachnoid haemorrhage (WFNS grade 2 and Fischer grade 3). Clinical signs included the presence of an EVD, noradrenaline infusion and localising with right side. Candidates were asked to evaluate the patient and describe their management plan for the day.

50-year-old male, day 7 ICU, admitted following out-of-hospital VF cardiac arrest secondary to STEMI, requiring multi-system support with VA ECMO, mechanical ventilation, vasopressor and inotropic support and CRRT. Candidates were asked to assess him with a view to making a plan for that day and projecting forward for the subsequent few days.

69-year-old male, day 2 ICU following a fall from a standing height. Background history included hypercholesterolaemia, C-spine fusion and insulin dependent T2DM. His injuries included intracranial haemorrhage and base of skull fracture with blood in the right external auditory meatus. Candidates were asked to examine him with a view to identifying his main injuries and any ongoing issues

16 - year - old male, day 3 ICU , admitted having been found unconscious after presumed high voltage electrocution and subsequent fall. Clinical signs included bilateral upper limb and gluteal fasciotomies with VAC dressings, GCS 15 and haemodynamic stability. Candidates were asked to examine him and elucidate his clinical issues with particular reference to why he was still requiring ICU management .

35 - year - old male, day 1 ICU, admitted following attempted suicide by hanging. He required 5 min CPR at the scene and GCS was 3/15 on presentation to hospital. Background included a history of IV drug use and alcohol abuse.
Candidates were asked to assess him , say which investigations they would perform and to give a management plan for the next 72 hours .

45 - year - old man, day 3 ICU, admitted with fever and respiratory failure and left empyema. Background of long - term LVAD for cardiomyopathy. On examination he was awake and alert with an old sternotomy scar and a new left thoracotomy wound , three intercostal catheters in situ, and reduced breath sounds on the left side
Candidates were asked to assess him for the source of the fever.

A 34 - year - old with multi - trauma following a five storey fall onto a car, with respiratory failure and unstable haemodynamics. The patient had chest and spinal inju ries and an unstable pelvic fracture awaiting surgical fixation. Candidates were asked to examine him and describe why his haemodynamics were problematic.

A 23 - year - old man with a severe traumatic brain injury following a motor vehicle accident. Patient h a d poor conscious level with non - reactive pupils and a CSF leak. Candidates were told the family wished to meet to discuss prognosis, and to exami ne the patient and present their findings.

A 77 - year - old male admitted two days ago, having fallen down the s tairs. Found unconscious by his wife and intubated at the scene by paramedics. Underwent an emergency craniotomy. Candidates were asked to examine him with an emphasis on neurology and injuries, and to present their plan of management for the day.

A 59 - ye ar - old woman admitted twelve days previously with a WFNS Grade 4 subarachnoid haemorrhage. Candidates were asked to examine her focussing on neurology and to present an ongoing plan of management.

A 63 - year - old man admitted four days previously following a laparotomy for small bowel resection, with a background of ulcerative colitis . The patient had just returned from the operating theatre. Candidates were asked to examine him and present their plan for weaning his ventilation.

A 63 - year - old man admitted 24 hours previously following an out of hospital cardiac arrest. Relevant background history included hypertension, Type 2 diabetes and rheumatic fever. He was in cardiogenic shock requiring inotropic support and IABP with clonus on neurological exam. Candidates were asked to examine him and outline their management plan.

A 74 - year - old woman who had undergone a redo coronary artery grafting procedure the previous day. Relevant background included diabetes, hypertension and aortic valve replacement. Candidates were asked if they would determine her suitability for extubation .

A 31 - year - old man who had been admitted to ICU eight days previously with limb weakness secondary to cervical epidural abscess . Clinical findings included sensory level at T2 with decreased power in upper limbs and absent motor function in his lower limbs with upgoing plantars; a weak moist cough with decreased air entry at the left base. Candidates were asked if he was ready to be discharged to the ward.

A 71 - year - old man who had been admitted to the ICU six days previously with intra - abdominal sepsis. Candidates were asked their approach to weaning his ventilation.

24 - year - old male with a history of intravenous drug use and mitral valve endocarditis, which resulted in an embolic str oke. The patient subsequently had surgery for a mitral valve replacement from which he was recovering. Candidates were directed to perform a neurological examination and a relevant general examination.

44 - year - old female with acute liver failure and hypox ia on a background of alcohol excess and heavy smoking. Transferred from a peripheral hospital and intubated on arrival for hypoxia and delirium . Candidates were directed to identify and discuss active issues and make a plan for the following week.

31 -year - old female following re - do liver transplant. The patient had an actively discharging surgical wound, was jaundiced and was on CRRT. Candidates were required to identify the current problems and formulate a plan of management.

70 - year - old man 2 weeks fol lowing resection of a large mediastinal sarcoma that included oesophagectomy. His postoperative course was complicated by a bronchial injury and chyle leak. The patient was slow to wean from the ventilator - issues included potential sources of sepsis (inc luding VAP and mediastinal), ongoing chyle leak, acute brain syndrome and neuromuscular weakness. Candidates were directed to identify causes for the slow wean from ventilatory support

81 - year - old female who had suffered a cardiac arrest following an acute coronary syndrome, which was complicated by a stroke. The patient had undergone percutaneous intervention (PCI) and had an intra - aortic balloon pump in place. Candidates were directed to assess the patient’s progress and formulate a management plan .

26 - year - old male day 4 ICU following fall from roof. He had sustained a severe head injury with extradural haematoma, contrecoup inju ry, SAH and temporal bone fracture extending to carotid canal. On examination there was a craniotomy scar and a pack in his left ear and he was waking up, localising with both upper limbs.
Candidates were asked to examine him with a view to assessing the severity of his head injury, and any other associated injuries likely to affect his recovery.

38 - year - old female farmer day 8 ICU, admitted with severe sepsis and respiratory failure secondary to community - acquired pneumonia, and now with new - onset fever. Clinical signs included right - sided bronchial breathing, high minute ventilation, and a hyperdynamic circulation with a systolic murmur. Candidates were asked to examine her and provide a summary of the clinical findings, differential diagnosis and manage ment plan.