2015, Hot Cases 2

Unspecified hospital in Adelaide

60-year-old male, ICU day 9, presented following a seizure at work secondary to a sub arachnoid haemorrhage, with an initial GCS of 6. The aneurysm was clipped on day 1 and he subsequently failed extubation. Clinical findings included hypertension, the presence of an EVD wound scar, GCS E1 M2-3 VT, hypotonia, no response to facial pain and upgoing plantars bilaterally.

Candidates were directed to assess and explain his neurological status.

Discussion points included causes for deterioration after sub-arachnoid haemorrhage, investigation and management of vasospasm, and the causes of fever.

58-year-old male, day 3 ICU, who had undergone thoracic surgery three days earlier and suffered an intraoperative arrest.

Candidates were directed to examine the patient and discuss a management plan.

Discussion points included the causes of intra operative arrest and the complications of pneumonectomy.

59-year-old male, day 25 ICU, having presented with pneumonia on a background of COAD, anxiety and alcoholism. Clinical findings included and alert and co-operative patient with evidence of muscle wasting with preserved strength, an in situ tracheostomy with subglottic suction and reduced breath sounds at the bases.

Candidates were directed to assess the patient and formulate a management plan including the consideration for decannulation.

Discussion points included the management of pulmonary haemorrhage, and the significance of pseudomonas colonisation.

64-year-old male, day 6 ICU, having presented to a regional hospital six days earlier with infected left foot ulcer and Hb 67 g/l. He was transfused one unit of packed red cells and rapidly developed respiratory failure. He was transferred later that day for respiratory support and was intubated on arrival at the second hospital. Background included diabetes, peripheral vascular disease and coronary artery grafts. The patient had been extubated the previous day, requiring BIPAP overnight.

The candidates were directed to assess his current respiratory status and postulate causes of his initial respiratory failure.

60-year-old male, day 31 ICU, admitted to hospital, one month earlier with severe respiratory failure secondary to legionella pneumonia, mechanically ventilated since with increasing O2 requirements over the previous 36 hours. Clinical findings included fever, tachycardia with atrial flutter, peripheral oedema, palpable liver edge and hyper-reflexia.

Candidates were directed to examine him for potential causes of his ongoing ventilatory requirement and for the deterioration in the past 36 hours.

Discussion points also included the management of elevated creatinine, and the significance of a positive blood culture for candida.

31-year-old female, day 27 ICU, having presented with a 4-week history of infective respiratory symptoms. She had an in hospital cardiac arrest with a brief period of CPR before return of spontaneous circulation. In ICU, treatment strategies included VV ECMO, dialysis and tracheostomy for weaning.

Candidates were directed to comment on her readiness for weaning and to give a further management plan.

Discussion points included interpretation of chest CT scan, the microorganisms likely to cause cavitating lung lesions, as well as criteria for readiness to wean.

44-year-old female, day 45 ICU, who presented with fever, shortness of breath and cough seven weeks earlier. Clinical findings included right-sided pleural effusion, a thoracostomy wound, ECMO scars in the groin, a recent decannulated tracheostomy site, a tender abdomen and significant muscle weakness.

Candidates were directed to examine her with respect to readiness for the ward and management plans for ongoing intensive care problems.

Discussion points included the differential diagnosis and investigation plan of muscle weakness in this setting, as well as the management of the patients respiratory function and rehabilitation.

43-year-old male, admitted to ICU one week earlier with septic shock and respiratory failure, intubated 2 days later and developed seizures. Background included active IV drug use. Clinical findings included sedated and intubated, splinter haemorrhages, Janeway lesions, injection sites in the groin and mitral regurgitant murmur.

Candidates were directed to examine him to determine the cause of his septic shock. Discussion points included antibiotic therapy, contra-indications to surgery and prognosis.

44-year-old male admitted to ICU 2 weeks earlier having been found collapsed in the dialysis unit car park with a GCS 3, heart rate 30 bpm and temp 41.7oC. CPR was started in the ambulance with ROSC in ED 10 minutes later following treatment for K+ 8.1 mmol/L. Background included IDDM and end-stage kidney disease on haemodialysis 3x /week. Clinical findings included GCS 4 with roving eye movements, increased tone with extensor response to pain and upgoing plantar reflexes and the presence of an A-V fistula in his forearm.

Candidates were directed to examine him with a view to assessing his neurological prognosis and possible causes of the cardiac arrest

Discussion points included management of the initial arrest, neurological prognostication, pros and cons of tracheostomy and family discussion re prognosis

77-year-old female with Wegener’s granulomatosis, admitted the previous day with difficulty swallowing and drooling secondary to lateral pharyngeal wall cellulitis. On examination she had a bull neck but no clear signs of external swelling, was intubated with a size 6.0 ETT and requiring minimal ventilatory support. The ETCO2 trace showed a pattern of obstruction.

Candidates were directed to assess her suitability for extubation. Discussion points also included management of upper airway obstruction.

75-year-old female, day 2 post emergency coronary artery grafting for severe left main disease and NSTEMI with persisting low cardiac output state. Background included type 2 diabetes and hypertension. She was intubated and ventilated with cardiovascular support including an intra-aortic balloon pump, nor-adrenaline and milrinone.

Candidates were directed to review her and outline their plan of management for the day. Discussion points also included management of the IABP and weaning and extubation.

59-year-old male admitted to ICU 2 weeks earlier with cardiorespiratory failure secondary to unknown bronchial adenocarcinoma causing obstruction of right upper lobe bronchus and pleural and pericardial effusions with tamponade. He had been extubated 10 days earlier but readmitted 2 days later for respiratory failure and started chemotherapy whilst ventilated. Past history included liver transplantation for cirrhosis one year ago. Findings on examination included left cervical lymphandenopathy, LLL collapse, liver transplant surgery scar, indications of chemotherapy in progress and minimal respiratory support.

Candidates were asked to assess his suitability for extubation.

Discussion points also included interpretation of imaging including the initial echo findings and the issues surrounding chemotherapy in a ventilated patient.

80-year-old woman day 2 in ICU following presentation with haematemesis and aspiration pneumonitis, intubated for endoscopy that was negative. Background history included atrial fibrillation and short bowel syndrome on home TPN. Findings on examination included an awake patient on minimal respiratory support, raised JVP, atrial fibrillation with a displaced apex beat, and a Hickman line in situ.

Candidates were directed to assess her suitability for extubation.

Discussion points also included differential diagnosis for her presentation and further investigation and management of the GI bleed

72-year-old male, day 1 ICU with respiratory failure following a respiratory illness for five days. Findings on examination included morbid obesity, signs of obstructive sleep apnoea and left pleural effusion with ICC

Candidates were directed to assess his current status and make a management plan.

Discussion points included management of underwater seal drain and interpretation of pleural fluid biochemistry.

62-year-old female, day 5 ICU, admitted with decreased level of consciousness from hepatic encephalopathy, secondary to decompensated liver disease with acute renal failure and haematemesis. Findings on examination included signs of decompensated chronic liver disease and hepatic encephalopathy, intubated on minimal ventilatory support and haemodynamic stability.

Candidates were directed to provide a differential diagnosis for her decreased level of consciousness and to provide a management plan.

Discussion points included interpretation of investigations, precipitants of hepatic encephalopathy and prognostication.

35-year-old female, three weeks in ICU post re-do MVR with peri-operative multi-organ failure, complicated post-operative course and slow ventilatory wean. Background included ESRF on dialysis. Findings on examination included tracheostomy, high sputum load, old ICC site, small tidal volumes on moderate level of pressure support ventilation, low vasopressor requirement, prosthetic heart valve, signs of right heart failure, general deconditioning and global weakness, presence of AV fistula in left forearm, and evidence of melaena in faecal management system.

Candidates were directed to identify the major issues with a plan for their management. Discussion points included causes of failure to progress.

75-year-old male, day 2 ICU, admitted with respiratory failure. Findings on examination included the presence of droplet precautions, poor peripheral perfusion, the presence of a pacemaker/ICD and coarse crackles throughout all lung fields.

Candidates were directed to provide a differential diagnosis for his respiratory failure based on the findings on examination.

Discussion points included interpretation of imaging and echo findings and further assessment of his cardiac function.

67-year-old male, one month in ICU, transferred from SE Asia following a prolonged acute illness with liver abscess, sepsis and multi-organ failure. Background included CNS lymphoma. Findings on examination included tracheostomy, old craniotomy scar, breathing spontaneously on humidified oxygen with decreased breath sounds on the right, deconditioning and critical illness weakness syndrome with significant proximal weakness.

Candidates were directed to examine him and outline a management plan.

Discussion points included interpretation of the neuromuscular signs, respiratory weaning and interpretation of abnormal liver function tests.

73-year-old male day 1 ICU admitted following a MET call for decreased conscious state that required intubation. He had been admitted with shortness of breath, fever, headache and collapse and found to have meningococcal meningitis. Background included ischaemic heart disease on dual anti-platelet therapy and COPD. Findings on examination included ecchymoses, bronchial breathing left lung, right upgoing plantar and the absence of meningism.

Candidates were directed to determine the likely cause for the decrease in conscious state.

Discussion points included interpretation of the CSF results, management of meningitis and the role of steroids.

54-year-old female, day 5 ICU, admitted with massive haematemesis from oesophageal varices on a background of Child’s B cirrhosis secondary to auto-immune hepatitis. Other co-morbidities included biventricular failure, atrial fibrillation, hypothyroid disease and polycythaemia. Findings on examination included generalised oedema, bilateral crackles on auscultation with decreased breath sounds at the bases, distended abdomen and neurological signs with brisk reflexes and ankle clonus.

Candidates were told that she had presented with upper GI bleeding that had been treated and were directed to examine her focussing on the neurological system and provide a differential diagnosis for her current clinical status.

Discussion points included interpretation of biochemistry, causes of encephalopathy and management of bleeding oesophageal varices.

68-year-old male day 3 ICU admitted with respiratory failure and septic shock secondary to pneumonia complicated by acute kidney injury. Background included type 2 diabetes and alcohol dependence. Findings on examination included mechanical ventilatory support with relatively high ventilatory requirements, bilateral chest signs and vasopressor dependent shock.

Candidates were told he had presented with dyspnoea increasing over several days and were directed to provide a differential diagnosis for his initial presentation and make a management plan.

78-year-old male, day 2 ICU, admitted following a MET call for altered conscious state and hypoxaemia. He had been admitted to hospital for management of melaena and falls. Background included significant cardiovascular disease and limited mobility. Clinical findings included sedated patient with loud aortic stenotic murmur and left hemiplegia with upgoing plantar reflex

Candidates were directed to examine him and comment on the major current issues.

Discussion points included interpretation of arterial blood gas and imaging, the clinical dilemma of thrombotic stroke in a patient who is a bleeding risk and the implications of aortic stenosis in this patient.

30-year-old male, day 5 ICU, admitted with 55% scald burn from the shower. Background of epilepsy. He had just returned from debridement. Clinical findings included sedated and ventilated, oliguric on CVVHDF, abdominal distension and the presence of a scalp haematoma.

Candidates were directed to assess him and make a management plan.

Discussion points included weaning of sedation and ventilation and the use of renal replacement therapy.

26-year-old male, day 4 ICU following a high-speed motorcycle accident. On presentation there was no sensation below the waist. Clinical findings included the presence of a tachycardia, left below-knee amputation, right external fixator, dark urine with an IVC filter and would not obey commands.

Candidates were directed to assess him and make a management plan.

Discussion points included weaning of sedation and ventilation and the role of DVT prophylaxis.

66-year-old male, day 15 ICU, admitted following a 2m fall from a truck. Clinical findings included a patient who was febrile, delirious, oedematous with rapid shallow breathing, no movement in his legs and hyper-reflexia.

Candidates were directed to examine with a view to identifying his major management issues. Discussion points included his neurological findings, fever, ventilatory status and fluid balance.