This hot case typically takes one of two possible courses. Its either an attempt to work out what has caused this cardiac arrest, or what the prognosis is likely to be.
Important prognostic features include the following:
Previous hot cases with this sort of theme to them can be found below.
The standard introduction
Ask examiners about turning up the lights
The physical examination
The details of this section can be seen in the opposite column.
The obs and investigations
The Physical Examination in Brief Detail
Ask the examiners to sit the patient up
Ask the examiners about any language barriers
Ask examiners to lay the patient flat.
A pacing box?
Sensitivity and pacing threshold may not be relevant.
One can ask the examiners the following questions:
One should ask about the following parameters:
One should ask to look at the pressure-volume loops.
It would be useful to note whether the patient is triggering the ventilator.
There may be surgical drains (what is in them? How much of it?). Asking how much has been coming out may be relevant.
The pleural catheters are also interesting. One should make a mental note of whether the ICCs are on free drainage or on suction. The content of these drains could be informative, especially if one notices blood or chyle. Haemothorax may have been caused by vigorous CPR efforts.
A CVVHDF or SLEDD process may be in progress. The savvy candidate may wish to ask the following questions:
These questions may go unanswered. The CRRT machine is a good marker of poor prognosis. Either the patient already has end-stage renal failure, or they are suffering multi-organ system failure in the wake of their prolonged downtime.
The patient you are examining may have some sort of extra gadget hooked up. If ECMO is in progress, one may wish to ask about the following parameters:
If IABP counterpulsation is in progress, it raises additional questions. One may wish to ask the examiners whether one may be able to switch it to 1:2, to assess the efficacy of augmentation.
The IABP also alerts one to the possibility that the patient has had a VF arrest following a STEMI, and have now been revascularised.
This stage is critically important. The drug and fluid infusions which are currently in progress give a clue as to what problem is currently being addressed.
Important infusions not to miss:
If the patient is paralysed, ask the examiners to perform a train of four. You will be denied; the examiners will probably just tell you the results.
One should observe the following features of an EVD:
The cardiac arrest survivor does not routinely score an EVD. Its presense suggests that an intracranial catastrophe may have been responsible for the arrest; typically a massive SAH is one such catastrophe.
One should note the temperature.
A patient cooled to 33° is not going to be a fruitful neurological examinee.
Ideally, one should get the patient sitting up to 30-45°. This may not be possible. However, one should still ask for it.
Ideally, the patient should be exposed from the waist up. Peel back the cooling blanket, if one is allowed to do so. The candidate can then stand back and look for anything externally obvious:
Performing the GCS should be the first step, unless you notice that a neuromuscular junction blocker is among the infusions. The level of consciousness then determines how you go about examining the rest of the patient. Again, the process of cooling may render this step redundant.
A traditionalist, who is examining Mr Bloggs, would approach the GCS in the following manner:
One has just performed a GCS assessment; one is still holding the hands.
Now, time to look at them more closely.
First, one should spent a second assessing whether they are warm or cold.
Then, one can focus on the nails. Nail signs are numerous and deserve their own page.
In brief, the nail signs one could look for are as follows:
Look for the presence of any sort of characteristic deformities, eg. assymetrical wasting of the small muscles, or the joint changes of rheumatoid arthritis.
Assess the pulse. While one still has both of the patient's hands, one ought to try to compare the radial pulses.
Tone of the upper limbs
Move up from the hands. While you are still holding the hands, you can perform a sort of gross examination of tone by pronating and supinating the wrists, and by flexing and extending the elbows.
In the conscious patient, it may be possible to assess asterixis by asking the patient to hold both their arms up with the wrists dorsiflexed. The presence of asterixis late in the recovery phase of cardiac arrest may suggest that a severe ischaemic liver injury has occurred. More likely, the patient will be too comatose to perform this trick.
Examine the cubital fossa for
One should then palpate the axillary lymph nodes.
Palpate the neck:
The examination of the face and head is always affected by the level of consciousness, which is in turn related to the core temperature and the level of sedation.
The cardiac arrest survivor, unless extremely lucky, will be totally comatose, with few cranial nerve signs. The awake uncooled cardiac arrest survivor may have signs.
Thus, this section can be divided into three broad groups:
|The paralysed hypothermic patient||The unconscious nortmothermic patient||The awake post-arrest patient|
A Snellen chart is ideal, but probably will not be available.
The extubated patient should be able to read the time on the clock in the room.
One performs this test with each eye individually.
This tests CN II.
Ask the examiners to dim the room lights.
Open both eyes. Each eye is exposed to light. The opposite pupil should constrict consensually.
This tests CN II (afferent) and CN III (efferent).
The cornea (not the sclera) is touched lightly with a moistened corner of a piece of gauze.
A normal reflex is to blink.
This tests CN V (afferent) and CN VII (efferent)
The conscious patient will be able to follow the tip of the candidate's finger.
The pattern of movements should be tracing the six cardinal points: superior left, inferior left, superior center, inferior center, superior right, inferior right.
This tests CNs II, IV and VI.
Typically, this is performed by putting some pressure on the superior orbital notch.
The patient should either open their eyes or localise.
This tests CN V.
The conscious patient will be able to perform a series of grimaces to assess the bilateral motor control of facial muscles:
In the comatose patient, as the head is moved from left to right, the eyes should move in the opposite direction. A fixed unchanging gaze is a negative test; the reflex is not working.
This tests CNs III, IV, VI, and most importantly VIII.
Cold water is funneled into the patient's ear. A positive reflex consists of the eyes turning towards the chilled ear. This is a more potent stimulus for CN VIII than the oculocephalic reflex.
Now that one has finished with the upper cranial nerves, one can move on to the mouth, airway, and swallowing apparatus.
The Yankeur sucker is used to probe the posterior pharynx, on both sides. A gag reaction should result from this.
This collectively tests CN X and IX.
While on the subject of CN X, one may test the cough reflex by suctioning the trachea.
This tests CN X.
This is also a convenient time to ask about the volume and character of the secretions.
The conscious patient is asked to protrude their tongue, and move it from side to side.
This tests CN XII.
The uvula deviates away from the lesion.
This tests CN X and IX.
The conscious patient is asked to shrug their shoulders against resistance.
This tests CN XI.
During the cranial nerve examination, one will inevitably end up tripping over the endotracheal tube. One should note whether there is anything unusual there; for instance, is there a dual-lumen tube, or a bronchial blocker?
One puts both their hands on the chest to assess the symmetry of chest expansion.
During this part of the examination, one should make a point of looking for rib fractures. These will affect ventilator weaning, and are an important factor to mention when discussing the long-term outlook.
One might wish to percuss the chest.
Changes in percussion resonance may be worth commenting on.
One may begin by auscultating the apices anteriorly. Then, one should auscultate as posteriorly as possible. The money is in the bases.
Specifically, one is looking for evidence of pneumothorax or aspiration pneumonia, both of which may be complicating recovery from this arrest.
The clever candidate will make a big show of palpating both the apex and the right sternal edge.
One should auscultate in the following sequence:
The various clicks and murmurs one encounters are discussed elsewhere.
For this, one should ask to lay the patient flat.
The pelvic content would have been palpated during the abdominal examination.
The more important part of this examination is the groin.
At this stage, the patient should be re-draped - cover them from the waist up, and uncover their legs.
Observation and palpation of the pelvis:
Examination of the lines
Examination of the genitals and rectum
Once one is finished with the pelvis, one should cover it again, so that only the legs are sticking out.
One should ask to remove TEDs and compression stockings.
Leg muscle tone
The best way to test muscle tone is by holding the knee. Roll the knee gently to distract the patient; then try to lift it off the bed. In the presence of increased tone, the leg will remain straight and the whole thing will lift up; with normal or decreased tone, only the knee will bend
In the conscious patient, one might be able to assess whether a gentle calf squeeze produces the characteristic pain which suggests a DVT may be present.
This brings one to the feet, and to the beginning of the neurological examination.
The feet would have already been palpated to assess their temperature, and to look for pitting oedema.
Observation of the feet
One should look specifically for changes suggestive of chronic diabetic foot disease, or chronically poor vascular supply.
Palpation of the feet
This should consist of palpating the dorsalis pedis and posterior tibial pulse.
One should test the Babinsky bilaterally.
One should attempt to assess clonus in both feet.
The conscious post-arrest patient may allow the candidate to perform a proper neurological exam.
However, the patient most likely to be selected for this hot case will likely be in a deep coma.
Power of the muscle groups may be tested in the following sequence:
Now that one is back to the upper limb, one may as well start their reflex tests there.
The reflexes may be tested in the following order:
Ask to see the obs chart. If it is not allowed, ask for the following:
One may also wish do demonstrate an interest in the trends of any sort of advanced haemodynamic monitoring, eg. cardiac index as measured by PAC or PiCCO
One needs to show an interest in the following labs:
One should always ask for the following:
You sometimes want to see the following:
"Mr Bloggs has suffered a cardiac arrest, which was probably caused by [insert clever diagnosis here]."
"I have come to this conclusion on the basis of the following findings: [insert clinical findings here]"
"I would like to confirm my diagnosis with the following investigations: [insert appropriate investigations]"
"The current management issues are as follows: [a brief list of management priorities]"
"I would approach the management of these issues in the following manner: [list of management strategies; it helps to organise this into an A,B,C,D,E approach if one has a complex multisystem problem to manage]"
"Given the current progress, I suspect Mr Bloggs' prognosis is [guarded, very poor, or reasonably good]"
”Mr Bloggs has suffered a cardiac arrest."
"I have been unable to arrive at a specific cause for this on my limited examination." Or: "With the available data, I am unable to make a confident statement about Mr Bloggs' prognosis".
"The possible aetiologies responsible for this arrest could include [list of differentials]"
"I have identified clinical findings which support some of these differentials: namely, [insert list of findings]."
"Furthermore, I note the following organ failures: [list organ problems]."
"In order to aid prognostication, I would like to perform the following investigations: [list of investigations]"
"In view of the organ system dysfunction, I would offer the following supportive therapies:[list of supportive measures]"
"Additionally, I would like to enlist the help of the following specialties [insert list of consults], for whom I will have the following specific requests/questions: [what questions will you ask these specialist teams]"