Scenario: A 51 year old man is transferred to Intensive Care from the Emergency Medicine Department. He had been struck by a car while riding a motor bike. He was hypotensive on arrival in Emergency (systolic 70 mm Hg) but became normotensive after 1L crystalloid. He has not been intubated and is breathing supplemental oxygen.
Examination and extensive imaging have revealed the following injuries:
• Closed head injury. GCS 12 on scene and now 15. CT head shows L occipital contusions, intraventricular and subarachnoid blood. CT cervical spine normal. Thoraco-lumbar spine plain films show no fracture or malalignment.
• Closed fracture R humerus and R radial head.
• Bilateral rib fractures, R haemopneumothorax, small L haemothorax and R pulmonary contusions.
• Splenic injury with small amount of free fluid.
• Bilateral renal contusions.
An arterial line has been inserted. There is an indwelling urinary catheter, and he is passing 80 mL/hr of lightly blood-stained urine. A right-sided intercostal catheter has been inserted and is swinging, draining small amounts of blood stained fluid, but not bubbling. The surgeons have elected to manage the splenic injury non-operatively.
Introductory question: What factors do you consider when deciding whether to intubate and ventilate?
Ten out of twenty-eight candidates passed this section.
Disclaimer: the viva stem above may be an original CICM stem, acquired from their publicly available past papers. Or, perhaps it is a slightly altered version of the original CICM stem. Or, it is a completely original viva stem, concocted by the monstrously amoral author of Deranged Physiology for nothing more than his own personal amusement. In either case, because the college do not make the main viva text or marking criteria available, almost everything here has been confabulated. It might sound like a plausible viva and it could be used for the purpose of practice, but all should be aware that it does not represent the "true" canonical CICM viva station.