2014, Paper 2 Vivas

You are the Consultant Intensivist in charge for the day with a new registrar in their first week working in ICU. You are called about a 53-year-old man with hypotension 30 minutes after elective admission post coronary artery bypass grafts and mitral valve repair. He had an acute myocardial infarction 4 weeks ago; his pre-operative echo showed moderate left ventricular dysfunction and moderate to severe mitral regurgitation. His blood pressure is now 70/45 and the registrar requests your
immediate help at the bedside.

Describe your management approach to this problem, including the major differential diagnoses you would consider.

(I have changed the script somewhat to more closely reflect the logical approach to an unstable post-op cardiac patient)

(Cardiothoracic Intensive Care) - Pass rate ; highest mark .

Management of raised intracranial pressure and osmotherapy in detail

(Neurology and Neurosurgery) - Pass rate ; highest mark .

 58-year-old morbidly obese woman is admitted to your ICU following an out of hospital cardiac arrest. The arrest was witnessed and bystander CPR was provided immediately and continued for 20 minutes until Ambulance arrival. The initial rhythm was VT and she had a single DC shock with return of spontaneous circulation.

She was making non-purposeful movements in the ED prior to being anaesthetised, intubated and sent to cardiac cath lab. She returns to the ICU with vitals; HR 90 bpm SR, BP 95/55, temperature 37.8.

Outline your initial assessment.

(Cardiac Arrest and Resuscitation) - Pass rate ; highest mark .

You are taking over the care of a long-term patient in your Intensive Care Unit whom you have not previously treated.

The patient is a previously well 72-year-old female with an admission diagnosis of Guillain-Barre syndrome. She has been an inpatient in your unit for the last three months, and has suffered numerous complications during her stay, but is now reported to be clinically stable. She has a tracheostomy in situ and is awake and responsive, but remains ventilator dependant.

You are taking over the care of this patient for the first time. Outline your approach and how you would assess her.

(Miscellaneous Topics) - Pass rate ; highest mark .

A 45 year-old man post-attempted hanging was found 4 days ago by his family in cardiac arrest. His initial rhythm was asystole. He received 45 minutes of cardiopulmonary resuscitation before return of spontaneous circulation.

Past history includes previous suicide attempts, moderate alcohol intake, hypertension and multiple skin cancer excisions.
At present his pupils are fixed and dilated and corneal reflex is absent. He is breathing spontaneously and has a cough reflex.

He initially had myoclonus but now only extends to pain. He has not had any sedation for 72 hours. He is on 0.2mcg/Kg/min noradrenaline for BP support and does not have any other overt organ failure.

His CT scan done 24 hours earlier shows loss of grey-white matter differentiation and bilateral thalamic infarcts.

Can you outline the important information about this man’s cardiac arrest and why?

(Cardiac Arrest and Resuscitation) - Pass rate ; highest mark .

You have been asked to assist with the intubation of a patient with respiratory failure related to influenza infection.

What are the infection control measures that you and the nursing staff need to take for this patient in this situation?

(The viva then evolved into an exhibition of correct PPE attire use) 

(Equipment and Procedures) - Pass rate ; highest mark .

Consisted of 5 plain X-ray images and 3 CT scans for interpretation.

(Radiology) - Pass rate ; highest mark .

You have just started your week on duty as the consultant. On handover you have been advised that the family representative is coming in for a discussion today about George. George is a 67-year-old man, day 7 after resuscitation following an unwitnessed cardiac arrest. He has had no sedation for 3 days, has a Glasgow Coma Score of 3, unresponsive pupils and a weak cough. CT scan of head shows evidence of diffuse hypoxic brain injury. George is also on high levels of respiratory support due to concomitant aspiration pneumonia.

The family has been unwilling to accept his poor prognosis. They have made it clear that he is to
have all active treatment, including CPR in the event of an arrest, as George would want "everything” done.

This morning he is looking increasingly unstable with worsening hypoxia.

The family spokesperson has arrived and is waiting to talk to you.

(Communication and Ethics) - Pass rate ; highest mark .