A 55-year-old female with no reported comorbid conditions has been admitted unexpectedly to your tertiary intensive care unit from the operating theatre. She had an uneventful general anaesthetic for a total hip replacement.
Forty-five minutes later, she was found unrousable by the attending nurse. An arterial blood gas showed the following:
Parameter |
Patient Value |
Normal Adult Range |
pH |
7.01 |
7.35 – 7.45 |
PaCO2 |
110 mmHg (14.5 kPa) |
35 – 45 (4.6 – 6.0) |
PaO2 |
100 mmHg (13.1 kPa) (15 L/min oxygen via non-rebreather mask) |
|
Base excess |
+2 mmol/L |
-2 – +2 |
Lactate |
1.1 mmol/L |
< 1.5 |
She was urgently reintubated and transferred to your ICU. She is hemodynamically stable.
This is taken from the chapter on hypercapnoea
Decreased minute ventilation |
Central nervous system
Neuromuscular
Respiratory
Metabolic, endocrine and environmental
|
Increased dead space |
Increased anatomical dead space
Increased alveolar dead space (i.e. ventilated but not perfused)
|
Increased CO2 production |
Increased metabolic rate
|
Observation:
Start with the hands.
Axillae and neck
Face and cranial nerves
Chest
Abdomen
Lower limbs
A massive list of differentials can be generated.
Ideally, the trainee will organise these in groups, or at least in some sort of order where they start centrally and move peripherally.
A suggested list of differentials:
Clinical setting
Motor weakness
Sensory loss
Reflexes
Cranial nerve involvement
Features expected of myopathy:
Also...
Emergent crisis management:
Maintenance
Specific management
This comes from the excellent article by Abel and Eisenkraft (2002)
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.
Chapter 57 (pp. 617) Neuromuscular diseases in intensive care by George Skowronski and Manoj K Saxena
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