Table of Contents

Positive pressure ventilation affects preload, afterload and ventricular compliance. The net effect in most situations is a decrease in cardiac output. However, the effect may be beneficial in the context of decompensated heart failure, where the decreased preload and afterload result in a return to a more productive part of the Starling curve. In this rests the chief benefit of CPAP in the management of acute pulmonary oedema.

Frequently, the college will put some sort of horrible LFT picture up for the candidates and ask them to make sense of it. The general trend of questions seems to be coma, flavoured with a recent history of discharge from an alcohol rehab institution of some sort. There is one specific question which is frequently repeated where the ammonia is also elevated, and the LFTs are raised in a non-specific pattern. Give six differentials, they usually ask.

Status epilepticus has been asked about in  Question 16 from the second paper of 2014, where it was presented wrapped in a case of subarachnoid haemorrhage. Specifically, the college wanted a demonstration of an escalating "ladder of management", as well as drug doses, strategies for weaning sedation, and some opinion about prognosis (which probably has more to do with the subarachnoid haemorrhage than with the seizures). Other questions on this topic have included Question 22 from the second paper of 2005.

This is all about generating a broad range of differentials. One's assessment of the unconscious patient searches for focal neurological signs and meningism. If these are absent, one is left looking for subtle clues in the examination which may explain the decreased level of consciousness. Apart from our very own Oh's Manual, one may also examine an excellent article by David E Bateman from 2001, which details the neurological assessment of coma. A suggested pattern of examination for the unconscious patient in the CICM exam is available elsewhere.

Frequently, the college will present the candidate with some of this information; eg. "this is a Gram-negative rod in the anaerobic bottle. What could it be?" Thus, the SAQ becomes a game of "Name That Microbe". The table below lists selected organisms which for whatever reason seemed to be of interest. Needless to say, the list is not definitive.

Though a distinction is being made between diabetic ketoacidosis and HONK, the two really form a part of the same disease spectrum. Some ketoacidosis is present in HONK, and some hyperosmolarity is present in DKA. However, different mechanisms are at play. HONK is distinct form DKA, and the distinction is not entirely arbitrary, at least from the management point of view. For instance, even though the conditions co-exist 30% of the time, it is possible to treat pure HONK without any supplemental insulin (because there is a satisfactory amount of it in circulation already).DKA is 3 times more common, but HONK has 3 times greater mortality. The chapter on DKA presents a table of discriminating features to help distinguish HONK from DKA.

Positioned on the end of the ETT, the capnograph should be able to pick up the expired carbon dioxide (EtCO₂ ) in whatever  gas happens to be wafting past it, and this concentration is recorded on a graph. This is plotted as a very useful waveform. The pattern of CO₂ concentration over time has features which give us some information about the gas movement in the airways and in the alveoli. These features, though they have no standardised names, are well recognised, and sometimes crop up in the fellowship exams as questions demanding certain waveforms to be graphed.

LITFL has an excellent synopsis of the current BTF guidelines, which is a well-referenced revision resource. The BTF guidelines also form the basis of the summary detailed below.  An extensive rambling discussion of these recommendations is also available at the end of this chapter, but it  has diminished relevance in the context of pre-exam panic. Links to discussions with greater detail are made available for those who are interested. Specific SAQs interrogating this topic consist of Question 15 from the first paper of 2013; however there are numerous questions which inidrectly address this issue by asking about the management of raised intracranial pressure.

The college loves to include "define this" or "calculate that" questions in the exam paper, largely because the definitions of statistics terminology are usually quite fixed, not open to interpretation, and therefore easy to grade (i.e. you either get zero or you get full marks). The only exception was the ancient Question 2b from the first paper of 2001, which asked  "What is the relevance of Evidence Based Medicine to your patients and how will you apply this?" which is equivalent to asking a high school English class to write essays on the topic of "What does freedom mean to me?". Fortunately, this sort of thing has not been seen for a while. Even raw definitions of such pleb items as sensitivity and specificity have not been seen since about 2008 (i.e they disappeared around the same time as the CICM Part I appeared on the scene; this primary exam then seems to have absorbed many of the EBM definition questions). These days, Part II tends to feature "fellow-level" questions about interpreting funnel plots and examining meta-analysis articles for validity.

These equations are important, because the questions upon which they are bases are rather binary. Either you get it right, in which case you get full marks, or you get it wrong, in which case you get nothing. This is an important concept to internalise, as there is nothing better than easy marks earned by the mindless rote-learning of equations. Commit these equations to memory. Ideally, on the day before the exam. This part of the training program has the poorest cortical retention rate; one must walk to the written Part II venue very slowly and carefully so that this information doesn't fall out on the way from the train station.

Therapeutic and prophylactic hypothermia are effective methods of controlling number-induced panic in the depressing setting of severe traumatic brain injury. To some extent ICP is regulated by the cerebral metabolic rate, and metabolic rate is affected by temperature: ergo, with the reduction of temperature one should be able to reduce the ICP. There are also seductive theoretical benefits, suspected influence on the cellular damage, inflammation,  oxidative injury, etc. More importantly, the intensivist feels better. With control of temperature comes a reduction in the ICP, and the anxiety-provoking monitor begins to display more pleasing values. Also, the use of muscle relaxant to reduce shivering has a calming effect on the nursing staff (a paralysed sedated patient is easy to look after). However, there may be no benefit in this technique as far as patient-centered outcomes are concerned