Table of Contents

There are unique problems associated with auscultating these subtle noises in the chest of a mechanically ventilated patient. How can you hear anything in there, one might ask, what with the wind howling through the ventilator tubing, and the rhythmic doof-doof of the balloon pump? I suppose one can make one's life rather easier by turning the ventilator rate to 1 per minute, turning the PEEP down to zero, and pausing the pump for a few seconds.

This is where the money is, as far as the ICU cranial nerve examination is concerned. Unfortunately, this important topic has only come up once in the last 15 years - Question 5 from the first paper of 2007 asked about pupil reactivity and diameter in the context of coma.The eyes, the poets say, are the windows to the soul. To the unpoetic intensivist, they are more like keyholes into the dressing room of the upper brainstem, and barometers of intracranial pressure.  Rather than escaping into comforting familiarity of well-known examination medicine textbooks, I will instead refer to a more ancient and venerable "Clinical Methods: The History, Physical, and Laboratory Examinations (3rd edition)" - specifically Chapter 58, by Rober H Spector. Unlike the crisp and clean interior of Talley and O'Connor, this hoary incunabula is overgrown with trailing fronds of references, featuring obscure and apocryphal authors, and discussing rare and extinct physical findings.

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.

Infective endocarditis featured in Question 21 from the first paper of 2008. The question, apart from interrogating the candidate's knowledge of the manifestations of endocarditis, also ventures into cardiothoracic territory by asking about the indications for urgent valve replacement. The college also mentioned IE briefly in Question 29.1 from the second paper of 2014, where they wanted to know which non-murmur clinical signs are normally associated with it.

Open disclosure is a hot and sexy topic for CICM examiners, as it ends up being an important part of the role of the intensivist. We tend to see many complications from other specialties, and we tend to perform many procedures with a high risk of complications. Our trainees are variably supervised and variably trained, giving rise to situations such as those in Question 28 from the second paper of 2014 or Question 18 from the second paper of 2010. Both SAQs concern a situation where one needs to counsel a junior trainee who caused a lifethreatening complication. 

Many past paper SAQs have asked the candidates to identify some rash, pupuric blotching, gangrenous embolic phenomena or some other visually impressive manifestation of disease. Irritatingly, the college examiners tend to remove these images from their published papers, presumably because they plan to reuse them. Previous questions of this sort have included Question 25.1  from the first paper of 2011 (erythema multiforme), Question 20.2  from the second paper of 2008 (Stevens-Johnson syndrome) and Question 10 from the first paper of 2005 (Toxic Epidermal Necrolysis). Question 15.1 from the second paper of 2012 was more about the non-specific approach to the evaluation of a gross whole-body rash. This approach is discussed below.

Heart failure management is a massive daunting topic. In order to approach this in a systematic manner, I have separated the problems of heart failure into the variables which govern cardiac output, and the means of manipulating those variables. The approach resembles that of the similar chapter from the section on cardiothoracic intensive care. The definitive resource for this is probably this 2013 guideline statement by the AHA/ACC. Unless otherwise reported, it is my source for most of the information below. For the sane exam candidate who may be disinclined to read the entire fifty-page document,  of particular interest may be Section 7.3.2,  Pharmacological Treatment for Stage C HFrEF.

Right heart failure and pulmonary hypertension for some reason occupy such a dominant position among the SAQs on heart failure in the CICM Fellowship exam that the time-poor trainee may be forgiven for completely neglecting the left chambers of the heart, as something unlikely to be examined. The prevalence of this disease state in the past papers is of course completely divorced from its prevalence in the community. Though it is seen in perhaps 18-21% of heart failure cases, it is the focus of approximately 80% of the CICM past paper SAQs on the topic of heart failure, and so much like the focus on fat embolism and medical gas supply testing likely represents a form of construct misalignment (i.e where the assessment is designed in a way which cannot possibly address the intended learning outcomes of the curriculum). 

Question 21.2 from the first  paper of 2014  and the identical Question 9.1 from the first  paper of 2011 asked the candidates to interpret some formal pulmonary function tests, complete with fancy carbon monoxide diffusion values and faintly remembered variables from that annoying respiratory volumes diagram. An excellent overview of this can be found in a 2005 article by Pellegrino et al.

Removing some of the skull is a neat way of cheating the Monro-Kellie doctrine. Pity it does you no favours.   LITFL have an excellent page devoted to this practice. Additionally, an article directed at neurosurgeons is available and it highlights all the important features.  Decompressive craniectomy (not specifically in TBI) was the subject of in Question 9 from the first paper of 2009, and its use in malignant MCA infarction appeared in  Question 2 from the second paper of 2014.

Given that this is a common and practical ICU problem, the college have wisely included it among their SAQs - Question 10  from the second paper of 2008 asks the candidate to "Outline  and justify your approach to “clearing” the cervical spine in an adult multi-trauma patient with a severe closed head injury". Other similar SAQs include Question 11 from the second paper of 2013 and Question 4 from the second paper of 2011. College answers to their own question are cut-and-pasted from The Alfred official evidence-based C-spine clearance protocol (2009).