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Core Topics in ICU
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CICM Part II Revision Notes and SAQs
CICM Part II Past Papers
Recently Updated Questions
Question 1 - 2017, Paper 2 SAQs;
Snake bite envenomation - a brown snake, probably Pseudonaja textilis
Question 26.1 - 2016, Paper 1 SAQs;
Another game of "Name That ECG Abnormality"- WPW, this time in AF
Question 15.3 - 2017, Paper 2 SAQs;
ECG (WPW)
Question 28.1 - 2008, Paper 2 SAQs;
Clinical testing for brain death: preconditions for the diagnosis of brain death
Question 12.1 - 2010, Paper 2 SAQs;
Clinical testing for brain death: preconditions for clinical testing
Recently Updated Material
Response to 1L of Hartmann's compound sodium lactate
Thursday, February 25 (2021);
These are the physiological effects of infusing one litre of Hartmann's compound sodium lactate into a patient.
The use of albumin in critical illness
Wednesday, February 24 (2021); Electrolytes and Fluids
Question 25 from the first paper of 2010 and the near-identical Question 5 from the second paper of 2004 both asked the candidate to "critically evaluate the use of albumin" in critically ill patients. Judging by the college answers, these questions were not after an indepth dissction of outcomes literature. Rather, they may be better worded as "how many legitimate uses of albumin can you think of?"
Measurement of dead space
Wednesday, February 24 (2021); Respiratory system
It is possible to measure anatomical dead space and physiological dead space; alveolar dead space can then be determined by subtracting the first from the second. Physiological dead space can be measured using the Bohr-Enghoff method, using either alveolar CO2 (Bohr version) or arterial CO2 (Enghoff modification) to determine the ratio of exhaled CO2 concentration to PACO2 or PaCO2. The anatomical dead space can be determined using the Fowler method, which involves using a single breath of 100% oxygen to displace all the nitrogen from the anatomical dead space.
Wolff- Parkinson-White syndrome
Tuesday, February 23 (2021); Cardiology
Wolff-Parkinson-White syndrome is a relatively common preexcitation syndrome which has appeared multiple times in the Second Part CICM exam. Its appearances are usually of the same basic format. The trainees are usually posed with an ECG which bears a characteristic delta wave, and then asked to comment on the management of a tachyarrhythmia. The ECG interpretation is usually worth very few marks, because it is a boring exercise in pattern recognition for a very obvious pattern. The real test of character is in the decisionmaking around antiarrhythmic choice, when trying to address an acute SVT in these patients. As should become apparent from the discussion below, this is far from straightforward, as there does not appear to be any consistency in expert recommendations for best practice, nor in the college examiner comments.
Abnormal processes of cardiac excitation and electrical activity
Tuesday, February 23 (2021); Cardiovascular system
Abnormal cardiac excitation can be classified as automatic or triggered. Abnormal automaticity is the spontaneous generation of action potentials in excitable cardiac tissues which are usually not expected to act as pacemakers (eg. Purkinje cells). Early afterdepolarisations are triggered depolarisations which occur during Phase 3, and which are promoted by anything which prolongs the repolarisation. Late afterdepolarisations are triggered depolarisations which occur during Phase 4, and which are promoted by anything that might increase the intracellular calcium.
Clinical testing for brain death
Saturday, February 20 (2021); Cardiac Arrest and Resuscitation
Clinical testing for brain death is a favourite topic of the examiners. It frequently comes up in the SAQs and vivas. The most "examinable" aspects are the preconditions to testing, the precise sequence of testing, which cranial nerves are involved, and the expected findings of the apnoea test. Again, the ANZIC statement on Brain Death and Organ Donation is my primary resource for this summary. At the time of writing, the recent edition is Version 3.2 (2013).
Indications for intracranial pressure monitoring
Saturday, February 20 (2021); Neurology and Neurosurgery
Under which circumstances must one be so interested in intracranial pressure, so as to introduce things into the patient's skull? This question, in a variety of permutations, is a College favourite. For instance, it has recently appeared in Question 27 of the first paper of 2014, less recently in Question 16 of the first paper of 2009, and Question 27.2 from the first paper of 2008. The advantages and disadvantages of various ICP monitoring techniques are discussed elsewhere; this is the chapter which debates the very need for something like this.
Anatomy of the temporary pacemaker circuit
Saturday, February 20 (2021); Cardiothoracic Intensive Care
These are the circuit of an externalised artificial cardiac conduction system. The difference between these systems is mainly impedance, and the amount of required current. A bipolar circuit has both the electrode inside the heart, with the heart muscle and intraventricular blood completing the circuit. A unipolar circuit on the other hand relies on a large amount of tissue and body fluid to complete the circuit, and therefore has a much higher impedance. In the majority of situations these days the bipolar circuit is favoured. There is much less electrical interference and substantially less current is required.
Amiodarone
Sunday, February 14 (2021); Cardiovascular system
Amiodarone is a Class III antiarrhythmic with Class I, Class II and Class IV effects. Given acutely as an infusion, it mainly acts as a beta-blocker and calcium channel blocker, increasing the refractory period of the AV node and therefore counteracting supraventricular tachycardias. Prolonged therapy reveals more of a Class I and Class III effect, which decreases the velocity of action potential propagation and decreases the risk of reentry from ectopic minipacemakers. Amiodarone has uniquely tenacious pharmacokinetics, is extensively tissue bound, and has a half life measured in tens of days. ,/p>
Preload and fluid responsiveness in the post-bypass patient
Sunday, February 14 (2021); Cardiothoracic Intensive Care
The question, as always, is "can I give this guy more fluid?" For any given patient, there will be some sort of unique and magical volume which represents their ideal ventricular filling volume. Achieving this ideal volume results in the greatest contractility improvement and the highest cardiac output for this specific patient.
Classification of antiarrhythmic agents
Sunday, February 14 (2021); Cardiovascular system
The Vaughan Williams classification of antiarrhythmic agents divides these drugs into four main classes according to the mechanism of antiarrhythmic effect. Class I are the sodium channel blockers, Class II are the beta-blockers, Class III block potassium channels and Class IV are calcium channel antagonists. Many agents fall into multiple classes, and some agents (eg. amiodarone) exhibit activity from each class.
Synergy and toxicity in antiarrhythmic polypharmacy
Sunday, February 14 (2021); Pharmacology and Toxicology
In the CICM part II exam, this does not come up nearly as often as it does in real life. Specifically, Question 2 from the first paper of 2017 had presented the candidates with an ECG of a patient suffering from complete heart block after being dosed with both sotalol and verapamil. It was given to her by well-meaning radiology technicians who just wanted to get some nice CT images of her coronaries. The more conventional scenario for this is a patient being treated for refractory rapid atrial fibrillation, who ends up on multiple agents and becomes haemodynamically unstable from complete heart block. The college have only ever explored this in the context of a CCB/β-B cocktail, and so the majority of this chapter will be dedicated to this specific problem, and its management. Other more exotic combinations make for an interesting digression, but do not form a part of core CICM exam preparation, and can be safely ignored forever.
Quantal dose-response curves
Friday, February 12 (2021); Pharmacodynamics
This chapter is related to one of the aims of Section C(i) from the 2017 CICM Primary Syllabus, which expects the exam candidate to "define and explain dose-effect relationships of drugs, including dose-response curves with reference to... graded and quantal response".
Approach to the haemodynamically unstable cardiac surgical patient
Friday, February 12 (2021); Cardiothoracic Intensive Care
There is an important subset of cardiothoracic ICU-related CICM SAQs which interrogate the candidate's understanding of life-threatenening post-CABG complications. They are frequently repeated. This was supposed to be a condensed revision of Ruesch and Levy's chapter on the practical aspects of post-op care for an unstable cardiothoracic surgical patient. That chapter, and the entire book, can be found here - thanks to the good people of tele.med.ru. Unfortunately, this summary is in advanced stages of apocryphal bloat. The discerning reader is advised to return to the original documents for a dose of clarity and brevity.