A free online resource for Intensive Care Medicine.
An unofficial Fellowship Exam (CICM Part 2) preparation resource.
Deranged Physiologyis a slowly growing archive of discussions and study notes relevant (or if not relevant, then at least interesting) to the practice of intensive care medicine. The content provides an introduction to the fundamental themes in intensive care: mechanical ventilation, vasopressors, electrolyte management, hemodynamic monitoring, dialysis, and so forth. Attention is directed at equipment in intensive care, and there are attempts to revisit interesting pharmacology and physiology. The aim of this resource is to supplement the bedside teaching of senior staff, and to consolidate resources for intensive care trainees in the initial stages of their training.
This appeared in Question 18.1 from the first paper of 2008. The cylinders, according to a reputable source, can withstand a pressure of 24,000 kPa, but normally rest at around 12,000-17,000 (that is the "green zone" on the gauge). The standard (mandatory) wall gas pressure is 415 kPa (about 4 atmospheres). For the gas which powers surgical tools, the pressure is 1400 kPa.
This thing was asked about in Question 6.3 from the second paper of 2009. The main distinguishing feature of this device is the tube which has a curved portion and a straight portion, which allows the flange to be adjusted to the appropriate pretracheal tissue thickness. One can therefore use this tracheostomy tube for patients with all sorts of unattractive fat neck anatomy.
This rarely seen item was used as a visual prop in Question 24.1 from the second paper of 2012. The candidates weren't expected to recognise it- the examiners were more interested in its uses, advantages and disadvantages.
The cuff pilot balloon is one of the safety features of the ETT, which has received some attention from the examiners. More on this topic is written elsewhere. Suffice to say, this little bubble is a goldmine of information; however, paradoxically, what it doesn't tell you is the cuff pressure. Ample evidence exists to suggest that senior anaesthetists, veteran ED doctors and practicing paramedics can neither generate nor estimate cuff pressures using the pilot balloon.
This device has never appeared in the CICM Fellowship exam as a written paper question (at least not since the year 2000). However, it is ubiquitous enought to merit some attention. Certainly, the NSW Health policy authors think so; they have dedicated a 43 page document to the art and science of tracheal suctioning.
Apart from being a ubiquitous part of the ICU househould, the ETT seems to be a regular favourite of the CICM examiners. Its features are frequently asked about in the written papers and the vivas. One example of this is Question 30.1 from the second paper of 2013, "List six design features of a standard endotracheal tube which improve its safety". Another question (Question 28.2 from the first paper of 2011) asks about the above-cuff suction port. Question 18.2 from the first paper of 2008 also asks the candidate to estimate a paediatric tube size. This is a brief exam-oriented summary, shaved down to naked point form. A more indepth discussion of the ETT is available in the massive and excessively detailed chapter dedicated to this device.
Question 1 from the second paper of 2005 asks the candidate to describe this anatomy: " Describe the anatomy of the tracheobronchial tree, as seen down a bronchoscope inserted via an endotracheal tube."
LITFL go into considerable detail with the fiberoptic bronchoscope. From CICM, Question 5 from the second paper of 2009 addresses the problem of safely performing a bronchoscopy in an infectious patient. The major points are detailed in the discussed answer to that question.
LITFL go into considerable detail with this item. From CICM, there are a couple of bronchoscopy questions: Question 1 from the second paper of 2005 (anatomy of the bronchial tree), and Question 5 from the second paper of 2009 (safety of bronchoscopy in an infectious patient).
Determinants of cardiac output and methods of its measurement were asked about in Question 2a, Question 2b and Question 2c from the second paper of 2000. Subsequent years have not brought any further questions of this sort. A brief survey of primary exam candidates has revealed that questions like this have submerged into the CICM Part I repertoir of vivas.
In 2003, the CICM candidates were asked to "Compare and contrast the roles of the pulmonary artery catheter and transoesophageal echocardiography in the management of the critically ill patient with shock." This question has never appeared again, perhaps because the majority (91%) of the candidates were able to pass this question. The answer to that SAQ (Question 5 from the second paper of 2003) is presented below with little modification.