2006, Paper 2 Vivas

Joanne, 60 years old, was admitted to intensive care with severe community acquired pneumonia. After several days of instability, she began to improve. Her only daughter, Mary kept a vigil at her side, sleeping in the waiting room overnight. On day 5, Joanne woke up and communicated with daughter. Mary decided to go home for a rest. While she was gone, during a dose change in noradrenaline, from 6.0 to 5.0 mcg/min, an error was made. The decimal point was omitted and Joanne was commenced on 50 mcg/min of noradrenaline. Soon after, she went into ventricular fibrillation and was not able to be resuscitated. The dose error was 
discovered late in the cardiac arrest. Mary has been rung by the nursing staff and asked to come back urgently to the hospital. She does not know that her mother has died. Please explain what has occurred and answer her questions as best you can. 

Chest X-Rays: 

XRays included those with findings suggestive of hyperinflation and COPD, massive pleural effusion, hilar mass with upper lobe collapse and those featuring a number of artefacts (CV catheter, PA catheter, IABP etc)

CT scans 

CTs included those with free gas in the abdomen in the setting of trauma, pancreatic syst and pancreatic calcification, subdural hematoma with midline shift in the setting of trauma and a reconstruction of a neck CT showing C6 displacement on C5

Equipment station 

Displayed pieces of equipment included Medical Air pressure regulator, Ayre's T-piece, PF 95 duck billed mask and a temperature probe.

Procedure Station 

The procedure which was examined was insertion of a transvenous pacemaker. The indications for, principles of pacemaker insertion and testing for sensitivity and thresholds and complications were examined.

Monitoring station 

This focussed on ICP monitoring. A scenario of traumatic brain injury (TBI) was provided. Candidates were expected to identify an EVD, discuss indications for ICP monitoring in TBI, discuss principles of measurement of ICP ( zeroing, reference level etc) . The scenario also went into discussion of a blocked drain (because of ventricular collapse – CT provided) and its management.

Clinical Case history 1 

This focussed on principles of antibiotic management of staph aureus bacteremia and Gram negative sepsis.

This focussed on a paediatric trauma scenario and involved interpretation of CT abdomen (hepatic and renal laceration) and abnormal biochemistry and blood gases.

A previously well 27 year old woman has been admitted to ICU following an appendectomy for a perforated appendix. Her Pulse is 130/min, BP 65/30 despite six litres of crystalloid resuscitation. Her SpO2 is 90% on FIO2 of 0.7, PEEP 10 cm H2O, SIMV. A noradrenaline infusion is being drawn up. 

Would you give steroids to this patient? 

Focus of discussion: Evidence base for using steroids in sepsis and other critical care illnesses – ARDS, TBI, Spinal injury