2011, Paper 2 Vivas

A 69-year-old man has been ventilated for an infective exacerbation of chronic obstructive pulmonary disease (COPD). His ICU course has been complicated by septic shock and acute kidney injury that required renal replacement therapy. His therapy has included steroids and an aminoglycoside in addition to other standard care for his COPD.

12 days later neurological examination off sedation reveals spontaneous eye opening, obeying of commands, and normal cranial nerves. Motor examination of the limbs reveals symmetric reduction in tone and tendon reflexes with moderate to severe weakness. Plantar responses are equivocal. Sensory examination is normal. Examination of the chest and recent CXR are both unremarkable. He remains intubated with a spontaneous mode of ventilation (Pressure Support of 15, PEEP 7, FiO2 0.35). Attempts to wean pressure support have been poorly tolerated. Other vital signs and organ function remain stable.

1.   List the differential diagnoses for his weakness and explain your reasoning.

The rest of the viva focussed on the diagnosis and management of critical illness neuromyopathy

In this viva, the focus of the question will be on Evidence Based Medicine

Please read this modified abstract of a study recently published in the New England Journal of Medicine

Decompressive Craniectomy in Diffuse Traumatic Brain Injury

Background

It is unclear whether decompressive craniectomy improves the functional outcome in patients with severe traumatic brain injury and refractory raised intracranial pressure.

Methods

Of 3478 patients screened, we randomly assigned 155 adults with severe diffuse traumatic brain injury and intracranial hypertension that was refractory to first-tier therapies to undergo either decompressive craniectomy or standard care. Intracranial hypertension was defined in the study as an increase in intracranial pressure above 20 mm Hg for more than 15 minutes. Patients with intracranial mass lesions were excluded from the study.

Results

(Research and Evidence-Based Practice) - Pass rate ; highest mark .

You are asked to review an 88-year-old man who has fallen from a ladder. He is in the ED with a large subdural haematoma (SDH) and significant mid-line shift. His GCS is 6/15. He has a past medical history that includes ischaemic heart disease (CABG in 2008), chronic airflow limitation (inhaled bronchodilators and oral steroids), atrial fibrillation (warfarin and digoxin), chronic renal impairment (creatinine 190umol/L), non-insulin-dependent diabetes and mild memory impairment.

1.   What are the factors in this patient’s story that suggest his outcome might be poor?

The rest of the viva focussed on severity scoring and the management of the elderly critically ill patient

Massive variceal haemorrhage and the Sengstaken-Blakemore tube

Central line cultures, CLAB and infective endocarditis

Candidates were asked to comment on chest X-rays, head and abdominal CT scans

You are asked to speak to the parent of a 21-year-old male, Kevin Smith, who was readmitted to your ICU last night. He was originally admitted to your ICU with a severe traumatic brain injury 4 months ago. He had aggressive treatment including a decompressive craniectomy. He was discharged from your ICU with severe neurological deficits.

He has been on a rehabilitation ward for the last 2 months, making a slow recovery. His treating team believe that he still has the potential to make a reasonable neurological recovery, although he currently remains severely neurologically impaired. He was readmitted to ICU last night with pneumonia requiring invasive mechanical ventilation.

The nursing staff informs you that his parent wants to speak to you.

You are called to review a 56 yr old 120 kg lady who has been admitted with a community acquired pneumonia . She is on 50% O2 ,on a CPAP of 10cm H2O with an SaO2 of 90% and has a respiratory rate of 35bpm. You have decided to intubate and ventilate this lady.

1. Please list the equipment that you require to assist you in this intubation.

The rest of the viva focused on airway management.