Clinical Cases in Critical Care

✍ Scribed by Alice Myers, Theophilus Samuels

• Publisher: Wiley-Blackwell
• Year: 2022
• Tongue: English
• Leaves: 400
• Edition: 1
• Category: Library

✦ Synopsis

Clinical Cases in Critical Care

In Clinical Cases in Critical Care, the authors explore core clinical topics and basic sciences in a practical and realistic way, and include comprehensive discussions focusing on critically unwell patients with a variety of presentations and underlying disorders, including COVID-19, hypotension, stroke and drug overdose.

Each case begins with a clinical vignette which generates a series of questions the reader must address. Cases are expanded to discuss differential diagnoses, investigations and management issues. Further questions direct the reader to explore relevant clinical and scientific knowledge - similar to the structure of many professional oral examinations. The final section of the book consists of exam style questions in a multiple choice and single best answer style.

Perfect for medical practitioners working in critical care settings, Clinical Cases in Critical Care provides a thorough and accessible reference for trainee physicians with an interest in critical and emergency care, as well as allied health professionals in the field. This engaging textbook will be an essential companion for anyone getting to grips with the foundation of specialist knowledge required by professionals working in intensive care medicine.

✦ Table of Contents

Cover
Title Page
Copyright Page
Contents
Foreword
Author Information
Acknowledgements
List of Abbreviations
Part I Introduction
Section 1 A Brief Introduction to Critical Care
Setting the scene
The ICU and its role within the hospital
Levels of care
Bed capacity
What can be offered in critical care?
Interface with the hospital
The critical care team
Psychological and psychiatric issues in the ICU
Communication
Psychological issues amongst ICU staff
Infection control
Clinical governance and quality assurance
Further reading
Section 2 Intubation of the Critically Unwell Patient
Why?
Why not?
When?
Where?
Who?
How?
Failed intubation
Following intubation
Setting the ventilator
Further reading
Part II The Cases
Case 1 The Patient with Rising Vasopressor Requirements
What is your initial management?
With these results and examination findings, what is the most likely diagnosis?
Which factors may affect the risk of anastomotic leakage?
Describe how focused ultrasonography can be useful in assessing fluid responsiveness
Inferior vena cava (IVC) index
Left ventricle appearance
Presence of A-lines and/or B-lines
Why might focused ultrasonography be difficult in this case?
Which methods can be used to measure cardiac output?
Transpulmonary thermodilution
Transpulmonary lithium dilution
Pulse contour analysis
Echocardiography
Transoesophageal aortic Doppler
Thoracic electrical bioimpedance
Briefly discuss how stroke volume variation (SVV) can be used to predict fluid responsiveness
Describe the changes that occur in stroke volume during passive mechanical ventilation
Describe how SVV can be measured
What are your immediate concerns regarding the transfer of David to the CT suite?
How would you stratify David’s perioperative risk of morbidity and mortality?
Further reading
Case 2 The Patient with Respiratory Distress I
What may be the cause of the problem?
Lower respiratory tract infection
Chronic obstructive pulmonary disease (acute exacerbation)
Asthma
Anaphylaxis
Pneumothorax
Pulmonary oedema
Pulmonary embolus (PE)
Myocardial infarction (MI) or acute cardiac event
Renal impairment or metabolic disturbance
Underlying malignancy
What is your analysis of the situation?
What is the alveolar gas equation and what is its relevance?
What are the types of hypoxia and how can oxygen delivery be increased?
How do you proceed?
What is compliance and why may Geoffrey’s lungs feel stiff, i.e. poorly compliant?
What action do you take?
Does this new information affect your assessment or management of Geoffrey?
Do you want any further investigations or any other specialist review?
How do you interpret these lung function tests?
What is the pathophysiology of right ventricular dysfunction in COPD?
Why extubate straight to NIV?
What is the significance of failed extubation?
What is an SBT?
What are the main issues you would like to raise in the MDT discussion?
How will you document your discussions and communicate your decisions?
Further reading
Case 3 The Patient with Respiratory Distress II
What is Guillain–Barré syndrome?
How does Guillain–Barré usually present?
What is myasthenia gravis (MG)?
What else could cause a similar presentation?
Why is the medical registrar calling you?
How will you assess Jim’s respiratory function?
How do you proceed?
What investigations would you like to perform now and over the next few days in addition to the standard critical care blood panel?
What are the indications, contraindications, and complications regarding lumbar puncture?
Indications
Contraindications
Complications
What is the pathophysiology of GBS?
What are the options for management?
Immunomodulation
Supportive measures
What is the evidence for plasmapheresis as compared with IVIg?
Would your treatment plan differ if this were myasthenia gravis?
Is there an argument to support early tracheostomy in this case?
What are the indications for tracheostomy?
Emergency
Elective
What are the risks of tracheostomy?
Immediate or procedure related
Medium term
Long term
How would you perform a tracheostomy?
Indications and consent
Preparation
Drugs
Equipment
Personnel
Procedure
Postprocedure management
What are the principles behind a respiratory weaning plan?
Who should be involved in Jim’s ongoing care?
What is the likely outcome for Jim?
What post-critical care issues do patients suffer?
Further reading
Case 4 The Patient with Abdominal Pain and Vomiting
What is the likely cause of this endocrine disturbance?
Why do you suspect DKA?
Describe the pathophysiology of DKA
How do you diagnose DKA?
How can the severity of DKA be classified?
Can a patient develop DKA with normal serum blood glucose levels?
Explain why you consider this to be DKA and not a hyperosmolar hyperglycaemic state (HHS)?
How would you calculate and interpret the anion gap for Brian?
What is the AG in this case?
What are the causes for a raised AG?
What are the main treatment goals when managing DKA?
How should insulin be prescribed to treat patients in DKA?
What are the metabolic treatment targets in DKA?
What are the main complications from DKA that would concern you?
When would you consider this episode of DKA to be resolved?
How long would you expect it to take for Brian’s DKA to resolve?
With his previous history of biliary colic, what do you think may be the cause of his severe abdominal pain?
Apart from acute pancreatitis, what other conditions might cause his severe abdominal pain?
What are the causes of acute pancreatitis?
Which biochemical tests could you request for presumed acute pancreatitis?
Which imaging studies can be used in the diagnosis of acute pancreatitis?
Which grading systems are you aware of for acute pancreatitis?
Why is grading the severity of acute pancreatitis useful?
What are the management strategies for patients presenting with acute pancreatitis?
Which complication of acute pancreatitis could this be?
What is necrotising pancreatitis?
How would you diagnose necrotising pancreatitis?
What is the role of surgery in pancreatic necrosis?
What are the long-term outcomes for these patients?
Further reading
Case 5 The Patient Involved in a Road Traffic Collision
What are the goals of the primary survey?
What are the potentially life-threatening conditions associated with these clinical findings and how should each one be managed?
What are the advantages and disadvantages of using focused assessment with sonography in trauma (FAST) versus radiographic imaging?
How might bedside focused lung ultrasonography help identify the cause of Danielle’s deterioration?
What might the effusion suggest and what are the treatment goals?
What are the most common blood groups?
What issues should you consider when transfusing Danielle specifically with regard to blood typing?
What would be your next steps in Danielle's management?
What do you think could be causing this change in her neurological status?
Define the role of an antifibrinolytic agent in traumatic brain injury (TBI)
What is the evidence for cooling in TBI?
For which complications do you need to monitor Danielle over the next 24–48 hours?
What would be your concerns regarding this finding?
How common is BCI?
Which types of trauma-related injuries are associated with BCI?
What are the myocardial patterns of injury associated with BCI?
How would you diagnose and evaluate BCI in this patient?
Further reading
Case 6 The Patient with a Raised Temperature
What might be the cause of her clinical presentation?
Given the history, what do you think is the most likely diagnosis?
Which resources are available in the UK for information and advice on acute intoxications and poisonings?
What are the signs and symptoms usually associated with the use of MDMA?
What are the major patterns of clinical toxicity associated with MDMA overdose?
What is serotonin syndrome?
Which factors may increase the risk of serotonin syndrome?
What is the treatment for serotonin toxicity?
What is neuroleptic malignant syndrome (NMS) and how does it compare to serotonin syndrome?
What is your initial management of Jane’s hyperpyrexia?
What specific medication should you consider for muscular hyperactivity in MDMA overdose?
Which additional biochemical test should you request and what might it demonstrate?
How could her hyperpyrexia be further managed?
What might be the cause of her low serum sodium?
When does rhabdomyolysis occur?
Describe the Kidney Disease Improving Global Outcomes (KDIGO) staging of AKI
How does rhabdomyolysis cause acute kidney injury?
How would you manage the rhabdomyolysis that has occurred?
What are the indications for RRT in critical care?
Has optimal timing been established for when CRRT should be initiated in the critical care patient?
Describe the characteristics that form the basis of RRT
Briefly describe the different methods for delivering RRT
What dose (mL/kg/h) would you prescribe for Jane?
Why are continuous therapies preferred over intermittent therapy in critical care?
What are the disadvantages of continuous RRT therapies in critical care?
What is a Deprivation of Liberty Safeguards (DoLS) order?
How does DoLS apply in intensive care?
Should Jane be referred for DoLS?
Further reading
Case 7 The Patient with Haematemesis
How would you initially assess John?
How might you assess bleeding severity at the bedside?
What primary prophylaxis is available for preventing upper gastrointestinal bleeding (UGIB) in acutely unwell critical care patients?
How useful is the haematocrit at this initial stage?
How can you differentiate clinically between an upper and lower gastrointestinal bleed?
Discuss the potential sources of non-variceal upper gastrointestinal bleeding
What are the options for patients who need to continue NSAIDs after they present with bleeding peptic ulcers?
How could cirrhosis contribute to the development of varices in John?
Describe the Child–Pugh classification of cirrhosis
What do you think is the source of John’s bleeding?
What is the recommended haemoglobin level for transfusion in variceal bleeding?
What is the role of tranexamic acid in acute UGIB?
Describe the treatment options available for variceal bleeding
Non-endoscopic
Endoscopic
What is the role of prophylactic antibiotics in patients with variceal bleeding?
How would you proceed?
How can massive transfusion (MT) be defined?
What are the complications associated with a massive transfusion?
How does this INR result affect the ability to perform endoscopy?
Describe factors that increase the risk of death after hospital admission for acute UGIB
Further reading
Case 8 The Patient Who Is Difficult to Ventilate
What may be causing lack of synchrony with the ventilator?
What is the likely cause of Susan’s chest sepsis?
What is your assessment of the clinical situation?
What is synchronised intermittent mandatory ventilation?
Categorise the available modes of mechanical ventilation
What types of ventilator asynchrony do you know?
What is peak pressure and how is it different from plateau pressure?
What are your options to combat Susan’s ventilator dyssynchrony?
What is acute respiratory distress syndrome?
What is the Murray score?
Is there evidence to support the use of neuromuscular blockade in cases of ARDS?
Why does Susan need so much noradrenaline and what can you do to improve her cardiovascular status?
Should you instigate renal replacement therapy? What is the evidence for ‘early’ vs ‘late’ renal replacement therapy?
What is the evidence for starting steroids?
What are the rescue methods for critical hypoxaemia in severe ARDS?
How do you achieve prone positioning?
How does prone positioning improve oxygenation?
Once Susan is safely in the prone position, what is your plan for her ongoing management at this stage (in addition to haemofiltration)?
What is the likely outcome in this case?
Besides sepsis and multiorgan failure, what are some possible complications of pneumonia?
Further reading
Case 9 The Patient with Chest Pain
What could be the most likely causes of deterioration in this case?
What are the principles of management of acute PE?
How do we define haemodynamic instability in acute high-risk pulmonary embolism?
How might the presence of antiphospholipid antibodies be relevant to her presentation?
What other risk factors increase your risk for VTE?
Which blood tests could aid in diagnosing PE?
Which electrocardiogram (ECG) abnormalities might be found in PE?
Which ECG abnormalities are associated with a poor prognosis in patients diagnosed with PE?
What is the rationale for ordering a chest radiograph?
Which imaging modality is considered the ‘gold standard’ for diagnosing PE?
What are the advantages and disadvantages of performing a CTPA in patients with suspected PE?
Advantages
Disadvantages
In which circumstances might a CTPA result be indeterminate?
Which pretest probability scores are used for PE?
Using the Wells criteria, what would be the probability that Grace has developed a PE?
What role does echocardiography have in the work-up for diagnosing PE?
What is the association between right ventricle dysfunction and prognosis in PE?
What other factors are associated with poor outcome in patients with PE?
Which presenting clinical feature is considered the most influential predictor of outcome?
What are your immediate concerns?
Briefly outline the steps you should consider before, during and after you perform intubation of her trachea
What do you think is most probably going on at this point?
Do you think it is safe to transfer Grace for a CTPA at this point?
What are your main treatment priorities at this point?
Describe the absolute and relative contraindications to thrombolysis
Which thrombolytic agent(s) can be used in PE?
Describe the major advantages and disadvantages of thrombolytic therapy in acute PE
Is there any role for pulmonary vasodilators in the treatment of PE?
What are the early and late complications associated with PE?
Further reading
Case 10 The Out-of-Hospital Cardiac Arrest Patient
How can we define cardiac arrest?
What is the chain of survival?
What are the approximate survival rates for OHCA in the UK?
How could you classify the causes of OHCA?
What is the evidence surrounding thrombolysis in cardiac arrest?
For thrombolysis
Against thrombolysis
Should we perform immediate coronary angiography in all patients after cardiac arrest?
Describe how echocardiography can help in the management of cardiac arrest
Can you use focused echocardiography to prognosticate in cardiac arrest?
How would you interpret the ABG result?
What is the potential association between hyperoxaemia and cardiac arrest?
Discuss the role of targeting hypothermia at 33 °C in OHCA comatose survivors?
What is the role of targeting MAP in OHCA comatose survivors?
Which tests can we use to predict poor neurological outcome in OHCA survivors?
Which findings, if any, might suggest a good neurological outcome?
Describe the Cerebral Performance Category Scale
How does the CPC relate to long-term prognosis following cardiac arrest?
Describe the modified Rankin Scale (mRS)
What are the disadvantages of using measures such as the CPC and mRS for classifying outcomes following OHCA?
Further reading
Case 11 The Patient with Hyponatraemia
Define hyponatraemia
Classify hyponatraemia according to serum sodium concentration, time of development, symptoms, serum osmolality and volume status
Discuss and describe hyponatraemia according to severity of symptoms
What is the pathophysiology behind disturbances in sodium homeostasis and what is the likely cause in this case?
What is normal serum osmolality?
Define osmolality and osmolarity. What is the difference?
Why is it important to establish whether hyponatraemia is hypotonic?
How is normal serum osmolality physiologically maintained?
Describe how ADH works
What other factors influence the synthesis and release of ADH?
Describe the management of severe symptomatic hyponatraemia
What do you do next with regard to her symptomatic severe hyponatraemia?
What are the concerns surrounding delayed and overly rapid correction of hyponatraemia?
List risk factors for developing osmotic demyelination syndrome
What can be done if the serum sodium concentration rises too rapidly (i.e. rapid overcorrection)?
Explain how serum and urinary concentration of electrolytes can help clinically in determining the aetiology of sodium disorders
Which urinary tests can aid in diagnosing the causes of hyponatraemia?
Describe the RASS
What is delirium?
What are the different subtypes of delirium?
How common is delirium in critical care patients?
Broadly speaking, what are the risk factors for delirium?
What role do benzodiazepines have in the development of delirium?
How can we screen for delirium in critical care?
How can we manage delirium?
What is the ICU Liberation Bundle?
Do patients who experience delirium in the ICU have a poorer outcome?
Further reading
Case 12 The Patient in Status Epilepticus
What could be causing his seizures?
What are your main concerns?
Life-threatening issues
Establishing the underlying cause(s) of seizures
What are your management priorities?
What is the definition and pathophysiology of status epilepticus?
What is the pharmacological management of refractory convulsive status epilepticus?
Classify epilepsy
Seizure types
Epilepsy types
Aetiology
Would you give this patient antimicrobials?
Which organisms commonly cause meningitis?
What are the causes of encephalopathy?
Would you give steroids?
What is your plan in intensive care?
Organ support
Manage pathology
Investigate underlying cause
Basic intensive care management
What are your concerns regarding his slow neurological progress?
What do you do about the antimicrobials?
What are the next steps in management?
Neurological management
Investigations
Safeguarding
What is the role of EEG in intensive care and how does it work?
What is an IMCA and why might you want one in this case?
What is burst suppression and how do you do it?
What outstanding issues do you need to highlight for follow-up on discharge to the ward?
Further reading
Case 13 The Patient Who is Hypotensive
What could be some of the potential causes for Joan’s sudden deterioration?
How do we define shock?
How can we classify the different types of shock?
What do you now think is the most likely cause?
Define sepsis
Define septic shock
Describe the qSOFA Score
Describe NEWS2
How can organ dysfunction be identified in sepsis?
Describe the SOFA Score
How does sepsis lead to hypotension?
What is the ‘hour-1 bundle’?
What is the significance behind developing the ‘hour-1 bundle’?
Which antibiotics would you start?
How can focused echocardiography help in differentiating the causes of shock?
How do you proceed at this point?
Which vasopressors are recommended in sepsis?
Describe how these vasopressors work
What role do corticosteroids have in the management of sepsis?
What do you think has happened based on her clinical findings?
How can lung ultrasonography help you differentiate between these two potential causes?
What is the significance of gram-negative bacilli in a blood culture?
Which organisms are most likely to be responsible for gram-negative sepsis in this case?
Briefly describe the differences between gram-positive and gram-negative bacteria
To which class of antibiotics does meropenem belong and what is its general spectrum of activity?
Briefly describe the other beta-lactam antibiotics and how they work
What does the term extended-spectrum beta-lactamase (ESBL) mean?
Further reading
Case 14 The Patient Who Deteriorates Post Intubation
What could be the causes of his persistent hypotension despite increases in noradrenaline and adequate fluid resuscitation?
What is the normal range for aortic valve area and peak transvalvular flow?
What are the echocardiographic criteria for diagnosing severe aortic stenosis?
How would you interpret the reported echocardiogram?
How might you explain the inconsistencies in the reported echocardiogram regarding the estimated AV area and pressure measurements?
What is low-gradient aortic stenosis?
What is the prevalence of AS in the general population?
What are the main causes of aortic stenosis?
What is aortic sclerosis?
Describe the morphological changes to the LV that can occur with severe aortic stenosis
What is the physiological role of LV hypertrophy?
What are the problems that can arise with LV hypertrophy?
What do we mean by the term ‘preload’?
How is preload affected in AS?
What is meant by the term ‘afterload’?
How is afterload affected in the presence of severe AS?
What treatment options are available for severe AS?
Percutaneous interventions
Surgical intervention
What is the prognosis for patients with symptomatic severe AS?
Define acute heart failure (AHF)
What are the treatment principles for managing AHF?
How might you adjust your treatment for AHF in Michael given that he has severe AS?
Further reading
Case 15 The Patient with Reduced Consciousness
What could be the cause of Debbie’s low GCS?
What are your main concerns at this point?
Review this CT image (Figure 15.1). What is the diagnosis?
What is the Monro–Kellie Doctrine?
What is cerebral perfusion pressure (CPP)?
What is secondary brain injury and how can youminimise it?
Conservative
Medical
Anaesthetic
Surgical
What is the incidence and what are the causes of subarachnoid haemorrhage (SAH)?
Incidence
Causes
Draw a diagram to represent the circle of Willis
What scoring systems can be used to grade the severity of SAH?
What are the treatment options for aneurysmal SAH?
Apart from the issues already explored, how else will you manage Debbie in critical care?
Physiological optimisation
Follow-up investigations
Prophylactic medication
What do you think might have occurred?
What is the significance of the TCD and CT head report?
What other methods are used to diagnose cerebral vasospasm?
What methods can be used for intracranial pressure monitoring and how do they work?
How do you manage cerebral vasospasm?
How do you manage Debbie’s blood pressure?
What do you think is happening and why?
How do you manage this?
Of which other sodium regulation disorders is Debbie at risk?
What problems can SAH patients experience during the recovery period?
Further reading
Case 16 The Patient Who had A Stroke
What causes ischaemic stroke?
What are the risk factors for ischaemic stroke?
Modifiable
Non-modifiable
What are the options for managing acute thrombotic stroke?
General measures
Thrombolysis with alteplase
Thrombectomy
Review the CT head image (Figure 16.1). What is the diagnosis?
What patterns of neurological deficit can be seen in stroke?
What do you think may have happened?
What are your management priorities?
Review the images in Figure 16.2. What is the diagnosis?
What is the pathophysiology of Edward’s deterioration?
How does information from the CT head influence your management now?
How will you manage Edward in neurocritical care at this point?
What are the complications of neurosurgery?
Why is it important to examine Edward’s eyes regularly?
Describe the clinical presentations of different patterns of brain herniation secondary to raised ICP
What is your management plan in light of your neurology assessment?
What other signs might you expect to see?
What is your assessment of the clinical situation and how will you proceed?
What preconditions must be met before you commence brainstem testing?
Who can perform brainstem death testing?
Which nerves are tested in brainstem death testing?
Which tests are performed?
How do you perform the apnoea test?
What is the definition of death?
Is brainstem death testing a universally accepted process?
What is the significance of this?
What kind of donation would be possible for Edward?
What investigations may be done at this stage?
What medications and management strategies might you need to employ at this stage?
Which organs can be donated?
Further reading
Case 17 The Patient with Chest Pain and a Rash
What differential diagnoses are you considering at this point?
What investigations do you need at this point?
Bedside investigations
Blood
Microbiology/virology
Imaging
What is piperacillin/tazobactam (‘pip-taz’)? What is gentamicin?
What do you think about this choice of antibiotic regimen?
What additional antimicrobial agents might you consider?
What could be the cause of the dermatological manifestations?
What are the causes of lymphadenopathy?
What is the significance of oral candidiasis?
Are there any particular elements of the history you would like to know?
With this new information, will you add any diagnoses to your original list of differentials?
How does this information affect your investigations?
If a family member wants to know Sudip’s HIV status, what can you tell them?
What is HIV?
What drug treatments are available for HIV?
How do you interpret the CD4+/CD8+ ratio and viral load results?
What treatments are available for TB?
What antifungal drugs are available and how do they work?
What is the mortality for patients with HIV?
Further reading
Case 18 The Young Patient Who Collapses
Describe Figure 18.1. What is the diagnosis?
What are the adverse features of arrhythmias?
How do you proceed?
What could be the underlying cause of Belle’s arrhythmia?
What are your immediate concerns?
Which key aspects of Belle’s medical history do you want to know?
What investigations do you need?
Bedside tests
Blood tests
Imaging
What is Belle’s anion gap?
What are the most likely causes of Belle’s raised anion gap?
What are the main clinical concerns and where would you like Belle to be managed?
Which other healthcare professionals should you involve in Belle’s care?
What is anorexia?
What are the cardiovascular complications of anorexia and starvation?
How do you proceed?
Do you know any guidelines for the management of critically unwell patients with anorexia?
What is Belle’s BMI?
What other features can be used to categorise risk in patients with anorexia nervosa?
Physical examination
Blood tests
ECG
What are the stages of starvation?
Do you start full nasogastric feed immediately? Justify your answer.
What is refeeding syndrome?
Which other patients are particularly at risk of refeeding syndrome?
How will you manage Belle to avoid refeeding syndrome?
Would you use parenteral nutrition to feed Belle?
What are the risks associated with parenteral nutrition?
What are Belle’s daily nutritional requirements?
What are the non-cardiac complications of severe malnutrition?
What are the possible outcomes for Belle now?
Further reading
Case 19 The Patient Who has Taken an Overdose
What are your concerns regarding her airway?
What are the medico-legal and ethical implications of attempting to save this woman’s life?
What is capacity?
What could be the cause of Sarah’s decreased GCS?
What is your management plan at this point?
Emergency management
Monitoring
Bedside tests
Lab tests
Imaging
Transfer Sarah to critical care for ongoing management
What is the pathophysiology of paracetamol overdose?
What are the stages of paracetamol hepatotoxicity?
What treatments are available for paracetamol toxicity and resultant acute liver failure?
Initial management of significant paracetamol overdose
Coagulopathy arising from subsequent liver impairment
Management of hepatic encephalopathy
Drug treatments to consider for encephalopathy
General ICU care
How is LOLA believed to work?
How does NAC work?
What are the risk factors for increased likelihood of toxicity in paracetamol overdose?
What are the criteria for referral to a liver transplant centre?
In cases of paracetamol toxicity
In non-paracetamol toxicity
What is the pathophysiology of aspirin (salicylate) toxicity and how do you interpret Sarah’s level of 34 mg/dL?
What are the options for management of tricyclic antidepressant (TCA) overdose?
In which ways can drugs cause liver injury?
How is liver failure categorised?
Acute liver failure
Chronic liver disease
Acute on chronic liver failure
What are the causes of acute or fulminant hepatic failure?
What are the causes of chronic liver disease?
How many solid organ transplants occur each year?
What scoring systems are used in the assessment of liver failure?
What are the West Haven grades of severity of encephalopathy?
Does Sarah have hepatorenal syndrome? Explain your answer.
Diagnostic criteria for HRS (International Ascites Club)
Categorisation
What is the likely outcome for Sarah now she is on the transplant list?
What is ‘DBD’ donation? How does this compare with ‘DCD’ donation?
How should Sarah be managed post transplant?
What medication will Sarah require following her transplant?
What complications can occur following transplant?
Early
Delayed
What are the complications related to long-term immunosuppression?
Further reading
Case 20 The Unwell Obstetric Patient
What immediate actions do you take?
How can cardiopulmonary resuscitation (CPR) be adapted for the pregnant patient?
Why do you need to tilt the patient or manually displace the gravid uterus?
How common is cardiac arrest in pregnancy?
How common is maternal death?
Which co-morbidities are implicated in obstetric mortality?
What are the ‘4Hs and 4Ts’ (RCUK) and how may these reversible causes be particularly pertinent in the obstetric patient?
What could be the possible causes for Oksana’s presentation?
What are your management priorities?
What cardiovascular changes occur during pregnancy?
What are the non-cardiovascular changes of pregnancy and how do they affect your management of Oksana?
Respiratory
Gastrointestinal
Renal
Endocrine
Who else needs to be involved in Oksana’s care?
What is the definition of major obstetric haemorrhage?
What are the causes of maternal haemorrhage?
What are the options for management of maternal haemorrhage?
Medical
Surgical
Interventional radiological
General measures
What are your main concerns for Oksana at this point?
What is your management plan?
What specific issues should you consider when speaking with Gemma?
What is the likely cause of these CT findings?
What is the prognosis for PRES?
What could be the cause of Oksana’s pulmonary oedema?
Further reading
Case 21 The Patient in Cardiac ICU
What could be the cause of hypotension in Isaac?
What does ‘on-pump’ mean?
Describe a cardiopulmonary bypass circuit
What is the significance of the aortic cross-clamp time in CABG?
What are the complications of CPB?
What do you expect Isaac’s coagulation status to be at this point?
On examination, you note that Isaac has wires coming from his chest which are connected to a small control box. What are these and why are they there?
What are your concerns regarding the TOE findings?
How does cardiac tamponade present in postcardiac surgery patients?
If Isaac were to arrest, which resuscitation protocol would be the most appropriate to follow?
What are the next steps in management of this patient?
What could be the cause of this failure to weanfrom CPB?
What management options do you expect the team in theatres to be considering?
By which mechanisms does levosimendan exert its effects?
Compare venoarterial and venovenous (VA/VV) ECMO
What are the complications due to the use of ECMO?
Would an Impella device or a VAD be useful in this scenario?
What is thromboelastography?
What is the theoretical basis for the use of IABP?
What is the evidence for the use of IABP?
What other issues need to be addressed to optimise Isaac’s condition in critical care?
Why is atrial fibrillation a problem and how will you manage Isaac’s AF?
What could be the cause of Isaac’s agitation and failure to wake appropriately?
Are there any pharmacological management strategies for delirium?
What is the prognosis for patients undergoing CABG?
What is the prognosis for patients undergoing aortic valve replacement?
What should you include in your handover to the ward team regarding Isaac’s ongoing management?
Further reading
Case 22 The Patient Who was in A House Fire
What are your main concerns?
What type of injury can be caused by explosion?
How do you secure Philip’s airway?
What should you do now regarding immediate management, monitoring and further investigations?
Immediate management
Monitoring
Investigations
How do you calculate fluid resuscitation requirements?
How do you assess percentage and depth of burn?
What are the indications for discussion with specialist burns centre?
What is an escharotomy and why may one be performed?
What are your concerns regarding cyanide poisoning?
What is the mechanism for toxicity from carbon monoxide and what is the management?
How do you set the ventilator for Philip?
Why might Philip be difficult to ventilate?
Why may it be challenging to control Philip’s temperature?
What are the causes of renal failure in burnsvictims?
Why is Philip likely to be in pain?
What are the risks and benefits of performing bronchoscopy in cases of inhalational injury?
Benefits
What grade of severity is Philip’s ARDS?
How would you assess Philip’s premorbid status and frailty?
What scoring systems could you use to grade the severity of Philip’s organ dysfunction?
Why is gut failure a significant problem for Philip?
Comment on the clotting derangement
Why is Philip hypoglycaemic?
What are the outcomes for burns patients?
What problems are faced by survivors with burns injuries?
Further reading
Case 23 The Patient with Low Platelets
How would you interpret these results?
Define thrombocytopenia
What are the risks of thrombocytopenia?
What would be your platelet count threshold for performing a lumbar puncture (LP)?
How are platelets made in the body?
What is the normal lifespan of platelets?
How common is thrombocytopenia in critical care?
What are the mechanisms of thrombocytopenia?
What can lead to a decreased production of platelets?
What can lead to an increased destruction of platelets? Non-immune mechanisms
Immune-mediated mechanisms
How does platelet sequestration lead to thrombocytopenia?
What is heparin-induced thrombocytopenia (HIT)?
What causes HITT and how is it diagnosed?
When does HIT usually occur?
What is the mortality rate associated with HITT?
When can heparin be given after an acute episode of HITT?
By what mechanisms does sepsis cause thrombocytopenia?
What is DIC?
What are the laboratory abnormalities that can occur in DIC?
What other blood tests could be run on the samples already sent at this point?
What does the indirect bilirubin result represent?
What is the purpose behind ordering a Coombs test?
How do you interpret these results?
Considering the haematology results, what are the most likely causes for her thrombocytopenia?
What is thrombotic microangiopathy?
What is HUS?
How is HUS treated?
What is thrombotic thrombocytopenic purpura?
What causes TTP?
What scoring systems do you know that can predict the likelihood of ADAMTS13 activity of less than 10%?
Briefly describe the treatment for TTP
Briefly describe plasma exchange therapy (PEX)
Further reading
Case 24 The Patient with COVID-19
What is PPE and what are its main characteristics?
What is meant by the term ‘air-borne disease’ and what methods can be used to reduce transmission?
Can you summarise your main concerns?
What is COVID-19?
Do you want the ED registrar to continue setting up high-flow nasal oxygen (HFNO)?
What other management strategies should you be considering at this stage to improve his oxygenation?
What else do you need to consider at this point?
What are the radiological changes in COVID-19?
What is your decision? Give your reasoning
What are the main strategic considerations for pandemic planning in critical care units?
What are the impacts of a pandemic on the delivery of routine healthcare?
What do you do for him in critical care?
Monitoring
Medications
Communication
What other pharmacological treatments may be of use in COVID-19?
Interpret the ventilator flow–time curve labelled A (Figure 24.1)
What are the potential problems associated with the flow-time curve in Figure 24.1?
What driving pressure is being used here? What are your concerns about this?
Draw the compliance curve and mark the lower and upper inflexion points. Use the graph to explain overdistension
Discuss static respiratory compliance
What do you think could have happened?
How would you proceed?
What do you do next?
What would you discuss with your consultant?
Further reading
Part III Test Yourself
MCQs - Multiple Choice Questions Mark each option (A–E) as true or false
SBAs - Choose the answer which is the most correct from the options (A-E)
Answers
Index
EULA