Hot case approach
The CICM fellowship Hot Case is probably the component of the exam that causes the greatest anxiety, yet it is the part that most reflects day-to-day ICU practice. the following article presents a suggested approach to this component of the exam. However, it is not definitive and individuals may already have adopted techniques that suit them well.
Take your time getting your gloves and gown on. It might be useful to ask the bulldog (your chaperone) to hold on to any equipment that you have brought to the exam and pass items to you as you ask for them. This avoids poking around in pockets and dropping things during the stress of examination. Once you are ready, let the bulldog take you over to the examiners. Once the examiners greet you, the clock is ticking, so be happy that you are ready before rushing over to them.
Introductory stem given by examiner and given examination task
Summarise case and confirm task – Some chose to do this out loud to the examiners, as it helps them to confirm the details of the case and focus on the tasks being requested of them. Others feel that this wastes valuable minutes and has the potential to irritate the examiners by appearing to be stalling. So instead they repeat the details to themselves, in their heads, while surveying the room from the end of the bed. The truth is that either approach is reasonable and you should do whatever helps you the most.
Introduce yourself to the patient:
“Good morning Mr Smith. My name is Matthew. I’m one of the candidates who is going to examine you today. I’m going to step back for a minute, but I will be with you again in a moment.”
Around the bed
Ventilator – settings.
• Ventilator FiO2 low with good SpO2 => low Aa gradient
• Good Vt with minimal PEEP and PS = good compliance (Cstat = [Vt – PEEP] / Pplat)
• Large minute ventilation with normal or raised EtCO2 => large dead space
• If EtCO2 is low with large Mv => significant respiratory drive; eg metabolic acidosis, severe asthma
Vitals on the monitor –
• HR, rythmn, hypo-/hypertension, RR, hypoxia, other (eg. temp, CVP, PA catheter, etc).
• “Are these values representative of the past 24 hours?”
Infusions – rates ->
• “Can you tell me about the infusions that are running?” – This is acceptable and usually quicker than trying to examine every infusion pump that is running, especially if the pump is a brand that you are not familiar with.
• “Are there any infusions that have recently been ceased?” – e.g. antibiotics, recombinant APC, NMB infusion
Feeding – if enteral -> “What are the aspirates like?”
Urine catheter – output over the past 24 hours
Other drains – output over the past 24 hours
Other equipment –
• Pacing box
• Dialysis
• IABP
• EVD
• ICP
• VAC
Examining the patient
“Mr Smith, I’m going to examine you now.” If awake: “Have you any pain anywhere?”
CVS, respiratory, abdominal examination
Standard fingers up arms to head and neck, down chest, abdomen, pelvis and legs to toes approach, with brief neurological if appropriate, will suffice for most cases. However, some scenarios need a tailored process; e.g. the trauma tertiary survey, post OHCA neurological prognosis.
Case history hints
Structural cardiac disease + fever => Endocarditis
Look specifically for:
Splinter haemorrages
Janeway lesions (palmar macules, vasculitis)
Osler’s nodes (tender, septic emboli)
Clubbing of fingernails may suggest cyanotic congenital cardiac disease (tetralogy, transposition, tight pulmonary stenosis, single ventricle and truncus arteriosis – the terrible T’s)
IV sites
Roth spots (vasculitis)
Murmurs
Left heart endocarditis -> pulmonary oedema
Right heart endocarditis -> raised JVP, prominent v-wave (TR), pulsatile liver edge
Splenomegaly
Feet as for hands -> splinters, Janeway, Osler, clubbing
End of the bed jaundice
Look specifically for:
Asterixis (encephalopathy)
Leuconychia (low albumen)
Palmar erythema (CLD)
Easy bruising
Excoriation (obstructive jaundice)
Raised JVP
Spider naevi > 6 Abdominal striae
Caput medusae
Liver size, texture, edge, pulsatility
Splenomegaly
Ascites
Lymphadenopathy
Clonus
Hippus
Urinalysis – urobilinogen, haematuria (might suggest haemolysis as cause rather than liver)
Neurological examination
GCS
Higher mental function if appropriate
Cranial nerves
Upper limbs – inspection, T/P/R/C +/- sensation
Lower limbs – inspection, T/P/R/C +/- sensation
Cerebellar function – PINARDS
Chest/abdo – abdominal reflexes, sensory level if spinal cord pathology suspected
Brief CVS, respiratory exam, fundoscopy
Trauma
Level of alertness ->
“Mr. Smith, can you open your eyes?”
“Can you poke out your tongue?”
“Can you squeeze my fingers tightly?”
GCS -> E / V / M A.B.C.
Then as for secondary survey -> Head, face, neck and if able to sit up vertebral column, clavicles out along upper limbs, chest + heart + respiratory, abdomen + pelvis, lower limbs.
Log roll for vertebral column & back if unable to sit up.
Look for:
Head & neck: scalp wounds, skull defects, facial injury, eyes, haemotympanum, CSF otorhea / rhinorhea, epistaxis, dental injury, mobile midface (LeFort III)
Neck: tracheal injury, C-spine injury, carotid bruit (dissection)
Clavicles and upper limbs: deformity, open wounds, vascular injury, nerve injury (response to nailbed pressure in intubated sedated patient). Presence of splint = fracture, dislocation or fasciotomy
Chest: flail, contusions, chest drains, thoracotomy
Abdomen: midline laparotomy => damage control, scrotal bruising (urethral injury)
Pelvis: don’t spring it
Lower limbs: deformity, open wounds, vascular injury, nerve injury (response to nailbed pressure in intubated sedated patient). Presence of splint = fracture, dislocation or fasciotomy
Log roll: visible injury, tender / step in spine, PR Complications of surgery / ICU management
Failure to wean / Ready to extubate
Level of alertness ->
“Mr. Smith, can you open your eyes?”
“Can you poke out your tongue?”
“Can you squeeze my fingers tightly?”
GCS -> E / V / M
Neurological examination -> cranial nerves, upper limb T/P/R/C/+-S, lower limb T/P/R/C/+-S
Standard fingers around to toes approach for CVS, respiratory and abdominal examination.
Note muscle wasting of hands, shoulder girdle, temporalis & masseter and quads on the way around
Round-up
After any of the above examinations
Temperature over the past 24 hours
Fluid balance
Blood glucose
Any case specific observations that might be useful; e.g. sputum culture results, patient reporting sensation of rectal fullness following an enema during care for a spinal cord injury
Presentation
Wash hands while preparing presentation
Some useful lead-in phrases:
“This is Mr. Smith, a 62yo man, who has been in the unit for 3 days, following admission with …”
“The focus of my examination was …”
“My examination demonstrates a picture / pattern of …”
“Specific findings which support this include … (relevant positives and negatives)”
If able -> “His prognosis is likely to be …”
“Priorities of his management include …”
“My next steps would be … (further targetted investigations, therapeutic interventions, relevant consults)”
Presentation style
Hybrid is probably best.
Comment on key findings during the around-the-bed and fingers-to-face portion of the examination. Then examine the core (CVS, respiratory, neuro, etc) portion quietly, only commenting on something that stands out. Then present as outlined above, concentrating on the key findings relevant to the question initially asked. This way, side issues, such as the presence of an arterial catheter or patch of cellulitis have been noted to the examiners, but don’t become a distraction during the main presentation.
If the diagnosis or core problem is obvious, state it and then go through relevant supporting positives and negatives. If the diagnosis or core problem is not obvious, present systematically the key findings (Resp / CVS / Neuro / Abdo / Renal /Liver / Haem / Skin / Sepsis / Trauma) and the issues thereof. Try to bring it all together in a summary line.
Move on to the principles of the illness, possible outcomes, priorities of management and next steps to be taken in assessment and management.
Good luck!