Specialist & Consultant Critical Care Medicine oral assessment prep

Knowledge: This is severe ARDS from influenza pneumonia, with a PaO2/FiO2 ratio of about 69 mmHg on high PEEP and bilateral opacities not explained by cardiac failure. The threats are refractory hypoxaemia, ventilator-induced lung injury and right ventricular failure from hypercapnia and high pressures. Ventilation at 6 mL/kg predicted body weight with plateau pressure at or below 30 cmH2O reduces mortality. In PROSEVA, prone positioning for at least 16 hours a day reduced mortality when PaO2/FiO2 was below 150 mmHg. The 2023 ESICM guideline recommends prone positioning in moderate to severe ARDS and referral of eligible patients to an ECMO centre, informed partly by EOLIA. Bacterial co-infection, especially Staphylococcus aureus, must be considered.

Management: Now I would reduce tidal volume to 6 mL/kg, accept permissive hypercapnia with pH above about 7.20, titrate PEEP to oxygenation and compliance while watching haemodynamics, and aim for driving pressure below 15 cmH2O. I would deepen sedation and use neuromuscular blockade for a limited period if dyssynchrony persists, not routinely. I would prone him within hours, for at least 16 hours a session, with a trained team. I would continue oseltamivir and, after cultures, add antibiotics covering Staphylococcus aureus and pneumococcus. Repeat echocardiography assesses the right ventricle. If PaO2/FiO2 stays below about 80 mmHg or pH below 7.25 with high PaCO2 despite proning, I would call the regional ECMO centre early, before he is too unstable to move. I would use a conservative fluid strategy once shock resolves and avoid high-frequency oscillation.

Ethics and communication: His wife needs regular, honest updates on a serious prognosis, including why proning and possible ECMO are proposed. As he lacks capacity, procedures follow UAE law and facility policy, with emergency treatment not delayed. Staff need appropriate droplet and aerosol precautions. If ECMO capacity is limited, referral should follow agreed criteria rather than family pressure.

Reference: Grasselli G et al, ESICM guidelines on acute respiratory distress syndrome: definition, phenotyping and respiratory support strategies, Intensive Care Medicine, 2023; Guerin C et al, Prone Positioning in Severe Acute Respiratory Distress Syndrome (PROSEVA), New England Journal of Medicine, 2013; Combes A et al, Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome (EOLIA), New England Journal of Medicine, 2018

Knowledge: He has severe traumatic brain injury with sustained ICP above the Brain Trauma Foundation threshold of 22 mmHg, a cerebral perfusion pressure of only 54 mmHg and a new pupillary change suggesting herniation. The goal is to prevent secondary injury from hypotension, hypoxaemia, hypercapnia, fever, hyponatraemia and seizures. BTF guidance targets CPP of 60 to 70 mmHg. The SIBICC consensus provides a tiered algorithm, escalating from basic measures through hyperosmolar therapy and deeper sedation to second-tier options. In RESCUEicp, decompressive craniectomy for refractory ICP reduced mortality but increased survival with severe disability. Corticosteroids are harmful in traumatic brain injury.

Management: Immediately I would check the monitor, nurse him 30 degrees head-up with a neutral neck and loose tube ties, deepen sedation and analgesia, and give hyperosmolar therapy, such as 3% saline or mannitol 0.5 to 1 g/kg. For the dilating pupil I would allow brief hyperventilation to a PaCO2 of about 30 to 35 mmHg as a bridge only. I would raise mean arterial pressure with noradrenaline to keep CPP at least 60 mmHg, treat fever toward normothermia, and consider continuous EEG for non-convulsive seizures. I would repeat CT urgently and involve the neurosurgeon. If ICP remains high, options include an external ventricular drain, neuromuscular blockade, barbiturate coma and decompressive craniectomy, decided jointly with neurosurgery. I would avoid prolonged hyperventilation, hypotonic fluids and hypotension. Once stable, he needs thromboprophylaxis when safe, nutrition and early rehabilitation planning.

Ethics and communication: His family should hear an honest account of severity and uncertainty, avoiding early prognostic certainty that can become self-fulfilling. If craniectomy is considered, survival with severe disability must be part of the discussion with his relatives, in line with UAE law and facility policy. Police reporting of the collision follows facility procedures, and medical information is shared only as legally required.

Reference: Carney N et al, Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition, Brain Trauma Foundation, 2016; Hawryluk GWJ et al, A management algorithm for patients with intracranial pressure monitoring: the Seattle International Severe Traumatic Brain Injury Consensus Conference (SIBICC), Intensive Care Medicine, 2019; Hutchinson PJ et al, Trial of Decompressive Craniectomy for Traumatic Intracranial Hypertension (RESCUEicp), New England Journal of Medicine, 2016

Knowledge: The picture suggests death by neurological criteria, but the diagnosis requires a protocolised process. First come an established catastrophic cause and exclusion of confounders: sedatives, hypothermia, hypotension and severe electrolyte, endocrine or metabolic disturbance. Then a full examination must show coma and absent brainstem reflexes, followed by an apnoea test. The World Brain Death Project recommends a PaCO2 of at least 60 mmHg with acidaemia and no respiratory effort, and ancillary tests when the examination or apnoea test cannot be completed. Her hypernatraemia and polyuria indicate diabetes insipidus, and severe hypernatraemia is a confounder that must be corrected first. The procedure, examiners and documentation must follow UAE law and the facility's protocol.

Management: I would treat diabetes insipidus with desmopressin and replacement of free water, and optimise blood pressure, temperature and oxygenation. Once prerequisites are met, testing is done by qualified doctors independent of the transplant team, with ancillary testing if any part cannot be completed. I would meet the family before testing and explain what it involves. If death is confirmed, I would tell them clearly that she has died, using that word, and record the time of death as the protocol specifies. The donation conversation is kept separate from the determination of death and led by the trained coordinator with me present. Support continues only while donation is considered; otherwise ventilation stops after the family have had time.

Ethics and communication: Separating the treating team from transplant interests protects trust and the dead donor rule. Families may hold differing religious views on brain death, so I would offer a religious adviser and time, while explaining that continuing the ventilator cannot change the outcome. Donation must never be pressed, and a refusal must not change her care. Her dignity continues after death.

Reference: Greer DM et al, Determination of Brain Death/Death by Neurologic Criteria: The World Brain Death Project, JAMA, 2020; WHO Guiding Principles on Human Cell, Tissue and Organ Transplantation, 2010

Knowledge: This is cardiogenic shock after anterior STEMI, SCAI stage D, deteriorating despite escalating vasoactive drugs, with end-organ hypoperfusion. Mechanical complications, right ventricular infarction and tamponade must be excluded. In multivessel disease, CULPRIT-SHOCK favoured culprit-only PCI at the index procedure. The intra-aortic balloon pump did not reduce mortality in IABP-SHOCK II. In DanGer Shock, a microaxial flow pump in selected STEMI shock without coma reduced 180-day mortality but increased bleeding, limb ischaemia and kidney replacement therapy. In ECLS-SHOCK, routine VA-ECMO did not reduce 30-day mortality.

Management: I would convene the shock team at once: interventional cardiology, cardiac surgery and intensive care. I would place arterial and central lines and a pulmonary artery catheter to measure cardiac power output and filling pressures, avoid fluid unless preload is low, and keep noradrenaline as the vasopressor with an inotrope titrated to response. Given stage D shock from an anterior infarct without coma, I would consider a microaxial flow pump, weighing vascular access, bleeding and limb ischaemia. VA-ECMO is a bridge only for refractory shock in a candidate for recovery, a durable device or transplant. With a device in place I would manage anticoagulation and monitor limb perfusion, haemolysis and kidney function, starting kidney replacement therapy if needed. Intubation, if required, is hazardous and needs a cardiostable induction. I would review escalation and de-escalation daily, and if recovery does not come, discuss durable options or a ceiling of care.

Ethics and communication: Mechanical support should be offered as a bridge to a defined destination, and the family must understand that a device does not guarantee recovery. He should consent himself if he has capacity; otherwise treatment proceeds under the emergency provisions of UAE law. Expensive, scarce therapies should follow agreed institutional criteria. I would document goals and the ceiling of care early.

Reference: Naidu SS et al, SCAI SHOCK Stage Classification Expert Consensus Update, Journal of the Society for Cardiovascular Angiography and Interventions, 2022; Moller JE et al, Microaxial Flow Pump or Standard Care in Infarct-Related Cardiogenic Shock (DanGer Shock), New England Journal of Medicine, 2024; Thiele H et al, Extracorporeal Life Support in Infarct-Related Cardiogenic Shock (ECLS-SHOCK), New England Journal of Medicine, 2023; Federal Decree-Law No. 4 of 2016 on Medical Liability and Cabinet Resolution No. 40 of 2019 (UAE)

Knowledge: Triage aims to give ICU care to those most likely to benefit, judged on clinical grounds and not on status, nationality, insurance or influence. The SCCM triage framework supports decisions based on potential benefit, transparent criteria and an accountable decision-maker, usually the ICU consultant. The young woman has septic shock and a high chance of full recovery. The older man has progressive metastatic cancer, and his goals, performance status and wishes are not yet known; ICU may offer limited benefit, though high-flow oxygen or non-invasive ventilation may still help. Options also include stepping down a stable ICU patient or using a high-dependency area.

Management: I would assess both patients promptly myself and start resuscitation wherever they are: for the woman, antibiotics, source assessment with obstetrics and a vasopressor through a peripheral line if needed; for the man, oxygen and senior review. I would also look for a stable ICU patient who can safely step down. I would admit the woman to the free bed on grounds of benefit and urgency. For the man, I would speak with him, if he can talk, and with his oncologist about goals and wishes. Ward-based high-flow oxygen or non-invasive ventilation with palliative support may be right, or later ICU admission or transfer. I would brief the hospital director factually and document my reasoning and plan for each patient. Continued pressure is escalated through facility procedures.

Ethics and communication: Justice requires that equal clinical need is treated equally and that connections do not decide. Transparency and documentation protect patients and clinicians. Declining ICU admission is not declining care: the man must still receive good treatment and palliation. I would speak honestly and kindly with his son, and raise recurrent bed shortages through governance.

Reference: Nates JL et al, ICU Admission, Discharge, and Triage Guidelines: A Framework to Enhance Clinical Operations, Development of Institutional Policies, and Further Research, Critical Care Medicine, 2016

Knowledge: This is haemorrhagic shock with trauma-induced coagulopathy, bleeding from the abdomen and probably the pelvis. The 2023 European guideline recommends tranexamic acid within three hours of injury, 1 g over 10 minutes then 1 g over 8 hours, and a target systolic pressure of 80 to 90 mmHg until bleeding stops when there is no brain injury. It recommends plasma at a ratio of at least 1:2 with red cells, or a fibrinogen-based strategy, and fibrinogen replacement when Clauss fibrinogen is 1.5 g/L or less. CRASH-2 showed that early tranexamic acid reduces deaths from bleeding, and PROPPR supported balanced ratios. Damage control surgery or angioembolisation, not definitive repair, is the priority.

Management: I would activate the massive haemorrhage protocol, give tranexamic acid now, and transfuse warmed products at a balanced ratio through a rapid infuser, guided by viscoelastic testing where available. I would give fibrinogen concentrate 3 to 4 g or cryoprecipitate, calcium chloride to normalise ionised calcium, and active warming, while minimising crystalloid. As he is not responding, he goes straight to theatre or a hybrid suite for damage control laparotomy, pelvic packing or angioembolisation; CT is for responders. Once bleeding is controlled I would target haemoglobin 70 to 90 g/L and monitor potassium, acid-base and lactate. In ICU I would continue rewarming and correcting coagulopathy, watch for abdominal compartment syndrome and plan the second-look operation. Pharmacological thromboprophylaxis starts within 24 hours of bleeding control, followed by tertiary survey and spinal clearance.

Ethics and communication: Emergency treatment proceeds without consent under UAE law. I would inform his family once identified, sharing only what is needed. As a migrant worker he may fear cost or losing his job, so I would involve social work and ensure his care is not shaped by insurance status. Injury reporting follows facility policy.

Reference: Rossaint R et al, The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition, Critical Care, 2023; CRASH-2 trial collaborators, Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage, Lancet, 2010; Holcomb JB et al, Transfusion of Plasma, Platelets, and Red Blood Cells in a 1:1:1 vs a 1:1:2 Ratio and Mortality in Patients With Severe Trauma (PROPPR), JAMA, 2015