Hot Cases | CICM Part 2 Exam Guide

The hot case is a working memory exam. By the time you sit it, you know the medicine — the challenge is retrieving it under pressure with your headspace maxed out. This guide breaks the hot case into chunks you can learn, practise, and automate in isolation, so that on the day, your mental bandwidth stays free for clinical reasoning.

1 Reading 2 Opening 3 Walkaround 4 Exam 5 Closure 6 Presentation 7 Discussion

The System

A step-by-step framework for the hot case. Each step is a chunk you can practise in isolation, then assemble.

1 Reading time Pre-load your framework before you enter the bed space

Remember the patient's name
Decide if this is a general, neuro, or special exam format
Consider what you expect to see so that it's easy to recognise if it's not there (e.g. 20 days ventilated — usually would have a trache; if not, why?)
Note the specific question and pre-load your presentation format. Issues will always be:
1. Issue(s) from the stem
2. Issues identified from exam (six organ failures + fever)
3. Seeking and treating specific complications of the primary problem
4. Supportive ICU management

2 Opening The same every time. Zero mental effort.

Hand wash, curtains closed, lights on
Script Introduction to the nurse: "Can I ask if [name] has any mobility restrictions, or any communication barriers like deafness?"
Stand at end of bed and take in the room — notice things to check on the walkaround, look at the whiteboard
Script Introduction to patient: "Hello [name], my name is X, I am one of the doctors. I've come to do an examination with you for the next 10 minutes. I will take good care of you."

3 Walkaround Systematic data gathering before you examine

Infusions

If many infusions, completely fine to ask what they are
Ask about trends over last shift
If not spontaneously breathing, ask about muscle relaxant
Ask if appropriate to pause sedation
- High doses prompt you to consider ARDS, raised ICP, seizures, or drug tolerance
- If off sedation, ask which agents/doses they were on and when they were stopped
If any antibiotics, ask about all antibiotics

Monitor

Look at every number AND wave on the screen
Interpret rather than narrate numbers:
- Rhythm
- Pulse pressure
- PAPi (PASP−PADP/CVP)
- Normal/obstructed CO₂ trace
- If EtCO₂ low, check MV on vent to see if it's explainable by hyperventilation — otherwise likely dead space
Ask about stability of parameters
Ask about fever in the last 24 hours

Ventilator

Spontaneous vs mandatory
Oxygenation — PEEP, FiO₂
- "Moderate hypoxic respiratory failure, I note the EtCO₂ is X"
- "There is adequate gas exchange"
Ventilation — Vt, RR, MV
- "No evidence of restrictive or obstructive pathology"
If paralysed, assess and comment on dynamic compliance
Waveforms
Look for ventilator strategy:
- Lung protective with proportionally high PEEP/FiO₂ and DP <15
- Low RR and high I:E?

End of the bed

General appearance — stated age, frailty, restraints, BMI
Feeds — rate/concentration, gastric residual volumes, vomiting
Drains — location, output quality and quantity
IDC — urine output
Colour of waste bins
Drugs to be drawn up
Whiteboard info
Photos on wall

Equipment quick-reference

Bedside triggers. See the device, load the checklist.

Tracheostomy

Surgical vs percutaneous
Wound site — infected or broken down?
Cuff up/down
Secretions above and below cuff

EVD

Open/closed
Height
Pressure
Drainage output
CSF bloodstained?
Reasons: SAH, intraventricular haemorrhage, SOL causing obstructive hydrocephalus, TBI

Chest drain

On suction or not
Swing
Leak — is it bubbling? How much? If only during coughing, probably small. If significant leak (e.g. during speech), check VTi vs VTe on vent
Drainage quality and quantity

Abdominal drains

Ask where they are
Ask for output

Dialysis

Mode — "Can I just check if this is a standard CVVHDF mode?"
Anticoagulation
Dose
Fluid removal
Effluent colour — haemolysis?

Heparin infusion

DVT/PE or other clot
AF
Valve
Prothrombotic disorder

Defib pads

Arrest
Concern for impending arrest
Need for pacing

Hypertonic saline

Intracranial hypertension
Severe hyponatraemia / SIADH / CSW

4 Examination Three formats, rehearsed to automaticity

The examination follows the same anatomical sequence every time: hands → arms → neck → face → chest → abdomen → pelvis → legs → back. By always moving in the same direction, the structure becomes automatic and you free your attention for what you're finding.

Region	What to check
GCS / Pupils	With your hands behind your back, ask the patient to open their eyes, poke their tongue out, and wiggle their fingers and toes. Responds → check movement in all limbs; if extubated ask year/month/day/place No response → open eyes and check eye movements (locked in?), look at pupils + conjunctiva for pallor/jaundice, shoulder squeeze then nailbed pressure If paralysed: skip GCS and check pupils. If in restraints: "I will defer my GCS assessment until the end of my exam."
Hands	Warmth, cap refill, clubbing, stigmata of IE, wasting, nicotine staining, palmar erythema, asterixis
Arms	Jaundice, bruising, scars, fistulae
Pulse	Radial-radial delay
Neck	JVP / CVP
Face	Eyes — pale or jaundiced
Mouth	Candida, ETT, sputum load (even if extubated)
Chest	Inspection: scars, WOB, stand back and assess symmetry. Palpation: subcutaneous emphysema, RV heave / apex beat. Auscultation: lungs (AE/creps/wheeze, make concerted effort to get to back of lungs), murmurs (all 4 areas, right up into axilla → carotids, loud P2 = pulmonary hypertension). Percussion. If cooperative: lean forward and examine back — scars/pressure injuries, oedema, auscultation, percussion, vocal tactile fremitus.
Abdomen	Ask to lie patient flat. Inspection: scars, distension, caput medusae, spider naevi, Grey Turner or Cullen signs. Palpation: tenderness, liver (pulsatile?), spleen, shifting dullness/ascites. Bowel sounds. Ask about NG feeds, gastric residual volumes, and bowels.
Groins	Lines, scars/dressings from previous punctures
Lower limbs + back	Neuro exam of lower limbs. Ask about back for: scars, rashes, pressure sores, dependent oedema.

GCS

With your hands behind your back, ask the patient to open their eyes, poke their tongue out, and wiggle their fingers and toes.

Responds → check movement in all limbs; if extubated ask year/month/day/place
No response → open eyes and check eye movements (locked in?), look at pupils + conjunctiva for pallor/jaundice, shoulder squeeze then nailbed pressure

Cranial nerves

Pupils
Corneal reflex (don't do if will obviously be present)
Oculocephalic reflex
Cough on suctioning
Neck stiffness

Peripheral exam

Inspection: fasciculations and wasting
Tone: proximal → distal, left → right. Check for clonus.
Reflexes: bicep (C5/6), tricep (C7/8), knee (L3/4), ankle (S1/2), plantar

GCS

With your hands behind your back, ask the patient to open their eyes, poke their tongue out, and wiggle their fingers and toes.

Responds → check movement in all limbs; if extubated ask year/month/day/place
No response → open eyes and check eye movements (locked in?), look at pupils + conjunctiva for pallor/jaundice, shoulder squeeze then nailbed pressure

Delirium assessment (CAM-ICU)

"Squeeze my hands when I say the letter A" — SAVEAHEAART (allowed 2 errors)
"Will a stone float on water?"
"Are there fish in the sea?"
"Can you hold up this many fingers" (2) → "now can you add one more finger"

Cranial nerves (summarised for awake patient)

Pupils
H test of eye movements
Facial sensation
Facial movements
Cough
Shrug shoulders
Turn head L→R
Tongue L→R
Specifically check for photophobia and neck stiffness

Peripheral exam

	Upper	Lower
Inspection	Fasciculations and wasting
Tone	Proximal → distal, left → right. Check for clonus.
Power	Chicken, Boxer, Superman. "Stay strong, don't let me move your arm" → Push/Pull	"Lift your leg up" → push into bed. "Push your leg down" → try to lift up. "Bend your knee" → pull on heel. Rest knee on your arm → push lower leg down. "Lift your foot up." "Push your foot down." Each with "stay strong, don't let me move your leg"
Reflexes	Arms across chest. Bicep (C5/6), Tricep (C7/8)	Knee (L3/4), Ankle (S1/2), Plantar
Sensation	Cotton wool then toothpick. Close eyes, "say yes when you feel it." Reference point: chin. Lateral + medial upper arm (C5/T1) Lateral + medial forearm (C6/T8) Middle of back of hand (C7)	Lateral + medial upper leg (L2/3) Lateral + medial lower leg (L5/4) Midline back lower leg (S1) Midline back upper leg (S2)
Coordination	Finger-nose, dysdiadochokinesia	Heel-shin test, ataxia

5 Closure Use dead time to prepare your presentation

Tuck patient back in
Thank patient
Thank nurse
If time remaining:
- Pause and think about the stem
- Formulate presentation
- Search the room / repeat endobedogram
- Go back and check anything missed

6 Presentation The structure that frees you to reason

Block 1 — Opening Script

"I saw [name] who has been in ICU for X days after [reason]."

Block 2 — Motherhood statement Script

Choose one:

"[Name] appears to be in a stable/recovery phase of their critical illness."
"I am worried about [name]..."
- Elderly/frail/comorbid/obese with complications after XYZ
- They have had a long ICU stay
- Whilst they seem primarily to have single organ failure, it is severe
- Has not followed the expected trajectory after XYZ
- Multi-organ dysfunction including XYZ

Block 3 — Exam findings

"I'll briefly outline my examination findings and then come to the question of XYZ..."

Only present the systems of interest. One-liner for unremarkable systems.

System	Template	Ask for
Neuro	Script "On [sedation], [name] is GCS E_V_M_, with/without meningism, with/without focal neurological signs, with/without UMN/LMN findings." Pupils Cranial nerves Tone/clonus Power Reflexes/plantar Coordination	BSL, sodium, urea, LFTs, neuro imaging
CVS	Script "[Name] is cold and shut down/mottled OR warm, vasodilated and hyperdynamic OR has features of mixed shock. There is an element of vasoplegia as evidenced by low diastolic pressure, wide pulse pressure, warm peripheries. I think there is/is not an element of cardiac dysfunction..." Left heart failure: perfusion, pulse pressure, creps Right heart failure: CVP, oedema, hepatomegaly, jaundice Heave/thrill/apex/heart sounds Volume state: warmth, swing/PPV Obstructive causes: chest symmetrical, not tachycardic/hypoxic, abdomen soft, CVP	ECG, echo
Resp	Script "[Name] has evidence of chronic lung disease. They have hypoxic/hypercapnic/mixed respiratory failure with evidence of obstructive/restrictive pathology." Chronic lung disease signs: nicotine stains, clubbing Oxygenation, EtCO₂/MV Obstructive/restrictive: EtCO₂, vent wave, pressures, auscultation WOB Sputum load	ABG, CXR
GI	Feeds. Bowels. Abdomen exam.	Abdo imaging
Renal	Urine output.	UEC
Liver	Signs of CLD — bruising, spider naevi, ascites. Jaundice. Hepatomegaly.	LFTs, BSL, Plt, albumin, INR
Fever	Script "I note that [name] was febrile. The causes could be infectious or non-infectious. On examination there was/wasn't obvious evidence of CNS, cardiac, respiratory, GI, renal tract, or skin infection. Their lines were clean."	WCC, CRP, procalcitonin, culture results

Block 4 — Restate question and list missing information Script

"I was asked about XYZ. In addition to the examination I've performed today, to comprehensively assess that I'd also need to gather some extra information, specifically about [dotpoints]."

Then: "However, from my examination today..."

Block 5 — Answer the question / issues list

If issues list, present in this hierarchy:

Primary problem (e.g. shock state, open abdomen, SAH)
Seek and treat complications of the primary problem (e.g. "It will be important to monitor for the development of vasospasm")
Subsequent organ failures / fever — six failures + fever: Neuro, CVS, Resp, GI, GU, Liver, Fever
Big picture — "I'm worried about [name], they are elderly and now have multi-organ dysfunction." "I'd like to speak to the admitting unit and [name]'s family to learn more about them as a person, express my concerns about how sick they are, and come up with a plan for if things don't improve or deteriorate from here."
Management of comorbidities (from stem or exam — don't forget obesity)
Prevention and management of ICU-acquired complications (CLINGED P): Critical illness weakness, Lines (?PEG, ?PICC), Infections (HAP, CLABSI), Nutrition, Goals of care / family, Encephalopathy / delirium, DVT, Pressure injuries

Block 6 — Next steps

"Overall my goal is over the next 48 hours to progress [name] by..." (consultant-style goal statement).

Then: Resuscitation → Referrals → Definitive management → Specific supportive → ICU supportive care (CLINGED P)

7 Discussion Pre-loaded phrases for common questions

Useful phrases Script

Massive transfusion

"With regard to bleeding I have two priorities:

1) Confirming that we've achieved surgical haemostasis and that [name]'s haemoglobin is stable.

2) Ensuring that their coagulation status is optimised. I would check their platelet count, coagulation profile, ionised calcium, and the results of any viscoelastic thromboelastography, if available."

Vasopressor requirement

"[Name] has an adequately supported blood pressure on [dose] vasopressor support.

[Name] was warm and well perfused peripherally and had a good pulse pressure without inotropic support.

I'd like to do a bedside echo to assess cardiac function and volume state, but I suspect their shock is primarily distributive rather than cardiogenic, obstructive, or hypovolaemic."

Inotrope requirement

"[Name] was receiving [drug] inotropic support, and on this had [quality] peripheral perfusion and pulse pressure.

I'd like to assess their cardiac function with a bedside echo looking for tamponade, contractility, RWMAs, valvular function, and volume state.

On exam — right heart: CVP, oedema, ascites, hepatomegaly, jaundice.

Left heart: creps, peripheral perfusion, pulse pressure.

Chest inspection, heart sounds, heave/thrill, apex beat."

Analgosedation

"There are three components to this — pain, delirium, and tube intolerance.

Pain: assess for chronic pain or opioid tolerance/dependence, look for grimacing on turns, manage with multi-modal analgesia.

Delirium: non-pharmacological measures first; if pharmacological management required, first choice is dexmedetomidine or quetiapine.

Tube intolerance: if after managing pain and delirium the patient remains intolerant, titrate propofol to effect; in the right circumstance, consider tracheostomy."

High pressure support

"I note that [name] required [level] pressure support to achieve [volume] tidal volumes.

Given their gas exchange appeared reasonable, I suspect this is primarily due to sedation and/or weakness rather than parenchymal pathology.

OR: Given their gas exchange was also impaired, I think they may have an element of restrictive pathology."

Wide pulse pressure

"Consider sepsis or aortic regurgitation."

Mnemonics

Non-infectious causes of fever

PATCHED HAN

P — Pancreatitis
A — Alcohol withdrawal
T — Transfusion reaction
C — Cancer
H — Hyperthyroidism
E — Embolism (PE)
D — Drugs (drug fever, dexmedetomidine, malignant hyperthermia, serotonin syndrome, NMS)
H — HLH
A — Autoimmune (vasculitis, rheumatological disease)
N — Neurogenic (intracranial blood, TBI, encephalitis, surgery near hypothalamus)

Causes of respiratory failure

ABCD OO

A — Airway (ETT malposition, upper: OSA/OHS, lower: bronchospasm)
B — Breathing (mechanical: haemopneumothorax/atelectasis; fluid: pneumonia/aspiration/pulmonary haemorrhage; inflammatory: ARDS/TRALI/autoimmune/drug reaction; fibrosis)
C — Circulation (PE, LV failure/APO, RV failure)
D — Disability (decreased conscious state, neuromuscular disease: GBS/myasthenia/myopathy, pain/splinting)
O — Obesity
O — Failure of O₂ delivery (dyshaemoglobinaemia, CO/cyanide toxicity)

Causes of shock

PROVED

P — Pump (ischaemia, valvular, drugs, SAM/LVOT obstruction, stunning, commotio cordis, myocarditis, tamponade, cardiomyopathy, tachy/brady)
O — Obstruction (tamponade, emboli, tension pneumothorax, abdominal compartment syndrome, dynamic hyperinflation)
V — hypoVolaemia (haemorrhage, GI/renal losses)
E — Endocrine (myxoedema, adrenal failure, severe acidosis/electrolyte imbalance)
D — Distributive (sepsis, SIRS, neurogenic, anaphylaxis, liver failure, drugs/epidural)
Also consider: spurious result (cuff size, transducer, vasopressor disconnected)

Acute liver failure

DAVE

D — Drugs (paracetamol, idiosyncratic)
A — Alcohol/Autoimmune
V — Viral (Hep A→E, CMV, HSV, EBV)
E — Extras (fatty liver of pregnancy, HELLP, Wilson's)

Chronic liver disease

VANAM

V — Viral (chronic Hep B/C)
A — Alcohol
N — NAFLD
A — Autoimmune (including PBC, PSC)
M — Metabolic (haemochromatosis, Wilson's, alpha-1-antitrypsin)

ICU-acquired complications

CLINGED P

C — Critical illness weakness
L — Lines (?PEG, ?PICC)
I — Infections (HAP, CLABSI)
N — Nutrition
G — Goals of care / family
E — Encephalopathy / delirium
D — DVT
P — Pressure injuries

The Scenarios

Select a category to view scenarios:

Readiness for extubation Readiness for ward discharge

Readiness for extubation

Opening thoughts

Need for ongoing operative management?
Airway grade / difficult airway / availability of airway staff?
Airway patent and protected (cough, gag, swallow; ETT cuff leak; trache cuff down and capping trials)?
Respiratory function (oxygenation, ventilation, minute volume, WOB, secretion burden)?
Cardiovascular function (impact of increased LV afterload with loss of positive pressure)?
Neuropsychiatric (delirium, anxiety, pain)?
Neuromuscular strength?
Aspiration risk?
Plan if they fail (reintubate, trache, palliate)?

Infusions

Depth and duration of sedation — can it be stopped?
Haemodynamic stability?
Dexmedetomidine suggests delirium

Monitor

Haemodynamic stability, fever

Vent

Spontaneous breathing — if on PS ask how long
Vt/RR/RSBI (>105 predicts failure)
Oxygenation (SpO₂ >90% on FiO₂ <40% and PEEP ≤5)
Ventilation (PaCO₂ near normal on ≈5 PS/5 PEEP; ask about EtCO₂-PaCO₂ gap)
Minute ventilation
Strength (vital capacity breath >10mL/kg IBW with ≤5cmH₂O PS)
Any spontaneous breathing trials?

Exam

Screening neuro (delirium, anxiety, pain)
Features of difficult airway — ask about laryngoscopy grade
Cuff leak; if trache: cuff down? PMV or capping trial?
Respiratory: chest wall (bruising, symmetry/flail/diaphragmatic palsy, WOB), auscultation (effusions, creps, wheeze), secretions
Cardiovascular: murmurs, signs of heart failure (creps, JVP, oedema)
Strength: neck off pillow, elbows off bed for >5s. Consider NMJ disorder.
Abdomen: acute abdomen indicating aspiration risk
Ask for CXR, ABG, fluid balance

Presentation

Prior to extubation, optimise:

Respiratory drive (treat fever, metabolic acidosis, pain)
Respiratory resistance (ETT upsize or tracheostomy, bronchodilators, secretion management)
Respiratory compliance (treat underlying lung disease, diuresis, drain effusions, recruit with PEEP, decompress abdomen, sit up to 45°)
Neuromuscular function (treat delirium, multi-modal analgesia, physio, avoid sedatives/steroids, protein intake, normalise electrolytes)
Systemic oxygen delivery (treat myocardial dysfunction, correct anaemia)

SBT: if tolerates 30 minutes, >75% chance of successful extubation. Consider extubating onto NIV or staged extubation with airway exchange catheter.

Readiness for ward discharge

Suitability

Confirm no longer requires ICU-level therapies or monitoring
Trajectory towards improvement
Ward capacity to manage things like pacing, ICC, NIV
Time of day appropriate

Logistics

Ensure referrals are in place
Rationalise IV access, consider PICC
Go through drug chart and cross off ICU-only meds
Call home team to handover
Arrange ICU outreach nurse follow-up
Consensus about whether patient would be for readmission to ICU if required

Coma Respiratory failure Fever Shock Renal failure Jaundice Abdominal catastrophe Weakness Liver failure

Coma

DDx — Coma

Meningism: SAH, meningitis
Focal signs: stroke (ischaemic/haemorrhagic), abscess, tumour, cerebral vasculitis, pre-existing neurology with new superimposed coma
No focal signs: Delirium/Drugs/Seizure, Sugar/Salt/Temperature, BEWITCH (Brainstem stroke with RAS damage, Encephalopathy — septic/hepatic/uraemic, Wernicke's, Ischaemia — hypoxaemia/HIE/diffuse vasculitis, Trauma — concussion/DAI, CO₂, Hypothyroid/hypoadrenalism)

Opening thoughts

Goal is to establish: conscious state, focal signs, meningism, organ failures that might explain.

Infusions

Depth and duration of sedation — can it be paused? Deep sedation suggests high ICP, seizures, or drug tolerance. Nimodipine suggests SAH. High inopressor requirement — encephalopathy secondary to organ failure? Dexmedetomidine suggests delirium.

Monitor

ICP, CPP

Vent

Spontaneously breathing?

Endobedogram

Urine output / CRRT — uraemic encephalopathy?

Exam

Neuro exam
Focal signs → intracranial DDx: stroke, abscess, tumour, vasculitis, or pre-existing neurology
No focal signs → systems exam
Signs of seizure (tongue biting, EEG)
Signs of liver failure (jaundice, ascites, caput medusae, spider naevi)
Signs of renal failure (UO, CRRT, fistula, Tenckhoff)
Evidence of arrest/ischaemic insult (angiography site, pads, TTM)

Presentation

Neurologically: [Name] is GCS E_V_M_, with/without meningism and with/without focal neurological signs. Pupils were X and corneal, oculocephalic, and cough reflexes were intact. Tone (UMN vs LMN), reflexes (UMN vs LMN), power, coordination.

Respiratory failure

Opening thoughts

ABCD OO

A — Airway (ETT malposition, upper: OSA/OHS, lower: bronchospasm)
B — Breathing (mechanical: haemopneumothorax/atelectasis; fluid: pneumonia/aspiration/pulmonary haemorrhage; inflammatory: ARDS/TRALI/autoimmune/drug reaction; fibrosis)
C — Circulation (PE, LV failure/APO, RV failure)
D — Disability (decreased conscious state, neuromuscular disease: GBS/myasthenia/myopathy, pain/splinting)
O — Obesity
O — Failure of O₂ delivery (dyshaemoglobinaemia, CO/cyanide toxicity)

Infusions

—

Monitor

High EtCO₂ → permissive hypercapnia. Low EtCO₂ → may be dead space.

Vent

A-a gradient normal → asthma, neuro, dyshaemoglobinaemia. Inspiratory and expiratory hold → compliance. Minute ventilation and EtCO₂ → dead space? Significant respiratory drive?

Endobedogram

Cushingoid (steroid dependent), obesity (OHS), malnutrition (CF)

Exam

Tar staining, stigmata of IE, clubbing, vasculitis rashes, evidence of chest trauma (bruising, rib fractures, flail, old ICC sites), big abdomen compressing lungs

Presentation

Ask for ABG, CXR, CTPA/CT-Chest, TTE

Fever

Opening thoughts

Infection or PATCHED HAN
Think about infective source as the five failures + lines/skin

Infusions

—

Monitor

Fever may be masked by paracetamol, extracorporeal circuit, active cooling, or immunocompromise

Vent

—

Endobedogram

—

Exam

In addition to normal exam:

Neck stiffness + photophobia
Dental hygiene + peripheral stigmata of IE
Abdomen/RUQ pain (cholangitis?)
Palpate sinuses/parotids/mastoids
Lines
Drugs in room / cytotoxic bins (chemo? immunocompromised?)
Cullen's and Grey Turner signs (pancreatitis?)
Tone and reflexes (thyroid, NMS)

Sepsis source search:

CNS (neck stiffness, photophobia, altered consciousness)
Resp (FiO₂, PEEP, sputum)
IE (murmur, wide PP/AR, conduction block, dental, peripheral stigmata)
GI (distension, FMD)
Cholecystitis/cholangitis (RUQ pain, jaundice, cholecystostomy)
Renal (turbid/sediment urine, nephrostomy)
Skin and wounds
Lines

Also consider:

Malignancy (chemo, cachexia)
Autoimmune (rash, haemoptysis, AKI)
Pancreatitis (Grey Turner, Cullen's, distension)
Hyperthyroidism (tachycardia, hypertension, hyperreflexia, propranolol/labetalol)
Drug related (pupils, reflexes, tone, HR/BP)

Presentation

Ask to check fever chart — "I'd correlate with medications, surgeries, lines, and other events"
Ask about: inflammatory markers and culture results, drugs/blood products/anaesthetic agents, autoimmune history/screen, ferritin, malignancy screening (film, CT-CAP, tumour markers)
Consider: organisms on MCS may be colonisers, immunosuppressed patients may not have localising signs

Shock

Opening thoughts

PROVED

P — Pump (ischaemia, valvular, drugs, SAM/LVOT obstruction, stunning, commotio cordis, myocarditis, tamponade, cardiomyopathy, tachy/brady)
O — Obstruction (tamponade, emboli, tension pneumothorax, abdominal compartment syndrome, dynamic hyperinflation)
V — hypoVolaemia (haemorrhage, GI/renal losses)
E — Endocrine (myxoedema, adrenal failure, severe acidosis/electrolyte imbalance)
D — Distributive (sepsis, SIRS, neurogenic, anaphylaxis, liver failure, drugs/epidural)

Also consider: spurious result (cuff size, transducer, vasopressor disconnected)

Infusions

Inotrope vs vasopressor? Epidural? PPI infusion or MTP evidence suggesting major bleeding?

Monitor

CVP, PAP, cardiac index, pulse pressure, pulse pressure variation (hypovolaemia?)

Vent

If respiratory failure, consider PE or dynamic hyperinflation

Endobedogram

Active warming → sepsis, hypothyroidism, or hypoadrenalism

Exam

Peripheral perfusion/CRT, oedema
Angio sites (revascularisation, TEVAR, EVAR, angioembolisation)
Eyes (jaundice = liver failure, pallor = anaemia)
Face (rash/bronchospasm/angioedema)
Standard cardio/resp exam — rate, rhythm, BP on X supports
Right heart: CVP, oedema, ascites, hepatomegaly, jaundice
Left heart: creps, peripheral perfusion, pulse pressure
Chest inspection, heart sounds, heave/thrill, apex beat
Abdomen for liver failure: jaundice, petechiae/ecchymosis, ascites, splenomegaly, spider naevi, caput medusae

Presentation

Warm → distributive
Cool → cardiogenic, obstructive, or hypovolaemic
"I'd like to do a bedside echo looking for tamponade, contractility, RWMAs, valvular function, and volume state"

Renal failure

Opening thoughts

Acute renal failure (pre-renal, renal, post-renal)
Shocked?
Liver failure → hepatorenal?
Abdominal compartment syndrome?
Malignant hypertension?
Jaundice suggesting haemolysis?
Compartments suggesting rhabdo?
Drugs causing AIN?
Nephrostomy indicating obstruction?
CKD: evidence of metabolic syndrome (obesity, insulin, HTN)?
Renal transplant with a complication?

Infusions

—

Monitor

—

Vent

—

Endobedogram

—

Exam

—

Presentation

Prognosis depends on: premorbid renal function, nature of initial insult (ischaemic has better prognosis than rapidly progressive GN), severity and duration of acute insult.

Notably: AKI doubles in-hospital mortality. Of patients who need RRT, 60-day mortality is approximately 50% (AKIKI).

Jaundice

Opening thoughts

Pre-hepatic: haemolysis or GI bleed
Hepatic: acute or chronic liver failure (look for chronicity)
Post-hepatic: obstruction

Haemolysis: DIC, TTP/HUS, malignancy, virus, autoimmune, HELLP, mechanical (ECMO, valve)

Obstruction: choledocholithiasis, malignant obstruction, PSC

Infusions

Octreotide/terlipressin → liver failure
Blood products → haemolysis requiring transfusion?

Monitor

—

Vent

—

Endobedogram

SB tube or blood in NGT bag → GI bleed

Exam

Liver failure signs:

Palmar erythema, asterixis, jaundice, encephalopathy
Petechiae/ecchymosis, ascites, splenomegaly
Spider naevi, caput medusae

Complications: GI bleed, SBP, encephalopathy, hepatorenal, portopulmonary or hepatopulmonary syndrome

Presentation

Ask about liver function: LFTs, platelet count, BSL, albumin, coags, ultrasound
DDx of ascites: cirrhosis, Budd-Chiari, SOS/VOD, heart failure, nephrotic syndrome/renal failure, malignancy, TB

Abdominal catastrophe

Opening thoughts

AAA
Bowel: colitis/diverticulitis/toxic megacolon, obstruction SBO/LBO, perforation, ischaemia
Cholangitis/cholecystitis
Pancreatitis
Peritonitis (spontaneous, secondary bacterial)
Complication of surgery (e.g. anastomotic leak)

Infusions

—

Monitor

—

Vent

—

Endobedogram

—

Exam

Apply the standard walkaround and examination framework, focusing on abdominal findings.

Presentation

—

Weakness

Opening thoughts

Localise the level:

Intracranial: over-sedation, stroke, locked-in
Spinal cord: infarction, trauma, epidural abscess, transverse myelitis
Peripheral nerve: MND/ALS/SMA, GBS, myasthenia gravis, Lambert-Eaton
Muscle: critical illness polyneuromyopathy, myopathy/myositis, severe electrolyte derangement, rhabdomyolysis

Infusions

—

Monitor

—

Vent

—

Endobedogram

—

Exam

Neuro exam
If conscious state and cranial nerves normal → more likely cord or peripheral
If lateralising neurology → more likely intracranial or cord
Pattern of upper vs lower and proximal vs distal useful (CIW usually proximal > distal)
Presence or absence of reflexes useful

Presentation

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Neuropathy vs Myopathy

Feature	Neuropathy	Myopathy
Pattern	Uniform or distal	Proximal > distal
Sensation	May be affected	Usually normal
Reflexes	Lost early	Preserved till late
Fasciculations	Can be present	Not typical
Contractures	Can be present	Absent
CK	Normal	Elevated

Liver failure

Opening thoughts

Acute — DAVE

D — Drugs (paracetamol, idiosyncratic)
A — Alcohol/Autoimmune
V — Viral (Hep A→E, CMV, HSV, EBV)
E — Extras (fatty liver of pregnancy, HELLP, Wilson's)

Chronic — VANAM

V — Viral (chronic Hep B/C)
A — Alcohol
N — NAFLD
A — Autoimmune (including PBC, PSC)
M — Metabolic (haemochromatosis, Wilson's, alpha-1-antitrypsin)

Infusions

Octreotide/terlipressin, noradrenaline, dextrose

Monitor

High CO / low SVR

Vent

ARDS?

Endobedogram

Ascitic drain, CRRT (MOF or hepatorenal)

Exam

—

Presentation

—

Spinal injury

Level, complications, ASIA grading

Post cardiac surgery

Valve vs CABG, complications, recovery

Post AAA repair

Open vs EVAR, complications

Post cardiac arrest

Cause by system, prognostication

Trauma

Injuries, intervention, CLINGED P

Burns

Phase, resuscitation, airway

Subarachnoid haemorrhage

Securing aneurysm, EVD, DCI

Spinal injury

Opening thoughts

Consider cause: trauma, space-occupying lesion (abscess, tumour), ischaemia (IABP, aortic cross-clamp, AAA repair), transverse myelitis. Find the spinal level. Identify complications: respiratory failure, neurogenic shock or autonomic dysreflexia, gastroparesis/ileus, DVT/PE, pressure injuries. Other associated injuries.

Infusions

Vasopressor suggesting neurogenic shock and/or intentional hypertension. MAP target >85 for first week after traumatic injury. Supranormal MAP for anterior cord syndrome.

Monitor

Being hypertensed?

Vent

Triggering the vent or diaphragm paralysed? High pressure support → respiratory failure?

Endobedogram

Signs of trauma (exfix), ischaemic injury (IABP), autoimmune disease (PLEX)

Exam

ASIA spinal exam: cranial nerves (if CN pathology → likely intracranial), tone and reflexes (UMN vs LMN), dermatomes (standardised points; reference point on chin; cotton wool then neurotip; if level not found in limbs check torso), myotomes, ask for DRE (sacral sensation and tone — determines complete/incomplete).

The neurological level of injury is the highest level with intact sensation and ≥3/5 power.

Respiratory: power, secretions, need for tracheostomy.
Abdomen: ileus?
Legs: DVT?
Back: pressure sores?

Presentation

—

Cord syndromes reference

Syndrome	Cause	Findings
Complete cord transection	Transverse myelitis	Complete loss of motor and sensory below level
Cord hemisection	MS	Ipsilateral loss of motor and proprioception. Contralateral pain and temperature loss.
Central cord syndrome	Neck hyperextension, spinal syrinx	Motor impairment greater in upper limbs than lower. Variable sensory loss. Bladder dysfunction.
Anterior cord syndrome	Anterior spinal artery occlusion, long aortic cross-clamp, aortic dissection, IABP, post AAA	Bilateral loss of motor. Bilateral loss of pain and temperature. Preserved proprioception and vibration.
Cauda equina	Disc protrusion	Bladder/bowel dysfunction. Saddle area sensation changes. Lower limb weakness.

ASIA grading reference

Grade	Type	Features
A	Complete	No motor or sensory below level. No sacral sensation or motor (no anal tone or S4/5 sensation).
B	Incomplete	Sensory but not motor below level
C	Incomplete	50% of muscles power <3 (can't lift arms/legs)
D	Incomplete	50% of muscles power >3 (can lift arms/legs)
E	Incomplete	Normal

SCI management notes

Respiratory impairment after SCI

C5 or above invariably mandate intubation — consider early tracheostomy
C5–8: can lose intercostals + accessory muscles, risk of ventilatory failure, mandatory HDU admission
If not intubated: daily spirometry (FVC <1000mL → consider NIV/ETT), position FLAT for first week for high spinal injuries (maximise diaphragm mechanical advantage), chest physio + assisted cough

Haemodynamic support after SCI

Neurogenic shock: loss of sympathetic outflow → decreased HR, inotropy, SVR; loss of muscle tone → venous pooling. Rx: IVF + inotrope + vasopressor
Autonomic dysreflexia (if injury above T6): volatile HR/BP, triggered by pain/urinary retention/constipation/sexual stimulation
If traumatic SCI: target MAP 85–90 for 7 days post injury

Spinal shock

Transient physiologic (not anatomic) reflex depression below the level of injury, with loss of sensorimotor function.

Post cardiac surgery

Opening thoughts

Valve vs CABG vs other. Elective vs emergent. Complications. Post-op management.

Infusions

—

Monitor

—

Vent

—

Endobedogram

—

Exam

Graft sites, recent angio?, features of metabolic syndrome (RFs for OCAD), murmur?, evidence of complications (stroke, bleeding, arrhythmia, respiratory failure, AKI).

Presentation

Ask for: antiplatelet/anticoagulation status pre-op, surgical operation report + anaesthetic chart + perfusionist's record, TOE findings pre and post surgery, post-op bloods/CXR/ECG.

Assess cardiac function: HR, rhythm, preload, contractility, afterload; CI, SvO₂, lactate, UO, peripheral warmth, pulse pressure.

Articulate 24-hour goal then detail how to get there: treatment of original pathology (aspirin/statin, anticoagulation for mechanical valves), weaning of supports (specific steps and review criteria), weaning sedation → extubation, deplumbing (PAC, art line, IDC), monitoring for complications (graft dysfunction, valvular disease, SAM, arrhythmia, bleeding, atelectasis, AKI), treatment of comorbidities, ICU prophylaxis (clexane, PPI).

Post AAA repair

Opening thoughts

Open vs EVAR. Complications: stroke, HIE, spinal ischaemia, AKI (hypovolaemia, ischaemic cross-clamp time, rhabdo), gut ischaemia, lower limb ischaemia, abdominal compartment syndrome, coagulopathy from bleeding and MTP.

Infusions

Labetalol for impulse control?

Monitor

—

Vent

—

Endobedogram

—

Exam

Look for complications above — neuro exam and feel compartments. Femoral access sites for EVAR. Lower limb: warm/cold, pulses, sensation, power, compartments soft?

Presentation

—

Post cardiac arrest

Opening thoughts

Cause by system: A (loss of airway/hypoxia), B (PE, pneumothorax, hypoxia), C (AMI — even if no STEMI could be NSTEMI, arrhythmia, hypovolaemia, tamponade), D (SAH/stroke, drugs/overdose), Trauma, Metabolic (acidosis, electrolyte disturbance).

Infusions

—

Monitor

—

Vent

—

Endobedogram

—

Exam

—

Presentation

Ask about: witnessed vs unwitnessed, bystander CPR, first rhythm, time from arrest to ROSC, seizure activity.

Ask to see: ECG, troponin, TTE, angiogram, CTB + pan scan.

Trauma

Opening thoughts

Big picture: age/injury severity/stability. Find injuries: TBI, spine, chest (ribs, haemopneumothorax, pulmonary/cardiac contusions, blunt aortic injury), liver/spleen, renal, bowel, orthopaedic/limb/compartments. Evidence of surgical or IR intervention. Analgesia. Supportive ICU management — CLINGED P.

Infusions

Analgesia/PCA?

Monitor

—

Vent

—

Endobedogram

Massive transfusion tallies on whiteboard? Haematuria (renal tract injury)? Surgical drains?

Exam

GCS.

Head: scalp wounds, ICP monitor, eye injury/pupils/H-test, CSF oto/rhinorrhoea, haemotympanum, facial bone fracture.

Neck: C-spine precautions, swelling/subcutaneous emphysema/bruising, carotid bruit (dissection).

Shoulder girdle and upper limbs: bruising/deformity/wounds, splints (fracture/dislocation/fasciotomy), ROM/power.

Chest: especially subcutaneous emphysema, tenderness, flail, contusions.

Abdomen: midline laparotomy (damage control), Grey Turner or Cullen's (retroperitoneal haematoma), scrotal bruising (urethral injury).

Pelvis: exfix or surgical scars.

Groin: genitalia injury, angio site (angioembolisation or IVC filter).

Lower limbs: as upper.

Ask for log roll: "visible injury, spinal tenderness or step deformity, and DRE for tone/blood."

Presentation

Injuries/issues identified. Specific complications of these. Management of comorbidities. Analgesia. Supportive ICU management — CLINGED P (including ?IVC filter for DVT).

Burns

Opening thoughts

Phase: resus, post-resus/post-op, inflammatory, recovery. Look for other trauma.

Infusions

Maintenance fluids (NaCl, hypertonic NaCl, albumin), vasopressors (burns shock), inotrope (cardiac depression), antibiotics?

Monitor

Fevers? CO monitor.

Vent

Evidence of airway burn? FiO₂ 1.0 for CO/CN poisoning?

Endobedogram

Whiteboard details. CRRT (rhabdo?). Fed and absorbing?

Exam

ETT wired in? Room in neck for trache? Sputum load — carbonaceous? Dressings — strike-through? Urine output (myoglobinuria = rhabdo, purple = cyanokit).

Presentation

Ask about:
• Burn (TBSA%, what has been done — BTM/biobrane/autograft, surgical plan, appearance at last dressing change, clinical photography?)
• Airway/breathing (bronch results, COHb levels, cyanokit given?)
• Circulation (TTE/TOE)
• Disability (analgesia on chart, CTB)
• EF (fluid balance/UO, Hb/Hct, Na, albumin, CK)
• GI (feed tolerance)
• H (coags, temp, Ca, pH)
• I (micro, fevers, inflammatory markers)

Subarachnoid haemorrhage

Opening thoughts

Key initial management: BP management, securing aneurysm, EVD, nimodipine. Neuroprognostication. Complications: aspiration, neurogenic cardiomyopathy, DCI, seizure, rebleeding, ventriculitis.

Infusions

Nimodipine? High-dose vasopressor to support nimodipine administration? High-dose sedation or levetiracetam (seizures)? Hypertonic saline (SIADH/CSW)?

Monitor

Hypertensive suggests aneurysm secured. Fever — worry about ventriculitis.

Vent

—

Endobedogram

Craniotomy site (clipping). Angio site (coiling). EVD (obstructive hydrocephalus). Very bloody CSF → high-grade SAH or rebleed. Ask about last CSF result (ventriculitis?).

Exam

Neurological exam — any findings could be primary or secondary to DCI. Aspiration or APO from cardiomyopathy? Neurogenic cardiomyopathy?

Presentation

—

Exam wisdom

Don't use a drug or infusion to justify a diagnosis. Find other evidence. E.g. don't use milrinone to diagnose cardiogenic shock — look for other features. If not present: "I didn't find features of cardiogenic shock, but I note the patient was supported by low-dose milrinone."
Be very specific with plans, as if giving instructions to a junior registrar. E.g. "I would wean the milrinone by halving it every two hours, assessing at each stage for deteriorating cardiac function by examining BP, pulse pressure, CI, lactate, urine output, and peripheral perfusion."
Split plans into time frames, open with the longer-term goal: "My aim would be to have Mr Smith extubated and approaching ward readiness by this time tomorrow. To achieve that I'd spend the next 6 hours doing ABC, then after that XYZ."
When going through a DDx list, follow it up with the relevant negatives.
Comment on unusual things ("I note the EVD is at 5cmH₂O — that's very low...").
Speak in short, clear sentences.
When you get muddled: "Apologies, I'll rephrase that."

The thinking behind this guide

The CICM Part 2 hot case gives you 10 minutes at the bedside and 10 minutes to present. In that time you need to absorb a stem, survey the room, read the monitor, interpret the ventilator, examine the patient, synthesise everything you've found, and deliver a structured presentation that sounds like a consultant ward round.

People will tell you this is what you do every day. It isn't. On a ward round you've pre-read the notes. You've had a handover. You integrate information over hours, not minutes. The hot case asks you to go from zero to a polished, integrated assessment of a complex patient in 10 minutes flat. That is not a normal ward round.

By this stage of training, you know the differential diagnosis for shock. You know the components of an extubation assessment. The knowledge is there. The challenge is accessing it, organising it, and delivering it clearly while your working memory is completely jammed — while you're running on adrenaline after a year of preparation, under the gaze of two examiners, in an unfamiliar unit, with a patient you've never met.

Under those conditions, your functional working memory narrows dramatically. The hot case asks you to use far more of it than you have. The standard advice is to start early and do as many hot cases as possible. Practice matters — but undirected repetition isn't enough. What matters more is deliberate preparation: recognising that the fundamental problem is cognitive overload, and then systematically building structures that address it before you walk into the room.

The approach I used — and the one documented in the guide above — is chunking. Every repeated element of the hot case gets pre-packaged into a single retrievable unit, rehearsed until it's automatic. When I saw a tracheostomy during the walkaround, I didn't think through what to check from first principles. I loaded a pre-built block: surgical or percutaneous, wound site, cuff up or down, secretions above and below. One slot, not five.

The same thinking applies everywhere you can find cognitive slack. Take the infusion pumps: rather than hunting for every pump, reading the labels, converting doses, and mentally sorting them into categories, ask the examiner. They'll read them in category order — sedation, then vasopressors, then everything else. The finding, reading, converting, and sorting is done for you. You just listen and interpret. It's a small example, but the principle scales: identify every point where you're spending working memory on structure rather than reasoning, and find a way to offload it.

The presentation structure works the same way. If your opening sentence, your system-by-system format, and your issues list framework are rehearsed to the point of automaticity, they cost you almost nothing cognitively. Your working memory stays free for the thing the examiners actually want to see: clinical reasoning about this specific patient.

This is the same design principle behind every tool in the Critical Condition portfolio. Offload the structure. Protect working memory. Keep your brainspace free for the decisions that matter.

The guide above is the system I built for myself. It won't teach you the content of intensive care medicine. It's a cognitive architecture for deploying what you already know under pressure.