Critical Care & Emergency Scenarios

TL;DR

Critical care vivas test your ability to quickly assess, prioritize, and manage life-threatening situations. You'll need to know your ABCDEs inside out and understand the immediate management steps for common emergencies. Practice articulating your thought process clearly and confidently, even under pressure.

1. The Mental Model

Think of yourself as a highly structured problem-solver in a high-stakes environment. Your mental model should be a rapid, systematic sweep for immediate threats, followed by targeted interventions and reassessment. It's about buying time and stabilizing the patient.

2. The Core Material

Critical care scenarios are all about rapid assessment and immediate action. The foundational principle is the ABCDE approach. This is your mental checklist for every emergency. You need to know what each letter stands for, what to look for, and what immediate actions to take.

The ABCDE Approach: Your Lifesaver

• A - Airway: Is it clear? Is the patient talking? Look for obstruction (e.g., foreign body, swelling).
  • Actions: Head tilt-chin lift, jaw thrust, suction, OPA/NPA, consider intubation.
• B - Breathing: Is the patient breathing? How fast (rate)? How deep (depth)? Are there any sounds (wheeze, crackles)?
  • Actions: High-flow oxygen, consider nebulizers, chest X-ray, assist ventilation.
• C - Circulation: What's the heart rate? Blood pressure? Capillary refill time? Are they pale/clammy? Any signs of bleeding?
  • Actions: IV access, fluid bolus, bloods (FBC, U&E, Coags, G&S), ECG, stop obvious bleeding.
• D - Disability: What's their GCS? Are their pupils equal and reactive? Is there a focal neurological deficit? Check blood glucose.
  • Actions: Correct hypoglycaemia, consider CT head, neurological assessment.
• E - Exposure/Environment: Fully expose the patient to look for rashes, trauma, hidden bleeding, tracks. Prevent hypothermia.
  • Actions: Keep patient warm, full top-to-toe assessment, privacy.

Remember, this is a continuous cycle. After each intervention, you reassess ABCDE.

Common Emergency Scenarios to Master

You'll likely face scenarios like:
* Anaphylaxis: Acute allergic reaction. Think ABCDE, adrenaline, antihistamines, steroids.
* Sepsis: Life-threatening organ dysfunction caused by a dysregulated host response to infection. Think ABCDE, fluids, antibiotics, source control.
* Acute Asthma Exacerbation: Sudden worsening of asthma symptoms. Think ABCDE, oxygen, nebulized bronchodilators, steroids.
* Diabetic Ketoacidosis (DKA): High blood sugar, acidosis, ketones. Think ABCDE, IV fluids, insulin infusion, monitor electrolytes.
* Massive Haemorrhage: Significant blood loss. Think ABCDE, stop bleeding, blood products, tranexamic acid.
* Cardiac Arrest: No pulse, unresponsive. Think BLS/ALS, CPR, defibrillation.

For each of these, know the key diagnostic features and your immediate management plan.

graph TD
    Start["Patient presents acutely unwell"] --> A["A: Airway"]
    A --> A_Assess["Assess: Patency, sounds, obstruction"]
    A_Assess --> |Obstruction?| A_Act["Act: Head tilt, jaw thrust, suction, adjuncts"]
    A_Act --> ReassessA["Reassess Airway"]

    ReassessA --> B["B: Breathing"]
    B --> B_Assess["Assess: Rate, effort, sounds, sats"]
    B_Assess --> |Abnormal?| B_Act["Act: O2, neb, CXR, assist vent"]
    B_Act --> ReassessB["Reassess Breathing"]

    ReassessB --> C["C: Circulation"]
    C --> C_Assess["Assess: HR, BP, CRT, skin, bleeding"]
    C_Assess --> |Abnormal?| C_Act["Act: IV access, fluids, bloods, ECG, stop bleed"]
    C_Act --> ReassessC["Reassess Circulation"]

    ReassessC --> D["D: Disability"]
    D --> D_Assess["Assess: GCS, pupils, glucose, neuro deficit"]
    D_Assess --> |Abnormal?| D_Act["Act: Correct hypogly., CT head, neuro check"]
    D_Act --> ReassessD["Reassess Disability"]

    ReassessD --> E["E: Exposure/Environment"]
    E --> E_Assess["Assess: Full body scan, temperature"]
    E_Assess --> |Abnormal?| E_Act["Act: Keep warm, manage injuries"]
    E_Act --> ReassessE["Reassess Patient"]

    ReassessE --> Repeat_ABCDE{"Is patient stable?"}
    Repeat_ABCDE --> |No, still unstable| A
    Repeat_ABCDE --> |Yes, stable| Further_Mgmt["Further investigation & definitive management"]

Communication and Teamwork

In a viva, you're expected to articulate your actions. State what you are doing, why you are doing it, and what you expect to happen. Don't forget to mention calling for help early. This demonstrates professionalism and an understanding of your limitations.

3. Worked Example

Scenario: You are called to a patient who has collapsed in the waiting room.
Your Approach (Verbalised):
"Okay, I'm faced with a collapsed patient. My immediate priority is to ensure their safety and stabilize them using an ABCDE approach.

First, Airway: I'd quickly check if the patient is responsive or talking. If they're unresponsive, I'll open their airway with a head tilt-chin lift and look for any obstruction. I'd then visually inspect the airway. If it's clear and they're making respiratory effort, I'd move to breathing. If obstructed, I'd apply a jaw thrust; if still obstructed, I'd consider suction or requesting an OPA/NPA.

Next, Breathing: I'd look, listen, and feel for breathing. I'd count their respiratory rate, observe their chest expansion, listen for breath sounds, and check oxygen saturations if a monitor is available. If they're not breathing or breathing inadequately, I'd immediately call for help, administer 15L/min oxygen via a non-rebreather mask, and prepare to assist ventilation.

Then, Circulation: I'd simultaneously check for a pulse (carotid or radial), assess their skin colour and temperature, and check their capillary refill time. I'd immediately get an IV cannula inserted and send off urgent bloods (FBC, U&Es, G&S, lactate). If hypotensive, I'd prepare a rapid fluid bolus of 500mL 0.9% Saline, and get an ECG. I'd also ask if there's any obvious bleeding.

Disability: Whilst these initial interventions are ongoing, I'd conduct a quick GCS assessment, check their pupils, and crucially, check a capillary blood glucose level, as hypoglycaemia can cause collapse.

Finally, Exposure: I'd quickly and respectfully expose the patient's chest and abdomen to look for any rashes, signs of trauma, or hidden pathologies. I'd ensure they're kept warm with blankets.

Throughout this, I would have already called for senior medical help and a crash team if warranted, and delegated tasks to any available staff. I would then reassess ABCDE after every intervention."

4. Key Takeaways

• Always start with the ABCDE approach; it's your primary framework for every emergency.
• Prioritize immediate life threats (e.g., airway obstruction, no breathing, massive bleeding).
• Call for help early – don't try to manage everything alone.
• Be systematic and articulate your thought process clearly; tell the examiner what you're doing and why.
• Know the doses for common emergency drugs (e.g., adrenaline in anaphylaxis) and fluid boluses.
• Reassess the patient after every intervention – things can change quickly.
• Practice common scenarios like anaphylaxis, asthma, and sepsis, knowing immediate steps for each.

Common Mistakes to Avoid:
- Jumping straight to a diagnosis without completing a primary survey (ABCDE).
- Forgetting to call for help or delegate tasks.
- Not reassessing the patient after an intervention.
- Getting flustered and losing your systematic approach.

5. Now Try It

Exercise: Imagine you are in an emergency department and a patient with known chronic obstructive pulmonary disease (COPD) suddenly becomes acutely short of breath and unresponsive. You are the first person to reach them.
What to do: Verbally walk through your entire initial management plan, detailing each step of your ABCDE assessment and immediate interventions. Time yourself for 5 minutes.
What success looks like: You articulate a clear, structured, and prioritized plan following the ABCDE approach, including calling for help, considering likely immediate causes (e.g., exacerbation, cardiac event), and outlining specific initial treatments before moving on to further diagnostics or definitive care.