FFICM SBA · Consultant-Level Revision High Yield · With Nuance ⚡ Updated to RCUK/ERC 2025

ICU Guidelines
Deep Dive

All guidance reviewed to latest available versions — Resuscitation Guidelines 2025 (RCUK/ERC), DAS 2025, GPICS V3, Global ARDS Definition 2024, plus key NICE (sepsis, head injury) and BTS/SIGN (asthma, COPD/NIV) guidance. Pitched at ST6/imminent-consultant level for the Final FFICM SBA.

Tier 1 — Essential Expect multiple questions per sitting

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Sepsis — Surviving Sepsis Campaign 2021 CURRENT

Hour-1 Bundle · Vasopressor Hierarchy · Steroids · Source Control · Biomarkers

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📖Sepsis-3 Definition (2016): Life-threatening organ dysfunction (SOFA ≥2 acute change) due to dysregulated host response to infection. Septic shock = sepsis + vasopressors to maintain MAP ≥65 + lactate >2 mmol/L despite adequate resuscitation. qSOFA (≥2/3: RR≥22, altered mentation, SBP≤100) = screening tool only, NOT diagnostic — do not use to define sepsis.

Hour-1 Bundle — All 5 Elements

Measure Lactate — re-measure within 2h if initial >2 mmol/L; lactate >4 mmol/L = high-risk regardless of BP
Blood cultures before antibiotics — 2 sets, 2 sites; do not delay antibiotics >45 min for cultures
Broad-spectrum antibiotics within 1 hour — anti-pseudomonal beta-lactam ± MRSA cover; de-escalate per cultures
30 ml/kg IV crystalloid — for hypotension or lactate ≥4 mmol/L; reassess fluid responsiveness after each bolus (not a minimum to always give)
Noradrenaline if hypotensive during/after fluids — target MAP ≥65 mmHg; can start peripherally pending CVC

⚠️ Exam Trap — EGDT AbandonedARISE, ProCESS, PROMISE (2014–2015): EGDT (targeting ScvO₂ >70%, CVP 8–12, Hct ≥30%) showed NO mortality benefit vs usual care. CVP is a poor predictor of fluid responsiveness. EGDT is abandoned. Do NOT select CVP targets or ScvO₂ >70% as resuscitation endpoints.

⚠️ Exam Trap — CLASSIC Trial (2022)Restrictive IV fluid strategy (250 ml boluses only for severe hypoperfusion signs) vs standard in septic shock — no difference in 90-day mortality. MORE fluid ≠ BETTER outcomes. The 30 ml/kg bundle component is a ceiling to initiate, not a minimum to always deliver. Always reassess fluid responsiveness.

Vasopressor Hierarchy — With Trial Evidence

1st: Noradrenaline — alpha-1 dominance, less tachycardia/arrhythmia than dopamine (De Backer 2010 RCT — dopamine no longer recommended)
2nd: Vasopressin 0.01–0.03 u/min — VASST: reduces norad requirement; may reduce AKI progression in less severe shock; do NOT exceed 0.03–0.04 u/min (cardiac ischaemia risk)
3rd: Adrenaline — if MAP not achieved despite norad + vasopressin
Dobutamine 2.5–20 mcg/kg/min — add if evidence of cardiac dysfunction (low CO, high lactate despite adequate MAP and filling)
Terlipressin: NOT recommended in septic shock (ATTRESS trial — no benefit, possible harm)

Corticosteroids — ADRENAL / APROCCHSS

💊Indication: noradrenaline (or adrenaline) >0.25 mcg/kg/min AND not achieving haemodynamic goals at 4 hours. Hydrocortisone 200 mg/day — 50 mg QDS IV or 200 mg continuous infusion. Do NOT use ACTH stimulation test to guide (CORTICUS, ADRENAL, APROCCHSS). Fludrocortisone 50 mcg OD enteral (per APROCCHSS) — reduces 90-day mortality in that trial; practice varies. SSC 2021 does not mandate fludrocortisone — know the nuance.

Source Control & Antibiotic Stewardship

Source control within 6–12 h where feasible (abscess drainage, anastomotic leak, infected device removal) — inadequate source control = treatment failure
Procalcitonin (PCT)-guided de-escalation — PRORATA trial: safe, reduces antibiotic duration; rising PCT suggests inadequate source control
Antifungals empirically: consider in high-risk (prolonged ICU, TPN, abdominal surgery, Candida colonisation, immunosuppression) — fluconazole first line; echinocandin (anidulafungin) if critically ill or azole-resistant risk

ARISE/ProCESS/PROMISE — EGDT abandoned De Backer 2010 — dopamine inferior, more arrhythmias VASST — vasopressin spares norad dose ADRENAL/APROCCHSS — hydrocortisone in refractory shock PRORATA — PCT-guided de-escalation safe CLASSIC 2022 — restrictive fluid non-inferior in septic shock

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ARDS & Mechanical Ventilation GLOBAL DEF 2024

Berlin 2012 · Global Definition 2024 · ARDSNet · Proning · HFOV · ECMO · Steroids

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⚡Global ARDS Definition 2024 (Matthay et al., AJRCCM Jan 2024): Expands Berlin 2012 to include: (1) Non-intubated ARDS — patients on HFNO ≥30 L/min or NIV/CPAP ≥5 cmH₂O; (2) SpO₂/FiO₂ ≤315 (if SpO₂ ≤97%) as alternative to P:F ratio; (3) Lung ultrasound as imaging modality; (4) Resource-limited category (no PEEP requirement). Berlin severity thresholds (mild/moderate/severe) unchanged for intubated patients. The global definition is NOT yet universally adopted — Berlin remains current clinical standard; both may appear in exam.

Berlin Definition (2012) — Intubated Patients

200–300Mild (P:F, mmHg)

100–200Moderate

<100Severe

≤315SpO₂/FiO₂ (global def, SpO₂ ≤97%)

ℹ️Berlin criteria ALL required: (1) onset ≤1 week of known insult; (2) bilateral opacities not fully explained by effusion/collapse/nodules; (3) respiratory failure not fully explained by cardiac failure/overload; (4) PEEP ≥5 cmH₂O. P:F ratio calculated on current PEEP setting.

Lung-Protective Ventilation — ARDSNet/ARMA Trial

6 ml/kgTidal volume (IBW)

<30Plateau pressure (cmH₂O)

<15Driving pressure (cmH₂O)

88–95%SpO₂ target

4.5–6.0PaCO₂ target (kPa)

IBW FormulaMales: 50 + 0.91 × (height cm − 152.4) Females: 45.5 + 0.91 × (height cm − 152.4)

🔵 Driving Pressure — Independently PrognosticDriving pressure (Pplat − PEEP) independently associated with mortality even when Vt and Pplat are within targets (Amato 2015, NEJM). Target <15 cmH₂O. May need to reduce PEEP (not just Vt) if driving pressure elevated on high PEEP settings.

PEEP Strategy

ARDSNet low PEEP table: titrate PEEP to FiO₂ (e.g., FiO₂ 0.4 → PEEP 5; FiO₂ 0.8 → PEEP 14)
Higher PEEP: no mortality benefit in ALVEOLI, LOVS, ExPress trials; may improve oxygenation
ART Trial (2017) — HARM: staircase RM (40/40 RM + high PEEP) increased 28-day mortality. Aggressive sustained inflation RMs are harmful — do NOT use

Prone Positioning — PROSEVA Trial

✅Prone if P:F <150 on FiO₂ ≥0.6 + PEEP ≥5 cmH₂O for ≥16 hours/day. PROSEVA: 28-day mortality 16% vs 33% (NNT ~6). This is an absolute treatment, not just oxygenation rescue. Continue until sustained P:F >150 on FiO₂ ≤0.6 after ≥4h supine; minimum 4 sessions before abandoning. Apply in moderate-severe ARDS proactively.

NMB — ACURASYS vs ROSE

ACURASYS (2010)

48h cisatracurium in P:F <150; reduced 90-day mortality & barotrauma; confounded by deep sedation in control arm

ROSE Trial (2019)

Early NMB vs light sedation control — NO mortality benefit. Control arm RASS 0 to −1 (key difference from ACURASYS)

⚠️Routine early NMB NOT recommended. Use NMB for: severe ventilator dyssynchrony unresponsive to sedation, refractory hypoxia (P:F <100 despite prone + optimised vent), ICP management. Always pair with adequate analgesia/sedation when using NMB.

HFOV — Contraindicated

🚫OSCILLATE (2013) stopped early — increased in-hospital mortality in HFOV arm. OSCAR neutral. HFOV is NOT recommended in adult ARDS. This is a harm-causing intervention.

VV-ECMO — CESAR & EOLIA

CESAR (2009): transfer to ECMO centre improved 6-month survival (63% vs 47%); limitation — control arm did not always receive optimised conventional ventilation
EOLIA (2018): VV-ECMO in P:F <80 — 60-day mortality 35% vs 46%, p=0.07 (NS primary endpoint); 28% crossover to ECMO in control; treatment effect likely real, underpowered
Current practice: consider VV-ECMO as rescue in refractory severe ARDS (P:F <80 despite prone, NMB, optimised vent) at ECMO-capable centre

Corticosteroids in ARDS — DEXA-ARDS

✅DEXA-ARDS (2020): Dexamethasone 20 mg/day × 5d then 10 mg × 5d in moderate-severe ARDS — reduced 60-day mortality (21% vs 36%) and increased ventilator-free days. Consider early dexamethasone in P:F <200. RECOVERY trial (dexamethasone 6 mg in COVID) — benefit only in those requiring O₂/ventilation, not in mild/no supplemental O₂ group.

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AKI & RRT — KDIGO 2012 (Updated 2024)

KDIGO Staging · RRT Timing · CRRT Dose · Anticoagulation · What Doesn't Work

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Stage	Creatinine	Urine Output
1	×1.5–1.9 baseline (7 days) OR ≥26 µmol/L rise (48h)	<0.5 ml/kg/hr for 6–12h
2	×2.0–2.9 baseline	<0.5 ml/kg/hr for ≥12h
3	×3.0 baseline OR ≥354 µmol/L OR initiation of RRT	<0.3 ml/kg/hr ≥24h OR anuria ≥12h

🔵 2024 KDIGO Update — BiomarkersKDIGO 2024 incorporates biomarkers for AKI risk stratification: TIMP-2 × IGFBP-7 (NephroCheck) ≥0.3 (ng/ml)²/1000 — identifies patients at high risk for AKI within 12h; can guide early intervention. NGAL (urinary/plasma) — less specific but established. Furosemide stress test: 1 mg/kg IV (naive) — urine output <200 ml in 2h = progression to Stage 3 likely. These are emerging risk stratification tools, not diagnostic criteria.

RRT Indications — AEIOU

🔴 Absolute / Urgent

Acidosis — refractory (pH <7.1)
Electrolytes — K⁺ >6.5 or ECG changes
Ingestion — dialysable toxins (Li, salicylates, methanol, ethylene glycol, metformin)
Overload — refractory pulmonary oedema
Uraemia — encephalopathy, pericarditis, neuropathy

🟠 Threshold-Based

Urea >30–35 mmol/L (rising)
Creatinine >500 µmol/L (context-dependent)
Oliguria <200 ml/12h unresponsive to optimisation
Stage 3 AKI + multi-organ failure

⚠️ Exam Trap — No Benefit to Early RRTSTARRT-AKI (2020) and AKIKI (2016): early RRT vs delayed — NO mortality benefit; early initiation associated with more adverse events (hypotension, hypophosphataemia). Do NOT start RRT on KDIGO staging alone without a clinical AEIOU indication.

CRRT — Mode, Dose, Anticoagulation

20–25CRRT effluent dose (ml/kg/hr)

25–30Prescribed dose to deliver 20–25

1.2–1.4IHD Kt/V per session

ℹ️ATN and RENAL trials: higher CRRT doses (35–45 ml/kg/hr) NOT superior to 20–25 ml/kg/hr. Prescribed dose ≠ delivered dose — downtime reduces delivery; prescribe 25–30 to achieve 20–25 ml/kg/hr delivered. CVVHDF has marginal advantage over CVVH/CVVHF for solute clearance.

Regional citrate anticoagulation (RCA) — preferred; anticoagulates circuit without systemic effect; prolongs filter life; monitor ionised Ca²⁺: circuit 0.25–0.35 mmol/L; systemic 1.0–1.2 mmol/L; contraindicated in severe liver failure (citrate accumulation — citrate toxicity: rising AG, rising total:ionised Ca²⁺ ratio)
Systemic UFH — alternative; APTT 45–65 sec; HIT risk
Argatroban — anticoagulant of choice in confirmed HIT requiring CRRT

What Does NOT Work (Abandoned Practices)

Low-dose dopamine ("renal dose"): DAG trial — no benefit; abandoned
NAC/NaHCO₃ for contrast nephropathy: PRESERVE trial — no benefit over IV saline
Furosemide: does NOT prevent or treat AKI — only treats fluid overload; forced diuresis is harmful
Routine furosemide stress test-guided RRT initiation: emerging but not standard of care

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Cardiac Arrest — Resus Council UK / ERC 2025 RCUK 2025

ALS · PARAMEDIC2 · TTM2 · COACT/TOMAHAWK · Post-ROSC · Neuroprognostication

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📋RCUK/ERC 2025 (published Oct 2025, into courses Jan 2026): No major change to the adult ALS algorithm vs 2021. Core priorities retained: early recognition, high-quality compressions with minimal interruptions, early defibrillation, treat reversible causes. New emphasis on effective ventilation and correct pad placement. Adrenaline timing unchanged (early in non-shockable; after 3rd shock in shockable). New mentions: CPR-induced consciousness (manage with sedation/analgesia) and eCPR in specialist centres for refractory arrest.

4H's

Hypoxia
Hypovolaemia
Hypo/Hyperkalaemia (metabolic)
Hypothermia

4T's

Tension pneumothorax
Tamponade
Toxins
Thromboembolism (PE/coronary)

1 mgAdrenaline (every 3–5 min)

300 mgAmiodarone (after 3rd shock)

150 mgAmiodarone (2nd dose)

⚠️ Exam Trap — Atropine RemovedAtropine was removed from the ALS algorithm in 2010. It is NOT recommended for cardiac arrest, PEA, or asystole. Do not select it as a cardiac arrest drug.

💊PARAMEDIC2 (2018): Adrenaline improves ROSC and 30-day survival (3.2% vs 2.4%) but NOT neurologically favourable survival (2.2% vs 1.9%, p=0.49). Adrenaline remains guideline-recommended but its benefit is predominantly physiological survival without quality-of-life benefit.

Post-ROSC Care — RCUK 2025 (ABC approach)

94–98%SpO₂ — controlled oxygenation, avoid hyperoxia

4.5–6.0PaCO₂ — normocapnia (kPa)

>100 / 60–65SBP (mmHg) OR MAP 60–65

6–10Glucose (mmol/L)

🔄2025 BP target change Changed 2025: target systolic >100 mmHg or MAP 60–65 mmHg (2021 simply specified MAP ≥65 and avoiding hypotension). Use whichever your unit references — both are now within guidance.

12-lead ECG immediately — STEMI or strong suspicion of coronary occlusion → immediate coronary angiography regardless of neurological status
No STEMI → COACT (2019) + TOMAHAWK (2021): immediate angiography does NOT improve 90-day survival vs delayed selective angiography in OHCA without STEMI. Do NOT routinely take to cathlab without STEMI.
Whole-body CT recommended to identify non-coronary causes (e.g. PE, intracranial haemorrhage, aortic dissection) where cause uncertain Emphasised 2025
Seizures: treat with levetiracetam or sodium valproate. Routine seizure prophylaxis and neuroprotective drugs are NOT recommended

Temperature Management — TTM2 (2021) + RCUK 2025

🌡️TTM2 (2021): Hypothermia 33°C vs targeted normothermia — NO difference in 6-month mortality or neurological outcome. Active cooling to 33°C no longer routinely recommended. RCUK 2025 Changed 2025: actively prevent fever, target ≤37.5°C, with temperature control maintained for 36–72h in comatose patients (2021 wording was ≤37.7°C). Continuous EEG to detect seizures.

Neuroprognostication — Multimodal, ≥72h Post-ROSC

🧠No single test sufficient. Multimodal approach required. Assess no earlier than 72h post-ROSC (or 72h post-rewarming). Must exclude confounders: residual sedation, hypothermia, metabolic disturbance. RCUK 2025: withdrawal of life-sustaining therapy (WLST) must be a separate decision from prognostication, based on wider clinical and patient-centred factors — not driven solely by a prognostic test result.

Test	Poor Prognosis Indicator	Notes
Pupils (Day 3)	Bilaterally absent NPR	Quantitative pupillometry (NPR <0.1) reduces subjectivity
SSEP (Day 3+)	Bilateral absent cortical N20	Lowest false positive rate — most robust single test
EEG (Day 2+)	Burst suppression / flat / persistent seizures	Reactive EEG = better prognosis; continuous monitoring preferred
NSE (48–72h)	>60 µg/L	Haemolysis causes false elevation — always check
CT Brain (≥24h)	Diffuse anoxic injury (grey-white ratio <1.22)	Early CT may underestimate injury
MRI (Day 2–7)	Diffuse DWI restriction	Most sensitive imaging modality

🔵 Self-Fulfilling Prophecy WarningPremature withdrawal based on single pessimistic test risks self-fulfilling prophecy. Even with absent SSEP N20, 4–7% recover. Holistic decision with family. At least 2 concordant poor-prognosis tests required before considering withdrawal — never on one test alone.

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Special Circumstances in Resuscitation — RCUK/ERC 2025 RCUK 2025

Hypothermia · Drowning · Toxins · Hyperkalaemia · Anaphylaxis · PE · Pregnancy

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📋Standard ALS algorithm remains the foundation. Always address the 4Hs/4Ts. 2025 reinforces rapid recognition and treatment of reversible causes beyond ischaemic heart disease, and selective eCPR in refractory arrest — particularly hypothermia, thrombosis (PE), or toxins. Common SBA territory — know the algorithm modifications.

Accidental Hypothermia — Algorithm Modifications

🧊"Not dead until warm and dead." Measure core temp with a low-reading thermometer; use the Swiss Staging System if unmeasurable. Transfer patients in arrest (or at risk of imminent arrest) directly to an ECLS/ECPR centre for rewarming.

VF persisting after 3 shocks: withhold further defibrillation attempts until core temp >30°C
Adrenaline below 30°C: withhold — it accumulates and may do more harm than good. 30–35°C: double the dosing interval (i.e. every 6–10 min); normal interval only once >35°C
Core temp <28°C and continuous CPR not feasible: delayed or intermittent CPR is acceptable during extrication/transfer
Rewarming is the priority; ECMO/cardiopulmonary bypass is the rewarming method of choice in arrest

Drowning

🌊Cardiac arrest in drowning is fundamentally hypoxic. Give 5 initial rescue breaths/ventilations before chest compressions Mainstream 2025 (previously emphasised mainly for trained rescuers). Correct hypoxia early; expect a primary respiratory cause. Hypothermia frequently coexists — combine algorithms.

Toxins / Poisoning

Supportive ALS + specific antidotes; consider prolonged CPR and eCPR as toxin is metabolised/cleared
Opioids: naloxone (restores ventilation; does not replace CPR in arrest)
Local anaesthetic systemic toxicity (LAST): 20% lipid emulsion (Intralipid) — 1.5 mL/kg bolus then infusion; stop the LA
Beta-blocker/Ca-channel blocker: high-dose insulin euglycaemia, calcium, glucagon, vasopressors
TCA: sodium bicarbonate for QRS widening/arrhythmia
Cyanide: hydroxocobalamin · Digoxin: DigiFab
Contact TOXBASE / National Poisons Information Service early

Life-Threatening Hyperkalaemia (arrest)

⚡Calcium chloride 10% 10 mL IV (or calcium gluconate 10% 30 mL) for cardioprotection, then 10 units soluble insulin + 25 g glucose IV to shift K⁺. Consider sodium bicarbonate and dialysis. In arrest, give these alongside standard ALS.

Anaphylaxis (RCUK Emergency Treatment)

💉IM adrenaline 0.5 mg (0.5 mL of 1:1000) into the anterolateral thigh at first suspicion; repeat after 5 min if no improvement. Remove trigger; high-flow O₂; early IV crystalloid bolus. Refractory anaphylaxis (≥2 IM doses without improvement): start IV adrenaline infusion by experienced clinicians. Antihistamines/steroids are no longer first-line and have a reduced/de-emphasised role. Measure mast cell tryptase.

Massive PE & Pregnancy

Suspected PE arrest: consider thrombolysis (e.g. alteplase) — if given, continue CPR for 60–90 min before terminating. Consider eCPR/surgical embolectomy
Pregnancy ≥20 weeks: manual left uterine displacement, standard ALS, and resuscitative hysterotomy (perimortem CS) within 5 min of arrest, at the bedside — aids maternal resuscitation by relieving aortocaval compression Term 2025: "resuscitative hysterotomy"

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Paediatric Life Support (PLS / EPALS) — RCUK/ERC 2025 RCUK 2025

5 rescue breaths · 15:2 · weight-based drugs · fluid 10 mL/kg · vasoactives

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📋Paediatric = 0–18 yrs (infant = neonate–1 yr; child = 1–12 yr; adolescent = 13–18 yr). Cardiac arrest in children is usually secondary to hypoxia/respiratory or circulatory failure — prevention via early recognition (structured tools, ABCDE) and prompt resuscitation is the priority. 2025 adds a new special circumstances chapter and paediatric post-resuscitation care.

Core BLS / ALS Sequence

5Initial rescue breaths before CPR

15:2Compression:ventilation (2 rescuers)

100–120Compression rate (min⁻¹)

⅓Chest depth (AP diameter)

Key Weight-Based Drug Doses

Drug	Dose	Notes
Adrenaline (arrest)	10 mcg/kg IV/IO (0.1 mL/kg of 1:10,000)	Every 3–5 min; max single dose 1 mg
Amiodarone	5 mg/kg IV/IO bolus (max 300 mg)	After 3rd and 5th shocks (shockable)
Defibrillation	4 J/kg	2025: may escalate to a max of 360 J for refractory VF/pVT
Fluid bolus	10 mL/kg balanced crystalloid	2025 Changed: adolescents (14+) up to 500 mL per bolus (was 250 mL); reassess after each
Glucose	2 mL/kg of 10% dextrose	For documented hypoglycaemia
Adrenaline (anaphylaxis IM)	<6 mo 100–150 mcg; 6 mo–6 yr 150 mcg; 6–12 yr 300 mcg; >12 yr 500 mcg	Repeat after 5 min

2025 Updates Worth Knowing

Vasoactives: noradrenaline = first-line vasopressor; adrenaline = first-line inotrope; milrinone = first-line inodilator. Start early — not later than after 3–4 fluid boluses (30–40 mL/kg)
Pre-arrest hypotensive/bradycardic child: small incremental IV adrenaline 1–2 mcg/kg
Use POCUS to guide IV/IO access and identify reversible causes (e.g. tamponade)
Consider early eCPR (or open-chest compressions if eCPR unavailable) when conventional CPR is failing in suitable cases
New special-circumstances focus: trauma, asthma, drowning, hypothermia

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Newborn Life Support (NLS) — RCUK/ERC 2025 RCUK 2025

3:1 ratio · 5 inflation breaths · air in term · cord clamping · adrenaline q4min

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📋Newborn arrest is almost always respiratory/hypoxic — aeration of the lungs is the single most important step. Ratios differ fundamentally from paediatric/adult ALS — do not confuse them.

Core Sequence

5Inflation breaths (each 2–3 s)

3:1Compression:inflation ratio

<60HR (min⁻¹) → start CPR after 30 s good ventilation

30Inflation pressure (cmH₂O, term)

Inflation breaths: 5 sustained inflations (~2–3 s each). If HR not improving, the commonest problem is failure to aerate the lungs — recheck airway/seal/technique before escalating
Compressions: start only if HR <60/min despite 30 s of effective ventilation that moves the chest. Rate ~90 compressions + 30 inflations per min (3:1)
Oxygen: start in air (21%) for term; titrate to pre-ductal SpO₂ targets. Preterm <32 wk start 21–30%
Adrenaline: 0.2 mL/kg of 1:10,000 (20 mcg/kg) IV/IO if HR <60 despite ventilation + compressions; repeat every ~4 min Standardised 2025
Glucose: 2.5 mL/kg 10% dextrose for hypoglycaemia post-resuscitation

2025 Changes New

Less emphasis on skin colour for assessment (unreliable across skin tones) — prioritise heart rate, breathing, tone, response to stimulation
Sodium bicarbonate no longer recommended
Airway: two-person jaw thrust, earlier use of supraglottic airway, and video laryngoscopy where available
Out-of-hospital newborn life support now explicitly included (home births, unexpected births, ambulance care)
Cord: deferred cord clamping ≥60 s if no resuscitation needed; clamp <30 s if resuscitation required (or intact-cord stabilisation if safe, especially <34 wk)
Post-resus: temperature control (avoid hyper-/hypothermia; therapeutic hypothermia for HIE per local pathway), glucose management, early prognostic assessment, family involvement

⚠️ Exam Trap — RatiosNewborn = 3:1. Paediatric = 15:2 (2 rescuers). Adult = 30:2. A baby who adapted to extrauterine life then collapses (e.g. presents to A&E) is resuscitated on the paediatric (15:2) algorithm, not NLS.

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Acute Asthma — BTS/SIGN (SIGN 158, amended 2024)

Severity grading · O₂ 94–98% · steroids · IV magnesium · ICU triggers

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📋The Nov 2024 BTS/NICE/SIGN guideline covers diagnosis and chronic management only. Acute asthma is still governed by the amended 2019 BTS/SIGN guideline (SIGN 158) within the joint asthma pathway — the severity grading and acute treatment below are unchanged and remain exam-stable.

Severity Grading (PEF % best or predicted)

Level	PEF	Defining features
Moderate	50–75%	Increasing symptoms; no features of acute severe
Acute severe	33–50%	Any one of: RR ≥25; HR ≥110; cannot complete sentences in one breath
Life-threatening	<33%	Any one of: SpO₂ <92%, PaO₂ <8 kPa, normal/rising PaCO₂, silent chest, cyanosis, poor effort, exhaustion, ↓GCS, arrhythmia, hypotension
Near-fatal	—	Raised PaCO₂ and/or requiring mechanical ventilation with raised inflation pressures

⚠️ Exam Trap — Normal/Rising CO₂A normal or rising PaCO₂ in acute asthma is a life-threatening sign (the patient should be hyperventilating and hypocapnic — a "normalising" CO₂ means they are tiring). It mandates senior/ICU review and consideration of ventilation. Do not be reassured by a "normal" gas.

Management (acute severe / life-threatening)

Oxygen: titrate to SpO₂ 94–98%; nebulisers oxygen-driven (≥6 L/min)
Salbutamol: nebulised 5 mg, repeat / back-to-back; continuous 5–10 mg/hr if poor response
Ipratropium: 0.5 mg nebulised 4–6 hourly (add in severe/life-threatening or poor response)
Steroids: prednisolone 40–50 mg PO OD, or hydrocortisone 100 mg IV QDS if cannot swallow — continue ≥5 days
IV magnesium sulfate 1.2–2 g over 20 min — single dose, in acute severe with poor response to initial bronchodilators (senior decision). Note: 3Mg trial showed no clear benefit; nebulised magnesium not recommended
Senior/ICU: consider IV salbutamol or IV aminophylline (pro-arrhythmic, unproven in life-threatening) → escalation to invasive ventilation

🔵 Ventilation in AsthmaIntubation/IPPV is high-risk: severe bronchospasm causes dynamic hyperinflation / breath-stacking and gas trapping (auto-PEEP), risking barotrauma and hypotension. Ventilate with low rate, long expiratory time, permissive hypercapnia; ketamine is a useful induction agent (bronchodilatory). Watch for tension pneumothorax and the need to disconnect/decompress the chest if sudden cardiovascular collapse.

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AECOPD & NIV — NICE NG115 + BTS/ICS AHRF 2016

O₂ 88–92% · NIV pH 7.25–7.35 · IPAP/EPAP · IMV threshold

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📋Acute exacerbation of COPD (AECOPD): NICE NG115 for medical management; BTS/ICS Guideline for the Ventilatory Management of Acute Hypercapnic Respiratory Failure (AHRF), 2016 for oxygen and NIV. AHRF complicates ~20% of AECOPD admissions and signals advanced disease.

Acute Medical Management (one-page summary)

AECOPD — Stepwise Approach

O₂

Controlled oxygen — target SpO₂ 88–92%

Use a 24% or 28% Venturi mask. Obtain ABG; repeat after 30–60 min. Hypercapnic/acidotic patients are at risk of CO₂ narcosis with uncontrolled O₂. The 88–92% target applies to all causes of AHRF.

Bronchodilators

Nebulised salbutamol + ipratropium. If hypercapnic/acidotic, drive nebulisers with air (or O₂ for ≤6 min) to avoid worsening hypercapnia.

Corticosteroids + antibiotics

Prednisolone 30 mg PO for 5 days. Antibiotics only if clinical signs of infection (purulent sputum / consolidation / raised inflammatory markers).

Decide on ventilatory support — repeat ABG

If persistent respiratory acidosis after ≥1 h of optimal therapy → NIV. Theophylline only if inadequate response; doxapram only if NIV unavailable/unsuitable.

NIV — Indications & Thresholds (BTS/ICS 2016)

7.25–7.35pH window — strongest NIV indication

>6.5PaCO₂ (kPa) defining hypercapnia

<7.25More severe — trial NIV in HDU/ICU, low threshold for IMV

88–92%SpO₂ target on NIV

Indication: AECOPD with respiratory acidosis (pH <7.35 + PaCO₂ >6.5 kPa) persisting despite ≥1 h optimal medical therapy and controlled O₂
Starting settings: IPAP ~15 cmH₂O, titrate up by 2–5 to 20–30 as tolerated to correct CO₂; EPAP ~4–5 cmH₂O. Repeat ABG ~1 h after each change
NOT indicated: hypercapnia without acidosis (treat medically); pure metabolic acidosis; or where intubation is clearly more appropriate
Ceiling of care: document at initiation whether NIV is a trial before IMV or the ceiling — escalation plan must be explicit
CPAP not NIV: first-line for cardiogenic pulmonary oedema with persistent hypoxia (NIV reserved if CPAP fails)

⚠️ Exam Trap — Acidosis, Not CO₂, Drives NIVNIV is indicated for hypercapnia with acidosis. A chronically hypercapnic COPD patient with a compensated, normal pH does not need NIV — optimise medical therapy and controlled oxygen. The reversible, acute respiratory acidosis is the target.

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Key NICE Guidelines for UK ICU Practice

Sepsis NG51 · Head injury NG232 · AKI NG148 · Anaphylaxis · Stroke

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📋UK SBAs frequently test the NICE position where it differs from international guidance. The high-yield ones below complement the dedicated cards elsewhere (Sepsis/SSC, SAH NG228, Organ Donation NG135).

Sepsis — NICE NG51 (updated Jan 2024)

2024 change: risk stratification now anchored to NEWS2 in adults ≥16 (not pregnant) in acute hospital/ambulance settings — two mortality inflection points: NEWS2 ≥7 (highest), 5–6 (intermediate), ≤4 (lower)
Reasserts clinical judgement over rigid triggers; comprehensive risk assessment by a clinician at FY2-equivalent or above
Antibiotic timing tiered by risk (per AoMRC 2022): highest-risk/meets high-risk criteria → broad-spectrum antibiotics within 1 hour; lower-risk groups allow time for assessment/investigation rather than blanket 1-hour dosing
Lactate >2 and especially >4 mmol/L marks higher risk; senior review and source control remain core

Head Injury — NICE NG232 (2023)

🧠CT head within 1 hour if any of: GCS <13 on initial assessment; GCS <15 at 2 h; suspected open/depressed skull fracture; sign of basal skull fracture; post-traumatic seizure; focal neurological deficit; >1 episode of vomiting.

CT head within 8 hours for LOC or amnesia plus: age ≥65; bleeding/clotting disorder; dangerous mechanism; >30 min retrograde amnesia
Anticoagulated (e.g. warfarin/DOAC) with any head injury and no other indication → CT head within 8 hours
ICU relevance: maintain CPP, avoid hypoxia/hypotension/hypercapnia; detail in the TBI card (BTF) — these are management thresholds, NG232 is the imaging-selection tool

Other High-Yield NICE Points

AKI (NG148): nephrotoxin review, accurate fluid/urine output; refer for RRT discussion by nephrology/critical care if not responding — staging is KDIGO (see AKI card)
Anaphylaxis (NG134): admit/observe after treatment; measure mast cell tryptase (ASAP, ~1–2 h, and ≥24 h baseline); prescribe two adrenaline auto-injectors and refer to specialist clinic
Stroke (NG128): thrombolysis (alteplase/tenecteplase) within 4.5 h of onset after haemorrhage excluded; thrombectomy up to 24 h in selected large-vessel occlusion with favourable imaging
Cardiac arrest framing: NICE does not produce the ALS algorithm — that is RCUK/ERC 2025 (see Cardiac Arrest card). NICE/NCEPOD inform escalation, recognising deterioration (NEWS2) and post-arrest pathways

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Death by Neurological Criteria — AoMRC 2008 UK ONLY

Preconditions · 7 Brainstem Tests · Apnoea Protocol · Spinal Reflexes · Confirmatory Tests

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🇬🇧UK uses "Death by Neurological Criteria" (DNC) — not "brain stem death" or "brain death" (philosophical ambiguity). Death is legally declared at the time of the first set of tests. Criteria differ from US (where confirmatory EEG/cerebral angiography may be required) — do NOT apply non-UK criteria in the exam.

Preconditions — ALL Must Be Met

Known irreversible structural brain injury consistent with DNC — aetiology must be established
Patient is deeply comatose + apnoeic + mechanically ventilated
All potentially reversible causes excluded

Exclusions to Eliminate Before Testing

Sedatives/opioids — allow ≥5 half-lives; check drug levels
Core temperature <34°C — warm before testing
Severe metabolic disturbance (Na, glucose, phosphate)

Neuromuscular blocking agents — confirm with train-of-four
Endocrine: hypothyroidism, Addisonian crisis
Reversible circulatory cause

7 Brainstem Reflex Tests

Pupils: no response to bright light (CN II, III) — need not be maximally dilated, just unreactive
Corneal reflex: no blink to light touch (CN V, VII)
Vestibulo-ocular (caloric): no eye movement to 50 ml ice-cold water each ear (CN VIII, III, VI) — observe 1 minute each side; canal must be unobstructed
Pain (cranial nerve territory): no motor response to deep supra-orbital pressure or jaw pressure — note: limb response is spinal and does NOT invalidate
Gag reflex: no response to posterior pharyngeal stimulation (CN IX, X)
Cough reflex: no cough on deep tracheal suction (CN X)

Apnoea Test — Exact Protocol

Pre-oxygenate FiO₂ 1.0 for ≥10 min; ensure PaO₂ >26.6 kPa (oxygen reserve)
Baseline PaCO₂ must be ≥5.3 kPa before disconnection (if low, briefly hypoventilate)
Disconnect ventilator; insufflate O₂ at carina (6 L/min) to prevent desaturation
Observe 5 minutes for spontaneous respiratory effort
Perform ABG: test confirms DNC if PaCO₂ ≥6.0 kPa AND pH <7.40 — demonstrates adequate hypercapnic drive was present; no respiratory response = DNC confirmed
Abandon if haemodynamic instability or SpO₂ falls — reconnect, reschedule

2Doctors required

≥5 yrsPost-full registration

2Separate test sets

1st setLegal time of death

🔵 Critical Distinctions — Exam Favourites (1) Spinal reflexes (Lazarus sign: limb flexion/extension, finger movements) CAN persist after DNC — they do NOT invalidate the diagnosis. They are spinally mediated. Warn families and staff.

(2) Confirmatory tests (EEG, cerebral angiography, CT perfusion) are NOT required in the UK — unlike some countries. They may be used if brainstem tests cannot be completed (e.g., severe facial/petrous fractures).

(3) Neither doctor can be a member of the transplant team. At least one must be a consultant.

(4) A new DNACPR/ReSPECT form is NOT required — DNC documentation is specific and separate from resuscitation planning documents.

Tier 2 — High Yield Numbers, nuances and trial distinctions tested

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Sedation, Analgesia & Delirium — PADIS 2018 CURRENT

ABCDEF Bundle · Sedation Scales · Drug Choice · PICS · Propofol Infusion Syndrome

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💡ABCDEF Bundle: A=Assess/manage Analgesia, B=Both SAT+SBT daily, C=Choice of sedation/analgesia, D=Delirium screen/manage, E=Early mobility/Exercise, F=Family engagement. Bundle adherence associated with reduced mortality, delirium, and ICU stay.

Scale	Range	ICU Target	Notes
RASS	−5 to +4	−2 to 0	0=alert; −5=unarousable; deep sedation (≤−3) associated with 180-day mortality
SAS	1–7	2–3	4=calm/cooperative; 1=unarousable
CPOT	0–8	<2	Pain scale for non-verbal; ≥3 = significant pain requiring treatment
BPS	3–12	<5	3 components × 1–4; validated in non-communicative patients

Sedation Agent Choice

Dexmedetomidine (alpha-2 agonist): preserves arousability; preferred for agitated delirium and weaning; less delirium vs midazolam (MENDS trial) and lorazepam; not for deep sedation; bradycardia/hypotension side effects
Propofol: flexible, titratable; risk of Propofol Infusion Syndrome (PRIS) at doses >4 mg/kg/hr for >48h — lactic acidosis, rhabdomyolysis, renal failure, new RBBB/Brugada-like ST changes, cardiac failure; treat by stopping propofol immediately; ECG monitoring recommended on high doses
Benzodiazepines: increased delirium, prolonged ventilation (MENDS, SLEAP trials) — avoid in general ICU; reserve for alcohol withdrawal (CIWA protocol), status epilepticus, specific anxiety disorders
Ketamine: NMDA antagonist; bronchodilator; opioid-sparing; procedural sedation; emerging evidence as analgesic adjunct reducing opioid consumption; may increase secretions

⚠️ Deep Sedation — Independently HarmfulDeep sedation (RASS −3 to −5) in first 48h is independently associated with 180-day mortality (SPICE trials). RASS ≤−3 appropriate ONLY for: refractory ICP, severe ARDS requiring NMB/prone, status epilepticus, procedural necessity. Do not default to deep sedation.

Delirium — Screening, Prevention, Treatment

CAM-ICU: 4 features — (1) Acute onset/fluctuation, (2) Inattention, (3) Altered consciousness (RASS ≠ 0), (4) Disorganised thinking; CAM-ICU+ = features 1+2 + either 3 or 4
ICDSC: 8-item; ≥4 = delirium; 1–3 = subsyndromal delirium (also has prognostic significance)
Haloperidol: HOPE-ICU + MIND-USA — no reduction in delirium duration. May use for symptom control (distress/agitation) but does NOT treat underlying delirium
Non-pharmacological: reorientation, day/night cycle, early mobilisation, hearing aids/glasses, dehydration prevention — primary prevention strategy

Post-Intensive Care Syndrome (PICS)

🔮PICS = cognitive impairment + PTSD/anxiety/depression (up to 50% of survivors) + ICUAW. ICUAW in 25–60% of prolonged ICU admissions; risk: NMB, deep sedation, hyperglycaemia, inactivity. GPICS V3 (2026) recommends ICU follow-up clinic for all level 3 patients; rehabilitation pathway from ICU through hospital and beyond. The exam increasingly tests PICS awareness and prevention strategies (light sedation, mobilisation, family involvement).

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Glycaemic Control — NICE-SUGAR Trial

Leuven Trials · Current Target · Hypoglycaemia Harm

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6–10Current target (mmol/L)

4.5–6.0AVOID — tight control (HARM)

7.8–10Pragmatic target some centres

<4.0Hypoglycaemia — independently harmful

Trial	Population	Target	Result
Leuven I (2001)	Surgical ICU, single centre, Ghent	4.4–6.1 mmol/L	Reduced ICU mortality — sparked enthusiasm; not reproducible
Leuven II (2006)	Medical ICU	4.4–6.1 mmol/L	No overall mortality benefit in intention-to-treat
NICE-SUGAR (2009)	Multi-centre, n=6104	4.5–6.0 vs 8–10 mmol/L	Tight control: 90-day mortality 27.5% vs 24.9% (p=0.02) — HARM

⚠️ Exam TrapNICE-SUGAR: harm driven by severe hypoglycaemia (6.8% vs 0.5%). Leuven I results likely due to nutrition differences (TPN control arm). Never select 4.5–6 mmol/L as a glucose target. Current evidence: 6–10 mmol/L with IV insulin infusion protocol.

Check glucose hourly when titrating insulin infusion
Treat hypoglycaemia (<4 mmol/L): 50 ml 50% glucose or 150–200 ml 10% glucose IV
In T2DM or ACS: accept 8–12 mmol/L to reduce hypoglycaemia risk
SC insulin is NOT appropriate for tight glycaemic control in ICU — use IV infusion

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Nutrition — ESPEN ICU 2019

Early EN · EPaNIC · CALORIES · Refeeding Syndrome · EFFORT Trial

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<48 hrsStart enteral nutrition

20–25Acute phase kcal/kg/day

1.3 g/kgProtein target /day

Day 7+Start supplemental PN only

⚠️EPaNIC (2011): Early PN (day 1) vs late PN (day 8) — late PN: more patients discharged alive, fewer infections, shorter ventilation. Early PN is harmful. Do not start PN in first week unless EN completely contraindicated.

ℹ️CALORIES trial (UK, 2014): Early PN vs early EN — NO significant mortality difference (33.1% vs 34.2%). EN remains first-line for gut integrity, lower cost, central line avoidance — but the mortality benefit of EN over PN in a pragmatic UK ICU setting is not proven.

Protein: 1.3 g/kg/day; EFFORT trial: high protein (>2.2 g/kg/day) no benefit; possible harm in AKI and ventilated subgroups — do NOT overdo protein
Glutamine: REDOXS trial — increased 6-month mortality in MOF. IV glutamine contraindicated in renal/hepatic failure. Not recommended in critically ill
Antioxidants (Vit C, selenium): CITRIS-ALI — no benefit. Not recommended routinely
Omega-3: OMEGA trial — negative. Not recommended
Indirect calorimetry = gold standard for caloric targets; predictive equations inaccurate in ICU

Refeeding Syndrome — NICE NG22

🚨At-risk: BMI <16, weight loss >15% in 3–6 months, minimal intake >10 days, pre-feeding low K⁺/Mg²⁺/PO₄³⁻. Refeeding causes intracellular electrolyte shift — hypophosphataemia is the hallmark (respiratory failure, cardiac arrhythmias, haemolysis, encephalopathy).

Replace phosphate, potassium, magnesium before starting nutrition
Thiamine 200–300 mg IV BEFORE first glucose load (prevents Wernicke's/Korsakoff's)
Start at 10 kcal/kg/day, increase slowly — no more than 50% increase per day over 4–7 days
Monitor K⁺, Mg²⁺, PO₄³⁻ daily for first week

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Fluid Resuscitation — SMART / CLASSIC / SAFE

Fluid Choice · SOSD Phases · Fluid Responsiveness Assessment · Colloids

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✅SMART (2018): Balanced crystalloids (PlasmaLyte/LRS) vs 0.9% NaCl — balanced crystalloids reduced MAKE30 (composite of death, RRT, creatinine doubling), especially in sepsis. Use balanced crystalloids as default resuscitation fluid.

Fluid	Use	Avoid / Notes
Hartmann's / LRS	Default resuscitation; 1st line	Avoid in TBI (slightly hypotonic — use 0.9% NaCl); pH 6.5 but metabolised to bicarbonate
PlasmaLyte	Preferred balanced; more physiological pH/composition	Higher cost than LRS
0.9% NaCl	TBI, hypochloraemic alkalosis, drug dilution	Large volume → hyperchloraemic acidosis + AKI (SMART, SPLIT)
4.5% Albumin	SBP prophylaxis in cirrhosis; large volume paracentesis (>5L) — 8g/L removed	SAFE trial: no benefit vs saline in general sepsis; ALBIOS — no benefit in septic shock
HES/Starches	None	CONTRAINDICATED in sepsis/critically ill: CHEST + 6S — increased AKI, RRT, mortality
Gelatins	Limited; not recommended in sepsis	Risk of anaphylaxis, coagulopathy; no outcome data

SOSD Phases of Fluid Therapy

ResuscitationEmergency perfusion restoration

OptimisationFluid-responsive preload optimisation

StabilisationMaintenance; minimise positive balance

De-escalationActive negative balance / diuresis / UF

Fluid Responsiveness Assessment

PLR (Passive Leg Raise) + CO measurement: gold standard dynamic test; raise legs 45° for 1 min (autotransfusion ~300 ml); CO increase ≥10–15% = fluid responsive; reversible, no fluid given, valid in AF and spontaneous breathing
PPV (Pulse Pressure Variation) >13%: fluid responsive — ONLY valid in: (1) controlled ventilation, (2) sinus rhythm, (3) no spontaneous breaths, (4) Vt ≥8 ml/kg IBW, (5) no severe RV failure or raised intra-abdominal pressure
End-expiratory occlusion test: hold ventilation at end-expiration 15s; CO increase ≥5% = responsive; useful in spontaneously breathing patients
CVP: poor predictor of fluid responsiveness — abandoned as resuscitation endpoint (multiple trials)

🔵 SPLIT vs SMART — Apparent ConflictSPLIT trial (2015, NZ): no difference in AKI between PlasmaLyte and 0.9% NaCl. SMART (2018, larger, 15,800 patients): balanced crystalloids reduced MAKE30. The discrepancy is likely due to SMART's larger size and more septic patients. Current recommendation: balanced crystalloids preferred. SPLIT does not negate SMART.

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Blood Products — TRICC / TRISS / BSH

Restrictive Thresholds · Massive Haemorrhage · ROTEM · Reversal Agents · MINT 2023

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Population	Threshold (g/L)	Trial
General ICU (stable)	70	TRICC
Septic shock	70	TRISS — 70 = 90 g/L in septic shock
Cardiac disease / post-cardiac surgery	80	TRICS III
ACS / acute MI	80	MINT (2023) — see below
GI bleeding	70–80	Villanueva 2013, TRIGGER

⚠️ MINT Trial (2023) — Recent UpdateMINT trial in ACS patients: restrictive threshold (Hb 80 g/L) was non-inferior overall; however the pre-specified ACS subgroup had a signal favouring liberal strategy. Standard answer for ACS: transfuse if Hb <80 g/L. Know that debate continues in this subgroup.

Massive Haemorrhage Protocol (MHP) — BSH

Activate MHP early — call blood bank; do NOT wait for labs
Target ratio: 1:1:1 — FFP : Platelets : pRBC
Tranexamic Acid (TXA): give within 3 hours of injury/haemorrhage — CRASH-2 (trauma), WOMAN (PPH), CRASH-3 (mild-moderate TBI); 1g IV over 10 min then 1g over 8h; TXA >3h may be harmful
Calcium — 10% calcium gluconate 10 ml per 4 units pRBC; citrate chelation causes hypocalcaemia impairing coagulation and cardiac function
Fibrinogen: target >1.5–2.0 g/L — fibrinogen concentrate (4g) or cryoprecipitate
Platelets: target >50 ×10⁹/L; >100 ×10⁹/L if TBI/multiple trauma
"Lethal triad": hypothermia + acidosis + coagulopathy — treat all three simultaneously

ROTEM/TEG — Viscoelastic Haemostatic Assays

ITACTIC trial: VHA-guided resuscitation reduces total blood product use vs standard lab-guided
FIBTEM MCF <12 mm → fibrinogen concentrate/cryoprecipitate
EXTEM MCF <50 mm + normal FIBTEM → platelets
EXTEM CT prolonged + EXTEM/INTEM ratio >1.5 → FFP
LI60 <85% (hyperfibrinolysis) → TXA

Drug	Reversal Agent	Notes
Warfarin	PCC (4-factor) + Vit K 10mg IV	PCC faster/less volume than FFP; FFP inferior for urgent reversal
Dabigatran	Idarucizumab (Praxbind) 5g IV	Specific; dialysable
Rivaroxaban/Apixaban	Andexanet alfa (Ondexxya) or PCC 50 units/kg	Andexanet licensed; PCC pragmatic alternative
UFH	Protamine 1mg per 100 units UFH (max 50mg)	Partial reversal of LMWH only

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Traumatic Brain Injury — BTF 4th Edition 2016 CURRENT

ICP/CPP Targets · Osmotherapy · Decompression · Contraindications · Seizure Prophylaxis

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>22ICP treat above (mmHg)

60–70CPP target (mmHg)

MAP − ICPCPP formula

ℹ️Age-based SBP targets (BTF 4th Ed): ≥50 mmHg age 15–49 and >70 years; ≥60 mmHg age 50–69. Autoregulation impaired in severe TBI — CPP becomes pressure-passive; PRx monitoring can identify CPP-optimal targets.

Tier	Intervention	Notes
0 (always)	HOB 30°, neutral neck, normothermia, normoglycaemia, avoid hypotension/hypoxia	Non-negotiable baselines regardless of ICP
1 (first line)	Sedation/analgesia, CSF drainage (EVD), mild hyperventilation (PaCO₂ 4.5–5.0 kPa)	Hyperventilation: temporary bridge only — vasoconstriction causes ischaemia risk if prolonged
2 (second line)	Osmotherapy (mannitol or HTS), NMB	Monitor osmolality (mannitol <320); Na target 145–155 (HTS)
3 (rescue)	Decompressive craniectomy, barbiturate coma, hypothermia	Third-tier carries significant risk; quality of life discussion required

🔵 Mannitol vs HTS DistinctionMannitol 0.25–1 g/kg: osmolar diuresis; avoid if hypovolaemic; monitor osmolality gap (<10); max serum osmolality 320 mosmol/kg. Hypertonic saline (3%): Na target 145–155 mmol/L; no diuresis; preferred if haemodynamically unstable or when mannitol contraindicated. 23.4% HTS (30 ml) — rapid bolus for impending herniation/uncal herniation.

Contraindicated Interventions in TBI

Steroids (methylprednisolone): MRC CRASH trial — increased 14-day and 6-month mortality. Absolutely contraindicated
Therapeutic hypothermia for ICP: EUROTHERM3235 — hypothermia 32–35°C for ICP control increased unfavourable outcomes vs standard care. Do NOT use
Prophylactic hyperventilation: PaCO₂ <4.0 kPa — cerebral ischaemia; use only as temporary bridge
Hypotonic fluids (Hartmann's): worsen cerebral oedema — use 0.9% NaCl in TBI

Decompressive Craniectomy Trials

DECRA (2011)

Bifrontal DC for ICP >20 (>15 min); reduced ICP/ICU stay; worse neurological outcomes (unfavourable GOS); criticised: low threshold, surgical technique differences

RESCUEicp (2016)

DC for ICP >25 after full medical management; reduced mortality (27% vs 49%); more survivors in vegetative state (8.5% vs 2.1%); quality-of-life discussion essential

Anticonvulsant Prophylaxis

Recommended for 7 days only — reduces early post-traumatic seizures, not late epilepsy; do NOT continue beyond day 7
Levetiracetam preferred over phenytoin — fewer drug interactions; non-inferior for status epilepticus (ESETT trial)

Tier 3 — Know the Key Points & Distinctions Nuanced questions appear regularly

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DKA & HHS — JBDS 2023 CURRENT

FRIII · Euglycaemic DKA · SGLT-2i · HHS Distinction

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>11Glucose (mmol/L)

<7.3pH

<15Bicarbonate (mmol/L)

>3.0Blood ketones (mmol/L)

FRIII — JBDS 2023Fixed Rate Insulin Infusion = 0.1 units/kg/hr (actual body weight, max 15 units/hr)

DO NOT give IV insulin bolus — risk of precipitous hypoglycaemia and hypokalaemia
Continue long-acting insulin (Lantus/Levemir) at usual dose throughout — prevents rebound ketosis on stopping FRIII
Add 10% glucose 125 ml/hr when BG falls to <14 mmol/L — allows continued FRIII to clear ketones
Add potassium 40 mmol/L to fluids if K⁺ <5.5 mmol/L (confirm urine output first)
Sodium bicarbonate: NOT indicated in DKA regardless of pH — paradoxical CSF acidosis, worsens hypokalaemia, no outcome benefit. Never select in SBA

Resolution Criteria

>7.3pH

>15Bicarbonate (mmol/L)

<0.6Blood ketones (mmol/L)

Euglycaemic DKA — Increasingly Examined

🔮Euglycaemic DKA = glucose <11 mmol/L despite ketosis + acidosis. Key cause: SGLT-2 inhibitors (empagliflozin, dapagliflozin, canagliflozin) — now widespread in T2DM and heart failure with reduced EF. Also: fasting/low-carb diet, pregnancy, partial insulin use. Treat identically to standard DKA with FRIII; add 10% glucose earlier (from outset) to maintain BG 8–12 mmol/L while continuing insulin to clear ketones. Can occur in T2DM, not just T1DM.

Feature	DKA	HHS
Glucose	>11 mmol/L	>30 mmol/L
Osmolality	Variable	>320 mosmol/kg
Ketones	>3 mmol/L (strongly positive)	Absent/minimal (<3)
Acidosis	Yes (pH <7.3)	No (pH >7.3)
Insulin infusion	0.1 units/kg/hr	0.05 units/kg/hr (only if ketones >1.0)
Fluid replacement	0.9% NaCl; replace over hours	0.9% NaCl; reduce osmolality 3–8 mosmol/kg/hr; over 24–72h
VTE risk	Moderate	Very high — LMWH mandatory throughout

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Pulmonary Embolism — ESC 2019 / 2024 Update

Risk Stratification · PESI · Thrombolysis · YEARS · Duration

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Risk Category	Criteria	Management
High Risk	SBP <90 mmHg / drop ≥40 mmHg for >15 min / vasopressors required	Immediate systemic thrombolysis (alteplase 100 mg/2h); if fails/CI → surgical embolectomy or catheter-directed
Int-High	PESI III–IV or sPESI ≥1 + RV dysfunction (echo/CT) + elevated troponin	LMWH/UFH; HDU/ICU monitoring; rescue thrombolysis if deterioration
Int-Low	PESI III–IV or sPESI ≥1 — but only RV dysfunction OR troponin (not both)	Anticoagulation; hospitalisation
Low Risk	PESI I–II or sPESI 0	DOAC; early discharge/outpatient treatment

🚨Systemic thrombolysis — Alteplase 100 mg over 2h. Absolute CI: haemorrhagic stroke ever, ischaemic stroke <3 months, CNS tumour, active internal bleeding, major surgery <3 weeks, significant head trauma <3 months. In cardiac arrest secondary to PE: 50 mg IV bolus (modified regimen).

YEARS Algorithm (Diagnostic)

3 criteria: (1) signs of DVT, (2) haemoptysis, (3) PE most likely diagnosis
0 criteria: exclude if D-dimer <1000 ng/ml; ≥1 criteria: exclude if D-dimer <500 ng/ml; otherwise: CTPA
Reduces CTPA rate by ~14% vs standard Wells + D-dimer
Age-adjusted D-dimer: (age × 10 µg/L if age >50) — increases specificity for PE exclusion in elderly

DOACs preferred for stable PE — rivaroxaban 15 mg BD × 21d then 20 mg OD; apixaban 10 mg BD × 7d then 5 mg BD
Antiphospholipid syndrome: DOAC inferior to warfarin — use LMWH bridge to warfarin
Cancer-associated VTE: DOAC or LMWH (CARAVAGGIO, SELECT-D); LMWH remains option for GI tumours due to DOAC bleeding risk
Duration: provoked (surgical) = 3 months; provoked (non-surgical transient) = 3–6 months; unprovoked = indefinite extended therapy after weighing bleeding risk

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Subarachnoid Haemorrhage — NICE NG228 (2022)

Grading · Nimodipine · DCI vs Vasospasm · SIADH vs CSW

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WFNS Grade

I: GCS 15
II: GCS 13–14, no motor deficit
III: GCS 13–14 + motor deficit
IV: GCS 7–12
V: GCS 3–6

Modified Fisher (CT — vasospasm risk)

1: No SAH, no IVH
2: Thin SAH, no IVH
3: Thin SAH + IVH
4: Thick SAH ± IVH (highest risk)

60 mgNimodipine oral (q4h)

21 daysNimodipine duration

4–14DCI risk window (days)

<24 hrsSecure aneurysm (coiling preferred)

🔵 Vasospasm vs DCI — Critical DistinctionVasospasm = radiological (TCD MCA velocity >120 cm/s; CT angiography). DCI (Delayed Cerebral Ischaemia) = clinical — new neurological deficit or infarct not otherwise explained (days 4–14). Not all vasospasm causes DCI; DCI can occur without vasospasm. Treat DCI (new focal deficit), not asymptomatic vasospasm.

⚠️ SIADH vs Cerebral Salt Wasting — Critical DistinctionBoth cause hyponatraemia with high urine sodium. SIADH = euvolaemic/hypervolaemic → fluid restrict. CSW = hypovolaemic (negative sodium balance) → IV sodium replacement + fluids. Fluid restriction in CSW is DANGEROUS — worsens hypovolaemia and DCI risk. In SAH, CSW is probably more common. Assess volume status carefully — not by CVP alone.

Nimodipine reduces DCI risk — give to ALL aSAH patients regardless of severity
Induced hypertension ONLY after aneurysm secured — target SBP 160–200 mmHg for symptomatic vasospasm
Maintain euvolaemia (not hypervolaemia) — triple-H therapy no longer recommended
Cardiac complications: neurogenic stunned myocardium; ECG changes (QTc prolongation, T-wave inversion, ST changes) — not ischaemia; troponin may rise; echo shows wall motion abnormalities
Phenytoin associated with worse outcomes in SAH — use levetiracetam for seizure prophylaxis

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Acute Liver Failure — EASL / King's College Criteria

KCC · NAC · Cerebral Oedema · Coagulopathy Nuance

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Paracetamol ALF — KCC

pH <7.25 post-resuscitation (regardless of encephalopathy)
OR all 3: INR >6.5 + creatinine >300 µmol/L + Grade III–IV encephalopathy
Lactate >3.5 mmol/L at 4h or >3.0 mmol/L at 12h post-resuscitation (additional criterion)

Non-Paracetamol ALF — KCC

INR >6.5 (PT >100s) regardless of encephalopathy
OR 3 of 5: age <10 or >40; aetiology (seroneg hepatitis, halothane); jaundice→encephalopathy >7d; INR >3.5; bilirubin >300 µmol/L

N-Acetylcysteine (NAC): paracetamol ALF — effective within 24h; continue even if late presentation; also give in non-paracetamol ALF (ALFSG trial 2009 — improved transplant-free survival in Grade I–II encephalopathy 40% vs 27%)
Do NOT correct INR unless active bleeding or invasive procedure — INR reflects synthetic function, not actual bleeding risk; ROTEM more useful; VitK is reasonable (if deficient)
Cerebral oedema (Grade III–IV): ICP monitoring; mannitol 20%; hypertonic saline Na target 145–155; avoid benzodiazepines; short-acting sedation
Hypoglycaemia: common (impaired gluconeogenesis); monitor hourly; 10–50% glucose infusion
Any KCC-positive patient: discuss with liver transplant centre urgently

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Infective Endocarditis — ESC 2023 CURRENT

Duke Criteria · Surgical Indications · Endocarditis Team · Regimens

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Major Criteria

Blood cultures: typical organism ×2 or persistent bacteraemia
Echo: vegetation, abscess, new partial dehiscence of prosthetic valve, new regurgitation
Positive FDG-PET/CT or SPECT-CT (prosthetic valve — added in ESC 2023)

Minor Criteria

Predisposing condition / IV drug use
Fever >38°C
Vascular phenomena (septic emboli, Janeway lesions)
Immunological phenomena (Osler nodes, Roth spots, RF)
Positive blood culture not meeting major criteria

🔪Urgent surgery for: (1) Heart failure — severe AR/MR/valve obstruction causing pulmonary oedema/cardiogenic shock; (2) Uncontrolled infection — abscess, fistula, heart block, persistent bacteraemia >7d, increasing vegetation on antibiotics; (3) Embolism prevention — vegetation >10mm with prior embolism, >15mm mobile, >30mm isolated. Surgical timing: emergency (24h), urgent (days), elective (weeks).

🔵 Endocarditis Team — ESC 2023 Key Addition"Endocarditis team" concept enshrined in ESC 2023: cardiologist + cardiac surgeon + ID/microbiology specialist + neurologist (if embolic events) — multidisciplinary management at IE-referral centre. This is directly examinable. Mortality reduced when managed at specialist centres with endocarditis team.

Streptococcal NVE: Amoxicillin/Penicillin G × 4 weeks ± gentamicin (2 weeks only — nephrotoxicity risk)
Staphylococcal NVE: Flucloxacillin 12g/day × 4–6 weeks; MRSA → vancomycin ± rifampicin
Staphylococcal PVE: Flucloxacillin + rifampicin + gentamicin × 6 weeks (gentamicin first 2 weeks only)
Enterococcal: Ampicillin + ceftriaxone × 6 weeks (equal to ampicillin + gentamicin; less nephrotoxicity)

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Organ Donation — NHSBT / NICE NG135 CURRENT

DBD · DCD Maastricht · Opt-Out 2020 · NRP · Hormonal Resuscitation

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Maastricht Cat.	Description	UK Use
I	Dead on arrival	Rare
II	Unsuccessful resuscitation (uncontrolled DCD)	Specialist centres
III	Planned withdrawal of life-sustaining treatment (controlled DCD)	Most common UK DCD
IV	Cardiac arrest in a brain-dead patient	Occasional
V	Unexpected cardiac arrest in ICU	Emerging

⚖️Opt-out legislation: Organ Donation (Deemed Consent) Act 2019 — England; deemed consent for adults resident in England >12 months who have not opted out. Does NOT override family objection in practice. Human Tissue Act 2004 — governs consent, storage and use of human tissue. Elective ventilation solely for organ donation: NOT legal without prior consent (unlike anaesthesia for surgery).

60–80DBD MAP target (mmHg)

4–10CVP (mmHg)

<155Na target (mmol/L)

>80Hb target (g/L)

🔮Normothermic Regional Perfusion (NRP) in DCD: ECMO-based technique after cardiac arrest in Cat III DCD — restores normothermic oxygenated perfusion to abdominal organs before retrieval (arch vessels clamped to prevent brain reperfusion). Significantly improves DCD liver graft function and reduces primary non-function. Standard practice at most UK DCD centres now. Know this concept.

Hormonal resuscitation (DBD haemodynamic instability): T3 4µg bolus then 3µg/hr; vasopressin 0.5–4 u/hr; methylprednisolone 15 mg/kg IV; insulin infusion (glucose 4–8 mmol/L)
SNOD (Specialist Nurse in Organ Donation) — involve early; family approach must be separated from withdrawal decision discussion

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Tracheostomy — TRACMAN / NTSP / DAS Emergency

TRACMAN · PDT Techniques · Emergency Airway · Decannulation · Speaking Valves

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⚠️TRACMAN (2013): Early (day 1–4) vs late (>day 10) tracheostomy — NO difference in 30-day mortality, ICU stay, sedation use, or VAP. Do NOT rush to tracheostomy. Consider if ventilation anticipated >10–14 days.

NTSP Emergency Algorithm — Maturity Matters

🚨Immature stoma (<7 days): Do NOT attempt blind tracheostomy reintubation — false passage risk. Attempt oral intubation first; if fails → surgical airway (eFONA). Mature stoma (≥7 days): Attempt tracheostomy tube reinsert (same size or one smaller); if fails → oral intubation; if fails → eFONA. Mandatory bedside equipment: dilators, spare tube (same + smaller), suction, syringe, ETT.

PDT: Ciaglia Blue Rhino (single-step, guidewire, bronchoscope-guided) most common in UK
PDT contraindications: INR >1.5, Plt <50, FiO₂ >0.6, high PEEP, neck anatomy issues, <10 years age, emergency
Always bronchoscope-guided PDT — reduces posterior wall injury and malposition
Decannulation requires: GCS ≥8, cuff deflation tolerated ≥24h, secretions manageable, not ventilator-dependent, passes cough/swallow assessment
Passy-Muir speaking valve: one-way; inhalation via trache, exhalation via larynx; cuff MUST be fully deflated — otherwise obstruction; benefits: speech, swallow, secretion management

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VAP / HAP — IDSA 2016 / ESICM

Prevention Bundle · SDD Controversy · Short-Course Antibiotics · CPIS Diagnosis

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HOB 30–45°; daily sedation hold; oral chlorhexidine 0.12–0.2%; subglottic secretion drainage tubes; closed suction systems; avoid unnecessary reintubation
Short-course antibiotics: 7 days — non-inferior to 14 days; exception: Pseudomonas/Acinetobacter may need longer (8–14 days) due to relapse risk
PCT-guided de-escalation — safe, reduces antibiotic days (PRORATA)
BAL (≥10⁴ CFU/ml) — most accurate diagnosis; reduces antibiotics vs non-invasive methods

🔵 SDD/SOD Controversy — Know Both SidesSDD (selective digestive decontamination): oral + enteral non-absorbable antibiotics + short systemic cephalosporin; multiple European trials showed VAP reduction and mortality benefit (de Jonge 2003, ICHE 2009). SuDDICU trial (2022, Australia/NZ): SDD — NO 90-day mortality benefit in a setting with higher baseline antibiotic resistance than European studies. Conclusion: SDD effective in low-resistance environments; may select for MDR organisms in high-resistance settings. Not universally adopted in UK — ongoing debate.

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Obstetric Critical Care — MBRRACE / RCOG Guidelines

MgSO₄ Protocol · Magnesium Toxicity · PPH Uterotonics · Perimortem CS

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📊MBRRACE-UK — maternal mortality audit; leading causes of death: cardiovascular disease (1st), thromboembolism, neurological, sepsis. Systemic trends: indirect causes overtaking direct causes; mental health deaths; Black women at higher risk (5× white women). These inequality issues are increasingly examined.

MgSO₄ — Magpie Trial Protocol Loading: 4g IV over 5–15 min Maintenance: 1g/hr IV for ≥24h post-delivery or last seizure Recurrent seizure: 2–4g IV bolus

🚨Magnesium toxicity: Therapeutic range 2–3.5 mmol/L. Loss of patellar reflexes ~3.5–5 mmol/L → stop infusion. Respiratory arrest ~6–7.5 mmol/L. Cardiac arrest >15 mmol/L. Antidote: 10% calcium gluconate 10 ml IV — keep at bedside at all times. Monitor urine output ≥25 ml/hr; reduce dose in renal impairment.

Antihypertensives — severe PET (SBP ≥160 mmHg): Labetalol IV (20 mg bolus to 300 mg total; or 20–160 mg/hr infusion) 1st line; Hydralazine 5 mg IV boluses 2nd line; Oral nifedipine MR — effective; do not combine with MgSO₄ (hypotension/neuromuscular block)
ACEi and ARBs: CONTRAINDICATED in pregnancy
TXA (WOMAN trial): give within 3 hours of PPH; reduces death from PPH by 31%
PPH uterotonics: Oxytocin → Ergometrine (avoid in hypertension) → Carboprost (avoid in asthma) → Misoprostol PR/SL

🔵 Perimortem Caesarean SectionCardiac arrest in pregnancy ≥20 weeks: standard ALS + deliver within 5 minutes of arrest onset at the bedside (not in theatre). Aortocaval compression by gravid uterus significantly impairs CPR effectiveness and venous return. Delivery may also aid maternal resuscitation by relieving this compression.

Difficult Airway Society (DAS) Airway guidelines — high exam yield for ICM

😤

DAS 2025 — Unanticipated Difficult Tracheal Intubation NEW 2025

Plan A→D · Physiologically Difficult Airway · First-Pass Success · eFONA · Human Factors

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⚡DAS 2025 Guidelines (Ahmad et al., BJA December 2025) supersede the DAS 2015 guidelines. 65 recommendations from 3-year systematic review (1,241 papers, 3-round Delphi process). Core algorithm (Plan A→D) is maintained but substantially updated. This is now the definitive UK airway guideline.

Core Algorithm — Plan A → B → C → D

DAS 2025 Linear Algorithm — Progress rapidly if failure occurs

Tracheal Intubation

Maximise first-attempt success: correct patient positioning (ear-to-sternal notch for obese/high-risk), optimal pre-oxygenation, video laryngoscopy as primary tool, bougie/stylet use, appropriate blade size. Limit to 3 attempts maximum (including attempt by most experienced person available). Maintain oxygenation between attempts. Declare "failed intubation" at 3 attempts. Confirm placement with waveform capnography — mandatory.

Supraglottic Airway Device (SAD) Ventilation

2nd generation SAD preferred (i-gel, ProSeal LMA, Supreme LMA) — provide better seal, allow gastric tube passage. Maximum 3 attempts. If SAD successful and ventilation adequate: consider "wake up" if feasible; if proceeding under SAD, evaluate whether intubation through SAD is appropriate (Aintree technique). 2025 update: SAD can also be used as conduit for intubation via bronchoscope.

Face Mask Ventilation

2-person technique if needed (4-handed). Oral ± nasal airway adjuncts. If face mask ventilation is successful: wake patient up if possible. Assess ability to wait for further senior help vs proceed to Plan D.

Emergency Front of Neck Access (eFONA) — CICO

"Can't Intubate, Can't Oxygenate": scalpel-bougie-tube technique preferred in adults. Horizontal stab incision through skin → cricothyroid membrane → bougie (or finger dilate) → 6.0 cuffed ETT or Portex tracheostomy tube. Do NOT use needle cricothyroidotomy in adults — high failure rate, inadequate ventilation, kinking. Jet ventilation only if purpose-built device available. Confirm with capnography.

Key 2025 Updates vs 2015

Video laryngoscopy — universal use expected as primary Plan A tool; recommended as default where available (not "if video laryngoscope available" — it should be available); improves glottic view but does NOT guarantee success; tube delivery may be harder on VL without bougie
Physiologically difficult airway — new concept in 2025: patient with abnormal physiology (haemodynamic instability, severe hypoxia, high aspiration risk, metabolic acidosis) requiring modified approach regardless of anatomical difficulty; pre-oxygenation and haemodynamic optimisation before intubation
Pre-oxygenation — HFNO 60 L/min FiO₂ 1.0 for 3–5 min (apnoeic oxygenation throughout); NIV/CPAP for patients with de-saturating or respiratory failure; 25° head-up position; ear-to-sternal notch (ramp position) for obesity
First-pass success — maximising first-attempt intubation success is prioritised (not just managing failure); bougie/stylet use routine with VL; muscle relaxation (rocuronium 1.2 mg/kg) optimises laryngoscopy conditions
Human factors — team briefing, role assignment, cognitive aids (difficult airway trolley checklist), simulation training, clear communication and escalation; 2025 guidelines emphasise systems and people as much as devices
POCUS in airway — pre-tracheal ultrasound to identify cricothyroid membrane (especially in obesity/anatomically difficult), confirm tracheal tube position (ring-down artefact), confirm bilateral lung sliding post-intubation
Documentation & follow-up — mandatory: document what happened, what device worked, why failure occurred if applicable, plan for extubation/future airway. Patient letter recommended. Alert bracelet/system where appropriate.

Physiologically Difficult Airway — New 2025 Concept

🔴Patients with: (1) Haemodynamic instability — RSI may cause cardiovascular collapse; give push-dose vasopressors (metaraminol 0.5–1 mg, phenylephrine 100 mcg, or dilute adrenaline) and fluid pre-load; ketamine preferred induction agent; (2) Severe hypoxia — pre-oxygenate aggressively with HFNO ± NIV; accept lower SpO₂ threshold to act vs waiting for perfect conditions; (3) Obesity/high aspiration risk — head-up position, modified RSI with cricoid pressure, consider awake intubation; (4) Metabolic acidosis — post-intubation respiratory acidosis can be fatal; maintain high RR post-intubation; avoid apnoeic periods

RSI in ICU Context (DAS 2025)

Induction agents: Ketamine 1–2 mg/kg — preferred in haemodynamic instability (sympathomimetic); bronchodilator; preserves airway reflexes. Propofol 0.5–1.5 mg/kg — use cautiously in cardiovascular instability. Thiopentone 3–5 mg/kg — rapid offset; cardiovascular depression
Muscle relaxant: Rocuronium 1.2 mg/kg — preferred for RSI (sugammadex 16 mg/kg available for reversal); Suxamethonium 1.5 mg/kg — when rocuronium not available or specific indication; avoid in hyperkalaemia, burns, crush injury, neuromuscular disease
Sugammadex — must be immediately available if rocuronium used for RSI; 16 mg/kg IV for immediate reversal of 1.2 mg/kg rocuronium
Post-intubation: anticipate and prevent hypotension (vasopressors at bedside before starting); start sedation infusion before induction

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DAS 2019 — Awake Tracheal Intubation (ATI) CURRENT

Indications · AFOI vs Awake VL · Topicalisation · Sedation Options

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💡ATI preserves spontaneous ventilation and airway reflexes when predicted or confirmed difficult airway makes general anaesthesia/RSI unsafe. The key indication: when you cannot predict ability to oxygenate after induction. DAS 2019: ATI should be considered whenever predictors of difficult airway management are present.

Indications for ATI

Predicted difficult DL/VL (limited mouth opening, neck immobility, distorted airway anatomy)
Predicted difficult face mask ventilation AND difficult laryngoscopy simultaneously
Obese patients with predicted difficult airway who cannot tolerate supine position
Cervical spine instability (rheumatoid arthritis, ankylosing spondylitis, post-trauma) — DAS/AoA/BSOA/ICS/NACCS 2024 guidelines specifically address this
Known difficult airway from previous anaesthetic alert
Airway obstruction requiring assessment before securing

ATI Protocol — Key Steps

Antisialogogue: glycopyrrolate 200 mcg IV 20–30 min before procedure — reduces secretions, improves topicalisation quality
Supplemental O₂: HFNO or nasal cannula throughout — must be administered during ATI
Topicalisation: lidocaine — maximum dose 9 mg/kg lean body weight; techniques: nebulised (4% lidocaine), "spray-as-you-go" through bronchoscope, Krause forceps for superior laryngeal nerve block, transtracheal injection (4 ml 4% lidocaine); test topicalisation before advancing scope
Sedation (optional, cautious): Dexmedetomidine TCI or IV infusion (most evidence, preserves ventilatory drive); Remifentanil TCI Ce 1–2 ng/ml; Midazolam titrated (risk of over-sedation); avoid deep sedation — defeats purpose of ATI
AFOI (awake fibreoptic intubation): gold standard — passes scope nasally or orally, visualises vocal cords, rail-roads ETT
Awake VL: increasingly used — easier to teach; less secretion-sensitive; good for anticipated difficult laryngoscopy
Confirm tracheal placement with capnography before inducing anaesthesia

⚠️ Exam Trap — Failed ATIIf ATI fails: do NOT immediately proceed to Plan A RSI. Consider: (1) further topicalisation optimisation; (2) calling for senior help; (3) awake surgical airway under LA if immediate airway threat; (4) only proceed to RSI if airway is adequate for rescue.

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DAS 2017 — Critically Ill Adults + DAS 2012 Extubation Guidelines

ICU vs Theatre Context · Modified RSI · Pre-Oxygenation · Extubation Risk Stratification

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⚠️Critically ill patients differ from theatre patients: reduced physiological reserve, unstable haemodynamics, high aspiration risk, limited pre-oxygenation time, altered drug pharmacokinetics, reduced team experience with difficult airways, unfamiliar environments. The DAS 2017 guidelines (Higgs et al., Anaesthesia) address all hospital locations outside theatre.

Pre-Intubation Optimisation (DAS 2017/2025)

Position: ramped/25° head-up — improves FRC, reduces aspiration risk, improves glottic view; ear-to-sternal notch in obese
Pre-oxygenation: HFNO 60 L/min FiO₂ 1.0 for ≥3–5 min; NIV/BiPAP in de-saturating patients; target SpO₂ >95% before intubation; continue HFNO during intubation attempt (apnoeic oxygenation)
Haemodynamic preparation: vasopressors at bedside; fluid bolus if hypovolaemic; avoid propofol as sole induction in haemodynamic instability
Team briefing: declare difficulty grade, which plan to use, role assignment (laryngoscopist, assistant, drug-giver, capnography), "what is the plan if this fails?"

Modified RSI vs Standard RSI

Element	Classic RSI	Modified RSI (ICU/Critically Ill)
BMV before intubation	Avoided (aspiration risk)	Used if SpO₂ falling — oxygenation priority over aspiration risk
Cricoid pressure	Routinely applied (Sellick's manoeuvre)	Applied; may be released if impeding laryngoscopy; evidence for benefit limited
Opioid pre-dose	Not used	Fentanyl 1–2 mcg/kg to blunt intubation response; ketamine analgesic adjunct
Induction agent	Thiopentone 5 mg/kg	Ketamine (haemodynamic instability); propofol (lower dose 0.5–1.5 mg/kg)

DAS 2012 Extubation Guidelines — Risk Stratification

DAS Extubation: 4-Step Process

Plan Extubation — Is it safe?

Assess: extubation risk factors (anticipated difficult re-intubation, predicted upper airway problem, general risk factors — obesity, obstructive sleep apnoea, supine procedure); optimise reversible factors first

Prepare for Extubation

Low-risk: standard extubation. At-risk: choose technique — awake extubation (preferred in at-risk), remifentanil TCI (smooth emergence), airway exchange catheter (AEC — Cook), consider extubation to NIV/HFNO if respiratory risk

Perform Extubation

Awake: patient responsive, following commands, protective airway reflexes present. Asleep: only if low-risk and no anticipated difficult re-intubation. Suction; deflate cuff; remove tube; apply O₂ immediately

Post-Extubation Care

HDU/ICU-level monitoring; HFNO or NIV rescue if SpO₂ deteriorates; low threshold for re-intubation (plan and equipment at bedside); avoid "trial and error" re-intubation attempts; predict and prevent laryngospasm (heliox if upper airway obstruction)

💡Airway Exchange Catheter (AEC/Cook): hollow, semi-rigid catheter left in trachea post-extubation; allows O₂ insufflation or re-intubation railroading; patient tolerates with some discomfort; used when re-intubation predicted to be difficult if patient deteriorates; remove after 1–2 hours once extubation success confirmed.

🔵 Cuff Leak Test in ICUBefore extubation in prolonged intubated ICU patients: deflate cuff, occlude ETT — hear/feel air leak around tube. Absence of leak = laryngeal oedema/subglottic swelling; consider dexamethasone (0.1 mg/kg IV, 4 doses 6-hourly before planned extubation) — reduces post-extubation stridor and failed extubation (ADAGIO trial).

FICM / ICS — Guidelines & Standards UK-specific governance and service delivery

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GPICS V3 — Guidelines for the Provision of ICU Services NEW 2026

Levels of Care · Staffing · Governance · Follow-Up · Patient/Family Involvement

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⚡GPICS V3 (January 2026) published by FICM/ICS — the definitive reference for planning, commissioning and delivering adult ICU services in the UK. Supersedes V2.1 (2022). Key changes: terminology updated (standards → minimum standards; recommendations → recommendations for a quality service); patient/family co-production embedded in guidelines development; new chapters on sustainability, equality/diversity/inclusion (EDI), and pandemic preparedness.

Levels of Critical Care

Level	Definition	Nurse:Patient ratio
Level 1	Enhanced care — at risk of deterioration; single organ support not requiring ICU	Variable (not defined in GPICS as standard ICU)
Level 2	HDU — detailed monitoring and intervention; single (non-respiratory) organ support; post-operative	1:2 minimum
Level 3	ICU — advanced respiratory support (IPPV) OR ≥2 organ support	1:1 minimum for IPPV

🔵 GPICS V3 — Minimum Standards (Key Exam Points) "Minimum standards" (previously "standards") are defined as must-do requirements — all UK ICUs expected to meet them or record on a risk register if unmet.

Key minimum standards include:
— ICU must have a designated consultant intensivist responsible for each patient
— Consultant-led ward rounds at least twice daily for level 3 patients
— Consultant direct presence on the unit for ≥16h/day; available 24h
— 1:1 nursing for all IPPV patients (level 3); 1:2 for level 2
— Pharmacist with critical care training on each ward round
— Physiotherapy available 7 days a week
— Microbiologist/ID physician available for antimicrobial advice 24h
— Access to renal support (RRT) 24h
— Echocardiography available 24h
— Critical Care Outreach (CCO) team — 24h availability recommended

CRITCON Levels (ICS 2023 Update)

CRITCON 0Normal ICU function

CRITCON 1Local pressure — increased demand

CRITCON 2Network pressure — regional escalation

CRITCON 3National pressure — exceptional measures

ICU Follow-Up & PICS Care Pathway

GPICS V3 recommends ICU follow-up clinics for all level 3 patients as a recommendation for quality service
Minimum: formal assessment at hospital discharge + 2–3 month post-ICU clinic
PICS domains: cognitive, psychological (PTSD, anxiety, depression), physical (ICUAW, functional impairment)
ICU diaries — written by staff and families; reduces PTSD incidence in survivors (Garrouste-Orgeas trial)
Rehabilitation needs assessment tool (RNT) — used at discharge from ICU and beyond
NICE NG236 (2022) — rehabilitation after critical illness: structured programme from ICU through community

Governance Requirements (GPICS V3)

ICUs must participate in a national audit programme — ICNARC (Intensive Care National Audit and Research Centre) in England/Wales; SICSAG in Scotland
Multidisciplinary clinical governance meetings including mortality and morbidity analysis — minimum requirement
Participation in mortality review programme (structured judgement review or equivalent)
Healthcare-associated infection surveillance programme
Documentation of pre-admission consultation, agreed ceilings of therapy, and time-limited treatment trials
GPICS V3 is used as the benchmark by CQC (Care Quality Commission) for inspection and peer review

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FICM End of Life Care 2019 / ESICM 2024

Withholding · Withdrawal · MCA · Best Interests · ReSPECT · Futility

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📖FICM/FPM "Care at the End of Life" (2019) + NICE NG31 (2015) — Care of the Dying Adult. ESICM published updated end-of-life and palliative care guidelines (2024) — largely consistent with UK framework but with differences in legal/cultural context. Know UK-specific framework.

Key Ethical and Legal Framework (UK)

Mental Capacity Act 2005 (MCA): 5 principles — (1) capacity assumed unless proven otherwise; (2) all practicable steps to support decision-making; (3) unwise decisions ≠ lack capacity; (4) best interests; (5) least restrictive option. Capacity is decision-specific and time-specific
Best interests decision: when patient lacks capacity — involve family/carers, previous expressed wishes, LPA for health/welfare, advance decision to refuse treatment (ADRT). Best interests = not only medical interests but values, beliefs, quality of life
Lasting Power of Attorney (LPA) for Health and Welfare: valid only when patient lacks capacity; LPA can refuse life-sustaining treatment only if specifically stated; cannot demand treatment
Advance Decision to Refuse Treatment (ADRT): legally binding if valid, applicable, in writing with witness for life-sustaining treatment; cannot compel treatment

ReSPECT Form (Recommended Summary Plan for Emergency Care)

📋ReSPECT replaces DNACPR in many UK settings — broader tool capturing patient priorities, goals of care, and care in emergency situations. Sections include: clinical summary, personal priorities, and clinically appropriate emergency care (including CPR decision). A ReSPECT form is NOT the same as a DNACPR form — it encompasses more than just resuscitation. It is not legally binding but is a clinical decision tool.

Withholding vs Withdrawing — Key Distinctions

Withholding

Not starting a treatment (e.g., not intubating, not starting RRT)
Most common form of treatment limitation
Ethically equivalent to withdrawal (UK law/ethics)
No requirement for patient consent to withhold futile treatment

Withdrawal

Stopping an existing treatment (e.g., stopping vasopressors, extubation)
Less common; often requires greater documentation and family communication
Ethically and legally equivalent to withholding in UK
Clinician cannot be compelled to continue treatment deemed futile

Doctrine of Double Effect: an action intended to relieve suffering (e.g., opioids for dyspnoea) is permissible even if it may hasten death — intention is key. This is legally accepted in UK law
Futility: UK courts have upheld clinicians' right to withhold/withdraw treatment deemed futile even against family wishes — but families must be fully involved in discussions and given time to understand. Seek ethics committee input if dispute
Palliative care team involvement — FICM recommends early integration of palliative care for patients with poor prognosis or complex symptom management needs; not just for the dying

Symptom Management at End of Life (ICU)

Comfort measures: analgesia (morphine/alfentanil infusion), anxiolytics (midazolam), antisecretory agents (glycopyrrolate), anti-emetics
Ventilator withdrawal: typically 2-stage — reduce FiO₂ and PEEP first, then CPAP, then extubate (or leave breathing on CPAP if this is comfortable)
Routine monitoring (arterial lines, CVP, invasive monitoring) — discontinue unless required for comfort management
Document clearly the goals of care and symptom targets; regular multidisciplinary family meetings

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FICM/ICS/AAGBI — Transfer of Critically Ill Adults

Minimum Standards · Team Composition · Monitoring · Handover · Acceptability Criteria

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🚗FICM/ICS/AAGBI Guidelines for Transfer of Critically Ill Adults — covers both intra-hospital (between clinical areas) and inter-hospital (primary and secondary transfers). All critically ill transfers carry risk; transfers should only occur when the benefits outweigh risks.

Team Composition (Level 3 / ICU Transfer)

Minimum 2 suitably trained personnel: one doctor (ST4+ or equivalent ICU/anaesthesia experience, or ACP) + one nurse or paramedic with critical care training
Transfer doctor must have: airway management skills, ICU drug knowledge, emergency management skills, familiarity with transport equipment
Accompanying nurse — ICU-trained, familiar with transport environment
For complex patients: consider consultant-led transfer team

Minimum Monitoring During Transfer

ECGContinuous

SpO₂Continuous

ETCO₂Mandatory (IPPV)

IBPInvasive BP if arterial line

TempActive warming

⚠️ETCO₂ is mandatory during transfer if patient is intubated/ventilated — confirms tube position, detects disconnection/obstruction. Non-negotiable. Do not transfer intubated patients without waveform capnography.

Pre-Transfer Stabilisation — Minimum Standards

Airway secured and confirmed (ETT, cuffed trache) — do NOT transfer with unsecured airway if avoidable
Adequate IV access (minimum 2 large-bore peripheral or one CVC/IO)
Haemodynamic stability achieved or attempt made — document if transferred with ongoing instability
Adequate O₂ supply calculated (consider FiO₂, ventilator dead space, journey time × 2 as safety margin)
Drug infusions checked and adequate for journey + contingency
Full documentation: current status, monitoring trends, drug infusions, transfer letter, radiological images

ATMIST / SBAR Handover

ATMIST

Age/sex
Time of incident/admission
Mechanism of injury/diagnosis
Injuries/conditions found
Signs (vital signs, clinical status)
Treatment given

SBAR

Situation — who/what
Background — context
Assessment — clinical findings
Recommendation — what do you need?

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FICM — Clinical Frailty Scale & POCUS in ICU

CFS in ICU Admission · FICM POCUS Guidance · Ultrasound Applications

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Clinical Frailty Scale (CFS) in ICU

👴CFS — validated tool for frailty assessment; increasingly embedded in ICU triage and end-of-life decision-making. GPICS V3 recommends frailty assessment for all ICU admissions.

1–3Not frail — independent, active

4Vulnerable — not dependent

5–6Mildly/moderately frail — some dependence

7–9Severely frail → terminal illness

CFS should be based on pre-morbid status (2 weeks before acute illness onset) — NOT current acute functional status
CFS ≥5 associated with significantly worse ICU outcomes; CFS ≥7 — very high 1-year mortality
CFS alone should NOT determine ICU admission decisions — it is one factor in holistic assessment
COVID-19 used CFS ≥7 as indicator for critical care triage during pandemic — CFS emerged as nationally significant tool during this period
CFS in acute illness: assess based on baseline, not acute presentation; frailty is not synonymous with age

FICM POCUS Guidance — ICU Applications

🔊FICM and FAMUS (Faculty of Acute Medicine Ultrasound) have published joint guidance on point-of-care ultrasound in critical care. GPICS V3 recommends POCUS availability 24h.

Cardiac POCUS

LV/RV function (qualitative)
Pericardial effusion/tamponade
Volume status (IVC collapsibility — limited in IPPV)
Valve pathology (gross)
Post-cardiac arrest guidance

Lung POCUS

Pneumothorax (absent lung sliding)
Pleural effusion (quantification)
Consolidation (hepatisation)
Pulmonary oedema (B-lines)
ARDS diagnosis (global def 2024)

Other Applications

Vascular access guidance (CVC, arterial)
Airway — cricothyroid membrane identification
Thoracentesis / paracentesis guidance
Bladder volume assessment
FAST exam in trauma

🔵 POCUS Limitations — Exam Favourites IVC collapsibility as fluid responsiveness marker: ONLY valid in mechanically ventilated, non-spontaneously breathing, sinus rhythm patients. IVC collapse >50% (spontaneous breathing) or IVC distensibility >18% (mechanically ventilated) suggests fluid responsiveness. Completely invalid in spontaneously breathing patients or those with raised intra-abdominal pressure. TTE windows limited by body habitus, drains, dressings — TOE (trans-oesophageal echo) may be required for adequate cardiac assessment.

📌 Final FFICM SBA Strategy — Consultant-Level Approach

Negative trials matter as much as positive ones — ART (aggressive RM), OSCILLATE (HFOV), NICE-SUGAR (tight glucose), ROSE (routine NMB), EPaNIC (early PN), TRACMAN (early trach), STARRT-AKI (early RRT), EGDT (ARISE/ProCESS/PROMISE), TTM2 (hypothermia), COACT/TOMAHAWK (urgent angio without STEMI)
Know the 2025/2026 updates: RCUK/ERC Resus 2025 (no major ALS change; post-ROSC SBP >100 / MAP 60–65, fever prevention ≤37.5°C for 36–72h, levetiracetam/valproate for seizures, whole-body CT, WLST separate from prognostication; new special-circumstances, paediatric & neonatal chapters; NLS drops NaHCO₃ & de-emphasises skin colour); DAS 2025 (physiologically difficult airway, VL as standard, 65 recommendations); GPICS V3; Global ARDS definition 2024 (non-intubated ARDS, SpO₂/FiO₂); MINT 2023 (ACS transfusion threshold nuance)
UK guidelines override international — DNC (AoMRC 2008 — DNC not brain death), DKA (JBDS 2023 not ADA), Organ Donation (NHSBT/NICE NG135 + opt-out 2020), Resuscitation (RCUK/ERC 2025), End of Life (FICM 2019 + MCA 2005 framework)
FICM/GPICS governance — ICU standards, CRITCON levels, audit requirements, staffing ratios (1:1 for IPPV), consultant presence 16h direct + 24h available, ICNARC participation. GPICS V3 now the benchmark for CQC inspection
DAS airway hierarchy — Plan A (max 3 attempts, VL primary tool) → B (2nd gen SAD) → C (BMV) → D (eFONA — scalpel-bougie-tube, NOT needle). Physiologically difficult airway is a new 2025 concept. ATI when predicted difficult and cannot safely induce
Number precision — the SBA relies on exact thresholds: ICP >22 mmHg; CPP 60–70; CRRT 20–25 ml/kg/hr; FRIII 0.1 units/kg; MgSO₄ 4g loading/1g/hr; 6 ml/kg IBW; transfusion 70 g/L (80 g/L cardiac); Nimodipine 60 mg q4h × 21 days; DNC apnoea PaCO₂ ≥6.0 kPa + pH <7.40
Read the stem for the distractor — SBAs often include one option that was correct 10 years ago (EGDT CVP target, HFOV, tight glucose, EGDT ScvO₂) or one option that is one step beyond current guidance

Complete Trial Reference — 2025 Status

ARISE/ProCESS/PROMISE — EGDT abandoned NICE-SUGAR — tight glycaemia harmful ART — aggressive RM harmful OSCILLATE — HFOV harmful ROSE — routine NMB no benefit TRACMAN — no early tracheostomy benefit STARRT-AKI/AKIKI — no early RRT benefit EPaNIC — early PN harmful REDOXS — glutamine in MOF harmful PRESERVE — no NAC/NaHCO₃ for contrast nephropathy MRC CRASH — steroids in TBI harmful EUROTHERM3235 — hypothermia for ICP harmful COACT/TOMAHAWK — no urgent angio without STEMI TTM2 — 33°C no better than normothermia De Backer 2010 — dopamine inferior to noradrenaline SuDDICU — SDD no mortality benefit (high-resistance settings) EFFORT — high-dose protein no benefit; possible harm PROSEVA — prone 16h in P:F <150 reduces mortality ARDSNet/ARMA — 6 ml/kg reduces mortality Magpie — MgSO₄ prevents eclampsia DEXA-ARDS — dexamethasone reduces 60-day ARDS mortality CRASH-2 — TXA within 3h reduces traumatic haemorrhage mortality WOMAN — TXA within 3h reduces PPH death ALFSG (Lee 2009) — NAC improves transplant-free survival in early ALF SMART — balanced crystalloids reduce MAKE30 vs 0.9% NaCl ITACTIC — VHA-guided resus reduces blood product use EOLIA — VV-ECMO trend to benefit in severe ARDS (p=0.07) CESAR — transfer to ECMO centre improves outcome CALORIES — EN not superior to PN in pragmatic UK trial CLASSIC 2022 — restrictive fluid non-inferior in septic shock VASST — vasopressin spares noradrenaline dose DECRA — early DC worse neurological outcomes in TBI RESCUEicp — DC reduces mortality but more vegetative survivors PARAMEDIC2 — adrenaline improves ROSC not neurological outcome MINT 2023 — transfusion threshold nuance in ACS ADAGIO — dexamethasone reduces post-extubation stridor/failure ACURASYS — NMB benefit in ARDS (confounded by sedation)