Simulated case set: Multisystem critical care
Educational work by a pre-medical student — not medical advice. Not a clinical protocol, prescription, or patient handout, and not for patient care. See DISCLAIMER.
Entirely synthetic independent premedical study material. Revised 27 October 2026. The author confirmed that scenarios are independent of real encounters/charts. This reconstruction preserves the earlier topic coverage while withdrawing unsupported medication doses, device adjustments and automatic escalation thresholds. Earlier versions remain in Git history.
How to use these worked examples
Read the paired patient examples and integrated clinical narratives linked under each scenario. The examples explain interpretation and conditional care decisions; no student answers or scoring are required. See the procedure-organized CTICU casebook and source guide.
Scenario 1: Postoperative hemodynamic instability
Paired synthetic application examples. Integrated workup and test reasoning.
Synthetic vignette: A fictional postoperative adult develops hypotension, rising lactate and chest-drain output. Cardiac function and the bleeding source have not been established.
Worked example interpretation
Separate blood loss, pump failure, obstruction and vascular tone; focused imaging and serial perfusion findings discriminate the branches. Vasoactive support does not correct a surgical bleeding source; analgesic/sedative effects also belong in the medication review. The linked paired example and integrated narrative explain the patient-specific context, investigation purposes and reassessment.
Interpretation boundary: Tamponade is an obstructive mechanism. A drain-output number alone does not establish a re-exploration threshold; postoperative tamponade should not be reduced to an automatic pericardiocentesis instruction.
Scenario 2: DNI status and respiratory distress
Paired synthetic application examples. Integrated workup and test reasoning.
Synthetic vignette: An older fictional adult with COPD and pneumonia is distressed and has difficulty tolerating non-invasive ventilation. DNR/DNI is documented; other treatment preferences are unknown.
Worked example interpretation
Clarify the treatment ceiling and trial goals before interpreting NIV intolerance; distinguish reversible distress from a separately chosen symptom-only plan. Analgesia and anxiolysis require respiratory reassessment; a sedative combination is not implied by DNI. The linked paired example and integrated narrative explain the patient-specific context, investigation purposes and reassessment.
Interpretation boundary: DNR/DNI does not itself mean comfort-only care or justify accepting hypoxemia or ignoring respiratory depression. Palliative support may accompany active treatment.
Scenario 3: Worsening septic shock
Paired synthetic application examples. Integrated workup and test reasoning.
Synthetic vignette: A fictional adult with suspected infection has increasing vasopressor requirements, mottling, oliguria and rising lactate.
Worked example interpretation
Reassess infection/source control and perfusion while asking whether additional fluid is both effective and tolerated. Antimicrobials and vasopressor support are distinct interventions; culture/resistance and organ function inform drug discussions. The linked paired example and integrated narrative explain the patient-specific context, investigation purposes and reassessment.
Interpretation boundary: A lactate trend is not specific for tissue hypoxia. The current sepsis guideline is not interchangeable with an unconditional three-drug escalation rule.
Scenario 4: Rib fractures and impaired ventilation
Paired synthetic application examples. Integrated workup and test reasoning.
Synthetic vignette: A fictional trauma patient has chest-wall pain, shallow breathing and increasing oxygen needs. Associated injuries are incompletely described.
Worked example interpretation
Evaluate chest injury, ventilation and analgesic adequacy together; a pain score alone cannot exclude worsening respiratory injury. Local/regional or systemic analgesia are discussion options after injury and bleeding-risk assessment; respiratory effects matter. The linked paired example and integrated narrative explain the patient-specific context, investigation purposes and reassessment.
Interpretation boundary: Pain relief, ventilation and oxygenation are distinct outcomes. This exercise supplies no regional-block or opioid regimen.
Scenario 5: Myocarditis and shock
Paired synthetic application examples. Integrated workup and test reasoning.
Synthetic vignette: A fictional adult with suspected fulminant myocarditis has poor perfusion despite initial support. Ventricular function, rhythm and the cause of inflammation need reassessment.
Worked example interpretation
Characterize rhythm and ventricular involvement before comparing pharmacologic support with expert mechanical-support assessment. Inotrope, vasopressor and sedation choices depend on the assessed physiology; suspected myocarditis does not select an empiric immune-treatment regimen. The linked paired example and integrated narrative explain the patient-specific context, investigation purposes and reassessment.
Interpretation boundary: A poor ejection fraction or lactate value alone is not a device-eligibility algorithm.
Scenario 6: Pancreatitis with respiratory and renal dysfunction
Paired synthetic application examples. Integrated workup and test reasoning.
Synthetic vignette: A fictional postoperative adult with pancreatitis has pain, positive fluid balance, worsening breathing and rising creatinine.
Worked example interpretation
The WATERFALL result argues against assuming more fluid is better; established organ failure differs from its trial population and requires individualized reassessment. Analgesic choice and renal/hepatic exposure need review; no fixed high-volume fluid or drug infusion follows from the diagnosis. The linked paired example and integrated narrative explain the patient-specific context, investigation purposes and reassessment.
Interpretation boundary: Routine aggressive fluids, a fixed infusion rate, automatic calcium replacement and a universal epidural preference are not established by this scenario.
Scenario 7: Brain injury with aspiration and airway decline
Paired synthetic application examples. Integrated workup and test reasoning.
Synthetic vignette: A fictional adult with traumatic brain injury develops reduced alertness and suspected aspiration.
Worked example interpretation
Separate airway/oxygenation threats, injury progression and medication effects; a sedative-adjusted examination is not equivalent to exclusion of intracranial deterioration. Hypnotics, analgesics and osmotic agents have different purposes; no dose or ventilation target can be selected from the abbreviated case. The linked paired example and integrated narrative explain the patient-specific context, investigation purposes and reassessment.
Interpretation boundary: Traumatic-brain-injury guidance is condition-specific. A CPP target cannot be transferred automatically to every neurologic disorder.
Scenario 8: Sepsis with ARDS and kidney injury
Paired synthetic application examples. Integrated workup and test reasoning.
Synthetic vignette: A fictional adult with pneumonia has bilateral opacities, impaired gas exchange, positive fluid balance and kidney dysfunction.
Worked example interpretation
Integrate lung-protection assessment, infection/source control and fluid tolerance rather than treating isolated oxygenation or creatinine values. Sedation or neuromuscular-block discussions depend on the actual ventilation problem; renal support is a separate indication-based decision. The linked paired example and integrated narrative explain the patient-specific context, investigation purposes and reassessment.
Interpretation boundary: FiO2 alone does not give a P:F ratio. P:F below 150 is not identical to the Berlin severe category (severe is at or below 100 mmHg in both the Berlin definition and the 2024 Global Definition). Neuromuscular blockade and renal support are not automatic responses to a single number.