Simulated case set: Advanced hemodynamic reasoning
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: Shock immediately after CABG
Paired synthetic application examples. Integrated workup and test reasoning.
Synthetic vignette: A fictional adult after coronary bypass has hypotension, low estimated output, hypothermia and ongoing drain output.
Worked example interpretation
Use surgical assessment and verified output measurements to distinguish blood loss from pump failure, while allowing coexistence. A vasopressor, inotrope or transfusion discussion addresses different mechanisms; none is selected solely by MAP. The linked paired example and integrated narrative explain the patient-specific context, investigation purposes and reassessment.
Interpretation boundary: A single cardiac-index or drain-output cutoff is not a complete treatment rule.
Scenario 2: VA-ECMO after myocardial infarction
Paired synthetic application examples. Integrated workup and test reasoning.
Synthetic vignette: A fictional adult on VA-ECMO has improving lactate but oliguria and concern about limb perfusion.
Worked example interpretation
Falling lactate does not settle limb perfusion or kidney questions; evaluate each organ and circuit configuration. Anticoagulation, vasoactive and analgesic choices require bleeding/perfusion context and specialist oversight. The linked paired example and integrated narrative explain the patient-specific context, investigation purposes and reassessment.
Interpretation boundary: Post-oxygenator oxygenation does not alone establish upper-body oxygenation. Flow changes, cannula procedures and renal-support prescriptions require an ECMO team.
Scenario 3: Early LVAD and RV function
Paired synthetic application examples. Integrated workup and test reasoning.
Synthetic vignette: A fictional adult after LVAD implantation has changing displayed flow and pulsatility with borderline RV function.
Worked example interpretation
Interpret loading, rhythm, ventricular interaction and device data together before assigning a device cause. Fluid and vasoactive changes are not substitutes for device assessment; no universal speed or dose follows from a display value. The linked paired example and integrated narrative explain the patient-specific context, investigation purposes and reassessment.
Interpretation boundary: No universal pulsatility-index target, CVP range, speed change or anticoagulation sequence is established here.
Scenario 4: Pneumonia-associated ARDS
Paired synthetic application examples. Integrated workup and test reasoning.
Synthetic vignette: A fictional adult with ARDS has a reported P:F ratio near 87, increased driving pressure and vasopressor support.
Worked example interpretation
Check comparability and mechanics before grading severity; assess lung protection and hemodynamic tolerance before discussing conditional adjuncts. Corticosteroids or neuromuscular blockade are indication-dependent options in the cited guideline, not automatic responses to a ratio. The linked paired example and integrated narrative explain the patient-specific context, investigation purposes and reassessment.
Interpretation boundary: A reported ratio is not a self-contained rescue protocol. Ventilator mode names do not guarantee lung protection.
Scenario 5: Aortic repair, hypertension and AKI
Paired synthetic application examples. Integrated workup and test reasoning.
Synthetic vignette: A fictional adult after type A dissection repair develops hypertension, oliguria and rising creatinine.
Worked example interpretation
Assess anatomy and organ perfusion as well as pressure; distinguish possible malperfusion from congestion or medication-related kidney changes. Rate/pressure-control discussion is specific to repair and perfusion; repeated fluid or antihypertensive changes are not an imaging substitute. The linked paired example and integrated narrative explain the patient-specific context, investigation purposes and reassessment.
Interpretation boundary: No blood-pressure prescription or delay-to-imaging rule is supplied.
Scenario 6: Lung transplantation and graft dysfunction
Paired synthetic application examples. Integrated workup and test reasoning.
Synthetic vignette: A fictional lung-transplant recipient develops poor compliance, impaired gas exchange and fluid accumulation.
Worked example interpretation
Check transplant timing, imaging and competing causes before using PGD classification; donor/recipient size and mechanics need context. Diuresis, ventilator support and immune therapy answer different questions; none is established by poor compliance alone. The linked paired example and integrated narrative explain the patient-specific context, investigation purposes and reassessment.
Interpretation boundary: Blanket PEEP reduction, fixed diuresis targets and an assumed immunosuppression regimen are withdrawn. Transplant-specific care is specialist work.
Scenario 7: Sepsis and an open abdomen
Paired synthetic application examples. Integrated workup and test reasoning.
Synthetic vignette: A fictional adult with abdominal sepsis has worsening shock, oliguria and positive fluid balance.
Worked example interpretation
Review source control and measured pressure with new organ dysfunction; isolated pressure is not the whole syndrome. Antimicrobial and hemodynamic treatment require reassessment; no dressing manipulation or fixed fluid-removal rate is implied. The linked paired example and integrated narrative explain the patient-specific context, investigation purposes and reassessment.
Interpretation boundary: A pressure number alone does not diagnose abdominal compartment syndrome or authorize altering a surgical dressing.
Scenario 8: SAH with stress cardiomyopathy
Paired synthetic application examples. Integrated workup and test reasoning.
Synthetic vignette: A fictional adult after aneurysm treatment has cardiac dysfunction and concern about cerebral perfusion.
Worked example interpretation
Check cerebral perfusion measurements and whether symptomatic delayed ischemia is present before discussing competing circulatory goals. Nimodipine and hemodynamic augmentation have different indications; prophylactic hypertension or a fixed sodium regimen is not inferred. The linked paired example and integrated narrative explain the patient-specific context, investigation purposes and reassessment.
Interpretation boundary: No prophylactic hypertension, hypervolemia or fixed hypernatremia regimen is supplied.