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ICM Diploma (UK) - Examination Syllabus

Created: 25/10/2006
Updated: 26/10/2006

 

SYLLABUS FOR THE DIPLOMA IN INTENSIVE CARE MEDICINE

This should be read in conjunction with the Regulations and the Intercollegiate Board’s guidance on competency based training in intensive care medicine which expresses the breadth and the depth of knowledge expected at each stage in training.
This syllabus is not fully comprehensive but gives a guide to the subjects to be examined. The trainee will be expected to have completed advanced life support and advanced trauma life support courses and to have obtained other skills listed in the training guidance.

RESUSCITATION

A knowledge of theory and practice for basic and advanced life support, and of application of algorithms of resuscitation.

expired air resuscitation
bag-valve-mask (bvm) ventilation
oropharyngeal airways
tracheal intubation
laryngeal mask airways
closed chest compression
defibrillation
vascular access
pericardial drainage
chest drainage
crico-thyrotomy
cannulation of large central veins (e.g. internal jugular)
cut down
cardiac pacing
peritoneal lavage
tracheostomy
basic paediatric and neonatal resuscitation (with particular reference to acute airway obstruction)

ANATOMY

Anatomical knowledge of the body areas relevant to diagnosis and treatment of critically ill patient including that related to:

insertion of arterial and venous access lines
drainage of closed cavities
local anaesthesia and provision of pain relief
insertion of variceal tamponade devices
insertion of intracranial pressure monitors
secondary airway control (tracheostomy)
neuroanatomy for understanding 
    brain stem death testing  
    pain relief 
    assessment of nerve conduction
Areas include: 
    wrist 
    ankle 
    antecubital fossa 
    anterior triangle of the neck 
    deep structures of the neck 
    subclavian area 
    femoral triangle 
    chest wall 
    lungs, bronchial tree, pleura 
    abdominal wall (and surface marking of organs) 
    heart and coronary circulation 
    pharynx and larynx 
    oesophagus and stomach 
    vertebral column 
    brachial plexus 
    spinal cord, brain, brain stem 
    epidural and subarachnoid space and spinal canal 
    sympathetic and parasympathetic nervous system

PHYSIOLOGY

Applied physiological knowledge of systems primarily or secondarily compromised by critical illness or to be optimised in critically ill patients. This will include knowledge of:

control of consciousness
locomotor activity
peripheral nervous system
muscle action
control of cardiac output, blood pressure and flows
pathophysiology of control and mechanics of respiration 
    work of breathing
pathophysiology of oxygen transport 
    in the peripheral circulation and within the cell and relevant physio-biochemistry
control of fluid balance and the milieu interieur

This will also include an understanding of:
fluid challenge
Starling (or equivalent) relationship
oxygen consumption, carbon dioxide production
respiratory quotient
shunt, dead space, ventilation/perfusion mismatch
oxygen dissociation curve
oxygen therapy in acute and chronic respiratory failure
investigation and treatment of acute renal failure
neuromuscular function using the nerve stimulator
nutritional assessment

It will include physiology applied to acute and chronic disease:
cardiac failure
inotrope dependence
respiratory failure
ventilator dependence
hepatic failure
gastrointestinal failure
endocrine disturbance 
    eg thyrotoxicosis 
    Addison’s disease
coagulation failure
Application of physiology to assessment of organ function

PHARMACOLOGY

Applied pharmacology (including pharmacokinetics and dynamics) of drugs used in:

cardiopulmonary resuscitation including 
    magnesium, esmolol, vasopressin
local anaesthesia including 
    opioids for extradural and intrathecal use
cardiovascular support or control
inotropes including 
    sympathomimetics 
    phosphodiesterase inhibitors 
    glucagon 
    digoxin
vasodilators including 
    nitrates 
    sympathetic blockers 
    centrally acting drugs 
    calcium channel blockers
vasoconstrictors including 
    sympathomimetics 
    vasopressin
antiarrhythmics
anti hypertensives (including ACE inhibitors)
diuretics
anticoagulants
respiratory support 
    oxygen therapy 
    respiratory stimulants 
    bronchodilators 
    nitric oxide 
    epoprostanol
analgesics 
    opioids 
    NSAIDS 
    clonidine 
    ketamine 
    amitryptiline
sedatives 
    benzodiazepines 
    α2 blocking agents 
    anaesthetic induction agents used for continuous infusion 
    inhalational agents
anti-convulsants 
    including those used by infusion and second line drugs
major tranquillisers
anaesthetic agents 
    induction agents 
    neuromuscular blocking agents 
    reversal drugs 
    anticholinesterases 
    flumazenil 
    naloxone 
    inhalational agents
intravenous fluids 
    blood products 
    artificial colloids 
    crystalloids
nutritional agents 
    carbohydrates, fats, nitrogen
steroids
antimicrobial agents and the treatment of: 
    bacterial infection 
    tuberculosis 
    protozoa (malaria, pneumocystis) 
    fungal infection (candida) 
    viral infection (herpes)
miscellaneous groups of drugs which require dosage alteration/reduction in critically ill patients 
    antidotes
pathopharmacology of drug and substance abuse 
    cannabis 
    "ecstasy", other amphetamines 
    ketamine 
    fentanyl derivatives 
    cocaine 
    heroin 
    barbiturates 
    benzodiazepines
pathopharmacology of drugs used for self poisoning 
    aspirin 
    paracetamol 
    tricyclics 
    lithium 
    methanol 
    ethylene glycol 
    aminophylline 
    digoxin 
    anticholinesterases 
    paraquat 
    carbon monoxide

KNOWLEDGE TO SUPPORT CLINICAL PRACTICE

Interpretation of physiological displays
Interpretation of pathological data
Interpretation of imaging data
Application of clinical examination to pharmacological strategies
Application of anatomy and physiology to clinical procedures 
    vascular access in adults, children and neonates 
    Seldinger and dilatational techniques for cannulation 
    difficult airway management 
    adults, children and neonates 
    laryngeal mask airway 
    tracheostomy 
    bronchoscopy, laryngoscopy 
    bronchoalveolar lavage 
    lung biopsy 
    insertion of pacemaker 
    insertion of pulmonary artery catheter 
    cardiopulmonary bypass in adults 
    Sengstaken-Blakemore tube insertion 
    renal replacement therapies 
    plasma exchange 
    insertion of intracranial pressure monitoring devices 
    brain stem death testing 
    organ retrieval 
    imaging

CLINICAL MANAGEMENT PLANNING

Applied knowledge to permit formulation of a management plan for patients with: 
acute and chronic respiratory failure 
cardiac failure 
diffuse head injury 
subarachnoid haemorrhage 
acute renal failure 
massive blood loss 
    gastro-intestinal haemorrhage 
    traumatic injury 
    major vessel rupture 
cardiopulmonary arrest 
multiple organ failure

USE OF RELEVANT TECHNICAL EQUIPMENT

artificial airways
equipment for management of a difficult airway
airway exchange equipment
anaesthetic masks
Water’s type breathing systems
unidirectional valves eg Ambu
self reflating bags (eg Ambu, Laerdal)
laryngoscopes (adult, child)
endotracheal tubes and cuffs 
    manipulating forceps 
    bougies, stylets
Seldinger wire-through-needle access (with or without dilatation)
oxygen therapy equipment 
    flow meters 
    Ventimasks, MC/Hudson masks 
    CPAP 
    oxygen cylinders
endotracheal suction equipment 
    vacuum controller 
    suction controller 
    suction catheters 
    sterility
blood pressure measurement equipment (non-invasive and invasive)
CVP
pulse oximetry
ECG recording machines
monitoring equipment (non-invasive and invasive)
transducers and related equipment
pressure infusor/"intraflo" system
capnograph (side stream/mainstream)
oxygen analyser (including calibration)
syringe driver (including bolus and PCAs)
infusion pumps
nebulisers
chest drain systems
nerve stimulator
tamponade devices (including Sengstaken- Blakemore tube)
ultrasound imaging devices
rapid infusion devices (eg ‘Level 1’)

The trainee should understand the use of:
ventilators (and ventilatory techniques) in use in the ICU (intermittent positive pressure ventilation,
inverse ratio ventilation, biphasic airway pressure, pressure support ventilation, airway pressure
release ventilation, positive end-expiratory pressure)
routine weaning techniques included in ventilators (synchronised intermittent mandatory ventilation,
pressure support ventilation, biphasic airway pressure, airway pressure release ventilation)
cardiac output monitors
transport ventilators and other transfer equipment
all CPAP systems
laboratory equipment for measurement of blood gases, electrolytes

The trainee should have a working knowledge of:
renal replacement equipment
high flow blood infusion equipment (‘Level 1’)
pressurised suits
bronchoscope injectors
high frequency ventilators
double lumen endotracheal tubes
warming and cooling equipment (blankets, mattresses - air/water)
echocardiography: transthoracic and transoesophageal
ultrasound examination of abdomen and guided aspiration
haematology, pathology and microbiology technology/techniques 
    eg: Coulter counter 
    coagulation measurement 
    multichannel chemistry analysers (SMAC) 
    routine plating and microscopy of sputum, urine, etc 
bronchoalveolar lavage

PHYSICS & MEASUREMENT

An understanding of physiology (eg flow of gases and liquids) and measurement (eg measurement of pressure, damping, resonance) as is needed for care of the patient with particular reference to recognition of measurement error.

Pressure, volume and the gas laws
Physics of flow of gases and liquids
Electro magnetic radiation
Electrical energy
Vibration and sound
Recording equipment and signal processing
Measurement of flow and volume
Measurement of pressure in gases and liquids
Statistics relevant to intensive care

An understanding of the following equipment, sufficient to be aware of its problems and pitfalls:

Ventilators
Airway pressure and flow measurement (low pressure transducers, siting of transducers,
pneumotachographs and simple flow meters)
Metabolic measurement (VO2, VCO2)
Mechanics measurements (including P0.1)
Oxygen blenders and measuring devices (pressure regulators, paramagnetic analysers, polarographs,
fuel cells, etc)

Cardiovascular Equipment
Transducers (frequency response, damping, resonance, signal degradation, zero drift and calibration)
Sphygmomanometry and oscillotonometry
Cardiac output measurement (indicator dilution, impedance, echo, Doppler)
Flow measurement (Doppler, electromagnetic)
Pulse oximetry

ICU Laboratory Physics and Measurement
PO2, PCO2 and pH electrodes
Transmission (Co-)oximetry
Ion selective electrodes
Photo electrodes
Oncometry
Osmometry

Imaging Equipment outside ICU
Ultrasound
X-ray and CT
MR

SPECIALIST DISEASES AND SYNDROMES


The trainee must have specific knowledge of a number of syndromes or diseases where their severity or symptom complex require the patient to be admitted to the ICU.

Organ System Failures (Acute or Acute on Chronic)
Respiratory failure
Cardiovascular failure
Renal failure
Hepatic failure
Brain failure
Coagulation failure
Gut failure
Immunological failure

Specific Syndromes or Complications
Sepsis
Acute Respiratory Distress Syndrome
Massive transfusion
Hypothermia
Post cardiopulmonary arrest management
Disseminated intravascular Coagulopathy

Specialist Diseases commonly needing Intensive Care
Polyneuropathies
Tetanus
Botulism
Myasthenia 
    Eaton Lambert, and muscle relaxant myopathy
Accelerated hypertension
Poisoning including: 
    tricyclics 
    SSRIs 
    anti-epileptics 
    ‘ecstasy’ 
    lithium 
    aminophylline 
    paracetamol 
    methanol 
    ethylene glycol 
    beta blockers 
    calcium channel blockers 
    digoxin 
    anticholinesterases
Purpura fulminans (and meningococcal septicaemia)
Epiglottitis (including adult)
DIC
Necrotising fasciitis
Goodpasture's syndrome
Haemolytic uraemic syndrome
Burns
Malignant hyperthermia and heat stroke
Diffuse head injury
Chronic obstructive airways disease
Sleep apnoea (and surgery)
Thyroid storm
Myxoedema
Addison's disease
Phaeochromocytoma
Malaria
Status epilepticus
Eclampsia/PET/HELLP

The trainee must know the methods of and indications for:
Respiratory Support
Institution of airway control
Institution of IPPV
PEEP
Weaning and techniques
Tracheostomy
Indications for unusual support (ECMO, transplant)

Cardiovascular Support
Invasive monitoring
Pulmonary artery catheter insertion
Cardiac output monitoring and control
Use of inotropes, constrictors, dilators
Pacemaker insertion/arrhythmia control
Balloon pumping

Renal Support
Peritoneal dialysis
Haemodialysis
Continuous haemo(dia)filtration/techniques
Haemoperfusion
Plasmapheresis or exchange

Nutritional Support
Enteral nutrition
Parenteral nutrition
Metabolic measurement
Enterostomy
Hormonal manipulation

Hepatic Support
Treatment for variceal haemorrhage
Coma treatment & support

Brain Support
Control of intracranial pressure
Triple H therapy
Vasomotor manipulation
Brain (stem) death testing
 
Haematologic Support
Therapies of massive bleeding (components, fibrinolysis control)
Blood substitutes
Haemodilution

INTER- AND INTRA-HOSPITAL TRANSPORT AND TRANSFER

The trainee should be familiar with the problems of transport:
the physiological consequences of movement (acceleration)
the environmental problems (space, vibration, temperature) on the patient and transport equipment
minimal monitoring and transfer
pre-transfer assessment and resuscitation
intra-transfer care
choice and problems of transfer and transport equipment

The trainee should know the problems of patient management in unusual environments within the hospital
eg imaging suites (angiography, Doppler), CT and magnetic environments (MR).
The trainee should understand the paramedic system and the problems of retrieval, resuscitation and
monitoring.

IMAGING

Trainees should be able to interpret and comment on:
departmental and portable CXR: supine and erect
plain abdominal X-ray films: supine, erect and lateral
cervical spine X-ray
lumbar spine X-ray
pelvic X-ray
long bone X-ray
lateral skull X-ray
CT brain
CT thorax
CT abdomen (kidney, pancreas)
echo cardiography 
    pericardial effusion 
    dyskinesis 
    vegetations (valves) 
    dilated ventricles
trans oesophageal echo 
    ventricular functional failure
ultra sound chest 
    pneumothorax
ultra sound abdomen 
    subphrenic collections 
    pancreatic swelling/pseudocyst/abscess 
    renal outlines and urinary tract
Doppler ultra sound 
    blood flow to brain (carotid), kidneys, gut 
    venous obstruction/thrombosis 
    subclavian, internal jugular, femoral, popliteal veins
dipyridamole-thallium scanning
ventilation-perfusion scanning
labelled white cell scanning 

INFORMATION TECHNOLOGY

Word processing
Database management
Graphics package
Knowledge of a major statistics package eg SPSS
Literature search

AUDIT

Principles of audit, severity scoring, outcome prediction
ICNARC

MEDICAL ETHICS

Principles
Application to intensive care


ArticleDate:20061025
SiteSection: Article
 
   
    
                                            
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