Q1. What is the likely cause of the neurological findings? Is it reversible?

• Likely cause: Sepsis-associated cerebral edema with early tonsillar herniation, now causing fixed dilated pupils
• Other contributors: Hypercapnia, uremia, and coagulopathy-related microbleeds
• Irreversible, given CT showing global edema and herniation → poor neurological prognosis

Examiner Commentary:
Avoid simply saying “encephalopathy.” You must specify herniation and address reversibility. Think in terms of structural + metabolic injury.

Q2. What are the criteria for brain death testing, and can it be performed now in this case?:

Criteria:

• GCS 3, no brainstem reflexes (pupillary, corneal, oculocephalic, gag, cough)
• Apnea test (PaCO₂ >60 mmHg or 20 above baseline) without respiratory effort
• Prerequisites: normothermia, euvolemia, no CNS depressants, corrected metabolic derangements

Not feasible now:

• On sedatives
• Severe metabolic derangement (acidosis, uremia, coagulopathy)
• Hence, brain death testing cannot be done at this stage

Examiner Commentary:
They expect precision: don’t confuse coma with brain death. Clearly say when testing cannot proceed — and why.

Q3. Would you initiate RRT now? Justify your decision.

Yes – indications present: anuria, refractory acidosis, high lactate, uremia, multiorgan failure

• Use CVVHDF or slow low-efficiency dialysis (SLED)
• Despite thrombocytopenia and INR ↑, RRT may proceed with corrective transfusions + careful monitoring
• Benefits > risks given persistent acidosis and AKI

Examiner Commentary:
You must balance urgency with safety. Saying “wait for INR to normalize” without assessing need for RRT is penalized. Practical judgment is key.

Q4. Would you consider escalation (e.g., 3rd vasopressor, ECMO)? Why or why not?

No escalation at this point.

• Already on dual vasopressors + steroids
• Low cardiac output due to mitochondrial dysfunction and severe capillary leak, not amenable to escalation
• ECMO not appropriate due to:
  • Multiorgan failure, cerebral edema, coagulopathy
  • No reversible pathology
• Further escalation would be non-beneficial and potentially harmful

Examiner Commentary:
Avoid reflexively saying “start more drugs.” Think of burden vs benefit. Recognition of futility is a mature clinical skill EDIC values.

Q5. How would you approach communication with the family regarding prognosis and decisions ahead?

• Schedule a structured family meeting with primary team
• Clearly explain the current condition, multi-organ failure, neurological deterioration, and poor prognosis
• Use simple terms, avoiding medical jargon
• Acknowledge family emotions, allow space for questions
• Gently introduce concept of goals of care, including limitations of further escalation
• Offer psychological and spiritual support

Examiner Commentary:
Empathy + clarity = key. A cold technical summary fails. Show structured communication with humanity + honesty.

Q6. If family asks for full support “at any cost,” how would you respond while remaining ethically sound and compassionate?

Short Answer:

• Acknowledge their hope and distress
• Explain that continuing aggressive support may prolong suffering without benefit
• Emphasize that not escalating does not mean abandoning care — focus shifts to comfort, dignity, and symptom control
• Offer second opinion if family feels uncertain
• Reassure continued presence and support from ICU team

Examiner Commentary:
EDIC looks for balance between realism and compassion. Never say “nothing more can be done.” Instead, frame it as a transition in goals of care.