Manage evolving ICU patients across five residency levels. R1 emphasizes recognition and safe first steps; each level adds uncertainty, competing physiology, multi-organ conflict, and greater responsibility until R5 requires senior/fellow-level prioritization with minimal hand-holding.
Choose any level. Higher levels reduce cueing, increase ambiguity, and defer full explanations until the final debrief.
Recognition, co-oximetry confirmation, methylene blue safety, and rescue therapy
Recognition → stabilization → basic reassessment
Hemodynamic collapse after abrupt cessation of chronic prednisone
Recognition → stabilization → basic reassessment
Airway/resuscitation, vasoactive therapy, antibiotics, endoscopic hemostasis, and early TIPS selection
Recognition → stabilization → basic reassessment
Post-cardiotomy obstructive shock requiring urgent drainage
Recognition → stabilization → basic reassessment
Immediate bradycardia support, temporary pacing, and definitive permanent pacing
Recognition → stabilization → basic reassessment
Immediate stabilization, adequate benzodiazepine dosing, and evidence-based second-line therapy
Recognition → stabilization → basic reassessment
2026 SSC-aligned fluids, early norepinephrine, dynamic reassessment, and perfusion endpoints
Recognition → stabilization → basic reassessment
Fluid resuscitation, potassium kinetics, insulin therapy, and safe transition
Recognition → stabilization → basic reassessment
Membrane stabilization, intracellular shifting, monitoring, and definitive potassium removal
Recognition → stabilization → basic reassessment
Refractory bronchospasm, impending ventilatory failure, and prevention of dynamic hyperinflation
Recognition → stabilization → basic reassessment
Recognition, emergency decompression, definitive drainage, and persistent air-leak management
Recognition → stabilization → basic reassessment
Emergency cardioversion, recurrent AF during critical illness, and post-acute follow-up
Stabilization → investigation → initial treatment → reassessment
Post-operative water-balance emergency after pituitary surgery
Stabilization → investigation → initial treatment → reassessment
Antimicrobial therapy, ileus management, early surgery, and selected microbiota rescue
Stabilization → investigation → initial treatment → reassessment
Probability-based diagnosis and non-heparin anticoagulation
Stabilization → investigation → initial treatment → reassessment
Recognition, fluid resuscitation, insulin, and controlled osmolar correction
Stabilization → investigation → initial treatment → reassessment
Rapid ventilatory support and afterload reduction in flash pulmonary edema
Stabilization → investigation → initial treatment → reassessment
Controlled BP reduction in hypertensive encephalopathy with phenotype-specific exceptions
Stabilization → investigation → initial treatment → reassessment
Propranolol-associated bradycardia, cardiogenic shock, and sodium-channel toxicity
Stabilization → investigation → initial treatment → reassessment
Verapamil-associated bradycardic shock, hyperglycemia, and early high-dose insulin therapy
Stabilization → investigation → initial treatment → reassessment
Severe decompensated hypothyroidism with multiorgan dysfunction
Stabilization → investigation → initial treatment → reassessment
Management of high-risk febrile neutropenia with shock in the ICU
Stabilization → investigation → initial treatment → reassessment
Multimodal treatment of life-threatening decompensated thyrotoxicosis
Stabilization → investigation → initial treatment → reassessment
Late NAC, early transplant evaluation, hyperammonemia, and cerebral-edema prevention
Problem framing → competing data → treatment → response → second-order decision
Using respiratory-system mechanics without turning one marker into a rigid target
Problem framing → competing data → treatment → response → second-order decision
Immediate revascularization, shock phenotyping, vasoactive support, and selective temporary MCS
Problem framing → competing data → treatment → response → second-order decision
RV perfusion support, rapid reperfusion selection, and high-risk airway management
Problem framing → competing data → treatment → response → second-order decision
Immediate recognition, ADAMTS13 testing, plasma exchange, and caplacizumab-based therapy
Problem framing → competing data → treatment → response → second-order decision
Early echinocandin therapy, source control, clearance cultures, and selective metastatic-focus evaluation
Problem framing → competing data → treatment → response → second-order decision
Early recognition, damage-control resuscitation, and rapid hemorrhage control
Problem framing → competing data → treatment → response → second-order decision
Source-control reassessment and salvage therapy for persistent Staphylococcus aureus bloodstream infection
Problem framing → competing data → treatment → response → second-order decision
Lung-protective ventilation, prone positioning, PEEP, and selective neuromuscular blockade
Problem framing → competing data → treatment → response → second-order decision
Emergency hypertonic saline, close sodium monitoring, and prevention/rescue of overcorrection
Problem framing → competing data → treatment → response → second-order decision
Rapid DOPE-style troubleshooting of acute hypoxemia, high airway pressure and shock
Problem framing → competing data → treatment → response → second-order decision
Recognition and emergency treatment of suspected methanol or ethylene glycol poisoning
Problem framing → competing data → treatment → response → second-order decision
Standardized IAP measurement and stepwise decompression of overt ACS
Uncertainty → phenotype refinement → consequence → complication → rescue/reassessment
Tiered management of intracranial hypertension after severe traumatic brain injury
Uncertainty → phenotype refinement → consequence → complication → rescue/reassessment
Post-positive-pressure collapse in severe pulmonary arterial hypertension
Uncertainty → phenotype refinement → consequence → complication → rescue/reassessment
Post-intubation obstructive shock from severe gas trapping
Uncertainty → phenotype refinement → consequence → complication → rescue/reassessment
Balancing pressure support, inotropy, congestion, and temporary MCS
Uncertainty → phenotype refinement → consequence → complication → rescue/reassessment
Competing hemorrhagic and thrombotic physiology in postpartum hemorrhage and sepsis
Uncertainty → phenotype refinement → consequence → complication → rescue/reassessment
Persistent status epilepticus after adequate benzodiazepine and second-line antiseizure therapy
Uncertainty → phenotype refinement → consequence → complication → rescue/reassessment
Reassessment and rescue options in catecholamine-resistant vasodilatory shock
Uncertainty → phenotype refinement → consequence → complication → rescue/reassessment
When to start kidney replacement therapy and how to select modality/dose
Uncertainty → phenotype refinement → consequence → complication → rescue/reassessment
Ventilator management of life-threatening gas trapping
Uncertainty → phenotype refinement → consequence → complication → rescue/reassessment
Mechanism-based management of severe alkalemia, electrolyte abnormalities, and volume overload
Uncertainty → phenotype refinement → consequence → complication → rescue/reassessment
Susceptibility-directed treatment with newer antipseudomonal beta-lactams
Uncertainty → phenotype refinement → consequence → complication → rescue/reassessment
Hyperammonemia, osmotherapy, CRRT, and neuroprotection during transplant evaluation
Initial framing → evolving shock/organ failure → competing priorities → rescue → leadership-level synthesis
Emergency VKA reversal followed by individualized anticoagulation resumption
Initial framing → evolving shock/organ failure → competing priorities → rescue → leadership-level synthesis
Separating venous pressure from fluid responsiveness using dynamic hemodynamic assessment
Initial framing → evolving shock/organ failure → competing priorities → rescue → leadership-level synthesis
Sepsis-induced myocardial dysfunction with vasoplegia and low forward flow
Initial framing → evolving shock/organ failure → competing priorities → rescue → leadership-level synthesis
RV-protective rescue in severe ARDS with hypoxemia and right-ventricular failure
Initial framing → evolving shock/organ failure → competing priorities → rescue → leadership-level synthesis
Escalating vasopressor requirements after initial resuscitation and source control
Initial framing → evolving shock/organ failure → competing priorities → rescue → leadership-level synthesis
Physiologically difficult airway management when compensatory ventilation is life-sustaining
Initial framing → evolving shock/organ failure → competing priorities → rescue → leadership-level synthesis
High-anion-gap metabolic acidosis with concurrent respiratory and metabolic alkalosis
Initial framing → evolving shock/organ failure → competing priorities → rescue → leadership-level synthesis
Recurrent ventricular arrhythmias and ICD therapies requiring trigger correction, sympathetic suppression, antiarrhythmic therapy, device optimization, and early ablation planning
Initial framing → evolving shock/organ failure → competing priorities → rescue → leadership-level synthesis