TEMI Adulto (AMIB / AMB) common mistakes
TEMI Adulto (AMIB / AMB) · Understand the traps and how to avoid them.
Classifying respiratory failure and choosing ventilatory support based on the PaO2 alone, ignoring the PaCO2, pH and the patient's respiratory effort, so that a hypercapnic acidotic patient is treated as if he had isolated hypoxemia.
The candidate anchors on the most eye-catching number on the blood gas and defaults to 'low oxygen means high FiO2 and PEEP', skipping the systematic step of first deciding whether the failure is oxygenation, ventilation, or both, and whether it is acute or chronic.
What to do instead
Before selecting support, always write down four items: PaO2/FiO2, PaCO2 with pH, respiratory rate and pattern, and the chronic baseline if known. State explicitly 'type I, type II, or mixed' and then justify the choice (high-flow nasal oxygen, noninvasive ventilation, or invasive ventilation) with a physiological argument. Practise 20 blood gases in this four-line format until it is automatic.
In a patient on mechanical ventilation who deteriorates, immediately manipulating the ventilator (increasing PEEP, changing modes, adjusting FiO2) without first performing a structured check of tube position, patency, circuit, and a quick lung and hemodynamic assessment.
Ventilator knobs are visible and actionable, while the DOPES-type differential (displacement, obstruction, pneumothorax, equipment, stacked breaths) requires a deliberate pause; under time pressure the candidate reaches for the familiar intervention and misses a mainstem intubation, a mucus plug, or a tension pneumothorax.
What to do instead
Adopt a fixed sequence for any acute desaturation or high-pressure alarm: disconnect and bag with 100% oxygen, confirm tube depth and cuff, auscultate and check chest symmetry, look at the flow-time and pressure-time curves, then examine for pneumothorax and check hemodynamics. Only after this loop should ventilator settings change. Rehearse the sequence aloud in simulated scenarios.
Judging resuscitation adequacy in shock by blood pressure and heart rate alone, without integrating lactate clearance, capillary refill, urine output, central or mixed venous oxygen saturation, and bedside echocardiographic or dynamic indices of fluid responsiveness.
Blood pressure is the easiest variable to see and the one most reinforced by monitors and by the traditional teaching of 'pressure equals perfusion'; the candidate therefore stops titrating once a numeric target is reached and either over-resuscitates with fluid or under-treats a persistent flow deficit.
What to do instead
For every shock case, build a perfusion bundle in writing: MAP, lactate and its trend, urine output, skin and mental status, ScvO2 or venous-arterial CO2 gap when available, and a fluid-responsiveness test (passive leg raise, pulse pressure or stroke volume variation) before each bolus. State the shock phenotype (hypovolemic, distributive, cardiogenic, obstructive) and the endpoint chosen to stop fluids.
Treating sepsis as a single time-zero event and delivering the initial bundle but failing to reassess and escalate: not repeating lactate, not re-culturing or de-escalating antibiotics, not re-measuring fluid responsiveness, and not recognizing when the patient has moved from early distributive shock into a different physiology.
Protocols are memorized as a checklist of first-hour actions, so the candidate's mental model ends when the bundle is complete; the exam's later-stage vignettes reward dynamic reassessment, which is under-practiced.
What to do instead
Structure every sepsis answer in three time blocks: first hour (cultures, antibiotics, fluids, lactate, source control), 6 to 12 hours (lactate clearance, vasopressor need, fluid balance, source control confirmation), and 24 to 72 hours (de-escalation, review of cultures, organ recovery). Explicitly name the reassessment triggers and the criteria for escalation or de-escalation.
Managing an acute neurologic deterioration with a single reflex intervention (for example, giving mannitol or hypertonic saline) without first securing the airway and oxygenation, checking and treating blood pressure and glucose, and excluding non-neurologic causes such as hypoxia, hypercapnia, hypotension, seizures, or drug effect.
The dramatic neurologic picture pulls attention to the brain, and osmotic therapy feels definitive; the candidate skips the reversible systemic contributors that dominate bedside prognosis and that the exam deliberately embeds in the stem.
What to do instead
Use a fixed pre-coma checklist: airway and ventilation, PaO2 and PaCO2, MAP and cerebral perfusion pressure, temperature, glucose and sodium, seizure activity, and sedative or opioid contribution. Only then move to osmotic therapy, head positioning, and consideration of intracranial pressure monitoring, stating the target numbers you would use.
Interpreting acid-base disorders by reading the pH and bicarbonate and labeling the picture, without applying the expected compensatory response and the anion gap, so that a mixed disorder is reported as a simple one and the delta gap is never calculated.
The candidate memorizes the four primary disorders as labels and does not routinely perform the arithmetic steps (expected PaCO2 for the metabolic disorder, expected bicarbonate for the respiratory disorder, anion gap with albumin correction, delta-delta), so mixed disorders are invisible.
What to do instead
Adopt a mandatory arithmetic template: pH, PaCO2, HCO3, then calculate expected compensation, then anion gap corrected for albumin, then delta gap. Write the conclusion as 'primary disorder plus or minus a second disorder' and never accept a label without the numbers supporting it. Practise with mixed-disorder cases until the template takes under a minute.
In acute coronary syndrome and other critical cardiology scenarios, choosing reperfusion or inotropic strategy from the ECG and troponin alone, without integrating right ventricular involvement, hemodynamic stability, bleeding risk, renal function, and the interaction between the chosen drug and the current hemodynamic profile.
Cardiology vignettes cue a pattern-recognition response (ST elevation means thrombolysis or catheterization), and the candidate under-weights the accompanying shock state, right ventricular infarction, or contraindications that change the correct answer.
What to do instead
For every cardiovascular emergency, force a two-column answer: the ischemic diagnosis and the hemodynamic profile (blood pressure, perfusion, right versus left ventricular failure, congestion). Then check contraindications and renal dosing explicitly. If the patient is in shock with right ventricular infarction, state why fluids and avoiding vasodilators changes management before any reperfusion decision.
Designing sedation as a fixed continuous infusion with a single target score, failing to perform daily sedation interruption or light-sedation trials, and not distinguishing pain from agitation from delirium, so that analgesia is under-treated while sedatives accumulate.
Sedation is treated as a comfort prescription rather than a monitored therapy; the candidate does not routinely pair the sedation scale with a delirium screen and a pain assessment, and does not plan the weaning interaction in advance.
What to do instead
For each sedation question, state three separate assessments: pain score, sedation score with the target explicitly defined, and delirium screening. Then state the strategy: analgesia-first, light sedation unless a specific indication for deep sedation exists, daily interruption or spontaneous awakening trial paired with a spontaneous breathing trial, and a planned exit strategy with drug choice justified by organ function.
Prescribing nutrition and metabolic management by routine or by formula without individualizing for the phase of critical illness: starting full caloric targets early in shock, ignoring refeeding risk, failing to monitor electrolytes, glucose, and triglycerides, and missing endocrine emergencies such as adrenal crisis or thyroid storm.
Nutrition and endocrine topics are perceived as low-yield and are studied as isolated facts, so the candidate does not build the habit of linking feeding advancement to hemodynamic stability, electrolyte trends, and organ function.
What to do instead
For every nutrition or metabolic question, state the phase (early acute, late acute, recovery), the route and the rate of advancement, the monitored parameters (phosphate, potassium, magnesium, glucose, triglycerides), and the criteria to withhold or reduce feeding. Separately memorize the trigger-and-treatment pairs for adrenal crisis, myxedema coma, thyroid storm, and diabetic emergencies with their first-line drugs and doses.
Transfusing or correcting coagulation based on a single abnormal laboratory number (hemoglobin, platelet count, INR) without linking it to active bleeding, the planned procedure, and the clinical context, and without recognizing transfusion reactions or the indications for specific blood products and reversal agents.
Laboratory thresholds are easy to memorize and are taught as triggers, so the candidate applies them mechanically and forgets that the decision depends on bleeding status, procedure invasiveness, and the underlying cause of the abnormality.
What to do instead
For each hematology question, state the clinical scenario first (active bleeding, prophylaxis before a procedure, or incidental abnormality), then the threshold you would use and why, then the product and dose, then the monitoring and the stop rule. Add a routine check for transfusion reaction recognition and for anticoagulant-specific reversal agents with their monitoring tests.
Approaching an acute abdomen or hepatic failure in the intensive care unit as a purely medical problem, ordering laboratory tests and antibiotics but delaying imaging, surgical consultation, and source control, and not adjusting drug choice and dosing for hepatic dysfunction.
The candidate works within the specialty silo of intensive care and treats imaging and surgery as downstream steps rather than as time-critical components of resuscitation; hepatic dosing adjustments are also under-practiced.
What to do instead
In any abdominal or hepatic vignette, write a parallel plan: resuscitation, immediate imaging choice with justification, and a named surgical or gastroenterological consultation with a time frame. Separately list which drugs need dose adjustment or avoidance in hepatic failure and which electrolyte and coagulation derangements change management.
In trauma and burns, following a rigid sequence without applying damage-control principles: over-resuscitating with crystalloid, missing occult hemorrhage and the need for massive transfusion activation, failing to warm the patient and correct calcium and acidosis, and misjudging burn fluid requirements and inhalation injury.
Trauma is taught as a linear primary survey, and the candidate recites the sequence without integrating the physiology of the lethal triad and the dynamic decision to move to hemorrhage control rather than continue infusing.
What to do instead
For each trauma or burn scenario, explicitly state the lethal triad status (temperature, calcium and coagulation, pH and lactate), the trigger for massive transfusion, the ratio-based product strategy, and the timing of definitive hemorrhage control. For burns, calculate fluid requirements with a named formula, state the titration endpoint (urine output), and separately address airway risk from inhalation injury.
Answering ethics, quality, and end-of-life questions by personal opinion or by vague appeal to 'do everything possible', without applying the recognized framework of patient autonomy, proportionality of treatment, surrogate decision-making, and the distinction between withholding and withdrawing, and without naming the institutional process for conflict resolution.
These topics feel subjective and are under-studied relative to physiology, so the candidate improvises and confuses legal, ethical, and clinical reasoning, or defaults to maximal treatment as the safe answer.
What to do instead
Prepare a fixed structure: assess decision-making capacity, identify the legal surrogate and the standard they must apply, weigh benefit and burden proportional to the patient's values, document the goals-of-care discussion, and name the palliative care and ethics consultation pathways and the conflict-resolution steps. Practise writing the reasoning in that order for five end-of-life scenarios.