How to Prepare for the CICM Second Part Paediatric Examination in 2026: What You Actually Need to Know

A practical guide for paediatric intensive care trainees sitting the CICM Second Part Paediatric Examination in the next twelve months. PRIMEX started in 2025 when an anaesthetic trainee at a regional NSW hospital built study tools for the ANZCA Primary. It now covers Australasian specialty exams because trainees from each specialty asked us to build for them. The CICM Second Part Paediatric Examination curriculum on PRIMEX is maintained against the College's published syllabus, with topic mapping reviewed for accuracy.

The exam at a glance

The College of Intensive Care Medicine of Australia and New Zealand (CICM) sets the Second Part Paediatric Examination as the final hurdle before Fellowship in paediatric intensive care. It is a clinical exam, not a basic science exam, and it is paediatric throughout. The College expects consultant-level reasoning across the breadth of paediatric intensive care, from the resuscitation of a neonate with duct-dependent circulation to the ventilation strategy for a child with severe ARDS, with the depth that lets you safely run a paediatric ICU. There is a written short answer component and an oral component made up of structured vivas and bedside hot cases. There is no multiple-choice paper. The College sets the standard by reference to examiner judgement and structured marking, with an Angoff-derived cut for the written papers, rather than a single fixed numerical pass mark.

The written section (Short Answer Questions)

• Two written papers of 15 SAQs each, so 30 SAQs and 300 marks in total, with 150 minutes per paper
• Each SAQ is worth 10 marks, which works out at roughly 10 minutes per question against the clock
• Every question is a paediatric intensive care scenario. The register is weight-based, age-aware management, not adult ICU and not basic science
• The written total contributes to progression, and an Angoff cut-off must be reached to move to the oral section
• Paper-based at college-nominated venues. As of 2026, confirm the delivery format directly with CICM ahead of your sitting

The hot cases

• Two unseen paediatric ICU patients, examined live with the bedside team. Roughly 20 minutes per patient with a short introduction, focused examination, summary, and management plan
• Examiners assess your ability to take a complex critically ill child, organise the problem list, and present a prioritised, weight-appropriate management plan in real time
• The patient is real, often a ventilated infant or child on multiple infusions and devices, and you have one chance to get it right
• The component rewards the trainee who can integrate organ systems quickly, name the differential, and articulate what they would do next at paediatric intensivist level

The structured viva

• 8 structured oral viva stations, each approximately 12 minutes long, with around 2 minutes of reading and 10 minutes of discussion per station
• Each viva opens on a paediatric clinical scenario stem and probes management priorities, weight-based drug doses, monitoring targets, complications, and the ethical or family communication dimension
• Examiners use a structured mark sheet. The questions are standardised across the cohort to keep the assessment fair across centres
• The viva is where vague answers go to die. "Start an inotrope" is a fail-track answer. "Adrenaline 0.05 to 0.3 mcg/kg/min titrated to perfusion and a low-normal lactate, with arterial line and central access" is the register

Sittings and pass standard

The Second Part Paediatric Examination is held once a year. The written papers are sat first, followed several months later by the clinical components (hot cases and structured vivas) at college-nominated centres. CICM does not publish a single headline pass rate for this examination. It is criterion-referenced, with an Angoff-derived written cut score set for each sitting, and the College reports per-sitting, per-component performance in its examination reports. To progress from the written to the oral section a candidate typically needs a total score of at least half the available marks, no more than one section failed, and no poor performance in the clinical (hot case) section. Read the published examination reports carefully, because they signal exactly which patterns of answer were marked down.

What the College actually tests

The CICM Second Part Paediatric curriculum on PRIMEX maps to 85 published learning objectives, drawn from the CICM Syllabus for the Second Part Examination in Paediatric Intensive Care Medicine, First Edition (February 2025). Every SAQ stem, hot case, and viva scenario maps to one or more of these objectives. The syllabus covers the breadth of the paediatric intensivist role, organised across the major systems and process domains: Structure and Process, Decision Making, Sepsis and Infections, Cardiovascular Intensive Care, Respiratory Intensive Care, Gastrointestinal and Metabolic Intensive Care, Renal Intensive Care, Neurological Intensive Care, Endocrine Intensive Care, Immunological and Rheumatological Intensive Care, Haematological and Oncological Intensive Care, Trauma Intensive Care, Environmental Injuries and Toxicology, Organ and Tissue Donation, Populations Requiring Special Considerations, Neonatal Intensive Care, Peri-operative Issues, Intensive Care Procedures, Radiology, Applied Pharmacology, and Professional Practice.

The breadth is genuinely large, and the depth is paediatric intensivist level throughout. A handful of clusters come up disproportionately based on examination reports and the structure of the syllabus. These are seven of the highest-yield areas to anchor your preparation.

1. Paediatric sepsis, septic shock and MODS

Sepsis is the perennial SAQ and the perennial viva. The College expects you to recognise the shocked child early (capillary refill, tachycardia, altered conscious state, with hypotension a late sign in children), to give fluid in 10 to 20 mL/kg boluses with reassessment after each one, and to escalate to vasoactive support for fluid-refractory shock. Know that the commonest paediatric phenotype is cold shock (high systemic vascular resistance, low cardiac output), which is adrenaline-responsive, in contrast to the warm vasodilatory shock seen more often in adults and adolescents. Source control, antimicrobial timing and the management of multiple organ dysfunction syndrome all turn up. Candidates who recite a bundle without articulating what they would do at hour two if the child is not improving are exactly the candidates the examiners are filtering out.

2. Respiratory failure, ARDS and acute severe asthma

Paediatric ARDS (PARDS) and its lung-protective ventilation strategy, the escalation ladder in acute severe asthma (oxygen, inhaled and intravenous bronchodilators, magnesium, aminophylline and the decision to ventilate), and the haemodynamic interaction of high airway pressures in a small chest. Expect at least one ventilation question per sitting and expect it to push into trouble-shooting: the deteriorating ventilated child (the DOPES checklist of displacement, obstruction, pneumothorax, equipment and stacked breaths), auto-PEEP in obstructive disease, and the threshold for non-invasive support or ECMO. Generic answers about lung protection do not score. Numbers and decision points score.

3. Airway obstruction and the difficult paediatric airway

Upper-airway obstruction is a paediatric emergency in its own right. Croup with its Westley score, dexamethasone and nebulised adrenaline, epiglottitis and bacterial tracheitis, and the congenital lesions (laryngomalacia, subglottic stenosis, vascular rings) that present with stridor. The College rewards the candidate who knows not to examine the throat or distress the child with suspected epiglottitis, and who can describe a calm, planned, theatre-based airway with ENT and anaesthesia present. The paediatric airway is small, the margin for desaturation is short, and the examiners want to hear that you respect both.

4. Neurocritical care in children

Status epilepticus stepping through the benzodiazepine and second-line algorithm, meningitis and encephalitis with empirical therapy and supportive care, raised intracranial pressure and hypoxic-ischaemic encephalopathy with ICP and cerebral perfusion targets and the role of therapeutic hypothermia after cardiac arrest, and acute cerebrovascular injury in children. Neurocritical care turns up across all components and rewards specificity in weight-based numbers (lorazepam 0.1 mg/kg, levetiracetam 40 to 60 mg/kg, sodium targets, osmotherapy doses).

5. Congenital and acquired heart disease

The duct-dependent congenital lesion presenting in the first days of life, the physiology of single-ventricle and shunt-dependent circulations, post-operative care after cardiac surgery, and acquired disease such as myocarditis, cardiomyopathy and the cardiac complications of Kawasaki disease and MIS-C. The College expects you to understand how prostaglandin keeps a duct open, how to balance pulmonary and systemic blood flow, and how to support a failing post-bypass heart. This is one of the areas that most clearly separates paediatric from adult intensive care.

6. Endocrine and metabolic emergencies

Diabetic ketoacidosis with its deliberate, slow rehydration to avoid cerebral oedema (the dominant cause of DKA death and disability in children), the careful potassium and insulin sequencing, and the recognition and treatment of cerebral oedema if it develops. Sodium disorders (diabetes insipidus, SIADH, cerebral salt wasting) distinguished by water and sodium handling, adrenal crisis, and the inborn errors of metabolism that present to PICU. These are perennial SAQ topics and they reward specific, cautious, weight-based numbers and clear escalation thresholds.

7. Ethics, child protection and the family meeting

Withdrawal and withholding of treatment in a child, the best-interests framework, consent and the role of parents, the structured family meeting, the organ donation conversation, and the recognition and mandatory reporting of non-accidental injury. Examination reports repeatedly flag that candidates who deliver flawless clinical management but never address the ethical, child-protection or family dimension lose marks they did not need to lose. The Second Part Paediatric Examination is a test of the consultant role in a children's hospital, not the encyclopaedia.

Common pitfalls that fail candidates

• Answering at an adult or generalist level. The single most common trap. This is a paediatric intensive care exam. Weight-based doses, age-specific physiology and the differences from adult ICU are the register the examiners reward.
• Vague, non-consultant phrasing. "Manage the airway", "give fluid", "start an inotrope". The expected register is specific: drug name, dose in mg/kg or mcg/kg/min, route, monitoring target, and what you would re-assess.
• Missing ethics, child protection and family communication. Many SAQs and most vivas have an explicit ethics, safeguarding or family component. Candidates who treat them as add-ons lose easy marks.
• Forgetting the cerebral-oedema and fluid-overload risks unique to children. Cautious fluid in DKA, careful sodium correction, and the small-child margin for fluid overload are recurring marking points.
• Insufficient attention to complications and contingency planning. The College rewards anticipatory thinking. Answers that stop at acute management lose marks for not stating what would change the plan.
• Hot case: presenting before structuring. The candidate who walks straight from the bedside to the examiner without thirty seconds of mental structuring tends to ramble. Take the breath. Order the problem list. Then present.
• Viva: giving examiners what they did not ask for. A viva question about ventilating a child with bronchiolitis is not the place to recite a definition. Answer the question asked, give specific weight-based numbers, and stop.

A realistic study timeline

The right run-up depends on your full-time-equivalent paediatric ICU exposure, how recently you sat the First Part, and how comfortable you already are with the breadth of the curriculum. Three sample plans, in rising order of comfort.

Nine-month plan (8 to 10 hours per week)

Suits a trainee working full-time clinically with significant non-work commitments who wants slow steady coverage rather than a sprint.

• Months 1 to 3. Walk through the CICM Second Part Paediatric curriculum systematically. Cover two or three sections per week across the paediatric ICU systems. Build a flashcard deck as you go and answer 30 to 50 recall items per week to surface gaps. Read examination reports in parallel; they tell you exactly which content patterns are being marked.
• Months 4 to 6. SAQ practice begins. Aim for two timed SAQs per week (10 minutes each), marked carefully against a model answer with weight-based doses. Begin viva practice with one structured station per week, ideally with a study partner or a simulator that plays the examiner.
• Months 7 to 8. Timed SAQ mocks under exam conditions. Viva practice scales to two or three stations per week across the major content domains. Identify weak curriculum sections and target them. Organise hot case sessions with consultants willing to run a mock at the PICU bedside.
• Final month. Two full timed SAQ mocks (15 SAQs in 150 minutes). Hot case practice scales up: two patients per session at minimum, ideally across a mix of ventilated infants, post-cardiac-surgery children and neurocritical care patients. Final polishing on high-yield clusters: sepsis, respiratory failure, neurocritical care, DKA.

Six-month plan (12 to 15 hours per week)

The standard plan for most candidates. Tight enough to keep momentum, long enough to cover the curriculum properly.

• Months 1 to 2. Walk through every curriculum section. Cover three or four sections per week. Build the flashcard deck. 50 to 80 recall items per week. Begin reading every recent CICM examination report.
• Months 3 to 4. SAQ practice becomes the main work. Three to five timed SAQs per week, marked carefully against a model answer. Maintain recall practice. Start viva practice at one to two stations per week, mixing clinical management with ethics, child-protection and family communication scenarios.
• Month 5. First full timed SAQ mock (15 SAQs in 150 minutes). Viva volume doubles to two or three stations per week. Hot case practice begins in earnest: one to two PICU bedside cases per week with consultant feedback if you can get it.
• Final month. Two more SAQ mocks under exam conditions. Daily hot case or viva practice. Final round of weak-area content reading. Sleep and wind down for the last 48 hours.

Four-month plan (18 to 22 hours per week)

The compressed plan. Doable if you are part-time clinical or have a study leave block, painful otherwise.

• Month 1. Speed-read the curriculum. Three to four sections per week, focused on weak areas. Heavy recall volume from week one (100 plus items per week). Begin SAQ practice in week three.
• Month 2. Timed SAQs daily or every second day. Viva practice begins twice a week. Target a mix of clinical management, ethics, and family-meeting stations. Hot case practice begins by week six at the latest.
• Month 3. Full timed mocks start. SAQ mock weekly, viva mock weekly with a peer or simulator. Hot case practice three times per week with consultant feedback wherever you can get it.
• Final month. Polish weak areas. Two SAQ mocks, daily viva practice, two or three hot case sessions per week. Sleep and wind down for the last 48 hours.

When to start each component

• Recall and content reading: from week one. They build curriculum coverage and surface weak areas faster than passive reading.
• Timed SAQs: from month two at the latest. The 10-minute discipline is brutal until it is practised, and then it is fine. Untimed SAQs for the first two weeks are sensible. After that, write to the clock.
• Viva stations: from month three at the latest, even on a four-month plan. Verbal performance under time pressure needs reps. Reading about the viva does not transfer.
• Hot case practice at the bedside: from month three at the latest. The hot case skill is structured rapid assessment under observation, and that has to be built on real ventilated children with real lines and infusions. Reading cases on paper builds knowledge, not the bedside skill.
• Past content and full mocks: last six to eight weeks for SAQ. Earlier than that and you have not yet covered enough ground for the result to be meaningful.

Weekly study split that holds up

Most candidates run into trouble because their week is shapeless and the work that feels easy crowds out the work that matters. A simple template that works: two SAQ sessions per week of 60 to 90 minutes each, two viva sessions per week of 45 to 60 minutes each from month two onward, one hot case session per week from month three, one curriculum reading session tied to whichever weak section emerged from the practice, and flashcard reps in the background as ten-minute blocks between patients or on commutes. Protect your viva and hot case slots the way you protect a clinical commitment. If you let them move, they stop happening.

Track what you got wrong, not what you got right. Keep a running list of missed marking points by curriculum section. After a month you will see two or three sections that come up repeatedly and you can target them directly. The worst study plans are the ones that confuse curriculum coverage with curriculum mastery.

The single biggest mistake people make

You leave the hot cases until the last six weeks. The written papers feel concrete and tractable, so you grind SAQs first because the feedback is immediate and the score is a number. The viva feels manageable because you can practise it sitting at a desk with a study partner. The hot cases sit at the back of the plan, untouched, and you tell yourself you will get to them when you are closer to the date.

Then you wake up two months out, realise you have never run a structured bedside assessment under observation on a real ventilated child, and try to compress all your hot case work into the run-in. By that point your SAQ stamina is good, your viva is rehearsed, and your hot case is the rate-limiting weakness in your sitting. The pattern that breaks competent candidates in the Second Part Paediatric Examination is exactly this: strong SAQ, acceptable viva, hot case below standard, overall result below the line.

The hot case is not a knowledge test. It is a performance under observation in real time, on a real child, with real numbers and real risks, and the only way to get fluent at it is to do it badly thirty times before you do it well. You need the muscle memory of structuring the bedside assessment, organising the problem list under pressure, presenting back to the examiner with a clear weight-appropriate management plan, and answering the follow-up probes without losing your structure. That muscle memory takes months to build, not weeks. Start hot case practice in month one or two of your run-up. One PICU bedside case a week is enough to keep the skill alive. By the time you sit, the structure should feel automatic and your conscious bandwidth should be free for the clinical reasoning.

How PRIMEX helps

• The SAQ grader generates CICM Second Part Paediatric SAQs and marks each response at paediatric intensivist level with examiner-style feedback against marking points, including the weight-based doses, monitoring targets and ethical components that examination reports flag. Open the CICM Second Part Paediatric page on PRIMEX to see the format.
• The structured oral viva simulator runs paediatric ICU vivas with a consultant examiner persona, voice mode, and a debrief that flags missing ethics, child-protection, complication management and family communication components. Open it from the oral exam feature on the CICM Second Part Paediatric page.
• The curriculum tracker maps every study note and flashcard to the 85 CICM Second Part Paediatric learning objectives, so you can check coverage rather than guess at it.
• Ask PRIMEX is a clinical question tool that pulls answers from the paediatric ICU study notes and references the underlying evidence. Available inside the app at primexstudy.com.au/app.

Worked topic deep-dives

Three high-yield topics drawn straight from the PRIMEX CICM Second Part Paediatric study notes. Each one is a teaser; the full note carries the complete management and hot-case framing.

Paediatric septic shock

The shocked child is a recognition-and-resuscitation emergency, and the paediatric physiology differs sharply from the adult. Hypotension is a late, pre-arrest sign in children, so you act on tachycardia, prolonged capillary refill, cool peripheries and altered conscious state long before the blood pressure falls.

• Resuscitate in 10 to 20 mL/kg isotonic crystalloid boluses, reassessing after each for response and for signs of fluid overload (hepatomegaly, increased work of breathing, worsening oxygenation). In known cardiac disease or severe malnutrition, start with 5 to 10 mL/kg.
• Fluid-refractory shock (persisting after about 40 mL/kg in the first hour) needs early vasoactive support. Cold shock, the commonest paediatric phenotype, is adrenaline-responsive; warm shock is noradrenaline-responsive.
• Give broad-spectrum antibiotics early, take cultures without delaying treatment, and actively pursue source control rather than treating it as an afterthought.

How it is examined: the hot case and viva reward rapid recognition, a weight-based fluid and inotrope plan, and a clear escalation pathway. Common pitfall: waiting for hypotension before treating, or giving large unmonitored fluid volumes without reassessing.

Read the full note →

Paediatric status epilepticus

Status epilepticus is a time-critical algorithm, and the doses are weight-based. Surface GABA-A receptors are internalised as a seizure continues, which is why early benzodiazepine administration is far more effective than late, and why second-line agents that target different receptors are needed as the seizure extends.

• First-line: IV or IO lorazepam 0.1 mg/kg (maximum 4 mg), repeated once after 5 minutes if needed. Without IV access, use buccal or intranasal midazolam (around 0.2 to 0.3 mg/kg, maximum 10 mg). Have airway equipment and bag-mask ventilation ready before you give the benzodiazepine.
• Second-line at 15 to 20 minutes if the benzodiazepine has failed: levetiracetam 40 to 60 mg/kg, or sodium valproate 25 to 40 mg/kg, or fosphenytoin or phenytoin 20 mg/kg phenytoin equivalents. Phenobarbitone 20 mg/kg is the preferred second-line agent in neonates.
• Refractory status epilepticus that fails two adequate agents needs intubation and an anaesthetic infusion. Avoid a propofol infusion for ongoing seizure suppression in children under 16 because of propofol infusion syndrome risk.

How it is examined: the viva expects the time-staged algorithm with exact weight-based doses and the airway plan that runs alongside it. Common pitfall: under-dosing the benzodiazepine, or stalling on the second-line agent past the 20-minute mark.

Read the full note →

Paediatric upper-airway obstruction

The small paediatric airway turns modest swelling into critical obstruction, so the examiners want calm, planned management and an early recognition of which child cannot be examined or distressed.

• Croup (viral laryngotracheobronchitis): use the Westley score to grade severity; give dexamethasone 0.15 to 0.6 mg/kg orally or IV; add nebulised adrenaline for moderate-to-severe disease and watch for rebound over the next 2 to 4 hours.
• Epiglottitis: do not examine the throat, attempt IV access or lay the child supine before the airway is secured. Plan a calm inhalational induction in theatre with ENT and anaesthesia present, then start a third-generation cephalosporin once the airway is safe.
• Bacterial tracheitis: high fever, toxaemia and failure to respond to croup treatment point to it. It often needs early, sometimes difficult, intubation, frequent ETT suctioning, and anti-staphylococcal cover.

How it is examined: the hot case and viva reward distinguishing the causes of stridor and choosing a safe, staged airway plan for the child you must not distress. Common pitfall: instrumenting or upsetting a child with suspected epiglottitis before a definitive airway plan is in place.

Read the full note →

Frequently asked questions

Related study guides

• CICM Second Part (Fellowship) 2026 Study Guide
• RACP Paediatrics 2026 Study Guide