1.1 Principles of Emergency Medicine

Question 1

Describe the initial emergency medicine approach to a patient in ACEM in Australia.

Answer 1

• ABCDE framework
• Zero, primary, secondary, tertiary surveys
• Triage, treat and transfer

There has been a move towards a C-ABC approach, with the first ‘C’ standing for cerebral perfusion.

This is why for example, chest compressions and haemorrhage control take priority in a cardiac arrest and trauma patient respectively.

ABCDE can be returned to and reassessed at any stage of a patient’s journey, especially if management is not having desired effect. Serial examinations are important.

Question 2

Explain recognition of ‘risk’ in the undifferentiated and differentiated emergency patient.

Answer 2

Risk exists in the undifferentiated and differentiated emergency patient and is dynamic and can change at any stage of diagnosis, management.

Question 3

A 35-year old woman presents with pleuritic chest pain. Select one or more statements from below which you feel are correct and reflect a risk-aware approach.

Answer 3

Question 4

Explain ‘prioritisation’ in an emergency patient.

Answer 4

Prioritisation refers to recognising ‘severity’ in patients. Severity often dictates treatment in the ED setting, meaning that treatment and management can often occur simultaneously or even before a fully clear history, ECG or investigations.

Question 5

An elderly man is brought into the ED complaining of severe abdominal pain.

He appears very unwell and is diaphoretic.

PR 140/min, BP 70/45.

What are your priorities?

Answer 5

Question 6

Interventions can be categorised as:

1. Urgent/non-urgent
2. Temporising/definitive

Explain what each of these categories mean.

Answer 6

1. Urgent

• Means it has to be dealt with immediately, e.g. airway
  
  • Temporising: E.g. BVM ventilation
  • Definitive: E.g. ETT tube airway

2. Non-urgent

• Means it can be dealt with later, e.g. broken elbow
  
  • Temporising: E.g. Backslab
  • Definitive: E.g. relocation elbow

Question 7

A 6 year old child presents with…

Answer 7

Question 8

A 28-year old woman presents with…

Answer 8

Question 9

Name 8 critical symptoms you do not want to miss.

Why are these important?

Answer 9

Recognition of single critical symptoms or a constellation of discriminating symptoms often are critical to early recognition of pathology.

1. Neurology
   
   • Altered LOC, including presyncope
   • Acute onset neurology (stroke call)
2. Cardiology
   
   • Chest pain
   • Presyncope with palpiations
3. Respiratory
   
   • SOB
   • Pleuritic pain with syncope
4. Abdominal
   
   • Abdominal pain in elderly
5. Systemic
   
   • Fever, headache, photophobia

Question 10

A 68-year old woman presents to ED…

Answer 10

Question 11

A 23-year old man has…

Answer 11

I personally disagree with this answer as the CT head is essential to ruling out Chiari malformations prior to LP.

Question 12

Explain the concept ‘the differential of consequence’ and how it affects your management.

Answer 12

It is the most serious differential and must always be considered at triage, hx and Ix.

Consider tests to exclude it, e.g. D-dimer for PE.

Question 13

An 80-year old man presents to ED…

Answer 13

Question 14

List 6 features of the unstable patient.

Answer 14

Question 15

List 4 features of the potentially unstable patient.

Answer 15

1. Hx and findings with any red flag
2. Trends in vital signs away from normal
3. Significant risk factors
4. Multiple co-morbidities

Question 16

List 4 features of the stable patient.

Answer 16

1. No red flags in Hx and findings.
2. Trends in vital signs stable.
3. May have co-morbidities, but these are quiescent.
4. Management plan in place.

Question 17

A 76-year old man…

Answer 17

Question 18

Describe some common demographic differences that can affect medical treatment.

Answer 18

1. Age
   
   • Very young and very old
   • Often easily dismissed or misinterpreted
2. Gender
   
   • Use a chaperone
3. Culture
   
   • May cause offence/ taboos
   • Language
4. Aboriginal/Torres Strait Islander

Question 19

You are working…

Answer 19

Question 20

What is a ‘red flag’?

What is the appropriate management if a ‘red flag’ appears?

Answer 20

A red flag is any feature from history or exam that points to the likelihood (even if small) of the most serious diagnosis being the actual diagnosis.

Red flags must not be ignored.

Need to go by a policy of “rule out” and to exclude, even if another more likely diagnosis appears.

Question 21

Which of the following situations…

Answer 21

Question 22

Explain the IMIST-AMBO handover tool.

Answer 22

It is used for ambulance staff in New South Wales. After the IMIST component, medical staff can interrupt and ask questions.

Question 23

Explain the ISBAR handover tool.

Answer 23

Question 24

What should you prepare when you hear a pre-arrival call?

Answer 24

Go through ‘ABCDE’.

Do you need BiPap? Do you need to call the blood bank? A bag of fluids? Do you need to let a team know, e.g. cardiology?

Question 25

Explain what the ‘zero survey’ is.

What are the 4 questions that you need to ask?

Answer 25

Is the patient well or unwell?

What do they need NOW? Do we need help?

First impression of the severity of the illness may include colour, diaphoresis, signs of life/breathing, signs of CO, gross level of consciousness, agitation, restlessness, AVPU, obvious abnormality or deformity.

The 4 questions you need to ask are:

1. Resuscitation - Do they need resus?
2. Timeframe - How long do I have to act?
3. Severity - How bad is the problem?
4. Call for help - Do I need senior assistance?

Question 26

Explain what the primary survey is.

Answer 26

Use the ABCDE system and fix problems as you find them! Aim is to stabilise the patient.

A - Airway

B - Breathing

C - Circulation

D - Disability

E - Exposure

Question 27

Explain what the secondary survey is.

Answer 27

The secondary survey is to relook at your differentials now the patient is stable.

History

1. How do they look now?
2. Review presenting complaint and history in more depth
3. AMPLE
   
   • Allergies
   • Medications
   • PMHx
   • Last ate
   • Event - PCHx

Examination

• Comprehensive top-to-toe examination

Investigations

• Urgent investigations to further determine differentials