Master Acute Care
for MCCQE Part 1

Core Concepts

Acute Care involves the immediate assessment, stabilization, and initial management of critically ill or injured patients. The overarching goal is to identify and treat life-threatening conditions rapidly, prevent further deterioration, and prepare for definitive care. A systematic approach is crucial.

• Systematic Approach (ABCDE): A foundational principle for all acute presentations.
  • Airway: Patency, protection (e.g., GCS < 8, obstruction).
  • Breathing: Rate, depth, effort, oxygenation, ventilation.
  • Circulation: Heart rate, blood pressure, capillary refill, pulses, signs of shock/hemorrhage.
  • Disability: Neurological status (GCS, pupils, focal deficits), glucose.
  • Exposure/Environment: Full body exam, temperature regulation, toxicology screen.
• Resuscitation Principles: Restore vital organ perfusion and function.
  • Oxygenation and ventilation support.
  • Fluid resuscitation (crystalloids, blood products).
  • Vasopressors/Inotropes for shock refractory to fluids.
  • Targeted temperature management post-cardiac arrest.
• Early Recognition & Management of Syndromes:
  • Sepsis and Septic Shock: Time-sensitive management with fluids, antibiotics, vasopressors.
  • Acute Respiratory Failure: Hypoxemic vs. Hypercapnic, need for ventilatory support.
  • Cardiogenic Shock/Acute Coronary Syndromes: Rapid diagnosis and reperfusion/support.
  • Anaphylaxis: Epinephrine is first-line.
  • Hypoglycemia: Immediate glucose administration.
• Monitoring: Continuous vital signs, ECG, SpO2, urine output, end-tidal CO2.

Clinical Presentation

• Altered Mental Status (AMS): Confusion, lethargy, obtundation, coma. Can indicate hypoxia, hypoperfusion, metabolic derangement (hypoglycemia, uremia, hepatic encephalopathy), infection (meningitis, sepsis), stroke, intoxication, or head trauma.
• Respiratory Distress: Tachypnea, dyspnea, accessory muscle use, retractions, nasal flaring, stridor, wheezing, grunting, cyanosis, decreased breath sounds. Indicative of airway obstruction, lung pathology (pneumonia, asthma, COPD exacerbation, pulmonary edema, PE, pneumothorax).
• Circulatory Shock: Hypotension, tachycardia, cool/clammy extremities, prolonged capillary refill, weak/absent pulses, oliguria, altered mental status. Types include hypovolemic, cardiogenic, distributive (septic, anaphylactic, neurogenic), obstructive (PE, tamponade, tension pneumothorax).
• Severe Pain: Acute abdomen (peritonitis, appendicitis, cholecystitis, bowel obstruction, AAA rupture), chest pain (ACS, PE, aortic dissection, pneumothorax), headache (subarachnoid hemorrhage, meningitis).
• Acute Neurological Deficit: Sudden onset weakness, paralysis, numbness, speech disturbance (aphasia, dysarthria), visual changes, balance issues (stroke, TIA, seizure).
• Fever/Signs of Infection: Unexplained fever with chills, rigors, malaise, localized pain/swelling, associated with AMS or hypotension (sepsis).
• Poisoning/Overdose: Specific toxidromes (e.g., opioid-induced respiratory depression, anticholinergic delirium).

Diagnosis (Rapid Identification of Life-Threatening Conditions and Underlying Etiologies)

Diagnosis in acute care is often syndromic and relies on a rapid synthesis of clinical findings with key investigations:

• Clinical Assessment: Detailed history (if possible) and physical exam (ABCDE approach).
• Bedside Diagnostic Tools:
  • ECG: Acute coronary syndrome, arrhythmias, electrolyte abnormalities, pericarditis.
  • Point-of-Care Ultrasound (POCUS): Rapid assessment for cardiac function, pericardial effusion, pneumothorax, free fluid, DVT, IVC collapsibility (fluid status).
  • Arterial Blood Gas (ABG): Oxygenation, ventilation, acid-base status, lactate (tissue hypoperfusion).
  • Capillary Blood Glucose: Essential for AMS.
• Laboratory Investigations:
  • CBC: Anemia, infection, thrombocytopenia.
  • Electrolytes, Creatinine, Urea: Renal function, electrolyte imbalances, hydration.
  • Liver Function Tests: Hepatic injury/dysfunction.
  • Cardiac Enzymes (Troponins): Myocardial injury.
  • D-dimer: Rule out PE/DVT (if low pre-test probability).
  • Lactate: Indicator of tissue hypoperfusion/hypoxia.
  • Cultures (blood, urine, sputum, CSF): Suspected infection.
  • Toxicology Screen: Suspected overdose/poisoning.
• Imaging:
  • Chest X-ray (CXR): Pneumonia, pulmonary edema, pneumothorax, pleural effusion, tube/line placement.
  • CT Scans (head, chest, abdomen/pelvis): Depending on clinical suspicion (stroke, hemorrhage, PE, aortic dissection, appendicitis).

Management (First Line)

• Airway Management:
  • Positioning, chin lift/jaw thrust, oral/nasal airways.
  • Endotracheal intubation for airway protection (GCS < 8, severe respiratory failure) or persistent hypoxemia/hypercapnia.
  • Cricothyrotomy (surgical airway) for failed intubation.
• Breathing Support:
  • Supplemental oxygen (nasal cannula, mask, non-rebreather).
  • Non-invasive Positive Pressure Ventilation (NIPPV) for COPD exacerbation, cardiogenic pulmonary edema.
  • Mechanical ventilation for severe respiratory failure.
  • Bronchodilators for bronchospasm.
  • Needle decompression/chest tube for tension pneumothorax/large pneumothorax.
• Circulation Support:
  • Establish 2 large bore IVs (or intraosseous access).
  • Fluid resuscitation (crystalloids, blood products for hemorrhage).
  • Vasopressors (norepinephrine, dopamine) for shock refractory to fluids.
  • Antiarrhythmics for unstable arrhythmias; cardioversion/defibrillation for life-threatening arrhythmias.
  • Pericardiocentesis for cardiac tamponade.
  • Massive transfusion protocol for severe hemorrhage.
• Disability Management:
  • Glucose administration (D50W) for hypoglycemia.
  • Naloxone for opioid overdose.
  • Benzodiazepines for seizures/agitation.
  • Elevate head of bed for suspected intracranial hypertension.
• Environmental/Exposure:
  • Fever: Antipyretics, cooling blankets.
  • Hypothermia: Warming blankets, warmed IV fluids.
  • Rapid administration of broad-spectrum antibiotics for suspected sepsis after cultures.
  • Specific antidotes for poisonings.
• Pain Management: Timely analgesia.