Master Emergency Medicine & Trauma
for PLAB 1

Core Concepts

Emergency Medicine & Trauma centers around immediate, life-saving interventions. The foundational approach is the **Primary Survey (ABCDE)**: Airway, Breathing, Circulation, Disability, Exposure. This is followed by a **Secondary Survey** (head-to-toe examination, AMPLE history). Key trauma concepts include understanding **mechanisms of injury** (blunt vs. penetrating) and recognizing signs of **shock** (hypovolemic, cardiogenic, distributive, obstructive). Neurological assessment frequently uses the **Glasgow Coma Scale (GCS)**. An **AMPLE history** (Allergies, Medications, Past medical history, Last meal, Events leading to injury) is crucial for all emergency patients.

Clinical Presentation

• **Trauma:**
  • **General:** Pain, deformity, bleeding, bruising, altered consciousness (GCS <15), vital sign abnormalities (tachycardia, hypotension, tachypnoea).
  • **Head:** Headache, nausea/vomiting, pupil changes, focal weakness, seizures, CSF leak.
  • **Chest:** Dyspnoea, chest pain, decreased breath sounds, crepitus, bruising, JVD.
  • **Abdomen:** Abdominal pain/tenderness, distension, guarding, rigidity, signs of internal bleeding (hypotension, tachycardia).
  • **Pelvis/Limbs:** Pelvic instability, limb deformity, swelling, neurovascular compromise (absent pulses, pallor, paraesthesia).
• **Medical Emergencies (Common PLAB scenarios):**
  • **Cardiac:** Chest pain (crushing, radiating), dyspnoea, palpitations, syncope, hypotension, signs of heart failure (rales, oedema, JVD).
  • **Respiratory:** Acute dyspnoea, wheeze, stridor, cough, fever, cyanosis, accessory muscle use, reduced oxygen saturation.
  • **Neurological:** Sudden onset focal weakness, speech disturbance, visual changes, altered mental status, seizures, severe headache, neck stiffness, fever.
  • **Abdominal:** Acute severe abdominal pain, vomiting, fever, changes in bowel habit, jaundice, signs of peritonitis.
  • **Sepsis:** Fever/hypothermia, tachycardia, tachypnoea, hypotension, altered mental status, lactate >2 mmol/L.
  • **Anaphylaxis:** Urticaria, angioedema, broncho/laryngospasm, hypotension, tachycardia.

Diagnosis (Gold Standard)

Initial diagnosis relies on clinical assessment (Primary/Secondary Survey). Investigations are guided by presentation:

• **Trauma:**
  • **Imaging:**
    • **FAST scan:** Rapid bedside ultrasound for free fluid (pericardial, peritoneal).
    • **X-rays:** Cervical spine, Chest, Pelvis (for major trauma).
    • **CT scan:** Head (GCS <15, neuro signs), Chest, Abdomen/Pelvis (definitive assessment of internal injuries).
  • **Bloods:** FBC, U&Es, G&S/Crossmatch, Coagulation screen, ABG (lactate, oxygenation), Troponins (chest injury), Tox screen.
• **Medical:**
  • **ECG:** All chest pain, syncope, palpitations, altered mental status.
  • **Bloods:** Cardiac enzymes (Troponins), D-dimer (PE/DVT suspicion), Cultures (blood, urine, sputum for sepsis), Inflammatory markers (CRP, Procalcitonin), Electrolytes, Glucose, Liver/Renal function, Thyroid function (arrhythmias), Tox screens.
  • **Imaging:**
    • **CXR:** Dyspnoea, chest pain, fever.
    • **CT Head:** Stroke, severe headache, altered mental status.
    • **CT Abdomen/Pelvis:** Severe abdominal pain.
    • **CTPA:** Suspected Pulmonary Embolism.
  • **Other:** Lumbar puncture (suspected meningitis/encephalitis), Urinalysis.

Management (First Line)

Management follows the ABCDE principles, with concurrent life-saving interventions:

• **Airway:** Jaw thrust/chin lift, suction, oropharyngeal/nasopharyngeal airway, definitive airway (endotracheal intubation) if GCS <8 or airway compromise. Consider c-spine immobilisation.
• **Breathing:** High-flow oxygen, assist ventilation (bag-valve-mask), identify and treat life-threatening conditions:
  • **Tension Pneumothorax:** Needle decompression (2nd ICS, mid-clavicular line), followed by chest drain.
  • **Open Pneumothorax:** Three-sided occlusive dressing, then chest drain.
  • **Massive Haemothorax:** Chest drain, fluid/blood resuscitation.
• **Circulation:**
  • Gain IV access (two large bore cannulae).
  • Fluid resuscitation (IV crystalloids e.g., 0.9% NaCl, Hartmann's), blood products (O-negative, then cross-matched) for haemorrhagic shock.
  • External haemorrhage control (direct pressure, tourniquet).
  • **Cardiac Tamponade:** Pericardiocentesis.
  • **Cardiac Arrest:** ALS protocol (CPR, defibrillation, adrenaline).
• **Disability:** Rapid neuro assessment (GCS, pupils), check blood glucose (treat hypoglycaemia with IV Glucose).
• **Exposure:** Full patient examination, prevent hypothermia (warm blankets, IV fluids).
• **Pain Management:** Early analgesia (e.g., IV paracetamol, opiates).
• **Specific Medical Emergencies:**
  • **Anaphylaxis:** IM Adrenaline (0.5mg of 1:1000 for adults), IV fluids, antihistamines, steroids.
  • **Sepsis (Sepsis Six):** Oxygen, IV fluids, obtain cultures, IV broad-spectrum antibiotics, check lactate, monitor urine output.
  • **Acute Coronary Syndrome:** Oxygen, Aspirin, GTN, Morphine, Clopidogrel (if no contraindication).
  • **Stroke:** Urgent CT head, consider thrombolysis if indicated and within time window.
• **Open Fractures:** Cover with sterile dressing, give antibiotics (e.g., co-amoxiclav), tetanus prophylaxis, immobilise.

Exam Red Flags