HomePLAB 1Emergency Medicine & Trauma

Master Emergency Medicine & Trauma
for PLAB 1

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HIGH YIELD NOTES ~5 min read

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

  • **Altered Level of Consciousness:** Any acute change in GCS or persistent GCS <15.
  • **Hemodynamic Instability:** Persistent hypotension (SBP <90 mmHg), unexplained tachycardia, signs of shock (cold/clammy peripheries).
  • **Respiratory Distress:** Tachypnoea (>30 bpm), SaO2 <90% on high-flow oxygen, accessory muscle use, silent chest.
  • **Focal Neurological Deficits:** Sudden onset weakness, speech changes, visual loss.
  • **Severe, Unresponsive Pain:** Especially chest, abdominal, or headache.
  • **Non-blanching Rash:** Especially with fever/meningism (suggests meningococcal sepsis).
  • **Abnormal Pupillary Responses:** Anisocoria, fixed/dilated pupils.
  • **Signs of Spinal Cord Injury:** New sensory/motor deficit, priapism.
  • **Active Severe Bleeding:** External or suspected internal.

Sample Practice Questions

Question 1

A 35-year-old female presents to the emergency department after being stung by a bee. She developed widespread urticaria, angioedema of her lips, inspiratory stridor, and dizziness. Her blood pressure is 80/50 mmHg and heart rate is 120 bpm. What is the most appropriate initial treatment?

A) Intravenous hydrocortisone
B) Nebulized salbutamol
C) Intramuscular adrenaline (epinephrine)
D) Oral antihistamines
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Question 2

A 40-year-old male presents with sudden onset severe central chest pain radiating to his back. He describes the pain as 'tearing'. His blood pressure is 180/100 mmHg in the right arm and 140/80 mmHg in the left arm. Heart rate is 95 bpm. ECG shows no significant ST-T changes. What is the most important initial diagnostic investigation?

A) Troponin levels
B) Chest X-ray
C) CT angiography of the aorta
D) Echocardiogram
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Question 3

A 35-year-old male presents with sudden onset, severe, tearing chest pain radiating to his back. His blood pressure is 180/100 mmHg in the right arm and 140/80 mmHg in the left arm. Heart rate is 90 bpm. On examination, a new diastolic murmur is noted. The most appropriate initial pharmacological management is to:

A) Administer intravenous nitroglycerin to reduce preload
B) Administer intravenous labetalol to reduce heart rate and blood pressure
C) Administer intravenous morphine for pain relief
D) Administer oral aspirin to prevent thrombosis
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