Surgery and Emergency Medicine
Core concepts
Emergency and surgical questions test prioritisation. Use ABCDE: airway with cervical spine control, breathing, circulation, disability, exposure. Know shock (hypovolaemic, septic, cardiogenic, obstructive), acute abdomen, appendicitis and cholecystitis, trauma, burns, fractures and compartment syndrome, wound care, anaphylaxis, sepsis, and time-critical stroke and ACS care.
Traps
- Tension pneumothorax is a clinical diagnosis: needle decompression before any imaging.
- Do not remove an impaled object; stabilise it and transfer.
- Analgesia does not mask appendicitis; give it.
- Burns: calculate fluid with the Parkland formula (4 mL x weight in kg x %TBSA over 24 hours, half in the first 8 hours from the burn), and do not include superficial erythema in the area.
- Compartment syndrome: pain out of proportion, pain on passive stretch, paraesthesia; pulselessness is late, so act before it.
- Anaphylaxis: intramuscular adrenaline 0.5 mg (1:1000) into the anterolateral thigh, repeated after 5 minutes; antihistamines and steroids are adjuncts only.
- Stroke: check glucose, establish the last-known-well time, and consider thrombolysis or thrombectomy within the window.
Worked example
A 24-year-old driver after a high-speed collision is restless and hypotensive, with distended neck veins, absent right breath sounds and tracheal deviation to the left. This is a tension pneumothorax. Give high-flow oxygen, decompress the right chest immediately with a needle in the second intercostal space in the mid-clavicular line, then insert a chest drain and continue the primary survey.
Rule of thumb
In emergencies, treat the greatest threat first: if the airway or breathing is the problem, no amount of fluid or imaging will fix it.