Emergency Medicine: Primary Survey, Red Flags, and Disposition
The Emergency Medicine domain tests the recognition, stabilization, and disposition of urgent and emergent presentations that a family physician may encounter in office, clinic, or hospital settings. The CFPC expects key features for chest pain, dyspnea, abdominal pain, sepsis, trauma, altered mental status, anaphylaxis, and pediatric emergencies. The exam rewards a reproducible primary survey and explicit red-flag reasoning, not exhaustive differentials.
Core rules and concepts
- ABCDE first: Airway, Breathing, Circulation, Disability, Exposure. Assess and reassess after every intervention.
- Vital signs are data: abnormal heart rate, blood pressure, respiratory rate, oxygen saturation, temperature, and glucose drive disposition.
- Time-critical diagnoses: STEMI, stroke, sepsis, anaphylaxis, tension pneumothorax, ectopic pregnancy, meningitis, and major trauma. State the action and the timeframe.
- Risk stratification: HEART for chest pain, Wells for PE/DVT, Canadian CT Head Rule, Ottawa Ankle Rules, and validated sepsis criteria. Use them to justify admission or discharge.
- Disposition and safety-netting: state whether the patient is admitted, observed, or discharged; give explicit return precautions and follow-up.
Worked example
A 62-year-old smoker with hypertension has 40 minutes of crushing substernal chest pain, nausea, and diaphoresis. He is pale and anxious; BP 150/90, HR 100, RR 22, SpO2 96%.
Reasoning: this is a primary-survey patient. ABCDE, oxygen only if hypoxemic, IV access, monitors, 12-lead ECG within 10 minutes, aspirin 160–325 mg chewed, nitroglycerin if not contraindicated, and analgesia. The ECG shows ST elevation in II, III, aVF. Call EMS or activate the STEMI pathway immediately; do not wait for troponin. Give a P2Y12 inhibitor per local protocol and arrange urgent reperfusion. Reassess pain and vital signs. Document the disposition and contraindications. The key feature is recognizing STEMI and acting on the ECG, not achieving a perfect differential.
Traps that cost marks
- Anchoring on “musculoskeletal” without an ECG.
- Forgetting atypical presentations in women, older adults, and people with diabetes.
- Failing to reassess after treatment.
- Discharging without safety-netting or a documented recheck plan.
- Missing a pregnancy test in a woman of childbearing age with abdominal pain.