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ECOM-CR Medical Licensure study materials
ECOM-CR Medical Licensure study resources

ECOM-CR Medical Licensure: Clinical Skills and Emergency Medicine: Structured Assessment and Time-Critical Action

ECOM-CR Medical Licensure · Work through your exam, one topic at a time.

All guide sections

Clinical Skills and Emergency Medicine: Structured Assessment and Time-Critical Action

The Clinical Skills and Emergency Medicine domain tests structured assessment, interpretation of bedside data, and time-critical resuscitation. It rewards a systematic approach and penalises skipped steps.

Core rules

  • History and examination: use a structured framework (SOCRATES for pain, ABCDE for emergencies) and reassess after every intervention.
  • ABG: check pH first, then determine whether PaCO2 and HCO3 fit a single disorder or a mixed one. Expected PaCO2 in metabolic acidosis = 1.5 × HCO3 + 8 ± 2 (Winter's formula). Anion gap = Na − (Cl + HCO3); delta ratio = (measured AG − 12)/(24 − HCO3).
  • ECG: rate, rhythm, axis, intervals, ischaemia. ST elevation in two contiguous leads indicates STEMI; activate reperfusion.
  • ACLS: compressions 100–120/min at 5–6 cm with minimal interruptions; defibrillate shockable rhythms immediately; adrenaline 1 mg every 3–5 minutes.
  • Anaphylaxis: intramuscular adrenaline 0.5 mg of 1:1000 into the anterolateral thigh, repeated every 5 minutes as needed; intravenous fluids; secure the airway.
  • Sepsis: cultures and antibiotics within 1 hour; 30 mL/kg crystalloid for hypotension or lactate ≥4 mmol/L.
  • Acute stroke: non-contrast CT excludes haemorrhage; thrombolysis within 4.5 hours and thrombectomy within 6 hours at appropriate centres.
  • Toxidromes: anticholinergic (hot, dry, flushed, mydriasis), cholinergic (bradycardia, salivation, lacrimation, diarrhoea), opioid (pinpoint pupils, respiratory depression), sympathomimetic (tachycardia, hypertension, agitation).

Worked example

An unconscious patient has pH 7.28, PaCO2 24 mmHg, HCO3 11 mmol/L, Na 138, Cl 100. Anion gap = 138 − (100 + 11) = 27, so there is a high-anion-gap metabolic acidosis. Expected PaCO2 = 1.5 × 11 + 8 = 24.5 ± 2, so respiratory compensation is appropriate and there is no second respiratory disorder. Delta ratio = (27 − 12)/(24 − 11) = 15/13 ≈ 1.15, indicating a pure high-anion-gap acidosis without a superimposed normal-gap component.

Traps

  • Calculating the anion gap but never checking whether compensation is appropriate.
  • Giving intravenous instead of intramuscular adrenaline in anaphylaxis, or repeating it too slowly.
  • Delaying antibiotics in sepsis while waiting for imaging.
  • Interrupting compressions for prolonged pulse checks.