Iraqi Board Emergency Medicine cheat sheet

Cardiac arrest with shockable rhythm (VF/pVT): immediate defibrillation, then CPR 2 min before rhythm recheck; epinephrine 1 mg IV/IO every 3-5 min and amiodarone 300 mg after the third shock.

Non-shockable arrest (asystole/PEA): epinephrine 1 mg IV/IO every 3-5 min as early as possible; no defibrillation; search for 5H/5T reversible causes.

High-quality CPR targets: compression rate 100-120/min, depth 5-6 cm, full recoil, chest compression fraction >60%, and interruption <10 s.

STEMI reperfusion: primary PCI within 120 min of first medical contact is preferred; fibrinolysis is indicated when PCI cannot be achieved within 120 min and symptom onset is <12 h without contraindication.

Acute decompensated heart failure with hypotension and congestion: IV loop diuretic plus vasodilator if SBP >110 mmHg; inotropes (dobutamine) if SBP <90 mmHg with hypoperfusion.

Unstable tachyarrhythmia with hypotension, ischaemic chest pain, acute heart failure or altered mentation: synchronised cardioversion; pulseless VT is treated as VF.

Aortic dissection: pain-free anti-impulse therapy first - target heart rate <60/min and SBP 100-120 mmHg with IV beta-blocker before vasodilator; urgent surgical/endovascular consultation for type A.

Hypertensive emergency: reduce mean arterial pressure by no more than 25% in the first hour, then to 160/100 mmHg over 2-6 h; exceptions are aortic dissection and eclampsia.

Acute severe asthma: SABA by nebuliser or MDI-spacer plus ipratropium, early systemic corticosteroid, and titrated oxygen to target SpO2 94-98%; consider IV magnesium sulfate 1.5-2 g over 20 min for poor response.

Life-threatening asthma signs: silent chest, exhaustion, altered consciousness, SpO2 <92%, PaCO2 normal or rising (a normal PaCO2 in a tachypnoeic asthmatic is a warning sign).

COPD exacerbation: controlled oxygen targeting SpO2 88-92% in those at risk of hypercapnia, nebulised bronchodilators, systemic steroid, and non-invasive ventilation for pH 7.25-7.35 with hypercapnia.

Tension pneumothorax is a clinical diagnosis: hypotension, unilateral absent breath sounds, tracheal deviation and distended neck veins - immediate needle decompression, then chest drain.

Massive pulmonary embolism with haemodynamic instability: systemic thrombolysis (e.g. alteplase 50-100 mg) or catheter-directed therapy; anticoagulation alone is insufficient in shock.

Pneumonia severity: CURB-65 (confusion, urea >7 mmol/L, respiratory rate >=30, BP <90/60, age >=65) - score >=2 suggests admission, >=3 severe.

ARDS (Berlin definition): acute onset within 1 week, bilateral opacities, not fully explained by cardiac failure, PaO2/FiO2 <=300 mmHg with PEEP >=5 cmH2O; use lung-protective tidal volume 6 mL/kg predicted body weight.

Primary survey follows ABCDE with simultaneous catastrophic haemorrhage control; hypotension in trauma is haemorrhage until proven otherwise.

Permissive hypotension targets SBP 80-90 mmHg in penetrating torso trauma without traumatic brain injury; in TBI maintain SBP >=110 mmHg to preserve cerebral perfusion.

Massive transfusion protocol ratio approximates 1:1:1 of packed red cells, plasma and platelets; give tranexamic acid 1 g within 3 h of injury, then 1 g over 8 h.

FAST examines pericardial, perihepatic, perisplenic and pelvic windows; a positive FAST in an unstable patient is an indication for immediate laparotomy.

Pelvic fracture with haemodynamic instability: apply a pelvic binder at the level of the greater trochanters and consider preperitoneal packing or angioembolisation.

Burn resuscitation: Parkland formula 4 mL/kg/% total body surface area lactated Ringer's in the first 24 h, half in the first 8 h from the time of injury; urine output target 0.5-1 mL/kg/h.

Tension haemothorax or haemothorax with instability: insert a large-bore chest drain; if >1500 mL drains immediately or >200 mL/h for 2-3 h, proceed to thoracotomy.

Acute ischaemic stroke: non-contrast CT excludes haemorrhage; IV alteplase within 4.5 h of onset (0.9 mg/kg, 10% bolus) and mechanical thrombectomy for large vessel occlusion up to 6 h, selected cases to 24 h.

Alteplase contraindications include BP >185/110 mmHg refractory to treatment, INR >1.7, platelets <100 x10^9/L, recent intracranial surgery and hypoglycaemia (<2.8 mmol/L) as a stroke mimic.

Status epilepticus: benzodiazepine first line (IV lorazepam 0.1 mg/kg or IM midazolam 10 mg), then second-line IV levetiracetam, valproate or phenytoin; refractory cases need anaesthetic doses of propofol, midazolam or thiopentone.

Subarachnoid haemorrhage: CT within 6 h of onset is highly sensitive; if CT negative and suspicion persists after 6 h, perform lumbar puncture for xanthochromia at least 12 h after onset.

Raised intracranial pressure: head-up 30 degrees, avoid hypoxia and hypercapnia, target PaCO2 35-40 mmHg, osmotherapy with mannitol 0.25-1 g/kg or hypertonic saline; brief hyperventilation only for impending herniation.

Bacterial meningitis: dexamethasone 10 mg IV before or with the first antibiotic dose, plus ceftriaxone and vancomycin (and ampicillin if >50 years or immunocompromised).

Acute behavioural disturbance: verbal de-escalation first; if sedation is required, use IM olanzapine, haloperidol plus benzodiazepine, or ketamine, with monitoring for neuroleptic malignant syndrome and serotonin syndrome.

Paracetamol overdose: N-acetylcysteine is indicated if the 4-h level exceeds the treatment line on the Rumack-Matthew nomogram; if timing is unknown or staggered, treat empirically.

Salicylate toxicity: alkaline diuresis with sodium bicarbonate targeting urine pH 7.5-8.0; haemodialysis for levels >6.5 mmol/L, seizures, renal failure or pulmonary oedema.

Tricyclic antidepressant toxicity: sodium bicarbonate for QRS >100 ms or ventricular arrhythmia; avoid class IA and IC antiarrhythmics; physostigmine is contraindicated.

Beta-blocker overdose with shock: glucagon 3-10 mg IV is first line, followed by high-dose insulin-euglycaemia or intravenous lipid emulsion.

Carbon monoxide poisoning: 100% oxygen; hyperbaric oxygen for loss of consciousness, neurological signs, pregnancy or carboxyhaemoglobin >25%.

Organophosphate poisoning: atropine titrated to drying of secretions, plus pralidoxime early; monitor for intermediate syndrome and delayed neuropathy.

Serotonin syndrome (clonus, hyperthermia, agitation): stop serotonergic agents, benzodiazepines, cooling; avoid antipsychotics and antipyretics are ineffective for the hyperthermia.

Paediatric assessment uses the triangular model of work of breathing, circulation to skin and appearance; weight estimate is (age in years + 4) x 2 kg.

Paediatric cardiac arrest is usually hypoxic/asphyxial: start CPR with 5 rescue breaths, compression:ventilation ratio 15:2 for two rescuers (30:2 single rescuer), rate 100-120/min.

Fluid bolus in paediatric shock is 10-20 mL/kg crystalloid, reassessing after each bolus; in septic shock with malnutrition or cardiac disease use 5-10 mL/kg.

Paediatric defibrillation energy is 2 J/kg for the first shock, 4 J/kg for subsequent shocks; use the largest paddles that fit without touching.

Croup: single dose dexamethasone 0.15-0.6 mg/kg and nebulised adrenaline 0.5 mL/kg of 1:1000 (max 5 mL) for stridor at rest; observe at least 2-4 h after adrenaline.

Bronchiolitis: supportive care with oxygen and hydration; bronchodilators, corticosteroids and antibiotics are not routinely indicated.

Febrile infants under 3 months: full sepsis workup including lumbar puncture and empirical antibiotics; well-appearing infants 29-90 days may be risk-stratified but require careful follow-up.

Ectopic pregnancy: a negative urine pregnancy test does not exclude it if clinical suspicion is high - send quantitative beta-hCG; a discriminatory zone of 1500-3500 mIU/mL should show an intrauterine sac on transvaginal ultrasound.

Ovarian torsion: sudden unilateral pelvic pain with nausea; urgent pelvic ultrasound (enlarged oedematous ovary with reduced Doppler flow) and gynaecological referral for detorsion.

Pre-eclampsia with severe features: magnesium sulfate 4-6 g IV loading then 1-2 g/h for seizure prophylaxis, plus labetalol, hydralazine or nifedipine for BP control; delivery is definitive.

Postpartum haemorrhage: uterine massage and oxytocin first, then ergometrine, carboprost or misoprostol; tranexamic acid 1 g IV within 3 h; balloon tamponade and surgery for refractory cases.

Eclampsia: magnesium sulfate is superior to phenytoin and diazepam for seizure control and recurrence prevention; monitor for magnesium toxicity (loss of reflexes, respiratory depression).

Shoulder dystocia: McRoberts manoeuvre plus suprapubic pressure first, then internal rotational manoeuvres; avoid fundal pressure.

Ruptured ectopic with haemodynamic instability: resuscitate with blood products and proceed to immediate laparotomy or laparoscopy by the obstetric/gynaecology team.

Open fracture: antibiotics within 1 h, tetanus prophylaxis, and tetanus status documentation; urgent debridement and stabilisation by orthopaedics.

Compartment syndrome: pain out of proportion and pain on passive stretch are the earliest signs; pulselessness and paralysis are late - measure compartment pressure and perform urgent fasciotomy.

Necrotising fasciitis: pain out of proportion, rapidly spreading erythema, crepitus, systemic toxicity; urgent surgical debridement plus broad-spectrum antibiotics including clindamycin for antitoxin effect.

Septic arthritis: joint aspiration before antibiotics if possible; send cell count, Gram stain and culture; do not delay empirical antibiotics for a septic joint.

Cauda equina syndrome: saddle anaesthesia, bladder/bowel dysfunction and bilateral leg weakness require urgent MRI and neurosurgical referral within hours.

Ankle fracture decision rules (Ottawa): image if pain in the malleolar zone plus bone tenderness at the posterior edge of either malleolus or inability to bear weight 4 steps.

Cellulitis versus abscess: abscess requires incision and drainage; add antibiotics for systemic signs, immunosuppression, or extensive surrounding cellulitis.

Diabetic ketoacidosis: isotonic saline, IV insulin infusion 0.1 units/kg/h after initial fluid, and potassium replacement once K+ <5.5 mmol/L; add dextrose when glucose <14 mmol/L and continue insulin until ketones clear.

Hyperosmolar hyperglycaemic state: profound dehydration and hyperosmolality with minimal ketosis; fluid resuscitation is the priority and insulin is started after fluids.

Severe hypoglycaemia: 25 g IV glucose (or 1 mg IM glucagon if no IV access), then recheck glucose in 10-15 min and start a glucose infusion.

Hyperkalaemia with ECG changes: IV calcium gluconate first for membrane stabilisation, then insulin-dextrose, salbutamol, and definitive removal with dialysis or potassium binders.

Hyponatraemia: correct symptomatic severe hyponatraemia with hypertonic 3% saline; limit correction to 8-10 mmol/L in 24 h to avoid osmotic demyelination.

Thyroid storm: propranolol, thionamide (propylthiouracil or methimazole), iodine load at least 1 h after thionamide, plus corticosteroids and supportive care.

Adrenal crisis: hydrocortisone 100 mg IV immediately, then 50 mg every 6 h, with concurrent isotonic saline for hypotension.

Sepsis-3 definition: suspected infection plus organ dysfunction, defined as an acute rise in SOFA score of >=2; qSOFA (RR >=22, altered mentation, SBP <=100) is a screening tool, not a diagnosis.

Septic shock: persistent hypotension requiring vasopressors to maintain MAP >=65 mmHg with lactate >2 mmol/L despite adequate fluid resuscitation.

Antibiotics within 1 h for septic shock and within 3 h for possible sepsis without shock; obtain blood cultures before antibiotics when this does not delay treatment.

Initial fluid resuscitation in sepsis is 30 mL/kg crystalloid for hypotension or lactate >=4 mmol/L, with dynamic reassessment rather than fixed volumes in heart or renal failure.

Norepinephrine is the first-line vasopressor targeting MAP >=65 mmHg; add vasopressin or epinephrine for refractory shock.

Meningococcal sepsis: droplet precautions until 24 h of effective antibiotics; notify public health and offer chemoprophylaxis to close contacts.

Tetanus-prone wounds: give toxoid if booster overdue and immunoglobulin for dirty wounds with unknown or incomplete immunisation.

FAST windows: subxiphoid (pericardial), right upper quadrant (Morison's pouch), left upper quadrant (splenorenal) and suprapubic (pelvis); free fluid appears anechoic.

Cardiac arrest ultrasound: use only during rhythm checks to limit compression interruptions; absence of cardiac motion has poor specificity for death and must not alone terminate resuscitation.

Ocular ultrasound: optic nerve sheath diameter >5-6 mm suggests raised intracranial pressure; absence of retinal detachment and normal globe exclude other causes.

Lung ultrasound: B-lines indicate interstitial fluid (pulmonary oedema), absent lung sliding suggests pneumothorax, and lung point confirms pneumothorax.

Gallbladder: wall thickening >3 mm, pericholecystic fluid and sonographic Murphy sign support acute cholecystitis; common bile duct >6-8 mm suggests obstruction.

DVT study: non-compressibility of the common femoral or popliteal vein on graded compression is diagnostic; isolated calf veins require repeat study.

Focused echo in undifferentiated shock: a collapsed IVC with hyperdynamic ventricles suggests hypovolaemia; a dilated right ventricle with septal flattening suggests right heart strain or pulmonary embolism.

RSI: preoxygenate with high-flow oxygen or non-invasive ventilation for 3 min; use ketamine or etomidate for haemodynamic instability; rocuronium 1-1.2 mg/kg or suxamethonium 1-1.5 mg/kg.

Cannot intubate, cannot oxygenate: insert a front-of-neck airway (scalpel-bougie-tube or cannula techniques) without delay; do not persist with supraglottic rescue beyond a few attempts.

Difficult airway predictors: Mallampati 3-4, thyromental distance <6 cm, mouth opening <3 cm, limited neck extension, obesity and previous difficult intubation.

Post-intubation: confirm with waveform capnography, secure the tube, set ventilator with lung-protective tidal volumes, and give sedation and analgesia.

Central venous access: ultrasound guidance reduces complications; for internal jugular, confirm venous placement by manometry and ultrasound, and use a checklist to reduce infection.

Thoracocentesis and chest drain: insert in the safe triangle (5th intercostal space, mid-axillary line); avoid the intercostal neurovascular bundle by inserting above the rib.

Lumbar puncture: contraindicated with local infection, raised ICP with focal signs, or coagulopathy; check platelets and INR when risk factors exist.

Crowding metrics include ED occupancy, boarding time and time to physician; prolonged boarding is associated with increased mortality and is a key operational target.

Triage systems such as the Emergency Severity Index use a 5-level scale based on acuity and expected resource needs; ESI 1 requires immediate life-saving intervention.

Key performance indicators: door-to-physician time, door-to-needle time for stroke and STEMI, left-without-being-seen rate, and 72-hour unscheduled return rate.

Documentation should record time of arrival, triage category, clinical findings, consent, procedures, and disposition with follow-up arrangements.

Incident reporting is a non-punitive system for near-misses and adverse events; root cause analysis examines system factors rather than individual blame.

Staffing models should account for peak arrival patterns and the supervision of junior trainees; handover should use a structured format such as SBAR.

Informed consent requires capacity, adequate information and voluntariness; in life-threatening emergencies treatment may proceed under the doctrine of necessity.

Capacity assessment: patient can understand, retain, weigh and communicate a decision; if capacity is absent, treat in best interests and document.

Confidentiality may be breached only where there is a legal duty or serious public health risk (e.g. notifiable diseases) and must be limited to the minimum necessary.

Disaster triage uses colour categories: red (immediate), yellow (delayed), green (minor) and black (expectant/deceased); resources are allocated to those most likely to benefit.

Mass casualty incident command uses an incident management structure with a single incident commander, and clear sectors for triage, treatment and transport.

Ethical allocation in disasters prioritises saving the most lives and life-years, with transparency and consistency; individual clinicians should not be asked to make allocation decisions alone.

Do-not-attempt-resuscitation orders must be clearly documented, reviewed, and communicated to the team; they do not preclude other treatments such as analgesia and fluids.