Emergency Medicine and Critical Care: prioritise, then calculate
Emergency and critical care items test sequencing. The correct answer is usually the action that comes first in a validated algorithm, and the wrong answers are plausible later steps. Learn the ABCDE approach, the Glasgow Coma Scale, the sepsis bundle and the reversible causes of cardiac arrest.
Core rules
- Glasgow Coma Scale: eye 4, verbal 5, motor 6, total 15. A score of 8 or less mandates a definitive airway; the motor component is the strongest prognostic element.
- Anaphylaxis: intramuscular adrenaline 0.5 mg of 1:1000 solution into the anterolateral thigh, repeated every 5 minutes as needed, with airway and fluid support.
- Sepsis: measure lactate, take blood cultures before antibiotics, give broad-spectrum antibiotics and 30 mL/kg crystalloid for hypotension or lactate of 4 mmol/L or more, and start vasopressors to keep mean arterial pressure at 65 mmHg or above.
- Reversible causes of arrest: hypovolaemia, hypoxia, hydrogen ion, hypo/hyperkalaemia, hypothermia, tension pneumothorax, tamponade, toxins, thrombosis.
Worked example
A colliding rugby player opens eyes to painful stimulus, makes incomprehensible sounds and withdraws from pain. Score: eyes 2, verbal 2, motor 4, total 8. Because the total is 8 or less, the patient cannot protect the airway and needs intubation. Note how the reasoning works: you score each component independently against its descriptor, then use the total to trigger a decision rule, not to make a diagnosis.
Traps that cost marks
- Giving intravenous adrenaline in anaphylaxis instead of intramuscular, or delaying it while obtaining investigations.
- Assuming a patient who localises pain is fully orientated; the verbal score is separate.
- Using the shock index (heart rate divided by systolic pressure, normal 0.5-0.7) as a diagnosis rather than a red flag.
- Ordering computed tomography before airway and breathing are secured in an unstable patient.