Emergency and Critical Care Medicine: Time-Critical Resuscitation
Emergency and Critical Care Medicine tests immediate recognition and resuscitation of time-critical illness: airway compromise, shock, sepsis, arrhythmia, coma and respiratory failure. The examination expects ABCDE priority-setting, reversible-cause thinking and physiological targets rather than exhaustive differential diagnosis.
Core rules
- In septic shock, obtain cultures before antibiotics only if this does not delay treatment; give broad-spectrum antibiotics within 1 hour and 30 mL/kg crystalloid for hypotension or lactate ≥4 mmol/L.
- Start norepinephrine when mean arterial pressure remains <65 mmHg despite fluids; do not use hydroxyethyl starch.
- In anaphylaxis, give intramuscular adrenaline 0.5 mg of 1:1000 solution into the anterolateral thigh and repeat every 5 minutes if needed; give oxygen and rapid crystalloid.
- In diabetic ketoacidosis, begin isotonic fluid and insulin infusion; if potassium is <3.3 mmol/L, replace potassium before insulin.
- In a predicted difficult airway, optimise position, preoxygenate and use a planned rapid-sequence intubation strategy with ready backup.
Worked example
A 45-year-old woman with fever, hypotension (BP 82/50 mmHg) and lactate 4.2 mmol/L after 30 mL/kg crystalloid remains hypotensive. This is septic shock: obtain blood cultures immediately, give broad-spectrum antibiotics within 1 hour, and start norepinephrine titrated to MAP ≥65 mmHg. Reassess fluid responsiveness with dynamic measures rather than giving repeated unmonitored boluses; avoid starch and colloids.
Traps
- Delaying antibiotics to obtain cultures in an unstable patient.
- Giving insulin before potassium in DKA when potassium is <3.3 mmol/L.
- Using hydroxyethyl starch or unreassessed fluid boluses in septic shock.
- Missing hypoglycaemia or anaphylaxis as reversible causes of altered consciousness.