Tasty Morsels of EM 135 – #FRCEM Pearls from the ERC Guidelines

6 Sep

I’m entering a few months prep for the UK and Ireland exit exam in Emergency Medicine: the FRCEM. I’ll be adding lots of little notes on pearls I’ve learned along the way. A lot of my revision is based around the Handbook of EM as a curriculum guide and review of contemporary, mainly UK guidelines. I also focus on the areas that I’m a bit sketchy on. With that in mind I hope they’re useful.

You can find more things on the FRCEM on this site here.

The ERC guidelines are huge and summarised for ALS by the resus council in a much more abbreviated form.

They do contain a lot of guidance on critical illness and not just cardiac arrest but also lots of specific recommendations for cardiac arrest in special circumstances (which seems to be a favourite exam question.)

What is the recommended time for a pulse check

  • turns out this is 5 seconds (i had 10 in my head for some reason…)
  • except in hypothermia where you check for signs of life for at least 1 min

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What about hyperkalaemia

  • they borrow direct from the renal.org guidance covered here
  • key points
    • calcium only if ECG changes
    • 30 mls gluconate or 10mls chloride
    • HCO3 and dialysis have a role intraarrest
  • for hypokalaemia
    • 20mmol/hr max infusion rate but they make an allowance that you can give 2mmol/min if arrest imminent

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What are recommendations for heat stroke

  • temp>40 with mental state changes and usually organ dysfunction
  • split into
    • exertional in the young marathoners
    • classic in the elderly in a heat wave
  • risk factors
    • lack of accliatisiation
    • dehydration
    • obesity
    • alcohol
    • drugs
    • skin conditions
  • treatment is all cooling with spraying tepid water on a naked patient and fanning them being the most useful and practical along with ice packs
  • dantrolene not recommended
What are recommendations for exercise associated hyponatraemia
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  • exercise associated hyponatraemia has its own guidance
    • overall it’s down to excess hypotonic fluid intake (even the sports drinks are hypotonic)
    • most people with it have either gained or maintained weight with their exercise (when they should have lost at least some)
    • management
      • prevent by drinking to thirst
      • for asymptomatic low Na then restrict fluid until they’ve peed
      • for severe symptoms (vomiting, headache, AMS, seizure) they recommend liberal use of 3% saline – remember this is all very acute in onset so the concerns over rapid correction are quite different than in your standard hyponatraemia

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What are recommendations for traumatic cardiac arrest

  • good prognostic factors
    • pupil reaction
    • spont respiration
    • organised ECG rhythm
    • duration of arrest
  • steps in the ERC algorithm
    • stop massive external bleeding
    • airway
    • decompress chest (they recommend bilateral thoracostomies extended to a clamshell if needed)
    • relieve tamponade – thoracotomy (<10 mins from arrest for blunt and <15 for penetrating)
    • cross clamp
    • massive transfusion

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What about PE?

  • nothing solid on when to lyse but basically if you think a PE caused the arrest then give it
  • no recommendations on agent or dose but mine is 50mg alteplase stat (nice discussion on ALIEM)
  • they recommend continuing CPR for at least 60-90 mins post treatment

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What about Ventricular Assist Devices?

  • difficult to know if arrested, ERC allows if they are unresponsive and apnoeic consider them to be in arrest.
  • can also check the device read outs or look at invasive lines or a doppler of a big vessel
  • priority is to get a rhythm identified and shock it which may require turning off the pacing
  • they do allow for compressions if still no response at that stage.

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What about pregnancy?

  • above 20/40 should consider section
  • start at 4 mins, be done by 5 mins (but they allow that intact foetal survival reported at 20 mins post arrest delivery)
  • remember to displace the uterus

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2 Replies to “Tasty Morsels of EM 135 – #FRCEM Pearls from the ERC Guidelines

  1. T minus 1/7

    Always worth a last minute morsel!

    Thanks Andy, these have been an excellent aid in navigating the labyrinth of the RCEM curriculum for the FRCEM final!

    Best of luck tomorrow one and all!

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