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
NICE is due with a guideline later this year but the BTS/SIGN 2016 guidelines seem to be the current standard. NICE 2015 for bronchiolitis.
RCEM Learning has a 2 part podcast on it two
How do we assess asthma in adults?
- Moderate
- inreasing symptoms
- PEF >50-75%
- Acute Severe (any)
- PEF 33-50%
- RR>25
- HR>110
- inability to complete sentences
- Life threatening (any)
- PEF<33%
- sats<92
- PaO2 <8
- Normal PaCO2
- silent chest
- cyanosis
- poor effort
- arrhythmia
- exhaustion
- altered conscious level
- hypotension
- Near Fatal
- raised PaCO2
- and/or requiring ventilation
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Reasons to get a CXR in adults
- suspect pneumothorax or pneumomediasatinum
- suspect consolidation
- lief threatening
- not responding
- requiring vent
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Reasons to get an ABG
- sats<92
- any life threatening features
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Criteria for admission in adults
- any with life threatening or near fatal
- any severe features after initial treatment
- as a converse if PEF>75% at one hour then they can probably go home
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Treatment in adults
- oxygen only if hypoxic
- give nebs with oxygen
- give lots of Beta agonist nebs
- give ipratroium bromide if acute severe and poor initial response
- give steroids for all (40-50mg for 5 days)
- neb magnesium not recommended for adults
- IV mag if acute severe and poor response to initial treatment
- (IV salbutamol noted by its absence…)
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How do we assess asthma in kids?
- acute severe (similar apart from physiological limits)
- PEF 33-50%
- can’t complete sentences or feed
- HR>125 (>5 yrs)
- HR>140 (1-5 yrs)
- RR>30 (>5 yrs)
- RR>40 (1-5 yrs)
- sats<92
- life threatening (again very similar just less of them)
- sats<92 plus
- PEF<33%
- silent chest
- cyanosis
- poor effort
- hypotension
- exhaustion
- confusion
- sats<92 plus
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What about Treatment in kids?
- space Beta agonist is preferred in mild-moderate
- add ipratropium if refractory
- consider adding neb mag in acute severe
- steroids
- 10mg <2
- 20mg 2-5
- 30-40mg >5
- 3 days is the standard course
- consider IV salbutamol early (15mcg/kg) if poor response
- consider IV aminophylline in life threatening and not responding
- consider IV mag (40mg/kg/day) if poor response
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Asthma in pregnancy?
- give all meds as needed inc steroids, aminophylline and mag seems to be the answer
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What is and how should we diagnose bronchiolitis?
- a seasonal illness amongst kids, mainly 3-6 months but can be older
- presents with airway obstruction type symptoms from viral inflammation and mucous plugging
- 75% is RSV, the rest being influenza, para influenza, adenovirus
- NICE says diagnose it when
- coryzal prodrome 1-3 days
- cough and
- tachypnoea or recession and
- wheeze or crackles
- They note that in under 6 weeks apnoea might be all you get
- Risk factors
- <6/52 old, born at <35/40
- immunosuppresed
- cardiac disease
- smokers (the parents not the child…)
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How do we manage it?
- Admit
- apnoea (even if only report)
- sats less than 92 on room air
- inadequate intake (50-75% of normal)
- persistent distress (RR>70, grunting)
- Don’t give any of the things that you might want to give including
- hypertonic
- salbutamol
- steroids
- adrenaline
- And don’t do a CXR
- And don’t routinely suction though do do it on all the apnoeic ones and consider where feeding is a problem
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Hi Andy,
Your podcasts are amazing so are these notes. Which question bank do you follow for exam preparation and along OHEM what other resources do you recommend for the FRCEM…please help; your guidance is highly appreciated.
I don’t have a question bank i follow. I’m making these questions up myself
Hi Andy, these notes are brill, and I like the layout. Very pleasing. Note they have squeezed in Sats<92% for Acute Severe in kids.
cheers lotte
These are brilliant Andy!