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

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

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
  • 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

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

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

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.

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


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!

Leave a Reply

Your email address will not be published. Required fields are marked *

This site uses Akismet to reduce spam. Learn how your comment data is processed.