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© eduAcute Pty Ltd www.eduacute.com.au Page 1 ACEM Fellowship Exam Core Revision Notes (Forth Edition)

© eduAcute® Pty Ltd 2017 All Rights Reserved. www.eduacute.com.au Page 2 ACEM Fellowship Exam Core Revision Notes (Forth Edition)

TABLE OF CONTENTS

Preface ............................................................................................................................................... 9

Acknowledgements .......................................................................................................................... 10

Copyright and Use ............................................................................................................................ 11

Foreword ......................................................................................................................................... 12

How to use this book? ...................................................................................................................... 13

Online Navigation Instructions ................................................................................................................... 13

Resuscitation .................................................................................................................................... 14

Learning & Examination Processes Covered ................................................................................................ 14

Life Support ............................................................................................................................................... 14 Basic Life Support ................................................................................................................................................................14 Advanced Life Support .........................................................................................................................................................14 Paediatric Advanced Life Support ........................................................................................................................................16 Post ROSC Cares ...................................................................................................................................................................18 Torsades de Points (Form of Polymorphic VT) .....................................................................................................................19 Neonatal Life Support ..........................................................................................................................................................19 AIRWAY Obstruction / Choking ............................................................................................................................................22

Rapid Sequence Induction .......................................................................................................................... 22 RSI Standard .........................................................................................................................................................................23 RSI Modified .........................................................................................................................................................................23 RSI Drugs ..............................................................................................................................................................................24

Ventilation Strategies ................................................................................................................................ 25 Lung Protective strategy ......................................................................................................................................................25 Obstructive Strategy -Permissive Hypercapnia ...................................................................................................................25 Post-intubation package ......................................................................................................................................................26 Trouble shooting post intubation low Sats (DOPES) ............................................................................................................26 Rescue Drugs .......................................................................................................................................................................26 ETT Drugs and Doses (LANA) ...............................................................................................................................................26

Resuscitation Sizing ................................................................................................................................... 27 Paediatric Weight Equations ...............................................................................................................................................27 Endotracheal Tube Sizing .....................................................................................................................................................27 Intra-osseous needles ..........................................................................................................................................................28 Nasogastric and Intercostal Drain Sizing ..............................................................................................................................28

Circulatory Shock ....................................................................................................................................... 28 IV Fluids ................................................................................................................................................................................29 Vasopressors and Inotropes ................................................................................................................................................29 Paediatric Airway changes ...................................................................................................................................................29 Paediatric Shock Targets ......................................................................................................................................................30 Management Shocked Neonate ..........................................................................................................................................30

Anaesthetics..................................................................................................................................... 31


Analgesia ................................................................................................................................................... 31


Local Anaesthetics ...............................................................................................................................................................31 Anti-emetics .........................................................................................................................................................................32

Anaesthesia Assessment ............................................................................................................................ 32

Procedural Sedation Agents: ...................................................................................................................... 33 PROCEDURES .......................................................................................................................................................................33

Medicine .......................................................................................................................................... 35


CARDIOLOGY ............................................................................................................................................. 35 ECG Rate and Rhythm Differentials .....................................................................................................................................35 Cardiac Differential Diagnosis (DIE) (CMV) ..........................................................................................................................36 VT Criteria (VT vs SVT with aberrancy) ................................................................................................................................36 Ischemia ...............................................................................................................................................................................37 Causes Long QT ....................................................................................................................................................................38 Causes Short QT ...................................................................................................................................................................39 Tachycardia with WPW ........................................................................................................................................................39 Pacemaker ...........................................................................................................................................................................39 Atrial Fibrillation ..................................................................................................................................................................39 ECG changes in PE ................................................................................................................................................................40 Pericarditis ...........................................................................................................................................................................40 Rheumatic Fever ..................................................................................................................................................................41 Paediatric ECG differences ...................................................................................................................................................41 Antihypertensives ................................................................................................................................................................41 Critical Care ..........................................................................................................................................................................42

RESPIRATORY ............................................................................................................................................ 42 Asthma .................................................................................................................................................................................42 Croup ...................................................................................................................................................................................43 Bronchiolitis .........................................................................................................................................................................43 Pulmonary Embolism ...........................................................................................................................................................45 Pneumonia ...........................................................................................................................................................................46

NEUROLOGY .............................................................................................................................................. 46 Seizure Management ...........................................................................................................................................................46 SAH.......................................................................................................................................................................................47 CVA ......................................................................................................................................................................................47 Vertigo Peripheral vs Central Cause ....................................................................................................................................48 Headache .............................................................................................................................................................................48 Benign intracranial Hypertension ........................................................................................................................................50 Upper Motor Neuron (Spasticity) ........................................................................................................................................50 Lower motor Neuron (Flaccidity) .........................................................................................................................................51 GBS .......................................................................................................................................................................................51 Paralysis ...............................................................................................................................................................................51

ENDOCRINE ............................................................................................................................................... 51 Paediatric DKA: ....................................................................................................................................................................51 Adult DKA .............................................................................................................................................................................52 HHS vs DKA ..........................................................................................................................................................................54 Thyroid Storm ......................................................................................................................................................................55

HEAMATOLOGY ......................................................................................................................................... 55 Anaemia ...............................................................................................................................................................................56


Thrombocytopenia ..............................................................................................................................................................57 Neutropenia .........................................................................................................................................................................58 Pancytopenia .......................................................................................................................................................................58 Transfusion ..........................................................................................................................................................................59 Massive Transfusion Protocol ..............................................................................................................................................59 Haemophilia A: (Factor VIII deficiency) ................................................................................................................................59 Haemophilia B: (Factor XI deficiency) ..................................................................................................................................59 Thrombus Prevention ..........................................................................................................................................................59 Thrombolysis: (fibrinolysis) ..................................................................................................................................................60 Contraindications for Thrombolysis ABC CHAMP ................................................................................................................60 Reversal Anticoagulation .....................................................................................................................................................60 Petechiae Differential Diagnosis ..........................................................................................................................................62

INFECTIOUS DISEASE .................................................................................................................................. 62 Sepsis ...................................................................................................................................................................................62

Antibiotics for specific infections ................................................................................................................ 63 Fever no Source (Paeds) ......................................................................................................................................................63 Neonatal Sepsis/Meningitis .................................................................................................................................................63 CAP (Paeds) ..........................................................................................................................................................................64 CAP (Adults) .........................................................................................................................................................................64 Adult Sepsis (source unknown) ............................................................................................................................................64 Febrile neutropenia .............................................................................................................................................................64 Meningococcal .....................................................................................................................................................................64 Infective Endocarditis ..........................................................................................................................................................65 Necrotising Fasciitis .............................................................................................................................................................65 Other infections ...................................................................................................................................................................66 Orbital / Peri-orbital Cellulitis ..............................................................................................................................................69 UTI ........................................................................................................................................................................................69 Kawasaki Disease .................................................................................................................................................................69 HIV infection ........................................................................................................................................................................70 Meningitis CSF .....................................................................................................................................................................71 Pneumonia ...........................................................................................................................................................................71 Indications for Urinary Ag Assay ..........................................................................................................................................71 Pleural Tap (Lights Criteria) (PF = Pleural fluid) ...................................................................................................................72 Ascites ..................................................................................................................................................................................72 Needle stick .........................................................................................................................................................................73 ID precautions ......................................................................................................................................................................73 Cervical neck lump ...............................................................................................................................................................74

Immunology .............................................................................................................................................. 74 Anaphylaxis ..........................................................................................................................................................................74

Metabolic .................................................................................................................................................. 74 Hyperkalaemia .....................................................................................................................................................................74 Hypokalaemia ......................................................................................................................................................................75 Hyponatraemia ....................................................................................................................................................................75 Hypernatremia: ....................................................................................................................................................................76 Hypercalcaemia ...................................................................................................................................................................76 Hypocalcaemia .....................................................................................................................................................................77 Hypermagnesemia ...............................................................................................................................................................77 Hypomagnesaemia: .............................................................................................................................................................77

Acid Base ................................................................................................................................................... 78


Metabolic Acidosis ...............................................................................................................................................................78 Metabolic Alkalosis ..............................................................................................................................................................79 Respiratory Acidosis .............................................................................................................................................................79 Respiratory Alkalosis ............................................................................................................................................................79 A-a Gradient - (Normal age/4+4) .........................................................................................................................................80

Neonates and Infants ................................................................................................................................. 80 Normal Neonate ..................................................................................................................................................................80 Neonatal Seizures escalating treatment ..............................................................................................................................80 Neonatal Jaundice ...............................................................................................................................................................81 Congenital Heart Disease .....................................................................................................................................................81 Opthalmica Neonatorum .....................................................................................................................................................81

Surgical ............................................................................................................................................ 83


TRAUMA ................................................................................................................................................... 83 Trauma assessment .............................................................................................................................................................83 Haemorrhagic Shock ............................................................................................................................................................85 Hypotension DDx in Trauma ................................................................................................................................................85

Specific Situations in Trauma ..................................................................................................................... 85 Severe Head Injury ...............................................................................................................................................................85 C-Spine Trauma ....................................................................................................................................................................86 Spinal cord syndromes .........................................................................................................................................................87 Facial trauma .......................................................................................................................................................................87 Ocular trauma ......................................................................................................................................................................87 Neck Trauma ........................................................................................................................................................................88 Haemothorax .......................................................................................................................................................................88 Aortic injury .........................................................................................................................................................................89 Pelvic Trauma.......................................................................................................................................................................89

Clinical Decision rules ................................................................................................................................ 89 C-Spine .................................................................................................................................................................................90 CT Head (Paeds) ...................................................................................................................................................................90 Trauma and Pregnancy ........................................................................................................................................................90 Burns ....................................................................................................................................................................................92

Other surgical topics .................................................................................................................................. 92 Bowel Obstruction ...............................................................................................................................................................92 Volvulus ...............................................................................................................................................................................93 Intussusception ....................................................................................................................................................................93 GI Tract Foreign Bodies: .......................................................................................................................................................94 Pancreatitis ..........................................................................................................................................................................95 Boerhaave’s Syndrome ........................................................................................................................................................95 AAA >3cm ............................................................................................................................................................................96 Aortic Dissection ..................................................................................................................................................................96

ORTHOPAEDICS ......................................................................................................................................... 97 Upper limb ...........................................................................................................................................................................98 Paeds Ortho .........................................................................................................................................................................99 Child with a Limp .............................................................................................................................................................. 100 Air on X-rays ...................................................................................................................................................................... 100

UROLOGY ................................................................................................................................................ 101


Testicular Torsion ............................................................................................................................................................. 101 Priapism ............................................................................................................................................................................ 101 Nephrolithiasis .................................................................................................................................................................. 102

Obstetrics and Gynaecology ............................................................................................................ 103

Learning & Examination Processes Covered .............................................................................................. 103

OBSTETRICS AND GYNACOLOGY ............................................................................................................... 103 General Notes Pregnancy: ................................................................................................................................................ 103 Hyperemesis Gravidarum ................................................................................................................................................. 103 Ectopic .............................................................................................................................................................................. 103 Anti D ................................................................................................................................................................................ 104 DDx Vaginal bleeding ........................................................................................................................................................ 104 Miscarriage ....................................................................................................................................................................... 104 Pre-eclampsia/Eclampsia .................................................................................................................................................. 104 Rupture of Membranes .................................................................................................................................................... 105 Post-Partum Bleed ............................................................................................................................................................ 105 Ovarian Cysts .................................................................................................................................................................... 105 Menorrhagia ..................................................................................................................................................................... 106 RF PID ................................................................................................................................................................................ 106

Psychiatry ....................................................................................................................................... 107


PSYCHIATRY ............................................................................................................................................ 107 The Mental Health Act: ..................................................................................................................................................... 107 Restraint Management (Take Down) ................................................................................................................................ 107 Mental state exam ............................................................................................................................................................ 107 Suicide RF .......................................................................................................................................................................... 108 Personality Disorder ......................................................................................................................................................... 108 Post-Partum ...................................................................................................................................................................... 108 Somatoform disorders ...................................................................................................................................................... 108

Toxicology ....................................................................................................................................... 109


TOXICOLOGY ........................................................................................................................................... 109 Toxicology work up ........................................................................................................................................................... 109 Toxidrome comparison ..................................................................................................................................................... 110 Decontamination .............................................................................................................................................................. 110 Na Blockers QRS prolongation .......................................................................................................................................... 111 K blockade QTc Prolongation ............................................................................................................................................ 111 Two pills that can kill in Paeds: ......................................................................................................................................... 112 Tricyclic poisoning ............................................................................................................................................................. 112 Carbamazepine poisoning; ............................................................................................................................................... 113 Beta-blocker (BB) .............................................................................................................................................................. 113 Body-packing; ................................................................................................................................................................... 113 Calcium channel blocker (CCB) ......................................................................................................................................... 114 Digoxin .............................................................................................................................................................................. 114 Lithium poisoning ............................................................................................................................................................. 115 Salicylate poisoning; ......................................................................................................................................................... 115 Iron poisoning ................................................................................................................................................................... 116 Paracetamol poisoning ..................................................................................................................................................... 116


Toxic alcohols .................................................................................................................................................................... 117 Sulphonylurea poisoning .................................................................................................................................................. 117 Carbon Monoxide poisoning;............................................................................................................................................ 117 Hydrofluoric Acid; ............................................................................................................................................................. 117 Organophosphate poisoning ............................................................................................................................................ 118 Methamphetamine poisoning .......................................................................................................................................... 118 Mushroom poisoning; ....................................................................................................................................................... 118 Quinine poisoning ............................................................................................................................................................. 119 Toxic Levels Summary ....................................................................................................................................................... 119

Environmental ................................................................................................................................. 120


ENVIRONMENTAL .................................................................................................................................... 120 Snake Envenomation ........................................................................................................................................................ 120 Spider bite ......................................................................................................................................................................... 122 Marine envenomation ...................................................................................................................................................... 122 Summary Antivenom ........................................................................................................................................................ 123 Altitude ............................................................................................................................................................................. 124 BLAST INJURIES: ................................................................................................................................................................ 124 Acute Radiation Syndrome ............................................................................................................................................... 124 Drowning .......................................................................................................................................................................... 124 Hypothermic Resuscitation ............................................................................................................................................... 125 Hypothermia ..................................................................................................................................................................... 125 Hyperthermia .................................................................................................................................................................... 126 DIVING .............................................................................................................................................................................. 126

Radiology in Emergency Medicine ................................................................................................... 127

Learning & Examination Processes Covered .............................................................................................. 127 Chest X-Ray ....................................................................................................................................................................... 127 USS Utility in ED ................................................................................................................................................................ 128

Legal ............................................................................................................................................... 129


MEDICO-LEGAL ........................................................................................................................................ 129 Principles of Good Medical practice ................................................................................................................................. 129 Consent ............................................................................................................................................................................. 129 Capacity ............................................................................................................................................................................ 130 Impaired colleague: .......................................................................................................................................................... 130 Sexual assault .................................................................................................................................................................... 130 Domestic Violence ............................................................................................................................................................ 131 Driving ............................................................................................................................................................................... 131

Prehospital and Retrieval ................................................................................................................ 132


Retrieval Medicine ................................................................................................................................... 132 Transfer Patient ................................................................................................................................................................ 132

Disaster Medicine ............................................................................................................................ 133



DISASTER ................................................................................................................................................. 133 Disaster Triage .................................................................................................................................................................. 133

Disaster Management .............................................................................................................................. 133 Out of Hospital: CSCATTT .................................................................................................................................................. 133 In hospital Preparation ..................................................................................................................................................... 134

Administration and Management .................................................................................................... 135


Departmental Management ..................................................................................................................... 135 Overcrowding ................................................................................................................................................................... 135 Access Block ...................................................................................................................................................................... 135 Debriefing Team ............................................................................................................................................................... 136 Guidelines development ................................................................................................................................................... 136 Complaints: Chance for Quality assurance ....................................................................................................................... 137 Adverse events ................................................................................................................................................................. 137 Root cause analysis: .......................................................................................................................................................... 137

Supplementary Content ................................................................................................................... 138

DIAGNOSTIC SIEVE ............................................................................................................................................................ 138 DIFFERENTIAL DIAGNOSES for Presenting complaints ..................................................................................................... 138 Investigations and their justification ................................................................................................................................ 141 Paediatric memory aides .................................................................................................................................................. 142 CLINICAL APPROACH (The Macroscopic view) .................................................................................................................. 142

List of Acronyms .............................................................................................................................. 145

References ...................................................................................................................................... 146

Revision Notes ................................................................................................................................. 147


PREFACE

This book is a collection of high yield facts designed to remind the reader of the ‘consultant level issues’

in particular topics. It is written in a style that can be directly applied to the ACEM Fellowship exam and

indeed to any issues one may encounter when ‘on the floor’.

The work behind this book was done during a period incorporating three separate sittings of the exam

and at a time of change to the new format. This book is the result of a close clinical partnership that

formed during a challenging time in both of our careers during which we also had the pressures and

delights of balancing work, study and a young family.

I would like to thank my many teachers at The Prince Charles Hospital for taking the time to not only

share their knowledge and approach with us but for taking the time to help guide us on our journey.

I would particularly like to thank my wife for her never-ending support during the difficult exam process.

Without this support this book and indeed my career would not be possible.

A friend once told me that the journey to success at fellowship level is like climbing a mountain. There

were many times during the journey where I wanted to either turn back or not press on. Through shear

‘bloody mindedness’ I persevered and want to encourage you, ‘the reader’ to do the same on your

journey. I hope that this book helps you on your way to success and that your patients ultimately benefit

at the end of the day.

Dr Simon Keane (BSc, MBBS, FACEM)

I would like to thank my teachers and mentors for their guidance, care and patience over the past few

years. To my wife for her dedicated support over a challenging time in the life of an Emergency trainee.

And to Simon, for his firm friendship. I hope this book is useful to the exam candidate for rapid recall of

facts in a time-pressured exam. Certainly, I learnt the value of wrote learning and economy of expression

in the process of studying for this exam. Finally, I would like to thank our publishers, eduAcute®, for the

great work to turn study notes into a visually pleasing and practical book.

Dr Jonathan Thomson (BSc, BHB, MBChB, FACEM)


ACKNOWLEDGEMENTS

We acknowledge Mr Maurice Hendriks for his technical writing assistance in the preparation of this book.

We also acknowledge The Prince Charles Hospital Emergency Department Fellowship Training Program

for their support and commitment to our training.

We finally acknowledge the support received from the following courses:

Advanced Fellowship in Emergency Medicine Course (AFEM)

Advanced Paediatric Emergency Medicine (APEM)

Paediatric Emergency Medicine (PEM)


COPYRIGHT AND USE

Refer to the online eduAcute® Pty Ltd Terms of Service for details on copyright and use of this book.


FOREWORD

This set of revision notes has been compiled by two newly appointed FACEMs who had the dubious

pleasure of being able to study for both the old format ACEM fellowship exam and the new exam (which

they successfully completed). As a result, their study notes were refined and whittled down so that only

the essential points and difficult to remember poignant lists remained.

Unlike many of the other texts that march through the emergency medicine curriculum in infinite detail,

the authors have really focussed in on the vital topics and key facts that are needed to be remembered

to pass the fellowship written exam. Of note these very facts are also required in both the fellowship

OSCE as the medical expertise component of stations and in every day practice as an emergency

physician.

The notes are presented in the chapters according to the ACEM Emergency Learning and Processes

document and should be used as a revision aid after study of the curriculum is complete. The lists have

been compiled from many sources and have been gathered in one spot for easy reference. Included are

the treatment aims and endpoints which allow treatments to be guided to effect. Knowledge of these

endpoints is vital both for demonstration of consultant level knowledge in the exam and in future

practice.

This guide will serve you well to be accessed in your workplace as it contains many of the key lists, doses,

treatment pathways and aides to memoire that assist even us “more mature” emergency physicians in

caring for the public who present to emergency departments across Australia and New Zealand.

Dr Michelle Davison

FACEM, FACEM (PEM)

Grad Cert Healthcare Sim

Director eduAcute® Pty Ltd

www.eduacute.com.au


HOW TO USE THIS BOOK?

The best way to use this book is as a revision guide after you have completed your run through of the

curriculum. This book covers many of the essential topics and also many of the topics that appear in the

written examination. In many instances the facts are presented in a manner so that they can be quickly

recalled and answers to the exam questions can be effectively and succinctly presented. Doses are

chosen to be mid-range and weight based and commonly questioned comparison tables are provided.

Whilst it would not be possible to pass the written exam by solely memorising these facts, if the

candidate has spent sufficient time working in emergency medicine and pouring over the texts that

explain the curriculum, then these summary lists and notes provide a very good set of revision notes for

focus in the lead up to the exam. The notes are not exhaustive and not every topic that comes up will be

covered but many of the important topics and higher level reasoning required is presented in these

pages.

The topics are presented under curriculum headings and in short hand so that they can be quickly

covered. Relevant acronyms for terms not in common use are provided in the appendix. Where possible

endpoints have been highlighted in bold with the AIMS of treatment as these are vital both for good

practice and to ensure coverage of the subject in an exam answer.

Use this book to refine your knowledge in the last few weeks before your exam and as a quick reference

as you travel along your career as an emergency physician.

ONLINE NAVIGATION INSTRUCTIONS

This book is published online as a PDF document. To navigate through the chapters, use the links in the

Table of Contents.

To get back to the Table of Contents you can click on the eduAcute® logo on any page.

More details can be found at www.eduacute.com.au.

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