Resus to Results - MRCEM prep

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Resus to Results - MRCEM Exam Prep This group is for MRCRM preperation Managed by a EM Consultant in UK

📊 Are You Using Shock Index (SI) Before Intubation? 🫁💉

⚠️ Post-intubation hypotension is a common and dangerous complication — often predictable before you push RSI drugs.

🧮 Shock Index (SI) = Heart Rate ÷ Systolic BP

📌 Why it matters:
Recent ED & ICU studies show:
• 🔴 SI > 0.8–1.0 → strongly associated with post-intubation hypotension
• 📉 Higher risk of peri-intubation morbidity & mortality

🧠 The trap:
Some patients don’t look shocked at first glance 👀

➡️ Example:
❤️ HR 110
🩸 SBP 105
🧮 SI = 1.05 🚨

❗ Normal-looking vitals ≠ haemodynamic safety

🛠️ How to use SI in practice:
• 🧠 Calculate SI before RSI
• 💧 Optimise preload (fluids ± blood)
• 💊 Consider early vasopressors
• 🫁 Adjust induction agent & dose
• ⏱️ Pause to resuscitate before you intubate

💡 Key message:
🛑 Don’t rush the tube
📊 A simple calculation can prevent a crash

🔑 SI is fast. SI is free. SI saves lives.

📚

🔥 The Child with an Unbreakable Fever 🔥
🧒 Paediatric ED Learning Case

⸻

🧾 Case History

👦 4-year-old boy, previously well
🌡️ 6 days of high fever – not responding to paracetamol
😠 Irritable, poor oral intake
💊 Treated with oral antibiotics for tonsillitis → no improvement

🩺 Examination findings:
• 🔥 Temp 39.5°C
• ❤️ HR 140 bpm, alert but irritable
• 👄 Cracked red lips, strawberry tongue
• 👀 Bilateral non-purulent conjunctivitis
• 🌸 Maculopapular rash (trunk & limbs)
• ✋🤚 Swollen hands and feet
• 🧠 Cervical lymphadenopathy

🧪 Investigations:
• 📈 CRP 120 mg/L
• 📈 ESR 60 mm/hr
• 🔬 Neutrophilia
• 🩻 CXR & urine dip: normal

🚨 Persistent fever despite antibiotics → concern for systemic inflammatory disease

⸻

❓ Question 1

What is the most likely diagnosis?

• Scarlet fever
• Kawasaki disease ✅
• Viral exanthem
• Toxic shock syndrome

✅ Answer: Kawasaki disease

✔️ Fever ≥5 days
✔️ ≥4 diagnostic features present:
1️⃣ Conjunctival injection
2️⃣ Oral mucosal changes
3️⃣ Rash
4️⃣ Extremity changes
5️⃣ Cervical lymphadenopathy

⸻

❓ Question 2

What is the most serious potential complication?

• Pneumonia
• Coronary artery aneurysm ✅
• Glomerulonephritis
• Meningitis

✅ Answer: Coronary artery aneurysm

🫀 Major cause of long-term morbidity & mortality
📉 Preventable with early treatment

⸻

❓ Question 3

What treatment most reduces the risk of coronary complications?

• High-dose corticosteroids
• Intravenous immunoglobulin (IVIG) ✅
• Broad-spectrum antibiotics
• Warfarin

✅ Answer: IVIG

💉 IVIG 2 g/kg (single dose) within 10 days of fever onset
⬇️ Dramatically reduces coronary artery aneurysm risk

⸻

🧠 Kawasaki Disease – Explained Simply

🩺 A systemic vasculitis of childhood
👶 Typically affects children

😊 Paediatric Bell’s Palsy – Key Facts for ED & Paediatric Teams 🧠

⚠️ Not a stroke
• Unlike acute stroke, most cases recover spontaneously
• Once red flags are excluded, reassurance is powerful

📊 Prognosis (very reassuring):
• ✅ 70–90% achieve full recovery within 3 months
• ⏳ Gradual improvement is expected
• 🧘 Most children recover without long-term deficits

🩺 Management is threefold:

👁️ Preventative – Eye care (essential)
• Lubricating drops
• Eye patch / taping at night if incomplete closure
• Prevents corneal drying & injury

💊 Symptom reduction
• Steroids (early use recommended)
• ± Antivirals in selected cases
• Aim: reduce inflammation & speed recovery

🧠 Psychosocial considerations (often overlooked)
• School-age children may feel:
🔹 Self-conscious
🔹 Anxious
🔹 Vulnerable to teasing
• Temporary facial asymmetry can have a significant emotional impact

🎒 Why this matters:
• Even short-term facial weakness can make a child feel “different”
• Support, reassurance & clear explanations are key

💡 Clinical takeaway:
✔️ Exclude sinister causes
✔️ Protect the eye
✔️ Treat early where appropriate
✔️ Support the child and family

🔖 Save for paediatric ED shifts
🔁 Share with colleagues
📘 Follow for simple, high-yield paediatric clinical pearls

🩺 Post-Tonsillectomy Haemorrhage: What Every Clinician Should Remember 🩸

📌 Tonsillectomy is one of the most common ENT procedures
➡️ >50,000 operations/year in the UK

⚠️ Post-tonsillectomy haemorrhage (PTH)
• Occurs in ~5% of patients
• 🚨 Most common serious complication of this routine surgery

🩸 Bleeding facts you must know:
• ✅ Majority are self-limiting
• 🔁 Around 1% require return to theatre for haemorrhage control
• ❗ Bleeding may be occult – not always obvious
• ⏱️ Early recognition saves lives

🚨 Why this matters:
• Rarely, bleeding can be sudden and catastrophic
• Risk of:
🔹 Airway obstruction
🔹 Hypovolaemic shock
🔹 Death

🏥 Modern surgical pathways:
• Shorter hospital stays
• Minimal or no routine post-op follow-up
• 👉 Many patients present first to the Emergency Department

👩‍⚕️👨‍⚕️ Key takeaway for ED teams:
🔎 Maintain a high index of suspicion
🗣️ Take bleeding complaints seriously – even if mild
🛑 Early ENT involvement can be life-saving

💡 Common operation. Uncommon complication. High-stakes outcome.

🔖 Save this.
🔁 Share with your ED & ENT colleagues.
📘 Follow for more high-yield clinical reminders.

Try the RCEML Sunday question

SUNDAY QUESTION:

What is the most common presenting symptom in acute generalised tetanus?

A. Opisthotonus
B. Convulsion
C. Muscle spasm adjacent to the entry wound
D. Trismus
E. Local wound inflammation

Answer below!

When you sit the Anatomy examination