Domain – Emergency medicine (Guiding topics)

Topics and content covered in this section:

• Important features of emergency and trauma care
• Resuscitation
• Time-critical, life-threatening emergency presentations
• Other emergency presentations.

Important features of emergency and trauma care

• Understand the significance of the environmental context when calling for help and managing emergency and trauma presentations, including locations such as:
  • public area
  • roadside
  • clinic
  • aged care or disability facility
  • small or large hospital
  • metropolitan and rural locations.

Location	Environmental Context	Significance When Calling for Help	Emergency and Trauma Management Considerations
Public Area	High visibility, potential for bystander assistance, limited medical resources	Call emergency services (000 in Australia) quickly, utilize public AEDs if available	Ensure crowd control, use bystanders for assistance, provide basic first aid until help arrives
Roadside	High risk of additional accidents, limited access to medical resources, potential weather-related challenges	Call emergency services (000), provide precise location details	Ensure scene safety, use vehicle’s hazard lights, perform CPR if needed, avoid moving the patient unless necessary
Clinic	Access to basic medical equipment and trained staff	Activate internal emergency protocols, call emergency services (000) if needed	Use available resuscitation equipment (oxygen, AED), follow clinic protocols, stabilize patient for transfer if required
Aged Care or Disability Facility	Residents with multiple comorbidities, staff may have basic medical training, limited advanced medical resources	Call emergency services (000), inform facility management	Assess and manage based on resident’s medical history, use facility’s emergency equipment, ensure comfort and dignity, consider Do Not Resuscitate (DNR) orders if applicable
Small Hospital	Basic emergency care available, limited specialized resources	Activate internal emergency protocols, call for external support if needed	Stabilize using available resources, prepare for transfer to a larger facility if necessary, prioritize based on triage
Large Hospital	Advanced medical resources and specialist staff available	Utilize internal emergency services, access specialized departments directly	Follow advanced life support protocols, access specialized care rapidly, comprehensive diagnostics and treatment available
Metropolitan Location	Access to advanced medical facilities and emergency services, high traffic	Call emergency services (000), expect quick response time	Utilize available advanced medical resources, coordinate with multiple emergency services, potential for rapid transfer to specialized centers
Rural Location	Limited access to advanced medical facilities, longer emergency response time	Call emergency services (000), provide detailed location, use telemedicine if available	Provide initial stabilization, prepare for prolonged wait for emergency services, utilize local resources effectively, consider air transport for critical cases

Summary

• Public Areas: Utilize bystanders, public AEDs, and crowd control.
• Roadside: Ensure safety, precise location communication, and basic life support.
• Clinic: Use internal resources, activate protocols, stabilize for transfer.
• Aged Care/Disability Facility: Consider comorbidities, use facility resources, respect DNR orders.
• Small Hospitals: Stabilize, prepare for possible transfer.
• Large Hospitals: Access advanced care, follow protocols, rapid specialist intervention.
• Metropolitan Areas: Quick emergency response, access to advanced facilities.
• Rural Areas: Prolonged response times, utilize local resources, consider telemedicine and air transport.

Appropriately manage the following in emergency and trauma care:

• dangers to self and others in all contexts (including use of appropriate personal protective equipment)
• local resources; and understand how to activate these (including retrieval, ambulance, police, fire, other emergency services)
• handover to team members
• effective interventions, appropriate to level of skill
• algorithmic approach to resuscitation and time-critical emergency and trauma presentations
• leadership with situational awareness
• membership of a team, with closed loop communication
• post-resuscitation care
• communication with family, including decisions to cease resuscitation efforts and institute end-of-life care
• consent in emergency and trauma (in particular, decisions regarding detention under mental health acts)
• respect for cultural expectations, even during life-threatening emergency and trauma care.

• Understand the potential differences in Aboriginal and Torres Strait Islander emergency and trauma presentations, including:
  • younger age at presentation for acute coronary artery disease, stroke, and renal failure
  •  high rates of diseases, including acute rheumatic fever, severe pneumonia, scabies, disseminated strongyloidiasis.

Health Context for Aboriginal and Torres Strait Islander Populations

Condition	Younger Age at Presentation	High Rates of Disease	Significance for Health Management
Acute Coronary Artery Disease	Aboriginal and Torres Strait Islander people often present with acute coronary artery disease at a younger age compared to non-Indigenous populations.	N/A	Early screening and intervention, culturally sensitive education on lifestyle modifications, and access to cardiovascular care.
Stroke	Higher prevalence of stroke at a younger age in Aboriginal and Torres Strait Islander populations.	N/A	Early identification and management of risk factors (hypertension, diabetes), access to stroke care, rehabilitation services.
Renal Failure	Chronic kidney disease and progression to renal failure occur at younger ages in Aboriginal and Torres Strait Islander communities.	N/A	Early screening for kidney disease, management of risk factors (diabetes, hypertension), access to dialysis and transplant services.
Acute Rheumatic Fever	N/A	Higher incidence, particularly in rural and remote areas.	Early diagnosis and treatment, ongoing secondary prophylaxis, community education on prevention.
Severe Pneumonia	N/A	Higher rates due to underlying health and socio-economic factors.	Timely vaccination, access to antibiotics, improving living conditions, and addressing social determinants of health.
Scabies	N/A	High prevalence, particularly in overcrowded living conditions.	Community-wide treatment programs, improving hygiene and living conditions, access to topical and oral treatments.
Disseminated Strongyloidiasis	N/A	Higher rates due to environmental and socio-economic factors.	Early detection and treatment with anti-parasitic medications, improving sanitation, and health education.

Key Strategies for Management

1. Early Screening and Diagnosis:
   • Implement regular health checks for cardiovascular, renal, and infectious diseases.
   • Use culturally appropriate screening tools and methods.
2. Culturally Sensitive Health Education:
   • Provide education on risk factors and prevention strategies in a culturally sensitive manner.
   • Engage community leaders and Indigenous health workers in education programs.
3. Access to Healthcare Services:
   • Improve access to specialist care, including cardiologists, nephrologists, and infectious disease specialists.
   • Ensure availability of essential medications and treatments in remote and rural areas.
4. Management of Risk Factors:
   • Focus on controlling hypertension, diabetes, and hyperlipidemia.
   • Provide support for smoking cessation and promote healthy lifestyles.
5. Community Health Programs:
   • Develop and support community-based health programs addressing hygiene, housing conditions, and preventive care.
   • Implement mass drug administration programs for conditions like scabies and strongyloidiasis.
6. Integrated Care Models:
   • Promote integrated care models that include primary care, specialist services, and social support.
   • Ensure care coordination, especially for patients with chronic and complex conditions.
7. Policy and Advocacy:
   • Advocate for policies that address the social determinants of health, including housing, education, and employment.
   • Support initiatives that aim to reduce health disparities between Indigenous and non-Indigenous populations.

Population Group	Clues of Significance	Management Considerations
Neonatal	– Apgar Scores: Low scores at 1 and 5 minutes. <br> – Prematurity: Higher risk in preterm infants (<37 weeks). – Perinatal History: Complications during delivery (prolonged labor, meconium-stained fluid, maternal infections). – Respiratory Distress: Grunting, flaring, retractions, cyanosis immediately after birth.	– Airway and Breathing: Immediate clearing of the airway, positive pressure ventilation. – Thermal Management: Maintain warmth to prevent hypothermia. – Circulation: Chest compressions if heart rate <60 bpm despite adequate ventilation.
Paediatric	– Respiratory Distress: Most common cause of cardiac arrest. – Trauma: History of falls, accidents, non-accidental trauma. – Infections: Signs of sepsis, meningitis, severe dehydration. – Congenital Conditions: Known congenital heart disease, metabolic disorders.	– Airway Management: Ensure open airway, provide oxygen. – Breathing: Ventilate if necessary. – Circulation: Start chest compressions if no pulse or poor perfusion, use pediatric defibrillation doses. – Drugs: Administer appropriate medications for resuscitation (e.g., adrenaline, fluids).
Adult	– Cardiac History: Previous myocardial infarction, known coronary artery disease. – Substance Use: Overdose or intoxication history. – Trauma: Blunt or penetrating injuries, falls. – Chronic Conditions: Diabetes, hypertension, chronic obstructive pulmonary disease (COPD).	– Defibrillation: Early use of AED if indicated. – Advanced Life Support: Follow ACLS protocols, including drug administration and advanced airway management. – Circulation: High-quality CPR, chest compressions, and defibrillation as needed.
Obstetric	– Pregnancy Complications: Preeclampsia, eclampsia, hemorrhage, amniotic fluid embolism. – Gestational Age: Impacts management strategies, particularly in third trimester. – Maternal History: Pre-existing conditions, multiple gestations.	– Airway Management: Positioning to prevent aortocaval compression, early intubation if necessary. – Circulation: y displace the uterus to the left or use a wedge to tilt the woman to prevent aortocaval compression. – Emergency Delivery: Consider perimortem cesarean delivery if maternal resuscitation is unsuccessful within 4 minutes.
Trauma	– Mechanism of Injury: High-impact collisions, falls, penetrating injuries. – Vital Signs: Hypotension, tachycardia, altered mental status. – Visible Injuries: External bleeding, deformities, open fractures.	– Airway: Ensure patency, consider cervical spine protection. – Breathing: Assess and treat pneumothorax, hemothorax. – Circulation: Control bleeding, administer IV fluids or blood products. – Disability: Rapid neurological assessment. – Exposure: Fully expose patient to identify all injuries, prevent hypothermia.
Metropolitan	– Proximity to Advanced Care: Quick access to specialized hospitals. – Emergency Services Availability: Rapid EMS response times.	– Utilize Advanced Resources: Rapid transport to specialized centers, access to advanced imaging and interventions.
Rural	– Limited Access to Care: Longer transport times to definitive care. – Resource Limitations: Limited availability of advanced medical equipment.	– Stabilization: Focus on initial stabilization, maintain airway, breathing, and circulation. – Telemedicine: Use telemedicine to consult with specialists. – Transport: Prepare for air or ground transport to higher-level care facilities.

Resuscitation

• Understand the significance of resuscitation in specific population groups and presentations, including:
  • neonatal
  • paediatric
  • adult
  • obstetric
  • trauma

• Be able to manage the following in a resuscitation event:
  • airway:
    • oropharyngeal suction
    • bag-valve-mask ventilation
    • placement of oropharyngeal airways (Guedel)
    • placement of second-generation laryngeal mask airway (i-gel)
  • cervical spine:
    • understand the principles of immobilisation
  • breathing:
    • titration of oxygen appropriate to the resuscitation
    • appropriate use of oxygen supply devices
    • needle decompression of tension pneumothorax
  • circulation:
    • appropriate use of an automated defibrillator (use of manual defibrillator if appropriate competency)
    • placement of intravenous (IV) or intraosseous (IO) access and appropriate fluid resuscitation
  • disability:
    • appropriate blood sampling and interpretation
    • appropriate use of overdose reversal agents
    • pain management in emergency and trauma.

Time-critical, life-threatening emergency presentations

• Identify emergency and trauma presentations which have the potential to immediately threaten life, limb or sight, and be able to triage multiple emergency and trauma presentations, including:
  • loss of airway, and potential and imminent loss of airway
  • breathing distress and fatigue associated with respiratory failure
  • circulatory shock and situations at risk of circulatory compromise
  • altered conscious state, electrolyte imbalance, temperature regulation.
• Identify and understand the principles of managing emergency and trauma presentations which have the potential to immediately threaten life, limb or sight, including:
  • non-specific presentations:
    • fever with signs of shock
    • loss of consciousness
    • multi-trauma
    • anaphylaxis/angio-oedema
    • overdose and poisoning
    • envenomation
    • drowning
    • electrocution
    • the unwell child
    • hyper/hypothermia
  • cardiovascular:
    • acute coronary syndromes
    • life-threatening arrhythmias (ventricular fibrillation, ventricular tachycardia, tachy/brady arrhythmias with circulatory compromise)
    • acute pulmonary oedema
    • aortic dissection
    • malignant hypertension
    • shock
    • cardiac tamponade
    • acute vascular occlusion (limb ischaemia)
  • respiratory and airway:
    • acute airway obstruction (including trauma, inhaled foreign body, epiglottitis, croup)
    • acute exacerbation of chronic obstructive pulmonary disease (COPD)
    • severe asthma with status asthmaticus
    • acute respiratory distress syndrome (as seen in influenza, novel coronavirus, SARS)
    • pulmonary tuberculosis
    • infantile apnoea
    • bronchiolitis
    • pulmonary embolism
    • pneumothorax including tension pneumothorax
    • hypoventilation
    • hypoxia
  • gastrointestinal:
    • acute abdominal pain
    • abdominal visceral rupture
    • acute pancreatitis
    • acute liver failure
    • bowel obstruction
    • appendicitis
    • ischaemic bowel
    • intussusception
    • sigmoid volvulus
    • incarcerated hernia
    • acute gastrointestinal bleed
  • neurology:
    • cerebrovascular ischaemia
    • intracerebral haemorrhage
    • subarachnoid haemorrhage
    • subdural haemorrhage
    • meningitis
    • encephalitis
    • status epilepticus
    • raised intracranial pressure
    • spinal trauma (including cervical spine trauma)
    • Guillain-Barré syndrome
    • cauda equina syndrome
  • endocrine:
    • diabetic ketoacidosis
    • acute hypoglycaemia
    • Addisonian crisis
    • thyrotoxic crisis
    • hyperosmolar coma
    • myxoedema coma
  • renal and urology:
    • testicular torsion
    • acute kidney injury
  • electrolyte:
    • disorders of electrolyte balance (including hypo/hyperkalaemia, hypo/hypernatraemia, hypo/hypercalcaemia, acidosis, alkalosis)
  • haematology:
    • acute bleeding in the anticoagulated patient
    • acute leukaemia
    • clotting disorders
    • thrombocytopenia
    • febrile neutropenia
  • infectious diseases:
    • septic shock
    • pertussis
    • necrotising fasciitis
    • meningococcal septicaemia
  • orthopaedic, musculoskeletal and rheumatological:
    • osteomyelitis
    • long bone fractures
    • compound fractures
    • fractures with neurovascular compromise
    • compartment syndrome
    • rhabdomyolysis
    • acute systemic vasculitis
  • ear, nose, throat:
    • mastoiditis
    • major epistaxis
    • post-tonsillectomy bleeding
    • palatal/laryngeal trauma
    • caustic ingestions
  • dental and oral:
    • maxillofacial trauma
    • Ludwig’s angina
  • dermatology:
    • facial/deep/large burns
    • deep or large lacerations (including contaminated)
    • staphylococcal scalded skin syndrome
    • Stevens-Johnson syndrome
  • ophthalmology:
    • ocular trauma (blunt, penetrating, chemical/flash burns)
    • herpes simplex/zoster
    • periorbital/orbital cellulitis
    • acute visual loss
    • sudden diplopia
    • acute glaucoma
    • retinal detachment
    • vascular occlusion
    • proptosis
    • papilloedema
    • red eye with blurred vision
    • flashes/floaters with reduced vision or visual changes
  • obstetric and gynaecological:
    • ectopic pregnancy
    • first trimester bleeding (threatened miscarriage/miscarriage)
    • bleeding after 20 weeks
    • puerperal infection
    • abdominal trauma in pregnancy
    • eclampsia
    • premature labour (including precipitant delivery)
    • ovarian torsion
  • psychological:
    • acute suicidal ideation
    • psychosis (including drug induced, schizophrenia, bipolar)
    • anger and agitation
    • withdrawal syndromes (including alcohol and benzodiazepine).

Other emergency presentations

• Identify and understand the principles of managing the following emergency and trauma presentations:
  • non-specific presentations:
    • fever
    • minor trauma
    • acute rash
  • cardiovascular:
    • arrhythmias (atrial fibrillation, tachy/brady arrhythmias without circulatory compromise)
  • respiratory and airway:
    • lower respiratory tract infections
  • gastrointestinal:
    • acute cholecystitis
    • acute hepatitis
    • diverticulitis
    • swallowed foreign body
  • neurology:
    • seizure
    • head trauma (including concussion)
    • delirium
  • endocrine:
    • hyperglycaemia (including first presentation of type 1 diabetes)
  • renal and urology:
    • acute urinary obstruction
    • priapism
  • electrolyte:
    • disorders of electrolyte balance (including hypo/hyperkalaemia, hypo/hypernatraemia, hypo/hypercalcaemia, acidosis, alkalosis)
  • haematology:
    • anaemia (inclusive of multiple causes)
  • infectious diseases:
    • cellulitis, abscess
    • needle-stick injury
  • orthopaedic, musculoskeletal and rheumatological:
    • fractures (including growth plate injuries)
    • dislocations
    • acute back pain and sciatica
    • temporal arteritis
  • ear, nose, throat:
    • barotrauma
    • tympanic membrane perforation
    • temporal bone fracture
    • ear/nose foreign body
    • otitis externa
    • otitis media
    • labyrinthitis
    • minor epistaxis
    • nasal trauma
    • quinsy
    • acute hearing loss
  • dental and oral:
    • dental trauma
    • avulsion/luxation/broken dentition
    • complications of dental procedures
    • dental abscess and infection
  • dermatology:
    • minor burns
    • minor lacerations
    • blistering skin conditions
    • pyoderma gangrenosum
    • erythema multiforme
    • systemic lupus erythematosus (SLE)
    • erythroderma
    • acute febrile neutrophilic dermatosis
    • signs of abuse
  • ophthalmology:
    • haemorrhage (vitreous/retinal)
    • superficial foreign body
    • uveitis
    • iritis
    • corneal ulcer
    • optic neuritis
  • obstetric and gynaecological:
    • pre-eclampsia (including hypertension in pregnancy)
    • complicated ovarian cysts
    • acute pelvic inflammatory disease
    • pelvic injury and trauma (including rape)
    • concealed pregnancy
    • premature rupture of membranes
  • psychological:
    • severe depression/anxiety
    • mania and hypomania.