Royal College of Emergency Medicine

Royal College of Emergency Medicine To promote importance of Emergency Medicine around globe

20/06/2026

MRCEM SBA HIGH YEILD TOPIC RECALLS FROM 2026 TOXICITY OF LOCAL ANESTHESIA VERY IMPORTANT

18/06/2026

MRCEM SBA RECALL JAN 2026

18/06/2026

Resuscitative Thoracotomy

Indications

Penetrating thoracic trauma with witnessed signs of life & cardiac arrest

18/06/2026

Damage control resuscitation9:

Damage control resuscitation is a systematic approach to managing critically ill trauma patients.

It consists of a triad of:

Permissive hypotension
Haemostatic (balanced) resuscitation
Damage control surgery
This method aims to correct the “lethal triad” of coagulopathy, acidosis and hypothermia; and control haemorrhage, while maintaining a sufficient circulating volume for tissue perfusion.

Damage control resuscitation has been shown to reduce rates of acute respiratory distress syndrome (ARDS) and multiorgan dysfunction syndrome (MODS).

Haemostatic resuscitation:10

Aims to mimic whole blood with transfusion of blood products in a ratio of 1-2 PRBCs:1 FFP:1 platelets.

May also be guided by blood results:

Haemoglobin1.5 à transfuse FFP
Platelets

18/06/2026

Pneumomediastinum is the presence of air in the mediastinum.

This can occur secondary to trauma, or any condition in which air leaks into the chest cavity from the airways, lungs or bowels.

Spontaneous pneumomediastinum occurs without any obvious cause. Secondary pneumomediastinum has various potential underlying causes including respiratory disease, trauma, Boerhaave syndrome, Valsalva manoeuvre, childbirth, scuba diving, and substance abuse2.

Recently, there has been a global rise in the incidence of substance misuse. Nitrous oxide is a popular recreational drug amongst teenagers and young adults.

Nitrous oxide induced pneumomediastinum can be explained by forceful inhalation from a cannister increasing the intrapulmonary pressure and causing a barotrauma effect on the alveoli resulting in air leaks into the intra-thoracic cavity3.

Physical examination may reveal presence of crepitus on the anterior chest wall sometimes tracking to the paravertebral fascia around the neck.

Hamman’s crunch is an audible crunching or clicking sound on auscultation, synchronous with the heartbeat4.

The diagnosis of pneumomediastinum can be confirmed by chest x-ray or CT Thorax. While dependent on aetiology, it usually has a good prognosis.

Treatment:

Admission for minimum 24 hours observation
High flow oxygen (improves the reabsorption of free air by 6-fold)
Anti-tussives
Adequate analgesia
Advise these patients to avoid any strenuous exercise for a minimum of 4 weeks, and to avoid air travel for 3 weeks.

Rarely complications such as worsening pneumomediastinum, tension pneumomediastinum, pneumothorax or extensive subcutaneous emphysema could necessitate a drain and, occasionally, a thoracotomy for decompression.

Key Learning Points

Nitrous oxide use is a potential underlying cause of spontaneous pneumomediastinum.
Hamann’s sign in the absence of any anomaly on CXR should warrant further imaging such as CT Thorax to identify the underlying pathology.
After discharge from hospital, advice should be given to patients with pneumomediastinum to avoid air travel and strenuous exercise for an average of 4 weeks.

18/06/2026

A BRUE refers to a sudden, brief (lasting < 1 minute), resolved episode in an infant under one year of age, comprising ≥1 of the following1:

cyanosis or pallor
absent, decreased or irregular breathing.
marked change in tone (hypertonia or hypotonia)
altered level of responsiveness
This event cannot be explained by identifiable medical conditions. BRUE is a diagnosis of exclusion2.

Gastroesophageal reflux (GOR) can result in laryngospasm, airway obstruction, or aspiration. Symptoms of GOR include choking or gagging after vomiting.

Reported history of events which is incongruous with examination findings or infant’s developmental age should warrant consideration of child abuse. Concerning features for non-accidental injury (NAI) include a previous BRUE, inconsistent history, and concerning physical examination (e.g., torn frenulum, unexplained bruising). Clinicians and nursing staff should obtain a social history to identify risk factors for NAI in infants with BRUE.

History should include any fever or respiratory symptoms in the preceding days. Details of these symptoms should be obtained to out rule an infective process. Of note, pertussis is a recognised cause of apnoea in young infants.

In the presence of a family history of sudden, unexplained death in first-degree relatives (under the age of 35), a cardiac arrhythmia may be considered.

An infant is stratified as lower-risk BRUE if there are no concerning historical features or clinical findings with the presence of all the following1:

Age >60 days
Born ≥32 weeks gestation and corrected gestational age ≥45 weeks
No CPR by trained clinical professional
First event
Event lasted

18/06/2026

PERITONSILAR ABSCESS QUINSY

A peritonsillar abscess (quinsy) is common following:

Acute tonsillitis
Infectious mononucleosis
Smoking
Chronic periodontal disease
Common causative microorganisms include4,5:

Group A beta-hemolytic Streptococcus
Staphylococcal
Pneumococcal
Hemophilic organisms
Rare organisms are:

Lactobacillus
Actinomyces
Micrococcus
Often growth is mixed with both aerobic and anaerobic microorganisms.

Clinical Features

Clinical features include progressively increasing pain in throat which is usually unilateral.

There may be referred earache on the same side.

Odynophagia (painful swallowing) may be present and become very severe, preventing the patient from swallowing their own saliva, so they may start drooling pooled saliva.

If the abscess size increases due to disease progression, then it may result in muffled speech or a typical “hot potato” voice5.

Neck pain may occur secondary to inflamed cervical lymph nodes as well as referred pain from the throat5.

Trismus (muscle spasm of the jaw making mouth opening difficult) occurs in most of the cases due to inflammation of the pterygoid muscles.

Other features may include fever, rigors, malaise, body ache, headache and nausea.

On examination, the patient usually appears unwell and sick5.

Clinical presentation of peritonsillar abscess varies, ranging from the mild acute tonsillitis with a minimal unilateral pharyngeal bulge to a severe degree of dehydration and sepsis5.

On local examination:

Abscess collection is most common at superior pole of the tonsils.
Trismus of varying degree is present.
The affected tonsil is pushed downward and medially due to the abscess.
The uvula is swollen and oedematous and pushed to the opposite side.
There may be a bulge on soft palate and anterior tonsillar pillar.
Mucous (saliva) may be seen overlying the tonsillar region.
Cervical lymphadenopathy may be present.
Diagnosis

The diagnosis is mainly clinical. Features which raises suspicion of quinsy are:

Unilateral swelling of peritonsillar area.
Bulge on unilateral soft palate.
Ill looking patient with sepsis.
Laboratory Investigations:

Raised inflammatory markers (white blood cell count and CRP).
Pus culture sensitivity from needle aspiration.
Radiological imaging:

CT imaging with contrast is helpful especially in young patients but it is not required routinely as it involves high radiation exposure and an increased risk of cancer

Management

Following the immediate medical treatments administered in the ED, the patient may require needle aspiration and intraoral incision and drainage of the peritonsillar abscess. This is performed with the patient sitting upright to prevent the aspiration of pus. The oral and laryngeal mucosa is anesthetised with lidocaine 10% spray. Incision is given at the point of the maximum bulge above the upper pole of the affected tonsil5.

In uncooperative or in very young patients, the surgical procedure may require use of general anaesthesia5.

Differential Diagnosis:

Dental infections
Epiglottitis
EBV infectious mononucleosis
Pharyngitis
Retropharyngeal abscess
Complications:

Complications of a peritonsillar abscess includes:

Para-pharyngeal abscess
Retro-pharyngeal abscess
Laryngeal edema leading to airway compromise
Rarely pneumonia or lung abscess following aspiration of a ruptured abscess.
Sepsis10
Prognosis:

Most of the patients suffering with a peritonsillar abscess who received urgent surgical drainage and are subsequently treated with (post procedural) antibiotics recover within next few (usually 4-7) days.

Approximately 1-5% of patients may get complications such as recurrent abscess formation. These patients may require formal tonsillectomy once they recover from their acute illness. The risk of recurrence is highest in young people.

Complications after surgical treatment of peritonsillar abscess, such as bleeding, have been reported in the minority (less than 0.1% of patients)11,12.

Key Learning Points

A peritonsillar abscess (quinsy) is a common clinical condition which must be considered in any septic/toxic appearing patient with a sore throat, especially with unilateral involvement.
Commence intravenous fluids, early intravenous antibiotics and refer urgently to the ENT team for the surgical management of a peritonsillar abscess.
Prognosis is good if the peritonsillar abscess (quinsy) is identified and treated promptly in the emergency department.

17/06/2026

PNEUMOTHORAX 2

The BTS guidance contains an evidence review comparing various treatments to an intercostal drain. According to this:

Evidence shows that conservative management leads to the least risk of recurrence.

Patients who have a successful aspiration can be discharged home with outpatient follow up.

There is no difference between the rate of recurrence after chest drain insertion or aspiration.

The complication rate between the two procedures is similar, this risk of subcutaneous emphysema is probably slightly greater after chest drain insertion than needle aspiration.

There is no difference in the rate of patient re-admission, the need for pleural procedures or complications between ambulatory and inpatient drains.

Additional Information

The new guidance from BTS places the emphasis on patient choice when managing simple pneumothoraces in low-risk patients. Patients who have a pneumothorax which is smaller than 2 cm apically or laterally on chest x-ray, but who are symptomatic should have a CT chest to plan further intervention.

Patients who are now separated into high risk requiring an immediate drain by the following characteristics:

Haemodynamic compromise, significant hypoxia, bilateral pneumothorax, underlying lung disease, greater than or equal to 50 years of age with significant smoking history, haemopneumothorax.

Conditions associated with pneumothorax are cystic fibrosis, and endometriosis causing catamenial pneumothorax, found in around 25% of women with recurrent pneumothorax. 10% are familial. These patients should be investigated with CT and referred to a specialist as they can be associated with various syndromes.

Key Learning Points

Patients who are professional divers, in the military or have a tension pneumothorax should be referred to thoracics at presentation for consideration of surgery.
For patients with minimal chest pain and breathlessness the best treatment option may be conservative management.
Consider rare causes of pneumothoraces in patients who have menstruated within 72 hours of presentation or who have a family history.

17/06/2026

PNEUMOTHORAX 1

A pneumothorax within 72 hours before or after menstruation should (particularly if there is haemoptysis) bring to mind the possibility of catamenial pneumothorax in which endometrial deposits in a woman with endometriosis are the cause.

It is important to consider barotrauma as cause of pneumothorax in all divers, in this case it was several weeks since she had been diving.

However, if she had been diving recently arterial gas embolism must be considered and advice should be sought from the national diving accident helpline in the UK.

Physical exercise has not been shown to increase risk of pneumothorax.

Smoking crack co***ne and cannabis are risk factors for pneumothorax. These patients are also at risk of bullous lung disease and so it is important to ensure you have identified the lung edge before proceeding to drainage. This answer is incorrect as there is no relationship with M**A.

The management of a pregnant woman with a pneumothorax is complicated, with both C-section and spontaneous delivery to be avoided, respiratory and obstetrics should be involved early. However, it is not a known risk factor for pneumothorax.2

Flight should not be undertaken after pneumothorax until it has been fully resolved, as the changes in air pressure are likely to cause it to expand however it is not a known risk factor for pneumothorax without another co-existing lung pathology.

06/06/2026

Resuscitative Thoracotomy

Indications

Penetrating thoracic trauma with witnessed signs of life & cardiac arrest

Address

London

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