Comprehensive Guide to Major and Acute Presentations in Clinical Training

1. The Major and Acute Presentations Bringing it all together

2. Major presentations • 6 over 2 years • 2 in EM; 2 in AM; 2 in any module • Septic patient ideally assessed during ICM • Anaphylaxis assessment may be on a simulated patient (e.g. during Anaesthetics) • Anaphylaxis • Cardiorespiratory Arrest (Valid ALS Certificate Mandatory) • Major Trauma • Septic Patient • Shocked Patient • Unconscious Patient

3. Forms required for Majors • Use specific forms when available and generic forms when not • Ideally use the forms of the specialty to which you are attached at the time of the assessment • Major Presentation descriptors • Mini-CEX - specific forms available for: • Shock • Sepsis • Major Trauma • Cardiac Arrest • Anaphylaxis • Unconscious patient • CBD • Summative CBD (generic form)

4. Mini-CEX form for Shock

5. Expected knowledge, skills and behaviour being assessed: from ACCS curriculum • Skills • Recognise significance of major physiological perturbations • Perform immediate (physical) assessment (A,B,C) • Institute immediate, simple resuscitation (oxygen, iv access, fluid resuscitation) • Arrange simple monitoring of relevant indices (oximetry, arterial gas analysis) and vital signs (BP, pulse & respiratory rate, temp, urine output) • To be able to gain vascular access in the shocked patient, including central venous (using Ultrasound), arterial line, intra-osseous and cut down techniques • Order, interpret and act on initial investigations appropriately: ECG, blood cultures, blood count, electrolytes, CVP measurements • Recognition of the need for urgent surgical intervention • Shocked Patient • The trainee will be able to identify a shocked patient, assess their clinical state, produce a list of appropriate differential diagnoses and initiate immediate management • Knowledge • Identify physiological perturbations that define shock and understand the pathophysiology of its cause • Identify principle categories of shock • Elucidate main causes of shock in each category (e.g. MI, heart failure, PE, blood loss, sepsis) • Demonstrate knowledge of sepsis syndromes • Demonstrate a knowledge of the roles and the different types of monitoring required for the shocked patient • Understand the role of imaging in the diagnosis of shock e.g. FAST scan, CT etc and be able to interpret the fundamentals of this imaging • Demonstrate a knowledge of the different fluids fluids and drugs e.g. inotropes used in the treatment of shock • Behaviour • Exhibit calm and methodical approach to assessing critically ill patient • Adopt leadership role where appropriate • Involve senior and specialist (e.g. critical care outreach) services promptly

6. Acute Presentations • 38 Acute Presentations • Complete 10 AP in AM and 10 AP in EM: • 5 AP using specific mini-CEX/generic summative CBD forms in EM • 5 AP using Formative CBD/Mini-CEX forms in AM (ICM) • 5 AP in an ACAT for AM or EM • Plus 8 -10 additional AP in AM and EM using: • E-learning modules • Audit and Teaching • Reflective notes • Additional ACATs

7. List of acute presentations

8. Mini-CEX form for Acute Presentation: Head injury

9. Expected Behaviour in assessment of Acute Presentation 5 Head Injury

10. Generic summative Mini-CEX form for acute presentations

11. Summary: Sample CT1-2 CT1 first placement: EM • 2 Major presentations: • Major Trauma: mini-CEX • Shock: Summative CBD • 5 Acute presentations (summative): • Abdominal pain: CBD • Head injury: Mini-CEX • Breathlessness: Mini-CEX • Mental Health: CBD • Chest pain: Mini-CEX • 5 AP: ACAT- EM: • Cough • Falls • Syncope • Traumatic limb injuries • Acute Back pain • 8 AP: • E-learning modules: 5 on BMJ.com and Doctors.net (Pelvic pain, Wound assessment, Red eye, Rash, Painful ear) • Teaching (Vaginal bleeding) • Audit (Pain management) • Reflective notes: Fits/Seizure

12. CT1 second placement: Acute Medicine • 2 Major Presentations: • Cardiac arrest: Mini-CEX • Anaphylaxis: Mini-CEX • 10 Acute presentations: • Oliguric patient: CBD • Palpitations: CBD • Jaundice: CBD • Headache: mini-CEX • Blackout/Collapse: CBD • 1 ACAT- AM: • Abdominal swelling • Cyanosis • Haematemesis & Melaena • Dizziness & Vertigo • Confusion • 9 AP: • 2 ACAT-AM • Neck pain • Nausea and vomiting • Stroke • Poisoning • Fever • Disturbed behaviour • Teaching: Diarrhoea • E-learning: Sore throat, Atraumatic limb pain

13. Summary CT2: 3rd placement: Anaesthetics No Major or Acute presentations required CT2: 4th placement: ICM • 2 major presentations: • Septic patient: Mini-CEX • Unconscious patient: CBD • 1 Remaining acute presentation: • Ventilatory support: Mini-CEX • Not required if all completed during EM and AM Done, until CT3 in your parent specialty!