UK Medical Licensing Assessment (UKMLA) Acute and Emergency Medicine Syllabus

List the key components of post-resuscitation (post-ROSC) care.

Targeted oxygenation ($\ce{SpO2}$ $94$–$98\%$) and normocapnia, 12-lead ECG and consider urgent coronary angiography, treat the precipitating cause, targeted temperature management (avoid fever, target $\leq 37.5^{\circ}\mathrm{C}$), maintain MAP, control glucose and seizures, and delayed neuroprognostication.

What is the recommended target oxygen saturation after return of spontaneous circulation (ROSC), and why avoid hyperoxia?

Target $\ce{SpO2}$ $94$–$98\%$. Hyperoxia increases reperfusion oxidative injury and worsens neurological outcome, so titrate oxygen down once ROSC is achieved.

How does the paediatric basic life support sequence differ from the adult sequence?

Children: give $5$ initial rescue breaths before starting compressions, use a $15{:}2$ compression:ventilation ratio (healthcare providers), and compress to one-third of chest depth. Lone rescuers perform $\sim 1$ min of CPR before going for help.

What single dose of IV/IO adrenaline is used in paediatric advanced life support?

$10$ \mu g/kg (i.e. $0.1$ mL/kg of $1{:}10{,}000$ adrenaline), repeated every $3$–$5$ minutes.

What are the four conditions under which CPR may be lawfully and ethically withheld or a DNACPR decision made?

When CPR will not restart the heart/breathing (futile), when it is against the patient's recorded wishes/valid advance decision, when an attorney/court deputy with relevant authority refuses on their behalf, or when the burdens/harms outweigh benefits and it is not in the patient's best interests.

Does a DNACPR decision affect any treatment other than CPR, and who makes the final decision?

No – a DNACPR applies only to cardiopulmonary resuscitation; all other appropriate treatment continues. It is ultimately a clinical decision made by the senior responsible clinician, but must involve discussion with the patient (or those close to them if the patient lacks capacity).

List the ECG territories and the coronary arteries supplying them for STEMI localisation.

Inferior (II, III, aVF) – right coronary artery; Anteroseptal (V1–V4) – left anterior descending; Lateral (I, aVL, V5–V6) – left circumflex; Posterior (tall R/ST depression V1–V3) – RCA/circumflex.

State the immediate drug management ('MONA' plus) of suspected acute coronary syndrome.

Aspirin $300$ mg, a second antiplatelet (e.g. ticagrelor/clopidogrel/prasugrel), GTN, oxygen only if $\ce{SpO2}<94\%$, and analgesia (morphine $\pm$ antiemetic). Reperfusion: primary PCI for STEMI if available within 120 min, otherwise thrombolysis.

Give three 'cannot-miss' life-threatening causes of acute chest pain other than ACS, and a distinguishing feature of each.

Aortic dissection (tearing pain radiating to back, BP differential between arms), pulmonary embolism (pleuritic pain, dyspnoea, hypoxia, raised D-dimer), and tension pneumothorax (sudden dyspnoea, tracheal deviation, absent breath sounds, hypotension).

What is the Wells score used for, and what does a 'PE likely' result trigger?

The Wells score risk-stratifies the probability of pulmonary embolism. 'PE likely' ($>4$ points) → proceed directly to CT pulmonary angiogram; 'PE unlikely' ($\leq 4$) → D-dimer first, and CTPA only if positive.

List the immediate management steps for a tension pneumothorax.

Immediate needle decompression (large-bore cannula, 2nd intercostal space mid-clavicular line, or 4th–5th space anterior/mid axillary line) without waiting for imaging, followed by definitive chest drain insertion.

Outline the stepwise acute management of an adult having a life-threatening asthma attack.

High-flow oxygen, back-to-back nebulised salbutamol ($\ce{O2}$-driven) and nebulised ipratropium, IV/oral steroids, consider IV magnesium sulfate, and senior/ICU review for possible aminophylline or ventilation.

Define an 'acute abdomen' and name the four cardinal patterns of abdominal pain by mechanism.

An acute abdomen is the sudden onset of severe abdominal pain requiring urgent assessment for possible surgical cause. Patterns: visceral (poorly localised, midline), parietal/somatic (sharp, localised, with peritonism), referred, and colicky (waxing-waning, from a hollow viscus).

What clinical signs suggest peritonitis on examination of the acute abdomen?

Guarding, rigidity ('board-like' abdomen), rebound tenderness, percussion tenderness, and a patient lying very still; bowel sounds are often absent.

Describe the classic migratory pain pattern of acute appendicitis.

Central/peri-umbilical (visceral) pain that later localises and shifts to the right iliac fossa (McBurney's point) as the parietal peritoneum becomes involved, with anorexia, low-grade fever and local peritonism.

What are the three components of the Glasgow Coma Scale and the maximum/minimum scores?

Eye opening (max $4$), Verbal response (max $5$), Motor response (max $6$). Total range $3$ (worst) to $15$ (normal).

At what GCS is definitive airway protection (intubation) generally indicated, and why?

GCS $\leq 8$, because of loss of protective airway reflexes and high aspiration risk ('GCS 8, intubate').

What reversible causes should be actively excluded in a patient with reduced consciousness or coma?

Hypoglycaemia (check capillary glucose), opioid toxicity (give naloxone), hypoxia/hypercapnia, hypothermia, hyponatraemia/metabolic derangement, seizure/post-ictal state, intracranial haemorrhage/mass, and infection (meningitis/encephalitis).

What clinical features distinguish true cardiac/arrhythmic syncope from a benign vasovagal faint?

Red-flag (cardiac) features: syncope on exertion or while supine, no/short prodrome, associated palpitations or chest pain, family history of sudden death, and abnormal ECG. Vasovagal: clear trigger, prodrome (nausea, sweating, visual greying), upright posture, and rapid full recovery.

What are the key examination and ECG checks in a patient presenting after collapse/syncope?

Lying and standing BP (postural drop $\geq 20$ mmHg systolic), 12-lead ECG looking for long QT, Brugada, heart block, WPW, ischaemia or arrhythmia; plus cardiac auscultation for outflow murmurs (e.g. aortic stenosis, HOCM).

What is a thunderclap headache and what is the most important diagnosis to exclude?

A severe headache reaching maximum intensity within $1$ minute (often described as 'worst ever'). Subarachnoid haemorrhage (SAH) must be excluded as the priority.

What is the recommended investigation pathway for suspected subarachnoid haemorrhage?

Urgent non-contrast CT head (most sensitive within 6 hours of onset). If CT is negative but suspicion remains and onset was $>6$ h ago, perform lumbar puncture at $\geq 12$ h looking for xanthochromia.

Outline the general 'TOXBASE' approach to the poisoned patient.

Resuscitate using ABCDE first, then identify the toxin (history, examination, toxidromes), consult TOXBASE/poisons centre, consider decontamination (e.g. activated charcoal if within 1 h), give specific antidotes, and enhance elimination where indicated.

Match these poisons to their specific antidotes: paracetamol, opioids, benzodiazepines, beta-blockers, organophosphates, iron.

Paracetamol → N-acetylcysteine; opioids → naloxone; benzodiazepines → flumazenil (rarely used); beta-blockers → glucagon; organophosphates → atropine ($\pm$ pralidoxime); iron → desferrioxamine.

How is the decision to treat paracetamol overdose with N-acetylcysteine made?

Plot the serum paracetamol level (taken $\geq 4$ h post-ingestion) on the treatment nomogram; treat if on/above the line. Treat regardless of level if staggered overdose, unknown timing, or already $>8$ h since ingestion.

Describe the management priorities for severe accidental hypothermia.

Handle gently (risk of arrhythmia), use active rewarming (warmed IV fluids, warm humidified $\ce{O2}$, forced-air blankets, or extracorporeal rewarming if cardiac arrest), and prolong resuscitation because 'no one is dead until warm and dead' – do not stop CPR until core temperature $>32$–$35^{\circ}\mathrm{C}$.

What are the features and management of severe anaphylaxis?

Acute onset of Airway/Breathing/Circulation compromise with skin/mucosal changes after exposure. Treatment: IM adrenaline $500$ \mu g ($0.5$ mL of $1{:}1000$) into the anterolateral thigh, repeated every $5$ min; plus high-flow $\ce{O2}$, IV fluids, and lay flat with legs raised.

What scoring tool assesses alcohol withdrawal severity, and what is the first-line drug treatment?

The CIWA-Ar score assesses withdrawal severity. First-line treatment is a benzodiazepine (e.g. chlordiazepoxide or diazepam), often given as a reducing regimen or symptom-triggered.

What is the triad of Wernicke's encephalopathy and how is it prevented/treated in alcohol-related emergencies?

Triad: confusion, ophthalmoplegia/nystagmus, and ataxia. Prevent/treat with parenteral thiamine (e.g. IV Pabrinex) given before any glucose, as glucose can precipitate Wernicke's in thiamine-deficient patients.

In ATLS, what does the primary survey assess and in what sequence?

Catastrophic haemorrhage control then ABCDE: A – Airway with cervical-spine protection, B – Breathing, C – Circulation with haemorrhage control, D – Disability, E – Exposure/environment. Often written as <C>ABCDE.

How does the secondary survey in trauma differ from the primary survey?

The secondary survey is a head-to-toe examination plus a full AMPLE history (Allergies, Medications, Past history, Last meal, Events), performed only once the primary survey is complete and the patient is stabilised, to detect all other injuries.

List the Canadian CT Head Rule high-risk criteria indicating a CT head within 1 hour after head injury (NICE).

GCS $<13$ on initial assessment or $<15$ at 2 h, suspected open/depressed or basal skull fracture, post-traumatic seizure, focal neurological deficit, or $>1$ episode of vomiting.

What clinical signs suggest a basal skull fracture?

Periorbital ('panda/raccoon') eyes, Battle's sign (mastoid bruising), CSF rhinorrhoea or otorrhoea, and haemotympanum.

What is the lethal triad of trauma that worsens haemorrhage outcomes?

Hypothermia, acidosis, and coagulopathy – a self-perpetuating cycle that must be interrupted by damage-control resuscitation and rapid haemorrhage control.

What is 'permissive hypotension' in trauma resuscitation and what blood product strategy accompanies it before surgical haemorrhage control?

Deliberately keeping blood pressure low (e.g. systolic $\sim 80$–$90$ mmHg, or a palpable radial pulse) to avoid dislodging clot, while using a balanced 1:1:1 ratio of packed red cells, plasma and platelets and giving tranexamic acid early.

What is the role and timing of tranexamic acid (TXA) in major trauma haemorrhage?

TXA (an antifibrinolytic) reduces mortality from bleeding when given early – ideally within 3 hours of injury (loading $1$ g over 10 min, then $1$ g over 8 h); benefit is lost and harm possible if given $>3$ h after injury.

Define a tension pneumothorax versus an open ('sucking') chest wound and give the immediate management of each.

Tension pneumothorax: one-way air accumulation causing mediastinal shift and obstructive shock → needle decompression then chest drain. Open chest wound: air drawn through a chest wall defect → three-sided occlusive dressing then chest drain.

What is Beck's triad and which condition does it indicate?

Beck's triad = hypotension, raised JVP/distended neck veins, and muffled heart sounds. It indicates cardiac tamponade, managed by pericardiocentesis or thoracotomy.

What is the START triage system and its four colour categories?

START (Simple Triage And Rapid Treatment) sorts mass-casualty patients by ability to walk, respirations, perfusion and mental status into: Green (minor/walking), Yellow (delayed), Red (immediate), and Black (deceased/expectant).

What does the major-incident mnemonic CSCATTT stand for?

Command and control, Safety, Communication, Assessment, Triage, Treatment, Transport – the structured framework for managing a major incident.