RCEM Syllabus Summaries: Resus Overview

RCEM Syllabus Summaries: Resus Overview Emergency Medicine Resuscitation Presentations and Clinical Conditions

Clinical Presentations	Condition / Issues
RP1. Acute airway obstruction	RC1. Choking
RP2. Anaphylaxis/Anaphylactoid reaction	RC2. Stridor
RP3. Cardiorespiratory arrest	RC3. Organ donation
RP4. Major Trauma	RC4. BRUE
RP5. Respiratory failure	RC5. SUDIC Protocol
RP6. Sepsis
RP7. Shock
RP8. Unconsciousness

The Royal College of Emergency Medicine (RCEM) 2021 curriculum marks a significant evolution in the training and practice of emergency medicine in the United Kingdom, specifically through its focus on Specialty Learning Outcomes (SLOs) that demand both technical proficiency and sophisticated clinical decision-making.[1] SLO3—identifying the sick adult patient, resuscitating, and knowing when to stop—serves as the cornerstone for the resuscitation (RESUS) presentations discussed in this report.[1, 2, 3] This comprehensive overview is designed for the emergency physician and highly trained professional working within the National Health Service (NHS) in England, synthesizing the latest guidance from the Resuscitation Council UK (RCUK), the National Institute for Health and Care Excellence (NICE), and NHS Blood and Transplant (NHSBT).[4, 5, 6]

Executive Summary

The modern management of resuscitation presentations in the Emergency Department (ED) requires a standardized approach using the Airway, Breathing, Circulation, Disability, and Exposure (ABCDE) framework, integrated with the National Early Warning Score 2 (NEWS2) to drive risk stratification.[4, 5, 7] Significant updates in the 2025 NICE sepsis guidance (NG253) have introduced a more conservative fluid resuscitation protocol—utilizing 250ml boluses—to mitigate the risks of fluid overload while maintaining a focus on delivering broad-spectrum antibiotics within one hour for high-risk patients.[5, 8] In the realm of anaphylaxis, the 2021 RCUK guidelines reinforce intramuscular (IM) adrenaline as the definitive first-line intervention, significantly reducing the reliance on corticosteroids and antihistamines in the acute phase.[4, 9]

Major trauma care continues to be optimized through regional networks, prioritizing the <C>ABCDE sequence and permissive hypotension in hemorrhagic shock.[10, 11] The curriculum also emphasizes the ethical and legal complexities of end-of-life care, particularly the "whole hospital" approach to organ donation, where timely referral to a Specialist Nurse for Organ Donation (SNOD) is now a quality standard for patients with devastating brain injuries.[6, 12, 13] Finally, pediatric presentations like Brief Resolved Unexplained Events (BRUE) and the Sudden Unexpected Death in Infancy and Childhood (SUDIC) protocol require a meticulous, sensitive, and multi-agency approach to ensure patient safety and legal compliance.[14, 15]

RP1, RC1 & RC2: Acute Airway Obstruction, Choking, and Stridor

Acute airway obstruction represents one of the most time-critical emergencies in clinical practice. The transition from partial to complete occlusion can occur within seconds, particularly in the pediatric population where the reserve is minimal and the anatomy is predisposed to rapid compromise.[16, 17, 18]

Definition and Classification

Airway obstruction is the partial or complete blockage of the respiratory conduit extending from the nares to the terminal bronchioles.[19, 20] It is classified anatomically into three primary regions:

• Supraglottic: Includes the nose, nasopharynx, and oropharynx down to the level of the epiglottis.[19, 21]
• Glottic/Laryngeal: Involves the vocal folds and the immediate laryngeal structures.[19, 21]
• Subglottic/Tracheal: Encompasses the region below the vocal cords, including the cricoid cartilage and the trachea.[21, 22]

Obstructions are further categorized as extrathoracic (above the suprasternal notch) or intrathoracic (below the suprasternal notch), a distinction that dictates the clinical sound (stridor vs. wheeze) based on the pressure dynamics of the respiratory cycle.[18, 23]

Epidemiology and Aetiology

The incidence of acute airway obstruction is markedly higher in children than in adults. In the UK, viral croup (laryngotracheobronchitis) remains the most common infectious cause in children, typically affecting those aged 6 months to 3 years.[16, 24] Epiglottitis, once common, is now rare in the UK due to the Haemophilus influenzae type b (Hib) vaccination program, although it still occurs in non-immunized individuals and can be caused by other pathogens.[17, 24]

In adults, the aetiology is more diverse, including:

• Foreign Body Aspiration (Choking): Common in both extremes of age and those with neurological impairment.[25]
• Angioedema: Often associated with ACE-inhibitor use or hereditary C1-esterase deficiency.[22, 26]
• Trauma: Laryngeal fractures or thermal injury from smoke inhalation.[24, 27]
• Malignancy: Obstructive tumors of the pharynx, larynx, or thyroid.[20, 28]

Clinically Relevant Anatomy

The larynx is the primary site of airway protection and phonation, consisting of nine cartilages held together by ligaments and intrinsic muscles.[19, 29] In infants, the larynx is located more cranially (at the level of C3–C4), and the epiglottis is broader and more "U-shaped" than in adults.[16, 17]

Feature	Pediatric Airway	Adult Airway
Shape	Funnel-shaped	Cylindrical
Narrowest Point	Cricoid Cartilage	Glottis (Vocal Cords)
Larynx Position	Higher (C3-C4)	Lower (C5-C6)
Tongue Size	Relatively large for oral cavity	Proportional

[16, 17, 29]

The sensory supply to the upper airway is derived from the vagus nerve (CN X). The superior laryngeal branch provides sensation above the vocal cords and motor supply to the cricothyroid muscle (the tensor of the cords).[29] The recurrent laryngeal nerve supplies all other intrinsic laryngeal muscles and provides sensation below the cords.[19, 29] Unilateral injury to the recurrent laryngeal nerve causes hoarseness, while bilateral injury can result in acute stridor and respiratory distress as the cricothyroid muscles act unopposed to adduct the cords.[29]

Clinical Assessment and Bedside Recognition

Assessment must follow a rapid ABCDE sequence. The presence of stridor—a loud, high-pitched, musical sound—is the hallmark of significant upper airway narrowing.[18, 21] Research indicates that the timing of stridor provides a positive likelihood ratio (PLR) for localizing the obstruction:

Clinical Sign	Timing	Level of Obstruction	Likelihood Ratio (PLR)
Inspiratory Stridor	Inspiration	Supraglottic / Laryngeal	5.90 [30]
Expiratory Stridor	Expiration	Intrathoracic / Bronchial	High for lower airway [18]
Biphasic Stridor	Both phases	Subglottic / Fixed lesion	High for mid-airway [18]
Stertor (Snoring)	Inspiration	Naso-/Oropharynx	N/A (low-pitched) [18]

Danger signs indicating imminent complete obstruction include the "tripod" position, drooling (inability to swallow secretions), cyanosis, and a silent chest despite significant respiratory effort.[18, 24, 26] The FEV1/PEFR ratio is a useful physiological index; a ratio $>10$ is highly suggestive of significant upper airway obstruction.[23, 31]

Management and Choking Algorithm (RC1)

Management focuses on maintaining patency and oxygenation. The RCUK 2021 choking algorithm provides a clear sequence:

1. Mild Obstruction: Victim is able to speak and cough. Action: Encourage coughing and monitor.[25, 32]
2. Severe Obstruction (Conscious): Victim cannot speak or cough effectively.
   • Adults/Children ($>1$ year): deliver 5 back blows followed by 5 abdominal thrusts.[25, 32, 33]
   • Infants ($<1$ year): deliver 5 back blows followed by 5 chest thrusts. Abdominal thrusts are contraindicated due to risk of organ damage.[33]
3. Unconscious Victim: Lower to the ground and start CPR immediately.[25, 32]

For infectious or inflammatory causes (Croup/Epiglottitis), nebulized adrenaline ($5\text{ml}$ of 1:1000) can provide rapid, temporary reduction in mucosal edema.[17, 34] Definitive airway management (intubation or surgical airway) should involve senior anesthetics and ENT surgical support.[29, 35]

RP2: Anaphylaxis and Anaphylactoid Reactions

Anaphylaxis is a severe, life-threatening, generalized hypersensitivity reaction characterized by rapidly developing airway, breathing, or circulation problems.[4, 34]

Epidemiology and Aetiology

The incidence of anaphylaxis is increasing in the UK, with at least 20,000 cases presenting to EDs annually.[4, 9, 36] Triggers are typically:

• Foods: Peanuts, tree nuts, cow's milk, and seafood are the most common in children.[36]
• Medicines: Antibiotics (beta-lactams) and NSAIDs.[36]
• Insect Stings: Wasps and bees.[26, 36]
• Idiopathic: In some cases, no clear trigger is identified.[26]

Pathophysiology and Pathology

Anaphylaxis is traditionally an IgE-mediated Type 1 hypersensitivity reaction. Exposure to an allergen causes mast cell and basophil degranulation, releasing histamine, leukotrienes, and prostaglandins.[9, 26] This leads to:

• Systemic Vasodilation: Causing distributive shock.[34]
• Increased Capillary Permeability: Up to $35\%$ of the intravascular volume can extravasate into the tissues within minutes.[26, 34]
• Bronchoconstriction and Mucosal Edema: Resulting in airway obstruction and respiratory failure.[26, 34]

Clinical Assessment (ABCDE Style)

Diagnosis is based on the rapid onset of symptoms following allergen exposure, usually involving the skin or mucosa ($>80\%$ of cases) plus ABC problems.[4, 34]

ABCDE Step	Signs and Symptoms	Pathophysiological Basis
Airway	Tongue/throat swelling, hoarse voice, stridor	Angioedema of upper airway
Breathing	Tachypnea, wheeze, cyanosis, fatigue	Bronchospasm and hypoxia
Circulation	Hypotension, tachycardia, pale/clammy skin	Vasodilation and fluid shift
Disability	Confusion, agitation, sense of "impending doom"	Cerebral hypoperfusion
Exposure	Urticaria, erythema, angioedema	Mast cell mediator release

[26, 34]

Emergency Treatment (RCUK 2021)

The 2021 guidelines emphasize early IM adrenaline and de-emphasize corticosteroids and antihistamines.[4, 37]

• IM Adrenaline: First-line treatment. Dose for adults: 500 micrograms ($0.5\text{ml}$ of 1:1000) IM in the anterolateral thigh. Repeat after 5 minutes if no improvement.[4, 34]
• Posture: The patient must remain supine with legs elevated. Sudden sitting or standing can cause fatal cardiovascular collapse.[4, 26]
• IV Fluids: For refractory hypotension, deliver an isotonic crystalloid bolus (Adults: 500–1000ml; Children: $20\text{ml/kg}$).[4, 5, 26]
• Oxygen: High-flow oxygen to achieve saturations of $94\text{–}98\%$.[34]

Refractory Anaphylaxis and Complications

Refractory anaphylaxis is defined as a failure of respiratory or cardiovascular symptoms to resolve after two appropriate doses of IM adrenaline.[4, 38] This mandates critical care escalation for a titrated IV adrenaline infusion, which should only be performed in a high-dependency setting by experienced clinicians due to the risk of lethal arrhythmias and hypertensive crises.[4, 26, 37]

Biphasic Reactions: These occur in up to $20\%$ of cases, where symptoms recur 1 to 72 hours after initial resolution. Risk factors include severe initial presentation or the need for multiple adrenaline doses.[4, 9]

RP3 & RC3: Cardiorespiratory Arrest and Organ Donation

Cardiorespiratory arrest represents the cessation of effective mechanical activity of the heart, resulting in the absence of a pulse and breathing.[39]

Epidemiology and Outcomes

In England, approximately 115,000 OHCAs occur annually, with bystander CPR provided in $60\text{–}73\%$ of cases.[39] 30-day survival for OHCA is approximately $10\%$, while IHCA survival to discharge is $26\%$ overall, rising to $53\%$ for shockable rhythms (VF/pVT).[39]

Management: The ALS Sequence

Resuscitation follows the RCUK 2021 ALS algorithm, prioritizing high-quality chest compressions and early defibrillation.[39, 40]

• Chest Compressions: 100–120 bpm, 5–6 cm depth, minimizing interruptions to ensure a coronary perfusion pressure $>15\text{ mmHg}$.[40]
• Drug Therapy: Adrenaline $1\text{mg}$ IV/IO after the 3rd shock and then every 3–5 minutes. Amiodarone $300\text{mg}$ after the 3rd shock.[37]
• Post-ROSC Care: Focuses on maintaining hemodynamic stability, managing temperature, and identifying the reversible cause.[39]

RC3: Organ Donation

Organ donation is now recognized as a standard component of end-of-life care in the ED. The strategy emphasizes a "whole hospital" approach.[6, 12]

Classification of Donors

1. Donation after Brain Death (DBD): Death is confirmed using neurological criteria. The patient must have an irreversible, non-survivable brain injury and be on mechanical ventilation.[13, 41]
2. Donation after Circulatory Death (DCD): Death is confirmed using cardio-respiratory criteria.
   • Controlled DCD: Occurs after the planned withdrawal of life-sustaining treatment (WLST).[6, 42, 43]
   • Uncontrolled DCD: retrieval of organs after a sudden, unexpected cardiac arrest where resuscitation is unsuccessful.[6, 42]

Timely Referral and Clinical Triggers

ED clinicians must refer a patient to the SNOD (0300 123 0873) if they meet any of the following clinical triggers:

• A GCS score of 4 or less that is not explained by sedation.[13, 41]
• The absence of one or more brainstem reflexes.[13, 41]
• A decision has been made to withdraw life-sustaining treatment.[13, 44]

Note: In England, the "opt-out" law (Max and Keira's Law) means that adults are presumed to have consented to donation unless they have recorded a decision to opt out, but family consultation remains essential.[41]

RP4: Major Trauma

Major trauma is a leading cause of death and disability in those under 45 in the UK. Care is organized through Regional Trauma Networks.[11, 45]

Definition and Risk Stratification

Major trauma is defined as an Injury Severity Score (ISS) $>15$. Patients are risk-stratified pre-hospital using triage tools to ensure they are directed to a Major Trauma Centre (MTC) rather than a Trauma Unit (TU) if their injuries require specialized surgical or radiological intervention.[11, 46]

Management: The ABCDE Sequence

The trauma primary survey emphasizes the control of catastrophic hemorrhage before airway management.[10, 47]

Step	Action	Critical Intervention
	Catastrophic Hemorrhage	Tourniquets, Haemostatic dressings, Pelvic binder [10, 47]
A	Airway + C-Spine	Jaw thrust, MILS (Manual In-Line Stabilisation) [22, 35]
B	Breathing	Needle decompression for tension pneumothorax [10, 47]
C	Circulation	Permissive hypotension, 1:1:1 Blood product ratio [10, 48]
D	Disability	GCS and Pupils; assess for basal skull fracture signs [27, 49]
E	Exposure	Log roll, maintain normothermia [14, 48]

Haemorrhage Control and the Lethal Triad

Resuscitation in trauma aims to prevent the "Lethal Triad": Hypothermia, Coagulopathy, and Acidosis. Permissive hypotension (maintaining a palpable radial pulse or MAP $\sim 65\text{ mmHg}$) is used until definitive surgical or radiological hemorrhage control is achieved.[10, 48] Tranexamic acid ($1\text{g}$ bolus then $1\text{g}$ infusion) should be given within 3 hours of injury.[10]

RP5: Respiratory Failure

Respiratory failure is defined as the inability of the respiratory system to maintain adequate gas exchange, resulting in hypoxia with or without hypercapnia.[50]

Classification

• Type 1 (Hypoxemic): $Pa{O}_2<8\text{ kPa}$ with a normal or low $PaC{O}_2$. Caused by V/Q mismatch or shunt (e.g., pneumonia, pulmonary edema).[50]
• Type 2 (Hypercapnic): $Pa{O}_2<8\text{ kPa}$ and $PaC{O}_2>6\text{ kPa}$. Caused by an inadequate "respiratory pump" (e.g., COPD, neuromuscular disease).[50, 51]

Management and NIV (BTS/ICS Guidance)

Non-Invasive Ventilation (NIV) is the standard treatment for acute hypercapnic respiratory failure (AHRF) secondary to COPD exacerbations.[52, 53]

• Target Saturations: $88\text{–}92\%$ for all patients at risk of hypercapnic failure.[52, 53, 54]
• Settings: Initial IPAP 10–12 cm $H_{2}O$ and EPAP 4–5 cm $H_{2}O$. IPAP is titrated upwards to reduce $PaC{O}_2$ and respiratory rate.[51, 52]
• Interface: A full-face mask is preferred initially for patient comfort and efficiency.[52, 54]

Contraindications to NIV:

• Respiratory arrest or severe multi-organ failure.[52]
• Facial trauma or recent upper GI surgery.[54]
• Uncontrolled agitation (though small doses of benzodiazepines or morphine can be considered to improve tolerance).[52]

RP6: Sepsis

The 2025 NICE update (NG253) provides a refined approach to sepsis, prioritizing clinical suspicion and the NEWS2 score for risk stratification.[5, 8]

Recognition and Risk Factors

Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection.[8] Vulnerability factors include age $>75$, immunocompromise, recent surgery ($<6$ weeks), and indwelling catheters.[5]

Risk Stratification using NEWS2

NICE NG253 mandates the use of NEWS2 in all acute healthcare settings for patients over 16.[5, 7]

NEWS2 Score	Risk Level	Clinical Action
$\ge$ 7	High Risk	Immediate senior review; "Sepsis Six" within 1 hour [5, 7]
5–6	Moderate Risk	Review within 1 hour; assess lactate for hypoperfusion [5]
1–4	Low Risk	Review within 4–6 hours; consider alternative diagnoses [5]

Management: The 2025 Protocols

1. Antimicrobials: High-risk patients must receive IV antibiotics within 1 hour.[5]
2. Fluid Resuscitation: Use a 250ml bolus of isotonic crystalloid over 15 minutes. Reassess after every infusion. Stop and seek senior help if $>1000\text{ml}$ is required without improvement.[5, 8, 48]
3. Lactate: Serial lactate measurements are essential to monitor the response to resuscitation. A lactate $>2.0\text{ mmol/L}$ despite fluid signifies high risk.[5, 55]
4. Source Control: Identification and surgical or radiological drainage of the infection source is as critical as pharmacological treatment.[5]

RP7: Shock

Shock is a state of systemic tissue hypoperfusion resulting in cellular hypoxia.[48]

Classification of Shock Types

Management depends on identifying the underlying pathophysiological mechanism.[48, 56]

Shock Type	Primary Abnormality	Examples	Bedside Ultrasound (RUSH)
Hypovolemic	$\downarrow$ Preload	Hemorrhage	Collapsed IVC, empty heart [56]
Distributive	$\downarrow$ SVR	Sepsis, Anaphylaxis	Hyperdynamic heart, wide IVC [56]
Obstructive	Barrier to Flow	Tamponade, PE	Pericardial effusion, RV strain [56]
Cardiogenic	$\downarrow$ Pump	MI, Myocarditis	Poor LV function, B-lines [56]

[47, 48, 56]

Clinical Assessment: The Shock Index (SI)

The SI ($HR/SBP$) is a sensitive early marker for shock. An SI $\ge$ 0.9 predicts significant physiological compromise even when blood pressure is "normal".[57] In the pediatric population, the presence of two or more clinical signs (altered mental status, $CRT>2\text{s}$, weak pulses, cold extremities) has a relative risk of 4.98 for organ dysfunction.[58]

VIP Resuscitation Strategy

• V (Ventilation): Optimize oxygen delivery. Mechanical ventilation reduces the work of breathing and myocardial oxygen demand.[48, 56]
• I (Infusion): Balanced crystalloids are preferred over colloids.[48]
• P (Pressors): Norepinephrine is the first-line vasopressor for both septic and cardiogenic shock.[48, 56]

RP8: Unconsciousness

The assessment of the unconscious patient focuses on protecting the brain from secondary insult (hypoxia and hypotension).[27]

The Glasgow Coma Scale (GCS)

The GCS provides an objective measure of impaired consciousness. A GCS $\le$ 8 typically necessitates definitive airway management.[27, 35, 49]

Head Injury and CT Criteria (NICE)

In the UK, the NICE head injury criteria determine the urgency of neuroimaging.[27, 35]

• Immediate CT (within 1 hour): GCS $<13$ on arrival, GCS $<15$ at 2 hours, focal neurology, signs of basal skull fracture, or post-traumatic seizure.[27, 35]
• Urgent CT (within 8 hours): Patients on anticoagulants (e.g., Warfarin, DOACs) or age $>65$ with loss of consciousness.[27, 35, 59]

RC4 & RC5: BRUE and the SUDIC Protocol

RC4: Brief Resolved Unexplained Event (BRUE)

A BRUE is an event in an infant ($<1$ year) that is sudden, brief, and now resolved.[14, 60]

Low-Risk Stratification: Infants can be managed in the outpatient setting if they are over 60 days old, were born $\ge 32$ weeks gestation, the event lasted $<1$ minute, and it was the first event.[14, 60] A single ECG and bedside glucose are the only recommended investigations for low-risk infants.[60]

RC5: SUDIC Protocol

SUDIC refers to any sudden unexpected death in a child ($<18$ years).[15]

Immediate ED Requirements:

• Notification: Alert the on-call Paediatrician and Police Senior Investigating Officer (SIO).[15]
• Preservation of Evidence: Do not remove any medical equipment (ET tubes, IV lines). ET tubes must be confirmed in situ by a second clinician before death is confirmed.[15]
• Investigations: A "SUDIC Set" including blood cultures, toxicology (1–2ml fluoride oxalate), and a metabolic screen (Guthrie card) must be collected promptly.[15]
• Legal: In England, the death must be reported to the Coroner.[15]

EPIC EHR Documentation Template Structure

Effective documentation for RESUS presentations should prioritize clarity of thought and the capture of time-critical data points.[61, 62]

Header and Triage Data

• Time of Arrival: @ARRTIME@
• Chief Complaint: @CHIEFCOMPLAINT@
• Initial NEWS2: @NEWS2@

Physical Examination (NoteWriter Macros)

• Airway: [ ] Patent [ ] Obstructed [ ] Assisted with
• Breathing: [ ] Symmetric chest rise [ ] Accessory muscle use [ ] Stridor [ ] Wheeze
• Circulation: [ ] CRT < 2s [ ] CRT > 2s [ ] Radial pulse present [ ] Monitor rhythm:
• Disability: GCS: E__ V__ M__ Total: __ Pupils: [ ] PEARL [ ] Fixed/Dilated

Medical Decision Making (MDM) Smart Block

• Clinical Reasoning: Narrative explaining the synthesis of history, vitals, and initial response to treatment (e.g., "The patient's initial Shock Index of 1.1 improved to 0.7 following a 250ml bolus, suggesting fluid responsiveness but necessitating close monitoring for sepsis vs occult hemorrhage").[62, 63, 64]
• Sepsis Screening: [ ] Sepsis Six initiated at[ ] High risk criteria met.[63]
• Consultant Review: [ ] Case discussed with [Name] ST3/Consultant at.

Disposition and Follow-up

• Final Decision: [ ] Admit to ICU/HDU [ ] Transfer to MTC [ ] Discharge with Safety Netting.[63, 64]
• Discharge Instructions: .ANAPHYLAXISFOLLOWUP (Inserts instructions for AAI use and allergy referral).[36, 65]

Mnemonics and Learning Aids

1. "VIP" for Shock: Ventilation, Infusion, Pressors.[56]
2. "I-GRAB" for Sepsis 2025 (Initial Assessment): Identify source, Grade risk (NEWS2), Resuscitate (250ml bolus), Antibiotics (within 1 hr), Blood tests (Lactate).[5]
3. "TRACHY" for Airway Risk: Tumor, Reconstruction, Anatomy, Coexisting conditions, History of radiation, Laterality of neck dissection.[28]
4. "C-A-B-D-E" for Trauma: Catastrophic hemorrhage, Airway, Breathing, Circulation, Disability, Exposure.[10]

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