Executive Summary

This briefing document provides a comprehensive guide for Acute Care Common Stem (ACCS) trainees in Emergency Medicine to achieve excellence in the learning outcome of providing safe basic anaesthetic care and procedural sedation. Mastery extends beyond pharmacology to encompass meticulous preparation, environmental optimization, airway stewardship, and human factors. Excellence is defined by proactive preparation, creating a safe environment before the patient is present.

Key principles for safe practice include a profound understanding of sedative agents (Propofol, Ketamine, Midazolam, Fentanyl), their physiological profiles, and potential complications. Adherence to national guidelines, such as those from the Royal College of Emergency Medicine (RCEM) and the Academy of Medical Royal Colleges (AoMRC), is fundamental, treating procedural sedation with the same vigilance as general anaesthesia. The procedural framework is structured into five phases: Knowledge Foundation, Preparation, Execution, RSI Assistance, and Recovery.

Essential steps for every procedure involve a formal airway assessment using the LEMON mnemonic, a thorough equipment check using the SOAP-ME checklist, and a structured team brief. Capnography is mandatory for breath-by-breath ventilation analysis, as pulse oximetry has a significant lag time. Pre-oxygenation via high-flow nasal cannulae (apnoeic oxygenation) is the most critical step to prevent desaturation. Post-procedure, vigilant 1:1 monitoring must continue until the patient returns to their baseline, as a significant number of airway complications occur during recovery. Evidence for this competency is gathered through Direct Observation of Procedural Skills (DOPS), Case-Based Discussions (CbD), simulation, and a comprehensive logbook.

This briefing synthesizes key guidance and curriculum requirements for performing invasive and high-risk procedures within the Emergency Department (ED). The Royal College of Emergency Medicine (RCEM) has issued a Best Practice Guideline (October 2023) to provide pragmatic recommendations for ED clinicians, adapting the national NatSSIPs 2 standards for the unique, time-critical environment of emergency medicine (1).

The core principles for all invasive procedures revolve around a triad of safety checks: obtaining patient consent (or acting in their best interest), independent verification of the procedure site by two practitioners (one of whom must be ST4 or above), and conducting a team brief to ensure all members understand the plan. The use of checklists, such as the modified 'NatSSIPs Eight', is strongly encouraged to ensure auditable compliance and account for significant risks. In time-critical emergencies where full compliance is not possible, clinicians must document their rationale.

In parallel, the RCEM curriculum's Specialty Learning Outcome 6 (SLO6) defines the skillset required for EM physicians to proficiently deliver key life- and limb-saving procedural skills. It outlines a structured progression of learning and entrustment from ACCS to Intermediate and Higher training. Proficiency is developed through a combination of eLearning, simulated practice, and observed clinical performance, with assessment via tools like DOPS and logbooks. This ensures clinicians are prepared for both common and rarely performed critical procedures.

Executive Summary: Transitioning from Exposure to Entrustment

This report details a best-practice, longitudinal roadmap designed for Emergency Medicine (EM) doctors in training to achieve Specialty Learning Outcome (SLO) 6: Deliver Key Procedural Skills, adhering rigorously to the RCEM 2021 curriculum and its assessment frameworks. The foundational strategic shift articulated within the 2021 curriculum is the elevation of assessed quality—measured by the RCEM Universal Entrustment Scale—over mere quantity or procedural volume.[1, 2]The methodology emphasizes the critical need for Simulation-Based Mastery Learning (SBML), formalized through adoption of a systematic progression model such as the OASIS framework, to ensure structured, deliberate practice, the attainment of proficiency milestones, and the integration of crucial non-technical skills.[3, 4] A specific focus is placed on Point of Care Ultrasound (PoCUS), where the curriculum mandates explicit modality sign-offs and clarifies that verified clinical competence (Entrustment Level) is the primary determinant of progression, taking precedence over indicative scan volume.[2] Successful implementation of this roadmap requires strict adherence to assessment protocols, including the correct delineation between technical assessment (Direct Observation of Procedural Skills, DOPS, filed in SLO 6) and cognitive/contextual assessment (Case-based Discussions, CbDs, or Acute Care Assessment Tools, ACATs, filed in SLO 1).[5, 6]

Executive Summary: The Strategic Imperative of PEM Sub-Specialty Accreditation

Paediatric Emergency Medicine (PEM) is formally recognised as a sub-specialty of both Emergency Medicine (EM) and Paediatrics in the United Kingdom.[1, 2] For Emergency Medicine trainees, pursuing PEM sub-specialty accreditation represents a critical professional choice that significantly enhances clinical capability and career marketability. The successful completion of the stipulated training programme culminates in the Royal College of Emergency Medicine (RCEM) recommending the doctor to the General Medical Council (GMC) for inclusion on the Specialist Register, noting PEM as a sub-specialty alongside EM.[1]

Hand injuries account for approximately 20% of all Emergency Department (ED) attendances in the UK. The complexity of hand anatomy means that seemingly minor surface wounds can mask debilitating injuries to tendons, nerves, or joints.

Critical Takeaways:

• Position of Injury: Wounds must be explored through the full range of motion (ROM) to detect retracted tendon injuries.

• Fight Bites: Any laceration over the metacarpal head (knuckle) is a human bite until proven otherwise. These require aggressive washout and antibiotics due to high risk of septic arthritis.

• Rotational Deformity: Scissoring of fingers on flexion is the hallmark of malrotated metacarpal/phalangeal fractures and requires reduction/fixation.

• Kanavel’s Signs: Recognition of these four signs is vital for diagnosing flexor tenosynovitis, a surgical emergency.

The Royal College of Emergency Medicine (RCEM) Specialty Learning Outcome 5 (SLO 5) defines the required competence for Emergency Medicine trainees in Paediatric Emergency Medicine (PEM). This outcome is comprehensive, demanding expertise in the care of children of all ages, across all stages of development, and explicitly including those with complex medical and social needs.[1] Achieving SLO 5 is not simply about clinical proficiency but requires integration across professional domains: evaluation, investigation, decision-making, safeguarding, resuscitation, and empathetic care for families and loved ones attending the Emergency Department (ED) [1].

Effective teamwork within high-acuity environments, such as the Emergency Department (ED) caring for critically unwell patients, necessitates a paradigm shift away from traditional, hierarchical models of interaction. While leadership is often lauded, organizational reliability critically depends on the quality of followership. The common societal perception often portrays followers as passive, weak, or unmotivated individuals. In the healthcare context, this stereotype is not only misleading but poses a significant safety threat. A comprehensive strategy for improving teamwork requires the professional rebranding of followership from a subordinate role to that of an "Engaged Sentinel"—an essential, proactive safety layer.

Executive Summary

This document provides a comprehensive briefing on the assessment and management of "Silver Trauma"—significant injury in patients aged 65 and over. This patient demographic now constitutes the majority of major trauma cases in the UK, frequently presenting after low-energy falls (<2 metres). The core challenge lies in their diminished physiological reserve, multiple comorbidities, and polypharmacy, which blunt the typical signs of severe injury, leading to systemic under-triage, delayed diagnosis, and disproportionately high morbidity and mortality.

The fundamental principle of care is a shift from an injury-centric to a patient-centric, holistic model. Key best practices include mandatory triage modification with early senior clinician involvement, universal screening for frailty (Clinical Frailty Score) and delirium (4AT test), and the adoption of modified physiological thresholds for shock. A Systolic Blood Pressure < 110 mmHg, a Heart Rate > 90 bpm, or a venous lactate > 2.5 mmol/L are critical indicators of occult hypoperfusion requiring aggressive intervention.

Management requires a multidisciplinary team (MDT) approach initiated in the Emergency Department, incorporating geriatric principles into the standard trauma survey. This includes proactive management of geriatric syndromes (summarised by the PINCHME mnemonic: Pain, Infection, Nutrition, Constipation, Hydration, Medication, Environment), optimised analgesia with a focus on regional blocks, and a low threshold for comprehensive CT imaging. The use of structured screening tools, such as the 'Shake, Rattle, Rock and Roll' assessment, is advocated to detect occult truncal and head injuries. This integrated pathway aims to address the patient's intrinsic vulnerability concurrently with their acute injuries, thereby improving outcomes and ensuring they receive safe, high-quality, and dignified care.