Surgery, Trauma, Emergency Medicine and Anaesthesia for PRES Level 2

Scope and time budget

Twelve in every 100 questions makes this one of the four largest blocks in our split, and it is the domain where the first five minutes of care decide the outcome. Questions tend to be framed around the sick patient in front of you: what do you do first, what do you order, who do you call. Toxicology belongs here for our purposes. The sample paper includes paracetamol, lithium and other poisoning scenarios, and they are decided by time since ingestion and a few key results.

What is tested

• Abdominal surgery. Acute abdomen and appendicitis, intestinal obstruction and hernias, cholecystitis and cholangitis, anorectal disease (haemorrhoids, fissure, abscess).
• Breast, thyroid and neck. Mastitis, benign lumps and cancer, thyroid, parotid and neck lumps.
• Vascular. Acute limb ischaemia and abdominal aortic aneurysm.
• Trauma. Major trauma with the primary survey and haemorrhage control, head, neck and spinal injury, fractures and compartment syndrome, burns and wounds.
• Resuscitation and critical care. Sepsis recognition and management, shock and fluid resuscitation, anaphylaxis, hypothermia and heat illness.
• Poisoning. Paracetamol, salicylate, lithium and carbon monoxide.
• Peri-operative care. Pre-operative assessment, post-operative complications, analgesia including in kidney impairment, and opioids.
• Anaesthesia and blood. Airway management, local anaesthetic toxicity, blood transfusion and transfusion reactions.

Local guideline points

• Sepsis. The NCEC publishes a national clinical guideline on sepsis. Learn recognition, early antibiotics and fluid logic. We have not quoted figures from it here, so take any thresholds from the guideline itself.
• Peri-operative care. NCEC and national programme guidance cover perioperative care, including diabetes, anticoagulants and pre-operative assessment.
• Trauma. The primary survey follows the ATLS approach: airway with spine protection, breathing, circulation, disability, exposure.
• Consent and emergencies. Treating an unconscious patient or a patient who lacks capacity falls under the Medical Council's Guide and the 2015 capacity Act. See professionalism, ethics, law and prescribing.
• Poisons. Irish clinicians use the National Poisons Information Centre. Know that specialist advice is part of management.

How the questions are framed

Surgical stems often give you a patient in pain and a handful of observations, then ask for the most likely diagnosis or the next step. Trauma stems follow the primary survey, so the answer is usually the first thing to fix in the order. Poisoning stems give a drug, a dose or time, and a level, and ask whether to treat. Peri-operative stems ask what to do with a patient's regular drugs before surgery.

The deciding detail is often physiological: low blood pressure, rising lactate, rigid abdomen, absent pulse in a limb or a falling conscious level. Find it first.

Three typical traps

1. Investigating before resuscitating. An unstable patient needs immediate resuscitation. Imaging comes after.
2. Treating paracetamol overdose by the clock alone. Timing matters, but so do unknown time of ingestion and staggered ingestion. Read what the stem says and follow the guideline logic.
3. Stopping or continuing the wrong regular drug before surgery. Anticoagulants, diabetes drugs and antihypertensives each have their own rule. A stem that mentions a drug list is testing this.

How to revise it

1. Memorise the primary survey and practise saying what you do at each letter for different scenarios.
2. Build an acute abdomen table with pain pattern, signs, first test and first action.
3. Write a poisoning sheet with the drug, the toxic effect, the key test and the antidote or treatment.
4. Learn sepsis and shock together, since they share the first hour.
5. Practise ethics-in-emergency cases such as an unconscious patient with no relatives.

This domain overlaps with cardiovascular and respiratory for arrest and shock, with GI and haematology for bleeding, and with paediatrics for the injured child.

Subtopic notes: the decision behind each topic

• Acute abdomen. Localise the pain, find the sign that tells you the abdomen needs surgery and decide what to do while waiting.
• Obstruction and hernias. Features of strangulation, imaging and the place of conservative management.
• Biliary disease. Separate colic, cholecystitis and cholangitis by fever, jaundice and tests, and choose the timing of intervention.
• Breast, thyroid and neck lumps. Triple assessment for the breast, and the features that make a neck lump suspicious.
• Anorectal disease. The common causes of rectal bleeding and pain, and the red flags.
• Vascular emergencies. The six features of an acutely ischaemic limb and the signs of a leaking aneurysm.
• Major trauma. The order of the primary survey, control of bleeding and the indications for urgent imaging.
• Fractures and compartment syndrome. Neurovascular checks, pain out of proportion, and the urgent action.
• Burns. Estimating the area, fluid replacement and referral criteria.
• Sepsis and shock. Recognition, antibiotics, fluids and escalation within the first hour.
• Anaphylaxis. Intramuscular adrenaline first, then adjuncts, and the observation period.
• Poisoning. Paracetamol, salicylate, lithium and carbon monoxide: when to treat, how and what to monitor.
• Peri-operative care. Assessing risk, managing regular drugs and spotting complications early.
• Analgesia, airway and transfusion. Choosing analgesia in kidney impairment, recognising local anaesthetic toxicity, and the signs of a transfusion reaction.

Revising across two weeks

Use the first week for emergencies: trauma, sepsis, shock, anaphylaxis and poisoning. Use the second for elective and acute surgery and for peri-operative care. Each day, take one scenario and say out loud the first five actions in order. Add ten questions at the end of each session. In the last three days, take a timed block that mixes surgery, cardiology and electrolyte questions, since an unwell surgical patient rarely has only one problem.