PHEM curriculum unit 2.11 · Theme 2: Providing Pre-hospital Emergency Medical Care
The DipIMC is blueprinted against phase 1 of the UK Pre-hospital Emergency Medicine (PHEM) curriculum. This page covers unit 2.11, Manage elderly patients in the pre-hospital environment.
Below are 3 free practice questions from the DipIMC.Ninja bank, in the Part A single best answer format. Every answer names the textbook page, guideline or statute it was written from, so you can check it rather than take it on trust. The bank holds 9 questions on this unit.
Question 1 · Medical & Resuscitation · Moderate
An 86-year-old woman weighing about 45 kg has a suspected fractured neck of femur after a fall at home and is in severe pain (score 9 of 10). She is frail but alert, blood pressure 132/80, respiratory rate 16, and intravenous (IV) access has been obtained. Applying the JRCALC morphine guidance, which morphine regimen is most appropriate?
A10 mg slow IV, then 2 mg every 5 minutes to a maximum of 20 mg
B1–2 mg slow IV, then 2 mg every 5 minutes to a maximum of 10 mg
C5 mg intramuscular, repeated after 60 minutes to a maximum of 10 mg
D4.5 mg slow IV (100 micrograms/kg), once more to a maximum of 9 mg
E2.5 mg subcutaneous, any repeat only on senior clinical advice
Show answer
Answer: B
1–2 mg slow IV, then 2 mg every 5 minutes to a maximum of 10 mg
JRCALC's intravenous morphine table gives an adult weighing less than 50 kg an initial dose of 2 mg, repeated in 2 mg doses at 5-minute intervals to a maximum of 10 mg, rather than the 10 mg initial dose and 20 mg maximum for adults of 50 kg or more; it adds that smaller initial doses, for example 1 mg, should be considered for frail and older patients, who are more susceptible to complications. Morphine is diluted to 1 mg/ml and given by slow injection at about 2 mg per minute, with the patient observed for at least 5 minutes before any repeat, alongside pain-score monitoring and consideration of an antiemetic. The intramuscular row for an adult under 50 kg (5 mg, repeat after 60 minutes, maximum 10 mg) is for when intravenous or intraosseous access is not available, because absorption by that route is variable in trauma and shock; she has a cannula. 100 micrograms/kg with a maximum of 200 micrograms/kg is the children's regimen. The 2.5 mg subcutaneous dose with repeats only on senior advice is the end-of-life table for opioid-naive adults, which does not apply to acute trauma pain. ABC of Prehospital Emergency Medicine adds the principle that all drug doses in older people take account of weight, physiological age and likely impairment.
Where this comes from
JRCALC Clinical Guidelines — Morphine sulfateJRCALC / AACE·Table 1 IV/IO (not end of life)“Morphine sulfate — Table 1 IV/IO: adult <50 kg row”
JRCALC Clinical Guidelines — Morphine sulfateJRCALC / AACE·Dosage and administration: adults“Morphine sulfate — dosage and administration: smaller initial doses for frail or older patients”
JRCALC Clinical Guidelines — Morphine sulfateJRCALC / AACE·Table 1 IV/IO (not end of life)“Morphine sulfate — Tables 1–2 (not end of life): adult ≥50 kg rows”
JRCALC Clinical Guidelines — Morphine sulfateJRCALC / AACE·Table 2 SC/IM (not end of life)“Morphine sulfate — Table 2 SC/IM: adult <50 kg row”
JRCALC Clinical Guidelines — Morphine sulfateJRCALC / AACE·Dosage and administration: children“Morphine sulfate — dosage and administration: children 100 micrograms/kg”
JRCALC Clinical Guidelines — Morphine sulfateJRCALC / AACE·Table 4 pain end of life SC/IM“Morphine sulfate — Table 4 end of life SC/IM: opioid naive row”
ABC of Prehospital Emergency Medicinep. 167Ch. 30 Care of Special Groups: The Elderly Patient · Appropriate drug doses“taking into account the patients weight, likely physiological age and potential impairment”
med-091 · Medical & Resuscitation · Medical · Moderate · v3
Question 2 · Medical & Resuscitation · Easy
A 79-year-old man with Parkinson's disease is conveyed to hospital after a fall. On arrival the crew are told there will be a two-hour wait to hand over. His co-beneldopa is due in 20 minutes and his wife has brought his dosette box. Which of the following is the most appropriate action?
AWithhold the dose until the emergency department doctor has reviewed him and prescribed it
BLeave the dosette box with him and mention the dose timing at the eventual verbal handover
CSend the dosette box home with his wife and let the department supply his medication
DRecord the missed dose on the patient report form and ask his family doctor to review it
EFlag to the receiving team now that his time-critical Parkinson's dose is due in 20 minutes
Show answer
Answer: E
Flag to the receiving team now that his time-critical Parkinson's dose is due in 20 minutes
JRCALC's medicines overview carries the AACE and Royal College of Emergency Medicine 'MISSED' list of time-critical medicines: Movement disorders (Parkinson's and myasthenia drugs), Immunomodulators including human immunodeficiency virus (HIV) medicines, Sugar (diabetes medication), Steroids for Addison's and adrenal insufficiency, Epilepsy drugs, and direct oral anticoagulants (DOACs) and warfarin. It states that time-critical medicines should not be missed or omitted unless there is a valid clinical or safety reason discussed with a clinician, that the patient's medicines should be taken to hospital, that patients on time-critical medicines who are delayed on an ambulance should be flagged to the receiving team so a decision is made about giving the dose, and that in Parkinson's even a delay of 30 minutes can be harmful. Waiting two hours for a formal review, or mentioning the timing only at the eventual handover, lets the dose pass; sending the medicines home removes the supply the guidance says to bring to hospital; recording a missed dose accepts the harm rather than preventing it. Be alert also to patients who have already missed doses because of a long lie after a fall or because they were told to take nothing by mouth. Metoclopramide, which JRCALC says to avoid in Parkinson's disease, is a related trap.
Where this comes from
JRCALC Clinical Guidelines — Medicines overviewJRCALC / AACE·3. Time critical medicines (MISSED)“Medicines overview — section 3, time critical medicines (MISSED)”
med-092 · Medical & Resuscitation · Medical · Easy · v3
Question 3 · Trauma · Moderate
An 81-year-old woman who takes apixaban for atrial fibrillation trips on a kerb and strikes the back of her head on the pavement. Bystanders say she was unresponsive for about 30 seconds. When the ambulance arrives she is GCS 15 with a small occipital haematoma, has not vomited, and has a normal neurological examination. She would like to go home. Applying NICE NG232, which of the following is the most appropriate plan?
ADischarge at scene with written head injury advice and a responsible adult at home
BRefer to her general practitioner for a face-to-face review next day, with safety-netting
CConvey to the emergency department for a CT head scan within 1 hour of arrival
DConvey to the emergency department for a CT head scan within 8 hours of the injury
ELeave her at home under observation, conveying for CT only if she vomits or her GCS falls
Show answer
Answer: D
Convey to the emergency department for a CT head scan within 8 hours of the injury
NICE NG232 recommendation 1.5.9 says that for people 16 and over who have had some loss of consciousness or amnesia since the injury, a CT head scan should be done within 8 hours of the head injury if they have any of: age 65 or over, any current bleeding or clotting disorder, a dangerous mechanism of injury, or more than 30 minutes' retrograde amnesia. She is 81 and was unresponsive for about 30 seconds, so she meets 1.5.9 outright. Recommendation 1.5.13 separately says to consider CT within 8 hours for people on anticoagulant or antiplatelet treatment (excluding aspirin monotherapy) who have no other indication. The 1-hour criteria in recommendation 1.5.8 (among them a low or falling GCS, suspected skull fracture, post-traumatic seizure, focal deficit and more than one episode of vomiting) are absent, so a 1-hour scan is not the NICE timeframe here. Discharge at scene, general practitioner (GP) review or observation at home all leave an older patient with a loss of consciousness unscanned. ABC of Prehospital Emergency Medicine lists late presentation of significant head injury among the complicating factors in older trauma patients.
ABC of Prehospital Emergency Medicinep. 167Ch. 30 Care of Special Groups: The Elderly Patient · Trauma in elderly people — Table 30.2“Late presentation of significant head injury”