OSCE Curriculum Guide

Presenting complaint: Use SOCRATES — Site (epigastric, RIF, LIF, suprapubic, generalised), Onset (sudden → perforation/rupture vs gradual → obstruction/inflammation), Character (colicky → obstruction; constant → peritonitis), Radiation (shoulder tip → diaphragmatic irritation; loin to groin → renal colic; back → pancreatitis/AAA), Associated symptoms (vomiting, bowel habit change, urinary symptoms, PV bleeding), Timeline, Exacerbating/relieving, Severity.

Systemic enquiry: Fever, rigors, weight loss, appetite change, jaundice. Ask specifically about melaena and haematemesis. In females always ask LMP and possibility of pregnancy.

Past medical/surgical history: Previous abdominal surgery (adhesions → SBO), gallstones, inflammatory bowel disease, AAA screening, peptic ulcer disease.

Medications: NSAIDs (gastritis/perforation), anticoagulants (bleeding risk), steroids (mask peritonitis), opioids (constipation).

Social: Alcohol intake (pancreatitis, liver disease), travel (tropical infection), occupation, diet.

Onset: Thunderclap (peak within seconds) = subarachnoid haemorrhage until proven otherwise. Gradual onset = more likely primary headache or raised ICP if progressive over days/weeks.

Character & location: Unilateral throbbing + photophobia + nausea = migraine. Band-like bilateral pressure = tension-type. Unilateral with autonomic features (lacrimation, rhinorrhoea) = cluster headache. Whole head with morning predominance + worse on coughing/straining = raised ICP.

Red flags ("SNOOP"): Systemic symptoms (fever, weight loss, rash); Neurological deficit; Onset — sudden/thunderclap; Older age (>50 → GCA); Positional/progressive/papilloedema/pregnancy.

Temporal arteritis screen (if >50): Jaw claudication, scalp tenderness, visual disturbance, proximal muscle stiffness (PMR).

Meningism: Neck stiffness, photophobia, rash, fever.

Medications: Medication overuse headache (analgesics >15 days/month or triptans >10 days/month). Anticoagulants (bleeding risk).

Onset and timeline: Acute (minutes) → pneumothorax, PE, anaphylaxis, acute asthma. Subacute (hours/days) → pneumonia, HF exacerbation, COPD. Chronic/progressive → HF, COPD, ILD, anaemia.

Associated symptoms: Chest pain (PE, ACS, pneumonia), cough (productive → infection; dry → PE, HF, ILD), haemoptysis (PE, TB, lung Ca), wheeze (asthma, COPD), orthopnoea & PND (HF), leg swelling (DVT→PE, HF), fever (pneumonia, sepsis).

PE risk factors: Recent surgery, immobility, long-haul travel, malignancy, OCP/HRT, previous DVT/PE, pregnancy.

Cardiac history: Known IHD, valvular disease, AF. Exercise tolerance — quantify (flights of stairs, walking distance). NYHA class.

Respiratory history: Known asthma (previous ITU = severity marker), COPD (home O₂, NIV), ILD, occupational exposures.

Smoking: Quantify in pack-years. Include vaping.

Details of exposure: Device type (hollow bore = highest risk). Body fluid (blood = highest risk). Depth of injury. Was it used on a patient?

Source patient: Known HIV, Hep B, Hep C status. Can source be tested (with consent)? High-risk groups — IVDU, known BBV+, unknown source.

Recipient details: Hep B vaccination status and response (anti-HBs titre). Current HIV status. Pregnancy status in females.

First aid already given: Encouraged bleeding, washed with soap and running water, covered. Do NOT suck the wound.

HIV PEP: Within 72 hours (ideally within 1 hour). Risk ≈ 0.3% from percutaneous injury. Current regimen: Truvada + raltegravir (28 days). Follow-up serology at 6 weeks, 3 months, 6 months.

Hepatitis B: If recipient vaccinated with good response → reassurance. If non-responder/unvaccinated + source HBsAg positive → HBIG within 48 hours + accelerated vaccination.

Hepatitis C: No PEP available. Baseline HCV RNA, repeat at 6 and 12 weeks. Refer hepatology if positive.

Red flags — must ask all: Cauda equina symptoms (urinary retention/incontinence, faecal incontinence, saddle anaesthesia, bilateral sciatica); age >50 or <20 with new back pain; history of cancer (breast, lung, prostate, renal, thyroid → bony mets); weight loss; fever/rigors (discitis, epidural abscess); progressive neuro deficit; pain at rest / night pain; IVDU or immunosuppression; recent trauma; thoracic pain.

Neurological symptoms: Distribution of radiculopathy — L4 (anterior thigh/knee), L5 (lateral leg/dorsum foot — foot drop), S1 (posterior calf/lateral foot — absent ankle jerk). Ask about weakness, numbness, tingling.

Functional impact: Can the patient walk? Sit? Work? Sleep? Mobility aids. Home support.

Presenting complaint in patient's own words. Use open questions: "Can you tell me what has been happening?"

HPC: Timeline, precipitants, previous episodes. Screen mood (low mood, anhedonia, sleep, appetite, energy, concentration, guilt, hopelessness). Screen psychosis (hallucinations, delusions, thought disorder). Screen anxiety.

Risk assessment (crucial): Suicidal ideation — ask directly: "Have you had thoughts of ending your life?" If yes: plan, means, intent, timeline, access to means, protective factors. Previous self-harm — method, frequency, escalation. Risk to others. Risk from others.

Past psychiatric history: Previous diagnoses, admissions (voluntary or sectioned), crisis team, CMHT.

Medications: Psychotropic medications and compliance. Previous trials. Recreational drugs and alcohol (quantify).

Social: Living situation, support network, employment, dependants (safeguarding if children at home), forensic history.

Introduction: Wash hands, introduce, confirm identity, explain examination, consent, expose, chaperone.

Inspection: Posture, gait, muscle wasting, scoliosis (structural vs postural), kyphosis, skin (scars, tuft of hair = spina bifida occulta).

Palpation: Midline spinous processes — tenderness. Paraspinal muscles — spasm. SI joints.

Movement: Flexion (modified Schober's test — should increase ≥5cm; reduced in ankylosing spondylitis). Extension. Lateral flexion. Rotation.

Neurological — lower limb: Power (hip flexion L1/2, knee extension L3/4, ankle dorsiflexion L4/5, big toe extension L5, plantarflexion S1/2). Sensation (dermatomes). Reflexes (knee L3/4, ankle S1/2, plantar). SLR (Lasègue's — true positive = radicular pain below knee at <60°).

Cauda equina screen: Perianal sensation (S2-4), anal tone (with consent). Ask about urinary symptoms.

Look: Swelling, erythema, deformity, skin changes (psoriatic plaques, tophi), muscle wasting, scars.

Feel: Temperature (dorsum of hand, compare sides), tenderness (joint line, bony landmarks), effusion (patella tap for knee), crepitus.

Move: Active ROM first, then passive. Document in degrees. Compare sides. Assess instability.

Special tests: Shoulder — Hawkins, Neer, empty can. Knee — McMurray (meniscus), Lachman (ACL). Hip — Thomas test, FABER/FADIR. Ankle — anterior drawer, Ottawa rules.

Functional assessment: Fine motor tasks for hands. Gait for lower limb. Always assess neurovascular status distally.

Inspection: Wasting (T1 = small muscles, median = thenar, ulnar = hypothenar), fasciculations, tremor.

Tone: Spasticity (UMN — "clasp-knife") vs rigidity (extrapyramidal — "lead-pipe" / "cogwheel").

Power (MRC 0–5): Shoulder abduction C5, elbow flexion C5/6, extension C7, wrist extension C6/7, finger extension C7, finger abduction T1, thumb opposition (median).

Reflexes: Biceps C5/6, supinator C5/6, triceps C7.

Sensation: Light touch, pin prick, proprioception. Dermatomes C5-T1.

Coordination: Finger-nose test, dysdiadochokinesis.

Gait: Observe — foot drop (steppage), spastic (scissoring), cerebellar (broad-based), Parkinsonian (shuffling). Romberg's test.

Power: Hip flexion L1/2, extension L5/S1, knee extension L3/4, flexion L5/S1, ankle dorsiflexion L4/5, plantarflexion S1/2, big toe extension L5.

Reflexes: Knee L3/4, ankle S1/2, plantar (Babinski — upgoing = UMN).

Preparation: Patient supine, one pillow, arms by sides, exposed from xiphisternum to pubic symphysis.

Inspection: General — cachexia, jaundice, pallor, chronic liver disease signs (spider naevi, gynaecomastia, palmar erythema, caput medusae). Abdomen — distension (5 F's: Fat, Fluid, Flatus, Faeces, Foetus), scars, visible peristalsis, stomas, hernial orifices.

Palpation: Ask about pain first — start away from it. Light then deep, all 9 regions. Guarding (voluntary vs involuntary), rebound. Organomegaly: liver (start RIF, up on inspiration), spleen (start RIF), kidneys (ballotable). Aorta — expansile pulsation.

Percussion: Shifting dullness (ascites), liver span (6–12cm), splenic dullness.

Auscultation: Bowel sounds (absent = ileus; tinkling = obstruction). Bruits over aorta and renal arteries.

Complete: Offer hernial orifices, external genitalia, PR, urine dip, observation chart.

Core symptoms (need ≥2 for diagnosis): Persistent low mood (most of the day, ≥2 weeks), anhedonia, fatigue.

Additional: Reduced concentration, self-esteem, guilt, pessimism, sleep disturbance (early morning waking), appetite change, suicidal ideas.

Severity: Mild (2 core + 2 additional, can function), Moderate (2 core + 3-4 additional), Severe (3 core + ≥4 additional ± psychotic features).

Screen for bipolarity: Always ask about elevated mood episodes, increased energy, reduced sleep need, grandiosity. Missing bipolar → harmful treatment.

Risk assessment: Current suicidal ideation, plan, intent, means, access, protective factors.

Organic causes: Hypothyroidism, anaemia, malignancy, substance misuse, medications.

Medical assessment first: ABC, treat medical emergency (paracetamol → NAC if indicated). NICE CG16: every self-harm presentation needs psychosocial assessment.

Details of the act: What substance/method? How much? When? Alcohol? Planned or impulsive? Precautions against discovery? Did they seek help or were found?

Intent: Did they intend to die? What did they expect? How do they feel about surviving? Would they do it again? Current ideation?

Circumstances: Precipitant — relationship breakdown, financial stress, bereavement, psychosis, substance misuse.

Background: Previous self-harm (frequency, escalation), psychiatric history, support, social situation, dependants.

Protective factors: Reasons for living, children, social support, engagement with services, future plans, faith.

Disposition: Safe to discharge? Psychiatric admission? Crisis team? Safety plan (remove means, crisis numbers, 48h follow-up).

1. Presumption of capacity — every adult has capacity unless proven otherwise.

2. Supported decision-making — all practicable steps to help them decide before concluding they lack capacity.

3. Unwise decisions ≠ lack of capacity — capacity is about the process, not the outcome.

4. Best interests — decisions for someone lacking capacity must be in their best interests.

5. Least restrictive option.

Stage 1 — Diagnostic: Is there an impairment of mind/brain? (head injury, intoxication, dementia, delirium, mental illness)

Stage 2 — Functional (all four must be tested): Can they (a) Understand, (b) Retain, (c) Use or Weigh, (d) Communicate the decision? Failure at any one = lacks capacity for that decision.

Key points: Capacity is decision-specific and time-specific. Document clearly. If lacking capacity → best interests decision, consult family/LPA, involve IMCA if needed.

Sites (order of preference): Radial (safest — dual supply), femoral (easier in shock), brachial (last resort — end-artery), dorsalis pedis.

Modified Allen's test: Before radial puncture. Clench fist, occlude both arteries, open hand (blanched), release ulnar only. Normal: colour returns within 5-7s. If >10s → use other wrist.

Procedure: Consent. Wrist extended 15-30°. Clean with chlorhexidine. Heparinised ABG syringe. Palpate artery. Insert at 30-45° bevel up. Pulsatile bright red flash. Collect 1-2ml. Withdraw, firm pressure 5 minutes. Expel air bubbles, cap, label, analyse immediately.

Complications: Haematoma, arterial spasm, thrombosis, pseudoaneurysm, nerve injury, infection.

Indications: Emergency access when IV failed/delayed, especially cardiac arrest, critically unwell, paediatric. ALS: IO if IV cannot be obtained within 2 minutes.

Sites: Proximal tibia (most common — 1-2cm below, 1cm medial to tibial tuberosity). Distal tibia. Proximal humerus (adults). Distal femur (paediatric).

Contraindications: Fracture in target bone, previous IO same bone in 24-48h, prosthesis, overlying infection, cannot identify landmarks.

Technique (EZ-IO): Identify landmark. Clean. Stabilise limb (do NOT place hand behind leg). Insert at 90°. Drill until "give." Remove trocar. Aspirate marrow. Flush 10ml NS (no subcut swelling). In conscious patients: 2% lidocaine 40mg slowly over 2 min before use — IO is painful.

Complications: Extravasation, compartment syndrome, osteomyelitis, fracture, fat embolism.

Indication: "Can't intubate, can't oxygenate" (CICO) — final step in DAS failed airway algorithm.

Anatomy: Cricothyroid membrane between thyroid and cricoid cartilages. ~9mm high, 30mm wide. Relatively avascular and superficial in midline.

Scalpel technique (DAS 2015): Extend neck. Laryngeal handshake. Transverse stab through skin AND membrane (size 10 scalpel). Turn blade 90° (edge caudally). Insert bougie caudally. Railroad 6.0 cuffed tube over bougie. Inflate cuff. Confirm with capnography.

Needle cricothyroidotomy: Children <8 years. 14G cannula + syringe. Aspirate air confirms placement. High-flow oxygen (jet insufflation). Temporising only — inadequate CO₂ removal.

Complications: Haemorrhage, false passage, subglottic stenosis, posterior tracheal wall injury.

Indications: Haemodynamically unstable tachyarrhythmia (BP <90, chest pain, HF, reduced consciousness). Also elective for persistent AF/flutter/SVT.

Synchronised vs unsynchronised: Synchronised = shock on R wave (all organised rhythms: AF, flutter, SVT, VT with pulse). Unsynchronised = VF and pulseless VT only.

Energy (biphasic): Broad complex: 120-150J. AF: 120-150J. Flutter/SVT: 70-120J. Up to 3 attempts, escalating.

Procedure: Consent. IV access. Monitoring (defib pads anterolateral or anteroposterior). Sedate (propofol 0.5-1mg/kg or midazolam). Remove O₂ from face. Select SYNC mode. Charge. Clear everyone. Shock. Assess rhythm. If refractory: amiodarone 300mg IV then reattempt.

Post-procedure: 12-lead ECG, monitoring, check haemodynamics. Anticoagulation if AF >48h or unknown duration (need TOE or 3 weeks therapeutic anticoagulation prior).

Confirm arrest: Unresponsive + not breathing normally. Call for help. CPR 30:2 (100-120/min, depth 5-6cm). Attach defibrillator ASAP.

Shockable (VF/pVT): Defib 150-200J → CPR 2 min → rhythm check. Adrenaline 1mg IV after 3rd shock then q3-5min. Amiodarone 300mg after 3rd shock, 150mg after 5th.

Non-shockable (PEA/Asystole): CPR 2 min → check. Adrenaline 1mg ASAP then q3-5min. No amiodarone. Treat reversible causes.

4H's & 4T's: Hypoxia, Hypovolaemia, Hypo/hyperkalaemia, Hypothermia + Thrombosis (coronary/PE), Tamponade, Tension pneumothorax, Toxins.

Airway: BVM → i-gel → ETT. Once advanced airway → continuous compressions + ventilate 10/min. Confirm with waveform capnography.

Quality CPR: Minimise interruptions (<10s for checks). Rotate compressors q2min. Full chest recoil.

Key differences: Usually secondary to respiratory failure/shock (not primary arrhythmia). Prioritise ventilation. Start with 5 rescue breaths.

CPR ratio: 15:2. Depth ≥1/3 AP diameter (~4cm infant, ~5cm child). Rate 100-120/min. Infant: two-thumb encircling preferred.

Defibrillation: 4 J/kg all shocks. Paediatric pads <8yr/<25kg if available.

Drug doses: Adrenaline 10 mcg/kg (0.1ml/kg of 1:10,000). Amiodarone 5mg/kg after 3rd and 5th shocks. Weight: (age+4) × 2 for ages 1-10.

Common causes: Respiratory failure, sepsis, congenital heart disease.

Recognition: Rapid onset of airway compromise (swelling, stridor) + breathing difficulty (wheeze, hypoxia) + circulatory compromise (hypotension, tachycardia) ± skin changes. Skin changes may be absent in 20%.

Immediate management:

1. Remove trigger. 2. Call for help.

3. IM Adrenaline (anterolateral thigh): Adult 500mcg (0.5ml 1:1,000). Child 6-12yr: 300mcg. Child <6yr: 150mcg. Infant: 100-150mcg. Repeat q5min. IM NOT IV initially.

4. Position: Flat with legs elevated (hypotensive). Sitting if breathing difficulty. Left lateral if pregnant.

5. High-flow O₂ 15L NRB. 6. IV fluid 500ml-1L rapid (adult) / 20ml/kg (child).

7. Adjuncts (second-line): Hydrocortisone 200mg IV, Chlorphenamine 10mg IV — do NOT delay adrenaline for these.

After: Observe for biphasic reaction (4-12h). Adrenaline auto-injector prescription. Allergy clinic referral. Mast cell tryptase at onset, 1-2h, and 24h.

<C>ABCDE approach:

<C> Catastrophic haemorrhage: Direct pressure/tourniquet. Activate major haemorrhage protocol.

A — Airway + C-spine: Jaw thrust (not head tilt). Suction. OPA/NPA. C-spine immobilisation. RSI if GCS ≤8.

B — Breathing: Expose chest. Identify & treat: tension pneumothorax (needle decompression), open pneumothorax (3-sided seal), massive haemothorax (chest drain), flail chest.

C — Circulation: 2× large-bore IV. Warmed crystalloid. Permissive hypotension (SBP 80-90 penetrating, 100 in TBI). MHP 1:1:1 ratio. TXA 1g within 3h. Pelvic binder. FAST scan.

D — Disability: GCS, pupils, glucose, lateralising signs.

E — Exposure: Fully expose, log roll, then cover & warm. Prevent the "lethal triad" (hypothermia + acidosis + coagulopathy).

Montgomery ruling (2015): Doctor must ensure patient is aware of material risks and reasonable alternatives. A risk is "material" if a reasonable person would attach significance to it.

Valid consent requires: Capacity (MCA functional test), informed (risks, benefits, alternatives explained), voluntary (no coercion).

What to explain: Nature of procedure. Why recommended. Benefits. Material risks (common + rare serious). Alternatives (including doing nothing). What happens if declined.

Children: 16-17yr can consent. Under 16 can consent if Gillick competent. Parental consent can override child's refusal. If parents refuse life-saving treatment → court order.

Emergency: Lacking capacity + immediately necessary → proceed in best interests (MCA Section 5).

Common scenario: Patient wants to self-discharge AMA.

Approach: Explore why (unmet need? fear? responsibilities?). Address concerns. Explain risks clearly. Assess capacity (MCA framework). If they have capacity → they can leave. Complete self-discharge form, safety-net, arrange follow-up.

If lacking capacity: Duty of care. Detain and treat under MCA Section 5 (physical health). NOT the MHA (mental health only). Least restrictive option. Document. Involve family/LPA.

DoLS/LPS: If restriction amounts to deprivation of liberty, authorisation needed (can be retrospective in emergency).

Red flags: Unexplained injuries, injuries inconsistent with developmental stage, delay in presentation, changing history, multiple attendances, inappropriate parental affect, withdrawn child. Patterns: cigarette burns, bite marks, loop marks, spiral fractures in non-ambulant, rib fractures in infants, subdural haematomas.

Actions: Treat injuries. Document meticulously with body maps. Record history verbatim. Do NOT interrogate. Discuss with senior + safeguarding team. Refer to Children's Social Care. Parental consent NOT needed for referral.

Care Act 2014: Safeguard adults with care/support needs who are at risk of abuse and unable to protect themselves.

Domestic abuse: See patient alone. Ask directly but gently. Document. Offer MARAC/IDVA/police referral. Safety plan. Consider children in household.

Peyton's 4-step approach: 1. Demonstration (normal speed, no commentary). 2. Deconstruction (slowly, explaining each step). 3. Comprehension (learner talks you through it). 4. Performance (learner performs while narrating).

OSCE adaptation: Assess prior knowledge ("What do you know about...?"). Explain indication + anatomy. Demonstrate steps clearly. Check understanding. Invite questions. Use signposting ("First step... second step...").

Principles: Clear learning objective. Pitch to learner's level. Visual aids. Encourage questions. Constructive feedback. Confirm learning.

NICE NG143 traffic light: Green = low risk, Amber = intermediate (urgent assessment), Red = high risk (possible sepsis/meningitis).

Red flags: Non-blanching rash, bulging fontanelle, neck stiffness, focal seizures, bile-stained vomiting, reduced consciousness, pale/mottled/cyanotic, weak cry, poor feeding, T ≥38°C in <3 months (→ full septic screen + empirical antibiotics).

Assessment: Paediatric assessment triangle (appearance, WOB, circulation). Full examination including ENT. Check fontanelle. Inspect skin fully.

<3 months with fever: High risk. Full septic screen: blood cultures, urine, FBC, CRP, consider LP. Empirical IV antibiotics (ceftriaxone + amoxicillin for Listeria cover in neonates).

Bronchiolitis (<1yr, typically RSV): Coryzal prodrome → wheeze, cough, feeding difficulty. Supportive: minimal handling, NG/IV fluids, O₂/CPAP. Salbutamol, steroids, antibiotics NOT indicated (NICE NG9). Admit if SpO₂ <92%, apnoea, <50% feeds, severe distress, <6 weeks.

Acute asthma (BTS/SIGN): Moderate: SpO₂ ≥92%, talks, PEFR >50%. Severe: SpO₂ <92%, can't complete sentences, PEFR 33-50%. Life-threatening: silent chest, cyanosis, exhaustion, PEFR <33%.

Asthma Rx: O₂ → salbutamol MDI+spacer or neb → ipratropium if poor response → prednisolone 1-2mg/kg PO 3-5 days. Severe: IV MgSO₄ 40mg/kg, IV salbutamol, consider PICU.

Croup: Barking cough, stridor, hoarse voice. Dexamethasone 0.15mg/kg PO (all). If moderate/severe: + nebulised adrenaline 0.5ml/kg 1:1,000 (max 5ml). Observe 2-4h post-adrenaline.

Suspicious patterns: Bruising in non-mobile infant. Multiple bruises different ages. Unusual locations (face, ears, trunk, buttocks). Patterned injuries. Immersion scalds (glove/stocking). Fractures in infants (ribs, metaphyseal corner, skull). Multiple fractures different healing stages.

History red flags: Delay in presentation. Changing/inconsistent history. History incompatible with developmental stage. Multiple ED attendances.

Approach: Treat injuries. Document meticulously — body maps, measure injuries, photograph. Record history verbatim. Do NOT accuse parent. Discuss with senior + safeguarding lead. Refer Children's Social Care. Consider skeletal survey + ophthalmology (retinal haemorrhages). Do NOT discharge until safeguarding assessment complete.

Meningitis: Fever, non-blanching rash, neck stiffness (unreliable in infants), irritability, altered consciousness. Infants: poor feeding, high-pitched cry, bulging fontanelle. Rx: IV ceftriaxone immediately (don't wait for LP). Dexamethasone 0.15mg/kg QDS 4 days. Notify public health. Close contacts: ciprofloxacin.

Status epilepticus (>5min or ≥2 without recovery): Step 1 (5min): buccal midazolam 0.5mg/kg. Step 2 (10min): repeat benzo. Step 3 (15-20min): phenytoin 20mg/kg IV over 20min. Step 4: RSI + PICU.

Paediatric DKA: Do NOT bolus insulin (→ cerebral oedema). Fluids first: 10ml/kg NS if shocked, then 48h deficit replacement. Insulin infusion 0.05-0.1 units/kg/hr after fluid. K⁺ replacement guided by levels. Watch for cerebral oedema (headache, ↓GCS, bradycardia, HTN) → hypertonic saline/mannitol.

Paediatric anaphylaxis: IM adrenaline: <6mo 100-150mcg, 6mo-6yr 150mcg, 6-12yr 300mcg, >12yr 500mcg.

Definition: Seizure with fever in child 6mo-5yr, without CNS infection.

Simple vs complex: Simple: generalised tonic-clonic, <15min, single in 24h, full recovery. Complex: focal, >15min, recurrent, or incomplete recovery → needs investigation.

Management: If seizing → status pathway. After: identify fever source. Antipyretics for comfort only (do NOT prevent recurrence). Reassure parents — epilepsy risk only ~1-2% vs 0.5%.

Investigate if: <12 months + fever + seizure (LP threshold low), complex features, meningism, prolonged postictal. EEG/imaging NOT routinely needed for simple FC.

Discharge advice: Recovery position if recurs, don't put anything in mouth, time it, call 999 if >5min. Return if rash, reduced consciousness, further seizures.

NICE CG232 — CT head within 1 hour: GCS <13 at any point, GCS 13-14 at 2h post-injury, suspected open/depressed skull fracture, basal skull fracture signs (panda eyes, Battle's, CSF leak, haemotympanum), post-traumatic seizure, focal neuro deficit, >1 vomiting episode.

CT within 8 hours: Age ≥65 + LOC/amnesia, dangerous mechanism, on anticoagulants, >30min retrograde amnesia.

Anticoagulated patients: All on warfarin → CT regardless of symptoms. DOACs → CT within 8h, specific reversal agents if bleeding.

GCS monitoring: Half-hourly until 15, then hourly for 4h, then 2-hourly. Deterioration → repeat CT + escalate.

Discharge: Head injury advice card. Responsible adult 24h supervision.

Assessment: Mechanism. Deformity, swelling, tenderness, crepitus. Neurovascular status distally (document before AND after manipulation). Open fractures: Gustilo-Anderson classification. Photograph open wounds.

Open fracture (BOAST 4): Remove gross contamination. Saline-soaked gauze. IV antibiotics within 1h (co-amoxiclav ± gentamicin). Tetanus. Realign + splint. Photograph. Do NOT close wound. Urgent ortho + plastics. Debridement within 12-24h.

Ottawa ankle rules: X-ray if: tenderness posterior/tip lateral malleolus, tenderness posterior/tip medial malleolus, or inability to weight-bear (4 steps). Foot: navicular base, 5th MT base, or inability to weight-bear.

Reduction: For displaced fractures, neurovascular compromise, open fractures, dislocations. Sedation options. Check NV status post-reduction. Post-reduction X-ray.

Primary survey first: Airway burns (singed nasal hairs, soot, hoarse voice, stridor, facial burns) → early intubation.

Depth: Superficial (erythema, painful). Superficial partial thickness (blisters, very painful). Deep partial (blotchy, reduced sensation). Full thickness (white/waxy/charred, painless).

TBSA: Wallace rule of nines (adults). Lund and Browder for children. Palm ≈ 1%. Only count partial thickness+ for fluid calculation.

Fluids (Parkland formula): >15% adult (>10% child): 4ml × kg × %TBSA over 24h (Hartmann's). Half in first 8h (from time of burn). Titrate to UO (0.5-1ml/kg/hr adult, 1ml/kg/hr child).

Refer to burns unit: >10% adult (>5% child), full thickness >1%, face/hands/feet/genitalia/joints, circumferential, electrical/chemical, inhalation injury.

Pre-arrival: Brief team. Assign roles (airway, procedures, primary survey lead, scribe, nurse TL). Equipment check.

Handover: ATMIST — Age, Time, Mechanism, Injuries, Signs, Treatment.

Team leader role: Foot of bed (overview). Direct <C>ABCDE. Situational awareness. Delegate by name. Closed-loop communication.

Decision points: MHP activation. CT vs theatre. Specialist input. Emergency thoracotomy. Major trauma centre transfer.

Documentation: Scribe in real-time. Record all interventions with times. Trauma proforma.