📋

Alcohol History — Alcohol Dependence and Withdrawal

History · 8 minStation 1 of 10

✓

▼

8:00

Station type

History Taking

Time allowed

8 minutes

Pass mark

12 / 20

📄 Candidate Briefing

👁 Examiner Instructions

✅ Mark Scheme

📄 Candidate Instructions

You are the ED doctor. Mr Brendan Walsh, 46 years old, has been brought in by ambulance. He is tremulous and sweating. His last drink was approximately 18 hours ago.

Obs: HR 112, BP 148/94, RR 18, Temp 37.4°C, BM 5.8 mmol/L. He is alert but anxious and mildly confused.

Please take a focused alcohol history from Mr Walsh, apply the AUDIT-C screening questions, assess for alcohol dependence and withdrawal severity, and outline your immediate management plan. You have 8 minutes.

💡 Alcohol Dependence — AUDIT-C, CAGE, CIWA-Ar, Withdrawal, Wernicke's ▼

AUDIT-C screening (3 questions — quick screen for hazardous drinking):
- Q1: How often do you have a drink containing alcohol? (0 = never; 1 = monthly or less; 2 = 2–4×/month; 3 = 2–3×/week; 4 = 4+×/week)
- Q2: How many units of alcohol do you drink on a typical day when drinking? (0 = 1–2; 1 = 3–4; 2 = 5–6; 3 = 7–9; 4 = 10+)
- Q3: How often have you had 6 or more units on one occasion? (0 = never; 1 = less than monthly; 2 = monthly; 3 = weekly; 4 = daily or almost daily)
- Score ≥5 in men, ≥4 in women = positive screen for hazardous/harmful drinking. Proceed to full history.
Full alcohol history — quantity and pattern:
- How many units per day and per week? (1 unit = 10 mL/8 g pure alcohol. A pint of 4% beer = 2.3 units. A large glass of 13% wine = 3.3 units. A 25 mL measure of spirits = 1 unit.)
- What type of drink? (spirits = rapid high BAC; cider/wine = sustained)
- When does drinking start? Morning drinking (drinking to avoid withdrawal) = key dependence feature.
- Pattern: daily drinking vs binge drinking. Ever drinking alone? Hiding drinks?
- How long has this been going on? When did it escalate?
Alcohol dependence features (ICD-11 — requires ≥3 of 6):
- Tolerance: Needs more alcohol to get the same effect. "Do you need to drink more than you used to, to feel the same effect?"
- Withdrawal: Physical symptoms when stopping or reducing. "What happens if you don't drink?"
- Loss of control: Drinking more or for longer than intended.
- Preoccupation: Spending a lot of time getting, using, or recovering from alcohol.
- Giving up activities: Social, occupational, or recreational activities reduced due to drinking.
- Continuing despite harm: Continuing to drink despite knowing it causes physical or psychological problems.
Withdrawal history — critical questions:
- When did you last drink, and how much?
- Have you had withdrawal symptoms before? What were they? (Tremor, sweating, anxiety, nausea/vomiting — mild. Seizures — moderate-severe. Hallucinations — visual, tactile, auditory — severe. Delirium tremens — severe.)
- Have you ever had a withdrawal seizure? When? How many? Were you hospitalised?
- Have you ever seen, heard or felt things that weren't there when stopping alcohol? (Hallucinations — alcoholic hallucinosis or DT feature.)
- Have you ever had delirium tremens (DTs)? (Extreme agitation, confusion, hyperthermia, autonomic instability — mortality up to 5–15% if untreated.)
- Previous detox attempts: how many? In-patient or community? Medications (chlordiazepoxide, lorazepam)? How long abstinent?
CAGE questionnaire (4 questions — dependence screen):
- C — Have you ever felt you should Cut down on your drinking?
- A — Have people Annoyed you by criticising your drinking?
- G — Have you ever felt Guilty about your drinking?
- E — Have you ever had a drink first thing in the morning (Eye-opener) to steady your nerves or get rid of a hangover?
- Score ≥2 = clinically significant (sensitivity 71–93%, specificity 68–96% for dependence).
Complications and impact:
- Liver disease: jaundice, ascites, haematemesis (varices), easy bruising, encephalopathy. Any previous liver disease diagnosis?
- Pancreatitis: recurrent epigastric pain radiating to back, nausea/vomiting.
- Cardiomyopathy: exertional dyspnoea, peripheral oedema.
- Peripheral neuropathy: tingling/numbness in hands and feet.
- Work: is he currently employed? Has he lost jobs due to drinking?
- Relationships: partner, family situation, social isolation.
- Legal: drink driving convictions, criminal charges?
- Finances: spending most money on alcohol?
- Safeguarding — children at home: Are there children in the household? If yes — mandatory consideration of their welfare. Refer to social services if children present and parent has significant alcohol dependence.
Wernicke's encephalopathy — recognition and prevention:
- Caused by thiamine (Vitamin B1) deficiency — common in chronic alcohol excess (poor diet, impaired absorption, increased demand).
- Classic triad: Confusion (acute encephalopathy), Ophthalmoplegia (horizontal nystagmus, lateral rectus palsy — CN VI), Ataxia (cerebellar, wide-based gait). Full triad only in ~10% — any one feature should trigger treatment.
- Korsakoff's syndrome: if Wernicke's untreated → irreversible anterograde and retrograde amnesia with confabulation.
- CRITICAL — Give Pabrinex (IV thiamine) BEFORE any glucose. Giving glucose without thiamine in thiamine-depleted patient can precipitate acute Wernicke's (glucose metabolism consumes thiamine). BNF: Pabrinex 2 pairs (2 ampoules IM or IV) TDS for 3–5 days if Wernicke's suspected. If frank Wernicke's — IV Pabrinex high dose (2 pairs TDS).
- Screen: ask about diet quality, thiamine supplementation, any memory problems, any eye or balance problems.
CIWA-Ar score (Clinical Institute Withdrawal Assessment for Alcohol — revised): 10-item scale assessing withdrawal severity. Items: nausea/vomiting (0–7), tremor (0–7), paroxysmal sweats (0–7), anxiety (0–7), agitation (0–7), tactile disturbances (0–7), auditory disturbances (0–7), visual disturbances (0–7), headache/fullness in head (0–7), orientation/clouding of sensorium (0–4). Total score: <10 = mild; 10–20 = moderate (pharmacotherapy); >20 = severe (high risk seizures/DTs, requires inpatient management). Mr Walsh: tremor, sweating, tachycardia, mild confusion = likely moderate-severe withdrawal.
Immediate management:
- IV/IM Pabrinex — before any glucose. 2 pairs IV TDS for 3–5 days (or IM if IV access difficult).
- Chlordiazepoxide reducing regime (long-acting benzodiazepine — preferred over diazepam for alcohol withdrawal in outpatients due to less abuse potential; in hospital — diazepam IV titrated by CIWA score is used in severe withdrawal). Standard fixed dose reducing regime: e.g. 30 mg QDS day 1, 20 mg QDS day 2, 15 mg TDS day 3, 10 mg TDS day 4, 5 mg BD day 5, then stop. Adjust by CIWA score.
- Lorazepam IV/IM if seizures — first-line for alcohol withdrawal seizures (as per NICE CG100). IV lorazepam 0.1 mg/kg or diazepam 10–20 mg IV.
- Fluids: IV 0.9% NaCl if dehydrated. Monitor electrolytes — hypokalaemia and hypomagnesaemia common (reduce seizure threshold).
- Admit for CIWA-Ar monitoring, detox regime, nutritional support.
- Alcohol liaison nurse/addiction service referral before discharge.

⚠️ Examiner / Role-player Instructions — Not for Candidate

Play Mr Walsh — dishevelled, tremulous, slightly defensive but cooperative when approached without judgement. He has been drinking approximately 1 litre of vodka per day for 3 years. He wakes up needing a drink — "if I don't have one by 8am I start shaking." He has had two withdrawal seizures in the past, both in hospital, both 2–3 years ago. He has never had hallucinations. No DTs. He has two children (ages 8 and 11) who live with his ex-wife — he has weekend access. He hasn't been to work in 6 months (lost his job as a delivery driver). CAGE — all 4 positive. Wernicke's: no current ophthalmoplegia or ataxia, but poor diet — "I don't really eat." Last drink was 18 hours ago, 250 mL vodka. Key checkpoints: Did candidate take AUDIT-C? Did they ask about morning drinking? Did they ask about withdrawal seizures specifically? Did they mention Pabrinex before glucose? Did they ask about children at home?

🎭 Patient Script ▼

Drinking pattern: "Every day. Have done for years. I drink vodka mainly — about a litre a day maybe more." If asked about morning drinking: "Yeah I need one first thing or the shaking starts." If asked about units: "I don't really count — I just drink until I feel normal."
Withdrawal history: "I've had fits before — twice, in hospital. That was a couple of years back. Never seen things that weren't there though." If asked about DTs: "What's that? No, I don't think so."
Impact: "Lost my job. Ex-wife took the kids. I live alone in a flat." If asked about children: "They live with their mum — I see them at weekends." If asked about diet: "I don't really eat much — maybe a sandwich here and there."
CAGE: C — "Yeah I know I should cut down." A — "My sister never stops going on about it." G — "Course I feel guilty." E — "Yeah — that's the first thing I do in the morning."

🔔 Examiner Cues ▼

If candidate doesn't ask about morning drinking: "Is there a specific drinking pattern that would indicate dependence rather than harmful use?"
If candidate omits withdrawal seizure history: "Are there any specific complications of acute alcohol withdrawal that are life-threatening and which you need to screen for?"
If candidate orders IV dextrose before Pabrinex: "Before you give IV glucose — is there a nutritional concern in this patient that needs addressing first?"
If candidate doesn't ask about children: "Mr Walsh mentions he has children — does that change anything about your management or documentation?"
At 7 minutes: "What is Mr Walsh's CIWA-Ar score likely to be and what does it mean for his management setting?"

Criterion	Marks
Screening and Quantity
AUDIT-C or CAGE applied; units per day/week established; morning drinking specifically asked (key dependence marker)	2
Dependence features — tolerance, withdrawal symptoms, loss of control, preoccupation, impact on daily life assessed	2
Withdrawal Assessment
Last drink and amount established; withdrawal symptoms asked — tremor, sweating, anxiety, nausea	2
Withdrawal seizure history specifically asked — previous seizures, number, hospitalisation; hallucinations and DTs history asked	2
CIWA-Ar score or equivalent severity assessment applied; moderate-severe withdrawal recognised (tremor, sweating, tachycardia, confusion)	2
Complications and Safeguarding
Wernicke's risk screened — diet quality, ophthalmoplegia, ataxia, confusion; Pabrinex (IV thiamine) before any glucose stated explicitly	3
Liver disease, social impact, employment, relationships explored; safeguarding — children at home asked; if yes — child welfare referral considered	2
Management
Chlordiazepoxide reducing regime and IV Pabrinex plan stated; admit for monitoring; alcohol liaison referral	3
Total	20

📋

Mixed Drug and Alcohol Overdose — History and Risk Stratification

History · 8 minStation 2 of 10

✓

▼

8:00

Station type

History Taking

Time allowed

8 minutes

Pass mark

12 / 20

📄 Candidate Briefing

👁 Examiner Instructions

✅ Mark Scheme

📄 Candidate Instructions

You are the ED doctor. Miss Kezia Oduya, 31 years old, was found unconscious by her flatmate approximately one hour ago. Empty blister packs of diazepam and amitriptyline were found beside her, and there is a strong smell of alcohol. She has now regained consciousness and is drowsy but responsive.

Obs: HR 118, BP 104/68, RR 12, SpO₂ 94% on air, GCS 12 (E3 V4 M5), pupils 5 mm bilaterally sluggish, skin dry and flushed.

Please take a focused overdose history, identify the toxidromes present, and risk-stratify for the appropriate level of care. You have 8 minutes.

💡 Mixed OD — TCA Toxidrome, Benzodiazepine, Alcohol Synergism, Risk Stratification ▼

Overdose history — systematic approach (AMPLE + toxicology):
- What was taken? All substances — prescription, OTC, recreational drugs, alcohol. Count remaining tablets if possible (total prescribed minus remaining = approximate ingested). Blister packs: diazepam and amitriptyline. How many of each were prescribed? How many are missing?
- When was it taken? Timeline critical for toxicity prediction and treatment window. "When were you last seen well by your flatmate?" "Do you know what time you took the tablets?" "How long ago was your last drink?"
- How much alcohol? Type, estimated volume, timing relative to tablets (alcohol accelerates absorption and compounds CNS/respiratory depression).
- Why was it taken? Deliberate self-harm (DSH) vs accidental. "Did you mean to hurt yourself?" Non-judgemental approach. If DSH — risk assessment: was there a plan, suicidal intent, note left, did she want to be found, has she told anyone?
- Previous overdoses and mental health history: Number of previous ODs, hospitalisations, psychiatric admissions, current psychiatric follow-up, current mental health diagnosis (depression — amitriptyline prescribed?), current psychological stressors.
- Why is diazepam prescribed? Anxiety, epilepsy, muscle spasm? Is this her normal dose or excess?
- Why is amitriptyline prescribed? Depression, neuropathic pain, migraine prophylaxis, IBS? Dose prescribed — 10 mg, 25 mg, 50 mg, 75 mg, 150 mg?
- Allergy, social history: Lives alone or with others? Support network? Safe to return to if discharged?
TCA (tricyclic antidepressant) toxidrome — amitriptyline is a TCA:
- Anticholinergic features (sodium channel blockade + muscarinic blockade):
  - Dry hot flushed skin (anhidrosis — "dry as a bone, red as a beet, hot as a hare")
  - Urinary retention
  - Ileus / reduced bowel sounds
  - Dilated pupils (mydriasis)
  - Tachycardia
  - Confusion, delirium, agitation
- Cardiac toxicity (sodium channel blockade — most dangerous feature):
  - Widened QRS on ECG — QRS >100 ms = significant toxicity; QRS >160 ms = high risk of VT/VF/cardiac arrest
  - Right axis deviation in lead aVR (R wave in aVR — TCA-specific finding)
  - QTc prolongation → torsades de pointes
  - Hypotension (alpha-1 blockade + myocardial depression)
- CNS toxicity: Sedation, seizures (lowers seizure threshold), coma
- Management of TCA toxicity:
  - ECG immediately — monitor continuously
  - If QRS >100 ms or haemodynamic compromise → IV Sodium Bicarbonate 1–2 mmol/kg (alkalinisation reduces sodium channel blockade, improves haemodynamics). Target pH 7.45–7.55. Repeat doses until QRS narrows.
  - Do NOT give flumazenil — lowers seizure threshold in mixed TCA/BDZ overdose
  - Activated charcoal 50 g orally if within 1 hour and airway protected
  - Intubation if GCS deteriorating, respiratory failure, or seizures
Benzodiazepine toxidrome — diazepam:
- CNS depression: drowsiness, slurred speech, ataxia, amnesia
- Respiratory depression — especially when combined with alcohol or opioids
- BDZs alone rarely cause death. The danger here is synergism with amitriptyline and alcohol.
- Flumazenil: Do NOT give flumazenil in mixed TCA/BDZ overdose — reversal of BDZ sedation unmasks TCA CNS excitatory effects → precipitates seizures. Flumazenil also has short half-life (1 hour) — resedation occurs.
Alcohol synergism: Alcohol enhances CNS depression from both diazepam and amitriptyline. Respiratory depression compounded. Hypotension worsened. Difficult to assess baseline GCS. Alcohol also delays gastric emptying, potentially increasing bioavailability of co-ingested tablets.
Risk stratification — level of care:
- ITU criteria: GCS <8 (airway at risk), respiratory failure (RR <12, SpO₂ <92%), haemodynamic instability (SBP <90), QRS >100 ms or arrhythmia, seizures. Kezia: GCS 12, RR 12, SpO₂ 94% — borderline. ECG needed immediately.
- Resus/monitored bay: TCA confirmed, ECG changes, GCS 12, declining trajectory.
- General ward: Not appropriate here — TCA OD requires monitored environment.
- Psychiatric review after medical stabilisation — risk assessment for further self-harm before discharge.

⚠️ Examiner / Role-player Instructions — Not for Candidate

Play Miss Oduya — drowsy, slow to respond, speech slightly slurred. She is cooperative but answers require prompting. She took approximately 20 × 5 mg diazepam tablets and 10 × 50 mg amitriptyline tablets with approximately half a bottle of wine (375 mL, 13%) around 3 hours ago. She took them deliberately — "I wanted it to stop." She has depression (amitriptyline 50 mg prescribed by GP), anxiety (diazepam 5 mg PRN). Previous one OD 2 years ago — paracetamol, no hospitalisation. Lives with a flatmate. No note left. She did not hide what she was doing — flatmate found her quickly. Key checkpoints: Did candidate ask what was taken and how much? Did they ask about deliberate vs accidental? Did they identify TCA anticholinergic features on examination? Did they state ECG immediately? Did they know NOT to give flumazenil?

🎭 Patient Script ▼

What was taken: "Some tablets... the diazepam... and the others... the blue ones." If asked how many: "About 20 of the diazepam and maybe 10 of the others — I don't know exactly." If asked about the amitriptyline dose: "50 mg — I was told to take one at night."
When and why: "About... 3 hours ago I think. I just... I wanted everything to stop." If asked about intent: "Yes. I meant to."
Mental health: "I've had depression for about 5 years. I overdosed once before, 2 years ago. I've been seeing my GP but I haven't seen a psychiatrist."
Current stressor: "I lost my job last month. My relationship ended. I just couldn't see the point any more."
Alcohol: "I had some wine — half a bottle, maybe a bit more."

🔔 Examiner Cues ▼

If candidate doesn't recognise anticholinergic features: "The patient's skin appears dry and flushed, pupils are 5 mm and sluggish, HR 118 — what toxidrome does this suggest?"
If candidate orders flumazenil: "Before you give flumazenil — are there any contraindications in the context of this specific overdose?"
If candidate doesn't request ECG urgently: "The QRS complex on the monitor looks wide — what investigation would you prioritise immediately and why?"
At 7 minutes: "GCS drops to 9 and RR falls to 9 — what is your next step and what level of care does this patient need?"

Criterion	Marks
Overdose History
All substances identified — diazepam dose and quantity, amitriptyline dose and quantity, alcohol type/volume; timing of ingestion established	2
Deliberate self-harm established; intent explored non-judgementally; previous OD history and current psychiatric support asked	2
Reason for prescriptions asked — why amitriptyline (depression), why diazepam (anxiety/epilepsy?); social history — lives alone vs with others	1
Toxidrome Recognition
TCA anticholinergic toxidrome identified — dry/hot/flushed skin, tachycardia, dilated sluggish pupils, urinary retention, confusion listed	3
TCA cardiac toxicity recognised — ECG requested urgently; QRS widening >100 ms significance explained; sodium bicarbonate stated as treatment if QRS wide	3
Flumazenil contraindicated in TCA/BDZ mixed OD — reason given (precipitates seizures, short half-life resedation)	2
Risk Stratification and Management
Alcohol synergism with CNS/respiratory depression recognised; activated charcoal considered (within 1 hour, airway protected)	2
Level of care determined — resus/monitored bay minimum; ITU criteria if GCS falls or QRS widens; psychiatric review after stabilisation	3
Total	20

🩺

FAST Examination — Acute Stroke Screening and Thrombolysis Pathway

Examination · 8 minStation 3 of 10

✓

▼

8:00

Station type

Clinical Examination

Time allowed

8 minutes

Pass mark

12 / 20

📄 Candidate Briefing

👁 Examiner Instructions

✅ Mark Scheme

📄 Candidate Instructions

You are the ED doctor. Mr Raymond Cole, 67 years old, has been brought in by ambulance with sudden onset right-sided facial droop, right arm weakness, and slurred speech. Symptom onset was 45 minutes ago — he is within the thrombolysis window.

Obs on arrival: HR 88 irregularly irregular, BP right arm 168/96, BP left arm 162/94, RR 16, SpO₂ 97% on air, BM 6.4 mmol/L, Temp 37.1°C.

Please perform a rapid targeted neurological examination and walk through the thrombolysis activation pathway. The examiner will provide positive and negative findings as you examine. You have 8 minutes.

💡 Stroke FAST Exam, NIHSS, Thrombolysis — Full Framework ▼

Immediate priorities on arrival — TIME IS BRAIN: Door to needle target: <60 minutes from ED arrival (NICE NG128). Every 15-minute delay = 1 million neurons lost. Immediate actions: activate stroke team/thrombolysis pathway, CT head within 25 minutes, bloods (FBC, coag, glucose, U&E), ECG, 2 large-bore IV cannulas, consent.
FAST screening:
- F — Face: "Mr Cole, can you smile for me and show me your teeth?" Look for asymmetry. Right-sided facial droop — lower face (UMN pattern: forehead sparing — contralateral cortex lesion). LMN facial palsy (Bell's palsy, parotid tumour) affects all of face including forehead (ipsilateral CN VII lesion).
- A — Arms: "Can you raise both arms out in front of you and hold them there for 10 seconds?" Look for pronator drift (affected arm pronates and drops — upper limb pyramidal weakness). Right arm drift = left hemisphere lesion (motor cortex/corticospinal tract).
- S — Speech: "Can you repeat this phrase: 'The cat sat on the mat'?" Assess: Dysarthria (slurred but correct words — motor speech disorder; can understand) vs Dysphasia/Aphasia (incorrect words, paraphasias, word-finding difficulty, comprehension impairment — language disorder). Ask him to name objects (confrontation naming), follow a 2-step command (comprehension test). Expressive dysphasia (Broca's — left frontal) vs receptive dysphasia (Wernicke's — left temporal) vs global.
- T — Time: Document exact onset time. "Last known well" time if uncertain — this is the time to use for thrombolysis window.
Focused cranial nerve examination:
- CN II: Visual fields (hemianopia — posterior cerebral artery stroke). Fundoscopy (papilloedema — raised ICP? Hypertensive retinopathy?).
- CN III, IV, VI: Eye movements — conjugate gaze palsy (eyes deviate toward lesion in cortical stroke; deviate away from lesion in pontine stroke — "eyes look toward the stroke" in hemisphere lesion).
- CN VII: Upper vs lower motor neuron pattern — critical distinction. UMN (central) = forehead sparing (bilateral cortical representation of forehead). LMN (peripheral) = complete ipsilateral hemifacial weakness including forehead.
- CN XII: "Stick your tongue out." Tongue deviates to the side of the lesion (LMN — peripheral nerve or brainstem) or away from the lesion (UMN — contralateral).
Upper limb power and sensation: Pronator drift test. Grip strength (ask patient to squeeze your fingers — compare sides). Finger extension against resistance. Sensation — pin prick comparison bilateral upper limb. Proprioception (finger position sense). Reflexes — brisk on affected side in acute stroke, may be flaccid acutely then become spastic.
NIHSS (National Institutes of Health Stroke Scale): 15-item scale, 0–42. Key domains: level of consciousness, gaze, visual fields, facial palsy, motor (arm and leg × 2), ataxia, sensation, language, dysarthria, extinction/inattention. Score >4 = candidate for thrombolysis consideration. Score ≥22 = major stroke. In this station — Mr Cole likely scores 4–6 (mild-moderate) based on findings. Candidate should state they would calculate NIHSS formally as part of the assessment.
Blood pressure both arms — why: Significant bilateral BP difference (>20 mmHg SBP) suggests aortic dissection as cause of stroke (carotid artery origin from dissected false lumen). Here — BP both arms similar (168/96 and 162/94, difference <10 mmHg) — dissection less likely. BP should NOT be lowered before thrombolysis unless >185/110 (hypertension with thrombolysis is a relative contraindication if uncontrolled — target <185/110 before rtPA).
ECG — why important: Irregularly irregular rhythm = AF. AF is the most common cardioembolic cause of ischaemic stroke. Informs anticoagulation decision post-thrombolysis (no anticoagulation for 24 hours after tPA). Also check for recent MI (mural thrombus), prolonged QT, LBBB.
BM 6.4 mmol/L: Glucose must be checked — hypoglycaemia (BM <3.0) can mimic stroke perfectly and is immediately reversible. Normal glucose does not exclude hypoglycaemia as cause if BM wasn't checked early. Hyperglycaemia worsens stroke outcomes.
CT head — before thrombolysis: Must exclude haemorrhagic stroke before giving thrombolysis (rtPA — alteplase 0.9 mg/kg IV, max 90 mg). CT is insensitive for early ischaemic stroke (may appear normal in first 6–12 hours) but reliably excludes haemorrhage. ASPECTS score (Alberta Stroke Programme Early CT Score) — used to predict outcome from thrombolysis. Score <6 = poor prognosis, caution with thrombolysis.
Thrombolysis inclusion/exclusion criteria (key points for MRCEM):
- Onset <4.5 hours (extended window to 9 hours with CT perfusion in selected patients — wake-up strokes).
- No haemorrhage on CT.
- BP <185/110 (treat with labetalol IV or glyceryl trinitrate if over).
- No recent surgery (<14 days), no recent haemorrhage.
- Not on anticoagulants with therapeutic INR/DOAC (check last dose).
- Platelet count >100.
- NIHSS ≥4 (though clinical judgement in milder deficits).

⚠️ Examiner Instructions — Not for Candidate

Provide findings as candidate examines: "Right-sided lower facial droop — forehead movement preserved." "Right arm drifts and pronates after 5 seconds." "Speech is slurred — he is saying the right words but they are hard to understand." "No visual field defect. Eyes move conjugately. Tongue protrudes midline." "Right grip reduced compared to left. Reflexes equal and present bilaterally." If candidate asks about ECG: "Irregularly irregular rhythm confirmed." If candidate asks about BM: "6.4 mmol/L." Key checkpoints: Did candidate activate stroke pathway immediately? Did they assess for AF on ECG? Did they check BM to exclude hypoglycaemia? Did they state CT before thrombolysis? Did they give door-to-needle target (<60 min)?

🔔 Examiner Cues ▼

If candidate doesn't distinguish UMN vs LMN facial palsy: "The forehead appears to move normally on both sides — what does that tell you about the site of the lesion?"
If candidate doesn't check BM before thrombolysis: "Before you activate the thrombolysis pathway — is there a reversible cause you must exclude first?"
If candidate doesn't mention CT before thrombolysis: "You're about to give alteplase — what investigation is absolutely mandatory first and why?"
At 7 minutes: "BP is 192/108. Does this change anything about your thrombolysis plan?"

Criterion	Marks
FAST and Rapid Assessment
Stroke pathway activated immediately; last known well time documented; BM checked to exclude hypoglycaemia mimicking stroke	2
FAST performed correctly — Face (smile/show teeth, asymmetry noted), Arms (pronator drift), Speech (dysarthria vs dysphasia distinguished)	3
Focused Neurological Examination
CN VII — UMN vs LMN pattern correctly identified and explained (forehead sparing = UMN/central); CN XII tongue deviation assessed	2
NIHSS components stated; upper limb power, sensation, pronator drift assessed; ECG obtained — AF identified as cardioembolic cause	2
BP both arms — dissection screening; BP 185/110 threshold for thrombolysis stated; bilateral BP difference significance explained	2
Thrombolysis Pathway
CT head before thrombolysis — haemorrhage exclusion mandatory; CT interpretation (normal in early ischaemic stroke does not exclude diagnosis)	3
Thrombolysis criteria applied — onset <4.5 hours, no haemorrhage, BP <185/110, no anticoagulants; door-to-needle <60 minutes target stated	2
Alteplase dose — 0.9 mg/kg IV (10% as bolus, 90% over 60 min); post-thrombolysis monitoring and no anticoagulation for 24 hours stated	2
Total	20

🩺

Paediatric Examination — Wheeze and Acute Asthma Severity

Examination · 8 minStation 4 of 10

✓

▼

8:00

Station type

Clinical Examination

Time allowed

8 minutes

Pass mark

12 / 20

📄 Candidate Briefing

👁 Examiner Instructions

✅ Mark Scheme

📄 Candidate Instructions

You are the ED doctor. Callum, 6 years old, has been brought in by his mother with a 2-hour history of wheeze and cough. He is a known asthmatic — diagnosed at age 3, on salbutamol inhaler PRN. He has had two previous hospital admissions for asthma, none to PICU.

Obs on arrival: RR 38, HR 130, SpO₂ 92% on air, Temp 37.8°C. He is sitting slightly forward, appears anxious. His mother is present.

Please perform a targeted respiratory examination, classify the severity of his asthma attack using BTS/SIGN guidelines, and outline your immediate management. The examiner will provide positive and negative findings as you examine. You have 8 minutes.

💡 Paediatric Asthma — BTS/SIGN Severity, Examination, Management ▼

Paediatric approach — ALWAYS observe first before touching:
- Gain the child's trust — get to their eye level, explain what you're doing, use a gentle voice. Examine with parent present and child on parent's lap if needed (especially under 3 years). Don't rush — anxiety worsens bronchospasm.
- Observe from the end of the bed (inspection):
  - Respiratory rate — count for a full 60 seconds (paediatric rates are higher: normal 6-year-old = 22–28 bpm; >30 = tachypnoea; >40 = significant; >50 = severe).
  - Work of breathing: accessory muscle use (sternomastoid, scalenes), subcostal/intercostal recession, tracheal tug, nasal flaring.
  - Posture: tripod position (leaning forward on hands) = severe respiratory distress.
  - Skin colour: central cyanosis (lips, tongue — severe), peripheral cyanosis (acral), pallor.
  - Demeanour: anxious and alert (moderate-severe), quiet and apparently calm in severe (exhaustion), altered consciousness (life-threatening).
Respiratory examination:
- Inspection: Chest shape (hyperinflation = barrel chest in chronic/acute severe). Chest wall recession sites and severity.
- Palpation: Tracheal position (midline — deviation in pneumothorax). Chest expansion (symmetry, reduced in severe attack).
- Auscultation: Wheeze — expiratory (typical asthma), inspiratory or biphasic (severe). Distribution — bilateral. Air entry — symmetric vs reduced (asymmetric reduction = mucus plug, pneumothorax, consolidation). Silent chest = life-threatening — so little airflow that no wheeze is audible, not improvement. Prolonged expiratory phase (I:E ratio >1:2 in asthma).
- SpO₂: 97–100% normal. 94–96% = mild concern. 92–93% = moderate. <92% = severe/life-threatening. Callum: 92% = borderline severe.
- Peak flow (PEFR): Only usable in cooperative children >5 years. Express as % predicted for height. <50% predicted = severe. <33% = life-threatening. 50–75% = moderate. Callum is 6 — attempt PEFR.
- Heart rate: Tachycardia in asthma — partly disease severity, partly salbutamol effect. Normal 6-year-old HR 80–120. Callum: 130 — above normal range. Severe asthma HR >120 in school-age child.
BTS/SIGN 2019 paediatric asthma severity classification (age ≥2 years):
- Mild: SpO₂ ≥94%, mild wheeze, can talk in sentences, RR mildly elevated, HR normal or mildly elevated, PEFR ≥75% predicted.
- Moderate: SpO₂ 92–94%, moderate wheeze and recession, too breathless to complete sentences, RR elevated (>30 in 6-year-old), HR elevated (>120 in school-age), PEFR 50–75%.
- Severe: SpO₂ <92%, severe wheeze or silent chest, can't speak, RR >40, HR >130 school-age, PEFR <50%, use of accessory muscles.
- Life-threatening: SpO₂ <92% despite O₂, silent chest, cyanosis, poor respiratory effort, exhaustion, altered consciousness, PEFR <33%.
- Callum: SpO₂ 92%, RR 38, HR 130 = moderate to severe (borderline severe).
Management — moderate to severe asthma in a 6-year-old:
- Oxygen: High-flow oxygen via face mask to achieve SpO₂ ≥94%. BTS: 94–98% target in asthma (avoid hyperoxia).
- Salbutamol: MDI + spacer (Volumatic or AeroChamber) is preferred over nebuliser for mild and moderate asthma (BTS SIGN — equivalent efficacy, fewer side effects, faster delivery). 10 puffs of 100 mcg salbutamol via spacer, every 20–30 minutes initially. Nebulised salbutamol 2.5 mg (under 5 years) or 5 mg (5+ years) via tight-fitting mask for severe attacks or if spacer not tolerated. Continuous nebulisation in life-threatening.
- Ipratropium bromide: Add for moderate and severe. 0.25 mg (250 mcg) nebulised, up to 3 doses in first hour, then every 4–6 hours. Combination with salbutamol reduces hospital admission rate. Not recommended for mild asthma.
- Prednisolone oral: 1–2 mg/kg (max 40 mg) for moderate and above. Start immediately — anti-inflammatory effect takes 4–6 hours. If vomiting: IV hydrocortisone 4 mg/kg.
- IV Magnesium sulphate 40 mg/kg (max 2g) IV over 20 minutes — for severe asthma not responding to initial bronchodilators and steroids. Bronchodilator mechanism (calcium channel blockade in smooth muscle). Safe and effective in paediatrics. BTS recommends after 1st hour of bronchodilator treatment if still severe.
- IV Aminophylline: Reserve for life-threatening or near-fatal asthma not responding to above. Loading dose 5 mg/kg over 20 min (omit if on theophylline at home), then infusion 1 mg/kg/hour. Monitor theophylline levels and ECG. Narrow therapeutic window — toxicity: nausea, arrhythmia, seizures.
- PICU referral criteria: Life-threatening features, failure to respond to IV magnesium, requiring ventilatory support, SpO₂ <92% despite maximum treatment, exhaustion.
- Admission criteria: Moderate-severe asthma, SpO₂ <94% after treatment, PEFR <75% predicted after treatment, poor home conditions or previous severe attack.

⚠️ Examiner / Role-player Instructions — Not for Candidate

Provide findings as candidate examines: "Callum is sitting forward on the trolley, appears anxious. RR 38, HR 130, SpO₂ 92% on air." "On inspection — subcostal and intercostal recession visible bilaterally. Nasal flaring. Trachea midline." "On auscultation — bilateral expiratory wheeze, reduced air entry at both bases. Prolonged expiratory phase. No focal crackles." "Peak flow attempt: Callum manages 105 L/min — predicted 185 L/min for his height (= 57% predicted)." Key checkpoints: Did candidate observe before touching? Did they count RR for a full minute? Did they classify severity correctly (moderate-severe)? Did they know MDI + spacer is preferred over nebuliser for moderate? Did they add ipratropium? Did they prescribe prednisolone?

🔔 Examiner Cues ▼

If candidate immediately starts nebuliser without spacer attempt: "BTS/SIGN guidelines favour which device as first-line for moderate asthma in a cooperative 6-year-old?"
If candidate omits ipratropium for moderate asthma: "What bronchodilator would you add to salbutamol for moderate and severe paediatric asthma?"
If candidate doesn't classify severity: "Based on the findings — what BTS/SIGN severity grade is this attack, and which clinical features are driving your classification?"
At 7 minutes: "After two rounds of salbutamol and ipratropium, SpO₂ remains 91% and Callum looks more tired. What is your next step?"

Criterion	Marks
Paediatric Approach and Inspection
Child-centred approach — gain trust, parent present, observe before touching, explain to child; RR counted for full 60 seconds	2
Inspection — work of breathing assessed (recession, tracheal tug, nasal flaring, accessory muscles, posture); SpO₂, HR, PEFR documented	2
Examination Findings
Auscultation — bilateral wheeze, prolonged expiratory phase, air entry, silent chest significance explained; PEFR 57% predicted calculated	2
BTS/SIGN severity correctly classified — moderate-severe (SpO₂ 92%, RR 38, HR 130, PEFR 57%); life-threatening features enumerated	3
Management
Oxygen to target SpO₂ 94–98%; salbutamol via MDI + spacer (preferred over nebuliser in moderate) — 10 puffs 100 mcg; ipratropium added for moderate/severe	3
Prednisolone 1–2 mg/kg oral immediately; IV magnesium 40 mg/kg for severe not responding to initial treatment; aminophylline for life-threatening	3
PICU referral criteria stated — life-threatening features, failure to respond, requiring ventilation; admission criteria for moderate-severe	3
Total	20

🔧

Pericardiocentesis — Cardiac Tamponade Recognition and Drainage

Procedure · 8 minStation 5 of 10

✓

▼

8:00

Station type

Practical Procedure

Time allowed

8 minutes

Pass mark

12 / 20

📄 Candidate Briefing

👁 Examiner Instructions

✅ Mark Scheme

📄 Candidate Instructions

You are the ED registrar. Mr Arthur Patel, 55 years old, presented 3 days post cardiac surgery with progressive breathlessness, BP 80/60, HR 128. On examination: raised JVP, muffled heart sounds, pulsus paradoxus >10 mmHg. A bedside echo confirms a large pericardial effusion with tamponade physiology (RV diastolic collapse).

Obs: HR 128, BP 80/60, RR 24, SpO₂ 94% on 4L O₂, GCS 15.

Please talk the examiner through your diagnosis, the pericardiocentesis technique, and immediate management. The examiner will play the role of the assisting nurse. You have 8 minutes.

💡 Cardiac Tamponade — Pericardiocentesis Technique, Complications ▼

Cardiac tamponade — recognition:
- Beck's triad: Hypotension + raised JVP + muffled heart sounds. Present together in only ~40% of tamponade — do not wait for all three.
- Pulsus paradoxus: Exaggerated fall in SBP >10 mmHg on inspiration (normal ≤10 mmHg). Mechanism: inspiration increases RV filling → interventricular septum shifts left → reduces LV filling → SBP falls. Measure with sphygmomanometer — inflate, deflate slowly, note BP at first Korotkoff sound on expiration, then on inspiration; difference >10 = significant. Also visible on arterial line trace or pulse oximetry waveform variation.
- Echo findings of tamponade physiology: Large pericardial effusion. RV diastolic collapse (most sensitive sign — occurs before haemodynamic compromise). RA systolic collapse. IVC plethora (dilated, non-collapsing IVC on inspiration >50%). Respiratory variation in mitral/tricuspid inflow >25%.
- Causes of pericardial effusion leading to tamponade: Post-cardiac surgery (haemopericardium — this case), malignancy (most common non-traumatic in adults), uraemia, viral pericarditis, aortic dissection (type A — haemopericardium), hypothyroidism, TB, SLE, radiation.
- Post-cardiac surgery tamponade: Can be loculated — posterior effusion may not drain via standard subxiphoid approach. Urgent cardiothoracic surgery referral. Surgical drainage (pericardial window) is definitive. Pericardiocentesis is temporising here.
Pericardiocentesis is a TEMPORISING procedure — definitive = surgical drainage: Especially in post-surgical tamponade where loculated clot may not drain via needle. However, in haemodynamic collapse — pericardiocentesis can be life-saving temporising measure.
Technique — subxiphoid approach (standard):
- Positioning: Patient at 30–45° semi-recumbent (brings pericardium anteriorly, shifts fluid inferiorly, improves access).
- Monitoring: Continuous ECG (12-lead attached), continuous SpO₂, BP monitoring. Echo guidance if available (reduces complications by ~50% — identifies optimal window, confirms needle position, avoids lung).
- Procedure site: Subxiphoid approach — insert needle at the xiphisternum–left costal margin angle, angled at 45° toward the left shoulder (not left nipple — too lateral; not straight up — too anterior). Angle accounts for cardiac axis.
- Equipment: 18G spinal needle (or specific pericardiocentesis kit) with 3-way stopcock and 20–50 mL syringe, guidewire, dilator, pigtail drain (Seldinger technique for prolonged drainage).
- Local anaesthesia: 1% lidocaine skin infiltration along needle track.
- Advance the needle: Slowly, aspirating continuously under negative pressure. Angle: 45° to skin, aiming toward left shoulder. You are passing through: skin → subcutaneous fat → linea alba → pericardium.
- ECG monitoring during advancement: Connect needle to V lead of ECG via an alligator clip. If you see: ST elevation or ventricular ectopics (PVCs) → myocardial contact — withdraw the needle slightly until ECG normalises. This is the "injury current" from myocardial contact.
- Confirming pericardial position: Aspiration of fluid. If uncertain whether blood is from pericardium or ventricle: pericardial blood typically does NOT clot (defibrinated by cardiac motion); ventricular blood clots. Or inject 1–2 mL saline with air bubbles under echo guidance — bubbles in pericardium = correct position; in ventricle = withdraw.
- Aspirate: Remove fluid — start with 20–50 mL. Even small aspiration (20 mL) can dramatically improve haemodynamics in tamponade (pericardium is inelastic). Record volume, colour, appearance. Send for: cytology, MC&S, LDH, glucose, protein, pH, AFB (TB). Save sample for haematology (haematocrit).
- Leave drain in situ: Insert guidewire through needle (Seldinger), dilate track, insert pigtail catheter. Connect to closed drainage bag. Secure with suture and dressing. Drain until no further output then clamp and remove after repeat echo.
- Reassess haemodynamics immediately after aspiration: BP and HR should improve. JVP should fall. Pulsus paradoxus should reduce. Repeat echo to confirm reduction in effusion and normalisation of RV filling.
Complications:
- Myocardial perforation: Most serious. Suggested by: ventricular ectopics or ST elevation on ECG during procedure, worsening haemodynamics, bright red blood aspirated that clots. Management: if haemodynamically compromised → immediate cardiothoracic surgery.
- Arrhythmia: Ventricular ectopics, VT/VF if myocardial contact. Ensure defibrillator immediately available.
- Pneumothorax: Lung puncture. CXR post-procedure.
- Air embolism: Avoid introducing air into the pericardial space.
- Coronary artery or vein laceration: Haemopericardium worsens.
- Infection: Strict aseptic technique.
- Unsuccessful drainage: Loculated effusion (especially post-surgical) — surgical window required.
Cardiothoracic surgery referral: All post-surgical tamponade requires urgent cardiothoracic review — pericardiocentesis is bridging only. Post-surgical haemopericardium is often loculated and clotted — requires surgical exploration and irrigation.

⚠️ Examiner Instructions — Not for Candidate

This is a structured viva/simulation station. Act as assisting nurse. Prompt: "Everything is set up — talk me through exactly what you're going to do." Then: "You're advancing the needle — what are you watching on the ECG?" Then: "You see a run of VEs and the ECG shows ST elevation in V1–V3." Expect candidate to recognise myocardial contact and withdraw needle. Then: "ECG normalises — you aspirate 60 mL of dark brown non-clotting fluid. BP rises to 100/70." Key checkpoints: Did they position patient at 45°? Did they state left shoulder angle? Did they know ECG monitoring during advancement (ST elevation = myocardial contact)? Did they state pericardiocentesis is temporising? Did they call cardiothoracics for this post-surgical patient?

🔔 Examiner Cues ▼

If candidate states pericardiocentesis is definitive treatment: "Given this is a post-cardiac surgery patient — is needle drainage always the final treatment?"
If candidate omits ECG monitoring on the needle: "How will you know if your needle has contacted the myocardium during advancement?"
If candidate doesn't know what to do with the aspirated fluid: "The fluid is dark brown and non-clotting — what does that tell you? What do you send it for?"
At 7 minutes: "60 mL drained, BP improved to 100/70. Do you remove the needle now or leave a drain?"

Criterion	Marks
Diagnosis and Preparation
Cardiac tamponade diagnosed — Beck's triad, pulsus paradoxus, echo findings (RV diastolic collapse); haemodynamic compromise recognised	2
Pericardiocentesis stated as temporising only; cardiothoracic surgery called urgently for post-surgical tamponade — loculated clot may require surgical drainage	2
Patient positioned 30–45° semi-recumbent; continuous ECG, SpO₂, BP monitoring; echo guidance if available; defibrillator ready	2
Technique
Subxiphoid approach stated — needle at xiphisternum-left costal margin angle; angled 45° toward left shoulder; local anaesthetic infiltrated	2
ECG monitoring during advancement — ST elevation or VEs = myocardial contact, withdraw needle immediately; recognises this complication when presented	3
Aspirate fluid — confirms non-clotting dark blood = pericardial; volume aspirated; fluid sent for cytology, MC&S, LDH, glucose, protein	2
Post-procedure
Pigtail drain left in situ via Seldinger technique for ongoing drainage; reassess haemodynamics after aspiration (BP/HR/JVP/echo)	3
Complications stated — myocardial perforation, arrhythmia, pneumothorax, air embolism, coronary vessel injury	2
Total	20

🔧

Acute Compartment Syndrome — Recognition and Emergency Fasciotomy Referral

Procedure · 8 minStation 6 of 10

✓

▼

8:00

Station type

Practical Procedure

Time allowed

8 minutes

Pass mark

12 / 20

📄 Candidate Briefing

👁 Examiner Instructions

✅ Mark Scheme

📄 Candidate Instructions

You are the ED registrar. Mr Kyle Henderson, 28 years old, was brought in 3 hours ago following a crush injury to his right forearm at work. A backslab has been applied. He is now reporting severe, worsening pain in the forearm — far worse than expected — and tingling in the right hand.

Obs: HR 108, BP 132/84, RR 18, SpO₂ 99% on air, GCS 15. His right forearm feels tight and is visibly swollen. Radial pulse is palpable.

Please assess Mr Henderson, make a diagnosis, describe how you would measure compartment pressure, and outline your immediate management. The examiner will provide findings on request. You have 8 minutes.

💡 Acute Compartment Syndrome — 6 Ps, Pressure Measurement, Fasciotomy ▼

Acute compartment syndrome (ACS) — definition: Raised pressure within a closed fascial compartment that compromises perfusion pressure, causing ischaemia of the muscles and nerves within. Surgical emergency — irreversible muscle necrosis begins within 6–8 hours of ischaemia. Every minute matters.
Common causes in ED: Fractures (especially tibial — most common; forearm, femoral, humeral). Crush injuries. Reperfusion after ischaemia. Burns with circumferential eschar. Tight casts, splints, or circumferential dressings. Bleeding disorders. IV infiltration of fluids. Prolonged immobility (drug overdose, seizures).
Clinical diagnosis — the 6 Ps (in order of appearance):
- 1. Pain out of proportion — the cardinal and earliest sign. Pain far exceeding what would be expected for the injury. Does NOT correlate with fracture severity. Continuous, burning, deep aching. Increasing analgesia requirement. This should trigger immediate suspicion.
- 2. Pain on passive stretch — highly sensitive and specific early sign. Passively extend the fingers (for forearm compartment) or dorsiflex the foot (for leg compartment) → reproduces or markedly worsens the compartment pain. This stretches the ischaemic muscles. Perform gently — do not cause unnecessary distress. A positive passive stretch test is strongly suggestive of ACS even with normal neurovascular status.
- 3. Pressure (compartment feels tense) — palpate the compartment. The forearm (or leg) feels woody, tense, non-compressible. Swelling is present. Even gentle deep palpation is exquisitely tender.
- 4. Paraesthesia — tingling, numbness in the distribution of the nerve traversing the compartment. For forearm: median nerve (palmar aspect thumb, index, middle), ulnar nerve (ring and little finger), anterior interosseous nerve. Early neurological sign — indicates nerve ischaemia. Mr Henderson has tingling in his hand — this is present.
- 5. Pallor — skin pallor distal to the compartment. Later sign. Pulses may still be palpable (compartment pressure rarely exceeds systolic BP until very late — do NOT be falsely reassured by a palpable radial pulse).
- 6. Paralysis — inability to actively move digits/limb. Late sign — indicates irreversible muscle/nerve damage. If paralysis is present, irreversible damage may already have occurred. Do not wait for paralysis to act.
CRITICAL POINT — Presence of pulses does NOT exclude ACS: Compartment pressure only needs to exceed capillary perfusion pressure (~30 mmHg) to cause ischaemia — not systolic BP. A patient can have ACS with a normal radial pulse. Loss of pulse is a very late, pre-necrosis sign. Never use "pulse present" to exclude the diagnosis.
Immediate management — before pressure measurement:
- Remove ALL circumferential dressings, splints, and casts immediately. This alone may reduce pressure by up to 65% in early ACS. Cut down to skin — bivalve the cast, cut bandages, remove backslab entirely. Do not simply loosen — remove completely.
- Limb position — elevate to HEART LEVEL ONLY. Do NOT elevate above heart level — this reduces arterial perfusion pressure to the compartment and worsens ischaemia. Counter-intuitively, elevation in ACS is harmful. Heart level = neutral position is optimal.
- Analgesia — IV morphine/opioids titrated. However, be aware: adequate analgesia may mask the cardinal symptom. Use pain trends (increasing vs improving) and passive stretch to continue monitoring.
- Urgent orthopaedic referral immediately — for emergency fasciotomy. Do NOT delay referral while waiting for pressure measurement if the clinical diagnosis is established. The decision to operate should be made on clinical grounds.
- Keep NBM (nil by mouth) — surgical procedure imminent.
- IV access, bloods — FBC, U&E, coagulation, group and save. Urine myoglobin/CK — rhabdomyolysis.
- IV fluids — maintain urine output >1 mL/kg/hour to prevent myoglobinuric renal failure. Sodium bicarbonate to alkalinise urine may be added.
Compartment pressure measurement — technique (Stryker device or arterial line manometer method):
- When to measure: Useful in: unconscious patients (cannot report pain), equivocal clinical signs, uncooperative patients, litigation risk. Do NOT delay surgical referral for pressure measurement if clinical diagnosis is clear.
- Stryker intra-compartmental pressure monitor (most common in UK EDs):
  1. Assemble the Stryker device — attach 18G needle, fill syringe with 3 mL 0.9% NaCl, prime the tubing.
  2. Identify the correct compartment to measure. For forearm: volar (anterior) compartment is most commonly involved.
  3. Clean skin with antiseptic. Local anaesthetic optional (may affect reading).
  4. Insert needle perpendicular to skin into the centre of the compartment (not near fracture site — may give false reading).
  5. Inject 0.3 mL saline — ensures needle is patent and within the compartment. Watch pressure reading on device.
  6. Wait for reading to stabilise. Record pressure in mmHg.
  7. Measure multiple compartments if clinical suspicion — forearm has volar, dorsal, and mobile wad compartments.
- Interpretation:
  - Normal compartment pressure: <10–20 mmHg.
  - Absolute pressure threshold for fasciotomy: >30 mmHg (some centres use >20 mmHg).
  - Delta pressure (ΔP) threshold — most clinically useful: ΔP = Diastolic BP − Compartment pressure. ΔP ≤30 mmHg = fasciotomy indicated. Accounts for individual perfusion pressure. Example: diastolic BP 80 mmHg, compartment pressure 55 mmHg → ΔP = 25 mmHg → fasciotomy. Or: diastolic 60 mmHg, compartment pressure 35 mmHg → ΔP = 25 → fasciotomy (even though absolute pressure <40). Hypotensive patients (trauma, shock) can develop ACS at lower absolute compartment pressures.
Emergency fasciotomy: Performed under general anaesthesia in theatre. For forearm: two-incision technique (volar and dorsal). For lower leg: four-compartment fasciotomy via two incisions (medial and lateral). Wounds left open — closed at 48–72 hours once swelling resolves, or skin grafted. Orthopaedic surgeon performs (or vascular if vascular injury component).
Complications of missed or delayed ACS:
- Volkmann's ischaemic contracture: Permanent contracture of forearm flexor muscles due to ischaemic fibrosis. Wrist and fingers held in flexion. Life-long disability. Classic complication of missed forearm ACS (especially supracondylar fracture in children).
- Rhabdomyolysis and myoglobinuria: Myoglobin from necrotic muscle → acute tubular necrosis → acute kidney injury. Urine turns brown (myoglobinuria). Treat with aggressive IV fluids, urine alkalinisation.
- Renal failure requiring dialysis.
- Amputation if tissue necrosis is extensive.
- Sepsis from necrotic muscle (gas gangrene — Clostridial infection).
- Medicolegal liability: Missed ACS is one of the most common causes of orthopaedic negligence claims.

⚠️ Examiner Instructions — Not for Candidate

Provide findings as candidate examines: "On palpation — the forearm is tight and woody, exquisitely tender diffusely." "Passive finger extension markedly worsens his forearm pain." "Sensation reduced over the lateral 3½ fingers of the right hand — median nerve distribution." "Radial pulse palpable, capillary refill 2 seconds." If candidate elevates limb above heart level: "You've elevated the arm — is there any concern about elevation in compartment syndrome?" If candidate waits for Stryker readings before calling orthopaedics: "Is the diagnosis clear enough clinically to make the referral now?" Key checkpoints: Did they remove the backslab immediately? Did they know elevation should be to heart level ONLY? Did they state delta pressure ≤30 mmHg threshold? Did they NOT delay surgical referral? Did they mention Volkmann's contracture as a complication?

🔔 Examiner Cues ▼

If candidate elevates above heart level: "How does limb position affect compartment perfusion pressure — and what is the recommended position in ACS?"
If candidate states 'pulse present, so no ACS': "At what pressure does compartment syndrome cause ischaemia — and how does this relate to systolic BP?"
If candidate waits for Stryker before orthopaedic referral: "The clinical picture is clear — what is the cost of delay in acute compartment syndrome?"
At 7 minutes: "Orthopaedics review and agree — they want a compartment pressure reading first. Diastolic BP is 78. Stryker reads 52 mmHg in the volar compartment. What is the delta pressure and what does it mean?"

Criterion	Marks
Diagnosis
ACS diagnosed clinically — pain out of proportion and on passive stretch as cardinal signs; tense compartment and paraesthesia supporting; palpable pulse does NOT exclude diagnosis	3
6 Ps correctly described — in order; late signs (pallor, paralysis) distinguished from early signs; explains irreversible damage if late signs present	2
Immediate Management
All circumferential dressings and backslab removed immediately; limb positioned at heart level only — above heart level harmful (reduces perfusion pressure)	3
Urgent orthopaedic referral made immediately — does NOT delay for pressure measurement when clinical diagnosis established; keeps NBM, IV access, bloods including CK/myoglobin	2
Pressure Measurement
Stryker technique described correctly — prime, insert into compartment, inject 0.3 mL saline, wait for stable reading	2
Threshold stated: absolute >30 mmHg OR delta pressure (diastolic − compartment pressure) ≤30 mmHg; delta pressure calculated correctly in examiner scenario (78−52=26 ≤30 → fasciotomy)	3
Complications of missed ACS: Volkmann's contracture, rhabdomyolysis/myoglobinuric renal failure, amputation stated	3
Total	20

💬

Paediatric Resuscitation — Communication with Parents (RCPCH/RCEM Guidance)

Communication · 8 minStation 7 of 10

✓

▼

8:00

Station type

Communication

Time allowed

8 minutes

Pass mark

12 / 20

📄 Candidate Briefing

👁 Examiner Instructions

✅ Mark Scheme

📄 Candidate Instructions

You are the ED registrar leading the resuscitation of Amelia Chen, 4 years old, who was found unresponsive at home and brought in by ambulance. She is currently being resuscitated in resus bay — the team leader has taken over and you have been asked to speak with her parents.

Mr and Mrs Chen have just arrived at the ED — they were called by a neighbour. They are extremely distressed and do not know the details of what has happened.

The examiner will play both parents. Please speak with Mr and Mrs Chen — update them on Amelia's situation, address their questions and requests, and manage this communication sensitively. You have 8 minutes.

💡 Paediatric Resuscitation — Family Communication, Parental Presence, RCPCH/RCEM ▼

Immediate priorities when family arrives:
- Do NOT keep them waiting in the main waiting room — they must be seen immediately.
- Escort to a designated family liaison area or quiet side room — away from clinical activity, private, with seating. Not a corridor.
- Introduce yourself clearly: full name and role. "I'm Dr [name], one of the emergency medicine registrars. I've been asked to come and speak with you while my colleagues are caring for Amelia."
- Ensure a dedicated nurse (family liaison nurse, bereavement nurse, or resus nurse) is assigned to stay with the family throughout — never leave parents alone.
- Offer tissues, water. Ask if there is anyone else they would like present (another family member, friend).
Delivering the update honestly — what to say (and not say):
- Use plain, clear language: "Amelia is very seriously ill. Our team is doing everything they can for her right now." Do NOT use: "She's coding," "She's crashing," "She's in arrest," "She's flatlined" — these are clinical terms that may cause confusion or panic.
- Be honest about severity: "I have to be honest with you — Amelia's heart has stopped, and our team is working to restart it. This is a very serious situation." Use the word "heart stopped" rather than "cardiac arrest" if needed for clarity, but do not hide the severity.
- Explain what is happening in the resus bay: "There is a large team of doctors and nurses around her. They are giving her medicines and breathing for her. Everything that can be done is being done."
- Do NOT give false hope ("I'm sure she'll be fine") or premature certainty of outcome.
- Do NOT speculate on cause at this stage — you do not yet know. "We don't yet know exactly why this happened — we're focused on helping her right now."
Parental presence during resuscitation — RCPCH and RCEM guidance:
- Parents should be offered the option to be present during resuscitation of their child. This is evidence-based — studies show most parents who are present report it helps them cope with bereavement, reduces post-traumatic stress, and they feel they were able to say goodbye.
- Offer but do not insist — some parents will not wish to be present and this must be respected.
- If they choose to be present: escort them in, assign the family liaison nurse to be beside them at all times. Brief them before entering: "It can look frightening — there are a lot of people around Amelia and a lot of equipment. The nurse will be with you the whole time." Maintain their position at the foot of the bed — do not interfere with active resuscitation.
- If parents choose not to be present: update them regularly (every 5–10 minutes). Do not abandon them between updates.
Addressing father's demand to "do everything":
- Validate the emotion: "I completely understand — she is your child. We want to do everything possible for her too."
- Reassure: "The full team is with her. Every intervention that is appropriate is being done right now."
- Do not make promises about outcome: "I can't promise you what will happen — but I can promise you that our team is doing everything they can."
- If a decision to stop resuscitation becomes necessary — this is a separate conversation, done sensitively, with the most senior clinician available. This station does not necessarily reach that point but candidate should be prepared to transition if the examiner takes it there.
Preparing family for possible outcome:
- This must be done gently but honestly: "I want to be honest with you — Amelia is very seriously ill, and despite everything we are doing, I have to prepare you that we may not be able to save her. I hope that is not the case, but I need you to know."
- Allow silence after this. Respond to emotion first before continuing.
- Offer chaplaincy/spiritual support proactively regardless of apparent religion.
If resuscitation is unsuccessful — transition to breaking bad news:
- Ask team leader to pause briefly to speak with parents. Return to family liaison room (do not break news in resus bay).
- Use SPIKES framework — Setting, Perception, Invitation, Knowledge (use "died"), Emotions, Strategy. (As per Bank 10, Station 7.)
- Offer to view Amelia. Explain that tubes may still be in place.
- Coroner referral — child unexpected death. Child death review process (CDOP — Child Death Overview Panel) mandatory for all unexpected child deaths.
- Safeguarding consideration — any unexpected child death requires safeguarding review. Do not discharge family until police/social services have been informed (standard procedure).
Documentation: Document all communications with family — time, content, who was present, what was said, family's response, who was assigned as family liaison nurse.

⚠️ Examiner / Role-player Instructions — Not for Candidate

Play both parents. Mrs Chen: Initially silent and shaking, then quietly asks "Is she going to be okay?" Becomes tearful when told the severity. Later asks to see Amelia. Mr Chen: Immediately demands "What's happening? I need to see her! Do EVERYTHING — whatever it takes, money is no object, I don't care." If candidate offers parental presence: "Yes, I want to be in there." If resus unsuccessful (at 6 minutes, if candidate is managing well): "The team leader comes to the door and gives you a thumbs down — resus has been stopped." Expect candidate to transition to breaking bad news. Key checkpoints: Did candidate find a private room? Did they use plain language (not "arrest", "crash")? Did they offer parental presence? Did they assign a nurse to family? Did they prepare parents for possible bad outcome? Did they transition to breaking bad news if prompted?

🎭 Parent Script ▼

Mr Chen (immediately): "What is happening? Where is my daughter? I want to see her NOW. Do EVERYTHING — you hear me? Whatever it takes."
Mrs Chen (quietly): "She was fine this morning. She was playing. I don't understand. Is she going to be okay?" [Begins crying quietly].
If offered parental presence: Mr Chen — "Yes, I want to go in there." [Expect candidate to brief him before entering: equipment, what to expect, nurse will be with him].
If resus stopped: Both parents should react with shock. Mrs Chen: "No. No. No." Mr Chen: angry, then collapses into grief. "She's only 4. How? Why?"
Question about cause: "Why did this happen? Was it something we did? Could we have done something?" [Expect candidate to not speculate, validate grief, not assign blame].

🔔 Examiner Cues ▼

If candidate uses "coding" or "arrest": "Mr Chen looks confused — 'What does that mean? She's been arrested?'"
If candidate doesn't offer parental presence: "Mr Chen asks again to be present — does RCPCH/RCEM guidance support this?"
If candidate doesn't assign a nurse to stay with family: "You're called back into resus — who is looking after Mr and Mrs Chen?"
If candidate doesn't prepare family for possible poor outcome: "Is it fair to the parents not to prepare them for the possibility that Amelia might not survive?"
At 6 minutes (if station needs challenge): "Resus team leader gives a thumbs-down — resus has been stopped. What do you do now?"

Criterion	Marks
Setting and Introduction
Private room used immediately — not waiting room or corridor; introduced self with name and role; dedicated nurse assigned to stay with family throughout	2
Plain language used — "heart has stopped," not "coding/crashing/arrest"; severity communicated honestly without false hope	2
Parental Presence
Parental presence offered — RCPCH/RCEM guidance cited; offer but not insist; family briefed before entering (equipment, nurse with them)	3
Father's "do everything" demand acknowledged empathically — reassured team is doing everything appropriate; no false promises about outcome	2
Preparation and Transition
Family prepared gently for possible poor outcome — honest, allows silence, responds to emotion; chaplaincy offered	3
Transition to breaking bad news if resus unsuccessful — returns to private room; uses word "died"; does not deliver news in resus bay	3
Safeguarding and child death review process (CDOP) mentioned; coroner referral; documentation of communication	3
Total	20

💬

Responding to a Written Complaint — Duty of Candour and PALS Process

Communication · 8 minStation 8 of 10

✓

▼

8:00

Station type

Communication

Time allowed

8 minutes

Pass mark

12 / 20

📄 Candidate Briefing

👁 Examiner Instructions

✅ Mark Scheme

📄 Candidate Instructions

You are an ED consultant. You have received a formal written complaint from Mrs Patricia Howard regarding the care of her 78-year-old husband, Mr George Howard, who attended the ED last month with a hip fracture.

Mrs Howard's complaint states: "My husband waited for 6 hours in pain before anyone gave him anything for it. We asked for help multiple times and staff were dismissive and rude. He is still traumatised."

Mrs Howard has agreed to attend a face-to-face meeting with you today. The examiner will play Mrs Howard. Please conduct the meeting — acknowledge the complaint, explain the investigation process, and manage the meeting sensitively. You have 8 minutes.

💡 Complaint Response — Duty of Candour, PALS, Investigation Process ▼

Preparing for the meeting — before Mrs Howard arrives:
- Review the available records: triage documentation, drug chart (when analgesia prescribed and administered), nursing notes, medical notes. Do not attend the meeting without having reviewed what you can access — you may not have seen Mr Howard personally but you should know the basic timeline.
- Have a clinical governance or patient experience colleague available (optional but supportive). Some hospitals require a patient liaison or complaints officer to be present.
- Ensure a private room — not a corridor or public area. Sit across from, not behind a desk (removes barrier).
Opening the meeting — acknowledgement:
- Introduce yourself: "I'm Dr [name], one of the consultant emergency physicians. Thank you for coming in today, and thank you for taking the time to write to us."
- Acknowledge immediately and sincerely: "First of all, I want to say that I'm genuinely sorry for the experience your husband had. What you've described — waiting in pain for 6 hours — is not the standard of care we aim to provide, and I understand why you are upset and why you felt you needed to raise this."
- This is NOT an admission of liability — it is an expression of empathy and acknowledgement of their experience. Saying "I'm sorry this happened" or "I'm sorry you experienced this" is different from "I admit we were negligent."
- Allow Mrs Howard to tell her account first before you respond with information. "Would you like to tell me, in your own words, what happened from your perspective?" Listen actively — do not interrupt, do not take notes during her account (it signals you are not listening).
Duty of Candour (Health and Social Care Act 2008, Regulation 20 — Statutory Duty of Candour):
- Applies when a patient has suffered moderate to severe harm (or death) as a result of a notifiable safety incident — including failure to provide appropriate analgesia for a painful condition in a vulnerable adult.
- Duty of Candour requires the trust to: (1) inform the patient/family that an incident has occurred as soon as reasonably practicable, (2) provide a reasonable explanation of the facts, (3) offer an apology, (4) provide a written record.
- Candidate should reference Duty of Candour explicitly: "As part of our Duty of Candour, we have an obligation to be open and honest with you about what happened to your husband."
- If the investigation reveals an error or gap in care — this must be disclosed honestly and a further apology offered.
Apology — how to frame it:
- Always apologise for the distress caused — this is always appropriate and genuine. "I am sorry that your husband was in pain and that you felt dismissed."
- Apologise for the experience even if you do not yet know whether the care was clinically substandard — "I'm sorry this was your experience."
- Do NOT apologise for specific clinical decisions until you have reviewed the records and know what happened — you do not yet know if analgesia was prescribed and not given, given and not documented, or genuinely not prescribed.
- Do NOT be defensive: "Well, the department was very busy that day" or "There are very strict protocols we have to follow" — even if true, this sounds like you are making excuses and dismisses the complaint.
- Do NOT offer financial compensation — this is outside your remit and could prejudice legal proceedings. Direct to PALS/NHSR (NHS Resolution) if compensation is sought.
Explaining the complaints investigation process:
- PALS (Patient Advice and Liaison Service): Informal complaints and concerns — PALS can often resolve issues quickly. If Mrs Howard has already submitted a formal complaint, this is now in the formal process.
- Formal complaint process (NHS Complaints Regulations 2009):
  - Formal written response from the Trust within 25 working days (or agreed extended timeline with complainant if more complex).
  - Response signed by the Chief Executive or nominated clinician.
  - What will be reviewed: triage records (time of arrival, triage category assigned — expected analgesia within 30 minutes for fracture hip under RCEM standards), drug charts (when analgesia prescribed and given), nursing notes (requests for pain relief), medical notes (first review time), staffing levels at the time.
  - Root cause analysis (RCA) if serious incident criteria met.
  - If not satisfied with Trust response — Parliamentary and Health Service Ombudsman (PHSO) — independent review.
What changes may result (learning):
- "Regardless of the investigation outcome, we take this seriously and will use what we learn to improve care."
- Potential actions: audit of analgesia documentation for elderly trauma patients, mandatory pain assessment at triage for hip fracture (RCEM quality indicator), staff communication training, introduction of dedicated elderly care coordinator in ED.
- Share findings with Mrs Howard once complete — offer follow-up meeting.
Offer follow-up: "Once the investigation is complete, I would like to meet with you again to share what we found and what we have done as a result. Would that be helpful?" Give her a named contact (complaint coordinator's details).
RCEM standard for pain management in hip fracture: RCEM Quality Improvement guidelines recommend analgesia assessment and prescribing within 30 minutes of triage for suspected hip fracture. Pain scores should be documented. Femoral nerve block / fascia iliaca block should be offered. This is the standard against which Mr Howard's care will be reviewed.

⚠️ Examiner / Role-player Instructions — Not for Candidate

Play Mrs Howard — upset, dignified, not aggressive. She is not after money — she wants an apology and to know that "this won't happen to someone else." She has a list of points she wants to raise: (1) "He was in agony for 6 hours — no one came." (2) "When I asked the nurse she said 'we're busy, love' and walked off." (3) "He has hip surgery now and he's still scared of hospitals." She is satisfied by genuine acknowledgement, apology, and an explanation of what will happen. She is NOT satisfied by defensiveness or excuses. Key checkpoints: Did candidate apologise sincerely without being defensive? Did they mention Duty of Candour? Did they explain the 25 working day response timeline? Did they offer a face-to-face follow-up meeting? Did they NOT offer financial compensation?

🎭 Complainant Script ▼

Opening: "Thank you for seeing me. I just want to understand what happened and why. I don't want this to happen to anyone else's husband." [Sits down, composed but emotional].
Her account: "We arrived at 10am. He was in absolute agony. He'd fallen in the garden. We were told to wait. We waited, and waited. I asked the nurse twice — once she said 'we'll be with you shortly' and that was it. By 4pm he still hadn't had a single paracetamol. 4pm! Six hours."
If candidate is defensive: "So you're saying it was acceptable? That my 78-year-old husband with a broken hip should wait 6 hours in pain?" [Becomes more distressed — tests candidate's ability to de-escalate].
If candidate apologises sincerely: [Softens slightly] "I appreciate that. I just needed to hear someone say that. What happens next?"
If candidate mentions compensation: "I'm not after money. I just want answers and for this not to happen again."

🔔 Examiner Cues ▼

If candidate is defensive ("the department was very busy"): "Mrs Howard looks hurt — 'Does that mean it was acceptable for my husband to wait 6 hours in agony?'"
If candidate doesn't mention Duty of Candour: "Are there any statutory obligations the Trust has in relation to patient harm that you should mention?"
If candidate gives vague timeline ("we'll look into it"): "Mrs Howard asks — how long will this take and who will write back to me?"
At 7 minutes: "Mrs Howard asks: 'What if I'm not happy with the written response — what can I do next?'"

Criterion	Marks
Acknowledgement and Apology
Mrs Howard listened to fully before responding; sincere apology for distress and pain caused — not defensive, not making excuses	3
Duty of Candour referenced — obligation to be open and honest when harm has occurred; not admission of negligence but acknowledgement of experience	2
Investigation Process
PALS explained (informal route); formal complaint process explained — written response within 25 working days, signed by CE/senior clinician	3
Records to be reviewed stated — triage documentation, drug chart, nursing notes, medical review time; RCEM 30-minute analgesia standard for hip fracture referenced	2
PHSO (Parliamentary and Health Service Ombudsman) as escalation route if unsatisfied with Trust response	1
Learning and Follow-up
Learning outcomes mentioned — potential audit, triage analgesia protocol review, staff communication; results will be shared with Mrs Howard	2
Follow-up meeting offered; named contact provided; financial compensation NOT offered (outside remit)	2
Tone maintained throughout — empathic, non-defensive, professional; Mrs Howard's primary goal (acknowledgement and learning) addressed	3
Total	20

📊

Troponin and Serial ECG — NSTEMI Diagnosis and GRACE Risk Stratification

Data Interpretation · 8 minStation 9 of 10

✓

▼

8:00

Station type

Data Interpretation

Time allowed

8 minutes

Pass mark

12 / 20

📄 Candidate Briefing

👁 Examiner Instructions

✅ Mark Scheme

📄 Candidate Instructions

You are the ED registrar. Mr Frank Hussain, 59 years old, has presented with central chest pain for 4 hours. He is a smoker, hypertensive, and has a family history of IHD. No previous cardiac history.

Obs: HR 88, BP 148/92, RR 16, SpO₂ 97% on air, GCS 15. No signs of haemodynamic compromise.

The examiner will provide the ECG findings and serial troponin results. Please interpret each result, make a diagnosis, apply risk stratification, and outline your management plan. You have 8 minutes.

💡 NSTEMI — ECG, Troponin, GRACE Score, NICE NG185 Management ▼

ECG findings (examiner will read aloud): "Sinus rhythm, rate 88. ST depression 1 mm in leads V4, V5, V6, I and aVL. T-wave inversion in I and aVL. No ST elevation. No new LBBB. QRS width 80 ms. No Q waves."
ECG interpretation:
- ST depression in V4–V6 and lateral leads (I, aVL) = subendocardial ischaemia in the lateral territory.
- T-wave inversion I and aVL = further evidence of lateral ischaemia.
- This is NOT a STEMI — no ST elevation, no new LBBB. Does NOT activate primary PCI pathway.
- Lateral territory (I, aVL, V4–V6) suggests left circumflex (LCx) artery or diagonal branch of LAD.
- Critical distinction — ST depression in aVR and V1 as reciprocal changes: ST elevation in aVR with diffuse ST depression = left main stem disease or proximal LAD disease. Not present here — localised lateral changes suggest LCx territory.
- No Q waves — no completed infarction. If Q waves present — may represent completed infarct or old MI.
Troponin interpretation:
- High-sensitivity troponin T (hsTnT): Normal upper reference limit (URL) = <14 ng/L (99th percentile of reference population).
- Initial troponin T: 18 ng/L — above normal (>14), but only mildly elevated. Could represent: early MI (not yet peaked), demand ischaemia (Type 2 MI), myocarditis, PE, sepsis, renal failure.
- Repeat troponin at 3 hours: 62 ng/L.
- Delta troponin: Rise from 18 to 62 = rise of 44 ng/L = 244% rise from baseline. A rise of >50% from baseline (absolute rise >3 × URL) at 3 hours = significant delta — confirms acute MI. (ESC 0h/3h algorithm: absolute rise ≥5 ng/L + initial value ≥5 = rule-in at 0h; rise ≥4 ng/L at 1 hour with initial ≥5 = early rule-in.)
- Diagnosis: NSTEMI (Non-ST Elevation Myocardial Infarction) — significant troponin rise (delta troponin >50% at 3h), ECG changes (ST depression, T-wave inversion), clinical context (chest pain, risk factors). No ST elevation, no new LBBB → not STEMI → no primary PCI activation.
- NSTEMI vs Unstable Angina: Unstable angina = ACS without troponin rise (troponin within normal range). NSTEMI = ACS with troponin rise. Treatment broadly similar but NSTEMI carries higher short-term risk.
- Type 1 MI vs Type 2 MI: Type 1 = plaque rupture with thrombosis (this case — classic presentation). Type 2 = supply-demand mismatch without plaque rupture (tachycardia, anaemia, sepsis, PE). Distinction affects management — Type 2 requires treating the underlying cause.
GRACE score (Global Registry of Acute Coronary Events) — risk stratification:
- Predicts in-hospital and 6-month mortality in ACS. Variables: age, HR, SBP, creatinine, Killip class, cardiac arrest at presentation, ST deviation on ECG, elevated cardiac enzymes.
- For Mr Hussain (estimate): Age 59 (moderate), HR 88 (low), BP 148 (low-moderate), no Killip HF, ST changes (moderate), troponin rise (moderate) → GRACE score likely intermediate to high.
- GRACE >140 = high risk → angiography within 24 hours.
- GRACE 109–140 = intermediate risk → angiography within 72 hours.
- GRACE <109 = low risk → consider early discharge with outpatient angiography (NICE NG185).
- TIMI score is an alternative but GRACE is more accurate for NSTEMI.
Management — NICE NG185 (ACS 2020):
- Antiplatelet therapy: Aspirin 300 mg oral loading dose immediately (75 mg daily thereafter). Ticagrelor 180 mg oral loading dose + 90 mg BD thereafter — preferred P2Y12 inhibitor over clopidogrel for NSTEMI (PLATO trial). Clopidogrel 300–600 mg if ticagrelor not tolerated. Do NOT give P2Y12 inhibitor before angiography if CABG may be needed (risk of bleeding).
- Anticoagulation: Fondaparinux 2.5 mg SC daily — first-line anticoagulant for NSTEMI (OASIS-5 — lower bleeding risk than LMWH, non-inferior). Or LMWH (enoxaparin 1 mg/kg SC BD) if fondaparinux unavailable. UFH if immediate angiography planned. Continue until angiography.
- Statin: High-intensity statin immediately — atorvastatin 80 mg daily.
- Beta-blocker: Metoprolol or bisoprolol orally if no contraindication (no acute HF, no bradycardia, no severe asthma). Reduces cardiac work and ischaemia.
- GTN: Sublingual GTN for ongoing chest pain. IV GTN if recurrent ischaemia.
- Oxygen: Only if SpO₂ <94% (NICE — routine oxygen not recommended in normoxic patients — AVOID2 trial).
- Analgesia: IV morphine for pain (with antiemetic — metoclopramide). Note: morphine in ACS associated with worse outcomes in some studies (may delay absorption of P2Y12 inhibitors) — use judiciously.
- Cardiology referral: Immediate — NSTEMI is a cardiology emergency. Admit to coronary care unit (CCU). Timing of angiography by GRACE score (see above).
- Monitoring: Continuous ECG monitoring — watch for dynamic ECG changes (new LBBB, ST elevation = converts to STEMI → primary PCI). Repeat troponin at 6–12 hours if diagnosis unclear. Echo if LV function query.

⚠️ Examiner Instructions — Not for Candidate

Read ECG findings aloud: "Sinus rhythm, rate 88. ST depression 1 mm in V4, V5, V6, I and aVL. T-wave inversion in I and aVL. No ST elevation. No new LBBB. QRS width 80 ms." Then: "Initial troponin T: 18 ng/L. Normal is less than 14." Pause for interpretation. Then: "3-hour troponin T: 62 ng/L." Pause again. Then ask: "What is your diagnosis and management plan?" Key checkpoints: Did candidate correctly diagnose NSTEMI (not STEMI)? Did they identify the lateral territory? Did they calculate delta troponin rise as significant? Did they prescribe fondaparinux over LMWH as first-line? Did they know GRACE >140 = angiography within 24 hours?

🔔 Examiner Cues ▼

If candidate activates primary PCI pathway: "There is no ST elevation and no new LBBB — does this ECG meet STEMI criteria for primary PCI?"
If candidate diagnoses unstable angina: "The troponin has risen from 18 to 62 ng/L — what is the significance of this delta troponin, and does it change the diagnosis?"
If candidate prescribes LMWH without mentioning fondaparinux: "NICE NG185 recommends a specific anticoagulant as first-line for NSTEMI — which is it?"
At 7 minutes: "GRACE score comes back as 155. How does this change the timing of angiography?"

Criterion	Marks
ECG Interpretation
Systematic ECG interpretation — rate, rhythm, ST changes, T-wave inversion; lateral territory identified (I, aVL, V4–V6); LCx likely territory	2
Correctly NOT STEMI — no ST elevation, no new LBBB; does NOT activate primary PCI; subendocardial ischaemia pattern explained	2
Troponin and Diagnosis
Initial troponin 18 ng/L (above URL 14) and 3h troponin 62 ng/L interpreted; delta troponin >50% = significant rise; NSTEMI diagnosed (not unstable angina)	3
Type 1 vs Type 2 MI distinction made; NSTEMI vs unstable angina difference explained (troponin rise vs no rise)	2
GRACE and Management
GRACE score variables listed; GRACE >140 = high risk → angiography within 24 hours; intermediate 109–140 → within 72 hours	3
Dual antiplatelet — aspirin 300 mg + ticagrelor 180 mg loading; fondaparinux 2.5 mg SC as first-line anticoagulation (NICE NG185); statin and beta-blocker	3
Cardiology referral, CCU admission, continuous ECG monitoring; oxygen only if SpO₂ <94%	3
Total	20

📊

Paediatric X-Ray — Non-Accidental Injury Pattern Recognition (TEN-4, Skeletal Survey)

Data Interpretation · 8 minStation 10 of 10

✓

▼

8:00

Station type

Data Interpretation

Time allowed

8 minutes

Pass mark

12 / 20

📄 Candidate Briefing

👁 Examiner Instructions

✅ Mark Scheme

📄 Candidate Instructions

This is a two-part station. You are the ED registrar.

Part 1: An 8-month-old boy has been brought in by his parents with a history of "falling from the sofa." He is irritable and not bearing weight on the left leg. The examiner will describe the X-ray findings.

Part 2: A 2-year-old girl has been brought in by her mother with bruising noticed at nursery. The examiner will describe the bruising pattern.

For each part: interpret the findings, identify any high-risk features for non-accidental injury (NAI), and outline your immediate management. You have 8 minutes.

💡 NAI — High-Risk Fracture Patterns, TEN-4 Bruising Rule, Safeguarding Pathway ▼

Part 1 — X-ray findings (examiner will describe): "CXR shows bilateral posterior rib fractures at the costotransverse junction — multiple, in different stages of healing. Skeletal survey of the left lower limb shows a metaphyseal corner fracture ('bucket handle' lesion) at the distal femoral metaphysis. No apparent recent fall injuries consistent with the history."
Fracture patterns with high specificity for NAI:
- Posterior rib fractures — highest specificity for NAI among fracture types. Caused by forceful squeezing of the infant's chest (holding and shaking). The costotransverse junction is a leverage point stressed maximally during squeezing. Not caused by falls, CPR (CPR causes anterior/lateral rib fractures not posterior). Posterior rib fractures in an infant without a very high-velocity mechanism = NAI until proven otherwise.
- Metaphyseal corner fractures (MCF) / 'bucket handle' fractures — high specificity for NAI. Occur at the corners of the metaphysis (growth plate region) due to violent shaking and twisting of the limb. The periosteum is avulsed at the metaphyseal-periosteal junction. Classic appearance: thin curved fracture fragment = "bucket handle" on X-ray. Also called "corner fractures" or "classic metaphyseal lesions (CML)." Extremely rare in accidental injury without very high mechanism.
- Other high-specificity fractures for NAI: Scapular fractures, sternal fractures, spinous process fractures, bilateral acute fractures, fractures in different stages of healing (indicating repeated injury).
- Fractures with low specificity (can be accidental): Clavicle fracture, linear parietal skull fracture (especially if history of fall from height), isolated long bone fracture in mobile child. But in a pre-mobile infant (<9 months) — ANY fracture requires explanation.
- Key NAI principle — the history must explain the injury: "Fall from the sofa" — a pre-mobile 8-month-old cannot stand up on a sofa and fall. Even if mobile, a fall from standard sofa height (50 cm) rarely causes long bone fractures or rib fractures. A mismatch between the history and the injury pattern is itself a red flag.
Part 1 — Immediate management (NAI high suspicion):
- Do NOT discharge the child. Keep the child in a safe, secure environment in the hospital.
- Do NOT accuse the parents directly — maintain professional, non-confrontational approach. Do NOT say "we think you hurt your child." Say: "We need to do some more tests to understand what's caused these injuries — we want to make sure [child's name] is safe and well."
- Immediate senior review — ED consultant and on-call paediatric consultant.
- Safeguarding referral — MASH (Multi-Agency Safeguarding Hub): Mandatory referral. In hours: referral via social services. Out of hours: emergency duty team. Do NOT delay.
- Skeletal survey — full body radiographic survey to identify all fractures in different stages of healing. Includes skull, chest, spine, pelvis, long bones. Royal College of Paediatrics and Child Health (RCPCH) protocols. Repeat skeletal survey at 11–14 days (some fractures only visible on follow-up).
- Ophthalmology review — retinal haemorrhages are highly associated with abusive head trauma (shaken baby syndrome). Bilateral retinal haemorrhages at multiple layers = strong indicator. Must be done by paediatric ophthalmologist (not by general examination).
- CT head — to exclude subdural haemorrhage, contusions, diffuse axonal injury, cerebral oedema. Abusive head trauma (AHT) is the most lethal form of NAI. MRI brain if CT abnormal.
- Bloods — FBC (thrombocytopenia causes bruising — exclude bleeding disorder), coagulation screen, vitamin D (rickets causes metaphyseal changes — rare but must exclude), calcium, phosphate, ALP, LFT (hepatic trauma from abdominal blows — raised AST/ALT).
- Photography — clinical photographs of injuries by appropriately trained clinician, with consent. Medico-legal documentation.
- Social work and paediatric team involvement — paediatric safeguarding consultant or designated doctor for safeguarding must be notified.
- Secure and contemporaneous documentation — verbatim quotes from parents, exact history given, any inconsistencies noted. Do NOT write interpretations — document facts.
- Police notification — MASH referral triggers police involvement. Police may attend hospital. Do NOT interfere with police investigation.
Part 2 — Bruising pattern (examiner will describe): "A 2-year-old girl. Multiple bruises of varying size — some yellow/green (older), some purple/blue (recent). Bruises on the right ear, posterior neck, and right torso (lateral chest wall). No bruises on the shins or knees. Mother says 'she's always falling over.'"
TEN-4 bruising rule (validated clinical decision tool for NAI):
- T — Torso bruising (trunk, chest, abdomen, back, buttocks)
- E — Ears (any bruising on ears or around ears)
- N — Neck (any bruising on neck)
- 4 — Any bruising in a child <4 months old (pre-mobile infant — any bruise is suspicious)
- A positive TEN-4 = any bruising on torso, ears, or neck in ANY child, OR any bruising in a child under 4 months = HIGH concern for NAI. Sensitivity ~97%, specificity ~84% for NAI in children presenting to ED.
- Why the distinction from shin/knee bruises: Accidental bruising in mobile children typically occurs on bony prominences of the lower limbs (shins, knees, forehead). Bruising on non-bony, non-mobile surfaces (torso, ears, neck) = not explained by typical falls.
- Multiple bruises in different stages of healing = repeated trauma over time.
- History mismatch: "always falling over" does NOT explain ear bruising, neck bruising, and lateral chest wall bruising.
Part 2 — Immediate management: Same safeguarding pathway as Part 1. Immediate MASH referral. Do NOT discharge. Senior review. Document bruises (with photographs and body map). Bloods — bleeding screen. Skeletal survey. Social services and police.

⚠️ Examiner Instructions — Not for Candidate

Part 1: Read aloud: "CXR — bilateral posterior rib fractures at the costotransverse junction, multiple, in different stages of healing. Left leg X-ray — metaphyseal corner fracture at the distal femoral metaphysis with a curved fragment — a classic bucket handle appearance." Pause for candidate to interpret. Part 2: Read aloud: "Multiple bruises of varying ages. Bruises on the right ear, posterior neck, and right lateral chest wall. No lower limb bruises. Mother states she's always falling over." Key checkpoints: Did candidate identify posterior rib fractures and MCF as high-specificity NAI patterns? Did they immediately involve safeguarding, not accuse parents? Did they request skeletal survey, ophthalmology, and CT head? Did they apply TEN-4 correctly in Part 2? Did they NOT discharge either child?

🔔 Examiner Cues ▼

If candidate doesn't recognise posterior rib fractures as high-specificity NAI: "What mechanism causes posterior rib fractures at the costotransverse junction in infants — and is this consistent with a fall from a sofa?"
If candidate confronts parents directly: "How might confronting the parents impact the safeguarding investigation and the immediate safety of the child?"
If candidate discharges Part 2 child: "You're about to discharge her — the TEN-4 rule flags this bruising pattern. What does TEN-4 stand for and what does a positive result mean for management?"
At 7 minutes: "The father of the 8-month-old is becoming angry and demands to take the child home. What do you do?"

Criterion	Marks
Part 1 — Fracture Pattern Recognition
Posterior rib fractures identified as high-specificity NAI — caused by squeezing, not consistent with fall from sofa; multiple fractures in different stages = repeated trauma	3
Metaphyseal corner fracture / bucket handle lesion identified — high specificity for shaking/twisting; classic metaphyseal lesion terminology used	2
History-mechanism mismatch recognised — pre-mobile 8-month-old cannot fall from sofa in the described manner; this mismatch itself is a red flag	1
Part 1 — Safeguarding Response
Child NOT discharged; senior review (ED consultant + paediatric consultant) called; parents NOT directly accused; professional non-confrontational language used	2
MASH referral made immediately; skeletal survey; CT head; ophthalmology for retinal haemorrhages; bloods (coag, vitamin D, LFT); secure contemporaneous documentation	3
Part 2 — TEN-4 Application
TEN-4 rule correctly applied — T (torso/lateral chest), E (ears), N (neck); explains that bruising in these locations is NOT consistent with accidental falls; multiple ages indicates repeated injury	3
Immediate MASH referral; child NOT discharged; body map and clinical photography; skeletal survey; senior review; police notification via MASH	4
Total	20

OSCE Station Bank 11

📄 Candidate Instructions

📄 Candidate Instructions

📄 Candidate Instructions

📄 Candidate Instructions

📄 Candidate Instructions

📄 Candidate Instructions

📄 Candidate Instructions

📄 Candidate Instructions

📄 Candidate Instructions

📄 Candidate Instructions