Cardiac and respiratory emergencies are the most commonly tested clinical scenarios in JCF interviews across all specialties. Even if you are applying for a surgical or non-acute post, you may be tested on these presentations because the panel needs to know you can manage a deteriorating patient safely regardless of your specialty interest.
Acute Chest Pain
When presented with chest pain, the panel expects you to rapidly consider life-threatening causes. The key differentials to discuss are: Acute Coronary Syndrome (ACS — STEMI, NSTEMI, unstable angina), Pulmonary Embolism (PE), Aortic Dissection, Tension Pneumothorax, and Pericarditis/Cardiac Tamponade. Your approach should include: A–E assessment, 12-lead ECG (look for ST elevation, ST depression, T-wave inversion, right heart strain pattern), troponin (note: high-sensitivity troponin may take 3–6 hours to rise), chest X-ray (widened mediastinum in dissection, pneumothorax), and D-dimer if PE is suspected (or proceed directly to CTPA if Wells score is high). For suspected ACS: give aspirin 300mg (unless contraindicated), GTN sublingual if systolic BP allows, morphine for pain, and refer to cardiology for PCI pathway if STEMI is confirmed. For suspected PE: anticoagulate with treatment-dose LMWH while awaiting CTPA, following NICE guideline NG158. For tension pneumothorax: immediate needle decompression (2nd intercostal space, midclavicular line) followed by chest drain insertion.
Acute Breathlessness
Key differentials: pneumonia, COPD exacerbation, acute asthma, pulmonary oedema, PE, pneumothorax. Your assessment should focus on respiratory rate, oxygen saturations, chest auscultation findings, and work of breathing. For COPD exacerbation: controlled oxygen therapy (target SpO2 88–92% per BTS guidelines for patients at risk of hypercapnic respiratory failure, using a Venturi mask), nebulised bronchodilators (salbutamol 5mg and ipratropium 500mcg), oral prednisolone 30mg, consider antibiotics if infective exacerbation. For acute severe asthma (unable to complete sentences, RR >25, HR >110, PEF 33–50% predicted): nebulised salbutamol 5mg, ipratropium 500mcg, hydrocortisone 100mg IV or prednisolone 40mg oral, consider IV magnesium sulphate 1.2–2g over 20 minutes if poor response. For pulmonary oedema: sit the patient upright, high-flow oxygen, IV furosemide 40–80mg, consider GTN infusion if systolic BP allows, and urgent senior review.
- Key scoring point: Always state the specific oxygen target. Saying “I would give oxygen” scores less than saying “I would target SpO2 94–98% using the NEWS2 oxygen saturation scale, or 88–92% if the patient is at risk of hypercapnic respiratory failure.” This demonstrates awareness of the British Thoracic Society oxygen therapy guidelines and NEWS2 (developed by the Royal College of Physicians and adopted across NHS England).
- Resource: Cardiac & Respiratory Emergency Summary Cards (6 conditions with key management steps).