How to use these practice questions
The ACEM Fellowship Examination assesses whether you can practise independently at consultant level. Its structured, time-limited stations commonly use viva-style oral and clinically focused scenarios. Candidates need to make safe decisions and explain their reasoning under pressure.
The questions below are single-best-answer practice prompts, not a claim about the examination’s question format. Use each as a short rehearsal: identify the immediate threat, say what you would do first, explain the next steps and state how you would escalate or decide disposition. In an oral station, make your reasoning audible rather than giving only the final action.
MySummaries can put a clinical decision into a question format for focused practice. The first prompt tests what to do when a patient is becoming haemodynamically unstable.
A 34-year-old develops generalised urticaria, wheeze and dizziness minutes after an IV antibiotic. They are pale, with a blood pressure of 78/46 mmHg. What is the immediate treatment?
Give IM adrenaline promptly for anaphylaxis with airway or breathing compromise or hypotension; an adult dose is 0.5 mg of 1 mg/mL solution into the anterolateral thigh, repeated after 5 minutes if needed. Call for help, position the patient safely, provide oxygen and IV crystalloid as indicated. Hydrocortisone and antihistamines do not replace adrenaline or treat the immediate circulatory threat; do not delay treatment for transfer.
The key is not to let adjuncts displace the first lifesaving treatment. In a viva, state the dose and route, call for assistance, and then describe reassessment and further management.
Questions: prioritise the immediate threat
This case checks whether you recognise instability and act before completing a detailed history.
A 68-year-old has a regular narrow-complex tachycardia at 190 beats/min. They are confused, clammy and hypotensive despite initial assessment. What is the next priority?
This is an unstable tachyarrhythmia: altered conscious state and hypotension require urgent treatment. Prepare for synchronised cardioversion and involve experienced help; do not delay for a complete work-up. Adenosine can be appropriate in selected regular narrow-complex tachycardias, but it is not a reason to postpone electrical treatment in a haemodynamically unstable patient.
In an oral answer, link the intervention to the instability, mention monitoring and team roles, and describe what you will do if the first intervention fails. Avoid presenting a medication as a trial that delays definitive treatment.
The next question tests whether a likely immediately reversible cause of shock is treated before imaging.
A patient with blunt chest trauma becomes severely hypotensive. They have marked respiratory distress and absent breath sounds on the left. What is the most appropriate immediate action?
In an unstable trauma patient with findings strongly suggesting tension pneumothorax, decompress the chest immediately according to local practice and follow with definitive pleural drainage. Do not wait for imaging when that would delay treatment of a life-threatening condition. Resuscitation and a systematic trauma assessment continue in parallel, with early senior and trauma-team escalation.
A strong explanation includes both the immediate action and the reason imaging must not delay it. Also state that you will reassess breathing and circulation after the intervention.
This question examines recognition of a dangerous ECG change and the difference between stabilising the myocardium and removing potassium.
A patient with advanced kidney disease has a potassium concentration of 7.1 mmol/L and a broad QRS complex with tall, peaked T waves. Which intervention most directly protects the myocardium immediately?
IV calcium is the immediate membrane-stabilising treatment for hyperkalaemia with ECG changes. It does not lower the potassium concentration, so shifting and removal strategies are also required, with urgent senior and renal input. Insulin with glucose and salbutamol help shift potassium intracellularly but do not replace calcium when the ECG shows dangerous effects. Do not wait for dialysis before stabilising the myocardium.
Be explicit about the two aims: stabilise the cardiac membrane first, then lower and remove potassium while monitoring ECG and glucose. Local protocols guide drug preparation, repeat dosing and subsequent treatment.
Questions: investigate, escalate and plan disposition
A critically unwell patient may need airway support before routine treatments have time to work. This prompt tests that judgement.
A patient with severe asthma has received initial bronchodilator treatment. They are now tiring, becoming drowsy and have very poor air entry. What is the best next step?
Drowsiness, exhaustion and very poor air entry in severe asthma are signs of impending respiratory failure. Escalate immediately to experienced airway and critical-care support while continuing active treatment and close monitoring. A quieter chest is not necessarily improvement when air entry is poor. Imaging must not delay escalation in a deteriorating patient.
In a viva, do not jump straight to intubation as though it were routine. Explain that you are summoning experienced help, preparing for deterioration and continuing appropriate asthma treatment while planning airway management if required.
The next case tests the order of assessment and treatment in suspected acute stroke.
A 72-year-old develops sudden aphasia and right-sided weakness. Their family confirms the symptoms began 50 minutes ago. What is the most appropriate immediate pathway?
Treat this as a time-critical suspected stroke: establish the time last known well, check glucose for a mimic, activate the local stroke pathway and arrange urgent imaging to distinguish haemorrhage from ischaemia and guide treatment. Aspirin should not be given before intracranial haemorrhage has been excluded. Follow local pathways and involve the stroke team promptly.
A complete oral response would also include a focused neurological assessment, relevant anticoagulant history, immediate physiological stabilisation and a clear handover. Avoid promising a particular reperfusion treatment before imaging and specialist assessment.
This prompt checks whether resuscitation, investigations and antimicrobial treatment are coordinated rather than performed as isolated tasks.
A 59-year-old with suspected pneumonia is febrile, confused and hypotensive. Their lactate is elevated. What is the best initial approach?
This patient has suspected infection with shock and needs immediate resuscitation, prompt antimicrobials and frequent reassessment. Obtain cultures first when feasible, but do not allow them to delay treatment. Give IV fluids according to the patient’s response and clinical context, monitor closely and escalate early. Waiting for cultures or imaging leaves a time-critical threat untreated.
State how you will judge response: repeat observations, perfusion, mental state and relevant investigations, and reassess the need for further fluids or vasopressor support with senior input. A single initial intervention is not a disposition plan.
The final question tests safe management of a sick child and the need to call for help early.
A 3-year-old has fever, a non-blanching rash, mottled skin and delayed capillary refill. They are becoming less responsive. What is the priority?
A febrile child with a non-blanching rash, poor perfusion and reduced responsiveness may have life-threatening sepsis. Escalate immediately, support airway, breathing and circulation, obtain vascular or intraosseous access as appropriate, and give urgent treatment including antimicrobials in line with local paediatric sepsis guidance. Do not wait for laboratory results or use absence of neck stiffness to reassure yourself.
The strongest answers make the first actions unmistakable, then add focused assessment, relevant investigations, treatment, escalation, disposition and communication. In a station, use short headings or signposts so the examiner can follow your priorities. Include closed-loop communication and a clear handover, not just a list of clinical tasks.
Review the errors, not just the score
A single correct answer does not prove a topic is secure. After a practice set, identify whether a missed mark came from delayed prioritisation, a knowledge gap, an omitted safety step or an unclear explanation. The weakest area should determine your next revision task. The frequency below represents practice-set tracking, not official ACEM topic frequency.
For each weak area, rehearse a concise answer aloud: immediate priorities, focused assessment, differential, targeted investigations, management and disposition, then communication and safety-netting. If you cannot justify why one action comes before another, return to the clinical principle and practise again.
A repeated error should become a specific retrieval prompt, not a vague note to “revise resuscitation”.
You lost this mark twice: in an unstable regular narrow-complex tachycardia with hypotension and altered consciousness, what is the immediate priority, and why should treatment not wait for a full diagnostic work-up?
How MySummaries helps
Build a revision board from your own notes, then use it to generate question practice and flashcards from the areas you need to revisit. For this task, practise stating a first action, defending it with concise clinical reasoning and reviewing repeated omissions. Open MySummaries.