Part A: Texts A - D

Text A

Primary Clinical Care Guidelines: Management of Head Injuries

▪ Monitor observations including BP (blood pressure) and GCS (level of
consciousness according to the Glasgow Coma Scale 1 – 15 ) .
▪ Notify MO (Medical Officer) immediately if level of consciousness alters.
▪ Prepare for intubation if GCS is 8 or less.
▪ Maintain BP as advised by MO.
▪ Keep patient warm.
▪ If there is a rapid deterioration in GCS of 2 or more and/or if one pupil becomes
fixed and dilated, this may indicate expanding (intracranial) haemorrhage. Consult
MO immediately.
▪ Give opioids with caution to patients with head injuries.
▪ If the skin is broken, check tetanus vaccination status. Administer tetanus containing
vaccine/ immunoglobulin as appropriate.
▪ Assume all head injuries have an associated neck injury.

Text
B
Text C
Intermediate High risk
Head injury clinical features – child
risk factors factors
Age < 1 year
Witnessed loss of consciousness < 5 minutes > 5 minutes
Anterograde or retrograde amnesia Possible > 5 minutes
Mild agitation or Abnormal
Behaviour
altered behaviour drowsiness
Episodes of vomiting without other cause 3 or more
Seizure in non-epileptic patient Impact only Yes
Non-accidental injury is
suspected/parental
No Yes
history is inconsistent with injury
History of coagulopathy, bleeding
disorder
No Yes
or previous intracranial surgery
Comorbidities Present Present
Persistent or
Headache Yes
increasing
Motor vehicle accident < 60 kph > 60 kph
Fall 1-3 metres > 3 metres
Moderate impact High speed /
heavy projectile
Force or unclear or
mechanism object
Glasgow Coma Scale 14-15 < 14
Focal neurological abnormality Nil Present
Penetrating injury
Haematoma,
/ Possible
Injury swelling or
depressed skull
laceration > 5 cm
fracture.
 TEXT D

Advice for patients who have received an injury to the head

● Rest quietly for the day.

● Use ‘ice packs’ over swollen or painful areas. Wrap ice cubes, frozen peas or a sports ice
pack in a towel. Do not put ice directly on the skin.

● Take simple painkillers for any headache.

● If an injured patient is discharged in the evening, make sure they are woken several
times during the night.

● Do not let the injured patient drive home.

● Do not leave them alone for the next 24 hours.

● Do not let them drink alcohol for at least 24 hours.

● Do not let them eat or drink for the first six to 12 hours (unless advised otherwise by the
MO). Then offer them food and drink in moderation.

● Do not let them take sedatives or other medication unless instructed.

● Return to the clinic immediately if the patient has repeated vomiting, ‘blacks out’, has
a seizure/fit or cannot be woken or is not responsive.

● Patient to return to clinic if they have any symptoms they or the carer are concerned
about.
 Part A

TIME: 15 minutes

● Look at the four texts, A-D, in the separate Text Booklet.

● For each question, 1-20, look through the texts, A-D, to find the relevant information.

● Write your answers on the spaces provided in this Question Paper.

● Answer all the questions within the 15-minute time limit.

● Your answers should be correctly spelt.

Head injuries: Questions

Questions 1-5

For each question, 1-5, decide which text (A, B, C or D) the information comes from.

You may use any letter more than once.

In which text can you find information about

1 what patients should and shouldn’t do when they return home? _____
2 the possible cause of abnormality apparent in a patient’s eyes? _____
3 reasons why patients should seek medical attention after being discharged?_____
4 procedures to follow dependent on the type of head injury?
_____
5 past interventions and conditions to be considered when assessing risk? _____

Questions 6-16, with a word or short phrase from one of the Answer each of the questions,
texts. Each answer may include words, numbers or both.

Children presenting with head injuries are assessed as high risk if they have:

● had memory loss lasting (6) ____________ or more

● fallen (7) ____________ or more
● been hit by a weighty object or one moving at (8) ____________
● unusual levels of (9) ____________
● a (10) ____________ which gets worse over time
● Escalation: Children assessed as intermediate or high risk should undergo a (11)____________

All patients presenting with (12) ________________________ head injuries must be

referred straight to the MO.

Patients with GCS below 8 may need (13) ________________________.

The MO should be informed without delay if there is a drop in BP or change in a

patient's level of (14) ________________________.

Staff should be especially careful when administering (15) _______________ to

head injury patients.

Head injury patients may also have an injury to their (16) _______________.

Questions 17 – 20

Answer the questions below. For each answer use a word or short phrase from the text. Each
answer may include words, numbers or both.

17. If there are no significant risk factors, how long after a head injury can you discharge a
patient?
_______________________________________________________

18 What should you provide head injury patients with when you discharge them?

_______________________________________________________

19 What should you advise patients to take to control headaches?

_______________________________________________________

20 What can patients use to avoid contact between ice packs and their skin?

________________________________________________________
 Part B

In this part of the test, there are six short extracts relating to the work of health
professionals. For questions 1 to 6, choose the answer (A, B or C) which you think fits best
according to the text.

Write your answers on the separate Answer Sheet.

1. The purpose of the memo about IV solution bags is to remind health practitioners

A of the procedures to follow when using them.

B of the hazards associated with faulty ones.

C why they shouldn’t be reused.

Memo to staff - Intravenous solution bags

IV fluids are administered via a plastic IV solution bag which collapses on itself as it empties. When a
bag is disconnected by removing the giving set spike, air can enter the bag. If it is then reconnected
to an IV line, air can potentially enter the patient’s vein and cause an air embolism. For this reason,
partially used IV bags must never be re-spiked. All IV bags are designed for single use only - for use
in one patient and on one occasion only. All registered large volume injections, including IV bags,
are required to have this warning (or words to the same effect) clearly displayed on the labelling. In
addition to the potential risk of introducing an air embolus, re-spiking can also result in
contamination of the fluid, which may lead to infection and bacteraemia.

2. What do we learn about the use of TENS machines?

a) Evidence for their efficacy is unconfirmed.

b) They are recommended in certain circumstances.
c) More research is needed on their possible side effects.

Update on TENS machines

The Association of Chartered Physiotherapists in Women’s Health has an expert panel which could not find
any reports suggesting that negative effects are produced when TENS has been used during pregnancy.
However, in clinical practice, TENS is not the first treatment of choice for women presenting with
musculoskeletal pain during pregnancy. The initial treatment should be aimed at correcting any joint or
muscle dysfunction, and a rehabilitation programme should be devised. However, if pain remains a
significant factor, then TENS is preferable to the use of strong medication that could cross the placental
barrier and affect the foetus. No negative effects have been reported following the use of this modality
during any of the stages of pregnancy. Therefore, TENS is preferable for the relief of pain.

3. If surgical instruments have been used on a patient suspected of having prion

disease, they

a) must be routinely destroyed as they cannot be reused.

b) may be used on other patients provided the condition has been ruled out.

c) should be decontaminated in a particular way before use with other

patients.

Guidelines: Invasive clinical procedures in patients with suspected prion disease

It is essential that patients suspected of suffering from prion disease are identified prior to any
surgical procedure. Failure to do so may result in exposure of individuals on whom any surgical
equipment is subsequently used. Prions are inherently resistant to commonly used disinfectants
and methods of sterilisation. This means that there is a possibility of transmission of prion disease
to other patients, even after apparently effective methods of decontamination or sterilisation have
been used. For this reason, it may be necessary to destroy instruments after use on such a patient,
or to quarantine the instrument until the diagnosis is either confirmed, or an alternative diagnosis is
established. In any case, the instruments can be used for the same patient on another occasion if
necessary.
4. The email suggests that POCT devices

a) should only be used in certain locations.

b) must be checked regularly by trained staff.

c) Can produce results that may be misinterpreted.

To: All Staff

Subject: Management of Point of Care Testing (POCT) Devices

Due to several recent incidents associated with POCT devices, staff are requested to read the following

advice from the manufacturer of the devices.

The risks associated with the use of POCT devices arise from Management of Point of Care Testing Devices
Version 4 January 2014, the inherent characteristics of the devices themselves and from the
interpretation of the results they provide. They can be prone to user errors arising from unfamiliarity with
equipment more usually found in the laboratory. User training and competence is therefore crucial.

5. It’s permissible to locate a baby’s identification band somewhere other than the ankles
when

a) the baby is being moved due to an emergency.

b) the bands may interfere with treatment.

c) the baby is in an incubator.

d)

Identification bands for babies

The identification bands should be located on the baby’s ankles with correct identification

details unless the baby is extremely premature and/or immediate vascular access is required. If

for any reason the bands need to be removed, they should be relocated to the wrists or if this is

not possible, fixed visibly to the inside of the incubator. Any ill-fitting or missing labels should be
replaced at first check. Identity bands must be applied to the baby’s ankles at the earliest

opportunity as condition allows and definitely in the event of fire evacuation or transportation.
6. What is the memo doing?

a) providing an update on the success of new guidelines

b) reminding staff of the need to follow new guidelines

c) announcing the introduction of new guidelines

Memo: Administration of antibiotics

After a thorough analysis and review, our peri-operative services, in conjunction with the
Departments of Surgery and Anaesthesia, decided to change the protocols for the administration
of pre-operative antibiotics and established a series of best practice guidelines. This has resulted in
a significant improvement in the number of patients receiving antibiotics within the recommended
60 minutes of their incision. A preliminary review of the total hip and knee replacements
performed in May indicates that 88.9% of patients received their antibiotics on time
EXTRACT 1