SLO 3 carries more weight than any other domain in the FRCEM SBA—40 questions worth 22.2% of your total marks. Resuscitation isn't just the heaviest weighted topic; it's also where confident, rapid decision-making under pressure separates passing candidates from those who fail.
Most candidates know basic life support. What trips them up are the nuanced scenarios: atypical arrest rhythms, challenging toxicology cases, end-of-life decisions under pressure, and shock management when the textbook presentation doesn't quite fit.
This guide breaks down the high-yield topics within SLO 3, focusing on what actually appears in FRCEM questions and how to approach them systematically.
Understanding SLO 3 Structure
The 2021 RCEM curriculum defines SLO 3 as "Resuscitate and stabilise patients in the ED, knowing when it is appropriate to stop." This encompasses far more than cardiac arrest algorithms.
SLO 3 question distribution (40 questions total):
Cardiac arrest management (12-15 questions)
Shock recognition and management (8-10 questions)
Toxicology and poisoning (6-8 questions)
End-of-life care and resuscitation decisions (4-6 questions)
Peri-arrest arrhythmias (3-5 questions)
Major haemorrhage (2-4 questions)
The breadth is significant. You can't just memorize ALS algorithms and expect to score well. Success requires understanding underlying physiology, current guidelines, and ethical frameworks.
Adult Advanced Life Support Algorithms
If you take nothing else from this guide, memorize the ALS algorithms until you can recite them under pressure. These form the foundation for 12-15 questions.
Shockable Rhythms (VF/pVT)
The rhythm everyone recognizes, but exam questions focus on nuance:
Standard algorithm:
Recognize shockable rhythm
Deliver one shock (150-200J biphasic, 360J monophasic)
Immediately resume CPR for 2 minutes
Check rhythm
If still shockable, deliver second shock
Resume CPR for 2 minutes
After third shock, give adrenaline 1mg IV and amiodarone 300mg IV
Continue cycle: shock → CPR → rhythm check
High-yield FRCEM question angles:
Timing of drugs: Adrenaline after third shock in shockable rhythms, then every 3-5 minutes. Many candidates incorrectly give it earlier.
Amiodarone dosing: 300mg after third shock, further 150mg after fifth shock if VF/pVT persists. This specific dosing appears frequently.
What "immediately resume CPR" means: Don't check pulse, don't check monitor. The second the shock is delivered, hands go back on chest. Questions test whether you understand this no-delay principle.
Reversible causes during CPR: You're simultaneously managing 4 Hs and 4 Ts, not waiting until rhythm stabilizes. Questions present clinical clues (hyperkalaemia ECG changes, tension pneumothorax signs) during ongoing resuscitation.
Non-Shockable Rhythms (PEA/Asystole)
Where candidates lose marks through incorrect drug timing:
Standard algorithm:
Recognize non-shockable rhythm
Start CPR immediately
Give adrenaline 1mg IV as soon as IV access available
Continue CPR for 2 minutes
Check rhythm
If still non-shockable, continue CPR
Give adrenaline every 3-5 minutes (alternate loops)
Aggressively treat reversible causes
High-yield FRCEM question angles:
Immediate adrenaline: Unlike shockable rhythms, you give adrenaline as soon as you establish IV access in PEA/asystole. Questions test whether you know this difference.
PEA with organized rhythm: You see an organized rhythm on the monitor but no pulse. This is PEA, not VF. Treatment is CPR and adrenaline, not defibrillation. Questions often present ECG traces testing this distinction.
Rhythm check timing: Every 2 minutes, not after drug administration. Candidates who think you check rhythm after giving adrenaline select wrong answers.
When to consider stopping: If rhythm remains asystole after 20 minutes of good quality CPR with reversible causes addressed, discussion about stopping becomes appropriate. Questions test your understanding of futility.
The 4 Hs and 4 Ts: Beyond Simple Lists
Every candidate knows to consider hypoxia, hypovolaemia, hyper/hypokalaemia, hypothermia, thrombosis, tamponade, tension pneumothorax, and toxins. FRCEM questions test whether you can recognize and manage them during resuscitation.
Hyperkalaemia (commonly tested):
Recognition during arrest:
Tall tented T waves
Wide QRS complexes
Sine wave pattern in severe cases
History of renal failure, dialysis, or potassium-sparing drugs
Management during CPR:
Calcium chloride 10ml 10% IV (immediate membrane stabilization)
Insulin/dextrose (10 units actrapid in 50ml 50% glucose)
Sodium bicarbonate if severe acidosis
Salbutamol nebulized or IV
FRCEM angle: Questions present arrest with ECG showing hyperkalaemic changes. Correct answer includes calcium chloride administration during CPR, not waiting for ROSC.
Tension pneumothorax (frequently appears):
Recognition during arrest:
Unilateral reduced air entry
Tracheal deviation (late sign)
Hypotension
Distended neck veins
Recent trauma, mechanical ventilation, or central line insertion
Management:
Needle thoracocentesis (5th intercostal space, mid-axillary line)
Followed by chest drain
Don't wait for chest X-ray during arrest
FRCEM angle: Questions describe post-intubation or post-central line arrest. Correct answer is immediate needle decompression, not imaging.
Pulmonary embolism (PE):
Recognition:
Sudden collapse
Recent surgery, long-haul flight, or known DVT
Raised JVP
Right heart strain on ECG (if obtained pre-arrest)
Management:
Consider thrombolysis during CPR if PE suspected
Alteplase 50mg IV bolus
Continue CPR for 60-90 minutes post-thrombolysis
FRCEM angle: Questions about thrombolysis decision-making during arrest. Correct answer recognizes that if PE is likely cause, thrombolysis is given despite ongoing CPR.
Shock Management
Shock questions appear in 8-10 SLO 3 questions, testing your ability to recognize types and initiate appropriate management rapidly.
Shock Classification and Recognition
Hypovolaemic shock:
Tachycardia, hypotension
Cool peripheries
Delayed capillary refill
Low JVP
History of bleeding, vomiting, or diarrhoea
Cardiogenic shock:
Tachycardia (or bradycardia if arrhythmia)
Hypotension
Raised JVP
Pulmonary oedema
History of MI or known heart failure
Obstructive shock:
Sudden onset
Raised JVP
Causes: PE, tamponade, tension pneumothorax
Specific signs depend on cause
Distributive shock (septic/anaphylactic):
Warm peripheries initially (septic)
Bounding pulse
Wide pulse pressure
Allergic features if anaphylactic
FRCEM questions focus on:
Distinguishing between shock types using clinical features. Questions present vital signs, examination findings, and brief history. You must identify shock type and select appropriate initial management.
Initial fluid resuscitation volumes. For hypovolaemic shock, 500ml boluses repeated based on response. For cardiogenic shock, cautious fluid (250ml) or vasopressors/inotropes.
When to call for help. Any patient in shock requires senior involvement and often ICU input. Questions test whether you escalate appropriately.
Septic Shock: The Sepsis Six
Septic shock appears frequently because it integrates recognition with time-critical management.
The Sepsis Six (within one hour):
Three tests:
Blood cultures (before antibiotics if possible)
Lactate measurement
Urine output monitoring (catheter)
Three treatments:
Oxygen (target SpO2 94-98%)
IV antibiotics (broad-spectrum, local policy)
IV fluid resuscitation (500ml bolus, reassess)
FRCEM angles:
Antibiotic timing: Questions ask about a patient who's been waiting 90 minutes for blood culture bottles. Correct answer: give antibiotics now, don't delay for cultures.
Fluid bolus dose: 500ml crystalloid boluses, reassessed after each. Not "liters" or continuous infusion. Specific volumes matter.
Early vasopressor use: If hypotension persists despite 2 litres fluid, start vasopressors (noradrenaline). Don't keep pouring in fluid.
Lactate as severity marker: Lactate >4mmol/L indicates severe sepsis. Questions use lactate results to prompt urgency.
Toxicology and Poisoning
Toxicology contributes 6-8 questions to SLO 3, focusing on life-threatening poisonings requiring immediate intervention.
Paracetamol Overdose
Despite being common, FRCEM tests nuanced management:
Initial assessment:
Time of ingestion (critical for treatment decisions)
Amount ingested
Staggered overdose vs single time point
Patient weight (NAC dosing)
Management pathway:
If presenting <1 hour post-ingestion: Activated charcoal 50g orally (if cooperative, no contraindications)
If presenting >4 hours post-ingestion: Measure paracetamol level, use treatment nomogram
If presenting 4-15 hours and level above treatment line: Start N-acetylcysteine (NAC)
If staggered overdose or >15 hours: Start NAC immediately, don't wait for levels
FRCEM angles:
Staggered overdose management: Questions describe someone taking "several tablets over 2-3 days." Correct answer starts NAC immediately regardless of levels.
High-risk patients: Lower threshold for treatment if malnourished, on enzyme inducers (phenytoin, carbamazepine), or chronic alcohol use. Questions test whether you identify these risk factors.
NAC side effects: Anaphylactoid reactions (flushing, wheeze, urticaria) occur in 15%. Management is slow/stop infusion, antihistamine, restart at slower rate. Questions present mid-infusion reactions.
Tricyclic Antidepressant (TCA) Overdose
Dangerous and frequently tested:
Recognition:
Altered consciousness
Seizures
Arrhythmias (broad complex tachycardia, QT prolongation)
Anticholinergic signs (dry mouth, dilated pupils, urinary retention)
ECG changes predicting severity:
QRS >100ms indicates moderate toxicity
QRS >160ms indicates severe toxicity with high arrhythmia risk
Rightward axis of terminal QRS (R wave in aVR)
Management:
Initial stabilization:
Airway protection (intubate if GCS <8)
Activated charcoal if <1 hour post-ingestion
IV fluids
Cardiac monitoring
For arrhythmias/wide QRS:
Sodium bicarbonate 50ml 8.4% IV bolus
Repeat until QRS narrows or pH reaches 7.50-7.55
Don't use antiarrhythmics (most are contraindicated)
FRCEM angles:
Sodium bicarbonate is first-line arrhythmia treatment. Questions present TCA overdose with broad complex tachycardia. Correct answer is bicarbonate, not amiodarone or beta-blockers.
ECG criteria for severe toxicity. Questions show ECG and ask about severity or need for critical care. QRS width determines answer.
Lipid emulsion therapy: For cardiac arrest from TCA, consider 20% Intralipid. Questions test knowledge of this rescue therapy.
Opioid Overdose
Simple but commonly tested:
Recognition:
Reduced consciousness
Respiratory depression
Pinpoint pupils
Bradycardia
Management:
Airway support (bag-valve-mask if apnoeic)
Naloxone 400mcg IV (repeat every 2-3 minutes to max 2mg)
Consider naloxone infusion if long-acting opioid
FRCEM angles:
Naloxone dosing and timing. Initial dose 400mcg, not 2mg bolus. Questions test incremental dosing approach.
Duration of monitoring. Short-acting naloxone (30-60 minutes) vs long-acting opioids (morphine, methadone). Questions ask about safe discharge timing. Answer: minimum 6 hours observation, often admission needed.
Withdrawal precipitation. Giving too much naloxone to opioid-dependent patient precipitates severe withdrawal. Questions test whether you recognize this risk.
End-of-Life Decisions and DNACPR
SLO 3 includes 4-6 questions on end-of-life care, resuscitation decision-making, and capacity around these decisions.
DNACPR Decision Framework
FRCEM tests your understanding of when DNACPR is appropriate and who makes the decision.
DNACPR is appropriate when:
CPR would be futile (won't restore circulation)
CPR success is possible but patient has advanced decision refusing it
CPR success is possible but burdens outweigh benefits in patient's best interests
DNACPR is NOT appropriate when:
Patient would benefit from CPR but is elderly
Patient has disabilities or chronic illness but CPR would work
Made based on resource availability or bed pressures
Who decides:
If patient has capacity: Discuss CPR, respect their informed decision. DNACPR is made if they refuse or you both agree it's inappropriate.
If patient lacks capacity: Best interests decision made by senior clinician, considering patient's previously expressed wishes and consulting family (but family don't have legal veto).
FRCEM angles:
Family cannot demand CPR. Questions present family insisting on CPR for patient in whom it would be futile. Correct answer: explain sensitively that clinical decision is that CPR would not work.
Family cannot refuse CPR. Questions present family saying "don't resuscitate" for patient who might benefit. Correct answer: if patient would benefit, CPR is given unless patient themselves had refused it.
Advanced decisions: Patient previously documented refusal of CPR. This is legally binding if valid and applicable. Questions test whether you recognize this.
Palliative Care in Resuscitation Context
Transitioning to comfort care:
When resuscitation is inappropriate or fails, focus shifts to comfort:
Symptom control (pain, breathlessness, agitation)
Stopping futile interventions
Involving palliative care team
Supporting family
FRCEM angles:
When to stop resuscitation. Questions describe prolonged arrest with no ROSC. Options include continuing CPR, stopping, or discussing with family. Correct answer recognizes clinical decision-making, not family veto.
End-of-life medication. Questions about managing dying patient's symptoms. Correct answers: morphine for breathlessness/pain, midazolam for agitation, stopping unnecessary monitoring.
Peri-Arrest Arrhythmias
Beyond full cardiac arrest, SLO 3 includes unstable arrhythmias requiring urgent intervention.
Bradycardia with Adverse Features
Adverse features indicating urgent treatment:
Shock (hypotension, poor perfusion)
Syncope
Myocardial ischaemia (chest pain)
Heart failure
Management pathway:
If adverse features present:
Atropine 500mcg IV (repeat up to 3mg total)
If atropine ineffective or inappropriate, consider:
Transcutaneous pacing
Isoprenaline infusion (5mcg/min)
Adrenaline infusion (2-10mcg/min)
FRCEM angles:
When atropine is inappropriate: Complete heart block, Mobitz type II, broad complex bradycardia suggesting ventricular escape rhythm. Questions present ECG showing these. Correct answer bypasses atropine and goes straight to pacing.
Atropine dose: 500mcg, not 3mg bolus. Questions test incremental dosing.
Transcutaneous pacing immediacy: If patient is shocked with bradycardia, don't delay pacing waiting for atropine effect. Questions test understanding that pacing is immediate intervention when critically unwell.
Tachycardia with Adverse Features
Same adverse features apply: shock, syncope, ischaemia, heart failure
Management depends on QRS width:
Broad complex tachycardia (QRS >0.12s):
Assume VT unless proven otherwise
Synchronized DC cardioversion (if conscious, give sedation first)
120-150J initially, escalate if needed
Narrow complex tachycardia:
If irregular: likely AF, rate control or cardioversion depending on stability
If regular: likely SVT, try vagal manoeuvres then adenosine
FRCEM angles:
Broad complex tachycardia is VT until proven otherwise. Questions present broad complex tachycardia asking about immediate management. Correct answer is synchronized cardioversion if adverse features present, not rate-control medications.
Adenosine contraindications: Asthma (can precipitate severe bronchospasm). Questions present SVT in known asthmatic. Correct answer is cardioversion, not adenosine.
Synchronized vs unsynchronized shock: Synchronized for organized rhythms (VT, AF, SVT). Unsynchronized only for VF or pulseless VT. Questions test this distinction.
Major Haemorrhage Protocol
Major haemorrhage contributes 2-4 SLO 3 questions, testing your knowledge of early aggressive management.
Activation criteria:
Blood loss >150ml/min
Loss of one blood volume within 24 hours
50% blood volume loss within 3 hours
Systolic BP <90mmHg with bleeding
Initial management:
Call major haemorrhage protocol: Mobilizes blood bank, lab, porters, and senior help.
Resuscitation:
Large bore IV access (14-16G, two sites)
Rapid fluid warmer
O-negative blood if immediately life-threatening
Crossmatched blood when available
Tranexamic acid 1g IV within 3 hours of injury
Balanced blood product replacement:
Packed red cells : FFP : Platelets in 1:1:1 ratio
Massive transfusion packs often pre-prepared in this ratio
FRCEM angles:
Tranexamic acid timing: Within 3 hours of traumatic injury. After 3 hours, may increase mortality. Questions provide timeline and ask about TXA appropriateness.
Blood product ratios: Questions present major haemorrhage and ask about transfusion strategy. Correct answer recognizes balanced product replacement, not just packed red cells.
Permissive hypotension: In trauma, target systolic 80-90mmHg until bleeding controlled. Over-aggressive resuscitation increases bleeding. Questions test whether you know this concept.
Putting It Together: Practicing SLO 3 Questions
Understanding these topics is foundation. Passing FRCEM requires applying them under time pressure in exam-style questions.
Practice strategy:
Focus on decision-making speed. SLO 3 questions often have clear right answers if you know algorithms. Your challenge is recognizing patterns quickly.
Use scenario-based learning. Don't just memorize algorithms. Practice applying them to clinical vignettes that mirror exam questions.
Identify your weak areas. If you're consistently getting toxicology questions wrong, that's your signal to review poisoning management systematically.
For comprehensive practice across all SLO 3 topics with detailed explanations, try our free demo to experience FRCEM-style questions.
Common SLO 3 Mistakes to Avoid
Giving adrenaline too early in shockable rhythms. Wait until after third shock, then every alternate cycle.
Forgetting amiodarone in refractory VF. After third shock, amiodarone is due. Many candidates miss this.
Delaying defibrillation to give drugs. Shock is priority in VF/pVT. Drugs are secondary.
Using wrong shock energy. 150-200J biphasic (or 360J monophasic) for each shock, not escalating doses with modern biphasic defibrillators.
Treating PEA as VF. Organized rhythm without pulse needs CPR and adrenaline, not defibrillation.
For more on avoiding critical FRCEM mistakes across all domains, see our complete mistakes guide.
SLO 3 Study Timeline
Months 1-2:
Memorize ALS algorithms until automatic
Learn 4 Hs and 4 Ts management
20-30 practice questions daily focusing on SLO 3
Months 3-4:
Deep dive into toxicology (common poisonings)
Practice shock recognition scenarios
40-50 SLO 3 practice questions daily
Months 5-6:
Review end-of-life decision frameworks
Complete full SLO 3 mock sections
Focus on persistent weak areas only
Final month:
Quick algorithm reviews only
Maintain skills, don't learn new content
For integrating this into a busy work schedule, see our guide on studying for FRCEM while working full time.
Frequently Asked Questions
How many SLO 3 questions do I need to get right?
With 40 questions total and a pass mark around 60%, you need roughly 24 correct SLO 3 answers. However, marks are cumulative across all SLOs. Stronger performance in SLO 3 compensates for weaker areas elsewhere.
Should I memorize drug doses exactly?
Yes, for key resuscitation drugs. Adrenaline 1mg, amiodarone 300mg then 150mg, atropine 500mcg, naloxone 400mcg, calcium chloride 10ml 10%. These appear frequently in questions.
What if I don't know toxicology well?
Focus on the commonest six: paracetamol, TCAs, opioids, salicylates, benzodiazepines, and carbon monoxide. These account for >90% of toxicology questions.
Are end-of-life questions common?
Yes, 4-6 questions per exam. Don't neglect them. Understanding DNACPR frameworks and capacity issues provides predictable marks.
How detailed should my ALS knowledge be?
You should be able to recite the algorithms from memory, including timing of drugs, shock energies, and rhythm check intervals. This level of detail appears in questions.
SLO 3 is the highest-weighted domain for good reason—resuscitation and stabilization are fundamental emergency medicine competencies. The breadth is significant, covering cardiac arrest, shock, toxicology, and end-of-life care.
Success requires both breadth and depth: knowing ALS algorithms by heart while understanding nuanced scenarios like staggered paracetamol overdose or hyperkalaemic cardiac arrest. These 40 questions significantly impact your overall score.
Master SLO 3 through consistent practice with high-quality questions that mirror exam difficulty and clinical realism. Understanding principles matters more than memorizing isolated facts.
Ready to practice SLO 3 questions with detailed explanations? Register with StudyFRCEM for comprehensive SLO-mapped questions designed for first-attempt success.
