Severe Aortic Stenosis · Emergent Hip Fracture

About this case

An 82-year-old with critical aortic stenosis needs an emergent hip hemiarthroplasty. She last took apixaban 18 hours ago and has borderline baseline cognition. Nothing here is a crisis yet, which is the point — the examiner is assessing judgement rather than reflexes.

Key clinical features

• Critical AS

  AVA 0.7 cm², mean gradient 52 mmHg, peak velocity 4.6 m/s

• On Apixaban

  Last dose 18h ago — neuraxial considerations

• Frail · Baseline Cognition

  MoCA 22 — delirium prevention priority

• Emergent Surgery

  <48h window for hip fracture mortality benefit

What the examiner is testing

• Your understanding of the haemodynamic goals critical AS imposes and how they constrain every anaesthetic option.
• The neuraxial-versus-general decision in the context of recent anticoagulation, and how you defend it.
• How you weigh the mortality benefit of early surgery against the desire for further cardiac workup.
• Whether you address delirium risk and postoperative disposition, not just the intraoperative period.

Where candidates lose points

• Reflexively choosing spinal anaesthesia without engaging with either the anticoagulation or the fixed cardiac output.
• Delaying surgery for investigations that will not change management, when the examiner has given you a time-sensitive indication.
• Discussing monitoring in generic terms without tying it to this patient's specific lesion.

How it is scored

Every BoardSim case is scored across the same five phases — pre-operative evaluation, anaesthetic plan, intra-operative management, crisis management, and emergence — for a total of 100 points, with a pass set at 70 and no missed critical action. You receive a written report against each phase rather than a single number. Read the scoring methodology.