A 44-year-old woman is brought to the Emergency Department by ambulance 15 minutes after eating prawns at a restaurant. She has a known shellfish allergy but the dish was mislabelled. She developed facial swelling, difficulty breathing, and feels lightheaded. On arrival, she has extensive facial and tongue swelling, inspiratory stridor, widespread wheeze, and appears cyanosed. Her blood pressure is 75/40 mmHg, heart rate 135 bpm, respiratory rate 32/min, oxygen saturation 85% on high-flow oxygen. She has received two doses of intramuscular adrenaline 500 micrograms (at 5-minute intervals) with minimal improvement. What is the most appropriate next management step?
Q102
A 71-year-old woman with metastatic lung cancer on palliative chemotherapy presents to the Emergency Department with a 12-hour history of fever, rigors, and productive cough. She appears unwell. Observations show: temperature 38.1°C, heart rate 98 bpm, blood pressure 105/65 mmHg, respiratory rate 22/min, oxygen saturation 93% on room air. Blood tests reveal: WCC 1.2 × 10⁹/L, neutrophils 0.4 × 10⁹/L, CRP 156 mg/L. Her chest X-ray shows right lower lobe consolidation. What is the most appropriate immediate antibiotic regimen?
Q103
A 28-year-old woman collapses at a train station. Bystanders report she was standing on a crowded platform when she suddenly fell to the ground. She regained consciousness within 30 seconds and is now alert and oriented. She reports feeling hot and dizzy just before the collapse. She has no significant past medical history and takes no medications. On examination in the Emergency Department, she is clinically well with normal observations and cardiovascular examination. Her ECG shows sinus rhythm with a rate of 68 bpm, normal axis, and normal QT interval (QTc 410 ms). What is the most appropriate next step in her management?
Q104
A 63-year-old man with type 2 diabetes presents with a 4-day history of productive cough, fever, and increasing shortness of breath. He is diagnosed with severe community-acquired pneumonia and sepsis. His observations are: temperature 38.9°C, heart rate 118 bpm, blood pressure 88/55 mmHg, respiratory rate 28/min, oxygen saturation 89% on room air. Blood tests show lactate 4.2 mmol/L and glucose 18.4 mmol/L. He has received initial fluid resuscitation with 1 litre of crystalloid over 30 minutes with minimal improvement in blood pressure. What is the most appropriate next step in his management?
Q105
A 48-year-old woman presents to the Emergency Department with a 3-day history of increasing confusion, fever, and general malaise. She recently returned from a camping trip in rural Wales. On examination, she is febrile at 39.2°C, drowsy with a GCS of 13 (E3, V4, M6), and has neck stiffness. A non-blanching purpuric rash is noted on her lower limbs. Blood tests show: WCC 18.2 × 10⁹/L, CRP 245 mg/L, lactate 3.4 mmol/L. A CT head is performed and shows no contraindications to lumbar puncture. What is the most appropriate immediate management?
Q106
A 76-year-old man presents with a syncopal episode that occurred while he was having breakfast. His wife reports he suddenly lost consciousness for approximately 20 seconds, with no preceding warning symptoms. He has a history of hypertension and takes amlodipine. On examination, he has a slow-rising pulse, blood pressure 130/80 mmHg, and a harsh ejection systolic murmur heard loudest at the right upper sternal border radiating to the carotids. The murmur decreases with squatting. What is the underlying mechanism of syncope in this patient?
Q107
A 41-year-old woman is brought to the Emergency Department after a bee sting 20 minutes ago. She is known to be allergic to bee venom. On examination, she has generalised urticaria, facial swelling, and audible wheeze. Her blood pressure is 85/50 mmHg, heart rate 125 bpm, respiratory rate 28/min, and oxygen saturation 90% on air. She has already received 500 micrograms of intramuscular adrenaline. Her symptoms persist. What is the appropriate timing for administering a second dose of intramuscular adrenaline?
Q108
A 54-year-old woman attends the Emergency Department with acute central chest pain that began 30 minutes ago whilst at rest. She describes it as crushing in nature, radiating to her left arm. She has a history of hypertension and is a current smoker. Her ECG shows ST-segment elevation of 3 mm in leads V2-V4. Her blood pressure is 145/90 mmHg, heart rate 88 bpm, and oxygen saturation 98% on air. What is the maximum acceptable door-to-balloon time for primary percutaneous coronary intervention in this patient?
Q109
A 67-year-old man presents to the Emergency Department with a 24-hour history of fever and dysuria. He is diagnosed with urosepsis. His observations show: temperature 38.7°C, heart rate 105 bpm, blood pressure 110/70 mmHg, respiratory rate 20/min, oxygen saturation 96% on room air. Blood tests reveal lactate 2.8 mmol/L. According to the Sepsis Six care bundle, which intervention should be completed within the first hour of presentation?
Q110
A 25-year-old man with no significant past medical history presents to the Emergency Department 30 minutes after eating at a seafood restaurant where he inadvertently consumed prawns despite a known shellfish allergy. He describes lip tingling, throat tightness, and generalized itching. On examination, there is mild facial swelling, generalized urticaria, but no wheeze on auscultation. His observations are: temperature 37.1°C, heart rate 95 bpm, blood pressure 118/75 mmHg, respiratory rate 18 breaths per minute, oxygen saturation 98% on room air, peak expiratory flow rate 520 L/min (predicted 580 L/min). Based on current UK guidelines for anaphylaxis management, what is the most appropriate immediate treatment?
Acute Medical Presentations UK Medical PG Practice Questions and MCQs
Question 101: A 44-year-old woman is brought to the Emergency Department by ambulance 15 minutes after eating prawns at a restaurant. She has a known shellfish allergy but the dish was mislabelled. She developed facial swelling, difficulty breathing, and feels lightheaded. On arrival, she has extensive facial and tongue swelling, inspiratory stridor, widespread wheeze, and appears cyanosed. Her blood pressure is 75/40 mmHg, heart rate 135 bpm, respiratory rate 32/min, oxygen saturation 85% on high-flow oxygen. She has received two doses of intramuscular adrenaline 500 micrograms (at 5-minute intervals) with minimal improvement. What is the most appropriate next management step?
A. Administer a third dose of intramuscular adrenaline 500 micrograms
B. Commence intravenous adrenaline infusion at 0.05-0.1 micrograms/kg/min (Correct Answer)
C. Administer intravenous hydrocortisone 200 mg and chlorphenamine 10 mg
D. Proceed with emergency cricothyroidotomy to secure the airway
E. Administer nebulised adrenaline 5 mg and intravenous glucagon 1-2 mg
Explanation: ***Commence intravenous adrenaline infusion at 0.05-0.1 micrograms/kg/min***- In cases of **refractory anaphylaxis** where there is minimal response to two doses of **intramuscular adrenaline**, an IV infusion is the next indicated escalation step.- This patient exhibits life-threatening **respiratory failure** and **hypotension**, necessitating the titration of adrenaline to stabilize vascular tone and reduce airway edema.*Administer a third dose of intramuscular adrenaline 500 micrograms*- While IM adrenaline can be repeated every 5 minutes, guidelines suggest shifting to **intravenous therapy** when two doses fail to stabilize a deteriorating patient.- Continuing IM injections may delay the definitive concentration of medication needed to reverse **circulatory collapse** in refractory cases.*Administer intravenous hydrocortisone 200 mg and chlorphenamine 10 mg*- These are **adjunctive therapies** that work over hours and do not provide the immediate life-saving vasoconstriction or bronchodilation required for **anaphylactic shock**.- Steroids and antihistamines are primarily used to prevent **biphasic reactions** rather than treating the acute airway and circulatory crisis.*Proceed with emergency cricothyroidotomy to secure the airway*- This is a last-resort procedure for a "cannot intubate, cannot oxygenate" (CICO) scenario and is not the immediate next step before attempting **advanced medical management**.- While the airway is threatened by **tongue swelling and stridor**, medical reversal of the edema with adrenaline and expert-led intubation should be pursued first.*Administer nebulised adrenaline 5 mg and intravenous glucagon 1-2 mg*- **Glucagon** is specifically indicated for patients on **beta-blockers** who are resistant to adrenaline, which is not mentioned in this history.- Nebulized adrenaline may help with **upper airway edema**, but it does not address the systemic **hemodynamic instability** or widespread bronchospasm as effectively as IV infusion.
Question 102: A 71-year-old woman with metastatic lung cancer on palliative chemotherapy presents to the Emergency Department with a 12-hour history of fever, rigors, and productive cough. She appears unwell. Observations show: temperature 38.1°C, heart rate 98 bpm, blood pressure 105/65 mmHg, respiratory rate 22/min, oxygen saturation 93% on room air. Blood tests reveal: WCC 1.2 × 10⁹/L, neutrophils 0.4 × 10⁹/L, CRP 156 mg/L. Her chest X-ray shows right lower lobe consolidation. What is the most appropriate immediate antibiotic regimen?
A. Intravenous co-amoxiclav
B. Intravenous piperacillin-tazobactam (Correct Answer)
C. Oral amoxicillin and clarithromycin
D. Intravenous meropenem and vancomycin
E. Intravenous ceftriaxone and clarithromycin
Explanation: ***Intravenous piperacillin-tazobactam***- The patient meets the criteria for **neutropenic sepsis** (neutrophils < 0.5 × 10⁹/L and fever/infection signs), which requires immediate **anti-pseudomonal beta-lactam** monotherapy.- **Piperacillin-tazobactam** is the recommended first-line empirical choice because it covers a broad range of Gram-negative pathogens, including ***Pseudomonas aeruginosa***, which poses a high risk to neutropenic patients.*Intravenous co-amoxiclav*- This antibiotic lacks sufficient activity against ***Pseudomonas***, making it inadequate as initial empirical therapy for neutropenic sepsis.- It is generally used for multi-organism community-acquired infections rather than high-risk **oncological emergencies**.*Oral amoxicillin and clarithromycin*- **Oral therapy** is inappropriate for a patient presenting with systemic features of sepsis, rigors, and significant **tachycardia/tachypnea**.- This regimen is designed for low-risk **community-acquired pneumonia** (CAP), whereas neutropenic sepsis mandates urgent **intravenous (IV)** broad-spectrum coverage.*Intravenous meropenem and vancomycin*- These are reserved as **second-line treatments** or for patients failing to respond to first-line agents like Piperacillin-tazobactam.- **Meropenem** is often held back to prevent the development of **carbapenem resistance**, and vancomycin is only added if there is high suspicion of **MRSA** or catheter-related infections.*Intravenous ceftriaxone and clarithromycin*- While effective for severe **community-acquired pneumonia**, this combination lacks the necessary **anti-pseudomonal** properties required for neutropenic protocols.- **Ceftriaxone** is a third-generation cephalosporin that does not reliably cover *Pseudomonas aeruginosa*, unlike ceftazidime or piperacillin-tazobactam.
Question 103: A 28-year-old woman collapses at a train station. Bystanders report she was standing on a crowded platform when she suddenly fell to the ground. She regained consciousness within 30 seconds and is now alert and oriented. She reports feeling hot and dizzy just before the collapse. She has no significant past medical history and takes no medications. On examination in the Emergency Department, she is clinically well with normal observations and cardiovascular examination. Her ECG shows sinus rhythm with a rate of 68 bpm, normal axis, and normal QT interval (QTc 410 ms). What is the most appropriate next step in her management?
A. Discharge with advice about vasovagal syncope and adequate hydration (Correct Answer)
B. Admit for 24-hour cardiac monitoring with telemetry
C. Arrange outpatient transthoracic echocardiography
D. Perform carotid sinus massage to assess for carotid sinus hypersensitivity
E. Arrange outpatient tilt-table testing
Explanation: ***Discharge with advice about vasovagal syncope and adequate hydration***
- The patient presents with classic **vasovagal syncope** (fainting) triggered by prolonged standing and a crowded environment, preceded by a **prodromal phase** (feeling hot and dizzy).
- Given the **normal ECG**, absence of structural heart disease, and rapid recovery, she is classified as **low-risk** and requires only lifestyle advice and hydration.
*Admit for 24-hour cardiac monitoring with telemetry*
- Admission is reserved for **high-risk patients** with red flags such as syncope during exertion, family history of sudden death, or abnormal ECG findings.
- Telemetry is not indicated here as there are no features suggesting a **cardiac arrhythmia** as the primary cause of collapse.
*Arrange outpatient transthoracic echocardiography*
- Echocardiography is indicated only if there is clinical suspicion of **structural heart disease** or an abnormal cardiovascular examination.
- This patient has a **normal physical exam** and no prior cardiac history, making structural abnormalities a very unlikely cause of her syncope.
*Perform carotid sinus massage to assess for carotid sinus hypersensitivity*
- **Carotid sinus massage** is generally indicated for patients over the age of 40 with syncope of unknown origin.
- It is not routinely performed in a **28-year-old** where the history clearly points toward a reflex (vasovagal) mechanism.
*Arrange outpatient tilt-table testing*
- **Tilt-table testing** is a second-line investigation used when the diagnosis of reflex syncope is uncertain or to distinguish it from **orthostatic hypotension**.
- In this case, the clinical history is sufficiently typical for **vasovagal syncope**, meaning further diagnostic testing is unnecessary.
Question 104: A 63-year-old man with type 2 diabetes presents with a 4-day history of productive cough, fever, and increasing shortness of breath. He is diagnosed with severe community-acquired pneumonia and sepsis. His observations are: temperature 38.9°C, heart rate 118 bpm, blood pressure 88/55 mmHg, respiratory rate 28/min, oxygen saturation 89% on room air. Blood tests show lactate 4.2 mmol/L and glucose 18.4 mmol/L. He has received initial fluid resuscitation with 1 litre of crystalloid over 30 minutes with minimal improvement in blood pressure. What is the most appropriate next step in his management?
A. Commence noradrenaline infusion immediately
B. Arrange immediate transfer to intensive care for mechanical ventilation
C. Administer a further 1 litre crystalloid bolus and reassess (Correct Answer)
D. Start dobutamine infusion to improve cardiac output
E. Insert a central venous catheter to guide fluid management
Explanation: ***Administer a further 1 litre crystalloid bolus and reassess***
- The **Surviving Sepsis Campaign** guidelines recommend an initial fluid resuscitation of at least **30 mL/kg** of crystalloid for sepsis-induced hypoperfusion.
- This patient has only received **1 litre** so far; further boluses are necessary to achieve adequate volume expansion before diagnosing fluid-refractory **septic shock**.
*Commence noradrenaline infusion immediately*
- **Noradrenaline** is the first-line vasopressor but is typically indicated only after **adequate fluid resuscitation** has failed to restore mean arterial pressure.
- Initiating vasopressors too early without addressing **hypovolemia** can lead to profound tissue ischemia and organ dysfunction.
*Arrange immediate transfer to intensive care for mechanical ventilation*
- While the patient has **Type 1 respiratory failure** and may eventually require ICU, emergent bedside stabilization with **fluid resuscitation** and oxygen must happen first.
- **Mechanical ventilation** is indicated for refractory hypoxia or work of breathing but does not replace the immediate need for circulatory support in sepsis.
*Start dobutamine infusion to improve cardiac output*
- **Dobutamine** is an inotrope used specifically when there is evidence of **persistent hypoperfusion** despite adequate fluid and vasopressor therapy, often suggesting myocardial dysfunction.
- There is no evidence of low **cardiac output** or heart failure in this clinical presentation to justify its use as a primary step.
*Insert a central venous catheter to guide fluid management*
- While **central venous pressure (CVP)** monitoring can assist in complex cases, it should not delay the rapid administration of **fluid boluses** in acute sepsis.
- **Static CVP measurements** are no longer prioritized over clinical reassessment and dynamic measures of fluid responsiveness in early resuscitation.
Question 105: A 48-year-old woman presents to the Emergency Department with a 3-day history of increasing confusion, fever, and general malaise. She recently returned from a camping trip in rural Wales. On examination, she is febrile at 39.2°C, drowsy with a GCS of 13 (E3, V4, M6), and has neck stiffness. A non-blanching purpuric rash is noted on her lower limbs. Blood tests show: WCC 18.2 × 10⁹/L, CRP 245 mg/L, lactate 3.4 mmol/L. A CT head is performed and shows no contraindications to lumbar puncture. What is the most appropriate immediate management?
A. Administer intravenous benzylpenicillin and delay lumbar puncture for 24 hours
B. Perform lumbar puncture to confirm diagnosis before starting any antibiotic therapy
C. Perform lumbar puncture immediately, then administer intravenous ceftriaxone
D. Administer intravenous ceftriaxone immediately, then perform lumbar puncture (Correct Answer)
E. Administer intravenous dexamethasone followed by ceftriaxone, then perform lumbar puncture
Explanation: ***Administer intravenous ceftriaxone immediately, then perform lumbar puncture***
- In suspected **bacterial meningitis** or **meningococcal septicaemia**, early antibiotic administration is the most critical factor in reducing mortality.
- While a **lumbar puncture (LP)** is ideally done first, it must never delay the start of life-saving **empirical antibiotics** like **ceftriaxone**.
*Administer intravenous benzylpenicillin and delay lumbar puncture for 24 hours*
- **Benzylpenicillin** is often used in the pre-hospital setting, but **ceftriaxone** offers broader coverage and is preferred in severe hospital-admitted cases like this.
- There is no medical indication to **delay a lumbar puncture** for 24 hours if a CT scan has already cleared the patient for the procedure.
*Perform lumbar puncture to confirm diagnosis before starting any antibiotic therapy*
- Delaying antibiotics to await an LP or results in a patient with **sepsis** and **meningism** significantly increases the risk of death or permanent **neurological deficit**.
- Although cultures are more accurate before antibiotics, **PCR testing** can still identify pathogens in the CSF even after the first dose.
*Perform lumbar puncture immediately, then administer intravenous ceftriaxone*
- This sequence is preferred only if it causes **zero delay**; however, guidelines prioritize immediate antibiotics if there is any logistical hurdle to a rapid LP.
- Given the signs of severe **septicaemia** (elevated lactate, purpuric rash), systemic stabilization and treatment with antibiotics take precedence over diagnostic steps.
*Administer intravenous dexamethasone followed by ceftriaxone, then perform lumbar puncture*
- **Dexamethasone** should be given **with or just before** the first dose of antibiotics to reduce the inflammatory response, particularly in suspected pneumococcal meningitis.
- While beneficial, the absolute immediate priority in a patient with a **purpuric rash** (highly suggestive of meningococcus) and **elevated lactate** is the rapid delivery of antibiotics to treat the underlying infection.
Question 106: A 76-year-old man presents with a syncopal episode that occurred while he was having breakfast. His wife reports he suddenly lost consciousness for approximately 20 seconds, with no preceding warning symptoms. He has a history of hypertension and takes amlodipine. On examination, he has a slow-rising pulse, blood pressure 130/80 mmHg, and a harsh ejection systolic murmur heard loudest at the right upper sternal border radiating to the carotids. The murmur decreases with squatting. What is the underlying mechanism of syncope in this patient?
A. Reduced cerebral perfusion due to vasovagal response
B. Reduced cardiac output due to fixed obstruction to left ventricular outflow (Correct Answer)
C. Transient arrhythmia causing impaired cardiac output
D. Orthostatic hypotension from antihypertensive medication
E. Dynamic obstruction of left ventricular outflow during systole
Explanation: ***Reduced cardiac output due to fixed obstruction to left ventricular outflow***
- The patient's **slow-rising pulse** (pulsus parvus et tardus) and **harsh ejection systolic murmur** heard at the right upper sternal border radiating to the carotids are classic clinical signs of severe **aortic stenosis**.
- Syncope in severe **aortic stenosis** is a cardinal symptom that occurs because the **fixed outflow obstruction** prevents the heart from adequately increasing **cardiac output** to meet systemic demands, leading to **transient cerebral hypoperfusion**.
*Reduced cerebral perfusion due to vasovagal response*
- **Vasovagal syncope** is typically preceded by a prodrome of **nausea, pallor, or sweating**, which were explicitly absent in this patient's sudden loss of consciousness.
- The presence of clear **cardiac findings** (murmur, slow pulse) makes a simple vasovagal response less likely as the primary mechanism.
*Transient arrhythmia causing impaired cardiac output*
- While arrhythmias can cause syncope, the prominent **harsh ejection systolic murmur** and **slow-rising pulse** strongly suggest a primary mechanical obstruction rather than an electrical disturbance.
- Syncope due to arrhythmia would not typically be associated with the specific **murmur characteristics** or its response to maneuvers observed in this case.
*Orthostatic hypotension from antihypertensive medication*
- **Orthostatic hypotension** typically occurs upon standing; however, this patient experienced syncope while **having breakfast**, implying he was seated or had been upright for some time, making this less likely.
- Although he takes amlodipine, the distinct **cardiac examination findings** are more indicative of a structural heart problem than solely medication-induced orthostatic hypotension.
*Dynamic obstruction of left ventricular outflow during systole*
- This mechanism describes **Hypertrophic Obstructive Cardiomyopathy (HOCM)**, which typically presents with a **jerky pulse**, a contrasting finding to the **slow-rising pulse** noted in this patient.
- While the murmur in HOCM can **decrease with squatting**, the overall clinical picture, especially the **slow-rising pulse** and the harsh quality radiating to carotids, is more indicative of a **fixed obstruction** like aortic stenosis.
Question 107: A 41-year-old woman is brought to the Emergency Department after a bee sting 20 minutes ago. She is known to be allergic to bee venom. On examination, she has generalised urticaria, facial swelling, and audible wheeze. Her blood pressure is 85/50 mmHg, heart rate 125 bpm, respiratory rate 28/min, and oxygen saturation 90% on air. She has already received 500 micrograms of intramuscular adrenaline. Her symptoms persist. What is the appropriate timing for administering a second dose of intramuscular adrenaline?
A. After 5 minutes if there is no improvement (Correct Answer)
B. After 10 minutes if there is no improvement
C. After 15 minutes if there is no improvement
D. After 20 minutes if there is no improvement
E. Only if the patient deteriorates further
Explanation: ***After 5 minutes if there is no improvement***
- According to **Resuscitation Council UK guidelines**, intramuscular **adrenaline** (1:1000) should be repeated every **5 minutes** if symptoms of anaphylaxis persist or recur.
- This patient remains **hypotensive** and **hypoxic** despite the initial dose, necessitating a rapid second dose to prevent **cardiovascular collapse**.
*After 10 minutes if there is no improvement*
- Waiting **10 minutes** is dangerously long in the management of **anaphylaxis**, as delay in adrenaline administration is a major risk factor for **fatal outcomes**.
- Peak plasma concentrations and therapeutic effect after **intramuscular injection** are typically assessed within 5 minutes.
*After 15 minutes if there is no improvement*
- Guidelines for **anaphylaxis** emphasize that doses should be repeated much sooner than **15 minutes** to ensure early control of **bronchoconstriction** and **vasodilation**.
- A 15-minute interval is inappropriate for a patient showing active signs of **shock** and **respiratory distress**.
*After 20 minutes if there is no improvement*
- **20 minutes** exceeds the standard clinical window for evaluating the response to initial **emergency pharmacotherapy** in a life-threatening situation.
- By 20 minutes, a patient with **refractory anaphylaxis** who has not received repeated doses may have already progressed to **respiratory or cardiac arrest**.
*Only if the patient deteriorates further*
- Treatment should not be withheld until further deterioration; the lack of **clinical improvement** is sufficient justification for a second dose of **adrenaline**.
- Persistent **hypotension** and **audible wheeze** indicate that the initial dose was insufficient to reverse the **systemic inflammatory response**.
Question 108: A 54-year-old woman attends the Emergency Department with acute central chest pain that began 30 minutes ago whilst at rest. She describes it as crushing in nature, radiating to her left arm. She has a history of hypertension and is a current smoker. Her ECG shows ST-segment elevation of 3 mm in leads V2-V4. Her blood pressure is 145/90 mmHg, heart rate 88 bpm, and oxygen saturation 98% on air. What is the maximum acceptable door-to-balloon time for primary percutaneous coronary intervention in this patient?
A. 60 minutes
B. 90 minutes (Correct Answer)
C. 120 minutes
D. 150 minutes
E. 180 minutes
Explanation: ***90 minutes***
- For patients with **ST-elevation myocardial infarction (STEMI)** presenting directly to a **PCI-capable center**, the target **door-to-balloon time** is 90 minutes from first medical contact.
- This timeframe is critical for **myocardial salvage**, as rapid reperfusion minimizes infarct size and reduces the risk of long-term complications or death.
*60 minutes*
- While the **door-to-needle** time for fibrinolysis is traditionally 30 minutes, 60 minutes is often an internal goal but not the maximum standard for **PCI**.
- The formal international guideline limit for **primary PCI** at a specialized center remains higher to allow for mobilization of the catheterization lab team.
*120 minutes*
- This is the maximum acceptable delay if a patient requires **transfer** from a non-PCI center to a facility capable of performing the procedure.
- In this scenario, since the patient has already reached the **Emergency Department**, the more stringent 90-minute target applies.
*150 minutes*
- This exceeds the recommended guidelines for **primary reperfusion** in a STEMI patient.
- Delays of this length significantly increase the risk of **irreversible myocardial necrosis** and poor clinical outcomes.
*180 minutes*
- A 180-minute delay is well beyond the window where **Primary PCI** is considered optimally effective compared to other strategies.
- Guidelines suggest that if PCI cannot be performed within 120 minutes of contact, **fibrinolysis** should generally be considered instead.
Question 109: A 67-year-old man presents to the Emergency Department with a 24-hour history of fever and dysuria. He is diagnosed with urosepsis. His observations show: temperature 38.7°C, heart rate 105 bpm, blood pressure 110/70 mmHg, respiratory rate 20/min, oxygen saturation 96% on room air. Blood tests reveal lactate 2.8 mmol/L. According to the Sepsis Six care bundle, which intervention should be completed within the first hour of presentation?
A. Administer intravenous broad-spectrum antibiotics (Correct Answer)
B. Insert a central venous catheter for monitoring
C. Arrange immediate computerised tomography of the abdomen
D. Commence intravenous insulin infusion
E. Transfer to the intensive care unit
Explanation: ***Administer intravenous broad-spectrum antibiotics***- Early administration of **broad-spectrum antibiotics** is a core component of the "Give" section of the **Sepsis Six** bundle and must occur within one hour.- Rapid antibiotic treatment is critical as every hour of delay in administration is associated with a significant increase in **mortality** in septic patients.*Insert a central venous catheter for monitoring*- While monitoring is important, **central venous pressure (CVP)** monitoring is not part of the initial Sepsis Six bundle required within the first hour.- Initial fluid resuscitation is typically guided by **peripheral access** and clinical parameters such as blood pressure and urine output.*Arrange immediate computerised tomography of the abdomen*- **Imaging** may be necessary to identify the source of infection, but it should not delay the life-saving interventions of the Sepsis Six bundle.- Priority must be given to clinical stabilization, including **fluid resuscitation** and **antibiotic therapy**, before moving the patient for a CT scan.*Commence intravenous insulin infusion*- **Insulin therapy** is used to manage hyperglycemia in the critically ill but is not a component of the Sepsis Six bundle.- Routine insulin infusion is not indicated unless the patient demonstrates significant **glycemic derangement** secondary to the stress response.*Transfer to the intensive care unit*- The **Sepsis Six** bundle is designed to be initiated immediately by the first responding clinical team in the **Emergency Department** or ward.- While the patient may eventually require **ICU admission**, the initial stabilization and bundle completion should be prioritized regardless of the patient's location.
Question 110: A 25-year-old man with no significant past medical history presents to the Emergency Department 30 minutes after eating at a seafood restaurant where he inadvertently consumed prawns despite a known shellfish allergy. He describes lip tingling, throat tightness, and generalized itching. On examination, there is mild facial swelling, generalized urticaria, but no wheeze on auscultation. His observations are: temperature 37.1°C, heart rate 95 bpm, blood pressure 118/75 mmHg, respiratory rate 18 breaths per minute, oxygen saturation 98% on room air, peak expiratory flow rate 520 L/min (predicted 580 L/min). Based on current UK guidelines for anaphylaxis management, what is the most appropriate immediate treatment?
A. Intramuscular adrenaline 500 micrograms immediately (Correct Answer)
B. Intravenous chlorphenamine 10 mg and intravenous hydrocortisone 200 mg only
C. Oral antihistamine and observation
D. Inhaled salbutamol and oral prednisolone
E. Intramuscular adrenaline 300 micrograms immediately
Explanation: ***Intramuscular adrenaline 500 micrograms immediately***
- The patient's presentation with **throat tightness**, **lip tingling**, **facial swelling**, and **generalized urticaria** after shellfish exposure indicates **anaphylaxis with airway involvement**.
- According to current UK guidelines, **intramuscular adrenaline 500 micrograms (0.5 mL of 1:1,000 solution)** is the **first-line treatment** for adults with anaphylaxis.
*Intravenous chlorphenamine 10 mg and intravenous hydrocortisone 200 mg only*
- These are **second-line** and **adjunctive treatments** for anaphylaxis, having a slower onset of action compared to adrenaline.
- They do not address the immediate life-threatening features of **airway obstruction** or **cardiovascular collapse** in anaphylaxis, and therefore should not be given as the sole initial treatment.
*Oral antihistamine and observation*
- This approach is completely inappropriate for a patient exhibiting **airway symptoms** such as throat tightness and facial swelling, indicating a severe allergic reaction.
- **Oral antihistamines** are only suitable for mild, localized allergic reactions (e.g., isolated urticaria) without systemic involvement or risk of rapid deterioration.
*Inhaled salbutamol and oral prednisolone*
- While **salbutamol** treats lower airway bronchospasm, it is ineffective for the patient's primary concern of **upper airway swelling** (throat tightness).
- **Oral prednisolone** has a delayed onset of action and does not provide immediate relief for the acute, life-threatening symptoms of anaphylaxis.
*Intramuscular adrenaline 300 micrograms immediately*
- This dose of **intramuscular adrenaline (300 micrograms)** is generally reserved for children aged **6 to 12 years**.
- Administering an **underdose** to an adult patient with anaphylaxis may lead to insufficient clinical response and potentially worsen the patient's condition.
