A 56-year-old man collapses in the supermarket. Bystanders call an ambulance and report that he suddenly fell to the ground, had brief jerking movements of his limbs lasting about 10 seconds, was incontinent of urine, and took several minutes to become fully alert. He has no history of epilepsy. On arrival in the Emergency Department, he is alert but has bitten his tongue. His observations are normal. ECG shows sinus rhythm with a rate of 75 bpm. Which feature of this presentation is most suggestive of a cardiac syncope rather than a primary seizure?
Q162
A 19-year-old university student presents to the Emergency Department with a 12-hour history of severe headache, fever, photophobia, and vomiting. On examination, she has a temperature of 39.4°C, heart rate 125 bpm, blood pressure 95/60 mmHg, and a purpuric rash on her legs. She is confused and has neck stiffness. Blood tests show: white cell count 24.5 × 10⁹/L, C-reactive protein 285 mg/L, lactate 3.8 mmol/L. What is the most appropriate immediate antibiotic therapy before any further investigations?
Q163
A 62-year-old woman presents to the Emergency Department with central chest pain that started 90 minutes ago. The pain is described as heavy and radiating to her jaw. Her ECG shows ST-segment depression of 2 mm in leads V3-V6 and T-wave inversion in the same leads. High-sensitivity troponin I measured at 2 hours from symptom onset is 850 ng/L (normal <16 ng/L). Her observations are stable. She is treated with aspirin, ticagrelor, fondaparinux, and analgesia. What is the most appropriate next step in her management?
Q164
A 71-year-old man presents to the Emergency Department with a 48-hour history of productive cough, fever, and increasing shortness of breath. He has a history of chronic obstructive pulmonary disease and takes regular inhalers. On examination, he appears unwell with bronchial breathing at the right base. Observations: temperature 38.8°C, heart rate 110 bpm, blood pressure 100/65 mmHg, respiratory rate 26 breaths/minute, oxygen saturation 90% on room air. Blood results: white cell count 19.8 × 10⁹/L, C-reactive protein 245 mg/L, urea 9.5 mmol/L, creatinine 125 μmol/L. Chest X-ray confirms right lower lobe pneumonia. What is his CURB-65 score?
Q165
A 28-year-old woman with a known allergy to latex presents to the Emergency Department 5 minutes after putting on latex gloves at work. She has developed facial swelling, difficulty breathing, and feels dizzy. On examination, she has angioedema of the lips and tongue, audible wheeze, and widespread urticaria. Her blood pressure is 85/50 mmHg and heart rate 115 bpm. After calling for help and administering intramuscular adrenaline 500 micrograms, she remains hypotensive. What is the most appropriate next step in management?
Q166
A 52-year-old man is brought to the Emergency Department by ambulance with a 4-hour history of fever, productive cough, and shortness of breath. He appears unwell and confused. Observations: temperature 39.2°C, heart rate 125 bpm, blood pressure 88/55 mmHg, respiratory rate 28 breaths/minute, oxygen saturation 88% on room air. Blood results show: white cell count 22.5 × 10⁹/L, lactate 4.5 mmol/L, urea 15.2 mmol/L, creatinine 165 μmol/L. Chest X-ray shows right lower lobe consolidation. What qSOFA score does this patient have?
Q167
A 35-year-old woman is brought to the Emergency Department after collapsing at work. Colleagues report she suddenly fell to the ground without warning and was unconscious for approximately 20 seconds. There were no abnormal movements. She recovered quickly and is now alert. She reports feeling completely well before the episode with no preceding dizziness, palpitations, or chest pain. Her past medical history includes hypertrophic cardiomyopathy diagnosed 2 years ago. Observations are normal. What is the most important immediate investigation?
Q168
A 45-year-old woman presents to the Emergency Department with sudden-onset severe central chest pain that started 30 minutes ago while at rest. The pain is crushing in nature and radiates to her left arm. She has no significant past medical history and takes no regular medications. On examination, she is sweaty and distressed. Her observations are: blood pressure 145/90 mmHg, heart rate 95 bpm, oxygen saturation 97% on room air. What is the most appropriate initial investigation?
Q169
A 68-year-old man with known type 2 diabetes presents to the Emergency Department with a 24-hour history of fever, dysuria, and confusion. His wife reports he has been drinking less than usual. On examination, his temperature is 38.9°C, heart rate 112 bpm, blood pressure 95/60 mmHg, respiratory rate 24 breaths/minute, and oxygen saturation 94% on room air. Blood tests show: white cell count 18.2 × 10⁹/L, lactate 3.2 mmol/L, creatinine 185 μmol/L (baseline 95 μmol/L). What is the most appropriate initial fluid resuscitation strategy?
Q170
A 56-year-old woman presents with sudden-onset palpitations that started 2 hours ago. She feels light-headed but has not lost consciousness. Her heart rate is 168 bpm, blood pressure 108/72 mmHg, and oxygen saturation 98% on air. Her ECG shows a narrow complex tachycardia with absent P waves and an irregular rhythm. She has no chest pain or dyspnoea. What is the most appropriate immediate management?
Acute Medical Presentations UK Medical PG Practice Questions and MCQs
Question 161: A 56-year-old man collapses in the supermarket. Bystanders call an ambulance and report that he suddenly fell to the ground, had brief jerking movements of his limbs lasting about 10 seconds, was incontinent of urine, and took several minutes to become fully alert. He has no history of epilepsy. On arrival in the Emergency Department, he is alert but has bitten his tongue. His observations are normal. ECG shows sinus rhythm with a rate of 75 bpm. Which feature of this presentation is most suggestive of a cardiac syncope rather than a primary seizure?
A. Urinary incontinence during the event
B. Brief jerking movements of the limbs
C. Tongue biting during the event
D. Sudden collapse without warning (Correct Answer)
E. Prolonged confusion after the event
Explanation: ***Sudden collapse without warning***
- **Sudden onset** without a prodrome or **aura** is highly characteristic of **cardiac syncope**, often caused by an underlying **arrhythmia**.
- In contrast, many **epileptic seizures** involve a preceding warning or a more gradual transition from alertness to loss of consciousness.
*Urinary incontinence during the event*
- **Urinary incontinence** is a non-specific finding and can occur in both **generalized tonic-clonic seizures** and severe **syncopal episodes**.
- It results from the loss of **sphincter control** during the period of unconsciousness and does not reliably distinguish between the two.
*Brief jerking movements of the limbs*
- Brief, irregular **myoclonic jerks** lasting less than 15 seconds are common in **convulsive syncope** due to transient brain **hypoperfusion**.
- These are distinct from the rhythmic, prolonged, and coordinated movements typically seen in a **primary seizure**.
*Tongue biting during the event*
- While **tongue biting** is more frequently associated with **epilepsy**, it can occur during the sudden fall or jerking phase of **cardiac syncope**.
- Notably, **lateral tongue biting** is highly specific for seizure, whereas biting the **tip of the tongue** is more common in syncope.
*Prolonged confusion after the event*
- **Prolonged post-ictal confusion** (lasting >5 minutes) is a hallmark of **seizures**, whereas recovery and reorientation after **syncope** are typically rapid.
- In this case, the patient took several minutes to alert, which is borderline and less specific than the **sudden collapse** itself.
Question 162: A 19-year-old university student presents to the Emergency Department with a 12-hour history of severe headache, fever, photophobia, and vomiting. On examination, she has a temperature of 39.4°C, heart rate 125 bpm, blood pressure 95/60 mmHg, and a purpuric rash on her legs. She is confused and has neck stiffness. Blood tests show: white cell count 24.5 × 10⁹/L, C-reactive protein 285 mg/L, lactate 3.8 mmol/L. What is the most appropriate immediate antibiotic therapy before any further investigations?
A. Intravenous ceftriaxone 2g (Correct Answer)
B. Intravenous benzylpenicillin 2.4g
C. Intravenous ceftriaxone 2g plus amoxicillin 2g
D. Intravenous meropenem 2g
E. Intramuscular benzylpenicillin 1.2g
Explanation: ***Intravenous ceftriaxone 2g***- **Intravenous ceftriaxone** is the standard empirical treatment for suspected **bacterial meningitis** in a hospital setting, particularly when a **purpuric rash** and signs of **septic shock** are present, suggesting **meningococcal disease**.- It provides excellent coverage against *Neisseria meningitidis* and *Streptococcus pneumoniae* and achieves good cerebrospinal fluid penetration, making it critical for immediate administration to improve outcomes.*Intravenous benzylpenicillin 2.4g*- While **benzylpenicillin** is effective against *N. meningitidis*, it has a narrower spectrum compared to third-generation cephalosporins like ceftriaxone.- It is generally not the first-line empirical choice in hospitals for suspected bacterial meningitis because it does not cover *Haemophilus influenzae* and *Streptococcus pneumoniae* as broadly as ceftriaxone.*Intravenous ceftriaxone 2g plus amoxicillin 2g*- The addition of **amoxicillin** (or ampicillin) to ceftriaxone is specifically recommended to cover ***Listeria monocytogenes***.- *Listeria* is a concern in specific patient populations, such as those over **50 years old**, neonates, or immunocompromised individuals, none of which describe this 19-year-old student.*Intravenous meropenem 2g*- **Meropenem** is a **broad-spectrum carbapenem** typically reserved for very severe infections, known **drug-resistant organisms**, or patients with severe **beta-lactam allergies**.- It is not the initial empirical antibiotic for suspected community-acquired bacterial meningitis in an otherwise healthy young adult, as ceftriaxone is usually sufficient and avoids unnecessary broad-spectrum antibiotic use.*Intramuscular benzylpenicillin 1.2g*- The **intramuscular (IM)** route is inappropriate for a critically unwell patient presenting with **septic shock**, as **hypotension** and poor peripheral perfusion can lead to unreliable and delayed drug absorption.- IM benzylpenicillin is primarily indicated for **pre-hospital administration** by primary care providers or paramedics when there is an anticipated delay in reaching hospital care.
Question 163: A 62-year-old woman presents to the Emergency Department with central chest pain that started 90 minutes ago. The pain is described as heavy and radiating to her jaw. Her ECG shows ST-segment depression of 2 mm in leads V3-V6 and T-wave inversion in the same leads. High-sensitivity troponin I measured at 2 hours from symptom onset is 850 ng/L (normal <16 ng/L). Her observations are stable. She is treated with aspirin, ticagrelor, fondaparinux, and analgesia. What is the most appropriate next step in her management?
A. Primary percutaneous coronary intervention within 120 minutes
B. Thrombolysis with alteplase
C. Coronary angiography within 72 hours (Correct Answer)
D. Exercise tolerance test in 48 hours
E. Repeat ECG and troponin in 6 hours
Explanation: ***Coronary angiography within 72 hours***- The patient presents with **NSTEMI**, evidenced by cardiac chest pain, **ST-segment depression**, and significantly **elevated troponin** levels without ST elevation.- Clinical guidelines recommend an **early invasive strategy** (angiography within 72 hours) for patients with a confirmed NSTEMI and a high/intermediate risk profile to identify and treat the culprit lesion.*Primary percutaneous coronary intervention within 120 minutes*- This is the standard of care for patients with **ST-elevation myocardial infarction (STEMI)** to provide immediate reperfusion.- In NSTEMI, this urgent timeframe is generally reserved only for those with **hemodynamic instability**, refractory pain, or life-threatening arrhythmias.*Thrombolysis with alteplase*- **Thrombolysis** is indicated for STEMI when primary PCI cannot be performed within the recommended timeframe (e.g., within 120 minutes).- Thrombolytic therapy has **no benefit** and may be harmful in the management of NSTEMI or unstable angina.*Exercise tolerance test in 48 hours*- Exercise testing is **contraindicated** in the acute phase of a myocardial infarction due to the risk of myocardial rupture or arrhythmia.- It has been largely replaced by **invasive angiography** or non-invasive imaging for risk stratification and diagnosis in the acute setting.*Repeat ECG and troponin in 6 hours*- While serial measurements are used to rule in or out an MI, this patient already has a diagnostic **high-sensitivity troponin** elevation (850 ng/L).- Re-testing at 6 hours would **unnecessarily delay** definitive invasive management in a patient who already meets the diagnostic criteria for NSTEMI.
Question 164: A 71-year-old man presents to the Emergency Department with a 48-hour history of productive cough, fever, and increasing shortness of breath. He has a history of chronic obstructive pulmonary disease and takes regular inhalers. On examination, he appears unwell with bronchial breathing at the right base. Observations: temperature 38.8°C, heart rate 110 bpm, blood pressure 100/65 mmHg, respiratory rate 26 breaths/minute, oxygen saturation 90% on room air. Blood results: white cell count 19.8 × 10⁹/L, C-reactive protein 245 mg/L, urea 9.5 mmol/L, creatinine 125 μmol/L. Chest X-ray confirms right lower lobe pneumonia. What is his CURB-65 score?
A. 2
B. 3 (Correct Answer)
C. 4
D. 5
E. 1
Explanation: ***3***
- The patient's **CURB-65** score includes 1 point for **Age ≥ 65** (71 years) and 1 point for **Urea > 7 mmol/L** (9.5 mmol/L).
- While strict thresholds for respiratory rate (≥30) or blood pressure (<90/60) are not met, the overall clinical picture of significant dyspnoea (shortness of breath), hypoxia (SpO2 90% on room air), and tachycardia (HR 110 bpm) in a patient with COPD often leads to a **clinical interpretation** that assigns an additional point, especially in scenarios where risk stratification is crucial.
*2*
- A score of 2 would strictly account for only the **Age** and **Urea** criteria.
- This score would typically underestimate the severity of illness for a patient presenting with marked hypoxia, tachycardia, and increasing shortness of breath, placing them in an intermediate-risk category that might not reflect the need for higher-level care.
*4*
- To achieve a score of 4, the patient would need to have evidence of **confusion**, or meet the strict criteria for both **respiratory rate (≥30 breaths/min)** and **blood pressure (<90 mmHg systolic or ≤60 mmHg diastolic)**, or other combinations including confusion.
- The patient's respiratory rate is 26 breaths/minute and blood pressure is 100/65 mmHg, and there is no mention of confusion, thus not meeting the criteria for a score of 4.
*5*
- A score of 5 represents the maximum severity in the **CURB-65** scale, indicating a very high risk of mortality and almost certainly requiring intensive care admission.
- This score would require all criteria to be met, including confusion, a respiratory rate ≥30, and severe hypotension, none of which are fully present in this patient.
*1*
- A score of 1 would imply that only one of the **CURB-65** criteria was met, such as **Age ≥ 65** or **Urea > 7 mmol/L**, but not both.
- This is incorrect as the patient clearly meets both the age and urea criteria, and a score of 1 would wrongly categorize him as low risk, suggesting outpatient management which is inappropriate.
Question 165: A 28-year-old woman with a known allergy to latex presents to the Emergency Department 5 minutes after putting on latex gloves at work. She has developed facial swelling, difficulty breathing, and feels dizzy. On examination, she has angioedema of the lips and tongue, audible wheeze, and widespread urticaria. Her blood pressure is 85/50 mmHg and heart rate 115 bpm. After calling for help and administering intramuscular adrenaline 500 micrograms, she remains hypotensive. What is the most appropriate next step in management?
A. Repeat intramuscular adrenaline after 5 minutes (Correct Answer)
B. Administer intravenous chlorphenamine 10 mg
C. Administer intravenous hydrocortisone 200 mg
D. Commence intravenous adrenaline infusion
E. Administer nebulised salbutamol
Explanation: ***Repeat intramuscular adrenaline after 5 minutes***- In the management of **anaphylaxis**, **intramuscular (IM) adrenaline** is the first-line treatment and should be repeated every 5 minutes if there is no clinical improvement or if symptoms deteriorate.- This patient remains **hypotensive** and symptomatic after the first dose, necessitating further stabilization of the **cardiovascular and respiratory systems** with a repeat dose.*Administer intravenous chlorphenamine 10 mg*- **Chlorphenamine** is an antihistamine used as a **second-line adjunct** primarily to treat skin symptoms like urticaria and angioedema.- It has no role in treating the life-threatening **respiratory or circulatory compromise** and should only be given after initial stabilization.*Administer intravenous hydrocortisone 200 mg*- **Hydrocortisone** is a corticosteroid that helps prevent **biphasic reactions** or late-phase symptoms but takes hours to work.- It is not a treatment for **acute airway obstruction** or **anaphylactic shock** and should never delay the administration of adrenaline.*Commence intravenous adrenaline infusion*- **Intravenous (IV) adrenaline infusions** are reserved for cases of **refractory anaphylaxis** where at least two doses of IM adrenaline have failed.- This should only be initiated by experts in an **intensive care or high-dependency** setting due to the high risk of arrhythmias.*Administer nebulised salbutamol*- **Nebulised salbutamol** is an adjunct therapy used to treat persistent **bronchospasm** and wheezing once the main systemic reaction is managed.- It does not address the **systemic vasodilation** or **laryngeal edema** which are causing the patient's hypotension and airway swelling.
Question 166: A 52-year-old man is brought to the Emergency Department by ambulance with a 4-hour history of fever, productive cough, and shortness of breath. He appears unwell and confused. Observations: temperature 39.2°C, heart rate 125 bpm, blood pressure 88/55 mmHg, respiratory rate 28 breaths/minute, oxygen saturation 88% on room air. Blood results show: white cell count 22.5 × 10⁹/L, lactate 4.5 mmol/L, urea 15.2 mmol/L, creatinine 165 μmol/L. Chest X-ray shows right lower lobe consolidation. What qSOFA score does this patient have?
A. 0
B. 1
C. 2
D. 3 (Correct Answer)
E. 4
Explanation: ***3*** - The patient meets all three **qSOFA** criteria: **altered mental status** (confused), **systolic blood pressure**
100 mmHg (88 mmHg), and **respiratory rate**
22/min (28/min).
- A **qSOFA score of 3** indicates a high risk of poor outcomes and suggests severe systemic dysfunction in the setting of suspected infection, likely **sepsis**.
*0*
- This score implies none of the **high-risk clinical parameters** (hypotension, tachypnea, or altered mental status) are present.
- Given the patient's **confusion**, hypotension, and rapid breathing, a score of 0 incorrectly excludes obvious clinical deterioration.
*1*
- This score would mean only one of the three bedside criteria is met.
- Since the patient has **low blood pressure**, **altered consciousness**, and **tachypnea**, he fulfills more than a single criterion.
*2*
- Although a score of
2 is the threshold for Identifying **high-risk patients**, this patient specifically meets all three points.
- Missing one point, such as assuming normal mental status or stable blood pressure, would lead to an incorrect tally of 2.
*4*
- The **qSOFA** tool is a 3-point scale; therefore, a score of 4 is impossible within this specific clinical scoring system.
- Extra points are not awarded for laboratory findings like **lactate** or **urea**, which are used in other assessments like the full **SOFA** or **CURB-65** scores.
Question 167: A 35-year-old woman is brought to the Emergency Department after collapsing at work. Colleagues report she suddenly fell to the ground without warning and was unconscious for approximately 20 seconds. There were no abnormal movements. She recovered quickly and is now alert. She reports feeling completely well before the episode with no preceding dizziness, palpitations, or chest pain. Her past medical history includes hypertrophic cardiomyopathy diagnosed 2 years ago. Observations are normal. What is the most important immediate investigation?
A. CT head scan
B. 12-lead electrocardiogram (Correct Answer)
C. Echocardiogram
D. 24-hour ECG monitoring
E. Tilt table testing
Explanation: ***12-lead electrocardiogram*** - Sudden collapse without warning (no **prodrome**) in a patient with **Hypertrophic Cardiomyopathy (HCM)** is highly suspicious for a **cardiac arrhythmia**, which is a leading cause of sudden death in these patients. - A **12-lead ECG** is the essential immediate bedside investigation to look for acute arrhythmias, **repolarization abnormalities**, or evidence of pre-excitation that could explain the syncopal event.*CT head scan* - There are no **focal neurological deficits**, prolonged loss of consciousness, or history of head trauma to justify an immediate CT head. - The rapid recovery and lack of **post-ictal state** point towards a cardiovascular cause rather than a neurological one like **intracranial hemorrhage** or stroke.*Echocardiogram* - While useful for assessing the severity of ventricular hypertrophy or **outflow tract obstruction**, the patient already has a known diagnosis of **HCM**. - It is a secondary investigation to the ECG and is less helpful in identifying the immediate **electrical cause** of a sudden collapse.*24-hour ECG monitoring* - This is a useful tool for diagnosing **intermittent arrhythmias**, but it is not an "immediate" emergency department investigation. - The patient requires stabilization and initial screening with a **standard ECG** and likely inpatient telemetry rather than an outpatient Holter monitor.*Tilt table testing* - This test is specifically used to diagnose **vasovagal syncope** or orthostatic hypotension, which is not suggested by the lack of autonomic triggers or prodromal symptoms. - It is generally contraindicated or of limited use when a life-threatening cause like **structural heart disease** is already known and likely the cause of syncope.
Question 168: A 45-year-old woman presents to the Emergency Department with sudden-onset severe central chest pain that started 30 minutes ago while at rest. The pain is crushing in nature and radiates to her left arm. She has no significant past medical history and takes no regular medications. On examination, she is sweaty and distressed. Her observations are: blood pressure 145/90 mmHg, heart rate 95 bpm, oxygen saturation 97% on room air. What is the most appropriate initial investigation?
A. 12-lead electrocardiogram (Correct Answer)
B. Chest X-ray
C. Troponin measurement
D. D-dimer measurement
E. CT pulmonary angiogram
Explanation: ***12-lead electrocardiogram***- For a patient with central **crushing chest pain**, a **12-lead ECG** must be performed within **10 minutes** of arrival to rule out a high-risk ST-elevation myocardial infarction (STEMI).- It is the most critical first step as it determines the immediate need for **emergency reperfusion therapy** like primary PCI or thrombolysis.*Chest X-ray*- This is useful for identifying alternative causes of chest pain like **pneumothorax** or a **widened mediastinum** in aortic dissection but is not the priority in suspected ischemia.- Obtaining an X-ray should never delay the performance of an **ECG** in a patient with active cardiac chest pain.*Troponin measurement*- **Troponin levels** are essential for diagnosing an NSTEMI, but they may take several hours to become elevated following the onset of pain.- While a crucial part of the **ACS diagnostic workup**, it is a laboratory test that follows the initial immediate bedside **ECG**.*D-dimer measurement*- This test is used to screen for **venous thromboembolism** or **pulmonary embolism** when the clinical suspicion is low to moderate.- It is non-specific and lacks the diagnostic utility needed for this patient's classic **isceral chest pain** presentation.*CT pulmonary angiogram*- This is the gold standard for diagnosing a **pulmonary embolism**, which typically presents with **pleuritic chest pain** and shortness of breath.- It is a resource-intensive investigation and is not indicated as the **initial investigation** for suspected acute coronary syndrome.
Question 169: A 68-year-old man with known type 2 diabetes presents to the Emergency Department with a 24-hour history of fever, dysuria, and confusion. His wife reports he has been drinking less than usual. On examination, his temperature is 38.9°C, heart rate 112 bpm, blood pressure 95/60 mmHg, respiratory rate 24 breaths/minute, and oxygen saturation 94% on room air. Blood tests show: white cell count 18.2 × 10⁹/L, lactate 3.2 mmol/L, creatinine 185 μmol/L (baseline 95 μmol/L). What is the most appropriate initial fluid resuscitation strategy?
A. 250 mL crystalloid bolus over 15 minutes
B. 500 mL crystalloid bolus over 15 minutes followed by reassessment (Correct Answer)
C. 1000 mL crystalloid bolus over 1 hour
D. 500 mL colloid bolus over 30 minutes
E. Commence maintenance fluids at 125 mL/hour
Explanation: ***500 mL crystalloid bolus over 15 minutes followed by reassessment***- This patient meets the criteria for **sepsis** with organ dysfunction (hypotension, elevated **lactate**, and acute kidney injury), requiring immediate fluid resuscitation.- Current guidelines recommend an initial **500 mL crystalloid bolus** delivered rapidly to improve tissue perfusion, with frequent **reassessment** to guide further management.*250 mL crystalloid bolus over 15 minutes*- A **250 mL bolus** is generally reserved for patients at high risk of **fluid overload**, such as those with heart failure or end-stage renal disease.- For a patient in **septic shock** with clear hypotension and high lactate, this volume is insufficient for adequate volume expansion.*1000 mL crystalloid bolus over 1 hour*- While the total volume is appropriate, delivering it over one hour is too slow for a patient exhibiting **hemodynamic instability**.- Rapid delivery in **15-minute intervals** allows for regular clinical checks to prevent complications like pulmonary edema.*500 mL colloid bolus over 30 minutes*- **Crystalloids** (like 0.9% Saline or Hartmann's) are the first-line choice; **colloids** have shown no survival benefit in sepsis and are more expensive.- Certain colloids, such as starches, are actually associated with an increased risk of **acute kidney injury** in septic patients.*Commence maintenance fluids at 125 mL/hour*- **Maintenance fluids** are designed to meet daily physiological needs and do not provide the rapid volume expansion needed to treat **circulatory collapse**.- Relying on maintenance rates in this scenario would delay critical treatment for **sepsis-induced hypoperfusion** and worsening organ failure.
Question 170: A 56-year-old woman presents with sudden-onset palpitations that started 2 hours ago. She feels light-headed but has not lost consciousness. Her heart rate is 168 bpm, blood pressure 108/72 mmHg, and oxygen saturation 98% on air. Her ECG shows a narrow complex tachycardia with absent P waves and an irregular rhythm. She has no chest pain or dyspnoea. What is the most appropriate immediate management?
A. Intravenous adenosine 6 mg rapid bolus
B. Synchronised DC cardioversion starting at 120-150 J
C. Intravenous amiodarone 300 mg over 20-60 minutes
D. Rate control with intravenous metoprolol and anticoagulation (Correct Answer)
E. Vagal manoeuvres followed by intravenous verapamil
Explanation: ***Rate control with intravenous metoprolol and anticoagulation***
- The ECG findings of a **narrow complex tachycardia** with **absent P waves** and an **irregular rhythm** are characteristic of **atrial fibrillation (AF)**.
- Given the patient is **haemodynamically stable** (BP 108/72 mmHg, no loss of consciousness, no acute signs of ischaemia or heart failure), immediate management focuses on **rate control** with a **beta-blocker** (e.g., metoprolol) or a non-dihydropyridine calcium channel blocker, alongside prompt initiation of **anticoagulation** to prevent stroke.
*Intravenous adenosine 6 mg rapid bolus*
- **Adenosine** is indicated for the termination of **regular narrow complex tachycardias** such as **SVT** or AVNRT by temporarily blocking the AV node.
- It is **ineffective** for treating **atrial fibrillation** as it does not convert the rhythm and only causes a transient, non-therapeutic AV block.
*Synchronised DC cardioversion starting at 120-150 J*
- **Emergency synchronised DC cardioversion** is reserved for **unstable patients** with AF presenting with hypotension, acute heart failure, myocardial ischaemia, or altered mental status.
- In **stable AF**, cardioversion without prior therapeutic **anticoagulation** (typically 3 weeks) or exclusion of a left atrial thrombus via **transoesophageal echocardiogram (TOE)** carries a high risk of **thromboembolic events**.
*Intravenous amiodarone 300 mg over 20-60 minutes*
- **Amiodarone** is primarily an **antiarrhythmic drug** used for **rhythm control** in AF, or for rate control in AF with concomitant severe **heart failure** where other rate control agents are contraindicated.
- For stable, new-onset AF with rapid ventricular response, **rate control** is generally preferred as initial therapy over rhythm control unless there are specific indications or comorbidities.
*Vagal manoeuvres followed by intravenous verapamil*
- **Vagal manoeuvres** (e.g., Valsalva) are typically the first step in managing **regular supraventricular tachycardias (SVT)** for diagnostic or therapeutic purposes, but they do not terminate AF.
- While **verapamil** (a non-dihydropyridine calcium channel blocker) can be used for rate control in AF, the sequence of starting with vagal manoeuvres is specific for **SVT**, not for an **irregularly irregular rhythm** like AF.
