A 42-year-old man is brought to the Emergency Department following a collapse while running. Bystanders initiated CPR and an AED delivered one shock before the ambulance arrived. He now has return of spontaneous circulation (ROSC). ECG shows ST elevation in leads V1-V4. His Glasgow Coma Scale is 6 (E1, V1, M4). What is the most appropriate management regarding targeted temperature management?
Q202
A 32-year-old woman presents to the Emergency Department with sudden-onset severe headache which she describes as 'the worst headache of my life'. She vomited twice. On examination, she has photophobia and neck stiffness. CT head performed 8 hours after symptom onset shows no abnormality. What is the most appropriate next investigation?
Q203
A 78-year-old woman is brought to the Emergency Department after collapsing at home. She reports that she stood up from her chair and immediately felt dizzy and collapsed. This has happened twice before in the past month. She takes amlodipine, ramipril, doxazosin, and bisoprolol. Lying blood pressure is 145/85 mmHg with heart rate 65 bpm. Standing blood pressure after 3 minutes is 105/70 mmHg with heart rate 68 bpm. ECG shows sinus rhythm. What is the most likely cause of her symptoms?
Q204
A 55-year-old man with a history of poorly controlled hypertension presents to the Emergency Department with severe chest pain radiating to his back for the past hour. Blood pressure is 180/110 mmHg in the right arm and 175/105 mmHg in the left arm. ECG shows left ventricular hypertrophy with no acute ischaemic changes. CT aortography confirms Type B aortic dissection (distal to left subclavian artery) without complications. What is the most appropriate initial management?
Q205
A 25-year-old woman with known peanut allergy accidentally consumed a food item containing peanuts 20 minutes ago. She has developed generalized urticaria and lip swelling but no stridor, wheeze, or respiratory distress. Her blood pressure is 118/75 mmHg, heart rate 88 bpm, respiratory rate 16/min, oxygen saturation 98% on room air. She has been given oral chlorphenamine. What is the most appropriate management?
Q206
A 45-year-old man with no significant past medical history presents with 2 hours of severe central chest pain. ECG shows ST-segment elevation of 3mm in leads V1-V4. The nearest primary percutaneous coronary intervention (PCI) centre is 90 minutes away by ambulance. He presented to the Emergency Department 30 minutes ago. What is the most appropriate management?
Q207
A 68-year-old man presents with a syncopal episode while shopping. He has no recollection of the event but witnesses report sudden collapse without warning. He has a history of myocardial infarction 3 years ago. ECG shows sinus rhythm with Q waves in leads II, III, and aVF, and frequent ventricular ectopic beats. His echocardiogram from 6 months ago showed left ventricular ejection fraction of 35%. What is the most appropriate next investigation?
Q208
A 58-year-old woman with type 2 diabetes presents to the Emergency Department with a 48-hour history of productive cough, fever, and right-sided pleuritic chest pain. Observations: temperature 38.7°C, blood pressure 110/70 mmHg, heart rate 105 bpm, respiratory rate 24/min, oxygen saturation 93% on room air. Blood tests show: WCC 16.2 × 10⁹/L, CRP 185 mg/L, urea 8.5 mmol/L. Chest X-ray confirms right lower lobe consolidation. Her CURB-65 score is 2. What is the most appropriate antibiotic regimen?
Q209
A 36-year-old man is brought to the Emergency Department by ambulance 10 minutes after eating prawns at a restaurant. He has facial swelling, urticarial rash, stridor, and appears distressed. Blood pressure is 85/55 mmHg, heart rate 120 bpm, oxygen saturation 91% on room air. He has been given high-flow oxygen. What is the most appropriate immediate management?
Q210
A 72-year-old man with chronic kidney disease stage 4 presents to the Emergency Department with a 36-hour history of vomiting and diarrhoea. He appears unwell with cool peripheries and delayed capillary refill time. Blood pressure is 95/60 mmHg, heart rate 110 bpm. Blood tests show: creatinine 380 µmol/L (baseline 210 µmol/L), urea 28 mmol/L, lactate 3.8 mmol/L, bicarbonate 18 mmol/L. He has been given 1 litre of 0.9% sodium chloride over the past hour. What is the most appropriate next step in fluid resuscitation?
Acute Medical Presentations UK Medical PG Practice Questions and MCQs
Question 201: A 42-year-old man is brought to the Emergency Department following a collapse while running. Bystanders initiated CPR and an AED delivered one shock before the ambulance arrived. He now has return of spontaneous circulation (ROSC). ECG shows ST elevation in leads V1-V4. His Glasgow Coma Scale is 6 (E1, V1, M4). What is the most appropriate management regarding targeted temperature management?
A. Immediate cooling to 33°C for 24 hours using ice packs
B. Maintain normothermia (36-37°C) and treat any fever that develops
C. Therapeutic hypothermia to 32-34°C for 24 hours followed by slow rewarming (Correct Answer)
D. Cooling to 35°C for 12 hours then rapid rewarming
E. No specific temperature management is required
Explanation: ***Therapeutic hypothermia to 32-34°C for 24 hours followed by slow rewarming***
- For comatose patients (GCS < 8) following **out-of-hospital cardiac arrest (OHCA)** with a shockable rhythm, **Targeted Temperature Management (TTM)** at 32-34°C for at least 24 hours is recommended to improve neurological outcomes.
- Controlled **slow rewarming** (0.25-0.5°C per hour) is essential to prevent secondary brain injury from metabolic shifts, electrolyte disturbances, and rebound cerebral edema.
*Immediate cooling to 33°C for 24 hours using ice packs*
- While 33°C is a valid target temperature within the recommended range, **ice packs** alone are generally insufficient for the precise induction and maintenance of therapeutic hypothermia.
- Evidence favors the use of **dedicated cooling devices** (intravascular or surface) to prevent temperature fluctuations and ensure a stable maintenance phase.
*Maintain normothermia (36-37°C) and treat any fever that develops*
- Although recent evidence suggests 36°C may be comparable to 33°C for some patient groups, simply maintaining standard normothermia is not the primary recommendation for a patient with a **shockable rhythm** and depressed GCS post-ROSC who remains comatose.
- **TTM** requires a strict, proactive protocol to achieve and maintain a specific target temperature (32-36°C) rather than reactive treatment of fever, which is crucial for **neuroprotection** following global ischemia.
*Cooling to 35°C for 12 hours then rapid rewarming*
- A duration of **12 hours** is inadequate; current guidelines recommend maintaining the target temperature for at least **24 hours** to maximize the neuroprotective effects and recovery of mitochondrial function.
- **Rapid rewarming** is contraindicated because it can cause severe **hemodynamic instability**, hyperkalemia, and worsening of cerebral edema.
*No specific temperature management is required*
- This is incorrect as **active temperature management** is a cornerstone of post-cardiac arrest care, especially for patients who do not follow commands after ROSC.
- Failing to manage temperature actively increases the risk of **post-cardiac arrest syndrome** and significantly reduces the likelihood of good neurological outcomes and survival.
Question 202: A 32-year-old woman presents to the Emergency Department with sudden-onset severe headache which she describes as 'the worst headache of my life'. She vomited twice. On examination, she has photophobia and neck stiffness. CT head performed 8 hours after symptom onset shows no abnormality. What is the most appropriate next investigation?
A. MRI brain with contrast
B. CT angiography of cerebral vessels
C. Lumbar puncture (Correct Answer)
D. Repeat CT head in 24 hours
E. No further investigation needed; diagnose migraine and discharge
Explanation: ***Lumbar puncture***- In cases where a **subarachnoid haemorrhage (SAH)** is suspected and a **non-contrast CT head** is negative more than 6 hours after symptom onset, a **lumbar puncture** is the gold standard next step.- The **cerebrospinal fluid (CSF)** must be analysed for **xanthochromia** (ideally 12 hours after onset) and **red blood cells** to confirm the diagnosis.*MRI brain with contrast*- While MRI can identify underlying vascular malformations, it is **less sensitive** than CT in the first 24 hours for detecting acute blood.- It is not the recommended initial investigation to exclude SAH after a negative CT scan.*CT angiography of cerebral vessels*- This investigation is primarily used to **locate an aneurysm** or vascular abnormality once the diagnosis of SAH has already been confirmed.- It should not be used as a primary screening tool for SAH, as a negative CTA does not rule out the presence of subarachnoid blood.*Repeat CT head in 24 hours*- The sensitivity of a CT head for SAH **decreases with time** as blood is reabsorbed; repeating it after an initial negative result is not a reliable strategy.- Delaying diagnosis by waiting 24 hours significantly increases the risk of **rebleeding**, which carries high morbidity and mortality.*No further investigation needed; diagnose migraine and discharge*- The patient's presentation of a **'worst headache of my life'** (thunderclap headache) demands exclusion of SAH due to its life-threatening nature.- A **normal CT head** performed 8 hours after symptom onset only has a sensitivity of approximately 90-95% for SAH, making further investigation essential.
Question 203: A 78-year-old woman is brought to the Emergency Department after collapsing at home. She reports that she stood up from her chair and immediately felt dizzy and collapsed. This has happened twice before in the past month. She takes amlodipine, ramipril, doxazosin, and bisoprolol. Lying blood pressure is 145/85 mmHg with heart rate 65 bpm. Standing blood pressure after 3 minutes is 105/70 mmHg with heart rate 68 bpm. ECG shows sinus rhythm. What is the most likely cause of her symptoms?
A. Cardiac arrhythmia
B. Orthostatic hypotension (Correct Answer)
C. Carotid sinus hypersensitivity
D. Vasovagal syncope
E. Vertebrobasilar insufficiency
Explanation: ***Orthostatic hypotension***
- This patient demonstrates a **systolic blood pressure drop of 40 mmHg** (145 to 105 mmHg) within 3 minutes of standing, exceeding the diagnostic threshold of **≥20 mmHg systolic** or ≥10 mmHg diastolic drop.
- The symptoms occur **immediately upon standing** and are likely exacerbated by her polypharmacy, specifically the use of **alpha-blockers (doxazosin)** and **beta-blockers (bisoprolol)** which blunt compensatory responses.
*Cardiac arrhythmia*
- Though a common cause of syncope, the **ECG shows sinus rhythm** and the events are consistently linked to **postural changes** rather than occurring randomly.
- The lack of **palpitations** prior to collapse and the clear BP drop on standing make this a less likely primary cause.
*Carotid sinus hypersensitivity*
- This typically presents with syncope triggered by **mechanical stimulation** of the neck, such as wearing a tight collar or **turning the head**.
- While common in the elderly, it does not explain the significant **documented drop in blood pressure** specifically tied to the act of standing.
*Vasovagal syncope*
- Usually preceded by a **prodrome** (nausea, warmth, pallor) and triggered by **prolonged standing**, pain, or emotional stress, rather than the immediate act of rising.
- This patient's collapse occurs **immediately after standing**, which is the hallmark of orthostatic dysfunction rather than a vasovagal reflex.
*Vertebrobasilar insufficiency*
- Typically presents with auxiliary **neurological symptoms** such as vertigo, diplopia, ataxia, or cranial nerve deficits during the episode.
- It is related to **reduced posterior circulation blood flow**, usually triggered by neck extension, rather than a clear systemic drop in **postural blood pressure**.
Question 204: A 55-year-old man with a history of poorly controlled hypertension presents to the Emergency Department with severe chest pain radiating to his back for the past hour. Blood pressure is 180/110 mmHg in the right arm and 175/105 mmHg in the left arm. ECG shows left ventricular hypertrophy with no acute ischaemic changes. CT aortography confirms Type B aortic dissection (distal to left subclavian artery) without complications. What is the most appropriate initial management?
A. Emergency surgical repair
B. Emergency endovascular stent grafting
C. Intravenous labetalol for blood pressure control targeting systolic BP 100-120 mmHg and heart rate <60 bpm (Correct Answer)
D. Intravenous glyceryl trinitrate infusion for blood pressure control
E. Thrombolysis with alteplase
Explanation: ***Intravenous labetalol for blood pressure control targeting systolic BP 100-120 mmHg and heart rate <60 bpm***
- For **Type B (uncomplicated) aortic dissection**, the primary management is medical therapy to reduce **aortic wall stress (dP/dt)** by lowering both heart rate and blood pressure.
- **Labetalol** is a first-line choice because its combined **alpha and beta-blocking** properties allow for rapid titration to the recommended targets of systolic BP **100-120 mmHg** and heart rate **<60 bpm**.
*Emergency surgical repair*
- Surgery is the standard for **Type A dissections** (involving the ascending aorta) but is generally avoided for uncomplicated **Type B** due to higher morbidity and mortality with open repair.
- It is reserved for complicated Type B dissections, such as those with **malperfusion syndromes**, rupture, or refractory pain.
*Emergency endovascular stent grafting*
- **Thoracic Endovascular Aortic Repair (TEVAR)** is primarily indicated for **complicated Type B dissections** to cover the tear and promote false lumen thrombosis, but not for stable, uncomplicated cases initially.
- Medical management with aggressive **blood pressure and heart rate control** is the initial and often definitive treatment for uncomplicated Type B dissections.
*Intravenous glyceryl trinitrate infusion for blood pressure control*
- **Glyceryl trinitrate** (GTN) is a pure vasodilator and, if used alone, can cause **reflex tachycardia**, which increases the **shear stress (dP/dt)** on the aortic wall and can worsen the dissection.
- Vasodilators should only be considered *after* adequate **beta-blockade** has been established to ensure the heart rate remains controlled.
*Thrombolysis with alteplase*
- Thrombolytic therapy is **absolutely contraindicated** in aortic dissection as it can lead to catastrophic, fatal bleeding into the false lumen or surrounding structures.
- This treatment is primarily used for **acute myocardial infarction** or **ischemic stroke**, conditions that were not confirmed in this patient given the CT findings and ECG.
Question 205: A 25-year-old woman with known peanut allergy accidentally consumed a food item containing peanuts 20 minutes ago. She has developed generalized urticaria and lip swelling but no stridor, wheeze, or respiratory distress. Her blood pressure is 118/75 mmHg, heart rate 88 bpm, respiratory rate 16/min, oxygen saturation 98% on room air. She has been given oral chlorphenamine. What is the most appropriate management?
A. Discharge home with advice and provide an adrenaline auto-injector prescription
B. Administer intramuscular adrenaline 500 micrograms immediately
C. Observe for 2 hours; if stable, discharge with adrenaline auto-injector advice
D. Observe for at least 6-12 hours due to risk of biphasic reaction (Correct Answer)
E. Administer intravenous hydrocortisone and observe for 2 hours before discharge
Explanation: ***Observe for at least 6-12 hours due to risk of biphasic reaction***
- This patient has **urticaria** and **angioedema** (lip swelling) which are signs of an allergic reaction that, while not currently anaphylactic, can progress or have a **biphasic reaction**.
- The risk of a **biphasic anaphylactic reaction**, where symptoms recur hours after initial resolution without further allergen exposure, necessitates an extended observation period, typically **6-12 hours**, especially when angioedema is present.
*Discharge home with advice and provide an adrenaline auto-injector prescription*
- Discharging the patient so soon (20 minutes post-exposure, after receiving only an oral antihistamine) is unsafe given the risk of symptom progression or a **biphasic reaction**.
- While an **adrenaline auto-injector** prescription is crucial for future management, it does not negate the need for **acute medical observation** after a significant allergic exposure.
*Administer intramuscular adrenaline 500 micrograms immediately*
- **Intramuscular adrenaline** is the first-line treatment for **anaphylaxis**, which is defined by life-threatening **airway, breathing, or circulatory problems**.
- This patient currently lacks these features (no stridor, wheeze, respiratory distress, and stable blood pressure), so adrenaline is **not indicated** at this stage.
*Observe for 2 hours; if stable, discharge with adrenaline auto-injector advice*
- A **2-hour observation period** is generally considered insufficient for reactions involving mucosal swelling like **angioedema**, or for patients with a known severe allergy who have ingested the allergen.
- The peak risk for a **biphasic reaction** typically falls outside a 2-hour window, often occurring **4 to 8 hours** after the initial event.
*Administer intravenous hydrocortisone and observe for 2 hours before discharge*
- **Corticosteroids** like hydrocortisone have a **delayed onset of action** and are not primary treatments for acute allergic reactions or anaphylaxis, nor do they shorten the observation period.
- Current evidence does not definitively support the use of steroids in preventing **biphasic anaphylaxis**, and a **2-hour observation** remains insufficient for a significant allergic exposure with angioedema.
Question 206: A 45-year-old man with no significant past medical history presents with 2 hours of severe central chest pain. ECG shows ST-segment elevation of 3mm in leads V1-V4. The nearest primary percutaneous coronary intervention (PCI) centre is 90 minutes away by ambulance. He presented to the Emergency Department 30 minutes ago. What is the most appropriate management?
A. Arrange immediate transfer for primary PCI (Correct Answer)
B. Administer thrombolysis and transfer for rescue PCI if needed
C. Administer thrombolysis and transfer for angiography within 24 hours
D. Arrange transfer for PCI within 12 hours
E. Perform a repeat ECG in 30 minutes before deciding on reperfusion strategy
Explanation: ***Arrange immediate transfer for primary PCI***
- For an acute **STEMI**, primary PCI is the preferred reperfusion strategy if it can be performed within **120 minutes** from diagnosis or the time thrombolysis could otherwise be administered.
- In this scenario, the total time from ED presentation to potential PCI (30 minutes in ED + 90 minutes transfer) is **120 minutes**, which is within the acceptable window to prioritize PCI over thrombolysis.
*Administer thrombolysis and transfer for rescue PCI if needed*
- **Thrombolysis** is generally recommended only if **primary PCI** cannot be delivered within the required 120-minute window from diagnosis.
- **Rescue PCI** is specifically indicated for patients who show clinical or ECG signs of **failed reperfusion** 60 to 90 minutes after thrombolysis, which is not the initial management strategy here.
*Administer thrombolysis and transfer for angiography within 24 hours*
- This approach, known as a **pharmacoinvasive strategy**, is primarily utilized when primary PCI is geographically or temporally unavailable beyond the 120-minute window.
- Since the patient can reach a **PCI-capable center** within the recommended 120-minute window, immediate definitive intervention via primary PCI is preferred over this delayed angiography strategy.
*Arrange transfer for PCI within 12 hours*
- For **acute STEMI**, immediate reperfusion is critical to minimize **myocardial damage** and improve patient outcomes.
- Delaying reperfusion for **12 hours** would result in significant myocardial necrosis, leading to higher rates of heart failure and mortality, and is therefore inappropriate for an acute presentation.
*Perform a repeat ECG in 30 minutes before deciding on reperfusion strategy*
- The current ECG clearly shows significant **ST-segment elevation**, indicating an acute STEMI requiring urgent reperfusion.
- Delaying the decision to reperfuse by performing a repeat ECG in this context would prolong **myocardial ischemia** and increase the extent of myocardial damage, which is detrimental to the patient.
Question 207: A 68-year-old man presents with a syncopal episode while shopping. He has no recollection of the event but witnesses report sudden collapse without warning. He has a history of myocardial infarction 3 years ago. ECG shows sinus rhythm with Q waves in leads II, III, and aVF, and frequent ventricular ectopic beats. His echocardiogram from 6 months ago showed left ventricular ejection fraction of 35%. What is the most appropriate next investigation?
A. 24-hour Holter monitor (Correct Answer)
B. Exercise tolerance test
C. Tilt table testing
D. CT head scan
E. Carotid Doppler ultrasound
Explanation: ***24-hour Holter monitor***
- This patient has multiple high-risk factors for **arrhythmic syncope**, including a history of **myocardial infarction**, significantly **reduced left ventricular ejection fraction (35%)**, and frequent **ventricular ectopic beats**.
- A **Holter monitor** is the most appropriate next investigation to detect intermittent **ventricular tachycardia** or other life-threatening arrhythmias that could cause sudden collapse in this setting.
*Exercise tolerance test*
- An **exercise tolerance test** primarily assesses for **exercise-induced ischemia** or arrhythmias, which is not the primary concern for a syncopal episode occurring at rest or during light activity.
- Performing this test could be unsafe in a patient with **severe left ventricular dysfunction** and known **ventricular ectopy**, as it might provoke dangerous arrhythmias.
*Tilt table testing*
- **Tilt table testing** is primarily indicated for diagnosing **vasovagal syncope** or **orthostatic hypotension** in patients, typically those without significant structural heart disease.
- Given this patient's history of **MI** and **low LVEF**, a **cardiac arrhythmia** is a much more likely cause of syncope, making tilt table testing less relevant.
*CT head scan*
- A **CT head scan** is indicated for neurological causes of collapse such as **stroke**, **intracranial hemorrhage**, or significant head trauma, which are not suggested by the clinical presentation of sudden, unwarned syncope without focal deficits.
- Syncope is a transient loss of consciousness due to **global cerebral hypoperfusion**, which is usually cardiac or vasovagal in origin, not primarily a structural brain lesion.
*Carotid Doppler ultrasound*
- **Carotid Doppler ultrasound** is used to evaluate for **carotid artery stenosis**, which typically causes **focal neurological symptoms** (TIAs or stroke) rather than isolated, sudden syncopal episodes.
- Severe bilateral carotid disease can rarely cause syncope, but it is a much less probable cause compared to an **arrhythmic etiology** in a patient with a history of MI and severely impaired LVEF.
Question 208: A 58-year-old woman with type 2 diabetes presents to the Emergency Department with a 48-hour history of productive cough, fever, and right-sided pleuritic chest pain. Observations: temperature 38.7°C, blood pressure 110/70 mmHg, heart rate 105 bpm, respiratory rate 24/min, oxygen saturation 93% on room air. Blood tests show: WCC 16.2 × 10⁹/L, CRP 185 mg/L, urea 8.5 mmol/L. Chest X-ray confirms right lower lobe consolidation. Her CURB-65 score is 2. What is the most appropriate antibiotic regimen?
A. Oral amoxicillin 500mg three times daily
B. Oral amoxicillin 500mg three times daily and oral clarithromycin 500mg twice daily
C. Intravenous co-amoxiclav 1.2g three times daily
D. Intravenous benzylpenicillin 1.2g four times daily and oral doxycycline 200mg loading then 100mg daily
E. Intravenous co-amoxiclav 1.2g three times daily and intravenous clarithromycin 500mg twice daily (Correct Answer)
Explanation: ***Intravenous co-amoxiclav 1.2g three times daily and intravenous clarithromycin 500mg twice daily***
- For a **CURB-65 score of 2**, indicating moderate-severity pneumonia, and given the patient's **hypoxia (93% on room air)** and **elevated inflammatory markers (WCC 16.2, CRP 185)**, intravenous dual therapy is indicated.
- This regimen provides broad-spectrum coverage, with **co-amoxiclav** targeting typical bacterial pathogens and **clarithromycin** covering atypical pathogens, ensuring comprehensive initial treatment.
*Oral amoxicillin 500mg three times daily*
- This **monotherapy** is typically recommended for **low-severity Community-Acquired Pneumonia (CAP)** (CURB-65 score 0-1) in patients who are clinically stable and do not have significant comorbidities.
- It lacks coverage for **atypical pathogens** and is insufficient for a patient with moderate severity CAP, hypoxia, and diabetes.
*Oral amoxicillin 500mg three times daily and oral clarithromycin 500mg twice daily*
- While this offers appropriate **dual coverage**, oral administration is generally reserved for patients with moderate CAP who are hemodynamically stable and not significantly hypoxic.
- The patient's **hypoxia**, elevated inflammatory markers, and comorbidity (Type 2 Diabetes) suggest a need for more aggressive initial **intravenous therapy** to achieve rapid therapeutic levels.
*Intravenous co-amoxiclav 1.2g three times daily*
- This is **intravenous monotherapy**, which is inadequate for moderate-to-severe CAP as it does not cover **atypical pathogens** like *Mycoplasma* or *Legionella*.
- Guidelines for patients requiring hospital admission for CAP mandate the addition of a **macrolide** (or doxycycline) to a beta-lactam to ensure comprehensive coverage and improve outcomes.
*Intravenous benzylpenicillin 1.2g four times daily and oral doxycycline 200mg loading then 100mg daily*
- While this combination offers dual coverage, **benzylpenicillin** has a narrower spectrum compared to **co-amoxiclav**, which is often preferred in patients with comorbidities like **Diabetes Mellitus**.
- Using an **oral atypical agent** when an intravenous regimen is otherwise indicated for a moderate-severity presentation is less standard; consistent IV therapy for both agents is usually preferred initially to ensure rapid and reliable drug delivery.
Question 209: A 36-year-old man is brought to the Emergency Department by ambulance 10 minutes after eating prawns at a restaurant. He has facial swelling, urticarial rash, stridor, and appears distressed. Blood pressure is 85/55 mmHg, heart rate 120 bpm, oxygen saturation 91% on room air. He has been given high-flow oxygen. What is the most appropriate immediate management?
A. Intramuscular adrenaline 500 micrograms (0.5ml of 1:1000) (Correct Answer)
B. Intravenous hydrocortisone 200mg
C. Intravenous chlorphenamine 10mg
D. Nebulised adrenaline 5mg
E. Intravenous adrenaline infusion at 0.05 micrograms/kg/min
Explanation: ***Intramuscular adrenaline 500 micrograms (0.5ml of 1:1000)***
- This patient is presenting with **anaphylaxis**, defined by life-threatening **airway (stridor)**, **breathing (hypoxia)**, and **circulatory (hypotension)** compromise following an allergen trigger.
- **Intramuscular (IM) adrenaline** into the anterolateral thigh is the first-line treatment as it rapidly reverses **peripheral vasodilation** and **bronchoconstriction**.
*Intravenous hydrocortisone 200mg*
- Corticosteroids are considered **second-line treatments** used primarily to prevent **biphasic reactions** rather than treating the acute emergency.
- They have a **slow onset of action** (several hours) and do not provide the immediate life-saving alpha-agonist effects needed for **hypotension**.
*Intravenous chlorphenamine 10mg*
- Antihistamines are **adjunctive therapies** that help manage **skin symptoms** like urticaria but do not treat **airway obstruction** or shock.
- Administration of chlorphenamine should never delay the delivery of **IM adrenaline** in a patient with respiratory or circulatory distress.
*Nebulised adrenaline 5mg*
- While it may provide temporary relief for **upper airway edema** (stridor), it does not address the systemic **vasodilation and hypotension** characteristic of anaphylaxis.
- The **IM route** is the standard of care as it ensures reliable systemic absorption and rapid peak plasma concentrations.
*Intravenous adrenaline infusion at 0.05 micrograms/kg/min*
- IV adrenaline infusions are reserved for **refractory anaphylaxis** that has failed to respond to multiple IM doses.
- This intervention requires **expert supervision** and cardiac monitoring due to the high risk of **arrhythmias** and myocardial ischemia.
Question 210: A 72-year-old man with chronic kidney disease stage 4 presents to the Emergency Department with a 36-hour history of vomiting and diarrhoea. He appears unwell with cool peripheries and delayed capillary refill time. Blood pressure is 95/60 mmHg, heart rate 110 bpm. Blood tests show: creatinine 380 µmol/L (baseline 210 µmol/L), urea 28 mmol/L, lactate 3.8 mmol/L, bicarbonate 18 mmol/L. He has been given 1 litre of 0.9% sodium chloride over the past hour. What is the most appropriate next step in fluid resuscitation?
A. Continue 0.9% sodium chloride at 125 ml/hour
B. Give further 500ml bolus of 0.9% sodium chloride over 15 minutes then reassess (Correct Answer)
C. Switch to Hartmann's solution at 125 ml/hour
D. Give 500ml of 5% dextrose over 4 hours
E. Give 500ml of 4.5% human albumin solution over 30 minutes
Explanation: ***Give further 500ml bolus of 0.9% sodium chloride over 15 minutes then reassess***
- The patient exhibits clear signs of **hypovolaemic shock** (hypotension, tachycardia, cool peripheries, delayed capillary refill, rising creatinine, elevated lactate) despite initial fluid administration, indicating a need for further aggressive **fluid resuscitation**.
- A rapid **fluid bolus** (e.g., 250-500ml over 15 minutes) followed by immediate **reassessment** is crucial to improve organ perfusion and reverse shock, with the risk of fluid overload in CKD being secondary to the immediate life-threatening hypovolaemia.
*Continue 0.9% sodium chloride at 125 ml/hour*
- This rate of infusion is typically considered a **maintenance fluid rate**, which is entirely inadequate for a patient in active **hypovolaemic shock** requiring rapid volume expansion.
- Continuing at this slow rate would delay critical resuscitation, leading to persistent **tissue hypoperfusion**, worsening **acute kidney injury**, and increased risk of multi-organ failure.
*Switch to Hartmann's solution at 125 ml/hour*
- While Hartmann's solution is a **balanced crystalloid** and often preferred, the prescribed **infusion rate** of 125 ml/hour is too slow for effective resuscitation of a patient in shock.
- Furthermore, Hartmann's contains **potassium**, which may be a concern in a patient with **CKD Stage 4** and potentially impaired potassium excretion, although volume resuscitation is the immediate priority.
*Give 500ml of 5% dextrose over 4 hours*
- **5% dextrose** is primarily used for providing free water and is not effective for **intravascular volume expansion** as it rapidly distributes into the intracellular compartment.
- Administering any fluid over a prolonged 4-hour period is entirely inappropriate for a patient presenting with acute **haemodynamic instability** and signs of shock.
*Give 500ml of 4.5% human albumin solution over 30 minutes*
- **Colloid solutions** like albumin are generally not recommended as first-line for initial fluid resuscitation in hypovolaemic shock due to higher cost and lack of proven superior efficacy compared to crystalloids.
- Current guidelines typically recommend **crystalloids** (such as 0.9% sodium chloride) as the initial fluid choice for most cases of hypovolaemic shock.
