A 56-year-old woman with known asthma presents with an exacerbation. She is treated with nebulized salbutamol, ipratropium bromide, oral prednisolone, and oxygen. After 2 hours, she develops sudden-onset facial flushing, urticarial rash, wheeze, and her blood pressure drops to 85/50 mmHg. Peak expiratory flow rate has improved from initial presentation. What is the most appropriate immediate management?
Q242
A 28-year-old woman collapses while giving blood at a donation centre. Witnesses report she went pale and sweaty before losing consciousness for approximately 20 seconds. She recovered spontaneously and is now alert. She denies chest pain, palpitations, or tongue biting. She had not eaten breakfast this morning. Examination reveals blood pressure 110/70 mmHg lying, 105/68 mmHg standing, heart rate 76 bpm regular. ECG is normal. What is the most likely diagnosis?
Q243
A 45-year-old man with no past medical history presents with sudden-onset central chest pain radiating to his jaw while playing football. The pain started 20 minutes ago and is associated with sweating and nausea. His ECG shows ST-segment elevation of 3 mm in leads II, III, and aVF with reciprocal ST depression in leads I and aVL. His blood pressure is 135/82 mmHg, heart rate 92 bpm. Which coronary artery is most likely occluded?
Q244
A 62-year-old woman presents to the Emergency Department with a 12-hour history of fever and rigors. She has a background of recurrent urinary tract infections. On examination, her temperature is 38.9°C, heart rate 118 bpm, blood pressure 88/52 mmHg, respiratory rate 24 breaths/min, and oxygen saturation 94% on room air. Blood tests show: white cell count 18.2 × 10⁹/L, lactate 3.2 mmol/L, creatinine 168 μmol/L (baseline 85 μmol/L). What is the most appropriate initial fluid resuscitation strategy?
Q245
A 38-year-old woman presents with a 6-hour history of severe generalized abdominal pain, fever, and rigors. She has been unwell for 2 days with dysuria. Observations show temperature 38.7°C, heart rate 118 bpm, blood pressure 96/62 mmHg, respiratory rate 24/min. Blood tests reveal: white cell count 18.9 × 10⁹/L, C-reactive protein 245 mg/L, lactate 3.1 mmol/L, creatinine 156 μmol/L (baseline 82 μmol/L). She is allergic to penicillin (previous anaphylaxis). According to UK sepsis guidelines, what is the most appropriate initial empirical antibiotic regimen for suspected urinary source?
Q246
A 70-year-old woman presents with central chest pain lasting 3 hours. Her ECG shows ST-segment elevation in leads V1-V4. She is diagnosed with anterior STEMI and is being prepared for primary PCI. Her initial blood pressure is 145/88 mmHg, heart rate 94 bpm. She suddenly becomes severely hypotensive with blood pressure 78/52 mmHg and heart rate drops to 42 bpm. Repeat ECG shows new ST elevation in leads II, III, and aVF in addition to the anterior changes. Examination reveals elevated jugular venous pressure and clear lung fields. What is the most likely diagnosis?
Q247
A 25-year-old man is brought to the Emergency Department after developing facial swelling, difficulty swallowing, and a sensation of throat tightness following administration of intravenous antibiotics for cellulitis. He is anxious and sitting upright. On examination, there is marked lip and tongue swelling, inspiratory stridor, respiratory rate 24/min, oxygen saturation 93% on 15L oxygen, blood pressure 118/76 mmHg, heart rate 96 bpm. He has received two doses of intramuscular adrenaline 500 micrograms at 5-minute intervals with minimal improvement. What is the most appropriate next step?
Q248
A 52-year-old woman collapses at home. She has a witnessed tonic-clonic seizure lasting approximately 2 minutes. On arrival in the Emergency Department 20 minutes later, she is drowsy but rousable. Blood glucose is 6.2 mmol/L. Blood pressure is 132/84 mmHg, heart rate 88 bpm regular. She has a past history of epilepsy but has been seizure-free for 5 years on lamotrigine. Her husband reports she has been compliant with medication. Examination reveals a bitten tongue but is otherwise unremarkable. What is the most important next investigation?
Q249
A 65-year-old man is admitted with suspected sepsis secondary to a urinary tract infection. He is started on intravenous antibiotics and fluid resuscitation. Initial lactate is 3.2 mmol/L. After 2 hours and administration of 2 litres of crystalloid, his repeat lactate is 3.4 mmol/L, mean arterial pressure is 62 mmHg, heart rate 108 bpm, and urine output over the last hour was 15 mL. Central venous pressure monitoring is established and shows 11 mmHg. What is the most appropriate next step in management?
Q250
A 42-year-old woman presents with palpitations and pre-syncope. She reports three similar episodes in the past year. ECG during an episode shows a regular narrow complex tachycardia at 180 bpm. Blood pressure is 108/72 mmHg and she is alert. Vagal manoeuvres are attempted without success. What is the most appropriate next management step?
Acute Medical Presentations UK Medical PG Practice Questions and MCQs
Question 241: A 56-year-old woman with known asthma presents with an exacerbation. She is treated with nebulized salbutamol, ipratropium bromide, oral prednisolone, and oxygen. After 2 hours, she develops sudden-onset facial flushing, urticarial rash, wheeze, and her blood pressure drops to 85/50 mmHg. Peak expiratory flow rate has improved from initial presentation. What is the most appropriate immediate management?
A. Administer further nebulized bronchodilators
B. Administer intramuscular adrenaline 0.5 mg (1:1000) (Correct Answer)
C. Administer intravenous hydrocortisone 200 mg
D. Administer intravenous chlorphenamine 10 mg
E. Commence non-invasive ventilation
Explanation: ***Administer intramuscular adrenaline 0.5 mg (1:1000)*** - The patient exhibits classic signs of **anaphylaxis**, including **sudden onset**, **hypotension (85/50 mmHg)**, **urticarial rash**, and **wheeze**, necessitating immediate **intramuscular adrenaline**. - Adrenaline is the first-line treatment as it provides **alpha-1 mediated vasoconstriction** to treat hypotension and **beta-2 mediated bronchodilation** for the respiratory symptoms.*Administer further nebulized bronchodilators* - While the patient has a **wheeze**, its recurrence alongside **hypotension** and **rash** indicates a systemic reaction rather than a simple asthma relapse. - Bronchodilators will not address the life-threatening **cardiovascular collapse** or the systemic mast cell degranulation occurring in **anaphylaxis**.*Administer intravenous hydrocortisone 200 mg* - **Corticosteroids** are considered second-line or adjunctive treatments that help prevent the **biphasic reaction**, but they have a slow onset of action. - Giving steroids must never delay the administration of life-saving **adrenaline** in the setting of acute **anaphylactic shock**.*Administer intravenous chlorphenamine 10 mg* - **Antihistamines** like chlorphenamine may help reduce skin symptoms like **urticaria**, but they do not treat **airway obstruction** or **hypotension**. - International guidelines state that antihistamines are **not first-line** and should only be given after the patient is stabilized with **adrenaline**.*Commence non-invasive ventilation* - **Non-invasive ventilation (NIV)** is primarily used for **COPD exacerbations** or **acute pulmonary edema** and is not a treatment for **anaphylaxis**. - The primary respiratory issue here is **laryngeal edema** or **bronchospasm** under a systemic shock context, which requires pharmacological reversal with **adrenaline**.
Question 242: A 28-year-old woman collapses while giving blood at a donation centre. Witnesses report she went pale and sweaty before losing consciousness for approximately 20 seconds. She recovered spontaneously and is now alert. She denies chest pain, palpitations, or tongue biting. She had not eaten breakfast this morning. Examination reveals blood pressure 110/70 mmHg lying, 105/68 mmHg standing, heart rate 76 bpm regular. ECG is normal. What is the most likely diagnosis?
A. Vasovagal syncope (Correct Answer)
B. Cardiac arrhythmia
C. Postural hypotension
D. Hypoglycaemia
E. Pulmonary embolism
Explanation: ***Vasovagal syncope***
- This classic presentation involves a clear **precipitant** (blood donation/venepuncture) and a characteristic **autonomic prodrome** (pallor and sweating) prior to the loss of consciousness.
- The episode was brief with **spontaneous recovery**, absence of post-ictal confusion, and a **normal ECG**, all of which are hallmarks of reflex syncope mediated by increased vagal tone.
*Cardiac arrhythmia*
- Arrhythmias typically cause a **sudden loss of consciousness** without a prodrome, often occurring during exertion or while seated/supine.
- The absence of **palpitations** and the presence of a completely **normal ECG** make a primary cardiac cause much less likely in a young patient.
*Postural hypotension*
- This is defined by a drop in systolic blood pressure of **>20 mmHg** or diastolic of **>10 mmHg** upon standing; this patient’s BP drop was minimal (5/2 mmHg).
- While the patient had not eaten, the syncope occurred during a stressful stimulus (needle/blood loss) rather than immediately upon **changing position** from lying to standing.
*Hypoglycaemia*
- Hypoglycaemia usually presents with a **drawn-out recovery** and lingering confusion (neuroglycopenic symptoms) rather than a rapid, 20-second spontaneous return to full alertness.
- While fasting is a risk factor, it rarely causes sudden **transient loss of consciousness** (syncope) unless the blood glucose level is severely low for a prolonged period.
*Pulmonary embolism*
- Massive PE can cause syncope, but it is typically associated with **tachycardia**, **hypoxia**, **pleuritic chest pain**, or sudden onset dyspnoea.
- This patient’s **normal heart rate (76 bpm)** and lack of respiratory distress or hemodynamic instability effectively rule out a significant pulmonary embolic event.
Question 243: A 45-year-old man with no past medical history presents with sudden-onset central chest pain radiating to his jaw while playing football. The pain started 20 minutes ago and is associated with sweating and nausea. His ECG shows ST-segment elevation of 3 mm in leads II, III, and aVF with reciprocal ST depression in leads I and aVL. His blood pressure is 135/82 mmHg, heart rate 92 bpm. Which coronary artery is most likely occluded?
A. Left anterior descending artery
B. Left circumflex artery
C. Right coronary artery (Correct Answer)
D. Left main stem artery
E. Posterior descending artery
Explanation: ***Right coronary artery***- ST-segment elevation in **leads II, III, and aVF** is diagnostic of an **inferior wall myocardial infarction (ST-elevation MI)**.- The **Right Coronary Artery (RCA)** is the culprit vessel for inferior MIs in approximately 85% of people (right-dominant circulation) and is associated with **reciprocal changes in leads I and aVL**.*Left anterior descending artery*- Occlusion typically presents with ST elevation in **leads V1 to V4**, indicating an **anterior wall MI**.- It supplies the **interventricular septum** and the anterior wall of the left ventricle, which are not involved in this ECG pattern.*Left circumflex artery*- This artery typically supplies the **lateral wall** of the heart, with ECG changes visible in **leads I, aVL, V5, and V6**.- While it can cause an inferior MI in left-dominant individuals, the presence of reciprocal depression in **lead I** strongly favors the RCA over the LCx.*Left main stem artery*- Occlusion is usually catastrophic, presenting as **widespread ST depression** across multiple leads with ST elevation in **lead aVR**.- It affects the majority of the left ventricle, rather than isolated **inferior leads**, often leading to cardiogenic shock.*Posterior descending artery*- The **Posterior Descending Artery (PDA)** specifically supplies the inferior wall, but it is typically a **distal branch** of either the RCA or LCx.- In clinical practice and boards, the **primary occlusion site** responsible for inferior ST elevation is identified as the parent **Right Coronary Artery**.
Question 244: A 62-year-old woman presents to the Emergency Department with a 12-hour history of fever and rigors. She has a background of recurrent urinary tract infections. On examination, her temperature is 38.9°C, heart rate 118 bpm, blood pressure 88/52 mmHg, respiratory rate 24 breaths/min, and oxygen saturation 94% on room air. Blood tests show: white cell count 18.2 × 10⁹/L, lactate 3.2 mmol/L, creatinine 168 μmol/L (baseline 85 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 clinical 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 clinical reassessment***- This patient presents with **septic shock** (hypotension, tachycardia, and lactate >2 mmol/L), requiring rapid volume expansion to restore **organ perfusion**.- Current guidelines recommend an initial **crystalloid bolus** of 500 mL delivered rapidly, followed by immediate **clinical reassessment** of hemodynamics and fluid responsiveness.*250 mL crystalloid bolus over 15 minutes*- This volume is typically reserved for patients at high risk of **fluid overload**, such as those with known **congestive heart failure** or end-stage renal disease.- In a patient with clear **septic shock** and no heart failure history, 250 mL is generally considered an insufficient initial volume to correct the **hypovolemia**.*1000 mL crystalloid bolus over 1 hour*- While a larger volume is often required in **sepsis** management, delivering it over one hour is too slow for a patient with a **systolic blood pressure** <90 mmHg.- Immediate, rapid boluses allow for quicker stabilization of **mean arterial pressure** and a more timely decision on the need for **vasopressors**.*500 mL colloid bolus over 30 minutes*- **Crystalloids** (such as 0.9% saline or Hartmann’s) are the preferred first-line fluids for resuscitation; **colloids** (like starch) are generally avoided due to cost and safety concerns.- Evidence suggests no survival benefit of **albumin** or other colloids over crystalloids in the initial management of **septic shock**.*Commence maintenance fluids at 125 mL/hour*- **Maintenance fluids** are intended to provide daily requirements for water and electrolytes, not to treat **acute circulatory collapse**.- Providing fluids at this rate would fail to address the patient's **hypotension** and high **lactate**, leading to worsening **acute kidney injury** and tissue hypoxia.
Question 245: A 38-year-old woman presents with a 6-hour history of severe generalized abdominal pain, fever, and rigors. She has been unwell for 2 days with dysuria. Observations show temperature 38.7°C, heart rate 118 bpm, blood pressure 96/62 mmHg, respiratory rate 24/min. Blood tests reveal: white cell count 18.9 × 10⁹/L, C-reactive protein 245 mg/L, lactate 3.1 mmol/L, creatinine 156 μmol/L (baseline 82 μmol/L). She is allergic to penicillin (previous anaphylaxis). According to UK sepsis guidelines, what is the most appropriate initial empirical antibiotic regimen for suspected urinary source?
A. Intravenous gentamicin and metronidazole (Correct Answer)
B. Intravenous ciprofloxacin and gentamicin
C. Intravenous teicoplanin and gentamicin
D. Intravenous meropenem
E. Intravenous co-amoxiclav and gentamicin
Explanation: ***Intravenous gentamicin and metronidazole***
- This regimen is suitable for **urosepsis with severe sepsis/septic shock** in a patient with **penicillin anaphylaxis**, as both are non-beta-lactam antibiotics.
- **Gentamicin** provides broad **Gram-negative coverage** against common urinary pathogens, while **metronidazole** adds crucial **anaerobic coverage**, important for severe sepsis with abdominal symptoms.
*Intravenous ciprofloxacin and gentamicin*
- This combination lacks **anaerobic coverage**, which may be critical in severe sepsis with generalized abdominal pain.
- Furthermore, **ciprofloxacin resistance** in common uropathogens is increasing, making it less reliable as a sole broad-spectrum agent in critically ill patients.
*Intravenous teicoplanin and gentamicin*
- **Teicoplanin** primarily targets **Gram-positive bacteria** like MRSA, which are not typically the initial cause of urosepsis, especially community-acquired.
- This regimen would leave significant gaps in coverage for common **Gram-negative** uropathogens or potential **anaerobic** co-infections in severe abdominal sepsis.
*Intravenous meropenem*
- While broad-spectrum, **meropenem** is a carbapenem and carries a risk of **cross-reactivity with penicillin** in patients with a history of anaphylaxis, although lower than other beta-lactams.
- It is generally reserved for suspected **ESBL-producing organisms** or highly resistant infections, not typically first-line empirical therapy in this specific scenario due to allergy concerns.
*Intravenous co-amoxiclav and gentamicin*
- **Co-amoxiclav** is a **beta-lactam antibiotic** and is absolutely contraindicated due to the patient's history of **anaphylaxis to penicillin**.
- Administering this drug would pose a severe and life-threatening risk of an immediate **hypersensitivity reaction**.
Question 246: A 70-year-old woman presents with central chest pain lasting 3 hours. Her ECG shows ST-segment elevation in leads V1-V4. She is diagnosed with anterior STEMI and is being prepared for primary PCI. Her initial blood pressure is 145/88 mmHg, heart rate 94 bpm. She suddenly becomes severely hypotensive with blood pressure 78/52 mmHg and heart rate drops to 42 bpm. Repeat ECG shows new ST elevation in leads II, III, and aVF in addition to the anterior changes. Examination reveals elevated jugular venous pressure and clear lung fields. What is the most likely diagnosis?
A. Acute left ventricular failure
B. Cardiac tamponade from ventricular free wall rupture
C. Right ventricular infarction (Correct Answer)
D. Acute mitral regurgitation from papillary muscle rupture
E. Cardiogenic shock from extensive myocardial damage
Explanation: ***Right ventricular infarction***
- The sudden onset of **severe hypotension**, **bradycardia**, **elevated jugular venous pressure (JVP)**, and **clear lung fields** is the classic presentation for **right ventricular infarction**.
- The repeat ECG showing new **ST elevation in leads II, III, and aVF** indicates acute **inferior myocardial infarction**, which is commonly supplied by the **right coronary artery (RCA)**. The RCA also typically supplies the right ventricle.
*Acute left ventricular failure*
- **Left ventricular failure** is characterized by signs of **pulmonary congestion** like crackles or rales on lung auscultation, which are absent here as the patient has **clear lung fields**.
- It would not specifically explain the new **inferior ST elevation** or the pronounced **bradycardia** in this context.
*Cardiac tamponade from ventricular free wall rupture*
- While it causes hypotension and elevated JVP, **cardiac tamponade** typically presents with **muffled heart sounds** and **pulsus paradoxus**, which are not mentioned.
- Ventricular free wall rupture usually occurs later in the course of MI, typically **3 to 5 days** post-event, not acutely within 3 hours.
*Acute mitral regurgitation from papillary muscle rupture*
- This condition presents with a **new holosystolic murmur** and acute **flash pulmonary edema** due to severe left heart failure.
- The presence of **clear lung fields** and the absence of a murmur make this diagnosis less likely.
*Cardiogenic shock from extensive myocardial damage*
- While the patient is in cardiogenic shock, this diagnosis is too general and does not explain the specific constellation of findings.
- Extensive **left ventricular damage** leading to cardiogenic shock would typically result in significant **pulmonary edema**, which is not seen here; the specific ECG and clinical findings point to a more localized issue.
Question 247: A 25-year-old man is brought to the Emergency Department after developing facial swelling, difficulty swallowing, and a sensation of throat tightness following administration of intravenous antibiotics for cellulitis. He is anxious and sitting upright. On examination, there is marked lip and tongue swelling, inspiratory stridor, respiratory rate 24/min, oxygen saturation 93% on 15L oxygen, blood pressure 118/76 mmHg, heart rate 96 bpm. He has received two doses of intramuscular adrenaline 500 micrograms at 5-minute intervals with minimal improvement. What is the most appropriate next step?
A. Administer intravenous hydrocortisone and chlorphenamine
B. Prepare for emergency cricothyroidotomy (Correct Answer)
C. Commence intravenous adrenaline infusion
D. Administer third dose of intramuscular adrenaline
E. Perform rapid sequence intubation
Explanation: ***Prepare for emergency cricothyroidotomy***- The patient presents with **severe upper airway obstruction** (stridor, lip/tongue swelling, difficulty swallowing) that is unresponsive to two doses of **intramuscular adrenaline**, indicating **refractory anaphylaxis** with imminent airway collapse.- In this critical situation, where standard intubation is likely to fail due to marked anatomical distortion from **angioedema**, preparing for a **surgical airway** (cricothyroidotomy) is the most appropriate and life-saving next step to secure ventilation.*Administer intravenous hydrocortisone and chlorphenamine*- These medications are **second-line treatments** for anaphylaxis with a delayed onset of action, typically taking hours to exert their full effect.- They will not rapidly resolve the acute, life-threatening **upper airway obstruction** that the patient is experiencing.*Commence intravenous adrenaline infusion*- While an **intravenous adrenaline infusion** is indicated for refractory anaphylaxis, its primary role is to manage systemic symptoms and prevent cardiovascular collapse.- It will not mechanically relieve the immediate and severe **upper airway obstruction** caused by significant tissue swelling.*Administer third dose of intramuscular adrenaline*- The patient has already received two doses of **intramuscular adrenaline** with minimal improvement, suggesting that this route and dosage are insufficient for the severity of the **airway compromise**.- Further delaying definitive airway management by administering another IM dose increases the risk of complete **respiratory arrest**.*Perform rapid sequence intubation*- **Rapid sequence intubation (RSI)** is extremely high-risk in severe **angioedema** because the distorted anatomy makes visualization of the vocal cords difficult or impossible.- Attempting RSI without immediate preparation for a **surgical airway** can lead to complete airway loss without a rescue plan, due to trauma and further swelling.
Question 248: A 52-year-old woman collapses at home. She has a witnessed tonic-clonic seizure lasting approximately 2 minutes. On arrival in the Emergency Department 20 minutes later, she is drowsy but rousable. Blood glucose is 6.2 mmol/L. Blood pressure is 132/84 mmHg, heart rate 88 bpm regular. She has a past history of epilepsy but has been seizure-free for 5 years on lamotrigine. Her husband reports she has been compliant with medication. Examination reveals a bitten tongue but is otherwise unremarkable. What is the most important next investigation?
A. Urgent CT head
B. Serum lamotrigine level
C. 12-lead ECG (Correct Answer)
D. Electroencephalography (EEG)
E. Lumbar puncture
Explanation: ***12-lead ECG***
- A **12-lead ECG** is the most vital immediate investigation to rule out **cardiac arrhythmias** or syndromes like **Long QT** that can cause **convulsive syncope**, which mimics a seizure.
- Even in patients with known epilepsy, identifying a hidden cardiac etiology is a priority as it carries a high risk of **sudden cardiac death**.
*Urgent CT head*
- This is indicated for patients with **focal neurology**, persistent coma, or signs of **raised intracranial pressure**, none of which are present here.
- The patient is appropriately **post-ictal** (drowsy but rousable) and has no history of trauma, making an acute intracranial event less likely.
*Serum lamotrigine level*
- While **drug compliance** is a consideration, serum levels are rarely available urgently and do not assist in the immediate stabilization or diagnosis of life-threatening mimics.
- Monitoring levels is typically reserved for assessing **toxicity** or therapeutic failure in a non-acute outpatient setting.
*Electroencephalography (EEG)*
- **EEG** is not an acute emergency investigation and is usually performed in a controlled setting to help **categorize seizure types** after the event.
- A normal EEG does not rule out epilepsy, and it should never delay the search for a potentially lethal **cardiac cause**.
*Lumbar puncture*
- This invasive test is only indicated if there is clinical suspicion of **meningitis**, encephalitis, or a **subarachnoid hemorrhage** with a negative CT.
- The absence of **fever**, meningismus, or a thunderclap headache makes a lumbar puncture unnecessary in this presentation.
Question 249: A 65-year-old man is admitted with suspected sepsis secondary to a urinary tract infection. He is started on intravenous antibiotics and fluid resuscitation. Initial lactate is 3.2 mmol/L. After 2 hours and administration of 2 litres of crystalloid, his repeat lactate is 3.4 mmol/L, mean arterial pressure is 62 mmHg, heart rate 108 bpm, and urine output over the last hour was 15 mL. Central venous pressure monitoring is established and shows 11 mmHg. What is the most appropriate next step in management?
A. Administer further 500 mL crystalloid bolus
B. Commence noradrenaline infusion (Correct Answer)
C. Commence dobutamine infusion
D. Insert arterial line for blood pressure monitoring
E. Arrange urgent ICU review for intubation
Explanation: ***Commence noradrenaline infusion***
- This patient exhibits persistent **hypotension (MAP 62 mmHg)** and **hyperlactatemia (3.4 mmol/L)** despite initial **fluid resuscitation (2 liters)**, fulfilling the criteria for **septic shock**.
- **Noradrenaline** is the recommended first-line **vasopressor** to increase **mean arterial pressure** and improve organ perfusion by counteracting the profound **vasodilation** characteristic of septic shock.
*Administer further 500 mL crystalloid bolus*
- The patient has already received 2 liters of crystalloid, and a **CVP of 11 mmHg** suggests that further fluid boluses may not be beneficial and could lead to **fluid overload** without addressing the underlying vasodilation.
- Persistent **oliguria** and **hypotension** despite initial fluid administration indicate a need for **vasopressor support** rather than additional fluids.
*Commence dobutamine infusion*
- **Dobutamine** is an **inotrope** used to improve **cardiac contractility** in cases of cardiac dysfunction or persistent hypoperfusion after adequate volume and MAP have been achieved.
- In this patient, the primary hemodynamic issue is **vasodilation** leading to hypotension, making a **vasopressor** (like noradrenaline) the more appropriate initial intervention.
*Insert arterial line for blood pressure monitoring*
- While an **arterial line** provides **continuous and accurate blood pressure monitoring**, which is essential in **septic shock** for vasopressor titration, it is a diagnostic/monitoring tool, not an immediate therapeutic intervention.
- The immediate priority is to **restore perfusion** to vital organs by correcting the **hypotension** with **vasopressors**, then optimize monitoring.
*Arrange urgent ICU review for intubation*
- There is no clinical information provided in the scenario to suggest **respiratory failure**, severe altered mental status, or an inability to protect the airway that would necessitate immediate **intubation**.
- While an **ICU review** is appropriate for septic shock, the most urgent and immediate physiological intervention needed is hemodynamic stabilization with **vasopressors**.
Question 250: A 42-year-old woman presents with palpitations and pre-syncope. She reports three similar episodes in the past year. ECG during an episode shows a regular narrow complex tachycardia at 180 bpm. Blood pressure is 108/72 mmHg and she is alert. Vagal manoeuvres are attempted without success. What is the most appropriate next management step?
A. Intravenous adenosine 6 mg rapid bolus (Correct Answer)
B. Intravenous amiodarone 300 mg over 20 minutes
C. Intravenous verapamil 5 mg over 2 minutes
D. Synchronized DC cardioversion at 120 J
E. Intravenous metoprolol 5 mg
Explanation: ***Intravenous adenosine 6 mg rapid bolus***- This is the **first-line pharmacological treatment** for **haemodynamically stable** patients with **regular narrow complex tachycardia** (SVT) after **vagal manoeuvres** have failed.- **Adenosine** works by temporarily blocking the **AV node**, interrupting re-entrant pathways and terminating the arrhythmia.*Intravenous amiodarone 300 mg over 20 minutes*- **Amiodarone** is generally reserved for **broad complex tachycardias** or narrow complex tachycardias that are **refractory to adenosine** and other first-line agents.- Its slower onset of action and potential side effects make it unsuitable as a primary agent for acute SVT termination in stable patients.*Intravenous verapamil 5 mg over 2 minutes*- **Calcium channel blockers** like verapamil are alternative **second-line agents** for SVT if **adenosine** is ineffective or contraindicated.- However, adenosine is preferred as the initial pharmacological agent due to its rapid onset and short half-life, making it safer to use first.*Synchronized DC cardioversion at 120 J*- **Synchronized DC cardioversion** is indicated for **unstable tachycardias**, characterized by symptoms such as **hypotension**, altered mental status, signs of shock, acute heart failure, or ischemic chest pain.- This patient is **haemodynamically stable** (BP 108/72 mmHg, alert), so cardioversion is not immediately warranted.*Intravenous metoprolol 5 mg*- **Beta-blockers** can be used for rate control in SVT, but they are not the first-line choice for **rapid termination** of acute SVT in a stable patient when adenosine is available.- Like verapamil, they are considered if **adenosine** is ineffective or contraindicated.
