PLAB 2 Acute Management — Questions and Answers
Question 1: A patient in A&E presents with an acute asthma attack. Their peak flow is 40% of predicted, they cannot complete sentences, and their respiratory rate is 28/min. According to BTS/SIGN guidelines, how should this be classified and what is the immediate management?
- Mild asthma — prescribe a salbutamol inhaler and discharge
- Acute severe asthma — give high-flow oxygen, nebulised salbutamol 5 mg, nebulised ipratropium bromide 500 mcg, and oral prednisolone 40-50 mg (or IV hydrocortisone 100 mg) (Correct answer)
- Moderate asthma — advise the patient to use their inhaler more frequently
- Life-threatening asthma — proceed directly to intubation
Correct answer: Acute severe asthma — give high-flow oxygen, nebulised salbutamol 5 mg, nebulised ipratropium bromide 500 mcg, and oral prednisolone 40-50 mg (or IV hydrocortisone 100 mg)
BTS/SIGN criteria for acute severe asthma include: PEF 33-50% predicted, respiratory rate ≥25, heart rate ≥110, and inability to complete sentences. Immediate management is high-flow oxygen, nebulised beta-2 agonist, ipratropium bromide, and systemic corticosteroids. IV magnesium is used if response is poor.
Question 2: A 65-year-old man presents to A&E with central crushing chest pain for 30 minutes, diaphoresis, and nausea. ECG shows 3 mm ST elevation in leads II, III, and aVF. What is the immediate management?
- Observe and repeat ECG in 6 hours
- Give MONA (Morphine, Oxygen if SpO2 <94%, Nitrate, Aspirin 300 mg) and arrange emergency primary percutaneous coronary intervention (PCI) or thrombolysis if PCI not available within 120 minutes (Correct answer)
- Prescribe GTN spray and discharge with GP follow-up
- Start oral beta-blocker and admit to a general ward
Correct answer: Give MONA (Morphine, Oxygen if SpO2 <94%, Nitrate, Aspirin 300 mg) and arrange emergency primary percutaneous coronary intervention (PCI) or thrombolysis if PCI not available within 120 minutes
Inferior STEMI (ST elevation in II, III, aVF) requires immediate dual antiplatelet therapy (aspirin + ticagrelor/clopidogrel), pain management, oxygen only if SpO2 <94%, and emergency reperfusion — primary PCI within 120 minutes of first medical contact, or thrombolysis if PCI is not available in time.
Question 3: A patient with type 1 diabetes presents with vomiting, abdominal pain, Kussmaul breathing, and a blood glucose of 28 mmol/L. Blood gases show pH 7.1, bicarbonate 10 mmol/L, and ketones 5.5 mmol/L. What is the diagnosis and first priority of management?
- Hyperglycaemic hyperosmolar state — give oral fluids
- Diabetic ketoacidosis — IV 0.9% sodium chloride fluid resuscitation is the first priority, followed by fixed-rate IV insulin infusion (0.1 units/kg/hour) (Correct answer)
- Hypoglycaemia — give IV dextrose
- Lactic acidosis — give IV sodium bicarbonate
Correct answer: Diabetic ketoacidosis — IV 0.9% sodium chloride fluid resuscitation is the first priority, followed by fixed-rate IV insulin infusion (0.1 units/kg/hour)
DKA is defined by hyperglycaemia (>11 mmol/L), ketosis (ketones >3 mmol/L), and acidosis (pH <7.3 or bicarbonate <15 mmol/L). UK Joint British Diabetes Societies guidelines prioritise IV fluid resuscitation (0.9% NaCl 1L in first hour), then fixed-rate insulin infusion. Potassium replacement is critical and must be monitored.
Question 4: A 75-year-old woman is found on the floor at home. She is confused with a GCS of 12. Her blood glucose is 1.8 mmol/L. What is the immediate management?
- Give oral glucose gel
- Administer IV glucose (10% or 20% dextrose) as the patient has reduced consciousness and cannot safely swallow, followed by longer-acting carbohydrate once conscious (Correct answer)
- Wait and recheck glucose in 30 minutes
- Administer insulin to stimulate glucose release
Correct answer: Administer IV glucose (10% or 20% dextrose) as the patient has reduced consciousness and cannot safely swallow, followed by longer-acting carbohydrate once conscious
Severe hypoglycaemia with reduced consciousness requires parenteral glucose — IV 10% or 20% dextrose (or IM glucagon 1 mg if no IV access). Oral glucose is contraindicated in reduced consciousness due to aspiration risk. Once the patient is alert, give longer-acting carbohydrate to prevent recurrence.
Question 5: A patient presents to A&E with sudden onset weakness of the right arm and leg and slurred speech. Symptoms started 90 minutes ago. CT head excludes haemorrhage. According to NICE stroke guidelines, what is the most appropriate acute management?
- Admit to a general medical ward and start aspirin
- Administer IV alteplase (thrombolysis) within the 4.5-hour window, as the patient has an acute ischaemic stroke with no contraindications (Correct answer)
- Prescribe warfarin and discharge
- Arrange an MRI brain as an outpatient
Correct answer: Administer IV alteplase (thrombolysis) within the 4.5-hour window, as the patient has an acute ischaemic stroke with no contraindications
Acute ischaemic stroke within 4.5 hours of onset (and CT excluding haemorrhage) should be treated with IV thrombolysis (alteplase) as per NICE guidelines. Mechanical thrombectomy should also be considered for large vessel occlusion within 6 hours (or up to 24 hours in selected cases).
Question 6: A patient in A&E develops anaphylaxis after a penicillin injection. They have widespread urticaria, wheeze, stridor, and a blood pressure of 70/40 mmHg. What is the first-line treatment?
- IV chlorphenamine and hydrocortisone
- IM adrenaline 500 micrograms (0.5 mL of 1:1000) into the anterolateral thigh, repeated every 5 minutes if needed (Correct answer)
- Nebulised salbutamol only
- Oral antihistamine and observation
Correct answer: IM adrenaline 500 micrograms (0.5 mL of 1:1000) into the anterolateral thigh, repeated every 5 minutes if needed
UK Resuscitation Council guidelines state that IM adrenaline (1:1000, 500 mcg for adults) is the first-line treatment for anaphylaxis. It is given into the anterolateral thigh and can be repeated every 5 minutes. IV fluids, chlorphenamine, and hydrocortisone are adjuncts but must not delay adrenaline.
PLAB 2 Acute Management
A patient in A&E presents with an acute asthma attack.
Their peak flow is 40% of predicted, they cannot complete sentences, and their respiratory rate is 28/min.
According to BTS/SIGN guidelines, how should this be classified and what is the immediate management?