PLAB 2 Acute Management 2 — Questions and Answers
Question 1: A patient on the ward develops a tonic-clonic seizure that has lasted 7 minutes. According to NICE epilepsy guidelines, what is the first-line treatment for status epilepticus?
- Oral carbamazepine
- IV lorazepam 4 mg (or buccal midazolam 10 mg if no IV access), repeated once after 10 minutes if seizure continues (Correct answer)
- IM adrenaline
- Wait 30 minutes before intervening as most seizures self-terminate
Correct answer: IV lorazepam 4 mg (or buccal midazolam 10 mg if no IV access), repeated once after 10 minutes if seizure continues
Status epilepticus is defined as a seizure lasting >5 minutes (or recurrent seizures without recovery). First-line treatment is IV lorazepam 4 mg (repeated once after 10 minutes) or buccal midazolam if no IV access. If seizures continue, second-line options include IV phenytoin or IV levetiracetam.
Question 2: A 60-year-old man presents to A&E with a 4-hour history of severe tearing chest pain radiating to the back, and asymmetric blood pressure readings in both arms. What is the most likely diagnosis and most appropriate urgent investigation?
- Pulmonary embolism — perform CTPA
- Aortic dissection — perform urgent CT angiography of the aorta (Correct answer)
- Acute coronary syndrome — perform coronary angiography
- Musculoskeletal chest pain — discharge with analgesia
Correct answer: Aortic dissection — perform urgent CT angiography of the aorta
Sudden severe tearing chest pain radiating to the back with blood pressure asymmetry between arms is classic for aortic dissection. CT aortography is the investigation of choice. Type A (ascending aorta) requires emergency surgery. Type B (descending) is usually managed medically with IV labetalol to reduce shear stress.
Question 3: A patient presents to A&E with pleuritic chest pain, tachycardia, and haemoptysis 10 days after a long-haul flight. Their Wells score is 7. What is the most appropriate next investigation?
- Chest X-ray only
- CT pulmonary angiography (CTPA) — as the Wells score >4 indicates PE is likely, CTPA is the first-line imaging investigation (Correct answer)
- D-dimer test
- V/Q scan as first-line
Correct answer: CT pulmonary angiography (CTPA) — as the Wells score >4 indicates PE is likely, CTPA is the first-line imaging investigation
A Wells score >4 indicates PE is likely, and NICE recommends proceeding directly to CTPA without D-dimer (D-dimer is used when Wells score ≤4). Interim treatment with anticoagulation (LMWH or DOAC) should be started while awaiting imaging if PE is clinically likely.
Question 4: A patient on a medical ward develops a NEWS2 score of 9 with a respiratory rate of 30, SpO2 of 88% on air, heart rate of 125, systolic BP of 85 mmHg, and new confusion. What is the appropriate escalation?
- Continue routine observations and review in 4 hours
- This constitutes a medical emergency — immediately call the critical care outreach team or cardiac arrest team, commence ABCDE assessment, and consider ICU admission (Correct answer)
- Increase observation frequency to hourly
- Ask a junior doctor to review when available
Correct answer: This constitutes a medical emergency — immediately call the critical care outreach team or cardiac arrest team, commence ABCDE assessment, and consider ICU admission
A NEWS2 score ≥7 is a red score indicating a clinical emergency. RCP guidelines require an urgent or emergency response — immediate clinical assessment using ABCDE, critical care outreach or medical emergency team review, and consideration of ICU transfer. Do not delay escalation.
Question 5: A patient presents with a GCS of 3 and is in cardiac arrest with a shockable rhythm (ventricular fibrillation). According to UK Resuscitation Council guidelines, what is the correct sequence?
- Start CPR for 10 minutes before considering defibrillation
- Deliver a shock immediately, then commence 2 minutes of CPR (30:2 ratio), reassess rhythm, give adrenaline 1 mg IV after the third shock, then amiodarone 300 mg IV after the third shock (Correct answer)
- Administer IV adrenaline first, then defibrillate
- Perform CPR only — defibrillation is not first-line for VF
Correct answer: Deliver a shock immediately, then commence 2 minutes of CPR (30:2 ratio), reassess rhythm, give adrenaline 1 mg IV after the third shock, then amiodarone 300 mg IV after the third shock
For shockable rhythms (VF/pulseless VT): deliver a shock immediately, then 2 minutes of CPR. Adrenaline 1 mg IV is given after the third shock (then every 3-5 minutes). Amiodarone 300 mg IV is also given after the third shock. The cycle continues: shock → 2 min CPR → reassess.
Question 6: A 40-year-old woman presents with acute severe upper abdominal pain, rigidity, and signs of peritonism. An erect chest X-ray shows free gas under the diaphragm. What is the most likely diagnosis and management?
- Acute pancreatitis — manage conservatively
- Perforated peptic ulcer — this is a surgical emergency requiring urgent laparotomy/laparoscopy after resuscitation (Correct answer)
- Biliary colic — administer analgesia and discharge
- Pneumoperitoneum from recent colonoscopy — observe
Correct answer: Perforated peptic ulcer — this is a surgical emergency requiring urgent laparotomy/laparoscopy after resuscitation
Free gas under the diaphragm (pneumoperitoneum) indicates a perforated hollow viscus — most commonly a perforated peptic ulcer. This is a surgical emergency requiring IV resuscitation, IV antibiotics, IV PPI, nasogastric tube, urinary catheter, and urgent surgical repair (laparotomy or laparoscopic repair).
PLAB 2 Acute Management 2
A patient on the ward develops a tonic-clonic seizure that has lasted 7 minutes.
According to NICE epilepsy guidelines, what is the first-line treatment for status epilepticus?