Clinical SBAs
Clinical Emergencies: (24 questions)

Questions

• 1
  A 12-year old boy is found at home confused, his mother says she found an empty bottle of tablets next to him. He complains of a headache, his respiratory rate is 44 breaths/min, his pupils are equal and reactive to light and ABG shows pH = 7.2. What is the most likely cause of his overdose?
  Difficulty: Medium     Topic: Aspirin overdose
  a

  Aspirin

  b

  Diazepam

  c

  Fluoxetine

  d

  Imipramine

  e

  Paracetamol
  Explanation: This boys is suffering from an aspirin overdose. Aspirin (salicylic acid) causes a metabolic acidosis with raised anion gap but also stimulates hyperventilation, thus the respiratory alkalosis helps to prevent severe acidosis. Headache, nausea, vomiting, tinnitus and sweating are other common features. Diazepam causes drowsiness and reduced respiratory rate in severe overdose. Fluoxetine causes tachycardia, anxiety and restlessness but is usually not life-threatening unless in combination with other serotonergic medications. Imipramine is a tricyclic antidepressant which causes fatal cardiac arrhythmias and seizures with metabolic acidosis. Imipramine would cause dilated pupils. Paracetamol causes acute fulminant liver failure 2-3 days after a toxic overdose.
• 2
  A 15-year old girl has collapsed after being stung by a bee. She is hypotensive and has marked laryngeal oedema. What is the most appropriate initial management?
  Difficulty: Easy     Topic: Anaphylaxis
  a

  0.5ml adrenaline at 1:1,000 IV

  b

  0.5ml adrenaline at 1:10,000 IM

  c

  5ml adrenaline at 1:1,000 IV

  d

  0.5ml adrenaline at 1:1,000 IM

  e

  0.5ml adrenaline at 1:10,000 IV
  Explanation: This girl is in anaphylaxis, which presents with skin and mucosal changes, bronchospasm, angioedema of the airway and hypotension. Initial treatment is to withdraw the causative agent and give 0.5mg (0.5ml of 1:1,000) IM adrenaline, followed by a rapid IV fluid challenge with 500mL crystalloid. Repeat IM adrenaline as necessary and the fluid challenge if it improves haemodynamic parameters. She should be put on high flow oxygen and the on call anaesthetist should be altered. Chlorphenamine IV and hydrocortisone IV should also be given for anaphylaxis. 50mcg (0.5ml of 1:10,000) adrenaline IV is used peri-arrest under senior supervision and only the minimum dose is used.
• 3
  A 55-year old man with known oesophageal varices and alcoholic cirrhosis presents with 1 hour of central chest pain and 4mm ST-elevation in V5-6. What is the most appropriate management?
  Difficulty: Medium     Topic: Chest pain in alcoholic cirrhosis
  a

  Primary percutaneous coronary intervention (PCI)

  b

  Streptokinase

  c

  Alteplase plus LMWH

  d

  Alteplase plus unfractionated heparin IVI

  e

  Tenecteplase bolus
  Explanation: This man has presented with a STEMI that meets criteria for thrombolysis. The best treatment is PCI however this is not offered in all centres and if it cannot be performed within 90 minutes of first medical contact then thrombolysis should be given, unless contraindicated. Advanced liver disease and oesophageal varices puts this patient at much higher risk of a GI bleed following thrombolysis, which a further reason why PCI is the best option in this patient. Tenecteplase and alteplase are a recombinant tissue plasminogen activators, which can be given even if the patient has received thrombolysis previously. This is not the case for streptokinase that causes development of antibodies therefore is not effect on re-administration. After a STEMI you must also initiate anti-platelet therapy and anti-coagulation.
• 4
  A 17-year old boy is taken to A&E by his parents. He is semiconscious and is vomiting. He has bulimia nervosa and acne vulgaris, treated with fluoxetine and tetracycline, respectively. On examination he is apyrexial, there is abdominal tenderness and Kernig’s sign is negative. INR = 2.7. What is the most likely diagnosis?
  Difficulty: Medium     Topic: Semiconsciousness and vomiting
  a

  Fluoxetine overdose

  b

  Tetracycline overdose

  c

  Alternative medication overdose

  d

  Meningitis

  e

  Migraine
  Explanation: This boy has taken a paracetamol overdose. He is suffering from acute liver failure, with coagulopathy and encephalopathy. Paracetamol OD also causes acute tubular necrosis, contributing to reduced GCS and nausea. Kernig's sign is resistance to passive knee extension when the hip is flexed - due to meningism. Also meningococcal infection presents with a severe fever and purpuric bruising. None of the other conditions cause a raised INR. Fluoxetine is relatively safe in overdose alone but may cause serotonin syndrome in combination with tricyclic antidepressants.
• 5
  A 17-year old type 1 diabetic is discovered unconscious at home. Paramedics find his blood glucose to be 1.6mmol/L. What is the most appropriate initial management?
  Difficulty: Medium     Topic: Hypoglycaemia at home
  a

  Buccal glucose gel

  b

  50ml of 50% glucose IV

  c

  100ml of 20% glucose IV

  d

  200ml of 10% glucose IV

  e

  1mg glucagon IM
  Explanation: Hypoglycaemia management depends on conscious level and IV access. This patient cannot take oral treatment (due to unconsciousness) and is without IV access (he was at home). Therefore 1st line is IM glucagon, which helps to mobilise glycogen stores from the liver. 10% or 20% IV glucose would be 1st treatment if IV access were present. 50% glucose is no longer recommended due to high risk of extravasation injury. Buccal gel has been shown to be unreliable.
• 6
  A 18-year old man presents with severe breathlessness. The airway is patent and there is polyphonic wheeze throughout the chest. RR 34/min, HR 114/min, SaO2 94%. What is the most appropriate initial management?
  Difficulty: Easy     Topic: Breathlessness with polyphonic wheeze
  a

  Salbutamol nebuliser with air

  b

  Salbutamol nebuliser with oxygen

  c

  Salbutamol & ipratropium nebuliser with air

  d

  Salbutamol & ipratropium nebuliser with oxygen

  e

  Salbutamol nebuliser with oxygen plus magnesium sulphate IV
  Explanation: This man is having a severe asthma attack. First line for all severities is salbutamol and ipratropium bromide nebuliser with oxygen. This may need to be given continuously for very severe attacks. In addition steroids should be given; route of admission makes no difference for the steroids (oral prednisolone or IV hydrocortisone). If still refractory then magnesium sulphate can be given. Aminophylline is a further option, and ITU should be contacted if life-threatening signs are present.
• 7
  A 21-year old man presents with headache, fever and purpuric rash on his legs. He has photophobia and neck stiffness but is haemodynamically stable. 1.2mg benzylpenicillin IM has already been given. What is the next most appropriate step?
  Difficulty: Hard     Topic: Headache and purpuric rash
  a

  IV dexamethasone

  b

  Lumbar puncture

  c

  2g cefotaxime IV

  d

  CT head

  e

  Aciclovir IVI
  Explanation: This man has meningitis, most likely due to Neisseria meningitidis. IM (or IV) benzylpenicillin should be given first. Following this, if they are unstable with septicaemia then cefotaxime should be given and LP can be delayed until following resuscitation and antibiotics. If they are mostly meningitic (in this case) then dexamethasone should be given next, followed by LP unless there are signs of raised ICP. CT cannot reliably exclude raised ICP. ITU may be needed.
• 8
  A 22-year old man is involved in a RTA. He is producing clear words but they don’t make sense and aren’t in sentences. He shows a decorticate posture to pain and does not open his eyes. What is his GCS?
  Difficulty: Easy     Topic: Glasgow coma scale
  a

  5

  b

  6

  c

  7

  d

  8

  e

  9
  Explanation: The Glasgow Coma Scale scores patients level of conscious level using Eyes (out of 4), verbal response (out of 5) and motor response (out of 6). Eye opening: 4 - spontaneous, 3 - to voice, 2 - to pain, 1 - none. Verbal: 5 - oriented, 4 - confused, 3 - inappropriate words, 2 - incomprehensible sounds, 1 - none. Motor: 6 - obeys commands, 5 - localising to pain, 4 - withdrawal to pain, 3 - flexes (decorticate) to pain, 2 - extends (decerebrate) to pain, 1 - none. This patient: Eyes - 1, Verbal - 3, Motor - 3.
• 9
  A 23-year old man has been involved in a RTA. He is in respiratory distress with BP 58/36mmHg. There is tracheal deviation to the left with the thorax is dull on the right. What is the most appropriate management?
  Difficulty: Easy     Topic: RTA chest trauma
  a

  Insert a 14G needle in the right mid-clavicular line just under the 2nd rib

  b

  Insert a 16G needle in the right mid-clavicular line just above the 3rd rib

  c

  Insert a chest drain on the right

  d

  Insert a chest drain on the left

  e

  Perform pericardiocentesis
  Explanation: Respiratory distress and hypotension with tracheal deviation following trauma is either a massive haemothorax or tension pneumothorax. Given dull percussion, haemothorax is most likely therefore a chest drain should be inserted contralateral to the tracheal deviation. If tension pneumothorax were suspected then needle decompression would be appropriate. The 2nd intercostal space is below the 2nd rib and above the 3rd. The largest intercostal neurovascular bundle runs inferior to each rib, therefore needles should be insert immediately superior to the rib.
• 10
  A 26-year old woman with type 1 diabetes presents with shortness of breath, vomiting and abdominal pain. Capillary blood glucose = 23mmol/L. What is the first step in her management?
  Difficulty: Easy     Topic: Shortness of breath, vomiting and pain
  a

  0.9% saline IVI

  b

  5% dextrose IVI

  c

  Actrapid subcutaneously

  d

  8U/hr insulin IVI

  e

  0.9% saline plus 20mmol/L potassium IVI
  Explanation: DKA occurs due to absolute insulin deficiency however the fluid correction of dehydration is the initial priority. This initially uses 0.9% saline without potassium due to risk of hyperkalaemia. However following the first litre of fluid, potassium should then be added by sliding scale to avoid hypokalaemia. A high-rate insulin infusion is begun until blood glucose is below 15mmol/L.5% dextrose is not given as initial fluid resuscitation. Subcutaneous actrapid is not used to treat acutely unwell patients with DKA.
• 11
  A 31-year old woman is rescued from a house fire. She is hypotensive with pink peripheries and 100% SaO2. What is the definitive management?
  Difficulty: Easy     Topic: House fire complications
  a

  100% oxygen

  b

  Active cooling

  c

  IV benzylpenicillin and metronidazole

  d

  IV dexamethasone ± mannitol

  e

  Neurosurgery
  Explanation: Carbon monoxide poisoning gives a picture that is similar to sepsis with peripheral vasodilatation and bounding pulse. In both cases, oxygen delivery to tissues is poor. CO poisoning should be considered with high suspicion in burns patients especially if they have spent an extended period trapped. Ordinary pulse oximeters will falsely read 100% SpO2. Diagnosis can be made by an ABG analyser with a co-oximeter or a special pulse oximeter designed for this purpose. Treatment is with 100% oxygen. Endotracheal intubation and ventilation is indicated if PaCO2 begins to rise or the alveolar-arterial oxygen gradient is high. Active cooling is used for hyperpyrexia e.g. malignant neuroleptic syndrome. IV dexamethasone (with mannitol) is used for cerebral oedema, which is a possible complication of hypoxic brain injury due to CO poisoning. Antibiotic therapy is not appropriate.
• 12
  A 32-year old epileptic woman presents with a tonic-clonic seizure that has lasted 15minutes and did not respond to diazepam PR. What is the initial treatment?
  Difficulty: Medium     Topic: Seizure management
  a

  Diazepam IVI

  b

  Dexamethasone IV

  c

  Phenytoin IVI

  d

  Lorazepam IV

  e

  Propofol IVI
  Explanation: Continuous or resistant seizures should be treated as status epilepticus and should aim to be stopped within 20minutes. Reversible causes should be excluded e.g. hypoglycaemia. First line is a bolus of lorazepam IV, though this may further compromise the airway. A phenytoin infusion is 2nd treatment, with diazepam as a further option. General anaesthesia is the last option, which may use propofol. Dexamethasone is only of use if an oedematous SOL is thought to be the cause.
• 13
  A 32-year old woman presents with shortness of breath and the following arterial blood gases: pH 7.44, PaO2 14kPa, PaCO2 2.1kPa, HCO3- 21mmol/L, anion gap is raised. Which investigation will give the diagnosis?
  Difficulty: Easy     Topic: Blood gas analysis
  a

  Serum paracetamol

  b

  Serum lactate

  c

  Venous blood glucose

  d

  Serum salicylate

  e

  Paraquat urine test
  Explanation: The ABGs show a high-normal pH however there is a raised anion gap, which indicates a metabolic acidosis as the underlying pathology. There has been complete respiratory compensation, which occurs with salicylate overdose because initially there is stimulation of the respiratory centre that directly causes a respiratory alkalosis. Metabolic acidosis develops later. Urine alkalinisation with bicarbonate helps to increase aspirin elimination. Main complications are: renal failure, severe acidosis or seizures.
• 14
  A 33-year old woman presents with breathlessness and chest pain. ECG shows narrow QRS complexes with a ventricular rate of 246/min. What is the most appropriate management?
  Difficulty: Medium     Topic: Narrow complex tachycardia
  a

  Amiodarone IV

  b

  Adenosine bolus

  c

  Synchronised cardioversion

  d

  Unsynchronised cardioversion

  e

  Overdrive pacing
  Explanation: Narrow QRS complexes indicate that this is a supra-ventricular tachycardia (SVT). 1st line treatment for unstable SVT is synchronised cardioversion, followed by amiodarone infusion. Amiodarone can also be used to medically cardiovert stable AF. If stable then adenosine is given, which may terminate the SVT or reveal the underlying atrial rhythm that will help direct further treatment. Unsynchronised cardioversion is only used for VF. Overdrive pacing is used for resistant tachycardias.
• 15
  A 42-year old farmer presents unconscious with faecal and urinary incontinence. His pupils are constricted and he is sweating profusely. What is the most likely diagnosis?
  Difficulty: Hard     Topic: Overdose
  a

  Furosemide overdose

  b

  Atropine overdose

  c

  Organophosphate overdose

  d

  Benzodiazepine overdose

  e

  Digoxin overdose
  Explanation: Organophosphates are chemical used in many herbicides and insecticides. When taken they are cholinesterase inhibitors therefore augment the cholinergic responses with: incontinence, pupillary constriction, sweating, salivation, lacrimation with bradycardia. A muscarinic antagonist, atropine, is the treatment of choice. Furosemide overdose causes severe diuresis, electrolyte loss and nausea. Atropine overdose causes tachycardia, hypotension and arrhythmias. Benzodiazepine overdose causes sedation and respiratory depression. Digoxin overdose causes nausea, dizziness and arrhythmias.
• 16
  A 42-year old man is on the medical assessment unit with pneumonia. He becomes more severely short of breath with bilateral fine basal inspiratory crackles. Fluid balance charts show that he has been >500ml positive for the last 3 days. What is the most appropriate initial management?
  Difficulty: Easy     Topic: Pneumonia complications
  a

  IV morphine and metoclopramide

  b

  Salbutamol and ipratropium nebuliser with oxygen

  c

  IV hydrocortisone

  d

  IV furosemide and diamorphine

  e

  IV amoxicillin and hydrocortisone
  Explanation: This man has developed acute pulmonary oedema as a complication of his pneumonia; this may go on to develop into ARDS. This is made more likely by the fact that he has a positive fluid balance. Initial management is with a loop diuretic and a venous dilator (diamorphine), which is fast acting, gives analgesia and helps to reduce the patient's anxiety. Nitrates may also be given but if the patient continues to deteriorate then CPAP or mechanical ventilation may be required.
• 17
  A 42-year old woman is brought to A&E by her husband Semiconscious. GCS = 10. He found her next to empty packets of her medication, she takes: diazepam, bendroflumethiazide & imipramine. What is the most appropriate management?
  Difficulty: Hard     Topic: Multiple medication overdose
  a

  Best supportive management

  b

  IV naloxone

  c

  IV naltrexone

  d

  IV flumazenil

  e

  IV glucose
  Explanation: It is likely that this woman has taken a mixed medication overdose. Bendroflumethiazide is relatively safe in OD. Benzodiazepines (BZD) cause sedation, respiratory depression and coma. TCA are very dangerous and have a high risk of seizures and arrhythmia. Here, the BZD will be helping to resist the pro-seizure effect of TCAs therefore reversal with flumazenil may trigger severe seizures. Only give flumazenil if there is life-threatening respiratory depression or loss of airway.
• 18
  A 55-year old woman presents with pleuritic chest pain followed by collapse with BP 44/28mmHg. The right calf is red, tender and swollen. What is the most appropriate definitive management?
  Difficulty: Medium     Topic: Pleuritic pain and collapse
  a

  Subcutaneous low-molecular weight heparin

  b

  Unfractionated heparin IVI

  c

  Dobutamine IVI

  d

  Noradrenaline IVI

  e

  Surgery
  Explanation: Pulmonary embolism is usually treated with anticoagulation with heparin and warfarin. However if the patient is acutely unwell and peri-arrest (as this case) then thrombolysis or surgical thrombectomy is indicated. If the patient is hypotensive but not requiring immediate intervention then shock is corrected using fluid, then dobutamine, then noradrenaline.
• 19
  A 60-year old man presents with chest pain and dizziness. ECG shows a regular broad complex tachycardia. He cardioverts following 2 synchronised DC shocks. What is the next appropriate management?
  Difficulty: Medium     Topic: Broad complex tachycardia
  a

  Lidocaine infusion

  b

  External pacing

  c

  Angiography

  d

  Amiodarone infusion

  e

  LMWH, aspiring and clopidogrel
  Explanation: Treatment of arrhythmias is determined by whether they are 'stable' or 'unstable', indicated by: shock, syncope, signs of heart failure or MI. Chest pain and reduced conscious level are taken to be indicators of insufficient cardiac output. If the pulse is absent then the Adult Life Support arrest protocol should be used. First line for unstable ventricular tachycardia is synchronised DC shocks. Following this, amiodarone infusion should be used. If refractory, other drugs that can be used are: lidocaine, flecainide and overdrive pacing.
• 20
  A 61-year old diabetic woman presents with central chest pain and 2mm ST-depression in V5-V6. Which of the following is least likely to be part of her management?
  Difficulty: Medium     Topic: Chest pain and ST-depression
  a

  Tirofabin

  b

  Tenecteplase

  c

  Abciximab

  d

  Enoxaparin

  e

  IV glyceryl trinitrate
  Explanation: This woman has presented with a non-STEMI and thrombolysis is not recommended in the management however PCI may be used (if available) in high-risk patient. Tirofiban and abciximab are GpIIb/IIIa antagonists, which potently block platelet interaction and are used in high risk-patients who have not had pain relief from conventional management. LMWH and IV GTN form part of the management of all patients.
• 21
  A 67-year old woman is brought to A&E unconscious. She has a history of hypertension treated with ramipril and hyperthryoidism treated with radio-iodine ablation. Heart rate is 32bpm and regular. Capillary blood glucose = 4mmol/L. Temperature 36.9 degrees. What is the most appropriate management?
  Difficulty: Medium     Topic: Unconsciousness with bradycardia
  a

  10% dextrose IVI

  b

  Dexamethasone IV

  c

  CT head

  d

  Warming blankets

  e

  Triiodothyronine
  Explanation: The main causes of bradycardia and coma are: hypoglycaemia, hypothermia and myxoedema coma. Radio-iodine ablation frequently results in over-treatment and hypothyroidism, which in this case has results in a myxoedema coma. The active hormone, T3 (triiodothryonine) is given to correct the state. This woman's blood glucose is low-normal, which occurs in myxoedema coma, however 10% dextrose will not increase conscious level. Dexamethasone is not indicated here. CT head is unlikely to give any useful information. Warming blankets may be tried as hypothyroidism can cause mild hypothermia.
• 22
  A 75-year old man presents in acute urinary retention. Urea 13mmol/L, K+ 6.7mmol/L with tall T-waves on ECG. What is the most appropriate initial management?
  Difficulty: Easy     Topic: Acute urinary retention
  a

  Haemodialysis

  b

  Haemofiltration

  c

  Calcium resonium

  d

  Calcium glucuronate

  e

  Insulin-dextrose IVI
  Explanation: This man has renal failure with hyperkalaemia, most likely due to prostatic obstruction. First line treatment is with calcium glucuronate, which does not reduce serum potassium levels but is cardioprotective. Insulin increases intracellular movement of potassium and is given 2nd with dextrose to prevent hypoglycaemia. If this fails, a high-dose salbutamol nebuliser should be tried. Calcium resonium binds potassium in the gut and slowly reduces serum levels. Haemodialysis is used if ECG changes are present or if resistant, and haemofiltration for haemodynamically unstable patients.
• 23
  A 78-year old is discovered lying on the floor at home. Her GCS is 3 and there are J-waves on ECG. What is the most appropriate management?
  Difficulty: Medium     Topic: Unconsciousness with J-waves
  a

  IV dexamethasone

  b

  IV triiodothyronine

  c

  Slow warming

  d

  Slow IVI potassium and 0.9% saline

  e

  10% dextrose IVI
  Explanation: J-waves are small upward deflections immediately following the QRS complex, which are pathognmonic of hypothermia. It may present with severe coma and bradycardia almost such that signs of life are absent. Patients should be warmed before death is declared. Warming should be gradual to prevent hypotension from peripheral vasodilatation. Hypoglycaemia and hypothyroidism are the 2 main differentials but they do not cause J-waves. Hypokalaemia causes U-waves, for which slow potassium IVI is the treatment.
• 24
  A man has fallen from a ladder and paramedics arrive on scene. His wife does not know how high he was when he fell. What is the most appropriate immediate management?
  Difficulty: Easy     Topic: Primary survey
  a

  Head-tilt

  b

  Chin-lift

  c

  Jaw-thrust

  d

  Guedel airway

  e

  Nasopharyngeal airway
  Explanation: The primary survey begins with assessing for danger, checking the patient's response and calling for help. Airway follows next and the management ladder begins with head tilt and chin lift however when the mechanism of injury is unknown or it is potentially traumatic (e.g. fall) then cervical spine injury must be assumed. Head-tilt and chin-lift can move unstable cervical spine fractures (risking spinal cord injury) therefore a jaw thrust should be used first.