Mastering PLAB 2: Navigating Common Emergency Scenarios

For aspiring doctors looking to practice in the UK, the PLAB 2 exam is a crucial hurdle. While the exam tests a wide range of clinical skills and communication, a significant portion often revolves around Emergency Medicine scenarios. These stations are designed to assess not only your medical knowledge but also your ability to think under pressure, manage a crisis, and communicate effectively with patients and colleagues. Mastering these scenarios is key to acing your PLAB 2.

Why Emergency Scenarios are High-Yield in PLAB 2

Emergency medicine forms the backbone of acute clinical practice. The General Medical Council (GMC) expects doctors to be competent in handling common medical emergencies. In PLAB 2, these scenarios are often practical, requiring you to demonstrate:

1. Systematic Approach: Applying a structured approach like ABCDE.

2. Prioritisation: Identifying immediate life threats and acting upon them.

3. Clinical Acumen: Diagnosing and initiating appropriate management.

4. Communication: Explaining urgency, obtaining consent, safety-netting.

5. Professionalism: Staying calm, showing empathy, escalating appropriately.

The ABCDE Approach: Your Guiding Star

Regardless of the specific emergency, the ABCDE (Airway, Breathing, Circulation, Disability, Exposure) approach is your universal framework. Always start here. Systematically assess each component, intervene as necessary, and then re-assess. This ensures you don't miss life-threatening conditions.

• A - Airway: Is it patent? Listen, look, feel. Clear it if obstructed.

• B - Breathing: Look, listen, feel. Respiratory rate, oxygen saturation, work of breathing, chest symmetry, added sounds. Administer high-flow oxygen if indicated.

• C - Circulation: Heart rate, blood pressure, capillary refill time, skin colour, urine output. Check for signs of shock. Establish IV access, take bloods, administer fluids.

• D - Disability: Level of consciousness (AVPU/GCS), pupil size and reaction, motor function. Check blood glucose.

• E - Exposure: Fully expose the patient to look for rashes, bleeding, trauma. Maintain patient dignity and warmth.

Common PLAB 2 Emergency Scenarios and How to Approach Them

Let's delve into some frequently tested emergency scenarios and what the examiners are looking for:

1. Anaphylaxis

Scenario: A patient develops sudden rash, swelling, and difficulty breathing after receiving a medication.

PLAB 2 Focus:

• Recognition: Spotting the classic signs quickly.

• Immediate Management: Administering IM Adrenaline (first-line), lying the patient flat, raising legs, high-flow oxygen.

• Calling for Help: Escalating to a senior doctor/resuscitation team.

• Supportive Care: IV fluids, antihistamines, steroids (second-line).

• Safety-netting: Advising on allergen avoidance, Epipen use, follow-up.

2. Acute Asthma Exacerbation

Scenario: A patient presents with acute shortness of breath and wheezing.

PLAB 2 Focus:

• Assessment: Severity assessment (PEFR, sats, speech, use of accessory muscles, silent chest).

• Management: High-flow oxygen, salbutamol nebuliser, ipratropium nebuliser, oral/IV steroids. Consider magnesium sulphate/IV salbutamol for severe cases.

• Monitoring: Continuous monitoring of sats, PEFR, respiratory rate.

• Communication: Reassuring the patient, explaining treatments, discharge planning (relievers, preventers, inhaler technique).

3. Acute Coronary Syndrome (ACS) - Myocardial Infarction

Scenario: A patient presents with sudden onset central crushing chest pain radiating to the arm/jaw.

PLAB 2 Focus:

• Recognition: History taking for characteristic pain, risk factors.

• Immediate Actions: MONA (Morphine, Oxygen, Nitrates, Aspirin) + Clopidogrel/Ticagrelor. Note: Aspirin is first-line antiplatelet.

• Investigations: 12-lead ECG (crucial for STEMI/NSTEMI differentiation), cardiac enzymes (troponin).

• Referral: Urgent cardiology referral for primary PCI or thrombolysis.

• Communication: Explaining the condition and urgency to the patient and relatives.

4. Seizures (Status Epilepticus)

Scenario: A patient is actively seizing or has had multiple seizures without full recovery.

PLAB 2 Focus:

• Safety: Protecting the patient from injury during the seizure.

• Time: Timing the seizure duration (important for status epilepticus definition >5 mins).

• Immediate Management: ABCDE. IV access. IV Lorazepam/Diazepam (first-line). If no IV access, buccal Midazolam/rectal Diazepam. Second-line: IV Phenytoin/Levetiracetam.

• Investigations: Blood glucose, electrolytes, toxicology screen, neuroimaging once stable.

• Post-ictal Care: Recovery position, monitoring.

5. Hypoglycaemia

Scenario: A diabetic patient presents with confusion, sweating, and tremor.

PLAB 2 Focus:

• Recognition: Clinical signs, immediate capillary blood glucose (CBG).

• Management: Oral glucose (if conscious and able to swallow), IV 20% Dextrose (if unconscious/unable to swallow), IM Glucagon (if no IV access available and no contraindications).

• Addressing Cause: Enquiring about insulin dose, missed meals, increased exercise.

• Safety-netting: Educating the patient on prevention, recognition, and management of future episodes.

General Tips for Emergency Stations

• Stay Calm: Panic can make you forget essential steps. Take a deep breath.

• Prioritise: Always deal with immediate life threats first.

• Think Aloud: Verbalise your thought process and actions for the examiner.

• Communicate Clearly: Explain what you're doing, why, and what to expect.

• Call for Help: Don't hesitate to say you'd call a senior doctor, resuscitation team, or nurse. This demonstrates good clinical practice.

• Documentation: Briefly mention you would document your findings and management.

• Practice, Practice, Practice: Simulate these scenarios with colleagues, focusing on the flow and critical steps.

Emergency scenarios in PLAB 2 are designed to test your competence in high-pressure situations. By adopting a systematic ABCDE approach, knowing the immediate management for common conditions, and communicating effectively, you will demonstrate the skills required to practice safely as a doctor in the NHS. Good luck!