UKMLA Acute & Emergency: 10 Must-Master Presentations

Emergency medicine is disproportionately represented on the UKMLA AKT. On any given paper, 20–25% of stems describe an acutely unwell patient — someone crashing on a ward, arriving in A&E, or deteriorating during a routine GP consult. These questions are examiner-favourites because they test the cognitive skill that defines safe F1 practice: recognising a sick patient fast, applying a structured approach, and picking the intervention that prevents death in the next fifteen minutes.

The good news is that acute medicine is finite and pattern-rich. Ten presentations account for almost every emergency stem you will see. Each has a recognisable trigger, a scored or named protocol (qSOFA, Wells, GCS, FAST, ABCDE), and a short list of interventions where the correct first step is rigid rather than nuanced. Learn the ten presentations cold and you have defended the largest single mark cluster on the AKT.

This masterclass walks through the ten emergencies the UKMLA tests most aggressively, frames each through the ABCDE assessment every UK F1 is expected to run on autopilot, and closes with the specific question templates the AKT uses to sort candidates who can manage a sick patient from candidates who cannot. Every section is aligned to the GMC content map's "urgent and emergency care" theme and to the 2026 Resuscitation Council UK guidance.

Table of contents

1. Why emergency medicine dominates the AKT
2. The ABCDE framework — your exam operating system
3. Chest pain — ACS, PE, aortic dissection
4. Breathlessness — pulmonary oedema, PE, pneumothorax, anaphylaxis
5. Sepsis
6. DKA and HHS
7. Hypoglycaemia
8. Acute stroke
9. Altered consciousness
10. Anaphylaxis
11. Major haemorrhage
12. Acute abdomen
13. Common AKT question patterns
14. FAQ

1. Why emergency medicine dominates the AKT

The GMC content map contains three overarching themes; "acute care" is the one that cuts across every clinical specialty. Cardiology, respiratory, endocrine, neurology, and surgery each contribute their own acute presentations, and the AKT tests them collectively. A typical 200-question paper contains 40–55 stems where the patient is acutely unwell — roughly a quarter of the whole exam.

These stems are also the least forgiving. Diagnostic stems allow partial credit in your thinking (you can narrow a differential even if you miss the final answer). Emergency stems are binary: you either give IV adrenaline 500 mcg IM for anaphylaxis or you don't. Candidates who have internalised rigid first-response protocols score heavily here; candidates who improvise lose marks fast.

The reason emergency medicine is drillable is that the correct first step for almost every emergency is protocolised. Resus Council UK, NICE, and the Royal College of Emergency Medicine publish explicit algorithms — sepsis six, ALS, ABCDE, DKA pathway. The AKT tests recognition of these protocols and the threshold at which each triggers. Drill the protocols and the marks come automatically.

Your target: 80%+ subscore on emergency/acute-care Q-bank filters. The cardiology masterclass covers ACS in detail; this post cross-references and expands into the nine other dominant emergencies.

2. The ABCDE framework — your exam operating system

Before any specific emergency, embed ABCDE as the retrieval backbone for every acute stem. The AKT rewards candidates who can tag where on the ABCDE assessment the stem is probing and retrieve the correct intervention for that step.

A — Airway.

• Look: is it patent? Obstruction signs — stridor, gurgling, paradoxical chest movement.
• First action: open airway (head tilt-chin lift unless C-spine concern), suction, consider adjunct (oropharyngeal/nasopharyngeal airway).
• Escalation: definitive airway (intubation) if GCS ≤8 or airway cannot be maintained.

B — Breathing.

• Look: rate, effort, symmetry, tracheal position, chest movement.
• Listen: air entry, wheeze, crackles, pleural rub.
• Feel: percussion note.
• Measure: SpO₂, ABG if needed.
• First action: 15L O₂ non-rebreather if critically unwell; titrate down in COPD.

C — Circulation.

• Look: colour, capillary refill, JVP, peripheral oedema.
• Feel: pulse rate, rhythm, volume.
• Measure: BP, 12-lead ECG.
• First action: two large-bore cannulae, bloods (FBC, U&E, troponin, CRP, glucose, VBG, cultures if sepsis), IV fluid bolus 500 mL crystalloid if shocked.

D — Disability.

• AVPU or GCS.
• Pupils: size, symmetry, reactivity.
• Glucose — always.
• Temperature.

E — Exposure.

• Full head-to-toe examination.
• Look for rashes, bleeding, bruising, trauma, bites, burns.
• Maintain dignity and warmth.

Every emergency stem in the AKT probes one or more ABCDE steps. When you read a stem, explicitly tag which letter is failing — that letter tells you the first action.

3. Chest pain — ACS, PE, aortic dissection

Three can't-miss diagnoses drive almost every chest pain stem.

Acute coronary syndrome. Central crushing chest pain, radiating to arm/jaw, with autonomic features (sweating, nausea). Covered in detail in the cardiology masterclass. First actions: aspirin 300 mg, second antiplatelet, oxygen only if hypoxic, GTN, morphine. ECG within 10 minutes. STEMI → PPCI within 120 minutes; NSTEMI → GRACE-stratified angiography within 72 hours.

Pulmonary embolism. Pleuritic chest pain, sudden dyspnoea, often with risk factors (immobility, surgery, malignancy, pregnancy, COCP). Wells score ≥4 → CTPA. Wells <4 → D-dimer; positive → CTPA. First-line anticoagulation: apixaban 10 mg BD for 7 days, then 5 mg BD, or rivaroxaban 15 mg BD for 21 days then 20 mg OD. Massive PE with haemodynamic instability → thrombolysis (alteplase).

Aortic dissection. Sudden severe tearing chest pain radiating to back. Hypertensive history. Unequal BPs between arms. Widened mediastinum on CXR. Diagnosis: CT angiogram of aorta. Management: urgent cardiothoracic referral, IV labetalol to BP 100–120 systolic, type A (ascending) → emergency surgery; type B (descending) → usually medical management.

Exam triage. Chest pain + ST elevation → STEMI pathway. Chest pain + pleuritic + risk factor → PE pathway. Chest pain + back radiation + unequal BPs → dissection. These three triages cover 80% of chest pain stems.

4. Breathlessness — pulmonary oedema, PE, pneumothorax, anaphylaxis

Breathlessness is the most frequent AKT presentation (more than any other single symptom). Four can't-miss causes dominate.

Acute pulmonary oedema. Orthopnoea, PND, bilateral fine crackles, raised JVP. CXR: bat-wing shadowing, Kerley B lines, cardiomegaly. Management: sit up, 15L O₂, IV furosemide 40–80 mg, GTN infusion if BP allows, CPAP if distressed. The cardiology masterclass covers the chronic HF management that follows.

Pulmonary embolism. See above. On AKT, a stem describing tachycardia + pleuritic chest pain + recent surgery/flight/OCP is PE until proven otherwise.

Pneumothorax. Sudden pleuritic chest pain + dyspnoea + reduced breath sounds on affected side + hyperresonance. Tension pneumothorax — tracheal deviation away, hypotension, raised JVP. Management: large-bore cannula 2nd intercostal space mid-clavicular line (or 4–5th intercostal space anterior axillary line per updated ATLS) immediately, then chest drain. Primary spontaneous pneumothorax → aspirate if >2 cm rim or symptomatic; smaller conservatively. Secondary (COPD patient) → chest drain.

Anaphylaxis. Covered in section 10 in full — but if breathlessness stem describes stridor, urticaria, angio-oedema, hypotension, think anaphylaxis and give IM adrenaline first.

Other breathlessness causes (asthma, COPD exacerbation, CAP, pleural effusion) are covered in the respiratory masterclass.

5. Sepsis

Recognition. qSOFA: ≥2 of (RR ≥22, altered mental status, SBP ≤100) identifies high-risk patients outside ICU. NEWS2 is more sensitive for ward-based recognition.

Sepsis Six (within one hour):

1. Give high-flow oxygen
2. Take blood cultures
3. Give IV antibiotics (broad-spectrum — typically piperacillin-tazobactam or ceftriaxone depending on source and trust guidelines)
4. Give IV fluids (500 mL crystalloid bolus, repeat up to 30 mL/kg if hypotensive)
5. Measure serum lactate
6. Measure urine output (hourly)

Source identification. Ask: chest, urine, abdomen, skin/soft tissue, line, meningitis. Order appropriate imaging and cultures.

Septic shock. Persistent hypotension despite fluids + vasopressors + lactate ≥2 mmol/L. Escalate to ICU, noradrenaline first-line vasopressor.

AKT question pattern. Patient with fever, tachycardia, hypotension, altered mental status. Stem asks for first action or next investigation. Answer: Sepsis Six within one hour — usually the specific step not yet done (bloods if cultures missing, IV abx if antibiotics missing, fluids if bolus missing).

6. DKA and HHS

DKA diagnostic triad:

• Ketones ≥3 mmol/L (or urine ketones 2+)
• Blood glucose >11 mmol/L (or known T1DM)
• Acidosis: pH <7.3 or bicarbonate <15 mmol/L

DKA management (2023 JBDS guideline):

1. Fluid resuscitation: 0.9% saline 1L over 1 hour, then reassess.
2. Fixed-rate insulin infusion: 0.1 units/kg/hour (50 units actrapid in 50 mL saline).
3. Continue long-acting insulin if patient normally uses one (e.g. Lantus).
4. Add potassium to IV fluids once K drops to <5.5 (usually in the second litre).
5. Switch to 10% dextrose + continue insulin when glucose <14.
6. Monitor ketones, glucose, pH, K hourly.
7. Identify precipitant: infection, missed insulin, MI, pancreatitis.

Resolution: ketones <0.6, pH >7.3, bicarbonate >18. Then transition to subcutaneous insulin overlapping with infusion for 30 min.

HHS (Hyperosmolar Hyperglycaemic State). Older T2DM patients. Glucose usually >30 mmol/L. Osmolality >320 mOsm/kg. No significant ketosis. Managed with slower fluid resuscitation than DKA (aim correction over 24–48 hours) and insulin only once fluids are underway (start at 0.05 units/kg/hour). Aggressive insulin + fluids in HHS risks central pontine myelinolysis.

AKT question pattern. Young T1DM patient with vomiting, abdominal pain, Kussmaul breathing, raised ketones. First action? IV 0.9% saline 1L then fixed-rate insulin. Common distractor: starting insulin before fluids (wrong).

7. Hypoglycaemia

Definition. BG <4.0 mmol/L (symptomatic) or <3.0 mmol/L regardless.

Management:

• Conscious, swallowing: 15–20 g fast-acting glucose (Lucozade, glucose tablets, sugary drink) → recheck in 15 minutes → repeat if needed → long-acting carbohydrate (toast, biscuit).
• Unconscious or unsafe swallow: IV 10% dextrose 150–200 mL or IM glucagon 1 mg. Avoid 50% dextrose (extravasation risk).
• Repeated hypoglycaemia + malnutrition/alcoholism: give Pabrinex (IV B vitamins) to prevent Wernicke's before glucose load.

Causes: insulin overdose, sulfonylurea overdose (long half-life, can be prolonged), alcohol, Addison's, sepsis, post-gastric bypass dumping, insulinoma.

AKT question pattern. T2DM patient on gliclazide presents unconscious. BG 2.1. First action? IV dextrose or IM glucagon. Then: admit for 24-hour observation because sulfonylurea hypoglycaemia can recur.

8. Acute stroke

FAST recognition. Face droop, Arm weakness, Speech disturbance, Time to call 999. ROSIER score in A&E to stratify.

Immediate management:

1. CT head within 1 hour — exclude haemorrhage.
2. Ischaemic stroke + within 4.5 hours of onset + no contraindications → alteplase (IV thrombolysis).
3. Large vessel occlusion + within 6 hours (up to 24h in selected) → mechanical thrombectomy.
4. Aspirin 300 mg OD for 2 weeks then clopidogrel 75 mg OD lifelong.
5. Haemorrhagic stroke → urgent neurosurgical referral, BP control (target <140 systolic if spontaneous ICH within 6 hours), reverse anticoagulation.

TIA. Symptoms resolve within 24 hours (usually minutes). ABCD² score historically used but now largely superseded; current NICE advice is to give aspirin 300 mg immediately and refer to stroke clinic within 24 hours. MRI + carotid Doppler within 24 hours. Carotid stenosis >50% → endarterectomy within 2 weeks.

Stroke secondary prevention:

• Antiplatelet (clopidogrel)
• Statin (atorvastatin 80 mg)
• BP control (<130/80 in most; lower in specific scenarios)
• Anticoagulation if AF (DOAC)
• Lifestyle: smoking cessation, diet, exercise
• Carotid endarterectomy if indicated

AKT question pattern. Patient presents 2 hours after right-sided weakness and dysphasia. CT shows no bleed. Next step? IV alteplase (within 4.5 hour window). Distractor: aspirin first (wrong — thrombolysis first if eligible).

9. Altered consciousness

GCS assessment:

• Eye: spontaneous (4), voice (3), pain (2), none (1)
• Verbal: oriented (5), confused (4), inappropriate words (3), sounds (2), none (1)
• Motor: obeys (6), localises (5), withdraws (4), flexion (3), extension (2), none (1)

Maximum 15, minimum 3. GCS ≤8 = definitive airway protection required (intubation).

AVPU (quicker): Alert, responds to Voice, responds to Pain, Unresponsive.

Differential — "AEIOU TIPS":

• Alcohol
• Epilepsy, electrolytes
• Insulin (hypo/hyperglycaemia)
• Opiates and overdose
• Uraemia
• Trauma
• Infection (sepsis, meningitis, encephalitis)
• Psychiatric
• Stroke, shock

First actions in any altered consciousness patient:

1. ABCDE
2. Glucose — always
3. Pupils — pinpoint (opioid toxicity) vs blown (raised ICP) vs equal reactive (metabolic)
4. Temperature
5. Naloxone if pinpoint pupils or opioid context
6. Flumazenil if benzodiazepine overdose suspected (use cautiously)
7. CT head if trauma, focal signs, or unexplained
8. Lumbar puncture if meningitis/encephalitis suspected after CT

Meningitis emergency protocol. Fever + neck stiffness + photophobia + headache + altered consciousness ± rash. IV/IM benzylpenicillin in community before transfer then ceftriaxone 2 g BD in hospital. LP after CT (if CT indicated). Add dexamethasone 10 mg IV if pneumococcal suspected. Meningococcal contacts → prophylaxis (ciprofloxacin or rifampicin).

AKT question pattern. Unconscious patient found at home. Pinpoint pupils. First intervention? IV naloxone 400 mcg (may repeat).

10. Anaphylaxis

Recognition. Sudden onset + airway/breathing/circulation involvement + skin or mucosal changes. Not all anaphylaxis has rash.

Management (2021 Resus Council UK update):

1. Remove trigger.
2. Call for help.
3. Lay patient flat, raise legs (if breathing allows).
4. IM adrenaline 500 mcg (0.5 mL of 1:1000) into anterolateral thigh. Repeat every 5 minutes if no response.
5. Establish airway; high-flow O₂.
6. IV fluid bolus 500–1000 mL crystalloid.
7. After resuscitation: non-sedating antihistamine (cetirizine 10 mg PO) — this replaces chlorphenamine in the 2021 update, which removed the routine IV antihistamine recommendation.
8. Hydrocortisone is no longer routinely recommended for anaphylaxis (another 2021 change — distractor on updated stems).

Paediatric IM adrenaline doses:

• <6 months: 100–150 mcg
• 6 months – 6 years: 150 mcg
• 6–12 years: 300 mcg

• 12 years: 500 mcg

Post-event: observe for 6–12 hours (biphasic reactions). Prescribe two auto-injectors (EpiPen, Jext, Emerade), refer to allergy clinic, provide written anaphylaxis action plan.

AKT question pattern. Patient stung by wasp, develops wheeze + hypotension + urticaria. First action? IM adrenaline 500 mcg thigh. Distractor: IV hydrocortisone (outdated).

11. Major haemorrhage

Triggers for major haemorrhage protocol:

• Blood loss ≥150 mL/min
• Blood loss ≥50% blood volume in 3 hours
• Signs of class III/IV shock + ongoing bleeding

Activation. Call major haemorrhage protocol (hospital-specific number). Deliver fixed ratios of packed red cells:FFP:platelets (typically 1:1:1) rapidly.

Tranexamic acid 1 g IV bolus then 1 g infusion over 8 hours — given within 3 hours of traumatic injury (CRASH-2 trial), or within 3 hours of postpartum haemorrhage onset (WOMAN trial). Also used in GI bleeding per HALT-IT, though evidence less strong.

Reverse anticoagulation:

• Warfarin: IV vitamin K 5–10 mg + prothrombin complex concentrate (Beriplex) 25–50 units/kg.
• DOAC (apixaban/rivaroxaban): andexanet alfa if available; otherwise PCC. Dabigatran: idarucizumab.
• Heparin: protamine sulphate.

Upper GI bleed specific. Glasgow-Blatchford score ≥1 → admit. Rockall score for severity. Endoscopy within 24 hours (within 2 hours if unstable). Terlipressin + prophylactic antibiotics for suspected variceal bleed.

Postpartum haemorrhage. "4 Ts": Tone (atonic uterus — oxytocin, ergometrine, misoprostol, carboprost), Trauma (lacerations), Tissue (retained products), Thrombin (coagulopathy). Bimanual compression, uterine tamponade balloon, surgical escalation.

AKT question pattern. Trauma patient, ongoing bleed, HR 140, BP 85/50. First action sequence: two large-bore cannulae, bloods + crossmatch 4–6 units, activate major haemorrhage, tranexamic acid if within 3 hours.

12. Acute abdomen

Can't-miss diagnoses:

Appendicitis. Peri-umbilical pain migrating to RIF, anorexia, fever, guarding over McBurney's point. CT or US in most UK centres. Laparoscopic appendicectomy.

Perforated peptic ulcer. Sudden severe epigastric pain, "board-like" rigid abdomen, free air under diaphragm on erect CXR. IV fluids, antibiotics (broad-spectrum), urgent surgical referral.

Bowel obstruction. Colicky pain, vomiting, distension, constipation. "Drip and suck" — IV fluids + NG tube. CT abdomen to identify cause. Small bowel obstruction usually adhesions; large bowel obstruction usually malignancy.

Ectopic pregnancy. Female of reproductive age + abdominal pain + vaginal bleeding = always do a pregnancy test. β-hCG and transvaginal US. Ruptured ectopic with haemodynamic instability → urgent laparoscopy. Medical management (methotrexate) in selected stable cases.

Ruptured AAA. Older male + sudden epigastric/back pain + pulsatile mass + hypotension. Permissive hypotension (SBP 90) until theatre. Urgent vascular surgical referral. Do not fluid-resuscitate to normal BP — it dislodges clot.

Acute pancreatitis. Epigastric pain radiating to back, raised amylase/lipase. Glasgow/Ranson scoring. Causes: gallstones, ethanol, trauma, steroids, mumps, autoimmune, scorpion, hypercalcaemia/hyperlipidaemia, ERCP, drugs (GET SMASHED mnemonic). Management: aggressive IV fluids, analgesia, treat cause.

Mesenteric ischaemia. Severe abdominal pain "out of proportion" to clinical findings. AF or vascular risk factors. Lactate high. CT angiogram.

AKT question pattern. Sudden severe epigastric pain, rigid abdomen, free air under diaphragm. Diagnosis? Perforated peptic ulcer. First action? IV fluids, IV PPI, IV broad-spectrum antibiotics, urgent surgical referral.

13. Common AKT question patterns

Five recurring emergency stem templates drive most of the mark distribution.

Template 1 — First action given ABCDE findings. Stem gives obs and one abnormality; task is first intervention. Mistake: picking a detailed investigation before ABCDE-appropriate resuscitation.

Template 2 — Score-triggered action. qSOFA ≥2, Wells ≥4, GCS ≤8, CHA₂DS₂-VASc ≥2, Glasgow-Blatchford ≥1. Task is naming the triggered action. Mistake: not memorising the thresholds.

Template 3 — Drug dose or route. IM adrenaline 500 mcg, IV hydrocortisone 200 mg, IM benzylpenicillin 1.2 g. Mistake: picking IV adrenaline (cardiac arrest dose, not anaphylaxis).

Template 4 — Time-critical window. Thrombolysis <4.5 hours. PPCI <120 minutes. Sepsis Six <1 hour. Tranexamic acid <3 hours. Mistake: missing the window or confusing the thresholds.

Template 5 — Outdated vs updated protocol. Stems test 2021+ updates: no routine IV hydrocortisone in anaphylaxis, no chlorphenamine, updated asthma NG245. Mistake: answering with pre-2021 protocols from older textbooks.

MLA Prep tags every emergency question by template and time-critical threshold — so your drilling targets the exact windows the AKT tests. Start the free diagnostic to benchmark your emergency subscore in 20 minutes.

14. FAQ

How many AKT marks come from emergency medicine? Approximately 40–55 of 200 questions touch acute or emergency presentations, spread across specialties.

Is the ABCDE framework tested explicitly? Yes and no. Explicit ABCDE-labelled stems are rare, but almost every acute stem implicitly asks "what's the next step on ABCDE?" Training yourself to tag each stem speeds answering significantly.

Do I need to memorise every protocol's exact dose? Yes, for the ones listed in each section above. Wrong doses are common distractors — IV adrenaline 500 mcg (wrong, that's cardiac arrest dose) vs IM 500 mcg (right, that's anaphylaxis).

What's the difference between anaphylaxis adrenaline and cardiac arrest adrenaline? Anaphylaxis: IM 500 mcg (0.5 mL of 1:1000). Cardiac arrest: IV 1 mg (10 mL of 1:10,000). Both memorise; the AKT loves mixing these as distractors.

How is DKA different from HHS on management? DKA: aggressive fluid + immediate fixed-rate insulin. HHS: slower fluid, delayed/slower insulin (0.05 u/kg/hr not 0.1), watch for osmotic complications.

What if a stem describes competing possible diagnoses? Use the red-flag features embedded in the stem. Each can't-miss diagnosis has specific discriminators (tearing back pain = dissection; pleuritic + risk factor = PE; pinpoint pupils = opioid).

How recent are the protocols the AKT uses? Current. 2021 Resus Council anaphylaxis update, 2023 JBDS DKA guidance, 2024 NG245 asthma, 2025 NICE sepsis updates all expected to be tested on 2026 papers. Use the most recent sources.

How does emergency medicine intersect with CPSA? CPSA communication stations test your ability to run an ABCDE out loud while speaking to a simulated patient or examiner. The CPSA strategy post expands this — but the underlying content is identical. Drilling emergencies for AKT doubles as prep for CPSA.

Should I memorise every hospital-trust-specific antibiotic protocol? No. Learn the generic UK-wide defaults (ceftriaxone + amoxicillin for meningitis, piperacillin-tazobactam for neutropenic sepsis, amoxicillin + clavulanate for hospital-acquired pneumonia with specific modifiers). Trust-specific variations exist but are rarely the AKT answer.

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Ten emergencies, one framework (ABCDE), and a handful of time-critical thresholds. That's the whole surface area of the biggest single mark cluster on the AKT. Each emergency has a rigid first-action — memorise those and the marks come regardless of how the stem is dressed up.

Drill these in tandem with the cardiology masterclass, the respiratory masterclass, and the neurology essentials. The content map post and the 12-week plan tell you how to slot this block into your schedule.

MLA Prep's emergency module includes 200+ AKT-style SBAs across the ten presentations above, ABCDE-tagged, with time-critical-window drills and updated-protocol distractors. Start the free diagnostic to see where you stand, or compare plans for full access.