Collapsed patient in the waiting room — ABCDE assessment

PLAB 2 & PRES 3 · emergency medicine / general practice · medium · 10 minutes

Candidate brief

You are an FY2 doctor in a GP surgery. The receptionist has just called you urgently into the waiting room: Mr Reginald Cole, 68, who was waiting for a routine appointment, has slumped sideways in his chair and is unresponsive. The surgery has a defibrillator, oxygen, a glucose meter, glucose gel, glucagon, and emergency drugs; a nurse is available to help. Initial findings when you reach him: he is not responding to voice or shaking. His breathing is slow and snoring. There are other patients in the waiting room. Please assess and manage this patient.

What examiners look for

Collapse is a presentation, not a diagnosis, and ABCDE is how you survive it. The structure exists precisely for the moment your mind blanks: open the airway, prove breathing, prove a pulse, then work the letters — treating each problem before moving on. The first discrimination is binary: breathing with a pulse, or not. Snoring respirations and a palpable pulse mean this man needs an airway and a cause, not compressions. Candidates lose the station in the first thirty seconds by reaching for the defibrillator instead of the chin lift. An obstructed airway announces itself — snoring is the sound of a tongue, and silence from a "snoring" patient is worse, not better. Jaw thrust, adjunct, recovery position: three unglamorous manoeuvres that do more for this man's brain than any drug in the building. D is for Don't Ever Forget Glucose. 2.4 mmol/L explains everything in this station and would have been missed by any amount of elegant neurology. The glucose meter is part of the primary survey, as non-negotiable as the pulse check — in collapse, in confusion, in seizures, in "drunk" patients. Nothing by mouth means nothing. Glucose gel, juice and jelly babies are for patients who can swallow and protect their airway. In the unconscious patient the correct routes are IM glucagon or IV glucose — and the correct expectation is minutes, not seconds, so recheck on schedule instead of piling on doses. Sulfonylurea hypos come back. Gliclazide keeps working for many hours, so a man who "recovers and feels fine" at 11 a.m. can be unconscious again by teatime. Observation, long-acting carbohydrate, medication review and an honest driving conversation are the treatment; the glucagon was just the beginning. The collapse is also a disclosure: he skipped breakfast because he misunderstood a blood test, and told nobody he felt ill because he didn't want a fuss. Prevention lives in those two sentences — correcting them kindly prevents the sequel better than any prescription change alone.

Guideline references

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