2021 Virtual - Acute Abdomen.pdf - T

Please enable JavaScript to view the full PDF

Acute Abdomen Competition: Virtual SimWars 2021, Limerick Round: Heat 2 Participants: Undergraduate Medical/Nursing Students. Teams of 5 Learning Objectives 1. Perform ABCDE assessment including checking glucose 2. Identification of the deteriorating patient 3. Recognition of an Acute Abdomen 4. Differentials for an Acute Abdomen 5. General principles for management of Acute Abdomen 6. Teamwork and communication Scenario Location: Majors area, Emergency Department Condition: Bowel obstruction 75 year old female “ Mary”, has been brought to the emergency department by ambulance. She was found in bed by her daughter this morning who phoned an ambulance and has provided a list of her medications. Her daughter tells you she has been complaining of abdominal pain for the last two days and thinks she may have been vomiting last night. You are also told she has not opened her bowels. She is drowsy and confused. Initial Observations: RR 30, SpO2 90% RA, HR 130 (irregular), BP 90/65, Temp 34.0 Appearance: Pale, responsive to voice. Distended abdomen. Past Medical / Surgical History Type 2 Diabetes, Atrial fibrillation, Hypertension, High cholesterol Medications: Apixaban 5mg BD, Bisoprolol 5mg OD, Ramipril 10mg OD, Gliclazide 30mg OD Allergies NKDA Examination Cardiac: HS I+II normal, nil added. Heart rate 130, irregular. Hypotensive. Capillary refill 4 seconds Respiratory: RR 30, O2 sats 90% RA. Clear on auscultation Gastrointestinal: Abdomen distended, tense, with generalised evidence of peritonism. Empty rectum on DRE. Tender irreducible lump below and lateral to pubic tubercle (if patient is examined for hernias) Neurology: No focal neurology. Moving all 4 limbs. PERLA. Responsive to voice (GCS 13 - E3, V4, M6) Investigations ECG: Fast atrial fibrillation X-Ray: Portable CXR shows no free air. Plain film abdomen shows dilated loops of small bowel CT Abdomen: “The CT scanner is out of service for unscheduled maintenance.” Progression With Appropriate Resuscitation Time 00:00 00:02 00:04 00:06 00:08 10:00 Condition Verbal Alert l Verbal Verbal Verbal Verbal Pulse 130 115 110 110 100 100 BP 105/65 105/75 110/72 112/68 105/65 110/75 Sp02 90% on RA 90% on O2 92% on O2 94% on O2 96% on O2 94% on O2 RR 30 25 22 22 20 18 Without Appropriate Resuscitation Time 00:00 00:02 00:04 00:06 00:08 10:00 Condition Alert Verbal Pain Pain Pain Pain Pulse 130 140 140 145 145 145 BP 105/65 100/60 90/45 88/40 88/42 80/40 Sp02 89% on RA 88% RA 87% on RA 88% on RA 86% on RA 84% on O2 RR 30 32 34 36 38 40 Patient State/Vitals Patient Status Expected learner Modifiers and Triggers Actions Initial Settings 1. Attach monitoring If all actions are complete, A:Patent, groaning Drowsy, Responding to 2. Perform ABCDE move to state 3. B:90% RA RR24 voice. Wincing in pain if assessment and check C:105/65 Sats:90% abdomen is palpated glucose If hypoglycemia is not D: Responds to voice. 3 Apply oxygen recognised move to state Pupils reactive. Moving all 4. Insert IV cannula 2. limbs. 5. Request blood tests – E: Distended abdomen. FBC, U+E, Renal, CRP, Blood Glucose 1.5 LFTs, Amylase, Temp 34.0 6. Perform venous blood gas 7. Give IV glucose 10% 8. Perform ECG State 2 - Deterioration 1.Turn patient on side If Blood sugar not A: Patent Patient begins to vomit 2. Suction vomit checked- Give results of B: RR32. Sats 90% 3. Give antiemetic blood gas at 3 minutes C:HR140, BP 100/60. Cap 4. Treat Hypoglycaemia and highlight glucose refill 4 seconds 5. Continue IV D: Drowsy- responsive to resuscitation After IV glucose and IV pain. fluid treatment E2,M5,V3 commenced move to state E: Cool peripheries. 3 Distended abdomen. Blood Glucose 1.1 State 3 - Stabilisation Patient now able to give 1.Abdominal -Adequate resuscitation A: Patent history of abdominal examination- Absent -formulation B: RR 24 Sats 94 pain for 2 days. Not able bowel sounds -request for further C: HR 110 BP to eat or drink. Has 2. Perform PR exam – imaging; AXR/CT to move 121/68. Cap reill3 been taking empty rectum final state D: Awake- eyes opening medications.. Bowels 3. Request imaging spontaneously. Orientated haven’t opened in two Portable CXR E: Distended abdomen days. Severe nausea and 4. Continue IV fluid Glucose 10. Temp 34.5 vomiting. resuscitation Heart rate and BP 5. Give pain relief respond to IV fluid 6. Give antiemetic bolus. 7. IV antibiotics 8. Insert Urinary Catheter Patient vomits x 1 State 4 - Disposition Following anti-emetic 1.Interpret imaging Clear ISBAR handover to A: Patent and analgesia vital signs 2.Insert NG tube surgical team highlighting B: RR20 Sats 94% improve and patient 3. Refer to surgical team surgical emergency of C HR 100 BP 110/75. Cap appears more 4. Stop anti- small bowel obstruction refill 2 seconds comfortable hypertensive/nephrotoxic secondary to incarcerated D: Alert Imaging results given to drugs on admission hernia. E: Distended abdomen team CXR Case courtesy of Dr Henry Knipe, <a href="https://radiopaedia.org/">Radiopaedia.org</a>. From the case <a href="https://radiopaedia.org/cases/39616">rID: 39616</a> AXR Source:BMJ CaseReports https://casereports.bmj.com/content/2018/bcr-2018-225174 ECG ABG CT “The CT scanner is out of service for unscheduled maintenance.” Acute Abdomen - Team Assessment Care Provided 50 Points Marks Marks Criteria Available Awarded Patient Assessment Consider - Systemic approach to assessment/exam - Recognition that the patient is acutely unwell. - Relevant medical history obtained 15 - Early recognition of abdominal source. - Formation of differentials from medical history + risk factors. Initial Resuscitation Consider - Address hypotension - fluid bolus - Address hypoxia - supplemental oxygen 10 - Treatment of hypoglycaemia - Delivery of IV Antibiotic Cover - Catheterisation Investigations Consider - Request for CT Abdomen/Pelvis, CXR/PFA - Bloods (FBC, U&E, ABG/Serum Lactate, amylase, CRP) - Request for group and hold 10 - Blood Cultures - Urinalysis and urine culture - Consideration of FAST/Pelvic Ultrasound. Diagnosis - Recognise initial hypoglycaemia - Recognition of acute surgical emergency 10 - Recognise dilated loops Disposition - Need for urgent surgical intervention 5 - Succinct ISBAR handover Acute Abdomen - Team Assessment Non-Technical Skills 50 Points Marks Marks Criteria Available Awarded Team Work Consider - Demonstrating leadership. - Exchanging information. 20 - Regaining situational awareness if team loses focus - Delegating Roles/tasks - Supporting Team Task Management Consider - Planning & preparing - Prioritising 10 - Providing & maintaining standards - Identifying & utilising resources Situation Awareness Consider - Gathering information 10 - Recognising & understanding task fixation - Anticipating Decision Making Consider - Identifying options - Balancing risks & selecting options 10 - Re-evaluating