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 li st 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 Observat ions: 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 au scultation 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. Responsiv e 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.” P rogression 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 A:Patent, groaning B:90% RA RR24 C:105/65 Sats:90% D: Responds to voice. Pupils reactive. Moving all limbs. E: Distended abdomen. Blood Glucose 1.5 Temp 34.0 Drowsy, Responding to voice. Wincing in pain if abdomen is palpated 1. Attach monitoring 2. Perform ABCDE assessment and check glucose 3 Apply oxygen 4. Insert IV cannula 5. Request blood tests – FBC, U+E, Renal, CRP, LFTs, Amylase, 6. Perform venous blo od gas 7. Give IV glucose 10% 8. Perform ECG If all actions are complete, move to state 3. If hypoglycemia is not recognised move to state 2. State 2 - Deterioration A: Patent B: RR32. Sats 90% C:HR140, BP 100/60. Cap refill 4 seconds D: Drowsy - responsive to pain. E2,M5,V3 E: Cool peripheries. Distended abdomen. Blood Glucose 1.1 Patient begins to vomit 1.Turn patient on side 2. Suction vomit 3. Give antiemetic 4. Treat Hypoglycaemia 5. Continue IV resuscitation If Blood sugar not checked - Give results of blood gas at 3 minutes and highlight glucose After IV glucose and IV fluid treatment commenced move to state 3 State 3 - Stabilisation A: Patent B: RR 24 Sats 94 C: HR 110 BP 121/68. Cap reill3 D: Awake - eyes opening spontaneously. Orientated E: Distended abdomen Glucose 10. Temp 34.5 Patient now able to give history of abdominal pain for 2 days. Not able to eat or drink. Has been taking medications.. Bowels haven’t opened in two days. Severe nausea and vomiting. Heart rate and BP respond to IV fluid bolus. Patient vomits x 1 1.Abdo minal examination - Absent bowel sounds 2. Perform PR exam – empty rectum 3. Request imaging Portable CXR 4. Continue IV fluid resuscitation 5. Give pain relief 6. Give antiemetic 7. IV antibiotics 8. Insert Urinary Cathete r - Adequate resuscitation - formulation - request for further imaging; AXR/CT to move final state State 4 - Disposition A: Patent B: RR20 Sats 94% C HR 100 BP 110/75. Cap refill 2 seconds D: Alert E: Distended abdomen Following anti - emetic and analgesia vital signs improve and patient appears more comfortable I maging results given to team 1.Interpret imaging 2.Insert NG tube 3. Refer to surgical team 4. Stop anti - hypertensive/nephrotoxic drugs on admission Clear I SBAR handover to surgical team highlighting surgical emergency of small bowel obstruction secondary to incarcerated hernia. 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 Criteria Marks Available Marks Awarded Patient Assessment Consider - Systemic approach to assessment/exam - Recognition that the patient is acutely unwell. - Relevant medical history obtained - Early recognition of abdominal source. - Formation of differentials from medical history + risk factors. 15 Initial Resuscitation Consider - Address hypotension - f luid b olus - Address hypoxia - supplemental oxygen - Treatment of hypoglycaemia - Delivery of IV Antibiotic Cover - Catheterisation 10 Investigations Consider - Request for CT Abdomen/Pelvis, CXR/PFA - Bloods (FBC, U&E, ABG/Serum Lactate, amylase , CRP) - Request for group and hold - Blood Cultures - Urinalysis and urine culture - Consideration of FAST/Pelvic Ultrasound. 10 Diagnosis - Recognise initial hypogl ycaemia - Recognition of acute surgical emergency - Recognise dilated loops 10 Disposition - Need for urgent surgical intervention - Succinct ISBAR handover 5 Acute Abdomen - Team Assessment Non - Technical Skills 50 Points Criteria Marks Available Marks Awarded Team Work Consider - Demonstrating leadership. - Exchanging information. - Regaining situational awareness if team loses focus - Delegating Roles/tasks - Supporting Team 20 Task Management Consider - Planning & preparing - Prioritising - Providing & maintaining standards - Identifying & utilising resources 10 Situation Awareness Consider - Gathering information - Recognising & understanding task fixation - Anticipating 10 Decision Making Consider - Identifying options - Balancing risks & selecting options - Re - evaluating 10