Location: Emergency Department Patient: Actor (Pain++ but able to give history) Condition: Ruptured Ectopic Pregnancy 29 year old female ‘Sarah’ has presen ted to the emergency department with a 1 week history of intermittent abdominal pain, nausea and vomiting. The abdominal pain has worsened significantly overnight. She states she suffers from “an irritable bowel” but this “is worse and Buscopan has not hel ped”. She has been brought to the major’s area after collapsing in the waiting room. Initial Observations: RR 22, Sp02 98% RA, HR 122 (Sin us), BP 134/84 Temp 38.7 GCS: 15 Appearance: In distress, guarding abdomen. Past Medical: • Cholecystectomy aged 20 • Ir ritable Bowel Syndrome, “Miscarriage 4 years ago, at about 9 weeks” • LMP: 4 weeks ago. • Mire na Coil removed 2 years ago • Sexually active. o 1 partner. o No longer uses barrier contraception as her partner had a vasectomy 2 weeks ago. Medications: Buscopan 10mg prn, Allergies: NKDA Acute Abdomen S cena rio Dr Tiarnán Byrne Dr James Condren This work is licensed under a Creative Commons Attribution - NonCommercial - ShareAlike 4.0 International L icense Participants: Medic al Students (Clinical Years). Team of 5. Competition: SimWars 2019, Cork Round: Heats Learning Objectives • Identification of the deteriorating patient. • Recognition of an Acute Abdomen • Differentials for Acute Abdomen. • General principles for management of acute abdomen. • Management of ruptured ectopic pregnancy • Teamwork and communication. Progression of Scenario Acute Abdomen Recognition of Acute Abdomen Intial Resuscitation & Work - Up Diagnosis based on HCG Early contact with obstetric team. ITU informed. Arrange for transfer to theatre. Failure to Resuscitate No clinical improvement throughout scenario Increasingly confused and distressed. Scenario Ends Exam Results Cardiac: HS I+II normal, nil added. Tachycardic. Respiratory: Airway clear. Air entry normal bilaterally. Tachypnoea. Gastrointestinal: Abd omen v ery t ender throughout with guarding and rebound tender ness in the Left Iliac Fossa. Bowel sounds present DRE normal , no blood. Neuro: No focal neurology. Urine HCG: Positive ECG: Sinus Tachycardia CXR – Normal Abdomen XR – Normal CT – Abdomen Pelvis – Not available With Appropriate Resuscitation Time 00:00 00:02 00:04 00:06 00:08 10:00 Condition Alert Verbal Verbal Verbal Verbal Verbal Pulse 122 ( Sinus) 1 18 110 90 92 88 BP 100 / 7 2 102/74 110/74 115/82 118/80 112/84 Sp02 98 % RA 98 % 100 % 98 % 99 % 99 % RR 22 24 24 24 24 24 Without Appropriate Resuscitation Time 00:00 00:02 00:04 00:06 00:08 10:00 Condition Alert Verbal Pain Pain Pain Pain Pulse 122 (Sinus) 120 124 130 128 132 BP 100 /72 92/68 90 / 59 84/60 86/62 84/60 Sp02 98% RA 9 6% 9 6 % 96 % 95% 95% RR 22 24 30 30 30 30 Ultrasound – Unavailable Labs – If sent, unavailable before Sim End. (Other than blood gas). ECG VBG: CXR Image courtesy of Dr Usman Bashir, <a href ="https://radiopaedia.org/">Radiopaedia.org</a>. From the case <a href="https://radiopaedia.org/cases/18394"> rID: 18394</a> AXR Creative Commons Licence - Nevit Dilmen - https://commons.wikimedia.org/wiki/Category:X - rays_of_the_abdomen#/media/File:Med ical_X - Ray_imaging_ALP02_nevit.jpg Acute Abdomen - Team Assessment Care Provided 50 Points Cr iteria Marks Available Marks Awarded Patient Assessment Consider - Systemic approach to assessment/exam - Recognition that patient is acutely unwell. - Relevant medical history obtained - Early recognition of abdominal source. - Formation of differentia ls from medical history + risk factors - Recognise need check pregnancy status 15 Initial Resuscitation Consider - Fluid Bolus vs - Early Consideration of Blood Transfusion Protocol - Supplemental Oxygen - Delivery of IV Antibiot ic Cover - Cathet erisation - Promp t obstetric consult 10 Investigations Consider - Request for CT Abdomen/Pelvis, CXR/AbdoXR - Bloods (FBC, U&E, VBG/Serum Lactate, β - hcg , CRP) - Request for x - Match and Rh - factor - Blood Cultures - Urinalysis and urin e culture - Consideration of FAST/Pelvic Ultrasound. 5 Diagnosis - Recognition of acute surgical / obstetric emergency - Clear r ecognition of probable ruptured ectopic 5 Disposition - Need for urgent surgical intervention and ICU level care 5 Acute Abdomen - Team Assessment Non - Technical Skills 50 Points Criteria Marks Available Marks Awarded Team Work Consider - Coordinating activities - Exchang ing information - Use of authority & assertiveness - Assessing capabilities - Supporting others 20 Task Management Consider - Planning & preparing - Prioritising - Providing & maintaining standards - Identifying & utilising resources 10 Situation Aw areness Consider - Gathering information - Recognising & understanding - Anticipating 10 Decision Making Consider - Identifying options - Balancing risks & selecting options - Re - evaluating 10