Sim Wars - Acute Abdomen.pdf - T

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Acute Abdomen Competition: SimWars 2019, Cork Round: Heats Participants: Medical Students (Clinical Years). Team of 5. 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. Scenario Location: Emergency Department Patient: Actor (Pain++ but able to give history) Condition: Ruptured Ectopic Pregnancy 29 year old female ‘Sarah’ has presented 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 helped”. She has been brought to the major’s area after collapsing in the waiting room. Initial Observations: RR 22, Sp02 98% RA, HR 122 (Sinus), BP 134/84 Temp 38.7 GCS: 15 Appearance: In distress, guarding abdomen. Past Medical: • Cholecystectomy aged 20 • Irritable Bowel Syndrome, “Miscarriage 4 years ago, at about 9 weeks” • LMP: 4 weeks ago. • Mirena 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 Dr Tiarnán Byrne This work is licensed under a Creative Commons Attribution- Dr James Condren NonCommercial-ShareAlike 4.0 International License Progression of Scenario Acute Abdomen Recognition of Acute Failure to Resuscitate Abdomen Intial Resuscitation & Work-Up No clinical improvement throughout scenario Diagnosis based on HCG Increasingly confused and distressed. Early contact with obstetric team. ITU informed. Arrange for transfer to theatre. Scenario Ends Results Exam Cardiac: HS I+II normal, nil added. Tachycardic. Respiratory: Airway clear. Air entry normal bilaterally. Tachypnoea. Gastrointestinal: Abdomen very tender throughout with guarding and rebound tenderness 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 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) 118 110 90 92 88 BP 100/72 102/74 110/74 115/82 118/80 112/84 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 96% 96% 96% 95% 95% RR 22 24 30 30 30 30 CT – Abdomen Pelvis – Not available 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:Medical_X-Ray_imaging_ALP02_nevit.jpg Acute Abdomen - Team Assessment Care Provided 50 Points Marks Marks Criteria Available Awarded Patient Assessment Consider - Systemic approach to assessment/exam - Recognition that patient is acutely unwell. - Relevant medical history obtained 15 - Early recognition of abdominal source. - Formation of differentials from medical history + risk factors. - Recognise need check pregnancy status Initial Resuscitation Consider - Fluid Bolus vs - Early Consideration of Blood Transfusion Protocol 10 - Supplemental Oxygen - Delivery of IV Antibiotic Cover - Catheterisation - Prompt obstetric consult 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 5 - Blood Cultures - Urinalysis and urine culture - Consideration of FAST/Pelvic Ultrasound. Diagnosis - Recognition of acute surgical / obstetric emergency 5 - Clear recognition of probable ruptured ectopic Disposition - Need for urgent surgical intervention and ICU level care 5 Acute Abdomen - Team Assessment Non-Technical Skills 50 Points Marks Marks Criteria Available Awarded Team Work Consider - Coordinating activities. - Exchanging information. 20 - Use of authority & assertiveness - Assessing capabilities - Supporting others Task Management Consider - Planning & preparing - Prioritising 10 - Providing & maintaining standards - Identifying & utilising resources Situation Awareness Consider - Gathering information 10 - Recognising & understanding - Anticipating Decision Making Consider - Identifying options - Balancing risks & selecting options 10 - Re-evaluating