A 23 year old man presents to the Emergency Department complaining of central chest pain over the past eight hours which is sharp in nature, worse on deep inspiration and laying down. He has also noticed palpitations with his heart beating rapidly. His PR is 144/min and BP is 120/80 mmHg. There is a pericardial rub heard on auscultation. How would you assess and manage him?
PDx: pericarditis
DDx: ACS, pneumonia, pneumothorax, PE, aortic dissection
Concern - OBSTRUCTIVE SHOCK
Primary survey A B: O2, morphine, nitrates as necessary C: ECG and other monitoring; bloods -> FBC, CRP, trops D: BSL, analgesia E: temp
History
- symptoms - SOCRATES, relevant associated symptoms
- past history - esp (pericarditis) MI, CT disease, uraemia, infection; (MI) CVD risk factors; (PE) DVT and DVT risk factors; (aortic dissection) CT disease
- meds, allergies, FHx, SHx
Exam
- gen obs
- vitals
- CV and resp: ?pericardial rub; ?Beck’s triad; ?signs of DDx
Investigations
- ECG, FBC, CRP, CXR, echo
- UEC, LFTs
- trops
Management
- Pericardiocentesis if necessary
- Treat underlying cause
- Supportive care: NSAIDs, fluids –> consider colchicine if no response
A 20 year old woman presents to the Emergency Department six hours after extraction of a molar tooth. She has persistent bleeding from the socket. How would you manage her?
PDx: vWF
DDx: platelet deficiency (ITP, bone marrow suppression, malignancy), coagulopathy
Primary survey and resus A B C: monitoring; take bloods (FBC, coags, EUC, LFTs), stop bleeding with pressure +/- local and ice, consider BP support D E
History
- Acute bleed: how much, any symptoms of anaemia, unwellness
- Past bleeding history
- Assoc sx/RF of DDx: FHx, consanguineous parents, cancer sx/FHx, meds, chemoradiotherapy
Exam
- haem exam esp bleeding
- anaemia
Investigations
- FBC, coags
- vWF antigen, vWF function assay (ristocetin cofactor assay), factor VIII
Management
- start with pressure, ice, local
- consider vWF concentrate, desmopressin
- if severe, platelet transfusion, cryoprecipitate
A 78 year old man is brought to the Emergency Department from a nursing home. He had a past stroke which left him with left-sided weakness and dysphasia. He is now confused, febrile (38.6°C), and has been groaning when his abdomen is palpated. He has mild abdominal distension and obvious but variable abdominal tenderness. How would you assess and manage him?
PDx: sepsis secondary to intra-abdomial abscess/perforation
DDx: ischaemic colitis, bowel obstruction, pancreatitis/diverticulitis/cholecystitis/appendicitis
Primary survey and resus A B C: ABG + UO; consider fluid resus; abx (amp + gent + met) D: E: ?infection, sources of infection
Assessment
- gastro symptoms and past history (incl ischaemia RF)
- systems review
- GI exam incl PR; CV/resp for ?infection
- ECG, urinalysis, ABG by the bedside;
abdo (UEC, CMP, LFTs, lipase), infective (FBC, CRP, blood cultures) and preop (coags, G&H) bloods;
any possible microbio (MSU, sputum)
CXR, CT abdo, consider CT abdo angiography
Management
- supportive: monitoring, analgesia, fluids, NBM, DVT prophylaxis, abx
- treat underlying cause: eg exploratory lap and bowel resection, drain abscess
A 27 year old woman presents to ED after taking 4 packets of Panadol. How would you assess and manage her?
PDx: paracetamol overdose
DDx: co-ingestion, factitious disorder
Primary survey in case of co-ingestion
Assessment
- Assess exactly what and how much was taken and when, any sequelae so far, circumstances and reasons for it being taken
- Assess for sx of acute liver failure = abdo pain, n+v, encephalopathy
- Assess underlying comorbidities that would reduce glutathione residues (malnutrition, cachexia, known liver disease), drugs affecting metabolism
- Monitoring as per history (resus unnecessary for paracetamol)
- LFTs, paracetamol level, BSL, coags; consider serum salicylate, other as per hx
Management
- Decide to give NAC or not based on nomogram - stop at 24 hours if LFTs and coags fine
- Regular monitoring
- Deal with underlying reasons for OD
A 70 year old man presents to the Emergency Department with symptoms compatible with acute cardiac ischaemia. His symptoms improve and he decides to leave without any investigations or treatment. How would you manage this situation?
Issues
- ACS
- DAMA
If unstable: duty of care Primary survey and resus A B C: ECG and other monitoring; cannulae and bloods; MONA HEP C; blood pressure support etc D E
If stable: non-judgemental
- understand their perspective
- communicate risks, benefits, alternatives; tailoring to patient’s values
- establish capacity -> understands info, retains info, able to weigh decision, able to communicate decision back
- if must DAMA:
1) provide as much safe management as possible eg aspirin
2) organise F/U with GP
3) encourage to re-present
4) F/U call
A 25 year old man presents after a motor bike accident. He has fallen onto his left chest and is complaining of severe pain. How would you assess and manage him?
THORACIC TRAUMA
Potential issues
- A: airway obstruction
- B: tension/open pneumothorax, massive haemothorax, flail chest, pulmonary contusions
- C: cardiac tamponade, aortic dissection/rupture, abdo path eg splenic rupture
- D: rib fractures
1) Primary survey
A
B: asymmetrical chest movement, tracheal deviation, air entry, added sounds
C: balance BP - reduce exsanguination but maintain perfusion; FAST scan
D: treat seizures, treat hypo
E: avoid hypothermia (deadly triad), log roll
2) MISTAMPLE (simultaneously)
3) Secondary survey
- neck: tracheal deviation, wounds, external markings, laryngeal disruption, venous distension, emphysema
- trauma series (xrays)
Management of specific injuries
- pneumo: emergency decompression; chest drain
- haemothorax: chest drain
- flail chest: supportive = HF O2, analgesia, resp monitoring, consider I+V
An 85 year old woman is brought to the Emergency Department by her family. She was quite well until three days ago when she suddenly become confused and unaware of her surroundings. How would you assess and manage her?
Confusion DDx - brain hypoxia - metabolic/toxic (drugs, liver, kidney, endocrine) - neuro (stroke, SOL) - infections (encephalitis, sepsis, pneumonia, UTI etc) - constipation, urinary retention - psych
Assessment
- primary survey
- characterise confusion (?delirium)
- associated symptoms: neuro (incl falls and head trauma), infections, constipation/urinary retention
- history of metabolic/toxic contributors
- vitals and systemic exam
Investigations
- bedside: ECG, VBG (unless worried about sats), BSL
- bloods: FBC, CRP, UEC, CMP, LFT, TFTs, BSL; consider trops etc as per hx
- imaging: CXR and then as per hx
Management
- treat underlying cause
- supportive care: fluids, analgesia, limited stimuli, familiar faces and voices, orientation, consider sedation
A 20 year old man fell whilst skiing, his bindings did not release and he suffered a twisting injury to his right knee. He presents with severe pain and tenderness in the knee and marked swelling of the joint. How would you assess and manage him?
PDx: meniscal tear
DDx: damage to other articular structures (ACL, PCL, MCL, LCL), fracture
Assessment
- primary survey if necessary
- MIST
- risk factors: knee joint arthritis, knee instability, past history of knee injuries
- rest of history: predisposition, significance of injury, factors affecting management
- examine knee + exclude other injuries to body
- MRI and knee xrays
Management
- ortho referral
- conservative: RICE, analgesia, activity modification, physio
- surgery (loss of function, no improvement with conservative management): arthroscopy -> meniscectomy, meniscus repair, meniscus replacement
A 40 year old construction worker has stood on a plank of wood and has a penetrating injury to the right heel from a nail. How would you assess and manage him?
Concerns
- damage to structures
- infection: tetanus, osteomyelitis
Assessment
- HoPC: MIST
- PMHx: tetanus, factors affecting healing
- examine wound and distal neurovasc/tendon actions
- xrays (CT/MRI if plastic/aluminium/wood)
- supportive care: analgesia, tetanus, abx (augmentin 5 days)
- debridement and washout, surg referral
A 22 year old man presents with an open fracture of his right lower leg after a skateboard accident. How would you manage him?
Concerns
- fracture
- damage to surrounding structures
- haemorrhage
- other injuries incl head injury
Assessment
- Primary survey: particularly worried about circulation (give fluclox and met if deep and contaminated)
- MIST AMPLE: don’t forget tetanus!!
- Secondary survey, including examining wound (washout and debridement), testing distal neurovascular status, xrays
- Supportive care: analgesia, fluids
- Ortho referral, preop bloods (incl G&H), NBM -> ORIF
- Monitoring, incl for compartment syndrome, DVT
A 70 year old woman who has bony metastases from breast cancer presents to the Emergency Department with a one week history of constipation, lethargy, thirst and increasing confusion. She is dehydrated. Her serum creatinine is 220umol/L (50-110), urea 25mmol/L (3.8-8.0), calcium 3.30mmol/L (2.1-2.6) and albumin 33g/L (32-45). How would you manage her?
Hypercalcaemia and AKI 2o to breast ca mets
DDx: hyperPTH (primary or secondary to CKD), drugs (eg thiazides), Addison’s
Primary survey and resus incl ECG and fluid resus
Assess for causes + symptoms (incl PTH, PTHrP)
Confirm hyperCa (Ca, albumin) and check for other issues eg electrolyte disturbance, vit D def
Treat AKI: fluids (if not overloaded), stop nephrotoxic drugs
Treat hyperCa: forced diuresis if heart and kidney fine BUT if not, haemodialysis; also consider calcitonin and bisphosphonates
Treat bone mets: onc referral, consider rtx
Supportive care: reorientation
A 28 year old man has been involved in a fight and presents with a swollen, bruised left eye. How would you assess and manage him?
PDx: periorbital haematoma
DDx: other head injuries, other injuries
Primary survey, MIST AMPLE, secondary survey if necessary
History
- mechanism and setting (eg intox), known injuries, any sx of complications (pain elsewhere, raised ICP, visual changes), treatment so far
- PMHx, meds etc
Exam
- palpate orbit, examine eye (incl slit lamp), test vision
- test facial sensation and movement
- palpate entire head, check for base of skull # signs
- secondary survey
Investigations: CT brain
- consider U/S of eyes, preop bloods
Management
- supportive: eye shield, elevate bed, analgesia, education
- vision affected => ophthal; fracture => surg
A 70 year old man with a history of prostatitism presents in acute urinary retention. How would you manage him?
PDx: obstruction from BPH
DDx: other obstruction (massive prostate ca, stones, prostatitis), neuro dysfunction (stroke, SCI, DM/PD, drugs)
Concern
- detrusor dysfunction, bladder rupture
- hydronephrosis
Assessment
- hx of urinary retention, any precipitants
- any hx of causes (incl prostatism sx) and any assoc sx of them
- rest of hx
- check vitals, palpate bladder + DRE, neuro exam (saddle anaesthesia, anal reflex)
- bladder U/S and EUCs, investigate for cause
- supportive care: fluids, analgesia
- insert catheter (urethral if possible, suprapubic if not) - have in for about same duration as retention (1-2weeks usually) and then they re-present for TOV (in the morning)
- admit if AKI/septic/SCI/malignancy
- treat underlying cause (BPH -> alpha1 blocker, TURP)
A 23 year old man presents with sudden pain in the right side of the chest, especially on breathing. He is slightly breathless and feels faint. How would you assess and manage him?
PDx: pneumothorax
DDx: PE, pneumonia, pericarditis, ACS, aortic dissection, oesophageal rupture
Concern
- obstructive shock
Primary survey and resus; simultaneous AMPLE
- A
- B: assess for pneumo, pleural effusion, pneumonia -> emergency decompression; O2
- C: assess incl ECG, consider trops; support BP etc
- D: BSL etc
- E: ?infection
AMPLE: trauma, phx of pneumo
Ongoing management: xray, chest drain (below chest level, no kinks, no air leak) supportive care, monitoring (at least 6 hr until pnemothorax completely gone as per xray), education and discharge advice
A 38 year old woman presents to the Emergency Department complaining of sudden onset of shortness of breath and pleuritic chest pain. How would you assess and manage her?
PDx: PE
DDx: pneumonia, pneumothorax, pleuritis, pericarditis, ACS, aortic dissection, oesophageal rupture
Concern: obstructive shock
Primary survey and resus if necessary
Assessment
- rf/sx of ddx
- contraindications to anticoag: stroke in past 6 months, recent head trauma/surgery, known bleeding risk
- resp/CV exam incl ECG: S4, loud P2, RHF; lower limb for ?DVT
- Well’s criteria -> CTPA; CXR; ABG, FBC, CRP, UEC, LFTs, coags; consider infection bloods and trops
Management
- supportive
- anticoagulation: therapeutic clexane plus warfarin for 3 months/6 months/lifelong
- consider thrombolysis/thrombectomy if haemodynamically unstable
A 35 year old man with asthma presents to the Emergency Department too dyspnoeic to be able to speak. How would you assess and manage him?
PDx: asthma
DDx: anaphylaxis, pneumonia, pneumothorax, PE, pericarditis, ACS, AS, CCF exac, COPD exac
Call for help
Primary survey and resus
A: assess, support, I+V if necessary
B: assess esp ?wheeze, ?silent chest, ?signs of other causes -> O2, nebulised SABA (20minly), oral CS -> consider aminophylline, LAMA, MgSO4, nebulised adrenaline if really unwell
C: support; bloods - consider trops, infection bloods
D: assess
E: assess
Simultaneous AMPLE
- P: asthma progression and management
- E: potential triggers, associated symptoms
After stabilisation
- more detailed hx and exam
- wean ventolin (>3hrly)
- supportive incl K
- consider triggers eg infection, smoking, poor inhaler technique
- asthma action plan and GP F/U
A 68 year old man is brought in by ambulance to the Emergency Department after a fight on the streets. He has been stabbed multiple times in the abdomen with a 20cm knife. Outline your management of this patient.
Abdominal trauma
Concerns
- intra-abdominal haemorrhage
- infection and sepsis
Call for help
1) Primary survey, esp C - do FAST scan, get O-, consider MTP, preop bloods and NBM - and E - identify and locate all injuries incl PR for blood (local wound care for injuries that don’t penetrate abdo fascia)
2) Simultaneous AMPLE: where was the fight, knife-
clean/dirty, length, width, patient position during stabbing, path of knife, blood loss at scene, tetanus, any underlying comorbidities, any pain (incl shoulder tip)
—->Consider emergency laparotomy if haemodynamic instability, evisceration, peritonitis, in situ implement, frank blood on NG/PR
3) Secondary survey -> trauma series (CXR, C-spine, pelvis), CT abdo
4) Supportive care: analgesia, fluids, consider abx
5) Lap - exploratory/diagnostic + repair of structures
A 70 year old man presents to the Emergency Department with an acutely painful and pulseless right leg. How would you assess and manage him?
PDx: acute limb ischaemia
Ask for assistance
Primary survey
Assessment
- progression of sx: vascular, sensory, motor
- source of embolus/thrombus and risk factors
- test vascular supply, muscle tenderness, sensation and motor function (blue toe syndrome indicates small vessel rather than large vessel disease)
- doppler; angiogram only if light touch intact
- preop bloods esp coags
Management
- supportive: analgesia, O2 if necessary
- anticoagulation immediately PLUS treat cause eg embolectomy
- amputation if not viable
- long term risk factor modification
