Simulation case | A 68 year old with abdominal pain and fever

James Hobson   Published 10th February 2023

Handover from ambulance

Kimura Sung - 68yr old female brought in by ambulance due to severe abdominal pain, vomiting and PR bleeding getting worse since this morning. She is lethargic. Kimura has also had a fever for a few days and has not been eating/drinking well. PMH – well-controlled diabetes (T2). Current smoker.

On further questioning:

  • Her pain is generalised all over her abdomen, no specific area. Constant 10/10. Kimura first noticed a bit of discomfort a couple of days ago in the lower left side, associated with a fever. The fever is now worse, and she's getting chills
  • She have vomited twice. There was no blood in the vomit. She hasn’t eaten/drunken anything today due to nausea
  • Kimura has had some bleeding from the back passage the last few days – mostly patches on the toilet paper and mixed into stools – it is bright red in colour
  • She has T2DM and take metformin 500mg TDS – glucose/HbA1c is always well controlled. NKDA
  • Her father recently passed away following a stroke
  • She lives with her daughter, she smokes ~15/day and has alcohol occasionally

HR 123, BP 86/51, RR 22, SpO2 87% OA, Temp 38.9C, Lethargic

Airway

Examination

Kimura is talking. Airway patent and self-maintaining.

Investigations

None required.

Interventions

None required.

Breathing

Examination

RR: 22, SpO2: 87%

Chest expansion – normal and equal.

Percussion - normal resonance.

Auscultation - good air entry bilaterally with no added sounds.

Investigations

VBG – respiratory cause is unlikely here so VBG is sufficient.

CXR – although primary abdominal problem, likely to get portable CXR

Interventions

15 L/min O2 via NRB

Venous Blood Gas for Kimura Sung


Metabolic acidosis with high lactate

Chest X-Ray for Kimura Sung


Airway and lung fields are normal.

Right sided pneumoperitoneum - suggestive of bowel perforation

Circulation

Examination

HR 132, BP 84/49, Temp 38.9C

Clammy skin

Pulse is fast, regular and bounding

CRT < 2 seconds

HS I + II + 0

No peripheral oedema

If asked about urine output – you’ve not been at all today and very little yesterday

Dry mucous membranes

Investigations

Insert two IV cannulae – 14G (Orange) or 16G (Grey)

Blood cultures - two samples from two distinct sites

Bloods – ask to justify:

  • FBC – blood loss, infection, platelet count
  • U&Es – renal function and electrolyte depletion
  • LFTs – liver function for medications and HPB causes of acute abdomen
  • CRP – ?infection
  • Clotting - ?coagulopathy
  • Amylase/lipase - ?pancreatic cause

VBG for glucose and lactate – if not already done in B

12-lead ECG

Urinalysis/Urine MC&S – if suspecting urinary cause

Interventions

Patient is hypovolaemic

  • Start IV fluid resuscitation
  • 500ml bolus over 15 mins of normal saline or Hartmann’s

After blood cultures are taken, immediately start IV antibiotics

  • In UHL, IV meropenem 1g STAT, then TDS if to continue mero

Catheterise for urine output.

Consider antipyretics (paracetamol).

Consider blood products for blood loss/coagulopathy.

Get senior support and consider the need for alerting ITU/critical care.

ECG for Kimura Sung


  • Rate ~150bpm
  • P waves precede QRS = sinus rhythm
  • Rhythm is regular
  • All waves/intervals are normal

This ECG shows sinus tachycardia.

Blood results for Kimura Sung

Infection and inflammatory markers are raised, indicating infection.

Haemoglobin and RBCs are low suggesting blood loss.

There are clotting and electrolyte derangements, commonly seen in sepsis.

Disability

Examination

Weak, lethargic and drowsy

GCS 13/15 – E3 V4 M6

PEARL

Investigations

Bedside CBG – 6.5 mmol/L

Interventions

None required.

Exposure

Examination

Clammy and pale skin

Abdomen is extremely tender, Kimura screams if students palpate. Rigidity and guarding. Reduced bowel sounds.

Calves SNT

No peripheral oedema

Kimura doesn’t think she could be pregnant

Investigations

Abdominal imaging (CTAP will be required for definitive diagnosis) – USS is most practical in ED – shows free fluid in the abdomen

Urine pregnancy test - negative

Interventions

Provide analgesia in accordance with pain ladder

Unlikely to want to eat… but patient should be kept NBM

Post-ABCDE Actions

Can you confirm a diagnosis?

What will you do now?

  1. Re-assess the patient regularly (Now SpO2 95%, BP 93/64, HR 112, GCS 13/15)
  2. NEWS, GCS, lactate and urine output checked at least hourly
  3. Discuss with ITU/critical care for admission
  4. Discuss with general surgery for urgent review

Handover using SBAR technique

  1. “Hello my name is X, I am calling from ED resus at Leicester Royal Infirmary. I have a patient, Kimura Sung, who is being treated for abdominal sepsis that needs to be seen by general surgery.
  2. The patient is a 68-year-old female admitted with severe generalised abdominal pain, PR bleeding and a high fever. She has a background of well-controlled type 2 diabetes.
  3. On admission, she was lethargic, hypotensive at 86/51 and had a fever of 38.9 – with peritonitic signs. She has not passed urine in the last 24 hours. CXR showed pneumoperitoneum. I’ve started the red flag sepsis care bundle with IV meropenem. Lactate is 4.1, infection markers are significantly raised. She is responding to fluid resuscitation, her last BP was 93/64. ITU have accepted her for admission. She is booked for a CTAP this evening.
  4. Can I please arrange for you to see her for an urgent surgical review.”

Useful resources

UHL Sepsis Screening Tool (PDF, 454KB)

Leicester Wilderness and Emergency Medicine Society

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e: hello@lwems.co.uk

 

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