Scenario Run Sheet: Leg pain in a sick patient



SIMulatED RDH Emergency Department - Author: D Barnes, C NorrisScenario Run Sheet: Leg pain in a sick patientLearning ObjectivesTarget Group: Emergency dept registrars and nursing staffGeneralResuscitation of haemodynamically unstable patientExposure as a key part of thorough examination of the critically unwell patientScenario SpecificAdequate analgesia to facilitate full assessmentConsidering the diagnosis of necrotising fasciitisPushing for early surgical intervention as the key treatment modalityScenario OverviewBrief Summary: You are the registrar in fast-track asked to review a young female patient who has just had a collapse on the way to the bathroom. She had just returned from ultrasound and was careflighted in from community as query left leg DVT 10 days post-partum. After haemodynamic collapse in the emergency department she is resuscitated and diagnosed with necrotising fasciitis.Intro TimeScenario TimeDebrief TimeSoundbite 10251010Observers’ Engagement TaskEquipment ChecklistMannikin:3G/ALS/Paed/Baby/Live Actor/Other:Monitoring:3G / iSimulate / Other:Docs and Forms EDNA, Green sheet, Vent sheetEquipmentIV Pumps, Syringe Driver, USS, Oxylog, Neopuff, Other:ConsumablesMedicationsSim PromptsCXR, Other Xray, USS worksheet, 12 Lead, VBGs, Other:Sim EquipmentFluid receiver, Task trainer, Other:ParticipantsStaff 3 Doctors, 3 NursesInstructor RolesAdditional Information/Medical HistoryDemographics 21 year old womanHPC “Sorry to cause a fuss, just the pain in my leg really got to me when I stood up, could I have something for the pain?”Had a presyncopal event at home 2 days ago in the shower and banged her knee (no LOC, no head injury or actual collapse, no other red flags)Early hours of the morning yesterday her knee pain was getting worse and she was seen at her community health clinic (CHC)Delivered at her district hospital 10 days ago, uncomplicated vaginal delivery (no PROM / no fever / no Abx / GBS neg) with a first degree tear, discharged next day with simple analgesiaDenies fevers, no change to lochia or PV discharge, no abdominal pain, no dysuria / haematuriaNo dyspnoea, no palpitations, no chest pain, no cough / haemoptysisSwollen tender calf with a positive Homen’s sign (increased pain on ankle dorsiflexion), external exam of genitalia wound appeared healed, sutures removed, given a stat dose of clexane and transferred to Darwin for further investigationIf asked – observations at the CHC tachycardia 110 and tachypnoea 30 that settled with analgesia with normal saturations and afebrilePMH Previously well, 1 week post partum, NKDA, Nil reg meds – has been taking Panadol and neurofen for perineal discomfortExamFlushed uncomfortable 21 year old female dressed in t-shirt and light trackpants, no IV access drip removed on arrival as tissued and uncomfortableA - patent ownB – chest is clear, obs belowC – obs below, warm peripherally with strong pulsesD – alert and oriented though in painE – soft abdo, left leg swollen, erythematous exquisitely tender skin over calf, no visible knee wounds or abrasions, pain on ranging the knee joint but no clinical effusion, tender beyond erythema distallyOnly if adequately exposed – region of indurated tender skin extending down from proximal medial thigh with blisters at junction with perineum; perineal wound slightly swollen and also tender but no frank pus or dehiscenceInvestigationsWorksheet from the Ultrasound shows all the deep veins to the iliacs to be patentCXR clear, ECG sinus tachycardiaBloods taken at CHC were sent to the lab on arrival they showHb 110, platelets 90White cells of 5 neutrophils of 4 and lymphocytes of 0.4Na 137, K 4.2, Cl 104, Ur 9, Cr 110Bili 26, AST 200, ALP 100, GGT 120, Alb 30CRP 360VBG machine is initially calibrating when back it showspH 7.1CO2 30HCO3 10, BE 10Na 134, K 5.0, Ca 1.1Cr 200lactate 8 Proposed Scenario ProgressionFlushed uncomfortable 21 year old female dressed in t-shirt and light trackpants, 30deg head up in a bed in fast track. Receives opiate for leg pain states she feels unwell, becomes drowsy diaphoretic and vomitsSeptic shower after morphine, hypotensive, drowsy, diaphoretic and vomits, moved to resus, rest of team arrives, unresponsive to 2L fluid, combative and difficult to assess due to painConsideration of differential diagnosis – with increasing information diagnostic progression towards necrotising fasciitis and involvement of surgeonsIf scenario progressing rapidly/senior team then surgeon obstructive and states “its vagina cellulitis and needs to go to O&G”. Requires graded assertiveness and ultimately for ED doctor to call surgical consultant or ED Consultant.Scenario Preparation/Baseline ParametersStage 1Progression TriggerIV Morphine, vomitStage 2Progression TriggerStart vasopressorsStage 3RR2540SpO298%94%HR/Rhythm110130BP110/6090/50T36.837.4OtherBSL 9Debriefing/Guided Reflection OverviewOpening GambitWhat was going on in this scenarioAnticipated themes:Exploration with key playersNo fever – why wasn’t this PEEngaging the general groupCould this lady have had a PE too?How can you tell the difference between obstructive shock from PE and septic shock at the bedside (clinical exam/Echo features of both)Sharing facilitator’s thoughtsAround diagnostic biases and early closure – “this thing fits so I’m not investigating any other avenues”Any other questions or issues to discuss?Bedside scalpel test – dishwater exudateSummaryNeeds surg – near 100% mortality with NF without itThe Soundbiteleft7620Neck fash – Not just a trendy abbreviation for scarves, pashminas and neck warmersNecrotising fasciitis – a rapidly progressive infection of the deep fascial planes that divide tissue compartments (typically muscle with the fat and skin above them) with a mortality as high as 50%2 main subtypes (but some separate into 4)Many bugs – at least one anaerobe with aerobes One bug – Group A strep (that is Strep Pyogenes)Rates have been described as low as 0.4 cases per 100,000 people / yearThere are ~150,000 people in the NTlatest data - 95 cases at RDH either local or transferred from 2005-2013 (which is 7 per 100,000 per year, and does not include people that never made it to transfer or hospital)Risk FactorsHave a high index of suspicion – as in this case Group A strep NF can kill young healthy people with no orbid diseaseDiabetes 40-60% prevalenceOrgan failure - Cirrhosis, Heart failure, Renal failureUnderlying malignancyHypertension, peripheral vascular diseaseImmunosuppression – drugs, old age, pregnancyLifestyle factors – obesity, IVDU, Alcohol abuseNSAID use – debate about whether there is a causative role of the anti-inflammatory effect of NSAIDs in changing disease versus pain relief simply delaying diagnosisRaw seafood (for vibrio / aeromonas infections in a Southeast Asian study)left219075Clinical presentationDiagnosisNotoriously challenging – in one review article covering 9 trials with ~1500 patients 75% of patients were misdiagnosed initiallyLRINEC is a scoring system that uses Lab values to examine risk of NFDepending on where the score was used it was variably good or crapThe surgical department here has done a retrospective case control validation here reporting sensitivity of 76% and specificity of 93%The key take home is that there are cases of NF with LRINEC score of 0Laboratory featuresWhite cells either high, or lowThrombocytopaeniaImpaired renal function (Cr >200)Impaired coagulationImpaired liver enzymesElevated CRPElevated CK (low >6-700)Note that in a case series of 14 patients with GAS NF from Darwin there were some atypical features notedErythema was less common but pain and swelling were still presentNo patients had elevated white cells, but all had lymphopaeniaCRP was >100 in all that had it measured (up to 500)80% had renal impairment, and all had hypoalbuminaemiaTreatmentNever let the sun set on pus; Heal with steel; Never let the skin stand between you and the diagnosisAntibiotics – depends on the bug but for GAS beta-lactam plus clindamycinConsider: hyperbaric oxygen and IVIGGeneral Feedback Prompts/Examples:Opening Gambit:What did you feel were your specific challenges there?Let’s talk.Can you describe to me what was happening to the patient during that scenario?Can you describe to me what was going on?What was important to you in choosing to manage that situation?Can you tell me what your plan was and to what extent that went according to plan?That seemed to me to go smoothly, what was your impression?That looked pretty tough. Shall we see if we can work out together what was going on there so that you can find a way to avoid that situation in the future?Exploration with key playersQuestions to deepen thinkingQuestions to widen conversationIntroduce new concepts; challenge perceptions; listen and buildSo what you’re saying is…Can you expand on…Can you explain what you meant by…When you said…I noticed that you…Engaging the general groupLet’s check with the rest of the group how they reacted to you saying that.Did you [scenario participants/observers] feel the same?What did you [scenario participants/observers] want from [scenario participant] at that point?What ideas or suggestions has anyone else got for how to deal with that situation?Sharing facilitator’s thoughtsUse advocacy with inquiry to share your observations and explore their perceptionWhat does the protocol say on…..What do you think was happening ….?How do you think … would respond to…. ?What about next time…..?Do you think there’s anything to be gained from…?Any other questions or issues to discuss?Summary ................
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