You are the ST3 on-call for general surgery. You are called to review a patient in A&E resus who has presented with severe abdominal pain. The patient is a 79-year-old woman who reports severe lower abdominal pain. On examination, she has a heart rate of 70, BP 90/60 and has signs consistent with peritonitis. Her medical history includes colonic diverticulosis, atrial fibrillation, ischaemic heart disease and type 2 diabetes mellitus. Despite her co-morbidities, she manages her activities independently at home. She is taking beta blockers, warfarin and medication for diabetes. Blood tests reveal: WCC 23 CRP 367 Hb 101 Na 134 K 6.1 Cr 304 Bili 6 ALT 45 ALP 100 amylase 96, lactate 5.
This patient is unwell, haemodynamically unstable (N.B. use of a beta blocker which may mask a tachycardia) and has an acute abdomen. The differential diagnosis is wide but based on the available information the possibilities include ischaemic bowel, perforated viscus and ruptured AAA. She will need urgent resuscitation, diagnostic investigations and probably surgery (e.g. laparotomy). She has several co-morbidities that raise concern in terms of fitness for surgery. Firstly, she is on warfarin for AF; her INR will need to be checked and reversed with PCC. Secondly, she has acute kidney injury with hyperkalaemia; this will require urgent correction. Finally, she has ischaemic heart disease which will require evaluating prior investigations e.g. transthoracic echo, perfusion studies, angiograms, to determine the severity of her cardiac disease and fitness for surgery.
The priority is patient safety. This will include resuscitation, diagnostic investigations and definitive management, which will likely be surgical.
- Organise team: call FY1/SHO to come to A&E to help with resuscitation
- Communicate with team members: A&E, ward, theatre co-ordinator
- Gather information to aid prioritisation e.g. current management
- Update them on your situation e.g. 10 minutes away
- What can be done before you arrive e.g. fluid resuscitation, blood tests, ABG, ensuring clotting & group and save done, catheter
Review priority patient
- Ensure patient is in a safe environment (e.g. Resus)
- Delegate responsibilities to team members (e.g. nurse to check observations, FY1 to establish IV access and take bloods/ABG)
- Get initial information to plan assessment e.g. handover from paramedics
CCRISP Assessment: ABCDE, history, examination, chart/notes review, investigations, definitive management
- NBM
- Supplementary oxygen (15 L/min via a Hudson mask)
- Analgesia (IV morphine)
- IV fluids (20ml/kg if hypotensive; 10ml/kg if normotensive; 5ml/kg if risk of heart failure)
- IV antibiotics (Surviving Sepsis Bundle)
- Bloods: FBC, U&E, CRP, LFT, amylase, glucose, clotting profile, cross match 4 units (major haemorrhage call for PRCs/FFP/platelets?)
- Arterial blood gas: lactate
- Cultures: blood, urine, stool, wound, lines
- Urinary catheter
- Nasogastric tube (if vomiting/perforation)
- Chest radiograph (portable erect)
- ECG
- Hx: From patient, paramedics, A&E doctors, nurse
- Examine: pulse, volume status, chest, abdomen, stomas, wounds, drains, lines, legs
- Chart review: case notes, operation note, observation, fluid balance, anaesthetic chart, drug chart
- Results: blood, microbiology, radiology
- CT scan +/- theatre/endoscopy/IR suite
- Direct to theatre/endoscopy/IR suite
- Escalation to level 2/3 care
- Active observation (NBM, regular review/blood tests)
- Resuscitate and transfer
Prepare for theatre:
- Escalate: Consultant on-call
- MDT: Critical Care, Anaesthetist, other relevant specialties
- Contact: Theatres
- Book and consent for theatre (N.B. Consent form 4 if lacks capacity)
- P-POSSUM score
- Offer to speak to next of kin