A 21-year-old female presenting with sudden onset right iliac fossa pain 6 hours ago.

She has had less than 12 hours of vomiting and loose stool since the onset of pain. She has no past medical history and is not on any regular medications. She was seen quickly in Assessment Area and treated for sepsis and diagnosed as a ?gastroenteritis.

Observations

A – Clear and self-maintained

B – Rate 26, SpO2 98%

C – Pulse 110, BP 89/60

D – GCS 15 pupils equal reactive

E – Temp 36.9°C

Clinical Findings

  • Tender abdomen

  • Localised guarding to RIF

  • Bowel sounds present

This sim has been completed by our junior staff previously with the possibility of an ectopic pregnancy being missed. We ran it for one of the third year emergency medicine trainees to explore what effect having a prior diagnosis had on the thought process and management.

So, Why Did We Sim?

Abdominal pain accounts for 5-10% of all emergency presentations. In women of childbearing age, the most important life-threatening cause to be excluded is ectopic pregnancy. It is relatively easy to exclude using either urinary or serum βHCG.

As our previous blog showed ectopic pregnancy has an incidence of 1.1% in the UK and is on the increase. If a patient presenting with abdominal pain has a positive pregnancy test and has not yet had a scan showing a uterine pregnancy then an ectopic needs to be ruled out. If the patient has haemodynamic compromise in this situation then a ruptured ectopic pregnancy should be considered.

Cognitive Load (EM3).jpeg

Working in a busy Emergency Department can be associated with information overload. We are forced to make lots of decisions, often with limited information. Many of these decisions are made while we are being interrupted by both staff and patients. This is especially difficult if the department is crowded (which is so often the case) or if there is insufficient staffing.

When patients are not responding in a way you would expect from your treatment – reassess them! Going back to the start and deciding if the are sick or not is useful, and then trying to rule out “what could kill them” or in other words what is the worst case scenario?

Further Reading:

Learning Outcomes

  1. In all women of childbearing age presenting with abdominal pain, consider an ectopic pregnancy and get a urine sample for a pregnancy test.
  2. A quick review in the assessment area by a senior clinician doesn’t replace a good focused history and examination.
  3. Be wary of making a diagnosis if the patient is not presenting in a way you would “typically” expect. If the presentation doesn’t fit...

Positive Feedback

  • Good ABCDE approach

  • Re-evaluated the patient when no improvement

  • Asked for help when realised something else was going on and too task focused

  • Analgesia given early

Edit & Peer review by Pandora Spilman-Henham

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