#SimBlog: The Returned Traveller
“A 20-year-old, presenting with a 3-week history of fever and muscle aches.”
Observations
A – Patent
B – RR18, Sats 98% (Air), Chest Clear
C – HR 115, BP 106/76,
D – Alert, BM 2.4
E – Temperature 40.1°C
Clinical Findings
No Rashes or bruises
Why We Simulated
Patients presenting to the ED with fever and tachycardia are not unusual, it is easy to become complacent and simply commence antibiotics, label them as Septic and admit. However we need to think carefully about possible causes and make sure we have made a complete assessment, especially in the context of non-specific symptoms.
Malaria should be considered in any febrile or unwell patient who has visited an endemic area, and these can be seen here.
Most cases present within 3 months of return, but it can be longer so a travel history should extend at least this far back!
Mortality (in the UK) is roughly 1%, although delay in recognition and treatment increases mortality and complications. It is also important to consider other infections in anyone who has traveled and consider isolation until the diagnosis is confirmed.
Infection is with one of 5 Plasmodium species (falciparum, vivax, ovale, malariae and knowlesi).
The initial symptoms are nonspecific: chills, malaise, fatigue, sweating, headache, cough, nausea, vomiting, abdominal pain, diarrhoea, arthralgia & myalgia.
The features of severe malaria include:
Altered GCS / Seizures
Respiratory distress or ARDS
Shock
Metabolic acidosis
Renal failure / Heamoglobinuria
Hepatic failure
Coagulopathy +/- DIC
Severe anaemia or massive intravascular haemolysis
Hypoglycemia
High parasite count
Further Resources:
- #EM3: Lightning Learning: Malaria
- The CDC (US): Approach to the returned traveller
- RCEM Learning: The Returning Traveller
Learning Outcomes
Remember to take a travel history.
If treating something uncommon remember to access guidelines.
SEPTIC patients are not always as simple as the SEPSIS 6 and admit - consider alternative diagnoses
Positive Feedback
Worked as a team and canvased for ideas.
Used summaries to good effect so that whole team knew what was going on.
Treated low glucose, but discussed whether IV dextrose was needed over giving something orally.
