A 21-year-old female presenting with sudden onset right iliac fossa pain 6 hours ago. She’s had 2 episodes of vomiting since the onset of pain. She has no past medical history and is not on any regular medications.

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

We ran this simulation as part of a trial of our ‘bookable simulation’ programme. There were 4 candidates for this simulation and we ran the same simulation for each candidate. This allowed us to find some interesting common learning points.

So, Why Did We Sim?

Abdominal pain is a common presenting complaint to the Emergency Department. It can range from mild to severe and has a range of underlying pathologies, which fall under different specialties. It is important to rule out life threatening and serious conditions and ensure patients are admitted (if required) under the correct specialty.

Ectopic pregnancy has an incidence of 1.1% in the UK and is on the increase. This is thought to be associated with increased rates of PID and smoking. 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.

The most common site for implantation in an ectopic pregnancy is in the fallopian tube (approx. 97% of cases). If this is not picked up early it can result in a rupture of the fallopian tube. Severe bleeding can start if rupture occurs which can cause haemodynamic instability and shock. In these cases the patient will need urgent gynaecology review and surgical repair.

Learning Outcomes

In all women of childbearing age presenting with abdominal pain, consider an ectopic pregnancy and get a urine sample for a pregnancy test.

In this case an USS performed by an ED doctor is of limited use. Unless the clinician performing the USS has a high level of training they will be unlikely to be able to rule in/out an intrauterine pregnancy.

If a AAA is suspected and the whole vessel can be visualised and is of normal calibre then it is possible to rule this out. However, the visualisation of free fluid does not give a diagnosis so if a pregnancy is ruled out the patient would require a CT scan.

Positive Feedback

  • Good ABCDE approach

  • Good recognition of shock and treatment, initially giving fluid moving to consideration of blood when Hb found to be low

  • Prompt pain management

Edit & Peer review by Damian Roland & Darren Whitelaw

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