Emergency medicine and critical care with 100 common cases: Part 1

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Nội dung Text: Emergency medicine and critical care with 100 common cases: Part 1

100 Cases in Emergency Medicine and Critical Care
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100 Cases in Emergency Medicine and Critical Care Eamon Shamil MBBS MRes MRCS DOHNS, AFHEA Specialist Registrar in ENT – Head & Neck Surgery Guy’s and St Thomas’ NHS Foundation Trust, London, UK Praful Ravi MA MB BChir MRCP Resident in Internal Medicine, Mayo Clinic, Rochester, MN, USA Dipak Mistry MBBS BSc DTM&H FRCEM Consultant in Emergency Medicine, University College London Hospital NHS Foundation Trust, London, UK 100 Cases Series Editor: Janice Rymer Professor of Obstetrics & Gynaecology and Dean of Student Affairs, King’s College London School of Medicine, London, UK Boca Raton London New York CRC Press is an imprint of the Taylor & Francis Group, an informa business
CRC Press Taylor & Francis Group 6000 Broken Sound Parkway NW, Suite 300 Boca Raton, FL 33487-2742 © 2018 by Taylor & Francis Group, LLC CRC Press is an imprint of Taylor & Francis Group, an Informa business No claim to original U.S. Government works Printed on acid-free paper International Standard Book Number-13: 978-1-139-03547-8 (Paperback) International Standard Book Number-13: 978-1-138-57253-9 (Hardback) This book contains information obtained from authentic and highly regarded sources. While all reasonable efforts have been made to publish reliable data and information, neither the author[s] nor the publisher can accept any legal responsibility or liability for any errors or omissions that may be made. The publishers wish to make clear that any views or opinions expressed in this book by individual editors, authors or contributors are personal to them and do not necessarily reflect the views/opinions of the publishers. The information or guidance contained in this book is intended for use by medical, scientific or health-care professionals and is provided strictly as a supplement to the medical or other professional’s own judgement, their knowledge of the patient’s medical history, relevant manufac- turer’s instructions and the appropriate best practice guidelines. Because of the rapid advances in medical science, any information or advice on dosages, procedures or diagnoses should be independently verified. The reader is strongly urged to consult the relevant national drug formulary and the drug companies’ and device or material manufactur- ers’ printed instructions, and their websites, before administering or utilizing any of the drugs, devices or materials mentioned in this book. This book does not indicate whether a particular treatment is appropriate or suitable for a particular individual. Ultimately it is the sole responsibility of the medical professional to make his or her own profes- sional judgements, so as to advise and treat patients appropriately. The authors and publishers have also attempted to trace the copyright holders of all material reproduced in this publication and apologize to copyright holders if permis- sion to publish in this form has not been obtained. If any copyright material has not been acknowledged please write and let us know so we may rectify in any future reprint. Except as permitted under U.S. Copyright Law, no part of this book may be reprinted, reproduced, transmitted, or utilized in any form by any electronic, mechanical, or other means, now known or hereafter invented, including pho- tocopying, microfilming, and recording, or in any information storage or retrieval system, without written permis- sion from the publishers. For permission to photocopy or use material electronically from this work, please access www.copyright.com (http:// www.copyright.com/) or contact the Copyright Clearance Center, Inc. (CCC), 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400. CCC is a not-for-profit organization that provides licenses and registration for a variety of users. For organizations that have been granted a photocopy license by the CCC, a separate system of payment has been arranged. Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. Visit the Taylor & Francis Web site at http://www.taylorandfrancis.com and the CRC Press Web site at http://www.crcpress.com
To Mum, Dad, Dania, and Adam for their unconditional love. To Mohsan, Shah, and Praful for their endless support. And to my patients and teachers, who have drawn me closer to humanity. Eamon Shamil To my parents, patients and teachers. Praful Ravi To my wife, Snehal, for her endless support. Dipak Mistry
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CONTENTS Contributors xi Introduction xiii Critical Care Case 1: Respiratory distress in a tracheostomy patient 1 Case 2: Nutrition 5 Case 3: Shortness of breath and painful swallowing 9 Case 4: Collapse while hiking 13 Case 5: Fever, headache and a rash 17 Case 6: Nausea and vomiting in a diabetic 19 Case 7: Stung by a bee 23 Case 8: A bad chest infection 27 Case 9: Head-on motor vehicle collision 31 Case 10: Intravenous fluid resuscitation 35 Case 11: Found unconscious in a house fire 37 Case 12: Painful, spreading rash 41 Case 13: Submersion 45 Case 14: Crushing central chest pain 49 Internal Medicine Case 15: Short of breath and tight in the chest 53 Case 16: A productive cough 57 Case 17: A collapse at work 61 Case 18: Dysuria and weakness 63 Case 19: Leg swelling, shortness of breath and weight gain 67 Case 20: Chest pain in a patient with sickle cell anaemia 71 Case 21: Fever, rash and weakness 75 Case 22: Rectal bleeding with a high INR 77 Case 23: Back pain, weakness and unsteadiness 81 Case 24: Feeling unwell while on chemotherapy 83 Case 25: Productive cough and shortness of breath 87 Case 26: Vomiting, abdominal pain and feeling faint 89 Case 27: Seizure and urinary incontinence 91 Case 28: Chest pain in a young woman 95 Case 29: Faint in an elderly woman 99 Case 30: An abnormal ECG 103 Case 31: Fever in a returning traveller 107 Case 32: Loose stool in the returned traveller 111 vii
Contents Mental Health and Overdose Case 33: Unconscious John Doe 115 Case 34: An unresponsive teenager 119 Case 35: Deteriorating overdose 125 Case 36: Attempted suicide 129 Neurology and Neurosurgery Case 37: Back pain at the gym 133 Case 38: Passed out during boxing 137 Case 39: Headache, vomiting and confusion 141 Case 40: Motor vehicle accident 143 Case 41: Slurred speech and weakness 147 Case 42: A sudden fall while cooking 151 Case 43: Neck pain after a road traffic accident 153 Trauma and Orthopaedics Case 44: My back hurts 155 Case 45: My shoulder popped out 159 Case 46: Fall on the bus 163 Case 47: Motorbike RTC 165 Case 48: Fall onto outstretched hand (FOOSH) 167 Case 49: Painful hand after a night out 171 Case 50: Cat bite 173 Case 51: Pelvic injury in a motorcycle accident 177 Case 52: Unable to stand after a fall 181 Case 53: Twisted my knee skiing 185 Case 54: Fall in a shop 187 Case 55: I hurt my ankle on the dance floor 191 Case 56: Fall whilst walking the dog 195 General Surgery and Urology Case 57: Upper abdominal pain 199 Case 58: Gripping abdominal pain and vomiting 203 Case 59: My ribs hurt 207 Case 60: Severe epigastric pain 211 Case 61: Left iliac fossa pain with fever 213 Case 62: Acute severe leg pain 217 Case 63: Abdominal pain and nausea 219 Case 64: Epigastric pain and nausea 223 viii
Contents Case 65: A 68-year-old man with loin to groin pain 227 Case 66: Right flank pain moving to the groin 231 Case 67: Testicular pain after playing football 235 ENT, Ophthalmology and Maxillofacial Surgery Case 68: Recurrent nosebleeds in a child 237 Case 69: Worsening ear pain 241 Case 70: Chicken bone impaction 243 Case 71: Ear pain with discharge and facial weakness 245 Case 72: Post-tonsillectomy bleed 247 Case 73: A swollen eyelid 249 Case 74: Red eye and photosensitivity 253 Case 75: Painful red eye 257 Case 76: Visual loss with orbital trauma 261 Case 77: Difficulty opening the mouth 265 Paediatrics Case 78: Cough and difficulty breathing in an infant 269 Case 79: A child with stridor and a barking cough 271 Case 80: A child with fever of unknown origin 273 Case 81: My son has the ‘runs’ 277 Case 82: A child with lower abdominal pain 281 Case 83: A child acutely short of breath 283 Case 84: A child with difficulty feeding 287 Case 85: A child with head injury 291 Case 86: The child with prolonged cough and vomiting 293 Case 87: A child with a prolonged fit 297 Obstetrics and Gynaecology Case 88: Vomiting in pregnancy 301 Case 89: Abdominal pain in early pregnancy 305 Case 90: Bleeding in early pregnancy 309 Case 91: Pelvic pain 313 Case 92: Abdominal pain and vaginal discharge 317 Case 93: Vulval swelling 321 Case 94: Fertility associated problems 325 Case 95: Headache in pregnancy 329 Case 96: Breathlessness in pregnancy 333 Case 97: Postpartum palpitations 337 ix
Contents Medicolegal Case 98: Consenting a patient in the ED 341 Case 99: A missed fracture 345 Case 100: A serious prescription error 349 Appendix: Laboratory test normal values 353 Index 355 x
CONTRIBUTORS Mental Health and Overdose, Ophthalmology, Maxillofacial Dr Mohsan M. Malik BSc, MBBS Specialist Trainee in Ophthalmology The Royal London Hospital Barts Health NHS Trust London, UK Obstetrics and Gynaecology Dr Hannan Al-Lamee MPhil, MBChB Specialist Trainee in Obstetric and Gynaecology Imperial College Healthcare NHS Trust London, UK Paediatrics Dr Noor Kafil-Hussain BSc, MBBS, MRCPCH Specialist Trainee in Paediatric Medicine London Deanery London, UK Neurology and Neurosurgery Dr Vin Shen Ban MB BChir, MRCS, MSc, AFHEA Resident in Neurological Surgery University of Texas Southwestern Medical School Dallas, Texas xi
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INTRODUCTION Emergency Medicine and Critical Care are difficult specialties and they can be quite daunt- ing for new physicians. The modern Emergency Medicine physician has to take a focused history, which can often be incomplete due to the patient’s care being spread over several hos- pitals, examining the patient, arranging rational investigations and then treating the patient. This is often combined with seeing multiple patients simultaneously as well as time pressure. Similarly, in Critical Care, there is the challenge of having to very rapidly assess unwell or deteriorating patients and initiating a suitable management strategy. This book has been written for medical students, doctors and nurse practitioners. One of the best methods of learning is case-based learning. This book presents a hundred such ‘cases’ or ‘patients’ which have been arranged by system. Each case has been written to stand alone so that you may dip in and out or read sections at a time. Detail on treatment has been deliberately rationalised as the focus of each case is to recognise the initial presentation, the underlying pathophysiology, and to understand broad treatment principles. We would encourage you to look at your local guidelines and to use each case as a springboard for further reading. We hope that this book will make your experience of Emergency Medicine and Critical Care more enjoyable and provide you with a solid foundation in the safe management of patients in this setting, an essential component of any career choice in medicine. Eamon Shamil Praful Ravi Dipak Mistry xiii
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CRITICAL CARE CASE 1: RESPIRATORY DISTRESS IN A TRACHEOSTOMY PATIENT History An 84-year-old patient is brought into the resuscitation area of the Emergency Department by a blue-light ambulance. He is in obvious respiratory distress and has a tracheostomy sec- ondary to advanced laryngeal cancer. Examination On examination, he is cyanotic and visibly tired with a respiratory rate of 28. His oxygen saturation is 84% on room air, blood pressure 94/51, pulse 120 and temperature 36.4°C. Questions 1. What are the indications for a tracheostomy? 2. How do you manage a patient with a tracheostomy in respiratory distress? 3. What is the standard care for a tracheostomy patient? 1
100 Cases in Emergency Medicine and Critical Care DISCUSSION A tracheostomy refers to a stoma between the skin and the trachea. It means that air bypasses the upper aerodigestive tract. This removes the natural mechanisms of voice production (larynx) and humidification (nasal cavity). Patients are more prone to chest infections from mucus accumulating in the lungs. Tracheostomy emergencies may be encountered in the Emergency Department, Intensive Care Unit or the ward. Indications for a tracheostomy include the following: • Weaning patients from prolonged mechanical ventilation is the commonest indi- cation in ICU. The tracheostomy reduces dead space and the work of breathing compared to an endotracheal tube. The TracMan study in the United Kingdom has shown that there is no difference in hospital length of stay, antibiotic use or mortal- ity between early (day 1–4 ICU admission) or late (day 10 or later) tracheostomy. • Emergency airway compromise – e.g. supraglottitis, laryngeal neoplasm, vocal cord palsy, trauma, foreign body, oedema from burns and severe anaphylaxis. • In preparation for major head and neck surgery. • To manage excess trachea–bronchial secretions – e.g. in neuromuscular disorders where cough and swallow is impaired. If a patient with a tracheostomy is in respiratory distress Call for urgent help from both an anaesthetist and an ENT surgeon and have a difficult airway trolley at the bedside. Apply oxygen (15 L/min) via a non-rebreather mask to the face and tracheostomy site. Use humidified oxygen if available. Look, listen and feel for breath- ing at the mouth and tracheostomy site. Remove the speaking valve and inner tracheostomy tube, and then insert a suction catheter to remove secretions that may be causing the block- age. If suction does not help, deflate the tracheostomy cuff so air can pass from the mouth into the lungs. Look, listen and feel for breathing and use waveform capnography to moni- tor end-tidal CO2. If the patient is not improving and is NOT in imminent danger, then a fibreoptic endoscope can be inserted into the tracheostomy to inspect for displacement or obstruction. If a single lumen tracheostomy is blocked and suction and cuff deflation does not provide adequate ventilation, remove the tracheostomy and insert a new tube of the same or smaller size whilst holding the stoma open with tracheal dilators. If you cannot insert a new trache- ostomy tube, insert a bougie into the stoma or railroad a tube over a fibreoptic endoscope to allow insertion under direct vision. If you are unable to unblock or change the tracheostomy tube, then perform bag-valve mask ventilation via the nose and mouth with a deflated tracheostomy cuff and cover stoma with gauze and tape to prevent air leak. If this does not work, then try to bag-valve-mask ventilate over the tracheostomy stoma after closing the patient’s mouth and nose. If the patient has normal anatomy (i.e. no airway obstruction from a tumour or infection), then think about oral intubation or bougie-guided stoma intubation. In contrast, laryngectomy patients have an end stoma and cannot be oxygenated by the mouth or nose unlike tracheostomy patients. If passing a suction catheter does not unblock a lar- yngectomy tube/stoma, then remove the laryngectomy tube from the stoma and look, listen and feel or apply waveform capnography to assess patency. If the stoma is not patent, apply a 2
Case 1: Respiratory distress in a tracheostomy patient paediatric facemask to the stoma and ventilate. A secondary attempt can be made to intubate the laryngectomy stoma with a small tracheostomy tube or cuffed endotracheal tube. A fibre- optic endoscope can be used to railroad the endotracheal tube in the correct position. Post-tracheostomy care should be conducted by an appropriately trained nurse or trained patient/carer and includes • Humidified oxygen with regular suctioning • Bedside spare tracheostomy tube, introducer and tracheal dilators • Pen and paper for patient to communicate • Tracheostomy change after 7 days to allow speaking valve application and formation of a stoma tract • Patient and family education Key Points • Indications for a tracheostomy include the following: weaning patients from pro- longed mechanical ventilation, emergency airway compromise, in preparation for major head and neck surgery and managing excess trachea–bronchial secretions • When facing a tracheostomy patient in respiratory distress, think of the three C’s: 1. Cuff – Put the cuff down so the patient can breathe around it. 2. Cannula – Change the inner cannula. 3. Catheter – Insert a suction catheter into the tracheostomy. 3
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CASE 2: NUTRITION History A 54-year-old man has been admitted into the Intensive Care Unit with severe gallstone pancreatitis, complicated by acute kidney injury and acute respiratory distress syndrome (ARDS). He is currently intubated and ventilated, and requires haemofiltration. He will likely require a prolonged hospital admission. The intensive care consultant asks you to ‘take care of his nutrition’. Questions 1. What are the causes of nutritional disturbance? 2. How can nutrition be assessed? 3. What are the options for optimising nutrition? Name some complications. 5