SimMan: Fracture Leg - Pulmonary Embolism

Casebank Simman
1

FY2 in Orthopedics Department
Kimberley Pam aged 82 years old was admitted 2 weeks ago after sustaining a fracture of the left leg. She was successfully treated and ready to be discharged home.
She has gone for physiotherapy session and was noticed to be unwell.
The nurse has asked you to come and review her.
Assess and Manage

Patient Information

  • You had a fall at home and sustained a fracture of your left tibia.
  • You’ve been on admission for two weeks.
  • You were on physiotherapy and while it was ongoing, you suddenly developed shortness of breath.
  • If the doctor attempts to take history from you while you’re still unstable, just reply with a “Hello”.
  • Patient has a grey cannula on her right hand

Examiner’s promp:
Temp: 39 degrees | PR: 120 bpm | BP: 90/60 mmHg | RR: 30 pm | SPO2: 88%

Airway

  • the patient is verbalising
  • Chest wall tenderness
  • Vesicular breath sounds

CVS: First and second heart sounds
Abdominal exam: Normal findings
Pupils normal in size and briskly reactive
RBS 7mmol

APPROACH

  • GRIPS
  • Confirm name and age
  • Observe universal precautions
  • Acknowledge that the patient is breathless
    “I can see that you’re in distress and I’m here to help you and i wont be leaving your sight”

ABCDE assessment
Airway
you can say a few words and that means your airway is patent. Can you give me a moment to look at your monitor?

Breathing

  • your oxygen level is quite low and your breathing rate is fast, do you have smoker’s cough?
    – If no, start the patient on 15L of high flow oxygen through a nonrebreather mask
    – If yes, start the patient on 2 to 4L of 24% oxygen through a venturi mask
  • Then examine the chest
    – “I’ll be examining your chest and it will involve me looking, feeling, tapping and listening to it. I’ll do it in the presence of a chaperone and I’ll ensure your privacy”
    – There will be chest wall tenderness: Order for CXR and ABG

Circulatio:

  • Kimberly, your blood pressure is low and your heart beat is fast
  • check capillary refill
  • examine pulses and listen to heart sounds
  • set two wide bore cannulae, at the same time take blood samples for FBC, clothing screening, UECr, LFT, serum Lactate, GXM
  • Start IVFs either N/S or hartmann’s solution 500ml over less than 15mins into each arm
  • recheck vitals , if still hypotensive then repeat IVFs
  • pass urethral catheter to monitor urine output

If the patient is stable enough then take a focused history at this point

Disability
Check RBS, examine pupils, assess consciousness using AVPU scale

Exposure in a controlled environment

  • Examine for rashes
  • Examine the limbs with special attention on the fractured site
  • Examine the abdomen

ASS: PULMONOLOGY EMBOLISM.

Plan

  • Hold on with discharge
  • Transfer the patient to the ICU
  • Do some tests
    – CTPA
    – D-dimers
    – Clotting screening
    – FBC, LFT, UECr
  • Inform your seniors
  • Invite the specialist (pulmologist)
  • Start on anticoagulants: injection for 5days, review for oral afterwards. Possibly for 3 months.
  • Painkillers
  • Consider surgery
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