SimMan: Hematemesis: After Endoscopy

Casebank Simman
1

Who You Are:
You are an FY2 n Gastroenterology Department.

Who is you Patient:
Peter Drink, a 50 years old gentleman, presented with vomiting of blood.

Other Information:
An upper GI Endoscopy was done to him 3 hours back, while he was in the recovery room
he vomited blood again, the patient is not feeling well.

Your Task:
Take focused history, assess his condition and manage him.

Opening

  1. Candidate Identification:
    To examiner: I'm [First & Last Name], My GMC reference number is 7970822.

  2. Universal precaution:
    Think loud: I assume, I've taken all the universal precautions.

  3. Introduction & Pt Identification:
    To pt: Hello, I'm Dr [Last Name], one of the junior doctors here in the emergency department. Are you Peter Drink? Can you please confirm your age?

  4. PC:
    To pt: Peter, How can I help you today?
    Pt: “I’ve been vomiting Dr.”

  5. Acknowledge & Reassure: If pt is conscious
    To pt: Peter, I see that you're in distress, but don't worry you are in safe hands now.

  6. Check Monitor: If not attached
    Think loud: I would like to attach my patient to the monitor.
    Observe vitals. Think loud: My pt O2 saturation is __.

  7. HPC: If patient is able to speak take HPC
    To pt: Signpost Peter, I'll be asking you few questions regarding your complaint of vomiting.
    To pt: Onset-TRAC When did this start? What were you doing when it started? Has this happened Before? how much? Content? Bleeding anywhere else?
    DDs Heart racing? Dizziness? Abdominal Pain ? Chest Pain?
    To pt: MMA Do you have any medical condition (Bleeding disorders) ? Are you taking any regular medication (Blood thinners) ? Are you allergic to anything?

  8. Consent & Chaperone:
    To pt: Peter, to help you better, I'll be doing some examination, which involve exposing different parts of your body and I'll also be listening, touching, tapping and feeling them. Is that okay with you?
    To pt: We also have chaperone, for your privacy.

  9. Position:
    Think loud: Ideally I would like to place my pt on left lateral position.

  10. Signpost ABCDE:
    Think loud: I would like to manage my patient according to ABCDE approach.

Airway

  1. Signpost Airway:
    Think Loud: Now, I'm going to start with A, which is airway.
  2. Check Airway Patency:
  • If pt can talk: Airway patent
    Think loud: As my patient is talking to me his/her airway is patent.
  • If pt can’t talk:
    Think loud: I would like to perform the Head Tilt-Chin Lift maneuver.
  1. Check O2 Saturation & Any Swelling:
  • Think loud: My pt O2 saturation is __.
    • (If O2 <94%)
      Think loud: Target O2 saturation is 94%, therefore I would like to start my patient on 24-40% O2 via Nasal cannula at flow of 1-4 L/min.
      From Trolley: Collect nasal cannula.
      To pt: Peter I'm putting this cannula on you, it'll help you breathe better.
  1. Reassess:
    To pt: Peter, Are you feeling a little bit better now?

Breathing

  1. Signpost Breathing:
    Think loud: Now, I'm moving to B, which is breathing.
  2. Check RR & Trachea Position
    Think loud: My pt RR is __
    To pt: Peter, I’m going to feel you over the neck now.
    Think loud: Trachea is (centrally placed/ deviated).
  3. Chest Examination:
    From Trolley: Collect stethoscope.
    To pt: Peter, I'm going to uncover your chest & examine you now.
    • Inspection:
      Think loud: I'm looking for surgical scar mark, rashes or abnormal chest movement.
    • Palpation: compare temperature, B/L chest expansion
      To pt: Peter, Can you breathe for me?
    • Percussion: 6 sites
      To pt: I'm going to tap on your chest now.
    • Auscultation: 6 sites, also auscultate heart: 4 sites.
      To pt: I'm going to listen to your lung and heart sounds now.
      To pt: Peter, How are you feeling now?
  4. Ix: (ACE)
    Think loud: I would like to do few Ix for my pt ABG, CXR & 12 lead ECG.
  5. Remaining History:
    To pt: Peter, How are you feeling now? Do you think you can answer my few question?

Circulation

  1. Signpost Circulation:
    Think Loud: Now, I'm moving to C, which is Circulation.
  2. Check BP & Examine CRT and peripheral pulse.
    Think loud: My pt BP is __ .
    To pt: Peter, I’m going to press your finger nail now.
    Think loud: Ideally I would do this for 5 seconds.
    To pt: Peter, I’m going to feel your pulse now.
    Think loud: My pt's pulse volume is (adequate/ low) & rhythm is (regular/ irregular)
  3. Insert IV Cannula, Collect Blood sample and Start Fluids:
    From Trolley: Collect IV cannula, vacutainer and fluids.
    • Insert IV Cannula:
      – If BP normal:
      Think loud: I’m going to maintain two large bore (16G) Grey colour IV cannula in each arm.
      To pt: Peter, a sharp scratch is coming.
    • Collect Blood sample:
      Think loud: I would like to collect blood sample for FBC, RFT, LFT, U&E, G&S (Group and Safe), Coagulation profile & Iron studies.
    • Start Fluids:
      Think loud: I'm going to start my pt on Hartmann Solution 500ml in 15 min, 1L in 30 min and 2L in 1hr. Maximum 2L.
  4. Examine tummy
    Think loud: I would like to activate massive hemorrhagic protocol & arrange 6 units of pre-warmed O negative blood. If my pt's BP doesn't improve on fluids then I'll transfuse 2 units of blood at 2 ml/min.

Disability

  1. Signpost Disability
    Think Loud: Now, I'm moving to D, which is Disability.
  2. Check Temperature:
    Think loud: My pt temperature is __
  3. Check Blood Sugar:
    Think loud: I would like to collect blood sugar now.
    From Trolley: Collect glucometer and strips.
    To pt: Peter, a sharp scratch is coming.
  4. Check GCS-
    To pt: Peter, can you please move your leg?
    Think loud: My pt is opening his eyes spontaneously, he is speaking and following verbal commands, hence his GCS is normal.
  5. Check Pupillary Reflex:
    From Trolley: Collect torch.
    To pt: Peter, I'm going to shin light in your both eyes now.
  6. Reassess BP: If BP still low, transfuse blood and reassess.

Exposure

  1. Signpost Exposure
    Think Loud: Now, I'm moving to E, which is Exposure.
  2. Catheterisation:
    Think loud: I'm going to catheterise my pt.
    From Trolley: Collect Catheter.
    To pt: Peter, we'll be putting a flexible tube from your front passage.
  3. Full exposure:
    To pt: Peter, I'm going to expose your leg now.

Final 2 minutes

  1. To examiner: ISBAR
    – Introduction: (Your Name, Position & Department) (Pt name & age)
    – Situation: PC
    – Background: PMH
    – Assessment: Positive findings
    – Recommendation: Admit, Rx, Senior
  2. To pt: 3P
    – Past: How are you feeling? narrate story
    – Present: Explain Management
    – Future: Further Invx ( Erect X-ray). Involve
    Senior. Urgently Involve Specialist to do a camera test (Endoscopy). Safety Netting.

Quoted from Nice Guidelines:

Base decisions on blood transfusion on the full clinical picture, recognizing that over-transfusion may be as damaging as under-transfusion. So decide when to start with blood immediately or start fluid then give blood.

3 Likes
2

great job , thank you for this station

3 Likes
3

Good one. It’s quite extensive and I love it.:smiling_face_with_three_hearts:

1 Like