Emergency Medicine Simulation Workbook. Группа авторов

Chief complaint: Confusion. Patient's medical history: Hypertension, diabetes, stroke. Surgical istory: Appendectomy, hernia repair. Allergies: None. Social history: Previous cigarette smoker; no alcohol or drug use. Family history: Non‐contributory. Medications: Lisinopril, metformin, aspirin, clopidogrel.

      Initial Scenario Conditions

      A 60‐year‐old man is brought in by EMS from home. Patient is moaning due to abdominal pain, complaining of feeling sick.

Vital signs:	Temp 102.5°F (39.2°C), HR 125, RR 22, BP 80/60, SpO2 99% on room air.
Head:	Atraumatic, normocephalic.
Eyes:	Icteric sclerae; pupils 4 mm bilaterally and reactive to light; extraocular movement intact without nystagmus.
Ears/nose/mouth:	Dry mucous membranes, with subungual icterus (if asked).
Neck:	Supple, full range of movement, no meningeal signs.
Heart:	Tachycardic, regular, no murmurs/rubs/gallops.
Lungs:	Clear to auscultation bilaterally (patient reports worsening belly pain when taking deep breaths).
Abdomen:	Distended, with hypoactive bowel sounds. Tender to palpation in the upper abdomen, most significant in the right upper quadrant and epigastric region. No rebound. Voluntary guarding in all quadrants.
Extremities:	No edema, cyanosis, or clubbing.
Skin:	Warm to the touch.
Neurologic:	Alert and oriented to person and place, but not to time. Answers most questions appropriately but seems confused and takes a while to respond to simple questions. No focal deficits. Cranial nerves intact. No asterixis.

      Physical exam findings that are not available on your mannequin may be offered verbally to learners if they ask (e.g. if unable to simulate icteric sclera, can verbally report the scleral exam to the learners if they specifically ask for this information).

See flow diagram (Figure 1.15) for scenario changes based on learner actions.

      Case Narrative, Continued

      For all learners, the case should begin with obtaining a complete history as well as performing a thorough physical exam. The nurse can help the learners to set the patient up on the monitor to obtain vital signs. This should also include obtaining a fingerstick glucose, in light of the patient's slightly altered mental state.

      Learners should order initial labs, imaging, IV fluids and medications.

      If there is inadequate fluid resuscitation, the patient's hypotension will worsen. Continued failure to appropriately fluid resuscitate will lead to PEA, requiring CPR.

      For novice learners, administration of an appropriate fluid bolus (30 cc/kg) will cause the patient's blood pressure to increase to a mean arterial pressure greater than 65 mmHg and his heart rate will slowly lower. With these improvements, the patient's mental status will also improve. Laboratory tests and imaging will then be available for review and appropriate consultation should be made with general surgery/GI, as well as an admitting physician. The case will end after appropriate disposition and consultation have occurred.

      For advanced learners, despite initiation of IV fluids and broad‐spectrum antibiotics, the patient will continue to be hypotensive and altered, requiring initiation of vasopressors and intubation. Failure to do so will result in PEA arrest. Once intubation is performed and vasopressors are initiated, the patient will stabilize. Consultation with general surgery/GI and the intensive care admitting physician should then occur. The case will end after appropriate disposition and consultation have occurred.

      Instructor Notes

      Pathophysiology

       Acute (or ascending) cholangitis results from inflammation and infection of the biliary system, often related to a blockage of the bile ducts or hepatic ducts:Biliary obstruction leads to bacterial growth within the bile and subsequent infection.Common causes of blockage include choledocholithiasis, malignancy, strictures, primary sclerosing cholangitis, and AIDS‐related cholangiopathy.

       Most frequent pathogens found in acute cholangitis include Escherichia coli, Klebsiella spp., Enterococcus spp., and Enterobacter spp.

       Anaerobes such as Bacteroides fragilis and Clostridium perfringens have also been accountable, often in elderly patients or those with prior biliary surgery [1].

      Clinical Features

       Charcot's triad:Fever, right upper‐quadrant abdominal pain, and jaundice.“Classic” presentation, although it is only around 25% sensitive for acute cholangitis to have all three, 80–90% of patients with acute cholangitis will have fever and/or abdominal pain [2].

       Reynold's pentad:Charcot's triad plus hypotension and altered mental state.Severe presentation, but only seen in 5–7% of cases [2].

      Diagnosis

       Laboratory tests that may support diagnosis:Leukocytosis (with neutrophilic predominance).Transaminitis.Hyperbilirubinemia (conjugated).Elevated alkaline phosphatase.Elevated gamma‐glutamyl transferase level.

       Imaging:Ultrasound:Best initial study. Can detect dilation of the common bile duct, gallstones, and other evidence of pathology.CT with IV contrast:Helpful for looking at other potential causes of biliary obstruction.May show complications such as hepatic abscesses.CT findings that may support the diagnosis of cholangitis include dilation of intra‐ or extra‐hepatic biliary ducts, thickening of the ductal walls, presence of gallstones. Magnetic resonance cholangiopancreatography:Sensitive imaging modalityMay not be readily available at all institutions.

      Management

       Resuscitation:IV fluid administration.Broad‐spectrum IV antibiotics (with Gram‐negative