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ED GovCast Episode 10
From Zero to Hero - Dr. Hesham Ibrahim

ED GovCast - Episode 10
​Paediatric Pain, Back Pain Red Flags, Aneurysm, and Strangulation

Clinical Learning Highlights from ED GovCast Episode 10

ED GovCast Episode 10 delivers a high-yield review of diverse and challenging emergency cases — spanning from paediatric pain assessment to neurological emergencies and safeguarding in domestic violence.
The episode illustrates how structured evaluation, empathy, and clinical governance combine to protect patients across all age groups.

1. Paediatric Pain Assessment in the ED

Overview

Pain in children is often underestimated or poorly managed.
This episode references the RCEM resource “Painful to Think About?” — emphasizing the importance of consistent pain scoring and timely analgesia in paediatric emergency care.

Best Practice Tools

Age Group

Pain Assessment Tool

0–3 years

FLACC scale (Face, Legs, Activity, Cry, Consolability)

3–8 years

Wong-Baker Faces Scale

≥8 years

Numeric Rating Scale (0–10)

Learning Point:

Always record a pain score at triage and re-evaluate after intervention — it’s a key metric for both quality improvement and patient safety.

Governance Insight: Pain management QIPs are measurable, impactful, and directly improve paediatric patient satisfaction and outcomes.

🔗 Reference:RCEM – Paediatric Pain Resource

2. Back Pain with Shock – Think Abdominal Aortic Aneurysm (AAA)

Case Overview

A 50-year-old man presented with sudden severe back pain, SBP 100 mmHg, HR 120, Lactate 10.
Bedside POCUS revealed a large infrarenal abdominal aortic aneurysm.

Key Learning

“Back pain with shock = AAA until proven otherwise.”

Immediate Priorities:

  • Activate vascular surgery and theatre team early.
  • Maintain permissive hypotension (target SBP 90–100).
  • Avoid aggressive fluid resuscitation — preserve clot stability.

Governance Reminder:

Every ED should have ready access to ultrasound and staff trained in focused aortic scanning.

🔗 Reference:RCEM Ultrasound – Aortic Aneurysm Protocol

3. Missed Back Pain Diagnosis – Discitis Secondary to Endocarditis

Case Overview

A 45-year-old woman re-presented to ED with worsening back pain and rigors after being discharged twice with “musculoskeletal strain.”
Her CRP was 250, and subsequent MRI revealed discitis due to bacterial endocarditis.

Key Lessons

  • Inflammatory back pain (high CRP, fever, rigors) is never benign.
  • Always consider discitis, spinal abscess, or metastatic infection in recurrent presentations.
  • Blood cultures and MRI are essential when suspicion remains.

Clinical Insight: Back pain is one of the most common ED complaints — yet one of the easiest to miss when it hides infection or vascular pathology.

4. Oculomotor Nerve Palsy due to Aneurysm

Case Overview

A 67-year-old woman presented with ptosis, dilated pupil (mydriasis), and eye pain.
CT angiography revealed a posterior communicating artery aneurysm compressing the third cranial nerve.

Red Flag Rule

“Painful third nerve palsy = aneurysm until proven otherwise.”

Next Steps:

  • Urgent neurosurgical referral.

    • Manage blood pressure and pain while avoiding sudden hypertension.
    • Consider coiling or clipping depending on anatomy and comorbidities.

      Governance Perspective:

      Always correlate cranial nerve findings with neuroimaging, and document complete neurological exams before discharge.

      🔗 Reference:BMJ Best Practice – Cranial Nerve Palsies

      5. Strangulation in Domestic Violence (Non-Fatal Strangulation)

      Case Overview

      A female victim of domestic assault presented after a manual strangulation episode with transient loss of consciousness.

      Key Actions

      • CT Angio (neck + intracranial vessels) to rule out:
        • Arterial dissection
        • Carotid thrombosis
        • Laryngeal trauma or soft-tissue edema
      • Observe for airway compromise for ≥6 hours.
      • Document safeguarding details and activate MARAC referral (Multi-Agency Risk Assessment Conference).

      Learning Point:

      Non-fatal strangulation can cause delayed airway obstruction or stroke hours later — imaging and observation are mandatory.

      Governance Note: This is both a medical and forensic emergency — documentation and safeguarding actions are critical components of patient care.

      🔗 Reference:RCEM – Non-Fatal Strangulation Guidance

      6. DVT Mimic – Intramuscular Hematoma

      Case Overview

      A 42-year-old male presented with unilateral calf pain and elevated D-dimer.
      POCUS identified a hematoma within the gastrocnemius muscle, not a DVT.

      Learning Points

      • Elevated D-dimer ≠ Thrombosis.
        • Trauma, infection, and hemorrhage can also elevate it.
      • Use POCUS to confirm before anticoagulating unnecessarily.
      • If uncertain → proceed to formal duplex ultrasound.

      Governance Insight: 

      Routine POCUS competence reduces misdiagnosis and unnecessary anticoagulation risk.

      🔗 Reference:BTS – DVT Diagnostic Pathway

      Governance Reflection: Holistic Awareness in Emergency Medicine

      Across all cases, Episode 10 reinforces the governance mindset:
      seeing beyond the symptom, connecting systemic clues, and prioritizing safety.

      Domain

      Key Insight

      Paediatrics

      Pain assessment must be structured, repeated, and documented

      Vascular

      Back pain + shock = AAA until proven otherwise

      Infection

      Recurrent back pain with inflammation = Discitis

      Neurology

      Painful 3rd nerve palsy = Posterior communicating aneurysm

      Safeguarding

      Strangulation = forensic and airway emergency

      Musculoskeletal

      D-dimer is nonspecific — confirm with imaging

      “Clinical governance is not about catching mistakes — it’s about catching patterns before they become mistakes.”


      FAQs: Learning Points from ED GovCast Episode 10

      1. What is the safest approach to paediatric pain assessment?
      Use age-appropriate tools (FLACC, Wong-Baker, or Numeric Scale) and reassess after every analgesic intervention.

      2. What are red flags in back pain?
      Fever, elevated CRP, neurological deficits, or hemodynamic instability — consider infection or AAA.

      3. Why does a painful 3rd nerve palsy suggest aneurysm?
      Because compression of the nerve by a posterior communicating artery aneurysm affects both pain fibres and pupil function.

      4. What should be done after non-fatal strangulation?
      Perform CT Angio (neck + intracranial), observe airway for ≥6 hours, and trigger safeguarding protocols.

      5. How can POCUS prevent DVT misdiagnosis?
      It differentiates between vascular and soft tissue pathology, preventing unnecessary anticoagulation.

      🔗 References & Further Reading:

      Listen To Episode 10