ED GovCast - Episode 3
Case 1: Hypertensive Emergency
● Presentation:
Referred by ophthalmology for papilledema noted on fundoscopy. Patient had 2 months of blurred vision but no other symptoms.
Referred by ophthalmology for papilledema noted on fundoscopy. Patient had 2 months of blurred vision but no other symptoms.
● Findings:
○ Initial BP could not be measured.
○ Manual reading was approximately 300 mmHg systolic.
○ Arterial line confirmed systolic pressure >300 mmHg.
- Followed the British and Irish Hypertension Society guidelines, which categorize hypertensive crises into:
- Treatment varied based on the subtype.
- Reference: Hypertension Crisis Guidelines (also available via the EOLAS app).
● Management:
■ Acute severe hypertension
■ Malignant hypertension
■ Hypertensive emergency
Case 2: Rib Fractures and Delayed Haemothorax in an Elderly Patient
● Initial Presentation:
○ Elderly woman, several days post-fall onto her left side.
○ Tenderness on the left chest wall; no surgical emphysema.
○ CT confirmed rib fractures.
○ After assessment with the frailty team and senior clinicians, she was discharged.
● Re-presentation:
○ Returned a week later with symptoms of haemothorax.
○ CT confirmed a left-sided haemothorax.
● Management:
○ Chest drain insertion.
○ Multidisciplinary input from ICU, outreach, and cardiothoracic teams.
○ Good recovery.
● Additional Points:
○ Pain control options: oral analgesia, lidocaine patches, rib blocks.
○ Risk assessment tool: STUMBL Battle Score.
Guest: Dr. J Chitnis on Cauda Equina Syndrome
● Clinical Features:
○ Sudden or worsening back pain.
○ Neurological symptoms: lower limb weakness, sensory loss, saddle anesthesia.
○ Bowel or bladder changes: incontinence, retention.
● Assessment:
○ Bladder scanning (pre- and post-void), test of catheter sensation and catheter tug.
● Imaging:
○ Urgent MRI recommended within four hours of presentation, if confirmed: Immediate contact with spinal surgical team.
- Resource: GIRFT Cauda Equina Pathway.
Procedural Complication: Carotid Artery Cannulation
● Scenario:
○ Attempted ultrasound-guided central line placement.
○ In-plane view did not show guide wire clearly; relied on blood characteristics.
○ Inadvertent carotid artery cannulation; artery became dilated.
● Outcome:
○ Patient was intubated and ventilated in ICU.
○ Subsequently suffered a stroke.
● Key Management Points:
○ Do not remove the line.
○ Do not flush with heparin or use the line.
○ Urgent referral to vascular surgery is essential for removal.
Paediatric Cases
Case 1: Post-Tonsillectomy Bleed
● Presentation:
○ Bleeding occurred five days post-op at 7 a.m.
○ No ENT on-site over the weekend.
● Management:
○ Intravenous access and resuscitation.
○ IV tranexamic acid administered.
○ Discussion around transfer with anaesthetic escort.
○ Preparation for potential airway emergency.
○ Use of adrenaline via gauze or nebuliser discussed.
Case 2: Head Injury at Soft Play Centre
● Presentation:
○ Repeated vomiting post-minor trauma.
○ Vitals: HR 80–90, BP ~110 mmHg.
● Actions:
○ 2222 call for paediatrics and anaesthetics support.
○ CT scan was normal.
○ Consulted with PICU retrieval team; patient later extubated and discharged.
● Learning Point:
○ Early escalation via 2222 enables timely, safe care and transfer.