"Episode 10"

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"Show Notes"

"Pain assessment and management of paediatric patients in ED?"

RCEM “Painful to think about" Assessment and Management of Pain in the ED”

provides excellent guidance on this.

Have you considered using this guidance to help improve your local hospital’s management of pain in paediatric patients?

"Back pain"

Clinical Governance Case 1:

50 years old male presented with back pain.

SBP 100, HR 120, VBG showed: lactate 10.

What is your differential diagnosis (D.D.)?

AAA (abdominal aortic aneurysm)

must be at the top of your D.D. list!

Learning point:

- Early recognition of AAA is important.

- Escalation to a senior where appropriate.

- Bedside POCUS can be helpful.

Clinical Governance Case 2:

45 years old female presented with back pain.

Initial focused history and examination presented no red flags, and observations were unremarkable.

3 weeks later, the patient presented again with ongoing back pain and a new rash.

How would you manage this case?

- History revisited

- Blood was sent for teats & showed CRP 250.

- No spinal tenderness.

- The patient was admitted and had further investigations.

Diagnosis:

"Discitis secondary to infective endocarditis"

Learning point:

- Diagnosis may not always be obvious initially, discharge the patient with clear safety netting advice

- Have a broad differential diagnosis of back pain, especially the rare but potentially serious causes.

- Revise RCEM summary of “Acute lower back pain”.

"Headache"

Clinical Governance Case:

67 years old female presented with a 3-week headache with a background of migraine.

On examination, you found mydriasis and ptosis with no diplopia..

What are your thoughts?

https://www.allaboutvision.com/conditions/related/third-nerve-palsy/

"Oculomotor nerve palsy"

Causes:

- vascular ischemia, trauma, intracranial neoplasm, haemorrhage, congenital, idiopathic (1)

In this patient’s case: the CT head showed: Nothing acute; the CT Angio showed: a posterior communicating aneurysm.
The patient was admitted to the specialist team and underwent elective DSA (Digital subtraction angiography) 48 hours after admission.

"Strangulation"

Clinical Governance Case:

A female patient presented with domestic violence, she suffered from a non-fatal strangulation (NFS) with loss of consciousness (LOC).

How would you manage this case?

- Helpful guide: ENT UK, “Guidelines for clinical management of non-fatal strangulation in acute and emergency care services”.

- The patient had LOC, which is considered a red flag in NFS, and thus imaging is recommended.

- CT angiography of neck and intracranial vessels performed

- Fortunately, it showed no acute injuries.

Learning point:

- Do not forget to manage potential safeguarding concerns and offer domestic/sexual abuse support where appropriate.

Is this a DVT?

Clinical Governance Case:

42 years old patient presented to the Emergency Department (ED) via GP for suspected Deep vein thrombosis (DVT) and was commenced on a Direct oral anticoagulant (DOAC).

History-taking showed that the patient developed a sudden onset of right calf pain and swelling, which worsened over the last 8-9 days. Now the pain is out of proportion.

Examination: Swollen tender right calf. No history of trauma/chest pain or SOB.