Questions

CASE SCENARIO I (INITIAL ASSESSMENT)

You are on duty, and you received a phone call from UCC Hospital. They have a
hypoxic female professor who is unconscious and in shock. They have given several
litters of fluids, but the patient is still in shock and has not produced adequate urine
over the past 4 hours. They want to bring the patient here for specialist care as they
can’t seem to figure out what is happening.
Vitals T34.5 RR-40cpm BP-70/40mmHg HR 193bpm SPO2- 89% on NRM UPT-
negative RBS-10.3 mmol/L.

1. Outline how you will assess the situation before the referral is made to your
facility?

Solution

Assessment Outline:

 Primary Survey (ABCDE Approach):

o Airway: Ensure airway patency, check for obstructions, and consider intubation if
compromised.
o Breathing: Assess respiratory rate, oxygenation, and provide high-flow oxygen. Use
mechanical ventilation if necessary.
o Circulation: Review blood pressure, heart rate, and perfusion status. Begin
aggressive fluid resuscitation with crystalloid solutions and consider vasopressors if
hypotension persists.
o Disability: Evaluate consciousness level (GCS), assess for neurologic deficits, and
check blood glucose.
o Exposure: Fully expose to check for any injuries or signs of infection.
 Focused History and Laboratory Tests:

o Perform blood gas analysis, complete blood count, and electrolytes.

o Test renal function and urinary output.
o Arrange for urgent transfer to a facility with intensive care.

CASE SCENARIO II (INITIAL ASSESSMENT)

A 40-year-old obese male presents with sudden loss of consciousness. Relatives say
he is an alcohol abuser who has been taking alcohol over the past 5 years after he lost
his mum in a road traffic accident. He fell from a bicycle about 8 days ago but
sustained minor bruises on his forehead. 3 days ago, he started complaining of
headaches and was noted to be sleeping more than usual. He was sent to the hospital
nearby where he was given some pain medications that made him feel much better.
This morning while going to the bathroom, he fell and was noted to be twitching on
his left arm and leg. He has been brought here for treatment.

1. How will initially assess the patient in the ED?

2. List your most likely diagnosis and 2 other differentials.
Solution

1. Initial ED Assessment:
1. Primary Survey (ABCDE): Start with airway and breathing assessment, proceed to
circulation with intravenous access and fluids, then neurologic evaluation (GCS and
pupils).
2. Focused Neurological Exam: Assess for lateralizing signs and perform a full
neurologic examination to evaluate for intracranial issues.
2. Diagnosis and Differentials:

1. Most Likely Diagnosis: Subdural Hematoma (due to the fall and altered
consciousness).
2. Differentials: Acute alcohol withdrawal seizures, hypoglycemia, or subarachnoid
hemorrhage.

SCENARIO III

A 40-year-old female with chest pain and a history of rheumatoid arthritis presented
to the ER with chest pains and breathlessness.
She is talking in short sentences as she pauses in-between to catch her breath. She has
a respiratory rate of 30cpm with reduced air entry bilaterally, spo2 of 89% on room
and dull notes to percussion.
Her BP is 84/40mmHg and she has cold clammy skin. She is diaphoretic and her heart
sounds are heard but rather distant. Her heart rate was 120bpm, regular and with
reduced volume. You also notice that her neck veins seem distended. Her ECG shows
a low-voltage QRS complex on the cardiac monitor. Her eyes are spontaneously open
and her pupils are equal and reactive to light. She however seems a bit confused as
her speech is incoherent and she withdraws from pain. Her random glucose was
10.8mmol/L and seems to move all limbs equally.

Questions
1. What is the GCS of this patient?
Glasgow Coma Scale (GCS) Calculation:

 Eye Opening (E): Spontaneous - 4 points

 Verbal Response (V): Confused - 4 points
 Motor Response (M): Withdrawal from pain - 4 points
 Total GCS: 4 (E) + 4 (V) + 4 (M) = 12/15

2. What is the next most appropriate step in the management of this patient?
A. Set 2 large bore cannulas and give 1L bolus of 5%ringers lactate and reassess her
bp status
B. Refer the patient immediately to a specialist as the patient's condition is serious.
C. Give oxygen to the patient and reassess her oxygenation status
D. Pass bilateral chest tubes immediately to improve oxygenation.
E. reassess the patient's airway and perform patency manoeuvres
3. Based on the clinical information above, what is the most likely diagnosis?
A) severe left ventricular failure
B) acute myocardial infarction
C) massive pulmonary embolism
D) cardiac tamponade
E) tension pneumothorax

4. What 1 bedside investigation can be done to confirm the patient's diagnosis?

 Answer: Bedside Echocardiogram

 Explanation: A focused bedside ultrasound or echocardiogram will provide direct
visualization of any pericardial effusion and assess for signs of tamponade physiology, such as
diastolic collapse of the right atrium or right ventricle. This investigation is rapid, non-
invasive, and definitive for cardiac tamponade.

5. What is the immediate intervention for this patient's diagnosis?

· Answer: Pericardiocentesis
· Explanation: Cardiac tamponade is a life-threatening condition that requires immediate relief of
pericardial pressure by removing the excess fluid surrounding the heart. Pericardiocentesis is a crucial
intervention to prevent circulatory collapse in this patient.

6. What is the shock index of this patient?

—And what does the patient's score mean?
— what class of shock is this patient in?
— what type of shock does this patient have?

· Shock Index Calculation:

 · Heart Rate (HR): 120 bpm

 Systolic Blood Pressure (SBP): 84 mmHg
 Shock Index (SI) = HR / SBP = 120 / 84 ≈ 1.43

· Interpretation of Shock Index:

 · An SI greater than 1 suggests significant circulatory compromise and potential shock. A

value of 1.43 indicates a critical state where immediate intervention is necessary.

· Class of Shock: This patient falls into Class III shock, characterized by
tachycardia, hypotension, and signs of poor perfusion such as clammy skin and
altered mental status.

· · Type of Shock: Obstructive Shock

 · Explanation: Cardiac tamponade leads to obstructive shock by limiting the heart's ability
to fill adequately, reducing cardiac output. This, in turn, leads to hypotension and
hypoperfusion of tissues.
Scenario

Rebecca went to the beach and was challenged by Collins to dive in the pool. Rebecca
was peer pressured to dive for the first time. She dived and landed her head at the base
of the pool and felt a sharp pain in her neck. She could not feel her hands and legs
soon after but was suddenly rescued by a lifeguard as whe nearly drowned. She was
brought to your emergency department where you are the clinician on duty.
On initial assessment, the airway was patent but had a midline c-spine tenderness,
breathing was mildly labored with a rate of 25cpm and had fine bibasal crepitations.
Her Bp was 100/60 and HR was 50bpm, regular, CRT was 3 seconds and had warm
extremities.
GCS is 15/15, pupils are equal and reactive to light but power is 2 in all LIMBS. RBS
was 10mmol/L
She has a scalp contusion, and her sphincter tone was lax on rectal exams.

Questions
A. Which unstable c-spine injury is likely in this patient based on the mechanism of
injury?
· Answer: Jefferson Fracture (C1 burst fracture)
· Explanation: Diving headfirst into a hard surface can cause axial loading, which compresses the
cervical spine and may lead to an unstable fracture, such as a Jefferson fracture. Given her inability to
feel her limbs, there is a high suspicion of a significant cervical spine injury.

B. List 3 other unstable c-spine injuries you know.

· Hangman’s Fracture – Fracture of the pars interarticularis of C2, typically due to hyperextension.
· Odontoid (Dens) Fracture – Fracture of the odontoid process of C2, common in trauma.
· Flexion Teardrop Fracture – Often occurs in high-energy trauma and is associated with severe
spinal cord injury.

C. What type of shock is likely in this patient giving the clinical presentation?
· Answer: Neurogenic Shock
· Explanation: Neurogenic shock is suggested by the hypotension (BP 100/60), bradycardia (HR 50),
and warm extremities, which are characteristic of a loss of sympathetic tone due to a high spinal cord
injury.

D. Mention the most likely non-cardiogenic cause of this patients’ pulmonary edema.
· Answer: Neurogenic Pulmonary Edema
· Explanation: Neurogenic pulmonary edema can result from a significant central nervous system
injury, which may lead to increased pulmonary capillary permeability due to a sudden surge in
sympathetic activity. This condition is common following severe brain or spinal cord trauma.

E. List 3 medications that is usually used in the management of this patients shock
· Norepinephrine – Acts as a vasopressor to maintain blood pressure in cases of hypotension due to
loss of sympathetic tone.
· Atropine – Used to manage bradycardia associated with neurogenic shock by increasing heart rate.
· IV Fluids – Typically administered to ensure adequate preload, although with caution to avoid fluid
overload, especially if there’s neurogenic pulmonary edema.

F. Write an x ray request for this patient that will help you to assess this patients c-
spine injury.
· X-Ray Request Wording:

 “Please perform an AP, lateral, and open-mouth (odontoid) view of the cervical spine to
assess for any cervical spine fracture or instability.”

· Explanation: A full cervical spine series, including the odontoid view, will help visualize any
fractures of the cervical vertebrae and assess alignment, which is critical for diagnosing unstable
injuries in trauma cases like this one.