Authors: Susie Hewitt, Jonny Acheson / Codes: SLO2, SLO6, SLO7, SuC10, SuP1, SuP2, SuP7 / Published: 21/01/2015
This is the second in a series of Emergency Casebooks from the virtual hospital CFN General, with key learning points for staff working in an Emergency Department (ED).
Source CFN Inquest
An 81-year-old female who had only previously attended the CFN General Emergency Department on three occasions for minor injuries presented via ambulance. The dispatch information given to the crew en route to the patient’s home was “acute retention”. The paramedic documented that she had a one-day history of vomiting on a background of reduced mobility over the previous 5 weeks. She had vomited about 300mls. After questioning her more about the vomiting the paramedic concluded this was “coffee ground”. The patient was opening her bowels regularly but said she had not passed urine for 30 hours. She complained of pain around the umbilicus, which had moved to the epigastrium. Her vital signs were normal with the crew but she described her pain as 5/10.
On arrival at the CFN General ED her pain score was 2/10 and she declined pain relief. Observations were recorded: temperature 37.1 degrees, respiratory rate 16 breaths/min, pulse 92 beats/min, BP 188/85mmHg and oxygen saturation 94% on room air. The ED assessment nurse requested a bladder scan and blood tests. A urine test was also requested and a urinary catheter was considered. An ultrasound bladder scan was performed showing an estimate of 495ml of urine in the bladder. The patient was examined by one of the CFN General ED doctors. The doctor documented a background of hypertension, congestive heart failure and depression. Her regular medication was bisoprolol, fumarate and citalopram. The CFN doctor understood that the patient lived with and was cared for by her daughter. The doctor documented the main concerns were that she had pain all over her abdomen and had been vomiting that day. She had been unable to pass urine. On specific enquiry the patient denied chest pain, shortness of breath or palpitations. She also denied a cough and a fever. She had not suffered from constipation or diarrhoea. The ED doctor described the patient as looking dehydrated. Examination of the chest showed crepitations in both bases. Heart sounds were normal. The abdomen was documented as “soft”. Both feet were noted to be swollen.
The initial conclusion was of possible urinary retention but the patient had by then passed approximately 500ml of dark coloured urine. This was tested and showed blood 4+ and protein 4+. The ED doctor prescribed paracetamol and metoclopramide. A chest x-ray was considered to show haziness of the left base with a possible pleural effusion. An ECG was normal. Blood results included: haemoglobin 163, white cell count 20.1 and platelets of 361. Renal function: sodium 136, potassium 4.9, urea 11.5 and creatinine 51. Glucose was 7.2. A repeat set of observation were performed: temperature 37.7 degrees, BP 154/89mmHg and pulse 79 beats/min.
The CFN ED doctor thought the patient was suffering from gastritis and advised her to increase her oral fluid intake and to elevate her legs. The doctor noted the raised white cell count and documented that no source was found. The patient’s daughter was happy to take her home.
The patient returned to the CFN General ED two days later. She had continued to vomit since she had been discharged and said the vomit was brown and foul smelling. She had not opened her bowels for 5 days. Another ED doctor saw the patient and described her as unwell, dehydrated with no fever. Examination of the chest and heart were normal. The abdomen was noted to be distended and diffusely tender. A rectal examination showed no masses or tenderness and normal stool.
A venous blood gas showed a compensated metabolic acidosis. A chest x-ray showed a small pleural effusion on the left and consolidation at the right base. The abdominal film showed a few loops of small bowel and was non-diagnostic. The patient was transferred to the surgical ward.
Around two hours later she had a cardiac arrest. During the resuscitation faeculent material was noted in both the nasogastric and endotracheal tube. Although circulation was restored the patient remained profoundly acidotic and she was transferred to the Intensive Care Unit. On the unit a surgical registrar examined the abdomen and noted an incarcerated left femoral hernia. The surgical consultant considered that the patient was too unwell for surgery at this stage and she died soon after this.
General learning points
- Beware of abdominal pain in the elderly, the cause is often surgical
- Document a full abdominal examination: “soft” is not sufficient
- If blood test results are unexplained or the diagnosis is not clear, seek senior advice and give detailed safety net advice and document this in the notes
- Older patients have poor airway reflexes and will aspirate when vomiting
- Femoral hernias are relatively uncommon (2-8% of all adult groin hernias, accounting for a fifth of all groin hernias in females but less than 1% of groin hernias in males)
- Incarcerated femoral hernias are the most common incarcerated abdominal hernia, with strangulation of a viscus carrying up to 14% mortality.
- Femoral hernias are a common cause of small bowel obstruction
- Forty percent present acutely and are associated with a 10-fold increased risk of mortality
- Patients may present with vague symptoms including groin discomfort that may be attributed to other disease such as osteoarthritis
- As femoral hernias are typically small, they may be easily missed on examination, particularly in obese patients
- Femoral hernias may be mistaken for inguinal hernias and referred for surgical opinion on a non-urgent basis.
- About a third of patients do not complain of symptoms directly attributable to a hernia and a groin lump is not always present. Other diagnoses, such as gastroenteritis, enlarged groin lymph node, diverticulitis, or constipation, may be made in error.
Outcome The coroner made a narrative conclusion. During the inquest the coroner placed emphasis on learning about femoral hernias. Follow us on twitter @EM3FOAMed Contact via email email@example.com or firstname.lastname@example.org Post any questions or comments below and we will address them in a subsequent podcast