You are called to review an 86-year-old female, with severe pleuritic chest pain and difficulty breathing following dilation of an oesophageal stricture. Her CT thorax scan confirms an oesophageal perforation.
Outline your management of this problem, including the options for definitive treatment.
This is an emergency situation. Leakage of oesophageal and gastric contents results in a severe necrotising mediastinitis with sequelae of septic shock, multi-
organ failure and death. Mortality is about 20% and probably higher in this age group.
The principles of management are:
An acceptable answer for a pass mark included the following elements:
Resuscitation
Antimicrobial therapy
Surgical and non-surgical options
Nutrition
Additional Examiners' Comments:
Most candidates were able to describe surgical and non-surgical options for definitive treatment. However candidates who did not pass provided superficial answers with insufficient detail. Most candidates addressed the ABCs but did not address the specific issues for the case. For example, issues such as consideration of nutrition, keeping the patient nil by mouth, analgesia and treatment limitations were commonly missed in the answers. Some candidates did not appreciate the need for resuscitation
Immediate management
Investigations:
Specific Management
Supportive management:
Idiosyncratic ICU issues
Social issues
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