Seeing is Believing...

This is our 2nd case in a case series exploring the care of patients with GI related illnesses in the Emergency Department.  Similar to our "Out on a Limb" and "Sepsis Smackdown" case series, the case presented is followed by a series of questions, with a discussion in the comment section facilitated by the post authors.  In approximately 1 month, the authors of the post will conduct a combined simulation/small group session reinforcing the learning points from the posts during Grand Rounds.  Around this time, they will also curate the comments from the discussion and publish a post highlighting these learning points.  Looking forward to a great discussion!

You settle in to your 6th of 6 shifts in a row in B Pod in your tertiary referral center when you sign up for your first patient. Ms. Circling is an 86 year old female who presents with abdominal pain and altered mental status. She presents with her family who gives most of the history that for the last 2 days the patient has been complaining of abdominal pain and has not been eating or as active as normal.

Her past medical history includes atrial fibrillation (on rivaroxaban, diltiazem), hyperlipidemia, diabetes (metformin only), coronary artery disease (on ASA, carvedilol), chronic kidney disease (baseline Cr 1.5),

On examination, the patient is arousable but sleeping when not stimulated and in pain when awoken. She has tacky oral mucosa, heart examination reveals tachycardia with an irregular rhythm. Her abdomen is diffusely and nonfocally tender, when asked to identify a focal area, she points to her umbilicus.

Initial vital signs: Temp 100.4, HR 110, BP 100/40, O2 saturation 96% on room air, RR 18

Pertinent labs include a WBC of 17, Hgb of 10.2, sodium of 130, potassium 4.8, chloride 96, HCO3 14, BUN 43, creatinine 2.2, VBG: 7.25, CO2 25, BE -6, lactic acid 3.8

When responding you need only respond to 1 or 2 questions (leave some fodder for others!) and please begin your response with Q1, Q2, etc, denoting to which question you are responding.

Question 1

What is your differential diagnosis and what additional laboratory studies will you need? In the patient’s clinical scenario, with acute on chronic renal insufficiency and a creatinine of 2.2, what imaging do you choose to use? If you choose to use contrast, what kind?

Question 2

Your charge nurse informs you that there are a number of traumas coming in and your CT scanner will be tied up for hours, does this change your diagnostic strategy? How?

Question 3

You settle on a non-contrasted CT of the abdomen and pelvis which reveals colonic ischemia with stranding at the splenic flexure. What is included in your initial stabilization and therapy? What services are you going to get involved?

Question 4

After your initial resuscitation your repeat vital signs and labs are T 99.2, HR 94, BP 110/55, O2 96%, RR 16 with unchanged CBC and renal panel, VBG: 7.3, CO2 30, BE -4, lactic acid 3.2. Does this change your management and disposition for this patient?