uh this is case study number 11. uh patient presenting with abdominal pain pretty cool one um let's get to thinking all right guys you guys know the deal these cases are made up they're not real um we make them for educational purposes only alrighty so first thing here we go you got a 65 year old female whoopsie you got a 65 year old female she comes in to the ed with a past medical history of atrial fibrillation hypertension and just a recent diagnosis of diverticulosis she presents to the ninja nerd clinic actually let's say the ninja nerd emergency department with an acute onset of constant non-radiating diffuse abdominal pain without any kind of palliative factor so nothing has been helping at all to relieve this pain she's just begging for help to relieve the pain she also says that she has some associated nausea vomiting you ask her when her last bowel movement was and she says it was around 10 hours ago okey dokey so 69 year old female past medical history afib hypertension recent diagnosis of diverticulosis comes in with diffuse non-radiating acute onset abdominal pain which nothing is making it better she has associated nausea vomiting and a bowel movement about 10 hours ago you walk into the room when you walk into the room you notice on the uh vitals like on the actual camera the um on the vitals signs there you notice that she has a heart rate of 150 beats per minute you notice a respiratory rate of 32 you notice a bp of 110 over 70. you notice a temp of 101.4 degrees fahrenheit and an spo2 of 94 percent okay so she is tachycardic she is to kipnick she is not hypotensive but she's on like the you know a normal range technically um and then temp wise she is fibril and she has an spo2 of 94 so she's not hypoxic so she's definitely takeipnic and tachycardic and fibril cardiovascular-wise she is tachycardic she has an irregular rhythm she has an s1 and s2 that's her normals you don't hear any other murmurs rubs or gallops okay pulmonary wise she's takeipnic you can visibly see that and she has some by basilar crackles but no wheezing or ronchi abdominal wise she is just grimacing in pain okay while she's holding her abdomen but when you go over to touch it it's it's not really hard it's nice and soft it's non-tender she has normal active bowel sounds when you're listening there and she doesn't even really have any rebound tenderness okay so right now we have a patient who is 65 female history of afib hypertension diverticulosis diffuse abdominal pain acute and onset non-radiating nausea vomiting bowel movement 10 hours ago tachypnic tachycardic febrile and in grimacing pain with really no obvious sounds uh signs on her abdominal exam that are you know really could point to why she's having this pain okay i hope that makes sense so with all of that being said from our history and our physical examination what's your suspected diagnosis what's your differential and you guys got to go through all of your different thoughts here about abdominal pain it's a pretty broad differential and you're supposed to use a couple different things utilize their history utilize their physical exam particularly where is their abdominal pain is it in the right upper quadrant is in the left upper quadrant is it periumbilical is it left lower is it right lower is it diffuse those are all things to be thinking about but if i were to just kind of give you guys a very generalized broad differential diagnosis that i'm going to give you guys options here which one of these do you guys have a high suspicion about okay maybe it's a couple of them maybe it's none of them maybe it's only one of them that you guys are really really thinking about but which one out of these do you guys definitely have a high suspicion about and maybe if nothing is on this list put in the comment box what else you guys are thinking about okay so some are saying mesenteric ischemia some are saying cholecystitis someone saying may be complicated diverticulitis acute bowel ischemia gi bleed small bowel obstruction acute mesenteric ischemia so it's a lot of them are coming between bowel obstruction and mesenteric ischemia someone asked a really good question jazz medicine a really good question is she anticoagulated no she's not taking any anticoagulation great great question super good question can we rule out appendicitis because of no rebound tenderness you can think about it there's also those other tests that you learn in school that you got to be thinking about right so you can perform uh you know you can think about like mcburney's point tenderness your rosving signed so those are other things that you could be thinking about but no i don't think it's completely off the table okay cystitis acute mesenteric ischemia so i'm getting a good chunk of acute mesenteric ischemia bowel obstruction i'm kind of getting a mixture and that's okay we can't like you know definitively say like what we think it exactly is but it seems like the most common one that's coming up here is acute mesenteric ischemia small bowel obstruction is coming up and some diverticulitis and some bowel purpose coming up a lot and i think that's a pretty good differential i think you guys are doing a great job okay so these are some of the things that we're thinking about the good thing to do from here is let's say that we have this as our differential things to be thinking about with some of these in a perfect scenario is pancreatitis we should think about what are the risk factors you know gallstones is there any kind of alcoholic you you know are they alcohol abuser of some kind that could be a trigger do they have hyperlipidemia you know is there any steroid use is there any particular drugs that they're on that could be a potential trigger do they have mumps virus you know you guys remember the mnemonic for pancreatitis i get smashed that's kind of a helpful way to think about potential etiologies but the most common ones is going to be you know alcohol abuse and gallstones by far she doesn't have any alcohol use she doesn't have at this point we don't know if she has gallstones she could we don't know that so there's a potential but pancreatitis usually presents with kind of like an epigastric kind of maybe mid abdominal pain that can kind of start radiating to the back okay and then they could present with some hypotension they could present with tachycardia they can present with fever small bowel obstruction again think about particular things uh small bowel obstruction it could be due to some type of mass she is older it could be like cancer related she doesn't have any history of any kind of recent abdominal surgeries that's a very very common causes like adhesions secondary to multiple kind of abdominal surgeries of some kind you know again there's also if she had like a hernia if there are certain things that could potentially make me think bile obstruction that's possible but bowel obstruction you usually think about some type of abdominal pain you think about vomiting you think about abdominal distension and potentially you know again some tenderness upon palpating the abdomen with some history of some kind of abdominal surgery usually in a perfect clinical vignette case appendicitis right right lower quadrant abdominal pain is the classic sign they have you know pain whenever you're palpating in their left lower quadrant and you're releasing sometimes it can cause some pain that kind of refers or radiates to that right lower quadrant they can have mcburney's point tenderness usually when you're kind of lifting they have what's called that iliac like the iliopsoas kind of test when you're lifting up their leg you're flexing at the hip it can kind of compress and squeeze near that appendix and that can cause some pain but again hers isn't really right lower quadrant usually with appendicitis you have way more like localized pain it can kind of radiate to like the periumbilical region and if it does perforate you can get some signs of peritonitis but usually there's some more pain upon palpating the abdomen a is definitely a possibility she's older all right so she's 65 she's female she has hypertension um you know we don't have any history of her smoking she says that she denies smoking we don't also know what her lipid panel looks like as well she could have hyperlipidemia which is another trigger but she's older she's female she has a history of hypertension there is no definitive smoking history but again it's possible because that can potentially be a significant thing to think about especially if that ruptures and then she develops significant hypotension or hemorrhagic shock that's a big thing to think about pyelonephritis she doesn't have any flank pain it doesn't radiate but again it's something to think about she does have fever she does have some you know diffuse abdominal pain that's maybe difficult to identify it's a potential for a pyloritis peptic ulcer disease um again you know this is another thing to think about usually that's kind of like an epigastric pain usually kind of a burning one radiates to the back also want to think about this in patients who you know there is inside use that's a potential thing but it's used usually like helicobacter pylori and the pain depends upon where it is if it's a duodenal ulcer or if it's a gastric ulcer the pain kind of differentiating those depends upon when they're eating if they're developing pain when they're eating or if they're developing pain after they're eating but usually it's somewhere around that acute mesenteric ischemia she has atrial fibrillation and someone asked a great great question which is she's not on any anticoagulation so that's a good thing to be thinking about because if she is on anticoagulation there's some form of basically trying to prevent her from forming clots on that valve that could pop off and potentially embolize enteric vessels as a potential thing to think about here diverticulitis she's older she has a history of diverticulosis she didn't complain of any obvious gi bleed like lower like bright red blood per rectum but it's a possibility she has a fever usually that's a little bit more left lower quadrant pain but it's something to think about with her recent diagnosis of diverticulitis so that's a possibility cholecystitis right upper quadrant abdominal pain again usually with that one you can have fever usually there's a positive murphy sign again things to think about here it's a possibility bowel perf it's unlikely since she doesn't really have any super rigidity of the abdomen uh she's not super hemodynamically unstable at this moment and usually there is some like rebound tenderness and just rigidity of the abdomen um nephrolithiasis that's a possibility again kind of lower on the differential but i think you guys a lot of you guys made a pretty good like for the most part uh differential out of these which is most of you guys have said acute mesenteric ischemia diverticulitis some of you guys said some small bowel obstruction i don't think that that's a bad idea but i think yeah pretty pretty good stuff so far okay let's move on so we got our kind of some of the things that we're thinking about the next thing that now that we kind of have a good idea of their history their physical exam we have a differential running through our head at this point in time what labs would be the things that you would say okay hey can you can we start off with these these these because these might help me to potentially rule out some of these things so you got to think about it these are some of the things that we have on our differential here is there any labs that i could order here to say okay this potentially could rule out this condition or it's still i haven't i don't have enough evidence to rule this out yet it just kind of is going to help me to determine to kind of go through my differential and say what kind of labs could i order that would help me out at least somewhere in this to say it's unlikely that it's this or it's still likely that it's this okay what do you guys think okay we got some tons of laps we got cbc bmp abg we got some coags um we got hepatitis lfts fecal occult blood tests i think someone meant to put you i think toyo meant you and a so you at urinalysis lipase amylase blood cultures okay crp lactate yeah i think all of these are are great man you guys are awesome one of you guys picked one that i didn't think of which i think is not a bad idea and it's a good idea i actually probably should have put that down so good call on the blood cultures i did not put that down but she does have a fever it's not a bad idea to start some blood cultures but yeah we can start with the cbc first but i don't think it's a bad idea to have a consideration of someone coming in with just this very diffuse abdominal pain nothing really specific on their actual um physical exam that really points out what's going on with the abdomen having a fever and not really like hypotensive or anything but it's it's not a bad idea since they're tachycardic they're febrile they're tachypnic i don't think it's a bad idea so crp esr those are okay i'm not a big fan of you know crp and esr they can sometimes be helpful but the question that i want you guys to ask yourself is what would they tell me how would that help me in my diagnosis it's going to tell me that there's some generalized inflammation i don't think it's going to point me towards a diagnosis it's not a bad thing to order i just don't think it's going to be super helpful to get that but i think most of these are pretty good so let's go ahead and see what we order right here we go we ordered a bunch of those tests i'm just gonna say that the other one that somebody asked about the blood cultures they were negative okay that was a good one though that was a good i thought that was a good thought but here's what we got as our lab results so on the lab results our cbc came back we got a white count 20k so they got a leukocytosis we got their cmp back their anion gap is 14. their bicarb is 16 which is low ua within normal limits abg ph is 7.25 so they're acidotic their po2 is 84 so they're not hypoxemic they're within the 80 to 100 range 46 is their co2 it's just like one point higher than normal so it's not super significant and their bicarb is 15. okay so we have so far a leukocytosis an anion gap metabolic acidosis based upon their bicarb and their abg from their cmp here their lactate is 5.8 so i got a lactic acidosis you always want to think about that right if someone has an anion gap metabolic acidosis if you guys watched our video on metabolic acidosis think about the three particular things ketoacidosis uremic acidosis lactic acidosis or some type of toxin or drug mediated lactic acid i'm sorry toxin or drug mediated acidosis so we have our reason here which is the fact that she has a lactate of 5.8 so we know that she has a lactic acidosis a leukocytosis her lipase and amylase is it's within the normal limits her typing screen just in case you can always order a type in screen in case you suspect that this person needs blood a positive her troponins i was kind of surprised so sometimes here's a big thing to think about i missed it one time had a patient who came in with some epigastric abdominal pain any time someone has abdominal pain you should always be thinking about the potential of an mi especially inferior myocardial infarctions i think someone might have said it in there but don't forget about those okay just because someone's presenting with abdominal pain doesn't rule out that there's something going on with the heart sometimes the referred pain from an inferior mi could potentially be uh you know something that is actually kind of causing that radiating abdominal pain so don't forget it so you want to get like an ekg and correlate it with their troponins their troponins were negative thank goodness right so the troponins were less than 0.02 so normal and you got some serial ones too her fecal blood test was negative as well so she doesn't have any like obvious blood on on her exam okay let's see what you guys are saying here i just want to check it out here okay is it too early to do endoscopy um yeah i would say so uh when you perform an x-ray of the abdomen we'll get there they're not specific this soon on amylase lipase sorry just looking at you guys is so why is patient acidotic that's a good question we'll get to it in a second well actually let's think about it now what's what's causes for lactic acidosis why uh what would make you guys think of lactic acidosis like what are some potential causes there's two types type a type b type a tells us that there's some type of hypoperfusion to the tissue not enough oxygen is being delivered to the tissue if not enough oxygen is being delivered to the tissue your uh your process of glucose getting converted into pyruvate and then into acetyl coa right that step from pyruvate to acetyl-coa is going to be hindered you aren't able to convert pyruvate into acetyl coa instead those nadhs can't be used in the electron transport chain they dump it off on pyruvate shunting into making lactate so there's something that's causing her to not get enough perfusion to the tissue that's one potential cause the second one is type b there's some drug mediated inhibition of the mitochondrial or electron transport chain of some kind that's potentially inhibiting her from being able to make atp or inhibiting some aspect there that's altering her uh aerobic cellular respiration krebs cycle electron transport chain there's no real drugs that she's on right now that's going to cause the type b so i'm leaning more towards type a type a lactic acidosis you got to think about this type a lactic acidosis would be due to what could be due to something's wrong with the lungs the lungs aren't being able to oxygenate okay to bring oxygen in and if they aren't able to bring oxygen get into the blood there's low oxygen as a hypoxemia from the lungs okay that's one potential thing she's sadding 94 percent she is a little too kipnic but that could be because she's acidotic and trying to breathe off her co2 that's one potential reason okay it also could be that she has a low blood volume so if she has a low blood volume there's less blood that's actually being delivered to the tissue that's less oxygen being delivered to the tissue that's also causing the lactate bump her blood pressure was on the low-ish side okay if we slap on the ultrasound and we start look to see what her ivc tells us let's say that it says that it's indeterminate she's somewhat fluid responsive but not like super collapsed okay so i'm not leaning towards that other things to think about is does she have like sepsis is there an infection a systemic infection that's causing her to be septic and there therefore she's having a lot of leaky capillaries and a lot of her effective arterial blood volume is dropping does she have severe anemia where she doesn't have enough red blood cells to be able to deliver oxygen to the tissues or is there a clot that's blocking blood flow to an organ and therefore that organ is not getting oxygen and it's starting to be it's starting to spit out lactate as a byproduct okay so that is the things to think about of why she could have uh potentially a lactic acidosis okay so i think at this point we can rule out that it's a hypoxemia from the lungs she doesn't look like she's her cbc was only thing that was pertinent was her white cell council she doesn't have a severe anemia on her blood pressure she's not super tanking she could be septic she has a white count we don't know if she has an identified infection i did tell you her blood cultures were negative her ua is normal we got a chest x-ray that didn't really show anything so i'm kind of leaning toward not being septic um and again we established that her ivc wasn't like super collapsible she wasn't super volume down we gave her some fluid boluses and she kind of improved a little bit but i'm kind of leaning towards the other option here is is there a clot somewhere and that clot is obstructing blood flow to the organ and the organ isn't getting perfused and therefore it's spitting out lactate could be her piece in amylase is within normal limits what can that kind of it's not a guarantee but what can that kind of rule out at this point can you guys tell me what we can at least say i have a low suspicion of this now just reading you guys comments while you guys are answering and stuff what could i say again out of amylase and lipase kind of for the moat yeah good job it's not a completely clear rule out but i have a lower suspicion of pancreatitis for the most part so at the most part i kind of at least ruled out that her troponins were negative i still i haven't looked at her ekg yet so i can't say that she doesn't have an mi yet i don't have enough other tests i know that she doesn't have an obvious gi bleed right now her fecal cold blood test is negative so it's tough to say i still don't have really enough i could just say i have a kind of a lower suspicion of her having any kind of pancreatitis a cholecystitis generally there's some kind of elevation in billy there's a potential to have an elevation in their lfts those are all normal i'm not saying that again it's not possible but i'm not like super you know confident and you know suspicious of cholecystitis peptic ulcer disease is unlikely to cause a massive white count like this is unlikely nephrolithiasis is unlikely to cause a massive white count like this pyelonephritis could still do this appendicitis you can get an elevated white count and if she did perf there's a potential that she could have some underlying sepsis again it's we're not super confident about what's going on here yet okay i think we can kind of say that from the lab results all right so what images would you guys want so we haven't completely ruled everything out i'd say for the most part we have a low suspicion of pancreatitis i'd say i have a lower suspicion of peptic ulcer disease i'd say i have a lower suspicion of cholecystitis i have a lower suspicion of nephrolithiasis based on her exam i also am not like super enthusiastic about about perf but i don't want to miss anything i still think she could have diverticulitis i still think that she could have acute mesenteric ischemia there's still a possibility of pilo aaa i'm not really leaning towards that either you know triple a's aren't generally just going to cause a massive leukocytosis and fever i i'm not leaning towards that either so you know i kind of have a low suspicion of some of them and a relatively higher suspicion of others okay so you guys tell me what images you want and we'll we'll think about those okay x-ray i'm all about it i love just simple quick you know tests that you can just order it's a really quick like if we had you know if she's relatively unstable you can get a portable abdominal x-ray or you can take her to x-ray if she's relatively stable at this point in time so i think an x-ray is a great thing ultrasound you can't go wrong with an ultrasound you can do a bedside or you can get a formal ultrasound i'm a high i'm a big believer of being able to perform point of care ultrasound at bedside can really speed up some processes and just help in aiding in your diagnosis in a quicker rate um lolly 95 she was not a smoker um like when we talked about her history there was no underlying kind of uh uh social history of tobacco abuse or tobacco use good question though so you get an abdominal x-ray ultrasound what else do people like a ct of the abdomen okay with contrast sounds good yeah and you can do a ct i think someone was saying ct with contrast you could do it with oral contrast or you can do it you know with iv conscious you can do both so you could do a ct you know oral contrast iv contrast and just hit it in the different phases maybe you want it in the arterial phase maybe you want in the venous phase for the iv contrast and then if you do the at you know what the oral contrast is going to light up parts of your gi tract so a lana why would you avoid any contrast imaging so jazz and medicine you have to hurry up ctiv contrast i i would agree with that i think that's a good idea but yeah if you want to do a quick abdominal x-ray there's no hurt in that if you have ease of access usually the x-ray techs are within near close by proximity of the er it's a quick easy thing that usually they're on standby you can have them come in shoot a quick abdominal x-ray and then take a look and then send them over to ct x-ray you may potentially miss something if you get the if you don't get the ct that's not to say it's not possible for you to pick something up but if you get an x-ray it might help to rule out something like a you know a pneumoperitoneum any obvious obstructive bowel syndrome like signs if you get an ultrasound it could help to potentially rule out any kind of cholecystitis ductile dilation any perinephritic fat stranding peri-pancreatic fat fat stranding maybe even you could throw on some doppler and potentially to see if there's any decreased flow in any areas that's potential but it's not a complete thing to rule out some of these conditions uh cyara her so she did get a cmp and her renal function was normal so she has no issues with her creatinine she has no issues with her gfr and again here's another big thing maybe we'll talk about this in the future but contrast induced nephropathy should not be a reason why you do not give someone contrast in an emergent situation that requires an immediate diagnosis that should not hinder you from performing an exam you can always fluid resuscitate them give them tons of fluid as a contrast prep and then get the study but it should never hinder you from performing a study that is necessary to diagnose and potentially treat something that could be serious i'm sorry i don't mean to be crazy i have a very big like pet peeve about contrast studies um i think that it's one of those things that again it should never hinder you from performing a study if there's a way that you can get a diagnostic test a definitive diagnosis it should not be something that hinders you from doing that test you get more acute kidney injury from drugs that we prescribe commonly like vancomycin that can cause more significant acute kidney injury than contrast will sorry i'm gonna get off my uh my pedestal i apologize a little bit of a pet peeve for me for that one okay so i think we got for the most part we're gonna start off with an x-ray we'll then go ahead and get an ultrasound we'll get a ct some people want a ct with contrast and then we can get a ct angiogram i think somebody else said i think those are good tests alrighty so we get an abdominal x-ray no bowel obstruction there's no pneumoperitoneum okay there should be no bowel obstruction no pneumoperitoneum ct with oral contrast that showed no obvious bowel obstruction there was no gastric thickening there was no peripancreatic or perinephritic fat stranding no obvious appendicitis the abdominal aorta was 3.5 centimeters so it's not dilated ultrasound of the abdomen with doppler showed that there was no cholecystitis no pancreatitis there was no hydro there was no appendicitis present her abdominal aorta was 3.5 centimeters and she has decreased flow in her sma cta of the abdomen showed an occlusion of the superior mesenteric artery okay so if you wouldn't have gotten the ct you could have potentially missed it now that's not to say if you got the ultrasound of the abdomen with doppler you couldn't have said there's a decreased flow in the sma why but you should probably confirm that with an actual test which is a cta or an angiogram okay and i think yeah so great so she has ischemia to the bowel so someone's like so it's the occlusion that causes the lactic acidosis exactly so she has ischemia one of the big things that you guys have to remember that's super important uh when you're thinking about this for your exams is if a patient comes in they're a woman they're greater than 60 years of age they also have history of atrial fibrillation and they have diffuse abdominal pain that's out of proportion to what their abdominal physical exam it kind of indicates high suspicion right away for acute mesenteric ischemia okay again i'll repeat that greater than 60 years of age female history of atrial fibrillation and someone asked an amazing question in there is she on anticoagulation no diffuse abdominal pain acute and onset and associated nausea vomiting and a physical exam that is she's got this pain that is just disproportionate to what her abdominal physical exam finding is have a high suspicion for acute mesenteric ischemia okay it's good to be thinking about all these other things and we can rule those out have the differential think about what labs and imaging will help me to rule those things out and rule in something else okay so i think that for the most part gives us our diagnosis another thing that helps us with our diagnosis is an ekg we were asking about that and i think someone also said did she have an mi well let's look here if we take a look at her ekg what do we do we determine our rate first it always should be rate we can see that there's about two boxes between here it's it's irregular you could count all of the r waves and then multiply it by six you could take for the most part finding an area where it's at least you know between the r waves it's at least two boxes so she's around 150 beats per minute we also had that on the monitor that she was around 150. so we know that she's around 150 beats per minute ish we look to see the rhythm is it regular irregular there's variation in our r interval it's irregular right is it sinus do we have p waves in lead two well there's no like definitive p waves that i see in lead two i see my qrs i see my t wave you can say i wonder if this is a p wave it's tough to say right we look at our avr and the avr should be inverted i don't see any obvious inverted p waves here i kind of actually see like little fibulatory waves but there's no obvious p wave that is upright and lead to and inverted in avr so therefore i can't say that it's sinus rhythm because again i don't have an i have what maybe looks like an upright p wave but it should be inverted in avr correct and the way we can do this let's say that we find an area that we think could be a p wave now let's say that we think like let's say okay i think this is a p wave and i follow this all the way up there should be an inverted p wave in avr that lines up with that there isn't so therefore i don't think that this is an obvious sign of sinus rhythm what would we do next okay what kind of rhythm is it well we can have a differential in our heads tachycardia irregular rhythm no obvious sinus rhythm okay we should think about afib atrial flutter which is in a you know a variable conduction block or multifocal atrial tachycardia i don't see any again differences in p waves and how do we determine the difference between flutter and afib the best lead to look at your money lead for atrial activity is v1 look at that look at that crap there there's all of these fibulatory waves here and v1 that's your money lead okay so she's an obvious afib the next thing is to say does she have any st segment elevation st segment depression because that was something that we were trying to look for well i don't really appreciate any st segment elevation or depression and really any of my inferior like my inferior leads i don't appreciate really any in my lateral leads i don't appreciate any st segment elevation or depression and my septal leads i don't appreciate any um again there's always a discordance between here between your actual your uh your septal leads but if you follow scarbosa's criteria this would not fit scarbosa c criteria um and again i don't appreciate any st segment elevation depression in any of my precordial leads so again with that being said i don't have a very high suspicion of an n-stemi or a stemi okay so what's likely to happen that happened with this lady is that she probably was in atrial fibrillation there was inadequate atrial kicks she had decreased flow from the atria down into the ventricles leading to a embolus or a clot that formed in the atria wall within the left atrial appendage on the left atrial mitral valve then what happened is she popped that clawed off it then floated into the left ventricle into the aorta down the aorta off the superior mesenteric artery got lodged there and decreased the blood flow downstream to the organs that the superior mesenteric artery supplies which is the bowels and she's probably starting to just begin to infarct those actual organs those small bowel uh parts of her organs okay so anything that's supplied by the superior mesentery in this case her small bowel is probably beginning to infart it hasn't infarcted enough where she's actually started to bleed usually that's a little bit more of a later sign where they developed that the current jelly bloody stools but she's she's getting there and so this is something that we need to take care of pretty quickly okay so good good thing that we've at this point in time we have a female greater than 60 she has afib not on anticoagulation obvious afib she has diffuse abdominal pain not character pain is out of proportion to her exam we have definitive diagnosis on our cta okay the most gold standard diagnosis is an angiogram though so the next question is what's our diagnosis we know it's acute mesenteric ischemia secondary to atrial fibrillation not on anticoagulation okay now you guys did great so what's the treatment what are we going to give her what are we going to give her guys what should i treat her with okay let's let's say the first thing to think about which side some type of ck would increase that's a good question nate gardner you could also see a ck you could also definitely see a cpk elevation as well good good question i think that's a great question so yeah expect to also i forgot to put that in here but that's a great question cpk will also potentially be elevated from potentially some of the you know infarcting of the bowel wall there's also smooth muscle within that area as well and so there's definitely a potential that you could infarct some of the the bowel wall releasing some of the ck from those smooth muscle cells so definitely great great great okay so some people are saying i think thrombolytic treatment is a priority i would agree with you yup heparin yep how long has she had afib without anticoagulation i want to talk to her cardiologist yeah that's a good thing yeah yeah she probably probably should have been on anticoagulation definitely definitely definitely oversight potentially on the uh the pcp or the cardiologist how do you guys determine need for anticoagulation what's the two md calc scoring systems that you should utilize to determine if this patient needs a long-term anticoagulation and then use that risk versus benefit there's two scoring systems that you guys should um utilize to think about that margaret you're funny yeah denton that's true man it's a good thing it didn't go to her brain yeah elana great chad vasque yep chad vasquez is a good thing to determine if she has you know the need for anticoagulation then yep christina has blood scores a good thing to determine like you know the risk from being on anticoagulation and does the risk you know is the benefit of being on anticoagulation gonna you know outweigh the the potential risk of having bleeds associated with that um so that's a good good question good question all right so sorry i got all uh distracted with that so the treatment for her is we gotta give her some fluids okay so she's not hypotensive but she's probably starting to infarct her bowel okay what she obviously is starting to infarct her bowel because again if she has that lactic acidosis she's probably starting to infarct the bowel because she hasn't have enough oxygen being delivered to the sm the small bowel so she's probably starting to infarct that and then she's definitely at risk if she infarcts that small bowel that part of the bowel will stop working effectively and she can start developing a obstruction proximal to that so we got to give her fluids got to give her tons of fluids we want to put an ng tube in kind of prophylactically in case she's not able to if she does start infecting that bowel and we have to decompress the bowel proximal to where the infarct is we should have an ng tube that's able to do that for us antiomedx should also be there because she does have some nausea she's in insane amounts of pain so we should give her analgesia and then we should give her antibiotics why should we give her antibiotics i want you guys to think about that if she started to infarct her bowel wall what is the problem with that and why should we start her on antibiotics not just because the white counts elevated definitely that's one reason and because she's febrile but what is the fear that if she infarcted her bowel what is potentially the issue with that oh sub sabashri i love lactated ringers to be honest lactated bringers is is uh there's tons of articles that suggest that lr is superior to normal saline in various categories um the only time where normal saline may be a little bit more preferred is in kind of a neuroscience icu for patients who have high intracranial pressure it's not a bad idea to kind of go with the ns the normal saline but lr i pretty much use that for anybody without any other kind of intracranial pressure concern it's just superior yeah so great you guys are all saying it is that if she if she infarcts that bowel now the bacteria have no true barrier no no true protective barrier that's hindering them from going straight from the gi tract lumen into the actual mesenteric blood easily can have bacteremia that can progress to septicemia boom okay so i i i would definitely agree with that she needs to be on antibiotics okay margaret i don't love lr because it's not compatible with anything okay i love lr i there i know there's always these questions of is it good with calcium and stuff like that a lot of the literature says that you know there's no problems with calcium um it's not really a concern also like ceftriaxone just get two ivs if you can and run it through different ivs if possible uh and then there's even this concern of hyperkalemia actually lr is less likely to cause hyperkalemia and and normal saline is more likely to cause hyperkalemia normal saline loves to cause acidosis lactates just a more balanced crystalloid but anyway off off another pedestal okay so we got iv fluids running through i prefer lr margaret likes doesn't like that but that's okay we have an ng tube to potentially decompress the bowel if the infarct progresses and she doesn't have any motility there we get anti-medics to stop the nausea we get analgesics first severe pain we're going to put them on some broad spectrum antibiotics because there is definitely a risk of her developing some type of septicemia related to that bowel infarct we're going to start her on anticoagulants right because starter on heparin that's going to help the progression of the clot and then we can do plus or minus tpa i'd probably go ahead and say give her the tpa so we probably put her on heparin and then give her a hit of tpa to start trying to break up that clot another thing to start thinking about here is that there is another drug that sometimes is used i haven't seen it used too often but the literature does say that you can consider it is if you want to try to your best to perfuse parts of the bowel that is it's still salvageable you can try to dilate the the part of the bowel and some of the blood vessels actually dilate some of the blood vessels that are serving parts of the bowel that is salvageable and you can use this drug called papa byron and it might help in that scenario vasopressors if she did become hypotensive you probably would like oh man i got to put her on leave a fed i got to put her on phenylephrine i got to put her on something to help epinephrine whatever actually you should really try to minimize the uh the inoppressors those are the ones that you probably want to try to be very very careful of because if you squeeze down and clamp on those peripheral vessels you could potentially reduce blood flow to the bowel even more that's something to just think about potentially if i had someone who's becoming hypotensive i would consider giving them something called an inodilator like dobutamine which gives you inotropic contraction as well as dilates the peripheral vessels milranone same thing okay margaret's joking yeah yeah jazz i so that's a you know that's a good thing to think about so tpa again it depends upon the scenario uh and embolectomy is probably going to be the best scenario for her but if you if she's not really like a great surgical candidate at this point in time you can try heparin you can do plus or minus tpa but again an imbilectomy would be a nice thing to do if you can go in there with a catheter generally when you're going to do that anyway you should have them on heparin that's why i have plus or minus tpa definitely give heparin because you're going to need that generally no matter what to prevent the you know the prevention the prevent the continual development of the clot plus or minus tpa is based upon if they're going to get an embolectomy or not if you go to do an embolectomy you can do that with a catheter potentially like a catheter like like aspiration or maybe surgically going in and actually cutting out the emboli but if that that's not a possibility uh tpa would kind of be the next go-to in this scenario okay so you guys let's say that she she got her fluid she got her ng tube antibiotics pain medication all that good stuff antibiotics eventually her blood cultures and all that stuff came back and she didn't have any kind of like obvious uh positive blood cultures again her blood pressure started improving with the fluids um she got her heparin she didn't need an embolectomy let's say the significant kind of like septic bowel bowel perforation something of that nature so great stuff all right let me see questions here okay okay that was a good question i asked before okay why no adenosine okay why would you want adenosine i guess is a question so adenosine is great for doing what for blocking the av node um in atrial fibrillation you can give adenosine um but it's not going to be a super like a beneficial thing in patients with afib it would be beneficial in someone with an svt like a superventricular tachycardia of some kind but adenosine not so great you can try it if it doesn't really help there is other options things like beta blockers and calcium channel blockers i would just be careful okay the only thing here is and again this might be a little bit more of like my bias if a person is hypotensive on the verge of hypotension i'm probably not going to reach for a beta blocker or a calcium channel blocker because those can drop your blood pressure they shouldn't but they can i like to give magnesium magnesium is a great great drug it really helps to have kind of a rate and rhythm control so sometimes i'll give a person two to four grams of magnesium and an infusion and if they're really hemodynamically unstable and i really want to convert them out of afib i may try something like amiodarone i like amiodrome because it's a little bit more hemodynamically stable so that's something to think about if you're trying to convert them out of afib or try to control their afib i generally give a mag infusion and i'll try something like amiodarone if they're hemodynamically more robust then i'll try to rate control them with a beta blocker calcium channel blocker dige okay yeah dentin again you can definitely cardio you can cardiovert them as well if if you wanted to definitely a possibility you just have to and again you can chemically cardiovert or you can electrically cardiovert them um again in an ed setting people are more likely to get kind of like an electrical cardioversion and icu setting i'm a little bit more likely to chemically cardiovert somebody but you're going to be anti-coagulating them anyway so it's it's there's nothing wrong with being able to convert them pry in a icu setting i would probably go ahead and try to do something like amiodarone and again a mag infusion and see how they respond with that if i really needed to and they became acutely hemodynamically unstable i would electrically cardiovert them but again i'm more kind of the guy that reaches towards amiodarone or magnesium a chemical cardioversion and if they're hemodynamically robust i rate control them with beta blockers calcium channel blockers and something like dige if they're acutely hemodynamically unstable and i just need to do something quickly i will probably electrically cardiovert them okay another thing to think about is how long she had this a-fib i didn't really give you an answer if she's a chronic afib but it's going to be a lot harder to get her out of that a-fib if it's an acute afib which is not likely it's not likely that it's an acute afib it may be easier to be able to convert her with a chronic afib it's a little bit tougher so daniella asked in order to cardiovert we need first and uh t-e-e to rule out intra-cardiac clots it depends there's some literature there was like a um a study out in like the uk that was talking about this um and it's still kind of a tough thing to be honest with you and in the in the textbook definition yes uh you should always you know if someone's been in afib for uh particularly like greater than 48 hours or something of that nature you should definitely consider like checking to make sure that they don't have an obvious clot it's likely that she she did or does still that's why she developed kind of a um a mesenteric ischemia and acute mesenteric ischemia but yeah it's she's going to get heparinized so she's going to be getting anticoagulation anyway um so i don't know if it's necessarily that important to be able to go ahead and get a tee since you're going to be trying to anticoagulator anyway again i don't think it's necessary right now based upon her condition you're going to be giving your anticoagulants and again just stressing this i probably wouldn't be working too hard right now and trying to cardiovert this patient and get them back into normal sinus rhythm it's likely that this is a chronic afib and i'm just going to go ahead and try my best to make them hemodynamically stable and i'll start something with mag if they're hemodynamically stable i'll try something like beta blocker calcium channel blocker to rate control them if they are really like hemodynamically unstable and i'm still like they're starting to really tack up away towards the 160s 170s and it's starting to affect their blood pressure i'll reach for something like amiodarone or potentially electrically cardiovert them i don't see us needing to do that right now i think that she's tachycardic because of her lactic acidosis because of her mesenteric ischemia okay let's see how do you chemically cardio very well yeah i think we answered the high white count we talked about the chemical cardioversion uh digoxin is hard to initiate and dial in the dose yeah i'm not a i don't go for dig dig is kind of like a third line agent for i i would do ditch if someone is you know they take it at home um it's not hard to kind of go ahead and get that started you can always load them up with dige um and then kind of start them on a maintenance dose and then get your dige levels um but yeah digi i'm not super big fan of it's it's okay um if it's something that they use at home i'll go ahead and do that but you do get a little bit of an inotropic kick and you get a little av nude blockade from it as well but it's relatively easy to go ahead and start um but this is probably not something i would start right away okay but let's go ahead and focus back on the real issue which is our mesenteric ischemia okay so crackles why does she have the crackles could be a couple reasons uh she could potentially have uh some just a natural kind of like uh by basal or crackle sometimes individuals who get a little bit older they can naturally have some buy basilar crackles um could be that she has maybe some underlying uh heart failure you know we didn't really get an echo of her heart so we don't know what her ejection fraction is maybe there's a little bit of backflow into the pulmonary veins um she's not saddened you know the saturation for o2 isn't significant we can throw in a chest x-ray we can throw in potentially you know getting an echo a little bit later um seeing if she has any obvious signs of heart failure and if she needs some diuresis a little bit later we can do that but i wouldn't be too worried about the buy basilar crackles sorry just looking here any other questions that you guys have how to assess if it wasn't about to perforate or bleed to avoid anticoagulation again it's kind of like you know you obviously know the cause here the person has a clot within one of their vessels and it's starting to infarct their bowel you have to anticoagulate them you have to potentially give them thrombolytics or go in there and potentially remove that clot it's just like for example it seems very weird but in a person who develops is called a cerebral venous sinus thrombosis as a clot within one of the veins of their brain and sometimes they can develop bleeds because of the back pressure behind that clot in the vein that's a bleed within the brain guess what you do guess what you treat these patients with cerebral venous sinus thrombosis you treat them with anticoagulation and it seems like oh my gosh they have a bleed why would i do that it's because if i don't take care of that clot they'll continue to bleed it's kind of the same concept here i have to anticoagulate them i have to either do an embolectomy or give them tpa because if i don't get rid of that cloth they're going to infarct their entire potential bowel wall and they're going to potentially perforate okay so which ones would i prefer um i'd probably go with venk um cover your gram positive cefepime or zosin to cover your gram negatives and your pseudomonas and then metronidazole to cover any kind of anaerobes okay all right guys i hope all of this made sense i hope you guys all enjoyed it i know that this was a uh a cool one i really enjoyed doing this one with you guys i hope that it helped i hope that you guys liked it i hope i was able to answer answer all of your questions again one of the things i think to think about is that when we do these case studies i try to remember that we're looking at this i'm trying to do this for in for two reasons one is to help us out to look at particular cases and truly try to understand the history the physical exam what those things mean how to potentially pick out diagnoses how to treat but also i'm trying to do it in two ways i'm trying to give this help for you know your exams for whenever you have to take your usmles or your pants or your nclex or whatever it may be but also at the same time try to provide a little bit of clinical context for when you guys have to go out um in the wards and treat people so i hope all of this made sense i hope that you guys enjoyed it and engineers i love you i thank you and as always until next time