Case for everyone: Elderly abdominal pain

[MediMike]

@LT_Oneal_PAC Oh don't bother waiting on lil' 'ol me. 

Who doesn't love a little VitK? People who are already HTN at baseline..but if we assume her HTN is due to pain then it's a good call.

Having done critical care transport in the past I understand where the medic is coming from...no one wants to drive that far, but while this lady is in obvious pain I'm not convinced it's worth the price/risk of a helicopter.  Hemodynamics look good, she has normalized her lactate suggesting she is perfusing her gut, as long as we aren't in the midst of an icy blizzard I'd say ground-pound it.

@GetMeOuttaThisMess nice thought on the angioedema!

Edit: What IS the weather like?

Edited June 29, 2020 by MediMike

[LT_Oneal_PAC]

4 hours ago, MediMike said:

@LT_Oneal_PAC Oh don't bother waiting on lil' 'ol me. 

Who doesn't love a little VitK? People who are already HTN at baseline..but if we assume her HTN is due to pain then it's a good call.

Having done critical care transport in the past I understand where the medic is coming from...no one wants to drive that far, but while this lady is in obvious pain I'm not convinced it's worth the price/risk of a helicopter.  Hemodynamics look good, she has normalized her lactate suggesting she is perfusing her gut, as long as we aren't in the midst of an icy blizzard I'd say ground-pound it.

@GetMeOuttaThisMess nice thought on the angioedema!

Edit: What IS the weather like?

I’ll go ahead with the big reveal then.

 

She came in, and after hearing the story I was immediately concerned for ischemia. 
 

learning point, there is evidence that people with paroxysmal afib go in and out 6 times a year without ever knowing it.

so even with the NSR, this is my primary concern. Mesenteric ischemia is the ACS of the gut. Time is of the essence and mortality is high. I felt that dissection and AAA were possible too, but she was not initially hypertensive and no history of HTN. The mass was nonpulsatile. She only took the metoprolol for rate control. With this being my primary concern, I went to CTA immediately after labs and EKG and aorta POCUS and 50mcg of fentanyl. She looked a little groggy after the fentanyl but couldn’t lay flat for the scanner. same story I told before in the scanner

learning point: you can be unconscious and still in severe pain. Also, Little old ladies like to stop breathing. I once gave a lady 1mg dilaudid just before induction in the OR and she was awake, eyes open, not breathing. She was looking at me as she was turning blue.

we go back while I wait for the tech to reconstitute and upload images. Gave her ketamine and zofran. Labs back with everything normal except lactic. WTF? Dimer negative? I thought for sure this would help me clinch it quickly. 1L NS bolus. Some relief for a minute and I go to read the CT. I see a weird uterus that I just said was thick. I wasn’t thinking much about it because the bowel was much more prominent. patent vasculature but significant mesenteric edema and mild bowel edema. I’ve seen mesenteric ischemia only once before and it looked exactly like this, but everything here looked patent? Saw mesenteric vein thrombosis once as well, but the bowel wall edema was much worse and that guy had pain for weeks before he came in. I immediately called the rad company and said this needs to be their number one priority. Maybe ketamine is disinhibiting her, but she is constantly wailing now. Given a second Zofran and another ketamine (I misspoke earlier and said I NGed during first ketamine), brief relief and pushed NG.

20 minutes go by and I’ve had enough. Start heparin, call the chopper, pull my cell and call the L1 for ED to ED transfer, put in my AirPod so I can move and work while I listen to shitty hold music. Repeat lactic 1.7.

learning point: lactic acidosis has about a 70% sensitivity for detecting mesenteric ischemia.

I’m treating this clinically. I’ve never seen anyone have this much pain except when tissue is dying from ischemia (ischemic legs, gut, etc), so it’s mesenteric ischemia until proven not by angiogram to me, which is the gold standard.

Learning point: ALWAYS read your own scans before rads. You’ll learn so much and after a while, you’ll be able to answer your own clinical question and all you need radiology for is the incidental findings.

Closest chopper is 20 minutes but they aren’t flying because of weather. Call the university chopper and they’ll come, but flight time is typically 40 minutes, unknown delay due to flying around weather. 
 

look outside and there is good weather over top, but for a spread of about 200 degrees around me looks like crap. Lightening, gnarly weather.

30 minutes after scan I receive the report as previously listed. Cannot rule out ischemia enteritis.

I’m on hold for 30 minutes and no answer. I hang up and call the ED direct. I get a clerk and she is going to have an attending call me back. 
 

I give 1mg dilaudid and she isn’t screaming as much, but she is still in pain, asking if I would kill her to stop the pain, she wants to die, to which I had an extremely visceral reaction to. 
 

the helicopter arrives 1 hour I call for it and ask who my accepting is, I say I don’t have one as I’ve been waiting for an hour to speak with the L1 and we need auto accept. They call the direct line to the attending, one of my old attendings known to be a grouch, who gives me shit saying in the future I should call the transfer line that I’ve been waiting an hour for, and accepts.
 

Air care slams in 30mg ketamine push and she’s out. The most comfortable I’ve seen. Needs some O2 but breathing. Take their time loading her. They whisk her away.

All told she was in my shop for about 2.5 hours from door to out the door. It’s a 40 minute flight to the L1

I still don’t get to sleep because 2 more show up. I actually call in the back up at 30 hours because I just couldn’t do it anymore. I sleep 2 hours and he sees 2 patients that he is soft admitting, and I run behind him to fix everything. He does not write a note...

i get a text from the APP resident who was a year behind me and about to graduate. Says good job, repeat lactic 2.4 and still all labs otherwise normal, landed writhing again, couldn’t control her pain, lady went class A to OR. Lots of bruised bowel, pale, dying. Surgical resident said it looked like a garbage fire in her bowel. Found a tight band of scar tissue cutting off circulation. It was released, bowel pinked up after a few minutes and eventually even saw peristalsis. It never even occurred to me that this could happen. I’ll be writing a case report.

final learning point, trust yourself. It’s easy for me to say that since I’ve seen Ischemia before and maybe I was just lucky. Actually I know I was lucky, but I’m glad I pushed for this lady. I easily could have been made a fool. Treat the patient and not scans, labs, and monitors.

[MediMike]

@LT_Oneal_PAC great case man. There are definite challenges working out in the woods where you do.

Couple of questions...

1.) Source for the lactate sensitivity? I've always learned a sensitivity of anywhere from 75% - 85%, clearly it will have a low specificity but I've never seen 30%. https://pubmed.ncbi.nlm.nih.gov/24238311/

2) Your transfer system sounds terrible. Any way you can lean on your receiving facilities to change practices and make that a little easier?

3) Would have been great to be the one doing the adhesiolysis, slice it, stitch 'er up and send her home!

4) What criteria are you using in your practice to determine mode of transport? Clearly this lady had your gestalt all fired up, but when you've got crap weather what line are your drawing for ground versus air?

Again, fun case. Always a challenge to hop into a different specialty and play in their sandbox, thanks for the opportunity!

 

 

[LT_Oneal_PAC]

3 hours ago, MediMike said:

@LT_Oneal_PAC great case man. There are definite challenges working out in the woods where you do.

Couple of questions...

1.) Source for the lactate sensitivity? I've always learned a sensitivity of anywhere from 75% - 85%, clearly it will have a low specificity but I've never seen 30%. https://pubmed.ncbi.nlm.nih.gov/24238311/

2) Your transfer system sounds terrible. Any way you can lean on your receiving facilities to change practices and make that a little easier?

3) Would have been great to be the one doing the adhesiolysis, slice it, stitch 'er up and send her home!

4) What criteria are you using in your practice to determine mode of transport? Clearly this lady had your gestalt all fired up, but when you've got crap weather what line are your drawing for ground versus air?

Again, fun case. Always a challenge to hop into a different specialty and play in their sandbox, thanks for the opportunity!

 

 

Correction, I flipped my numbers! Thanks for catching that! The way I remember is 70% sensitivity and 30% specificity. It’s actually more like 40% specificity, but I try to make my number easy to remember.

the system actually works really well, most of the time. I only transfer to the L1 if others decline or they need subspecialty support. Most of the time it’s not that emergent and I have them stabilized, packaged, essentially fixed, and ready to go by ground ambulance. 
 

I choose the chopper when time is of the essence. Stroke, MI, etc. or if I think it needs to expertise of air EMS. Sometimes my guys aren’t comfortable with certain things, some will take whatever as long as  I promise to be available for questions. 
 

I also have to fly anyone intubated. For some reason overall EMS certification of the group the CCP can’t do vents? If I send by ground I have to lose my only in house RT for 3 hours. No other closer hospital has an ICU. 
 

if the weather is bad and they say they aren’t flying, well, time for us to suck it up and drive like a bat out he’ll. If it’s a delay, rarely would it be longer than ground ambulance if you include the time it takes for us to call a second crew to get dressed, come in, load patient, etc.

 

[GetMeOuttaThisMess]

Pain anywhere in the body that is not chronic but acute, is refractory to typical med dosing which provides relief in the majority of other cases, and is not consistent with the clinical picture presenting in front of you, should be considered ischemia.  It may be a compartment sx. if extremity related and it DOESN'T have to involve a hx. of trauma (runner for example), or as in this case mesenteric ischemia.  Good case.  I'd still f/u on her reproductive tract.  It'd be a case just like this one where you do well and yet get bit on the backside later.  Back to Adam-12 reruns after a trip to WallyWorld.

Edited June 29, 2020 by GetMeOuttaThisMess

[LT_Oneal_PAC]

8 minutes ago, GetMeOuttaThisMess said:

Pain anywhere in the body that is not chronic but acute, is refractory to typical med dosing which provides relief in the majority of other cases, and is not consistent with the clinical picture presenting in front of you, should be considered ischemia.  It may be a compartment sx. if extremity related and it DOESN'T have to involve a hx. of trauma (runner for example), or as in this case mesenteric ischemia.  Good case.  I'd still f/u on her reproductive tract.  It'd be a case just like this one where you do well and yet get bit on the backside later.  Back to Adam-12 reruns after a trip to WallyWorld.

Oh yes, the endometrial thickening does need to be followed up, but that’s not my department. Hopefully they don’t just send her home without addressing it.

ill be following up and writing a case report. It’s easy as we actually share the same EMR so I plan on checking it out later today.

[ohiovolffemtp]

The "pain out of proportion to exam" is what I was taught as the classic sign of mesenteric ischemia.  Surprised her lactate wasn't higher.  Surprised the CT reads weren't definitive, but sending her based on S/S is a must - just like you did.  Some other thoughts for early on pain & nausea control: reglan or compazine - phenergan would potentiate the opiates, but might also potentiate the respiratory depression; bentyl if the pain seemed crampy or spasmodic; stadol for longer acting pain control with less risk of respiratory depression.

In my CAH, helicopter transport isn't the cure-all either.  The flight crews are the slowest on the ground I've ever seen, spending 30+ minutes on scene.

[LT_Oneal_PAC]

28 minutes ago, ohiovolffemtp said:

The "pain out of proportion to exam" is what I was taught as the classic sign of mesenteric ischemia.  Surprised her lactate wasn't higher.  Surprised the CT reads weren't definitive, but sending her based on S/S is a must - just like you did.  Some other thoughts for early on pain & nausea control: reglan or compazine - phenergan would potentiate the opiates, but might also potentiate the respiratory depression; bentyl if the pain seemed crampy or spasmodic; stadol for longer acting pain control with less risk of respiratory depression.

In my CAH, helicopter transport isn't the cure-all either.  The flight crews are the slowest on the ground I've ever seen, spending 30+ minutes on scene.

Same here. They were so slow to get her out. But with the L1 before a half our away, they are always faster there, and for real serious stuff, it’s about the only place that will take them.

i think I actually did give her promethazine somewhere in there. It helped the nausea, but nothing on the pain. I don’t believe we have stadol, but do agree it’s a good drug.

[EMEDPA]

sorry I am late to the show. Just had 4 days in a row of nightmare pts. One of my rural jobs is right next to a cancer center. what could go wrong...3 pts in dept at same time with neutropenic fever! three!

anyway, Sounds like a great case. My last one was kinda similar. lots of dilaudid, lots of lopressor, bled like stink....