Case: 50 yo woman with sudden onset of lower abd pain with syncope followed by persistent hypotension, ECG abnormal and bloodwork shows severe anemia. Bedside u/s of abdomen unremarkable. CT abd/pelvis done after delay of hours as patient unstable in ED and shows active bleeding of iliac artery aneurysm. Surgery subsequently consulted and patient belatedly taken to OR.
- Surgery should be called as soon as possible when there is hypotensive pt where there is concern about a surgical problem. Although some may not call surgery until CT done as they have experienced surgery not willing to see pt until CT done. In a hypotensive pt, surgery must be called immediately. This is because surgery needs to be involved in the early decision making process and pt very well may need to go to OR without CT scan.
- Even if pt not being taken to OR unitl CT done, it is important to get them involved before CT so they are on board with CT and ready to go when CT is completed
- In this case, sudden onset of lower belly pain with hypotension is concerning for vascular event such as a dissection or AAA or perforation or obstruction. The finding of very low hct confirms surgical problem and need for blood. However, surgery should be called based on the pt history of sudden onset RLQ pain and syncope even before low hct returns
- You don’t need to ID specific source of bleeding before calling consultant
- In hypotensive pt with suspected surgical problem, the surgical attending must be involved early in the management of the pt
- If the surgical resident doesn’t recognize gravity of situation, get the surgical attending involved. The EM attending should contact the surgical attending directly. Attending contact numbers should be readily available
- There are other sources of bleeding beside AAA and dissection
- In patient with suspected vascular problem too unstable for CT, angiogram in the OR is option and there should be no delay trying to get CT prior to going to OR
- 2 units of blood not enough in pt persistently hypotensive with very low hct
- It is important to recognize the limitations of U/S or any study that you do
- U/S doesn’t visualize the retroperitoneum which is where AAA bleeds into. Bleeding may overflow into peritoneum and thus be visible on u/s
- Although the upper aorta may be visualized and assumed not to have bled if the aorta is of normal size, u/s doesnt visualize well the aorta beneath the bifurcation, even in experienced hands
- The official u/s showed collection of heterogeneous fluid in the peritoneum. Clotted blood may be misinterpreted as tissue. The recognition of blood in the abdomen initially likely would have prompted earlier sx consult
- ECG changes may be a reflection of other problem. In this case, ST changes and brief episode of VT likely were a result of ischemia from bleeding.
- Don’t anchor on cardiac cause of hypotension in pt with abnormal ECG who has signs and sxs not c/w this diagnosis (ie abd complaint and very low ht)