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A32) Abdominal pain in a patient with shock
Review the Learning Outcomes, Hx, PE and Labs, and begin the module with your Provisional Diagnosis. Keep hitting "Next" to move through the module.
Learning Outcomes
- Articulate your relationship with the consulting diagnostic radiologists in the evaluation of a patient with hypotension.
- Review the DDx considerations in a patient with hypotension.
- Identify the spectrum of imaging findings in appropriate modalities for evaluating a patient with hypotension.
History
A 73-year-old male patient is in the ICU following gasoline contact burns while working on his 1963 Corvette. His face, arms, and back were severely burned, covering 45% of his body. Over the past day, he develops progressive confusion, left upper extremity pain, and moderate abdominal distension and pain.
Physical Exam
BP: 76/55, HR 116, RR 24, Temp 102.6F, O2 saturation 92%. Left upper extremity warm and erythematous with indistinct borders, compared to right upper extremity. Abdomen diffusely tender to palpation. No peritoneal signs.
Labs
Leukocytes: 23 x 109/L with 15% immature granulocytes;
Urine output: .25 mL/kg/hr;
ALT: 90 U/L (normal 7-55U/L);
AST: 80 U/L (normal 8-40U/L);
Tbili: 2 U/L (normal 0.1-1.2mg/dL);
Creatinine: 2.1 (previously 1.2);
Lactic acid: 11mmol/L (nl 2-4mmol/L);
Right heart catheterization (PA catheter):
PCWP: decreased;
Cardiac output: increased;
SVR: decreased
Provisional Diagnosis
Select the Dx you believe is most appropriate
Distributive shock includes septic and neurogenic shock. The patient is most likely experiencing septic shock from bacteremia from left upper extremity cellulitis secondary to his burn injuries. Their hemodynamic profile (low PCWP, high CO, low SVR) and other clinical findings are consistent with this diagnosis.
Well done. You were correct
Potential Acuity
What is your assessment of the likely acuity for this patient?
Well done. You were correct
Severe hypotension from septic shock can lead to organ damage secondary to malperfusion.
First Imaging Study
What is the first imaging study you will order?
Considering the patient’s abdominal pain and distension, a CT abdomen with IV contrast should be performed to rule out any other sources of shock. It may also detect ischemic organ damage from malperfusion.
Well done. You were correct
Pertinent Imaging Observations
Click on the links below to view images from the study, and assess these key findings as best you can.
CT Abdomen with IV contrast
There is abnormal appearance of the small bowel
There is bowel wall edema and wall thickening.
The intra-abdominal organs are abnormally enhancing
The spleen, pancreas, and part of the liver are hypoenhancing. The adrenal glands are hyperenhancing.
The IVC is collapsed
The IVC is collapsed, reflecting low intravascular volume.
View the full study if you'd like to take a look yourself.
Second Imaging Study
What is the next imaging study you will order?
The abdominal CT reinforces the diagnosis of septic shock. No further imaging is required.
Well done. You were correct
What is your Diagnosis now that you have seen the imaging results?
The patient has septic shock with organ dysfunction as evidenced by the altered mental status (brain), elevated creatinine (kidneys), and elevated LFTs (liver).
Current Acuity
Initially, you selected and we suggested acuity.
Has your concern for this patient changed?
The patient requires urgent management for their septic shock.
Assessment and Plan
Please provide your assessment and plan for this patient
This patient is experiencing severe septic shock. They will require aggressive IV fluids, and empiric antibiotic therapy. Vasopressors should be considered but used judiciously as to not exacerbate the intestinal ischemia.
Lessons Learned:
- The CT hypoperfusion syndrome is commonly secondary in trauma patients with hypovolemic shock and severe hypotension. It can also occur secondary to septic shock and cardiac arrest.
- Septic shock is defined as: Temperature >100F or <96F, HR >90 bpm RR >20 bpm, pCO2 <32 mmHg, Leukocytes >12,000 per ml or <4,000 per ml, or >10% immature (band) forms.
Socioeconomic Factors: Increased mortality rates from sepsis are correlated with lower socioeconomic status.
That's the end of the module! Once you've reviewed the video(s), you can click here for another case challenge.
Contributors:
John Cerillo, MS2 - Content Contributor
Kevin Pierre, MD - Editor
Robbie Slater, MD - Supervising Editor
Bayar Batmunh, MS - Coordinator
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