9/21/15. Joshua Pruitt, MD, FAAEM Medical Director, LifeGuard Air Ambulance Iowa PA Society Fall CME Conference September 29, 2015

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1 Unless they prove otherwise. ~Every ED attending ever Joshua Pruitt, MD, FAAEM Medical Director, LifeGuard Air Ambulance Iowa PA Society Fall CME Conference September 29, 2015 AAA with rupture Mesenteric Ischemia Perforated viscus Ascending cholangitis Acute pancreatitis Mortality rate ~90% 65% die before reaching the hospital Frequency ranges from % 13 th leading cause of death in the US, causing ~15,000 deaths per year If they reach the ED, survival drops by 1% per minute unrepaired Present in only about 30% of cases!!! 1

2 Have a high index of suspicion Age >65 PAD Tobacco use COPD HTN Marfan s, Ehler s-danlos, other connective tissue diseases Collagen vascular diseases Mycotic aneurysm First-degree relative with AAA Often asymptomatic until the rupture Some sentinel symptoms Back pain Groin pain oftentimes isolated Due to retroperitoneal expansion and pressure on a femoral nerve Flank pain Abdominal pain Symptoms due to local compression Early satiety N/V Urinary obstructive symptoms Venous thrombosis from venous compression Abdominal pain Back pain Pulsatile abdominal mass Groin pain Mimics: Renal calculus Diverticulitis Incarcerated hernia Lumbar spine disease Rupture into the IVC Forms aorto-caval fistula 4% of ruptures Continuous abdominal bruit High-output heart failure Rupture into the duodenum Very rare Sentinel upper GI bleed Sudden, massive GI exsanguination Syncope Paralysis Flank mass Transient hypotension Frank shock 2

3 Mortality rate 71-74% Occurs in only 0.1% of hospital admissions Broken down into 4 categories Mesenteric artery embolus Mesenteric artery thrombosis Mesenteric vein thrombosis Non-occlusive Much more common in the elderly All-cause mortality of patients >60 YOA presenting with abdominal pain to the ED is 10% (MI only 5%) Present in about 80% of cases. Have a high index of suspicion Labs are nonspecific Normal lactate does NOT rule out Imaging Go straight to CT with contrast Sensitivity % Specificity 89-94% CT Angiography does not provide significant benefit Sensitivity 71-96% Specificity 92-94% MRA Sensitivity 100% Specificity 91% Broad-spectrum antibiotics or angiography suite 3

4 Overall mortality is ~20% Varies widely based on etiology Etiologies include perforated ulcer, trauma, post-endoscopy Rapidly progresses to sepsis Plain radiographs Sensitivity 30-80% 50% false negative rate 10-14% of positives have a nonsurgical cause CT Sensitivity 95-98% With po and IV contrast Can actually be seen on bedside ultrasound Labs Not for diagnosis More for management Broad-spectrum antibiotics 4

5 Mortality 5-10% Bacterial infection superimposed on obstruction Advanced age, medical comorbidities, delay in decompression increase mortality to 17% Median age years Charcot s Triad RUQ pain Fever Jaundice Present in 15-20% of cases Reynolds Pentad RUQ pain Fever Jaundice Hypotension Mental status changes Present less commonly than Charcot s Triad Labs Imaging US Normal US does not rule out the diagnosis CT Use as adjunct to US Broad-spectrum antibiotics ERCP Consult surgery and GI Overall mortality 10-15% Inflammation of the pancreas caused by toxins, trauma, infection, or obstruction Median age depends on etiology Alcohol: 39 (35% of cases) Biliary tract-related: 69 (40% of cases) Trauma: 66 Drug-induced: 42 ERCP-caused: 58 AIDS-related: 31 Vasculitis-related: 36 5

6 The sting of this South-American scorpion can cause pancreatitis. Labs Imaging Only if the diagnosis is unclear of there is lack of clinical improvement Evaluate for pseudocyst on CT Ranson s Criteria (on admission) (there are also 48-hour criteria, but who cares?) WBC >16,000 Age > 55 Glucose > 200 AST > 250 LDH > positive: 15% mortality predicted 5 positive: 40% mortality predicted NPO Surgery only indicated for biliary etiologies 6