# ABD Distension after Nitro???



## MedicPrincess (Jan 9, 2009)

0230 hrs-

PT-  64 y/o F pt, found laying in bed, in some distress.  She c/o CP, substernal with radiation to L shoulder and arm, sharp/stabbing, 9/10, constant without ability to get any relief for the past 12 hrs.  Pt also c/o N/V, SOB, generalized weakness, and near syncope throughout the day.  The pt is figity, seems to be trying to get comfortable, rubbing her chest.

Med Hx- HTN, AAA repair 20 years ago without problems since, multiple back surgeries, multiple cosmetic surgeries - last on 3 years ago.

Meds- Atenolol, Metoprolol, Morphine Pump, Synthroid, HCTZ

NKA

Exam-  HEENT- paralysis to R side of pts mouth.  Pt states her 7th cranial nerve had been cut in a previous surgery.  Pupils PERL.  CHEST- surgical scars present from previous cosmetic surgeries.  ABD- soft nontender, no distension, no rigidity.  No palpable masses.  EXTREMITIES- pts moves all well.  Cap refill < 2 seconds.  SKIN- pink, warm, slightly moist.  BBS- equal, CTA.

INITIAL VITALS-  BP(manuel) 190/102, HR 58, RR 22, SaO2 98% RA

The pt was carried to the stretcher, placed semi-fowlers and taken to ambulance.  Pt having repeated episodes of vomitting.

ECG 4 and 12 ld show Sinus Brady at 55 without any changes.  
Repeat Vitals- BP 188/109, HR 55, RR 20, SaO2 97% 2lpm NC.
IV established - 20g R forearm.
Zofran 4mg IVP with relief of the vomitting.
ASA 324mg
Nitro 0.4mg SL pill

Approx 2 minutes after the Nitro the pt began to c/o increasing ABD pain, to a 10/10, described as "Oh God, Its Awful."

Re-Exam of the ABD and she is now rigid and distended, looks to be about 5 months along.

New Vitals-
BP R Arm-  148/73
BP L Arm-  144/78
HR 57
RR 24

5 more minutes to the ER, and she now looks to be about 7 months along.

15 minutes after arriving at the ER 2 physicians are in there, somehow the IV got "pulled" while they were drawing blood and they were scrambling to get another (so very poor access, what I got was what she had!), and she now looks like she is about 9 months along with triplets and is now Pale, Lethargic, no longer even really moving or complaining about her pain however the slightest touch of her ABD and the pain is visable on her face.

Vitals have not really changed from the BP in the 140's and HR in the 50's.

I unfortunatly did not get back to check on what they found.....

So....  Your opinions????


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## rhan101277 (Jan 9, 2009)

I don't know what would cause this very large abd distention you are talking about.  I was thinking maybe blood loss, but her pulse and heart rate leads me to think that that wasn't the case.  You weren't bagging here, I have heard of bagging causing distention when there is a tear somewhere letting the air get between the subq and the skin.

How low did her pressure drop when you administered nitro.

Had to be blood loss, you got 6L in you its gotta go somewhere, maybe the aorta tore somehow.


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## DT4EMS (Jan 9, 2009)

I am gonna say AAA. I think the MS pump is keeping her pain down. Cardiac meds keeping HR down.

I am curious if she is still alive.

Last one I had was mowing the yard and became "air hungry". Bled out and went into PEA.


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## KEVD18 (Jan 9, 2009)

a slow leak probably wouldnt distend the bladder that much and a patient with an actue bleed wouldly be able to hold their own like that.

im stumped.


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## DrankTheKoolaid (Jan 9, 2009)

*re*

Very interesting indeed.  While i dont think it was a AAA i do think it may have been due to the NTG.  NTG is a not a specific vasodilator.  The patient may have also had other problems such as a mesenteric infarct being masked by the chest pain.  Im guessing after the administration of NTG it may have caused rebound vaso constriction completing the infarct and a tear in the bowel with subsequent gas release into the peritneum.  You note that she was on double beta blocker therapy which would explain no increase in HR even with the falling bood pressure.  Even with beta blocker therapy her baseline BP my have been hypertensive so when her BP came down to a lower pressures she became shocky worsening the problem as her body went into fight or flight mode causing further contriction of the mesentary decreasing the amount of blood to the gut to save the heart and brain.  

Theres my guess in a nutshell


Corky


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## pumper12fireman (Jan 10, 2009)

Did the vomit have that "coffee ground" like appearance? Any blood in vomit or stool?? I doubt you'd have this info, but maybe social hx of alcoholism, or with chronic HTN, some sort of espohageal varice ruptured?? It'd be very interesting to see if you can get any follow up info...


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## Ridryder911 (Jan 10, 2009)

MedicPrincess said:


> 0230 hrs-
> 
> Med Hx- HTN, *AAA repair 20 years *ago without problems since, multiple back surgeries, multiple cosmetic surgeries - last on 3 years ago.



I'll let others answer


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## traumateam1 (Jan 10, 2009)

AAA, makes perfect sense.


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## mace85 (Jan 10, 2009)

Ridryder911 said:


> I'll let others answer



Incoming PM Rid.


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## KEVD18 (Jan 10, 2009)

KEVD18 said:


> a slow leak probably wouldnt distend the bladder that much and a patient with an actue bleed wouldly be able to hold their own like that.
> 
> im stumped.


 

ok, im not quite sure where i came up with bladder, but i meant abdomen.


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## MSDeltaFlt (Jan 10, 2009)

MedicPrincess said:


> 0230 hrs-
> 
> PT-  64 y/o F pt, found laying in bed, in some distress.  She c/o CP, substernal with radiation to L shoulder and arm, sharp/stabbing, 9/10, constant without ability to get any relief for the past 12 hrs.  Pt also c/o N/V, SOB, generalized weakness, and near syncope throughout the day.  The pt is figity, seems to be trying to get comfortable, rubbing her chest.
> 
> ...



Yeah, That'd be my guess.  While contradictory BP's in both arms are indicative, they are not conclusive.


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## MedicPrincess (Jan 10, 2009)

I had been thinking the AAA as well, was curious if y'all had any other thoughts.  

 I work again tonight, if I get to that hospital I'm going to see if I can find out anything.


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## artman17847 (Jan 10, 2009)

I read this post when it first went up and thought about what could be the cause of such a thing all nite. 

I have always believed that most pt's problems, especially in the older folks, is related somehow, to their PMH.

I could only think that this is most probably another AAA.

The pt must have been having refered CP due to the AAA. Is it possible that if the AAA was beginning to tear that the admistration of the ASA (reduces platlet binding) and Nitro (vasodialator) only speeded up the process?

I will be curious as to the final outcome of this pt.


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## EMT-P633 (Jan 10, 2009)

I think the Repair to the AAA came undone. 

Or

Due to the patients many cosmetic surg. along with her medical surg. there may have been an overlooked nick to the bowl. the NTG dialated the area and caused a rupture. due to the weakened scar tissue?

Or 

What would you guys think about the possibility of a hepatic anyurism?


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## Epi-do (Jan 10, 2009)

Princess, have you been able to find out any sort of follow up for this patient?


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## medic_charli (Jan 10, 2009)

I'm leaning toward AAA problems, thinking the beta blockers that she was on kept her heart rate low, her resp are high, as is her pressure. Did she have a fever??? How long had she had cp - was it sudden or did it come on slowly.  Did she complain of a backache???  Sharp and Stabbing - haven't seen that much with cardiac - I get more pressure than pain especially from females.  Really an interesting case - is there anyway you can find out what the problem was with this patient???


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## DrankTheKoolaid (Jan 10, 2009)

*re*

Any word yet?  im curious to the end result of this one.  By history AAA would be an obvious treatment path.  With the immediate ABD distention i think gas release.  Good stuff for sure.   

Corky


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## MedicPrincess (Jan 11, 2009)

I did finally get back there.  The verdict is...

Small bowel obstruction.

Her ABD was full of and filling with air.

Didn't have time to talk to the Dr about the relation between the Nitro and the onset.  I would guess the lowering of her BP and relieved some the of the constriction she had going on, allowing the leak.

The Chest pain was referred pain.

Odd.....


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## DrankTheKoolaid (Jan 11, 2009)

*re*

Yeah makes sense for sure.  Thanks for getting back to us.

Corky


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## bonedog (Jan 11, 2009)

A check of the femorals may have given an indication if AAA was involved.

Side effects of opiates...


good one


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## Veneficus (Jan 11, 2009)

bonedog said:


> A check of the femorals may have given an indication if AAA was involved.
> 
> Side effects of opiates...
> 
> ...



or deep palpation of the abdomen. Physical exam is a dying art.


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## bonedog (Jan 11, 2009)

Palpation of a dissecting aortic aneurysm should be done carefully and not too deep when you feel the water balloon pulsating...


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## june125 (Jan 19, 2009)

You can find the diagnosis through your medical director, to make this a better learning experience. Let us know, Im curious to know the final diagnosis.


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