A 68-year-old man with a history of diabetes, hypertension and atrial fibrillation is admitted to the ER for severe abdominal pain. He has vomited twice in the last hour and has had one bloody stool. The patient is complaining of severe pain but your exam reveals a soft abdomen. His vitals are: HR:140 bpm, BP:85/60 mmHg, RR:19 rpm, T:38.9°C. An abdominal x-ray shows pneumatosis intestinalis (air in the bowel wall).
Which of the following would be your next best step?
Correct Answer E: With this patient’s history of pain out of proportion to physical findings, vomiting, bloody stool, unstable vitals and pneumatosis intestinalis on x-ray you should be highly suspicious of acute mesenteric ischemia (AMI). It is very likely that the source of the AMI was an arterial embolus most likely as a result of the patient’s atrial fibrillation (>75% of emboli originate in the heart).
AMI risk factors include: atrial fibrillation, recent MI, valvular heart disease and recent vascular catheterization. The most common anatomic sites for ischemia are “Sudeck’s point” at the sigmoid flexure and “Griffith’s point” at the transverse-descending colon flexure.
Immediate surgery is the gold standard for diagnosis but CT, mesenteric angiography, abdominal radiography and ECG are useful for diagnosis.
→ Colonoscopy, is not useful for suspected cases of AMI.
→ No laboratory test sufficiently rules in or rules out the diagnosis of mesenteric ischemia. Laboratory findings in mesenteric ischemia are nonspecific and generally unreliable.
→ Barium enema, is contraindicated. Considering a mortality rate of >50% in cases of AMI.
→ Watchful waiting would serve only to render a negligence lawsuit against you.
Key point: If AMI is suspected surgical exploration should not be delayed.
A 71 year old man admitted for a surgery develops confusion on the 5th post-operative day.
Which one of the following would be feature suggestive of delirium?
Correct Answer C: Delirium is a sudden, fluctuating, and usually reversible cognitive disorder characterized by disorientation, the inability to pay attention, the inability to think clearly, and a change in the level of consciousness. Because delirium is a temporary condition, determining how many people have it is difficult. Delirium, which is usually a sign of a newly developed disorder, affects about one third of hospitalized people aged 70 or older.
Being in the hospital can also contribute to or trigger delirium. About 10 to 20% of older people develop delirium while they are in the hospital. Delirium is also very common after surgery, probably because of the stress of surgery, the anesthetics used during surgery, and the analgesics used after surgery. Delirium usually begins suddenly and progresses over hours or days. The actions of people with delirium vary but roughly resemble those of a person who is becoming progressively more intoxicated.
The hallmark of delirium is an inability to pay attention. People with delirium cannot concentrate, so they have trouble processing new information and cannot recall recent events. People with delirium may be frightened by bizarre visual hallucinations, seeing things or people that are not there. Some people develop paranoia or have delusions (false beliefs usually involving a misinterpretation of perceptions or experiences).
Immediately after a surgery a patient presents with sudden hallucination, agitation and is very confused.
The most likely diagnosis is:
Correct Answer C: Delirium is an acute, transient, usually reversible, fluctuating disturbance in attention, cognition, and consciousness level.
Causes include almost any disorder, intoxication, or drug. Recent exposure to anesthesia also increases risk, especially if exposure is prolonged and if anticholinergics are given during surgery.
Delirium is characterized primarily by difficulty focusing, maintaining, or shifting attention (inattention). Consciousness level fluctuates; patients are disoriented to time and sometimes place or person. They may have hallucinations. Confusion regarding day-to-day events and daily routines is common, as are changes in personality and affect.
Symptoms may include inappropriate behavior, fearfulness, and paranoia. Patients may become irritable, agitated, hyperactive, and hyperalert, or they may become quiet, withdrawn, and lethargic.
Diagnosis is clinical, with laboratory and usually imaging tests to identify the cause. Treatment is correction of the cause and supportive measures.
A 70 year old white female who has been your patient for 10 years had an emergency cholecystectomy 2 days ago. When you see her today while making rounds, she appears to be confused. When you ask her how she is, she just stares at your stethoscope, and then says, “That snake may bite you”. When you ask further questions she seems distracted and does not answer the question asked. At times, she closes her eyes and seems to fall asleep unless questioning. She does not know her daughter, who is in the room when you are.
Which one of the following additional observations would help you differentiate delirium from dementia?
Correct Answer D: An acute onset and fluctuating course, along with an altered level of consciousness, illusions, and destructibility are consistent with delirium according to current diagnostic criteria. A normal neurologic and general physical examination, as well as memory and orientation problems, are common to both states.
You are asked to perform a preoperative evaluation on a 75-year-old male scheduled for a cholecystectomy.
Which one of the following would be most predictive of postoperative delirium?
Correct Answer B: Older patients have a high incidence of post-anesthesia delirium and thus should have a mental state examination before and after surgery. Although patients with anxiety, depression, and psychosis may have particular perioperative problems, patients with dementia are more likely to develop postoperative delirium.
Click to expand