Sim Lab 3 - Small Bowel Obstruction

Diagnosis/Assessment:

Small Bowel Obstruction 


Chief Complaint:

Abdominal Pain


HPI/Patient Presentation:

Mr. Smith is a 38 yo male w/ PMH significant for IVDA, HTN, DM2 and abdominal stab wound 1 week ago s/p open repair w/ partial bowel resection who is presenting with abdominal pain x3 days. Pain is non-radiating, dull, and has been increasing in intensity since onset. Pt. states that the pain is currently a 10/10. Pt. states he has not had a bowel movement in 4 days.  Pt. denies: chest pain, trouble breathing, prior similar episodes, cough,  n/v/d, hematochezia.

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AFTER SBO IS DIAGNOSED BY THE TEAM: ... 4 hours later after the patient's case has been presented to the attending by the resident but has not  yet been seen, the patient is found to be unresponsive by the nurse. Resume case with decompensated vitals. Fecal matter is found in the airway.


 

PMH:

IVDA, HTN, DM2

s/p open repair of abd stab wound w/ partial bowel resection

medication non-compliance


Monitor and Vital Signs:

(Please list the initial vital signs as well as the vital signs as they would respond to the pertinent interventions)

Monitor (Initial): NSR 86

Initial Vitals:

HR: 86

BP: 162/100

RR: 18

O2%: 98%

Temp: 98.6

Glucose: 98


Decompensation Vitals (NSR 150):

AOx0, withdraws to pain.

HR: 150, pulse present but weak

BP: 96/52

RR: 0

O2%: 70%

Temp: 98.6

Glucose: 96


Initial Physical Findings:

CV: wnl

Lungs: wnl

Abd: grossly distended, tender to palpation in LRQ and LLQ, no rebound, fluid wave or guarding present. No pulsating masses appreciated. Hepatomegaly appreciated.

Rectal: normal tone, hemoccult negative


Diagnostics/Management:

Pre-decompensation:

 

  1. Imaging: suspected SBO: order abdominal U/S or Abd CT. If ordering CT, order w/ IV contrast to r/o mesenteric ischemia. Aorta U/S to r/o AAA. Can consider lung U/S to r/o pneumonia
  2. EKG
  3. Labs: [fingerstick glucose already performed], CBC, CMP, d-dimer + lactate (r/o mesenteric ischemia), troponin, tox screen (for consideration and management of potential withdrawal later in hospital course if necessary).
  4. upon receipt of CT results: consult surgery and administer water-soluble contrast agent to delineate disposition (i.e. surgical vs. conservative see this link for source)

Post-decompensation (patient is found unconscious a few hours later by the nurse who calls you to his bedside):

  1. pulse check and mental status assessment
  2. repeat VS, ensure appropriate IV access is established
  3. start 2L NSS upon finding relative hypotension
  4. assess airway (visualize oropharynx--> fecal matter found in airway)
  5. suction airway, prepare to intubate, place NG tube immediately to decompress GI tract and prevent further airway obstruction.
  6. upon successful NG tube placement and intubation, patient enters VFib
  7. start CPR, place pads, immediate shock, push 1mg 1:10,000 epi
  8. continue CPR for 2 minutes ---> return of spontaneous circulation at next pulse check.
  9. Peform ROSC care.

Diagnostics Results:

CMP:

  • AST: 56
  • ALT: 60
  • AlkP: wnl
  • TBili: wnl
  • electrolytes, creatinine, BUN, HCO3: wnl
  • glucose 92

CBC: wnl

lactate: 1.8

d-dimer: 0.1

Urine Tox Screen: + opiates

Abd U/S shows dilated bowel loops next to compressed bowel loops.

Abd CT w/ IV contrast shows small bowel obstruction.


Sources:

http://pubs.rsna.org/doi/10.1148/radiol.15131519

Academic Emergency Medicine: Official Journal of the Society for Academic Emergency Medicine 2013, 20 (6)… http://sumo.ly/b3aP via @QxMD

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3299163/

http://onlinelibrary.wiley.com/store/10.1002/bjs.7019/asset/7019_ftp.pdf?v=1&t=iex998pg&s=c3396d1fbc103bb2401e7a477c91c9ed6489fd8f