MedEd Portal
Human Patient Simulation
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Title: Mesenteric Ischemia
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Target Audience: Emergency Medicine Resident
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Learning Objectives:
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Environment:
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Primary
– Recognize mesenteric ischemia
– Recognize that acute abdominal pain in elderly patients is
associated with significant morbidity and mortality.
Secondary
– Recognize when the patient is decompensating and intervene with
appropriate actions (IVF, blood, vasoconstrictive medications,
consultation, antibiotics)
Critical Actions Checklist
– volume resuscitation
– pain control
– recognize atrial fibrillation on EKG
– order abdominal CT as long as patient is stable
– FAST if patient decompensates
– antibiotics
– type and cross
– surgical consultation
– consider anticoagulation but hold as patient is heme positive
Environment
– 25 bed ED in community hospital
Manikin Set Up
– Code cart
– Intubation equipment
– Code drugs
– RSI drugs
– Bedside ultrasound
Props
– EKG with atrial fibrillation with RVR
– Negative FAST
Distractors
– Patient keeps asking for medicine during the history giving the
resident a hard time obtaining information
Actors: (All roles may be played by residents participating)
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Resident running the case
Nurse to place IVs and give medications
Another resident to be the Surgery or MICU consultant (able to give
recommendations if necessary)
Case Narrative:
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Chief Complaint: Abdominal Pain
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History: Seventy-seven year-old female presents with abdominal pain for
the past 3 hours. It started soon after she finished eating lunch today. She
saw her primary care doctor today who set her up for an outpatient
abdominal ultrasound next week to evaluate her gallbladder. Her
abdominal pain is generalized. She has had some loose stools, vomiting,
and feels more short of breath lately. She states that she “just doesn’t feel
good.”
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Additional history given only if asked: There is history of “poor
circulation” in her legs. Patient also notes that she’s lost 10 pounds
without trying in the last 6 weeks and has occasionally had pain after
eating.
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PMHx: peptic ulcer disease, hypertension, hyperlipidemia
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Social Hx: Retired schoolteacher who lives in a retirement community.
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Meds: Hydrochlorothiazide; Simvastatin
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Surgical Hx: Partial hysterectomy when she was 38 years old; carpal
tunnel release surgery
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Allergies: Penicillin
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ROS: Subjective fevers and occasional chest discomfort
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Physical Exam
– BP 179/95, HR 111, RR 25, Temp 37.2, O2 sat 94%RA
– GCS 15 in mild distress, clutching her abdomen
– HEENT – NCAT, pupils 3mm bilaterally and reactive, EOMI
– Resp – tachypnea; clear lungs bilaterally
– CVS – tachycardia, irregularly irregular
– Abd – soft, diffuse mild tenderness, a little more so in the
epigastric region, no guarding or rebound, minimally diminished
bowel sounds; no organomegaly
– Rectal- moderate heme positive
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Ext – no gross deformities; evidence of PVD in lower extremities
bilaterally
Neuro – completely intact
Skin –pale, cool
Instructors Notes:
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Tips to Keep the Scenario Flowing
– The patient should start out with relatively normal vital signs
(except tachycardia) and progressively worsen throughout the
simulation
– Pain is not eased with IV opioids and the patient keep asking for
more medication
– Make sure the resident provides IV fluids and checks an EKG
early on
– Pain is initially out of proportion to exam. Over time, the patient’s
abdomen becomes progressively more painful and peritonealemphasize the importance of serial abdominal exams
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Tips to Direct Actors
– The director should help the resident form a wide differential
concerning her abdominal pain.
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Scenario Steps
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Optimal Management Path
 Resident realizes the many causes of abdominal pain in an
elderly patient and forms a wide differential: gallbladder or
liver etiology, pancreatitis, bowel obstruction, GI
bleed/peptic ulcers, appendicitis, volvulus, mesenteric
ischemia. The resident orders lab work including CBC,
Chem 10, LFTs, lipase, amylase, and lactate. A 3 way
abdominal film will be unremarkable. An abdominal CT
should be ordered as well. An EKG and cardiac enzymes
should be ordered based on her additional history of chest
discomfort and shortness of breath. The EKG will pick up
atrial fibrillation. This finding should clue the resident in to
mesenteric ischemia. Surgery and intensivist consultations
should be called.
Potential Complications Path
 If the patient fails to recognize mesenteric ischemia in a
timely manner, the patient decompensates and becomes
septic quickly, requiring fluids, blood, and vasoconstrictive
medications.
Potential Errors Path
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Topics to discuss
– What is the classic triad of superior mesenteric artery embolism?
– What is the definitive treatment for mesenteric ischemia?
– What are the most common causes of mesenteric ischemia?
– What are the pitfalls to diagnosing mesenteric ischemia?
Pilot Testing and Revision:
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Imaging and Labs
– CBC: WBC 16, Hgb 11, Hct 32, Plts 214
– Chem 10: Na 135, K 3.6, Cl 101, CO3 22, BUN 12, Creat 1.3, Ca
8, Mg 2.1, Phos 4.3
– Lactate 2.1
– LFTs: AST 34, ALT 32, Alk Phos 121, Tbili 0.8
– Lipase 24
– Amylase 189
– D-dimer 301
– 3 way abdominal film: WNL
– CT A/P: superior mesenteric artery ischemia
– EKG: Atrial fibrillation with RVR
Debriefing Plan:
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The resident may not order an EKG and treat the atrial
fibrillation with RVR which could progress into an unstable
rhythm
The resident may proceed with the GI bleed treatment
pathway due to the heme positive stool
Based on prior history of needing an ultrasound, the
resident may order a RUQ ultrasound, delaying the
definitive diagnosis.
The relatively normal lactate may confuse the resident as to
the diagnosis. (Initial lactate’s are not sensitive for
mesenteric ischemia and should be repeated if persistent
suspicion.)
Number of Participants – 4
Evaluation form for participants – generic handout
Authors:
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John B. Seymour M.D. University of North Carolina Department of
Emergency Medicine, PGY – 3
Rochelle Chijioke, M.D. University of North Carolina Department of
Emergency Medicine, PGY-2
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Kevin Biese M.D. University of North Carolina Department of Emergency
Medicine, Associate Professor and Residency Director
Graham Snyder M.D. Wake Med Health and Hospitals Department of
Emergency Medicine, Assistant Program Director and Simulation Director
Jan Busby-Whitehead M.D. University of North Carolina Division of
Geriatric Medicine/ Institute on Aging, Professor and Chief
Copyright © 2011 The University of North Carolina School of Medicine