Vomiting, abdominal pain, significant bradycardia

[Akulahawk]

Obviously, you haven't read the FDA's dossage guidelines. The standard dose of Zofran in surgical cases is 4mg IV Q 4 Hours. See rxlist.com/zofran-injection-drug/indications-dosage.htm The reason for giving half the standard dose is because of the fact that you want it to wear off by the time a surgical consult rolls around, given the fact that it is statiscally likely to be GI obstruction, given the whole bile thing.

This drug can also be administered this way: 8mg q 8 hours, or potentially in even greater doses for certain reasons. You really don't want to go "light" with this stuff. It's much better to stop the nausea. I'm not that worried about blotting out nausea even in potential surgical cases. Bile isn't exactly a specific indicator of GI obstruction. Presence or absence of nausea at the time of exam isn't going to change the ED MD's decision as far as getting a surgical consult. Since this guy has a relatively slow HR, I want to know if he's got a long QT. If he does, then Zofran is contraindicated.

What's this patient going to get from me? Likely 4 mg Zofran and a nice, easy ride in to the ED. What am I also going to ask about? Has the patient been taking marijuana for a long time or has there been a recent increase in daily usage? I've seen this more than a few times... Any chance that the patient gets relief by taking very hot showers?

 

[SpecialK]

I have no idea what is wrong with this guy's tummy.

I require no further information to decide he needs to go to the hospital. I can't leave him, or refer him to somebody, in the community.

Ambulance is the most appropriate transport method.

Basic care: IV, IV ondasetron, analgesia (IV morphine, then oral paracetamol. ibuprofen and tramadol).

No lights or siren.

 

[dutemplar]

Basic care: IV, IV ondasetron, analgesia (IV morphine, then oral paracetamol. ibuprofen and tramadol).

I almost overlooked that since we primarily use it for modest trauma, i.e.: fractures, but IV paracetamol here would be a viable option if he's at risk of puking the pills up.

 

[Summit]

I agree with other posters that there is zero reason to withhold zofram unless this person has a really long QTc.

Hypothyroid yet 100 pounds of unintended weight loss is actually potentially one of the most alarming findings here for this person long term.

One could come up with a very long list of possible causes for n/v... cancer, drugs, ileus, intussusception, long long list. This patient needs a thorough medical workup.

 

[TF Medic]

I'm still doing collegiate education.

Have you been solely responsible for an ALS patient?

I don't mind anybody responding, but I think it should be clarified whether you have any experience before espousing about surgical consults and the like.

For the others, I agree that a full house load of narcs likely isn't the bset choice, but that wasn't my decision at the time. Thanks for the discussion.

 

[StCEMT]

I have no idea what could cause this. Potential OD or misdosed meds? Some other problem we cant see? Don't know. I would at least give 4mg of Zofran. Not sure I would rush to treat the bradycardia with anything since he seems to not have any symptoms other than lethargy. I might run it by a doc once he hit 30's, but if he still is mentating fine and has no other signs, then I still wouldn't be jumping to treat right away. Definitely would be watching this dude very closely and asking a bunch of questions to try and find some information that might be pertinent.

 

[bakertaylor28]

I have no idea what could cause this. Potential OD or misdosed meds? Some other problem we cant see? Don't know. I would at least give 4mg of Zofran. Not sure I would rush to treat the bradycardia with anything since he seems to not have any symptoms other than lethargy. I might run it by a doc once he hit 30's, but if he still is mentating fine and has no other signs, then I still wouldn't be jumping to treat right away. Definitely would be watching this dude very closely and asking a bunch of questions to try and find some information that might be pertinent.

The most common causes of vomiting bile that are consistent with abdominal pain are GI obstruction, Gastroenteritis, and Food Posioning.
with the least probability being assigned to a drug OD.

On the Flip SIde, excessive vomiting alone without any other cardiac influences is usually going to cause Sinus Tachycardia, and, in the extreme, perhaps A-Flutter/A-Fib/SVT If the patient is presdisposed to any of those. It usually DOESN'T cause brady-arrhthmias, which tend to indicate CNS depression. However, this can't be hard-coded as a rule, either.

 

[bakertaylor28]

Have you been solely responsible for an ALS patient?

I don't mind anybody responding, but I think it should be clarified whether you have any experience before espousing about surgical consults and the like.

For the others, I agree that a full house load of narcs likely isn't the bset choice, but that wasn't my decision at the time. Thanks for the discussion.

For the record, I'm in year 2 of a 4-year med program. That means I have cleared ACLS credentials. Years 2 and 3 are internship and year 4 crosses over into residency. I can GUARANTEE you the first thing the ER doc is going to do is get an abdominal CT or MRI looking for obstruction- because bile with abdominal pain practically lay it out on the table that your most likely dealing with GI obstruction, Gastroenteritis, Food Poisoning, or more rarely a drug OD. The thing is that they will be looking and thinking on the terms of the worst case scenario- which is GI obstruction, and ruling that out first.

We can (probably) safely rule out the drug thing because of the fact that if my mind serves me correctly, at least one of the regular drugs that were mentioned was a Trycyclic antidepressant- which is going to cause a prolonged QT interval that rapidly degrades to Torsades as that is the classic trycyclic OD syndrome.

 

[Handsome Robb]

I'll toss a DDx out there. Cyclic vomiting syndrome. Presents with abdominal pain and intractable vomiting and nausea. He's had this same thing before and has not been diagnosed. A blockage is a possibility but if he's been having normal BMs it'd be odd for him to have a spontaneous blockage, especially for his age.

I'd be willing to bet he's bradycardia from increased catalog tone secondary to the vomiting and the pain, yes pain can cause bradycardia.

Give the kid some zofran, potentially som metoclopramide if the zofran doesn't resolve his wretching and some fentanyl for his pain. If you're truly worried about him bradying out because of the narcotics then ketamine is another option.


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[Akulahawk]

For the record, I'm in year 2 of a 4-year med program. That means I have cleared ACLS credentials. Years 2 and 3 are internship and year 4 crosses over into residency. I can GUARANTEE you the first thing the ER doc is going to do is get an abdominal CT or MRI looking for obstruction- because bile with abdominal pain practically lay it out on the table that your most likely dealing with GI obstruction, Gastroenteritis, Food Poisoning, or more rarely a drug OD. The thing is that they will be looking and thinking on the terms of the worst case scenario- which is GI obstruction, and ruling that out first.

We can (probably) safely rule out the drug thing because of the fact that if my mind serves me correctly, at least one of the regular drugs that were mentioned was a Trycyclic antidepressant- which is going to cause a prolonged QT interval that rapidly degrades to Torsades as that is the classic trycyclic OD syndrome.

Keep adding to the differential Dx list. Given the recent, rapid weight loss, you could add intestinal parasites to the list and you might also consider the possibility of CA. None of the drugs this patient takes are known to be a TCA. Bupropion (Wellbutrin) is an antidepressant but it is not a TCA. It has no known interaction issues with ondansetron.

Oh, and unless the ED has a dedicated MRI machine, the EDMD isn't going to use the MRI machine for this when a CT scan is much faster and should be able to yield at least as much info about a bowel obstruction as the MRI will.

 

[Summit]

Keep adding to the differential Dx list. Given the recent, rapid weight loss, you could add intestinal parasites to the list and you might also consider the possibility of CA.

And in the setting of hypothyroid with a presentation that suggests that excessive hormone replacement is not present.... it's super concerning for CA. Parasites is a good thought though...

Acute abdomen is probably the hardest medical workup there is.

Oh, and unless the ED has a dedicated MRI machine, the EDMD isn't going to use the MRI machine for this when a CT scan is much faster and should be able to yield at least as much info about a bowel obstruction as the MRI will.

Agree with this 100%

 

[Akulahawk]

And in the setting of hypothyroid with a presentation that suggests that excessive hormone replacement is not present.... it's super concerning for CA. Parasites is a good thought though...

Acute abdomen is probably the hardest medical workup there is.


Agree with this 100%

That's why I listed it. A sufficiently bad parasite infection could also cause similar issues though IIRC there'd be a distended belly and there's no mention of that here and IIRC there's no mention of an abdominal exam per se here either, just symptoms.