Volume 27, Issue 24

December 21, 2010

SUDDEN EVENTS: ABDOMINAL PAIN/CARDIAC ARREST

Sudden Abdominal Pain: Diverting Disaster David Pearson, MD, Director of Didactic Curriculum, Carolinas Medical Center, Charlotte, NC Sudden pain: always consider vascular cause; chest pain, consider aortic dissection; leg pain, arterial occlusion Case: woman, 39 yr of age, gravida 3/para 2; 12 wk pregnant; presents with severe left-sided abdominal pain; lightheaded and vomiting, with last 2 episodes bloodstreaked; physical examination (PE) tachycardic and hypotensive; ill-appearing; dry mucous membranes; lungs clear; abdomen tender throughout, but worse on left side; no leg pain; no rash; patient in shock; consider ruptured ectopic pregnancy until proven otherwise; bedside ultrasonography (US) instant pregnancy test; stat hemoglobin of 6.8 g/dL indicated acute hemorrhagic shock; first place to look Morison pouch (hepatorenal recess), where free fluid seen; also consider trauma; interpersonal violence number one cause of homicide for pregnant women; US showed intrauterine pregnancy; other diagnoses to consider ruptured heterotopic pregnancy; ruptured ovarian cyst; splenic artery aneurysm; computed tomography (CT) of abdomen and pelvis showed 1.5-cm splenic artery aneurysm Splenic artery aneurysm: rare; disease of pregnancy; most often found on CT as incidental finding, and occasionally with abdominal pain; 2% to 10% of patients present with hemodynamic collapse and shock; more common in third trimester; concept of double rupture patient bleeds out around aneurysm into lesser omental sac; tamponade created until enough pressure reached to rupture; patients stabilized 25% of time, only to have hemodynamic collapse 6 to 12 hr later; most frequent visceral aneurysm; abdominal aortic aneurysm most frequent abdominal aneurysm; exact cause unclear; progesterone probably plays role in integrity of arterial wall; frequency of rupture increases with parity; mortality high secondary to delayed diagnosis; treatment recommended for symptomatic expanding aneurysms (>2 cm) and in women of childbearing age; options include surgery and stenting; vessel usually tortuous if predisposed to development of aneurysm; coil embolization another option Case: woman, 35 yr of age, presents with burning epigastric pain with nausea and vomiting; PE normal vital signs and slightly tender epigastrium; suprapubic mass palpated; laboratory tests urine pregnancy test (UPT) negative; serum lipase 120 mIU/mL; US showed homogeneous mass with cysts and vesicles; diagnosis molar pregnancy; reasons for false-negative UPT interstitial pregnancy; -human chorionic gonadotropin (-hCG) level too low; hook effect not unique to -hCG assays (seen in prostate-specific antigen and ferritin levels); once immunoassay oversaturated with -hCG, ability of antibodies required to make test positive lost; may also obtain false-negative qualitative serum test; usually occurs when serum -hCG >1 million mIU/mL Molar pregnancy: gestational trophoblastic disease or hydatidiform mole; appearance similar to cluster of grapes from spontaneous abortion; due to overproduction of trophoblastic tissue that typically develops into placenta; 1 in 2000 pregnancies; if no fetal tissue present, complete mole (incomplete mole if fetal tissue present); incidence of neoplastic gestational disease 50%; presentation uterine size incompatible with gestational age; consider if serum -hCG level high; snowstorm appearance with old US machines; complications second-trimester hypertension; significant uterine bleeding; hyperemesis gravidarum often described; pulmonary embolization; if patient believes she is pregnant, consider UPT; if suprapubic mass present, perform US and consider molar pregnancy, even if UPT negative; obtain qualitative and quantitative serum -hCG assay Case: woman, 32 yr of age, 16 wk pregnant; presents with sudden severe right lower quadrant (RLQ) abdominal pain that radiates to groin; PE slight tenderness in RLQ and right adnexa; no masses palpated; white blood
the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the following has been disclosed: Dr. Ackerman has financial relationships with Boston Scientific, Medtronic, Pfizer, PGx Health, and St. Jude Medical. Dr. Pearson and the planning committee reported nothing to disclose.

Educational Objectives
The goal of this program is to improve the management of sudden abdominal pain and syncopal episodes to prevent sudden death. After hearing and assimilating this program, the clinician will be better able to: 1. Diagnose the cause of sudden abdominal pain. 2. Identify the events or activities that can trigger syncope. 3. Determine which syncopal episodes warrant further investigation. 4. Demonstrate the importance of obtaining an adequate history for warning signs of sudden death. 5. Interpret electrocardiography results accurately to diagnose prolonged QT interval.

Acknowledgements
Dr. Pearson was recorded at 19th Annual National Emergency Medicine Conference, held April 29-39, 2010, in Huntington Beach, CA, and sponsored by Kaiser Permanente. Dr. Ackerman was recorded at 3rd Annual Sudden Cardiac Arrest: From Awareness to Prevention, held April 17-18, 2010, in San Diego, CA, and sponsored by Scripps Clinic. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.

Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within

AUDIO-DIGEST EMERGENCY MEDICINE 27:24

cell count 16,000 x 103/L; differential diagnosis tubo-ovarian abscess; appendicitis; ectopic pregnancy; ovarian torsion Ovarian torsion: review showed that in 60% of cases, onset sudden; 70% with sharp, stabbing pain; 50% with radiating pain; few with peritoneal signs; 70% with nausea and vomiting; size of ovary matters; 90% with enlarged ovary (>5 cm); 25% reported history of ovarian cyst; in pregnant patient, US preferable to CT (opposite in nonpregnant patient); adnexal mass other finding that suggests diagnosis; if clinical suspicion high, involve obstetrics and gynecology surgeon and perform US; adnexal mass >5 cm in 83% of patients; normal color Doppler flow in 60%; US not dependable for diagnosis; because of dual blood supply from ovarian and uterine arteries, persistent arterial flow still present; abnormal venous flow in 93% to 100% of patients, although no clinical utility seen; in pregnancy enlarged corpus luteum cyst predisposes ovary to torsion; 60% occur on right side; ovarian salvage rate same as in nonpregnant population (<10%); study showed false-negative US in 61% of patients (45% in nonpregnant patients); recurrence rate 19.5%; treatment laparoscopic detorsion without pexy if patient desires pregnancy; recurrence higher with pregnancy; one of pitfalls persistent unrelenting pain; consider in pregnant patient if ovarian mass present on CT or US, or with history of pelvic surgery; take-home message size matters; diagnosis not ruled out by normal color Doppler or US found with LQTS; syncope triggers included acute illness, drug treatment, emotion, bodily function (eg, micturition syncope), reflex fainting from curling hair, while in shower or church, and during exercise (consider dangerous until proven otherwise; risk increases from <1% to 30%-40% chance that fainting due to genetic heart disease); most fainting while running track vasovagal; problem with electrocardiography (ECG) that patient falsely labeled with LQTS based on finding of borderline QT interval Case: girl, 11 yr of age, had 2 episodes of passing out in swimming pool; in first episode, disappeared from view of lifeguard; in second episode, noted floating with face down and pulled from water within few minutes; past history revealed fainting episode in church (vision went yellow and blurred, which stopped after she sat down); fainting in church almost always benign; some instances of unexplained drowning may represent sentinel event of genetic heart rhythm diseases; girl sent to pediatric neurology; no pathology found on examination, with autonomic oversensitivity as suspected etiology; pediatric cardiologist found no evidence of cardiovascular disease, with slightly prolonged QT interval (QTc; 450 msec) in itself of no significance; advised that no restriction of activities necessary, but to swim only with companion; girl eventually died suddenly; cause of death determined as mutation causing type 1 LQTS (uniquely coupled to swimming-triggered events, compared to other types); further investigation revealed that girl had ingested erythromycin (contraindicated due to side effect of QTc prolongation); must view swimminginduced fainting as potentially lethal; vasovagal fainting should not occur physiologically when individual in water Case: boy, 17 yr of age, perfectly well until found dead in bed; autopsy negative; family history revealed that mother had fallen from 3-m diving board 30 yr before; mothers ECG normal at rest, but with abnormal epinephrine stress test; gene for type 1 LQTS discovered in mother and in boys 13-yr-old brother; boys pre-sports participation inventory 11 mo before death showed positive answers to questions of whether he had dizziness during or after exercise, chest pain during or after exercise, and any death due to heart problems or occurrence of SUD of family member <50 yr of age Demographics of SUD cohort: average age 18 yr; 51 of 146 subjects had personal or family history of warning signs; catecholaminergic polymorphic ventricular tachycardia two-thirds due to mutation of ryanodine receptor (RyR); highly treatable, but potentially lethal; speaker believes that in youthful SUD, 50% preventable at present time with recognition of warning signs, obtaining better history, and reacting to positive answers on questionnaires; remaining 50% of SUD sentinel events detected only by screening or robust automated external defibrillator (AED) sudden death safety net surveillance program Pearls: must not ignore fainting episode; must view exercise-induced, auditory-triggered, or postpartumtimed faints or seizures as potential sudden death warning signs that warrant careful scrutiny; exerciseinduced, doorbell-triggered epilepsy more likely due to condition in heart than brain; improve pre-sports

Distinguishing the Benign Faint From a Warning Sign of Sudden Death Michael J. Ackerman, MD, PhD, Professor of Medicine, Pediatrics, and Molecular Pharmacology, Mayo Clinic, and Director, Long QT Syndrome Clinic and Windland Smith Rice Sudden Death Genomic Laboratory, Rochester, MN Case: boy, 12 yr of age, has 3 episodes of syncope; warning signs of sweating and lightheadedness; most recent episode at Wrigley Field; fainted 3 yr before while playing kickball; family history of mother experiencing 3 fainting episodes (once in church) and sudden unexplained death (SUD) of maternal paternal great aunt in her 20s; diagnosis of neurocardiogenic syncope (vasovagal syncope) Case: boy, 16 yr of age; high school volunteer at Mayo Clinic; suddenly collapses on ward while ophthalmology team discussing resection of orbital tumor; laceration to back of head; brief generalized tonic-clonic seizure activity; undergoes extensive evaluation; negative family history (multiple interviews); diagnosis of arrhythmogenic syncope secondary to genetically proven type 2 long QT syndrome (LQTS); speakers interview of patients mother elicited history of collapse while running, when car pulled out in front of her and honked; most fainting episodes in young individuals not harbinger of sudden death; most potentially lethal genetic heart conditions have warning sign before sudden death; warning sign is syncope; must evaluate each episode of syncope Study: looked at 151 teenagers presenting to emergency department (ED) for fainting; mean age 14 yr; only 1

AUDIO-DIGEST EMERGENCY MEDICINE 27:24

participation questionnaire (no uniformity); sudden death prevention questionnaire should include 3 questions, 1) is respondent aware of him- or herself or any family member having particular disease (list of diseases provided)? 2) has respondent ever fainted suddenly and without warning during specific activity? 3) has any family member died suddenly or unexpectedly at <50 yr of age? positive answer to any of 3 questions warrants further evaluation; 12-lead ECG best test for screening for many of possible etiologies; must determine which individuals interpret ECG and their training; must not rely on computers reading of QTc; computer accurate about QTc only 90% of time; physicians must act on ECG Questions and answers: swimming unknown whether intrinsically arrhythmogenic or more irritating to heart with LQTS; Japanese study found more ventricular ectopy with swimming than with dry-land aerobics; other possibility that for same level of aerobic expenditure while swimming, heart rate much slower compared to dry-land equivalent; high sympathetic and parasympathetic tone present (possibly more arrhythmogenic in vulnerable host); evaluation of relatives of SUD victim no consensus on whether to evaluate or method of evaluation; evidence of genetic heart disease process in 25% to 35% from genetic testing of victim of SUD or rigorous cardiologic evaluation of victims first-degree relatives; cardiologic evaluation of brother of above 17-yr-old victim warranted; depth of evaluation depends on physician; postmortem genetic testing of decedent ideal; molecular autopsy of decedent more cost-effective first test than cardiac tests of decedents first-degree relatives

Suggested Reading
Agrawal GA et al: Splenic artery aneurysms and pseudoaneurysms: clinical distinctions and CT appearances. AJR Am J Roentgenol, 2007 Apr;188(4):992-9; Bahr R: Can electrocardiographic screening prevent sudden death in athletes? No. BMJ, 2010 Sep 14;341:c4914; Hayashi M et al: Incidence and risk factors of arrhythmic events in catecholaminergic polymorphic ventricular tachycardia. Circulation, 2009 May 12;119(18):2426-34; Jons C et al: Risk of fatal arrhythmic events in long QT syndrome patients after syncope. J Am Coll Cardiol, 2010 Feb 23;55(8):783-8; Kruszka PS, Kruszka SJ: Evaluation of acute pelvic pain in women. Am Fam Physician, 2010 Jul 15;82(2):141-7; Lamris W et al: OPTIMA study group. Imaging strategies for detection of urgent conditions in patients with acute abdominal pain: diagnostic accuracy study. BMJ, 2009 Jun 26;338:b2431; MacCormick JM et al: Misdiagnosis of long QT syndrome as epilepsy at first presentation.
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Ann Emerg Med, 2009 Jul;54(1):26-32; Marek JC: Electrocardiography and preparticipation screening of competitive high school athletes. Ann Intern Med, 2010 Jul 20;153(2):131-2; author reply 132-3; Myerburg RJ, Hendel RC: Expanding riskprofiling strategies for prediction and prevention of sudden cardiac death. J Am Coll Cardiol, 2010 Jul 13;56(3):215-7; Parry SW, Tan MP: An approach to the evaluation and management of syncope in adults. BMJ, 2010 Feb 19;340:c880; Rose MZ et al: Snowstorms and grape clusters. Am J Obstet Gynecol, 2008 May;198(5):605.e1-2; Sclafani JJ et al: Intensive education on evidence-based evaluation of syncope increases sudden death risk stratification but fails to reduce use of neuroimaging. Arch Intern Med, 2010 Jul 12;170(13):1150-4; Sebire NJ, Seckl MJ: Gestational trophoblastic disease: current management of hydatidiform mole. BMJ, 2008 Aug 15;337:a1193; Taggart NW et al: Diagnostic miscues in congenital long-QT syndrome. Circulation, 2007 May 22;115(20):2613-20.

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AUDIO-DIGEST EMERGENCY MEDICINE 27:24 SUDDEN EVENTS: ABDOMINAL PAIN/CARDIAC ARREST

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1. Identify the incorrect statement about splenic artery aneurysm. (A) Occurrence rare (B) Seen more commonly in the first trimester of pregnancy (C) Most often found on computed tomography as incidental finding (D) Treatment recommended if symptomatic and >2 cm in size 2. In which of the following presentations should a molar pregnancy be considered? (A) Uterine size incompatible with gestational age (B) High level of serum -human chorionic gonadotropin (C) Snowstorm appearance on ultrasonography (US) (D) All the above 3. US is dependable for the diagnosis of ovarian torsion. (A) True 4. Which of the following can trigger syncope? 1. Acute illness 2. Medication 3. Emotion 4. Bodily function, eg, micturition (A) 1,3 (B) 2,4 (B) False

(C) 1,2,3

(D) 1,2,3,4

5. Exercise-induced fainting should be considered dangerous until proven otherwise. (A) True (B) False 6. Which of the following is contraindicated in a patient with long QT syndrome (LQTS)? (A) Penicillin (C) Trimethoprim sulfamethoxazole (B) Erythromycin (D) Aspirin 7. Which of the following conditions is due to the mutation of the ryanodine receptor? (A) LQTS (B) Hypertrophic cardiomyopathy (C) Catecholaminergic polymorphic ventricular tachycardia (D) Mitral valve prolapse 8. Which of the following questions should be included in a sudden death prevention questionnaire? (A) Whether respondent aware of him- or herself or any family member having particular disease (list provided) (B) Whether respondent has ever fainted suddenly and without warning while performing specific activity (C) Whether any family member has died suddenly or unexpectedly at <50 yr of age (D) All the above 9. Which of the following is the best test for screening many of the possible etiologies of sudden death? (A) 12-lead electrocardiography (C) Electroencephalography (B) Echocardiography (D) Computed tomography angiography 10. A Japanese study found more ventricular ectopy with _______ than with _______. (A) Swimming; dry-land aerobics (B) Dry-land aerobics; swimming Answers to Audio-Digest Emergency Medicine Volume 27, Issue 23: 1-A, 2-D, 3-D, 4-B, 5-A, 6-C, 7-D, 8-D, 9-A, 10-A

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