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Acute Abdominal Pain in a Patient With Atrial Fibrillation


Case Study

The bedside nurse initiated a rapid response event after the patient had an abrupt onset of severe abdominal pain while sitting calmly watching television. On prompt arrival of the rapid response team, the patient started to have severe nausea and vomiting. It was noted that the patient was a 70-year-old female with a known history of persistent atrial fibrillation, coronary artery disease with coronary stent placement a month before. She was admitted to the hospital for evaluation after a mechanical fall at home. Her apixaban was currently being held while the safety of restarting anticoagulation in the patient was being determined.

Vital Signs

  • Temperature: 98.2 °F, axillary

  • Blood Pressure: 130/85 mmHg

  • Pulse: 120 beats per min – irregular rhythm with rapid ventricular rate on telemetry

  • Respiratory Rate: 25 breaths per min

  • Pulse Oximetry: 97% on room air

Focused Physical Examination

A quick exam showed an elderly African American female in significant distress. Her abdominal exam showed a soft, non-tender, non-distended abdomen without peritoneal signs indicating pain out of proportion to the exam. A cardiovascular exam showed an irregular rhythm with no abnormal heart sounds. The pulmonary exam was benign.

Interventions

A cardiac monitor with pacer pads was attached. The patient was immediately given 2 mg intravenous (IV) morphine with some improvement in pain. 4 mg IV ondansetron was administered for nausea. A stat abdominal X-ray was unremarkable. Lab workup, including a complete blood count, comprehensive metabolic panel, lactic acid level, and lipase level, were sent. Fluid resuscitation was provided after the laboratory results showed increased hematocrit with concerns for hemoconcentration and metabolic derangements. Because of the pain out of proportion of abdominal exam and history of atrial fibrillation, there was a high suspicion of mesenteric ischemia; thus, a stat mesenteric angiography was ordered. Computed tomography (CT) angiography showed a complete lack of visualization of the superior mesenteric artery (SMA) origin. Stat general surgery consult was placed, the patient was started on therapeutic heparin infusion, and was transferred to the intensive care unit for further care.

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