An unusual cause of an acute surgical abdomen.

0 Dr. Richard Wolfe: We received a call via the paramedic dispatcher that in approximately three minutes we were going to receive a ‘IO-year old female with back and abdominal pain, no obtainable blood pressure, and a heart rate of 140. Due to the patient’s proximity to the hospital and the acuity of the patient’s condition, there was not time for the paramedics to communicate with us via the biocom. The attending physician in the emergency department, at approximately the same time, received a phone call from the patient’s private physician to relay some useful information regarding the patient’s medical history. The patient had called her physician because she became acutely ill with severe abdominal and back pain, weakness, and an inability to ambulate because of the severity of the pain. Her physician relayed to us that she had a history of panhypopituitarism, severe peripheral vascular and coronary artery disease. She was status post bilateral carotid artery endarterectomies and an aorto-bifemoral bypass because of her peripheral vascular disease. Her medication list was given to us by her physician, which included warfarin, hydrocortisone, triazolam, pentoxifylline, levothyroxine, fludrocortisone, and furosemide. As the paramedics arrived, they relayed additional information regarding their encounter with the patient. They found the patient lying down, somewhat lethargic, complaining of severe back and abdominal pain that began approximately four hours earlier. There was obvious incontinence of loose stool at the scene and en route. In the field, the paramedics were unable to obtain a blood pressure and immediately established two large-bore intravenous lines with normal saline. They infused 50% dextrose without a response and enroute gave 700 milliliters of normal saline, and obtained a blood pressure of 80/palpable just prior to their arrival to the emergency department. Are there any questions regarding the pre-hospital course?