A 70-year-old woman with known atrial fibrillation on warfarin presents with acute severe periumbilical pain out of proportion to a soft, non-tender abdomen. Initial lactate is at the upper-normal threshold, masking early bowel ischemia.
Acute Resuscitation Milestones & Priorities
Clinical phases and key interventions encountered in this emergency module:
Post-Revascularization Critical Care & Second-Look Planning
High-Yield Clinical Pearls
Acute mesenteric ischemia classically presents with severe pain disproportionate to a soft, non-tender abdomen — the 'pain out of proportion' sign.
A normal early lactate does not exclude AMI; serial measurement and CT angiography are required when clinical suspicion is high.
CT angiography is the diagnostic gold standard and should be obtained within minutes, not hours, when AMI is suspected.
Therapeutic IV unfractionated heparin should be initiated immediately on clinical suspicion unless contraindicated by bleeding or perforation.
Endovascular mechanical thrombectomy with catheter-directed thrombolysis is first-line for embolic AMI without peritonitis.
A planned second-look laparotomy at 24–48 hours prevents premature resection of ischemic-but-recoverable bowel.
Test Your Clinical Reasoning in Real Time
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