A 58-year-old female with a previously undiagnosed ileal mass undergoing exploratory laparotomy develops sudden cutaneous flushing, labile blood pressure cycling between severe hypertension and profound hypotension, and refractory bronchospasm during tumor manipulation, suggesting an intraoperative carcinoid crisis.
Acute Resuscitation Milestones & Priorities
Clinical phases and key interventions encountered in this emergency module:
Recognition of Endocrine Storm Mimicking Anaphylaxis
Carcinoid crisis is the endocrine analog of pheochromocytoma but is driven by serotonin, bradykinin, histamine, and tachykinins — making octreotide the definitive rescue agent rather than alpha blockade.
Brisk flushing + bronchospasm + labile BP during tumor manipulation is carcinoid crisis until proven otherwise; misdiagnosis as anaphylaxis or MH is the most common cognitive error.
Avoid histamine-releasing anesthetic agents (morphine, atracurium, succinylcholine) and succinylcholine-induced fasciculations in known/suspected carcinoid patients.
Surgical manipulation must STOP immediately; continuing resection during active crisis carries mortality exceeding 80%.
Refractory carcinoid bronchospasm responds to IV magnesium and volatile bronchodilators (sevoflurane), not beta-agonists.
Chromogranin A and 24-hour urinary 5-HIAA are the diagnostic biochemical confirmatory tests; Octreoscan localizes primary and metastatic disease.
Octreotide infusion must continue 24–72 hours post-crisis because rebound mediator release is common.
Test Your Clinical Reasoning in Real Time
Step into the active clinician role for this case. Order diagnostic tests, analyze live laboratory panels, and navigate branching clinical decisions with real-time feedback.