o ED Course Medical decision making  arrival to ED 5:54 am on 5/10/21  Patient with altered mental status from an unknown cause.  Her pupils were dilated and slow to react and she was in some respiratory distress and very diaphoretic.  At this point airway was controlled 5 oh endotracheal intubation using the glide scope and during the intubation patient was noted for copious amounts of dark brown vomitus coming from her esophagus which was guaiac positive.  Her blood pressure was low she was sedated initially with propofol etomidate was used for the intubation however because of her hypotension the propofol was slowed and she was given Versed which did seem to control her agitation and maintain her blood pressure.  Patient had IV fluid initiated wide open and CT scan was obtained of head chest abdomen pelvis given the fact that her altered mental status could be from some kind of intracerebral catastrophe and the patient's abdominal exam being unobtainable certainly possible that her GI bleeding could be from a perforated viscus.  CT scan of the brain does not demonstrate any stroke that appears to be acute however there may be some ischemia present although it may be remote and an MRI will need to be done when the patient is more stable.  CT of the chest abdomen pelvis shows what is likely an aspiration pneumonia on the right as well as a perforated viscus in her abdomen.  Radiology feels is probably somewhere in the right colon terminal ileum.  At this point the patient was given Cipro and Flagyl and that should also aid with her aspiration pneumonia.  Her blood pressure did start to decrease her temperature was noted to be elevated at 101.8.  She was given Tylenol rectally and fluids were allowed to run wide open.  Her blood pressure continued to decline and Levophed was instituted.  Case was discussed in detail with surgery and she will go to the OR immediately.  Her temperature continued to rise and was 104.5 upon transfer to the operating room as blood pressure was 78 systolic ED COURSE: o ED Course Medical decision making  Patient with altered mental status from an unknown cause.  Her pupils were dilated and slow to react and she was in some respiratory distress and very diaphoretic.  At this point airway was controlled 5 oh endotracheal intubation using the glide scope and during the intubation patient was noted for copious amounts of dark brown vomitus coming from her esophagus which was guaiac positive.  Her blood pressure was low she was sedated initially with propofol etomidate was used for the intubation however because of her hypotension the propofol was slowed and she was given Versed which did seem to control her agitation and maintain her blood pressure.  Patient had IV fluid initiated wide open and CT scan was obtained of head chest abdomen pelvis given the fact that her altered mental status could be from some kind of intracerebral catastrophe and the patient's abdominal exam being unobtainable certainly possible that her GI bleeding could be from a perforated viscus.  CT scan of the brain does not demonstrate any stroke that appears to be acute however there may be some ischemia present although it may be remote and an MRI will need to be done when the patient is more stable.  CT of the chest abdomen pelvis shows what is likely an aspiration pneumonia on the right as well as a perforated viscus in her abdomen.  Radiology feels is probably somewhere in the right colon terminal ileum.  At this point the patient was given Cipro and Flagyl and that should also aid with her aspiration pneumonia.  Her blood pressure did start to decrease her temperature was noted to be elevated at 101.8.  She was given Tylenol rectally and fluids were allowed to run wide open.  Her blood pressure continued to decline and Levophed was instituted.  Case was discussed in detail with surgery and she will go to the OR immediately.  Her temperature continued to rise and was 104.5 upon transfer to the operating room as blood pressure was 78 systolic      CRITICAL CARE: o Critical Care Indication patient was critically ill...  o Critical Care Indication Patient was critically ill with a high probability of imminent or life threatening deterioration. o Critical Care Time Spent 75-104 minutes (1 hour 15 minutes-1 hour 44 minutes)  2 hours and 50 minutes    ED WORKING DIAGNOSIS:   Perforated abdominal viscus (R19.8): Status: Active  Septic shock (A41.9): Status: Active    DISCHARGE/ADMISSION/TRANSFER DISPOSITION: o Disposition admitted  o Admit To To OR    CONDITION ON DISCHARGE/ADMISSION/TRANSFER: o Condition Critical  Date of OR Procedure  o Date of Procedure 05/10/2021 10:01  Pre Op Dx, Post Op Dx, Procedure  o Pre Operative Diagnosis: Perforated viscus o Post Operative Diagnosis: Ischemic bowel, most likely from shower emboli.  Most of the small intestine and large intestine was affected. o Procedure: Exploratory laparotomy, ICG injection for evaluation of perfusion  Indication and Consent  Findings: . Findings: Even after the ICG injection.  There was spotty tissue necrosis from mid jejunum all the way through sigmoid colon.  Most areas were blackened with a foul smell.  There was some highlighted areas secondary to the ICG but not a significant amount that would lend for an anastomosis.  Black ascites was present throughout the abdomen.  Unfortunately after much contemplation there was no surgical intervention.   Procedure  Procedure: Patient was placed in supine position.  Was intubated in the emergency room so, we were able to proceed with resuscitation through our anesthesia team.  Patient's abdomen was prepped and draped in usual fashion.  Proceeded to make a midline incision.  The blood supply in the subcutaneous tissues did not even bleed.  Appeared to be darkened and almost coagulated.  As we entered through the fascia we were able to open the peritoneum between 2 hemostats.  The large rush of free air through from the abdomen.  We then proceeded to open the abdomen for the length of her incision.  This was done with electrocautery.  From here there was a black ascites present within the abdomen.  There was a large amount of dead intestine that we could immediately see.  I worked my way to the ligament of Treitz.  There was no adhesions so this was easily found.  That intestine did appear to be pink.  It lasted for about a foot.  After that area everything was either black or purple in color with a few pink spots in between.  This went all the way down to the terminal ileum where pneumatosis was visualized.  We then looked at the colon from cecum through rectum.  It appeared to be blackened as well.  Not knowing whether all of this intestine was dead or not especially with patient being hypotensive I injected ICG dye approximately 2 cc.  This was to evaluate perfusion.  Unfortunately perfusion was no better than what I could visualize.  I could not even find enough room of the colon or small intestine to make an anastomosis.  Was very hard decision, however, we did not resect any bowel.  I closed the patient's abdomen.  Patient will be taken to ICU on ventilator.  Discussed with daughter with pastor present.