A 68-year-old man comes to the emergency department due to 12 hours of worsening abdominal pain, nausea, and vomiting. The patient has had intermittent abdominal discomfort and nausea over the past several months but not to this severity. He has had no diarrhea, and his most recent bowel movement was 1 day ago. The patient has no known medical conditions and takes no medications. He has smoked a pack of cigarettes daily for 30 years and drinks 1 or 2 alcoholic beverages daily. Temperature is 38.5 C (101.3 F), blood pressure is 106/64 mm Hg, pulse is 112/min, and respirations are 18/min. On physical examination, the patient appears to be in discomfort and is diaphoretic. The abdomen is tender and rigid throughout. Bowel sounds are absent. Abdominal imaging shows free air under the diaphragm. Intravenous fluids and empiric antibiotics are started, and surgical consultation is obtained. While being prepared for laparotomy, the patient develops new-onset atrial fibrillation with a ventricular rate of 118/min. The patient reports no palpitations, chest pain, or dyspnea. Blood pressure is 110/70 mm Hg. Which of the following is the best next step in management of this patient?

Question

A 68-year-old man comes to the emergency department due to 12 hours of worsening abdominal pain, nausea, and vomiting.  The patient has had intermittent abdominal discomfort and nausea over the past several months but not to this severity.  He has had no diarrhea, and his most recent bowel movement was 1 day ago.  The patient has no known medical conditions and takes no medications.  He has smoked a pack of cigarettes daily for 30 years and drinks 1 or 2 alcoholic beverages daily.  Temperature is 38.5 C (101.3 F), blood pressure is 106/64 mm Hg, pulse is 112/min, and respirations are 18/min.  On physical examination, the patient appears to be in discomfort and is diaphoretic.  The abdomen is tender and rigid throughout.  Bowel sounds are absent.  Abdominal imaging shows free air under the diaphragm.  Intravenous fluids and empiric antibiotics are started, and surgical consultation is obtained.  While being prepared for laparotomy, the patient develops new-onset atrial fibrillation with a ventricular rate of 118/min.  The patient reports no palpitations, chest pain, or dyspnea.  Blood pressure is 110/70 mm Hg.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: This patient exhibits signs of a gastrointestinal perforation (ie, free air under the diaphragm) and needs to undergo emergency exploratory laparotomy. He also has new-onset atrial fibrillation, which is commonly discovered during preoperative workup of both emergency and nonemergency surgical patients. In hemodynamically stable patients who need emergency surgery, ventricular rate control of atrial fibrillation is the preferred course of management. This is best accomplished with the administration of an intravenous beta blocker (eg, esmolol infusion, metoprolol 5 mg every 5 min as needed) or nondihydropyridine calcium channel blocker (eg, diltiazem infusion). In acutely ill patients such as this one, some level of tachycardia is expected and is appropriate to meet metabolic needs; therefore, a goal rate of 100-110/min is often pursued. Care must be taken to ensure these medications do not cause significant hypotension. The risk of an atrial fibrillation-related thromboembolic event during surgery is low; therefore, initiating anticoagulation prior to surgery is not necessary. Anticoagulation should be initiated postoperatively in patients for whom the thromboembolic risk indicates it. thromboembolic risk For new-onset atrial fibrillation recognized prior to nonemergency surgery, delaying surgery to work up a potential cause of the atrial fibrillation (eg, hyperthyroidism) and to optimize pharmacologic management is often appropriate. (Choice A) Digoxin is sometimes used as an adjunctive agent for extended rate control of atrial fibrillation, but it is not used for rate control in the acute setting. This is due to less effectiveness and more difficulty in dosing compared to beta blockers and nondihydropyridine calcium channel blockers. In addition, a goal ventricular rate of <90/min is not appropriate in an acutely ill patient. (Choices B and C) Restoration of sinus rhythm, either with pharmacologic agents (eg, flecainide) or electrical cardioversion, is not indicated prior to emergency surgery. Electrical cardioversion is performed in the preoperative setting only if the patient is hemodynamically unstable (eg, severe hypotension, confusion, ischemic chest pain, acute heart failure). (Choice E) Echocardiography is indicated in the workup of new-onset atrial fibrillation (eg, to evaluate for valvular abnormalities), but it should not delay emergency surgery in patients who are hemodynamically stable. Educational objective: For new-onset atrial fibrillation recognized prior to emergency surgery, hemodynamically stable patients should proceed with surgery with ventricular rate control using intravenous beta blockers or nondihydropyridine calcium channel blockers.

A 68-Year-Old Man Comes to the Emergency Department Due to 12