History – V, D, abdo pain –> consider DDX – Gastroenteritis,

Surgical causes (cholecysttis, pancreatitis, other), Medical causes ( DKA, other)

Vitals – hypotensive, bradycardia –> fluid depletion, electrolyte abnormalities, cardiac Ischaemia, other..

Lab results

Two major abnormalities

1. Severe hypokalaemia requiring immediate replacement. Replace Mg (aim for Mg >1)- see comment by Ken in ECG of the week. Urgent ECG for changes.

2. High Lipase indicating Pancreatitis (Lipase level is not an indication of severity). Remember to look for causes – alcohol, gallstones (normal LFT here) etc

Also,

high WCC and Neutrophil count – necrotising pancreatitis, other sources of sepsis

mildly elevated CL and low HCO3 – hyperchloraemic acidosis –> normal saline rehydration, sepsis, pancreatitis etc.

Immediate priorities include :

Fluid resuscitation

Replace Potassium and Magnesium

Cardiac/ ECG monitoring

HDU consult – large amounts of Potassium may be required via central access

Gen surgery review +- CT abdomen

This patient should not go to a ward unmonitored unless the Potassium has been addressed and the ECG and K level is normal.

So… why all these bloods?

Remember Ranson’s criteria

On admission 

age>55

WCC >16

Glu>10

AST>250

LDH>350

At 48hrs

Ca<2

Hct drop of >10%

Urea increase >1.8

BE > -4

fluid sequestration > 6litres

This one is for alcohol aetiology, there is a slightly different one for gallstones.

Score  >2 is severe

0-2                    2% mortality

3-4                    15%

5-6                     40%

7-8                     100%

other scoring systems to be familiar with include…

Glasgow

Balthazar

APACHE II