32-year-old, “otherwise healthy,” man with severe, sharp, epigastric abdominal pain. Your differential is broad enough, but you target a few questions: Drinker? (No.) Gastritis/GERD/PUD in the past? (No.) Gallstones? (No.) Smoker/Hypertensive/your-aorta-or-mesenterics-are-in-trouble? (No.) Bitten by a scorpion lately? (No.) Jokes aside, you’re thorough. He has had terrible, worsening, constant pain for the last 2-3 days. No fevers or diarrhea, but today he started vomiting (without any blood) and he’s very nauseated (even looking at the nurse’s coffee made him gag). He has no surgical history, and has never felt this way before. The exam: soft, non-distended, but tender over the epigastrium (not guarding, no rebound). He’s the slightest bit tachypneic, but no fever and his HR/BP are within-normal-limits.

    After you order some labs and see a few more patients, a bunch of “lab canceled” errors come back. You call the lab to find out why and are told his blood is grossly lipemic (i.e. filled with lipids) and the machines cannot accurately assess his electrolytes, cell counts, or much else. It will be a little while for results, she says, and asks if you want her to run a lipid profile. You do–and shockingly she already did because she was curious. The patient’s triglyceride level is >12,000mg/dl. A few minutes later the lipase pops up at 6,000 as well. Bam, diagnosis: acute pancreatitis secondary to hypertriglyceridemia.

    Pancreatitis is mostly (>80% of the time) caused by stones or alcohol, but #3 on the list: hypertriglyceridemia. This is a pearl, so read about the mechanisms elsewhere, but this (like most metabolic pathophysiology) is a derangement in manufacture and breakdown on triglycerides, most commonly occurring in patients with familial hypertriglyceride pathology (not just a buffet-style weekend). This is a simplification, so read more.

    Normal pancreatitis treatment first: IV fluids, pain control, nutritional support (later, NPO for now). In this case, you add an insulin drip (use similar doses to your DKA drips, 0.1-0.3units/kg/hr; plus a D5 added solution based on the glucose) to the treatment plan, to be discontinued at a triglyceride level <500. Insulin works by (1) up-regulating insulin-sensitive lipoprotein lipase (i.e. accelerating triglyceride metabolism) and (2) inhibiting hormone-sensitive lipase in adipocytes (preventing release of more fatty acids into circulation).

    This is a helpful flowchart from UpToDate, and includes some of the high risk features to consider when your patient is sicker–i.e. when to consider plasmapheresis.

    tl;dr — acute pancreatitis secondary to hypertriglyceridemia; treat with fluids, pain control, NPO, insulin drip, and consider plasmapheresis in the sickest patients.

    • Welcome! This is the website for the Mount Sinai Emergency Ultrasound Division. It serves as an information resource for residents, fellows, medical students and others seeking information about point-of-care ultrasound. There is a lot ofRead more

    • Put down that FOBT

      “The HgB has dropped, have you checked a guaic?” How many times have you checked a FOBT in your workup for anemia? Let’s take a look at what FOBT is supposed to be used for. FOBTRead more

    • A ‘normal’ chest Xray

      What do you see when you take a look at this Chest radiograph? It isn’t immediately noticeable (and was read as normal), and is a good reminder of why you should always check your ownRead more

    • Overshot that INR

      There have been a few cases of supra-therapeutic INR in the Sinai ED recently, and at the request of one of our superstar interns, below you will find a brief set of recommendations regarding SupratherapeuticRead more

    • Ketamine PSA with Desaturation

      During a busy day in the ED, it becomes apparent that the pulling and yanking on your patient’s shoulder has done absolutely nothing to reduce their shoulder. You perform your pre-procedure PSA Checklist, know that thisRead more

    • Sinusitis In Pediatrics?

      You’re working in pediatrics, when a mother comes in stating her 5 year old has sinusitis. He presents with fever, cough, runny nose, and some discomfort over where his frontal sinuses are. Does he haveRead more

    • Ring Removal

      Over the past week, we’ve had a strange uptick in number of patients presenting to the ER with rings stuck on their finger. This is a quick review on the options that you have regardingRead more

    • TPA For Minor Stroke?

        So, you’re working in the ED when a new stroke code is activated. You walk over and see a young gentleman with the complaint of left facial tingling, right arm and leg weakness withRead more

    • Central Line Wizardry

      I was scrolling through twitter this morning when I came across a quick video from @CriticalCareNow for an awesome central line trick. And then I went to his feed and found some more. They areRead more