What is the differential diagnosis and final diagnosis for a patient with 2 days of vomiting and abdominal pain who progressed to shock, cardiac arrest, and death despite CPR with 14 doses of epinephrine?

Differential and Final Diagnosis for Sudden Cardiovascular Collapse Following Vomiting and Abdominal Pain

The most likely final diagnosis in this young, athletic patient who died after 2 days of vomiting and abdominal pain followed by sudden cardiovascular collapse requiring 14 doses of epinephrine is acute aortic dissection, mesenteric ischemia, or ruptured abdominal aortic aneurysm—all catastrophic vascular emergencies that present with abdominal pain and progress to refractory shock and death. 1, 2

Critical Differential Diagnoses

Life-Threatening Vascular Emergencies (Most Likely)

• Acute aortic dissection should be the primary consideration given the sudden progression from abdominal pain to cardiovascular collapse and death despite aggressive resuscitation 1

  • Abdominal pain is a presenting feature in aortic dissection, particularly when involving the descending thoracic or abdominal aorta 1
  • Hypotension or shock in acute aortic dissection suggests rupture, hemopericardium with tamponade, or contained rupture into adjacent structures, all of which mandate immediate operative intervention 1
  • Medical management options for dissection-related hypotension are extremely limited, and vasopressors (like the 14 doses of epinephrine given) may actually cause further false lumen propagation 1

• Mesenteric ischemia presents with abdominal pain out of proportion to physical findings, followed by rapid deterioration to shock 2

  • Thromboembolic disease leads to ischemia and eventual infarction of intra-abdominal organs 2
  • These conditions are time-sensitive, leaving organ blood flow at risk and frequently resulting in mortality 2

• Ruptured abdominal aortic aneurysm causes sudden abdominal pain followed by rapid hypovolemic shock and death if not diagnosed 2

  • A high index of suspicion is critical as physical examination may not reveal clear abnormalities 2

Cardiac Causes

• Acute myocardial infarction with cardiogenic shock can present with abdominal pain and progress to cardiac arrest 1

  • Cardiac arrest is common among patients with acute MI complicated by cardiogenic shock and confers increased mortality 1
  • However, the 2-day prodrome of vomiting makes this less likely as the primary diagnosis 1

• Massive pulmonary embolism should be considered in the differential for sudden collapse 1

  • Can present with abdominal pain and progress to obstructive shock 1
  • Basketball activity could theoretically increase risk, though no specific risk factors mentioned 1

Toxic/Metabolic Causes

• Severe electrolyte disturbances from prolonged vomiting could precipitate fatal arrhythmias 1

  • Severe hypokalemia can lead to life-threatening ventricular arrhythmias 1
  • Hyperkalemia causes flaccid paralysis, ECG changes (peaked T waves, widened QRS), and can progress to asystolic cardiac arrest 1

• Toxic ingestion (e.g., yew leaves or other cardiotoxins) can cause vomiting, abdominal pain, and refractory ventricular arrhythmias leading to cardiogenic shock and death 3

  • Yew leaf ingestion specifically causes ventricular conduction defects and arrhythmias unresponsive to medical treatment, with death from irreversible cardiogenic shock 3

Other Serious Causes

• Boerhaave's syndrome (spontaneous esophageal rupture) occurs after excessive vomiting and has high mortality if untreated 4

  • Presents with sudden upper abdominal pain after vomiting 4
  • However, typically causes septic shock rather than immediate cardiovascular collapse 4

• Acute adrenal insufficiency (Addisonian crisis) can present with abdominal pain, vomiting, and progression to shock 5

  • Would be unusual in a previously healthy young athlete without prior symptoms 5

Key Clinical Reasoning

The requirement for 14 doses of epinephrine during resuscitation is highly significant and suggests refractory shock from a mechanical/structural problem rather than a rhythm disturbance alone. 6

• High cumulative doses of epinephrine during CPR are strongly associated with cardiocirculatory death, with adjusted odds ratios of 23.71 for >5 mg compared to no epinephrine 6
• The need for this many doses indicates either ongoing hemorrhage, mechanical obstruction to cardiac output, or severe myocardial dysfunction 6
• In non-shockable cardiac arrest with return of spontaneous circulation, epinephrine dose is strongly associated with early cardiocirculatory death even after adjustment for resuscitation duration 6

Most Likely Final Diagnosis

Given the clinical presentation—young athletic patient, 2-day prodrome of vomiting and abdominal pain, sudden progression to "pale and weak," cardiovascular collapse, and death despite 14 doses of epinephrine—the most probable final diagnosis is acute aortic dissection with rupture or acute mesenteric ischemia. 1, 2

The basketball activity is relevant as physical exertion can trigger aortic dissection in patients with underlying connective tissue disorders or undiagnosed hypertension 1. The refractory nature of the shock despite massive epinephrine dosing strongly suggests a mechanical catastrophe (rupture/hemorrhage) rather than a primary cardiac rhythm problem 1, 6.

Definitive diagnosis would require autopsy, but the clinical course is most consistent with a catastrophic vascular emergency where surgical intervention was the only potential life-saving measure, and medical resuscitation alone was futile. 1, 2