jump to navigation

Case Conclusion — Retching Patient With Diabetes June 15, 2014

Posted by Andy Jagoda, MD in : Hematologic/Allergic/Endocrine Emergencies , add a comment

Case Recap: You walk into a busy Monday evening shift, and one of the nurses asks you to see a patient who has been waiting for several hours. The nurse states that the 26-year-old woman is sleepy, with a heart rate of 126 beats/min. He advises you that the patient has diabetes, for which she has been medically compliant by taking her insulin. The patient stated that she had not been feeling well for a few days, after which she developed fever, nausea, and vomiting. As you enter the room, you observe the patient retching. You note her respiratory rate is 32 breaths/min, her heart rate is 124 beats/min, and that her blood pressure is 88/50 mm Hg. You start considering your differential and wonder if this presentation is due to her diabetes or if there is something else you might be missing.

Conclusion: You ordered the appropriate tests for the first patient, the 26-year-old woman who was vomiting and sleepy, and discovered that her serum beta-hydroxybutyrate was 4 times normal. You asked the nurse to start the normal saline IV, and the patient received several liters prior to the lab tests returning. The tests showed that she had a serum potassium of 5.8 mEq/L, so you initiated the insulin drip at 0.14 units/kg/h and decided to forgo the insulin bolus, based on your recent reading about insulin in DKA. Since the patient’s bicarb was 9 mEq/L, you decided to admit her to the ICU. Unfortunately, there were no ICU beds, so for the next 8 hours you managed the patient in the ED. When her serum glucose approached 200 mg/dL, you changed to D5 half-normal saline for the fluid infusion, and decreased the insulin infusion to 0.04 units/kg/h. By the time she went up to the ICU, her gap had decreased from 29 to 19 mEq/L and her bicarbonate had increased to 18 mEq/L. She had an unremarkable course in the ICU, was eventually transferred to the floor, and by her fourth day in the hospital, was able to be safely discharged.

Thank you to everyone who participated in this month’s challenge!

Would you like to learn more about new strategies for managing patients with diabetes?

Retching Patient With Diabetes June 12, 2014

Posted by Andy Jagoda, MD in : Hematologic/Allergic/Endocrine Emergencies , add a comment

June’s Case: You walk into a busy Monday evening shift, and one of the nurses asks you to see a patient who has been waiting for several hours. The nurse states that the 26-year-old woman is sleepy, with a heart rate of 126 beats/min. He advises you that the patient has diabetes, for which she has been medically compliant by taking her insulin. The patient stated that she had not been feeling well for a few days, after which she developed fever, nausea, and vomiting. As you enter the room, you observe the patient retching. You note her respiratory rate is 32 breaths/min, her heart rate is 124 beats/min, and that her blood pressure is 88/50 mm Hg. You start considering your differential and wonder if this presentation is due to her diabetes or if there is something else you might be missing.

Share your diagnosis in the comments box below — The case conclusion will be revealed on June 16!

Case Conclusions — Mosquito-Borne Illness May 11, 2014

Posted by Andy Jagoda, MD in : Infectious Disease , add a comment

Recap of Case 1: A 50-year-old man presents with fever for 3 days. He is an immigrant from Nigeria, but has resided in the United States for a decade. Ten days ago, he visited his family in a rural part of his homeland. He complains of fever, chills, and vomiting. His only medication was chloroquine, which was prescribed by his primary care physician prior to his trip. You recall reading something about increased resistance to one of the antimalarial medications in certain countries, but you can’t remember the specifics. A nurse brings you an ominous-looking ECG from EMS, just as you’re attempting to recall where to look up that information…

Recap of Case 2: A 35-year-old woman presents with fever and malaise for 1 day. While taking her blood pressure, she is noted to have petechiae on the ipsilateral arm. She says she recently returned from a trip to Puerto Rico. You have heard that there is a current outbreak of dengue on the island, but you have never seen the disease before, so you need to quickly assess whether your patient has dengue and how to manage her disease…

Case Conclusions: For your 50-year-old patient from Nigeria, you checked the CDC malaria website and called the CDC malaria hotline ([855] 856-4713), and they were able to assist you in navigating the case. The patient was well appearing and did not meet any criteria for complicated malaria. In your discussions with the patient, he felt safe going home with a prescription for atovaquone/proguanil, pending the results of the thick and thin smears.

You examined the 35-year-old female patient with petechiae who recently visited Puerto Rico, and after evaluation of the WHO Clinical Criteria for suspected dengue, you were comfortable that she did not have any warning signs for dengue. You sent off the appropriate tests (dengue virus PCR and dengue IgM antibody testing). You asked her to either return to the ED or be seen by her primary care doctor in 48 hours once her fever resolved. You carefully explained why reevaluation was so crucial, given the natural history of dengue. You made sure she understood the return precautions prior to discharging her from the ED.

Thank you to everyone who participated in this month’s challenge!

Would you like to learn more about treating mosquito-borne illness in the ED? Simply click the links below:

Mosquito-Borne Illness May 6, 2014

Posted by Andy Jagoda, MD in : Infectious Disease , add a comment

Read the following cases and let us know how you would care for these two patients in the comments box below.

Case 1: A 50-year-old man presents with fever for 3 days. He is an immigrant from Nigeria, but has resided in the United States for a decade. Ten days ago, he visited his family in a rural part of his homeland. He complains of fever, chills, and vomiting. His only medication was chloroquine, which was prescribed by his primary care physician prior to his trip. You recall reading something about increased resistance to one of the antimalarial medications in certain countries, but you can’t remember the specifics. A nurse brings you an ominous-looking ECG from EMS, just as you’re attempting to recall where to look up that information…

Case 2: A 35-year-old woman presents with fever and malaise for 1 day. While taking her blood pressure, she is noted to have petechiae on the ipsilateral arm. She says she recently returned from a trip to Puerto Rico. You have heard that there is a current outbreak of dengue on the island, but you have never seen the disease before, so you need to quickly assess whether your patient has dengue and how to manage her disease…

Our answers will be posted on May 12. Thanks in advance for participating!

Case Conclusion — Brief Loss of Consciousness April 6, 2014

Posted by Andy Jagoda, MD in : Neurologic Emergencies , add a comment

Recap of April’s Case:It is a busy day in your ED when a 51-year-old woman arrives by EMS. She felt faint while riding her racing bicycle and got off just before losing consciousness. EMS found her conscious, but pale, with a heart rate, 50 beats/min; blood pressure, 90/50 mm Hg; respiratory rate, 25 breaths/min; and oxygen saturation, 98% on room air. She tells you that just before she got off her bike, she experienced pain in her throat, but she denies chest pain, shortness of breath, or headache. Her initial ECG shows a sinus bradycardia but is otherwise normal. She is an experienced marathon runner and has never had similar complaints. You wonder what could have caused the syncope and persistent bradycardia.

Case conclusion:  The 51-year-old bicyclist who was also a marathon runner did not have improvement of her SBP, which remained at 90 mm Hg. Furthermore, she had throat pain, which could have been an angina equivalent. Your primary concern was that she had a cardiac outflow problem because of an aortic dissection or a pulmonary embolism. A neurally mediated component to her syncopal event could not be excluded. A CT aortogram was ordered to assess for dissection. It showed a type A aortic dissection starting in the ascending aorta extending to just above her renal arteries. Her spinal cord arteries originated from the true lumen, explaining why she had no neurologic or other symptoms. The throat pain was attributed to radiating pain from the intimal tear in her ascending aorta. She developed pain between her shoulder blades later during her stay in the ED while awaiting surgical intervention. She made a full recovery after surgery.

Thank you to everyone who participated in this month’s challenge!

Would you like to learn more about treating syncope in the ED? Simply click the links below:

Brief Loss of Consciousness March 31, 2014

Posted by Andy Jagoda, MD in : Neurologic Emergencies , 15comments

April’s Case: It is a busy day in your ED when a 51-year-old woman arrives by EMS. She felt faint while riding her racing bicycle and got off just before losing consciousness. EMS found her conscious, but pale, with a heart rate, 50 beats/min; blood pressure, 90/50 mm Hg; respiratory rate, 25 breaths/min; and oxygen saturation, 98% on room air. EMS provided 1 liter of normal saline without a change in her vital signs. In the ED, her BP is still 90/50 mm Hg. She tells you that just before she got off her bike, she experienced pain in her throat, but she denies chest pain, shortness of breath, or headache. She appears uncomfortable and complains of persisting throat pain and states she is afraid of dying. Her initial ECG shows a sinus bradycardia but is otherwise normal. Her past medical history is not significant. She takes no medications. She is an experienced marathon runner and has never had similar complaints. You wonder what could have caused the syncope and persistent bradycardia.

Share your diagnosis with us in the comments box below. The case conclusion will be published on April 7!

Case Conclusion — Shock in the Emergency Department March 6, 2014

Posted by Andy Jagoda, MD in : Uncategorized , add a comment

Recap of March’s Case: You are working in the ED late one evening when an 82-year-old man is brought in by his son. His son reports that earlier today, his father had been in his usual state of health, but this evening he found his father confused, with labored breathing. He is delirious and unable to answer questions. A focused physical examination demonstrates tachycardia without extra heart sounds or murmurs, right basilar crackles on lung auscultation, a benign abdomen, and 1+ lower extremity pitting edema. You establish intravenous access with a peripheral catheter and send basic labs. A further history obtained from the son reveals that his father has congestive heart failure with a low systolic ejection fraction, as well as a history of several prior myocardial infarctions that were treated with stent placement. As you consider this case, you ask yourself whether this patient is in shock, and if he is, what are the specific causative pathophysiologic mechanisms?

Case Conclusion: You rapidly determined that the patient was in shock. Although his blood pressure was within acceptable limits, he had clear clinical evidence of impaired end-organ perfusion as evidenced by altered mental status (impaired cerebral perfusion) and respiratory insufficiency. While you recognized the possibility of a cardiogenic process contributing to his presentation, the majority of the clinical data supported an infectious process (specifically, a right lower lobe pneumonia) resulting in a systemic inflammatory response and distributive pathophysiology due to septic shock. You administered a bolus of 30 mL/kg of lactated Ringer’s. You requested a comprehensive laboratory panel be sent, including CBC, chemistries and renal function analyses, arterial blood gas, serum lactate concentration, and blood cultures. You ordered a chest x-ray to better characterize his presumptive pneumonia. Because the patient was in shock due to sepsis, you ordered empiric broad-spectrum antibiotics based on your hospital’s antibiogram – in this case you elected to administer vancomycin 15 mg/kg (as the patient’s renal function is not yet known) and cefepime 2 gm IV. Despite these interventions, his blood pressure progressively decreased in the setting of an increasing temperature and worsening oxygenation. Given his clinical deterioration, you made the decision to intubate him and initiate mechanical ventilation with low-tidal-volume ventilation. Then, you placed a left subclavian central venous line and initiated a continuous infusion of norepinephrine, titrated for a MAP goal of > 65 mm Hg. His laboratory studies demonstrated leukocytosis (WBC 27 x 109/L), thrombocytopenia (90 x 109/L), acute renal failure (creatinine 3.1 mg/dL), and a lactic acidosis (lactate 7.2 mmol/L, bicarbonate concentration of 16 mmol/L, and base excess of -10 mEq/L). After receiving high-quality, evidence-based care in the ED, he was admitted to the MICU in critical condition, but ultimately made a full and uneventful recovery.

Thank you to everyone who participated in this month’s challenge!

Would you like to learn more about shock in the ED? Simply click the links below:

Shock in the Emergency Department February 28, 2014

Posted by Andy Jagoda, MD in : Cardiovascular , 10comments

March’s Case: You are working in the ED late one evening when an 82-year-old man is brought in by his son. His son reports that earlier today, his father had been in his usual state of health, but this evening he found his father confused, with labored breathing. On arrival, the patient has the following vital signs: temperature, 38°C; heart rate, 130 beats/min; blood pressure, 110/60 mm Hg; respiratory rate, 34 breaths/min; and oxygen saturation, 89% on room air. He is delirious and unable to answer questions. A focused physical examination demonstrates tachycardia without extra heart sounds or murmurs, right basilar crackles on lung auscultation, a benign abdomen, and 1+ lower extremity pitting edema. You establish intravenous access with a peripheral catheter and send basic labs. A further history obtained from the son reveals that his father has congestive heart failure with a low systolic ejection fraction, as well as a history of several prior myocardial infarctions that were treated with stent placement. As you consider this case, you ask yourself whether this patient is in shock, and if he is, what are the specific causative pathophysiologic mechanisms? You review which diagnostic tests are indicated to assist with the differential diagnosis of shock and you consider options for the initial management of this patient.

Tell us your diagnosis in the comments box below and check back regularly to see what other emergency physicians have said.  The correct diagnosis will be published on March 8!

Case Conclusion — Cardiotoxicity February 6, 2014

Posted by Andy Jagoda, MD in : Cardiovascular, Drugs & Emergency Procedures, Hematologic/Allergic/Endocrine Emergencies, Toxicologic and Environmental Emergencies , add a comment

You tracheally intubated the young woman who had been taking verapamil and collapsed. You then gave her atropine and calcium and started her on a norepinephrine infusion. However, despite these therapies, she remained hypotensive and bradycardic. You then administered high-dose insulin therapy (1 U/kg/h), with a 10% dextrose infusion. Her hemodynamic status began to stabilize, with resolution of her hypotension and bradycardia. She was admitted to the ICU for further management.

Thank you to everyone who submitted a diagnosis to this month’s challenge. Would you like to learn more about cardiotoxicity management?

Download a complimentary copy of the risk management pitfalls from the latest issue of Emergency Management Practice.

Purchase the complete issue, featuring an evidence-based review on ED management of calcium-channel blocker, beta blocker, and digoxin toxicity from Wesley Palatnick, MD, FRCPC and Tomislav Jelic, MD.

Cardiotoxicity January 29, 2014

Posted by Andy Jagoda, MD in : Uncategorized , 19comments

Late one evening, a 32-year-old woman is brought to your ED via EMS after her boyfriend found her slumped over in a chair. He states that they were arguing last evening and that she was quite upset. Her boyfriend provides a medical history significant for migraine headaches, and he knows that she is taking verapamil for the same. Her fingerstick glucose is normal, and she has a heart rate of 28 beats/min and a blood pressure of 74/36 mm Hg. Consider what the best initial step in management for this patient would be — Is there a role for GI decontamination? What about hemodialysis?

Submit your diagnosis in the comments box below, and be sure to check back on February 8 to see if you were correct!

 

About EB Medicine:

Products:

Accredited By:

ACCME ACCME
AMA AMA
ACEP ACEP
AAFP AAFP
AOA AOA
AAP AAP

Endorsed By:

EMRA EMRA
AEMAA AEMAA
HONcode HONcode
STM STM

 

Last Modified: 05-26-2017
© EB Medicine