Dysrhythmias in the ED… January 31, 2013

Posted by Andy Jagoda, MD in: Cardiovascular , 16 comments

The morning shift in the ED has just started and the nurse approaches about an 85-year-old male from a nursing home who is febrile to 39.5°C, is tachycardic with a heart rate of 160 beats/min, and has a blood pressure of 98/57 mm Hg. He has a history of dementia, diabetes, and hypertension and is nonverbal at baseline. He is minimally responsive and unable to give additional information. You begin fluid resuscitating him and administer acetaminophen, and you notice on the monitor that his heart rhythm is irregular.

What is the safest way to control the patient’s rhythm? Should he be anticoagulated and if so how?

(Enter to win a free copy of the February 2013 issue of Emergency Medicine Practice, which features this case, by submitting your answer to the question above. To do so, simply enter your response in the comments box. The deadline to enter is February 6th.)

“High-risk of stroke…” Case Conclusion January 7, 2013

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

Case re-cap:

A 72-year-old woman with a history of hypertension, diabetes, coronary artery disease, and chronic kidney disease presents shortly after experiencing a 20-minute episode of slurred speech and right facial droop. She denies experiencing similar events in the past, but she does endorse a transient episode of vision loss a week ago, intermittent vertigo, and left-sided weakness last month. On exam, her blood pressure is 178/100 mm Hg, her heart rate is 80 beats per minute and regular, and the ECG shows a sinus rhythm. Her stroke scale is zero, and noncontrast cranial CT scan shows an old small cerebellar infarct. It is Friday evening, and you have no inhouse neurology and no MRI capabilities overnight. The patient attributes her symptoms to stress and states that she has experienced anxiety and palpitations recently. She asks if it is necessary for her to be admitted or whether she can seek follow-up with her primary care physician next week.

Case conclusion:

You correctly identified that the 72-year-old woman was at a high short-term risk of stroke with an ABCD2 score of 6 and multiple recent episodes in different vascular territories as well as evidence of an old infarct on CT scan. At your recommendation, she agreed to admission. You arranged expedited etiologic workup, including carotid duplex and transcranial Doppler ultrasound, which was initially unrevealing. She experienced a brief episode of atrial fibrillation, which was captured on the cardiac monitor, before leaving the ED. Knowing that cardioembolic causes correlate with increased stroke severity and stroke mortality, you arranged for transthoracic echocardiography the next morning, which revealed a left atrial thrombus. She was started on anticoagulation and was recurrence-free at 3 months.

Congratulations to Ramy Yakobi, Jim Mitch, Patrick Bruss, Michael Dawson, and CD  — this month’s winners of the exclusive discount coupon for Emergency Medicine Practice. For an evidence-based review of the etiology, differential diagnosis, and diagnostic studies for Transient Ischemic Attack: An Evidence-Based Update, purchase the Emergency Medicine Practice issue on this topic.