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Novel Oral Anticoagulant Agents… September 30, 2013

Posted by Andy Jagoda, MD in : Hematologic/Allergic/Endocrine Emergencies, Trauma , 1 comment so far

Your first patient of the evening is a 78-year-old woman who had a witnessed mechanical fall at home approximately 3 hours prior to arrival. She reports a mild frontal headache, and her family reports that she is “just not acting right.” She takes dabigatran for stroke prophylaxis, given her nonvalvular atrial fibrillation. She is neurologically intact on your examination and is oriented to person, place, and time. The CT of her head, however, shows a 5-mm intraparenchymal hemorrhage. Her PTT is 64 seconds, and her INR is 1.5. You wonder about the relevance of her coagulation studies, what the risk of deterioration is, and whether there is anything available to reverse her anticoagulation.

True to form, your second patient is yet another hematologic challenge: a 68-year-old man with a recent history of coronary artery disease and a distant history of gastric ulcer who was recently placed on warfarin for a deep vein thrombosis. He presents today to your ED after 6 days of progressive weakness, dyspnea on exertion, and melenic stools. Immediately prior to arrival, he had a syncopal episode, but he has awoken by the time he is brought in by EMS. His triage heart rate is 100 beats/min, and his blood pressure is 92/54 mm Hg. He looks pale, and his stool is tarry and guaiac positive. His initial hematocrit is 23.1%, and his INR is 2.4. Once again, you find yourself wondering what the management options available in treating this patient are.

How would you manage these patients?

(Leave a comment to be eligible to receive a free copy of the October 2013 issue of Emergency Medicine Practice, which features this case. To do so, simply enter your response in the comments box. The deadline to enter is October 6th.)

“Bradydysrhythmias…” Case Conclusion September 9, 2013

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

Case re-cap:

It is about 20 minutes into your shift when EMS arrives with a pleasant 80-year-old woman who has had a syncopal event. She describes standing in her home earlier today and becoming lightheaded and falling to the ground. She is now resting comfortably, and her vital signs are: blood pressure, 140/72 mm Hg; pulse rate, 74 beats/min; respiratory rate, 14 breaths/min; and oxygen saturation, 99% on room air. You have just begun to take her history when you are interrupted and called to your next patient…

You approach the bedside of a 27-year-old woman who is pale, diaphoretic, and writhing in pain. The only history you are able to obtain is that she has had mild lower abdominal pain for a few days that acutely worsened today. Initial vital signs are: blood pressure, 70/40 mm Hg; pulse rate, 58 beats/min; respiratory rate, 20 breaths/min; and oxygen saturation, 99% on room air. Your brief exam is significant for diffuse abdominal tenderness and guarding. You then hear a flurry of activity from the hallway…

Your next patient is being rushed down the hall on a stretcher. Brought in by a family member for intermittent lightheadedness and shortness of breath, this 64-year-old man is pale and diaphoretic, with depressed mental status. A quick check of his radial artery demonstrates a weak pulse with a palpable rate of approximately 40 beats/min. You quickly place him on the cardiac monitor and notice what appears to be a third-degree heart block. Initial vitals are: blood pressure, 82/40 mm Hg; pulse rate, 38 beats/ min; respiratory rate, 18 breaths/min; and oxygen saturation, 98% on room air.

These 3 cases represent some of the variable presentations of patients with bradydysrhythmias. The underlying pathology for these patients ranges from the benign to the life threatening. You approach each case in a systematic manner, knowing that prompt evaluation, recognition, and treatment can make the difference.

Case conclusion:

When you returned to complete the history on your 80-year-old female patient who had the syncopal event at home, you found that she had no prodrome before the syncopal event, although she did describe recent episodes over the past few weeks where she suddenly became very lightheaded. These episodes apparently resolved spontaneously. She appeared stable upon arrival to the ED. After being placed on cardiac telemetry in the ED, a couple of episodes with sinus arrest were recorded, and some were followed by sinus tachycardia. Based on her brief telemetry monitoring in the ED, you suspected tachy-brady syndrome, and you admitted her to the hospital for continued monitoring, cardiology consultation, and consideration of pacemaker placement.

Your 27-year-old female patient with abdominal pain, hypotension, and bradycardia had a history of lower abdominal pain and had experienced significant worsening of the pain within the last few hours. You inquired as to pregnancy, and she confirmed a recent positive pregnancy test. Her last menstrual period placed her around 8 weeks’ gestation. Her vital signs were notable for profound hypotension with paradoxical bradycardia. As intravenous access was obtained, you prepared for fluid resuscitation as well as blood transfusion. A rapid FAST exam confirmed your suspicions of hemoperitoneum. A quick call to the in-house gynecologist requested emergent surgery for this patient with a ruptured ectopic pregnancy.

Meanwhile, your 64 year-old patient with bradycardia was noted to be pale, diaphoretic, and altered. Initial ECG analysis demonstrated third-degree heart block. You quickly secured IV access and gave him IV atropine, but he had minimal-to-no response in the conduction block. You initiated transcutaneous pacing, capture was demonstrated, and you noted marked improvement of his distal perfusion and mental status. Because of the discomfort associated with transcutaneous pacing, you obtained central venous access and transitioned the patient to a transvenous pacer. From his health records, you learned that he had long-standing bundle branch block from dilated cardiomyopathy. With the transvenous pacer, he appeared to be doing much better, and he was admitted to the cardiac critical care unit with a plan to place a permanent pacer/ AICD soon.

Download free risk management pitfalls for Bradydysrhythmias In The Emergency Department.

Congratulations to Jesus Llabres, Uttam Bhatta, Nga Collard, Giovanni Moschini, and John Ventura — this month’s winners get a free copy of the latest issue of Emergency Medicine Practice on this topic: Evaluation And Management Of Bradydysrhythmias In The Emergency Department. Didn’t win but want to get a complete systematic, evidence-based review on this topic? Purchase the issue today including 4 CME credits!

Bradydysrhythmias… September 1, 2013

Posted by Andy Jagoda, MD in : Cardiovascular , 12comments

It is about 20 minutes into your shift when EMS arrives with a pleasant 80-year-old woman who has had a syncopal event. She describes standing in her home earlier today and becoming lightheaded and falling to the ground. She is now resting comfortably, and her vital signs are: blood pressure, 140/72 mm Hg; pulse rate, 74 beats/min; respiratory rate, 14 breaths/min; and oxygen saturation, 99% on room air. You have just begun to take her history when you are interrupted and called to your next patient…

You approach the bedside of a 27-year-old woman who is pale, diaphoretic, and writhing in pain. The only history you are able to obtain is that she has had mild lower abdominal pain for a few days that acutely worsened today. Initial vital signs are: blood pressure, 70/40 mm Hg; pulse rate, 58 beats/min; respiratory rate, 20 breaths/min; and oxygen saturation, 99% on room air. Your brief exam is significant for diffuse abdominal tenderness and guarding. You then hear a flurry of activity from the hallway…

Your next patient is being rushed down the hall on a stretcher. Brought in by a family member for intermittent lightheadedness and shortness of breath, this 64-year-old man is pale and diaphoretic, with depressed mental status. A quick check of his radial artery demonstrates a weak pulse with a palpable rate of approximately 40 beats/min. You quickly place him on the cardiac monitor and notice what appears to be a third-degree heart block. Initial vitals are: blood pressure, 82/40 mm Hg; pulse rate, 38 beats/ min; respiratory rate, 18 breaths/min; and oxygen saturation, 98% on room air.

These 3 cases represent some of the variable presentations of patients with bradydysrhythmias. The underlying pathology for these patients ranges from the benign to the life threatening. You approach each case in a systematic manner, knowing that prompt evaluation, recognition, and treatment can make the difference.

How would you manage these 3 patients?

(Leave a comment to be eligible to receive a free copy of the September 2013 issue of Emergency Medicine Practice, which features this case. To do so, simply enter your response in the comments box. The deadline to enter is September 6th.)

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