What’s Your Diagnosis? a 9-month-old infant gasping for air September 30, 2019


Posted by Andy Jagoda, MD in: What's Your Diagnosis , 1 comment so far

But before we begin, check out if you got last month’s case right, about the 11-year-old boy with acute abdominal pain. Click here to check out the answer!

Case Presentation: an 9-month-old infant gasping for air

As your shift is winding down at 4 AM, a mother brings in her 9-month-old infant, whom she describes as “gasping for air.” The baby has had a runny nose and cough for a few days as well as a low-grade fever, but now he is breathing rapidly and wheezing, with lower intercostal retractions.

The mother states that the infant has had wheezing in the past, and she asks if he might have asthma since “it runs in the family.” She also indicates that in the last 12 hours, he has not taken his usual amount of fluids.

His oxygen saturation level is 87% on room air.

You begin to think… should I treat this as reactive airway disease, asthma, or bronchiolitis? When should I give the patient albuterol, nebulized epinephrine, or oxygen? Does the infant need steroids? You also wonder whether this patient is going to tire and require assisted ventilation or whether there are any other alternatives to intubation.

Case Conclusion

You quickly determined that your patient had severe bronchiolitis, and you knew that aggressive management was required. You placed the patient on pulse oximetry because the infant had wheezed previously, and started a trial of a nebulized bronchodilator with oxygen while closely monitoring his clinical response to treatment. Your patient’s respiratory rate was still in the 70s, with minimal decreases in the work of breathing. His pulse oximetry level was 87% on room air, so you administered supplemental oxygen via HFNC. The patient started to cry without tears, and you noticed his dry mucous membranes, so you administered IV fluids. His respiratory rate was 55 breaths/min with no retractions, and he was able to take his bottle for only a brief period even after the nurse suctioned his nasal secretions. His SpO2 level remained at 90% on room air. You decided to admit the patient because his tachypnea was leading to compromised oral intake and because of his persistent hypoxia, and you kept him on the HFNC in the meantime.

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What’s Your Diagnosis? Nonconvulsive Status Epilepticus: Overlooked and Undertreated September 30, 2019


Posted by Andy Jagoda, MD in: What's Your Diagnosis , 1 comment so far

But before we begin, check out if you got last month’s case, on assistance with air travel emergencies, right. Click here to check out the answer!

Case Presentation: An 81-year-old woman presents with 1 day of behavioral changes

An 81-year-old woman presents with 1 day of behavioral changes. On examination, she is disoriented, with no focal neurologic findings and no evidence of seizure activity. Her medical history is remarkable for anxiety, arthritis, and hypertension; she has no history of stroke, trauma, or immunocompromise. Her medications include furosemide, lorazepam, and acetaminophen. After an extensive workup in the ED including ECG, CBC, CMP, UA, and
brain CT, all of which were normal, she was admitted to the floor.

You wonder: Is there something you forgot to consider in your differential diagnosis?

Case Conclusion

The 81-year-old woman with AMS was evaluated by a neurologist on the floor. Her EEG showed irregular, rhythmic, generalized 2.0–2.5 Hz sharp-and-slow wave complexes that ceased after 10 mg of IV diazepam. Later, her husband noted that her daily lorazepam had recently been discontinued abruptly due to a change in insurance. The patient was diagnosed with NCSE. NCSE can develop in a patient with or without underlying epilepsy, and should be included in the differential of unexplained AMS, especially in the setting of chronic benzodiazepine use. A high level of suspicion is essential for early diagnosis, but urgent confirmatory EEG is required.

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Brain Teaser: Signs of pneumothorax when seen on thoracic ultrasound September 13, 2019


Posted by Andy Jagoda, MD in: Brain Tease , add a comment

The pediatric patient is arguably more suited for emergency ultrasound than the adult patient. Children generally have a smaller body habitus than adults and, therefore, less tissue for the ultrasound beams to penetrate. This often leads to clearer images of the different organ systems, which should yield better diagnostic accuracy.

Test your knowledge and see how much you know on pediatric ultrasound!


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The correct answer: D.

Review this Pediatric Emergency Medicine Practice issue to get up-to-date on POCUS in the ED.

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Clinical Pathway for Management of Hemorrhage in Patients Taking Direct Oral Anticoagulant Agents September 10, 2019


Posted by Andy Jagoda, MD in: Feature Update , 1 comment so far

Direct oral anticoagulant (DOAC) agents have become commonly used over the last 9 years for treatment and prophylaxis for thromboembolic conditions, following approvals by the United States Food and Drug Administration.

These anticoagulant agents, which include a direct thrombin inhibitor and factor Xa inhibitors, offer potential advantages for patients over warfarin; however, bleeding emergencies with DOACs can present diagnostic and therapeutic challenges because, unlike traditional anticoagulants, their therapeutic effect cannot be easily monitored directly with common clotting assays.

This clinical pathway will help you improve care in the management of hemorrhage in patients taking direct oral anticoagulant agents. Download now.

Clinical Pathway for Management of Hemorrhage in Patients Taking Direct Oral Anticoagulant Agents

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Test Your Knowledge: Concussion in the ED September 10, 2019


Posted by Andy Jagoda, MD in: Brain Tease , add a comment

An increasing number of patients with concussive injuries are presenting to the ED, due to a combination of factors, including media attention to sport-related concussion, early dedication to competitive sport, and improved screening and diagnostic tools for concussion.

Emergency clinicians play an important role in diagnosing concussion, initiating treatment, and providing concussion education to patients and their caregivers to optimize recovery.

Can you get it right?


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The correct answer: D.

Check out the issue on Concussion in the Emergency Department: A Review of Current Guidelines to brush up on the subject. Plus earn CME for this topic by purchasing this issue.

Clinical Flowchart for the Diagnosis of Appendicitis in Pediatric Patients September 10, 2019


Posted by Andy Jagoda, MD in: Feature Update , add a comment

Appendicitis is the most common condition in children requiring emergency abdominal surgery. Delayed or missed diagnosis in young children is common and is associated with increased rates of perforation. Although several scoring systems have been developed, there is still no consensus on clinical, laboratory, and imaging criteria for diagnosing appendicitis.

The dangers associated with misdiagnosis, delay, and perforation make quick and accurate diagnosis of appendicitis essential. This flowchart provides guidance for the management of children with appendicitis

Click the image to download your flowchart.

Clinical Pathway for the Diagnosis of Appendicitis in Pediatric Patients

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