Shock in the Emergency Department
February 28, 2014


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

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. read more

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. read more

“Broken CT Scanner…” Case Conclusion
December 7, 2013


Posted by Andy Jagoda, MD in: Cardiovascular , 2 comments

Case re-cap:

The next week, you are working at a free-standing ED where the patients are checking in at record volume. You are getting pressure to see and discharge patients as fast as possible when you see a 21-year-old male presenting with chest pain radiating to his back, along with some shortness of breath. The patient reports no improvement in symptoms with over-the-counter analgesics. The patient plays on the local varsity basketball team. He has no known medical history, and his social history is negative for tobacco, alcohol, or illicit drugs. He appears slightly anxious and has a blood pressure of 155/90 mm Hg and a heart rate of 95 beats/min. He is tall and thin and has reproducible chest tenderness. Your CT scanner has unexpectedly gone down and is unavailable for the rest of the night. ECG shows a normal sinus rhythm without evidence of ischemia and a plain chest radiograph appears normal. As you start to watch your department getting backed up, the nurse states that he is concerned about this patient. You assess the patient as low risk for pulmonary embolism, so you decide to get a D-dimer, which comes back negative. You wonder if this patient has something more significant and what your diagnostic options are… read more

Broken CT Scanner…
December 1, 2013


Posted by Andy Jagoda, MD in: Cardiovascular , 39 comments

The next week, you are working at a free-standing ED where the patients are checking in at record volume. You are getting pressure to see and discharge patients as fast as possible when you see a 21-year-old male presenting with chest pain radiating to his back, along with some shortness of breath. The patient reports no improvement in symptoms with over-the-counter analgesics. The patient plays on the local varsity basketball team. He has no known medical history, and his social history is negative for tobacco, alcohol, or illicit drugs. He appears slightly anxious and has a blood pressure of 155/90 mm Hg and a heart rate of 95 beats/min. He is tall and thin and has reproducible chest tenderness. Your CT scanner has unexpectedly gone down and is unavailable for the rest of the night. ECG shows a normal sinus rhythm without evidence of ischemia and a plain chest radiograph appears normal. As you start to watch your department getting backed up, the nurse states that he is concerned about this patient. You assess the patient as low risk for pulmonary embolism, so you decide to get a D-dimer, which comes back negative. You wonder if this patient has something more significant and what your diagnostic options are… read more

Bradydysrhythmias…
September 1, 2013


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

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… read more

“Dysrhythmias in the ED…” Case Conclusion
February 6, 2013


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

Case re-cap:

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. read more

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. read more

“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. read more

High-risk of stroke…
December 28, 2012


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

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. read more

“Lost consciousness on the job…” Case Conclusion
December 6, 2012


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

The 49-year-old construction worker, acute coronary syndromes was your primary concern; however, given the patient’s recent history of deep vein thrombosis, a CTPA was ordered to assess for PE. This showed multiple central pulmonary emboli, including a saddle embolism. The exact wording at the end of this preliminary reading was, “clinically correlate if patient still alive.” You performed bedside cardiac ultrasound and saw a dilated right ventricle. Based on these findings, the patient was admitted to the ICU. Approximately 6 hours later, the patient became increasingly dyspneic and tachycardic. A repeat bedside ultrasound showed increased dilatation of the right ventricle. The patient was taken emergently to angiography, where rt-PA was administered into the central pulmonary vasculature. The patient’s hemodynamics improved, as did his symptoms. He was eventually discharged from the hospital on warfarin therapy. read more