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.

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“Traumatic Pain Management…” Case Conclusion August 6, 2012

Posted by Andy Jagoda, MD in: Drugs & Emergency Procedures, General Emergency Medicine, Trauma , add a comment

After establishing hemodynamic stability with your motor vehicle collision patient, you considered the potential for masking serious injuries with analgesia but realized that appropriate pain control has not been shown to contribute to missing serious injuries in this context. After a dose of IV fentanyl, her heart rate normalized and her pain improved, but she still had tenderness with palpation of the left upper quadrant. A CT scan showed a grade II splenic laceration but no other emergent pathology. You consulted a trauma surgeon, who agreed with your plan for admission for observation and pain control.

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Traumatic Pain Management… July 25, 2012

Posted by Andy Jagoda, MD in: Drugs & Emergency Procedures, General Emergency Medicine, Trauma , 5 comments

A 35-year-old female who was the restrained driver in a front-impact motor vehicle collision arrives. Her airbag deployed, and there was significant damage to her car. The paramedics report tachycardia to 120 beats/minute; her other vital signs are normal. Your examination reveals a young woman in pain, with a patent airway, equal breath sounds, strong distal pulses, and tenderness to palpation in her abdomen. She has a band-like ecchymosis across her chest wall and abdomen, consistent with placement of a seat belt. She is neurologically intact and is able to report that she did not hit her head or lose consciousness. She has no other tenderness or deformities. After reporting a normal fingerstick glucose and negative pregnancy test, the nurse asks you if you would like to order something for pain; the answer is yes, but you consider the risk of lowering her blood pressure or changing her exam findings, and you wonder what the safest strategy might be.

What do you do?

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“Antimicrobial Therapy” … Case Conclusion January 7, 2012

Posted by Andy Jagoda, MD in: Drugs & Emergency Procedures, Infectious Disease , add a comment

The Conclusion Is…

The 35-year-old female was young and healthy, and therefore a decision was made for outpatient management that included coverage for atypical organisms. In the ED, 500 mg of azithromycin was administered and a prescription for 4 additional days at 250-mg-per-day dosing was provided. She was given strict instructions to return if she felt more shortness of breath or worse in any way. She followed up with her primary care doctor in 3 days, feeling much better.

The 70-year old female was presumed to have a mild delirium induced by her UTI. She was given IV ciprofloxacin, and her mental status returned to normal on hospital day 2. Her urine culture grew E coli sensitive to fluoroquinolones, and she was discharged on oral ciprofloxacin on hospital day 4.

The 23-year-old with the infected forearm had the abscess incised and drained in the ED. Because there was also a surrounding cellulitis, he was given oral trimethoprim-sulfamethoxazole and instructed to return for a wound check. His arm was markedly improved by a day 3 wound check, and his wound culture was positive for CA-MRSA.

The 85-year-old from the nursing home had a CT of the abdomen and pelvis that revealed diverticulitis with no evidence of abscess or perforation. Treatment with cefepime and metronidazole was initiated, and he was admitted. The hospital discharge summary indicated that he defervesced after 4 days and was sent back to the nursing home on day 8.

Congratulations to Dr. Barone, Dr. Brown, Dr. Cohen, Dr. Nabhani, and Dr. Tampi— this week’s winners of Emergency Medicine Practice’s “Evidence-Based Guidelines For Evaluation And Antimicrobial Therapy For Common Emergency Department Infections!” For a discussion of common infectious diseases presenting to the ED and a review of the current literature and guidelines, read this issue.

Antimicrobial Therapy… December 30, 2011

Posted by Andy Jagoda, MD in: Drugs & Emergency Procedures, Infectious Disease , 25 comments

At 7:00 on a Monday morning, the day begins with a full line-up of “to be seen.” A 35-year-old female with no past medical history presents to the ED complaining of cough and shortness of breath for 2 days that is progressively worsening. On physical examination, she is febrile with an oxygen saturation of 94% on room air and decreased breath sounds at the right base. You order a chest x-ray that shows right lower lobe consolidation.

The second patient on your tracking board is a 70-year-old female with fever, nausea, and back pain for 3 days. She is accompanied by her daughter, who states her mother hasn’t been herself today and that she had a similar presentation when she had a UTI 2 years ago. She is febrile to 38.3°C (101°F), oriented x2, with left costovertebral angle tenderness. Her urine dipstick is positive for leukocyte esterase and nitrites.

In the next bed, you are evaluating a 23-year-old male who has had a painful, swollen right forearm for 2 days. He reports a subjective fever earlier in the evening, but no other systemic symptoms. He denies any past medical history and has no IV drug abuse and no history of diabetes. He is afebrile with normal vital signs. A 6-cm area of erythema, induration, and tenderness is noted on his proximal forearm with a 2-cm central fluctuant, raised area. He has full range of motion at the elbow.

Just as you sit down for a cup of coffee, the triage nurse notifies you that she just received an 85-year-old male from a nursing home that was sent in for evaluation for fever. He has a history of insulin-dependent diabetes mellitus, hypertension, and dementia. On physical examination, he is febrile, with otherwise normal vital signs. His abdomen is slightly distended, soft, but diffusely tender to palpation.

Four infectious disease cases in a row — it feels like an epidemic. In the age of emerging pathogens — and when the right antibiotic choice may be the difference between a good or bad outcome — which antibiotic(s) do you use?

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