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Case Conclusion — Retching Patient With Diabetes June 15, 2014

Posted by Andy Jagoda, MD in : Hematologic/Allergic/Endocrine Emergencies , add a comment

Case Recap: You walk into a busy Monday evening shift, and one of the nurses asks you to see a patient who has been waiting for several hours. The nurse states that the 26-year-old woman is sleepy, with a heart rate of 126 beats/min. He advises you that the patient has diabetes, for which she has been medically compliant by taking her insulin. The patient stated that she had not been feeling well for a few days, after which she developed fever, nausea, and vomiting. As you enter the room, you observe the patient retching. You note her respiratory rate is 32 breaths/min, her heart rate is 124 beats/min, and that her blood pressure is 88/50 mm Hg. You start considering your differential and wonder if this presentation is due to her diabetes or if there is something else you might be missing.

Conclusion: You ordered the appropriate tests for the first patient, the 26-year-old woman who was vomiting and sleepy, and discovered that her serum beta-hydroxybutyrate was 4 times normal. You asked the nurse to start the normal saline IV, and the patient received several liters prior to the lab tests returning. The tests showed that she had a serum potassium of 5.8 mEq/L, so you initiated the insulin drip at 0.14 units/kg/h and decided to forgo the insulin bolus, based on your recent reading about insulin in DKA. Since the patient’s bicarb was 9 mEq/L, you decided to admit her to the ICU. Unfortunately, there were no ICU beds, so for the next 8 hours you managed the patient in the ED. When her serum glucose approached 200 mg/dL, you changed to D5 half-normal saline for the fluid infusion, and decreased the insulin infusion to 0.04 units/kg/h. By the time she went up to the ICU, her gap had decreased from 29 to 19 mEq/L and her bicarbonate had increased to 18 mEq/L. She had an unremarkable course in the ICU, was eventually transferred to the floor, and by her fourth day in the hospital, was able to be safely discharged.

Thank you to everyone who participated in this month’s challenge!

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Retching Patient With Diabetes June 12, 2014

Posted by Andy Jagoda, MD in : Hematologic/Allergic/Endocrine Emergencies , add a comment

June’s Case: You walk into a busy Monday evening shift, and one of the nurses asks you to see a patient who has been waiting for several hours. The nurse states that the 26-year-old woman is sleepy, with a heart rate of 126 beats/min. He advises you that the patient has diabetes, for which she has been medically compliant by taking her insulin. The patient stated that she had not been feeling well for a few days, after which she developed fever, nausea, and vomiting. As you enter the room, you observe the patient retching. You note her respiratory rate is 32 breaths/min, her heart rate is 124 beats/min, and that her blood pressure is 88/50 mm Hg. You start considering your differential and wonder if this presentation is due to her diabetes or if there is something else you might be missing.

Share your diagnosis in the comments box below — The case conclusion will be revealed on June 16!

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.

Thank you to everyone who submitted a diagnosis to this month’s challenge. Would you like to learn more about cardiotoxicity management?

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“Anemic patient….” Case Conclusion November 7, 2013

Posted by Andy Jagoda, MD in : Hematologic/Allergic/Endocrine Emergencies , add a comment

Case re-cap:

A 54-year-old Hispanic male presents to the ED with the complaints of fatigue and weakness. The weakness is described as generalized, and the symptoms have been present and constant for the last 2 days. The patient denies hematemesis, hematochezia, dark-colored stools, hematuria, or other evidence of bleeding. He also denies chest or abdominal pain, dyspnea, diaphoresis, fever, or chills. The patient has not seen a doctor in the last 15 years and does not think he has any medical conditions. The only medication he has been taking is over-the-counter ibuprofen, which he has been taking daily since he injured his back at work 2 weeks ago. The patient works as a construction laborer and denies past surgeries or allergies. His vital signs are: blood pressure, 110/50 mm Hg; heart rate, 127 beats/min; respirations, 22 breaths/min; and SpO2, 97% on room air. The patient is afebrile. His skin is warm and dry but, despite being dark-skinned, he appears a little pale. On eye examination, the sclerae appear to have a yellow hue. Cardiovascular examination reveals bounding pulses, a hyperdynamic precordium, and a grade II over VI soft, systolic murmur. The remainder of the examination is unremarkable, including a rectal examination, which is negative for occult blood. An ECG shows a sinus tachycardia but is otherwise normal. A basic chemistry panel is within normal limits; however, the CBC reveals a hemoglobin of 5.4 g/dL, hematocrit of 16%, WBC of 8000, and platelet count of 154,000. Based on the presenting symptoms and signs, the patient is likely to need RBC transfusions. An IV catheter is placed, and a normal saline infusion is initiated. A 500-mL bolus of normal saline reduces the heart rate to 105 beats/min.

Case conclusion:

In this case, the RBC indices were normal (MCV = 86.7 fL, MCH = 27.3 pg, MCHC = 34.5%); however, the RDW was increased at 23.9%. Because the patient had scleral icterus and the RDW was elevated, a peripheral blood smear was ordered, which showed spherocytes. Based on the peripheral blood smear results, you were concerned for a hemolytic anemia and ordered LDH, haptoglobin levels, and a Coombs test. The LDH was elevated at 717 IU/L and the haptoglobin was reduced at 15 mg/dL. The Coombs test was positive, which confirmed the diagnosis of an acute autoimmune hemolytic anemia. Because RBC transfusion was anticipated but the patient had an acute autoimmune hemolytic anemia, you consulted hematology. Prednisone (1.5 mg/kg) was given and transfusion was also recommended with a goal of hemoglobin > 7 to 8 g/dL. The hematologist noted that there would likely be considerable delay in crossmatching blood for the patient. He recommended monitoring the hemoglobin and hematocrit every 3 to 4 hours, and if the patient became more anemic prior to receiving crossmatched blood, type-specific uncrossmatched blood should be transfused. The patient was admitted to the ICU in a stable condition, with a final diagnosis of acute autoimmune hemolytic anemia, likely caused by the ibuprofen.

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Anemic patient…. November 1, 2013

Posted by Andy Jagoda, MD in : Hematologic/Allergic/Endocrine Emergencies , 18comments

A 54-year-old Hispanic male presents to the ED with the complaints of fatigue and weakness. The weakness is described as generalized, and the symptoms have been present and constant for the last 2 days. The patient denies hematemesis, hematochezia, dark-colored stools, hematuria, or other evidence of bleeding. He also denies chest or abdominal pain, dyspnea, diaphoresis, fever, or chills. The patient has not seen a doctor in the last 15 years and does not think he has any medical conditions. The only medication he has been taking is over-the-counter ibuprofen, which he has been taking daily since he injured his back at work 2 weeks ago. The patient works as a construction laborer and denies past surgeries or allergies. His vital signs are: blood pressure, 110/50 mm Hg; heart rate, 127 beats/min; respirations, 22 breaths/min; and SpO2, 97% on room air. The patient is afebrile. His skin is warm and dry but, despite being dark-skinned, he appears a little pale. On eye examination, the sclerae appear to have a yellow hue. Cardiovascular examination reveals bounding pulses, a hyperdynamic precordium, and a grade II over VI soft, systolic murmur. The remainder of the examination is unremarkable, including a rectal examination, which is negative for occult blood. An ECG shows a sinus tachycardia but is otherwise normal. A basic chemistry panel is within normal limits; however, the CBC reveals a hemoglobin of 5.4 g/dL, hematocrit of 16%, WBC of 8000, and platelet count of 154,000. Based on the presenting symptoms and signs, the patient is likely to need RBC transfusions. An IV catheter is placed, and a normal saline infusion is initiated. A 500-mL bolus of normal saline reduces the heart rate to 105 beats/min.

As you write the order for the transfusion, your nurse asks, “What is the goal for the transfusion and what is the cause of the anemia?” What do you say?

(Leave a comment to be eligible to receive a free copy of the November 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 November 6th.)

“Novel Oral Anticoagulant Agents…” Case Conclusion October 7, 2013

Posted by Andy Jagoda, MD in : Hematologic/Allergic/Endocrine Emergencies, Trauma , add a comment

Case re-cap:

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.

Case conclusion:

The 78-year-old woman with the 5-mm intraparenchymal hemorrhage did well. You initially focused on temporizing measures, including blood pressure control and seizure prophylaxis. You verified that her creatinine clearance was normal and supported her renal function with judicious IV fluids. After a discussion about her elevated risk for thrombosis with rFVIIa and 3-factor PCC, you obtained informed consent for administration of both of these agents. She was admitted to the neurology service, and her follow-up CT demonstrated no progression of the lesion.

You gave the 68-year-old man with coronary artery disease and a presumed upper gastrointestinal bleed 3-factor PCC, a single unit of fresh frozen plasma, vitamin K 10 mg IV, 2 units of packed red blood cells, and an IV proton pump inhibitor infusion. Fifteen minutes after the PCC and fresh frozen plasma infusion, his INR was 1.2. He was admitted to the medicine service and was found to have a single gastric ulcer that was successfully banded via endoscopy the following morning. He remained hemodynamically stable throughout his hospitalization.

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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.)

“Patient with vaginal bleeding…” Case Conclusion August 7, 2013

Posted by Andy Jagoda, MD in : Hematologic/Allergic/Endocrine Emergencies, Renal and Genitourinary Emergencies , add a comment

Case re-cap:

Your radio goes off and a panicked paramedic reports that they are en route with a 42-year-old woman who is having profuse vaginal bleeding and appears very ill. She is pale, tachycardic, and hypotensive. She has a history of fibroids. She has been bleeding heavily for 3 days, and the bleeding has acutely increased in the past few hours. The on-call gynecologist is delivering a baby at the hospital across town, and you will have to stabilize this patient and manage her on your own for a few hours…

Case conclusion:

The bleeding 42-year-old woman was quite ill upon arrival to the ED, with blood pressure of 96/52 mm Hg, heart rate of 124 beats/min, respiratory rate of 17 breaths/ min and oxygen saturation of 97% on room air. Two large-bore peripheral IVs were placed, and fluid resuscitation with normal saline boluses was started. On physical exam, she was bleeding heavily from the cervical os, and her uterus was large, firm, and irregularly shaped. A pregnancy test was negative. You started treatment with conjugated equine estrogen 25 mg IV. Her initial CBC showed a hemoglobin of 6.8 g/dL, and she was transfused with 2 units of packed red blood cells. After receiving the normal saline boluses and packed red blood cells, there was improvement in her vital signs. Her bleeding began to slow, and after a second dose of IV estrogen 4 hours later, the bleeding stopped completely and she was admitted to the gynecology service in stable condition. As the patient had completed child-bearing and had had little success with medical management of her heavy bleeding in the past, she elected for hysterectomy, which was performed the next day.

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Patient with vaginal bleeding… July 26, 2013

Posted by Andy Jagoda, MD in : Hematologic/Allergic/Endocrine Emergencies, Renal and Genitourinary Emergencies , 14comments

Your radio goes off and a panicked paramedic reports that they are en route with a 42-year-old woman who is having profuse vaginal bleeding and appears very ill. She is pale, tachycardic, and hypotensive. She has a history of fibroids. She has been bleeding heavily for 3 days, and the bleeding has acutely increased in the past few hours. The on-call gynecologist is delivering a baby at the hospital across town, and you will have to stabilize this patient and manage her on your own for a few hours…

How would you manage this patient?

(Leave a comment to be eligible to receive a free copy of the August 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 August 6th.)

“Multiple medical concerns to consider…” Case Conclusion October 4, 2012

Posted by Andy Jagoda, MD in : Hematologic/Allergic/Endocrine Emergencies , add a comment

Your elderly patient had multiple medical concerns that required emergent evaluation. You diagnosed her with severe hypernatremia, likely secondary to her underlying disease processes, combined with a lack of access to free water. In addition to her pneumonia, she had been having gastrointestinal losses from vomiting, along with her known underlying renal insufficiency. On arrival, she was hypotensive and febrile. You immediately established 2 large-bore IVs, placed her on 2 L oxygen via nasal cannula, and obtained a finger-stick blood glucose. You began her management by correcting her hypoperfusion and hypovolemia with a 500- mL NS bolus followed by a second 500-mL NS bolus for her persistent hypotension after the pulmonary exam and confirmation of her past medical history. You then began treatment of the underlying causes of her hypernatremia with antipyretics, antiemetics, and antibiotics for her fever, vomiting, and pneumonia, respectively. After 2 NS boluses, her vital signs normalized, and slow correction of hypernatremia was initiated with 1/2NS at 100 mL/h over 48 hours as an inpatient.

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