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“Lower back pain…” Case Conclusion July 8, 2013

Posted by Andy Jagoda, MD in : Musculoskeletal Emergencies, Neurologic , add a comment

Case re-cap:

A 45-year-old man presents after 7 days of pain in his lower back. He reports that it began the day after he started at a new job site. The pain initially improved with ibuprofen, but he woke up this morning with a severe exacerbation of the pain. He denies a fall or other trauma, and he states that the pain radiates from his left buttock to his left foot. He has had intermittent back pains in the past, but he never required any imaging or interventions. Employed in the construction industry, he has a history of hypertension and is going through a divorce. He is afebrile, has a benign abdominal exam, and displays an antalgic gait. He has intact patella and Achilles reflexes, and he has a positive left straight-leg raise sign and crossed straight-leg raise sign. Strength and sensation, including the perineum, are intact and symmetrical. The patient insists that he needs an MRI but you’re not convinced that’s necessary.

Case conclusion:

You wanted to be sure your 45-year-old construction worker patient had no red flag signs or symptoms, so you specifically asked him if he had any prior history of cancer and inquired into his habits (including illicit drug use) and told him that use of intravenous drugs would alter your management. Your physical exam was consistent with a radiculopathy. You inquired about bowel or bladder abnormalities, and he reported all was good on that front. You made a diagnosis of lumbar radiculopathy, and you decided to treat with NSAIDs and a muscle relaxant. You explained that no imaging or blood testing was needed and informed him that his symptoms needed to be reassessed in 4 weeks, as more than 85% of patients are better by then. He asked for extra pain medication, and you agreed to a short course of tramadol. He will follow up with his workers’ compensation clinic, and they will determine when he can return to work.

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Congratulations to Dr. Eak, Dr. Mayeri, Dr. Lock, Dr. Shahzad, and Dr. Cohen — this month’s winners get a free copy of the latest issue of Emergency Medicine Practice on this topic: An Evidence-Based Approach To The Evaluation And Treatment Of Low Back Pain 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!

Lower back pain… June 24, 2013

Posted by Andy Jagoda, MD in : Musculoskeletal Emergencies, Neurologic , 10comments

A 45-year-old man presents after 7 days of pain in his lower back. He reports that it began the day after he started at a new job site. The pain initially improved with ibuprofen, but he woke up this morning with a severe exacerbation of the pain. He denies a fall or other trauma, and he states that the pain radiates from his left buttock to his left foot. He has had intermittent back pains in the past, but he never required any imaging or interventions. Employed in the construction industry, he has a history of hypertension and is going through a divorce. He is afebrile, has a benign abdominal exam, and displays an antalgic gait. He has intact patella and Achilles reflexes, and he has a positive left straight-leg raise sign and crossed straight-leg raise sign. Strength and sensation, including the perineum, are intact and symmetrical. The patient insists that he needs an MRI but you’re not convinced that’s necessary.

How would you manage this patient?

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

“Motor collision…” Case Conclusion March 7, 2013

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

Case re-cap:

It is 2 am on a relatively busy shift on a Saturday night in the ED. EMS arrives with a 27-year-old male involved in a high-speed motor vehicle collision. He was not wearing a seat belt, and he was found ejected from the vehicle. Upon EMS arrival on scene, the paramedics found him unresponsive, with a GCS score of 9 (E2, V3, M4). The patient had been alone in the car, and he did not have identifying information with him. His vital signs included: blood pressure of 110/80 mm Hg, heart rate of 126 beats per minute, shallow respiratory rate of 8 breaths per minute, and oxygen saturation of 96% on room air. The paramedics attempted an oral airway, but it was aborted, because the patient exhibited a gag reflex. Bilateral nasal trumpets were placed, and a nonrebreather facemask with 100% oxygen was administered. He had deformities to his right ankle and left forearm. He smelled of alcohol. The patient was transported on a backboard with a rigid cervical spine collar to maintain immobilization. As you evaluate him on arrival to the ED, his vitals are essentially unchanged; however, you note that his GCS score is now 7 (E2, V2, M3), as he flexes his right arm to painful stimulus. IV access is established, and as you prepare to endotracheally intubate him, you recognize that this patient’s survival and ultimate neurologic outcome may depend on your initial management.

Case conclusion:

The 27-year-old male was successfully intubated after premedication with fentanyl and RSI with etomidate and succinylcholine and was placed on mechanical ventilation, with the tidal volume calculated for 8 cc/kg per ideal body weight. He was monitored with continuous ETCO2 capnography, and his CO2 target was 40 mm Hg. Sedation and analgesia were administered via continuous infusions of propofol and fentanyl, and he received an initial dose of levetiracetam for seizure prophylaxis. The trauma and neurosurgery teams were activated, and he received a cranial, cervical spine, abdomen, and pelvis CT. His injuries were limited to his head, where he was noted to have diffuse axonal injury, scattered subarachnoid hemorrhage, a frontal intraparenchymal contusion, and a small subdural hematoma. His spine was radiographically cleared of fractures, and the head of the bed was raised to 30°. The neurosurgeon elected to transfer the patient to the neurologic ICU for placement of a ventriculostomy, brain tissue oxygen monitoring, and continuous EEG. The patient ultimately did not require surgical intervention, his ICP was medically managed, and he was ultimately discharged with a tracheostomy and percutaneous enterogastrostomy to a long-term acute care facility after 14 days. After 9 months of intensive physical, occupational, and speech therapy, he was functionally independent and back at work with mild right-leg weakness, short-term memory loss, and occasional word-finding deficits.

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Congratulations to Dr. Jacobson, Dr. Allgood, Dr. Masoumi, Dr. Jaiswal, and Dr. Fasika— this month’s winners get a free copy of the latest issue of Emergency Medicine Practice on this topic: Severe Traumatic Brain Injury In Adults. Didn’t win but want to get a complete systematic, evidence-based review on this topic? Purchase the issue today including 4 CME credits!

Motor collision… February 27, 2013

Posted by Andy Jagoda, MD in : Neurologic , 11comments

It is 2 am on a relatively busy shift on a Saturday night in the ED. EMS arrives with a 27-year-old male involved in a high-speed motor vehicle collision. He was not wearing a seat belt, and he was found ejected from the vehicle. Upon EMS arrival on scene, the paramedics found him unresponsive, with a GCS score of 9 (E2, V3, M4). The patient had been alone in the car, and he did not have identifying information with him. His vital signs included: blood pressure of 110/80 mm Hg, heart rate of 126 beats per minute, shallow respiratory rate of 8 breaths per minute, and oxygen saturation of 96% on room air. The paramedics attempted an oral airway, but it was aborted, because the patient exhibited a gag reflex. Bilateral nasal trumpets were placed, and a nonrebreather facemask with 100% oxygen was administered. He had deformities to his right ankle and left forearm. He smelled of alcohol. The patient was transported on a backboard with a rigid cervical spine collar to maintain immobilization. As you evaluate him on arrival to the ED, his vitals are essentially unchanged; however, you note that his GCS score is now 7 (E2, V2, M3), as he flexes his right arm to painful stimulus. IV access is established, and as you prepare to endotracheally intubate him, you recognize that this patient’s survival and ultimate neurologic outcome may depend on your initial management.

What would you do next?

(Enter to win a free copy of the March 2013 issue of Emergency Medicine Practice, which features this case, by submitting your answer to the question above. To do so, simply enter your response in the comments box. The deadline to enter is March 6th.)

“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.

Case conclusion:

You correctly identified that the 72-year-old woman was at a high short-term risk of stroke with an ABCD2 score of 6 and multiple recent episodes in different vascular territories as well as evidence of an old infarct on CT scan. At your recommendation, she agreed to admission. You arranged expedited etiologic workup, including carotid duplex and transcranial Doppler ultrasound, which was initially unrevealing. She experienced a brief episode of atrial fibrillation, which was captured on the cardiac monitor, before leaving the ED. Knowing that cardioembolic causes correlate with increased stroke severity and stroke mortality, you arranged for transthoracic echocardiography the next morning, which revealed a left atrial thrombus. She was started on anticoagulation and was recurrence-free at 3 months.

Congratulations to Ramy Yakobi, Jim Mitch, Patrick Bruss, Michael Dawson, and CD  — this month’s winners of the exclusive discount coupon for Emergency Medicine Practice. For an evidence-based review of the etiology, differential diagnosis, and diagnostic studies for Transient Ischemic Attack: An Evidence-Based Update, purchase the Emergency Medicine Practice issue on this topic.

High-risk of stroke… December 28, 2012

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

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.

How would you handle this patient?

(Enter to win a discount coupon for an Emergency Medicine Practice subscription by submitting your answer to the question above. To do so, simply enter your response in the comments box. The deadline to enter is December 6th.)

“4 cases, 4 head injuries…” Case Conclusion September 6, 2012

Posted by Andy Jagoda, MD in : Neurologic, Radiology, Trauma , add a comment

Your 16 year-old soccer champ had no history of loss of consciousness, and while in the ED, his symptoms resolved completely within 2 hours. Using the CDC guidelines, you determined that a CT was not indicated. You discussed this with his parents, and he was discharged home symptom-free 6 hours after his injury. You instructed him and his parents about the importance of physical and cognitive rest (based on the Zurich Guidelines) until cleared by his primary care provider.

The 38-year-old woman in the low-speed motor vehicle crash had a loss of consciousness but no symptoms or risk factors. Based on the CDC guidelines, you do not think a CT is indicated. You discussed with her the very low likelihood of a clinically important ICI, and she was discharged with head injury precautions and information about postconcussive syndrome.

The history on the 2-month old baby was inconsistent, so you suspected abuse. She had a small hematoma in the left parietal region, and you ordered a CT, which revealed a small subdural. Child Protective Services was called, and the patient was admitted to the PICU.

Your drinking buddy sobered up quickly, but you convinced him to wait for the CT you ordered based on the following CDC criteria: presumed loss of consciousness, intoxication, and physical evidence of trauma above the clavicles. His CT showed atrophy but was otherwise normal. You provided him with follow-up and clear discharge instructions, which he promptly threw in the trash on the way out. Another night in the ED…

Congratulations to  Dr. Jordan, Dr. Achacoso, Dr. Song, Dr. Vikas, and Dr. Naidu — this month’s winners of the exclusive discount coupon for Emergency Medicine Practice. For an evidence-based review of the etiology, differential diagnosis, and diagnostic studies for Management Of Mild Traumatic Brain Injury In The Emergency Department, purchase the Emergency Medicine Practice issue.

4 cases, 4 head injuries… August 23, 2012

Posted by Andy Jagoda, MD in : Neurologic, Radiology, Trauma , 8comments

It’s 8 PM and you are just getting into the groove of your first in a series of several night shifts. After picking up your fourth head injury chart, you think to yourself, “Good grief, are we having a sale on head injury tonight?” Your patients are:

These are 4 cases of what appear to be minor injuries, although you know there is the chance that any of the patients may be harboring a neurosurgical lesion and that all 4 are at risk for sequelae. In your mind, you systematically go through the high-return components of the physical exam of a head-injured patient, the indications for neuroimaging in the ED, and the information needed at discharge to prepare the patients and their families for what might lie ahead. The medical student working with you is very impressed with the complexity of managing these cases, which he thought were so straightforward.

How do you handle these cases?

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“Treating Stroke…” Case Conclusion July 5, 2012

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

You recognized the severity of the patient’s acute ischemic stroke and responded quickly. With the knowledge of ECASS III data on extending the rt-PA window to 4.5 hours, you immediately consulted with your stroke neurologist. You treated the patient with IV rt-PA and admitted him to your stroke unit, where he had a meaningful neurological recovery.

Congratulations to  Dr. Showaihi, Dr. Orellana, Dr. Peschanski, Dr. Noman, and Dr. Naidu— this month’s winners of the exclusive discount coupon for Emergency Medicine Practice. For an evidence-based review of the etiology, differential diagnosis, and diagnostic studies for The Emergent Treatment Of Acute Ischemic Stroke in the ED, purchase the Emergency Medicine Practice issue.

Treating Stroke… June 26, 2012

Posted by Andy Jagoda, MD in : Neurologic , 9comments

A 64-year-old male presents to the ED with the acute onset of profound right-sided motor weakness and expressive aphasia. The patient has no headache, no history of trauma, and no other problems upon presentation. His only chronic medical problem is hypertension that is well controlled on his medications. His wife witnessed the onset of his symptoms while they were eating dinner 3.5 hours prior to arrival. He has normal vital signs, and a stat CT scan of the head is normal as are his laboratory studies. His deficits have persisted throughout his expedited workup and he is now 4 hours into an acute ischemic stroke (an hour beyond the FDA-approved treatment window for intravenous rt-PA), with a calculated NIHSS score of 16.

What emergent treatment options, if any, do you have for this patient?

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