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“Trauma In Pregnancy…” Case Conclusion April 5, 2013

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

Case re-cap:

Your radio going off as a very distraught paramedic hurriedly relates that they’re about 2 minutes out with a motor vehicle collision victim who looks sick and is tachycardic, hypotensive, and having agonal respirations. He relates that the husband is frantically screaming that she’s due next month to have a baby girl. As your team gears up for the patient about to enter your trauma room, you realize that the ambulance is going to arrive much faster than your obstetrician on call (who is coming from home). You fully appreciate that the opening moves of this drama are going to be entirely up to you.

Case conclusion:

The patient arrived to the ED with a barely palpable pulse and a fundus that was well above the umbilicus. Because she was nonresponsive to pain upon arrival, you placed a wedge under the spine board, which improved her pulse, but you decided to intubate for airway protection. This went uneventfully, and you began rapid infusion of crystalloid and called for O-negative blood. As you performed a FAST exam, you anticipated the worst and had a knife and chlorhexidine at the bedside “just in case.” With volume, her vitals improved, and she was stabilized and placed on electronic fetal monitoring, with some variable decelerations. In consultation with the surgeons, she was taken to the CT scanner, where several intra-abdominal injuries were noted, including a splenic laceration and left kidney laceration, but no evidence of placental abruption or uterine trauma was seen. She was taken to the surgical ICU, where over the next 3 weeks she had a rocky course, but ultimately she underwent a cesarean section and delivery of a healthy baby girl.

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Congratulations to Dr. Brostoski, Dr. Htay, Dr. Naidu, Dr. Davids, and Dr. Krembs — this month’s winners get a free copy of the latest issue of Emergency Medicine Practice on this topic: Trauma In The Pregnant Patient: An Evidence-Based Approach To Management. Didn’t win but want to get a complete systematic, evidence-based review on this topic? Purchase the issue today including 4 CME credits!

Trauma In Pregnancy… March 22, 2013

Posted by Andy Jagoda, MD in : Obstetric Emergencies, Radiology, Trauma , 9comments

Your radio going off as a very distraught paramedic hurriedly relates that they’re about 2 minutes out with a motor vehicle collision victim who looks sick and is tachycardic, hypotensive, and having agonal respirations. He relates that the husband is frantically screaming that she’s due next month to have a baby girl. As your team gears up for the patient about to enter your trauma room, you realize that the ambulance is going to arrive much faster than your obstetrician on call (who is coming from home). You fully appreciate that the opening moves of this drama are going to be entirely up to you.

How do you plan to approach the management of this patient?

(Enter to win a free copy of the April 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 April 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?

(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 September 6th.)

“Troubling headache….” Case Conclusion June 6, 2012

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

Your second patient was more concerning. Although she had a known primary headache disorder, she described several red-flag features, including nuchal rigidity and pain worst at onset. You recalled a popular headache review paper that highlighted the danger of assuming all headaches in patients with known migraines are benign. You decided to order neuroimaging and, while waiting, moved on to another patient.

Later as you were printing out the discharge paperwork for some other patients, you examined the CT head from your first patient and were surprised to find blood in the basal cisterns. You took a deep breath – thankfully, you did not just refill her prescription.

Congratulations to  Dr. Achacoso, Dr. Noman, Dr. Dibartolo, Dr. Sisson, and Dr. Peschanski— 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 Acute Headaches in the ED, purchase the Emergency Medicine Practice issue.

Troubling headache…. May 30, 2012

Posted by Andy Jagoda, MD in : Neurologic, Radiology , 28comments

Your first patient of the day is a 46-year-old female with a history of migraine headaches who presents with a severe, constant pain that started suddenly while running. She admits this “feels different than my normal headaches.” On examination, she appears ill and is vomiting. Her neurologic examination demonstrates mild neck stiffness. She asks for a refill of her sumatriptan, which “always works for my headaches.” While she has a known primary headache disorder, the features of her headache are concerning.

What do you do next?

(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 June 6th.)

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