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“Bradydysrhythmias…” Case Conclusion September 9, 2013

Posted by Andy Jagoda, MD in : Infectious Disease, Respiratory Emergencies , add a comment

Case re-cap:

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…

You approach the bedside of a 27-year-old woman who is pale, diaphoretic, and writhing in pain. The only history you are able to obtain is that she has had mild lower abdominal pain for a few days that acutely worsened today. Initial vital signs are: blood pressure, 70/40 mm Hg; pulse rate, 58 beats/min; respiratory rate, 20 breaths/min; and oxygen saturation, 99% on room air. Your brief exam is significant for diffuse abdominal tenderness and guarding. You then hear a flurry of activity from the hallway…

Your next patient is being rushed down the hall on a stretcher. Brought in by a family member for intermittent lightheadedness and shortness of breath, this 64-year-old man is pale and diaphoretic, with depressed mental status. A quick check of his radial artery demonstrates a weak pulse with a palpable rate of approximately 40 beats/min. You quickly place him on the cardiac monitor and notice what appears to be a third-degree heart block. Initial vitals are: blood pressure, 82/40 mm Hg; pulse rate, 38 beats/ min; respiratory rate, 18 breaths/min; and oxygen saturation, 98% on room air.

These 3 cases represent some of the variable presentations of patients with bradydysrhythmias. The underlying pathology for these patients ranges from the benign to the life threatening. You approach each case in a systematic manner, knowing that prompt evaluation, recognition, and treatment can make the difference.

Case conclusion:

When you returned to complete the history on your 80-year-old female patient who had the syncopal event at home, you found that she had no prodrome before the syncopal event, although she did describe recent episodes over the past few weeks where she suddenly became very lightheaded. These episodes apparently resolved spontaneously. She appeared stable upon arrival to the ED. After being placed on cardiac telemetry in the ED, a couple of episodes with sinus arrest were recorded, and some were followed by sinus tachycardia. Based on her brief telemetry monitoring in the ED, you suspected tachy-brady syndrome, and you admitted her to the hospital for continued monitoring, cardiology consultation, and consideration of pacemaker placement.

Your 27-year-old female patient with abdominal pain, hypotension, and bradycardia had a history of lower abdominal pain and had experienced significant worsening of the pain within the last few hours. You inquired as to pregnancy, and she confirmed a recent positive pregnancy test. Her last menstrual period placed her around 8 weeks’ gestation. Her vital signs were notable for profound hypotension with paradoxical bradycardia. As intravenous access was obtained, you prepared for fluid resuscitation as well as blood transfusion. A rapid FAST exam confirmed your suspicions of hemoperitoneum. A quick call to the in-house gynecologist requested emergent surgery for this patient with a ruptured ectopic pregnancy.

Meanwhile, your 64 year-old patient with bradycardia was noted to be pale, diaphoretic, and altered. Initial ECG analysis demonstrated third-degree heart block. You quickly secured IV access and gave him IV atropine, but he had minimal-to-no response in the conduction block. You initiated transcutaneous pacing, capture was demonstrated, and you noted marked improvement of his distal perfusion and mental status. Because of the discomfort associated with transcutaneous pacing, you obtained central venous access and transitioned the patient to a transvenous pacer. From his health records, you learned that he had long-standing bundle branch block from dilated cardiomyopathy. With the transvenous pacer, he appeared to be doing much better, and he was admitted to the cardiac critical care unit with a plan to place a permanent pacer/ AICD soon.

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“Pregnant asthmatic…” Case Conclusion June 7, 2013

Posted by Andy Jagoda, MD in : Airway, Infectious Disease, Respiratory Emergencies , 1 comment so far

Case re-cap:

While establishing IV access and calling respiratory therapy for your first patient, a 24-year-old Hispanic female with a history of asthma who is 15 weeks pregnant presents with tachypnea and acute shortness of breath with audible wheezing. She has been taking albuterol and fluticasone at home with no relief of symptoms. She has a blood pressure of 110/78 mm Hg, heart rate of 110 beats/ min, respiratory rate of 40 breaths/min, and pulse oximetry of 93% on room air. Physical exam demonstrates accessory respiratory muscle usage, decreased breath sounds, and expiratory wheezing. You recognize that your patient is at risk for deteriorating, and you wonder which interventions are safest to use in pregnancy…

Case conclusion:

For the 24-year-old pregnant female with a mild asthma exacerbation, you began 3 consecutive metereddose inhaler treatments with albuterol. You also administered 16 mg of dexamethasone orally. Peak flows performed before and after the first treatment were 125 L/min (predicted 235), and auscultation revealed loud expiratory wheezing and better airflow. Peak expiratory flow rate continued to improve, and there was clearing of breath sounds and much-improved airflow. Her respiratory rate was 24 breaths/min at that time, and her heart rate was 108 beats/min. After 2 hours, her symptoms were nearly resolved; you gave her a prescription for repeat dexamethasone with a metered-dose inhaler refill and sent her home.

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Congratulations to Dr. Masa, Dr. Samuels, Dr. Woodard Jr., Dr. Flynn, and Dr. Murphy — this month’s winners get a free copy of the latest issue of Emergency Medicine Practice on this topic: Management Of Acute Asthma 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!

Pregnant asthmatic… May 22, 2013

Posted by Andy Jagoda, MD in : Respiratory Emergencies , 20comments

While establishing IV access and calling respiratory therapy for your first patient, a 24-year-old Hispanic female with a history of asthma who is 15 weeks pregnant presents with tachypnea and acute shortness of breath with audible wheezing. She has been taking albuterol and fluticasone at home with no relief of symptoms. She has a blood pressure of 110/78 mm Hg, heart rate of 110 beats/ min, respiratory rate of 40 breaths/min, and pulse oximetry of 93% on room air. Physical exam demonstrates accessory respiratory muscle usage, decreased breath sounds, and expiratory wheezing. You recognize that your patient is at risk for deteriorating, and you wonder which interventions are safest to use in pregnancy…

How would you approach this patient’s treatment?

(Enter to win a free copy of the June 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 June 6th.)

“Dying on arrival…” Case Conclusion May 8, 2013

Posted by Andy Jagoda, MD in : Psychiatric and Social Emergencies, Respiratory Emergencies , add a comment

Case re-cap:

On a quiet overnight shift, you receive a call from EMS. They are en route to your ED with a 55-year-old woman in respiratory distress. You walk to the resuscitation room and prepare for rapid sequence intubation, wondering what catastrophic event might have precipitated this patient’s respiratory failure. As the patient arrives, you notice that she is cachectic and pale, gasping for breath as she tries to pull off the nonrebreather mask on her face. Her distraught husband walks alongside the stretcher, stroking her hair and crying. The patient appears to be terminally ill, and when you ask her husband what’s going on, he says, “She has lung cancer. We just stopped chemo because it wasn’t working anymore. We’re supposed to get hospice, but it hasn’t been set up yet.” Meanwhile, the paramedics read her vital signs out loud: “temp 99°, heart rate 120, respiratory rate 40, pulse ox 90%, blood pressure 100/50.” You briefly wish that it was the middle of the day so your hospital’s newly formed palliative care service would be available. Faced with this clearly uncomfortable, dying patient, the traditional emergency medicine tools of endotracheal intubation and mechanical ventilation are clearly inappropriate? You have read that patients often receive morphine at the end of life, but you don’t want to be accused of .hastening anyone’s death. Her husband pleads, “Please help her, doctor. I can’t watch her suffer like this.” Despite your desire to do everything possible to make this patient comfortable, you reflect on the unique legal and ethical framework that surrounds care of the dying patient and want to ensure that you are doing the right thing.

Case conclusion:

After an assessment of the patient and review of her chart through the electronic medical record, you become concerned that this patient may be in the last days to weeks of her life. A brief discussion with the patient revealed that she is confused and too distressed to participate in decision-making, so you took the husband to a quiet corner of the ED to talk. When you asked, “What have the doctors told you about your wife’s condition?” the husband responded by saying, “She’s dying. I know. But I can’t manage this at home.” You validated his concerns and decisions about calling EMS and then asked, “Knowing that her time is short, what would your wife tell us is most important to her right now?” Her husband explained that she would want him by her side and that she “doesn’t want to suffocate.” You assured him that you will do your very best to support these goals. You found a quiet, private room in the ED and had the patient transported there. A chair was placed next to the bed so that the husband could be by his wife’s side. The patient already had IV access that was obtained in the prehospital setting, so the parenteral route could be used to deliver medications. Her husband reported that “she takes a Percocet® every now and then, but that’s it,” so you considered her relatively opioid-naïve. You ordered morphine 1 mg IV. After this, her respiratory rate declined from 40 to 35 breaths per minute, but it still appeared labored. You administered 2 mg, and then 4 mg, in 10-minute time intervals. After this last dose, the patient’s respiratory rate decreased to 20 and her face appeared relaxed, with her accessory muscles no longer visible with breathing. Her oxygen saturation increased from 90% to 99% with 3 L oxygen via nasal cannula. You and the husband decided to continue oxygen delivery, with a plan to reassess the utility of this intervention in the morning. You placed a call to the palliative care consult service. Although they were not in-house, they said they would see your patient in the morning, and they agreed with your treatment decisions. They made a plan to transfer the patient to the palliative care unit in the morning, when a bed would be available. When you updated the patient’s husband regarding the plan, he said, “Thank you. I really appreciate everything you’ve done. She looks so peaceful.”

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Congratulations to Dr. Cousineau, Dr. Lozanoff, Dr. Ella, Dr. Ghilarducci, and Dr. Fowler — this month’s winners get a free copy of the latest issue of Emergency Medicine Practice on this topic: Emergency Management Of Dyspnea In Dying Patients. Didn’t win but want to get a complete systematic, evidence-based review on this topic? Purchase the issue today including 4 CME credits!

Dying on arrival… April 25, 2013

Posted by Andy Jagoda, MD in : Psychiatric and Social Emergencies, Respiratory Emergencies , 30comments

On a quiet overnight shift, you receive a call from EMS. They are en route to your ED with a 55-year-old woman in respiratory distress. You walk to the resuscitation room and prepare for rapid sequence intubation, wondering what catastrophic event might have precipitated this patient’s respiratory failure. As the patient arrives, you notice that she is cachectic and pale, gasping for breath as she tries to pull off the nonrebreather mask on her face. Her distraught husband walks alongside the stretcher, stroking her hair and crying. The patient appears to be terminally ill, and when you ask her husband what’s going on, he says, “She has lung cancer. We just stopped chemo because it wasn’t working anymore. We’re supposed to get hospice, but it hasn’t been set up yet.” Meanwhile, the paramedics read her vital signs out loud: “temp 99°, heart rate 120, respiratory rate 40, pulse ox 90%, blood pressure 100/50.” You briefly wish that it was the middle of the day so your hospital’s newly formed palliative care service would be available. Faced with this clearly uncomfortable, dying patient, the traditional emergency medicine tools of endotracheal intubation and mechanical ventilation are clearly inappropriate? You have read that patients often receive morphine at the end of life, but you don’t want to be accused of .hastening anyone’s death. Her husband pleads, “Please help her, doctor. I can’t watch her suffer like this.” Despite your desire to do everything possible to make this patient comfortable, you reflect on the unique legal and ethical framework that surrounds care of the dying patient and want to ensure that you are doing the right thing.

What other medical strategies exist to help this distressed, symptomatic patient?

(Enter to win a free copy of the May 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 May 6th.)

“Badly Swollen Lips…” Case Conclusion November 7, 2012

Posted by Andy Jagoda, MD in : Gastrointestinal, Respiratory Emergencies , add a comment

The patient with the lip swelling was able to tell you later that the medication he takes is lisinopril. You realized that the diphenhydramine, cimetidine, and prednisone that you already gave him were unlikely to change his clinical course; however, you were reassured that despite how impressive his lip swelling may have been, this would be considered Ishoo stage I and thus unlikely to need airway intervention. You decided to observe him in the ED. After 6 hours, he had marked improvement. You decided to discharge the patient after contacting his primary care provider who would be able to see him the next afternoon. You instructed the patient that the lisinopril is most likely the cause of his swelling and that he should never take this medication or any medication of the same class again.

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Badly Swollen Lips… October 30, 2012

Posted by Andy Jagoda, MD in : Gastrointestinal, Respiratory Emergencies , 17comments

In the middle of an unusually slow evening shift, a 52-year-old black male presents to the ED from walk-in triage with a complaint of lip swelling. He states that he noticed a tingling in his lips shortly after waking that morning, but it wasn’t until he brushed his teeth that he noticed how large his lips had become. He decided to come to the hospital almost 12 hours later only after family members insisted that he get “checked out.” He denies any recent trauma, infection, or known exposures to possible allergens. He denies any pain or itching. His past medical history is significant for hypertension and borderline diabetes. He is unable to remember the name of the medication that he takes for his blood pressure, but he says he has been taking it for years. His vital signs are: heart rate, 74 beats per minute; blood pressure, 156/82 mm Hg; respiratory rate, 16 breaths per minute; temperature, 36.8C; and oxygen saturation, 98% on room air. He is comfortable and in no apparent distress. It would be impossible to miss the rather impressive size of his lips. The upper lip looks to be about 10 times the normal size and the lower lip is only somewhat less enlarged. You are able to examine his oropharynx and find no further swelling of the uvula or posterior pharynx. The rest of his examination is unremarkable. Your nurse checks the airway cart out of concern that the patient will need to be immediately intubated. Your medical student asks the following logical questions:

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