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“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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Congratulations to this month’s winners. They get a free copy of the latest issue of Emergency Medicine Practice on this topic: Emergency Department Management Of Patients On Novel Oral Anticoagulant Agents. Didn’t win but want to get a complete systematic, evidence-based review on this topic? Purchase the issue today including 4 CME credits!

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.)

“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.)

“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.

Congratulations to  Dr. Nasser, Dr. Oelhaf, and Dr. Noman — 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 An Evidence-Based Approach To Traumatic Pain Management In The Emergency Department, purchase the Emergency Medicine Practice issue.

Traumatic Pain Management… July 25, 2012

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

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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“Something doesn’t add up…” Case Conclusion April 6, 2012

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

The Conclusion Is…

A subdural or epidural hematoma would have to be extensive to cause hemiparesis, hemisensory loss, and neglect. A Todd paralysis after seizure was possible, but was considered only after ischemic causes were ruled out. Since the initial noncontrast head CT showed a small subdural hematoma, ischemic stroke was the next most-worrisome possibility. Concern for dissection should be raised when ischemic stroke is considered in the setting of trauma. A CTA was obtained that showed near occlusion of the right internal carotid artery. IV tPA was not administered for this traumatic dissection for concern of worsening or creating hemorrhagic complications. Interventional neuroradiology was consulted immediately, and the patient was placed on a heparin infusion as a bridge to the procedure. Stenting of the vessel was performed, and though it was not successful in reversing her neurological deficits, it may have prevented further ischemic damage.

Congratulations to  Dr. Cohen, Dr. Orecchioni, Dr. Brown, Dr. Averick, and Dr. Kerr— 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 Carotid And Verebral Arterial Dissections, purchase this issue.

Something doesn’t add up… March 26, 2012

Posted by Andy Jagoda, MD in : Cardiovascular, Neurologic, Trauma , 31comments

A 29-year-old woman is brought in by EMS after a motor vehicle accident in which she was an unrestrained driver. She was found by the medics lying across the steering wheel with a large gash on her forehead. At the scene, she was awake, but disoriented, and there was a strong odor of alcohol on her breath. Her ED assessment revealed a small right-sided subdural hematoma and a zygoma fracture. Her serum ETOH level was 260 dL/mL, and she was placed under observation status on the trauma service. Six hours later, she becomes agitated and then rapidly develops left-sided weakness and neglect. Your first thought is that she must have had a seizure and is left with a Todd paralysis . . . but it doesn’t quite add up, and you wonder what else might have happened.

Is there anything you should be doing?

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