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How best to assess his anticoagulation status July 29, 2019

Posted by Andy Jagoda, MD in : What's Your Diagnosis , add a comment

As you begin your shift, the first patient is a 70-year-old man brought in for a ground-level fall with isolated head injury. A review of the patient’s history reveals atrial fibrillation, and he is currently on anticoagulation with apixaban. A rapidly obtained CT scan of the head shows
a subdural hematoma.

As you resuscitate the patient, you wonder how best to assess his anticoagulation status and how best to address reversal.

What are your next steps?

Leave your solution in the comments below and review the issue to find out what was the authors’ recommendation.

Not a subscriber? You can find out the conclusion and if you got it right, next month when a new case is posted, so stay tuned!

Click to review this Emergency Medicine Practice Issue

How Do You Manage Bariatric Surgery Complications? July 11, 2019

Posted by Robin Wilkinson in : What's Your Diagnosis , 2comments

Case Recap:
You are called to the bedside of patient who presents for nausea and vomiting. He is a 38-year-old man who is 2 weeks out from the placement of a laparoscopic adjustable gastric band. He reports that he had an acute onset of nausea and vomiting this evening. He is actively vomiting on presentation and complains of diffuse abdominal pain, but is hemodynamically stable. While attempting to contact his surgeon, you wonder what the best imaging modality is to make the diagnosis. What would you do?

Case Conclusion:
You returned to your patient, in whom you had a concern for a slipped gastric band. You considered obtaining either an upper GI series or CT scan with oral and IV contrast; after speaking to his surgeon, you decided on an upper GI series, as the patient was now more stable. The patient was admitted to the surgery service; on follow-up, you learned that the balloon was subsequently deflated/repositioned, and the patient was discharged home in stable condition.

68-year-old woman presents with severe abdominal pain May 31, 2019

Posted by Andy Jagoda, MD in : What's Your Diagnosis , add a comment

Case Recap:
As you begin your shift, a 68-year-old woman presents with severe abdominal pain. She requires 4 mg of morphine before you can even talk to her. Surprisingly, her abdomen is soft, and not particularly tender. She is tachycardic to the 120s, and her pulse feels irregular. Her blood pressure is 100/50 mm Hg. It seems strange that her pain is so incongruent with her exam, and you wonder: What is the best imaging study to help clarify things?

Case Conclusion:
You recognized that she needed pain control and fluids along with a full sepsis workup, including lactate, ECG, CT abdominal angiography, and an almost-certain surgical consult. Her ECG showed atrial fibrillation, and the CT angio confirmed the diagnosis. She was emergently taken to the OR, where a dead bowel segment was resected and she had a surprisingly good recovery, thanks to your rapid mobilization of specialty care.

Did you get it right?

Brush up on most recent best practices in evaluating patients with abdominal pain in the ED with our 20th anniversary Emergency Medicine Practice issue, Assessing Abdominal Pain in Adults: A Rational, Cost-Effective, and Evidence-Based Strategy.

P.S. Emergency Medicine Practice celebrates its 20th anniversary this month! Click here to check out our story, our plans and our great anniversary sale!

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A 3-year-old girl with a known peanut allergy May 31, 2019

Posted by Andy Jagoda, MD in : What's Your Diagnosis , add a comment

Case Recap:
A 3-year-old girl with a known peanut allergy arrives to your ED via EMS. The girl was given a cookie by a classmate and immediately developed a generalized urticarial rash. EMS personnel gave her 12.5 mg of oral diphenhydramine and transported her to the ED. On examination, the patient has a heart rate of 160 beats/min with normal oxygenation and perfusion. She has bilateral periorbital swelling, without respiratory distress, wheezing, vomiting, or diarrhea. The accompanying daycare teacher tells you that the girl has previously been admitted to the intensive care unit for anaphylaxis.

You call the girl’s parents for more information and wonder what to do in the meantime. Is diphenhydramine sufficient treatment for this patient? Are corticosteroids indicated? Is this just an allergic reaction or could it be an anaphylactic reaction? What are the criteria for diagnosis of anaphylaxis? What are the indications for administering epinephrine in patients with anaphylaxis?

Case Conclusion:
The parents of the 3-year-old girl stated that the girl’s previous anaphylactic reaction began with urticaria and facial swelling that progressed, resulting in a critical care admission for airway compromise due to angioedema. You administered epinephrine 0.01 mg/kg IM for suspected anaphylaxis and observed the patient in the ED for 4 hours. The girl had complete resolution of the facial swelling and urticarial rash. You reviewed the signs and symptoms of anaphylaxis with the parents, discussed allergen avoidance, and demonstrated appropriate use of an epinephrine autoinjector. You discharged the patient with a prescription for 2 epinephrine autoinjectors and an anaphylaxis action plan.

Did you get it right?

Brush up on most recent best practices in evaluating and treating pediatric patients with anaphylaxis in the ED with the latest issue of Pediatric Emergency Medicine Practice issue, Anaphylaxis in Pediatric Patients: Early Recognition and Treatment Are Critical for Best Outcomes.

P.S. Emergency Medicine Practice celebrates its 20th anniversary this month! Click here to check out our story, our plans and our great anniversary sale!

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It is Trauma Awareness Month! Can you solve the trauma case below? May 10, 2019

Posted by Andy Jagoda, MD in : What's Your Diagnosis , add a comment

Do you need to do anything regarding the missing fragment? — ED Management of Dental Trauma in Pediatric Patients

Case Recap:
You are then asked to see a 15-year-old adolescent boy who has come in with a tooth avulsion. He was at basketball practice when another player accidentally elbowed him in the mouth. He did not lose consciousness and has pain only in his mouth. He was immediately brought to your ED, which is about 15 minutes away from where the accident happened. His coach arrives with the boy’s tooth in a container of milk. On physical examination, the patient has lost his right lateral incisor and a clot remains where his tooth had been. How much time do you have to replace the tooth to have the best success of replantation? What do you need to consider while handling, storing, and cleaning the tooth?

Case Conclusion:
For the 15-year-old boy, you decided to replace the tooth as soon as possible. The patient had no other medical problems. You used Yankauer suction and light irrigation to remove the clot from the socket. You held the tooth by the crown, briefly rinsed it off, and used firm, gentle pressure to reinsert the tooth without any difficulty. You had Coe PakTM paste available at your facility, and you created a temporary splint to secure the tooth. You instructed the mother to follow up with the dentist tomorrow and to provide only a soft diet until then. You told the coach and the boy’s mom that, in the future, they should attempt to reimplant the tooth at the time of the accident and instructed them on the steps involved.

Did you get it right?

Click here to review the issue, Emergency Department Management of Dental Trauma: Recommendations for Improved Outcomes in Pediatric Patients (Trauma CME and Pharmacology CME).

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It is Stroke Awareness Month! Can you solve the stroke case below? May 10, 2019

Posted by Andy Jagoda, MD in : What's Your Diagnosis , 1 comment so far

Was it a “mini stroke”? — ED Management of Transient Ischemic Attack

Case Recap:
A 59-year-old obese woman presents to your community hospital ED after experiencing a distinct episode in which her left hand felt “clumsy,” along with a left facial droop and left-sided numbness. She denies experiencing frank weakness and states that the symptoms resolved in less than 10 minutes. She mentions that she experienced a similar episode 2 weeks prior, and is concerned because both her parents and an older sibling experienced disabling ischemic strokes. Her vital signs and point-of-care glucose were normal, and her ECG showed sinus rhythm. Her physical examination, including a detailed neurologic examination, was largely unrevealing, with no facial asymmetry, unilateral weakness, sensory loss, or dysmetria appreciated. A noncontrast cranial CT scan of the brain was remarkable only for nonspecific subcortical and periventricular white matter changes without evidence of acute or old infarction, mass, or hemorrhage. Although she is relieved to learn that she has not had a stroke, she is concerned that this may be a precursor of a more serious event. She does not have a primary care physician and states that she has not seen a physician in several years. She asks whether this was a “mini stroke” and, if yes, what the chances are that she will have a stroke in the future?

Case Conclusion:
The 59-year-old obese patient’s detailed description of abrupt, negative symptoms appropriately raised your concern for a right anterior circulation TIA. You calculated her ABCD2 score as a 2, correctly counting her reported facial droop and unilateral weakness. Knowing recent risk stratification data, you counseled her that her 7-day stroke risk was very low; however, you also remembered that the periventricular white matter hypointensities on CT may be indicative of underlying small-vessel cerebrovascular disease, and her report of multiple recent episodes raised your concern. Since your observation unit was at capacity, you insisted on hospital admission. As an inpatient, she underwent MRI/MRA, revealing extensive small-vessel disease and multiple lacunar infarctions of varying ages. She was seen by a neurologist, started on antiplatelet therapy, and counseled on diet and exercise strategies. She remained stroke-free at a 3-month follow-up appointment.

Did you get it right?

Brush up on most recent stroke care best practices and earn 8 stroke CME with this great online resource, Emergency Stroke Care: Advances And Controversies, Volume II.

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Do you need to do anything regarding the missing fragment? — ED Management of Dental Trauma in Pediatric Patients April 11, 2019

Posted by Andy Jagoda, MD in : What's Your Diagnosis , add a comment

Case Recap:
Your first patient of the day is a 2-year-old girl who tripped and fell while walking, hitting her mouth on the concrete sidewalk. On your examination, her left central incisor tooth appears to be fractured, with a yellow dot visible inside the tooth. The tooth is nontender and nonmobile. The parents don’t have the other part of the tooth and think it fell onto the street. You start to consider: How do you determine what kind of fracture this is and how serious it is? How does management differ between primary teeth versus permanent teeth, and how can you tell if this is a primary tooth or a permanent tooth? Do you need to do anything regarding the missing fragment?

Case Conclusion:
After seeing the 2-year-old girl with the chipped tooth, you realized that, given her age, this was likely primary dentition, which you confirmed with the parents. You could also tell on examination that the upper right central incisor was more of a milky-white color with a smooth edge, which is also consistent with primary dentition. You decided that the management priorities were to prevent further harm to the developing permanent dentition and to confirm that the tooth fragment was truly lost. You were unable to detect any retained foreign bodies on your physical examination, but you decided to obtain radiographic images to confirm. On facial radiography, there appeared to be a small foreign body inside her right upper lip. You repeated your physical examination and were able to extract the small tooth fragment. The girl’s left central incisor appeared to be an uncomplicated crown fracture. The girl was able to drink without difficulty. You did not have dental panoramic radiography available at your institution, so you instructed the parents to follow up with the girl’s dentist for assessment of her permanent dentition. You recommended a soft diet and to clean the tooth with chlorhexidine until the patient was able to see the dentist.

Did you get it right?

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Should you give antivenom again? — ED Management of North American Snake Envenomations April 11, 2019

Posted by Andy Jagoda, MD in : What's Your Diagnosis , 2comments

Case Recap:
A 26-year-old man arrives to the ED via private vehicle with his arm in a makeshift sling. He reports that his pet rattlesnake bit him on his right index finger about 45 minutes ago. His hand and wrist are swollen. He reports that he has no past medical history besides his 3 previous visits for snakebites. He reports having a “reaction” to the snakebite antidote during his last visit. You wonder whether the patient is immune . . . or should you give antivenom again?

Case Conclusion:
The 26-year-old man with 3 prior rattlesnake bites was at risk for significant morbidity related to this fourth snakebite, including impaired use of his dominant hand. Additionally, his initial lab values showed a developing coagulopathy. You decided to administer 6 vials of antivenom, but you ordered pretreatment with IV corticosteroids and antihistamines. You moved the patient to your resuscitation area for administration of antivenom and admitted him to the ICU for continued monitoring; fortunately, there were no side effects with the initial dose of antivenom.

Did you get it right?

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Quiet morning shift. What do you do? March 8, 2019

Posted by Andy Jagoda, MD in : What's Your Diagnosis , 3comments

You are working a quiet morning shift when a patient is brought in after a motor vehicle crash. The patient is hypotensive, and the FAST exam reveals a pericardial effusion. You know that time is of the essence, so you rapidly assess the options and wonder whether a needle pericardiocentesis is the best option…

Case Conclusion:
The patient was triaged directly to the resuscitation unit and the trauma surgery service was immediately available at bedside. Further review of the FAST exam revealed right ventricular collapse, and the initial blood pressure of 80/40 mm Hg was consistent with pericardial tamponade. Two large-bore peripheral IVs were placed, and an ECG revealed sinus tachycardia. A bedside pericardiocentesis was performed under ultrasound guidance and 25 mL of blood was aspirated. Repeat blood pressure was 100/60 mm Hg. Chest and pelvic x-rays were within normal limits. The patient was then emergently transported to the operating room for further management. A thoracotomy was performed and noted a 2.5-mm rupture of the right anterior ventricular wall. The defect was repaired, and the patient had an uneventful recovery.

Would you have done it different? Tell us how you would have handled this case.

Pediatric Hypertension. How would you intervene? March 8, 2019

Posted by Andy Jagoda, MD in : What's Your Diagnosis , 2comments

Your string of shifts is almost over when you are called into a room for an infant with respiratory distress. You’ve just seen 4 kids with upper respiratory infections, and you feel confident that this is the scenario. The 4-month-old, who was born at 26 weeks’ gestation, shows mild-to-moderate respiratory distress; however, there has been no viral prodrome. A chest x-ray demonstrates moderate pulmonary edema. Back in the room, you note that her blood pressure is 110/80 mm Hg, and you begin to wonder whether that is high for an infant. What additional testing—if any—is necessary? Do you need to intervene? Is there anything specific you should be worried about?

Case Conclusion:
The 4-month-old girl had clear evidence of cardiac failure and hypertension. She was started on an esmolol drip that was slowly titrated, and given a dose of furosemide. Her work of breathing slowly improved, and she was admitted to the intensive care unit, where it was learned that she had had an umbilical arterial line and had a renal artery thrombosis.

Would you have done it different? Tell us how you would have handled this case.

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Last Modified: 08-18-2019
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