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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!

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It is Stroke Awareness Month! May 16, 2019

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10 Risk Management Pitfalls For Cervical Artery Dissections

Cervical artery dissections involve the carotid or vertebral arteries. Although the overall incidence is low, they remain a common cause of stroke in children, young adults, and trauma patients. Symptoms such as headache, neck pain, and dizziness are commonly seen in the emergency department, but may not be apparent in the obtunded trauma patient. A missed diagnosis of cervical artery dissection can result in devastating neurological sequelae, so emergency clinicians must act quickly to recognize this event and begin treatment as soon as possible while neurological consultation is obtained.

Use these risk management pitfalls to avoid unwanted outcomes when performing cervical artery dissections. Download now.

1. “This patient has a left temporal headache that radiates into his left ear. His examination is benign, except his pupil is smaller on that side. I did a noncontrast CT head and it’s negative. The headache is probably just due to a hard game of basketball yesterday. I’m going to give him some IV ketorolac and send him out.”

Dissections can occur spontaneously or as a result of minor trauma, even from a basketball game. Failure to consider the diagnosis will result in a missed diagnosis. Headaches in carotid artery dissections can be nonspecific, but are mostly located in the frontal or temporal regions; the radiation to the ear is also characteristic. His examination is also concerning for a partial Horner syndrome. Both of those are suspicious for carotid artery dissection and warrant further vascular imaging.

2. “She has a history of migraines, and she says that this one is different from what she usually feels, but it definitely sounds like a migraine because it is unilateral, pulsatile, and she had a visual aura. I’m going to give her the usual migraine cocktail and see how she does.”

Not suspecting cervical arterial dissection in the beginning of the evaluation results in a significant delay to diagnosis. It can be many hours by the time she has a couple of migraine cocktails before you realize her headache isn’t better and you need to rethink your plan. Due to the risk of early stroke in these patients, a delay in diagnosis could lead to long-term neurological sequelae. Headaches in carotid dissections can be unilateral, pulsatile, and with an aura. Any time a patient with a history of migraines states that the symptoms are not typical, take note.

3. “A 35-year-old woman was attacked by her boyfriend. He hit her on the right side of the neck near her jaw, causing her head to snap around to the left. Her neurological examination is completely normal. She is in a great deal of pain, but it seems to be related to the soft-tissue injury from the hit, because her noncontrast CT head and c-spine are negative. I’m going to treat her pain and see how she feels.”

Pain due to the trauma could mask specific signs or symptoms of dissection. In these patients, relying on the history to identify high-risk factors is important. Due to the location of the blow, it may have caused a hyperextension and rotation of her head in addition to direct trauma, which could have caused a dissection. Patients with risk factors should have advanced vascular imaging (CTA or MRA).

4. “I couldn’t do a neurological examination because she was in too much pain. I’ll treat her headache and then try again later.”

Although it seems kind to give patients a little time to obtain comfort before performing an examination, a prompt neurological examination is absolutely necessary in order to determine any findings that need to be addressed immediately, such as an acute stroke.

5. “A 12-year-old boy fell off of his bike after running into a parked car, and then he had a seizure. The noncontrast CT head and c-spine were normal. He is still in some pain, but I don’t see anything abnormal on his neuro examination, so I’m going to clear his c-spine.”

Pediatric patients with dissection have different symptoms from adults; seizure has been shown to be a presenting symptom in 12.5% of cases. The seizure, along with the mechanism, should prompt vascular imaging to assess for a cervical artery dissection before the cervical collar is removed.

6. “I really thought that patient with the headache, anterolateral neck pain, and partial Horner syndrome had a carotid dissection, but the CTA was read as negative, so I guess I was wrong. I’ll just treat her pain and send her home.”

CTA is an excellent screening tool, but it is not 100% sensitive and can miss small intimal flaps, intramural hematomas, or a slight fusiform dilatation of the vessel. In patients for whom there is a high suspicion of dissection and a negative or equivocal CTA or MRA, further imaging with MRI or digital subtraction angiography is indicated.

7. “The CTA showed a dissection, so I gave him an aspirin and called neurology. However, he now says he doesn’t want to wait and wants to go home. His neuro examination is normal, so I was thinking of sending him out on aspirin.”

Sending the patient home in the acute setting without consultation is not a good idea. Due to high risk of stroke in the first 24 hours and the high incidence of progression of lower-grade dissections, these patients warrant close monitoring and early follow-up imaging to determine the need for escalation of care.

8. “The intubated trauma patient had his noncontrast CT head and c-spine and the radiologist just called and said there is a temporal bone fracture through the carotid canal. I’m going to pass it along and let the trauma service finish the workup after he gets to the intensive care unit.”

This will lead to a significant delay in diagnosis, which could be devastating for the patient. Due to its sensitivity and availability in the ED, a CTA should be performed prior to the patient being transported upstairs, so treatment can be started immediately.

9. “The CTA showed a vertebral artery dissection on that patient from the roller coaster ride, so I consulted the neurology service for admission. Her neuro examination is normal, so I’m going to wait to treat her and see what they recommend.”

An antithrombotic agent for stroke prevention needs to be started on this patient and can be started in the ED to avoid treatment delays. Studies in this population have not shown superiority of one over the other, so the choice of aspirin or heparin depends on patient factors. For uncomplicated dissections, antiplatelet agents are sufficient, and heparin is preferred in patients with an acute thrombus or high risk for thromboembolic events if no contraindications exist.

10. “The patient is a 42-year-old man presenting with an acute onset of right-sided hemiplegia and global aphasia that started 1 hour ago while at the grocery store. His CT head was negative for hemorrhage, but the CTA showed a dissection in his left carotid artery with about 50% vessel occlusion. Unfortunately, that excludes him from treatment with rtPA due to the risk of hemorrhage or intramural hematoma expansion.”

Data have shown rtPA to be as safe in patients with cervical dissections as with patients with strokes due to other causes. Therefore, this patient should be treated with rtPA as soon as possible if there are no contraindications. Endovascular treatment should also be considered if there are contraindications to IV rtPA or if he does not improve after treatment.

Need more information or Stroke CME?
Click here to review the issue and take the CME test, but hurry, CME expires August 1, 2019!

A 6-year-old girl with a history of sickle cell disease presents with leg pain — Brain Teaser. Do you know the answer? March 23, 2019

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Test your knowledge and see how much you know about treating and managing pediatric hypertension and hypertensive emergencies.

Did you get it right? Click here to find out!

The correct answer: D.

Earn CME for this topic by purchasing this issue. 

A 68-year-old man with past medical history of atrial fibrillation on warfarin presents to the ED after motor vehicle crash — Brain Teaser. Do you know the answer? March 23, 2019

Posted by Andy Jagoda, MD in : Brain Tease , add a comment

Test your knowledge and see how much you know about treating and managing blunt cardiac injury in the ED.

Did you get it right? Click here to find out!

The correct answer: C.

Earn CME for this topic by purchasing this issue. 

Clinical Pathway for Management of Emergency Department Patients With Suspected Blunt Cardiac Injury March 16, 2019

Posted by Andy Jagoda, MD in : Feature Update , 1 comment so far

Blunt cardiac injury describes a range of cardiac injury patterns resulting from blunt force trauma to the chest. Due to the multitude of potential anatomical injuries blunt force trauma can cause, the clinical manifestations may range from simple ectopic beats to fulminant cardiac failure and death. Because there is no definitive, gold-standard diagnostic test for cardiac injury, the emergency clinician must utilize an enhanced index of suspicion in the clinical setting combined with an evidence-based diagnostic testing approach in order to arrive at the diagnosis. This review focuses on the clinical cues, diagnostic testing, and clinical manifestations of blunt cardiac injury as well as best-practice management strategies.

This clinical pathway will help you improve care in the management of patients with suspected blunt cardiac injury. Download now 

Clinical Pathway for Management of Emergency Department Patients With Suspected Blunt Cardiac Injury

Dosing Information for Antihypertensive Medications March 16, 2019

Posted by Andy Jagoda, MD in : Feature Update , add a comment

For children with severe acute hypertension without further evidence of end-organ damage, initiation of oral agents may be recommended to lower blood pressure. Based on the available studies, aggressive bolus dosing of antihypertensive agents should be avoided in the younger child; careful initiation of a drip for children who are symptomatic is a safer strategy. The therapeutic window for all medications is wider for adolescent children and, likely, none of the oral agents will cause inadvertent hypotension or side effects. For the school-age child, a careful discussion with a specialist will help guide decisions. See Table 3 for dosing recommendations.

Download the table for yourself and check out more content like this at www.ebmedicine.net/topics.

Dosing Information for Antihypertensive Medications

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.

24-year-old subdued with taser — Brain Teaser. Do you know the answer? November 24, 2018

Posted by Andy Jagoda, MD in : Brain Tease , 1 comment so far

Test your knowledge and see how much you know about treating and managing electrical injuries in the ED.


Did you get it right? Click here to find out!

The correct answer: C.

Earn CME for this topic by purchasing this issue. 


10 Risk Management Pitfalls for Electrical Injuries in the Emergency Department November 17, 2018

Posted by Andy Jagoda, MD in : Feature Update , add a comment

Human tissues have varying resistance characteristics and susceptibility to damage, so injuries may be thermal, electrical, and/or mechanical, potentially causing burns, thrombosis, tetany, falls, and blast injury. Here are 10 risk management pitfalls to avoid and 4 time- and cost-effective strategies for when you’re managing eletrical Injuries.

10 Risk Management Pitfalls for Electrical Injuries in the Emergency Department

1. “I sent the patient with a low-voltage minor electrical burn home and told her she was fine (she was!). She came back to the ED 2 weeks later and is angry because she developed dizziness and paresthesia in her fingers.”

Electrical injuries have a high incidence of delayed neurological sequelae,41 with studies noting between 25% and 80% of patients reporting neurological complaints after electric shock.39,40 It is important to give specific, detailed discharge instructions, including return precautions for numbness, dizziness, weakness, and mental status changes.

2. “I admitted an electrician with upper extremity and facial burns and airway management who was injured working on a high-voltage line. The orthopedic surgeon called and is angry because he has an open foot fracture. The ED was busy; I can’t take every single patient’s boots off.”

High-voltage injuries have a high incidence of orthopedic injuries, and electrical current at entrance and exit sites can be sufficient to cause open injuries. Remember to completely undress patients so you do not miss injuries on your primary and secondary survey.

3. “The man was found lying in the grass, unconscious. His CT scan and labs were normal. He seemed confused on re-evaluation, so I admitted him for altered mental status, which I thought was probably drug-related. The next day I got a call from the hospitalist; apparently the ENT said he has extensive inner and middle ear damage and is now deaf.”

Patients found unconscious for no apparent reason in an open area should have lightning strike in the differential. (Lightning can strike even when it is not raining, during an event called a “dry” thunderstorm.) The concussive force of the strike can be sufficient to rupture tympanic membranes and cause inner ear damage.47 A thorough ENT examination is necessary.

4. “A patient was brought in by the police last night. He was ‘minding his own business’ and somehow ended up Tasered. He said it hurt to lift his arm. I x-rayed his humerus and elbow, both negative, with normal pulses and sensation, so I discharged him into police custody. Unfortunately, they brought him back 2 days later… he ended up being diagnosed with a scapular fracture.”

Taser (or other electroshock weapon) injuries are on the rise in the United States, and 1 out of 9 police-related injuries presenting to United States EDs are caused by these devices.76,77 The majority of injuries are minor abrasions, lacerations, and contusions. Forceful muscle contraction can cause fractures, including spinous process fractures and scapular injuries. Cardiac electrical capture with subsequent ventricular fibrillation and asystole is a rare complication.78

5. “I work at the regional burn center. EMS brought in a 45-year-old lineman who touched a high-voltage line. The shock entered his left arm and exited his right leg. I admitted him to burn ICU, gave IV fluids for his open injuries, but I didn’t have time to recheck him. He needed multiple doses of pain medicine. While he was holding in the ED his arm became tight, shiny, and pale…he had a delay in his emergent fasciotomy.”

Burn patients with significant orthopedic injuries are at high risk for compartment syndrome, and electrical burns are at even higher risk because of the full-thickness nature of many of these injuries. Frequent neurovascular checks are a must, especially in the first 12 hours. Your ED should have a protocol for neurovascular checks for these patients, and progressive or uncontrolled pain should prompt further investigation.

6. “The 2-year-old had a small burn on his face after playing with an electrical cord. There was no airway involvement, and I sent him home to follow up with a burn specialist. Then 24 hours later, he came back bleeding profusely from the mouth…that airway was touch-and-go.”

Oral burns in children who chewed on an electrical cord have up to 24% incidence of bleeding from the labial artery. Proper initial management is controversial, but ENT consultation should be obtained, and if the patient goes home, you must give strict discharge instructions and set patient/family expectations for the possibility of bleeding.48,49

7. “This patient was transferred to our burn center for evaluation of his high-voltage burns after he was cleared by the trauma center. We admitted him to the burn floor, where he had a seizure and then became obtunded. It turned out he had a basilar skull fracture. The surgeon asked me if I had looked behind his ears.’”

Initial traumatic injuries may not be apparent in high-voltage exposures, and you should do a thorough traumatic evaluation in these patients. In this case, early recognition of a skull fracture (which may reveal the Battle sign, with bruising behind the ears) could have prompted seizure prophylaxis, neurosurgical consultation, intracranial pressure monitoring, etc.

8. “My patient had a high-voltage burn that had entry at his head and exit from the right arm. He had some minor facial burns and an arm fracture. We admitted him to the floor, but he boarded in the ED for a while. I’m glad he did, because he became progressively more dyspneic and needed emergent intubation. He had a lot of edema; I barely got the tube passed.”

Remember that the extent of burn seen on the skin in high-voltage burns may not give an accurate picture of underlying burn injury. You cannot use traditional burn metrics of soot in the mouth or nares, facial hair singeing, or burns to the lips as risk factors for intubation. Maintain a high index of suspicion for airway involvement and consider fiberoptic laryngoscopy or early intubation in electrical burns involving the face or neck.

9. “We saw a patient who grabbed a low-voltage line with both hands. She said that her left arm hurt, but there was no sign of trauma, x-ray was negative, and her ECG was completely normal. That night she returned, and her arm was cold and pale.”

There is a risk of acute arterial and venous thrombosis in patients injured by electric current. This is hypothesized to be due to both thermal damage and electrical damage to the intima of the vessel. In a patient with unexplained pain in a limb after electrical injury, you must document neurovascular status and serial examinations. If pain persists, further workup is necessary, which may include ultrasound, CT angiography, or formal angiography.

10. “This high-voltage injury patient came to the ED with 10% total body surface area burns. I followed the Parkland formula for fluids, but she stayed hypotensive and, during her hospital course, developed acute renal failure. I thought that formula was solid for taking care of a burn patient.”

Electrical burns on the skin do not necessarily give a clear picture as to how much tissue was actually damaged by thermal and electrical energy. Isotonic IV fluids sufficient to maintain urine output at 1.0 to 1.5 cc/kg/ hr must be given to these patients. Continue fluid resuscitation until you reach that urine output and urine myoglobin has cleared. Fluid requirements may be much higher than specified by the Parkland formula. CK levels and myoglobinuria should be monitored.

4 Time- and Cost-Effective Strategies


39. Singerman J, Gomez M, Fish JS. Long-term sequelae of low voltage electrical injury. J Burn Care Res. 2008;29(5):773-777. (Retrospective study; 38 patients)
40.* Bailey B, Gaudreault P, Thivierge RL. Neurologic and neuropsychological symptoms during the first year after an electric shock: results of a prospective multicenter study. Am J Emerg Med. 2008;26(4):413-418. (Prospective cohort study; 86 patients)
41. Tondel M, Blomqvist A, Jakobsson K, et al. [Immediate and delayed outcomes after electrical injury. A guide for clinicians]. Lakartidningen. 2016 Dec 1;113. (Descriptive study and review of Swedish national data; 300 patients)
47. Modayil PC, Lloyd GW, Mallik A, et al. Inner ear damage following electric current and lightning injury: a literature review. Eur Arch Otorhinolaryngol. 2014;271(5):855-861. (Meta-analysis; 35 articles)
48. Canady JW, Thompson SA, Bardach J. Oral commissure burns in children. Plast Reconstr Surg. 1996;97(4):738-744. (Descriptive study; 24 patients)
49. Thomas SS. Electrical burns of the mouth: still searching for an answer. Burns. 1996;22(2):137-140. (Review and case report; 5 patients)
76. Cherington M. Lightning injuries. Ann Emerg Med. 25(4):516-519. (Practice guidelines)
77. Pfortmueller CA, Yikun Y, Haberkern M, et al. Injuries, sequelae, and treatment of lightning-induced injuries: 10 years of experience at a Swiss trauma center. Emerg Med Internat. 2012;2012:167698. (Retrospective study; 9 patients)
78. Gluncic I, Roje Z, Gluncic V, et al. Ear injuries caused by lightning: report of 18 cases. J Laryngol Otol. 2001;115(1):4-8. (Case series; 18 patients)


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