What’s Your Diagnosis? Supraventricular Tachydysrhythmias in the Emergency Department
July 20, 2020


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Welcome to this month’s What’s Your Diagnosis Challenge!

But before we begin, check to see if you got last month’s case on Ventilator Management of Adult Patients in the Emergency Department right. read more

Test Your Knowledge: Failure to Thrive
March 24, 2020


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Emergency Medicine Practice Blog Brain Teaser

Failure to thrive (FTT) is a relatively common presentation in the emergency department. Up to 90% of cases of FTT have no identifiable cause and are categorized as nonorganic. Before deciding that FTT is nonorganic, it is imperative to consider and rule out organic causes. Identifying the underlying issues surrounding FTT is essential, as it will likely impact the treatment the patient receives. read more

What’s Your Diagnosis? A 6-Month-Old Boy Who Presents With Poor Weight Gain
March 3, 2020


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Welcome to this month’s What’s Your Diagnosis Challenge!

Case Presentation: a 6-month-old boy who presents with poor weight gain

Your first patient is a previously healthy, vaccinated 6-month-old boy who presents with poor weight gain. The child has been seen by his primary care provider multiple times within the last several weeks, and the mother is very concerned because he has not shown any improvement. read more

What’s Your Diagnosis? 76-year-old With Chest Pain
January 3, 2020


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

Welcome to this month’s What’s Your Diagnosis Challenge!

But before we begin, check out if you got last month’s case, on the timing-and-triggers approach to the patient with acute dizziness, right. Click here to check out the answer!

Case Presentation: A 76-year-old woman presents to the ED with chest pain

A 76-year-old woman presents to the ED with chest pain.

She said that for the past month she has been getting short of breath more easily on her daily walks, with occasional discomfort in her chest, requiring her to stop and rest.

Two hours prior to ED arrival, she was doing yard work and developed chest pain that was much more severe. The pain is located in the center of her chest, and she describes it as a “pressure” sensation. Her only past medical history is hypertension.

In the ED, her vital signs are within normal limits and her exam is unremarkable. Her ECG shows nonspecific ST-segment flattening, and her initial troponin is 0.09 ng/mL (reference range, 0-0.04 ng/mL).

Your intern asks if she can go home since her troponin is low and she looks well… read more

Clinical Pathway for Management of Hemorrhage in Patients Taking Direct Oral Anticoagulant Agents
September 10, 2019


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

Direct oral anticoagulant (DOAC) agents have become commonly used over the last 9 years for treatment and prophylaxis for thromboembolic conditions, following approvals by the United States Food and Drug Administration.

These anticoagulant agents, which include a direct thrombin inhibitor and factor Xa inhibitors, offer potential advantages for patients over warfarin; however, bleeding emergencies with DOACs can present diagnostic and therapeutic challenges because, unlike traditional anticoagulants, their therapeutic effect cannot be easily monitored directly with common clotting assays.

This clinical pathway will help you improve care in the management of hemorrhage in patients taking direct oral anticoagulant agents. Download now.

Clinical Pathway for Management of Hemorrhage in Patients Taking Direct Oral Anticoagulant Agents

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How best to assess his anticoagulation status
July 29, 2019


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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?

Case Conclusion

Your patient on apixaban with traumatic subdural hematoma received initial resuscitation focusing on maintenance of the airway, breathing, and circulation, as appropriate for head trauma. After reviewing your hospital’s policy on DOAC reversal and local availability of specific reversal agents for this DOAC, you administered a dose of 4-factor PCC at 50 units/kg in the ED. He was admitted to the neurosurgical ICU for continued care, and a repeat CT of the head showed no interval expansion of the hemorrhage.

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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.

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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.

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The correct answer: D.

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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


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

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The correct answer: C.

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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