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Case Conclusion — Brief Loss of Consciousness April 6, 2014

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

Recap of April’s Case:It is a busy day in your ED when a 51-year-old woman arrives by EMS. She felt faint while riding her racing bicycle and got off just before losing consciousness. EMS found her conscious, but pale, with a heart rate, 50 beats/min; blood pressure, 90/50 mm Hg; respiratory rate, 25 breaths/min; and oxygen saturation, 98% on room air. She tells you that just before she got off her bike, she experienced pain in her throat, but she denies chest pain, shortness of breath, or headache. Her initial ECG shows a sinus bradycardia but is otherwise normal. She is an experienced marathon runner and has never had similar complaints. You wonder what could have caused the syncope and persistent bradycardia.

Case conclusion:  The 51-year-old bicyclist who was also a marathon runner did not have improvement of her SBP, which remained at 90 mm Hg. Furthermore, she had throat pain, which could have been an angina equivalent. Your primary concern was that she had a cardiac outflow problem because of an aortic dissection or a pulmonary embolism. A neurally mediated component to her syncopal event could not be excluded. A CT aortogram was ordered to assess for dissection. It showed a type A aortic dissection starting in the ascending aorta extending to just above her renal arteries. Her spinal cord arteries originated from the true lumen, explaining why she had no neurologic or other symptoms. The throat pain was attributed to radiating pain from the intimal tear in her ascending aorta. She developed pain between her shoulder blades later during her stay in the ED while awaiting surgical intervention. She made a full recovery after surgery.

Thank you to everyone who participated in this month’s challenge!

Would you like to learn more about treating syncope in the ED? Simply click the links below:

Brief Loss of Consciousness March 31, 2014

Posted by Andy Jagoda, MD in : Neurologic Emergencies , 13comments

April’s Case: It is a busy day in your ED when a 51-year-old woman arrives by EMS. She felt faint while riding her racing bicycle and got off just before losing consciousness. EMS found her conscious, but pale, with a heart rate, 50 beats/min; blood pressure, 90/50 mm Hg; respiratory rate, 25 breaths/min; and oxygen saturation, 98% on room air. EMS provided 1 liter of normal saline without a change in her vital signs. In the ED, her BP is still 90/50 mm Hg. She tells you that just before she got off her bike, she experienced pain in her throat, but she denies chest pain, shortness of breath, or headache. She appears uncomfortable and complains of persisting throat pain and states she is afraid of dying. Her initial ECG shows a sinus bradycardia but is otherwise normal. Her past medical history is not significant. She takes no medications. She is an experienced marathon runner and has never had similar complaints. You wonder what could have caused the syncope and persistent bradycardia.

Share your diagnosis with us in the comments box below. The case conclusion will be published on April 7!

Shock in the Emergency Department February 28, 2014

Posted by Andy Jagoda, MD in : Cardiovascular , 10comments

March’s Case: You are working in the ED late one evening when an 82-year-old man is brought in by his son. His son reports that earlier today, his father had been in his usual state of health, but this evening he found his father confused, with labored breathing. On arrival, the patient has the following vital signs: temperature, 38°C; heart rate, 130 beats/min; blood pressure, 110/60 mm Hg; respiratory rate, 34 breaths/min; and oxygen saturation, 89% on room air. He is delirious and unable to answer questions. A focused physical examination demonstrates tachycardia without extra heart sounds or murmurs, right basilar crackles on lung auscultation, a benign abdomen, and 1+ lower extremity pitting edema. You establish intravenous access with a peripheral catheter and send basic labs. A further history obtained from the son reveals that his father has congestive heart failure with a low systolic ejection fraction, as well as a history of several prior myocardial infarctions that were treated with stent placement. As you consider this case, you ask yourself whether this patient is in shock, and if he is, what are the specific causative pathophysiologic mechanisms? You review which diagnostic tests are indicated to assist with the differential diagnosis of shock and you consider options for the initial management of this patient.

Tell us your diagnosis in the comments box below and check back regularly to see what other emergency physicians have said.  The correct diagnosis will be published on March 8!

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