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Clinical Pathway for Emergency Department Management of Subarachnoid Hemorrhage February 17, 2019

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

Headache is the fourth most common reason for emergency department encounters, accounting for 3% of all visits in the United States. Though troublesome, 90% are relatively benign primary headaches –migraine, tension, and cluster headaches. The other 10% are secondary headaches, caused by separate underlying processes, with vascular, infectious, or traumatic etiologies, and they are potentially life-threatening.

This clinical pathway will help you improve care in the management of patients with subarachnoid hemorrhage. Download now.


Life-Threatening Headache. What do you do? February 12, 2019

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

A 55-year-old man with history of nonsmall cell lung cancer who is on cisplatin presents with an acute headache and lethargy for 6 hours. His vital signs are remarkable for a blood pressure of 210/120 mm Hg, heart rate of 70 beats/min, and a temperature of 36.7°C (98°F). His physical exam reveals a lethargic patient with no localizing neurologic signs and no meningismus. You order a noncontrast CT of the head and consider lowering this patient’s blood pressure, though you wonder how much and how fast it should be reduced…

Case Conclusion:
You recognize that this cancer patient’s change in mental status and severely elevated blood pressure was likely the result of PRES. You obtained a CT of the head, which revealed white-matter changes in the posterior cerebral hemispheres. Utilizing IV nicardipine, you lowered the patient’s MAP by 25% over the first hour. In addition, you temporarily discontinued his chemotherapy medication. He subsequently became more alert and responsive.

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

“High-risk of stroke…” Case Conclusion January 7, 2013

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

Case re-cap:

A 72-year-old woman with a history of hypertension, diabetes, coronary artery disease, and chronic kidney disease presents shortly after experiencing a 20-minute episode of slurred speech and right facial droop. She denies experiencing similar events in the past, but she does endorse a transient episode of vision loss a week ago, intermittent vertigo, and left-sided weakness last month. On exam, her blood pressure is 178/100 mm Hg, her heart rate is 80 beats per minute and regular, and the ECG shows a sinus rhythm. Her stroke scale is zero, and noncontrast cranial CT scan shows an old small cerebellar infarct. It is Friday evening, and you have no inhouse neurology and no MRI capabilities overnight. The patient attributes her symptoms to stress and states that she has experienced anxiety and palpitations recently. She asks if it is necessary for her to be admitted or whether she can seek follow-up with her primary care physician next week.

Case conclusion:

You correctly identified that the 72-year-old woman was at a high short-term risk of stroke with an ABCD2 score of 6 and multiple recent episodes in different vascular territories as well as evidence of an old infarct on CT scan. At your recommendation, she agreed to admission. You arranged expedited etiologic workup, including carotid duplex and transcranial Doppler ultrasound, which was initially unrevealing. She experienced a brief episode of atrial fibrillation, which was captured on the cardiac monitor, before leaving the ED. Knowing that cardioembolic causes correlate with increased stroke severity and stroke mortality, you arranged for transthoracic echocardiography the next morning, which revealed a left atrial thrombus. She was started on anticoagulation and was recurrence-free at 3 months.

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High-risk of stroke… December 28, 2012

Posted by Andy Jagoda, MD in : Cardiovascular, Neurologic , 16comments

A 72-year-old woman with a history of hypertension, diabetes, coronary artery disease, and chronic kidney disease presents shortly after experiencing a 20-minute episode of slurred speech and right facial droop. She denies experiencing similar events in the past, but she does endorse a transient episode of vision loss a week ago, intermittent vertigo, and left-sided weakness last month. On exam, her blood pressure is 178/100 mm Hg, her heart rate is 80 beats per minute and regular, and the ECG shows a sinus rhythm. Her stroke scale is zero, and noncontrast cranial CT scan shows an old small cerebellar infarct. It is Friday evening, and you have no inhouse neurology and no MRI capabilities overnight. The patient attributes her symptoms to stress and states that she has experienced anxiety and palpitations recently. She asks if it is necessary for her to be admitted or whether she can seek follow-up with her primary care physician next week.

How would you handle this patient?

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Last Modified: 03-18-2019
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