The Narrow Gate
The patient first felt winded one night after doing the dishes. She was breathing so hard by morning that she was barely able to get out of bed. And a cough had started. “The flu” went through her mind. She stayed home from work to rest, but all day she just couldn’t catch her breath. The cough got worse and was making her chest hurt, and she felt her heart racing. She was exhausted by evening, but knew she wasn’t going to be able to sleep. The temperature was below 0°F outside, but she bundled up and drove herself the three miles to the emergency department. Barely able to speak by the time she stepped up to the ...
Source: Spontaneous Circulation - April 7, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
A Stressing Situation
A 64-year-old woman presented to the emergency department with two days of severe nausea, numerous episodes of vomiting, and progressively worsening right upper quadrant/epigastric abdominal pain. She was continuously spitting clear secretions into an emesis bag on arrival in triage. Her 8/10 dull ”ripping” pain originated in the right upper quadrant and radiated in a band-like pattern to her epigastrium. She was not experiencing any chest pain or shortness of breath. Her medical history included hypertension, type 2 diabetes mellitus, recurrent acute pancreatitis secondary to hyperglycemia, peripheral artery disease, ...
Source: Spontaneous Circulation - March 10, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
A Stressing Situation
A 64-year-old woman presented to the emergency department with two days of severe nausea, numerous episodes of vomiting, and progressively worsening right upper quadrant/epigastric abdominal pain. She was continuously spitting clear secretions into an emesis bag on arrival in triage. Her 8/10 dull ”ripping” pain originated in the right upper quadrant and radiated in a band-like pattern to her epigastrium. She was not experiencing any chest pain or shortness of breath. Her medical history included hypertension, type 2 diabetes mellitus, recurrent acute pancreatitis secondary to hyperglycemia, peripheral artery disease, ...
Source: Spontaneous Circulation - March 10, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
More Than a Number
A 68-year-old woman with a history of schizophrenia, severe coronary artery disease, hypertension, and type 2 diabetes mellitus was found in her bed minimally responsive by staff at the group home where she lived. She had been discharged from the hospital two days earlier with a diagnosis of segmental pulmonary embolism and on Coumadin anticoagulation. Lower extremity Doppler ultrasounds were negative for deep vein thrombosis during that hospitalization.
EMS brought her to the emergency department, and had intubated for airway protection. She was febrile, tachycardic, and hypotensive, and had a hemoglobin of 4 g/dL. A...
Source: Spontaneous Circulation - February 12, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
More Than a Number
A 68-year-old woman with a history of schizophrenia, severe coronary artery disease, hypertension, and type 2 diabetes mellitus was found in her bed minimally responsive by staff at the group home where she lived. She had been discharged from the hospital two days earlier with a diagnosis of segmental pulmonary embolism and on Coumadin anticoagulation. Lower extremity Doppler ultrasounds were negative for deep vein thrombosis during that hospitalization.
EMS brought her to the emergency department, and had intubated for airway protection. She was febrile, tachycardic, and hypotensive, and had a hemoglobin of 4 g/dL. An ...
Source: Spontaneous Circulation - February 12, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
A Constricting Diagnosis
The heart, vasculature, and blood (pump, pipes, and fluid) work together to meet the metabolic demands of the body. End organs and tissue are not adequately perfused when the system fails, leading to injury and deranged physiology. Understanding the hemodynamic relations in normal cardiovascular physiology and how it changes in pathologic conditions helps us make the correct diagnosis and implement the right treatment.
Physical examination can provide indirect clues to hemodynamics, though invasive evaluation has been the traditional gold standard. This can include arterial and central venous pressure measurements, ca...
Source: Spontaneous Circulation - December 12, 2013 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
A Constricting Diagnosis
The heart, vasculature, and blood (pump, pipes, and fluid) work together to meet the metabolic demands of the body. End organs and tissue are not adequately perfused when the system fails, leading to injury and deranged physiology. Understanding the hemodynamic relations in normal cardiovascular physiology and how it changes in pathologic conditions helps us make the correct diagnosis and implement the right treatment.
Physical examination can provide indirect clues to hemodynamics, though invasive evaluation has been the traditional gold standard. This can include arterial and central venous pressure measurements, card...
Source: Spontaneous Circulation - December 12, 2013 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
A Sweet Wide Complex Tachycardia
A 29-year-old man with history of type 1 diabetes mellitus presents with two weeks of feeling ill that became worse over the previous two days. This included a productive cough, subjective fevers, and frequent vomiting. He reports no headache, chest pain, or abdominal pain. He has had financial problems after losing his job about a month earlier, and is currently living in a local motel. His brother brought him to the emergency department for evaluation after finding him in bed confused, with vomit on the floor.
He appeared ill, and was oriented only to self. Vital signs were blood pressure 78/43 mm Hg, pulse 146 bpm,...
Source: Spontaneous Circulation - November 12, 2013 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
A Sweet Wide Complex Tachycardia
A 29-year-old man with history of type 1 diabetes mellitus presents with two weeks of feeling ill that became worse over the previous two days. This included a productive cough, subjective fevers, and frequent vomiting. He reports no headache, chest pain, or abdominal pain. He has had financial problems after losing his job about a month earlier, and is currently living in a local motel. His brother brought him to the emergency department for evaluation after finding him in bed confused, with vomit on the floor.
He appeared ill, and was oriented only to self. Vital signs were blood pressure 78/43 mm Hg, pulse 146 bpm, r...
Source: Spontaneous Circulation - November 12, 2013 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
Take Me Out to the Ballgame
A 31-year-old man presented to the ED with syncope. He was previously healthy, takes no medications, and had run a marathon the day before. He was riding the light rail home from a baseball game when he developed vague 4/10 epigastric abdominal pain associated with nausea and diaphoresis. He remembers feeling lightheaded and flushed before momentarily passing out.
His wife said he became quite pale immediately beforehand. He did not have any headache, chest pain, or shortness of breath before or after the syncopal episode. He has a significant family history of premature coronary artery disease. He had normal vital signs...
Source: Spontaneous Circulation - October 11, 2013 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
Take Me Out to the Ballgame
A 31-year-old man presented to the ED with syncope. He was previously healthy, takes no medications, and had run a marathon the day before. He was riding the light rail home from a baseball game when he developed vague 4/10 epigastric abdominal pain associated with nausea and diaphoresis. He remembers feeling lightheaded and flushed before momentarily passing out.
His wife said he became quite pale immediately beforehand. He did not have any headache, chest pain, or shortness of breath before or after the syncopal episode. He has a significant family history of premature coronary artery disease. He had normal vital signs ...
Source: Spontaneous Circulation - October 11, 2013 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
Arrhythmia Masquerading as Cardiac Ischemia
A 45-year-old woman with a history of medication-controlled essential hypertension, stage 2 chronic kidney disease, type 2 diabetes mellitus, and a pack-a-day cigarette habit presented less than 60 minutes after acute onset of severe shortness of breath that awoke her from sleep. She had felt well the previous day, and went to bed with no complaints.
Around 4 a.m., she woke up from sleep very dyspneic, with moderate chest “discomfort” over her left chest that radiated to her back and was unchanged by position or respirations. She denied other symptoms such as fever, cough, nausea, vomiting, numbness, or abdominal ...
Source: Spontaneous Circulation - September 12, 2013 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
Arrhythmia Masquerading as Cardiac Ischemia
A 45-year-old woman with a history of medication-controlled essential hypertension, stage 2 chronic kidney disease, type 2 diabetes mellitus, and a pack-a-day cigarette habit presented less than 60 minutes after acute onset of severe shortness of breath that awoke her from sleep. She had felt well the previous day, and went to bed with no complaints.
Around 4 a.m., she woke up from sleep very dyspneic, with moderate chest “discomfort” over her left chest that radiated to her back and was unchanged by position or respirations. She denied other symptoms such as fever, cough, nausea, vomiting, numbness, or abdominal pa...
Source: Spontaneous Circulation - September 12, 2013 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
Myocardial Infarction with Dual Culprit Lesions
A 59-year-old man without prior cardiac history presented with three hours of severe upper sternal chest pressure that radiated to his throat, which he described as “strangulating.”
An ECG was obtained, and is shown here. It demonstrates a sinus rhythm at rate of approximately 75 bpm. The PR and QT intervals are normal.
There is concerning 1 mm of ST-elevation in V5 and V6 with ST-segment depression in V2 and V3, suggestive of a posterior myocardial infarction.
The initial ECG was concerning for 1 mm of ST-elevation in V5 and V6 with ST-segment depression in V2 and V3. This is suggestive of a posterior myocardial...
Source: Spontaneous Circulation - July 18, 2013 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
Myocardial Infarction with Dual Culprit Lesions
A 59-year-old man without prior cardiac history presented with three hours of severe upper sternal chest pressure that radiated to his throat, which he described as “strangulating.”
An ECG was obtained, and is shown here. It demonstrates a sinus rhythm at rate of approximately 75 bpm. The PR and QT intervals are normal.
There is concerning 1 mm of ST-elevation in V5 and V6 with ST-segment depression in V2 and V3, suggestive of a posterior myocardial infarction.
The initial ECG was concerning for 1 mm of ST-elevation in V5 and V6 with ST-segment depression in V2 and V3. This is suggestive of a posterior myocardial inf...
Source: Spontaneous Circulation - July 18, 2013 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
