Case-Based

46-year-old male arrived to the ED in January via EMS who reported the patient had abdominal pain and shortness of breath and was initially anxious but then fell asleep en route.  On arrival, the patient was calm and kept his eyes closed without speaking much.  He mumbled that he was having trouble breathing recently and gave vague history of recent chest pain, abdominal pain, and coughing.  The patient fell asleep during history taking but was arousable to voice.  He had been seen the day before in our ED complaining of shortness of breath.   That chart revealed he had a history of methamphetamine abuse, cardiomyopathy, LV mural thrombus on Eliquis, and PTSD.  The day before, a full cardiac workup was unremarkable and he was discharged. The patient appeared withdrawn and somnolent, not speaking much.  I considered whether he was coming off of a meth binge, and experiencing the hypersomnia and encephalopathy sometimes seen with a meth crash.  It was noted that his hands and feet were cold and cyanotic, but the medics stated that the house was very cold and perhaps cold exposure was causing vasoconstriction.  Initial blood pressure was 100/70, heart rate of 76, SaO2 97%.  Initial EKG is shown below. The workup was ordered and the patient was rechecked and condition was not improving.  Pulse ox was not showing good waveform.  The medical student called me when the patient became agitated and profusely diaphoretic.  Subsequently, the patient said “I’m going to die!”, laid back, and lost consciousness.  He continued breathing and had a very weak femoral pulse.  While trying to decide whether to begin CPR, I noted a flurry of dysrhythmias on the monitor.  There were several beats of bradycardia followed by a few multifocal PVCs followed by a very wide-complex tachycardia with giant T waves with a…

An Unusual Cause of Urticaria ER Presentation:  A 45 y/o female arrived by EMS because she was awoken while sleeping with abdominal pain, n/v, scattered hives and dyspnea. She felt lightheaded when ambulating but there was no syncope. Pertinent negatives:  no fever, cough, chest pain, throat pain or swelling in throat. Denied possible allergen exposure. Past medical history: noncontributory. Medications: none recently. Allergies: None known Social: no tobacco, alcohol or recreational drugs use. Physical exam: Vitals: Afebrile, HR 120 and regular, BP 100/70, RR 20 and mildly labored, O2 sat 97% RA Gen: Anxious-appearing female in mild respiratory distress. Skin: Classic urticarial lesions on back, legs and arms. HEENT: Normal. Neck: No adenopathy, thyromegaly, tenderness or swelling. Lungs: Wheezing in all fields with prolonged expiratory phase, no rales. CV: RRR, mild tachycardia, no audible murmurs or rubs. Puerperal pulses present in all extremities, 3 over 4 in intensity. Abdomen: Normal BS, nontender without masses or HSM. Medical decision making: This healthy patient appears to be having an allergic reaction and will need to be observed especially in view of the dyspnea, light headedness at home and soft BP with tachycardia on arrival to the ER. She is awake and alert, has no lip or tongue swelling, but angioedema is in the differential. Working diagnosis: allergic reaction, cause unknown. Differential diagnosis: the cause of hives is broad, hives with wheezing is usually caused by an exposure to an allergen, but other entities or processes must be considered. Such as: Scombroid: Caused by consuming fish containing scombroid (histamine fish poisoning) such as tuna, mackerel, mahi-mahi, and blue fish that are not properly refrigerated. Bacteria in these fish can produce high levels of histamine and thus as allergic type reaction. Serum Sickness: A type 3 (immune complex) hypersensitivity, seen in conditions such as…

A 53-year-old female with past medical history of type 1 diabetes, asthma, anxiety, and depression, was brought in by EMS with CPR in progress. She called EMS with complaint of difficulty breathing. When EMS arrived, patient was talking and using a nebulizer treatment. Shortly after their arrival, she became unresponsive, apneic, and pulseless. CPR was initiated. An iGel was placed and Lucas chest compression device was placed. On rhythm check, no shock was advised. On arrival to the hospital, SpO2 was 55%, despite bilateral breath sounds and 100% oxygen and adequate bagging. An IV was placed and patient was given Narcan 2 mg, SoluMedrol 125 mg, and magnesium sulfate 2 g IV. She also received epinephrine 0.3 mg IM and a DuoNeb inline.  On rhythm check, sinus tachycardia with a pulse was noted and compressions discontinued. Patient continued to have only agonal respirations. The iGel was removed and she was intubated using etomidate and rocuronium. Her heart rate and blood pressure were increasing and a second dose of etomidate was given while a ketamine infusion was being initiated. EKG showed sinus tachycardia with rate 121 and RBBB. There was also ST depression in the inferior leads and inverted T waves in the lateral leads.  CXR showed ETT in good position 3 cm above the carina and no infiltrates or effusions. Labs: WBC 15.6, H/H 14.2/45.0, plt 322.  INR 1.0, PTT 33.0, dimer 812 (normal 100-599). VBG pH 6.786, pCO2 104, pO2 47, HCO3 15.8, O2 sat 41%. K 5.6, anion gap 23.6. Glucose 399. Trop-I (high sensitivity) 153. After receiving the VBG results, the patient was given bicarb 1 amp. Increased ventilatory rate was used to decrease ETCO2 down to the 40s. Accepting intensivist requested CT head and CTA chest/abd/pel and recommended 2 more amps of bicarb and ceftriaxone be…

Shoulder dislocation HPI: 20 yo otherwise healthy individual presents to you with acute left upper arm pain. The patient reports that they were mountain-bike riding, lost control of their bike and crashed. They are not sure how they landed but report immediate pain and numbness in their left upper extremity post-crash. Patient is concerned since they cannot move their upper arm and report it feels numb over the lateral aspect of their shoulder. They were able to ambulate into your emergency department and deny other injuries. They deny prior UE trauma, chronic joint pains, illnesses, or systemic symptoms.   Question 1: Based on your knowledge of anatomy, describe some potential causes of traumatic upper arm pain. Common causes of acute traumatic upper arm pain include humeral fracture, clavicular fracture, Acromioclavicular (AC) joint separation, glenohumeral dislocation, rotator cuff tear.   Question 2: What is the typical mechanism of injury for each of the above potential items? Think about the anatomy and how it might be disrupted. Proximal Humeral Fracture: Most often are caused by a fall or direct blow to the lateral shoulder. Type of fracture is determined by the body and arm position when the direct force is applied. (i.e., outstretched vs adducted arm) Clavicular Fracture: Often occurs with a fall onto a shoulder or being stuck over the clavicle with a heavy object. AC separation: Typically occurs from direct trauma to the superior or lateral aspect of the shoulder with the arm adducted Glenohumeral dislocation: An anterior shoulder dislocation is usually caused by a blow to the abducted, externally rotated, and extended arm. Examples would be fall on an outstretched arm, blocking a basketball shot, or blow to the posterior humerus. Rotator cuff tear: Most rotator cuff tears are seen in the middle aged or older adults and are…