Post a good case, dammit.

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Zebra Hunter said:
Has to be a chronic dissection...right? For my own sanity.
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No, definitely acute. There was prior imaging from a week before and you could clearly see that their was a difference in the contour of the aorta.
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Jabbed said:
No, definitely acute. There was prior imaging from a week before and you could clearly see that their was a difference in the contour of the aorta.
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along these lines we had a female patient come in with a STEMI, chest x-ray prior to cath-lab showed a wide mediastinum, emergent CT showed aortic aneurysm. (I can't remember how large, but pt ended up having repair a few days later). To quote the ED doc, the STEMI saved her life.
 
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GassYous said:
Could be vascular ehlers danlos, could be pregnancy related vascular issues, etc.
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Not pregnant, but the going theory is collagen vascular disorder. No other obvious clinical findings though.
 
Jabbed said:
Not pregnant, but the going theory is collagen vascular disorder. No other obvious clinical findings though.
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Could be related to manipulation of the aorta in surgery maybe?

I had a 40-something healthy male recently dissect his axillary artery all the way back to the aortic arch after a fellow ED doc had reduced it the day prior.

That case is going to be a medico-legal nightmare. He was swearing up and down how he was going to sue everyone in the hospital.
 
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Heroin induced leukoencephalopathy seen by a radiologist on a heroine abuser with altered mental status and clumsiness. Never heard of it before. Frightening disease.
 
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The Knife & Gun Club said:
Could be related to manipulation of the aorta in surgery maybe?

I had a 40-something healthy male recently dissect his axillary artery all the way back to the aortic arch after a fellow ED doc had reduced it the day prior.

That case is going to be a medico-legal nightmare. He was swearing up and down how he was going to sue everyone in the hospital.
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Reduced what... a glenohumeral joint?
 
RustedFox said:
Reduced what... a glenohumeral joint?
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Sorry clarity is not my strong suit.

Dislocated shoulder put back in by ED physician at OSH that I knew personally.

Actually called her on her cell to ask if he had pulses on exam after she reduced and if she charted it. Cuz the guy had an ischemic arm (and a bunch of other psychosocial factors) and was actively swearing he was gonna sue everyone into oblivion while waiting for OR.
 
Wasn't a great save. Wasn't a great diagnosis. I felt awful at the end of the shift. Not quite a "talk and die" case but it came close.

Young woman around 28 weeks pregnant with a history of recurrent pancreatitis. Walked in with typical pancreatitic pain. Looked good. Felt reasonable but sore in the usual way. Smiling and even joking through the pain. Vitals normal. Labs normal apart from a lipase just barely over 3 times the upper limit of normal. "Feels exactly like my last bout of pancreatitis."

Gets some morphine and immediately starts staying she can't breath and there's an elephant sitting on her chest. No wheeze on auscultation but ECG shows interior STE with multi-regional TWI. I literally wheelchair her over to Resus and dump her onto a bed. The nurse in charge starts whining about staffing/bed allocation. All I say is "don't care" and crack on. By the time she gets aspirin and heparin, her pain settles/ST segments normalise but BP is dropping. Bedside TTE is very suggestive of Takotsubo's with basal sparing (I had a very careful look at the aortic root). Start an adrenaline infusion, slam in some lines, and phone the mothership for an urgent transfer. Get some betamethasone and Mg going for bub. Cardio says it's reasonable to treat like NSTE-ACS for now. By the time she leaves, she's relatively stable, pain free, and does well for most of the flight.

Apparently she crumped a couple hours after landing, EF around 5%, crashed onto VA-ECMO after an emergent C-section in ICU. CXR is basically white with congestion. Clean cath. Absolutely bananas.
 
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lymphocyte said:
Wasn't a great save. Wasn't a great diagnosis. I felt awful at the end of the shift. Not quite a "talk and die" case but it came close.

Young woman around 28 weeks pregnant with a history of recurrent pancreatitis. Walked in with typical pancreatitic pain. Looked good. Felt reasonable but sore in the usual way. Smiling and even joking through the pain. Vitals normal. Labs normal apart from a lipase just barely over 3 times the upper limit of normal. "Feels exactly like my last bout of pancreatitis."

Gets some morphine and immediately starts staying she can't breath and there's an elephant sitting on her chest. No wheeze on auscultation but ECG shows interior STE with multi-regional TWI. I literally wheelchair her over to Resus and dump her onto a bed. The nurse in charge starts whining about staffing/bed allocation. All I say is "don't care" and crack on. By the time she gets aspirin and heparin, her pain settles/ST segments normalise but BP is dropping. Bedside TTE is very suggestive of Takotsubo's with basal sparing (I had a very careful look at the aortic root). Start an adrenaline infusion, slam in some lines, and phone the mothership for an urgent transfer. Get some betamethasone and Mg going for bub. Cardio says it's reasonable to treat like NSTE-ACS for now. By the time she leaves, she's relatively stable, pain free, and does well for most of the flight.

Apparently she crumped a couple hours after landing, EF around 5%, crashed onto VA-ECMO after an emergent C-section in ICU. CXR is basically white with congestion. Clean cath. Absolutely bananas.
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An awful but interesting case. I'm curious why you didn't activate this as a STEMI? It's a bit ballsy to treat a hypotensive inferior STEMI as an NSTEMI in a pregnant patient. Even if STEs normalized, a patient with an NSTEMI and cardiogenic shock is indication for immediate cath lab activation. Not a candidate for tPA given high risk for SCAD in pregnancy, however. I don't think we have anywhere near the expertise to be diagnosing Takotsubo from the ER, as this is a diagnosis that should be made in the cath lab when STEs are present. Honestly I don't even think a cardiologist should be making that diagnosis in the ER. Obviously it wouldn't have changed outcomes ultimately, but this is an extremely high risk case medicolegally and probably best to play things conservatively.
 
Zebra Hunter said:
An awful but interesting case. I'm curious why you didn't activate this as a STEMI? It's a bit ballsy to treat a hypotensive inferior STEMI as an NSTEMI in a pregnant patient. Even if STEs normalized, a patient with an NSTEMI and cardiogenic shock is indication for immediate cath lab activation. Not a candidate for tPA given high risk for SCAD in pregnancy, however. I don't think we have anywhere near the expertise to be diagnosing Takotsubo from the ER, as this is a diagnosis that should be made in the cath lab when STEs are present. Honestly I don't even think a cardiologist should be making that diagnosis in the ER. Obviously it wouldn't have changed outcomes ultimately, but this is an extremely high risk case medicolegally and probably best to play things conservatively.
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This was a rural ED I sometimes work in. Nearest cath lab is an hour by helicopter if there's a helicopter around. The point of retrieval was to get them to a facility with a cath lab (among other things).
 
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Zebra Hunter said:
An awful but interesting case. I'm curious why you didn't activate this as a STEMI? It's a bit ballsy to treat a hypotensive inferior STEMI as an NSTEMI in a pregnant patient. Even if STEs normalized, a patient with an NSTEMI and cardiogenic shock is indication for immediate cath lab activation. Not a candidate for tPA given high risk for SCAD in pregnancy, however. I don't think we have anywhere near the expertise to be diagnosing Takotsubo from the ER, as this is a diagnosis that should be made in the cath lab when STEs are present. Honestly I don't even think a cardiologist should be making that diagnosis in the ER. Obviously it wouldn't have changed outcomes ultimately, but this is an extremely high risk case medicolegally and probably best to play things conservatively.
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Transferring to a PCI-capable facility is all that you can do. Besides, the odds of this being due to occlusive coronary disease are low. The real intervention that you're sending this person for is mechanical circulatory support.

OP did a fantastic job IMO, but some cases are just tough and stain your soul.
 
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Jabbed said:
Transferring to a PCI-capable facility is all that you can do. Besides, the odds of this being due to occlusive coronary disease are low. The real intervention that you're sending this person for is mechanical circulatory support.

OP did a fantastic job IMO, but some cases are just tough and stain your soul.
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I disagree with the bolded. You can say that confidently retrospectively, but certainly not prospectively. Pregnant women are at increased risk of occlusive coronary disease. Agree that he did a great job, just had one nitpick. I would probably have stressed the need for this patient to go to cath emergently rather than agreeing that this patient only needed NSTE-ACS management. Looking at this case prospectively, you have a pregnant woman presenting with epigastric pain, inferior STE, and cardiogenic shock who has dynamic ECG changes. Odds are much higher that this is actually an OMI. I have seen two pregnant or peri-partum STEMIs in my career, both were due to occlusive disease, one happened to be SCAD, but still required a stent. Takotsubo CM leading to STEs and cardiogenic shock in a pregnant patient is a much rarer presentation than SCAD or regular old CAD.
 
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Zebra Hunter said:
I disagree with the bolded. You can say that confidently retrospectively, but certainly not prospectively. Pregnant women are at increased risk of occlusive coronary disease. Agree that he did a great job, just had one nitpick. I would probably have stressed the need for this patient to go to cath emergently rather than agreeing that this patient only needed NSTE-ACS management. Looking at this case prospectively, you have a pregnant woman presenting with epigastric pain, inferior STE, and cardiogenic shock who has dynamic ECG changes. Odds are much higher that this is actually an OMI. I have seen two pregnant or peri-partum STEMIs in my career, both were due to occlusive disease, one happened to be SCAD, but still required a stent. Takotsubo CM leading to STEs and cardiogenic shock in a pregnant patient is a much rarer presentation than SCAD or regular old CAD.
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Sure. If the complaint was chest pain/dyspnea or even isolated upper abdominal pain. But she has pancreatitis. Really bad pancreatitis leading to non-ischemic cardiomyopathy and cardiogenic shock.

As an aside, pancreatitis is also a known cause of inferior STEs irrespective of cardiomyopathy.

We are splitting hairs on what amounts to an upstairs decision anyway. She will inevitably get a cath and/or device with this presentation. All you can do is ask for help and transfer.
 
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Jabbed said:
Sure. If the complaint was chest pain/dyspnea or even isolated upper abdominal pain. But she has pancreatitis. Really bad pancreatitis leading to non-ischemic cardiomyopathy and cardiogenic shock.

We are splitting hairs on what amounts to an upstairs decision anyway. She will inevitably get a cath and/or device with this presentation. All you can do is ask for help and transfer.
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I rarely hang my hat on a pancreatitis diagnosis with a mildly elevated lipase, especially with someone that likely has chronically elevated lipase levels given their reported history of recurrent pancreatitis. I've lost count of the number of times I have admitted patients for "recurrent pancreatitis" with a lipase just above the 3x upper limit of normal who end up with a completely different diagnosis upon hospital discharge.

The problem is that deciding on whether to go to cath lab is not an upstairs decision, it is a downstairs decision, much like the decision to push tPA for a stroke. If you are on a recorded line telling the transfer center cardiologist, "yeah, I think this is just takotsubo CM caused by physiologic stress from pancreatitis" and it turns out they have an acute OMI, who do you think the lawyers will go after? Now obviously if you pushed for emergent cath activation, and they refused, and you had no where else to transfer the patient, then sure, not much you can do.

Ultimately the patient didn't need it, but I definitely don't think it was the appropriate call in the moment for the cardiologist to say "just treat this medically" when you have a young, pregnant patient in cardiogenic shock with reported STEs in the inferior leads. That patient needs to go to cath lab immediately, if only to have an IABP placed sooner rather than later, but also in the case that PCI is necessary and potentially lifesaving.
 
Zebra Hunter said:
I rarely hang my hat on a pancreatitis diagnosis with a mildly elevated lipase, especially with someone that likely has chronically elevated lipase levels given their reported history of recurrent pancreatitis. I've lost count of the number of times I have admitted patients for "recurrent pancreatitis" with a lipase just above the 3x upper limit of normal who end up with a completely different diagnosis upon hospital discharge.

The problem is that deciding on whether to go to cath lab is not an upstairs decision, it is a downstairs decision, much like the decision to push tPA for a stroke. If you are on a recorded line telling the transfer center cardiologist, "yeah, I think this is just takotsubo CM caused by physiologic stress from pancreatitis" and it turns out they have an acute OMI, who do you think the lawyers will go after? Now obviously if you pushed for emergent cath activation, and they refused, and you had no where else to transfer the patient, then sure, not much you can do.

Ultimately the patient didn't need it, but I definitely don't think it was the appropriate call in the moment for the cardiologist to say "just treat this medically" when you have a young, pregnant patient in cardiogenic shock with reported STEs in the inferior leads. That patient needs to go to cath lab immediately, if only to have an IABP placed sooner rather than later, but also in the case that PCI is necessary and potentially lifesaving.
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The CT this lady had after C-section showed changes consistent with mild pancreatitis. Combined with an elevated lipase and typical pancreatitic pain, this meets diagnostic criteria for pancreatitis (in fact, just two of the three will do). The Takotsubo's event was intercurrent, not a diagnostic mimic.

The point of managing medically was to temporize for transfer. I'm really not sure what else to say other than there was no cath lab within 200km.
 
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lymphocyte said:
The CT this lady had after C-section showed changes consistent with mild pancreatitis. Combined with an elevated lipase and typical pancreatitic pain, this meets diagnostic criteria for pancreatitis (in fact, just two of the three will do). The Takotsubo's event was intercurrent, not a diagnostic mimic.

The point of managing medically was to temporize for transfer. I'm really not sure what else to say other than there was no cath lab within 200km.
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I think they’re just saying that it’s tough to say it’s not an OMI until you have a negative cath. As is the case for all stress cardiomyopathy. Either way needed a transfer to a tertiary center with PCI capabilities. Just an unusual cardiology recommendation, almost always these cases are managed as ACS until a negative cath.
 
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lymphocyte said:
The CT this lady had after C-section showed changes consistent with mild pancreatitis. Combined with an elevated lipase and typical pancreatitic pain, this meets diagnostic criteria for pancreatitis (in fact, just two of the three will do). The Takotsubo's event was intercurrent, not a diagnostic mimic.

The point of managing medically was to temporize for transfer. I'm really not sure what else to say other than there was no cath lab within 200km.
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It sounds like your management of that case was on point, probably a helluva lot better than I would've done. I have no idea why these guys are fixated on this one small part. If I'm inferring correctly, it sounds like the cardiologist recommended hemodynamic management as well as typical ACS stuff.

If the patient really needs to go emergently to the OR in order to get crashed onto ecmo followed by a section (remember kids, in the critically ill pregnant population, delivery is for the mother's benefit), they're not gonna benefit from being made a stemi activation. It's sorta akin to someone in status being made a code stroke--it doesn't get them what they need and it diverts attention from the real issue.

Also, I think lymphocyte might be from Oz so it's a very different system than what we're used to.
 
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Not my case, but one our medical director saw.

middle aged male suicide attempt, via consuming gobs of fiesta store brand curing salt.

For the med students/residents -

what's the problem ingredient here, and what's the treatment?

I'll give you a hint: treatment ends up being the same color as the patient at this stage of the game.
 
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bravotwozero said:
Not my case, but one our medical director saw.

middle aged male suicide attempt, via consuming gobs of fiesta store brand curing salt.

For the med students/residents -

what's the problem ingredient here, and what's the treatment?

I'll give you a hint: treatment ends up being the same color as the patient at this stage of the game.
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Methylene blue!! Last time I was trying to help the nurse by prepping the dose and I turned my fingers blue. Lol
 
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Correct! you answered one of two questions. Other one's still up for grabs...
 
Dred Pirate said:
Methylene blue!! Last time I was trying to help the nurse by prepping the dose and I turned my fingers blue. Lol
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That's the treatment. Not the problem agent.

sodium nitrite.

Edit: I misread the part asking for both cause and treatment. Apologies.
 
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I only know the answer because I had a guy during residency who ate spoonfuls of the straight chemical itself in a SA. Got tons of methylene blue and exchange transfusions. Lived. Looked like a Smurf for a while.
 
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Apollyon said:
C'mon man, you really don't know that?

/sarcasm
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I suppose it's unfair to ask this from residents/med students, as this type of thing is so rare even seasoned attendings would have trouble with it.

But as suggested before, yes the concerning agent here is sodium nitrite. Toxic dose in people is about 1 gram, and leads to methemoglobinemia.

Treatment of course is methylene blue. You have to push slow, and then extract it back, and push again, is my understanding.

FYI

methemoglobinemia from curing salt.
 
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bravotwozero said:
I suppose it's unfair to ask this from residents/med students, as this type of thing is so rare even seasoned attendings would have trouble with it.

But as suggested before, yes the concerning agent here is sodium nitrite. Toxic dose in people is about 1 gram, and leads to methemoglobinemia.

Treatment of course is methylene blue. You have to push slow, and then extract it back, and push again, is my understanding.

FYI

methemoglobinemia from curing salt.
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Was the guy thirsty? What was his serum Na+?
 
thegenius said:
You ever eat salted pork?
Prosciutto?
European Ham?
Salted cod?

All delicious stuff.
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All except the cod.
Try as I might (and I have tried several times)... I just don't like the taste of fish.

Good, honest efforts at it.

And I don't want to hear anyone say anything like: "B-but THIS fish doesn't taste fishy like others do."

Yes. Yes it does. Knock it off.
 
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RustedFox said:
All except the cod.
Try as I might (and I have tried several times)... I just don't like the taste of fish.

Good, honest efforts at it.

And I don't want to hear anyone say anything like: "B-but THIS fish doesn't taste fishy like others do."

Yes. Yes it does. Knock it off.
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I said the exact same thing until I had turbot.
 
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thegenius said:
Was the guy thirsty? What was his serum Na+?
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I would imagine that his serum Na was not insane as his kidneys should have dumped the vast majority of that sodium. That said, I don't remember the Na on my guy as it was almost a decade ago. Maybe @bravotwozero can chime in on the one he posted about.

Fun thing with the case I had as a resident: we looked up survivability data on this particular OD. It said something like a methemoglobin level of 70+% was generally fatal. His was over 90%. It helped that the EMS call in included the guy's statement about exactly what he took and his rather rapid onset regret in doing so before he arrived, so we had methylene blue and blood ready to go when he arrived. Still got tubed, but lived.
 
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RustedFox said:
All except the cod.
Try as I might (and I have tried several times)... I just don't like the taste of fish.

Good, honest efforts at it.

And I don't want to hear anyone say anything like: "B-but THIS fish doesn't taste fishy like others do."

Yes. Yes it does. Knock it off.
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Yeah, I feel like you'd probably hate salt cod. It's basically the fishiest fish ever fished (then cured).
 
bravotwozero said:
I suppose it's unfair to ask this from residents/med students, as this type of thing is so rare even seasoned attendings would have trouble with it.

But as suggested before, yes the concerning agent here is sodium nitrite. Toxic dose in people is about 1 gram, and leads to methemoglobinemia.

Treatment of course is methylene blue. You have to push slow, and then extract it back, and push again, is my understanding.

FYI

methemoglobinemia from curing salt.
Click to expand...
The reason I knew it was because we had a similar case with "poppers"
 
bravotwozero said:
I suppose it's unfair to ask this from residents/med students, as this type of thing is so rare even seasoned attendings would have trouble with it.

But as suggested before, yes the concerning agent here is sodium nitrite. Toxic dose in people is about 1 gram, and leads to methemoglobinemia.

Treatment of course is methylene blue. You have to push slow, and then extract it back, and push again, is my understanding.

FYI

methemoglobinemia from curing salt.
Click to expand...
A good toxidrome to be familiar with, actually had a similar case with a young intentional overdose and turned out to be nitrite toxicity causing methemoglobinemia. Apparently it’s now included in some suicide kits available on the internet.
 
Yeah not sure about the guys serum sodium level, wasn’t my case. He lived too, color changed immediately with methylene blue, so his toxicity level probably wasn’t too high..
 
blood in urine.png

3 day old infant with blood in urine. Treatment? Work-up?
 
Boy? Girl?
Is the infant sick? Vitals otherwise normal?
DDx: trauma, contaminated urine sample, UTI, pyelo, some hematologic problem causing hemolysis -> hematuria

I would not empirically treat unless sick looking.

1. UA (which you did) / UCx
2. US renal
3. CBC, CMP, PT/INR (basically a basic hemolysis panel) and BCx x1

I would do minimally #1, and then if I were not busy I would call someone who knows more about this than I do BEFORE doing #2,#3. But if I were really busy, I would do #2,3 then make a call when I have some free time.
 
turkeyjerky said:
I’m not sure I even check a UA with this complaint, am I crazy?
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No...but you would probably look it up like everybody else. Or call someone. Anytime a 3 day old comes in, no matter what, I'm gonna call someone. What good thing can happen when a 3 day old comes in?

Nothing.

Unless the blood came from somewhere else. But the OP said "blood in urine" although he didn't say "urinalysis with blood"
There's a difference
 
RonWeezy said:
View attachment 348128
3 day old infant with blood in urine. Treatment? Work-up?
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Door #1: CT renal. Flomax, urine strainer and dc with Urology follow up of kidney stone.

Door #2: Prostate biopsy. ED prostatectomy and dc with both Urology and Oncolology follow up of rapid onset prostate cancer following billable tobacco cessation counseling.

Door #3: No workup (other than bili level if juandiced or septic workup if febrile). Evaluate weight gain, UOP and feeding status. Supplement with formula if breastfeeding and becoming dehydrated. Close follow up with PCP.

Didn’t learn this at all during medical school, residency or during first several years of attending practice. Really parenting taught me more than medicine. Neonatal hematuria can just be a sign of dehydration and not necessarily overly complicated. It doesn’t take labs, IVFs and admission. I’ll certainly defer though to the pediatric experts on the forum.
 
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