J Emerg Med
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Review Case Reports
Cardiac Memory: A Case Report and Review of the Literature.
A variety of clinical syndromes can cause T-wave inversion (TWI), ranging from life-threatening events to benign conditions. One benign cause of TWI is cardiac memory, which is characterized by the transient inversion of T-waves following abnormal activation of the ventricles, commonly due to intermittent left bundle branch block (LBBB), tachydysrhythmias, electrical pacing, or ventricular pre-excitation. ⋯ A 72-year-old man presented to the emergency department with chest pain, nausea, vomiting, and headache. Upon arrival, his electrocardiogram (ECG) showed new-onset LBBB with appropriate secondary ST-T wave changes. A subsequent ECG showed disappearance of LBBB and newly inverted T-waves in precordial leads V1-V5, followed by a repeat ECG that again showed LBBB. Serial troponin testing was unremarkable. During hospitalization, echocardiogram and nuclear perfusion stress test were normal. The transient TWIs in this patient were believed to be due to cardiac memory. We performed a literature review and identified 39 published cases of cardiac memory. The most common etiology for cardiac memory was after cardiac pacemaker placement, followed by intermittent LBBB (as was seen in our patient), and post-tachydysrhythmia. Patient ages ranged from 21 to 88 years, with an equal number of cases reported in men and women. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Cardiac memory is a poorly understood, rarely observed phenomenon that can occur in the setting of intermittent LBBB. Testing for acute cardiac ischemia and underlying coronary artery disease is still recommended, as the diagnosis of cardiac memory can only be made after negative workup.
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Cardiopulmonary resuscitation (CPR) requires effective chest compressions and ventilations to circulate and oxygenate blood. It has been established that a 2-handed mask seal is superior when providing bag-valve-mask (BVM) ventilations. However a 1-handed technique remains the standard with which health care providers are trained to perform 2-rescuer CPR. ⋯ Two-rescuer CPR incorporating a 2-handed face mask seal can be performed effectively without impacting chest compression quality during simulated cardiac arrest.
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A spontaneous cervical epidural hematoma (SCEH) is a rare occurrence, with < 500 cases reported to date. Clinically, it usually presents with quadriparesis, but in extremely rare cases it can present with hemiparesis or hemiplegia, and can easily be misdiagnosed as stroke. The cervical epidural hematoma by itself is an urgent condition that requires a quick and accurate diagnosis and a prompt surgical treatment. ⋯ We present a case where an SCEH mimicked the much more frequent condition of a stroke, and discuss the importance of diagnostics procedures that help differentiate SCEH from acute cerebral infarction. The patient's history of neck pain and spondylosis render this case more challenging. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Considering that the emergency tissue plasminogen activator treatment for acute cerebral infarction can worsen the state of an SCEH patient, or even lead to permanent damage or death, it is of great importance to rapidly and accurately differentiate these two conditions.
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Sodium-glucose co-transporter 2 (SGLT2) inhibitors have been reported to cause euglycemic diabetic ketoacidosis (eDKA), a diagnosis that may be challenging to establish in the emergency department (ED). ⋯ This is a case report of missed eDKA in a 47-year-old male taking empagliflozin (a SGLT2 inhibitor) that presented to the ED with generalized weakness. His past medical history included multiple sclerosis (MS) diagnosed 4 years ago and type 2 diabetes mellitus. The patient attributed his weakness to MS. His neurologist was consulted and agreed with the plan to discharge the patient with diagnoses of asthenia and dehydration and a prescription of prednisone. The patient returned to the ED the next day with similar symptoms and was admitted to the hospital for treatment of eDKA. He was eventually treated per the hospital diabetic ketoacidosis (DKA) protocol and discharged home with instructions to discontinue empagliflozin. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The increasing utilization of SGLT2 inhibitor in patients with type 2 diabetes mellitus will inevitably lead to more cases of eDKA seen in the ED. Emergency physicians need to consider this diagnosis in patients taking these medications that present with symptoms including weakness, nausea, vomiting, abdominal pain, and dehydration. Patients taking these medications should be warned about these symptoms, especially because they may be falsely reassured by relatively low plasma glucose levels on home glucometer readings.