Aortic Stenosis with A Fib and CHF

This case is written by Dr. Donika Orlich. She is a staff physician practising in the Greater Toronto Area. She completed her Emergency Medicine training at McMaster University along with a fellowship in Simulation and Medical Education.

Why it Matters

The management of patients with aortic stenosis can be tenuous at the best of times. When these patients present with CHF or dysrhythmias, their management is much more nuanced than the typical patient presenting with the same complaints. This case nicely highlights the following management differences:

  • The need for expedient rate control in a patient with aortic stenosis (in this case, most safely accomplished via cardioversion)
  • The need for judicious treatment of CHF, including careful diuresis and avoiding nitroglycerin use
  • The importance of early consultation with both cardiac surgery and cardiology

Clinical Vignette

A 78-year-old male presents via EMS with 4 days of increased SOB. The triage nurse comes to tell you she has put him in the resuscitation bay due to unstable vitals. HR was in the 150s. The O2SAT was 86% on RA when EMS arrived, but is now 95% on a NRB.

Case Summary

A 78-year-old male presents with increased SOB over the past 4 days. A recent ECHO will be presented showing severe AS. The ECG will demonstrate new A Fib with a HR of 150 and the CXR will show CHF. The patient will be normotensive at first but will become hypotensive shortly after. The team will then need to decide whether to cardiovert the patient or attempt rate control. If these are done safely, the patient will respond and then develop worsening CHF. Definitive management should be sought with early cardiology/cardiac surgery consult. If management is not carried out judiciously, the patient will become profoundly hypotensive.

Download the case here: Aortic Stenosis with A Fib and CHF

Initial ECG for the case found here:

ECG- A.fib + LVH

(ECG source: http://www.wikidoc.org/index.php/Atrial_fibrillation_EKG_examples)

Second ECG for the case (after cardioversion) found here:

ECG- LVH

(ECG source: http://bestpractice.bmj.com/best-practice/monograph/409/resources/image/bp/5.html)

CXR for the case found here:

CHF

(CXR source: https://www.med-ed.virginia.edu/courses/rad/cxr/pathology2Bchest.html)

Lung ultrasound for the case found here:

Thyroid Storm

This case is written by Dr. Cheryl ffrench, a staff Emergency Physician at the Health Sciences Centre in Winnipeg. She is the Associate Program Director and the Director of Simulation for the University of Manitoba’s FRCP-EM residency program; she is also on the Advisory Board of emsimcases.com.

Why it Matters

Thyrotoxicosis is a rare presentation to the ED that can masquerade as many other conditions. This case nicely reviews the following:

  • The importance of maintaining a broad differential diagnosis in any patient who presents with an altered level of consciousness and a fever
  • The nuances associated with managing atrial fibrillation in the context of thyrotoxicosis
  • The multiple medications required in order to treat thyroid storm

Clinical Vignette

You are working the evening shift at a tertiary care hospital. A 31-year-old female two weeks postpartum is brought in by EMS accompanied by her husband. He is concerned because she is delirious and somewhat difficult to rouse.

Case Summary

A 31 year-old-female presents by EMS with altered LOC and fever due to thyroid storm precipitated by recent parturition. The patient is tachycardic and hypoxic on arrival. Her level of consciousness will continue to deteriorate despite IV fluids and antibiotics and will require intubation. The husband will be at the bedside, and the team will need to discuss the need for intubation with him. After intubation, lab results will come back indicating possible thyrotoxicosis. The patient’s rhythm will change to atrial fibrillation at this time. The team will be expected to manage the thyroid storm in consultation with Endocrinology and ICU.

Download the case here: Thyroid Storm Case

Sinus tachycardia ECG for the case found here:

Sinus tachycardia

(ECG source: http://lifeinthefastlane.com/ecg-library/hyperthyroidism/)

Atrial fibrillation ECG for the case found here:

rapid-a-fib

(ECG source: http://lifeinthefastlane.com/ecg-library/atrial-fibrillation/)

CHF CXR for the case found here:

severe-chf

(CXR source: http://www.radiologyassistant.nl/en/p4c132f36513d4/chest-x-ray-heart-failure.html)