missed subarachnoid hemorrhage

Subarachnoid hemorrhage is a classic emergency medicine diagnosis: rare, deadly, and easiest to miss in its early stages when there’s the greatest chance of intervention. A third of SAH die immediately, a third have longterm neurological consquences, and a third make a good recovery–and it’s this last group that has the highest miss rate and…

approach to cocaine intoxication

Cocaine intoxication provides a hypertensive crisis, sodium channel blockade, a dose of serotonin, inflammation from the debris, and potential acute and chronic injury from the portal of entry. So we need a systematic method to consider complications while stabilizing the patient. A: Apply C-spine and Assess airway C-spine injury from fall aspiration risk B: CHEST…

missed PE

Pulmonary embolism is both over-investigated in young people and missed in elderly people and those with comorbid conditions, and those with PE can have a benign or complicated course. I’ve shared some bounceback cases on PE, and here are a few studies to keep in mind to better assess and manage patients with potential PE…

bouncebacks: posterior circulation stroke

Posterior circulation strokes are less common and have a wide spectrum of symptoms and signs, so it’s not surprising they are easily missed. Here are a few misses/near misses, and their associated misdiaganoses   ‘GASTRO’ 60yoM with a history of DM/HTN presents with dizzy/vomiting all day, one diarrhea. No documented neuro exam, given fluids and…

bouncebacks: PE

If a patient presents with pleuritic chest pain, shortness of breath and a clear chest on auscultation and xray, we obviously think of pulmonary embolism. But PEs are missed 10-30% on their initial presentations, so we should be aware of the atypical presentations. Here are a few misses/near misses based on the misdiagnosis   ‘REACTIVE…

Emergency medicine: a practice prone to error?

Emergency Medicine: A practice prone to error? CJEM 2001 Oct;3(4): 271-276. This classic article by Drs. Croskerry and Sinclair, pioneers in the study of emergency medicine error, is just as relevant now as it was when it was written 15 years ago. Some excerpts: On the unknown scale of the problem of errors: “The first…

bounceback: vision loss

Two bounceback cases highlighted the importance of considering occipital stroke and examining for visual field defects CASE 1 47F HTN/lipid c/o decreased vision left eye O/E decreased visual field left eye, sent to ophtho Ophtho found homonymous hemianopsia, send back for CT: occipital infarct   CASE 2 61M HTN/smoke c/o decreased peripheral vision right eye…

missed appendicitis

Appendicitis classically presents as RLQ pain, fever, vomiting without diarrhea, a high WBC and normal UA. But pattern recognition is a great way to miss appendicitis–especially in children, women and the elderly–as the following studies makes clear.   CHILDREN The implications of missed opportunities to diagnose appendicitis in children. Acad Emerg Med 2013 Jun;20(6):592-6. In…

POCUS: early diagnosis of ruptured ectopic

A healthy woman at 5 weeks pregnancy presents with one day of recurring syncope and abdominal pain, no vaginal bleeding, BP 80/40. On POCUS With an unstable early pregnant patient with free fluid in the abdomen, I was able to diagnose a presumed ruptured ectopic at the bedside, cross-match blood and call Gynecology. This was…