The American journal of emergency medicine
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Review Meta Analysis
Tranexamic acid for traumatic brain injury: a systematic review and meta-analysis.
The antifibrinolytic agent tranexamic acid (TXA) has demonstrated clinical benefit in trauma patients with severe bleeding, but its effectiveness in patients with traumatic brain injury (TBI) is unclear. We conducted a systematic review to evaluate the following research question: In ED patients with or at risk of intracranial hemorrhage (ICH) secondary to TBI, does TXA compared to placebo improve patients' outcomes? ⋯ Pooled results from the 2 RCTs demonstrated statistically significant reduction in ICH progression with TXA and a nonstatistically significant improvement of clinical outcomes in ED patients with TBI. Further evidence is required to support its routine use in patients with TBI.
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Case Reports
Heparin-induced anaphylactoid reaction associated with heparin-induced thrombocytopenia in the ED.
Although rare, heparin-induced anaphylactic and anaphylactoid reactions have been previously described in the literature. We present a case of a patient who presented to the emergency department with dyspnea and was subsequently diagnosed with an acute pulmonary venous thromboembolism. Shortly after being started on intravenous unfractionated heparin, she developed sudden cardiovascular collapse leading to a cardiopulmonary arrest. She was successfully resuscitated and, after further diagnostic evaluation, was found to have developed a heparin-induced anaphylactoid reaction.
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Venous thromboembolism (VTE) is a disease spectrum that ranges from deep vein thrombosis (DVT) to pulmonary embolism (PE). Rapid diagnosis and treatment of VTE by emergency care providers are critical for decreasing patient mortality, morbidity, and the incidence of recurrent events. Recent American College of Chest Physicians guidelines recommend initial treatment with unfractionated heparin, low-molecular weight heparin, or fondaparinux overlapped with warfarin for a minimum of 5 days for the treatment of VTE in most cases. ⋯ These trials have demonstrated that TSOACs exhibit similar or lower bleeding rates, particularly intracranial bleeding rates compared with warfarin. Anticoagulation therapy with TSOACs may allow early discharge or outpatient management options for low-risk patients with DVT and PE. This review addresses the importance of early diagnosis and treatment of VTE, outcomes of VTE risk assessment, key efficacy and safety data from phase 3 clinical trials for the various TSOACs for the treatment of DVT and PE, and the corresponding considerations for clinical practice.
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Case Reports
Spontaneous spinal epidural hematoma after abrupt sneezing with prompt recovery of severe paraparesis.
Spontaneous spinal epidural hematoma (SSEH) is a rare neurologic condition with threatening consequences when spinal cord compression is present. The diagnosis must be performed quickly using magnetic resonance imaging (MRI), which shows collection of blood in the epidural space. With spinal cord compression, there is an indication for urgent surgical decompression. ⋯ Decompression was recommended, but the patient refused surgery, while neurologically improving with time. Complete neurologic recovery was observed within 24 hours after SSEH onset. A conservative therapeutic approach with careful observation may therefore be considered as a treatment of choice in some cases where surgery is refused, (due to high risk or other reasons) and neurologic recovery is early and sustained.
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Validate the sensitivity and specificity of 2 age adjustment strategies for d-dimer values in identifying patients at risk for pulmonary embolism (PE) compared with traditional D-dimer cutoff value (500 ng/mL) to decrease inappropriate computed tomography pulmonary angiography (CTPA) use. ⋯ Each age-adjusted D-dimer cutoff strategy for the evaluation of PE was associated with increased specificity and statistically insignificant decreased sensitivity when compared with the traditional D-dimer cutoff value.