The American journal of emergency medicine
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Review Case Reports
Factor Xa inhibition and sPESI failure in intermediate-high-risk pulmonary embolism.
We report the case of a 61-year-old man who presented at the Emergency Department (ED), complaining of sudden-onset dyspnea and chest pain after a long flight from Tokyo to Houston. Considering his clinical stability and sPESI 0, enoxaparin 1 mg/kg BID was started for 24 h, and the patient was then considered for early discharge with apixaban 10 mg BID. Direct-factor Xa inhibition did not improve extensive thrombus burden and right ventricular dysfunction despite D-dimer measurement reduction. ⋯ We also did not find any evidence of cases that reported strategies for urgent thrombolysis in PE patients on NOACs. To the best of our knowledge, apixaban's failure to reduce thrombus burden, persistent right ventricular dysfunction, and a NOACs-thrombolysis bridge in patients with PE on apixaban has not been previously described. Both the bedside risk stratification and the therapeutic failures should alert clinicians in the ED to the potential limitations of low-molecular-weight heparin, NOACs therapy, and sPESI in the setting of intermediate-high-risk PE.
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Case Reports
Left atrial rhabdomyosarcoma diagnosed by Emergency Department point-of-care echocardiography.
We present a case of intracardiac rhabdomyosarcoma associated with cardiopulmonary instability which was diagnosed by emergency providers using point-of-care echocardiography. ⋯ A previously healthy 49-year-old man presented to the Emergency Department with progressive dyspnea and hypotension. Emergency providers identified a left atrial mass using point-of-care ultrasound. Expedited advanced imaging and surgical management showed a malignant cardiac rhabdomyosarcoma. Why should an emergency physician be aware of this? This case report highlights the utility of point-of-care ultrasound in the work-up of patients with undifferentiated dyspnea and hypotension, even in cases of rare diagnoses. Early diagnosis and management of both benign and malignant intracardiac tumors is essential to preoperative planning and patient prognosis. Ultrasound findings consistent with intracardiac masses should be recognized and used to guide further consultation, advanced imaging, and treatment.
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Drug induced acute respiratory distress syndrome (ARDS) is a common clinical condition. Patients typically present with noncardiogenic pulmonary edema. Large number of ARDS cases reported induced by antineoplastic drugs and other drug intoxications. ⋯ To the best of our knowledge, ARDS following normal doses of NSAID ingestion has not been reported previously. The case showed that ARDS may occur after ingestion of therapeutic doses of NSAID. NSAID ingestion should be considered in the differential diagnosis of patients with non-cardiogenic pulmonary edema.
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Randomized Controlled Trial
Propofol-fentanyl versus propofol-ketamine for procedural sedation and analgesia in patients with trauma.
Many procedures performed in emergency department are stressful and painful, and creating proper and timely analgesia and early and effective assessment are the challenges in this department. This study has been conducted in order to compare the efficacy of propofol and fentanyl combination with propofol and ketamine combination for procedural sedation and analgesia (PSA) in trauma patients in the emergency department. ⋯ It seems that regarding PSA in the emergency department, PF caused better analgesia and deeper sedation and it is recommended to use PF for PSA in the emergency departments.