The American journal of emergency medicine
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Case Reports
Spontaneous splenic hemorrhage after initiation of dabigatran (Pradaxa) for atrial fibrillation.
Dabigatran etexilate (Pradaxa; Boehringer Ingelheim Pharmaceuticals, Inc, Ridgefield, CT) is an oral anticoagulant that produces a reliable, dose-dependent anticoagulant effect without the need for routine laboratory monitoring. Dabigatran is a direct thrombin inhibitor, acting like other members in its class (bivalirudin, argatroban) to impede the clotting process through selective and reversible binding with both free and clot-bound thrombin. ⋯ Currently, there is no laboratory test on the market by which a physician can quantify the anticoagulation effect of dabigatran, nor is there any antidote to reverse a life-threatening bleed should it occur. We present a case of a patient with splenic hemorrhagic soon after initiation of dabigatran.
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Patients are often referred to the emergency department for further evaluation, yet the astute physician will maintain a broad differential to avoid anchoring on prior diagnoses. In this case, a 56-year-old man was referred to our emergency department from the radiology suite secondary to concerns for an “allergic reaction” to prior magnetic resonance imaging contrast. ⋯ A chest x-ray that demonstrated right mediastinal mass was ordered, and a computed tomographic scan confirmed compression of the superior vena cava. A brief discussion on the history, etiologies, presentation, and evaluation of superior vena cava syndrome is discussed.
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The risks of intravenous (IV) lidocaine before rapid sequence induction (RSI) have become a great concern. No study has investigated the hemodynamic effects of IV lidocaine during endotracheal intubation in patients with severe traumatic brain injury. ⋯ Intravenous lidocaine in addition to RSI before endotracheal intubation was not associated with significant hemodynamic changes in patients with severe traumatic brain injury.
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Amiodarone is a widely used antiarrythmic drug for various atrial and ventricular arrhythmias. It has the potential to cause prolongation of the QT interval, which, in turn, can increases the incidence of torsade de pointes. ⋯ Other causes of QT prolongation as electrolyte abnormalities or administration of other drugs that prolong the QT interval were excluded. Awareness of this phenomenon and method of calculation of QT interval in this scenario is of utmost importance.
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Spontaneous urinary bladder perforation is a rare and life-threatening condition similar to traumatic and iatrogenic perforation. The connection with the underlying bladder damage due to previous radiotherapy, inflammation, malignancy, obstruction, or other causes can be found in almost all cases. The symptoms are often nonspecific, and misdiagnosis is common. ⋯ It appears probable that the infection was due to local interference with the blood supply (arterial, capillary, or venous) combined with the systemic metabolic upset that led to the bladder condition. In our case, we observed partial necrosis of the bladder rather than distortion of the entire blood supply to the bladder as consequences of the microvascular effects of diabetes. Urinary bladder perforation must be considered in the differential diagnosis of patients presenting with free fluid in the abdomen/peritonitis, decreased urine output, and hematuria, and in whom increased levels of urea/creatinine are detected in serum and/ or peritoneal fluid aspirate.