The American journal of emergency medicine
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International guidelines recommend antibiotics within 1 hour of septic shock recognition; however, a recently proposed performance measure is focused on measuring antibiotic administration within 3 hours of emergency department (ED) arrival. Our objective was to describe the time course of septic shock and subsequent implications for performance measurement. ⋯ Nearly 1 of 5 patients cannot be captured for performance measurement within 3 hours of ED arrival due to the variable progression of septic shock. Use of this measure would misclassify performance in 23% of patients. Measuring antibiotic administration based on the clinical course of septic shock rather than from ED arrival would be more appropriate.
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Case Reports
Life-threatening hypocalcemia associated with denosumab in a patient with moderate renal insufficiency.
Denosumab, a human monoclonal antibody to the receptor activator of nuclear factor-κB ligand, is a novel therapy to osteoporotic fracture and skeletal-related events in patients with bone metastases. Hypocalcemia is its known adverse effect, although it is generally mild and transient and usually occurs in patients with severe chronic kidney disease or end-stage renal disease. We reported a case 61-year-old woman who received a single dose of denosumab and developed severe symptomatic hypocalcemia associated with prolong QTc interval requiring hospitalization for intravenous calcium.
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Case Reports
Severe blood loss anemia in a Jehovah's Witness treated with adjunctive hyperbaric oxygen therapy.
We describe the case of a 39-year-old African-American woman who developed sudden onset, near-term placental abruption with severe blood loss anemia whose religious beliefs precluded her from receiving any blood products. The patient had lost most of her blood volume, with a reported hemoglobin level of 1.9 g/dL, developed multisystem failure, and disseminated intravascular coagulation with bilateral deep venous thrombosis. Adjunctive hyperbaric oxygenation (HBO) therapy was considered, and the patient was referred for treatment. ⋯ She was discharged to a rehabilitation facility on hospital day 29 and then to home, soon thereafter. The patient had no evidence of sustained physical or cognitive impairment at time of discharge, and there were no reported complications associated with HBO therapy. Adjunctive HBO therapy should be considered in the management of patients with exceptional severe blood loss anemia who refuse the use of blood products.
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Transient ischemic attack or ischemic stroke in hereditary hemorrhagic telangiectasia (HHT), a rare genetic disease, is frequent in clinical practice and often associated to pulmonary arteriovenous malformations (PAVMs), potentially determining paradoxical cerebral embolism. We describe the case of a 53-year-old woman with a previous history of recurrent epistaxis, admitted to our unit for a transient episode of diplopia and unbalance. ⋯ Secondary cerebrovascular prevention with antithrombotic therapy was early stopped for the worsening of epistaxis. Neurologic symptoms are common in HHT, and saline contrast transcranial Doppler can be a reliable alternative to echocardiography for detection of right to left shunt commonly related to underlying PAVMs.
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Case Reports
Early onset of cooling catheter-related right atrial thrombus following cardiac arrest.
Catheter-related right atrial thrombus (RAT) is an uncommon life-threatening complication. Few cases of endovascular cooling catheter–related complications have been reported. We report the first case of endovascular cooling catheter–related RAT. ⋯ Anticoagulation with enoxaparin for 2 weeks completely resolved the RAT, and he was consequently treated with radiofrequency ablation and received an implanted cardiac defibrillator. This case report highlights the occurrence of endovascular cooling catheter–related RAT early after the placement of a catheter. Physicians should monitor whether RAT occurs during and following therapeutic hypothermia with a cooling catheter.