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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We report a case of atypical cerebellar infarction following accidental inhalation of toluene mixed paint. An unconscious 57-year-old housewife with hypertension arrived at our emergency department by ambulance. She had been rescued from a basement (30 m3) 12 h after exposure to paint containing toluene (34%). ⋯ We serially measured urinary hippuric acid concentrations (reference range, ≤2.5 g/g creatinine) from 74 h (3.88) after hospital arrival to 218 h (0.5). She was discharged on day 14. Herein we presented a near fatal toluene intoxication (>45,000 mg/m3 estimated based on the basement volume and quantity of paint used) with atypical cerebellar infarction, compared with prior findings of bilateral involvement or reversibility.