The American journal of emergency medicine
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To examine the safety and effectiveness of intranasal midazolam and fentanyl used in combination for laceration repair in the pediatric emergency department. ⋯ Our results suggest that the combination of INM and INF may be a safe and effective strategy for procedural sedation in young children undergoing simple laceration repair.
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Observational Study
Impact of altitude-adjusted hypoxia on the Pulmonary Embolism Rule-out Criteria.
The Pulmonary Embolism Rule-out Criteria (PERC) defines hypoxia as an oxygen saturation (O2 sat) < 95%. Utilizing this threshold for hypoxia at a significant elevation above sea level may lead to an inflated number of PERC-positive patients and unnecessary testing. The aim of this study was to determine the effect of an altitude-adjusted O2 sat on PERC's sensitivity and the potential impact on testing rates. ⋯ Adjusting the PERC O2 sat threshold for altitude may result in decreased rates of advanced imaging for PE without a substantial change in the sensitivity of the PERC rule.
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Regular, narrow complex tachycardia with a ventricular rate around 150 can be challenging. The differential includes sinus tachycardia, atrioventricular nodal reentrant tachycardia (AVNRT), atrioventricular reentrant tachycardia (AVRT), and atrial tachycardia (focal or macro re-entrant - i.e. flutter). We present a case of a 90-year-old woman presenting with shortness of breath in which the ECG was not diagnostic, but the presence of regular neck pulsations helped secure the diagnosis of AVNRT. ⋯ When the right atrium attempts to contract against a closed tricuspid valve, an abrupt increase in venous pressure is encountered. This increase in venous pressure manifests as prominent neck pulsations termed "cannon A waves." The patient was ultimately successfully electrically cardioverted resulting in resolution of her presenting symptoms, neck pulsations, and tachycardia. While irregular "cannon A waves" can be seen in conditions of AV dissociation, regular "cannon A waves" strongly favor the diagnosis of AVNRT.
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The incidence of patients who present with life-threatening bleeding complications has been increasing as the use of direct oral anticoagulation (DOAC) has increased. Therefore, effective reversal agents are urgently needed. Current guidelines recommend the use of prothrombin complex concentrates (PCCs) and activated PCCs (aPCC) for reversal of DOAC anticoagulant activity in the setting of traumatic and non-traumatic intracranial hemorrhage (ICH). However, little data is available. ⋯ This case series suggests that FEIBA administration is relatively safe and effective to reverse DOACs in the setting of hemorrhage or need for urgent surgical procedures. Until target-specific reversal agents are available, future studies are warranted to evaluate the effectiveness of aPCC administration for DOAC-associated hemorrhagic complications.