J Emerg Med
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Assessment for pulmonary embolism (PE) in the emergency department (ED) remains complex, involving clinical decision tools, blood tests, and imaging. ⋯ Many patients with negative d-dimer and PERC still received imaging. Our data support the use of age adjustment, and perhaps adjustment for other factors seen in patients evaluated for PE.
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Emergency intubation in a patient with advanced ankylosing spondylitis (AS) who presents with severe thoracic kyphosis deformity, rigid cervical flexion deformity of the neck, and an inability to achieve the supine position is particularly challenging to emergency physicians. ⋯ This study reports on an AS patient presenting with these difficult airway characteristics and acute respiratory failure who was successfully intubated using video laryngoscope-assisted inverse intubation (II) and blind digital intubation (BDI). By using Pentax AirwayScope-assisted inverse intubation, the tracheal tube tip was passed through the glottic opening, but an unexpected resistance occurred during tube advancement, which was overcome by subsequent BDI. By using laryngoscope-assisted II complemented by the BDI technique, the patient was successfully intubated without complications. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Our case demonstrated that these two emergency airway management techniques are valuable backup methods and complement each other when applied to certain unstable airways, especially when the traditional patient position is not easily accomplished. Unexpected difficulty is not rare during airway management; emergency physicians should always be well prepared both mentally and practically.
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Tranexamic acid (TXA) is a synthetic anti-fibrinolytic agent used to prevent and treat various bleeding complications. In many studies, investigators have evaluated its utility and safety orally, intravenously, and topically, but few studies have described the potential benefits of nebulized TXA. ⋯ We present a case of massive hemoptysis treated with nebulized TXA in the emergency department (ED) that led to the cessation of bleeding and avoidance of endotracheal intubation. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: In massive hemoptysis, rapidly available nebulized TXA may be considered a therapeutic option, serving either as primary therapy or as a bridge until other definitive therapies can be arranged.
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Compression ultrasonography is the most effective diagnostic tool in the emergency department (ED) for the diagnosis of deep vein thrombosis (DVT). It has been demonstrated to be highly accurate and cost-effective. ⋯ Emergency physicians can obtain a level of competence equivalent to that of radiologists, but it requires substantial training and practice to achieve and maintain this performance. Providers should be aware of their limitations and maintain regular training with ultrasound applications.
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Case Reports
Local Anesthetic-Induced Methemoglobinemia During Pregnancy: A Case Report and Evaluation of Treatment Options.
Methemoglobinemia is a well-recognized adverse drug reaction related to the use of certain local anesthetic agents. The mainstay of treatment for methemoglobinemia is i.v. methylene blue, along with provision of supplemental oxygen; however, methylene blue is listed as a category X teratogen. This poses an issue should methemoglobinemia develop during pregnancy. ⋯ A 35-year-old, 20-week and 5-day gravid female was transferred from an outpatient oral surgeon's office for hypoxia. She was undergoing extraction of 28 teeth and was administered an unknown, but "large" quantity of prilocaine during the procedure. Given this exposure, the concern was for methemoglobinemia. This was confirmed with co-oximetry, which showed 34.7% methemoglobin. The initial treatment plan was methylene blue; however, this drug is a category X teratogen. Thus, an interdisciplinary team deliberated and decided on treatment with high-dose ascorbic acid and transfusion of a single unit of packed red blood cells. The patient was managed with noninvasive ventilation strategies and a total of 8 g ascorbic acid. She was discharged on hospital day 3 with no obstetric issues noted. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Intravenous ascorbic acid appears to be a potential alternative to methylene blue in this patient population. The data surrounding teratogenicity of methylene blue are mostly related to intra-amniotic or intra-uterine administration. In life-threatening cases of methemoglobinemia during pregnancy, the benefits of i.v. methylene blue may outweigh the risks.