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A 30-year-old woman was admitted to the emergency department one and half hours after severe bupropion extended-release intoxication, estimated to be between 18 and 36 g. She initially presented with seizures and later developed signs of cardiotoxicity with persisting sustained ventricular tachycardia. Despite multiple defibrillation attempts and the administration of sodium bicarbonate,
calcium gluconate and magnesium, restoration of sinus rhythm was found unsuccessful. In another attempt to treat this refractory ventricular tachycardia lidocaine was given followed by deterioration to asystole. During cardiopulmonary resuscitation (CPR), the quality of chest compression was assessed and optimised using transoesophageal echocardiography. Eventually venoarterial extracorporeal membrane oxygenation (VA-ECMO) was needed to achieve hemodynamic stability. In this case report we discuss the successful use of VA-ECMO after bupropion intoxication, which has only been reported in 3 other cases but should be considered as one of the treatment options in severe overdose cases. Also, the rare complication of asystole after lidocaine administration and the value of transoesophageal echocardiography during CPR will be discussed.
Bupropion; Intoxication; Extracorporeal membrane oxygenation; TEE guided resuscitation; Antiarrhythmic therapy.
Traumatic cervical are injuries are very common due to high motility of cervical spine and its vulnerability to traumatic injuries. Optimal time for stabilizing the patients with traumatic spinal fractures remains controversial. It is almost due to different outcomes in various studies and the lack of consensus about it. Here we explain an ultra–early cord decompression that led to complete recovery of a patient with severe cervical cord injury.
The patient was a 27-year-old gymnast woman with a recent history of spinal cord injury caused by high jumping with head back and neck hyperextension presented within 2-hours of trauma. As a critical case and lack of advanced radiologic equipment, only cervical spinal radiographs were used for decision-making within the first 3 hours of injury to save the patient’s cord function by surgical decompression.
Many studies have proposed different intervention times for achieving the optimal result; however, we present an ultra-early surgery (within 3-hours of injury), conducted in a context of limited medical facilities. This case revealed an excellent result after 12-months follow-up.
Cervical spine; Early decompression; Surgery; Trauma.
The outbreak of coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory distress syndrome coronavirus 2 (SARS-CoV- 2), has been recently declared a pandemic by the World Health Organization. Apart from acute respiratory manifestations, SARS-CoV-2 may also adversely affect other organ systems. To date, however, there is a very limited understanding
of the manifestations and management of COVID-19 related conditions outside of the pulmonary system. This study provides an overview of the current literature about the extra pulmonary manifestations of COVID-19 that may affect the renal, cardiovascular, gastrointestinal, hematological, hematopoietic, neurological, or reproductive systems. This study also describes the current understanding of the extra pulmonary manifestations caused by COVID-19 to improve the management and prognosis of patients with COVID-19.
Materials and Methods
A total number of 200 hospitalized patients with COVID-19 disease were retrospectively evaluated for extra-pulmonary manifestations findings or complications. These patients had undergone various imaging studies, blood examinations during the course of hospital stay. The data reviewed using the institutional PACS, database system over a period of four months (August to November 2020).
Among the 200 patients (males and females), 175 of them had extra-pulmonary complications. Various extra-pulmonary findings such as acute kidney injury, renal failure, cytokinase strome, acute myocardial injury, congestive cardiac failure, pulmonary thromboembolism,
gastrointestinal, neurological complications were observed.
Inclusion and Exclusion Criteria
All retrospective clinical studies, case series, and case reports with data on extra-pulmonary manifestations in COVID-19 that were published from the end of December 2019 till the end of February 2021 were included. Studies that did not mention extrapulmonary manifestations were excluded.
The review was based on publications available on PubMed and data collected by the World Health Organization (WHO). Search terms used were ‘novel coronavirus 2019 (2019-nCoV)’, ‘SARS- CoV-2’, or ‘COVID-19’ combined with ‘asymptomatic’, ‘gastrointestinal’, ‘cardiac’, ‘neurological’, ‘hepatic’, ‘hematological’, ‘renal’, ‘psychiatric’, ‘hematological’, and ‘atypical’.
COVID-19; SARS-CoV-2; 2019-nCoV.
Vertebral artery dissection (VAD) is caused by an intimal tear that leads to bleeding into the vascular wall, which may cause vascular occlusion by thrombus formation and subsequent distal emboli (leading to ischemic stroke), aneurysm formation and subarachnoid hemorrhage. Cervical artery dissections (either carotid or vertebral artery dissection) are an important cause of stroke in patients under 50-years of age. Headache with or without neck pain is a common symptom. Usually, it occurs with focal neurological signs but sometimes it may occur without any neurological deficits and may mimic migraine. Often it occurs spontaneously without trauma but sometimes there is history of minor traumas, sudden neck movements or chiropractic manipulation. Imaging modalities include magnetic resonance imaging (MRI) brain, magnetic resonance angiography (MRA), and computed tomography angiography (CTA). Treatment involves anticoagulation or antiplatelet agents.
Vertebral artery dissection; Migraine; Headache; Neck pain.
Sudden cardiac arrest continues to have a high mortality rate. Out of hospital cardiac arrest (OHCA) has a poor outcome compared to those occurring in a healthcare setup due to lack of awareness and appropriate resources. The most common rhythm abnormality in OHCA is ventricular fibrillation which requires early defibrillation, ideally on the location.
A 19-years male was witnessed by lay bystanders to have become unresponsive following contact with an electric lighting pole on the road median in Chandigarh. A passer-by medical resident detected no pulse and initiated chest compression. Since there was no immediate return of spontaneous circulation and aetiology suggested a defibrillate rhythm. The patient was taken in the car and rushed to a tertiary care centre, 10-minutes away. Cardiopulmonary resuscitation (CPR) was interrupted during transport for lack of adequate personnel. Ventricular fibrillation was noted and shock was delivered along with inotropes. Around 26-minutes into the resuscitation, the patient had the return of spontaneous circulation. After post-cardiac arrest care in intensive care unit (ICU), he was extubated and discharged home in 1-week with full neurological recovery.
Recovery of full neurologic function could be explained by the alternating presence of stable and unstable cardiac rhythms and in part at least brought about by immediate attempts at resuscitation. The report seeks to review these aspects of emergency care besides highlighting the need for both immediate and accurate emergency medical services such as lay responder training, public access defibrillation and responsive transport systems for such patients.
Sudden cardiac arrest; Out of hospital cardiac arrest; Ventricular fibrillation; Early defibrillation; Electrical injury.
The synthetic antifibrinolytic drug, tranexamic acid, is widely used intravenously, orally and topically to treat various bleeding complications. In recent years, there has been increasing evidence of its use as inhalation drug for hemoptysis. In this review, the available literature about aerosolized tranexamic acid is listed.
In this case report, we present a patient with severe pyelonephritis who presented complaining of passing worm-like tissue from his penis. This patient was passing macroscopic ureteral white blood cell casts resulting from a severe pyelonephritis caused by Klebsiella pneumoniae.
Acute pyelonephritis; White blood cell casts; Urinary tract infections; Urinary tract infection (UTI); Ureteral casts.
Prothrombin complex concentrates (PCC) has long been used to reverse vitamin K antagonists (VKA)-induced coagulopathy rapidly and safely. However, its use in trauma-induced coagulopathy (TIC) in patients not using VKA drugs is yet to be elucidated. This article is a narrative review and analysis of the most recent literature to analyse consequences, and intended effects associated with this treatment modality in TIC. Utilization of PCC was addressed in the literature data found by searches of databases. The indications, efficacy and outcomes associated with the use of the product were reviewed in the articles. Some studies point out promising results with respect to PCC use to overcome the VKA-related coagulopathy in victims of trauma. PCC may be a viable option for resuscitation in emergency and critical care in the management of severe hemodynamic deterioration induced by trauma, despite contradictory findings in the literature.
Blood coagulation factor; Trauma; Hemorrhagic shock; Exsanguinating hemorrhage.
Director Department of Emergency Medicine National Taiwan University Hospital Yunlin Branch No 579, Sec 2, Yunlin Road, Douliou 640, Taiwan
EMS Fellowship Director Professor Department of Emergency Medicine Georgia Regents University Augusta, Georgia Area USA
Assistant Professor Department of Emergency Medicine Harvard University Brigham & Women’s Hospital 75 Francis Street Boston, MA 02115, USA
Staff Physician Emergency Department Geisinger Medical Center 100 North Academy Avenue Danville, PA 17822, USA