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The use of Inferior Vena Cava (IVC) filters is increasing for patients who cannot otherwise receive anticoagulation for a deep vein thrombosis (DVT) or pulmonary embolism (PE). In this case, a 60-year-old man presenting with abdominal pain was found to have migration of his IVC filter into his intrahepatic IVC. Interventional radiology (IR) and vascular surgery were consulted as the migrated IVC filter was felt to be the likely cause of the patient's pain. Consideration was given to transferring the patient to a liver transplant center to retrieve the migrated filter. When patients with a history of IVC filter placement present to the emergency department, a high index of suspicion for IVC filter complication should be maintained and there should be a low threshold for ordering CT imaging. If a severe IVC filter complication is discovered, patients may ultimately require transfer to a center with hepatic surgery capability for definitive treatment given the complex vasculature involved.
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Angioedema is a subcutaneous or submucosal tissue swelling due to capillary leakage and transudation of fluid into the interstitial tissue. It can be localized or generalized as part of a widespread reaction known as anaphylaxis. Millions of people in United States and all over the world receive ACEI antihypertensive therapy. ACEI is known to cause angioedema with an incidence of 0.7 percent. We present a case of 40-year-old female who was started on lisinopril three days prior to presentation for newly diagnosed hypertension. She presented with nonspecific severe abdominal pain, nausea, and vomiting. She denied having difficulty breathing or swelling anywhere in the body. On exam, she did not have facial, lip, tongue, or throat swelling. Her abdomen was tender without guarding or rigidity. Laboratory examination was unrevealing except for mild leukocytosis. Computed tomography scan (CT scan) of the abdomen with oral and IV contrast revealed a moderate amount of ascites with diffuse wall thickening, hyperenhancement, and mucosal edema of the entire small bowel. In the absence of any other pathology, matching history, and imaging findings highly suggestive of angioedema, she was diagnosed with isolated small bowel angioedema as a result of ACEI therapy. She was managed conservatively, and lisinopril was discontinued. A week later on follow-up, all her symptoms had resolved, and repeat CT scan showed resolution of all findings.
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BACKGROUND: Health care providers are often called to respond to in-flight medical emergencies, but lack familiarity with expected supplies, interventions, and ground medical control support. OBJECTIVE: The objective of this study was to determine whether a mobile phone app (airRx) improves responses to simulated in-flight medical emergencies. METHODS: This was a randomized study of volunteer, nonemergency resident physician participants who managed simulated in-flight medical emergencies with or without the app. Simulations took place in a mock-up cabin in the simulation center. Standardized participants played the patient, family member, and flight attendant roles. Live, nonblinded rating was used with occasional video review for data clarification. Participants participated in two simulated in-flight medical emergencies (shortness of breath and syncope) and were evaluated with checklists and global rating scales (GRS). Checklist item success rates, key critical action times, GRS, and pre-post simulation confidence in managing in-flight medical emergencies were compared. RESULTS: There were 29 participants in each arm (app vs control; N=58) of the study. Mean percentages of completed checklist items for the app versus control groups were mean 56.1 (SD 10.3) versus mean 49.4 (SD 7.4) for shortness of breath (P=.001) and mean 58 (SD 8.1) versus mean 49.8 (SD 7.0) for syncope (P<.001). The GRS improved with the app for the syncope case (mean 3.14, SD 0.89 versus control mean 2.6, SD 0.97; P=.003), but not the shortness of breath case (mean 2.90, SD 0.97 versus control mean 2.81, SD 0.80; P=.43). For timed checklist items, the app group contacted ground support faster for both cases, but the control group was faster to complete vitals and basic exam. Both groups indicated higher confidence in their postsimulation surveys, but the app group demonstrated a greater increase in this measure. CONCLUSIONS: Use of the airRx app prompted some actions, but delayed others. Simulated performance and feedback suggest the app is a useful adjunct for managing in-flight medical emergencies.
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BACKGROUND: Airline carriers have equipment, procedures, and protocols in place to handle in-flight medical events (IFMEs). Community physicians may be asked for aid during IFMEs. Cross-Sectional Survey of Physicians on Providing Volunteer Care for In-Flight Medical Events surveyed self-assessed awareness and knowledge, perceived barriers, and suggestions for improving responses to IFMEs. METHODS: We composed a survey regarding clinicians' self-assessed understanding of in-flight resources, procedures, flight environmental issues, and Good Samaritan protections. The survey was distributed primarily via electronic mail to medical staff list serves to a total of approximately 1300 physicians representing 2 health networks that serve urban, suburban, and rural areas in both inpatient and outpatient settings. RESULTS: Total number of responses was 418. Physician response rate was 29.2% (379/1300). In 3% (39/1300), the responder either failed to indicate their background or was another type of health care professional (e.g., dentist, medical student, physician assistant). Of the physicians, 37.5% (142/379) were primary care and 42% (177/418) of responders reported at least one experience of being asked to volunteer. When asked how well they understand the protocols with which medical events are handled, 64% (262/412) responded "not at all" and 23% (94/412) reported "a little" knowledge. Only 56% (223/397) answered that 75% or more of U.S. flights have ground medical support available. There were 73% (298/411) who believed airlines were required to have medical supplies, but 54% (222/410) reported no knowledge of supplies available. A total of 69% (279/403) believed or were sure that the U.S. has a Good Samaritan law that applies to IFMEs. DISCUSSION: Many physicians lack basic knowledge about IFMEs. Responders may assist more effectively if better informed about protocols and the availability of ground medical support. Education and timely information support are recommended.Chatfield E, Bond WF, McCay B, Thibeault C, Alves PM, Squillante M, Timpe J, Cook CJ, Bertino RE. Cross-Sectional Survey of Physicians on Providing Volunteer Care for In-Flight Medical Events. Aerosp Med Hum Perform. 2017; 88(9):876-879.
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Aviación , Tratamiento de Urgencia , Médicos , Voluntarios , Estudios Transversales , Femenino , Humanos , Masculino , Encuestas y CuestionariosRESUMEN
STUDY OBJECTIVE: Adverse drug events (ADEs) have been studied in hospitalized patients. Less is known about this common type of injury in emergency department patients. This study seeks to measure the risks, incidence, severity, and costs of ADEs in an ED population. METHODS: ED charts of visits to a university-affiliated tertiary-care ED occurring between March 1 and May 31, 1997, were retrospectively reviewed. The main outcome measures were ADE incidence, severity, and total cost. Visits identified by investigators as containing a suspected ADE were further assessed by using the Naranjo Adverse Drug Reaction (ADR) probability scale. Events judged as probable ADEs (Naranjo ADR probability scale score of >4) were compared with ED control visits best matched by age for disposition, survival, severity, payer, sex, race, age, number of drugs, and total cost. RESULTS: Of 13,602 visits, 13,004 records were available. Three hundred twenty-one had suspected and 217 had probable ADEs (1.7% of evaluable encounters); these were compared with visits by 217 age-matched control patients. Insulin and warfarin were the most commonly responsible drugs. Patients with ADEs were older (mean age 45.1 versus 36.8 years; mean difference 8.3; 95% confidence interval [CI] 3.7 to 12.9), were more often women (odds ratio [OR] 1.48; 95% CI 1.01 to 2.16), took more drugs (mean number of drugs 4.1 versus 1.9; mean difference 2.2; 95% CI 1.7 to 2.8), and were hospitalized more frequently (OR 2.29; 95% CI 1.33 to 3.94) than control patients. CONCLUSION: ADEs encompassed an important segment of ED encounters and annual health care costs. ED screening may provide useful information about the epidemiology of outpatient ADEs.