Nebulized vs IV Tranexamic Acid for Hemoptysis: A Pilot Randomized Controlled Trial.

BACKGROUND: Tranexamic acid (TA) is used to control bleeding in patients with hemoptysis. However, the effectiveness of the different routes of TA administration has not been studied. RESEARCH QUESTION: Does the nebulized route of TA administration reduce the amount of hemoptysis compared with the IV route in patients presenting to the ED with hemoptysis? STUDY DESIGN AND METHODS: This was a pragmatic, open-label, randomized, parallel, single-center, pilot trial of nebulized TA (500 mg tid) vs IV TA (500 mg tid) in adult patients presenting to the ED with active hemoptysis. The primary outcome was cessation of bleeding at 30 min. Secondary outcomes included amount of hemoptysis at 6, 12, and 24 h; interventional procedures; and side effects of TA. Patients who were hemodynamically unstable or requiring immediate interventional procedure or mechanical ventilation were excluded from the study. RESULTS: Of the 55 patients in each arm, hemoptysis cessation at 30 min following TA administration was significantly higher in the nebulization arm (n = 40) compared with the IV arm (n = 28): χ2 (1, n = 110) = 5.55; P = .0019. Also, hemoptysis amount was reduced significantly in the nebulization arm at all time periods of observation (P value at 30 min = .011, at 6 h = .002, 12 h = .0008, and at 24 h = .005). Fewer patients in the nebulization arm required bronchial artery embolization (13 vs 21; P = .024) and thereby had higher discharge rates from the ED (67.92% vs 39.02%; P = .005). Two patients in the nebulization arm had asymptomatic bronchoconstriction that resolved after short-acting beta-agonist nebulization. No patient discharged from the ED underwent any interventional procedure or revisited the ED with rebleed during the 72 h follow-up period. INTERPRETATION: Nebulized TA may be more efficacious than IV TA in reducing the amount of hemoptysis and need for ED interventional procedures. Future larger studies are needed to further explore the potential of nebulized TA compared with IV TA in patients with mild hemoptysis. CLINICAL TRIAL REGISTRATION: Clinical Trials Registry-India; No.: CTRI/2019/05/019337; URL: http://ctri.nic.in/Clinicaltrials/advancesearchmain.php.

Alleviating Refractory Abdominal Pain in Cholangiocarcinoma Using Erector Spinae Plane Block in the Emergency Department.

BACKGROUND: Acute pain management in the emergency department (ED) is a challenging task, more so in pain due to malignancy. Opioids have life-threatening side effects in ED patients, along with the risk of dependency. Erector spinae plane block (ESPB) is a recently described plane block technique with ease of performance and minimal side effects, making it suitable for emergency settings. CASE REPORT: A 62-year-old male patient recently diagnosed with cholangiocarcinoma presented to the ED with severe right upper abdominal pain. There was no pain relief with high doses of analgesics. ESPB was administered at T7 vertebrae level. The patient's Defense and Veteran Pain Rating Scale score reduced from 8/10 pre-procedure to 3/10 within 15 min, and 2/10 1 h after the procedure. He reported that he had an uninterrupted pain-free sleep after 4 days. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: ESPB is a novel regional analgesia that may help in management of uncontrolled severe pain not relieved with analgesics in patients with cholangiocarcinoma in the ED.

Kounis syndrome and atrial fibrillation after bee sting: A case report.

Bee sting can lead to allergic reactions which can present as life-threatening emergencies. Kounis syndrome is an acute coronary syndrome caused by mast cell activation after exposure to an allergen. Atrial fibrillation (AF) along with Kounis syndrome after allergen exposure is a rare presentation. A 40-year-old male patient presented to the emergency department (ED) with multiple bee stings to the face and neck. He complained of retrosternal chest pain along with facial pain and swelling. An electrocardiogram (ECG) showed AF with ST elevation in aVR and generalized ST segment depression. Troponin levels were elevated. He was diagnosed with Kounis syndrome along with AF secondary to a bee sting. The patient improved symptomatically with removal of stings and conservative management (steroids, antihistamines, antiplatelet drugs). ECG reverted to sinus rhythm and resolution of ST-T changes. He was discharged from the ED in stable condition. The bee sting may lead to significant cardiovascular events such as AF and Kounis syndrome, which require a high index of suspicion and prompt treatment. Kounis syndrome should be suspected in the ED in young patients with no cardiovascular risk factors after exposure to an allergen.

Erector spinae plane block for pain control in patients with pancreatitis in the emergency department.

Nerve blocks are frequently used in emergency department for pain management in patients with fractures. Their utility in medical conditions with severe intactable pain is largely unknown. We report a series of seven patients with pancreatitis who presented with severe abdominal pain (defense and veteran pain rating scale > 7) and had no relief on regular analgesia. They were subjected to erector spinae plane block (ESPB), and reduction in pain score at different time intervals, side effects, and additional analgesic dose requirements were noted. The objective of this case series is to explore the utility of ESPB in patients with pancreatitis.