Clinical factors associated with adverse outcomes in the acute period of management of submassive pulmonary embolism.

The majority of patients with intermediate-to-severe submassive pulmonary embolism are hemodynamically stable upon presentation. There is a lack of evidence for the clinical relevance and safety of initially employed therapies in this population. The objective of current analysis was to determine predictors associated with adverse outcomes in submassive pulmonary embolism patients. This was a single-center, retrospective chart review identifying patient characteristics and clinical factors associated with adverse outcomes within the management of patients presenting to the emergency department for submassive pulmonary embolism. A total of 122 admissions for submassive pulmonary embolism were included. Among these patients, 41% (n = 50) of admissions had an adverse outcomes. Fluid volume was associated with adverse events in an incremental manner (odds ratio 2.1, 95% confidence interval, 1.4-3.2). These findings demonstrate a significant incidence of adverse events in patients with submassive pulmonary embolism and an incremental increase in likelihood of adverse events with each liter of fluid.

Emergency department management of North American snake envenomations.

There are approximately 10,000 emergency department visits in the United States for snakebites every year, and one-third of those involve venomous species. Venomous North American indigenous snakes include species from the Crotalinae (pit vipers) and Elapidae (coral snakes) subfamilies. Treatment relies on supportive care, plus antivenom for select cases. While certain principles of management are widely accepted, controversies exist with regard to prehospital use of pressure immobilization, antivenom use, coagulation testing after copperhead envenomation, and fasciotomy. An evidence-based approach to management of North American venomous snakes will be discussed, along with a review of the current controversies.

Thromboelastography in the management of snakebite-induced coagulopathy: a case series and literature review.

: North American crotaline envenomations are a significant source of morbidity annually. Envenomation is marked by a constellation of effects that can include severe tissue damage, systemic effects such as anaphylaxis, and coagulopathy with bleeding. Traditionally, static plasma-derived tests such as protime and PTT are used to assess coagulation status. However, other tests are available that provide a whole blood assessment of all portions of coagulation including initiation, propagation, and clot maintenance. One such analytical test is TEG. Minimal data is available regarding the effect of snake venom on TEG results. We report on three cases of North American crotaline envenomation with subsequent TEG analysis. Our results show that TEG analysis does relate the same information as traditional monitoring parameters. Although only in an isolated case, the TEG analysis potentially revealed a fibrinolytic process prior to the same process being apparent with traditional monitoring. Future research is necessary to identify the role of TEG in crotaline snakebite management.

Points & Pearls: Emergency department management of North American snake envenomations

There are approximately 10,000 emergency department visits in the United States for snakebites every year, and one-third of those involve venomous species. Venomous North American indigenous snakes include species from the Crotalinae (pit vipers) and Elapidae (coral snakes) subfamilies. Treatment relies on supportive care, plus antivenom for select cases. While certain principles of management are widely accepted, controversies exist with regard to prehospital use of pressure immobilization, antivenom use, coagulation testing after copperhead envenomation, and fasciotomy. An evidence-based approach to management of North American venomous snakes will be discussed, along with a review of the current controversies. [Points & Pearls is a digest of Emergency Medicine Practice.]