Tuba Karabey1*, Şerife Karagözoğlu2
1Tokat Gaziosmanpaşa University, Faculty of Health Sciences, Tokat, Turkey
2Cumhuriyet University, Faculty of Health Sciences, Nursing Department, Sivas, Turkey
Aim: The aim of this study is to develop a valid and reliable measurement tool to determine the knowledge level of nurses about the ventrogluteal area.
Method: The study was based on the methodological method. The study was carried out with 250 nurses who worked in the private unit, internal and surgical clinics of a university hospital in Turkey between February 20, 2021 and April 20, 2021 and agreed to participate in the study. The data were analyzed with IBM SPSS V23 and the factor structure was revealed by explanatory factor analysis. KMO-Bartlett test was used for sample adequacy. Tukey's Test for Nonadditivity was used to determine whether the scale was additive or not. The Cronbach Alpha value was checked for the reliability of the scale, and the dependent groups t-test was used for test repetition, and the Pearson correlation test was used for the relationship.
Results: After the psychometric analysis, the Ventrogluteal Area Information Scale was finalized with a single sub-dimension and 17 items. The lowest score that can be obtained from 17 items is 17 and the highest score is 85. There is no item that needs to be reverse scored in the created scale. As the score obtained from the scale increases, it is determined that the knowledge of the nurses about the ventrogluteal area increases. According to the internal consistency reliability analysis results, the Cronbach alpha reliability coefficient of the Ventrogluteal Area Information Scale was 0.96; The scale was found to be quite reliable.
Conclusion: It has been concluded that the Ventrogluteal Area Information Scale is a reliable and valid measurement tool that can be used in nursing practices.View / Download Pdf
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Van N. Trinh, Joseph E. Villaluz
Department of Anesthesiology, Kaweah Health Medical Center, Visalia, California, USA
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Hilde M. Buiting1,2,3,4*, Lisan Ravensbergen4,5, Christa van Schaik6, Vincent K.Y. Ho7, Gabe S. Sonke3,8
1Antoni van Leeuwenhoek, Netherlands Cancer Institute, Amsterdam, the Netherlands
2University Medical Center, Utrecht, the Netherlands
3University of Amsterdam, Amsterdam, the Netherlands
4O2PZ, Platform of Palliative Care, Amsterdam, the Netherlands
5Red Cross Hospital, Department of Anesthesiology, Beverwijk, the Netherlands
6Meander Medisch Centrum, Department of Medical Oncology, Amersfoort, the Netherlands
7Netherlands Comprehensive Cancer Organization, Utrecht, the Netherlands
8Antoni van Leeuwenhoek, Netherlands Cancer Institute, Department of Medical Oncology, Amsterdam, the Netherlands
Physical and Rehabilitation Medicine department & Chronic Pain Unit, Hospital de Braga, Sete fontes-São Victor, Braga, Portugal
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Robert S Katz1*, Frank Leavitt2, Ben J Small3
1Section of Rheumatology, Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA
2Department of Behavioral Sciences, Rush University Medical Center, Chicago, IL, USA
3Department of Rheumatology, Northwestern Memorial Hospital, Chicago, IL, USA
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Jay Suggs*, Garrett G. Perry
Crestwood Medical Center, One Hospital Drive, Huntsville, AL, USA
Anudeep Jafra1, Jeetinder Kaur Makkar1*, Nidhi Bhatia1, Narinder Pal Singh2
1Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Sector-12, Chandigarh, India
2Department of Anaesthesia, MMIMSR, MM (DU), Mullana-Ambala, India
Caesarean delivery is one of the commonest surgical procedures being performed world-wide, and with it comes the burden for management of acute post-operative pain in parturient. A number of modalities including neuraxial opioids, intravenous drugs and truncal nerve blocks are available to control acute postsurgical pain. Quadratus lumborum block has recently been emerged as a modality for pain relief following caesarean delivery. This review highlights the anatomical aspects, mechanism of action of block, relevant literature search and future directions for use of quadratus lumborum block in parturient undergoing caesarean delivery.View / Download Pdf
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Elad Dana1,2*, James S. Khan3
1Department of Anesthesia, Intensive Care and Pain Medicine, Meir Medical Center, Kfar Saba, Israel. Affiliated to the Sackler School of Medicine, Tel Aviv University, Israel
2Department of Anesthesia and Pain Medicine, Mount Sinai Hospital, Toronto, Ontario, Canada
3Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
Jonathan Nieves*, Tarig S. Elhakim, Valentina Rojas Ortiz, Gabriell Silva, Robert Hernandez, Jose Gascon
Department of Internal Medicine, Kendall Regional Medical Center, Miami, Florida, USA
COVID-19 has been associated with multiple complications including Acute Respiratory Distress Syndrome (ARDS), thrombo-embolism, and septic shock. A rare complication is a Spontaneous pneumomediastinum (SPM), pneumothorax (PNX), and subcutaneous emphysema (SCE) unrelated to positive pressure ventilation. These complications can become life threatening if a large amount of air is present and cannot escape to the neck or retroperitoneum causing obstructive shock or tension pneumothorax. Studies suggest that the cytokine storm in COVID-19 can result in diffuse alveolar injury, which can result in the alveolar wall being vulnerable to rupture. It is also speculated that the cause of the alveolar rupture is due to the diffuse alveolar damage resulting in air leak to the mediastinum. A recent case series of COVID19 autopsies have identified the microthrombi formation and the mononuclear response that leads to diffuse alveolar damage. In addition, recent studies have shown that COVID 19 infected patients are associated with worse clinical outcomes and increase intra and postoperative pulmonary complications and mortality risk. Meaning that patients with SPM had a higher chance of intubation and a higher chance of death. For anesthesiologists, the preoperative evaluation and risk assessment have always been a crucial step in determining whether it is safe to take a patient for surgery. Studies have shown that patients who test positive for COVID 19 are associated with worse clinical outcomes and increase postoperative complications and mortality. Obtaining accurate information, using clinical judgement and having open communication with surgeons may help reduce these risks.View / Download Pdf
Karishma Kodia*, Dao M. Nguyen
Section of Thoracic Surgery, Division of Cardiothoracic Surgery, University of Miami, Miami, Florida, USA
Enhanced recovery after surgery protocols (ERAS®) have become increasingly popular in the past few decades. Initially instituted by csolorectal and gynecologic surgery, these optimized "fast track" pathways have expanded across surgical sub-specialties. We discuss critical components of such pathways, the implementation process, and particular facets of perioperative care that apply to various surgical subspecialties including cardiac, colorectal, gynecologic, and thoracic surgery. The spirit of ERAS® emphasizes a continuous internal auditing process. ERAS® protocols are known for faster recovery, shorter length of stay, improved pain control, and optimization of a patient’s perioperative course by way of a standardized protocol. The unique aspects of enhanced recovery after thoracic surgery (ERATS) protocols are discussed. We focus on intercostal nerve blocks as an important component of ERATS pathways and optimized postoperative pain control. Intercostal nerve blocks in thoracic surgery allow for excellent postoperative pain control, which is critical for early ambulation, improved chest physiotherapy and easier progression through the post-operative course. This mini-review serves to highlight key features of ERAS®, salient aspects of niche surgical specialties, and focuses on thoracic surgery enhanced recovery protocols and intercostal nerve blocks in the context of ERATS for optimized postoperative pain control.View / Download Pdf
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Bernice Ofosu1, Dan Ofori2, Michael Ntumy1,3, Kwaku Asah-Opoku1,3, Theodore Boafor1,3*
1Department of Obstetrics & Gynaecology, Korle-Bu Teaching Hospital, Korle-Bu, Accra, Ghana
2University of Ghana Business School, Legon, Ghana
3University of Ghana Medical School, Korle-Bu, Accra, Ghana
Heather R. Walker1*, Heather Mueller1, Tyson Christensen1, Heidi Cozart1, Scott R. Junkins2
1University of Utah Health, Medical Group, Utah, USA
2University of Utah Health, Department of Anesthesiology, Utah, USA
Background: Following the publication of the Center for Diseases Control and Prevention Guidelines for Prescribing Opioids in Primary Care, providers and institutions alike have been modifying practices and policies for prescribing controlled substances (2016).
Study Setting:The University of Utah Health implemented a series of data-driven adaptive and innovative programs and initiatives to improve opioid prescribing across its connected hospital and ambulatory health centers.
Data Collection: Using data mined from the electronic heath record system, researchers have been developing a data-driven approach with a collaborative team spanning clinical and data analytics backgrounds.
Objective: This article discusses those collaborative initiatives and presents a discussion of mindfulness in prescribing practices.
Conclusion: The multi-tiered data-driven approach taken by the University of Utah collaborative team demonstrates a model of change that other health care systems can emulate.View / Download Pdf
Stacia B. Shipman*, Kelly A. Painter
Department of Emergency Medicine, INTEGRIS Southwest Medical Center, Oklahoma City, OK, USA
Corneal abrasions are known to be extremely painful and are a commonly seen eye condition. Topical anesthetic drops used for diagnosis of corneal abrasions provide immediate pain relief for most patients, but their use for outpatient use has been controversial. There is lack of consensus regarding ideal management of pain associated with corneal abrasions, with some physicians prescribing nonsteroidal anti-inflammatory drugs or opioids which both can have serious side-effects and/or abuse potential. In recent years, several studies have been conducted to assess the efficacy and safety of short term topical anesthetic use for the treatment of acute corneal abrasions. For this review, four published randomized controlled trials were identified that focused on the effectiveness and safety of various topical analgesics used in treating corneal abrasions. These showed varying degrees of efficacy depending on the outcomes measured without any significant difference in complication rates. Additionally, we reviewed an observational study that investigated whether routinely sending corneal abrasion patients home with a 24-hour supply of topical tetracaine is safe. They found no increased risk of ED revisits, fluorescein uptake at follow up, or ophthalmology clinic referrals. Larger prospective studies are still required to establish definitive safety, but the current available evidence suggests use of topical anesthetics for simple corneal abrasions is efficacious and safe.View / Download Pdf
Joanna R. O'Sullivan*, Nicola Crowley
Guys and St Thomas's NHS Foundation Trust, UK
The recent publication of a new framework for practice from the British Association of Perinatal Medicine has altered the management of babies born in the UK at the threshold of viability. A risk stratification is used to determine which infants will receive active management, and which receive palliative management. This is achieved through a combination of assessment of risk factors and discussion with parents. The most notable feature of the new framework is the recommendation to consider babies of 22 weeks gestation for active care. This has been the subject of much discussion amongst neonatal and obstetric teams. The framework also emphasises the importance of early transfer to a maternity unit with a co-located neonatal intensive care unit if active management is pursued. This new guidance has led to a change in the way the management of extreme prematurity is approached, and will continue to impact on neonatal, obstetric, and anaesthetic care.View / Download Pdf
Fariba Farrokhi1, Sneha Priyadarshini Honnabovi1, Marisa Pavone1, Kamal AL-Eryani2, Oussama Abousamra3, Reyes Enciso4*
1Advanced graduate, Master of Science Program in Orofacial Pain and Oral Medicine, Herman Ostrow School of Dentistry, University of Southern California, Los Angeles, CA, USA
2Assistant Professor of Clinical Dentistry, Division of Periodontology, Diagnostic Sciences & Dental Hygiene, Herman Ostrow School of Dentistry, University of Southern California, Los Angeles, CA, USA
3Assistant Professor of Clinical Orthopaedic Surgery, Children’s Hospital Los Angeles, University of Southern California, Los Angeles, CA, USA
4Associate Professor – Instructional, Division of Dental Public Health and Pediatric Dentistry, Herman Ostrow School of Dentistry, University of Southern California, Los Angeles, CA, USA
The authors conducted a systematic review and meta-analysis to determine if Core Decompression (CD) with Bone Marrow Stem Cells (BMSC) is more effective in treating Osteonecrosis of the Femoral Head (ONFH) compared to CD. Authors used Cochrane Library, EMBASE, PubMed, Web of Science, and hand-searched references through January 2020, identifying relevant randomized controlled trials (RCTs). Risk of bias was assessed with Cochrane's handbook. Fifty-four abstracts were screened, and eight RCTs (five at high and three at unclear risk of bias) with 432 patients were included. Meta-analyses found statistically significant improvement in Harris Hip Score (HHS) at 12 months (Difference in Means [DM]=10.065;95% Confidence Interval [CI]=4.509 to 15.622; p<0.001) and pain intensity at 24 months (DM=-7.364;95% CI=-12.113 to -2.615;p=0.002) in CD+BMSC group compared to CD alone although these results may not be clinically significant. Risk of Total Hip Replacement (THR) in patients receiving CD+BMSC was 33.4% lower than in CD group though not significant (RR=0.666; 95% CI=0.355 to 1.250;p=0.206). Though meta-analyses found the addition of BMSC to CD significantly improves clinical outcomes (HHS and pain intensity) compared to CD only, evidence was of moderate/low quality due to high risk of bias, imprecision, and small sample sizes. Further research is needed to confirm the results.View / Download Pdf
Kimberly Ting1, Albert Huh1, Carlos J. Roldan1,2*
1Department of Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
2McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, Texas, USA
Scope of the investigation: No standard protocol has been established for the treatment of myofascial pain syndrome (MPS). Invasive therapies such as dry needling and trigger point injection (TPI) with active pharmacological agents are commonly used. Growing evidence suggests the efficacy of TPI is independent of the injectate selected. Normal saline (NS) solution has been described as an efficient injectate used in TPI for the treatment of MPS.
Methods: A broad literature search was performed to compare the use of NS and other pharmacological agents as the injectate in TPI for the treatment of MPS.
Results: We identified 13 reports comparing the safety and efficacy of NS with that of botulinum toxin A or local anesthetic with or without steroid in TPI.
Conclusion: Pain of myofascial origin can be adequately treated with TPI independent of the injectate used. The use of NS in TPI offers lower cost, safety, and a more favorable side effect profile than other TPI injectates.View / Download Pdf
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The Prince Charles Hospital, Brisbane, James Cook University, Australia
Erick Gomez-Marroquin1, Yuka Abe1,2, Mariela Padilla1*, Reyes Enciso3, Glenn T. Clark1
1Orofacial Pain and Oral Medicine, Herman Ostrow School of Dentistry of University of Southern California, Los Angeles, California, USA
2Department of Prosthodontics, Showa University School of Dentistry, Tokyo, Japan. Visitor Scholar Herman Ostrow School of Dentistry, University of Southern California, Los Angeles, California, USA
3Division of Dental Public Health and Pediatric Dentistry, Herman Ostrow School of Dentistry of University of Southern California, Los Angeles, California, USA
Aim: To assess treatment efficacy in the management of orofacial myogenous conditions by a retrospective study of patients seen at an orofacial pain clinic.
Methods: A single researcher conducted a retrospective review of charts of patients assigned to the same provider, to identify those with myogenous disorders. The reviewed charts belonged to patients of the Orofacial Pain and Oral Medicine Center of the University of Southern California, seeing from June 2018 to October 2019.
Results: A total of 129 charts included a myogenous disorder; the most common primary myogenous disorder was localized myalgia (58 cases, 45.0%). Arthralgia was the most common TMD concomitant condition (82.9%), followed by internal derangement (41.9%). Forty-six patients were given a home-based conservative physical care protocol; ten additional cases also received trigger point injections (lidocaine or mepivacaine) with pain assessed by verbal numerical rating scale (NRS), pre- and post-treatment follow-up within 24 weeks. There was a significant overall pain improvement in NRS pain from pre- to post-treatment (p<0.001), though no difference was found between conservative treatment and trigger points in NRS pain (p=0.130). However, the rate of NRS unit improvement per week in the conservative treatment group was significantly greater than the trigger point group (p=0.036). These apparently contradictory results might be due to the small sample size of the trigger point injections group (n=10).
Conclusion: In this small sample size study, the addition of trigger point injections to conservative treatment provided inconclusive results, further studies are needed.View / Download Pdf
Jessi Humphreys*, Laura Schoenherr
Division of Palliative Medicine, Department of Medicine, University of California, San Francisco, USA
As the COVID-19 pandemic proceeds, systems continue to struggle with the need to decrease provider exposure and minimize personal protective equipment use while maintaining high quality patient care. The reduced visitation capacity in hospitals has resulted in high levels of patient and family suffering, and patients both with and without COVID-19 require expert symptom management and goals of care conversations. A manuscript was published describing the rapid implementation of telepalliative medicine consultation by the Inpatient Palliative Care team at UCSF in attempts to meet these critical patient and family needs. This piece details additional lessons learned that were inadequately addressed in the original manuscript and/or that have been revealed in the months since the program’s inception. Key learning points include the need for: committed investment in effective hardware and software; communication skills adapted to effectively utilize technology to benefit patients and families; creative workforce models to render technology effective; interdisciplinary input in care models to reduce provider as well as patient and family suffering; and attention to burdens placed on already overstretched nurses and intensivists during respiratory pandemics.View / Download Pdf
Joanne Szewczyk, Benjamin H Nguyen, Nestor Villamizar, Dao M. Nguyen*
Section of Thoracic Surgery, Department of Surgery, University of Miami, Miami, Florida, USA
In the last decade, the implementation of enhanced recovery protocol for patients undergoing thoracic surgical procedures, either by thoracotomy or thoracoscopy, has gained significant recognition. Such protocols have been developed following the enhanced recovery after surgery (ERAS) guiding principles, yet have been tailored with attention to the unique nuances of thoracic surgical patients. Over the last 5 years, a body of literature has been published attesting to the success of the enhanced recovery after thoracic surgery (ERATS) protocol, with reported improvements of measurable outcome metrics. This mini-review focuses on postoperative pain control using the innovative strategy of opioid-sparing multimodal analgesics of the ERATS care pathway.View / Download Pdf
Alex K. Saltzman1, Thuyvan H. Luu1, Nicole Brunetti1, James D. Beckman1,2, Mary J. Hargett1, Stephen C. Haskins1,2*
1Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, USA
2Department of Anesthesiology, Weill Cornell Medicine, New York, USA
Background and Objectives: Point-of-care ultrasound (POCUS) in the form of focused cardiac ultrasound (FOCUS) is a powerful clinical tool for anesthesiologists to supplement bedside evaluation and optimize cardiopulmonary resuscitation in the perioperative setting. However, few courses are available to train physicians. At Hospital for Special Surgery (HSS), from March of 2013 to May of 2016, nine basic Focused Assessed Transthoracic Echocardiography (FATE) training courses were held. A large percentage of the participants were practicing regional anesthesiologists or trainees in fellowship for regional anesthesia and acute pain. In this study, a survey was used to assess clinical utilization as well as potential barriers to use for regional anesthesiologists.
Methods: Following IRB approval, 183 past participants of the basic FATE training course were contacted weekly from November 22nd, 2016, through January 3rd, 2017, via email and sent a maximum 40-item electronic survey hosted on REDCap. Responses were analyzed by a blinded statistician.
Results: 92 participants responded (50%), and 65 of the 92 (70.7%) indicated they had regional anesthesiology training or practice regional anesthesia regularly. Of the total number of respondents, 50% (95% CI: 40.3%, 59.8%; P-value = 0.001) have used FOCUS to guide clinical decision making. Of the regional anesthesiologists, 27 (45.8%) have used FOCUS to guide clinical decision making with left ventricular function assessment (40.7%) and hypovolemia (39.0%) being the most common reasons. Regional anesthesiologists utilized FOCUS in the following settings: preoperatively (44.6%), intraoperatively (41.5%), postoperatively (41.5%), and in the Intensive Care Unit (40.0%). Limitations were due to lack of opportunities (52.3%), resources (36.9%), and comfort with performance (30.8%). 84.4% agreed that basic FOCUS training should be a required part of anesthesia residents or fellows’ curriculum.
Conclusions: This study is the first formal evaluation of the impact of the implementation of a FOCUS training course on regional anesthesiologists’ current practice. Nearly 50% of regional anesthesiologists used FOCUS to guide clinical decision-making following formal training. The limitations to the use of FOCUS were a lack of relevant opportunities and resources. This evaluation of clinical use following training provides insight into how FOCUS is used by regional anesthesiologists and the limitations to implementation in the perioperative setting.DOI: 10.29245/2768-5365/2020/2.1104 View / Download Pdf
Gerald E. Davis II1,2, George Sarandev1, Alexander T. Vaughan1, Kamal Al-Eryani3, Reyes Enciso4*
1Advanced graduate, Master of Science Program in Orofacial Pain and Oral Medicine, Herman Ostrow School of Dentistry of USC, Los Angeles, California, USA
2Assistant Dean of Academic Affairs, Assistant Professor, Restorative Dentistry, Meharry Medical College, School of Dentistry, Nashville, Tennessee, USA
3Assistant Professor of Clinical Dentistry, Division of Periodontology, Dental Hygiene & Diagnostic Sciences, Herman Ostrow School of Dentistry of USC, Los Angeles, California, USA
4Associate Professor (Instructional), Division of Dental Public Health and Pediatric Dentistry, Herman Ostrow School of Dentistry of USC, Los Angeles, California, USA
Background: Current treatments for pemphigus and Behcet's disease, such as corticosteroids, have long-term serious adverse effects.
Objective: The objective of this systematic review was to evaluate the efficacy of biologic agents (biopharmaceuticals manufactured via a biological source) on the treatment of intraoral lesions associated with pemphigus and Behcet's disease compared to glucocorticoids or placebo.
Methods: PubMed, Web of Science, Cochrane Library, and EMBASE were searched for randomized controlled studies up to January 2019. Bias was assessed with the risk of bias tool.
Results: Out of 740 references retrieved, only four randomized controlled trials (RCTs) were included, comprised of a total of 158 subjects (138 pemphigus and 20 Behcet's disease). All studies were assessed at high risk of bias. Heterogeneity of data prevented the authors from performing a meta-analysis. Infliximab or rituximab with short-term prednisone showed higher safety and lowered cumulative prednisone dose than prednisone alone in the treatment of pemphigus. Subcutaneous injection of etanercept provided 45% of patients free of ulcers compared to 5% in the placebo group in one study with Behcet's disease; however, no difference was found in pemphigus patients.
Conclusion: Though biological agents alone or in combination with prednisone showed favorable results in three RCTs compared to prednisone alone or placebo, a meta-analysis could not be undertaken due to high heterogeneity. Results are inconclusive, and larger, well-designed RCTs are needed.DOI: 10.29245/2768-5365/2020/1.1105 View / Download Pdf
Sedat Özbay1, Abuzer Coskun1*, Sevki Hakan Eren2
1Department of Emergency, Sivas Numune Hospital, Sivas, Turkey
2Department of Emergency Medicine, Gaziantep University, Gaziantep, Turkey
Objective: This study aimed to evaluate acute coronary syndrome (ACS), serum procalcitonin levels, Platelet/Mean Platelet Volume ratio (PMR) and Neutrophil/lymphocyte ratio (NLR) concerning post-myocardial infarction (MI) complications, mortality, and morbidity.
Material and Method: The study included a total of 913 patients with ACS who presented to the emergency department with chest pain between January 2013 and December 2017. The patients were categorized as ST-elevated MI (STEMI), non-ST elevated MI (NSTEMI) and unstable angina (UA) according to the diagnosis. The demographic and laboratory characteristics of the patients were compared for three-vessel disease (TVD) and mortality rates.
Result: Post MI complications, TVD, and mortality were significant among acute coronary syndrome groups. The three-vessel disease was mostly observed in anterior MI with a maximum rate of 58 (39.7%). Mortality was found as 23 (16.3%) in anterior MI and 18 (12.2%) in NSTEMI. Serum procalcitonin levels were highest in anterior MI. Platelet to Mean Platelet Volume ratio was higher in UA, whereas it was lower in STEMI and NSTEMI. Neutrophil to lymphocyte ratio was the lowest in UA. The cTn I values of STEMIs at 0, 6, 12 hours were higher than UA, and the 12th-hour cTnI values in anterior MI were higher than NSTEMIs. It was found that procalcitonin and NLR had a positive correlation with post-MI complications, mortality, and TVD, whereas PMR exhibited a negative correlation.
Conclusion: The levels of procalcitonin, PMR, and NLR may be significant in respect of post-complications, mortality, and morbidity in acute coronary syndrome.DOI: 10.29245/2768-5365/2020/1.1103 View / Download Pdf
Abuzer Coskun1*, Sevki Hakan Eren2
1Department of Emergency, Sivas Numune Hospital, Sivas, Turkey
2Department of Emergency Medicine, Gaziantep University, Gaziantep, Turkey
Pulmonary thromboembolism in which hemostatic balance is disrupted is a disease with high morbidity and mortality rates with challenging diagnosis. A 73-year-old female patient presented to the emergency department with respiratory distress. She had undergone surgery for femoral neck fracture three months ago. She had gradually aggravating respiratory distress for the last 3-4 days. The patient was admitted to the hospital with the diagnosis of massive pulmonary embolism. She had a cardiac arrest after completion of thoracic computed tomography (thoracic CT). Cardiopulmonary resuscitation (CPR) was initiated. Alteplase (rt-PA) was infused at 100 mg/2 hours starting at the 37th minute of CPR in the late phase. As there was no room on the wards, she was admitted to the emergency room observation unit and extubated on the 9th day. Coumadin (warfarin) dose was adjusted and the patient was discharged on day 17 with an INR (International Normalized Ratio) of 2.3.DOI: 10.29245/2768-5365/2020/1.1102 View / Download Pdf