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Back Pain on Eliquis

 

Scroll to bottom for case answer and EMeducation. 

History: A 72-year-old female with multiple medical problems including paroxysmal atrial fibrillation for which she takes Eliquis presents to the ED with low back pain that started tonight and is worse when she moves. She denies any symptoms in her legs, abdominal pain, vomiting, chest pain, shortness of breath or other complaints. She has never had this pain in the past.

Exam: Vital signs are normal.  She is in mild to moderate distress and grimaces when she has to sit up or move in bed. Abdomen is benign, but she does have bilateral CVA tenderness as well as spinal percussion tenderness in the upper lumbar and lower thoracic area. The rest of the exam is normal

Initial Concern(s): Spinal epidural hematoma from Eliquis, compression fracture, or both

Testing: An MRI of the spine is done to assess for spinal hematoma.  See image below

Question(s): What does the IMAGE show?  What should you do next?

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ANSWER: The spine looks fine, but next to it is a dissected aorta (false lumen filled with clot (white), true lumen with flowing blood (black).  Call a surgeon!

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E-meducation page-shot on AORTIC DISSECTION from the Emergency Medicine 1-minute Consult Pocketbook

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CASE CONCLUSION: The patient remained stable so the surgeon waited for the Eliquis to wear off prior to going to the OR.  An esmolol drip was started and maintained.

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