A 50-year-old Asian male presented to the emergency department with sudden onset of bilateral lower limb weakness preceded by lower back pain, which developed after lifting a moderately heavyweight. As the pain increased in intensity, the patient was transferred by ambulance to the emergency department, and en-route lost complete motor (0/5 power and absent reflexes) and sensory control over his lower limbs. The patient's medical history was significant for diabetes mellitus, hypertension, chronic kidney disease, and coronary artery disease with percutaneous coronary intervention in 2018 and 2019. He was taking dual antiplatelets (aspirin and clopidogrel) along with other medications. Magnetic resonance imaging (MRI) showed findings suggestive of acute and extensive extradural hematoma extending from the foramen magnum to the level of the fifth lumbar vertebra (L5), exerting severe mass effect on the cord with evidence of edema, most severe at the level from 7th to 10th dorsal vertebrae (D7-D10) vertebral level. The clinical features and the radiological findings confirmed the diagnosis of acute cauda equina syndrome. This review is intended to promote awareness about a possible clinical correlation between the use of dual antiplatelet therapy as a risk factor of spinal hematomas and the cauda equina syndrome.

Procedural sedation is essential in the ED to conduct painful procedures effectively. Ketamine and benzodiazepines/opioids are commonly used, with ketamine providing adequate analgesia and preserving airway muscle tone. However, ketamine is associated with adverse effects while benzodiazepines/opioids can lead to respiratory depression. This study compares the safety and efficacy of ketamine and midazolam/fentanyl. Two search methods were used to identify studies related to our topic, including a database search and a manual search involving screening reference lists of articles retrieved by the database search. A methodological quality appraisal was conducted on the articles suitable for inclusion using Cochrane's risk of bias tool in the Review Manager software (Review Manager (RevMan) (Computer program). Version 5.4, The Cochrane Collaboration, 2020). Moreover, pooled analysis was performed using the Review manager software.The study analyzed 1366 articles, of which seven were included for analysis. Pooled data showed that ketamine and midazolam/fentanyl had similar effects on pain scores during procedures and sedation depth measured by the University of Michigan sedation scale. However, the Modified Ramsay Sedation Score showed significantly more profound sedation in the ketamine group. The only significant adverse events were vomiting and nausea, which had a higher incidence in the ketamine group.Our data suggest that ketamine is as effective as the midazolam/fentanyl combination for procedural sedation but is associated with higher incidences of adverse events. Therefore, midazolam/fentanyl can be recommended for procedural sedation in the ED. However, it should be provided in the presence of a physician comfortable with airway management due to high incidences of oxygen desaturation.

COVID-19 vaccines were safe and efficacious in clinical trials. A two-dose regimen of the Pfizer-BioNTech COVID-19 vaccine confers no less than 95% protection against COVID-19 with an adequate safety profile. To date, no reports have been made in the literature regarding the onset of acute viral pericarditis after vaccination with the Pfizer BNT162b2 vaccine. But on the other hand, pericarditis is reported to occur in rare instances of COVID-19 infection, and this may be attributed to the pro-inflammatory effects of the spike protein. In this article, we describe the case of an elderly male patient with a known case of hypothyroidism who presented to our emergency department with fever, chills, and dry cough for ten days after the third dose of the Pfizer-BioNTech COVID-19 vaccine. Although we cannot mention a direct effect, it is essential to note a potential adverse reaction to vaccine administration following the expression of SARS-CoV-2 spike protein-induced from the vaccine’s mRNA.