Anticoagulation carries a tremendous therapeutic advantage in reducing morbidity and mortality with venous thromboembolism and atrial fibrillation. For over six decades, traditional anticoagulants like low molecular weight heparin and vitamin K antagonists like warfarin have been used to achieve therapeutic anticoagulation. In the past decade, multiple new direct oral anticoagulants have emerged and been approved for clinical use. Since their introduction, direct oral anticoagulants have changed the landscape of anticoagulants. With increasing indications and use in various patients, they have become the mainstay of treatment in venous thromboembolic diseases. The safety profile of direct oral anticoagulants is better or at least similar to warfarin, but several recent reports are focusing on spontaneous hemorrhages with direct oral anticoagulants. This narrative review aims to summarize the incidence of spontaneous hemorrhage in patients treated with direct oral anticoagulants and also offers practical management strategies for clinicians when patients receiving direct oral anticoagulants present with bleeding complications.

Enterovirus-human-rhinovirus (EV-HRV) are small RNA viruses that are airborne and can spread by direct contact or fomites and usually cause the common cold, asthma and chronic obstructive pulmonary disease exacerbation. EV-HRV-associated acute respiratory distress syndrome (ARDS) is common in children but is a rare cause of ARDS in adults. ARDS is defined according to the Berlin criteria and can be mild, moderate or severe depending on the PaO_² to FiO₂ ratio. We report a case of a 70-year-old female with cardiac comorbidities, emphysema, second-hand smoking of 25 years, on methotrexate for rheumatoid arthritis presenting with ARDS secondary to EV-HRV infection. Despite initial treatment with appropriate antibiotics, steroids, low tidal volume mechanical ventilation, rescue maneuvers such as ventilation in prone positioning, paralyses, and inhaled nitric oxide, she passed away. EV-HRV causes upper respiratory tract infections but causes cytokine releases such as IL-1, IL-6, and IL-8 in the lower respiratory tract and in the blood which can cause ARDS. Very few cases of EV-HRV ARDS in immunocompetent adults are reported in the literature. Female sex is also associated with EV-HRV ARDS. No antiviral therapy exists for patients critically ill with EV-HRV; however, one case of successful treatment with high-dose intravenous vitamin C (HIVC) is reported in the literature. EV-HRV is one of the most common viruses identified in patients admitted with viral pneumonia in the intensive care unit. It should not be forgotten as a cause of ARDS.

Foreign body (FB) aspiration can present with acute life-threatening asphyxiation to recurrent infections with lung damage. Although most esophageal FBs pass spontaneously, sharp ones can get embedded requiring treatment. Tracheobronchial FBs and hypopharyngeal FBs are occasionally seen as well. We present a case of an oropharyngeal FB presenting with signs of stroke, pulmonary embolism, pulseless, and causing airway compression and extubation failure. Old age and neurocognitive disability are important predisposing factors of FB airway obstruction (FBAO), with food being the most common cause. The classic triad of cough, dyspnea, and cyanosis is seen in only a small percentage of patients with FBAO. Laryngeal edema, soft tissue collapse, and laryngospasm are among the common causes of upper airway obstruction and extubation failure. Laryngeal traumatism that can occur during emergency intubations can cause post-extubation stridor that can be treated with corticosteroids. Dentures and blood have been reported to cause post-extubation complications but oropharyngeal FB causing airway compression and leading to extubation failure has not been reported before. We recommend FB to be considered in the differential diagnosis of immediate hypoxia and extubation failure regardless of the history of a witnessed aspiration event as it is an easily fixable cause and can be missed in the initial history of presentation. A high degree of suspicion for this should be maintained as it is easy to miss. Computed tomography of the neck can aid in the diagnosis.