Aortic dissection presenting with acute pulmonary edema

Background

Acute aortic dissection is a cardiovascular emergency with high mortality that necessitates prompt diagnosis and immediate treatment. Though asymmetric extremity pulses/blood pressures and mediastinal widening on chest roentgenogram are often clues to diagnosis, aortic regurgitation (AR) of variable degrees could be the only sign on initial assessment. Mostly resulting from dilated aortic ring with valvular insufficiency, the AR could be caused by different pathogenic mechanisms. Herein we report a case of Stanford type A aortic dissection presenting with acute pulmonary edema. Physical examination detected severe AR murmur and bedside echocardiogram confirmed prolapsed dissecting intima flap with interference of aortic valve closure as a specific mechanism.

Moderate brain hypothermia started before resuscitation improves survival and neurobehavioral outcomes after CA/CPR in mice

Aim of the studyNo definitive experimental or clinical evidence exists whether brain hypothermia before, rather than during or after, resuscitation can reduce hypoxic-ischemic brain injury following cardiac arrest/cardiopulmonary resuscitation (CA/CPR) and improve outcomes. We examined the effects of moderate brain hypothermia before resuscitation on survival and histopathological and neurobehavioral outcomes in a mouse model.MethodsAdult C57BL/6 male mice (age: 8–12 weeks) were subjected to 8-min CA followed by CPR. The animals were randomly divided into sham, normothermia (NT; brain temperature 37.5 °C), and extracranial hypothermia (HT; brain temperature 28–32 °C) groups. The hippocampal CA1 was assessed 7 day after resuscitation by histochemical staining. Neurobehavioral outcomes were evaluated by the Barnes maze (BMT), openfield (OFT), rotarod, and light/dark (LDT) tests. Cleaved caspase-3 and heat shock protein 60 (HSP70) levels were investigated by western blotting.ResultsThe HT group exhibited higher survival and lower CA1 neuronal injury than did the NT group. HT mice showed improved spatial memory in the BMT compared with NT mice. NT mice travelled a shorter distance in the OFT and tended to spend more time in the light compartment in the LDT than did sham and HT mice. The levels of cleaved caspase-3 and HSP70 were non-significantly higher in the NT than in the sham and HT groups.ConclusionsModerate brain hypothermia before resuscitation improved survival and reduced histological neuronal injury, spatial memory impairment, and anxiety-like behaviours after CA/CPR in mice.     

Diagnostic accuracy of the Extended Focused Abdominal Sonography for Trauma (E-FAST) performed by emergency physicians compared to CT

Introduction

The diagnostic accuracy of the FAST exam performed by EM residents were shown to be similar to radiology residents. However, in the last 2 decades, an extended-FAST (E-FAST) protocol including thoracic examination to exclude pneumo- and hemothorax was introduced. The accuracy of emergency physicians (EPs) while performing E-FAST is a less studied area, especially in Europe. The aim of this study was to compare the diagnostic accuracy of the E-FAST exam performed by EM residents with the results of CT scan as a gold standard.

The ratio of N-terminal pro-B-type natriuretic peptide to troponin I for differentiating acute coronary syndrome

IntroductionIt is difficult to differentiate whether coronary or non-coronary causes in patients with elevated troponin I (TnI) in emergency department (ED). The aim of this study was to develop a clinical decision tool for differentiating a coronary cause in the patients with elevated TnI.MethodsThis was a retrospective observational study that enrolled consecutive ED patients. Patients were included in the study if they were ≥16 years of age, had admitted through ED with a medical illness, and TnI levels at initial evaluation in the ED were ≥0.2 ng/mL. Patients diagnosed with ST elevation myocardial infarction or congestive heart failure were excluded. Coronary angiography, electrocardiogram, laboratory results, echocardiography, and clinical characteristics were analyzed.ResultsAmong the included 1441 patients, 603 and 838 patients were categorized into an acute coronary syndrome (ACS) group and non-acute coronary syndrome (non-ACS) group, respectively. The ratio of N-terminal pro-Btype natriuretic peptide (NT-proBNP) to TnI was significantly higher in the non-ACS group compared to the ACS group. The AUC of NT-proBNP/TnI (0.805, 95% CI, 0.784-0.826) was significantly superior to that of NT-proBNP/creatinine kinase-MB, TnI, and NT-proBNP. The patients of the non-ACS group with high levels of TnI and BNP showed more critically ill manifestation at the time of presentation and higher mortality.ConclusionNT-proBNP/TnI may help to distinguish medical patients with elevated TnI whether the elevated TnIs were caused from ACSs or from conditions other than ACS.     

Resuscitation quality of rotating chest compression providers at one-minute vs. two-minute intervals: A mannequin study

Objective

The aim of this randomized cross-over study was to compare one-minute and two-minute continuous chest compressions in terms of chest compression only CPR quality metrics on a mannequin model in the ED.

Osborn wave in hypothermia and relation to mortality

Background & aimThe aim of this study was to compare hypothermia patients with and without an Osborn wave (OW) in terms of physical examination findings, laboratory results, and clinical survival.MethodsThe study was carried out retrospectively on hypothermic patients. The hypothermic patients were divided into two groups. Group 1 comprised patients with OW on electrocardiogram (ECG), and Group 2 comprised patients without OW on ECG. The Mann–Whitney U test was used to compare the two groups, and the relationships between the variables and the presence of OW and mortality were analyzed with ANOVA. A value of p < 0.05 was considered statistically significant.ResultsOW was detected on ECG of 41.9% of the patients (Group 1). The mean body temperature was 30.8 ± 4.1 °C in Group 1 and 33.3 ± 1.6 °C in Group 2 (p = 0.106). The mean creatinine level was 1.01 ± 0.6 mg/dl in Group 1 and 0.73 ± 0.5 mg/dl in Group 2 (p = 0.046). The mean bicarbonate level was 15.9 ± 3.8 mmol/l in Group 1 and 18.6 ± 3.5 mmol/l in Group 2 (p = 0.038). A relationship was determined between the presence of OW and pH, bicarbonate, and creatinine levels (p = 0.026; 0.013; 0.042, respectively). The mortality rate was 69.2% in Group 1 and 77.8% in Group 2 (p = 0.689).ConclusionAlthough there is a relationship between the decrease in bicarbonate levels, changes in kidney functions that cause acidosis, and the presence of OW, it has no effect on mortality. The presence of OW in hypothermic patients is insufficient to make a decision regarding mortality.     

Low dose intramuscular methadone for acute mild to moderate opioid withdrawal syndrome

Study objective

To assess the efficacy of 10 mg intramuscular (IM) methadone in patients with opioid withdrawal syndrome (OWS).

The critical care literature 2017

An emergency physician (EP) is often the first health care provider to evaluate, resuscitate, and manage a critically ill patient. Between 2001 and 2009, the annual hours of critical care delivered in emergency departments (EDs) across the United States increased >200% [1]! This trend has persisted since then. In addition to seeing more critically ill patients, EPs are often tasked with providing critical care long beyond the initial resuscitation period. In fact, >33% of critically ill patients who are brought to an ED remain there for >6?h [1]. Longer ED boarding times for critically ill patients have been associated with a negative impact on inpatient morbidity and mortality [2]. During these crucial early hours of illness, detrimental pathophysiologic processes begin to take hold. It is during these early hours of illness where lives can be saved, or lost. Therefore, it is important for the EP to be knowledgeable about recent developments in critical care medicine. This review summarizes important articles published in 2017 pertaining to the resuscitation and care of select critically ill patients in the ED. We chose these articles based on our opinion of the importance of the study findings and their application to clinical care. The following topics are covered: sepsis, vasolidatory shock, cardiac arrest, post-cardiac arrest care, post-intubation sedation, and pulmonary embolism.     

Real-time tidal volume feedback guides optimal ventilation during simulated CPR

Purpose

We performed this study to investigate whether real-time tidal volume feedback increases optimal ventilation and decreases hyperventilation during manikin-simulated cardiopulmonary resuscitation (CPR).

Serum apoprotein A-I and A-II levels in liver diseases and cholestasis

Serum apoprotein A-I and A-II levels were determined by electroimmunoassay in patients with liver diseases and cholestasis. Significant decreases in apoprotein A-I and A-II levels were observed in such patients. The decreases were especially pronounced in the early phase of acute hepatitis and cholestasis. The decreases in A-II levels were more prominent than the decreases in A-I in severe hepatic dysfunction or cholestasis. Accordingly, the A-I/A-II ratio showed no change in the convalescent phase of acute hepatitis or chronic hepatitis but increased significantly in the early phase of acute hepatitis, cirrhosis of the liver, hepatoma, and cholestasis. The results suggested the existence of a high density lipoprotein with an abnormal apoprotein composition or a more profound decrease of HDL3 than of HDL2 in severe hepatocellular dysfunction of cholestasis.     

Successful resuscitation with extracorporeal membrane oxygenation support for refractory ventricular fibrillation caused by left main coronary artery occlusion

Refractory ventricular fibrillation with cardiac arrest caused by occlusion of the left main coronary artery may rapidly become fatal. In this report, we describe the case of a 70-year-old male who presented to emergency department with chest pain. Electrocardiogram showed ST-segment elevation in leads aVR and aVL and ST-segment depression in leads v3, v4, v5, v6, 2, 3, and aVF. Occlusion of the left main coronary artery was suspected. While waiting for percutaneous coronary intervention, the patient experienced sudden refractory ventricular fibrillation with cardiac arrest. In the emergency department, resuscitation of a patient with refractory ventricular fibrillation caused by occlusion of the left main coronary artery and ongoing cardiopulmonary resuscitation is a clinical challenge. Resuscitation with extracorporeal membrane oxygenation support was initiated approximately 35?min after prolonged conventional cardiopulmonary resuscitation. Emergency coronary angiography showed almost total occlusion of the left main coronary artery. Percutaneous coronary intervention with a stent restored coronary perfusion. The patient was discharged on day 6 without serious sequelae or neurological deficits.     

Serum beta2-microglobulin in controls and cancer patients.

Serum beta2-microglobulin levels have been measured in 210 cancer and control patients to assess the significance of this investigation in cancer patients. Subjects studied included patients with breast and gastrointestinal cancer, corresponding control patients in both categories, and healthy volunteers. The composition of these groups allowed an assessment of the relative importance of changes related to cancer, benign disease, age and sex. A significant rise in serum beta2-microglobulin levels with advancing age was demonstrated in the control subjects. Mean levels were also consistently higher in females than in males in each patient group. After statistical correction for these age and sex effects, mean values remained significantly higher in each of the various cancer groups than in their controls. Patients with more advanced breast cancer had higher levels than those with 'early' disease, as did patients with stomach cancer compared to those with colo-rectal cancer. One possible interpretation is that levels increase with increasing tumour bulk, and therefore the estimation of serum beta2-microglobulin may be useful as one of a battery of tests in the management of cancer patients.