A 44-Year-Old Woman with Dyspnea and Hemoptysis in the Setting of Remote Bariatric Surgery

CASE PRESENTATION

A 44-year-old woman was transferred to the ED from an outside hospital because of hemoptysis and concern for left-sided pulmonary infiltrate with associated pleural effusion. The patient presented to this outside hospital multiple times over the past 3 months because of left-sided shoulder pain, diffuse myalgias, and supraventricular tachycardia. On her third visit, she was found to have a left-sided pleural effusion and underwent diagnostic and therapeutic thoracentesis; 1.5 L of fluid was removed. Fluid studies reportedly demonstrated an exudative pleural effusion with negative bacterial cultures and no evidence of neoplastic process. The patient was referred to the Rheumatology Department by the outside hospital for suspected underlying autoimmune process. In the months leading up to her current presentation, the patient had been prescribed one prednisone burst and two prednisone tapers. She was then placed on a regimen of 10 mg prednisone daily and 200 mg hydroxychloroquine bid by her primary care doctor. This was tapered by the Rheumatology Department such that the patient was on 7.5 mg of prednisone daily on arrival to this ED. Rheumatologic workup until this point revealed only low titer (1:80) positive antinuclear antibody. Prior to these ED visits, the patient had been otherwise healthy with only a history of a Roux-en-Y gastric bypass 17 years earlier. Aside from recent daily low-dose prednisone use, the patient did not have other preexisting immune compromise or risk factors for aspiration such as seizure disorder, chronic alcohol use, or cognitive impairment. Before her transfer, the patient experienced foul-smelling, maroon-colored hemoptysis as well as anemia that required a higher level of care. On arrival to the ED, she was in acute hypoxic respiratory failure. The patient was intubated emergently and was admitted to the medical critical care unit for further treatment.

Descriptive Analysis of Extubations Performed in an Emergency Department-based Intensive Care Unit

Introduction

Extubation of appropriate patients in the emergency department (ED) may be a strategy to avoid preventable or short-stay intensive care unit (ICU) admissions, and could allow for increased ventilator and ICU bed availability when demand outweighs supply. Extubation is infrequently performed in the ED, and a paucity of outcome data exists. Our objective was to descriptively analyze characteristics and outcomes of patients extubated in an ED-ICU setting.

Methods

We conducted a retrospective observational study at an academic medical center in the United States. Adult ED patients extubated in the ED-ICU from 2015–2019 were retrospectively included and analyzed.

Results

We identified 202 patients extubated in the ED-ICU; 42% were female and median age was 60.86 years. Locations of endotracheal intubation included the ED (68.3%), outside hospital ED (23.8%), and emergency medical services/prehospital (7.9%). Intubations were performed for airway protection (30.2%), esophagogastroduodenoscopy (27.7%), intoxication/ingestion (17.3%), respiratory failure (13.9%), seizure (7.4%), and other (3.5%). The median interval from ED arrival to extubation was 9.0 hours (interquartile range 6.2–13.6). One patient (0.5%) required unplanned re-intubation within 24 hours of extubation. The attending emergency physician (EP) at the time of extubation was not critical care fellowship trained in the majority (55.9%) of cases. Sixty patients (29.7%) were extubated compassionately; 80% of these died in the ED-ICU, 18.3% were admitted to medical-surgical units, and 1.7% were admitted to intensive care. Of the remaining patients extubated in the ED-ICU (n = 142, 70.3%), zero died in the ED-ICU, 61.3% were admitted to medical-surgical units, 9.9% were admitted to intensive care, and 28.2% were discharged home from the ED-ICU.

Conclusion

Select ED patients were safely extubated in an ED-ICU by EPs. Only 7.4% required ICU admission, whereas if ED extubation had not been pursued most or all patients would have required ICU admission. Extubation by EPs of appropriately screened patients may help decrease ICU utilization, including when demand for ventilators or ICU beds is greater than supply. Future research is needed to prospectively study patients appropriate for ED extubation.

Epinephrine Administered for Anaphylaxis Unmasking a Type 1 Brugada Pattern on Electrocardiogram

BACKGROUND

Brugada pattern on electrocardiography (ECG) can manifest as type 1 (coved pattern) and type 2 (saddleback pattern). Brugada syndrome represents an ECG with Brugada pattern in a patient with symptoms or clinical factors, including syncope, cardiac arrest, ventricular dysrhythmias, and family history. Brugada syndrome is caused by a genetic channelopathy, but the Brugada pattern may be drug-induced. Epinephrine-induced Brugada pattern has not been reported previously.

CASE REPORT

A 63-year-old man developed anaphylaxis secondary to a bee sting, had a transient loss of consciousness, and self-administered intramuscular epinephrine. He subsequently presented to the emergency department and was found to have a type 1 Brugada pattern on ECG that resolved during observation. A historic ECG was reviewed that demonstrated a baseline type 2 Brugada pattern. His anaphylaxis was managed with steroids and antihistamines. He was observed without subsequent dysrhythmic events on telemetry or any further symptoms. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The differential diagnosis for syncope includes dysrhythmia, such as Brugada syndrome. Among other possible drugs, epinephrine may induce a type 1 Brugada pattern. Patients with Brugada pattern on ECG should be referred immediately to electrophysiology for consideration of implantation of a cardioverter-defibrillator device, given the association of Brugada pattern with sudden cardiac arrest and ventricular dysrhythmias.

Shutting down operating theater ventilation when the theater is not in use: infection control and environmental aspects

OBJECTIVE

In hospital operating rooms (ORs), specially conditioned air is supplied to protect patients from airborne agents that may cause infections. This study investigated whether it is hygienically safe to shut down the air supply at night if measures are taken to ensure a timely restart before surgery is performed.

DESIGN

Experimental study.

SETTING

Neurosurgical OR of a German university hospital.

METHODS

The ventilation system was switched off and restarted after 10 hours. Particles suspended in the air near the operating table were counted, OR temperature was measured, and settle plates were exposed and incubated.

RESULTS

In 13 investigations, a median of 1.3 x 10(4) particles 0.5 microm/m3 or greater (range, 5.8 x 10(3) to 1.1 x 10(5)) were documented immediately after restart in the morning. After 10 minutes and subsequently, no test showed a particle count exceeding the threshold limit of 1.0 x 10(4) particles 0.5 microm/m3 or greater recommended by the German Society of Hygiene and Microbiology. Only a few colony-forming units (CFU) were detected per settle plate (median, 0 CFU/60 cm2; range, 0 to 8) and OR temperatures quickly reached normal levels.

CONCLUSIONS

Shutting down OR ventilation during off-duty periods does not appear to result in an unacceptably high particle count or microbial contamination of the OR air shortly after the system is restarted. Because substantial energy and cost savings are likely, this should be considered in hygienically safe heating, ventilation, and air conditioning systems. However, normal ventilation should be established at least 30 minutes before surgical activity.

[A Calcutript-Lithoclast comparison: electrohydraulic lithotripsy versus acoustic pressure wave lithotripsy. An in vitro study on chalk cubes]

Intracorporeal lithotripters are available in nearly all urological institutions. The authors compared the CALCUTRIPT made by K. Storz Co. and the Swiss LITHOCLAST in in vitro studies. No major difference in the efficacy of disintegration was observed after subjecting chalk cubes to the two modalities. Human tissue of the renal pelvis, ureter and bladder was exposed to both energy-sources. In the case of the electrohydraulic shock wave the authors found complete rupture of all three layers of the ureteric wall after exposure even with low energy, while tissue perforation was observed in only one of 72 tissue samples exposed to the LITHOCLAST. The authors recommend the LITHOCLAST because of its minimal invasiveness for the treatment of calculi especially in the ureter.

[Urethroplasty using a free dermo-epidermal of preputial mesh graft: Meshgraft urethroplasty]

Long urethral strictures raise serious problems in terms of appropriate treatment. Reconstruction techniques using scrotal skin have a high recurrence rate. In order to avoid complications, a dermoepidermal or preputial Meshgraft was used to reconstruct a new urethra in two stages. In the first stage, the graft was raised and transplanted onto the open urethra. 8 to 12 weeks later, in the second stage, the new urethra is closed. Since 1977, Meshgraft urethroplasty has been performed in 128 patients, using the skin of the foreskin (n = 75) or medial surface of the thigh (n = 53). A good anatomical and functional result was obtained in all but three cases, regardless of the graft donor site. This operative technique constitutes a very effective method for the lasting treatment of long or complicated urethral strictures, for example in patients with spinal cord injuries.

[Wall-stent for treatment of bulbar urethral stricture and DSD in spastic bladder]

Since may 1989 a urethral Wallstent has been used for the treatment of short urethral strictures and for DSD in paraplegic patients with reflex bladder activity. Forty-nine patients have now been followed-up, which exceeds the 6-month margin. Out of these, 25 suffered from a short stricture of the bulbous urethra and 24 had spastic bladders with severe DSD. Eighteen of the 25 patients with strictures had previous unsuccessful direct vision urethrotomies; 17 in the DSD group had undergone failed sphincterotomies. In all but 2 cases the infravesical obstruction could be treated effectively solely by stent implantation. The results obtained equal those of a well-performed end-to-end anastomosis of the bulbous urethra or a 12, o'clock sphincterotomy.

[Is down-staging of advanced bladder cancer by neoadjuvant chemotherapy possible?--MVEC protocol]

In 22 patients with advanced transitional cell carcinoma of the bladder, neoadjuvant chemotherapy according to the MVEC regimen was given. Subsequent radical cystectomy showed down-staging in 7 patients (32%). The preoperative clinical staging revealed regression of the bladder cancer in 77% of all cases. Down-grading was seen in only 2 patients. Because of the discrepancy between preoperative clinical staging and the histopathological staging after radical cystectomy, invasive tumour surgery is necessary even when clinical staging has not revealed a tumour after chemotherapy.