Intra-Cardiac Arrest Use of Stellate Ganglion Block for Refractory Ventricular Tachycardia.

BACKGROUND: Refractory ventricular dysrhythmia, or electrical storm, is a cardiac condition consisting of three or more episodes of ventricular dysrhythmia resistant to treatment within a 24-hour period. These dysrhythmias carry high morbidity and mortality if not diagnosed and abated promptly. When traditional resuscitative algorithms fail to return a patient to a perfusing rhythm, providers need to consider other, more novel techniques to terminate these dangerous dysrhythmias. One approach is the use of a stellate ganglion block, which has been documented in the literature only a handful of times for its resuscitative use in cardiac arrest. CASE SERIES: This case series details two cases from an urban emergency department (ED) in a large metropolitan city, where the use of ultrasound-guided stellate ganglion blocks during cardiac arrest provided successful ablation of the tachydysrhythmia. The first case involves a patient who went into cardiac arrest while in the ED and was found to be in refractory pulseless ventricular tachycardiawhile. The second case describes a patient who went into a witnessed out-of-hospital cardiac arrest while with emergency medical services. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The stellate ganglion block is a procedure currently being used as a treatment modality for a variety of neurologic, psychological, and cardiac conditions. This intervention may provide a viable and lifesaving option for emergency physicians to adopt when traditional resuscitative algorithms fail to break resistant ventricular tachydysrhythmias.

Prevalence of Bacteremia in Febrile Patients With Sickle Cell Disease: Meta-Analysis of Observational Studies.

OBJECTIVE: Pneumococcal vaccination has decreased the bacteremia rate in both the general pediatric and sickle cell disease (SCD) populations. Despite this decrease, and an increasing concern for antibiotic resistance, it remains standard practice to obtain blood cultures and administer antibiotics in all febrile (>38.5°C) patients with SCD. We conducted a systematic review and meta-analysis of the available studies of the prevalence of bacteremia in febrile patients with SCD. METHODS: We searched the medical literature up to November 2018 in PUBMED, EMBASE, and Web of Science with terms epidemiology, prevalence, bacteremia, and sickle cell anemia. We only included studies with patients after 2000, when the pneumococcal 7-valent conjugate (PCV7) vaccine became widely available. The prevalence of bacteremia [95% confidence interval (CI)] was calculated by dividing the number of positive blood cultures by the number of febrile episodes. The I2 statistic measured heterogeneity between prevalence estimates. Bias in our studies was quantified by the Newcastle-Ottawa Quality Assessment Scale. RESULTS: Our search identified 228 citations with 10 studies meeting our inclusion/exclusion criteria. The weighted prevalence of bacteremia across all studies was 1.9% (95% CI, 1.22%-2.73%), and for Streptococcus pneumoniae bacteremia, it was 0.31% (95% CI, 0.16%-0.50%). Risks for bacteremia except central lines could not be determined because of the low prevalence of the outcome. CONCLUSIONS: There appears to be a need to develop a risk stratification strategy to guide physicians to manage febrile patients with SCD based on factors including, but not limited to, history and clinical examination, vaccination status, use of prophylactic antibiotics, laboratory values, likely source of infection, and accessibility to health care.

Flank pain and hematuria is not always a kidney stone.

BACKGROUND: Patients with flank pain and hematuria are common emergency department presentations of nephrolithiasis. We may anchor on this etiology and potentially miss other less common differentials. We present a case of a patient with hematuria and flank pain typical of nephrolithiasis who was diagnosed with a Page kidney causing secondary hypertension. A 50 year-old male with no significant past medical history presented to the Emergency Department with severe left-sided flank pain, vomiting, and blood-tinged urine. We pursued a diagnosis of nephrolithiasis and found a left renal subcapsular hematoma on non-contrast CT. A CTA was done with no active hemorrhage found. The patient had no history of recent trauma and was found to be hypertensive on evaluation. Urology was consulted and management for the patient's hypertension was initiated. He was diagnosed with Page Kidney and admitted to medicine for observation and hypertension management with an angiotensin-converting enzyme inhibitor. Page Kidney is a diagnosis that describes compression of the renal parenchyma by a hematoma or mass causing secondary hypertension through the activation of the renin-angiotensin-aldosterone system. Causes may include traumatic subcapsular hematoma, renal cyst rupture, tumor, hemorrhage, arteriovenous malformation, among others. Treatment may involve conservative measures including hypertension management, or more invasive measures like evacuation or nephrectomy. We describe the case of a patient presumed to have nephrolithiasis presenting with typical left-sided flank pain, diagnosed with Page kidney, and treated conservatively.