Rare Thrombotic Complications of COVID-19: A Case Series.

Coronavirus disease 2019 (COVID-19) is known to manifest with bilateral pneumonia and acute respiratory distress syndrome. This infection with severe acute respiratory syndrome coronavirus 2 (SAR-CoV-2) is alarming because it not only affects the respiratory system but may also cause thromboembolic events. Multiple studies have reported procoagulation/hypercoagulable complications in COVID-19. This case series is a valuable addition to the literature because it reflects unique presentations of thrombotic events in COVID-19 patients. We report two cases in which patients presented with thromboembolic complications secondary to COVID-19 infection: one with severe bowel ischemia and the other with blue toe syndrome. To formulate management strategies to prevent fatal outcomes for patients with COVID-19, physicians must be vigilant in identifying life-threatening thromboembolic complications from this disease.

Critical Care Management of a Severe Acute Respiratory Distress Syndrome COVID-19 Patient With Control Cesarean Section.

We share our experience of one 29-year-old female, G2 P1, with acute respiratory distress syndrome (ARDS) and at 30 weeks of pregnancy. The 30-week gravid uterus in combination with a poor ventilation-perfusion ratio creates a restrictive lung pattern that may prove to be lethal for both the mother and baby. Due to her rapid deterioration and increased hemodynamic instability we opted for controlled delivery in the operating room with an ICU physician, a Neonatologist, and an Obstetric team. At 3.27 minutes from induction, the baby was born with Apgar scores of 7 and 8. The mother was placed on a RotoProne® bed, treated with remdesivir, steroids, and was subsequently extubated seven days later. The newborn was admitted to the Neonatal Intensive Care Unit (NICU) after delivery. We have reviewed the literature and provided a concise set of recommendations based on our field experience and current world literature review. Prompt delivery in a controlled environment with multiple resuscitating teams provided expeditious treatment of both patients, maintaining oxygenation and perfusion while keeping hemodynamic stability. The controlled environment and the proximity of all teams avoided deleterious consequences to the unborn baby. This is an example where the risk of keeping the baby in the womb outweighs the premature delivery into a NICU. Both mother and baby were downgraded from their respective Intensive Care Units (ICUs) and discharged home in one month.

Hypercalcemia As the Sole Initial Presentation of Precursor B-cell Acute Lymphoblastic Leukemia.

A 24-year-old female presented with nausea, vomiting and abdominal pain. Physical examination was unremarkable. The patient's laboratory studies showed calcium of 17.2 mg/d, white cell count: 9,000/mcL with a normal peripheral blood smear. The patient had low PTH and PTHrp. She was hydrated, given calcitonin of four units/kg every 12 hours subcutaneously for 24 hours and zoledronate IV 4mg given once, with which calcium levels normalized and symptoms resolved. The patient returned one week later, with bone pain and bruises. Platelet count: 51,000/mcL, WBC count: 9,000/mcL, with lymphocytosis. A peripheral smear showed lymphoblasts. Flow cytometry confirmed precursor B-cell acute lymphoblastic leukemia (ALL) with 43% blasts. Hypercalcemic patients may have blasts at presentation, but can be "aleukemic." Unexplained hypercalcemia with bone pain should lead to the suspicion of ALL, and a bone marrow exam should be performed even without peripheral blastosis to diagnose and treat ALL immediately.

Will Automated Compressing Devices Save More Lives in Recalcitrant Ventricular Fibrillation Cardiac Arrest?

We present a 55-year-old male that developed ventricular fibrillation cardiac arrest in the setting of ST-elevation acute myocardial infarction with recalcitrant and persistent ventricular fibrillation arrest that was successfully resuscitated with a good neurological outcome. The persistent chest compressions were performed in our intensive care unit with an automated chest compression system. The patient required defibrillations and nonstop chest compressions which were the key factors for his survival. This is an example we should consider in all our intensive care units. It's time for a paradigm shift in replacing the compressor of a code team with an automated system. The out-of-hospital evidence in acute care is compelling to bring this technology that has been proven crucial in transports from hospital areas, ambulances, helicopters, and ships to the inpatient ICU bedside. In ventricular tachycardia and ventricular fibrillation (Vt/Vf), the electrical storm created is the perfect example of the need to have the best compressions to provide the best care possible with the best survival and neurological outcomes.