Development of a multisystem point of care ultrasound skills assessment checklist.

BACKGROUND: Many institutions are training clinicians in point-of-care ultrasound (POCUS), but few POCUS skills checklists have been developed and validated. We developed a consensus-based multispecialty POCUS skills checklist with anchoring references for basic cardiac, lung, abdominal, and vascular ultrasound, and peripheral intravenous line (PIV) insertion. METHODS: A POCUS expert panel of 14 physicians specializing in emergency, critical care, and internal/hospital medicine participated in a modified-Delphi approach to develop a basic POCUS skills checklist by group consensus. Three rounds of voting were conducted, and consensus was defined by ≥ 80% agreement. Items achieving < 80% consensus were discussed and considered for up to two additional rounds of voting. RESULTS: Thirteen POCUS experts (93%) completed all three rounds of voting. Cardiac, lung, abdominal, and vascular ultrasound checklists included probe location and control, basic machine setup, image quality and optimization, and identification of anatomical structures. PIV insertion included additional items for needle tip tracking. During the first round of voting, 136 (82%) items achieved consensus, and after revision and revoting, an additional 21 items achieved consensus. A total of 153 (92%) items were included in the final checklist. CONCLUSIONS: We have developed a consensus-based, multispecialty POCUS checklist to evaluate skills in image acquisition and anatomy identification for basic cardiac, lung, abdominal, and vascular ultrasound, and PIV insertion.

Pseudohypoxemia From Leukocyte Larceny in a Patient With Chronic Myelogenous Leukemia.

Arterial blood gas (ABG) analysis is a generally reliable and frequently employed test for evaluating blood oxygen content. False readings of low oxygen content are rare but can be expected in specific clinical scenarios such as leukemia patients with marked leukocytosis who can develop "leukocyte larceny," a phenomenon of excess oxygen consumption by leukocytes. Awareness of this phenomenon may lead to early recognition and avoidance of unnecessary diagnostic and therapeutic interventions. This case report presents a patient with marked leukocytosis from chronic myelogenous leukemia whose extubation was briefly delayed due to pseudohypoxemia on ABG measurements.

Awakening from post anoxic coma with burst suppression with identical bursts.

BACKGROUND: Electroencephalography (EEG) is commonly used after cardiac arrest. Burst suppression with identical bursts (BSIB) has been reported as a perfectly specific predictor of poor outcome but published case series are small. We describe two patients with BSIB who awakened from coma after cardiac arrest. METHODS: We identified two out-of-hospital cardiac arrest (OHCA) patients with coma and BSIB. We determined the etiology of arrest, presenting neurological examination, potential confounders to neurological assessment, neurodiagnostics and time to awakening. We reviewed and interpreted EEGs using 2021 American Clinical Neurophysiology Society guidelines. We quantified identicality of bursts by calculating pairwise correlation coefficients between the first 500 ms of each aligned burst. RESULTS: In case one we present a 62-year-old man with OHCA secondary to septic shock. EEG showed burst suppression pattern, with bursts consisted of high amplitude generalized spike waves in lock-step with myoclonus (inter-burst correlation = 0.86). He followed commands 3 days after arrest, when repeat EEG showed a continuous, variable and reactive background without epileptiform activity. Case two was a 49-year-old woman with OHCA secondary to polysubstance overdose. Initial EEG revealed burst suppression with high amplitude generalized polyspike-wave bursts with associated myoclonus. She followed commands on post-arrest day 4, when repeat EEG showed a continuous, variable and reactive background with frequent runs of bifrontal predominant sharply contoured rhythmic delta activity. CONCLUSION: These cases highlight the perils of prognosticating with a single modality in comatose cardiac arrest patients.

Damage control resuscitation.

The United States Navy originally utilized the concept of damage control to describe the process of prioritizing the critical repairs needed to return a ship safely to shore during a maritime emergency. To pursue a completed repair would detract from the goal of saving the ship. This concept of damage control management in crisis is well suited to the care of the critically ill trauma patient, and has evolved into the standard of care. Damage control resuscitation is not one technique, but, rather, a group of strategies which address the lethal triad of coagulopathy, acidosis, and hypothermia. In this article, we describe this approach to trauma resuscitation and the supporting evidence base.

Exertional Rhabdomyolysis in a Long-Distance Migrant.

BACKGROUND: Exertional rhabdomyolysis is a common condition with potentially life-threatening consequences; early recognition can prevent severe downstream complications. Some migrants and undocumented immigrants who have travelled to the United States have encountered extreme heat or other austere conditions during their journey, many of which have involved long stretches of travel on foot. These factors can combine to put these migrants at risk for rhabdomyolysis. Hospitals near the border of Mexico and the United States commonly encounter patients with adverse medical complications related to the process of border crossing. CASE REPORT: We report a patient with exertional rhabdomyolysis complicated by acute kidney injury who presented to a hospital located thousands of miles from the United States-Mexico border. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Undocumented immigrants frequently disperse to disparate metropolitan areas after crossing the border, and therefore medical providers should remain vigilant for the medical complications of this dangerous journey.

Acetonitrile shortage: use of isopropanol as an alternative elution system for ultra/high performance liquid chromatography.

Acetonitrile is a choice of solvent for almost all chromatographic separations. In recent years, researchers around the globe have faced an acetonitrile shortage that affected routine analytical operations. Researchers have tried to counter this shortage by applying many innovative solutions, including using ultra performance liquid chromatography (UPLC) columns that are shorter and smaller in diameter than traditional high performance liquid chromatography (HPLC) columns, thus significantly decreasing the volume of eluent required. Although utilizing UPLC in place of HPLC can alleviate the solvent demand to some extent, acetonitrile is generally thought of as the solvent of choice due to its versatility. In the following communication, we describe an alternative eluent system that uses isopropanol in place of acetonitrile as an organic modifier for routine chromatographic separations. We report here the development of an isopropanol based UPLC protocol for G5 PAMAM dendrimer based conjugates that was transferred to semi-preparative applications.