High risk and low prevalence diseases: Eclampsia.

INTRODUCTION: Eclampsia is a rare partum and puerperal condition that carries a high rate of morbidity and mortality. OBJECTIVE: This review highlights the pearls and pitfalls of the care of patients with eclampsia, including presentation, evaluation, and evidence-based management in the emergency department (ED). DISCUSSION: Eclampsia is a hypertensive disease of pregnancy defined by new onset tonic-clonic, focal, or multifocal seizures or unexplained altered mental status in a pregnant or postpartum patient in the absence of other causative etiologies. However, signs and symptoms of preeclampsia and prodromes of eclampsia are often subtle and non-specific, making the diagnosis difficult. Thus, it should be considered in pregnant and postpartum patients who present to the ED. Laboratory testing including complete blood cell count, renal and liver function panels, electrolytes, glucose, coagulation panel, fibrinogen, lactate dehydrogenase, uric acid, and urinalysis, as well as imaging to include head computed tomography, can assist, but these evaluations should not delay management. Components of treatment include emergent obstetric specialist consultation, magnesium administration, and blood pressure control in patients with hypertension. Definitive treatment of eclampsia requires emergent delivery in pregnant patients. If consultants are not in-house, emergent stabilization and immediate transfer are required. CONCLUSIONS: An understanding of eclampsia can assist emergency clinicians in rapid recognition and timely management of this potentially deadly disease.

COVID-19 in pregnancy and the puerperium: A review for emergency physicians.

BACKGROUND: Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) is a novel virus responsible for causing the novel coronavirus disease of 2019 (COVID-19). OBJECTIVE: This article discusses the clinical manifestations of COVID-19 in pregnant patients, the effects of pregnancy on the course of COVID-19 disease, and the impact of COVID-19 on pregnancy outcomes. DISCUSSION: The physiological and mechanical changes associated with pregnancy increase maternal susceptibility to infections and complicate intubation and mechanical ventilation. The most common symptoms of COVID-19 in pregnant patients are cough and fever, although many infected individuals are asymptomatic. The majority of pregnant women diagnosed with COVID-19 disease have a mild course of illness and will recover without needing to deliver, but the risks of critical illness and need for mechanical ventilation are increased compared to the general population. Risk factors for death and severe disease include obesity, diabetes, and maternal age > 40 years. Women in their third trimester have the highest risk for critical illness, intensive care unit admission, and need for mechanical ventilation. Adverse fetal outcomes of maternal COVID-19 infection include increased risk of miscarriage, prematurity, and fetal growth restriction. Vertical transmission of SARS-CoV-2 is possible but has not been conclusively proven. CONCLUSIONS: COVID-19 is a potentially deadly infection, but data are limited concerning the pregnant population. Pregnant patients appear to present similarly to the general population, with fever and cough being the most reported symptoms in studies. Knowledge of these presentations and outcomes can assist clinicians caring for these patients.

Consideration of Occult Infection and Sepsis Mimics in the Sick Patient Without an Apparent Infectious Source.

BACKGROUND: Evaluation and treatment of the acutely ill patient is typically complicated by multiple comorbidities and incomplete medical histories. This is exemplified by patients with sepsis, whose care is complicated by variable presentations, shifting definitions, and a variety of potential sources. Many practitioners fail to consider and recognize less-common sources of infection in a timely manner. Additionally, multiple noninfectious conditions can present with the fever and tachycardia typical of the septic patient. The errors of anchoring and premature closure may lead to delay in, or failure of, diagnosis of these conditions. OBJECTIVE: This review addresses the evaluation of the acutely ill-appearing patient without an apparent source, focusing on occult sources of infection and conditions that mimic sepsis. DISCUSSION: Musculoskeletal, cardiac, neuraxial, and abdominal sources of sepsis should be considered in the acutely ill patient. Indwelling devices should be carefully examined for signs of infection. Consideration for sepsis mimics, such as neuroleptic malignant syndrome, malignant hyperthermia, medication toxicity, and thyroid storm, in patients who fail to respond to standard therapies for sepsis, may lead the physician to potentially reversible life-threatening diagnoses and management. CONCLUSION: In the seemingly septic patient who does not respond to antimicrobials and fluids, the differential should be broadened to include acutely life-threatening conditions that can mimic sepsis. A review of the patient's medical history, medications, and recent exposures can assist in identifying the source of the patient's elevated body temperature and tachycardia. Consideration of potential sources and other mimics of sepsis is needed in the emergency department.

Update to post-acute sequelae of SARS-CoV-2 infection: Caring for the 'long-haulers'.

An estimated 10% of COVID-19 survivors continue to experience symptoms several weeks to months after the appearance of initial symptoms, a condition termed post-acute sequelae of SARS-CoV-2 infection (PASC). These patients, also called "long-haulers," most commonly report protracted symptoms of fatigue, cough, dyspnea, chest tightness, difficulty concentrating, arthralgia, olfactory dysfunction, and headache. While age, comorbid medical conditions, and COVID-19 severity are suspected risk factors for PASC, young and previously healthy individuals with mild COVID-19 are also at risk. Recognition of symptoms, evaluation, supportive treatment, and attention to medical comorbidities are the cornerstones of medical management.

Post-acute sequelae of SARS-CoV-2 infection: Caring for the 'long-haulers'.

An estimated 10% of COVID-19 survivors continue to experience symptoms several weeks to months after the appearance of initial symptoms, a condition termed post-acute sequelae of SARS-CoV-2 infection (PASC). These patients, also called "long-haulers," most commonly report protracted symptoms of fatigue, cough, dyspnea, chest tightness, difficulty concentrating, arthralgia, olfactory dysfunction, and headache. While age, comorbid medical conditions, and COVID-19 severity are risk factors, young and previously healthy individuals with mild COVID-19 are also at risk. Recognition of symptoms, evaluation, supportive treatment, and attention to medical comorbidities are the cornerstones of medical management.

A Case Report of B-cell Lymphoblastic Leukemia/Lymphoma Presenting as Isolated Torticollis in a 2-year-old Female.

INTRODUCTION: Malignancy is a rare cause of acquired torticollis in children, and spinal cord involvement from hematolymphoid malignancies is similarly unusual. Neurologic abnormalities may not be present on initial evaluation, and delayed diagnosis and treatment is associated with increased risk of permanent paralysis. CASE REPORT: The author describes a case of isolated torticollis in a 2-year-old evaluated multiple times in the emergency department (ED) and outpatient settings. For her first three presentations, the patient had no associated neurologic abnormalities. She was discharged with return precautions and a presumptive diagnosis of viral infection/lymphadenitis. She later developed weakness of her left arm and was diagnosed with a B-cell lymphoblastic leukemia/lymphoma causing spinal cord compression. CONCLUSION: This case highlights the importance of continued comprehensive and meticulous physical examination in patients with repeat ED visits, as well as the value of detailed discharge instructions in mitigating diagnostic delays in these patients.

Disease specific thresholds for determining extubation readiness: The optimal negative inspiratory force for chronic obstructive pulmonary disease patients.

OBJECTIVES: The negative inspiratory force (NIF) has been used to help clinicians predict a patient's likelihood of successful liberation from mechanical ventilation (MV). However, the utility of the traditional threshold of ≤-30 cmH 2O may not be appropriate for patients with chronic obstructive pulmonary disease (COPD). This study aims to define the optimal predictive NIF threshold for COPD patients. METHODS: A prospective-observational multi-center study was conducted in intensive care units of six academic medical centers. All patients had COPD and were intubated for hypercapnic respiratory failure. The process of weaning from MV was conducted according to the defined hospital protocol. NIF was measured after 120 min of spontaneous breathing trial (SBT). The sensitivity, specificity, positive, and negative predictive value (PPV, NPV), positive and negative likelihood ratios (LR+, LR-) were calculated, and the diagnostic accuracy recorded. RESULTS: A total of 90 patients with COPD (39 males and 51 females) were included. Of these, 43 patients (47.8%) were successfully extubated whereas 47 patients (52.2%) failed SBT or required re-intubation (P = 0.654). The threshold value of ≤-25 cmH2O offered the optimal performance in COPD patients: area under the receiver operating characteristic (ROC) curves ROC curves 0.836, sensitivity 95.0%, specificity 86.0%, PPV 84.4%, and NPV 95.6%., LR+ 6.79, LR- 0.06, and the diagnostic accuracy 90.7%. CONCLUSIONS: In mechanically ventilated COPD patients with hypercapnic respiratory failure, the NIF threshold of ≤-25 cmH2O was a moderate-to-good predictor for successful ventilator liberation, and outperforms the traditional threshold of ≤-30 cmH2O.