The Role of Troponin Testing in Patients with Supraventricular Tachycardia, Systematic Review and Meta-Analysis.

BACKGROUND: Supraventricular tachycardia (SVT) is commonly evaluated in the emergency department (ED). While troponin has been shown to be elevated in SVT, its usefulness for predicting coronary artery disease and future adverse cardiovascular outcomes has not been shown. OBJECTIVES: We aimed to evaluate the prognostic utility of troponin measurement as part of SVT management in the ED. METHODS: We performed a literature search in the PubMed and Scopus databases from inception to August 30, 2023, including all studies reporting troponin measurements in adult patients (age > 18 years) presenting to the ED with supraventricular tachycardia. The primary outcome of interest for this study was the prevalence of elevated troponin in patients with SVT. Secondary outcomes included the prevalence of major adverse cardiac events (MACE) and additional cardiac testing with significant findings. RESULTS: We included 7 studies (500 patients) in our analysis. Six studies reported the number of patients with SVT and elevated troponin, with a pooled prevalence of 46% (95% CI 27-66%, I2 93%). The pooled prevalence of all MACE in our study was 6% (95% CI 1-25%), while the prevalence for MACE among patients with elevated serum troponin levels was 11% (95% CI 4-27%). CONCLUSIONS: Troponin levels are frequently ordered for ED patients with SVT and are often elevated. However, this review suggests that they have low prognostic value in predicting MACE.

Analyzing unmanned aerial vehicle (drone) attacks; a disaster medicine perspective.

INTRODUCTION: Unmanned aerial vehicles (UAVs), more commonly known as drones, have rapidly become more diverse in capabilities and utilization through technology advancements and affordability. While drones have had significant positive impact on healthcare and consumer delivery particularly in remote and austere environments, Violent Non-State Actors (VNSAs) have increasingly used drones as weapons in planning and executing terrorist attacks resulting in significant morbidity and mortality. We aim to analyze drone-related attacks globally against civilians and critical infrastructure for more effective hospital and prehospital care preparedness. METHODS: We retrospectively reviewed the Global Terrorism Database (GTD) from 1970 to 2020 to analyze the worldwide prevalence of drone-related attacks against civilians and critical infrastructure. Cases were excluded if they had insufficient information regarding a drone involvement, and if attacks were conducted by the government entities. The trends in the number of attacks per month, as well as the number of fatalities and injuries, were examined using time series and trend analysis. RESULTS: The database search yielded 253 drone-related incidents, 173 of which met inclusion criteria. These incidents resulted in 92 fatalities and 215 injuries with civilian targets most commonly attacked by drones (76 events, 43.9%), followed by military (46 events, 26.5-%). The Middle East region was most affected (168 events, 97% of attacks) and the Islamic state of Iraq was the most common perpetrator (106 events, 61.2%). Almost all attacks were by explosive devices attached to drones (172 events, 99.4%). Time series with linear trend analyses suggested an upward trends of drone attacks by VNSAs, resulting in a greater number of injuries and fatalities, that became more frequent over the years. CONCLUSIONS: Overtime, there were upward trends of drone attacks, with higher lethality and morbidity. There were more injuries compared to fatalities. Most common region affected was the Middle East, and most common type of weapon employed by drone technology was explosive weapon. Investment in medical personnel training, security, and research is crucial for an effective mass-casualty incident response after the drone attacks.

Reply to Brea et al. Comment on "Levitt et al. Approach to Decompensated Right Heart Failure in the Acute Setting. J. Clin. Med. 2024, 13, 869".

We would like to acknowledge and thank the authors of "Defining the Plethoric IVC" [...].

COVID-19 Pandemic and Impact on Research Publications in Critical Care.

OBJECTIVES: The COVID-19 pandemic precipitated a significant transformation of scientific journals. Our aim was to determine how critical care (CC) journals and their impact may have evolved during the COVID-19 pandemic. We hypothesized that the impact, as measured by citations and publications, from the field of CC would increase. DESIGN: Observational study of journal publications, citations, and retractions status. SETTING: All work was done electronically and retrospectively. SUBJECTS: The top 18 CC journals broadly concerning CC, and the top 5 most productive CC journals on the SCImago list. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: For the top 18 CC journals and specifically Critical Care Medicine (CCM), time series analysis was used to estimate the trends of total citations, citations per publication, and publications per year by using the best-fit curve. We used PubMed and Retraction Watch to determine the number of COVID-19 publications and retractions. The average total citations and citations per publication for all journals was an upward quadratic trend with inflection points in 2020, whereas publications per year spiked in 2020 before returning to prepandemic values in 2021. For CCM total publications trend downward while total citations and citations per publication generally trend up from 2017 onward. CCM had the lowest percentage of COVID-related publications (15.7%) during the pandemic and no reported retractions. Two COVID-19 retractions were noted in our top five journals. CONCLUSIONS: Citation activity across top CC journals underwent a dramatic increase during the COVID-19 pandemic without significant retraction data. These trends suggest that the impact of CC has grown significantly since the onset of COVID-19 while maintaining adherence to a high-quality peer-review process.

C3-C4 cervical disc herniation producing Brown-Séquard syndrome: A case report and review of the literature.

Brown-Séquard Syndrome (BSS) is a rare form of incomplete spinal cord injury and is characterized by ipsilateral motor deficit and contralateral sensory loss. BSS is commonly associated with traumatic etiologies, but non-traumatic causes should be considered as well. A 38-year-old woman presented with a 3-week history of weakness in her right upper extremity, and she has developed numbness and tingling in her left upper and lower extremities over the past week and a half, along with some motor difficulty. Imaging showed a large right paracentral disc protrusion at the C3-C4 level causing severe spinal canal narrowing and resulting in abnormal cord signal. The patient subsequently underwent a C3-4 cervical total disk replacement. Hemovac placed during surgery was removed on post-op day one, and she was re-evaluated by PT/OT and recommended for outpatient therapies on post-op day two. Our case, along with a review of the literature, highlights those non-traumatic causes of BSS should be considered as a cause of BSS. BSS produced by a herniated cervical disc is extremely rare and is often misdiagnosed.

Approach to Decompensated Right Heart Failure in the Acute Setting.

Acute right heart failure (ARHF) arises when the right ventricle fails to pump blood efficiently to the pulmonary circulation. This inefficiency leads to a decreased blood supply to various organs. ARHF is a significant health concern, often leading to increased hospital admissions and being associated with a higher risk of mortality. This condition underscores the importance of effective cardiac care and timely intervention to manage its complications and improve patient outcomes. Diagnosing ARHF involves a comprehensive approach that includes a physical examination to evaluate the patient's fluid status and heart-lung function, blood tests to identify potential triggers and help forecast patient outcomes and various imaging techniques. These imaging techniques include electrocardiograms, point-of-care ultrasounds, computed tomography, cardiac magnetic resonance imaging, and other advanced monitoring methods. These diagnostic tools collectively aid in a detailed assessment of the patient's cardiac and pulmonary health, essential for effective management of ARHF. The management of ARHF focuses on addressing the underlying causes, regulating fluid balance, and enhancing cardiac function through pharmacological treatments or mechanical support aimed at boosting right heart performance. This management strategy includes the use of medications that modulate preload, afterload, and inotropy; vasopressors; anti-arrhythmic drugs; ensuring proper oxygenation and ventilation; and the utilization of heart and lung assist devices as a bridge to potential transplantation. This review article is dedicated to exploring the pathophysiology of ARHF, examining its associated morbidity and mortality, evaluating the various diagnostic tools available, and discussing the diverse treatment modalities. The article seeks to provide a comprehensive understanding of ARHF, its impact on health, and the current strategies for its management.

Author Response.

How to cite this article: Rahmatinejad Z, Hoseini B, Pourmand A, Reihani H, Rahmatinejad F, Eslami S, et al. Author Response. Indian J Crit Care Med 2024;28(2):183-184.

Approach to traumatic cardiac arrest in the emergency department: a narrative literature review for emergency providers.

BACKGROUND: Traumatic cardiac arrest (TCA) is a major contributor to mortality and morbidity in all age groups and poses a significant burden on the healthcare system. Although there have been advances in treatment modalities, survival rates for TCA patients remain low. This narrative literature review critically examines the indications and effectiveness of current therapeutic approaches in treating TCA. METHODS: We performed a literature search in the PubMed and Scopus databases for studies published before December 31, 2022. The search was refined by combining search terms, examining relevant study references, and restricting publications to the English language. Following the search, 943 articles were retrieved, and two independent reviewers conducted a screening process. RESULTS: A review of various studies on pre- and intra-arrest prognostic factors showed that survival rates were higher when patients had an initial shockable rhythm. There were conflicting results regarding other prognostic factors, such as witnessed arrest, bystander cardiopulmonary resuscitation (CPR), and the use of prehospital or in-hospital epinephrine. Emergency thoracotomy was found to result in more favorable outcomes in cases of penetrating trauma than in those with blunt trauma. Resuscitative endovascular balloon occlusion of the aorta (REBOA) provides an advantage to emergency thoracotomy in terms of occupational safety for the operator as an alternative in managing hemorrhagic shock. When implemented in the setting of aortic occlusion, emergency thoracotomy and REBOA resulted in comparable mortality rates. Veno-venous extracorporeal life support (V-V ECLS) and veno-arterial extracorporeal life support (V-A ECLS) are viable options for treating respiratory failure and cardiogenic shock, respectively. In the context of traumatic injuries, V-V ECLS has been associated with higher rates of survival to discharge than V-A ECLS. CONCLUSION: TCA remains a significant challenge for emergency medical services due to its high morbidity and mortality rates. Pre- and intra-arrest prognostic factors can help identify patients who are likely to benefit from aggressive and resource-intensive resuscitation measures. Further research is needed to enhance guidelines for the clinical use of established and emerging therapeutic approaches that can help optimize treatment efficacy and ameliorate survival outcomes.

A case report of point-of-care ultrasound directed thrombectomy: a reversible cause of cardiac arrest managed with extracorporeal membrane oxygenation cannulation.

Extracorporeal membrane oxygenation (ECMO) has been increasingly employed in the emergency department for patients with a potentially reversible cause of cardiac arrest. We present the case of a young female patient with an in-hospital cardiac arrest who was found to have severe right heart strain on point-of-care ultrasound (POCUS), suggesting a massive pulmonary embolism. Rapid bedside diagnosis using ultrasound expedited bedside cannulation and initiation of ECMO as a bridge to surgical thrombectomy, and ultimately the patient survived with full neurologic function. With its ready availability and increasing acceptance by consultants, POCUS should be incorporated into cardiac arrest algorithms as the standard of care to rule in thrombotic and obstructive causes of cardiac arrest.

Prevalence of intra-abdominal injury among patients with seatbelt signs, a systematic review and meta-analysis.

INTRODUCTION: The advancement of seat belts have been essential to reducing morbidity and mortality related to motor vehicle collisions (MVCs). The "seat belt sign" (SBS) is an important physical exam finding that has guided management for decades. This study, comprising a systematic review and random-effects meta-analysis, asses the current literature for the likelihood of the SBS relating to intra-abdominal injury and surgical intervention. METHODS: PubMed and Scopus databases were searched from their beginnings through August 4, 2023 for eligible studies. Outcomes included the prevalence of intra-abdominal injury and need for surgical intervention. Cochrane's Risk of Bias (RoB) tool and the Newcastle-Ottawa Scale (NOS) were applied to assess risk of bias and study quality; Q-statistics and I2 values were used to assess for heterogeneity. RESULTS: The search yielded nine observational studies involving 3050 patients, 1937 (63.5%) of which had a positive SBS. The pooled prevalence of any intra-abdominal injury was 0.42, (95% CI 0.28-0.58, I2 = 96%) The presence of a SBS was significantly associated with increased odds of intra-abdominal injury (OR 3.62, 95% CI 1.12-11.6, P = 0.03; I2 = 89%), and an increased likelihood of surgical intervention (OR 7.34, 95% CI 2.03-26.54, P < 0.001; I2 = 29%). The measurement for any intra-abdominal injury was associated with high heterogeneity, I2 = 89%. CONCLUSION: This meta-analysis suggests that the presence of a SBS was associated with a statistically significant higher likelihood of intra-abdominal injury and need for surgical intervention. The study had high heterogeneity, likely due to the technological advancements over the course of this study, including seat belt design and diagnostic imaging sensitivity. Further studies with more recent data are needed to confirm these results.

Adjunctive Therapeutics in the Management of Cardiopulmonary Resuscitation: A Narrative Literature Review.

Nearly 565,000 patients will suffer from prehospital and inpatient cardiac arrest in the United States per annum. Cardiopulmonary resuscitation and all associated interventions used to achieve it remain an essential focus of emergency medicine. Current ACLS guidelines give clear instructions regarding mainstay medications such as epinephrine and antiarrhythmics; however, the literature remains somewhat controversial regarding the application of adjunctive therapeutics such as calcium, magnesium, sodium bicarbonate, and corticosteroids. The available data acquired in this field over the past three decades offer mixed pictures for each of these medications on the effects of core metrics of cardiopulmonary resuscitation (e.g., rate of return of spontaneous circulation, survival-to-hospitalization and discharge, 24 h and 30 d mortality, neurological outcome), as well as case-specific applications for each of these interventions (e.g., polymorphic ventricular tachycardia, electrolyte derangements, acidosis, post-arrest shock). This narrative literature review provides a comprehensive summary of current guidelines and published data available for these four agents and their use in clinical practice.

Application of Technology in Cardiopulmonary Resuscitation, a Narrative Review.

Novel medical technologies are designed to aid in cardiopulmonary resuscitation both in and out of the hospital. Out-of-hospital innovations utilize the skills of paramedics, bystanders, and other prehospital personnel, while in-hospital innovations traditionally aid in physician intervention. Our review of current literature aims to describe the benefits and limitations of six main technologic advancements with wide adoption for their practicality and functionality. The six key technologies include: extracorporeal membrane oxygenation (ECMO), real-time feedback devices, smart devices, video review, point-of-care ultrasound, and unmanned aerial vehicle (drone) automated external defibrillator (AED) delivery. The benefits and limitations of each technology were independently reviewed and expounded upon. Newer technologies like drone AED delivery, paramedic ultrasound use, and smart devices have been demonstrated to be safe and feasible, however, further studies are needed to compellingly demonstrate improved patient outcomes. In-hospital use of ECMO and ultrasound is well established by current literature to aid in cardiopulmonary resuscitation and improve patient outcomes.

Emergency department approach to monkeypox.

BACKGROUND: Monkeypox (mpox) is a viral infection that is primarily endemic to countries in Africa, but large outbreaks outside of Africa have been historically rare. In June 2022, mpox began to spread across Europe and North America, causing the World Health Organization (WHO) to declare mpox a public health emergency of international concern. This article aims to review clinical presentation, diagnosis, and prevention and treatment strategies on mpox, providing the basic knowledge for prevention and control for emergency providers. METHODS: We conducted a review of the literature using PubMed and SCOPUS databases from their beginnings to the end of July 2023. The inclusion criteria were studies on adult patients focusing on emerging infections that described an approach to a public health emergency of international concern, systematic reviews, clinical guidelines, and retrospective studies. Studies that were not published in English were excluded. RESULTS: We included 50 studies in this review. The initial symptoms of mpox are non-specific: fever, malaise, myalgias, and sore throat. Rash, a common presentation of mpox, usually occurs 2-4 weeks after the prodrome, but the presence of lymphadenopathy may distinguish mpox from other infections from the Poxviridae family. Life-threatening complications such as pneumonia, sepsis, encephalitis, myocarditis, and death can occur. There are documented co-occurrences of human immunodeficiency virus (HIV) and other sexually transmitted infections that can worsen morbidity. CONCLUSION: The initial presentation of mpox is non-specific. The preferred treatment included tecovirimat in patients with severe illness or at high risk of developing severe disease and vaccination with two doses of JYNNEOS. However, careful history and physical examination can raise the clinicians' suspicion and point toward a prompt diagnosis. There are different modalities to prevent and treat mpox infection.

Trend of Outcome Metrics in Recent Out-of-Hospital-Cardiac-Arrest Research: A Narrative Review of Clinical Trials.

Cardiopulmonary resuscitation (CPR) research traditionally focuses on survival. In 2018, the International Liaison Committee on Resuscitation (ILCOR) proposed more patient-centered outcomes. Our narrative review assessed clinical trials after 2018 to identify the trends of outcome metrics in the field OHCA research. We performed a search of the PubMed database from 1 January 2019 to 22 September 2023. Prospective clinical trials involving adult humans were eligible. Studies that did not report any patient-related outcomes or were not available in full-text or English language were excluded. The articles were assessed for demographic information and primary and secondary outcomes. We included 89 studies for analysis. For the primary outcome, 31 (35%) studies assessed neurocognitive functions, and 27 (30%) used survival. For secondary outcomes, neurocognitive function was present in 20 (22%) studies, and survival was present in 10 (11%) studies. Twenty-six (29%) studies used both survival and neurocognitive function. Since the publication of the COSCA guidelines in 2018, there has been an increased focus on neurologic outcomes. Although survival outcomes are used frequently, we observed a trend toward fewer studies with ROSC as a primary outcome. There were no quality-of-life assessments, suggesting a need for more studies with patient-centered outcomes that can inform the guidelines for cardiac-arrest management.

Ventilation assisted feedback in out of hospital cardiac arrest.

Excessive ventilatory volumes and rates during cardiopulmonary resuscitation (CPR) can lead to adverse effects, such as elevated intrathoracic pressure and decreased coronary blood flow. The 2020 American Heart Association (AHA) guidelines acknowledge the value of real-time feedback devices in improving CPR performance. In this case series, three out-of-hospital cardiac arrest cases received ventilation feedback during prehospital resuscitation and the initial in-hospital care phase. In each case, a notable increase in ventilation rate and volume was observed following the transfer of care from emergency medical services to hospital staff. This deviation from established ventilation guidelines emphasizes the importance of monitoring and addressing ventilation strategy during the transition to hospital care. Existing evidence supports the importance of maintaining specific ventilation rates and tidal volumes during cardiac arrest to improve outcomes. We believe further research is essential to establish a definitive link between ventilation strategies and patient outcomes, ultimately enhancing resuscitation efforts and patient survival rates. Integrating real-time ventilation feedback devices both in and out of the hospital during cardiac arrest presents an opportunity for quality improvement and adherence to national standards.

Prevalence of peri-intubation major adverse events among critically ill patients: A systematic review and meta analysis.

BACKGROUND: Peri-intubation major adverse events (MAEs) are potentially preventable and associated with poor patient outcomes. Critically ill patients intubated in Emergency Departments, Intensive Care Units or medical wards are at particularly high risk for MAEs. Understanding the prevalence and risk factors for MAEs can help physicians anticipate and prepare for the physiologically difficult airway. METHODS: We searched PubMed, Scopus, and Embase for prospective and retrospective observational studies and randomized control trials (RCTs) reporting peri-intubation MAEs in intubations occurring outside the operating room (OR) or post-anesthesia care unit (PACU). Our primary outcome was any peri-intubation MAE, defined as any hypoxia, hypotension/cardiovascular collapse, or cardiac arrest. Esophageal intubation and failure to achieve first-pass success were not considered MAEs. Secondary outcomes were prevalence of hypoxia, cardiac arrest, and cardiovascular collapse. We performed random-effects meta-analysis to identify the prevalence of each outcome and moderator analyses and meta-regressions to identify risk factors. We assessed studies' quality using the Cochrane Risk of Bias 2 tool and the Newcastle-Ottawa Scale. RESULTS: We included 44 articles and 34,357 intubations. Peri-intubation MAEs were identified in 30.5% of intubations (95% CI 25-37%). MAEs were more common in the intensive care unit (ICU; 41%, 95% CI 33-49%) than the Emergency Department (ED; 17%, 95% CI 12-24%). Intubation for hemodynamic instability was associated with higher rates of MAEs, while intubation for airway protection was associated with lower rates of MAEs. Fifteen percent (15%, 95% CI 11.5-19%) of intubations were complicated by hypoxia, 2% (95% CI 1-3.5%) by cardiac arrest, and 18% (95% CI 13-23%) by cardiovascular collapse. CONCLUSIONS: Almost one in three patients intubated outside the OR and PACU experience a peri-intubation MAE. Patients intubated in the ICU and those with pre-existing hemodynamic compromise are at highest risk. Resuscitation should be considered an integral part of all intubations, particularly in high-risk patients.