The effect of calcium gluconate in the treatment of hyperkalemia.

OBJECTIVES: Intravenous (IV) calcium salts are routinely recommended as a cardio-protective therapy in the emergency treatment of severe hyperkalemia. However, this recommendation is supported by a low level of evidence and is anecdotal. The aim of this study is to determine the effectiveness of IV Calcium (Ca) gluconate in the treatment of hyperkalemia. MATERIALS AND METHODS: Patients with hyperkalemia and with the electrocardiogram (ECG) changes due to hyperkalemia over a 1 year period were included in this prospective observational study. Patients' ECGs were measured, before and after IV Ca-gluconate treatment and after normalization of potassium levels. Wilcoxon test and McNemar's test were used to compare the ECG parameters before and after Ca-gluconate therapy. RESULTS: The mean potassium value of 111 patients who met the inclusion criteria was 7.1 ± 0.6 mmol/l. In this study, a total of 243 ECG pathology related to hyperkalemia, 79 of which included main rhythm disorders, and the remaining 164 were nonrhythm disorders in ECG parameters, were analyzed. No statistically significant changes were determined in patients' nonrhythm ECG disorders with IV Ca-gluconate treatment (P = 0.125). However, nine of the 79 main rhythm disorders due to hyperkalemia improved with calcium gluconate treatment and this change was statistically significant (P < 0.004). CONCLUSION: IV Ca-gluconate therapy was found to be effective, albeit to a limited degree, in main rhythm ECG disorders due to hyperkalemia, but it was not found to be effective in nonrhythm ECG disorders due to hyperkalemia. Therefore, Ca-gluconate may be effective only in the main rhythm disorders due to hyperkalemia.

A rare complication of continuous positive airway pressure treatment - rectus sheath hematoma: a case report.

Noninvasive mechanical ventilation (NIMV) has a relevant role in the treatment of critically ill patients displaying severe dyspnea. Continuous positive airway pressure (CPAP), a method of NIMV, is also widely used in the management of acute heart failure, chronic obstructive pulmonary disease (COPD) exacerbation, and symptomatic sleep apnea. However, numerous traumatic complications of CPAP treatment in the face region, head, and thorax have been reported and may be related to the application of a continuous positive high pressure to the airway. Conversely, we have observed no complications due to CPAP-related increased intra-abdominal pressure. In this article, we describe a clinical case of a patient with an acute rectus sheath hematoma during CPAP treatment. This previously unreported complication demonstrates that CPAP should be carefully used in patients with exacerbated COPD with difficulty in expiration.

A Rare Ultrasonographic Finding of Emphysematous Cholecystitis: The Champagne Sign.

BACKGROUND: Emphysematous cholecystitis (EC) is a form of cholecystitis with high mortality rates more commonly seen in patients with medical histories such as diabetes, hypertension, and peripheral vascular disease. The common features of these medical diseases are impaired pain perception, particularly abdominal pain, due to advanced age and peripheral neuropathies. Accurate evaluation of characteristics observed at ultrasonography, the method of first choice in the diagnosis of EC, is therefore highly important in these patients. CASE REPORT: This study reports a case of the champagne sign, rarely seen in EC, together with other EC findings. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The champagne sign is a little-known sonographic finding that is evidence of the presence of gas in the gallbladder. The champagne sign that will be detected while evaluating the hepatobiliary system on bedside ultrasound is one of the valuable findings in the diagnosis of emphysematous cholecystitis with high mortality.

The value of the inferior vena cava ultrasound in the decision to hospitalise in patients with acute decompensated heart failure; the best sonographic measurement method?

OBJECTIVES: The primary aim of this study was to determine the value of the inferior vena cava (IVC) ultrasound in the decision to hospitalise acute decompensated heart failure (ADHF) patients. Our secondary aim was to find the most successful IVC measurement method in monitoring volume status. METHODS: ADHF patients were accepted over a 1-year period in this study. Patients' vital signs, laboratory tests and IVC measurements measured by six methods (in B- and M-mode; maximum, minimum diameter and caval index) performed on an hourly basis were recorded. The presence of any statistically significant difference between the IVC measurement methods, laboratory tests and vital parameters between the hospitalised and discharged patients was calculated. ROC curves were produced in order to determine the ability of parameters to differentiate two groups. Spearman's correlation test was used to investigate correlation between the IVC measurement methods and patients' urine outputs. RESULTS: A total of 71 patients were included in the study; 42 of these were hospitalised and 29 were discharged. Potassium, brain natriuretic peptide, respiration rate, urine output, maximum and minimum IVC diameters differed significantly between the two groups. Minimum IVC diameter measured in M-mode was identified as a weak marker with 65% sensitivity and 64% specificity (+PPV: 73%; -NPV:54%) for hospitalisation. Change in maximum IVC diameter measured in B-mode exhibited a high degree of correlation with change in body fluid (cc: 0.802). CONCLUSION: IVC ultrasound may have a limited value in the decision to hospitalise ADHF patients. But Maximum IVC diameter may be an ideal method for monitoring hypervolemic patients' volume status. CLINICAL TRIALS IDENTIFIER: NCT02725151.

Bedside ultrasound in the management of critically ill patients; Echocardiographic signs of acute respiratory distress syndrome and pulmonary embolism can be very similar, and lung ultrasound can act as a key: A case report.

Right-sided heart failure (RHF) diagnosed at point-of-care-ultrasonography examination of critical patients may reveal an acute disease, such as pulmonary embolism (PE), requiring emergency thrombolytic treatment. However, acute respiratory distress syndrome (ARDS) and PE leading to acute RHF may exhibit very similar echocardiographic features. We report the case of a 27-year-old pregnant woman diagnosed with ARDS due to septic abortion, and in whom ARDS mimicked PE both clinically and on echocardiography. Such similarity may lead to inappropriate administration of thrombolytic therapy and/or delay the correct treatment. Lung ultrasonography may help avoiding this pitfall.

How would you like your COVID-19? From a host with mild course disease, or from a severe one?

The clinical course of COVID-19 presents a broad spectrum, being asymptomatic in some individuals while following a severe course and resulting in mortality in others. It is known that such factors as age and chronic diseases can result in a different clinical courses in individuals, however, variable clinical courses among the similar individuals in terms of age and chronic diseases are also seen. Other possible factors affecting the course of the disease that are mostly speculative or under investigation are genetic factors and the origin of transmission or possible subtype of novel coronavirus. Whether the source of transmission is important in the clinical course of the disease is unknown. A case series composed of seven individuals in a similar age group, with different lines of descent and different genetic structures, but who were infected from the same source is presented here. The similar and different clinical, laboratory and radiological findings of the cases residing in the same nursing home, who presented to the hospital altogether, were evaluated. The aim of the study was to analyze whether the source of transmission is influential in the clinical course of the disease.

A comparison of noninvasive methods for early detection of hemorrhage: Inferior vena cava ultrasonography and spectrophotometric hemoglobin levels.

OBJECTIVES: Blood hemoglobin concentration measurements using a spectrophotometric method (SpHb), and inferior vena cava ultrasonography (IVC-US) are noninvasive methods used to follow-up hemorrhages. We compared their efficacy using voluntary blood donation as a model of moderate (approx. 500 mL) blood loss. METHODS: In this prospective observational study enrolling blood-donor volunteers (BD) and matched controls, we recorded SpHb, IVC diameters, and vital signs. Changes in variables from baseline were compared between BD and controls using the paired t test and Wilcoxon signed rank test. RESULTS: We included 118 subjects in the BD group and 95 healthy subjects in the control group. Changes in IVC maximum diameter, IVC minimum diameter, pulse rate, mean arterial pressure, pulse pressure, and shock index, but not in other variables, were significantly different in the BD and the control group (P < 0.05). IVCmax ≥1.1 mm yielded a 74% sensitivity and 77% specificity (PPV 79.8%, NPV 70.2%) in detecting early hemorrhage. With these cutoff values, IVCmax or PR reached a 90% sensitivity, while IVCmin and PR reached 98% specificity. CONCLUSIONS: IVC ultrasound may be superior to SpHb in predicting blood loss and may be useful in addition to vital signs for its follow-up.

Estimation of Cardiac Systolic Function Based on Mitral Valve Movements: An Accurate Bedside Tool for Emergency Physicians in Dyspneic Patients.

OBJECTIVES: The purpose of this study was to determine the success of mitral valve movements in the estimation of left ventricular ejection fraction (LVEF). METHODS: Adult patients whose principal symptom was dyspnea were included in this prospective observational study. The distance from the anterior mitral valve (AMV) to the interventricular septum (IVS) during early diastole was measured first in B-mode in the parasternal long axis (PLAX) named parasternal long axis-anterior leaflet septal separation. Second, the AMV-IVS distance was measured in M-mode in the PLAX named E-point septal separation. Third, AMV-IVS distance was measured in B-mode in the apical 4-chamber view named apical 4-chamber view-anterior leaflet septal separation. Finally, maximum distance between the 2 mitral leaflets in the apical 4-chamber view was measured and named mitral valve leaflet separation. Comprehensive echocardiography was performed by an experienced cardiologist. Correlation was calculated between mitral valve measurements and LVEF. Cutoff values were determined using receiver operating characteristic curves and the chi-square test. RESULTS: A total of 118 patients were included in the study. Parasternal long axis-anterior leaflet septal separation, E-point septal separation, and apical 4-chamber view-anterior leaflet septal separation were highly correlated with LVEF (correlation coefficient, -0.848, -0.833, and-0.822 [P < .001]). Parasternal long axis-anterior leaflet septal separation values less than 2.30 mm, E-point septal separation values less than 2 mm, and mitral valve leaflet separation values greater than 25.15 mm exhibited a 100% negative predictive value in excluding reduced LVEF. Parasternal long axis-anterior leaflet septal separation values less than 4.95 mm, EPSS values less than 5.85 mm, apical 4-chamber view-anterior leaflet septal separation values less than 6.95 mm, and mitral valve leaflet separation values greater than 24.05 mm exhibited a 100% negative predictive value in excluding severe reduced LVEF. CONCLUSIONS: Mitral valve measurement methods may be useful in predicting LVEF or values thereof as a complementary method of diagnosing challenging patients on echocardiographic images.

A new side effect of synthetic cannabinoid use by the bucket (waterpipe) method: Acute respiratory distress syndrome (ARDS).

The use and content of synthetic canibinden (SCs) has been rapidly increased in the last decades. The complex content of these substances bring along a wide spectrum of side effects. In addition to the expected neuropsychological side effects of pleasure-inducing substances such as agitation, anxiety, panic attack and hallucinations, rare cases of cerebrovascular diseases, seizures, acute renal injury, myocardial infarction and chronic lung injury have also been previously reported. Here we report a 19-year -old male who was presented with acute respiratory distress syndrome (ARDS) within hours of inhaled SC use with the rarely preferred bucket method. There is limited information in the literature about pulmonary effects of SCs and we could not detect any other ARDS case that develoed within hours after consumption of SC with the bucket method.

How much can synthetic cannabinoid damage the heart? A case of cardiogenic shock following resistant ventricular fibrillation after synthetic cannabinoid use.

New substances are constantly being added to the content of synthetic cannabinoids (SCs). SCs can affect the cardiovascular system and cause hypotension and bradycardia, myocardial infarction, atrial fibrillation, prolonged QTc, and Mobitz type II atrioventricular block. However, no cases associated with ventricular fibrillation (VF) have been reported to date. We report a case of a 26-year-old male patient admitted to the emergency department due to altered consciousness after SC use and requiring prolonged cardiopulmonary resuscitation due to resistant VF and cardiogenic shock.

A young puerperal woman presenting to emergency department with severe dyspnea.

Peripartum cardiomyopathy (PPCM) is an idiopathic cardiomyopathy presenting with heart failure (HF) secondary to left ventricular systolic dysfunction towards the end of pregnancy or in the months following delivery, where no other cause of HF is found. The symptoms and signs of this rare disorder mimic those of the physiological changes of pregnancy or other cardiovascular diseases. Consequently, its diagnosis is frequently delayed, which worsens an already poor prognosis. Here, we report a young adult who was diagnosed with PPCM, early, with the help of focused cardiac ultrasonography, performed after presenting to the emergency department with nonspecific respiratory complaints, including dyspnea and hemoptysis, which suggested at first pulmonary embolism.

The role of inferior vena cava diameter in volume status monitoring; the best sonographic measurement method?

OBJECTIVES: This study aims to determine the site of and the best sonographic method for measurement of inferior vena cava (IVC) diameter in volume status monitoring. METHODS: This observational before-and-after study was performed at the intensive care unit of the emergency department. It included hypotensive adult patients with suspected sepsis who were recommended to receive at least 20 mg/kg fluid replacement by the emergency physician. The patients were fluid replaced at a rate of 1000 mL/h, and maximum and minimum IVC diameters were measured and the Caval index calculated sonographically via both B-mode and M-mode. Hence, IVC's volume response was assessed by a total of 6 parameters, 3 each in M-mode and B-mode. Freidman test was used to assess the change in IVC diameter with fluid replacement. Wilcoxon test with Bonferroni correction was used to determine which measurement method more sensitively measured IVC diameter change. RESULTS: Twenty-eight patients with a mean age of 71.3 were included in the final analysis.The IVC diameter change was significant with all 6 methods (P < .001). The IVC minimum diameter change measured on M-mode during inspiration (M-mode i) was the only measurement method that significantly showed diameter change with each 500-mL fluid replacements. The initial and the subsequent M-mode i values after each 500 mL of fluid were 5.65 ± 3.34; 8.05 ± 3.66; 10.16 ± 3.61, and 11.21 ± 2.94, respectively (P < .001, P < .002, and P < .003, respectively). CONCLUSION: Inferior vena cava diameter was changed by fluid administration. The M-mode i method that most sensitively measures that change may be the most successful method in volume status monitoring.