Cerebral Arterial Gas Embolism due to Helium Inhalation from a High-Pressure Gas Cylinder.

Cerebral arterial gas embolism (CAGE) is a rare but serious cause for acute neurologic deficit that occurs most often in divers who breathe compressed gas at depth or iatrogenically from a variety of invasive medical procedures. We present a rare case of CAGE caused by inhaling helium from an unregulated, high-pressure gas cylinder. Following inhalation, the patient experienced loss of consciousness, neurologic deficits, pneumomediastinum, and pneumothorax requiring transfer and treatment at a hyperbaric facility with resulting resolution of neurologic symptoms. This case highlights the importance of rapid diagnosis and hyperbaric oxygen treatment (HBO), facilitated by close coordination among community emergency departments, pediatric tertiary care centers, hyperbaric facilities, and poison control.

Providing Early Attending Physician Expertise via Telemedicine to Improve Rapid Response Team Evaluations.

OBJECTIVES: To evaluate the effect of providing early attending physician involvement via telemedicine to improve the decision process of rapid response teams. DESIGN: Quasi-experimental; three pairs of control/intervention months: June/July; August/October; November/December. SETTING: Single-center, urban, quaternary academic children's hospital with three-member rapid response team: critical care fellow or nurse practitioner, nurse, respiratory therapist. Baseline practice: rapid response team leader reviewed each evaluation with an ICU attending physician within 2 hours after return to ICU. SUBJECTS: 1) Patients evaluated by rapid response team, 2) rapid response team members. INTERVENTIONS: Implementation of a smartphone-based telemedicine platform to facilitate early co-assessment and disposition planning between the rapid response team at the patient's bedside and the attending in the ICU. MEASUREMENTS AND MAIN RESULTS: As a marker of efficiency, the primary provider outcome was time the rapid response team spent per patient encounter outside the ICU prior to disposition determination. The primary patient outcome was percentage of patients requiring intubation or vasopressors within 60 minutes of ICU transfer. There were three pairs of intervention/removal months. In the first 2 pairs, the intervention was associated with the rapid response team spending less time on rapid response team calls (June/July: point estimate -5.24 min per call; p < 0.01; August/October: point estimate -3.34 min per call; p < 0.01). During the first of the three pairs, patients were significantly less likely to require intubation or vasopressors within 60 minutes of ICU transfer (adjusted odds ratio, 0.66; 95 CI, 0.51-0.84; p < 0.01). CONCLUSIONS: Early in the study, more rapid ICU attending involvement via telemedicine was associated with rapid response team providers spending less time outside the ICU, and among patients transferred to the ICU, a significant decrease in likelihood of patients requiring vasopressors or intubation within the first 60 minutes of transfer. These findings provide evidence that early ICU attending involvement via telemedicine can improve efficiency of rapid response team evaluations.