Cardiovascular collapse and McConnell's sign as early manifestations of leucostasis.

A man in his late 70s with chronic myelomonocytic leukaemia presented for evaluation of acute leukaemic transformation and initiation of cytoreductive therapy after being found to have asymptomatic hyperleucocytosis. Within 24 hours, the patient developed vasopressor-refractory shock, severe lactic acidosis and multiorgan failure. Serial echocardiographic assessments revealed interval enlargement of the right ventricle with development of the McConnell's sign, and abdominal CT showed diffuse bowel wall thickening, likely due to ischaemia. CT angiography excluded pulmonary embolism or occlusion of intra-abdominal arteries. Despite aggressive care, the patient died from cardiovascular collapse within 8 hours of the onset of hypotension. An autopsy revealed extensive infiltration of early myeloid cells in pulmonary, myocardial, hepatic and intestinal microvasculature. This case illustrates different mechanisms by which leucostasis causes acute cardiovascular collapse and stresses the emergent nature of this diagnosis.

Use of Point-of-Care Ultrasound by Intensive Care Unit Triage Teams in Evaluating Unstable Patients Outside Intensive Care Units.

Introduction Point-of-care ultrasound (POCUS) has become an integral asset in intensive care units (ICUs). However, there is limited literature on the value of POCUS in evaluating deteriorating patients outside the ICU. In this study, we sought to investigate the use and impact of POCUS by ICU triage teams in hospitals outside of the ICU setting. Methods ICU triage fellows were provided a portable ultrasound to use as part of their evaluations during consultations and hospital code activations. Fellows were asked to fill out a survey on how ultrasound was used and its impact on patient management. Free-text data such as reason for ultrasound use, views obtained, clinical impressions before and after ultrasound, and clinical actions were recorded. These data were transcribed and categorized electronically. Results A total of 51 total resuscitations were documented. The most common reason for ICU triage team evaluation was hypotension (53%, N=27). The most common clinical focus for ultrasound use was cardiac assessment (53%, N=27), followed by volume status assessment (35%, N=18). The most common ultrasound views per encounter obtained were parasternal long (82%, N=42), followed by apical four-chamber view (76%, N=39) and subcostal view (75%, N=38). Out of 38 encounters with clinical impressions documented, 79% (N=30) of pre-ultrasound clinical impressions were confirmed by ultrasound use. Of total encounters, 35% (N=18) had a significant clinical action taken based on ultrasound findings (fluid resuscitation, vasopressor initiation, etc.). Conclusions Ultrasound is a valuable tool for patient evaluation in non-ICU wards, especially in confirming clinical impressions and guiding therapeutic actions. Some limitations of this study include reporting bias and incomplete capture of ultrasound use in non-ICU wards.

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.

Comparison of Language and Memory Lateralization by Functional MRI and Wada Test in Epilepsy.

The intracarotid sodium amobarbital procedure (ISAP or Wada test) lateralizes cerebral functions to the cerebral hemispheres preoperatively. Functional magnetic resonance imaging (fMRI) is increasingly used to characterize preoperative language and memory lateralization. In this study, concordance of fMRI with Wada was examined in patients with medically intractable seizures. The relationship of the distance between the epileptogenic focus to functional activation area with patients' post-operative deficits in language was also analyzed. 27 epilepsy patients with preoperative fMRI and Wada data were analyzed using established fMRI paradigms for language and memory. Activation of Broca's and Wernicke's areas were measured in three dimensions. Language and memory lateralization were determined, and standard neuropsychiatry Wada test procedures were used for comparison. The shortest distance between a language area to the border of surgical focus (LAD) was also measured and compared with postoperative language deficits. Our study found that concordance between fMRI and Wada testing was 0.41 (Kappa's 'fair to good' concordance) for language dominance and 0.1 (Kappa's 'poor' concordance) for memory. No significant correlation was found between LAD and post-op language deficit (p=0.439). A correlation was found between LAD and post-op memory deficit (p=0.049; the further distance from surgical lesion to language area is associated with less post-operative memory loss). Females demonstrated significantly increased postoperative seizure improvement (Fisher's p-value=0.0296; female=8; male=6). A significant association between handedness (right-handed subjects) and postoperative seizure improvement was found (p=0.02) as well as a significant trend for interaction of gender and handedness on postoperative seizure improvement (p=0.09). Overall, our results demonstrate fMRI as a useful preoperative adjunct to Wada testing for language lateralization in patients with medically intractable seizures.

Critical Care Education Day: A Novel, Multidisciplinary, and Interactive Critical Care Education Session for Emergency Medicine Residents.

Critical care medicine (CCM) is central to emergency medicine (EM) resident education. We feel that the traditional lecture format is not the ideal way to teach EM critical care, which requires integration and prioritization of diagnostic workup and team-based resuscitation under time pressure. We describe a novel critical care education day where an interactive, practical, and multidisciplinary critical care educational experience was provided for EM residents using case-based small-group sessions and fast-paced simulation.

Protocolized use of Factor Eight Inhibitor Bypassing Activity (FEIBA) for the reversal of warfarin induced coagulopathy.

INTRODUCTION: Coagulopathy due to warfarin in patients with major bleeding was traditionally reversed with fresh frozen plasma and intravenous (IV) vitamin K, but prothrombin complex concentrates (PCC) are increasingly used in the treatment of these patients. Factor Eight Inhibitor Bypassing Activity (FEIBA) is an activated four-factor PCC most commonly used in patients with hemophilia. We aimed to evaluate the efficacy and safety of FEIBA and IV vitamin K for the reversal of warfarin-associated coagulopathy in patients with major bleeding, by measuring the percentage of patients who achieved target INR ≤ 1.5 and the incidence of thrombotic adverse events (TAE). METHODS: In this prospective observational study, we enrolled patients presenting to the Emergency Department (ED) with warfarin associated coagulopathy (INR > 1.5) and major bleeding. Patients received FEIBA using an INR based dosing strategy and IV vitamin K. RESULTS: In 43 patients, median initial INR was 4.0 (2.7, 7.3 interquartile range (IQR)). Median time to result the second INR was 45 min (38, 55 IQR) and the median INR was 1.4 (1.3, 1.6 IQR). Out of the 43 patients, 93% achieved the target INR of ≤1.5. In-hospital mortality was 40% (17 patients). There were 11 TAEs in 6 patients (14%); 4 events in 2 patients (5%) were attributed to FEIBA. CONCLUSION: A protocolized use of FEIBA and IV vitamin K resulted in the efficacious reversal of warfarin-induced coagulopathy in patients with major bleeding. TAEs occurred in 14% of patients and were attributed to FEIBA in 5% of patients.

Acute Respiratory Distress Syndrome: Etiology, Pathogenesis, and Summary on Management.

The acute respiratory distress syndrome (ARDS) has multiple causes and is characterized by acute lung inflammation and increased pulmonary vascular permeability, leading to hypoxemic respiratory failure and bilateral pulmonary radiographic opacities. The acute respiratory distress syndrome is associated with substantial morbidity and mortality, and effective treatment strategies are limited. This review presents the current state of the literature regarding the etiology, pathogenesis, and management strategies for ARDS.

Needle-guided ultrasound technique for axillary artery catheter placement in critically ill patients: A case series and technique description.

PURPOSE: Axillary arterial cannulation for blood pressure monitoring has been reported in adults since 1973. Reported failure rates using palpation landmarks are high. This report describes a needle-guided ultrasound technique for axillary arterial line placement in critically ill patients. METHODS: A retrospective review of all patients requiring axillary arterial cannulation attempts with ultrasound-assisted needle guidance for hemodynamic monitoring was performed from July 2010 to June 2016 at a single institution. RESULTS: One hundred fifty nine (159) cannulation attempts were performed in 155 patients. The overall success rate was 97%, with a first pass success rate of 84%. Inexperienced operators performed 49% of procedures under direct faculty supervision, and had a 99% success rate, which was not different from experienced operators. Almost 20% of patients had moderate-to-severe coagulopathy (platelets<50k/uL, INR>2.0 or PTT>60s). Complications reported included the following: nonfunctioning of catheter (6%) and hematoma (6%). Ischemia was noted in 2 patients (1%), but only one was attributed to the arterial catheter. CONCLUSIONS: Use of the needle-guided ultrasound assisted approach for axillary arterial line placement is easily teachable and can be used to promote safe and successful placement of axillary arterial lines for novice learners.