Venoarterial extracorporeal membrane oxygenation in combination with Levosimendan as a bridge to recovery for a case of severe yew intoxication in a 13-year-old patient.

In an adolescent patient with severe yew intoxication and consecutive cardiac arrest, non-responsive to conventional resuscitation necessitating extracorporeal life support, Levosimendan has been implemented in the early acute phase of hemodynamic stabilization, without obvious side effects. However, the additive value of this treatment in severe yew intoxication remains speculative.

Severe acute respiratory syndrome coronavirus 2, primary varicella zoster virus coinfection, and a polymicrobial ventilator-associated tracheobronchitis in an adult immunocompetent male: a case report.

BACKGROUND: The spectrum of clinical manifestations and differential diagnosis associated with coronavirus disease 2019 is broad, ranging from fever and cutaneous eruptions to respiratory distress or even neurological disorders. Coexisting multipathogen infections significantly increase the complexity of the proper diagnostic and therapeutic approach and correlate with the rate of intensive care unit admissions and in-hospital mortality. CASE PRESENTATION: We present a case of multipathogen respiratory infection with severe acute respiratory syndrome coronavirus 2, varicella zoster virus, and polymicrobial tracheobronchitis in a 48-year-old Caucasian male hospitalized after traumatic brain injury. The patient tested positive for severe acute respiratory syndrome coronavirus 2 infection upon admission. During his stay in the intensive care unit, the patient developed a vesicular exanthema along with respiratory failure and signs of septic shock. CONCLUSION: This case of an adult presenting with severe acute respiratory syndrome coronavirus 2 infection and simultaneous primary varicella zoster virus infection illustrates the importance of considering coinfections in patients with coronavirus disease 2019 with unusual clinical manifestations.

Rotational Thromboelastometry Values After On-Pump Cardiac Surgery - A Retrospective Cohort Study.

BACKGROUND: Viscoelastic coagulation monitoring is recommended for coagulation management after cardiac surgery, but optimum target values are poorly defined. AIMS: To determine "to-be-expected" values in rotational thromboelastometry (ROTEM) after heparin reversal, to correlate ROTEM parameters with fibrinogen levels and platelet count, and to estimate the effect of hemoglobin levels on these measurements. METHODS: We retrospectively analyzed 571 consecutive adult patients undergoing cardiac surgery with cardiopulmonary bypass from 12/2018 to 08/2020. ROTEM and conventional laboratory measurements were performed 5 to 10 minutes after protamine administration. RESULTS: Clotting times in EXTEM, INTEM, and FIBTEM were significantly prolonged (72.6%, 96.1%, and 31.8% above reference ranges, respectively). Clot firmness parameters in EXTEM and INTEM were relevantly reduced (7.9% to 14.4% and 9.1% to 32.3% below the reference ranges, respectively). There was an excellent linear correlation of FIBTEM amplitude after 10 min (A10) and of maximal clot firmness (MCF) with fibrinogen concentrations (r = .81 and .80). Areas under receiver operating characteristic (AUROC) for identifying hypofibrinogenemia <1.5 g/L were between .80 and .87. No effect of hematocrit was observed. We also found a linear correlation of EXTEM, INTEM, and EXTEM-FIBTEM at both A10 and MCF with platelet counts (.32 to .68). The AUROCs for identifying thrombocytopenia (<100,000/µL) were .79 to .84, and were greater for A10 than for MCF measurements (P=.074, .001, and <.001, respectively). CONCLUSIONS: "To-be-expected" ROTEM values after CPB are different from the published reference ranges. ROTEM parameters might allow for reliable estimation of fibrinogen level and platelet count without being influenced by hematocrit.

Case Report: Left Ventricular Unloading Using a Mechanical CPR Device in a Prolonged Accidental Hypothermic Cardiac Arrest Treated by VA-ECMO - a Novel Approach.

We recently treated a 36-year-old previously healthy male with a prolonged hypothermic (lowest temperature 22.3°C) cardiac arrest after an alcohol intoxication with a return of spontaneous circulation after 230min of mechanical cardiopulmonary resuscitation and rewarming by veno-arterial ECMO with femoral cannulation and retrograde perfusion of the aortic arch. Despite functional veno-arterial ECMO, we continued mechanical cardiopulmonary resuscitation (Auto Pulse™ device, ZOLL Medical Corporation, Chelmsford, USA) until return of spontaneous circulation to prevent left ventricular distention from persistent ventricular fibrillation. The case was further complicated by extensive trauma caused by mechanical cardiopulmonary resuscitation (multiple rib fractures, significant hemothorax, and a liver laceration requiring massive transfusion), lung failure necessitating a secondary switch to veno-venous ECMO, and acute kidney injury with the need for renal replacement therapy. Shortly after return of spontaneous circulation, the patient was already following commands and could be discharged 3 weeks later without neurologic, cardiac, or renal sequelae and being entirely well. Prolonged accidental hypothermic cardiac arrest might present with excellent outcomes when supported with veno-arterial ECMO. Until return of spontaneous circulation, one might consider continuing with mechanical cardiopulmonary resuscitation in addition to ECMO to allow some left ventricular unloading. However, the clinician should keep in mind that prolonged mechanical cardiopulmonary resuscitation may cause severe injuries.

Unexpected collateral impact after out of hospital resuscitation using LUCAS system.

BACKGROUND: Mechanical chest compression using a piston device during reanimation is often the only way to ensure stable chest compression at a constant rate and force. However, its use can be associated with severe fractures of the thoracic rib cage and endanger the clinical course of the patient. Thus, the usage of such a piston device during the reanimation has currently been classified as a mere Class IIB indication. CASE PRESENTATION: We present a case of a 66-year-old male who underwent emergent CABG surgery after receiving out-of-hospital resuscitation as a result of myocardial infarction using the LUCAS system. Due to severe bilateral rib fractures a concomitant emergency chest-wall stabilization surgery had to be performed to ensure uncompromised graft flow to obtain stable cardiac function and hemodynamics. CONCLUSIONS: Reanimation using LUCAS-System might enable stable resuscitation conditions. However, it is crucial not to underestimate potential collateral damage which can in turn aggravate patient's clinical condition.

Does nonmedical hospital admission staff accurately triage emergency department patients?

OBJECTIVES: Utilization of hospital emergency departments (EDs) is continuously increasing. Though nurses and physicians are ultimately responsible for the definite triage decisions, initial ED patient triage is frequently performed by hospital admission staff. This study analyzes the quality of assessment of the severity of emergencies and the choice of treatment unit made by hospital admission staff. METHODS: One thousand fifty-nine consecutive surgical and medical patients entering the ED of the University Hospital Basel during an 11-day period were independently assessed by hospital admission staff without formal medical training, ED nursing staff, and ED physicians. Emergencies were classified by severity (intervention within minutes/hours/days) or by severity and resource utilization (immediate intervention with/without life-threatening condition, delayed intervention with high/low/no demand of resources). Emergency assessment and triage decision (surgical/medical, outpatient/inpatient treatment) were documented independently by all three ED staff groups. RESULTS: In 64% of the cases, initial assessment by admission staff corresponded with the final assessment by the ED physician. Concordance was, however, poor (kappa=0.23). Underestimation of the severity occurred in 7.5% of cases without severe or lethal consequences. Ninety-four percent of patients were treated in the unit to which they were originally triaged by the admission staff. CONCLUSION: Triage quality regarding the choice of treatment unit was found to be excellent, whereas the quality of the assessment of the severity of the emergency by nonmedical ED admission staff was acceptable. ED patients have to be assessed by medical staff early after admission to ensure adequate and timely interventions.