Adan Mora

Metformin-induced lactic acidosis with emphasis on the anion gap.

The presence of an anion gap in a diabetic patient, especially if associated with evidence of compromised renal function, should prompt clinicians to consider metformin as a contributing factor. This consideration is especially important in patients with severe anion gaps associated with lactic acidosis out of proportion to the patients clinical presentation.

Myxedema coma with cardiac tamponade and severe cardiomyopathy.

Myxedema coma is an infrequent but potentially fatal complication of hypothyroidism. We present a rare case of previously undiagnosed hypothyroidism presenting in cardiogenic shock from pericardial tamponade and depressed myocardial contractility in myxedema coma. Here, we focus on cardiovascular complications associated with the condition.

Left upper lobe torsion in pneumothorax

Abstract We report a case of left upper lobe torsion in a patient who had a pneumothorax as a complication of subclavian venous access for an elective neurosurgical operation. Despite appropriate management of the pneumothorax, the patient’s chest radiograph did not improve. Computed tomography of the chest was concerning for left upper lobe torsion. Fiberoptic bronchoscopy revealed near complete obstruction of the left upper lobe bronchus. Review of computed tomography imaging before and after bronchoscopy and subsequent thoracotomy confirmed lobar torsion. Consideration of lobar torsion in the differential diagnosis of patients with persistently abnormal chest imaging despite appropriate management after complications of routine procedures is important for early recognition and intervention of a potentially life-threatening problem.

Massive hemoptysis managed by rescue extracorporeal membrane oxygenation

Abstract Massive hemoptysis can have a rapid and potentially fatal clinical course. A 68-year-old woman presented with recurrent hemoptysis complicated by refractory hypoxemia and shock despite aggressive intervention. The use of veno-venous extracorporeal membrane oxygenation was a nontraditional intervention that ultimately proved to be lifesaving, but is by no means recommended for routine use in this setting.

Adrenal Crisis and Autoimmune Polyglandular Syndromes

We report a 67-year-old woman who presented with adrenal crisis as a manifestation of autoimmune polyglandular syndrome 2, a polygenic disorder characterized by concurrent primary adrenal insufficiency and either autoimmune thyroid disease or type 1 diabetes mellitus.

PH Grand Rounds: When Pulmonary Arterial Hypertension Is Complicated by Pericardial Disease

Patients with pulmonary hypertension whose case is complicated by a pericardial effusion pose a management dilemma. These patients are more complex given their unique set of hemodynamics, and the decision to proceed with a pericardial fluid drainage is not straightforward and mortality is potentially high. The current medical literature does not provide strict guidelines or a formal consensus regarding this clinical presentation. It appears management should be tailored to individual cases. We present a case of a patient in whom medical management spared the risk posed by drainage.

Vanishing lung syndrome.

Giant bullae often mimic pneumothorax on radiographic appearance. We present the case of a 55-year-old man admitted to a referring hospital with dyspnea, cough, and increasing sputum production; he refused thoracotomy for tension pneumothorax and presented to our hospital for a second opinion. A computed tomography (CT) scan at our hospital revealed a giant bulla, which was managed conservatively as an exacerbation of chronic obstructive pulmonary disease. Thoracic surgery was consulted but advised against bullectomy. Giant bullae can easily be misdiagnosed as a pneumothorax, but the management of the two conditions is vastly different. Distinguishing between the two may require CT scan. Symptomatic giant bullae are managed surgically. We highlight the etiology, presentation, diagnosis, and treatment of bullous lung disease, especially in comparison to pneumothorax.

348: EVALUATION OF NEW INTERN ACLS RHYTHM INTERPRETATION USING SIMULATION LAB

Learning Objectives: Rhythm recognition is the most important aspect of Advanced Cardiac Life Support (ACLS); correct identification leads the provider down a set pathway of interventions. We set out to evaluate new interns’ ability to recognize basic ACLS rhythms and the initial management step as they are expected to be ACLS trained prior to residency and respond to our institution’s codes. Methods: At Baylor University Medical Center in Dallas, 20 interns participated in a #3G Sim Man mega code scenario during their orientation. Recognition and management of an initial rhythm and five pulse/rhythm checks were executed. They were asked to anonymously identify the rhythms and the next best management step. A total of six rhythms (Supraventricular tachycardia (SVT), Torsades de Pointes (TdP), Ventricular Fibrillation, pulseless electrical activity, monomorphic ventricular tachycardia, and third degree AV block) were shown. Afterward, participants had a lecture reviewing code blues and rhythms by an intensivist. They then returned to the simulation lab and the six rhythms were again shown in random order which they were anonymously asked to identify and state the next best management step. Results: Of the 20 participants, 80% (16) had completed their ACLS within 6 months (mo.) of orientation: 20% (4) 3-6 mo. prior, 55% (11) 1-3 mo. prior, 5% (1) < 1 mo. prior; 20% (4) completed ACLS > 6 mo. prior. For those within the past 6 months, the average score on the initial quiz was 67%. For those > 6 mo. ago, the average score was 56%. In order to attain credit, both rhythm identification and initial management had to be correct. The total average score was 65%. The two rhythms that had more incorrect answers were SVT and TdP. After the code rhythm review and feed back from an intensivist, the post quiz average was 95%. Conclusions: Time from ACLS training affects interns’ ability to recognize rhythms and determine the right management strategy. A review course for all interns before residency starts is important because it improves their ability to recognize correct rhythms. Simulation training can assist with this goal.

273: OUTCOMES AND DISPOSITIONS AMONG PATIENTS SUFFERING IN-HOSPITAL CARDIAC ARREST

Crit Care Med 2016 • Volume 44 • Number 12 (Suppl.) (0.77) and final (0.74) CI than for change in CI (0.92); AUC values for initial (0.48), final (0.67) and change in LVEF (0.71) were lower than for CI values. Conclusions: LVEF, SV, and CI all increased on repeat inpatient TTE after OHCA, but these changes were smaller in patients who died during follow-up. Transient reductions in systolic function early after OHCA may be benign.

West Nile virus and the 2012 outbreak: The Baylor University Medical Center experience.

West Nile virus (WNV) has been responsible for multiple outbreaks and has shown evolution in its clinical manifestation. The Centers for Disease Control and Prevention has provided diagnostic criteria in classifying the variety of WNV infection; however, application of these criteria can prove challenging during outbreaks, and understanding the array of presentations and patient population is clinically important. In this article, we present the challenges encountered during the 2012 outbreak at one institution.