Gabriel Wardi

Right ventricle dysfunction and echocardiographic parameters in the first 24 h following resuscitation in the post-cardiac arrest patient: A retrospective cohort study

OBJECTIVES To describe the echocardiographic parameters of the right ventricle (RV) in first 24h post-cardiac arrest (CA) in humans; to determine if the etiology of arrest predicts RV dysfunction; to quantify parameters of the right ventricle in the first 24h post-CA. DESIGN Retrospective cohort study. Arrests were categorized by as circulatory, respiratory, or arrhythmia. RV fractional area change (RVFAC), longitudinal strain (LS), tricuspid annular plane systolic excursion (TAPSE), and right ventricular dimensions were evaluated. We defined RV dysfunction as the presence of an abnormal RVFAC, TAPSE or LS based on the latest echocardiographic guidelines. Structural abnormalities were defined as the presence of abnormal longitudinal strain, RV mid-diameter, basal diameter and RV end diastole/systole. SETTING Two academic inpatient facilities between 2010 and 2013. PATIENTS All patients with successful resuscitation following CA with a technically adequate echocardiogram within 24h. MEASUREMENTS AND MAIN RESULTS Fifty-nine patients met inclusion criteria. Nineteen subjects had CA from a circulatory etiology, 23 from arrhythmias, and 17 from respiratory causes. Fifty-two of 59 patients met criteria for having functional anomalies of the RV. There was no statistical difference between the etiology of CA and the presence of RV dysfunction (p=0.106). Fifty-seven of 59 patients had evidence of structural abnormalities. CONCLUSIONS RV dysfunction is present in the majority of post-CA patient regardless of the etiology of arrest. Further studies are needed to investigate if there are relationships between echocardiographic findings and survival and to assess temporal findings of RV function post-CA.

A case of delayed presentation of thigh compartment syndrome.

BACKGROUND Thigh compartment syndrome is a rare and devastating process. It generally occurs within hours to days of a traumatic event, although cases have been reported nearly 2 weeks after the initial event. OBJECTIVES To evaluate the literature describing the timing between inciting event and presentation of thigh compartment syndromes, with a focus on delayed presentations of this rare condition. To describe the unique properties of thigh compartments, and finally, to review the anatomy and techniques needed to measure the compartment pressures of the thigh. CASE REPORT A case of a 54-year-old man is presented. He sustained trauma to his thigh 17 days prior to presenting to our ED with severe, sudden-onset pain in his right thigh. Compartment pressures were measured and confirmed the diagnosis of compartment syndrome caused by two large intramuscular hematomas. No other contributing events were identified. CONCLUSIONS Compartment syndrome in the thigh should be considered in patients with a concerning examination and a history of recent trauma. This particular case represents the longest reported time between injury and development of a thigh compartment syndrome.

Propofol Use for Toxin‐Related Seizures

The use of propofol as treatment of toxin‐induced seizures is unclear. The goal of this study was to characterize the use of propofol for toxin‐related seizures as reported to a statewide poison system.

Increased Risk of Death, in the Hospital and Outside the Intensive Care Unit, for Patients With Cirrhosis After Cardiac Arrest

Increased Risk of Death, in the Hospital and Outside the Intensive Care Unit, for Patients With Cirrhosis After Cardiac Arrest Megan E. Reinders,* Gabriel Wardi,* Ricki Bettencourt, Daniel Bouland,* Jessica Bazick,* Michel Mendler,k Irine Vodkin,k Denise Kalmaz,k Thomas Savides,k David Brenner,k Rebecca E. Sell, and Rohit Loomba§,k *Division of Internal Medicine, Division of Pulmonary and Critical Care, kDivision of Gastroenterology, Department of Medicine, Division of Epidemiology, Department of Family Medicine and Public Health, University of California at San Diego, La Jolla, California

An Unusual Case of an Icteric Infant with Abdominal Distention

BACKGROUND Jaundiced infants are uncommon in most emergency departments (EDs). Biliary rupture remains one of the more rare and less described causes of this condition. CASE REPORT A 5-month-old male presented to our ED with scleral icterus, increasing abdominal distention, and increased irritability. A bedside ultrasound revealed a moderate amount of ascites and further imaging suggested he had a rupture of his common bile duct. Surgical exploration confirmed this and revealed the presence of choledocholithiasis, which was the likely cause of the rupture. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Biliary rupture remains a rare but serious condition in very young patients. Emergency physicians should consider bedside ultrasound as an adjunct in undifferentiated abdominal distention or jaundice in this patient population.

Stenotrophomonas maltophilia Necrotizing Soft Tissue Infection in an Immunocompromised Patient

Introduction To report on the first recorded case of necrotizing soft tissue infection (NSTI) in an immunocompromised individual caused by Stenotrophomonas maltophilia in the Western Hemisphere and highlight the challenges that medical providers face in promptly diagnosing and treating NSTI in this highly vulnerable patient population. Case Presentation We report a case of NSTI caused by S. maltophilia in a neutropenic patient admitted for treatment of acute lymphoblastic leukemia. The patient presented with laboratory and clinical findings atypical for a NSTI that may have confounded its diagnosis and delayed surgical intervention. Despite aggressive medical care and surgical debridement, the patient unfortunately passed away due to overwhelming septic shock. Conclusions Providers should consider atypical organisms as causative in NSTI in immunocompromised patients and recognize that these patients may present without classic clinical and laboratory findings.

The DAGMAR Score: D-dimer assay-guided moderation of adjusted risk. Improving specificity of the D-dimer for pulmonary embolism.

&NA; We generated a novel scoring system to improve the test characteristics of D‐dimer in patients with suspected PE (pulmonary emboli). Electronic Medical Record data were retrospectively reviewed on Emergency Department (ED) patients 18 years or older for whom a D‐dimer and imaging were ordered between June 4, 2012 and March 30, 2016. Symptoms (dyspnea, unilateral leg swelling, hemoptysis), age, vital signs, medical history (cancer, recent surgery, medications, history of deep vein thrombosis or PE, COPD, smoking), laboratory values (quantitative D‐dimer, platelets, and mean platelet volume (MPV)), and imaging results (CT, VQ) were collected. Points were designated to factors that were significant in two multiple regression analyses, for PE or positive D‐dimer. Points predictive of PE were designated positive values and points predictive of positive D‐dimer, irrespective of presence of PE, were designated negative values. The DAGMAR (D‐dimer Assay‐Guided Moderation of Adjusted Risk) score was developed using age and platelet adjustment and points for factors associated with PE and elevated D‐dimer. Of 8486 visits reviewed, 3523 were unique visits with imaging, yielding 2253 (26.5%) positive D‐dimers. 3501 CT scans and 156 VQ scans were completed, detecting 198 PE. In our cohort, a DAGMAR Score < 2 equated to overall PE risk < 1.2%. Specificity improved (38% to 59%) without compromising sensitivity (94% to 96%). Use of the DAGMAR Score would have reduced CT scans from 2253 to 1556 and lead to fewer false negative results. By considering factors that affect D‐dimer and also PE, we improved specificity without compromising sensitivity.

Factors and outcomes associated with inpatient cardiac arrest following emergent endotracheal intubation

BACKGROUND Inpatient peri-intubation cardiac arrest (PICA) following emergent endotracheal intubation (ETI) is an uncommon but potentially preventable type of cardiac arrest (CA). Limited published data exist describing factors associated with inpatient PICA and patient outcomes. This study identifies risk factors associated with PICA among hospitalized patients emergently intubated out of the operating room and compares PICA to other types of inpatient CA. METHODS Retrospective case-control study of patients at our institution over a five-year period. Cases were defined as inpatients emergently intubated outside of the operating room that experienced cardiac arrest within 20min after ETI. The control group consisted of inpatients emergently intubated out of the operating room without CA. Predictors of PICA were identified through univariate and multivariate analysis. Clinical outcomes were compared between PICA and other inpatient CAs, identified through a prospectively enrolled CA registry at our institution. RESULTS 29 episodes of PICA occurred over 5 years, accounting for 5% of all inpatient arrests. Shock index ≥1.0, intubation within one hour of nursing shift change, and use of succinylcholine were independently associated with PICA. Sustained ROSC, survival to discharge, and neurocognitive outcome did not differ significantly between groups. CONCLUSION Patients outcomes following PICA were comparable to other causes of inpatient CA. Potentially modifiable factors were associated with PICA. Hemodynamic resuscitation, optimized staffing strategies, and possible avoidance of succinylcholine were associated with decreased risk of PICA. Clinical trials testing targeted strategies to optimize peri-intubation care are needed to identify effective interventions to prevent this potentially avoidable type of CA.

Evaluating vancomycin and piperacillin-tazobactam in emergency department patients with severe sepsis and septic shock

Study objective: To determine the frequency and cause of inadequate initial antibiotic therapy with vancomycin and piperacillin‐tazobactam in patients with severe sepsis and septic shock in the emergency department (ED), characterize its impact on patient outcomes, and identify patients who would benefit from an alternative initial empiric regimen. Methods: Retrospective cohort study conducted between 2012 and 2015 in which 342 patients with culture‐positive severe sepsis or septic shock who received initial vancomycin and piperacillin‐tazobactam were reviewed to determine appropriateness of antimicrobial therapy, risk factors for inappropriate use, and outcome data. Univariate and multivariate regression analyses were determined to identify associations between inappropriate antibiotic use and outcomes and to identify risk factors that may predict which patients would benefit from an alternative initial regimen. Results: Vancomycin and piperacillin‐tazobactam were inappropriate for 24% of patients with severe sepsis or septic shock, largely due to non‐susceptible infections, particularly ESBL organisms and Clostridium difficile. Risk factors included multiple sources of infection (OR 4.383), admission from a skilled nursing facility (OR 3.763), a history of chronic obstructive pulmonary disease (COPD) (OR 3.175), intra‐abdominal infection (OR 2.890), and immunosuppression (OR 1.930). We did not find a mortality impact. Conclusion: Vancomycin and piperacillin‐tazobactam were an inappropriate antibiotic combination for approximately 24% of patients with either severe sepsis or septic shock in the ED. Patients with known COPD, residence at a skilled nursing facility, a history concerning for Clostridium difficile, and immunosuppression would benefit from an alternative regimen. Future prospective studies are needed to validate these findings.

Anti-N-Methyl-D-Aspartate Receptor Encephalitis, an Underappreciated Disease in the Emergency Department.

Anti-N-Methyl-D-Aspartate Receptor (NMDAR) Encephalitis is a novel disease discovered within the past 10 years. Antibodies directed at the NMDAR cause the patient to develop a characteristic syndrome of neuropsychiatric symptoms. Patients go on to develop autonomic dysregulation and often have prolonged hospitalizations and intensive care unit stays. There is little literature in the emergency medicine community regarding this disease process, so we report on a case we encountered in our emergency department to help raise awareness of this disease process.