Nidhi Aggarwal

Methylene blue reverses recalcitrant shock in β-blocker and calcium channel blocker overdose

β-blocker and calcium channel blocker toxicity generally present with bradycardia and hypotension. A 69-year-old woman presented after a suicide attempt with a β-blocker and calcium channel blocker overdose. Her blood pressure was 69/35 mm Hg and her HR was in the 40s. She was treated with calcium chloride, glucagon, a dextrose–insulin infusion and three vasopressors, but remained hypotensive. She suffered two cardiac arrests and required a transvenous pacemaker. When all interventions failed, she was started on a methylene blue infusion for refractory vasodilatory shock which resulted in a dramatic improvement in her blood pressure. The patient was successfully weaned off all vasopressors and from mechanical ventilation without any end-organ damage.

Pulmonary artery catheter coiled in the main pulmonary artery trunk.

Pulmonary artery (PA) catheterisation has been performed for over four decades. It is utilised in intensive care units and perioperatively to titrate fluid and pressor therapy. Major and minor complications have been reported. The catheter can infrequently loop and coil in the right atrium, right ventricle and superior vena cava .We report a case of coiling of the PA catheter in the main PA. A 33-year-old woman was admitted with multiorgan failure and shock. She required mechanical ventilation, was in severe pulmonary oedema and required vasopressors for shock. We placed a PA catheter to assist in the management of her haemodynamic collapse. The catheter coiled in the main pulmonary trunk, which is extremely rare. The catheter was removed without any complications.

Immeasurable glycosylated haemoglobin: a marker for severe haemolysis

Glycosylated haemoglobin (HbA1c) is a measurement commonly performed in patients with diabetes. Factors causing a change in the life span of the red blood cell (RBC) can affect the measurement of HbA1c. Thus haemolysis is an important factor that may affect the HbA1c level determination. Haemolysis has been shown to cause a falsely low HbA1c. A 62-year-old man with a history of autoimmune haemolytic anaemia was admitted for severe haemolytic anaemia and an Hb of 2.9 g/dL. HbA1c tested during hospitalisation was unrecordable due to the extremely low Hb. The patient was treated with intravenous steroids, immunoglobulin, fluids and RBC transfusions but continued to haemolyse and eventually expired. We emphasise that an extremely low HbA1c level can serve as a marker of haemolysis and an unrecordable HbA1c level may point towards fatal haemolysis.

Chronic Lymphocytic Leukemia: A Rare Cause of Pathological Fracture of the Femur

The incidence rate of chronic lymphocytic leukemia (CLL) in the United States is approximately 0.005%; men are at slightly higher risk than women. Bony involvement or pathological fracture rarely occurs in CLL, and it may be the initial presentation. An 85-year-old woman presented with acute respiratory failure secondary to pneumonia. Symptomatology included dyspnea. She was found to have pathological fracture of the femur caused by CLL. The diagnosis of CLL had been made 6 years previously, but the patient had refused therapy. On admission, the patient required endotracheal intubation, mechanical ventilation, and admission to the medical intensive care unit. Endotracheal intubation extubation was successful after 48 hours. The patient then complained of severe left knee pain. Bone radiograph and femoral computed tomography scan revealed acute pathological fracture of the left distal femur. There was no history of trauma. The fracture was stabilized with extension lock splint. Pathological fracture in patients with CLL is associated with hypercalcemia, Richter’s transformation, or multiple myeloma. This patient exemplifies the fact that pathological fracture can be caused by CLL in the absence of hypercalcemia, Richter’s transformation, or multiple myeloma and can be the initial presentation of CLL.

Enterovirus-Human Rhinovirus: A Rare Cause of Acute Respiratory Distress Syndrome:

A 22-year-old Asian woman presented with respiratory distress, cough, and wheezing for 1 week. Prior history included asthma and Turner syndrome. On presentation to the emergency department, the patient was hypotensive, tachycardic, tachypneic, with an oxyhemoglobin saturation in the mid 80% range while breathing ambient air. Chest radiograph revealed pulmonary vascular congestion and a left lower lobe infiltrate. Endotracheal intubation, mechanical ventilation, and vasopressors were initiated. Empiric therapy for community-acquired pneumonia was administered utilizing broad-spectrum intravenous antibiotics. Routine sputum culture was negative for pathogens. Nasopharyngeal swab submitted for multiplex amplified nucleic acid testing yielded enterovirus-human rhinovirus (EV-HRV). Thus, the diagnosis of EV-HRV pneumonia complicated by acute respiratory distress syndrome (ARDS) was established. Multiple attempts to wean from the ventilator were unsuccessful, and a tracheostomy was performed. This report highlights EV-HRV as a cause of severe ARDS and prolonged respiratory failure in adults.

Authenticity and Reliability of the Cardiac Monitor Alarms in the ICU: A Patient Safety Concern Due to Alarm Fatigue

PURPOSE: It is desirable for the cardiac monitor (CM) to have a high sensitivity. Frequent alarms may cause alarm fatigue of the medical personnel leading to delayed or no response to the alarms, which could jeopardize patient’s safety. The impact of following standard processes/protocols such as pertinent skin preparation, changing electrocardiogram (EKG) leads daily, customization of alarm parameters, and education of the nursing staff to reduce the false alarms remains unclear. The aim of this study was to analyze the accuracy of the CM alarms in the intensive care unit (ICU) with utilization of the standard protocol.

Altered mental status and complete heart block: an unusual presentation of aspirin toxicity

Aspirin is one of the most commonly used medications. We report a patient who presented with severe weakness, altered mental status and complete heart block requiring temporary pacing. Despite the patients family denying that the patient used aspirin, an arterial blood gas that revealed a respiratory alkalosis and metabolic acidosis suggested the diagnosis of salicylate toxicity. The salicylate level was extremely elevated and the patient was successfully treated with haemodialysis. Our case illustrates that salicylate toxicity should be considered in a patient with a combined metabolic acidosis and respiratory alkalosis. A prompt salicylate level should be obtained. This is also the first case of salicylate toxicity causing complete heart block in an adult. The heart block resolved with treatment of the salicylate toxicity.