ST-SEGMENT-ELEVATION MYOCARDIAL INFARCTION in COVID-19

Introduction: The Severe Acute Respiratory Syndrome Coronavirus-2 have been associated with cardiovascular adverse events including acute myocardial infarction due to a prothrombotic and hypercoagulable status, and endothelial dysfunction. Case report: We report the case of a 62-year-old women, admitted to the hospital via the emergency room for acute chest pain and dyspnea. A nasopharyngeal swab was positive for COVID19 real-time reverse transcriptase-polymerase chain reaction 11 day ago. On admission, she was hypotensive with systolic blood pressure measering 87 mmHg and tachycardic with 117 beats/min, oxygen saturation (SO2) was 94%. An 18-lead ECG revealed an infero-postero-lateral ST-elevation myocardial infarction with right ventricular involvement and a seconddegree- Mobitz Type 1 atrioventricular block. The coronary angiography from the right femoral artery showed acute thrombotic occlusion of the first diagonal branch with TIMI 0 flow and acute thrombotic occlusion of proximal right coronary artery with TIMI 0 flow. The most likely diagnosis was myocardial infarction secondary to a non-atherosclerotic coronary occlusion. The angioplasy was performed with dilatations with a semi compliant balloon, bailout implant of BMS, manual thrombus aspiration and intracoronary injection of tirofiban in the right coronary artery. The myocardial revascularization was ineffective. The patient developed significant severe hemodynamic instability and cardiac arrest for pulseless electric activity after 24 hours. Conclusion(s): The COVID-19 outbreak implies deep changes in the clinical profile and therapeutic management of STEMI patients who underwent PCI. At present, the natural history of coronary embolism is not well understood;however, the cardiac mortality rate are hight. This suggests these patients require further study to identify the natural history of the condition and to optimize management to improve outcome.

Coronary Artery Calcium Score: Current Efficacy of Cardiac CT in Patients at Hail Region, Saudi Arabia

Calcium levels in the Coronary Artery are an indicative marker of the presence and extent of atherosclerosis. This serves as an additional prognostic indicator in addition to traditional risk factors. Moreover, the coronary calcium test is associated with a descriptor known as the calcium score or calcium score (Cs), which is primarily useful for stratifying the risk of asymptomatic patients, while for patients with acute or chronic chest pain, coronary axial computed tomography is generally required. A retrospective analysis of data was conducted in the radiology department of King Salman Specialist Hospital in Hail City, the kingdom of Saudi Arabia, between January and May 2022. A total of 40 patients were randomly selected, 25 males and 15 females. The study included all patients with or suspected of having a calcium deposit who underwent a CT scan using the Siemens SOMATOM definition MDC scan. Patients underwent a scan with the preparations and laboratory tests required for their coronary artery calcium scores. In this study, males were more likely to be affected by calcium deposits (64%), whereas females were 36%. Approximately 50 percent of the study populations were found to be normal (no identifiable calcium deposits) and 37.5% to have moderate calcium deposits. There is a significant association between CACS and moderate CVD risks based on age and gender in this study. Better control of cardiovascular system (CVS) risks is recommended in all primary care centers in the Kingdom of Saudi Arabia (KSA).Copyright © 2022 International Journal of Pharmaceutical Research and Allied Sciences. All rights reserved.

Traditional Cardiopulmonary Resuscitation In Cardiac Arrest For Patients On Venovenous Extracorporeal Membrane Oxygenation

Introduction: Mortality for patients on VV-ECMO remains high despite increased use during the COVID-19 pandemic. Unlike VA-ECMO which provides life support for cardiac failure and can be used as a bridge to definitive therapy during cardiac arrest (e-CPR), patients who arrest while on VV-ECMO currently may undergo traditional cardiopulmonary resuscitation (CPR). This poses many challenges such as potential cannula position disruption of the VV-ECMO system during compressions and it is unclear if patients on VV-ECMO will benefit from being offered traditional CPR. Hypothesis: Traditional CPR is effective in patients who arrest while on VV-ECMO. Method(s): A retrospective chart review of inpatient cardiac arrest data from a high-volume ECMO center was performed. Patients who arrested while on VV-ECMO were included. Data including demographics, etiology of arrest, return of spontaneous circulation (ROSC) and survival to discharge were reviewed. Survival data was compared with the ECLS International Summary of Statistics. Result(s): We identified 19 patients on VV-ECMO who underwent CPR for cardiac arrest between September 2012 and November 2021. The average age of the patients was 42.7 years and 89.5% (n=17) were men. Seven of the nineteen total patients (36.8%) were being treated for ARDS from COVID-19 pneumonia. The arrest occurred on average 35.6 days into hospitalization (range: 1-132 days). The initial rhythm was pulseless electrical activity in 13 patients (68.4%), and the etiologies of arrest included hypoxemia (n=10, 52.6%), ECMO machine failure or during oxygenator exchange (n=3, 15.8%), pneumothorax (n=2, 10.5%), and cardiac tamponade (n=1, 5.3%). ROSC occurred in all 19 patients (100%), however only 4 patients (21.1%) survived to discharge with good neurologic recovery. Survival to discharge for all-comers on VV-ECMO is 66%. Conclusion(s): While there is limited evidence for the effectiveness of traditional CPR for patients on VV-ECMO, in this sample, ROSC was universal and one-fifth of patients survived to discharge. Future studies should continue to study the utility of CPR on VV-ECMO and how to optimize technique to improve outcomes for these critically-ill patients.

Covid-19 Cardiac Arrest: Resuscitate Or Not?

Introduction: Coronavirus disease 2019 (COVID-19) has been associated with high in-hospital mortality. Since the implementation of guidelines and improvement in the quality of cardiopulmonary resuscitation (CPR), the survival rate for non-COVID-19 patients has improved. There is, however, scarce data regarding in-hospital cardiac arrest outcomes in COVID-19 patients. This study aimed to investigate cardiac arrest outcomes in patients hospitalized for COVID-19. Method(s): Retrospective study of the data of 994 adult patients admitted to a single-center high acuity critical care COVID-19 unit between March 2020 and February 2022 with COVID-19 diagnosis. Patients who underwent CPR were identified. Resuscitation registers and demographic information were obtained. The primary outcome was survival to hospital discharge. Secondary assessments were the initial rhythm and duration of CPR. Descriptive statistics were utilized. Result(s): A total of 994 COVID-19 patients were included in the study. 129 (13%) had a cardiac arrest and underwent CPR. Two patients survived hospital discharge (1.6%). Of them, 91(70.5%) were male. Mean age was 68.6 (+/-13.5) years. Median BMI was 29.1 [25.8-35.7] Kg/m2. The most frequent comorbidity was hypertension in 59 patients (46.1%), followed by diabetes type 2 in 30 patients (23.4%), and there were 37 (28.9%) patients with no comorbidities. The median time from admission to cardiac arrest was 12[6-18.5] days, the most common rhythm at the time of cardiac arrest was asystole in 94 (72.9%) patients, followed by pulseless electrical activity in 25 (19.4%);Ventricular dysrhythmias occurred in 7 (5.5%)of the cases. Finally, the median duration of CPR was 20[13.7-29] minutes. Conclusion(s): Survival of COVID-19 patients after in-hospital cardiac arrest was dismal, despite the adequate implementation of resuscitation protocols. Many of these patients were overweight or obese with comorbid conditions. The most common presenting rhythm was a non-shockable rhythm.

USE OF POINT-OF-CARE ULTRASONOGRAPHY (POCUS) TO PREVENT DILTIAZEM-INDUCED CARDIOGENIC SHOCK

SESSION TITLE: Using Imaging for Diagnosis Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Point of care ultrasonography (POCUS) uses an ultrasound technique that helps physicians augment physical examination findings and guide clinical decision-making at the bedside. We present a case that became a watershed moment for internal medicine residents at Abington Jefferson Hospital to use POCUS for every patient with atrial flutter/fibrillation with RVR prior to initiating diltiazem drip. CASE PRESENTATION: A 73-year-old male presented to the emergency department with complaints of palpitations. He was tachycardic with a heart rate in the 150s, and his rhythm was irregular. His basic labs were normal;an electrocardiogram investigation showed that he was experiencing an atrial flutter with 2:1 and 3:1 blocks. Chest X-ray was clear. He was given IV metoprolol 10 mg twice without achieving rate control and then started on a diltiazem drip, which initially improved his heart rate to 70s with rhythm changing to atrial flutter with 4:1 block. However, he started to become hypoxic, requiring intubation and then hemodynamically unstable, requiring initiation of pressors. Postintubation CXR indicated bilateral diffuse pulmonary edema and vascular congestion. Subsequently, he had Pulseless electrical activity (PEA) arrest. Return of spontaneous circulation (ROSC) was achieved after 3 minutes of chest compression and one round of epinephrine injection. Transthoracic echocardiogram showed an ejection fraction of 10%. He had a right heart catheterization which showed a CI of 1.7 and elevated PCWP and RVP. He was started on milrinone for ionotropic support and needed norepinephrine, vasopressin and phenylephrine to sustain his blood pressure. DISCUSSION: Atrial flutter and fibrillation are routinely seen arrhythmias in hospital settings. Patients with irregular rhythm who are in rapid ventricular rate and normotensive are often given IV metoprolol few times and then started on a diltiazem drip if RVR continues. Diltiazem not only decreases heart rate (negative chronotropic) but also decreases ventricular squeeze (negative ionotropic). It is contraindicated in patients with reduced ejection fraction. Patients’ ejection fraction values are not always known, especially if they have never had a transthoracic echocardiogram in the past or prior records are not available. POCUS helps physicians and residents to access and estimate LV function quickly and augments clinical decision making at the bedside. CONCLUSIONS: Internal Medicine Residents at Abington Hospital have made it a part of their protocol to always perform bedside ultrasonography in patients with atrial flutter/fibrillation with rapid ventricular rate before initiating diltiazem drip to prevent further avoidable cardiogenic shocks. Reference #1: Fey H, Jost M, Geise AT, Bertsch T, Christ M. Kardiogener Schock nach bradykardisierender Therapie bei tachykardem Vorhofflimmern : Fallvorstellung einer 89-jährigen Patientin [Cardiogenic shock after drug therapy for atrial fibrillation with tachycardia : Case report of an 89-year-old woman]. Med Klin Intensivmed Notfmed. 2016 Jun;111(5):458-62. German. doi: 10.1007/s00063-015-0089-9. Epub 2015 Oct 6. PMID: 26440099. Reference #2: Bitar ZI, Shamsah M, Bamasood OM, Maadarani OS, Alfoudri H. Point-of-Care Ultrasound for COVID-19 Pneumonia Patients in the ICU. J Cardiovasc Imaging. 2021 Jan;29(1):60-68. doi: 10.4250/jcvi.2020.0138. PMID: 33511802;PMCID: PMC7847790. Reference #3: Murray A, Hutchison H, Popil M, Krebs W. The Use of Point-of-Care Ultrasound to Accurately Measure Cardiac Output in Flight. Air Med J. 2020 May-Jun;39(3):218-220. doi: 10.1016/j.amj.2019.12.008. Epub 2020 Jan 14. PMID: 32540116. DISCLOSURES: No relevant relationships by Fnu Aisha No relevant relationships by Lucy Checchio No relevant relationships by Ans Dastgir No relevant relationships by Shravya Ginnaram No relevant relationships by Syeda Hassan No relevant relationships by Chaitra Janga No relev nt relationships by Rameesha Mehreen No relevant relationships by Rahat Ahmed Memon No relevant relationships by Binod Poudel No relevant relationships by Shreeja Shah

ACUTE HEPATIC SEQUESTRATION CRISIS: AN OFTEN UNDERDIAGNOSED AND FATAL SYNDROME

SESSION TITLE: Critical Renal and Endocrine Disorders Case Report Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Sickle Cell Disease (SCD) is an autosomal recessive disease characterized by an abnormal beta-globin chain of hemoglobin (Hb) that leads to malformed sickled cells with a multitude of downstream microvascular occlusions and anemia. While splenic infarction is by far the most common gastrointestinal (GI) manifestation, vaso-occlusion may occur in the liver, leading to an acute hepatic crisis. Acute hepatic sequestration of sickled erythrocytes is an exceedingly rare manifestation. CASE PRESENTATION: A 43-year-old man with homozygous sickle cell disease complicated by End-Stage renal disease was admitted with generalized malaise, right upper quadrant (RUQ) abdominal pain, nausea and vomiting. He was febrile with a temperature of 38.1°C, hypotensive with a blood pressure of 93/61 mmHg and tachycardic with a heart rate of 120 bpm. He was lethargic and uncomfortable with diffuse abdominal tenderness without guarding. Due to concern for septic shock, blood cultures, COVID PCR and influenza were obtained, and the patient was rapidly transferred to the intensive care unit for closer monitoring. Empiric vancomycin and cefepime were started promptly. The initial hemoglobin level was 6.1mg/dL with a leukocytosis of 31.2 K/CUMM and absolute neutrophil count of 21.8 K/CUMM;total hyperbilirubinemia of 17.45 mg/dL, direct hyperbilirubinemia of 11.46mg/dL and elevated INR at 1.66. Computed tomography of the abdomen and pelvis without contrast showed a known 4 cm cystic lesion of the right hepatic lobe and atrophic kidneys. Duplex flow of the abdomen and pelvis showed no portal vein thrombosis and patent flow in the portal vein and artery. Over the course of several hours, the patient's hemoglobin dropped to 3.8mg/dL with a steep rise in LDH and total bilirubin to 632 U/L and 27.04 mg/dL, respectively consistent with hepatic sequestration crisis. Patient was transfused with two units of packed red blood cells, fluid hydration and initiation of erythrocyte exchange transfusion. Prior to receiving exchange transfusion, the patient experienced rapid clinical deterioration with subsequent pulseless electrical activity. Return of spontaneous circulation was achieved transiently however patient's family at this point opted for palliative measures and the patient passed away shortly thereafter. DISCUSSION: Complications of SCD manifest in multiple organ systems. One of the few acute manifestations, hepatic sequestration crisis, is often unfamiliar to many clinicians and left unrecognized, results in poor clinical outcomes. It is rarely encountered and treatment options with blood and, more importantly, exchange transfusion remains often underutilized. CONCLUSIONS: Acute hepatic sequestration crisis is an often-unrecognized manifestation of SCD in which delay in diagnosis and prompt treatment with exchange and blood transfusions may impart a significant risk of mortality in an already prone patient population. Reference #1: Shah R, Taborda C, Chawla S. Acute and chronic hepatobiliary manifestations of sickle cell disease: a review World J Gastrointestinal Pathophysiology 2017;8(3): 108-116 Reference #2: Norris W. Acute hepatic sequestration in sickle cell disease. J of the National Medical Association 2004;96: 1235-1239 Reference #3: Praharaj D, Anand A. Sickle Hepatopathy J of Clinical and Experimental Hepatology 2021;11: 82-96 DISCLOSURES: No relevant relationships by Karim Dirani No relevant relationships by Georgiana Marusca No relevant relationships by Aryan Shiari

BOOZE, BETAS, AND A FATTY SOLUTION TO SPARE PANDEMIC WOES

SESSION TITLE: Cases of Overdose, OTC, and Illegal Drug Critical Cases Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: The COVID-19 pandemic raised economic strife, social isolation, fear from contagion, and anxiety to a level where 45% of surveyed U.S. adults report a detriment to their mental health. With U.S. suicide rates up from 10 to 14 cases per 100,000 over the past 20 years, the health and safety of a vulnerable mental health population becomes more of a concern. We report a case of an individual with depression who was resuscitated after severe toxicity from alcohol and beta-blocker ingestions. CASE PRESENTATION: A 58-year-old woman with prior suicide attempts was found in an obtunded state after finishing a 20-pack of beer and swallowing a propranolol 20 mg pill bottle. On admission, she presented with bradycardia, hypotension, and alteration to a Glasgow Coma Scale of 9 with emesis residue on her face. Her blood gas revealed an anion-gap metabolic acidosis with a pH of 7.26, lactate of 2.53, normal potassium and calcium, and glucose of 134 mg/dL. Toxicity labs were notable for an alcohol of 199 mg/dL. Her EKG demonstrated a junctional bradycardia with a p-wave complex after the QRS consistent with retrograde depolarization of the atrium (Image 1). She was intubated to protect her airway. She subsequently developed cardiac arrest secondary to pulseless electrical activity. She underwent CPR for 33 minutes with boluses of intravenous epinephrine, glucagon, insulin, calcium gluconate, and sodium bicarbonate prior to return of spontaneous circulation. Due to failure of transcutaneous pacing, a transvenous pacer was placed. In concert with Poison Control, she was started on an a euglycemic insulin drip and an intralipid infusion. Her hemodynamics improved, and she was weaned off pacing and ICU interventions within 24 hours. She was discharged a week after admission with no residual morbidities. DISCUSSION: Overdose from nonselective beta-blockers can result in bradycardia, hypotension, seizures, QRS widening, QTc prolongation with ventricular tachy-arrhythmias, hyperkalemia, and hypoglycemia. Understanding the pharmacodynamics of beta-blocker toxicity enables targeted interventions to improve: chronotropy with epinephrine, glucagon, and pacing;inotropy with insulin, calcium, glucagon, and phosphodiesterase inhibitors;QRS widening with sodium bicarbonate;and QTc prolongation with magnesium or lidocaine. The high lipid solubility of propanol allows for intravenous lipid infusions to aid in drug elimination for patients in refractory cardiogenic shock. CONCLUSIONS: Despite a lack of labs for monitoring beta blocker toxicity, our case demonstrates successful resuscitation in a severe overdose. Perhaps an absence of hyperkalemia, hypoglycemia, QRS and QTc changes, and tachy-arrhythmias in this incident portended to a decreased morbidity and mortality. Ultimately, we reaffirmed the role of intralipid infusions as a critical treatment adjunct for recovery from cardiogenic shock secondary to beta blockade. Reference #1: Sher L. The impact of the COVID-19 pandemic on suicide rates. QJM. 2020;113(10):707-712. Reference #2: Kerns W 2nd. Management of beta-adrenergic blocker and calcium channel antagonist toxicity. Emerg Med Clin North Am. 2007;25(2):309-viii. Reference #3: Anderson AC. Management of beta-adrenergic blocker poisoning. Clin Pediatr Emerg Med. 2008;9(1):4–16. DISCLOSURES: No relevant relationships by Jackie Hayes No relevant relationships by Andrew Salomon

CARDIAC TAMPONADE SECONDARY TO COVID-19 INFECTION

SESSION TITLE: Infections In and Around the Heart Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Due to the novelty of COVID-19 virus, complications of this severe respiratory infection are continually emerging. The inflammatory response to the virus carries a high mortality rate and can lead to a variety of cardiothoracic complications such as acute coronary syndrome, thromboembolism, and heart failure [1]. Here, we present a case of a young female who suffered cardiac tamponade (CT) from a pericardial effusion (PEEF) attributed to COVID-19 infection, which has only been described a handful of times in the literature. CASE PRESENTATION: A 33-year-old female with a history of Down syndrome and morbid obesity presented with worsening dyspnea and fever for one week. Her initial oxygen saturation was 50% on room air, and bilevel noninvasive ventilatory support was initiated. Her viral PCR was positive for COVID-19. A computed tomography angiogram of the chest revealed small bilateral pulmonary emboli, diffuse ground-glass consolidations, and small bilateral pleural effusions. Her respiratory status continued to decompensate and she was placed on mechanical ventilation. She became hypotensive requiring vasopressor support. The following morning, an echocardiogram (TTE) revealed an ejection fraction of 40-45% and a new PEEF with early right ventricular diastolic collapse consistent with CT physiology. She underwent emergent pericardiocentesis, and 220 mL of bloody fluid was drained. PEEF studies revealed a glucose level of 186 mg/dL, LDH of 1380 U/L, and protein of 3.0 g/dL. Total nucleated count was 16,545/uL with 68% neutrophils. Gram stain showed a few white blood cells without organisms, and final bacterial, fungal, and acid-fast cultures were negative. A pericardial drain was left in place, but the procedure was complicated by a pneumothorax and a chest tube was placed. A follow-up TTE the next day revealed improvement of the PEEF without signs of CT. A repeat chest x-ray showed resolution of the pneumothorax. Unfortunately, the patient’s oxygenation and hemodynamic status continued to worsen. She eventually suffered cardiac arrest with pulseless electrical activity and succumbed to her illness. DISCUSSION: New knowledge regarding complications of COVID-19 infection is continually emerging. According to a February 2022 systematic review, only 30 cases of severe PEEFs with CT secondary to COVID-19 have been recorded. The mechanism by which PEEFs form is unclear. It is proposed that the entry of the virus into inflammatory cells causes a release of cytokines such as TNF-alpha, IL-1, IL-6, and IL-8. This resulting cytokine storm allows rapid inflammation and infiltration of fluid into the pericardial sac [1]. CONCLUSIONS: In a decompensated patient with COVID-19, a stat TTE should be obtained to rule out PEEF. Physicians must be cognizant of this uncommon yet highly fatal complication in unstable COVID-19 patients, as cardiac tamponade is a potentially reversible cause of cardiac arrest. Reference #1: Kermani-Alghoraishi, M., Pouramini, A., Kafi, F., & Khosravi, A. (2022). Coronavirus Disease 2019 (COVID-19) and Severe Pericardial Effusion: From Pathogenesis to Management: A Case Report Based Systematic Review. Current problems in cardiology, 47(2), 100933. https://doi.org/10.1016/j.cpcardiol.2021.100933 DISCLOSURES: No relevant relationships by Amanda Cecchini No relevant relationships by Arthur Cecchini No relevant relationships by Kevin Cornwell No relevant relationships by Krupa Solanki

Apnoeic oxygenation with a rigid bronchoscope during cardiopulmonary resuscitation

Introduction: The potential utility of apnoeic oxygenation combined with continuous chest compressions during cardiopulmonary resuscitation (CPR) is recognised in ERC Guidelines but is not routinely recommended. Case Presentation: A female 73 years old patient, ASA PS 3, with a recent hospitalization because of COVID 19, was scheduled for lung cancer staging mediastinoscopy. After anesthesia induction, patient exhibited difficult ventilation due to increased airway pressures. Direct bronchoscopy with a fiberoptic bronchoscope was conducted, which revealed trachea compression due to an extra tracheal tumor at the level of the carina. Initially, tumor debulking was attempted with the fiberoptic bronchoscope and, thereafter, with the rigid one. During those attempts, patient suffered a pulseless electrical activity (PEA) cardiac arrest (CA). Immediate CPR with chest compressions was performed. Tracheal occlusion was negotiated with the help of the rigid bronchoscope and apnoeic oxygenation was applied since ventilation with the anesthesia ventilator was not effective (Fig. 1). Chest compressions qualitywas evaluatedby usingdata fromthearterial pressure waveform (Fig. 2). Return of spontaneous circulation (ROSC) was achieved after 10 min CPR and administration of 2 mg of epinephrine. AfterROSC, oral endotracheal intubationwas accomplished and patient was transferred to the ICU (Fig. 3). She remained under sedation for 24hrs and was extubated after 30hrs in good condition. PaCO2 after ROSC was 120mmHg compared to 55 mHg before CA, whereas PaO2 was 230 mmHg compared to 250 mmHg before CA. (Figure Presented) Conclusions: Apnoeic oxygenation is awell-established technique since many years1. It can be combined with several other techniques, can be applied in various clinical settings and is an oxygenation alternative during CPR2

Adult respiratory syncytial virus infection and hypoxic cardiac arrest – Coexistent or causal?

Purpose of the study: Respiratory syncytial virus (RSV) is a wellknown pathogen in pediatric patients. (1) However, it also causes substantial morbidity and mortality in adults, posing a major healthcare problem. (2). Methods:We reviewed a patient suffering from cardiac arrest (CA) and acute RSV infection who was admitted to the Department of Emergency Medicine, Medical University of Vienna, Austria. Results: A 74-year-old male patient complained about dyspnea and later went into CA. Bystander BLS was conducted for 7 minutes, and arriving EMS performed advanced life support (ALS). The initial rhythm check showed pulseless electrical activity. After further 6 minutes of ALS, sustained return of spontaneous circulation (ROSC) was achieved, and the patient was transported to the emergency department (ED). At the ED, the ECG showed no ischemia-like patterns, and point-of-care ultrasound revealed a highly reduced left ventricular function. Laboratory results showed signs of inflammation, and a routine PCR turned out positive for RSV. Awhole body computed tomography revealed no acute pathology, and before a background of chronic pulmonary disease, the CA event was deemed as hypoxic caused by exacerbation of the chronic pulmonary pathologies either parallel to- or directly through an acute RSV infection. Conclusion: An RSV infection should be considered during post- ROSC in adult patients with presumed hypoxic etiology of CA. From a public health perspective, an immune-naivety for RSV caused by the COVID-19 pandemic may potentially induce a rise in cases, morbidity, and mortality in the future.

TCAR Can Safely Be Performed With Regional Anesthesia and No ICU Stay

Objectives: Hospital resource usage is under constant review, and the extent and intensity of postoperative care requirements for vascular surgical procedures has been especially relevant in the setting of the COVID-19 (coronavirus disease 2019) pandemic and its impact on staffed intensive care unit (ICU) beds. We evaluated the feasibility of regional anesthesia and low-intensity postoperative care for patients undergoing transcarotid artery revascularization (TCAR) at our institution. Methods: All patients at high risk for carotid endarterectomy undergoing TCAR at a single institution from 2018 to 2020 were reviewed. Perioperative management was standardized by the use of an institutional protocol that included hemodynamic parameters and requisite medications, anticoagulation and/or antiplatelet regimens, neurovascular examination guidelines, and nursing instructions. The anesthetic modality was at the surgeon’s preference. Patients were transferred to the postanesthesia care unit (PACU) for 2 hours (with a 1:1 or 1:2 nursing ratio) followed by the step-down unit (1:4 nursing ratio) for 4 hours, followed by transfer to the floor (1:6 ratio) or, alternatively, were transferred to the ICU (1:1 ratio). Intravenous (IV) blood pressure medications could be administered in all environments, except for the floor. The recovery location and length of stay were recorded. Results: A total of 83 patients had undergone TCAR during the study period. The mean age was 72 ± 9 years, 59% were men, and 36% were symptomatic. Regional anesthesia was used for 84%, with none converted to general anesthesia intraoperatively. Postoperatively, only seven patients (8%) had required monitoring in the ICU overnight (decided perioperatively). This was mostly for patients with prior neurologic symptoms but for one patient was because of a postoperative neurologic event and for another patient because of pulseless electrical activity arrest. Of the 83 patients, 76 (92%) had been monitored in the PACU, with 8 transferred to the floor after 4 hours and 13 discharged directly from the PACU (owing to limited bed availability). Of the patients in the PACU, 55 were transferred to the step-down unit after 2 hours and discharged from there. Six patients had required IV antihypertensive agents, and eight had required IV vasoactive support postoperatively. The mean length of stay in the ICU was 3.7 days (range, 1-15 days). The mean length of hospital stay was 1.8 ± 2.3 days (3.7 ± 5.4 days for those requiring the ICU and 1.4 ± 1.2 days for those not requiring the ICU). The incidence of stroke, death, and myocardial infarction was 2.4%. There was one postoperative stroke considered to be a recrudescence of a prior stroke, and one respiratory arrest fatality in a frail patient with a neck hematoma, both of whom had been treated under general anesthesia. Conclusions: Using perioperative care protocols, TCAR can safely be performed while avoiding both general anesthesia and an ICU stay for most patients.

Clinical and Social Determinants of Change in Code Status among Patients Hospitalized with Covid-19

Background: Patients hospitalized with COVID-19 who develop cardiopulmonary arrest often have poor prognosis, prompting discussions with families about goals of care. The relationship between clinical and social determinants of code status change is poorly understood. Methods: This retrospective study included adult COVID-19 positive patients admitted to the intensive care unit with cardiac arrest in a multihospital center over the first 9 months of the pandemic (3/1/2020-12/1/2020). Data on medical and social factors was collected and adjudicated. Results: We identified 208 patients over the study timeline. The mean age was 63.7 ± 14.5 years and 54.3% (n=113) were male. The majority of patients with cardiopulmonary arrest had pulseless electrical activity (PEA) as their initial rhythm (91.3%, n=190). Code status was changed in 56.3% (n=117) of patients. The majority of COVID-19 patients with cardiac arrest were Hispanic (53.4%, n=111), followed by African American (27.9%, n=58), and White patients (13.5%, n=28). Race/ethnicity did not affect the rate of code status change. COVID-19 patients who had a code status change were statistically more likely to have a lower salary ($54,838 vs $62,374), have a history of stroke/transient ischemic attack (15.4 vs 4.4%, 18:4), or heart failure (28.2 vs 15.6%, 33:14), all with P<0.05. Patients with code status change had shorter courses of cardiopulmonary resuscitation (11.9 vs 16.9 minutes, P<0.05). Both groups had similar levels of aggressive care received including continuous renal replacement therapy, vasopressor and broad-spectrum antibiotics requirements. Insurance status, ethnicity, religion, and education did not lead to statistically significant changes in code status in COVID patients. Conclusion: Patients hospitalized with cardiopulmonary arrest and positive for COVID-19 are more likely to have a change in code status. This code status change is affected by cardiovascular comorbidities such as stroke and heart failure, along with lower income but not by insurance status, ethnicity, religion, and educational level.

A rare case of cardiogenic shock due to lupus myocarditis in a patient with HIV

INTRODUCTION: Lupus Myocarditis is a rare and severe manifestation of systemic lupus erythematosus. We describe a patient with Human Immunodeficiency Virus (HIV) presenting with cardiogenic shock due to lupus myocarditis. DESCRIPTION: A 33 year old man with history of congenital HIV infection on anti-retroviral therapy, CD4 count 338/ mm3 and undetectable viral load, recurrent Pneumocystis jirovecii pneumonia, disseminated zoster and chronic kidney disease stage 3 presented with shortness of breath for 2 weeks and hypotension with cold extremities and leg edema. Transthoracic echocardiogram demonstrated acute severe biventricular dysfunction with ejection fraction of 10%. CXR showed ground glass opacities with bibasilar consolidation. He was subsequently intubated for acute hypoxic respiratory failure and admitted to the cardiac intensive care unit for management of cardiogenic shock mixed with sepsis due to presumed multifocal pneumonia. He was treated with high dose vasopressors, inotropes and empiric antibiotics. Infectious work up revealed methicillin-resistant Staphylococcus aureus (MRSA) in respiratory culture and negative viral infection including SARS-CoV-2. His course was complicated by worsening renal function with proteinuria and refractory metabolic acidosis required continuous venovenous hemofiltration and he suffered pulseless electrical activity (PEA) arrest with return of spontaneous circulation in 5 minutes. Coronary angiogram was normal. Auto-immune work up revealed elevated serologies: anti-Ds DNA >300 IU/ ml, Anti-Smith Ab: 1 (0-0.9 AI), Anti-chromatin Ab >8 (0 to 0.9 AI) with markedly low complement levels. Endomyocardial biopsy revealed lymphocytic infiltrate in endocardium and myocardium with no granulomas or thrombi. Based on these findings, he was diagnosed with lupus myocarditis and lupus nephritis. The patient clinically improved after treatment with pulse dose steroids and cyclophosphamide. His renal function recovered and cardiac function improved. He was weaned off from the ventilator and discharged to rehabilitation facility. DISCUSSION: Lupus Myocarditis requires urgent clinical attention as it may progress to heart failure and fatal cardiogenic shock. Early diagnosis with high index of suspicion and treatment with steroids and immunotherapy are the keys for better outcome.

Comparison of outcome of cardiopulmonary resuscitation in covid positive versus covid negative patients;a tertiary care hospital experience from pakistan cardiopulmonary resuscitation in covid positive versus covid negative patients

Introduction: The impact of Covid-19 on outcomes of In-hospital cardiac arrest IHCA remains unclear. Aims & Methodology: We, conducted a retrospective cohort study to compare the characteristics and outcome of CPR in Covid positive V/s Covid negative patients, at our institute. Data were retrieved from a review of the medical records of all patients who underwent cardiac arrest during the pandemic period. Taking Covid-19 as the exposure variable, our sample population was divided into two cohorts. Results: Eighty patients who underwent CPR were included in the study with;40 patients in each group. The mean age was 61 in the positive group and 65 in the negative group. The male to female ratio was equal in the covid positive group but the male population was higher in the negative group. (77%). The most frequent comorbidities were the same (Diabetes, hypertension, and ischaemic heart disease) in both groups. All of the patients had ARDS in Covid positive group while septic shock was the commonest diagnosis (48.9%) in the negative group. In the positive group, 74% of patients were in high dependency unit (HDU) and 26% were in ICU. In the negative group,94% of patients were in HDU and 6% in ICU. The initial rhythm was Pulseless electrical activity (PEA) in 52% of the positive group and all of the patients (100%) in the negative group. Eight percent of covid positive patients had shockable rhythm while remaining had asystole. The median duration of CPR was 15 minutes in the positive group and 17 minutes in the negative group. Although the return of spontaneous circulation (ROSC) was achieved in 14% of patients in covid positive, none of them survived to discharge. In the negative group, 30% of patients achieved ROSC while survival to discharge was 15%. The odds of mortality were 6.88 [95% confidence interval (CI)0.789-60] times higher in COVID-19-positive patients, compared to negative patients. Conclusions: Covid-19 infection is associated with poor outcomes in IHCA compared to non-covid illnesses.

Adult and Paediatric Case-based Conference 2020

The proceedings contain 60 papers. The topics discussed include: a rare case of reactive arthritis secondary to COVID-19;parechovirus in a pathologist;adult onset PIMS-TS with secondary haemophagocytic lymphistiocytosis: into the eye of the cytokine storm;persistent non-fulminant COVID-19 infection in a GPA patient on rituximab;a case of hyperinflammatory COVID-19 that responded to tocilizumab therapy;active Bechet's with life threatening arterial disease, complicated by concurrent COVID-19 infection at the peak of the COVID-19 pandemic: did immunosuppression help or hinder?;isolated muscular sarcoidosis revealed by calcitriol-mediated hypercalcaemia and fluorodeoxyglucose positron emission tomography;pulseless electrical activity arrest in a young woman: could renal tubular acidosis due to Sjogren's syndrome be the underlying cause?;back to the future: attempting to distinguish between inflammatory and non-inflammatory back pain;and recognition of subclinical macrophage activation syndrome in an adolescent systemic juvenile idiopathic arthritis patient receiving tocilizumab: a case report.

A Perspective of International Collaboration Through Web-Based Telecommunication-Inspired by COVID-19 Crisis.

The tsunami effect of the COVID-19 pandemic is affecting many aspects of scientific activities. Multidisciplinary experimental studies with international collaborators are hindered by the closing of the national borders, logistic issues due to lockdown, quarantine restrictions, and social distancing requirements. The full impact of this crisis on science is not clear yet, but the above-mentioned issues have most certainly restrained academic research activities. Sharing innovative solutions between researchers is in high demand in this situation. The aim of this paper is to share our successful practice of using web-based communication and remote control software for real-time long-distance control of brain stimulation. This solution may guide and encourage researchers to cope with restrictions and has the potential to help expanding international collaborations by lowering travel time and costs.