'Critical Concepts': Development of an online Introduction to Intensive Care lecture series

Introduction: Background: Intensive Care Learning in the North East is a group of intensive care doctors in the North East of England, passionate about education in ICM.1 The SARS-CoV-2 pandemic has necessitated social distancing and disrupted traditional in-person courses. However, this has borne opportunities for virtual courses delivered to a national audience.2 Course content: We describe the second iteration of an eight-part online and interactive lecture series entitled 'Critical Concepts: An Introduction to Intensive Care'. The lectures focus on the A-E management of the critically ill patient, with additional sessions on 'Return of Spontaneous Circulation', and 'Applications and Careers in ICM.' The lectures were delivered fortnightly via Zoom,3 and consist of a 45-minute lecture followed by a 45-minute break-out room to discuss interactive cases with a facilitator and four participants. The lectures were available for two weeks on YouTube4 via private link, to enable participants to catch-up if not able to attend. Objective(s): We wished to examine the effectiveness and quality of our lecture series through a pre-course and a post-course questionnaire. We designed the questionnaire to elicit qualitative and quantitative feedback from the participants. Method(s): We invited the 60 course participants to fill in a pre- and post-course questionnaire, and received 28 and 51 responses respectively. Result(s): Participant demographics: 25% of delegates were in FY1, 75% were in FY2. 50% had no prior experience of working in an ICU, 21.4% had worked in an ICU during FY, 28.6% had undertaken a Taster Week in ICU. Quantitative results: * 'How would you rate your current apprehension regarding redeployment to ICU?' (1 - very apprehensive;5 - not apprehensive), the mean self-rating prior to the course was 2.54, and following completion of the course was 3.51. * 'How would you rate your understanding of what happens in an ICU?' (1 - very poor understanding;5 - very good understanding), the mean self-rating prior to the course was 2.75, and following completion of the course was 4.00. * 'How confident do you feel in discussing escalation of care with critical care staff?' (1 - not confident at all;5 - very confident), the mean self-rating prior to the course was 3.00, and following completion of the course was 4.04. YouTube catch-up The mean number of weeks that participants were able to attend in real-time was 4. 4 participants were able to attend all weeks, 78.8% of participants missing at least 1 week were able to catch-up on all weeks using YouTube, 21.2% were able to catch-up on some weeks, and no participants did not use this facility. Conclusion(s): We have demonstrated that our online teaching course has improved understanding of the care delivered on ICU, and reduced apprehension surrounding working in ICU and discussing patients with colleagues. We have demonstrated that YouTube is a free and well utilised method to enable to enable participants to catch-up on lecture content they were unable to attend in real-time. We believe that courses such as this will remain as Covid-19 restrictions are lifted.

Evaluation of Out-of-Hospital Cardiac Arrests in Births and Neonates: Opportunities to Improve Care

INTRODUCTION: Home births have increased 77% from 2004 to 2017 and further increased with the COVID-19 pandemic. While the majority of home births are uneventful, some are complicated and require attendance of emergency medical services (EMS). Understanding characteristics of out-of-hospital births and EMS care is increasingly important to improve care. METHODS: We conducted a chart review of pediatric out-of-hospital cardiac arrests (POHCAs) from EMS agencies across the United States to evaluate the care provided by first responders. The study was approved by Oregon Health & Science University and respective IRBs. RESULTS: Of 1,020 POHCAs, 54 were responses to births and 43 were for other neonates. While most neonatal POHCAs occurred in a home or residence (84%), some births occurred at other locations such as a health care facility, public or commercial building, and street or highway. Bystander cardiopulmonary resuscitation was performed in less than half of births but more than half of other neonates. Return of spontaneous circulation was twice as likely for births as for other neonates (27% versus 13%). Overall, serious adverse safety events were observed in three-fourths of neonatal resuscitations. Births were more likely to be associated with failure to follow the correct resuscitation algorithm and lack of positive pressure ventilation. CONCLUSION: There are unique challenges in the care of out-of-hospital births for the EMS system. There is an opportunity to improve use of neonatal resuscitation protocols and early ventilation. [ FROM AUTHOR] Copyright of Obstetrics & Gynecology is the property of Lippincott Williams & Wilkins and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

Initial five and ten-minute regional cerebral oxygen saturation as a predictor of the futility of resuscitation for out-of-hospital cardiac arrest

This study aimed to investigate the usefulness of cerebral regional oxygen saturation (rSO2) during the initial 5 and 10 minutes of cardiopulmonary resuscitation (CPR) compared with an initial rSO2 and mean rSO2 during entire CPR to predict the futility of resuscitation for patients without of-hospital-cardiac arrest (OHCA). This was a prospective study involving 52 adult patients presenting in OHCA and whose cerebral rSO2 values were measured until either CPR was terminated or sustained return of spontaneous circulation (ROSC) was achieved. Receiver operating characteristics analyses were used to evaluate which time and type of measurement is better to predict non-ROSC. The area under the curve (AUC) of each rSO2 value according to measurement time (overall, initial 5 minutes and 10 minutes) were the highest value of 0.743, 0.724, and 0.739, mean values of 0.724, 0.677 and 0.701 and rSO2 (Changes in values of regional cerebral oxygen) value of 0.722, 0.734 and 0.724, respectively, while all of the initial values had a poor AUC (<0.7) and also were not statistically significant. The optimal cut-off value of each rSO2 values during overall, initial 5 minutes and 10 minutes were the highest value of 26% (sensitivity, 53.9% specificity, 92.3%), 24% (sensitivity, 56.4% specificity, 92.3%), and 30% (sensitivity, 61.5% specificity, 84.6%), mean value of 15.2%, 15.3% and 16%, respectively. None of the patients with a persistent rSO2 <=18% during the overall period achieved ROSC. Initial 5 minutes and 10 minutes cerebral rSO2 values an out-of-hospital-cardiac arrest (OHCA) are a better predictor in deciding the futility of CPR, compared to initial and overall measurements.Copyright © 2023 The Author(s). Published by MRE Press.

Intentional Taxus Baccata Ingestion Presenting with Cardiogenic Shock and Ventricular Tachycardia

Background The prevalence of anxiety and depression has increased following the COVID pandemic. Young women are disproportionally at risk of suicidal behaviors. Ingestion of Taxus baccata (English Yew) may lead to cardiotoxicity and death. Intoxication is known to be resistant to standard treatments with no effective antidotes. Case A 20-year-old female with a history of major depressive disorder presented to our emergency department unresponsive in pulseless ventricular tachycardia (VT) (figure 1A). She underwent CPR and achieved ROSC, however, was persistently hypotensive despite multiple pressors and was subsequently placed on VA ECMO. Review of a home journal revealed a plan to ingest 50 grams of Yew with suicidal intent. Decision-making Taxoids have been reported to have similar properties to digoxin and therefore digoxin-specific FAB antibodies were administered. She was also started on amiodarone and lidocaine for management of VT. After 3 hours she converted into sinus rhythm and had no further episodes of VT. Her clinical course was complicated by severe LV dysfunction and dilation while on VA-ECMO necessitating placement of an LV impella. By day three, all mechanical support was weaned off and she had normalization of her EF. Patient was discharged to an inpatient psychiatry facility on day 7 of hospitalization. Conclusion Ingestion of English Yew with suicidal intent is rare but may cause cardiogenic shock and VT requiring aggressive hemodynamic support until the toxin is metabolized. [Formula presented]Copyright © 2023 American College of Cardiology Foundation

Purulent Pericardial Effusion with a Swinging Heart Post-Sars-Cov-2 Infection: A Case Report

Background Acute bacterial pericarditis is rare and can decompensate quickly to cardiac tamponade and cardiac arrest. Targeted antibiotic therapy, pericardiocentesis, and pericardiotomy are the cornerstones of management. Case 51-year-old male presented with 2-weeks of progressive chest pain, cough, and fatigue. A month prior he tested positive for COVID-19. On exam he was tachycardiac, tachypneic, and normotensive. JVD and peripheral edema were present. Labs revealed elevated WBC, BNP, HS-troponin, and ESR/CRP. Blood cultures were positive for methicillin susceptible Staphylococcus aureus (MSSA). Echo showed a large pericardial effusion with a swinging heart. ECG showed diffuse ST elevations and PR depression. He was not clinically in tamponade but shortly after became bradycardic and had a PEA arrest. Emergent bedside pericardiocentesis was performed, and after 9-minutes of ACLS, ROSC was attained. Pericardial fluid grew MSSA. Decision-making Vancomycin and cefepime were started and tapered to cefazolin to cover MSSA bacteremia and pericarditis. Repeat blood cultures were negative. A month after discharge he had no cardiac symptoms and echo showed minimal pericardial fluid. Conclusion In patients with COVID-19 and pericardial effusion, bacterial pericarditis can be secondary to contiguous spread from lung parenchyma or myopericarditis with superimposed infection, or due to primary pericarditis. This is the second reported case of spontaneous purulent pericarditis with MSSA. [Formula presented]Copyright © 2023 American College of Cardiology Foundation

Evaluate the Features of Ohca Patients Living in Pakistan Both before and after the Covid-19 Epidemic in Order to Determine Their Outcomes

Aim: Bystander cardiopulmonary resuscitation (CPR) combined with public-access defibrillation has been shown to enhance overall survival for out-of-hospital cardiac arrest. This is one of top reasons of mortality across the globe. The COVID-19 global epidemic has modeled numerous problems for emergency medical services, along with reference of compression-only resuscitation also guidelines for comprehensive protective equipment. These suggestions and advice have created shortcomings and protracted fast response. On the other hand, the risk variables that determine the results of OHCA while the pandemic is ongoing are not well established. The main aim of our research remained to exploremedical features in addition results of OHCA individuals in Pakistan both before and after the COVID-19 epidemic. Method(s): The electronic medical records and paper records kept by EMS were utilized to compile the data for this single-center, retrospective observational analysis. The number of emergency hospital returns based on varying qualities in Sir Ganga Ram Hospitalized patients during and prior to the COVID-19 pandemic in Pakistan were collected. Patients with OHCA who went to the emergency department at Sir Ganga Ram Hospital in Lahore before the COVID-19 pandemic (April 2019 to March 2020) were identified. Result(s): Here were a total of 145 patients who participated in this study (80 males, or 58.2% of the total;mean [SD] age, 64.7 years);64 among those individuals contributed in our currentresearch during the COVID-19 era, and 75 among those individuals contributed in our currentresearch before COVID-19 period. Bystander witnessing and method of chest compression was always the two general baseline features that were found to be substantially different between the two groups (p-values of less than 0.002 and less than 0.002, accordingly). Duringthe COVID-19 era, the ED ROSC was substantially lower than it had been before the COVID-19 period (25.68 percent vs 45.04 percent;adjusted odds ratio of 0.22;p-value less than 0.002) Survival to admission remainedsuggestivelyinferiorthroughout COVID-19 phase compared to the previous time period (26.01 percent vs 41.78 percent, accustomed odds ratio of 0.27, p-value of 0.006). On the other hand, there was no important statistically substantial difference in the 28-day survival rates (4.5% throughout COVID-19 era also 11.54% earlier COVID-19 period). Conclusion(s): Patients who had cardiac arrest outside of a hospital in Pakistan had a much lower chance of surviving long enough to be admitted during the COVID-19 epidemic that occurred there. In addition, the two groups' witness reactions and methods of cardiopulmonary resuscitation couldn't have been more different from one another.Copyright © 2023, Anka Publishers. All rights reserved.

Impact of COVID-19 on Out-of-Hospital Cardiac Arrest in Korea.

BACKGROUND: Coronavirus disease 2019 (COVID-19) is a global public health crisis that has had a significant impact on emergency medical services (EMS). Several studies have reported an increase in the incidence of out-of-hospital cardiac arrest (OHCA) and a decreased survival due to COVID-19, which has been limited to a short period or has been reported in some regions. This study aimed to investigate the effect of COVID-19 on OHCA patients using a nationwide database. METHODS: We included adult OHCA patients treated by EMS providers from January 19, 2019 to January 20, 2021. The years before and after the first confirmed case in Korea were set as the non-COVID-19 and COVID-19 periods, respectively. The main exposure of interest was the COVID-19 period, and the primary outcome was prehospital return of spontaneous circulation (ROSC). Other OHCA variables were compared before and after the COVID-19 pandemic and analyzed. We performed a multivariable logistic regression analysis to understand the independent effect of the COVID-19 period on prehospital ROSC. RESULTS: The final analysis included 51,921 eligible patients, including 25,355 (48.8%) during the non-COVID-19 period and 26,566 (51.2%) during the COVID-19 period. Prehospital ROSC deteriorated during the COVID-19 period (10.2% vs. 11.1%, P = 0.001). In the main analysis, the adjusted odds ratios (AORs) for prehospital ROSC showed no significant differences between the COVID-19 and non-COVID-19 periods (AOR [95% confidence interval], 1.02 [0.96-1.09]). CONCLUSION: This study found that the proportion of prehospital ROSC was lower during the COVID-19 period than during the non-COVID-19 period; however, there was no statistical significance when adjusting for potential confounders. Continuous efforts are needed to restore the broken chain of survival in the prehospital phase and increase the survival rate of OHCA patients.

Stop and smell the onions: Case report of delayed cardiotoxicity post ingestion of veratrum viride

Background: Vertatrum viride (false hellebore) is a perennial commonly found in eastern North America. The most common cause of exposure is misidentification when foraging for wild onion, or skunk cabbage. One regional poison center saw an increase in foraging-related poisonings during initial COVID-19 restrictions. The case report highlights severe delayed cardiac effects after ingestion of Veratrum viride in an otherwise healthy, young, female athlete. Case report: A 24-year-old female presented to an emergency room alongside family with complaints of nausea and vomiting that started 30 min after a meal consisting of foraged wild onion (Allium triccocum). Five others ate the same meal and noted similar symptoms. Vitals upon arrival (3 h post ingestion) are as described: HR 51, BP 88/52, Temp 36.7, RR 18 and O2 sat 100% on room air. The patient had no previous cardiac history and was athletic. Management included D5LR with K replacement, and dopamine infusion at 10mcg/kg/min. Dopamine was tapered slowly, down to 6 mcg/kg/min at 16.5 h. Vitals continued to be stable at 17.5 h post ingestion and dopamine was discontinued. The patient developed severe bradydysrhythmia 15 min later, consisting of complete heart block leading to prolonged sinus pause. She responded to 10 s of CPR with return of spontaneous circulation with a junctional escape rhythm which reverted back to sinus bradycardia. A repeat EKG was unremarkable. The dopamine infusion was reinstituted at 4 mcg/kg/min and continued until 26.5 h post ingestion. She was monitored an additional 9.5 h, and remained in sinus rhythm with mild complaints of dizziness that resolved before discharge. Discussion(s): Veratrum spp. toxicity is due to alkaloids found throughout the plant which cause sodium channel opening when bound to type 2 sodium channels. By increasing sodium ion influx during the resting potential and delaying inactivation to create a late sodium current, these alkaloids increase automaticity in conductive cells. This mechanism, paired with the Bezold-Jarisch reflex, is likely responsible for increased vagal tone leading to bradycardia, hypotension, sinus arrhythmia, and junctional escape rhythm. It is noteworthy that even 18 h post ingestion in a relatively stable patient with no significant cardiac history, cardiac arrest occurred just after treatment tapering. Clinicians should consider prolonged observation time in the setting of discontinuation of vasopressors. Conclusion(s): Both clinicians and amateur foragers should be aware of the risks associated with ingestion of Veratrum viride, especially during early spring when it more closely resembles wild onion. While uncommon, significant delayed cardiac effects are possible. Mistaking the plant for edible wild onions can be the difference between a delectable dinner, and a night in the ICU.

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

COVID-19: A CONFOUNDING MIMICKER OF HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS

SESSION TITLE: Challenging Cases of Hemophagocytic Lymphohistiocytosis SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Hemophagocytic lymphohistiocytosis (HLH) is a rare syndrome involving pathologic immune activation that is often fatal. The link between the cytokine storm related to COVID-19 and development of HLH has been reported since the onset of the pandemic, but little is known about clinical manifestations of HLH, thereby delaying treatment. CASE PRESENTATION: A 50 year-old male presented with a several day history of progressive weakness in the setting of missed dialysis session. Medical history was significant for ESRD on dialysis and diastolic heart failure (EF 35%). Initial vitals were unremarkable. Physical exam was notable for peripheral edema bilaterally. Laboratory studies were consistent with hyperkalemia, elevated ferritin (28,383) and elevated liver function tests. COVID-19 PCR was positive upon admission. Chest x-ray, CTA chest and a right upper quadrant ultrasound were unremarkable. He was admitted to the medical ICU for emergent dialysis. Soon after arrival to the ICU, he became lethargic and confused with increasing oxygen requirements and a subsequent a code blue was called. Cardiopulmonary resuscitation was immediately initiated, with a first rhythm consistent with ventricular fibrillation. He was shocked and placed on an amiodarone infusion with return of spontaneous circulation. TTE revealed a severely reduced EF <10%. Despite initiation of advanced COVID-19 therapies with Solu-Medrol and tocilizumab he remained ventilator dependent. Due to hemodynamic instability and persistent metabolic acidosis, he was transitioned to continuous renal replacement. Further blood work showed worsening inflammatory markers (ferritin 33,500, LDH 6981). Because of the significantly elevated ferritin, there were concerns for possible HLH. Triglycerides and IL-2 receptor were 395 mg/dL and 9300 pg/mL respectively. Total NK cells were decreased to 1.2%. He remained persistently unstable despite aggressive measures. He suffered a second cardiopulmonary arrest, which was unable to achieve return of spontaneous circulation and he ultimately passed away. DISCUSSION: HLH is characterized by uncontrolled activation and proliferation of benign macrophages in reticuloendothelial organs. This results in histiocytic hemophagocytosis, worsening peripheral blood cytopenia(s), cytokine storm, and cytokine mediated biochemical alteration ultimately culminating in multiorgan dysfunction and disseminated intravascular coagulation. Although a distinctive constellation of features has been described for HLH, diagnosis remains challenging as patients have diverse presentations associated with a variety of triggers. CONCLUSIONS: As HLH is a medical emergency with poor prognosis, prompt recognition and early treatment is crucial for improving clinical outcomes. We hope this case will create increased awareness and timely diagnosis of cytokine storm syndromes in patients with severe COVID-19 infection. Reference #1: Meazza Prina M, Martini F, Bracchi F, Di Mauro D, Fargnoli A, Motta M, Giussani C, Gobbin G, Taverna M, D'Alessio A. Hemophagocytic syndrome secondary to SARS-Cov-2 infection: a case report. BMC Infect Dis. 2021 Aug 13;21(1):811. doi: 10.1186/s12879-021-06532-7. PMID: 34388982;PMCID: PMC8361241. Reference #2: Schnaubelt, Sebastian MDa,*;Tihanyi, Daniel MDb;Strassl, Robert MDc;Schmidt, Ralf MDc;Anders, Sonja MDb;Laggner, Anton N. MDa;Agis, Hermine MDd;Domanovits, Hans MDa Hemophagocytic lymphohistiocytosis in COVID-19, Medicine: March 26, 2021 - Volume 100 - Issue 12 - p e25170 doi: 10.1097/MD.0000000000025170 DISCLOSURES: No relevant relationships by Garrett Fiscus No relevant relationships by Niala Moallem No relevant relationships by Resham Pawar

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

RAPIDLY PROGRESSIVE PERIMYOCARDITIS IN SARS-COV-2 INFECTION

SESSION TITLE: Extraordinary Cardiovascular Reports SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 01:35 pm - 02:35 pm INTRODUCTION: The COVID-19 pandemic has resulted in millions of deaths worldwide. Many cases involved a primary pulmonary process, yet myocarditis associated with COVID-19 has been observed.1 We present a novel case of rapidly progressive fulminant peri-myocarditis with minimal lung involvement in acute COVID-19 infection. CASE PRESENTATION: A 39-year-old female with no medical history presented with chest pain and dyspnea with an acute COVID-19 infection. She had a brief cardiac arrest with rapid ROSC and no intubation. Chest CT angiogram showed essentially normal pulmonary parenchyma and moderate pericardial effusion. EKG showed sinus tachycardia with global ST segment elevation. An echocardiogram showed an ejection fraction (EF) of 25% with a moderate sized pericardial effusion and right ventricle collapse. She was transferred for emergent drainage of the effusion to our institution. Her circulatory shock initially improved following pericardial drainage, yet she declined warranting increasing vasopressor and inotropic support. An emergent echo showed an EF of less than 10% and no re-accumulation of pericardial fluid. It was clear that the patient required mechanical circulatory support (MCS) and was transferred to the catheterization lab. While in the lab, the patient suffered cardiac arrest and an Impella device was placed during prolonged ACLS without achieving ROSC. Venoarterial ECMO cannulation was then performed. She was transferred to a cardiac transplant center where she later developed multi-organ failure leading to death. DISCUSSION: While COVID-19 has been shown to affect multiple organs apart from the lungs, this case was notable due to minimal pulmonary involvement. The patient's manifestation of her infection was almost entirely cardiac in nature. MCS was discussed in the catheterization lab at the time of pericardial drain insertion. The decision was made to not pursue MCS as the patient's shock had improved. Additionally, the patient did not undergo pulmonary arterial catheter (PAC) placement. Prompt placement of a PAC has been associated with early access to MCS and reduced in-hospital mortality.2 Perhaps we would have obtained MCS earlier if PAC data supported this intervention before the patient deteriorated. It will be important to consider primary cardiac manifestations of COVID-19 infection and early consideration of invasive hemodynamic monitoring to identify a need for timely MCS. CONCLUSIONS: We present the first reported case of fulminant peri-myocarditis in the absence of acute hypoxemic respiratory failure or radiographic pulmonary parenchymal lung abnormality. Isolated rapidly progressive cardiogenic shock secondary to COVID-19 associated peri-myocarditis is a phenomenon important for critical care clinicians to be aware of during this pandemic. One should have a low threshold to establish invasive hemodynamic monitoring and consideration for early MCS in these cases. Reference #1: Siripanthong B, Nazarian S, Muser D, et al. Recognizing COVID-19-related myocarditis: The possible pathophysiology and proposed guideline for diagnosis and management. doi:10.1016/j.hrthm.2020.05.001 Reference #2: Osman M, Syed M, Patel B, et al. Invasive Hemodynamic Monitoring in Cardiogenic Shock Is Associated With Lower In-Hospital Mortality. Journal of the American Heart Association J Am Heart Assoc. 2021;10:21808. doi:10.1161/JAHA.121.021808 DISCLOSURES: No relevant relationships by Samuel Bullick No relevant relationships by Jonathan Greenberg No relevant relationships by Scott Slusarenko

TULAREMIA PRESENTING AS LARGE GI ULCERATION AND HEMORRHAGE

SESSION TITLE: Critical Care Infections SESSION TYPE: Case Reports PRESENTED ON: 10/19/2022 09:15 am - 10:15 am INTRODUCTION: Francisella tularensis is a zoonotic disease by an aerobic, gram negative coccobacillus. It is transmitted by exposure to infected animal or vectors in individuals who landscape or camp. Common symptoms are fever, chills, anorexia, and headache. Abdominal tularemia can present with abdominal pain, emesis, diarrhea, and rarely intestinal ulceration and hemorrhage. It is treated with aminoglycosides, fluoroquinolones and tetracycline. CASE PRESENTATION: 38-year-old male presented with fever, cough, anorexia, and black stool for 5 days. Patient worked as a landscaper. He has no pets, travel history or sick contacts. He does not take any medications at home. Physical exam was significant for sinus tachycardia and rhonchi of right upper lobe. Significant labs include WBC of 9.8 with 41% bands, hemoglobin 15.5, sodium 125, procalcitonin 27.3, and lactic acid 1.8. COVID-19, MRSA, Legionella and Pneumococcal urine antigen were negative. CTA chest revealed mass-like opacity in right upper lobe with multiple bilateral pulmonary nodules. Lower respiratory culture showed Candida albicans. Patient was empirically started on ceftriaxone and azithromycin. He was transferred to intensive care for worsening respiratory status and was placed on non-invasive ventilation on hospital day 1. Antibiotics were broadened to ceftaroline and levofloxacin due to suspicion of tularemia. Amphotericin B was added. Labs for Histoplasma, Blastomyces, TB, Leptospira, and HIV were negative. Patient then suffered a cardiac arrest on hospital day 2 after having large brown secretions pouring from his mouth. Cardiopulmonary resuscitation was initiated and patient was intubated and started on vasopressors with return of spontaneous circulation. Massive blood transfusion protocol was initiated. Emergent bedside upper endoscopy showed large blood clot adherent to duodenal ulcer. Interventional radiology planned on performing gastric duodenal artery embolization. However, patient suffered two more cardiac arrest with resuscitation efforts terminated per family request. Karius Digital Culture later was positive for Francisella tularensis. Autopsy revealed diffuse alveolar hemorrhage, hilar lymphadenopathy, and perforated duodenal ulceration with large adherent clot. DISCUSSION: Gastrointestinal tularemia is rare and usually from drinking contaminated water or oral inoculation of bacteria. Intestinal tract involvement can present with mesenteric lymphadenopathy and ulcerative lesions resulting in gastrointestinal bleeding with case fatality rate of 50%. Even though this is noted in the literature, to our knowledge no case reports have been published. CONCLUSIONS: Careful history taking and early identification of risk factors are important when severe tularemia infection is suspected such as in individuals with extensive outdoor activities. Treatment should be empirically initiated in high risk patients. Reference #1: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4585636/ Reference #2: https://casereports.bmj.com/content/2017/bcr-2017-22125. Reference #3: Altman GB, Wachs JE. Tularemia: A pathogen in nature and a biological weapon. Aaohn Journal. 2002 Aug;50(8):373-9. DISCLOSURES: No relevant relationships by Maria Haider Baig

RETURN TO LIFE: A CASE OF THE LAZARUS PHENOMENON

SESSION TITLE: Shock and Sepsis in the ICU Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: The Lazarus Phenomenon, also known as auto-resuscitation, is a rare event where cessation of CPR results in a delayed return of spontaneous circulation (ROSC). The phenomenon was named after the story of Lazarus, who was restored to life four days after death. We present a case of a 78-year-old male who presented to the hospital for septic shock and had intra-hospital cardiac arrest with ROSC after cessation of CPR. CASE PRESENTATION: 78 year old male with a medical history of paroxysmal atrial fibrillation, stage IIIA NSCLC and COPD, presented for progressive dyspnea. He complains of feeling weak with loss of appetite and had a recent mechanical fall. Initial vital signs were temperature 96F, BP 141/78, HR 75 bpm, RR 18/min, SaO2 100% on 2LNC. Initial labs showed lactic acid 11.6, BUN 55, creatinine 3.7, CO2 9, anion gap 25, AST 2654, ALT 2120, ALP 159, total bilirubin 0.8, troponin <0.1, CK 399, INR 4.2, PTT 36, WBC 16.5, Hb 10.8, and plt 202. COVID-19 testing was negative. CXR demonstrated a retro-cardiac opacity consistent with previous diagnosis of lung cancer versus a dense consolidation. He was started on antibiotics for sepsis and admitted to the ICU for his metabolic status and shock liver. He remained hemodynamically stable for a few hours until a he had sudden onset of unresponsiveness with asystole. Code blue was called. Repeat labs demonstrated lactic acid 15.5, potassium 6.3, CO2 9. He underwent resuscitation for 32 minutes when compressions were stopped. Within 5 minutes post arrest, sinus activity was noted on the cardiac monitor. The patient had a radial pulse on evaluation. Manual blood pressure measurement was 119/71 with a HR of 99. Arterial blood gas after ROSC showed a pH 7.0, pCO2 68, pO2 273, HCO3 16, lactic acid 19. A few hours later, the patient rapidly de-compensated and underwent resuscitation for a second time. Efforts were deemed futile and the patient expired. DISCUSSION: The physiologic description of the Lazarus phenomenon is yet to be fully elucidated. Hypotheses include auto-PEEP due to rapid manual ventilation generating increased intrathoracic pressure and decreased venous return, delayed drug effect and stunned myocardium during active chest compressions (1). Once chest compressions and positive pressure ventilation via manual bag-mask stops, sudden decrease in intrathoracic pressure allows for sudden venous return and re-perfusion of cardiac tissue, resulting in ROSC in some cases. A recent literature review cited 65 published cases over the past 30 years with the most common rhythm being asystole (2). Most cases of auto-resuscitation occurred between 5-10 minutes post stopping of chest compressions (2). Mortality of these cases were 70% post resuscitation (2). CONCLUSIONS: It is important for clinicians to be aware of the Lazarus phenomenon post resuscitative efforts and to observe patients carefully post resuscitation. Reference #1: Adhiyaman V, Adhiyaman S, Sundaram R. The Lazarus phenomenon. J R Soc Med. 2007;100(12):552-557. doi:10.1177/0141076807100012013 Reference #2: Gordon, L., Pasquier, M., Brugger, H. et al. Autoresuscitation (Lazarus phenomenon) after termination of cardiopulmonary resuscitation - a scoping review. Scand J Trauma Resusc Emerg Med 28, 14 (2020). https://doi.org/10.1186/s13049-019-0685-4 DISCLOSURES: No relevant relationships by Vincent Chan No relevant relationships by Mackenzie Kramer No relevant relationships by Nathaniel Rosal No relevant relationships by Laura Walters No relevant relationships by William Ward

WHEN ST-ELEVATION MYOCARDIAL INFARCTION (STEMI) IS JUST THE BEGINNING: DISSEMINATED INTRAVASCULAR COAGULATION (DIC) FROM COVID-19 INFECTION PRESENTING AS ACUTE MYOCARDIAL INFARCTION

SESSION TITLE: Cardiovascular Complications in Patients with COVID-19 SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: COVID-19 is associated with a hypercoagulable state and has been linked with Disseminated Intravascular Coagulation (DIC) [1]. DIC causes systemic thrombosis in micro- and macro- vasculature and in rare instances can involve coronary arteries [2]. In this case report, we present a patient who presented as an ST-segment elevation myocardial infarction (STEMI) and DIC in the setting of severe COVID-19 disease. CASE PRESENTATION: A 46-year-old lady with a history of hypertension presented with acute onset of typical chest pain. She tested positive for COVID-19 infection. Emergency room EKG showed anterior STEMI, and the patient underwent cardiac catheterization via a femoral approach which revealed a 99% stenosis in the proximal LAD, with filling defects consistent with a thrombus. Thrombectomy was performed and three drug-eluting stents were placed in the left anterior descending artery. Following stent placement, the patient went into ventricular fibrillation cardiac arrest followed by PEA. ROSC was attained after 3 rounds of CPR. Labs showed an acute drop in hemoglobin from 14 gm/dL to 5 gm/dL with CT evidence of extensive retroperitoneal bleed, extraperitoneal bleed, and large abdominal aorta thrombus proximal to the bifurcation. Labs were significant for prolonged INR (2.1), PT (23.4 seconds), PTT (106.7 seconds), elevated D-dimer (>4.0), decreased platelets (101K/μl), and increased fibrin split products (80uG/mL) consistent with DIC. The acute aortoiliac occlusive thrombus resulted in acute limb ischemia, rhabdomyolysis causing renal failure, and compartment syndrome requiring bedside fasciotomy. She was treated with triple therapy and demonstrated gradual clinical improvement. DISCUSSION: DIC was a possible precipitant of STEMI in this patient with evidence of thrombotic occlusion of LAD. DIC is a life-threatening coagulopathy characterized by mixed hypo- and hypercoagulation. This often leads to a systemic distribution of clots, evidenced by thrombi present in the coronary and aortoiliac arteries. Historically, bacterial sepsis was more strongly linked with DIC than viral causes;however, there has been an increasing amount of evidence linking COVID-19 with DIC, likely due to the severity of the illness. In this patient with recent stent placement, large aortic thrombus, and extensive retroperitoneal bleed, management was complicated by need for dual antiplatelet therapy for drug-eluting stents as well as anticoagulation for acute limb ischemia. Another diagnosis to keep in the differential includes heparin-induced thrombocytopenia, characterized by similar findings to DIC, but is associated with antibodies against platelet factor 4, which was not found in our patient. CONCLUSIONS: In this case, a young female patient without traditional cardiac risk factors was found to have an anterior STEMI, likely precipitated by DIC as a complication of COVID-19 infection. Reference #1: Asakura, Hidesaku, and Haruhiko Ogawa. "COVID-19-associated coagulopathy and disseminated intravascular coagulation.” International journal of hematology vol. 113,1 (2021): 45-57. doi:10.1007/s12185-020-03029-y Reference #2: M. Sugiura, K. Hiraoka, and S. Ohkawa, "A clinicopathological study on cardiac lesions in 64 cases of disseminated intravascular coagulation,” Japanese Heart Journal, vol. 18, no. 1, pp. 57–69, 1977. DISCLOSURES: No relevant relationships by radhika deshpande No relevant relationships by Shruti Hegde No relevant relationships by Robert Kropp No relevant relationships by Prashanth Singanallur

Characteristics and outcomes of out-of-hospital cardiac arrest patients before and during the COVID-19 pandemic in Thailand.

BACKGROUND: Out-of-hospital cardiac arrest (OHCA) remains one of the leading causes of death worldwide, and bystander CPR with public-access defibrillation improves OHCA survival outcomes. The COVID-19 pandemic has posed many challenges for emergency medical services (EMS), including the suggestion of compression-only resuscitation and recommendations for complete personal protective equipment, which have created operational difficulties and prolonged response time. However, the risk factors affecting OHCA outcomes during the pandemic are poorly defined. This study aimed to assess the characteristics and outcomes of OHCA patients before and during the COVID-19 pandemic in Thailand. METHODS: This single-center, retrospective cohort study used data from electronic medical records and EMS paper records. All OHCA patients who visited Ramathibodi Hospital's emergency department before COVID-19 (March 2018 to December 2019) and during COVID-19 (March 2020-December 2021) were identified, and the number of emergency department returns of spontaneous circulation (ED-ROSC) and characteristics in OHCA patients before and during the COVID-19 pandemic in Thailand were collected. RESULTS: A total of 136 patients were included (78 men [59.1%]; mean [SD] age, 67.9 [18] years); 60 of these were during the COVID-19 period (beginning March 2020), and 76 were before the COVID-19 period. The overall baseline characteristics that differed significantly between the two groups were bystander witness and mode of chest compression (p-values < 0.001 and < 0.001, respectively). The ED ROSC during the COVID-19 period was significantly lower than before the COVID-19 period (26.67% vs. 46.05%, adjusted OR 0.21, p-value < 0.001). There were significant differences in survival to admission between the COVID-19 period and before (25.00% and 40.79%, adjusted OR 0.26, p-value 0.005). However, 30-day survivals were not significantly different (3.3% during the COVID-19 period and 10.53% before the COVID-19 period). CONCLUSIONS: During the COVID-19 pandemic in Thailand, ED ROSC and survival to admission in out-of-hospital cardiac arrest patients were significantly reduced. Additionally, the witness responses and mode of chest compression were very different between the two groups. TRIAL REGISTRATION: This trial was retrospectively registered on 7 December 2021 in the Thai Clinical Trial Registry, identification number TCTR20211207006.

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.