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1.
Int J Emerg Med ; 15(1):46, 2022.
Article in English | PubMed | ID: covidwho-2021235

ABSTRACT

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.

2.
Acta Anaesthesiol Scand ; 2022 Jul 27.
Article in English | MEDLINE | ID: covidwho-1997184

ABSTRACT

OBJECTIVE: The COVID-19 pandemic changed the time-dependent cardiac arrest network. This study aims to understand whether the rescue standards of CPR and out-of-hospital cardiac arrest (OHCA) were handled differently during pandemic compared to the previous year. METHODS: Data for the years 2019 and 2020 were provided by the records of the Lombardy office of the Regional Agency for Emergency and Urgency (AREU). We analysed where the cardiac arrest occurred, when CPR started and whether the bystanders used PAD. RESULTS: During 2020, there was a reduction in CPRs performed by bystanders (OR = 0.936 [CI95% 0.882-0.993], P = 0.029) and in the return of spontaneous circulation (ROSC) (OR = 0.621 [CI95% 0.563- 0.685], P < 0.0001), while there was no significant reduction in the use of PAD. Analysing only March, the period of the first wave in Lombardy, the comparison shows a reduction in bystanders CPRs (OR = 0.727 [CI95% 0.602- 0.877], P = 0.0008), use of PAD (OR = 0.441 [CI95% 0.272-0.716], P = 0.0009) and in ROSC (OR = 0.179 [CI95% 0.124-0.257], P < 0.0001). These phenomena could be influenced by the different setting in which the OHCAs occurred; in fact, those that occurred in public places with a mandatory PAD were strongly reduced (OR = 0.49 [CI95% , 0.44-0.55], P < 0.0001). CONCLUSIONS: COVID-19 had a profound impact on the time-dependant OHCA network. During the first pandemic wave, CPR and PAD used by bystanders decreased. The different context in which OHCAs occurred may partially explain these differences.

3.
Resuscitation ; 175:S57-S58, 2022.
Article in English | EMBASE | ID: covidwho-1996694

ABSTRACT

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

4.
Resuscitation ; 175:S33-S34, 2022.
Article in English | EMBASE | ID: covidwho-1996686

ABSTRACT

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.

5.
Resuscitation ; 175:S25-S27, 2022.
Article in English | EMBASE | ID: covidwho-1996684

ABSTRACT

Background: The COVID-19 pandemic has overwhelmed healthcare systems, strained ambulance services and, directly or indirectly, affected community responses to patients who experience cardiac arrests outside hospitals. Previous observational studies have shown a notable rise in Out-of-Hospital Cardiac Arrest (OHCA) cases during the pandemic in different parts of the world compared to the same period in 2019, including the United Kingdom and the United States 1, 2. This systematic review’s intention is to shed light on the incidence and survival outcomes of adult OHCA patients. Methods: A comprehensive review of MEDLINE, EMBASE, the Cochrane Library, Web of Science, WHO’s Global Index Medicus, WHO’s Global Research Literature on Coronavirus 2019 and medRxiv up to 8 September 2021 was conducted to identify articles and preprints that reported OHCA figures before and during the COVID-19 pandemic. Primary outcomes were OHCA incidence, Return of Spontaneous Circulation (ROSC) and survival to hospital discharge. Results: Twenty-one studieswere included in the final analysis, out of 2877 potentially eligible records. There were 12,619 OHCA cases during the COVID-19 pandemic, compared with 8353 OHCA cases in the same period of 2019, representing a 51.1% increase in OHCA incidence during the pandemic. In terms of survival outcomes, ROSC and survival to hospital discharge rates were substantially reduced during the pandemic compared to the pre-pandemic period. Conclusion: The pandemic has had an impact on the incidence and survival outcomes among adult OHCA patients compared to the prepandemic period. Moreover, the pandemic has delayed ambulance care processes and disrupted community responses to OHCA. 1. Fothergill RT et al. Out-of-hospital cardiac arrest in London during the COVID-19 pandemic. Resusc Plus. 2021;5:100066. 2. Lai PH et al. Characteristics associated with out-of-hospital cardiac arrests and resuscitations during the Novel Coronavirus Disease 2019 pandemic in New York City. JAMA Cardiol. 2020;5(10):1154– 63.(Table Presented)(Table Presented)

6.
Journal of General Internal Medicine ; 37:S490-S491, 2022.
Article in English | EMBASE | ID: covidwho-1995632

ABSTRACT

CASE: A 75-year-old incarcerated man presented to the ED with one week of chills, body aches, dry cough, and dyspnea. His past medical history was significant for hypertension, type II diabetes, and obesity. He had been incarcerated for 18 years and was looking forward to his release in five months. He was identified as African-American in his chart. On initial evaluation, his oxygen saturation was 87% on room air with otherwise normal vitals. His breathing was labored with crackles in the lung bases. His chest x-ray showed multifocal opacities. He tested positive for SARS-CoV- 19 and was admitted on high-flow nasal cannula. In the following week, his oxygen needs escalated and he was transferred to the Medical ICU. Multiple requests for medical clearance to contact family were declined by the correctional facility. On day 8, he was intubated, paralyzed, and proned. He remained shackled to his bed with two correctional officers posted outside his door. On day 14, he suffered a PEA arrest with return of spontaneous circulation following ACLS. Attempts to contact family are approved and his care plan is changed to comfort measures only. He was terminally extubated and passed away soon after. Throughout the hospitalization, including during his cardiac arrest, the patient remained shackled to his hospital bed by the left ankle. Two correctional officers were stationed outside his hospital room 24 hours per day. The medical team had been unable to contact the patient's next of kin until the day he arrested, at which time they opted to pursue comfort measures. Months later, a medical resident who had cared for him shared the following words during a reflective writing session: “Nobody should die in handcuffs.” IMPACT/DISCUSSION: End-of-life care for incarcerated people is a pressing issue in the United States, where approximately 2.4 million individuals are held within the prison system. Due to an aging prison population, more incarcerated patients are dying than ever before. It is predicted that by 2030, the number of elderly prisoners is expected to reach 400,000 - an increase of 4,400% since 1981, according to a 2012 report from the ACLU. Most jurisdictions in the United States require shackling of the hands or feet when inmates are transported outside the prison setting. For patients with debilitating illness, shackling in the medical setting violates the principles of beneficence, non-maleficence, and autonomy essential to the practice of medicine. The COVID-19 pandemic has further underscored the ethical, legal, and moral dilemmas which clinicians face in preserving the dignity of the dying patient. CONCLUSION: Given the expected changes in demographics within the US correctional system, clinicians must advocate for compassionate policies such as the removal of shackles at the end of life. Potential avenues for change in practice can involve increased medical-legal dialogue and partnerships with correctional officers and other stakeholders within medical and correctional institutions.

7.
Hong Kong Journal of Emergency Medicine ; 29(1):23S-24S, 2022.
Article in English | EMBASE | ID: covidwho-1978657

ABSTRACT

Background: Regional variations in the impact of the coronavirus disease-2019 (COVID-19) pandemic on out-of-hospital cardiac arrest (OHCA) have been reported. We aimed to examine differences in the community response, emergency medical services (EMS) interventions, and outcomes of OHCA, in Singapore (population 5.7 million) and Atlanta (population 4.16 million), before and during the pandemic. Methods: Using prospectively collected Singapore Pan-Asian Resuscitation Outcomes Study (PAROS) and Atlanta Cardiac Arrest Registry to Enhance Survival (CARES) data, we compared EMS-treated adult OHCAs (≥18 years) during the pandemic period (17weeks from the date of first confirmed COVID-19 case) and pre-pandemic period (corresponding weeks in 2019). The primary outcome was pre-hospital return of spontaneous circulation (ROSC). We reported adjusted odds ratios (aOR) for OHCA characteristics, pre-hospital interventions, and outcomes using binary logistic regression. Results: Of the 3987 EMS-treated OHCAs (overall median age 69 years, 60.1% males) in Singapore and Atlanta, 2084 occurred during the pandemic and 1903 during the pre-pandemic period. Compared with Atlanta, OHCA cases in Singapore were older (median age 72 vs 66 years), received more bystander interventions (65.1% vs 41.4% received cardiopulmonary resuscitation (CPR) and 28.4% vs 10.1% had automated external defibrillator application), yet observed less pre-hospital ROSC (11.3% vs 27.1%). When compared with the pre-pandemic period, the likelihood of residential OHCAs doubled in both cities during the pandemic;in Singapore, OHCAs were more likely to be witnessed (aOR 1.95, 95% confidence interval (CI), 1.59-2.39) yet less likely to receive CPR (aOR 0.81, 95% CI, 0.65-0.99) during the pandemic. OHCAs occurring during the pandemic, compared with pre-pandemic, were less likely to be transported in Singapore and Atlanta (aOR 0.50, 95% CI, 0.42%-0.85%, and 0.36, 95% CI, 0.26-0.50, respectively), without significant differences in overall pre-hospital ROSC. Conclusion: Changes in OHCA characteristics and pre-hospital interventions during the pandemic were likely collateral consequences, with regional variations partly reflecting differences in systems of care and other sociocultural factors. These highlight opportunities for public education and the need for further study into lower transport rates during the pandemic.

8.
Acta Clinica Belgica: International Journal of Clinical and Laboratory Medicine ; 77(sup1):1-33, 2022.
Article in English | EMBASE | ID: covidwho-1886341
10.
Journal of Investigative Medicine ; 70(4), 2022.
Article in English | EMBASE | ID: covidwho-1865814

ABSTRACT

The proceedings contain 292 papers. The topics discussed include: the hemodynamic benefits of brief 100% oxygen use during preterm resuscitation with an intact umbilical cord using asphyxiated and non-asphyxiated surfactant deficient ovine model;initial use of 100% but not 60% or 30% oxygen achieved a target heart rate of 100 and preductal saturations of 80% faster in a bradycardic preterm model;randomized trial of preductal target SPO2 of 90-94% vs. 95-99% in neonatal ovine hypoxic respiratory failure;side vs over-the-head chest compressions in neonates: does rescuer height alter efficacy?;initiating resuscitation with chest compressions and ventilation in a neonatal cardiac arrest model significantly reduced the time to establish return of spontaneous circulation;utility of emergent magnetic resonance imaging in children with persistent traumatic neck pain without radiographic injury;and high-risk markers and infection rates in febrile infants aged 29-60 days presenting to the emergency department during the COVID-19 pandemic compared with previous years.

11.
Journal of the American College of Cardiology ; 79(9):3417, 2022.
Article in English | EMBASE | ID: covidwho-1768659

ABSTRACT

Background: The occurrence of myocardial infarction (MI) with coronary vessel occlusion in an otherwise young, healthy adult with a mechanical aortic valve is rare. Case: A 25-year-old male with a history of congenital AS status-post mechanical aortic valve replacement presented to the hospital with an acute MI due to thromboembolism due to subtherapeutic INR. The patient developed ventricular fibrillation en route to the emergency department. Return of spontaneous circulation was achieved after one round of CPR with synchronized cardioversion. On admission, labs were significant for high sensitivity troponin >27,000 x 3, BNP 23, INR 1.8. The patient was positive for COVID-19 but was asymptomatic. EKG showed ST elevations in leads I, AVL with reciprocal depressions in leads II, III and AVF. The patient underwent an emergent left heart catheterization which showed a normally functioning mechanical aortic valve and 100% occlusion of the mid LAD. After several rounds of balloon angioplasty, a thrombus was aspirated, mechanical thrombectomy was performed and a drug-eluding stent was deployed under IVUS guidance with restoration of TIMI 3 flow. A transthoracic echocardiogram following PCI showed an ejection fraction of 40% with anterior wall hypokinesis and mean aortic valve gradient of 10mmHg. The patient followed up in clinic two months later and was doing well. Decision-making: The effect of valvular heart disease on heart failure and cardiogenic shock is well studied. However, the occurrence of myocardial infarction due to thromboembolism in young patients with a subtherapeutic INR in the setting of mechanical aortic valve is not well described in literature. Conclusion: This case highlights both the importance of compliance with anticoagulation in patients with mechanical valves and a rare cause of myocardial infarction;i.e., non-compliance with anticoagulation in the setting of mechanical aortic valve. In addition, COVID-19 has been well established as a prothrombotic disease process, adding to the plot of this unusual case.

12.
US Endocrinology ; 17(1):10-13, 2021.
Article in English | EMBASE | ID: covidwho-1766544

ABSTRACT

We assessed real-time continuous glucose monitoring (rtCGM) data in an individual with type 2 diabetes who presented with severe symptoms of COVID-19, and suffered a fatal cardiac arrest during hospitalization. In this retrospective analysis, we used rtCGM to evaluate changes in blood glucose levels in a 71-year-old male with COVID-19 symptoms who suffered a fatal cardiac arrest. Blood glucose levels remained constant at 220–225 mg/dL after the first cardiac arrest, slowly decreased to 167 mg/dL after return of spontaneous circulation was achieved, and rose to 198 mg/dL prior to the second arrest. After the patient expired, glucose levels decreased to the 141 mg/dL over the first hour, but quickly declined to undetectable levels within the next 20 minutes. Wider adoption of rtCGM use in patients with COVID-19 may help identify blood glucose patterns and uncover new insights to various comorbidities and conditions

13.
Journal of the Hong Kong College of Cardiology ; 28(2):77, 2020.
Article in English | EMBASE | ID: covidwho-1743663

ABSTRACT

Objectives: To analyse the incidence of emergency medical serviceattended out-of-hospital cardiac arrests (OHCAs) and prehospital return of spontaneous circulation (ROSC) outcomes in Singapore from January to May 2020, as compared to the same period in 2018 and 2019. Methods: This was a retrospective observational study comparing current and previous emergency medical service (EMS) data and OHCA records maintained by the Singapore Civil Defence Force (SCDF). These figures were tabulated from data input by experienced paramedics responding to EMS calls and verified by an internal audit team. The study was conducted in accordance with the STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) guidelines, and examined factors that may have contributed to an increase or decrease in OHCA incidence and prehospital ROSC attainments during the different time periods. Results: Coronavirus Disease 2019 (COVID-19) is a global pandemic of unparalleled scale. Despite total EMS call volumes and overall OHCA incidence remaining comparable to pre-COVID periods, there was a concerning decrease in pre-hospital ROSC attainments between January to May 2020 (an average of 8.4%). Based on multivariable logistic regression, this was much lower when compared to previous years, where the pre-hospital ROSC rates remained around 12% (p<0.001). Further analyses did not reveal significant differences in terms of the median age of OHCA victims, the percentage of shockable rhythm or response times. However, it was noted that more OHCAs were occurring in residential homes, while those in public spaces decreased considerably compared to previous years (p<0.001). In addition, there was also a drop in the overall bystander cardiopulmonary resuscitation (CPR) rates compared to pre-COVID periods (p<0.001). Conclusion: The findings remain preliminary and follow-up data in the subsequent months are necessary to further investigate these trends. Nonetheless, they provide important lessons for public education and pandemic preparedness. To strengthen the first links in the survival chain, members of the public should be educated to initiate CPR and automated external defibrillator (AED) for any non-responsive victim (even without mouth-to-mouth ventilation).

14.
Front Cardiovasc Med ; 9: 799446, 2022.
Article in English | MEDLINE | ID: covidwho-1709658

ABSTRACT

BACKGROUND: Mortality after out-of-hospital cardiac arrest (OHCA) with return of spontaneous circulation (ROSC) remains high despite numerous efforts to improve outcome. For patients with suspected coronary cause of arrest, coronary angiography is crucial. However, there are other causes and potentially life-threatening injuries related to cardiopulmonary resuscitation (CPR), which can be detected by routine computed tomography (CT). MATERIALS AND METHODS: At Hannover Medical School, rapid coronary angiography and CT are performed in successfully resuscitated OHCA patients as a standard of care prior to admission to intensive care. We analyzed all patients who received CT following OHCA with ROSC over a three-year period. RESULTS: There were 225 consecutive patients with return of spontaneous circulation following out-of-hospital cardiac arrest. Mean age was 64 ± 13 years, 75% were male. Of them, 174 (77%) had witnessed arrest, 145 (64%) received bystander CPR, and 123 (55%) had a primary shockable rhythm. Mean time to ROSC was 24 ± 20 min. There were no significant differences in CT pathologies in patients with or without ST-segment elevations in the initial ECG. Critical CT findings qualifying as a potential cause for cardiac arrest were intracranial bleeding (N = 6), aortic dissection (N = 5), pulmonary embolism (N = 17), pericardial tamponade (N = 3), and tension pneumothorax (N = 11). Other pathologies were regarded as consequences of CPR and relevant for further treatment: aspiration (N = 62), rib fractures (N = 161), sternal fractures (N = 50), spinal fractures (N = 11), hepatic bleeding (N = 12), and intra-abdominal air (N = 3). CONCLUSION: Early CT fallowing OHCA uncovers a high number of causes and consequences of OHCA and CPR. Those are relevant for post-arrest care and are frequently life-threatening, suggesting that CT can contribute to improving prognosis following OHCA.

15.
Journal of Investigative Medicine ; 70(2):506, 2022.
Article in English | EMBASE | ID: covidwho-1707363

ABSTRACT

Case Report Hemophagocytic lymphohistiocytosis (HLH) is a potentially fatal disease characterized by excessive immune response and cytopenia. Severe COVID-19 infection induces a life-threatening inflammatory syndrome associated with intense cytokine release that similar to HLH. We present a patient who developed takotsubo cardiomyopathy due to HLH. Case 24-year olrd man with a past medical history of obesity was admitted at the medical intensive care unit (MICU) due to acute respiratory distress syndrome secondary to COVID- 19 pneumonia. During the MICU stay, the patient required a high dose of vasopressors and ventilatory support. For Covid management, the patient received tocilizumab, high dose steroids (20 mg daily of dexamethasone), and empiric antibiotic coverage with vancomycin and cefepime. On day six of MICU admission, the patient developed hypertriglyceridemia (TGL) that was initially thought to be secondary to propofol, but after discontinuing propofol the patient continued to have increasing TGL levels. On day 8 of MICU admission, the suspicion of HLH increased, HSscore was calculated, and the patient had a 70-80% probability of having HLH (181 points: Temperature of 103 °F, ferritin 2580 ng/ml, TGL:771 mg/dl, Fibrinogen 220 mg/dl, AST:116 u/L). On day 10 of MICU admission, troponins increased from 7.5 to 2,966 ng/L, telemetry showed diffuse ST elevations, but ECG did not show any ischemic changes. At that time, his clinical parameters included HR: 96 bpm, BP: 92/42 mmHg, O2 Sat:93% on mechanical ventilation with pressure support FIO2: 100%, Hb: 11.6 g/dl, WBC:10.36 k/dl, Plt: 210 k/dl. Acute stress cardiomyopathy secondary to HLH was suspected. Transthoracic echocardiogram demonstrated preserved ejection fraction and inferoapical akinesia consistan as takotsubo cardiomyopathy. On day 11 of MICU admission, the patient had a cardiac arrest and after 30 minutes of cardiopulmonary resuscitation no return of spontaneous circulation was achieved. Discussion HLH induces a cytokine cascade that causes an excessive inflammatory response and multi-organ dysfunction that can be secondary to infections such as Covid-19. Takotsubo cardiomyopathy also known as stress cardiomyopathy, is a reversible dysfunction characterized by acute hypokinesia/ akinesia of the apical and middle segments of the left ventricle that extends beyond a unique coronary territory. We conclude that the trigger for takotsubo cardiomyopathy in this case was related to excess catecholamine release secondary to HLH.

16.
Kidney International Reports ; 7(2):S359, 2022.
Article in English | EMBASE | ID: covidwho-1705323

ABSTRACT

Introduction: Here, we discuss a chronic kidney disease (CKD) patient with large pericardial effusion who arrested secondary to tamponade and had an unintentional pericardial decompression secondary to cardio pulmonary resuscitation (CPR) that subsequently saved his life. Methods: PRESENTATION 67 years old male, a case of CKD on maintenance hemodialysis (for last two years) but inadequately dialyzed over last two months after recent covid pneumonia was detected to have large pericardial effusion (red arrows) on echocardiography (Figure 1). He was planned for intensive heparin free dialysis in view of absence of frank clinical and echocardiographic findings of tamponade with close surveillance for pericardial effusion. 60 minutes into hemodialysis, patient developed dyspnea, hypotension, and cardiac arrest. Return of spontaneous circulation was achieved after three cycles of cardiopulmonary resuscitation. Echocardiography (echo) guided pericardiocentesis was planned based on clinical suspicion of tamponade. But, echocardiography revealed only mild pericardial effusion (Figure 1). Chest x ray showed new left pleural effusion. Pleurocentesis revealed hemorrhagic fluid. Subsequently done CT thorax showed multiple rib fractures. Patient was discharged on day eleven in stable condition with repeat chest X ray and echocardiography showing no further collection. Figure1: Panel A ( Pre CPR echo, Large pericardial effusion - red arrows), Panel B (Post CPR echo, minimal pericardial effusion) [Formula presented] Results: DISCUSSION Though cardiac tamponade is largely a clinical diagnosis, various other features like echocardiography aid in its diagnosis. Diagnosis of tamponade in CKD patient with pericardial effusion is difficult because of several reasons. All classical clinical features of tamponade like hypotension or elevated systemic pressures may not be manifested all the time in cases of tamponade. Our patient developed clinical signs of tamponade 60 minutes into dialysis session indicating that precipitation of tamponade was likely due to reduction in preload due to ultrafiltration (UF) during hemodialysis. Though, daily dialysis is the initial preferred treatment of choice for uremic pericardial effusions in CKD patients without clinical or echocardiographic signs of tamponade, there are case reports which support early pericardiocentesis as treatment of choice in all large pericardial effusions in CKD patients on maintenance hemodialysis (MHD). In our case of large pericardial effusion, due to absence of frank clinical/ echocardiographic evidence of tamponade, we were prompted to go for aggressive dialysis treatment plan, but had tamponade during dialysis. CPR can cause inadvertent injury to surrounding structures, ribs, abdominal organs and vascular injury. In our case, CPR associated injury lead to unintentional pericardial decompression probably due to rib injury or due to high force generated during CPR coupled with high pericardial pressures which overcame the tensile strength of pericardium resulting in pericardial decompression. Findings of fractured ribs on CT scan post resuscitation in our case supports that high force and pressure were generated during CPR. Conclusions: This case report supports early pericardiocentesis as treatment of choice for large pericardial effusion in CKD patients on MHD. Also, care should be taken while dialyzing these patient as rapid UF can precipitate tamponade. No conflict of interest

17.
Journal of Investigative Medicine ; 70(2):515, 2022.
Article in English | EMBASE | ID: covidwho-1700524

ABSTRACT

Case Report A Rare Presentation of Multivessel Vasospastic Angina in the Setting of Septic Shock Background Prinzmetal or vasospastic angina is an unusual but important consideration when evaluating a patient with chest pain. Unlikely acute coronary syndromes (ACS) which primarily occur as a result of coronary artery occlusion, prinzmetal angina occurs angina occurs mainly as a result of coronary artery vasospasm. We present the unusual case of a patient who suffered cardiac arrest and was found to have >90% occlusion in multiple coronary arteries on a left heart catheterization (LHC) performed within 60 minutes. Case presentation Patient is a 70-year-old female who was initially being treated in the hospital for COVID-19. She spent a few days in the ICU due to requiring high flow nasal cannula but was transferred to the floor after she was weaned down to 3L/min via regular nasal cannula. On day of arrest, patient had increasing oxygen requirements and was on ventimask immediately prior to the code blue. Patient received 2 rounds of CPR and her initial rhythm was found to be ventricular fibrillation. Pt was defibrillated and ROSC was immediately achieved. EKG showed ST elevations in inferior leads. Patient was, however, alert and oriented x3 on initial evaluation by critical care team. She was not intubated after the arrest. She was transferred to the intensive care unit, given 300 mg intravenous amiodarone and therapeutic dose lovenox. On LHC, her left anterior descending artery (mid/ distal portion), distal diagonal vessel, left circumflex artery (mid portion), distal portion of the obtuse marginal and right coronary artery were found to be severely spasmodic. Patient had recurrence of angina after the catheterization which was transiently relieved with nitro. Patient had sustained relief of angina after starting nitro drip. Patient was also started on amiodarone drip upon transfer back to the ICU. Discussion The obvious side-effect of our therapeutic treatment was hypotension that was initially responsive to intravenous fluids. Patient, however, became hypoxic a few hours later and needed to be diuresed to return to baseline oxygen requirement. Patient was then started on norepinephrine drip with goal to maintain mean arterial pressure above 65. After patient was loaded with amiodarone, nitro drip was discontinued. She was then transitioned to oral amiodarone. She was started on isosorbide dinitrate prior discontinuing nitro drip. Patient's blood pressure stabilized as her per oral intake improved and norepinephrine drip soon thereafter. Novel presentations require novel treatment and creative thinking lead to the decision to continue nitro drip to keep her stable, even if it meant the simultaneous use of an anti-hypertensive and a pressor. It is possible that COVID-19 served as a trigger for such a global vasospasm event. Patient was restarted on her home medication of long-acting nitrates which were held on admission due to hypotension.

18.
Critical Care Medicine ; 50(1 SUPPL):208, 2022.
Article in English | EMBASE | ID: covidwho-1691886

ABSTRACT

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.

19.
Crit Care Explor ; 4(2): e0605, 2022 Feb.
Article in English | MEDLINE | ID: covidwho-1677316

ABSTRACT

OBJECTIVES: The utility and risks to providers of performing cardiopulmonary resuscitation after in-hospital cardiac arrest in COVID-19 patients have been questioned. Additionally, there are discrepancies in reported COVID-19 in-hospital cardiac arrest survival rates. We describe outcomes after cardiopulmonary resuscitation for in-hospital cardiac arrest in two COVID-19 patient cohorts. DESIGN: Retrospective cohort study. SETTING: New York-Presbyterian Hospital/Columbia University Irving Medical Center in New York, NY. PATIENTS: Those admitted with COVID-19 between March 1, 2020, and May 31, 2020, as well as between March 1, 2021, and May 31, 2021, who received resuscitation after in-hospital cardiac arrest. INTERVENTIONS: None. MEASUREMENT AND MAIN RESULTS: Among 103 patients with coronavirus disease 2019 who were resuscitated after in-hospital cardiac arrest in spring 2020, most self-identified as Hispanic/Latino or African American, 35 (34.0%) had return of spontaneous circulation for at least 20 minutes, and 15 (14.6%) survived to 30 days post-arrest. Compared with nonsurvivors, 30-day survivors experienced in-hospital cardiac arrest later (day 22 vs day 7; p = 0.008) and were more likely to have had an acute respiratory event preceding in-hospital cardiac arrest (93.3% vs 27.3%; p < 0.001). Among 30-day survivors, 11 (73.3%) survived to hospital discharge, at which point 8 (72.7%) had Cerebral Performance Category scores of 1 or 2. Among 26 COVID-19 patients resuscitated after in-hospital cardiac arrest in spring 2021, 15 (57.7%) had return of spontaneous circulation for at least 20 minutes, 3 (11.5%) survived to 30 days post in-hospital cardiac arrest, and 2 (7.7%) survived to hospital discharge, both with Cerebral Performance Category scores of 2 or less. Those who survived to 30 days post in-hospital cardiac arrest were younger (46.3 vs 67.8; p = 0.03), but otherwise there were no significant differences between groups. CONCLUSIONS: Patients with COVID-19 who received cardiopulmonary resuscitation after in-hospital cardiac arrest had low survival rates. Our findings additionally show return of spontaneous circulation rates in these patients may be impacted by hospital strain and that patients with in-hospital cardiac arrest preceded by acute respiratory events might be more likely to survive to 30 days, suggesting Advanced Cardiac Life Support efforts may be more successful in this subpopulation.

20.
Circulation ; 144(SUPPL 1), 2021.
Article in English | EMBASE | ID: covidwho-1638304

ABSTRACT

Introduction: The coronavirus disease 2019 (COVID-19) pandemic has influenced epidemiology through direct and indirect effects, yet the impact on out-of-hospital cardiac arrest (OHCA) is unclear. We aimed to evaluate the impact of the pandemic on the incidence, characteristics, and clinical outcomes of OHCA. Hypothesis: We hypothesized that compared to the pre-pandemic period, the COVID-19 pandemic period was associated with increased incidence and case fatality rate (CFR) of OHCA, as well as decreased rates of intermediate clinical outcomes (termination of resuscitation [TOR], return of spontaneous circulation [ROSC], survival to hospital admission, and survival to hospital discharge). We further postulated that there was a change in the etiologies of OHCA during the pandemic as well as a decline in the rate of shockable rhythm as the initial presenting rhythm. Methods: In this systematic review and meta-analysis, five scientific databases were searched from inception to May 3, 2021. Meta-analyses were performed for the primary outcomes, secondary outcomes, and clinical characteristics. This study was registered in the International Prospective Register of Systematic Reviews (PROSPERO) (CRD42021253879). Results: The search yielded 966 articles. 20 articles were included for analysis. The COVID-19 pandemic was associated with a 39.5% increase in pooled annual OHCA incidence (p<0.001). Pooled CFR was increased by 2.65% (p<0.001), with an odds ratio (OR) of 1.95 for mortality (95% confidence interval [95%CI] 1.51-2.51). There was increased field TOR (OR=2.46, 95%CI 1.62- 3.74). There were decreased ROSC (OR=0.65, 95%CI 0.55-0.77), survival to hospital admission (OR=0.65, 95%CI 0.48-0.89), and survival to discharge (OR=0.52, 95%CI 0.40-0.69). There was decreased shockable rhythm (OR=0.73, 95%CI 0.60-0.88) and increased asphyxial etiology of OHCA (OR=1.17, 95%CI 1.02-1.33). There was moderate-to-high statistical heterogeneity. Findings were robust to sensitivity analyses, with no publication bias detected. Conclusions: The COVID-19 pandemic was associated with significant changes in OHCA epidemiology. Compared to the pre-pandemic period, the pandemic period was associated with increased OHCA incidence and worse outcomes.

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