Hydropneumothorax With Persistent Air Leak in a Patient With Mild COVID-19 Disease.

COVID-19 is a pandemic viral disease with a catastrophic global impact. The severity of COVID-19 symptoms ranges from very mild to severe and affects mainly the respiratory system. Spontaneous pneumothorax and pleural effusion are rarely seen in spontaneously breathing COVID-19 patients. We herein report a case of a patient with mild COVID-19 disease presenting to the emergency department with hydropneumothorax. Due to persistent air leak, the patient was managed with video-assisted thoracoscopic surgery (VATS) bullectomy and talc pleurodesis. Clinicians managing these patients should be alert to early diagnose this complication.

Drones for Automated External Defibrillator Delivery: Where Do We Stand?

BACKGROUND: Out-of-hospital cardiac arrest (OHCA) is an important cause of mortality and disability worldwide. The health care community hoped that, with the development of the automated external defibrillator (AED), the mortality and functional outcomes of patients with OHCAs would improve. Despite their effectiveness, their use in OHCA has not yet become common practice. Unfortunately, in 18-59% of cases, public access AEDs were deemed to be in poorly accessible areas or not available all of the time. OBJECTIVE: We present the existing literature on the implementation of drone delivery of AEDs to improve the response time of the emergency medical services. DISCUSSION: Test flights and mathematical/geographic models have been used to assess the effectiveness of drones in delivering AEDs to patients with OHCA. The results of those studies showed promising outcomes given that drone usage led to improved delivery times of AEDs compared with emergency medical services delivery. CONCLUSIONS: While drones have the potential to dramatically improve cardiac arrest patient care, further studies are needed to evaluate their effectiveness in real-life clinical scenarios.

COVID-19 pandemic and cardiovascular disease: where do we stand?

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the cause of coronavirus disease 2019 (COVID-19) which recently has been characterized as a pandemic by the World Health Organization (WHO) having killed almost 250,000 people worldwide as of May 4th, 2020. Despite the fact that SARS-CoV-2 seems to predominantly affect the respiratory system leading to pneumonia and acute respiratory distress syndrome, it is now evident that it may also affect the cardiovascular system in multiple ways. The current paper is a review of the most recent literature regarding SARS-CoV-2 infection and its associated main cardiovascular clinical manifestations. Cardiovascular disease represents a prevalent underlying comorbidity associated with increased mortality rates among COVID-19 affected individuals. In addition, various cardiovascular manifestations have been linked to the viral insult, including among others acute coronary syndromes, myocarditis, acute heart failure, cardiac injury, arrhythmias and acute pulmonary embolism. Further studies are required in order to establish the complicated association between SARS-CoV-2 infection and its effects on the cardiovascular system. Our knowledge regarding diagnostic approaches, therapeutic management and preventive measures is constantly enriched throughout an abundance of ongoing research in the respective fields.

Celiac Artery Avulsion Secondary to Blunt Trauma: A Case Report.

Celiac artery (CA) injuries are very rare and are often associated with high mortality. These injuries are associated more often with penetrating trauma rather than blunt trauma injury. Our case highlights a blunt trauma injury of CA in a hemodynamically stable patient without any symptoms that was treated conservatively.

Benign metastasizing leiomyoma presenting as cavitating lung nodules.

Benign metastasizing leiomyoma (BML) was initially used to describe single or multiple pulmonary nodules composed of proliferating smooth muscle cells (lacking cellular atypia) in premenopausal females 3 months to 20 y after hysterectomy for uterine leiomyoma. The lung is the most commonly involved site, thus including many malignant and benign entities in the differential diagnosis. The present case refers to a 47-y-old premenopausal woman with a history of subtotal hysterectomy for a uterine leiomyoma presenting with bilateral cavitating pulmonary nodules. A number of nodules were resected by video-assisted thoracoscopic surgery. The histological findings in correlation with the immunohistochemical results were consistent with the diagnosis of BML. A bilateral salpingo-oophorectomy was performed, combined with complete removal of the remaining cervix. One year later, the subject remains asymptomatic, and the pulmonary nodules are stable with regard to number, size, location, and morphology.

Use of the impedance threshold device improves survival rate and neurological outcome in a swine model of asphyxial cardiac arrest*.

OBJECTIVE: To assess whether intermittent impedance of inspiratory gas exchange improves hemodynamic parameters, 48-hr survival, and neurologic outcome in a swine model of asphyxial cardiac arrest treated with active compression-decompression cardiopulmonary resuscitation. DESIGN: Prospective, randomized, double-blind study. SETTING: Laboratory investigation. SUBJECTS: Thirty healthy Landrace/Large-White piglets of both sexes, aged 10 to 15 wks, whose average weight was 19 ± 2 kg. INTERVENTIONS: At approximately 7 mins following endotracheal tube clamping, ventricular fibrillation was induced and remained untreated for another 8 mins. Before initiation of cardiopulmonary resuscitation, animals were randomly assigned to either receive active compression-decompression cardiopulmonary resuscitation plus a sham impedance threshold device (control group, n = 15), or active compression-decompression cardiopulmonary resuscitation plus an active impedance threshold device (experimental group, n = 15). Electrical defibrillation was attempted every 2 mins until return of spontaneous circulation or asystole. MEASUREMENTS AND MAIN RESULTS: Return of spontaneous circulation was observed in six (40%) animals treated with the sham valve and 14 (93.3%) animals treated with the active valve (p = .005, odds ratio 21.0, 95% confidence interval 2.16-204.6). Neuron-specific enolase and S-100 levels increased in the ensuing 4 hrs post resuscitation in both groups, but they were significantly elevated in animals treated with the sham valve (p < .01). At 48 hrs, neurologic alertness score was significantly better in animals treated with the active valve (79.1 ± 18.7 vs. 50 ± 10, p < .05) and was strongly negatively correlated with 1- and 4-hr postresuscitation neuron-specific enolase (r = -.86, p < .001 and r = -.87, p < .001, respectively) and S-100 (r = -.77, p < .001 and r = -0.8, p = .001) values. CONCLUSIONS: In this model of asphyxial cardiac arrest, intermittent airway occlusion with the impedance threshold device during the decompression phase of active compression-decompression cardiopulmonary resuscitation significantly improved hemodynamic parameters, 24- and 48-hr survival, and neurologic outcome evaluated both with clinical and biochemical parameters (neuron-specific enolase, S-100).

Nifekalant in the treatment of life-threatening ventricular tachyarrhythmias.

The aim of the present study is to review the literature and discuss nifekalant's potential use as a first aid drug in an emergency care setting. The PubMed database was used to identify papers, using keywords nifekalant, MS-551, amiodarone and lidocaine. Nifekalant hydrochloride, formally known as MS-551, is a class III antiarrhythmic agent which acts only by increasing the time course of myocardial repolarization. It was developed and is currently being used only in Japan for the treatment of ventricular tachyarrhythmias. It is a non-selective K(+) channel blocker without any ß-blocking actions. Administration of nifekalant suppressed sustained ventricular tachyarrhythmias in acute coronary syndrome patients, and in cardiac arrest victims as well as during or after cardiac surgery. The major adverse effect of nifekalant is QT interval prolongation and occurrence of torsades de pointes which requires frequent monitoring of the QT interval during nifekalant infusion with adequate dose adjustment. Nifekalant is a possible effective antiarrhythmic agent for refractory ventricular tachyarrhythmias. Further clinical studies are required before nifekalant is routinely used in the emergency care setting.

A model of hemorrhagic shock and acute lung injury in Landrace-Large White Swine.

Traumatic injury is a leading cause of death worldwide for people between 5 and 44 y of age, and it accounts for 10% of all deaths. The incidence of acute lung injury, a life-threatening complication in severely injured trauma patients remains between 30% and 50%. This study describes an experimental protocol of volume-controlled hemorrhage in Landrace-Large White swine. The experimental approach simulated the clinical situation associated with hemorrhagic shock in the trauma patient while providing controlled conditions to maximize reproducibility. The duration of the protocol was 8 h and was divided into 5 distinct phases-stabilization, hemorrhage, maintenance, resuscitation, and observation-after which the swine were euthanized. Lung tissue samples were analyzed histologically. All swine survived the protocol. The hemodynamic responses accurately reflected those seen in humans, and the development of acute lung injury was consistent among all swine. This experimental protocol of hemorrhagic shock and fluid resuscitation in Landrace-Large White swine may be useful for future study of hemorrhagic shock and acute lung injury.

Hypertrophic cardiomyopathy and sudden cardiac death.

Hypertrophic cardiomyopathy (HCM) is a common genetic cardiovascular disease that affects the left ventricle. HCM can appear at any age, with the majority of the patients remaining clinically stable. When patients complain of symptoms, these include: dyspnea, dizziness, syncope and angina. HCM can lead to sudden cardiac death (SCD), mainly due to ventricular tachyarrhythmia or ventricular tachycardia. High-risk patients benefit from implantable cardioverter-defibrillators. Left ventricular outflow tract obstruction is not a rare feature in HCM, especially in symptomatic patients, and procedures that abolish that obstruction provide positive and consistent results that can improve long-term survival. HCM is the most common cause of sudden death in young competitive athletes and preparticipation screening programs have to be implemented to avoid these tragic fatalities. The structure of these programs is a matter of large debate. Worldwide registries are necessary to identify the full extent of HCM-related SCD.

Use of the impedance threshold device in cardiopulmonary resuscitation.

Although approximately one million sudden cardiac deaths occur yearly in the US and Europe, cardiac arrest (CA) remains a clinical condition still characterized by a poor prognosis. In an effort to improve the cardiopulmonary resuscitation (CPR) technique, the 2005 American Heart Association (AHA) Guidelines for CPR gave the impedance threshold device (ITD) a Class IIa recommendation. The AHA recommendation means that there is strong evidence to demonstrate that ITD enhances circulation, improves hemodynamics and increases the likelihood of resuscitation in patients in CA. During standard CPR, venous blood return to the heart relies on the natural elastic recoil of the chest which creates a transient decrease in intrathoracic pressure. The ITD further decreases intrathoracic pressure by preventing respiratory gases from entering the lungs during the decompression phase of CPR. Thus, although ITD is placed into the respiratory circuit it works as a circulatory enhancer device that provides its therapeutic benefit with each chest decompression. The ease of use of this device, its ability to be incorporated into a mask and other airway devices, the absence of device-related adverse effects and few requirements in additional training, suggest that ITD may be a favorable new device for improving CPR efficiency. Since the literature is short of studies with clinically meaningful outcomes such as neurological outcome and long term survival, further evidence is still needed.

Refined induction of anesthesia with remifentanil after bolus propofol administration in Landrace/Large White swine.

The authors report a prospective randomized blind study in which they used a refined anesthetic technique in male Landrace/Large White swine (n = 125 pigs, 19 ± 2 kg, 10-15 weeks old). The animals were first premedicated with ketamine, midazolam and atropine and then given a dose of 1, 2, 3, 4 or 5 µg remifentanil per kg body weight (dose amounts were randomly assigned) after a bolus dose of propofol. The authors assessed the intubation conditions (e.g., jaw relaxation and other parameters) 20 min after premedication and then 5 min after anesthesia induction. All animals that received each of the different remifentanil dose amounts were successfully intubated in less than 30 s. No animal developed apnea during intubation or experienced substantial reductions in heart rate or blood pressure (> 25%) between the two time points (20 min after premedication and 5 min after anesthesia induction). Overall intubation conditions were significantly better in animals that received 5 µg remifentanil per kg body weight than in animals that received other dose amounts (P < 0.001). The average time to intubation was significantly shorter for animals that received 5 µg remifentanil per kg body weight than for animals that received any of the other dose amounts (P < 0.001). The authors concluded that for this study, 5 µg remifentanil per kg body weight resulted in excellent intubating conditions in this swine breed.