Prone Cardiopulmonary Resuscitation (CPR) Protocol: A Single-Center Experience at Implementation and Review of Literature.

The prone position is a crucial position used in the operating rooms and the intensive care units, with its importance highly recognized during the COVID-19 pandemic in patients with acute respiratory distress syndrome (ARDS). Cardiopulmonary resuscitation (CPR) is a cardinal procedure that is indicated and performed on any eligible patient who has cardiopulmonary arrest and resultant lack of perfusion and oxygenation. When a patient has a cardiopulmonary arrest in the prone position, the options include rotating the patient supine before starting cardiopulmonary resuscitation (CPR) or beginning CPR while prone. Prone CPR has not had a widely accepted use so far. In this article, we narrate the process of protocol development and staff education at our hospital for the initiation of prone CPR and review the literature related to it. Prone CPR is an effective technique with good outcomes and involves a learning curve. Appropriate training needs to be done before implementing the protocol, and adequate quality control measures need to be set to ensure that the skill set is maintained.

Honoring Long-Lived Cultural Beliefs for End-of-Life Care: Are We Prepared in the Modern Western Society?

The Hippocratic Oath establishes the principle of primum non nocere or "first do no harm" in Western medicine. This not only includes physical health but also encompasses emotional and spiritual health. Various end-of-life care (EOLC) practices exist in different societies, and it is hard but vital for the healthcare community to be aware of these practices to allow wholesome care for their patients, which is emotionally and spiritually fulfilling.  A 57-year-old male with a history of metastatic squamous cell carcinoma of the head and neck region presented to the emergency department after an out-of-hospital cardiac arrest. After appropriate post-cardiac arrest care, the patient remained unresponsive, and the family decided to transition to comfort-focused care. Based on their religious and cultural preferences, they preferred palliative extubation at a place where the patient would not have a roof over his head at the time of death, as well as sought help to facilitate a same-day funeral. After coordinating with various departments in the hospital, the patient was taken to the hospital helipad and extubated there in the family's presence. The patient's remains were released to the family within an hour of death for a timely funeral.  This case is an example of cultural and religious diversity that exists within our community. Healthcare is a complex field and EOLC is a crucial part of patient care. With a multi-disciplinary approach towards EOLC, the distress related to death can be reduced among families as well as healthcare teams.

E-cigarette or Vaping Product Associated Lung Injury (EVALI) Presenting As Cardiac Arrest.

E-cigarettes or vaping products became available in the market in 2004. Since then, their use has rapidly increased in all sections of society. They have been increasingly used as a "safer" alternative for combustible cigarettes and as an aid toward smoking cessation. Over time, the acceptability of e-cigarettes in public spaces increased. Lack of regulatory control also led to a rapid rise in the rate of e-cigarette/vaping product users. We report a case of a 35-year-old female who recently switched from conventional cigarettes to e-cigarette usage, and who presented to the emergency department after an out-of-hospital cardiac arrest. She was found to have bilateral extensive nodular ground-glass opacities on a CT angiogram of the chest. She needed non-invasive ventilation and was initially started on broad-spectrum antibiotic treatment for possible pneumonia. Due to a worsening clinical status, e-cigarette or vaping product associated lung injury (EVALI) diagnosis was considered, and she was started on parenteral steroid therapy, leading to rapid recovery in respiratory status. With a tapering course of steroid therapy and cessation of e-cigarette use, there was complete clinical and radiological recovery. This case highlights that EVALI can have varied clinical presentations, and the diagnosis should be considered in anyone who presents with an acute cardio-pulmonary decline and a concomitant history of e-cigarette use.

Community-Acquired, Post-COVID-19, Methicillin-Resistant Staphylococcus aureus Pneumonia and Empyema.

The coronavirus disease 2019 (COVID-19) pandemic has presented unprecedented challenges to the healthcare system globally, with opportunistic and secondary infections being one of the biggest challenges. Most secondary infections occur as nosocomial infections due to exposure to multidrug-resistant organisms in healthcare facilities. Secondary bacterial pneumonia complicates the care of hospitalized COVID-19 pneumonia patients. We present the case of a 77-year-old male who was diagnosed with COVID-19 pneumonia about four weeks before the current presentation to the hospital and was treated symptomatically in the community setting. During workup, he was diagnosed with multifocal pneumonia and right-sided empyema caused by methicillin-resistant Staphylococcus aureus (MRSA). He underwent chest tube thoracostomy followed by intrapleural fibrinolysis along with targeted antibiotic therapy. He needed video-assisted thoracoscopy with decortication due to inadequate improvement with intrapleural fibrinolysis. This case is a rare presentation of a community-acquired MRSA lung infection that occurred after recovery from COVID-19 pneumonia. This case emphasizes the importance of monitoring for secondary infections, as well as highlights the extent of secondary infections in COVID-19.

Adult-Onset Asthma Associated With E-Cigarette Use.

Electronic cigarettes (e-cigarettes) are being increasingly used as a "safer" alternative to regular cigarettes as a method of de-addiction or a bridge to nicotine cessation. However, a multitude of pulmonary pathologies have been described associated with its use and have been clubbed under the category of e-cigarette or vaping use-associated lung injury (EVALI). This case describes a patient who started e-cigarette smoking in order to quit combustible cigarette smoking and developed adult-onset severe asthma. The clinical effect was initially reversible but later developed into persistent symptoms requiring inhaled and systemic therapy.

Utility of Bronchoscopy With Endobronchial Ultrasound in Diagnosis and Monitoring of Pulmonary Embolism.

Pulmonary embolism (PE) is a common diagnosis made in the emergency department (ED). Although CT angiogram remains the preferred diagnostic modality, sometimes it is not possible to obtain due to hemodynamic instability, renal failure, pregnancy, etc. Bronchoscopy with endobronchial ultrasound (EBUS) has been used for the evaluation of mediastinal and hilar lesions. The proximity of pulmonary vasculature to mediastinal and hilar structures can aid in utilizing EBUS for bedside diagnosis and future monitoring of pulmonary embolism. This case describes a patient who presented with cardiac arrest, likely secondary to a massive pulmonary embolism, and later underwent bronchoscopy with EBUS that demonstrated the pulmonary emboli.

LUCAS 2™ device, compression depth, and the 2010 cardiopulmonary resuscitation guidelines.

The 2010 guidelines for cardiopulmonary resuscitation recommends that the chest be compressed at least 5 cm, with evidence that depths exceeding 5 cm may further aid resuscitation. The current piston-based mechanical device LUCAS 2™ is programmed to deliver a compression depth of 5 cm. We report 2 cases in which the LUCAS 2™ device failed to generate physiological surrogates of blood flow (ie, end-tidal carbon dioxide tension and aortic diastolic blood pressure) at levels indicative of effective chest compressions. A switch to manual compressions allowing greater compression depth yielded higher end-tidal carbon dioxide tension and arterial blood pressure. These cases depict limitations of the LUCAS 2™ device and the importance of guiding chest compression by physiological parameters. Consideration should be given to modifications to the LUCAS 2™, allowing rescuers to increase depth when required to optimize the hemodynamic efficacy of chest compression.