Cardiac Arrest as the First Presentation of Gitelman Syndrome

Gitelman syndrome is a salt-wasting tubulopathy characterized by profound hypokalemia, hypomagnesemia, metabolic alkalosis, and hypocalciuria. Cardiac arrest is a relatively rare manifestation of Gitelman syndrome. Here we present a case of Gitelman syndrome in a patient with recurrent cardiac arrest. A 43-year-old female was admitted for out-of-hospital cardiac arrest secondary to ventricular fibrillation. Initial workup revealed severe hypokalemia, hypomagnesemia, metabolic alkalosis, and prolonged QTc. The workup revealed a picture of salt-wasting tubulopathy with hypokalemia, hypomagnesemia, and hypocalciuria. Potassium was repleted aggressively, and the patient received potassium-sparing agents resulting in the stabilization of potassium levels. Before discharge, an implantable cardioverter defibrillator (ICD) was placed for secondary prevention of cardiac arrest. The patient remained symptom-free, and electrolytes remained stable. This case highlights the diagnostic challenges of Gitelman syndrome and the importance of accurate diagnosis in improving patient outcomes

Critical Care Delivery Solutions in the Emergency Department: Evolving Models in Caring for ICU Boarders

The National Academy of Medicine has identified emergency department (ED) crowding as a health care delivery problem. Because the ED is a portal of entry to the hospital, 25% of all ED encounters are related to critical illness. Crowding at both an ED and hospital level can thus lead to boarding of a number of critically ill patients in the ED. EDs are required to not only deliver immediate resuscitative and stabilizing care to critically ill patients on presentation but also provide longitudinal care while boarding for the ICU. Crowding and boarding are multifactorial and complex issues, for which different models for delivery of critical care in the ED have been described. Herein, we provide a narrative review of different models of delivery of critical care reported in the literature and highlight aspects for consideration for successful local implementation

Accelerated Critical Therapy Now in the Emergency Department Using an Early Intervention Team: The Impact of Early Critical Care Consultation for ICU Boarders

Evaluate the impact of an emergency department (ED)-based critical care consultation service, hypothesizing early consultation results in shorter hospital length of stay (LOS). DESIGN: Retrospective observational study from February 2018 to 2020. SETTING: An urban academic quaternary referral center. PATIENTS: Adult patients greater than or equal to 18 years admitted to the ICU from the ED. Exclusion criteria included age less than 18 years, do not resuscitate/do not intubate documented prior to arrival, advanced directives outlining limitations of care, and inability to calculate baseline modified Sequential Organ Failure Assessment (mSOFA) score. INTERVENTIONS: ED-based critical care consultation by an early intervention team (EIT) initiated by the primary emergency medicine physician compared with usual practice. MEASUREMENTS: The primary outcome was hospital LOS, and secondary outcomes were hospital mortality, ICU LOS, ventilator-free days, and change in the mSOFA. MAIN RESULTS: A total 1,764 patients met inclusion criteria, of which 492 (27.9%) were evaluated by EIT. Final analysis, excluding those without baseline mSOFA score, limited to 1,699 patients, 476 in EIT consultation group, and 1,223 in usual care group. Baseline mSOFA scores (±sd) were higher in the EIT consultation group at 3.6 (±2.4) versus 2.6 (±2.0) in the usual care group. After propensity score matching, there was no difference in the primary outcome: EIT consultation group had a median (interquartile range [IQR]) LOS of 7.0 days (4.0-13.0 d) compared with the usual care group median (IQR) LOS of 7.0 days (4.0-13.0 d), CONCLUSIONS: An ED-based critical care consultation model did not impact hospital LOS. This model was used in the ED and the EIT cared for critically ill patients with higher severity of illness and longer ED boarding times

Research Staff COVID-19 Pandemic Survey-Results from the Prevention and Early Treatment of Acute Lung Injury (PETAL) Network

Objectives: There is a lack of knowledge about the challenges of researchers who continued in-person research during the early phases of the COVID-19 pandemic. Design: Electronic survey assessing work-related exposure to COVID-19, logistical challenges, and procedural changes during the first year of the COVID-19 pandemic on clinical research. Setting: National Heart, Lung, and Blood Institute-sponsored Prevention and Early Treatment of Acute Lung Injury Clinical Trial Network Centers. Subjects: Research staff at research Network Sites. Measurements and Main Results: The 37-question survey was completed by 277 individuals from 24 states between 29 September 2020, and 12 December 2020, yielding a response rate of 37.7%. Most respondents (91.5%) indicated that non-COVID-19 research was affected by COVID-19 research studies. In response to the COVID-19 pandemic, 20% of respondents were reassigned to different roles at their institution. Many survey takers were exposed to COVID-19 (56%), with more than 50% of researchers requiring a COVID-19 test and 8% testing positive. The fear of infection was 2.7-times higher compared to pre-COVID-19 times. Shortages of personal protective equipment were encountered by 34% of respondents, primarily due to lack of access to N95 masks, followed by gowns and protective eyewear. Personal protective equipment reallocation from research to clinical use was reported by 31% of respondents. Most of the respondents (88.5%), despite these logistical challenges, indicated their willingness to enroll COVID-19 patients. Conclusions: During the first year of the COVID-19 pandemic, members of the research network were engaged in COVID-19 research despite logistical challenges, limited access to personal protective equipment, and fear of exposure. The research network’s survey experience can inform ongoing policy discussions to create research enterprises that can dexterously refocus research to address the knowledge gaps associated with novel public health emergencies while mitigating the effect of pandemics on existing research projects and research personnel

Project #37: Management Guidelines for Patients with COVID-19: Rapid Cycle Improvement

Project’s purpose is to rapidly devise, continually improve, educate, and implement a live and changing COVID-19 management guideline based upon emerging best available evidence. This project also aims to optimize the care of patients with COVID-19 and improve patient outcomes.https://scholarlycommons.henryford.com/qualityexpo2022/1004/thumbnail.jp

A case of community-acquired enterobacter aerogenes meningitis

Learning Objectives: Enterobacter aerogenes meningitis is a rare infection associated with high morbidity and mortality that usually occurs following disruption of the dura-arachnoid barrier secondary to neurologic trauma. We present the first documented case of community acquired Enterobacter a. meningitis in a patient without recent neurologic trauma. Methods: An 84-year-old female presented tachycardic but normotensive and afebrile with altered mental status. On exam she had right gaze deviation with rigidity and GCS of 8. Laboratory studies revealed a WBC of 25.5K/uL, acute kidney injury, pH 7.28, and pCO2 37.7mmHg. Head CT demonstrated a chronic infarct, but was otherwise unremarkable. In the ED, the patient was given Ativan and Keppra due to concern for seizures and was intubated for airway protection. EEG did not demonstrate epileptiform activity. Lumbar puncture was performed, patient was started empirically on antibiotics for meningitis, and she was admitted to the MICU. Cerebrospinal fluid (CSF) studies were indicative of bacterial meningitis, and CSF cultures grew Enterobacter aerogenes. Antibiotic treatment was changed to meropenem. Given the rarity of Enterobacter a. in CSF a second culture was obtained which was also positive for Enterobacter a. Blood cultures were negative. CT of the abdomen and pelvis was unremarkable, and echocardiogram showed no valvular vegetations. The patient completed a 21day course of meropenem with improvement in mental status. She was ultimately discharged to rehab after 30 days of hospital admission. Results: Enterobacter is a rarely observed cause of community acquired meningitis, especially in adults without recent neurologic injury.For Enterobacter meningitis, the most important predisposing factor is a history of neurosurgery.Other important risk factors include the presence of a CNS device or following neurotrauma. One study showed there was only a 47% rate of improvement with appropriate treatment along with a mortality rate of 21%. These meningitic strains are often resistant to third generation cephalosporins and appropriate treatment is typically with a carbapenem. In addition to its high rate of resistance, Enterobacter meningitis caries a high rate of mortality due to its associated delay in selecting appropriate antibiotic therapy. Given the critical nature of this disease process prompt recognition is prudent. While community acquired Enterobacter a. meningitis is rare, it should be considered in patients diagnosed with meningitis

A Case of Community-Acquired Enterobacter Aerogenes Meningitis

Learning Objectives: Enterobacter aerogenes meningitis is a rare infection associated with high morbidity and mortality that usually occurs following disruption of the dura-arachnoid barrier secondary to neurologic trauma. We present the first documented case of community acquired Enterobacter a. meningitis in a patient without recent neurologic trauma. Methods: An 84-year-old female presented tachycardic but normotensive and afebrile with altered mental status. On exam she had right gaze deviation with rigidity and GCS of 8. Laboratory studies revealed a WBC of 25.5K/uL, acute kidney injury, pH 7.28, and pCO2 37.7mmHg. Head CT demonstrated a chronic infarct, but was otherwise unremarkable. In the ED, the patient was given Ativan and Keppra due to concern for seizures and was intubated for airway protection. EEG did not demonstrate epileptiform activity. Lumbar puncture was performed, patient was started empirically on antibiotics for meningitis, and she was admitted to the MICU. Cerebrospinal fluid (CSF) studies were indicative of bacterial meningitis, and CSF cultures grew Enterobacter aerogenes. Antibiotic treatment was changed to meropenem. Given the rarity of Enterobacter a. in CSF a second culture was obtained which was also positive for Enterobacter a. Blood cultures were negative. CT of the abdomen and pelvis was unremarkable, and echocardiogram showed no valvular vegetations. The patient completed a 21day course of meropenem with improvement in mental status. She was ultimately discharged to rehab after 30 days of hospital admission. Results: Enterobacter is a rarely observed cause of community acquired meningitis, especially in adults without recent neurologic injury.For Enterobacter meningitis, the most important predisposing factor is a history of neurosurgery.Other important risk factors include the presence of a CNS device or following neurotrauma. One study showed there was only a 47% rate of improvement with appropriate treatment along with a mortality rate of 21%. These meningitic strains are often resistant to third generation cephalosporins and appropriate treatment is typically with a carbapenem. In addition to its high rate of resistance, Enterobacter meningitis caries a high rate of mortality due to its associated delay in selecting appropriate antibiotic therapy. Given the critical nature of this disease process prompt recognition is prudent. While community acquired Enterobacter a. meningitis is rare, it should be considered in patients diagnosed with meningitis

Novel Use of Glidescope Indirect Laryngoscopy for Insertion of a Minnesota Tube for Variceal Bleeding

BACKGROUND: With improvements in endoscopic and interventional radiologic therapies, insertion of gastroesophageal balloon tamponade catheters, commonly known as Sengstaken-Blakemore or Minnesota tubes, is a rarely performed procedure for esophageal or gastric variceal bleeding. In small hospitals or freestanding emergency departments, endoscopic or interventional radiology (IR) therapies might not be available, so patients with exsanguinating variceal bleeding must be stabilized or temporized for transport to larger hospitals. Occasionally, tamponade devices are necessary as a rescue therapy for failed endoscopic or IR therapies or can be used as definitive therapy in select cases. In addition to being rarely performed, there are multiple technical complications associated with blind insertion of tamponade catheters. DISCUSSION: We describe a novel use of indirect laryngoscopy using a Glidescope for assisting in placement of a Minnesota tube in 4 patients with exsanguinating esophageal bleeding. CONCLUSIONS: Insertion of a Minnesota tube for bleeding esophageal or gastric varices is an uncommon, technically challenging procedure that can be lifesaving, and is something emergency physicians, intensivists, and gastroenterologists should be capable of performing. Addition of indirect laryngoscopy may help to improve rapid, safe, and successful placement of these devices

Novel Use of Glidescope Indirect Laryngoscopy for Insertion of a Minnesota Tube for Variceal Bleeding.

BACKGROUND: With improvements in endoscopic and interventional radiologic therapies, insertion of gastroesophageal balloon tamponade catheters, commonly known as Sengstaken-Blakemore or Minnesota tubes, is a rarely performed procedure for esophageal or gastric variceal bleeding. In small hospitals or freestanding emergency departments, endoscopic or interventional radiology (IR) therapies might not be available, so patients with exsanguinating variceal bleeding must be stabilized or temporized for transport to larger hospitals. Occasionally, tamponade devices are necessary as a rescue therapy for failed endoscopic or IR therapies or can be used as definitive therapy in select cases. In addition to being rarely performed, there are multiple technical complications associated with blind insertion of tamponade catheters. DISCUSSION: We describe a novel use of indirect laryngoscopy using a Glidescope for assisting in placement of a Minnesota tube in 4 patients with exsanguinating esophageal bleeding. CONCLUSIONS: Insertion of a Minnesota tube for bleeding esophageal or gastric varices is an uncommon, technically challenging procedure that can be lifesaving, and is something emergency physicians, intensivists, and gastroenterologists should be capable of performing. Addition of indirect laryngoscopy may help to improve rapid, safe, and successful placement of these devices