An Unusual Case of Cardiovascular Collapse After EVALI

Introduction: In July of 2019, a new respiratory illness emerged as a cluster of healthy, young adolescents developed profound hypoxic respiratory failure. Investigation revealed that it was related to e-cigarette and vaping use. A new clinical syndrome of e-cigarette and vaping use-associated lung injury (EVALI) emerged. Its development was linked to tetrahydrocannabinol (THC) use and Vitamin E acetate. We present a case of vaping associated lung injury, resulting in severe acute respiratory distress syndrome with eventual, unexplained cardiovascular collapse and death. Case Summary: Patient is a 37 year-old male with migraines, obesity (BMI 34), chronic back pain, and tetrahydrocannabinol (THC) vaping who presented with fever, shortness of breath, and altered mental status. His symptoms started with a fever 3 days prior to arrival. He arrived in distress. He was febrile (38.6°C), tachycardic (HR 148), tachypneic (RR 66), and profoundly hypoxic to 54% on room air. His blood pressure was 113/59. Initial blood gas confirmed profound hypoxemia with pH 7.33, PCO2 35.5, PO2 32.9, and saturation of 63.8 with a lactate of 8.6 mmol/L. Initial chest x-ray showed bilateral infiltrates. He was trialed on CPAP, but remained hypoxic, requiring intubation and mechanical ventilation. His initial PaO2 to FI02 ratio was 111 on a PEEP of 12, consistent with moderate ARDS. He was treated empirically with vancomycin, piperacillin / tazobactam, and azithromycin. Infectious work-up showed a negative influenza and viral biofire PCR. Respiratory culture grew few non-pneumoniae Streptococcus. Blood cultures were negative. Bronchoscopy showed diffuse, pink frothy secretions in the upper airways with bronchoalveolar lavage (BAL) growing commensal flora. Echocardiogram revealed a preserved EF (58%) with normal LV size and thickness and a negative bubble study, ruling out intracardiac shunt. It did show a mildly enlarged right ventricle and mildly reduced global RV systolic function with PAP of 42 mmHg and mild tricuspid regurgitation. A computed tomography (CT) of the chest with contrast was also obtained and negative for pulmonary embolism, but demonstrated extensive, bilateral ground glass and airspace opacities. Given his overall clinical picture including bilateral infiltrates and vaping of THC, there was a high suspicion for EVALI. He was started on methylprednisolone at 1 mg/kg/day and completed a 14 day course of both steroids and antibiotics. He gradually improved with diuresis. He was extubated on hospital day 13; however, two days later, he decompensated. He became tachycardic, tachypneic, and was re-intubated. He remained profoundly tachycardic and developed shock requiring vasopressors. He developed new EKG changes with ST elevations, reciprocal depressions, and a significant troponin elevation. While the cardiac catheterization lab was being activated, the patient had a PEA arrest. Cardiac catheterization was emergently performed which demonstrated non-obstructed coronary arteries and patent pulmonary vasculature. Patient was initiated on veno-arterial extracorporeal membrane oxygenation (VA ECMO). Over the next 12 hours, the patient further decompensated developing multi-organ failure with increasing vasopressor requirements despite VA ECMO support. Due to his poor prognosis, the decision was ultimately made to withdraw care. Discussion: This patient fulfills diagnostic criteria for EVALI, including e-cigarette use within the last 90 days, lung opacities on chest radiograph or CT, exclusion of lung infection, and absence of alternative diagnosis. This case report highlights an instance of acute cardiovascular collapse in a patient with EVALI after initial course of improvement and extended treatment with antibiotics and steroids. Patients recovering from EVALI should undergo close monitoring for rapid deterioration with a low threshold to resume treatment in the appropriate clinical setting.https://scholarlycommons.henryford.com/merf2020caserpt/1065/thumbnail.jp

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

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Hospital factors that influence ICU admission decision-making: An ethnographic study of six hospitals

Rationale: Intensive care unit (ICU) triage-the decision whether to admit a patient to an ICU- should be guided by a patient\u27s severity of illness; yet, hospital characteristics are known to be a key driver of ICU use. We sought to understand how factors at the hospital-level (e.g., capabilities, staffing, structure) influence triage. Methods: We performed an ethnographic study of six hospitals across the state of Michigan. Acute care hospitals were selected based on urban/rural location, academic/community status, number of ICU beds, and all-cause ICU admission rates (based on 2015 Medicare data). We conducted hospital observations, surveyed hospital leadership, and interviewed ICU, emergency medicine, and hospitalist physicians as well as key, non-physician informants [(administrators, charge nurses, rapid response nurses, or advanced practice professionals)]. Interviews sought to understand how hospital characteristics influenced ICU triage and were semi-structured, audio-recorded, transcribed, and coded. Content was analyzed to identify prominent themes using an inductive, interpretive description approach. Hospital observations and surveys provided additional, detailed hospital-level data. Results: Among the six hospitals, 66 participants [15 ICU physicians, 14 emergency medicine physicians, 15 hospitalist physicians, 22 key informants] were interviewed. The six hospitals differed by key characteristics (Table). Three key themes related to ICU triage were identified from interviews, surveys, and observations. First, in smaller, rural hospitals, ICU triage was defined, not by whether a patient should receive ICU care, but rather by whether a patient should be transferred to a larger hospital for a higher-level of care. These patients were not admitted to the ICU in order to facilitate more rapid transfer by remaining in the emergency department. Second, ICU nurse staffing played an indirect, yet critical, role in triage. For example, some hospitals frequently experienced transient closure of ICU beds due to ICU nursing shortages-resulting from a difficulty in recruiting and retaining nurses with critical care training. Third, all hospitals noted that the severity of illness threshold for ICU admission often fluctuated based on ICU bed availability. The presence of intermediate care mitigated some, but not all, of this variability by providing an alternate care location for patients with moderate acuity. Conclusions: In a large, ethnographic study of six hospitals, we identified that physicians viewed the concept of ICU triage differently depending on the characteristics of the hospital in which they practiced. Yet, some of these characteristics cannot currently be measured on a large-scale, which may hinder efforts to change broad patterns of ICU use

The Impact of an Early Intervention Team in the Emergency Department for ICU Boarders

Study Objectives: Models that address delivery of critical care in the emergency department (ED) during times of crowding and boarding include: the physical space of an ED-ICU; the critical care consultation model (both ED-centric and ICU-centric); the hybrid ED-ICU model and promoting rapid transfers to the ICU. The aim of this study was to assess the impact of an ED-centric critical care consultation service for ICU boarders, composed of board-certified emergency medicine and critical care physicians and referred to as the early intervention team (EIT). This is a service available at Henry Ford Hospital Monday through Friday, 2pm to 10pm. Methods: This was a retrospective observational study of adult patients (age \u3e18 years) who presented to the emergency department at Henry Ford Hospital and were admitted to the ICU from February 5th, 2018 to February 4th, 2019. Those who received an EIT consultation were compared to those who received standard care without an EIT consultation. Patients were excluded if they were \u3c 18 years of age and had a documented limitation of care (DNAR or advanced directive) prior to arrival to the ED. The study cohort was identified by an electronic data query of the electronic medical record. The primary outcome of interest was hospital length of stay (LOS). Secondary outcomes of interest included mortality, ICU LOS, ventilator free days and change in modified SOFA score. Results: Eight hundred and seventy patients met inclusion criteria. Of these, 546 had all the variables available to calculate a modified SOFA score resulting in 148 (Tests) who received an EIT consult and 398 (Controls) who did not. Following propensity matching using age, BMI and race, there was no difference in the primary outcome of interest: hospital LOS. Patients who received an EIT consultation had a longer median (IQR) ED boarding time, 8(4-14) hours vs. 4(2-6) hours, p \u3c 0.001. Secondary analysis noted that there was a greater probability that the number of EIT cases increased as the quartile of baseline modified SOFA score increased, p \u3c 0.001. At 24 hours, the modified SOFA scores were significantly higher than baseline for both test and control cases. However, at 48 hours the modified SOFA scores were still significantly higher than baseline for control cases, but not for test cases. Conclusion: This retrospective observational study identified that an ED-centric critical care consultation service with specialty trained physicians for ICU boarders, is utilized in patients with longer boarding times and higher severity of illness. This is associated with an improvement in the baseline modified SOFA score at 48 hours of hospitalization

Hemodynamic Disturbances in Patients with Transient Ischemic Attack

Background: Poor hemodynamic function may impact management of neurological emergencies. Whether low cardiac index (CI) is a factor in transient ischemic attack (TIA) and acute ischemic stroke (AIS) is not well described. Objective: To compare CI measurements between ED patients with AIS versus TIA. Methods: We analyzed patients within an existing, prospective multicenter ED registry. Patient enrollment occurred at 4 academic EDs and was inclusive of patients with suspected stroke within 12 hours from symptom onset. We excluded patients that were pregnant or unable to provide consent. Study team member performed continuous non-invasive hemodynamic monitoring in the ED using arterial-wave form analysis. The final diagnosis was adjudicated by the treating stroke neurologist. Patients diagnosed with hemorrhage on CT or stroke mimics were excluded from analysis. Analysis consisted of univariate comparisons of hemodynamic parameters between patients diagnosed with TIA versus AIS. Results: There were 62 patients enrolled, 24 (39%) with TIA and 38 (61%) with AIS. Among patients with AIS, 15 (39%) had minor stroke (NIHSS 1 to 3) and 23 had moderate stroke (NIHSS 4 to 15). The average age of patients with TIA was 76 ± 24 compared to 60 ± 14 years in AIS patients (p \u3c 0.001). Patients with TIA and minor or moderate AIS did not differ in sBP (142 ± 27, 148 ± 26, and 132 ± 22 mmHg respectively, p=0.125) or systemic vascular resistance measurements (3658 ± 1213, 3100 ± 1271, and 3067 ± 1579 dynes/cm5/m2, p=0.28). Cardiac index was significantly lower among patients with TIA (2.3 ± 0.6 L/min/m2) compared to those with minor or moderate AIS (3 ± 0.9 L/min/m2), difference 0.7 L/min/m2 (95%CI 0.3-1.1 L/min/m2). Minor versus moderate AIS patients had no significant differences in hemodynamic parameters. Conclusions: On average, TIA patients in this cohort had significantly lower cardiac output than AIS patients. These findings raise the hypothesis that hemodynamic disturbances may be a common and underrecognized contributor to deficits in ED TIA patients

A roadmap for developing an emergency department based critical care consultation service: Building the early intervention team (EIT)

Emergency Department (ED) crowding and boarding impact safe and effective health care delivery. ED clinicians must balance caring for new arrivals who require stabilization and resuscitation as well as those who need longitudinal care and re-evaluation. These challenges are magnified in the setting of critically ill patients boarding for the intensive care unit. Boarding is a complex issue that has multiple solutions based on resources at individual institutions. Several different models have been described for delivery of critical care in the ED. Here, we describe the development of an ED based critical care consultation service, the early intervention team, at an urban academic ED