Determining the correct diagnosis of patients with dyspnea can be challenging. Early and accurate determination of the cause of dyspnea is vital in instituting timely and appropriate interventions. Hemodynamic parameters may aid in the evaluation of dyspnea, but are difficult to assess by physical exam. Impedance cardiography (ICG) is a newly validated method of determining hemodynamic parameters noninvasively. The purpose of this study was to determine the accuracy in differentiating cardiac from noncardiac causes of dyspnea utilizing ICG-derived hemodynamic parameters compared with that of emergency department (ED) physicians after initial history, physical, and laboratory tests. The final diagnosis, which was made retrospectively after review of the patient's hospital record by a senior ED physician blinded to the ICG data, was compared with the treating ED physician's and the ICG diagnoses. Thirty-eight patients who presented with dyspnea to a community ED were included in the study. There were significant differences in values of cardiac index by ICG (2.2 vs. 3.1; p<0.0001), systolic time ratio (0.52 vs. 0.37; p<0.01) and velocity index (32.9 vs. 42.7; p<0.01) between the cardiac and noncardiac groups, respectively. ICG measurements demonstrated greater sensitivity (92 vs. 83%), specificity (88 vs. 77%), and positive and negative predictive values (79 vs. 63% and 96 vs. 91%, respectively) compared with the ED physician in distinguishing cardiac from noncardiac cause of dyspnea. ICG can aid ED physicians in making more rapid and accurate determinations of cardiac vs. noncardiac cause of dyspnea.
Dexmedetomidine (DEX) is a selective α adrenergic agonist that is commonly used for sedation in the intensive care unit (ICU). The role of DEX for adjunctive treatment of refractory intracranial hypertension is poorly defined. The primary objective of this study was to determine the effect of DEX on the need for rescue therapy (ie, hyperosmolar boluses, extraventricular drain [EVD] drainages) for refractory intracranial hypertension. Secondary objectives included the number of intracranial pressure (ICP) excursions, bradycardic, hypotensive, and compromised cerebral perfusion pressure episodes. This retrospective cohort study evaluated patients admitted to the neurosurgical ICU from August 1, 2009, to July 29, 2015, and who received DEX for refractory intracranial hypertension. The objectives were compared between the 2 time periods-before (pre-DEX) and during therapy (DEX). Twenty-three patients with 26 episodes of refractory intracranial hypertension met the inclusion criteria. The number of hyperosmolar boluses was decreased after DEX therapy was initiated. Mannitol boluses required were statistically reduced (1 vs 0.5, P = .03); however, reduction in hypertonic boluses was not statistically significant (1.3 vs 0.9, P = .2). The mean number of EVD drainages per 24 hours was not significantly different between the time periods (15.7 vs 14.0, P = .35). The rate of ICP excursions did not differ between the 2 groups (24.3 vs 22.5, P = .62). When compared to pre-DEX data, there was no difference in the median number of hypotensive (0 vs 0), bradycardic (0 vs 0), or compromised cerebral perfusion pressure episodes (0.5 vs 1.0). Dexmedetomidine may avoid increases in the need for rescue therapy when used as an adjunctive treatment of refractory intracranial hypertension without compromising hemodynamics.
This is the first known community transmission case of the novel coronavirus disease (COVID-19) in the United States, with significant public health implications. Diagnosis of COVID-19 is currently confirmed with PCR based testing of appropriate respiratory samples. Given the absence of travel or known exposure history, this patient did not meet the criteria for testing according to CDC guidelines at the time of her presentation. Since this case, any patient with severe disease (eg, ARDS or pneumonia) requiring hospitalization without an explanatory diagnosis can be tested even if no clear source of exposure is identified. While influencing national health policies for revising screening criteria, this case also highlighted significant knowledge gaps in diagnosis and treatment and a desperate need for early, widespread, fast and cheap testing for COVID-19.
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