Younger patients without cardiopulmonary comorbidities are at highest risk of PI. Chest pain and pleural effusion significantly increased risk of PI while presence of radiographic emphysema reduced risk.
This is the first study to evaluate pulmonary critical care fellows' and intensivists' use of goal-directed echocardiography in diagnosing right ventricular dysfunction in acute pulmonary embolism. Pulmonary Critical Care Medicine Fellows and intensivists made a timely and accurate assessment. Screening for right ventricular dysfunction using goal-directed echocardiography can and should be performed by pulmonary critical care physicians in patients with acute pulmonary embolism.
Patient: Male, 52Final Diagnosis: Drug reaction with eosinophilia and systemic symptomsSymptoms: RashMedication: OxacillinClinical Procedure: —Specialty: Critical Care MedicineObjective:Rare diseaseBackground:Drug reaction with eosinophilia and systemic symptoms (DRESS) is an idiosyncratic life-threatening reaction comprised of fevers, rash, and leukocytosis with eosinophilia. Though characteristically associated with leukocytosis, there are rare case reports of DRESS-induced agranulocytosis. DRESS is most frequently caused by antiepileptic medications; however, it has very rarely been reported in relation to oxacillin. We describe a case of oxacillin-induced DRESS associated with agranulocytosis.Case Report:A 52-year-old male was admitted for an epidural abscess secondary to oxacillin-sensitive Staphylococcus aureus, for which an extended course of oxacillin and rifampin was initiated. On day 22 of therapy, the patient developed a fever of 38.7°C (101.6°F) with rigors. His complete blood cell count revealed new leukopenia (1.8×103/uL) with 16% eosinophils and 3% atypical lymphocytes. Antibiotics were transitioned from oxacillin and rifampin to vancomycin, cefepime, and rifampin for presumed sepsis of unclear etiology. On day 23, he was noted to have a pruritic erythematous blanching papular rash on his chest, trunk, neck, and left upper extremity. Infectious workup was unrevealing, and his fever curve up-trended to 39.3°C (102.7°F) with no clinical improvement on broad-spectrum antimicrobials, suggestive of a non-infectious etiology of his rash and fevers. His rash evolved into confluent red patches, and eosinophilia rose to 21%, which was concerning for a drug reaction. His RegiSCAR score was calculated to be 6, consistent with definite DRESS. Leukopenia resolved (6.3×103/uL) 4 days after discontinuing oxacillin. His epidural abscess was ultimately treated with daptomycin, and DRESS was managed supportively with antihistamines and triamcinolone cream.Conclusions:We highlight this case because of the rarity of DRESS with agranulocytosis related to oxacillin. Beta-lactam antibiotics are widely used, and while DRESS is an uncommon condition, clinicians should consider this diagnosis when managing patients with fevers, leukopenia, and rash.
A short-course corticosteroid taper in critically ill patients with AECOPD is associated with reduced hospital length of stay and decreased corticosteroid exposure without increased risk of treatment failure. A prospective randomized trial is warranted.
PURPOSE:The objective in management of patients experiencing cardiac arrest is to identify reversible causes. The introduction of Point-of-Care Ultrasound (POCUS) into critical care has opened avenues not previously available in the management of these patients. We aimed to observe the effects of introduction of POCUS in management of patients experiencing in-hospital cardiac arrest (IHCA). IHCA has been reported to have a survival rate of 6.6% to hospital discharge. While multiple protocols exist for intra-arrest echocardiography, a recent meta-analysis of 15 studies examining POCUS in cardiac arrest consisted entirely of prehospital and/or Emergency Department settings. This is the first study examining the impact of POCUS on IHCA.
METHODS:We collected a convenience sample of 19 patients with IHCA between July 2016 and February 2017 who had a POCUS performed as part of their management due to critical care fellow availability. In our tertiary-care urban community teaching hospital, we have ultrasound-trained critical care fellows and faculty. In general, we would perform POCUS in cases where a second fellow would be available to perform and interpret the exam since the primary fellow would be involved with other aspects of patient care during cardiac arrest.RESULTS: Out of 75 total IHCA at our institution during the study period, 24 occurred during times when 2 fellows would normally be present and were announced overhead. 15 of our studies occurred during this time period (4 occurred outside of this time period), yielding 63% of potential IHCA patients underwent POCUS. Average age of patients was 67.7 years and 52.6% of them were male. 47.4% of arrests occurred in the medical ICU and PEA was the initial rhythm in 73.7% of patients. Average time of CPR was 16.1 minutes (Range 4-37) and 73.7% of patients achieved ROSC. All patients had goal-directed echocardiography including, at minimum, a subcostal view. 5.3% of patients (1/19) received tPA due to severe RV dysfunction. One patient had a small IVC diameter and therefore received IV Fluids. All patients who were checked for lung sliding had lung sliding present and therefore pneumothorax was ruled out as a cause of cardiac arrest. No pericardial effusions were noted and therefore cardiac tamponade was ruled out as a cause of cardiac arrest. LV function was found to be normal or hyperdynamic in 6 patients, all of whom achieved ROSC. CONCLUSIONS: POCUS is feasible and useful in management of patients experiencing in-hospital cardiac arrest.CLINICAL IMPLICATIONS: POCUS should play a larger role for IHCA in hospitals which have that capability. Future studies should focus on larger patient population and potential use of POCUS in assessing efficacy of compressions by examining realtime surrogate markers of stroke volume.
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