BackgroundMethods to guide fluid therapy in spontaneously breathing patients are scarce. No studies have reported the accuracy of end-tidal CO2 (ET-CO2) to predict volume responsiveness in these patients. We sought to evaluate the ET-CO2 gradient (ΔET-CO2) after a passive leg rise (PLR) maneuver to predict volume responsiveness in spontaneously breathing healthy adults.MethodsWe conducted a prospective study in healthy adult human volunteers. A PLR maneuver was performed and cardiac output (CO) was measured by transthoracic echocardiography. ET-CO2 was measured with non-invasive capnographs. Volume responsiveness was defined as an increase in cardiac output (CO) > 12% at 90 s after PLR.ResultsOf the 50 volunteers, 32% were classified as volume responders. In this group, the left ventricle outflow tract velocity time integral (VTILVOT) increased from 17.9 ± 3.0 to 20.4 ± 3.4 (p = 0.0004), CO increased from 4.4 ± 1.5 to 5.5 ± 1.6 (p = 0.0), and ET-CO2 rose from 32 ± 4.84 to 33 ± 5.07 (p = 0.135). Within the entire population, PLR-induced percentage ∆CO was not correlated with percentage ∆ET-CO2 (R2 = 0.13; p = 0.36). The area under the receiver operating curve for the ability of ET-CO2 to discriminate responders from non-responders was of 0.67 ± 0.09 (95% CI 0.498–0.853). A ΔET-CO2 ≥ 2 mmHg had a sensitivity of 50%, specificity of 97.06%, positive likelihood ratio of 17.00, negative likelihood ratio of 0.51, positive predictive value of 88.9%, and negative predictive value of 80.5% for the prediction of fluid responsiveness.ConclusionsΔET-CO2 after a PLR has limited utility to discriminate responders from non-responders among healthy spontaneously breathing adults.Electronic supplementary materialThe online version of this article (10.1186/s40635-018-0187-0) contains supplementary material, which is available to authorized users.

Acute ascending aortic dissection has a high mortality rate and requires rapid diagnosis and treatment. Point-of-care ultrasound (POCUS) can aid in the diagnosis. The aortic root is usually evaluated in the parasternal long-axis view; however, a dissection flap is not always visible in this projection. We present three cases of acute, type A aortic dissection in which the dissection flap was only evident in the apical five-chamber and subxyphoid views. These cases suggest that POCUS may play a pivotal role in the initial diagnosis of acute ascending aortic dissection and highlight the importance of viewing multiple windows to fully evaluate this possibility.

Management of emergency care Background:The management of patients with tricyclic antidepressant drug overdose can be a challenge for the emergency department physician. Tricyclic antidepressants block alpha-adrenergic receptors and the anticholinergic effects may lead to cardiotoxicity, resulting in arrhythmias and hypotension that can lead to patient mortality. This report is of a case of a 28-year-old woman who presented with cardiac arrest due to amitriptyline overdose and who responded to intravenous lipid emulsion (ILE) therapy. Case Report:A 28-year-old woman was admitted to the emergency department with amitriptyline overdose. She suffered a cardiac arrest followed by cardiovascular and neurological complications. Hypotension and lack of a pulse did not respond to treatment with high-dose sodium, but she stabilized following treatment with ILE. The prompt response from the emergency team guaranteed rapid intervention that may have influenced the successful results. Conclusions:Despite the frequency and severity of poisoning with tricyclic antidepressants, there is little consensus among physicians regarding patient management. This case showed the successful use of ILE as rescue therapy in a patient in cardiac arrest following amitriptyline overdose. However, the successful outcome obtained in this case is not a recommendation for the use of ILE as a first-line treatment for the management of patients with tricyclic antidepressant drug overdose. Controlled clinical studies are required to evaluate the safety and efficacy of ILE in the management of tricyclic antidepressant drug overdose.

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