Case Reports in Critical Care The latest articles from Hindawi Publishing Corporation © 2014 , Hindawi Publishing Corporation . All rights reserved. Left Main Coronary Artery Compression following Melody Pulmonary Valve Implantation: Use of Impella Support as Rescue Therapy and Perioperative Challenges with ECMO Tue, 18 Mar 2014 08:31:39 +0000 The purpose of this case is to describe the complex perioperative management of a 30-year-old woman with congenital heart disease and multiple resternotomies presenting with pulmonary homograft dysfunction and evaluation for percutaneous pulmonary valve replacement. Transvenous, transcatheter Melody valve placement caused left main coronary artery occlusion and cardiogenic shock. An Impella ventricular assist device (VAD) provided rescue therapy during operating room transport for valve removal and pulmonary homograft replacement. ECMO support was required following surgery. Several days later during an attempted ECMO wean, her hemodynamics deteriorated abruptly. Transesophageal and epicardial echocardiography identified pulmonary graft obstruction, requiring homograft revision due to large thrombosis. This case illustrates a role for Impella VAD as bridge to definitive procedure after left coronary occlusion and describes management of complex perioperative ECMO support challenges. Erica D. Wittwer, Juan N. Pulido, Shane M. Gillespie, Frank Cetta Jr., and Joseph A. Dearani Copyright © 2014 Erica D. Wittwer et al. All rights reserved. Extreme Procalcitonin Elevation without Proven Bacterial Infection Related to Amphetamine Abuse Tue, 11 Mar 2014 13:11:37 +0000 Systemic inflammatory response with rhabdomyolysis and consequent multiorgan failure is a known sequela of psychotropic drug abuse. However, in cases with uncertain past medical history the initial diagnosis can be challenging. Here we report the case of a 21-year-old male who was admitted to the intensive care unit with severe neurological impairment caused by amphetamine intoxication. First laboratory investigations revealed extremely high serum procalcitonin (PCT) levels reaching a maximum concentration of 1640 ng/mL on the second day of observation. Although PCT has high sensitivity and specificity in differentiating bacterial sepsis from nonbacterial inflammation, our case report shows for the first time that it can be extremely elevated following serious amphetamine intoxication without bacterial infection. András Lovas, Zsuzsanna Ágoston, Klára Késmárky, Péter Hankovszky, and Zsolt Molnár Copyright © 2014 András Lovas et al. All rights reserved. Black Coloured Urine following Organophosphorus Poisoning: Report of Two Cases Tue, 04 Mar 2014 13:42:25 +0000 Organophosphorus poisoning is common in rural Asia. Clinical features result from overactivity of acetylcholine receptors. Blackish discoloration of urine is not a feature of organophosphorus poisoning. Only one case of black colored urine following quinalphos poisoning has been reported in literature. We report two cases of organophosphorus poisoning from two different compounds, following which patients passed black colored urine, in the absence of haemolysis or rhabdomyolysis. These cases indicate that blackish discoloration of urine in organophosphorus poisoning might not be as uncommon as it was believed to be. Besides, urinary excretion of metabolites might be an underlying mechanism, rather than hemolysis. Aneesh Basheer, Sudhagar Mookkappan, Vijay Shanmugham, Nagarajan Natarajan, and Kiran Kulirankal Copyright © 2014 Aneesh Basheer et al. All rights reserved. An Elusive Bullet in the Gastrointestinal Tract: A Rare Case of Bullet Embolism in the Gastrointestinal Tract and a Review of Relevant Literature Tue, 28 Jan 2014 07:52:29 +0000 Bullet embolism within the gastrointestinal system is extremely rare. Such bullet injuries are infrequently covered in the general literature, but the surgeon should be aware of the phenomenon. Smaller caliber bullets are more common in civilian gunshot wound (GSW) events. These bullets are able to tumble through the gastrointestinal tract and cause perforation of the intestinal lumen which is small enough to be easily missed. Bullets retained in the abdominal cavity should not be dismissed as fixed and should be carefully monitored to ensure that they do not embolize within the bowel and cause occult lesions during their migration. We present a unique case wherein a bullet caused a minute perforation in the small bowel, before migrating to the distal colon, which resulted in late presentation of sepsis secondary to peritonitis. Saptarshi Biswas, Catherine Price, and Sunil Abrol Copyright © 2014 Saptarshi Biswas et al. All rights reserved. The Use of Hemodialysis in Refractory Hypercalcemia Secondary to Parathyroid Carcinoma Tue, 21 Jan 2014 07:45:53 +0000 Parathyroid carcinoma is a rare cause of hypercalcemia. Hypercalcemic crisis is a medical emergency. Hemodialysis is rarely needed to treat hypercalcaemia. We report a case of refractory hypercalcaemia secondary to parathyroid carcinoma requiring haemodialysis. Huai Heng Loh and Nurain Mohd Noor Copyright © 2014 Huai Heng Loh and Nurain Mohd Noor. All rights reserved. Buried Bumper Syndrome Revisited: A Rare but Potentially Fatal Complication of PEG Tube Placement Thu, 16 Jan 2014 09:12:43 +0000 Percutaneous endoscopic gastrostomy (PEG) has been used for providing enteral access to patients who require long-term enteral nutrition for years. Although generally considered safe, PEG tube placement can be associated with many immediate and delayed complications. Buried bumper syndrome (BBS) is one of the uncommon and late complications of percutaneous endoscopic gastrostomy (PEG) placement. It occurs when the internal bumper of the PEG tube erodes into the gastric wall and lodges itself between the gastric wall and skin. This can lead to a variety of additional complications such as wound infection, peritonitis, and necrotizing fasciitis. We present here a case of buried bumper syndrome which caused extensive necrosis of the anterior abdominal wall. Saptarshi Biswas, Sujana Dontukurthy, Mathew G. Rosenzweig, Ravi Kothuru, and Sunil Abrol Copyright © 2014 Saptarshi Biswas et al. All rights reserved. Pulmonary Edema in Myasthenic Crisis Thu, 26 Dec 2013 13:34:25 +0000 We report a previously asymptomatic 50-year-old lady who came with myasthenic crisis as initial presentation of myasthenia gravis. She developed pulmonary edema following intravenous immunoglobulin administration and had ischemic changes in ECG and left ventricular dysfunction on echocardiography. She improved with diuretics, dobutamine, and fluid restriction alone. This is the first report in English-language medical literature describing the association between myasthenic crisis and likely takotsubo cardiomyopathy-related pulmonary edema following intravenous immunoglobulin administration. Uttara Swati Anand, Stalin Viswanathan, and Jayanthi Arulneyam Copyright © 2013 Uttara Swati Anand et al. All rights reserved. Air Embolism after Central Venous Catheter Removal: Fibrin Sheath as the Portal of Persistent Air Entry Mon, 07 Oct 2013 14:12:23 +0000 Central venous catheterization is of common practice in intensive care units; despite representing an essential device in various clinical circumstances, it represents a source of complications, sometimes even fatal, related to its management. We report the removal of a central venous catheter (CVC) that had been wrongly positioned through left internal jugular vein. The vein presented complete thrombosis at vascular ultrasonography. An echocardiogram performed 24 hours after CVC removal showed the presence, apparently unjustified, of microbubbles in right chambers of the heart. A neck-thorax CT scan showed the presence of air bubbles within the left internal jugular vein, left innominate vein, and left subclavian vein. A vascular ultrasonography, focused on venous catheter insertion site, disclosed the presence of a vein-to-dermis fistula, as portal of air entry. Only after air occlusive dressing, we documented echographic disappearance of air bubbles within the right cardiac cavity. This report emphasizes possible air entry even many hours after CVC removal, making it mandatory to perform 24–72-hour air occlusive dressing or, when inadequate, to perform a purse string. Meggiolaro Marco, Erik Roman-Pognuz, Baritussio Anna, and Scatto Alessio Copyright © 2013 Meggiolaro Marco et al. All rights reserved. Reversible Right-Sided Heart Failure Secondary to Carcinoid Crisis Tue, 01 Oct 2013 14:29:57 +0000 Carcinoid crisis is an infrequent and little-described complication of neuroendocrine tumors that can be life threatening. It may develop during induction of anesthesia, intraoperatively, during tumor manipulation and arterial embolization, or even spontaneously. The massive release of neuroendocrine substances can lead to potentially fatal complications. Somatostatin analogs inhibit the release of these substances and are the mainstay of treatment. The following case report describes a patient with reversible acute right-sided heart failure posterior to hepatic artery embolization. Mariana Soto Herrera, José A. Restrepo, Jesús H. Díaz, Andrés Ramos, Andrés Felipe Buitrago, and Mabel Gómez Mejía Copyright © 2013 Mariana Soto Herrera et al. All rights reserved. Extracorporeal Life Support in a Severe Blunt Chest Trauma with Cardiac Rupture Mon, 30 Sep 2013 15:07:30 +0000 This report presents a case of severe blunt chest trauma secondary to a horse riding accident with resultant free-wall rupture of the left ventricle in association with severe lung contusion. We describe the initial surgical and medical management of the cardiac rupture which was associated with a massive haemoptysis due to severe lung trauma. Extra corporeal membrane oxygenation (ECMO) support was initiated and allowed both the acute heart and lung failure to recover. We discuss the successful use and pitfalls of ECMO techniques which are sparsely described in such severe combined cardiac and thoracic trauma. Launey Yoann, Flecher Erwan, Nesseler Nicolas, Malledant Yannick, and Seguin Philippe Copyright © 2013 Launey Yoann et al. All rights reserved. Volkman’s Contracture, Persistent Limb Ischaemia, and Amputation: A Complication of Brachial Artery Catheterisation for Haemodynamic Monitoring Using PiCCO Thu, 26 Sep 2013 17:06:07 +0000 We report a case of a 64-year-old woman who was admitted to intensive care unit with multiorgan failure secondary to Plasmodium falciparum malaria. Haemodynamic monitoring using the transpulmonary thermodilution with pulse contour analysis system (PiCCO) was achieved via the left brachial artery. Two days later, a flexion deformity of the left hand was noted, and examination revealed left lower arm ischaemia. Removal of the catheter resulted in an immediate improvement of the contracture. However, distal pulses were still absent, and the arm remained ischaemic resulting in a below elbow amputation. This is the first documented case of a persistent limb ischaemia following the insertion of an arterial catheter for haemodynamic monitoring with PiCCO. We therefore highlight the need for regular assessment of limb perfusion after arterial catheterisation for haemodynamic monitoring with PiCCO. In addition, the brachial artery should be avoided, and femoral artery catheterisation is recommended. Veejay Bagga, Marion Palmer, Ramesh Sadasivan, and Govindan Raghuraman Copyright © 2013 Veejay Bagga et al. All rights reserved. Traumatic Mitral Valve and Pericardial Injury Tue, 10 Sep 2013 15:49:20 +0000 Cardiac injury after blunt trauma is common but underreported. Common cardiac trauma after the blunt chest injury (BCI) is cardiac contusion; it is very rare to have cardiac valve injury. The mitral valve injury during chest trauma occurs when extreme pressure is applied at early systole during the isovolumic contraction between the closure of the mitral valve and the opening of the aortic valve. Traumatic mitral valve injury can involve valve leaflet, chordae tendineae, or papillary muscles. For the diagnosis of mitral valve injury, a high index of suspicion is required, as in polytrauma patients, other obvious severe injuries will divert the attention of the treating physician. Clinical picture of patients with mitral valve injury may vary from none to cardiogenic shock. The echocardiogram is the main diagnostic modality of mitral valve injuries. Patient’s clinical condition will dictate the timing and type of surgery or medical therapy. We report a case of mitral valve and pericardial injury in a polytrauma patient, successfully treated in our intensive care unit. Nissar Shaikh, Firdous Ummunissa, and Mohamed Abdel Sattar Copyright © 2013 Nissar Shaikh et al. All rights reserved. Very Late Bare Metal Stent Thrombosis Wed, 21 Aug 2013 09:51:25 +0000 Very late stent thrombosis is a rare and not-well-understood complication after bare metal stent implantation. It usually presents as an ST elevation acute coronary syndrome and it is associated with high rates of morbidity and mortality. Pathophysiologic mechanisms are not well defined; nevertheless, recent studies have proposed a neoatherosclerotic process as the triggering mechanism. We present the case of a patient with bare metal very late stent thrombosis 12 years after implantation. Mariana Soto Herrera, José A. Restrepo, Andrés Felipe Buitrago, Mabel Gómez Mejía, and Jesús H. Díaz Copyright © 2013 Mariana Soto Herrera et al. All rights reserved. Shigella Bacteremia in a Patient with Visceral Leishmaniasis Mon, 19 Aug 2013 10:04:34 +0000 Bacteremia due to Shigella is rare. A 26-year-old HIV-negative male presented with a persistent high-grade fever of two months duration to the Leishmaniasis Research and Treatment Center of University of Gondar Hospital. He was anorexic and had lost significant weight (from 76 to 57 kg in 4 months, BMI = 17.2 kg/m2). He also complained of headache, chills, and rigor. In the last one year, he was experiencing a few episodes of acute bloody diarrhea, the last episode being two months ago. Microscopy from splenic aspiration showed Leishman-Donovan bodies with parasite load of +3. The blood culture showed Shigella species, but the stool was culture negative. The isolate was sensitive to most tested antibiotic discs, sulfamethoxazole, ceftriaxone, gentamicin, tetracycline, and norfloxacilin, except ampicillin. Therefore, requesting blood culture for identifying unexpected type of organisms causing infections in patients with underlying diseases like visceral leishmaniasis should be encouraged. Mengistu Endris, Rezika Mohammed, Yegnasew Takele, Desalegn Woldeyohannes, Moges Tiruneh, and Ermias Diro Copyright © 2013 Mengistu Endris et al. All rights reserved. Ketamine Infusion Associated with Improved Neurology in a Patient with NMDA Receptor Encephalitis Mon, 19 Aug 2013 09:52:35 +0000 A young lady was ventilated on intensive care for a prolonged period with NMDA receptor encephalitis. She had undergone steroid, immunoglobulin, and plasmapheresis with no evidence of recovery. Her main management issue was the control of severe orofacial and limb dyskinesia. Large doses of sedating agents had been used to control the dystonia but were ineffective, unless she was fully anaesthetised. The introduction of a ketamine infusion was associated with a dramatic improvement in her symptoms such that it was possible to remove her tracheostomy two days after commencement. She was discharged shortly after that and is making a good recovery. The successful use of ketamine has not previously been described in this context, and we hope this case report will provide some insight into the management of this rare but serious condition. Michael MacMahon, Morag R. Naysmith, Stephanie McCallion, and Jonathan Rhodes Copyright © 2013 Michael MacMahon et al. All rights reserved. The Rendu-Osler-Weber Disease Revealed by a Refractory Hypoxemia and Severe Cerebral Fat Embolism Thu, 01 Aug 2013 08:20:28 +0000 The Rendu-Osler-Weber disease is a genetic disease which may lead to severe hemorrhage and less frequently to severe organ dysfunction. We report the case of a 22-year-old patient with no personal medical history who was involved in a motorcycle accident and exhibited severe complications related to large arteriovenous pulmonary shunts during his ICU stay. The patient developed an unexplained severe hypoxemia which was attributed to several arteriovenous shunts of the pulmonary vasculature by a contrast study during a transesophageal echocardiographic examination. The course was subsequently complicated by a prolonged coma associated with hemiplegia which was attributed to a massive paradoxical fat embolism in the setting of an untreated femoral fracture. In addition to hemorrhagic complications which may lead to intractable shock, arteriovenous malformations associated with the Rendu-Osler-Weber disease may involve the pulmonary vasculature and result in unexpected complications, such as hypoxemia or severe cerebral fat embolism in high-risk patients. Leonel Barreto, Jean-Bernard Amiel, Anthony Dugard, Nicolas Pichon, Marc Clavel, Bruno François, and Philippe Vignon Copyright © 2013 Leonel Barreto et al. All rights reserved. Urine Biochemistry in the Early Postoperative Period after Cardiac Surgery: Role in Acute Kidney Injury Monitoring Sun, 28 Jul 2013 13:27:51 +0000 We have recently suggested that sequential urine electrolyte measurement in critically ill patients may be useful in monitoring kidney function. Cardiac surgery is one of the leading causes of acute kidney injury (AKI) in the intensive care unit (ICU). In this paper, we describe the sequential behavior of urine electrolytes in three patients in the early (first 60 hours) postoperative period after cardiac surgery according to AKI status: no AKI, transient AKI, and persistent AKI. We have found that the patient with no AKI had stable and high concentrations of sodium (NaU) and chloride (ClU) in sequential spot samples of urine. AKI development was characterized in the other two patients by decreases in NaU and ClU, which have started early after ICU admission. Transient AKI was marked by also transient and less severe decreases in NaU and ClU. Persistent AKI was marked by the less favorable clinical course with abrupt and prolonged declines in NaU and ClU values. These electrolytes in urine had a behavior like a “mirror image” in comparison with that of serum creatinine. We suggest that sequential urine electrolytes are useful in monitoring acute kidney injury development in the early postoperative period after cardiac surgery. Alexandre Toledo Maciel and Daniel Vitório Copyright © 2013 Alexandre Toledo Maciel and Daniel Vitório. All rights reserved. Ibuprofen-Induced Hypokalemia and Distal Renal Tubular Acidosis: A Patient’s Perceptions of Over-the-Counter Medications and Their Adverse Effects Thu, 25 Jul 2013 11:41:26 +0000 We highlight a case of distal renal tubular acidosis secondary to ibuprofen and codeine use. Of particular interest in this case are the patient’s perception of over-the-counter (OTC) medication use, her own OTC use prior to admission, and her knowledge of adverse reactions or side effects of these medications prior to taking them. Mark D. Salter Copyright © 2013 Mark D. Salter. All rights reserved. Traumatic Page Kidney Induced Hypertension in Critical Care: Immediately Resolved or Long-Term Resistant Problem Wed, 17 Jul 2013 11:03:57 +0000 Page kidney is a well-known phenomenon causing hypertension, due to compression of renal parenchyma by a subcapsular hematoma, of either traumatic or non-traumatic origin. The main therapeutic approach is based on surgical approach (nephrectomy or hematoma evacuation) and antihypertensive treatment. In this paper we present a post-traumatic case of Page Kidney in a Critical Care unit. We discuss different therapeutical opportunities to extremely elevated systemic blood pressure resistant to traditional drug therapy. E. Brotfain, L. Koyfman, A. Frenkel, A. Smolikov, A. Zlotnik, and M. Klein Copyright © 2013 E. Brotfain et al. All rights reserved. Prone Position Ventilation Used during a Transfer as a Bridge to Ecmo Therapy in Hantavirus-Induced Severe Cardiopulmonary Syndrome Mon, 15 Jul 2013 13:29:57 +0000 Background. Transport of critically ill patients is a complex issue. We present a case using prone positioning as a bridge to extracorporeal membrane oxygenation (ECMO), performed by a critical retrieval team from a university hospital. Case Report. A 28-year-old male developed fever, progressive respiratory failure, and shock. He was admitted to ICU from a public hospital, and mechanical ventilation was begun, but clinical response was not adequate. ECMO was deemed necessary due to severe respiratory failure and severe shock. A critical retrieval team of our center was assembled to attempt transfer. Prone positioning was employed to stabilize and transfer the patient, after risk-benefit assessment. Once in our hospital, ECMO was useful to resolve shock and pulmonary edema secondary to Hantavirus cardiopulmonary syndrome. Finally, he was discharged with normal functioning. Conclusion. This case exemplifies the relevance of a retrieval team and bridge therapy. Prone positioning improves oxygenation and is safe to perform as transport if performed by a trained team as in this case. Preparation and organization is necessary to improve outcomes, using teams and organized networks. Catastrophic respiratory failure and shock should not be contraindications to transferring patients, but it must be done with an experienced team. R. Cornejo, D. Ugalde, O. Llanos, P. Bisbal, L. De la Barrera, C. Romero, R. Neira, Roberto González, and J. Gajardo Copyright © 2013 R. Cornejo et al. All rights reserved. A 32-Year-Old Female with AIDS, Pneumocystis jiroveci Pneumonia, and Methemoglobinemia Thu, 27 Jun 2013 09:16:25 +0000 We report a case of methemoglobinemia with significant hemoglobin desaturation in a young female with AIDS who was being treated for Pneumocystis jiroveci pneumonia. A review of the etiology, pathophysiology, and treatment of methemoglobinemia is presented. Guillermo J. Giangreco, Dean Campbell, and Mark J. Cowan Copyright © 2013 Guillermo J. Giangreco et al. All rights reserved. Boerhaave's Syndrome: Still a Diagnostic and Therapeutic Challenge in the 21st Century Sun, 09 Jun 2013 14:58:57 +0000 Boerhaave's syndrome is a rare but potentially fatal condition characterised by a transmural tear of the distal oesophagus induced by a sudden increase in pressure. Diagnosis is challenging as the classic triad of vomiting, abdominal or chest pain, and subcutaneous emphysema is absent in many patients. Management is multidisciplinary and relies on rapid, distinct, and repeated imaging. Treatment has not been standardised and may be conservative, endoscopic, or surgical. We present a typical case which illustrates possible diagnostic pitfalls and the therapeutic conundrum surrounding management of the syndrome. Based on time of presentation and eventual presence of sepsis, a therapeutic algorithm is proposed. J. Spapen, J. De Regt, K. Nieboer, G. Verfaillie, P. M. Honoré, and H. Spapen Copyright © 2013 J. Spapen et al. All rights reserved. Aortic Root Abscess Presenting as Pyrexia of Unknown Origin and the Importance of Echocardiography Thu, 23 May 2013 17:52:14 +0000 Aortic root abscess in patients with aortic endocarditis is not uncommon. Aortic root abscess may cause persistent sepsis, worsening heart failure, conduction abnormalities, fistula formation, and an increased need for surgery. We present a young patient with aortic root abscess presenting as pyrexia of unknown origin. She had acute severe aortic and mitral regurgitation which produced very soft murmurs that were easily missed. This report reiterates that a high index of suspicion is needed in suspecting valvular endocarditis as well as a comprehensive transthoracic and transesophageal echocardiographic examination to diagnose complications like aortic root abscess. Prashanth Panduranga Copyright © 2013 Prashanth Panduranga. All rights reserved. Severe Diltiazem Poisoning Treated with Hyperinsulinaemia-Euglycaemia and Lipid Emulsion Mon, 20 May 2013 15:38:01 +0000 Introduction. Calcium channel blockers (CCBs) drugs are widely used in the treatment of cardiovascular diseases. CCB poisoning is associated with significant cardiovascular toxicity and is potentially fatal. Currently, there is no specific antidote and the treatment of CCB poisoning is supportive; however, this supportive therapy is often insufficient. We present a clinical case of severe diltiazem poisoning and the therapeutic approaches that were used. Case Report. A 55-year-old male was admitted to the intensive care unit (ICU) after voluntary multiple drug intake, including extended release diltiazem (7200 mg). The patient developed symptoms of refractory shock to conventional therapy and required mechanical ventilation, a temporary pacemaker, and renal replacement therapy. Approximately 17 hours after drug intake, hyperinsulinaemia-euglycaemia with lipid emulsion therapy was initiated, followed by progressive haemodynamic recovery within approximately 30 minutes. The toxicological serum analysis 12 h after drug ingestion revealed a diltiazem serum level of 4778 ng/mL (therapeutic level: 40–200 ng/mL). Conclusions. This case report supports the therapeutic efficacy of hyperinsulinaemia-euglycaemia and lipid emulsion in the treatment of severe diltiazem poisoning. Nadine Monteiro, Joana Silvestre, João Gonçalves-Pereira, Camila Tapadinhas, Vitor Mendes, and Pedro Póvoa Copyright © 2013 Nadine Monteiro et al. All rights reserved. A 75-Year-Old Female with Hemoptysis and Recurrent Respiratory Infections Tue, 23 Apr 2013 14:31:44 +0000 This paper describes the case of a 75-year-old female who presented with significant hemoptysis over a 7–10 day period. She had a history of a left lower lobectomy 10 years prior for a “lung abscess.” She subsequently had multiple episodes of cough, fevers, and possible pneumonia treated with multiple courses of Amoxicillin and Amoxicillin/Clavulanate. Review of her chest CT upon presentation to the hospital showed a large necrotic lingular infiltrate, which had been progressively increasing in size over at least one year. Bronchoscopy showed a yellowish, soft round body in the superior lingular subsegment. Endobronchial and transbronchial biopsies showed actinomyces species. This is a very interesting case of indolent actinomycosis which we suspect had a very slow progressive course secondary to the multiple courses of antibiotics that the patient was treated with. Mary S. Baker and Khalil Diab Copyright © 2013 Mary S. Baker and Khalil Diab. All rights reserved. Aortic Arch Thrombosis Mimicking Interrupted Aortic Arch Mon, 22 Apr 2013 11:34:09 +0000 We report a case of a 32-week-gestation male who presented initially with symptoms suggestive of an interrupted aortic arch. The absence of a VSD prompted further investigations, including a CT angiogram, which revealed that he had an extensive thrombus in his aorta. He underwent a successful aortic thrombectomy with arch repair on cardiopulmonary bypass support. In view of the extensive thrombus, the patient was referred to the haematology team. There was no family history of prothrombotic tendencies. Richard Neal, Katharina Mattishent, and Fiona Reynolds Copyright © 2013 Richard Neal et al. All rights reserved. Fibroelastoma as a Culprit of Syncope Mon, 15 Apr 2013 12:20:48 +0000 We present a case of a valvular mass diagnosed by emergency department bedside ultrasonography in a young patient with syncope. Bedside ultrasound has become a valuable tool in the evaluation of patients with syncope in the emergency department. This patient was believed to have a fibroelastoma on ultrasound that was confirmed by magnetic resonance and ultimately by postsurgical pathological evaluation. The indications and findings of using ultrasonography as part of the workup of syncope in the emergency department are discussed. Giuliano De Portu, L. Connor Nickels, Eike Flach, and Latha Ganti Stead Copyright © 2013 Giuliano De Portu et al. All rights reserved. Fatal Overdose due to Confusion of an Transdermal Fentanyl Delivery System Tue, 02 Apr 2013 18:25:45 +0000 Background. The use of transdermal fentanyl systems has increased over recent years, especially in patients with chronic pain. Large misuse potential and fatal outcomes have been described. Case Presentation. A 58-year-old patient presenting with clinical signs of opioid poisoning (hypoventilation, bradycardia, hypotension, and miosis) was admitted to our ICU. The first body check revealed a 75 mcg per hour fentanyl patch at the patient's right scapula. Some months ago, patient's aunt died after suffering from an oncological disease. During breaking up of her household, the patches were saved by the patient. Not knowing the risk of this drug, he mistook it as a heat plaster. Investigations. Laboratory test showed an impaired renal function and metabolic acidosis. Urine drug test was negative at admittance and 12 h later. CCT scan presented a global hypoxic brain disease. Treatment and Outcome. The patient was discharged 30 days after admittance in a hemodynamic stable condition but a vegetative state and transferred to a rehabilitation center. Learning Points. With the ongoing increase in fentanyl patch prescriptions for therapeutic reasons, it is likely that misuse cases will become more relevant. Conventional urine drug screening tests are not able to exclude the diagnosis fentanyl intoxication. History taking should include family member's drug prescriptions. Ingo Voigt Copyright © 2013 Ingo Voigt. All rights reserved. Does Early Decompressive Craniectomy Improve Outcome? Experience from an Active UK Recruiter Centre Wed, 20 Feb 2013 11:16:08 +0000 Introduction. The results of the recent DECRA study suggest that although craniectomy decreases ICP and ICU length of stay, it is also associated with worst outcomes. Our experience, illustrated by these two striking cases, supports that early decompressive craniectomy may significantly improve the outcome in selected patients. Case Reports. The first patient, a 20-year-old man who suffered severe brain contusion and subarachnoid haemorrhage after a fall downstairs, with refractory ICP of 35 mmHg, despite maximal medical therapy, eventually underwent decompressive craniectomy. After 18 days in intensive care, he was discharged for rehabilitation. The second patient, a 23-year-old man was found at the scene of a road accident with a GCS of 3 and fixed, dilated pupils who underwent extensive unilateral decompressive craniectomy for refractory intracranial hypertension. After three weeks of cooling, paralysis, and neuroprotection, he eventually left ICU for rehabilitation. Outcomes. Four months after leaving ICU, the first patient abseiled 40 m down the main building of St. Mary’s Hospital to raise money for the Trauma Unit. He has returned to part-time work. The second patient, was decannulated less than a month later and made a full cognitive recovery. A year later, with a titanium skull prosthesis, he is back to part-time work and to playing football. Conclusions. Despite the conclusions of the DECRA study, our experience of the use of early decompressive craniectomy has been associated with outstanding outcomes. We are currently actively recruiting patients into the RESCUEicp trial and have high hopes that it will clarify the role of the decompressive craniectomy in traumatic brain injury and whether it effectively improves outcomes. E. García Vicente, V. Garnelo Rey, M. Manikon, S. Ashworth, and M. H. Wilson Copyright © 2013 E. García Vicente et al. All rights reserved. Rituximab—A Drug with Many Facets and Cures: A Treatment for Acute Refractory Hypoxemic Respiratory Failure Secondary to Severe Granulomatosis with Polyangiitis Thu, 14 Feb 2013 09:24:56 +0000 Granulomatosis with Polyangiitis (GPA) is a rare systemic anti neutrophil cytoplasmic antibody (ANCA-) associated granulomatous vasculitis of the small and medium sized blood vessels. Diffuse alveolar hemorrhage (DAH) is a rare life-threatening complication of GPA. In our patient, cyclophosphamide was held secondary to complications of acute kidney injury, hematuria, and concern for a possible hemorrhagic cystitis. However, during the workup for hematuria the patient acutely developed respiratory failure and was found to have DAH. The patient was initially supported with mechanical ventilation volume control mode, steroids, and plasma exchange. With no improvement of oxygenation, the mode of ventilation was changed to airway pressure release ventilation (APRV) and the patient was started on rituximab. The patient clinically improved over the next few days, was able to be extubated, and was transferred out of the intensive care unit. Braden Powers, Aditya Uppalapati, Sindhura Gogineni, and Zafar Akram Jamkhana Copyright © 2013 Braden Powers et al. All rights reserved.