Case Reports in Critical Care The latest articles from Hindawi Publishing Corporation © 2015 , Hindawi Publishing Corporation . All rights reserved. Always Consider the Possibility of Opioid Induced Respiratory Depression in Patients Presenting with Hypercapnic Respiratory Failure Who Fail to Improve as Expected with Appropriate Therapy Sun, 29 Mar 2015 12:31:25 +0000 Hypercapnic respiratory failure is a frequently encountered medical emergency. Two common causes are acute exacerbations of chronic obstructive pulmonary disease (COPD) and as a side effect of opioids. The two causes may coexist leading to diagnostic confusion and consequent delay in optimal management. We report a case of what was initially thought to be an exacerbation of COPD. The patient failed to improve with treatment as expected which led to the empirical administration of naloxone resulting in a dramatic reversal of her respiratory failure. The patient was subsequently discovered to be taking regular dihydrocodeine for chronic back pain. Martin Steynor and Andrew MacDuff Copyright © 2015 Martin Steynor and Andrew MacDuff. All rights reserved. Recurrent Febrile Neutropenia and Thrombocytopenia in a Chronic Cocaine User: A Case of Levamisole Induced Complications Sun, 22 Mar 2015 10:43:36 +0000 Cocaine is used by approximately 1.5 million Americans each month and up to 69% of the cocaine seized contains levamisole. The real incidence of cocaine-levamisole induced neutropenia is unclear but probably underestimated. Associated complications include fever, thrombocytopenia, skin-vasculitis disorders, and rarely kidney injury. We present a young male, with chronic active cocaine use presenting with recurrent episodes of febrile neutropenia and thrombocytopenia. He underwent extensive work-up and was treated with many antibiotics and we suspect that his neutropenia and thrombocytopenia were caused by recurrent cocaine-levamisole use. Eduardo Martinez, Raza Alvi, Sindhaghatta Venkatram, and Gilda Diaz-Fuentes Copyright © 2015 Eduardo Martinez et al. All rights reserved. Nitric Oxide-Sensitive Pulmonary Hypertension in Congenital Rubella Syndrome Mon, 16 Feb 2015 13:02:43 +0000 Persistent pulmonary hypertension is a very rare presentation of congenital virus infection. We discuss the case of complete congenital rubella syndrome presenting at echocardiography with pulmonary hypertension that worsened after ductus ligation. Cardiac catheterization showed a normal pulmonary valve and vascular tree but a  mmHg. The infant promptly responded to inhaled nitric oxide while on mechanical ventilation and was later shifted to oral sildenafil. It is not clear whether our observation may be due to direct viral damage to the endothelium or to the rubella virus increasing the vascular tone via a metabolic derangement. Francesco Raimondi, Fiorella Migliaro, Elisa Di Pietro, Francesco Borgia, Antonio Rapacciuolo, and Letizia Capasso Copyright © 2015 Francesco Raimondi et al. All rights reserved. Staphylococcal Toxic Shock Syndrome Caused by Tampon Use Mon, 26 Jan 2015 07:37:14 +0000 The authors report a case of near-fatal sepsis with multiorgan failure resulting from a Staphylococcal tampon-associated toxic shock syndrome, requiring a lengthy critical care admission. Successful treatment of this condition focuses on early identification, source control, and administration of antimicrobial agents. Intravenous immunoglobulin therapy used early may prevent widespread tissue necrosis. Cian McDermott and Michael Sheridan Copyright © 2015 Cian McDermott and Michael Sheridan. All rights reserved. Management of Cerebellar Tonsillar Herniation following Lumbar Puncture in Idiopathic Intracranial Hypertension Sun, 18 Jan 2015 13:57:39 +0000 Lumbar puncture is performed routinely for diagnostic and therapeutic purposes in idiopathic intracranial hypertension, despite lumbar puncture being classically contraindicated in the setting of raised intracranial pressure. We report the case of a 30-year-old female with known idiopathic intracranial hypertension who had cerebellar tonsillar herniation following therapeutic lumbar puncture. Management followed guidelines regarding treatment of traumatic intracranial hypertension, including rescue decompressive craniectomy. We hypothesize that the changes in brain compliance that are thought to occur in the setting of idiopathic intracranial hypertension are protective against further neuronal injury due to axonal stretch following decompressive craniectomy. Kenneth R. Hoffman, Sean W. Chan, Andrew R. Hughes, and Stephen J. Halcrow Copyright © 2015 Kenneth R. Hoffman et al. All rights reserved. Systemic Capillary Leak Syndrome: Is Methylene Blue the Silver Bullet? Sun, 07 Dec 2014 00:10:26 +0000 Background. Systemic capillary leak syndrome (SCLS) is a rare disorder characterized by unexplained, recurrent episodes of transient, abrupt increase in endothelial permeability, leading to severe hypotension, generalized edema, and hemoconcentration. Case Report. We report the case of a patient suffering from systemic capillary leak syndrome and present a possible interpretation of the pathophysiology of this condition. Besides the classical triad of hypotension, edema, and hemoconcentration, we recorded increased levels of methemoglobin, an index of NO overproduction. We present a possible interpretation of the pathophysiology of this condition based on the fast and complete reversal of symptoms after methylene blue administration (which opposes NO-induced effects) and speculate that increased NO levels could be implicated in the pathophysiology of the capillary leak phase. Why should an emergency physician be aware of this? The safety of this treatment and its fluid- and cathecolamine-sparing effect deserve consideration and further research. Michele Umbrello, Marco Gardinali, Davide Ottolina, Giancarlo Zanforlin, and Gaetano Iapichino Copyright © 2014 Michele Umbrello et al. All rights reserved. Early Implementation of THAM for ICP Control: Therapeutic Hypothermia Avoidance and Reduction in Hypertonics/Hyperosmotics Thu, 04 Dec 2014 09:01:31 +0000 Background. Tromethamine (THAM) has been demonstrated to reduce intracranial pressure (ICP). Early consideration for THAM may reduce the need for other measures for ICP control. Objective. To describe 4 cases of early THAM therapy for ICP control and highlight the potential to avoid TH and paralytics and achieve reduction in sedation and hypertonic/hyperosmotic agent requirements. Methods. We reviewed the charts of 4 patients treated with early THAM for ICP control. Results. We identified 2 patients with aneurysmal subarachnoid hemorrhage (SAH) and 2 with traumatic brain injury (TBI) receiving early THAM for ICP control. The mean time to initiation of THAM therapy was 1.8 days, with a mean duration of 5.3 days. In all patients, after 6 to 12 hours of THAM administration, ICP stability was achieved, with reduction in requirements for hypertonic saline and hyperosmotic agents. There was a relative reduction in mean hourly hypertonic saline requirements of 89.1%, 96.1%, 82.4%, and 97.0% for cases 1, 2, 3, and 4, respectively, comparing pre- to post-THAM administration. Mannitol, therapeutic hypothermia, and paralytics were avoided in all patients. Conclusions. Early administration of THAM for ICP control could potentially lead to the avoidance of other ICP directed therapies. Prospective studies of early THAM administration are warranted. F. A. Zeiler, L. M. Gillman, J. Teitelbaum, and M. West Copyright © 2014 F. A. Zeiler et al. All rights reserved. Hypertriglyceridemia Induced Pancreatitis (Chylomicronemia Syndrome) Treated with Supportive Care Sun, 23 Nov 2014 08:25:48 +0000 Hypertriglyceridemia is a rare cause of pancreatitis. In treatment pancreatic rest, lifestyle changes, medications (fibrates, n-3 polyunsaturated fatty acids, and nicotinic acid) are essential. Many experimental treatment modalities have been reported as insulin and heparin infusion and plasmapheresis. In this study we present the hypertriglyceridemia-induced pancreatitis treated with supportive care. Emin Uysal, Yahya Ayhan Acar, Emel Gökmen, Ahmet Kutur, and Hatice Doğan Copyright © 2014 Emin Uysal et al. All rights reserved. Air Embolism after Endoscopic Retrograde Cholangiopancreatography in a Patient with Budd Chiari Syndrome Tue, 18 Nov 2014 06:57:33 +0000 Endoscopic retrograde cholangiopancreatography is a procedure commonly used for the diagnosis and treatment of various pancreatic and biliary diseases. Air embolism is a rare complication, which may be associated with this procedure. This condition can be manifested as cardiopulmonary instability and/or neurological symptoms. Known risk factors include: sphincterotomy; application of air with high intramural pressure; anatomic abnormalities; and chronic hepatobiliary inflammation. It is important for the health-care staff, including anesthesiologists, interventional gastroenterologists, and critical care specialists, amongst others, to promptly recognize air embolism and to initiate therapy in a timely fashion, thus preventing potentially fatal outcomes. We submit a brief review of the literature and a case report of air embolism which occurred in the immediate postoperative stage of an endoscopic retrograde cholangiopancreatography, performed in a woman with a history of liver transplantation due to Budd Chiari syndrome and biliary stricture. Beatriz Wills-Sanin, Yenny R. Cárdenas, Lucas Polanco, Oscar Rivero, Sebastian Suarez, and Andrés F. Buitrago Copyright © 2014 Beatriz Wills-Sanin et al. All rights reserved. Maintaining Oxygenation Successfully with High Flow Nasal Cannula during Diagnostic Bronchoscopy on a Postoperative Lung Transplant Patient in the Intensive Care Thu, 13 Nov 2014 07:46:11 +0000 Bronchoscopy is an important diagnostic and therapeutic intervention for a variety of patients displaying pulmonary pathology. The heterogeneity of the patients undergoing bronchoscopy affords a challenge for providing minimal and safe respiratory support during anesthesia. Currently, options are intubation and general anesthesia versus frequently inadequate sedation or local anaesthesia with low flow oxygen through nasal prongs or mouthpiece. The advent of high flow nasal cannula allows the clinician to have a “middle man” that allows high flow oxygen delivery as well as a degree of respiratory support, which in some cases has been noted to be between 3 and 4 cm of continuous positive airway pressure-like effect. There are minimal data analyzing the use of high flow nasal cannula during anesthesia for bronchoscopy. We present a case report of orthotropic lung transplant recipient undergoing diagnostic bronchoscopy whilst being supported with high flow nasal oxygen in the intensive care unit. Sara Diab and John F. Fraser Copyright © 2014 Sara Diab and John F. Fraser. All rights reserved. Fatal Pulmonary Tumor Embolic Microangiopathy in Young Lady without Known Primary Malignancy Thu, 13 Nov 2014 06:57:49 +0000 Pulmonary embolism (PE) is a common cause of morbidity and mortality in hospitalized patients. Malignancy, prolonged recumbence, and chemotherapy are renowned risk factors for development of clinically significant PE. Cancer exerts a multitude of pathophysiological processes, for example, hypercoagulability and abnormal vessels with sluggish circulation that can lead to PE. One of the peculiar characteristics of tumor cells is their ability to reach the circulation and behave as blood clot—not a metastasis-occluding the pulmonary circulation. We present a case of fatal pulmonary embolism diagnosed histologically to be due to tumor cell embolism. Adel Hammodi, M. Ali Al-Azem, Ahmed Hanafy, and Talal Nakkar Copyright © 2014 Adel Hammodi et al. All rights reserved. Norepinephrine as a Potential Aggravator of Symptomatic Cerebral Vasospasm: Two Cases and Argument for Milrinone Therapy Sun, 09 Nov 2014 11:37:02 +0000 Background. During hypertensive therapy for post-subarachnoid hemorrhage (SAH) symptomatic vasospasm, norepinephrine is commonly used to reach target blood pressures. Concerns over aggravation of vasospasm with norepinephrine exist. Objective. To describe norepinephrine temporally related deterioration in neurological examination of two post-SAH patients in vasospasm. Methods. We retrospectively reviewed two charts of patients with delayed cerebral ischemia (DCI) post-SAH who deteriorated with norepinephrine infusions. Results. We identified two patients with DCI post-SAH who deteriorated during hypertensive therapy with norepinephrine. The first, a 43-year-old male presented to hospital with DCI, failed MABP directed therapy with rapid deterioration in exam with high dose norepinephrine and MABP of 140–150 mm Hg. His exam improved on continuous milrinone and discontinuation of norepinephrine. The second, a 39-year-old female who developed DCI on postbleed day 8 responded to milrinone therapy upfront. During further deterioration and after angioplasty, norepinephrine was utilized to drive MABP to 130–140 mm Hg. Progressive deterioration in examination occurred after angioplasty as norepinephrine doses escalated. After discontinuation of norepinephrine and continuation of milrinone, function dramatically returned but not to baseline. Conclusions. The potential exists for worsening of DCI post-SAH with hypertensive therapy directed by norepinephrine. A potential role exists for vasodilation and inotropic directed therapy with milrinone in the setting of DCI post-SAH. F. A. Zeiler, J. Silvaggio, A. M. Kaufmann, L. M. Gillman, and M. West Copyright © 2014 F. A. Zeiler et al. All rights reserved. Complete Heart Block and Persistent Lactic Acidosis as an Initial Presentation of Non-Hodgkin Lymphoma in a Critically Ill Newly Diagnosed AIDS Patient Thu, 06 Nov 2014 11:42:20 +0000 A 66-year-old male with newly diagnosed untreated acquired immunodeficiency syndrome (AIDS) presented with chronic nonspecific complaints of weakness, fatigue, myalgia, and weight loss. His initial EKG showed complete heart block necessitating temporary pacemaker placement. He had no previous history of cardiac disease. He was also found to have a persistent lactic acidosis and imaging studies showed abdominal lymphadenopathy. The patient underwent biopsy of these lymph nodes and was found to have diffuse large B-cell lymphoma. The hospital course was complicated by respiratory failure requiring mechanical ventilator support and cardiac arrest. Patient remained critically ill; he was not a candidate for chemotherapy and, after a month of hospitalization, he died. Lactic acidosis and heart block as an initial presentation of non-Hodgkin lymphoma in an AIDS patient are an unusual and unique presentation. Mohsin Ijaz, Hassan Tariq, Masooma Niazi, and Dmitry Lvovsky Copyright © 2014 Mohsin Ijaz et al. All rights reserved. Prolonged QT Syndrome in a 27-Year-Old Female Presenting as a Cardiac Arrest after Elective Surgery Thu, 06 Nov 2014 09:12:04 +0000 Cardiac arrest is a true medical emergency and clinicians should base the management on American Heart Association advanced cardiac life support algorithm. The potential triggers of cardiac arrest should be sought. We present a case of a 27-year-old female who developed cardiac arrest and was later found to have congenital long QT syndrome. The patient’s outcome was favorable. Discussion of the key management options will be discussed in the text. Aibek E. Mirrakhimov, Prakruthi Voore, and Alaa M. Ali Copyright © 2014 Aibek E. Mirrakhimov et al. All rights reserved. Intravenous Lormetazepam during Sedation Weaning in a 26-Year-Old Critically Ill Woman Wed, 08 Oct 2014 09:49:41 +0000 Recent evidence revealed that sedation is related to adverse outcomes including a higher mortality. Despite this fact, patients sometimes require deep sedation for a limited period of time to control, for example, intracranial hypertension. In particular in these cases, weaning from sedation is often challenging due to emerging agitation, stress, and delirium. The submitted research letter reports a rare case of severe and persisting agitation that was unresponsive to all available treatments. Ultimately, lormetazepam which has recently become available for intravenous use in Germany resolved the problem by stress-reduction and anxiolysis without leading to measurable sedation. Alawi Luetz, Bjoern Weiss, and Claudia D. Spies Copyright © 2014 Alawi Luetz et al. All rights reserved. Anterior Ischemic Optic Neuropathy as a Manifestation of HELLP Syndrome Mon, 29 Sep 2014 06:20:36 +0000 Thrombotic microangiopathies (TMAs) are a group of disorders characterized by occurrence of thrombi of fibrin and/or platelets with microvascular occlusion and organ ischemia especially the kidney and brain. Hemolysis with a microangiopathic blood smear, elevated liver enzymes, and low platelet count (HELLP syndrome) is a type of TMA peculiar to pregnancy and may be associated with neurological complications. Visual complications in HELLP are usually related to cortical blindness. We present the first case of HELLP associated with bilateral anterior ischemic optic neuropathy (AION) and blindness which resolved with plasma exchange. Boby Varkey Maramattom Copyright © 2014 Boby Varkey Maramattom. All rights reserved. Recurrent Sinus Pauses: An Atypical Presentation of Temporal Lobe Epilepsy Sun, 28 Sep 2014 13:20:29 +0000 Autonomic dysfunction related to seizures may give rise to a broad spectrum of cardiovascular abnormalities. Among these, ictal bradycardia and conduction delays may be encountered. Failure to recognize these abnormalities may contribute to sudden, unexplained death in epilepsy patients. We report a case of a Haitian female with temporal lobe epilepsy associated with recurrent sinus pauses. Martin Miguel Amor, Sherif Ali Eltawansy, Jeffrey Osofsky, and Neil Holland Copyright © 2014 Martin Miguel Amor et al. All rights reserved. Icatibant in the Treatment of Angiotensin-Converting Enzyme Inhibitor-Induced Angioedema Tue, 23 Sep 2014 06:09:26 +0000 We describe the case of a 75-year-old woman who presented with massive tongue and lip swelling secondary to angiotensin-converting enzyme inhibitor-induced angioedema. An awake fibre-optic intubation was performed because of impending airway obstruction. As there was no improvement in symptoms after 72 hours, the selective bradykinin B2 receptor antagonist icatibant (Firazyr) was administered and the patient’s trachea was successfully extubated 36 hours later. To our knowledge this is the first documented case of icatibant being used for the treatment of angiotensin-converting enzyme inhibitor-induced angioedema in the United Kingdom and represents a novel therapeutic option in its management. Neil H. Crooks, Jaimin Patel, Lavanya Diwakar, and Fang Gao Smith Copyright © 2014 Neil H. Crooks et al. All rights reserved. Transorbital Stab Injury with Retained Knife: A Narrow Escape Tue, 23 Sep 2014 05:39:41 +0000 Transorbital penetrating injuries are unusual but may cause severe brain damage if cranium is entered. These kinds of injuries are dangerous as the walls of orbit are very thin, hence easily broken by the otherwise innocent objects. Because of the very critical anatomical area involved, these injuries pose a serious challenge to the physicians who first receive them as well as the treating team. These may present as trivial trauma or may be occult and are often associated with serious complications and delayed sequel. Prompt evaluation by utilizing best diagnostic modality available and timely interference to remove them are the key aspects to avoid damage to vital organs surrounding the injury and to minimize the late complications. We report a case of transorbital assault with a 13 centimeter long knife which got broken from the handle and the blade was retained. The interesting aspect is that there was no neurological deficit on presentation or after removal. Muhammad Asim Rana, Abdulrehman Alharthy, Waleed Tharwat Aletreby, Basim Huwait, and Akhilesh Kulshrestha Copyright © 2014 Muhammad Asim Rana et al. All rights reserved. Acute Kidney Injury Induced by Systemic Inflammatory Response Syndrome is an Avid and Persistent Sodium-Retaining State Sun, 21 Sep 2014 10:48:55 +0000 Acute kidney injury (AKI) is a frequent complication of the systemic inflammatory response syndrome (SIRS), which is triggered by many conditions in the intensive care unit, including different types of circulatory shock. One under-recognized characteristic of the SIRS-induced AKI is its avidity for sodium retention, with progressive decreases in urinary sodium concentration (NaU) and its fractional excretion (FENa). This phenomenon occurs in parallel with increases in serum creatinine, being only transitorily mitigated by diuretic use. In the present case, we report a situation of two consecutive shocks: the first shock is hemorrhagic in origin and then the second shock is a septic one in the same patient. The SIRS and AKI triggered by the first shock were not completely solved when the second shock occurred. This could be viewed as a persistent avid sodium-retaining state, which may be appreciated even during renal replacement therapy (in the absence of complete anuria) and that usually solves only after complete AKI and SIRS resolution. We suggest that decreases in NaU and FENa are major characteristics of SIRS-induced AKI, irrespective of the primary cause, and may serve as additional monitoring tools in its development and resolution. Daniel Vitorio and Alexandre Toledo Maciel Copyright © 2014 Daniel Vitorio and Alexandre Toledo Maciel. All rights reserved. A Case of Airway Obstruction Secondary to Acute Haemorrhage into a Benign Thyroid Cyst Thu, 21 Aug 2014 00:00:00 +0000 A 70-year-old female, with a history of progressive dyspnoea, was admitted to the critical care unit after successful resuscitation following a witnessed, out of hospital cardiorespiratory arrest. A presumptive diagnosis of cardiorespiratory arrest secondary to an exacerbation of chronic obstructive pulmonary disease was made. However, on more detailed examination a large anterior, midline neck mass was noted. Following tracheal intubation, a computerised tomography scan of the patient’s neck and thorax revealed a seven-centimetre, well-defined, nonenhancing, rounded homogeneous opacity at the thoracic inlet, consistent with a large midline thyroid cyst. Needle aspiration of the cyst was performed and yielded approximately 50 mL of frank blood. After an uncomplicated tracheal extubation and recovery, an elective subtotal thyroidectomy was performed prior to hospital discharge. Histology of the specimen revealed a benign thyroid cyst within a multinodular goitre. Euthyroid multinodular goitres are more likely to be managed conservatively due to an asymptomatic clinical course in most patients. However, the risk of respiratory distress and acute airway obstruction from tracheal compression or acute haemorrhage should be kept in mind. Patients at risk of this life threatening complication should be managed with elective thyroidectomy to reduce morbidity and mortality. Ravi Vijapurapu, Kamal Kaur, and Neil H. Crooks Copyright © 2014 Ravi Vijapurapu et al. All rights reserved. Nicardipine-Induced Acute Pulmonary Edema: A Rare but Severe Complication of Tocolysis Tue, 19 Aug 2014 08:27:25 +0000 We report four cases of acute pulmonary edema that occurred during treatment by intravenous tocolysis using nicardipine in pregnancy patients with no previous heart problems. Clinical severity justified hospitalization in intensive care unit (ICU) each time. Acute dyspnea has begun at an average of 63 hours after initiation of treatment. For all patients, the first diagnosis suspected was pulmonary embolism. The patients' condition improved rapidly with appropriate diuretic treatment and by modifying the tocolysis. The use of intravenous nicardipine is widely used for tocolysis in France even if its prescription does not have a marketing authorization. The pathophysiological mechanisms of this complication remain unclear. The main reported risk factors are spontaneous preterm labor, multiple pregnancy, concomitant obstetrical disease, association with beta-agonists, and fetal lung maturation corticotherapy. A better knowledge of this rare but serious adverse event should improve the management of patients. Nifedipine or atosiban, the efficiency of which tocolysis was also studied, could be an alternative. Claire Serena, Emmanuelle Begot, Jérôme Cros, Charles Hodler, Anne Laure Fedou, Nathalie Nathan-Denizot, and Marc Clavel Copyright © 2014 Claire Serena et al. All rights reserved. Chest Pain in Adolescent Japanese Male Mimicking Acute Coronary Syndrome Mon, 18 Aug 2014 10:38:22 +0000 Acute chest pain with very elevated troponin level and abnormal EKG in adult population is considered sine qua non to acute coronary syndrome (ACS) unless proved otherwise. Similar presentation in adolescent population is seen less often but raises suspicion for ACS. Most common etiology for chest pain with cardiac enzyme elevation in adolescent population is usually viral myopericarditis. The adolescent population presenting with chest pain and elevated cardiac enzymes should be carefully evaluated for ACS and other etiologies including myocarditis, myopericarditis, pulmonary embolism, acute rheumatic fever, and trauma. We report one Japanese adolescent male with mycoplasma pneumoniae myocarditis who presented to the ER with chest pain, elevated cardiac enzymes, and abnormal EKG. Sachin K. Gupta and Zahra Naheed Copyright © 2014 Sachin K. Gupta and Zahra Naheed. All rights reserved. Circulatory Support with Venoarterial ECMO Unsuccessful in Aiding Endogenous Diltiazem Clearance after Overdose Sun, 17 Aug 2014 12:30:48 +0000 Introduction. In cardiovascular collapse from diltiazem poisoning, extracorporeal membrane oxygenation (ECMO) may offer circulatory support sufficient to preserve endogenous hepatic drug clearance. Little is known about patient outcomes and diltiazem toxicokinetics in this setting. Case Report. A 36-year-old woman with a history of myocardial bridging syndrome presented with chest pain for which she self-medicated with 2.4 g of sustained release diltiazem over the course of 8 hours. Hemodynamics and mentation were satisfactory on presentation, but precipitously deteriorated after ICU transfer. She was given fluids, calcium, vasopressors, glucagon, high-dose insulin, and lipid emulsion. Due to circulatory collapse and multiorgan failure including ischemic hepatopathy, she underwent transvenous pacing and emergent initiation of venoarterial ECMO. The peak diltiazem level was 13150 ng/mL (normal 100–200 ng/mL) and it remained elevated at 6340 ng/mL at hour 90. Unfortunately, the patient developed multiple complications which resulted in her death on ICU day 9. Conclusion. This case describes the unsuccessful use of ECMO for diltiazem intoxication. Although past reports suggest that support with ECMO may facilitate endogenous diltiazem clearance, it may be dependent on preserved hepatic function at the time of cannulation, a factor not present in this case. Erin N. Frazee, Sarah J. Lee, Ejaaz A. Kalimullah, Heather A. Personett, and Darlene R. Nelson Copyright © 2014 Erin N. Frazee et al. All rights reserved. Repetitive Myocardial Infarctions Secondary to Delirium Tremens Tue, 12 Aug 2014 13:02:36 +0000 Delirium tremens develops in a minority of patients undergoing acute alcohol withdrawal; however, that minority is vulnerable to significant morbidity and mortality. Historically, benzodiazepines are given intravenously to control withdrawal symptoms, although occasionally a more substantial medication is needed to prevent the devastating effects of delirium tremens, that is, propofol. We report a trauma patient who required propofol sedation for delirium tremens that was refractory to benzodiazepine treatment. Extubed prematurely, he suffered a non-ST segment myocardial infarction followed by an ST segment myocardial infarction requiring multiple interventions by cardiology. We hypothesize that his myocardial ischemia was secondary to an increased myocardial oxygen demand that occurred during his stress-induced catecholamine surge during the time he was undertreated for delirium tremens. This advocates for the use of propofol for refractory benzodiazepine treatment of delirium tremens and adds to the literature on the instability patients experience during withdrawal. David Schwartzberg and Adam Shiroff Copyright © 2014 David Schwartzberg and Adam Shiroff. All rights reserved. Use of Early Inhaled Nitric Oxide Therapy in Fat Embolism Syndrome to Prevent Right Heart Failure Mon, 11 Aug 2014 11:31:53 +0000 Fat embolism syndrome (FES) is a life-threatening condition in which multiorgan dysfunction manifests 48–72 hours after long bone or pelvis fractures. Right ventricular (RV) failure, especially in the setting of pulmonary hypertension, is a frequent feature of FES. We report our experience treating 2 young, previously healthy trauma patients who developed severe hypoxemia in the setting of FES. Neither patient had evidence of RV dysfunction on echocardiogram. The patients were treated with inhaled nitric oxide (NO), and their oxygenation significantly improved over the subsequent few days. Neither patient developed any cardiovascular compromise. Patients with FES that have severe hypoxemia and evidence of adult respiratory distress syndrome (ARDS) are likely at risk for developing RV failure. We recommend that these patients with FES and severe refractory hypoxemia should be treated with inhaled NO therapy prior to the onset of RV dysfunction. Evgeni Brotfain, Leonid Koyfman, Ruslan Kutz, Amit Frenkel, Shaun E. Gruenbaum, Alexander Zlotnik, and Moti Klein Copyright © 2014 Evgeni Brotfain et al. All rights reserved. Mechanical Ventilation Weaning in Inclusion Body Myositis: Feasibility of Isokinetic Inspiratory Muscle Training as an Adjunct Therapy Thu, 24 Jul 2014 09:04:42 +0000 Inclusion body myositis is a rare myopathy associated with a high rate of respiratory complications. This condition usually requires prolonged mechanical ventilation and prolonged intensive care stay. The unsuccessful weaning is mainly related to respiratory muscle weakness that does not promptly respond to immunosuppressive therapy. We are reporting a case of a patient in whom the use of an inspiratory muscle-training program which started after a two-week period of mechanical ventilation was associated with a successful weaning in one week and hospital discharge after 2 subsequent weeks. Leonardo Cordeiro de Souza, Josué Felipe Campos, Leandro Possidente Daher, Priscila Furtado da Silva, Alex Ventura, Pollyana Zamborlini do Prado, Daniele Brasil, Debora Mendonça, and Jocemir Ronaldo Lugon Copyright © 2014 Leonardo Cordeiro de Souza et al. All rights reserved. Acute Respiratory Distress Syndrome in Lemierre’s Syndrome Sun, 20 Jul 2014 06:34:19 +0000 Lemierre’s syndrome is an infectious disease defined by the presence of septic thrombophlebitis with associated embolic phenomenon, most commonly to the lungs. Here we present two cases from a single institution of acute respiratory distress syndrome (ARDS) developing as a result of Lemierre’s syndrome in previously healthy young adult men. ARDS can occur as a consequence of pulmonary septic emboli and sepsis, both of which are well-described consequences of Lemierre’s syndrome. We describe important diagnostic and management considerations in the care of patients with hypoxemic respiratory failure and Lemierre’s syndrome. Essential components of management include prompt antibiotic therapy, lung-protective ventilation strategies, and supportive care. Paul N. Hein, Maida V. Soghikian, and Munveer S. Bhangoo Copyright © 2014 Paul N. Hein et al. All rights reserved. Failure of Ketamine Anesthesia in a Patient with Lamotrigine Overdose Wed, 09 Jul 2014 08:45:37 +0000 Introduction. It is important to know which clinical situations prevent ketamine from working. Case Report. We present the case of the psychiatric inpatient who was admitted to our emergency department after ingesting a toxic dose of lamotrigine, unknown at that time. On admission, she was clearly in distress, displaying extreme agitation and violent ataxic movements. We opted to achieve sedation using intravenous ketamine boluses. Unexpectedly, after being injected with a total of 250 mg ketamine, our patient displayed no signs of dissociative anaesthesia. Discussion. There was no apparent reason for why ketamine failed, but an interaction between lamotrigine and ketamine was suspected. A literature search was performed. Very few articles describe interactions between lamotrigine and ketamine. Experimental studies, however, demonstrate how lamotrigine attenuates the neuropsychiatric effects of ketamine. Ketamine is classically described as an NMDA antagonist. Ketamine’s dissociative effects, however, are thought to be mediated by increased glutamate release via a pathway not dependent on NMDA receptors. Lamotrigine, on the other hand, is known to reduce cortical glutamate release. Conclusion. Lamotrigine reduces the glutamate release needed to mediate ketamine’s dissociative anaesthesia. This is important knowledge for anaesthesiologists in the emergency room where ketamine is often administered to unstable patients. Daniel Kornhall and Erik Waage Nielsen Copyright © 2014 Daniel Kornhall and Erik Waage Nielsen. All rights reserved. Myocardial Rupture following Carbon Monoxide Poisoning Wed, 09 Jul 2014 00:00:00 +0000 We present the first case of severe cardiotoxicity of carbon monoxide leading to myocardial rupture and fatal outcome. 83-year-old woman was hospitalized 4 hours after the fire in her house with no respiratory or cardiac symptoms. After two days, she has suffered sudden collapse leading to cardiac arrest. Postmortem examination revealed intramural haemorrhage with myocardial rupture at the apex of the left ventricle. Minimal stenosis was noted in the proximal coronary arteries with no evidence of distal occlusion or any other long-standing heart disease. This case supports recommendations for targeted cardiovascular investigations in cases of CO poisoning. Gabija Dragelytė, Jūris Plenta, Sigitas Chmieliauskas, Algimantas Jasulaitis, Romas Raudys, Tomas Jovaiša, and Robertas Badaras Copyright © 2014 Gabija Dragelytė et al. All rights reserved.