Case Reports in Critical Care The latest articles from Hindawi Publishing Corporation © 2014 , Hindawi Publishing Corporation . 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. Zinc Phosphide Poisoning Mon, 30 Jun 2014 11:35:41 +0000 Zinc phosphide has been used widely as a rodenticide. Upon ingestion, it gets converted to phosphine gas in the body, which is subsequently absorbed into the bloodstream through the stomach and the intestines and gets captured by the liver and the lungs. Phosphine gas produces various metabolic and nonmetabolic toxic effects. Clinical symptoms are circulatory collapse, hypotension, shock symptoms, myocarditis, pericarditis, acute pulmonary edema, and congestive heart failure. In this case presentation, we aim to present the intensive care process and treatment resistance of a patient who ingested zinc phosphide for suicide purposes. Erdal Doğan, Abdulmenap Güzel, Taner Çiftçi, İlker Aycan, Feyzi Çelik, Bedri Çetin, and Gönül Ölmez Kavak Copyright © 2014 Erdal Doğan et al. All rights reserved. Clinical and Imaging Resolution of Neonatal Hemochromatosis following Treatment Tue, 24 Jun 2014 09:13:37 +0000 Neonatal hemochromatosis (NH) is an acute liver disease associated with both hepatic and extrahepatic iron deposition and is a leading cause of neonatal liver transplantation. The concept that NH is an alloimmune disease has led to the emergence of a new treatment approach utilizing exchange transfusion and intravenous immunoglobulin therapy. We present a two-day old neonate with progressive liver dysfunction who was diagnosed with NH. Magnetic resonance imaging confirmed tissue iron overload. Treatment with intravenous immunoglobulins and exchange transfusion led to rapid improvement in liver function. Follow-up physical examination at the age of 8 months showed normal development and near normal liver function. A repeat abdominal magnetic resonance scan at 8 months showed no signs of iron deposition in the liver, pancreas, or adrenal glands. The present report provides further support for the use of exchange transfusion and immunoglobulin therapy in NH and is the first to document resolution of typical iron deposition by magnetic resonance imaging. Ayelet Machtei, Gil Klinger, Rivka Shapiro, Osnat Konen, and Lea Sirota Copyright © 2014 Ayelet Machtei et al. All rights reserved. Opiate Withdrawal Complicated by Tetany and Cardiac Arrest Sun, 15 Jun 2014 09:26:10 +0000 Patients with symptoms of opiate withdrawal, after the administration of opiate antagonist by paramedics, are a common presentation in the emergency department of hospitals. Though most of opiate withdrawal symptoms are benign, rarely they can become life threatening. This case highlights how a benign opiate withdrawal symptom of hyperventilation led to severe respiratory alkalosis that degenerated into tetany and cardiac arrest. Though this patient was successfully resuscitated, it is imperative that severe withdrawal symptoms are timely identified and immediate steps are taken to prevent catastrophes. An easier way to reverse the severe opiate withdrawal symptom would be with either low dose methadone or partial opiate agonists like buprenorphine. However, if severe acid-base disorder is identified, it would be safer to electively intubate these patients for better control of their respiratory and acid-base status. Irfanali R. Kugasia and Nehad Shabarek Copyright © 2014 Irfanali R. Kugasia and Nehad Shabarek. All rights reserved. Pulmonary Arterial Hypertension Secondary to Ethanol Sclerotherapy for Renal Artery Embolization Sun, 15 Jun 2014 00:00:00 +0000 Pulmonary arterial hypertension (PAH) has been reported as a major complication to consider and promptly manage in the use of ethanol sclerotherapy. Most of the available data on the development of PAH is derived from the use of ethanol for embolization of arteriovenous malformation, but it has been rarely reported in its other fields of application. We describe a case of outpatient renal artery embolization using ethanol, in which respiratory failure develops secondary to PAH despite adhering to safe practice protocols. We highlight the importance of pulmonary arterial pressure monitoring and the treatment steps to follow in order to avoid irreversible fatal outcomes. Raya Saba, James Davis, Arvind Balavenkataraman, Aibek E. Mirrakhimov, Aram Barbaryan, Shyam Chalise, and Nkemakolam Iroegbu Copyright © 2014 Raya Saba et al. All rights reserved. Starvation Ketoacidosis: A Cause of Severe Anion Gap Metabolic Acidosis in Pregnancy Tue, 20 May 2014 12:41:38 +0000 Pregnancy is a diabetogenic state characterized by relative insulin resistance, enhanced lipolysis, elevated free fatty acids and increased ketogenesis. In this setting, short period of starvation can precipitate ketoacidosis. This sequence of events is recognized as “accelerated starvation.” Metabolic acidosis during pregnancy may have adverse impact on fetal neural development including impaired intelligence and fetal demise. Short periods of starvation during pregnancy may present as severe anion gap metabolic acidosis (AGMA). We present a 41-year-old female in her 32nd week of pregnancy, admitted with severe AGMA with pH 7.16, anion gap 31, and bicarbonate of 5 mg/dL with normal lactate levels. She was intubated and accepted to medical intensive care unit. Urine and serum acetone were positive. Evaluation for all causes of AGMA was negative. The diagnosis of starvation ketoacidosis was established in absence of other causes of AGMA. Intravenous fluids, dextrose, thiamine, and folic acid were administered with resolution of acidosis, early extubation, and subsequent normal delivery of a healthy baby at full term. Rapid reversal of acidosis and favorable outcome are achieved with early administration of dextrose containing fluids. Nupur Sinha, Sindhaghatta Venkatram, and Gilda Diaz-Fuentes Copyright © 2014 Nupur Sinha et al. All rights reserved. The Abdomen in “Thoracoabdominal” Cannot Be Ignored: Abdominal Compartment Syndrome Complicating Extracorporeal Life Support Thu, 08 May 2014 14:38:46 +0000 Extracorporeal life support (ECLS) is an incredible life-saving measure that is being used ever more frequently in the care of the critically ill. Management of these patients requires extreme vigilance on the part of the care providers in recognizing and addressing the complications and challenges that may arise. We present a case of overt abdominal compartment syndrome (ACS) in a previously well young male on ECLS with a history of trauma, submersion, hypothermia, and no intra-abdominal injuries. The patient developed ACS soon after ECLS was initiated which resulted in drastically compromised flow rates. Taking into account the patient’s critical status, an emergent laparotomy was performed in the intensive care unit which successfully resolved the ACS and restored ECLS flow. The patient had an unremarkable course following and was weaned off ECLS but unfortunately died from his original anoxic injury. This case highlights several salient points: first, care of patients on ECLS is challenging and multiple etiologies can affect our ability to manage these patients; second, intra-abdominal pressures should be monitored liberally in the critically ill, especially in patients on ECLS; third, protocols for emergent operative treatment outside of traditional operating rooms should be established and care providers should be prepared for these situations. Arthur J. Lee, Bryan J. Wells, Rosaleen Chun, Chad G. Ball, and Andrew. W. Kirkpatrick Copyright © 2014 Arthur J. Lee et al. 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.