Secondary pyomyositis complicated by septic shock and sepsis-induced cardiomyopathy causing a massive erector spinae abscess in a patient after trigger point injection

Abstract

Trigger point injection is a common pain control method widely practiced around the world.

We report the case of a 53-year-old female who presented with lumbago and septic shock complicated with sepsis-induced cardiomyopathy three days after receiving a trigger point injection. She responded to sepsis treatment and empiric antibiotics but later required extensive drainage and debridement after a follow-up CT scan revealed a massive abscess above the fascia of erector spinae spanning from the level of the 1st thoracic spine to the 5th lumbar spine. With extensive surgical drainage and effective antimicrobial treatment, the patient recovered fully and was discharged without any sequelae.


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Post-surgical right coronary artery injury secondary to tricuspid valve repair

Abstract

Injury to the right coronary artery (RCA) is a rare complication of tricuspid annuloplasty. We report a 64-year-old woman with history of valvular heart disease that was admitted for decompensated right heart failure. The patient underwent aortic valve replacement and tricuspid annuloplasty. Shortly after tricuspid annuloplasty the patient developed right ventricular (RV) infarction with hemodynamic compromise. The coronary angiogram shows subtotal occlusion at the mid segment of right coronary artery probably due to stitch of the tricuspid ring. The RCA has successfully been revascularized by percutaneous coronary angioplasty with bare metal stent, however the patient got into multi-organs failure syndrome and died at day 15 postoperatively.


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Intubation practices at Wellington Hospital Emergency Department: an eight month retrospective observational study

Abstract

Objective: To determine the rate of intubations carried out in Wellington Hospital Emergency Department (tertiary hospital), New Zealand, to provide a description of intubating habits of clinicians including operator experience and methods, and to determine the rate of complications.

Design: Eight month, retrospective, observational study.

Setting: Wellington Hospital Emergency Department(WHED).

Location: New Zealand.

Patients and participants: All patients intubated in the Emergency Department were included.

Interventions: None. Audit related activity.

Measurements and results: Over the eight months 57 intubations occurred. The most common indications for intubation were head injury with reduced Glasgow Coma Scale (GCS) and overdose (both 18.9%) followed by stroke, seizure and cardiac arrest (9.4-11.3%). Most intubations (46%) occurred between 8 a.m.-5 p.m. Eighty-two point seven percent of patients were intubated by ED doctors where seniority of team leader and intubating doctor varied according to the time of day. Intubation was consultant led 68.4% of the time before 5 p.m. and 40% of the time overnight. Airway checklist use was reported in 54.5% with formal airway assessment documented in 50%. Successful first pass occurred in 77.2% of cases. Difficult laryngoscopy (grade 3-4) was reported in 16.6% using direct laryngoscopy and 18.8% using videolaryngoscopy. All patients were successfully intubated orally in 3 attempts or less. Etomidate was drug of choice (54.7%). Seventeen point five percent experienced one or more complications. Trends towards less complications related to direct laryngoscopy compared to videolaryngoscopy and use of cricoid pressure associated with a higher complication rate were noted. However there were low numbers and statistical significance was not reached.

Conclusion: The first pass success rate for intubation was lower in comparison to other studies although adverse event rate was also lower. As a high-risk procedure, an incidence of seven intubations per month highlights the need for more diverse training opportunities for skills maintenance.


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Late pacemaker perforation of the right ventricle. A case report and review of diagnosis and management

Abstract

Objectives: Pacemaker incidence and prevalence are on the rise over the last decade especially in the elderly population. Though complications are rare, most reported literature is about early pacemaker complication. Late complications are also reported, but mostly regarding malfunction or infections. Very few case reports and series report late cardiac perforations which could be catastrophic. We report a case of late cardiac perforation diagnosed and treated in our institution to raise the awareness of this very serious complication.

Case summary: A 65-year-old male who had a single chamber right ventricular pacemaker inserted two months earlier for sick sinus syndrome, presented to the hospital with complaint of shortness of breath. Chest X-ray (CXR) revealed new large left sided pleural effusions. Computed tomography (CT) scan of the chest suggested migration of the pacemaker lead with perforation of the right ventricle associated with hemothorax with no pericardial effusions. A bedside echo confirmed the perforation and showed minimal pericardial effusions with no cardiac tamponade. Clinically patient was hemodynamically stable. He underwent open surgical repair and placement of epicardial pacer leads.

Conclusions: Clinicians should be aware of the early and late complications of pacemaker insertions and how to diagnose and treat them appropriately to avoid unnecessary morbidity or mortality.


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Anticholinergic drug-induced benign unilateral anisocoria: common, but frequently overlooked side effect

Abstract

Sudden anisocoria have always been ominous signs among critically ill patients, which requires prompt attention. There are various causes of anisocoria, which call for comprehensive evaluation to rule out neurologic causes such as Adie’s pupil, uncal herniation, compression of third cranial nerve, meningeal irritation, and seizures as opposed to the pharmacological causes such as anticholinergic drugs, anesthesia, and recreational drugs versus causes such as migraine and trauma to the eye. We hereby report a case of a patient with unilateral anisocoria from dilated left pupil due to the nebulized ipratropium bromide, a cholinergic antagonist that resolved with discontinuation of the medication. The purpose of this case report is to emphasize the importance of thorough physical assessment, an early review of the medications, and the use of inexpensive diagnostic test to save time and avoid the expensive diagnostic study.


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Toward having safe environment in critical care units: a multisite study

Abstract

Objective: This study was conducted to assess the safety culture in Jordanian intensive care units.

Design: The study was descriptive, cross-sectional design, and multisite.

Setting: The Safety Attitude Questionnaire-Intensive Care Unit (SAQ-ICU) version was utilized. Three hundred completed questionnaires were returned from four critical care units.

Results: The results offered a fundamental element for further research on safety matter in Jordanian ICUs. Many recommendations were highlighted by the Jordanian nurses in order to improve the safety culture in the ICUs including standard nurse-patients ratio, good communication and collaboration between health professionals, enhance continuing education and training. To the knowledge, this is the first study conducted in Jordan using the SAQ to examine nurses’ safety culture attitudes in Jordanian ICUs.

Conclusion: The present findings provide a baseline for future research aiming for improving the quality of care in Jordanian ICUs.


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The optimal ICU organizational structure

A variety of intensive care units (ICU) staffing models exist, which to a large extent are based on local practice and economic factors rather than cost-effectiveness and the quality of care delivered. The organizational structure of ICU in the United States are usually classified according to two types of models, namely a low- or high intensity model, or an open- or closed ICU model. (1,2) In a low-intensity ICU, patients are managed by non-intensivists, however an intensivist may be consulted on some cases (open model), whereas in a high-intensity model intensivists are consulted on all patients (open model) or the intensivist assumes responsibility for the patient and directs all aspects of the care (closed model). The closed ICU structure is the predominant model in almost all Western nations. (3,4) There are significant organizational differences between open and closed ICU. Open units are those in which admission of patients to the ICU is uncontrolled and management of the patients is at the discretion of each attending physician (not an intensivist). Admissions are based on a first-come, first-served basis. As the attending of record does not have the time nor skills to provide “comprehensive critical care” he/she "portions off" the patients' care to a number of organ specific sub-specialists.


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