A 38-year-old with Turner syndrome presented with acute myocardial infarction due to multivessel spontaneous coronary artery dissection (SCAD) complicated by left ventricular free wall rupture. Conservative management for SCAD was pursued. She underwent sutureless repair for an oozing-type left ventricular free wall rupture. SCAD has not been previously reported in Turner syndrome. (Level of Difficulty: Advanced.).

We describe a case of severe biventricular failure and cardiovascular collapse following exposure to the manure gas hydrogen sulfide. Initial tests indicated uncoupling of cellular bioenergetics in addition to myocardial damage. Cardiopulmonary support with venoarterial extracorporeal membrane oxygenation was initiated, and the patient could be successfully weaned from support after 28 days. (Level of Difficulty: Advanced.).

UNASSIGNED: The Prehospital Optimal Shock Energy for Defibrillation (POSED) study will assess the feasibility of conducting a cluster randomised controlled study of clinical effectiveness in UK ambulance services to identify the optimal shock energy for defibrillation.
UNASSIGNED: POSED is a pragmatic, allocation concealed, open label, cluster randomised, controlled feasibility study. Defibrillators within a single UK ambulance service will be randomised in an equal ratio to deliver one of three shock strategies 120-150-200 J, 150-200-200 J, 200-200-200 J. Consecutive adults (≥18 years) presenting with out of hospital cardiac arrest requiring defibrillation will be eligible. The study plans to enrol 90 patients (30 in each group). Patients (or their relatives for non-survivors) will be informed about trial participation after the initial emergency has resolved. Survivors will be invited to consent to participate in follow-up (i.e., at 30 days or discharge).The primary feasibility outcome is the proportion of eligible patients who receive the randomised study intervention. Secondary feasibility outcomes will include recruitment rate, adherence to allocated treatment and data completeness. Clinical outcomes will include Return of an Organised Rhythm (ROOR) at 2 minutes post-shock, refibrillation rate, Return of Spontaneous Circulation (ROSC) at hospital handover, survival and neurological outcome at 30 days.
UNASSIGNED: The POSED study will assess the feasibility of a large-scale trial and explore opportunities to optimise the trial protocol.Trial registration: ISRCTN16327029.

Systemic thrombolytic therapy is frequently used in the treatment of massive pulmonary embolism. We describe a case of pulseless electrical activity arrest, refractory obstructive shock in the setting of massive pulmonary embolism despite tissue plasminogen activator that was successfully treated with catheter-directed aspiration thrombectomy. (Level of Difficulty: Intermediate.).

UNASSIGNED: In-Hospital Cardiac Arrest (IHCA) is a significant burden on healthcare worldwide. Outcomes of IHCA are worse in developing countries compared with developed ones. We aimed to study the epidemiology and factors determining outcomes in adult IHCA in a high income developing country.
UNASSIGNED: We abstracted prospectively collected data of adult patients admitted to our institution over a three-year period who suffered a cardiac arrest. We analysed patient demographics, arrest characteristics, including response time, initial rhythm and code duration. Pre-arrest vital signs, primary diagnoses, discharge and functional status, were obtained from the patients\' electronic medical records.
UNASSIGNED: A total of 447 patients were studied. The IHCA rate was 8.6/1000 hospital admissions. Forty percent (40%) achieved ROSC with an overall survival to discharge rate of 10.8%, of which 59% had a good functional outcome, with a cerebral performance category score of 1 or 2. Fifty-four percent (54%) of patients had IHCA attributed to causes other than cardiac or respiratory. Admission Glasgow Coma Scale (GCS), shockable rhythm and short code duration were significantly associated with survival (p < 0.001).
UNASSIGNED: A combination of patient and system-related factors, such as the underlying cause of cardiac arrest and a lack of DNAR policy, may explain the reduced survival rate in our setting compared with developed countries.

UNASSIGNED: Endotracheal suctioning (ETS) is required in critically ill patients but may lead to adverse physiologic effects. The aim of this study was to investigate risk factors associated with adverse respiratory and circulatory effects of ETS, in post-cardiac arrest patients receiving controlled ventilation.
UNASSIGNED: Patients with return of spontaneous circulation after out-of-hospital cardiac arrest were followed the first five days in the intensive care unit (ICU). For each ETS procedure performed, data were extracted from the electronic ICU records 10 min before and until 30 min after the procedure. Adverse events were defined as heart rate > 120 beats/min, systolic blood pressure > 200 or < 80 mmHg or SpO2 < 85%. Multivariate logistic regression was applied with SpO2 < 85% and systolic blood pressure < 80 mmHg as primary outcomes.
UNASSIGNED: For the 36 patients included in the study, the median number of ETS-procedures per patient was 13 (range 1-33). Oxygen desaturation occurred in 10.3% of procedures and severe hypotension in 6.6% of procedures. In the multivariate analysis, dose of noradrenaline, light sedation and oxygen desaturation prior to suctioning were associated with increased risk of oxygen desaturation. Doses of noradrenaline, suction with manual ventilation, suction in combination with patient repositioning, and first day of treatment in the ICU were significantly associated with severe hypotension.
UNASSIGNED: The risk of circulatory and respiratory deterioration during ETS in post-cardiac arrest patients is increased the first day of ICU care, and related to sedation, dose of noradrenaline and pre-procedure hypoxemia.

Clinically significant myocardial infiltration by leukemic cells is a rare phenomenon. We describe a case of a 47-year-old woman with newly diagnosed acute myeloid leukemia and pleuritic chest pain with rapid cardiopulmonary decompensation. Post-mortem analyses showed fibrinous pericarditis and extensive leukemic infiltration of the myocardium. (Level of Difficulty: Intermediate.).

The authors report a case of fulminant myocarditis from an influenza A (H3N2) infection in a healthy individual who experienced cardiac arrest requiring extracorporeal membrane oxygenation (ECMO). The case highlights the management of complications arising from the use of ECMO including differential hypoxia and left ventricular overload requiring left ventricular venting. (Level of Difficulty: Beginner.).

UNASSIGNED: Cross-sectional imaging is frequently obtained after sudden cardiac arrest (SCA) to determine the aetiology. Although imaging studies may reveal acute and/or chronic findings that may impact downstream medical management, lack of standardized guidelines results in significant practice variability. We aimed to perform a descriptive analysis and to report on radiographic findings after SCA.
UNASSIGNED: This was a retrospective observational descriptive study that included all adult SCA patients who presented to our emergency department (ED) over a 6-year period, achieved sustained return of spontaneous circulation, and subsequently received cross-sectional imaging while in the ED. Each imaging study was reviewed and graded based on a predefined scale, and significant radiographic findings were tabulated.
UNASSIGNED: 1573 patients were identified, and 452 patients remained after applying predefined exclusion criteria. A total of 298, 184, and 113 computed tomography (CT) studies were performed of the head, chest, and abdomen, respectively. For head, chest, and abdominal imaging, 13 (4.4%), 23 (12.5%), and 6 (5.3%) studies had radiographic findings that likely contributed to SCA, respectively. Altogether, 42 (7.1%) radiographic studies had findings that likely contributed to SCA. Eighty (13.4%) studies (head [n = 38, 12.8%], chest [n = 26, 14.1%], abdomen [n = 16, 14.2%]) resulted in a change of clinical care (e.g. specialty consultation or procedures).
UNASSIGNED: Given the clinical uncertainty and relative instability during the post-SCA phase, cross-sectional imaging frequently reveals important acute and chronic diagnostic findings.

UNASSIGNED: To determine which aspects of prehospital care impact outcomes after pediatric cardiac arrest.
UNASSIGNED: In this study, the authors examine 5 years of consecutive data from their county emergency medical system (EMS), to identify predictors of good outcome after pediatric cardiac arrest, including return of spontaneous circulation (ROSC), survival to hospital admission (HA) and survival to hospital discharge (HD). Three logistic regression models were performed using JMP 14.1 Pro for Windows, each with the following nine predictors: age, sex, ventilation method (endotracheal intubation vs. supraglottic airway), initial rhythm (pulseless electrical activity vs. asystole), epinephrine administration, bystander treatment prior to EMS arrival, time from collapse to EMS arrival, automatic external defibrillator (AED) placement, and whether the arrest was witnessed. Odds ratio confidence intervals were calculated using the Wald method, and corresponding p-values were obtained with the likelihood ratio χ2 test.
UNASSIGNED: From January 1, 2012 to December 31, 2016, there were 133 pediatric cardiac arrests, of which we had complete data on 109 patients for pediatric cardiac arrest. The median age was 8 months, with an IQR of 2.25-24 months, and a range of 0-108 months (0-9 years). There was return of spontaneous circulation (ROSC) in 20% of cases overall, with 16% making it to hospital admission, and 9% making it alive out of the hospital.The median time to EMS arrival for witnessed events was 10 min, with an interquartile range (IQR) of 6.5-16 min, and a range of 0-25 min. The median time to EMS arrival for unwitnessed events was 30 min, with an IQR of 19-62.5 min, and a range of 9-490 min.Predictors of ROSC included epinephrine administration (p = .00007), bystander treatment before EMS arrival (p = .0018), older age (p = .0025), shorter time to EMS arrival (p = .0048), and AED placement. Predictors of hospital admission included epinephrine NOT being administered (p = .0004), bystander treatment before EMS arrival (p = .0088), shorter time to EMS arrival (p = .0141), and AED placement (p = .0062). The only significant predictor of survival to hospital discharge alive that was identified was shorter time to EMS arrival (p = .0014), as there was insufficient data for many of the predictor variables in this analysis.
UNASSIGNED: Shorter time to EMS arrival from time of arrest, any bystander treatment prior to EMS arrival, and AED placement resulted in significantly higher rates of return of spontaneous circulation. Epinephrine administration significantly improved ROSC, but had the opposite effect on HA. Only shorter time to EMS arrival from time of arrest was significantly associated with survival to hospital discharge. Each additional minute for the EMS to arrive resulted in 5% decreased odds of ROSC and hospital admission, and 12% decreased odds of surviving to hospital discharge.