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Sympathetic crash acute pulmonary edema (SCAPE) is a life-threatening injury, which requires early recognition and intervention to prevent mortality. We present a case of 18-year-old woman with no previous comorbidity, presenting with SCAPE who was successfully resuscitated and eventually diagnosed with renal artery stenosis. Pickering syndrome is a rare cause of hypertensive emergency and should be considered in a young patient presenting with SCAPE in emergency department.

Sympathetic crashing acute pulmonary edema (SCAPE) describes the most severe presentation of acute heart failure (AHF). Immediate intervention is required to prevent hemodynamic decompensation and endotracheal intubation. Although high-dose nitroglycerin (>100 μg/min) has been described for this clinical scenario in limited case reports, the concern for adverse effects such as hypotension and syncope limit providers comfortability in initiating nitroglycerin at these doses. Described here is a case series of four patients who safely and effectively received high-dose nitroglycerin infusions for the management of SCAPE.

Background Hand, foot, and mouth disease (HFMD) is an acute infectious disease caused by human enterovirus 71 (EV71), coxsackievirus, or echovirus, which is particularly common in preschool children. Severe HFMD is prone to cause pulmonary edema before progressing to respiratory and circulatory failure; thus hemodynamic monitoring and fluid management are important to the treatment process. Methods We did a review of young patients who had been successfully treated in our department for severe HFMD, which had been caused by EV71. A total of 20 patients met the inclusion criteria. Eight cases were monitored by the pulse indicator continuous cardiac output (PiCCO) technique, and fluid management was administered according to its parameters. With regard to the treatment with PiCCO monitoring, patients were divided into two groups: the PiCCO group (8 patients) and the control group (12 patients). The groups were then compared comprehensively to evaluate whether PiCCO monitoring could improve patients’ clinical outcomes. Results After analysis, the findings informed that although PiCCO failed to shorten the length of ICU stay, reduce the days of vasoactive drug usage, or lower the number of cases which required mechanical ventilation, PiCCO did reduce the incidence of fluid overload (p = 0.085) and shorten the days of mechanical ventilation (p = 0.028). After effective treatment, PiCCO monitoring indicated that the cardiac index (CI) increased gradually(p p p < 0.0001), the global end diastolic volume index (GEDVI, p = 0.0043), and the systemic vascular resistance index (SVRI, p < 0.0001), all of which decreased gradually. Conclusion Our study discovered that PiCCO hemodynamic monitoring in young children with severe HFMD has some potential benefits, such as reducing fluid overload and the duration of mechanical ventilation. However, whether it can ameliorate the severity of the disease, reduce mortality, or prevent multiple organ dysfunction remain to be further investigated.

We present a case of left ventricular outflow tract (LVOT) obstruction after double valve re-replacement with bioprostheses. A 72-year-old man, who had undergone double valve replacement (DVR) with bioprosthetic valves 9 years previously, underwent re-replacement of valves because of structural valve deterioration. However, owing to LVOT obstruction related to the bioprosthesis in the mitral position, acute pulmonary edema occurred immediately after surgery. LVOT obstruction was diagnosed by emergent cardiac catheterization. So prompt re-replacement surgery using a mechanical prosthesis was performed.

INTRODUCTION: Healthy individuals may present with acute pulmonary edema when exposed to extreme environments (high-altitude or deep diving) or while performing strenuous exercises. Recent data support the hypothesis that these forms of acute pulmonary edema might be due to a limited number of stimuli, often overlapping each other, inducing pulmonary capillary stress failure.DISCUSSION: Pathophysiology of nontoxic pulmonary edema occurring in healthy people is still incompletely understood, but recent data suggest a role of three factors (hypoxia, increase in ambient pressure, and physical exercise) that, alone or in combination, may increase pulmonary capillary pressure up to a level overcoming the mechanical resistance of the blood-gas barrier. Evidence has been recently provided to support the existence of a genetic pattern predisposing healthy subjects to pulmonary edema. This paper reviews the evidence supporting a common background for pulmonary edema triggered by extreme environments or heavy effort; a preventive and therapeutic strategy will also be proposed. From these data, hypotheses on the pathophysiology of other forms of noncardiac related pulmonary edema, as those associated with obstructive sleep-apnea syndrome or during post-surgery intensive care, will be proposed.Marabotti C, Cialoni D, Pingitore A. Acute pulmonary edema in healthy subjects. Aerosp Med Hum Perform. 2020; 91(8):662–668.

Pregnancy-associated pulmonary embolism remains the leading cause of direct maternal mortality globally. We will present a case of a young lady who was one month post-delivery via normal vaginal delivery. She presented with pulmonary edema and her clinical examination was consistent with severe mitral stenosis. Notably, her previous and recent pregnancies were uneventful. The key question was: why is there a sudden deterioration? “Why now?”. This led to an industrious search of a precipitant for her presentation; a diagnosis of severe rheumatic mitral stenosis complicated by pulmonary edema precipitated by a pulmonary embolism was made. The patient later had a valve replacement with good outcomes.

Introduction: Young pregnant woman (32 weeks) following one-month illnessesm, including peripheral edema, paresthesia and shortness of breath, for which no specific diagnosis was made in the evaluations; she was hospitalized with severe respiratory distress and pulmonary edema. Re-examination revealed severe systolic heart failure (left ventricular ejection fraction: 10-15%) with preeclampsia. After the relative stabilization of the patient's vital signs, the pregnancy was terminated. One week after termination of pregnancy, the patient's heart failure improved.

Post-extubation acute pulmonary edema (PEAPE) is an uncommon complication of tracheal extubation, occurring in 0.1% of patients undergoing general anesthesia. It has rarely been described in pediatric age, but its incidence is thought to be underestimated, as many cases of post-operative respiratory distress may be misdiagnosed or unrecognized. A formerly healthy 15-year-old male diagnosed with acute appendicitis was submitted to a laparoscopic appendectomy under general anesthesia. Immediately after extubation, he developed signs and symptoms of respiratory distress, and chest radiograph was compatible with acute pulmonary edema. Due to suspicion of PEAPE, supplementary oxygen and intravenous furosemide were administered, with favorable outcome. PEAPE is a major anesthesia-related emergency, which may worsen the prognosis of low-risk surgical procedures. A high degree of suspicion should be maintained in children and adolescents presenting with signs of respiratory distress and hypoxia after general anesthesia, as prompt diagnosis and treatment are crucial for a favorable outcome., O edema pulmonar agudo pós-extubação (EPAPE) é uma complicação rara da extubação traqueal, que ocorre em 0,1% dos doentes submetidos a anestesia geral. Raramente é reportado em idade pediátrica, embora a sua incidência esteja previsivelmente subestimada devido a erros diagnósticos/não reconhecimento de muitos casos de dificuldade respiratória em contexto pós-operatório. Um rapaz de 15 anos previamente saudável, diagnosticado com apendicite aguda, foi submetido a apendicectomia laparoscópica sob anestesia geral. Imediatamente após a extubação, desenvolveu sinais e sintomas de dificuldade respiratória, e a radiografia do tórax foi compatível com edema agudo do pulmão. Perante suspeição de EPAPE, foi administrado oxigénio suplementar e furosemida endovenosa, com evolução favorável. O EPAPE é uma importante emergência médica relacionada com a anestesia, que pode agravar o prognóstico de procedimentos cirúrgicos de baixo risco. É importante relembrar este diagnóstico em crianças e adolescentes que apresentem sinais de dificuldade respiratória e hipóxia após anestesia geral, dado que um rápido diagnóstico e tratamento são essenciais para uma evolução favorável.

We focused on the role of Uric Acid (UA) as a possible determinant of Heart Failure (HF) related issues in Acute Coronary Syndromes (ACS) patients. Main outcomes were acute HF and cardiogenic shock at admission, secondary outcomes were the use of Non Invasive Ventilation (NIV) and the admission Left Ventricular Ejection Fraction (LVEF). We consecutively enrolled 1269 ACS patients admitted to the cardiological Intensive Care Unit of the Niguarda and San Paolo hospitals (Milan, Italy) from June 2016 to June 2019. Median age was 68 (first-third quartile 59–77) years and males were 970 (76%). All the evaluated outcomes occurred more frequently in the hyperuricemic subjects (UA higher than 6 mg/dL for females and 7 mg/dL for males, n = 292): acute HF 35.8 vs 11.1% (p < 0.0001), cardiogenic shock 10 vs 3.1% (p < 0.0001), NIV 24.1 vs 5.1% (p < 0.0001) and lower admission LVEF (42.9±12.8 vs 49.6±9.9, p < 0.0001). By multivariable analyses, UA was confirmed to be significantly associated with all the outcomes with the following Odds Ratio (OR): acute HF OR = 1.119; 95% CI 1.019;1.229; cardiogenic shock OR = 1.157; 95% CI 1.001;1.337; NIV use OR = 1.208; 95% CI 1.078;1.354; LVEF β = -0.999; 95% CI -1.413;-0.586. We found a significant association between UA and acute HF, cardiogenic shock, NIV use and LVEF. Due to the cross-sectional nature of our study no definite answer on the direction of these relationship can be drawn and further longitudinal study on UA changes over time during an ACS hospitalization are needed.

El edema pulmonar agudo posextubación constituye un evento poco frecuente en la práctica anestésica. Cuando ocurre es necesario administrar tratamiento adecuado, ya que las complicaciones del mismo pueden traducirse en mayor estancia hospitalaria y lesiones serias del aparato respiratorio, como edema pulmonar intersticial, elevación de la presión hidrostática capilar y aumento de la presión transmural de las cámaras cardiacas, lo que puede conducir a fallo del aparato cardiovascular y a la muerte subsecuente del paciente. Se presenta el caso de un paciente con clasificación del estado físico ASA (American Society of Anesthesiologist) II, sin patología pulmonar previa, quien al momento de la emersión anestésica presenta un episodio agudo de dificultad respiratoria, con evidencia de edema pulmonar posextubación confirmado por clínica e imágenes con ulterior resolución satisfactoria.

Acute pulmonary edema in pregnancy is a rare but life-threatening condition with high maternal and perinatal morbidity and mortality. Here we discuss a case of acute pulmonary edema in an antenatal woman with pregnancy complicated by chronic severe constipation, highlighting the importance of the need for close liaison between obstetricians and other specialties in the management of pregnant women.

Background Recombinant tissue plasminogen activator (rt-pa) is the first-line drug for the treatment of acute ischemic stroke, and can lead to some complications.There were rare reports of death due to acute pulmonary edema during rt-pa thrombolysis treatment. Case presentation This study reports a 30-year-old man was diagnosed with acute ischemic stroke and underwent rt-pa thrombolytic therapy. Finally he died despite active rescue. Conclusions The autopsy revealed that he died of acute pulmonary edema. This case suggests that it is necessary to pay close attention to the changes of vital signs during thrombolysis and be aware of possibility of pulmonary edema during thrombolysis.

Zinc phosphide is a commonly used rodenticide in India. Intoxication is associated with multiorgan failure and high mortality. We present a case of 17-year-old adolescent female with suicidal zinc phosphide poisoning, complicated to acute pulmonary edema and refractory shock. The patient responded well to supportive management and intravenous magnesium sulfate. As there is no specific antidote for zinc phosphide, the parenteral magnesium sulfate can be used as adjunct therapy.

Context: Acute pulmonary oedema (APO) in pregnant women is associated with increased maternal morbidity and mortality. Aim: The aim of this study was to evaluate the risk reduction strategy by a protocol-based approach to the management of APO in pregnancy in a low-resource center. Settings and Design: The study was conducted in a single obstetric tertiary care public sector hospital for 12 months. Materials and Methods: The pregnant women admitted with acute shortness of breath (SOB) were divided into two groups based on the implementation of pulmonary edema protocol. The data before protocol (Group A) and after (Group B) were compared. Results: A total of 38 patients were admitted with acute SOB. The incidence of APO was 0.10% (95% CI: 0.08,0.14). Majority (Group A: 92.87%; Group B: 81.25%) were admitted in the third trimester. Hypertension was the most common etiology (71.42% in Group A; 81.25% in Group B), followed by cardiovascular causes (42.85% in Group A; 6.25% in Group B) and sepsis (21.42% in Group A; 18.75% in Group B). Caesarean section was carried out in 57.14% in Group A; 62.5% in Group B. Noninvasive Ventilation (NIV) was started in 8 of 16 cases in Group B. Regional anesthesia was used in 87.5% in Group A and 100% in Group B. The maternal mortality was 9 (64.28%) in Group A as compared to 1 (6.25%) in Group B; P = 0.001. Conclusion: The protocol-based algorithm for APO in pregnancy decreases the maternal mortality. Hypertensive disorders of pregnancy are the most common cause followed by cardiac disease. NIV is useful in APO.

We developed a prospective observational study, obtaining clinical and analytical data of patients admitted to the intensive care unit of the Hospital Reina Sofía, who required noninvasive ventilation, from January 1, 2013 to December 31, 2015. The main objective was to determine the 90-day mortality in these patients and conditions, who required noninvasive ventilation as treatment for acute respiratory failure and who developed acute kidney injury. Acute renal failure was defined as an increase in serum creatinine0.3 mg/dl at 48 hours with respect to the baseline. The patients were followed for 90 days. We analyzed 221 patients, 65 (29.4%) presented acute kidney injury and 156 (70.6%) normal renal function. Overall mortality at 90 days was 44 (19.9%). In the group of acute kidneys injury, it was 33 (51.6%), being 11 (7.1%) in patients without acute kidney injury (RR 7.340, 95% CI: 3.974-13.559, p0.001). Hospital stay in days was 24.2 ± 24.1 with acute kidney injury vs. 21.5 ± 0.7, p = 0.429; stay in the intensive care unit in days was 10.9 ± 14.4 with acute kidney injury vs. 7.3 ± 9.6, p = 0.357, and days of non-invasive ventilation 3.4 ± 3.0 with acute kidney injury vs. 2.7 ± 1.9, p = 0.569, in those patients not affected by the presence of acute kidney injury. In conclusion, the presence of acute kidney injury is an independent factor of mortality in patients with acute respiratory failure requiring noninvasive ventilation.Se efectuó un estudio prospectivo observacional, obteniendo datos clínicos y analíticos de pacientes ingresados en la unidad de cuidados intensivos del Hospital Reina Sofía, que precisaron de ventilación mecánica no invasiva. El estudio se llevó a cabo desde el 1 de enero 2013 al 31 de diciembre de 2015. El objetivo principal fue determinar la mortalidad a los 90 días en pacientes ingresados con estas características en dicho periodo. Se definió como fracaso renal agudo al incremento de creatinina sérica0.3 mg/dl a las 48 horas con respecto al basal. Los pacientes fueron seguidos durante 90 días. Se analizaron 221 pacientes, 65 (29.4%) presentaron fracaso renal agudo y 156 (70.6%) función renal normal. La mortalidad global a los 90 días fue de 44 (19.9%); en el grupo del fracaso renal agudo fue de 33 (51.6%), y de 11 (7.1%) en los pacientes sin fracaso renal agudo (RR 7.340; IC 95%: 3.974-13.559. p0.001). La estancia hospitalaria fue de 24.2 ± 24.1 días en aquellos con fracaso renal agudo vs. 21.5 ± 20.7 días en el segundo grupo; p = 0.429), la estancia en la unidad de cuidados intensivos: 10.9 ± 14.4 con fracaso renal agudo vs. 7.3 ± 9.6; p = 0.357, sin dicha condición, y los días de ventilación mecánica no invasiva: 3.4 ± 3.0 con fracaso renal agudo vs. 2.7 ± 1.9; p = 0.569, en los que no se vieron afectados por la presencia del fracaso renal agudo. Como conclusión, la presencia de fracaso renal agudo es un factor independiente de mortalidad en los pacientes que presentan insuficiencia respiratoria aguda con necesidad de ventilación mecánica no invasiva.

Background Noninvasive ventilation (NIV) is recognized as first line ventilatory support for the management of acute pulmonary edema (APE) and chronic obstructive pulmonary disease (COPD) exacerbations. We aimed to study the prehospital management of patients in acute respiratory distress with an indication for NIV and whether they received it or not. Methods This retrospective study included patients ≥18 years old who were cared for acute respiratory distress in a prehospital setting. Indications for NIV were oxygen saturation (SpO2) 25/min with a presumptive diagnosis of APE or COPD exacerbation. Study population characteristics, initial and at hospital vital signs, presumptive and definitive diagnosis were analyzed. For patients who received NIV, dyspnea level was evaluated with a dyspnea verbal ordinal scale (D-VOS, 0-10) and arterial blood gas (ABG) values were obtained at hospital arrival. Results Among the 187 consecutive patients included in the study, most (n = 105, 56%) had experienced APE or COPD exacerbation, and 56 (30%) received NIV. In comparison with patients without NIV, those treated with NIV had a higher initial RR (35 ± 8/min vs 29 ± 10/min, p 2 (79 ± 10 vs 88 ± 11, p p 2 was 80 ± 10% in the NIV group versus 86 ± 11% in the non-NIV group (p = 0.0006). NIV was interrupted in 9 (16%) patients due to either discomfort (n = 5), technical problem (n = 2), persistent desaturation (n = 1), or vomiting (n = 1). Conclusions The results of this study contribute to a better understanding of the prehospital management of patients who present with acute respiratory distress and an indication for NIV. NIV was started on clinically more severe patients, even if predefined criteria to start NIV were present. NIV allows to improve vital signs and D-VOS in those patients. A prospective study could further elucidate why patients with a suspected diagnosis of APE and COPD are not treated with NIV, as well as the clinical impact of the different strategies. Trial registration The study was approved by our institutional ethical committee (CER-VD 2020-01363).

The use of intravenous (IV) oxytocin has been commonly associated with the development of nausea, vomiting, headache, flushing, and hypotension. To date, only a few previously published studies have linked the administration of IV oxytocin, in high doses exceeding 15 mU/min, with the development of acute pulmonary edema. In this article, we aim to report the rare occurrence of acute pulmonary edema following administration of IV oxytocin at a small dose of 2 mU/min, in a 20-year-old pregnant female, to allow its recognition and prompt treatment by the clinician caring for the patient.

Preeclampsia is a multifactorial pregnancy-specific syndrome, which can result in significant alterations in cardiovascular hemodynamics. We report an observation of unexpected relative bradycardia in a previously healthy woman who presented with postpartum preeclampsia and acute pulmonary edema. We observed an increase in heart rate following normalization of blood pressure, which suggested that the initial slower than expected heart rate may reflect a baroreceptor response to hypertension. Whether this finding should be regarded as a severe aspect of the disease spectrum needs further study.

Noninvasive ventilation (NIV) improves the outcome of acute cardiogenic pulmonary edema (AcPE) and acute exacerbation of chronic obstructive pulmonary disease (aeCOPD) but is not recommended in pneumonia. The aim of this study was to assess the appropriateness of the use of NIV in a prehospital setting, where etiological diagnostics rely mainly on clinical examination. This observational multicenter retrospective study included all the patients treated with NIV by three mobile medical emergency teams in 2015. Prehospital diagnoses and hospital diagnoses were extracted from the medical charts. The appropriateness of NIV was determined by matching the hospital diagnosis to the current guidelines. Among the 14,067 patients screened, 172 (1.2%) were treated with NIV. The more frequent prehospital diagnoses were AcPE (n = 102, 59%), acute respiratory failure of undetermined cause (n = 46, 28%) and aeCOPD (n = 17, 10%). An accurate prehospital diagnosis was more frequent for AcPE (83/88, 94%) than for aeCOPD (14/32, 44%, p &lt, 0.01). Only two of the 25 (8%) pneumonia cases were diagnosed during prehospital management. Prehospital NIV was inappropriate for 32 (21%) patients. Patients with inappropriate NIV had a higher rate of in-hospital intubation than patients with appropriate NIV (38% vs. 8%, 0.001). This high frequency of inappropriate NIV could be reduced by an improvement in the prehospital detection of aeCOPD and pneumonia.

Objective The various formulae used for QT correction by heart rate (HR) require the execution of operations with the aid of calculators or applications. This study aimed to evaluate the performance of a simple rule for QTc estimation, comparing the measurements obtained with those provided by the commonly used equations of Bazett, Fridericia, Framingham, and Hodges. Methods We used the database of a previous observational study, which analyzed patients prospectively with acute pulmonary edema admitted in an emergency service. One hundred four patients were included for QTc assessment, of whom 86 patients underwent two ECG: one ECG 24h after admission. Thus, a total of 190 ECGs were analyzed by two observers that manually measured QT and HR. QTc was obtained using the known formulae and the proposed equations: QTc = QT+2 (FC-60) for HR ≤ 90 bpm and QTc=QT+2(FC-60)-10 for HR>90 bpm. Results Bland-Altman plots show good agreement between the simple rule and Hodges equation, with a mean difference of -3,4, SD of 4.96 and 95% limits of agreement from -9,9 to 3.2. There was not a good agreement between the simple method and the other formulae. Conclusion The proposed method has good agreement with the measures of QTc by the equation of Hodges in the HR range of 40 to 130bpm in acutely ill patients. Our method may be a plausible option for quick QT correction in these subjects.

Pulmonary edema is one of the most serious complications of preeclampsia, that should be ruled out in case of dyspnea in a pregnant woman, especially in the context of preeclampsia. It is an indication of urgent pregnancy-termination. Many theories have been proposed to explain this phenomenon, such as hypervolaemia, left ventricular failure and pulmonary capillary leakage, but it is still not well understood. The prognosis is generally good after adequate management and symptoms completely disappear withing a few days of delivery. We report a case of a 30 year old woman with pulmonary edema that complicated preeclampsia and discuss the management options.

Swimming-induced pulmonary edema (SIPE) is a noncardiogenic form of acute pulmonary edema infrequently described in the general military literature. Its pathophysiology is poorly understood. Treatment is supportive. Knowledge of SIPE is important for the military physician and should remain a top differential for any patient presenting with acute pulmonary edema following a water sport. This is the case of a patient with SIPE occurring during the swim portion of a Half Ironman Triathlon.

Flail mitral leaflet (FML) with associated acute pulmonary edema and acute decompensated heart failure is an emergent condition requiring prompt recognition by the emergency physician (EP). Focused cardiac ultrasound (FOCUS) and lung ultrasound (LUS) have a vital role in the evaluation of FML in the emergency department. This case report describes the identification of a FML with EP-performed bedside echocardiography.

Treball Final de Grau en Medicina. Codi: MD1158. Curs acadèmic: 2019/2020. La insuficiencia cardiaca aguda se define como la aparición rápida o el empeoramiento de los síntomas o signos de insuficiencia cardiaca. Es una entidad potencialmente mortal, que requiere evaluación y tratamiento urgentes. En consecuencia, es necesario elaborar un protocolo para diagnosticar y tratar esta patología adecuada y precozmente. Este Trabajo de Final de Grado consiste en la realización de un protocolo asistencial para el Hospital Universitario de La Plana, con el objetivo de realizar un manejo estandarizado de los pacientes cuya área de salud sea la de este hospital. Para ello, se ha realizado una búsqueda sistemática de la evidencia disponible sobre esta patología, para después poder emplearla sobre nuestra población diana. En el protocolo se realiza una introducción sobre la insuficiencia cardiaca aguda, para posteriormente describir cómo realizar su diagnóstico y tratamiento. Asimismo, se ha generado una versión reducida del protocolo para su uso clínico. Acute heart failure is defined as a rapid onset or worsening of symptoms or signs of heart failure. It is a life-threatening entity which requires urgent evaluation and treatment. As a result, it is necessary to develop a protocol to diagnose and properly treat this pathology in a precocious manner. This end of degree project involves the realization of a care protocol for the La Plana Hospital, with the aim of providing standardized management of patients who belong to the health area of this hospital. For such purpose, a systematic search of the available evidence on this pathology has been carried out in order to use it later on our target population. The protocol introduces acute heart failure and describes how to perform its diagnosis and treatment. A reduced version of the protocol has also been generated for clinical use.

The aim of the current study was to describe lung ultrasonography (LUS) characteristics and to evaluate the agreement between LUS and chest radiography (CXR) in diagnosis of four conditions causing most acute dyspnea in children, namely, pneumonia, pleural effusion, pneumothorax and acute pulmonary edema in children at a teaching hospital in Vietnam. We reviewed the records of the chidren between January and June 2018, who presented to emergency department (ED) or pediatric intensive care unit (PICU) at children hospital 1 (CH1) with acute dyspnea and had final diagnosis of one of four etiologies including pneumonia, pleural effusion, pneumothorax and acute pulmonary edema. All patients underwent CXR and LUS at the time of admission. Eighty-one children with acute dyspnea including pneumonia (n=65, 80%), pleural effusion (n=9, 11%), pneumothorax (n=3, 4%) and acute pulmonary edema (n=4, 5%) were enrolled. LUS was identified among 100% of cases with pleural effusion and pneumothorax (CXR only showed 73.3% and 50%, respectively); 92.3% of cases with pneumonia (CXR showed 93.8%) and only 75% of cases with acute pulmonary edema (CXR showed 50%). When comparing LUS with CXR, we noticed a good agreeement between the 2 methods in the diagnosis of pneumonia (kappa=0.64, p

A healthy body activates the immune response to target invading pathogens (i.e. viruses, bacteria, fungi, and parasites) and avoid further systemic infection. The activation of immunological mechanisms includes several components of the immune system, such as innate and acquired immunity. Once any component of the immune response to infections is aberrantly altered or dysregulated, resulting in a failure to clear infection, sepsis will develop through a pro-inflammatory immunological mechanism. Furthermore, the severe inflammatory responses induced by sepsis also increase vascular permeability, leading to acute pulmonary edema and resulting in acute respiratory distress syndrome (ARDS). Apparently, potential for improvement exists in the management of the transition from sepsis to ARDS; thus, this article presents an exhaustive review that highlights the previously unrecognized relationship between sepsis and ARDS and suggests a direction for future therapeutic developments, including plasma and genetic pre-diagnostic strategies and interference with proinflammatory signaling.

Laurence Pincet,1 Gabriele Lecca2 1ENT Surgery Department, University Hospital Centre (CHUV), Lausanne, Switzerland; 2Department of Internal Medicine, Riviera – Chablais Hospital, Monthey Site, Route de Morgins, Monthey, Switzerland Background: Non-cardiogenic pulmonary edema (NCPE) after intravenous (iv) administration of non-ionic radiocontrast media (RCM) is a rare but life-threatening complication. In a context of emergency, its diagnosis is difficult. Case report: We report the case of a 55-year-old woman who developed an acute pulmonary edema following iv infusion of non-ionic, low-osmolar RCM during abdominal CT scan. She needed a 24-hour hospitalization in intensive care unit for an acute hypoxemic dyspnea. She was falsely treated at first for an anaphylactic reaction, and then for a cardiac failure. She improved with cortisone and diuretic treatment. Conclusion: Although NCPE has been rarely reported after RCM injection, it remains an acute severe complication that has to be considered. The differential diagnosis involves multiple pathogenic patterns giving furthermore complexity in choosing an appropriate treatment. Keywords: acute pulmonary edema, non-cardiogenic pulmonary edema, radiocontrast media, adverse reaction

A 70-year-old man presented as an emergency with acute pulmonary edema and hemodynamic compromise with a blood pressure of 60/38 mm Hg. His history included end-stage renal failure and rheumatic heart disease with tissue mitral valve replacement (27-mm Perimount Magma, Edwards Lifesciences, Irvine

Patient Initials or Identifier Number WS ### Relevant Clinical History and Physical Exam •F/88, ADLi, walks with stick •PMH: OA knee •Severe AS presented with acute pulmonary edema in March 2018 •Echo April 2018 heavily calcified AV with MG = 60 mmHg, PG = 103 mmHg, AVA = 0.52 cm2

Pulmonary edema refers to an excessive accumulation of fluid in the pulmonary interstitial and alveolar spaces. It may occur in low risk pregnancies but one very important predisposing factor is association with pre-eclampsia. Acute pulmonary edema during pregnancy is very rare and occurs in 0.08% pregnancies. About 3% of severe pre-eclamptic patients develop acute pulmonary edema. Several risk factors have been identified: preeclampsia or eclampsia, use of tocolytic therapy, severe infection, cardiac disease, iatrogenic fluid overload, and multiple gestations. This case examines one such presentation and reviews some of the diagnostic possibilities.

Objective: Noninvasive mechanical ventilation (NIMV) decreases the incidence of endotracheal intubation and complications related to the endotracheal intubation in acute respiratory failure. However, there is some concern that it can increase mortality due to the delay of endotracheal intubation. We aimed to evaluate the efficacy of NIMV in acute pulmonary edema (APE) and postoperative respiratory failure (PORF) patients. Materials and Methods: Records of 100 NIMV assisted patients suffering from APE and PORF were evaluated, retrospectively, for a period from Jan 01, 2011 to Dec 15, 2012. The patients were divided into two groups as APE (group 1; n=59) and PORF (group 2; n=41) patients. The demographic data of the patients having a frequency of endotracheal intubation after NIMV, the time between initiation of NIMV and intubation, ejection fraction (EF), systolic pulmonary arterial pressure, APACHE II scores, intensive care unit/hospital length of stay and mortality rate were recorded. Results: There were no significant differences between the groups in terms of endotracheal intubation incidence and the time between initiation of NIMV and intubation. The intubated patients had a longer length of hospitalization and stay in intensive care unit, higher baseline APACHE II scores, and mortality rates compared to nonintubated patients in both groups. The patients with chronic obstructive pulmonary disease in group 1 and with lower EF in group 2 were more likely to be intubated. Conclusion: In this study, we observed that higher baseline APACHE II scores were associated more with a high mortality rate than the extension of time between NIMV and endotracheal intubation in patients with two different acute respiratory failures, like APE and PORF. Keywords: Noninvasive mechanical ventilation, postoperative respiratory failure, acute pulmonary edema, atelectasis

Thiazides are drugs often used in management of high arterial blood pressure. Shock and acute pulmonary edema are rarely described as adverse reactions related to this drug. We report the case of a 55 years-old woman admitted at Hospital de Puerto Montt, Chile. Two hours after having her first dose of hydrochlorothiazide she presented dyspnea. Laboratory tests and images support the diagnosis of non-cardiogenic pulmonary edema. Resolution of her clinical picture was observed 48 hours after hydrochlorothiazide administration was discontinued and hemodynamic and non invasive ventilation support were supplied. The patient was discharged without symptoms, 3 days after entering to hospital.

Purpose: The present study proposes the comprehensive ultrasound evaluation of a consecutive batch of patients with acute cardiogenic pulmonary edema. Method: The registry included all patients with acute pulmonary edema from 2 emergency hospitals between February and May 2016. During the first 3 days of admission, a transthoracic ultrasound was performed which included the parameters of systolic and diastolic function of the left ventricle, right ventricular systolic function, heart cavity dimensions, estimated pulmonary pressure, and the presence and severity of valvular disease. Results: A total of 70 patients were enrolled in the registry. The mean ejection fraction of the left ventricle was 39.5±11.4% and the average indexed end-diastolic volume was 77.7±29.5ml/m⊃2, above the upper limit of normal. All patients in whom diastolic function could be evaluated had a degree of diastolic dysfunction. Functional parameters of the right ventricle were normalized as average, and the mean pulmonary artery pressure was increased: 40.9±16.7mmHg. The most common valvular heart disease were mitral and tricuspid insufficiency, with moderate or severe impairment in 82.8%, respectively 65.7% of the patients.

Background Pulmonary congestion is the main cause of hospital admission among heart failure (HF) patients. Lung ultrasound (LUS) assessment of B-lines has been recently proposed as a reliable and easy tool for evaluating pulmonary congestion. Objective To determine the prognostic value of LUS in predicting adverse events in HF outpatients. Methods Single-center prospective cohort of 97 moderate-to-severe systolic HF patients (53±13years; 61% males) consecutively enrolled between November 2011 and October 2012. LUS evaluation was performed during the regular outpatient visit to evaluate the presence of pulmonary congestion, determined by B-lines number. Patients were followed up for 4months to assess admission due to acute pulmonary edema. Results During follow-up period (106±12days), 21 hospitalizations for acute pulmonary edema occurred. At Cox regression analysis, B-lines number≥30 (HR 8.62; 95%CI: 1.8–40.1; p=0.006) identified a group at high risk for acute pulmonary edema admission at 120days, and was the strongest predictor of events compared to other established clinical, laboratory and instrumental findings. No acute pulmonary edema occurred in patients without significant pulmonary congestion at LUS (number of B-lines&nbsp

Acute heart failure, frequently observed in the emergency department, could be a life-threatening condition. Most intravenous therapies introduced for the treatment of acute heart failure continue to be used despite very limited studies (loop diuretics, nitrates) or studies showing their possible harmful effects (inotrope) (1). Likewise in the case of opiates—they continue to be used for some patients with acute heart failure, especially in those presenting with acute pulmonary edema. The use of opiates in the treatment of heart failure dates back to the 1960s, and opiates were considered one of the most important agents for treatment of heart failure in the 1970s (2,3).

The incidence of chronic kidney disease (CKD) continues rising recently. Chronic kidney disease is associated with many multiple complications. One of the complications related to the emergency situation is acute pulmonary edema (APE). Acute pulmonary edema is a condition where there is acute fluid accumulation in the lungs. Acute pulmonary edema can cause respiratory distress and severe hypoxia. Early recognition and initial treatment shall be considered to prevent further morbidity and mortality. This will be presented a case of 18-year-old female who came to the hospital with progressive dyspnea. After further diagnostic procedures, diagnosis of APE and CKD are constructed. Initial treatment in the emergency room did not give a good response. Then, the patient referred to the higher level hospital to receive possible dialysis treatment.

Objective Prompt afterload reduction with high dose nitrates remains the cornerstone of treatment for decompensated heart failure with acute pulmonary edema (APE). Nitrate therapy in the prehospital setting is often limited to relatively low doses of sublingual nitroglycerin (NTG), which has poor bioavailability and is challenging to administer with concurrent use of non-invasive ventilation. Conversely, treatment in the Emergency Department typically consists of high doses of nitroglycerin, either by continuous intravenous (IV) infusion or by IV bolus (IVB NTG). A growing body of evidence suggests the safety and efficacy of large doses of IVB NTG in the hospital and prehospital settings. In this study, we assessed the safety and effectiveness of a prehospital bundle of care, which included IVB NTG followed by maintenance IV infusion of NTG for the treatment of decompensated heart failure with acute pulmonary edema. Methods This is a retrospective chart review of patients who received IVB NTG for decompensated heart failure with APE between May 1, 2019 and January 31, 2020 in a large, geographically diverse EMS system in Minnesota and Wisconsin. Inclusion criteria for treatment under this protocol included a working diagnosis of APE, a systolic blood pressure ≥120 mmHg and SpO2 ≤93% following 0.8 mg of SL NTG. Treatment consisted of a 400-mcg IV bolus of NTG, repeated every 2 minutes as needed during transport if SBP ≥120 mmHg. For transport times ≥10 minutes, an intravenous infusion of NTG was initiated at 80 mcg/min and titrated as needed to improve symptoms. Hypotension was defined as a systolic blood pressure ≤ 90 mmHg or a MAP ≤ 65 mmHg. Results During the study period, 45 patients were treated with IVB NTG. 25 patients were treated with IVB NTG alone. The median (IQR) total bolus dose was 400 mcg (400-1200 mcg). 20 patients were treated with a NTG infusion following IVB NTG. The median (IQR) infusion dose was 80 mcg/min (80-100 mcg/min). For all patients, the initial median (systolic IQR) blood pressure was 191/113 mmHg (169-217), 5 minutes following IVB NTG was 158/94 mmHg (141-178), and on arrival to the ED was 152/89 mmHg (129-172). 5 minutes after the initial dose of IVB NTG, there was an increase in median (IQR) oxygen saturation (SpO2) to 92% (88-96) from an initial reading of 88% (78-93). Median (IQR) SpO2 at hospital arrival was 94% (90-98). Median (IQR) transport time was 14 minutes (8.5-19). One episode of transient hypotension occurred during EMS transport and resolved without intervention. There were no cases requiring prehospital advanced airway management in this series. Conclusion Patients treated with IVB NTG by paramedics for APE had reduction in blood pressure and improvement in SpO2compared to their original presentation. There was one instance of transient hypotension that resolved without intervention en route. There were no cases requiring advanced airway management.

Introduction: The necessity of rapid preload and afterload reduction in patients with decompensated congestive heart failure (CHF) and acute pulmonary edema (APE) is well established. In the hospit...

Stonefish sting lethality in man has been scarcely documented since the middle of the 20th century. We report three clinical cases, including one fatality, emphasizing the cardiovascular toxicity of the Synanceia verrucosa venom, and its potentially lethal effects. All clinical data have been recently collected in New Caledonia and French Polynesia.

HELLP syndrome is a combination of symptoms described as hemolysis, elevated liver enzymes and low platelets. HELLP is a common life-threatening complication of pregnancy thought to be a variant or complication of preeclampsia. In this case report, we aimed to present a woman with acute postpartum HELLP syndrome complicated by pulmonary edema after caesarean section following severe preeclampsia. Our experience suggests that early detection of HELLP syndrome and timely management will bring good outcomes.

Kardiyak miksomalar %0,0017-0,03 insidansına sahip oldukça nadir olan bir hastalık olup en sık üçüncü ve altıncı dekadlar arasında görülür. Olguların %65’ini kadınlar oluşturur. Olguların %75’inde sol atriyumdan, %18’inde sağ atriyumdan, %4’ünde ise ventriküllerden köken alırlar. En nadir görüldükleri yer ise kapak dokuları olup sıklık sırası triküspit kapak, mitral kapak, pulmoner kapak ve aortik kapaktır. Kapak kökenli miksomaları gerçek insidansı belirsizdir. Klinik belirtileri sistemik semptomlar, emboliler ve intrakardiyak obstrüksiyonlardan kaynaklanır. Güçsüzlük, ateş, kilo kaybı, eklem ağrıları sistemik semptomlardan bazılarıdır. Tromboemboliler tümoral dokunun kendisinden kaynaklanabildiği gibi kitle üzerinde organize olmuş pıhtılardan da meydana gelebilmektedir. Dispne, ortopne, baş dönmesi, senkop ve pulmoner ödem intrakardiyak obstrüksiyonlardan kaynaklanan semptomlardır ve lokalizasyon, boyut ve hareketliliğe göre değişkenlik gösterebilir. Bu makalede dispne, göğüs ağrısı ve taşikardi ile prezente olan ve ST elevasyonlu miyokard enfarktüsü, akut pulmoner ödem, pulmoner hipertansiyon, paroksismal atriyal fibrilasyona yol açan mitral anuler ve posterior kapakçıktan köken alan dev miksoma tanısı alan 77 yaşında bir kadın hastayı sunmayı amaçladık., Cardiac myxoma is a rare disease with an incidence of 0.0017-0.03%, and most frequently are seen between the third and sixth decades. The 65% of cases are female. They originate from left atrium in 75% of the cases, from right atrium in 18% and from ventricles in 4%. The most rarely seen cardiac origins are valvular tissues and respectively origin from tricuspid valve, mitral valve, pulmonary valve and aortic valve. The exact incidence of myxomas originating from the mitral valve is not clear. Clinical signs are classified in three groups such as systemic symptoms, symptoms related to thromboembolisms and symptoms related to intracardiac obstructions. Weakness, fever, weight loss, arthralgia are some of the systemic symptoms. Thromboembolisms are caused by either the tumoral tissue or the clot locating on the mass. Dyspnea, orthopnea, dizziness, syncope and pulmonary edema are examples of symptoms resulting from intracardiac obstructions, depending on the size, mobility and localization of the tumor. We aim to present a 77-year-old female presenting with dyspnea, angina pectoris and tachycardia and getting a diagnosis of a giant myxoma originating from the mitral annulus and posterior leaflet causing myocardial infarction with ST elevation, acute pulmonary edema, pulmonary hypertension, paroxysmal atrial fibrillation.