Stable Vital Signs Research Articles

Effects of Swaddle Bath on Temperature, Heart Rate and Oxygen Saturation in Premature Infants

Indonesia has the fifth highest rates of preterm birth. The action of premature infants bathing every day may result in stress. A swaddle bath is a technique of bathing to provide the feeling of the womb so that babies feel comfortable and avoid stress, shown by stability of vital signs and a lack of stress behavior. The purpose of this research was to examine the effects of a swaddle bath vs. conventional bath methods on the temperature, heart rate and oxygen saturation of premature infants. This research was a quasi-experimental pretest-posttest study with a control group. The 50 participants were divided into the swaddle bath group (n = 25) and the conventional bath group (n = 25). The inclusion criteria were: gestation age = 30-36 weeks, temperature > 35∘C and ≤ 37.5∘C, SpO2 = 90-94%, body weight ≥ 1,500 grams, and not in intensive care. Before and after bathing, the baby’s temperature was measured with an axilla thermometer, heart rate with a stethoscope and oxygen saturation with a pulse oximeter. The data were analyzed using the Wilcoxon test and Mann-Whitney test. The results showed that there was no significant difference in the temperature, heart rate or oxygen saturation before vs. after the swaddle bath (p= 0.087, p = 0.55, p = 1.00, respectively). However, there was a significant difference in the temperature, heart rate and oxygen saturation after the swaddle bath compared with the conventional bath (p = 0.019, p = 0.041, p = 0.024, respectively). We can conclude that the swaddle bath affected the temperature, heart rate and oxygen saturation in the premature infants and that the vital signs remained stable and normal.
 Keywords: conventional bath, heart rate, oxygen saturation, premature, swaddle bath

Comparison of diagnostic accuracy of point-of-care ultrasonography and X-ray of bony injuries of the knee.

We aimed to compare the accuracy of point-of-care ultrasonography (POCUS) and X-ray (XR) in the diagnosis of knee bone fractures and fracture characteristics in cases of injuries to the knee. The study was conducted in the emergency department (ED) of a tertiary hospital between March 2017 and March 2019. It included patients who presented to the ED with isolated knee injuries, were suspected to have a bony lesion based on clinical examinations, and were ultimately referred for XR. Five emergency physicians (EPs) who had at least three years of ED experience participated in the study. Before the study, these EPs received training on knee examination and radiographic investigation of the knee joint. They were also trained on how to assess the knee joint using POCUS. The knee bones, patella, femur, tibia, and fibula were evaluated. A POCUS examination of the knee bones was carried out according to the eight-step Kozaci Protocol. This study included 92 patients with knee trauma. The mean age of the patients was 34 ± 16years (6-55years). Using POCUS and XR, fractures were detected in 40 (43%) and 32 patients (35%), respectively. Relative to XR, for detecting fractures, POCUS showed sensitivity, specificity, positive predictive value, and negative predictive value of 97%, 85%, 78%, 98%, respectively, and the kappa value was 0.774. POCUS examination revealed hematoma and edema in the soft tissue in 34 (37%) patients and hemarthrosis in 33 patients (36%). XR is the first and most widely used imaging modality to identify fractures of the knee bone trauma. However, POCUS examination can successfully diagnose bony lesions of the knee in patients with stable vital signs and without life-threatening injuries. It can also easily diagnose hematoma and hemarthrosis. Therefore, POCUS can be used as a diagnostic tool in emergency situations where XR is not available.

PLACENTALABRUPTION AND FETAL DEATH FOLLOWING VEHICLE COLLISION: A CASE REPORT AND LITERATURE REVIEW

AIM: We present a case of placental abruption and fetal death following a motor vehicle accident, associated with air bag activation, and a short literature review of this important issue. Case report:A27-year-old women at 32nd gestational week presented after a head-on motor vehicle collision. Patient was restrained and air-bag deployed. Upon admission patient had stable vital signs, no visible major physical injuries, but was complaining of lower abdominal and the right leg pain. Physical examination revealed ecchymosis of the lower abdomen consistent with seatbelt trauma. Initial obstetric ultrasound examination showed no fetal cardiac activity, and the retro placental hematoma was identied. The labor was induced. Massive hemorrhage occurred after delivery of the placenta. Uterus atonia could not be managed conservatively with uterotonic agents or surgically, so hysterectomy had to be performed. The patient recovered and was discharged on the night postoperative day. Pathologic examination conrmed placental abruption. CONCLUSION:In conclusion all pregnant women who had a vehicle accident should be sent to the medical center with the possibility to take care of both trauma patients - the pregnant woman and fetus. Utmost attention should be paused to such patients as even the slightest trauma can have grave consequences on both the mother and fetus.

Atypical Symptom and Clinical Features of Right Atrial Myxoma: A Case Report

Cardiac tumors are rare in medicine. Myxomas are the most common benign cardiac tumors. Most myxomas (>80%) are found in the left atrium. The site of 15-20% of cases of myxoma is the right atrium. The incidence of cardiac myxoma peaks at 40 to 60 years of age. Most atrial myxomas occur sporadically and are more common in middle-aged women. Patients with atrial myxoma usually have one of the symptoms in the following tetrad: embolic phenomena, intracardiac flow obstruction, arrhythmias and constitutional symptoms. The modality of choice for diagnosis of cardiac myxoma is an Echocardiography. Surgery should be considered promptly, because embolic complications or sudden death can be occured. This surgery is usually safe with low morbidity and mortality. Operative mortality is reported to be within 5%, and will be increased with myxoma occurring in the ventricle. Our case was a 47-year-old Iranian male with right atrial myxoma and a history of heart burn, he does not mention fever and chill, cough, chest pain or dyspnea. In CT Angiography of pulmonary artery showing pulmonary thromboembolism. After echocardiography and pulmonary CT angiography he underwent cardiac surgery and mass with adhesion to the right atrial wall near the IVC was excised. The patient was discharged after surgery with good general condition and stable vital signs.

Colonic obstruction secondary to lithobezoar in a child.

A nine-years-old girl with no history of abdominal surgery was presented to the emergency department with a seven-days-lasting abdominal pain, yellow vomiting and constipation; the stool was brownish mixed with small stones. There was no history of fever or similar episodes. Her development history revealed multiple episodes of earth and stone-eating since her 3 years. The physical examination revealed a well-developed child with stable vital signs, the abdomen was slightly distended and tense in its lower part. There was a palpable lump in the hypogastric area and in left iliac fossa. Rectal examination demonstrated a rectal ampulla full of small stones. Abdominal X-ray showed gravel inside the large bowel and rectum with a distended transverse and left colic angle. Manual evacuation, and colonic lavage were done and repeated twice daily for three days. At the fourth day an abdominal X-ray showed clearance of all stones from the colon and no signs of colonic obstruction or perforation.

Abstracts for the 40th emergencies in medicine conference

Abstracts for the 40^th emergencies in medicine conference

A randomized controlled trial of bedside ultrasound RUSH process to improve the quality of anesthesia for elderly emergency surgery patients.

Objectives:The rapid ultrasound in shock examination (RUSH process) is an assessment of patient’s heart function, volume status, and vasculature, which can help anesthesiologist understand the patient’s physical condition. In this study, the RUSH process was applied to elderly emergency surgery patients to evaluate whether it is beneficial to maintain the patient’s vital signs stable during the operation.Methods:In this randomized controlled clinical study one hundred elderly patients who needed general anesthesia and emergency surgery from January 2021 to July 2021 were randomly divided into RUSH group (Group-A, n=52) and control group (Group-B, n=48). The main result include the area under the intraoperative blood pressure curve (AUC), liquid input, urine output, lactic acid levels, number of vasoactive drugs used.Results:There were no significant differences in patients’ basic information, preoperative blood pressure, intraoperative blood loss, intraoperative fluid input, intraoperative blood transfusion, and urine output. Intraoperative systolic blood pressure less than 90mmHg AUC of Group-A is less than Group-B(P<0.05), diastolic blood pressure less than 60mmHg AUC of Group-A is less than Group-B(P<0.05). After the operation, the blood gas analysis lactic acid level in Group-A was lower than that in Group-B(P<0.05). Group-A used more vasoactive drugs than Group-B(P<0.05).Conclusion:The bedside ultrasound RUSH process is of great significance for anesthesiologist to understand the preoperative physical condition of elderly emergency surgery patients, and is beneficial to maintain the stability of intraoperative vital signs.

Learning-Refined Integral Null Space Pursuit Algorithm for Noncontact Multisubjects Vital Signs Measurements Using SFCW-UWB and IR-UWB Radar

Under low signal-to-noise-and-clutter ratio circumstances, non-contact multi-subjects vital sign assessment based on ultrawideband (UWB) radar is extremely difficult. It is challenging to obtain an accurate measurement since the respiratory frequency harmonics are mixed with noise during detection and are extremely near to the frequency of the heartbeat signal. We use an impulse radio ultrawideband (IR-UWB) radar and a stepped-frequency continuous-wave ultrawideband (SFCW-UWB) radar in measurement to get reliable vital signs from several participants. For adaptively extracting respiratory and heartbeat patterns, it is proposed to use the learning refined integral null space pursuit algorithm (LR-INSP), which is based on the learning refined integral null space pursuit method and optimum route learning. The refined-INSP technique aims to provide fine-grained multi-layer and multi-branch harmonic components. Then, to obtain a reliable and stable vital sign path from the multi-branch decomposition, an optimum path learning technique is presented. According to the experimental findings, the average signal accuracy assessment (SAA) of the heartbeat and respiratory frequencies for IR-UWB radar is 95.41% and 89.97%, respectively. The average SAA of the heartbeat and respiratory frequencies for SFCW-UWB radar is 94.39% and 99.48%, respectively.

Pre-Hospital and In-Hospital Management of an Abdominal Impalement Injury Caused by a Tree Branch

In South Korea, most patients who visit trauma centers with abdominal injuries have blunt trauma, and penetrating injuries are relatively rare. In extremely rare cases, some patients are admitted with a long object penetrating their abdomen, and these injuries are referred to as abdominal impalement injuries. Most cases of impalement injuries lead to fatal bleeding, and patients often die at the scene of the accident. However, patients who survive until reaching the hospital can have a good prognosis with optimal treatment. A 68-year-old female patient was admitted to the trauma center with a 4-cm-thick tree branch impaling her abdomen. The patient was transported by a medical helicopter and had stable vital signs at admission. The branch sticking out of the abdomen was quite long; thus, we carefully cut the branch with an electric saw to perform computed tomography (CT). CT revealed no signs of major blood vessel injury, but intestinal perforation was observed. During laparotomy, the tree branch was removed after confirming that there were no vascular injuries, and enterostomy was performed because of extensive intestinal injury. After treating other injuries, the patient was discharged without any complications except colostomy. Abdominal impalement injuries are treated using various approaches depending on the injury mechanism and injured region. However, the most important consideration is that the impaled object should not be removed during transportation and resuscitation. Instead, it should only be removed after checking for injuries to blood vessels during laparotomy in an environment where injury control is possible.

Hemifacial spasm is not affected by state of consciousness: a case report

Background Hemifacial spasm (HFS) is a movement disorder caused by mechanical compression of the facial nerve after it has left the brainstem and is characterized by brief or sustained twitching of the muscles innervated by that nerve. Often we observe spasm in an awakening situation. Actually contractions persist during sleep. To our knowledge, there were no reports on how HFS manifests under disturbance of consciousness. Here, we report a case of primary HFS in which the patient's symptoms persisted in a coma.Case presentationA 74-year-old female with right-sided primary HFS for 20 years and had received botulinum toxin injections in our hospital. Unfortunately she was carried to emergency department after traumatic right pneumothorax by accident. During the emergency treatment, she lost consciousness due to simultaneous cardiac arrest and respiratory arrest. She was then admitted to the emergency intensive care unit for further treatment. During her hospitalization, she was in a coma with stable vital signs and persisting symptoms of HFS. Thus, a multidisciplinary consultation was requested to identify whether it was focal cortical seizures involving the right-side facial muscles. Physical examination revealed brief involuntary clonic or tonic contractions accompanied with the ‘Babinski-2 sign’. A combination of relevant data, including her past history, clinical presentation and a negative computed tomography scan of the head, led to a diagnosis of right-sided HFS. As the symptoms of HFS are not life-threatening, the use of anticonvulsants is unnecessary.ConclusionsFor the layperson, it is crucial to seek a multidisciplinary consultation to obtain a correct diagnosis.

Difficulty in Management of Advanced Pediatric Orbital Tumor

Introduction: Tertiary care centers often manage pediatric orbital tumors, especially in advanced lesions and complex management. We report a case of a young boy with a malignant orbital tumor involving intracranial infiltration. Case presentation: A four-year-old boy had proptosis on the left eye for two months accompanied with blurred vision, pain, and oftenly bleeds with ipsilateral nasal congestion. There was no history of trauma, eye disorders, systemic diseases, or growth disorders. The physical examination showed stable vital signs, however a weak general condition and no enlarged regional lymph nodes. Visual acuity of the left eye was no light perception. There was a mass with protrusion of the left eye, swelling of the eyelid with an irregular surface, and a tendency to bleeds. The cornea was hazy with partly scarring, so we could not evaluate the posterior segment. MRI of the head presented a malignant soft tissue mass of the left orbital region with intracranial infiltration. The patient was given adjuvant chemotherapy; however, he could not survive due to systemic complications. Conclusions: The definitive diagnosis for the orbital tumor is obtained by histopathological examination. The investigation with CT scan or MRI imaging could be considered if not possible. However, since the definitive diagnosis still not assessed, the management can be affected. It is essential to have a definitive diagnosis to provide adequate treatment for the patients. Delayed and inadequate management can make malignant orbital tumors potentially life-threatening.

Impact of diaper change frequency on preterm infants' vital sign stability and skin health: A RCT

BackgroundBundling nurse caregiving interventions are promoted to minimize infant stress. PurposeTo evaluate impact of bundled nursing care and diaper change frequency on vital sign stability and skin health of preterm infants born ≤32 weeks gestation. MethodStable preterm infants on a 3-hour feeding schedule were randomly assigned to 3- vs. 6-hour diaper changes. Diapers were changed prior to 6 h if stool was present. Direct observation of bundled care events (BCE) identify caregiving activities during each BCE. Skin pH, transepidermal water loss (TEWL), and neonatal skin condition scores (NSCS) were obtained. Vital sign data (HR, RR, O2 saturation) was downloaded from bedside monitors. ResultsForty-six infants contributed to 605 BCEs. BCEs lasted on average 28 min and included nine different activities (e.g., vital signs, feeding). Significant increases in heart rate during BCEs occurred in approximately half of the observations. Among observations with a diaper change increases in heart rate during diapering occurred in over 74% of observations Infants who were awake at the beginning of BCEs had 48% lower odds of having a change in heart rate than infants who were sleeping (p = .02). There were no group differences (3- vs. 6-hour diaper change) in skin health outcomes (TEWL, pH, NSCS). ConclusionReducing diaper change frequency without stool present should be considered to minimize caregiving stress in preterm infants. Additional research should evaluate the intrusiveness and clusters of activities that significantly impact physiologic stability to better individualize the timing of routine yet intrusive activities.Clinicaltrials.gov registry # NCT03370757

Prediction value of creatine kinase level in conservative treated unruptured tubal ectopic pregnancies

Objectives: An ectopic pregnancy (EP) occurs when a fertilized ovum implants outside the endometrial cavity. We investigated the creatine kinase (CK) enzyme in conservatively treated EP to determine the resolution time and predict cases that may progress to surgical intervention. Methods: We include 43 patients with stable vital signs at recruitment. All participants were examined by using transvaginal ultrasound (TVUS). Beta human chorionic gonadotropin (β-hCG) and creatine kinase (CK) levels were also measured. In cases diagnosed with EP, intramuscular methotrexate (MTX) at a dose of 50 mg / m2 was administered and monitored with β-hCG titers. Follow-up continued until β-hCG titer became negative, or surgery became mandatory due to acute abdominal pain. Results: The mean β-hCG Level in the presence of an adnexal mass was statistically significantly higher than the mean level in patients in whom TVUS failed to define a mass. The mean β-hCG level in the surgical exploration group of patients was significantly higher than in those who did not require surgery. At a cut-off of 6486 mIU/mL, β-hCG could predict the emergence of acute abdomen with a sensitivity of 75% and a specificity of 94.3%. We examined CK level to contribute the test's specificity, but we found no difference among cases with and without surgical exploration. Conclusions: In patients treated conservatively for EP, CK levels at the outset neither predict an acute abdomen to emerge nor shed light on the resolution period in patients who respond to medical therapy.

Evaluation of the consequences of early permission of mothers with cesarean delivery

Background: In Iran, there is a high tendency to give birth by cesarean section, while about 75% of them are unnecessary and selective. In many hospitals in the country, mothers who have undergone cesarean section are permission 24 hours after the operation if they have stable vital signs and are in good general condition. The aim of this study was to evaluate the consequences of early discharge in mothers who underwent cesarean section.Methods: This descriptive case-series study was performed on 400 pregnant women aged 18-40 years with a gestational age of 37 weeks and more who were admitted to the hospital in Ardabil city for cesarean section at year 2019. Patients without any preference were divided into two groups. The first group was discharged 24 hours and second group was discharged 72 hours after surgery. Individuals in both groups were followed up by telephone 1 and 6 weeks after permission. The relevant checklist was completed for all of them. Other necessary data were collected through a questionnaire containing demographic and clinical information.Results: Two groups were matched in terms of age and body mass index. At one and six weeks after discharge; there was no significant difference between two groups in terms of fever, readmission, symptoms of infection and use of antibiotics.Conclusions: The results of the present study showed that after cesarean section, if the patient's vital signs are stable, the patient can be discharged after 24 hours.

Influence of Dexmedetomidine on Diaphragm Function and Postoperative Outcomes in ICU Patients with Mechanical Ventilation.

Objective To probe into the influence of dexmedetomidine (DEX) on diaphragm function and postoperative outcomes of mechanically ventilated patients in the intensive care unit (ICU). Methods 84 patients with mechanical ventilation (MV) in the ICU of our hospital were selected as the research participants, including 38 patients in the control group (CG) sedated with midazolam (MZ) and 46 patients in the research group (RG) with DEX sedation. Ramsay sedation score, visual analogue scale (VAS), and restlessness score (RS) were used to evaluate their state before sedation (T0), as well as 2 h (T1), 6 h (T2), and 24 h (T3) after sedation, and the alterations of mean arterial pressure (MAP) and heart rate (HR) were recorded. Serum cortisol (Cor), adrenocorticotropic hormone (ACTH), superoxide dismutase (SOD), malondialdehyde (MDA), interleukin- (IL-) 1β, IL-6, and tumor necrosis factor-α (TNF-α) were measured before and 24 h after sedation. The end-inspiratory diaphragm thickness (DTei) and end-expiratory diaphragm thickness (DTee) were measured within 2 h after the initiation of MV and 5 min after the spontaneous breathing test (SBT), and the diaphragm thickening fraction (DTF) was calculated. Finally, the ventilator weaning, MV time, and the incidence of adverse reactions (ADs) of the two groups were counted. Results T0 and T3 witnessed no distinct difference in Ramsay, VAS, and RS scores between the two arms (P > 0.05), but at T1 and T2, RG had better sedation state and lower VAS and RS scores than CG (P < 0.05), with more stable vital signs (P < 0.05). After sedation, the contents of oxidative stress and inflammatory factors in RG were lower, while DTee, DTei, and DTF were higher, versus CG (P < 0.05). Moreover, RG presented higher success rate of first ventilator weaning, less MV time, and lower incidence of ADs than CG (P < 0.05). Conclusions DEX is effective in mechanically ventilated patients in the ICU, which can protect patients against diaphragm function damage, improve the success rate of ventilator weaning, and benefit the postoperative outcome, with excellent and rapid sedation effect and less stress damage to patients.

Safety and efficacy of dexmedetomidine hydrochloride combined with midazolam in fiberoptic bronchoscopy in children: a prospective randomized controlled study.

To study the safety and efficacy of dexmedetomidine hydrochloride combined with midazolam in fiberoptic bronchoscopy in children. A total of 118 children who planned to undergo fiberoptic bronchoscopy from September 2018 to February 2021 were enrolled. They were divided into a control group (n=60) and an observation group (n=58) using a random number table. The observation group received intravenous pumping of dexmedetomidine hydrochloride (2 μg/mL) at 1 μg/kg and then intravenous injection of midazolam at 0.05 mg/kg, followed by dexmedetomidine hydrochloride pumped intravenously at 0.5-0.7 μg/(kg·h) 10 minutes later to maintain anesthesia. The control group was given intravenous pumping of propofol at 2 mg/kg and then intravenous injection of midazolam at 0.05 mg/kg, followed by propofol pumped intravenously at 4-6 mg/(kg·h) 10 minutes later to maintain anesthesia. Fiberoptic bronchoscopy was performed after the children were unconscious. Heart rate (HR), respiratory rate, blood oxygen saturation, and mean arterial pressure (MAP) were recorded before inserting the bronchoscope (T0), at the time of inserting the bronchoscope (T1), when the bronchoscope reached the glottis (T2), when the bronchoscope reached the carina (T3), and when the bronchoscope entered the bronchus (T4). The intraoperative peak airway pressure (Ppeak), examination time, degree of sedation, extent of amnesia, incidence of adverse reactions, postoperative awakening time, and postoperative agitation score were also recorded. Compared with the control group, the observation group had significantly decreased MAP at T1 to T4 and HR at T1 to T3 (P<0.05). Compared with that at T0, MAP was significantly increased at T1 to T4 in the control group and at T3 in the observation group (P<0.05). HR was significantly higher at T1 to T3 than at T0 (P<0.05). Compared with the control group, the observation group showed significantly lower intraoperative Ppeak value, incidence of intraoperative adverse reactions, and postoperative agitation score, significantly shorter examination time, and better effects of amnesia and anesthesia (P<0.05). There was no significant difference in the degree of intraoperative sedation and postoperative awakening time between the two groups (P>0.05). Dexmedetomidine hydrochloride combined with midazolam is a safe and effective way to administer general anesthesia for fiberoptic bronchoscopy in children, which can ensure stable vital signs during examination, reduce intraoperative adverse reactions and postoperative agitation, shorten examination time, and increase amnesic effect.

Spontaneous Pneumothorax in a Child with COVID-19

Introduction: SARS-CoV2 (COVID-19) is a serious and global infection that has spread to numerous countries, including Iran. Pneumothorax may occur in cases of COVID-19 as a consequence of lung parenchymal damage, which can disrupt the healing process and increase mortality. Case Presentation: This manuscript describes the case of a 2-year-old boy with hyper IgM syndrome and COVID-19 infection. The patient developed spontaneous pneumothorax and recovered without chest tube by supportive care and was discharged in good general condition after the completion of the antibiotic course and cessation of fever. Conclusions: The severity, prognosis, and best treatment for spontaneous pneumothorax in COVID-19 infection, especially in children, remain nebulous. It is recommended that conservative treatment be performed if the patient has stable vital signs and no severe respiratory failure. However, this requires more detailed clinical evaluations.

Antepartum vaginal bleeding: characteristics associated with delivery within seven days

Objective: To identify maternal and/or fetal characteristics associated with delivery within seven days for patients who present with vaginal bleeding in the antepartum period. Methods: This is a retrospective chart review performed at a community-academic tertiary care center. Three hundred and twenty-two consecutive charts associated with admission for vaginal bleeding during pregnancy between January 2015 and May 2020 were reviewed. One hundred and twenty-six women were included based on singleton gestation, gestational age 24 0/7 − 36 6/7 weeks, self-limited vaginal bleeding, vital sign stability (blood pressure >100/60 mmHg, heart rate >60 beats per minute, respiratory rate <20 breaths per minute), absence of signs of labor, no known placenta previa/accreta, recent vaginal intercourse, or trauma. Patient demographic and clinical characteristics were compared using Fisher’s exact and two-sample t-tests tests when appropriate. Univariate and multivariate logistic regression models were fitted to predict delivery within 7 days. Results: Thirty-four percent of women who presented with light vaginal bleeding delivered within seven days, with a mean of 2.6 days (n = 44/126). Patients without evidence of labor but with sterile vaginal exam (SVE) >2 cm on admission were 14 times more likely to deliver within 7 days than SVE ≤ 2 cm (AOR 14.49, 95% CI 3.33–63.03); however, 35.2% of women with SVE ≤ 2 cm still delivered in this timeframe (n = 12/34). Of the 59 patients who had cervical lengths (CL) performed, those with CL ≤2.5 cm were 4.22 times more likely to deliver within 7 days (OR 4.22, 95% CI 1.10–16.20). Seventy-eight percent of the patients who had CL >2.5 cm and SVE 0–1 cm went on to deliver >14 days from their initial bleeds (n = 18/23). Conclusion: Patients who present with self-limited vaginal bleeding and SVE > 2 cm should be admitted for antenatal steroids. Prolonged inpatient observation beyond the typical steroid window of 48–72 h should be dependent on the individual patient. Given that CL ≤2.5 cm and regular contractions are known risk factors for preterm delivery, these characteristics alone may also warrant extended inpatient observation, though even in conjunction with vaginal bleeding, neither was a significant predictor for delivery in our study. In contrast, the majority of patients with vaginal bleeding and SVE <2 cm delivered >14 days after their initial bleeds and are likely eligible for shorter periods of observation.

PILL-INDUCED PNEUMONITIS PRECIPITATING GROSS HEMOPTYSIS BY ASPIRATED ANTICOAGULANT MEDICATION

TOPIC: Signs and Symptoms of Chest Diseases TYPE: Medical Student/Resident Case Reports INTRODUCTION: Pill pneumonitis (PP) is described as pulmonary inflammation and fibrosis secondary to the aspiration of pills. Those having dysphagia are at the highest risk for aspiration include neurologic impairment, anatomic deformity, and oropharyngeal dysfunction. The epidemiology of this condition is ill-defined to date given the scarcity of its diagnosis. Herein, we present a unique case of pill pneumonitis secondary to anticoagulant aspiration leading to gross hemoptysis. CASE PRESENTATION: A 26-year-old male, with a 2-year remote history of MVA complicated by right upper extremity DVT on Rivaroxaban, presented with a two-day history of gross hemoptysis with concurrent cough and dyspnea. PMH is otherwise unremarkable. The patient recalled choking a few days prior on his medications. Upon presentation, he had stable vital signs and a physical exam remarkable for mild left-sided rales.Laboratory workup demonstrated no leukocytosis and no significant change in hemoglobin. CT angiogram demonstrated peribronchial patchy consolidation with scattered ground-glass opacities; With reactive mediastinal and hilar lymphadenopathy. The patient was admitted for evaluation of new-onset hemoptysis and a subsequent bronchoscopy discerned diffuse patchy erythematous friable mucosa with foreign body particulates, most notably in the left mainstem bronchus. Otherwise, all accompanying testing was unyielding included infectious and autoimmune panels and tissue biopsies. The patient's Rivaroxaban was discontinued and the Ultrasound of the upper extremity showed no evidence of DVT. He received a course of steroids and antibiotics. The patient's gross hemoptysis resolved by the second day of hospitalization. DISCUSSION: PP is a serious complication to FBA and the acute onset of cough, wheezing, and dyspnea should raise suspicion in patients without other suggestive causes. These include pneumonia, congestive heart failure, or trauma. This case is noteworthy due to the patient's aspiration of an anticoagulant leading to an acute onset of pill pneumonitis with significant gross hemoptysis. A high degree of suspicion is needed to initiate early and aggressive diagnostic and interventional treatment, and the threshold of suspicion should be lowered in patients with a greater risk of aspiration. Our patent did not have risk factors for dysphagia, however, unnecessary use of anticoagulant therapy led to the acute progression of this patient's clinical presentation. Furthermore, management of pill pneumonitis is based on early and aggressive bronchoalveolar lavage and foreign body removal, which has shown to reduce disease progression and reverse inflammatory changes. CONCLUSIONS: This case describes a novel cause of PP, as no previous case describes aspiration of anticoagulant medication and emphasizes the importance of early diagnosis and proper anticoagulant use as a means of preventing unforeseen complications. REFERENCE #1: Hill, S. N., Main, A. N., & Fuggle, W. J. (1988). Covert inhalation of tablet causing fatal pneumonia. Postgraduate Medical Journal, 64(747), 66-67. doi:10.1136/pgmj.64.747.66 REFERENCE #2: Hu, X., Lee, J. S., Pianosi, P. T., & Ryu, J. H. (2015). Aspiration-related pulmonary syndromes. Chest, 147(3), 815-823. doi:10.1378/chest.14-1049 REFERENCE #3: Lee, P., Culver, D. A., Farver, C., & Mehta, A. C. (2002). Syndrome of iron pill aspiration. Chest, 121(4), 1355-1357. doi:10.1378/chest.121.4.1355 DISCLOSURES: No relevant relationships by Connor Kerndt, source=Web Response no disclosure on file for Shahid Mohammed; No relevant relationships by Mitchelle Zolotarevsky, source=Web Response

REFRACTORY THROMBOTIC THROMBOCYTOPENIC PURPURA DUE TO COVID-19

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Thrombotic Thrombocytopenic Purpura (TTP) is a hematologic emergency with a mortality of 90% if left untreated. Its is formerly characterized by a pentad of fever, thrombocytopenia, microangiopathic hemolytic anemia (MAHA), acute kidney injury (AKI), and neurologic deficits. These were classic before the routine use of therapeutic plasma exchange (PEX) because the majority of patients developed progressive thrombotic microangiopathy(TMA) and died from untreated disease. There are multiple etiologies associated with TTP and among those rarely reported is COVID-19. SARS-CoV-2 can result in the production of platelet-rich microthrombi and decrease the level of ADAMTS13. This can precipitate TMA and rarely result in TTP. CASE PRESENTATION: A 44-year-old African-American Female with no medical history presented to our facility complaining of vomiting and diarrhea associated with bleeding gums and easy bruising. On presentation, she was calm with stable vital signs. On physical exam, she had scleral icterus and conjunctival pallor associated with petechial rash and localized ecchymosis. Initial labs were remarkable for anemia(8.6g/dL), severe thrombocytopenia(3x103/µL), AKI(creatinine 1.70mg/dL), elevated lactate-dehydrogenase(1297Units/L), and high D-dimer(636ng/mLDDU). Hemolysis workup revealed MAHA and schistocytes were confirmed on blood smear. The PCR for COVID-19 was positive. All stool studies and other workup was unremarkable. Her PLASMIC score was 6 indicating high risk for severe ADAMTS13 deficiency, and therefore she was immediately admitted to the ICU and started on steroids, rituximab, and PEX. After 5-days of PEX, her platelet count improved to 199x103/µL and was deemed responsive to initial therapy. The following day the platelet count dropped to 8x103/µL and the patient was restarted on PEX. She failed to improve despite appropriate therapy and the disease was deemed to be refractory. A multidisciplinary decision was made to initiate Caplacizumab. She completed a total of 17 PEX sessions and significant improvement in her clinical course was achieved. She was eventually discharged home in stable condition on a tapered course of steroids. DISCUSSION: When ADAMTS13 is deficient, von Willebrand factor multimers accumulate and increase platelet aggregation causing TTP. Since its activity testing has a prolonged turnaround time, the PLASMIC score is validated to identify patients at risk for severe ADAMTS13 deficiency and facilitate timely management. Our patient ADAMTS13 activity was 2.2% correlating with a severe deficiency. PEX is associated with a significant decline in mortality as it replaces the deficient ADAMTS13 and removes the inhibitory autoantibodies from the circulatory system. CONCLUSIONS: TTP is a hematologic emergency that requires prompt therapy. It's important to include COVID-19 as a potential etiology and to explore other therapeutic approaches for a refractory TTP. REFERENCE #1: Sayani, F. A., & Abrams, C. S. (2015). How I treat refractory thrombotic thrombocytopenic purpura. Blood, 125(25), 3860–3867 REFERENCE #2: Bendapudi PK, Hurwitz S, Fry A, et al. Derivation and external validation of the PLASMIC score for rapid assessment of adults with thrombotic microangiopathies: a cohort study. Lancet Haematol 2017; 4:e157. REFERENCE #3: Sweeney, J. M., Barouqa, M., Krause, G. J., Gonzalez-Lugo, J. D., Rahman, S., & Gil, M. R. (2021). Low ADAMTS13 Activity Correlates with Increased Mortality in COVID-19 Patients. TH open : companion journal to thrombosis and haemostasis, 5(1), e89–e103 DISCLOSURES: No relevant relationships by Joel Brooks, source=Web Response No relevant relationships by Ruben Cabrera, source=Web Response No relevant relationships by Jorge Cruz, source=Web Response No relevant relationships by Nathalie De paz, source=Web Response No relevant relationships by Tarig Elhakim, source=Web Response No relevant relationships by Jose Gascon, source=Web Response No relevant relationships by Daniel Gonzalez, source=Web Response No relevant relationships by Carlos Guida, source=Web Response No relevant relationships by Robert Hernandez, source=Web Response No relevant relationships by Ilde Lee, source=Web Response No relevant relationships by Daniel Zapata, source=Web Response