SESSION TITLE: Challenges in AsthmaSESSION TYPE: Rapid Fire Case ReportsPRESENTED ON: 10/18/2022 10:15 am - 11:10 amINTRODUCTION: Rhabdomyolysis in the setting of status asthmaticus is a rare but potentially fatal complication. The hallmark of rhabdomyolysis is an elevation in serum creatine phosphokinase (CPK) secondary to muscle necrosis, which may be categorized as: traumatic, nontraumatic exertional, and nontraumatic non-exertional.1 We report a case of a rhabdomyolysis in the setting of status asthmaticus, neuromuscular blockade, and steroid use.CASE PRESENTATION: A 21-year-old male with a history of asthma presented with respiratory distress, tachypnea, and tachycardia. Physical exam revealed diffuse bilateral wheezing and accessory muscle use. ABG revealed a pH of 7.11 and a PCO2 of 101.9 mmHg. Despite treatment with multiple nebulizers, systemic steroids, magnesium, and intramuscular epinephrine, he required tracheal intubation for acute hypercarbic respiratory failure due to status asthmaticus. He was sedated with fentanyl and midazolam. Due to ventilator dyssynchrony, continuous neuromuscular blockade with cisatracurium was initiated. High dose methylprednisolone and continuous albuterol nebulization was initiated in the ICU. On day 3 of admission, the patient was found to have a CPK level of 20,123 U/L suggestive of rhabdomyolysis. There was no evidence of trauma or compartment syndrome. Due to concern for medication induced rhabdomyolysis, cisatracurium was discontinued and methylprednisolone was rapidly tapered, and CPK levels subsequently decreased after peaking at 20,253 U/L. Intravenous fluids were continued to maintain hydration. He continued to clinically improve and was successfully extubated on the 10th day of admission and eventually discharged with pulmonary follow-up.DISCUSSION: Rhabdomyolysis in the setting of status asthmaticus has several possible etiologies. Status asthmaticus leading to hypercapnia results in a respiratory acidosis while also preventing carbon dioxide and oxygen exchange within muscle tissue causing muscular hypoxia and necrosis. This may be further complicated by increased exertion of the respiratory muscles. Rhabdomyolysis resulting from the combination of corticosteroids and neuromuscular blocking agents is rare. Although steroid use may lead to glucocorticoid myopathy, it is uncommon to have elevations in CPK.2 However, when steroids are concomitantly used with neuromuscular blocking agents, patients are at increased risk of developing critical illness myopathy and elevations in CPK.3 The patient's subsequent decline in CPK after cisatracurium was discontinued and systemic steroids were significantly reduced leads us to believe that the combination of these medications was the likely precipitant to this patient's rhabdomyolysis.CONCLUSIONS: Our case highlights the importance of recognizing the development of rhabdomyolysis in patients presenting with status asthmaticus, especially when receiving a combination of neuromuscular blockade and high dose systemic steroids.Reference #1: Shefner, J. (2021). Causes of Rhabdomyolysis. Dashe, J. (Ed.). UpToDate. Available from: https://www.uptodate.com/contents/causes-of-rhabdomyolysis?search=rhabdomyolysis&topicRef=5169&source=see_link#H31734829Reference #2: Qiao, H., Cheng, H., Liu, L. et al. Potential factors involved in the causation of rhabdomyolysis following status asthmaticus. Allergy Asthma Clin Immunol 12, 43 (2016). https://doi.org/10.1186/s13223-016-0149-6Reference #3: Lacomis, D. (2021). Neuromuscular weakness related to critical illness. Dashe, J. (Ed.). UpToDate. Available from: https://www.uptodate.com/contents/neuromuscular-weakness-related-to-critical-illness?sectionName=Prolonged%20neuromuscular%20junction%20blockade&search=rhabdomyolysis&topicRef=1590&anchor=H2863159186&source=see_link#H2863159186DISCLOSURES: No relevant relationships by Vincent CourantNo relevant relationships by Satwant GrewalNo relevant relationships by Arpanjeet KaurNo relevant relationships by Sara LubyNo relevant relationships by Pavan PakaNo relevant relationships by James SaloniaNo relevant relationships by Tal ShachiNo relevant relationships by Patrick Tobin-Schnittger SESSION TITLE: Challenges in Asthma SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 10:15 am - 11:10 am INTRODUCTION: Rhabdomyolysis in the setting of status asthmaticus is a rare but potentially fatal complication. The hallmark of rhabdomyolysis is an elevation in serum creatine phosphokinase (CPK) secondary to muscle necrosis, which may be categorized as: traumatic, nontraumatic exertional, and nontraumatic non-exertional.1 We report a case of a rhabdomyolysis in the setting of status asthmaticus, neuromuscular blockade, and steroid use. CASE PRESENTATION: A 21-year-old male with a history of asthma presented with respiratory distress, tachypnea, and tachycardia. Physical exam revealed diffuse bilateral wheezing and accessory muscle use. ABG revealed a pH of 7.11 and a PCO2 of 101.9 mmHg. Despite treatment with multiple nebulizers, systemic steroids, magnesium, and intramuscular epinephrine, he required tracheal intubation for acute hypercarbic respiratory failure due to status asthmaticus. He was sedated with fentanyl and midazolam. Due to ventilator dyssynchrony, continuous neuromuscular blockade with cisatracurium was initiated. High dose methylprednisolone and continuous albuterol nebulization was initiated in the ICU. On day 3 of admission, the patient was found to have a CPK level of 20,123 U/L suggestive of rhabdomyolysis. There was no evidence of trauma or compartment syndrome. Due to concern for medication induced rhabdomyolysis, cisatracurium was discontinued and methylprednisolone was rapidly tapered, and CPK levels subsequently decreased after peaking at 20,253 U/L. Intravenous fluids were continued to maintain hydration. He continued to clinically improve and was successfully extubated on the 10th day of admission and eventually discharged with pulmonary follow-up. DISCUSSION: Rhabdomyolysis in the setting of status asthmaticus has several possible etiologies. Status asthmaticus leading to hypercapnia results in a respiratory acidosis while also preventing carbon dioxide and oxygen exchange within muscle tissue causing muscular hypoxia and necrosis. This may be further complicated by increased exertion of the respiratory muscles. Rhabdomyolysis resulting from the combination of corticosteroids and neuromuscular blocking agents is rare. Although steroid use may lead to glucocorticoid myopathy, it is uncommon to have elevations in CPK.2 However, when steroids are concomitantly used with neuromuscular blocking agents, patients are at increased risk of developing critical illness myopathy and elevations in CPK.3 The patient's subsequent decline in CPK after cisatracurium was discontinued and systemic steroids were significantly reduced leads us to believe that the combination of these medications was the likely precipitant to this patient's rhabdomyolysis. CONCLUSIONS: Our case highlights the importance of recognizing the development of rhabdomyolysis in patients presenting with status asthmaticus, especially when receiving a combination of neuromuscular blockade and high dose systemic steroids. Reference #1: Shefner, J. (2021). Causes of Rhabdomyolysis. Dashe, J. (Ed.). UpToDate. Available from: https://www.uptodate.com/contents/causes-of-rhabdomyolysis?search=rhabdomyolysis&topicRef=5169&source=see_link#H31734829 Reference #2: Qiao, H., Cheng, H., Liu, L. et al. Potential factors involved in the causation of rhabdomyolysis following status asthmaticus. Allergy Asthma Clin Immunol 12, 43 (2016). https://doi.org/10.1186/s13223-016-0149-6 Reference #3: Lacomis, D. (2021). Neuromuscular weakness related to critical illness. Dashe, J. (Ed.). UpToDate. Available from: https://www.uptodate.com/contents/neuromuscular-weakness-related-to-critical-illness?sectionName=Prolonged%20neuromuscular%20junction%20blockade&search=rhabdomyolysis&topicRef=1590&anchor=H2863159186&source=see_link#H2863159186 DISCLOSURES: No relevant relationships by Vincent Courant No relevant relationships by Satwant Grewal No relevant relationships by Arpanjeet Kaur No relevant relationships by Sara Luby No relevant relationships by Pavan Paka No relevant relationships by James Salonia No relevant relationships by Tal Shachi No relevant relationships by Patrick Tobin-Schnittger

SESSION TITLE: Practice Management Beyond Coding and Staffing SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/17/2022 12:15 pm - 1:15 pm PURPOSE: Early identification and risk stratification of venous thromboembolism (VTE) can be lifesaving. Point-of-care ultrasound (POCUS) is an increasingly accessible tool allowing for earlier identification of VTE and treatment. POCUS has typically been taught in small groups with low instructor to participant ratios, making it time consuming and challenging to coordinate training for large numbers. It is our hope that virtual POCUS training may alleviate these shortcomings. We aim to show that short virtual didactic sessions, focused on deep vein thrombosis (DVT) and right ventricular (RV) size assessment can quickly improve competency amongst large groups of internal medicine house staff, and in the future reduce delays in diagnosis. METHODS: Internal medicine housestaff at an academic teaching hospital completed an anonymous and voluntary REDCap survey before and after a one-hour remotely delivered didactic POCUS session focused on DVT and RV size. The pre- and post-test surveys were identical, consisting of multiple choice and closed-ended questions using Likert scales to ascertain participants’ confidence levels. RESULTS: Of the 62 participating housestaff (26 interns, 36 residents), 54 completed the pre-test (18 interns, 36 residents), and 41 (11 interns, 30 residents) completed the post-test (76.5% response rate overall). 37% (23/62) had formal training in ultrasound. Both interns and residents reported weekly use of POCUS. SPSS software was used for paired t-test analysis of pre- and post-test results. There was a significant increase (P=0.003) in the percent of correct responses post lecture amongst all participants (pre-test M 0.47, SD ± 0.17; post-test M 0.84, SD ± 0.09), amongst interns (P<0.001; pre-test M 0.40, SD ± 0.19; post-test M 0.86, SD ± 0.14), and amongst residents (P=0.009; pre-test M 0.50, SD ± 0.20; post-test M 0.79, SD ± 0.10). There was a significant increase in the percent of correct responses post lecture amongst participants with formal US training (P=0.007; pre-test M 0.56, SD ± 0.19; post-test M 0.84, SD ± 0.09) and amongst participants without formal US training (P=0.002; pre-test M 0.39, SD ± 0.17; post-test M 0.77, SD ± 0.11). CONCLUSIONS: All groups studied demonstrated increased competency after a short didactic session. Need for in-person small group learning, a barrier to POCUS training en masse, may be overcome with this new approach. Study limitations include small sample size and discrepancies in group numbers pre- and post-test. As POCUS proficiency spreads amongst internal medicine housestaff, in part by these virtual didactic sessions, delays to timely VTE diagnosis and thereby treatment may be reduced. CLINICAL IMPLICATIONS: Short focused didactic sessions appear promising at increasing bedside VTE identification amongst large groups learning remotely and may be useful at improving competency in other POCUS topics. DISCLOSURES: No relevant relationships by Yoni Balboul No relevant relationships by Adam Rothman No relevant relationships by Patrick Tobin-Schnittger

When endoscopy is performed for acute GI bleeding, therapeutic endoscopic procedures are infrequently required (only 6% of cases). We sought to determine the natural history of GI hemorrhage in patients who have undergone therapeutic endoscopy. We queried our hospital database for inpatients with acute GI bleeding who underwent therapeutic endoscopy between 2015 and 2017. The primary endpoints were recurrence of bleeding and the subsequent need for repeated endoscopic interventions, angioembolization, or surgery. Demographic information was collected. We reviewed 205 hospitalized patients: mean age was 70 years, 58 per cent were male, and mean hemoglobin was 9 g/dL. Patients had medical conditions predisposing them to bleeding in 59 per cent and history of previous GI bleeding in 37 per cent of cases. Sixty per cent were on antiplatelet/ anticoagulation medications, and 10 per cent were receiving nonsteroidal anti-inflammatory medications. Blood transfusions were given to 78 per cent of patients, with an average of 2.3 units of packed red blood cells transfused per patient before intervention. Recurrence of hemorrhage after therapeutic endoscopy was seen in 9 per cent of patients. Only 2 per cent underwent a second therapeutic endoscopic procedure, and 5 per cent had surgery or angioembolization (half of these patients then had a further recurrence of bleeding). In total, seven patients died (3%). Recurrence of GI bleeding after therapeutic endoscopies is uncommon (9%). Surgery and angioembolization are not commonly necessary, but when used are only successful in 50 per cent of cases.

Background: Referral letters sent from primary to secondary or tertiary care are a crucial element in the continuity of patient information transfer. Internationally, the need for improvement in this area has been recognised. This aim of this study is to review the current literature pertaining to interventions that are designed to improve referral letter quality. Methods: A search strategy designed following a Problem, Intervention, Comparator, Outcome model was used to explore the PubMed and EMBASE databases for relevant literature. Inclusion and exclusion criteria were established and bibliographies were screened for relevant resources. Results: A total of 18 publications were included in this study. Four types of interventions were described: electronic referrals were shown to have several advantages over paper referrals but were also found to impose new barriers; peer feedback increases letter quality and can decrease 'inappropriate referrals' by up to 50%; templates increase documentation and awareness of risk factors; mixed interventions combining different intervention types provide tangible improvements in content and appropriateness. Conclusion: Several methodological considerations were identified in the studies reviewed but our analysis demonstrates that a combination of interventions, introduced as part of a joint package and involving peer feedback can improve.

Background: Most of the primary autonomic disorders are chronic in nature, with symptoms often initiating in an insidious fashion.However, in acute autonomic neuropathies, the onset can be dramatic with presentation as a generalized dysautonomia.We present a case where the initial presentation in retrospect was small bowel atony.A fit, healthy, active 75 year old patient presented initially to the surgical service with an acute abdomen.A plain abdominal film showed small bowel dilatation consistent with small bowel obstruction.There were no obvious pathogenic basis for this.The patient

Background Referral letters sent from primary to secondary or tertiary care are a crucial element in the continuity of patient information transfer. Internationally, the need for improvement in this area has been recognised. This aim of this study is to review the current literature pertaining to interventions that are designed to improve referral letter quality. Methods A search strategy designed following a Problem, Intervention, Comparator, Outcome model was used to explore the PubMed and EMBASE databases for relevant literature. Inclusion and exclusion criteria were established and bibliographies were screened for relevant resources. Results A total of 18 publications were included in this study. Four types of interventions were described: electronic referrals were shown to have several advantages over paper referrals but were also found to impose new barriers; peer feedback increases letter quality and can decrease ‘inappropriate referrals’ by up to 50%; templates increase documentation and awareness of risk factors; mixed interventions combining different intervention types provide tangible improvements in content and appropriateness. Conclusion Several methodological considerations were identified in the studies reviewed but our analysis demonstrates that a combination of interventions, introduced as part of a joint package and involving peer feedback can improve.