EKG#1
EKG #2
EKG #3
EKG #4
EKG #5
EKG #6
EKG#1
Third Degree Heart Block
EKG#2
Hypertrophic Cardiomyopathy
EKG#3
Wolff Parkinson White
EKG#4
Arrhythmogenic Right Ventricular Dysplasia (ARVD)
EKG#5
Brugada
EKG#6
Prolonged QT
Vaping and Vaping Associated Lung Injury (VAPI)
Background
What is vaping?
The process of inhaling/exhaling aerosol (aka vapor) produced by an e-cigarette or other similar (handheld, and now commonly, portable) device.
These devices are thought to be “safe” by the general public because they do not produce tobacco smoke. Instead, they produce aerosolized vapor that contains harmful particles, which the public also mistakenly believes is just harmless water vapor (its not...).
Around since 2007ish when the e-cig first came out.
Now, there are a ton of vaping pens/devices (juul, zip, mods, insert cool name here, etc.)
Vape device consists of a mouthpiece, battery, pocket for e-liquid/juice, and a heating component
E-liquid contains propylene glycol or vegetable glycerin liquid with nicotine and other chemicals/flavorings (yes, even crème brule...)
Again, not tobacco, but don’t be fooled…
One juul pod/cartridge (~200 puffs) has the same amount of nicotine as 1 box of cigarettes.
Many people vape THC and synthetic drugs as well
Has led to 500+ illnesses and 8 deaths across the US
Possibly linked to contaminated THC based vape cartridges
Similar to other drugs, distributors (usually on the black market) are possibly cutting their product with other dangerous and cheaper substances
Specifically, vitamin e acetate, an oil that could cause lung inflammation if not heated up properly during vaping
Most recent development linked to two brothers/illegal cannabis vaping ring in Wisconsin. Check it out here.
If you have a suspected case, then please call the poison control center and/or call a tox consult depending on where you are working
per Dr. Harmouche, our awesome toxicologist (by the way, thanks for the useful info!), the poison control center can report to the DOH who can then decide to investigate/test samples.
the national toxicology registry is also collecting cases for research purposes.
*if you have a patient (especially young one) who has worsening respiratory symptoms, please be diligent and ask about a vaping history in the last 90 days. They may have the below condition, which can cause them to deteriorate quickly if unnoticed and untreated.
VAPI
Young patients (~20 YOs), but can affect any age group
~75% male
~80% of cases reported vaping with THC
~94% vaped within a week of symptom onset
100% have some sort of constitutional symptom
fever, chills, fatigue, weight loss
29% of victims have presented febrile
98% have respiratory symptoms
SOB, cough, chest pain, hemoptysis
URI symptoms not common (rhinorrhea, sneezing, congestion)
81% have GI symptoms
n/v/d, abdominal pain
CXR
Commonly shows BL infiltrates
Worsens quickly
CT chest
Should be obtained in suspected cases
Will show BL groung glass opacities (see below, very impressive)
May also see pleural effusions, pneumomediastinum, and tree-in-bud opacities
Labs
CBC may show leukocytosis
May show eisopnipholia
ESR and CRP likely to be elevated
RSV, flu, HIV testing if indicated
Consider legionella testing
Diagnosis of exclusion
And may not need a bronchoscopy if the rest of the work up (mainly infectious/malignancy) is negative, and other parts of history don’t provide more likely diagnosis/explanation for respiratory findings
Treatment
Antibiotics until PNA excluded
Steroids (1mg/kg/day)
May need intubation (30% of cases already)
Takes several days to recover
The unknown
Pathophysiology of it all unclear
Possibly lipoid pneumonia from bad ccannabis oil/liquid being vaped
Vitamin e, mentioned above, has been recently been used as aliquid carrier
This is harmful
OR different cases may have different pathophysiological processes going on
Again, unclear
Second Victim Syndrome (SVS)
Background
Medical errors are the third leading cause of death in the US
Poor outcomes can be due to a larger system failure or a human error
Examples include incorrect medication dosages, improper management, harm during a procedure, missed diagnoses, etc.
Second victim
Defined in 2000 by Albert Wu
In situations where medical errors are made or safety is compromised, the first victim is the patient and the second victim is the healthcare professional (EMT, nurse, physician) who can also be affected or traumatized by the event.
SVS
Aforementioned events can have a lasting impression on a provider
He/she tends to repeat the event over and over in his/her mind leading to emotional distress and scars
Immediate symptoms
Anxiety, guilt, shame, sadness, fear, anger
Can have sympathomimetic manifestations—tachycardic, elevated BP, etc
Later symptoms
Depression, loss of confidence, loss of job satisfaction, hypervigilance, poor decision making
Can develop PTSD like symptoms
Insomnia, flashbacks, SI, isolation
Identifying Second Victims
Symptoms and behavior can be similar to those who suffer from burn out
Different stages of SVS (see below)
Management
Support from colleagues is helpful
Provides a sense of shared understanding
M&Ms/patient safety conferences that are supportive instead of punitive
Culture change
Shift toward a “Just Culture”
Balancing accountability and support instead of perpetuating a blame/shame culture
TRUST mnemonic
Treatment that is Just
Respect
Understanding and compassion
Supportive care
Transparency and opportunity to contribute
