A 56-Year-Old, Otherwise Healthy Woman Presenting With Light-headedness and Progressive Shortness of Breath.

A 56-year-old white woman was referred to the pulmonary clinic for evaluation of unexplained shortness of breath. She enjoyed good health until 3 months prior to this visit when she reported experiencing recurrent episodes of shortness of breath and oppressive retrosternal chest discomfort with radiation to the neck. Episodes lasting 5 to 10 min often occurred at rest and were inconsistently related to physical activity. These symptoms became progressively worse and were often associated with light-headedness and presyncope. Her past medical history was uneventful apart from a prior diagnosis of breast cysts and suspected prolactinoma. Her symptoms escalated to such a level that she was forced to seek urgent medical attention at our institutional ED on two separate occasions in the preceding weeks. These visits precipitated a number of investigations and, eventually, a referral to the pulmonary clinic.

General medicine and surgery for dental practitioners: part 3. Management of specific medical emergencies in dental practice.

In this paper, the actions needed to manage specific medical emergencies are discussed. Each emergency requires a correct diagnosis to be made for effective and safe management. Contemporary management in dental practice avoids the intravenous route when drugs are required to treat the emergency.

Medical emergency management among Iranian dentists.

AIMS: More than 18,000 patients need medical emergencies management in dental offices in Iran annually. The present study investigates medical emergencies management among Iranian dentists. MATERIALS AND METHODS: From the list of the cell phone numbers of the dentists practicing in the city of Tehran, 210 dentists were selected randomly. A self-administered questionnaire was used as the data collection instrument. The questionnaire requested information on personal and professional characteristics of the dentists, as well as their knowledge and self-reported practice in the field of medical emergency management, and availability of required drugs and equipments to manage medical emergencies in their offices. RESULTS: Totally, 177 dentists (84%) completed the questionnaire. Less than 60% of the participants were knowledgeable about characteristics of hypoglycemic patient, chest pain with cardiac origin, and true cardiopulmonary resuscitation (CPR) practice. Regarding practice, less than one quarter of the respondents acquired acceptable scores. In regression models, higher practice scores were significantly associated with higher knowledge scores (p < 0.001). CONCLUSION: The results call for a need to further education on the subject for dentists. Continuing education and changing dental curriculum in the various forms seems to be useful in enhancement of the self-reported knowledge and practice of dentists. CLINICAL SIGNIFICANCE: To successful control of medical emergencies in the dental office, dentists must be prepared to recognize and manage a variety of such conditions. In addition to dentist's knowledge and skill, availability of necessary equipments and trained staff is also of critical importance.

[Device diagnosis and combined treatment of hyperventilation syndrome].

Hyperventilation syndrome is a separate disease and a symptom of other psychosomatic diseases. A variant of device diagnosis of the disease is proposed--integral rheoplethysmography by M. I. Tischenko and cardiointervalography by R. M. Baevsky. Hyper- and asthenic courses of the disease are described, the pathological psychoemotional pattern is recognized. The proposed treatment combines physiohemotherapy (laser treatment) and pharmacotherapy.

Traumatic brain injury: review of current management strategies.

Head injury is a common condition with a high morbidity and mortality. Serious intracranial haematomas require early recognition and evacuation to maximise chances of independent outcomes. Recent organisational changes have promoted the development of trauma units and major trauma centres where patients can go through triage and be managed in an appropriate environment, and the development of management pathways in intensive treatment units has resulted in improvements in the outcome of traumatic brain injuries. Evidence for the treatment of cerebral perfusion pressure, and management of hyperventilation, osmotherapy, tracheostomy, and leakage of cerebrospinal fluid (CSF) has accumulated during the last decade and is important in the management of patients in all clinical settings. Since head injury is commonly associated with maxillofacial injuries, this review will be relevant to all who deal with this aspect of trauma.

A case of pulmonary AV fistula. Possible involvement of adenosine in hyperventilation.

A 21-yr-old man with multiple pulmonary AV fistulae presented with moderate hypoxemia with chronic hyperventilation, which continued even after sufficient oxygenation by 100% O2 inhalation. The infusion of aminophylline, an adenosine receptor blocker, not only increased PaCO2 from 35 to 39 mm Hg but also depressed the magnitude of hypoxic ventilatory response (HVR). After a surgical removal of the major fistulae, PaCO2 increased to 42 mm Hg. At this time, aminophylline increased the resting ventilation and slightly augmented the HVR value, which was opposite to the findings of preoperation. Dipyridamole, which potentiates endogenous adenosine by inhibiting its cellular uptake, increased the magnitude of HVR both before and after the operation. We propose that the hyperventilation observed in this case can at least in part be attributed to the ventilatory stimulation by endogenous adenosine, which presumably passed through the fistulae without being metabolized in the pulmonary circulation.

Pulmonary embolism in children.

Pulmonary embolism is an uncommon diagnosis in the pediatric patient, often discovered on autopsy. The mortality rate of untreated pulmonary embolism approaches 30%, and the best way to prevent death is by swift diagnosis and initiation of therapy. This article reviews the risk factors, clinical presentation, pathophysiology, diagnostic modalities, and treatment of pulmonary embolism in children.

Breathing retraining: effect on anxiety and depression scores in behavioural breathlessness.

Thirty-six patients underwent assessment of behavioural breathlessness which included monitoring of breathing patterns and end tidal CO2 concentration and completion of questionnaires relating to hyperventilation (HV), anxiety and depression. Twenty-two patients had a positive assessment and underwent breathing retraining. Assessments were repeated immediately after re-training and 2 months later. Ten of the patients (Group A) had behavioural breathlessness either as the primary problem or secondary to an established clinical condition, and twelve (Group B) in association with chronic fatigue. Before re-training, resting end-tidal PCO2 was significantly lower in Group A than Group B (p < 0.05), but there was no significant difference in mean scores for HV-related symptoms, anxiety or depression. Following breathing retraining, both groups showed improvements in breathing patterns, end tidal CO2 levels and scores for HV-related symptoms which were sustained. In Group A the mean score for anxiety decreased (p < 0.01) and the score for depression was significantly lower than in Group B (p < 0.05). Although mean scores for anxiety and depression in Group B did not change significantly, some individuals in the group did show sustained improvement. There was no improvement in symptoms associated with chronic fatigue in Group B. In behavioural breathlessness, breathing retraining is of benefit, not only in restoring more normal patterns of breathing but also in reducing anxiety, particularly in patients without the complication of chronic fatigue.

Urgent paralysis and intubation of trauma patients: is it safe?

Physicians, fearful of an increase in the incidence of intubation mishaps (IMs) and pulmonary complications (PUCs), have been reluctant to use paralysis and intubation (PI) outside the OR. This study examines the correlations between PI, IM, and PUC. Since 1987, we have used PI when complex injury or combative behavior warranted. From January through December 1989, 851 patients meeting major trauma triage guidelines were evaluated. The medical records of 231 patients (27%) who underwent PI within 8 hours of admission were reviewed; 27 patients were eliminated because of incomplete records. The indications for PI were emergency surgery (131), airway control (30), combativeness (24), and hyperventilation (19). The location was the OR (121), ED (82), other (1). Presence or absence of IM was documented in 198 of 204 charts: Twenty-four IMs (12%) occurred--14 multiple attempts, seven aspirations, three esophageal intubations. Frequency of IM was not statistically related to PI location (Fisher's exact test), AIS, or ISS. In 194 of 204 patients who survived at least 24 hours, there were 15 PUCs (8%): eight pneumonia, five persistent infiltrates, two severe atelectases. No deaths were related to IM or PUC. There was no statistical relationship between IM and PUC (Fisher's exact test). However, patients with PUCs had a significantly higher AIS-chest score (2.9 +/- 1.7 vs. 0.9 +/- 1.5) (p < 0.0005, Student's t test) and ISS (27.3 +/- 9.6 vs. 14.5 +/- 10.8) (p < 0.0005, Student's t test). In our hands, PI is associated with low morbidity, no mortality, and can be safely used to facilitate injury management or to control combative behavior.

Trauma de craneo / Head trauma

Existen muchos factores que modifican el flujo sanguíneo cerebral a través de cambios en la resistencia vascular cerebral y que a su vez inciden en el funcionamiento celular. Las lesiones que aparecen como consecuencia de un trauma de cráneo, pueden traducirse en aumento de la presión intracraneana y ésta en herniación o isquemia cerebral. La tomografía axial computarizada es el estudio de elección en las primeras 72 horas. Por su parte la radiografía de cráneo tiene un valor muy limitado. La resonancia magnética permite la determinación del metabolismo cerebral y los potenciales evocados tienen utilidad diagnóstica en los pacientes con trauma de cráneo. El uso de la hipertensión, manitol, furosemida son las formas terapéuticas de elección en el control de la presión intracraneana. En cambio los esteroides y los barbitúricos están cuestionados. Múltiples complicaciones se asocian al trauma de cráneo, entre ellas: las infecciones locales como meningitis, ventriculitis y abscesos; electrolíticas al síndrome de secreción inapropiada de hormona antidiurética y diabetes insípida; y por último, las complicaciones respiratorias son múltiples y puedden comprometer la disponibilidad de oxígeno a la célula cerebral

Hyperventilation syndrome: report of case.

Hyperventilation is a common response to anxiety or threatening situations. In certain individuals, it is a mechanism for producing alarming physiologic and metabolic changes. The changes as well as the causes and treatment have been described.

[Enlarge indications for controlled respiration (author's transl)]. / Erweiterte Indikation zur kontrollierten Beatmung.

Controlled respiration should have a place not only in cases of hypoventilation but also in the treatment of comatose and hyperventilating persons. Hyperventilation is liable severely to interfere with the blood supply to the brain, and this disturbance, in conjunction with the primary disease responsible for the comatose condition, such as hyperglycaemia, diabetes or cerebral trauma, may be a contributing factor to the lethal outcome. Controlled respiration helps towards regulation of the cerebral circulation and of the acid-base balance and provides improved conditions for normalization of the disturbed metabolism and thus greatly improves the prognosis of these cases.