A case of a critically injured diver with multiorgan failure and severe pulmonary overinflation syndrome in a resource-limited setting.

A diver practicing controlled emergency ascent training on the island of Guam suffered bilateral pneumothorax, pneumomediastinum, coronary arterial gas embolism, and developed multiple organ dysfunction syndrome. Due to limitations of available resources he was medically managed in the intensive care unit until he could be transferred to University of California San Diego for definitive management. We provide an account of our management of the patient, the pathophysiology of injury as well as a review of the safety of recreational diving skills training, current standards of practice and potential pitfalls when considering proper management of a critically injured diver.

Dissection flap masquerading as double aortic valve: an acquired complication.

Aortic dissection usually presents as an acute emergency and less commonly presents as chronic dissection. Two-dimensional and transoesophageal echocardiographic features of aortic dissection generally show dissection flap, dilated aorta and aortic regurgitation. We report a very unusual and extremely rare case of a 40-year-old female patient with chronic aortic dissection presenting as functional double aortic valve.

Assessment of Volume Status and Appropriate Fluid Replenishment in the Setting of Nephrotic Syndrome.

BACKGROUND: When the permeability of the glomerular filtration barrier increases, leading to proteinuria, nephrotic syndrome (NS) occurs. First episodes or relapses of NS can be concurrent with acute gastroenteritis (AGE) infections. This condition can cause further deterioration of the hypovolemic state, as intravascular water is lost through both AGE-related vomiting/diarrhea and NS-related fluid shifting into the interstitium. In this case report, we wish to raise the issues about the difficult management of children presenting with both NS and AGE. CASE REPORT: We report two cases characterized by concurrence of NS and AGE. Despite our intervention, case #1 required dialysis, whereas in the case #2 we restored the patient's liquid homeostasis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: No guidelines helping general physicians in the management of children presenting with both NS and AGE are available in the literature. However, it is common for these patients to seek the first line of treatment at emergency departments. In these patients, restoring the liquid homeostasis is a challenge, but some key points can help the physicians with first-line management: 1) carefully evaluate the signs of hypovolemia (edematous state can be misleading); 2) bear in mind that-in hypovolemic, severely hypoalbuminemic (serum albumin levels < 2 g/dL) NS children-initial fluid administration should be followed by a 20% albumin infusion if oligoanuria persists; intravenous 4.5% albumin may be a valid alternative as a first-line therapy instead of crystalloid and 20% albumin; and 3) pay attention when using furosemide; it should only be administered after albumin infusion or after hypovolemia correction.

Assessment of prevalence and pathological response to orthostatic provocation in patients with multiple sclerosis.

OBJECTIVE: The aim of this study was to determine the prevalence of pathologic response to orthostatic challenge in patients with relapsing remitting multiple sclerosis (RRMS) and the difference of the response in patients in relapse and remission. PATIENTS AND METHODS: We included 112 RRMS patients; group 1 included 53 patients in a relapse and group 2, 59 patients in remission. The head up tilt table test was used to provoke an orthostatic reaction. RESULTS: 71 (63%) patients (60.4% and 66% of relapse and remission subjects respectively) had a pathological response to orthostatic provocation. Syncope was found in 9 (17%) patients in group 1 compared to 22 (37.3%) in group 2 (p=0.014). Postural orthostatic tachycardia syndrome (POTS) was found in 17 (32%) patients in group 1 compared to 4 (6.8%) in group 2 (p=0.001). There was a significantly negative correlation between the Expanded Disability Status Scale (EDSS) and POTS (-0.201; p=0.034) and a positive correlation between the EDSS and syncope (0.190; p=0.044). CONCLUSION: The prevalence of distinct types of orthostatic autonomic dysfunction in different phases of RRMS seems to be in direct correlation with the EDSS. Furthermore, certain autonomic dysfunctions of orthostasis, more specifically syncope and POTS, tend to be increased in remission and relapse respectively.

Perioperative hemodynamics in free flap breast reconstruction: incidence, predictors, and management of tachycardia.

BACKGROUND: The physiologic and hemodynamic changes occurring after abdominally based free flap breast reconstruction have not been well described. In this study, we examine perioperative circulatory and physiologic changes in an effort to identify risk factors and complications associated with postoperative tachycardia. METHODS: A retrospective review of all immediate abdominal free flaps performed by the senior author (J.M.S.) between 2005 and 2009 was performed. End points of interest included patient demographics, comorbidities, preoperative and postoperative heart rate (HR), mean arterial pressure, operating room fluid, pain score, urine output, and preoperative and postoperative hemoglobin. We define tachycardia as a sustained HR of 100 beats per minute or greater. Tachycardic patients were compared to patients with normal sinus rhythm. RESULTS: In 237 patients, 371 flaps were identified (103 unilateral and 268 bilateral). There was a 36% overall incidence of tachycardia, with a 20% and 47% incidence in unilateral and bilateral flaps, respectively (P<0.0001). Preoperative HR, operating room fluid, estimated blood loss, and bilateral reconstruction predicted postoperative tachycardia. Regression analysis revealed that preoperative HR and internal mammary artery predicted tachycardia in unilateral flaps, whereas preoperative HR, operative time, and estimated blood loss predicted tachycardia in bilateral flaps. We found higher rates of wound healing complications and delayed venous thrombosis in tachycardic patients. CONCLUSIONS: Patient and perioperative factors associated with tachycardia include preoperative HR, bilateral reconstruction, recipient artery choice, and operative time. These results suggest that postoperative tachycardia may be associated with perfusion-related complications such as delayed wound healing and thrombosis. Preoperative assessment should include an evaluation of patient risk factors for postoperative tachycardia.

[Risk management in brachial plexus block].

Peripheral nerve block has many advantages in surgical anesthesia with or without general anesthesia; postoperative analgesia, faster postoperative rehabilitation, and chronic pain management. However, serious adverse complications after peripheral nerve block can happen. Therefore, anesthetists should obtain full informed consent for possible complications, and require scrupulous attention to this procedure. This review focuses on complications of brachial plexus block because it is the most popular peripheral nerve block.

Crisis management during anaesthesia: tachycardia.

BACKGROUND: Tachycardia during anaesthesia is a common event. In most cases the cause is easily identified and the problem promptly resolved. However, in some the cause may be rare or obscure. Under such circumstances, attempting to initiate appropriate supportive therapy and to consider a large differential diagnosis in a comprehensive manner may lead to delays which can put a patient at risk. OBJECTIVES: To examine the role of a previously described core algorithm "COVER ABCD-A SWIFT CHECK", supplemented by a specific sub-algorithm for tachycardia, in the management of tachycardia developing in association with anaesthesia. METHODS: The potential performance of this structured approach for each of the relevant incidents among the first 4000 reported to the Australian Incident Monitoring Study (AIMS) was compared with the actual management as reported by the anaesthetists involved. RESULTS: There were 145 causative events identified in 123 reports of tachycardia during anaesthesia which were extracted and studied from the first 4000 incidents reported to AIMS. Subgroups were identified based on blood pressure at the time of presentation. Of the 145 causes, tachycardia was associated with hypotension (33%), normotension (27%), hypertension (26%), and cardiac arrest (17%). For simplicity it is recommended that other cardiovascular sub-algorithms are followed when the blood pressure is also abnormal. This includes cardiac arrest and hypotension. In hypotensive states the tachycardia sub-algorithm should be followed until the cardiac rhythm is diagnosed. Sinus tachycardia and hypotension should be managed as hypotension. It was considered that, correctly applied, the core algorithm COVER would have diagnosed 35% of cases and led to resolution in 70% of these. It was estimated that completion of COVER followed by the sub-algorithm for tachycardia would have led to earlier recognition of the problem and/or better management in four cases when compared with actual management reported. CONCLUSION: Tachycardia during anaesthesia is frequently associated with a simultaneous change in other monitored vital signs. The differential diagnosis is large. Addressing it in a comprehensive fashion requires a structured approach. A specific sub-algorithm treatment for tachycardia based on the associated blood pressure and on the prevailing heart rhythm in the case of hypotension offers a systematic guide which complements the benefits obtained by employing the core algorithm COVER ABCD.

Cardiovascular reactivity score for the assessment of dysautonomia in familial Mediterranean fever.

OBJECTIVE: The aim of this study was to assess the presence of dysautonomia, as manifested in abnormal cardiovascular reactivity, in patients with familial Mediterranean fever (FMF). METHODS: Fifty-five consecutive patients with FMF and 23 age- and sex-matched healthy controls were evaluated. Cardiovascular reactivity was studied: (1) using recordings of blood pressure (BP) and heart rate (HR) during 10 min of recumbence and 30 min of head-up tilt test to identify clinical endpoints and (2) during tilt-test, identifying parameters acting as independent predictors of FMF reactivity and enabling computation of a cardiovascular reactivity score (CVRS). RESULTS: Clinically, vasovagal reaction, postural tachycardia syndrome, and/or orthostatic hypotension were observed in ten patients (18.1%). Utilizing a derived equation, the group average CVRS in FMF was 5.83+/-1.78 (healthy group -7.60+/-5.41) ( P=<0.0001). A CVRS of >3.25 was associated with FMF, with 98% sensitivity and 100% specificity. CONCLUSION: A very high percentage of FMF patients exhibit abnormal cardiovascular reactivity which is clinically occult but can be detected on autonomic challenge and application of the CVRS.

[Three patients with massive pulmonary embolism]. / Drie patiënten met massale longembolieën.

Three patients presenting with massive venous pulmonary thrombo-embolism are described, who have been selected from a series of 22 patients treated with thrombolysis during a 6-year period. A 23-year-old female presented with tachycardia and dyspnoea. She had pulmonary angiography following scintigraphy with a perfusion deficit of more than 60%. Thrombolysis resulted in open blood vessels and a disappearance of the complaints. A 51-year-old woman presented with profound hypoxemia, probably due to a patent foramen ovale, with shunting and tachycardia. Perfusion defects on scintigraphy combined with a normal chest radiograph in the absence of pre-existent pulmonary disease established the diagnosis. She responded favourably to intravenous streptokinase. The third patient was an 80-year-old woman with hypertension. She developed dyspnoea, tachycardia and shock following immobilisation due to a fractured hip. Despite an initial improvement on streptokinase, she deteriorated and died from right-sided heart failure. The diagnostic tests should be limited and aimed at ruling out left-sided heart failure and pericardial tamponade. Echocardiography is often diagnostic in these patients. Thrombolysis may be life saving but there are no randomised trials to prove that survival rate is indeed better compared to heparin therapy. Streptokinase is less expensive than alteplase and there is no evidence from trials to suggest that it is inferior to more expensive thrombolytics such as alteplase or urokinase.

Brady-tachycardia syndrome after radiotherapy for lung cancer. Assessment by computed tomography and carbon-11 methionine positron emission tomography.

A 74-year-old male who had received radiotherapy (total 54 Gy) for right lung cancer 7 months earlier developed a symptomatic brady-tachycardia syndrome requiring the implantation of a permanent pacemaker. Chest CT showed a pulmonary tumor of 2-cm diameter in the right lower lobe with direct extension into the surrounding tissue, suggesting the possibility of cardiac invasion. Carbon-11 methionine positron emission tomography (PET) indicated the absence of visible invasion of the heart with lung cancer. The bradytachycardia syndrome, therefore, was considered to be associated with sinus node injury due to radiation. Carbon-11 methionine PET metabolic imaging might play an important role in evaluating noninvasively the cause of the arrhythmia in this patient.

Conversion of recent onset atrial fibrillation with single loading oral dose of propafenone: is in-hospital admission absolutely necessary?

A population of 283 patients with recent onset (< 72 hours) AF, without heart failure, who received a single 450- or 600-mg oral dose of propafenone, or digoxin 1 mg, or placebo for conversion to sinus rhythm (SR), was studied to determine whether a routine admission to the hospital for drug administration is justified. Previous bradyarrhythmias or sick sinus syndrome (SSS), and concomitant use of antiarrhythmic drugs were exclusion criteria. None of the 283 patients studied experienced VT or VF and none of them needed implantation of a temporary pacemaker. Periods of atrial tachyarrhythmias with regularization of atrial waves and 1:1 AV conduction were observed in only two cases, both receiving placebo. No predictor of proarrhythmia was found among the clinical variables considered (age, etiology, arrhythmia duration, atrial dimension, and blood potassium). No serious hemodynamic adverse effects were noted in either group. The rates of conversion to SR after 4 hours were: 80 (57%) of 141 patients who received propafenone and 35 (25%) of 142 patients who received digoxin or placebo (P < 0.001). Acute oral treatment with propafenone is simple and effective for the conversion of recent onset AF to SR in patients without clinical signs of heart failure. The routine admission of these patients to the hospital is not necessary. Home-based administration of oral propafenone to a selected group of patients could significantly increase the cost effectiveness of this treatment.

The natural history of the systemic inflammatory response syndrome (SIRS). A prospective study.

OBJECTIVE: Define the epidemiology of the four recently classified syndromes describing the biologic response to infection: systemic inflammatory response syndrome (SIRS), sepsis, severe sepsis, and septic shock. DESIGN: Prospective cohort study with a follow-up of 28 days or until discharge if earlier. SETTING: Three intensive care units and three general wards in a tertiary health care institution. METHODS: Patients were included if they met at least two of the criteria for SIRS: fever or hypothermia, tachycardia, tachypnea, or abnormal white blood cell count. MAIN OUTCOMES MEASURES: Development of any stage of the biologic response to infection: sepsis, severe sepsis, septic shock, end-organ dysfunction, and death. RESULTS: During the study period 3708 patients were admitted to the survey units, and 2527 (68%) met the criteria for SIRS. The incidence density rates for SIRS in the surgical, medical, and cardiovascular intensive care units were 857, 804, and 542 episodes per 1000 patient-days, respectively, and 671, 495, and 320 per 1000 patient-days for the medical, cardiothoracic, and general surgery wards, respectively. Among patients with SIRS, 649 (26%) developed sepsis, 467 (18%) developed severe sepsis, and 110 (4%) developed septic shock. The median interval from SIRS to sepsis was inversely correlated with the number of SIRS criteria (two, three, or all four) that the patients met. As the population of patients progressed from SIRS to septic shock, increasing proportions had adult respiratory distress syndrome, disseminated intravascular coagulation, acute renal failure, and shock. Positive blood cultures were found in 17% of patients with sepsis, in 25% with severe sepsis, and in 69% with septic shock. There were also stepwise increases in mortality rates in the hierarchy from SIRS, sepsis, severe sepsis, and septic shock: 7%, 16%, 20%, and 46%, respectively. Of interest, we also observed equal numbers of patients who appeared to have sepsis, severe sepsis, and septic shock but who had negative cultures. They had been prescribed empirical antibiotics for a median of 3 days. The cause of the systemic inflammatory response in these culture-negative populations is unknown, but they had similar morbidity and mortality rates as the respective culture-positive populations. CONCLUSIONS: This prospective epidemiologic study of SIRS and related conditions provides, to our knowledge, the first evidence of a clinical progression from SIRS to sepsis to severe sepsis and septic shock.

Sustained ventricular tachycardia associated with sarcoidosis: assessment of the underlying cardiac anatomy and the prospective utility of programmed ventricular stimulation, drug therapy and an implantable antitachycardia device.

The presentation, cardiac anatomy and utility of programmed ventricular stimulation in seven patients with sustained ventricular tachycardia associated with sarcoidosis are described. The mean patient age was 38 +/- 8 years. Pulmonary involvement was apparent in three patients and no systemic manifestations of sarcoidosis were present in one patient. All patients had electrocardiographic abnormalities at rest and six had a left ventricular ejection fraction less than 45%. All seven patients had left ventricular wall motion abnormalities and five had mitral valve dysfunction. Sustained ventricular tachycardia was easily induced in all patients. Spontaneous sustained ventricular tachycardia was not prevented with corticosteroid administration. Despite antiarrhythmic drug therapy, two patients had sudden cardiac death and an additional four had recurrence of ventricular tachycardia. Four patients had an automatic cardioverter-defibrillator implanted and received drug therapy; all four received appropriate shocks. This report represents the largest descriptive series of consecutive patients with sustained ventricular tachycardia associated with sarcoidosis. Antiarrhythmic drug therapy of ventricular tachycardia in patients with sarcoidosis, even when guided with programmed ventricular stimulation, is associated with a high rate of arrhythmia recurrence or sudden death, or both. Thus, implantation of an automatic antitachycardia device (cardioverter-defibrillator) should be considered as primary therapy in such patients. Furthermore, sarcoidosis should be excluded, with Kveim skin testing if necessary, in any patient with sustained ventricular tachycardia of unknown origin.

The role of late potentials in the assessment of myocardial degeneration in idiopathic dilated cardiomyopathy.

In order to determine whether or not late potentials indicate either a degree of myocardial fibrosis or necrosis, the relationship between late potentials and thallium-201 myocardial perfusion images was studied in 13 patients with idiopathic dilated cardiomyopathy. Late potentials were defined as low-amplitude waveforms having duration of over 20 msec after the end of the QRS complex using a high-resolution ECG (Marquette electronics, MAC 1). In the T1-201 myocardial perfusion image, the segmental perfusion state was assessed by use of a parameter called the uptake index (= normalized sector counts/maximal normalized sector counts) of each of 6 different segments. Segments which showed an uptake index of -2SD less than the normal value were judged to be abnormal. Late potentials were detected in 8 (61.5%) of the 13 patients. All of the patients showing late potentials also had ventricular tachycardia. Among the patients showing no late potential, ventricular tachycardia was observed in only one patient. Seven of the 8 patients showing late potentials and 3 of 5 patients not showing late potentials, however, had both a higher degree and a greater extent of abnormal perfusion images than the patients not showing late potentials. Therefore, late potentials may reflect a degree of myocardial fibrosis or necrosis in patients with dilated cardiomyopathy, those showing abnormal thallium images are apt to show late potentials, and these patients seem to be also at a high risk of suffering from ventricular tachycardia.

Long-term prognostic assessment of ventricular tachycardia with respect to sudden death in patients with and without overt heart disease.

The purpose of this study is to investigate the long-term prognosis of ventricular tachycardia (VT) mainly with respect to sudden death (SCD) in patients with ischemic heart disease (IHD), idiopathic cardiomyopathy (ICM), miscellaneous heart disease (MHD) and idiopathic ventricular tachycardia (IVT). The study included 117 patients with VT (80 male, 37 female). The number of patients with IHD, ICM, MHD and IVT were 40, 18, 26 and 33, respectively. Follow-up was conducted by means of a mailed standardized questionnaire. The mean follow-up period was 46.8 +/- 32.0 months (range from 6 to 125 months). In 24 out of the 117 patients the cause of death was SCD, in 9 there was no sudden cardiac death and in 5 no cardiac death. The other 76 were surviving. The number of SCD in IHD, ICM, MHD and IVT was 14/40 (35%), 4/17 (24%), 6/25 (24%) and zero (0%), respectively. The number of having had syncope in IHD, ICM, MHD and IVT was 19/40 (48%), 7/18 (39%), 6/26 (23%) and 6/33 (18%), respectively. Out of the 19 IHD patients with syncope, 15 had had ventricular fibrillation (VF). As for IVT with syncope, only one of the 6 had VF, which was induced by a disopyramide injection. In IVT, the patients with syncope had a significantly higher VT rate than those without syncope (p less than 0.01). There were no significant differences in the electrocardiographical high risk parameters for SCD, the age, follow-up periods, the presence or absence of VF and ejection fraction between the SCD and the surviving groups.(ABSTRACT TRUNCATED AT 250 WORDS)