Estratégia educativa com profissionais de enfermagem sobre hipertermia maligna em um centro cirúrgico cardiovascular / Educational strategy with nursing professionals on malignant hypertermia in a cardiovascular surgical center / Estrategia educativa con profesionales de enfermería en hipertermia maligna en un centro quirúrgico cardiovascular

Objetivos: Avaliar o conhecimento da equipe de enfermagem do centro cirúrgico (CC) sobre hipertermia maligna (HM), antes e depois de aula expositiva, e implantar kit para tratamento da HM com os anestesiologistas. Método: Estudo quase experimental do tipo antes e depois. Coleta de dados com 43 profissionais (três enfermeiros, sete técnicos e 33 auxiliares) do CC de um hospital de cardiologia de São Paulo. Aplicaram-se cinco questões antes e depois de aula expositiva, e utilizaram-se teste exato de Fisher e teste de McNemar. Após análise da literatura e dos materiais do setor e reunião com equipe médica, elaborou-se um kit de tratamento. Resultados: Houve diferença significante (p<0,05) em relação ao conhecimento da equipe sobre HM; após a aula, viu-se progresso nas três categorias (auxiliares 89,42%, técnicos 90% e enfermeiros 100%). As questões com porcentagem acima de 90%, após a aula, foram: definição de HM, agentes desencadeantes e tratamento. Foi elaborado e implantado um kit de tratamento. Conclusão: Avaliou-se o conhecimento da equipe de enfermagem sobre HM, antes e depois da aula expositiva, e implantou-se kit de tratamento. O conhecimento da equipe foi satisfatório após a aula ministrada.

Objectives: To evaluate the knowledge of the nursing staff of the surgical center (SC) about malignant hyperthermia (MH), before and after lecture, and to implant a kit for the treatment of MH with anesthesiologists. Method: Quasi-experimental before and after study. Data collection with 43 professionals (three nurses, seven technicians and 33 assistants) from the SC of a cardiology hospital in São Paulo. Five questions were applied before and after lecture, and McNemar and Fisher's exact tests were used. After analyzing the literature and industry materials and meeting with the medical team, a treatment kit was prepared. Results: There was a significant difference (p <0.05) regarding the team's knowledge about MH; After class, progress was seen in the three categories (assistants 89.42%, technicians 90%, and nurses 100%). The questions with percentage above 90% after class were: definition of MH, triggering agents, and treatment. A treatment kit was developed and implemented. Conclusion: The knowledge of the nursing staff about MH before and after the lecture was evaluated, and a treatment kit was implemented. The knowledge of the team was satisfactory after the taught class.

Objetivos: Evaluar el conocimiento del personal de enfermería del quirófano (CQ) sobre la hipertermia maligna (HM), antes y después de la conferencia, e implantar un kit para el tratamiento de HM con anestesiólogos. Método: Cuasi-experimental antes y después del estudio. Recopilación de datos con 43 profesionales (tres enfermeras, siete técnicos y 33 asistentes) del CQ de un hospital de cardiología en São Paulo. Se aplicaron cinco preguntas antes y después de la conferencia, y se utilizaron la prueba exacta de Fisher y la prueba de McNemar. Después de analizar la literatura y los materiales de la industria y de reunirse con el equipo médico, se preparó un kit de tratamiento. Resultados: Hubo una diferencia significativa (p<0.05) con respecto al conocimiento del equipo sobre MH; Después de la clase, se observó progreso en las tres categorías (auxiliares 89.42%, técnicos 90% y enfermeras 100%). Las preguntas con un porcentaje superior al 90% después de la clase fueron: definición de MH, agentes desencadenantes y tratamiento. Se desarrolló e implementó un kit de tratamiento. Conclusión: Se evaluó el conocimiento del personal de enfermería sobre MH antes y después de la conferencia, y se implementó un kit de tratamiento. El conocimiento del equipo fue satisfactorio después de la clase impartida.

Arritmias cardíacas na sala de emergência e UTI. Bradicardias: como identificar e tratar o paciente com baixa perfusão / Cardiac arrhythmias in the emergency room and ICU. Bradyarrhythmias: how to identify and treat the patient with low perfusion

O sistema cardiovascular é responsável pelo fluxo circulatório adequado, o qual depende do volume sistólico e frequência cardíaca (FC). Quando insuficientes, causa hipofluxo cerebral e incapacidade de realizar atividades. A bradicardia é causada por: a) disfunção sinusal, manifestada por FC inapropriadas, pausas ou síndrome de taqui-bradicardia, síncopes, tonturas e intolerância aos esforços, sem risco à vida; b) distúrbio da condução atrioventricular (bloqueios atrioventriculares - BAV): de primeiro, segundo (Mobitz I, Mobitz II e avançado) e terceiro grau (Total) . O BAV de primeiro grau e do tipo Mobitz I tem bom prognóstico. O BAV Mobitz II, avançado e total, mesmo oligossintomático ou transitório, sem causas removíveis, tem maior morbimortalidade; c) distúrbios neuromediados e a síncope reflexa são desencadeados por posição ortostática ou exposição à estresse emocional e a síndrome do seio carotídeo associada à estimulação da carótida. A FC baixa pode estar associada a um maior risco, sendo que os sinais e sintomas indicam gravidade. Na urgência, deve-se tratar as causas subjacentes assegurar o bom funcionamento das vias aéreas administrar O2 monitorar ritmo, FC, pressão arterial, e, também, o acesso venoso. É importante analisar o ritmo, exame físico e histórico, além de pesquisar e tratar os fatores contribuintes. Caso haja sinais de baixa perfusão, deve-se administrar atropina. A estimulação por marcapasso transcutâneo é indicada, caso a atropina seja ineficaz. Além disso, deve-se considerar a adrenalina ou dopamina e estimulação transvenosa

The cardiovascular system is responsible for adequate circulatory flow, which depends on systolic volume and heart rate (HR). When insufficient, it causes cerebral hypoflow and inability to perform activities. Bradycardia is caused by: a) sinus dysfunction, manifested by inappropriate HR, pauses or tachycardia-bradycardia syndrome, syncope, dizziness and intolerance to exertion, without risk to life; b) atrioventricular conduction disorder (atrioventricular (AV) blocks): first, second (Mobitz type I, Mobitz type II and advanced) and third degree (complete). First-degree and Mobitz type I AV block both have good prognosis. Mobitz type II, advanced and complete AV block, even oligosymptomatic or transient, without removable causes, have higher morbidity and mortality; c) neuromediated disorders and reflex syncope are triggered by orthostatic position or exposure to emotional stress and carotid sinus syndrome, associated with carotid stimulation. Low HR may be associated with increased risk, and signs and symptoms indicate severity. In emergency conditions the underlying causes should be treated to ensure good functioning of the airways; administer O2; monitor cardiac rhythm, HR, blood pressure, and venous access. It is important to analyze rhythm, and conduct a physical examination and clinical history, and to check for and treat contributing factors. If there are signs of low perfusion, atropine should be administered. Simulation by transcutaneous pacemaker is indicated if atropine is ineffective. Epinephrine or dopamine and transvenous stimulation should also be considered

Anaphylaxis to Intravenous Ferric Carboxymaltose

The efficacy and the adverse effects of intravenous iron formulas have been well established. However, there are few reports of anaphylaxis of ferric carboxymaltose (FCM). A man received intravenous FCM for the treatment of restless legs syndrome. The FCM gave rise to angioedema, urticaria, chest tightness, sinus tachycardia, and hypotension. In the end, epinephrine and dexamethasone resolved the symptoms. The findings were consistent with anaphylactic hypersensitivity reaction from FCM. We need to be careful when we administer FCM in clinics.

Prompt diagnosis of ST-elevation myocardial infarction with papillary muscle rupture by point-of-care ultrasound in the emergency department

A previously healthy 61-year-old man presented to the emergency department with chest pain and dyspnoea for 6 hours. Examination revealed distress with an apical pansystolic murmur. Initial electrocardiogram showed sinus tachycardia and ST elevation in leads II, III, and aVF compatible with an inferior ST-elevation myocardial infarction. Point-of-care echocardiography in the emergency department showed a flail anterior mitral leaflet and severe mitral regurgitation, leading to a provisional diagnosis of papillary muscle rupture. Emergency cardiac catheterization showed 100%, 80%, and 70% occlusion of the middle right coronary, left anterior descending, and left circumflex arteries, respectively. An emergency triple vessel coronary artery bypass grafting and mitral valve replacement was performed. Posteromedial papillary muscle rupture resulting in mitral regurgitation was confirmed intraoperatively. The patient recovered uneventfully. In the absence of primary percutaneous coronary intervention, thrombolysis decisions should be made with extreme caution if mechanical complications of ST-elevation myocardial infarction are suspected.

A case report on cerebrogenic fatal cardiac arrhythmia in a patient with acute ischemic stroke

BACKGROUND: Patients with acute ischemic stroke are susceptible  to  cardiac  arrhythmias  however,fatal arrhythmias  are  rare  in  the  absence  of  cardiac  disease.Cardiac arrhythmias can develop in lesions at the right side of the brain specifically the insular,frontal and parietal area.Data that show the direct relationship of ischemic stroke and arrhythmia are scarce but they are indirectly attributed to an imbalance in the autonomic nervous system.This paper aims to present a rare case of an association between a fatal arrhythmia and right thalamic infarct.   CASE: Presenting a case of a 39-year-old admitted as a survivor of sudden cardiac death from ventricular fibrillation.She presented with a history of left sided weakness a week prior but no work-up was done. Baseline serum electrolytes and  cardiac markers were all normal.Electrocardiogram (ECG) post-cardioversion showed sinus tachycardia.Echocardiogram   and cardiac computed tomography (CT) angiography were normal.  Magnetic resonance imaging (MRI) and angiography (MRA) of the brain showed an acute infarct at the right thalamus and an absent left internal carotid artery (ICA).Electroencephalogram (EEG) was negative.Bisoprolol was given and an Automatic Implantable Cardioverter Defibrillator (AICD) was subsequently placed.No recurrence of cardiac arrhythmia was noted on continuous cardiac telemetry monitoring during her hospitalization and on six months of follow-up.CONCLUSION: Fatal cardiac arrhythmias, can occur in patients with  acute  thalamic  infarct  even  beyond  24  hours  in  the presence of other confounding factors despite the absence of cardiac pathology. This case showed the association of heightened  autonomic  imbalance  caused  by  an  acute stroke, decreased cerebral flow, and fatal arrhythmia. This elucidates the importance of cardiac monitoring in acute ischemic stroke. With the paucity of information on serious cardiac arrhythmia and ischemic stroke, a future study on this correlation will be useful.

A case report on cerebrogenic fatal cardiac arrhythmia in a patient with acute ischemic stroke

@#<p style="text-align: justify;"><strong>BACKGROUND:</strong> Patients with acute ischemic stroke are susceptible  to  cardiac  arrhythmias  however,fatal arrhythmias  are  rare  in  the  absence  of  cardiac  disease.Cardiac arrhythmias can develop in lesions at the right side of the brain specifically the insular,frontal and parietal area.Data that show the direct relationship of ischemic stroke and arrhythmia are scarce but they are indirectly attributed to an imbalance in the autonomic nervous system.This paper aims to present a rare case of an association between a fatal arrhythmia and right thalamic infarct.   <br /><strong>CASE:</strong> Presenting a case of a 39-year-old admitted as a survivor of sudden cardiac death from ventricular fibrillation.She presented with a history of left sided weakness a week prior but no work-up was done. Baseline serum electrolytes and  cardiac markers were all normal.Electrocardiogram (ECG) post-cardioversion showed sinus tachycardia.Echocardiogram   and cardiac computed tomography (CT) angiography were normal.  Magnetic resonance imaging (MRI) and angiography (MRA) of the brain showed an acute infarct at the right thalamus and an absent left internal carotid artery (ICA).Electroencephalogram (EEG) was negative.Bisoprolol was given and an Automatic Implantable Cardioverter Defibrillator (AICD) was subsequently placed.No recurrence of cardiac arrhythmia was noted on continuous cardiac telemetry monitoring during her hospitalization and on six months of follow-up.<br /><strong>CONCLUSION:</strong> Fatal cardiac arrhythmias, can occur in patients with  acute  thalamic  infarct  even  beyond  24  hours  in  the presence of other confounding factors despite the absence of cardiac pathology. This case showed the association of heightened  autonomic  imbalance  caused  by  an  acute stroke, decreased cerebral flow, and fatal arrhythmia. This elucidates the importance of cardiac monitoring in acute ischemic stroke. With the paucity of information on serious cardiac arrhythmia and ischemic stroke, a future study on this correlation will be useful.</p>

A case report on cerebrogenic fatal cardiac arrhythmia in a patient with acute ischemic stroke

BACKGROUND: Patients with acute ischemic stroke are susceptible  to  cardiac  arrhythmias  however,fatal arrhythmias  are  rare  in  the  absence  of  cardiac  disease.Cardiac arrhythmias can develop in lesions at the right side of the brain specifically the insular,frontal and parietal area.Data that show the direct relationship of ischemic stroke and arrhythmia are scarce but they are indirectly attributed to an imbalance in the autonomic nervous system.This paper aims to present a rare case of an association between a fatal arrhythmia and right thalamic infarct.   CASE: Presenting a case of a 39-year-old admitted as a survivor of sudden cardiac death from ventricular fibrillation.She presented with a history of left sided weakness a week prior but no work-up was done. Baseline serum electrolytes and  cardiac markers were all normal.Electrocardiogram (ECG) post-cardioversion showed sinus tachycardia.Echocardiogram   and cardiac computed tomography (CT) angiography were normal.  Magnetic resonance imaging (MRI) and angiography (MRA) of the brain showed an acute infarct at the right thalamus and an absent left internal carotid artery (ICA).Electroencephalogram (EEG) was negative.Bisoprolol was given and an Automatic Implantable Cardioverter Defibrillator (AICD) was subsequently placed.No recurrence of cardiac arrhythmia was noted on continuous cardiac telemetry monitoring during her hospitalization and on six months of follow-up.CONCLUSION: Fatal cardiac arrhythmias, can occur in patients with  acute  thalamic  infarct  even  beyond  24  hours  in  the presence of other confounding factors despite the absence of cardiac pathology. This case showed the association of heightened  autonomic  imbalance  caused  by  an  acute stroke, decreased cerebral flow, and fatal arrhythmia. This elucidates the importance of cardiac monitoring in acute ischemic stroke. With the paucity of information on serious cardiac arrhythmia and ischemic stroke, a future study on this correlation will be useful.

Differential Diagnosis of Supraventricular Tachycardia

Supraventricular tachycardia (SVT) refers to a heterogeneous group of arrhythmias localized within the upper part of the heart (the His bundle or above). In general, the term SVT does not include atrial fibrillation. Common forms of SVT include atrioventricular nodal reentrant tachycardia, atrioventricular reentrant tachycardia, focal atrial tachycardia, and atrial flutter. Other, less common arrhythmias also fall under the category of SVT, including inappropriate sinus tachycardia and junctional reentrant/ectopic tachycardia. Paroxysmal supraventricular tachycardia refers to AVNRT and AVRT. SVTs can be identified and classified by clinical manifestation/physical examination, ECG, and/or electrophysiologic analysis.

Hipertermia maligna: reporte de un caso clínico / Malignant hyperthermia: report of a clinical case / Hipertermia maligna: relatório de um caso clínico

Resumen: La Hipertermia Maligna (HM), es un síndrome clínico que ocurre en pacientes susceptibles tras la exposición a un agente anestésico desencadenante. La mortalidad desciende con tratamiento específico, por lo que es fundamental su diagnóstico y tratamiento precoz. Se presenta el caso clínico de una niña de 3 años y 10 meses, en estudio por hemiparesia derecha de 3 meses de evolución. Se plantea probable enfermedad desmielinizante. Se le realizaron dos resonancias magnéticas (RNM) previas con anestesia sin incidentes. Por mala evolución de su enfermedad, se realiza nueva RNM con anestesia. A las 5 horas presenta episodio de distonías, acidosis, CPK elevada. Se interpreta como HM, se inicia tratamiento para la misma con mejoría del cuadro clínico. Presentamos este caso con el objetivo de exponer un enfoque diagnóstico y terapéutico de esta patología.

Summary: Malignant Hyperthermia (MH)is a clinical syndrome that occurs in susceptible patients after exposure to a triggering anesthetic agent. Associated mortality decreases with specific treatment, which is why its diagnosis and early treatment is essential. We present the case of a 3-year and 10-month-old girl, who presented a right hemiparesis. Possible demyelinating disease was suspected. Two previous magnetic resonance imaging (MRI) were performed under general anesthesia without complications. Due to poor evolution of his disease, new MRI is performed with anesthesia. After the procedure, she presented an episode of dystonias, acidosis, elevated CPK. It was interpreted as MH, and specific treatment was initiated instated. We present this case with the objective of exposing a diagnostic and therapeutic approach to this pathology.

Resumo: A hipertermia maligna (HM), è uma sindrome clinica que ocorre em pacientes sucetíveis devido a exposição a um agente anestésico desencadeante. A mortalidade diminui com tratamento específico, para o qual é fundamental diagnostico e tratamento precoce. Apresenta-se um caso clínico de uma criança de 3 anos e 10 meses de idade, em estudo por hemiparesia direita de 3 meses de evolução. Questiona-se provável doença desmielinizante. Foram realizadas duas ressonância magnéticas (RNM) previas, sob anestesia, sem incidentes. Devido à má evolução de sua doença, realizuo-se nova RNM sob anestesia. Cinco horas após apresentou episódios de rigidez muscular, acidose e CPK elevada. Interpretou-se como HM, iniciando-se tratamento específico, obtém-se melhoria do quadro clínico. Apresentamos este caso clínico com o objetivo de expor um enfoque diagnóstico e terapêutico desta patologia.

Electrocardiographic parameters of the American Miniature Horse: influence of age and sex / Parâmetros eletrocardiográficos de equinos Mini Horse: influência da idade e sexo

The veterinary cardiology has growing importance in equine medicine. There are studies of standardization of electrocardiographic parameters of many races, according to their stature and ability. However, no studies are in the literature with the American Miniature Horse. To evaluate the electrocardiogram (ECG) tracing configuration of this breed at rest and to verify the influence of age and sex on ECG parameters, 203 horses including 143 females and 60 males were divided into four age groups (foals, yearlings, adults and elderly). Electrocardiographic parameters were performed by computerized electrocardiogram (TEB), and the parameters were evaluated in six leads of frontal plane (Lead I, II, III, aVR, aVL and aVF) and base-apex (BA). Heart rates (HR) decreased with increasing age were higher in males than in females. Sinus tachycardia followed by sinus arrhythmia was dominant in both sexes. The cardiac axis was higher in males and ranged between 120° and 150° for foals, 30° and 60° for yearlings and adults, and 60° and 90° for the elderly. The P wave was bifid in several animals. The P-wave amplitude and T-wave duration from lead II and BA were larger in males than in females. The majority of the animals exhibited ST segment depression and a negative T-wave. The most common QRS complex morphology was Qr. Differences were observed between the electrocardiographic tracings of males and females, and age influenced the ECG parameters. Therefore, this study established the ECG patterns for the American Miniature Horse breed and could be used to determine the influence of age and sex on several of the studied variables.(AU)

A cardiologia veterinária possui crescente importância na medicina equina. Existem estudos de padronização dos parâmetros eletrocardiográficos de muitas raças, de acordo com sua estatura e aptidão. No entanto, não há na literatura trabalhos com os equinos da raça Miniature Horse. Os objetivos deste trabalho foram avaliar a configuração do traçado do eletrocardiograma (ECG) em repouso, de equinos desta raça, além de verificar a influência do sexo e da idade sobre os parâmetros eletrocardiográficos desses animais. Foram utilizados 203 equinos desta raça, hígidos, sendo 143 fêmeas e 60 machos, classificados em quatro faixas etárias (potros, sobreanos, adultos e idosos). Os exames eletrocardiográficos foram realizados por eletrocardiograma computadorizado (TEB), e os parâmetros foram avaliados em seis derivações do plano frontal (DI, DII, DIII, aVR, aVL e aVF) e base-ápice (BA). A frequência cardíaca (FC) diminuiu com a progressão da idade, e foi maior nos machos do que nas fêmeas. O ritmo mais comum em ambos os sexos foi taquicardia sinusal, seguido de arritmia sinusal. O eixo cardíaco foi maior nos machos do que nas fêmeas, e nos potros ficou entre 120 e 150o, nos sobreano e adultos permaneceu entre 30 e 60o, e nos idosos entre 60 e 90o. A amplitude da onda P e a duração da onda T foram maiores nos machos do que nas fêmeas na DII e BA. A maioria dos animais apresentou segmento ST infradesnivelado e onda T negativa. A morfologia do complexo QRS mais encontrada em todos os casos foi Qr. Este estudo permitiu estabelecer os padrões eletrocardiográficos para a raça Mini Horse e conseguiu verificar a influência da progressão da idade nas diversas variáveis estudadas, bem como a diferença entre os sexos.(AU)

Sinus Tachyarrhythmia

Sinus tachycardia is an accelerated rhythm in which the rate of impulses arising from the sinoatrial node is elevated. Uncontrolled sinus tachycardia may result in a poor prognosis, particularly in patients with cardiovascular disease, because of a hemodynamic disturbance arising from the tachycardia itself. When sinus tachycardia is specifically triggered by anemia, shock, or fever, it is referred to as physiological sinus tachycardia. Physiological sinus tachycardia should resolve with correction of the underlying cause. Inappropriate sinus tachycardia (IST) is unexplained by physiological demand. Palpitation is the most frequent symptom in IST patients. Even though treatment of IST has insufficient efficacy and a relatively high recurrence rate, several treatment strategies such as use of a β-blocker, ivabradine, and radiofrequency catheter ablation can be used for IST patients.

Inappropriate Sinus Tachycardia

Since inappropriate sinus tachycardia (IST) occurs due to various reasons, it can be diagnosed after exclusion of all causes and diseases that may result in sinus tachycardia. In particular, it is important to differentiate postural orthostatic tachycardia syndrome (POTS), and a multidisciplinary approach is necessary for differentiating psychiatric events. In addition, whether the clinical symptoms coincide with tachycardia events should be checked before treatment. β-adrenergic blocker is the most effective drug, and exercise training is recommended for controlling clinical symptoms. Furthermore, discontinuation of smoking and alcohol consumption, and decrease in caffeine intake may be useful. Recently, ivabradine has been found effective, and catheter ablation can be considered in cases of drug refractory IST presenting with clinical symptoms.

A case of thyrotoxic periodic paralysis as initial manifestation of Graves' disease in a 16-year-old Korean adolescent

Thyrotoxic periodic paralysis (TPP) is a rare complication of hyperthyroidism, with recurrent muscle paralysis and hypokalemia that are caused by an intracellular shift of potassium. TPP is relatively common in Asian males, but is extremely rare in children and adolescents, even for those of Asian descent. We describe a 16-year-old Korean adolescent presenting with a two-week history of episodic leg weakness in the morning. He showed sinus tachycardia, lower leg weakness, and hypokalemia. Thyroid function test showed hyperthyroidism, and thyroid ultrasonography revealed a diffuse enlarged thyroid with increased vascularity, consistent with Graves' disease. He was treated with beta-adrenergic blocker and antithyroid drugs. He has been symptom free for one year, as his hyperthyroidism has been controlled well with antithyroid drugs. TPP should be considered in children and adolescents with acute paralysis of the lower extremities and hypokalemia.

Taquicardia sinusal inapropriada: o papel da ecocardiografia fetal transvaginal: relato de caso / Inappropriate sinus tachycardia: the role of trasvaginal fetal echocardiography: case report / Taquicardia Sinusal Inapropiada: El papel de la Ecocardiografía Fetal Transvaginal ­ Relato del Caso

Introdução: A taquicardia sinusal inapropriada é rara na população em geral, tem maior prevalência em mulheres jovens e sua etiologia é desconhecida. Caracteriza-se por uma frequência cardíaca, persistentemente, elevada com uma resposta exagerada à atividade física. Objetivo: Relatar um caso raro de taquicardia sinusal inapropriada em fase precoce da gestação, enfatizando a importância da ecocardiografia fetal transvaginal. Relato de caso: Gestante encaminhada para realização de ecocardiografia transvaginal por taquicardia fetal persistente. Ao exame de nove semanas, o feto apresentava uma FC de 240 batimentos por minuto (bpm), com condução atrioventricular de um para um e sem sinais de hidropisia. Utilizados a digoxina e, posteriormente, o flecainide, ambos sem sucesso terapêutico. Iniciado sotatol com redução gradual e posterior normalização da FC fetal. O parto ocorreu a termo, concepto nasceu bem e evoluiu com taquicardia persistente. O eletrocardiograma realizado demonstrou onda P com morfologia de ritmo sinusal. As possíveis causas de taquicardia sinusal foram afastadas, confirmando assim o diagnóstico acima. Comentários: O autor reforça a importância da ecocardiografia fetal transvaginal para o diagnóstico e tratamento precoce de arritmias fetais, evitando complicações.

Introduction: The inappropriate sinus tachycardia is rare in the general population, more frequently affects young women, and its etiology is unknow. It is characterized by a persistently elevated cardiac frequency with na exaggerated response to physical activity. Objective: Report a rare case of inappropriate sinus tachycardia in the early phase of pregnancy and emphasize the importance of transvaginal fetal echocardiography. Case report: Pregnant referred due to persistente fetal tachycardia after obstretic ultrasonography. The transvaginal echocardiogram performed at 9 weeks' gestation showed a fetal heart rate of 240 beats min (bpm) with normal conduction from atria to ventricle (1:1)and no signal hydropsy. Digoxin therapy and Flecainide were used with no sucess. Sotatol use was chose when the fetal heart rate (HR) reduced to tolerable levels and then the number of heartbeats normalized at thirty six weeks gestation. The baby was born well at term and developed persistente tachycardia. The electrocardiogram performed showed P-ware morphology of sinus rhythm. Possible causes of sinus tachycardia were excluded, thus confirming the diagnosis above. Comments: The author describes the imortance of transvaginal fetal echocardiography for the diagnosis and early treatment of fetal arrhythmias avoiding complications.

Introducción: La taquicardia sinusal inapropiada es rara en la población en general, predomina mayormente en mujeres jóvenes y su etiología es desconocida. Se caracteriza por una frecuencia cardíaca, persistentemente, elevada con una respuesta exagerada a la actividad física. Objetivo: Relatar un caso raro de taquicardia sinusal inapropiada en fase precoz de la gestación, enfatizando la importancia de la ecocardiografía fetal transvaginal. Relato del caso: Gestante derivada para la realización del ecocardiograma transvaginal por taquicardia fetal persistente. En el examen de nueve semanas, el feto presentaba una FC de 240 latidos por minuto (lpm), con conducción aurículoventricular de uno para uno y sin señales de hidropesía. Se utilizó la digoxina y, posteriormente, el flecainide, ambos sin éxito terapéutico. Iniciado sotatol con reducción gradual y posterior normalización de FC fetal. El parto ocurrió a término, nació bien y evolucionó con taquicardia persistente. El electrocardiograma realizado demostró onda P con morfología de ritmo sinusal. Las posibles causas de taquicardia sinusal se eliminaron, confirmando así el diagnóstico señalado. Comentarios: El autor refuerza la importancia de la ecocardiografía fetal transvaginal para el diagnóstico y tratamiento precoz de arritmias fetales, evitando complicaciones

Pulmonary embolism as a cause of unexplained sinus tachycardia after right ventricular myocardial infarction

We present the case of a patient who developed new-onset asymptomatic sinus tachycardia after undergoing treatment for a right ventricular myocardial infarction. Even after excluding heart failure, infection and bleeding, the sinus tachycardia persisted. Computed tomography pulmonary angiography showed multiple bilateral pulmonary emboli. The vital sign abnormality resolved after treatment with an anticoagulant. We postulate that the pulmonary emboli originated from thrombi that were formed in the infarcted and dysfunctional right ventricle. Pulmonary embolism is a very rare complication of right ventricular myocardial infarction, and patients usually present with pleuritic chest pain. Our case highlights that asymptomatic sinus tachycardia could be a presenting feature of pulmonary embolism after the occurrence of a right ventricular myocardial infarction. A high index of suspicion is warranted in order to detect this potentially lethal complication.

Electrocardiographic findings in heat stroke and exhaustion: a study on Makkah pilgrims

Over two million pilgrims perform annual rituals in Makkah region, which when coincides with summer months, exposes them to outdoor temperatures exceeding 45 °C and humidity approaching 80%. Accordingly, heat illnesses are common including explicit heat strokes and heat exhaustion. No previous studies elaborated on electrocardiographic changes among this unique cohort. To compare electrocardiographic changes in three groups exposed to high outdoor temperatures, namely, patients with heat stroke compared to patients with heat exhaustion and a control group exposed to the same outdoor temperatures without clinical manifestations. Through case control design, two case groups of patients were selected. The first group [Gl] was 34 patients admitted to the cooling units with clinical picture of heat stroke and the second group [G2] comprised 28 patients admitted with heat exhaustion. The control group [G3] included 31 patients selected from relatives of patients and outdoor workers. The outcome for comparison was 12-lead electrocardiographic changes done for all selected individuals. For [Gl], the ECG was done while they were prepared for cooling or immediately when cooling was started. In Gl, 18 were females and 16 males with ages of 20-76 years [59 +/- 11 years]. Their heart rates ranged from 64 to 160 beats per minute [mean 120 +/- 24 per minute]. Only 5/34 ECGs were completely normal. Sinus tachycardia was present in 27/34 patients [79%], with ischemic changes in 9/34 ECGs. In G2, 24 were males and four females with ages of 25-80 [mean 47 +/- 15 years], the heart rate ranged from 64 to 170 per minute [mean 97 +/- 16 per minute]. Seven out of 28 ECGs were normal [25%] while 21/28 had some abnormalities. None had ischemic changes. Control group [G3], was five females and 26 males ages 18-80 years [mean 38 +/- 15 years], 22/31 had normal ECGs [71%]. All had normal sinus rhythm, 56-98 beats per minute [74 +/- 11]. Nine patients had some electrocardiographic abnormalities but none had ischemic changes. We conclude that electrocardiographic abnormalities occur with a high frequency in patients with heat stroke and heat exhaustion, with sinus tachycardia and ischemic changes occurring more frequently in patients with heat stroke

Death due to Cardiac Metastasis after Treatment of Oral Squamous Cell Carcinoma: An Autopsy Case / 대한법의학회지

A 60-year-old man presented with electrocardiographic abnormalities after treatment for oral squamous cell carcinoma with surgical resection and radiation therapy 7 months ago. The patient died within 2 h without response to CPR after sudden arrest. Electrocardiographic changes 9 h before death included low QRS voltage and sinus tachycardia. Autopsy revealed cardiac metastasis with chronic active fibrinoid pericarditis accompanied by tumor cell infiltration. Although the frequency of cardiac metastasis in patients with oral cancer is reportedly low, clinicians should be aware that cardiac metastasis may exist if there are electrocardiographic changes in patients receiving follow-up care for primary malignancy. We report a rare medicolegal case of cardiac metastasis-related sudden death.

A Case of Acute Myocarditis as the Initial Presentation of Crohn's Disease

We experienced a case of acute myocarditis as the initial presentation of Crohn's disease. A 19-year-old woman was admitted with impaired consciousness, shock, and respiratory failure. She had suffered from frequent diarrhea and abdominal pain for several years. Cardiac troponin I and creatine kinase-MB fraction levels were elevated to 5.32 and 16.66 ng/mL, respectively. A 12-lead electrocardiogram showed sinus tachycardia, and a chest radiograph revealed interstitial pulmonary edema. An echocardiogram showed dilated ventricles with akinesia of the basal to apical inferoseptal, anteroseptal, anterior, and inferior left ventricular walls and severely impaired systolic function. Intensive care with inotropic support was effective, and her clinical condition gradually improved. Two weeks later, a colonoscopy revealed ulceration with stenosis in the terminal ileum and multiple aphthous ulcers in the rectum. A biopsy of the rectum revealed non-caseating granulomatous inflammation. She was diagnosed with Crohn's disease presenting with acute myocarditis.

A Case of Carbon Dioxide Poisoning by Malfunction of a Carbon Dioxide- Based Fire Extinguishing System

Carbon dioxide is a colorless, odorless, nonirritating gas with many practical uses. In particular, because it can displace oxygen from the environment, it is used as a fire extinguisher. We describe an incident that occurred as a result of malfunction of a carbon dioxide-based fire extinguishing system in our hospital. Twelve casualties reached our emergency department. Symptoms of exposure included nausea, dizziness, loss of consciousness, vomiting, chest discomfort, and seizure. Results of initial arterial blood gas analysis showed acidosis in five patients. A new pneumonic infiltration at the left. upper lung field was observed in one patient, while sinus tachycardia in electrocardiography (ECG) was observed in another patient. Oxygen was initially supplied to all casualties, until symptoms of intoxication had disappeared. Three patients were admitted to the hospital, but were discharged without complication. Despite occurrence of massive casualties, with significant symptoms due to unintentional exposure to high concentrations of carbon dioxide, patients' symptoms were relieved by supportive care.