Hypoxic respiratory distress potentially secondary to phosphorus trifluoride gas exposure.

We herein report a rare, probable exposure of a patient to phosphorus trifluoride gas. The objective of this case report is to highlight the potential exposure to phosphorus trifluoride gas and discuss the best management of it. A 48-year-old worker at a specialty gases laboratory was transported to the community Emergency Department (ED) in respiratory distress, presenting with peripheral cyanosis, an unobtainable oxygen saturation, chocolate-colored blood, and a Glasgow coma scale of 15. A non-rebreather was placed, poison control was contacted, and the patient was administered empiric methylene blue intravenously due to worsening cyanosis and respiratory distress. Upon arrival at the academic facility, the patient was no longer cyanotic and reported improvement of his symptoms. The patient's employer informed staff that a canister of phosphorus trifluoride gas in his workstation was found to be empty but should have been full. It was also discovered that a coworker left work early the same day with similar but milder symptoms. Hyperbaric oxygen therapy was considered; however, the patient was improving on oxygen via non-rebreather, and he had no other indications. Because the patient continued to require supplemental oxygen to maintain their oxygen saturation above 92%, he was admitted to the ICU and treated with prednisone daily for chemical pneumonitis. After 4 days, he successfully transitioned to room air without hypoxia. While exposures such as this do not occur frequently, it is important to maintain a broad differential and treatment plan as we continue to investigate the etiology and best treatment option.

Breath-Holding Spells in Pediatrics: A Narrative Review of the Current Evidence.

BACKGROUND: Breath-holding spells are common, frightening, but fortunately benign events. Familiarity with this condition is important so that an accurate diagnosis can be made. OBJECTIVE: To familiarize physicians with the clinical manifestations, diagnosis, evaluation, and management of children with breath-holding spells. METHODS: A PubMed search was completed in Clinical Queries using the key term "breath-holding spells". The search strategy included meta-analyses, randomized controlled trials, clinical trials, observational studies, and reviews. Only papers published in the English literature were included in this review. The information retrieved from the above search was used in the compilation of the present article. RESULTS: Breath-holding spells affect 0.1 to 4.6% of otherwise healthy young children. The onset is usually between 6 and 18 months of age. The etiopathogenesis is likely multifactorial and includes autonomic nervous system dysregulation, vagally-mediated cardiac inhibition, delayed myelination of the brain stem, and iron deficiency anemia. Breath-holding spells may be cyanotic or pallid. The former are usually precipitated by anger or frustration while the latter are more often precipitated by pain or fear. In the cyanotic type, the child usually emits a short, loud cry, which leads to a sudden involuntary holding of the breath in forced expiration. The child becomes cyanosed, rigid or limp, followed by a transient loss of consciousness, and a long-awaited inspiration and resolution of the spell. In the pallid type, crying may be minimal or "silent". The apneic period in the pallid type is briefer than that in the cyanotic type prior to the loss of consciousness and posture. The episode in the pallid type then proceeds in the same manner as a cyanotic spell except that the child in the pallid type develops pallor rather than cyanosis. In both types, the entire episode lasts approximately 10 to 60 seconds. The spells usually disappear spontaneously by 5 years of age. CONCLUSION: Although breath-holding spells are benign, they can be quite distressing to the parents. Confident reassurance and frank explanation are the cornerstones of treatment. Underlying cause, if present, should be treated. Interventions beyond iron supplementation may be considered for children with severe and frequent breath-holding spells which have a strong impact on the lifestyle of both the child and family.

Microvascular endothelial dysfunction during cardiopulmonary bypass in surgery for correction of cyanotic and acyanotic congenital heart disease.

OBJECTIVE: To evaluate endothelium-dependent microvascular reactivity during cardiopulmonary bypass (CPB) in surgery for the correction of cyanotic and acyanotic congenital heart disease (CHD) in children and infants using laser Doppler perfusion monitoring (LDPM). METHODS: This cross-sectional observational study included one hundred consecutive acyanotic (AC, n = 61) and cyanotic (C, n = 39) pediatric patients scheduled for cardiac surgery for correction of CHD. The endothelium-dependent microvascular vasodilation of the skin of the forehead was evaluated using a single-point LDPM coupled with local thermal hyperemia (LTH). RESULTS: LTH induced significant increases in microvascular conductance both in AC and C patients after the induction of anesthesia, during CPB and after weaning from CPB. Nevertheless, the vasodilation induced by LTH was significantly blunted during CPB when compared with values obtained after the induction of anesthesia both in AC and C patients. Microvascular endothelial reactivity nearly normalized after the discontinuation of CPB. CONCLUSION: The evaluation of systemic microvascular reactivity on the forehead skin of infants and children using LDPM appears to be a valuable tool for optimizing microvascular perfusion during CPB in pediatric cardiac surgery.

Methemoglobinemia in a Case of Paint Thinner Intoxication, Treated Successfully with Vitamin C.

BACKGROUND: Methemoglobin (MetHb) is an oxidized form of hemoglobin. It is a poor transporter of oxygen and is unable to deliver oxygen to the tissue. Globally, drug & toxin induced methemoglobinemia is more common as compared with the congenital form. Methemoglobinemia caused by paint thinner intoxication is rare. Methylene blue is well established as the first-line therapy for severe methemoglobinemia. CASE REPORT: A 25-year old man was brought to the Emergency Department after accidental consumption of paint thinner. On clinical examination, he had cyanosis and there were discrepancies in his pulse oximetry and arterial blood gas (ABG) analysis results. With this clue and supporting laboratory investigations, the diagnosis of toxin-induced methemoglobinemia was made. Due to the unavailability of methylene blue, alternative treatment with high-dose vitamin C was attempted, to which the patient responded. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The role of vitamin C in the treatment of methemoglobinemia has not been well established, with only a few published case reports. This patient had severe methemoglobinemia, with MetHb of 46.4%, which responded dramatically to vitamin C therapy, with no side effects. This case shows that high-dose vitamin C is safe and has the potential to be an effective alternative for the treatment of severe methemoglobinemia. In the presence of cyanosis, mismatch of pulse-oximetry and ABG-analysis are the key for the physician to suspect methemoglobinemia.

Metahemoglobinemia relacionada con ingesta de puré de acelgas / Methemoglobinemia due to ingestion of chard puree

La metahemoglobinemia es un síndrome clínico dado por la presencia de una forma aberrante de hemoglobina, ocasionada por diversos agentes oxidantes. Se describe un caso clínico de metahemoglobinemia severa asociada a la ingesta de puré de acelgas con alto contenido en nitratos y nitritos. Paciente de un año, con antecedentes de comunicación interauricular (CIA), que presentó un cambio en coloración de la piel 7 h antes, en forma progresiva, acompañado de vómitos. Ingresó al Departamento de Emergencia con cianosis generalizada que no mejoró con oxigenoterapia, taquicardia y tendencia a hipotensión arterial. En cuidados intensivos se realizó ecocardiograma que evidenció CIA sin repercusión hemodinámica. Metahemoglobinemia 37%. Se realizó dosis de azul de metileno al 1% por vía intravenosa, con franca mejoría clínica a la hora de la administración del antídoto y descenso de niveles de metahemoglobina. Alta médica a las 36 horas del ingreso. Existía una relación cronológica entre la exposición a nitratos por ingesta de un puré de acelgas y la aparición del cuadro. Los niveles de nitratos hallados en dicho alimento fueron muy elevados considerando estándares internacionales, lo que sumado a una inadecuada conservación del alimento cocido los días previos, permitió confirmar el planteo etiológico realizado. Resulta importante sospechar esta entidad patológica poco frecuente frente a cianosis que no mejora con oxígeno, y prevenir cuadros similares al descrito mediante una adecuada manipulación y conservación de las verduras con alto contenido en nitratos.

Methemoglobinemia is a clinical syndrome due to the presence of an aberrant form of hemoglobin, caused by various oxidizing agents. The study reports a case of severe methemoglobinemia associated with the ingestion of chard puree with high levels of nitrates and nitrites. A 1-year-old patient with a history of atrial septal defect (ASD), who progressively showed change of skin color 7 hours earlier, accompanied by vomiting. She was admitted to the Emergency Department with generalized cyanosis not improving with oxygen therapy, tachycardia and tendency to hypotension. In the intensive care unit, an echocardiogram showed ASD without hemodynamic complications. Methemoglobinemia 37%. A 1% methylene blue dose was administered intravenously, with clinical improvement one hour after antidote administration and decrease in methemoglobin levels. Medical discharge at 36 hours of admission. There was a chronological relationship between nitrates exposure by ingestion of chard puree and the clinical onset of methemoglobinemia. The toxic cause was confirmed after high nitrates levels were found in this vegetable considering international standards, and an inadequate preservation of the cooked chard on previous days. It is important to suspect this rare pathological entity when cyanosis fails to improve with oxygen, and to prevent poisonings similar to those described by an adequate manipulation and preservation of vegetables with high nitrate levels.

A 5-hour-old male neonate with cyanosis.

Methemoglobin (MetHb) is a form of hemoglobin in which heme iron is oxidized and unable to bind oxygen; its normal basal production is counteracted by an efficient MetHb-reduction pathway. The causes of methemoglobinemia are classified as congenital or acquired. Shortly after his birth, the 5-hour-old male Caucasian neonate, whose case we present herein, developed central cyanosis that was unresponsive to supplemental oxygen. Oxygen saturation as determined via pulse oximetry was normal. In contrast, blood gas testing by multiwave CO-oximetry indicated decreased fractional oxyhemoglobin and an elevated MetHb fraction. The patient was subsequently diagnosed with a congenital cytochrome b5 reductase deficiency. This case emphasizes causes of methemoglobinemia and differences among analytical methods used to measure oxygen status when MetHb is present.

Emergency manual systemic-to-pulmonary artery autotransfusion for severe cyanotic spell.

Cyanotic spell is an important complication of tetralogy of Fallot. We report a simple, innovative method that bailed out a patient with life-threatening, refractory cyanotic spell in the catheterization laboratory. Manual autotransfusion of blood from aorta into the pulmonary arteries resulted in significant clinical improvement.

Protective effects of hydroalcoholic extract from rhizomes of Cynodon dactylon (L.) Pers. on compensated right heart failure in rats.

BACKGROUND: The rhizomes of Cynodon dactylon are used for the treatment of heart failure in folk medicine. In the present study, we investigated the effects of hydroalcoholic extract of C. dactylon rhizomes on cardiac contractility in normal hearts and on cardiac functions in right-heart failure in rats. METHODS: Right-heart failure was induced by intraperitoneal injection of monocrotaline (50 mg/kg). Two weeks later, the animals were treated orally with different doses of the extract for fifteen days. At the end of the experiments cardiac functions and markers of myocardial hypertrophy were measured. RESULTS: The treated rats showed very less signs of fatigue, peripheral cyanosis and dyspnea. The survival rate was high in the extract treated groups (90%). Administration of C. dactylon in monocrotaline-injected rats led to profound improvement in cardiac functions as demonstrated by decreased right ventricular end diastolic pressure (RVEDP) and elevated mean arterial pressure. RVdP/dtmax, and RVdP/dt/P as indices of myocardial contractility were also markedly (p < 0.001; using one way ANOVA) increased by the extract. The extract reduced heart and lung congestion by decreasing tissue wet/dry and wet/body weight ratios (p < 0.01). In the isolated rat hearts, the extract produced a remarkable (P < 0.001) positive inotropic effect concomitant with a parallel decrease in LVEDP. CONCLUSION: The results of this study indicated that C. dactylon exerted a strong protective effect on right heart failure, in part by positive inotropic action and improving cardiac functions.

Vomiting and apparent life-threatening event.

We describe a 6-month-old girl who had an apparent life-threatening event after a vomiting episode resulting in activation of emergency medical services for transport to the emergency department. The differential diagnosis for this presentation is broad but easily narrowed down given the additional clinical information. Her resultant diagnosis of intussusception is a common diagnosis but with an uncommon presentation.

Metahemoglobinemia en una lactante por consumo de puré vegetal / Infant methemoglobinemia after eating mixed vegetable puree

La cianosis es un signo clínico consistente en coloración azulada de piel y mucosas debida a un aumento de la hemoglobina reducida en los capilares, o menos frecuentemente, a la presencia de metahemoglobinemia (forma férrica de la hemoglobina) que puede ser ocasionada por contacto o ingesta de agentes oxidantes exógenos tóxicos como tintes de anilina, nitrobenceno, fármacos o compuestos nitrogenados de diferente procedencia, como son las verduras con alto contenido en nitratos (1 y 2). Presentamos el caso clínico de una lactante de 8 meses que fue traída a urgencias por presentar cianosis labial y de partes acras (manos y pies), sin otro tipo de sintomatología, tras la ingestión de un puré vegetal preparado y conservado a temperatura ambiente. La determinación de metahemoglobina fue del 22,8% mediante determinación por cooximetría. La evolución del lactante fue satisfactoria con tratamiento con oxígeno y observación durante 24 horas (AU)

Cyanosis is a clinical sign due to the presence of bluish coloration of skin and mucosae, caused by an increase in the reduced form of hemoglobin in the capillaries, or, less frequently, to the presence of methemoglobinemia (ferric form of hemoglobin). Its origin can be contact or ingestion of exogenous oxidating toxic agents like aniline dyes, nitrobencene, drugs or nitrogen compounds from different origin or vegetables with high nitrate content (1 and 2). We report a case of a 8-month-old female infant who was brought to the emergency room with no symptoms except cyanosis of the lips and acral areas (hands and feet) after the ingestion of a mixed vegetable puree, prepared and conserved at room temperature. Her methemoglobin level determined by cooximetry was 22.8%. She was treated during 24 hour with oxygen and observation and evolved satisfactorily (AU)

Sensory changes in the forehead of patients with complex regional pain syndrome.

The aim of this study was to investigate involvement of central mechanisms in complex regional pain syndrome (CRPS). In particular, we wished to determine whether hyperalgesia extends ipsilaterally from the affected limb to the forehead. The heat-pain threshold, pressure-pain threshold, and ratings of cold and sharpness were investigated on each side of the forehead and in the affected and unaffected limbs of 38 patients with features of CRPS. In addition, touch thresholds were investigated in the limbs. The pressure-pain threshold was lower on the ipsilateral forehead than contralaterally, consistent with the presence of static mechanical hyperalgesia. Although the heat-pain threshold and ratings of sharpness and cold did not differ between the two sides of the forehead in the group as a whole, the sharpness of pinprick sensations in the affected limb was mirrored by similar sensations in the ipsilateral forehead. Conversely, diminished sensitivity to light touch in the affected limb was associated with diminished sensitivity to sharpness, cold and heat-pain in the ipsilateral forehead. These findings suggest that central nociceptive processing is disrupted in CRPS, possibly due to disturbances in the thalamus or higher cortical centres.

An unexpected cause of an acute hypersensitivity reaction during recovery from anaesthesia.

Acute hypersensitivity reactions to chlorhexidine in the operating room are probably more likely to occur during the early phases of anaesthesia because chlorhexidine is often used for cleaning the surgical field or during placement of indwelling catheters. We report a case of an acute hypersensitivity reaction that occurred in the post anaesthetic care unit. Subsequent skin testing suggested sensitivity to chlorhexidine, which had been applied over the vaginal mucosa at the end of surgery. Relevant issues in the investigation of acute hypersensitivity reactions in the post anaesthetic period are discussed.

Cardiogenic hypertrophic osteopathy in a dog with a right-to-left shunting patent ductus arteriosus.

A 5-year-old castrated male Shetland Sheepdog was examined because of progressive bilateral hind limb thickening. Cyanosis of the preputial mucous membranes was evident, whereas the oral mucous membranes had a normal color. A well-structured, palisade-like periosteal reaction with no underlying bone destruction was evident on radiographs of the hind limbs. The radiographic changes were consistent with hypertrophic osteopathy (HO). Severe right-sided cardiomegaly was seen on thoracic radiographs, and a diagnosis of patent ductus arteriosus with right-to-left shunting was made by means of echocardiography and contrast echoaortography. The cyanotic heart disease was believed to be the cause of the HO. Hypertrophic osteopathy has been associated with a number of diseases in animals and humans. In humans, congenital heart defects that cause cyanosis are among the most common causes of HO.

Late presentation of Bochdalek hernia: clinical and radiological aspects.

Three infants with late presentation of Bochdalek hernia are presented. The presenting symptoms were cough, intermittent vomiting, dyspnea, and cyanosis. Initial diagnoses of isolated paravertebral mass and foreign material aspiration were made in two infants, based on plain chest x-ray findings and history of the patients. Further radiological investigations, such as contrast upper gastrointestinal series or enema, computerized tomography, and magnetic resonance imaging of the chest, suggested the diagnosis of Bochdalek hernia. The hernia was found on the left side in two patients and on the right side in one. At operation, the stomach, small intestine, and spleen were found as herniated organs in one patient, ascending colon in one, and all of the small intestine together with ascending colon in the other. A congenital diaphragmatic defect should be suspected in every child presenting with unusual respiratory or gastrointestinal symptoms and with abnormal chest x-ray findings. The radiological findings vary greatly from one case to another, and even in the same case at different times because of differences in herniated organs and intermittent spontaneous reduction. The possibility of congenital diaphragmatic hernia should be kept in mind to avoid a wrong diagnosis, undue delay in diagnosis, and inappropriate treatment.

[Acrocyanosis: changing concepts and nosological limitations]. / Acrocyanose, évolution des concepts et limites nosologiques.

Acrocyanosis is undoubtedly the most commonplace acrosyndrome, both in terms of pathogenesis and prognosis. Patients experience functional impairment and an esthetic prejudice that must not be neglected. Adopting the nosological classifications described for Raynaud's syndrome, primary acrocyanosis must be distinguished from exceptional secondary phenomena that have a radically different clinical course. Primary acrocyanosis is generally observed in a young woman who appears thin or has recently lost weight. No paroxysmal episode (syncope, cyanosis, suspicious event involving the fingers) is found. The physical examination is negative and no complementary explorations are needed. Current pathophysiological hypotheses remain insufficient but suggest that vasospasticity rather than hemorheology is involved. The hypothesis that a thermoregulation disorder could be associated with weight loss deserves further study. Symptomatic care relies on dietary and hygiene counseling, emphasizing the importance of warm clothing. The psychological element must also be considered even in the most common forms.

When patients become cyanotic: acquired methemoglobinemia.

BACKGROUND: The authors conducted literature review to create a heightened awareness of the potential for developing toxic methemoglobinemia from local anesthetics. Methemoglobin normally is present in the blood at levels less than 1 percent. Levels may become toxic as hemoglobin is oxidized to methemoglobin after local anesthetics such as benzocaine and prilocaine are administered. TYPES OF STUDIES REVIEWED: The authors searched the medical and pharmaceutical industry literature. They found and reviewed case studies of incidences of methemoglobinemia that resulted from local anesthetic overdoses. RESULTS: Cases of local anesthetic-induced methemoglobinemia in dental practice are under-recognized and rare. Reported cases of prilocaine-induced methemoglobinemia have resulted in recent changes in some prilocaine literature. These changes include maximum recommended doses for patients of various weights. CLINICAL IMPLICATIONS: Dentists should identify patients who are at increased risk of developing methemoglobinemia before administering local anesthetics. They also should follow new recommended dosing guidelines for prilocaine and be aware of symptoms of this adverse reaction.

Retinol is specifically required during midgestation for neonatal survival.

Previous work has demonstrated that vitamin A-deficient, retinoic acid-supplemented pregnant rats cannot complete gestation without the administration of retinol. As little as 2 micrograms administered on day 10 of gestation is sufficient to prevent the characteristic fetal resorption that begins at day 15 of gestation. This single dose of retinol supports continued development through day 20 of gestation. However, if gestation is allowed to proceed to parturition, the newborn pups die within a few minutes of being severed from the umbilical cord. The pups are born with a pink and healthy skin tone, but within seconds of umbilical separation, they begin to gasp for air, become cyanotic in appearance, and die within several minutes from an apparent inability to obtain oxygen. Histological examination of these neonates demonstrates delayed pulmonary development. Branching and scalloping of ducts and saccule and subsaccule formation are decreased. This phenotype is consistent with that observed in respiratory distress syndrome seen in some premature human infants.

Acrocyanosis in a spinal cord injured patient--effects of computer-controlled neuromuscular electrical stimulation: a case report.

This case report documents the treatment of a spinal cord injured patient with acrocyanosis of both feet. The 37-year-old white male patient sustained a traumatic spinal cord injury at the age of 16 years, which resulted in an incomplete vertebral fracture of the C5-C6 level. He was treated with computerized neuro-muscular electrical stimulation (NMES) of the quadriceps femoris muscle with weights applied to the ankles an average of two times per week for six weeks. Improvements in the color of the patient's skin and toe ulcers, stronger pedal pulses bilaterally, decreased swelling bilaterally, and subjective reports of less discomfort were noted. The empirical findings of this case report suggest that computerized NMES may be effective for improving circulation in the spinal cord injured individual with acrocyanosis. Further study, however, is needed to determine whether a relationship may exist between blood flow and computerized NMES.