Cardiac and Pulmonary Ultrasound for Diagnosing TRALI.

Unexpected acute respiratory failure after anesthesia is a diagnostic challenge: residual neuromuscular blockade, bronchial hyperresponsiveness, laryngospasm, atelectasis, aspiration pneumonitis, and other more uncommon causes should be taken into account at diagnosis. Lung ultrasound and echocardiography are diagnostic tools that would provide the differential diagnosis. We report a suspected case of a transfusion related acute lung injury (TRALI) following administration of platelets. The usefulness of lung and cardiac ultrasound is discussed to facilitate the challenging diagnosis of the acute early postoperative respiratory failure.

Ritmo circadiano y variaciones temporales en el paro cardiaco súbito extrahospitalario / Circadian rhythm and time variations in out-hospital sudden cardiac arrest

Objetivos: Analizar las características cronobiológicas y las variaciones temporales del paro cardiaco extrahospitalario (PCEH). Diseño: Estudio descriptivo retrospectivo. Pacientes: Todos los casos de PCEH de origen cardíaco registrados en la base de datos del servicio de emergencias médicas (SEM) de la Comunidad Autónoma de Castilla y León (España) durante 18 meses. Variables de interés principales: Edad, sexo, recuperación de la circulación espontánea, primer ritmo monitorizado (desfibrilable /no desfibrilable), lugar de alerta [(hogar, lugar público, centro atención primaria (AP)], testigo (familiar, transeúnte, fuerzas de seguridad, personal AP), hora de alerta (0-8; 8-16; 16-24), hora de activación del equipo de emergencias, hora de atención y día de la semana. Análisis univariante mediante Chi2, varianza y tests no paramétricos. Análisis cronobiológico mediante transformada rápida de Fourier y test Cosinor. Resultados: Se estudiaron 1.286 casos registrados entre enero 2007 y junio 2008. Se observaron diferencias estadísticas significativas en menor edad (p<0,05), mayor incidencia en el hogar (p<0,001) y mayor frecuencia de familiares-convivientes como testigos (p<0,001) en el periodo de 0-8h. El análisis cronobiológico mostró ritmo diario (circadiano) con acrofase a las 11:16h (p<0,001) y ritmo semanal (circaseptano) con acrofase en miércoles (p<0,05). Las medianas de intervalos alerta-atención y activación-atención fueron respectivamente 11,7min y 8,0min, sin diferencias entre periodos horarios. Conclusiones: Se demuestra la presencia de un ritmo diario de aparición del PCEH con pico matinal y un ritmo semanal con pico en miércoles. Estos resultados orientan al ajuste preventivo y a la planificación de recursos y mejoras en la respuesta, en determinados periodos horarios (AU)

Objectives: To analyze the chronobiological and time variations of out- hospital cardiac arrest (OHCA). Design: A retrospective descriptive study was made. Patients: All cases of OHCA of cardiac origin registered over 18 months in the database of the emergency medical service (EMS) of the Autonomous Community of Castilla y León (Spain) were evaluated. Variables analyzed: Age, sex, recovery of spontaneous circulation (ROSC), first monitored rhythm (amenable / not amenable to defibrillation), alert site [(home, public place, primary care (PC) center], alerting person (family, witness, law enforcement member, PC center staff), alert time (0-8; 8-16; 16-24), emergency team activation time, care time and day of the week. Univariate analysis (chi-squared), variance, and nonparametric tests comparing the variables in three periods of 8hours. Chronobiological analysis by fast Fourier transform and Cosinor testing. Results: We studied 1286 cases reported between January 2007 and June 2008. Statistically significant differences were observed in terms of younger age, higher incidence in the victim's home, and greater frequency of family-cohabiting persons as witnesses in the period between 0 and 8hours. Chronobiological analysis found daily rhythm (circadian) with acrophase at 11.16h (p<0.001) and weekly rhythm (circaseptan) with acrophase on Wednesday (p<0.05). The median alert time-care time interval and emergency team activation time-care time were 11.7min and 8.0min, respectively, without differences between periods. Conclusions: We have demonstrated the presence of a daily rhythm of emergence of OHCA with a morning peak and a weekly rhythm with a peak on Wednesdays. These results can guide the planning of resources and improvements in response in certain time periods (AU)

Características generales de la parada cardiaca extrahospitalaria registrada por un servicio de emergencias médicas / General characteristics out of hospital cardiac arrest of cardiac origin recorded by an emergency medical service

Objetivo: Analizar las características generales de la parada cardiaca extrahospitalaria(PCEH) en una comunidad autónoma y los factores asociados a la recuperación de la circulación espontánea (RCE).Método: Estudio descriptivo retrospectivo de las PCEH de origen cardiaco incluidas en la base de datos del servicio de emergencias (SEM) de Castilla y León en un periodo de18 meses. El objetivo primario fue la RCE. Las variables analizadas fueron la edad, sexo, ritmo desfibrilable (DF), lugar del paro, testigo, intervalo alerta-atención inicial e intervalo despacho SEM-atención inicial. Resultados: Se estudiaron 1.286 PCEH, que representan 0,34 casos/1.000 habitantes/año. La mediana de edad fue de 73,0 años (rango intercuartílico 21,0), y el66,5% fueron hombres. Se consiguió RCE en el 22,2%. Las características de la PCEH fueron: ritmo DF 15,3%; en el hogar 72,2%, en un lugar público 21,3%, en un centro atención primaria (AP) 6,5%; presenciada por un familiar 49,1%, por un transeúnte 31,6%, por fuerzas seguridad 2,6% y por personal AP 15,7%. Fueron variables independientes asociadas a la RCE: edad inferior a 50 años [OR 1,6 (IC 95%: 1,03; 2,4)],ritmo DF [OR 3,8 (IC 95%: 2,7; 5,3)], lugar del paro en centro AP [OR 2,7 (IC 95%:1,4; 4,9)] y en lugar público [OR 1,8 (IC 95%: 1,2; 2,7)].Conclusiones: La incidencia de PCEH fue similar a otras series europeas. Destaca el bajo porcentaje de ritmos DF. Se confirma el hogar como lugar de más frecuente presentación, y una menor edad, la presencia de ritmos DF y la presentación en lugares públicos o centros sanitarios, como factores independientes asociados a RCE (AU)

Objective: To analyze the general characteristics out of hospital cardiac arrest (OHCA) including the frecuency of return of spontaneous circulation and related factors. Methods: Retrospective descriptive analysis of cases of OHCA in the records of the emergency medical service of Castile-Leon covering a period of 18 months. The main independent outcome analyzed was return of spontaneous circulation. Independent variables analyzed were age, sex, presence of shockable rhythm, location of cardiac arrest, witness, time between emergency call and initiation of care, and time between ambulance dispatch and initiation of care. Results: The EMS attended a total of 1286 cases of OHCA, representing an annual incidence of 0.34 cases per 1000 population. The median age (interquartile range) was 73.0 (21.0) years; 66.5% of the patients were men, spontaneous circulation returned in 22.2%, and a shockable rhythm was present in 15.3%. Cardiac arrest occurred in the home in72.2% of the cases, in a public place in 21.3%, and at a primary health care clinic in 6.5%. Witnesses were a familymember (49.1%), a passer-by (31.6%), a member of a security force (2.6%), and a primary care staff member (15.7%).Independent variables related to return of spontaneous circulation were age under 50 years (odds ratio [OR], 1.6; 95% confidence interval [CI], 1.03-2.4), presence of a shockable rhythm (OR, 3.8; 95% CI, 2.7-5.3); cardiac arrest at a primary health care clinic (OR, 2.7; 95% CI, 1.4-4.9) or in a public place (OR, 1.8; 95% CI, 1.2-2.7).Conclusions: The incidence of OHCA was similar to that reported for other European series. The low percentage of shockable rhythm was noteworthy. The home was confirmed as the most common setting for cardiac arrest; lower age, presence of shockable rhythm, occurrence of cardiac arrest in a public place or at a primary care clinic were confirmed as variables independently associated with return of spontaneous circulation (AU)

[Circadian rhythm and time variations in out-hospital sudden cardiac arrest]. / Ritmo circadiano y variaciones temporales en el paro cardiaco súbito extrahospitalario.

OBJECTIVES: To analyze the chronobiological and time variations of out- hospital cardiac arrest (OHCA). DESIGN: A retrospective descriptive study was made. PATIENTS: All cases of OHCA of cardiac origin registered over 18 months in the database of the emergency medical service (EMS) of the Autonomous Community of Castilla y León (Spain) were evaluated. VARIABLES ANALYZED: Age, sex, recovery of spontaneous circulation (ROSC), first monitored rhythm (amenable / not amenable to defibrillation), alert site [(home, public place, primary care (PC) center], alerting person (family, witness, law enforcement member, PC center staff), alert time (0-8; 8-16; 16-24), emergency team activation time, care time and day of the week. Univariate analysis (chi-squared), variance, and nonparametric tests comparing the variables in three periods of 8 hours. Chronobiological analysis by fast Fourier transform and Cosinor testing. RESULTS: We studied 1286 cases reported between January 2007 and June 2008. Statistically significant differences were observed in terms of younger age, higher incidence in the victim's home, and greater frequency of family-cohabiting persons as witnesses in the period between 0 and 8 hours. Chronobiological analysis found daily rhythm (circadian) with acrophase at 11.16 h (p<0.001) and weekly rhythm (circaseptan) with acrophase on Wednesday (p<0.05). The median alert time-care time interval and emergency team activation time-care time were 11.7 min and 8.0 min, respectively, without differences between periods. CONCLUSIONS: We have demonstrated the presence of a daily rhythm of emergence of OHCA with a morning peak and a weekly rhythm with a peak on Wednesdays. These results can guide the planning of resources and improvements in response in certain time periods.

[69 years old male patient, with impairment of physical condition, hyperpigmentation, cutaneous lesion and a deficient response to treatment]. / Varón de 69 años con afectación del estado general, hiperpigmentación, lesión cutánea y respuesta deficiente al tratamiento.

We submit the case of a male patient, suffering from a tuberculous ethiology adrenal primary insufficiency, showing a dermal lesion, in which necrotizing granulomas were found, and from which bacterial culture growth yielded mycobacterium bovis. Given the clinical findings, and awaiting for the bacterial culture result, a triple treatment with tuberculostatics was started, but had to be discontinued because of hepatic toxicity. After culture of cutaneous biopsy yielded micobaterium tuberculosis, treatment with streptomycin, rifampicin and etambutol was restarted. Three weeks later, in spite of increasing hydrocortisone dose to 40 mg, adrenal insufficiency reappeared. Under the circumstances, we chose to continue rifampicin and double hydrocortisone dose. The case is of concern because of the concurrency of three nowadays infrequent disorders: tuberculous ethiology adrenal insufficiency, cutaneous tuberculosis due to mycobacterium bovis and primary adrenal insufficiency due to rifampicin treatment, the latter resolved after increasing hydrocortisone dose.