Rare combined heart and kidney transplant in a pediatric patient: a case study.

Multiple reports of successful combined heart and kidney transplants adults suggest that this may be a viable option for a small subset of patients with coexisting end-stage heart and kidney failure. A review of the literature, however, reveals that few combined heart and kidney transplants have been reported in children. This article presents the case of a 13-year-old boy who underwent unsuccessful palliative surgery for a congenital heart defect. The patient developed heart failure with subsequent acute renal failure, and ultimately required a combined heart and kidney transplant. The combined procedure was successful in this patient and he is alive and well 27 months postoperatively.

Experimental tricyclic antidepressant toxicity: a randomized, controlled comparison of hypertonic saline solution, sodium bicarbonate, and hyperventilation.

STUDY OBJECTIVE: We sought to compare the effects of hypertonic sodium chloride solution (HTS), sodium bicarbonate solution, and hyperventilation (HV) on severe tricyclic antidepressant (TCA) toxicity in a swine model. METHODS: Twenty-four mixed-breed, domestic swine of either sex were given an intravenous infusion of nortriptyline (NT) until development of both a QRS duration longer than 120 ms and a systolic blood pressure (SBP) less than or equal to 50 mm Hg. Animals were randomly assigned to 1 of 4 groups. On reaching toxicity, the control group received 10 mL/kg of 5% dextrose in water (D5W); the HTS group received 10 mL/kg of 7.5% NaCl solution (15 mEq Na+/kg); the NaHCO3 group received 3 mEq/kg of 8.4% sodium bicarbonate solution followed by enough D5W solution to equal 10 mL/kg of total volume; and the HV group was mechanically hyperventilated to maintain arterial pH between 7.50 and 7.60 and given 10 mL/kg of D5W. RESULTS: The mean SBP 10 minutes after treatment was 54+/-18 mm Hg in the control group, 134+/-21 mm Hg in the HTS group, 85+/-19 mm Hg in the NaHCO3 group, and 60+/-12 mm Hg in the HV group (P<.05). Mean QRS duration 10 minutes after treatment was 144+/-38 ms in the control group, 80+/-14 ms in the HTS group, 105+/-38 ms in the NaHCO3 group, and 125+/-46 ms in the HV group (P<.05). CONCLUSION: In this model of TCA, toxicity HTS was more effective than sodium bicarbonate. Hyperventilation had little effect. Sodium loading may be the most important factor in reversing TCA toxicity.

ECG changes with perforated duodenal ulcer mimicking acute cardiac ischemia.

A 38-year-old man presented to the emergency department with severe epigastric pain. An electrocardiogram (ECG) showed T wave inversions in leads V2 through V4 consistent with myocardial ischemia. The patient had undergone stress thallium testing and cardiac angiography several months prior for recurrent chest pain, and results from both studies were normal. Pneumoperitoneum seen on a chest X-ray prompted emergency laparotomy. A perforated duodenal ulcer was found and repaired. The ECG changes reverted to normal after surgery.

Recovery from severe cyclic antidepressant overdose with hypertonic saline/dextran in a swine model.

OBJECTIVE: To determine the effect of a hypertonic saline and dextran (HSD) solution on blood pressure and QS duration during severe cyclic antidepressant (CA) toxicity in swine. METHODS: Ten domestic swine weighing 20-24 kg were anesthetized and placed on mechanical ventilation. Nortriptyline solution was infused intravenously to achieve hypotension (systolic blood pressure equal to 50% of baseline) and a QRS duration of 120 msec. After reaching toxicity, the animals received in a randomized fashion either 10 mL/kg of a 7.5% saline/6% dextran solution or an equal volume of 0.9% saline as a rapid intravenous bolus. The animals were observed for one hour or until they died. Blood pressure and ECG were recorded continuously. Arterial pH was maintained in the physiologic range by controlled ventilation. RESULTS: Mean systolic blood pressure 10 minutes after treatment was 45 +/- 8 torr in the normal- saline group compared with 115 +/- 12 torr in the HSD group (p < 0.05). Mean QRS duration 10 minutes after treatment was 180 +/- 8 msec in the normal-saline group; it was 88 +/- 13 msec in the HSD group (p < 0.05). All normal-saline--group animals died within 20 minutes, and four of the five animals in the HSD group survived to 60 minutes (p < 0.05). The mean peak sodium concentration was 157 mmol/dL (mEq/dL) in the HSD group, and this was transient. CONCLUSION: In this swine model of severe CA toxicity, a solution of 7.5% saline/6% dextran significantly reversed hypotension and QRS prolongation. HSD also improved survival to 60 minutes.

Intravenous adenosine in the prehospital treatment of paroxysmal supraventricular tachycardia.

STUDY OBJECTIVE: To determine the clinical efficacy and safety of IV adenosine administration in the field for the treatment of paroxysmal supraventricular tachycardia (PSVT). DESIGN: Prospective, consecutive case series. SETTING: An urban emergency medical services system. PARTICIPANTS: Thirty-seven adult patients in whom paramedics made the diagnosis of PSVT. INTERVENTIONS: Six milligrams of adenosine was administered by rapid IV bolus. If there was no effect within two minutes, a 12-mg bolus was given. This dose was repeated once if necessary. If there still was no effect, the medical command physician was contacted for further management. MEASUREMENTS: Vital signs, symptoms, and a single-channel ECG were recorded before, during, and after the administration of adenosine. RESULTS: On review of the ECG tracings, 26 patients (70%) were in PSVT. Eleven had rhythms other than PSVT on review, including five with atrial fibrillation, four with sinus tachycardia, and two with ventricular tachycardia. Of the 26 patients with PSVT, 23 (88%) converted to sinus rhythm after adenosine administration. Eleven patients were hypotensive at presentation. Seven of these were in PSVT and became hemodynamically stable on conversion with adenosine. The four hypotensive patients with rhythms other than PSVT (two with atrial fibrillation and two with ventricular tachycardia) had no change in blood pressure after adenosine administration. Nine patients were subsequently found to have wide-complex tachycardia. None of these patients suffered hemodynamic compromise after adenosine administration, and side effects were infrequent, mild, and transient. CONCLUSION: Adenosine appears to be effective and safe for the pre-hospital treatment of PSVT.

Complete recovery following an unusual cardiac stab wound.

A 17-year-old female was stabbed in the chest and found by paramedics in extremis. She arrived at the receiving hospital with spontaneous respirations and an improved blood pressure. Upon thoracotomy in the operating room, lacerations through the main pulmonary artery and the left atrium were found. The combined efforts of a sophisticated EMS system providing rapid in-field stabilization and transport, a ready in-house trauma team able to quickly assess and provide definitive care, and a prepared operating room team, including cardiopulmonary bypass capability, resulted in a complete and uncomplicated recovery from this rare and lethal injury.

Ventilation-perfusion scintigraphy.

Ventilation-perfusion scintigraphy remains an important diagnostic tool in the evaluation of patients suspected of having PE. It is important for the emergency physician to be able to use the information from a lung scan appropriately in the diagnostic management of this elusive and life-threatening disorder. This requires a clear knowledge of how these scans are interpreted as well as a consultative approach between the physician ordering the lung scan and the nuclear medicine physician interpreting it. Each can ultimately contribute to the development of an effective management plan. It is important for the clinician to understand that a low-probability lung scan does not rule out PE, but in fact can have up to a 40% probability of PE when clinical suspicion is high.

Epstein-Barr virus infection complicated by acute rhabdomyolysis.

A patient presented with infectious mononucleosis complicated by acute rhabdomyolysis following physical exertion. This infrequent complication should be identified and treated quickly to prevent serious sequelae of rhabdomyolysis, which may include renal failure and disseminated intravascular coagulation.

Pregnancy after corticosteroid administration in premature ovarian failure (polyglandular endocrinopathy syndrome).

A patient with polyglandular failure syndrome first had documented ovarian failure at age 28 years. Fifteen years later after treatment for Addisonian crisis, she resumed menses, conceived, and was delivered of a normal infant. Patients with this syndrome should be identified because they are at risk for other endocrinopathies and because they may have a treatable form of ovarian failure.

Nutrition and the fertility of younger women in Kinshasa, Zaire.

PIP: This paper examines the relationship between various measures of household nutrition and fertility in Zaire (where malnutrition is rampant), in particular, the total effect of these nutrition measures on the length of time between births when infant mortality rates are held constant. Closed birth intervals (including average birth interval and length of 1st and 2nd closed birth intervals) and probability of occurrence of 2nd birth after the 1st birth, whether or not the 2nd birth occurred before the survey date, are examined to provide support to the hypothesis that there is a negative relationship between calorie consumption and interval between births. Data used for analysis are households (taken from the 1969 Socio-Economic Survey of Kinshasa) headed by a man with only 1 wife (aged 20-24 years at survey date). The main policy implication of the study is that rises in calorie consumption associated with the early stages of modernization may be expected to increase fertility in noncontracepting populations if there is no change in infant mortality rates. If infant mortlaity declines, the total effect of an increase in calorie consumption on the fertility of women is ambiguous. Another implication is that if calorie consumption can be held constant and protein consumption increases, both infant mortality and fertility may fall. A fall in infant mortality may result in a fall in fertility, although the average length of the period of postpartum amenorrhea may fall. A combined examination of similar data from other cities of Zaire and a cross time study of other data sets may help unravel the complex biological and behavioral determinants of fertility.^ieng