Effectiveness of intravenous prostaglandin to reduce digital amputations from frostbite: an observational study.

PURPOSE: We assessed the effectiveness and safety of a 5-day intravenous prostaglandin (iloprost) protocol at reducing digital amputation for patients with severe frostbite injuries at urban emergency departments. METHODS: This retrospective study examines consecutive patients who presented to Calgary emergency departments from April 2017 to April 2020 with Grade 2-4 frostbite injuries. Patients from February 2019 onward were managed using a 5-day iloprost infusion protocol, whereas patients prior to this time were managed with standard care (local best practice without iloprost as a therapeutic option). The primary effectiveness outcome was rate of affected digits amputated, stratified by frostbite severity. The secondary safety outcome was the incidence of serious adverse events associated with iloprost (allergic reactions or symptomatic hypotension requiring treatment or discontinuation of the infusion). RESULTS: 90 patients were included, 26 were treated with iloprost, compared to 64 patients who received usual care. Both the treatment and usual care groups experienced substantial rates of homelessness and substance use. No digital amputations were required for patients with Grade 2 injuries in either group, but significantly lower digital amputation rates were observed for patients with more severe frostbite injuries treated with iloprost versus usual care: Grade 3 (18% vs 44%, p < 0.001), Grade 4 (46% vs 95%, p < 0.001). No serious adverse events were associated with iloprost. CONCLUSION: In this unselected socially complex urban population, administration of iloprost for patients with frostbite was shown to be safe and was associated with lower digital amputation rates, particularly for those with more severe injuries.

RéSUMé: OBJECTIF: Nous avons évalué l'efficacité et la sécurité d'un protocole de 5 jours de prostaglandine intraveineuse (iloprost) pour réduire l'amputation digitale chez les patients souffrant d'engelures graves dans les services d'urgence urbains. MéTHODES: Cette étude rétrospective examine des patients consécutifs qui se sont présentés aux services d'urgence de Calgary d'avril 2017 à avril 2020 avec des engelures de niveau 2 à 4. À compter de février 2019, les patients ont été traités au moyen d'un protocole de perfusion d'iloprost de 5 jours, tandis que les patients avant cette période ont été pris en charge avec des soins standard (meilleures pratiques locales sans iloprost comme option thérapeutique). Le principal résultat d'efficacité était le taux de doigts affectés amputés, stratifié selon la gravité des gelures. Le critère secondaire de sécurité était l'incidence des événements indésirables graves associés à l'iloprost (réactions allergiques ou hypotension symptomatique nécessitant un traitement ou l'arrêt de la perfusion). RéSULTATS: 90 patients ont été inclus, 26 ont été traités avec de l'iloprost, contre 64 patients qui ont reçu les soins habituels. Les groupes de traitement et de soins habituels ont tous deux connu des taux importants de sans-abrisme et de consommation de substances. Aucune amputation digitale n'a été nécessaire pour les patients présentant des lésions de grade 2 dans l'un ou l'autre groupe, mais des taux d'amputation digitale significativement plus faibles ont été observés pour les patients présentant des lésions de gelures plus sévères traités par iloprost par rapport aux soins habituels : Grade 3 (18 % contre 44 %, p < 0,001), Grade 4 (46 % contre 95 %, p < 0,001). Aucun événement indésirable grave n'a été associé à l'iloprost. CONCLUSION: Dans cette population urbaine non sélectionnée et socialement complexe, l'administration d'iloprost pour les patients souffrant d'engelures s'est avérée sûre et a été associée à des taux d'amputation digitale plus faibles, en particulier pour ceux présentant des blessures plus graves.

Columbia Icefield Bus Rollover: A Case Study of Wilderness Mass Casualty Triage, Treatment, and Transport.

Mass casualty incidents (MCIs) are rare in wilderness and mountain settings. Few case studies have reported the response of such events within jurisdictions with well-developed trauma and emergency medical services systems (EMS). Here we explore a MCI in a wilderness setting on the Columbia Icefield inside the Jasper National Park within the Canadian Rocky Mountains. An all-terrain bus was involved that had rolled over while transporting tourists to explore the glacier. The bus rolled multiple times down the slope adjacent to the road, leading to 3 deceased and 21 patients requiring transport. A massive pre-hospital response ensued.Due to the location, extreme environment, and unusual complexities, the response involved significant use of aeromedical resources, physician field deployment, and centralized coordination centers. Readers are reminded of the importance of aeromedical surge capacity in allowing for effective distribution of patients to multiple receiving facilities. Our experience aligns with and reinforces many of the recommendations for wilderness MCI management; however, future research should focus on determining optimal triage strategies for mountain MCIs. Furthermore, future research should explore optimal strategies for developing a rescue chain given the availability of mixed transport resources, as well as the role of physicians in MCI response and where they are best placed in the incident command system.

Postural orthostatic tachycardia syndrome is associated with significant employment and economic loss.

BACKGROUND: Postural orthostatic tachycardia syndrome (POTS) is a debilitating form of chronic orthostatic intolerance that primarily affects women and causes substantial impairment in quality of life and function. Yet, there is minimal literature describing the employment and economic consequences of POTS. We explored these aspects of the POTS patient experience through a self-reported study designed using community-based participatory research principles. METHODS AND RESULTS: A comprehensive questionnaire, including employment and economic consequences, was developed in partnership with Dysautonomia International, a patient advocacy organization. The POTS community engaged in all stages of the research design and analysis. Participants were recruited through Dysautonomia International's website and social media channels. The analysis included 5,556 adult (age ≥18 years) participants with a physician-confirmed diagnosis of POTS. The majority of participants were female (95%). Forty-eight per cent of participants reported employment during the three months prior to the survey, and of these participants, 66.8% would work greater hours if not for illness limitations. Over two-thirds (70.5%) of participants have lost income due to POTS symptoms, with 36.0% of the total cohort losing more than $10,000 USD in the 12 months prior to the survey. Almost all (95%) participants reported POTS-related out-of-pocket medical expenses since diagnosis, with 51.1% of participants spending $10,000 USD or more. CONCLUSIONS: This is the largest study reporting the employment and economic challenges experienced by individuals with POTS. Exposure of these challenges emphasizes the need for earlier diagnosis and improved therapeutic strategies to reduce the negative individual and societal consequences of this disorder.

A Pacchionian Puzzle.

A 73-year-old male with a history of chronic ataxia presented with transient facial droop to the Emergency Department. A CT angiogram and MRI with diffusion weighted imaging (DWI) were negative for stroke. However, incidental note was made of numerous giant arachnoid granulation pits in the posterior fossa predominantly involving the left occipital bone (Figure 1). These arachnoid pits demonstrated multiple foci of herniation of the adjacent cerebellar parenchyma into the pits with gliosis of the herniated parenchyma and focal encephalomalacia of the subjacent cerebellar parenchyma. Review of bone windows on a remote CT brain performed almost 13 years earlier confirmed this to be a longstanding abnormality (Figure 2). The patient's physical exam was suggestive of cerebellar ataxia with left-sided dysmetria on finger to nose testing and a wide-based unsteady gait.

Relationships between orthostatic hypotension, frailty, falling and mortality in elderly care home residents.

BACKGROUND: Orthostatic hypotension (OH; profound falls in blood pressure when upright) is a common deficit that increases in incidence with age, and may be associated with falling risk. Deficit accumulation results in frailty, regarded as enhanced vulnerability to adverse outcomes. We aimed to evaluate the relationships between OH, frailty, falling and mortality in elderly care home residents. METHODS: From the Minimum Data Set (MDS) document, a frailty index (FI-MDS) was generated from a list of 58 deficits, ranging from 0 (no deficits) to 1.0 (58 deficits). OH was evaluated from beat-to-beat blood pressure and heart rate (finger plethysmography) collected during a 15-min supine-seated orthostatic stress test. Retrospective and prospective falling rates (falls/year) were extracted from facility falls incident reports. All-cause 3-year mortality was determined. Data are reported as mean ± standard error. RESULTS: Data were obtained from 116 older adults (aged 84.2 ± 0.9 years; 44% males) living in two long term care facilities. The mean FI-MDS was 0.36 ± 0.01; FI-MDS was correlated with age (r = 0.277; p = 0.003). Those who were frail (FI ≥ 0.27) had larger Initial (- 17.8 ± 4.2 vs - 6.1 ± 3.3 mmHg, p = 0.03) and Consensus (- 22.7 ± 4.3 vs - 11.5 ± 3.3 mmHg, p = 0.04) orthostatic reductions in systolic arterial pressure. Frail individuals had higher prospective and retrospective falling rates and higher 3-year mortality. Receiver operating characteristic curves evaluated the ability of FI-MDS alone to predict prospective falls (sensitivity 72%, specificity 36%), Consensus OH (sensitivity 68%, specificity 60%) and 3-year mortality (sensitivity 77%, specificity 49%). Kaplan Meier survival analyses showed significantly higher 3-year mortality in those who were frail compared to the non-frail (p = 0.005). CONCLUSIONS: Frailty can be captured using a frailty index based on MDS data in elderly individuals living in long term care, and is related to susceptibility to orthostatic hypotension, falling risk and 3-year mortality. Use of the MDS to generate a frailty index may represent a simple and convenient risk assessment tool for older adults living in long term care. Older adults who are both frail and have impaired orthostatic blood pressure control have a particularly high risk of falling and should receive tailored management to mitigate this risk.

Optimal diagnostic thresholds for diagnosis of orthostatic hypotension with a 'sit-to-stand test'.

OBJECTIVE: This study aimed to identify optimal blood pressure cut-offs to diagnose orthostatic hypotension during a sit-to-stand manoeuvre. METHODS: This was a cross-sectional study of patients and healthy controls from the Vanderbilt Autonomic Dysfunction Center. Blood pressure was measured while supine, seated and standing. Blood pressure changes were calculated from supine-to-standing and seated-to-standing. Orthostatic hypotension was diagnosed on the basis of a supine-to-standing SBP drop at least 20 mmHg or a DBP drop at least 10 mmHg. Receiver operator characteristic (ROC) curves identified optimal sit-to-stand cut-offs. RESULTS: Amongst the 831 individuals, more had systolic orthostatic hypotension [n = 354 (43%)] than diastolic orthostatic hypotension [n = 305 (37%)] during lying-to-standing. The ROC curves had good characteristics [SBP area under curve = 0.916 (95% confidence interval: 0.896-0.936), P < 0.001; DBP area under curve = 0.930 (95% confidence interval: 0.909-0.950), P < 0.001]. A sit-to stand SBP drop at least 15 mmHg had optimal test characteristics (sensitivity = 80.2%; specificity = 88.9%; positive predictive value = 84.2%; negative predictive value = 85.8%), as did a DBP drop at least 7 mmHg (sensitivity = 87.2%; specificity = 87.2%; positive predictive value = 80.1%; negative predictive value = 92.0%). CONCLUSIONS: A sit-to-stand manoeuvre with lower diagnostic cut-offs for orthostatic hypotension provides a simple screening test for orthostatic hypotension in situations wherein a supine-to-standing manoeuvre cannot be easily performed. Our analysis suggests that a SBP drop at least 15 mmHg or a DBP drop at least 7 mmHg best optimizes sensitivity and specificity of this sit-to-stand test.

Orthostatic Hypotension After Continuous-Flow Left Ventricular Assist Device Implantation in a Patient With Longstanding Diabetes Mellitus.

A continuous-flow left ventricular assist device (CF-LVAD) benefits patients with advanced heart failure as a bridge to cardiac transplantation. However, unanticipated complications may occur. We report a patient with end-stage heart failure and longstanding diabetes who experienced functionally debilitating orthostatic hypotension from autonomic insufficiency after CF-LVAD implantation. This case demonstrates a role for comprehensive autonomic function testing in the workup of orthostatic hypotension after LVAD implantation.

Clinical challenges in the diagnosis and management of postural tachycardia syndrome.

Postural tachycardia syndrome (POTS) is a multifactorial clinical syndrome defined by an increase in heart rate of ≥30 bpm on standing from supine position (or ≥40 bpm in children). It is associated with symptoms of cerebral hypoperfusion that are worse when upright and improve when in supine position. Patients often have additional symptoms including severe fatigue and difficulty concentrating. There are several possible pathophysiologic mechanisms including hypovolaemia, small-fibre peripheral neuropathy and hyperadrenergic states. POTS can also be associated with several disorders including mastocytosis, Ehlers-Danlos syndrome (hypermobility type) and autoimmune disorders. The treatment is focused on symptom relief and not solely on reducing tachycardia. Given its varying presentations, it is important to employ a practical, mechanism-focused approach to the diagnosis and management of POTS.

Cardiovascular responses to orthostasis and their association with falls in older adults.

BACKGROUND: Orthostatic hypotension (OH) refers to a marked decline in blood pressure when upright. OH has a high incidence and prevalence in older adults and represents a potential intrinsic risk factor for falls in these individuals. Previous studies have not included more recent definitions for blood pressure responses to orthostasis, including initial, delayed, and recovery blood pressure responses. Furthermore, there is little research examining the relationships between cerebrovascular functioning and falling risk. Therefore, we aimed to: (i) test the association between different blood pressure responses to orthostatic stress and retrospective falling history and; (ii) test the association between cerebrovascular responses to orthostatic stress and falling history. METHODS: We tested 59 elderly residents in long term care facilities who underwent a passive seated orthostatic stress test. Beat-to-beat blood pressure and cerebral blood flow velocity (CBFV) responses were assessed throughout testing. Risk factors for falls and falling history were collected from facility records. Cardiovascular responses to orthostasis were compared between retrospective fallers (≥1 fall in the previous year) and non-fallers. RESULTS: Retrospective fallers had larger delayed declines in systolic arterial pressure (SAP) compared to non-fallers (p = 0.015). Fallers also showed poorer early (2 min) and late (15 min) recovery of SAP. Fallers had a greater decline in systolic CBFV. CONCLUSIONS: Older adults with a positive falling history have impaired orthostatic control of blood pressure and CBFV. With better identification and understanding of orthostatic blood pressure impairments earlier intervention and management can be implemented, potentially reducing the associated risk of morbidity and mortality. Future studies should utilize the updated OH definitions using beat-to-beat technology, rather than conventional methods that may offer less accurate detection.

Orthostatic hypotension: managing a difficult problem.

Orthostatic hypotension (OH) leads to a significant number of hospitalizations each year, and is associated with significant morbidity and mortality among affected individuals. Given the increased risk for cardiovascular events and falls, it is important to identify the underlying etiology of OH and to choose appropriate therapeutic agents. OH can be non-neurogenic or neurogenic (arising from a central or peripheral lesion). The initial evaluation includes orthostatic vital signs, complete history and a physical examination. Patients should also be evaluated for concomitant symptoms of post-prandial hypotension and supine hypertension. Non-pharmacologic interventions are the first step for treatment of OH. The appropriate selection of medications can also help with symptomatic relief. This review highlights the pathophysiology, clinical features, diagnostic work-up and treatment of patients with neurogenic OH.

The effect of orthostatic stress type on cardiovascular control.

OBJECTIVES: We aimed to compare the cardiovascular responses of a novel orthostatic stress test, the passive seated orthostatic stress test (PSOST), with those during passive head-up tilt testing (HUTT). We hypothesized that cardiovascular responses during PSOST would be similar to those during HUTT (the 'gold standard'). METHODS: We tested 15 healthy volunteers, who underwent both PSOST and HUTT during one session in a random order. We measured beat-to-beat blood pressure, heart rate, peripheral resistance, stroke volume, cardiac output, and middle cerebral artery blood flow velocity during each test. RESULTS: Blood pressure responses were not significantly different between PSOST and HUTT, except for a significantly lower delayed nadir and 15-min recovery value in systolic arterial pressure during HUTT. HUTT elicited a significantly larger increase in heart rate during all test intervals in comparison with PSOST, as well as a larger decline in stroke volume during almost all test intervals. Responses for the other hemodynamic variables were not significantly different between the tests at any test interval. Repeated HUTT has large inherent variability, which was also evident from the variability in the mean differences on comparing PSOST and HUTT. There was a significant bias for larger heart rate increases (P<0.01) and a greater delayed systolic arterial pressure decline during HUTT. CONCLUSION: We have shown that PSOST and HUTT elicit similar blood pressure and cerebrovascular responses in the early stages of the upright phase. We believe that PSOST is a reasonable surrogate for HUTT in assessing orthostatic hypotension in population groups that are unable to stand for prolonged periods of time.

The relationship between orthostatic hypotension and falling in older adults.

Falls are devastating events and are the largest contributor towards injury-related hospitalization of older adults. Orthostatic hypotension (OH) represents an intrinsic risk factor for falls in older adults. OH refers to a significant decrease in blood pressure upon assuming an upright posture. Declines in blood pressure can reduce cerebral perfusion; this can impair consciousness, lead to dizziness, and increase the likelihood of a fall. Although theoretical mechanisms linking OH and falls exist, the magnitude of the association remains poorly characterized, possibly because of methodological differences between previous studies. The use of non-invasive beat-to-beat blood pressure monitoring has altered the way in which OH is now defined, and represents a substantial improvement for detecting OH that was previously unavailable in many studies. Additionally, there is a lack of consistency and standardization of orthostatic assessments and analysis techniques for interpreting blood pressure data. This review explores the previous literature examining the relationship between OH and falls. We highlight the impact of broadening the timing, degree, and overall duration of blood pressure measurements on the detection of OH. We discuss the types of orthostatic stress assessments currently used to evaluate OH and the various techniques capable of measuring these often transient blood pressure changes. Overall, we identify future solutions that may better clarify the relationship between OH and falling risk in order to gain a more precise understanding of potential mechanisms for falls in older adults.