Bedside Echocardiography in Acute Myocardial Infarction Patients with Hemodynamic Deterioration.

Ventricular septal (VS) rupture after acute myocardial infarction (AMI) is an uncommon complication in the reperfusion era. Bedside echocardiography (BECH) continues to be a strong diagnostic tool for emergency physicians treating dyspneic patients, especially for decision-making on the management strategies to use with these unstable patients. In the case we present here, a patient is diagnosed with a delayed mechanical complication after AMI, and a swift management plan is made with the aid of point-of-care BECH. The patient is a 72-year-old man with dyspnea who was admitted to the ED 5 days after receiving a primary percutaneous coronary intervention with stent implantation for AMI; in the ED, the patient was diagnosed, via BECH, with a VS rupture. On arrival, his vital signs and the results of his physical examination depicted shock and low perfusion with wet lung. A cardiac examination revealed a new 2/6 harsh holosystolic murmur along the left sternal border without pretibial oedema. Emergency physicians performed BECH, and subcostal views of the heart revealed a wide interventricular septal rupture and left-to-right shunting with minimal pericardial effusion. The patient underwent surgery immediately to repair the defect. The post-operative course was uneventful, and he was discharged in stable condition on the seventh day after the surgery. The use of BECH to recognize a VS rupture is critical because such a defect may be the most important determinant of mortality in AMI patients who are in shock. BECH thus can influence clinicians' acute management and disposition decisions.

Monitoring the response to treatment of acute heart failure patients by ultrasonographic inferior vena cava collapsibility index.

OBJECTIVE: Our aim was to determine if N-terminal pro-brain natriuretic peptide (NT-proBNP) or sonographic measurements of inferior vena caval (IVC) diameters and collapsibility index (IVC-CI) have a role in the monitoring of acute heart failure (AHF) therapy. METHODS: Inferior vena caval diameters of 50 healthy people (control group) were measured to determine the normal values of the IVC parameters. We then prospectively enrolled patients who were admitted to the emergency department (ED) with a primary diagnosis of AHF. At presentation, IVC diameters were measured during expiration and inspiration, and blood was drawn for NT-proBNP. We repeated the measurement of the IVC parameters and collected a second blood sample 12 hours after the therapy was administered. The data were analyzed in SPSS 15.0 (IBM, Armonk, NY) using the Student t test and Mann-Whitney U test. RESULTS: A total of 97 subjects were enrolled: 47 in the patient group and 50 in the control group. The mean IVC during expiration was 2.10 ± 0.37 cm before and 1.57 ± 0.24 cm after the therapy (P < .001). The mean IVC during inspiration was 1.63 ± 0.40 cm before and 0.90 ± 0.26 cm after the therapy (P < .001). The mean IVC-CI rose from 22.80% ± 10.97% to 43.09% ± 13.63% (P < .001). After the therapy, there was no difference between the IVC-CI of the patients and controls (P = .246). There was no significant change in the mean NT-proBNP levels after the therapy. CONCLUSION: Inferior vena caval collapsibility index may be helpful in monitoring AHF patients' responses to therapy in the ED.

The prognostic value of cystatin C compared with trauma scores in multiple blunt trauma: a prospective cohort study.

BACKGROUND: Many scoring systems have been developed to predict the prognosis of the traumatized patients in Emergency Departments, and the necessary calculations make complex scoring systems difficult to use as a part of the initial trauma patient assessment, and they also have limited accuracy. STUDY OBJECTIVE: This study compares the accuracy of cystatin C with trauma scoring systems in predicting the mortality of trauma patients. METHODS: Serum cystatin C levels were measured upon arrival in consecutive adult multiple blunt trauma patients during a 12-month period. Correlation analysis was used to assess the relationship between Injury Severity Score (ISS), Revised Trauma Score (RTS), Glasgow Coma Scale (GCS) Score, and cystatin C. Trauma scores and cystatin C were used in Cox regression models to predict trauma patients' risk of death. RESULTS: During the study period, 153 patients were enrolled and 18 died. There were negative correlations between cystatin C levels and the GCS (r = -0.666, p < 0.001) as well as the RTS (r = -0.229, p = 0.004). A moderate correlation was found between the ISS and the cystatin C level (r = 0.492, p < 0.001). In Cox regression models, every increase in units of cystatin C levels and ISS (the cut-off levels were 0.93 mg/L and ≥ 16, respectively) results in a 4.22- and 1.068-fold increase in mortality, respectively. CONCLUSION: Cystatin C may represent an important severity-of-illness indicator, easily available to clinicians during the initial assessment of trauma victims on admission.