Oesophageal Doppler ultrasound in the assessment of haemodynamic status of patients admitted to the medical intensive care unit with septic shock.

INTRODUCTION: Haemodynamic monitoring is an essential element in the management of critically ill patients in the intensive care unit (ICU). However, there have been increasing concerns about the clinical utility and safety profile of the invasive pulmonary artery catheter (PAC). Oesophageal Doppler (ED) monitoring has emerged recently as a safer and less invasive tool which can be used by the intensivist to estimate cardiac output in the critically ill patient. Validation studies have thus far only been performed in surgical patients perioperatively and in mixed surgical/medical ICU patients. Currently, minimal data are available in any sizeable Asian population or in patients with severe sepsis. The assumption that these normograms and data hold true for our local medical ICU patients may not be valid due to differences in body habitus. MATERIALS AND METHODS: Our primary aim is to validate the oesophageal Doppler as a reliable measure of cardiac index, systemic vascular resistance (SVR) and preload in our local Asian population of patients with severe sepsis and septic shock in the medical ICU. This was a prospective pilot study on 12 consecutive mechanically ventilated patients in our medical ICU with the diagnosis of septic shock as defined by SCCM/ESICM/ACCP/ATS/SIS International Sepsis definitions Conference-Critical Care Medicine 2003 and required PAC haemodynamic monitoring as indicated by Medical Intensive Care Unit attending. RESULTS: Ninety-seven paired cardiac output measurements were made. Cardiac output ranged from 2.87 to 11.0 L/ min (calculated cardiac index ranging from 1.73 to 6.36 L/min/m2) when measured using the PAC with thermodilution technique and from 2.0 to 12.1 L/min (calculated cardiac index of 1.2 to 7.2 L/min/m2) using the trans-oesophageal Doppler. There was moderately good correlation between CIpac and CIed (correlation coefficient, r = 0.762 with PCA = 58%). The mean bias was 0.26 L/min/m2 (P <0.07), while the limit of agreement was +/- 1.44 L/min/m2. CONCLUSION: ED has good correlation with PAC in measuring cardiac index in Asians with septic shock but is an unreliable measure of both pre-load and SVR.

Cardiac troponin T in acute coronary syndrome with renal insufficiency.

Cardiac troponin levels are frequently elevated in patients with chronic renal failure, hence diagnosis of myocardial necrosis is difficult. The prevalence of elevated serum troponin T was determined and its diagnostic value in acute coronary syndrome was assessed in patients with chronic renal insufficiency. A retrospective cross-sectional analysis was performed in 227 patients with chronic renal insufficiency and a diagnosis of unstable angina, non-ST or ST-segment elevation myocardial infarction. All patients had baseline serum troponin T levels measured at previous visits; the baseline troponin T level was raised in 53.3%. Cardiac troponin T levels did not correlate with creatinine levels, and were not affected by dialysis. Mortality after an acute coronary event was high (46.3%). Because of the elevated baseline cardiac troponin T levels, detection of acute coronary syndrome in patients with chronic renal failure requires evaluation of serial cardiac enzyme measurements and serial 12-lead electrocardiograms. Early and definitive cardiac interventions may contribute towards decreasing the mortality rate in this group of patients.

Verapamil for ventricular tachycardia.

Fascicular ventricular tachycardia (VT; also known as left VT) belongs to a subclass of idiopathic VTs. It can be confused with VT and supraventricular tachycardia. It is an entity well recognized by the cardiology community but not as frequently by emergency medicine physicians because of its infrequency. Idiopathic left VT was first described in 1979. Belhassen et al were the first to report on the characteristic termination of this VT with intravenous verapamil, hence accounting for the terms Belhassen VT and verapamil-responsive VT to describe the condition. We report on the cases of 2 patients who presented with complaints of palpitations. The first patient was incorrectly diagnosed with supraventricular tachycardia with aberrant conduction, whereas the second patient was correctly diagnosed with fascicular VT. Both cases were medically converted with verapamil. We also discuss the differentiation of ischemic VT and fascicular VT as well as the related therapeutic options and management approaches.

Broad complex atrial fibrillation.

The management of broad complex atrial fibrillation is complex and may be a source of morbidity and mortality if not correctly recognized and treated appropriately. We present a case series of 3 patients who were managed in our emergency department after complaints of palpitations. They presented with varying forms of rapid atrial fibrillation that had broad complexes on the 12-lead electrocardiogram. The first 2 patients were treated with calcium channel blockers for rate control, and treatment was complicated by rapid arrhythmia that required cardioversion. The final patient was correctly treated with intravenous procainamide. The diagnosis of Wolff-Parkinson-White syndrome was eventually made in all these patients. Broad complex atrial fibrillation must be treated with respect. Cases with rapid ventricular rate can decompensate from mismanagement due to poor ability to recognize the possibility of Wolff-Parkinson-White syndrome in such patients. Procainamide forms the cornerstone of treatment in hemodynamically stable rapid broad complex atrial fibrillation of unknown origin.

When the storm passes unnoticed--a case series of thyroid storm.

INTRODUCTION: Thyroid crisis is an acute manifestation of thyrotoxicosis. Approximately 1-2% of patients progress to a thyroid storm, often precipitated by a physiologically stressful event. If unrecognized or left untreated, thyroid storm may result in cardiovascular collapse and death. AIM: We describe three patients who presented to the Emergency Department of Singapore General Hospital in a thyroid storm. They had complications of thyrocardiac disease with heart failure and arrhythmias. METHODS: An analysis of case records of patients presenting to the emergency department of Singapore General Hospital with a primary diagnosis of thyrotoxicosis was made over the period of 2004-2005. Three patients with thyroid storm were identified. All the patients presented heart failure and cardiac arrhythmias (1 atrial flutter, 2 atrial fibrillation). DISCUSSION AND CONCLUSION: Thyroid storm is a rare manifestation of thyrotoxicosis, usually occurring in females during the third to sixth decades of life. Serious complications such as heart failure and hypotension resulting in cardiovascular collapse and death may occur. Our case series consists of young males presenting with thyrocardiac failure. One patient was treated with beta-blockers and another with calcium channel blockers. Both developed cardiovascular collapse. The third patient was managed with digoxin with a good outcome. The current pathophysiology and therapeutic options are explored. A high index of suspicion should be maintained in young males presenting with heart failure and arrhythmia.

Asthma fatalities at the Emergency Department of the Singapore General Hospital.

BACKGROUND: Bronchial asthma is one of the most common chronic diseases in Singapore and the prevalence is increasing. Despite this, the worldwide mortality rate from asthma has been noted to be low at an average of 2.0 per 100,000 people in developed countries such as the United States. Risk factors for fatal asthma attacks that have been described include excessive use of short acting beta-agonists, errors in clinical judgement, poor compliance, psychosocial disorders, use of three or more groups of asthma medication and indicators of asthma severity. AIM: We aim to study the incidence of asthma deaths occurring in the emergency department of a tertiary care hospital in Singapore. METHODS: Of the total number of patients at the Department of Emergency Medicine in Singapore General Hospital from January 1999 to June 2005, eight fatalities were attributed to exacerbation of bronchial asthma. The characteristics of these patients are described. RESULTS: A low incidence of asthma-related deaths is found in Singapore.

Spontaneous pneumothorax outcome study (SPOT phase I): a 2-year review.

OBJECTIVE: We aim to describe the incidence of spontaneous pneumothorax presenting to the Emergency Department, the treatment given and the outcomes of treatment. METHODS: We conducted a retrospective review of patients with spontaneous pneumothorax presenting to the Emergency Department of the Singapore General Hospital from 1 January 2000 to 31 December 2001. RESULTS: Of a total of 159 patients, with a mean age of 36.1 years (standard deviation 19.3), 94.3% were men, 75 (47.2%) were treated in the Emergency Department with chest-tube insertion, 28 (17.6%) were treated with needle aspiration, and 56 (35.2%) were observed. Significantly more patients had complete re-expansion with chest-tube (65.3%) compared with needle aspiration (17.9%) (P<0.001). Patients with needle aspiration or those being observed were more likely to have a second procedure (P<0.001), whereas patients with chest tubes were more likely to have definitive treatment subsequently (pleurodesis, thoracotomy). The mean duration of hospitalization was significantly longer for chest-tube insertion (7.4 days) compared with other groups (needle aspiration 4 days). There was no significant difference in the complication rates between treatment groups at one year. CONCLUSION: We found a male predominance locally. Treatment with chest-tube insertion is still the most popular method in the Emergency Department. Needle aspiration results in a shorter hospitalization, but a high proportion require a second procedure. Complication rates do not seem to differ from chest-tube insertion.