Postpartum aortic dissection diagnosed by point-of-care ultrasound in the emergency department: A case study.

Aortic dissection is a rare but clinically significant cause of chest pain in the emergency department (ED). While classic risk factors include advanced age, male sex, and tobacco use, pregnancy is also an independent and easily overlooked risk factor. Aortic dissection carries both high maternal and fetal morbidity and mortality. Point-of-care ultrasound is increasingly employed in the ED and has been shown to be useful in the evaluation of abdominal aortic pathologies. We present a case in which abdominal aortic ultrasound was utilized in the diagnosis of an acute Stanford type B aortic dissection in a recently postpartum patient.

Bupropion Overdose Complicated by Cardiogenic Shock Requiring Vasopressor Support and Lipid Emulsion Therapy.

BACKGROUND: Bupropion overdose is a commonly encountered presentation in the emergency department (ED). While the majority of cases resolve with supportive care, serious adverse effects, including seizures, cardiogenic shock, and death, can occur. Intravenous lipid emulsion (ILE) therapy has been utilized for a multitude of poisonings with varying levels of success. Although a number of cases suggest the value of ILE therapy in cases of bupropion overdose, more recent data propose that its role may be overstated. CASE REPORT: A young woman presented to the ED with altered mental status complicated by seizure after bupropion overdose. She subsequently developed cardiogenic shock requiring vasopressor support. Bedside echocardiogram revealed a decreased left ventricular ejection fraction (LVEF). She received ILE therapy with significant improvement in both hemodynamic status and LVEF by bedside ultrasound. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Although the majority of patients presenting with bupropion overdose improve with supportive care, life-threatening sequelae are possible. ILE therapy has shown promise in a variety of different overdose situations, although the evidence in cases of bupropion poisoning has been varied, and it has traditionally been utilized as a last-line rescue modality. Based on hemodynamic parameters and bedside ultrasound, this case suggests that early initiation of ILE therapy should be considered in these cases, as the potential benefits likely outweigh the theoretical risks.

A Low-Fidelity, High-Functionality Ultrasound-Guided Serratus Plane Block Model.

BACKGROUND: Thoracic injuries present many challenges for management in the acute and inpatient settings, including achieving appropriate pain control. Traditional modalities, such as opioids and spinal epidural anesthesia, are associated with multiple complications. Ultrasound-guided regional nerve blocks are becoming more prevalent, and they have been shown to be an effective modality of pain control for other traumatic injuries. Models comprised of animal tissue to simulate human anatomy are widely utilized to facilitate training of needle-guided procedures, but no such model for the serratus anterior plane block has yet been defined in the literature. OBJECTIVES: Our goal was to produce a high-functionality serratus anterior plane block model with reasonable anatomic fidelity from low-cost materials. DISCUSSION: We describe the creation of an inexpensive high-functionality serratus anterior plane block model from common materials, including pork ribs and chicken breasts, to realistically simulate human anatomy, including multiple muscle and fascial planes, as well as to allow hydrodissection. CONCLUSIONS: This model will facilitate training and can improve success when caring for patients with thoracic trauma.

Epinephrine Administered for Anaphylaxis Unmasking a Type 1 Brugada Pattern on Electrocardiogram.

BACKGROUND: Brugada pattern on electrocardiography (ECG) can manifest as type 1 (coved pattern) and type 2 (saddleback pattern). Brugada syndrome represents an ECG with Brugada pattern in a patient with symptoms or clinical factors, including syncope, cardiac arrest, ventricular dysrhythmias, and family history. Brugada syndrome is caused by a genetic channelopathy, but the Brugada pattern may be drug-induced. Epinephrine-induced Brugada pattern has not been reported previously. CASE REPORT: A 63-year-old man developed anaphylaxis secondary to a bee sting, had a transient loss of consciousness, and self-administered intramuscular epinephrine. He subsequently presented to the emergency department and was found to have a type 1 Brugada pattern on ECG that resolved during observation. A historic ECG was reviewed that demonstrated a baseline type 2 Brugada pattern. His anaphylaxis was managed with steroids and antihistamines. He was observed without subsequent dysrhythmic events on telemetry or any further symptoms. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The differential diagnosis for syncope includes dysrhythmia, such as Brugada syndrome. Among other possible drugs, epinephrine may induce a type 1 Brugada pattern. Patients with Brugada pattern on ECG should be referred immediately to electrophysiology for consideration of implantation of a cardioverter-defibrillator device, given the association of Brugada pattern with sudden cardiac arrest and ventricular dysrhythmias.

Direct cerebral oxygenation monitoring--a systematic review of recent publications.

This review has been compiled to assess publications related to the clinical application of direct cerebral tissue oxygenation (PtiO2) monitoring published in international, peer-reviewed scientific journals. Its goal was to extract relevant, i.e. positive and negative information on indications, clinical application, safety issues and impact on clinical situations as well as treatment strategies in neurosurgery, neurosurgical anaesthesiology, neurosurgical intensive care, neurology and related specialties. For completeness' sake it also presents some related basic science research. PtiO2 monitoring technology is a safe and valuable cerebral monitoring device in neurocritical care. Although a randomized outcome study is not available its clinical utility has repeatedly been clearly confirmed because it adds a monitoring parameter, independent from established cerebral monitoring devices. It offers new insights into cerebral physiology and pathophysiology. Pathologic values have been established in peer-reviewed research, which are not only relevant to outcome but are treatable. The benefits clearly outweigh the risks, which remains unchallenged in all publications retrieved. It is particularly attractive because it offers continuous, real-time data and is available at the bedside.

Cerebral autoregulation and ageing.

Little is known about the effects of ageing on cerebral autoregulation (CA). To examine the relationship between age and CA in adults, we conducted a prospective study using a non-invasive protocol without external stimuli. We studied 32 subjects, aged 23-68 years. They were assigned to a young group (28+/-5 years) and an old group (54+/-8 years). The groups were sex-matched. Transcranial Doppler ultrasonography (TCD) was used to record bilateral middle cerebral artery flow velocities (CBFV, cm/sec). Noninvasive beat-to-beat tonometric arterial blood pressure (ABP) measurement of the radial artery was used to record spontaneous blood pressure fluctuations. The Mx, an index of dynamic cerebral autoregulation (dCA), was calculated from a moving correlation between ABP and CBFV. We did not find a correlation between age and Mx. No statistically significant difference in the Mx between the groups (0.27+/-0.23, young, vs. 0.37+/-0.24, old) was demonstrated. Age does not affect dynamic cerebral autoregulation assessed by the Mx index in healthy adult subjects. This study supports findings from previous papers wherein CA was measured with protocols which require external stimuli. Further studies are needed to determine CA in subjects above 70 years of age.

Multimodality monitoring in severe traumatic brain injury: the role of brain tissue oxygenation monitoring.

Traumatic brain injury (TBI) is a major cause of morbidity and mortality with widespread social, personal, and financial implications for those who survive. TBI is caused by four main events: motor vehicle accidents, sporting injuries, falls, and assaults. Similarly to international statistics, annual incidence reports for TBI in Australia are between 100 and 288 per 100,000. Regardless of the cause of TBI, molecular and cellular derangements occur that can lead to neuronal cell death. Axonal transport disruption, ionic disruption, reduced energy formation, glutamate excitotoxicity, and free radical formation all contribute to the complex pathophysiological process of TBI-related neuronal death. Targeted pharmacological therapy has not proved beneficial in improving patient outcome, and monitoring and maintenance of various physiological parameters is the mainstay of current therapy. Parameters monitored include arterial blood pressure, blood gases, intracranial pressure, cerebral perfusion pressure, cerebral blood flow, and direct brain tissue oxygen measurement (ptiO2). Currently, indirect brain oximetry is used for cerebral oxygenation determination, which provides some information regarding global oxygenation levels. A newly developed oximetry technique, has shown promising results for the early detection of cerebral ischemia. ptiO2 monitoring provides a safe, easy, and sensitive method of regional brain oximetry, providing a greater understanding of neurophysiological derangements and the potential for correcting abnormal oxygenation earlier, thus improving patient outcome. This article reviews the current status of bedside monitoring for patients with TBI and considers whether ptiO2 has a role in the modern intensive care setting.

Noninvasive cerebrovascular autoregulation assessment in traumatic brain injury: validation and utility.

A moving correlation index (Mx-CPP) of cerebral perfusion pressure (CPP) and mean middle cerebral artery blood flow velocity (CBFV) allows continuous monitoring of dynamic cerebral autoregulation (CA) in patients with severe traumatic brain injury (TBI). In this study we validated Mx-CPP for TBI, examined its prognostic relevance, and assessed its relationship with arterial blood pressure (ABP), CPP, intracranial pressure (ICP), and CBFV. We tested whether using ABP instead of CPP for Mx calculation (Mx-ABP) produces similar results. Mx was calculated for each hemisphere in 37 TBI patients during the first 5 days of treatment. All patients received sedation and analgesia. CPP and bilateral CBFV were recorded, and GOS was estimated at discharge. Both Mx indices were calculated from 10,000 data points sampled at 57.4Hz. Mx-CPP > 0.3 indicates impaired CA; in these patients CPP had a significant positive correlation with CBFV, confirming failure of CA, while in those with Mx < 0.3, CPP was not correlated with CBFV, indicating intact CA. These findings were confirmed for Mx-ABP. We found a significant correlation between impaired CA, indicated by Mx-CPP and Mx-ABP, and poor outcome for TBI patients. ABP, CPP, ICP, and CBFV were not correlated with CA but it must be noted that our average CPP was considerably higher than in other studies. This study confirms the validity of this index to demonstrate CA preservation or failure in TBI. This index is also valid if ABP is used instead of CPP, which eliminates the need for invasive ICP measurements for CA assessment. An unfavorable outcome is associated with early CA failure. Further studies using the Mx-ABP will reveal whether CA improves along with patients' clinical improvement.

Therapeutic approaches to vasospasm in subarachnoid hemorrhage.

Delayed vasospasm as a result of subarachnoid blood after rupture of a cerebral aneurysm is a major complication. It is seen in over half of patients and causes symptomatic ischemia in about one third. If left untreated, it leads to death or permanent deficits in over 20% of patients. The essential cause and the relative contribution of true muscle spasm and other changes in the vessel wall remain uncertain. The mainstays of treatment are careful maintenance of fluid balance, induced hypervolemia and hypertension, calcium antagonists, balloon or chemical angioplasty, and, in some centers, cisternal fibrinolytic drugs. Promising future lines of treatment include gene therapy, nitric oxide donors, magnesium, sustained release cisternal drugs, and several other drugs that are under experimental or clinical trial.

Facial nerve palsy after intracisternal papaverine application during aneurysm surgery--case report.

A 61-year-old woman suffered transient mydriasis and prolonged facial nerve palsy after intracisternal papaverine application subsequent to elective clipping of an unruptured middle cerebral artery aneurysm. The mydriasis resolved within 90 minutes, but the facial nerve dysfunction persisted for 2 months before complete recovery. Prolonged irrigation of the cisterns may have washed the papaverine into contact with the facial nerve. This case supports previously reported evidence of a possible effect of topical intracisternal papaverine hydrochloride application on the facial nerve.

Organizational predictors of prenatal HIV counseling and testing.

OBJECTIVES: Efforts to prevent perinatal transmission of HIV include implementation of prenatal counseling and testing programs. The objective of this study was to assess organizational predictors of HIV counseling and testing. METHODS: Surveillance records were collected on 5900 prenatal patients from 9 hospital and community clinics in Connecticut. RESULTS: Some organizational factors (e.g., type of clinic, dedicated staff) that enhanced counseling rates had the opposite effect on test acceptance. For instance, patients were more likely to be counseled when counseling was conducted by providers; however, test acceptance was more likely when dedicated counselors were available. CONCLUSIONS: These results provide important information concerning clinic resources needed as HIV counseling and testing services continue to be incorporated into prenatal care.

Primary hypothyroidism presenting as a pituitary mass.

Pituitary enlargement secondary to primary hypothyroidism is a known but uncommon occurrence, which can be difficult to distinguish on computerized tomography (CT) and magnetic resonance imaging (MRI) from primary pituitary tumors. We describe a 33 year old female who was referred to a neurosurgeon for removal of a pituitary mass. The markedly elevated thyrotrophin stimulating hormone (TSH), absence of clinical features of hyperthyroidism, and low thyroid hormone values led to a diagnosis of pituitary enlargement secondary to primary hypothyroidism. The pituitary gland returned to normal size with thyroxine replacement therapy. Surgery was not indicated.

Single daily dose of methimazole compared to every 8 hours propylthiouracil in the treatment of hyperthyroidism.

This study to compare single-dose and multiple-dose antithyroid therapy was prompted by a perceived lack of compliance in our University Medical Clinics by those patients using multidose regimens. Twenty-two hyperthyroid patients were randomly assigned to two therapy groups. Twelve received methimazole (Tapazole) 30 mg once daily in the morning; 10 received propylthiouracil 100 mg every 8 hours. Patients were seen every 4 weeks for 3 months and assessed clinically, as well as having the appropriate thyroid tests done. Univariate analysis revealed no difference in the two groups at baseline. Posttreatment assessment revealed the once-a-day methimazole therapy to be just as effective as propylthiouracil in improving thyroid indices and clinical markers. Compliance with methimazole was 83.3% compared to 53.3% with propylthiouracil. In conclusion, once-a-day methimazole was just as effective as propylthiouracil every 8 hours in this population. Compliance was also improved with the once-a-day therapy.

Intrarenal aneurysm associated with "Ask-Upmark kidney": imaging pitfalls and limitations.

The imaging of a case of intrarenal aneurysm with associated "Ask-Upmark kidney" is presented. Pitfalls and limitations encountered with imaging in this case are discussed. Magnetic resonance imaging (MRI) proved to be the best imaging modality for visualization and characterization of the mass lesions present.

Estrogen replacement in middle-aged women: thermoregulatory responses to exercise in the heat.

Thermoregulatory, cardiovascular, and body fluid responses during exercise in the heat were tested in five middle-aged (48 +/- 2 yr) women before and after 14-23 days of estrogen replacement therapy (ERT). The heat and exercise challenge consisted of a 40-min rest period followed by semirecumbent cycle exercise (approximately 40% maximal O2 uptake) for 60 min. At rest, the ambient temperature was elevated from a thermoneutral (dry bulb temperature 25 degrees C; wet bulb temperature 17.5 degrees C) to a warm humid (dry bulb temperature 36 degrees C; wet bulb temperature 27.5 degrees C) environment. Esophageal (Tes) and rectal (Tre) temperatures were measured to estimate body core temperature while arm blood flow and sweating rate were measured to assess the heat loss response. Mean arterial pressure and heart rate were measured to evaluate the cardiovascular response. Blood samples were analyzed for hematocrit (Hct), hemoglobin ([Hb]), plasma 17 beta-estradiol (E2), progesterone (P4), protein, and electrolyte concentrations. Plasma [E2] was significantly (P < 0.05) elevated by ERT without affecting the plasma [P4] levels. After ERT, Tes and Tre were significantly (P < 0.05) depressed by approximately 0.5 degrees C, and the Tes threshold for the onset of arm blood flow and sweating rate was significantly (P < 0.05) lower during exercise. After ERT, heart rate during exercise was significantly lower (P < 0.05) without notable variation in mean arterial pressure. Isotonic hemodilution occurred with ERT evident by significant (P < 0.05) reductions in Hct and [Hb], whereas plasma tonicity remained unchanged.(ABSTRACT TRUNCATED AT 250 WORDS)

Severe hypertension associated with an intrarenal aneurysm.

A 26-year-old woman with regularly documented normal blood pressure had sudden onset of severe hypertension. Investigation revealed an intrarenal artery aneurysm involving the upper pole of the left kidney, as well as elevated levels of both renin and aldosterone. With ACE inhibitor therapy, blood pressure promptly returned to normal, and subsequent surgical removal of the upper pole of the involved kidney has resulted in normal blood pressure for 9 months of follow-up. Although uncommon, intrarenal aneurysms may lead to severe renal vascular hypertension that is relieved by surgery. This definitive procedure may not take place if one is not aware of the excellent response to ACE inhibitors in this situation.

Disposable insulin syringe reuse and aseptic practices in diabetic patients.

Diabetic patients are traditionally taught to discard plastic syringe/needle units after a single use and to employ aseptic technique for administering insulin injections. We surveyed 87 diabetic outpatients for compliance with aseptic recommendations. We then studied prospectively the effects of reusing disposable syringes in 56 diabetic patients who reused syringes a mean of 6.6 times for 8.3 months and an aggregate of 23,664 injections. Almost half (49%) of diabetic patients in a combined university clinic and private practice reused supposedly disposable insulin syringes a mean of 3.9 times. Compliance with standard aseptic precautions was poor, with only 29% of patients following recommended practices. No adverse effect of syringe reuse was identified. The authors conclude that diabetic patients frequently reuse disposable syringes, without apparent harmful effect.

Medical and financial implications of discontinuing a statewide free insulin program involving 3,720 people.

In 1981 a statewide program supplying free insulin to 3,720 patients of state health clinics was discontinued. We attempted to assess whether this action had an adverse effect medically and financially on those concerned. A computer randomized sample of 351 patients (9%) was studied by personal interview and questionnaire. Information obtained focused on certain events that occurred 18 months before and after the program ceased. Measurements used to determine medical impact were number of hospitalizations, emergency room and physician visits, changes in weight and glucose levels, and episodes of ketoacidosis. Financial impact was measured by cost of hospitalization and physician visits. Our results revealed no significant changes in any of the medical parameters studied except for fasting serum glucose levels above 300 mg/dl, which occurred less frequently after the free insulin program was discontinued. There were fewer hospitalizations, more visits to physicians, and no change in number of emergency room visits after discontinuance of the free program. The overall cost saving was estimated to be +883,558 for the 18-month study period, in addition to the +550,000 the plan had been costing the state.