Effects of ground EMS and ED personnel on air medical trauma on-site times.

INTRODUCTION: On-site times for helicopter EMS (HEMS) providers are hypothesized to increase when procedures indicated by national standards of care and local HEMS are not consistently completed by ground EMS (GEMS) or ED providers before HEMS arrival in trauma cases. METHODS: In this prospective study, we divided all trauma missions (120) flown by a university-based HEMS during a 3-month period into interfacility missions (between hospitals, ground providers are ED personnel) and scene missions (between scenes and hospitals, ground providers are GEMS). HEMS completed forms identifying which procedures were completed and omitted by GEMS or ED providers. We collected relevant times from county dispatchers and HEMS flight control. RESULTS: Ground providers frequently did not complete indicated basic and advanced procedures. A relationship existed between scene GEMS omissions and HEMS on-site times. If no procedures were omitted, average HEMS time on-site was 13 minutes, increasing to 17 minutes for one procedure omitted and 20 minutes for two or more. No relationship was found on interfacility missions between ED provider omissions and HEMS on-site times. However, any existing effect may have been eclipsed by external factors significantly extending HEMS on-site times (mean 43 minutes). An average of 93 minutes elapsed between the request for HEMS transport and patient arrival at the transferring hospital. CONCLUSION: GEMS frequently omit indicated procedures. For scene missions, reducing the number of indicated procedures omitted by scene GEMS providers could reduce on-site HEMS times. For interfacility missions, further study is indicated to determine what occurs before HEMS is contacted and while HEMS is on-site.

Dysphonia and dysphagia following the anterior approach to the cervical spine.

BACKGROUND: Speech and swallowing dysfunctions are common following the anterior approach to the cervical spine. Despite functional morbidity and legal implications, the incidence and etiologic factors of these complications have not been adequately elucidated. OBJECTIVE: To better define speech and swallowing dysfunction both in the quantitative and qualitative sense. METHODS: A questionnaire was mailed to 497 patients who had undergone anterior cervical fusion or anterior cervical discectomy at a university hospital (study group). One hundred fifty questionnaires were sent to a control group. RESULTS: The study group response rate was 46%; the control group response was 51%. The incidence of hoarseness in the study group was 51%; the incidence in the control group was 19%. The difference was statistically significant (P<.01). Dysphagia was present in 60% of study group patients vs 23% of control group patients (P<.01). Qualitative questions revealed that constant hoarseness, pain with talking, difficulty eating solid foods, and odynophagia were significantly more common following the anterior approach to the cervical spine. CONCLUSIONS: Our findings show a much higher incidence than previously reported of both voice and swallowing impairment following the anterior approach to the cervical spine. Hoarseness and dysphagia may adversely affect recovery and the patient's sense of well-being. Preoperative counseling and postoperative evaluation are essential.

A rare complication of aortic valve endocarditis: diagnosis with transesophageal echocardiography.

Rupture of the membranous interventricular septum resulting in a left ventricular to right atrial shunt is a rare complication of endocarditis. Early recognition of this complication is essential because these patients require early surgical intervention. We report a case of a left ventricular-right atrial shunt complicating aortic valve endocarditis in which transesophageal echocardiography was used to accurately diagnose the lesion before surgery. We will discuss the role of transesophageal echocardiography in the diagnosis of this lesion and will review the existing literature pertaining to this rare complication.

Five-year follow-up study of the prevalence and progression of pulmonary hypertension in systemic lupus erythematosus.

The purpose of this study was to determine the prevalence and progression of pulmonary hypertension over a 5-year follow-up period in 28 patients with systemic lupus erythematosus (SLE) who were originally enrolled in an echocardiographic study of pulmonary hypertension in 1985 and 1986. Twenty healthy volunteers without cardiac or pulmonary disease participated as normal controls. Each patient and control underwent a complete Doppler echocardiographic study. Doppler echocardiographic recordings of tricuspid insufficiency, with saline contrast enhancement when necessary, were used to calculate pulmonary artery systolic pressure according to the modified Bernoulli equation. Doppler echocardiographic measurement of cardiac output was performed at rest for each subject, and pulmonary resistance was calculated by dividing the pulmonary artery systolic pressure by the cardiac output. These results were compared to results of the original studies to detect serial changes in pulmonary pressure and pulmonary resistance; results were also compared to the group of normal controls. The prevalence of pulmonary hypertension increased from 14% at the first study to 43% at follow-up. A significant increase in mean systolic pulmonary artery pressure was detected in the SLE patients during the follow-up period: 23.4 vs 27.5 mm Hg (p < 0.005). In addition, a significantly higher pulmonary artery pressure was detected in the SLE patients compared with the normal controls (p < 0.005).(ABSTRACT TRUNCATED AT 250 WORDS)

Transesophageal echocardiographic diagnosis of a ruptured tricuspid valve chordae tendinae as the etiology for cardiogenic shock.

Acute tricuspid insufficiency is an uncommon cause of cardiogenic shock. Previous reported cases have involved patients with right ventricular infarction. We report a case of acute tricuspid insufficiency causing cardiogenic shock in a patient without evidence of right ventricular infarction. Transesophageal echocardiography (TEE) was used to diagnose a ruptured chordae tendinae as the etiology of tricuspid insufficiency.

Evaluation of left atrial contribution to left ventricular filling in aortic stenosis by velocity-encoded cine MRI.

Velocity-encoded cine MRI (VEC-MRI) can measure volume flow at specified site in the heart. This study used VEC-MRI to measure flow across the mitral valve to compare the contribution of atrial systole to left atrial filling in normal subjects and patients with left ventricular hypertrophy. The study population consisted of 12 normal subjects (mean age 34.5 years) and nine patients with various degrees of left ventricular hypertrophy resulting from aortic stenosis (mean age 70 years). VEC-MRI was performed in double-oblique planes through the heart to measure both the mitral inflow velocity pattern (E/A ratio) and the volumetric flow across the mitral valve. The left atrial contribution to left ventricular filling (AC%) was calculated. The results were compared with Doppler echocardiographic parameters. The VEC-MRI-derived mitral E/A ratios showed a significant linear correlation with E/A ratios calculated from Doppler echocardiography (r = 0.94), and the VEC-MRI-derived E/A ratios (2.1 +/- 0.5 vs 1.0 +/- 0.4) and AC% values (24.9 +/- 7.2 vs 45.7 +/- 16.4) were significantly different between normal subjects and patients with aortic stenosis (p < 0.01 in both groups). The same differences were seen in the Doppler echocardiographic parameters. The VEC-MRI-derived E/A ratio and AC% showed significant hyperbolic and linear correlations with left ventricular mass indexes (r = 0.95 and 0.86). In addition, the VEC-MRI-determined E/A ratio and the volumetric AC% displayed a highly significant hyperbolic correlation (r = 0.95). Thus VEC-MRI can be used to evaluate left ventricular diastolic filling characteristics in normal subjects and patients with abnormalities of diastolic filling.

Exercise capacity and hemodynamics in systemic lupus erythematosus: a Doppler echocardiographic exercise study.

Although pulmonary hypertension is a well-described manifestation of systemic lupus erythematosus, there are few data regarding the pulmonary artery pressure response to exercise. We hypothesized that exercise capacity was reduced and that the pulmonary artery pressure response to exercise was abnormal in patients with systemic lupus erythematosus. To test these hypotheses, we performed Doppler exercise echocardiography in 18 patients with lupus and 10 normal control subjects. Exercise duration was significantly reduced in the patients with lupus (8.1 vs 14.4 minutes for control subjects, p < or = 0.001). Pulmonary artery pressure was significantly higher in the patients with lupus at rest and during the first two stages of exercise (p < 0.05). Cardiac indexes at rest were similar in the two groups, suggesting that increased pulmonary vascular resistance was the mechanism for the higher pulmonary pressure we observed. We conclude that abnormal exercise hemodynamics may contribute to reduced exercise capacity in patients with lupus.

Pulsed Doppler characterization of left atrial appendage flow.

Recent evidence suggests that left atrial (LA) appendage velocities may provide clues to the thrombogenic potential of this structure. Pulsed Doppler evaluation of LA appendage flow during transesophageal echocardiography was performed in 109 patients to evaluate the effects of rhythm, mitral regurgitation, and spontaneous contrast. During sinus rhythm, there was a forward LA appendage contraction wave of 46 +/- 18 cm/sec followed by a retrograde filling wave of 46 +/- 17 cm/sec. In 40% of the patients in sinus rhythm, additional forward and retrograde velocities of 23 +/- 10 and 22 +/- 11 cm/sec, respectively, were seen. In contrast, atrial fibrillation was associated with reduced forward and retrograde flows in an irregularly irregular pattern. In sinus rhythm moderate to severe mitral regurgitation did not appear to affect the LA appendage velocities. Last, although forward LA appendage velocities were found to be significantly reduced in patients with spontaneous contrast by univariate analysis, multivariate analysis demonstrated that only the presence of atrial fibrillation was a significant predictor for spontaneous contrast.

The left ventricle in systemic lupus erythematosus: initial observations and a five-year follow-up in a university medical center population.

The objectives of this study were to determine the natural history of abnormalities in left ventricular size and function in patients with systemic lupus erythematosus and to determine whether changes in ventricular function can be attributed to a primary lupus cardiomyopathy. The design was a prospective 5-year follow-up study in a university hospital. There were 28 patients with systemic lupus erythematosis who were enrolled in an echocardiographic study from 1985 to 1986 and who were available for follow-up echocardiographic examinations. Patients were prospectively subgrouped according to the presence or absence of systemic hypertension. Twenty healthy volunteers participated as normal control subjects. Measurements of left ventricular mass index, mean wall thickness, volumes, and ejection fraction and Doppler indices of mitral inflow were performed on all patients and control subjects. Increases in left ventricular mass index, mean wall thickness, and end-systolic volume and decreases in ejection fraction were seen in the patients with lupus when compared with control subjects (p < or = 0.05) and were related to the presence of hypertension and coronary artery disease. In the group of patients without hypertension, no significant differences in left ventricular mass index, volumes, or ejection fraction were detected when compared with the control group. The normotensive patients did demonstrate mild abnormalities of mitral inflow that did not worsen during the follow-up period. It was concluded that abnormalities of systolic and diastolic left ventricular function are common in patients with lupus, are progressive over time, and are related to the coexistence of hypertension and coronary artery disease.(ABSTRACT TRUNCATED AT 250 WORDS)

Transesophageal echocardiographically detected atherosclerotic aortic plaque is a marker for coronary artery disease.

OBJECTIVES: The aim of this study was to test the hypothesis that atherosclerotic plaque in the thoracic aorta detected by transesophageal echocardiography is a marker for coronary artery disease. BACKGROUND: Previous pathologic and roentgenographic studies have suggested a relation between aortic plaque and coronary artery disease but have lacked clinical utility. METHODS: We performed transesophageal echocardiography on 61 patients (30 women and 31 men aged 22 to 83 years [mean 60 +/- 14]) who had previously undergone cardiac catheterization with coronary angiography. The clinical indications for angiography were angina (n = 26), valvular heart disease (n = 17), positive noninvasive evaluation for ischemia without angina (n = 6), postmyocardial infarction (n = 5), familial hypercholesterolemia (n = 4), coronary cameral fistula (n = 1), atrial myxoma (n = 1) and suspected aortic dissection (n = 1). All patients underwent transesophageal echocardiography with imaging of the thoracic aorta. The criteria used to diagnose atherosclerotic plaque on transesophageal echocardiography were the presence of linear or focal increased echo-density with lumen irregularity and thickening or calcification of the aortic intima. RESULTS: In 41 of the 61 patients, obstructive coronary artery disease was detected by angiography in at least one vessel (> 50% left main coronary artery stenosis or > 70% stenosis in the left anterior descending, right coronary or left circumflex artery distribution). In 37 of the 41, atherosclerotic plaque was detected in the thoracic aorta by transesophageal echocardiography. Twenty of the 61 patients had normal coronary angiographic findings or nonobstructive lumen irregularities. In 2 of these 20 patients, plaque was detected in the thoracic aorta on transesophageal echocardiography. The presence of aortic plaque on transesophageal study had a sensitivity of 90% and a specificity of 90% for angiographically proved obstructive coronary artery disease. The positive predictive value of aortic plaque for obstructive coronary artery disease was 95% and the negative predictive value was 82%. CONCLUSIONS: The detection of atherosclerotic plaque in the thoracic aorta by transesophageal echocardiography appears to be a marker for the identification of obstructive coronary artery disease and deserves further investigation.

Pulmonary valve endocarditis: improved diagnosis with biplane transesophageal echocardiography.

Pulmonary valve endocarditis is an uncommon disease. Improved visualization of the pulmonary valve on the longitudinal views provided by biplane transesophageal echocardiography (TEE) improves the diagnostic utility of TEE in pulmonary valve endocarditis. We report three cases of isolated pulmonary valve endocarditis diagnosed with biplanar TEE.