1/336. Anoxic-hypotensive brain injury: neuropsychological performance at 1 month as an indicator of recovery. DESIGN: This case control study included assessments at 3 and 8 weeks post brain injury. Controls were the non-brain injured subjects whose normative data has been published for neuropsychological measures. Data and medical information were obtained with informed consent. OBJECTIVE: This study explored cognitive sequella of anoxic-hypotensive brain injury following cardiac arrest in a 49 year old man with high premorbid function. RESULTS: Improvement was noted at 3 weeks post-injury. By 8 weeks neuropsychological test scores including verbal and visual memory were in the normal range, although they were likely to be lower than premorbid levels. CONCLUSIONS: Relatively good cognitive function within the first month post-anoxia likely indicates improved recovery and benefit from continued rehabilitation. Despite initial presentation, steep recovery curves can be found among survivors of anoxia with eventual return to independent function including driving/child care and return to gainful employment. rehabilitation teams are encouraged to remember that good cognitive function is not predicted by initial Glasgow coma Scores, but may be predicted by return of recall memory during the first month post-anoxic event. Serial cognitive screens can identify individuals with the potential for better recovery. ( info) |
| Congenital paraplegia, with partial improvement over the first months of life, occurred in a female neonate born at 35 weeks' gestation, whose mother had suffered hypotension and hypoxaemia due to anaphylaxis 12 weeks earlier. Our patient subsequently had an acute encephalopathy during a respiratory illness with later developmental delay. We speculate that the baby's paraplegia resulted from spinal-cord ischaemia in utero. The aim of this report is to describe the spinal presentation. ( info) |
| Hypoxemia during bronchoscopy occurs frequently. It can usually be managed by supplemental oxygen and bronchodilators or, in some cases, occasionally stopping the procedure. benzocaine spray is commonly used as a topical anesthetic agent during bronchoscopy. However, it has been associated with the development of methemoglobinemia. The following is a case report of hypoxia during bronchoscopy from benzocaine-induced methemoglobinemia and its management. ( info) |
4/336. Apneustic breathing in children with brainstem damage due to hypoxic-ischemic encephalopathy. To confirm the presence of apneusis in patients with hypoxic-ischemic encephalopathy and to clarify which factors influence their respiratory patterns, polygraphic studies were performed on two patients. Apneusis was clinically suspected in both patients who had severe brainstem damage. In one subject, inputs of vagal afferents from the gastrointestinal tract and the urinary bladder often resulted in extreme tachypnea instead of apneusis. lung inflation facilitated expiration during inspiratory arrest. Expiration preceded a periodic inhibition of rigospastic discharge in the right biceps muscle. In the other subject, prolonged inspiratory pauses with cyanosis occurred with or without preceding epileptic seizure. Both phenytoin dose reduction and treatment with tandospirone, a serotonin-1A agonist, were effective in improving the respiratory distress in this subject. ( info) |
5/336. drowning and near-drowning--some lessons learnt. Over a period of sixteen months, 17 cases of submersion injury (encompassing victims of drowning and near-drowning) were attended to at our Accident and Emergency Department at Changi General Hospital. Most of the victims were inexperienced recreational swimmers, and in 6 of them, early bystander cardiopulmonary resuscitation enabled them to recover without severe morbidity. Non-cardiogenic pulmonary oedema with resulting chest infection was the commonest complication in survivors. Most of the episodes occurred in an urban setting in swimming pools without supervision by lifeguards. About two-thirds of the cases were adults over the age of fifteen years. In addition, there were patients in whom submersion injury was associated with more sinister conditions (fits, traumatic cervical spine injury, dysbarism, intoxication from alcohol or drugs), some of which were unsuspected by the doctors initially. Apart from the immediate threats of hypoxia and pulmonary injury, active search for any possible precipitating causes and associated occult injury should be made. In this study, the determinants of survival from near-drowning were early institution of cardiopulmonary resuscitation, presence of pupil reactivity, and presence of a palpable pulse and cardiac sinus rhythm. ( info) |
6/336. Hypoxia due to patent foramen ovale in the absence of pulmonary hypertension. In most patients with a patent foramen ovale, blood flows from the left atrium to the right atrium in the absence of pulmonary hypertension. Our report describes a patient with a patent foramen ovale in whom flow occurred from the right atrium to the left atrium in the absence of pulmonary hypertension. We discuss hemodynamic findings and present a brief review of the pertinent medical literature regarding this phenomenon. We also discuss the role of transesophageal echocardiography in the diagnosis of this condition and in the elucidation of the underlying mechanisms, and we suggest several mechanisms that may explain the occurrence of this phenomenon in our patient. ( info) |
7/336. Acquisition of novel semantic information in amnesia: effects of lesion location. Two patients with severe global amnesia are described who differ in the extent to which they have acquired new semantic information. Patient SS, who has extensive medial temporal lobe damage including the hippocampus as well as surrounding cortical areas, has failed to acquire virtually any new information regarding vocabulary or famous faces that entered the public domain since the onset of his amnesia. In contrast, patient PS, who has a selective lesion of the hippocampus proper, has gained a sense of familiarity of novel vocabulary and famous people, even though her effortful retrieval of this new semantic knowledge remains impaired. These findings extend to amnesia of adult onset, the proposal of Vargha-Khadem and colleagues that in patients with selective hippocampal injury, cortical areas surrounding the hippocampus may play an important role in new semantic learning [Vargha-Khadem, F., Gadian, D.G., Watkins, K. E., Connelly, A., Van Paesschen, W. and Mishkin, M., regarding the importance of the subhippocampal cortices in the mediation of new semantic learning in children with hippocampal lesions, science, 1997, 277, 376-380]. ( info) |
| In the management of adult respiratory distress syndrome pressure limited mechanical ventilation may protect the lungs from overdistention injury. Unacceptable hypoxia may be avoided by adding nitric oxide to the inspiratory gas, and thus make pressure limited ventilation easier to perform. There exists no consensus about an acceptable lower limit of SaO2, and in the present case we gave preference to pressure limitation at the cost of oxygenation. A young woman with severe adult respiratory distress syndrome was set on pressure limited mechanical ventilation with peak pressures of 35-38 cm H2O, PEEP of 10-12 cm H2O, and FiO2 of 0.95 with 20 ppm nitric oxide. SaO2 varied between 75 and 85%, and cardiac output ranged between 5.2 and 7.5 L min-1. oxygen consumption was in the upper normal range, and she did not became acidotic. After 3 days, she started to improve. In conclusion, it seems that hypoxia might be well tolerated as long as the circulation is not compromised. It might prove beneficial to accept some hypoxia to avoid ventilator induced lung damage. ( info) |
9/336. Transient swallow syncope during periods of hypoxia in a 67-year-old patient after self-extubation. OBJECTIVE: To describe the case of an adult patient with swallow syncope after bypass surgery, possibly related to hypoxia. DESIGN: Case report. SETTING: University hospital, medical-cardiologic intensive care unit. PATIENT: A 67-yr-old patient after second aortocoronary bypass operation for unstable angina. MAIN RESULTS: After the patient managed to extubate himself, he was in a borderline respiratory condition with an oxygen mask. When drinking for the first time after extubation, asystole was observed coincidentally with interruption of oxygen insufflation. During the next days, similar events occurred during food ingestion or when drinking liquids after a fall of oxygen saturation. The bradyarrhythmia was readily reversible on administration of atropine and ventricular backup pacing via temporary pacing wires. After normalization of gas exchange, no more episodes of swallowing-associated asystole were observed and the patient was discharged without a permanent pacemaker. There was no esophageal or gastrointestinal disease. Pre- and postoperative PR and QRS durations were normal. CONCLUSION: Extrinsic and transient mechanisms, rather than intrinsic conduction system disease, seem to have been operative in this case. It is suggested that hypoxia reinforced the vagal pharyngocardiac reflex as described in pediatric patients. ( info) |
10/336. Beneficial effects of serotonin precursors in postanoxic action myoclonus. In two patients with postanoxic action myoclonus, L-tryptophan or a monoamine oxidase inhibitor induced a moderate improvement, but L-5-hydroxytryptophan had greater therapeutic effect. methysergide, a potent blocker of serotonin receptors, consistently induced a marked deterioration in myoclonus. Pretreatment cerebrospinal fluid 5-hydroxyindoleacetic acid levels were reduced significantly in both patients. These findings suggest that postanoxic action myoclonus likely is associated with insufficient serotonergic activity in the central nervous system. Data are inadequate to determine whether this apparent insufficiency reflects structural changes in 5HT-containing raphe nuclei due to a direct anoxic damage to these structures of functional changes caused by a secondary reduction in the activity of intact serotonergic neurons. ( info) |