1/21. Severe transmyocardial ischemia in a patient with tension pneumothorax.OBJECTIVE: To report tension pneumothorax (TP) as a cause of severe myocardial ischemia. DESIGN: Clinical case report. SETTING: Medical intensive care unit of a university hospital. patients: One patient with severe shock attributable to right TP after unsuccessful percutaneous central venous catheterization. INTERVENTIONS: blood pressure, electrocardiogram (ECG), chest radiograph, and echocardiography during and after shock. MEASUREMENTS AND MAIN RESULTS: On admission the patient was in profound state of shock (heart rate 140 beats/min, blood pressure 65/30 mm Hg). Twelve-lead ECG showed pronounced ST segment elevation in leads II, III, aVF, and V4-V6. Chest radiograph revealed right TP with complete displacement of the mediastinum and the heart to the left side. Immediate right-sided tube thoracostomy resulted in reexpansion of the lung followed by instantaneous hemodynamic and respiratory improvement as well as nearly complete resolution of the ECG changes. Peak value of the creatine phosphokinase was 4140 U/L without significant elevation of the MB isoenzyme at any time. Moreover, the initial hypokinesia of the posterior and lateral left ventricular wall resolved completely, as demonstrated by echocardiography. CONCLUSION: The specific condition of TP may lead to impaired systolic and diastolic coronary artery blood flow affecting ventricular repolarization and T-wave configuration in ECG indicative of transmyocardial ischemia. General symptoms, namely hypotension, tachycardia, and hypoxemia, are likewise typical for cardiogenic shock attributable to myocardial infarction. Yet any therapeutic measure directed toward revascularization, such as thrombolysis or even percutaneous transluminal coronary angioplasty, would have had devastating consequences. Therefore, thorough physical examination of our patient was pivotal in disclosing the true origin of profound shock.- - - - - - - - - - ranking = 1keywords = coronary (Clic here for more details about this article) |
2/21. Unusual petal-like fibromuscular dysplasia as a cause of acute abdomen and circulatory shock.fibromuscular dysplasia (FMD) is a nonatherosclerotic, noninflammatory segmental arterial occlusive disorder that involves primarily the renal and carotid arteries, and less often the coronary, iliac, and visceral arteries. We report the case of 78-year-old Japanese woman who presented with acute abdomen complicated by shock. autopsy revealed hemorrhagic necrosis of the small intestine due to severe narrowing of the mesenteric arteries. Histologically, smooth muscles showed in-bundle hyperplasia surrounding the adventitia together with medial and perimedial fibrodysplasia of these arteries, forming the characteristic petal-like appearance of FMD. No occlusive thrombus was observed. Further, another medial fibrodysplasia type of FMD was also seen in the renal and left circumflex coronary arteries. Unusual proliferation of smooth muscles resulted in the petal-like atypical FMD at the superior mesenteric artery.- - - - - - - - - - ranking = 1keywords = coronary (Clic here for more details about this article) |
3/21. The syndrome of absent or faint second heart sound, rapid systole and forward collapsing pulse.A syndrome consisting of an absent or faint second heart sound, prominent cardiac impulse and non-regurgitant or forward collapse of the pulse is described. There was, moreover, no second sound or flow murmur audible in either the aortic or the pulmonary area even though the impulse and collapsing pulse suggested a hyperdynamic circulation; the upstroke was sharp but without the full waterhammer knock. It is argued that the dominant cause of the collapsing pulse will usually be vasodilation, that absence or faintness of the second sound is due to a narrow angle of divergence between the ventricular and arterial pressure decay curves, and that in marked contrast to aortic regurgitation the quality of the impulse derives from rapid systole of lightly loaded ventricles. Although they described its separate elements, pre-homeostatic era clinicians may have overlooked the syndrome in the belief that the heart regulated a largely passive circulation, regarding only primary intracardiac events and the first heart sound as important. Sir William Stokes nevertheless foresaw that alterations in the second sound might be due to changes in vascular tone as well as in elasticity. Wider recognition, deeper understanding and appropriate correction of this syndrome may prove both useful and enlightening.- - - - - - - - - - ranking = 1.487950873085keywords = circulation (Clic here for more details about this article) |
4/21. Acute management of a cyanotic episode in an infant after a Norwood procedure.In infants with a Norwood stage I reconstruction, the respiratory management to direct pulmonary to systemic blood flow ratio is of critical importance. Disturbance of this delicate blood-flow balance can occur causing rapid deterioration of the infant's condition requiring urgent interventions. However, the emergency staff personnel that are generally the first to be called may not be familiar with these patients' complex pathophysiology. We report on the resuscitation of an infant with a Norwood circulation who developed deep central cyanosis in an out-of-hospital environment. The infant deteriorated because of stenoses in both the neoaortic arch and the aortopulmonary shunt. Emergency therapy, especially for out-of-hospital treatment, can only consist of basic measures, which are discussed.- - - - - - - - - - ranking = 0.7439754365425keywords = circulation (Clic here for more details about this article) |
5/21. prolapse of aortic intimal flap into the left ventricle: a rare cause of global myocardial ischemia in acute type A aortic dissection.A 62-year-old woman experienced an acute type A aortic dissection complicated with profound shock caused by acute myocardial ischemia. Intraoperative transesophageal echocardiography (TEE) identified a circumferentially dissected intimal flap at 5.5 cm above the aortic valve, prolapsing into the left ventricle through the aortic valve during diastole and obstructing both coronary ostia. Acute aortic dissection must be kept in mind when presented with myocardial ischemia and TEE is the most useful method for detecting a prolapsing cylindrical intimal flap.- - - - - - - - - - ranking = 0.5keywords = coronary (Clic here for more details about this article) |
6/21. Nonocclusive mesenteric ischemia associated with propranolol overdose: implications regarding splanchnic circulation.We describe a case of massive propranolol overdose in a healthy 19-year-old woman associated with isolated mesenteric ischemia following shock. We postulate that endogenous catecholamine release from shock combined with massive beta-adrenergic blockade led to severe splanchnic vasoconstriction from unopposed alpha-adrenergic activity. This case supports current thinking regarding the effect of vasoactive mediators on the gastrointestinal tract in humans and might be relevant to the mechanism of action of propranolol in the prophylaxis of variceal bleeding.- - - - - - - - - - ranking = 2.97590174617keywords = circulation (Clic here for more details about this article) |
7/21. Low plasma ionized calcium and response to calcium therapy in critically ill man.Marked lowering of plasma ionized calcium concentrations [Ca ] occurred in eight patients (2 days to 54 years old) who required extensive pharmacologic support of the circulation. [Ca ]'s ranged from 0.21 to 0.53 mM. Only one patient survived. The hypocalcemia occurred in the absence of massive transfusion of citrated whole blood or well after such transfusions had been discontinued. These abnormally low concentrations of ionized calcium were not readily corrected by intravenous administration of calcium salts in doses generally recommended. The process responsible for inadequate hemodynamic function appeared to be associated with a severe disturbance in calcium metabolism. Contribution of the latter to the severity of hemodynamic deterioration is unclear, and little benefit from intravenous calcium therapy was found. In two patients, normal [Ca ] could not be restored by administration of CaCl2 alone, but [Ca ] rose to normal following continued calcium replacement therapy in conjunction with increased isoproterenol infusion. There was no predictable relationship between total and ionized plasma calcium concentrations. Thus, measurement of total calcium provided no indication of the level of the biologically active moiety. [Ca ] was low with both normal and low plasma pH values. The data suggest that a very high infusion rate of CaCl2 may required to restore [Ca ] to normal and that hypocalcemia occurring during low-flow states often cannot be corrected by calcium therapy alone. It is recommended that calcium replacement therapy be undertaken only with close monitoring of [Ca ].- - - - - - - - - - ranking = 0.7439754365425keywords = circulation (Clic here for more details about this article) |
8/21. necrosis of the colon as a complication of shock.Colonic necrosis secondary to hypotension and shock in previously healthy, young patients is a rare occurrence with only ten cases reported in the literature. In all but one instance the necrosis was limited to the right colon. Three additional cases of transmural necrosis involving both the right and left colon following a documented episode of shock are reported. Two cases were related to hemorrhagic shock following trauma and the third case followed a drug overdose with associated hypotension. An episode of hypotension was the common denominator in all cases previously reported. The lowest mean blood pressure in the present series was 35 mmHg. A diagnosis of subtotal colonic infarction was made at laparotomy in these three patients two to nine days after the initial hypotensive episode. Pathologic examination of the excised colon revealed transmural necrosis in all three cases with no evidence of a thrombotic or embolic process accounting for the colonic necrosis. The etiology was felt to be a low flow state within the splanchnic circulation. The data suggests that patients who present with a history of prolonged hypotension and shock are at risk for the development of colonic infarction. Successful management involves early diagnosis and resection of the infarcted colon.- - - - - - - - - - ranking = 0.7439754365425keywords = circulation (Clic here for more details about this article) |
9/21. Cardiac beriberi. A report of 4 cases.Four cases of beriberi were diagnosed on clinical grounds and 3 were confirmed biochemically. The cases cover a spectrum of beriberi heart disease ranging from a hyperdynamic circulation to circulatory shock. They are Shoshin beriberi, beriberi with high output failure, beriberi with signs of a hyperdynamic circulation alone and beriberi with underlying cardiomyopathy.- - - - - - - - - - ranking = 1.487950873085keywords = circulation (Clic here for more details about this article) |
10/21. Reversible hypovolaemic shock and myocardial ischaemia caused by contrast medium administered during diagnostic cardiac angiography. A case report.A 65-year-old white man with severe symptomatic four-vessel atherosclerotic coronary artery disease underwent selective coronary arteriography. Two hours after this procedure he developed hypovolaemic shock secondary to the hyperosmolar contrast medium, as well as severe angina pectoris accompanied by myocardial ischaemia. This diagnosis was established with the aid of Swan-Ganz catheterisation and the patient was successfully managed with intravenous fluid replacement and emergency coronary artery bypass graft surgery. Pathophysiological aspects are discussed with comments on the possible prevention of such a potentially life-threatening complication of selective coronary angiography.- - - - - - - - - - ranking = 2keywords = coronary (Clic here for more details about this article) |
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