1/1312. Fatal cardiac ischaemia associated with prolonged desflurane anaesthesia and administration of exogenous catecholamines. PURPOSE: Four cardiac ischaemic events are reported during and after prolonged anaesthesia with desflurane. CLINICAL FEATURES: We have evaluated desflurane in 21 consecutive patients undergoing advanced head and neck reconstructive surgery. Four deaths occurred which were associated with cardiac ischaemic syndromes either during or immediately after operation. All patients in the study received a similar anaesthetic. This comprised induction with propofol and maintenance with alfentanil and desflurane in oxygen-enriched air. Inotropic support (either dopamine or dobutamine in low dose, 5 micrograms.kg.min-1) was provided as part of the anaesthetic technique in all patients. Critical cardiovascular incidents were observed in each of the four patients during surgery. These were either sudden bradycardia or tachycardia associated with ST-segment electrocardiographic changes. The four patients who died had a documented past history of coronary heart disease and were classified American Society of Anesthesiologists (ASA) II or III. One patient (#2) did not survive anaesthesia and surgery and the three others died on the first, second and twelfth postoperative days. Enzyme increases (CK/CK-MB) were available in three patients and confirmed myocardial ischaemia. CONCLUSION: These cases represent an unexpected increase in the immediate postoperative mortality for these types of patients and this anaesthetic sequence. ( info) |
2/1312. Neonatal atrial flutter following fetal exposure to vibroacoustic stimulation. The use of vibroacoustic stimulation (VAS) has become a common modality for testing fetal well being. A case of neonatal atrial flutter, following fetal exposure to VAS is presented. It should be emphasized that although VAS is a common and reliable test for evaluating fetal status, complications may occur. ( info) |
3/1312. Failure of right atrial premature beats to reset atriofascicular tachycardia. A patient with a right atriofascicular (Mahaim) tachycardia was found to have inducible antidromic supraventricular tachycardia, but atrial premature beats from the right atrial free wall failed to reset the tachycardia. An interesting transition from AV nodal reentry tachycardia to Mahaim tachycardia is also presented. ( info) |
4/1312. [Case report on the problem of individual glycoside requirements] A report is given on a patient with ischaemic heart disease, whose recompensation in tachyarrhythmia absoluta was for some times possible only by means of unusually high doses of digitoxin (fully effective dose to 5.72 mg, maintenance dose to 0.4 mg). The patient survived a severe decompensation with pulmonary oedema, which appeared under "normal" applications of glycosides, 2 1/2 years under this therapy. Thus it must again be referred to an individual glycoside treatment. ( info) |
5/1312. mercury intoxication presenting with hypertension and tachycardia. An 11 year old girl presented with hypertension and tachycardia. Excess urinary catecholamine excretion suggested phaeochromocytoma but imaging studies failed to demonstrate a tumour. Other symptoms included insomnia and weight loss, and she was found to have a raised concentration of mercury in blood and urine. mercury intoxication should be considered in the differential diagnosis of hypertension with tachycardia even in patients presenting without the skin lesions typical of mercury intoxication and without a history of exposure. ( info) |
6/1312. Right posterior atrioventricular ring: a location for different types of atrioventricular accessory connections. We present an unusual case of a 28-year-old female patient with recurrent episodes of tachycardias due to participation of two accessory connections located in the posterior tricuspid annulus. Both connections were of the atrioventricular type, the one with non decremental fast conducting properties at the right posteroseptal area, the other with node-like properties at the posterolateral tricuspid ring. Both pathways were successfully ablated transvenously with radiofrequency energy application at the same session. Implications about a common embryological origin of the two pathways as well as review of the literature for similar cases are presented. ( info) |
| A 16-year-old boy was diagnosed with idiopathic postural orthostatic tachycardia syndrome (POTS) during head-up tilt testing. During a passive tilt, the patient's heart rate (HR) increased by 30 beats/min within 5 min. After 25 min of tilting, his HR further increased to 133 beats/min and he began to complain of lightheadedness and weakness without hypotension. Power spectral analysis of HR variability during the tilt test revealed that the ratio of low and high frequency powers increased with the onset of orthostatic intolerance. propranolol (10mg every morning) dramatically alleviated his clinical symptoms, and he has been asymptomatic with gaining weight after discontinuing his crowded train commuting. ( info) |
8/1312. Wide QRS complex tachycardia: ECG differential diagnosis. Wide QRS complex tachycardias (WCT) present significant diagnostic and therapeutic challenges to the emergency physician. WCT may represent a supraventricular tachycardia with aberrant ventricular conduction; alternatively, such a rhythm presentation may be caused by ventricular tachycardia. Other clinical syndromes may also demonstrate WCT, such as tricyclic antidepressant toxicity and hyperkalemia. Patient age and history may assist in rhythm diagnosis, especially when coupled with electrocardiographic (ECG) evidence. Numerous ECG features have been suggested as potential clues to origin of the WCT, including ventricular rate, frontal axis, QRS complex width, and QRS morphology, as well as the presence of other characteristics such as atrioventricular dissociation and fusion/capture beats. Differentiation between ventricular tachycardia and supraventricular tachycardia with aberrant conduction frequently is difficult despite this clinical and electrocardiographic information, particularly in the early stages of evaluation with an unstable patient. When the rhythm diagnosis is in question, resuscitative therapy should be directed toward ventricular tachycardia. ( info) |
9/1312. The nondiagnostic ECG in the chest pain patient: normal and nonspecific initial ECG presentations of acute MI. The 12-lead electrocardiogram (ECG) is a powerful clinical tool used in the evaluation of chest pain patients, assisting in the selection of the proper therapy. Unfortunately, the ECG is diagnostic of acute myocardial infarction (AMI) in only one-half of such patients at initial hospital evaluation. In the remaining group of patients with the nondiagnostic 12-lead electrocardiogram, the ECG may be entirely normal, show nonspecific sinus tachycardia (ST) segment-T wave abnormalities, or obvious ischemic changes. In adult chest pain patients treated in the emergency department (ED), 1% to 4% of such patients with an absolutely normal ECG had a final hospital diagnosis of AMI; furthermore, patients with nonspecific electrocardiographic abnormalities experienced AMI in 4% of cases. These findings reinforce the teaching point that the history is the most important tool used in the evaluation of chest pain patients. Furthermore, overreliance on a normal or nonspecifically abnormal ECG in a patient with a classic description of anginal chest pain is dangerous. ( info) |
10/1312. acebutolol-induced ventricular tachycardia reversed with sodium bicarbonate. BACKGROUND: acebutolol is a unique beta blocker that possesses cardioselectivity, partial agonist activity, and membrane stabilizing activity. sodium bicarbonate is used to reverse the cardiotoxic effects of other drugs with membrane stabilizing activity. There have been no reported cases of acebutolol-induced ventricular dysrhythmias treated successfully with bolus sodium bicarbonate. CASE PRESENTATION: A 48-year-old man ingested approximately 6.4 g of acebutolol with ethanol (blood ethanol 61 mmol/L). There were no other coingestants identified. One hour after presentation, the patient had a cardiac arrest with the monitor showing ventricular tachycardia. sodium bicarbonate 50 mEq intravenous push converted the patient to sinus rhythm and the blood pressure improved to 129/90 mm Hg. CONCLUSION: This case demonstrates a temporal relationship between bolus sodium bicarbonate administration and the termination of acebutolol-induced ventricular tachycardia. ( info) |