Common Mechanism Of Death Research Articles

Trauma Profile of Homicide Victims at Dr. Soetomo General Academic Hospital, Surabaya, during the COVID-19 Pandemic

Highlights: Most homicide victims were predominantly in the productive age range of 21-40 years old. Males were more likely to be homicide victims than females. Abstract Introduction: The injuries of homicide victims are clues in forensic medicine to uncover a possible crime. In Indonesia, there are not many studies on trauma profiles, specifically in homicide cases. This study aimed to provide an overview of the trauma profile of homicide victims at Dr. Soetomo General Academic Hospital, Surabaya. Methods: This was a descriptive study. Secondary data was collected from 34 forensic examination reports at Dr. Soetomo General Academic Hospital, Surabaya. Data such as age, sex, type of injury, sites of injury, number of injuries, cause of death, and mechanism of death were analyzed statistically. Results: Most victims were between 21 and 30 years old and 31 and 40 years old (26.47%). Sex was dominated by men (76.47%). The most common type of injury was abrasion (25.71%). The most common injury sites were head-neck (34.34%) and chest-upper back (34.34%). The most common number of injuries was ≥10 (44.12%). The most common cause of death was sharp-force trauma (54.54%), and the most common mechanism of death was exsanguination (54.54%). Conclusion: Males predominated in the age ranges of 21 to 30 years old and 31 to 40 years old. The most common type of injury was abrasion. The most common sites of injury were the head, neck, and chest upper back. The most common number of injuries was ≥10. Most victims died of sharp-force trauma. Exsanguination was the most common mechanism of death.

Joint Trauma System, Defense Committee on Trauma, and Armed Services Blood Program consensus statement on whole blood.

Hemorrhage is the most common mechanism of death in battlefield casualties with potentially survivable injuries. There is evidence that early blood product transfusion saves lives among combat casualties. When compared to component therapy, fresh whole blood transfusion improves outcomes in military settings. Cold-stored whole blood also improves outcomes in trauma patients. Whole blood has the advantage of providing red cells, plasma, and platelets together in a single unit, which simplifies and speeds the process of resuscitation, particularly in austere environments. The Joint Trauma System, the Defense Committee on Trauma, and the Armed Services Blood Program endorse the following: (1) whole blood should be used to treat hemorrhagic shock; (2) low-titer group O whole blood is the resuscitation product of choice for the treatment of hemorrhagic shock for all casualties at all roles of care; (3) whole blood should be available within 30 min of casualty wounding, on all medical evacuation platforms, and at all resuscitation and surgical team locations; (4) when whole blood is not available, component therapy should be available within 30 min of casualty wounding; (5) all prehospital medical providers should be trained and logistically supported to screen donors, collect fresh whole blood from designated donors, transfuse blood products, recognize and treat transfusion reactions, and complete the minimum documentation requirements; (6) all deploying military personnel should undergo walking blood bank prescreen laboratory testing for transfusion transmitted disease immediately prior to deployment. Those who are blood group O should undergo anti-A/anti-B antibody titer testing.

Factors Influencing Acceptance and Transplantation of Hearts from Hepatitis C+ Donors

<h3>Purpose</h3> This study investigates reasons for rejection of hearts from Hepatitis C+ donors, and predictive factors for acceptance and transplantation. <h3>Methods</h3> The United Network for Organ Sharing deceased donor registry was queried for adult donors with offers for heart donation from 2015-2020. We excluded patients from whom consent was not obtained or received, and incomplete data. HCV status was determined by nucleic acid testing (NAT). <h3>Results</h3> A total of 49,045 HCV- and 3,136 HCV+ donors were consented for heart donation from 2015-2020. HCV+ donors were younger (38.5 vs 43.5 years, p<0.001) with fewer comorbidities (p<0.001 for all): myocardial infarct (2.9% vs 4.6%), coronary artery disease (2.6% vs 7.0%), diabetes (6.3% vs 13.6%), and hypertension (23.9% vs 38.8%). The most common mechanism of death was stroke (30.1%) in HCV- donors and drug overdose (48.4%) in HCV+ donors. HCV+ donors were less likely to undergo recovery of the heart (20.0% vs 30.4%, p<0.001) and eventual transplantation (19.9% vs. 30.1%, p<0.001). HCV- organs were more often refused due to organ quality (HCV+: 21.0% vs HCV-:24.8%) or recovered and discarded (HCV+: 1.3% vs HCV-: 13.9%), while HCV+ hearts were more likely to be unused due to lack of recipient or accepting institution (25.0% vs 5.6%, p<0.001). Hepatitis was the primary reason for refusal in 12.2% of HCV+ donors. On multivariable analysis, HCV+ status was an independent negative predictor of acceptance and transplantation (OR 0.32, p<0.001). Negative predictors include age (OR 0.93, p<0.001), history of MI (OR 0.53, p<0.001), coronary artery disease (OR 0.11, p<0.001), diabetes (OR 0.57, p<0.001), smoking history (OR 0.84, p<0.001), chest trauma (OR 0.82, p<0.001), and cardiovascular mechanism of death (OR 0.71, p<0.001). <h3>Conclusion</h3> HCV+ hearts were less likely to be recovered and transplanted despite lower rates of cardiovascular comorbidities. Reasons for discard were primarily unrelated to organ quality or function, and may reflect ongoing skepticism in use of HCV+ organs.

Skin and heart histopathology in fatal electrocution with otherwise inconclusive autopsyfindings: A case series

The macroscopic evidence of low voltage electrocution in the skin is seen in the form of a crater with raised areolar edges and a surrounding pale area. This typical picture ofskin is mostly minimal or altogether absent in many cases of electrocution. The issue gets complicated in the absence of any eye witnesses or circumstantial evidences. Under such a scenario, it is advisable to do a histopathological examination of the suspected skin wounds. Since cardiac arrest is the most common mechanism of death following electrocution, heart histopathology may also yield vital evidence. We report three cases of electrocution. In one case, there were eye witnesses to the electrocution incident. In the second case the body was recovered from a swimming pool with no direct eye witness. In the third case the victim suddenly collapsed while welding. All the three cases were received dead in our hospital with inconclusive skin findings during autopsy examination.The histopathological examination of heart along with the skin wounds provides the vital evidence in favor of electrocution. Through these case reports we stress the importance of histopathologically examining the skin and heart in alleged cases of electrocution with inconclusive autopsy findings.

Suicides and deaths of undetermined intent among veterinary professionals from 2003 through 2014.

To analyze data for death of veterinary professionals and veterinary students, with manner of death characterized as suicide or undetermined intent from 2003 through 2014. Death records for 202 veterinary professionals and veterinary students. Decedents employed as veterinarians, veterinary technicians or technologists, or veterinary assistants or laboratory animal caretakers and veterinary students who died by suicide or of undetermined intent were identified through retrospective review of National Violent Death Reporting System records. Standardized mortality ratios (SMRs) and 95% confidence intervals were calculated, and mechanisms and circumstances of death were compared among veterinary occupational groups. 197 veterinary professionals and 5 veterinary students had deaths by suicide or of undetermined intent. Among decedents employed at the time of death, SMRs for suicide of male and female veterinarians (1.6 and 2.4, respectively) and male and female veterinary technicians or technologists (5.0 and 2.3, respectively) were significantly greater than those for the general US population, whereas SMRs for suicide of male and female veterinary assistants or laboratory animal caretakers were not. Poisoning was the most common mechanism of death among veterinarians; the drug most commonly used was pentobarbital. For most (13/18) veterinarians who died of pentobarbital poisoning, the death-related injury occurred at home. When decedents with pentobarbital poisoning were excluded from analyses, SMRs for suicide of male and female veterinarians, but not veterinary technicians or technologists, did not differ significantly from results for the general population. Results suggested higher SMRs for suicide among veterinarians might be attributable to pentobarbital access. Improving administrative controls for pentobarbital might be a promising suicide prevention strategy among veterinarians; however, different strategies are likely needed for veterinary technicians or technologists.

Temporal and Regional Trends in Heart Transplantation from Hepatitis C Donors

Background In the past, donors with hepatitis C (HCV) viremia were rarely accepted for orthotopic heart transplantation (HT) due to post-transplantation risks. A successful cure, the opiate epidemic and the shortage of available donors have led to a paradigm shift with increasing HT from HCV donors. We sought to examine the temporal and regional trends utilizing a national database. Methods We utilized the Scientific Registry of Transplant Recipients (SRTR) to identify adult HT from HCV donors from October 1987 to August 2018. Patients listed for combined organ transplantations were excluded. Results 7950 HCV donors were made available resulting in 589 HT (7.7%) from HCV donors accounting for 0.95% (589/61692) of all adult HTs during the study period. These 589 HCV donors were predominantly male (75%), Caucasian (87%) with a mean age 35.7 (± 9.5) years and drug intoxication as the most common mechanism of death (30.7%). An average of 32 annual HT from HCV donors were performed between 1994 and 2002. This trend decreased to an average of 3 annual HT from HCV donors between 2003 and 2015. However, a rising trend was noted from 2015 onwards with 146 HT from HCV donors in 2018 (146/1966, 7.4%) (Figure 1). The largest number of HCV donors came from the North East region (272/589, 46.2%) with the highest number of HCV donors coming from the state of Pennsylvania (11.2%) (Figure 2). Conclusions There is a rising trend in adult HT from HCV donors, although utilization varied between regions. Regional variation suggests a potential to improve heart acceptance rates in under-performing regions supported by research and policy efforts.

Sudden death and hydatid cyst: A medicolegal study.

The discovery of a hydatid cyst at autopsy poses the problem of its involvement in the mechanism of death. The aim of this study is to analyse the epidemiological and etiopathogenic characteristics of death attributed to hydatid disease, to discuss the mechanism of death and to propose preventive measures. This is a retrospective descriptive study of 26 cases of death with hydatid cyst autopsic discovered, collected at the forensic department of Fattouma Bourguiba University Hospital of Monastir (Tunisia) over a period of 27 years (from 1990 until 2017). In 26 cases, hydatid cyst was observed during autopsy of sudden death cases, which corresponds to 0.33% of the total of autopsies in this period. Of the 26 victims, 13 (50%) were men; the mean age was 43 years. Most victims were from rural zones (18 cases). In 20 cases, the complicated cyst was hepatic. It was cardiac in two cases. Of all cases, three cysts were cracked, and nine were broken. Of the 26 cases, only 15 were implicated in the death mechanism. Death was attributed to anaphylaxis in 12 cases, hydatid pulmonary embolism in 1 case, cardiac arythmia in one case and hemothorax in one case. Sudden death is the most dangerous complication of the hydatid cyst which can be discovered at autopsy. Several causes may explain its occurrence, the most common of which is anaphylactic shock.

Homicide victims and mechanisms in Lithuania from 2004 to 2016

A retrospective analysis of 2000 intentional homicide cases from the State Forensic Medicine Service (Vilnius, Lithuania) was carried out in order to evaluate the portrait of homicide victims and mechanisms of death between 2004 and 2016. The definition of intentional homicide appears to be quite straightforward, as a homicide occurs when one person's cause of death can be attributed to another one. Moreover, homicide is accomplished by conscious, active, intentional, or unintentional activities or inaction. All included cases of homicide were qualified as intentional murder. Children rarely become victims of intentional homicide. The group of child intentional murder made only 4.2% of all homicide cases. Seventy-three percent of homicide victims were male. The female victims were older than male and were murdered using a larger variety of objects (p < 0.001). Heavily alcohol-intoxicated victims were murdered using more traumatic affliction by sharp, stabbing-cutting objects (p < 0.001). The largest number of traumatic afflictions was associated with using a blunt object (p < 0.001). Lithuania differs from other European countries in terms of death by shooting: while 13% of homicides resulted from gunshot wounds in Europe, in Lithuania, only 5.6% of homicides did. This fact can be attributed to a relatively lower firearm ownership in Lithuania. This research is the first study that evaluates homicide in Lithuania based on autopsy findings. This study is highly important for homicide investigation tactics, as it emphasizes the portrait of the victim, providing valuable information about the most common mechanism of death, used weapons and traumatic afflictions for the law enforcement agencies.

Noonan Syndrome Case Report: PTPN11 and Other Potential Genetic Factors Contributing to Lethal Hypertrophic Right Ventricular Cardiomyopathy

Noonan syndrome is a genetic condition with a heterogeneous phenotype and multisystem involvement. The pathogenesis of this disorder has been attributed to the mutations in the RAS/MAPK signaling pathway involved in cell proliferation and differentiation. The most common clinical presentations are related to cardiovascular abnormalities with congestive heart failure as the most common mechanism of death. We present the autopsy findings from a Noonan syndrome patient who died as a result of an unusual form of right ventricular obstruction associated with a rare PTPN11 variant previously reported without details of the cardiac findings. Discussion follows that includes overview of the incidence, genetic causes, types of right-sided obstructive lesions, PTPN11 genotype-cardiac phenotype correlations, and other potential mechanisms that may contribute to disease heterogeneity.

Fentanyl-related deaths: A 5-year retrospective study (2010–2014, 81 cases) in the department of forensic medicine, Newcastle, Forensic and Analytical Science Service

Background: Fentanyl is a synthetic opioid developed in the 1960s and is 50–100 times more potent than morphine. Fentanyl is recognised to be abused in the community. The Department of Forensic Medicine Newcastle, Forensic and Analytical Science Service (DOFM, Newcastle) has recently experienced an increase in fentanyl related deaths. This study was carried out to characterise fentanyl related death in DOFM, Newcastle.Method: A retrospective study (5 years, 2010–2014) of deaths related to fentanyl in DOFM, Newcastle, was carried out noting the age, gender, cause of death, toxicological analysis, mode of delivery, and presumed mechanism of death.Result: There was a striking increase in death related to fentanyl from 1 case in 2010 to 38 cases in 2014 (n=81). Most of the fatal cases had a fentanyl blood level between 0.01–0.029 mg/L with the highest level being 0.08 mg/L. The most common cause of death was mixed drug toxicity. The victims were mostly middle aged males and the most common mechanism of death was respiratory depression. Other substances detected apart from fentanyl were benzodiazepine, opioids and alcohol. The most common route of administration was via extracting fentanyl from a patch and injecting it intravenously. Background: Fentanyl is a synthetic opioid developed in the 1960s and is 50–100 times more potent than morphine. Fentanyl is recognised to be abused in the community. The Department of Forensic Medicine Newcastle, Forensic and Analytical Science Service (DOFM, Newcastle) has recently experienced an increase in fentanyl related deaths. This study was carried out to characterise fentanyl related death in DOFM, Newcastle. Method: A retrospective study (5 years, 2010–2014) of deaths related to fentanyl in DOFM, Newcastle, was carried out noting the age, gender, cause of death, toxicological analysis, mode of delivery, and presumed mechanism of death. Result: There was a striking increase in death related to fentanyl from 1 case in 2010 to 38 cases in 2014 (n=81). Most of the fatal cases had a fentanyl blood level between 0.01–0.029 mg/L with the highest level being 0.08 mg/L. The most common cause of death was mixed drug toxicity. The victims were mostly middle aged males and the most common mechanism of death was respiratory depression. Other substances detected apart from fentanyl were benzodiazepine, opioids and alcohol. The most common route of administration was via extracting fentanyl from a patch and injecting it intravenously.

Meigs′ syndrome in an elderly woman with short of breath

The Meigs' syndrome is a rare syndrome defined as the triad of benign solid ovarian tumors, ascites, and pleural effusion, which resolve spontaneously and permanently after tumor resection. Lung collapse due to a large amount of pleural effusion is a common mechanism of death. It always requires surgical treatment. We report an 84-year-old woman with a large ovarian fibroma associated with Meigs' syndrome and short of breath. It is difficult to diagnose preoperatively and is usually misdiagnosed as an ovarian malignancy. Considering the patient's serious clinical condition and assuming that she had Meigs' syndrome with a large ovarian mass and possible lung collapse due to large amount of pleural effusion, we chose the most appropriate surgical treatment after pathologic examination, then enabled definitive diagnosis of the benign tumor and removed the huge ovarian fibroma. This resulted in a timely symptoms resolution, short hospitalization, and relatively low morbidity in elderly.

Colombia: Social Transition and Peace Process. Has The Reduction in Violence Had Any Impact On Organ Procurement and Transplantation? New Society, New Strategies.

Introduction: Colombia is known worldwide for its high rates of violence as the result of the narcotics war and the presence of political-rebel groups; guerrillas. The violence increased dramatically during the 1990s and early 2000s, which is when it achieved its greatest influence. Nowadays the situation has changed. The Colombian government has retaken control, acting to decrease the macro and micro narco-traffic and a peace process with the guerrillas is ongoing. Because of this, Colombia is undergoing a social transition and the rate of all types of violence has decreased substantially. Aim: To investigate and report the direct impact of the decreased rates of violence on organ procurement and transplantation in Colombia. Materials and Methods: A 10-year retrospective study of national and international data reports on interpersonal violence, intentional homicide and car accidents including the data of The National Institute of Coroners and Forensic Science of Colombia. Results: The homicide rate in Colombia has decreased from 67.5 per 100,000 inhabitants in 2002 to 33 per 100,000 inhabitants in 2012; 91% of murders occurred in males aged 20 to 35 years in the last decade. The primary homicide trigger was the guerrillas war in 2002 and now seems to be the interpersonal fights in 2012. Although shooting has declined substantially from >24,000 in 2002 to <12,000 in 2012, it remains the most common mechanism of death (75%). On the other hand, the rate of deaths due to car accident has also decreased. Regarding organ procurement, the number of effective brain-death donors has decreased substantially. Also, the main cause of brain death changed from trauma in 2002 to stroke in 2012. Conclusions: It is quite interesting to see how the social transition and the peace process that Colombia is undergoing directly impacts on the health system including the Colombian Network of Organ Procurement and Transplantation (CNOPT). There is a reduction in all types of violence; brain-death donors due to gunshot wounds and traffic accidents are less now than 10 years ago. Thus, the transplants performed using living and extended-criteria donors are now fundamental. Designing new strategies has been necessary to adjust the CNOPT to a modern society, in order to increase the amount of effective donors. Those strategies may be an archetype to the countries that are living in a social transition like Colombia.

Retrospective Autopsy Based Study of Fatal Road Traffic Accidents in Fiji

Objective: To describe the demographic profile and distribution of injuries from autopsy cases due to fatal Road Traffic Accidents (RTA) in Fiji. Methods: This is a retrospective autopsy based study consisting of 102 medico-legal autopsies performed by the Fiji Institute of Forensic Science, Fiji Police Force during the period of two calendar years from January 1st 2011 to December 31st 2012. Results: Out of the 1454 medico-legal autopsies performed during the study period, 102 (7%) were due to fatal RTA. There were 72 (70.5%) males and 30 (29.5%) female fatalities with an overall male and female ratio of 2.3:1 and the 30 to 44 years age group showed highest number of victims of 30 (29.4%). The months of October in 2011 and August in 2012 took the maximum toll of road traffic deaths of 9 (8.8%) and 12 (11.6%) respectively. The highest number within the road user group were the passengers of 53 (51.9%) followed by the pedestrians and drivers of 32 (31.2%) and 16 (15.6%) respectively. Human behavioural errors or factors by all the road users of 95 (93.1%) was the highest contributing factor and pre-hospital mortality was most common, particularly road traffic death at the scene (51.9%) and those whilst en route to hospital (29.4%). Highest number of injuries were head injuries of 67 (65.7%), followed by multiple injuries of 57 (55.6%), thoracic injuries of 56 (54.9%), abdominal injuries of 31 (30.3%), vertebral injuries 21 (20.5%) and major vessel injuries of 12 (11.7%). The most common mechanism of death was haemorrhagic shock of 90 (88.2%) followed by asphyxia of 7 (6.8%), arrhythmias of 3 (2.9%) and finally septic shock of 2 (1.9%). Conclusion: This study emphasizes the need for better pre-hospital and hospital trauma management, improved traffic law enforcement, effective traffic related and health policy creation, and the establishment of a national traffic traumatic injury surveillance registry in Fiji.

Molecular mechanisms of cisplatin resistance in bladder cancer

Metastatic disease is the most common mechanism of death in patients with advanced bladder cancer. As for most solid tumors, chemotherapy remains the only realistic option for palliating or curing metastatic disease. However, bladder cancer is characterized by chemoresistance. Only modest response rates are obtained using multiagent regimens including cisplatin. These low response rates and the toxicity of these regimens limit their use to patients at highest risk. Here, we review the molecular mechanisms of cisplatin resistance. These include methods to reduce cisplatin bioavailability within a cell, and defects in the machinery that produces cell death following cisplatin-induced DNA damage. While overcoming these mechanisms is a potential therapeutic approach that can increase response rates, in the short term this knowledge could be used to predict response in individual tumors.

Frequency of nocturnal sudden death in patients with multiple system atrophy

Sudden death has been reported in patients with multiple system atrophy (MSA), although the frequency of this event has not been well delineated. We investigated the frequency and potential causes of sudden death in patients with MSA. During the 5-year observation period, 10 of 45 patients with probable MSA died. The causes of death included sudden death of unknown etiology (seven patients), aspiration pneumonia (one patient), asphyxia after vomiting (one patient), and lung cancer (one patient). The mean survival time of patients with sudden death was 63.0 +/- 24.7 months (range, 39-116 months). Among seven patients who experienced sudden death, six were found to have died during sleep. Among these patients, two had been treated with tracheostomy and three with continuous positive airway pressure (CPAP) or noninvasive positive pressure ventilation (NPPV) during sleep, suggesting that these treatments do not always prevent sudden death in patients with MSA. Nocturnal sudden death should be recognized as the most common mechanism of death in patients with MSA.

Cardiovascular News

Cardiovascular News

Cardiac Resynchronization and Death From Progressive Heart Failure

Progressive heart failure is the most common mechanism of death among patients with advanced heart failure. Cardiac resynchronization, a pacemaker-based therapy for heart failure, enhances cardiac performance and quality of life, but its effect on mortality is uncertain. To determine whether cardiac resynchronization reduces mortality from progressive heart failure. MEDLINE (1966-2002), EMBASE (1980-2002), the Cochrane Controlled Trials Register (Second Quarter, 2002), The National Institutes of Health ClinicalTrials.gov database, the US Food and Drug Administration Web site, and reports presented at scientific meetings (1994-2002). Search terms included pacemaker, pacing, heart failure, dual-site, multisite, biventricular, resynchronization, and left ventricular preexcitation. Eligible studies were randomized controlled trials of cardiac resynchronization for the treatment of chronic symptomatic left ventricular dysfunction. Eligible studies reported death, hospitalization for heart failure, or ventricular arrhythmia as outcomes. Of the 6883 potentially relevant reports initially identified, 11 reports of 4 randomized trials with 1634 total patients were included in the meta-analysis. Trial reports were reviewed independently by 2 investigators in an unblinded standardized manner. Follow-up in the included trials ranged from 3 to 6 months. Pooled data from the 4 selected studies showed that cardiac resynchronization reduced death from progressive heart failure by 51% relative to controls (odds ratio [OR], 0.49; 95% confidence interval [CI], 0.25-0.93). Progressive heart failure mortality was 1.7% for cardiac resynchronization patients and 3.5% for controls. Cardiac resynchronization also reduced heart failure hospitalization by 29% (OR, 0.71; 95% CI, 0.53-0.96) and showed a trend toward reducing all-cause mortality (OR, 0.77; 95% CI, 0.51-1.18). Cardiac resynchronization was not associated with a statistically significant effect on non-heart failure mortality (OR, 1.15; 95% CI, 0.65-2.02). Among patients with implantable cardioverter defibrillators, cardiac resynchronization had no clear impact on ventricular tachycardia or ventricular fibrillation (OR, 0.92; 95% CI, 0.67-1.27). Cardiac resynchronization reduces mortality from progressive heart failure in patients with symptomatic left ventricular dysfunction. This finding suggests that cardiac resynchronization may have a substantial impact on the most common mechanism of death among patients with advanced heart failure. Cardiac resynchronization also reduces heart failure hospitalization and shows a trend toward reducing all-cause mortality.

Looking at trauma and deaths: Diyarbakır city in Turkey

There were 329 trauma related deaths in Diyarbakır in 1997. Of these 226 were male (69%) and 103 were female (31%). The median age was 20 years old (range 1–82 years). Of the deaths, 30.5% were under 10, 51% were under 20 and 67% were under 30 years old. Two hundred and eleven deaths occurred in the hospital while 118 deaths occurred prehospital. Seventy-seven percent of hospital deaths (191) occurred in the first day. The most common cause of death was multiple injuries (151, 46%). Head injuries were the main reason for 128 deaths (46%). The most common mechanism of death was motor vehicle accident (131, 40%). The second was falls from a residential building (117, 33.7%).

Intensive Care Unit ECG Monitoring

Perhaps the most useful means of monitoring the critically ill patient is the electrocardiogram (ECG). A 12lead ECG is useful to rule out cardiac complications in the acutely injured patient, the postoperative patient, and the septic patient [1]. Limb lead II or chest lead V may be continuously monitored for evidence of progressive cardiac disease and complicating dysrhythmias [1]. This section summarizes the usefulness and indications of the ECG in monitoring of the high-risk, critically ill patient and possibilities for future clinical use. Interpretation of the ECG waveform provides the basis for diagnosis and therapy of numerous conditions associated with disorders of the myocardium in the intensive care unit (ICU) [1]. Continuous ECG monitoring is essential for the adult patient with acute myocardial infarction because dysrhythmias are the most common life-threatening complication [1]. Continuous ECG monitoring of the postoperative general surgical patient is not as useful because the incidence of lifethreatening dysrhythmias is lower [1,2]. However, in adults and children with decreased myocardial function, hypovolemia, or hypoxemia, the ECG may show PVCs, PACs, ST segments changes, altered T-waves, and bradycardia [1]. These abnormalities may be produced by inadequate oxygen delivery to the myocardium and therefore serve to alarm the physician of potentially signi~cant pathophysiologic disturbances. One of the main uses for the ECG is the determination of heart rate or pulse. Most ICUs measure heart rate as a calculated time-averaged signal from the bedside ECG monitor. Heart rate is a very nonspeci~c cardiorespiratory variable. However, tachycardia may signal signi~cant and abrupt cardiovascular compromise such as hypovolemia, hypoperfusion, or diminished myocardial contractility in the critically ill patient [3]. The degree of tachycardia is roughly proportional to the severity of the cardiovascular impairment. Tachycardia is also present in association with infection, anxiety, stress, fever, exercise, pain, and anxiety. Bradycardia may occur with inferior myocardial infarction, arteriosclerotic heart disease, or severe systemic hypoxemia [3]. Heart rate may also be used during invasive hemodynamic monitoring with thermodilution pulmonary arterial catheters to calculate stroke volume and other hemodynamic variables. The ECG may be used directly or as an adjunctive test in the diagnosis of numerous diseases and conditions affecting the critically ill patient. Myocardial ischemia may occur in the critically ill patient with shock, even in the absence of primary coronary artery disease [1]. Myocardial ischemia ultimately results in T-wave inversion. Myocardial injury due to ischemia may cause elevation of the ST segment if the ischemia is transmural or ST segment depression if the ischemia is nontransmural and predominantly subendocardial [1]. Progressive ischemia results in myocardial infarction which is often manifested in the ECG by Qwave deepening and distortion, loss of R-wave voltage, and/or an increased R-wave amplitude [1]. However, ECG abnormalities characterizing myocardial ischemia and infarction are nonspeci~c. Serial ECGs should be followed to speci~cally diagnose and localize myocardial ischemia and infarction [1]. Table 1 lists characteristic changes in the ECG associated with other disease states commonly seen in critically ill patients. ECG changes observed in drug overdose or poisoning, and electrolyte and metabolic disturbances are shown in Tables 2 and 3. Abnormal cardiac rhythms may occur during critical illness at any time and are the most common mechanism of death in adults [1]. Automated arrhythmia detection algorithms are commercially available and in use in many ICUs. These algorithms ~lter the incoming ECG signal, detect and classify the QRS complex, identify ectopic events and ventricular rhythms, and generate alarms. For ventricular ectopic beats, the system has a reported sensitivity of up to 90% with a false positive rate of #1%. However, the algorithms may result in false positive alarms if the Tor P-waves are $50% of the R-wave amplitude, and are not useful for detection of aberrantly conducted beats, atrial ~brillation and _utter, and intermittent bundle branch block. In summary, the clinical utility and cost effectiveness of these and other automated forms of ECG monitoring in the ICU, such as automated ST segment monitoring [5] and signal-averaged electrocardiography (detailed in subsequent sections), have yet to be determined. The ECG waveform itself may be an important source of clinical information that has only recently

Sudden death in athletes

HCM, as well as coronary and myocardial structural abnormalities, is the most common pathology leading to SCD in young athletes. Furthermore, SCD from fatal arrhythmia seems to be the most common mechanism of death. In this population, however, data are insufficient to support either invasive or noninvasive approaches to clarify risk stratification for SCD. Because of the large population, variants of normal found within the athletic population, and the rarity of the disease, screening for individuals at risk is neither practical nor cost-effective. Not all athletes with HCM are at the same risk for SCD; a thorough history and physical examination should alert the health professional to potential risk factors. Efforts are under way to stratify athletes at risk for SCD to determine who can participate in competitive sports and who should not. However, until research can accurately define variables of hemodynamic and electrical instability that permit reliable identification of athletes with HCM who are at risk for SCD, the recommendation is to disqualify athletes with confirmed HCM from moderate- to high-intensity competitive sports. This recommendation includes athletes with or without symptoms or left ventricular outflow obstruction. Due to the decreased risk of SCD in older athletes, individual judgment of eligibility may be used. Athletes thought to have had myocarditis should be withdrawn from all competitive sports for a convalescent period of approximately 6 months, with thorough cardiac assessment and testing performed before returning to training. Athletes with atrial or ventricular tachyarrhythmia must be screened for structural abnormality, heart response during exercise, and the frequency and duration of the arrhythmia.(ABSTRACT TRUNCATED AT 250 WORDS)