Cyanotic Extremities Research Articles

Abstract #1408136: The Calm Before the Storm: Cardiogenic Shock in Graves’ Disease

This case highlights the endocrine and cardiopulmonary physiology of thyroid storm in a patient with comorbid rapid atrial fibrillation, severe heart failure with reduced ejection fraction and resultant cardiogenic shock in order to raise awareness regarding the risk of circulatory collapse, as well as the value of bedside ultrasound in management. A 42-year-old man presented to our hospital with 2 months of worsening dyspnea and lower extremity edema, 2 years of diarrhea and 50-pound weight loss followed by weight gain. He was hypertensive and in rapid atrial fibrillation (HR 180/min). A diltiazem drip was initiated, but he continued to be tachycardic (HR 120/min). Bedside point-of-care ultrasound (POCUS) was concerning for a severe cardiomyopathy. Chest x-ray demonstrated pulmonary edema. Labs demonstrated TSH < 0.01 mcIUnit/mL, free T4 2.9 mcg/dL (0.7-1.5 mcg/dL), and free T3 12.1 pg/mL (1.6-3.9 pg/mL). He met criteria highly suggestive of thyroid storm by the Burch-Wartofsky Point Scale, scoring 70 points, so management became focused on this. The diltiazem drip was discontinued in favor of an intravenous metoprolol challenge. Soon thereafter, his heart rate decreased to 80 bpm with low-normal mean arterial pressures. He developed acute hypoxemic respiratory failure with cool, cyanotic extremities. He was placed on non-invasive positive pressure ventilation with norepinephrine and dobutamine for treatment of cardiogenic shock secondary to thyroid storm. Hydrocortisone and propylthiouracil were administered. Echocardiogram showed severe left ventricular global hypokinesis with ejection fraction of 15%. As vasopressors were weaned, he underwent cautious diuresis. A short course of propranolol was started, which was subsequently switched to metoprolol tartrate. Thyrotropin receptor and thyroperoxidase antibodies were elevated. Thyroid ultrasound suggested autoimmune thyroiditis. He was transitioned to methimazole and discharged home. Thyroid storm patients are at risk of circulatory collapse after treatment with rate-control agents, especially in the presence of systolic dysfunction. In one study, underlying hyperthyroidism was unknown in 32% of patients admitted to the ICU for thyroid storm, and ICU mortality rates were 17%. Thyroid hormone sensitizes the myocardium to adrenergic input by upregulating adrenergic receptors, resulting in baseline tachycardia to maintain cardiac output and subsequent high-output heart failure.

Aortic Thromboembolism in a Cat

Background: The aortic thromboembolism in cats is usually associated with cardiomyopathy, when a thrombus or a clot is formed in the heart, transported through the bloodstream and fixed at somewhere. According to Virchow’s triad, changes in the endocardial surface or in the blood flow/composition can result in thrombus formation. The most common clinical signs are: hind limb paralysis, lack of femoral pulse, cold and cyanotic extremities. The treatment should be performed as soon as possible and it is based on antiplatelet agents, anticoagulants, thrombolytics agents or surgical procedures. It is reported the case of a cat presenting aortic thromboembolism.Case: Macroscopically it was observed that the hind limb extremities were with a dark red color and with a bad odor on cut. There were in the subcutaneous tissue of the hind limbs a severe and diffuse accumulation of a reddish material, translucent, shiny, gelatinous (intense diffuse edema) and the skeletal muscles of the hind limbs had extensive pale and friable areas. Inside the medial saphenous vein lumen there was a greyish-white and soft material which adhered to the vessel wall. The lungs were not fully collapsed, it had a smooth and shiny surface and an extensive dark red area in the right middle lobe (moderate extensive bleeding). The spleen was with slightly bulging edges and on cut flowed moderate amount of blood (moderate congestive splenomegaly). In the kidneys there was numerous whitish and slightly depressed areas measuring approximately 0.5 cm in diameter, which was deep and wedge-shaped on cut (multifocal infarction). Microscopically it was observed mild diffuse congestion in the spleen; mild diffuse congestion and moderate focal bleeding in the lungs; intense multifocal neutrophilic infiltrate associated with coagulation necrosis in the cortical and medullary with multifocal cysts in moderate amounts in the kidneys; abdominal aorta artery with intense accumulation of fibrin, red blood cells and cellular debris organized and stuck in the tunica intima featuring a multifocal thrombosis area. The saphenous artery contained fibrin organization in the lumen, which was compatible with embolus.Discussion: The patient presented paralysis of hind limbs, absence of superficial and deep pain, cyanotic and cold hind limb extremities, loss of proprioception of the limbs and absence of detectable pulse in the vascular Doppler, which is characteristic of thromboembolic disease, but no specific sign of the underlying cause. Thromboembolic episodes are compatible with thrombus in the trifurcation of the abdominal aorta artery and the embolus in the saphenous artery. The focal lung bleeding can be the clinical sign of pulmonary thromboembolism. The unilateral renal infarction may have been induced after surgical excision of the thrombus, as the patient had no change in renal biochemical parameters prior to the surgical procedure. This is a complication, because small thrombus fragments can break off and cause thromboembolism elsewhere. The surgical procedure is generally non indicated because most domestic cats that have arterial thrombus have significant heart disease and more than half have congestive heart failure, making them poor candidates for surgery, which did not occur in the clinical case described. The repetitions of the events are common, and significant embolization of the kidney, intestines or other organs worsen the prognosis.Keywords: aortic thromboembolism, feline.

Management of methylergonovine induced respiratory depression in a newborn with naloxone

Introduction. We report a case of a female neonate who developed respiratory depression following the unintentional administration of methylergonovine. The respiratory depression appeared to improve after the administration of bag mask ventilation, stimulation, and naloxone; and the baby was able to be managed without endotracheal intubation and prolonged positive-pressure ventilation. Case. A full-term female neonate was delivered vaginally without issue. Approximately 10 min after delivery, the infant was inadvertently administered 0.1 mg of methylergonovine intramuscularly instead of vitamin K. Thirty minutes later the child developed cyanotic extremities and respiratory depression with an oxygen saturation of 75%. Naloxone, 0.4 mg IM, was recommended to mitigate respiratory depression. Within 5 min the patient's respirations improved to 40 breaths per minute, cyanosis improved, and she began resisting ventilations and crying loudly. The child continued to improve and was back to baseline that evening. Discussion. Methylergonovine toxicity in neonates has been commonly associated with respiratory depression necessitating ventilatory support. In consideration of chemical structural similarity between methylergonovine and morphine, as well as signs/symptoms consistent with opioid-induced respiratory depression, naloxone was suggested. Conclusion. It appears that naloxone may reverse methylergonovine toxicity in neonates. The identification of a safe and potentially useful antidote to mitigate respiratory depression, potentially avoiding the need for intubation and more invasive interventions in this patient population is important.

A Case of Phlegmasia Cerulea Dolens as a Complication Caused by Placement of Inferior Vena Cava Filter

Inferior vena cava filters are increasingly being used as an alternative to anticoagulation therapy for the prevention of pulmonary embolism. However, using an Inferior vena cava filter may result in clinically significant complications. Phlegmasia cerulea dolens is a rare disease that presents with acute complete venous occlusion due to extensive thrombosis in the lower extremity. It is characterized by intense pain, edema, decreased pulses and a cyanotic extremity. We report here on a case of phlegmasia cerulea dolens that was accompanied with disseminated intravascular coagulation (DIC) as a complication of the placement of an inferior vena cava filter in a patient who had been previously diagnosed with pulmonary embolism, and the patient had recently developed a cerebral hemorrhage due to a traffic accident. (Tuberc Respir Dis 2008;65:225-229)

Myocarditis Presenting as Gastritis in Children

Vomiting and abdominal pain are common pediatric complaints encountered by emergency physicians. The differential diagnosis of abdominal pain is extensive. Herein, we report 2 cases with fatal myocarditis who initially presented with abdominal pain and vomiting. Both cases were presented with abdominal pain, vomiting, and loose stools. On arrival at our emergency department, hypotension, tachycardia, and cyanotic extremities were found. Their serum troponin-I levels were elevated. The echocardiogram demonstrated poor left ventricular performance and a decreased ejection fraction. In both cases, an arrhythmia and a coma developed within hours and were shortly followed by death. The clinical presentations of acute myocarditis are variable, ranging from an initial mild discomfort to acute progressive heart failure, and at times, even death. Abdominal pain may be a manifestation of systemic disease, an extra-abdominal lesion, or myocarditis. Although myocarditis associated with abdominal pain or vomiting remains a diagnostic challenge to physicians, it should be considered in the differential diagnosis of children with gastritis and hypotension or who are refractory to rehydration therapy.

Clinicopathological Conference: A 73‐year‐old Man with Shock, Stroke, and Cyanotic Extremities

Clinicopathological Conference: A 73‐year‐old Man with Shock, Stroke, and Cyanotic Extremities

A Patient With Pulseless Extremities: An Unusual Manifestation of Cardiac Tamponade

We describe a 51-year-old man who came to our institution with cold cyanotic extremities. He was receiving radiation therapy for adenocarcinoma of the lung and superior vena cava syndrome. Findings on initial physical examination were notable for absent peripheral pulses and increased jugular venous pulsations. Shortly after admission, the patient experienced severe dyspnea and tachypnea. Arterial blood gas studies revealed mild metabolic acidosis. A chest roentgenogram showed an enlarged cardiac silhouette and the known mass in the right upper lobe of the lung. An electrocardiogram demonstrated no evidence of ischemia but low-voltage QRS complexes. An emergency echocardiogram disclosed a large pericardial effusion and evidence of hemodynamic compromise. With use of echocardiographic-guided pericardiocentesis, 600 ml of bloody fluid was removed; the pulses were immediately palpable in the patient's extremities. Although symptoms associated with the extremities are unusual as the initial complaint of patients with cardiac tamponade, we illustrate several key physical findings and abnormal results of laboratory test characteristic of this disorder. In addition, we underscore the importance of considering this diagnosis, especially in patients with a malignant tumor, and we describe the prompt response to therapy.

Toxic shock syndrome: management and long-term sequelae.

Little information is available on the optimal management of toxic shock syndrome and on its sequelae. The most appropriate antibiotic treatment, the efficacy of colloid infusions, and the potential role of gamma globulin preparations have not yet been completely ascertained. Coagulase-positive staphylococci associated with toxic shock syndrome had minimal inhibitory concentrations of 0.06 microgram/mL or less to rifampin, 0.25 microgram/mL or less to gentamicin, and 0.50 microgram/mL or less to both nafcillin and clindamycin. In the 36 patients studied abnormal chest roentgenograms were commoner in those who had received albumin than in those who had not. Radioimmunoassay showed antibody titers to staphylococcal enterotoxin F, a marker protein in toxic shock syndrome, of 1:4000 or more for intravenous gamma globulin (12/15 lots) and 1:40 000 or more for intramuscular gamma globulin. Major sequelae of toxic shock syndrome include late-onset rash, compromised renal function, cyanotic extremities, and prolonged neuromuscular abnormalities.

Treatment of Shock in Myocardial Infarction

ALTHOUGH shock complicating acute myocardial infarction is a catastrophic event, it should not be approached with an attitude of hopelessness; instead, a stepwise logical evaluation and treatment should be undertaken. Such evaluation and treatment requires adequate monitoring of certain critical hemodynamic measurements since the shock syndrome is, after all, a manifestation of preterminal hemodynamic deterioration. The clinical syndrome includes depression of the CNS as manifested by obtundation, decreased renal perfusion as manifested by oliguria to less than 0.5 ml of urine per minute, and decreased peripheral perfusion as manifested by cold cyanotic extremities. Acute myocardial infarction should be documented electrocardiographically and confirmed by enzyme studies. In addition to a standard ECG for the rhythm changes, hemodynamic monitoring must include a direct measurement of intraarterial pressure and some measure of left ventricular filling pressures. Indirect measurements of left ventricular filling pressure are the pulmonary-capillary wedge pressure and the end-diastolic pressure in

Ischemic Forms of Venous Thrombosis: Phlegmasia Cerulea Dolens, Venous Gangrene

A critical analysis of 175 collected cases including 50 personal observations is given in this monograph, which describes a truly frightening, ignored, and poorly understood syndrome. The incidence ranges from 1.7% to 10% of all deep venous thromboses, the frequency depending on the observer and the time of observation. The nurses' notes and the observations of the house-staff, describing the onset of a massive venous thrombosis, may record a blue purple cyanotic extremity vastly improved next morning on elevation or hot packs. There is much controversy about the mechanism of decreased or absent arterial inflow when venous pressure rises above a critical point. The author writes an excellent chapter on the perverted physiology of ischemic thrombosis, but it follows instead of preceding the chapters on clinical manifestations and diagnosis. The text is noncommittal on the exact indications for anticoagulants, fibrinolytics, sympathetic blockade, thrombectomy, and fasciotomy. All in all, an unbiased

THE THERAPEUTIC EFFECT OF ADRENAL CORTEX EXTRACT ON THE PSYCHOTIC PATIENT

The problem of the treatment of mental disorders is a very real one, and numerous substances have been used in the past in order to find an agent which would offer some hope to the psychotic patient and to his family. The purpose of this experiment was not to add to the list of therapeutic agents, nor to find a strange use for a specific glandular extract, but rather to apply the therapeutic test to a theory of the author concerning some of the clinical manifestations which have been observed. In cases labelled dementia praecox, previous observers have noted the presence of an immature cardio-vascular apparatus, cyanotic extremities, asthentic habitus, and fairly low blood pressures. And in the chronic case of long duration is frequently found a muddy discoloration of the skin which is not entirely the result of poor hygiene. Many of these cases appear to be related to hypoadrenalism since the physical complaints and general appearances approximate those seen in Addison's disease.

THE INTRACUTANEOUS SALT SOLUTION WHEAL TEST

Vasomotor and other circulatory disturbances of the extremities have been the subject of a great deal of study and investigation at the Mount Sinai Hospital, Cleveland, on account of both the relatively large numbers of cases coming under observation and the paucity of our medical knowledge concerning them. Up to a few years ago, one of the greatest obstacles to a more extended study was the lack of an accurate and convenient method of measuring the blood supply. A given case may have presented the picture of cold, painful and cyanotic extremities, with the limb changing rapidly from purple to waxy white and back again, on elevation of the limb and then lowering it below the level of the body; and if the pulse in the dorsalis pedis artery was absent, it was held that the patient had a serious obstruction to circulation. If the same conditions were present, except