Evidence Of Hemodynamic Compromise Research Articles

Primary intraventricular cardiac tumors in children: contemporary diagnostic and management options.

We reviewed the intraventricular cardiac tumors presenting at our institution between 1985-1991, studying the presentation, modes of investigation, and evidence of hemodynamic compromise. Thirteen patients presented with intraventricular tumors during the study period. Two of the tumors were rhabdomyosarcomas, one was a myxoma, and 10 were rhabdomyomas. All patients were evaluated with two-dimensional and pulsed Doppler echocardiography and B-color imaging was undertaken in three patients. Four patients presented for elective scans to complement investigations for tuberous sclerosis, seven patients had cardiac symptoms, and two patients presented prenatally. Obstruction to intracardiac flow was present in five patients. Two patients had the tumor excised and one had an open biopsy of the tumor. One patient had an transvascular biopsy at cardiac catheter. Early detection of cardiac tumors is increasing, particularly rhabdomyomas. With fetal echocardiography, more patients should come to attention prenatally. B-color may be useful addition in assessing cardiac tumors, aiding detection and definition of intramural lesions.

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.

Efficacy and safety of potassium infusion therapy in hypokalemic critically ill patients

To evaluate the efficacy and safety of potassium replacement infusions in critically ill patients. Prospective cohort study. Multidisciplinary critical care unit. Forty-eight critically ill adult patients, age 25 to 86 yrs. Patients entered the study when hypokalemia (potassium less than 3.5 mmol/L) was noted on routine laboratory blood analysis. Most common primary diagnoses on ICU admission included postoperative cardiac surgery (n = 9), sepsis and multiple organ system failure (n = 9), complicated myocardial infarction (n = 7), and respiratory failure (n = 5). Potassium chloride infusions (20, 30, or 40 mmol in 100 mL normal saline over 1 hr) were administered to patients for serum potassium levels of less than 3.5 but greater than 3.2 mmol/L (n = 26), 3.0 to 3.2 mmol/L (n = 11), and less than 3.0 mmol/L (n = 11), respectively. Serum and urine potassium levels were monitored during and for 1 hr after the infusion. All patients tolerated the infusions without evidence of hemodynamic compromise, ECG change, or new dysrhythmia requiring treatment. The mean maximum potassium increase was 0.5 +/- 0.3 mmol/L, 0.9 +/- 0.4 mmol/L, and 1.1 +/- 0.4 mmol/L in the 20-, 30-, and 40-mmol groups, respectively. The increase in serum potassium was maximal at the completion of the infusion and was significant (p less than .05) compared with baseline in all groups. Peak potassium levels were the same in patients with normal renal function (n = 33) compared with those with renal insufficiency (n = 15). Urinary excretion of potassium increased in all groups during the infusion and was significant (p less than .05) in the 30- and 40-mmol groups, but was no greater in those patients who had received diuretics (n = 8) compared with those patients who had not (n = 40). In the select group of hypokalemic patients studied, potassium infusions of 20 to 40 mmol delivered over 1 hr were safe to administer and effectively increased serum potassium levels in a dose-dependent and predictable fashion. Furthermore, these results were independent of the patient's underlying renal function or associated diuretic administration.

Experience with the use of tPA in the treatment of acute myocardial infarction

Early experience with the use of tissue plasminogen activator (tPA) in acute myocardial infarction is reviewed, including comparisons with other thrombolytic agents, a summary of hemorrhagic complications associated with its use, and the rationale for adjunctive therapeutic strategies. The use of tPA has been associated with improvement in left ventricular function, a lower mortality, and a decrease in congestive heart failure signs and symptoms. A protocol for evaluation of patients with possible myocardial infarction for thrombolytic therapy is presented. Consideration must be given to other possible diagnoses, and the ECG must be evaluated carefully to ensure that appropriate criteria are met. Risk factors for hemorrhagic complications include recent trauma, surgery, gastrointestinal and genitourinary bleeding, stroke, and focal neurologic findings. Greater benefit of therapy is expected in patients with larger infarcts who have more marked ST segment changes or evidence of hemodynamic compromise, especially when they are treated early after the onset of symptoms (within the first several hours). Adjunctive measures that can be considered in the emergency department include prophylactic lidocaine, IV nitroglycerin, beta blockade, aspirin, volume replacement and monitoring for dysrhythmias, bleeding, and recurrent ischemia. A comprehensive understanding of these rapidly evolving concepts will assist the emergency physician in the evaluation and management of patients with acute myocardial infarction.

Invasive Cardiac Procedures-Reply

In Reply. —I am sorry for your misunderstanding of the emphasis of the article. This patient had a massive pericardial effusion and had some evidence of hemodynamic compromise. The pericardiocentesis was performed to improve her overall cardiovascular status. It was not done to determine the efficacy of doing two-dimensional echocardiography simultaneously with the pericardiocentesis. The point that was apparently misunderstood was that simultaneous two-dimensional echocardiography was performed with a clinically and therapeutically indicated pericardiocentesis to determine the efficacy of using the two-dimensional instrument to visualize the pericardiocentesis needle. We clearly did not mean to imply that the pericardiocentesis was indicated to determine the efficacy of using the two-dimensional technique. Just the opposite is true. Furthermore, the published article does convey, by means of the physical description and the evidence of pulsus paradoxus, that the patient did have hemodynamic compromise. I do appreciate your letter. I must assure you that even