Rapid Loss Of Consciousness Research Articles

Prospective Randomized Controlled Trial Comparing Anesthetic Management With Remimazolam Besylate and Flumazenil Versus Propofol During Awake Craniotomy Following an Asleep-awake-asleep Method.

Awake craniotomy is performed to resect brain tumors in eloquent brain areas to maximize tumor reduction and minimize neurological damage. Evidence suggests that intraoperative anesthetic management of awake craniotomy with remimazolam is safe. We compared the time to arousal and efficacy of anesthetic management with remimazolam and propofol during awake craniotomy. In a single-institution randomized, prospective study, patients who underwent elective awake craniotomy were randomized to receive remimazolam and reversal with flumazenil (group R) or propofol (group P). The primary end point was time to awaken. Secondary end points were time to loss of consciousness during induction of anesthesia, the frequency of intraoperative complications (pain, hypertension, seizures, nausea, vomiting, and delayed arousal), and postoperative nausea and vomiting. Intraoperative task performance was assessed using a numerical rating scale (NRS) score. Fifty-eight patients were recruited, of which 52 (26 in each group) were available for the efficacy analysis. Patients in group R had faster mean (±SD) arousal times than those in the P group (890.8±239.8 vs. 1075.4±317.5s; P=0.013)and higher and more reliable intraoperative task performance (NRS score 8.81±1.50 vs. 7.69±2.36; P=0.043). There were no significant intraoperative complications. Compared with propofol, remimazolam was associated with more rapid loss of consciousness and, after administration of flumazenil, with faster arousal times and improved intraoperative task performance.

Bobbing, weaving, collapsing and dying-preventing boxing deaths in the ring

Background: Professional boxing is a popular combat sport around the world. It is unfortunately also a sport which carries a very high risk of concussion and more severe forms of traumatic brain injury (TBI). In a sport where every punch thrown to the opponent’s head is thrown with the intention of winning by causing a knockout (KO), TBI is an omnipresent danger. Traumatic subdural hematoma is the most common cause of boxing related mortality. The boxer either collapses in the ring during the fight or in the immediate aftermath of the fight. Discussion: Boxers with traumatic epidural and subdural hematoma often have a lucid interval and then exhibit rapid at times precipitous neurological deterioration as the hematoma expands. Rapid loss of consciousness follows leading to a comatose state. Development of brain edema and secondary ischemic injury are the other substrates of delayed neurological deterioration. Conclusion: Both the referee and the ringside physician (s) should be aware of this clinical presentation of acute TBI so that the fights can be stopped in a timely fashion, neither too early but certainly never too late! Innovate solutions can help present tragedies in the ring.

Euthanasia of whales: the effect of .375 and .485 calibre roundnosed, full metal-jacketed rifle bullets on the central nervous system of the common minke whale

The effect of rifle projectiles used for the euthanasia of stranded or hunted whales has been an issue for debate, in particular in the International Whaling Commission (IWC) and the North Atlantic Marine Mammal Commission (NAMMCO). In the Norwegian hunt for common minke whales, 9.3mm, .375 or .458 calibre rifles are used as backup weapons to euthanise whales that are not deemed dead after being hit with a harpoon grenade. When using the rifle, the hunters aim at the brain of the animal. The present study investigates the effects of the two rifle calibres .375 and .458 and round nosed, full-metal jacketed bullets in 29 common minke whales. The whales were examined post mortem shipboard and 22 of the brains were fixed in situ and later subjected to gross and light microscopic examination. The results show that the two types of bullets are fully capable of penetrating the skull and spinal bones of common minke whales and fatally damaging the central nervous system, resulting in immediate or very rapid loss of consciousness.

From Snake Venoms to Therapeutics: A Focus on Natriuretic Peptides

Snake venom is a cocktail of multifunctional biomolecules that has evolved with the purpose of capturing prey and for defense. These biomolecules are classified into different classes based on their functions. They include three-finger toxins, natriuretic peptides, phospholipases and metalloproteinases. The focus for this review is on the natriuretic peptide (NP), which is an active component that can be isolated from the venoms of vipers and mambas. In these venoms, NPs contribute to the lowering of blood pressure, causing a rapid loss of consciousness in the prey such that its mobility is reduced, paralyzing the prey, and often death follows. Over the past 30 years since the discovery of the first NP in the venom of the green mamba, venom NPs have shown potential in the development of drug therapy for heart failure. Venom NPs have long half-lives, different pharmacological profiles, and may also possess different functions in comparison to the mammalian NPs. Understanding their mechanisms of action provides the strategies needed to develop new NPs for treatment of heart failure. This review summarizes the venom NPs that have been identified over the years and how they can be useful in drug development.

English

BACKGROUND Propofol is an appropriate intravenous anaesthetic induction agent for rapid induction and suppression of airway reflexes and is widely used for laryngeal mask airway insertion. Sevoflurane is a halogenated, non-pungent and non-explosive liquid anaesthetic agent with low blood gas solubility administered by inhalation for use in induction and maintenance of general anaesthesia. We wanted to compare the characteristics of sevoflurane and propofol for the induction of anaesthesia and laryngeal mask airway (LMA) insertion. METHODS We conducted a randomized control study among 70 patients (n=35 in each group) undergoing elective surgery. Patients were anaesthetised with either vital capacity breaths of 8% sevoflurane with 50% N2O and O2 or IV propofol, with loss of eyelash reflex considered as the end point of induction. RESULTS Both the drugs produced almost similar rapid loss of consciousness (propofol-45.29 ± 11.98 sec, sevoflurane-51.03±14.68 sec). The LMA was inserted more rapidly in propofol group (20.43±9.460 sec) than in the sevoflurane group (34.37 ± 17.338 sec), p=0.018. The score for jaw opening was better in the propofol group (2.94 ± 0.236) than in the sevoflurane group (2.66 ± 0.482), p=0.000. The ease of LMA insertion score was better in the propofol group (2.91 ± 0.284) than in the sevoflurane group (2.66 ± 0.482), p=0.008. Both groups had stable haemodynamic parameters. CONCLUSIONS Propofol was more favourable than sevoflurane for laryngeal mask airway insertion due to better jaw relaxation and less insertion time. However, sevoflurane is an alternative to propofol as an induction agent for laryngeal mask airway insertion. KEY WORDS Propofol, Sevoflurane, Laryngeal Mask Airway.

Complex Pathology of Cardiac Syncope in Old Patients

Syncope is characterized by a transient and rapid loss of consciousness for a short duration, with full spontaneous recovery within minutes. Syncope causes up to 2% of all emergency medical consultations. The incidence of syncope is similar in men and women, is higher in old patients (slightly higher in old women). The prevalence of syncope is up to 23% for the institutionalized elderly. In elderly patients, syncope often presents atypically, such as with falls; these patients might also have difficulty recalling events. The true incidence and prevalence of syncope in elderly patients are expected to be higher than those estimated in most studies. The causes of syncope are highly age-dependent. Reflex or neurally mediated syncope is the most common cause, particularly in younger patients. As individuals age, orthostatic hypotension and cardiac syncope become more frequent. In elderly patients, neurally mediated syncope is the most prevalent form of syncope. Orthostatic syncope is more frequent in the elderly than in young patients. In the elderly, cardiac causes account for about 15% of all cases, and in about 10% of the cases, the origin of syncope is unknown. A combination of different etiologies is common in geriatric patients because many pathophysiologies coexist, including age-related physiological changes, co-morbidities (e.g., neurological pathologies), multiple medications (with interactions, or with lowering of BP and HR), malnutrition, sarcolepsy, and prolonged bed rest. The available clinical guidelines for the diagnosis, investigation, and treatment of syncope are insufficient to address syncope in elderly patients. A comprehensive geriatric approach that considers the functional and cognitive capacities of individuals along with the medical and psychosocial aspects would be more appropriate. Modern medicine can be used to treat syncope in some geriatric patients and should be offered whenever possible.

Evaluation of Oral Transmucosal Administration of Pentobarbital for Euthanasia of Conscious Wild Birds

ABSTRACT This prospective study evaluated oral transmucosal pentobarbital sodium at three doses in 110 wild-caught wild birds requiring euthanasia. Birds received transmucosal pentobarbital at five (430 mg/kg), six (516 mg/kg), and seven times (602 mg/kg) the intravenous dose for mammals. Time to first effects and loss of consciousness, presence of pupillary light and corneal reflexes, apnea, and asystole were recorded each minute. When asystole was not achieved at 5 minutes, IV pentobarbital was administered. Combining data for all doses, loss of consciousness occurred at a median (range) of 2 minutes (0–4.75 min), apnea at 3 minutes (0–6 min), and asystole at 4 minutes (0.5–5 min). Loss of consciousness and apnea occurred significantly faster in the 602 mg/kg dose group than in the 430 mg/kg group (p = 0.009, difference of 0.6 ± 0.2 min; p = 0.024, difference of 0.7 ± 0.3 min), respectively. Apnea and asystole were achieved in 80/110 birds within 5 minutes. Oral transmucosal pentobarbital results in rapid loss of consciousness and respiratory arrest and provides a reliable alternative euthanasia method compared to intravenous administration.

Activation of anterior thalamic reticular nucleus GABAergic neurons promotes arousal from propofol anesthesia in mice.

Propofol is widely used for the induction and maintenance of anesthesia, which causes a rapid loss of consciousness. However, the mechanisms underlying the hypnosis effect of propofol are still not fully understood. The thalamic reticular nucleus (TRN) is crucial for regulating wakefulness, sleep rhythm generation, and sleep stability, while the role of TRN in the process of propofol-induced anesthesia is still unknown. Here, we investigated the function of the anterior TRN in propofol general anesthesia. Our results demonstrated that the neural activity of anterior TRN is suppressed during propofol anesthesia, whereas it is robustly activated from anesthesia by recording the calcium signals using fiber photometry technology. The results showed that the activation of anterior TRN neurons by chemogenetic and optogenetic methods shortens the emergency time without changing the induction time. Conversely, chemogenetic or optogenetic inhibition of the TRN neurons leads to a delay in the recovery time. Our study showed that anterior TRN is crucial for behavioral arousal without affecting the induction time of propofol anesthesia.

Resuscitation Following a Bupivacaine Injection for a Cervical Paravertebral Block.

BackgroundCardiac arrest related to nerve blockade using a local anaesthetic is a rare event. We report a case of bupivacaine severe cardiovascular toxicity following cervical paravertebral nerve block.Case presentationA 44-year-old female was admitted to Republican Vilnius University Hospital, with symptoms of sustained severe pain in her neck that radiated to both arms. Multiple cervical intervertebral hernias with spinal stenosis were confirmed by magnetic resonance imaging. Following infiltration of the subcutaneous tissue with a 0.5 % bupivacaine solution, an 18-gauge spinal needle was used to perform the paravertebral block at the C6 level. Bupivacaine was injected in incremental doses to a total of 10 mL. Rapid loss of consciousness and cardiovascular collapse suggested a neuraxial injection of bupivacaine. Long-lasting cardiopulmonary resuscitation, including chest compressions, defibrillation attempts for refractory ventricular fibrillation, medications, mechanical ventilation, and intravenous lipid emulsion infusion, was successful. No severe adverse outcomes other than acute kidney injury and chest pain related to prolonged chest compressions were documented.ConclusionsThis case report emphasizes the necessity of ensuring adequate safety precautions to avoid local anaesthetic systemic toxicity. Lipid emulsion preparations should be available in all hospital settings where local anaesthetics are used for regional anaesthesia or pain management.

Inconspicuous longitudinal tears of the intracranial vertebral artery in traumatic basal subarachnoid hemorrhage.

Blunt force trauma to the head or neck region can cause traumatic basal subarachnoid hemorrhage (TBSAH), which can result in rapid loss of consciousness and death; however, detecting such a vascular injury is difficult. Posterior neck dissection was performed to investigate the bleeding focus in TBSAH cases 2018 and 2019. In all four cases, autopsies revealed a longitudinal tear in the midsection of the vertebral artery’s intracranial portion. The midportion of the intracranial vertebral artery appears to be most vulnerable to TBSAH. Interestingly, three of the cases showed only a vaguely visible longitudinal fissure in the artery without a grossly apparent tear; rupture was confirmed by microscopic examination. Longitudinal fissures of the intracranial vertebral artery, which are difficult to identify without detailed examination, may be overlooked in some cases of TBSAH. Thus, careful gross and microscopic examination of the vertebral artery is recommended in cases of TBSAH.

The hypnotic effect of propofol involves inhibition of GABAergic neurons in the lateral hypothalamus.

Propofol is widely used for induction and maintenance of anaesthesia, which causes a rapid loss of consciousness. So far the mechanisms underlying the effect of propofol are still largely unknown. Here, we found that microinjection of propofol in the lateral hypothalamus caused a significant decrease in wakefulness and an increase in the amount of non-rapid eye movement sleep and rapid eye movement sleep. Application of propofol in the lateral hypothalamus affected the electroencephalogram power spectra with a decrease in theta oscillations and an increase in the delta oscillations. Additionally, using whole-cell patch clamp recording, we found propofol inhibited the excitability of the GABAergic neurons in the lateral hypothalamus, which plays a critical role in controlling wakefulness. Altogether, these findings indicate that propofol targets lateral hypothalamus and generates a hypnotic state, which might involve the inhibition of GABAergic neurons. These results provide a novel mechanism to explain propofol-elicited anaesthesia.

Widespread subdural metastasis from breast cancer progressing rapidly with cerebral herniation: A case report.

We herein present the case of a 49-year-old female patient presenting with nausea and headache. The patient's medical history included breast cancer with bone and lymph node metastasis. Computed tomography (CT) examination revealed a high-density lesion in the right subdural space, suggesting hematoma. During surgery planned for subdural hematoma drainage, an en plaque subdural yellowish-white tumor was identified, without hematoma. Histopathological examination revealed metastatic breast cancer. The patient was administered predonisolone and her neurological symptoms gradually recovered. However, 12 days after the first operation, the clinical course was complicated by vomiting and rapid loss of consciousness. Emergency CT revealed that the subdural tumor had enlarged and decompression was performed as life-saving surgery. However, the patient's condition progressively deteriorated and she finally succumbed to the disease 2 months after the second operation. The aim of this study was to present the case of a patient with a large en plaque subdural tumor mimicking subdural hematoma and causing rapid loss of consciousness and cerebral herniation.

Chloroform ingestion causing severe gastrointestinal injury, hepatotoxicity and dermatitis confirmed with plasma chloroform concentrations

Context: Poisoning due to chloroform ingestion is rare. The classic features of acute chloroform toxicity include central nervous system (CNS) and respiratory depression, and delayed hepatotoxicity.Case details: A 30-year-old female ingested 20–30 mL of 99% chloroform solution, which caused rapid loss of consciousness, transient hypotension and severe respiratory depression requiring endotracheal intubation and ventilation. She was alert by 12 h and extubated 16 h post-overdose. At 38-h post-ingestion, her liver function tests started to rise and she was commenced on intravenous acetylcysteine. Her alanine transaminase (1283 U/L), aspartate transaminase (734 U/L) and international normalized ratio (2.3) peaked 67- to 72-h post-ingestion. She also developed severe abdominal pain, vomiting and diarrhoea. An abdominal CT scan was consistent with severe enterocolitis, and an upper gastrointestinal endoscopy showed erosive oesophagitis, severe erosive gastritis and ulceration. She was treated with opioid analgesia, proton pump inhibitors, sucralfate and total parenteral nutrition. Secretions caused a contact dermatitis of her face and back. Nine days post-ingestion she was able to tolerate food. Her liver function tests normalized and the dermatitis resolved. Chloroform was measured using headspace gas chromatograph mass spectrometry, with a peak concentration of 2.00 μg/mL, 4 h 20 min post-ingestion. The concentration-time data fitted a 1-compartment model with elimination half-life 6.5 h.Discussion: In addition to early CNS depression and delayed hepatotoxicity, we report severe gastrointestinal injury and dermatitis with chloroform ingestion. Recovery occurred with good supportive care, acetylcysteine and management of gastrointestinal complications.

Psychological profile of children with neurogenic syncope

At present, syncope is still a matter of great concern and anxiety for both parents and children. Neurocardiogenic syncope is the most common type of syncope in children with an incidence of 70%. It usually has a benign etiology, with rapid loss of consciousness and spontaneous resolution. In case of neurocardiogenic syncope, it is important to assess the emotional and/or adaptive capacity of the patient. From a psychological point of view, the presence of a traumatic area of development has been reported in pediatric patients with syncope. This area is characterized by symptoms of anxiety and/or depression, self-withdrawal, somatic complaints and dissociation. Neurocardiogenic syncope in pediatric age can be the expression of a psychosomatic disorder underlying psychopathological vulnerability.

Complex visual imagery and cognition during near-death experiences.

Abstract: Near-death experiences (NDEs) entail complex and structured conscious experience during conditions known to coincide with rapid loss of consciousness often associated with decline or disruption of the neurological correlates currently held to be causative factors of visual imagery and cognition. In this study, 653 NDE reports of cardiac and/or respiratory arrest patients were analyzed for unprompted, spontaneous references to quality of conscious visual imagery and mentation during an NDE. Results indicate that in a majority of NDEs, both figurative and abstract mentation are either preserved or markedly improved during unconsciousness and unresponsiveness in the context of respiratory and cardiac arrests. These findings underscore the call to further study the mechanisms behind the 'outliving' of a conscious sense of selfhood and complex, structured visual imagery and cognition during severely deteriorating physiological function -- and perhaps especially during clinical death.

A Fatal Work-Related Poisoning by Hydrogen Sulfide

Hydrogen sulfide (H2S) is a colorless and potentially deadly gas that may cause rapid loss of consciousness and respiratory depression without warning. Although occupational exposure to H2S and the medical management of H2S-associated toxicity are widely established, it remains a problem in the sour gas industry and in other industrial settings, predominantly in new workers. In this article, the authors report a fatal case of a factory worker who died after breathing in H2S while undertaking a task that he was not trained to perform. Toxicological assessment supported by autopsy findings and circumstantial data was essential to clarify the cause of death, determined as H2S poisoning. This case emphasizes the need to develop work safety initiatives, improve on-the-job training, and introduce more consciousness to put on protective equipment for workers; indeed, correct training and education for workers regarding safety in the workplace may help to reduce worker fatalities.

Coronary and cerebral air embolism: a rare complication of computed tomography-guided transthoracic lung biopsy

A 71-year-old man with a history of excessive smoking was evaluated for an abnormal chest X-ray. He had no angina and no risk factors for coronary artery disease. Considering a high probability of lung cancer in this patient, computed tomography-guided transthoracic lung biopsy was performed by an experienced radiologist. A co-axial 18-gauge needle system was used to enter the lung and two core biopsy samples were obtained. During the procedure the patient was asked to inhale in order to reach the lesion. After the biopsy he developed mild haemoptysis followed by rapid loss of consciousness. After a couple of seconds the patient regained consciousness, was asymptomatic and did not show any signs of respiratory or haemodynamic complications. However, the ECG showed ST-segment elevation in leads I, II, aVL, aVF and V3-6 without reciprocal ST-segment depression suggestive of an acute myocardial infarction involving the distributions of more than one coronary artery (Fig. 1c). Review of the multi-slice CT images showed a mild pneumothorax, pulmonary haemorrhage, and air bubbles in both the circumflex coronary artery and descending aorta, diagnostic of an air embolism of the arterial system (Fig. 1a, b). He was placed in a mild Trendelenburg position and was administered 100 % high-flow non-rebreathing oxygen. Anticoagulation therapy was not initiated due to the pulmonary haemorrhage. Electrocardiography showed complete resolution of the ST-segment elevation after 20 min. However, 3 h later he developed seizures likely due to air embolisation to the cerebral circulation. A subsequent blood test showed cardiac troponin I elevation of 11.0 μg/l, whereas echocardiography demonstrated hypokinesis in the distal inferior and anteroseptal regions. The patient was eventually discharged after 1 week without any cardiac, pulmonary or neurological symptoms.

Physical and Physicochemical Factors Effecting Transport of Chlorohydrocarbon Gases from Lung Alveolar Air to Blood as Measured by the Causation of Narcosis

This systematic investigation examines gas transport in the lung for two sets of chlorohydrocarbons (CHCs): the chloromethanes (C1) and chloroethanes (C2). The C1 series includes chloromethane, methylene chloride, chloroform, and carbon tetrachloride, and the C2 series includes chloroethane, 1,2-dichloroethane, 1, 1, 2-trichloroethane, and 1, 1, 2, 2-tetrachloroethane. Most CHC gases cause narcosis. The comprehensive narcosis work of Lehmann and colleagues on CHCs was used as a basis for the narcosis endpoint in the present examination [1]. The sites for narcosis are located in the brain (midline cortex and posterior parietal area), the spine, and at many peripheral nerve sites. Central nervous system (CNS) exposure executes a multisite, neural transmission set of inhibitions that promotes rapid loss of consciousness, sensory feeling, and current and stored memory while providing temporary amnesia. Absorption into the system requires dissolution into many lipid membranes and binding to lipoproteins. Lipophilicity is a CHC property shared with many anesthetics according to the Meyer-Overton Rule. Many structurally different lipid chemicals produce the narcosis response when the lipid concentration exceeds ∼67 mM. This suggests narcotic or anesthetic dissolution into CNS membranes until the lipid organization is disrupted or perturbed. This perturbation includes loading of Na+- and K+-channel transmembrane lipoprotein complexes and disrupting their respective channel functional organizations. The channel functions become attenuated or abrogated until the CHC exposure ceases and CHC loading reverses. This investigation demonstrates how the CHC physical and chemical properties influence the absorption of these CHCs via the lung and the alveolar system on route to the blood. Narcosis in test animals was used here as an objective biological endpoint to study the effects of the physical factors Bp, Vp, Kd (oil: gas) partition, Henry's constant (HK), and water solubility (S%) on gas transport. Narcosis is immediate after gas exposure and requires no chemical activation only absorption into the blood and circulation to CNS narcotic sites. The three physical factors Bp, Kd (oil: air), and S% vary directly with unitary narcosis (UN) whereas Vp and HK vary inversely with UN in linear log-log relationships for the C2 series but not for the C1 series. Physicochemical properties of C1 series gases indicate why they depart from what is usually assumed to be an Ideal Gas. An essential discriminating process in the distal lung is the limiting alveolar film layer (AFL) and the membrane layer of the alveolar acini. The AFL step influences gas uptake by physically limiting the absorption process. Interaction with and dissolution into aqueous solvent of the AFL is required for transport and narcotic activity. Narcotics or anesthetics must engage the aqueous AFL with sufficient strength to allow transport and absorption for downstream CNS binding. CHCs that do not engage well with the AFL are not narcotic. Lipophilicity and amphipathicity are also essential solvency properties driving narcotics’ transport through the alveolar layer, delivery to the blood fats and lipoproteins, and into critical CNS lipids, lipoproteins, and receptor sites that actuate narcosis. AFL disruption is thought to be strongly related to a number of serious pulmonary diseases such acute respiratory distress syndrome, infant respiratory distress syndrome, emphysema, chronic obstructive pulmonary disease, asthma, chronic bronchitis, pneumonia, pulmonary infections, and idiopathic pulmonary fibrosis. The physical factors (Bp, Vp, Kd [oil: gas] partition, Henry's constant, and water solubility [S%]) combine to affect a specific transport through the AFL if lung C > C0 (threshold concentration for narcosis). The degree of blood CHC absorption depends on dose, lipophilicity, and lung residence time. AFL passage can be manipulated by physical factors of increased pressure (kPa) or increased gas exposure (moles). Molecular lipophilicity facilitates narcosis but lipophilicity alone does not explain narcosis. Vapor pressure is also required for narcosis. Narcotic activity apparently requires stereospecific processing in the AFL and/or down-stream inhibition at stereospecific lipoproteins at CNS inhibitory sites. It is proposed that CHCs likely cannot proceed through the AFL without perturbation or disruption of the integrity of the AFL at the alveoli. CHC physicochemical properties are not expected to allow their transport through the AFL as physiological CO2 and O2 naturally do in respiration. This work considers CHC inspiration and systemic absorption into the blood with special emphasis on the CHC potential perturbation effects on the lipid, protein liquid layer supra to the alveolar membrane (AFL). A heuristic gas transport model for the CHCs is presented as guidance for this examination. The gas transport model can be used to study absorption for other gas delivery endpoints of environmental concern such as carcinogens.

Massive Clonidine Overdose During Refill of an Implanted Drug Delivery Device for Intrathecal Analgesia: A Review of Inadvertent Soft-Tissue Injection During Implantable Drug Delivery Device Refills and Its Management

The study aims to highlight the potentially serious consequences of inadvertent soft-tissue injection of intrathecal drugs such as clonidine, during refills of implanted drug delivery devices, and to suggest strategies to reduce this complication. Case report and literature review were used. We report the case of a 51-year-old female with chronic arm pain who sustained a massive clonidine overdose (18,000 mcg) due to inadvertent soft-tissue injection during a refill of an implanted drug delivery device, resulting in rapid loss of consciousness and significant cardiovascular instability requiring urgent resuscitation, subsequent myocardial infarction, cardiac failure, and other significant complications. The risks of inadvertent soft-tissue injection of intrathecal drugs during implanted drug delivery device refills and management of such events is poorly documented in the literature. Inadvertent soft-tissue injection is possibly an underappreciated and underreported complication of intrathecal analgesia via an implanted drug delivery device. Under some circumstances, large doses of other intrathecal drugs such as bupivacaine, opioids, ziconotide, and baclofen may also be delivered by inadvertent soft-tissue injection with potentially life-threatening consequences. We recommend that practitioners, institutions, and professional bodies who manage patients with intrathecal analgesia via intrathecal drug delivery devices highlight and audit this complication and develop systems to manage it.

Agonal Sequences in 14 Filmed Hangings With Comments on the Role of the Type of Suspension, Ischemic Habituation, and Ethanol Intoxication on the Timing of Agonal Responses

The Working Group on Human Asphyxia has analyzed 14 filmed hangings: 9 autoerotic accidents, 4 suicides, and 1 homicide. The following sequence of agonal responses was observed: rapid loss of consciousness in 10 ± 3 seconds, mild generalized convulsions in 14 ± 3 seconds, decerebrate rigidity in 19 ± 5 seconds, beginning of deep rhythmic abdominal respiratory movements in 19 ± 5 seconds, decorticate rigidity in 38 ± 15 seconds, loss of muscle tone in 1 minute 17 seconds ± 25 seconds, end of deep abdominal respiratory movements in 1 minute 51 seconds ± 30 seconds, and last muscle movement in 4 minutes 12 seconds ± 2 minutes 29 seconds. The type of suspension and ethanol intoxication does not seem to influence the timing of the agonal responses, whereas ischemic habituation in autoerotic practitioner might decelerate the late responses to hanging.