Return Of Pulse Research Articles

Reliability of Digital Artery Palpation and Pulse Oximetry Waveform As Alternatives to Radial Pulse in the Assessment of Upper Limb Injuries.

Radial pulse palpation is widely accepted as a gold standard clinical method to assess distal vascular perfusion of the upper limb. In some instances, the radial pulse may not be accessible due to splints, casts, or swelling, or the injury may be at the level or distal to the radial artery. Here, the authors assess two alternative methods of assessing perfusion of the hand more distally: palpation of the digital pulse and pulse oximetry (PO) waveform. Twenty-four healthy adult volunteers (48 hands) were assessed by two assessors. Digital artery pulses were palpated, and ease of location was recorded. A brachial cuff pressure was inflated to 20 mmHg above systolic pressure to occlude distal perfusion. Radial pulse, digital artery pulse, and PO waveform were monitored as the brachial cuff pressure was deflated in 5 mmHg increments to ascertain when each returned and compare the reliability of these tests to the gold standard of the radial pulse. The digital artery pulse was easily located in 20/24 participants, most reliably over the proximal phalanx of the index finger. With occlusion of the brachial artery, no distal pulses could be felt, and PO showed no waveform. As the brachial artery cuff pressure was incrementally deflated, the digital pulse returned with the same cuff pressure or a lower cuff pressure than the radial pulse in all cases, suggesting a high positive predictive value of radial pulse presence. PO waveform returned at a higher cuff pressure or with the same cuff pressure as the return of the radial pulse, suggesting a higher sensitivity than radial pulse palpation in assessing hand perfusion. Digital pulse palpation can be used as a surrogate method of assessing hand perfusion. When present, it can be assumed a radial pulse is present due to a high positive predictive value and no false positives seen in any participant. When absent, further investigation is required. The PO waveform was found to be more sensitive than digital or radial pulse palpation as a measure of distal perfusion, with a return of waveform prior to palpable pulses. This likely represents a more accurate clinical test of distal perfusion and can be relied upon even when pulses are not palpable.

THE OUTCOME OF IRREDUCIBLE PULSELESS SUPRACONDYLAR FRACTURE OF HUMERUS TREATED VIA ANTERIOR APPROACH – A CASE SERIES

Background: Treatment of a pulseless pediatric supracondylar humeral fracture is controversial and varies from closed reduction percutaneous pinning to Surgical Exploration. Present study aimed to analyze outcome of Irreducible pulseless supracondylar fractures treated with Open reduction and exploration via anterior approach. in this prospective study of 7 patients Method: with pulseless Supracondylar fracture, 2 were treated by Close reduction percutaneous pinning and the other 5, irreducible on table by Open intervention. The later 5 cases were followed up at 3 weeks, 6 weeks, and 3 months and functionally assessed using MEPS. 3 cases Results: showed immediate return of pulse, 2 recovered within 6 hours. All cases at 3 months showed MEPS >90. Anterior approach is excellent Conclusion: for surgical decompression of the neurovascular bundle.

Supracondylar fracture humerus with pink pulseless hand and angiogram confirmed vascular injury – Case report

Supracondylar fracture of the humerus is a common injury in paediatric population. Neurovascular damage is a well-known serious complication of this injury. This should be managed urgently by the treating clinician in order to prevent severe disability to the child. In this case report, we illustrate the presentation, management and follow up of a 7-year-old boy presented with a supracondylar humerus fracture, highlighting the diagnostic and therapeutic measures taken in sequential manner.
 The child presented following a domestic fall and having pain, swelling and acute deformity of the left elbow. Clinically, no distal radial pulse or oxygen saturation using pulse oximetry detected on admission, even though the left hand was warm and pink with normal capillary refill time. X-ray confirmed the clinical diagnosis of supracondylar fracture humerus, and it was classified as Gartland type III.
 Manipulation and casting done without internal fixation on the next available casualty list and even after 72 hours of the procedure no return of distal pulse despite warm, pink hand. After vascular opinion, CT Angiogram revealed no flow segment of 2.2cm of brachial artery at the trauma site and minimum demonstrable flow distally. However, watchful waiting was selected as the management option by both vascular and orthopaedic teams as this child continues to have warm, pink hand with normal capillary refilling and minimal pain.
 In 6 months follow up, the child has gained both radial and ulnar pulses, full range of elbow motion, complete neurological recovery and good hand function.

S2663 The Eroding Ulcer

Introduction: Massive upper gastrointestinal (GI) bleeds can be life threatening. Common causes are peptic ulcer disease and esophagogastric varices. These, when presented, often can be managed endoscopically. Ulcers in the GI tract can, rarely, erode into major arteries including the splenic artery and cause bleeding that may need embolization or surgery to control. Here we report a case of a massive upper GI bleed. Case Description/Methods: Patient is a 65 year old male with PMH of alcohol abuse, drug use, bed bound who presented with reported hematemesis. Initially patient reported he drank red liquid prior and refused an endoscopy. A day into hospitalization he had another episode of hematemesis and hypotension and was transferred to the ICU. There he transfused and stabilized. He underwent an endoscopy discovering a gastric ulcer in the fundus. Epinephrine was injected with good effect and cautery was initiated with bipolar probe starting at the periphery of the visible vessel and on the edges of the ulcer. While performing cautery, the vessel in the ulcer started to hemorrhage causing red out and inability to visualize. He was intubated and started massive transfusion protocol. Interventional radiology (IR) and surgery was consulted. He had three cardiac arrests with rapid return of pulse. When he made it to the IR suite, underwent angiography which showing significant bleeding from mid splenic artery which was coiled (d). With the location the ulcer had eroded into the splenic artery causing a fistula. He recovered well and was later discharged from the hospital. He underwent a repeat endoscopy a few days later (a) and another a few weeks after discharge (b,c). Discussion: Often with vascular fistulas there is an initial small bleed followed by a more significant bleed as seen in this case. When encountering massive GI bleeding, one must keep enteric vascular fistulas in the differential and have interventional radiology and surgery engaged early. Presenting with a splenic artery aneurysm with bleeding is rare, 0.01 to 10.4% depending on literature. Hemorrhage is one of the most common presentation for splenic artery pseudoaneurysms with 47% of cases and mortality approaches 90% if not properly managed. This case reminds us to keep a broad differential and to involve IR and surgery early in a massive GI bleed.Figure 1.: A.Endoscopy post coiling with coil emerging from ulcer. B. Endoscopy after discharge. C. Endoscopy after discharge, coils still present from ulcer. D. Angiogram showing active bleeding.

Treatment of pediatric supracondylar humerus fractures accompanied with pink pulseless hands

BackgroundThe optimal treatment for pediatric supracondylar humeral fractures accompanied with a pink pulseless hand is controversial. Some clinicians recommend close observation after closed reduction and percutaneous pinning of the fractures, while some recommend surgical exploration if the radial pulse is unpalpable. The present study aimed to analyze the benefits and outcomes of close observation for treating pediatric supracondylar humeral fractures with a pink pulseless hand.MethodsThirteen consecutive children presenting with a pink pulseless hand following supracondylar humeral fracture were enrolled in this study. Preoperative and postoperative color-flow Duplex ultrasound detection was used to assess brachial artery compromise in most cases. Urgent closed reduction and percutaneous pinning of the fractures were attempted first. Close observation was carried out when the hand was pink and pulseless with an absent radial pulse.ResultsPreoperative color-flow Duplex ultrasound showed no disruption of the brachial artery in cases detected. Compression of the artery by the proximal fragment was observed in most cases, with one case of entrapment of the artery between fragments, and thrombus considered in two cases. All cases underwent urgent surgery, after which nine experienced immediate return of the radial pulse. The remaining four without a palpable pulse were managed with close observation and no deterioration of the vascular status was observed; therefore, no surgical exploration was performed. Postoperative color-flow Duplex ultrasound revealed continuity of the artery and rich collateral circulation. Patients completed an average of 4.5 years of follow-up, during which no major complications occurred. All patients achieved excellent limb function.ConclusionsOur study demonstrates that close observation after urgent closed reduction and percutaneous pinning is a sufficient approach for the treatment of pediatric supracondylar humeral fractures accompanied with a pink pulseless hand. Surgical exploration is not necessary as long as the hand is warm and well perfused. Color-flow Duplex ultrasound is beneficial for assessing vascular compromise and determining treatment strategies.

Vascular emergencies-The new COVID-19 crisis?

Vascular emergencies-The new COVID-19 crisis?

Duration and clinical features of cardiac arrest predict early severe cerebral edema

BackgroundSevere brain edema appears early after cardiopulmonary resuscitation (CPR) in a subset of patients and portends a poor prognosis. We tested whether clinical features of patients or resuscitation during out-of-hospital cardiac arrest (OHCA) are associated with early, severe cerebral edema. Method/research designWe reviewed pre-hospital and hospital records for comatose patients surviving to hospital admission after OHCA who had computed tomography (CT) of brain at the time of hospital admission available for inspection. We measured the gray-white ratio (GWR) of X-ray attenuation between the caudate nucleus and posterior limb of the internal capsule, defining severe cerebral edema as GWR < 1.20. We calculated associations between severe cerebral edema and patient or resuscitation variables. ResultsBetween 2010 and 2019, 1340 subjects were admitted of whom 296 (22%) showed severe cerebral edema on initial CT. Subjects with severe edema had lower survival (5/296, 2% vs. 377/1044, 36%). Severe edema was independently associated with total CPR duration, total dose of epinephrine, younger age, non-shockable arrest rhythms, fewer total number of rescue shocks, rearrest after initial return of pulses, and non-cardiac arrest etiology. Prevalence of severe cerebral edema increased from 2% among subjects with 0–10 min of CPR to 31% among subjects with >40 min of CPR. ConclusionCPR duration along with easily measurable clinical and resuscitation characteristics predict early severe cerebral edema after OHCA. Future interventional trials should consider targeting or preventing cerebral edema after prolonged hypoxic-ischemic brain injury especially in patients with high risk clinical features.

Ventilation Is an Important Confounding Variable When End-Tidal Carbon Dioxide Is Used to Help Guide Cardiopulmonary Resuscitation

Ventilation Is an Important Confounding Variable When End-Tidal Carbon Dioxide Is Used to Help Guide Cardiopulmonary Resuscitation

DON'T MESS WITH TEXAS? DON'T MESS WITH THE COLD! ACCIDENTAL HYPOTHERMIA WITH CARDIAC ARREST TREATED SUCCESSFULLY WITH PROLONGED RESUSCITATION AND REWARMING

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Accidental hypothermia is an uncommon but potentially life-threatening presentation, more frequently occurring in colder climates. We present a case of severe hypothermia with cardiac arrest in the characteristically warm state of Texas, in a patient who had arrived to the emergency department (ED) several times during the prior week. CASE PRESENTATION: A 55 year old man with a history of alcohol (ETOH) abuse and schizophrenia is brought into the ED after being found down. Records indicate that he had arrived here 10 different times in the prior 2 weeks due to ETOH intoxication and mild hypothermia, with oral and rectal temperatures between 90-95°F. Each time, after being rewarmed, he would act inappropriately, verbally abusing staff despite warnings from security. Social workers provided warm clothing, shelter information, food pantry and other basic needs, but he would decline assistance and was escorted out by security. On this presentation, he was hypothermic to 79°F rectally, unresponsive and pulseless, in ventricular fibrillation (VF) cardiac arrest. CPR was initiated along with intubation, and a cardioversion once returned pulses. Active rewarming began with forced air blankets, warm IV fluids, bladder and esophageal irrigation. The patient again lost pulses, CPR was resumed and a second shock delivered with return of pulses. He then went into pulseless electrical activity (PEA), received multiple rounds of CPR and epinephrine, and had a return of pulses after 3 hours of resuscitation. Bilateral chest tubes were inserted and warm thoracic lavage began. His rectal temperatures improved to 85°F then to the 90s°F, in sinus rhythm with good distal pulses, and the medical Intensive care unit staff was notified for further management. Within days, he showed complete recovery neurologically and was successfully extubated. He did not meet criteria for involuntary commitment, engaged in motivational interviewing and was discharged in good spirits. He was provided transportation to another city where he stated his family resides. DISCUSSION: This patient arrived to the ED several times in the days prior with Stage I and II hypothermia, but his care was complicated by intoxication, combativeness, and he repeatedly refused resources. His last arrival to the ED required full cardiac resuscitation and active rewarming with thoracic lavage. This case illustrates the importance of identifying patients at risk for accidental hypothermia, particularly the homeless, and those with a history of alcohol abuse, even in central Texas. His case may highlight a paucity of guidelines and framework for homeless individuals at risk for hypothermia, in areas that typically remain warm year-round. CONCLUSIONS: Accidental hypothermia can be a life threatening presentation, and identification of those at risk, particularly the homeless, those with a history of alcohol abuse, and poor mental health, is vital. Reference #1: J L Tan, M Saks, J M DelCollo, M Paryavi, S Visvanathan, C Geller; Accidental hypothermia cardiac arrest treated successfully with invasive body cavity lavage, QJM: An International Journal of Medicine, Volume 111, Issue 8, 1 August 2018, Pages 563–564, https://doi.org/10.1093/qjmed/hcy075 Reference #2: Husby, P., Andersen, K.S., Owen-Falkenberg, A. et al. Intensive Care Med (1990) 16: 69. https://doi.org/10.1007/BF01706328 DISCLOSURES: No relevant relationships by Liwayway Andrade, source=Web Response No relevant relationships by Zachary Pinchover, source=Web Response No relevant relationships by Mohi Syed, source=Web Response

Estimating Changes in Leaf Area, Leaf Area Density, and Vertical Leaf Area Profile for Mango, Avocado, and Macadamia Tree Crowns Using Terrestrial Laser Scanning

Vegetation metrics, such as leaf area (LA), leaf area density (LAD), and vertical leaf area profile, are essential measures of tree-scale biophysical processes associated with photosynthetic capacity, and canopy geometry. However, there are limited published investigations of their use for horticultural tree crops. This study evaluated the ability of light detection and ranging (LiDAR) for measuring LA, LAD, and vertical leaf area profile across two mango, macadamia and avocado trees using discrete return data from a RIEGL VZ-400 Terrestrial Laser Scanning (TLS) system. These data were collected multiple times for individual trees to align with key growth stages, essential management practices, and following a severe storm. The first return of each laser pulse was extracted for each individual tree and classified as foliage or wood based on TLS point cloud geometry. LAD at a side length of 25 cm voxels, LA at the canopy level and vertical leaf area profile were calculated to analyse tree crown changes. These changes included: (1) pre-pruning vs. post-pruning for mango trees; (2) pre-pruning vs. post-pruning for macadamia trees; (3) pre-storm vs. post-storm for macadamia trees; and (4) tree leaf growth over a year for two young avocado trees. Decreases of 34.13 m2 and 8.34 m2 in LA of mango tree crowns occurred due to pruning. Pruning for the high vigour mango tree was mostly identified between 1.25 m and 3 m. Decreases of 38.03 m2 and 16.91 m2 in LA of a healthy and unhealthy macadamia tree occurred due to pruning. After flowering and spring flush of the same macadamia trees, storm effects caused a 9.65 m2 decrease in LA for the unhealthy tree, while an increase of 34.19 m2 occurred for the healthy tree. The tree height increased from 11.13 m to 11.66 m, and leaf loss was mainly observed between 1.5 m and 4.5 m for the unhealthy macadamia tree. Annual increases in LA of 82.59 m2 and 59.97 m2 were observed for two three-year-old avocado trees. Our results show that TLS is a useful tool to quantify changes in the LA, LAD, and vertical leaf area profiles of horticultural trees over time, which can be used as a general indicator of tree health, as well as assist growers with improved pruning, irrigation, and fertilisation application decisions.

POINT CLOUD GENERATION FROM GAUSSIAN DECOMPOSITION OF THE WAVEFORM LASER SIGNAL WITH GENETIC ALGORITHMS

Abstract: Recent developments in LIDAR technology lead to the availability of the waveform systems, which capture and digitize the whole return of the emitted LASER pulse. As many objects may cause multiple returns in the same echo, one task is to detect and separate different echoes within the same digitized measurement. In this paper the results of a study aimed at LASER signal waveform decomposition using genetic algorithms are introduced. The proposed method is based on the Gaussian decomposition approach and analyzes each digitized return to compute one or more points. Initially, the number of peaks contained in the waveform is determined by a simple peak detection method, with a local maximum point algorithm. When more than one peak is detected, genetic algorithms are applied to estimate the amplitude, time and standard deviation of each peak within the digitized signal. With this methodology it was possible to increase the number of points by approximately 17 % compared to the point cloud obtained using commercial software. The best results were obtained in areas with high vegetation, and thus the methodology can be applied to the generation of denser points cloud in forest areas.

Flow-mediated dilatation to relieve puncture-induced radial artery spasm: A pilot study.

Puncture-induced radial artery spasm (RAS) may extend the duration of coronary an-giography (CAG) or cause transradial access failure. Flow-mediated dilatation (FMD), a widely-used noninvasive approach for assessing endothelial function, was reported to remove the entrapped radial sheath after percutaneous coronary intervention. Herein, the efficacy and safety of FMD in treating puncture-induced RAS before transradial CAG was investigated. Ninety patients with puncture-induced RAS were randomized in a 1:1:1 ratio into three groups: FMD group was immediately treated with blockage of brachial artery blood for 5 min using a sphygmomanometric cuff and then rapid relief; nitroglycerin (NTG) group was administered with 0.5 mg sublingual NTG instantly; and the no-therapy group was treated with a wait-and-watch strategy. The time of radial pulse recovery, and regional and systemic complications were recorded. The rate of radial pulse recovery within 30 min in FMD group was significantly higher than that in no-therapy group (97% vs. 73%, p = 0.026). The median time to return of radial pulse in FMD group and NTG group was significantly shorter than that in no-therapy group (7 [6.5-9] min vs. 15 [12-18] min, 8 [7-9] min vs. 15 [12-18] min, respectively; both p < 0.001). Headache and decreased blood pressure were more prevalent in NTG group than those in FMD and no-therapy groups. FMD is a feasible, noninvasive and nonpharmacological approach to relieve RAS and facilitate radial artery cannulation after an initial failed attempt. (Cardiol J 2018; 25, 1: 1-6).

Dexmedetomidine: A Potential Cause of Circulatory Collapse in Patient With Severe Pulmonary Arterial Hypertension

SESSION TITLE: Cardiothoracic Surgery SESSION TYPE: Global Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Dexmedetomidine is an alpha2 receptor agonist with unique mechanism of action for sedation and sympatholysis via receptors in the locus ceruleus, analgesia via receptors in the spinal cord without significant effect on respiration. Due to these properties, it has been increasingly used in the ICU and more recently in patient requiring non-invasive ventilation (NIV) who cannot tolerate this modality. A prostective randomized study compared dexmedetomidine vs midazolam in patients requiring NIV and sedation if they cannot tolerate the positive pressure ventilation.1 Dexmedetomidine was found to more desirable than midazolam in terms of level of awake sedation, shortened duration of mechanical ventilation and length of the ICU stay. However, patients treated with DM had statistical significant increase in bradycardia without needing intervention or stopping the medication. Although the study included patients with cardiogenic pulmonary edema they had normal EF. A retrospective multicenter international study found that about 80% of hospitalized patients with PAH who had circulatory collapse and cardiopulmonary rescusitation (CPR) did not survive the resuscitation effort despite minimal delay between collapse and initiation of CPR. ECG at the time of the CPR showed bradycardia in 45% of the patients. CASE PRESENTATION: We report the case of 75-year-old female with long-standing pulmonary fibrosis with secondary moderate to severe pulmonary arterial hypertension (PAH) who developed bradycardia requiring cardiovascular resuscitation believed secondary to dexmedetomidine (DM) infusion. Patient was on high oxygen for 4 weeks on acute-care floor before she had altered level of consciousness and worsening oxygenation requiring non- invasive ventilation (NIV) and transfer to the ICU. She was started on DM drip at 0.3 mcg/kg/min due to agitation, in part due to not being able to tolerate the NIV. Without developing hypoxemia, patient had a sudden onset of severe bradycadia with loss of blood pressure requiring advanced cardiopulmonary resuscitation. She responded to 1 mg epinephrine and brief chest compression with return of pulse and blood pressure. Dexmedetomidine was immediately stopped. After intubation, patient developed severe hypotension requiring multiple pressors. Bedside echo showed severe RV dilation and global hypokinesis. DISCUSSION: There is limited published studies on the use of DM in patients with PAH. Successful elective procedural sedations with DM were anecdotally reported in few adults and pediatric patients with severe PAH. Based on the above case, we caution against the use of DM in patients with severe PAH in the ICU due to risk of bradycardia that jeopardize the patient cardiac output that is highly dependent on heart rate. There are limited studies and inconclusive results on the effect of DM on pulmonary arterial pressure and pulmonary vascular resistance both in humans and animal models. CONCLUSIONS: Patients with severe PAH requiring NIV have significant comorbid condition, tenuous cardiac output and are at increased risk of acute de-compensation . DM should be avoided due to inceased risk of bradycardia and circulatory collapse. Any deterioration requiring acute resuscitation and emergency intubation are likely to be detrimental in this patient population. Reference #1: Dexmedetomidine versus Midazolam for sedation of Patients with Non-invasive Ventilation Failure. Huang, Z. Internal Medicine 2012; 51:2299-2305. Reference #2: Outcome after Cardiopulmonary Resuscitation in Patients with Pulmonary Arterial Hypertension. AM J Respir Crit Care Med 2002;165:341-344 Reference #3: Dexemedetomidine and Pulmonary Hypertension: A Case Report and Review of the Literature J Med Cases 2013; 4(7):481-484. DISCLOSURE: The following authors have nothing to disclose: Khaled Saleh, Fadi Hamed No Product/Research Disclosure Information

The need to resume chest compressions immediately after defibrillation attempts: An analysis of post-shock rhythms and duration of pulselessness following out-of-hospital cardiac arrest

AimCurrent consensus guidelines for cardiopulmonary resuscitation (CPR) recommend that chest compressions resume immediately after defibrillation attempts and that rhythm and pulse checks be deferred until completion of 5 compression:ventilation cycles or minimally for 2min. However, data specifically confirming the post-shock duration of asystole or pulseless electrical activity before return of spontaneous circulation (ROSC) are lacking. Our aim was to describe the frequency of the various post-shock cardiac rhythms and the duration of post-shock pulselessness in out-of-hospital non-traumatic cardiac arrest. MethodUsing prospectively-collected data from the Resuscitation Outcomes Consortium (ROC) Epistry database, the investigators reviewed monitor-defibrillator recordings of 176 patients who received defibrillation attempts in the out-of-hospital setting for ventricular fibrillation (VF) or ventricular tachycardia (VT) with absent pulses,. ResultsAmong 376 different defibrillation attempts delivered in the 176 patients, there were 182 resulting episodes of post-shock asystole. The mean interval of asystole after defibrillation was 69±136s (median 20s; IQR 36) and the mean interval for return of an organized rhythm was 64±157s (median 7s; IQR 26). The mean time to ROSC was 280±320s (median 136s; IQR 445). ConclusionAfter defibrillation attempts, the majority of patients remain pulseless for over 2min and the duration of asystole before return of pulses is longer than 120s beyond the shock gap in as many as 25%. These data support the recommendation to immediately resume chest compressions for 2min following attempted defibrillation.

Near-infrared spectroscopy for detection of vascular compromise in paediatric supracondylar fractures

Children suffering supracondylar fractures of the humerus are at risk of vascular compromise, which is currently assessed clinically, although other modalities such as angiography, pulse oximetry, Doppler ultrasound and magnetic resonance angiography have been used. We sought to ascertain whether tissue haemoglobin oxygenation (StO2) measurement could distinguish between patients with and without clinical vascular compromise following supracondylar fractures of the humerus. We prospectively observed StO2 using near-infrared spectroscopy in 29 paediatric patients with supracondylar fractures requiring operative manipulation. The injured and uninjured volar forearm compartments were monitored immediately before and after fracture reduction. The relationship between StO2 in the injured and uninjured limb, and the presence of pre-operative vascular compromise was assessed. Seven out of 29 children presented with vascular compromise. Patients with clinical vascular compromise had significantly lower pre-reduction StO2 (63.5% ± 15%, mean ± standard deviation), compared to those without compromise (80.9% ± 10%). StO2 normalized following surgery in all children with vascular compromise. These improvements in muscle StO2 were associated, in all patients, with the clinical return of pulses and resolution of neurological symptoms if present. StO2 monitoring can identify patients with clinical vascular compromise, can identify the return of adequate perfusion following operative correction of supracondylar fractures, and may be a useful adjunct to clinical assessment.

1209

Introduction: High dose insulin (HDI) and intravenous lipid emulsion (ILE) have emerged as treatment options for severe calcium channel blocker (CCB) and beta-blocker (BB) toxicity. Insulin causes increased glucose uptake into cardiac myocytes and affects various intra-cellular pathways resulting in positive inotropic effects. ILE therapy is theorized to work by sequestering highly lipophilic compounds and preventing them from reaching their site of action. It provides a fatty acid substrate to stressed myocardial cells and improves the function of calcium ion membrane channels on myocardial cells therefore increasing inotropy and chronotropy. Case Series Description: The first patient was a 35 year old male who arrived in the emergency department (ED), in bradycardic arrest (20 beats/min) without a measurable blood pressure (BP). He ingested 30-amlodipine 5mg (150mg), 47-metoprolol 25mg (1.2g), and 57-verapamil ER 180mg (10.3g). He was given atropine, glucagon, and calcium along with infusions of dopamine, epinephrine, and glucagon with return of measurable vital signs. After return of a palpable femoral artery pulse and subsequent intubation for mental status the patient was transferred to the medical intensive care unit (MICU). HDI was initiated with a 1unit/kg (83 units) bolus, an insulin infusion 1unit/kg/hr (80 units/hr), and D10% infusion at 100ml/hr approximately five hours after arrival to the ED. The glucagon infusion and dopamine were discontinued within one hour of the HDI bolus. Due to the amount of medication ingested and persistent shock it was decided to start ILE therapy. It was started approximately seven hours after arrival to the ED and included a bolus of ILE 20% 1.5ml/kg (130ml) and an infusion of 0.25ml/kg/min for 60min. The epinephrine was discontinued approximately an hour after initiation of the ILE. On hospital day three the patient started to spontaneously move his extremities and was extubated with a full neurological recovery. The second patient was a 59 year old male who presented after a witnessed suicide attempt where he ingested approximately 60-metformin (30g), 30-amlodipine (3g), 30-lisinopril (3g), and simvastatin of an unknown quantity. He received activated charcoal and calcium prior to arrival. Upon arrival to the ED, he was hypotensive (78/36 mmHg) and bradycardic (54 beats/minute). His initial pH was 7.2 showing a severe lactic acidosis with an anion gap of 17, and a lactate of 6.6mmol/L. He was started on norepinephrine and a sodium bicarbonate infusion for his severe metabolic acidosis. Approximately six hours after arrival, the patient received HDI [bolus-1unit/kg (70units), infusion-1unit/kg/hr (70 units/hr)], ILE [bolus-1.5ml/kg (105ml), infusion (0.25ml/kg/min for 60min)], and D10% at 100ml/hr. Six hours after initiation of HDI the dextrose infusion was converted to D20% due to hypoglycemia. He was initiated on continuous renal replacement therapy in the MICU. While the drip was running, the patient's BGs were checked hourly and 25g of dextrose was administered for any BG <100mg/dL. HDI was continued for 55 hours after initiation with a mean BG of 121 ± 43 (57-223)mg/dL. He experienced one episode of hypoglycemia (BG < 70mg/dL). After discontinuation of the insulin drip, the patient was transferred to the general medicine floor where his renal function improved over the next few days. He was discharged neurologically intact back to his institution.

Should You Explore the Brachial Artery in Children Who Have a Perfused Hand but No Palpable Radial Pulse After Sustaining a Supracondylar Humeral Fracture?

The articles by Weller et al. and Scannell et al. add another seventy patients to the literature describing good outcomes for closely observed patients who have a perfused hand but no palpable radial pulse after undergoing closed reduction and percutaneous pinning of a supracondylar humeral fracture. Weller et al. described a high-volume experience at their institution, where the approach is to observe most patients who have a perfused hand but no palpable pulse in association with a supracondylar humeral fracture (this approach varies according to the preference of the attending surgeon, however, so some of these fractures were explored during the time course of the study). If a palpable radial pulse does not return following closed reduction and percutaneous pinning, the rationale for exploration of the brachial artery in their center hinges on the outcome of Doppler assessment of the radial artery; that is, vascular consultation and exploration for those without a Doppler signal, and observation for those who have a Doppler signal. Their paper has the limitations of a retrospective study, and they do not have very long follow-up on the patients. They do report on the cases of two patients that provide valuable teaching points. One patient, who had improved vascular status after undergoing closed reduction and percutaneous pinning, had subsequent deterioration during observation and was returned to the operating room for exploration after developing a cool, poorly perfused hand. Another patient with a perfused hand but no palpable radial pulse developed an ischemic contracture of the forearm despite having a benign and routine postoperative hospital course. This patient had no palpable pulse before or after closed reduction and percutaneous pinning but had a Doppler signal at the radial artery before and after and had a palpable pulse prior to discharge from the hospital. After discharge, the patient …

The Perfused, Pulseless Supracondylar Humeral Fracture: Intermediate-Term Follow-up of Vascular Status and Function

This study provides intermediate-term follow-up data on the vascular status of a cohort of children with a perfused, pulseless supracondylar humeral fracture who were managed with closed reduction, percutaneous pinning, and observation. Pediatric patients who sustained a perfused, pulseless supracondylar humeral fracture in the period from 2007 to 2011 and who had at least six months of clinical follow-up were identified and returned for evaluation. The primary outcome was vascular status as indicated by palpation of the radial pulse, the wrist brachial index, and arterial patency on duplex ultrasound. Secondary outcomes included functional parameters assessed with the Pediatric Outcomes Data Collection Instrument (PODCI), arm circumference, arm length, elbow motion, neurologic findings, muscle endurance, grip strength, and intolerance to cold. Follow-up data were obtained for twenty of thirty-six patients with a Gartland type-III fracture who had been managed with closed reduction and percutaneous pinning. Five patients had a return of a palpable pulse in the operating room after closed reduction and percutaneous pinning. All twenty had a palpable radial pulse at the time of the latest follow-up, and all nerve palsies resolved. Duplex ultrasound performed at the time of follow-up showed that fourteen patients had a patent brachial artery, five had brachial artery occlusion with large collateral vessels, and one had severe arterial stenosis. All fourteen patients with a patent brachial artery, two of the five with an occluded brachial artery, and the patient with a stenotic brachial artery had a normal wrist brachial index. Three patients with an occluded brachial artery had an abnormal wrist brachial index (0.73, 0.71, and 0.80). No differences between the injured and uninjured sides were observed with regard to arm circumference, arm length, elbow motion, muscle endurance, or grip strength. Thirteen of the twenty patients had higher functioning in all domains of the PODCI questionnaire compared with the general population. Two patients (one with an occluded artery and one with a patent artery) had lower values on the global functioning score. After an average of twenty months of follow-up, children with a perfused, pulseless supracondylar humeral fracture that had been treated with closed reduction, percutaneous pinning, and observation demonstrated a palpable distal radial pulse, normal growth of the arm, and good/excellent functional outcomes, although five of the twenty patients had an occluded brachial artery. Therapeutic level IV. See Instructions for Authors for a complete description of levels of evidence.

Low dose tissue plasminogen activator treatment for vascular thrombosis following cardiac catheterization in children: A single center experience

To assess the efficacy and safety of low dose tissue plasminogen activator (tPA) therapy in children with vascular thrombosis following cardiac catheterization. Currently, heparin is the standard of care for vascular thrombosis, however, it may not be efficacious in dissolving existing thrombi. Although tPA is an accepted thrombolytic therapy for life-threatening thrombosis in children, it is not a well-established treatment for the thrombosis of femoral vessels following cardiac catheterization. A retrospective analysis was performed from 1/1/2009 until 6/30/2011 at Rady Children's Hospital-San Diego (RCHSD) reviewing all cases with venous or arterial thrombosis at the vascular access site following cardiac catheterization, and a survey was conducted among the Congenital Cardiovascular Interventional Study Consortium members regarding their experience in tPA therapy. At RCHSD, out of 1,155 catheterizations, 12 children developed femoral thrombosis. In three children, where 12-h heparin therapy was unsuccessful in resolving thrombosis, we used low-dose tPA according to the following regime: 0.05 mg/kg/h for 30 min, followed by 0.1 mg/kg/h for 4 h. We achieved thrombolysis in all cases evidenced by repeat ultrasound and return of palpable pulse with normal limb circulation. No complications were encountered. The survey confirmed that adult tPA dose (0.1-0.5 mg/kg/h) has 100% efficacy in resolving thrombi in children with vascular thrombosis, however, the rate of serious complications was not negligible (15%). tPA is an efficacious therapy to dissolve thrombi that developed as a complication of cardiac catheterization in children. The rate of complications due to tPA may be reduced using a lower dose: 0.05-0.1 mg/kg/h.

G75 ‘A Bolt from Blue – Be Aware!!’

AimProlonged QT syndrome is now recognised as a major cause of sudden unexpected cardiac death, especially in children and adolescents.MethodsSelected from Paediatric Cardiology clinic listResultsA 3 1/2 year old fit...