Aécio Flávio Teixeira de Góis

Ondine's curse after brainstem infarction.

This report describes a rare case of acquired Ondines curse. The patient developed central sleep apnea syndrome named Ondines curse after a brainstem infarction. Lesions involving the descending medullocervical pathways that subserve automatic breathing can result in this syndrome.

Focused Cardiac Ultrasound Using a Pocket-Size Device in the Emergency Room

Background Cardiovascular urgencies are frequent reasons for seeking medical care. Prompt and accurate medical diagnosis is critical to reduce the morbidity and mortality of these conditions. Objective To evaluate the use of a pocket-size echocardiography in addition to clinical history and physical exam in a tertiary medical emergency care. Methods One hundred adult patients without known cardiac or lung diseases who sought emergency care with cardiac complaints were included. Patients with ischemic changes in the electrocardiography or fever were excluded. A focused echocardiography with GE Vscan equipment was performed after the initial evaluation in the emergency room. Cardiac chambers dimensions, left and right ventricular systolic function, intracardiac flows with color, pericardium, and aorta were evaluated. Results The mean age was 61 ± 17 years old. The patient complaint was chest pain in 51 patients, dyspnea in 32 patients, arrhythmia to evaluate the left ventricular function in ten patients, hypotension/dizziness in five patients and edema in one patient. In 28 patients, the focused echocardiography allowed to confirm the initial diagnosis: 19 patients with heart failure, five with acute coronary syndrome, two with pulmonary embolism and two patients with cardiac tamponade. In 17 patients, the echocardiography changed the diagnosis: ten with suspicious of heart failure, two with pulmonary embolism suspicious, two with hypotension without cause, one suspicious of acute coronary syndrome, one of cardiac tamponade and one of aortic dissection. Conclusion The focused echocardiography with pocket-size equipment in the emergency care may allow a prompt diagnosis and, consequently, an earlier initiation of the therapy.

Warfarin-induced gastric intramural hematoma

IntroductIon Gastric intramural hematoma is extremely rare. Most cases of gastrointestinal tract hematomas are located in the esophagus or in the duodenum, being usually associated with anticoagulant therapy, coagulopathy, trauma, ulcer, amyloid angiopathy, repeated vomiting, complications of endoscopy and idiopathic disease.1-7 A case of gastric hematoma in a patient using warfarin in a conservative measure will be described in this short report. A 41-year-old female patient came to a clinic complaining of four-day nausea and abdominal pain. She referred to a mild pain, which was intermittent, burning, radiating to the left hypochondrium, associated with nausea and one vomiting event. There was no history of alcohol use, tobacco smoking or overeating. The past medical history had shown leiomyosarcoma in the right kidney one year prior to admission, treated with right nephrectomy. She had also had thrombosis of inferior vena cava extending to both common iliac veins to the right atrium beyond pancreatic and adrenal metastasis. She had undergone maintenance treatment with warfarin and palliative chemotherapy with docetaxel and gemcitabine. Initially she had been medicated with omeprazole and tramadol with a good relief of symptoms. Laboratory data have shown hemoglobin 10.1 g/dL (12-15.5), leucocytes 28.4 x 109/l (3.5–10.5), thrombocytes 148 x109/l (150–450), amylase 52 U/l (0–99), creatinine 1.41 mg/dL (0.5-0.9), INR 3.51 (0.8-1.2) and normal values of markers of myocardial necrosis and hepatic injury. After a first two-day assessment, she developed severe epigastric pain, pale skin, sudoresis and lipothymia. Physical examination had shown a distressed woman with blood pressure of 74/38 mmHg, a pulse rate of 110 per minute, a respiration rate of 26 per minute and normal temperature. Further physical examination presented pain in epigastric palpation. Electrocardiogram showed sinusal tachycardia with hemoglobin levels of 3.9 g/dL, creatinine 2.52 mg/dL and INR 8.76. She had been resuscitated by saline infusion and red blood cells transfusion. A computed tomography scan of the abdomen demonstrated a 17.6 × 12.4 × 7.08 cm large fluid collection in the stomach, heterogenic with hyper attenuating areas in between, consistent with hematoma, which after injection of contrast medium, had shown foci of active bleeding (Figure 1).

Rhabdomyolysis as a manifestation of clomipramine poisoning

CONTEXT Tricyclic antidepressive agents are widely used in suicide attempts and present a variety of deleterious effects. Rhabdomyolysis is a rare complication of such poisoning. CASE REPORT A 55-year-old woman ingested 120 pills of 25 mg clomipramine in a suicide attempt two days before admission. After gastric lavage in another emergency department on the day of intake, 80 pills were removed. On admission to our department, she was disoriented, complaining of a dry mouth and tremors at the extremities. An electrocardiogram showed a sinus rhythm with narrow QRS complexes. Laboratory results showed high creatine phosphokinase (CK = 15,094 U/l on admission; normal range = 26 to 140 U/l), hypocalcemia, slightly increased serum transaminases and mild metabolic acidosis. The patients medical history included depression with previous suicide attempts, obsessive-compulsive disorder, hypothyroidism and osteoporosis. She presented cardiac arrest with pulseless electric activity for seven minutes and afterwards, without sedation, showed continuous side-to-side eye movement. She developed refractory hypotension, with need for vasopressors. Ceftriaxone and clindamycin administration was started because of a hypothesis of bronchoaspiration. The patient remained unresponsive even without sedation, with continuous side-to-side eye movement and a decerebrate posture. She died two months later. Rhabdomyolysis is a very rare complication of poisoning due to tricyclic drugs. It had only previously been described after an overdose of cyclobenzaprine, which has a toxicity profile similar to tricyclic drugs. CONCLUSIONS Although arrhythmia is the most important complication, rhabdomyolysis should be investigated in cases of clomipramine poisoning.

Intubação orotraqueal: avaliação do conhecimento médico e das práticas clínicas adotadas em unidades de terapia intensiva

OBJETIVOS: Avaliar o conhecimento medico sobre as tecnicas de intubacao e identificar as praticas mais realizadas. METODOS: Estudo prospectivo, envolvendo tres diferentes unidades de terapia intensiva de um hospital universitario: da anestesiologia (ANEST), da pneumologia (PNEUMO) e do pronto socorro (PS). Todos os medicos que trabalham nessas unidades e que concordaram em participar do estudo, responderam um questionario contendo dados demograficos e questoes sobre intubacao orotraqueal. RESULTADOS: Foram obtidos 85 questionarios (90,42% dos medicos). ANEST teve maior media de idade (p = 0,001), com 43,5% sendo intensivistas. Foi referido uso da associacao hipnotico e opioide (97,6%) e pre oxigenacao (91,8%), mas apenas 44,6% referiram utilizacao de coxim suboccipital, sem diferenca entre as UTIs. Na ANEST, referiu-se maior uso de bloqueador neuromuscular (p < 0,000) e maior cuidado com estomago cheio (p = 0,002). O conhecimento sobre sequencia rapida foi restrito (nota media - 2,20 ± 0,89, com p = 0,6 entre as unidades de terapia intensiva. A manobra de Sellick era conhecida por (97,6%), mas 72% usaram-na inapropriadamente. CONCLUSOES: O conhecimento medico sobre intubacao orotraqueal em terapia intensiva nao e satisfatorio, mesmo entre profissionais qualificados para tal procedimento. E necessario avaliar se ha concordância entre as respostas dos questionarios e as praticas clinicas efetivamente adotadas.

Cohort study on the factors associated with survival post-cardiac arrest

CONTEXT AND OBJECTIVE Cardiac arrest is a common occurrence, and even with efficient emergency treatment, it is associated with a poor prognosis. Identification of predictors of survival after cardiopulmonary resuscitation may provide important information for the healthcare team and family. The aim of this study was to identify factors associated with the survival of patients treated for cardiac arrest, after a one-year follow-up period. DESIGN AND SETTING Prospective cohort study conducted in the emergency department of a Brazilian university hospital. METHODS The inclusion criterion was that the patients presented cardiac arrest that was treated in the emergency department (n = 285). Data were collected using the In-hospital Utstein Style template. Cox regression was used to determine which variables were associated with the survival rate (with 95% significance level). RESULTS After one year, the survival rate was low. Among the patients treated, 39.6% experienced a return of spontaneous circulation; 18.6% survived for 24 hours and of these, 5.6% were discharged and 4.5% were alive after one year of follow-up. Patients with pulseless electrical activity were half as likely to survive as patients with ventricular fibrillation. For patients with asystole, the survival rate was 3.5 times lower than that of patients with pulseless electrical activity. CONCLUSIONS The initial cardiac rhythm was the best predictor of patient survival. Compared with ventricular fibrillation, pulseless electrical activity was associated with shorter survival times. In turn, compared with pulseless electrical activity, asystole was associated with an even lower survival rate.

Diabetes insípido em paciente com esclerose múltipla

Multiple Sclerosis (ME) is a chronic progressive disease characterized by relapses of demyelination that can occur anywhere in the brain stem, spinal cord and optic nerve. Since central diabetes insipidus (DI) is mainly caused by central nervous system damage (such as trauma, surgery, tumor, infection, sarcoidosis), ME is included among its possible etiologies. However, this association is not commonly described. The clinical suspicion must be made in the presence of polyuria and polydipsia or refractory hypernatremia (in patients without free access to water) during the evolution of ME. We will describe a clinical report in which this association occurred and, after the beginning of desmopressin therapy, the clinical findings were reverted.

Purple urine bag syndrome: case report for Streptoccocus agalactiae and literature review

We report a case of purple urine bag syndrome, associated to Streptococcus agalactiae urinary tract infection, progressing to septic shock and death. We present a review of the literature on the subject and take the opportunity to attend readers about increasing incidence with population aging and its potential bad outcome.

Characterization of cardiac arrest in the emergency department of a Brazilian University Reference Hospital: A prospective study

Background & objectives: Sudden cardiac arrest (CA) represents one of the greatest challenges for medicine due to the vast number of cases and its social and economic impact. Despite advances in cardiopulmonary resuscitation (CPR) techniques, mortality rates have not significantly decreased over decades. This study was undertaken to characterize patients that have suffered CA and to identify factors related to mortality. Methods: This prospective study was conducted at Emergency Department of São Paulo Hospital, Brazil. Two hundred and eighty five patients were followed for one year after treatment for CA. The mean age was 66.3±17.2 yr, and they were predominantly male (55.8%) and Caucasian (71.9%). Mortality rate and factors associated with mortality were the primary and secondary outcome measures. Data were collected using an in-hospital Utstein-style report. A logistic regression analysis was used to determine which variables were related to mortality. Results: Regarding the characteristics of CPR, 76.5 per cent occurred in hospital, respiratory failure was the most common presumed immediate cause of CA (30.8%) and pulseless electrical activity was the most frequent initial rhythm (58.7%). All attempts at CPR utilized chest compressions and ventilation and the most utilized interventions were epinephrine (97.2%) and intubation (68.5%). Of all patients treated, 95.4 per cent died. Patients with pulseless electrical activity had a higher risk of death than those patients with ventricular fibrillation. Interpretation & conclusions: The findings of the study highlighted that the mortality rate among CA patients was high. The variable that best explained mortality was the initial CA rhythm.

One-year follow-up of neurological status of patients after cardiac arrest seen at the emergency room of a teaching hospital

ABSTRACT Objective: To describe neurological status and associated factors of survivors after cardiac arrest, upon discharge, and at 6 and 12 month follow-up. Methods: A cohort, prospective, descriptive study conducted in an emergency room. Patients who suffered cardiac arrest and survived were included. A one-year consecutive sample, comprising 285 patients and survivors (n=16) followed up for one year after discharge. Neurological status was assessed by the Cerebral Performance Category before the cardiac arrest, upon discharge, and at 6 and 12 months after discharge. The following factors were investigated: comorbidities, presence of consciousness upon admission, previous cardiac arrest, witnessed cardiac arrest, location, cause and initial rhythm of cardiac arrest, number of cardiac arrests, interval between collapse and start of cardiopulmonary resuscitation, and between collapse and end of cardiopulmonary resuscitation, and duration of cardiopulmonary resuscitation. Results: Of the patients treated, 4.5% (n=13) survived after 6 and 12 months follow-up. Upon discharge, 50% of patients remained with previous Cerebral Performance Category of the cardiac arrest and 50% had worsening of Cerebral Performance Category. After 6 months, 53.8% remained in the same Cerebral Performance Category and 46.2% improved as compared to discharge. After 12 months, all patients remained in the same Cerebral Performance Category of the previous 6 months. There was no statistically significant association between neurological outcome during follow-up and the variables assessed. Conclusion: There was neurological worsening at discharge but improvement or stabilization in the course of a year. There was no association between Cerebral Performance Category and the variables assessed.