Joseph Varon

Acute thoracic aortic dissection: The basics

With an increasing incidence, aortic dissection is the most common acute illness of the aorta. In the setting of chronic hypertension, with or without other risk factors for aortic dissection, this diagnosis should be considered a diagnostic possibility in patients presenting to the emergency department with acute chest or back pain. Left untreated, about 75% of patients with dissections involving the ascending aorta die within 2 weeks of an acute episode. But with successful initial therapy, the 5-year survival rate increases to 75%. Hence, timely recognition of this disease entity coupled with urgent and appropriate management is the key to a successful outcome in a majority of the patients. This article reviews acute thoracic aortic dissection, including ED diagnosis and management.

In-hospital resuscitation among the elderly: Substantial survival to hospital discharge☆

The appropriateness of aggressive resuscitation in many clinical settings has been questioned. Survival rates from cardiac arrest in the elderly are generally reported as poor, and satisfactory results from resuscitation attempts prolonged beyond 15 minutes are said to be rare. It was the purpose of this study to examine success rates for resuscitation in a cohort of elderly inpatients suffering cardiac arrest. We retrospectively reviewed 213 consecutive cardiac arrests occurring during a 12-month period in a large tertiary private hospital. Patient age, presenting rhythm, and survival to hospital discharge were recorded. Elderly was defined as 70 years or older. Cardiac arrests in the elderly totaled 89. Average age in this cohort was 76.2 +/- 4.5 years. Eighteen patients (20.2%) had return of spontaneous circulation and 8 patients survived to hospital discharge (44.4% of those with return of spontaneous circulation). No significant difference in age or presenting rhythm of survivors versus nonsurvivors could be demonstrated, although a trend to more frequent ventricular fibrillation or ventricular tachycardia was seen (P = .059, Fishers exact). Time for resuscitation averaged 25.75 +/- 9.2 minutes for survivors and 32.6 +/- 22.1 minutes for nonsurvivors. Survival to hospital discharge occurs in 9% of in-hospital cardiac arrests in the elderly following average CPR times substantially in excess of 15 minutes.

Feasibility of noninvasive mechanical ventilation in the treatment of acute respiratory failure in postoperative cancer patients

PURPOSEnPatients with cancer who require mechanical ventilation have high mortality rates. Although oncological patients have multiple clinical problems, including nutritional and immunological deficiencies, added complications from mechanical ventilation by themselves may be life-threatening and may further compromise the ability of these patients to recover from an episode of acute respiratory failure (ARF). Noninvasive mechanical ventilatory support (NIMV) using positive-pressure-ventilation delivered through a mask has gained popularity for the treatment of ARF and may limit some mechanical ventilation complications. The purpose of this study was to prospectively evaluate NIMV in cancer patients with ARF.nnnMATERIALS AND METHODSnAll patients admitted to the surgical intensive care unit (SICU) at The University of Texas M.D. Anderson Cancer Center from August 1, 1994, to April 15, 1996, with hypoxemic or hypercapnic ARF were eligible for this study. NIMV was delivered with the BiPAP S/T-D (Respironics, Murrysville, PA) device. The initial settings were adjusted to achieve a tidal volume of 5 to 7 mL/kg and a SaO2 greater than 0.90. Demographic data, duration of therapy, and need for endotracheal intubation were recorded for each patient.nnnRESULTSnSixty patients were included in this study. There were 21 women (35%) and 39 men. The primary cancer sites of these patients were gastrointestinal (25 patients), genitourinary (15), hematological (8), lung (6), sarcoma (4), and skin (2). Fifty-three patients (88%) had hypoxemic ARF and 7 had hypercapnic ARF. The mean duration of NIMV was 1.83 days (range, 1 to 5 days) with a median of 2 days. Forty-two patients (70%) were weaned from NIMV and were spared endotracheal intubation. The remaining 18 patients deteriorated and ultimately required intubation and assisted mechanical ventilation. No complications related to the use of NIMV were seen in this study population.nnnCONCLUSIONSnNIMV was effective in the treatment of ARF in cancer patients at our institution substantially decreasing the need for intubation. This ventilatory technique is a viable option for cancer patients with ARF.

Automated external versus blind manual defibrillation by untrained lay rescuers

INTRODUCTIONnsudden cardiac death is an important cause of mortality in the United States today. A major determinant of survival from sudden cardiac death is rapid defibrillation. Communities with high rates of bystander cardiopulmonary resuscitation (CPR) and early defibrillation enjoy the highest survival rates from out-of-hospital cardiac arrest. First responders and emergency medical technicians (EMTs) have been trained to use external defibrillators (AEDs). The period of instruction for successful use of the AED remains to be determined. It was the purpose of this study to compare AED versus blind manual defibrillation (BMD) by untrained lay rescuers using a simple instruction sheet and following a 20-min training period.nnnMETHODSn50 employed volunteers were confronted with a stimulated cardiac arrest and asked to attempt defibrillation using either AED or BMD by following a written instruction sheet. Success was defined as delivery of three countershocks during the simulated resuscitation. Time to first and third shocks were recorded.nnnRESULTSn24 of 25 volunteers (96%) were successful in operating the AED compared to none in the BMD group. Time to delivery of first shock averaged 119.5 +/- 45.0 s and time to third shock averaged 158.7 +/- 46.3 s. A 95% confidence interval for time to first shock for untrained lay rescuers was 100.5-138.4 s.nnnCONCLUSIONSnuntrained lay rescuers demonstrated a very high success rate using the AED during simulated cardiac arrest. Success with BMD by untrained rescuers is poor. This study suggests that prehospital personnel can be successfully trained in the use of AED in a substantially shorter period of time than in current practice. Strategic placement of AEDs like fire hoses and pool-side life preservers could result in improved survival from sudden cardiac death.

Congestive heart failure and pulmonary edema for the emergency physician

Congestive heart failure (CHF) and pulmonary edema are major health problems in the United States as well as across the rest of the developing world. The prevalence of CHF and pulmonary edema in the general population results in a significant number of these patients presenting to Emergency Departments (EDs). Mortality from these disorders is substantial, with a 5-year mortality rate for patients requiring hospitalization of approximately 50%. Understanding of the clinical syndromes of CHF and pulmonary edema requires review of the basic determinants of cardiovascular performance. Preload, afterload, contractility, and heart rate may all be modified by pharmacological or mechanical techniques. Diuretics, vasodilators, cardiac glycosides, and other inotropes all may play a role in the ED management of CHF. In rare instances, mechanical devices for support of the heart and circulation may be indicated.

Moritz Kaposi: Idiopathic pigmented sarcoma of the skin☆

Moritz Kaposi first published a description of the entity that bears his name in 1872, calling it idiopathic multiple pigmented sarcoma of the skin. For many years thereafter, Kaposis sarcoma was considered to be a relatively rare, slow-growing malignancy, most commonly seen in middle-aged and elderly men. This changed in 1981, with Alvin Friedman-Keins report of what eventually proved to be HIV-associated (epidemic) Kaposis sarcoma. Kaposis sarcoma is now one of the diagnostic markers of the acquired immunodeficiency syndrome, as well as the most common neoplastic complication of that disease. HIV-associated Kaposis sarcoma tends to disseminate widely to mucous membranes and the viscera. Almost all of the cases reported in the United States have occurred in homosexual and bisexual men, and a number of hypotheses have been suggested to explain this association. Over the past several years, however, the incidence of HIV-associated Kaposis sarcoma has declined, and the reasons for this are also uncertain.

Practical uses of end-tidal carbon dioxide monitoring in the emergency department

Qualitative and quantitative measurement of the carbon dioxide (CO2) concentration in respiratory gases is readily available with current technology. End-tidal CO2 (PetCO2) monitoring, whether by qualitative colorimetric methods or by solid-state spectrophotometric techniques, is becoming increasingly valuable in the Emergency Department (ED). These techniques offer a practical adjunct to the ED management of critical interventions including endotracheal intubation, conscious sedation, and cardiopulmonary resuscitation.

Nalmefene : a long-acting opioid antagonist. Clinical applications in emergency medicine

The use of the opioid antagonist naloxone is well known to the experienced health care provider. The availability of the longer acting opioid antagonist nalmefene has several potential benefits in clinical practice. Nalmefene has a plasma half-life of almost 11 h, compared to 60-90 min for naloxone. Nalmefene has been shown to reverse opioid intoxication for as long as 8 h, reducing the need for continuous monitoring of intoxicated patients and repeated dosing of naloxone. Single dose administration has also been used effectively in the reversal of opiate-assisted conscious sedation. In addition, this agent has been used in the treatment of diseases as diverse as interstitial cystitis and chronic alcohol dependence. However, the long duration of action enables extended withdrawal reactions in the chronically opioid-dependent patient. The prolonged opioid antagonism of nalmefene has several applications in the clinical practice of emergency medicine, and is a useful addition in certain situations to the pharmacologic armamentarium of the practicing emergency physician.

Mediastinal teratoma presenting as massive hemoptysis in an adult.

Massive hemoptysis is a rare but potentially life-threatening presentation in the emergency department (ED). We describe a case of massive hemoptysis caused by a mediastinal teratoma in an otherwise healthy young man. The teratoma had invaded into a bronchus and was resected successfully. The literature regarding massive hemoptysis due to mediastinal teratoma is reviewed. A differential diagnosis for massive hemoptysis is presented. The initial management of these patients in the ED and the diagnostic options are discussed.

ACUTE PANCREATITIS SECONDARY TO IFOSFAMIDE

Acute pancreatitis in cancer patients can be secondary to the malignant process itself. It is also a rare complication of antineoplastic agent administration. Ifosfamide is an effective drug in the treatment of several tumors and has known neurologic, renal, and hematologic toxicities. There is only one recent report in the literature of pancreatitis associated with ifosfamide. We report a case of a 65-year-old woman with small cell bronchogenic carcinoma without pancreatic metastases who developed acute pancreatitis after ifosfamide administration.