Karin Janata

Severity assessment of acute pulmonary embolism with spiral CT: evaluation of two modified angiographic scores and comparison with clinical data.

Spiral computed tomography (CT) has shown promising results in the detection of acute pulmonary embolism. The aim of this study was to investigate whether the severity of acute pulmonary embolism could be quantitatively assessed with spiral CT examinations and to test the potential clinical impact of this information. In a consecutive series of 123 patients screened with spiral CT for suspected acute pulmonary embolism, 31 patients (25%) had evidence of emboli. The severity of pulmonary arterial obstruction in those 31 spiral CT examinations was evaluated by two independent observers using angiographic scores previously described by Walsh (29) and Miller (30), adapted to the needs of spiral CT. Clinical patient subgroups were defined according to oxygen saturation, heart rate, and echocardiographic signs of right ventricular strain. CT severity scores were then correlated to each other and to clinical parameters using the Spearman rank test. Interobserver agreement was calculated using the analysis of variance. Both modified Walsh and Miller scores were readily reproducible and showed interobserver agreements of 0.85 and 0.96, respectively (p = 0.001). Patients with mild and marked clinical abnormalities showed statistically significant differences between CT severity scores. Differences between severity scores of patients with moderate and marked clinical abnormalities were somewhat significant. No significant mean severity score differences were seen between patients with mild and moderate clinical abnormalities. Although correlations of severity scores and detailed clinical parameters within the defined subgroups were moderate to poor, threshold scores greater than 10 (Miller) and greater than 11 (Walsh) always indicated marked clinical abnormalities. The modified scores presented in this study constitute a readily reproducible method for the quantitative assessment of acute pulmonary embolism severity on spiral CT examinations.

Cardiac troponin T in the severity assessment of patients with pulmonary embolism: cohort study

Right ventricular function is an important prognostic factor for pulmonary embolism.1 Massive pulmonary embolism may lead to right ventricular failure, reduced left ventricular output, and even death.2 Cardiac troponins are routinely applied markers of minor and major myocardial damage in patients with acute coronary syndromes. In small case series, troponin concentrations were raised in patients with massive pulmonary embolism. 3 4 The role of troponin as a prognostic factor is, however, unclear. We assessed the association between serum concentrations of cardiac troponin T and severity of pulmonary embolism as well as the role of troponin T as a predictor of mortality. We assessed 136 consecutive patients who were admitted to the emergency department of a tertiary care university hospital between December 1999 and November 2001 with pulmonary embolism, confirmed by computed tomography or scintigraphy. Two patients with terminal illness and seven patients admitted after cardiac arrest …

Radiographic detection of intrabronchial malpositions of nasogastric tubes and subsequent complications in intensive care unit patients.

Objective: The aim of our study was to illustrate the radiographic spectrum of the intrabronchial malposition of nasogastric tubes and subsequent complications, and to discuss the role of radiography in the detection of such malpositions. Design: Retrospective clinical investigation. Setting: Tertiary care university teaching hospital. Patients and methods: We reviewed chest radiographs of 14 intensive care patients with nasogastric tubes malpositioned in the tracheobronchial tree. The site and anatomic location of the malposition were recorded. Complications due to tube malpositioning were monitored on follow-up radiographs and on computed tomographic examinations, which were available in 4 patients. Results: Nine of 14 nasogastric tubes were inserted in the right and 5 in the left tracheobronchial tree. Tube tips were malpositioned in the lower lobe bronchi (50 %), the intermediate bronchus (36 %), and the main bronchi (14 %). There was perforation of the bronchial system with subsequent pneumothorax in 4 patients. In 4 other patients, pneumonia developed at the former site of the malpositioned tube tip. Radiographic detection of nasogastric tube malpositioning was prompt in 9 patients and delayed in 5 patients. Conclusions: Whereas clinical signs of nasogastric tube malpositioning in intensive care patients may be absent or misleading, chest radiography can accurately detect nasogastric tube malpositions in the tracheobronchial tree, may prevent complications, and avoid the use of further costly or invasive diagnostic techniques.

Cardiopulmonary resuscitation performed by bystanders does not increase adverse effects as assessed by chest radiography.

Important adverse effects of bystander cardiopulmonary resuscitation (CPR) are well known. We describe the number of nonmedical professional CPR-related complications in patients surviving cardiac arrest, as assessed by chest radiograph. Within 2 yr, all consecutive patients admitted to the department of emergency medicine at a university hospital who had a witnessed, nontraumatic, normothermic cardiac arrest were studied. Radiologically evaluated adverse effects were compared with Mann-Whitney U-tests between patients who received bystander basic life support (Bystander group) and patients who did not receive bystander basic life support before advanced life support was started (ALS group). For assessment of bystander CPR-associated complications, chest radiographs were used. Of 224 patients, 173 were eligible. The median age was 58 yr (interquartile range, 51–71 yr), and 126 patients (73%) were men. The incidence of adverse effects associated with assisted-ventilation maneuvers and external chest compressions did not differ significantly between groups (severe gastric insufflation, 17% vs 18% between the Bystander group [n = 59] and the ALS group [n = 96], respectively; suspicion of aspiration, 22% vs 17%, respectively; soft tissue emphysema, 2% vs 1%, respectively; and serial rib fractures, 8% vs 8%, respectively). CPR administered by nonmedical personnel did not increase the number of life support-related adverse effects in patients surviving cardiac arrest as assessed by means of chest radiograph on admission.

Pre-Operative N-Terminal Pro-Brain Natriuretic Peptide Predicts Outcome in Type A Aortic Dissection

BACKGROUND Acute Stanford type A aortic dissection (AAD) is associated with substantial perioperative mortality and morbidity. OBJECTIVE N-terminal pro-brain natriuretic peptide (NT-proBNP) is a prognostic biomarker of outcome in cardiovascular disease. Its predictive power in patients undergoing emergency surgery for acute type A aortic dissection is yet unknown. METHODS We prospectively measured pre-operative NT-proBNP in 104 patients (39 female, 35%; median age 61 years) undergoing emergency surgery for AAD during a 6-year study period. European System for Cardiac Operative Risk Evaluation risk scores were recorded and patients were followed for 30-day mortality and major adverse events (MAEs) as defined by the need for rethoracotomy, occurrence of postoperative heart failure, neurologic deficit, lung failure, renal failure, or sepsis. RESULTS Median logistic European System for Cardiac Operative Risk Evaluation in the cohort was 12 (interquartile range 7 to 19). During the first 30 days, 23 patients (22%) died, and 53 patients (51%) experienced MAEs. Median (interquartile range) NT-proBNP levels in survivors versus nonsurvivors were 328 pg/ml (157 to 569) versus 2,240 pg/ml (515 to 4,734; p < 0.001), and in patients without versus with MAEs, 227 pg/ml (107 to 328) and 719 pg/ml (442 to 2,287; p < 0.001), respectively. Adjusted odds ratios for increasing tertiles of NT-proBNP compared with the lowest tertile were 0.98 (95% confidence interval [CI] 0.18 to 5.33; p = 0.98) and 11.67 (95% CI 2.61 to 52.09; p = 0.001) for 30-day mortality and 9.07 (95% CI 2.58 to 31.83; p = 0.001) and 50.21 (95% CI 10.85 to 232.45; p < 0.001) for MAEs, respectively, indicating a significant association between pre-operative NT-proBNP levels and outcome. CONCLUSIONS Pre-operative NT-proBNP predicts outcome in patients undergoing surgery of AAD.

Sudden cardiac death of a teenage girl

Anomalies of coronary artery origin can be of little clinical significance and only an incidental autopsy finding. However recent case reports have shown that a wide range of potential pathologic alterations of congenital coronary anomalies are associated with clinical symptoms and exercise related sudden death. We describe the case of a 16-year-old girl who sustained a cardiac arrest and died after cardiopulmonary resuscitation (CPR) of intractable cardiogenic shock. The sporty and previously healthy girl suddenly fainted after swimming in a tributary of the Danube. Autopsy revealed an anomalous origin of the left coronary artery from the anterior sinus of Valsalva and its course between aorta and pulmonary artery. The cause of this anomalous origin and possible mechanism for sudden death is discussed. We conclude that this congenital anomaly should be considered in cases of major cardiac events in young people.

Pulmonalembolie nach chirurgischer Fettreduktion

SummarySurgical reduction of fat surplus is usually performed on healthy individuals and is reported as a safe procedure as it is not associated with a lethal outcome. Due to the anticipation of peri- and postoperative bleeding as a result of the large wound area, which may have a negative influence on the cosmetic result, patients often receive no or only inadequate anticoagulation. We report three cases in which surgical reduction of fat surplus led to sudden collapse and cardiac arrest. In all of our patients, fatal pulmonary embolism was the cause of cardiac arrest. These patients received only inadequate or no anticoagulation. Early postoperative mobilization, elastic stockings and compressive wound-dressing did not prevent pulmonary embolism. In addition to early postoperative mobilization of the patient and even though there is a risk of perioperative bleeding complications, the use of anticoagulation is highly recommended in surgical procedures like abdominoplasty or dermolipectomy. If sudden dyspnea, chest pain, collapse or cardiac arrest occurs after surgical interventions like these, pulmonary embolism should be considered and further diagnostic steps should be initiated.ZusammenfassungChirurgische Eingriffe zur Fettreduktion werden an Gesunden durchgeführt, gelten als risikoarm und werden nicht mit einem tödlichen Ausgang in Zusammenhang gebracht. Infolge der großen Wundfläche und der möglichen Beeinträchtigung des kosmetischen Ergebnisses sind postoperative Blutungen eine gefürchtete Komplikation, eine Antikoagulation wird daher vielfach nur selten bis gar nicht durchgeführt. Wir beschreiben 3 Patientinnen, bei welchen nach chirurgischer Fettreduktion durch Dermolipektomie bzw. Abdominoplastik ein plötzlicher Kollaps mit Herz-Kreislaufstillstand aufgetreten ist. Als Ursache für den Herz-Kreislaufstillstand, der letztlich in allen 3 Fällen zum Tod führte, fand sich eine Pulmonalembolie. Die Patientinnen waren nicht oder nur inadäquat antikoaguliert. Eine frühe Mobilisierung, Kompressionsverbände und Stützstrümpfe konnten die Thromboembolie nicht verhindern. Bei der chirurgischen Fettreduktion ist trotz der Gefahr einer peri- und postoperativen Blutung und der frühen Mobilisierung als Thromboembolieprophylaxe eine zusätzliche Antikoagulation zu fordern. Bei plötzlichem Auftreten von Dyspnoe, Thoraxschmerzen, Kollaps oder Herz-Kreislaufstillstand bei Patienten nach chirurgischer Fettreduktion muss an das Vorliegen einer Pulmonalembolie gedacht und entsprechende diagnostische Schritte eingeleitet werden.