The Outcome of Cardiac Dysfunction in Critically Ill Trauma Patients: Myocardial Contusion Complicated by Refractory Hypotension

Abstract Background:  This work attempted to define the care and course of those most severely affected patients in the setting of blunt chest trauma, who had hypotension refractory to routine fluid resuscitation. Methods:  Twenty-three critically ill blunt trauma ICU patients were resuscitated and enrolled with ongoing hypotension required placement of a pulmonary artery catheter. The REF^?Explorer (Baxter, Edwards, Anaheim, CA) catheter was placed in the right heart measuring pressure, volume and oxygen utilization information, as well as recording Injury Severity Score, EKG, CXR, CPK/MB and echocardiography over the initial 72-h time period. Results:  There were an approximately 2,300 Level I trauma patients admitted annually over a 4-year period with an overall mortality rate of 4.3% (100) patients with 3.4% (79) patients “ruling in” with elevated cardiac enzymes, associated with an increased mortality rate of 6.7% (p < 0.05). The 23 patients were male (17, 74%), mean age 41.2 years, with no past medical history (19, 83%), in a motor vehicle accident (21, 91%), with pulmonary injury (9, 39%), undergoing celiotomy in (10, 44%). They presented with moderate to severe trauma acuity defined as mean GCS of 8.6, TS of 11.3, and ISS of 34 with an increased mean hospital stay of 15 days versus 6 days in the ICU; and a 26 days versus 10 days overall stay for those with myocardial contusion (p < 0.05). Analysis of diagnostic variables found an abnormal EKG in (21, 91%), CXR in (20, 87%) and echocardiogram in (8, 37%). The total CPK was found to be elevated, mean 2,219 (204–8,278 U/l), while the MB fraction was normal 2.3 ± 1.3%. Invasive cardiac monitoring found an increase in CO of 1.6 l/min from 5.9 to 7.8 l/min during the first 24 h of recovery. Survival was worsened with increased ISS (29 vs. 43) p < 0.02, but improved with longer ICU (17 vs. 8) p < 0.03 and hospital (39 vs. 7) p < 0.05 stay in days. The analysis of commonly used diagnostic modalities – EKG, CXR, ECHO, or CO, did not correlate with survival, but the total CPK was increased in survivors (2,715 vs. 1,432 U/l) p < 0.009. Conclusion:  There is worsened morbidity with a 2-fold increase in ICU LOS and hospital stay, and a 1.5-fold increase in mortality in the severe myocardial contusion group. The diagnostic dilemma posed by lack of definitive testing continues unresolved after analysis of routinemodalities – EKG, CXR, ECHO, CPK or CO – failing to yield a “best test”.     

Hospitalist performance of cardiac hand-carried ultrasound after focused training

Purpose

Because the training that noncardiologists require to perform cardiac hand-carried ultrasound has not been defined, we studied how well hospitalists perform hand-carried echocardiography after limited training.

Methods

Ten hospitalists completed a focused training program that included performing an average of 35 hand-carried echocardiograms. Hospitalists’ echocardiograms were compared with gold-standard conventional echocardiograms, and hospitalists were compared with 5 certified echocardiography technicians in their ability to acquire, measure, and interpret hand-carried ultrasound images and with 6 senior cardiology fellows in their ability to interpret echocardiograms.

Results

Echocardiography technicians had significantly higher performance scores for image acquisition, measurement, and interpretation than hospitalists. Senior cardiology fellows outperformed hospitalists in most aspects of image interpretation. For hospitalists, learning image acquisition was more difficult than image interpretation.

Conclusions

Hospitalists can learn aspects of hand-carried echocardiography, but after 35 training echocardiograms cannot replicate the quality of conventional echocardiography. Whether the lower performance skills are important will depend on the clinical context of hand-carried echocardiography performed by hospitalists.     

经气管超声多普勒测定心排血量的临床应用及评价

心脏手术和腹腔镜胆囊切除术（ＬＣ）各２０例，术中采用ＴＴＤ连续监测ＣＯ；心脏手术病人术前行彩色超声（ＥＣＨＯ）测定主动脉直径（ＡＯＤ）并与ＴＴＤ测定的ＡＯＤ进行相关分析。结果：ＴＴＤ与ＥＣＨＯ的ＡＯＤ高度相关（ｒ＝０．９３，ｎ＝２０）；心脏手术病人ＣＯ在术毕明显增加，ＳＶＲ降低，ＣＶＰ和ＨＲ无显著变化；ＬＣ病人ＣＯ在气腹后１、５ｍｉｎ明显降低，ＳＶＲ在气腹后增加，ＭＡＰ在气腹后５、１０ｍｉｎ升高，     

血管紧张素Ⅱ受体拮抗剂对糖尿病患者心功能和死亡率的影响

目的探讨缬沙坦对2型糖尿病患者左室收缩和舒张功能的临床疗效。方法糖尿病左室舒张功能障碍患者121例，随机分为缬沙坦组61例，对照组60例，两组均给予硝酸异山梨醇酯10mg一日三次，肠溶阿司匹林每日100mg，缬沙坦组加服缬沙坦每日80～160mg，尼群地平10～20mg一日三次，6个月为一疗程。用超声心动图检查观察两组疗效。结果反映左室收缩及舒张功能指标，缬沙坦组自身比较以及与对照组比较差异有统计学意义（P〈0．05）。临床疗效评定，缬沙坦组总有效率95．1％，明显高于对照组的50．0％，缬沙坦组死亡率为1．6％，对照组死亡率10．0％，两组比较差异有统计学意义（P〈0．05）。结论缬沙坦可改善糖尿病患者的心功能，并可明显降低其死亡率。     

福辛普利与卡托普利对原发性高血压对照研究

目的　比较福辛普利与卡托普利治疗高血压的临床疗效。方法　 6 0例轻、中度高血压病人采用配对单盲对照法 ,分为福辛普利组和卡托普利组。分别观察治疗 6周后的坐位血压、动态血压、以及超声心动图变化。结果　福辛普利组与卡托普利组总有效率分别是 93 4 %和 90 % (P >0 0 5 )。谷峰比分别是 6 7 5 %和 4 2 3% (P <0 0 5 )。超声心动图两组两组心功能均有改善 ,唯组间相比差异不大。结论　福辛普利治疗高血压谷峰比好于卡托普利 ,每天一次可获稳定而持久降压效应。     

小心脏综合征的超声心动图诊断标准

对254名临床上无器质性心脏病的招飞体检申请者进行超声心动图研究，以建立小心脏综合征的超声心动图诊断标准。按标准方法，用ALOKASSD－260超声诊断仪检查。测量计算左室舒张末期内径（EDD）、舒张末期容积（EDV）、心肌质量（LVM）、心搏量（SV）、短轴缩短率（FS）和射血分数（EF），以x－2s的方法确定左室功能各参数的下限，分别为4.1cm（EDD）、60．91ml（EDV）、110．9g（LVM）、32．2ml（SV）、0．26（FS）和0．52（EF）。EDD、EDV、LVM有一项以上达不到上述下限者，属于小心脏。小心脏合并左室功能下降者诊断为小心脏综合征，建议后者招飞体检不合格。     

First heart sound spectra in relation to anterior mitral-leaflet closing velocity

A mathematical model is presented to relate mitral valve leaflet closing velocity to the subsequent vibrational magnitude following valve closure. This relationship is investigated experimentally by means of phonocardiographic and echocardiographic recordings from 17 human subjects. Fast Fourier transform analysis of digitised first heart sounds from each subject reveals that the sound intensities in different frequency bands are not uniformly related to the valve-leaflet closing velocity, obtained from the anterior mitral leaflet echocardiogram. It is found that, in the frequency range up to 150 Hz, closing velocity correlates best with sound intensity in the 30–45 hz bandwidth.     

藏族慢性高原病患者心脏二维超声检查分析

目的观察“青海标准”慢性高原病心脏二维超声检查改变。方法回顾性分析95例慢性高原病患者心脏二维超声检查结果,统计分析左、右心室心房以及主动脉、主肺动脉直径,左心室收缩功能和舒张功能指标及各瓣膜关闭不全,并将这些指标与50例健康正常人作对照。结果右心房室和主肺动脉差别有高度显著性（均为P〈0、01）。左心房室和主动脉差别无显著性（均为P〉0、05）,左心室收缩舒张功能减低,差别有显著性（0．01〈P〈0．05）。三尖瓣和肺动脉瓣关闭不全超过80％。结论“青海标准”慢性高原病心脏仍然以右心增大和肺动脉增宽为主,符合既往诊断慢性高原病心脏改变的规律,藏族人心脏代偿功能较好。     

四维自动左房定量技术评价尿毒症血液透析患者左房功能

目的：心血管损伤是尿毒症血液透析患者的主要并发症,左房形变与左室充盈压及功能障碍有关,目前量化左房功能仍有一定挑战。本研究探讨四维自动左房定量(LAQ)技术评估保留左室射血分数(LVEF)的尿毒症血液透析患者的左房功能。方法：选取LVEF正常的尿毒症血液透析患者37例和正常对照组34例,所有参与者行常规超声心动图和LAQ检查。主要采集胸骨旁左室长轴和心尖四腔心切面图像,通过脱机分析软件EchoPac 203测量左房直径、容积、射血分数和应变参数,并对两组进行分析比较。结果：与正常对照组相比,尿毒症组的左室扩大、左室壁肥厚,左房直径和容积增加,左房排空分数虽有一定降低,但仍在正常范围内。左房储存、管道及辅泵期的纵向应变均降低,周向应变仅储存和管道期降低,辅泵期无明显差异。结论：尿毒症血液透析患者的心肌损害早于LVEF异常,左房应变比常规超声参数更敏感、更早期发现左房结构和功能的损害。LAQ作为一种新方法,可早期检出LVEF正常的尿毒症患者的左房功能障碍,为临床早期诊疗提供有价值的信息。