High-Dose Insulin and Intravenous Lipid Emulsion Therapy for Cardiogenic Shock Induced by Intentional Calcium-Channel Blocker and Beta-Blocker Overdose: A Case Series

Background

Recently, high-dose insulin (HDI) and intravenous lipid emulsion (ILE) have emerged as treatment options for severe toxicity from calcium-channel blocker (CCB) and beta blocker (BB).

Objective

Our aim was to describe the use and effectiveness of HDI and ILE for the treatment of CCB and BB overdose.

Case Reports

We describe 2 patients presenting to the emergency department after intentional ingestions of CCBs and BBs. A 35-year-old man presented in pulseless electrical activity after ingesting amlodopine, verapamil, and metoprolol. A 59-year-old man presented with cardiogenic shock (CS) after ingesting amlodopine, simvastatin, lisinopril, and metformin. Both patients were initially treated with glucagon, calcium, and vasopressors. Shortly after arrival, HDI (1 unit/kg × 1; 1 unit/kg/h infusion) and ILE 20% (1.5 mL/kg × 1; 0.25 mL/kg/min × 60 min) were initiated. This led to hemodynamic improvement and resolution of shock. At the time of hospital discharge, both patients had achieved full neurologic recovery.

Conclusions

HDI effectively reverses CS induced by CCBs and BBs due to its inotropic effects, uptake of glucose into cardiac muscle, and peripheral vasodilatation. ILE is theorized to sequester agents dependent on lipid solubility from the plasma, preventing further toxicity. To our knowledge, these are the first two successful cases reported using the combination of HDI and ILE for reversing CS induced by intentional ingestions of CCBs and BBs.     

Cardiotoxicity in a Citalopram and Olanzapine Overdose

Background

This is a case of a citalopram and olanzapine overdose causing seizures and severe cardiotoxicity.

Case Report

A 21-year-old man presented unresponsive, with seizures, to an Emergency Department. The patient’s initial electrocardiogram demonstrated a widened QRS of 160 ms and a normal QT/QTc interval of 400/487 ms consistent with cardiac sodium channel blockade. Within 30 min of arrival, peak citalopram and olanzapine levels were measured to be 522 ng/mL and 505 ng/mL, respectively. Measured levels remained supratherapeutic until 13.6 h and 42.6 h after arrival for citalopram and olanzapine, respectively. The patient developed bradycardia and hypotension that required multimodal therapies including sodium bicarbonate boluses, vasopressors, and transvenous pacing. Seizures and cardiotoxicity continued while citalopram, but not olanzapine, was supratherapeutic.

Conclusions

This case describes cardiotoxicity directly correlated with supratherapeutic citalopram levels in overdose.     

Glucagon and Phenylephrine Combination vs Glucagon Alone in Experimental Verapamil Overdose

Objective: To evaluate glucagon and phenylephrine in combination as a treatment for the hemodynamic effects of verapamil overdose. Methods: Pentobarbital–anesthetized and instrumented dogs were overdosed using a previously developed verapamil overdose model (15 mg/kg IV over 30 minutes). The animals were maintained and observed for 90 minutes or until death. Cardiac output (CO), heart rate (HR), and mean arterial pressure (MAP) were monitored. Following the 30–minute verapamil infusion (toxicity), the control animals received no treatment; the glucagon animals received a 5–mg glucagon bolus and a drip of 5 mg/90 minutes; and the glucagon/ phenylephrine animals received the same glucagon therapy plus a phenylephrine drip titrated to 180 (μg/ min over 15 minutes. The groups were compared using analysis of variance: the experimental variables were group and time; the response variables were changes from toxicity for the hemodynamic parameters. Post–hoc comparisons were done with a set at 0. 05. Results: A significant change in CO was seen in the glucagon group (Δ = 2. 6 L/min) and the glucagon/ phenylephrine group (Δ = 1. 9 L/min) compared with the control group (Δ = 0. 8 L/min). The change in CO was significantly larger for the glucagon animals compared with the glucagon/phenylephrine animals. The change in MAP for the glucagon/phenylephrine group (Δ = 24 mm Hg) was significant compared with the control group (Δ = 14 mm Hg). The MAP change for the glucagon group (Δ = 19 mm Hg) was not significantly different from that of either the control or the glucagon/phenylephrine group. The change in glucagon HR (Δ = 6 beats/min) was significant compared with the control group (Δ = –4 beats/min) and the glucagon/phenylephrine group (Δ = –4 beats/min). Conclusion: The glucagon/phenylephrine therapy improved MAP compared with the control, but reduced CO and HR compared with glucagon alone. Glucagon/phenylephrine therapy is not as effective as glucagon alone in reversing the hemodynamic effects of experimental verapamil overdose.     

高强度聚焦超声联合乳化碘油损伤不切肋骨山羊肝脏组织的实验研究

目的探讨高强度聚焦超声（HIFU）损伤不切肋骨山羊肝脏组织的可行性。方法31只羊随机分成两组，实验组经静脉注入乳化碘油，用HIFU对肝脏进行辐照，比较坏死组织体积、能效因子、靶区灰度及组织病理检查。对照组以normal saline代替乳化碘油，余步骤同实验组。结果两组损伤组织均为凝固性坏死。实验组损伤率、靶区灰度阳性率分别为71．1％和26．8％，对照组分别为16.3％和4.1％（P〈0．05）。结论乳化碘油可增强HIFU的损伤效果，通过一定的手段实现在不切肋骨条件下对肝脏组织的HIFU损伤是可行的。     

连续性肾脏替代治疗在主动脉球囊反搏抢救心源性休克并急性肾衰的应用

目的:探讨连续性肾脏替代治疗(CRRT)在主动脉球囊反搏(IABP)抢救心源性休克并急性肾功能衰竭(ARF)的效果.方法:回顾性分析我院1998至2009年在积极药物治疗基础上使用IABP联合CRRT(CRRT组)31例或床边血液透析治疗(HD)(HD组)21例抢救心源性休克并ARF患者的临床资料,观察两组疗效及并发症.结果:CRRT组抢救成功12例,死亡率为61.3%;HD组抢救成功3例,死亡率90.5%(P<0.05).两组在出血、下肢缺血等并发症无显著差异.结论:在IABP抢救心源性休克并ARF时,CRRT是首选透析方式.     

Sternal Fracture Complicated by a Subcutaneous Abscess in a 5-Year-Old Boy and Diagnosed Using Point-of-Care Ultrasound

Background

Although fractures of the sternum are rare in young children, owing to the compliance of the chest wall, these fractures are still possible and require thorough examination. We present a case that emphasizes the usefulness of point-of-care ultrasound in the diagnosis of a pediatric sternal fracture complicated by a subcutaneous abscess.

心源性休克介入治疗后心肌灌注分级和死亡率的关系

目的:探讨急性心肌梗塞后心源性休克经皮冠状动脉介入治疗后心肌灌注分级和死亡率的关系。方法:选择2 0 0 1- 0 1～2 0 0 4 - 0 1我院收治的急性心肌梗塞所致的心源性休克患者4 1例,急诊行经皮冠状动脉介入治疗,男2 9例,女12例,中位年龄(6 7±13)岁。用心肌灌注分级将患者分为无复流(MBG0 / 1)和复流(MBG2 / 3)两组,观察院内死亡率和随访死亡率;用L ogistic多元回归方法分析心源性休克介入治疗后死亡的相关因素。结果:心源性休克介入治疗后心肌灌注分级无复流组的院内死亡率和随访死亡率均显著高于复流组(81%比14 % ,81%比2 9% ,P<0 .0 1)。多因素回归分析上述因素与死亡率的关系显示年龄与死亡率呈正相关(OR3.8,P=0 .0 4 ) ,MBG2 / 3与死亡率呈负相关(OR0 .0 6 ,P=0 .0 1) ,而高血压、糖尿病、TIMI3级血流获得率及治疗前收缩压未显示与死亡率的相关性。结论:心肌灌注分级是急性心肌梗塞所致心源性休克介入治疗后较强的死亡预测因子。     

A multifaceted approach to calcium channel blocker overdose: a case report and literature review

Calcium channel blocker toxicity can be devastating. Initial therapy with fluid, calcium, and adrenoreceptor agonists should be prompt and novel therapies can be added if no response. Determining cardiogenic shock versus vasoplegia with echocardiogram or other hemodynamic monitoring may guide treatment options.     

Assessment of Resynchronization Therapy on Functional Status and Quality of Life in Patients Requiring an Implantable Defibrillator

Background: The effect of cardiac resynchronization therapy (CRT) on physical function and Quality of Life (QoL) in patients who require an implantable defibrillator but do not meet guideline criteria for CRT has not been studied in detail. Methods and Results: This was a randomized study of 72 patients with high risk of sudden cardiac death, ejection fraction (EF) ≤35%, mild‐to‐moderate heart failure symptoms, and QRS > 120 ms. Patients received a CRT defibrillator and were randomized to CRT turned ON or OFF. Objective and subjective measures were performed at baseline and after 6 months. There was no difference in change in left ventricular end‐systolic volume (ESV) by radionuclid angiogram scan, the primary endpoint, between the CRT ON group (ΔESV =?7 ± 52 mL), and CRT OFF group (ΔESV =?30 ± 47 mL). Similarly, echocardiogram measures of ESV and EF showed no difference between the two groups. In the CRT ON group, selected measures of QoL and subjective exercise tolerance but not heart failure symptoms improved significantly. Six‐minute walk distance prolonged in the CRT ON group (baseline 313.6 ± 114.4 m, 6‐month 365.0 ± 122.5 m, P = 0.01), but the difference in change in walk distance between the two groups was not significant. Conclusion: Further studies with larger sample size and longer follow‐up will be required to allow definite conclusions regarding the potential benefit of CRT in this patient population.     

Prevalence of Cancelled Shock Therapy and Relationship to Shock Delivery in Recipients of Implantable Cardioverter-Defibrillators Assessed by Remote Monitoring

Background: Cancelled shock therapy (CxTx) may presage shock delivery and shorten battery longevity of implantable cardioverter-defibrillators (ICDs). However, it is silent and has received little attention. Remote home monitoring (HM) with continuous surveillance and automatic daily data archiving allows investigation of CxTx.
Methods and Results: We retrospectively analyzed a database of 4,960 recipients of HM ICD, from 2002 to 2007. Over a mean follow-up of 445 ± 253 days, CxTx occurred in 1,392 (28%) patients, mostly as single episodes (n = 1,120). However, 142 patients (10% of patients with CxTx, 2.9% of the whole ICD population) had >10 CxTx. CxTx was followed by shock delivery in 432 patients, in 239 (55%) of whom CxTx occurred >10 days prior to shock delivery. In 113 patients (26%), CxTx occurred in the 72-hour period preceding the shock. A single CxTx preceded the shock in 74 of these 113 patients, and only eight patients had >3 CxTx.
Conclusion: CxTx was highly prevalent in unselected ICD recipients, though the intraindividual density of episodes was low. In 2.9% of the overall population, the number of CxTx was sufficient to shorten the battery longevity. A high number of CxTx usually did not predict the delivery of shocks.     

激素替代疗法和负重健走对绝经妇女骨密度及血脂的影响

目的探讨雌激素、负重健走运动及两者的联合对绝经妇女血脂、骨代谢和骨密度的影响。方法52名绝经妇女分成激素替代疗法组(n=12)、负重健走组(n=14)、激素替代疗法+负重健走组(n=12)和对照组(n=14)。激素替代疗法组服用复方尼尔雌醇片;负重健走组负5 kg重量,以60%～80%最大耗氧量进行健走运动;激素替代疗法+负重健走组同时接受前两组的干预。试验期为6个月,试验前后检测血脂、血碱性磷酸酶(ALP)、尿钙(Ca)和尿肌酐(Cr)的比值、L₂～L₄及左腿股骨头密度。结果试验结束后,3个试验组被试的血胆固醇(TC)、TC/高密度脂蛋白胆固醇(HDL-C)均低于试验前和对照组(P<0.05);负重健走组和激素替代疗法+负重健走组的HDL-C高于试验前水平和对照组(P<0.05);试验组血清ALP和空腹尿Ca/Cr均低于试验前(P<0.05)及对照组(P<0.01);3个试验组L₂～L₄及左腿股骨头骨密度均高于对照组(P<0.01)及试验前(P<0.05)。结论激素替代疗法和负重健走运动均能有效改善绝经后妇女的血脂组成,并有效预防和逆转妇女绝经引发的骨质疏松症。     

Power Doppler Ultrasound Findings before and after Focused Extracorporeal Shock Wave Therapy for Achilles Tendinopathy: A Pilot Study on Pain Reduction and Neovascularization Effect

Extracorporeal shock wave therapy (ESWT) has been found to have a positive effect in the treatment of pain in Achilles tendinopathy, although the exact mechanism is not yet completely understood. Among the mechanisms suggested to underlie ESWT effects are direct stimulation of healing, neovascularization and direct suppressive effects on nociceptors and hyperstimulation, which would block the gate-control system. The neovascularization observed in flogistic tissue is associated with stimulated nerve fibers around tendons and induces a painful condition. The objectives of the present study were to evaluate the effect of ESWT on pain and function in patients with non-insertional Achilles tendinopathy (NIAT) and to assess the neovascularization phenomenon using power Doppler ultrasound (PDU). Twelve patients with NIAT underwent five sessions of focused ESWT over 5 wk. Outcome measures were the visual analogue scale, the Victorian Institute of Sport Assessment–Achilles questionnaire and active dorsiflexion and plantar flexion ankle articular range of motion. Moreover, the patients’ clinical impressions of treatment results after ESWT were investigated using the Roles and Maudsley score. Patients were assessed at baseline and 1 and 3 mo after treatment. They had a significant reduction in pain with improvement of arthrokinematic motion and functionality and a positive clinical impression of treatment outcome (50% of patients considered their clinical picture as good/excellent after 3 mo). However, the pulse Doppler ultrasound exam did not reveal neovascularization in 91.7% of the patients 1 and 2 mo after focused ESWT, and in some patients there was a reduction in blood vessels related to flogistic processes. The present observational study confirmed the efficacy of ESWT in pain reduction in NIAT, with a higher degree of patient satisfaction, although doubt persists over the neovascularization effect on the Achilles tendons treated.     

布-加综合征介入治疗前后血流动力学变化的彩色多普勒研究

目的 搪塞布－加综合征（ＢＣＳ）介入治疗前后特征性异学血管形态及血流动力学变化。方法 对１８６例ＢＣＳ分别于治疗前及治疗后一周进行彩色多普勒检测。结果 １８６例ＢＣＳ中,下腔静脉狭窄或阻塞者,远下腔静脉扩张,肝狭窄或阻塞者,其血流通过肝内侧支至未闭的肝静脉,或通过副肝静脉流处下腔静脉。治疗后可见知流通过开通的肝静脉及下腔静脉,内支架形状清晰可见。结论彩色多普蚵准确观察ＢＣＳ特异性为其诊断及随访的主     

Effects of Extracorporeal Shock Wave Therapy on Functional and Strength Recovery of Handgrip in Patients Affected by Epicondylitis

Extracorporeal shock wave therapy (ESWT) is effective in the treatment of tendinopathy. We designed a prospective observational clinical study to assess the correlation between clinical and functional measures and recovery of strength after ESWT for epicondylitis. We analyzed 26 patients. We measured progressive improvement in visual analogue scale values (p < 0.0005) and Mayo Elbow Performance Index scores (p = 0.004) for the pathologic limb. Monitoring of handgrip failed to reveal changes in values at any follow-up (p > 0.05). We found no correlation between degree of clinical function and muscle deficit during follow-up. After ESWT, there was a tendency toward a decrease in grip strength, especially in the dominant limb. This could be related to the effects of ESWT, which reduces spasticity in painful hypertonic muscles. These data may be useful in defining the expectations for function during ESWT for epicondylitis, particularly for elite athletes.     

血液净化治疗大负荷军事训练所致横纹肌溶解症并急性肾衰竭的多脏器功能障碍综合征

目的观察血液净化治疗大负荷军事训练所致横纹肌溶解并急性肾衰竭的多脏器功能障碍综合征（MODS）的临床效果。方法回顾性分析1988～2010年10例大负荷军事训练所致横纹肌溶解症并急性肾衰竭的MODS患者的临床资料,观察患者血液净化治疗前后尿素、肌酐、肌酸激酶及同工酶、乳酸脱氢酶、丙氨酸转氨酶、电解质、生命体征变化及预后。结果 10例均行血液净化治疗,其中4例采用单纯血液透析治疗,2例采用血液透析、血液透析滤过交替进行的方法,4例采取持续性血液净化疗法。死亡3例,痊愈出院7例。结论对于大负荷军事训练所致横纹肌溶解症并急性肾衰竭的MODS患者应尽早行血液净化治疗,特别是及时行持续性血液净化治疗可改善患者预后。     

药枕盐熨疗法对椎动脉型颈椎病血流动力学变化的影响及疗效观察

目的:采用药枕盐熨疗法干预椎动脉型颈椎病,分析其对双侧椎-基动脉血流动力学变化的影响,并对患者症状、颈椎功能以及临床疗效进行观察。方法:将80例椎动脉型颈椎病患者采用SPSS 17.0软件随机序列生成模块按1∶1比例分为观察组和对照组,每组40例。观察组以大青盐为中药热导体,采用长柱形药枕进行盐熨治疗,对照组予以颈椎牵引加蜡疗干预,2组均治疗4周。经颅多普勒超声(TCD)检查,对2组治疗前后双侧椎-基底动脉血流速度及不对称性、搏动指数(PI)进行比较,采用《颈性眩晕症状与功能评估量表》(ESCV)评定患者症状程度与功能变化,根据《中医病证诊断疗效标准》评估临床疗效。结果:①治疗前,2组双侧椎-基底动脉血流速度与不对称性、PI、ESCV评分组间比较,差异均无统计学意义(P>0.05)。②干预4周后,2组血流速度减慢患者双侧椎-基底动脉收缩期峰值血流速度的均值[(LVA+RVA)Vp/2]、舒张末期血流速度均值[(LVA+RVA)Vd/2]较治疗前均显著升高(P<0.05),2组血流速度增快患者(LVA+RVA)Vp/2较治疗前明显降低(P<0.05),(LVA+RVA)Vd/2下降不如(LVA+RVA)Vp/2显著;组间比较,仅观察组中血流速度减慢患者(LVA+RVA)Vp/2较对照组显著升高(P<0.05)。③2组治疗后PI较治疗前均下降(P<0.05),观察组中血流速度减慢患者PI较对照组更明显(P<0.05)。④双侧椎-基底动脉血流速度不对称性结果显示,治疗后观察组双侧椎-基底动脉收缩期峰值血流速度的差值[|LVA-RVA|Vp]较治疗前明显下降,差异有统计学意义(P<0.05);2组ESCV评分治疗后均较治疗前显著提高(P<0.05),观察组[(23.13±3.15)分]高于对照组[(21.73±3.39)分],差异无统计学意义(P>0.05);2组疗效比较,差异无统计学意义(P>0.05),且均未见不良反应。结论:药枕盐熨疗法作用于椎动脉型颈椎病,能明显改善椎-基动脉血流状况,有效缓解椎动脉型颈椎病患者的症状,提高颈椎功能。