Successful resuscitation of hypermagnesaemic asystolic cardiac arrest with the use of early transvenous cardiac pacemaker: a case report

A 63 year old woman presented to the emergency department (ED) with 1 week of progressive dyspnoea, constipation, and generalized weakness. She had undergone spinal fustion surgery 10 days previously, and had a history of chronic renal insufficiency. The patient had been using milk of magnesia and magnesium citrate in unknown amounts to alleviate her constipation over this time frame. During her ED stay she became progressively hypotensive and bradycardic, and despite aggressive resuscitative measures she suffered an asystolic arrest 1 hour into her ED course. She was resuscitated with conventional therapy, but her haemodynamic profile did not improve significantly until transvenous cardiac pacing was employed. Her magnesium level was 10.4 mmol/l. Treatment of magnesium overload has focused upon haemodialysis, forced diuresis, and the use of intravenous calcium salts. Case reports have previously documented survival of moderately to severely ill patients when these modalities have been used. Likewise, failure of resuscitation despite use of these methods has been previously noted. To our knowledge, this is the first reported case clearly demonstrating the efficacy of transvenous cardiac pacing to successfully resuscitate a patient upon whom multiple vasopressors, fluids, and calcium previously had no clear effect.     

治疗技术和方法

exploration of vertebral canal 椎管探查术 section of sensory root of trigeminal nerve 三叉神经感觉根切断术 ventriculo-peritoneal shunt 脑室腹腔引流术     

Contraception--a woman's dilemma

The case history of a 36-year-old West German woman--Elsa--who had an abortion is recounted along with information obtained from other members of staff involved with her care--a medical social worker, a family planning nurse, and a doctor. Conversation with Elsa revealed that she had ambivalent feelings about birth control. When Elsa learned she was pregnant, she seriously considered her subsequent decision to have an abortion. Actually, she would have preferred to have the baby if she could have depended on her boyfriend's encouragement and his commitment to being a father. At the clinic, Elsa was found to be in good physical condition. She informed the doctor that she had already had 2 terminations of pregnancy, 15 and 11 years ago. Following the birth of her son she had taken an oral contraceptive (OC) for 4 years, but had stopped taking it in 1976 because she thought she was too old for the pill and had been taking it too long. She had then used an IUD, but this had supposedly been removed 10 weeks before the abortion, after she had suffered from recurrent menorrhagia and heavy vaginal discharge. Elsa was then fitted with a diaphragm which she had been using when she became pregnant. After the abortion, Elsa continued to be undecided about what form of contraception to use in the future. She did not want to become pregnant again before she was in a position to have the baby. Elsa had good reason for concern about using OC, i.e. OCs containing estrogen and progestogen, at the age of 36. Along with discussion about the use of OC, Elsa sought more information about the diaphragm. Elsa finally decided to use OCs, but it is doubtful if she will ever be content with either this method or the diaphragm. Family planning nurses have an important role to play in educating people about contraceptives and their use, but they should never tell people that they should or should not be controlling their fertility.     

Sudden cardiac death of an adolescent during dieting

We describe a 16-year-old girl who had sudden onset of cardiorespiratory arrest while at school. She had recently attempted weight loss using a low-carbohydrate/high-protein, calorie-restricted dietary regimen that she had initiated on her own. During resuscitation, severe hypokalemia was noted. At postmortem examination, no other causes for the cardiac arrest were identified. Toxicologic findings were negative. The potential role of the dietary regimen as a contributing factor to the hypokalemia and subsequent cardiac arrest are discussed.     

APATHETIC THYROTOXICOSIS

A previously fit 37-year-old woman was admitted with acute left ventricular failure, atrial fibrillation and a left-sided thromboembolic stroke. Her ventricular rate progressively increased despite full digitalisation. She had a cardiac arrest and was successfully resuscitated. Investigations revealed evidence of hyperthyroidism and she was treated for thyrotoxic crisis. She has made a complete recovery from the hemiparesis and is now in sinus rhythm. She denied any symptoms of hyperthyroidism. This patient had apathetic thyroid crisis, which is exceedingly rare in the young.     

Law relating to the classification and regulation of controlled drugs

Mary, a newly qualified staff nurse, was asked by the night sister to draw up a syringe of morphine for a patient who was in severe pain. She had understood that she should not be doing this on her own, but the night sister said that they were too short of staff to provide another person.     

Reporting of injuries,diseases and dangerous occurrences

Case Scenario: Clematis, a staff nurse in an orthopaedic ward, injured her back when lifting a patient with another nurse from the bed to a wheelchair. She was admitted to hospital and was off sick for many weeks. When she returned to work she noticed that the accident from which she had completed was still on the ward and copies did not appear to have been circulated. What is the law and what is her responsibility?     

A successful treatment of cardiac tamponade due to an aortic dissection using open-chest massage

An 81-year-old woman became unconsciousness after complaining of a backache, and then, an ambulance was called. She was suspected to have an aortic dissection by the emergency medical technicians and was transferred to our department. On arrival, she was in shock. Emergency cardiac ultrasound disclosed good wall motion with cardiac tamponade but no complication of aortic regurgitation. Computed tomography of the trunk revealed a type A aortic dissection with cardiac tamponade. During performance of pericardial drainage, she lapsed into cardiopulmonary arrest. Immediately after sterilization of the patient's upper body with compression of the chest wall, we performed a thoracotomy and dissolved the cardiac tamponade by pericardiotomy and obtained her spontaneous circulation. Fortunately, blood discharge was ceased immediately after controlling her blood pressure aggressively. As she complicated pneumonitis, conservative therapy was performed. Her physical condition gradually improved, and she finally could feed herself and communicate. In cases of acute cardiac tamponade, simple pericardiocentesis often is not effective due to the presence of the clot, and a cardiac tamponade by a Stanford type A aortic dissection is highly possible to complicate cardiac arrest, so emergency physicians should be ready to provide immediate open cardiac massage to treat such patients.     

Drug misuse at work

Doctor J joined the A&E team as a locum senior house officer to cover sick leave. She had trained in New Zealand and had been doing a number of locums in the UK over the last year. Sister T had been working with Doctor J for three days and found her work to be of a very high standard. She was confident and skilled in all aspects of A&E care and the rest of the staff enjoyed working with her. At 11 am one Friday morning, Staff Nurse R reported to Sister T that she could not find Doctor J. On conducting a search of the department, the staff toilet was found to be locked with no answer to knocking. The cubicle was broken into the Doctor J was found unconscious with an empty ampoule of pethidine and a needle still in situ in her thigh muscle. Doctor J was quickly transferred to the resuscitation room, where she was successfully resuscitated. What would be the most appropriate next steps?     

Cardiopulmonary arrest induced by anaphylactoid reaction with contrast media

Anaphylactoid reactions to iodinated contrast media can cause life-threatening events and even death. A 44-year-old woman presented with cardiopulmonary arrest (CPA) immediately following the administration of nonionic iodinated contrast media for an intravenous pyelography. Her cardiac rhythm during CPA was asystole. She was successfully resuscitated by the radiologists supported by paged emergency physicians using the prompt intravenous administration of 1 mg of epinephrine. Neither laryngeal edema nor bronchial spasm was observed during the course of treatment, and she was discharged on the 4th day without any complications. The patient did not have a history of allergy, but had experienced a myocardial infarction and aortitis. She had undergone 11 angiographies and had been taking a beta-adrenergic receptor antagonist. Planned emergency medical backup is advisable to ensure resuscitation in the event of an anaphylactoid reaction to the use of contrast media in-hospital settings.     

Legal aspects of consent 16: statutory provisions and living wills

Case Scenario: Mary had cared for her invalid mentally infirm mother for many years and was determined that if she ever lost her own mental capacity she would not wish to be kept alive. She drew up a document, witnessed by her sister, that stated in the event of her suffering from any form of mental incapacity she would not wish to be fed or have any medical or nursing intervention. Some years later she began to suffer from the early signs of Alzheimer's disease. Her sister had died, but staff were aware that Mary still carried this living will on her person. She is now refusing all food. What is the law?     

Teaching the stoma care routine to a patient with low vision

Teaching the patient with a newly formed stoma but who also has low vision to manage his/her stoma independently can be a difficult task. This case study shows how a nurse taught a patient with low vision to become independent in relation to his newly formed stoma, with a view to being discharged home successfully. At the time the stoma care nurse used her past experience and common sense in achieving this aim. After the event the stoma care nurse researched the literature and discovered that there are accessories/devices available to assist patients with low vision to manage their stoma and help improve their vision. On reflection, the stoma care nurse felt she did not have sufficient time preoperatively with the patient, which prevented her from being able to change the course of action. She has now improved her knowledge, which will assist her in the future if she has to care for another patient with low vision who has had a newly formed stoma.     

Identification and recovery of co-dependent school nurses.

It is 4:30 p.m. and Christie, a school nurse, is just finishing work. She feels helpless, exhausted, and driven as she reviews the day's activities and the many tasks not done. To be ready for tomorrow's work, she realizes she must take work home to complete that night. Christie has worked as a school nurse for 10 years. She is the only school nurse for the 2,500 students enrolled in one high school, one junior high school, and three elementary schools. This student population includes a number of developmentally disabled children. Because Christie works in a school system rather than a medical facility, she has no immediate medical support or back-up. Christie feels a keen sense of responsibility to provide a good school health program, yet she worries about whether she is doing an adequate job. Christie is beginning to feel resentment and anger at the long hours she works and the multiple demands on her time, but she has difficulty expressing those feelings. Sometimes she even feels guilty about having them--after all, her job is to meet the health care needs of the children in her schools. Christie wonders if her supervisor, a school administrator, understands and appreciates all the work she does.     

Making Conflict Work for You

About 40 nurses at the Cleveland, Ohio, Visiting Nurse Association walked off their jobs in 1982 after administrators at the agency sought to eliminate a caseload clause from an already existing contract. The nurses charge the management of the VNA has failed to keep its commitment on the issue of caseload and therefore is in breech of contract (VNA Strike Continues, 1982). Ever since the new home health care manager refused her salary increase, Johanna has been angry and miserable in her job as staff nurse at a private home health care agency. For the past four years, she had regularly received good performance ratings as well as salary increases. She knew the reason she was refused her raise was because the new administrator, a woman five years her junior in age as well as experience, resented her knowledge and expertise. Now Johanna is thinking of quitting. Bob and Jerry had been coming to the group for over three months. The community health nurse started the group for veterans recovering from recent amputations. Lately, however, group members were beginning to stop coming to the meetings. The only problem Ken, the community health nurse, could think might be the cause was that Bob and Jerry had monopolized the past three meetings and there was little participation from the other group members. Ken could feel the tension mounting, and even he began to dread coming to the group because he felt frustrated and helpless dealing with Bob's and Jerry's behavior.     

Successful resuscitation for cardiac arrest due to severe accidental hypothermia accompanied by mandibular rigidity: a case of cold stiffening mimicking rigor mortis

Background

In cases of severe accidental hypothermia, it was recommended that resuscitation should be continued until the patient has rewarmed, as hypothermia itself can preserve cerebral function, and hypothermic cardiac arrest is reversible. During cardiopulmonary resuscitation for normothermic patients, muscle rigidity suggests the initiation of postmortem changes such as rigor mortis and can lead to the termination of resuscitation. Currently, the prognosis of cardiac arrest due to severe accidental hypothermia accompanied by rigidity is unknown.

Case presentation

A 29-year-old woman was found unresponsive near a snowy mountain trail. Upon discovery, she was found to be in cardiac arrest with an initial asystole rhythm and exhibited mandibular rigidity. On admission, her core temperature was 22 °C. Although cardiac arrest continued, and she showed no response to normal resuscitation, blood gas analysis revealed that her initial serum potassium level was 5.4 mmol/L. Extracorporeal membrane oxygenation (ECMO) for systemic perfusion and rewarming was initiated. After ECMO was introduced, return of spontaneous circulation was achieved. She showed no neurological impairments at discharge.

Conclusions

Muscle rigidity does not rule out the possibility of resuscitation in patients with severe accidental hypothermia under cardiac arrest. Serum potassium levels may assist in deciding whether ECMO should be introduced, even if a patient is in asystole. This knowledge may help emergency physicians to save the lives of such patients.

     

Sudden death in a young woman from medium chain acyl-coenzyme A dehydrogenase (MCAD) deficiency

Medium chain acyl-coenzyme A dehydrogenase (MCAD) deficiency is an inherited disorder of fatty acid metabolism that usually presents in early childhood. This case report describes a 19-year-old woman who presented with lethargy, disorientation, and vomiting. She had a cardiopulmonary arrest from which she could not be resuscitated 24h after the onset of the illness. Pre-mortem blood studies confirmed MCAD deficiency. An MCAD deficiency and other metabolic disorders lie within the differential diagnosis of a patient presenting with acutely altered mental status. The inheritance of MCAD deficiency and its clinical presentation, pathophysiology, treatment, and prevention are discussed.     

Profile of an invaluable colleague: Lisa Goulet, nurse clinician for organ and tissue donation

Lis Goulet is the Nurse Clinician for Organ and Tissue Donation at the McGill University Health Centre (MUHC). She was the first nurse in Quebec to be appointed to such a position. She is not only a pioneer in this clinical area, but also an inspiration to others and a guide for those who are following in her footsteps. As colleagues, we wish to acknowledge her many contributions which include the challenges she has met, the hurdles she has to overcome, and the inroads she has made to the Organ and Tissue Donation Program at the MUHC.     

Confidentiality. 7: Human fertilization and embryology issues

A woman who was having in-vitro fertilization (IVF) treatment was involved in a road accident. Her sister, a nurse, who was with her at the time, knew the drugs which she was taking as part of the IVF treatment and passed this information on to those caring for her in the accident and emergency department. Subsequently, the patient complained that this information should not have been passed on. She did not want anyone else to know that she was receiving fertility treatment. What is the law?     

Snakes and ladders: reflections of a novice researcher

This article provides a reflective overview of some of Mary Wilson's experiences of changing from being a UK continence nurse specialist to a novice researcher. She reflects on how her study was relevant to her nursing specialty but as a novice researcher, she had to re-think ingrained and often subconscious perspectives gained from years of continence nursing     

Guidelines for the diagnosis and treatment of celiac disease in children

Jennifer, age 2 years, is being seen for her regular 2-year well child visit. You note her weight is only at the 5% and has been dropping percentiles over the past year When you ask her mother about Jennifer's diet, she reports Jennifer is a "picky eater" and often complains of a "stomach ache." Her mother reports her stomach looks "bloated. " Steven, age 7 years, is brought into the clinic because of recurrent abdominal pain with occasional constipation or diarrhea. Steven's mother had been told in the past that he probably had "irritable bowel syndrome" but changes in his diet, occasional use of a laxative, and relaxation techniques have not improved his symptoms. Rebecca, age 12 years, is brought into your clinic because her mother has recently learned that two first cousins have been diagnosed with celiac disease. She is wondering if Rebecca should be screened for this condition since she has heard it runs in families.