急性心肌梗塞猝死的诱因及抢救(附13例报告)

本文报告了急性心肌梗塞猝死13例。分析猝死的诱因主要有血清钾浓度降低,严重心律失常,包括室内传导阻滞、室性并行心律、室性早搏等。近年来急性心肌梗塞的发病率日趋增高,心源性猝死也随之增多,有必要对猝死的诱因进行探讨,以采取有效的抢救措施。     

A Retrospective Review of the Use and Safety of Droperidol in a Large, High-risk, Inner-city Emergency Department Patient Population

Droperidol (DROP) is used in the emergency department (ED) for sedation, analgesia, and its antiemetic effect. Its ED safety profile has not yet been reported in patients (pts). OBJECTIVES: To document the use of DROP in high-risk pts (those with head injury, alcohol or cocaine intoxication, and/or remote or recent seizures), and to determine the number of serious and minor adverse events (AEs)-seizures, hypotension, extrapyramidal side effects (EPSEs)-after DROP. METHODS: The ED database (EmSTAT) was queried to determine who received intramuscular or intravenous DROP in the ED in 1998; further chart review was done if the patient was considered high risk for or had experienced an AE. Multiple regression analysis using a random-effects model determined the significance of each variable in the occurrence of AEs. RESULTS: 2,468 patients (aged 20 months to 98 years; 112 < or =17 years; 141 > or =66 years) received DROP for agitation (n = 1,357), pain (1,135), anxiety (99), vomiting (173), or other reasons (50). There were 945 pts considered high risk; 933 charts were reviewed (DROP mean dose 4.1 +/- 2.0 mg); of these, 50 patient visits did not meet the criteria for high risk. There were 622 pts with head trauma (401 with alcohol use), including 47 with computed tomography (CT) scans positive for brain injury, 64 with cocaine use, and 197 with recent or remote seizures (137 with alcohol use). Minor AEs such as transient hypotension occurred in 96 pts after DROP (73 with alcohol use); 20 received intravenous fluids, while an additional 28 pts (8 with alcohol use) received rescue medications for EPSEs. Six possible serious AEs occurred in pts with serious comorbidities; 2 cases of respiratory depression, 3 post-DROP seizures, and 1 cardiac arrest (resuscitated) 11 hours after DROP in a cocaine-intoxicated pt (normal QT interval). There was no significant difference among high-risk groups in the occurrence of AEs. CONCLUSIONS: The vast majority of pts who received DROP in the ED did not experience an AE. A few serious AEs were noted following DROP in patients with serious comorbidities; it is not clear that DROP was causative.     

Successful weaning from cardiopulmonary bypass after cardiac surgery using inhaled nitric oxide

Two cases of very difficult weaning from cardiopulmonary bypass after cardiac surgery in children with pulmonary hypertension and ventricular dysfunction are reported. Children fail to respond to conventional therapy combining nitrovasodilators and inotropic support and react successfully to combined inhaled nitric oxide (NO) and epinephrine or left atrial infused norepinephrine. Postoperative NO inhalation must be prolonged and no toxicity appears. Pulmonary endothelial function recovers only after several days.     

城市医疗救治体系在应对公共卫生事件中的管理实践与思考

医疗救治体系是公共卫生体系建设的重要组成部分 ,建立和完善医疗救治体系对于提高收治率、降低病死率 ,缓解公共卫生危机具有直接而关键的作用。该文总结回顾了上海在防治SARS期间医疗救治工作的组织与管理 ,简要介绍了上海构建突发公共卫生事件医疗救治体系的基本思路     

Modified Ultrafiltration Attenuates Dilutional Coagulopathy in Pediatric Open Heart Operations

Background. Extreme hemodilution caused by relatively large prime volumes required for cardiopulmonary bypass in infants causes a dilutional coagulopathy, characterized by low concentrations of fibrinogen and other circulating coagulation factors. Modified ultrafiltration results in hemoconcentration and is associated with decreases in postoperative bleeding and transfusion requirements in children. This study was undertaken to quantify the effect of modified ultrafiltration on concentrations of fibrinogen, plasma proteins, and platelets in infants and small children.

Methods. Twenty patients less than 15 kg were studied. Cardiopulmonary bypass circuits were primed with crystalloid solutions. Red blood cells were added during cardiopulmonary bypass for hematocrits less than 15%. Colloid solutions were not administered. Concentrations of fibrinogen, plasma proteins, and platelets, and hematocrit were measured before cardiopulmonary bypass, before modified ultrafiltration, and after modified ultrafiltration.

Results. Modified ultrafiltration was associated with significant (p < 0.001) increases in hematocrit (19% ± 6% to 31% ± 9%), fibrinogen (65 ± 29 to 101 ± 45 mg/dL), and total plasma proteins (2.7 ± 0.3 to 4.9 ± 0.7 g/dL), but no change (p = 0.129) in platelet count.

Conclusions. We conclude that modified ultrafiltration significantly attenuates the dilutional coagulopathy associated with cardiopulmonary bypass in infants.     

Air Embolism Death of a Pregnant Woman Secondary to Orogenital Sex

Air embolism produced by vaginal insufflation is an unusual but potentially lethal consequence of sexual activity, especially in the pregnant patient. Reported here is the case of a young pregnant woman who presented to the ED in full cardiac arrest, with little history to explain her condition. Despite aggressive resuscitative measures, the patient died, but her infant son was delivered via perimortem cesarean section and survived. A high level of suspicion for air embolism should be maintained for young women who unexpectedly develop cardiac arrest, particularly during sexual activity. Air embolism patients may require vigorous medical resuscitation, hyperbaric oxygen therapy, or surgical intervention to survive. The emergency physician should be familiar with the indications for perimortem cesarean delivery in the third-trimester patient presenting to the ED with cardiac arrest.     

Relation Between Cycle Length, Volume, and Pressure in Type I Atrial Flutter

Assuming that type I atrial flutter is a macroreentrant circuit, its cycle length should vary with the atrial dimensions. In order to test this hypothesis, flutter cycle length was measured while inducing atrial volume and pressure changes by postural and pharmacological means in seven patients undergoing a therapeutic programmed stimulation for type 1 atrial flutter conversion. Right atrial volume was estimated from B-mode echocardiography data. Basal values were compared with those obtained during inspiration, expiration, Valsalva maneuver, negative tilt (head down), and positive tilt (head up) with 0.8–1.6 mg p.o. nitroglycerin. The right atrial size increased slightly from 17.8 to 18.3 cm² (P = 0.04) during the pressure load induced by negative tilt (+ 3 mmHg), with a corresponding lengthening of the flutter cycle length from 228 to 233 msec (P = 0.02). Similarly, pressure unloading of -2 mmHg by positive tilting and nitrates was accompanied by a decrease in right atrial size to 16.6 cm² (P = 0.04), with a corresponding decrease in cycle length from 228 to 219 msec (P = 0.03). Respiratory maneuver yielded similar results with an inspiratory cycle lengthening, expiratory shortening, and further shortening during Valsalva maneuver. These experiments demonstrate a direct relation between cycle length and atrial volume in human type I atrial flutter. They underline the importance of the right heart preload and atrial size for the electrophysiological characteristics of type I atrial flutter. Beside its fundamental interest, this finding is important for the understanding of the mechanism of maintenance and therapeutic responses of this common arrhythmia.     

大鼠心内神经节支配肺的研究

15只大鼠分别于左肺门区注入辣根过氧化物酶（HRP，5只）、快蓝（FB，5只），右肺内支气管腔内注入FB（5只），在房壁心内神经节发现示踪剂标记神经细胞。三组标记率分别为1.4％、2.5％及0.9％。标记细胞的出现证实心内神经节部分神经细胞亦是支配呼吸系统肺内、外支气管和肺血管壁、肺泡壁的局部神经细胞；提示心内神经节参与了心肺间功能相互联系及协调的调控。