Echocardiographic Observations in Survivors of Acute Electrical Injury: CASE REPORTS

Case 1

A 25-year-old previously well man lost consciousness when he touched an electrical wire. At least ten minutes elapsed before cardiopulmonary resuscitation (CPR) was initiated. On arrival at the hospital he was successfully defibrillated after several DC countershocks but he never regained consciousness. Although physical examination subsequently revealed stable vital signs and normal results of cardiac examination, findings from neurologic examination and diagnostic testing were consistent with severe anoxic brain damage. The electrocardiogram (ECG) revealed sinus tachycardia with poor R-wave progression in V, through V_e. His creatine kinase value was 9,800 units/L with 5 percent MB. A two- dimensional echocardiogram revealed severe biventricular hypoki- nesis with left ventricular apical dyskinesis (Fig 1). The left ventricular ejection fraction calculated by gated blood pool scanning was 15 percent. A repeat echocardiogram four days later was unchanged. A rest thallium study revealed apical, inferior, and septal defects. The patients neurologic status deteriorated and he died six days later.

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Echocardiographic Observations in Survivors of Acute Electrical Injury

Although it is well known that cardiopulmonary arrest is the main cause of immediate death due to electrical injury, there is a paucity of information concerning the cardiovascular sequelae in survivors of the acute event. Enzyme changes consistent with myocardial necrosis have been reported. However, these may be difficult to interpret in the context of extensive noncardiac muscular damage at the time of the original injury and/or during resuscitation. Electrocardiographic patterns of myocardial infarction have also been described immediately following the electrical insult. These typically normalize dramatically and in long-term survivors have been reported to be totally reversible. Similarly, the single previous case report describing left ventricular function following acute electrical injury also suggested that there is total recovery of left ventricular function.

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Long-term Compliance with Nasal Continuous Positive Airway Pressure Therapy: DISCUSSION part 2

Compliant and noncompliant patients were not distinguished by age, sex, or weight at the time of presentation. Each group had equally severe OSA as measured by AHI and the degree of nocturnal oxygen desaturation. Noncompliant patients responded as well as compliant patients to nasal CPAP with dramatic reductions in apneas and less severe oxygen desatur­ation. No significant differences were noted in the prescribed level of nasal CPAP or in weight change.

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Long-term Compliance with Nasal Continuous Positive Airway Pressure Therapy: DISCUSSION

Obstructive sleep apnea can be successfully treated in most patients with nasal CPAP Sanders reported a dramatic reduction in sleep-disordered breathing, as measured by the apnea index in 18 of 21 patients with OSA using nasal CPAP. In our experience, 110 of our 125 patients with OSA tolerated a nasal CPAP trial and achieved remarkable alleviation of their sleep- disordered breathing. Although the utility of this therapy in OSA has been convincing, concern exists as to the realistic expectation for long-term compli­ance.

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Long-term Compliance with Nasal Continuous Positive Airway Pressure Therapy: RESULTS part 2

The mean level of nasal CPAP prescribed did not differ in the compliant and noncompliant groups (10.6 ±2.6 cm H_aO for each group). Seventy (96 percent) of the 73 compliant patients used nasal CPAP nightly. One compliant patient did not use CPAP on weekends and two patients used CPAP on alternate nights. Therefore, all compliant patients used nasal CPAP at least four of seven nights. When questioned about time of use per night, every compliant patient reported CPAP use for at least all but two hours of sleep time. The mean duration of therapy in the compliant group was 14.5 ±10.7 months compared with 6.2 ±7.1 months in those noncompliant (p<0.05, Students t test). Mean duration of therapy was not significantly different in noncompliant patients with previous UPPP compared with other noncompliant patients. Change in weight while receiving nasal CPAP therapy was not significantly different in the two groups (- 3.39 ± 8.3 kg vs – 7.2 ± 10.8 kg).

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Long-term Compliance with Nasal Continuous Positive Airway Pressure Therapy: RESULTS

The baseline characteristics of the 96 long-term home nasal CPAP patients are displayed in Table 1. Eighty percent complained of severe daytime sleepi­ness and 20 (21 percent) had undergone previous uvulopalatopharyngoplasty (UPPP) that was unsuc­cessful. The patients were predominantly male and obese (114.7 ±30 kg, mean±SD). All patients had significant OSA with sleep disruption and nocturnal hypoxemia. Table 2 shows the AHI, sleep staging, and minimum Sa0₂ in the entire group at baseline and during nasal CPAE Nasal CPAP clearly reduced the sleep-disordered breathing, improved nocturnal Sa0₂, and increased the percentage of stage 3 plus 4 and REM sleep.

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Long-term Compliance with Nasal Continuous Positive Airway Pressure Therapy: METHODS

Records from all patients with OSA referred to the Georgetown University Medical Center Sleep Disorders Center, Washington, DC, for nasal CPAP trials from October 1984 to September 1987 were included in this review (n = 125). Nineteen patients refused a home nasal CPAP trial or did not tolerate nasal CPAP in the laboratory and were excluded from this review of long-term compliance. Ten patients were unavailable for follow-up. The remaining 96 patients were followed up by telephone questionnaire at a single point in time in November 1987. Those patients still ising nasal CPAP at that time were designated “compliant” and :hose who had discontinued therapy were “noncompliant.”  The following parameters in the compliant and noncompliant patients were compared at presentation and after the initial nasal CPAP trial: age, sex, weight, severity of daytime sleepiness, apnea plus hypopnea index (AHI), sleep stages, and minimum nocturnal oxygen saturation (SaOJ. The presence of severe daytime sleepiness prior to therapy was assessed by review of charts and sleep history questionnaires obtained at the time of the diagnostic polysomnogram. At the time of follow-up patients were asked to retrospectively quantitate the severity of their daytime sleepiness compared with their pretreatment level of daytime sleepiness according to a scale described by Sink et al. Patients were asked to grade their symptoms (feeling sleepy or struggling to stay awake in the daytime) on a scale from 1 to 5, where l = none, 2 = slight, 3 = moderate, 4=fairly severe, and 5 = very severe. Subjects who answered 4 or 5 were said to be “positive” for severe daytime sleepiness, whereas those who answered 1, 2, or 3 were said to be “negative” for severe daytime sleepiness. Sleep architecture was analyzed by comparing the percentages of stage 1 plus 2, stages 3 plus 4, and rapid eye movement (REM) sleep, respectively, with and without nasal CPAP in the compliant and noncompliant patients.

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