Takotsubo Caused by Pulmonary Embolism

 

Abstract

Takotsubo is a transient acute coronary myocardial infarction due to a catecholaminergic discharge accounting for 1 in 36,000 adults after intense physical or psychological stress. Most often found in women over 50 years of age. Its association with pulmonary embolism is very rare.

With this in mind, we report the case of a 76-year-old female patient with poorly followed chronic obstructive pulmonary disease (COPD). She presented to the emergency department with acute respiratory distress and lipothymia. Clinical examination revealed hypoxia with SaPO2 at 86% in free air, blood pressure at 120/80mmHg, tachycardia at 112 beats/min. The electrocardiogram showed S1Q3, hyper-right axial deviation, complete right bundle branch block with fragmented QRS, positive AVR with a tachycardia of 125 beats/min. A thoracic angioscan was performed, showing a bilateral pulmonary embolism of segmental and sub-segmental level. Ultrasensitive troponins were highly elevated at 1530ng/l with transthoracic echocardiography showing signs of acute pulmonary heart disease associated with apical ballooning, very akinetic with hyperkinesia of the bases, LVEF 26% suggestive of takotsubo confirmed by coronary angiography coupled with ventriculography giving an amphora-like appearance with a healthy coronary. The patient was initially admitted to the intensive care unit and then to the hospital for an intermediate-high risk pulmonary embolism complicated by takotsubo. The etiological work-up of the pulmonary embolism was normal. She received apixaban, Ramipril and bisoprolol. The evolution was marked by a recovery of the bi ventricular function with an LVEF of 58% in 1 month.

Takotsubo was secondary to respiratory failure caused by pulmonary embolism through catecholaminergic discharge resulting in a redistribution of beta receptors in the myocardium.

 

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Clinical, Radiographic, and Histologic Outcomes of Ankle Arthrodesis in a Diabetic Patient using a Biphasic Calcium Phosphate Bone Graft with a Novel Submicron Needle-shaped Surface Topography

 

Abstract

Patients with diabetes mellitus who sustain ankle fractures are at increased risk of complications including non-union, malunion, wound dehiscence, soft tissue infection, osteomyelitis, deterioration to Charcot arthropathy, and amputation [1-3]. Multiple publications have evaluated treatment options for diabetic patients with ankle fractures; management options include non-surgical treatment and immobilization, open reduction internal fixation, arthrodesis of the tibiotalar joint, arthrodesis of the tibiotalocalcaneal joints, external fixation, and amputation [4-7]. It is important to identify an effective bone graft for these cases, as well as to understand the science behind the bone graft selected. In recent years, the study of osteoimmunology has confirmed the reciprocal interaction of bone forming mesenchymal stem cells and immune cells on bone growth. This report describes an adult female patient with a late presenting ankle fracture dislocation, initially treated with ankle arthrodesis using a novel bone graft with submicron needle-shaped surface topography. The patient developed Charcot arthropathy and was revised to a tibiotalocalcaneal (TTC) nail. During revision, a biopsy was taken of a solidly fused segment and sent for histology. Radiographic, clinical, and histological data were tracked and showed solid fusion at 6 weeks radiographically, which was confirmed via histology and surgical exploration at 12 weeks, indicating notable results in this challenging arthrodesis case using a novel bone graft with submicron needle-shaped surface topography.

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Laryngeal Mask Insertion Using a Laryngoscope: Description of Technique - Juniper Publishers

 Juniper Publishers- Open Access Journal of Case Studies

Laryngeal Mask Insertion Using a Laryngoscope: Description of Technique

Authored by Ali Shahriari

Commentary

Appropriate airway management is an important mission for the anesthesiologist. However endotracheal intubation remains the gold standard for the airway management, this maneuver can be difficult or impossible in some circumstances [1].

Incorrect insertion of the laryngeal mask airway (LMA) can lead to pneumonia aspiration, and airway obstruction [2]. Correct airway insertion is confirmed when there is no air leak during ventilation and the patient has an acceptable chest expansion during ventilation and normal airway pressure. To date, multiple methods have been proposed for the placement of LMA such as classic [3], reverse classic, inflated cuff methods [4]. Fatemeh Roodneshin & Mahvash Agah [5] presented a method: the index finger of the left hand must be placed on the tongue pushing it downwards (towards the floor of the mouth) when inserting the LMA

Goyal et al. [6] proposed two methods of insertion of LMA: In one method: the laryngeal mask airway must be inserted from the head end of the patient when the cuff is partially inflated, the posterior surface of the cuff must be lubricated with. The patient’s head was supported on a firm ring with neck flexed and head extended. The tube portion of the laryngeal mask was grasped as if it were a pen; the index finger was pressed on the point where the tube adjoins the mask. The patient’s mouth was opened; the tip of the mask was placed against the inner surface of the upper incisors or gums with the aperture facing anteriorly (and the black line facing the patient’s upper lip). The mask was pressed back against the hard palate to keep it flattened as it advanced into the hypopharynx, using the index finger to push upward against the palate. The tube was grasped with the other hand, straightened slightly, and then pressed down with a single, quick but gentle movement until a definite resistance was felt [7].

In other group, the LMA was inserted from the right side of the patient, i.e. the operator stood facing the patient, in the angle made by the chest and right arm of the patient. After partially inflating the cuff (i.e. filled with half the recommended air in the cuff), the posterior surface of the cuff was lubricated with water-soluble jelly. The patient’s head was supported on a firm ring with neck flexed and head extended. The tube portion of the laryngeal mask must be grasped in a pen-like fashion; the mask must be pressed by the thumb. After opening the patient’s mouth, the tip of the mask was placed against the inner surface of the upper incisors with the aperture facing anteriorly. The mask must be pressed against the hard palate must be pushed into the pharynx until a major resistance was felt. In this technique, the thumb was used to apply pressure against the hard palate while advancing the LMA [8].

The method that we proposed is using a laryngoscope for LMA insertion: At first step, the anesthesiologist opens the patient’s mouth, the head must be extended. Holding a laryngoscope in the left hand, he inserts it into the mouth of the patient with the blade directed to the right part of the mouth. Once the right tonsil is reached, the laryngoscope is swept to the midline, keeping the tongue on the left part of the mouth, to bring the epiglottis into view. Next, the laryngoscope is forced upwards, and in this step the anesthesiologist takes the LMA in the right hand and starts inserting it through the mouth opening.

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