bluuebunny/crossref_metadata_2025 huggingface dataset:
Parkinsonism
Authors: Brody David L
Published: April 2015

The classic triad of parkinsonism includes bradykinesia (slowness of movement and speech), rigidity (increased resistance of the arms, legs, neck, and torso to passive movement) and tremor (typically in the hands or arms, present at rest, but not with movement). Parkinsonism can be a delayed consequence of multiple concussions, and is often part of chronic traumatic encephalopathy. It is not likely to be caused by a single concussion. If the patient has parkinsonism, the first priority is to determine whether there is a reversible cause, most commonly a medication. If there is no reversible cause, consider pharmacological treatment with carbidopa-levodopa or a dopamine agonist. Refer to physical therapy for balance training and education on how to reduce fall risk. Importantly, multiple concussion-related parkinsonism is not the same as Parkinson’s disease. Injury-related parkinsonism does not usually get worse over time and can stay stable over decades.
Hearing Problems
Authors: Brody David L
Published: April 2015

The most common hearing problems after concussion are hypersensitivity to sound, tinnitus (ringing in the ears), and hearing loss. Any of these situations might merit referral to an ENT. Excessive sensitivity to sound can be due to migraine, damage to the ear and auditory nerve, or neuropathic pain. Consider trials of migraine abortive agents and neuropathic pain agents. For tinnitus, assess for medications that adversely affect the inner ear and reduce them if possible. Test thyroid function. Consider an MRI scan of the brain to make sure that the concussion didn’t unmask another problem such as a tumor or vascular malformation. A complaint of hearing loss can reflect true hearing loss due to middle or inner ear damage, attention deficit, or a language problem such as aphasia. Test for these conditions.
Sexual Dysfunction
Authors: Brody David L
Published: April 2015

This chapter addresses issues surrounding sexual dysfunction after concussion. Ask the patient specifically about sexual dysfunction in private, and if appropriate ask the collateral source separately. Assess for depression, severe fatigue or hypersomnia, untreated pain, and alcohol or drug abuse (especially marijuana). Check medications for sexual side effects; serotonin specific reuptake inhibitors are the most common culprits. Test for hormonal imbalances and unrecognized cauda equina or lower spinal cord injury. Consider a trial of a PDE5 inhibitor and refer to urology for more advanced options.
Return to Work
Authors: Brody David L
Published: April 2015

Return to work planning is complex and requires individualized assessments. The patient should receive optimal treatment for headaches, sleep disorders, fatigue, anxiety, depression, mood instability, and attention deficit. An occupational therapist should try to simulate the patient’s workplace or most important work-related tasks to see how the patient performs, then attempt to develop compensatory strategies. Be more conservative with patients in high-risk occupations. Communicate directly with the patient’s supervisor to fully understand the nature of the work and whether there are lower-risk “light-duty” options. Advise patients in high cognitive demand professions not to make major decisions or take on any major new responsibilities during the rehabilitation process.
Return Visit Times
Authors: Brody David L
Published: April 2015

Active, immediately dangerous issue (e.g. suicidal, homicidal): admit to hospitalActive, time-sensitive issue: within 1 weekActive, potentially dangerous issue: 1-3 weeksActive, severely impairing issue: 1-2 months.Patient starting a new medication which requires monitoring. 1 week to 3 monthsTypical patient with moderate issues: 3 monthsStable patient, medications requiring monitoring: 6 monthsStable patient, no new medications and no medication requiring monitoring: 1 year
The Collaborative Approach to Preventing Infection
Authors: Saint Sanjay
Published: April 2015

When hospitals join in a collaborative infection prevention project, they agree to work within the requirements and discipline of the sponsors. That includes providing baseline and monthly infection rate data to the collaborative leaders and committing some staff members to intense weekly phone talks with the collaborative experts and other coaching sessions. Ideally, a community emerges, both online and in-person. The community members exchange experiences and ideas related to the initiative, socialize, and establish a behavioral norm within each hospital that can help convince resisters, particularly physicians, to change their ways. To make up for the limited attention paid to the problems individual hospitals may encounter, some collaboratives provide a troubleshooting group of expert advisors. The collaborative approach has strong support from federal and state agencies, but some studies have questioned its effectiveness.
Training and certification in acute cardiac care
Authors: Heras Magda , Sionis Alessandro , Price Susanna
Published: April 2015

Advances in the treatment of cardiovascular diseases have changed their natural course and resulted in improved outcomes with prolongation of life. In parallel, subspecialization in cardiology has meant that training in the advanced management of critically ill cardiac patients to the level that is now required is no longer met within general cardiology. The growing demand for training in intensive cardiac care has led to the recognition of acute cardiac care as a subspecialty in its own right. This chapter describes the concept of clinical competence and its assessment within this challenging field. It also details the core curriculum and certification process established by the Acute Cardiovascular Care Association of the European Society of Cardiology to train and certify physicians in acute cardiac care.
Sudden cardiac death: epidemiology and prevention
Authors: Arntz Hans-Richard
Published: April 2015

Even if sudden cardiac death is considered to be the most frequent cause of death in adults in industrialized countries, its incidence varies widely, depending on the definition and the source and quality of underlying data. It is estimated that about 70-80% of cases are due to coronary heart disease. The remaining 20% are attributable to a wide variety of inborn, genetically determined or acquired diseases, including a small group with hitherto undefined background. Prevention primarily encompasses the treatment of cardiovascular risk factors to avoid manifestations of coronary heart disease. Furthermore, preventive strategies are targeted to define groups of patients with an increased risk for sudden cardiac death or individuals at risk in specific populations, e.g. competitive athletes. A major target group are patients with impaired left ventricular function, preferentially due to myocardial infarction. These patients, and some less clearly defined patient groups with non-ischaemic cardiomyopathy and heart failure, may benefit from the insertion of an implantable cardioverter-defibrillator. With regard to pharmacological prevention, treatment of the underlying condition is the mainstay, since no antiarrhythmic substance-with the exemption of beta-blockers in some situations-has shown to be of efficacy.
Acute dyspnoea in the emergency department
Authors: Mueller Christian
Published: April 2015

Acute dyspnoea is a very common symptom in the acute cardiac care setting. In contrast to current beliefs, acute dyspnoea, as the leading symptom in the emergency department, is associated with about twice the mortality risk, compared to acute chest pain. Rapid and accurate identification of the cause of dyspnoea is critical to the initiation of specific and effective treatment. In most patients, a rapid and accurate diagnosis in the emergency department can be achieved by a combination of vital signs, including pulse oximetry, detailed patient history, physical examination, blood tests (including natriuretic peptides—BNP, NT-proBNP, or MR-proANP), venous blood gases, and C-reactive protein in all patients, and D-dimers in selected patients, electrocardiograms, and chest X-ray. It is key to remember that the prevalence of acute heart failure in unselected patients with acute dyspnoea is about 50%. Therefore, a high awareness for the presence of acute heart failure is mandatory. Acute heart failure, pneumonia, obstructive pulmonary diseases (chronic obstructive pulmonary disease and asthma), pulmonary embolism, and anxiety disorders represent more than 90% of all cases with acute dyspnoea in the emergency department. In about 10–15%, two acute causes (e.g. acute heart failure and pneumonia) may be present and require combined treatment. Transthoracic echocardiography should be immediately performed in all patients with acute dyspnoea and shock, and in those patients in whom the diagnosis remains uncertain, even after initial work-up.
Recommendations for the structure, organization, and operation of intensive cardiac care units
Authors: Nahir Menachem , Zahger Doron , Hasin Yonathan
Published: April 2015

Care for the critically ill cardiovascular patients and their families requires a unique environment that is structurally different from other clinical units. Coronary care units were introduced in the 1960s for the main purpose of prevention and prompt treatment of life-threatening cardiac arrhythmias related to acute myocardial infarction. Since then, major progress in cardiology in general and acute cardiac care, in particular, dictated a major change in the structure and organization of these units, symbolically expressed in the new title of ‘intensive cardiac care unit’. Contemporary intensive cardiac care units receive older and more complex patients, often with multiple comorbidities and diverse diagnoses. The modern intensive cardiac care unit incorporates sophisticated monitoring and up-to-date equipment to meet the changing needs of the patient with cardiovascular disease requiring critical care. The intensive cardiac care unit operates in the centre of the hospital’s cardiology service, receiving patients from the mobile care unit (directly or via an ST elevation myocardial infarction network), the emergency department, and other wards, including coronary, structural, and electrophysiology intervention laboratories and operating rooms. Patients are usually unstable and require immediate full attention by highly trained medical and nursing staff. The 2005 recommendations for the structure, organization, and operations of the intensive cardiac care unit were issued by Hasin et al. for the Working Group of Acute Cardiac Care of the European Society of Cardiology, which serves as basis for this chapter. The chapter will focus on the requirements for staffing, training, and accreditation, as well as the structure organization and equipment of the intensive and intermediate cardiac care units.
The heart team in acute cardiac care
Authors: Kappetein Arie Pieter , Windecker Stephan
Published: April 2015

The complexity of acute cardiac care today makes it necessary that patients are looked after by more than one health care professional. Complex tasks require complex systems. Teamwork is essential for minimizing adverse events caused by miscommunication and misunderstanding about roles and responsibilities, and it can have an immediate and positive impact on the patient. The increasing complexity and specialization of care of the cardiac patient in the acute setting make it necessary to coordinate teams of doctors for each specialty area. Multidisciplinary decision making optimizes care and is mandatory in light of evolving options and improvement of quality of care and will lead to more efficiency.
Pathophysiology and clinical assessment of the cardiovascular system (including pulmonary artery catheter)
Authors: Barthélémy Romain , Gayat Etienne , Mebazaa Alexandre
Published: April 2015

Haemodynamic instability in acute cardiac care may be related to various mechanisms, including hypovolaemia and heart and/or vascular dysfunction. Although acute heart failure patients are often admitted for dyspnoea, many mechanisms can be involved, including left ventricular diastolic and/or systolic dysfunction and/or right ventricular dysfunction. Many epidemiological studies show that clinical signs at admission, morbidity, and mortality differ between the main scenarios of acute heart failure: left ventricular diastolic dysfunction, left ventricular systolic dysfunction, right ventricular dysfunction, and cardiogenic shock. Although echocardiography often helps to assess the mechanism of cardiac dysfunction, it cannot be considered as a monitoring tool. In some cases (in particular, in cases of refractory shock secondary to both vascular and heart dysfunction or in cases of refractory haemodynamic instability associated with severe hypoxaemia), pulmonary artery catheter can help to assess and monitor cardiovascular status and to evaluate response to treatments. Last, macro- and microvascular dysfunctions are also important determinants of haemodynamic instability.
The respiratory system
Authors: Vieillard-Baron Antoine
Published: April 2015

The respiratory system is key to the management of patients with respiratory, as well as haemodynamic, compromise and should be monitored. The ventilator is more than just a machine that delivers gas; it is a true respiratory system monitoring device, allowing the measurement of airway pressures and intrinsic positive end-expiratory pressure and the plotting of pressure/volume curves. For effective and reliable monitoring, it is necessary to keep in mind the physiology, such as the alveolar gas equation, heart-lung interactions, the equation of movement, etc. Monitoring the respiratory system enables adaptation of not only respiratory management, but also haemodynamic management.
Neurological assessment of the acute cardiac care patient
Authors: De Deyne Cathy , Dens Jo
Published: April 2015

Many techniques are currently available for cerebral physiological monitoring in the intensive cardiac care unit environment. The ultimate goal of cerebral monitoring applied during the acute care of any patient with/or at risk of a neurological insult is the early detection of regional or global hypoxic/ischaemic cerebral insults. In the most ideal situation, cerebral monitoring should enable the detection of any deterioration before irreversible brain damage occurs or should at least enable the preservation of current brain function (such as in comatose patients after cardiac arrest). Most of the information that affects bedside care of patients with acute neurologic disturbances is now derived from clinical examination and from knowledge of the pathophysiological changes in cerebral perfusion, cerebral oxygenation, and cerebral function. Online monitoring of these changes can be realized by many non-invasive techniques, without neglecting clinical examination and basic physiological variables such as invasive arterial blood pressure monitoring or arterial blood gas analysis.
Monitoring of the kidneys, liver, and other vital organs
Authors: Werdan K , Patel B , Girndt M , Ebelt H , Schröder J , Nuding S
Published: April 2015

The prognosis of critically ill cardiac patients in the critical care unit and intensive cardiac care unit depends not only on the underlying cardiac disease, but also on the development of secondary organ complications and failures. Therefore, close monitoring of vital organs is mandatory in all critically ill cardiac patients to detect the development of non-cardiac organ failure as early as possible.
Echocardiography and thoracic ultrasound
Authors: Flachskampf Frank A , Myrianthefs Pavlos , Beyer Ruxandra , Myrianthefs Pavlos M.
Published: April 2015

For the emergency management of cardiovascular disorders, echocardiography and thoracic ultrasound are indispensable imaging techniques at the bedside. In the intensive care environment, crucial questions, such as left and right ventricular function, valvular heart disease, volume status, aortic disease, cardiac infection, pleural effusion, pulmonary oedema, pneumothorax, and many others, can be sufficiently and reliably answered by using these techniques; in fact, it is almost impossible to manage patients with acute severe haemodynamic impairment reasonably well without a prompt and repeated access to echocardiography. This is confirmed by the prominent place that echocardiography has in the guideline-based diagnosis and treatment of all major cardiovascular emergencies, from acute heart failure to the acute coronary syndrome to pulmonary embolism, etc. Moreover, it is the ideal tool to follow the patient, since repeat examinations pose no risk to the patient and demand relatively little logistics and resources. To benefit from the wealth of information that echocardiography and thoracic ultrasound can provide, modern equipment (including a transoesophageal probe) and systematic training of echocardiographers must be ensured. The availability of prompt and experienced echocardiography and thoracic ultrasound services at all times is fundamental for sound contemporary cardiovascular intensive care.
Ultrasound-guided vascular access in intensive/acute cardiac care
Authors: Paul Richard
Published: April 2015

Vascular access is an essential requirement for the care of the critically ill cardiac patient, being necessary for drug and fluid delivery and monitoring of a patient’s haemodynamic response to an instigated therapy. The most common vascular access procedures conducted in the acute cardiac care unit are central venous and peripheral venous access, and arterial cannulation. Traditional landmark methods are associated with complication rates, ranging from 18 to 40%, depending on the site of access. The use of ultrasound to guide venous and arterial access has been shown to reduce the incidence of complications, such as inadvertent arterial puncture and pneumothorax formation (venous) and posterior wall puncture (arterial), to reduce the time taken and number of attempts to place a catheter, and to reduce the incidence of complete failure to insert a vascular access device. Since 2002, international consensus groups have published recommendations that two-dimensional ultrasound guidance be the preferred method for elective and emergency internal jugular catheter insertion. This chapter explores the evidence for the use of ultrasound to guide vascular access across multiple sites of insertion and describes the basic equipment and techniques necessary for successful deployment.
Cardiac magnetic resonance in the intensive and cardiac care unit
Authors: Schwitter Juerg , Bremerich Jens
Published: April 2015

Current applications of cardiac magnetic resonance offer a wide spectrum of indications in the setting of acute cardiac care. In particular, cardiac magnetic resonance is helpful for the differential diagnosis of chest pain by the detection of ischaemia, myocardial stunning, myocarditis, and pericarditis. Also, Takotsubo cardiomyopathy and acute aortic diseases can be evaluated by cardiac magnetic resonance and are important differential diagnoses in patients with acute chest pain. In patients with restricted windows for echocardiography, according to guidelines, cardiac magnetic resonance is the method of choice to evaluate complications of an acute myocardial infarction. In an acute myocardial infarction, cardiac magnetic resonance allows for a unique characterization of myocardial damage by quantifying necrosis, microvascular obstruction, oedema (i.e. area at risk), and haemorrhage. These features will help us to understand better the pathophysiological events during infarction and will also allow us to assess new treatment strategies in acute myocardial infarction. To which extent the information on tissue damage will guide patient management is not yet clear, and further research, e.g. in the setting of the European Cardiovascular MR registry, is ongoing to address this issue. Recent studies also demonstrated the possiblity to reduce costs in the management of acute coronary syndromes when cardiac magnetic resonance is integrated into the routine work-up. In the near future, applications of cardiac magnetic resonance will continue to expand in the acute cardiac care units, as manufacturers are now strongly focusing on this aspect of user-friendliness. Finally, in the next decade or so, magnetic resonance imaging of other nuclei, such as fluorine and carbon, might become a reality in clinics, which would allow for metabolic and targeted molecular imaging with excellent sensitivity and specificity.
Chest tubes
Authors: Atchabahian Arthur , Laplace Christian , Tazarourte Karim
Published: April 2015

Percutaneous chest tube insertion is routinely performed on surgical wards, in the intensive care unit, in the emergency department, and in pulmonary medicine. While it has been shown that trained physicians can safely perform chest tube insertion, severe complications have been described, associated with a lack of proper training and/or an incorrect insertion or management of chest tubes. The proper technique of thoracic drainage is key for safety and effectiveness. Chest tube insertion has been well described, step by step, in the British Thoracic Society guidelines. The level of scientific proof of these recommendations ranges from a high level of evidence (A) to an expert opinion (C) (see Table 28.1).
Renal support therapy
Authors: Ronco Claudio , Ricci Zaccaria
Published: April 2015

Renal dysfunction is known to be frequently a component of multiple organ failure, a complex syndrome affecting the most severely ill critical patients. Bidirectional interaction between the kidneys and other organs has always been suspected; evidence suggests that severe kidney injury is an important protagonist in acute illness, even when managed by dialysis. In fact, if it seems that increasing the dose of renal replacement therapy does not reduce mortality, it could be inferred that acute kidney injury influences mortality through means that are not reversed by conventional renal support, either because the putative culprit toxins are not removed by renal replacement therapy or because renal replacement therapy is started too late to prevent these effects. It is known that the kidneys exert effects on other organs, such as the lung, liver, heart, and brain, in a process called ‘crosstalk’. This effect means that the kidney is not only a victim, but also a culprit regarding the malfunction of other organs. This chapter will detail some traditional aspects of different renal replacement therapy modalities and prescription schedules, but it will also describe the most recent evidence on the management and support of the kidney during failure of other organs.
Implanted cardiac support devices
Authors: Morley-Smith Andrew C , Simon André R , Pepper John
Published: April 2015

Mechanical circulatory support forms a crucial and expanding element of advanced heart failure management. Short-term assistance is delivered in emergency situations or where the underlying condition is likely to quickly worsen, and these approaches are discussed in Chapter 30. This chapter focuses on implantable devices intended for the medium and long term. The first half of the chapter is aimed directly at practical clinical management, whilst the second half considers the evidence base for contemporary practice. The chapter concludes by considering new paradigms for implantable cardiac support. Most frequently, these devices support left ventricular function (left ventricular assist devices), and this comprises the majority of our discussion.
Biomarkers in acute heart failure
Authors: Choudhary Rajiv , Shah Kevin , Maisel Alan
Published: April 2015

Acute heart failure continues to be a worldwide medical problem, associated with frequent readmissions, high mortality, and a profound economic impact on national health care systems. In the past decade, biomarkers have shifted the way in which acute heart failure is managed by the cardiologist. The search for the ideal biomarker to aid in the diagnosis, prognosis, and treatment of acute heart failure is ongoing. The natriuretic peptides have proved extremely useful in determining whether acute dyspnoea has a cardiac aetiology. In addition, recent trials have demonstrated the use of natriuretic peptides in inpatient and outpatient prognosis, as well as in titrating medications in outpatients with chronic heart failure to prevent acute heart failure hospitalizations. Other emerging acute heart failure biomarkers include mid-regional pro-adrenomedullin, mid-regional proatrial natriuretic peptide, troponin, ST2, and neutrophil gelatinase-associated lipocalin.
The universal definition of myocardial infarction
Authors: Thygesen Kristian , Alpert Joseph S , Jaffe Allan S , White Harvey D
Published: April 2015

Myocardial infarction is defined pathologically as myocyte necrosis due to prolonged ischaemia. These conditions are met when there is a detection of a rise and/or fall of cardiac biomarkers, preferably troponins, with at least one value above the 99th percentile of the upper reference limit, together with evidence of myocardial ischaemia, as recognized by at least one of the following: symptoms of ischaemia, electrocardiographic changes of new ischaemia, the development of pathological Q waves, imaging evidence of a new loss of viable myocardium or new regional wall motion abnormality, or the identification of an intracoronary thrombus by angiography or autopsy.
Mechanical complications of myocardial infarction
Authors: López-Sendón José , López de Sá Esteban
Published: April 2015

Mechanical complications after an acute infarction include different forms of heart rupture, including free wall rupture, interventricular septal rupture, and papillary muscle rupture. Its incidence decreased dramatically with the widespread use of reperfusion therapies but may occur in 2–3% of ST-elevation myocardial infarction patients, and mortality is very high if not properly diagnosed, as surgery is the only effective treatment. Echocardiography is the most important tool for diagnosis that should be suspected in patients with hypotension, heart failure, or recurrent chest pain. Awareness and well-established protocols are crucial for an early diagnosis. Modern imaging techniques permit a more reliable and direct identification of left ventricular free wall rupture, which is almost impossible to identify with conventional echocardiography. Mitral regurgitation, secondary to papillary muscle ischaemia or necrosis or left ventricular dilatation and remodelling, without papillary muscle rupture, is frequent after myocardial infarction and is considered as an independent risk factor for outcomes. Revascularization to control ischaemia and surgical repair should be considered in all patients with severe or symptomatic mitral regurgitation in the absence of severe left ventricular dysfunction. Other mechanical complications include true aneurysms and thrombus formation in the left ventricle. Again, these complications have decreased with the use of early reperfusion therapies and, for thrombus formation, with aggressive antithrombotic treatment. In a single large randomized trial (STICH), surgical remodelling of the left ventricle failed to demonstrate a significant improvement in outcomes, although it still may be an option in selected patients.
Coronary artery bypass graft surgery
Authors: Davierwala Piroze M , Mohr Friedrich W
Published: April 2015

The surgical management of acute coronary syndrome still remains a challenge for the cardiac surgeon. Although most patients can be managed by percutaneous coronary intervention, for patients with complex multivessel or left main coronary artery disease (high SYNTAX score), in whom percutaneous coronary intervention is not possible or is unsuccessful, urgent or emergent coronary artery bypass graft surgery is the only available option. It is very important for surgeons to determine the optimum timing of surgical intervention, which is usually based on the clinical presentation, coronary anatomy, and biomarkers. Surgeons should be conversant with the different operative techniques, whether off- or on-pump coronary artery bypass graft surgery, that would help in achieving the best possible outcomes in such situations. Early and late survival of patients depends not only on an efficiently executed operation, but also on the competency of the post-operative care delivered. Modern perioperative management is reinforced by the availability of a variety of mechanical cardiopulmonary assist devices, like the intra-aortic balloon pump, the extracorporeal membrane oxygenation, and an array of ventricular assist devices, which aid us in managing very sick patients presenting with cardiogenic shock. The results of coronary artery bypass graft surgery for acute coronary syndrome, as published in the literature, vary significantly, because of the heterogeneity of patient populations, operative timing, and haemodynamic status, making a comparison of surgical outcomes almost impossible. Only one randomized trial has been conducted to that effect, to date. A heart team approach, involving an interventional cardiologist and a cardiac surgeon, is mandatory to determine the best treatment strategy and achieve the best possible outcomes in patients with acute coronary syndrome.
Acute heart failure: epidemiology, classification, and pathophysiology
Authors: Farmakis Dimitrios , Parissis John , Filippatos Gerasimos
Published: April 2015

Acute heart failure is defined as the rapid development or change of symptoms and signs of heart failure that requires urgent medical attention and usually hospitalization. Acute heart failure is the first reason for hospital admission in individuals aged 65 or more and accounts for nearly 70% of the total health care expenditure for heart failure. It is characterized by an adverse prognosis, with an in-hospital mortality rate of 4-7%, a 2-3-month post-discharge mortality of 7-11%, and a 2-3-month readmission rate of 25-30%. The majority of patients have a previous history of heart failure and present with normal or increased blood pressure, while about half of them have a preserved left ventricular ejection fraction. A high prevalence of cardiovascular or non-cardiovascular comordid conditions is further observed, including coronary artery disease, arterial hypertension, atrial fibrillation, diabetes mellitus, renal dysfunction, chronic lung disease, and anaemia. Different classification systems have been proposed for acute heart failure, reflecting the clinical heterogeneity of the syndrome; the categorization to acutely decompensated chronic heart failure vs de novo acute heart failure and to hypertensive, normotensive, and hypotensive acute heart failure are among the most widely used and clinically relevant classifications. The pathophysiology of acute heart failure involves several pathogenetic mechanisms, including volume overload, pressure overload, myocardial loss, and restrictive filling, while several cardiovascular and non-cardiovascular causes or precipitating factors lead to acute heart failure through a single of these mechanisms or a combination of them. Regardless of the underlying mechanism, peripheral and/or pulmonary congestion is the hallmark of acute heart failure, resulting from fluid retention and/or fluid redistribution. Myocardial injury and renal dysfunction are also involved in the precipitation and progression of the syndrome.
Non-pharmacological therapy of acute heart failure: when drugs alone are not enough
Authors: Vranckx Pascal , Mullens Wilfried , Vijgen Johan
Published: April 2015

Acute heart failure syndrome has been defined as new-onset or a recurrence of worsening signs and symptoms of heart failure, necessitating urgent or emergency management. The management of acute heart failure syndrome is challenging, given the heterogeneity of the patient population, in terms of the clinical presentation, pathophysiology, prognosis, and therapeutic options. The management of acute heart failure syndrome is a dynamic process, requiring ongoing simultaneous diagnosis (monitoring) and treatment. Pharmacological agents remain the mainstay of therapy for acute heart failure syndrome. However, at all time, during the early diagnostic, aetiologic, and therapeutic work-up, non-pharmacologic therapy may be indicated and should be considered. The management of the complex cardiac patient with acute heart failure syndrome and/or (potential) haemodynamic compromise has become a special dimension for specialized myocardial intervention centres, providing 24 hours per day and 7 days per week state-of-the-art facilities for (primary) percutaneous coronary intervention and cardiac intensive care, including mechanical ventilation, ultrafiltration, with or without dialysis, and short-term percutaneous mechanical circulatory support. Through the understanding of the underlying pathophysiology and approaches into the problems of acute heart failure syndrome, one should be better prepared to understand and treat its many facets.
Cardiac emergencies in pregnancy
Authors: Presbitero Patrizia , Zavalloni Dennis , Agnoli Benedetta
Published: April 2015

Cardiac diseases are an increasingly important cause of morbidity and mortality in pregnant women. Pregnancy leads to several changes in physiological processes, and the cardiovascular system progressively adapts to modifications that may worsen pre-existing pathological conditions or unmask previously undiagnosed diseases. Furthermore, pregnancy may be complicated by specific pathologies, which are harmful for patients with cardiac diseases. Admission to the intensive cardiac care unit is a rare event (0.1–0.9% of deliveries), but mortality rates range from 3.5% to 21%. When treating pregnant women, we are taking care of two subjects: the mother and the fetus. The possible adverse effects of diagnostic examination and/or therapies on the fetus should always be considered, and, even after delivery, possible drug interactions on breastfeeding should be taken in account. In this chapter, an overview on the main cardiac emergencies that may affect pregnancy is provided, with a particular focus on treatments allowed for both mother and fetal protection.
Acute respiratory failure and acute respiratory distress syndrome
Authors: Gattinon Luciano , Carlesso Eleonora
Published: April 2015

Respiratory failure (RF) is defined as the acute or chronic impairment of respiratory system function to maintain normal oxygen and CO2 values when breathing room air. ‘Oxygenation failure’ occurs when O2 partial pressure (PaO2) value is lower than the normal predicted values for age and altitude and may be due to ventilation/perfusion mismatch or low oxygen concentration in the inspired air. In contrast, ‘ventilatory failure’ primarily involves CO2 elimination, with arterial CO2 partial pressure (PaCO2) higher than 45 mmHg. The most common causes are exacerbation of chronic obstructive pulmonary disease (COPD), asthma, and neuromuscular fatigue, leading to dyspnoea, tachypnoea, tachycardia, use of accessory muscles of respiration, and altered consciousness. History and arterial blood gas analysis is the easiest way to assess the nature of acute RF and treatment should solve the baseline pathology. In severe cases mechanical ventilation is necessary as a ‘buying time’ therapy. The acute hypoxemic RF arising from widespread diffuse injury to the alveolar-capillary membrane is termed Acute Respiratory Distress Syndrome (ARDS), which is the clinical and radiographic manifestation of acute pulmonary inflammatory states.
Hyperglycaemia, diabetes, and other endocrine emergencies
Authors: Debaveye Yves , Mesotten Dieter , Berghe Greet Van den
Published: April 2015

Although endocrine pathology is usually treated in outpatient clinic, intensive care may be required when endocrinopathies are associated with other medical illnesses or reach a state of decompensation. Although endocrine emergencies are quite rare, they are potentially life-threatening, if not recognized promptly and managed effectively. Therefore, every clinician should always be attentive to a possible diagnosis of these complex disorders. The three major diabetic emergencies comprise diabetic ketoacidosis, hyperglycaemic hyperosmolar state, and prolonged hypoglycaemia. Hyperglycaemic crises are characterized by hypovolaemia, electrolyte disturbances, and potentially life-threatening triggers. Hence, airway-breathing-circulation securement, diagnosis and treatment of the underlying condition, and fluid resuscitation are the cornerstones of acute diabetic ketoacidosis/hyperglycaemic hyperosmolar state management. Subsequently, monitoring and correction of electrolyte disturbances and insulin treatment are initiated. Profound hypoglycaemia should be suspected in every coma patient with an indistinct history or treated with insulin or sulfonylurea/meglitinide. This condition warrants an immediate and a sufficiently long administration of glucose, under blood glucose monitoring. Alternatively, glucagon may be injected subcutaneously, or preferably intramuscularly. Hyperglycaemia in intensive care unit patients is associated with adverse outcome which can be prevented via the implementation of glucose control with intravenous insulin. One should hereby target glucose levels to be as close to normal as possible, without evoking unacceptable glucose fluctuations and hypoglycaemia. The classical non-diabetic endocrine emergencies comprise thyroid storm, myxoedema coma, acute adrenal crisis, and phaeochromocytoma. They all pose diagnostic and therapeutic challenges and require specific treatment such as endocrine replacement or blockage therapy. It is important to note that they are occasionally the presenting manifestation in undiagnosed patients. This chapter also briefly discusses amiodarone-induced thyroid dysfunction.
Anaemia and transfusion
Authors: Bassand Jean-Pierre , Schiele François , Meneveau Nicolas
Published: April 2015

Anaemia, irrespective of the cause-whether linked to, or worsened by, bleeding or phlebotomy, has an unfavourable impact on outcome, in terms of death and myocardial infarction, in acute coronary syndromes. In addition, it is an independent predictor of the risk of bleeding. The treatment of anaemia includes a search for the cause and its mechanism, blood transfusion, and iron therapy. Erythropoietin-stimulating agents are contraindicated. Blood transfusion should be considered with caution. It is indicated in cases of haemodynamic or ischaemic instability. However, in stable patients, blood transfusion should not be administered in patients with a haematocrit of >25%, since deleterious effects of transfusion have been described in this situation. For haematocrit below 25%, blood transfusion should be administered. Target post-transfusion haemoglobin levels are in the range of 9–10 g/dL. In practical terms, the risks of further ischaemic events and bleeding have to be assessed on a case-by-case basis in every patient admitted for acute coronary syndrome. Pharmacotherapy and invasive strategies have to be customized, depending on the ischaemic and bleeding risks, bearing in mind that those patients at highest risk of further ischaemic events are often the same patients who are at highest bleeding risk.
Infection, sepsis, and multiorgan dysfunction syndrome
Authors: Ortiz Julian Arias , Favory Raphaël , Vincent Jean-Louis
Published: April 2015

Sepsis is the main cause of multiple organ failure and remains a concern because of the associated high morbidity and mortality. In recent years, important advances have been made in the understanding of the pathophysiology of sepsis. Sepsis and septic shock are the end result of complex interactions between infecting organisms and various elements of the host response. A key feature of the common sequence of organ failure is dysfunction of the cardiovascular system, including microcirculatory elements. Outcome improvement in sepsis is based on recognizing the process early and instituting effective therapies. The time window for intervention is relatively short, and treatment must promptly control the source of infection, restore haemodynamic homoeostasis, and support failing organ systems.
Special considerations in the immunosuppressed patient
Authors: Moreau Anne-Sophie , Favory Raphaël , Durocher Alain
Published: April 2015

Because of improved treatment of haematological malignancies, autoimmune diseases, and HIV infection, an increasing number of patients are being immunocompromised. Immunosuppression varies according to the underlying disease, and different patterns of complications may be encountered. Among the complications of immunosuppressive treatments, infectious diseases are the most frequently encountered, but drug-related toxicities and secondary neoplasias have to be recognized. Making a rapid diagnosis is the most important step in taking these patients in charge. In such setting, cardiac involvement is severe and often leads to admission to intensive care units. This chapter will focus on the cardiac complications of immunosuppression, from heart transplantation to HIV treatment-related toxicity and cardiac infections.
Perioperative cardiac care of the high-risk non-cardiac patient
Authors: Balik Martin
Published: April 2015

Non-cardiac surgery conveys a cardiac risk related to the status of the patient’s cardiovascular system. Cardiac-related risk of surgery can be assessed by integrating the risk and urgency of the procedure with cardiovascular risk factors, which include age, ischaemic heart disease, heart failure, stroke, diabetes mellitus, chronic obstructive pulmonary disease, and renal dysfunction. An individual assessment can include simple multivariate scoring systems, developed with the aim of evaluating cardiac risk prior to non-cardiac surgery. Patient assessment can be extended for indicated additional tests. The indications for further cardiac testing and treatments are the same as in the non-operative setting, but their timing is dependent on the urgency of surgery, and patient-specific and surgical risk factors. A delay in surgery, due to the use of both non-invasive and invasive preoperative testing, should be limited to those circumstances in which the results of such tests will clearly affect patient management. In high-risk patients, the result of the cardiac assessment helps to choose adequate perioperative monitoring and to indicate for an intensive care unit stay perioperatively. Chronic medications can be adjusted, according to the current knowledge on perioperative management. Drugs with the potential to reduce the incidence of post-operative cardiac events and mortality include beta-blockers, statins, and aspirin. Chronic platelet anti-aggregation and anticoagulation therapies have to be adapted by weighing the risk of bleeding against the risk of thrombotic complications.
A Video Atlas of Neuromuscular Disorders
Authors: Shaibani Aziz
Published: April 2015

This online title is the first real cases video atlas of neuromuscular disorders. It contains close to 300 video cases taken directly from a real neuromuscular clinic, illustrating a myriad of disorders and shedding light on their diagnosis and treatment, as well as providing updates about many of them. It provides an invaluable approach that should benefit anyone interested in neuromuscular disorders which comprise more than 50% of presenting disease to general neurologists and even to general practitioners. Some rare diseases are also described, giving an opportunity for future diagnosis of these conditions in patients, despite the rarity of the condition and its infrequent presentation in clinic.
Gait Disorders
Authors: Shaibani Aziz
Published: April 2015

Gait is a complicated process that is initiated and maintained by different mechanisms, neurological including neuromuscular, and non-neurological including musculoskeletal. Neuromuscular clinics receive referrals about patients who may have non-neuromuscular disorders such as Parkinsondisease, focal foot dystonia, and multiple sclerosis. It is important for a neuromuscular specialist to be aware of other gait disorders. Important neuromuscular disorders of gait include neuropathies (foot drop, sensory ataxia), myopathies, muscle stiffness and spasms, myotonia, and motor neuron disease. Functional gait disorder comprises a significant entity that may lead to extensive non-necessary investigations that can be saved if the specialist is aware of these symptoms.
Ptosis
Authors: Shaibani Aziz
Published: April 2015

A droopy eyelid is a common problem. Causes may range from simple and non-progressive disorders such as congenital ptosis to progressive multisystemic disorders such as mitochondrial disease. Myasthenia gravis is a very important and treatable cause of ptosis that should always be considered in the differential diagnosis. Apraxia of eyelid opening can be confused with ptosis or blepharospasm, leading to delay of the diagnosis. Horner’s syndrome has different causes and management. Knowledge of the anatomy and physiology of the eyelids is crucial for understanding the pathological processes that affect them.
Diplopia
Authors: Shaibani Aziz
Published: April 2015

Diplopia is a very bothersome symptom and very often leads to early medical attention. However, some patients modify their lifestyle, wear dark glasses, prisms, or an eye patch, and only seek advice if these measures fail. A careful knowledge and examination of the extraocular muscles and their nerves from the orbit to the brainstem is crucial for the right diagnosis. Myasthenia gravis can mimic any single or combined oculomotor nerves palsy and should always be considered in the differential diagnosis of diplopia. The presence of sensory symptoms or severe retro-orbital pain should prompt looking for a different cause than myasthenia gravis.
Dyspnea
Authors: Shaibani Aziz
Published: April 2015

The most common causes of dyspnea are not neuromuscular but rather are cardiac and pulmonary. However, dyspnea is an important and serious manifestation of many neuromuscular disorders, and it may compound an underlying pulmonary or cardiac problem. The diaphragm is a skeletal muscle under the control ofperipheral nerves(phrenic nerves) and may be targeted by inflammatory neuropathies such as Guillain-Barrésyndrome(GBS), chronic inflammatory demyelinating polyneuropathy(CIDP), and brachial plexitis, myopathies such as acid maltase deficiency and muscular dystrophies, and neuromuscular disorders such as myasthenia gravis. Periodic measurement of pulmonary function isrecommended in neuromuscular clinics.
Proximal Arm Weakness
Authors: Shaibani Aziz
Published: April 2015

Proximal arm muscles include supra and infra spinatii, pectoralis major and minor, teres major and minor, rhomboids, serratus anterior, deltoids, biceps, and triceps. The main function of these muscles is to lift the arms. The first sign of proximal weakness is difficulty in raising the arms above a horizontal level. Shoulder conditions like supraspinatus tendonitis are often confused as proximal weakness. In myopathies, usually proximal arm weakness is associated with proximal leg weakness. Motor neuron diseases like ALS and SMA and neuropathies like CIDP may present with symmetrical proximal weakness. For differentiation, EMG/NCS is crucial.
Proximal Leg Weakness
Authors: Shaibani Aziz
Published: April 2015

Proximal leg weakness is a common presentation in neuromuscular clinics. Hips flexion, abduction, adduction, and rotation are mainly achieved by iliopsoas, glutei, and obturator muscles. Hip pathology, especially when painless, may lead to diagnostic confusion that needs a good EMG of these muscles to be cleared. Most myopathies present with painless proximal leg weakness (difficulty climbing stairs and arising out of a deep chair). CIDP, diabetic amyotrophy, motor neuron diseases, and lumbar plexitis may all present similarly. Severe pain is typical of plexus pathology and is rarein myopathies. Students should be taught to avoid the assumption that proximal weakness is only caused by myopathies.