File:Ellis-type-III-coronary-perforation.gif

2014-09-19T15:15:46Z

Jolanta Marszalek: Jolanta Marszalek uploaded a new version of "File:Ellis-type-III-coronary-perforation.gif"

PCI complications: vessel perforation

2014-09-19T15:12:29Z

Jolanta Marszalek: /* Diagnosis */

__NOTOC__
{{PCI}}
{{CMG}}; '''Associate Editor-In-Chief:''' {{CZ}}

==Overview==
Coronary perforations are uncommon (< 1%) [[complication]]s of percutaneous coronary intervention (PCI) and are associated with significant [[morbidity]] and [[mortality rate]]s. <ref>Fasseas P, Orford JL, Panetta CJ, Bell MR, Denktas AE, Lennon RJ, Holmes DR, Berger PB. Incidence, correlates, management, and clinical outcome of coronary perforation: analysis of 16,298 procedures. Am Heart J. 2004 Jan; 147 (1):140-5. PMID 14691432</ref><ref>Dippel EJ, Kereiakes DJ, Tramuta DA, Broderick TM, Shimshak TM, Roth EM, Hattemer CR, Runyon JP, Whang DD, Schneider JF, Abbottsmith CW. Coronary perforation during percutaneous coronary intervention in the era of abciximab platelet glycoprotein IIb/IIIa blockade: an algorithm for percutaneous management. Catheter Cardiovasc Interv. 2001 Mar; 52 (3):279-86. PMID 11246236</ref><ref>Javaid A, Buch AN, Satler LF, Kent KM, Suddath WO, Lindsay J Jr, Pichard AD, Waksman R. Management and outcomes of coronary artery perforation during percutaneous coronary intervention. Am J Cardiol. 2006 Oct 1; 98 (7):911-4. Epub 2006 Aug 7. PMID 16996872</ref><ref>Klein LW. Coronary artery perforation during interventional procedures. Catheter Cardiovasc Interv. 2006 Nov; 68 (5):713-7.PMID 17039517</ref><ref>Stankovic G, Orlic D, Corvaja N, Airoldi F, Chieffo A, Spanos V, Montorfano M, Carlino M, Finci L, Sangiorgi G, Colombo A. Incidence, predictors, in-hospital, and late outcomes of coronary artery perforations. Am J Cardiol. 2004 Jan 15; 93 (2): 213-6. PMID 14715351</ref> Coronary perforations are infrequent in patients undergoing balloon angioplasty (0.1%) compared with patients undergoing atheroablative [[therapy]] (1.3%; p< 0.001)<ref>Dippel EJ, Kereiakes DJ, Tramuta DA, Broderick TM, Shimshak TM, Roth EM, Hattemer CR, Runyon JP, Whang DD, Schneider JF, Abbottsmith CW. Coronary perforation during percutaneous coronary intervention in the era of abciximab platelet glycoprotein IIb/IIIa blockade: an algorithm for percutaneous management. Catheter Cardiovasc Interv. 2001 Mar; 52 (3):279-86. PMID 11246236</ref><ref>Ellis SG, Ajluni S, Arnold AZ, Popma JJ, Bittl JA, Eigler NL, Cowley MJ, Raymond RE, Safian RD, Whitlow PL. Increased coronary perforation in the new device era. Incidence, classification, management, and outcome. Circulation. 1994 Dec; 90 (6): 2725-30. PMID 7994814</ref>. Perforation due to [[coronary]] [[guidewire]]s may present late after the procedure.
==Classification==

Coronary artery perforation has been classified by ''Ellis et al.'' based on its angiographic apperance:<ref name="pmid7994814">{{cite journal| author=Ellis SG, Ajluni S, Arnold AZ, Popma JJ, Bittl JA, Eigler NL et al.| title=Increased coronary perforation in the new device era. Incidence, classification, management, and outcome. | journal=Circulation | year= 1994 | volume= 90 | issue= 6 | pages= 2725-30 | pmid=7994814 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7994814 }} </ref>

{| style="border: 2px solid #DCDCDC; font-size: 90%;"
! align="center" style="background: #DCDCDC;" | '''Type'''
! align="center" style="background: #DCDCDC;" | '''Definition'''
|-
| style="background: #F5F5F5; padding: 0 10px; font-weight: bold;" | Type I
| style="background: #F5F5F5; padding: 0 10px;" | A crater extending outside of the lumen only and in the absence of linear staining angiographically suggestive of a dissection.
|-
| style="background: #F5F5F5; padding: 0 10px; font-weight: bold;" | Type II
| style="background: #F5F5F5; padding: 0 10px;" | Pericardial or myocardial blush without a ≥1 mm exit hole.
|-
| style="background: #F5F5F5; padding: 0 10px; font-weight: bold;" | Type III
| style="background: #F5F5F5; padding: 0 10px;" | Frank streaming of contrast through a ≥1 mm exit hole.
|-
| style="background: #F5F5F5; padding: 0 10px; font-weight: bold;" | Cavity Spilling
| style="background: #F5F5F5; padding: 0 10px;" | Contrast flow from the site of perforation into an anatomic cavity (eg, cardiac chamber or coronary sinus) as opposed to into the pericardium or myocardium.
|}


==Risk Factors==
===PCI Equipment===
*The use of stiff [[guidewire]]s, [[hydrophilic]] [[guidewire]]s and [[guidewire]]s in which the core extends to the tip of the [[guidewire]] are associated with perforation.
===PCI Technique===
* [[Balloon]] to [[artery]] ratio > 1.1
* Over expansion of a [[stent]] at high pressures
* Use of [[debulking]] procedure such as [[rotational atherectomy]]
===Lesion Risk Factors===
Complex [[coronary]] [[anatomy]] including:
*[[Chronic total occlusions]]
*[[Calcified lesions]]
*[[Tortuous vessels]]
==Natural History, Complications and Prognosis==
===Complications===
[[Complication]]s of [[vessel]] perforation include [[cardiac tamponade]], [[MI|myocardial infarction (MI)]] and death. It is important to maintain [[hemodynamic]] stability. Should [[tamponade]] occur, it is important to detect and treat it immediately.

[[Hemodynamic assessment in the cardiac catheterization laboratory|Hemodynamic assessment]] with [[right heart]] pressure monitoring should be considered with particular attention being paid to a sudden rise in right [[atrial]] filling pressures. Also, it is important to monitor heart borders on [[fluoroscopy]] to detect signs of [[tamponade]], as signified by a lack of movement of the heart borders.

Urgent [[echocardiography]] should be performed to evaluate for the presence of [[pericardial effusion]] and [[tamponade]] [[physiology]]. Immediate notification of the [[Cardiac surgery|cardiothoracic surgical]] team is important so as to facilitate drainage of an effusion and urgent surgery to close the perforation if needed.

===Prognosis===
The [[prognosis]] based upon the Ellis Classification is as follows<ref name="pmid7994814">{{cite journal |author=Ellis SG, Ajluni S, Arnold AZ, ''et al.'' |title=Increased coronary perforation in the new device era. Incidence, classification, management, and outcome |journal=Circulation |volume=90 |issue=6 |pages=2725–30 |year=1994 |month=December |pmid=7994814 |doi= |url=}}</ref>:
* ''Type I'' - No deaths or [[myocardial infarction]], [[tamponade]] [[incidence]] 8%
* ''Type II'' - No deaths, [[myocardial infarction]] [[incidence]] 14%, [[tamponade]] [[incidence]] 13%
* ''Type III'' - [[Mortality]] [[incidence]] 19%, [[cardiac tamponade]] [[incidence]] 63%, the need for urgent [[bypass surgery]] 63%
* ''Type III "cavity spilling" (CS)'' - No deaths, [[myocardial infarction]] or [[tamponade]], but sample limited in size

==Diagnosis==
Perforation is an [[angiographic]] [[diagnosis]]. It appears as a small extraluminal [[extravasation]] of blush in the distribution of the target [[vessel]]. Care should be taken to routinely visualize the distal extent of the [[vessel]] following PCI to exclude the presence of a wire perforation. Emergency [[echocardiography]] should be performed to rule out the presence of a [[pericardial effusion]] or [[pericardial tamponade]].

==Treatment==
Initial management strategies include:
===Reversal of Anticoagulation===
One is the initial steps is to reverse the [[anticoagulation]]. This includes the administration of [[protamine]] to reverse [[heparin]]. [[Protamine]] will also partially reverse the [[antithrombotic therapy|antithrombotic]] effect of [[enoxaparin]] if this [[antithrombin]] was used. Administration of [[platelet]]s can be considered if [[abciximab]] has been administered. If it is greater than four hours after a maintenance [[dose]] of [[prasugrel]] or greater than six hours after a [[loading dose]] of [[prasugrel]], then a [[platelet]] [[infusion]] should also be considered.

===Prolonged Balloon Inflation===
Inflations up to 20 minutes may be needed to achieve [[hemostasis]]. For this reason it is often wise for a [[cardiac catheterization]] laboratory to have [[perfusion]] balloons in a range of sizes available.
===Covered Stent===
In [[refractory]] cases, [[polytetrafluoroethylene]] covered [[stent]]s ([[Stent Graft|stent grafts]]) can be used to seal the perforation<ref>Ly H, Awaida JP, Lespérance J, Bilodeau L. Angiographic and clinical outcomes of polytetrafluoroethylene-covered stent use in significant coronary perforations. Am J Cardiol. 2005 Jan 15; 95 (2): 244-6. PMID 15642559</ref><ref>Gercken U, Lansky AJ, Buellesfeld L, Desai K, Badereldin M, Mueller R, Selbach G, Leon MB, Grube E. Results of the Jostent coronary stent graft implantation in various clinical settings: procedural and follow-up results. Catheter Cardiovasc Interv. 2002 Jul; 56 (3): 353-60. PMID 12112888</ref>. They can be used for most [[coronary]] perforations, but small, excessively angulated or [[tortuous]] vessels may not be amenable to them.
===Other Techniques===
Other techniques include coil [[embolization]], the injection of [[clot]]ted blood, the use of [[gel]] [[foam]] and the [[injection]] of [[thrombin]] at the site of the perforation. Coil [[embolization]] is suitable for small side branch perforations, but it will lead to [[tissue]] [[infarction]] and may not be available in all [[Cath lab|catheterization laboratories]]. Coil [[embolization]] is suited for small [[vessel]]s, [[distal]] locations, [[artery|arteries]] that supply limited viable [[myocardium]], or situations where surgery is [[contraindicated]].
===Surgery===
Approximately one third of cases of PCI-associated [[coronary artery]] perforation require emergent [[cardiac surgery]]. [[surgery|Surgical]] closure is necessary for perforations that demonstrate continued [[bleeding]] despite minimal invasive therapy, [[refractory]] [[ischemia]], or recurrent [[hemorrhage]]. Incomplete closure is signified by persistent [[dye]] [[extravasation]], while [[pericardial fluid]] collection and impending [[cardiac tamponade]] is signified by increasing [[right atrial]] pressure. Peristent fluid accumulation or [[pericardial drainage|pericardial drain]] output (>24 h) should prompt [[surgery|surgical repair]].
===Echocardiographic Monitoring===
Serial [[echocardiography]] should be performed q 6-12h to detect the presence of an expanding [[pericardial effusion]] or [[cardiac tamponade]] [[physiology]].

==References==
{{Reflist|2}}
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[[Category:Cardiology]]
[[Category:Up-To-Date]]
[[Category:Up-To-Date cardiology]]

Jolanta Marszalek:

__NOTOC__
{{Salmonellosis}}
{{CMG}}

==Overview==
Patients with Salmonellosis typically present with abdominal pain, nausea and vomiting, acute diarrhea that may be bloody, and fever.

==Symptoms==
The onset of symptoms due to Salmonellosis usually occurs between 6 and 72 hours after ingestion of contaminated food or water. Symptoms usually begin with acute cramping abdominal pain and diarrhea that may or may not be bloody. Nausea and vomiting commonly occur. Fever may also be present. In children, the infection is associated with a longer duration as well as increased frequency of bloody diarrhea.<ref name="pmid17146467">{{cite journal| author=Coburn B, Grassl GA, Finlay BB| title=Salmonella, the host and disease: a brief review. | journal=Immunol Cell Biol | year= 2007 | volume= 85 | issue= 2 | pages= 112-8 | pmid=17146467 | doi=10.1038/sj.icb.7100007 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17146467 }} </ref>

==References==
{{reflist|2}}

[[Category:Bacterial diseases]]
[[Category:Foodborne illnesses]]
[[Category:Zoonoses]]

[[Category:Disease]]
[[Category:Infectious disease]]
[[Category:Emergency medicine]]
[[Category:Intensive care medicine]]

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Salmonellosis history and symptoms

2014-08-21T21:28:57Z

Jolanta Marszalek:

__NOTOC__
{{Salmonellosis}}
{{CMG}}

==Overview==
Patients with Salmonellosis typically present with abdominal pain, nausea and vomiting, acute diarrhea that may be bloody, and fever.

==Symptoms==
The onset of symptoms due to Salmonellosis usually occurs between 6 and 72 hours after ingestion of contaminated food or water. Symptoms usually begin with acute cramping abdominal pain and diarrhea that may or may not be bloody. Nausea and vomiting commonly occur. Fever may also be present. In children, the infection is associated with a longer duration as well as increased frequency of bloody diarrhea.

==References==
{{reflist|2}}

[[Category:Bacterial diseases]]
[[Category:Foodborne illnesses]]
[[Category:Zoonoses]]

[[Category:Disease]]
[[Category:Infectious disease]]
[[Category:Emergency medicine]]
[[Category:Intensive care medicine]]

{{WikiDoc Help Menu}}
{{WikiDoc Sources}}