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Fatal Pressure Over Neck by Hanging
Published in Sudhir K. Gupta, Forensic Pathology of Asphyxial Deaths, 2022
Stage of terminal agonal respiration: These are irregular and disorganized movements of respiration seen in the agonal period. There are respiratory movements during this phase, but these are not synchronized. The duration of this stage is variable and lasts for approximately 1–4 minutes in most cases. The muscles of neck become rigid during this phase.
Patient–Physician Relationship
Published in Eldo E. Frezza, Medical Ethics, 2018
There should be discussion as to what treatment and devices will be removed and what treatment will not be started. If the ventilator is an issue, extubation may allow the patient to talk if they are conscious and have minimal secretions. A discussion should occur as to what to expect – agonal respirations, changes in the monitor, etc. It is also essential to explain that time of death is impossible to predict and may take what seems like a long time. In the end, no matter how involved the discussions are in preparing the family, always expect significant grief and even the possibility of frustration or anger that at times may be directed at the physician or other members of the health care team.
Pathophysiology and Management of Shock
Published in Anthony R. Mundy, John M. Fitzpatrick, David E. Neal, Nicholas J. R. George, The Scientific Basis of Urology, 2010
The assessment begins with an evaluation of respiratory function and, in particular, the quality of the airway and breathing. Four broad situations can usually be recognized by (i) respiratory arrest, (ii) agonal respiration, (iii) abnormal breathing, and (iv) normal breathing. Tachypnea is an early and useful sign of clinical deterioration (21) and, in patients with shock, may reflect acidosis (tissue hypoperfusion, renal dysfunction) or increased carbon dioxide production associated with the hypermetabolism of sepsis. More recently, it has been shown that sepsis (22) induces early contractile failure in the diaphragm, a fact that may explain ventilatory failure in patients with an extrapulmonary source of sepsis. In adults, respiratory arrest is almost always secondary to cardiac arrest, the management of which is beyond the scope of this chapter. Agonal respiration is usually easily recognized as intermittent stertorous and labored respiration accompanied by marked impairment of neurological function. Assessment using the Glasgow scale is likely to reveal a patient whose eyes open to pain (2) or not at all (1), who is able to make incomprehensible sounds (2), and who either localizes (5) or withdraws from a painful stimulus. This peri-arrest situation requires immediate attention, with urgent tracheal intubation and mechanical ventilation by members of the ICU team. In the meantime, having established vascular access and initiated fluid resuscitation, further examination of the patient is likely to provide clues as to the underlying problem. Warm peripheries with a brisk capillary refill are typical of systemic inflammation, and in some patients gentle pressure on the nail-bed elicits the capillary pulsation of Quincke’s sign. Otherwise, cool peripheries with a prolonged capillary would be expected. Most patients in shock are likely to have a tachycardia up to 150/min, with a bounding pulse being typical of systemic inflammation, and a weak thready pulse indicating other types of shock.
Death by hand sanitizer: syndemic methanol poisoning in the age of COVID-19
Published in Clinical Toxicology, 2021
Sarah Denise Holzman, Jaiva Larsen, Ramandeep Kaur, Geoffrey Smelski, Steven Dudley, Farshad Mazda Shirazi
In September 2020, a 41-year-old female came to the ED due to severe abdominal pain and vomiting after reportedly drinking “vodka” for several days. On presentation she was agitated and became increasingly combative. Her initial vital signs were BP 136/99 mm Hg, HR 124 bpm, RR 20 br/min, O2 saturation 96%, temperature 36.3 °C. After the administration of an anti-emetic, sedatives, and IV fluids, she appeared to be resting comfortably. Approximately 3 h after arrival, her laboratory values revealed a profound metabolic acidosis (pH <6.82). Serum ethanol was reported as negative. Within the next hour, she developed agonal respirations. As she was being prepared for intubation, she developed cardiac arrest. During resuscitation she experienced multiple seizures. After return of spontaneous circulation, she received fomepizole, NaHCO3 for her metabolic acidosis, vasopressors for blood pressure support, and she was transferred to a tertiary HCF.
Trending gabapentin exposures in Kentucky after legislation requiring use of the state prescription drug monitoring program for all opioid prescriptions#
Published in Clinical Toxicology, 2019
Kiran A. Faryar, Ashley N. Webb, Bikash Bhandari, Timothy G. Price, George M. Bosse
In 2013, a 42-year-old female with no history of renal disease ingested 64,000 mg of gabapentin in an apparent suicide attempt. On scene, the patient exhibited agonal respirations for 90 minutes and paramedics noted oxygen saturations of approximately 80%. Prior to arrival at the healthcare facility, she developed bradycardia followed by pulseless electrical activity (PEA) for which cardiopulmonary resuscitation (CPR) was initiated. Post resuscitation, the patient had a complicated clinical course in the ICU for several days. She developed acute renal failure, autonomic instability, and a metabolic acidosis. Treatment efforts were eventually terminated due to anoxic brain injury. Her reported medication list included dicyclomine, fluoxetine, gabapentin, metformin, mirtazapine, omeprazole, and risperidone. Gabapentin levels were not performed in this patient and no autopsy or further toxicological testing was performed. Her initial urine drug screen was positive for opioids.
Brugada syndrome and the story of Dave
Published in Neuropsychological Rehabilitation, 2018
Samira Kashinath Dhamapurkar, Barbara A Wilson, Anita Rose, Gerhard Florschutz
There are several abnormal ECG patterns that identify BrS including a heart block affecting the right ventricle so that it is not directly activated by impulses travelling through the right bundle branch (known as the right bundle branch block). ST-segment elevations noted in leads v1–v3, prolonged PR and negative T wave may also indicate BrS (Brugada, 2016). This segment is part of the ECG. An ST segment elevation myocardial infarction (STEMI) is the name for one type of heart attack that arises from an acute interruption of blood supply to a part of the heart. Initially, it was believed that people with BrS had a structurally normal heart but this has been challenged (Frustaci et al., 2005) and the syndrome can also occur as a consequence of subtle structural changes in the right ventricular outflow tract (Antzelevitch, Brugada, Brugada, & Brugada, 2005; Nademanee et al., 2011). Other terms for this syndrome include sudden unexplained death syndrome; sudden unexplained nocturnal death syndrome and sudden arrhythmic death syndrome (Nademanee et al., 1997; Vatta et al., 2002). Symptoms vary from palpitations and giddiness to recurrent fainting, nocturnal agonal respiration (breathing with short, sporadic gasps) and sudden cardiac death (Antzelevitch & Patocskai, 2016; Wilde et al., 2002). The condition is accountable for 4% of all sudden deaths and 20% of sudden deaths reported to be in those without structural heart disease (Vohra & Rajagopalan, 2015). A family history is present in about 20 to 30% of patients.